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New Surgical Protocol to Create Interimplant Papilla:

The Preliminary Results of a Case Series

Stuart Froum, DDS1 Replacing missing teeth with den-

Miltiadis Lagoudis, DMD2 tal implants has become a viable
Giovanni Molina Rojas, DDS3 solution for conventional fixed or
Takanori Suzuki, DDS, PhD4 removable prosthodontics.1-3 How-
Sang-Choon Cho, DDS5 ever, the application of the prin-
ciples of osseointegration to single
The aim of this study was to introduce a new surgical technique to regenerate the missing teeth and partial edentu-
papilla adjacent to multiple or single implants using a novel instrument and a new lism has increased patient esthetic
incision design. A total of 10 consecutively treated patients with maxillary anterior demands. An important aspect of
implant-supported provisional restorations and missing interproximal papillae
the success criteria for dental im-
received a subepithelial connective tissue graft. The recipient site was prepared
with a buccal incision apical to the mucogingival junction and to the defective plants in the esthetic zone involves
papilla, and a palatal incision, followed by buccolingual tunneling performed the establishment of soft tissue
with a translingual curette (EBINA). A total of 10 sites were treated and evaluated contour with an intact interdental
pre- and postoperatively with the papilla score based on the Jemt classification. papilla and a gingival outline that
The final prosthesis was delivered 3 months after the papilla regeneration is harmonious with the gingival
surgical procedure. An average improvement in papilla index score from 0.8 to
silhouette of the adjacent healthy
2.4 was found after an average follow-up period of 16.3 months. This case series
demonstrated that interimplant papilla regeneration can be successful over a dentition.4,5
period of 11 to 30 months postloading. Long-term prospective studies on tissue Lack of interdental papilla can
stability and esthetic outcomes are needed to corroborate the findings in this lead to cosmetic deformities, pho-
study. Int J Periodontics Restorative Dent 2016;36:161–168. doi: 10.11607/prd.2603 netic difficulties, and food impac-
tion.6 The vertical distance from the
crest of the bone to the height of
the interproximal papilla between
adjacent implants,7 between im-
Clinical Professor and Director of Clinical Research, Ashman Department of Periodontology
1
plant and natural tooth, and be-
and Implant Dentistry, New York University College of Dentistry, New York, New York, USA.
2Implant Resident, Ashman Department of Periodontology and Implant Dentistry, tween implant and pontic has been
New York University College of Dentistry, New York, New York, USA. measured and reported.8 When
3Former Implant Resident, Ashman Department of Periodontology and Implant Dentistry,
this distance was 5 mm or less be-
New York University College of Dentistry, New York, New York, USA.
4Clinical Assistant Professor of Advanced Program for International Dentists in Implant
tween two adjacent teeth, the pa-
Dentistry, Ashman Department of Periodontology and Implant Dentistry, pilla completely filled this space
New York University College of Dentistry, New York, New York, USA. approximately 100% of the time.9
5Clinical Assistant Professor and Director of Advanced Program for International Dentists
In cases where an implant was adja-
in Implant Dentistry and Co-Director of Clinical Research, Ashman Department of
Periodontology and Implant Dentistry, New York University College of Dentistry,
cent to a natural tooth, the average
New York, New York, USA. height was reported to be 4.5 mm.8
However, the average height of tis-
Correspondence to: Dr Stuart Froum, 17 W 54th Street, Suite 1C/D,
sue over the crest of bone between
New York, NY 10019, USA. Fax: 212-246-7599. Email: [email protected]
two adjacent implants was report-
 ©2016 by Quintessence Publishing Co Inc. ed to be 3.4 mm.7 Thus, in cases of

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162

sionalization stage, and to report The inclusion criteria were as

Table 1 Classification of the clinical results. follows:
interproximal
papilla18
1. Presence of an implant-
Classification Description Materials and methods supported provisional
0 No papilla is present restoration
1 Less than half of the height The clinical data in this study was ex- 2. Absence of interproximal
of the papilla is present tracted as deidentified information papilla, Jemt classification 0 to 1
2 Half or more of the height from the implant database ID from (Table 1)18
of the papilla is present the routine treatment of patients at 3. Missing papilla in anterior
3 The papilla fills up the the Ashman Department of Peri- maxilla, between adjacent
entire proximal space
odontology and Implant Dentistry implants, between an implant
4 The papillae are at the New York University College and an adjacent natural tooth,
hyperplastic
of Dentistry Kriser Dental Center. or between an implant and an
The Office of Quality Assurance at adjacent pontic site
two adjacent anterior implants, de- the New York University College of
ficient interimplant papillae often Dentistry certified the ID. This study The exclusion criteria were as
occur. is in compliance with the Health In- follows:
Numerous methods have been surance Portability and Accountabil-
proposed to regenerate papilla. ity Act requirements and approved 1. Pregnant or lactating
However, due to compromised by the University Committee on Ac- 2. Active periodontal disease in
blood supply and scar tissue forma- tivities Involving Human Subjects. the remaining dentition
tion, these techniques were report- 3. Systemic diseases or
ed to be unpredictable.10–14 Villareal medications that could alter the
et al in 2010 described a predictable Study subjects tissue healing around dental
approach for papilla regeneration implants
using careful and gentle soft tissue Ten consecutively treated cases from 4. Unwillingness to commit to
manipulation during surgery.21 The the implant database that required a long-term post-therapy
protocol included papilla-sparing in- treatment with multiple or single maintenance program
cisions and minimal reflection of the maxillary anterior implants were in-
flap.11,12 The underlying concept was cluded in this study. Patients that
to preserve the blood supply to the presented with implant-supported Measurements
adjacent papilla and soft tissue and provisional crowns or bridges and
maintain soft tissue quality.10–15 For who had undergone the papilla re- Following provisional placement,
this reason, it was suggested that su- generation procedure between Au- measurements were made inter-
tures through or close to the papilla gust 2011 and August 2012 were proximally from the contact point of
should be avoided as they can cause included in this retrospective case se- the treatment site, vertically to the
trauma and inflammation, negatively ries. The subjects were 3 males and 7 crestal gingiva. Measurements were
affecting the outcome of the papilla females (average age: 45 years). The made with a North Carolina probe
regeneration procedure.14–17 treatment sites were papillae be- (Hu-Friedy) and recorded according
The purpose of the present tween adjacent implants, between to the Jemt classification. Measure-
case series was to introduce a new an implant and an adjacent natural ments were made independently by
surgical technique to regenerate tooth, and between an implant and two calibrated investigators to en-
the papilla adjacent to multiple or an adjacent pontic site, from position sure accuracy.
single implants during the provi- 13 to 23 (canine to canine).

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 163

Fig 1a  Clinical view of a provisional prosthesis with missing papilla Fig 1b  Oblique buccal incision above the mucogingival junction.
between the implant area of #12 and the pontic area of #11, after a
previous soft tissue grafting procedure.

Fig 1c  Palatal incision. Fig 1d  Translingual curette.

In no case did the investigators 1:100,000, Henry Schein), the provi- cal to the deficient papilla area (Fig
differ in their opinion of the 0 or 1 sional restoration was removed and 1b). Another full-thickness oblique
classification. At each recall visit fol- the embrasure space at the site of incision was made on the palatal
lowing placement of the final resto- the planned papillary augmentation side (Fig 1c). The incisions were
ration, the same two investigators was opened. Sufficient interproxi- made in an oblique direction from
measured and classified the papillae. mal embrasure widening was per- distal to mesial at a distance from
formed prior to surgery to achieve the papilla to preserve the blood
an esthetically acceptable restora- supply of the mucosa at the recipi-
Surgical procedure tion with adequate papilla volume ent site.13 The translingual curette
(Fig 1a). Prior to modification of the (TLC) (EBINA), a modified and twice
Preoperative antibiotics were given provisional restoration, the papilla in angulated curette (Fig 1d), provided
orally 1 hour prior to surgery (amoxi- the deficient site was indexed using access to the tunnel apically and
cillin 2 g, or clindamycin 600 mg, for the Jemt classification.18 The provi- easy access to the interproximal
patients allergic to penicillin). Follow- sional restoration was removed and area without causing any damage
ing the administration of local anes- a full-thickness oblique incision was to the tissue. It was gently inserted
thesia (lidocaine with epinephrine made in the vestibular mucosa, api- into the buccal incision, elevating

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164

Figs 2a to 2c  Periosteal elevation using

the translingual curette.

a b c

Fig 3  Connective tissue graft with the stabilization suture. Fig 4  Clinical view of the graft placement over
the defect.

the periosteum or flap, and used to (Fig 3). The graft was inserted into a soft diet and oral hygiene proce-
create a subperiosteal tunnel toward the recipient site through the buc- dures, were given to the patient.
the crest of the ridge, coronally to cal incision and pulled under the The patient was told to avoid brush-
the interproximal area (Fig 2). Care papillae through the lingual incision ing and flossing in the surgical area
was taken to avoid excessive eleva- (Fig 4). Once the graft was correctly and to use rinses of 0.9% saline 5
tion, keeping the dissection limited positioned over the interproximal to 6 times a day and chlorhexidine
to the defect size. The same eleva- papilla area, the resorbable 4/0 twice a day only. A follow-up ex-
tion was performed on the palatal chromic gut sutures placed at the amination was performed 7 to 14
side, creating a tunnel between the mesial and distal margins of the days postoperatively (Fig 6). After
buccal and lingual incisions. connective tissue graft were used a healing period of 3 months, the
Following local anesthesia, to secure it in position and then final restoration was delivered (Figs
a subepithelial connective tissue close the buccal and lingual entry 7a to 7d). The final restoration was
graft was harvested from the palate incisions (Fig 5). The postoperative carefully designed following the
according to the Langer and Calag- protocol consisted of antibiotics, exact interproximal contour of the
na and the Hürzeler and Weng amoxicillin 500 mg or clindamycin provisional. In sites where the pa-
techniques,19,20 and the donor site 150 mg three or four times a day, pillae was created but did not fully
was sutured with 4/0 chromic gut respectively, for 1 week, and anal- fill the interproximal area, a slight
sutures (Ethicon). Two 4/0 chromic gesics (ibuprofen 600 mg every 4 elongation of the contact point
gut sutures were placed at the me- to 6 hours). The patient was also in- was made in the final restoration.
sial and distal margins of the sub- structed to use 0.12% chlorhexidine All patients were recalled every 3
epithelial connective tissue graft to rinses twice a day starting 24 hours months following final restorations
facilitate the insertion and stabili- after surgery for 2 weeks. Postop- for follow-up examinations and
zation of the graft over the defect erative care instructions, including periapical radiographs. The papilla

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a b
Figs 5a and 5b  Schematic illustration of the graft placement over Fig 6  A follow-up examination 7 to 14 days postoperative.
the defect.

Fig 7a  Clinical view prior to insertion of the final prosthesis. Fig 7b  Clinical view of the insertion of the final prosthesis.

Fig 7c (above)  Clinical view of the final prosthesis.

Fig 7d (right)  Radiographic control of the implant area #12 and the
pontic area #11 after insertion of the final prosthesis.

height was again measured by the ed using the Jemt papilla classifica- In another case, a 55-year-old
same two investigators and record- tion during each recall. Asian woman presented with a chief

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166

Fig 8a  Deficient class 0 papillae between Fig 8b  Twelve months postsurgery, the Fig 8c  Radiographic control of left
splinted left central and lateral implants. reformed papillae closed the space and a new central and lateral implants show-
provisional was made with no alteration to the ing the bone level relative to the
contact point length. contact point.

Table 2 Results of the technique for the 10 patients included in the study
Interproximal Implant/pontic/ Starting score Ending score Duration
Subject papillae sites* tooth Abutment (Jemt classification) (Jemt classification) (mo)
 1 12, 11 I-I Titanium 1 3 30
 2 12, 11 I-T Titanium 1 3 11
 3 11, 21 I-I Titanium 0 1 10
 4 11, 21 I-P Titanium 1 3 10
 5 21, 22 P-I Titanium 1 3 12
 6 21, 22 I-I Zirconia 0 3 18
 7 12, 11 I-P Titanium 1 2 12
 8 12, 11 I-P Titanium 1 1 12
 9 21, 22 I-I Zirconia 1 3 18
10 21, 22 I-I Titanium 1 2 30
Mean: 0.8 Mean: 2.4 Mean: 16.3
*FDI tooth numbering system. I = implant; P = pontic; T = tooth.

complaint of “black space between Results Discussion

her implants” (Fig 8a). She present-
ed with two restored and splinted The results of the present case se- Several surgical methods have been
implants in the left central and lat- ries are summarized in Table 2. The advocated for papilla regeneration.
eral areas. The papilla was classified 10 reported cases were followed for Palacci et al suggested a full-thick-
as Jemt class 0. The same papilla re- an average period of 16.3 months ness flap elevation from the buc-
generation procedure as described (range: 11 to 30 months), with an av- cal and palatal sides of the ridge
previously was performed. Twelve erage improvement of Jemt papilla and 90-degree rotation to fill the
months postsurgery the papillae score from 0.8 to 2.4 (range: 0 to 3). interproximal space adjacent to an
completely filled the space (Jemt: 3) In only one case was no improve- implant.10 Adriaenssens et al intro-
and a new two-unit restoration was ment observed. duced the “palatal sliding strip flap”
fabricated (Figs 8b and 8c). to form papillae between implants

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 167

and natural teeth in the anterior ent authors’ knowledge, this is the dex of 1.6 (Jemt classification) with
area of the maxilla. This technique first study showing a predictable re- a range of 0.8 to 2.4 in esthetic ar-
includes sliding the palatal mucosa sult for papilla regeneration. eas between two adjacent implants,
in a labial direction.12 Nemcovsky The need for adequate instru- between implant and tooth, and be-
et al used a U-shaped incision.14 Ar- mentation to achieve the elevation tween implant and pontic site. The
noux et al described several tissue of the mucoperiosteal tunnel from papilla regeneration was achieved
augmentation techniques at stage 1 a remote incision and to minimize with carefully planned incision de-
and stage 2 surgery to enhance sin- the chance of perforation led to the sign, atraumatic tissue handling,
gle tooth esthetics.15 The reported development of the TLC. This in- minimal tension during suturing, and
surgical procedures were not pre- strument allows for a full-thickness meticulous home care after surgery.
dictable due to the limited blood reflection minimizing the risk of soft Further studies with more cases and
supply and presence of scar tissue tissue perforation due to its ana- longer follow-ups are required to
as a result of surgical trauma.21–23 tomical design. The TLC facilitated establish the long-term effective-
Chao presented the pinhole the soft tissue tunnel preparation, ness of this regenerative technique.
surgical technique (PST) as a root increasing the predictability of the
coverage procedure. The PST re- regenerative procedure (Figs 1d
quired no releasing incision, sharp and 2). Although 6 of the 10 treated Acknowledgments
dissection, or suturing. Similar to areas resulted in complete papilla
the technique presented in this ar- regeneration, the improvement in 3 Dr Cho has a patent pending (no. PCT/
ticle, it was proposed as a minimally of the 4 other cases was either ac- KR2014/007855), for Trans-Lingual Curette
[TLC]).
invasive procedure with the main cepted by the patient or allowed
difference being that PST uses one slight elongation of the contact
vestibular incision, using a biore- point of the final restoration. This
sorbable membrane (BM) (Bio-Gide, resulted in patient satisfaction with References
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168

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