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 61

Incision Design and Soft Tissue Management to

Maintain or Establish an Interproximal Papilla
Around Integrated Implants:
A Case Series
Stuart J. Froum, DDS1 Dental implants have demonstrated
Wendy Chia-Wei Wang, BDS, MSc2 high long-term survival rates when
Tarek Hafez, BDS2/Takanori Suzuki, DDS, PhD3 placed in healed alveolar ridges or
Yung Cheng Paul Yu, DDS3/Sang-Choon Cho, DDS4 with immediate placement follow-
ing tooth extraction.1–3 Today, how-
ever, the clinician’s goals extend
Maintenance or reconstruction of interproximal papilla for a successful dental beyond mere implant survival.4 The
implant restoration can be challenging. To date, the results from various surgical goal of both the clinician and the
and prosthetic techniques to maintain or regenerate papilla adjacent to dental patient is implant success, which im-
implants have been unpredictable. To maintain the quality of the soft tissue
plies a functional and stable implant
around an implant, the blood supply must be preserved and formation of scar
tissue must be minimized during surgery. Therefore, incision design is vital to with stable bone levels and esthetic
producing an esthetic and successful dental implant restoration. In this study, soft and hard tissue contours, in-
specific incision designs and soft tissue management techniques were used cluding intact papilla adjacent to the
to preserve or create interproximal papilla around single or adjacent implants. implants.
Int J Periodontics Restorative Dent 2018;38:61–69. doi: 10.11607/prd.2978 One of the challenges in creat-
ing an esthetic and successful im-
plant restoration is maintenance or
reconstruction of the interproximal
papilla. Many surgical and pros-
thetic techniques have been at-
tempted to regenerate missing
interproximal papilla adjacent to
implants.5–8 The results to date
have been unpredictable.9,10 The
papilla height between an implant
and a natural tooth was reported to
Clinical Professor and Director of Clinical Research, Ashman Department of
1
average 4.5 mm, with a maximum
Periodontology and Implant Dentistry, New York University College of Dentistry, of 5 mm 1 year after final prosthesis
New York, New York, USA.
2Implant Resident, Ashman Department of Periodontology and Implant Dentistry, insertion.11 The average height of
New York University College of Dentistry, New York, New York, USA. interproximal tissue between two
3Clinical Assistant Professor, Ashman Department of Periodontology and Implant Dentistry,
adjacent implants from the crestal
New York University College of Dentistry, New York, New York, USA.
4Program Director, Ashman Department of Periodontology and Implant Dentistry,
bone peak to the height of the pa-
New York University College of Dentistry, New York, New York, USA. pilla has been reported to be ap-
proximately 3.5 mm.12 However,
Correspondence to: Dr Stuart J. Froum, 17 W 54th Street, Suite 1C/D, improper management of soft tis-
New York, NY 10019, USA. Fax: 212-246-7599.
sues often results in loss of papilla
Email: dr.froum@verizon.net
between teeth and implants, which
©2018 by Quintessence Publishing Co Inc. is difficult to correct.13

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62
Three essential factors for
maintaining or regenerating soft
tissue quality and volume around
implants are preservation of the
blood supply to the adjacent papil-
la, preservation of the bone on the
adjacent teeth, and minimal scar tis-
sue formation during surgery.14 The
blood supply to the wound margin,
which represents the main nutrition
for tissue survival, is critical for opti-
mal wound healing.15 When soft tis-
sue becomes rigid and nonflexible
as a result of traumatic manipulation
or previous surgical interventions,
it does not allow for adaptation
or flexibility around implants. Tis-
sue that remains resilient, flexible,
and viable (referred to as moldable
tissue) depends on careful han-
dling and proper incision design.16
Knowledge of incision design is an
essential factor in preserving blood
supply, obtaining moldable tissue,
and regaining or creating interprox-
imal papilla.
The purpose of this study is to
present a retrospective series of 14
consecutive cases of 22 implants
(either single or two adjacent) in the
esthetic zone, where specific incision
designs and soft tissue management
techniques were used at the time
of implant placement and at the
second-stage abutment or provi-
sional restoration surgery. These fac-
tors helped preserve and, in some
cases, establish the interproximal
papilla around the implants.
Materials and Methods
Clinical data in this study was ob-
tained from the implant database
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(ID). The data was extracted as
deidentified information from the
routine treatment of patients at
the Ashman Department of Peri-
odontology and Implant Dentistry
at the New York University College
of Dentistry, Kriser Dental Center.
The Office of Quality Assurance
at New York University College of
Dentistry certified the ID. This study
is in compliance with the Health
Committee on Activities Involving
Human Subjects.
Study Subjects
A total of 14 consecutive patients
from the database were included
in this study. Of these patients, 8
received 10 nonadjacent implants
while 6 received 2 adjacent im-
plants. The implants were placed
using an early/delayed approach
following socket healing as part
of the replacement of extracted
hopeless teeth. The patients in-
cluded 6 males and 8 females. The
treatment sites included central
incisors, lateral incisors, and pre-
molars.
Inclusion Criteria
Patients who had implants placed
using a two-stage implant protocol
with the following parameters were
included:
1. Tooth or teeth in the esthetic
zone that required extraction
due to periodontal disease,
root fracture, or failure of
endodontic treatment and
were replaced with implants.
Patients who had presurgical
trauma to papilla from trauma
due to extraction or from
overcompression by provisional
prosthesis were noted but not
excluded.
2. Teeth adjacent to the proposed
implant site were required to
be periodontally healthy (no
bleeding on probing) with
≤ 5 mm clinical attachment loss.
3. Patients who had taken
a presurgical cone beam
computed tomography
(CBCT) scan prior to implant
placement.
4. Type 2 or 3 extraction socket
morphology (partial loss of
buccal bone plate or soft
tissue according to published
extraction socket classification)
present at time of implant
placement.17
5. Implants that were placed 4
to 6 weeks following tooth
extraction.
6. Implants that had papilla
preservation incisions at
placement and U-shaped
incision designs (with divergent
arms open toward the palatal)
at second-stage surgery.
7. Implants with provisional
abutments of a smaller
diameter than the implant
diameter (platform switching),
which were connected at
second-stage surgery.
8. Patients who returned to the
Department of Periodontology
and Implant Dentistry or
to their own dentist for
maintenance and monitoring at
least 2 to 3 times per year.
 63

a b c

d e f
Fig 1 (a) Clinical view of a missing maxillary left lateral incisor. (b) Papilla preservation incision design for ridge augmentation. (c) Flap
elevation allowed for access to the bone for implant placement. (d) Delivery of an implant-supported fixed prosthesis. (e) Radiograph of
abutment insertion. (f) Final delivery of the implant-supported fixed prosthesis.

Exclusion Criteria 4. Parafunctional habits using a xenograft and resorbable

Patients were excluded if they met
the following criteria:
1. Implant placement with
one-stage protocol
2. Generalized chronic
periodontal disease around
the remaining teeth
3. Systemic diseases or medication
that could have altered the
tissue integration of dental
implants (ie, uncontrolled
diabetes, a history of radiation
therapy, active autoimmune
diseases, a recent history of
intravenous bisphosphonates)
5. Inadequate home care
compliance
6. Pregnant or lactating women or
women intending to become
pregnant within 1 year of
implant placement
Clinical Procedures
Presurgical CBCT scans with implant
simulation (Simplant 17.0, Dentsply)
were prepared. Any site with a buc-
cal plate of bone of < 2 mm on the
simulated implant was planned for
simultaneous implant placement
and horizontal ridge augmentation
membrane barrier.
The incisions for implant place-
ment for a single implant or two
adjacent implants used a papilla
preservation flap approach. Com-
bined with periosteal releasing in-
cisions, these preserved the soft
tissue blood supply and allowed
flap advancement where necessary
following implant placement and
horizontal ridge augmentation (Figs
1a to 1c, 2a, and 2b).
Horizontal ridge augmentation
was performed simultaneously in 21
of the 22 implant placement proce-
dures and included bone decorti-
cation and the use of small particle

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64

a b

c d

e f
Figs 2a to 2f (a) Clinical view of missing maxillary central incisors. (b) Incision design used for tissue preservation. (c) Flap closure
post–implant placement with horizontal ridge augmentation using a resorbable membrane barrier. (d) Clinical view at 2-week follow-up.
(e) U-shaped incision design for second-stage surgery. (f) Opening of the cervical embrasure space.

anorganic bovine bone (BioOss
0.25–1.0 mm, Geistlich). The bone
substitute graft was covered with a
resorbable collagen membrane (Bio-
Gide, Geistlich) stabilized by tacks
into the bone or with resorbable su-
tures through the periosteum.
Implants were placed using a
surgical guide from an ideal wax-
up, made of thermoplastic material,
and following manufacturer instruc-
tions. All implants had cover screws
placed and were submerged when
horizontal augmentation proce-
dures were used. Complete closure
of the graft, membrane, and flap
was achieved without tension using
resorbable chromic 4-0 and 5-0 gut
sutures (Ethicon) (Figs 2c and 2d).
At least 90 days after implant
placement, second-stage abutment
insertion surgery was performed
following administration of local an-
esthesia. A U-shaped incision with
divergent arms open toward the pal-
atal was reflected (Fig 2e). The cover
screw was exposed and removed.
A platform-switching abutment was
connected. On the same visit, the
provisional prosthesis was fabricated
and placed, leaving enough clear-
ance in the embrasure area for the
papilla to reform (Fig 2f). All patients

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 65

g h

Figs 2g to 2j (g) Clinical view at 4-month follow-up after second-

stage surgery. (h) Clinical view at 4-year follow-up showing
the papilla between the central incisors. (i) Clinical view and
(j) radiograph of the implant-supported fixed prosthesis (a probe
was attached to measure the bone level radiographically).

i j

were given postoperative home care
instructions, which included nondis-
turbance of the papilla area.
Clinical photographs were taken
at various visits following prosthetic
loading with a fixed prosthesis to
monitor the tissue response (Figs 2g
and 2h).
Clinical and radiographic ex-
aminations were performed by two
independent calibrated clinicians to
evaluate the presence of papilla at
each postsurgical and maintenance
visit (Figs 1d to 1f, 2i, and 2j). In cas-
es of disagreement, a third calibrat-
ed clinician made the final decision.
The Jemt papillae index was used
to evaluate the presence and height
of the papillae. A Jemt score of 0,
1, or ≤ 2 was recorded as no papilla
present, and a score of > 2 or 3 was
recorded as papilla presence.18
Results
A total of 22 implants in 14 patients
were followed up to 7.25 years
(range: 6 to 7.25 years) with all im-
plants surviving following loading.
The presence of interproximal pa-
pilla with a Jemt score of > 2 or 3
around the implants was observed
in 12 of 14 patients (90.9%). The
summary of the results is shown in
Tables 1 and 2.
Discussion
The interproximal papilla is the gin-
gival portion of the periodontium
that occupies the space between
two adjacent teeth.19 It acts as a bio-
logic barrier in protecting the peri-
odontal structures, but it also plays
a crucial esthetic role. Therefore, it is
important to maintain the papillary
integrity during implant surgery, es-
pecially in the esthetic zone.20 Vari-
ous surgical techniques have been
proposed to preserve or regener-
ate interproximal papilla around
implants. The techniques described
generally fall into two broad catego-
ries: (1) specific incision and suture
designs7,8,21,22; and (2) fillers or soft
tissue grafting to fill the interproxi-
mal spaces.23–26 However, consistent
results have not been demonstrat-
ed.27–29 Nonsurgical intervention
such as orthodontic forced eruption
has also been used to generate the
papillae, but additional treatment
time and costs are involved and the
results are not predictable.30,31
The present case series dem-
onstrated that the interproximal

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66

Table 1 Clinical Data for Adjacent Implants

Papilla regeneration based on
Jemt papilla score
Implant Prior trauma Horizontal Provisional placed Follow-up
Patient site (FDI) to papilla augmentation at second stage Mesial Interproximal Distal (y)
1 11, 21 No Yes Yes Yes Yes Yes 7.25
2 11, 21 Yes Yes Yes Yes No Yes 6.5
3 21, 22 No Yes Yes Yes Yes Yes 7
4 11, 21 No Yes Yes Yes Yes Yes 7
5 11, 21 No Yes Yes Yes Yes Yes 6.4
6 11, 21 No Yes Yes Yes Yes Yes 6.8

Table 2 Clinical Data for Single Implants

Papilla regeneration based on
Jemt papilla score
Implant Prior trauma Horizontal Provisional placed Follow-up
Patient site (FDI) to papilla augmentation at second stage Mesial Interproximal Distal (y)
7 12 No Yes Yes Yes N/A Yes 6.2
7 21 No Yes Yes Yes N/A Yes 6.2
8 14 No Yes Yes Yes N/A Yes 6.8
9 22 No Yes Yes Yes N/A Yes 6.8
9 11 Yes Yes Yes Yes N/A Yes 6
10 22 Yes Yes Yes Yes N/A No 6.2
11 21 No Yes Yes Yes N/A Yes 7
12 11 No Yes Yes Yes N/A Yes 6.7
13 21 No No Yes Yes N/A Yes 6.4
14 12 Yes Yes Yes Yes N/A Yes 7

papilla around a single or two ad-
jacent implants can be predictably
maintained or regenerated by using
specific incision designs at the time
of implant placement and second-
stage surgery. Unlike techniques
that required extensive soft tissue
manipulation/mobilization/grafting
to recreate the papilla, the incision
designs proposed in this article are
based on the principles of preserva-
tion of vascular supply and preven-
tion of scar tissue formation as the
key elements in maintaining and/
or obtaining papillary integrity. The
result of this case series is consistent
with other techniques where vascular
supply was minimally disrupted and
papillary integrity was preserved.32,33
The vascularity of the papilla
is supplied by the vascular anasto-
moses crossing the alveolar ridge.34
Repeated disruption to the vascular
supply can lead to scar tissue for-
mation as a result of fibroblasts be-
coming prematurely activated and
forming excess fibrotic tissue.35 This
tissue becomes dense, rigid, difficult
to mold, and significantly less vascu-
larized. Minimizing scar tissue for-
mation enables the gingival tissue
to be reshaped under light pressure
and rebound to its original form on
removal of pressure. This character-
istic allows molding of the gingival
tissue with intermittent pressure to
maintain or regenerate the integrity
of the papilla.
The present case series intro-
duced a sequence of procedures
to maintain or reconstruct the inter-
proximal papilla (Table 3). The pre-
requisite to employ the procedures
described is that teeth adjacent
to the proposed implant must be
periodontally healthy with ≤ 5 mm
clinical attachment loss. The specific
incision design used at the time of
horizontal ridge augmentation and
implant placement preserves the pa-
pilla, retaining maximum vascularity

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 67

Table 3 Sequential Procedures to Preserve Papilla

Sequence Surgical Trauma Restorative Avoid
Extraction No incision No Flipper/Fixed Incision
Ridge augmentation Papillary sparing Minimal Flipper/Fixed Midcrestal incision
Stage 1: Papillary sparing Minimal Flipper/Fixed Midcrestal incision
Implant placement
Stage 2: U-shaped incision with divergent No Convert flipper to Labial incision
Implant uncovering arms open toward palatal fixed/fixed
Stage 3: None No Open embrasure Pressure on
Prosthetic connection space papillary tissue

a b

Fig 3 (a) U-shaped incision with diverging arms opening labially.

(b) Soft tissue defect due to labial U-shaped incision design.
(c) Scar tissue formation labially.

and minimizing scar tissue formation. A U-shaped inci-

sion with its divergent arms opening palatally without
sutures was employed at the second-stage implant un-
covering (Fig 2e). The incision was designed to avoid
an indentation formation following the incision line. If a
U-shaped incision is made with its diverging arms open-
ing labially, recession of the labial soft tissue, incision
indentation, and scar tissue formation often result, com-
promising the esthetic outcome as seen in Figs 3 and
4. The flap was minimally elevated following the incision,
and the implant-supported provisional prosthesis, with Fig 4 Example of scar tissue formation labially.

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68
designed clearance, was placed to
encourage soft tissue growth and
help mold the soft tissue (Fig 2f).
This sutureless technique with a
minimally invasive incision preserves
the blood flow to the papillary soft
tissue and therefore minimizes scar
tissue formation. In addition to im-
proved esthetics, minimal postoper-
ative discomfort was reported. The
case demonstrated in Fig 2 was a
heavy smoker. Despite the reduced
healing potential and tissue vascu-
larity typically associated with heavy
smoking,35 the proposed techniques
have re-established interproximal
papilla between two adjacent im-
plants. The interproximal bone peak
associated with neighboring natural
teeth maintained the distal papillae
of implant restorations. Avoiding in-
vasive surgery is considered one of
the most predictable methods for
soft tissue maintenance.14 The pro-
posed sequence avoided incisions
that repeatedly cross the papillae
and create areas with compromised
vascularization and lead to compro-
mised wound healing and increased
scar tissue formation.36
Careful planning and meticu-
lous execution to maintain healthy
soft tissue should be performed
throughout all procedures, with the
goal of obtaining resilient and less
fibrotic soft tissue. These consider-
ations include atraumatic tissue han-
dling, avoidance of any large flap
reflection, minimal tension during
reapproximation and suturing, ad-
equate tissue hydration, expedient
surgical procedures, and provisional
prostheses that do not compromise
blood supply. Although the data in
this study included a small number
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of patients and implants, the results
to date are comparable to those by
Kan et al,37 who reported on a 2- to
8-year follow-up in a study on max-
illary anterior single implants. Kan
et al37 suggested that in the pres-
ence of proper interproximal em-
brasure form (papilla sparing) and
underlying bony support, a certain
degree of spontaneous papilla re-
generation could occur over time.
Although that study involved im-
mediate placement of implants with
provisionalization, the underlying
concepts are similar to those used
in the current study in which main-
taining soft tissue quality during the
course of implant surgery remained
a critical factor in the papillary main-
tenance and growth observed.
Conclusions
To achieve and maintain the papil-
lary tissue integrity around single or
adjacent implants, careful planning
and meticulous execution of each
procedure is necessary. This pilot
study demonstrates specific incision
designs and soft tissue manage-
ment techniques used at different
stages to achieve maintenance and
regrowth of the interproximal papilla
around single or adjacent implants.
The critical factors for success were
the preservation of the blood sup-
ply to the adjacent papilla, preser-
vation of bone on the teeth adjacent
to the implant, and minimal scar tis-
sue formation. However, long-term
follow-up of prospective studies
with an increased number of cases
are needed to further validate the
results achieved in this case series.
Acknowledgments
The authors reported no conflicts of interest
related to this study.
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Volume 38, Number 1, 2018