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18 — issue 1/2015 Implant Dentistry Article precisionatthepointofentryanditssmall dimensionsmakeitpossibletocorrectany deviations from the ideal axis occurring during the first drilling (Fig. 17). In the vestibular palatal plane, it is es- sential to prepare a prosthetic treatment plan before inserting the implant because the positioning requirements differ: – for a screwed prosthesis, the axis of theimplantisverystrictlydetermined bythepointinthecingulumwherethe screw emerges; – with a cemented prosthesis, the tol- erance is slightly greater as it is pos- sible to make a correction to the axis by an abutment angled up to 15 de- grees or by a Procera type individu- alised abutment (Fig. 18). Position the implant under X-Ray monitoring. Soft tissue management Whether the soft tissue management is carried out at the time the implant is put in place or when it is exposed, the choice of surgical technique depends on an ex- amination of the initial situation: – horizontal deficit of soft tissue that couldresultintheunderlyingtitanium being visible; – vertical deficit in the papillae that could result in unsightly black trian- gles. Differentsurgicaltechniquescanbeused, depending on these deficits, which are takenfromthreepublications:therollflap developed by Abrams15, the envelope technique of Peter Raetzke16 and Carl Misch’s split-finger:17 – if there is just a horizontal deficit, a modified rolled flap6 can be carried out, without separation of papillae and without vestibular incisions, the palatal flap being folded into an en- velope flap (Figs. 19 to 25). The at- traction of this technique forthe pa- tient is that a second operation site to take a graft is not required. In ad- dition, it makes it possible to recre- ate a root eminence, considered al- ready20 years ago bySilverstein and Lefkove18 to be an important factor for the aesthetic outcome (Figs. 26 and 27a to c); – where there is a vertical deficit, a crestal W-shaped incision as de- scribed by Carl Misch17 is indicated. This makes it possible to recreate an anatomical gingival architecture while, as a first step, creating two vestibular neo-papillae (Fig. 28). Af- ter separating the sections, the palatal tissue (finger) is divided into two to make two palatal half-papil- lae, joined one on one with their vestibular counterparts (Fig. 29); – where there is a combined deficit, the same incisions are combined with a buried connective vestibular graft. Provided that there is suffi- cient volume, the graft is taken from the maxillary tuberosity, since this area has the advantage of providing graft tissue that is more dense, opaque and less adipose than the palate and, in addition, results in less postoperative pain. If the graft is transferred in a V or Y-shape, it can support the newly formed papillae. The shape of the palatal incision can be modified to a Y-shape to assist rotation of the palatal half papilla (Fig. 31). If the thickness of the buccal gingival tis- sues has not been augmented or if col- lagen substitutes are used that do not have the opacity characteristics of tuberosity connective tissue, the aes- thetic outcome can be compromised. If there is recession of the external table orthe titanium abutment underthin con- nective tissue, the grey titanium colour can be seen through the gum as a grey halo above the crown collar, which is detrimental to the aesthetic appearance (Figs. 32 and 33). Systematically augment the thickness of buccal connective tissue. Fig.17 Fig.19 Fig.20 Fig.21 Fig.22 Fig.18 Editorial note: A complete list of references is available from the publisher. This article appeared in the Éditions CdP prosthetic journal, No 167, September 2014.