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ePaper created 2015-05-29, 13:18:43 | version 1.38.0
I technique _ first part of an implant treatment _for a screwed prosthesis, the axis of the implant is verystrictlydeterminedbythepointinthecingulum where the screw emerges; _withacementedprosthesis,thetoleranceisslightly greater as it is possible to make a correction to the axis by an abutment angled up to 15 degrees or by a Procera type individualized 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 examination of the initial situation: _horizontal deficit of soft tissue that could result in the underlying titanium being visible; _vertical deficit in the papillae that could result in unsightly black triangles. Different surgical techniques can be used, de- pendingonthesedeficits,whicharetakenfromthree publications: the roll flap developed by Abrams,15 the envelope technique of Peter Raetzke16 and Carl Misch’s split-finger:17 _if there is just a horizontal deficit, a modified rolled flap6 canbecarriedout,withoutseparationofpapil- lae and without vestibular incisions, the palatal flap being folded into an envelope flap (Figs. 19 to 25). The attraction of this technique for the patient is that a second operation site to take a graft is not required. In addition, it makes it possible to recreate a root eminence, considered already 20 years ago by Silverstein and Lefkove18 to be an important fac- tor for the aesthetic outcome (Figs. 26 & 27a to c); _where there is a vertical deficit, a crestal W-shaped incision as described by Carl Misch17 is indicated. Thismakesitpossibletorecreateananatomicalgin- gival architecture while, as a first step, creating two vestibular neo-papillae (Fig. 28). After separating thesections,thepalataltissue(finger)isdividedinto twotomaketwopalatalhalf-papillae,joinedoneon one with their vestibular counterparts (Fig. 29); _wherethereisacombineddeficit,thesameincisions are combined with a buried connective vestibular graft. Provided that there is sufficient volume, the graft is taken from the maxillary tuberosity, since thisareahastheadvantageofprovidinggrafttissue thatismoredense,opaqueandlessadiposethanthe 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 tissues has not been augmented or if collagen substitutes are used that do not have the opacity characteristics of tuberosity connective tissue, the aesthetic outcome can be compromised. If there is recession of the exter- nal table or the titanium abutment under thin con- Fig. 28_Initial incision creating two vestibular half papillae. Fig. 29_Suture of half papillae (situation in Fig. 1). Fig. 30_De-epithelialisation tuberosity graft. 18 I cone beam2_2015 Fig. 28 Fig. 29 Fig. 30