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implants_international magazine of oral implantology No. 1, 2016

| research implants 1 201622 In this context the Precision Drill from the Nobel Biocare kits is particularly helpful. Its sharp point provides considerable precision at the point of en­ try and its small dimensions make it possible to correct any deviations from the ideal axis occurring during the first drilling (Fig. 17). In the vestibular palatal plane, it is essential to prepare a prosthetic treatment plan before insert­ ing the implant because the positioning require­ ments differ: –– for a screwed prosthesis, the axis of the implant is very strictly determined by the point in the cin­ gulum where the screw emerges; –– with a cemented prosthesis, the tolerance is slightly greater as it is possible to make a correc­ tion to the axis by an abutment angled up to 15 degrees or by a Procera type individualized abut­ ment (Fig. 18). “Positiontheimplant underX-raymonitoring.” 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 pending on these deficits, which are taken from three publications: the roll flap developed by Abrams,15 theenvelopetechniqueofPeterRaetzke16 and Carl Misch’s split-finger:17 –– if there is just a horizontal deficit, a modified rolled flap6 can be carried out, without separa­ tion of papillae and without vestibular incisions, the palatal flap being folded into an envelope flap (Figs. 19 to 25). The attraction of this tech­ nique 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 factor 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. This makes it possible to recreate Figs. 27a–c: Clinical and X-ray views, vitroceramic in place. 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. Fig. 27a Fig. 27b Fig. 28 Fig. 29 Fig. 30 Fig. 27c 1201622

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