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science & practice 25th EAO Annual Scientific Meeting 16 www.dental-tribune.com The Dental Tribune International Magazines Shipping Address Name Address Zip Code, City Country E-mail Date, Signature PayPal Credit Card Credit Card Number Expiration Date Security Code CAD/CAM Clinical Masters* cosmetic dentistry** implants laser ortho** roots Journal of Oral Science & Rehabilitation*** Fax: +49 341 48474 173 E-mail: subscriptions@dental-tribune.com EUR 44 per year (4 issues per year; incl. shipping and VAT for customers in Germany) and EUR 46 per year (4 issues per year; incl. shipping for customers outside Germany). * EUR 12 per year (1 issue per year; incl. shipping and VAT for customers in Germany) and EUR 14 per year (1 issue per year; incl. shipping for customers outside Germany). ** EUR 22 per year (2 issues per year; incl. shipping and VAT for customers in Germany) and EUR 23 per year (2 issues per year; incl. shipping for customers outside Germany). *** EUR 200 per year (4 issues per year; incl. shipping and VAT). Your subscription will be renewed automatically every year until a written cancellation is sent to Dental Tribune International GmbH, Holbeinstr. 29, 04229 Leipzig, Germany, six weeks prior to the renewal date. I would like to subscribe to SUBSCRIBE NOW! AD alveolar X-ray equipment, portable generators such as the AnyRay II (VATECH) are available on the mar- ket, which allow you to produce intra- operative images (Fig. 16). In this context the Precision Drill from the Nobel Biocare kits is particu- larly helpful. Its sharp point provides considerable precision at the point of entry 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 inserting the implant because the positioning re- quirements differ: – for a screwed prosthesis, the axis of the implant is very strictly deter- mined by the point in the cingulum where the screw emerges; – with a cemented prosthesis, the tolerance is slightly 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). Soft tissue management Whether the soft tissue manage- ment is carried out at the time the im- plant is put in place or when it is ex- posed, the choice of surgical tech- nique depends on an examination of the initial situation: – horizontal deficit of soft tissue that could result in the underlying tita- nium being visible; – vertical deficit in the papillae that could result in unsightly black tri- angles. Different surgical techniques can be used, depending on these deficits, which are taken from three publica- tions: 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 can be carried out, without separation of papillae 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, consid- ered already 20 years ago by Silver- stein and Lefkove18 to be an impor- tant factor for the aesthetic out- come (Figs. 26 & 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 pal- atal 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, re- sults 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-papillae (Fig. 31). If the thickness of the buccal gin- gival tissues has not been augmented or if collagen substitutes are used that do not have the opacity charac- teristics of tuberosity connective tis- sue, the aesthetic outcome can be compromised. If there is recession of the external table or the titanium abutment under thin connective tis- sue, the grey titanium colour can be seen through the gum as a grey halo above the crown collar, which is det- rimental to the aesthetic appearance (Figs. 32 & 33). Conclusion The aesthetic fundamentals for an implant are in the preprosthetic surgical stages of the treatment. Any approximation in the location of the implant in such a narrow implant cor- ridor, any lack of support for papillae or any deficiency in the thickness of hard or soft tissues, will result in aes- thetic problems. The prosthetic stages allow optimisation of the result as re- gards the gingival context but any er- ror in the surgical stage will often be impossible to correct during the pros- thetic stages. For this reason it is vital to approach this first part of the im- plant treatment for a lateral incisor with thoroughness and precision. Editorial note: A list of references is available from the publisher. This article was originally published in the Éditions CdP prosthetic journal, No 167, September 2014, and the Clin- ical Masters Magazine No 1/2015. Fig. 27a Fig. 27b Fig. 27c Fig. 28 Fig. 29 Fig. 30 Fig. 31 Fig. 32 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. 31: Insertion of connective graft buried under the papillae. Fig. 32: Clinical outcome in a case of gummy smile. Fig. 33: Insufficient soft tissue thickness alters the chromatic outcome. Author Dr Philippe Russe, former assistant at the Reims University and Hospital. He runs his private practice in Reims, France. Dr Patrick Limbour, MCU-PH, Head of department of oral surgery, Pontchaillou University Hospital, Rennes, France. Fig. 33 Fax: +4934148474173