Interproximal Papillae Reconstruction around Implant Using Subepithelial Connective Tissue Graft in Maxillary Anterior Region: A Case Series
Identifieur interne : 000695 ( Pmc/Corpus ); précédent : 000694; suivant : 000696Interproximal Papillae Reconstruction around Implant Using Subepithelial Connective Tissue Graft in Maxillary Anterior Region: A Case Series
Auteurs : Satish Gupta ; Vikas Deo ; Cecil WilliamsSource :
- Journal of Oral & Maxillofacial Research [ 2029-283X ] ; 2012.
Abstract
The present study was undertaken to evaluate the effectiveness of interproximal papillae reconstruction around early loaded single implant using subepithelial connective tissue graft in maxillary anterior region.
Ten systemically healthy patients (mean age = 29.3 [SD 7.9] years) in need of dental implants in maxillary anterior region were included in the study. Interproximal papillae reconstruction around single implant using subepithelial connective tissue graft was applied. The donor palatal tissue was harvested by a "trap door approach". Subepithelial connective tissue graft was inserted in the pouch created on mesial and distal site of implant. Clinical and radiographic parameters were recorded around the each implant, including papillary height and papillary gingival contour, at baseline, 3 and 6 months after operation.
The mesial papilla height was increased by 1.9 (SD 0.87) mm, P = 0.005 at 3 month and maintained at 1.5 (SD 0.97) mm, P = 0.007 at 6 months. The distal papilla height was increased by 2 (SD 0.66) mm, P = 0.004 at 3 month and maintained at 1.2 (SD 0.78) mm, P = 0.010 at 6 months. Assessment of papilla contour index showed 90% aesthetic success both for mesial and distal papilla at 6 months.
It can be concluded that subepithelial connective tissue graft may be used to successfully augment the gingival papillae adjacent to single tooth implant restoration.
Url:
DOI: 10.5037/jomr.2012.3201
PubMed: 24422008
PubMed Central: 3886102
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PMC:3886102Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Interproximal Papillae Reconstruction around Implant Using Subepithelial Connective Tissue Graft in Maxillary Anterior Region: A Case Series</title><author><name sortKey="Gupta, Satish" sort="Gupta, Satish" uniqKey="Gupta S" first="Satish" last="Gupta">Satish Gupta</name><affiliation><nlm:aff id="aff1"><institution>Department of Periodontology and Implantology, S.P Dental College</institution><addr-line>Wardha</addr-line><country>India.</country></nlm:aff></affiliation></author><author><name sortKey="Deo, Vikas" sort="Deo, Vikas" uniqKey="Deo V" first="Vikas" last="Deo">Vikas Deo</name><affiliation><nlm:aff id="aff2"><institution>Department of Periodontology and Implantology, Government Dental College</institution><addr-line>Jaipur</addr-line><country>India.</country></nlm:aff></affiliation></author><author><name sortKey="Williams, Cecil" sort="Williams, Cecil" uniqKey="Williams C" first="Cecil" last="Williams">Cecil Williams</name><affiliation><nlm:aff id="aff3"><institution>>Department of Prosthodontics, Daswani Dental College</institution><addr-line>Kota</addr-line><country>India.</country></nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">24422008</idno><idno type="pmc">3886102</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3886102</idno><idno type="RBID">PMC:3886102</idno><idno type="doi">10.5037/jomr.2012.3201</idno><date when="2012">2012</date><idno type="wicri:Area/Pmc/Corpus">000695</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000695</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Interproximal Papillae Reconstruction around Implant Using Subepithelial Connective Tissue Graft in Maxillary Anterior Region: A Case Series</title><author><name sortKey="Gupta, Satish" sort="Gupta, Satish" uniqKey="Gupta S" first="Satish" last="Gupta">Satish Gupta</name><affiliation><nlm:aff id="aff1"><institution>Department of Periodontology and Implantology, S.P Dental College</institution><addr-line>Wardha</addr-line><country>India.</country></nlm:aff></affiliation></author><author><name sortKey="Deo, Vikas" sort="Deo, Vikas" uniqKey="Deo V" first="Vikas" last="Deo">Vikas Deo</name><affiliation><nlm:aff id="aff2"><institution>Department of Periodontology and Implantology, Government Dental College</institution><addr-line>Jaipur</addr-line><country>India.</country></nlm:aff></affiliation></author><author><name sortKey="Williams, Cecil" sort="Williams, Cecil" uniqKey="Williams C" first="Cecil" last="Williams">Cecil Williams</name><affiliation><nlm:aff id="aff3"><institution>>Department of Prosthodontics, Daswani Dental College</institution><addr-line>Kota</addr-line><country>India.</country></nlm:aff></affiliation></author></analytic><series><title level="j">Journal of Oral & Maxillofacial Research</title><idno type="eISSN">2029-283X</idno><imprint><date when="2012">2012</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><title>ABSTRACT</title><sec sec-type="objectives"><title>Objectives</title><p>The present study was undertaken to evaluate the effectiveness of
interproximal papillae reconstruction around early loaded single implant
using subepithelial connective tissue graft in maxillary anterior
region.</p></sec><sec sec-type="material and methods"><title>Material and Methods</title><p>Ten systemically healthy patients (mean age = 29.3 [SD 7.9] years) in need of
dental implants in maxillary anterior region were included in the study.
Interproximal papillae reconstruction around single implant using
subepithelial connective tissue graft was applied. The donor palatal tissue
was harvested by a "trap door approach". Subepithelial connective tissue
graft was inserted in the pouch created on mesial and distal site of
implant. Clinical and radiographic parameters were recorded around the each
implant, including papillary height and papillary gingival contour, at
baseline, 3 and 6 months after operation.</p></sec><sec sec-type="results"><title>Results</title><p>The mesial papilla height was increased by 1.9 (SD 0.87) mm, P = 0.005 at 3
month and maintained at 1.5 (SD 0.97) mm, P = 0.007 at 6 months. The distal
papilla height was increased by 2 (SD 0.66) mm, P = 0.004 at 3 month and
maintained at 1.2 (SD 0.78) mm, P = 0.010 at 6 months. Assessment of papilla
contour index showed 90% aesthetic success both for mesial and distal
papilla at 6 months.</p></sec><sec sec-type="conclusions"><title>Conclusions</title><p>It can be concluded that subepithelial connective tissue graft may be used to
successfully augment the gingival papillae adjacent to single tooth implant
restoration.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Albrektsson, T" uniqKey="Albrektsson T">T Albrektsson</name></author><author><name sortKey="Gottlow, J" uniqKey="Gottlow J">J Gottlow</name></author><author><name sortKey="Meirelles, L" uniqKey="Meirelles L">L Meirelles</name></author><author><name sortKey="Ostman, Po" uniqKey="Ostman P">PO Ostman</name></author><author><name sortKey="Rocci, A" uniqKey="Rocci A">A Rocci</name></author><author><name sortKey="Sennerby, L" uniqKey="Sennerby L">L Sennerby</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Testori, T" uniqKey="Testori T">T Testori</name></author><author><name sortKey="Meltzer, A" uniqKey="Meltzer A">A Meltzer</name></author><author><name sortKey="Del, Fabbro M" uniqKey="Del F">Fabbro M Del</name></author><author><name sortKey="Zuffetti, F" uniqKey="Zuffetti F">F Zuffetti</name></author><author><name sortKey="Troiano, M" 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<front><journal-meta><journal-id journal-id-type="nlm-ta">J Oral Maxillofac Res</journal-id><journal-id journal-id-type="iso-abbrev">J Oral Maxillofac Res</journal-id><journal-id journal-id-type="publisher-id">JORM</journal-id><journal-title-group><journal-title>Journal of Oral & Maxillofacial Research</journal-title></journal-title-group><issn pub-type="epub">2029-283X</issn><publisher><publisher-name>Stilus Optimus</publisher-name><publisher-loc>Kaunas, Lithuania</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">24422008</article-id><article-id pub-id-type="pmc">3886102</article-id><article-id pub-id-type="publisher-id">v3n2e1ht</article-id><article-id pub-id-type="doi">10.5037/jomr.2012.3201</article-id><article-categories><subj-group subj-group-type="heading"><subject>Original Paper</subject></subj-group></article-categories><title-group><article-title>Interproximal Papillae Reconstruction around Implant Using Subepithelial Connective Tissue Graft in Maxillary Anterior Region: A Case Series</article-title></title-group><contrib-group><contrib id="contrib1" contrib-type="author"><name><surname>Gupta</surname><given-names>Satish</given-names></name><xref ref-type="aff" rid="aff1">1</xref></contrib><contrib id="contrib2" contrib-type="author" corresp="yes"><name><surname>Deo</surname><given-names>Vikas</given-names></name><xref ref-type="aff" rid="aff2">2</xref></contrib><contrib id="contrib3" contrib-type="author"><name><surname>Williams</surname><given-names>Cecil</given-names></name><xref ref-type="aff" rid="aff3">3</xref></contrib></contrib-group><aff id="aff1" rid="aff1"><sup>1</sup><institution>Department of Periodontology and Implantology, S.P Dental College</institution><addr-line>Wardha</addr-line><country>India.</country></aff><aff id="aff2" rid="aff2"><sup>2</sup><institution>Department of Periodontology and Implantology, Government Dental College</institution><addr-line>Jaipur</addr-line><country>India.</country></aff><aff id="aff3" rid="aff3"><sup>3</sup><institution>>Department of Prosthodontics, Daswani Dental College</institution><addr-line>Kota</addr-line><country>India.</country></aff><author-notes><corresp>Vikas Deo,
<addr-line>224, Padmawati B, Kings Road, Jaipur, 302019</addr-line><country>India</country><phone>+919950991918</phone>Fax: +911512230316<email>drvikas_81@yahoo.com</email></corresp></author-notes><pub-date pub-type="collection"><season>Apr-Jun</season><year>2012</year></pub-date><pub-date pub-type="epub"><day>1</day><month>7</month><year>2012</year></pub-date><volume>3</volume><issue>2</issue><elocation-id>e1</elocation-id><history><date date-type="received"><day>3</day><month>1</month><year>2012</year></date><date date-type="accepted"><day>10</day><month>4</month><year>2012</year></date></history><permissions><copyright-statement> Copyright © Gupta S, Deo V, Williams C. Published in the JOURNAL OF ORAL & MAXILLOFACIAL RESEARCH
(http://www.ejomr.org), 1 July 2012.</copyright-statement><copyright-year>2012</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc-nd/3.0/"><license-p>This is an open-access article, first published in the JOURNAL OF
ORAL & MAXILLOFACIAL RESEARCH, distributed under the terms of the
Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 Unported
License (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by-nc-nd/3.0/">http://creativecommons.org/licenses/by-nc-nd/3.0/</ext-link>), which permits unrestricted non-commercial use, distribution, and
reproduction in any medium, provided the original work and is properly
cited. The copyright, license information and link to the original
publication on <ext-link ext-link-type="uri" xlink:href="http://www.ejomr.org">http://www.ejomr.org</ext-link> must be included.</license-p></license></permissions><self-uri xlink:type="simple" xlink:href="http://www.ejomr.org/JOMR/archives/2012/2/e1/v3n2e1ht.htm"></self-uri><abstract><title>ABSTRACT</title><sec sec-type="objectives"><title>Objectives</title><p>The present study was undertaken to evaluate the effectiveness of
interproximal papillae reconstruction around early loaded single implant
using subepithelial connective tissue graft in maxillary anterior
region.</p></sec><sec sec-type="material and methods"><title>Material and Methods</title><p>Ten systemically healthy patients (mean age = 29.3 [SD 7.9] years) in need of
dental implants in maxillary anterior region were included in the study.
Interproximal papillae reconstruction around single implant using
subepithelial connective tissue graft was applied. The donor palatal tissue
was harvested by a "trap door approach". Subepithelial connective tissue
graft was inserted in the pouch created on mesial and distal site of
implant. Clinical and radiographic parameters were recorded around the each
implant, including papillary height and papillary gingival contour, at
baseline, 3 and 6 months after operation.</p></sec><sec sec-type="results"><title>Results</title><p>The mesial papilla height was increased by 1.9 (SD 0.87) mm, P = 0.005 at 3
month and maintained at 1.5 (SD 0.97) mm, P = 0.007 at 6 months. The distal
papilla height was increased by 2 (SD 0.66) mm, P = 0.004 at 3 month and
maintained at 1.2 (SD 0.78) mm, P = 0.010 at 6 months. Assessment of papilla
contour index showed 90% aesthetic success both for mesial and distal
papilla at 6 months.</p></sec><sec sec-type="conclusions"><title>Conclusions</title><p>It can be concluded that subepithelial connective tissue graft may be used to
successfully augment the gingival papillae adjacent to single tooth implant
restoration.</p></sec></abstract><kwd-group><kwd>dental papilla</kwd><kwd>single-tooth dental implant</kwd><kwd>early dental implant loading</kwd><kwd>tissue grafts</kwd><kwd>tissue transplants.</kwd></kwd-group></article-meta></front><body><sec><title>INTRODUCTION</title><p>In the past two decades, replacement of missing teeth with implant supported
prostheses has become a widely accepted treatment for the oral rehabilitation of
partially or fully edentulous patients. High clinical success rates with the
original implant protocols have given clinicians and researcher's confidence to
further develop and refine the osseointegrated technique and use of implants in
increasingly more challenging situations and on broader indications [<xref ref-type="bibr" rid="B1">1</xref>,<xref ref-type="bibr" rid="B2">2</xref>].
Earlier a submerged healing period of 3 - 6 months was considered a prerequisite for
achieving osseointegration of titanium implants. However, the time required for
treatment, the need for additional surgical procedures, and the need for indefinite
period of temporization is disadvantages of the standard protocol. During the past
10 - 15 years, clinical studies have reported the successful outcome of early and
immediate loading of implants in various clinical situations [<xref ref-type="bibr" rid="B3">3</xref>].</p><p>With the growing use of implant-supported oral rehabilitation in the partially
edentulous patient and single tooth restoration, emphasis has now changed towards
achieving predictable aesthetic success particularly in maxillary anterior region
and patients who may show the peri-implant soft tissue when smiling and speaking
[<xref ref-type="bibr" rid="B4">4</xref>]. Establishing a soft tissue contour
with an intact interproximal papillae around implant retained restoration is
challenging and failure to achieve these harmonious relationships of soft tissue
around implant may lead to unaesthetic appearance [<xref ref-type="bibr" rid="B5">5</xref>].</p><p>Various soft-tissue surgical procedures have been introduced in an attempt to
re-create the papillae around implants. Price and Price [<xref ref-type="bibr" rid="B6">6</xref>] presented a case report describing the use of subepithelial
connective tissue graft (SCTG) to restore the gingival papillae and augment soft
tissue ridge adjacent to dental implant. Azzi et al. [<xref ref-type="bibr" rid="B7">7</xref>] proposed periodontal plastic surgical procedure to improve the soft
tissue aesthetics. Therefore, the present study was undertaken to evaluate the
effectiveness of interproximal papillae reconstruction around early loaded single
implant using subepithelial connective tissue graft in maxillary anterior
region.</p></sec><sec sec-type="materials|methods"><title>MATERIAL AND METHODS</title><p><bold>Study population</bold></p><p>Ten subjects (8 males and 2 females; age 19 to 45 years, mean age = 29.3 [SD 7.9]
years) in need of dental implants were consecutively enrolled in the study from
April 1, 2010 to June 1, 2012. All participants have read and signed informed
consent form. The study protocol was approved by the Ethical Committee of D.M.I.M.S,
Wardha. Subjects with severe systemic health problems, e.g., uncontrolled diabetes,
immunodeficiency diseases, and heavy smokers (more than 10 cigarettes a day), were
excluded from the study. A relationship between implant complications and smoking
has proved to be a significant factor [<xref ref-type="bibr" rid="B9">9</xref>]. The
subjects had to fulfil the following criteria to be included in the study: good
general health, a need for single implant placement in the maxillary anterior
sextant, an absence of adjacent implant sites or prosthetic restorations, and the
availability of complete clinical records. The width of alveolar process at implant
recipient site was stated to be ≥ 6 mm and height ≥ 10 mm. The bone
quality should be D-1, D-2 or D-3 [<xref ref-type="bibr" rid="B8">8</xref>].</p><p>Seven subjects had maxillary central incisor missing and three had maxillary canine
missing. All the patients were treated by one stage implant and early loading
protocol along with reconstruction of papillae by SCTG. Ten screw-shaped, titanium
integrated surface (Hi-Tec Implants<sup>®</sup>, Herzlia, Israel) were placed accordingly. The
implant surgery was done by one oral surgeon and restorations were made by one
prosthodontist. The sites were evaluated at three time points: at baseline, at 3 and
6 months after dental implants placement.</p><p><bold>Initial therapy</bold></p><p>After proper examination and diagnosis, initial therapy consisting of oral hygiene
instructions, supra- and subgingival scaling, and root planing were performed.
Plaque control instructions were repeated until the patients achieve a plaque score
of ≤ 1. Before entering the surgical phase, diagnostic cast of each patient
was prepared to establish maxillary-mandibular relationship. A diagnostic wax up of
the missing natural tooth and a clear acrylic resin surgical drill guide was
prepared to facilitate correct implant placement. The clinical photograph,
periapical and panoramic radiographs were obtained.</p><p>Recording of clinical indices were carried out by the operator and the cross examiner
in all the patients. Mean of these values were obtained for the assessment of the
result.</p><p><bold>Periimplant tissue assessment</bold></p><p><bold><italic>Clinical assessment</italic></bold></p><p>Clinical parameters recorded around each implant includes modified plaque index (PI)
[<xref ref-type="bibr" rid="B10">10</xref>], modified bleeding index (PBI),
probing pocket depth (PPD) and clinical attachment level (CAL) [<xref ref-type="bibr" rid="B11">11</xref>,<xref ref-type="bibr" rid="B12">12</xref>].
PPD and CAL were recorded at four sites (i.e. mesial, buccal, distal and lingual) of
each implant by using a calibrated manual periodontal probe (UNC 15, Hu-Friedy,
Chicago, USA). The implant shoulder was used as a reference line for the location of
the mucosal margin. In addition, the width of the keratinized gingiva (WKG) was
assessed on mid-buccal aspect of each implant.</p><p><bold><italic>Radiographic assessment</italic></bold></p><p>Photographic measurements of radiographs were obtained at baseline, 3 months and 6
months after operation. Photographic measurements were transferred to data sheets
and analyzed statistically. To assess the changes at the interproximal alveolar
crestal bone height, the distance from the implant shoulder to the most coronal bone
to implant contact (DIB) was determined both at the mesial and distal aspect of each
implant (Figures <xref ref-type="fig" rid="fig1">1</xref> and <xref ref-type="fig" rid="fig2">2</xref>) [<xref ref-type="bibr" rid="B13">13</xref>,<xref ref-type="bibr" rid="B15">15</xref>]. Chances of having complete papillae around
single tooth implant supported crown are minimal when distance between contact
points to the crest of the alveolar bone is more than 5 mm [<xref ref-type="bibr" rid="B16">16</xref>].</p><fig id="fig1" orientation="portrait" position="float"><label>Figure 1</label><caption><p>Periapical radiograph of patient #1 showing the distance from the implant
shoulder to the most coronal bone to implant contact (DIB) both at the
mesial and distal aspect of the implant (white arrow).</p></caption><graphic xlink:href="jomr-03-e1-g001"></graphic></fig><fig id="fig2" orientation="portrait" position="float"><label>Figure 2</label><caption><p>Periapical radiograph of patient #2 showing the distance from the implant
shoulder to the most coronal bone to implant contact (DIB) at the distal
aspect of the implant (white arrow).</p></caption><graphic xlink:href="jomr-03-e1-g002"></graphic></fig><p><bold>Interproximal / interimplant papillae measurement</bold></p><p><bold><italic>Papillary height measurement</italic></bold></p><p>In order to measure the soft tissue changes in an apicocoronal dimension, clinical
photograph were obtained before surgery as well as at both periods of follow-up. The
reference line was drawn over the preoperative photograph from the most apical
points of gingival margins on the tooth [<xref ref-type="bibr" rid="B4">4</xref>].
Similarly, reference line was reproduced postoperatively on clinical photograph and
any change in vertical dimension of the soft tissue height both on mesial and distal
surface were calculated by comparing preoperative and postoperative measurements
(Figures <xref ref-type="fig" rid="fig3">3</xref> and <xref ref-type="fig" rid="fig4">4</xref>).</p><fig id="fig3" orientation="portrait" position="float"><label>Figure 3</label><caption><p>Papillary height measurement at baseline.</p></caption><graphic xlink:href="jomr-03-e1-g003"></graphic></fig><fig id="fig4" orientation="portrait" position="float"><label>Figure 4</label><caption><p>Papillary height measurement at 6 months follow-up.</p></caption><graphic xlink:href="jomr-03-e1-g004"></graphic></fig><p><bold><italic>Papillae contour measurement</italic></bold></p><p>Papillae contour was measured by using papilla index score (PIS) for mesial and
distal papillae from the clinical photograph taken preoperatively and
postoperatively (at 3 month and 6 month). The index designates four different levels
indicating the amount of papilla present [<xref ref-type="bibr" rid="B12">12</xref>,<xref ref-type="bibr" rid="B17">17</xref>]. The assessment was
measured from reference line drawn through the highest gingival curvature on the
adjacent teeth on the buccal side. The distance from this line to contact point of
the natural tooth/crown were assessed both on mesial and distal surface of implant
(Figures <xref ref-type="fig" rid="fig5">5</xref> and <xref ref-type="fig" rid="fig6">6</xref>).</p><fig id="fig5" orientation="portrait" position="float"><label>Figure 5</label><caption><p>Papillae contour measurement at baseline.</p></caption><graphic xlink:href="jomr-03-e1-g005"></graphic></fig><fig id="fig6" orientation="portrait" position="float"><label>Figure 6</label><caption><p>Papillae contour measurement at 6 months follow-up.</p></caption><graphic xlink:href="jomr-03-e1-g006"></graphic></fig><p><bold>Other soft tissue assessment</bold></p><p>Discoloration of the soft tissue above the restoration and visible titanium margins
was identified as present or not present. Signs of severe inflammation or fistulas
were also noted. A comparison was made between the situation at the time of
placement and at follow-up. The size of the papilla was determined and classified as
having increased, remained the same, or been reduced during the follow-up period;
and a change of the colour of the soft tissue and/or visible titanium if noted.</p><p><bold>Surgical procedure</bold></p><p><bold><italic>Implant placement</italic></bold></p><p>After infiltration with local anesthetic, a crestal incision was made along the crest
of the ridge using Bard-Parker #12 or #15C surgical blade, bisecting the existing
keratinized mucosa but without splitting the adjacent papillae. Vertical releasing
incisions were made extending to the vestibule. The papillae of the adjacent teeth
were not included in the flap design (<xref ref-type="fig" rid="fig7">Figure
7</xref>). A full thickness flap was raised buccally and palatally exposing the
underlined ridge of the implant site. A surgical drill guide was used for the
precise placement of the pilot drill. After pilot drill application, the osteotomy
was prepared with the corresponding size of parallel drill. The implants were placed
in the recipient site by means of an insertion device. The implant neck was
positioned at the crestal bone level or slightly submerged. The healing abutment
extension of the implant was placed in such a way that the head of the implant
protruded about 2 to 3 mm from the bone crest.</p><fig id="fig7" orientation="portrait" position="float"><label>Figure 7</label><caption><p>Incision excluding papillae of the adjacent teeth.</p></caption><graphic xlink:href="jomr-03-e1-g007"></graphic></fig><p><bold>Papilla reconstruction procedure</bold></p><p><bold><italic>Harvesting of subepithelial connective tissue graft (SCTG)</italic></bold></p><p>A sterile template was utilized to obtain the desired dimensions and shape of the
SCTG from the premolar-molar area. The donor palatal tissue was harvested by a "trap
door approach" from the area between the maxillary first molar and maxillary cuspid.
A template was placed at the recipient site to harvest a graft of the correct
dimensions. An incision was made in the palate that was parallel to the maxillary
premolar and first molar at a distance of approximately 3 mm apical to the gingival
margin. Perpendicular incisions were made to establish the width of the graft for
covering the entire area of furcation. A flap was reflected to expose the underlying
connective tissue. The SCTG was removed with a periosteal elevator. The graft was
then placed on a sterile gauze pad and irrigated with saline. The SCTG was split
into two triangular pieces and modified according the required dimensions.</p><p><bold><italic>Preparation of recipient site</italic></bold></p><p>Tunnelling was performed to create a pouch-like space beneath the buccal flap and a
portion of palatal tissue (<xref ref-type="fig" rid="fig8">Figure 8</xref>) [<xref ref-type="bibr" rid="B7">7</xref>]. On the buccal aspect, pouch was extended by
undermining the attached gingiva beyond mucogingival junction by #15C blade. An
intrasulcular incision was made around the necks of the teeth being treated. The
incision was extended to adjacent tooth, both mesially and distally. This incision
enabled access beneath the buccal gingiva and provided mobility to the pouch [<xref ref-type="bibr" rid="B18">18</xref>]. The cutting edge was directed toward the
bone to dissect the connective tissue apical to the mucogingival line and free the
buccal flap around each tooth. The papillae were also undermined carefully. The
detached buccal gingiva could now move coronally since the connective tissue
detachment was apical and into the mucosal tissue. The care was taken not to
perforate the buccal gingiva. One piece of SCTG was inserted in the pouch created on
mesial site of implant, while other on distal site of implant to protrude both the
papillae 2 - 3 mm coronally [<xref ref-type="bibr" rid="B7">7</xref>,<xref ref-type="bibr" rid="B19">19</xref>]. A suture was placed at one end of the
graft in guiding the graft while pushing through the sulcus and beneath each
interdental papilla (<xref ref-type="fig" rid="fig9">Figure 9</xref>). The border of
the each SCTG was gently pushed into the pouch using a tissue forceps and a packing
instrument. The submerged SCTG was anchored in the interdental papillae area. An
interrupted suture (4.0 Vicryl resorbable sutures) was used to hold the SCTG in
position beneath the gingiva. The SCTG was submerged beneath the buccal flap while
small portion of graft was kept exposed over papillary region (<xref ref-type="fig" rid="fig10">Figure 10</xref>).</p><p>After stabilization of both SCTG, the buccal flap was positioned around the implant
and sutured to the palatal flap using a combination of inverted mattress and
interrupted sutures to obtain primary closure (<xref ref-type="fig" rid="fig11">Figure 11</xref>). The inverted mattress sutures kept the bleeding edges of the
flap together, while the interrupted sutures sealed the edges.</p><fig id="fig8" orientation="portrait" position="float"><label>Figure 8</label><caption><p>Tunnelling beneath the papilla creating a pouch.</p></caption><graphic xlink:href="jomr-03-e1-g008"></graphic></fig><fig id="fig9" orientation="portrait" position="float"><label>Figure 9</label><caption><p>Suture placed to guide the graft beneath interdental papilla.</p></caption><graphic xlink:href="jomr-03-e1-g009"></graphic></fig><fig id="fig10" orientation="portrait" position="float"><label>Figure 10</label><caption><p>Connective tissue graft submerged beneath the flap.</p></caption><graphic xlink:href="jomr-03-e1-g010"></graphic></fig><fig id="fig11" orientation="portrait" position="float"><label>Figure 11</label><caption><p>Connective tissue grafts after suturing.</p></caption><graphic xlink:href="jomr-03-e1-g011"></graphic></fig><p><bold>Postoperative care</bold></p><p>Patients were prescribed antibiotics (Amoxicillin, 500 mg tds for 1 week) and
analgesics (Ibuprofen, 400 mg bd for 1 week). Sutures were removed 7 to 10 days
after surgery. Patients were instructed not to brush in the treated area and to
rinse twice daily with chlorhexidine digluconate 0.12% (Periogard, Colgate) for 10
days. The final impression was made one week after surgery using high viscosity
vinyl polysiloxane. Within 15 days, an appropriate customized abutment was fixed and
permanent restoration was finally cemented (<xref ref-type="fig" rid="fig12">Figure
12</xref>).</p><fig id="fig12" orientation="portrait" position="float"><label>Figure 12</label><caption><p>Final restoration placed.</p></caption><graphic xlink:href="jomr-03-e1-g012"></graphic></fig><p><bold>Statistical analysis</bold></p><p>The means and standard deviations (M [SD]) values were calculated for all clinical
parameters including PPD, CAL, GR, PI, PBI, and radiographic marginal bone loss
(DIB). Parametric Student's paired test and non-parametric Wilcoxon test was used to
compare data from baseline to those at 3 months and at 6 months for all the
patients. The significance level was P < 0.05.</p></sec><sec sec-type="results"><title>RESULTS</title><p>All implants achieved initial stability under 35 Ncm of insertion torque. During the
course of the study, wound healing was uneventful. No implants had to be removed.
None of the selected patients had dropped out before the termination of the
study.</p><p><bold>Clinical assessment</bold></p><p>The mean full mouth plaque index (FMPI) and full mouth papilla bleeding index (FMPBI)
examination at 3 and 6 month study periods revealed continuous improvement (<xref ref-type="table" rid="T1">Table 1</xref>).</p><table-wrap id="T1" orientation="portrait" position="float"><label>Table 1</label><caption><p>Comparison of clinical parameters at implant sites between 3 months and 6
months of follow-up</p></caption><table frame="hsides" rules="groups" width="570"><thead><tr><td rowspan="1" colspan="1"><bold>Clinical parameters</bold></td><td align="center" rowspan="1" colspan="1"><bold>3 months</bold><break></break>M (SD) </td><td align="center" rowspan="1" colspan="1"><bold>6 months</bold><break></break>M (SD) </td><td align="center" rowspan="1" colspan="1"><bold>Difference</bold><break></break>M (SD) </td><td align="center" rowspan="1" colspan="1"><bold>P<sup>a</sup> value</bold></td></tr></thead><tbody><tr><td rowspan="1" colspan="1"> Probing pocket depth (PPD) </td><td align="center" rowspan="1" colspan="1"> 2.95 (0.36) </td><td align="center" rowspan="1" colspan="1"> 2.55 (0.43) </td><td align="center" rowspan="1" colspan="1"> 0.40 (0.56) </td><td align="center" rowspan="1" colspan="1"> Ns<sup>b</sup></td></tr><tr><td rowspan="1" colspan="1"> Clinical attachment level (CAL) </td><td align="center" rowspan="1" colspan="1"> 2.85 (0.47) </td><td align="center" rowspan="1" colspan="1"> 2.55 (0.59) </td><td align="center" rowspan="1" colspan="1"> 0.30 (0.42) </td><td align="center" rowspan="1" colspan="1"> Ns<sup>b</sup></td></tr><tr><td rowspan="1" colspan="1"> Width of keratinized gingiva (WKG )</td><td align="center" rowspan="1" colspan="1"> 6.30 (2.26) </td><td align="center" rowspan="1" colspan="1"> 6.20 (2.20) </td><td align="center" rowspan="1" colspan="1"> 0.10 (0.31) </td><td align="center" rowspan="1" colspan="1"> Ns<sup>b</sup></td></tr><tr><td rowspan="1" colspan="1"> Plaque index (PI) </td><td align="center" rowspan="1" colspan="1"> 0.81 (0.10) </td><td align="center" rowspan="1" colspan="1"> 0.58 (0.18) </td><td align="center" rowspan="1" colspan="1"> 0.23 (0.12) </td><td align="center" rowspan="1" colspan="1"> 0.007<sup>c</sup></td></tr><tr><td rowspan="1" colspan="1"> Papillary bleeding index (PBI) </td><td align="center" rowspan="1" colspan="1"> 0.84 (0.10) </td><td align="center" rowspan="1" colspan="1"> 0.49 (0.20) </td><td align="center" rowspan="1" colspan="1"> 0.36 (0.16) </td><td align="center" rowspan="1" colspan="1"> 0.008<sup>c</sup></td></tr></tbody></table><table-wrap-foot><fn><p><sup>a</sup>Tested between 3 and 6 months value.</p><p><sup>b</sup>Nonsignificant, non-parametric Wilcoxon paired test.</p><p><sup>c</sup>Significant, non-parametric Wilcoxon paired test.</p><p>M (SD) = mean (standard deviation).</p></fn></table-wrap-foot></table-wrap><p>In all the patients, the mean PPD at 3 months of follow-up was 2.95 (SD 0.36) mm and
at 6 months, it was reduced to 2.55 (SD 0.43) mm (<xref ref-type="table" rid="T1">Table 1</xref>). Non-parametric Wilcoxon test indicated difference (P >
0.05) in mean PPD reduction (0.40 [SD 0.56] mm) between 3 to 6 months period.</p><p>The mean CAL of 2.85 (SD 0.47) mm was recorded at 3 months and 2.55 (SD 0.59) mm at 6
months of follow-up (<xref ref-type="table" rid="T1">Table 1</xref>). The mean CAL
gain of 0.30 (SD 0.42) mm at 6 months period was nonsignificant (P > 0.05).</p><p>The mean WKG at 3 months was 6.30 (2.26) mm, which was slightly decreased at 6 months
to 6.20 (SD 2.20) mm (<xref ref-type="table" rid="T1">Table 1</xref>). The
difference in the WKG (0.10 [SD 0.31] mm) between 3 and 6 months periods was
nonsignificant (P > 0.05).</p><p><bold>Radiographic assessment</bold></p><p>Radiographic crestal bone level (DIB) of mesial and distal surfaces of implants at
baseline and bone loss at 3 and 6 months for all patients are presented in <xref ref-type="table" rid="T2">Table 2</xref>. The evaluation of mean DIB at implant
site on mesial surface at baseline (3.5 [SD 0.70] mm) and at 3 months (4.0 [SD 0.66]
mm) revealed statistically significant (P = 0.025) mean bone loss of 0.5 (SD 0.67)
mm. At 6 month period, the value of the DIB was increased to 4.7 (SD 1.05) mm with
the statistically significant (P = 0.01) mean bone loss of 1.2 (SD 0.98) mm in
comparison to baseline data.</p><table-wrap id="T2" orientation="portrait" position="float"><label>Table 2</label><caption><p>Changes of mean radiographic bone level (mm) at implant site on mesial
and distal surfaces from baseline to 3 and 6 months of follow-up</p></caption><table frame="hsides" rules="groups" width="665"><thead><tr><th rowspan="1" colspan="1"> Surface </th><th rowspan="1" colspan="1"> Baseline </th><th rowspan="1" colspan="1"> 3 months </th><th rowspan="1" colspan="1"> Bone loss </th><th rowspan="1" colspan="1"> P<sup>a</sup> value </th><th rowspan="1" colspan="1"> 6 months </th><th rowspan="1" colspan="1"> Bone loss </th><th rowspan="1" colspan="1"> P<sup>a</sup> value </th></tr></thead><tbody><tr><td align="center" rowspan="1" colspan="1"><bold>Mesial</bold><break></break>M (SD) </td><td align="center" rowspan="1" colspan="1"> 3.5 (0.70) </td><td align="center" rowspan="1" colspan="1"> 4.0 (0.66) </td><td align="center" rowspan="1" colspan="1"> 0.5 (0.67) </td><td align="center" rowspan="1" colspan="1"> P = 0.025<sup>b</sup></td><td align="center" rowspan="1" colspan="1"> 4.7 (1.05) </td><td align="center" rowspan="1" colspan="1"> 1.2 (0.98) </td><td align="center" rowspan="1" colspan="1"> P = 0.01<sup>b</sup></td></tr><tr><td align="center" rowspan="1" colspan="1"><bold>Distal</bold><break></break>M (SD) </td><td align="center" rowspan="1" colspan="1"> 3.6 (0.51) </td><td align="center" rowspan="1" colspan="1"> 4.2 (0.42) </td><td align="center" rowspan="1" colspan="1"> 0.6 (0.53) </td><td align="center" rowspan="1" colspan="1"> P = 0.034<sup>b</sup></td><td align="center" rowspan="1" colspan="1"> 5.4 ± 1.17 </td><td align="center" rowspan="1" colspan="1"> 1.8 (1.02) </td><td align="center" rowspan="1" colspan="1"> P = 0.007<sup>b</sup></td></tr></tbody></table><table-wrap-foot><fn><p><sup>a</sup>Tested between baseline and at 3 and 6 months.</p><p><sup>b</sup>Significant, non-parametric Wilcoxon paired test.</p><p>M (SD) = mean (standard deviation).</p></fn></table-wrap-foot></table-wrap><p>The mean DIB at distal implant surface at baseline was 3.6 (SD 0.51) mm, and at 3
months of follow-up it increased to 4.2 (SD 0.42) mm with statistically significant
(P = 0.034) mean bone loss of 0.6 (SD 0.53) mm. At 6 months follow-up, the mean DIB
was further increased to 5.4 (SD 1.17) mm with statistically significant (P = 0.007)
mean bone loss of 1.8 (SD 1.02) mm.</p><p><bold>Interproximal / interimplant papillae measurement</bold></p><p><bold><italic>Papillary height (PH) measurement</italic></bold></p><p>The PH measurement of mesial and distal papilla of all individual patients at
baseline, 3 months and 6 months of follow-up are shown in <xref ref-type="table" rid="T3">Table 3</xref>. The mean mesial PH at baseline was 2.30 (SD 0.48) mm
and statistically significantly increased (1.90 [SD 0.87] mm, P = 0.005) at 3 months
up to 4.20 (SD 0.91) mm. At 6 months of follow-up, mean mesial PH (3.80 [SD 0.91]
mm) was slightly decreased as compared to 3 months; however, when comparison was
made between 6 month and baseline PH value, the mean mesial PH was increased by 1.50
(SD 0.97) mm and the difference was found to be statistically significant (P =
0.007).</p><table-wrap id="T3" orientation="portrait" position="float"><label>Table 3</label><caption><p>Changes of papillary height (mm) from baseline to 3 and 6 months of
follow-up</p></caption><table frame="hsides" rules="groups" width="680"><thead><tr><th rowspan="1" colspan="1"> Surface </th><th rowspan="1" colspan="1"> Baseline </th><th rowspan="1" colspan="1"> 3 months </th><th rowspan="1" colspan="1"> Gain in PH </th><th rowspan="1" colspan="1"> P<sup>a</sup> value </th><th rowspan="1" colspan="1"> 6 months </th><th rowspan="1" colspan="1"> Gain in PH </th><th rowspan="1" colspan="1"> P<sup>a</sup> value </th></tr></thead><tbody><tr><td align="center" rowspan="1" colspan="1"><bold>Mesial</bold><break></break>M (SD) </td><td align="center" rowspan="1" colspan="1"> 2.3 (0.48) </td><td align="center" rowspan="1" colspan="1"> 4.2 (0.91) </td><td align="center" rowspan="1" colspan="1"> 1.9 (0.87) </td><td align="center" rowspan="1" colspan="1"> P = 0.005<sup>b</sup></td><td align="center" rowspan="1" colspan="1"> 3.8 (0.91) </td><td align="center" rowspan="1" colspan="1"> 1.5 (0.97) </td><td align="center" rowspan="1" colspan="1"> P = 0.007<sup>b</sup></td></tr><tr><td align="center" rowspan="1" colspan="1"><bold>Distal</bold><break></break>M (SD) </td><td align="center" rowspan="1" colspan="1"> 2.3 (0.48) </td><td align="center" rowspan="1" colspan="1"> 4.3 (0.67) </td><td align="center" rowspan="1" colspan="1"> 2 (0.66) </td><td align="center" rowspan="1" colspan="1"> P = 0.004<sup>b</sup></td><td align="center" rowspan="1" colspan="1"> 3.5 (0.70) </td><td align="center" rowspan="1" colspan="1"> 1.2 (0.78) </td><td align="center" rowspan="1" colspan="1"> P = 0.01<sup>b</sup></td></tr></tbody></table><table-wrap-foot><fn><p><sup>a</sup>Tested between baseline and at 3 and 6 months.</p><p><sup>b</sup>Significant, non-parametric Wilcoxon paired test.</p><p>M (SD) = mean (standard deviation).</p><p>PH = papillary height.</p></fn></table-wrap-foot></table-wrap><p>The mean distal PH at baseline was 2.30 (SD 0.48) mm and at 3 months it increased (2
[SD 0.66] mm, P = 0.004) up to 4.3 (SD 0.67) mm. At 6 months period, mean distal PH
(3.5 [SD 0.70] mm) was slightly decreased as compared to 3 months; however, when
comparison was made between baseline and 6 month value, the mean distal PH was
statistically significant increased by 1.2 (SD 0.78) mm, P = 0.01.</p><p><bold><italic>Papillary contour (PC) measurement</italic></bold></p><p>The PC measurement of mesial and distal papilla of all individual patients at
baseline, 3 months and 6 months of follow-up are shown in <xref ref-type="table" rid="T4">Table 4</xref>. Only one patient showed complete loss of papilla on
both mesial and distal surface due to severe interproximal bone loss at 6 month
period.</p><table-wrap id="T4" orientation="portrait" position="float"><label>Table 4</label><caption><p>Mean papilla index score at baseline, 3 months and 6 months of
follow-up</p></caption><table frame="hsides" rules="groups" width="365"><thead><tr><th rowspan="1" colspan="1"> Surface </th><th rowspan="1" colspan="1"> Baseline </th><th rowspan="1" colspan="1"> 3 month </th><th rowspan="1" colspan="1"> 6 month </th></tr></thead><tbody><tr><td align="center" rowspan="1" colspan="1"><bold>Mesial</bold><break></break>M (SD) </td><td align="center" rowspan="1" colspan="1"> 1.3 (0.48) </td><td align="center" rowspan="1" colspan="1"> 2.7 (0.48) </td><td align="center" rowspan="1" colspan="1"> 2.8 (0.63) </td></tr><tr><td align="center" rowspan="1" colspan="1"><bold>Distal</bold><break></break>M (SD) </td><td align="center" rowspan="1" colspan="1"> 1.4 (0.51) </td><td align="center" rowspan="1" colspan="1"> 2.5 (0.52) </td><td align="center" rowspan="1" colspan="1"> 2.4 (0.69) </td></tr></tbody></table><table-wrap-foot><fn><p>M (SD) = mean (standard deviation).</p><p>Statistically significant (P < 0.05, non-parametric Wilcoxon paired
test) papilla index score changes.</p></fn></table-wrap-foot></table-wrap><p><xref ref-type="table" rid="T5">Table 5</xref> shows percentage of papilla index
scores at baseline and follow-ups. The frequencies of scores = 0 (failure) and 4
(hypertrophic) were 0% to both mesial and distal papilla. The frequency of a score =
1 (aesthetic failure) was present at 70% for mesial and 60% for distal papilla at
baseline and became only 10% for both mesial and distal papilla at 6 months
postoperatively. The frequency of a score = 2 (average aesthetic result) was present
at 30% for mesial and 40% for distal papilla at baseline and became 30% for mesial
and 50% for distal papilla at 3 months of follow-up. It improved at 6 months
becoming 0% for mesial and 40% for distal papilla. The frequency of a score 3
(aesthetic success) was 0% at baseline for both papillae while at 3 months, it
improved to 70% for mesial and 50 % for distal. At 6 months, it further improved to
90% for mesial and 50% for distal papilla.</p><table-wrap id="T5" orientation="portrait" position="float"><label>Table 5</label><caption><p>Percentage of papilla index score at baseline, 3 months and 6 months of
follow-up</p></caption><table frame="hsides" rules="groups" width="510"><thead><tr><th rowspan="2" colspan="1"> Time </th><th colspan="2" rowspan="1"> Score 1<break></break>(aesthetic failure) </th><th colspan="2" rowspan="1"> Score 2<break></break>(average aesthetic) </th><th colspan="2" rowspan="1"> Score 3<break></break>(aesthetic success) </th></tr><tr><th rowspan="1" colspan="1"> Mesial </th><th rowspan="1" colspan="1"> Distal </th><th rowspan="1" colspan="1"> Mesial </th><th rowspan="1" colspan="1"> Distal </th><th rowspan="1" colspan="1"> Mesial </th><th rowspan="1" colspan="1"> Distal </th></tr></thead><tbody><tr><td align="center" rowspan="1" colspan="1"><bold>Baseline</bold></td><td align="center" rowspan="1" colspan="1"> 70% </td><td align="center" rowspan="1" colspan="1"> 60% </td><td align="center" rowspan="1" colspan="1"> 30% </td><td align="center" rowspan="1" colspan="1"> 40% </td><td align="center" rowspan="1" colspan="1"> 0% </td><td align="center" rowspan="1" colspan="1"> 0% </td></tr><tr><td align="center" rowspan="1" colspan="1"><bold>3 months</bold></td><td align="center" rowspan="1" colspan="1"> 0% </td><td align="center" rowspan="1" colspan="1"> 0% </td><td align="center" rowspan="1" colspan="1"> 30% </td><td align="center" rowspan="1" colspan="1"> 50% </td><td align="center" rowspan="1" colspan="1"> 70% </td><td align="center" rowspan="1" colspan="1"> 50% </td></tr><tr><td align="center" rowspan="1" colspan="1"><bold>6 months</bold></td><td align="center" rowspan="1" colspan="1"> 10% </td><td align="center" rowspan="1" colspan="1"> 10% </td><td align="center" rowspan="1" colspan="1"> 0% </td><td align="center" rowspan="1" colspan="1"> 0% </td><td align="center" rowspan="1" colspan="1"> 90% </td><td align="center" rowspan="1" colspan="1"> 90% </td></tr></tbody></table></table-wrap></sec><sec sec-type="discussion"><title>DISCUSSION</title><p>The purpose of the present study was to evaluate the effectiveness of interproximal
papillae reconstruction around single implant in maxillary anterior region by using
SCTG. The study also emphasized the effectiveness of SCTG in terms of gain in
vertical interproximal / interimplant papillary height and the success rate of early
loaded implant by assessing periimplant changes using clinical and radiographic
parameters. The results showed that papillae reconstruction procedure using SCTG at
the time of implant placement resulted in statistically significant increase in
papillary height in mesial and distal papilla and that functional loading of early
implants as early as 15 days resulted in implant stability using clinical and
radiographic measures.</p><p>Each patient showed good oral hygiene level and a healthy gingival condition
throughout the duration of the study, as reflected by the low FMPI and FMPBI
score.</p><p>In the present study, the survival rate of implants was found to be 100% at 6 months
follow-up. Findings in the present study are comparable with previous reported
studies. De Rouck et al. [<xref ref-type="bibr" rid="B15">15</xref>] assessed
implant survival rate and aesthetic outcome 1 year after immediate placement and
provisionalization of single-tooth implants in the maxillary anterior region and
reported 97% success rate in 30 patients. Norton [<xref ref-type="bibr" rid="B16">16</xref>] reported 96.4% survival rate for immediately loaded implants with
observation period of 20.3 months (range 13 - 30 months) after implant
placement.</p><p>In the present study, the mean crestal bone loss at 6 months was found to be 1.2 (SD
0.98) mm and 1.8 (SD 1.02) mm on mesial and distal surface of implant respectively
and is comparable with previous reported studies. Turkyilmaz et al. [<xref ref-type="bibr" rid="B17">17</xref>] reported the average marginal bone loss of
0.7 mm for one stage implant at one year recall. Schwartz et al. [<xref ref-type="bibr" rid="B18">18</xref>] reported statistically significant (P <
0.05) bone loss around the implants placed in the maxilla, as compared to those in
mandible in edentulous patients. Higher mean marginal bone loss on mesial and distal
surfaces in the present study could be due to the fact that all the implants were
placed in maxillary anterior region. Bone loss occurs mostly in first year after
surgery, as reported by Weber et al. [<xref ref-type="bibr" rid="B19">19</xref>].
Authors showed that a large percentage of initial bone loss occurred during the
first month in one stage implant [<xref ref-type="bibr" rid="B19">19</xref>]. After
the first year of function, an immediate restoration did not seem to cause a greater
average amount of bone loss.</p><p>In the present study, the mean CAL observed at 3 months was 2.85 (SD 0.47) mm and
2.55 (SD 0.59) mm at 6 months. The difference (0.30 [SD 0.42] mm) between 3 months
and 6 months values was not statistically significant (P > 0.05). Similar
observations have been made by several other investigators [<xref ref-type="bibr" rid="B20">20</xref>,<xref ref-type="bibr" rid="B21">21</xref>].</p><p>Management of the papillae during implant placement does not always allow predictable
soft tissue wound healing and aesthetic integration of the prosthetic crown. This
may result in aesthetic failures. In the present study, papillae reconstruction was
performed using SCTG during implant placement. PH as well as papillae contour
measurements were recorded by using PIS [<xref ref-type="bibr" rid="B12">12</xref>].</p><p>In the present study, mean PH increased up to 1.9 (SD 0.87) mm and 2 (SD 0.66) mm for
mesial and distal papilla respectively at 3 month after papillae reconstruction
procedure. At 6 month, mean gain of PH decreased up to 1.5 (SD 0.007) mm for mesial
papilla and 1.2 (SD 0.01) mm for distal papilla, due to shrinkage of soft tissue.
Grossberg [<xref ref-type="bibr" rid="B4">4</xref>] attempted to reconstruct the
papillae around implant by creating a midline double pedicle flap during second
stage surgery and reported papillae reconstruction in 4 out of 12 patients in the
range of 0.4 to 2.3 mm. Though the mean papillary gain was not significant, he
suggested the use of fixed reference line to assess the PH.</p><p>In the present study, 90% of the mesial papilla and 50% of distal papilla showed
(PIS-3) complete regeneration while 10% of mesial papilla and 50% of distal papilla
showed (PIS-2) partially regenerated papilla at 6 months follow-up. Price and Price
[<xref ref-type="bibr" rid="B6">6</xref>] reported a case in which he used SCTG
for soft tissue augmentation along with papillae reconstruction around single tooth
implant restoration. Pouch was created within the buccal flap and SCTG were sutured
and complete gingivopapillary unit was moved coronally. He reported completely
filled papillae with provisional restoration provided considerable aesthetic
results. Azzi et al. [<xref ref-type="bibr" rid="B7">7</xref>] created a pouch in
the buccal flap and SCTG was inserted beneath the papillae and reported adequate
thickening of the existing gingiva and successful reconstruction of interdental
papillae around implant-supported restoration.</p><p>In the present study, 90% of the mesial papillae and 50% of the distal papillae
showed complete regeneration at 6 months follow-up. This difference could be
explained by the fact that there was more marginal bone loss on distal surface (1.8
[SD 1.02)] mm) than mesial surface (1.2 [SD 0.98] mm) at 6 months follow-up.</p><p>Creating the aesthetic implant restoration is a multifaceted puzzle requiring
ingenious treatment strategies. Further development in surgical techniques,
microsurgery, tissue engineering, growth factor and implant material will assist us
in achieving more predictable results in the future.</p></sec><sec sec-type="conclusions"><title>CONCLUSIONS</title><p>From the analysis of the results, and within the limitations of the present study, it
can be concluded that a subepithelial connective tissue graft may be used to
successfully augment the gingival papillae adjacent to single tooth implant
restoration and that one stage early loading implant protocol resulted in
predictable survival rate.</p></sec></body><back><ack><sec sec-type="acknowledgments and disclosure statements"><title>ACKNOWLEDGMENTS AND DISCLOSURE STATEMENTS</title><p>The authors declare that they have no conflict of interests.</p></sec></ack><ref-list><title>REFERENCES</title><ref id="B1"><label>1</label><element-citation publication-type="other"><person-group person-group-type="author"><name><surname>Albrektsson</surname><given-names>T</given-names></name><name><surname>Gottlow</surname><given-names>J</given-names></name><name><surname>Meirelles</surname><given-names>L</given-names></name><name><surname>Ostman</surname><given-names>PO</given-names></name><name><surname>Rocci</surname><given-names>A</given-names></name><name><surname>Sennerby</surname><given-names>L</given-names></name></person-group><source>Survival of NobelDirect implants: an analysis of 550 consecutively
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