The International Journal of Periodontics & Restorative Dentistry

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 161

New Surgical Protocol to Create Interimplant Papilla:

The Preliminary Results of a Case Series

Stuart Froum, DDS1 Replacing missing teeth with den-

Miltiadis Lagoudis, DMD2 tal implants has become a viable
Giovanni Molina Rojas, DDS3 solution for conventional fixed or
Takanori Suzuki, DDS, PhD4 removable prosthodontics.1-3 How-
Sang-Choon Cho, DDS5 ever, the application of the prin-
ciples of osseointegration to single
The aim of this study was to introduce a new surgical technique to regenerate the missing teeth and partial edentu-
papilla adjacent to multiple or single implants using a novel instrument and a new lism has increased patient esthetic
incision design. A total of 10 consecutively treated patients with maxillary anterior demands. An important aspect of
implant-supported provisional restorations and missing interproximal papillae
the success criteria for dental im-
received a subepithelial connective tissue graft. The recipient site was prepared
with a buccal incision apical to the mucogingival junction and to the defective plants in the esthetic zone involves
papilla, and a palatal incision, followed by buccolingual tunneling performed the establishment of soft tissue
with a translingual curette (EBINA). A total of 10 sites were treated and evaluated contour with an intact interdental
pre- and postoperatively with the papilla score based on the Jemt classification. papilla and a gingival outline that
The final prosthesis was delivered 3 months after the papilla regeneration is harmonious with the gingival
surgical procedure. An average improvement in papilla index score from 0.8 to
silhouette of the adjacent healthy
2.4 was found after an average follow-up period of 16.3 months. This case series
demonstrated that interimplant papilla regeneration can be successful over a dentition.4,5
period of 11 to 30 months postloading. Long-term prospective studies on tissue Lack of interdental papilla can
stability and esthetic outcomes are needed to corroborate the findings in this lead to cosmetic deformities, pho-
study. Int J Periodontics Restorative Dent 2016;36:161–168. doi: 10.11607/prd.2603 netic difficulties, and food impac-
tion.6 The vertical distance from the
crest of the bone to the height of
the interproximal papilla between
adjacent implants,7 between im-
Clinical Professor and Director of Clinical Research, Ashman Department of Periodontology
1
plant and natural tooth, and be-
and Implant Dentistry, New York University College of Dentistry, New York, New York, USA.
2Implant Resident, Ashman Department of Periodontology and Implant Dentistry, tween implant and pontic has been
New York University College of Dentistry, New York, New York, USA. measured and reported.8 When
3Former Implant Resident, Ashman Department of Periodontology and Implant Dentistry,
this distance was 5 mm or less be-
New York University College of Dentistry, New York, New York, USA.
4Clinical Assistant Professor of Advanced Program for International Dentists in Implant
tween two adjacent teeth, the pa-
Dentistry, Ashman Department of Periodontology and Implant Dentistry, pilla completely filled this space
New York University College of Dentistry, New York, New York, USA. approximately 100% of the time.9
5Clinical Assistant Professor and Director of Advanced Program for International Dentists
In cases where an implant was adja-
in Implant Dentistry and Co-Director of Clinical Research, Ashman Department of
Periodontology and Implant Dentistry, New York University College of Dentistry,
cent to a natural tooth, the average
New York, New York, USA. height was reported to be 4.5 mm.8
However, the average height of tis-
Correspondence to: Dr Stuart Froum, 17 W 54th Street, Suite 1C/D,
sue over the crest of bone between
New York, NY 10019, USA. Fax: 212-246-7599. Email: dr.froum@verizon.net
two adjacent implants was report-
 ©2016 by Quintessence Publishing Co Inc. ed to be 3.4 mm.7 Thus, in cases of

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162
Table 1 Classification of
interproximal
papilla18
Classification Description
0 No papilla is present
1 Less than half of the height
of the papilla is present
2 Half or more of the height
of the papilla is present
3 The papilla fills up the
entire proximal space
4 The papillae are
hyperplastic
two adjacent anterior implants, de-
ficient interimplant papillae often
occur.
Numerous methods have been
proposed to regenerate papilla.
However, due to compromised
blood supply and scar tissue forma-
tion, these techniques were report-
ed to be unpredictable.10–14 Villareal
et al in 2010 described a predictable
approach for papilla regeneration
using careful and gentle soft tissue
manipulation during surgery.21 The
protocol included papilla-sparing in-
cisions and minimal reflection of the
flap.11,12 The underlying concept was
to preserve the blood supply to the
adjacent papilla and soft tissue and
maintain soft tissue quality.10–15 For
this reason, it was suggested that su-
tures through or close to the papilla
should be avoided as they can cause
trauma and inflammation, negatively
affecting the outcome of the papilla
regeneration procedure.14–17
The purpose of the present
case series was to introduce a new
surgical technique to regenerate
the papilla adjacent to multiple or
single implants during the provi-
The International Journal of Periodontics & Restorative Dentistry
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sionalization stage, and to report
the clinical results.
Materials and methods
The clinical data in this study was ex-
tracted as deidentified information
from the implant database ID from
the routine treatment of patients at
the Ashman Department of Peri-
odontology and Implant Dentistry
at the New York University College
of Dentistry Kriser Dental Center.
The Office of Quality Assurance at
the New York University College of
Dentistry certified the ID. This study
is in compliance with the Health In-
surance Portability and Accountabil-
ity Act requirements and approved
by the University Committee on Ac-
tivities Involving Human Subjects.
Study subjects
Ten consecutively treated cases from
the implant database that required
treatment with multiple or single
maxillary anterior implants were in-
cluded in this study. Patients that
presented with implant-supported
provisional crowns or bridges and
who had undergone the papilla re-
generation procedure between Au-
gust 2011 and August 2012 were
included in this retrospective case se-
ries. The subjects were 3 males and 7
females (average age: 45 years). The
treatment sites were papillae be-
tween adjacent implants, between
an implant and an adjacent natural
tooth, and between an implant and
an adjacent pontic site, from position
13 to 23 (canine to canine).
The inclusion criteria were as
follows:
1. Presence of an implant-
supported provisional
restoration
2. Absence of interproximal
papilla, Jemt classification 0 to 1
(Table 1)18
3. Missing papilla in anterior
maxilla, between adjacent
implants, between an implant
and an adjacent natural tooth,
or between an implant and an
adjacent pontic site
The exclusion criteria were as
follows:
1. Pregnant or lactating
2. Active periodontal disease in
the remaining dentition
3. Systemic diseases or
medications that could alter the
tissue healing around dental
implants
4. Unwillingness to commit to
a long-term post-therapy
maintenance program
Measurements
Following provisional placement,
measurements were made inter-
proximally from the contact point of
the treatment site, vertically to the
crestal gingiva. Measurements were
made with a North Carolina probe
(Hu-Friedy) and recorded according
to the Jemt classification. Measure-
ments were made independently by
two calibrated investigators to en-
sure accuracy.
 163

Fig 1a  Clinical view of a provisional prosthesis with missing papilla Fig 1b  Oblique buccal incision above the mucogingival junction.
between the implant area of #12 and the pontic area of #11, after a
previous soft tissue grafting procedure.

Fig 1c  Palatal incision. Fig 1d  Translingual curette.

In no case did the investigators
differ in their opinion of the 0 or 1
classification. At each recall visit fol-
lowing placement of the final resto-
ration, the same two investigators
measured and classified the papillae.
Surgical procedure
Preoperative antibiotics were given
orally 1 hour prior to surgery (amoxi-
cillin 2 g, or clindamycin 600 mg, for
patients allergic to penicillin). Follow-
ing the administration of local anes-
thesia (lidocaine with epinephrine
1:100,000, Henry Schein), the provi-
sional restoration was removed and
the embrasure space at the site of
the planned papillary augmentation
was opened. Sufficient interproxi-
mal embrasure widening was per-
formed prior to surgery to achieve
an esthetically acceptable restora-
tion with adequate papilla volume
(Fig 1a). Prior to modification of the
provisional restoration, the papilla in
the deficient site was indexed using
the Jemt classification.18 The provi-
sional restoration was removed and
a full-thickness oblique incision was
made in the vestibular mucosa, api-
cal to the deficient papilla area (Fig
1b). Another full-thickness oblique
incision was made on the palatal
side (Fig 1c). The incisions were
made in an oblique direction from
distal to mesial at a distance from
the papilla to preserve the blood
supply of the mucosa at the recipi-
ent site.13 The translingual curette
(TLC) (EBINA), a modified and twice
angulated curette (Fig 1d), provided
access to the tunnel apically and
easy access to the interproximal
area without causing any damage
to the tissue. It was gently inserted
into the buccal incision, elevating

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164

Figs 2a to 2c  Periosteal elevation using

the translingual curette.

a b c

Fig 3  Connective tissue graft with the stabilization suture. Fig 4  Clinical view of the graft placement over
the defect.

the periosteum or flap, and used to
create a subperiosteal tunnel toward
the crest of the ridge, coronally to
the interproximal area (Fig 2). Care
was taken to avoid excessive eleva-
tion, keeping the dissection limited
to the defect size. The same eleva-
tion was performed on the palatal
side, creating a tunnel between the
buccal and lingual incisions.
Following local anesthesia,
a subepithelial connective tissue
graft was harvested from the palate
according to the Langer and Calag-
na and the Hürzeler and Weng
techniques,19,20 and the donor site
was sutured with 4/0 chromic gut
sutures (Ethicon). Two 4/0 chromic
gut sutures were placed at the me-
sial and distal margins of the sub-
epithelial connective tissue graft to
facilitate the insertion and stabili-
zation of the graft over the defect
(Fig 3). The graft was inserted into
the recipient site through the buc-
cal incision and pulled under the
papillae through the lingual incision
(Fig 4). Once the graft was correctly
positioned over the interproximal
papilla area, the resorbable 4/0
chromic gut sutures placed at the
mesial and distal margins of the
connective tissue graft were used
to secure it in position and then
close the buccal and lingual entry
incisions (Fig 5). The postoperative
protocol consisted of antibiotics,
amoxicillin 500 mg or clindamycin
150 mg three or four times a day,
respectively, for 1 week, and anal-
gesics (ibuprofen 600 mg every 4
to 6 hours). The patient was also in-
structed to use 0.12% chlorhexidine
rinses twice a day starting 24 hours
after surgery for 2 weeks. Postop-
erative care instructions, including
a soft diet and oral hygiene proce-
dures, were given to the patient.
The patient was told to avoid brush-
ing and flossing in the surgical area
and to use rinses of 0.9% saline 5
to 6 times a day and chlorhexidine
twice a day only. A follow-up ex-
amination was performed 7 to 14
days postoperatively (Fig 6). After
a healing period of 3 months, the
final restoration was delivered (Figs
7a to 7d). The final restoration was
carefully designed following the
exact interproximal contour of the
provisional. In sites where the pa-
pillae was created but did not fully
fill the interproximal area, a slight
elongation of the contact point
was made in the final restoration.
All patients were recalled every 3
months following final restorations
for follow-up examinations and
periapical radiographs. The papilla

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 165

a b
Figs 5a and 5b  Schematic illustration of the graft placement over Fig 6  A follow-up examination 7 to 14 days postoperative.
the defect.

Fig 7a  Clinical view prior to insertion of the final prosthesis. Fig 7b  Clinical view of the insertion of the final prosthesis.

Fig 7c (above)  Clinical view of the final prosthesis.

Fig 7d (right)  Radiographic control of the implant area #12 and the
pontic area #11 after insertion of the final prosthesis.

height was again measured by the ed using the Jemt papilla classifica- In another case, a 55-year-old
same two investigators and record- tion during each recall. Asian woman presented with a chief

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166

Fig 8a  Deficient class 0 papillae between Fig 8b  Twelve months postsurgery, the Fig 8c  Radiographic control of left
splinted left central and lateral implants. reformed papillae closed the space and a new central and lateral implants show-
provisional was made with no alteration to the ing the bone level relative to the
contact point length. contact point.

Table 2 Results of the technique for the 10 patients included in the study
Interproximal Implant/pontic/ Starting score Ending score Duration
Subject papillae sites* tooth Abutment (Jemt classification) (Jemt classification) (mo)
 1 12, 11 I-I Titanium 1 3 30
 2 12, 11 I-T Titanium 1 3 11
 3 11, 21 I-I Titanium 0 1 10
 4 11, 21 I-P Titanium 1 3 10
 5 21, 22 P-I Titanium 1 3 12
 6 21, 22 I-I Zirconia 0 3 18
 7 12, 11 I-P Titanium 1 2 12
 8 12, 11 I-P Titanium 1 1 12
 9 21, 22 I-I Zirconia 1 3 18
10 21, 22 I-I Titanium 1 2 30
Mean: 0.8 Mean: 2.4 Mean: 16.3
*FDI tooth numbering system. I = implant; P = pontic; T = tooth.

complaint of “black space between Results Discussion

her implants” (Fig 8a). She present-
ed with two restored and splinted
implants in the left central and lat-
eral areas. The papilla was classified
as Jemt class 0. The same papilla re-
generation procedure as described
previously was performed. Twelve
months postsurgery the papillae
completely filled the space (Jemt: 3)
and a new two-unit restoration was
fabricated (Figs 8b and 8c).
The results of the present case se-
ries are summarized in Table 2. The
10 reported cases were followed for
an average period of 16.3 months
(range: 11 to 30 months), with an av-
erage improvement of Jemt papilla
score from 0.8 to 2.4 (range: 0 to 3).
In only one case was no improve-
ment observed.
Several surgical methods have been
advocated for papilla regeneration.
Palacci et al suggested a full-thick-
ness flap elevation from the buc-
cal and palatal sides of the ridge
and 90-degree rotation to fill the
interproximal space adjacent to an
implant.10 Adriaenssens et al intro-
duced the “palatal sliding strip flap”
to form papillae between implants

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and natural teeth in the anterior
area of the maxilla. This technique
includes sliding the palatal mucosa
in a labial direction.12 Nemcovsky
et al used a U-shaped incision.14 Ar-
noux et al described several tissue
augmentation techniques at stage 1
and stage 2 surgery to enhance sin-
gle tooth esthetics.15 The reported
surgical procedures were not pre-
dictable due to the limited blood
supply and presence of scar tissue
as a result of surgical trauma.21–23
Chao presented the pinhole
surgical technique (PST) as a root
coverage procedure. The PST re-
quired no releasing incision, sharp
dissection, or suturing. Similar to
the technique presented in this ar-
ticle, it was proposed as a minimally
invasive procedure with the main
difference being that PST uses one
vestibular incision, using a biore-
sorbable membrane (BM) (Bio-Gide,
Geistlich) or acellular dermal matrix
(ADM) (Alloderm, Biohorizons) and
was described for root coverage.
However, this technique did not ad-
dress or result in any improvement
in the interproximal papilla.24
The present study presents
a technique to improve the pre-
dictability of papilla regeneration
procedures, achieving an average
increase in Jemt papilla score from
0.8 to 2.4. This technique can be
successfully used for papillae be-
tween implants and teeth, between
two adjacent implants, and be-
tween implants and pontic sites. Ac-
cording to the results of the present
study, papilla regeneration between
an implant and a tooth is more pre-
dictable than regeneration between
two adjacent implants. To the pres-
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ent authors’ knowledge, this is the
first study showing a predictable re-
sult for papilla regeneration.
The need for adequate instru-
mentation to achieve the elevation
of the mucoperiosteal tunnel from
a remote incision and to minimize
the chance of perforation led to the
development of the TLC. This in-
strument allows for a full-thickness
reflection minimizing the risk of soft
tissue perforation due to its ana-
tomical design. The TLC facilitated
the soft tissue tunnel preparation,
increasing the predictability of the
regenerative procedure (Figs 1d
and 2). Although 6 of the 10 treated
areas resulted in complete papilla
regeneration, the improvement in 3
of the 4 other cases was either ac-
cepted by the patient or allowed
slight elongation of the contact
point of the final restoration. This
resulted in patient satisfaction with
the esthetic result in all 3 cases. The
one case that failed to show any
gain was retreated and is currently in
the healing phase.
Although further studies are
needed to confirm the stability of
the soft tissue after papilla regen-
eration, this study suggests that the
technique proposed has the ability
to predictably improve and in most
cases achieve papilla integrity be-
tween implants, between implant
and tooth, and between implant
and pontic in the esthetic zone.
Conclusion
Within the limitations of this case
series, the present results show an
average improvement in papilla in-
167
dex of 1.6 (Jemt classification) with
a range of 0.8 to 2.4 in esthetic ar-
eas between two adjacent implants,
between implant and tooth, and be-
tween implant and pontic site. The
papilla regeneration was achieved
with carefully planned incision de-
sign, atraumatic tissue handling,
minimal tension during suturing, and
meticulous home care after surgery.
Further studies with more cases and
longer follow-ups are required to
establish the long-term effective-
ness of this regenerative technique.
Acknowledgments
Dr Cho has a patent pending (no. PCT/
KR2014/007855), for Trans-Lingual Curette
[TLC]).
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