IMMEDIATE IMPLANT PLACEMENT

Sulcular and submarginal incision, involving 2 teeth distal to the tooth to be extracted. No vertical incisions are performed.

 

Soft tissue margin of the tooth to be extracted more apically placed than the homologous natural tooth

 

 

IMPLANT POSITION 

VERTICAL: 3 to 4mm from the soft tissue margin (dictated by adjacent teeth)

BUCCO-LINGUAL: outer surface of the implant 2mm to 3mm palatally to the bone envelope

 

Suture the graft to the inner surface of the flap, as if it was a marionette suture.

 

PROCEDURE

Incision the papillae: split thickness leaving a good amount of connective tissue on the anatomical papillae

 

After that dissect along the buccal bone full thickness

 

After the flap is detached from the buccal bone we go again split thickness beyond the mucogingival junction, first periosteal releasing incision is a conventional deep one, then, with the blade parallel to the mucosa and keeping it very superficial, detaching the muscles that are attached to the alveolar mucosa, you can see the blade through the transparency of the mucosa.

 

ANATOMICAL PAPILLAE DESEPITHELIALIZATION

First with the blade and then microsurgical scissors

Zuchelli arta tarde 1, very important from minute 1’20’’

 

SOFT TISSUE GRAFT

Should be placed, ideally, 1mm more coronal than the soft tissue margin, sutured to the base of the anatomical papillae - this isn’t a problem on the delayed approach.

Should include both mesial and distal papillae

The flap should completely cover the graft

 

 

Suture the graft to the inner surface of the flap on the immediate implant placement

Anatomical papillae are more fragile, because they belong to the extracted tooth, so on immediate implant placement we are not suturing the graft to the anatomical papillae, we are suturing the graft to the base of the surgical papillae:

Base of the surgical papilla (entry at the buccal) - graft - needle back through the inner surface of  the flap - knot

 

Horizontal mattress suture

 

This allows a submarginal positioning of the graft and the inner aspect of the surgical papillae will be entirely available to join the outer aspect of the anatomical desepithelialized papillae.

 

Only the flap will advance maintaining the graft 1mm apical to the soft tissue margin, this will promote papilla growth in thickness at first and then in height (creeping).

 

Sling suture around adjacent teeth to CAF

Very important from minute 2’05’’

Perforate buccal mesial - sling - perforate buccal distal - sling - knot

 

 

 

Suture of the papillae of the implant site is last:

2 single sutures one shot perforates buccal and palatal, one at the mesial papilla and the other at the distal papilla.

The second suture to make the flap advancement sling suture