The position of the trapezoidal flap is more coronal in the implant site when compared to the tooth site. 

 

On the tooth, split thickness elevation of the surgical papillae and full thickness elevation of the flap apically to the base of the papillae.

 

On the implant not only the papillae, but also the entire flap is elevated on split thickness, and this is because the flap is so thin and adherent to the implant surface.

 

Deep incision: it detaches the entire alveolar mucosa from the periosteum, it shouldn't go too much apically.

The most important incision is the superficial incision, the blade runs parallel to the alveolar mucosa, very superficially (being careful enough not to perforate the flap) detaching all the muscles and the entire submucosal tissues from the alveolar mucosa.

This is completely different from what we do in bone augmentation, where we include muscles and submucosa in our flap.

 

 

SINGLE IMPLANT

Before starting the surgery it's always better to remove any abutment from the implant, to get better access with the blade and be more precise on the trapezoidal incision.

 

 

SINGLE TOOTH

4mm size in width (apico-coronal size of the graft)

 

GRAFT SIZE

for implant apico-coronally around 8mm

for tooth apico-coronally around 4mm.

For the implant we want the graft to increase the soft tissue thickness to at least 2mm and also mask the implant's metal.

 

 

Graft fixation around tooth, with single interrupted suture to the base of each anatomical papillae.

 

Graft fixation around implant

(15'17'')

with horizontal mattress suture, it enters the graft and in one shot it perforates the entire anatomical papilla, coming ou at the palatal, the needle enters again the palatal (at the same level) perforates the entire anatomic papilla towards the buccal, it does not perforate the graft and the knot is closed.

 

Both on implants and teeth we suture the flap, first at the most apical part of the mesial vertical incision (stretching the flap), 2 simple stitches.

 

 

On teeth

Sling suture

 

On implants

Double sling suture around adjacent teeth (22'32'') 

 

 

 

SINGLE IMPLANT

8mm size in width(apico-coronal size of the graft)

 

 

Flap elevation should be entirely done in split thickness

Deep periosteal incision first to detach the alveolar mucosa from the bone and then very superficial periosteal incision to detach all the muscles from the alveolar mucosa we shift only alveolar mucosa we don't shift the submucosa.

 

This a very different incision from the one done for bone augmentation where you go split and then full thickness an then split again.

 

Position of the graft should be 1mm more coronal than the soft tissue margin, to be able to do it it's important you connect the abutment to the implant, to provide for support.

 

Papillae desepithelialization first with a blade and the final portion with microsurgical scissors, towards their more palatal aspect.

 

Graft fixation is different from the one we do around teeth, because papillae are flat.

 

2 single interrupted sutures at the base of the vertical releasing incisions.

 

2 sling sutures to the two adjacent teeth, mesial and distal.

Sling sutures 6 0

 

Creeping of the papillae

Increase papillae height increasing soft tissue thickness