|DENTAL SCIENCE - CASE REPORT
|Year : 2015 | Volume
| Issue : 6 | Page : 819-822
Peri-implant soft tissue management: A case report (2 years follow-up) (Patrick Palacci technique revisited)
VR Balaji1, R Lambodharan2, V Lavanya1
1 Department of Periodontics, CSI College of Dental Sciences and Research, Madurai, Tamil Nadu, India
2 Department of Prosthodontics, CSI College of Dental Sciences and Research, Madurai, Tamil Nadu, India
|Date of Submission||28-Apr-2015|
|Date of Decision||28-Apr-2015|
|Date of Acceptance||22-May-2015|
|Date of Web Publication||1-Sep-2015|
V R Balaji
Department of Periodontics, CSI College of Dental Sciences and Research, Madurai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Peri-implant plastic surgery aims at improving the esthetic aspects of smile and masticatory function. Over the years, several techniques such as tissue punch technique, full thickness flaps, and scalloping adjustment of flaps around implants have been employed; it was very difficult to achieve a papilla like formation around implants. These added time and expense of the final results and led to undesirable complications. In order to overcome these difficulties, this case report describes a surgical technique where in papilla like formation and increase in width of attached gingiva around implants can be achieved with a single surgical procedure.
Keywords: Gingiva, implant, peri-implant esthetics, peri-implant surgery
|How to cite this article:|
Balaji V R, Lambodharan R, Lavanya V. Peri-implant soft tissue management: A case report (2 years follow-up) (Patrick Palacci technique revisited). J Pharm Bioall Sci 2015;7, Suppl S2:819-22
|How to cite this URL:|
Balaji V R, Lambodharan R, Lavanya V. Peri-implant soft tissue management: A case report (2 years follow-up) (Patrick Palacci technique revisited). J Pharm Bioall Sci [serial online] 2015 [cited 2019 Dec 15];7, Suppl S2:819-22. Available from: http://www.jpbsonline.org/text.asp?2015/7/6/819/163589
Peri-implant plastic surgery aims at improving the esthetic aspects of smile and masticatory function. Manipulation of soft tissue adjacent to implants enables proper peri-implant tissue healing and can result in soft tissue architecture similar to the healthy gingival anatomy seen around natural teeth. Hence, second stage surgery is considered critical for the long-term esthetic function of the implant.
Over the years, several techniques such as tissue punch technique, full thickness flaps, and scalloping adjustment of flaps around implants have been employed, it was very difficult to achieve a papilla like formation around implants.  Moreover, these procedures were unpredictable and in many cases needed multiple surgeries to reach an esthetic result. These added time and expense of the final results and led to undesirable complications. 
Sullivan et al.  reported that an improved surgical technique is needed to recreate the appearance of interdental papilla around implants. Along with interdental papilla, there should be increased the width of attached gingiva around implants or else there might be a chance to jeopardize the maintenance of soft tissue around implants.  Wennström et al.  reported lack of attached gingiva around implants also resulted in the failure of implants.
This case report describes a surgical technique where in papilla like formation and increase in width of attached gingiva around implants can be achieved with a single surgical procedure.
| Case Report|| |
A 25-year-old female patient who earlier had implant placement in relation to 46 and 47 reported to our department for second stage surgery. This patient was planned for papilla regeneration technique described by Palacci et al.  This technique was reported by Palacci et al. 1992 and Andresean et al. 1994,  in which the attached mucosa at the top of the ridge is moved in a buccal direction at second stage surgery to obtain a papilla like formation and increased bulk of tissue around implants.
| Technique|| |
The following steps are involved in this technique.([Figure 1]-schematic representation)
- Identify the location of the cover screws through the covering mucosa[Figure 2]
- Make an incision at the palatal/lingual aspect of the cover screws, followed by vertical releasing incisions in the buccal direction. It is important to preserve the gingival cuff at neighboring teeth [Figure 3]
- Elevate a full thickness flap in the buccal direction
- Remove the cover screws
- Select proper abutments and connect them to the fixtures [Figure 4]
- Make semilunar bevel incisions in the buccal flap toward each abutment. Start at the distal aspect of the most mesially located implant [Figure 5]
- Disengage the pedicle, and then rotate it 90° in the palatal direction to fill in the inter-implant space [Figure 5]
- Suture the tissues, allowing no tension within the pedicles [Figure 6].
| Discussion|| |
The clinical significance of attached gingiva around implants include
- Prevent spread of inflammation
- Prevents recession of marginal tissue
- Provides tight collar around implants
- Enable patients to maintain good oral hygiene.
This technique answered the above requirements, and yet it is very simple and provided excellent papilla like formation around implants. Moreover, it also provided us increased the volume of gingiva around implants. The healing abutment should be in place for 2 weeks for the tissues to heal like papilla [Figure 7].
The patient was observed every 6 months, till 2 years. After 8 weeks, the final abutments were connected and noted that excellent soft tissue manipulation around implants created a perimucosal soft tissue contour matching the gingival architecture [Figure 8] and [Figure 9]. This thickness of tissue/seal around implants was present even after 1-year follow-up and 2 years follow-up periods [Figure 10].
Mainly because of the thickness of mucosa obtained during the procedure, the patient was able to maintain the soft tissue around the implant with lesser plaque formation. Moreover, a tight tissue barrier was created like natural dentition, which correlated well with the tissue barrier concept postulated by Goldman and Cohen.
Friedman stated that "inadequate" zone of gingiva would facilitate Subgingival plaque formation because of improper pocket closure resulting from the movability of the marginal tissue. The absence of keratinized mucosa increases the susceptibility of peri-implant lesions and plaque-induced destruction. Mehdi Adibrad et al. reported that there is a significant influence of the width of keratinized mucosa on the health of the peri-implant tissues. The absence of adequate keratinized mucosa around implants supporting over dentures was associated with higher plaque accumulation, gingival inflammation, bleeding on probing, and mucosal recession. The thickness obtained with this technique resulting in less plaque accumulation and better maintenance correlated well with the studies reported above.
In order to have better papilla like formation the following should be considered:
- Careful handling of tissues in order to minimize trauma and maximize vascularization
- Bevel incisions in the mobile flaps should be delicate and should vary according to the needs
- Rotated pedicles should be tension free
- Suturing technique should provide a tight and firm connection of pedicles to bone and abutments.
| Conclusion|| |
It is imperative and proved by this case report that the operating surgeon should know the importance of papilla and attached mucosa around the implant. This case report was followed for 2 years and excellent prognosis obtained is very much evident [Figure 11]. This technique is simple and effortless in providing esthetic papilla formation and protective attached mucosa around implants.
| References|| |
Adell R, Lekholm U, Branemark PI. Surigcal procedures. In: Branemark PI, Zarb GA, Albertsson T, editors. Tissue Integrated Prosthesis: Osseointegration in Clinical Dentistry. 9 th
ed. Chicago: Quintessence; 1985. p. 211-32.
Moy PK, Weinlaender M, Kenney EB. Soft-tissue modifications of surgical techniques for placement and uncovering of osseointegrated implants. Dent Clin North Am 1989;33:665-81.
Sullivan D, Kay H, Schwarz M, Gelb D. Esthetic problems in the anterior maxilla. Int J Oral Maxillofac Implants 1994;9 Suppl:64-74.
Andreasen J, Kristerson L, Nilson H, Dahlin K, Schwatz O, Palacci P, et al
. Implants in the anterior region. In: Andreasen JO, Andreasen FM, editors. Textbook and Color Atlas of Traumatic Injuries to the teeth. 3 rd
ed., Ch. 20. Copenhagen: Munksgaard; 1994.
Wennström JL, Bengazi F, Lekholm U. The influence of the masticatory mucosa on the peri-implant soft tissue condition. Clin Oral Implants Res 1994;5:1-8.
Palacci P, Ericsson I, Engstrand P, Rangert B. Optimal Implant Positioning and Soft Tissue Management for the Branemark System. Chicago: Quintessence Publishing Co. Inc.; 1995. p. 59-70.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]