Johannes Kleinheinz Andre Buchter Birgit Kruse-Losler Dieter Weingart Ulrich Joos Authors afliations: Johannes Kleinheinz, Andre Buchter, Birgit Kruse- Losler, Ulrich Joos, Department of Cranio- Maxillofacial Surgery, University of Muenster, Muenster, Germany Dieter Weingart, Department of Maxillofacial and Plastic Surgery, Katharinenhospital, Stuttgart, Germany Correspondence to: Johannes Kleinheinz Department of Cranio-Maxillofacial Surgery University of Muenster Waldeyerstr. 30 D-48149 Muenster Germany Tel.: 49 251 834 7003 Fax: 49 251 834 7184 e-mail: joklein@uni-muenster.de Key words: implant dentistry, incision design, supply area, vascularization Abstract Objectives: The delivery of an adequate amount of blood to the tissue capillaries for normal functioning of the organ is the primary purpose of the vascular system. Preserving the viability of the soft tissue segment depends on the soft tissue incision being properly designed in order to prevent impairment of the circulation. A knowledge of the course of the vessels as well as of their supply area are crucial to the decision of the incision. The aim of this study was to visualize the course of the arteries using different techniques, to perform macroscopic- and microscopic analyses, and to develop recommendations for incisions in implant dentistry. Material and methods: The vascular systems of seven edentulous human cadavers were ushed out and lled with either red-colored rubber bond or Indian ink and formalin mixture. After xation a macroscopic preparation was performed to reveal the course, distribution and supply area of the major vessels. In the area of the edentulous alveolar ridge specimens of the mucosa were taken and analyzed microscopically. Results: The analyses revealed the major features of mucosal vascularization. The main course of the supplying arteries is from posterior to anterior, main vessels run parallel to the alveolar ridge in the vestibulum and the crestal area of the edentulous alveolar ridge is covered by a avascular zone with no anastomoses crossing the alveolar ridge. Conclusion: The results suggest midline incisions on the alveolar ridge, marginal incisions in dentated areas, releasing incisions only at the anterior border of the entire incision line, and avoidance of incisions crossing the alveolar ridge. Surgical disciplines are always confronted with the problem of cutting and therefore damaging healthy soft tissue in order to gain access to the area of interest in the human body. While the access require- ments have not changed over time, the incision techniques have changed (e.g. la- ser (Mausberg et al. 1993; Bryant et al. 1998), electrosurgical knife (Mausberg et al. 1993; Sinha & Gallagher 2003), water scalpel (Siegert 2000) and piezosur- gery (Shelley & Shelley 1986). Irrespective of the applied technique, the surgical access must provide for: (1) optimal visualization of the key area; (2) problem-free expansionof the soft tissue; (3) mobilization of the overlying soft tis- sue to cover the surgical eld; (4) no placement over bony defects or cavities; (5) sufcient vascularization of soft tissue; (6) minimum tissue damage; (7) assured wound healing; (8) minimum esthetic impairment and (9) good tissue covering. Mucosal closure has to protect the bone, the implant or the augmentation material, Copyright r Blackwell Munksgaard 2005 Date: Accepted 24 November 2004 To cite this article: Kleinheinz J, Bu chter A, Kruse-Lo sler B, Weingart D, Joos U. Incision design in implant dentistry based on vascularization of the mucosa. Clin. Oral Impl. Res. 16, 2005; 518523 doi: 10.1111/j.1600-0501.2005.01158.x 518 to establish a connection to the local supply systems as soon as possible, and to avoid infections or dehiscences. The consequences of any incision must always be kept in mind. Unlike embryolo- gical wound healing, where scarless healing is possible (Gary & Longaker 2000), any planned incision or injury of the covering soft tissue after birth will result in scarring which differs from regular skin or mucosa in terms of esthetics, functioning or nutri- tion and may be a weak point in the future. Among many factors, vascularization has proved to be decisive for any kind of tissue regeneration (Arnold & West 1991; End- rich & Menger 2000). Growth, maturation or reconstruction of the body are conceiva- ble without unimpaired vascularization (Folkman & Shing 1992). A knowledge of the course and of the supply area of the arteries is the basis for selection of the appropriate incision. The aim of this study was to establish recommendations for incisions, based on reliable knowledge of the distribution pat- terns and course of the vascular system in the oral mucosa. Material and methods Two different techniques were used to demonstrate the macro- and micro-archi- tecture of the arterial vascular system in seven edentulous human cadavers. A separate description of the venous system was not undertaken because it follows the arterial pathways in most parts of the body. Vascular corrosion cast A total of 150ml of red-colored rubber bond (MR Givul s Revultex, Heinrich Wagner, Bo blingen, Germany) was injected into the external carotid arteries on both sides after ushing out the vascular system with streptolysin solution at a pressure of 200 mm Hg. The head was then immer- sion-xed. This technique allows the de- monstration and macroscopic evaluation of vessels ranging from small calibres upto a diameter of 200mm. After solidication of the elastic substance, the specimens were frozen and cut in medio-sagittal direction. The vascular system of the maxilla and mandible was transected in the vestibular and palatal/lingual planes. The course of the vessels and their relationship to adja- cent anatomic structures and tissues were documented in layers. Indian ink injection In a second attempt 4ml of colored Indian ink and formalin (4%) mixture were in- jected into the facial, lingual and maxillary arteries after ushing out the vascular sys- tem with streptolysin solution passing through the capillary plexus. The colored areas of the mucosa were inspected, photo- graphed and resected in the edentulous area of the alveolar ridge. After cleaning of the specimens according to the method of (Spalteholz 1911) microscopic evaluation of the microvascularization was carried out. Macroscopic evaluation Following macroscopic preparation, single arteries were identied and their position and relationship to adjacent structures and their course from the exit from the bone up to the capillary systemwere described. The ink-stained areas of the mucosa were as- sessed with respect to their extent and borders and were assigned as a supply area to one of the injected arteries. Microscopic evaluation The mucosa of the edentulous alveolar ridge was evaluated microscopically with respect to the distribution and orientation of vessels. Special emphasis was placed on the crestal area where vestibular and oral parts of the mucosa are in direct contact. Results After preparation, the color-marked main vessels were identied and their course and relationship to other tissues and structures described (Fig. 1). After dissolution of the surrounding soft tissue the vessels were demonstrated directly on the underlying bony surface (Fig. 2). The points of exit from the foramen and the anastomoses to other vessels were shown. The results of all cases are summarized in Fig. 3. Vascular territories of the maxilla (Fig. 4) In the posterior part of the maxilla the vestibular gingiva was supplied by branches of the infraorbital artery, and the palatal mucosa by branches of the descending palatine artery. Anteriorly, in the area of the premaxilla, the supply was based on the facial artery regarding the vestibular parts Fig. 1. Course of main arteries in the maxilla after macroscopic preparation. Vessels lled with rubber bond can easily be identied. Fig. 2. After dissolution of soft tissue the relation of vessels and bone is demonstrated. Kleinheinz et al . Incisions in implant dentistry 519 | Clin. Oral Impl. Res. 16, 2005 / 518523 and partially on the infraorbital artery. In 66% palatal parts were supported by the descending palatine artery and in 33% by the anterior superior alveolar artery. Vascular territories of the mandible (Fig. 5) The posterior lateral part of the alveolar ridge was supplied by the facial artery, and the anterior part by the inferior labial artery and in 50% additionally by the mental artery. In 73% of the cases the lingual mucosa was supported exclusively by the submental artery and in 27% additionally by the sublingual artery. Regarding the lingual supply there were overlappings of both sides, whereas overlapping was found in 20% of the cases in the vestibular part covered by the facial artery. Crossing area on the edentulous alveolar ridge (Fig. 6a, b) A visible vestibularoral separation line between the two supply areas at the center of the edentulous segments was demon- strated in edentulous spaces, free-end situa- tions and totally edentulous jaws. Microscopic evaluation of the alveolar mucosa (Fig. 7a, b) The demonstrated gingival branches are arterioles or capillaries, which have the characteristics not of end-arteries but of net-arteries with numerous anastomoses. There is an almost avascular zone in the crestal area of the edentulous alveolar ridge. The descriptions can be summarized into three main vascularization characteristics: (1) The main course of the supplying arteries is from posterior to anterior. (2) These vessels run parallel to the al- veolar ridge in the vestibulum most of the time, only gingival branches stretch to the alveolar ridge. (3) The crestal area of the edentulous alveolar ridge is covered by a 12mm wide avascular zone with no anasto- moses crossing the alveolar ridge. Recommendations for the incision (Fig. 8 ad) Because of divergent dentitions and, es- thetic zones, as well as different parts of the gingiva (marginal, propria, mucosa) it is necessary to dene and distinguish differ- ent parts of the incision line. The three decisive areas are: the crestal part of the edentulous re- gion, the bordering papilla in cases of par- tially dentated jaws, the area of the releasing incision at the anterior and posterior limit of the incision. The midcrestal incision seems to be the ideal choice for the edentulous area of the planned implantation. Making the cut in the area of the avascular zone prevents the risk of cutting through anastomoses or cutting out avascular areas of the mucosa. Fig. 3. Overview after macroscopic preparation of the arteries in the maxilla and mandible. The main courses, distributions and relations are demonstrated. Fig. 4. Vascular territories of the maxilla. The colors show the supply areas of different arteries: blue infraorbital artery, red descending palatine artery, black facial and infraorbital arteries, green descending palatine and anterior superior alveolar arteries. Fig. 5. Vascular territories of the mandible. The colours show the supply areas of different arteries: blue facial artery, red submental and sublingual arteries, black inferior labial and mental arteries. Fig. 6. After Indian ink injection a vascular separation line is visible in the center of the edentulous alveolar ridge. Kleinheinz et al . Incisions in implant dentistry 520 | Clin. Oral Impl. Res. 16, 2005 / 518523 For esthetic reasons, only marginal inci- sions should be used in the frontal region. Releasing incisions in the vestibulum should be avoided because they will cut obliquely through dened esthetic zones and not at their borders. Releasing inci- sions should be carried out, if at all, only at the anterior border of the incision line to avoid cutting through the vessels coming from posterior to anterior. Trapezoid aps with anterior and posterior releasing inci- sions are avoidable in most cases because the surgical eld can be adequately visua- lized, and mobilization using incising of the periosteum can be achieved by anterior incision only. If it is essential not to touch the marginal mucosa, an incision in the vestibulum parallel to the alveolar ridge with tunneling preparation is recommended. The papilla will be included in the inci- sion in the anterior maxilla and recon- structed using microsurgical techniques during preparation and wound closure. In the lateral or posterior segment or in the event of a single posterior tooth in a free- end situation the papilla can be left un- touched by making the releasing incision in front of the papilla. Discussion The different factors to be taken into ac- count when planning a mucosal incision include esthetic aspects, plastic-reconstruc- tion potential and blood-supply require- ments. In a defect situation, the focus is on criteria relating to plastic reconstruction (e.g. preparation and mobilization of local aps for coverage or reconstruction pur- poses). Most ap preparation limitations are because of inadequacy of the supporting vascular system. Esthetic aspects play a decisive role, especially in the anterior part of the max- illa. It is essential to make an incision only at the border of esthetic zones or areas and to avoid damaging, displacement or redu- cing local tissue, because any substitute tissue is distinctive in its color, consis- tency, and surface structure. Among all planning principles, the vas- cular-nutritive principle seems to be the most important one. The vascular system at the margin of a wound represents the most important nutritional structure for survival and the basis for reliable wound healing and therefore must not be damaged under any circumstances (Arnold & West 1991; Endrich & Menger 2000; Filippi 2001). Consideration of the vessels involved in any soft tissue incision should be based on the extent and boundaries of the areas of supply of single major vessels. The ana- tomic principle of the vascular territories referred to in the literature under the term angiosomes (Taylor & Palmer 1987; Houseman et al. 2000). Evaluations of the vascularization of specic areas of the oral mucosa have also been carried out (Kin- dlova & Scheinin 1968; Mo rmann & Cian- cio 1977; Piehslinger et al. 1991; Bavitz et al. 1994; Kerdvongbundit et al. 2003) but only few studies have referred to total assessment and a subdivision into angio- somes (Whetzel & Saunders 1997). In agreement with the results of other study groups, the midcrestal incision in the edentulous area of the alveolar ridge seems to be indisputably the safest and most reliable method (Scharf & Tarnow 1993; Fig. 7. The histologic section of the alveolar mucosa shows a main arterial vessel and the gingival ramication in the lateral aspect of the alveolar mucosa (a). The avascular zone is in the middle of the alveolar ridge. There is only one anastomosis running over the midline (b). Fig. 8. Recommendations for the incision (a) edentulous areas, (b) edentulous areas: tunneling preparation, (c) free-end situation and (d) single tooth gap. Kleinheinz et al . Incisions in implant dentistry 521 | Clin. Oral Impl. Res. 16, 2005 / 518523 Cranin et al. 1998; Heydenrijk et al. 2000). Incisions, which will repeatedly cross the alveolar ridge will create small mucosal areas with uncertain vascularization, lead- ing to disturbed wound healing, bone re- sorption and mucosal necrosis. If the covering soft tissue has to be extended, e.g., in cases of lateral or vertical augmentation, this can be achieved with a periosteal incision and broad undermining mobilization. The creation of a trapezoid ap with an anterior and posterior releasing incision can be avoided in cases without the necessity of extended coverage of augmented sites be- cause sufcient visualization and mobili- zation can also be achieved using one single releasing incision. To prevent accidental cutting into the vessels running from pos- terior to anterior in the jaws, it seems appropriate to place the releasing incision at the anterior border of the midcrestal incision. The inclusion of the papilla adjacent to the edentulous area is controversially de- bated. Reports of shrinkage and loss of interproximal bone have led to recommen- dations for parapapillary incisions (line an- gle to line angle) (Gomez-Roman 2001; Velvart 2002). These alternatives, designed for primary preserving of the papilla, will not allow unrestricted visualization of the lateral marginal bone and the adjacent tooth. In the event of augmentation, lateral mobilization of the gingiva is almost im- possible. The marginal incision including the pa- pilla allows a complete overview of the entire edentulous alveolar ridge and exact placement of the implant equidistant from the neighboring teeth. This incision is recommended especially for esthetically problematic areas in the upper incisor re- gion (Wachtel et al. 2003; Erpenstein et al. 2004). Using microsurgical techniques for preparation of aps and reconstruction of the papilla (Burkhardt & Hurzeler 2000), shrinkage can be avoided when the under- lying alveolar bone is not reduced and the contact point of the prosthodontic treat- ment is not too far from the alveolar bone (Tarnow et al. 2003). From angiologic aspects the papilla is different from the adjacent edentulous al- veolar mucosa because the papilla is sup- plied by vascular anastomoses crossing the alveolar ridge. This key point allows differ- ent incisions including or excluding the papilla. The decision has to be made indivi- dually, with aspects of esthetics and plastic reconstruction being taken into account. Resume Fournir une quantite adequate de sang aux capillaires pour un fonctionnement normal de lorgane est le but premier du syste`me vasculaire. Preserver la viabilite du segment de tissu mou depend de linci- sion du tissu mou qui doit etre effectuee de manie`re precise pour prevenir la deterioration de la circula- tion. Une connaissance de geographie des vaisseaux ainsi que de leurs aires de reserve sont essentiels pour la decision de lincision. Le but de cette etude a ete de visualiser les arte`res en utilisant differentes techniques an deffectuer des analyses tant macro- que microscopiques et pour developper des recommandations pour les incisions lors de la pose dimplants dentaires. Les syste`mes vasculaires de sept cadavres humains edentes ont ete vides et remplis avec soit de lencre de Chine ou une solution rouge et du formol. Apre`s xation une preparation macroscopique a ete effectuee pour mettre en evi- dence le cours, la distribution et laire de reserve des principaux vaisseaux. Dans la zone du rebord al- veoaire edente des specimens des muqueuses ont ete preleves et analyses microscopiquement. Les ana- lyses ont mis en evidence les principaux caracte`res de la vascularisation de la muqueuse. Le cours principal des arte`res converge de larrie`re vers lavant, les vaisseaux principaux courent paralle`le- ment au rebord alveolaire dans le vestibule et laire crestale des rebords alveolaires edentes et sont cou- verts par une zone non-vascularisee sans anastomose traversant le rebord alveolaire. Ces resultats sugge`r- ent donc des incisions au milieu de la ligne du rebord alveolaire, des incisions marginales dans les zones dentees, des incisions dacce`s seulement dans la frontie`re anterieure de la ligne dincision generale et labstention dincision traversant la crete alveolaire. Zusammenfassung Die Gestaltung der Inzision in der dentalen Implantologie aufgrund der Vaskularisierung der Mukosa Ziele: Das erste Ziel des Gefasssystems ist es, eine adaquate Menge Blut zu den Kapillaren zu fu hren, um eine normale Funktion des Organs zu gewahr- leisten. Der Erhalt der Lebensfahigkeit des Weich- teilsegments hangt von der Weichgewebsinzision ab, welche sauber gestaltet sein sollte, um die Zirkula- tion nicht zu beeintrachtigen. Die Kenntnis des Verlaufs und der Versorgungsgebiete der Gefasse ist fu r die Wahl der Inzision entscheidend. Das Ziel dieser Studie war, den Verlauf der Arterien mittels verschiedener Techniken sichtbar zu machen, um makroskopische und mikroskopische Analysen durchfu hren zu ko nnen und um Empfehlungen fu r Inzisionen in der oralen Implantatchirurgie zu en- twickeln. Material und Methoden: Das Gefasssystem von 7 zahnlosen menschlichen Kadavern wurde ausge- spu lt und entweder mit rot gefarbter Gummiu s- sigkeit oder mit indischer Tinte und einer Formalinmixtur aufgefu llt. Nach der Fixierung wurde eine makroskopische Praparation durchge- fu hrt, um den Verlauf, die Verteilung und die Ver- sorgungsgebiete der grossen Gefasse aufzuzeigen. Im Bereich des zahnlosen Alveolarkammes wurden Proben der Mukosa entnommen und mikroskopisch analysiert. Resultate: Die Analysen zeigten die generellen Ei- genschaften der Vaskularisation von Schleimhauten. Die Hauptrichtung der versorgenden Gefasse ver- lauft von posterior nach anterior, die Hauptgefasse liegen parallel zum Alveolarkamm im Vestibulum und die Kammregion des zahnlosen Alveolar- kammes wird durch eine avaskulare Zone ohne den Alveolarkamm u berkreuzende Anastomosen bedeckt. Schlussfolgerung: Aufgrund der Resultate werden Inzisionen im Bereich der Kammmitte des zahnlo- sen Alveolarkammes und marginale Inzisionen imbezahnten Bereichvorgeschlagen. Entlastungssch- nitte sollten nur an der anterioren Grenze der gesamten Inzisionslinie gelegt werden. Inzisionen, welche den Alveolarkamm u berkreuzen, sollten vermieden werden. Resumen Objetivos: El suministro de una cantidad adecuada de sangre a los capilares tisulares para el funciona- miento normal de un o rgano es el propo sito primario del sistema vascular. La preservacio n de la viabilidad del segmento de tejido blando depende en la incisio n del tejido blando que debe estar debidamente disen - ada en orden a prevenir mermas en la circulacio n. Un conocimiento del curso de los vasos al igual que del area de suministro es crucial para la decisio n de la incisio n. La intencio n de este estudio fue visualizar el curso de las arterias usando diferentes tecnicas, para realizar analisis macro- y microsco picos, y desarrollar recomendaciones para incisiones en odontologa de implantes. Material y metodos: Se vaciaron los sistemas vas- culares de 7 cadaveres humanos edentulos y relle- nados con pegamento de goma de color rojo o con una mezcla de tinta india y formalina. Tras la jacio n se llevo a cabo una preparacio n macrosco - pica para revelar el curso, distribucio n y area de suministro de los vasos principales. En el area de la cresta alveolar edentula se tomaron especmenes y se analizaron microsco picamente. Resultados: Los analisis revelaron las principales caractersticas de la vascularizacio n mucosa. El curso principal de las arterias de suministro as desde posterior a anterior, los vasos principales corren paralelos a la cresta alveolar en el vestbulo y el area crestal de la cresta alveolar esta cubierta por una zona avascular sin anastomosis que crucen la cresta alveolar. Conclusio n: Los resultados sugieren incisiones en la cresta alveolar, incisiones marginales en areas den- tadas, incisiones liberadoras solo en el borde anterior de la lnea completa de incisio n, y evitar las inci- siones que crucen la cresta alveolar. Kleinheinz et al . Incisions in implant dentistry 522 | Clin. Oral Impl. Res. 16, 2005 / 518523 References Arnold, F. & West, D. (1991) Angiogenesis in wound healing. Pharmacology and Therapeutics 52: 407422. Bavitz, J., Harn, S. & Homze, E. (1994) Arterial supply of the oor of the mouth and lingual gingiva. Oral Surgery Oral Medicine Oral Pathol- ogy Oral Radiology and Endodontics 77: 232235. Bryant, G.L., Davidson, J.M., Ossoff, R.H., Garret, C.G. & Reinisch, L. (1998) Histologic study of oral mucosa wound healing: a comparison of a 6.0- to 6.8-mm pulsed laser and a carbon dioxide laser. Laryngoscope 108: 1317. Burkhardt, R. & Hurzeler, M.B. (2000) Utilization of the surgical microscope for advanced plastic periodontal surgery. Practical Periodontics and Aesthetic Dentistry 12: 171180. Cranin, A.N., Sirakian, A., Russell, D. & Klein, M. (1998) The role of incision design and location in the healing processes of alveolar ridges and im- plant host sites. International Journal of Oral & Maxillofacial Implants 13: 483491. Endrich, B. & Menger, M.D. (2000) Regeneration der Mikrozirkulation wahrend der Wundheilung? Unfallchirurg 103: 10061008. Erpenstein, H., Rasperini, G. & Silvestri, M. (2004) Lappenoperationen. In: Erpenstein, H. & Diedrich, P., eds. Atlas der Parodontalchirurgie. 1st edition, 111. Mu nchen: Elsevier Urban& Fischer. Filippi, A. (2001) Wundheilung der mundschleim- haut. Deutsche Zahnarztliche Zeitschrift 56: 517522. Folkman, J. & Shing, Y. (1992) Angiogenesis. Jour- nal of Biological Chemistry 267: 1093110934. Gary, H.G. & Longaker, M.T. (2000) Scarless Wound Healing. New York: Dekker. Gomez-Roman, G. (2001) Inuence of ap design on peri-implant interproximal crestal bone loss around single-tooth implants. International Jour- nal of Oral & Maxillofacial Implants 16: 6167. Heydenrijk, K., Raghoebar, G.M., Batenburg, R.H. & Stegenga, B. (2000) A comparison of labial and crestal incisions for the 1-stage placement of IMZ implants: a pilot study. Journal of Oral & Max- illofacial Surgery 58: 11191123. Houseman, N.D., Taylor, G.I. & Pan, W.R. (2000) The angiosomes of the head and neck: anatomic study and clinical applications. Plastic and Re- constructive Surgery 105: 22872313. Kerdvongbundit, V., Vongsavan, N., Soo-ampon, S. & Hasegawa, A. (2003) Microcirculation and micromorphology of healthy and inamed gingi- vae. Odontology 91: 1925. Kindlova, M. & Scheinin, A. (1968) The vascular supply of the gingiva and the alveolar mucosa in the rat. II. Spontaneous and experimentally induced changes of the microcirculation. Acta Odontologica Scandinavica 26: 629640. Mausberg, R., Visser, H., Aschoff, T., Donath, K. & Kruger, W. (1993) Histology of laser- and high- frequencyelectrosurgical incisions in the palate of pigs. Journal of Craniomaxillofacial Surgery 21: 130132. Mo rmann, W. & Ciancio, S.G. (1977) Blood supply of human gingiva following periodontal surgery. Journal of Periodontology 48: 681692. Piehslinger, E., Choueki, A., Choueki-Guttenbrun- ner, K. & Lembacher, H. (1991) Arterial supply of the oral mucosa. Acta Anatomica 142: 374378. Scharf, D. & Tarnow, D. (1993) The effect of crestal versus mucobuccal incisions on the rate of im- plant osseointegration. International Journal of Oral & Maxillofacial Implants 8: 187190. Shelley, E.D. & Shelley, W.B. (1986) Piezosurgery: a conservative approach to encapsulated skin le- sions. Cutis 38: 123126. Siegert, R. (2000) Wasserstrahldissektion in der par- otischirurgie erste klinische resultate. Laryngo- Rhino-Otologie 79: 780784. Sinha, U.K. & Gallagher, L.A. (2003) Effects of steel scalpel, ultrasonic scalpel, CO 2 laser, and monopolar and bipolar electrosurgery on wound healing in guinea pig oral mucosa. Laryngoscope 113: 228236. Spalteholz, W. (1911) U
ber Das Durchsichtigma-
chen Von Menschlichen Und Tierischen Prapar- aten. Leipzig: Hirzel. Tarnow, D.T., Elian, N., Fletcher, P., Froum, S., Magner, A., Cho, S.C., Salama, M., Salama, H. & Garber, D.A. (2003) Vertical distance from the crest of bone to the height of the interproximal papilla between adjacent implants. Journal of Periodontology 74: 17851788. Taylor, G.I. & Palmer, J.H. (1987) The vascular territories (angiosomes) of the body: experimental study and clinical applications. British Journal of Plastic Surgery 40: 113141. Velvart, P. (2002) Papilla base incision: a new approach to recession free healing of the interden- tal papilla after endodontic surgery. International Endodontic Journal 35: 453460. Wachtel, H., Schenk, G., Bohm, S., Wenig, D., Zuhr, O. & Hurzeler, M.B. (2003) Microsurgical access ap and enamel matrix derivative for the treatment of periodontal intrabony defects: a con- trolled clinical study. Journal of Clinical Perio- dontology 30: 496504. Whetzel, T.P. & Saunders, C.J. (1997) Arterial anatomy of the oral cavity: an analysis of the vascular territories. Plastic and Reconstructive Surgery 100: 582587. Kleinheinz et al . Incisions in implant dentistry 523 | Clin. Oral Impl. Res. 16, 2005 / 518523