PRACTITIONER SECTION

Optimising esthetics in second stage dental implant

surgery: Periodontists ingenuity
A Suchetha, Prajakta Vasant Phadke, N Sapna, HR Rajeshwari
ABSTRACT

Morphology of the peri-implant soft tissue adjoining the implant components plays a pivotal role in
displaying the implant esthetics. Creating an implant restoration that cannot be distinguished from
the rest of the natural dentition is the ultimate goal. Second stage surgery is often overlooked and
is considered non essential phase but actually could determine the health of the peri-implant tissue
.This phase gives an excellent opportunity to preserve, reconstruct and even maneuver the soft tissue
to optimize the soft tissue profile around the implant components. The article aims at enumerating
the various modalities available to contour the soft tissue profile around implants and thus help the
practioners in optimizing esthetics during second stage surgery.
KEY WORDS: Dental implants, esthetics, second stage surgery, soft tissue

INTRODUCTION
Every implant exposure is unique, crucial and technique
sensitive. The goal of the second stage surgery in esthetic
zone is not only to expose the implant interface for
performing the required restorative procedures, but also
to create a healthy marginal attached mucosa around
dental implants.[1]
The ability to preserve the architecture, modify and
even improvise the soft tissue contour lie in the hands
of the periodontist and this can greatly influence the
overall restorative result. Four potential time points
can be differentiated for soft/hard tissue management
at the time of implant placement, during healing of the
implant, during second stage surgery, and finally at the
maintenance phase.[2]
Department of Periodontics, DAPM RV Dental College, Bengaluru,
Karnataka, India
Address for correspondence: Dr Prajakta V Phadke,
Department of Periodontics, DAPM RV Dental College, CA-37, 24th Main, 1st
Phase, J. P. Nagar, Bengaluru - 560 078, Karnataka, India.
Email: prajuphadke@gmail.com

Access this article online

Quick Response Code:

Website:
www.jdionline.org

DOI:
10.4103/0974-6781.140898

170

The aim of this article is to compile the various techniques

available to enhance esthetics in implant second stage in
common to highly complicated clinical scenarios.
The treatment goals of second stage surgery in esthetic
zone[3] would include preservation of the continuity
of the keratinised tissue band, avoiding creation of
the tissue margins that are defective, creating an
implant-supported restoration that have symmetric
contours, postoperative stable soft tissue conditions.
Ultimately establish and accomplish natural soft tissue
dimensional architecture without formation of any scar
tissue on labial gingival interface and most importantly
preserve the inter-proximal papillae.
Implant exposure techniques were classified by Bichacho
and Landsberg[4] in 1997 as additive which was performed
to enhance tissue thickness when soft tissue thickness
was deficient; Subtractive in which kertainised tissue
overlying the coverscrew was excised and performed
when optimal soft tissue volume was present and
combination of both additive and subtractive techniques.
Another classification classified second stage surgery
as excisional Destructive techniques using scalpel,
tissue punch or laser and incisional Regenerative
techniques that was further subdivided into without
tissue transference and with tissue transference.
The decisive parameters that ultimately play a pivotal
role include the characteristics of the tissues that
Journal of Dental Implants | Jul - Dec 2014 | Vol 4 | Issue 2

Suchetha, et al.: Esthetics in second stage implant surgery

overlie the implant (keratinised/nonkeratinised),

the amount of attached gingiva, the thickness or the
biotype of overlying mucosa and presence or absence
of the interdental papilla. A very simple equation was
developed by Hertel et al.[1] to help the clinicians is based
on the amount of fixed mucosa is described in Table 1.
The factors that would prove critical in predicting the final
outcome would include blood supply for the viability
and undisturbed wound healing,[5] optimal implant
positioning especially the axial orientation that would
influence the distance from the contact point to the osseous
crest,[6] tissue biotype which influences the postoperative
response to trauma,[6] platform switching favors biologic
width development and minimizes the postoperative
resorption,[7] and most importantly optimal distance
between the implants and implant and natural teeth.
On regular basis the classic protocol[8] is carried out for
the implant exposure which starts with a long incision
over the crest and midway between buccolingual aspect
through the gingiva from the site of the distal implant
in mesial direction. Following a full or partial thickness
flap is raised to establish access to cover screw. Osseous
recontouring can be made and healing abutments
will be placed. But the technique included some
disadvantages like it caused more tissue manipulation
leading to trauma involved and exposure of large area
of the bone.
Enumeration of various modalities are done under
the following as excisional techniques and incisional
techniques as shown in Table 2.

EXCISIONAL TECHNIQUES
These techniques are ideal only if sufficient attached
gingival tissue is present around the head of the implant;
as this involves the removal and discarding of keratinised
tissue covering the cover screw. These include using
scalpel, soft tissue punching and laser using scalpel
the following techniques are described Bernhart et al.
described a minimally invasive procedure[9] consisting
of vertical incision on the gingival crest covering the
cover screw followed by a round incision about 1-3 mm
around the tissue to be removed and with a blunt
instrument stretching the tissue to remove the cover
screw and placement of healing abutment.
Key hole access expansion for flapless implant second
stage surgery[10] Happe et al. This procedure consists of
excising approximately 1 mm2 of soft tissue overlying
the cover screw following this the hole would be
firmly and slowly stretched using a microraspatory.
Five minutes later the hole would be large enough for
retrieval of cover screw and a larger healing abutment
Journal of Dental Implants | Jul - Dec 2014 | Vol 4 | Issue 2

Table 1: Simple equation was developed by

Hertel RC2
Based on the amount of fixed mucosa
When fixed mucosa>4 mm When fixed mucosa 1 mm to 4 mm
Excisional technique
Incisional technique
When too little mucosa is present then
Free gingival graft preceding the incisional technique

Table 2: Techniques for second stage surgery

in implant exposure
Excisional techniques
Benharts minimal invasive technique
Key hole expansion technique
Soft tissue punching
Laser tissue trimming
Incisional techniques: Without tissue transfer
[+] or [X] Incision technique
Incisional technique: With tissue transfer
Depending upon most of the clinical scenarios the techniques
are enumerated under the following main purposes
A. For increasing the Keratinised mucosa
Rotated Palatal Strap Technique , Palatal Sliding Strip Flap
Technique
B. For increasing the bulk of soft tissue on buccal aspect
Pouch Roll Technique, Rotated Palatal Strap Technique,
Palatal Sliding Strip Flap Technique, Split Finger Technique
C. For preservation/regeneration of interdental papilla
Mischs Split Finger Tehnique , Palaccis Papilla
Regeneration Technique, Ramp Mattress Sutures I
Shaped Incision, M Shaped Flap Design, Nemcovskys
Interdental papilla reconstruction
D. In compromised situations
Gingival Soft Tissue Augmentation , Jean-Pierre Arnoux
s Revised technique for stage two procedure for highly
resorbed mandible

is placed. This would cause ischemia but the ultimate

goal of expansion would have occurred. This procedure
offers the following advantage such as minimal soft
tissue trauma, minimal bone exposure, high ease of
performance.
Soft tissue punching consists of excising a circular
keratinised mucosa on top of cover screw using scalpel,
gum punching tool or diamond bur. Though this
technique gives the clinician the surgical ease it should
be noted that this technique is sensitive as imperfect
tissue punching could jeopardize labial tissue contour
and cause unnecessary loss of keratinised mucosa. It is
more of a guess work unless original surgical template
is present to locate the exact location of cover screw and
bone contouring is not possible in this technique.
Laser allows precise tissue trimming in a bloodless field
and also allows control of depth of tissue removal.
171

Suchetha, et al.: Esthetics in second stage implant surgery

INCISIONAL TECHNIQUES WITHOUT TISSUE

TRANFER
Cosmetic incisions using microsurgial blades and
avoiding perpendicular incisions to the bone preferably
using blades at 45 angulations would allow more
tissue adaptation thereby reducing tissue tag and scar
formation.
A very simple technique consisting of + and X incision
technique[11] would be sufficient and when adequate
attached gingiva is present. This technique would first
involve a small crestal incision that will later give place to
a cross type [+] incision. Diagonal incisions are used [X]
when the location of implant is exactly known.

INCISIONAL TECHNIQUE WITH TISSUE

TRANSFERANCE
Rotated palatal strap[12] was introduced by Nemcovsky
and Moses. A predictable technique that technique
consistently provides a wider zone of keratinized
gingiva in the buccal aspect of the future maxillary
implant-supported restoration.
This technique consists of crestal incision that would
be given palatal to the implants with buccal releasing
incisions and completed with the full-thickness flap
delineation leaving proximal interdental papillae
untouched [Figure 1a]. All tissues buccal to the crestal
incision would be labially repositioned and implant
cover screws would later be removed and replaced by
healing abutments [Figure 1b]. A sharp, deep, internally

beveled incision delineating a pediculated full-thickness

palatal flap would be made and the rotated palatal
flap [Figure 1c] would closely be adapted to healing
abutments.
This procedure procures adequate zone of keratinized
tissue around implants with added advantage of
avoiding a large zone of exposed implant-supporting
bone.
Nemcovsky et al. introduced a technique for implant
exposure with simultaneous inter-proximal papilla
reconstruction for maxillary implants[13] which consists
of U-shaped incisions open toward buccal aspect with
slight divergent arms [Figure 2a]. Adjacent papilla
would remain adherent. Both sides of the incisions
would be palatally connected. Outer edges of the
incision and the papilla would be de-epithelised. A full
thickness flap would be raised and healing cap would
be placed. The flap would be split at the centre into
mesial and distal halves [Figure 2b]. Each part of the
buccal flap would be positioned over the de-epithelised
papilla and would be secured with vertical mattress
sutures.
Palatal sliding strip flap[14] was developed to help form
papillae between implants and between natural teeth
in the anterior area of the maxilla and at the same time
augment the labial ridge by Adriaenssens et al.
This technique consisted of full-thickness sulcular and
palatal displaced incision. At two-thirds of the distance
between the two teeth, a full-thickness horizontal incision
would be prolonged on the palatal side. Two incisions,
parallel to each other in a buccopalatal direction, would
be made to create a partial-thickness flap extending in
the palate, leaving the periosteum intact [Figure 3a]
Healing abutments would be later inserted and a
semilunar incision would be made in the direction of the
contralateral side of the strip [Figure 3b]. The pedicles
would be disengaged and rotated toward the palatal
direction to fill the inter-proximal space [Figure 3c].

Figure 1: (a) Crestal incision that would be given palatal to the

implants with buccal releasing incisions and completed with
the full-thickness flap delineation leaving proximal interdental
papillae untouched. (b) All tissues buccal to the crestal incision
would be labially repositioned and Implant cover screws
would later be removed and replaced by healing abutments.
(c) A sharp, deep, internally beveled incision delineating a
pediculated full-thickness palatal flap would be made and the
Rotated palatal flap
172

Figure 2: (a) U shaped incisions open toward buccal aspect

with slight divergent arms. (b) The flap would be split at the
centre into mesial and distal halves
Journal of Dental Implants | Jul - Dec 2014 | Vol 4 | Issue 2

Suchetha, et al.: Esthetics in second stage implant surgery

The flap design for second-stage surgery appears to

have several advantages like minimal surgical trauma;
flap nutrition preservation; soft tissue augmentation;
formation of papilla like tissue; and avoidance of a donor
site with a second surgical area or multiple surgeries.
Pouch roll technique [15] a modification of roll flap
technique was described by Park and Wang et al. This
technique is simple, versatile for mild to moderate ridge
deficiency by thickening the soft tissue around implant.
In this buccal mini-pedicle flap 1-mm wider than the
diameter of the implant platform would be raised and
then de-epithelised [Figure 4a] followed by rolling of this
mini-pedicle underneath the buccal pouch [Figure 4b].
Misch et al. split finger technique[16] would comprise of
a sulcular incision made 2-3 mm to the palatal side from

each tooth with a loop design at least 2-2.5 mm adjacent

to the implant location. The incisions would be joined
facially by a semicircular incisions at the preplanned
tissue margin of implant crown [Figure 5a]. Following
this the facial fingers would be elevated to the desired
inter-implant height for papillae and the middle palatal
finger would then be split and reflected to respective
mesial and distal sides [Figure 5b] and later would be
secured by vertical mattress sutures.
Palacci and Nowzari technique to restore papilla
like tissue around implants[17] would comprise of full
thickness flap that would be elevated and reflected
labially [Figure 6a]. Healing abutments would
emerge from the tissues and hold them in place.
Semilunar bevel incision would be made, recreating
a scalloped shape similar to that of tissues around
natural teeth [Figure 6b]. Later the pedicles would be
rotated to fill the inter abutment and abutment-tooth
spaces [Figure 6c].
Ramp mattress sutures[18] Tinti and Benfenati came up
with an innovative technique of obtaining inter implant
papilla with suturing technique. In this technique a
sharp linear incision in a distomesial direction would

Figure 3: (a) At two-thirds of the distance between the two

teeth, a full-thickness horizontal incision would be prolonged
on the palatal side. Two incisions, parallel to each other in
a buccopalatal direction, would be made to create a partialthickness flap extending in the palate, leaving the periosteum
intact. (b) Healing abutments would be later inserted and
a semilunar incision would be made in the direction of the
contralateral side of the strip. (c) The pedicles would be
disengaged and rotated toward the palatal direction to fill the
inter-proximal space

Figure 4: (a) Buccal mini-pedicle flap 1mm wider than the

diameter of the implant platform would be raised and then
de-epithelised. (b) Rolling of this mini pedicle underneath the
buccal pouch

Figure 5: (a) A loop design at least 2-2.5 mm adjacent to the

implant location. The incisions would be joined facially by
a semicircular incisions at the preplanned tissue margin of
implant crown. (b) the facial fingers would be elevated to
the desired inter-implant height for papillae and the middle
palatal finger would then be split and reflected to respective
mesial and distal sides
Journal of Dental Implants | Jul - Dec 2014 | Vol 4 | Issue 2

Figure 6: (a) Full thickness flap that elevated and reflected

labially. (b) Semilunar bevel incision would be made,
recreating a scalloped shape similar to that of tissues around
natural teeth. (c) The pedicles would be rotated to fill the inter
abutment and abutment-tooth spaces
173

Suchetha, et al.: Esthetics in second stage implant surgery

be performed with a full thickness approach slightly

palatal to the implants, starting 5 mm posterior to the
most distal implant and finishing 5 mm mesial to the
most mesial implant.
Long healing abutments would be placed and healing
abutments would be able to keep the full-thickness
buccal flap raised during the healing period. The
vestibular gingival margin is in a more coronal position
compared to the palatal gingival margin. Ramp mattress
sutures would be placed to stabilize the flap at the new
desired position.
I shaped incision for papilla reconstruction[19] Lee et al.
Labial horizontal incision would be given about
0.51 mm inside from the border of implant followed
by vertical incision at the middle of the implant then
a palatal horizontal incision would be given along the
border of implant [Figure 7]. The flap would be reflected
with care and the implant would be exposed to remove
the cover screw. The healing abutment is later connected
and both flaps would be folded up alongside the healing
abutment intending them to heal without suture.
M shaped flap design was proposed for promoting
implant esthetics[20] by Paolantoni et al. This design
was proposed with an intension of preventing
buccal marginal recession and to achieve an esthetic
peri-implant soft tissue remodeling and predictable
implant-supported gingivo prosthetic integration,
particularly during the single tooth rehabilitations.
This technique consisted of an intrasulcular inner
beveled incision which would be performed around the
distal aspect of the adjacent teeth, rounding buccally
and palatally and connecting with a M-shaped incision.
The full thickness M flap would be raised to visualize
the bone surface and connect the implant abutment. The
flap would then be closed and sutured with a mattress

Figure 7: Labial horizontal incision would be given about

0.5-1 mm inside from the border of implant followed by
vertical incision at the middle of the implant then a palatal
horizontal incision would be given along the border of implant

174

monofilament suture at the gingival papilla to stabilize

the flap around the healing cap [Figure 8].
Guided soft tissue augmentation (GSTA) with submerged
healing abutments[21] was proposed by Salama et al.
to overcome the dilemma of black triangles with
three-dimensional enhancement of peri-implant soft
tissue by tenting the repositioned flap over anatomical
healing abutments of appropriate health.
In this procedure a full thickness labial flap would
be coronally advanced to cover the healing abutment
capable of supporting the vertical needs and allow the
three-dimensional GSTA.
Tenting of soft tissue with appropriate healing abutments
would allow space maintenance beneath the gingiva and
organize the blood clot which would be replaced by soft
tissue.
Six to eight weeks later healing abutments would be
removed and replaced by temporary restorations.
Revised technique for stage-two surgery in the severely
resorbed mandible[22] was proposed by Arnoux et al. that
would limit the detachment of the lingual flap, augment
the band of attached masticatory mucosa with a free
gingival graft, deepen the vestibule, and prevent the
reattachment of the muscles.
In this technique the incision would be made at the
mucogingival junction, so that the entire band of
keratinized masticatory mucosa would be included in
the lingual flap.
It is very important that the lingual flap not be elevated
in its entire length, but only around each implant so as

Figure 8: The full thickness M flap would be raised to

visualize the bone surface and connect the implant abutment

Journal of Dental Implants | Jul - Dec 2014 | Vol 4 | Issue 2

Suchetha, et al.: Esthetics in second stage implant surgery

to maintain maximum attachment to the body of the

mandible.
A partial-thickness dissection through the muscles of the
chin area would be performed on the labial vestibular
aspect to obtain a free graft. Periosteal incision would
be given at the base of the bed and the periosteum
would be elevated and a band of exposed bone would
be denuded to further minimize the reattachment of
the muscles to the future peri-implant area.
Placement of healing abutments that are 5-6 mm above
the gingival level would stabilization of the graft. The
graft would be stabilized by means of interrupted and
horizontal mattress.

CONCLUSION
There are various innovative methods for promoting
and preserving the soft tissue profile around the
implants. Second stage surgery should be given
emphasis and not just thought as a process of
uncovering the coverscrew. A whole lot can be done
and is an excellent opportunity to give finesse to the
soft tissue profiling around implant components. The
biological, functional, esthetic needs of the individual
patient can be sculpted with this essential step.

7.
8.
9.

10.

11.
12.

13.

14.

15.

16.
17.
18.

REFERENCES
1.

2.

3.

4.

5.

6.

Hertel RC, Blijdrop PA, Kaik W, Baker DL. Stage II surgical

techniques in endosseous implantation. Int J Oral Maxillofac
Implants 1994;9:273-8.
Hrzeler MB, Weng D. Periimplant tissue management: Optimal
timing for an aesthetic result. Pract Periodontics Aesthet Dent
1996;8:857-69.
Garber D, Belser U. Restoration-driven implant placement with
restoration-generated site development. Compend Contin Educ
Dent 1995;16:796-804.
Bichacho N, Landsberg CJ. Single implant restorations:
Prosthetically induced soft tissue topography. Pract Periodontics
Aesthet Dent 1997;9:745-52.
Berglundh T, Lindhe J, Jonsson K, Ericsson I. The topography of
the vascular systems in the periodontal and peri-implant tissues
in the dog. J Clin Periodontol 1994;21:189-93.
Gastaldo JF, Cury PR, Sendyk WR. Effect of the vertical and
horizontal distances between adjacent implants and between a
tooth and an implant on the incidence of interproximal papilla.
J Periodontol 2004;75:1242-6.

Journal of Dental Implants | Jul - Dec 2014 | Vol 4 | Issue 2

19.

20.

21.

22.

Pradeep AR, Karthikeyan BV. Peri-implant papilla reconstruction:

Realities and limitations. J Periodontol 2006;77:534-44.
Tarnow DP, Eskow RN, Zamzok J. Aesthetics and implant
dentistry. Periodontol 2000 1996;11:85-94.
Bernhart T, Haas R, Mailath G, Watzek G. A minimally invasive
second-stage procedure for single-tooth implants. J Prosthet Dent
1998;79:217-9.
Happe A, Krner G, Nolte A. The keyhole access expansion
technique for flapless implant stage-two surgery: Technical note.
Int J Periodontics Restorative Dent 2010;30:97-101.
Garg AK. Practical Implant Dentistry. Dallas: Taylor; 2001.
Nemcovsky CE, Moses O. Rotated palatal flap. A surgical
approach to increase keratinised tissue width in maxillary
implant uncovering: Technique and Clinical evaluation.
Int J Periodontics Restorative Dent 2002;22:607-12.
Nemcovsky CE, Moses O, Artzi Z. Interproximal papillae
reconstruction in maxillary implants. J Periodontol
2000;71:308-14.
Adriaenssens P, Hermans M, Ingber A, Prestipino V,
Daelemans P, Malevez C. Palatal sliding strip flap: Soft tissue
management to restore maxillary anterior esthetics at stage
2 surgery: A clinical report. Int J Oral Maxillofac Implants
1999;14:30-6.
Park SH, Wang HL. Pouch roll technique for implant soft tissue
augmentation: A variation of the modified roll technique. Int J
Periodontics Restorative Dent 2012;32:e116-21.
Misch CE, Al Shammari K, Wang HL. Creation of interdental papillae
through split finger technique. Implant Dent 2004;13:20-7.
Palacci P, Nowzari H. Soft tissue enhancement around dental
implants. Periodontol 2000 2008;47:113-32.
Tinti C, Benfenati SP. The ramp mattress suture: A new suturing
technique combined with a surgical procedure to obtain
papillae between implants in the buccal area. Int J Periodontics
Restorative Dent 2002;22:63-9.
Lee EK, Herr Y, Kwon YH, Shin SI, Lee DY, Chung JH. I-shaped
incisions for papilla reconstruction in second stage implant
surgery. J Periodontal Implant Sci 2010;40:139-43.
Paolantoni G, Cioffi A, Mignogna J, Riccitiello F, Sammartino G.
M flap design for promoting implant esthetics: Technique and
cases series. Periodontol Oral Surg Esthet Implant Dent Open
2013;1:29-35.
Salama H, Salama M, Garber D, Adar P. Developing optimal
peri-implant papillae within the esthetic zone: Guided soft tissue
augmentation. J Esthet Dent 1995;7:125-9.
Arnoux JP, Papasotiriou A, Weisgold AS. A revised technique for
stage-two surgery in the severely resorbed mandible: A technical
note. Int J Oral Maxillofac Implants 1998;13:565-8.
How to cite this article: Suchetha A, Phadke PV, Sapna N,
Rajeshwari HR. Optimising esthetics in second stage dental implant
surgery: Periodontist's ingenuity. J Dent Implant 2014;4:170-5.
Source of Support: Nil, Conflict of Interest: None.

175

Copyright of Journal of Dental Implants is the property of Medknow Publications & Media
Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv
without the copyright holder's express written permission. However, users may print,
download, or email articles for individual use.