The Effect of Moldable Tissue on the Papilla For mation
Around Implant Restorations
Implant Esthetics:
Form Meeting Function

Hanawa, Yasufumi; Vavalekas, Michail; Dunca, Flaviu; Froum, Scott; Saito, Hanae; Kye, Wayne; Cho, Sang-choon; Froum, Stuart; Elian, Nicolas; Tarnow, Dennis. Ashman Department of Periodontology and Implant Dentistry, New York University

New York University

8. Extracellular matrix formation
Twenty-one articles of the 211 collected satisfied the studies inclusion criteria
and were evaluated.

INTRODUCTION
uccessful ossseointegration of dental implants is well documented in theliterature (1-6). The criteria for success in implant dentistry has changed
from obtaining successful osseointegration only, to achieving osseointegration and aesthetic integration of prosthetic and soft tissue frameworks.
One of the main challenges in implant dentistry continues to be the achievement of a stable and predictable aesthetic result including both the presenceof an interproximal papilla and a harmonious mid-buccal gingival architecture. Inadequate dimensions of soft tissue can result in physical deformities,
phonetic impediments, and food impaction.

S

RESULTShe results from the literature review revealed that there is a difference
between “moldable tissue” and “non-moldable” scar tissue (Table 1).

T

The results also showed that the ability of a tissue to be moldable differs
between different techniques (Table 2).

There are a number of surgical and prosthetic techniques used to maintainthe integrity of the peri-implant soft tissue. These include atraumatic tooth
extraction with or without immediate placement and provisionalization (711), papilla sparing incisions for stage one and two procedures (12), and platform switching as a means of maintaining crestal bone levels. Platform
switching is the placement of a smaller diameter abutment on a larger diameter implant platform (13). There are also a number of techniques suggested
for regenerating lost papillae and mid-buccal tissue. Examples include soft
tissue grafting, forced eruption, guided bone regeneration, and tissue manipulation with the provisional restoration (14-15). Even with proper executionof these techniques, if the soft tissue is unable to conform to the implant
restoration the result will not be satisfactory to the patient or clinician. Thisoccurs when soft tissue becomes rigid and non-flexible because of increased
scar tissue formation in response to traumatic manipulation or previous surgical interventions. This tissue type does not allow adaptation or flexibility
around implants. On the other hand, tissue that is resilient, flexible, and able
to be adapted or shaped around an implant is desirable. We will identify tissue with these qualities as “moldable tissue” (Fig. 1, 2).

Fig. 1 Preserved moldable tissue

Berglundh et al. (17) observed that the vascular system of the peri-implantmucosa originated solely from the blood vessels extending from the alveolar
ridge. The connective tissue adjacent to implants contain few vessels, all ofwhich are terminal branches of the supra-periosteal blood vessels. Whenincising into healthy tissue around a tooth, changes are initiated at the levelof the vascular network. However, the same incisions in peri-implant tissue,
which has a decreased vascularity, elicit a profoundly different and limited
healing reaction. The healing potential of the peri-implant mucosa is notequal to that around natural teeth. Hence scar tissue appears, resulting in aless moldable soft tissue (Fig. 3).
Therefore, incision design and tissue handling around implants must addressthese differences (Fig. 6; Table 1). Clinicians need to alter their surgical technique in order to minimize scar tissue formation (Fig. 8). Maintaining theresilience and the moldability of soft tissue around implants requires atraumatic tissue handling, minimal tension during re-approximation, and suturing that avoids circulation impairment of wound margins which may lead toFig. 2 Occlusal view of moldable tissue

patients with a thin scalloped periodontium (20). Employing orthodontic
movements allow native tissue to be moved. Distraction osteogenesis canmove bone and soft tissue, but the directional forces are not similar to theones used in orthodontic movement and incisions are made in the bone andsoft tissue which compromise blood supply. While there is a progressive
manipulation of the tissue using orthodontics which can increase moldable
tissue, the same is not true with distraction osteogenesis (Table 2).
There exists a paucity of literature on scar tissue removal. One case report by
Cranska proported to remove scar tissue on the interproximal papilla with alaser in order to regain the interdental papilla height (21). The author
claimed that scar tissue was ablated with the laser and the stimulation of thegingival tissue caused proliferation of microvasculature and migration offibroblasts. To date there has been no research presented to verify theseclaims.
More experimental and clinical trials are necessary to better understand theFig. 5 Relatively invasive incision

Fig. 6 Papilla preserved incision

Moldable tissue is a key element in implant esthetics and is maintained byproper incision design, gentle handling, and adequate hydration during surgery. Another method of creating moldable tissue is with soft tissue grafting.
The purpose of this litereature review and case report was to demonstrateproper treatment planning, case selection, and surgical techniques that canpreserve and increase the moldable tissue around an implant and discuss
how moldable tissue can be achieved.

Fig 9 Moldable tissue after restoration

Moldable Tissue

Scar Tissue

Blood Supply

Sufficient

Poor

Biology

Fibrous tissue absent

Fibrous tissue present

Duration ofProcedure

Tissue Handling

MATERIALS AND METHODS
linical data in this study was obtained from the Implant Database (ID).
This data was extracted as de-identified information from the routine
treatment of patients at the Ashman Department of Periodontology
and Implant Dentistry at the New York University College of Dentistry(NYUCD) Kriser Dental Center. The ID was certified by the Office of Quality
Assurance at NYUCD. This study is in compliance with the Health Insurance
Portability and Accountability Act (HIPAA) requirements and approved by
the University Committee on Activities involving Human Subjects.
This literature review includes a total of 211 articles from peer reviewed journals published in English from January 1986 to January 2009 were collected from a search performed using MEDLINE at the Waldman Library at the
NYUCD Kriser Dental Center. The keywords utilized were “labial tissue” (23articles), “papilla regeneration” (6 articles), “inteproximal papilla” (20 articles), “soft tissue management” (162 articles). The inclusion criteria forarticle consideration included:
1. Human clinical studies
2. Animal studies
3. Differences in gingival tissue biotype
4. The biological processes of healing and scar tissue formation
5. Articles included information regarding soft tissue around implant
restorations
6. Regeneration of the soft tissue papilla
7. Surgical flap techniques and manipulation of the soft tissue flap

Incision Design

C

Fig. 3 Two GBRs and one CT graft lead to scar tissue

Fig. 4 Thick tissue but not moldable

DISCUSSION
he biology behind moldable tissue relies on the resilience of the gingival tissue. The extracellular connective tissue matrix is produced by
fibroblasts. This extracellular matrix (ECM) is composed of glycoproteins and proteoglycans containing glycosaminoglycans. The presence oflarge, flexible-chain, and negatively charged macromolecules on glycosaminoglycans regulate diffusion and fluid flow through the extracellularmatrix (16). Due to their structure and hydration, macromolecules exert
resistance towards deformation. Thus, when the gingival tissue is placed
under pressure the macromolecules are deformed. Removing the pressurecauses the macromolecules to regain their original form (16). This allows themolding of tissue with intermittent pressure. In normal healing, fibroblasts
forming the ECM do not lead to scar tissue formation if they are not prematurely activated by a rigid ECM (16). But with a rigid substrate (i.e. implant),
fibroblasts become prematurely activated and form excess fibrotic tissue leading to scar tissue formation (16). The excess fibrotic tissue is dense, rigid, difficult to mold, and significantly less vascularized (Fig. 3, 4, 5; Table 1).

T

Fig. 7 Excessive suture cause scar tissue

atrophy and/or necrosis (18) (Fig. 9, 10). This can be particularly problematic in submarginal flap designs, which result in difficult flap repositioning andmore tension on the tissues (Fig. 10).
Trauma such as stretching, tearing, or distortion should be avoided by careful tissue manipulation (18-19) and expedient surgical procedures that
decrease the risk of dessication of the tissues should be employed (Table 1).
The tissues must be kept moist at all times to avoid shrinkage and dehydration (18).
Techniques such as papilla sparring incisions (Fig 6), immediate placement
and provisionalization of implants (Fig. 1), and microsurgery have attempted
to preserve, maintain, and create moldable soft tissue. Orthodontic tooth
movement is one of the ways to create moldable tissue without surgical damage to the gingival tissues (Fig. 11). There are no incisions involved when
extruding a tooth using orthodontic movement. The extrusion of a tooth iseffective in increasing the height of the surrounding gingival tissues. The
increased volume of tissue creates a therapeutic reserve of tissue which canbe used when performing implant surgery in the esthetic zone, even in“...moldable tissue is a key element in implant esthetics and ismaintained by proper incision
design, gentle handling, and adequate hydration during surgery...”Fig. 8 Microsuture generate less scar tissue

Short procedure

Gentle handling

Proper design allows tissue
movement

Techniques

Preserving / increasing moldable tissue

Success of techniqueImmediate-implant placement / provisionalization

Preserving+++

Orthodontic tooth movement

Increasing+++

Soft Tissue/Connective Tissue Graft

Increasing++

Papilla sparring incision

Preserving++

Microsurgery

Preserving++

Palacrestal incision for implant
placement

Increasing++

Guided Bone Regeneration

Increasing+

Distraction osteogenesis

Increasing_

Long procedure

Traumatic manipulation

Poorly designed incision does not allow tissue movement

Table 1 Differences between moldable and scar tissue

interaction on a cellular and molecular-biologic level. Such work will provide
the basis for establishing highly specific and selective therapeutic approaches to reduce scarring and fibrosis and increase moldable tissue for papillary
regeneration procedures in papilla regeneration procedures. Preservation ofvascular supply and preventing formation of scar tissue are key elements inpreserving tissue moldability. This is essential for successful implant therapy.

CONCLUSIONS
he biology behind moldable tissue relies on the resilience and flexibility of the gingival tissue. Maintaining the moldability of soft tissue
around implants requires carefully planned incision design, atraumatic
tissue handling, minimal tension during re-approximation, and suturing thatavoids circulation impairment of wound margins which may lead to tissue
atrophy and necrosis. Techniques such as papilla sparring incisions, immediate placement and provisionalization of implants, microsurgery, and orthodontic movement of natural teeth prior to extraction have attempted to preserve, maintain, and create moldable soft tissue.

T

Fig. 10 Moldable tissue after orthodontic movement

Table 2. Different techniques for moldable tissue

REFERENCES
1. Branemark Pl, Hansson BO, Adell R, et al.
Osseointegrated implants in the treatment of the edentulous jaw. Experience from a ten-year period. Scand J
Plast Reconstr Surg 1977; 16 (Suppl): 1-132.
2. Adell R, Lekholm U, Rockler B, et al. A 15-year study ofosseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg 1981; 10:387-416.
3. Albrektson T. A multicenter report on osseointegrated
oral implants. J Prosthet Dent 1988; 60:75-84.
4. Lazzara R, Siddiqui AA, Binon P, et al. Retrospective
multicenter analysis of 3i endosseous dental implants
placed over a five-year period. Clin Oral Implants Res
1996; 7:73-83.
5. Lekholm U, Gunne J, Henry P, et al. Survival of thebranemark implant in partially edentulous jaws: A 10year prospective multicenter study. Int J Oral Maxillofac
Impl 1999; 14:639-645.
6. Buser D, Mericske-Stern R, Bernard JP, et al. Long-term
evaluation of non-submerged ITI Implants. Part 1:8-year
life table analysis of a prospective multi-center study
with 2359 implants. Clin Oral Implants Res 1997; 8:161172.
7. Froum SJ. Immediate placement of implants into extraction sockets: Rationale, outcomes, technique. 2005;

98:19-33.
8. Rosenquist B, Grenthe B. Immediate placement of
implants into extraction sockets: Implant survival. Int J
Oral Maxillofac Implants 1996; 11:205-209.
9. Kan J, Rungcharassaeng K, Lozada J. Immediate
placement and rovisionalization of maxillary anterior single implants: 1-Year prospective study. Int J Oral
Maxillofac Implants 2003;18:31-39.
10. De Kok I, Chang SS, Moriarty JD, Cooper LF. A retrospective analysis of periimplant tissue responses at
immediate load/provisionalized microthreaded implants.
Int J Oral Maxillofac Implants 2006; 21:405-412.
11. Covani U, Barone A, Cornellini R, Crespi R. Soft tissue
healing around implants placed immediately after tooth
extraction without incision: A clinical report. Int J Oral
Maxillofac Implants 2004; 19:549-553.
12. Joseph Y Kan, Kitichai. K. Rungcharassaeng:Interimplant papilla preservationin the esthetic zone: A report of six consecutive cases. Int
J Periodontics Restorative Dent 2003; 23:249–259.
13. Lazzara RJ,Porter SS. Platform switching: A new concept in implant dentistry for controlling postoperative
crestal bone levels. Int J Peri Rest Dent 2006; 26:9-17.
14. Salama S,Salama M, The role of orthodontic extrusive

remodeling in the enhancement of soft and hard tissue
profiles prior to implant placement. Int J of Periodontics
Restorative Dent. 1993; 13:3:12-334.
15. David E.Grossberg. Interimplant papilla reconstruction: Asessment of soft tissue changes and results of 12
consecutive cases J of Periodont 2001; 72:958-962.
16. Pierre-Jean Wipff, Boris Hinz, et al. Myofibroblast contraction activates latent TGF-â1 from the extracellularmatrix. The Journal of Cell Biology, 2007; 179: 6: 13111323.
17. Berglundh T. et al. The topography of the vascular systems in the periodontal and peri-implant tissues in thedog. J Clin Periodontol 1994; 22: 189-193.
18. Harrison J, Jurosky K. Wound healing in the tissues ofthe periodontium following periradicular surgery. I. The
incisional wound. J Endod 1991; 17:425–435.
19. Tibbetts LS, Shanelec D. Current status of periodontal
microsurgery. Curr Opin Periodontol 1996; 3: 118–125.
20. Salama H, Salama M, Kelly J. The orthodontic-periodontal connection in implant site development. Prac
Periodontics Aesthet Dent 1996 ;Nov-Dec;8(9):923-32.
21. Cranska, Jeffrey. Laser soft-tissue therapy to regenerate a gingival papilla. Dentistry Today 2007; Dec.

This Presentation was Sponsored by New York University Department of Implant Dentistry
Alumni Association (NYUDIDAA) and the Office for International Program