Gingival esthetics has become an important success criterion for implant-supported restoration. Unesthetic implant restoration, therefore, is considered to be a failure. Especially for the anterior maxilla, esthetic results are quite an important factor for successful restoration and establishment of intact papilla between implant and tooth, or between adjacent implants. The level of inter-implant papilla is influenced by the previous bone level, soft tissue quantity and quality, peri-implant biotypes, implant position, and inter-implant distance [6
]. Therefore soft and hard tissue quality and quantity, peri-implant biotype [17
], implant diameter, position, and emergence profile [18
] should be considered with adequate treatment planning and evaluation of the surgical site prior to implant placement. If needed, ridge augmentation procedures using guided bone regeneration or/and connective tissue grafts are carried out prior to implant placement to attain a more acceptable esthetic result in the inter-implant papillary area. However, the predictable regeneration of the inter-implant papilla remains a complex challenge because most groups of supracrestal fibers do not exist in the gingival tissue surrounding the implant abutment and the blood supply of inter-implant papilla is restricted [19
] due to the absence of the periodontal ligament and the associated blood vessel branches. Four potential time points can be differentiated for soft and/or hard tissue management: prior to implant placement; at time of placement or during the healing phase of the implant; at second-stage surgery; and in the maintenance phase [20
]. Various surgical techniques have been suggested to reconstruct inter-implant papilla at the time of second stage implant surgery, but comparison of efficacy among techniques or long-term results is still insufficient, and the procedure is not predictable.
In this case, we tried to reconstruct inter-implant papilla with I-shaped incisions and the sutureless technique, which is a modification of the method suggested by Shahidi et al. [16
]. According to the method of Shahidi et al. [16
], a U-shaped flap, from the occlusal view, was created by two mesiodistal horizontal incisions and another buccolingual incision perpendicular to them. If multiple implants were placed, the U-shaped incisions were added to the distal side of the most distal implant to form an H-shaped design. The mesiodistal horizontal incision line ended halfway between the implant platform and the adjacent implant or tooth. The buccal horizontal incision formed a parabola buccally at the buccal border of the implant platform to create a gingival margin around the implant.
In this case, we suggest a new method including an I-shaped incision which was done over every implant for our case. To minimize the possibility of labial gingival tissue recession, labial horizontal incision lines were positioned 0.5-1.0 mm inside from the labial border of implants. Also, the horizontal incision is limited to the mesiodistal distance of the implant neck. The flaps were minimally elevated and healing abutments were connected. Each flap was supported by the healing abutments and able to plump up stably.
The advantages of this new method, compared to old ones, are decreased chair time, less postoperative discomfort and improved esthetics. This sutureless method with minimal incision does not decrease blood flow to the overlying flap and it minimized the probability of trauma or inflammatory reaction [21
]. Therefore, the above-described surgical technique would be the least invasive one. Two weeks after the second stage implant surgery, the surgical site showed uneventful healing and the patient reported less postoperative discomfort. Comparing to before the surgery, remarkable soft tissue augmentation between the two implants was achieved.