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 .
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 .
the following steps are involved in this technique.([figure 1]-schematic representation ) technique ( hand drawn 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 directionremove the cover screwsselect 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 ] . 
 
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 ] .
the clinical significance of attached gingiva around implants include 
 prevent spread of inflammationprevents recession of marginal tissueprovides tight collar around implantsenable patients to maintain good oral hygiene . 
 
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 .
the healing abutment should be in place for 2 weeks for the tissues to heal like papilla [ figure 7 ] .
healing after 2 weeks  with healing abutments 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 [ figures 8 and 9 ] .
this thickness of tissue / seal around implants was present even after 1-year follow - up and 2 years follow - up periods [ figure 10 ] .
postoperative restoration postoperative after 3 months two years postoperative 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 .
 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 vascularizationbevel incisions in the mobile flaps should be delicate and should vary according to the needsrotated pedicles should be tension freesuturing technique should provide a tight and firm connection of pedicles to bone and abutments . 
 
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 .
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 .
 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 . 
Case Report
Technique
Discussion
Conclusion