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Esthetic considerations related to bone and

soft tissue maintenance and development


around dental implants: Report of the
Committee on Research in Fixed Prosthodontics
of the American Academy of Fixed Prosthodontics
Arthur M. Rodriguez, DMD, MSa and Stephen F. Rosenstiel
BDS, MSDb
University of Pittsburgh School of Dental Medicine and Veterans
Affairs Medical Center, Pittsburgh, Pa; The Ohio State University,
College of Dentistry, Columbus, Ohio
In recent years the frequency of and esthetic demand for implant restorations in the esthetic zone has increased.
Recent literature has revealed numerous consistent trends which may aid the clinician in achieving predictable esthetics. Maintaining generous facial bone by judicious placement as well as by using implants with diameters of less than
4 mm appears to be beneficial. Avoiding adjacent implants in the esthetic zone while maintaining an implant to tooth
distance of between 2 mm and 4 mm seems to aid in bone and soft tissue maintenance. Abutment connections in
which the abutment is narrower than the implant offer distinct advantages, most notably increased bone heights.
Also, provisional restoration, especially early in treatment provides long-term esthetic benefits. (J Prosthet Dent
2012;108:259-267)
Implant-retained restoration in the
esthetic zone have long been difficult
for reasons which are well documented in the literature and anecdotally
acknowledged by many clinicians.1-4
Most prevalent among these are a
lack of facial bone and inadequate
interproximal tissue. However, the esthetic demands of clinicians as well as
the expectations of patients continue
to grow along with advances in component design and clinical technique.
The following discussion summarizes
relevant current literature in an attempt to establish evidence-based
guidelines for esthetic implant restorations.
Bone availability and maintenance

Inadequate facial bone is a common problem that can present itself
at any time following extraction and
often leads to a more lingual implant
placement and an anterior ridge lap
restoration.5 In an attempt to avoid
this situation, osseous grafting or

regeneration techniques are used.6,7


However, these can be both time
consuming and unpredictable. Even
when an implant can be placed, a thin
plate of facial bone is often all that remains, leading to thread exposure or
unpredictable future tissue height.8
Huynh et al9 found the average maxillary anterior bony wall thicknesses
following maxillary anterior extraction to be approximately 0.8 mm with
87% less than 1 mm. Recent trends
by clinicians to use wider diameter
implants (4 mm or greater) have also
contributed to inadequate facial bone
thickness or facial tissue recession.10
Recession often occurs following the
initiation of the restorative phase as
thin attached tissue supported by
inadequate bone cannot withstand
the stress created by restorative contours. The theoretical advantage of
wider diameter implants is not well
supported in the literature. A finite
element analysis by Petrie et al11 did
show a decrease in crestal bone strain
as implant diameter and length in-

creased while modeling a 20 mm


mandibular section. However, clinical
data demonstrating the advantages
of wide diameter implants are scarce.
In fact clinical studies showed similar
or somewhat lower success rates for
wider diameter implants12-15 Degidi et
al15 showed a 99.4% success rate for
510 narrow diameter implants (<3.75
mm) over 8 years, with some evidence
of increased success for implants
wider than 3.4 mm. A clinical study
of 182 3.3-mm-diameter implants in
severely resorbed maxillae revealed a
survival rate of 99.4%.16 Zinsli et al17
reported a 98.7% 5-year survival rate
for 298 of the same reduced diameter
implants, over a 10-year period. In
this study the implants were restored
with a variety of restorations, including single teeth, fixed prostheses, and
overdentures.
It has also been suggested that the
amount of remaining facial or lingual
bone following osteotomy is critical
for implant success1 (Fig. 1). Even after implant placement in fresh extrac-

Staff Prosthodontist and Assistant Program Director, Veterans Affairs Medical Center; and Assistant Professor, Department of
Prosthodontics, University of Pittsburgh School of Dental Medicine.
b
Professor Emeritus, Division of Restorative and Prosthetic Dentistry, The Ohio State University.
a

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1 Remaining buccal and lingual bone width following


osteotomy preparation. Widths of 1.5 to 2.0 millimeters
have been recommended.
tion sites, thinning of the buccal and
lingual walls occurs within the first
few weeks with an associated decrease
in buccal wall height.18 In a study on
dogs, Qahash et al19 concluded that
buccal bone width strongly influenced alveolar ridge resorption and
recommended a buccal bone width
of 2 mm or greater following implant
placement. Thicknesses of 1.5 to 2.0
mm on both the buccal and lingual
surfaces have been associated with
high success rates.20,21 It is also reasonable to assume that initial implant
stability, often stated as a prime factor for implant success, can only be
enhanced when substantial facial and
lingual walls remain after osteotomy
site preparation.22-24 A narrower implant also allows the surgeon to avoid
bony defects more easily or to traverse them with less thread exposure.
In these instances, the implant could
still be placed with excellent stability
and perhaps augmented with a minor graft or guided tissue procedure
as opposed to separate graft and implant placement procedures. In addition, a narrower implant may allow
placement to be shifted slightly lingually, while still providing relatively
anatomic lingual contours in the final
restoration. Given this, the use of a
standard or slightly narrow diameter
implant of 3.75 mm or less to prevent
perforation or thinning of the buccal
bone and associated attached tissue

loss or implant exposure has been


suggested.25,26
Preserving interproximal bone and
associated soft tissue is obviously also
central to achieving optimum esthetics. Crestal bone loss adjacent to the
implant has been long observed and
even expected in clinical practice.27,28
Rigid criteria for determining implant
success have even included an expectation of initial bone loss up to 1 mm
with continued yearly bone loss of up
to 0.2 mm per year.29 Many clinicians
and authors have observed bone loss
progressing to the first thread of the
implant and then slowing.30,31 Recent
implant and prosthetic component
design as well as clinical technique
have focused on preventing or reducing this crestal loss.
Abutment connection

The nature and location of the
abutment to implant connection and
its effect on crestal bone loss and inflammation have been frequently discussed.32,33 Some studies have shown
that the mere presence of this mechanical junction, in addition to poor
oral hygiene, has led to increased
inflammation of the marginal tissues.33,34 Hermann et al35 in a study
of submerged and nonsubmerged implants in dogs observed that bone loss
and remodeling always occur apical
to the abutment/implant interface.

The Journal of Prosthetic Dentistry

Piattelli et al36 evaluated bone loss in


regard to the location of the implant/
abutment junction. They found that
bone resorption occurred when the
junction was placed below the bone
crest and that less bone loss occurred
when the junction was placed supracrestally. Hammerle et al37 found
similar results while studying a rough/
smooth implant abutment connection placed at the alveolar crest rather
than at 1 mm below the crest, with
the subcrestally placed implants displaying significantly greater bone loss.
It should be noted that in both of
these studies the implant/abutment
connection extended to the outer
circumference of the implant. Wang
et al38 found no difference in bone
loss between crestally and subcrestally placed implants for both external
hexagon and Morse taper abutment
connections. Conversely, Todescan et
al39 and Welander et al40 in dog studies found that subcrestal placement
of the implant/abutment junction led
to less bone loss and a tendency toward thicker epithelium and connective tissue than crestal or supercrestal
placement. In addition multiple authors have shown that eliminating the
microgap by incorporating a 1-piece
implant/abutment design decreased
inflammatory response.41-43 Finne et
al42 followed 152 1-piece implants in
87 participants for up to 2 years and
reported a 97.9% success rate, minimal bone loss, and an excellent soft
tissue response. While, biologically,
1-piece designs are promising, the lack
of restorative flexibility seems to be a
challenge.
It is well established that a stable
internal abutment connection is biomechanically advantageous for long
term prosthodontic success.44 Currently there are multiple internal configurations, including various internal
hexagons, an internal triangulated or
cloverleaf design, and conical connections (Fig. 2). In addition, there
are many variations of the previously
mentioned connections as well as
systems which combine elements of
more than one design. Recently, some

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October 2012
significant effect on bone loss, while
the nonwelded groups consistently
showed higher levels of bone loss.
Heijdenrijk et al51 compared 2-piece
abutment/implant connections with
the connections placed above and
below the tissues to a 1-piece system
and found no association between
the presence of a microgap and inflammation.
Platform switching

B
2 A, Conical internal abutment connection; B, Internal
hexagon abutment connection.

definite advantages of the conical


connection have surfaced.45-50 Tesmer
et al45 have shown a decreased tendency for bacterial colonization given
the intimate fit afforded by the conical connection. Biomechanical complications, such as screw loosening or
component fracture, also seem to occur less with the conical connection,
theoretically because of decreased
micromovement at the implant/abutment junction.46-48 Schwarz49 noted
that the conical Morse taper has virtually eliminated abutment screw loosening and fracture. In a finite element
analysis study comparing multiple
systems and examining stress transmission to the crestal bone during
multiple loading conditions, the conical Morse taper connection with platform switch demonstrated the most
favorable stress transmission during all
nonaxial loading simulations.50
In addition to the specific configu-

Rodriguez and Rosenstiel

ration of internal fit, the intimacy of


fit and, therefore, the movement of
the abutment relative to the implant
may also affect stress transmission
as well as tissue health and subsequent crestal bone loss.51,52 In fact,
connection stability may have a more
important role than the presence of
a microgap with regard to inflammation and bone loss. Hermann et al53
showed that welded 2-piece implants
displayed less bone loss than conventionally joined 2-piece implant/abutment connections regardless of the
size of the microgap. King et al,52 in a
follow-up study, also concluded that
stability or lack of movement at the
abutment/implant junction was more
important than microgap size. They
compared welded 1-piece connections to 2-piece connections, while
varying the microgaps for each group
between 10 and 100 m and found
that the size of the microgap had no

Locating the abutment/implant


connection internally or away from
the bone/tissue to implant interface
has also been attempted. This concept, which involves an abutment of
decreased diameter relative to the
implant, is sometimes referred to as
platform switching.54, 55 While many
consider platform switching to be
a new concept, it has been incorporated into various systems for over 20
years.20,47,48 Platform switching moves
the abutment-implant interface inward, away from the outer circumference of the implant (Fig. 3). This
has been reported to decrease crestal
bone loss, preserve tissue height,
and promote soft tissue health.56-74
Whether this advantage is gained mechanically or biologically is debatable.
Some theorize that this configuration
shifts the inflammatory infiltrate inward, encouraging soft tissue and/or
bone to biologically seal off the outer
circumference of the implant from
the oral environment.56 Becker et al74
found no histological advantage to a
0.3-mm platform switch with respect
to bone remodeling in a dog study
over 24 weeks, suggesting that the
advantage may be a consequence of
a physical barrier. Other authors75,76
have reported a more favorable stress
distribution within the bone for platform switched connections.
Hurzeler et al62 showed significantly less bone loss 1 year after restoration placement for 14 platform
switched implant single crowns than
for 8 similarly restored implants
that did not incorporate a platform
switch. In a pair of clinical studies in-

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3 Platform switched implant-abutment connection. Note


narrower diameter of abutment relative to implant allowing
bone to remain undisturbed throughout restorative phase.
volving implants placed immediately
into extraction sites, Canullo et al63,64
showed generally less bone loss than
previously described in the literature
after a mean follow-up of 22 months.
Also they noted significantly less buccal tissue recession and greater papilla height in an experimental platform
switched group than in a nonplatform switched group. The treatment
protocol for both groups included
immediate provisional restoration
and placement of the definitive restoration 2 months following implant
placement. Vela-Nebot et al77 also
reported dramatically less bone loss
when using implant systems incorporating a narrower diameter of restorative components relative to implant
diameter. A comprehensive literature
review of 10 studies and 1239 implants by Atieh et al67 showed strong
evidence of less bone loss around the
platform switched implants, although
there was no difference in overall implant survival. The authors also noted
that a more favorable bone response
was seen when the platform switch
was 0.4 mm or greater. Wagenberg
and Froum68 followed 94 platform
switched connections over 11 years
and found that approximately 75%
showed no radiographic bone loss
with 88% displaying 0.8 mm or less
bone loss. Conversely a 2 year study
by Crespi et al,78 which compared external hexagon regular platform im-

plants to platform switched implants


placed in fresh extraction sites and
immediately loaded, showed no difference in bone loss.
In an attempt to mimic platform
switching, some implant manufactures offer implant designs in which the
coronal portion of the implant flares
to accommodate an abutment that is
roughly the same diameter as the implant body but narrower than the flared
neck.54 Using this concept, it has been
stated that a residual ridge width of at
least 6.3 mm is necessary to accommodate the flared design.79 For example,
Cocchetto et al80 followed 15 implants
with a 5.8 mm diameter receiving a 4.1
mm abutment healing cap and showed
an average bone loss of only 0.3 mm
at 18 months. However, this study required a minimum bone width of 8
mm for inclusion. Because bone width
of this dimension is exceptional in the
esthetic zone, this design may have limited application. Neck diameters of this
dimension will most likely necessitate
removal of the same critical coronal
bone that the clinician is trying to preserve. Also the resulting distance from
the implant to the adjacent tooth will
be minimal at best, preventing the establishment of a desirable interproximal
distance. Therefore, given the above, a
parallel walled implant of standard or
slightly narrow diameter with reduced
diameter restorative components
seems preferable.

The Journal of Prosthetic Dentistry

A distinct advantage of the implant/abutment diameter difference


is the ability to place the implant
subcrestally, encouraging bone and
soft tissue at the superior edge of the
implant circumference to remain and
even grow to or over the edge of the
implant and remain there undisturbed
by restorative components.59,60,81,82
Novaes et al59,60 found this to be true,
while noting greater papilla fill and
less bone loss for subcrestal placement than for crestal placement in
2 dog studies of platform switched
implants. They also concluded that
the presence of a microgap did not
adversely affect tissue health. Weng
et al81 compared a platform switched,
Morse taper design placed subcrestally to an external hexagon design.
They demonstrated bony overgrowth
only in the former. Veis et al82 compared 193 regular platform implants
to 89 platform switched implants
and found that the platform switched
design resulted in less bone loss only
when placed subcrestally. Conversely,
Cochran et al83 found slightly more
bone loss for platform switched implants placed 1 mm subcrestally than
for those placed crestally or 1 mm supracrestally.
Tenenbaum et al84 showed a greater number and greater length of connective tissue fibers around implants
which incorporated a nonflared neck
with reduced diameter abutments
than other designs. Attached tissue
thickness of greater than 2 mm has
been associated with a decreased tendency for buccal bone loss and tissue
recession around platform switched
implants.85- 87 This effect was even more
dramatic when implants were placed
supracrestally. Interestingly, when the
mucosa was considered thin (less than
2 mm), the authors found no advantage with regard to bone level for the
platform switched design.88 Subcrestal
placement leads to other esthetic
advantages. The distance from the
top of the implant to the emergence
of the restoration is maximized, allowing adequate vertical length for
the development of anatomic con-

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October 2012
tours and proper emergence profiles.
Priest61 recommended providing at
least 3 mm from the implant margin
to the zenith of the facial margins
of adjacent teeth, while noting that
provisional restoration is essential in
developing optimum esthetics. This
is especially critical when soft tissue
thickness is minimal.
Provisional Restoration
As in conventional restorative and
fixed prosthodontics, provisional restorations are an invaluable esthetic
and diagnostic tool. Provisional restoration of implants is often neglected
probably because provisional components are often time consuming and
cumbersome. Also many provisional
components do not readily accommodate angle correction. Attached
gingiva can be sculpted and molded
by means of the provisional restoration to help create the illusion of interdental papillae as well as contributing
to more stable, predictable overall esthetics and providing increased function.89-92 Providing anatomic fixed
provisional restorations also avoids
the introduction of dramatically different restorative contours at the time of
final restoration placement, decreasing the likelihood of postplacement
recession.63,93 Lai et al94 and Gallucci
et al95 showed that dramatic soft tissue changes, both in dimension as well
as health, occur following the initial
establishment of anatomic contours.
Although bone response was similar
to delayed provisional restoration,
Block et al92 found an average increase
in tissue height of 1 mm for immediately provisionally restored implants
following their placement in fresh extraction sites. Establishing these contours immediately, either at placement
or during second stage uncovering
has been shown to be especially effective.63,79,93,95 DeRouck et al93 compared
the postrestoration soft tissue contours of 24 immediately provisionally
restored implants to 25 restored with
a conventional 2-stage approach. They
found 2.5 to 3 times less midfacial re-

Rodriguez and Rosenstiel

cession and better predictability of papilla heights in the immediately provisionally restored group.
The use of definitive stock abutments placed intraorally by the clinician as opposed to laboratory prepared custom abutments would seem
to offer distinct advantages in the esthetic zone. Provisional restoration is
simplified, allowing the establishment
of a proximal contact point early in
the restorative phase to initiate papilla formation. The use of cumbersome, interim, partial removable dental prostheses is also obviated. Most
of all this technique eliminates the
multiple switching of various components during the restorative phase. Although such evidence in the literature
could not be found, it is these authors
opinion that the techniques afforded
by this type of abutment offer distinct
biologic and clinical advantages.
Parameters influencing papillary
tissue development

The possibility of papilla fill is
greatly enhanced when interproximal
bone is preserved, creating a reasonable opportunity to provide a desirable distance of 5 mm or less from
the proximal contact to the interseptal bone as described in the literature
for natural teeth as well as recently
for implants immediately adjacent
to natural teeth.96-99 Lops et al98 and
Gastaldo et al99 recommend 3 to 4
mm and 3 to 5 mm, respectively, between proximal contacts and bone
crest when the implant is adjacent
to a natural tooth. However, papilla
fill was observed, in some instances,
where the bone to contact distance
was as great as 9 mm, suggesting, not
surprisingly, that multiple factors influence soft tissue response.97 Palmer
et al100 also found, in a study of 46
participants with platform switched
implants, that papilla fill was observed when the proximal contact to
bone distance exceeded 4 to 5 mm.
It should be noted that both of these
studies involved implants adjacent
to natural teeth. In addition, Kwon

et al66 observed that in the tooth-implant-tooth clinical scenario, the critical distance is that from the proximal
contact to the bone level adjacent to
the natural tooth, termed tooth side
bone level. In this study of 17 implants and 37 papillae, they found
virtually complete papilla fill when the
average bone to contact distance was
4.88 mm or less and a lack of papilla
fill when this distance exceeded 6 mm.
The situation becomes much more
challenging when adjacent implants
are present. In a dog study of platform-switched implants, de Oliveira
et al101 found that a 5 mm bone to
proximal contact distance proved to
be the critical factor for papilla development between implants, regardless
of interimplant distances, which varied between 1 and 3 mm. Other investigators have observed that to achieve
papilla fill between implants, a proximal contact to bone crest distance
of 3 mm or less is desirable, while a
distance of 3 to 5 mm can provide
papilla fill between an implant and a
natural tooth.98
As previously mentioned, interimplant distance and tooth-to-implant
distance have been shown to play a
role and possibly interact with bone
to proximal contact distance. In a
more recent study involving the same
type of implants, de Oliveira et al102
reported increased bone remodeling
when interimplant distance was 1 mm
or less than in groups with 2 to 3 mm
interimplant distance. In the natural
dentition, Martegani et al103 found
that papilla loss increased dramatically when interradicular distances were
2.4 mm or less and that this factor
had both an independent and combined effect with proximal contact
distance. Degidi et al104 examined 152
implants and 99 interimplant sites
and found that optimum interimplant distance for papilla development was greater than 2 mm but less
than 4 mm. They also found that optimum bone to contact height should
be 3 to 4 mm and that papilla height
decreased dramatically when this distance exceeded 6 mm. Tarnow et al25

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Volume 108 Issue 4


also concluded that less interproximal
bone loss occurs as interimplant distance increases, while recommending a
minimum of 3 mm, lending further support to their earlier mentioned recommendation of using standard to narrow
diameter implants in the esthetic zone.
Garber et al105 have recommended in
order to maintain interproximal bone
height and the accompanying papilla,
that the implant should be placed at
least 1.5 mm from adjacent teeth and
3 mm from adjacent implants. Traini et
al106 also recommend a minimum of 3
mm interimplant distance to provide
optimum alveolar bone health. They
observed a more desirable orientation of collagen fibers and significantly
increased marrow spaces for interimplant distances of 3 mm in a histological dog study of 48 implants, sacrificed
24 months after implant placement. In
a similar follow-up study, they observed
that an interimplant distance of 3 mm
allowed for an increase in the development of blood vessels.107
While it is difficult to isolate clinical variables scientifically, the literature seems to indicate that the risk
to interproximal bone increases for
tooth-to-implant distances less than
3 mm.108 Conversely, in a 5-year study
of interproximal bone changes between implants, Chang et al109 found
that interimplant distance played a
minor role in final bone levels and
that the coronal height of bone to
implant contact was a better predictor. Lee et al110 found that both interimplant distance and bone to implant
contact level had minimal effect on
papilla height and that the width of
keratinized tissue exerted a greater
influence. However, the literature is
fairly consistent in showing that the
maintenance of proximal bone height
and associated papilla height seems
to be more difficult between adjacent
implants than in the tooth-implant
situation.111-113 In a retrospective study
evaluating previously mentioned variables, Kourkouta et al112 followed 35
implants in 15 participants and found
bone crest and papilla heights to be
4.6 mm and 2 mm lower, respectively,

for the implant-implant clinical situation than for the tooth-implant situation. They also found only 1 mm of
missing papilla height when the interimplant distance was 3 mm and that
immediate provisional restoration
reduced papilla loss from 2 mm to
1 mm. It is also noteworthy that, in
this study, 87.5% of participants were
pleased with their esthetic result even
with a papilla height discrepancy of 2
mm. Because most of these changes
have been found to occur within the
first 6 months following placement, the
advantages of early and long term provisional restoration seem clear. Tarnow
et al113 also recommended caution,
while reporting mean papillary tissue
heights of only 3.4 mm for 136 adjacent implant sites in 33 participants.
While 3 to 4 mm appears to be the
ideal interimplant distance, the use of
a platform switched design may allow
more bone and soft tissue maintenance
for enhanced esthetics, effectively increasing the interabutment distances
for implants in close proximity65,105 In a
study of 41 pairs of platform switched
implants in 37 participants, Rodriguez-Ciurana et al65 demonstrated
bone maintenance to be an average of
2.4 mm above the implant/abutment
interface at interimplant distances
less than 3 mm. As stated previously,
Novaes et al59,60 also found improved
papilla fill for subcrestally placed platform switched implants than for those
placed crestally. However, the papilla
height was not influenced by interimplant distance, which varied from 1
to 3 mm.59,60 In addition to his previously mentioned recommendation of
a 3 mm distance from implant to adjacent gingival margin zeniths, Priest61
similarly recommended 3 mm of interimplant distance as well as orienting the center of the implant 3 mm
palatal to the future facial restorative
margin. Therefore, because of the esthetic challenges detailed above, the
placement of adjacent implants in the
esthetic zone should be avoided whenever possible.114

The Journal of Prosthetic Dentistry

SUMMARY

A review of the current literature
suggests that the use of standard to
narrow diameter implants, a platform switched design, and early provisional restoration should be considered when long term esthetics are
paramount. Also, maintaining interimplant and tooth-to-implant distances of approximately 3 mm is desirable with regard to crestal bone maintenance and papilla development.
Subcrestal placement may afford adequate space to develop restorative
contours from the top of the implant
to restoration emergence while avoiding facial thread exposure. This may
be even more effective in combination with a platform switched design.
In addition, abutment to implant
connections, which are extremely intimate and allow little to no relative
movement, seem to offer distinct advantages with regard to tissue health.
Lastly, the use of noncustomizable
abutments and abutment level restorative techniques provides for ease of
provisional restoration and treatment
sequencing while avoiding multiple
exposures of the implant/abutment
junction, although the biological advantages this may offer have yet to be
investigated.

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Corresponding author:
Dr Arthur M. Rodriguez
1834 Liberty Way
Valencia, PA 16059
Fax: 412-527-4616
E-mail: arod1@zoominternet.net
Copyright 2012 by the Editorial Council for
The Journal of Prosthetic Dentistry.