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Volume 71 Number 4

The Effect of Inter-Implant Distance on

the Height of Inter-Implant Bone Crest*
D.P. Tarnow, S.C. Cho, and S.S. Wallace

Background: The biologic width around implants has been

well documented in the literature. Once an implant is uncovered,
vertical bone loss of 1.5 to 2 mm is evidenced apical to the
newly established implant-abutment interface. The purpose of
this study was to evaluate the lateral dimension of the bone loss

T
he existence of the biologic width
at the implant-abutment interface and to determine if this lat-
around teeth has been documented
eral dimension has an effect on the height of the crest of bone
in the literature. It was a study by
between adjacent implants separated by different distances.
Gargiulo et al.1 in 1961 that gave us a
Methods: Radiographic measurements were taken in 36
dimensional understanding of this physio-
patients who had 2 adjacent implants present. Lateral bone loss
logic attachment apparatus. The average
was measured from the crest of bone to the implant surface. In
distance from the base of the sulcus to the
addition, the crestal bone loss was also measured from a line
crest of the bone was found to be 2.04 mm.
drawn between the tops of the adjacent implants. The data were
The epithelial attachment averaged 0.97
divided into 2 groups, based on the inter-implant distance at
mm and the connective tissue attachment
the implant shoulder.
averaged 1.07 mm in length. Another
Results: The results demonstrated that the lateral bone loss
cadaver study by Vacek et al.2 in 1994 con-
was 1.34 mm from the mesial implant shoulder and 1.40 mm
firmed the consistency of these dimensions
from the distal implant shoulder between the adjacent implants.
while showing the connective tissue attach-
In addition, the crestal bone loss for implants with a greater than
ment to average 0.77 mm and the epithe-
3 mm distance between them was 0.45 mm, while the implants
lial attachment to average 1.14 mm.
that had a distance of 3 mm or less between them had a cre-
The presence of a biologic width around
stal bone loss of 1.04 mm.
implants has also been investigated. Multiple
Conclusions: This study demonstrates that there is a lateral
research groups have verified that a biologic
component to the bone loss around implants in addition to the
width also exists around implants.3-8 This is
more commonly discussed vertical component. The clinical sig-
true for implants of all shapes after uncov-
nificance of this phenomenon is that the increased crestal bone
ering (stage 2) surgery. For 1-piece non-sub-
loss would result in an increase in the distance between the base
merged implants4,7,8 or 2-stage implants
of the contact point of the adjacent crowns and the crest of
used with a single-stage non-submerged pro-
bone. This could determine whether the papilla was present or
tocol, the biologic width will form at the time
absent between 2 implants as has previously been reported
of implant placement. This phenomenon is
between 2 teeth. Selective utilization of implants with a smaller
not related to loading and it will occur
diameter at the implant-abutment interface may be beneficial
whether the implant is unloaded or loaded.7
when multiple implants are to be placed in the esthetic zone so
The biologic rationale is that the bone
that a minimum of 3 mm of bone can be retained between them
exposed to the oral cavity will always cover
at the implant-abutment level. J Periodontol 2000;71:546-549.
itself with periosteum and connective tissue.
KEY WORDS Additionally, connective tissue will always
Dental implants; dental implantation; bone loss; alveolar bone; cover itself with epithelium. If a chronic irri-
papilla. tant, such as bacteria, reaches the implant-
abutment interface through screw-access
channels,9-12 or if the abutment is removed
* Department of Implant Dentistry, New York University College of Dentistry, New York, NY.
after initial healing,6 the bone will resorb to
create a distance from this chronically
exposed or irritated area. Tarnow et al.13 have
previously histologically documented a sim-
ilar bone response to subgingival crown
preparations that violate the attachment
apparatus on human teeth.
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J Periodontol April 2000 Tarnow, Cho, Wallace

Two-stage implants are usually placed at or near Table 1.

the crest of bone. Once they are uncovered, an implant-
abutment interface is established and the bone resorbs
Recorded Data for Lateral and Crestal Bone
about 1.5 to 2.0 mm apically.8 This vertical bone loss Loss (see Figure 1)
has been well researched. The purpose of this paper
was to evaluate the lateral bone loss at the implant- Bone Loss (mm)
abutment connection and to see if this lateral dimen- Lateral A (n = 36) B (n = 36)
sion has an effect on the height of the crest of bone
between 2 implants separated by different distances. Mean 1.34 1.40

MATERIALS AND METHODS SD () 0.36 0.60

Thirty-six patients were utilized for this radiographic
study. These patients were part of a longitudinal study
conducted at the New York University Department of
Implant Dentistry on machined titanium implants. Radi-
ographic measurements were taken at a minimum of
1 and a maximum of 3 years after implant exposure.
Only areas with 2 adjacent implants were utilized for this
study. All radiographs were taken with a parallel tech-
nique utilizing a customized XCP bite block as a posi-
tioning index for consistency and reproducibility of the
radiographic images. The radiographs were computer
scanned, imaged, and magnified for measurement. Fig-
ure 1 illustrates the measurements taken for this study.
The lateral distances from the crest of the inter-
implant bone to the implants were recorded (A and B
in Fig. 1). In addition, the radiographs were divided
into 2 groups: those where the inter-implant distance
(D in Fig. 1) was 3 mm or less, and those where the
inter-implant distance was greater than 3 mm.
RESULTS
The lateral distance from the implant to the crest of the
ridge was 1.34 mm (SD = 0.36 mm) for A and 1.40
Bone Loss (mm)
Crestal D C
3 mm (n = 25) 1.04
>3 mm (n = 11) 0.45
mm (SD = 0.60) for B. The crestal bone loss (C) for
implants with a 3 mm or less distance between them
(as measured by D) was 1.04 mm, while the crestal
bone loss (C) for implants that were more than 3.0
mm apart was 0.45 mm. These data are presented in
Table 1.
DISCUSSION
These findings demonstrate two important facts. The
first is that there is a lateral component to the bone loss
after abutment connection of a 2-stage implant. The
second is that this lateral component of bone loss can
result in greater inter-implant crestal bone loss if the
two implants are not spaced more than 3 mm apart
(measurement D). The lateral dimension of the defect
is readily observed in Figures 2 and 3.

Figure 1.
Radiographic measurements recorded. A and B represent the lateral
distance (bone loss) from the implant to bone crest; C, vertical crestal
bone loss; and D, the distance between implants at the implant-
abutment interface.
Figure 2.
Inter-implant distance greater than 3 mm. Lateral bone loss from
adjacent implants (A and B from Figure 1) does not overlap, with
minimal resultant crestal bone loss (C from Figure 1).

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Inter-Implant Distance in the Alveolar Bone Crest
Figure 3.
Inter-implant distance 3 mm or less. Lateral bone loss from adjacent
implants (A and B from Figure 1) overlap, with resultant increase in
crestal bone loss (C from Figure 1).
In 1978 Waerhaug14 demonstrated that there was a
1.78 mm distance between plaque on teeth and the
surrounding bone. In addition, in 1984 Tal15 examined
the presence or absence of intrabony defects when
roots were at different distances apart. It is interesting
to note that the minimum distance between roots for
2 separate angular defects to be present on adjacent
teeth was 3.l mm. In other words, the lateral aspect of
each angular defect appears to be at least 1.55 mm
on each root. This distance correlates with the present
finding of 1.34 mm and 1.40 mm of bone loss (Fig.
1A and B, respectively) in the lateral direction from an
implant to the crest of bone.
Separating the data into 2 groups, with the inter-
implant distance of the first group being 3 mm or less
and that of the second group being greater than 3 mm,
Figure 4.
Relationship between crestal bone loss and inter-implant distance (see
Figure 1).
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Volume 71 Number 4
was based on the hypothesis that 2 adjoining implants
with 3 mm or less of separation should have increased
inter-implant bone loss as a result of the horizontal
distance that bone will be lost on each side of the inter-
implant crest. The scatter graph shown in Figure 4
demonstrates the clear trend of increased crestal bone
loss as the inter-implant distance decreases.
CONCLUSIONS
This paper demonstrates that there is a lateral com-
ponent to the bone loss around implants once the bio-
logic width has formed.
The clinical significance of this phenomenon is that
the increased crestal bone loss results in an increase
in the distance between the base of the contact point
of the adjacent crowns and the crest of bone. This
could determine whether the papilla will be present or
absent between 2 implants, as has been reported by
Tarnow et al.,16 between 2 teeth. In that study, a small
difference of 1 mm was clinically significant. When the
distance from the contact point to the crest was 5 mm,
the papilla was almost always present. When this dis-
tance increased to 6 mm, the papilla completely filled
the embrasure space in only 55% of the observed
cases.
It is commonly observed that it is more difficult to
maintain or create a papilla between 2 adjacent
implants than it is to maintain or create the papilla
between an implant and a natural tooth. This may indi-
cate that the selective utilization of implants with a
smaller diameter at the implant-abutment interface
may be beneficial when multiple implants are to be
placed in the esthetic zone so that a minimum of 3
mm of bone can be retained between them at the
implant-abutment level. It may also indicate that wide-
bodied implants adjacent to one another may be of
limited use in the esthetic zone, since they would dimin-
ish the inter-implant distance and potentially lead to
increased crestal resorption. Measurements are pres-
ently underway to evaluate whether the papillae are
affected by this crestal resorption between adjacent
implants.
REFERENCES
1. Gargiulo AW, Wentz FM, Orban B. Dimensions and rela-
tions of the dentogingival junction in humans. J Peri-
odontol 1961;32:261-267.
2. Vacek JS, Gher ME, Assad DA, Richardson AC,
Giambarresi LI. The dimensions of the human den-
togingival junction. Int J Periodontics Restorative Dent
1994;14:155-165.
3. Berglundh T, Lindhe J, Ericsson I, Marinello CP, Liljen-
berg B, Thomsen P. The soft tissue barrier at implants
and teeth. Clin Oral Implants Res 1991;2:81-90.
4. Buser D, Weber HP, Donath K, Fiorellini JP, Paquette
DW, Williams RC. Soft tissue reactions to non-submerged
unloaded titanium implants in beagle dogs. J Periodon-
tol 1992;63:226-236.
9046_IPC_AAP_553150 4/20/00 3:20 PM Page 549

J Periodontol April 2000 Tarnow, Cho, Wallace

5. Abrahamsson I, Berglundh T, Wennstrom J, Lindhe J. 14. Waerhaug J. Healing of the dento-epithelial junction fol-
The peri-implant hard and soft tissues at different implant lowing subgingival plaque control. II: As observed on
systems. Clin Oral Implants Res 1996;7:212-219. extracted teeth. J Periodontol 1978;49:119-134.
6. Abrahamsson I, Berglundh T, Lindhe J. The mucosal 15. Tal H. Relationship between the interproximal distance
barrier following abutment disconnection. An experi- of roots and the prevalence of intrabony pockets. J Peri-
mental study in dogs. J Clin Periodontol 1997;24:568- odontol 1984;55:604-607.
572. 16. Tarnow DP, Magner AW, Fletcher P. The effect of the
7. Cochran DL, Hermann JS, Schenk RK, Higgenbottom distance from the contact point to the crest of bone on
FL, Buser D. Biologic width around titanium implants. A the presence or absence of the interproximal dental
histometric analysis of the implanto-gingival junction papilla. J Periodontol 1992;63:995-996.
around unloaded and loaded non-submerged implants in
the canine mandible. J Periodontol 1997;68:186-198. Send reprint requests to: Dr. Dennis Tarnow, 205 E. 64th
8. Hermann JS, Cochran DL, Nummikoski PV, Buser D. Street, Suite 402, New York, NY 10021. Fax: 212/754-6753.
Crestal bone changes around titanium implants. A radi-
ographic evaluation of unloaded non-submerged and Accepted for publication August 19, 1999.
submerged implants in the canine mandible. J Peri-
odontol 1997;68:1117-1130.
9. Berglundh T, Lindhe J, Marinello C, Ericsson I, Liljenberg
B. Soft tissue reaction to de novo plaque formation on
implants and teeth. An experimental study in the dog.
Clin Oral Implants Res 1992;3:1-8.
10. Traversy MC, Birek P. Fluid and microbial leakage of
implant-abutment assembly in vitro. J Dent Res 1992:
71(Spec. Issue):54(Abstr. 1909).
11. Quirynen M, van Steenberghe D. Bacterial colonization
of the internal part of 2-stage implants. Clin Oral
Implants Res 1993;4:158-161.
12. Jansen VK, Conrads G, Richter E. Microbial leakage and
marginal fit of the implant-abutment interface. Int J Oral
Maxillofac Implants 1997;12:527-540.
13. Tarnow D, Stahl SS, Magner A, Zamzock J. Human gin-
gival attachment responses to subgingival crown place-
ment. Marginal remodeling. J Clin Periodontol 1986;
13:563-569.

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