1006_IPC_AAP_553341 10/3/01 2:59 PM Page 1364

Volume 72 • Number 10

Clinical and Radiographic Evaluation of the

Papilla Level Adjacent to Single-Tooth
Dental Implants. A Retrospective Study in
the Maxillary Anterior Region
Vincent Choquet,* Marc Hermans,* Philippe Adriaenssens,* Philippe Daelemans,† Dennis P. Tarnow,‡
and Chantal Malevez*†

Background: The regeneration of gingival papillae after single-implant

treatment is an area of current investigation. This study was designed
to determine: 1) whether the distance from the base of the contact point
to the crest of the bone would correlate with the presence or absence
of interproximal papillae adjacent to single-tooth implants, and 2)
whether the surgical technique at uncovering influences the outcome.
Methods: A clinical and radiographic retrospective evaluation of the

L
ong-term efficiency of screw-
papilla level around single dental implants and their adjacent teeth was retained dental implants ad
performed in the anterior maxilla in 26 patients restored with 27 implants. modum Brånemark has been
Six months after insertion, 17 implants were uncovered with a standard clearly demonstrated in cases of
technique, while 10 implants were uncovered with a technique designed complete edentulism1-3 and partial
to generate papilla-like formation around dental implants. Fifty-two edentulism.4-7 The high success
papillae were available for clinical and radiographic evaluation. The rate has allowed the application of
presence or absence of papillae was determined, and the effects of the osseointegration principles to be
following variables were analyzed: the influence of the 2 surgical tech- extended to single-tooth edentulism,
niques; the vertical relation between the papilla height and the crest of with similar success regarding the
bone between the implant and adjacent teeth; the vertical relation survival rate and marginal bone sta-
between the papilla level and the contact point between the crowns of bility, as observed in complete and
the teeth and the implant; and the distance from the contact point to partial edentulism.8-18
the crest of bone. One of the major problems
Results: When the measurement from the contact point to the crest encountered after tooth extraction
of bone was 5 mm or less, the papilla was present almost 100% of the is the hard and soft tissue loss.19
time. When the distance was ≥6 mm, the papilla was present 50% of Nowadays, the increased esthetic
the time or less. The mean distance between the crest of bone and the and functional demand20 aims to
most coronal papilla level (interproximal soft tissue height) was 3.85 mm establish a soft tissue contour with
(SD = 1.04). When comparing the conventional and modified surgical an intact papilla and a gingival out-
technique, the relation shifted from 3.77 mm (SD = 1.01) to 4.01 mm line that is harmonious with the gin-
(SD = 1.10), respectively. gival silhouette of the adjacent
Conclusions: These results clearly show the influence of the bone healthy dentition. Therefore, differ-
crest on the presence or absence of papillae between implants and adja- ent management of the soft tissue
cent teeth. The data also show a positive influence for the modified sur- around the single-tooth restoration
gical technique, aimed at reconstructing papillae at the implant uncov- to achieve an esthetic result has
ering. J Periodontol 2001;72:1364-1371. been proposed as: 1) promotion of
KEY WORDS the soft tissue between stage 1 and
stage 2 with healing abutments21
Dental papilla/anatomy and physiology; dental implants, single tooth;
or soft tissue grafting,22 or 2) cre-
oral surgery/methods.
ation of a papilla22-24 at stage 2
surgery using periodontal plastic
* Department of Implant Dentistry, University of Brussels, Faculty of Medicine, School of Dentistry, Oral
Pathology and Maxillo-Facial Surgery; Clinique Universitaire de Bruxelles, Université Libre de
techniques.
Bruxelles, Erasme Hospital, Brussels, Belgium. Despite the surgical techniques
† Department of Maxillo-Facial Surgery, University of Brussels, Faculty of Medicine; Clinique
Universitaire de Bruxelles.
developed, the regeneration of the
‡ Department of Implant Dentistry, New York University, New York, NY. papilla adjacent to dental implants

1364
1006_IPC_AAP_553341 10/3/01 2:59 PM Page 1365

J Periodontol • October 2001 Choquet, Hermans, Adriaenssens, Daelemans, Tarnow, Malevez

is still a matter of debate. Some authors have demon- because they were considered to be in a non-esthetic
strated the benefits of surgical management in increas- region of the mouth.
ing the surrounding hard and soft tissue;25 others have Of the 54 patients examined, 26 (48.15%) presented
discussed the importance of flap design in minimizing minimal plaque accumulation and soft tissue inflam-
possible mid-buccal recession;26 while others have mation and were analyzed for the study.
advocated a possible spontaneous regeneration of the
Patient Characteristics
papilla.27 Therefore, creating predictable papilla recon-
In this cross-sectional clinical study, 26 patients (18
struction around the single-tooth implant remains a
women, 8 men; mean age, 43 years; range, 21 to 68
complex challenge.
years) received 27 maxillary dental implants in the
Because the single-tooth implant is located close to
Department of Oral and Maxillo-Facial Surgery at the
a natural tooth, it remains difficult to delineate the
Erasme Hospital (Université Libre de Bruxelles). Two
peri-implant mucosa, gingiva, and the mutual influence
patients were smokers (up to 20 cigarettes/day). The
on the achievement of a peri-implant papilla. As
surgery was performed by 2 experienced oral and max-
observed on natural teeth, the biologic width explains
illofacial surgeons (CM and PD) under local anesthe-
part of the soft tissue height, and this seems to be
sia, following the protocol recommended for these
encountered around implants as well.28-30 Moreover,
implants.34 Twelve implants were localized in the max-
around teeth, a close relationship between the dis-
illary incisal region, 6 replaced the lateral incisor, and
tance from the contact point to the alveolar bone level
3 were located in the canine region. Two implants
has explained the presence or absence of interdental
replaced the first premolars; 4 replaced the second
papilla.31 In 1997, a classification of papilla restora-
premolar.
tion around single-tooth implants was proposed.27 It
All the implants were 13 or 15 mm in length.
describes the soft tissue, but does not explain the
Twenty-six implants had a diameter of 3.75 mm. One
influence of the different anatomical, surgical, and
implant replacing a lateral incisor had a diameter of
prosthetic components of the single-tooth implant
3.3 mm. After 6 months, second-stage surgery was
restoration. The purpose of this study was to charac-
performed by an experienced periodontist (PA), fol-
terize the bone level and papilla height in relation to
lowing 2 techniques: 1) the first technique, “conven-
the contact point adjacent to single-tooth, implant-
tional,” was described by Adell et al.,35 Lekholm and
supported restorations. The results were also com-
Jemt,36 and Odman37 and uncovers the implant by
pared to determine whether a new surgical technique
using a crestal incision with small releasing incisions;
recently described24 had any influence on the papilla
2) the second technique, “modified,” was described by
height compared to conventional exposure techniques.
Adriaenssens et al.24 and augments the soft tissue vol-
MATERIALS AND METHODS ume to generate interdental papillae. No punch tech-
nique was applied. Seventeen implants were treated by
We recalled patients treated with single implants from
the conventional technique, 10 implants by the mod-
the Department of Implant Dentistry at Erasme Hos-
ified technique. Different abutments were selected,
pital (Brussels, Belgium). All patients who had been
from standard abutments (N = 14)¶ to anatomic abut-
wearing a single-tooth restoration for at least 6 months
ments customized by the laboratory (1 titanium abut-
on osseointegrated dental implants§ qualified for par-
ment,# 1 ceramic abutment**); some were the more
ticipation in the study. Fifty-four patients had been
recent computer-individualized abutments (N = 11).††
treated with single implants; from this list, 26 agreed
The prosthetic treatment was performed at the Depart-
to participate in the study.
ment of Implant Dentistry, Erasme Hospital. The mean
Clinical evaluations were done at 3 buccal sites and
time since crown insertion was 35 months (6 to 75
3 palatal sites: 1) probing depth, performed using a
months).
periodontal probeL with standardized markings; 2)
The evaluation of papillae was made through a clin-
modified bleeding index;32 3) presence/absence of
ical and photographic examination. The presence or
plaque;33 4) gingival recession; and 5) presence/
absence of the interproximal papilla was determined
absence of mucosa. These parameters were used as
visually prior to probing and with a photographic slide
evaluation criteria. If the soft tissue was inflamed with
taken perpendicularly to the buccal surface of the sin-
increased probing depth and plaque accumulation, the
gle-tooth restoration crown. The index used was
patient was regarded as “inflamed” that day and
described by Jemt27 and defined briefly as score 0,
rejected, unless they could pass a second examination.
They were then reinstructed on proper oral hygiene
§ Brånemark System, Nobelpharma AB, Gothenburg, Sweden.
and reexamined during another session. These pre- L Goldman Fox/Williams probe, Hu-Friedy, Chicago, IL.
cautions were set to avoid any interpretation of ¶ CeraOne, NobelBiocare AB, Gothenburg, Sweden.
# Tiadapt, NobelBiocare.
pseudopocketing due to inflammation. Implants placed ** Ceradapt, NobelBiocare.
in the mandible were also rejected from the study †† Procera, NobelBiocare.

1365
1006_IPC_AAP_553341 10/3/01 2:59 PM Page 1366
Dental Implants and Interproximal Papillae
no papilla is present (Fig. 1); score 1, less than half
of the papilla is present; score 2, at least half of the
papilla is present, but not all the way up to the contact
point between the teeth; score 3, the papilla fills up the
entire proximal space and is in good harmony with the
adjacent papillae (Fig. 2); score 4, the papilla is hyper-
plasic and covers too much of the single-implant
restoration and/or the adjacent tooth. The papilla eval-
uation was done by 2 blinded investigators (VC and
MH) based upon the clinical readings and the slides.
Radiographic Data
Retroalveolar radiographs‡‡ were taken using the long-
cone paralleling and standardized method.38 The radio-
Figure 1.
Picture showing a clinical case where the papilla between the natural
tooth (7) and the implant replacing the central incisor (8)
demonstrated a score 0 (no papilla is present).
Figure 2.
Picture showing a clinical case where the papilla between the natural
central incisor (9) and the implant replacing the lateral incisor (10) fills
up the entire proximal space and is in good harmony with the
adjacent papillae.The papilla was scored as a 3.
1366
Volume 72 • Number 10
graphs were not plicatured to avoid deformation. The
x-ray generator was set at 15 mA, 70 Kvp. The eval-
uation was done immediately after exposure.
The radiographs were then digitized, using a dedi-
cated scanner§§ with a resolution of 2,048 per 3,072
lines. Data were analyzed by a computer.  The com-
puterized data were then written on a CD-ROM.¶¶ The
images were treated using software## to perform the
measurements. No modification was done to the pic-
tures. Measurements were done by an operator trained
to read implant radiographs (VC). The zero value was
set at the fixture abutment junction (FAJ). Measure-
ments were expressed as pixels and then converted to
mm with the known value of the shoulder of the implant.
Measures Principle
Calibration. A reference line had to be set to deter-
mine the remaining measures.39 Because it is a known
diameter, the implant abutment joint was selected. A
correction factor was therefore calculated between the
radiographic measure and the known value. All radio-
graphs were corrected along this principle to calibrate
the readings between the series of radiographs.
Measurement
The reference unit was the papilla. Therefore, the
mesial or distal location was not taken into account.
The following distances presented in Figure 3 were
measured to the nearest 0.01 mm:
1. The horizontal measure of the width of the implant
shoulder at the fixture abutment junction (FAJ) to serve
as a calibration tool and a parallel reference line to
relate the other vertical measures.
2. The vertical distance between the shoulder of the
implant and the most coronal point of the bone level
contacting the implant (a).
3. The vertical distance between the shoulder of the
implant and the most coronal point of the bone level
facing the teeth (b).
4. The vertical distance between the shoulder of the
implant and the most coronal papilla level (c).
5. The vertical distance between the shoulder of the
implant and the most apical level of the contact point
between the crown of the teeth and the implant (d).
6. The vertical distance between the crest of bone
and the contact point (e) = (d-b).
From the 27 examined implants, 52 papillae were
available for examination. Due to incorrect position-
ing of the intraoral radiograph or failure to show the
entire area, 2 of the 54 papillae could not be stud-
ied. All measurements were made by 2 authors (CV
and MH).
‡‡ Kodak Ektaspeed, Eastman Kodak Co., Rochester, NY.
§§ Kodak 6000 in raw.
 Kodak PCD Datamanager S 200.
¶¶ Kodak Photo CD.
## Photoshop, Adobe, San Jose, CA.
1006_IPC_AAP_553341 10/3/01 2:59 PM Page 1367
J Periodontol • October 2001
Figure 3.
Schematic drawing showing the selected reference points (FAJ) and
measured distances (a-d).
In 10 implants (20 papillae), a second set of mea-
surements was performed randomly to evaluate the
intra-observer variability. The mean difference between
the first and second assessment was negligible.
Because this study is cross-sectional and based on
descriptive criteria with multiple parameters, statisti-
cal analysis was not performed due to the small sam-
ple size of the different parameters.
RESULTS
Table 1 shows the clinical distribution of the papilla
level between the surgical technique and scoring
method. The data show that index scores of 327 with
a perfect 100% of papilla fill were achieved only in
57.7% of the papillae studied. The modified technique
achieved a better score of 68.5% compared to 51.5%
for the conventional technique.
After the radiographic calculation, the mean dis-
tance between the FAJ and the most coronal bone
contact level (a) was −1.76 mm (SD = 0.75). The max-
imum papilla level was obtained when the marginal
Choquet, Hermans, Adriaenssens, Daelemans, Tarnow, Malevez
bone level at teeth was a mean distance of 5.13 mm
(SD = 0.92) coronal to the FAJ (b) and when the coro-
nal bone contact level facing the implant was −1.64
mm (± 0.30) to the FAJ.
To ensure correct soft tissue adaptation around the
implant and avoid pseudo-pocket formation with the
modified technique, the relationship between PD and
papilla level was analyzed in Table 2. The PD facing
the implant was slightly greater than the PD facing the
natural tooth, with up to 7 mm encountered at the
implant, while only 4.5 mm was seen at the natural
tooth. However, a slight difference could be observed
with the modified technique compared to the conven-
tional technique. These results clearly show that PD is
neither increased at the implant level nor at the teeth
after surgery to increase the soft tissue level. While
analyzing the data of the soft tissue height in relation
to the distance between the bone crest and contact
point (Table 3), the overall results, without disclosing
the surgical technique, show a soft tissue height of
3.85 mm for the papilla. When disclosing the surgical
technique, the straight line relation remains. For the
conventional technique, a soft tissue thickness of ±
3.77 mm was observed, while the modified technique
achieved a thickness of ± 4.01 mm. A discrepancy
between the missing space to fill (distance bone crest/
contact point–soft tissue width) was only 1.47 mm for
the modified technique versus 2.98 mm for the con-
ventional technique.
Table 4 shows the papilla level in relation to the
interproximal bone crest to the contact point. The
results demonstrated that the majority of areas exam-
ined were between 4 to 7 mm in distance between the
contact point to the bone crest. When the distance
from the base of the contact point to the bone crest
Table 1.
Distribution of Papilla Presence or Absence
According to Surgery Technique: Index
Score Evaluation*
Index Score Total† Conventional Modified
Evaluation
0 4 (7.7) 4 (12) 0 (0)
1 2 (3.8) 1 (3.0) 1 (5)
2 16 (30.8) 11 (33.5) 5 (26.5)
3 30 (57.7) 17 (51.5) 13 (68.5)
4 0 0 0
* Jemt.27
† Number of papillae observed (%).
1367
1006_IPC_AAP_553341 10/3/01 2:59 PM Page 1368

Dental Implants and Interproximal Papillae Volume 72 • Number 10

was 3 to 4 mm, the papilla was fully present or almost (score 2) with the conventional technique, and 4.40
fully present (Jemt Index 2 and 3); between 5 to 6 mm (score 3) with the modified technique.
mm, a clear shift seemed to occur with missing papil-
DISCUSSION
lae (Jemt Index 0 and 1) 50% of the time. Moreover,
with the Jemt index score, we could see that the space The papillae analyzed in the present study presented
was not always completely filled (score 3), regardless bleeding on probing and probing depth comparable
of the distance. with other studies. It is still a matter of debate on how
Table 5 shows the relationship between the mean to interpret the inflammatory signs around implants.40
distance of the contact point to the bone crest and the The papillae included in this study did not present any
mean soft tissue height in relation to the Jemt index signs or symptoms of inflammation; therefore, misin-
score.27 The data confirm a clear shift of the presence terpretation of increased papilla volume due to inflam-
or absence of papillae between 5 to 6 mm. Moreover, mation was avoided.
the soft tissue height is at a maximum of 4.00 mm The interpretation of clinical papillae is a difficult
task since many different clinical situations can be
Table 2. encountered while studying single-tooth restorations:
from normal gingiva to a denuded root without any
Probing Depth at Natural Adjacent Teeth papillae. It explains why, in this present study of 54
and Single-Tooth Implants (mm  SD) recall patients, few implants remained (27 implants in
26 patients) to be analyzed when it was necessary to
Overall (52) Conventional (33) Modified (19) disclose between inflamed gingiva and pathologic con-
ditions. Moreover, many patients, once they were
Teeth 2.40 ± 0.84 2.50 ± 0.81 2.23 ± 0.87
rejected after the first examination and received cor-
Implants 3.65 ± 1.26 3.69 ± 1.32 3.57 ± 1.16 rective prophylactic instructions, did not present for a
second examination.
Table 3. A major criticism of the present study is that
the analysis was done on a vertical level and did
Soft Tissue Height in Relation to Distance not take into account the horizontal inter-
Between Bone Crest and Contact Point restoration distance as done in other studies.10,41
(mm  SD) The single-tooth restoration is a specific entity;
the mesio-distal width is never standardized from
Overall (52) Conventional (33) Modified (19) case to case, and even the distance between the
mesial or distal side of one implant is never the
Soft tissue height 3.85 ± 1.04 3.77 ± 1.01 4.01 ± 1.10 same. Therefore, the present study analyzed the
Distance contact point 6.29 ± 2.25 6.75 ± 2.55 5.48 ± 1.32 papilla as a unit and focused on the relationship
to bone crest between the adjacent teeth and the implant in a
vertical dimension. In addition, interpretation of
Table 4.
Presence/Absence of Papilla Around Single-Tooth Implant in Relation to Distance (mm)
From Contact Point to Bone Crest

<3 3 4 5 6 7 8 9 ≥10

N (1) (5) (7) (17) (8) (4) (4) (2) (4)

% present 100 (1)* 100 (5) 100 (7) 88 (15) 50 (4) 75 (3) 50 (2) 50 (1) 75 (3)

% absent 0† 0 0 12 (2) 50 (4) 25 (1) 50 (2) 50 (1) 25 (1)

Jemt Index Score

0 0 0 0 0 0 0 50 (2) 50 (1) 25 (1)

1 0 0 0 12 (2) 0 0 0 0 0

2 0 20 (1) 43 (3) 29 (5) 50 (4) 25 (1) 50 (2) 0 25 (1)

3 100 (1) 80 (4) 57 (4) 59 (10) 50 (4) 75 (3) 0 50 (1) 50 (2)

* Percentage of papillae observed (N); Jemt Index 2 and 3 combined.
† Jemt Index 0 and 1 combined.

1368
1006_IPC_AAP_553341 10/3/01 2:59 PM Page 1369
J Periodontol • October 2001
Table 5.
Mean Distance (mm  SD) Between Contact Point to Bone Crest and Mean Soft Tissue
Height in Relation to Papilla Index Around Single-Tooth Implant
Jemt N Papillae Soft
Index Score Observed Overall Tissue Height
0 4 9.25 ± 1.15 3.60 ± 0.6
1 2 5.76 ± 0.56 3.76 ± 0.7
2 16 6.23 ± 1.89 3.70 ± 0.8
3 30 5.95 ± 2.37 3.98 ± 1.2
radiographs is difficult.39 The present method of digi-
tizing the intraoral radiographs increased the accuracy
of the reading through a simple and inexpensive
method.
The index described by Jemt27 has been utilized in
the present study for a more descriptive and scientific
evaluation of the presence or absence of papillae.
When we carefully observe Table 4, a discrepancy
between the simplified index with a presence or
absence of papilla and the index score seems to
appear. It should be recognized that an analysis of
“present” or “not present” is subjective and that mis-
interpretation has been observed when related to score.
Some papillae read as not present were, in fact, pres-
ent at the half level and were a score 2–a much more
positive and scientific evaluation.
The present data support the concept observed
around teeth of the relationship between the papilla
level and the distance from the contact point to the
crest of the bone.31 Nearly the same values could be
observed in this study adjacent to single-tooth
implants. It seems reasonable to confirm the impact
of the distance from the bone crest to the contact
point to predictably determine the presence or
absence of papillae. As observed by Tarnow et al.31
in a study on teeth, the present study demonstrates
a shift in the presence or absence of papilla when the
distance between the contact point to the interdental
crest of bone is between 5 to 6 mm on a single-tooth
implant. At 6 mm and above, some papilla is still
observed (even at 9 mm or more) on teeth as well
as single-tooth implants, but with no predictability. The
regeneration of gingival papillae after single-tooth
implant treatment is possible when the contact point is
5 mm from the crest. Above 5 mm, papilla regenera-
tion is at least 50%, but with no predictability.
The analysis of the surgical technique reported in
Tables 1, 3, and 5 shows a positive influence with the
modified surgical technique. However, Table 5, which
compares the conventional and modified techniques in
relation to the index score, does not show a clear influ-
Choquet, Hermans, Adriaenssens, Daelemans, Tarnow, Malevez
Soft Soft
N Conventional Tissue Height N Modified Tissue Height
4 9.25 ± 1.15 3.60 ± 0.6 0 0 0
1 5.72 3.82 1 5.8 3.71
11 6.69 ± 1.91 4.00 ± 0.6 5 5.23 ± 1.59 3.04 ± 0.83
17 6.26 ± 2.94 3.65 ± 1.2 13 5.55 ± 1.32 4.40 ± 1.00
ence of the surgical technique. This observation could
be explained by the fact that in the present sample of
papillae studied, the modified technique was not applied
at or above a 7 mm distance. Nevertheless, Tables 4
and 5 show a superior soft tissue thickness at single-
tooth implants when a modified surgical technique was
applied. From the present study on implants as well
as the Tarnow study on teeth,31 no explanations could
be presented for the occurrence of some papillae with
9 mm or more between the bone crest and the con-
tact point. Further research is indicated to determine
the impact of other variables such as the mesio-distal
distance between the teeth and the implant, the total
embrasure space, the prosthetic component, and sur-
gical protocol.
Because this study is cross-sectional and not
prospective, it does not provide information about the
possible creeping attachment that could occur within
the 6 months between crown insertion and maturation
of the adjacent gingiva.27 Moreover, since the contact
point reference in this study is artificial, one could argue
that some of the interpretations may be influenced by
an artificially closed or open embrasure space. Never-
theless, the present study confirms a relationship
between the marginal bone and soft tissue level.30 The
soft tissue thickness, an average of 3.85 mm (SD =
1.04) as reported in Table 3, seems to be in accor-
dance with the concept of biologic width around teeth
and implants.28,29,42
From the present investigation, we established that
the papilla level around single-tooth implant restora-
tions is mostly related to the bone level adjacent to
the teeth and more specifically to the bone crest. The
regeneration of papillae after single implant treatment
is successful with a distance of 5 mm between the
contact point to the bony crest. Above 5 mm, the
occurrence of papilla regeneration is at least 50% but
with no predictability.
A surgical technique at uncovering that aims to fill
the embrasure space may considerably improve the
result with an increased soft tissue thickness but may
1369
1006_IPC_AAP_553341 10/3/01 2:59 PM Page 1370
Dental Implants and Interproximal Papillae
not always be mandatory if the final contact point
related to bone crest is calibrated correctly.
REFERENCES
1. Adell R, Lekholm U, Rockler B, Brånemark P-I. A 15-
year study of osseointegrated implants in the treatment
of the edentulous jaw. Int J Oral Surg 1981;10:387-416.
2. Adell R, Eriksson B, Lekholm U, Brånemark PI, Jemt T.
Long-term follow-up study of osseointegrated implants
in the treatment of totally edentulous jaws. Int J Oral
Maxillofac Implants 1990;5:347-359.
3. Brånemark PI, Svensson B, van Steenberghe D. Ten-
year survival rates of fixed prostheses on four or six
implants ad modum Brånemark in full edentulism. Clin
Oral Implants Res 1995;6:227-231.
4. Jemt T, Lekholm U, Adell R. Osseointegrated implants
in the treatment of partially edentulous patients: A pre-
liminary study on 876 consecutively placed fixtures. Int
J Oral Maxillofac Implants 1989;4:211-217.
5. Henry PJ, Tolman DE, Bolender C. The applicability of
osseointegrated implants in the treatment of partially
edentulous patients: Three-year results of a prospective
multicenter study. Quintessence Int 1993;24:123-129.
6. van Steenberghe D. A retrospective multicenter eval-
uation of the survival rate of osseointegrated fixtures
supporting fixed partial prostheses in the treatment
of partial edentulism. J Prosthet Dent 1989;61:217-
223.
7. van Steenberghe D, Lekholm U, Bolender C, et al.
Applicability of osseointegrated oral implants in the reha-
bilitation of partial edentulism: A prospective multicen-
ter study on 558 fixtures. Int J Oral Maxillofac Implants
1990;5:272-281.
8. Jemt T, Laney WR, Harris D, Henry PJ, Krogh PHJ, Herr-
mann I. Osseointegrated implants for single-tooth replace-
ment: A 1-year report from a multicenter prospective
study. Int J Oral Maxillofac Implants 1991;6:29-36.
9. Jemt T, Pettersson P. A 3-year follow-up study on sin-
gle implant treatment. Dentistry 1993;21:203-208.
10. Esposito M, Ekestubbe A, Gröndhal K. Radiological eval-
uation of marginal bone loss at tooth surfaces facing
single Brånemark implants. Clin Oral Implants Res
1993;4:151-157.
11. Laney WR, Jemt T, Harris D, et al. Osseointegrated
implants for single-tooth replacement: Progress report
from a multicenter prospective study after 3 years. Int
J Oral Maxillofac Implants 1994;9:49-54.
12. Ekfeldt A, Carlsson GE, Börjesson G. Clinical evaluation
of single-tooth restorations supported by osseointegrated
implants: A retrospective study. Int J Oral Maxillofac
Implants 1994;9:179-183.
13. Andersson B, Ödman P, Lindvall A-M, Lithner B. Single-
tooth restorations supported by osseointegrated implants:
Results and experiences from a prospective study after
2 to 3 years. Int J Oral Maxillofac Implants 1995;10:702-
711.
14. Lewis S. Anterior single-tooth implant restorations. Int
J Periodontics Restorative Dent 1995;15:31-41.
15. Engquist B, Nilson H, Astrand P. Single-tooth replace-
ment by osseointegrated Brånemark implants. Clin Oral
Implants Res 1995;6:238-245.
16. Malevez C, Hermans M, Daelemans P. Marginal bone
levels at Brånemark system implants used for single-
tooth restoration. The influence of implant design and
anatomical region. Clin Oral Implants Res 1996;7:162-
169.
1370
Volume 72 • Number 10
17. Henry PJ, Laney WR, Jemt T, et al. Osseointegrated
implants for single-tooth replacement: A prospective 5-
year multicenter study. Int J Oral Maxillofac Implants
1996;11:450-455.
18. Scheller H, Urgell JP, Kultje C, et al. A 5-year multi-
center study on implant-supported single crown restora-
tions. Int J Oral Maxillofac Implants 1998;13:212-218.
19. Andreasen JO, Ravn JJ. Epidemiology of traumatic den-
tal injuries to primary and permanent teeth in a Danish
population sample. Int J Oral Surg 1972;1:235-239.
20. Öhrnell L-O, Hirsch JM, Ericsson I, Brånemark P-I. Sin-
gle-tooth rehabilitation using osseointegration. A mod-
ified surgical and prosthodontic approach. Quintessence
Int 1988;19:871-876.
21. Salama H, Salama M, Garber D, Adar P. Developing
optimal peri-implant papillae within the esthetic zone:
Guided soft tissue augmentation. J Esthet Dent 1995;7:
125-129.
22. Israelson H, Plemons JM. Dental implants, regenerative
techniques, and periodontal plastic surgery to restore
maxillary anterior esthetics. Int J Oral Maxillofac Implants
1993;8:555-561.
23. Palacci P. Peri-implant soft tissue management: Papilla
regeneration technique. In: Palacci P, Ericsson I,
Engstrand P, Rangaert B, eds. Optimal Implant Posi-
tioning & Soft Tissue Management for the Brånemark
System. Chicago: Quintessence Publishing Co., Inc.;
1995:59–70.
24. Adriaenssens P, Hermans M, Ingber A, Prestipino V,
Daelemans P, Malevez C. Palatal sliding strip flap: Soft
tissue management to restore maxillary anterior esthet-
ics at stage 2 surgery: A clinical report. Int J Oral Max-
illofac Implants 1999;14:30-36.
25. Garber D, Belser U. Restoration-driven implant place-
ment with restoration-generated site development. Com-
pendium Continuing Educ Dent 1995;16:796-804.
26. Becker W, Becker BE. Flap designs for minimization of
recession adjacent to maxillary anterior implant sites:
A clinical study. Int J Oral Maxillofac Implants 1996;
11:46-54.
27. Jemt T. Regeneration of gingival papillae after single-
implant treatment. Int J Periodontics Restorative Dent
1997;17:326-333.
28. Berghlund T, Lindhe J. Dimension of the periimplant
mucosa. Biological width revisited. J Clin Periodontol
1996;23:971-973.
29. Abrahamsson I, Berghlund T, Lindhe J. The mucosal bar-
rier following abutment dis/reconnection. An experimental
study in dogs. J Clin Periodontol 1997;24:568-572.
30. Bengazi F, Wennstrom JL, Lekholm U. Recession of the
soft tissue margin at oral implants. A 2-year longitudi-
nal study. Clin Oral Implants Res 1996;7:303-310.
31. Tarnow DP, Magner AW, Fletcher P. The effect of the
distance from the contact point to the crest of bone on
the presence or absence of the interproximal dental
papilla. J Periodontol 1992;63:995-996.
32. Mombelli A, Mühle T, Brägger U, Lang NP, Bürgin WB.
Comparison of periodontal and peri-implant probing by
depth-force pattern analysis. Clin Oral Implants Res
1997;8:448-454.
33. O’Leary TJ, Drake RB, Naylor JE. The plaque control
record. J Periodontol 1972;43:38.
34. Brånemark PI, Zarb GA, Albrektsson T. Surgical proce-
dures. In: Brånemark P-I, Zarb GA, Albrektsson T, eds.
Tissue-Integrated Prosthesis: Osseointegration in Clinical
Dentistry. Chicago: Quintessence Publishing Co., Inc.;
1985:211-232.
1006_IPC_AAP_553341 10/3/01 2:59 PM Page 1371

J Periodontol • October 2001 Choquet, Hermans, Adriaenssens, Daelemans, Tarnow, Malevez

35. Adell R, Lekholm U, Rockler B, et al. Marginal tissue 42. van der Velden U. Regeneration of the interdental soft tis-
reactions at osseointegrated titanium fixtures (I). A 3- sue following denudation procedures. J Clin Periodontol
year longitudinal prospective study. Int J Oral Maxillofac 1982;9:455-495.
Surg 1986;15:39-52.
36. Lekholm U, Jemt T. Principles for single-tooth replace- Send reprint requests to: Prof. Chantal Malevez, Department
ment. In: Albrektsson T, Zarb GA, eds. The Brånemark of Maxillo-Facial Surgery, Erasme Hospital, 808 Route de
Osseointegrated Implant. Chicago: Quintessence Pub- Lennik, 1070 Brussels, Belgium. Fax: 32 2 555 45 99;
lishing Co., Inc.; 1989:117-126. e-mail: cmalevez@ulb.ac.be.
37. Öhrnell LO, Palmquist J, Brånemark PI. Single tooth
replacement. In: Worthington P, Brånemark PI, eds. Accepted for publication April 6, 2001.
Advanced Osseointegration Surgery: Applications in the
Maxillofacial Region. Chicago: Quintessence Publishing
Co., Inc.; 1992:211-232.
38. Strid K-G. Radiographic procedures. In: Brånemark P-I,
Zarb GA, Albrektsson T, eds. Tissue-Integrated Prosthe-
sis: Osseointegration in Clinical Dentistry. Chicago: Quin-
tessence Publishing Co., Inc.; 1985:187-198.
39. Meijer HJA, Steen WHA, Bosman F. A comparison of
methods to assess marginal bone height around
endosseous implants. J Clin Periodontol 1993;20:250-
253.
40. Flemming I. Clinical probing and radiographic assess-
ment in relation to the histologic bone level at oral
implants in monkeys. Clin Oral Implants Res 1997;8:255-
264.
41. Tarnow D, Cho S, Wallace S. The effect of inter-implant
distance on the height of inter-implant bone crest. J Peri-
odontol 2000;71:546-549.

1371