208 PERI-IMPLANT PAPILLAE • CHOW
Factors and Techniques Influencing
Peri-Implant Papillae
Yiu Cheung Chow, DDS, MS,* and Hom-Lay Wang, DDS, MSD, PhD†
oday, in implant dentistry, pa-
T tients not only want to restore
the lost masticatory function but
also want to demand aesthetically
pleasing restorative treatments. In the
maxillary anterior region, they have
come to expect prostheses replacing
their missing teeth to be identical to
the contralateral natural healthy teeth
and the gingival outline harmonious
with the gingival silhouette of the ad-
jacent teeth. Even though the dental
implant is successfully osseointe-
grated, it is devastating to a patient if
“black triangles” (i.e., missing inter-
proximal papilla) exists when they
smile and speak. Moreover, the loss of
implant papilla can cause phonetic
problems and food impaction. As a
result, the presence/absence of inter-
implant papilla has become a topic of
concern.
In natural dentition, the dental pa-
pilla is the gingival tissue, which oc-
cupies the embrasure space beneath
the contact area of 2 adjoining teeth.
The lateral borders and tips of the den-
tal papilla are formed by marginal
gingiva, and the intervening portion
consists of attached gingiva. Simi-
larly, the peri-implant papilla is the
soft tissue underneath the contact be-
*Private practice, Toronto, Canada.
†Professor and Director of Graduate Periodontics, Department
of Periodontics and Oral Medicine, School of Dentistry,
University of Michigan, Ann Arbor, MI.
Reprint requests and correspondence to: Hom-Lay
Wang, DDS, MSD, PhD, Department of Periodontics
and Oral Medicine, University of Michigan, School of
Dentistry, 1101 N. University, Ann Arbor, MI 48109-
1078, Phone: 734-763-3383, Fax: 734-936-0374,
E-mail: homlay@umich.edu
ISSN 1056-6163/10/01903-208
Implant Dentistry
Volume 19 • Number 3
Copyright © 2010 by Lippincott Williams & Wilkins
DOI: 10.1097/ID.0b013e3181d43bd6
AND WANG
Aim: Loss of implant papilla is
one of the more troubling dilemmas in
implant dentistry. The “black trian-
gle” around the implant-supported
restoration causes not only phonetic
difficulties and food impaction but
also unpleasant esthetics. This is con-
sidered to be a failure in today’s
implant therapy standards. As a con-
sequence, many techniques have been
developed to either preserve or regen-
erate the interimplant soft tissue. It is
the purpose of this article to examine
factors that may affect the appearance
of the peri-implant papilla.
Materials: MEDLINE search was
used to identify articles published
through September 2007 related to
implant esthetics as interimplant
papillae.
tween a natural tooth and an implant
or 2 adjacent implants. However, there
are some significant anatomical and
histologic differences between dental
and peri-implant papillae (Table 1).1–5
For example, the soft tissues around
osseointegrated implants contain a
larger proportion of collagen and a
lower proportion of fibroblasts than
the tissues adjacent to natural teeth.
Because of the lack of cementum for
collagen fiber insertion, the fibers
around a dental implant run parallel to
the implant’s surface rather than per-
pendicularly attached to the root
surface as seen in natural teeth. In
addition, there are fewer blood vessels
in the peri-implant mucosa as com-
pared to the gingiva around natural
teeth. Another important difference is
the location of biologic width. A den-
tal implant usually has a flat platform
Results: Factors such as crestal
bone height, interproximal distance,
tooth form/shape, gingival thickness,
and keratinized gingival width have
all been identified to influence the ap-
pearance of the interimplant papillae.
In addition, many techniques/
materials have been successfully
used in promoting interimplant pa-
pillae formation.
Conclusion: This article presents
a comprehensive review of factors that
may influence the interimplant papil-
lae and illustrates techniques used in
attempting to recreate/correct this
challenging problem in implant
dentistry. (Implant Dent 2010;19:
208 –219)
Key Words: implant, papillae, esthet-
ics, interproximal soft tissue
at the coronal end. As a result, the
implant is almost always positioned
below the interproximal alveolar crest,
which places the interproximal bio-
logic width subcrestally instead of su-
pracrestally as seen in natural teeth.
The subcrestal formation of biologic
width results in loss of interproximal
bone. Consequently, all these differ-
ences make preservation or regenera-
tion of peri-implant papilla even more
challenging. Peri-implant tissues are
similar to the periodontium with a
junctional epithelium containing basal
lamina and hemidesmosomes and con-
nective tissue fibers.6 However, be-
cause of lack of cementum, the
implant sulcus is often located at junc-
tion of implant-bone interface. This is
different than the natural tooth where
the sulcus is situated at cemento-
enamel junction (CEJ). This translates
 IMPLANT DENTISTRY / VOLUME 19, NUMBER 3 2010 209

Table 1. Tooth vs Dental Implant

Hard tissue interface
Bone-to-tooth/implant
Soft tissue interfaces
Junctional epithelium (JE)
关Origin兴
Connective tissue (CT)
Tissue quality
CT composition
Vascular supply 关sources兴
Clinical characteristics
Biologic width
Probing depth
Probing penetration
Bleeding on probing
Other characteristics
Prioprioception
Adaptability
Fulcrum
Axial mobility
Movement phases
Movement patterns
Tooth Implant
Resilient connection: bone-periodontal Rigid connection: functional ankylosis/
ligament (PDL)-cementum osseointegration; lack of PDL
Hemidesmosomes and basal lamina Hemidesmosomes and basal lamina
关Reduced enamel epithelium兴 关Adjacent oral epithelium兴
Perpendicular collagen fibers inserted Parallel collagen fiber bundles
into cementum
Lower proportion of collagen Higher proportion of collagen
Higher proportion of fibroblasts Lower proportion of fibroblasts
More 关Supraperiosteal, vascular plexus of PDL兴 Less 关Supraperiosteal兴
JE—1 mm JE—2 mm
CT—1 mm CT—1 mm
ⱕ3 mm 2.5–4.0 mm
Healthy: apical 1/3 JE Healthy: supracrestal CT
Gingivitis: coronal 1/3 CT Disease: bone
Periodontitis: apical 1/3 CT
More reliable sign of inflammation Less reliable sign of inflammation
Highly sensitive receptors present within PDL No receptors
(e.g., Ruffini-like mechanorecptor, coiled
Meissner’s corpuscles)
Width of PDL can alter to allow tooth movement No adaptive capacity and orthodontic
movement impossible
Apical 1/3 root Crestal bone
25–100 ␮m 3–5 ␮m
I. Nonlinear and complex I. Linear and elastic
II. Linear and elastic
Primary: immediate movement Gradual movement
Secondary: gradual movement

to about 2 mm vertical height differ-
ence to ensure for the papillae appear-
ance in both conditions (implant: 3
mm and natural tooth: 5 mm) because
normal bone level is often located at 2
mm below the CEJ.7–11
Because the presence of papilla is
one of the essential elements of ante-
rior esthetics, the clinician may be
willing to attempt to regenerate or im-
prove deficient papillary form even
though limited blood supply and ac-
cess plague the procedure and signifi-
cantly increase the risk of failure.
Over the years, many surgical and
nonsurgical techniques have been
proposed to treat this soft tissue de-
formity and manage the interproxi-
mal space.12–14 Nonetheless, because
of the limited sample size of case
reports in natural studies, the pre-
dictability of these techniques re-
mains to be determined.
Because reconstruction of peri-
implant papilla remains one of the
most difficult and unpredictable pro-
cedures in implant therapy, presurgi-
cal planning becomes critical for the
success of the therapy. A well-thought
and well-sequenced treatment plan de-
mands clinician understanding the fac-
tors influencing the appearance of
peri-implant papilla. This article will
review these potential clinical factors
that may influence the appearance of
interimplant papilla. In addition, the
current techniques of peri-implant pa-
pilla enhancement are discussed.
POTENTIAL CLINICAL FACTORS
Crestal Bone Height
The underlying osseous morphol-
ogy has long been recognized as the
foundation for the support of gingival
tissue.15–17 In a classic study, Tarnow
et al7 investigated the effects of crestal
bone height on the presence or ab-
sence of dental papilla. The authors
examined 288 interproximal sites and
demonstrated that the papilla was
present almost 100% of the time when
the distance from the contact point to
the crest of the bone was 5 mm or
less. Salama et al8 assumed a similar
relationship in implant-supported
restoration. Grunder confirmed this
speculation. The author presented a
case report of 10 single dental im-
plants in the maxillary central/lateral
incisor area and evaluated changes
in papilla height 1 year after func-
tion.9 All the peri-implant papillae
reformed after the final crowns were
placed on the implants when the cr-
estal bone level on the adjacent tooth
was 5 mm or less from the contact
point. Similarly, Choquet et al 10
studied the papilla level around sin-
210 PERI-IMPLANT PAPILLAE • CHOW
Table 2. Conditions Favoring Peri-Implant Papilla Appearance
Interproximal dimensions
Bone crest-contact point
Interproximal distance
Tooth factors
Crown form/shape
Contact length
Tooth position
Soft tissue factors
Gingival thickness
Gingival scallop
Keratinized gingival width
gle dental implants in 26 patients
and reported papilla was present al-
most 100% of the time when the
distance from the contact point to the
crest of the bone was 5 mm or less.
Interestingly, the occurrence of pa-
pilla regeneration was at least 50%
of the time when the distance was
ⱖ6 mm. Therefore, other factors,
such as horizontal distance between
the 2 adjacent teeth at the level of
CEJ, probably contributed to the
presence of the papilla.
Compared with a single dental im-
plant, regenerating a papilla between 2
adjacent implants is even more chal-
lenging.11 In a series of case reports,
Elian et al18 found a 5 mm height of
tissue between 2 implants was not rou-
tinely possible. Tarnow et al19 agreed
with the previous finding. The authors
examined a total of 136 interimplant
papillary heights in 33 patients and
found the mean papillary height was
only 3.4 mm. Although there was a
range of 1 mm to 7 mm, the soft tissue
heights were 2, 3, or 4 mm in 90% of
the cases. On the basis of these data,
the ideal distance from the base of the
contact point to the bone crest between
adjacent implants is 3 mm and, be-
tween a tooth and an implant, ⱕ5 mm
(Table 2).
Interproximal Distance
The interproximal distance has
been thought to affect the appearance
of the hard and soft tissue in the em-
brasure space. Heins and Wider20
demonstrated very thin lamina dura
existed when the inter-root distance
was ⬍0.5 mm. When the inter-root
distance became ⬍0.3 mm, the crestal
bone disappeared. Instead, the adja-
cent root surfaces were connected by
AND WANG
Single implant: ⱕ5 mm
Two adjacent implants: ⱕ3 mm
Single implant: ⱖ1.5 mm
Two adjacent implants: ⱖ3 mm
Squared shape
Long
Diastemas (with thick interpoximal bone)
Thick
Flat
ⱖ2 mm
the 2 adjacent periodontal ligament
spaces. On the basis of these findings,
teeth with root proximity are more
susceptible to crestal bone loss, which
can subsequently cause the papillary
disappearance. In addition, Tal found
that a vertical defect occurs only when
there is at least of 1.5 mm interdental
distance. Otherwise, horizontal crestal
bone loss occurs with the recession of
dental papilla.21 In a recent study of
206 dental papillae in 80 patients, Cho
et al22 supported this notion. The au-
thors found the ideal vertical dimen-
sion for papilla formation should be
ⱕ5 mm from the contact point to the
alveolar crest while the ideal hori-
zontal dimension was 1.5–2.5 mm
between adjacent roots. Besides, the
authors suggested there were inde-
pendent and combined effects of
both dimensions on the existence of
papillae.
These findings in natural teeth
make the researchers question if there
is a similar correlation in implant-
supported restoration. Tarnow et al23
investigated the effect of the interim-
plant distance on the height of inter-
implant bone crest. The authors found
that there was a lateral component of
bone loss around implants, and 3 mm
was a critical interimplant distance. If
the distance was ⬍3 mm, 0.56 mm
more pronounced bone loss was ob-
served. The authors then speculated
that this interimplant distance might
play a significant role for presence of
the papilla. A recent study performed
by a Brazilian group confirmed this
speculation. In a group of 48 patients
with 96 interproximal sites, Gastaldo
et al24 examined the effects of the ver-
tical and horizontal distances between
adjacent implants and between a tooth
and an implant on the incidence of the
papilla. When the distance between
adjacent implants and between a tooth
and an implant were ⬍3 mm, papilla
was absent 100% of time, regardless
of the vertical distance. Furthermore,
they found that there was an interac-
tion between horizontal and vertical
distances when the interproximal
spacing was ⬎3 mm. In contrast, No-
vaes et al25,26 failed to show any
significant effects of interimplant dis-
tance on papilla formation in a dog
model. In one of their 2 studies, 2
implants were inserted in the mandible
separated by 2 mm (group 1).26 Other
2 implants were separated by 3 mm
(group 2). In all cases, final metallic
crowns were fabricated to maintain a
distance of ⬃5 mm between the inter-
proximal contact and crestal bone. The
mean papilla heights in groups 1 and 2
were similar with 3.07 mm and 3.55
mm, respectively. The probable rea-
sons for these contrary results could be
due to the different study models (e.g.,
human vs dog) and different implant
designs (e.g., machined titanium im-
plant vs rough surfaced implant). Fur-
ther studies are necessary to resolve
this controversy.
Tooth Form/Shape
Tooth shape can be classified into
triangular, ovoid and square while
tooth form can be defined as long nar-
row or short wide. In natural dentition,
gingival morphology is partly related
to the tooth shape and form.16,27–30 In a
study of 192 subjects, Olsson and
Lindhe31 demonstrated patients with
long-narrow/triangular-shaped upper
central incisors experienced more
recession of the gingival margin at
buccal surfaces than those with a
short-wide form/square shape.11 In
their next study, Olsson et al32 re-
ported that individuals with the long-
narrow tooth form displayed a thin
free gingiva, a narrow zone of keratin-
ized gingiva, shallow probing depth,
and a pronounced “scalloped” contour
of the gingival margin. Likely, the
tooth shape and form can influence the
peri-implant soft tissue architecture as
well. Indeed, Kois33,34 described tooth
shape as 1 of the 5 essential diagnostic
keys for the peri-implant esthetics,

which should be considered in the pre-
surgical phase of implant therapy. In
his opinion, it impacts the tissue both
coronal and apical to the free gingival
margin (FGM). Coronal to the FGM,
individuals with square-shaped teeth
have a more favorable esthetic out-
come because of the long proximal
contact and less amount of papilla tis-
sue to fill the interproximal space. On
the contrary, the contact of triangular
tooth is short and more incisally posi-
tioned. The interproximal area re-
quires more tissue height to fill.
Therefore, in the case of triangular
tooth shape, there is higher risk of
black hole, and peri-implant papilla
regeneration can be very challenging.
Kois suggested, in this situation, mod-
ification of the adjacent tooth shape
with either direct composite or porce-
lain veneer may be necessary after an
implant-supported restoration. Apical
to the FGM, the triangular tooth shape
is more favorable than the square one.
The triangular teeth allow for roots
positioned farther apart than the
squared ones. As a result, there is po-
tentially thicker interproximal bone,
which may minimize crestal bone loss
and subsequent papilla loss after ex-
traction and implant placement.
Gingival Thickness
Gingival tissue biotype is another
important diagnostic key for peri-
implant esthetics.33,34 It was proposed,
2 basic types of gingival architecture
exist—“scalloped thin” and “flat-
thick.”11,29 Thin gingival tissue has
been described to have less underlying
osseous support and less vasculariza-
tion. As a result, the thin tissue is more
susceptible to trauma and increases the
risks of facial recession and loss of
interproximal tissue after any surgical
procedure. In contrast, thick gingival
tissue implies thicker underlying bone
structure, more fibrotic tissue, and
more blood supply. Therefore, the
thick tissue is more resistant to phys-
ical damage and bacterial ingress. In-
deed, abundant empirical evidence
suggests thick gingival tissue not only
resists physical trauma and subsequent
tissue recession but also allows better
tissue manipulation, encourages
creeping attachment, improves papilla
IMPLANT DENTISTRY / VOLUME 19, NUMBER 3 2010
fill, reduces clinical inflammation, and
renders predictable surgical out-
comes.33– 45 In a clinical trial on 24
patients, Oh et al46 studied the effects
of flapless implant surgery on the soft
tissue prolife. The authors found better
papillary index (PI)47 with the thick
soft tissue (ie ⱖ3 mm) than the thin
tissue (i.e., ⬍3 mm); however, the dif-
ference was not significant. In a case
series of 45 patients, Kan et al48 eval-
uated the dimensions of the peri-
implant mucosa around 2-stage
maxillary anterior single implants af-
ter 1 year of function. The authors
categorized the peri-implant biotype
into a thick or thin group by placing a
periodontal probe into the facial aspect
of the peri-implant mucosa. If the out-
line of the underlying probe could be
seen through the gingiva, the peri-
implant biotype was defined as thin. If
the probe could not be seen, the bio-
type was thick. The interproximal den-
togingival dimension in the subjects
with the thick biotype was signifi-
cantly greater than those with the thin
biotype (ie 4.5 mm vs 3.8 mm). There-
fore, peri-implant papilla may be
maintained or re-established with the
thick biotype.
Other Potential Factors
The relative tooth position, type
of gingival scallop and amount of ke-
ratinized/attached gingiva are other
possible factors that may determine
the level of papilla around dental im-
plant. Before removal of the hopeless
tooth, it is critical to evaluate its posi-
tion relative to the remaining dentition
because the existing tooth position
will influence the presenting configu-
ration of the gingival architecture.33,34
For example, tooth with root proxim-
ity has a very thin interproximal bone.
This thin bone is highly susceptible to
resorption after extraction, which will
subsequently cause the interproximal
soft tissue loss. In contrast, tooth with
diastemas possess thicker interproxi-
mal bone, which is at less risk for
resorption after wound healing. As a
result, peri-implant papilla preserva-
tion or regeneration will be more
predictable.
Based on a survey of 100 patients,
the gingival scallop can be categorized
211
into high, normal or flat.49 Compared
with the normal or high gingival scal-
lop, flat gingival architecture has less
tissue coronal to the bone interproxi-
mally than facially. It tends to follow
the osseous scallop creating less dis-
crepancy and less risk of interproxi-
mal tissue loss after tooth extraction.
Consequently, the maintenance of
interproximal papilla becomes more
predictable.33,34
The role of keratinized/attached
gingiva around natural teeth is a con-
troversial issue. It has been suggested
2 mm of keratinized tissue with at
least 1 mm attached tissue was re-
quired to maintain gingival health.50
However, others have found that the
amount of keratinized or attached gin-
giva was not critical for tissue health
but patient’s oral hygiene.43,44,50 –54
Similarly, there is a debate over the
need for keratinized and attached tis-
sue for the maintenance of dental im-
plants.43,50,53– 62 Currently, the general
consent is, with a proper plaque con-
trol, lack of adequate keratinized/
attached tissue will not increase the
incidence of attachment loss or soft
tissue recession. However, under the
condition of inflammation, the site
with inadequate keratinized tissue
(ie ⬍2 mm)/attached tissue (ie ⬍1
mm) is highly susceptible to pro-
gressive attachment loss and reces-
sion. In addition, new evidence
suggested, regardless of the surface
configurations, the absence of ade-
quate keratinized and attached tissue
in dental implants is associated with
higher plaque accumulation and gin-
gival inflammation.63 On the basis of
these data, one can speculate that
keratinized/attached tissue may in-
fluence on the appearance peri-
implant papilla, particularly in the
situation of inflammation.
DENTAL PAPILLA
ENHANCEMENT TECHNIQUE
Over the last 2 decades, various
techniques have been proposed to pre-
serve the papillary area or restore the
missing papilla. In general, these tech-
niques can be classified as surgical
and non-surgical (Table 3). The surgi-
cal technique focuses on soft and hard
tissue management, such as flap de-
212 PERI-IMPLANT PAPILLAE • CHOW AND WANG

Table 3. Peri-Implant Papilla Preservation and Regeneration Techniques 100% success rate of immediate im-
plant placement after a 1-year fellow-
Surgical Techniques
up. According to the Jemt PI,47 64.3%
Hard tissue management Soft tissue management papillae showed a score of 2, and the
Atraumatic tooth extraction and ridge Papilla preservation flap design remaining 35.7% showed a score of 3.
preservation (i.e., bone graft and/or Soft tissue graft (e.g., “split-finger” technique, The authors suggested that, with care-
membrane) subepithelial connective tissue graft) ful evaluation of potential extraction
Immediate dental implant placement
sites, immediate implant placement
Flapless implant surgery
promotes optimal implant esthetics.
Nonsurgical Techniques
In the event of multiple failing
Restorative/prosthetic treatments (e.g., contact reshaping, ovate pontic, provisional anterior teeth, simultaneous extraction
resin crown) of the adjacent teeth often leads to
Orthodontic extrusion flattening of the interproximal bony
scallop and results in implant restora-
signs and grafting procedures. The In a study on 24 patients, Iasella et al70 tions with missing interimplant papil-
non-surgical technique involves re- compared extraction alone with ridge lae. To manage this esthetic setback,
storative, prosthetic, and orthodontic preservation using freeze-dried bone Kan et al75 proposed an interimplant
procedures. In addition, some novel allograft and a collagen membrane. papilla preservation technique involv-
approaches (e.g., titanium papillary The ridge preservation group gained ing alternate removal of teeth atrau-
insert, autologous fibroblast injec- an average of 1.3 mm bone height. In matically with immediate implant
tions) have been suggested and contrast, the extraction alone group placement and provisionalization. The
reported in the recent dental lost an average of 0.9 mm. Although authors claimed that 1 side of the
literature.12,64 both groups lost ridge width, the ridge proximal bone and the associated pa-
preservation group only showed min- pilla can always be maintained while
SURGICAL TECHNIQUES imal resorption (⬃1 mm) while the the other side is healing. In addition,
Hard Tissue Management extraction alone group shrunk ⬃3 the adjacent tooth form can serve as a
To date, hard tissue management mm. The authors concluded the ridge guide for implant placement and pro-
becomes an essential component in im- preservation is a predictable procedure visionalization. In 6 patients, the au-
plant dentistry. Crestal bone resorption for the maintenance of ridge height, thors showed all interimplant papillae
after tooth extraction not only compro- width, and position. with a mean PI score of 3 after a mean
mises ideal implant placement but also Recently, immediate dental im- functioning time of 22.6 months. All
leads to unacceptable esthetic outcomes plant placement has become a feasible patients were satisfied with the final
(e.g., uneven soft tissue margin and loss and popular treatment option in the esthetic outcome.
of interproximal papilla). Misch65 rec- anterior maxilla in select situations. Implant placement with flapless
ommended that clinician should aug- Numerous case reports and some clin- approach provides some distinct ad-
ment crestal and interproximal region ical trials have shown that immediate vantages over the conventional open-
with dense hydroxyapatite at implant implantation may allow preservation flap approach, such as a lessened
surgery to elevate the soft tissue to the of the alveoli and surrounding struc- surgical time, less bleeding and post-
height of the desired interdental/interim- tures with favorable esthetic out- operative discomfort, minimal
plant papillae. At present, ridge defi- comes.48,71–74 Kan et al48 evaluated the changes in crestal bone level, soft tis-
ciency can be enhanced by means of implant success and esthetic outcomes sue inflammation, and probing depth
guided bone regeneration, autogenous of immediately placed and provision- adjacent to implants.46,76 – 80 Therefore,
ridge augmentation, and distraction alized maxillary anterior single im- flapless implant surgery is one possi-
osteogenesis.66 – 68 plants on 35 patients. After 12 months, ble treatment option for enhancement
As discussed in the previous sec- all implants were successfully os- of implant esthetics. Becker et al76
tion, controlling and conserving the seointegrated. The average marginal placed 79 implants in 59 patients using
hard tissue height can help in achiev- bone loss was ⬍0.3 mm. The midfa- one-stage flapless technique. At 2
ing desired papillary height. There- cial gingival level and mesial and dis- years, the cumulative success rate was
fore, at the time of tooth removal, tal papilla levels lost an average of ⬃99%. The changes in crestal bone
ridge preservation is critical to prevent 0.55 mm, 0.53 mm, and 0.39 mm, level were insignificant (i.e., 0.1 mm).
the loss of the underlying bone and respectively. None of the patients had The authors concluded flapless im-
rebuild the lost papilla in the final noticed any changes at the gingival plant surgery is a predictable proce-
implant-supported restoration. The level. The authors concluded that im- dure. Oh et al replaced a missing
tooth should be atraumatically ex- mediately placed and provisionalized single tooth in the premaxillary region
tracted by means of forceps rotation/ maxillary anterior single implants pro- with an endosseous implant using a
periotomes, and the socket space can vided favorable implant success rate flapless technique.46 The implants
be maintained by placing bone substi- and excellent esthetic outcomes. were either immediately loaded or de-
tute with or without a membrane.13,69 Juodzbalys and Wang72 also reported layed loaded. At 6 months, no signif-

icant differences were detected
between the 2 treatment groups in any
clinical parameters. The mean PI in
the immediate loading group in-
creased from 1.50 at baseline to 2.09
at 2 months and then remained stable
up to 6 months (i.e., 2.30). In the de-
layed group, the mean PI stayed the
same (i.e., 2.06 at both baseline and 6
months). There were minimal changes
of the marginal soft tissue level in both
treatment groups over 6-month period.
Both studies demonstrated flapless
implant surgery provides esthetic soft
tissue profile around single-tooth im-
plant restorations, regardless of the
loading protocol.
Soft Tissue Management
Two soft tissue management ap-
proaches are generally found in the
dental literature. The first approach fo-
cuses on the flap designs or surgical
techniques to maintain full papillary
form after the surgical procedure.81– 89
The second approach uses grafting
techniques to fill the open interproxi-
mal spaces.90 –104 However, because of
the minimal blood supply and difficult
access to the papillary tissue, only lim-
ited success has been achieved with
these approaches.12
Takei et al87 developed the “pa-
pilla preservation technique” with the
aim to improve the deficient interprox-
imal papillae between multiple teeth.
Later, various modifications of
Takei’s technique (e.g., modified pa-
pilla preservation technique, simpli-
fied papilla preservation technique and
papillary amplification flap) have been
proposed to optimize interproximal
soft tissue preservation.81– 83,88,89 Simi-
larly, the concepts of preserving blood
supply to the peri-implant papillae and
minimizing soft tissue recession in the
esthetic zone, such as paramarginal
pedicle flap, flap without disturbing
the periosteum, are advocated.84 – 86
Gomez-Roman85 compared 2 different
flap designs: a widely mobilized flap
that included papillae and a limited
flap that protected papillae, and deter-
mined their effects on the peri-implant
interproximal crestal bone loss. One
year after crown placement, the mean
interproximal bone loss was signifi-
cantly lower after the use of a limited
IMPLANT DENTISTRY / VOLUME 19, NUMBER 3 2010
flap design than the widely mobilized
flap procedure (ie 0.29 mm vs 1.12
mm). As a result, the limited flap de-
sign minimized the risk of papilla loss.
In addition, Flanagan84 proposed an
incision design, which allows lifting
of the gingiva without disrupting the
periosteum and its blood supply, to
promote the gingival base for the cre-
ation of interdental implant papilla.
A number of techniques have
been published to describe surgical
reconstruction of deficient dental/peri-
implant papillae.90 –104 All these tech-
niques are based on the traditional
plastic surgical approaches (e.g., sub-
epithelial connective tissue graft).
Palacci102 developed an unique papilla
regeneration technique at stage 2 un-
cover for multiple implants, in which a
semilunar beveled incision is per-
formed in the elevated flap in relation
to each implant to create a pedicle.
The pedicle is then rotated 90 degree
toward the mesial aspect of the abut-
ment and stabilized with interrupted
mattress sutures to form a new interim-
plant papilla. Subsequently, numerous
modifications of Palacci’s technique
have been reported in case studies or
clinical trials.97,99,101 In a recent pilot
study, Misch et al99 used a “split-finger”
incision design to promote papilla for-
mation. The authors reported 16 single-
tooth implant restorations with a mean
PI score of 3 while 5 multiple implant-
supported prostheses had a mean PI
score of ⱖ2. In addition, soft tissue
grafting was also suggested to enhance
papillary appearance.93,103 In a single
case report, Price and Price103 described
the use of subepithelial connective tissue
graft to restore papillae adjacent to a
single dental implant. The authors
showed a 3-year clinical follow-up with
complete gingival papillae. Similarly,
Azzi et al93 reported 3 successful cases,
in which a subepithelial connective tis-
sue graft was inserted in a pouch to
move the entire peri-implant gingivo-
papillary unit incisially.
Despite these extensive efforts to
preserve or regenerate papillary tissue,
none of these procedures provide evi-
dence of predictability, and few dem-
onstrate long-term stability.
213
NONSURGICAL TECHNIQUES
Restorative/Prosthetic Treatment
In certain circumstances, restor-
ative/prosthetic techniques may be
helpful for treating papillary insuffi-
ciency, for example, when all hard and
soft tissue augmentation procedures
fail to achieve esthetic outcomes or
when patients refuse any surgical in-
terventions. By means of restorative/
prosthetic reshaping, the contact of the
crowns can be lengthened and located
more apically.98,105–107 As a result, the
open embrasure space is reduced with
an illusion of papilla regeneration.
After a single anterior tooth re-
moval, Spear108 advocated the use of
ovate pontic to help in molding the
papillary height and gingival embra-
sure form. In a single case report, Al-
Harbi109 adapted Spear’s concept and
successfully enhanced the interim-
plant papillary tissue by a cantilevered
fixed partial denture with an ovate
pontic. Similarly, Jemt110 attempted to
promote interimplant papillary forma-
tion by the means of placing a provi-
sional resin crown at the time of
second-stage surgery. The author
showed that the use of provisional
crowns were able to guide the soft
tissue into the interimplant space
faster than healing abutments alone;
however, the volumes of the papillae
adjacent to single-implant restorations
were similar after 2 years of function.
Orthodontic Therapy
Orthodontic therapy offers the best
esthetic outcomes in several distinct
clinical situations.107 In the presence of
diastema, the interdental papilla is ap-
parently missing. This situation can be
remedied by combining orthodontic
tooth approximation with apical posi-
tioning of the contact point through
stripping.111 Root divergence is another
situation that can lead to the open inter-
proximal space when the contact point
between the 2 clinical crowns is situated
too incisally. Again, orthodontic treat-
ment can create a new papilla by
aligning the roots and squeezing the in-
terproximal tissue.96 In addition, when
teeth or roots are indicated for extrac-
tion, forced orthodontic extrusion
should be considered to enhance both
hard and soft tissue profiles.112 This
214 PERI-IMPLANT PAPILLAE • CHOW
eruption technique can be valuable for
the improvement of the peri-implant pa-
pilla height.13
NOVEL APPROACH
McGuire and Scheyer 12 intro-
duced an innovative papilla priming
procedure in an attempt to enhance
papillary form. Twenty-one subjects
with interdental papillary deficiency
were enrolled. The deficient sites were
randomized to receive autologous fi-
broblast injections or placebo injec-
tions. At 2 months, the test sites
showed more papillary height gain
than the placebo sites. However, the
treatment effect disappeared at 4
months. Future research in this area is
certainly needed.
CONCLUSION
At this point, the crestal bone
level seems to be the primary factor
for the presence of peri-implant pa-
pilla. Similarily, the interproximal dis-
tance may affect the existence of the
papilla. In addition, there are also
other potential factors, such as tissue
thickness, keratinized/attached tissue
width, tooth form/shape and position.
Unfortunately, these factors have
never been fully investigated due to
lack of funding and long-term follow-
up. Future studies are necessary to
clarify the importance of each of these
factors. Although numerous tech-
niques showed successful papillary
preservation or regeneration, most
were documented in case reports, and
none has been proved to be predictable
in the long term. Therefore, more con-
trolled clinical trials are needed to
evaluate the efficiency of these papil-
lary enhancement techniques.
Disclosure
The authors claim to have no fi-
nancial interests, either directly or in-
directly, in the products or companies
listed in the study.
ACKNOWLEDGMENTS
This study was supported by the
Periodontal Graduate Student Re-
search Fund, University of Michigan.
AND WANG
REFERENCES
1. Berglundh T, Lindhe J, Ericsson I, et
al. The soft tissue barrier at implants and
teeth. Clin Oral Implants Res. 1991;2:
81-90.
2. Berglundh T, Lindhe J, Jonsson K,
et al. The topography of the vascular sys-
tems in the periodontal and peri-implant
tissues in the dog. J Clin Periodontol.
1994;21:189-193.
3. Cochran DL, Hermann JS, Schenk
RK, et al. Biologic width around titanium
implants. A histometric analysis of the
implanto-gingival junction around un-
loaded and loaded nonsubmerged
implants in the canine mandible. J Peri-
odontol. 1997;68:186-198.
4. Kim Y, Oh TJ, Misch CE, et al. Oc-
clusal considerations in implant therapy:
Clinical guidelines with biomechanical ra-
tionale. Clin Oral Implants Res. 2005;16:
26-35.
5. Oh TJ, Yoon J, Misch CE, et al. The
causes of early implant bone loss: Myth or
science? J Periodontol. 2002;73:322-333.
6. Etter TH, Hakanson I, Lang NP, et al.
Healing after standardized clinical probing
of the perlimplant soft tissue seal: A histo-
morphometric study in dogs. Clin Oral Im-
plants Res. 2002;13:571-180.
7. 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.
8. Salama H, Salama MA, Garber D,
et al. The interproximal height of bone: A
guidepost to predictable aesthetic strat-
egies and soft tissue contours in anterior
tooth replacement. Pract Periodontics
Aesthet Dent. 1998;10:1131-1141;
quiz 42.
9. Grunder U. Stability of the mucosal
topography around single-tooth implants
and adjacent teeth: 1-year results. Int J
Periodontics Restorative Dent. 2000;20:
11-17.
10. Choquet V, Hermans M, Adriaens-
sens P, et al. Clinical and radiographic
evaluation of the papilla level adjacent to
single-tooth dental implants. A retrospec-
tive study in the maxillary anterior region.
J Periodontol. 2001;72:1364-1371.
11. Garber DA, Salama MA, Salama H.
Immediate total tooth replacement. Com-
pend Contin Educ Dent. 2001;22:210-
216, 218.
12. McGuire MK, Scheyer ET. A ran-
domized, double-blind, placebo-
controlled study to determine the safety
and efficacy of cultured and expanded au-
tologous fibroblast injections for the treat-
ment of interdental papillary insufficiency
associated with the papilla priming proce-
dure. J Periodontol. 2007;78:4-17.
13. Pradeep AR, Karthikeyan BV. Peri-
implant papilla reconstruction: Realities
and limitations. J Periodontol. 2006;77:
534-544.
14. Prato GP, Rotundo R, Cortellini P,
et al. Interdental papilla management: A re-
view and classification of the therapeutic
approaches. Int J Periodontics Restorative
Dent. 2004;24:246-255.
15. Becker W, Ochsenbein C, Tibbetts
L, et al. Alveolar bone anatomic profiles as
measured from dry skulls. Clinical ramifica-
tions. J Clin Periodontol. 1997;24:727-
731.
16. Hirschfeld I. A study of skulls in the
American Museum of Natural History in re-
lation to periodontal disease. J Dent Res.
1923;241-265.
17. Ochsenbein C, Ross S. A concept
of osseous surgery and its clinical applica-
tion. In: Ward HL, Chas CT, eds. A Peri-
odontal Point of View. Springfield: Charles
C. Thomas Publisher Ltd.; 1973.
18. Elian N, Jalbout ZN, Cho SC, et al.
Realities and limitations in the manage-
ment of the interdental papilla between
implants: Three case reports. Pract
Proced Aesthet Dent. 2003;15:737-744;
quiz 746.
19. Tarnow D, Elian N, Fletcher P, et al.
Vertical distance from the crest of bone to
the height of the interproximal papilla be-
tween adjacent implants. J Periodontol.
2003;74:1785-1788.
20. Heins PJ, Wieder SM. A histologic
study of the width and nature of inter-
radicular spaces in human adult pre-
molars and molars. J Dent Res. 1986;65:
948-951.
21. Tal H. Relationship between the in-
terproximal distance of roots and the prev-
alence of intrabony pockets. J Periodontol.
1984;55:604-607.
22. Cho HS, Jang HS, Kim DK, et al.
The effects of interproximal distance be-
tween roots on the existence of interdental
papillae according to the distance from the
contact point to the alveolar crest. J Peri-
odontol. 2006;77:1651-1657.
23. Tarnow DP, Cho SC, Wallace SS.
The effect of inter-implant distance on the
height of inter-implant bone crest. J Peri-
odontol. 2000;71:546-549.
24. Gastaldo JF, Cury PR, Sendyk WR.
Effect of the vertical and horizontal distances
between adjacent implants and between a
tooth and an implant on the incidence of in-
terproximal papilla. J Periodontol. 2004;75:
1242-1246.
25. Novaes AB Jr, de Oliveira RR,
Muglia VA, et al. The effects of interimplant
distances on papilla formation and crestal
resorption in implants with a morse cone
connection and a platform switch: A histo-
morphometric study in dogs. J Periodon-
tol. 2006;77:1839-1849.
26. Novaes AB Jr, Papalexiou V,

Muglia V, et al. Influence of interimplant dis-
tance on gingival papilla formation and
bone resorption: Clinical-radiographic
study in dogs. Int J Oral Maxillofac Im-
plants. 2006;21:45-51.
27. Morris ML. The position of the mar-
gin of the gingiva. Oral Surg Oral Med Oral
Pathol. 1958;11:969-984.
28. Seibert JS. Surgical management
of osseous defects. In: Goldman HM, Co-
hen DW, eds. Periodontal Therapy. Saint
Louis: CV Mosby; 1973:765-766.
29. Weisgold A. Contours of the full
crown restoration. Alpha Omegan. 1977;
70:77.
30. Wheeler RC. Complete crown form
and the periodontium. J Prosthet Dent.
1961;11:722-734.
31. Olsson M, Lindhe J. Periodontal
characteristics in individuals with varying
form of the upper central incisors. J Clin
Periodontol. 1991;18:78-82.
32. Olsson M, Lindhe J, Marinello CP.
On the relationship between crown form
and clinical features of the gingiva in ado-
lescents. J Clin Periodontol. 1993;20:570-
577.
33. Kois JC. Predictable single tooth
peri-implant esthetics: Five diagnostic
keys. Compend Contin Educ Dent. 2001;
22:199-206; quiz 208.
34. Kois JC. Predictable single-tooth
peri-implant esthetics: Five diagnostic
keys. Compend Contin Educ Dent. 2004;
25:895-896, 898, 900 passim; quiz 906-
907.
35. Borghetti A, Gardella JP. Thick gin-
gival autograft for the coverage of gingival
recession: A clinical evaluation. Int J Peri-
odontics Restorative Dent. 1990;10:216-
229.
36. Harris RJ. Creeping attachment
associated with the connective tissue with
partial-thickness double pedicle graft.
J Periodontol. 1997;68:890-899.
37. Matter J. Creeping attachment of
free gingival grafts. A five-year follow-up
study. J Periodontol. 1980;51:681-685.
38. Muller HP, Eger T. Masticatory mu-
cosa and periodontal phenotype: A review.
Int J Periodontics Restorative Dent. 2002;
22:172-183.
39. Muller HP, Heinecke A, Schaller N,
et al. Masticatory mucosa in subjects with
different periodontal phenotypes. J Clin
Periodontol. 2000;27:621-626.
40. Muller HP, Schaller N, Eger T, et al.
Thickness of masticatory mucosa. J Clin
Periodontol. 2000;27:431-436.
41. Nelson SW. The subpedicle connec-
tive tissue graft. A bilaminar reconstructive
procedure for the coverage of denuded root
surfaces. J Periodontol. 1987;58:95-102.
42. Serino G, Wennstrom JL, Lindhe J,
et al. The prevalence and distribution of
gingival recession in subjects with a high
IMPLANT DENTISTRY / VOLUME 19, NUMBER 3 2010
standard of oral hygiene. J Clin Periodon-
tol. 1994;21:57-63.
43. Wennstrom J, Lindhe J. Plaque-
induced gingival inflammation in the ab-
sence of attached gingiva in dogs. J Clin
Periodontol. 1983;10:266-276.
44. Wennstrom J, Lindhe J. Role of at-
tached gingiva for maintenance of peri-
odontal health. Healing following excisional
and grafting procedures in dogs. J Clin
Periodontol. 1983;10:206-221.
45. Claffey N, Shanley D. Relationship
of gingival thickness and bleeding to loss of
probing attachment in shallow sites follow-
ing nonsurgical periodntal therapy. J Clin
Periodontol. 1986;13:654-687.
46. Oh TJ, Shotwell JL, Billy EJ, et al.
Effect of flapless implant surgery on soft
tissue profile: A randomized controlled
clinical trial. J Periodontol. 2006;77:874-
882.
47. Jemt T. Regeneration of gingival
papillae after single-implant treatment. Int
J Periodontics Restorative Dent. 1997;17:
326-333.
48. Kan JY, Rungcharassaeng K,
Lozada J. Immediate placement and pro-
visionalization of maxillary anterior single
implants: 1-year prospective study. Int
J Oral Maxillofac Implants. 2003;18:31-39.
49. Kois JC. Altering gingival levels:
The restorative connection part I: Biologic
variables. J Esthet Dent. 1994;6:3-9.
50. Lang NP, Loe H. The relationship
between the width of keratinized gingiva
and gingival health. J Periodontol. 1972;
43:623-627.
51. Ericsson I, Lindhe J. Recession in
sites with inadequate width of the keratin-
ized gingiva. An experimental study in the
dog. J Clin Periodontol. 1984;11:95-103.
52. Kennedy JE, Bird WC, Palcanis
KG, et al. A longitudinal evaluation of vary-
ing widths of attached gingiva. J Clin Peri-
odontol. 1985;12:667-675.
53. Miyasato M, Crigger M, Egelberg J.
Gingival condition in areas of minimal and
appreciable width of keratinized gingiva.
J Clin Periodontol. 1977;4:200-209.
54. Wennstrom JL. Lack of association
between width of attached gingiva and de-
velopment of soft tissue recession. A
5-year longitudinal study. J Clin Periodon-
tol. 1987;14:181-184.
55. Adell R, Lekholm U, Rockler B, et
al. A 15-year study of osseointegrated im-
plants in the treatment of the edentulous
jaw. Int J Oral Surg. 1981;10:387-416.
56. Becker W, Becker BE, Newman
MG, et al. Clinical and microbiologic find-
ings that may contribute to dental implant
failure. Int J Oral Maxillofac Implants. 1990;
5:31-38.
57. Block MS, Kent JN. Factors asso-
ciated with soft- and hard-tissue com-
promise of endosseous implants. J Oral
Maxillofac Surg. 1990;48:1153-1160.
215
58. Deporter DA, Watson PA, Pilliar
RM, et al. A histological evaluation of a
functional endosseous, porous-surfaced,
titanium alloy dental implant system in the
dog. J Dent Res. 1988;67:1190-1195.
59. Kirsch A, Ackermann KL. The IMZ
osteointegrated implant system. Dent Clin
North Am. 1989;33:733-791.
60. Warrer K, Buser D, Lang NP, et al.
Plaque-induced peri-implantitis in the
presence or absence of keratinized mu-
cosa. An experimental study in monkeys.
Clin Oral Implants Res. 1995;6:131-138.
61. Wennstrom JL, Bengazi F, Lek-
holm U. The influence of the masticatory
mucosa on the peri-implant soft tissue
condition. Clin Oral Implants Res. 1994;
5:1-8.
62. Zablotsky M. The surgical manage-
ment of osseous defects associated with
endosteal hydroxyapatite-coated and tita-
nium dental implants. Dent Clin North Am.
1992;36:117-149, discussion 49-50.
63. Chung DM, Oh TJ, Shotwell JL, et
al. Significance of keratinized mucosa in
maintenance of dental implants with differ-
ent surfaces. J Periodontol. 2006;77:
1410-1420.
64. el-Salam el-Askary A. Inter-implant
papilla reconstruction by means of a tita-
nium guide. Implant Dent. 2000;9:85-89.
65. Misch CE. Single tooth implants:
Difficult, yet overused. Dent Today. 1992;
11:46, 48-51.
66. Kaufman E, Wang PD. Localized
vertical maxillary ridge augmentation using
symphyseal bone cores: A technique and
case report. Int J Oral Maxillofac Implants.
2003;18:293-298.
67. Kay SA, Wisner-Lynch L, Marxer
M, et al. Guided bone regeneration: Inte-
gration of a resorbable membrane and a
bone graft material. Pract Periodontics
Aesthet Dent. 1997;9:185-194, quiz 96.
68. Lehrhaupt NB. Alveolar distraction:
A possible new alternative to bone grafting.
Int J Periodontics Restorative Dent. 2001;
21:121-125.
69. Zetu L, Wang HL. Management of
inter-dental/inter-implant papilla. J Clin
Periodontol. 2005;32:831-839.
70. Iasella JM, Greenwell H, Miller RL,
et al. Ridge preservation with freeze-dried
bone allograft and a collagen membrane
compared to extraction alone for implant
site development: A clinical and histologic
study in humans. J Periodontol. 2003;74:
990-999.
71. Cardaropoli D, Debernardi C,
Cardaropoli G. Immediate placement of
implant into impacted maxillary canine
extraction socket. Int J Periodontics Re-
storative Dent. 2007;27:71-77.
72. Juodzbalys G, Wang HL. Soft and
hard tissue assessment of immediate im-
plant placement: A case series. Clin Oral
Implants Res. 2007;18:237-243.
216 PERI-IMPLANT PAPILLAE • CHOW
73. Wheeler SL, Vogel RE, Casellini R.
Tissue preservation and maintenance of
optimum esthetics: A clinical report. Int
J Oral Maxillofac Implants. 2000;15:265-
271.
74. Zeren KJ. Minimally invasive ex-
traction and immediate implant placement:
The preservation of esthetics. Int J Peri-
odontics Restorative Dent. 2006;26:171-
181.
75. Kan JY, Rungcharassaeng K. In-
terimplant papilla preservation in the es-
thetic zone: A report of six consecutive
cases. Int J Periodontics Restorative Dent.
2003;23:249-259.
76. Becker W, Goldstein M, Becker
BE, et al. Minimally invasive flapless im-
plant surgery: A prospective multicenter
study. Clin Implant Dent Relat Res. 2005;7
Suppl 1:S21-27.
77. Campelo LD, Camara JR. Flapless
implant surgery: A 10-year clinical retro-
spective analysis. Int J Oral Maxillofac Im-
plants. 2002;17:271-276.
78. Kan JY, Rungcharassaeng K,
Ojano M, et al. Flapless anterior implant
surgery: A surgical and prosthodontic ra-
tionale. Pract Periodontics Aesthet Dent.
2000;12:467–474, quiz 76.
79. Oh TJ, Shotwell J, Billy E, et al.
Flapless implant surgery in the esthetic
region: Advantages and precautions. Int J
Periodontics Restorative Dent. 2007;27:
27-33.
80. Petrungaro PS. Immediate resto-
ration of implants utilizing a flapless ap-
proach to preserve interdental tissue
contours. Pract Proced Aesthet Dent.
2005;17:151-158, quiz 60.
81. Cortellini P, Prato GP, Tonetti
MS. The modified papilla preservation
technique. A new surgical approach for
interproximal regenerative procedures.
J Periodontol. 1995;66:261-266.
82. Cortellini P, Prato GP, Tonetti MS.
The simplified papilla preservation flap. A
novel surgical approach for the manage-
ment of soft tissues in regenerative proce-
dures. Int J Periodontics Restorative Dent.
1999;19:589-599.
83. Cortellini P, Tonetti MS. Microsur-
gical approach to periodontal regenera-
tion. Initial evaluation in a case cohort.
J Periodontol. 2001;72:559-569.
84. Flanagan D. An incision design to
promote a gingival base for the creation of
interdental implant papillae. J Oral Implan-
tol. 2002;28:25-28.
85. Gomez-Roman G. Influence of flap
design on peri-implant interproximal cr-
estal bone loss around single-tooth im-
plants. Int J Oral Maxillofac Implants. 2001;
16:61-67.
86. Khoury K, Happe A. Soft tissue
AND WANG
management in oral implantology: A review
of surgical techniques for shaping an es-
thetic and functional peri-implant soft tis-
sue structure. Quintessence Int. 2000;31:
483-499.
87. Takei HH, Han TJ, Carranza FA Jr,
et al. Flap technique for periodontal bone
implants. Papilla preservation technique.
J Periodontol. 1985;56:204-210.
88. Zucchelli G, De Sanctis M. The pa-
pilla amplification flap: A surgical approach
to narrow interproximal spaces in regener-
ative procedures. Int J Periodontics Re-
storative Dent. 2005;25:483-493.
89. Zucchelli G, Mele M, Checchi L. The
papilla amplification flap for the treatment of a
localized periodontal defect associated with
a palatal groove. J Periodontol. 2006;77:
1788-1796.
90. Adriaenssens P, Hermans M, Ing-
ber A, et al. Palatal sliding strip flap: Soft
tissue management to restore maxillary
anterior esthetics at stage 2 surgery: A clin-
ical report. Int J Oral Maxillofac Implants.
1999;14:30-36.
91. Azzi R, Etienne D, Carranza F. Sur-
gical reconstruction of the interdental pa-
pilla. Int J Periodontics Restorative Dent.
1998;18:466-473.
92. Azzi R, Etienne D, Sauvan JL, et al.
Root coverage and papilla reconstruction
in class IV recession: A case report. Int J
Periodontics Restorative Dent. 1999;19:
449-455.
93. Azzi R, Etienne D, Takei H, et al.
Surgical thickening of the existing gingiva
and reconstruction of interdental papillae
around implant-supported restorations. Int
J Periodontics Restorative Dent. 2002;22:
71-77.
94. Azzi R, Takei HH, Etienne D, et al.
Root coverage and papilla reconstruction
using autogenous osseous and connec-
tive tissue grafts. Int J Periodontics Restor-
ative Dent. 2001;21:141-147.
95. Beagle JR. Surgical reconstruction
of the interdental papilla: Case report. Int J
Periodontics Restorative Dent. 1992;12:
145-151.
96. Carnio J. Surgical reconstruction of
interdental papilla using an interposed
subepithelial connective tissue graft: A
case report. Int J Periodontics Restorative
Dent. 2004;24:31-37.
97. Grossberg DE. Interimplant papilla
reconstruction: Assessment of soft tissue
changes and results of 12 consecutive
cases. J Periodontol. 2001;72:958-962.
98. Han TJ, Takei HH. Progress in gin-
gival papilla reconstruction. Periodontol
2000. 1996;11:65-68.
99. Misch CE, Al-Shammari KF, Wang
HL. Creation of interimplant papillae
through a split-finger technique. Implant
Dent. 2004;13:20-27.
100. Nemcovsky CE. Interproximal pa-
pilla augmentation procedure: A novel sur-
gical approach and clinical evaluation of 10
consecutive procedures. Int J Periodontics
Restorative Dent. 2001;21:553-559.
101. Nemcovsky CE, Moses O, Artzi Z.
Interproximal papillae reconstruction in
maxillary implants. J Periodontol. 2000;71:
308-314.
102. Palacci P. Perio-Implant Soft Tis-
sue Management: Papilla Regeneration
Technique. Chicago: Quintessence; 1995.
103. Price RB, Price DE. Esthetic res-
toration of a single-tooth dental implant us-
ing a subepithelial connective tissue graft:
A case report with 3-year follow-up. Int J
Periodontics Restorative Dent. 1999;19:
92-101.
104. Tinti C, Benfenati SP. The ramp
mattress suture: A new suturing technique
combined with a surgical procedure to ob-
tain papillae between implants in the buc-
cal area. Int J Periodontics Restorative
Dent. 2002;22:63-69.
105. Bichacho N. Papilla regeneration
by noninvasive prosthodontic treatment:
Segmental proximal restorations. Pract
Periodontics Aesthet Dent. 1998;10:75,
77-78.
106. Blatz MB, Hurzeler MB, Strub JR.
Reconstruction of the lost interproximal
papilla–presentation of surgical and non-
surgical approaches. Int J Periodontics
Restorative Dent. 1999;19:395-406.
107. Kokich VG. Esthetics: The
orthodontic-periodontic restorative con-
nection. Semin Orthod. 1996;2:21-30.
108. Spear FM. Maintenance of the in-
terdental papilla following anterior tooth re-
moval. Pract Periodontics Aesthet Dent.
1999;11:21-28; quiz 30.
109. Al-Harbi SA. Nonsurgical man-
agement of interdental papilla associated
with multiple maxillary anterior implants: A
clinical report. J Prosthet Dent. 2005;93:
212-216.
110. Jemt T. Restoring the gingival
contour by means of provisional resin
crowns after single-implant treatment. Int J
Periodontics Restorative Dent. 1999;19:
20-29.
111. Ingber JS. Forced eruption: Alter-
ation of soft tissue cosmetic deformities.
Int J Periodontics Restorative Dent. 1989;
9:416-425.
112. Salama H, Salama M. The role of
orthodontic extrusive remodeling in the en-
hancement of soft and hard tissue profiles
prior to implant placement: A systematic
approach to the management of extraction
site defects. Int J Periodontics Restorative
Dent. 1993;13:312-333.
 IMPLANT DENTISTRY / VOLUME 19, NUMBER 3 2010
Abstract Translations
GERMAN / DEUTSCH
AUTOR(EN): Yiu Cheung Chow, DDS, MS, Hom-Lay
Wang, DDS, MSD, PhD
Faktoren und Methoden, die Papillen im Implantat an-
gelagerten Umfeld beeinflussen
ZUSAMMENFASSUNG: Zielsetzung: Der Verlust der Im-
plantatpapille ist eine der komplizierteren, weil vielfach Prob-
leme verursachenden unerwünschten Situationen in der
Implantat-Zahnheilkunde. Das “schwarze Dreieck” um die Im-
plantatgestützte Wiederherstellungslösung herum führt nicht nur
zu phonetischen Schwierigkeiten und dem Einklemmen von
Speiseresten, sondern ist auch aus ästhetischen Gesichtspunkten
unangenehm. Dies wird als Versagen gemäß den heutigen Stan-
dards der Implantattherapie angesehen. Folglich wurden eine
ganze Reihe von Methoden entwickelt, um entweder das Weich-
gewebe im Zwischenbereich des Implantats zu erhalten oder
wiederherzustellen. Das vorliegende Dokument zielt darauf ab,
die Faktoren zu ermitteln, die eventuell zum Auftreten des
Phänomens der das Implantat umlagernden Papille führen kön-
nen. Materialien und Methoden: Mittels MEDLINE-Suche
wurden Artikel herausgesucht, die im September 2007 veröf-
fentlicht wurden und im Zusammenhang mit der Implantatästhe-
tik durch Auftreten von Papillen im Zwischenimplantatbereich
standen. Ergebnisse: Faktoren, wie beispielsweise die Höhe des
Kammknochengewebes, der interproximale Abstand, die
Zahnform/-kontur, die Dicke des Zahnfleischs sowie die ver-
hornte Breite des Zahnfleischs, wurden allesamt als mögliche
Mitverursacher eines Auftretens von zwischen den Implantaten
liegenden Papillen herausgefunden. Außerdem wurden viel-
fache Techniken/Materialien erfolgreich zur Besserung der
Papillenausbildung im Bereich zwischen den Implantaten
angewendet. Schlussfolgerung: Der vorliegende Artikel
bietet einen umfassenden Überblick über die Faktoren, die
Papillen im Implantatzwischenraum beeinflussen können,
und beschreibt Methoden, die angewendet werden, um
dieses große Anforderungen stellende Problem in der
Implantat-Zahnheilkunde zumindest versuchsweise wied-
erherzustellen/zu korrigieren.
SCHLÜSSELWÖRTER: Implantat, Papillen, Ästhetik, inter-
proximales Weichgewebe
SPANISH / ESPAÑOL
AUTOR(ES): Yiu Cheung Chow, DDS, MS, Hom-Lay
Wang, DDS, MSD, PhD
Factores y técnicas que influencian las papilas periimplante
ABSTRACTO: Propósito: La pérdida de la papila del im-
plante es uno de los dilemas más preocupantes en la odon-
217
tología de implante. El “triángulo negro” alrededor de la
restauración apoyada en implantes no solamente causa difi-
cultades fonéticas y la acumulación de comida sino también
un resultado estético poco agradable. Esto se considera una
falla en las normas actuales de terapia con implantes. Como
consecuencia, se han creado muchas técnicas para proteger o
regenerar el tejido blando interimplante. El propósito de este
trabajo es examinar los factores que pueden afectar la papila
periimplante. Materiales y Métodos: Se usó una búsqueda en
MEDLINE para identificar artículos publicados hasta sep-
tiembre del 2007 relacionado con la estética del implante
como papila interimplante. Resultados: Factores tales como
la altura del hueso crestal, distancia interproximal, forma y
contorno del diente, espesor gingival y ancho gingival que-
ratinizado fueron identificados como que influencian el as-
pecto de la papila interimplante. Además, se han usado
muchas técnicas y materiales exitosamente en la promoción
de la formación de la papila interimplante. Conclusión: Este
artículo presenta una evaluación general de los factores que
pueden influenciar las papilas interimplante e ilustra técnicas
usadas para tratar de recrear o corregir este problema en la
odontología de implantes.
PALABRAS CLAVES: Implante, papilas, estética, tejido
blando interproximal
PORTUGESE / PORTUGUÊS
AUTOR(ES): Yiu Cheung Chow, Cirurgião-Dentista, Mestre
em Ciência, Hom-Lay Wang, Cirurgião-Dentista, Mestre em
Odontologia, PhD
Fatores e Técnicas que Influenciam Papilas Peri-implantes
RESUMO: Objetivo: A perda de papilas de implante é um
dos dilemas mais perturbadores na odontologia de implante.
O “triângulo negro” em torno da restauração suportada por
implantes não só causa dificuldades fonéticas e impactação
alimentar, mas também estética desagradável. Isso é consid-
erado uma falha nos padrões atuais de terapia de implante.
Como consequência, muitas técnicas foram desenvolvidas
para preservar ou regenerar o tecido mole interimplante. É
objetivo deste artigo examinar fatores que podem afetar o
aparecimento de papilas peri-implantes. Materiais e Méto-
dos: A busca no MEDLINE foi usada para identificar artigos
publicados ao longo de setembro de 2007 relacionados a
estética de implante como papilas interimplante. Resultados:
Fatores como altura da crista óssea, distância interproximal,
forma/formato do dente, espessura gengival e largura da
gengiva ceratinizada foram todos identificados como influ-
encidadores do aparecimento de papilas interimplante. Além
disso, muitas técnicas/materiais foram usados com sucesso na
promoção da formação de papilas interimplante. Conclusões:
218 PERI-IMPLANT PAPILLAE • CHOW AND WANG

Este artigo apresenta uma revisão abrangente de fatores que ло с усо солус дл фо-
podem influenciar as papilas interimplantes e ilustra técnicas о дс сосо
ко !ду л.
usadas na tentativa de recriar/corrigir esse problema desafia-  од.( до бо дсл
dor na odontologia de implante. с
 обо фкоо, л  сос-
о дс сосо
ко !ду л,
PALAVRAS-CHAVE: Implante, papilas, estética, tecido д одк,  дл  ос-
mole interproximal сод    о суо обл
дло лолог.

RUSSIAN / КЛ!' СЛО
: л, дс сос-

о
к, ск, !уб гк к

О: Yiu Cheung Chow, доко уг
ско
соолог, гс сс ук, Hom-Lay
Wang, доко уг
ско соолог, доко TURKISH / TÜRKÇE
флософ YAZARLAR: Yiu Cheung Chow, DDS, MS, Hom-Lay
Фк
о  
одк, л  фоо Wang, DDS, MSD, PhD
дс  сосоко окуг л

о Peri-implant Papillayı Etkileyen Faktör ve Teknikler
 !". #л$. У дс сосо
ко окуг ÖZET: Amaç: İmplant papillasının kaybı, implant dişçiliği-
л – о од  бол с nin en rahatsız edici sorunlarından biridir. İmplant ile destek-
обл дло лолог. « lenen restorasyonun etrafındaki “siyah üçgen” sadece fonetik
уголк», обу с окуг с с güçlüklere ve yiyecek maddelerinin gömülmesine neden ol-
ооо  л,  олко ууд  дк  makla kalmaz, ayrıca tatsız bir estetik görüntü de yaratır.
д! оск , о к! дсл Günümüzün implant terapi standartlarına göre bu bir başarı-
собо с
ск дфк.Со сд sızlık kabul edilir. Bu nedenle, inter-implant yumuşak
лолог оол с
 ко ул dokuyu ya korumak ya da yeniden üretmek için bir çok teknik
блго содо. Кк слдс, бло geliştirilmiştir. Bu çalışmanın amacı, peri-implant papillanın
боо о!со одк, оол лбо görünüşünü etkileyebilen faktörleri incelemektir. Gereç ve
со, лбо оссо гк к !ду Yöntem: Eylül 2007 tarihine kadar inter-implant papilla ve
л. $л до бо лс implant estetiğine ilişkin olarak yayınlanmış makaleleri bul-
у
 фкоо, сособ ол    mak amacıyla MEDLINE araması yapıldı. Bulgular: Kret
д !уб дс сосо
ко окуг л- kemik yüksekliği, interproksimal mesafe, diş formu/şekli, diş
о. "
л  
од . Дл оск с , оуб- eti kalınlığı ve keratinleşmiş diş eti genişliği gibi faktörlerin
лко до сб 2007 г. кл
ло, о inter-implant papillanın görünüşünü etkilediği saptandı. Ay-
с
ск ск лолог, с rıca, inter-implant papilla oluşumunu ilerletmek amacıyla bir
дс сосо
к, сололс лко çok teknik/gereç başarıyla kullanılmıştır. Sonuç: Bu makale,
б MEDLINE. &ул. Бло усоло,
о inter-implant papillayı etkileyen faktörlerin geniş çaplı bir
   д !уб дс сосо
ко  değerlendirmesini sağlamakta ve implant dişçiliğinin bu çetin
облс ло л к фко, кк problemini yaratmak/düzeltmek için kullanılan teknikleri
со лолого гб,  !уб sunmaktadır.
о!уко, фо кофгу убо, ол
дс   о коо дс. ANAHTAR KELİMELER: İmplant, papilla, estetik, inter-
Ко ого, о!со сусу одк  proksimal yumuşak doku

JAPANESE /
 IMPLANT DENTISTRY / VOLUME 19, NUMBER 3 2010 219

CHINESE /

KOREAN /