Styliani Kourkouta Konstantina Dina Dedi David W.

Paquette Andre Mol

Interproximal tissue dimensions in relation to adjacent implants in the anterior maxilla: clinical observations and patient aesthetic evaluation

Authors afliations: Styliani Kourkouta, Eastman Dental Hospital & Institute, University College London Hospitals NHS Foundation Trust, London WC1X 8LD, UK Styliani Kourkouta, Konstantina Dina Dedi, Department of Prosthodontics, School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7450, USA Konstantina Dina Dedi, UCL Eastman Dental Institute, London WC1X 8WD, UK David W. Paquette, Department of Periodontology, School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7450, USA Andre Mol, Department of Diagnostic Sciences & General Dentistry, School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7450, USA Correspondence to: Styliani Kourkouta Eastman Dental Hospital & Institute University College London Hospitals NHS Foundation Trust 256 Grays Inn Road London WC1X 8LD UK Tel.: 44 0207 915 2346 Fax: 44 0207 915 1028 e-mail: stella.k@hotmail.co.uk

Key words: aesthetic zone, anterior maxilla, dental implants, interimplant papilla, interproximal papilla Abstract Objectives: This clinical study aimed to assess (i) interproximal tissue dimensions between adjacent implants in the anterior maxilla, (ii) factors that may inuence interimplant papilla dimensions, and (iii) patient aesthetic satisfaction. Material and methods: Fifteen adults, who had two or more adjacent implants (total of 35) in the anterior maxilla, participated in the study. The study design involved data collection from treatment records, clinical and radiographic assessment, and a questionnaire evaluating aesthetic satisfaction. Results: The median vertical dimension of interimplant papillae, i.e., distance from tip of the papilla to the bone crest, was 4.2 mm. Missing papilla height (PH) at interimplant sites was on average 1.8 mm. Median proximal biologic width at interimplant sites was 7 mm. The most coronal bone-to-implant contact at implantimplant sites was located on average 4.6 mm apical to the bone crest at comparable neighbouring implanttooth sites. The tip of the papilla between adjacent implants was placed on average 2 mm more apically compared with implanttooth sites. The contact point between adjacent implant restorations extended more apically by 1 mm on average compared with implanttooth sites. Median missing PH was 1 mm when an immediate provisionalization protocol had been followed, whereas in the case of a removable temporary it was 2 mm. Split group analysis showed that for missing PH 1 mm, the median horizontal distance between implants at shoulder level was 3 mm. Patient satisfaction with the appearance of interimplant papillae was on average 87.5%, despite a Papilla Index of 2 in most cases. Conclusions: The apico-coronal proximal biologic width position and dimension appear to determine papilla tip location between adjacent implants. There was a signicant association between the provisionalization protocol and missing PH, which was also inuenced by the horizontal distance between implants. Patient aesthetic satisfaction was high, despite a less than optimal papilla ll.

Date: Accepted 12 May 2009

To cite this article: Kourkouta S, Dedi KD, Paquette DW, Mol A. Interproximal tissue dimensions in relation to adjacent implants in the anterior maxilla: clinical observations and patient aesthetic evaluation. Clin. Oral Impl. Res. 20, 2009; 13751385. doi: 10.1111/j.1600-0501.2009.01761.x

Dental implants, when placed according to established treatment protocols, are associated with high success rates and represent a predictable treatment modality for the rehabilitation of both partially and fully edentulous patients. Over the years there have been increasing aesthetic demands on

implant restorations, especially when located in the anterior maxilla (the aesthetic zone). In recent years, research studies on osseointegration and implant survival have been complemented with studies evaluating implant success. Factors that are considered by professionals to be of

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signicance for the aesthetic outcome of implant-supported restorations may not be of decisive importance for patient satisfaction (Chang et al. 1999), therefore subjective patient evaluation is also of primary importance for the assessment of a successful outcome in implant therapy. The replacement of multiple adjacent teeth with xed implant restorations in the anterior maxilla is particularly challenging for the clinician (Buser et al. 2004), but poorly documented, resulting in lack of predictability when it comes to restoring the contour of the interimplant soft tissue (Belser et al. 2004). In single implant restorations adjacent to natural teeth, the level of the marginal soft tissues and interproximal papillae is dictated by the attachment level on the adjacent teeth (Salama et al. 1998; Grunder 2000; Choquet et al. 2001; Kan et al. 2003). The situation is not so predictable in the case of two adjacent implants (Elian et al. 2003) (Fig. 1). Currently, an interimplant horizontal distance of at least 3 mm (Tarnow et al. 2000; Gastaldo et al. 2004) is recommended to reduce crestal bone loss due to the lateral component of peri-implant bone loss. If the distance between adjacent implants is o3 mm, the overlap of the lateral bone loss on the two xtures will lead to a reduction in crestal bone height, which, in turn, may result in absence of a complete interproximal papilla and compromised aesthetics. Regarding the vertical dimension, a distance from the base of the contact point to the bone crest of 2 4 mm (average 3.4 mm) between two adjacent implants (Tarnow et al. 2003), or

3 mm (Gastaldo et al. 2004) is recommended in order to improve the chances that an interproximal papilla will be present, thus avoiding black triangles in the critical aesthetic zone. A more recent study (Lee et al. 2005b) suggested that the width of the keratinized mucosa between two adjacent implants might be related to the dimension of the interproximal papilla between those implants. The above measurements have been based on evaluation of an assortment of implant systems (Tarnow et al. 2003), implant types, designs and surfaces (Tarnow et al. 2003; Lee et al. 2005b), types of restorations (Lee et al. 2005b), and jaw locations (Tarnow et al. 2003). It has even been suggested that xtures with a wide diameter may be of limited use in the aesthetic zone (Tarnow et al. 2000; Buser et al. 2004). A comparison of two distinctive implant systems showed similar dimensions of the interproximal soft tissue between adjacent implants irrespective of the horizontal distance of the xtures (Lee et al. 2006). However, interproximal dimensions strictly between adjacent single implants in the anterior maxilla have not been assessed. Furthermore, patient subjective evaluation of the appearance of interimplant papillae in the aesthetic zone has not been carried out. The aim of this clinical study was to assess (i) the dimensions of the interproximal tissues between adjacent implants in the anterior maxilla in relation to the presence of a papilla, (ii) factors that may inuence the dimensions of the interimplant papilla, and (iii) patient aesthetic satisfaction.

survival and/or success of implants, such as uncontrolled diabetes or immunocompromised states, iii. no pregnancy, and iv. absence of periodontal disease or periimplant inammation. The study design, observational crosssectional with a retrospective component, involved: (1) retrospective data collection from patients treatment records, (2) clinical assessment, (3) radiographic assessment, and (4) a questionnaire evaluating aesthetic satisfaction. (1) Information accessed from patients treatment records:  Timing of treatment provided, i.e., implant placement, temporisation, time since nal restoration. Surgical protocol, i.e., immediate or delayed placement and whether ridge augmentation had been performed. Type of provisional and nal restorations. Oral hygiene instructions, recall frequency and any noted complications, especially in relation to the soft tissue component, e.g. crown decementation, presence of excess cement.

 

(2) Variables that were assessed at the clinical examination:    Smile line: high/average/low (Tjan et al. 1984). Soft tissue biotype: thin/thick (Seibert & Lindhe 1989; Kois 2004). Papilla Index (PI) according to Jemt (1997) (see Table 1 legend for brief explanation): this was assessed on digital clinical photographs of the implant restorations and surrounding soft tissues. The photographs were taken perpendicular to the middle third of the facial surface of the crowns. Papilla height (PH): vertical distance from the tip of the papilla to a line connecting the zeniths of the soft tissue margins at adjacent crowns (Fig. 2). Width of keratinized mucosa (WKM): vertical distance from the tip of the papilla to the mucogingival junction. Vertical distance from the incisal edge to the apical end of the contact point (IC). Vertical distance from the incisal edge to the tip of the papilla (IP).
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Material and methods

Subjects were selected from the pool of treated implant cases at the School of Dentistry, University of North Carolina at Chapel Hill (UNC-CH), USA, according to the following inclusion criteria: i. Presence of two or more adjacent implants in the anterior maxilla that had been restored with single implant crowns or adjacent xed partial dentures, ii. healthy individuals: absence of systemic health complications, in particular conditions that might affect the

Fig. 1. Clinical problem: Absence of complete papilla between adjacent implants (12,11) in the aesthetic zone.

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Table 1. Frequency of Papilla Index at implantimplant and implanttooth sites

Papilla Indexn Implantimplant sites N 0 1 2 3 4
n

Implanttooth sites N 0 0 11 2 0 % 0 0 84.6 15.4 0

% 5.3 15.8 73.7 0 5.3

1 3 14 0 1

measurements, and interthread distance for the vertical measurements. The measurements were performed three times; the second and third sets of measurements were used for assessment of repeatability. The nal set of measurements was used for the actual project assessments. Arithmetic calculations:  Vertical distance from the apical end of the contact point to the bone crest: CB IB IC. VDP: Vertical dimension of papilla (vertical distance from tip of papilla to bone crest) PB IB IP. At implanttooth sites that coincides with the proximal biologic width on the tooth aspect. MPH: Missing PH CP IP IC. PBa: Proximal (interimplant) biologic width (sulcus depth junctional epithelium connective tissue contact) (Cochran et al. 1997; Hermann et al. 2000) PB BBa. Vertical distance from incisal edge to apical bone level (implantimplant sites): IBa IB BBa. Vertical distance from implant shoulder to bone crest: SB SBa BBa. Vertical distance from tip of papilla to implant shoulder: PS PB SB. Vertical distance from SLA-smooth surface junction to bone crest: JB SB 1.8 mm. Vertical distance from SLA-smooth surface junction to apical bone level: JBa SBa 1.8 mm.

0: no papilla is present, 1: o50% of the papilla is present (PHoMPH), 2: at least 50% of the papilla is present (PH ! MPH), 3: normal papilla, 4: hyperplastic papilla.

 

 
Fig. 2. Schematic representation of clinical and radiographic measurements. I, incisal edge; C, apical end of contact point; P, tip of papilla; S, implant shoulder; B, bone crest (most coronal point); J, SLA-smooth surface junction; F, xture body, just coronal to the rst thread; Ba, apical bone level (rst bone-to-implant contact); T, mesial surface of adjacent tooth. PH, papilla height (vertical distance from the tip of the papilla to a line connecting the zeniths of the soft tissue margins at adjacent crowns); WKM, width of keratinized mucosa (vertical distance from tip of papilla to mucogingival junction); VDP, vertical dimension of papilla (vertical distance from tip of papilla to bone crest); MPH, missing papilla height.

PH, WKM, IC, and IP were measured to the nearest 0.5 mm using a University of North Carolina (UNC-15) periodontal probe (Hu-Friedy, Chicago, IL, USA). (3) Variables that were determined from measurements on digital intra-oral radiographs (Fig. 2):  Horizontal distance between adjacent implants, measured at shoulder level (SS), SLA-smooth surface junction (JJ), and xture body level, just coronal to the rst thread (FF) (implantimplant sites).  Horizontal distance between implant and mesial surface of adjacent tooth at corresponding levels (ST, JT, FT) (implanttooth sites).  Vertical distance from the incisal edge of adjacent crowns to the bone crest (IB).
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Vertical distance from bone crest to the apical bone level (most coronal boneto-implant contact), i.e., subcrestal biologic width (BBa) (implantimplant sites). Vertical distance from implant shoulder to the apical bone level (SBa) (implant implant sites).

A strictly parallel long cone technique was employed for the radiographic assessment in order to minimize distortion. The beam focused on the papilla in question with the incisal edges of the adjacent crowns clearly showing on the images. Image analysis was performed with the use of Image-Pro Plus software (version 3.0.01, Media Cybernetics, Silver Spring, MD, USA). The images were calibrated according to the implant shoulder (restorative platform) width for the horizontal

4) Subjective aesthetic evaluation A questionnaire consisting of a visual analogue scale (VAS) and additional questions, including open-ended ones, was used with the aim to assess subjective aesthetic evaluation. It was lled by the subjects at the end of their clinical assessment appointment. The VAS answers were quantied using a 100 mm ruler; measurements were to the nearest 0.5 mm. The patients responses were measured twice and the means were used for the nal calculations. The study protocol was approved by the institutional review board for biomedical research at UNC-CH. The study aims and design were discussed with the patients, and written consent was obtained. Fifteen adult subjects, 12 female and three male, participated in the study (mean age 55 years; range 3571 years). Two of the patients were smokers. A total of 35

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Straumann implants (Institut Straumann AG, Waldenburg, Switzerland) were included in the study. They were of the Standard Plus SLA (sand-blasted, largegrit, acid-etched) type, i.e., the smooth collar height was 1.8 mm. Thirty of the xtures (85.7%) had a regular neck (4.8 mm restorative platform diameter and 4.1 mm implant body diameter), whereas ve xtures (14.3%) were narrow neck (3.5 mm restorative platform and 3.3 mm implant body diameter). In nine patients (60%) an immediate placement protocol had been followed. For the remaining six patients (40%) implants had been placed using a delayed approach. Ridge augmentation was performed in nine cases (60%) using an allograft or xenograft in combination with a resorbable membrane. Eight of the patients had been temporized with a removable partial or complete denture (53.3%), whereas in the remaining seven cases an immediate provisionalization approach had been followed using xed implant-supported restorations (46.7%). At the time of the assessment the nal restorations had been in place for an average 21.6 months (SD 14.2). Twenty-seven of the restorations (77%) were porcelainfused-to-metal (high noble alloy), and the remaining eight were ceramic (23%). Thirty-three of the nal restorations (94%) were cemented, whereas the remaining two (6%) were screw-retained. Seven of the patients (46.6%) had an average smile line, four had a high (26.7%) and the remaining four a low smile line. The distribution of implant and papilla sites is shown in Figs 3 and 4. For each interimplant papilla the adjacent site between the implant restoration and natural tooth was used for comparison where possible. A total of 20 implantimplant and 16 implanttooth sites were assessed. It should

be noted that some of the measurements could not be made at certain sites, for example in the absence of contact points, or in the case of four adjacent implants, where the middle interimplant papilla could not be matched to a toothimplant site. To allow comparison between IB (IBa), IP, and IC at implantimplant and implanttooth sites, the variables were adjusted to include only sites where the incisal edges were at comparable levels, e.g. by excluding sites with uneven tooth lengths, or midline interimplant papillae with no match control site. All measurements were performed by the principal investigator (S.K.), who was not involved with previous treatment of the subjects or their recall and was acting as an independent examiner.

2.

Intra-examiner repeatability

Intra-examiner repeatability was assessed for SS, FF, and IB according to the method by Bland & Altman (1986). Duplicate measurements were taken for all implant implant sites 10 days apart. The results were as follows: 1. SS: The mean difference between the two sets of measurements was 0.07 mm, SD 0.19 mm. This implies that the maximum likely difference between repeated measurements was 0.37 mm. The limits of agreement were 0.3 and 0.44 mm, i.e., 95% of the differences between the duplicate SS measurements would be expected to lie within these values. One hundred per cent of the differences were o1 mm.
Implant-implant sites Implant-tooth sites

FF: The mean difference between the two sets of measurements was 0.12 mm, SD 0.33 mm. This implies that the maximum likely difference between repeated measurements was 0.65 mm. The limits of agreement were 0.53 and 0.77 mm, i.e., 95% of the differences between the duplicate FF measurements would be expected to lie within these values. The percentage of differences that were o1 mm was 97.2%. 3. IB: The mean difference between the two sets of measurements was 0.22 mm, SD 0.36 mm, implying that the maximum likely difference between repeated measurements was 0.71 mm. The limits of agreement were 0.93 and 0.49 mm, i.e., 95% of the differences between the duplicate IB measurements would lie within these values. The percentage of differences that were o1 mm was 97.2%.

Statistical analysis

10 8 No of sites

14 12 No of sites 10 8 6 4 2 0 13 12 11 21 Implant sites 22

6 4 2 0

13-12 12-11 11-21 21-22 22-23 Papilla sites

Fig. 3. Distribution of implants.

Fig. 4. Distribution of implantimplant and implanttooth sites.

The majority of the data and their differences were non-normally distributed, therefore non-parametric tests were applied. The patient was used as the statistical unit for the analyses. The level of signicance was set at 0.01, rather than the conventional 0.05 to avoid spurious results due to multiple testing. The Wilcoxon signed ranks test was employed for comparison of PI, PH, WKM, IB (adjusted), IBa/IB (adjusted), IP (adjusted), IC (adjusted), CB, VDP, and MPH at implant implant and implanttooth sites. Correlation was sought between (i) VDP and biotype, surgical protocol, type of temporary restoration, SS, JJ, FF, and (ii) MPH and biotype, surgical protocol, type of temporary, WKM, SS, JJ, and FF. The Mann Whitney test was used for binary and the Spearmans rho for continuous data. Split group analysis was performed for: (i) biotype, surgical protocol, type of temporary, PI, PH, WKM, SS, JJ, FF, CB, VDP grouped according to MPH 1 or 41 mm, and (ii) PI, PH, VDP, MPH grouped according to (a) CB 5 or 45 mm, and (b) CBo6 or !6 mm. The Fishers exact test was used for categorical and the Mann Whitney for continuous data. SPSS for Windows 12.0 statistical software package was used for data analysis.
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Results
The PI at implantimplant and implant tooth sites is presented in Fig. 5, and PI frequency in Table 1. Descriptive statistics for the variables are presented in Tables 2 and 3. The questionnaire results are summarized in Tables 4 and 5. Most of the patients were content with the interimplant papillae and did not wish to change anything about the appearance of the soft tissue. Three patients, who had PI 0, 1, or 2, where the papillae were potentially visible in high smile, expressed some concern. Results of the Wilcoxon signed ranks tests are shown in Table 6. Statistically signicant differences between implant implant and implanttooth papillae were noted for PH, and IBa/IB, IP, IC (adjusted). PH was on average 1 mm greater at implanttooth compared with interimplant papillae (95% CI: 0.5 to 1.5 mm). IBa (adjusted) was greater by 4.6 mm, on average, compared with IB (adjusted) at implanttooth sites (95% CI: 2.47 6.82 mm). In a similar fashion, IP (adjusted) was greater at implantimplant sites by 2 mm on average (95% CI: 1 2.75 mm), and IC (adjusted) by 1 mm (95% CI: 14 mm). The only statistically signicant correlation was observed between MPH and type of temporary restoration (P 0.006). In the case of a xed temporary restoration (N 7) the median MPH was 1 mm (95% CI: 0.52 mm), whereas when a removable temporary had been used (N 7) the median MPH was 2 mm (95% CI: 1.75 2.5 mm).

Results of the split group analysis are shown in Tables 79. For MPH 1 mm (N 6), the type of temporary restoration was xed in all cases and the median horizontal distance between the implants was 3.02 mm at shoulder level (95% CI: 2.115.73 mm). The only other signicant result concerned the VDP, according to CB 5 or 45 mm, and CBo6 or !6 mm (Table 9).

Discussion
A favourable outcome of implant therapy and predictability of aesthetic success in the anterior maxilla depend on knowledge of those factors that may inuence the dimension of the interimplant papilla. Previous studies that attempted to assess interimplant papillae evaluated linked units in anterior and posterior sites (Tarnow et al. 2003), posterior sites only (Lee et al. 2005b, 2006), or unspecied jaw locations (Tarnow et al. 2000; Gastaldo et al. 2004).

This study was restricted to the aesthetic zone and assessed only individual units. The latter was mainly for the following reasons: rst, this would simulate as much as possible the situation between adjacent natural teeth from a biological standpoint and also in terms of oral hygiene methods, because the use of interproximal brushes between linked units may have an inuence on the height of the soft tissue. Secondly, the tendency nowadays is to keep prosthetic units separate rather than link them. Inevitably the sample size for this project was small, because of the specialized nature of the study. The average vertical dimension of the papilla (distance from tip of the papilla to the bone crest) was greater in this study compared with previous ones, i.e., 4.2 mm (range 1.47.9 mm), as opposed to 3.4 mm (range 17 mm) reported by Tarnow et al. (2003), and 3.3 mm as conrmed by Lee et al. (2005b). The latter study concerned posterior implants, where interproximal brushes were used for cleaning and this

Table 2. Median values of variables (95% CI for the median) at implantimplant and implanttooth sites
Variable Implantimplant sites N PI PH (mm) WKM (mm) SS/ST (mm) JJ/JT (mm) FF/FT (mm) 14 15 15 15 15 15 15 12 15 12 14 13 14 15 14 2 (1, 2) 2.33 (1.5, 2.5) 6 (5, 6.5) 2.15 (1.61, 2.9) 3.09 (2.47, 3.76) 3.82 (3.16, 4.28) 13.11 (11.53, 14.71) 12.32 (11.4, 13.72) 8.5 (8, 10) 8 (7.5, 9.75) 7 (6, 8.17) 7 (6, 8) 5.68 (4.33, 7.25) 4.22 (3.33, 5.6) 1.79 (1, 2) Implanttooth sites N 11 13 13 13 13 13 13 12 13 12 11 10 11 13 11 2 (2, 3) 3 (3, 4) 6 (6, 7.8) 1.15 (0.68, 2.16) 1.52 (0.83, 2.36) 1.68 (0.9, 2.31) 10.89 (8.71, 13.6) 10.88 (8.71, 11.43) 6 (5.75, 7.5) 6 (5.75, 7.5) 5 (3, 6.5) 5 (3, 6.5) 6.05 (4.39, 8.14) 4.25 (3.04, 6.05) 1.3 (0, 3)

14 12 No of sites 10 8 6 4 2 0 0

Implant-implant sites Implant-tooth sites

IB (mm) IB adjusted (mm) IP (mm) IP adjusted (mm) IC (mm) IC adjusted (mm) CB (mm) VDP (mm)

1 2 3 Papilla Index

MPH (mm)

Fig. 5. Description of Papilla Index.

The patient was used as the unit for the statistical analysis, therefore N refers to number of patients.

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Table 3. Median values of variables (95% CI for the median) at interimplant papillae (N number of patients)
Variable Interimplant papillae N BBa (mm) SBa (mm) SB (mm) JBa (mm) JB (mm) PS (mm) PBa (mm) IBa (mm) 15 15 15 15 14 15 14 15 2.21 (2.13, 2.75) 3.13 (2.75, 4.05) 0.75 (0.5, 1.32) 1.33 (0.95, 2.25) 1.05 ( 0.48, 1.1) 3.43 (2.01, 4.89) 6.96 (5.54, 8.31) 15.46 (14.28, 18.31) 14.83 (14.23, 15.85)

Table 4. First part of aesthetic evaluation questionnaire: visual analogue scale and results
Question Median (%) Range (%)

100% dissatisfied
1. 2. 3. 4.

Indifferent

100% satisfied
87.5 93.5 91.5 95 60 20 0 9 to to to to 100 100 100 100

Appearance of soft tissue (papilla) between your implant crowns Health of the soft tissue between implants Possibility to clean between implant crowns Level of overall satisfaction with implant treatment

Table 5. Summary of answers to the second part of the aesthetic evaluation questionnaire
Question No of patients % Do you clean in between your implant crowns? Yes 14 93.3 No 1 6.7 If yes, what do you use? Dental oss/tape 10 66.7 Super Floss 3 20 Toothpicks 1 6.7 Interdental brushes 1 6.7 Other 1 6.7 How often? Once a day 3 20 Twice a day 6 40 Once a week 2 13.3 Occasionally 3 20 Do you feel that the soft tissue between your implant crowns (papilla) is stable? Yes 14 93.3 No 1 6.7 Do you like the appearance of the papilla between your implant crowns? Yes 11 73.3 No 1 6.7 No opinion 2 13.3 Other 1 6.7 How would you feel if this soft tissue was partly or totally absent and a dark triangle was present in between your implant crowns? Would certainly dislike it 13 86.7 Not so important, provided the implants were still functional 1 6.7 Other 1 6.7 Would you recommend the implant procedure you had to another patient suffering from the same problem? Yes 14 93.3 No 1 6.7

IBa adjusted (mm) 12

may have inuenced the height of the soft tissue to an extent (Lee et al. 2006). It is not possible to make speculations about the effect, if any, of the implant system used, although it should be noted that data exist supporting a statistically signicantly more coronal location of the mucosal margin at one-piece compared with two-piece implants (Hermann et al. 2001). The average distance from the contact point to the bone crest in this study was 5.7 mm, and missing PH 1.8 mm. The subcrestal biologic width at interimplant sites equaled on average 2.2 mm, suggesting that in many cases a peak of bone was present between adjacent xtures. The apical bone level (most coronal bone-to-implant contact) was on average 1.3 mm apical to the SLAsmooth surface junction, and the latter was 1.1 mm apical to the bone crest. The distance from the implant shoulder to the apical bone level was on average 3.1 mm. The position of the implant shoulder, unlike the restoratively introduced contact point, is an important landmark, because it is consistently placed 12 mm apical to the anticipated mucosal margin or cementoenamel junction (CEJ) of adjacent teeth, provided the protocol for implant placement is followed. The implant shoulder was on average 0.75 mm coronal to the bone crest, and the papilla tip 3.4 mm coronal to the implant shoulder level. The distance from the papilla tip to the apical bone level, i.e., the biologic width (sulcus

depth epithelial attachment connective tissue contact) equaled on average 7 mm. This measurement is close to the proximal peri-implant mucosa dimensions that have been reported for single implants adjacent to teeth. Garber et al. (2001) quoted a proximal mean vertical soft tissue depth of 6.5 mm on the implant surface at toothto-implant sites. Kan et al. (2003) reported proximal bone sounding measurements of approximately 6 mm on implant surfaces of single implants adjacent to teeth. The biologic width is considered to be a physiologically formed structure, the overall

dimension of which remains stable over time (Hermann et al. 2000). In consistency with what has been reported in the literature regarding the dimensions of the periimplant mucosa, we would expect a vertical dimension of approximately 1 mm for the connective tissue contact and 2 mm for the epithelial attachment (Buser et al. 1992; Berglundh & Lindhe 1996; Cochran et al. 1997; Hermann et al. 2001), and more specically for one-piece nonsubmerged loaded implants, 1.05 0.38 mm for the connective tissue contact and 1.88 0.81 mm for the junctional
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Table 6. Median differences of variables at implantimplant and implanttooth papillae, 95% CI for the median, and P-values from Wilcoxon signed ranks tests
Variable N Median difference 95% CI P-value (variable at implantimplant minus variable at implanttooth papilla) PI PH (mm) WKM (mm) IB adjusted (mm) IBa/IB adjusted (mm) IP adjusted (mm) IC adjusted (mm) CB (mm) VDP (mm) MPH (mm)
n

11 13 13 12 12 12 10 11 13 11

0 1 1 1.75 4.6 2 1 0.65 0.04 0.5

1, 0 1.5, 0.5 2, 0 0.35, 2.97 2.47, 6.82 1, 2.75 1, 4 2.46, 1.97 1.65, 1.05 1.5, 1

0.06 0.006n 0.09 0.02 0.00n 0.002n 0.002n 0.9 0.96 0.85

Statistically signicant (Po0.01).

Table 7. P-values of split group analysis according to MPH

Biotype Grafting Imm/Del Temp MPH 40.99 0.58 1 mm (N 6) or 41 mm (N 8)
n

1 or 41 mm
JJ
n

PI

PH

WKM SS 0.008

FF

CB

VDP

0.63

0.005

0.24 0.07 0.51

0.02 0.04 0.35 0.76

Statistically signicant (Po0.01).

Table 8. Statistically signicant results from split group analysis according to MPH or 41 mm
Type of temporary restoration Fixed MPH 1 mm N6 MPH 41 mm N8 6 1 Removable 0 7 SS Median (95% CI for the median) 3.02 (2.11, 5.73) 1.71 (0.95, 2.82)

Table 9. Results of split group analysis according to CB or !6 mm

PI CB 5 mm N4 CB45 mm N 10 CBo6 mm N8 CB !6 mm N6 2 (2, 2 (1, 2 (0, 2 (1, 3) 2) 0.79 3) 2) P 0.12 PH 2.42 (2, 2.5) 2.13 (1, 3.33) 2.42 (0, 2.5) 2.13 (1, 4) P 0.55 VDP 2.34 (1.4, 3.33) 4.83 (3.95, 5.72) 3.36 (1.4, 4.91) 5.61 (4.7, 7.94)

5 or 45 mm, and CBo6

P 0.002n MPH 1.5 (0.5, 2) 1.79 (1, 2.5) 1.5 (0.5, 2) 1.79 (1, 2.5) P 0.75

0.93

0.003n

0.49

Median (95% CI) and P-values. n Statistically signicant (Po0.01).

epithelium (Hermann et al. 2000). Therefore, under the conditions of this study, it would appear reasonable to suggest that the connective tissue contact occupied most of the area between the rst bone-to-implant contact and SLA-smooth surface junction, whereas the junctional epithelium attached mostly to the smooth collar surface. The remaining coronal almost 4 mm, on average, of peri-implant mucosa interproxi 2009 John Wiley & Sons A/S c

mally would be expected to correspond to the peri-implant sulcus. As expected, based on previous research and clinical observation, the implantimplant sites did slightly worse in terms of soft tissue ll, compared with the implant tooth sites. In the majority of interimplant papillae the PI was 1 (16%) or 2 (74%), whereas at implanttooth sites it was 2 (85%) or 3 (15%). The PH was on average

1 mm greater at implanttooth sites. However, the width of keratinized mucosa, distance from contact point to bone crest, vertical dimension of papilla, and missing PH did not differ signicantly between implantimplant and implanttooth sites. The contact point extended more apically between adjacent implant restorations compared with implanttooth sites by 1 mm on average, therefore nullifying any differences in the distance from contact point to bone crest, and missing PH between implantimplant and implanttooth sites. The position of the contact point at implants is of little value, because it is introduced by the operator. It is interesting that the tip of the papilla was located on average 2 mm more apically at implant implant compared with implanttooth sites, which was close to the average subcrestal biologic width dimension of 2.2 mm. The most coronal bone-to-implant contact at implantimplant sites, i.e., the apical end of the proximal biologic width dimension, was placed on average 4.6 mm more apically compared with implanttooth sites. If we also consider the average proximal biologic width dimension of 7 mm, this appears to indicate that the biologic capacity for generation of a papilla between adjacent implants is exhausted at a more apical level compared with the situation between natural teeth or between a single implant and natural tooth. In other words, papilla formation between adjacent implants is at a more apical level, which appears as lack of tissue at a more coronal level and incomplete papilla ll. The facial position of the at implant shoulder, at least 12 mm apical to the CEJ, determines a more apical position for the bone crestpapilla complex interproximally between adjacent implants. In the case of healthy natural teeth or at implant tooth papillae, the 5 mm distance between the bone crest and contact point (Grunder 2000; Tarnow et al. 2000; Choquet et al. 2001) reects the proximal biologic width dimension (Kois 1994), which is the vertical distance from the underlying bone crest (Fig. 2, point B) to the papilla tip. In the case of adjacent implants, however, the biologic width forms, and therefore should be measured, from the apical bone level (Fig. 2, point Ba), not the bone crest, to the papilla tip. In this study the apical extent of the proximal biologic width dimension at

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adjacent implants (point Ba) was located on average 4.6 mm more apically compared with the apical level of the proximal biologic width at neighbouring teeth (point B). Despite that, the discrepancy in the papilla tip location between adjacent implants and neighbouring implanttooth sites was only 2 mm (in the same direction), a favourable outcome, probably due to the biologic capacity of the tissues and potentially in response to the characteristics of the implant system used. The clinical signicance of the more apical location of the bone crestpapilla complex between adjacent implants is that the deeper the implants are placed in the bone, to ensure an appropriate emergence prole and/or hide the metal part of the xtures under the tissues in the aesthetic zone, the more apical the rst bone-to-implant contact will be, resulting in a more apical biologic width formation and location of the papilla tip, therefore increasing the likelihood of unnatural, short papillae and dark triangles being present. On the other hand, the more coronal the rst bone-to-implant contact is established, the more coronal the proximal biologic width and therefore papilla tip location will be, increasing the likelihood of naturally looking papillae. Therefore, expecting to have a normal anatomy papilla between adjacent implants is often unattainable and obviously unpredictable, because it appears to exceed the biologic capacity of the tissues, since the biologic width forms at a more apical level. It resembles to an extent the situation of adjacent teeth that have lost attachment interproximally, resulting in the formation of intra-bony pockets; a complete papilla would not be expected to form predictably in such cases. Also, the variation in biologic width dimensions among individuals adds to the unpredictability of papilla formation between adjacent implants. A highly signicant correlation was observed between missing PH and the type of temporary restoration. Thus, missing PH was on average 1 mm where an implantsupported xed temporary restoration had been used in an immediate provisionalization approach, whereas in the case of a removable temporary the average missing PH was 2 mm. Ryser et al. (2005) compared immediate provisionalization to a delayed restoration protocol at single implants adjacent to natural teeth in anterior

and posterior maxillary and mandibular sites, and found no difference in papilla ll between the two groups. It is possible that in the case of single implants next to natural teeth the attachment level on the teeth will provide a more stable environment and withstand pressure from a removable provisional prosthesis, whereas in the case of adjacent implants, especially multiple ones, similar insults may have a negative effect on soft tissue height. There was no correlation between biotype or immediate vs. delayed placement and vertical papilla dimension or missing PH. Regarding the effect of the timing of implant placement on papilla dimensions, Schropp et al. (2005) compared in a randomized prospective clinical study interproximal papilla dimensions in early vs. delayed single implant placement, 1 week and 1.5 years after restoration. They reported that, although early placement was superior in terms of papilla generation initially, there was no difference in papilla dimensions between early and delayed protocols at 1.5-year follow-up. The average follow-up time in the present study was 22 months, therefore any difference in papilla dimensions in immediate vs. delayed placement, even if it did exist at rst, might have diminished with time. Lee et al. (2005b) assessed 72 posterior interimplant papillae in 52 patients, and found that the distance from the tip of the papilla to the bone crest was related to the width of the keratinized mucosa, but not to the distance from the contact point to the bone crest or to the horizontal distance between the xtures. In the present study no correlation was observed between missing PH and width of keratinized mucosa. No correlation was sought between vertical papilla dimension and width of keratinized mucosa, because there is an expected partof-a-whole association, because the VDP is part of WKM. The same applies to vertical dimension of papilla or missing PH and distance from contact point to the bone crest. The subjective aesthetic evaluation showed that most patients were content with the appearance of the interimplant papillae, despite the fact that the majority of those, almost three quarters, had a PI of 2. Only three patients, who had PI 0, 1, or 2, and where the papillae were potentially visible in high smile, expressed some con-

cern about the appearance of the soft tissue. This conrms the nding of Chang et al. (1999) that the signicance of certain factors which are considered important for the aesthetic outcome of implant-supported restorations may be interpreted differently by dentists and patients. Those authors suggested that clinicians tend to be more critical in the aesthetic evaluation than patients, and studies assessing the aesthetic outcome of various therapies should focus on patient rather than professional evaluation. This study showed that, from a patients perspective, a PI of 2 is acceptable in the majority of cases. This should not be interpreted to imply relaxed clinical standards; simply, in cases where optimal interimplant papillae cannot be attained, this may not be the determining factor for patient satisfaction. The clinical impression is that a missing PH of up to 1 mm usually goes unnoticed, as in most cases it gets lled with saliva and is not perceptible by the non-expert eye (Fig. 6). This study showed that for this condition to be met, i.e., missing PH of less or equal to 1 mm, a xed temporary restoration should be used in preference to a removable one, and the average horizontal distance between implants at shoulder level should be 3 mm. In almost all cases where a removable temporary restoration had been used, the missing PH was over 1 mm. That was also the case when the average distance between xtures at shoulder level was 1.7 mm. Thus, this study supports the accepted importance of a 3 mm horizontal distance between

Fig. 6. Adjacent single implants replacing the maxillary central incisors: the interimplant papilla is almost complete. Missing papilla height of up to 1 mm is not clinically important because the resultant space gets lled with saliva and is not perceptible by the non-expert eye.

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Fig. 7. The apico-coronal proximal biologic width (BW) position and dimension determine papilla tip location between adjacent implants. C, apical end of contact point; P, tip of papilla; B, bone crest; Ba, apical bone level (most coronal bone-to-implant contact).

adjacent implants (Tarnow et al. 2000; Gastaldo et al. 2004). However, the concept of predictable papilla ll in relation to the distance from the contact point to the bone crest that has been reported for interproximal dental papillae (Tarnow et al. 1992) and implant tooth papillae (Choquet et al. 2001; Ryser et al. 2005) was not conrmed in this study. This is also in agreement with Lee et al. (2005b). Split group analysis using the 5 or 6 mm distance from contact point to bone crest as the cut-off point, based on previous research (Choquet et al. 2001), did not show any signicant difference for the PI, PH, or missing PH. The only difference concerned the vertical dimension of the papilla. However, this is probably not very informative, because it should be expected that as the distance from the contact point to the bone crest increases, so does the height from papilla tip to bone crest (part to whole relationship). Split group analysis using the 3 or 4 mm vertical distance from contact point to bone crest as a cut-off point, based on the study by Gastaldo et al. (2004), was not reported here, because the size of one of the groups was too small (N 1 for CB 3 mm, and N 2 for CB 4 mm). These observations seem to conrm the concept that, when assessing interimplant papillae, it is the proximal biologic width location and dimension that are of importance, measured from the apical bone level to the papilla tip (Fig. 7). The position of the bone crest is not as
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critical, because it is not a determinant of biologic width dimension, unless it coincides with the apical bone level, and the location of the contact point provides little information, since it is articially introduced. The vertical papilla dimension of 3.4 mm that has been reported by Tarnow et al. (2003) and the ideal 3 mm distance from the apical extent of the contact point to the bone crest, as quoted by Gastaldo et al. (2004), would give a biologic width dimension, if added to the average subcrestal biologic width found in this study, of 5.6 and 5.2 mm, respectively. These numbers, although smaller than the average biologic width of 7 mm in this study, would appear to be within the normal range of proximal biologic width dimension, supporting the concept that it is the latter that is of importance in determining the interimplant soft tissue prole. Therefore it is not the distance from the contact point to the bone crest that determines papilla ll between adjacent implants, but the distance from the contact point to the apical bone level; if the latter equals the proximal biologic width dimension for that site, the papilla will be complete. The apico-coronal location of the biologic width will determine whether the papilla will look normal, i.e., at the correct level for that individual. Regarding the methodology, the PI as described by Jemt (1997) was used in this study, in an attempt to describe papilla ll in a systematic and objective manner.

Gastaldo et al. (2004) dened in their study a papilla as present when it lled the entire proximal space or part of that space. This is probably not an accurate enough description since, according to the PI, that would be a score of 1, 2, or 3. Choquet et al. (2001) reported both presence/absence of papilla and PI, and noted that the latter was a more descriptive and scientic evaluation of papilla presence. However, the PI may be criticized as rather crude, being a categorical system, therefore the PH was also assessed in the present study as a quantitative variable. This is in fact in line with a recommendation by Glauser et al. (2006), who carried out a systematic review of marginal soft tissue at implants subjected to immediate loading or restoration and concluded that, when documenting the aesthetic outcome related to interproximal soft tissue response, future studies should consider quantitative metrical measurements instead of Jemts Index. In previous research (Tarnow et al. 2003; Gastaldo et al. 2004) the vertical dimension of the papilla was measured by bone sounding. This is an invasive procedure that involves administration of local anaesthetic. A further criticism of that methodology is that because the nal restorations were already in place at the time of probing, it would not have been possible to insert the probe vertically exactly at the midcrest, but slightly to the facial, possibly introducing some error depending on the facio-lingual thickness of the contact point and the actual positioning of the probe. In the study by Choquet et al. (2001) all the measurements appear to be on radiographs, thus avoiding bone sounding for the assessment of the soft tissue component. However, it is not clear how the tip of the papilla was identied on the radiographs for the respective measurements to be carried out. Lee et al. (2005a) introduced a non-invasive method to measure the soft tissue height from the tip of the papilla to the bone crest, by applying a radiopaque material to the papilla tip, consisting of a 2 : 1 mixture of an endodontic sealer and barium sulphate. Although the method is non-invasive and overcomes the problem of visualising the tip of the papilla on radiographs, it appears to be technique sensitive in that if any of the material is placed (or displaced) beyond the papilla tip,

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a false reading will occur. Also, it may have practical limitations in large university or hospital settings, where the clinician applying the material would be located at a distance from the radiology department. This, together with the waiting time involved for the taking of the radiographs, may lead to dislodgement of the material, resulting in additional radiation, time, effort, and cost. In the present study, for reasons of patient comfort and to avoid an invasive procedure, the vertical dimension of the papilla was measured indirectly, by subtracting the incisal edge to papilla tip from the incisal edge to bone crest distance. Similarly, the distance from contact point to bone crest was calculated by subtracting the incisal edge to contact point from the incisal edge to bone crest distance. This was because it was not possible to detect precisely on radiographs the most apical end of the contact point due to the varying radiopacity of the porcelain, whereas clinical identication of the apical end of the contact point was more precise, and therefore the clinical measurements were used as more accurate. The incisal edge of the crowns was used as a reference for the horizontal plane on the radiographs. In the study by Choquet et al. (2001) the xture-abutment junction was used as a reference for the vertical measurements. However, implants are not always placed with their shoulder exactly parallel to the horizontal plane, therefore in this study the incisal edge of the crowns was deemed a

more accurate representation of the horizontal plane. This study evaluated the interproximal area between adjacent implants in the anterior maxilla in two dimensions, mesiodistal, and inciso-apical. Adding a third dimension in a further evaluation, i.e., facio-lingual, might contribute further to the understanding of some of the issues discussed in this paper.

2.

Conclusions
Formation of complete, naturally looking papillae between adjacent implants is considered unpredictable. This clinical study evaluated 35 adjacent implants in the aesthetic zone of 15 adult patients, where the nal restorations had been in place for an average of 22 months, and showed that: 1. The apico-coronal position of the rst bone-to-implant contact and the proximal biologic width dimension (sulcus depth epithelial attachment connective tissue contact) appear to determine the location of the papilla tip at interimplant sites. Proximal biologic width formation occurs at a more apical level between adjacent implants compared with neighbouring implant tooth sites, therefore dictating a more apical position for the interimplant papillae, which appears as lack of tissue at a more coronal level and incomplete papilla ll. In this study proximal

biologic width dimension at interimplant sites was 7 mm on average, and subcrestal biologic width 2.2 mm. The papilla tip and most coronal bone-toimplant contact were located 2 and 4.6 mm, respectively, more apically compared with the papilla tip and bone crest of neighbouring implant tooth sites. The median vertical dimension of interimplant papillae was 4.2 mm and missing PH 1.8 mm. In immediate provisionalization, missing PH was on average 1 mm, as opposed to 2 mm in cases where a removable temporary had been used. When missing PH was 1 mm, a clinically acceptable outcome for papilla ll, the horizontal distance between implants at shoulder level was on average 3 mm. Median patient satisfaction with the appearance of interimplant papillae was 87.5%, despite an incomplete papilla ll in most cases.

Acknowledgements: We wish to thank Dr Ceib Phillips, Professor, Department of Orthodontics, UNC School of Dentistry for her considerable help with the statistical analysis. Also, we greatly appreciate the contribution of Warren (Mac) McCollum, Senior Design Consultant at the Center for Educational Development and Informatics, UNC in producing the artwork for this paper.

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