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Effect of the Vertical and HorizontalDistances Between Adjacent Implantsand Between a Tooth and an Implanton the Incidence of Interproximal PapillaJose Fabio Gastaldo,* Patricia Ramos Cury,† and Wilson Roberto Sendyk*

Background: The interproximal dental papilla is consideredan essential component of the anterior and posterior regions ofthe maxilla and mandible. The absence of this structure hasesthetic and phonetical consequences and lateral food impactionproblems occur with the implant-supported prosthesis. The aimsof the present study were to: 1) evaluate the effect of the verticaland horizontal distances between adjacent implants (group 1)and between a tooth and an implant (group 2) on the presenceof the interproximal dental papilla; and 2) determine whether theinteraction between the vertical and horizontal distances mightbe associated with the incidence of the papilla.

Methods: In 48 patients, 96 interproximal sites in group 1and 80 in group 2 were examined. The distance from the baseof the contact point to the bone crest (D1), the distance betweentooth and implant or between two implants (D2), and the dis-tance from the base of the contact point to the tip of the papilla(D3) were measured.

Results: In both groups, when D2 was 3, 3.5, or 4 mm, thepapilla was present most of the time (P <0.05), and when D2 was2 or 2.5 mm, the papilla was absent 100% of the time (P <0.05).Further, in group 2, when D1 was between 3 and 5 mm, thepapilla was present most of the time (P <0.05). However, inGroup 1, only when D1 was 3.0 mm was the papilla presentmost of the time (P <0.05). For both groups, analysis of the inter-action between D1 and D2 showed that when D2 was ≤2.5 mm,the papilla was absent; otherwise, when D2 was ≥3 mm, therewas an interaction between D1 and D2.

Conclusions: We conclude that the ideal distance from thebase of the contact point to the bone crest between adjacentimplants is 3 mm and, between a tooth and an implant, 3 mmto 5 mm. The ideal lateral spacing between implants and betweentooth and implant is 3 mm to 4 mm. Further, there is an inter-action between horizontal and vertical distances when the lateralspacing is greater than 3 mm. J Periodontol 2004;75:1242-1246.

KEY WORDSDental implants; dental papilla/anatomy and histology; dentalprosthesis design; dental prosthesis, implant supported;gingiva/anatomy and histology.

* Department of Periodontics and Implantology, School of Dentistry, University of SantoAmaro, Santo Amaro, Brazil.

† Department of Oral Pathology, School of Dentistry, University of São Paulo, São Paulo,Brazil.

The application of osseointegrationprinciples to single-tooth and partialedentulism has increased patients’

esthetic demands. For dental implants inan esthetic zone, the criteria for successinvolve the establishment of a soft tissuecontour with an intact interproximal papillaand a gingival outline that is harmoniouswith the gingival silhouette of the adjacenthealthy dentition.1

The absence of the interproximal papillacan lead to cosmetic deformities, phoneticdifficulty, and food impaction.2 The contourof the interdental tissues, as well as thecolor and texture of the keratinized tissues,are essential factors in the esthetics ofanterior implant-supported restorations.3

Different surgical and prosthetic man-agement techniques of the soft tissuearound implant restorations have beendeveloped to achieve esthetic results.4,5

However, the predictable regeneration ofthe interproximal papilla adjacent to den-tal implants remains a complex challengeand the peri-implant mucosal response isnot clearly understood. Characterizationof the components that affect the pres-ence or absence of this papilla is thus ofgreat importance.

Recently, Choquet et al.1 reported a cor-relation between the distance from the baseof the contact point to the bone crest andthe presence or absence of the interprox-imal papilla. Their study showed that whenthe vertical distance is 3 mm, the papillafilled up the entire proximal space 80.0%of the time. The same group had previously

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Figure 1.Schematic drawing showing the distance from the base of the contactpoint to the bone crest (D1), inter-implant or inter-implant/toothdistance (D2), and distance from the base of the contact point to thetip of the papilla (D3).

reported that crestal bone loss for implants placed at aninter-implant distance of ≤3 mm was 1.04 mm, whilecrestal bone loss for implants spaced >3.0 mm apart was0.45 mm.2 Both studies were designed to establish theeffect of the distance from the contact point to the bonecrest or the inter-implant distance on the presence orabsence of the interproximal dental papilla and on theheight of the bone crest. However, the effect of the inter-action between these parameters on the incidence of thepapilla has not been studied.

The aims of the present study were to: 1) evaluatethe effect of the vertical (distance from the base of thecontact point to the bone crest) and horizontal distancesbetween adjacent implants (group 1) and between atooth and an implant (group 2) on the presence orabsence of the interproximal dental papilla; and 2) deter-mine whether the interaction between the vertical andhorizontal distances might be associated with the inci-dence of the papilla.

MATERIALS AND METHODSThe study protocol was approved by the University ofSanto Amaro Institutional Ethics Committee. Informedconsent was obtained from all subjects.

Forty-eight patients (28 women, 20 men; mean age,45 years; range, 19 to 72 years) who had implant-supported, fixed prostheses for a minimum of 18 monthsand a maximum of 6 years were included in the study.These patients had received their implants at theSchool of Dentistry, University of Santo Amaro, follow-ing the surgical and prosthetic protocols recommendedby the manufacturers. One hundred seventy-six inter-proximal areas were evaluated: 96 interproximal sitesin group 1 and 80 in group 2.

Clinical evaluations were performed by the sameexaminer using a periodontal probe. A 0.5 mm incre-mentally marked manual probe was designed and allmeasurements were rounded to the nearest millime-ter or half millimeter. The following parameters wereassessed: 1) presence/absence of a papilla; 2) distancefrom the base of the contact point to the bone crest(D1); 3) inter-implant or inter-implant/tooth distance(D2); 4) distance from the base of the contact pointto the tip of the papilla (D3) (Fig. 1); and 5) gingivalindex (GI).6

Evaluation of the papilla was performed visually andperpendicularly to the buccal surface of the restorationcrown prior to probing. The papilla was defined as pre-sent when it filled the entire proximal space or part ofthis space and exhibited a triangular or trapezoidalshape. For a more quantitative evaluation of the pres-ence or absence of the papillae, the distance from thebase of the contact point to the tip of the papilla (D3)was measured.

When the soft tissue presented clinical signs ofinflammation, the patient was excluded from the study.

To obtain the vertical measurement (D1), the patientwas anesthetized and the probe was inserted verticallyon the facial aspect of the contact point until the bonecrest was sounded. The horizontal measurement (D2)was obtained between the shoulders of the implants orbetween one shoulder and the adjacent tooth surface.

Statistical analyses comparing the differences inproportions were performed using the Z test. When Zwas between −2 and +2, a statistically significant dif-ference between the incidences of papilla absent andpresent was revealed. A significance level of P = 0.05was employed in all statistical comparisons.

RESULTSIn group 2, when the distance from the base of the con-tact point to the bone crest (D1) was between 3 and 5 mm, the papilla was present most of the time (P <0.05)(Table 1). However, in Group 1, only when D1 was 3 mm,the papilla was present most of the time (P <0.05)(Table 2). When D1 was ≥5 mm and ≥6 mm, respec-tively in group 1 and 2, papilla was absent in 60% to 75%of cases. The papilla filled the entire proximal space onlywhen D1 was 3 mm in group 1, and 3 and 4 mm in group 2; when D1 was only 1 mm greater than these mea-sures, the papilla did not fill the complete proximal space.As D1 increased, D3 also increased (Tables 1 and 2).

In both groups, when D2 was 3, 3.5, or 4 mm, thepapilla was present most of the time (P <0.05). How-ever, when D2 was 2 or 2.5 mm, the papilla was absent100% of the time (P <0.05) (Tables 3 and 4).

For both groups, analysis of the interaction betweenD1 and D2 showed that when D2 was ≤2.5 mm, the

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Table 4.

Group 2 (tooth-implant): Presence orAbsence of Interproximal Papilla Accordingto D2 (inter-implant or inter-implant/toothdistance)

% of Papilla

D2 N* Present Absent Z Significance

2.0 10 0 100 – P <0.05

2.5 16 0 100 – P <0.05

3.0 18 88 12 7.0 P <0.05

3.5 18 83 17 5.3 P <0.05

4.0 10 75 25 2.6 P <0.05

4.5 8 56 44 0.5 NS

* Number of areas examined.

Table 1.

Group 2 (tooth-implant): Presence or Absence of Interproximal Papilla and D3(mean distance in mm from the baseof the contact point to the crest of thepapilla) According to D1 (distance from thebase of the contact point to the bone crest)

Papilla Tooth-Implant

Present

D1 N* (%) D3 Absent (%) Z Significance

3 7 100 0 0 – P <0.05

4 24 100 0 0 – P <0.05

5 8 80 1 20 3.0 P <0.05

6 12 40 1 60 −1.0 NS

7 16 40 2 60 −1.2 NS

8 9 40 2 60 −0.9 NS

10 4 25 3 75 −1.6 NS

* Number of areas examined.

Table 3.

Group 1 (implant-implant): Presence orAbsence of Interproximal Papilla Accordingto D2 (inter-implant or inter-implant/toothdistance)

% of Papilla

D2 N* Present Absent Z Significance

2.0 14 0 100 – P <0.05

2.5 18 0 100 – P <0.05

3.0 22 82 18 5.5 P <0.05

3.5 20 81 19 4.9 P <0.05

4.0 12 71 29 2.3 P <0.05

4.5 10 48 52 −0.2 NS

* Number of areas examined.

papilla was absent, independent of D1. Otherwise,when D2 was ≥3 mm, an interaction between D1 andD2 was present (Fig. 2).

The gingival index was 0 in 94% of the areas and 1in 6%.

DISCUSSIONThe present study discloses three important findings.First and most important, for both adjacent implantsand an implant adjacent to a tooth, a horizontal distance(D2) <3 mm determines the absence of an interproxi-mal papilla, independent of the vertical distance (D1).Second, for both adjacent implants and an implant adja-

Table 2.

Group 1 (implant-implant): Presence or Absence of Interproximal Papilla and D3(mean distance in mm from the base of thecontact point to the crest of the papilla)According to D1 (distance from the baseof the contact point to the bone crest)

Papilla Implant-Implant

Present

D1 N* (%) D3 Absent (%) Z Significance

3 7 100 0 0 – P <0.05

4 27 50 0.5 50 0.0 NS

5 12 40 1 60 −1.0 NS

6 17 26 1 74 −3.2 P <0.05

7 15 40 2 60 −1.1 NS

8 14 40 2 60 −1.1 NS

10 4 25 3 75 −1.6 NS

* Number of areas examined.

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cent to a tooth, when D2 is ≥3 mm, there is an interac-tion between the vertical and horizontal distances. Third,when D1 is 3 mm between adjacent implants and 3, 4,or 5 mm between a tooth and an implant, and D2 is 3, 3.5,or 4 mm, the papilla is more frequently present.

The present study evaluated the interproximal area intwo dimensions: mesio-distal and apico-coronal and intwo groups: between adjacent implants and between atooth and an implant. Previous studies have analyzed theinterproximal area in only one dimension. Choquet et al.1

found that when the vertical distance is 3 mm, the papillafilled up the entire proximal space 80.0% of the time,which is similar to our results. We have shown that, whenthe vertical distance between adjacent implants is 3 mm,the papilla is present 100% of the time. Nevertheless, inthe present study, the incidence of the papilla betweena tooth and an implant was greater when D1 was between3 and 5 mm, which is in agreement with Tarnow et al.7

in their study on the distance between two natural teeth.Therefore, our results indicate that between two implantsthe results are less favorable than between a tooth andan implant from an esthetic standpoint.

In disagreement with the present study, Grunder8

showed that the total distance from the contact pointto the bone, between a tooth and an implant, wasalmost 9 mm, and all the cases had a “perfect papilla.”We found that when the vertical distance was 8 or10 mm, the papilla was absent 60% and 75% of thetime, respectively.

With regard to the mesio-distaldistance, Tarnow et al.2 havereported that crestal bone loss wasgreater for implants spaced 3 mmor less from each other than forimplants spaced more than 3.0mm apart. These authors did notanalyze the impact of this horizon-tal distance on the presence of thepapilla. Our study shows that amesio-distal distance of 3 to 4 mmis associated with a more frequentincidence of the papilla. Thus, wesuggest that the ideal distance be-tween implants or between animplant and the adjacent tooth isbetween 3 and 4 mm. In order tomeasure the horizontal distancebetween the shoulder of the implantand the adjacent tooth surfaceaccurately, this measurement wasobtained without any angle fromthe shoulder of the implant to theadjacent tooth surface, indepen-dent of cementoenamel junction.

In the present study the papillawas defined as being present when

it filled the entire proximal space or part of that space.However, for a more quantitative evaluation of the pres-ence or absence of papillae, the distance from the baseof the contact point to the papilla crest (D3) was mea-sured. Evidently, an affirmation of “present” or “absent”is subjective, and Choquet et al.1 showed that somepapilla considered absent were, in fact, classified aspresent using half the papilla height as a criterion.

Other variables, such as the degree of inflammation,fibrous or edematous nature of the tissue, anterior ver-sus posterior teeth, history of previous surgical com-plications or periodontal disease, the bucco-lingualdimension, and the form of restoration may contributeto the presence or absence of the papilla.7 However, itwas not the aim of the present study to examine thesefactors.

The current results show that an esthetically accept-able, implant-supported restoration requires thoroughsurgical and prosthetic treatment planning. In mostcases, it is virtually impossible for the restorative den-tist to achieve an esthetic restoration if the implant isnot properly placed in the mesio-distal and apico-coronalplanes by the surgeon. Thus, the clinical significanceof these results lies in the fact that the presence of thepapilla depends on the surgical and restorative phases,when the mesio-distal and apico-coronal dimensionsare established.

In conclusion, when the horizontal distance was<3 mm, the papilla was absent, independent of the

Figure 2.Group 1 plus group 2: Probability diagram of the presence of an interproximal papilla derived from D1 versus D2.

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vertical distance. However, when D2 was ≥3 mm, therewas an interaction between the horizontal and verticaldimensions. Further, to assure the presence of thepapilla, the ideal vertical distances are 3 mm betweenadjacent implants and 3, 4, or 5 mm between a toothand an implant, and the ideal lateral spacing betweenimplants or between tooth and implant was 3 to 4 mm.Further research is necessary to examine the effect ofthe facio-lingual distance on the presence of the inter-proximal papilla.

ACKNOWLEDGMENTThe authors thank Ms. Marisa Cury for the schematicdrawing.

REFERENCES1. Choquet V, Hermans M, Adriaenssens P, Daelemans P,

Tarnow DP, Malevez C. Clinical and radiographic eval-uation of the papilla level adjacent to single-tooth den-tal implants. A retrospective study in the maxillaryanterior region. J Periodontol 2001;72:1364-1371.

2. Tarnow DP, Cho SC, Wallace SS. The effect of inter-implant distance on the height of inter-implant bonecrest. J Periodontol 2000;71:546-549.

3. Tarnow DP, Eskow RN. Considerations for single-unitesthetic implant restorations. Compendium ContinuingEduc Dent 1995;16:778,780,782-784.

4. Garber DA, Belser UC. Restoration-driven implant place-ment with restoration-generated site development. Com-pendium Continuing Educ Dent 1995;16:796,798-802,804.

5. Becker W, Becker BE. Flap designs for minimization ofrecession adjacent to maxillary anterior implant sites: Aclinical study. Int J Oral Maxillofac Implants 1996;11:46-54.

6. Löe H, Silness JL. Periodontal disease in pregnancy. I.Prevalence and severity. Acta Odontol Scand 1963;21:533-551.

7. Tarnow DP, Magner AW, Fletcher P. The effect of thedistance from the contact point to the crest of bone onthe presence or absence of the interproximal dentalpapilla. J Periodontol 1992;63:995-996.

8. Grunder U. Stability of the mucosal topography aroundsingle-tooth implants and adjacent teeth: 1-year results.Int J Periodontics Restorative Dent 2000;20:11-17.

Correspondence: Dr. P.R. Cury, Department of Oral Pathology,School of Dentistry, University of São Paulo, Av. Lineu Prestes,2227, Cidade Universitária, CEP: 05508-000, São Paulo, SP,Brazil. Fax: 55-11-30917894; e-mail: curyp@usp.br.

Accepted for publication January 10, 2004.

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