interproximal tissue dimensions in relation to adjacent implants in the anterior maxilla- clinical...

Interproximal tissue dimensions inrelation to adjacent implants in theanterior maxilla: clinical observationsand patient aesthetic evaluation

Styliani KourkoutaKonstantina Dina DediDavid W. PaquetteAndre Mol

Authors’ affiliations:Styliani Kourkouta, Eastman Dental Hospital &Institute, University College London HospitalsNHS Foundation Trust, London WC1X 8LD, UKStyliani Kourkouta, Konstantina Dina Dedi,Department of Prosthodontics, School of Dentistry,University of North Carolina at Chapel Hill, ChapelHill, NC 27599-7450, USAKonstantina Dina Dedi, UCL Eastman DentalInstitute, London WC1X 8WD, UKDavid W. Paquette, Department of Periodontology,School of Dentistry, University of North Carolina atChapel Hill, Chapel Hill, NC 27599-7450, USAAndre Mol, Department of Diagnostic Sciences &General Dentistry, School of Dentistry, Universityof North Carolina at Chapel Hill, Chapel Hill, NC27599-7450, USA

Correspondence to:Styliani KourkoutaEastman Dental Hospital & InstituteUniversity College London Hospitals NHSFoundation Trust256 Gray’s Inn RoadLondon WC1X 8LDUKTel.:þ44 0207 915 2346Fax: þ 44 0207 915 1028e-mail: [email protected]

Key words: aesthetic zone, anterior maxilla, dental implants, interimplant papilla, inter-

proximal papilla

Abstract

Objectives: This clinical study aimed to assess (i) interproximal tissue dimensions between

adjacent implants in the anterior maxilla, (ii) factors that may influence 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 implant–implant sites was located on average

4.6 mm apical to the bone crest at comparable neighbouring implant–tooth sites. The tip of

the papilla between adjacent implants was placed on average 2 mm more apically

compared with implant–tooth sites. The contact point between adjacent implant

restorations extended more apically by 1 mm on average compared with implant–tooth

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 significant

association between the provisionalization protocol and missing PH, which was also

influenced by the horizontal distance between implants. Patient aesthetic satisfaction was

high, despite a less than optimal papilla fill.

Dental implants, when placed according to

established treatment protocols, are asso-

ciated 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 lo-

cated 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

Date:Accepted 12 May 2009

To cite this article:Kourkouta S, Dedi KD, Paquette DW, Mol A.Interproximal tissue dimensions in relation to adjacentimplants in the anterior maxilla: clinical observationsand patient aesthetic evaluation.Clin. Oral Impl. Res. 20, 2009; 1375–1385.doi: 10.1111/j.1600-0501.2009.01761.x

c� 2009 John Wiley & Sons A/S 1375

mailto:[email protected]

significance for the aesthetic outcome of

implant-supported restorations may not be

of decisive importance for patient satisfac-

tion (Chang et al. 1999), therefore subjec-

tive patient evaluation is also of primary

importance for the assessment of a success-

ful outcome in implant therapy.

The replacement of multiple adjacent

teeth with fixed implant restorations in

the anterior maxilla is particularly challen-

ging 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 re-

storations adjacent to natural teeth, the

level of the marginal soft tissues and inter-

proximal papillae is dictated by the attach-

ment 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). Cur-

rently, 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 fixtures will lead to a

reduction in crestal bone height, which,

in turn, may result in absence of a com-

plete interproximal papilla and compro-

mised 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 adja-

cent implants (Tarnow et al. 2003), or

3 mm (Gastaldo et al. 2004) is recom-

mended in order to improve the chances

that an interproximal papilla will be pre-

sent, 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 be-

tween those implants. The above measure-

ments 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

fixtures with a wide diameter may be of

limited use in the aesthetic zone (Tarnow

et al. 2000; Buser et al. 2004). A compar-

ison of two distinctive implant systems

showed similar dimensions of the inter-

proximal soft tissue between adjacent im-

plants irrespective of the horizontal

distance of the fixtures (Lee et al. 2006).

However, interproximal dimensions

strictly between adjacent single implants

in the anterior maxilla have not been as-

sessed. Furthermore, patient subjective

evaluation of the appearance of interim-

plant papillae in the aesthetic zone has

not been carried out.

The aim of this clinical study was to

assess (i) the dimensions of the interprox-

imal tissues between adjacent implants in

the anterior maxilla in relation to the pre-

sence of a papilla, (ii) factors that may

influence the dimensions of the interim-

plant papilla, and (iii) patient aesthetic

satisfaction.

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 im-

plants in the anterior maxilla that had

been restored with single implant

crowns or adjacent fixed partial den-

tures,

ii. healthy individuals: absence of sys-

temic health complications, in parti-

cular conditions that might affect the

survival and/or success of implants,

such as uncontrolled diabetes or im-

munocompromised states,

iii. no pregnancy, and

iv. absence of periodontal disease or peri-

implant inflammation.

The study design, observational cross-

sectional with a retrospective component,

involved: (1) retrospective data collection

from patients’ treatment records, (2) clin-

ical assessment, (3) radiographic assess-

ment, and (4) a questionnaire evaluating

aesthetic satisfaction.

(1) Information accessed from patients’

treatment records:

� Timing of treatment provided, i.e., im-

plant placement, temporisation, time

since final restoration.

� Surgical protocol, i.e., immediate or

delayed placement and whether ridge

augmentation had been performed.

� Type of provisional and final restora-

tions.

� Oral hygiene instructions, recall fre-

quency 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 digi-

tal clinical photographs of the implant

restorations and surrounding soft tis-

sues. The photographs were taken per-

pendicular 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).


to the tip of the papilla (IP).

Fig. 1. Clinical problem: Absence of complete pa-

pilla between adjacent implants (12,11) in the aes-

thetic zone.

Kourkouta et al . Interimplant papilla dimensions in the aesthetic zone

1376 | Clin. Oral Impl. Res. 20, 2009 / 1375–1385 c� 2009 John Wiley & Sons A/S

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 radio-

graphs (Fig. 2):

� Horizontal distance between adjacent

implants, measured at shoulder level

(SS), SLA-smooth surface junction (JJ),

and fixture body level, just coronal to

the first thread (FF) (implant–implant

sites).

� Horizontal distance between implant

and mesial surface of adjacent tooth at

corresponding levels (ST, JT, FT) (im-

plant–tooth sites).


of adjacent crowns to the bone crest

(IB).

� Vertical distance from bone crest to the

apical bone level (most coronal bone-

to-implant contact), i.e., subcrestal bio-

logic width (BBa) (implant–implant

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 assess-

ment 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 (restora-

tive platform) width for the horizontal

measurements, and interthread distance

for the vertical measurements. The mea-

surements were performed three times; the

second and third sets of measurements

were used for assessment of repeatability.

The final 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:

CB¼ IB� IC.

� VDP: Vertical dimension of papilla (ver-

tical distance from tip of papilla to bone

crest)¼PB¼ IB� IP. At implant–tooth

sites that coincides with the proximal

biologic width on the tooth aspect.

� MPH: Missing PH¼CP¼ IP� IC.

� PBa: Proximal (interimplant) biologic

width (sulcus depthþ junctional

epitheliumþconnective tissue contact)

(Cochran et al. 1997; Hermann et al.

2000)¼PBþBBa.

� Vertical distance from incisal edge to

apical bone level (implant–implant

sites): IBa¼ IBþBBa.

� Vertical distance from implant shoulder

to bone crest: SB¼SBa�BBa.

� Vertical distance from tip of papilla to

implant shoulder: PS¼PB� SB.

� Vertical distance from SLA-smooth sur-

face junction to bone crest:

JB¼SB� 1.8 mm.

� Vertical distance from SLA-smooth sur-

face junction to apical bone level:

JBa¼SBa� 1.8 mm.

4) Subjective aesthetic evaluation

A questionnaire consisting of a visual

analogue scale (VAS) and additional ques-

tions, including open-ended ones, was used

with the aim to assess subjective aesthetic

evaluation. It was filled by the subjects at

the end of their clinical assessment ap-

pointment. The VAS answers were quan-

tified 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 final 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 35–71 years). Two of

the patients were smokers. A total of 35

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, fixture body, just coronal to the first thread; Ba, apical bone level (first 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.

Table 1. Frequency of Papilla Index at implant–implant and implant–tooth sites

Papilla Indexn Implant–implant sites Implant–tooth sites

N % N %

0 1 5.3 0 01 3 15.8 0 02 14 73.7 11 84.63 0 0 2 15.44 1 5.3 0 0

n0: 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.


c� 2009 John Wiley & Sons A/S 1377 | Clin. Oral Impl. Res. 20, 2009 / 1375–1385

Straumann implants (Institut Straumann

AG, Waldenburg, Switzerland) were in-

cluded in the study. They were of the

Standard Plus SLA (sand-blasted, large-

grit, acid-etched) type, i.e., the smooth

collar height was 1.8 mm. Thirty of the

fixtures (85.7%) had a regular neck

(4.8 mm restorative platform diameter and

4.1 mm implant body diameter), whereas

five fixtures (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 augmenta-

tion was performed in nine cases (60%)

using an allograft or xenograft in combina-

tion 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 fixed

implant-supported restorations (46.7%).

At the time of the assessment the final

restorations had been in place for an aver-

age 21.6 months (SD 14.2). Twenty-seven

of the restorations (77%) were porcelain-

fused-to-metal (high noble alloy), and the

remaining eight were ceramic (23%).

Thirty-three of the final restorations

(94%) were cemented, whereas the re-

maining two (6%) were screw-retained.

Seven of the patients (46.6%) had an aver-

age 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 interim-

plant papilla the adjacent site between the

implant restoration and natural tooth was

used for comparison where possible. A

total of 20 implant–implant and 16 im-

plant–tooth 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 tooth–implant

site. To allow comparison between IB (IBa),

IP, and IC at implant–implant and im-

plant–tooth sites, the variables were ad-

justed 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 measure-

ments 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 indepen-

dent examiner.

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 dupli-

cate SS measurements would be ex-

pected to lie within these values. One

hundred per cent of the differences

were o1 mm.

2. FF: The mean difference between the


0.12 mm, SD 0.33 mm. This implies




were �0.53 and 0.77 mm, i.e., 95%


cate 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


� 0.22 mm, SD 0.36 mm, implying




were �0.93 and 0.49 mm, i.e., 95%


cate IB measurements would lie within

these values. The percentage of differ-

ences that were o1 mm was 97.2%.

Statistical analysis

The majority of the data and their differ-

ences were non-normally distributed,

therefore non-parametric tests were ap-

plied. The patient was used as the statis-

tical unit for the analyses. The level of

significance 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 (ad-

justed), IBa/IB (adjusted), IP (adjusted), IC

(adjusted), CB, VDP, and MPH at implant–

implant and implant–tooth sites. Correla-

tion was sought between (i) VDP and

biotype, surgical protocol, type of tempor-

ary restoration, SS, JJ, FF, and (ii) MPH and

biotype, surgical protocol, type of tempor-

ary, WKM, SS, JJ, and FF. The Mann–

Whitney test was used for binary and the

Spearman’s rho for continuous data. Split

group analysis was performed for: (i) bio-

type, 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 Fisher’s 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.

0

2

4

6

8

10

12

14

13 12 11 21 22Implant sites

No

of

site

s

Fig. 3. Distribution of implants.

0

2

4

6

8

10

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

No

of

site

s

Implant-implant sites

Implant-tooth sites

Fig. 4. Distribution of implant–implant and im-

plant–tooth sites.



Results

The PI at implant–implant 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 sum-

marized in Tables 4 and 5. Most of the

patients were content with the interim-

plant 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 visi-

ble in high smile, expressed some concern.

Results of the Wilcoxon signed ranks

tests are shown in Table 6. Statistically

significant differences between implant–

implant and implant–tooth papillae were

noted for PH, and IBa/IB, IP, IC (adjusted).

PH was on average 1 mm greater at im-

plant–tooth 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

implant–tooth sites (95% CI: 2.47–

6.82 mm). In a similar fashion, IP (ad-

justed) was greater at implant–implant

sites by 2 mm on average (95% CI: 1–

2.75 mm), and IC (adjusted) by 1 mm

(95% CI: 1–4 mm).

The only statistically significant correla-

tion was observed between MPH and type

of temporary restoration (P¼0.006). In the

case of a fixed temporary restoration

(N¼ 7) the median MPH was 1 mm (95%

CI: 0.5–2 mm), whereas when a removable

temporary had been used (N¼ 7) the

median MPH was 2 mm (95% CI: 1.75–

2.5 mm).

Results of the split group analysis are

shown in Tables 7–9. For MPH�1 mm

(N¼ 6), the type of temporary restoration

was fixed in all cases and the median

horizontal distance between the implants

was 3.02 mm at shoulder level (95%

CI: 2.11–5.73 mm). The only other

significant result concerned the VDP, ac-

cording 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 influence the

dimension of the interimplant papilla. Pre-

vious studies that attempted to assess in-

terimplant papillae evaluated linked units

in anterior and posterior sites (Tarnow et al.

2003), posterior sites only (Lee et al.

2005b, 2006), or unspecified 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: first, 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 influ-

ence on the height of the soft tissue. Sec-

ondly, 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 specia-

lized 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 1.4–7.9 mm), as opposed to 3.4 mm

(range 1–7 mm) reported by Tarnow et al.

(2003), and 3.3 mm as confirmed by Lee

et al. (2005b). The latter study concerned

posterior implants, where interproximal

brushes were used for cleaning and this

0

2

4

6

8

10

12

14

0 1 2 3 4Papilla Index

No

of s

ites

Implant-implant sitesImplant-tooth sites

Fig. 5. Description of Papilla Index.

Table 2. Median values of variables (95% CI for the median) at implant–implant andimplant–tooth sites

Variable Implant–implant sites Implant–tooth sites

N N

PI 14 2 11 2(1, 2) (2, 3)

PH (mm) 15 2.33 13 3(1.5, 2.5) (3, 4)

WKM (mm) 15 6 13 6(5, 6.5) (6, 7.8)

SS/ST (mm) 15 2.15 13 1.15(1.61, 2.9) (0.68, 2.16)

JJ/JT (mm) 15 3.09 13 1.52(2.47, 3.76) (0.83, 2.36)

FF/FT (mm) 15 3.82 13 1.68(3.16, 4.28) (0.9, 2.31)

IB (mm) 15 13.11 13 10.89(11.53, 14.71) (8.71, 13.6)

IB adjusted (mm) 12 12.32 12 10.88(11.4, 13.72) (8.71, 11.43)

IP (mm) 15 8.5 13 6(8, 10) (5.75, 7.5)

IP adjusted (mm) 12 8 12 6(7.5, 9.75) (5.75, 7.5)

IC (mm) 14 7 11 5(6, 8.17) (3, 6.5)

IC adjusted (mm) 13 7 10 5(6, 8) (3, 6.5)

CB (mm) 14 5.68 11 6.05(4.33, 7.25) (4.39, 8.14)

VDP (mm) 15 4.22 13 4.25(3.33, 5.6) (3.04, 6.05)

MPH (mm) 14 1.79 11 1.3(1, 2) (0, 3)

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



may have influenced 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 significantly

more coronal location of the mucosal mar-

gin at one-piece compared with two-piece

implants (Hermann et al. 2001). The aver-

age 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 inter-

implant sites equaled on average 2.2 mm,

suggesting that in many cases a peak of

bone was present between adjacent fix-

tures. The apical bone level (most coronal

bone-to-implant contact) was on average

1.3 mm apical to the SLA–smooth 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 restora-

tively introduced contact point, is an

important landmark, because it is

consistently placed 1–2 mm apical to the

anticipated mucosal margin or cemento-

enamel junction (CEJ) of adjacent teeth,

provided the protocol for implant place-

ment 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

depthþepithelial attachmentþconnective

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 tooth-

to-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 bio-

logic width is considered to be a physiolo-

gically formed structure, the overall

dimension of which remains stable over

time (Hermann et al. 2000). In consistency

with what has been reported in the litera-

ture regarding the dimensions of the peri-

implant mucosa, we would expect a verti-

cal 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 specifically for one-piece non-

submerged loaded implants, 1.05�0.38 mm for the connective tissue contact

and 1.88� 0.81 mm for the junctional

Table 3. Median values of variables (95%CI for the median) at interimplant papillae(N¼number of patients)

Variable Interimplant papillae

N

BBa (mm) 15 2.21(2.13, 2.75)

SBa (mm) 15 3.13(2.75, 4.05)

SB (mm) 15 0.75(0.5, 1.32)

JBa (mm) 15 1.33(0.95, 2.25)

JB (mm) 14 � 1.05(� 0.48, � 1.1)

PS (mm) 15 3.43(2.01, 4.89)

PBa (mm) 14 6.96(5.54, 8.31)

IBa (mm) 15 15.46(14.28, 18.31)

IBa adjusted (mm) 12 14.83(14.23, 15.85)

Table 4. First part of aesthetic evaluation questionnaire: visual analogue scale and results

Question Median (%) Range (%)

100%dissatisfied

100%satisfied

Indifferent

1. Appearance of soft tissue (papilla) between your implant crowns 87.5 � 60 to 1002. Health of the soft tissue between implants 93.5 � 20 to 1003. Possibility to clean between implant crowns 91.5 0 to 1004. Level of overall satisfaction with implant treatment 95 9 to 100

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 93.3No 1 6.7

If yes, what do you use?Dental floss/tape 10 66.7Super Floss 3 20Toothpicks 1 6.7Interdental brushes 1 6.7Other 1 6.7

How often?Once a day 3 20Twice a day 6 40Once a week 2 13.3Occasionally 3 20

Do you feel that the soft tissue between your implant crowns (papilla) is stable?Yes 14 93.3No 1 6.7

Do you like the appearance of the papilla between your implant crowns?Yes 11 73.3No 1 6.7No opinion 2 13.3Other 1 6.7

How would you feel if this soft tissue was partly or totally absent and a dark triangle waspresent in between your implant crowns?

Would certainly dislike it 13 86.7Not so important, provided the implants were still functional 1 6.7Other 1 6.7

Would you recommend the implant procedure you had to another patient suffering fromthe same problem?

Yes 14 93.3No 1 6.7



epithelium (Hermann et al. 2000). There-

fore, under the conditions of this study, it

would appear reasonable to suggest that the

connective tissue contact occupied most of

the area between the first 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 aver-

age, of peri-implant mucosa interproxi-

mally would be expected to correspond to

the peri-implant sulcus.

As expected, based on previous research

and clinical observation, the implant–im-

plant sites did slightly ‘worse’ in terms of

soft tissue fill, compared with the implant–

tooth sites. In the majority of interimplant

papillae the PI was 1 (16%) or 2 (74%),

whereas at implant–tooth sites it was 2

(85%) or 3 (15%). The PH was on average

1 mm greater at implant–tooth sites. How-

ever, the width of keratinized mucosa,

distance from contact point to bone crest,

vertical dimension of papilla, and missing

PH did not differ significantly between

implant–implant and implant–tooth sites.

The contact point extended more apically

between adjacent implant restorations

compared with implant–tooth sites by

1 mm on average, therefore nullifying any

differences in the distance from contact

point to bone crest, and missing PH be-

tween implant–implant and implant–tooth

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 implant–tooth

sites, which was close to the average sub-

crestal biologic width dimension of

2.2 mm. The most coronal bone-to-im-

plant contact at implant–implant sites,

i.e., the apical end of the proximal biologic

width dimension, was placed on average

4.6 mm more apically compared with im-

plant–tooth 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 be-

tween 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 fill.

The facial position of the flat implant

shoulder, at least 1–2 mm apical to the

CEJ, determines a more apical position for

the bone crest–papilla complex interproxi-

mally 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) reflects the proximal biologic width

dimension (Kois 1994), which is the ver-

tical 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

Table 6. Median differences of variables at implant–implant and implant–tooth papillae,95% CI for the median, and P-values from Wilcoxon signed ranks tests

Variable N Median difference 95% CI P-value

(variable at implant–implantminus variable at implant–tooth papilla)

PI 11 0 � 1, 0 0.06PH (mm) 13 � 1 � 1.5, � 0.5 0.006n

WKM (mm) 13 � 1 � 2, 0 0.09IB adjusted (mm) 12 1.75 0.35, 2.97 0.02IBa/IB adjusted (mm) 12 4.6 2.47, 6.82 0.00n

IP adjusted (mm) 12 2 1, 2.75 0.002n

IC adjusted (mm) 10 1 1, 4 0.002n

CB (mm) 11 � 0.65 � 2.46, 1.97 0.9VDP (mm) 13 0.04 � 1.65, 1.05 0.96MPH (mm) 11 0.5 � 1.5, 1 0.85

nStatistically significant (Po0.01).

Table 7. P-values of split group analysis according to MPH�1 or 41 mm

Biotype Grafting Imm/Del Temp PI PH WKM SS JJ FF CB VDP

MPH 40.99 0.58 0.63 0.005n 0.24 0.07 0.51 0.008n 0.02 0.04 0.35 0.76�1 mm (N¼ 6) or41 mm (N¼ 8)

nStatistically significant (Po0.01).

Table 8. Statistically significant results from split group analysis according to MPH�1or 41 mm

Type of temporary restoration SS

Fixed Removable Median (95% CI for the median)

MPH�1 mm 6 0 3.02N¼ 6 (2.11, 5.73)MPH 41 mm 1 7 1.71N¼ 8 (0.95, 2.82)

Table 9. Results of split group analysis according to CB�5 or 45 mm, and CBo6or �6 mm

PI P PH P VDP P MPH P

CB�5 mm 2 0.12 2.42 0.55 2.34 0.002n 1.5 0.75N¼ 4 (2, 3) (2, 2.5) (1.4, 3.33) (0.5, 2)CB45 mm 2 2.13 4.83 1.79N¼ 10 (1, 2) (1, 3.33) (3.95, 5.72) (1, 2.5)CBo6 mm 2 0.79 2.42 0.93 3.36 0.003n 1.5 0.49N¼ 8 (0, 3) (0, 2.5) (1.4, 4.91) (0.5, 2)CB �6 mm 2 2.13 5.61 1.79N¼ 6 (1, 2) (1, 4) (4.7, 7.94) (1, 2.5)

Median (95% CI) and P-values.nStatistically significant (Po0.01).



adjacent implants (point Ba) was located on

average 4.6 mm more apically compared

with the apical level of the proximal biolo-

gic width at neighbouring teeth (point B).

Despite that, the discrepancy in the papilla

tip location between adjacent implants and

neighbouring implant–tooth sites was only

2 mm (in the same direction), a favourable

outcome, probably due to the biologic ca-

pacity of the tissues and potentially in

response to the characteristics of the im-

plant system used. The clinical signifi-

cance of the more apical location of the

bone crest–papilla complex between adja-

cent implants is that the deeper the im-

plants are placed in the bone, to ensure an

appropriate emergence profile and/or hide

the metal part of the fixtures under the

tissues in the aesthetic zone, the more

apical the first bone-to-implant contact

will be, resulting in a more apical biologic

width formation and location of the pa-

pilla tip, therefore increasing the likelihood

of unnatural, short papillae and dark tri-

angles being present. On the other hand,

the more coronal the first 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 unpre-

dictable, 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 biolo-

gic width dimensions among individuals

adds to the unpredictability of papilla for-

mation between adjacent implants.

A highly significant correlation was ob-

served between missing PH and the type of

temporary restoration. Thus, missing PH

was on average 1 mm where an implant-

supported fixed temporary restoration had

been used in an immediate provisionaliza-

tion approach, whereas in the case of a

removable temporary the average missing

PH was 2 mm. Ryser et al. (2005) com-

pared immediate provisionalization to a

delayed restoration protocol at single im-

plants adjacent to natural teeth in anterior

and posterior maxillary and mandibular

sites, and found no difference in papilla

fill 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 environ-

ment and withstand pressure from a remo-

vable provisional prosthesis, whereas in the

case of adjacent implants, especially multi-

ple ones, similar insults may have a nega-

tive effect on soft tissue height. There was

no correlation between biotype or immedi-

ate vs. delayed placement and vertical pa-

pilla dimension or missing PH. Regarding

the effect of the timing of implant place-

ment on papilla dimensions, Schropp et al.

(2005) compared in a randomized prospec-

tive clinical study interproximal papilla

dimensions in early vs. delayed single im-

plant 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 first, 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 fixtures. In the present study

no correlation was observed between miss-

ing PH and width of keratinized mucosa.

No correlation was sought between vertical

papilla dimension and width of keratinized

mucosa, because there is an expected part-

of-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 confirms the finding of Chang et al.

(1999) that the significance of certain fac-

tors 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 evalua-

tion. This study showed that, from a pa-

tient’s perspective, a PI of 2 is acceptable in

the majority of cases. This should not be

interpreted to imply relaxed clinical stan-

dards; simply, in cases where optimal in-

terimplant 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 filled 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 fixed temporary

restoration should be used in preference to

a removable one, and the average horizon-

tal 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 fixtures 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 max-

illary central incisors: the interimplant papilla is

almost complete. Missing papilla height of up to

1 mm is not clinically important because the resul-

tant space gets filled with saliva and is not percep-

tible by the non-expert eye.



adjacent implants (Tarnow et al. 2000;

Gastaldo et al. 2004).

However, the concept of predictable pa-

pilla fill in relation to the distance from the

contact point to the bone crest that has

been reported for interproximal dental pa-

pillae (Tarnow et al. 1992) and implant–

tooth papillae (Choquet et al. 2001; Ryser

et al. 2005) was not confirmed 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 significant 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 ex-

pected 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 dis-

tance from contact point to bone crest as a

cut-off point, based on the study by Gas-

taldo et al. (2004), was not reported here,

because the size of one of the groups was

too small (N¼1 for CB�3 mm, and N¼ 2

for CB�4 mm). These observations seem

to confirm the concept that, when asses-

sing interimplant papillae, it is the prox-

imal 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

critical, because it is not a determinant of

biologic width dimension, unless it coin-

cides with the apical bone level, and the

location of the contact point provides little

information, since it is artificially intro-

duced. 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 subcres-

tal biologic width found in this study, of

5.6 and 5.2 mm, respectively. These num-

bers, 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, sup-

porting the concept that it is the latter that

is of importance in determining the inter-

implant soft tissue profile. Therefore it is

not the distance from the contact point to

the bone crest that determines papilla fill

between adjacent implants, but the dis-

tance 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-coro-

nal 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 fill

in a systematic and objective manner.

Gastaldo et al. (2004) defined in their

study a papilla as present when it filled

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 pre-

sence/absence of papilla and PI, and noted

that the latter was a more descriptive and

scientific 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 re-

lated to interproximal soft tissue response,

future studies should consider quantitative

metrical measurements instead of Jemt’s

Index.

In previous research (Tarnow et al. 2003;

Gastaldo et al. 2004) the vertical dimen-

sion of the papilla was measured by bone

sounding. This is an invasive procedure

that involves administration of local anaes-

thetic. A further criticism of that metho-

dology is that because the final restorations

were already in place at the time of probing,

it would not have been possible to insert

the probe vertically exactly at the mid-

crest, 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 assess-

ment of the soft tissue component. How-

ever, it is not clear how the tip of the

papilla was identified on the radiographs

for the respective measurements to be car-

ried 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,

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).



a false reading will occur. Also, it may have

practical limitations in large university or

hospital settings, where the clinician apply-

ing the material would be located at a

distance from the radiology department.

This, together with the waiting time in-

volved for the taking of the radiographs,

may lead to dislodgement of the material,

resulting in additional radiation, time, ef-

fort, and cost.

In the present study, for reasons of pa-

tient comfort and to avoid an invasive

procedure, the vertical dimension of the

papilla was measured indirectly, by sub-

tracting 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 clin-

ical identification of the apical end of the

contact point was more precise, and there-

fore 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

fixture-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 hori-

zontal plane.

This study evaluated the interproximal

area between adjacent implants in the ante-

rior maxilla in two dimensions, mesio-

distal, 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.

Conclusions

Formation of complete, naturally looking

papillae between adjacent implants is con-

sidered unpredictable. This clinical study

evaluated 35 adjacent implants in the aes-

thetic zone of 15 adult patients, where the

final restorations had been in place for an

average of 22 months, and showed that:

1. The apico-coronal position of the first

bone-to-implant contact and the

proximal biologic width dimension

(sulcus depthþepithelial attachmentþconnective tissue contact) appear to

determine the location of the papilla

tip at interimplant sites. Proximal bio-

logic 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 tis-

sue at a more coronal level and incom-

plete papilla fill. In this study proximal

biologic width dimension at interim-

plant sites was 7 mm on average, and

subcrestal biologic width 2.2 mm. The

papilla tip and most coronal bone-to-

implant contact were located 2 and

4.6 mm, respectively, more apically

compared with the papilla tip and

bone crest of neighbouring implant–

tooth sites.

2. The median vertical dimension of in-

terimplant 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 miss-

ing PH was �1 mm, a clinically ac-

ceptable outcome for papilla fill, 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 pa-

pilla fill 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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