oral & maxillofacial implants · martha e. nunn, dds, phd5/kasumi barouch, dos, phd6/ thomas e....

Volume 2}// Number 5 2008

w

ORAL & MAXILLOFACIAL IMPLANTS

'EMYOFOSSEOINTEGRATION

Kj*3o

Peyman Shahidi, DOS, MScDVZhimon Jacobson, DMD, MScD2/ Serge Dibart, DMD3/Jacob Pourati, DMD, MScD4/

Martha E. Nunn, DDS, PhD5/Kasumi Barouch, DOS, PhD6/ Thomas E. Van Dyke, DOS, PhD5

Purpose: To compare the efficacy of a new uncovering technique with that of the conventional uncov-ering technique for papilla generation. Materials and Methods: Thirty-three patients with 67 implantswere enrolled in the study. Patients were randomly assigned to 1 of 2 treatment groups (test and con-trol). Implants of the test group were uncovered by the new technique and implants of the other groupuncovered by the conventional technique (simple midcrestal incision). The height of each papilla afteruncovering at baseline, 3 months, and 6 months and the thickness of the tissue covering the implantprior the uncovering were measured. PPD, PI, Gl, and BOP measurements were made at 0 and 6months, and standardized radiographs were obtained at 0, 3, and 6 months. Subject means wereused for all statistical analyses. Results: The mean difference between the 2 surgical methodsrevealed that the new technique provided 1.5 mm greater papilla height (P < .001) at all 3 visits (base-line, 3, and 6 months) for implants adjacent to teeth. An overall significant difference for papilla heightbetween the implants was detected between the 2 groups (P = .02). There was no significant differ-ence between the 2 groups with regard to PPD, PI, Gl, BOP, thickness of soft tissue, or overall bonelevel measurements during the course of the study. Conclusion: Based on this study, it appears thatover the course of 6 months, the new surgical approach for uncovering leads to a more favorable softtissue response. INT J ORAL MAXILLOFAC IMPLANTS 2008;23:926-934

Key words: implant esthetics, papilla generation

Many researchers have suggested that papillaheight is a predetermined factor,1'2 thereby

challenging whether a soft tissue operation has anyeffect on the generation of an interproximal papilla.

Private Practice, Scottsdale, Arizona.2Professor, Center for Implantology, Boston University School ofDental Medicine, Boston, Massachusetts.

Associate Professor, Department of Periodontology and OralBiology, Boston University School of Dental Medicine, Boston,Massachusetts.

4Private Practice, Boston, Massachusetts.5Professor, Department of Periodontology and Oral Biology, Gold-man School of Dental Medicine, Boston University, Boston,Massachusetts.

6Assistant Professor, Department of Periodontology and Oral Biol-ogy, Goldman School of Dental Medicine, Boston University,Boston, Massachusetts.

Correspondence to: Dr Peyman Shahidi. Fax: 866 290 9365.E-mail: [email protected]

Presented at the Oral Presentation Session of the Academy ofOsseointegration Annual Meeting, Orlando, Florida, March 2005.

The simplest uncovering method is the conven-tional midcrestal uncovering method.3'4 Althoughhighly predictable, it is not capable of generatingpapillae. Current data suggest that papilla genera-tion in implant dentistry is only possible when ade-quate bone is available to support the soft tissue.1'2

Salama et al proposed a method for papilla gener-ation at the first stage of implant surgery in which ahealing abutment is buried beneath the gingival flapto produce a dead space. This space is filled by softt issue, which adds to the height of the futurepapilla.5 Other methods that were inspired by peri-odontal plastic surgery have been introduced for useduring second-stage implant surgery.6"10

This study introduces a new flap design and asutureless technique for papilla generation, whichcan be used for single and multiple implants duringsecond-stage surgery. The goal is to form a natural-looking soft tissue margin buccally and palatallyaround the implant, and to reconstruct the interprox-imal papillae between an implant and adjacentimplants or teeth. The advantages of this newmethod are decreased chair time, less postoperative

926 Volume 23, Number 5, 2008

Shahidi et al

discomfort, and better esthetics. This method doesnot require suturing, as using sutures can be trau-matic, trigger inflammation, increase the amount ofpostoperative discomfort, and negatively affect theoutcome of the papilla generation procedure.11

The purpose of this prospective randomized con-trolled study was to compare the efficacy of a newuncovering technique for papilla generation with theconventional midcrestal uncovering technique in a6-month clinical trial.

MATERIALS AND METHODS

Thirty-three patients who had already received 67implants—37 Biomet 3i (Palm Beach Gardens, FL)and 30 Centerpulse (Zimmer Dental, Carlsbad CA)—were selected for the study.The present investigationwas designed as a prospective randomized con-trolled blinded study at the time of second-stage(uncovering) surgery. All implants were placed 4months prior to uncovering in the mandible and 6months prior to uncovering in the maxilla in theGraduate Periodontology Clinic at Boston University.The following selection criteria were used: Inclusioncriteria were minimum of 3 mm distance betweenadjacent implants12 and 2 mm between an implantand a tooth,13 adequate keratinized tissue, and aminimum soft tissue thickness of 2 mm over theimplant(s). Exclusion criteria were absence of kera-tinized tissue on the crestal ridge, significant medicalhistory, pregnancy, need for premedication prior todental procedures, diseases of the soft or hard oraltissues, orthodontic appliances, antibiotherapywithin 1 month or during the study period, and par-ticipation in another clinical trial.

All participants completed the informed consentform approved by the internal review board ofBoston University and were operated on by the sameclinician (PS).

Using the randomized controlled stratifiedblinded clinical study protocol for uncovering,patients were distributed into a test and a controlgroup. All patients required partial arch replacement,except for 1 who received a complete maxillary archreplacement. Two clinicians performed all proce-dures and measurements at the baseline after ran-dom distribution of the patients. Preoperative intra-oral and postoperative photographs were taken atbaseline (prior to second-stage surgery) andrepeated at the 3- and 6-month follow-up visits. Peri-odontal pocket depth (PPD), Plaque Index (PI),14 Gin-gival Index (Gl),15 and bleeding on probing (dichoto-mous score of 0 or 1 indicating whether or not thesite bled on probing) were measured at baseline

prior to the second-stage surgery and repeated atthe 6-month follow-up visit. Oral hygiene mainte-nance was reinforced at each visit. Standardized peri-apical radiographs were taken to assure the properpositioning of the healing abutments and enableevaluation of any bone-level alterations aroundimplants. To standardize the geometry, a vinyl poly-siloxane impression material (GC America, Alsip, IL)was used. All radiographs were obtained with anx-ray unit (Gendex) operating at 70 KV, 7 mA, 1.4 sec-onds. After the induction of local anesthesia, theposition of the submerged implant was determinedusing a periapical radiograph and ridge mapping.16

Following the initial incision(s), the thickness ofthe tissue was recorded by applying a plastic probe(Biomet 3i, Palm Beach Gardens, FL) and a tissuegauge caliper. Implants were uncovered based onthe following protocol.

• The conventional uncovering technique (controlgroup): The implants in the control group wereuncovered with a conventional uncovering tech-nique. In this procedure the implants at edentu-lous locations were simply uncovered using amidcrestal incision only. At locations with adja-cent dentition, a midcrestal incision with proximalintrasulcular incision(s) at the adjacent tooth orteeth were used. Flaps were raised and properhealing abutments were placed. Flaps weresutured with 4-0 silk sutures. Patients thenreceived postoperative instructions and werescheduled for a follow-up visit within 7 to 10 days.

• The new surgical uncovering technique (test group):The new technique (Figs 1 to 9) was used touncover the implants in the test group. In this pro-cedure the goal was to guide the soft tissue thatformerly covered the implant over to the sides ofthe implant and to plump up this piece of tissueafter inserting the healing abutment. This wasdone to provide enough soft tissue interproxi-mally to allow for papilla generation.

• Single implant model (Figs Wa to Wd): From theocclusal view, a small "U"-shaped flap was cre-ated to allow mobilization of the tissue in themesial direction. Another U-shaped flap, mirror-ing the first and sharing in common the bucco-lingual incision, permitted mobilization of thetissue distally. Combined, these side-by-side fullor partial thickness U-shaped flaps formed an"H"-shape design from the occlusal view.

• Multiple implant model (Figs 11 a to 11d): The cov-ering tissue of the most mesial implant pro-vided the mesial papilla of that implant utilizingthe U-shape design. The second implant pro-

The International Journal of Oral & Maxillofacial Implants 927

Shahidi et al

Fig 1 Preoperative buccal view. Fig 2 Preoperative palatal view. Fig3 Entry mesiobuccal incisions.

Fig 4 Buccolingualincisions. Fig 5 Healing abutments in place. Fig 6 Two weeks postoperation.

Fig 7 Five months postoperation, buccalview. Fig8

view.Five months postoperation, palatal Fig 9 Five months postoperation,

occlusal view.

vided the distal papilla of the first (which wasalso the mesial of the second), also utilizing theU-shape design. The third implant provided thedistal papilla of the second implant (also themesial papilla of the third) in the same manner,and soon.

For both models the initial incisions were madeusing a no. 15 blade and were as follows:

1. The entry incision was in a mesiodistal directionon the buccal side. By inserting the blade atalmost a 45-degree angle, the tip of the bladecould be used to feel the occlusobuccal line angleof the alveolar ridge. The incision continued in aslight parabola buccally when there was adequatekeratinized gingiva on the buccal side to create agingival margin around the implant. The incisioncontinued in a slight parabola palatally if therewas not enough amount of the keratinized gin-

giva on the buccal aspect. Precautions were takento preserve buccal keratinized tissue. The incisionpassed the mesial or distal platform of the implantand ended halfway between the platform and theadjacent implant or tooth (Drawing Figs 10a, lOb,11a,and lib).A mesiodistal incision on the lingual (palatal)aspect in the same manner as described parallelto the incision on the buccal side was placed. Theincision for the anterior implants curved slightlyoff buccally in the middle, as the top of the papillashould be smaller than its base in the buccolin-gual direction. In posterior implants, the incisionwas also placed slightly palatally, since the widthof the platform of a posterior implant is usuallysmaller than the width of its crown. This wasessential in gaining an adequate buccolingual(palatal) papilla to cover the interproximal space(Figs10a,10b,11a,and1lb).

928 Volume 23, Numbers, 2008

Shahidi et al

Figs lOa and lObincision outlines.

Single implant model,

Figs lOc and lOd Multiple implantmodel, incision outlines.

Fig lla Single implant model, mini-flapelevation.

Fig lib Multiple implant model, mini-flapelevation.

Fig lie Single implant model, healingabutment placement.

Fig lid Multiple implant model, healingabutment placement.

3. A buccol ingual incision was made for eachimplant perpendicular to the 2 first incision lines(mesiodistal incisions). The location ranged fromthe mesial or distal edge of the platform of theimplant to the middle of the platform, dependingupon the amount of tissue needed betweenimplants or between the implant and the adja-cent tooth (Figs 10a, 10b, 11 a, and 11 b).

4. Flaps were elevated using the side of the scalpeland an Orban's knife. First, the soft tissues werereflected from the underlying implant, then eachmini-flap was undermined with the no. 15 bladeand the Orban's knife, and the full- or partial-thickness mini-flap was extended to about 1 mmaway from the adjacent implant or tooth (Figs 10cand 11c).

Flaps were mobilized and pushed in the mesialand distal directions to open a window for uncover-ing. Application of gauze in the area for a few min-utes facilitated molding of the tissue while pushingthe tissue to the sides. In some cases, the resiliency of

the flaps to be accommodated in the interproximalspace was inadequate. In those cases, the middle ofthe flap, the epithelium, was incised across the flapparallel to the buccolingual incision. This increasedthe flexibility of the flaps, since connective tissue isquite maleable. After removing the cover screw, ahealing abutment with a proper height, width, andshape was placed onto the implant. This shaped thefuture papilla by pushing the tissues to the sides andholding them upright. The same technique wasrepeated for implant(s) distal to the first mesialimplant, until the most distal implant or tooth adja-cent to implant(s). No sutures were required, sincehealing abutments held the tissue in the properposition (Figs 10d and 11d).

Patients then received postoperative instructionsand were scheduled for a follow-up visit within 7 to10 days.

Following the uncovering procedure, the distancefrom the highest point of the papilla to the top of thehealing abutment was measured by placing a plasticprobe (Biomet 3i, Palm Beach Gardens, FL) vertically


Shahidi et al

on the 4 corners of each healing abutment(mesiobuccal, mesiolingual, distobuccal, and distolin-gual).Then, the height of the papilla relative to theplatform of the implant was calculated by addingthat number to the height of the healing abutmentprovided by the manufacturer. If the implant was sit-uated at the end of the arch, the distal papilla wasexcluded. Healing abutments were used in all cases,and no provisional restorations were used duringthis study.

Subsequently, during the 3- and 6-month follow-up visits, a separate examiner (KB) who was blinded tothe uncovering techniques removed the healingabutments and made all measurements. All papillameasurements (from the tip of the papilla to the plat-form of the implant buccally and lingually) wererounded off to the nearest millimeter. In the case of 2adjacent implants, each papilla was measured againstthe contralateral side of the implant platform.

Following evaluations at intervals of 3 months thatincluded standardized radiograph(s) and papilla heightmeasurements, patients were referred to the prostho-dontic department for fixed prosthetic construction.

At 6 months, the final evaluation of all patientswas repeated. PPD, Gl, PI, and bleeding on probingwere measured, and standardized radiographs wereobtained. Papilla height measurements were per-formed in the same manner at the 3- and 6-monthfollow-ups.

Subject means were used for all analyses. Sum-mary statistics were computed for papillae height bylocation (between implant and tooth versusbetween implant and implant) and treatment group.Initial testing was conducted using independentsample f tests at each time point. Further analysiswas conducted using repeated-measures analysis ofvariance. Summary statistics for clinical measures (PI,Gl, bleeding on probing, probing depth) were alsocomputed at baseline and after 6 months. Mean clini-cal measures, calculated by treatment group at base-line and 6 months, were compared using indepen-dent sample f tests. Similarly, summary statistics forbone levels (mesial, distal, and overall) and healingabutment (mesial, distal, and overall) at 3 and 6months were computed by treatment group andcompared at each time point using independentsample f tests. P < .05 was considered to indicate sta-tistical significance.

RESULTS

Thirty-three subjects, 12 female and 21 male, agerange 18 to 78 years, with 67 implants to be exposedwere enrolled in the study. Forty implants in 17 sub-

jects were exposed using the standard techniquewhile the remaining 27 implants in 16 subjects wereexposed using the new technique. Of the 40implants exposed using the standard technique,32 were multiple implants in 9 subjects. Of the 27implants exposed using the new technique, 20 weremultiple implants in 9 subjects. The average age ofsubjects was 55.3 years (median, 56 years; SD, 16.6;range, 18 to 78 years). The average age of subjectswith implants exposed using the standard techniquewas 57.9 years (median, 56 years; SD, 15.9; range, 27to 78 years), while the average age of subjects withimplants exposed using the new technique was 52.6years (median, 58.5 years; SD, 17.4; range, 18 to 77years). An independent sample f test revealed no sig-nificant difference in age between the 2 treatmentgroups (P = .366).

Three patients with 7 implants at 3 months and2 subjects with 4 implants at 6 months dropped fromthe study.

At the time of the 3-month follow-up examina-tion, 1 of the test patients with 2 implants hadmoved to a different country, another patient fromthe same group with 2 implants was excludedbecause of a previously undetected infection aroundthe implants, and 1 of the control patients with3 implants withdrew from the study for personal rea-sons. At 6 months, 1 of the control patients with2 implants dropped out for personal reasons andanother with 2 implants from the same groupdropped out because of an infection caused by theproximity of an endodontically compromised tooth.

One patient had received his definitive fixed par-tial prosthesis at 6 months; it was removed and papil-lae measurements were performed. All other patientsstill had the healing abutments in place at the6-month recall appointment.

The mean difference between the test and controlgroups for papillae height between implant andtooth was 1.41 mm (P = .001) at baseline, 1.76 mm(P < .001) at 3 months, and 1.71 mm at 6 months

Average papillae heights were calculated for eachsubject by location (adjacent to tooth versus adjacentto implant) and by surgical technique (standard ver-sus new). The summary statistics were then computedfrom subject means, and comparisons were con-ducted using independent sample t tests (Table 1). Asignificant difference in papillae height between the 2treatment groups was detected for implants adjacentto teeth (P < .001). However, no change in papillaeheight was detected over time (P = .856) or by treat-ment group over time (P = .788). Repeated-measuresanalysis of variance was also conducted for papillaeheight for implants adjacent to implants over time. A


Shahidietal

1 Table 1 Average Papilla Height by Location and Surgical Method ^^^^^1

Location and method

BaselineImplant and tooth

ControlTest

Implant and implantControlTest

3 monthsImplant and tooth

ControlTest


6 monthsImplant and tooth

ControlTest


n

1414

129

1213

98

1112

88

Mean

3.324.73

2.904.04

3.124.88

2.393.50

3.024.73

2.663.44

Median

3.335.00

2.694.00

3.465.00

2.503.38

3.004.63

2.504.00

SD

1.130.94

1.130.79

1.081.04

0.710.89

1.110.75

0.781.15

Range

1.0 to 5.52.5 to 6.0

1.5 to 4.53.1 to 5.6

1.0 to 4.33. 5 to 6.5

1.0 to 3.22. 5 to 5.0

1.0 to 4.04.0 to 6.0

1.8 to 4.31.8 to 4.5

P

.001

.01

<.001

.012

<.001

.138

Table 2 Average PI, Gl,

Average PIBaseline

ControlTest

6 monthsControlTest

Average GlBaseline

ControlTest

6 monthsControlTest

Average bleeding on probing (%)Baseline

ControlTest

6 monthsControlTest

Average probing depthBaseline

ControlTest

6 monthsControlTest

Bleeding on Probing (%), and Clinical Probing Depth Over Time by Treatment ^^^^^1

n

1716

1414

1716

1414

1716

1414

1716

1414

Mean

1.391.35

0.800.77

1.031.00

0.730.74

5.513.0

6.310.8

2.272.17

2.022.04

Median

1.291.39

0.700.75

1.000.97

0.730.74

00

58.5

2.222.12

2.032.04

SD

0.840.77

0.330.30

0.360.30

0.150.16

12.022.7

4.37.1

0.250.38

0.400.17

Range

0.23 to 3.980.25 to 3.10

0.36 to 1.580.35 to 1.31

0.50 to 1.690.57 to 1.66

0.48 to 1.090.40 to 0.92

Oto48Oto73

OtolSIto26

1.83 to 2.921.74 to 3.34

1.23 to 3.061.69 to 2.30

P

.87

.81

.78

.90

.25

.05

.37

X.82

significant difference in papillae height between the 2treatment groups was detected for implants adjacentto other implants (P = .020). However, the change inpapillae height between adjacent implants over timedid not achieve statistical significance (P = .062), and

no significant change in papilla height over time bytreatment group was detected (P = .445). There is apossibility that these statistically significant results arein direct correlation with the small number of subjectsused in this preliminary study.


Shahidietal

Table 3 Average Bone Level Over Time by Treatment

Average Probing Depth

Mesial bone level3 months

TestControl

6 monthsTestControl

Distal bone level3 months

TestControl

6 monthsTestControl

Overall bone level3 months

TestControl

6 monthsTestControl

n

1415

1414

1212

1212

1415

1414

Mean

-0.08-0.16

-0.27-0.28

-0.09-0.22

0.00-0.06

-0.10-0.20

-0.17-0.19

Median

0.00-0.17

-0.10-0.16

0.00-0.16

0.00-0.12

-0.06-0.16

-0.07-0.16

SD

0.210.29

0.510.35

0.150.33

0.680.39

0.200.21

0.570.32

Range P

-0.66 to 0.25 .38-0.63 to 0.49

-1.32 to 0.25 .99-0.99 to 0.33

-0.49 to 0.00 .22-0.99 to 0.25

-1.07 to 1.92 .79-0.50 to 0.99

-0.66 to 0.16 .18-0.50 to 0.08

-1.32 to 1.08 .91-0.74 to 0.50

Table 4 Tissue Thickness at Baseline by Surgical Method ]

Tissue thickness

Implant and toothControlTest


n

1414

129

Mean

3.432.96

2.602.44

Median

3.382.75

2.532.50

SD

0.961.03

0.770.62

Range P

2.0 to 5. 5 0.222.0 to 4.5

1.8 to 4.5 0.601.5 to 3.8

Summary statist ics of measured periodontalindices over time by treatment group are presentedin Table 2. Based on independent samples t tests, nosignificant differences were detected for any of theseclinical measures.

Summary statistics for bone level at 3 and 6months were calculated by treatment group and arepresented in Table 3. No significant differences inbone level were detected.

Average preoperative tissue thickness by locationand surgical technique was also calculated.The sum-mary statistics with corresponding P values fromindependent samples t tests are presented in Table 4.

Generally, the surgical procedures were unevent-ful, and patients did not have any specific postopera-tive complications at any time during the study.

DISCUSSION

The new surgical uncovering technique yielded sig-nificantly better results compared to the conven-tional midcrestal implant uncovering technique (Figs

12 and 13). This is the first study that provides datacomparing papilla generation between implants andteeth and between 2 adjacent implants. The studyalso shows that papilla generation between animplant and a tooth is more predictable thanbetween 2 adjacent implants.This finding is in accor-dance with other studies about the soft tissue mar-gins. In a study of 53 single-tooth replacements,17 amajority of the implant-supported crowns (75%)showed soft tissue margin stability during a 5-yearfollow-up period. These results were different fromother studies in which the soft tissue alterations insubjects with multiple implants were investi-gated.18'19 Such findings may lead one to concludethat, overall, soft tissues around single implants aremore stable and predictable than soft tissues aroundmultiple implants. Avivi-Arber et al,20 in a study ofsingle implants, proposed that the soft tissue posi-tioning in proximal sites of an implant-supportedsingle crown restoration is likely influenced by thelevel of periodontal support of the adjacent teeth. Itwas also noticed that generated papillae betweenimplants were more stable and had better shapes


Shahidietal

6-1

+- 5-ttD 4 .

'CD|3-

2 'Old

— New

Baseline 3 mo 6 mo

Fig 12 Papilla height between implant and tooth over time bysurgical method.

6-1

^ 5-5P 4 -'

-Old

— New

Baseline 3 mo 6 mo

Fig 13 Papilla height between implants over time by surgicalmethod.

when they had a broader keratinized tissue. There-fore, it seems that the presence of abundant kera-tinized tissue plays a large role in papillae develop-ment. Further investigations are necessary to confirmthis hypothesis.

A potential drawback of the study was the inclu-sion of 2 different types of implants. The bone level atthe neck of the 3i external-hex implants is determinedby the microgap between the implant and the abut-ment, while with the Zimmer internal hex it is deter-mined by the rough/smooth border.21'22 The inclu-sion of 2 different implant systems may have played arole in the outcomes of the study. Further studies arenecessary to elucidate this possibility.

One of the determining factors when restoring animplant-supported crown is the thickness of the cov-ering tissue before implant placement.The thicknessof the tissue can be influenced by several factors: theprevious height of the alveolar bone, the relationshipto the adjacent teeth,20 the type of periodontal bio-type before extraction,23 and the pattern of boneloss pre- or postextraction. Surgical indexing of theimplants during stage-1 surgery is preferable.Thisapproach has the benefit of immediate insertion offixed prosthetics after uncovering to provide betteresthetics, increase the patient's comfort, and facili-tate better oral hygiene. In addition, it allows for abetter control of the provided space with which toaccommodate generated papilla.24'25

A survey of the literature shows 3 main surgicalmethods aimed at papilla generation. Palacci et alsuggested that a full-thickness flap be raised fromthe buccal and palatal side of the implant on theridge and rotated 90 degrees to accommodate theinterproximal space of the implant.7 Adriaenssens etal introduced the "palatal sliding strip flap" to formpapillae between implants and between natural

teeth on the anterior area of the maxilla. In this tech-nique the palatal mucosa slides in a labial direction.8Nemcovsky et al made use of a U-shaped incision.6The nature of this design was essentially the same asthe surgical approach introduced earlier by Adri-aenssens, but with some minor differences.

Temporization of the implant at uncovering hasthe benefit of providing better esthetics and improv-ing patient comfort and oral hygiene. In addition,there is more control of the provided space toaccommodate the generated papilla. Furthermore,by adding acrylic resin on a weekly basis, the gener-ated papilla may be molded until it reaches a favor-able form.26-27

Some authors have suggested that the reason forpapilla growth between implant and tooth may berelated to postoperational persistent inflammation.9'28'29

This has been challenged by Cooper et al in a 3-yearprospective multicenter investigation of 1-stage sin-gle implants. They demonstrated that despite thefact that the surfaces with inflammation decreased, amean gain in papilla length of 0.61 mm occurred.30

CONCLUSION

In the present preliminary study, the efficacy of anew uncovering technique was compared to theconventional uncovering technique for papilla gen-eration between implants and between implantsand teeth. The results showed that the mean gain inpapilla height favored the new technique and wasstatistically and clinically significant at 6 months.Theresults also suggested that a papilla between animplant and a tooth is more stable and predictablethan a papilla between implants.


Shahidietal

ACKNOWLEDGMENT

The authors would like to thank Sueanne Davood for her greatcontribution in conducting this clinical study.

REFERENCES

1. Tarnow DP, Magner AW, Fletcher P.The effect of the distancefrom the contact point to the crest of bone on the presenceor absence of the interproximal dental papilla. J Periodontol1992;63:995-996.

2. Tarnow D, Elian N, Fletcher P, et al. Vertical distance from thecrest of bone to the height of the interproximal papillabetween adjacent implants. J Periodontol 2003,74:1785-1788.

3. AlbrektssonT,ZarbG.The Branemark Osseointegrated Implant.Chicago: Quintessence, 1989:117-126.

4. Worthington P, Branemark P-l. Advanced OsseointegrationSurgery: Applications in the Maxillofacial Region. Chicago:Quintessence, 1992:211-232.

5. Salama H, Salama M, Garber D, Adar P. Developing optimalperi-implant papillae within the esthetic zone: Guided soft tis-sue augmentation. J Esthet Dent 1995,7:125-129.

6. Nemcovsky CE, Moses 0, Artzi Z. Interproximal papillae recon-struction in maxillary implants. J Periodontol 2000,71: 308-314.

7. Palacci P.Optimal Implant Positioning and Soft Tissue Man-agement for the Branemark System. Chicago: Quintessence,1995:35-39.

8. Adriaenssens P, Hermans M, Ingber A, Prestipino V, DaelemansP, Malevez C. Palatal sliding strip flap: Soft tissue managementto restore maxillary anterior esthetics at stage 2 surgery. Aclinical report. Int J Oral Maxillofac Implants 1999; 14:30-36.

9. Grunder U.The inlay-graft technique to create papillaebetween implants. J Esthet Dent 1997;9:165-168.

10. BernhartT, Haas R, Mailath G,WatzekG.A minimally invasivesecond-stage procedure for single-tooth implants. J ProsthetDent 1998,79:217-219.

11. Beagle JR. Surgical reconstruction of the interdental papilla:Case report. Int J Periodontics Restorative Dent 1992;12:145-151.

12. Tarnow DP, Cho SC, Wallace SS.The effect of inter-implant dis-tance on the height of inter-implant bone crest. J Periodontol2000;71:546-549.

13. Kan JY, Rungcharassaeng K, Ojano M, Goodacre CJ. Flaplessanterior implant surgery: A surgical and prosthodontic ratio-nale. Pract Periodontics Aesthet Dent 2000; 12:467-474; 476.

14. Turesky S, Gillmore N, Glickman I. Reduced plaque formationby thechromethyl analogue of vitamin C.J Periodontol1970;41:41-43.

15. Lobene RR, Weatherford T, Ross NM, Lamm RA, Menaker L Amodified gingival index for use in clinical trials. Clin Prev Dent1986;8:3-6.

16. Wilson DJ. Ridge mapping for determination of alveolar ridgewidth. Int J Oral Maxillofac Implants 1989;4:41 -43.

17. Scheller H, Urgell JP, Kultje C, et al.A 5-year multicenter studyon implant-supported single crown restorations. Int J OralMaxillofac Implants 1998;13:212-218.

18. Adell R, Lekholm U, Rockier B, et al. Marginal tissue reactions atosseointegrated titanium fixtures (I). A 3-year longitudinalprospective study. Int J Oral Maxillofac Surg 1986;15:39-52.

19. Bengazi F,Wennstrom JL, Lekholm U. Recession of the soft tis-sue margin at oral implants. A 2-year longitudinal prospectivestudy.Clin Oral Implants Res 19967:303-310.

20. Avivi-Arber L, Zarb GA. Clinical effectiveness of implant-sup-ported single-tooth replacement:The Toronto Study. Int J OralMaxillofac Implants 1996;11:311-321.

21. Hermann JS, Buser D, Schenk RK, Schoolfield JD, Cochran DLBiologic Width around one- and two-piece titanium implants.Clin Oral Implants Res 2001 ;12:559-571.

22. Hermann JS, Schoolfield JD, Schenk RK, Buser D, Cochran DL.Influence of the size of the microgap on crestal bone changesaround titanium implants. A histometric evaluation ofunloaded non-submerged implants in the canine mandible.J Periodontol 2001 ;72:1372-1383.

23. Becker W, Ochsenbein C,Tibbetts L, Becker BE. Periodontalcharacteristics in individuals with varying form of the uppercentral incisors.J Clin Periodontol 1997;24:727-731.

24. Spear FM. Maintenance of the interdental papilla followinganterior tooth removal. Pract Periodontics Aesthet Dent 1999;11:21-28; 30.

25. Breeding LC, Dixon DL.Transfer of gingival contours to a mas-ter cast.J Prosthet Dent 1996;75:341-343.

26. Garber DA, Belser UC. Restoration-driven implant placementwith restoration-generated site development. Compend Con-tin Educ Dent 1995;16:796,798-802,804.

27. Garber DA.The esthetic dental implant: Letting restoration bethe guide. J Am Dent Assoc 1995;126:319-325.

28. JemtT, Book K, Lie A, BorjessonT. Mucosal topography aroundimplants in edentulous upper jaws. Photogrammetric three-dimensional measurements of the effect of replacement of aremovable prosthesis with a fixed prosthesis. Clin Oral ImplantsRes 1994;5:220-228.

29. Priest G. Predictability of soft tissue form around single-toothimplant restorations. Int J Periodontics Restorative Dent 2003;23:19-27.

30. Cooper L, Felton DA, Kugelberg CF, et al.A multicenter 12-month evaluation of single-tooth implants restored 3 weeksafter 1 -stage surgery. Int J Oral Maxillofac Implants 2001 ;16:182-192.


oral & maxillofacial implants · martha e. nunn, dds, phd5/kasumi barouch, dos, phd6/ thomas e....

Documents