Two recent articles underscore the necessity for three dimensional visualization in treatment planning and clinical execution of various therapies. Romeo et al., have published an article in the Journal of Periodontology entitled “Surgical and Prosthetic Management of the Interproximal Region with Single Implant Restorations: A one year Perspective Study”.(1) In the same issue, Degidi et al., published “Outcome Analysis of Immediately Placed, Immediately Restored Implants in the Esthetic Area: The Clinical Relevance of Inter Implant Distances.”(2) Both of these articles discuss management of the interproximal papillae around implants.
Romeo et al., stated that the papilla was significantly present for inter implant – tooth distances of 2.5mm to 4mm, and for distances from the base of the contact point to the inter dental bone which were less than or equal to 7mm. They also noted that a thick biotype was more often associated with the presence of a papilla.
Degidi et al., reported that two implants with an inter implant distance less than 2mm seemed to lose less bone laterally, but lost more crestal bone vertically, than the group with an inter implant distance greater than 4mm. They also stated that the percentage of interproximal papilla present decreased when the distance between the bone crest and the contact point of the two implant crowns was greater than 6mm, or when the implants were placed at a distance greater than or equal to 4mm from each other.
The authors of both studies suggested the contact point should never be greater than 6mm from the bone crest, to help ensure the presence of a papilla.
The work of these investigative groups is based upon a ground breaking article by Tarnow et al., entitled “The Effect of Inter Implant Distance on the Height of the Inter Implant Bone Crest”. (3) This work was in turn followed by subsequent articles from Tarnow’s Group.
The work of Tarnow et al., is some of the most frequently cited, and misunderstood, literature at dental implant, periodontal and prosthetic meetings. While the observations made by Tarnow’s group are quoted correctly, their significance is often distorted.
The interproximal area must be viewed as a three dimensional entity, whether considering papillae around implants or teeth. The influence of bucco-lingual/palatal osseous ledging on the presence or absence of a soft tissue papilla has long been recognized around natural teeth (4). The buccopalatal dimension of the alveolar crest is also crucial to the development and maintenance of peri implant soft tissue papillae.
Numerous investigators have discussed the concept of performing regenerative therapy to increase buccal bone width, in an effort to dictate the final soft tissue contours and thus enhance papillary formation.
It is critical that we as clinicians not simply consider the distance from the bone crest to the contact point when determining whether or not we can expect soft tissue papilla generation following implant placement and restoration. Rather, we must consider the three dimensional aspect of this region, and perform hard tissue augmentation when necessary, to help ensure papillary formation.
We have lost count of the number of presentations we have seen, or articles we have read, which “document the success” of various regenerative techniques. However, when the cases are examined, it is easy to ascertain that no consideration has been given to regeneration of appropriate buccal bone and the hard tissue line angle of the edentulous area, in anticipation of eventual implant placement and restoration. Simply put, the hard tissues will dictate the envelope of possibility of soft tissue regeneration, and the final soft tissue form around implant restorations.
We are all more than capable of such three dimensional thinking, and must demand it both in our assessment of available literature, and in the treatment planning of our mutual patients.