Volume 79 • Number 6
Surgical and Prosthetic Management of Interproximal Region With Single-Implant Restorations: 1-Year Prospective Study Eugenio Romeo,* Diego Lops,* Alessandro Rossi,† Stefano Storelli,* Roberto Rozza,‡ and Matteo Chiapasco†
Background: Gingival esthetics around dental implants have become a main focus for clinicians. This study analyzed the surgical, prosthetic, and anatomic factors involved in the management of peri-implant tissues. Methods: Forty-eight subjects with one tooth scheduled for tooth extraction and immediate implant placement were included in the study. After healing, the implants were restored with single-crown fixed prostheses. The following parameters were assessed after 12 months: presence/absence of the interproximal papilla, interimplant–tooth distance (ITD), distance from the base of the contact point to the interdental bone (CPB), and soft tissue biotype. ITD and CPB values were derived from computer analysis of periapical radiographs. A statistical analysis determined the effect of ITD and CPB on the presence of the interproximal papilla. Results: Papilla was significantly present (P <0.05) for ITD of 2.5 to 4 mm in anterior and posterior areas and for CPB £7 mm in posterior areas. Thick biotype was significantly associated (P <0.05) with the presence of the papilla. Conclusions: The combination of surgical and prosthetic plans represents the key factor to optimize predictability in single-implant esthetics. The recommended interproximal distance between the implant and the adjacent tooth is 2.5 to 4 mm. The distance from the contact point to the interdental bone is recommended to be <7 mm. Papilla presence is also correlated with a thick gingival biotype. J Periodontol 2008; 79:1048-1055. KEY WORDS Dental implants; papilla; prosthesis.
* Department of Prosthodontics, Dental Clinic, School of Dentistry, University of Milan, Milan, Italy. † Department of Oral Surgery, Dental Clinic, School of Dentistry, University of Milan. ‡ Department of Periodontics, Dental Clinic, School of Dentistry, University of Milan.
A
n implant-supported fixed prosthesis for the rehabilitation of a single missing tooth has become a standard, predictable procedure.1 Given that implant survival and success rates are high,2-6 clinicians have focused their attention on attaining esthetically pleasing outcomes, particularly in frontal areas. To achieve an ideal esthetic outcome, implants must be placed in an optimal position and inclination in all three dimensions: apicocoronally, mesiodistally, and faciolingually. Any deviation from the optimal position may create difficulties in the final prosthetic restoration. The esthetic success of the rehabilitation is assessed by judging the appearance of periimplant soft tissues.7-10 The level, color, and texture of the peri-implant soft tissue are extremely important for the natural appearance of implant-supported, single-tooth restorations.11 In the case of dental implants, the criteria for success should involve the establishment of a soft tissue contour with an intact interproximal papilla and a gingival outline that is harmonious with the gingival silhouette of the healthy dentition. Retrospective studies12-14 investigated the presence of the interproximal papillae adjacent to single-tooth implants with respect to vertical distance from the base of the contact point to the alveolar crest. A vertical distance of 3 mm and a horizontal distance of 5 to 6 mm were doi: 10.1902/jop.2008.070431
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J Periodontol • June 2008
significantly associated with the presence of the interproximal papilla adjacent to single-tooth implants. The horizontal distance between the implant and the adjacent tooth and its correlation with the papilla filling the interdental region were also investigated.13 However, these data were not always reported in the literature.14 Furthermore, the dimensions of the peri-implant mucosa were correlated to the gingival biotype.10,15,16 To the best of our knowledge, no prospective study has analyzed the correlation of the factors influencing the presence or absence of the interproximal papilla between an implant and the adjacent tooth. The aim of the present prospective study was to determine the correlation between the presence of papilla in single-tooth implant restorations and 1) vertical and horizontal distances and 2) gingival biotype.
Table 1.
MATERIALS AND METHODS Over a 1-year period (January 2005 to March 2006), 48 subjects (22 males and 26 females; mean age, 46 years; range: 18 to 63 years) were included in the study. Each subject needed a single tooth extracted because of endodontic and caries lesions combined with root or crown fractures, for a total of 24 anterior (incisors and canines) and 24 posterior teeth (only premolars; no molar teeth were considered). No teeth were removed because of advanced periodontal disease. All 48 subjects were scheduled for tooth extraction and immediate implant placement into fresh extraction sockets. All subjects provided signed informed consent to participate in this study. All cases were consecutively treated with solid-screw, pure grade IV titanium with sand-blasted, large-grit, acidetched surface implants.§ Patients were treated at St. Paul Hospital Dental Clinic, School of Dentistry, University of Milan. The study protocol was approved by the University of Milan Institutional Ethics Committee. All subjects presented good general health at the time of the surgical procedure, the absence of local inflammation, and the absence of mucosal disease. The exclusion criteria were tobacco abuse (i.e., >10 cigarettes/ day), history of radiotherapy in the head and neck region, leukocyte diseases at the time of the surgical procedure, uncontrolled diabetes, severe clenching or bruxism, non-compliance, and treatment with bone grafts or local guided bone regeneration before implant placement. No subject received more than one single-tooth, implant-supported prosthesis. All subjects had natural dentition in the opposing arch. Subjects were followed for 12 months after placing the prosthetic crown. Surgical and Prosthetic Procedures Tooth removal was performed under local anesthesia.i A full-thickness mucosal envelope flap was
Implant Distribution Tapered Effect Implants (mm)
Maxillary Implants (n)
Mandibular Implants (n)
3.3 · 10
0
0
3.3 · 12
4
0
3.3 · 14
0
0
4.1 · 10
10
12
4.1 · 12
6
8
4.1 · 14
0
0
4.8 · 10
0
5
4.8 · 12
0
3
4.8 · 14
0
0
20
28
Total
raised beyond the mucogingival margin by placing incisions interproximally beneath the contact point. No releasing incisions were performed. Then, the tooth was carefully luxated with the use of small elevators. Forceps were used for tooth extraction, and the periodontal ligament attached to the bone in the socket wall was left undisturbed.16 The socket was prepared with standard drills using the bony walls as guides, and an implant¶ was placed. Implant diameter and length depended on the dimension of the edentulous site. Twenty implants were inserted in the maxilla, and 28 were inserted in the mandible (Table 1). The implant was positioned so that the shoulder of the implant was 1 mm apical to the cemento-enamel junction of the adjacent tooth.17 A transmucosal healing screw was screwed to the implant. The flap was replaced without coronal advancement and secured with simple interrupted sutures (silk 4/0).# All implants were semisubmerged, but all parts of the defects were covered by mucosal tissue. The healing screw was exposed to the oral environment. Removable prostheses or provisional fixed bridges were adjusted to avoid any pressure on the implants. After 8 weeks of healing, impressions were taken, and temporary acrylic resin crowns on a temporary abutment** were screwed to the implants and tightened to 15 Ncm. Three months later, the definitive prostheses were positioned using abutments†† for § i ¶ # ** ††
Standard Plus, Institute Straumann, Waldenburg, BL, Switzerland. Carbocaina, AstraZeneca, Basiglio, Italy. Straumann SynOcta abutment, Institute Straumann. Mersilk, Johnson & Johnson, Brussels, Belgium. Straumann SynOcta abutment, Institute Straumann. Straumann SynOcta abutment, Institute Straumann.
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Immediate Postextraction Implants: Papilla Management
Volume 79 • Number 6
cemented prostheses. A manual torque driver was used to secure the abutment at 35 Ncm by means of a titanium screw, as recommended by the manufacturer. Frameworks and esthetic veneers were fabricated in gold alloy and porcelain subsequently polished with a sequence of rubber burs. Zinc oxide eugenol paste cement‡‡ was used for the fixation. No difference in manufacturing was considered in the fabrication of anterior or posterior crowns. Selected Parameters Clinical and radiographic data were collected during the 12-month follow-up visit. The following parameters were assessed: presence/ absence of the interproximal papilla, soft tissue biotype,10 interimplant–tooth distance (ITD), and distance from the base of the contact point to the interdental bone (CPB); the interproximal bone level next to the adjacent tooth was considered the apical limit of CPB distance.10,12 Evaluation of the papilla was made clinically by using a dichotomous index: the presence or absence of the papilla was determined visually and perpendicularly to the buccal surface of the restoration crown prior to probing (Fig. 1). The interproximal papilla was diagnosed as present if it filled the entire proximal space. If even a small portion was missing, the papilla was considered absent. All cases were documented with panoramic radiographs taken before treatment and a series of periapical radiographs taken before treatment, at the time of implant placement, at the time of prosthetic rehabilitation, and at the 12-month follow-up. Periapical radiographs§§ were taken with the parallel technique to control projection geometry with the following exposure parameters: 65 to 90 kV, 7.5 to 10 mA, and 0.22 to 0.25 seconds.18,19 A computer analysis was performed with image processing softwareii to determine ITD and CPB values20,21 after converting periapical radiographs into digitized images¶¶ (Fig. 2). Radiographs taken 12 months after definitive implant restoration were selected for ITD and CPB measurements. The distance between the implant neck and the most apical point of each implant, along an ideal line running parallel to the long fixture axis, was chosen as a parameter to set the measurement system.20 Images were 512 · 512 pixels, with 64 gray levels. One of the authors (SS) performed all measurements; values were rounded to the nearest half millimeter for ITD values and to the nearest millimeter for CPB values. Ninety-six interproximal spaces were examined. To evaluate the intraobserver variability, a second set of ITD and CPB measurements was performed on 10 randomly selected implants (computer-generated numbers) on a total of 20 papillae. 1050
Figure 1. Evaluation of the interproximal papilla through a clinical examination perpendicular to the buccal surface of the restoration crown prior to probing.
Figure 2. Computer analysis performed to determine ITD and CPB after converting a periapical radiograph to a digitized image. The interproximal bone level next to the adjacent tooth was considered for the apical limit of CPB distance.
All cases were divided into two groups based on the soft tissue biotype (thick or thin). To evaluate the biotype, a periodontal probe was placed into the facial aspect of the peri-implant mucosa. The peri-implant biotype was categorized as thin if the outline of the underlying periodontal probe could be seen through the gingiva (Fig. 3) and thick if the probe could not be seen.10 The influence of the gingival biotype on the presence of the interproximal papilla was investigated only for subjects with CPB values between 3 and 7 mm because a correlation between the CPB parameter and the presence of the interproximal papilla was ‡‡ §§ ii ¶¶
Temp Bond, Kerr, Romulus, MI. Kodak Ekta-Speed EP-22, Eastman Kodak, Rochester, NY. Image-J, XL Imaging, Digital Technium, Swansea, U.K. CanoScan, Canon U.S.A., Lake Success, NY.
Romeo, Lops, Rossi, Storelli, Rozza, Chiapasco
J Periodontol • June 2008
Figure 3. Periodontal probe placed into the facial aspect of the peri-implant mucosa to evaluate the biotype. The peri-implant biotype was categorized as thin if the outline of the underlying periodontal probe could be seen through the gingiva and thick if the probe could not be seen.
reported in the international literature.12-14 Therefore, nine implants were excluded, and 39 implants were considered in the evaluation of the potential influence of the biotype on the presence of interproximal papilla. Statistical Analysis The effect of ITD and CPB on the presence of the interproximal papilla was evaluated by statistical analysis. The x2 test was used to find any statistical correlation between the presence of the papilla and the ITD and CPB values collected for all 96 interproximal spaces. The same statistical analysis was used to evaluate differences in results when considering the actual position (48 anterior and 48 posterior interproximal spaces). The presence of the interproximal papilla in subjects with a thick biotype was compared to subjects with a thin biotype using the same statistical method (P <0.05). RESULTS None of the implants were lost during the observation period, resulting in a 100% implant survival rate. During the 12 months of function, no severe soft tissue inflammation was diagnosed around the selected
implant-supported restorations; similarly, no prosthetic complications occurred. Mean mesial and distal ITD values were 3.66 – 1.34 mm and 3.67 – 1.75 mm, respectively; mean mesial and distal CPB values were 5.45 – 2.08 mm and 5.38 – 1.47 mm, respectively (Table 2). When ITD was 2.5 to 4 mm, the interproximal papilla was present in 84.3% of the cases; this correlation was statistically significant (x2 = 21.34). Conversely, this correlation was not statistically significant for ITD <2.5 mm (papilla was absent 70.6% of the time) and >4 mm (papilla was absent 39.3% of the time); x2 values were 2.88 and 1.28, respectively (Table 3). When CPB did not exceed 7 mm (Table 4), the interproximal papilla was present 71.8% (CPB £5 mm) and 70.4% (CPB from 5 to 7 mm) of the time. This correlation was statistically significant (x2 =7.40 and 7.36, respectively). In addition, the presence of the papilla was influenced by CPB only when ITD was ‡3 mm (P <0.05). Finally, the thick soft tissue biotype was significantly correlated with the presence of the interproximal papilla (x2 = 11.6). A significant relationship was not found for the thin soft tissue biotype (x2 = 0.35) (Table 5). Intraobserver variability was assessed; the 20 papillae randomly selected provided ITD and CPB values that were compared to the value collected previously for the same subject. The two sets of data were statistically similar (P <0.05). Because the position of the tooth may play an important role in the definition and maintenance of the papilla, a post hoc test was performed to evaluate the possible differences between teeth positioned in different areas of the mouth. The same statistical analysis was performed after dividing the sample into two groups with regard to the actual position of the implant (24 anterior versus 24 posterior). Full interproximal papilla for anterior (Table 6) and posterior implants (Table 7) were associated (x2 = 4.16 and 12.56, respectively) with ITD values between 3 and 4 mm. When the ITD values were <3 or >4 mm, this association was not confirmed statistically.
Table 2.
Dimension of Interproximal Space: Horizontal Crestal Alveolar Bone ITD and CPB Mesial Aspect
Distal Aspect
Interproximal ITD (mm; CPB (mm; Papilla Papilla Interproximal ITD (mm; CPB (mm; Papilla Papilla Space (n) mean – SD) mean – SD) Present (n) Absent (n) Space (n) mean – SD) mean – SD) Present (n) Absent (n) 48
3.66 – 1.34
5.45 – 2.08
34
14
48
3.67 – 1.75
5.38 – 1.47
30
18 1051
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Volume 79 â&#x20AC;˘ Number 6
Table 3.
Table 7.
Presence or Absence of Interproximal Papilla According to ITD
Presence or Absence of Interproximal Papilla in Posterior Areas According to ITD
ITD* (mm)
n
1 to 2.5 17
Papilla Present
%
Papilla Absent
%
x2
Significance (P <0.05)
5
29.4
12
70.6
2.88
3 to 4
51
42
84.3
9
>4
28
17
60.7
11
ITD* (mm)
n
Papilla Present
No
1 to 2.5
4
1
17.7 21.34
Yes
3 to 4
23
39.3
No
>4
21
1.28
%
Papilla Absent
%
x2
Significance (P <0.05)
25
3
75
1
No
20
86.9
3
13.1 12.56
Yes
13
61.9
8
38.1
No
1.19
n = number of interproximal spaces evaluated. * Measurements were rounded to the nearest half millimeter.
n = number of interproximal spaces evaluated. * Measurements were rounded to the nearest half millimeter.
Table 4.
Presence or Absence of Interproximal Papilla According to CPB CPB* (mm) <5
Papilla Present
n
%
Papilla Absent
%
x2
Significance (P <0.05)
39
28
71.8
11
28.2 7.40
Yes
5 to 7 44
31
70.4
13
29.6 7.36
Yes
5
38.5
8
61.5 0.69
No
>7
13
Presence or Absence of Interproximal Papilla According to Gingival Biotype Papilla Present
Thick
25
21
Thin
14
6
%
Papilla Absent
Papilla Absent
<5
21
14
66.6
7
33.3 2.33
No
5 to 7 21
14
66.6
7
33.3 2.33
No
2
33.3
4
66.7 0.66
No
x2
Significance (P <0.05)
Presence or Absence of Interproximal Papilla in Posterior Areas According to CPB
11.6
Yes
CPB* (mm)
n
Papilla Present
%
Papilla Absent
No
<5
18
14
77.7
4
22.3 5.55
Yes
5 to 7 23
17
73.9
6
26.1 5.26
Yes
3
42.8
4
57.2 0.14
No
84
4
16
42.8
8
57.2
0.35
Papilla Present
%
Papilla Absent
5
35.7
9
64.3 1.14
No
27
21
77.7
6
22.3 4.16
Yes
7
4
57.1
3
42.9 0.14
No
n
6
%
Table 9.
>7
1 to 2.5 14
%
x2
Significance (P <0.05)
n = number of interproximal spaces evaluated. * Measurements were rounded to the nearest half millimeter.
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%
Significance (P <0.05)
Presence or Absence of Interproximal Papilla in Anterior Areas According to ITD
>4
Papilla Present
x2
Table 6.
3 to 4
n
%
n = number of implants evaluated.
ITD* (mm)
CPB* (mm)
n = number of interproximal spaces evaluated. * Measurements were rounded to the nearest millimeter.
Table 5.
n
Presence or Absence of Interproximal Papilla in Anterior Areas According to CPB
>7
n = number of interproximal spaces evaluated. * Measurements were rounded to the nearest millimeter.
Biotype
Table 8.
7
%
x2
Significance (P <0.05)
n = number of interproximal spaces evaluated. * Measurements were rounded to the nearest millimeter.
Conversely, the ITD value demonstrated a statistically significant difference for the two groups. In the anterior areas, no statistically significant difference was found for any distance measured (Table 8). Although the frequency of the papilla was greater (66%) when the ITD was <7 mm, the statistical analysis showed no significant difference. In the posterior areas (Table 9), ITD values <7 mm were associated with the presence of the interproximal papilla.
J Periodontol • June 2008
DISCUSSION Over the years, implant survival rates have progressively improved, and osseointegration in standard implant practice has ceased to be a major concern. Although osseointegration is well documented, the integration and behavior of the soft tissues around the prosthetic framework require further research. Several clinician- and patient-dependent factors may play important roles in the esthetic outcome of the rehabilitation. Clinician-dependent factors include proper three-dimensional implant position and angulation, as well as appropriate contour of the provisional restoration.22 Proper guidelines regarding these issues have been established, and satisfactory outcomes have been reported.23 Patient-dependent factors include bone level, hard and soft tissue relationship, bone thickness, and soft tissue biotype. A conversion of unfavorable traits to favorable ones is fundamental to achieve good esthetic results. Data collected in the present prospective study showed how treatment planning and surgical maneuvers are important to allow correct prosthetic management of the soft tissues and, hence, an esthetically pleasant result. It was considered what might happen to soft tissue after immediate implantation and early (8 weeks) prosthetic rehabilitation, in particular if the interdental papilla is affected by the surgical and prosthetic planning. Clinical and radiographic parameters, such as ITD and CPB, have been considered. An intrinsic factor, such as the soft tissue biotype, was also investigated for any relationship with the presence or absence of the interdental papilla. The surgical protocol consisted of tooth removal and immediate implant placement. This choice was made by the authors to reduce the number of surgical stages and the interval between tooth removal and the insertion of the implant-supported restoration.24,25 Furthermore, studies26,27 described how the soft tissue management is simple and predictable, with or without immediate prosthetic rehabilitation. In addition, recent contributions28,29 demonstrated that the alveolar ridge after tooth extraction follows a resorption that is quite predictable but probably not influenced by implant insertion as much as previously believed. Finally, Schropp et al.25 observed that the presence of the interproximal papilla is not influenced by the early or delayed implant insertion after 1.5 years of prosthesis function. This study demonstrated the influence of the selected parameters on the maintenance of interproximal papilla: a horizontal distance (ITD) from 2.5 to 4 mm was statistically correlated to the papilla presence. ITDs between 1 and 2.5 mm did not show a statistically significant correlation with the absence of the papilla, despite a calculated frequency of 70.6%; the
Romeo, Lops, Rossi, Storelli, Rozza, Chiapasco
authors suggest that this may be due to the reduced number of group samples. Similar results were found by Gastaldo et al.13 in a retrospective examination of the incidence of the interproximal papilla between implant and tooth; it was also observed that the papilla was present most of the time (P <0.05) when the distance between tooth and implant was 3, 3.5, or 4 mm. However, these results were not confirmed by Ryser et al.,14 who found no significant relationship between horizontal distance and papilla maintenance. Other prospective studies about the influence of this parameter on the presence of the interdental papilla are not available with regard to single-tooth implants. The results of the present study concerning ITD values showed no differences between anterior or posterior teeth. Moreover, the study results showed that only a vertical distance (CPB) £7 mm is significantly associated with the interproximal papilla presence. This parameter has to be well known by the prosthodontist and the technician to plan a proper prosthesis design and avoid the unesthetic interproximal black holes. Study results about the influence of CPB on the papilla presence are partially confirmed by clinical trials on single-tooth implants and the adjacent teeth performed by Choquet et al.12 and Gastaldo et al.13 It was established that the papilla level around singletooth implant restorations is mostly correlated to the bone level adjacent to the teeth and, more specifically, to the bone crest. The regeneration of papillae after single-implant treatment was successful with a distance £5 mm between the contact point and the bony crest. At >5 mm, the occurrence of papilla regeneration is ‡50% but with no predictability. The results of the present study showed a difference in anterior or posterior areas. CPB <7 mm was statistically significant in the bicuspid area, whereas it was not statistically significant in the anterior areas. In agreement with the present study, the 1-year comparative study by Henriksson and Yemt30 followed 18 subjects presenting single-implant restorations in the central incisor area. The data collected did not allow the establishment of any statistical relationship (P >0.05) between the presence of papillae and the distance between the contact point and the underlying bone crest. In addition, Grunder8 evaluated soft tissue stability around single-tooth implants and adjacent teeth showing that the total distance from the contact point to the interdental bone was almost 9 mm, and all cases had a perfect papilla. These results may be due to several factors that need further investigation. For example, the behavior of the alveolar crest, thinner in anterior areas, may play an important role in the definition of the actual resorption following tooth extraction; therefore, it may be more difficult to predict the actual position of the 1053
Immediate Postextraction Implants: Papilla Management
implant neck during surgery. In the present study, the sample collected (48 interproximal anterior spaces) was too small to be analyzed properly. The frequency of the presence of the papilla was higher (66%) in cases with CPB <7 mm than when CPB was >7 mm (33%), but it still was not statistically significant. As far as soft tissue appearance is concerned, Kois22 described the gingival biotype as being thick or thin. A thick biotype implies more fibrotic tissue, more vascularization, and thicker underlying hard tissue that is more resistant to recession and often results in pocket formation in the presence of the bacterial insult. Thin gingival tissue has less underlying osseous support and less blood supply, which predisposes to recession after tooth extraction. Furthermore, Kois9 found a greater thickness of the peri-implant mucosa in the presence of a thick gingival biotype compared to a thin biotype. The propensity for recession after surgical insults of thin gingival tissue was reported by several investigators.10,15,22,23,31 The present study reported similar findings because only a thick gingival biotype was statistically associated with papilla presence. Further studies are needed to establish any relationship between intrinsic and extrinsic factors and their influence on the presence or absence of the interproximal papilla. CONCLUSIONS This study demonstrated that the recommended size of the interproximal space is 2.5 to 4 mm between an implant and the adjacent tooth and £7 mm between the base of the contact point and the interdental bone in posterior areas. In anterior areas, if the distance between tooth and implant played an important role in maintaining the papilla, the distance between the alveolar crest and the contact point did not. In addition, a thick gingival biotype is significantly associated with a full interproximal papilla. It can be concluded that the combination of surgical and prosthetic plans represents the key factor to optimize the edentulous site for predictable anterior single-implant esthetics. Therefore, the clinical evaluation before implantation should include the exact position of the implant in relation to the adjacent teeth and the distance from the contact point. Furthermore, we suggest that dental technicians design the anatomy of the tooth precisely to achieve a correct contact point in relation to anatomic factors. ACKNOWLEDGMENT The authors report no conflicts of interest related to this study. REFERENCES 1. Tarnow DP, Eskow RN. Considerations for single-unit esthetic implant restorations. Compend Contin Educ Dent 1995;16:778, 780, 782-784 passim; quiz 788. 1054
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2. Buser D, Mericske-Stern R, Bernard JP, et al. Longterm evaluation of non-submerged ITI implants. Part 1: 8-year life table analysis of a prospective multi-center study with 2359 implants. Clin Oral Implants Res 1997;8:161-172. 3. Palmer RM, Smith BJ, Palmer PJ, Floyd PD. A prospective study of Astra single tooth implants. Clin Oral Implants Res 1997;8:173-179. 4. Weber HP, Crohin CC, Fiorellini JP. A 5-year prospective clinical and radiographic study of non-submerged dental implants. Clin Oral Implants Res 2000;11:144153. 5. Cooper L, Felton DA, Kugelberg CF, et al. A multicenter 12-month evaluation of single-tooth implants restored 3 weeks after 1-stage surgery. Int J Oral Maxillofac Implants 2001;16:182-192. 6. Haas R, Polak CH, Fu ¨ rhauser R, Mailath-Pokorny G, ¨ rtbudak O, Watzek G. A long-term follow up of 76 Do Bra˚nemark single tooth implants. Clin Oral Implants Res 2002;13:38-43. 7. Belser U, Buser D, Higginbottom F. Consensus statements and recommended clinical procedures regarding esthetics in implant dentistry. Int J Oral Maxillofac Implants 2004;19(Suppl.):73-74. 8. Grunder U. Stability of the mucosal topography around single-tooth implants and adjacent teeth: 1-year results. Int J Periodontics Restorative Dent 2000;20:11-17. 9. Kois JC. Predictable single-tooth peri-implant esthetics. Five diagnostic keys. Compend Contin Educ Dent 2004;25:895- 896, 898, 900 passim; quiz 906907. 10. Kan JY, Rungcharassaeng K, Umezu K, Kois JC. Dimensions of peri-implant mucosa: An evaluation of maxillary anterior single implants in humans. J Periodontol 2003;74:557-562. 11. Phillips K, Kois JC. Aesthetic peri-implant site development. The restorative connection. Dent Clin North Am 1998;42:57-70. 12. Choquet V, Hermans M, Adriaenssens P, Daelemans P, Tarnow DP, Malevez C. Clinical and radiographic evaluation of the papilla level adjacent to single-tooth dental implants. A retrospective study in the maxillary anterior region. J Periodontol 2001;72:1364-1371. 13. Gastaldo JF, Cury PR, Sendyk WR. Effect of the vertical and horizontal distances between adjacent implants and between a tooth and an implant on the incidence of interproximal papilla. J Periodontol 2004; 75:1242-1246. 14. Ryser MR, Block MS, Mercante DE. Correlation of papilla to crestal bone levels around single tooth implants in immediate or delayed crown protocols. J Oral Maxillofac Surg 2005;63:1184-1195. 15. Kan JY, Rungcharassaeng K, Lozada JL. Bilaminar subepithelial connective tissue grafts for immediate implant placement and provisionalization in the esthetic zone. J Calif Dental Assoc 2005;33:865-871. 16. Botticelli D, Berglundh T, Linde J. Hard-tissue alterations following immediate implant placement in extraction sites. J Clin Periodontol 2004;31:820-828. 17. Buser D, Martin W, Belser UC. Optimizing esthetics for implant restorations in the anterior maxilla: Anatomic and surgical considerations. Int J Oral Maxillofac Implants 2004;19(Suppl.):43-61. 18. Hausmann E, Allen K, Dunford R, Christersson L. A reliable computerized method to determine the level of the radiographic alveolar crest. J Periodontal Res 1989;24:368-369.
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19. Hausmann E, Allen K, Clerehugh V. What alveolar crest level on a bite-wing radiograph represents bone loss? J Periodontol 1991;62:570-572. 20. Romeo E, Lops D, Margutti E, Ghisolfi M, Chiapasco M, Vogel G. Implant-supported fixed cantilever prostheses in partially edentulous arches. A seven-year prospective study. Clin Oral Implants Res 2003;14: 303-311. 21. Romeo E, Lops D, Amorfini L, Chiapasco M, Ghisolfi M, Vogel G. Clinical and radiographic evaluation of small-diameter (3.3-mm) implants followed for 1-7 years. A longitudinal study. Clin Oral Implants Res 2006;17:139-148. 22. Kois JC. Predictable single tooth peri-implant esthetics. Five diagnostic keys. Compend Contin Educ Dent 2001;22: 199-206; quiz 208. 23. Kan JY, Rungcharassaeng K, Lozada JL. Immediate placement and provisionalization of maxillary anterior implants: One-year prospective study. Int J Oral Maxillofac Implants 2003;18:31-39. 24. Schwartz-Arad D, Chaushu G. Placement of implants into fresh extraction sites: 4 to 7 years retrospective evaluation of 95 immediate implants. J Periodontol 1997;68:1110-1116. 25. Schropp L, Isidor F, Kostopoulos L, Wenzel A. Interproximal papilla levels following early versus delayed placement of single-tooth implants: A controlled clinical trial. Int J Oral Maxillofac Implants 2005;20:753761.
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26. Harvey BV. Optimizing the esthetic potential of implant restorations through the use of immediate implants with immediate provisionals. J Periodontol 2007; 78:770-776. 27. Saadoun AP, Touati B. Soft tissue recession around implants: is it still unavoidable? – Part I. Pract Proced Aesthet Dent 2007;19:55-62. ¨ m JL, Lindhe J. 28. Araujo MG, Sukekava F, Wennstro Tissue modeling following implant placement in fresh extraction sockets. Clin Oral Implants Res 2006;17: 615-624. ¨ m JL, Lindhe J. Modeling of the 29. Araujo MG, Wennstro buccal and lingual bone walls of fresh extraction sites following implant installation. Clin Oral Implants Res 2006;17:606-614. 30. Henriksson K, Jemt T. Measurements of soft tissue volume in association with single-implant restorations: A 1-year comparative study after abutment connection surgery. Clin Implant Dent Relat Res 2004;6:181-189. 31. Zetu L, Wang HL. Management of inter-dental/interimplant papilla. J Clin Periodontol 2005;32:831-839. Correspondence: Dr. Eugenio Romeo, Department of Prosthodontics, Dental Clinic, School of Dentistry, University of Milan, Via Beldiletto 1/3 20142, Milan, Italy. Fax: 39-02-5031-9040; e-mail: eugenio.romeo@unimi.it. Submitted October 31, 2007; accepted for publication December 19, 2007.
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