Factors and Techniques InfluencingPeri-Implant Papillae

Yiu Cheung Chow, DDS, MS,* and Hom-Lay Wang, DDS, MSD, PhD†

Today, in implant dentistry, pa-tients not only want to restorethe lost masticatory function but

also want to demand aestheticallypleasing restorative treatments. In themaxillary anterior region, they havecome to expect prostheses replacingtheir missing teeth to be identical tothe contralateral natural healthy teethand the gingival outline harmoniouswith the gingival silhouette of the ad-jacent teeth. Even though the dentalimplant is successfully osseointe-grated, it is devastating to a patient if“black triangles” (i.e., missing inter-proximal papilla) exists when theysmile and speak. Moreover, the loss ofimplant papilla can cause phoneticproblems and food impaction. As aresult, the presence/absence of inter-implant papilla has become a topic ofconcern.

In natural dentition, the dental pa-pilla is the gingival tissue, which oc-cupies the embrasure space beneaththe contact area of 2 adjoining teeth.The lateral borders and tips of the den-tal papilla are formed by marginalgingiva, and the intervening portionconsists of attached gingiva. Simi-larly, the peri-implant papilla is thesoft tissue underneath the contact be-

tween a natural tooth and an implantor 2 adjacent implants. However, thereare some significant anatomical andhistologic differences between dentaland peri-implant papillae (Table 1).1–5

For example, the soft tissues aroundosseointegrated implants contain alarger proportion of collagen and alower proportion of fibroblasts thanthe tissues adjacent to natural teeth.Because of the lack of cementum forcollagen fiber insertion, the fibersaround a dental implant run parallel tothe implant’s surface rather than per-pendicularly attached to the rootsurface as seen in natural teeth. Inaddition, there are fewer blood vesselsin the peri-implant mucosa as com-pared to the gingiva around naturalteeth. Another important difference isthe location of biologic width. A den-tal implant usually has a flat platform

at the coronal end. As a result, theimplant is almost always positionedbelow the interproximal alveolar crest,which places the interproximal bio-logic width subcrestally instead of su-pracrestally as seen in natural teeth.The subcrestal formation of biologicwidth results in loss of interproximalbone. Consequently, all these differ-ences make preservation or regenera-tion of peri-implant papilla even morechallenging. Peri-implant tissues aresimilar to the periodontium with ajunctional epithelium containing basallamina and hemidesmosomes and con-nective tissue fibers.6 However, be-cause of lack of cementum, theimplant sulcus is often located at junc-tion of implant-bone interface. This isdifferent than the natural tooth wherethe sulcus is situated at cemento-enamel junction (CEJ). This translates

*Private practice, Toronto, Canada.†Professor and Director of Graduate Periodontics, Departmentof Periodontics and Oral Medicine, School of Dentistry,University of Michigan, Ann Arbor, MI.

Reprint requests and correspondence to: Hom-LayWang, DDS, MSD, PhD, Department of Periodonticsand Oral Medicine, University of Michigan, School ofDentistry, 1101 N. University, Ann Arbor, MI 48109-1078, Phone: 734-763-3383, Fax: 734-936-0374,E-mail: homlay@umich.edu

ISSN 1056-6163/10/01903-208Implant DentistryVolume 19 • Number 3Copyright © 2010 by Lippincott Williams & Wilkins

DOI: 10.1097/ID.0b013e3181d43bd6

Aim: Loss of implant papilla isone of the more troubling dilemmas inimplant dentistry. The “black trian-gle” around the implant-supportedrestoration causes not only phoneticdifficulties and food impaction butalso unpleasant esthetics. This is con-sidered to be a failure in today’simplant therapy standards. As a con-sequence, many techniques have beendeveloped to either preserve or regen-erate the interimplant soft tissue. It isthe purpose of this article to examinefactors that may affect the appearanceof the peri-implant papilla.

Materials: MEDLINE search wasused to identify articles publishedthrough September 2007 related toimplant esthetics as interimplantpapillae.

Results: Factors such as crestalbone height, interproximal distance,tooth form/shape, gingival thickness,and keratinized gingival width haveall been identified to influence the ap-pearance of the interimplant papillae.In addition, many techniques/materials have been successfullyused in promoting interimplant pa-pillae formation.

Conclusion: This article presentsa comprehensive review of factors thatmay influence the interimplant papil-lae and illustrates techniques used inattempting to recreate/correct thischallenging problem in implantdentistry. (Implant Dent 2010;19:208–219)Key Words: implant, papillae, esthet-ics, interproximal soft tissue

208 PERI-IMPLANT PAPILLAE • CHOW AND WANG

to about 2 mm vertical height differ-ence to ensure for the papillae appear-ance in both conditions (implant: 3mm and natural tooth: 5 mm) becausenormal bone level is often located at 2mm below the CEJ.7–11

Because the presence of papilla isone of the essential elements of ante-rior esthetics, the clinician may bewilling to attempt to regenerate or im-prove deficient papillary form eventhough limited blood supply and ac-cess plague the procedure and signifi-cantly increase the risk of failure.Over the years, many surgical andnonsurgical techniques have beenproposed to treat this soft tissue de-formity and manage the interproxi-mal space.12–14 Nonetheless, becauseof the limited sample size of casereports in natural studies, the pre-dictability of these techniques re-mains to be determined.

Because reconstruction of peri-implant papilla remains one of themost difficult and unpredictable pro-cedures in implant therapy, presurgi-cal planning becomes critical for thesuccess of the therapy. A well-thoughtand well-sequenced treatment plan de-mands clinician understanding the fac-tors influencing the appearance ofperi-implant papilla. This article willreview these potential clinical factorsthat may influence the appearance ofinterimplant papilla. In addition, thecurrent techniques of peri-implant pa-pilla enhancement are discussed.

POTENTIAL CLINICAL FACTORSCrestal Bone Height

The underlying osseous morphol-ogy has long been recognized as thefoundation for the support of gingivaltissue.15–17 In a classic study, Tarnow

et al7 investigated the effects of crestalbone height on the presence or ab-sence of dental papilla. The authorsexamined 288 interproximal sites anddemonstrated that the papilla waspresent almost 100% of the time whenthe distance from the contact point tothe crest of the bone was 5 mm orless. Salama et al8 assumed a similarrelationship in implant-supportedrestoration. Grunder confirmed thisspeculation. The author presented acase report of 10 single dental im-plants in the maxillary central/lateralincisor area and evaluated changesin papilla height 1 year after func-tion.9 All the peri-implant papillaereformed after the final crowns wereplaced on the implants when the cr-estal bone level on the adjacent toothwas 5 mm or less from the contactpoint. Similarly, Choquet et al10

studied the papilla level around sin-

Table 1. Tooth vs Dental Implant

Tooth Implant

Hard tissue interfaceBone-to-tooth/implant Resilient connection: bone-periodontal

ligament (PDL)-cementumRigid connection: functional ankylosis/

osseointegration; lack of PDLSoft tissue interfaces

Junctional epithelium (JE) Hemidesmosomes and basal lamina Hemidesmosomes and basal lamina!Origin" !Reduced enamel epithelium" !Adjacent oral epithelium"Connective tissue (CT) Perpendicular collagen fibers inserted

into cementumParallel collagen fiber bundles

Tissue qualityCT composition Lower proportion of collagen Higher proportion of collagen

Higher proportion of fibroblasts Lower proportion of fibroblastsVascular supply !sources" More !Supraperiosteal, vascular plexus of PDL" Less !Supraperiosteal"

Clinical characteristicsBiologic width JE—1 mm JE—2 mm

CT—1 mm CT—1 mmProbing depth !3 mm 2.5–4.0 mmProbing penetration Healthy: apical 1/3 JE Healthy: supracrestal CT

Gingivitis: coronal 1/3 CT Disease: bonePeriodontitis: apical 1/3 CT

Bleeding on probing More reliable sign of inflammation Less reliable sign of inflammationOther characteristics

Prioprioception Highly sensitive receptors present within PDL(e.g., Ruffini-like mechanorecptor, coiledMeissner’s corpuscles)

No receptors

Adaptability Width of PDL can alter to allow tooth movement No adaptive capacity and orthodonticmovement impossible

Fulcrum Apical 1/3 root Crestal boneAxial mobility 25–100 "m 3–5 "mMovement phases I. Nonlinear and complex I. Linear and elastic

II. Linear and elasticMovement patterns Primary: immediate movement Gradual movement

Secondary: gradual movement

IMPLANT DENTISTRY / VOLUME 19, NUMBER 3 2010 209

gle dental implants in 26 patientsand reported papilla was present al-most 100% of the time when thedistance from the contact point to thecrest of the bone was 5 mm or less.Interestingly, the occurrence of pa-pilla regeneration was at least 50%of the time when the distance was#6 mm. Therefore, other factors,such as horizontal distance betweenthe 2 adjacent teeth at the level ofCEJ, probably contributed to thepresence of the papilla.

Compared with a single dental im-plant, regenerating a papilla between 2adjacent implants is even more chal-lenging.11 In a series of case reports,Elian et al18 found a 5 mm height oftissue between 2 implants was not rou-tinely possible. Tarnow et al19 agreedwith the previous finding. The authorsexamined a total of 136 interimplantpapillary heights in 33 patients andfound the mean papillary height wasonly 3.4 mm. Although there was arange of 1 mm to 7 mm, the soft tissueheights were 2, 3, or 4 mm in 90% ofthe cases. On the basis of these data,the ideal distance from the base of thecontact point to the bone crest betweenadjacent implants is 3 mm and, be-tween a tooth and an implant, !5 mm(Table 2).

Interproximal Distance

The interproximal distance hasbeen thought to affect the appearanceof the hard and soft tissue in the em-brasure space. Heins and Wider20

demonstrated very thin lamina duraexisted when the inter-root distancewas #0.5 mm. When the inter-rootdistance became #0.3 mm, the crestalbone disappeared. Instead, the adja-cent root surfaces were connected by

the 2 adjacent periodontal ligamentspaces. On the basis of these findings,teeth with root proximity are moresusceptible to crestal bone loss, whichcan subsequently cause the papillarydisappearance. In addition, Tal foundthat a vertical defect occurs only whenthere is at least of 1.5 mm interdentaldistance. Otherwise, horizontal crestalbone loss occurs with the recession ofdental papilla.21 In a recent study of206 dental papillae in 80 patients, Choet al22 supported this notion. The au-thors found the ideal vertical dimen-sion for papilla formation should be!5 mm from the contact point to thealveolar crest while the ideal hori-zontal dimension was 1.5–2.5 mmbetween adjacent roots. Besides, theauthors suggested there were inde-pendent and combined effects ofboth dimensions on the existence ofpapillae.

These findings in natural teethmake the researchers question if thereis a similar correlation in implant-supported restoration. Tarnow et al23

investigated the effect of the interim-plant distance on the height of inter-implant bone crest. The authors foundthat there was a lateral component ofbone loss around implants, and 3 mmwas a critical interimplant distance. Ifthe distance was #3 mm, 0.56 mmmore pronounced bone loss was ob-served. The authors then speculatedthat this interimplant distance mightplay a significant role for presence ofthe papilla. A recent study performedby a Brazilian group confirmed thisspeculation. In a group of 48 patientswith 96 interproximal sites, Gastaldoet al24 examined the effects of the ver-tical and horizontal distances betweenadjacent implants and between a tooth

and an implant on the incidence of thepapilla. When the distance betweenadjacent implants and between a toothand an implant were #3 mm, papillawas absent 100% of time, regardlessof the vertical distance. Furthermore,they found that there was an interac-tion between horizontal and verticaldistances when the interproximalspacing was $3 mm. In contrast, No-vaes et al25,26 failed to show anysignificant effects of interimplant dis-tance on papilla formation in a dogmodel. In one of their 2 studies, 2implants were inserted in the mandibleseparated by 2 mm (group 1).26 Other2 implants were separated by 3 mm(group 2). In all cases, final metalliccrowns were fabricated to maintain adistance of %5 mm between the inter-proximal contact and crestal bone. Themean papilla heights in groups 1 and 2were similar with 3.07 mm and 3.55mm, respectively. The probable rea-sons for these contrary results could bedue to the different study models (e.g.,human vs dog) and different implantdesigns (e.g., machined titanium im-plant vs rough surfaced implant). Fur-ther studies are necessary to resolvethis controversy.

Tooth Form/Shape

Tooth shape can be classified intotriangular, ovoid and square whiletooth form can be defined as long nar-row or short wide. In natural dentition,gingival morphology is partly relatedto the tooth shape and form.16,27–30 In astudy of 192 subjects, Olsson andLindhe31 demonstrated patients withlong-narrow/triangular-shaped uppercentral incisors experienced morerecession of the gingival margin atbuccal surfaces than those with ashort-wide form/square shape.11 Intheir next study, Olsson et al32 re-ported that individuals with the long-narrow tooth form displayed a thinfree gingiva, a narrow zone of keratin-ized gingiva, shallow probing depth,and a pronounced “scalloped” contourof the gingival margin. Likely, thetooth shape and form can influence theperi-implant soft tissue architecture aswell. Indeed, Kois33,34 described toothshape as 1 of the 5 essential diagnostickeys for the peri-implant esthetics,

Table 2. Conditions Favoring Peri-Implant Papilla Appearance

Interproximal dimensionsBone crest-contact point Single implant: !5 mm

Two adjacent implants: !3 mmInterproximal distance Single implant: #1.5 mm

Two adjacent implants: #3 mmTooth factors

Crown form/shape Squared shapeContact length LongTooth position Diastemas (with thick interpoximal bone)

Soft tissue factorsGingival thickness ThickGingival scallop FlatKeratinized gingival width #2 mm

210 PERI-IMPLANT PAPILLAE • CHOW AND WANG

which should be considered in the pre-surgical phase of implant therapy. Inhis opinion, it impacts the tissue bothcoronal and apical to the free gingivalmargin (FGM). Coronal to the FGM,individuals with square-shaped teethhave a more favorable esthetic out-come because of the long proximalcontact and less amount of papilla tis-sue to fill the interproximal space. Onthe contrary, the contact of triangulartooth is short and more incisally posi-tioned. The interproximal area re-quires more tissue height to fill.Therefore, in the case of triangulartooth shape, there is higher risk ofblack hole, and peri-implant papillaregeneration can be very challenging.Kois suggested, in this situation, mod-ification of the adjacent tooth shapewith either direct composite or porce-lain veneer may be necessary after animplant-supported restoration. Apicalto the FGM, the triangular tooth shapeis more favorable than the square one.The triangular teeth allow for rootspositioned farther apart than thesquared ones. As a result, there is po-tentially thicker interproximal bone,which may minimize crestal bone lossand subsequent papilla loss after ex-traction and implant placement.

Gingival Thickness

Gingival tissue biotype is anotherimportant diagnostic key for peri-implant esthetics.33,34 It was proposed,2 basic types of gingival architectureexist—“scalloped thin” and “flat-thick.”11,29 Thin gingival tissue hasbeen described to have less underlyingosseous support and less vasculariza-tion. As a result, the thin tissue is moresusceptible to trauma and increases therisks of facial recession and loss ofinterproximal tissue after any surgicalprocedure. In contrast, thick gingivaltissue implies thicker underlying bonestructure, more fibrotic tissue, andmore blood supply. Therefore, thethick tissue is more resistant to phys-ical damage and bacterial ingress. In-deed, abundant empirical evidencesuggests thick gingival tissue not onlyresists physical trauma and subsequenttissue recession but also allows bettertissue manipulation, encouragescreeping attachment, improves papilla

fill, reduces clinical inflammation, andrenders predictable surgical out-comes.33–45 In a clinical trial on 24patients, Oh et al46 studied the effectsof flapless implant surgery on the softtissue prolife. The authors found betterpapillary index (PI)47 with the thicksoft tissue (ie #3 mm) than the thintissue (i.e., #3 mm); however, the dif-ference was not significant. In a caseseries of 45 patients, Kan et al48 eval-uated the dimensions of the peri-implant mucosa around 2-stagemaxillary anterior single implants af-ter 1 year of function. The authorscategorized the peri-implant biotypeinto a thick or thin group by placing aperiodontal probe into the facial aspectof the peri-implant mucosa. If the out-line of the underlying probe could beseen through the gingiva, the peri-implant biotype was defined as thin. Ifthe probe could not be seen, the bio-type was thick. The interproximal den-togingival dimension in the subjectswith the thick biotype was signifi-cantly greater than those with the thinbiotype (ie 4.5 mm vs 3.8 mm). There-fore, peri-implant papilla may bemaintained or re-established with thethick biotype.

Other Potential Factors

The relative tooth position, typeof gingival scallop and amount of ke-ratinized/attached gingiva are otherpossible factors that may determinethe level of papilla around dental im-plant. Before removal of the hopelesstooth, it is critical to evaluate its posi-tion relative to the remaining dentitionbecause the existing tooth positionwill influence the presenting configu-ration of the gingival architecture.33,34

For example, tooth with root proxim-ity has a very thin interproximal bone.This thin bone is highly susceptible toresorption after extraction, which willsubsequently cause the interproximalsoft tissue loss. In contrast, tooth withdiastemas possess thicker interproxi-mal bone, which is at less risk forresorption after wound healing. As aresult, peri-implant papilla preserva-tion or regeneration will be morepredictable.

Based on a survey of 100 patients,the gingival scallop can be categorized

into high, normal or flat.49 Comparedwith the normal or high gingival scal-lop, flat gingival architecture has lesstissue coronal to the bone interproxi-mally than facially. It tends to followthe osseous scallop creating less dis-crepancy and less risk of interproxi-mal tissue loss after tooth extraction.Consequently, the maintenance ofinterproximal papilla becomes morepredictable.33,34

The role of keratinized/attachedgingiva around natural teeth is a con-troversial issue. It has been suggested2 mm of keratinized tissue with atleast 1 mm attached tissue was re-quired to maintain gingival health.50

However, others have found that theamount of keratinized or attached gin-giva was not critical for tissue healthbut patient’s oral hygiene.43,44,50 –54

Similarly, there is a debate over theneed for keratinized and attached tis-sue for the maintenance of dental im-plants.43,50,53–62 Currently, the generalconsent is, with a proper plaque con-trol, lack of adequate keratinized/attached tissue will not increase theincidence of attachment loss or softtissue recession. However, under thecondition of inflammation, the sitewith inadequate keratinized tissue(ie #2 mm)/attached tissue (ie #1mm) is highly susceptible to pro-gressive attachment loss and reces-sion. In addition, new evidencesuggested, regardless of the surfaceconfigurations, the absence of ade-quate keratinized and attached tissuein dental implants is associated withhigher plaque accumulation and gin-gival inflammation.63 On the basis ofthese data, one can speculate thatkeratinized/attached tissue may in-fluence on the appearance peri-implant papilla, particularly in thesituation of inflammation.

DENTAL PAPILLAENHANCEMENT TECHNIQUE

Over the last 2 decades, varioustechniques have been proposed to pre-serve the papillary area or restore themissing papilla. In general, these tech-niques can be classified as surgicaland non-surgical (Table 3). The surgi-cal technique focuses on soft and hardtissue management, such as flap de-

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signs and grafting procedures. Thenon-surgical technique involves re-storative, prosthetic, and orthodonticprocedures. In addition, some novelapproaches (e.g., titanium papillaryinsert, autologous fibroblast injec-tions) have been suggested andreported in the recent dentalliterature.12,64

SURGICAL TECHNIQUESHard Tissue Management

To date, hard tissue managementbecomes an essential component in im-plant dentistry. Crestal bone resorptionafter tooth extraction not only compro-mises ideal implant placement but alsoleads to unacceptable esthetic outcomes(e.g., uneven soft tissue margin and lossof interproximal papilla). Misch65 rec-ommended that clinician should aug-ment crestal and interproximal regionwith dense hydroxyapatite at implantsurgery to elevate the soft tissue to theheight of the desired interdental/interim-plant papillae. At present, ridge defi-ciency can be enhanced by means ofguided bone regeneration, autogenousridge augmentation, and distractionosteogenesis.66–68

As discussed in the previous sec-tion, controlling and conserving thehard tissue height can help in achiev-ing desired papillary height. There-fore, at the time of tooth removal,ridge preservation is critical to preventthe loss of the underlying bone andrebuild the lost papilla in the finalimplant-supported restoration. Thetooth should be atraumatically ex-tracted by means of forceps rotation/periotomes, and the socket space canbe maintained by placing bone substi-tute with or without a membrane.13,69

In a study on 24 patients, Iasella et al70

compared extraction alone with ridgepreservation using freeze-dried boneallograft and a collagen membrane.The ridge preservation group gainedan average of 1.3 mm bone height. Incontrast, the extraction alone grouplost an average of 0.9 mm. Althoughboth groups lost ridge width, the ridgepreservation group only showed min-imal resorption (%1 mm) while theextraction alone group shrunk %3mm. The authors concluded the ridgepreservation is a predictable procedurefor the maintenance of ridge height,width, and position.

Recently, immediate dental im-plant placement has become a feasibleand popular treatment option in theanterior maxilla in select situations.Numerous case reports and some clin-ical trials have shown that immediateimplantation may allow preservationof the alveoli and surrounding struc-tures with favorable esthetic out-comes.48,71–74 Kan et al48 evaluated theimplant success and esthetic outcomesof immediately placed and provision-alized maxillary anterior single im-plants on 35 patients. After 12 months,all implants were successfully os-seointegrated. The average marginalbone loss was #0.3 mm. The midfa-cial gingival level and mesial and dis-tal papilla levels lost an average of0.55 mm, 0.53 mm, and 0.39 mm,respectively. None of the patients hadnoticed any changes at the gingivallevel. The authors concluded that im-mediately placed and provisionalizedmaxillary anterior single implants pro-vided favorable implant success rateand excellent esthetic outcomes.Juodzbalys and Wang72 also reported

100% success rate of immediate im-plant placement after a 1-year fellow-up. According to the Jemt PI,47 64.3%papillae showed a score of 2, and theremaining 35.7% showed a score of 3.The authors suggested that, with care-ful evaluation of potential extractionsites, immediate implant placementpromotes optimal implant esthetics.

In the event of multiple failinganterior teeth, simultaneous extractionof the adjacent teeth often leads toflattening of the interproximal bonyscallop and results in implant restora-tions with missing interimplant papil-lae. To manage this esthetic setback,Kan et al75 proposed an interimplantpapilla preservation technique involv-ing alternate removal of teeth atrau-matically with immediate implantplacement and provisionalization. Theauthors claimed that 1 side of theproximal bone and the associated pa-pilla can always be maintained whilethe other side is healing. In addition,the adjacent tooth form can serve as aguide for implant placement and pro-visionalization. In 6 patients, the au-thors showed all interimplant papillaewith a mean PI score of 3 after a meanfunctioning time of 22.6 months. Allpatients were satisfied with the finalesthetic outcome.

Implant placement with flaplessapproach provides some distinct ad-vantages over the conventional open-flap approach, such as a lessenedsurgical time, less bleeding and post-operative discomfort, minimalchanges in crestal bone level, soft tis-sue inflammation, and probing depthadjacent to implants.46,76–80 Therefore,flapless implant surgery is one possi-ble treatment option for enhancementof implant esthetics. Becker et al76

placed 79 implants in 59 patients usingone-stage flapless technique. At 2years, the cumulative success rate was%99%. The changes in crestal bonelevel were insignificant (i.e., 0.1 mm).The authors concluded flapless im-plant surgery is a predictable proce-dure. Oh et al replaced a missingsingle tooth in the premaxillary regionwith an endosseous implant using aflapless technique.46 The implantswere either immediately loaded or de-layed loaded. At 6 months, no signif-

Table 3. Peri-Implant Papilla Preservation and Regeneration Techniques

Surgical Techniques

Hard tissue management Soft tissue managementAtraumatic tooth extraction and ridge

preservation (i.e., bone graft and/ormembrane)

Papilla preservation flap designSoft tissue graft (e.g., “split-finger” technique,

subepithelial connective tissue graft)Immediate dental implant placementFlapless implant surgery

Nonsurgical Techniques

Restorative/prosthetic treatments (e.g., contact reshaping, ovate pontic, provisionalresin crown)

Orthodontic extrusion

212 PERI-IMPLANT PAPILLAE • CHOW AND WANG

icant differences were detectedbetween the 2 treatment groups in anyclinical parameters. The mean PI inthe immediate loading group in-creased from 1.50 at baseline to 2.09at 2 months and then remained stableup to 6 months (i.e., 2.30). In the de-layed group, the mean PI stayed thesame (i.e., 2.06 at both baseline and 6months). There were minimal changesof the marginal soft tissue level in bothtreatment groups over 6-month period.Both studies demonstrated flaplessimplant surgery provides esthetic softtissue profile around single-tooth im-plant restorations, regardless of theloading protocol.

Soft Tissue Management

Two soft tissue management ap-proaches are generally found in thedental literature. The first approach fo-cuses on the flap designs or surgicaltechniques to maintain full papillaryform after the surgical procedure.81–89

The second approach uses graftingtechniques to fill the open interproxi-mal spaces.90–104 However, because ofthe minimal blood supply and difficultaccess to the papillary tissue, only lim-ited success has been achieved withthese approaches.12

Takei et al87 developed the “pa-pilla preservation technique” with theaim to improve the deficient interprox-imal papillae between multiple teeth.Later, various modifications ofTakei’s technique (e.g., modified pa-pilla preservation technique, simpli-fied papilla preservation technique andpapillary amplification flap) have beenproposed to optimize interproximalsoft tissue preservation.81–83,88,89 Simi-larly, the concepts of preserving bloodsupply to the peri-implant papillae andminimizing soft tissue recession in theesthetic zone, such as paramarginalpedicle flap, flap without disturbingthe periosteum, are advocated.84 – 86

Gomez-Roman85 compared 2 differentflap designs: a widely mobilized flapthat included papillae and a limitedflap that protected papillae, and deter-mined their effects on the peri-implantinterproximal crestal bone loss. Oneyear after crown placement, the meaninterproximal bone loss was signifi-cantly lower after the use of a limited

flap design than the widely mobilizedflap procedure (ie 0.29 mm vs 1.12mm). As a result, the limited flap de-sign minimized the risk of papilla loss.In addition, Flanagan84 proposed anincision design, which allows liftingof the gingiva without disrupting theperiosteum and its blood supply, topromote the gingival base for the cre-ation of interdental implant papilla.

A number of techniques havebeen published to describe surgicalreconstruction of deficient dental/peri-implant papillae.90–104 All these tech-niques are based on the traditionalplastic surgical approaches (e.g., sub-epithelial connective tissue graft).Palacci102 developed an unique papillaregeneration technique at stage 2 un-cover for multiple implants, in which asemilunar beveled incision is per-formed in the elevated flap in relationto each implant to create a pedicle.The pedicle is then rotated 90 degreetoward the mesial aspect of the abut-ment and stabilized with interruptedmattress sutures to form a new interim-plant papilla. Subsequently, numerousmodifications of Palacci’s techniquehave been reported in case studies orclinical trials.97,99,101 In a recent pilotstudy, Misch et al99 used a “split-finger”incision design to promote papilla for-mation. The authors reported 16 single-tooth implant restorations with a meanPI score of 3 while 5 multiple implant-supported prostheses had a mean PIscore of #2. In addition, soft tissuegrafting was also suggested to enhancepapillary appearance.93,103 In a singlecase report, Price and Price103 describedthe use of subepithelial connective tissuegraft to restore papillae adjacent to asingle dental implant. The authorsshowed a 3-year clinical follow-up withcomplete gingival papillae. Similarly,Azzi et al93 reported 3 successful cases,in which a subepithelial connective tis-sue graft was inserted in a pouch tomove the entire peri-implant gingivo-papillary unit incisially.

Despite these extensive efforts topreserve or regenerate papillary tissue,none of these procedures provide evi-dence of predictability, and few dem-onstrate long-term stability.

NONSURGICAL TECHNIQUESRestorative/Prosthetic Treatment

In certain circumstances, restor-ative/prosthetic techniques may behelpful for treating papillary insuffi-ciency, for example, when all hard andsoft tissue augmentation proceduresfail to achieve esthetic outcomes orwhen patients refuse any surgical in-terventions. By means of restorative/prosthetic reshaping, the contact of thecrowns can be lengthened and locatedmore apically.98,105–107 As a result, theopen embrasure space is reduced withan illusion of papilla regeneration.

After a single anterior tooth re-moval, Spear108 advocated the use ofovate pontic to help in molding thepapillary height and gingival embra-sure form. In a single case report, Al-Harbi109 adapted Spear’s concept andsuccessfully enhanced the interim-plant papillary tissue by a cantileveredfixed partial denture with an ovatepontic. Similarly, Jemt110 attempted topromote interimplant papillary forma-tion by the means of placing a provi-sional resin crown at the time ofsecond-stage surgery. The authorshowed that the use of provisionalcrowns were able to guide the softtissue into the interimplant spacefaster than healing abutments alone;however, the volumes of the papillaeadjacent to single-implant restorationswere similar after 2 years of function.

Orthodontic Therapy

Orthodontic therapy offers the bestesthetic outcomes in several distinctclinical situations.107 In the presence ofdiastema, the interdental papilla is ap-parently missing. This situation can beremedied by combining orthodontictooth approximation with apical posi-tioning of the contact point throughstripping.111 Root divergence is anothersituation that can lead to the open inter-proximal space when the contact pointbetween the 2 clinical crowns is situatedtoo incisally. Again, orthodontic treat-ment can create a new papilla byaligning the roots and squeezing the in-terproximal tissue.96 In addition, whenteeth or roots are indicated for extrac-tion, forced orthodontic extrusionshould be considered to enhance bothhard and soft tissue profiles.112 This

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eruption technique can be valuable forthe improvement of the peri-implant pa-pilla height.13

NOVEL APPROACH

McGuire and Scheyer12 intro-duced an innovative papilla primingprocedure in an attempt to enhancepapillary form. Twenty-one subjectswith interdental papillary deficiencywere enrolled. The deficient sites wererandomized to receive autologous fi-broblast injections or placebo injec-tions. At 2 months, the test sitesshowed more papillary height gainthan the placebo sites. However, thetreatment effect disappeared at 4months. Future research in this area iscertainly needed.

CONCLUSION

At this point, the crestal bonelevel seems to be the primary factorfor the presence of peri-implant pa-pilla. Similarily, the interproximal dis-tance may affect the existence of thepapilla. In addition, there are alsoother potential factors, such as tissuethickness, keratinized/attached tissuewidth, tooth form/shape and position.Unfortunately, these factors havenever been fully investigated due tolack of funding and long-term follow-up. Future studies are necessary toclarify the importance of each of thesefactors. Although numerous tech-niques showed successful papillarypreservation or regeneration, mostwere documented in case reports, andnone has been proved to be predictablein the long term. Therefore, more con-trolled clinical trials are needed toevaluate the efficiency of these papil-lary enhancement techniques.

Disclosure

The authors claim to have no fi-nancial interests, either directly or in-directly, in the products or companieslisted in the study.

ACKNOWLEDGMENTS

This study was supported by thePeriodontal Graduate Student Re-search Fund, University of Michigan.

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216 PERI-IMPLANT PAPILLAE • CHOW AND WANG

Abstract Translations

GERMAN / DEUTSCHAUTOR(EN): Yiu Cheung Chow, DDS, MS, Hom-LayWang, DDS, MSD, PhDFaktoren und Methoden, die Papillen im Implantat an-gelagerten Umfeld beeinflussen

ZUSAMMENFASSUNG: Zielsetzung: Der Verlust der Im-plantatpapille ist eine der komplizierteren, weil vielfach Prob-leme verursachenden unerwunschten Situationen in derImplantat-Zahnheilkunde. Das “schwarze Dreieck” um die Im-plantatgestutzte Wiederherstellungslosung herum fuhrt nicht nurzu phonetischen Schwierigkeiten und dem Einklemmen vonSpeiseresten, sondern ist auch aus asthetischen Gesichtspunktenunangenehm. Dies wird als Versagen gemaß den heutigen Stan-dards der Implantattherapie angesehen. Folglich wurden eineganze Reihe von Methoden entwickelt, um entweder das Weich-gewebe im Zwischenbereich des Implantats zu erhalten oderwiederherzustellen. Das vorliegende Dokument zielt darauf ab,die Faktoren zu ermitteln, die eventuell zum Auftreten desPhanomens der das Implantat umlagernden Papille fuhren kon-nen. Materialien und Methoden: Mittels MEDLINE-Suchewurden Artikel herausgesucht, die im September 2007 verof-fentlicht wurden und im Zusammenhang mit der Implantatasthe-tik durch Auftreten von Papillen im Zwischenimplantatbereichstanden. Ergebnisse: Faktoren, wie beispielsweise die Hohe desKammknochengewebes, der interproximale Abstand, dieZahnform/-kontur, die Dicke des Zahnfleischs sowie die ver-hornte Breite des Zahnfleischs, wurden allesamt als moglicheMitverursacher eines Auftretens von zwischen den Implantatenliegenden Papillen herausgefunden. Außerdem wurden viel-fache Techniken/Materialien erfolgreich zur Besserung derPapillenausbildung im Bereich zwischen den Implantatenangewendet. Schlussfolgerung: Der vorliegende Artikelbietet einen umfassenden Uberblick uber die Faktoren, diePapillen im Implantatzwischenraum beeinflussen konnen,und beschreibt Methoden, die angewendet werden, umdieses große Anforderungen stellende Problem in derImplantat-Zahnheilkunde zumindest versuchsweise wied-erherzustellen/zu korrigieren.

SCHLUSSELWORTER: Implantat, Papillen, Asthetik, inter-proximales Weichgewebe

SPANISH / ESPANOLAUTOR(ES): Yiu Cheung Chow, DDS, MS, Hom-LayWang, DDS, MSD, PhDFactores y tecnicas que influencian las papilas periimplante

ABSTRACTO: Proposito: La perdida de la papila del im-plante es uno de los dilemas mas preocupantes en la odon-

tología de implante. El “triangulo negro” alrededor de larestauracion apoyada en implantes no solamente causa difi-cultades foneticas y la acumulacion de comida sino tambienun resultado estetico poco agradable. Esto se considera unafalla en las normas actuales de terapia con implantes. Comoconsecuencia, se han creado muchas tecnicas para proteger oregenerar el tejido blando interimplante. El proposito de estetrabajo es examinar los factores que pueden afectar la papilaperiimplante. Materiales y Metodos: Se uso una busqueda enMEDLINE para identificar artículos publicados hasta sep-tiembre del 2007 relacionado con la estetica del implantecomo papila interimplante. Resultados: Factores tales comola altura del hueso crestal, distancia interproximal, forma ycontorno del diente, espesor gingival y ancho gingival que-ratinizado fueron identificados como que influencian el as-pecto de la papila interimplante. Ademas, se han usadomuchas tecnicas y materiales exitosamente en la promocionde la formacion de la papila interimplante. Conclusion: Esteartículo presenta una evaluacion general de los factores quepueden influenciar las papilas interimplante e ilustra tecnicasusadas para tratar de recrear o corregir este problema en laodontología de implantes.

PALABRAS CLAVES: Implante, papilas, estetica, tejidoblando interproximal

PORTUGESE / PORTUGUESAUTOR(ES): Yiu Cheung Chow, Cirurgiao-Dentista, Mestreem Ciencia, Hom-Lay Wang, Cirurgiao-Dentista, Mestre emOdontologia, PhDFatores e Tecnicas que Influenciam Papilas Peri-implantes

RESUMO: Objetivo: A perda de papilas de implante e umdos dilemas mais perturbadores na odontologia de implante.O “triangulo negro” em torno da restauracao suportada porimplantes nao so causa dificuldades foneticas e impactacaoalimentar, mas tambem estetica desagradavel. Isso e consid-erado uma falha nos padroes atuais de terapia de implante.Como consequencia, muitas tecnicas foram desenvolvidaspara preservar ou regenerar o tecido mole interimplante. Eobjetivo deste artigo examinar fatores que podem afetar oaparecimento de papilas peri-implantes. Materiais e Meto-dos: A busca no MEDLINE foi usada para identificar artigospublicados ao longo de setembro de 2007 relacionados aestetica de implante como papilas interimplante. Resultados:Fatores como altura da crista ossea, distancia interproximal,forma/formato do dente, espessura gengival e largura dagengiva ceratinizada foram todos identificados como influ-encidadores do aparecimento de papilas interimplante. Alemdisso, muitas tecnicas/materiais foram usados com sucesso napromocao da formacao de papilas interimplante. Conclusoes:

IMPLANT DENTISTRY / VOLUME 19, NUMBER 3 2010 217

Este artigo apresenta uma revisao abrangente de fatores quepodem influenciar as papilas interimplantes e ilustra tecnicasusadas na tentativa de recriar/corrigir esse problema desafia-dor na odontologia de implante.

PALAVRAS-CHAVE: Implante, papilas, estetica, tecidomole interproximal

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TURKISH / TURKCEYAZARLAR: Yiu Cheung Chow, DDS, MS, Hom-LayWang, DDS, MSD, PhDPeri-implant Papillayı Etkileyen Faktor ve Teknikler

OZET: Amac: Implant papillasının kaybı, implant disciligi-nin en rahatsız edici sorunlarından biridir. Implant ile destek-lenen restorasyonun etrafındaki “siyah ucgen” sadece fonetikgucluklere ve yiyecek maddelerinin gomulmesine neden ol-makla kalmaz, ayrıca tatsız bir estetik goruntu de yaratır.Gunumuzun implant terapi standartlarına gore bu bir basarı-sızlık kabul edilir. Bu nedenle, inter-implant yumusakdokuyu ya korumak ya da yeniden uretmek icin bir cok teknikgelistirilmistir. Bu calısmanın amacı, peri-implant papillanıngorunusunu etkileyebilen faktorleri incelemektir. Gerec veYontem: Eylul 2007 tarihine kadar inter-implant papilla veimplant estetigine iliskin olarak yayınlanmıs makaleleri bul-mak amacıyla MEDLINE araması yapıldı. Bulgular: Kretkemik yuksekligi, interproksimal mesafe, dis formu/sekli, diseti kalınlıgı ve keratinlesmis dis eti genisligi gibi faktorlerininter-implant papillanın gorunusunu etkiledigi saptandı. Ay-rıca, inter-implant papilla olusumunu ilerletmek amacıyla bircok teknik/gerec basarıyla kullanılmıstır. Sonuc: Bu makale,inter-implant papillayı etkileyen faktorlerin genis caplı birdegerlendirmesini saglamakta ve implant disciliginin bu cetinproblemini yaratmak/duzeltmek icin kullanılan tekniklerisunmaktadır.

ANAHTAR KELIMELER: Implant, papilla, estetik, inter-proksimal yumusak doku

JAPANESE /

218 PERI-IMPLANT PAPILLAE • CHOW AND WANG

CHINESE /

KOREAN /

IMPLANT DENTISTRY / VOLUME 19, NUMBER 3 2010 219