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Staff Prosthodontist and Assistant Program Director, Veterans Affairs Medical Center; and Assistant Professor, Department of
Prosthodontics, University of Pittsburgh School of Dental Medicine.
b
Professor Emeritus, Division of Restorative and Prosthetic Dentistry, The Ohio State University.
a
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October 2012
significant effect on bone loss, while
the nonwelded groups consistently
showed higher levels of bone loss.
Heijdenrijk et al51 compared 2-piece
abutment/implant connections with
the connections placed above and
below the tissues to a 1-piece system
and found no association between
the presence of a microgap and inflammation.
Platform switching
B
2 A, Conical internal abutment connection; B, Internal
hexagon abutment connection.
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October 2012
tours and proper emergence profiles.
Priest61 recommended providing at
least 3 mm from the implant margin
to the zenith of the facial margins
of adjacent teeth, while noting that
provisional restoration is essential in
developing optimum esthetics. This
is especially critical when soft tissue
thickness is minimal.
Provisional Restoration
As in conventional restorative and
fixed prosthodontics, provisional restorations are an invaluable esthetic
and diagnostic tool. Provisional restoration of implants is often neglected
probably because provisional components are often time consuming and
cumbersome. Also many provisional
components do not readily accommodate angle correction. Attached
gingiva can be sculpted and molded
by means of the provisional restoration to help create the illusion of interdental papillae as well as contributing
to more stable, predictable overall esthetics and providing increased function.89-92 Providing anatomic fixed
provisional restorations also avoids
the introduction of dramatically different restorative contours at the time of
final restoration placement, decreasing the likelihood of postplacement
recession.63,93 Lai et al94 and Gallucci
et al95 showed that dramatic soft tissue changes, both in dimension as well
as health, occur following the initial
establishment of anatomic contours.
Although bone response was similar
to delayed provisional restoration,
Block et al92 found an average increase
in tissue height of 1 mm for immediately provisionally restored implants
following their placement in fresh extraction sites. Establishing these contours immediately, either at placement
or during second stage uncovering
has been shown to be especially effective.63,79,93,95 DeRouck et al93 compared
the postrestoration soft tissue contours of 24 immediately provisionally
restored implants to 25 restored with
a conventional 2-stage approach. They
found 2.5 to 3 times less midfacial re-
cession and better predictability of papilla heights in the immediately provisionally restored group.
The use of definitive stock abutments placed intraorally by the clinician as opposed to laboratory prepared custom abutments would seem
to offer distinct advantages in the esthetic zone. Provisional restoration is
simplified, allowing the establishment
of a proximal contact point early in
the restorative phase to initiate papilla formation. The use of cumbersome, interim, partial removable dental prostheses is also obviated. Most
of all this technique eliminates the
multiple switching of various components during the restorative phase. Although such evidence in the literature
could not be found, it is these authors
opinion that the techniques afforded
by this type of abutment offer distinct
biologic and clinical advantages.
Parameters influencing papillary
tissue development
The possibility of papilla fill is
greatly enhanced when interproximal
bone is preserved, creating a reasonable opportunity to provide a desirable distance of 5 mm or less from
the proximal contact to the interseptal bone as described in the literature
for natural teeth as well as recently
for implants immediately adjacent
to natural teeth.96-99 Lops et al98 and
Gastaldo et al99 recommend 3 to 4
mm and 3 to 5 mm, respectively, between proximal contacts and bone
crest when the implant is adjacent
to a natural tooth. However, papilla
fill was observed, in some instances,
where the bone to contact distance
was as great as 9 mm, suggesting, not
surprisingly, that multiple factors influence soft tissue response.97 Palmer
et al100 also found, in a study of 46
participants with platform switched
implants, that papilla fill was observed when the proximal contact to
bone distance exceeded 4 to 5 mm.
It should be noted that both of these
studies involved implants adjacent
to natural teeth. In addition, Kwon
et al66 observed that in the tooth-implant-tooth clinical scenario, the critical distance is that from the proximal
contact to the bone level adjacent to
the natural tooth, termed tooth side
bone level. In this study of 17 implants and 37 papillae, they found
virtually complete papilla fill when the
average bone to contact distance was
4.88 mm or less and a lack of papilla
fill when this distance exceeded 6 mm.
The situation becomes much more
challenging when adjacent implants
are present. In a dog study of platform-switched implants, de Oliveira
et al101 found that a 5 mm bone to
proximal contact distance proved to
be the critical factor for papilla development between implants, regardless
of interimplant distances, which varied between 1 and 3 mm. Other investigators have observed that to achieve
papilla fill between implants, a proximal contact to bone crest distance
of 3 mm or less is desirable, while a
distance of 3 to 5 mm can provide
papilla fill between an implant and a
natural tooth.98
As previously mentioned, interimplant distance and tooth-to-implant
distance have been shown to play a
role and possibly interact with bone
to proximal contact distance. In a
more recent study involving the same
type of implants, de Oliveira et al102
reported increased bone remodeling
when interimplant distance was 1 mm
or less than in groups with 2 to 3 mm
interimplant distance. In the natural
dentition, Martegani et al103 found
that papilla loss increased dramatically when interradicular distances were
2.4 mm or less and that this factor
had both an independent and combined effect with proximal contact
distance. Degidi et al104 examined 152
implants and 99 interimplant sites
and found that optimum interimplant distance for papilla development was greater than 2 mm but less
than 4 mm. They also found that optimum bone to contact height should
be 3 to 4 mm and that papilla height
decreased dramatically when this distance exceeded 6 mm. Tarnow et al25
264
for the implant-implant clinical situation than for the tooth-implant situation. They also found only 1 mm of
missing papilla height when the interimplant distance was 3 mm and that
immediate provisional restoration
reduced papilla loss from 2 mm to
1 mm. It is also noteworthy that, in
this study, 87.5% of participants were
pleased with their esthetic result even
with a papilla height discrepancy of 2
mm. Because most of these changes
have been found to occur within the
first 6 months following placement, the
advantages of early and long term provisional restoration seem clear. Tarnow
et al113 also recommended caution,
while reporting mean papillary tissue
heights of only 3.4 mm for 136 adjacent implant sites in 33 participants.
While 3 to 4 mm appears to be the
ideal interimplant distance, the use of
a platform switched design may allow
more bone and soft tissue maintenance
for enhanced esthetics, effectively increasing the interabutment distances
for implants in close proximity65,105 In a
study of 41 pairs of platform switched
implants in 37 participants, Rodriguez-Ciurana et al65 demonstrated
bone maintenance to be an average of
2.4 mm above the implant/abutment
interface at interimplant distances
less than 3 mm. As stated previously,
Novaes et al59,60 also found improved
papilla fill for subcrestally placed platform switched implants than for those
placed crestally. However, the papilla
height was not influenced by interimplant distance, which varied from 1
to 3 mm.59,60 In addition to his previously mentioned recommendation of
a 3 mm distance from implant to adjacent gingival margin zeniths, Priest61
similarly recommended 3 mm of interimplant distance as well as orienting the center of the implant 3 mm
palatal to the future facial restorative
margin. Therefore, because of the esthetic challenges detailed above, the
placement of adjacent implants in the
esthetic zone should be avoided whenever possible.114
SUMMARY
A review of the current literature
suggests that the use of standard to
narrow diameter implants, a platform switched design, and early provisional restoration should be considered when long term esthetics are
paramount. Also, maintaining interimplant and tooth-to-implant distances of approximately 3 mm is desirable with regard to crestal bone maintenance and papilla development.
Subcrestal placement may afford adequate space to develop restorative
contours from the top of the implant
to restoration emergence while avoiding facial thread exposure. This may
be even more effective in combination with a platform switched design.
In addition, abutment to implant
connections, which are extremely intimate and allow little to no relative
movement, seem to offer distinct advantages with regard to tissue health.
Lastly, the use of noncustomizable
abutments and abutment level restorative techniques provides for ease of
provisional restoration and treatment
sequencing while avoiding multiple
exposures of the implant/abutment
junction, although the biological advantages this may offer have yet to be
investigated.
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