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NEW TECHNIQUE FOR INTER-IMPLANT PAPILLARECONSTRUCTION BETWEEN TWO OR MOREIMPLANTS IN PATIENTS WITH VARIABLY REABSORBEDRIDGES AND FLAT ANATOMY. PRELIMINARY RESULTSOF A 9 CONSECUTIVE CLINICAL CASE SERIESR. TIZZONI1, M. TIZZONI2

1 M.D. and D.D.S. Private practice, Milan, Italy; 2 M.D. and D.D.S. Private practice, Milan, Italy

SUMMARYNew technique for inter-implant papilla reconstruc-tion between two or more implants in patients withvariably reabsorbed ridges and flat anatomy. Prelimi-nary results of a 9 consecutive clinical case series.The aim of the work. Interimplant papilla reconstructionis difficult because the biologic width around an implantis apical to the implant-abutment connection and be-cause the biologic width creates subcrestally. The aim ofthis study is to investigate whether the reconstruction ofthe interimplant papilla can be achieved by the use of aninnovative surgical technique combined with scallopedimplants, in the most severe surgical conditions, i.e. invariably reabsorbed ridges with flat anatomy. Materials and method. Nine surgical sites, in eight con-secutive patients, were treated with at least two adjacentscalloped implants and fixed prosthesis. 23 scallopedimplants were placed using this new surgical techniqueon bone and soft tissue structures. One flat platform im-plant was also placed between two other scalloped im-plants. A total of 15 interimplant papillae were examined.Results. 100% of papilla reconstruction at first prosthesisinsertion. 13.3% failed to maintain interimplant papillae af-ter 6 months and 20% after 12 months. Also, papilla re-construction was maintained for 12 months in the mesialand distal embrasure spaces of the flat platform implant.Conclusion. The combination of the use of adjacentscalloped implants with this surgical approach, even inreabsorbed ridges with flat anatomy, may reform inter-implant bone peaks as support for the papillae.

Key words: inter-implant papilla reconstruction/regener-ation, scalloped implants, implant design, esthetics, den-tal papilla.

RIASSUNTONuova tecnica chirurgica per la ricostruzione della pa-pilla interimplantare fra due o più impianti in pazienticon vario grado di atrofia delle creste alveolari ed ar-chitettura anatomica piatta. Risultati preliminari di unaserie di 9 casi clinici consecutivi.Scopo del lavoro. La ricostruzione della papilla interim-plantare è difficile perché l’ampiezza biologica in implanto-logia si forma apicalmente alla connessione moncone-im-pianto e pertanto è a livello sottocrestale. Questo studio sipropone di verificare se può essere ottenuta la ricostruzio-ne della papilla interimplantare, grazie ad un’innovativatecnica chirurgica utilizzata in combinazione ad impianti fe-stonati, nelle condizioni cliniche più severe e cioè in crestealveolari atrofiche ad architettura anatomica piatta.Materiali e metodi. Sono stati trattati consecutivamente no-ve siti chirurgici in otto pazienti, i quali richiedessero almenodue impianti festonati adiacenti e riabilitazione protesica fis-sa. Sono stati inseriti 23 impianti festonati secondo la nuo-va tecnica, prevista sia per i tessuti duri che molli. È statoanche inserito un impianto a testa piatta fra altri due impiantifestonati. Sono state studiate 15 papille interimplantari.Risultati. Alla consegna dei manufatti protesici si è ottenu-to il 100% di ricostruzione papillare interimplantare. Nel13.3% dei casi non si è mantenuta la ricostruzione papilla-re interimplantare dopo 6 mesi e nel 20% dei casi dopo 12mesi. È stata anche ottenuta, e mantenuta per 12 mesi, laricostruzione dalle papille interimplantari mesiale e distalerelativa all’impianto a testa piatta. Conclusioni. La combinazione dell’utilizzo di questa nuovatecnica chirurgica con impianti festonati adiacenti sembrapoter riformare picchi ossei interimplantari di supporto perle papille gengivali perfino in caso di creste alveolari varia-bilmente atrofiche e con anatomia ossea piatta.

Parole chiave: ricostruzione/rigenerazione della papillainterimplantare, impianti festonati, disegno implantare,estetica, papilla dentale.

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Introduction

In the anterior maxillary area the shape and size ofthe gingival papillae play a crucial role in theesthetic outcome of oral implant rehabilitation.It is well established that reconstruction of inter-implant papilla is a technique sensitive approach de-pendent on clinician’ s skill and knowledge, and itsreliability, especially long term, is still a matter ofdebate (1-4).Tarnow et al. (5) demonstrated that in natural den-tition the interdental papilla is present nearly 100%of the cases when the distance between the dentalcrown contact point and the alveolar bone crest is 5mm or less.It is also known that in a single-tooth implant sup-ported restoration the shape of the papilla is main-ly influenced by the coronal position of the alveo-lar crest of the adjacent tooth (6,7) and the contactpoint (8-10): these interactions, however, are not al-ways established around implants (11).A reason why reconstruction of the gingival papil-la between two or more implants is very difficult andunpredictable is because the biologic width aroundan implant is apical to the implant-abutment con-nection (12) and to the crest of bone. In such a si-tuation the connective tissue and the epithelial at-tachment are not supportive of the inter-implant pa-pilla (2).From a literature research only few published arti-cles reported about results of inter-implant papillareconstruction (13,14).As described by Tarnow et al. (15), in order to pre-vent the risk of bone reabsorption between implants,a key role is played by inter-implant distance thatshould be at least 3 mm.This seems to be related to the horizontal componentof the biologic width that forms around implants. The average height of tissue from the crest of boneto the top of the papilla between adjacent implantsis 3,4 mm (2).Consequently the height of the bone crest often in-fluences the presence of a papilla in the inter-im-plant space (2,3): this shows that predictable esthe-tic results can only be achieved in cooperation withsubjacent bone level (6).

In this respect in the past decades several surgicaltechniques have been described by different authorsto correct bone atrophies and crest deformities(16-27). More recently the preservation of the inter-implantbone crest, by means of post-extractive immediateimplant placement, was reported to be paramount im-portant especially in the maxillary anterior area whe-re esthetic demands are higher (28-30).Furthermore in order to maximize the chances forgood tissues health, soft tissue profiles and main-tainance of septal bone height, immediate post-ex-tractive implants with immediate provisionalizationhave also been proposed (31,32): this approach wasreported to get high survival rates (33).As regards the role of the macrodesign of implants,notably in their most coronal part, Wohrle stated thatthe use of scalloped implants inserted in preservedosseous anatomy, with interproximal bone peaks andlower buccal and lingual crests, also significantly de-creases interproximal bone remodelling (34).The scalloped implant was conceived for patientswith preserved three-dimensional ridge morpholo-gy and it was also stated that this design only of-fers the potential to reconstruct previously lost in-terproximal bone peaks (34). In light of the above issues, a study was carried outto assess whether the reconstruction of an inter-im-plant papilla between two or more implants could beachieved by a new surgical technique on bone andsoft tissue structures combined with scalloped im-plants.

Patients and methods

Between November 2006 and May 2007 eight con-secutive patients (4 males and 4 females), aged bet-ween 18 e 58 years (mean 38 years) requiring im-plants and fixed prosthesis in any region of both jaws,were treated with Nobel Perfect groovy scalloped im-plants combined with this novel surgical approach.Total number of scalloped implants was 23. 1 No-bel Replace implant was also inserted between twoother Nobel Perfect scalloped implants. All the im-plants were two-stage implants and placed in hea-led sites, morphologically stable and with comple-

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ted bone maturation processes. All the treated are-as presented variably reabsorbed ridges with flat ana-tomy (i.e. preservation of the inter-dental bone peakwas not considered in this particular study). Before treatment informed written consent wasobtained from all the subjects. Patients were selectedaccording to the following inclusion criteria: a re-cipient bone site allowing the placement of at leasttwo adjacent implants with a minimum length of 10mm and a minimum diameter of 4,3 mm at the headportion; controlled oral hygiene. In addition to ex-clusion criteria universally accepted in implant sur-gery (35), the following exclusion criteria were adop-ted: heavy smokers (more than 15 cigarettes aday), unrealistic expectations about the procedure,bruxism and/or parafunctional habits. All patients butone were treated without need of bone augmenta-tion procedures. In one case, because of a car acci-dent, bone morphology was only corrected for ide-al three-dimensional positioning of the implants. Inorder to achieve stabilization, three patients un-derwent sinus lift procedure and implant placementat the same time. Periodontal plastic surgery was notperformed in any patient in the area of the papillae. Information included complete medical and dentalhistory, and clinical and radiographic evaluation.Photographs of the area intended to be treatedwere also taken.

Description of the newtechnique

Surgical templates were used to determine im-plants positioning.Local anesthesia was induced by infiltration with xy-loplyina 2% (Lidacain 1:50.000 adrenaline) (Den-tsply Italia s.r.l. Roma, Italy).After crestal incision a mucoperiosteal flap was ele-vated. For a better surgical exposure, when neces-sary, releasing incisions were made.A first osteotomy for implant placement was per-formed according to the manufacturer’s instruction.A second osteotomy was then performed, by usingof a round bur, from the buccal to the lingual aspectof the alveolar bone (Buccal-Palatal Osteotomy:BPO, or Buccal-Lingual Osteotomy: BLO) to remove

an adequate quantity of bone on the vestibular andlingual aspects of the alveolar ridge. This procedu-re permitted the scalloped outline of the implant col-lar to adapt to the reconstructed scalloped anatomyof the bone while generating immediate interimplantbone peaks (Figs. 1 and 2).Whenever possible all the implants were inserted 3mm apart. At first stage surgery the implant collarwas positioned 1,04 mm above the alveolar crest onan average (Fig. 3).All the implants got a primary implant stability ofat least 25 Ncm.The wound margins were allowed to heal with stra-tified sutures: first horizontal mattress sutures wereused and then superimposed uninterrupted suturesto stabilize the most coronal portion of the flap (Fig.4).Antibiotics, anti-inflammatory drugs and chlorhe-xidine mouth wash were prescribed to all patients.

Figure 2

Figure 1

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Sutures were removed after 7 days and the patientswere seen monthly for prophylaxis.All the implants healed submerged: time of healingwas 2 to 5 months (mean 3,5 months) in the man-dible and 5 to 8 months (mean 6,5 months) in the ma-xilla.With the use of the surgical template to identify im-plant location, second stages surgery was flapless andperformed by the round tip of an electro-surgical de-vice (Ida Surgery, Italy). In order to obtain a scal-loped shape of the soft tissue, an accurate gingi-vectomy following implant head outline was madeon both the vestibular and the lingual aspects (Fig.5).All the implants were rehabilitated with free stan-ding crowns.At implant placement a photograph of the implant

position with open flap and a radiograph with Rinncentrator (Dentsply, Elgin, Illinois, U.S.A.) were ta-ken. As regards registration during follow up, for each pa-tient, photographic evaluation of the length of the pa-pilla and assessment of the soft tissue contour ad-jacent to the implant, and radiographic measurementsof the first bone to implant contact were made at thefollowing time-points: permanent prosthesis delivery,6 and 12 months after loading respectively. The lo-wer corner of straight cylinder portion of the implantwas used as a reference point for radiographic mea-surements (Fig. 6).The first bone to implant contact was recorded abo-ve or below the reference point. Digital radio-graphs were obtained and viewed on a liquid crystaldisplay computer screen using a scanner. Each ra-

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Figure 3

Figure 6

Figure 5

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diograph was analysed by a software and measure-ment made by a dedicated software (Digora, Sore-dex, Helsinki, Finland). Measurements were obtai-ned on both the mesial and the distal aspect of eachimplant.Concerning implants distribution for position andtype, they are depicted in Table 1. A total of 15 inter-implant embrasure spaces wereexamined.

Results

All implants were stable and successfully in functionat one year follow-up resulting in 100% cumulati-ve survival rate (Table 2).Radiographic data: marginal bone level at implantplacement and 6 and 12 months after loading areshown as average (mesial + distal /2) in Table 3.Table 4 depicts marginal bone remodelling after 6

and 12 months from loading always expressed as ave-rage (mesial + distal / 2).Compared to another study (36), radiographic resultsat follow-ups time of the present study show bonelevels above the reference point at a higher percen-tage.In most of the cases the new technique was consi-stent for inter-implant papilla reconstruction. Out ofthe 15 embrasure spaces analysed, 100% showed pa-pilla reconstruction at first prosthesis insertion,only 2 (13.3%) failed to maintain inter-implant pa-pillae after a 6 months follow-up period and 3 (20%)after 12 months of follow-up time. Notably papillareconstruction was also achieved and maintained fora 12 months follow-up period, in the mesial and di-stal embrasure spaces of the flat platform Nobel Re-place implant positioned between two other NobelPerfect scalloped implants.It was observed that the smaller was the bone re-modelling the longer the papilla occurred.

Table 1 Table f the signs and symptoms of the patient group before therapy T0.

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Clearly, in patients showing unfavourable interarchrelationship, where oral-implant rehabilitations withlong prosthetic crowns were needed, papillae ful-ly filling the interdental embrasure spaces were notachieved according to the statement that the avera-ge height of tissue from the crest of bone to the topof the papilla between adjacent implants is 3,4 mm(2) (Figs. 7, 8 e 9: clinical cases at 1 year follow-up).

Discussion

The difficulty of reforming a papilla between two im-plants has been related to the fact that flat platform

implants place the biologic width subcrestally andapically to the implant-abutment connection (12). Onthe contrary in natural healthy dentition the biolo-gic width always creates supracrestally and bone peakthat exists between an implant and a tooth or two ad-jacent teeth is supportive of the papilla (2). Thus, alternate implant design supportive for bonepeaks and gingival papillae have been advocated (2)and bone augmentation procedures before placingtwo adjacent implants in the esthetic zone has beensuggested (2); Grunder et al. (37) confirmed thatmost cases of aesthetics need bone augmentationprocedures on the buccal aspect and interproximalarea of implants; Grossberg (4) considered bone andsoft tissue augmentation procedures the most suc-

Table 2 - Table f the signs and symptoms of the patient group before therapy T0.

Table 3 - Table f the signs and symptoms of the patient group before therapy T0.

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cessful method of achieving an aesthetic outcome.Wohrle proposed to adopt guided bone regenerationprocedures to create a peak of bone between twoscalloped implants (34), but these procedures are de-pendent on clinician’s skill and could be very un-predictable due to variable bone reabsorption (38).This augmented bone would then need to be main-

tained by placing the implants at least 3 mm apart(15). In this specific study, in case of scanty of spa-ce (1 patient, 2 embrasures spaces), it was impos-sible to insert all of the implants 3 mm apart, becausethe narrowest implant had a 4,3 mm diameter at thehead portion. As a consequence more bone remo-delling and less papillae reconstruction were ex-pected and noted.Implants with narrower heads may be necessary forcertain clinical cases. It should now be emphasized that vestibular osse-ous plate preservation was not taken into conside-ration in this study, undercontour of the labial

Table 4 - Table f the signs and symptoms of the patient group before therapy T0.

Figure 7

Figure 8

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emergence profile of the prosthetic restoration wasnot performed and the platform shifting concept wasnot applied in this particular study. Moreover, if bone and soft tissue augmentation pro-cedures had been applied in order to vertically in-crement the sites undergoing implant therapy, a morefavourable interarch relationship would have beenobtained and, probably, better inter-implant papil-lae reconstruction.For the reason of significant crestal bone loss thatoccurs following abutment loosening and tightening(39-41), implants were not provisionalized and fi-nal prosthesis was delivered without temporary pro-sthesis with no soft tissue conditioning. Another consideration is that the second techniqueassociated osteotomies (BLO: buccal-lingual osteo-tomy or BPO: buccal-palatal osteotomy) were per-formed by using a round bur not calibrated to the headof the scalloped implant intended to be used, becausenot already available at the moment of the placementof these implants. More traumatic drilling may haveled to more bone loss. More precise and dedicatedinstruments would now be needed for the new sur-gical procedure.The surgical technique presented in this study, in-terproximally, puts the bone level higher, with os-seous falls in midfacial and midlingual positions.From a clinical stand point this means that, in the ear-

ly phase of healing, there is better inter-implant softtissue support compared to flat platform implants.A one stage surgical approach might have probablyfurther limited marginal bone remodelling. When papillae are lost, regeneration may also dependon the inability of the cells present in the surroun-ding marginal gingiva to recapitulate the specific phe-notypic properties of the interdental papilla cells (42).However, it should be emphasized that it was ex-pected only 3,4 mm on an average of vertical distancefrom the crest of bone to the height of the inter-im-plant papilla (2).In some clinical cases the muco-gingival junctionshifted to a new more palatal position, where morekeratinized tissue was present, with better estheticsof the papillae on the palatal aspect. This was dueto bone reabsorption modalities and soft tissuemodifications of the maxilla (43).In the past decades, sophisticated periodontal sur-gical procedures (13,44-49) have obtained aesthe-tic but illusive (4) inter-implant papillae with pseu-do-pocket formation around implants (8), especial-ly in the interproximal areas.Thus, in cases of optimal clinical results, crown mar-gins equidistant from osseous structures and a 360°constant biologic width around the entire circum-ferences of scalloped implants, placed in combina-tion of the above presented technique, may reduceexcess of cement in the inter-implant areas as ad-vocated by some authors (32,50), prevent pseudo-pocket formation around implants which is a risk asstated by Choquet et al. (8), and lead to better pla-que control by the patient and by the hygienist, re-ducing the possibilities to develop periodontal di-sease. These findings also lead to the clinical con-sideration that the regeneration of a certain amountof inter-implant papilla in flat ridges, may have po-sitive effects on speech and decreases food impac-tion in the posterior as well as in the anterior areas.

Conclusions

The preliminary results of this study seem to sug-gest that the combination of the use of adjacent scal-loped implants with a novel surgical approach, evenin reabsorbed ridge with flat anatomy, may reform

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inter-implant bone peaks supportive for papillae andlower buccal and lingual crests and gingival margins. Further research is needed to confirm the validityof this new surgical technique for the reconstructionof the inter-implant papilla in flat ridge anatomy.

AcknowledgementsThis study has been partially financed by Nobel Bio-care, AB, Göteborg, Sweden.

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Correspondence to:Dott. Riccardo TizzoniVia San Barnaba, 30

Tel/fax: ++39-02-551-91-681E-mail: tizzoni.med@libero.it

20122 Milan, Italy

© CIC

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