A Focus on Soft Tissue in Dental Implantology

Most of the focus in the early dental implant literature is on the bone to titanium interface because a successful Osseo integrated implant requires direct bone contact to the implant surface. The importance of soft tissue in the ability of dental implants to restore function and esthetics has often been underestimated. This paper reviews the pertinent literature on soft tissue healing and management in partially edentulous dental implant patients. Patients seek treatment to replace missing teeth and to improve comfort, function and/or esthetics. Healing around dental implants is affected by the patient’s health, soft and hard tissue contours, and the use and care of the prosthesis, surgical augmentation and placement, and the design of the definitive prosthesis. Several surgical and non-surgical procedures have been proposed to treat the soft tissue deformities in the interproximal areas. This review also discusses the interdental papilla and various approaches to preserve and restore the same. Most of the research was based on scientifically legitimate sources of information obtained from primary literature, other appropriate technical references and searching using various online resources.     

Interdental papilla management: a review and classification of the therapeutic approaches

Several reasons contribute to the loss of interdental papillae and the establishment of "black triangles" between teeth. The most common reason in the adult population is loss of periodontal support because of plaque-associated lesions. However, abnormal tooth shape, improper contours of prosthetic restorations, and traumatic oral hygiene procedures may also negatively influence the outline of the interdental soft tissues. Several surgical and nonsurgical techniques have been proposed to treat soft tissue deformities and manage the interproximal space. The nonsurgical approaches (orthodontic, prosthetic, and restorative procedures) modify the interproximal space, thereby inducing modifications to the soft tissues. The surgical techniques aim to recontour, preserve, or reconstruct the soft tissue between teeth and implants. This review categorizes the various approaches in different clinical situations.     

Scalloped dental implants: a retrospective analysis of radiographic and clinical outcomes of 17 NobelPerfect implants in 6 patients

Background: The scalloped dental implant (NobelPerfect^TM, Nobel Biocare, Yorba Linda, CA, USA) is designed to biologically guide and facilitate interproximal bone remodeling during healing and to maintain bone height and papillae during functional loading. The design features of the scalloped implant include hard and soft tissue apposition areas, which are parallel to each other and mirror the cementoenamel junction. The hard tissue surface area is intended for osseointegration. The soft tissue surface area is meant to support the connective tissue zone and to provide a space for the subgingival margin of the restoration. Current literature on the clinical performance of the scalloped dental implant is limited. Purpose: The aim of this study was to evaluate whether the scalloped dental implant maintains interproximal bone and the overlying soft tissue. Materials and Methods: Radiographs for six patients (mean age 40.5 years) treated with 17 implants (NobelPerfect) were reviewed for an 18‐month follow‐up evaluation of bone response. Orthodontic movement and/or autogenous bone augmentation had been provided to obtain the best possible soft and hard tissue dimensions prior to implant placement. A surgical guide was used for an optimal implant placement. No surgical flap was reflected, and implants were placed a minimum of 2 mm and a maximum of 3 mm apical (midbuccally) to the most apical portion of the surgical guide. Final optimal rotational alignment was achieved in all cases by not exceeding 45 Ncm. Implants were immediately restored with provisional crowns. Photographic documentation provided the basis for analysis of papillary response. Radiographic change in the interproximal bone level was obtained by computer analysis (ImageJ for Windows, National Institutes of Health, Bethesda, MD) by measuring the distance from the interproximal shoulder of the scalloped implant to the crest of the bone. Results: When the scalloped implants were placed adjacent to existing natural dentition, the average bone level at placement and at 6, 12, and 18 months was ?1.7, ?3.5, ?3.8, and ?3.9 mm, respectively, compared with ?1.0, ?3.6, ?4.3, and ?4.4 mm respectively, when placed adjacent to other scalloped implants. Papillae formation exhibited no differences from the configuration that typically results after placement of conventional dental implants. Moreover, bone loss around the scalloped implants was notably greater than that expected after traditional implant placement. Conclusion: This chart review of 17 scalloped implants, followed for 18 months, determined that the scalloped implant design resulted in bone loss that was more severe than that associated with properly placed conventional dental implants. Further, the design showed no evidence of exceptional capacity to increase or maintain soft tissue height.     

Effect of Implant Position on Implant Restoration Design

SUMMARY
Preoperative discussions among the surgeon, restorative dentist, and the laboratory technician determine exact implant locations based on availability of supporting bone, the size of the tooth being replaced, prosthetic components to be used, and the interproximal soft tissue considerations. Once the ideal location has been determined, a surgical stent is constructed to provide a guide for the surgeon to position the implant in the best prosthetic position for maximum esthetic results.     

Influence of flap design on peri-implant interproximal crestal bone loss around single-tooth implants

The anterior maxilla represents a therapeutic challenge for single-tooth replacement with implants. The surgical trauma delivered to soft and hard tissues during implant placement can influence the future esthetic result. The clinician should use surgical techniques that prevent esthetic complications, such as increased crown length or loss of interdental papillae, without compromising osseointegration. This prospective study investigated the interproximal crestal bone loss occurring after placement of single-tooth implants using 2 different flap designs: a widely mobilized flap design that included papillae, and a limited flap design that protected papillae. The interproximal crestal bone loss was of practical importance and statistically significantly less following the use of a limited flap design versus the widely mobilized flap procedure.     

Comparison of applying particulate demineralized bone matrix (DBM), putty DBM and open flap debridement in periodontal horizontal bone defects. A 12-month longitudinal, multi-centre, triple-blind, split-mouth, randomized, controlled clinical study. Part 2 – evaluation of the interdental soft tissue

Summary To date, there have been many studies clinically evaluating periodontal regenerative procedures by the help of routinely used hard and soft tissue parameters; however, these parameters are not capable of assessing interdental soft tissue located above the regenerative periodontal surgery area. The purpose of this study was to assess interproximal soft tissue changes following application of (i) particulate form demineralized bone matrix (DBM), (ii) putty form DBM and (ii) open flap debridement (OFD, control), using modified curtain technique in the treatment of interproximal suprabony (horizontal) defects located in anterior maxillary region, as previously reported. Twenty‐five chronic periodontitis patients with 125 interproximal surgery sites (radiologically ≥4 mm horizontal bone defect) were also participate in this second stage of the triple‐blind, split mouth, randomized, controlled clinical trial. Surgery sites were assessed by (i) plaque index (PI), (ii) gingival index (GI), (iii) the presence of interdental soft tissue clefts or craters and (iv) the loss of interdental papilla height by using papilla presence index (PPI), during the healing period. At the baseline and 3, 6, 9 and 12 months after the operations, these measurements were repeated. In all groups, there is a significant increase in the prevalence of soft tissue cleft and crater formation (P < 0·01), with increase in PI and GI scores at interdental soft tissue defect areas (P < 0·001), 3 months after the operations. There was also an increase in PPI scores after the operations in all treatment groups (P < 0·01). Three procedures affected the interproximal soft tissues similarly. There was no significant difference among groups in terms of all parameters (P > 0·05). Particulate DBM, putty DBM and OFD demostrated similar interproximal soft tissue changes especially increasing interproximal PI and GI scores in 3 months follow‐up.     

Peri-implant tissue and radiographic bone levels in the immediately restored single-tooth implant: a retrospective analysis

BACKGROUND: The purpose of this study was to compare and evaluate bone and soft tissue levels in immediately restored single implants positioned in the esthetic anterior region. METHODS: Forty-five patients requiring single-implant crowns in the anterior region received 52 implants, which were restored immediately. Periapical radiographs and digital images of 368 interproximal sites were taken during regular follow-ups from 24 to 72 months after surgery. The interproximal papilla was assessed and compared to the distances between the bone crest and the contact point between the natural teeth and the restoration crown. RESULTS: Bone loss in the bone peak was statistically significantly greater in the postextraction sockets compared to the healed sites. No significant correlation was found between bone loss and papilla presence. The interproximal papilla showed average growth and decreased, in percentage terms, when the distance between the bone crest and the contact point between the tooth and the restoration crown was >7 mm. CONCLUSIONS: In the interproximal area between the implant and the natural tooth, the papilla does not seem to be affected by the peri-implant bone loss. The contact point between the natural tooth and the restoration crown should be < or =7 mm from the bone peak. Immediate restoration did not seem to cause a greater average amount of bone loss compared to that reported previously for one- and two-stage surgical procedures after the first year of function.     

Evaluation of the Esthetic Results of 64 Nonfunctional Immediately Loaded Postextraction Implants in the Maxilla: Correlation between Interproximal Alveolar Crest and Soft Tissues at 3 Years of Follow‐Up

Purpose: Many authors have emphasized that immediate loading protocols enable better esthetic results to be achieved compared with delayed loading, especially in the case of postextraction implants that are capable of maintaining the original esthetics of soft tissues. The aim of this study was to establish correlations between the interproximal crest, interproximal papilla, and marginal facial gingiva of immediately loaded postextraction implants by evaluating clinical and radiographic data. Materials and Methods: Fifty‐eight consecutive patients underwent a tooth extraction and immediate implant placement with 64 postextraction implants, which were immediately loaded using a provisional single crown from June 2005 to December 2006. At 6 months after surgery, all implants were restored with a definitive single crown. Clinical and radiographic data were recorded at the time of surgery, at the time of definitive restoration, and after 3 years of functioning, in order to evaluate soft tissues esthetics and bone tissue condition. Statistical analysis was used to assess significant correlations between the interproximal crest, interproximal papilla, and marginal facial gingiva (p = 0.05). Results: After 3 years of functioning, the implant success rate was 100% because no implants had failed. All parameters were stable and steady during the 3‐year follow‐up. The regression test revealed a statistically significant correlation between interproximal crest levels and interproximal papilla volume (p = 0.0134), and also between interproximal crest levels and marginal gingiva levels (p = 0.0226). Conclusions: Postextraction immediately loaded implants represent a predictable technique that should be considered the treatment of choice in cases of single anterior tooth restoration and other cases. Esthetic results seem to depend on correct positioning of the implants, considering the correlation between bone tissue and related soft tissues. Maintaining the original condition of both bone and soft tissues around the tooth to be removed is the key to obtaining optimal esthetic outcomes.     

Tissue preservation and maintenance of optimum esthetics: a clinical report

Today, most tooth replacement in the esthetic zone is done using implants placed in a delayed surgical protocol. Unfortunately, this delay can result in loss of both hard and soft tissue during the healing period, necessitating guided tissue regeneration techniques at the time of implant placement. Recent developments with tapered implants have facilitated predictable immediate implant placement, preserving the osseous structure surrounding the socket. Further developments with custom healing abutments can preserve the crestal soft tissues, including the papillae. This article reviews techniques that provide for the preservation of both bone and soft tissue while enhancing the esthetic results around implants.     

Interproximal space recovery using an orthodontic elastic separator before prosthetic restoration: a case report

The presence of a dental contact point is essential to maintain normal occlusion and to preserve the health of periodontal structures. Occasionally dental caries could compromise the interproximal contact point, leading to migration of the adjacent teeth with consequent retention of food, gingival inflammation, pocket formation, bone loss and dental mobility. In order to achieve an adequate restorative treatment, reestablishment of interproximal space is necessary. This report describes the interproximal space recovery between the maxillary first and second molars of a 45-year-old female patient before tooth reconstruction. In this case, an orthodontic elastic separator was indicated as an alternative to fixed orthodontic appliances in order to recover the necessary space. The technique was proven efficient, effective, economical, easy to perform and, above all, less invasive than other methods. The interproximal space was regained and a ceramic onlay was cemented for restoring the maxillary second molar. Periodical clinical and radiographic follow-up should be maintained to ensure long-term success.     

Single implant-supported restorations in the anterior maxilla

Achieving functional and esthetic implant-supported single-tooth restorations in the anterior region of the maxilla can be particularly challenging. Insufficient hard tissue can preclude proper implant positioning, while inadequately treated soft tissue will not exhibit a gingival appearance similar to that of the adjacent teeth. The aims of this article are to analyze the different clinical possibilities (standard and compromised situations) for implant-supported single-tooth restorations in the anterior zone and highlight the importance of knowing the biologic, anatomic, surgical, and prosthetic concepts, particularly the interproximal bone height of adjacent teeth, in the prognosis and predictability of achieving an esthetic result.     

Reconstruction of the interdental papilla with an underlying subepithelial connective tissue graft: technical considerations and case reports

This article introduces a surgical technique developed to achieve soft tissue augmentation of the interproximal space. The technique was designed to minimize surgical trauma and blockage of blood supply to the existing papilla by accessing the papillary area through vertical incisions and by elevating a single full-thickness flap without disrupting the papillary bridge. A free connective tissue graft was placed beneath the undermined papilla and secured with sutures. Advantages and variations of the technique are discussed.     

Evaluation of guided tissue regeneration in interproximal defects

Abstract This study clinically evaluates the use of expanded polytetrafluoroethylene (ePTFE) membranes with or without the addition of decalcified freeze-dried hone allograft (DFDBA) in the treatment of interproximal intraosseous defects, 25 patients (26 paired defects) diagnosed with advanced periodontitis and having at least 2 bilateral interproximal probing depths of s6 mm participated in the study. After the hygiene phase, measurements were made to determine soft tissue recession, pocket depth, and clinical attachment levels. Defects from each pair were randomly treated with either ePTFE alone (control), or ePTFE + DFDBA (experimental). Measurements were made during the surgery to determine crestal resorption, defect resolution and defect fill. Membranes were removed at 4 to 6 weeks. At 6 months, the soft and hard tissue measurements (surgical reentry) were repeated. Both groups showed statistically significant improvement when compared to baseline (p<0.001), but no difference was determined between groups. Control sites showed a 50% bone fill and experimental sites had 54% bone fill. The defect resolution changes were also similar between control and experimental groups, respectively (80%, 74%). For this short-term study, it was concluded that either technique was beneficial for the treatment of intraosseous defects. Other studies are needed to assess the long-term stability of the improvements rendered by these treatments.     

Human histologic evaluation of a bovine-derived bone xenograft in the treatment of periodontal osseous defects

This study evaluated a bovine-derived bone xenograft (Bio-Oss) in the treatment of human periodontal osseous defects. Four patients with at least one tooth that had been recommended for extraction because of interproximal advanced periodontal disease volunteered to participate. The surgical procedure consisted of flap reflection, soft tissue debridement, placing a notch in calculus as a histologic reference point, root planing, placement of the bovine-derived xenograft and a bioresorbable physical barrier, and flap closure. Patients were seen every 2 weeks for plaque control and any necessary adjunctive treatment. At 4 to 6 months postsurgery, 6 teeth, along with the adjacent graft site, were removed en bloc. Histologic observations demonstrated new bone, new cementum, and new periodontal ligament coronal to the reference notch in 3 of the 4 specimens. This study indicates that periodontal regeneration is possible following grafting with a bovine-derived xenograft.     

Effects of the multiple-piece maxillary osteotomy on the periodontium

Clinical indications exist for both the surgically assisted rapid maxillary expansion (SARME) and the multiple-piece maxillary osteotomy (MPMO). Recent trends, however, imply that the SARME combined with a subsequent 1-piece osteotomy can supplant the use of the MPMO. Those favoring the SARME frequently site morbidities associated with the MPMO. Major reported complications include loss of dentoalveolar segments, teeth, and oronasal or oroantral communication. Relapse, tooth devitalization, and damage to the periodontium, including bone loss and soft tissue alteration, comprise the minor morbidities. If these can be avoided or minimized, then the use of the MPMO for its inherent advantages over the SARME in certain clinical situations may be indicated The purpose of our study was to critically evaluate the periodontium following the use of the MPMO to ascertain if minor morbidities are inherent to the procedure, and to quantify them. Records of 24 MPMO patients were reviewed, ranging from 3 to 24 months after surgery. A specific surgical technique was utilized for all patients, including bone grafting. The vertical segmental osteotomy sites varied and were recorded for comparison. Periodontal probing depths at the segmental osteotomy sites were compared with the adjacent interproximal spaces of each patient. Independent dental examiners were used to review photographs and periapical radiographs to compare the papillae and alveolar bone height, respectively, at the osteotomy site versus the neighboring interproximal areas. A paired t test was used to compare probing depth measurements at the vertical osteotomy site and neighboring interproximal sites. The mean difference between these two sites was 0.01 mm with a standard deviation of 0.25 mm. This was not statistically significant. Statistical analyses were also performed to compare these probing depth differences at varying sites in the maxilla, and to compare probing depth differences to gender, total number of osteotomies performed on each patient, estimated blood loss, and length of procedure. These results were not statistically significant. Independent examiners found no difference in gingival architecture or alveolar bone levels when comparing vertical osteotomy sites to neighboring interproximal sites. This study showed that damage to the periodontium at vertical osteotomy sites was minimal, and not a reason to avoid use of the multiple-piece maxillary osteotomy.     

Dimension of interproximal soft tissue between adjacent implants in two distinctive implant systems

BACKGROUND: The purpose of this study was to compare the dimension of interproximal soft tissue between adjacent implants in distinctive implant systems. METHODS: This study involved 85 interproximal papillae between two adjacent implants in 50 patients who had implants placed adjacent to each other and who had prosthesis in place for longer than 1 year. The shortest distance between the radiopaque material on the tip of interimplant papilla and the most coronal portion of the interimplant crestal bone was measured (radiographic length of papilla [RL]). The horizontal distance (HD) between the two adjacent implants was measured at the fixture-abutment interface level. Considering the possible effect of interimplant crestal bone resorption on closely implanted sites, HDs were divided into two categories: HD <3 and >or=3 mm. The Mann-Whitney test was performed to find the difference in the dimension of interimplant papilla. RESULTS: In cases of HD <3 mm, RL did not differ statistically in both systems. Also, in cases of HD >3 mm, RL did not show a statistically significant difference in both systems. CONCLUSION: Both systems had similar dimensions of interproximal soft tissue between adjacent implants, irrespective of the horizontal distance of the fixture.     

Comparison of interproximal soft tissue height for single implants and contra-lateral natural teeth

Objective: To compare the interproximal soft tissue dimensions adjacent to single implant restorations in the premolar–molar position with those adjacent to the contra-lateral natural teeth.
Material and methods: Twenty-five patients with a single-tooth implant in premolar–molar position and healthy contra-lateral teeth were enrolled in this retrospective cross-sectional study. The reason for the extraction was periodontitis. Radiographs were used to measure the shortest distance from the tip of the papilla to the crestal bone in single implants and contra-lateral teeth. A Wilcoxon's signed-ranks test was used to examine the differences between the interproximal soft tissue dimensions adjacent to the single-tooth implant restorations (IS-STI) from those of the contra-lateral natural teeth (IS-NT).
Results: We found no significant difference between the mesial IS-STI and the mesial IS-NT (3.28±0.83/3.31±0.62; P =0.861), or between the distal IS-STI and the distal IS-NT (3.09±0.72/3.3±0.63; P =0.263).
Conclusions: The interproximal soft tissue height adjacent to single-implant-supported restorations in the premolar–molar position is similar to that adjacent to the contra-lateral natural teeth.     

Surgical and prosthetic management of interproximal region with single-implant restorations: 1-year prospective study

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 < or =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.