How can I promote esthetic papilla formation between adjacent implant-supported restorations on upper anterior teeth?

The following verbatim question was submitted by a practising dentist: My patient had implants to replace 11 and 21. I have placed contoured healing abutments and temporary crowns with the contact 4-5 mm above the bone (2 mm gingiva and 2 mm space). These have been in place 4 months and although the papilla has filled in between the laterals, the tissues are still flat between the 11 and 21 despite the fact that a periodontist placed the implants doing a graft to “bulk up”   the tissue. The patient is not overly concerned; however, you can see the area when he smiles, so I would like to improve the situation. Any suggestions?

Dr. Gordon Schwartz  from GumDocs provided these initial comments for consideration:

The replacement of two adjacent anterior teeth is one of the greater challenges in implant dentistry. The loss of the teeth can result in the loss of the bone and a change in the osseous architecture underlying the soft tissues. In particular, when two implants are placed beside each other, there can be an incompetence of the papilla which can compromise the esthetic results. Ideally, these cases should be treatment planned with care so that expectations are realistic and the therapies strategized to maximize results. We hope that this blog post will help provide a framework for discussing the relevant factors in determining what esthetic result can be reasonably expected, how to direct treatment towards the best possible result and what options to consider when the result is not what was desired. Many consider two studies by Dr. Dennis Tarnow (links to references below) to provide the framework for this approach (although the results may differ with present-day implants which are superior in many ways pertinent to the issues under discussion here).

Important Biologic Factors to consider are

Lip line: Some people show a lot of gingiva when they smile whereas others don’t even show teeth. The more the papilla and gingiva are shown, the more cautious and concerned we need to be (some patients however will still be concerned even if their gingiva is not visible).

Bio type: Many feel that thinner tissues are more prone to recession and loss of volume after any manipulation. In these patients, post extraction recession may be unpredictable and greater than hoped for.

Papilla height and shape: The greater the height of the adjacent papilla and the more acute the triangular form, the harder it will be to recreate. Shorter, flatter papillae are easier to replicate and blend in to. Generally, it is felt that we will not get a papilla height that is much greater than 5 mm from the height of bone.

Form of adjacent teeth: The shape of the dentition to be replaced is usually influenced by the adjacent maxillary anterior teeth.  The more apical the contact point between teeth (usually more squarely shaped teeth) the easier it will be to recreate a papilla. (There can be interplay between papilla height and tooth shape)   The converse is also true. According to Dr. Tarnow’s work, if the implants are placed 3 mm apart the soft tissue may reach a contact point 5 mm away.

Bone levels: The amount of bone remaining after the extraction is an important prognostic indicator. We might not be able to determine the bone height (and thus the final result) until the area has healed.

Width of edentulous space: It was determined that a minimum of 3 mm is needed between two implants in order to support some form of a papilla.

Occlusion: At times, it is suggested that the use of one implant with a cantilever be considered, in this case, the occlusal scheme and forces must be amenable to it.  At other times, narrower implants are an option and this cannot be used if the occlusal forces are too great.

Amount of soft tissue in edentulous site: If the remaining tissue is thin, ridge augmentation can be considered as well. There are, however, limitations to the predictability and how much tissue height can be attained. As well, grafting is ideally performed before implants are placed. It is harder to gain height once implants are in, harder still when healing caps or crowns are present.

Relevant treatment considerations 

Implant type: Sometimes, in order to assure that there is an adequate width of bone between implants a narrower implant may be considered. Most companies offer this option and some types can tolerate greater forces.

Implant placement: As in all esthetic cases it is necessary to place the implants at least 2 mm apical to the CEJ of adjacent teeth. As a general rule, there is greater risk in placing implants too much towards the buccal and implants emerging towards the cingulum might facilitate restoration.

Bone grafting and socket preservation: Ideally performed when teeth are extracted but bone width can also be expanded during implant placement or as a separate procedure.

Gingivally colored porcelain: Can be used to fill in edentulous areas not filled in, however, it is still does not look ideal and it is much harder to clean.

Don’t brush or floss: Obviously a controversial issue, however, inflammation can cause a slight swelling and increase in soft tissue volume. The effects of this on bone and the extent of inflammation must be monitored and evaluated. The bad news is that this is so anathema to our concept of oral health, thus it is difficult to justify.  The “good” news is that most patients don’t clean well enough anyway and it may simply occur organically. Wait: Time may work on your side. Gingiva need some time to react to their environment and so things might improve a bit.

The Nasopalatine canal: Sometimes, this can limit where you can place the implants supporting the central incisors.

Removal of adjacent teeth: This is also a less-than-ideal solution but if neighboring teeth are compromised or if a remaining root is small, it might be acceptable to remove them and place a three or four unit bridge. There is little additional cost to this and the bridge might look better.

Cantilever: This was suggested as a good alternative in one of the reports by Dr. Tarnow. At times, there can be an advantage to this as there is a better chance to get some ridge augmentation under the pontic, as opposed to between two implants. The lateral incisor, which is often involved, is generally, a small rooted tooth that does not receive much force.  In these cases, however, the occlusal forces must be assessed and a night guard is likely indicated. Many practitioners are hesitant to offer this.

Ovate Pontics and the converse: Some feel that ovate pontics allow them to better form the tissues.  They are not difficult to fabricate on a denture.  Care must be taken, however, not to have replacement denture teeth that compress too much tissue and reduce its volume.

Temporization: At times it might be advantageous to place temporary crowns on implants prior to restoring them permanently. This would allow both the dentist and the patient to assess the anticipated final result.

Two-stage surgeries: Sometimes using a second stage to uncover implants allows a better control of the tissues at the time of placing crowns.  Newer implants which switch platforms tend to use smaller healing caps and so this is becoming less necessary.  It still provides an extra step to add grafting if desired. In summary, patients and dentists need to know the factors that work for an ideal result and those that may compromise it.

References:

Vertical Distance from the Crest of  Bone to the Height of  the Interproximal Papilla Between Adjacent Implants. Tarnow et al.  J. Periodontol. 2003: 74;1785-1788.

The effect of inter-implant distance on the height of inter-implant bone crest.  Tarnow et al.  J. Periodontol. 2000: 71:546-549

By clicking on the links to these two references, you will get to the Medline abstracts of these articles. In the top right hand corner of each abstract, you will see a blue button that will get you to how you can the retrieve the article in question.

Follow-up: What further information would you like on this topic? Email us at jcdaoasis@cda-adc.ca

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