The International Journai of Periodonfics & Restorative Dentistry

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Regeneration of Gingival PapillaeAfter Single-Implant Treatment

JoTsten Jemt DDS, PhD'

An index to assess the size of the inferproximal gingivai papiiiae adjacentto single implant restorations was described and preliminary tested in opilot study of retrospective material comprising 25 crowns in 21 patients.The result indicated a significont spontaneous regenerotion of papillae(P < .001) after a mean fotlaw-up period of i.5 years. Bosed on theseresuits, the general conclusion was made thaf the proposed index allowsscientific assessment of soft tissue contour adjacent to singie-impiantrestorations. The results aiso indicated fhot soft tissue changed in a system-atic manner during the time period between insertion of the crowns andfoilow-up 1 fo 3 years later (IntJ Periodont Rest Dent 1997:17:327-333.)

•Associate Rrotessor,The Branemork Ciinio, Göteborg, Sweaen.

Reprint requests: Dr Torsten Jemt, Ttie Brânemark Clinic, RublicDentol Healtti, Medicinaregatan 12 C,S-413 90 Göteborg,Sweden.

The tirst single-crown restorationsupported by Brônemark im-plants (Nobei Biooare) waspiaced in December 1982,'"^The foiiowing years of deveiop-ment of the single-implant tech-nique focused on mechanicaland esthetic probiems asso-ciated with the abutmentcomponents. Accordingly, thesubgingivai singie-impiant abut-ment technique was tested thefoiiowing year,' thereby present-ing a technical solution forpiacement of the margin of thecrown in a controlled reiation tothe sott tissue morgin. Morerecent interest in the single-implant technique has focusedon different surgical proceduresfor restoring the aiveoiar crestand managing the soft tissuecontour adjacent ta the restora-tions. Severai techniques havedescribed the design of fhe sur-gicai flaps to minimize soft tissuerecession and to aiiow optimalheaiing of the papiiiae.""' How-ever, although the problem withinodequate papiiiae has beenidentified and extensively dis-

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cussed, data is lacking on thefrequency and extent of reces-sion ot papulae in routine singie-impiant treatment.

The objective of the presentstudy was to propose an indexto clinically evaiuate thedegree of recession and regen-eration of papiliae adjacent tcsingie-implant restorotions, andto test this proposed index in apiiot study for assessment of thesoft tissue at the time of crowninsertion and during foiiow-up.

Metiiod and materials

Retrospective group

This report was designed as aretrospective study. Patientswere identitied according tothe criteria that they had beentreated with routine single-implant restorations and photo-graphically documented atthe time of crown inserfion, andthat photographs of the clini-cal result 1 to 3 years ioter wereavailable.

Twenty-one patients with amean foilow-up time of 1.5years (SD = 0.6 years) werefound that fit the criteria. Nineof ttie patients were male, andthe mean age of the groupwas 23.7 years (SD = 7,0 yeors)at the time of stage onesurgery. The age ranged from14to 42 yeors.

Four patients received twosingle impiants, and the remain-ing 17 patients received oneimplant eoch. Five of thecrowns piaced were centraiincisors, 13 were lateral incisors,three were canines, and fourwere premoiars. Two of the pre-molars were placed in man-dible, and the remaining 23crowns were placed in maxiilo.

Standard Brânemori< im-plants were inserted foiiowingroutine surgicai protocoi,^ Afterheaiing, ali implants were pro-vided with standard or healingabutments of various iengths.The top of the abutments wereplaced close to or above thesott tissue margin to aliowproper healing of the sott tissue.Atter healing ot the sott tissue, afinal impression was made usingthe impiant transfer coping(DCA 099, Nobei Biocare) orCeraOne (DCB 119, NobeiBiocare) technique. The perma-nent crowns were eventuallycemented to a singie-impiantabutment by meons of conven-fional zinc phosphate cement,^No special emphasis withregard to oral maintenancewas given in connection to thepiacement of the artificiaicrowns, ie, normal toothbrush-ing and possibiy gentle proxi-mal cleaning with dentai flosswas suggested.

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Papilla contour measurements

An index of fhe oonfour of theproximal papillae was made torassessment of fhe photographstaken at placement of fhe sin-gle crowns arid 1 fo 3 yeorsiater.

The index designated tiveditferent levels indicating theamount of popilla present. Theossessment was measured troma reference line through thehighest gingivai curvatures otthe crown restoration on thebuccal side and the adjacentpermanent tooth. The distancefrom this line to the contactpoint of the naturai tooth/crown wos aiso assessed (Fig 1):

1, Index score 0: No populo ispresent, and there is no indi-cation of a curvature of thesotf tissue contour adjacentto the single-impiont restora-tion (Figs 2a ond 2b),

2, Index score 1: Less thon haifof the height of the papilio ispresent, A convex curvatureot the soft tissue contourodjacent to the single-implant crown ond the adja-cent tooth is observed (Figs3a and 3b),

3, Index score 2: At least holfof the height of the papiliois present, but not all theway up to the contact pointbetween the teeth, Popiiio isnet completely in hormonywith the adjacent popiliae

between the permanentteeth. Acceptable soft tis-sue contour is in hormonywith adjacent teeth (Figs 4aand 4b),

4, index score 3: The popiiia fillsup the entire proximai spoceand is in good hormony withthe adjacent papillae. Thereis optimal sotf tissue contour(Figs 5c and 5b),

5. Index score 4: The papillaeore hyperplastic and covertoo much of the single-implant resforotion ond/orthe adjocent tooth. The sotftissue contour is more or lessirreguiar (Figs óa and ob).

Ottier soft fissue assessments

Discoioration of the soft tissueabove the restoration and visi-ble titonium margins were iden-titied OS present or not present.Signs of severe infiammation orfisfulas were also nofed.

A comparison was madebetween the situation at thetime of placement and atfoiiaw-up. The foilowing assess-ments of the photogrophs weremode: (I) The size of thepapilia was determined andclassified as having increased,remained the same, or beenreduced during the tollow-upperiod; and (2) a change ofcolor cf the soft tissue and/or avisibie titanium margin wasnofed.

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Fig I The index was based on themeasurement of a reference finethrough the highest curvafures of thecrown lestorafioh on fhe buccai sideand fhe adjacent permanent toofh.The distance from this tine to fhe con-tacf poinf of the teefh/crowns was alsoassessed, and half of the height of fhepapiiia was recorded.

Fig 2 Index score 0—No papiiia Is pre-sent and there is no indication of a cur-vafure of the soft fteue contour adja-cent fo the singie-lmpianf restorationCieft). left lateral incisor with Papillaindex score of O(right).

Fig 3 Index score ¡—Less than holt ofIhe heighf of the papiiia is preseht. Aconvex curvature of fhe soft tissue coh-tour adjacent to fhe singie-implanfcrown and fhe adjacenf foofh Isobserved (left). Right lateral incisor wifha mesiai Papilla Index scare of I (right)

Consistenoy of measurements Stofistioa! analysis Resuits

Assessments of papiliae con-tour were determined for the25 crowns on two separateoccasions with a time intervalof 11 days. The mean differ-ence between the two registra-tions of popiiiae contour indexwas 0.11 CSD = 0.53),

The sign test far paired cam-porisons^ was used to statisti-caliy test changes in thepapiiia contour index at piace-ment ond follow-up on themesial and distai side of the sin-gie-implant restoration. AP vaiue greater than .05 wasnot considered significant.

The index scares at the papillaeranged from 0 to 3 at the timeot placement and from 1 to 4at the follow-up appointment.Distribution of the score of theindex at placement and toiiow-up is presented in Tabie 1. Theincrease in size ot the papiiiaewas significant for both themesial (P < .001) and distaisides (P< .001),

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Fig 4 index score 2—Half or more ofthe height of the papiiia is present, butdoes not extend ail the way up to thecontact point between the teeth. Thepapiiia is nat campieteiy in harmonywith the adjacent papiiiae betweenthe permanent teeth <ieft). ieft centralincisor with a distal Papiiia index scoreof 2 (right).

Fig S index score 3—The papiiiae fiiiup the entire proximai space and are ingood harmony with the adjacentpapiiiae. Optimai soft tissue contour(ieft). Left mandibuiar tirst premolar withPapilla Index score of ,3 (right).

Fig 6 Index score 4—The papiiiae arehyperplosfic and covers too much otthe singie-implant restoration and/orthe adjacent tooth. The soft tissue con-tour is more or iess irreguiar (]eü). Rightcentrai incisor with a mesial papiiloshowing a minor hyperplasia with anindex scare 01̂ 4 (right).

The mean index for fhe sizeot the mesial ond distoi papii-iae at crown piocement vi/os1,44 (SD ^ 0.94) ond 1.52 (SD =0,70). respectiveiy The corre-sponding meon vaiues ot foi-low-up were 2.48 (SD = 0.70)and 2.46 (SD = 0.72) for themesiai and distai sides, respeo-tiveiy Ten percent of the papil-lae were judged to be in opti-mai harmony with the adjaoentpapillae (index score 3) at thetime of insertion (Table 1 ). Af the

Table 1 Distribution of Papula Index

Mesiai papi l laePlacementFoiiow-up

Distai papi l laePlacementFoliow-up

0

50

11

Papiiia Index score

1

73

121

2

105

1010

3

317

212

4

00

01

A signiflconl increose of the papilloe was found on both the mesiol(P< .001) ond distal (P< .001) sides.

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time of foliow-up, 29 papiiiae(58%) had recovered com-pietely (Table 1).

When the photographswere compared simuitane-ously the size of the papilla wasconsidered to have increasedin 40 sites in the toilow-upphotographs. The remaining 10papiiiae were considered tobe of the same size.

For four crowns, the soft tis-sue had become more dark/grey above the restorations.Furthermore, in two crowns softtissue recession had occurredto the ievei that the titaniummargin of fhe abufment wasexposed, while in anofher twocases tissue recession was obvi-ous, but no mefai was visibie.No fistulas or loose crownrestorations were noted in thisstudy.

Discussion

The resuits of the present studyoleariy indicate that papulaeadjacent to single-implantrestorations regenerate to someextent affer 1 to 3 years withoutany ciinical manipulation of thesoff tissue. The reason for thisspontaneous recovery of papil-lae is unclear, buf if may besuggesfed fhat plaque accu-muiafion in the proximal areascreates inflammation and sub-sequent swelling of the soft tis-sue analogous with findingsreported by Jemt et a l ' in maxii-lary overdenture situations. Thus,

in time the hyperpiastic, in-tlamed tissue would matureand reorganize into papillae. Itthis is the case, optimal clean-ing procedures with dental flossand interproximal brushesimmediateiy atter insertion ofsingie-impiant restorationswould counteract a regenera-tion ot the soft tissue contourand would thereby compro-mise the long-term estheticresuit of the treatment!

Ot course it is natural to aimfor a surgical and resforativeprocedure that allows tor opti-mai heaith of the hard and softtissue surrounding the implantrestoration. Accordingiy, theBrânemark system was devei-oped following a very strict sur-gical procedure with regard fotissue health. However, whenfhe soff tissue was allowed toheal after the second surgery,̂an obvious recession ot theproximai soff fissue seemed tooccur, and only a few sifuationspresented in this material hadoptimal papilla contour at thetime of crown placement (seeTable 1, index score 3). It is inlight ot these findings fhaf dif-ferent surgical techniques tooptimize the soft tissue contourshould be discussed.''"'' Manyof the proposed surgical tech-niques have indicated goodearly esthetic resuits in singieclinical cases, but the pre-dictabiiity of these results in oconsecutive series of casesand the absence of clinicalcontrois cali for more scientitic

research in this tield. The pre-sent index was designed topropose a simple technique toevaluate the degree ot reces-sion and regeneration of thesott tissue in the proximal areas.

On average, about haif ofthe height ot fhe papilla wasiost (mean index 1.5: Tabie 2) inthe present group when thesoft tissue was aiiowed to healoompletely around the tempo-rary abutment prior to crownfabrication. However, after 1 to3 years, a spontaneous regen-eration was observed, and amajority of the papillae (58%)were completely recoveredand in harmony with the adja-cent natural teeth (see Table1). This esthetic situation hasbeen demonstrated in ran-domiy seiected clinicai cases;however, it is not possible toevaluate when the regenera-tion was achieved in the pre-sent cases, A conservative sur-gicai technique that aims tomaintain fhe soft tissue contourwouid probobly allow a betterresult at the time of insertion,but in long-term assessment, aspontaneous adaptation ot thesoft tissue would probablycompensate tor some ot theachieved defects. A betterknowiedge of the clinical sifua-tions in which this spontaneoushealing will occur would beadvantageous.

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in addition to regenerationof the papiliae, other changesin the soft tissue adjacent to thesingle-implant restorations wereobserved, A tendency of reces-sion was indicated in associa-tion with some crowns; in twopatients the soft tissue recessionwas such that the titaniumcyiinder was exposed. It is notclear whether these exposuresoccurred because the abut-ment cyiinders thot were cho-sen were too iong, or becauseot other reasons, such as incor-rect tooth-brushing technique.However, the changes in thetopography ot the sott tissueadjacent to single-implantrestorations in the present studyclearly indicóte that the soft tis-sue contours at the timeof crown insertion shouid notbe expected to remain un-ohanged. On the contrary, adynomic adaptat ion andchange ot tissue topographymust be anticipated during thefoilow-up period. Based onthese resuits, the gênerai con-clusions con be made that theproposed index aiiows a scien-titic ossessment of soft tissuecontour adjacent to singie-implant restorotions and thatsoft tissue seems to change in asystematic way trom insertion ofthe crowns to follow-up 1 to 3years later.

Acitnowiedgments

The outhor wauld like to aoi<nowiedgeDr P Milieding for his heip with the fig-ures.

References

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2. Lekholm U, Jemt T, Principies for singietootn repiacement. in: Aibrektsson TZorb GA (eds). The BrânemorkOsseointegrated impiont. Chicogo:Quintessence, 1989.117-126.

3. Jemt T Lekhoim U, Grondohi K. A 3-yeor foliow-up study of eariy singie-implont restorations o d modumBrânemork. int J Periodont Rest Dent1990; 10:341-349.

A. isroeison H. Piemons JM, Dentalimpiants, regenerotive tecnniquesond periodontoi plostio surgery torestore maxiiiary onterior esthetics.int J Oroi Maxillofac Impionts 1993:8:555-561,

5. Andreosen JO, Kristerson L, Niison H,Dohiin K, Sohworti O. Poiocci Pet oi,impionfs in the anterior region. In:Andreasen JO, Andreasen FM (eds).Textbook and Colour Atlas ofTroumatic Injuries fo the Teeth.Copennagen. Munksgoard 1994;ohop 3,

6. Poioooi PPeri-impiant soft tissue man-ogement: Popula regenerotion teoh-nique in: Paiacci R Eriosson i,Engstrand P Rangert B (eds). Optimaiimplont Positioning and Soft TissueManogement for the BrânemarkSystem, Chioogo, Quintessence. 1995;59-70.

7. Beci<er W, Becker B. Fiap designs torminimizotion of recession adjacentto maxiiiary anterior impiont sites: Aoiinicai study. Int J Oroi Moxiiiofacimplants 1996:11:46-54,

8. Lehmon E.L, Nonporametr ics:Statisticai Methods Based on Ranks.New York: Holden-Day, 1975:120-123.

9. Jemt T, Book K. Lie A, Bcrjesson T,Mucosai topography oroundimpionts in edentuious upper jows,Photogrommetricthree-dimensionolmeosurements of the et tect ofreplaoement of removabie prosthe-sis with o fixed prosthesis. Ciin Oraiimplants Res 1994-5:220-228.

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