A controlled study on the accuracy and precision of intraoral radiography in assessing interproximal bone defect morphology around teeth and implants

PURPOSE

The primary objective of the present controlled study was to determine the accuracy and precision of intraoral radiography in assessing interproximal bone defect morphology in patients suffering from periodontal disease as well as in patients with peri-implantitis. A secondary objective was to evaluate the possible impact of clinical experience on accuracy and precision.

MATERIALS AND METHODS

The study sample comprised a total of 99 interproximal bony defects (40 patients) needing surgical treatment. Forty-nine defects were periodontal (17 patients), while the remaining 50 were peri-implant defects (23 patients). Following reflection of a mucoperiosteal flap and removal of granulation tissue, the type of bone defect as classified by Goldman and Cohen (1958) was determined. This intrasurgical registration was considered the true bone defect morphology. An intraoral radiograph was taken for each interproximal site. Twenty clinicians determined the bone defect morphology on each intraoral radiograph twice, with a washout period of 3 months.

RESULTS

Using the Goldman and Cohen (1958) classification, the overall accuracy of intraoral radiography in assessing interproximal bone defect morphology was slight for teeth/implants (κ = 0.132; 95% CI: 0.091 to 0.173/κ = 0.126; 95% CI: 0.091 to 0.162). Duplicate evaluation indicated fair precision (κ = 0.369; 95% CI: 0.308 to 0.430/κ = 0.355; 95% CI: 0.230 to 0.414). Pooling one-, two- and three-wall defects into one category had a positive impact on accuracy (κ = 0.254; 95% CI: 0.201 to 0.307/κ = 0.387; 95% CI: 0.340 to 0.435), as well as on precision (κ = 0.504; 95% CI: 0.423 to 0.584/κ = 0.560; 95% CI: 0.463 to 0.657). A significant difference between experienced clinicians and trainees was not found (P ≥ 0.285).

CONCLUSIONS

Intraoral radiography lacks accuracy for assessing interproximal bone defect morphology around teeth and implants. Clinical experience does not seem to influence this.

Competence profiles in undergraduate dental education: a comparison between theory and reality

Background

Competence profiles are purposed to provide a blueprint in support to develop and/or benchmark the learning outcomes of undergraduate dental curricula. This study aims to investigate whether a competence profile as proposed by academic- and clinical experts is able to represent the real clinical reality.

Methods

A questionnaire was developed including questions about gender and age, perception about required competences, and educational organisation and was distributed among Flemish dentists via email and on paper during a symposium. The data was analysed using descriptive statistics, Chi-square and non-parametric Mann-Whitney U-tests.

Results

A total of 312 questionnaires were completed (=6.5% of dentist population, with similar gender and age characteristics). All competences in the European competence profile were rated between 7.2 and 9.4 on a 10-point scale. In dentists under 50 years, females rated the importance of identifying/managing anxiety and abnormal patient behaviour; and promoting/improving oral health as significantly higher than males. In dentists of 50 years and above, females rated 8 competences significantly higher than males, including obtaining/recording a complete history; identifying/managing anxiety and abnormal patient behaviour; obtaining/interpreting radiography; identifying temporomandibular and associated disorders; identifying orthodontic needs; awareness of own limitations/when to refer; managing dental urgencies; and basic-life-support/defibrillation. Clinical practice management was most frequently reported as additional competence to address in dental education. Furthermore, the respondents suggested an undergraduate dental curriculum based on 34% theoretical education, 26% preclinical skills training, and 40% clinical education and 86% agreed with a duration of 5 years. Finally, the respondents also illustrated the dynamic nature of dentistry including a reduction of amalgam fillings, a shift from individual practice to group practices, an increased administrative load, and more assertive patients.

Conclusion

Findings in the present study suggest the validation of the proposed competences for graduating European dentists within the clinical reality of dental professionals in daily practice. Nevertheless, the results have also demonstrated heterogeneity regarding gender and age within the dentist population and emphasised a continuously evolving dental profession and required competences. Hence, to maintain high quality of dental care, a strategy should be developed in which dental curricula are continuously benchmarked against an evolving clinical reality.

Electronic supplementary material

The online version of this article (doi:10.1186/s12903-017-0403-4) contains supplementary material, which is available to authorized users.

The patient undergoing implant therapy. Summary and consensus statements. The 4th EAO Consensus Conference 2015

INTRODUCTION

The assignment for this working group was to update the existing knowledge regarding factors considered being of special relevance for the patient undergoing implant therapy. This included areas where conflicting opinions exists since long or recently has been expressed, like the role of antibiotic prophylaxis in dental implant surgery and peri-implantitis. Also areas with growing interest and concern such as patient-reported outcome measures (PROMs) and health-economy was included in this review.

MATERIALS AND METHODS

The literature in the respective areas of interest (antibiotic prophylaxis, peri-implantitis, patient-reported outcome measurements and health-economic aspects) was searched using different strategies for the different papers. Search strategies ranged from a complex systematic review to systematic- and narrative reviews, depending on subject and available literature. All collected material was critically reviewed. Four manuscripts were subsequently presented for group analysis and discussion and plenum discussions and concensus approval. The selected areas were considered to be of key importance and relevance for the patient undergoing implant therapy.

RESULTS

The results and conclusions of the review process are presented in the respective papers. The group's conclusions, identified knowledge gaps, directions for future research and concensus statements are presented in this article. The following reviews were available for group discussions and the foundation for subsequent plenary sessions: Lund B, Hultin M, Tranaeus S, Naimi-Akbar A, Klinge B. (2015) Perioperative antibiotics in conjunction with dental implant placement. A complex systematic review. Renvert S & Quirynen M. (2015) Risk indicators for peri-implantitis. A narrative review. De Bruyn H, Raes S, Matthys C, Cosyn J. (2015) The current use of patient centered/reported outcomes in implant dentistry. A systematic review. Beikler T & Flemmig T.F. (2015) Economic evaluation of implant-supported prostheses. A narrative review.

Attitude of dental hygienists, general practitioners and periodontists towards preventive oral care: an exploratory study

INTRODUCTION

Promoting oral hygiene and stimulating patient's responsibility for his/her personal health remain challenging objectives. The presence of dental hygienists has led to delegation of preventive tasks. However, in some countries, such as Belgium, this profession is not yet legalized. The aim of this exploratory study was to compare the attitude towards oral-hygiene instructions and patient motivational actions by dental hygienists and by general practitioners/periodontists in a context without dental hygienists.

MATERIALS AND METHODS

A questionnaire on demographics (six items), oral-hygiene instructions (eight items) and patient motivational actions (six items) was distributed to 241 Dutch dental hygienists, 692 general practitioners and 32 periodontists in Flanders/Belgium. Statistical analysis included Fisher's exact-test, Pearson's chi-square test and multiple (multinomial) logistic regression analysis to observe the influence of profession, age, workload, practice area and chair-assistance.

RESULTS

Significant variance was found between general practitioners and dental hygienists (in 13 of 14 items), between general practitioners and periodontists (in nine of 14 items) and between dental hygienists and periodontists (in five of 14 items). In addition to qualification, chair-assistance was also identified as affecting the attitude towards preventive oral care.

CONCLUSION

The present study identified divergence in the application of, and experienced barriers and opinions about, oral-hygiene instructions and patient motivational actions between dental hygienists and general practitioners/periodontists in a context without dental hygienists. In response to the barriers reported it is suggested that preventive oriented care may benefit from the deployment of dental hygienists to increase access to qualified preventive oral care.

Intraoral radiography lacks accuracy for the assessment of peri-implant bone level - a controlled clinical study

PURPOSE

The aim of this study was to compare clinical and radiographic bone level assessments to intra-surgical bone level registration around implants with peri-implantitis and to identify the clinical variables rendering peri-implant bone level assessment accuracy.

MATERIALS AND METHODS

The study sample included 50 implants with peri-implantitis in 23 patients. Registration methods included probing of the vertical distance between the implant/abutment interface and the bottom of the pocket (= VPD), intraoral radiography, bone sounding without flap elevation and intra-surgically assessed interproximal bone level. The latter was considered the true bone level (gold standard). Twenty clinicians evaluated all radiographs.

RESULTS

VPD and intraoral radiography resulted in a significant underestimation of the true bone level by 1.0 mm (95% CI: 0.495-1.585; P < 0.001) and 2.3 mm (95% CI: 1.650-2.980; P < 0.013) respectively. Bone sounding without flap elevation did not differ significantly from the true bone level (mean difference 0.2 mm; 95% CI: -0.775 - 0.335; P = 0.429). Duplicate magnification registration of 50 implants resulted in excellent intra- and inter-rater reliability (ICC intra ≤ 0.99; ICC inter = 0.964; P < 0.001). Radiographic underestimation was significantly affected by defect depth (P < 0.001). Variation among clinicians was substantial (mean underestimation range 1.1 mm to 3.8 mm); however, clinical experience had no impact on radiographic underestimation (P = 0.796).

CONCLUSIONS

Bone sounding without flap elevation was the best predictor of peri-implant bone level, whereas intraoral radiography was the most inferior. Consequently, peri-implantitis may be under-diagnosed if examination is only based on radiographs. Conflict-of-interest statement: Prof Hugo De Bruyn is associated with education and research collaboration agreements with Dentsply Sirona and Southern Implants, on behalf of Ghent University. Prof Cosyn has a collaboration agreement with Nobel Biocare. All other authors declare that they have no conflict of interest.

Long-Term Effect of Surface Roughness and Patients' Factors on Crestal Bone Loss at Dental Implants. A Systematic Review and Meta-Analysis

Publications from 2011 to 2015 were selected to evaluate effect of implant surface roughness on long-term bone loss as surrogate for peri-implantitis risk. 87 out of 2,566 papers reported the mean bone loss after at least 5 years of function. Estimation of the proportion of implants with bone loss above 1, 2, and 3 mm as well as analysis the effect of implant surface roughness, smoking, and history of periodontitis was performed. By means of the provided statistical information of bone loss (mean and standard deviation) the prevalence of implants with bone loss ranging from 1 to 3 mm was estimated. The bone loss was used as a surrogate parameter for "peri-implantitis" given the fact that "peri-implantitis" prevalence was not reported in most studies or when reported, the diagnostic criteria were unclear or of dubious quality. The outcome of this review suggests that peri-implant bone loss around minimally rough implant systems was statistically significant less in comparison to the moderately rough and rough implant systems. No statistically significant difference was observed between moderately rough and rough implant systems. The studies that compared implants with comparable design and different surface roughness, showed less average peri-implant bone loss around the less rough surfaces in the meta-analysis. However, due to the heterogeneity of the papers and the multifactorial cause for bone loss, the impact of surface roughness alone seems rather limited and of minimal clinical importance. Irrespective of surface topography or implant brand, the average weighted implant survival rate was 97.3% after 5 years or more of loading. If considering 3 mm bone loss after at least 5 years to represent the presence of "peri-implantitis," less than 5% of the implants were affected. The meta-analysis indicated that periodontal history and smoking habits yielded more bone loss.

Facilitating Dental Student Reflections: Using Mentor Groups to Discuss Clinical Experiences and Personal Development

Despite the consensus on the importance of reflection for dental professionals, a lack of understanding remains about how students and clinicians should develop their ability to reflect. The aim of this study was to investigate dental students' and mentors' perceptions of mentor groups as an instructional method to facilitate students' reflection in terms of the strategy's learning potential, role of the mentor, group dynamics, and feasibility. At Ghent University in Belgium, third- and fourth-year dental students were encouraged to reflect on their clinical experiences and personal development in three reflective mentor sessions. No preparation or reports afterwards were required; students needed only to participate in the sessions. Sessions were guided by trained mentors to establish a safe environment, frame clinical discussions, and stimulate reflection. Students' and mentors' perceptions of the experience were assessed with a 17-statement questionnaire with response options on a five-point Likert scale (1=totally disagree to 5=totally agree). A total of 50 students and eight mentors completed the questionnaire (response rates 81% and 89%, respectively). Both students and mentors had neutral to positive perceptions concerning the learning potential, role of the mentor, group dynamics, and feasibility. The mean ideal total time for sessions in a year was 99 minutes (third-year students), 111 minutes (fourth-year students), and 147 minutes (mentors). Reported reflective topics related to patient management, frustrations, and practice of dentistry. Overall mean appreciation for the experience ranged from 14.50 to 15.14 on the 20-point scale. These findings about students' and mentors' positive perceptions of the experience suggest that mentor groups may be a potentially valuable strategy to promote dental students' reflection.

Immediate provisionalization of dental implants in grafted alveolar ridges in the esthetic zone: a 5-year evaluation

This clinical study assessed at 5 years both implant survival and peri-implant tissue architecture of immediately provisionalized implants placed 4 to 6 months following augmentation with demineralized bovine bone allograft and collagen membrane. Of 23 implants in 19 patients, one implant failed prior to loading (95.6% survival). Implant tissue relationships were stable following implant placement; marginal bone level changes from implant placement to 5 years (mean ± SD: -0.18 ± 0.79 mm, range: -1.6 to 1.4 mm, P = .51), the mesial and distal papilla length changes (mesial mean ± SD: 1.14 ± 0.92 mm, P < .001; distal mean ± SD: 0.74 ± 1.46 mm, P = .04), and the unchanged mucosal zenith location (mean ± SD: 0.24 ± 0.93 mm, P = .15) were recorded. There were no major surgical complications during the 5-year period. When augmentation is required, subsequent dental implant placement in the anterior maxilla may be achieved using immediate placement and provisionalization protocol to attain osseointegration success and stable peri-implant tissue responses.

"Peri-Implantitis": A Complication of a Foreign Body or a Man-Made "Disease". Facts and Fiction

BACKGROUND

The discrepancy between some scientific views and the daily clinical experience with dental implants has made the topic of "periimplantitis" highly controversial, especially the discussion whether "periimplantitis" should even be considered a "disease" or whether marginal bone loss instead would represent a complication of having a foreign body placed in the oral cavity.

PURPOSE

The aim of the present paper was to present the outcomes from a consensus meeting on "peri-implantitis" in Rome, Italy (January 8-10, 2016).

MATERIALS AND METHODS

Seventeen clinical scientists were invited to, based on prepared reviews of the literature, discuss topics related to "periimplantitis."

RESULTS AND CONCLUSIONS

Oral implants may lose bone or even display clinical failure. However, progressive bone loss threatening implant survival is rare and limited to a percent or two of all implants followed up over 10 years or more, provided that controlled implant systems are being used by properly trained clinicians. There is very little evidence pointing to implants suffering from a defined disease entity entitled "peri-implantitis." Marginal bone loss around implants is in the great majority of cases associated with immune-osteolytic reactions. Complicating factors include patient genetic disorders, patient smoking, cement or impression material remnants in the peri-implant sulcus, bacterial contamination of the implant components and technical issues such as loose screws, mobile components or fractured materials. These reactions combine to result in cellular responses with the end result being a shift in the delicate balance between the osteoblast and the osteoclast resulting in bone resorption. However, the great majority of controlled implants display a foreign body equilibrium resulting in very high survival rates of the implants over long term of follow-up.

Exploring the relation between online case-based discussions and learning outcomes in dental education

Online case-based discussions, parallel to theoretical dental education, have been highly valued by students and supervisors. This study investigated the relation between variables of online group discussions and learning outcomes. At Ghent University in Belgium, undergraduate dental students (years two and three) are required to participate in online case-based discussion groups (five students/group) in conjunction with two theoretical courses on basic periodontics and related therapy. Each week, a patient case is discussed under supervision of a periodontist, who authored the case and performed the treatment. Each case includes treatment history and demand, intra- and extraoral images, and full diagnostic information with periodontal and radiographic status. For this retrospective study, data were obtained for all 252 students in forty-three discussion groups between 2009 and 2012. Spearman's rank correlations were calculated to investigate the relation among group dynamics (number of group posts and views), individual student contributions (number of individual posts, newly introduced elements, questions, and reactions to other posts), supervisors' interventions (number of posts and posed questions), and learning outcomes (examination result). The results showed that learning outcomes were significantly related to the number of student posts (Spearman's rho (ρ)=0.19), newly introduced elements (ρ=0.21), reactions to other posts (ρ=0.14), number of supervisors' interventions (ρ=0.12), and supervisors' questions (ρ=0.20). These results suggest that individual student contributions during online case-based discussions and the provided supervision were related to learning outcomes.

Immediate provisionalization of dental implants placed in healed alveolar ridges and extraction sockets: a 5-year prospective evaluation

PURPOSE

This 5-year prospective multicenter study compared implant survival and success, peri-implant health and soft tissue responses, crestal bone level stability, and complication rates following immediate loading of single OsseoSpeed implants placed in anterior maxillary healed ridges or extraction sockets.

MATERIALS AND METHODS

Individuals requiring anterior tooth replacement with single implants were treated and immediately provisionalized. Definitive all-ceramic crowns were placed at 12 weeks. Implant survival, bone levels, soft tissue levels, and peri-implant health were monitored for 5 years.

RESULTS

One hundred thirteen patients received implants in fresh sockets (55) and healed ridges (58). After 5 years, 45 and 49 patients remained for evaluation, respectively. During the first year, three implants failed in the extraction socket group (94.6% survival) and one implant failed in the healed ridge group (98.3% survival); this difference was not significant. No further implant failures were recorded. After 5 years, the interproximal crestal bone levels were located a mean of 0.43 ± 0.63 mm and 0.38 ± 0.62 mm from the reference points of implants in sockets and healed ridges (not a significant difference). In both groups, papillae increased over time and peri-implant mucosal zenith positions were stable from the time of definitive crown placement in sockets and healed ridges. Compared to flap surgery for implants in healed ridges, flapless surgery resulted in increased peri-implant mucosal tissue dimension (average, 0.78 ± 1.34 mm vs 0.19 ± 0.79 mm).

CONCLUSION

After 5 years, the bone and soft tissue parameters that characterize implant success and contribute to dental implant esthetics were similar following the immediate provisionalization of implants in sockets and healed ridges. The overall tissue responses and reported implant survival support the immediate provisionalization of dental implants in situations involving healed ridges and, under ideal circumstances, extraction sockets.

Predictors of Alveolar Process Remodeling Following Ridge Preservation in High-Risk Patients

PURPOSE

(1) To clinically evaluate horizontal remodeling of the alveolar process (hard and soft tissues) following ridge preservation in high-risk patients and (2) to identify predictors of such remodeling.

MATERIALS AND METHODS

Periodontally healthy nonsmoking patients with a failing tooth in the anterior maxilla (15-25) were selected for a prospective case series. All were in need of a single implant and demonstrated high risk for aesthetic complications given an incomplete buccal bone wall and/or thin-scalloped gingival biotype. Following flapless tooth extraction, ridge preservation was performed using one or more collagen-enriched, bovine-derived block grafts (Geistlich Bio-Oss® Collagen® 100 mg, Geistlich Pharma AG, Wolhusen, Switzerland) without the additional use of membranes or soft tissue grafts. The change in buccopalatal dimension of the alveolar process between baseline (prior to tooth extraction) and 4 months was assessed on the basis of superimposed occlusal slides. Regression analysis was performed to identify predictors of alveolar process remodeling.

RESULTS

Forty-two patients (21 females, 21 males; mean age 38) met the selection criteria and consented to the treatment. Mean alveolar process remodeling was 14% (SD 7, range 4-30) with minimal remodeling (≤ 10%) in 16 patients (38%) and advanced remodeling (>20%) in 10 patients (24%). A single implant could be installed in all subjects without additional guided bone regeneration. Connective tissue grafting was performed later on in the treatment for aesthetic purposes, hereby compensating for tissue loss at the buccal aspect. Predictors of alveolar process remodeling were tooth location (central incisors and cuspids > laterals incisors and premolars), tooth abscess (p = .025), and buccal bone loss (p = .035).

CONCLUSION

Alveolar process remodeling seems inevitable yet acceptable following ridge preservation in high-risk patients. Proper case selection may reduce the incidence of advanced remodeling.

A prospective cohort study on the impact of smoking on soft tissue alterations around single implants

OBJECTIVES

To compare smokers to non-smokers in terms of soft tissue alterations following single implant treatment in healed bone.

MATERIAL AND METHODS

Non-smoking and smoking patients with sufficient bone volume in need of a single implant in the anterior maxilla (15-25) were consecutively recruited in three centres. Conventional single implant surgery was performed and an immediate provisional crown was installed. Eight to 12 weeks later, the latter was replaced by a permanent one (baseline). Papilla regrowth and midfacial recession was registered after 2 years of function.

RESULTS

The sample consisted of 39 non-smokers (21 females; mean age 42) and 46 smokers (22 females; mean age 45). Smokers had three early failures, whereas all implants integrated successfully in non-smokers. Statistically significant papilla regrowth was observed in non-smokers (distal 0.63 mm, mesial 0.76 mm), whereas smokers showed stable papillae (between cohorts: P ≤ 0.025). Midfacial soft tissue level demonstrated statistically significant regrowth in non-smokers (0.53 mm), whereas it remained stable in smokers (between cohorts: P = 0.004).

CONCLUSION

Smokers failed to demonstrate papilla regeneration and showed more midfacial recession following single implant treatment when compared to non-smokers.

Ongoing Crestal Bone Loss around Implants Subjected to Computer-Guided Flapless Surgery and Immediate Loading Using the All-on-4® Concept

BACKGROUND

The All-on-4(®) concept is widely applied for full-arch rehabilitations, using two tilted and two axially loaded implants in order to overcome anatomical constraints.

PURPOSE

The aim of this study was to assess the survival and individual success of implants immediately loaded with an All-on-4 full-arch screw-retained prosthetic bridge in fully edentulous mandibles or maxillae over up to 3 years.

MATERIALS AND METHODS

In total, 20 patients with atrophic jaws (9 maxillae, 11 mandibles) were treated with computer-guided flapless surgery and immediately provided with a provisional bridge. The final prosthesis was delivered after 6 months. In total, 80 TiUnite(™) Brånemark implants were placed. Radiographs were taken after surgery and 1 and 3 years later.

RESULTS

A 3-year survival rate of 100% was seen for all implants, both in lower and in upper jaw. None of the temporary or definite prostheses were lost over the follow-up period of 3 years. After 1 year, the mean bone loss was 1.13 mm (SD 0.94; range -0.1 to 3.8), and after 3 years, it was 1.61 mm (SD 1.40; range 0 to 5). The mean bone loss between the 1-year and 3-year follow-ups was 0.48 mm (SD 0.66; range -1.2 to 3.6). This difference was statistically significant (p < .001), indicative of ongoing bone loss. Twenty-six percent of the implants had bone loss above 1.5 mm after 1 year, but after 3 years, 30% of the implants had already lost more than 1.9 mm.

CONCLUSION

The implant and prosthetic survival was 100%, and patients benefited from the All-on-4 treatment. However, unacceptable ongoing bone loss was seen in 49.2% of the patients; this may be a warning sign for future problems and needs clinical attention. Overloading and surgery-related aspects need to be investigated as potential explanations.

A multifactorial analysis to identify predictors of implant failure and peri-implant bone loss

OBJECTIVE

To identify risk factors for failure and bone loss of implants in a large study sample on the basis of multivariate analyses.

MATERIALS AND METHODS

Patient files of all patients referred for implant treatment from November 2004 to December 2007 were scrutinized, and information on implant- and patient-related factors was collected. The study sample in this retrospective cohort study consisted of both partially dentate and fully edentulous patients referred for various indications. The only inclusion criterion was a follow-up of at least 2 years. Implant survival and bone loss were assessed by an external investigator (SV) comparing digital periapical radiographs taken during recall visits with the postoperative ones. Univariate and multivariate tests were adopted to identify possible risk indicators for implant failure and peri-implant bone loss.

RESULTS

Twenty-one of 1,320 (1.6%) implants were lost in 19 of 376 (5.1%) patients (210 female, 166 male; mean age 56, range 17-82) after a mean follow-up of 32 months (range 24-62). Based on multivariate analysis, only smoking (p = .001) and recall compliance (p = .010) had a significant influence on implant failure, with smokers more prone to failure. The overall mean bone loss was 0.36 mm (SD 0.68, range 0.00-7.10). Smoking (p = .001) and jaw of treatment (p = .001) affected peri-implant bone loss. More peri-implant bone loss was observed in smokers and in the maxilla. A clear discrepancy was found between univariate and multivariate analysis with regard to identification of risk factors.

CONCLUSION

Multivariate analysis demonstrated that implant-related factors did not affect the clinical outcome, but smoking was identified as a predictor for implant failure. Predictors for peri-implant bone loss were smoking and jaw of treatment.

Disparity in embrasure fill and papilla height between tooth- and implant-borne fixed restorations in the anterior maxilla: a cross-sectional study

PURPOSE

The objective of the present study was to compare inter-proximal fill and papilla height between different embrasures.

MATERIAL & METHODS

One hundred and fifty non-smoking consecutive patients (mean age 54, range 32-73; 63 males and 87 females) without periodontal disease were selected in a multidisciplinary practice during regular supportive care. All had been treated for multiple tooth loss in the anterior maxilla at least 1 year earlier by means of a fixed restoration on teeth (n = 50) or implants (n = 100) using straightforward procedures (without hard and/or soft tissue augmentation). Embrasure fill was assessed by means of Jemt's papilla index and papilla height was registered following local anaesthesia by means of bone sounding by one clinician.

RESULTS

Tooth-pontic and tooth-implant embrasures demonstrated comparable inter-proximal fill and papilla height (≥58% Jemt's score 3; mean papilla height ≥4.1 mm). Between missing teeth, embrasure fill and papilla height were lower regardless of the embrasure type. The implant-implant and implant-pontic embrasure demonstrated comparable outcome (≤42% Jemt's score 3; mean papilla height ≤ 3.3 mm; p ≥ 0.416), which was significantly poorer when compared to the pontic-pontic embrasure (82% Jemt's score 3; mean papilla height 3.7 mm; p ≤ 0.019). Overall, papilla index and papilla height demonstrated a weak correlation (Spearman's correlation coefficient: 0.198; p = 0.002).

CONCLUSIONS

The re-establishment of a papilla is difficult when there is no tooth involved. In that scenario a short papilla should be expected and implant-borne restorations demonstrate the poorest outcome. Moreover, an implant with a pontic may not perform better than adjacent implants.