Peri-Implant Papilla Reconstruction: Realities and Limitations

The use of hyaluronic acid injection for treatment of black triangle and reconstruction of lost interdental papilla in anterior teeth: a systematic review

OBJECTIVE

Non-surgical therapeutics to reconstruct lost interdental papilla are evolving; these include hyaluronic acid injection. The aim of this systematic review is to evaluate the efficacy, safety, and long-term outcomes of hyaluronic acid injection in the treatment of black triangles and reconstruction of lost interdental papilla in anterior teeth.

MATERIALS AND METHODS

The protocol was registered in PROSPERO (CRD42023446875) and in accordance with the Cochrane Handbook of Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis 'PRISMA'. The search involved four databases, PubMed/MEDLINE, The Cochrane Library, Google Scholar, and ProQuest for ''grey literature' with additional manual search for studies published up to May 2024. Human clinical studies of a prospective nature (randomised clinical trials and prospective cohort studies) were included. Exclusion criteria were case reports, case series, review articles, letter to editor, personal opinion, and animal studies. Furthermore, studies which utilised hyaluronic acid injection in conjunction with other therapeutic material, tissue graft, or any surgical procedure were also excluded. The data were extracted independently by the two authors and incorporated after consensus. The risk of bias was assessed using the RoB2: the revised Cochrane risk of bias tool for randomised clinical trials and the Newcastle Ottawa scale for prospective cohort studies.

RESULTS

24 studies, 15 prospective clinical studies and nine randomised clinical trials, were included with a total of 898 interdental papillae injected with hyaluronic acid. The studies showed promising outcomes in the reconstruction of lost interdental papilla with minimal adverse reactions. Risk of bias assessment among prospective clinical studies revealed 13 good quality studies with only two poor studies while the randomised clinical trials consisted of three with low, one with some concern, and five studies with high risk of bias. However, due to the high heterogeneity, a meta-analysis was not feasible.  Conclusion: Hyaluronic acid injection is an effective minimally invasive approach in treating black triangles and reconstructing lost interdental papilla in the anterior teeth. Further long-term well-designed randomised clinical trials employing standardised procedures are essential to validate this treatment and provide better quality of evidence.

Do different incision techniques for implant surgery affect gingival papilla height around dental implants? A retrospective study of 115 cases

BACKGROUND

Surgical incision designs are considered closely correlated to gingival papilla of dental implants. This study aims to explore whether different incision techniques for implant placement and second stage surgery affect gingival papilla height.

METHODS

Cases using different incision techniques (intrasulcular incisions or papilla sparing incisions) between November 2017 and December 2020 were selected and analyzed. A digital camera was used to capture images of gingival papilla at different time points. Ratio of papilla height to crown length using different incision techniques were measured and statistically compared.

RESULTS

A total of 115 papillae (68 patients) were eligible according to the inclusion/exclusion criteria. The average age was 39.6 years. Decreased postoperative papilla height were observed after implant placement surgery in all groups without statistical difference. However, for second stage surgery, intrasulcular incisions lead to more atrophy in gingival papilla compared to papilla sparing incisions.

CONCLUSIONS

Selection of incision techniques in implant placement surgery does not significantly affect papilla height. For second stage surgery, intrasulcular incisions significantly leads to more papilla atrophy compared with papilla sparing incisions. Trial registration KQCL2017003.

Incidence of Gingival Black Triangles following Treatment with Fixed Orthodontic Appliance: A Systematic Review

This systematic review aimed to investigate the relation between orthodontic treatment (OT) and the incidence of the gingival black triangle (GBT) after completing treatment with a fixed orthodontic appliance, as well as the associated risk factors and the level of alveolar bone. Electronic and hand searches were conducted in three electronic databases for relevant articles published up to March 2022. Retrieved articles went through a two-step screening procedure, and the risk of bias (RoB) was assessed by the Joanna Briggs Institute checklists. The incidence of GBT after OT was set as the primary outcome, while the secondary outcomes were the risk factors associated with GBT and alveolar bone loss following OT. Out of 421 papers, 5 were selected for the final analysis. The RoBs of three studies were moderate and the remaining two were low. The incidence of GBT following OT ranged from 38% to 58%. In addition, three studies reported that alveolar bone loss was reduced significantly following OT and associated with GBT, while one study found the opposite. Regarding the risk factors associated with GBT, the reported results attributed GBT to several factors including age, tooth-related factors, treatment duration, and soft tissue factors. The analysis indicates an increased incidence of GBT following OT; however, a firm conclusion cannot be drawn. Additionally, it was not possible to reach a consensus on risk factors associated with GBT due to the heterogeneity of the data. Therefore, further randomized clinical trials are highly recommended to draw a firm conclusion.

Preservation of Peri-Implant Papilla: A Narrative Review

Beside osseointegration and restoration of function, the patient's subjective satisfaction with the esthetic result is a touchstone of the success of implant therapy. The long-term maintenance and reconstruction of papilla-like soft tissue between two adjacent implants in the esthetic zone which is esthetically satisfactory is generally regarded as a challenge. The road to success is much more complicated with implants, because of biologic and anatomical limitations of peri-implant tissues. Numerous techniques have been proposed to manage the hard and soft tissues in an attempt to achieve ideal esthetic results which includes surgical and nonsurgical techniques. The goal of reconstructive procedures is to provide peri-implant bone that supports and maintains gingival contours. An interdisciplinary approach has an obvious advantage of long-term preservation of a healthy peri-implant tissue which is of key importance in ensuring acceptable function and subjective satisfaction of esthetics of dental implants. A detailed literature search was performed in English language from 1986 to 2012, which included review articles, original research, as well as case reports. The search was performed in National Library of Medicine's PubMed database, Google Search, and Science Direct. A manual search of hard copies of available journal was also performed using interdental papilla, peri-implant papilla, esthetics, and dental implant as key words, in an attempt to gain insight into the limitations of papilla preservation, the factors which may potentially affect the maintenance and reconstruction of inter-implant papilla, and the contemporary methods to augment it.

Hyaluronic acid injection to restore the lost interproximal papilla: a systematic review

OBJECTIVES

To assess the efficacy and safety of hyaluronic acid (HA) injections to restore the lost interproximal papilla.

MATERIALS AND METHODS

A systematic literature search was conducted in PubMed/MEDLINE, Scopus and Cochrane electronic databases with no time restriction up to September 2021. Any clinical study evaluating HA injection into the interproximal papilla loss Class I and II according to Norland & Tarnow, were included based on the following PICO questions (1) Are HA injections effective for the reconstruction of the interproximal papilla loss? (2) What are the side/adverse effects of using HA for the reconstruction of interproximal papilla loss? The risk of bias assessment was performed using the Cochrane Collaboration's the Newcastle Ottawa and Joanna Briggs institute tools.

RESULTS

A total of 1497 titles were retrieved. From these, eleven were included and underwent full data extraction. However, due to heterogeneity in the data among the included articles, a meta-analysis could not be performed. Three articles reported no-differences in term of papilla tip to contact point distance or the papilla fill reduction. Finally, five studies showed a reduction in the black triangle with a percentage range between 19 and 47%.

CONCLUSION

The non-surgical use of HA injection seems to have a positive effect on the re-establishment of interproximal papilla lost. However post-operative complications might develop.

A customized subepithelial connective tissue graft for interdental papilla reconstruction and soft tissue augmentation

OBJECTIVE

Due to the minimal blood supply and other reasons, stable reconstruction of interdental papilla is difficult. This article presented three cases, which describe a customized subepithelial connective tissue graft aiming to overcome the clinical challenge, with the combination of tunneling technique.

CLINICAL CONSIDERATIONS

An original customized subepithelial connective tissue graft combined with tunnel technique aimed to reconstruct interdental papilla (IP). The subepithelial connective tissue graft was partially spilt to create a bowtie-like shape, with four lateral wings and a main body. The four wings were tightly wrapped around the adjacent abutments, and the body part was used to reconstruct the IP.

CONCLUSIONS

With the customized subepithelial connective tissue graft, a favorable outcome has been preliminarily confirmed in these cases. Facing patients with a lack of gingival papilla and soft tissue fullness, the customized subepithelial connective tissue graft may be a good choice.

CLINICAL SIGNIFICANCE

This study provides a new method to reconstruct IP. The customized subepithelial connective tissue graft may be a good choice when a lack of gingival papilla and soft tissue fullness occurs, which will be of great benefit to meet the aesthetic needs of patients.

Factors Influencing the Presence of Papilla between Adjacent Implants and between a Tooth and an Implant

Aim

The aim this study was to evaluate the factors that influence the presence or absence of the interproximal papilla between implants adjacent to the teeth or other implants, through clinical and radiographic evaluation.

Material and Methods

The non-probabilistic sample comprised 44 patients of both genders aged between 21 and 68 years, rehabilitated with 114 osseointegrated implants. Through a retrospective clinical study, the patients were divided according to the presence or absence of the interproximal papilla: Group 1 - Absence of Papilla, Group 2 - Partial Presence of Papilla and Group 3 - Total Presence of Papilla. The success of the implants, the periodontal biotype, and the vertical and horizontal distances of the interproximal regions included in the study were evaluated.

Results

Of the 114 implants, 46.5% were considered unsuccessful, and bleeding was present in 29.8%. The periodontal biotype presented as thin and scalloped was found in 85.1% of the regions. The evaluation of the groups according to the confirmation of the interproximal space showed a statistically significant difference (p = 0.007), with 61.9% of the wide and long interproximal spaces classified as Group 1, while 31% of the narrow and short interproximal spaces were classified as Group 3.

Conclusion

It was concluded that the morphology of the interproximal space was the factor that was most strongly associated with the presence or absence of the interproximal papilla.

Regenerative Surgical Flap to Maintain Interdental Papilla around Dental Implant

The modified surgical flap technique for placement of implant in the anterior maxilla has been described. The flap design has been used to achieve optimal soft-tissue contour for implant restoration. A modification in the surgical technique has been employed with the intention to preserve the interdental papilla, which is the key to the maintenance of hygiene and esthetics around anterior implants. This, in turn, prevents black triangles and improves soft-tissue contours. The modified surgical flap method maintains both functional and esthetic values.

Use of different concentrations of hyaluronic acid in interdental papillary deficiency treatment: A clinical study

Background:

In the present era, demand of beauty and esthetics has increased rapidly. Interdental papilla construction, especially in the esthetic zone, is one of the most challenging tasks. Interdental papilla loss might occur due to several reasons as a consequence of periodontal surgery, trauma, and others.

Aim and Objective:

The present study was aimed to prepare economically feasible injectable form of hyaluronic acid (HA) gel in three different concentrations – 1%, 2%, and 5% HA to evaluate its efficacy in the enhancement of deficient interdental papilla (IDP).

Materials and Methods:

A total of 42 sites (mean age range was 29.6–30.6 years) was categorized into three groups; 1% HA group (16 sites), 2% HA group (14 sites), and 5% HA group (12 sites). Total 35 sites were followed up out of 42 in which 2% HA group included only 7 sites. Both maxillary (17 sites) and mandibular (18 sites) sites were included in this study. HA was injected at 2 mm apical to papillary tip at weekly interval for 3 weeks. The IDP augmentation was measured using UNC-15 probe and modified stent at 1, 3, and 6 months. The photographic analysis was done using Image J software.

Results:

On clinical measurement, 5% of HA showed highly significant enhancement (P = 0.001) of 19.2%, 20.6% 18.2% at 1, 3, and 6 months, respectively. On photographic analysis, 5% of HA showed 41%, 42.9%, and 39.8% at 1, 3, and 6 months, respectively. However, intergroup comparison showed nonsignificant improvement.

Conclusion:

This study results suggest that the use of 5% of HA is effective for interdental deficiency treatment with minimal rebound at the end of 6 months. The modified stent for IDP measurement used in this study for the first time in the literature is highly recommended. The photographic analysis using image J Analyzer serves a useful and dependable tool. Further, long-term clinical studies would throw more insight in this regard.

Comparison of interdental papilla around single implants in the anterior maxilla between two implant systems: A cohort study

Background. In successful replacement of a tooth with a dental implant, soft tissue esthetic is as important as stability and function of the implant. Quality and quantity of the peri-implant mucosa can influence esthetic outcomes. This study assessed implant esthetic success of two different implant systems. In this regard the interdental papilla was evaluated and the relation-ship between implant type and crestal bone loss adjacent to implant was assessed.

Methods. Eighteen patients (11 males, 7 females) with a total of 18 implants participated in this historical cohort study. Patients were divided into two groups based on the type of implants: Implantium group and SPI group; 36 interproximal papillae were evaluated photographically, using Jemt’s papillary presence index (PPI). Radiographic analysis was carried out to find out the relation between bone loss and type of implant. Analysis of data was performed with SPSS 18, using Fisher's exact test, independent t-test, Spearman's correlation coefficient and ANOVA.

Results. Comparison of photographs did not show a statistically significant difference in PPI between the two groups (P=0.94). Radiographic evaluation of crestal bone loss adjacent to implant shoulder did not reveal significant differences between the two groups (P=0.30).

Conclusion. Implant therapy in the anterior maxilla, using Implantium or SPI system, did not result in significant differences in esthetics. In this study, there was an inverse relationship between the distance of contact point to bone crest and papilla index (P=0.002 in the SPI group) (P=0.02 in the Implantium group).

A clinical assessment of the volume of interproximal papilla after definitive prosthesis around immediate and delayed loading implants placed in the maxillary esthetic zone: An in vivo study

Background:

The presence of the dental papilla is critical to achieve esthetics in a single tooth implant restoration.

Aim:

The purpose of this study was to determine if there were differences in the papilla fill between implant and teeth comparing immediate implant placement and provisionalised single tooth implant restorations with delayed implant placement and provisionalised single tooth implant restorations. The papilla fill in these two groups was evaluated using the Jemt papilla index.

Results:

It was seen that there was no statistically significant difference seen in the volume of the papilla between both the groups. There was a statistically significant difference seen in both the groups on the distal and mesial side from the initial stage go the follow up period of 10 days, 3 months and 6 months.

Conclusion:

The interpretation of clinical papilla is a difficult task since many different clinical situations can be encountered while studying single tooth implant restorations. The single tooth implant restoration is a specific entity; the distance between the mesial and the distal side of one implant is never the same. Therefore the present study analysed the papilla as a unit and focused on the vertical fill related to the implant and adjacent teeth.

Risk Indicators of Papillary Recession in the Anterior Maxilla

PURPOSE

The interdental papilla is the portion of the gingiva that occupies the space between two adjacent teeth. When papillary recession occurs, an array of problems arises ranging from phonetics to food impaction and esthetic concerns. The aim of this study was to identify risk indicators for visible papillary recession in the anterior maxilla among a Caucasian population utilizing an advanced analytical approach.

MATERIALS AND METHODS

A dataset of 211 adult dentate Caucasian patients that had undergone intraoral assessment of midline papillary recession and extra-oral assessment of visible papillary recession during maximum ("Duchenne") smile was utilized. An enhanced analytical approach was employed to identify risk indicators for papillary recession.

RESULTS

Approximately one-third of the participants (38%) demonstrated papillary recession during maximum smile ("visible papillary recession"). An association between sex (male preference) and visible papillary recession was found in this sample population, while age was found to be a risk indicator for papillary recession in individuals over 65 years of age.

CONCLUSIONS

Visible midline papillary recession in the maxilla is a highly prevalent clinical entity in Caucasian individuals, thus the development of efficacious treatment modalities for papillary regeneration is necessary. Findings of the present study on risk indicators for visible papillary absence, namely sex and age, may facilitate clinicians in treating patient with compromised interdental aesthetics as well as identifying patients that are in high risk for loss of interdental tissues.

CLINICAL SIGNIFICANCE

Findings of the present study on risk indicators for visible papillary absence, namely sex and age, indicate the need for careful assessment and meticulous treatment planning with respect to preservation of the interdental tissues. The consideration of these risk indicators can help dentists to identify patients at risk for papillary recession.

Clinical study of flap design to increase the keratinized gingiva around implants: 4-year follow-up

Since the presence of keratinized gingiva is so important for peri-implant outcome, the aim of this study is to describe a partial thickness flap design to increase the amount of keratinized peri-implant tissue as well as its thickness. A total of 131 implants were placed in 85 patients: 103 implants (78.63%) in the mandible and 28 implants (21.37%) in the maxilla. Before implant placement in edentulous ridge the residual keratinized mucosa usually was measured with a periodontal probe in a buccal-palatal direction. A palatal or lingual incision was made to raise a partial thickness flap with the residual keratinized tissue. After implant placement the flap was apically repositioned and secured with loose periosteal sutures. Keratinized tissue levels were calculated at baseline, at 6 months, and every year follow-up. Measurements were reported for each implant diameter. At 4-year follow-up, implant survival rate of 87.79% was reported. Peri-implant keratinized mucosa confirmed clinical gain in all cases; mean levels at 1- and 4-year follow-ups were 7.26 ± 2.01 mm and 7.37 ± 2.12 mm, respectively. The levels remained stable over time. This flap design allows immediate correction of adaptation of the keratinized tissue around the implant, increasing the thickness and amount of the keratinized tissue.

Correcting loss of a papilla following orthodontic space opening (Atherton´s patch) through implant supported rehabilitation. A case report

The objective of this case report is to describe a surgical and prosthetic technique to create a lost papilla following orthodontic space opening (Atherton´s patch) through implant supported rehabilitation. A switching platform implant was used to replace a left maxillary canine in a unitary interdental edentulous ridge with Atherton´s patch in the distal area of the upper lateral left incisor. The radiographic study revealed correct level of the interproximal bone of the adjacent teeth. A mucoperiosteal flap with crest incision and sulcular extension to the adjacent teeth was made. Special attention was paid to correct position of the implant and the distance (≥ 1.5 mm) between the platform and the roots of the adjacent teeth. A submerged technique was used. Tissue modeling through provisional crown was performed in order to create an ideal emergence profile with total papilla fill recorded at the Atherton´s patch area. Final screw retained CAD-CAM zirconia structure was place. Final follow up was performed 2 years after provisional crown placement, and total fill of both papilla, including at Atherton´s patch area, was recorded.

Key words:Atherton´s patch, papilla, switching platform, implant and orthodontics, esthetic score.

Abutment emergence modification for immediate implant provisional restorations

In their stock form, some titanium provisional implant abutments are not ideally designed for use in immediate placement/immediate provisional restoration treatment. This is largely due to the apical flare design that applies excessive pressure to the peri-implant soft tissue complex and crestal bone. This appears to have the undesirable effect of increasing peri-implant bone resorption and severely impeding the potential for increases in gingival volume. This type of stock titanium abutment will therefore benefit significantly from recontouring. The subgingival portion of the abutment is recontoured from the flared stock shape to a straight or parallel design. This modification minimizes pressure on the surgical site and provides additional space around the subgingival portion of the provisional restoration, within which the gingiva has the potential to remodel and fill. This allows the potential formation of additional peri-implant gingival volume and a coronal maintenance or migration of the soft tissue complex. In order to minimize the "graying effect" of titanium abutments, the retentive portion is opaqued by the technician or clinician. These modifications will improve the potential outcomes for both the peri-implant gingiva and the provisional restoration.

CLINICAL SIGNIFICANCE

Narrowing the emergence profile of implant abutments for use in immediate implant provisional restorations appears to allow for creation of greater peri-implant volume. Thus resulting in increased esthetic potential and predictability of the peri-implant gingiva.

Peri-implant esthetics assessment and management

Providing an esthetic restoration in the anterior region of the mouth has been the basis of peri-implant esthetics. To achieve optimal esthetics, in implant supported restorations, various patient and tooth related factors have to be taken into consideration. Peri-implant plastic surgery has been adopted to improve the soft tissue and hard tissue profiles, during and after implant placement. The various factors and the procedures related to enhancement of peri-implant esthetics have been discussed in this review article.

Omega-shaped (Ω) incision design to enhance gingival esthetics for adjacent implant placement in the anterior region

It is well accepted that achieving an optimal interdental papilla between adjacent implants is esthetically challenging in implant dentistry. In general, there are 2 kinds of interproximal soft tissues that can be present between adjacent implants. One is the true anatomic interdental papilla and the other is a "papilla-like" tissue created by surgical intervention and prosthetic contouring of the tissues. The former is challenging to preserve, and the latter is difficult to create. Multiple techniques have been suggested to create and preserve this volume of interproximal soft tissue between adjacent implants. This article describes another technique to achieve a papilla-like tissue using an omega-shaped (Ω) incision design when implants are placed adjacent to each other in partially edentulous ridges. This incision design is intended to spare an area of soft tissue of approximately 4 mm × 4 mm between the anticipated positions of the adjacent implants. The area of soft tissue that is free from surgical insult later helps in the creation of a papilla-like tissue through interim restorations. Case reports of this technique on long-term partially edentulous ridges are described, with a follow-up period of 3 to 4 years. The technique is relatively simple and does not involve additional surgeries or additional time for healing.

The peri-implant esthetics: An unforgettable entity

Esthetic demands in today's world of dentistry are scaling new heights, and are driven by the zest to look beautiful. The soft tissue esthetics around implants is the foci of attention, which, if failed to meet, leads to unacceptable esthetic failure. The aim of this article is to give a brief overview of the various vital parameters influencing the esthetics governing the peri-implant area.

Factors and techniques influencing peri-implant papillae

AIM

Loss of implant papilla is one of the more troubling dilemmas in implant dentistry. The "black triangle" around the implant-supported restoration causes not only phonetic difficulties and food impaction but also unpleasant esthetics. This is considered to be a failure in today's implant therapy standards. As a consequence, many techniques have been developed to either preserve or regenerate the interimplant soft tissue. It is the purpose of this article to examine factors that may affect the appearance of the peri-implant papilla.

MATERIALS

MEDLINE search was used to identify articles published through September 2007 related to implant esthetics as interimplant papillae.

RESULTS

Factors such as crestal bone height, interproximal distance, tooth form/shape, gingival thickness, and keratinized gingival width have all been identified to influence the appearance of the interimplant papillae. In addition, many techniques/materials have been successfully used in promoting interimplant papillae formation.

CONCLUSION

This article presents a comprehensive review of factors that may influence the interimplant papillae and illustrates techniques used in attempting to recreate/correct this challenging problem in implant dentistry.

I-shaped incisions for papilla reconstruction in second stage implant surgery

PURPOSE

Pink gingival esthetic especially on the anterior teeth has been an important success criterion in implant-supported restoration. Inter-implant papillae are a critical factor for implant esthetics, and various techniques for inter-implant papilla reconstruction have been introduced. The aim of this study is to suggest and evaluate a surgical technique for reconstructing inter-implant papillae.

METHODS

A 28-year-old man had an implant placed on the #13 and #14 area. Four months after implant placement, a second stage surgery was planned for inter-implant papilla reconstruction. At the time of the abutment connection, I-type incisions were performed on the #13i & #14i area followed by full-thickness flap elevation and connection of a healing abutment on underlying fixtures without suture.

RESULTS

Two weeks after the second stage implant surgery, soft tissue augmentation between the two implants was achieved.

CONCLUSIONS

I-shaped incisions for papilla reconstruction performed during the second stage implant surgery were useful for inter-implant papilla reconstruction and showed a good esthetic result.

Minimally invasive treatment for papillae deficiencies in the esthetic zone: a pilot study

BACKGROUND

The presence of papillary deficiencies adjacent to dental implants or teeth presents an esthetic concern for the dental team and patients.

PURPOSE

The aim of this pilot project is to evaluate a new method for reducing or eliminating small papillary deficiencies. The use of a commercially available gel was evaluated as a possible method for enhancing deficient papillae.

MATERIALS AND METHODS

Eleven patients, seven females and four males, with an average age of 55.8 years (ranging from 25 to 75 years) with 14 treated sites are included in this pilot study. Patients had a minimum of one papillary deficiency in the esthetic zone. Prior to treatment photographs were either taken at a 1:1 ratio or converted to a 1:1 ratio using a commercially available program. A standardization photographic device was not used. After administration of a local anesthetic, a 23-gauge needle was used to inject less than 0.2 mL of a commercially available and Food and Drug Administration-approved gel of hyaluronic acid 2-3 mm apical to the coronal tip of the involved papillae. Patients were seen every three weeks and treatment was repeated up to three times. Patients were followed from 6 to 25 months after initial gel application. A computer program measured changes in pixels between initial and final treatments. A formula was derived to determine percentage change in the negative space between initial and final examinations.

RESULTS

Each site was individually evaluated. Three implant sites and one site adjacent to a tooth had 100% improvement between treatment examinations. Seven sites improved from 94 to 97%, three sites improved from 76 to 88%, and one site adjacent to an implant had 57% improvement.

CONCLUSION

Results from this pilot study are encouraging and present evidence that small papillary deficiencies between implants and teeth can be enhanced by injection of a hyaluronic gel. Improvements were maintained for a range of 6 to 25 months.

Outcome evaluation of early placed maxillary anterior single-tooth implants using objective esthetic criteria: a cross-sectional, retrospective study in 45 patients with a 2- to 4-year follow-up using pink and white esthetic scores

BACKGROUND

To validate the concept of early implant placement for use in the esthetically sensitive anterior maxilla, clinical trials should ideally include objective esthetic criteria when assessing outcome parameters.

METHODS

In this cross-sectional, retrospective 2- to 4-year study involving 45 patients treated with maxillary anterior single-tooth implants according to the concept of early implant placement, a novel comprehensive index, comprising pink esthetic score and white esthetic score (PES/WES; the highest possible combined score is 20), was applied for the objective esthetic outcome assessment of anterior single-tooth implants.

RESULTS

All 45 anterior maxillary single-tooth implants fulfilled strict success criteria for dental implants with regard to osseointegration, including the absence of peri-implant radiolucency, implant mobility, suppuration, and pain. The mean total PES/WES was 14.7 +/- 1.18 (range: 11 to 18). The mean total PES of 7.8 +/- 0.88 (range: 6 to 9) documents favorable overall peri-implant soft tissue conditions. The two PES variables facial mucosa curvature (1.9 +/- 0.29) and facial mucosa level (1.8 +/- 0.42) had the highest mean values, whereas the combination variable root convexity/soft tissue color and texture (1.2 +/- 0.53) proved to be the most difficult to fully satisfy. Mean scores were 1.6 +/- 0.5 for the mesial papilla and 1.3 +/- 0.5 for the distal papilla. A mean value of 6.9 +/- 1.47 (range: 4 to 10) was calculated for WES.

CONCLUSIONS

This study demonstrated that anterior maxillary single-tooth replacement, according to the concept of early implant placement, is a successful and predictable treatment modality, in general, and from an esthetic point of view, in particular. The suitability of the PES/WES index for the objective outcome assessment of the esthetic dimension of anterior single-tooth implants was confirmed. However, prospective clinical trials are needed to further validate and refine this index.

Evaluation of the Presence or Absence of Papilla between Tooth and Implant

Objective:

The purpose of this study was to evaluate the papilla level adjacent to single-tooth implants in the maxillary anterior region in individuals with cleft lip, alveolus, and palate to verify whether there is correlation among the vertical distance, horizontal distance, dental/prosthetic crown shape, and periodontal/peri-implant biotype with the presence of interproximal papilla.

Design:

Cross-sectional.

Setting:

Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo (HRAC/USP).

Patients:

77 papillae in 40 patients.

Interventions:

The periodontal/peri-implant biotype was clinically evaluated and characterized as thin or thick. Intraoral photographs were used to evaluate the presence or absence of papilla.

Main Outcome Measures:

Classification in scores (0 to 3) and determination of length (CL) and width (CW) of crowns adjacent to papillae. The CW/CL ratio was calculated for each crown in order to characterize it as square-shaped or triangular-shaped. The vertical and horizontal distances were obtained by radiographic evaluation.

Results:

The correlations between vertical distance and papilla score and horizontal distance and papilla score were statistically significant (p  =  .02 and p  =  .01). There was no significant difference between crown shape and periodontal/peri-implant biotype in distinct correlations with the papilla score (p  =  .41 and p  =  .07).

Conclusion:

The results suggest that the vertical and horizontal distances may have independent or combined relationship with the existence of interproximal papilla; the periodontal/peri-implant biotype (phenotype) was not correlated with the presence or absence of papilla, as well as the shape of the dental/prosthetic crown.

Triple Immediate Therapy (ridge expansion, soft tissue augmentation, and provisional restoration) of Maxillary Anterior Single Implant

BACKGROUND

Immediate restoration during implant placement in the premaxillary area can achieve a favorable esthetic result. However, the treatment always poses a great challenge to clinicians, especially for patients with preexisting soft and hard tissue deficiencies. The aim of this clinical report was to present a protocol for a multidisciplinary approach to provide an immediate implant restoration for patients with ridge deficiency.

METHODS

A 21-year-old female presented with a mesial shift of the maxillary right canine due to loss of a lateral incisor at an early age. The treatment protocol included orthodontic space redistribution to open a canine space for implant placement. Subsequently, ridge expansion and implant placement combined with connective tissue grafting for the reconstruction of the soft tissue profile were performed, and an immediate provisional prosthesis was delivered simultaneously. A definitive University of California at Los Angeles-style ceramometal crown was completed 6 months later with periodical clinical maintenance.

RESULTS

The 18-month postoperative follow-up revealed that the implant was stable, and the buccal depression of the surgical area was reconstructed. Papillae were augmented, and a harmonious soft tissue margin was achieved in the esthetic zone. Radiographs demonstrated a normal vertical osseous height and excellent osseointegration of the implant.

CONCLUSIONS

The combination technique of ridge expansion and soft tissue augmentation can be applied to immediate implant restoration cases without the need for complicated bone grafting surgeries in atrophic ridges. This triple immediate strategy enabled us to reduce the number of surgeries, which simplified the overall procedure without compromising the esthetic results.