Nonsurgical management of interdental papilla associated with multiple maxillary anterior implants: A clinical report

Nonsurgical management of interdental papilla associated with multiple maxillary anterior implants: A clinical report
March 2005
Saad A. Al-Harbi, BDS
The Journal of Prosthetic Dentistry
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Abstract
An approach is described for the management of missing interdental papillae associated with multiple adjacent maxillary anterior implants. The use of 1 implant instead of multiple implants to support a cantilivered fixed partial denture with an ovate pontic successfully enhanced the soft tissue contours to satisfy the patient's esthetic needs and desires.
Restoration of adjacent implants in the anterior maxilla while maintaining acceptable interdental papillae presents a major restorative challenge. The contours and color of missing teeth may be reproduced using a variety of materials and techniques. However, the success of an implant-supported restoration is often limited by the provider's ability to create gingival contours that harmonize with a patient's remaining oral structures.1 The presence or absence of the interdental papilla associated with multiple adjacent implants may be affected by the amount of alveolar bone loss prior to implant placement, distance between adjacent implants, position of implants in relation to adjacent teeth, as well as the subgingival contours of the implant-supported restoration.2 In many instances, the loss of 2 or more maxillary anterior teeth results in flattening of edentulous segments and resorption of interproximal bone crests.3 The placement of implants may result in additional bone loss following bone remodeling and the establishment of biological widths.4 Inadequate interimplant spacing (less than 3 mm) may result in exaggerated bone loss and increased distance from proximal contact points to the associated alveolar bone crests.5 This may result in decreased papillary volume and accompanying ǃ?black trianglesǃ? within the esthetic zone. Papillary volume is inversely proportional to the distance from the interproximal contact area to the bone crest.6 At a distance of less than 5 mm, papillae fill 100% of the time; when the distance measures 5-7 mm, papillae fill the space 56% of the time. Finally, when the distance exceeds 7 mm, the space is filed only 27% of the time.
Optimal implant positioning in relation to the adjacent teeth is another important factor to be considered when restoring multiple adjacent missing teeth. In an apical-coronal position, it is recommended that the implant be positioned 2-3 mm below the cemento-enamel junction of adjacent teeth.7 Buccal-lingually, an implant that is positioned too far to the lingual may result in ridge lapping of the definitive restoration and compromise esthetic results.8 When optimal implant positioning is achieved, the transitional tissue could be altered using a customized abutment to create an emergence profile that mimics natural teeth and provides adequate support to the surrounding soft tissue. This can be performed with a provisional restoration at the time of uncovering the implant8,9 and could be transferred at a later stage to the definitive restoration.10
Many surgical techniques have been developed attempting to regenerate interdental papillae.11,12 Unfortunately, no single technique offers consistent clinical success. Therefore, when using implants to replace multiple maxillary anterior teeth, optimal implant positioning should be achieved. When a diminished mesial-distal space exists, the clinician should consider placing implants with smaller diameters.5 Alternatively, fewer implants with cantilevered fixed partial dentures may be considered. In each instance, the intent is to maximize the interimplant distance, minimize alveolar bone loss, and maintain acceptable soft tissue height for optimum esthetic results. This clinical report illustrates an approach to manage interdental papillae associated with multiple adjacent maxillary anterior implants.
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