Bone Sculpting to Achieve PapillaRegeneration Around Dental Implants

46 June 2002 CONTEMPORARY ESTHETICS AND RESTORATIVE PRACTICE

SA S EC T U D Y

Figure 1A—The patient was missingtooth No. 9.

Figure 1B—Ideal papilla formation wasseen in this patient with tooth No. 9replaced with a dental implant.

Figure 1C—A smile view reveals the beautiful harmony and esthetics of the cen-tral incisors. (Restoration courtesy of Dr.Stephen Rothenberg, Darien, Connecticut.)

Figure 2—An osteotome was used to pre-pare the implant site of tooth No. 8. Theatrophied ridge was expanded with theosteotome, allowing an implant to beplaced in the area of tooth No. 8.

Dental implants have movedinto mainstream dentistry.They are now part and par-

cel of routine dental practice. Thepredictable success of dentalimplant therapy1 has led to a rise in the number of dentalimplants being placed. Osseo-integration is now almost takenfor granted. However, the estheticsuccess of dental implants is notso predictable, and is therefore nottaken for granted.

Achieving successful estheticimplants begins with a properbony foundation in which to placethe dental implant. Adequatebone must be present if one is todevelop the proper emergenceprofile, soft tissue contour, crown-to-gingival relationships, andpapilla formation (Figures 1Athrough 1C). Three possible situ-ations are possible when implanttherapy is considered:• Bone is present at the time ofimplant placement.• Bone is grafted before implantplacement (site development).• Bone is grafted at the time ofimplant placement.

If adequate bone for implantplacement is not present(Figures 2 and 3), the clinicianmust decide whether to graft atthe time of implant placement orto bone graft before implantplacement. Grafting at the timeof implant placement has the fol-lowing advantages:• The patient does not have togo through a separate surgicalprocedure.• The amount of time fromsurgery to the final restoration isdiminished.• There is less cost to thepatient.

However, the major disad-vantage is surgical complication.Should the graft become infectedor heal less optimally, theimplant may fail. Worse yet, theimplant may integrate but withless than optimal bone forma-tion. An integrated implant withsignificant bone loss is not anideal starting point for an estheticrestoration. In fact, it is a pre-scription for esthetic failure.

An adequate bony founda-tion is the starting point for an

ideal implant restoration.Substantial alveolar bone in theproper position allows the clini-cian to place the implant in theideal mesial-distal, facial-palatal,and occlusal-apical positions.2

Thus, an ideal soft tissue profilemay be achieved. In addition, theproper dental-gingival relation-ships can be created between theimplant crown and the gingiva,and between the implant crownand the adjacent crowns. Dentalgingival harmony is the thera-peutic endpoint.

Last, but not least, a papillamust be present to ensure anesthetic restoration. The pres-ence or absence of a papillabetween implants or between animplant and a natural toothdepends on two variables, perthe author’s experience:• the vertical distance be-tween the contact point of theadjacent crowns and the crest ofthe alveolar bone• the horizontal distance be-tween the implants at theimplant–abutment interface orbetween the implant and naturaltooth at the level of the alveolarbone.

Tarnow and colleagues3 dem-onstrated that as the vertical distance between the contactpoint of adjacent crowns and thecrest of the alveolar boneincreased, the papilla was less

likely to fill the embrasure spaceand a black triangle wouldappear. If the vertical distancefrom contact point to alveolarbone measured 5 mm or less, apapilla would be present almost100% of the time. The same hasbeen found true with dentalimplants. To assure that a papillais present, the distance from thecontact point of adjacent crownsto bone should be around 5 mm.

The horizontal relationshipbetween teeth has not beenaddressed in papilla regenera-tion. However, with adjacentimplants, it has been determinedthat a distance of 3 mm is neces-sary to prevent bone loss andhence loss of papilla.4 In anattempt to make papilla regener-ation between dental implantsmore predictable, the followingrules apply:• Allow for a distance of atleast 3 mm between adjacentimplants.• A distance of approximately5 mm should exist between thecontact point of adjacent crownsand the crest of the alveolar bone.

The reformation of papillabetween prosthetically restoredteeth has become a relatively pre-dictable procedure. Similarly, thereformation of a papilla between asingle implant and a natural toothis much more straightforward.However, the reformation and

Michael Sonick,DMD

Private Practice Limited to Periodontics and Dental Implants

Fairfield, ConnecticutPhone: 203.254.2006Fax: 203.254.9201Email:

Boomerdent@aol.com

Assistant Clinical Professor of SurgeryYale School of MedicineNew Haven, Connecticut

Guest LecturerInternational ProgramNew York University

School of DentistryNew York, New York

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maintenance of a papilla betweenadjacent implants is often consid-ered much more difficult. Thepurpose of this article is todemonstrate a predictable way toregenerate papilla between adja-cent implant crowns. In addition,the concept of bone sculptingwill be discussed along with thefollowing case, which is used todemonstrate these concepts.

CASE STUDYThe patient, a high school

woodworking instructor, wasreferred for evaluation 3 daysafter trauma to the anterior max-illa (Figure 4). He had sustaineda traumatic injury to the lip,maxillary anterior alveolus, andmaxilla left central incisor whena 2 × 4 piece of wood catapultedfrom a table saw to his face.

The patient had lost his max-illary right central incisor 20years earlier. This had beenrestored with a single cantilevertooth off a restored left centralincisor. As an emergency proce-dure, a new provisional restora-tion was made (Figures 4 and 5)before his referral. Radiographsrevealed that tooth No. 9 had amidroot horizontal fracture andwas hopeless (Figure 6).

The Treatment PlanTreatment planning is the sine

qua non of predictable estheticdentistry. The treatment plan is the template on which the clinician can develop an idealrestoration. The development of the treatment plan allows for excellent communication be-tween the restorative dentist andthe periodontist. This is essentialto predictably create a restorationthat will be esthetic. A treatment-

planning template is provided inTable 1. It serves as a guide for implant dentistry. Alterationsto the protocol may occur becauseof individual variations. However,the basic sequence is useful.

Surgical TreatmentTooth No. 9 was determined

to be hopeless because it had a vertical root fracture. It was determined that it would be extracted and an implantwould be placed into the extrac-tion site. Immediate implantshave been shown to have a suc-cess rate similar to that ofdelayed implant placement.5

Tooth No. 8 was also to receivean implant. Before surgery it wasnot known whether an implantcould be placed, because thetooth had been lost for morethan 20 years and it was notknown how much ridge resorp-tion might have occurred duringthis time. A therapeutic contin-gency involved grafting the toothNo. 8 site for a future implant.

After local anesthesia, a full-thickness flap was elevated toexpose the underlying alveolarridge (Figure 7). Significant atro-phy of the alveolar ridge wasnoted in the area of tooth No. 8.Bone augmentation with ridgeexpansion was indicated. Using aSummers Osteotome Kit (3iImplant Innovations Inc.) theridge was expanded according to Summers’6 principles. Theridge was too narrow to com-plete expansion with anosteotome. However, the use ofan osteotome would allowenough increase in ridge volumefor an implant to be placed andstabilized (Figure 3).

Machine Titanium Threaded

Implants (3i Implant InnovationsInc.) were placed in the areas ofteeth Nos. 8 and 9. They wereplaced approximately 4 mm apicalto the anticipated cemento-enamel junctions (CEJs) of theimplant crowns. This wouldallow a proper emergence profilefor the final restoration.2 From arestorative perspective, bothimplants were in good positions.However, they were not com-pletely in bone. Implant No. 8was stable but had nine threadsexposed on the labial (Figure 3).Implant No. 9 was embedded inbone, but had a circumferentialdefect (Figure 8).

Bone GraftingBone regeneration is neces-

sary around both implants tohave a predictable stable result.Autogenous bone was harvestedfrom the osteotomy sites using abone trap (Osseous CoagulumTrap, Quality Aspirators) andplaced into sterile saline. A com-bination of 50% autogenous boneand 50% demineralized freeze-dried bone allograft (AmericanRed Cross) was then placed overthe labial surface of implant No. 8and into the extraction site oftooth No. 9, filling the voidaround the implant (Figure 8). Anexpanded polytetrafluoroethylene(e-PTFE) membrane (Gore-Tex®

oval 6, W.L. Gore & AssociatesInc.; distributed by NobelBiocare USA) was placed over thegraft and stabilized with twominiscrews (Figure 9). Stability ofthe use of a membrane in con-junction with a bone graft is oftenthe most predictable method toobtain bone regeneration.7 Theauthor has found that the use of amembrane in conjuction with abone graft is the most predictablemethod to obtain bone regenera-tion around implants.

Primary closure is also essen-tial to eliminate the possibility ofbacterial infiltration and subse-quent infection (Figure 10). Aconnective tissue graft was har-vested from the hard palate andplaced over the membrane andocclusal surfaces of the implants. Itwas stabilized with a 5-0 gutsuture (Ethicon Inc.) to prevent itsegress. Primary closure was thenachieved using Gore-Tex® CV-5sutures. These sutures allow forsynching of the flap and excellentadaptation. The e-PTFE suturesalso do not wick bacteria. Wound

Case Study continued

48 June 2002 CONTEMPORARY ESTHETICS AND RESTORATIVE PRACTICE

Figure 3—Implants were placed in idealpositions. Implants were 3 to 4 mm fromthe anticipated CEJ and from each other.Note the amount of bone present betweenthe implants that would eventually sup-port the interdental papilla.

Figure 5—Intraoral view of the provisionalrestoration.

Figure 4—View of the patient 3 days afterbeing hit in the mouth by a 2 × 4 during anindustrial accident. His lip had beenrecently sutured and he was wearing a newprovisional restoration—a one-tooth can-tilever with tooth No. 9 as a lone abutment.

Figure 6—Radiograph taken 3 days afterthe accident. Note that tooth No. 9 washorizontally fractured. The patient losttooth No. 8 more than 20 years earlier.

TABLE 1—TREATMENTPLAN TEMPLATE

1. Clinical and radiographicevaluation.

2. Joint consultationbetween periodontist andrestorative dentist.

3. Fabrication of provisionalrestoration.

4. Implant placement andbone regeneration, if necessary.

5. Two to 6 months of healing.6. Second-stage surgery

including bone sculptingand placement of EPTemporary HealingAbutments®.

7. One month of healing.8. Implant level impression.9. Placement of permanent

abutments and provision-alization.

10. Papillary maturation.11. Final impressions of abut-

ments and impression ofprovisional restoration.

12. Temporary cementation ofthe final prosthesis.

healing is much improved,because these sutures cause mini-mal irritation to the epithelium.The vertical incisions were closedwith 5-0 gut sutures, as they were

in alveolar mucosa. Healing wasextremely rapid in this tissue.Nonresorbable sutures can be verydifficult to remove when withinalveolar mucosa because of therapidity of the healing. Therefore,a resorbable suture was used.

Second-Stage Surgery IncludingBone Sculpting

Six months were allowed to

pass before the implants wereuncovered, thus allowing for opti-mal bone regeneration. A full-thickness flap was elevated andthe e-PTFE membrane removed(Figure 11). Complete boneregeneration was noted beneaththe membrane. The immediateimplant placed within the alveo-lar bony housing was completelyregenerated (Figure 11). It was

necessary to remove bone toaccess the cover screws of theimplants, and additional bonealso would have to be removed tocreate a smooth emergence pro-file. The removal of bone toachieve the proper soft tissue con-tour (bone sculpting) can be ac-complished three ways (Table 2).

All three bone sculptingmethods work. Hand instru-

CONTEMPORARY ESTHETICS AND RESTORATIVE PRACTICE June 2002 49

Figure 8—Occlusal view of the implants inplace before placement of the bone graftingmaterial. The implant in the area of toothNo. 9 was completely housed within bone.However, a circumferential defect was pre-sent and regenerated with the application ofa bone graft. A membrane was not needed.

Figure 7—Surgical view on the day toothNo. 9 was extracted and implants placedat teeth Nos. 8 and 9. A large full-thick-ness flap has been elevated, providing ade-quate access for implant placement andbone grafting.

Figure 9—Facial view of the e-PTFEmembrane in place. Note that the mem-brane does not cover the implant in thearea of tooth No. 9. Two mini-screws wereused to stabilize the membrane.

Figure 10—Primary closure was achievedusing e-PTFE sutures. The vertical inci-sions allowed the flap to be elevatedocclusally. A connective tissue graft alsowas harvested from the palate and placedbeneath the flap to assure primary closure.

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Case Study continued

mentation is the most tediousand time consuming. If the boneis thick, it is not always practi-cal to rely solely on hand instru-mentation. High-speed rotaryinstruments such as finishing bursand Neumeyer burs are very effi-cient. However, the platform ofthe implant is not protected andmay be damaged during the pro-cedure. Bone profiling instru-ments (3i Implant Innovations

Inc.) create a smooth emergenceprofile efficiently and safely. Thisis the author’s bone sculptingtechnique of choice.

Bone profilers were used tocreate a smooth emergence pro-file (Figure 12). The bone wassculpted; this was possiblebecause the implants wereplaced a little greater than 3 mmfrom each other and slightlybeneath the crest of bone. A peak

of bone was created to guide thesoft tissues of the gingiva to forma papilla. If the implants wereplaced within 3 mm of eachother, it was likely that the bonewould resorb and the peak ofbone (Figures 12 and 13) wouldbe lost, per the author’s experi-ence. Hence, the papilla wouldshrink and a dark triangle wouldform between the implantcrowns. After the completion of the bone sculpting, EPTemporary Healing Abutments®

(3i Implant Innovations Inc.)were placed (Figure 13).

The wound was sutured andallowed to heal for 4 weeks. Fourweeks after implant exposure, apapilla was already beginning toform, despite the absence of a

50 June 2002 CONTEMPORARY ESTHETICS AND RESTORATIVE PRACTICE

Figure 11—Second-stage surgery was per-formed at 6 months. Complete bone regener-ation occurred on the facial surface of theimplant in the area of tooth No. 8. Sevenpreviously exposed labial threads were nowcovered with bone. The implant in the areaof tooth No. 9 also was well integrated.

Figure 12—The platforms of the dentalimplants after bone removal, removal ofthe cover screws, and bone sculpting. Thereis a peak of bone between the implants. Asmooth emergence profile could now beachieved.

Figure 13—Temporary healing abutmentswere placed. Resultant papilla would formbetween the implants.

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TABLE 2—BONESCULPTING TECHNIQUES

• Hand instrumentationwith chisels and curets.

• High-speed rotary instru-mentation using finishingburs and Neumeyer burs(Brasseler USA®).

• Bone profiling instruments.

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fixed provisional restoration(Figure 14).

ProvisionalizationThe patient was now ready

for provisionalization. Initial softtissue healing was now completeand the gingival tissues were sta-ble. An impression was made ofthe implants at the level of theplatform. This was transferred tothe laboratory and custom

UCLA abutments (3i ImplantInnovations Inc.) were made, ormachined prepable abutmentscould be chosen. A provisionalrestoration was made to fit thecustom or machined abutmentsand delivered to the restorativedentist. The permanent abut-ments were placed (Figure 15),followed by placement of theacrylic provisional restoration(Figure 16). The patient was

then allowed to heal in the pro-visional until the dentist andpatient were both satisfied withthe tooth-to-soft-tissue relation-ships. During this phase of care,the provisional restoration canbe modified to help guide thesoft tissue. The goals of therapyof the provisional phase are:• development of a dentalpapilla• obtaining a smooth emer-gence profile• achieving dental-gingivalharmony• creation of proper toothshape, size, and contour.

The above requirementsmust be met before impressionsare taken for the final restora-tion. In no instance should finalimpressions be taken until anideal provisional restoration hasbeen achieved. The provisionalrestoration is a template for thefinal restoration. All too often,too little attention is paid to theprovisional restoration. If idealesthetics are not achieved in theprovisional, it is unlikely thatideal esthetics will be obtained inthe final restoration.

FINAL IMPRESSIONS ANDTHE FINAL RESTORATION

Final impressions includedimpressions of the permanentabutments and of the soft tissue.A soft tissue model should be fabricated to allow the labora-tory to create a restoration withthe proper emergence profile. In addition, final impressionsshould also include an impres-sion of the provisional restora-tion. The laboratory now has theabutment impression as well as

an impression of the provisional.The provisional impression servesas a template for the laboratory tomake the final restoration.

The final restoration wasmade with a high degree of pre-dictability. This sequence ofevents minimizes laboratory make-overs. It saves time for the patient,dentist, and laboratory, and makesesthetic rehabilitation predic-table and hence, more enjoyable.

The final restoration became arecapitulation of the provisionalrestoration (Figure 17). Papillareformation had been achievedbetween the implant crowns aswell as between the implantcrowns and the natural teeth. Theheight of contour of the centralincisors was equal to the height ofcontour of the canines and apicalto that of the lateral incisors(Figures 17 and 18). All this ispossible because the treatmentplan template was followed.

Radiographically, a smoothemergence profile was evident(Figure 19). In addition, the peakof alveolar bone between theimplants could be visualized; thissupported the papilla. The distance from implant crown con-tact point to bone was 5 mm andthe distance between implantswas between 3 and 4 mm. The ini-tial parameters of papilla regenera-tion between implants were fol-

Case Study continued

52 June 2002 CONTEMPORARY ESTHETICS AND RESTORATIVE PRACTICE

BB one profilers were used to

create a smooth emergence profile.

Figure 17—The final restoration in place, 2days after temporary cementation. The gin-gival tissues were still slightly inflamed andcomplete papillary regeneration had not yetbeen achieved. Within 1 year, the papillaand soft tissue would be stable. (Laboratorywork courtesy of Precision Dental CeramX:Jim Mallick, CDT, and Tim Anrico, CDT,both of Fairfield, Connecticut.)

Figure 15—Permanent abutments wereplaced and the patient was about to receivethe provisional restoration. A piece of flosswas used to help visualize the dental gingi-val-marginal relationships.

Figure 16—The provisional restorationin place. Papillae were maturing and theappropriate dental-gingival relationshipswere achieved. The patient had beenwearing the provisional restoration for 2months. He was now ready for finalimpressions.

Figure 14—View 4 weeks after the sec-ond-stage surgery. The soft tissue washealing and a papilla was beginning toform, despite the absence of a provisionalrestoration.

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lowed. The result is an estheticallypleasing restoration (Figures 17,18, and 20) and a happy, smilingpatient (Figure 21).

Over time, soft tissues contin-ue to mature. Soft tissues may

recede during the first year afterthe implant crown is cemented.8

Six years after the cementation ofthe restoration, the patientshowed about 1 mm of labial gin-gival recession and complete filland maturation of the papillabetween the implants (Figure 20).

CONCLUSIONPredictability in esthetic

implant dentistry is possible.This article outlines a treatmentplan template that should serveas a guide for communication, aswell as treatment. The concept ofbone sculpting and its clinicalsignificance is essential in layingthe foundation for an esthetic,functional restoration.

Excellent communicationbetween restorative dentist,implant surgeon, dental labora-tory, and patient is essential ifpredictable results are to beachieved. Each step of the treat-ment planning process is only asstrong as the preceding step. Thesuccess of the final crown restson the quality of the provisional,which in turn rests on the qualityof the laboratory-fabricated crownand abutment—which rests onthe quality of the bone and softtissue, the quality of the surgicaltechnique, and the quality of thetreatment plan. All elements of thedental treatment plan should bestrong to allow for an estheticimplant restoration. �

REFERENCES1. Adell R, Eriksson B, Lekholm U, et al: Long-term fol-

low-up study of osseointegrated implants in thetreatment of totally edentulous jaws. Int J OralMaxillofac Implants 5(4):347-359, 1990.

2. Sonick M: Hard and soft tissue regeneration forimplants in the esthetic zone. Contemp Esthet RestPract 5(10):64-76, 2001.

3. Tarnow DP, Magner AW, Fletcher P: The effect of thedistance from the contact point to the crest of boneon the presence or absence of the interproximal den-tal papilla. J Periodontol 63(12):995-996, 1992.

4. Tarnow DP, Cho SC, Wallace SS: The effect of inter-implant distance on the height of inter-implant bonecrest. J Periodontol 71(4):546-549, 2000.

5. Gelb DA: Immediate implant surgery: three-year ret-rospective evaluation of 50 consecutive cases. Int J Oral Maxillofac Implants 8(4):388-399, 2000.

6. Summers RB: The osteotome technique: Part 2—theridge expansion osteotomy (REO) procedure.Compend Contin Educ Dent 15(4):422-436, 1994.

7. Buser D, Dula K, Hirt HP, et al: Localized ridge aug-mentation using guided bone regeneration. In: BuserD, Dahlin C, Schenk R, Guided Bone Regeneration inImplant Dentistry. Chicago, Quintessence PublishingCo., 189-233, 1994.

8. Small PN, Tarnow DP: Gingival recession aroundimplants: a 1-year longitudinal prospective study. Int J Oral Maxillofac Implants 15(4):527-532, 2000.

CONTEMPORARY ESTHETICS AND RESTORATIVE PRACTICE June 2002 53

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Product References

Figure 19—Radiograph of the implantswith the final restoration. Note the peakof bone between the implants. This wouldserve as support for the gingival papilla.Also note the smooth emergence profile,from the platform of the implants to theCEJs of the implant crowns.

Figure 20—Intraoral view of the implantrestorations 1 year after cementation.Note that there has been about 1 mm oflabial gingival recession. The gingival tis-sues have matured and the papillae nowfill the embrasure space between theimplants and between the implants andnatural teeth, an ideal esthetic result.(Restoration courtesy of Dr. Stephen Gussof Fairfield, Connecticut.)

Figure 18—Smile view of the patientwith the new implant crowns. Compareto Figure 2. Ideal dental-gingival rela-tionships were achieved.

Figure 21—Postoperative view,full-face smile.

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