Papilla Formation in Response to Computer-Assisted Implant Surgery and Immediate Restoration
This retrospective analysis was undertaken to evaluate the effect of immediate implant restoration using a computer-assisted technique in partially edentulous sites on interimplant and intertooth bone level stability and papilla formation. Nine partially edentulous patients received a total of 23 implants that supported immediately placed implant restorations. Planning was accomplished using a radiographic guide, which allowed visualization of the emergence profile from the platform of the implant to the cervical of the planned restoration. Guided implants were placed according to the manufacturer's instructions, and restorations were screw retained directly to the implant. Multiple implants were splinted at surgery with autopolymerizing resin. Measurements were made at a mean of 545 days (range 288–958) postoperatively on the basis of radiographs and photographs. Measures were: (1) distance from bone crest to platform, (2) bone crest to contact point, (3) interimplant distance at the outer diameter of the platform, and (4) papilla from highest point to a reference line. At follow-up time, the bone ridge was located higher than the implant platform (mean 0.57 mm) compared to implants whose interimplant distance was less than 3 mm (mean 0.27 mm). Mean increase of the bone level between insertion and approximate 1-year follow-up was 0.047 mm. The mean distance from the contact point to bone was 2.39/3.93 mm postoperatively, resulting in 91/71% papilla fill between implants and between implant and adjacent tooth, respectively. Computer-assisted surgery with the preplanned immediate restoration seems to be an effective method to minimize bone loss at the implant platform resulting in support for papilla.
(a) Prosthesis waxup radiographic guide (b) was made from the waxup. (c) Actual radiographic guide was scanned and converted in the program to a virtual image in which the cervical area is visible. (d) Combining computerized tomography scan and the radiographic guide (outlined in black) allows the creation of natural emergence profile shown in yellow.
Figure 2. Stereolithographic surgical template generated from the computer program with the sleeve. Figure 3. Surgical template was used to create preimplant model. (a) Specialized components implant replicas are placed into the template. (b) Original model is cut away in area of replica. (c) Template with replica is placed on original cast, and stone is poured around replica. (d) The soft tissue is reproduced using a matrix of the precut ridge.
Figure 4. (a) Implants were placed 0.5 mm below the bony crest without a raising flap. (b) Implant crowns were placed immediately after the implant placement and were connected at arrows using autopolymerizing PMMA resin. (c) Postoperative radiograph shows definitive restoration at 1 year. Figure 5. Radiographic interimplant and bone to contact measurement. (a) Radiographic measurement between implant and tooth. Most apical extent of bone on the tooth, implant platform, most coronal extent of bone on implant, and contact point were identified; the distances between those were measured. (b) Contact point, implant platform, and bony crest were identified; interimplant distance and the distances between contact point to bony crest were measured. Purple circle = most coronal point of the bone level contacting the implant. Solid red line = fixture abutment junction. Blue circle = most coronal point of the bone level contacting the tooth. Yellow circle = contact. Pink circle = bone crest. Green circle = coronal extent of papilla transferred from intraoral photo. (c) Distance from bone level on implant to platform. (d) Distance from bone level on tooth to the platform. (e) Distance from contact to the bone level on tooth. (f and g) Lateral distance (bone loss) from the implant to bone crest. (h) Vertical crestal bone loss. (i) Distance between implants at the implant-abutment interface. (j) Contact to bone crest.
Figure 6. Papilla measurement. (a) Midbuccal marginal line was connected (blue line). The distance between most coronal extent of papilla (green dot) and baseline was measured as papilla height (a). (b) The distance between the most apical circle of contact point (yellow dot) to the baseline was used to calculate the vertical papilla fill percentage. Blue circle = baseline. Green circle = top of papilla. Yellow circle = (a) papilla height, (b) contact to baseline. Figure 7. Calibration. Calibration was performed between the intraoral photos and models. The measurement of the red line in Figure 6 divided by the red lines on the models were calculated as the magnification. The actual distances were calculated using this magnification. Figure 8. Papilla score. (a) Score 1 (<50% fill). (b) Score 2 (>50% fill). (c) Score 3 (100% fill).
Figure 9. Correlation between platform to most coronal point of the bone level contacting the tooth and papilla vertical fill. Correlation coefficient −0.46, P = .08 (Pearson's correlation). Figure 10. Relationship between crestal bone level and interimplant distance. Bone level from the platform was measured as j, and interimplant distance was measured as i radiographically, as shown in Figure 5a. Each dot represents an individual implant.
Representative clinical papilla formation. Preoperative photo of single (a) and multiple implant sites (c). Postoperative photo of single (b) and multiple implants (d) showing papilla formation at 1-year follow-up.
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