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MSc PROJECT 2005
Soft Tissue Morphology Around Maxillary Anterior Single Tooth Astra Implants (A Retrospective Study)
Nami Farkhondeh Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
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Introduction Since the introduction of the Branemark titanium implant some 30 to 35 years ago (Branemark et al., 1969) for the dental rehabilitation of totally and partially edentulous patients, followup studies have shown very promising success rates and a bewildering number of alternative systems have entered the market. The main aim of implant placement is to achieve osseointegration. That is a direct structural and functional connection between ordered living bone and the surface of a load carrying implant. Following this, and if second stage surgery is required, access is gained to the implant and the transmucosal abutment is placed (following the healing abutment which is in place until soft tissue heals). Subsequently an impression coping is taken to transfer the location of the implant body or abutment to a dental cast and the prosthodontic phase of treatment begins. Although osseointegration of the implant is an obvious prerequisite for stability, longterm retention and aesthetics depends on the proper epithelial and connective tissue attachment to the abutment/restoration surface.
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
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The placement of dental implants in the aesthetic zone is challenging for the clinician and the attainment of gingival contour and interproximal papillary form compatible with adjacent teeth is important.
Periodontal Tissues Teeth are unique structures in the body as they penetrate lining mucosal epithelium. During tooth eruption the connective tissue between the oral epithelium and the reduced enamel epithelium breaks down this gives rise to the gingiva and in particular the dentogingival junction. It is important to first of all understand the structure of the periodontium around normal teeth and compare with that found around implants. The structures that make up the periodontium are: 1) The gingiva 2) The periodontal ligament 3) The root cementum 4) The alveolar bone
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
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The function of the periodontium is to attach the tooth to the bone tissue of the jaws and maintain the integrity of the masticatory mucosa (Lindhe et al., 2003). The macroscopic and microscopic anatomy of the gingiva and dentogingival junction will be considered in the following sections. Macroscopic anatomy of the gingiva The gingiva is masticatory mucosa which covers the alveolar process of bone and surrounds the cervical portion of teeth. It provides attachment between the oral mucous membrane and the dental hard tissues and protects the underlying periodontal tissues from bacterial invasion. In health its margin is located on enamel, is scalloped and follows the contour of the cementoenamel junction. The gingiva rises between the teeth to form complex pyramidal structures called interdental papillae. The presence of a biological width (that is the distance from the most coronal aspect of the alveolar bone to the gingival margin) around teeth has been described in the literature and Garguilo et al. (1961). Two hundred and eighty seven teeth in thirty autopsy specimens were examined and results revealed an average distance from the crest of bone to the gingival margin as being 2.04mm with 1.07mm of this being the connective tissue
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
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attachment and 0.97 being epithelial attachment. Vacek et al. (1994) carried out a similar cadaver study and found the dimensions to be consistent although slightly different from the Garguilo study (connective tissue attachment averaged 0.77mm epithelial attachment averaged 1.14mm). The gingiva can be divided into two parts (see fig. 1): 1) The free gingiva 2) The attached gingiva
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
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Figure 1 Shows the free gingiva (FG), the attached gingiva (AG) and the mucogingival junction (MGJ) Taken from Lindhe et al. 2004 [ Nami Farkhondeh ]
Free gingiva The free gingival extends from the gingival margin in an apical direction to the free gingival groove which is positioned at a level corresponding to the base of the sulcus. The free gingival margin is rounded in such a way that a small sulcus is formed between the tooth and the gingiva. In health this crevice is either absent or of minimal depth (00.5mm). The shape of the interdental papilla is determined by 1) The contact relationship between the teeth 2) The buccolingual width of the approximal tooth surfaces Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
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3) The course/shape of the cementoenamel junction. Attached gingiva The attached gingiva is keratinized and is termed masticatory mucosa, it extends from the free gingival groove to the mucogingival junction apically. It is pink in colour, firm and stippled. Its name is given to the fact that it is firmly attached to the underlying bone and so comparatively immobile. In health a periodontal probe penetrates the junctional epithelium to some extent. However, in situations of inflammation the probe can penetrate further until it is stopped by tissue resistance or the most coronal intact gingival fibres. Microscopic anatomy of the periodontium Epithelium Histologically the gingival epithelium can be divided into three zones: 1) Oral epithelium 2) Oral sulcular epithelium Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
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3) Junctional epithelium
Figure 2 Macroscopic representation of the periodontium (taken from Lindhe et al 2004) [ Nami Farkhondeh ]
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
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Oral epithelium This is the epithelium which faces the oral cavity, it is stratified squamous and normally orthokeratinized in nature. Sulcular epithelium This comprises the epithelium which faces the tooth without attachment to the tooth surface. It is nonkeratinized and has a shallow retepeg pattern. Junctional Epithelium The junctional epithelium in health is attached to the enamel surface by hemidesmosomes, It can additionally form on root surface cementum, dentine and implant surface. Following excision, the junctional epithelium reforms, this regenerated epithelium is indistinguishable from that which originally existed. This junctional epithelium has a high turnover rate and is highly permeable. Connective Tissue
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
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The connective tissue constitutes the major component of the gingiva and is composed of fibres (about 60% by volume), cells (around 5%), vessels and nerves (around 35%) which are embedded in amorphous ground substance. The different cell types are fibroblasts (predominant), mast cells, macrophages and inflammatory cells. The main fiber type is collagen typically arranged in discrete bundles (circular, dentogingival, dentoperiosteal and transeptal fibers), additionally there are reticulin, oxytalan and elastic fibers. The teeth are attached to the alveolar crest of bone by a wide array of connective tissue fibers which insert into root cementum as Sharpey’s fibers. This forms an essential part of the periodontal ligament; a complex structure 0.1 to 0.2 mm in width providing viscoelastic support to teeth.
Periimplant Mucosa The implant is one of the few prosthetic devices that has been shown to successfully and permanently breach the surface epithelium with few complications. Periimplant mucosa like its natural teeth counterpart is comprised of similar components i.e. gingival sulcus and epithelial and connective tissue attachments. It also has a similar histological
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
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arrangement although some differences in cell/fibre ratios have been described (Abrahamson et al., 1997). There is a biological need for the formation of a similar complex around implants in that bone exposed to the oral cavity will always cover itself with periosteum and connective tissue. This connective tissue will also cover itself with epithelium. The portion of the mucosa that faces the surface of the implant can be divided into two zones; a marginal zone harboring a junctional epithelium (about 2mm high) similar to that around teeth in that it can adhere to the implant surface, synthesize basal lamina as well as hemidesmosomes and a more apical zone comprised of connective tissue rich in collagen but poor in cells and vascular structures (11.5mm high). The mucosa surrounding an implant has been compared with that around teeth in a number of studies. In a study by Berglundh et al (1991) beagle dogs were used to compare healthy gingiva and periimplant mucosa around lower premolars. Mandibular premolars were extracted on one side and replaced by Branemark implants according to established protocols. Four months after abutment connection biopsies were taken from both tooth and implant sites. The results of this study as well as follow up studies
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
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(Berglundh et al 1992, 1994, 1996 and Abrahamsson et al 1996,1997) showed the following : a) The gingiva and periimplant mucosa are covered by keratinized oral epithelium that is continuous with a marginal zone containing junctional epithelium about 2mm in length. b) An apical zone (that is apical to the junctional epithelium) in implants is comprised of a fiber rich (with collagen fibers running almost parallel to the implant surface) and cell poor connective tissue about 1mm in length. These two zones form an implant mucosal attachment about 34 mm in length. They found that after abutment connection the junctional epithelium never reached the bone crest but was consistently short of it by about 1mm, this is the connective tissue zone. Buser et al (1992) stated that in the supracrestal area a direct connective tissue contact to the implant was seen and this portion of connective tissue was free of blood vessels and resembled closely an inflammation free scar tissue formation.
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
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Abrahamsson et. al. (1996) carried out a study to compare differences in marginal periimplant tissues around one stage (nonsubmerged) and two stage (submerged) implants. Five beagle dogs were examined. Three months after the extraction of mandibular premolars, one fixture of each implant system (Astra Tech, Branemark and BonefitITI systems) were randomly installed. Analysis of periimplant tissue revealed the mucosal barrier had similar composition around one and two stage implant installations. It also showed that the amount of lamellar bone in the periimplant region around the three implant systems was almost identical. Hence, provided that initial stability is secured following implant insertion, the hard and soft tissue healing to the implant is independent of whether the implant is initially submerged or not. In the study by Berglundh and Lindhe (1996) five beagle dogs were used to determine the dimension of the mucosalimplant attachment at sites with reduced thickness of the ridge mucosa. In this case premolars were extracted on both sides of the mandible and replaced with Branemark implants, however the volume of the ridge mucosa was maintained on one side (control) and on the other side the vertical dimension of the soft tissue was reduced to about 2mm. They found that in test sites wound healing consistently included bone resorption to maintain an implant mucosa height of 3mm. They suggested that a certain minimum thickness of periimplant mucosa is required and that bone resorption may occur to allow proper soft tissue attachment to form. This may partly explain the Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
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crestal bone loss that occurs during the first year following abutment connection and loading in some implant systems. They also stated that once the implant is exposed to the oral environment and in function, a mucosal seal of a certain minimum dimension is required to protect the underlying bone.
Periodontal probing around implants Ericsson and Lindhe (1993) examined the resistance to mechanical probing of gingiva around teeth compared to periimplant mucosa in health. Findings revealed that around implants the probe penetrated the tissue further than around teeth (approximately 2mm compared to 0.7mm). Around implants the probe tip penetrated the connective tissue as well as the junctional epithelium stopping short of the bone crest, while at teeth the probe tip stopped short of the apical portion of the junctional epithelium. Also, importantly bleeding on probing was found occasionally around implants but rarely around teeth. Therefore the presence of bleeding on probing as a clinical indicator of inflammation around implants may be less useful.
Astra Tech Implants
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
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The Astra Tech implant design (Astra Tech, Molndal Sweden) was originally described in a prospective study (Palmer et al., 1997) as having an internal conical abutment to implant connection with an internal antirotational element and a self tapping threaded body. Available with a 3.5mm diameter in lengths of 11, 13, 15 and 17mm it had a wider tapered collar with a microthreaded surface with an outer diameter at the implant opening of 4.5mm. The implants are manufactured in titanium with titanium dioxide powder blasted onto the surface to increase surface area (TiO blast). In this study fifteen patients fitted with single tooth Astra Tech implants in the anterior maxilla were selected. Surgical and two stage implant protocols were utilized in implant placement and fitted with metal ceramic crowns. Clinical evaluation was carried out using clinical photographs and radiographs after crown cementation and at four to six month intervals over two years. The radiographs were taken using the paralleling technique and examined using ×4 magnification. Two blinded examiners took the measurements on mesial and distal aspects of the implant from a defined point at the top of the implant. The results revealed minimal changes at bone level margins at both the one and two years and none of the changes were statistically significant. When bone loss did occur, this was in the first year and stabilized at year two. The maintenance of bone levels was postulated to be attributed to the microthreading. They also found there to be a 100% survival rate of the implants after two years of function. Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
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Palmer et al. (2000) further assessed these patients at year 3 and 5. Results revealed no implant losses over this time, no loosening or soft tissue problems. At crown insertion the mean bone level was 0.46 ± 0.55mm to 0.48 ± 0.56mm apical to the top of the implant neck, and there were no statistically significant changes in the radiographic bone level over the five years. This stability of bone level over time gives us good evidence of the maintenance of osseointegration with these implants. PuchadesRoman et.al. (2000) studied thirty partially dentate patients with single tooth implants which had been in place for at least two years to compare clinical, radiographic and microbiological parameters with Astra and Branemark implants. They also assessed whether variations in the two implant systems had an impact on the dimensions and health of periimplant tissues. Results revealed statistically higher probing depths and spirochetes around implants as compared to teeth. Also, probing depths were higher around Branemark as compared to Astra Tech implants, although these were considered not to be clinically significant.
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
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The Swedish group of Engquist et al. (2001, 2004) carried out successive prospective studies comparing the Astra Tech and Branemark implant systems primarily with regard to bone level changes. Both implant systems are made of commercially pure titanium, but have some differences in micro and macro design and the study was designed to test whether these differences would have effects on marginal bone levels. Sixtysix patients with edentulous arches were included in the trial and were randomly allocated to the Astra Tech or Branemark group. Radiographic examination of each patient was carried out at baseline, one year, three year and five year follow ups using a paralleling technique. Reference points on each implant were used to measure bone level changes with a ×7 magnifying lens. At the three year examination results revealed that in the upper jaw bone levels were situated 1.7mm from the reference point in Astra Tech implants and 2.2mm at Branemark implants. There was no significant change in bone levels between the one and three year examinations and there were no differences between the implant systems. They concluded that after the three years Astra Tech implants had a slightly higher bone level than Branemark implants but that this was not significant. Also the values of marginal bone levels reach a steady state after one year with bone loss being several times greater between fixture insertion and baseline (prosthesis connection) than between baseline and five year follow up. After five years bone level changes in the maxilla were 1.74 ± 0.45 Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
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with Astra implants and 1.98 ± 0.21 with Branemark. According to Albrektsson & Isidor (1994) the criteria of success of an implant system demand an average marginal bone loss of less than 1.5 mm during the first year after insertion of the prosthesis and thereafter 0.2 mm annual bone loss, i.e. a maximum of 2.3 mm bone loss after 5 years in function.
Interproximal Papillae and Single Tooth Implants A single tooth implant is one which has natural teeth or crowns to either side of it and in the maxillary anterior region these represent a great aesthetic challenge. Hence, despite very good success rates for osseointegration with implants, the achievement of good soft tissue aesthetics and attainment of good quality periimplant mucosa may be much more unpredictable. The ideal soft tissue aesthetic objectives of implant therapy are the achievement of a harmonious gingival margin without abrupt changes in tissue height, maintaining intact papillae and obtaining or preserving a convex contour of the alveolar crest (as in Figure 3).
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
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Figure 3 Shows gingival aesthetics around the 11 single tooth implant (from subject 2 in present study) [ Nami Farkhondeh ]
One of the problems following tooth extraction is the potential loss of hard and soft tissue. Under normal circumstances a maxillary anterior tooth extraction leads to, on average, approximately 2mm loss in vertical tissue height. The underlying bone structure plays a key role in the attainment of esthetic soft tissue in the anterior maxilla (Buser et al., 2004). Two structures are important; the bone height of the alveolar crest in the interproximal areas and the height and thickness of the labial bone wall.
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
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The interproximal crest height is thought to play a part in the presence or absence of periimplant papillae. In an initial paper by Tarnow et al. (1992) the hypothesis of a relationship between distance from contact point to the bone crest and presence of the interproximal papilla was tested. The findings stated that when the distance was 5mm the papilla was present 98% of the time while at 6mm this dropped to only 56% and at 7mm this was 27%. There are however a number of shortcomings in this study; firstly a crude periodontal probe was used to measure the distances, secondly papillae were scored simply in terms of presence or absence and finally all sites were used with no distinction being made for anterior/posterior or maxillary/mandibular locations. Wu et al. (2003) examined fortyfive adult Taiwanese patients to see whether the distance from the contact point to the bone crest on standardized periapical radiographs of maxillary anterior teeth is related to the presence or absence of interproximal papillae. Maxillary canine and incisor regions were examined with 200 interproximal sites. Their results were comparable to the above study. A distance of less than 4.7mm correlated to papillae being present 100% of the time, when it was 5.7mm the papilla was present 51% of the time and when it was 6.7mm or greater the papilla was present 23% of the time. They put the difference with the Tarnow study down to theirs being limited to anterior teeth and anterior papilla being more prone to recession as they are longer and thinner in shape. Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
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Tarnow et al. (2000) then studied the effect of interimplant distance on the height of the interimplant bone crest. Their study revealed the following: a) There is a lateral component to bone loss after abutment connection of a two stage implant once the biological width has formed. b) The lateral bone loss can result in greater interimplant crestal bone loss if the two implants are not spaced more than 3mm apart. c) This increased crestal bone loss results in an increased distance between the contact point and crest of bone and hence the presence of papilla. They recruited thirtysix patients and periapical radiographs taken using standardized paralleling techniques were computer scanned, imaged and magnified. A followup paper by Choquet et al (2001), gave more useful data. In this study, patients with single tooth Branemark implants in place for at least six months in the anterior maxillary region (premolars were included) were examined. Visual and photographic aids were used to score papillae by two blinded examiners according to the Jemt index (Jemt, 1997). This index is based upon how well the papilla fills the embrasure space i.e.
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
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completely absent, less than ½ present, fully present and hyperplastic. The distance from the contact point to the bone crest was measured using digitized long cone periapical radiographs. A relationship was found between this distance and presence of papilla. 5mm or less the papilla was present almost 100% of the time, but at 6mm+ this dropped down to the papilla being present 50 % or less of the time. They also stated that the relationship was more strongly linked to the bone level around adjacent teeth. They concluded that this relationship confirmed the findings by Tarnow et al. (1992) but that this relationship holds only for maxillary anterior single tooth implants. Despite the relatively increased thoroughness of this study, a number of serious shortcomings still prevail, the main two points being that: a) No attempt was made to accurately demarcate the contact point. b) No statistical analysis was carried out. Tarnow et al. (2003) followed this up by studying the effect of vertical distance between adjacent implants. Thirty three patients were used and 136 papilla examined. Their conclusions were that two to four millimeters of soft tissue height can be expected to cover the inter implant crest of bone which leads to a one to two millimeter deficiency in papillary height and an esthetic problem. They also stated that attaining good papillae is
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
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more difficult between two implants when compared to that between an implant and a tooth. Gastaldo et al. (2004) carried out a study which included the effect of vertical and horizontal distances between a tooth and an implant on the incidence of interproximal papillae. They measured the effect of these two factors both independently and codependently on the presence or absence of papillae. Their findings concluded the following: a) The implant to tooth distance (horizontal measure from shoulder of implant to adjacent tooth) less than 3mm determines the absence of interproximal papilla independent of the vertical distance. b) When the implant to tooth distance is more than or equal to 3mm, there is an interaction between the horizontal and vertical distances. c) When the vertical distance between the base of the contact point and the bone crest is 3, 4 or 5mm and the horizontal measure is 3, 3.5 or 4mm the papilla is more frequently present. d) Between two implants the results are less favorable than between a tooth and an implant.
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
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The problems with this study are that bone sounding has been used. This is the use of a periodontal probe (0.5mm increments) to take all measurements. This method is quite crude and inaccurate for measuring vertical distances due to factors such as force used, and angulation of the probe. It would appear to be a most inaccurate way of measuring horizontal distances. A study by Kan et al (2003) carried out at Loma Linda University aimed to evaluate the dimensions of periimplant mucosa of two stage maxillary single tooth implants. Bone sounding using a periodontal probe was used in fortyfive patients with single tooth anterior maxillary implants. Their results showed that the level of the interproximal papilla was independent of the proximal bone level next to the implant but was related to the interproximal bone level next to the adjacent teeth. Again the use of bone sounding in the experiment by one examiner can be seen as leading to inaccuracies. Jemt (1997) concluded from his study that the papillae adjacent to single tooth implant restorations regenerates to some extent after 13 years without any clinical manipulation of the soft tissue. He reported 90% of his cases as not showing ‘perfect papilla’ on
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
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insertion of the final prosthesis, but after a mean follow up time of 1.5 years, 80% showed an increase in the soft tissue volume in the papillary area and 60% showed a ‘perfect papilla’. Both Bengazi et al. (1996) and Grunder (2000) found there to be recession of the soft tissue margin on the facial aspect of implants. The former found this to be 0.4 mm after 6 months and 0.7mm after 24 months. Unlike this study the latter used augmentation procedures (membrane placement during implant insertion and a connective tissue graft), findings showed similar amount of shrinkage; 0.6mm after 12 months, they also found the soft tissue volume in the papilla area increased on average by 0.38mm after the first year and none of the papillae lost height. Having labial bone of sufficient height and thickness is important for the long term stability of harmonious gingival margins around implants and adjacent teeth. Attempts to place implants in sites with labial bone defects can lead to soft tissue recession, potentially exposing implant collars and leading to loss of harmonious gingival contour (Buser et al., 2004). Once an implant is placed and following the insertion of the crown there may be some recession of the soft tissue margin (Bengazi et al., 1996) leading to possible exposure of the implant. To counteract this and create a favourable emergence profile it has been suggested to position the head of the implant apical to the cementoenamel junction of neighbouring teeth (Palacci et al, 1995) and placing the
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
Nami Farkhondeh Dentist, Page 26 of 61
abutment shoulder 12mm below the mucosal margin (Andersson et al., 1995), although this may favour soft tissue inflammation (Jemt et al., 1990). A study by Chang et. al. (1999) on twenty subjects compared teeth restored with single tooth Branemark implants and the contralateral tooth in terms of crown form and soft tissue dimensions. The implants were all restored with crowns that had been in place for at least six months and were compared with contralateral teeth in the maxillary aesthetic zone that were not restored. The crown of the tooth was assessed according to clinical length, width, faciolingual dimensions and contact point position, while the soft tissue dimensions were assessed using width of keratinized mucosa, mucosal thickness, soft tissue margin level and papillary height. Patient based satisfaction was also measured using a visual analogue scale (V.A.S.). Results revealed longer implant crowns compared to natural teeth and a smaller faciolingual width. The soft tissue margin at both facial and proximal sites was more apically located at implant sites compared to contralateral natural teeth. Moreover it was found that papillary dimensions were lower on the distal aspect of implants compared to corresponding teeth. This is however a contentious point as the majority of the teeth examined were maxillary central incisors that share their papillae with the adjacent central incisor. Also the subject number can be argued to be low. Interestingly patient satisfaction on the V.A.S. had a median value of 96% showing that the observed differences may have been of little concern to the patients themselves.
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
Nami Farkhondeh Dentist, Page 27 of 61
Patient Centred Outcome There is an increasing tendency to scientifically evaluate patients opinions of various types of implant supported prosthesis (Belser et al., 2004), especially when placed in the aesthetic zone. De Bruyn et al. (1997) in a three year study of Branemark implants investigated patient satisfaction with regards to eating, aesthetics, phonetics and overall satisfaction on a six point scale. Sixty one patients were questioned who had implant retained bridges and comparisons were made between preimplant situation, short term (less than four months) and longterm functioning (three years). Results showed that majority of patients were satisfied with their prosthesis. Vermylen et al. (2002) carried out a retrospective study to evaluate patient opinion regarding treatment outcome. Forty eight patients with single tooth Branemark implant restorations placed by periodontists and restored by general dental practitioners replied to a questionnaire by post. The questions related to aesthetics phonetics, cost to benefit ratio and opinion on the treatment procedure. The questionnaire was based on a six grade ordinal scale. These same patients were examined clinically (only forty patients attended) and radiographically to determine contact point to crestal bone distance. They concluded
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
Nami Farkhondeh Dentist, Page 28 of 61
that; overall patient satisfaction was high regarding aesthetics, phonetics, eating ability and overall satisfaction. The professional rating revealed restorations were of acceptable to perfect quality as assessed by an independent examiner with seventeen cases being perfect and twenty five cases acceptable. Levi et al. (2003) assessed patient satisfaction with their maxillary anterior implant restorations. Seventy eight patients responded to postal questionnaires. They found that five variables; implant position, definitive restoration shape, appearance, effect on speech and ability to chew were most strongly associated with overall satisfaction. Pjetursson et al. (2004) carried out a ten year prospective study on 104 patients with ITI implants. Questionnaires were filled in by each subject and a visual analogue scale (VAS) was used on a 0 to 100 continuum using the questions mentioned in the questionnaire. Results showed that over 90% of the patients were satisfied with their implants when asked questions such as function and chewing comfort, phonetics, aesthetics and cleansability. The majority of patients reported no difference between implants and their natural teeth, in fact some preferred the implants to their natural teeth. This was elicited by both questionnaires and using the VAS. Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
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AIMS The aims of the study were to: ● Evaluate the effect of vertical distance from the contact point to the crest of bone on both implant and adjacent tooth on the form and size of the papilla. ● Evaluate the effect of the distance from the implant shoulder to the adjacent tooth on the form of the papilla. ● Determine overall rates of patient satisfaction with their implant restorations and assess whether patient perception differs from that of a clinician.
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
Nami Farkhondeh Dentist, Page 30 of 61
MATERIAL AND METHODS Twentyeight patients (fourteen male and fourteen female) who were treated with single tooth implants at Guy’s and St. Thomas’s hospital London were recalled for this retrospective study. All these patients had a single tooth implant retained fixed prosthesis in function for at least twelve months. Ethical approval was gained for the study and informed consent was obtained from all patients. The following inclusion criteria were used: ● Presence of natural teeth on either side of an Astra Tech implant single tooth restoration. ● Only maxillary anterior implants were selected (i.e.within canine/incisor zone) ● Implant in function for at least one year. ● If more than one single tooth implant present, only one picked randomly using a coin toss. There were no specific exclusion criteria. Each subject was initially asked to fill out a satisfaction questionnaire (see figure 4) regarding crown shape and color, gum shape and color, ability to eat and talk, comfort, ease of care and any additional problems they may have had.
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
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Figure 4 The questionnaire filled out by subjects [ Nami Farkhondeh ]
Photographic Data Clinical photographs were taken from each patient using a canon EOS 300D digital camera with ring flash. A magnification of 1:1.2 was used with the same photographer taking each image. Three photographs were taken from each patient with images revealing the mesial papilla, mid gingiva and distal papilla. Images were taken perpendicular and tangential to the area of interest (Figure 5)
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
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Figure 5 An example of a photograph taken showing the mesial papilla around 11 revealing the deficient papilla and black triangle. [ Nami Farkhondeh ]
Photographs were evaluated by a blinded examiner to assess the presence of papilla and to give a score in terms of gingival colour/contour and crown shade/contour of the implant prosthesis using the same scale used by the patient. Radiographic Data A 0.25 mm orthodontic wire was placed between each contact point and tightened to demarcate the position of the contact point on the radiograph (Figure 6).
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
Nami Farkhondeh Dentist, Page 33 of 61
Figure 6 Picture of wire placed between single tooth implant and adjacent teeth to demarcate the contact point. [ Nami Farkhondeh ]
Periapical radiographs were taken using standardized paralleling technique with anterior Rinn holders (Figure 7).
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
Nami Farkhondeh Dentist, Page 34 of 61
Figure 6. Example of a periapical radiograph taken with a 0.25mm orthodontic ligature wire in place demarcating the contact points. [ Nami Farkhondeh ]
Measurements The radiographs were examined with a ×7 magnification (Peak Scale Lupe 7× Lens) to measure the distance from the contact point to the bone crest both on the implant and adjacent tooth at both mesial and distal sides. The measurement was taken to the closest 0.1mm. Horizontal measurements were also taken from the shoulder of the implant to the adjacent tooth using the lens again and again to the closest 0.1mm. The reference landmark was the widest point of the collar of the implant which approximately corresponds to the implantabutment interface (Fig. 8) Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
Nami Farkhondeh Dentist, Page 35 of 61
Figure 8. Shows the measurements taken. A – Contact point to bone crest on adjacent tooth B – Contact point to bone crest on implant C – Horizontal measurement (implant shoulder to tooth) [ Nami Farkhondeh ]
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
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Papillae Assessment Measurements of papillae score were taken both mesially and distally by a blinded examiner using the photographs. The assessment was made using the Jemt index (Jemt, 1997): ● Score 0 – No papilla is present, and there is no indication of a curvature of the soft tissue contour adjacent to the single implant restoration. ● Score 1 – Less than half of the height of the papilla is present. A convex curvature of the soft tissue contour adjacent to the single implant crown and the adjacent tooth is observed. ● Score 2 – Half or more of the height of the papilla is present, but does not extend all the way up to the contact point between the teeth. The papilla is not completely in harmony with the adjacent papillae between the permanent teeth. ● Score 3 – The papilla fills up the entire proximal space and is in good harmony with the adjacent papilla. Optimal soft tissue contour. ● Score 4 – The papilla is hyperplastic and covers too much of the single implant restoration and/or adjacent tooth. The soft tissue contour is more or less irregular.
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
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RESULTS Twenty eight subjects were recalled and evaluated. 3 subjects had more than one implant and therefore one implant was chosen at random for evaluation. One subject had open contact points mesially and distally, and 13 subjects had open contact points on one aspect. Because of this distal and mesial readings were assessed separately.
Implant Measures The mean measures from the contact point to the bone crest on both the implant and adjacent tooth and horizontal distances on both mesial and distal sides are shown below in Table 1.
Adjacent Tooth
Implant
Horizontal
Mesial
6.6 (+ 1.9)mm
10.1 (+ 2.8)mm
3.1 (+ 1.4)mm
(n=22)
(n=22)
(n=28)
5.8 (+ 1.3)mm
7.8 (+ 1.5)mm
1.8 (+ 0.6 )mm
(n=19)
(n=19)
(n=24)
Distal
Table 1. Mean (SD) vertical distances in mm’s from contact point to adjacent tooth and implant and horizontal measures in cases where measurements were possible (n). [ Nami Farkhondeh ]
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Nami Farkhondeh Dentist, Page 38 of 61
From the 28 subjects studied with 56 interproximal papillae, 31 (55%) presented with full papillae (Jemt score 3), 20 (36%) presented with more than half papillae present but not full (Jemt score 2), 4 (7%) with less than half the papilla present and 1 (2%) subject presented with a papilla judged to be hyperplastic. The median Jemt scores of the twentyeight patients are shown in Table 2. Few papillae received scores of 1 (n=3) and 4 (n=1), and therefore for statistical analysis the scores were dichotomized (1 plus 2 – absent to some degree and 3 plus 4 present or enlarged)
Jemt Score
Mesial papillae 3 (23) (n=28) Distal papillae
3 (23)
(n=28) Table 2. Median (and interquartile range) Jemt Scores [ Nami Farkhondeh ]
Table 3 shows the correlation between vertical radiographic measures and corresponding Jemt scores. Results show a significant correlation between the distance from the contact point to the bone crest on the adjacent tooth on the mesial side and the Jemt score (P Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
Nami Farkhondeh Dentist, Page 39 of 61
<0.05). The relationship between the distance from the contact point to the bone crest on the implant mesially and the Jemt score is approaching significance. However both distal measurements are not statistically significant.
Adjacent Tooth Mesial bone and Jemt Score of 21
Number Observations Spearman’s Rho Probability (P)
Adjacent Tooth Distal bone and Jemt Score 18
Implant Mesial bone and Jemt Score 21
Implant Distal bone and Jemt Score 18
0.57
0.30
0.39
0.15
0.007
0.22
0.08
0.56
Table 3. Spearman correlation coefficients between vertical radiographic measures and Jemt scores. [ Nami Farkhondeh ]
Table 4 describes the Jemt scores in relationship to the contact point to bone distances as described by Tarnow et al (1992, 2003) for the mesial papillae. This shows that mesially, when this distance is less than or equal to 5mm the papilla is always present. Between 5 and 6mm the papilla is only fully present two thirds of the time. Above 6mm the papilla is normally deficient.
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
Nami Farkhondeh Dentist, Page 40 of 61
≤ 5mm
5.16mm
>6mm
Jemt score 3/4
6
2
4
Jemt score 1/2
0
1
8
%age present
100%
66%
33%
Table 4. Distance from mesial contact point to the crest of bone on adjacent tooth and papilla presence. [ Nami Farkhondeh ]
When applied to the distal measure this relationship is not seen with only 66% of papilla fully present when the distance from contact point to crest of bone on adjacent tooth is less than or equal to 5mm. It is 100% present when the distance is 5.1 to 6mm and 33% when the distance is more than 6mm (Table 5).
≤ 5mm
5.16mm
>6mm
Jemt score ¾
4
6
2
Jemt score ½
2
0
4
%age present
66%
100%
33%
Table 5. Distance from distal contact point to the crest of bone on adjacent tooth and papilla presence. [ Nami Farkhondeh ]
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
Nami Farkhondeh Dentist, Page 41 of 61
14 subjects had both measurable mesial and distal bone level readings, providing data for 28 papillae (Table 6). Over the threshold of 6mm the presence of a papilla is less than 50%.
≤ 5mm
5.16mm
>6mm
Jemt score ¾
5
6
7
Jemt score ½
1
1
8
%age Present
83%
86%
47%
Table 6. Distance from contact point to crest of bone on adjacent tooth when mesial and distal readings taken together and papillary presence. [ Nami Farkhondeh ]
Table 7 describes the Jemt scores in relationship to the distance from the contact point to the bone crest on the implant for the mesial papillae. This shows that when the distance is less than 9mm the papilla is fully present 78% of the time, between 9 and 10mm the papilla is present 60% of the time. Above 10mm the papilla is only present 29% of the time.
<9mm
910mm
>10mm
Jemt score ¾
7
3
2
Jemt score ½
2
2
5
%age present
78%
60%
29%
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
Nami Farkhondeh Dentist, Page 42 of 61
Table 7. Distance from mesial contact point to bone crest on implant and papilla presence. [ Nami Farkhondeh ]
When taken for distal measures of contact point to bone crest of the implant, different parameters had to be used to keep a reasonable number of subjects in each group. The results are described in table 8 and show that when the distance from the contact point to implant is less than 7mm distally the papilla is fully present 66% of the time, between 7 and 9mm the papilla is fully present 75% of the time. Above 9mm the papilla is only present 50% of the time.
<7mm
79mm
>9mm
Jemt score 3/4
4
6
2
Jemt score 1/2
2
2
2
%age present
66%
75%
50%
Table 8. Distance from distal contact point to bone crest on implant and papilla presence.[ Nami Farkhondeh ]
For the 14 subjects with both mesial and distal bone level readings (28 papillae) the readings are described in table 9.
<8mm
810mm
>10mm
Jemt score 3/4
8
6
2
Jemt score 1/2
3
4
5
%age present
73%
60%
29%
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
Nami Farkhondeh Dentist, Page 43 of 61
Table 9. Distance from contact point to crest of bone on implant when mesial and distal readings taken together and papillary presence. [ Nami Farkhondeh ]
Table 10 shows the relationship between the horizontal measure from the implant abutment to the adjacent tooth and the presence or absence of papilla. Results show a relationship horizontally on the mesial side and the Jemt score which is approaching significance, however the measure distally is again not statistically significant.
Mesial Horizontal Distance Distal Horizontal Distance and Jemt Score and Jemt Score
Number of Observations
26
22
Spearman’s Rho
0.33
0.24
Probability
0.09
0.27
Table 10. Correlation between horizontal measures (implant shoulder to tooth) and Jemt scores.
[ Nami Farkhondeh ]
The horizontal measures from the shoulder of the implant to the adjacent tooth were all within a small range so the findings of Tarnow et al. (2000) could not be assessed.
Patient Satisfaction Patients filled out a questionnaire to express their degree of satisfaction with different aspects of their implant on a scale of 1 to 6. The clinical examiner also scored on the
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
Nami Farkhondeh Dentist, Page 44 of 61
same scale the crown shape/colour and gingival shape/colour. A blinded examiner also scored on these criteria using the photographs (see figure 9).
Figure 9. Mean scores for Crown Shape (C.S.), Crown Colour (C.C.), Gingival Shape (G.S.) and Gingival Colour (G.C.) as scored by the patient, clinical and photographic assessment. [ Nami Farkhondeh ]
These results show consistent differences in scoring with the patient scoring the highest, followed by the clinical examination and with the blinded photographic assessment consistently scoring the lowest. Kappa scores were calculated to assess agreement between the three. The agreement between the scorers was low as seen in the scores for crown shape in Table 11. Scores for the other three parameters generally followed the same pattern between the three scorers. Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
Nami Farkhondeh Dentist, Page 45 of 61
Patient/Student
Student/Consultant
Patient/Consultant
Agreement (%)
19.23
36.00
12.00
Kappa
0.09
0.13
0.02
Table 11. Kappa scores comparing the three scorers when scoring for crown shape. [ Nami Farkhondeh ]
Patient scores for ability to eat, ability to talk, comfort and ease of care were generally very good (see figure 10) with near to maximum scores in patient satisfaction in all parameters.
Figure 10. Mean patient scores for the different parameters. [ Nami Farkhondeh ]
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
Nami Farkhondeh Dentist, Page 46 of 61
DISCUSSION Implant Measure The importance of good soft tissue aesthetics and especially full papillae, without black triangles, in the anterior maxillary region is claimed to be of great importance and a number of papers have been published to examine the factors that may contribute to this. Initially Tarnow et al. (1992) examined whether the distance between the contact point of natural teeth and the crest of bone correlated with the presence or absence of interproximal papilla in humans. They examined 288 interproximal sites on both anterior and posterior teeth and measured contact point to bone crest distances using a Williams periodontal probe rounding off to the closest millimeter. Their findings revealed that when the distance from the contact point to the crest of bone was 5mm or less the papilla was present almost 100% of the time, when the distance was 6mm the papilla was present 56% of the time and at 7mm the papilla was present 27% of the time. Choquet et al (2001) applied this hypothesis to maxillary anterior single tooth implants. They examined 52 papillae and rather than judging the papillae to be either present or absent, as in the study above, the Jemt index was used to score the papilla. Additionally
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
Nami Farkhondeh Dentist, Page 47 of 61
long cone periapical radiographs were taken to measure distances from the contact point to the most coronal point of the bone level facing the teeth. They concluded from their findings that when this distance was less than 5mm the papilla was present almost 100% of the time, between 55.9mm the papilla was present 88% of the time and above or equal to 6mm the papilla was present 50% of the time or less. In our study a number of patients had no contact point to bone level reading due to open contact points. In addition mesial and distal readings were initially assessed separately as they are not independent. Generally the mean distance from contact point to bone crest on the adjacent tooth was less than the distance from the contact point to the bone crest on the implant (6.6 as compared to 10.1 mesially and 5.8 compared to 7.8 distally). A statistically significant relationship was found mesially between contact point to bone crest on the adjacent tooth distance and papilla presence. This relationship bears a similar resemblance to that found by Choquet et al. where, when less than or equal to 5mm the papilla is always present, between 5.1 to 6mm the papilla is present two thirds of the time and above 6mm only one third of the time. Distally, although not statistically significant, a relationship can be seen where when less than or equal to 6mm in distance, the papilla is present 83% of the time and above this distance only 33% of the time. With both mesial and distal readings taken, in patients who have both bone level readings present, the 6mm reading seems critical again. When the distance is 6mm or less, the papilla is fully present 85% of the time, above 6mm the papilla is only present 47% of the time.
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
Nami Farkhondeh Dentist, Page 48 of 61
When assessing the relationship between papilla presence and the distance from the contact point to bone crest on the implant, no statistically significant relationship is seen, although mesially the relationship is approaching significance. However, when mesial readings are taken on their own and when mesial and distal readings are taken, in those with both available, a relationship is seen with the cutoff point being 10mm. When both readings are taken, at less than 8mm distance, 73% of the papillae were fully present, between 810mm the papillae were fully present 60% of the time while above 10mm this becomes less than half that with papillae present only 29% of the time The horizontal relationship between the distance from shoulder of the abutment to the adjacent tooth and papilla presence is not statistically significant. Mesially this relationship is approaching significance. Unfortunately from our results these readings are difficult to analyse due to the narrow range. It has been stated that the minimal distance between the implant and adjacent tooth that will permit adequate interseptal bone and papilla formation is 1.5mm (Smukler et al, 2003). With our readings these distances were nearly all above 1.5mm so this distinction could not be made. Two major criticisms can be made of the Choquet et al.(2001) findings. Firstly no accurate definition of the contact point was made. It is impossible to accurately define the contact point between a single tooth implant restoration and the crown of the adjacent
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
Nami Farkhondeh Dentist, Page 49 of 61
tooth on a periapical radiograph, therefore, inaccuracies of 1mm or more can easily be made. Secondly, in assessing papillae they appear to have modified the scoring parameters to highlight their findings. As already stated a Jemt score of 3 denotes a full papilla with no evidence of black triangles while a score of 2 is for a papilla which is at least half present but not up to the contact point. In their results (Choquet et al 2001), for vertical measures of 6mm or less, when the papilla was said to be present almost 100% of the time, they accepted Jemt scores of both 2 and 3 to denote full papilla presence (as already stated a Jemt score of 2 indicates a incomplete papilla). While at measures of 6mm or more where they claimed the papilla was present 50% of the time or less they accepted a Jemt score of 2 to denote papillary absence. Strangely, at values of more than 9mm they again accepted a Jemt score of 2 to denote the papillae as being fully present (see their table reproduced in appendix 1). As seen in their table they have also incorrectly stated that from their findings, at distances of above 6mm, the papilla is present 50% or less of the time When all the papilla are used in the present study (n=39) and the results tabulated as in the Choquet et al. study (2001), but using a Jemt score of 3 as being fully present papilla and a Jemt score of 2 as absent papilla (see appendix 2) the results show a much clearer result with contact point to bone crest of adjacent tooth distances of over 6mm resulting in papillae being fully present 50% or less of the time. If we applied the same scoring
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
Nami Farkhondeh Dentist, Page 50 of 61
system as Choquet et al. used in their study (see appendix 3) we end up with a much more favouirable set of results.
Patient Satisfaction The success of dental implants and their prosthetic restoration is usually based on fixture survival or longevity of the prosthetic reconstruction, while data on patient opinion about their treatment results are less available. In our study patients scored on a scale of 16, varying criteria along with a comment on any problems they had experienced since the implant had been fitted. All the implants and prosthetic components were placed by a postgraduate students or clinical tutors in the areas of periodontology, implantology and prosthodontics. From our results on patient satisfaction levels, it can be seen that generally patients were very happy with their implant treatment. Patients scored aesthetics in terms of crown shape, crown colour, gum shape and gum colour. As seen in our results the mean score for all of these parameters was above 5 with patients rarely scoring under 5 for any of these variables. Additionally, these parameters were scored by the clinical examiner at the time of examination (the examiner was blinded to the patients completed questionnaire when scoring) and by a clinical tutor using the photographs available. The results show that the clinical examiner consistently scored lower than the patient with mean scores all between 4 and 5 for all four parameters. This showed that the Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
Nami Farkhondeh Dentist, Page 51 of 61
clinical examiner, with the opportunity to make comparisons with the contralateral tooth, to be generally satisfied with the aesthetics of the implant restoration. However, the scoring criteria was more critical than that applied by the patient. The scores given by the clinical tutor using photographs (usually without the ability to make comparisons with the contralateral tooth) were consistently lower than that of the clinical examiner with mean scores in the lower region of the 45 scale for the crown parameters and scores between 34 for the gingival parameters. It can be seen from the kappa scores for agreement between scorers that there was no similarities between the three. The patients were generally very satisfied with the aesthetics. This is in agreement with a number of other studies carried out (Chang et al., 1999, Vermylen et al., 2003). However, clinicians would tend to be more critical about aesthetics and so give lower scores on these parameters. The difference between the clinical examiner and the clinical tutor is explained by one of two factors: ● The greater experience of the tutor may lead to a more critical scoring system. ● The inability to compare the aesthetics of the implant site with the contralateral area may affect the results. Additionally, the patient scored a number of other criteria. These were the ability to eat and talk, comfort, ease of care and overall satisfaction. As seen in figure 10, their mean scores were all extremely high (between 5.7 and 5.9). Each patient also commented on any problems they had since the implant was fitted. Most of these areas were left blank.
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
Nami Farkhondeh Dentist, Page 52 of 61
A couple of patients noted that their implant restoration had come loose since being fitted and needed to be replaced and one commented that he occasionally had a throbbing sensation around the implant and surrounding gum tissue (in this case no clinical or radiographic pathology was noted).
CONCLUSIONS The assessment of the 28 subjects in our study, with anterior single tooth Astra Tech implants, revealed the majority to be of a high standard both aesthetically, as scored by the patients and clinicians and subjectively as scored by the patient. The interproximal area of these restorations is a crucial factor in the aesthetics and although in most cases the papilla was fully present, some cases revealed incomplete fullness with the presence of black triangles. The presence or absence of the papilla is related to the bone level on the adjacent tooth which should be within an appropriate distance (less than 6mm) from the contact point, in maxillary anterior single tooth Astra Tech implants, to provide support for the overlying soft tissue. The position of the bone crest on the adjacent tooth appears to be the determining factor while the position of the implant platform is of less significance in term of papillary height development. This can be used to good effect clinically in the pre Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
Nami Farkhondeh Dentist, Page 53 of 61
surgical analysis of a single tooth implant site, where clinical and radiographic bone height can be assessed on the adjacent teeth either side of an edentulous space to better predict aesthetic outcome. This research project is not the first to test this hypothesis, however it is the first to examine the effects with Astra Tech implants as opposed to Branemark implants. The use of a 0.25mm orthodontic ligature wire to demarcate the contact point is also a new concept, but one that was considered the best way to mark an area notoriously difficult to define. There are, however, a number of shortcomings in the present study. The subject number was low and due to the high proportion of open contact points or unreadable measures, many of these could not be used.
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
Nami Farkhondeh Dentist, Page 54 of 61
Appendix Distance <5 contact point to bone crest (mm) Number 13
5.16
6.17
7.18
8.19
>9
17
8
4
4
6
% present
100% 88%
50%
75%
50%
66%
% absent
0%
12%
50%
25%
50%
33%
Jemt 0
0
0
0
0
2
2
Jemt 1
0
2
0
0
0
0
Jemt 2
4
5
4
1
2
1
Jemt 3
9
10
4
3
0
3
Appendix 1 Presence/absence of papilla around single tooth implant in relation to distance (mm) from contact point to bone crest (from Choquet et al., 2001) [ Nami Farkhondeh ]
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
Nami Farkhondeh Dentist, Page 55 of 61
Distance <4 contact point to bone crest (mm) N 3
4.15
5.16
6.17
7.18
8.19
>9
9
9
9
4
3
2
% present
100%
78%
89%
44%
50%
0%
0%
% absent
0%
22%
11%
56%
50%
100%
100%
Jemt 0
0
0
0
0
0
0
0
Jemt 1
0
1
1
0
0
1
0
Jemt 2
0
1
0
5
2
2
2
Jemt 3
3
7
8
4
2
0
0
Appendix 2 Presence/absence of papilla around anterior single tooth implants in relation to distance from contact point to bone crest on adjacent tooth (present data all papillae). [ Nami Farkhondeh ]
Distance <4 contact point to bone crest (mm) N 3
4.15
5.16
6.17
7.18
8.19
>9
9
9
9
4
3
2
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
Nami Farkhondeh Dentist, Page 56 of 61
% present
100%
89%
89%
44%
50%
66%
100%
% absent
0%
11%
11%
56%
0%
33%
0%
Jemt 0
0
0
0
0
0
0
0
Jemt 1
0
1
1
0
0
1
0
Jemt 2
0
1
0
5
2
2
2
Jemt 3
3
7
8
4
2
0
0
Appendix 3. Presence/absence of papilla around anterior single tooth implants in relation to distance from contact point to bone crest on adjacent tooth (Our findings using Choquet et al. scoring system). [ Nami Farkhondeh ]
REFERENCES 1. Abrahamsson, I., Berglundh, T., Lindhe, J. The mucosal barrier following abutment dis/reconnection. An experimental study in dogs. Journal of Clinical Periodontology 1997; 24: 568572. 2. Abrahamsson, I., Berglundh, T., Wennstrom, J., Lindhe, J. The periimplant hard and soft tissue at different implant systems. A comparative study in the dog. Clinical Oral Implants Research 1996; 7: 212219.
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
Nami Farkhondeh Dentist, Page 57 of 61
3. Abrahamsson, I., Berglundh, T., Glantz P.O., Lindhe, J. The mucosal attachment at different abutments. An experimental study in dogs. Journal of Clinical Periodontology 1998; 25: 721727. 4. Abrahamsson, I., Berglundh., T., Moon, IS, Lindhe, J. Periimplant tissues at submerged and nonsubmerged titanium implants. Journal of Clinical Periodontology 1999; 26: 600607. 5. Astrand P., Engquist B., Dahlgren S., Grondahl K., Engquist E., Feldmann H. Astra Tech and Branemark system implants: a five year prospective study of marginal bone reactions. Clinical Oral Implants Research 2004; 15: 413423. 6. Bengazi, F., Wennstrom J.L., Lekholm U. Recession of soft tissue margin at oral implants. Clinical Oral Implants Research 1996; 7: 303310. 7. Belser U.C., Schmid B., Higginbottom F., Buser D. Outcome analysis of implant restorations located in the anterior maxilla: a review of the recent literature. International Journal of Oral and Maxillofacial Implants 2004; 19(Suppl): 3042. 8. Berglundh, T., Lindhe, J. Dimension of the periimplant mucosa. Biological width revisited. Journal of clinical periodontology 1996; 23: 971973. 9. Buser, D., Weber, H.P., Donath, K., Fiorellini, J.P., Paquette, D.W., Williams, R.C. Soft tissue reactions to nonsubmerged unloaded titanium implants in beagle dogs. Journal of Periodontology 1992; 66: 226236.
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
Nami Farkhondeh Dentist, Page 58 of 61
10. Cardaropoli, D., Re, S., Corrente, G.. The papilla presence index: a new system to assess interproximal papillary levels. International Journal of Periodontics and Restorative Dentistry 2004; 24: 488492. 11. Chang, M., Wennstrom, J.L., Odman, P., Andersson, B. Implant supported singletooth replacements compared to contralateral natural teeth. Crown and soft tissue dimensions. Clinical Oral Implants Research 1999; 10: 185194. 12. Choquet, V., Hermans, M., Adriaenssens, P., Daelemans, P., Tarnow, D., Malevez, C. Clinical and radiographic evaluation of the papilla level adjacent to single tooth dental implants. A retrospective study in the maxillary anterior region. Journal of Periodontology 2001; 72: 13641371. 13. De Bruyn, H., Collaert, B., Linden, U., Bjorn, A.L. Patient’s opinion and treatment outcome of fixed rehabilitation on branemark implants. A three year follow up study in private dental practices. Clinical Oral Implants Research. 1997; 8: 265271. 14. Engquist B., Astrand P., Dahlgren S., Engquist E., Feldmann H., Grondahl K. Marginal bone reaction to oral implants: a prospective comparative study of Astra Tech and Branemark system implants. Clinical Oral Implants Research. 2001; 13: 3037. 15. Garguilo, A. W., Wentz, F. M., Orban, B. Dimensions and relations of the dentogingival junction in humans. Journal of Periodontology 1961; 32: 261267.
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
Nami Farkhondeh Dentist, Page 59 of 61
16. Gastaldo, J. F., Cury, P. R., Sendyk, R. Effect of the vertical and horizontal distances between adjacent implants and between a tooth and an implant on the incidence of the interproximal papilla. Journal of Periodontology 2004; 75: 12421246. 17. Grunder, U. Stability of the mucosal topography around single tooth implants and adjacent teeth: one year results. International Journal of Periodontics and Restorative Dentistry 2000; 20: 1117. 18. Jemt, T. Regeneration of gingival papillae after single implant treatment. International Journal of Periodontics and Restorative Dentistry 1997; 17: 327333. 19. Kan, Y.K., Rungcharasaeng, K., Umeza, K., Kois, J.C. Dimensions of periimplant mucosa: an evaluation of maxillary anterior single implants in humans. Journal of Periodontology 2003; 74: 557562. 20. Levi, A., Psoter, W.J., Agar, J.R., Reisine, S.T., Taylor, T.D. Patient self reported satisfaction with maxillary anterior dental implant treatment. International Journal of Oral and Maxillofacial Implants 2003; 18: 113120. 21. Lindhe, J., Berglundh, T. The interface between the mucosa and the implant. Periodontology 2000. 1998; 17: 4754. 22. Lindhe Book 23. Moon, IS, Berglundh, T., Abrahamsson, I., Linder, E., Lindhe, J. The barrier between the keratinized mucosa and the dental implant. An experimental study in the dog. Journal of Clinical Periodontology 1999; 26: 658663.
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
Nami Farkhondeh Dentist, Page 60 of 61
24. Palmer R.M., Smith B.J., Palmer P.J., Floyd P.D. A prospective study of astra tech single tooth implants. Clinical Oral Implants Research. 1997; 8: 173179. 25. Palmer R.M., Palmer P.J., Smith B.J. A prospective study of astra tech single tooth implants. Clinical Oral Implants Research. 2000; 11: 179182. 26. Palmer, R. Teeth and implants. A clinical guide to implants in dentistry 27. Pjetursson. B.E., Karoussis. I., Burgin. W, Bragger. U, Lang. L.P. Patient satisfaction following implant therapy. Clinical Oral Implants Research 2004; 16: 185191. 28. Priest, G. Predictability of soft tissue form around single tooth implant restorations. International Journal of Periodontics and Restorative Dentistry 2003; 23: 1927. 29. PuchadesRoman, L., Palmer, R.M., Palmer, P.J., Howe, L.C., Ide, M., Wilson, R.F. A clinical, radiographic and microbiological comparison of Astra Tech and Branemark single tooth implants. Clinical Implant Dentistry and Related Research 2000; 2: 7884. 30. Tarnow, D.P., Magner, A.W., Fletcher, P. The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla. Journal of Periodontology 1992; 63: 995996. 31. Tarnow, D.P., Cho, S.C., Wallace, S. S. The effect of interimplant distance on the height of the bone crest. Journal of Periodontology 2000; 71: 546549.
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
Nami Farkhondeh Dentist, Page 61 of 61
32. Tarnow, D.P., Elian, N., Fletcher, P., Froum, S., Magner, A., Cho, SC., Salama, M., Salama, H., Garber, D.A. Vertical distance from the crest of bone to the height of the interproximal papilla between adjacent implants. Journal of Periodontology 2003; 74: 17851788. 33. Vermylen, K., Collaert, B., Linden, U., Bjorn, A, De Bruyn, H. Patient satisfaction and quality of single tooth restorations. Clinical Oral Implants Research 2003; 14: 119124. 34. Wu, Y., Tu, Y., Huang, S., Chan, C. The influence of the distance from the contact point to the crest of bone on the presence of the interproximal dental papilla. Chang Gung Medical Journal. 2003; 26(11): 8228.
Dr Nami Farkhondeh reviews this dental document that he once submitted as his dissertation at Guy’s, King’s College and St Thomas’s Hospital. Nami Farkhondeh, GDC registered as a dentist, undertakes his dental practice as a qualified and approved dental practitioner in London, United Kingdom. With a focus on periodontics and dental implants, check out his website. Patient testimonials are also provided on his website under Nami Farkhondeh review: http://www.namifarkhondeh.co.uk
