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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Clinical Outcome of Inter-Proximal Papilla between a Tooth and a Single Implant Treated with CAD/CAM Abutments: a Cross-Sectional Study</title><author><name sortKey="Borges, Tiago" sort="Borges, Tiago" uniqKey="Borges T" first="Tiago" last="Borges">Tiago Borges</name><affiliation><nlm:aff id="aff1"><institution>Department of Oral Surgery and Implant Dentistry, Portuguese Catholic University</institution><addr-line>Viseu</addr-line><country>Portugal.</country></nlm:aff></affiliation></author><author><name sortKey="Lima, Tiago" sort="Lima, Tiago" uniqKey="Lima T" first="Tiago" last="Lima">Tiago Lima</name><affiliation><nlm:aff id="aff2"><institution>Bragança Private Medical Centre</institution><addr-line>Bragança</addr-line><country>Portugal.</country></nlm:aff></affiliation></author><author><name sortKey="Carvalho, Agata" sort="Carvalho, Agata" uniqKey="Carvalho A" first="Ágata" last="Carvalho">Ágata Carvalho</name><affiliation><nlm:aff id="aff2"><institution>Bragança Private Medical Centre</institution><addr-line>Bragança</addr-line><country>Portugal.</country></nlm:aff></affiliation></author><author><name sortKey="Carvalho, Vasco" sort="Carvalho, Vasco" uniqKey="Carvalho V" first="Vasco" last="Carvalho">Vasco Carvalho</name><affiliation><nlm:aff id="aff1"><institution>Department of Oral Surgery and Implant Dentistry, Portuguese Catholic University</institution><addr-line>Viseu</addr-line><country>Portugal.</country></nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">24422016</idno><idno type="pmc">3886084</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3886084</idno><idno type="RBID">PMC:3886084</idno><idno type="doi">10.5037/jomr.2012.3304</idno><date when="2012">2012</date><idno type="wicri:Area/Pmc/Corpus">000696</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000696</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Clinical Outcome of Inter-Proximal Papilla between a Tooth and a Single Implant Treated with CAD/CAM Abutments: a Cross-Sectional Study</title><author><name sortKey="Borges, Tiago" sort="Borges, Tiago" uniqKey="Borges T" first="Tiago" last="Borges">Tiago Borges</name><affiliation><nlm:aff id="aff1"><institution>Department of Oral Surgery and Implant Dentistry, Portuguese Catholic University</institution><addr-line>Viseu</addr-line><country>Portugal.</country></nlm:aff></affiliation></author><author><name sortKey="Lima, Tiago" sort="Lima, Tiago" uniqKey="Lima T" first="Tiago" last="Lima">Tiago Lima</name><affiliation><nlm:aff id="aff2"><institution>Bragança Private Medical Centre</institution><addr-line>Bragança</addr-line><country>Portugal.</country></nlm:aff></affiliation></author><author><name sortKey="Carvalho, Agata" sort="Carvalho, Agata" uniqKey="Carvalho A" first="Ágata" last="Carvalho">Ágata Carvalho</name><affiliation><nlm:aff id="aff2"><institution>Bragança Private Medical Centre</institution><addr-line>Bragança</addr-line><country>Portugal.</country></nlm:aff></affiliation></author><author><name sortKey="Carvalho, Vasco" sort="Carvalho, Vasco" uniqKey="Carvalho V" first="Vasco" last="Carvalho">Vasco Carvalho</name><affiliation><nlm:aff id="aff1"><institution>Department of Oral Surgery and Implant Dentistry, Portuguese Catholic University</institution><addr-line>Viseu</addr-line><country>Portugal.</country></nlm:aff></affiliation></author></analytic><series><title level="j">Journal of Oral & Maxillofacial Research</title><idno type="eISSN">2029-283X</idno><imprint><date when="2012">2012</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><title>ABSTRACT</title><sec sec-type="objectives"><title>Objectives</title><p>The aim of this study was to assess the clinical outcomes achieved with
Computer-Assisted Design/Computer-Assisted Manufacturing implant abutments
in the anterior maxilla.</p></sec><sec sec-type="material and methods"><title>Material and Methods</title><p>Nineteen patients with a mean age of 41 (range form 26 to 63) years, treated
with 21 single tooth implants and 21 Computer-Assisted
Design/Computer-Assisted Manufacturing (CAD/CAM) abutments in the anterior
maxillary region were included in this study. The patients followed 4
criteria of inclusion: (1) had a single-tooth implant in the anterior
maxilla, (2) had a CAD/CAM abutment, (3) had a contralateral natural tooth,
(4) the implant was restored and in function for at least 6 months up to 2
years. Cases without contact point were excluded. Presence/absence of the
interproximal papilla, inter tooth-implant distance (ITD) and distance from
the base of the contact point to dental crest bone of adjacent tooth (CPB)
were accessed.</p></sec><sec sec-type="results"><title>Results</title><p>Forty interproximal spaces were evaluated, with an average mesial CPB of 5.65
(SD 1.65) mm and distal CPB of 4.65 (SD 1.98) mm. An average mesial ITD of
2.49 (SD 0.69) mm and an average distal ITD of 1.89 (SD 0.63) mm were
achieved. Papilla was present in all the interproximal spaces accessed.</p></sec><sec sec-type="conclusions"><title>Conclusions</title><p>The restoration of dental implants using CAD/CAM abutments is a predictable
treatment with improved aesthetic results. These type of abutments seem to
help maintaining a regular papillary filling although the variations of the
implant positioning or the restoration teeth relation.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Gibbard, Ll" uniqKey="Gibbard L">LL Gibbard</name></author><author><name sortKey="Zarb, G" uniqKey="Zarb G">G Zarb</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Lau, Sl" uniqKey="Lau S">SL Lau</name></author><author><name sortKey="Chow, J" uniqKey="Chow J">J Chow</name></author><author><name sortKey="Li, W" uniqKey="Li W">W Li</name></author><author><name sortKey="Chow, Lk" uniqKey="Chow L">LK Chow</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Priest, Gf" uniqKey="Priest G">GF Priest</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Lindh, T" uniqKey="Lindh T">T Lindh</name></author><author><name sortKey="Gunne, J" uniqKey="Gunne J">J Gunne</name></author><author><name sortKey="Tillberg, A" uniqKey="Tillberg A">A 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uniqKey="Holst S">S Holst</name></author><author><name sortKey="Block, Ms" uniqKey="Block M">MS Block</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Duret, F" uniqKey="Duret F">F Duret</name></author><author><name sortKey="Blouin, Jl" uniqKey="Blouin J">JL Blouin</name></author><author><name sortKey="Duret, B" uniqKey="Duret B">B Duret</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kucey, Bk" uniqKey="Kucey B">BK Kucey</name></author><author><name sortKey="Fraser, Dc" uniqKey="Fraser D">DC Fraser</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Voitik, Aj" uniqKey="Voitik A">AJ Voitik</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Priest, G" uniqKey="Priest G">G Priest</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Boudrias, P" uniqKey="Boudrias P">P Boudrias</name></author><author><name sortKey="Shoghikian, E" uniqKey="Shoghikian E">E Shoghikian</name></author><author><name sortKey="Morin, E" uniqKey="Morin E">E Morin</name></author><author><name sortKey="Hutnik, P" uniqKey="Hutnik P">P Hutnik</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Vigolo, P" uniqKey="Vigolo P">P Vigolo</name></author><author><name sortKey="Fonzi, F" uniqKey="Fonzi F">F Fonzi</name></author><author><name sortKey="Majzoub, Z" uniqKey="Majzoub Z">Z Majzoub</name></author><author><name sortKey="Cordioli, G" uniqKey="Cordioli G">G Cordioli</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Vigolo, P" uniqKey="Vigolo P">P Vigolo</name></author><author><name sortKey="Fonzi, F" uniqKey="Fonzi F">F Fonzi</name></author><author><name sortKey="Majzoub, Z" uniqKey="Majzoub Z">Z Majzoub</name></author><author><name sortKey="Cordioli, G" uniqKey="Cordioli G">G 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Mailath</name></author><author><name sortKey="Watzek, G" uniqKey="Watzek G">G Watzek</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Romeo, E" uniqKey="Romeo E">E Romeo</name></author><author><name sortKey="Lops, D" uniqKey="Lops D">D Lops</name></author><author><name sortKey="Margutti, E" uniqKey="Margutti E">E Margutti</name></author><author><name sortKey="Ghisolfi, M" uniqKey="Ghisolfi M">M Ghisolfi</name></author><author><name sortKey="Chiapasco, M" uniqKey="Chiapasco M">M Chiapasco</name></author><author><name sortKey="Vogel, G" uniqKey="Vogel G">G Vogel</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Lops, D" uniqKey="Lops D">D Lops</name></author><author><name sortKey="Chiapasco, M" uniqKey="Chiapasco M">M Chiapasco</name></author><author><name sortKey="Rossi, A" uniqKey="Rossi A">A Rossi</name></author><author><name sortKey="Bressan, E" uniqKey="Bressan E">E Bressan</name></author><author><name 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Bruyn</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Belser, Uc" uniqKey="Belser U">UC Belser</name></author><author><name sortKey="Grutter, L" uniqKey="Grutter L">L Grütter</name></author><author><name sortKey="Vailati, F" uniqKey="Vailati F">F Vailati</name></author><author><name sortKey="Bornstein, Mm" uniqKey="Bornstein M">MM Bornstein</name></author><author><name sortKey="Weber, Hp" uniqKey="Weber H">HP Weber</name></author><author><name sortKey="Buser, D" uniqKey="Buser D">D Buser</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="research-article"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">J Oral Maxillofac Res</journal-id><journal-id journal-id-type="iso-abbrev">J Oral Maxillofac Res</journal-id><journal-id journal-id-type="publisher-id">JORM</journal-id><journal-title-group><journal-title>Journal of Oral & Maxillofacial Research</journal-title></journal-title-group><issn pub-type="epub">2029-283X</issn><publisher><publisher-name>Stilus Optimus</publisher-name><publisher-loc>Kaunas, Lithuania</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">24422016</article-id><article-id pub-id-type="pmc">3886084</article-id><article-id pub-id-type="publisher-id">v3n3e4ht</article-id><article-id pub-id-type="doi">10.5037/jomr.2012.3304</article-id><article-categories><subj-group subj-group-type="heading"><subject>Original Paper</subject></subj-group></article-categories><title-group><article-title>Clinical Outcome of Inter-Proximal Papilla between a Tooth and a Single Implant Treated with CAD/CAM Abutments: a Cross-Sectional Study</article-title></title-group><contrib-group><contrib id="contrib1" contrib-type="author" corresp="yes"><name><surname>Borges</surname><given-names>Tiago</given-names></name><xref ref-type="aff" rid="aff1">1</xref></contrib><contrib id="contrib2" contrib-type="author"><name><surname>Lima</surname><given-names>Tiago</given-names></name><xref ref-type="aff" rid="aff2">2</xref></contrib><contrib id="contrib3" contrib-type="author"><name><surname>Carvalho</surname><given-names>Ágata</given-names></name><xref ref-type="aff" rid="aff2">2</xref></contrib><contrib id="contrib4" contrib-type="author"><name><surname>Carvalho</surname><given-names>Vasco</given-names></name><xref ref-type="aff" rid="aff1">1</xref></contrib></contrib-group><aff id="aff1" rid="aff1"><sup>1</sup><institution>Department of Oral Surgery and Implant Dentistry, Portuguese Catholic University</institution><addr-line>Viseu</addr-line><country>Portugal.</country></aff><aff id="aff2" rid="aff2"><sup>2</sup><institution>Bragança Private Medical Centre</institution><addr-line>Bragança</addr-line><country>Portugal.</country></aff><author-notes><corresp>Tiago Borges,
<addr-line>Rua João XXI, 59/60, R/Ch Esq., 5300-435 Bragança</addr-line><country>Portugal</country><phone>(00351) 917411447</phone>Fax: (00351) 273328639<email>geral@cmeb.pt</email></corresp></author-notes><pub-date pub-type="collection"><season>Jul-Sep</season><year>2012</year></pub-date><pub-date pub-type="epub"><day>1</day><month>10</month><year>2012</year></pub-date><volume>3</volume><issue>3</issue><elocation-id>e4</elocation-id><history><date date-type="received"><day>20</day><month>5</month><year>2012</year></date><date date-type="accepted"><day>27</day><month>9</month><year>2012</year></date></history><permissions><copyright-statement> Copyright © Borges T, Lima T, Carvalho Á, Carvalho
V. Published in the JOURNAL OF ORAL & MAXILLOFACIAL RESEARCH
(http://www.ejomr.org), 1 October 2012.</copyright-statement><copyright-year>2012</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc-nd/3.0/"><license-p>This is an open-access article, first published in the JOURNAL OF
ORAL & MAXILLOFACIAL RESEARCH, distributed under the terms of the
Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 Unported
License (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by-nc-nd/3.0/">http://creativecommons.org/licenses/by-nc-nd/3.0/</ext-link>), which permits unrestricted non-commercial use, distribution, and
reproduction in any medium, provided the original work and is properly
cited. The copyright, license information and link to the original
publication on <ext-link ext-link-type="uri" xlink:href="http://www.ejomr.org">http://www.ejomr.org</ext-link> must be included.</license-p></license></permissions><self-uri xlink:type="simple" xlink:href="http://www.ejomr.org/JOMR/archives/2012/3/e4/v3n3e4ht.htm"></self-uri><abstract><title>ABSTRACT</title><sec sec-type="objectives"><title>Objectives</title><p>The aim of this study was to assess the clinical outcomes achieved with
Computer-Assisted Design/Computer-Assisted Manufacturing implant abutments
in the anterior maxilla.</p></sec><sec sec-type="material and methods"><title>Material and Methods</title><p>Nineteen patients with a mean age of 41 (range form 26 to 63) years, treated
with 21 single tooth implants and 21 Computer-Assisted
Design/Computer-Assisted Manufacturing (CAD/CAM) abutments in the anterior
maxillary region were included in this study. The patients followed 4
criteria of inclusion: (1) had a single-tooth implant in the anterior
maxilla, (2) had a CAD/CAM abutment, (3) had a contralateral natural tooth,
(4) the implant was restored and in function for at least 6 months up to 2
years. Cases without contact point were excluded. Presence/absence of the
interproximal papilla, inter tooth-implant distance (ITD) and distance from
the base of the contact point to dental crest bone of adjacent tooth (CPB)
were accessed.</p></sec><sec sec-type="results"><title>Results</title><p>Forty interproximal spaces were evaluated, with an average mesial CPB of 5.65
(SD 1.65) mm and distal CPB of 4.65 (SD 1.98) mm. An average mesial ITD of
2.49 (SD 0.69) mm and an average distal ITD of 1.89 (SD 0.63) mm were
achieved. Papilla was present in all the interproximal spaces accessed.</p></sec><sec sec-type="conclusions"><title>Conclusions</title><p>The restoration of dental implants using CAD/CAM abutments is a predictable
treatment with improved aesthetic results. These type of abutments seem to
help maintaining a regular papillary filling although the variations of the
implant positioning or the restoration teeth relation.</p></sec></abstract><kwd-group><kwd>Computer-Assisted Design</kwd><kwd>Computer-Assisted Manufacturing</kwd><kwd>dental abutments</kwd><kwd>dental implants</kwd><kwd>outcomes assessment</kwd><kwd>dental esthetics.</kwd></kwd-group></article-meta></front><body><sec><title>INTRODUCTION</title><p>Nowadays, there are several restorative treatments alternatives for replacing a
missing tooth. Over recent years the rehabilitation of partially edentulous patients
with dental implants has become a well-established treatment [<xref ref-type="bibr" rid="B1">1</xref>,<xref ref-type="bibr" rid="B2">2</xref>].</p><p>Replacement of missing teeth in the aesthetic zone presents a complex challenge for
the clinicians, due to the difficulty in restore the natural appearing sulcular and
papillae anatomy surrounding rehabilitated zones [<xref ref-type="bibr" rid="B3">3</xref>]. There are several studies that report similar success rates for
implants rehabilitation in the anterior region compared to those placed in other
parts of the jaws [<xref ref-type="bibr" rid="B4">4</xref>-<xref ref-type="bibr" rid="B6">6</xref>]. Cordioli et al. in 1994 [<xref ref-type="bibr" rid="B7">7</xref>], Engquist et al. in 1995 [<xref ref-type="bibr" rid="B8">8</xref>]
and McMillan et al. [<xref ref-type="bibr" rid="B9">9</xref>] in 1998 reported a
single-tooth implant restoration survival rate of 94.4%, 97.6% and 96%
respectively.</p><p>The long-term unpredictable stability of the soft tissues is one of the problems of
single-tooth implant rehabilitation for clinicians [<xref ref-type="bibr" rid="B10">10</xref>,<xref ref-type="bibr" rid="B11">11</xref>]. In past decades, the
presence or absence of papillae between two teeth, a teeth and an implant and
between adjacent implants has been a topic widely discussed and important in oral
implants rehabilitations. Tarnow et al. [<xref ref-type="bibr" rid="B12">12</xref>-<xref ref-type="bibr" rid="B14">14</xref>] related the presence or
absence of the interdental papilla to the distance of bone to the contact point
between the teeth and between teeth and implants.</p><p>Dental implant abutment selection plays also an important role in achieving optimal
aesthetic results [<xref ref-type="bibr" rid="B15">15</xref>]. The Computer-Assisted
Design/Computer-Assisted Manufacturing (CAD/CAM) systems were incorporated in the
production of implant abutments and frameworks in the early 1990s and first applied
to titanium abutments [<xref ref-type="bibr" rid="B16">16</xref>-<xref ref-type="bibr" rid="B19">19</xref>]. CAD/CAM abutment technique consists in a
computer program that reproduces the position of the implant and allows a correct
abutment design with an ideal shape and tilt. This information is then transmitted
to a device that machines the final abutment [<xref ref-type="bibr" rid="B20">20</xref>]. Vigolo et al. [<xref ref-type="bibr" rid="B21">21</xref>,<xref ref-type="bibr" rid="B22">22</xref>] assessed in their studies the precision at
the implant-abutment interface of CAD/CAM abutments. For optimal mucogingival
aesthetics, implant abutments should have the appropriate emergence profile needed
to support the surrounding soft tissue and preferentially be made from
tooth-coloured material to prevent the bluish translucency of the overlying mucosa
[<xref ref-type="bibr" rid="B21">21</xref>-<xref ref-type="bibr" rid="B23">23</xref>]. The aim of this study was to assess the clinical outcomes achieved
with Computer-Assisted Design/Computer-Assisted Manufacturing implant abutments in
the anterior maxilla.</p></sec><sec sec-type="materials|methods"><title>MATERIAL AND METHODS</title><p><bold>Patient selection</bold></p><p>Nineteen patients (8 females and 11 males) with a mean age of 41 years (range form 26
to 63) who had been treated with 21 single tooth implants and 21 CAD/CAM abutments
in the anterior region of the maxilla were included in this study. The selection of
the patients for the implant treatment included patients with teeth lost due to
traumatic injury, endodontic failure or traditional fixed prostheses failure. The
patients with edentulous sites due to periodontal disease were excluded from the
study. After the treatment, the patients followed 4 criteria of inclusion: (1) had a
single-tooth implant in the anterior maxilla, (2) had a CAD/CAM abutment, (3) had a
contralateral natural tooth, (4) the implant was restored and was in function for at
least 6 months up to 2 years. The cases where did not exist contact point between
the implant and the teeth were excluded.</p><p>These patients were treated between January 2009 and January of 2010 in the
Department of Oral Surgery and Implant Dentistry of Private Medical Centre in
Bragança and all signed the consent form in accordance with the Helsinki
Declaration of 1975, revised in 2000. The control group was absent.</p><p><bold>Surgical and reconstructive treatment protocol</bold></p><p>The implants (OsseoSpeed™, AstraTech Dental, Möhndal, Sweden) were placed over
delayed extraction sites, with a time of healing 7 to 8 weeks, or immediate
extraction sites were there no compromise of the buccal bone plate. All the implants
were placed in the maxilla between teeth #14 - 24 area and left to heal for a period
of 6 to 10 weeks, following a two-stage protocol (<xref ref-type="fig" rid="fig1">Figure 1</xref>). After this period osseointegration was confirmed. All
implants were then restored with screw-retained resin provisional crowns (Protemp™
Plus Temporization Material, 3M ESPE, St. Paul, Minnesota, USA) during a period of 2
months. The implants were then rehabilitated with a CAD/CAM abutment system
(Atlantis™, Atlantis Europe, Möhndal, Sweden) using zirconia and gold titanium
abutments (<xref ref-type="fig" rid="fig2">Figure 2</xref>). The zirconia abutments
were made of Yttria-stabilized tetragonal zirconia polycristals (Y-TZP) and the
titanium abutments used were milled from titanium alloy 6Al-4V (grade 5) blank and
then coated with thin layer of titanium nitride (TiN) that provides the gold shade.
The peri-implant soft tissue anatomy was copied with the use of a light-curing
composite resin added to fill the space between the soft tissue and the impression
coping to prevent the tissues from collapsing while the impression was being poured
(<xref ref-type="fig" rid="fig2">Figure 2C</xref>). Then both the diagnostic
model and master cast are scanned in order to initiate the milling process of the
abutment. The virtual abutment design software accurately establishes the location,
orientation, angle and depth of the implant (<xref ref-type="fig" rid="fig3">Figure
3</xref>). All the abutments were then restored with all ceramic crowns, with
ceramic veneering in lithium disilicate (LS<sub>2</sub>) (IPS e.max Ceram, Ivoclar Vivadent AG,
Schaan, Principality of Liechtenstein), placed over the CAD/CAM abutments.</p><fig id="fig1" orientation="portrait" position="float"><label>Figure 1</label><caption><p>Surgical treatment protocol: A and B = clinical status and radiographical
aspect of the tooth 23; C = post-extraction socket; D = implant placement in
the fresh socket.</p></caption><graphic xlink:href="jomr-03-e4-g001"></graphic></fig><fig id="fig2" orientation="portrait" position="float"><label>Figure 2</label><caption><p>Prosthetic treatment protocol: A = screw-retained resin provisional crown; B
= soft tissue emergency profile after 10 weeks with provisional restoration;
C = implant-level impression; D = CAD/CAM gold titanium abutment; E and F =
ceramic restoration.</p></caption><graphic xlink:href="jomr-03-e4-g002"></graphic></fig><fig id="fig3" orientation="portrait" position="float"><label>Figure 3</label><caption><p>Computer aided design of the abutments.</p></caption><graphic xlink:href="jomr-03-e4-g003"></graphic></fig><p><bold>Follow-up evaluation protocol</bold></p><p>After a two-year period of the implant rehabilitation the 19 patients were recalled
as part of their recall program. One patient was excluded of the study group since
it had no contact points between the implant restoration and the adjacent teeth.
Standard clinical and radiographic examinations were made, regarding the implants
situation in terms of survival and success.</p><p><bold>Selected parameters</bold></p><p>The following parameters were evaluated: (1) presence/absence of the interproximal
papilla, (2) inter tooth-implant distance (ITD) and (3) distance from the base of
the contact point to dental crest bone of adjacent tooth (CPB).</p><p><bold>Interproximal papilla evaluation</bold></p><p>The presence/absence of the interproximal papilla was based in the pink aesthetic
score parameters for mesial and distal papilla [<xref ref-type="bibr" rid="B24">24</xref>] (<xref ref-type="table" rid="T1">Table 1</xref>). The inter-proximal
papilla was diagnosed as present if it filled up the entire proximal space and was
in good harmony with the adjacent papillae; half-present if the proximal space was
half filled with the papilla and if less than half of the papilla was present the
diagnosis was absent papilla.</p><table-wrap id="T1" orientation="portrait" position="float"><label>Table 1</label><caption><p>Papilla pink aesthetic scores</p></caption><table frame="hsides" rules="groups" width="370"><thead><tr><th rowspan="1" colspan="1"> Parameter </th><th rowspan="1" colspan="1"> Absent </th><th rowspan="1" colspan="1"> Incomplete </th><th rowspan="1" colspan="1"> Complete </th></tr></thead><tbody><tr><td align="center" style="font-weight: bold" rowspan="1" colspan="1"> Mesial papilla </td><td align="center" rowspan="1" colspan="1"> 0 </td><td align="center" rowspan="1" colspan="1"> 1 </td><td align="center" rowspan="1" colspan="1"> 2 </td></tr><tr><td align="center" style="font-weight: bold" rowspan="1" colspan="1"> Distal papilla </td><td align="center" rowspan="1" colspan="1"> 0 </td><td align="center" rowspan="1" colspan="1"> 1 </td><td align="center" rowspan="1" colspan="1"> 2 </td></tr></tbody></table></table-wrap><p>All implant crowns were captured with a digital SLR camera (Canon EOS 450D, Canon,
Tokyo, Japan. Em 140 DG Macro Flash, Sigma, Kanagawa, Japan. Sigma 105 mm DG Macro
Lens, Sigma, Kanagawa, Japan). The contralateral tooth was also completely and
symmetrically represented. Standardized clinical photographs (magnification x1) were
taken at each implant site and the contralateral tooth. The analyses were performed
by one experienced prosthodontist who had not been involved in the prosthetic
treatment of any patients represented in this study. After 2 weeks a second set of
ITD and CPB measurements was performed to evaluate the intra-observer variability.
The mean difference between the first and the second assessment was negligible.</p><p><bold>Radiographic assessment</bold></p><p>Peri-apical radiographs were taken 24 months after definitive implant restoration
with the parallelism technique using intra-oral X-ray device (Heliodent Plus, Sirona
Dental Systems Inc., NY, USA. XIOS Intra-oral Sensor System, Sirona Dental Systems
Inc., NY, USA). A computerizing analysis were performed, using commercially
available software Adobe<sup>®</sup> Photoshop<sup>®</sup> CS5 (Adobe Systems Inc., CA, USA) to determine
inter-implant-tooth distance (ITD) and the distance between the contact point to the
inter-dental bone (CPB) values (<xref ref-type="fig" rid="fig4">Figure 4</xref>).
The parameter chosen to set the measurement system was the distance between the
implant neck and the most apical point of each fixture, along an ideal line running
parallel to the long fixture axis [<xref ref-type="bibr" rid="B25">25</xref>,<xref ref-type="bibr" rid="B26">26</xref>]. If in the periapical radiographs were
found an overlapping zone with the adjacent tooth and the crown of the restored
implant, we accepted the medium point in the overlapping zone for effects of
measurement of CPB values.</p><fig id="fig4" orientation="portrait" position="float"><label>Figure 4</label><caption><p>Computerized analysis performed to determine values of the
inter-implant-tooth distance (ITD) and the distance from the base of the
contact point to the inter-dental bone (CPB) after converting the periapical
radiograph to a digitalized image.</p></caption><graphic xlink:href="jomr-03-e4-g004"></graphic></fig><p><bold>Statistical Analysis</bold></p><p>A statistical analysis was performed using computer software SPSS™, Statistical
Package for the Social Sciences, version 17.1 (IBM Corporation, Armonk, NY, USA).
Data distribution was characterized by mean value and standard deviation (SD).</p></sec><sec sec-type="results"><title>RESULTS</title><p>All the selected eighteen patients were present at this stage recall. Twenty implants
placed in the anterior maxilla (four in the site of 22, seven in the site of 21,
five in the site of 12, one in the site of 11 and three in the site of 23), were
evaluated. Forty interproximal sites, between tooth and implant were assessed,
regarding the papilla presence, ITD and CPB values. No implant failures were
reported in the two-year evaluation stage, resulting in a 100% implant success rate.
Clinical and radiographic parameters which were assessed are shown in <xref ref-type="table" rid="T2">Table 2</xref>.</p><table-wrap id="T2" orientation="portrait" position="float"><label>Table 2</label><caption><p>Clinical papilla radiographic assessments</p></caption><table frame="hsides" rules="groups" width="570"><thead><tr><th rowspan="2" colspan="1"> Implant </th><th rowspan="2" colspan="1"> Tooth </th><th colspan="2" rowspan="1"> Papilla presence </th><th colspan="2" rowspan="1"> CPB (mm) </th><th colspan="2" rowspan="1"> ITD (mm) </th><th rowspan="2" colspan="1"> Abutment </th></tr><tr><th rowspan="1" colspan="1"> Mesial </th><th rowspan="1" colspan="1"> Distal </th><th rowspan="1" colspan="1"> Mesial </th><th rowspan="1" colspan="1"> Distal </th><th rowspan="1" colspan="1"> Mesial </th><th rowspan="1" colspan="1"> Distal </th></tr></thead><tbody><tr><td align="center" rowspan="1" colspan="1"> 1 </td><td align="center" rowspan="1" colspan="1"> 22 </td><td align="center" rowspan="1" colspan="1"> 2 </td><td align="center" rowspan="1" colspan="1"> 2 </td><td align="center" rowspan="1" colspan="1"> 4.9 </td><td align="center" rowspan="1" colspan="1"> 2.8 </td><td align="center" rowspan="1" colspan="1"> 2.64 </td><td align="center" rowspan="1" colspan="1"> 1.29 </td><td align="center" rowspan="1" colspan="1"> Gold Ti </td></tr><tr><td align="center" rowspan="1" colspan="1"> 2 </td><td align="center" rowspan="1" colspan="1"> 12 </td><td align="center" rowspan="1" colspan="1"> 1 </td><td align="center" rowspan="1" colspan="1"> 1 </td><td align="center" rowspan="1" colspan="1"> 3.5 </td><td align="center" rowspan="1" colspan="1"> 2.55 </td><td align="center" rowspan="1" colspan="1"> 1.63 </td><td align="center" rowspan="1" colspan="1"> 1.05 </td><td align="center" rowspan="1" colspan="1"> Gold Ti </td></tr><tr><td align="center" rowspan="1" colspan="1"> 3 </td><td align="center" rowspan="1" colspan="1"> 12 </td><td align="center" rowspan="1" colspan="1"> 2 </td><td align="center" rowspan="1" colspan="1"> 2 </td><td align="center" rowspan="1" colspan="1"> 5.22 </td><td align="center" rowspan="1" colspan="1"> 2.89 </td><td align="center" rowspan="1" colspan="1"> 2.26 </td><td align="center" rowspan="1" colspan="1"> 1.13 </td><td align="center" rowspan="1" colspan="1"> Gold Ti </td></tr><tr><td align="center" rowspan="1" colspan="1"> 4 </td><td align="center" rowspan="1" colspan="1"> 12 </td><td align="center" rowspan="1" colspan="1"> 2 </td><td align="center" rowspan="1" colspan="1"> 2 </td><td align="center" rowspan="1" colspan="1"> 5.8 </td><td align="center" rowspan="1" colspan="1"> 2.56 </td><td align="center" rowspan="1" colspan="1"> 1.5 </td><td align="center" rowspan="1" colspan="1"> 1.35 </td><td align="center" rowspan="1" colspan="1"> Gold Ti </td></tr><tr><td align="center" rowspan="1" colspan="1"> 5 </td><td align="center" rowspan="1" colspan="1"> 21 </td><td align="center" rowspan="1" colspan="1"> 2 </td><td align="center" rowspan="1" colspan="1"> 2 </td><td align="center" rowspan="1" colspan="1"> 4.05 </td><td align="center" rowspan="1" colspan="1"> 6.21 </td><td align="center" rowspan="1" colspan="1"> 2.7 </td><td align="center" rowspan="1" colspan="1"> 2.13 </td><td align="center" rowspan="1" colspan="1"> Gold Ti </td></tr><tr><td align="center" rowspan="1" colspan="1"> 6 </td><td align="center" rowspan="1" colspan="1"> 22 </td><td align="center" rowspan="1" colspan="1"> 1 </td><td align="center" rowspan="1" colspan="1"> 2 </td><td align="center" rowspan="1" colspan="1"> 4.75 </td><td align="center" rowspan="1" colspan="1"> 4.81 </td><td align="center" rowspan="1" colspan="1"> 1.2 </td><td align="center" rowspan="1" colspan="1"> 2.72 </td><td align="center" rowspan="1" colspan="1"> ZIRCONIA </td></tr><tr><td align="center" rowspan="1" colspan="1"> 7 </td><td align="center" rowspan="1" colspan="1"> 12 </td><td align="center" rowspan="1" colspan="1"> 2 </td><td align="center" rowspan="1" colspan="1"> 2 </td><td align="center" rowspan="1" colspan="1"> 6.67 </td><td align="center" rowspan="1" colspan="1"> 5.56 </td><td align="center" rowspan="1" colspan="1"> 2.08 </td><td align="center" rowspan="1" colspan="1"> 2.24 </td><td align="center" rowspan="1" colspan="1"> Gold Ti </td></tr><tr><td align="center" rowspan="1" colspan="1"> 8 </td><td align="center" rowspan="1" colspan="1"> 21 </td><td align="center" rowspan="1" colspan="1"> 2 </td><td align="center" rowspan="1" colspan="1"> 2 </td><td align="center" rowspan="1" colspan="1"> 5.56 </td><td align="center" rowspan="1" colspan="1"> 4.17 </td><td align="center" rowspan="1" colspan="1"> 3.09 </td><td align="center" rowspan="1" colspan="1"> 1.81 </td><td align="center" rowspan="1" colspan="1"> Gold Ti </td></tr><tr><td align="center" rowspan="1" colspan="1"> 9 </td><td align="center" rowspan="1" colspan="1"> 22 </td><td align="center" rowspan="1" colspan="1"> 1 </td><td align="center" rowspan="1" colspan="1"> 1 </td><td align="center" rowspan="1" colspan="1"> 9.72 </td><td align="center" rowspan="1" colspan="1"> 7.09 </td><td align="center" rowspan="1" colspan="1"> 1.87 </td><td align="center" rowspan="1" colspan="1"> 2.04 </td><td align="center" rowspan="1" colspan="1"> Gold Ti </td></tr><tr><td align="center" rowspan="1" colspan="1"> 10 </td><td align="center" rowspan="1" colspan="1"> 21 </td><td align="center" rowspan="1" colspan="1"> 2 </td><td align="center" rowspan="1" colspan="1"> 2 </td><td align="center" rowspan="1" colspan="1"> 7.91 </td><td align="center" rowspan="1" colspan="1"> 5.66 </td><td align="center" rowspan="1" colspan="1"> 2.99 </td><td align="center" rowspan="1" colspan="1"> 1.6 </td><td align="center" rowspan="1" colspan="1"> ZIRCONIA </td></tr><tr><td align="center" rowspan="1" colspan="1"> 11 </td><td align="center" rowspan="1" colspan="1"> 11 </td><td align="center" rowspan="1" colspan="1"> 2 </td><td align="center" rowspan="1" colspan="1"> 1 </td><td align="center" rowspan="1" colspan="1"> 4.93 </td><td align="center" rowspan="1" colspan="1"> 5.33 </td><td align="center" rowspan="1" colspan="1"> 3.4 </td><td align="center" rowspan="1" colspan="1"> 1.55 </td><td align="center" rowspan="1" colspan="1"> GOLD Ti </td></tr><tr><td align="center" rowspan="1" colspan="1"> 12 </td><td align="center" rowspan="1" colspan="1"> 21 </td><td align="center" rowspan="1" colspan="1"> 2 </td><td align="center" rowspan="1" colspan="1"> 1 </td><td align="center" rowspan="1" colspan="1"> 5.45 </td><td align="center" rowspan="1" colspan="1"> 2.89 </td><td align="center" rowspan="1" colspan="1"> 2.76 </td><td align="center" rowspan="1" colspan="1"> 1.95 </td><td align="center" rowspan="1" colspan="1"> ZIRCONIA </td></tr><tr><td align="center" rowspan="1" colspan="1"> 13 </td><td align="center" rowspan="1" colspan="1"> 21 </td><td align="center" rowspan="1" colspan="1"> 1 </td><td align="center" rowspan="1" colspan="1"> 1 </td><td align="center" rowspan="1" colspan="1"> 3.92 </td><td align="center" rowspan="1" colspan="1"> 6.5 </td><td align="center" rowspan="1" colspan="1"> 3.19 </td><td align="center" rowspan="1" colspan="1"> 2.24 </td><td align="center" rowspan="1" colspan="1"> Gold Ti </td></tr><tr><td align="center" rowspan="1" colspan="1"> 14 </td><td align="center" rowspan="1" colspan="1"> 12 </td><td align="center" rowspan="1" colspan="1"> 2 </td><td align="center" rowspan="1" colspan="1"> 2 </td><td align="center" rowspan="1" colspan="1"> 4.29 </td><td align="center" rowspan="1" colspan="1"> 2.64 </td><td align="center" rowspan="1" colspan="1"> 2.24 </td><td align="center" rowspan="1" colspan="1"> 1.14 </td><td align="center" rowspan="1" colspan="1"> Gold Ti </td></tr><tr><td align="center" rowspan="1" colspan="1"> 15 </td><td align="center" rowspan="1" colspan="1"> 21 </td><td align="center" rowspan="1" colspan="1"> 2 </td><td align="center" rowspan="1" colspan="1"> 2 </td><td align="center" rowspan="1" colspan="1"> 6.11 </td><td align="center" rowspan="1" colspan="1"> 3.93 </td><td align="center" rowspan="1" colspan="1"> 4.07 </td><td align="center" rowspan="1" colspan="1"> 2.53 </td><td align="center" rowspan="1" colspan="1"> Gold Ti </td></tr><tr><td align="center" rowspan="1" colspan="1"> 16 </td><td align="center" rowspan="1" colspan="1"> 21 </td><td align="center" rowspan="1" colspan="1"> 1 </td><td align="center" rowspan="1" colspan="1"> 1 </td><td align="center" rowspan="1" colspan="1"> 8.17 </td><td align="center" rowspan="1" colspan="1"> 9.2 </td><td align="center" rowspan="1" colspan="1"> 2.93 </td><td align="center" rowspan="1" colspan="1"> 1.5 </td><td align="center" rowspan="1" colspan="1"> Gold Ti </td></tr><tr><td align="center" rowspan="1" colspan="1"> 17 </td><td align="center" rowspan="1" colspan="1"> 23 </td><td align="center" rowspan="1" colspan="1"> 2 </td><td align="center" rowspan="1" colspan="1"> 2 </td><td align="center" rowspan="1" colspan="1"> 4.33 </td><td align="center" rowspan="1" colspan="1"> 2.6 </td><td align="center" rowspan="1" colspan="1"> 2.35 </td><td align="center" rowspan="1" colspan="1"> 2.93 </td><td align="center" rowspan="1" colspan="1"> Gold Ti </td></tr><tr><td align="center" rowspan="1" colspan="1"> 18 </td><td align="center" rowspan="1" colspan="1"> 23 </td><td align="center" rowspan="1" colspan="1"> 2 </td><td align="center" rowspan="1" colspan="1"> 2 </td><td align="center" rowspan="1" colspan="1"> 5.19 </td><td align="center" rowspan="1" colspan="1"> 5.66 </td><td align="center" rowspan="1" colspan="1"> 2.28 </td><td align="center" rowspan="1" colspan="1"> 3.16 </td><td align="center" rowspan="1" colspan="1"> Gold Ti </td></tr><tr><td align="center" rowspan="1" colspan="1"> 19 </td><td align="center" rowspan="1" colspan="1"> 22 </td><td align="center" rowspan="1" colspan="1"> 2 </td><td align="center" rowspan="1" colspan="1"> 2 </td><td align="center" rowspan="1" colspan="1"> 5.98 </td><td align="center" rowspan="1" colspan="1"> 2.7 </td><td align="center" rowspan="1" colspan="1"> 2.25 </td><td align="center" rowspan="1" colspan="1"> 1.28 </td><td align="center" rowspan="1" colspan="1"> Gold Ti </td></tr><tr><td align="center" rowspan="1" colspan="1"> 20 </td><td align="center" rowspan="1" colspan="1"> 23 </td><td align="center" rowspan="1" colspan="1"> 2 </td><td align="center" rowspan="1" colspan="1"> 2 </td><td align="center" rowspan="1" colspan="1"> 5.67 </td><td align="center" rowspan="1" colspan="1"> 2.88 </td><td align="center" rowspan="1" colspan="1"> 2.53 </td><td align="center" rowspan="1" colspan="1"> 2.28 </td><td align="center" rowspan="1" colspan="1"> Gold Ti </td></tr></tbody></table></table-wrap><p><bold>Interproximal papilla evaluation</bold></p><p>An average mesial papilla score of 1.75 (SD 0.44) mm and a distal papilla score of
1.7 (SD 0.47) mm were achieved. At the mesial side, the papilla filled the
interproximal space completely at 75% of the sites and at the distal side the
papilla filled the interproximal space completely at 70% of the sites. An overall
completely papilla filing was found in 72.5% of the sites and in 100% of the sites
the papilla was either completely or half present.</p><p><bold>Radiographic assessment</bold></p><p>A mesial ITD average of 2.49 (SD 0.69) mm and a distal ITD average of 1.89 (SD 0.63)
mm were achieved. An overall CPB average of 5.11 (SD 1.86) mm was determined, with a
mesial CPB average of 5.65 (SD 1.65) mm and distal CPB of 4.65 (SD 1.98) mm (<xref ref-type="table" rid="T2">Table 2</xref>).</p></sec><sec sec-type="discussion"><title>DISCUSSION</title><p>This study comprised a retrospective analysis of 20 dental implants, placed in the
maxillary anterior region, restored with CAD/CAM abutments. Although the surgeon
skills and local anatomy play a major role in the peri-implant tissue stability,
clinical reports of the literature also tells us that custom abutments seem to
provide better results than stock abutments for ideal crown contours and
peri-implant soft tissue support [<xref ref-type="bibr" rid="B24">24</xref>]. To
minimize the impact that the surgical skills might had in the final aesthetic
result, all the surgical procedures were carried out by an experienced implant
surgeon (TB) and were only included in the study group patients that received dental
implants with no associated extensive regeneration procedures. A review on the
management of inter-dental/inter-implant papilla by Zetu and Wang [<xref ref-type="bibr" rid="B27">27</xref>] addressed factors that may influence its
appearance; these mainly included the dimension of the inter-proximal space, the
horizontal distance between a tooth and an implant, adequate bone volume, the
presence of adjacent tooth attachment and a proper soft tissue thickness.</p><p>The parameters that affected the incidence of inter-proximal papilla between a tooth
and an implant were also examined by Gastaldo et al. [<xref ref-type="bibr" rid="B28">28</xref>] in 48 patients (80 inter-proximal sites). These authors
compared different parameters like the distance from the base of the contact point
to the bone crest (D1), the distance between a tooth and an implant or between two
implants (D2) and the distance from the base of the contact point to the tip of the
papilla (D3) and stated that when D2 was 3, 3.5 or 4 mm, the papilla was present
most of the time and when D2 was 2 or 2.5 mm the papilla was absent 100% of the
time. When the distance between the contact point and the bone crest (D1) was 3,
3.5, 4 mm the papilla was present 100%. When the distance was 6 mm the interdental
papilla filled this space about 55% of the time and at 7 mm the interdental space
was completely filled about 25% of the time [<xref ref-type="bibr" rid="B27">27</xref>].</p><p>The results reported in the present study on the apico-coronal dimension of the
inter-proximal area are not confirmed by the investigation of Gastaldo et al. [<xref ref-type="bibr" rid="B28">28</xref>]. In fact, for an overall CPB > 5 mm we
assessed an overall 72.5% completely papilla presence and at least half-presence of
the papilla in all the interproximal spaces assessed (<xref ref-type="table" rid="T3">Table 3</xref>). Also, from the data collected we can report a papilla
presence in all the nine sites with an ITD between 1 - 1.5 mm (<xref ref-type="table" rid="T4">Table 4</xref>) and completely papilla presence on
86.7% of the fifteen (15) sites with a CPB ranging 5.0 - 7.0 mm (<xref ref-type="table" rid="T3">Table 3</xref>).</p><table-wrap id="T3" orientation="portrait" position="float"><label>Table 3</label><caption><p>Presence of inter-proximal papilla according to contact point to bone
crest distance (CPB)</p></caption><table frame="hsides" rules="groups" width="470"><thead><tr><th rowspan="1" colspan="1"> CPB<break></break>(mm) </th><th rowspan="1" colspan="1"> N </th><th rowspan="1" colspan="1"> Papilla present </th><th rowspan="1" colspan="1"> % </th><th rowspan="1" colspan="1"> Papilla half-present </th><th rowspan="1" colspan="1"> % </th></tr></thead><tbody><tr><td align="center" rowspan="1" colspan="1"> 2.0 - 3.0 </td><td align="center" rowspan="1" colspan="1"> 9 </td><td align="center" rowspan="1" colspan="1"> 8 </td><td align="center" rowspan="1" colspan="1"> 89 </td><td align="center" rowspan="1" colspan="1"> 1 </td><td align="center" rowspan="1" colspan="1"> 11 </td></tr><tr><td align="center" rowspan="1" colspan="1"> 3.0 - 5.0 </td><td align="center" rowspan="1" colspan="1"> 11 </td><td align="center" rowspan="1" colspan="1"> 8 </td><td align="center" rowspan="1" colspan="1"> 72.7 </td><td align="center" rowspan="1" colspan="1"> 3 </td><td align="center" rowspan="1" colspan="1"> 27.3 </td></tr><tr><td align="center" rowspan="1" colspan="1"> 5.0 - 7.0 </td><td align="center" rowspan="1" colspan="1"> 15 </td><td align="center" rowspan="1" colspan="1"> 13 </td><td align="center" rowspan="1" colspan="1"> 86.7 </td><td align="center" rowspan="1" colspan="1"> 2 </td><td align="center" rowspan="1" colspan="1"> 13.3 </td></tr><tr><td align="center" rowspan="1" colspan="1"> > 7 </td><td align="center" rowspan="1" colspan="1"> 5 </td><td align="center" rowspan="1" colspan="1"> 1 </td><td align="center" rowspan="1" colspan="1"> 20 </td><td align="center" rowspan="1" colspan="1"> 4 </td><td align="center" rowspan="1" colspan="1"> 80 </td></tr></tbody></table><table-wrap-foot><fn><p>N = number of interproximal spaces evaluated.</p></fn></table-wrap-foot></table-wrap><table-wrap id="T4" orientation="portrait" position="float"><label>Table 4</label><caption><p>Presence of inter-proximal papilla according to implant-tooth distance
(ITD)</p></caption><table frame="hsides" rules="groups" width="470"><thead><tr><th rowspan="1" colspan="1"> ITD<break></break>(mm) </th><th rowspan="1" colspan="1"> N </th><th rowspan="1" colspan="1"> Papilla present </th><th rowspan="1" colspan="1"> % </th><th rowspan="1" colspan="1"> Papilla half-present </th><th rowspan="1" colspan="1"> % </th></tr></thead><tbody><tr><td align="center" rowspan="1" colspan="1"> 1 - 1.5 </td><td align="center" rowspan="1" colspan="1"> 9 </td><td align="center" rowspan="1" colspan="1"> 6 </td><td align="center" rowspan="1" colspan="1"> 66.7 </td><td align="center" rowspan="1" colspan="1"> 3 </td><td align="center" rowspan="1" colspan="1"> 33.3 </td></tr><tr><td align="center" rowspan="1" colspan="1"> 1.5 - 3 </td><td align="center" rowspan="1" colspan="1"> 26 </td><td align="center" rowspan="1" colspan="1"> 19 </td><td align="center" rowspan="1" colspan="1"> 73 </td><td align="center" rowspan="1" colspan="1"> 7 </td><td align="center" rowspan="1" colspan="1"> 27 </td></tr><tr><td align="center" rowspan="1" colspan="1"> > 3 </td><td align="center" rowspan="1" colspan="1"> 5 </td><td align="center" rowspan="1" colspan="1"> 4 </td><td align="center" rowspan="1" colspan="1"> 80 </td><td align="center" rowspan="1" colspan="1"> 1 </td><td align="center" rowspan="1" colspan="1"> 20 </td></tr></tbody></table><table-wrap-foot><fn><p>N = number of interproximal spaces evaluated.</p></fn></table-wrap-foot></table-wrap><p>The results reported in the present study are also distant from the investigation by
Choquet et al. [<xref ref-type="bibr" rid="B10">10</xref>]. Although these authors
established that the papilla level around single-tooth implant restorations is
mostly related to the bone level adjacent to the teeth and more specifically to the
bone crest, they stated that the papillae regeneration after a single implant
treatment was successful with a distance of 5 mm between the contact point and the
bony crest. Above 5 mm the occurrence of papilla regeneration was at least 50% but
with no predictability [<xref ref-type="bibr" rid="B10">10</xref>].</p><p>Grunder [<xref ref-type="bibr" rid="B29">29</xref>] showed in his study that when an
implant is placed adjacent to a tooth, if a distance between the contact point and
the crest of bone was < 5 mm, results in a similar outcome in order to presence
or absence of papilla to that between two adjacent teeth. This author presented ten
case reports of single-tooth rehabilitation and referred that all the papillae were
presented after crowns were placed. The presence of healthy bone on adjacent tooth
and the location of the contact point at a distance of 5 mm or less were determinant
factors in Grunder's study. Although the differences established by different
authors regarding the papilla position, its clear that a missing contact point, the
implant-to-tooth distance and the distance of the bone peak to the contact point
address as important predictors in terms of papilla recession, plus the surgical
approach or flap design [<xref ref-type="bibr" rid="B30">30</xref>].</p><p>Since the present evaluation was a retrospective analysis we must take notice of the
absence of a control group, and the lack of parameters that were not considered like
the type of surgical flap or the execution of some regeneration procedures. The
attempt to correlate different parameters like ITD and CPB and a papilla score, that
relates to a direct comparison between the implant restoration and the soft tissue
status around the natural control tooth seems to be an acceptable protocol to
evaluate aesthetic outcomes [<xref ref-type="bibr" rid="B31">31</xref>]. In future
studies it would be interesting to relate this type of implant abutment restoration
with other abutment options for the anterior maxillary region, considering also
different timings of implant placement and related surgical procedures.</p></sec><sec sec-type="conclusions"><title>CONCLUSIONS</title><p>The restoration of dental implants using Computer-Assisted Design/Computer-Assisted
Manufacturing abutments appears to be a predictable treatment with improved
aesthetic results in anterior maxilla. Properly placement of the implant and correct
prosthetic considerations play a major role in the inter-proximal papilla
management. The restoration of dental implants using Computer-Assisted
Design/Computer-Assisted Manufacturing abutments seems to improve the papilla
presence between tooth and implant.</p></sec></body><back><ack><sec sec-type="acknowledgements and disclosure"><title>ACKNOWLEDGEMENTS AND DISCLOSURE</title><p>The authors declare that they have no conflict of interests.</p></sec></ack><ref-list><title>REFERENCES</title><ref id="B1"><label>1</label><element-citation publication-type="other"><person-group person-group-type="author"><name><surname>Gibbard</surname><given-names>LL</given-names></name><name><surname>Zarb</surname><given-names>G</given-names></name></person-group><source>A 5-year prospective study of implant-supported single-tooth
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