PERSPECTIVES CLINICAL DILEMMAS
Implants or pontics
Decision making for anterior tooth replacement
cience has provided
S today’s restorative
dentist with continu-
ally improving tools for
the replacement of
missing teeth, and providing
esthetically pleasing outcomes
for single missing anterior teeth
is a highly predictable procedure
in the hands of most clinicians.
The predictability decreases
substantially when significant
bone and soft tissue also have
been lost; however, even in this
scenario, a competent interdisci-
plinary team generally can pro-
duce an acceptable result by
using an implant or a fixed par-
tial denture with an ovate pontic
to replace the missing tooth.
When the loss is not of one tooth
but of numerous teeth, particu-
larly if those teeth are adjacent
to each other, the esthetic chal-
lenge is immensely more
complex.
As implants have improved
and placement techniques have
evolved to take advantage of
those improvements, the
Frank Spear, DDS, MSD
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informed clinician may gravitate
toward use of implants as the
preferred solution for all missing
teeth. As implant science con-
tinues to improve, the use of
fixed partial dentures may
become an anachronism, much
like the specialized preparations
of hemisectioned molars re-
quired in perioprosthodontics.
At one time, the technique for
creating these unusual prepara-
tions was taught in every dental
school; today, it is a lost art.
Fortunately, the loss is realized
only in situations in which bone
grafting, implant placement or
both are impossible—an ever-
decreasing occurrence. Although
it may be preferable to have a
“root” wherever a tooth is
missing, the esthetic challenges
presented by multiple missing
anterior teeth often require the
combination of implants and
ovate pontics to achieve accept-
able esthetic results.
The average papillary height
above bone between natural
teeth is 4.5 millimeters.1,2 When
September 2009
a single-tooth implant is placed,
papillary levels are determined
by the height of the bone on the
adjacent natural teeth, not by
that of the bone around the
implant.3-5 Therefore, the papil-
lary height between a tooth and
an implant will be similar to
what it was before tooth
removal. The facial gingival
margin around the implant is
related to the bone levels on the
implant, as well as to the thick-
ness and position of the free gin-
gival margin before tooth
removal.6,7
SINGLE MISSING ANTERIOR
TEETH
The least predictable soft-tissue
outcome with a single anterior
implant is associated with inter-
proximal bone loss in the adja-
cent natural teeth. Because
interproximal bone determines
papillary height, creating
esthetic papillary heights can be
difficult. If the newly edentulous
space is to receive not an
implant but rather a pontic as
part of a fixed partial denture,
the bone level on the teeth adja-
cent to the space still will deter-
mine the papillary heights.

The most significant differ-
ence between a pontic and an
implant is that the clinician can
significantly alter the soft tissue
that will surround a pontic and
create a papilla by means of
soft-tissue grafting procedures.
When the clinician places a soft-
tissue graft, the amount of
tissue above the bone between a
pontic and a natural tooth, or
between a pontic and an
implant, averages 6.5 mm—an
increase of 2.0 mm, or 44 per-
cent. In some patients, the
tissue height after grafting can
be as high as 9.0 mm.8
When natural teeth adjacent
to a single edentulous space
have bone loss, soft-tissue ridge
augmentation followed by place-
ment of a pontic always will
achieve greater coronal papil-
lary height than will a single-
tooth implant placed into the
edentulous space. In a situation
in which the papilla, to be
esthetically acceptable, must be
more than 4.5 mm above the
level of the bone, placement of a
fixed partial denture with an
ovate pontic is the most appro-
priate treatment decision.
MULTIPLE MISSING
ANTERIOR TEETH
When multiple teeth are
missing or require removal, the
soft-tissue ramifications are dif-
ferent because of the biology of
the periodontium and the
responses of the bone and soft
tissues. To understand these
ramifications, it is helpful to
consider the biological response
of the soft tissue after tooth
removal. In a case involving the
removal of two central incisors,
the interproximal bone height
on the lateral incisors will deter-
mine the papillary height be-
tween the lateral incisors and
whatever is placed in the space.
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The soft tissue on the mesial
side of the lateral incisor will act
exactly as it would in the case of
a single-tooth replacement. The
facial free gingival margin
height in each central incisor
site also will be similar in
response to a single missing
tooth. The facial bone level and
tissue thickness will determine
the height at which the facial
gingival margin stabilizes. The
difference between the single
The restorative challenge
created by the loss of both
central incisors relates
directly to the osseous
scallop that existed
between those incisors.
edentulous space and the space
created by removal of the two
central incisors is what happens
to the papilla that existed
between them before the
extractions.9,10
If we assume no periodontal
disease existed before tooth
removal, the osseous crest
around both central incisor sites
will follow the scalloped form of
the cementoenamel junction.
The gingiva on the facial bone
will be positioned so that, on
average, the free gingival
margin is 3.0 mm coronal to the
osseous crest. As the cemento-
enamel junction flows from the
facial aspect into the interprox-
imal aspect, the bone follows,
and an average osseous scallop
of 3.0 mm is created. Because
soft tissue follows the scallop of
the bone, the osseous scallop
presumably should result in a
gingival scallop of 3.0 mm. How-
ever, when teeth are present, an
interesting phenomenon occurs:
the papilla is 1.5 mm more
JADA, Vol. 140
PERSPECTIVES C L I N I C A L D I L E M M A S
coronal to the osseous crest than
to the facial tissue. This addi-
tional 1.5 mm added to the
3.0-mm average osseous scallop
results in the tip of the papilla’s
matching the 4.5-mm average
noted previously (Figure 1). The
restorative challenge created by
the loss of both central incisors
relates directly to the osseous
scallop that existed between
those incisors.
Replacement of the central
incisors with two single
implants adjacent to each other
is one of the prosthetic restora-
tive options available. During
placement, the clinician places
the implant apically until the
platform is level with the facial
osseous crest. Most implants in
use today are not scalloped;
because the bone is scalloped,
the interproximal platform of
the implant may be apical to the
interproximal osseous crest by
as much as 3.0 mm. Although
implant placement retains bone
that would be lost if the site
remained edentulous, a certain
amount of bone adjacent to the
implant is expected to resorb
across time, usually to the level
of the first thread of the
implant.11,12 Resorption of the
interproximal osseous crest
results in a flattening of the
osseous crest. Maintaining a
minimum distance of 3.0 mm
between implants seems to
lessen this flattening, but
researchers agree that, regard-
less of the distance between
implants, the crestal bone
undergoes some degree of
resorption and flattening.13
The visible and esthetic issue
in these osseous changes is the
corresponding flattening of the
gingival architecture. Tarnow
and colleagues13 identified a
papillary height of 4.5 mm above
bone between two adjacent teeth
http://jada.ada.org September 2009 1161
PERSPECTIVES C L I N I C A L D I L E M M A S

Figure 1. The average osseous scallop is 3.0 millimeters from the Figure 2. When adjacent implants are placed 3.0 or more millime-
facial aspect to the interproximal aspect, and the average gingival ters apart and the facial and interproximal osseous crest is retained
scallop is 4.5 mm from the facial aspect to the interproximal aspect (red lines), the papilla between the implants may be within 1.0 to
between natural teeth. 1.5 mm of the original papillary height (yellow line).

and of 4.5 mm above bone
between a natural tooth and an
adjacent implant. With the
placement of adjacent implants,
papillary height between the
implants changes from 4.5 mm
to between 3.0 and 3.5 mm
above the bone.13 This change
represents a dramatic and
potentially devastating esthetic
challenge to the replacement of
teeth with implants. Even if the
interproximal osseous crest
could be maintained perfectly
between two implants, the
papilla will stabilize 1.0 to 1.5
mm apical to where it was
between the teeth simply
because of the change in soft-
tissue levels above the bone
(Figure 2). Adding this 1.0- to
1.5-mm difference to the osseous
changes affecting the interprox-
imal crestal bone height makes
it clear why maintenance of an
esthetically correct papillary
height between adjacent
implants is such a difficult
proposition.
The use of pontics to replace
the two central incisors involves
its own challenges.14,15 The soft
tissue between the central
incisor pontics and the lateral
incisor abutments, as well as the
facial soft tissue, will behave as
described above when a pontic
replaces a single tooth. The chal-
lenge is the papilla between the
adjacent pontics, just as it is
between adjacent implants. The
interproximal crestal bone be-
tween the extracted central
incisors will resorb, creating a
flat bony ridge with subsequent
loss of potential papillary
height. This esthetic challenge
differs from that posed by the
implants because of the ability
to augment the soft-tissue
height above the flattened os-
seous crest between the lateral
incisors to an average 6.5 mm.
MAKING AN APPROPRIATE
DECISION
Thorough evaluation, careful
diagnosis of the existing condi-
tion and a clear understanding
of the responses of the hard and
soft tissues provide a basis for
predicting treatment outcome.
The following manifestations
are the four most common
esthetic dilemmas created by
multiple missing teeth.
dThe teeth are present and
need to be removed; there is no
periodontal disease affecting the
teeth to be removed.
dThe teeth are present and
need to be removed; there is
periodontal disease affecting the
teeth to be removed.
dThe teeth are missing and the
osseous and soft-tissue ridge are
flattened; the free gingival
margin location on the ridge is
acceptable as a papillary
position.
dThe teeth are missing and the
osseous and soft-tissue ridge are
flattened; the free gingival
margin is positioned signifi-
cantly apically to an acceptable
papillary position.
With knowledge of the usual
behavior of the bone and soft
tissue, we can discuss each of
the four manifestations and
select the most appropriate
treatment.
Tooth removal and re-
placement in the absence of
periodontal disease. The most
predictable situation is one in
which the patient requires
removal of multiple teeth in the
absence of periodontal disease.
The challenges in this situation
are related first to the choice
between implants and a fixed
partial denture and, second, if
implants are chosen, how many
should be placed and where. The
appropriate choices depend on
which teeth are being removed.
For example, if the two maxil-

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lary central incisors are being
removed and they are supported
by healthy bone, placing adja-
cent implants can result in a
predictable and esthetic final
result. The papilla between the
central incisor implants and the
adjacent lateral incisors will be
excellent, the facial gingival
margins can be augmented
easily, if required, and the
papilla between the central
incisor implants should remain
within 1.0 to 2.0 mm of the pre-
extraction papillary level if the
clinician places the implants
3.0 mm apart and most of the
interproximal osseous crest is
maintained (Figure 3). The clini-
cian could treat this same
patient with a fixed prosthesis
by using the lateral incisors as
abutments. Since the interprox-
imal bone between the extracted
central incisors most likely will
be lost, the risk of soft-tissue
recession in the area in which a
papilla needs to be created
between central incisor pontics
is an esthetic challenge. As
described previously, soft-tissue
augmentation before completing
the restoration creates signifi-
cant tissue height that could be
used to form an excellent papilla
between the pontics.
When the teeth to be removed
involve a central incisor and a
lateral incisor, or a lateral
incisor and a canine, the treat-
ment choices become much less
clear. The difficulty encountered
is twofold. First, placement of
adjacent implants in the central
incisor and lateral incisor sites,
or the lateral incisor and canine
sites, is difficult if the surgeon is
to maintain a minimum of 3.0
mm between the platforms of
the implants. This situation
means there is a high risk that
interproximal osseous crest will
be lost between the implants
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PERSPECTIVES C L I N I C A L D I L E M M A S
B
A C
Figure 3. A. A patient who required the extraction of both central incisors. Note the
excellent bone level and papillary height. B. Because the interproximal osseous crest was
maintained and the soft tissue supported at the time of tooth removal, an excellent interim-
plant papilla exists. C. Final restorations exhibit minimal change in papillary height when
compared with pre-extraction height. Even in this ideal situation, the difference is 1.0 to 1.5
millimeters apically. Photographs courtesy of Dr. Greggory Kinzer.
across time, with subsequent gical soft-tissue augmentation
loss of papillary height (Figure and placement of a fixed partial
4). Second, when papillary denture. Although this method
height is lost between the cen- can create a pleasing esthetic
tral incisor and lateral incisor result, it is a much more com-
on one side while natural teeth plex restoration structurally and
exist on the other side, the dis- functionally, particularly when
crepancy in papillary height is the lateral incisor and the
much more noticeable than a canine are being replaced by
slight loss of papillary height in pontics.
the middle of the face between When removal of three or four
adjacent central incisor im- adjacent anterior teeth with
plants. These reasons—combined good periodontal support is
with the fact that use of adja- required, my preference is place-
cent implants to replace a cen- ment of implants separated by
tral incisor and a lateral incisor, one or two pontics. If both cen-
or a lateral incisor and a canine, tral incisors and one lateral
is not required for force manage- incisor need to be removed, I
ment in the anterior aspect— would choose placement of one
make placement of a single implant in the proximal central
implant in the site of the central incisor site, placement of a cen-
incisor or the canine, with a can- tral incisor ovate pontic and
tilever replacing the lateral placement of the second implant
incisor as an ovate pontic, in the lateral incisor site. This
esthetically more predictable design allows the creation of
and functionally acceptable. excellent papillary heights in all
An alternative for prosthetic locations because of the pre-
replacement of a missing central dictability of the soft-tissue aug-
incisor and lateral incisor or lat- mentation in the ovate pontic
eral incisor and canine is sur- site (Figure 5).
JADA, Vol. 140 http://jada.ada.org September 2009 1163
PERSPECTIVES C L I N I C A L D I L E M M A S

acceptable esthetic, structural

and functional results.
Tooth removal and re-
placement in the presence of
periodontal disease. Consid-
ering the same manifestations
discussed previously, but adding
B the presence of pre-existing bone
loss resulting from periodontal
disease, provides new chal-
lenges. Foremost among these is
the loss of predictability of the
papillary height after tooth
removal in the areas of peri-
odontal disease. When peri-
odontal disease is present, the
A C bone does not always respond as
it would if it were healthy,
Figure 4. A. Adjacent implants placed in central and lateral positions. Note excellent inter-
proximal bone but minimal interimplant distance. B. At insertion, no black triangle was which often leads to greater
present; however, six months after insertion, papilla has receded as bone is lost. C. Twelve resorption of bone and a greater
months after implant placement, soft tissue has migrated apically as bone between the degree of papillary recession.
implants has continued to resorb.
Therefore, to avoid an open gin-
gival embrasure, the clinician
must position contacts more api-
cally than is esthetically desir-
able. The clinician is left with
the challenge of using implant
restorations that will be accept-
able functionally and struc-
turally but less so esthetically,
A B
or of forgoing the use of
implants and using soft-tissue
grafting with fixed partial den-
tures in areas in which grafting
and pontics can produce signifi-
cantly more soft tissue over the
interproximal bone. The differ-
ence between tissue heights of
3.5 and 6.5 mm above bone can
C D
be the difference between an
Figure 5. A. A patient with three ankylosed teeth but with excellent bone levels. esthetic success and an esthetic
B. Teeth nos. 8, 9 and 10 were removed and immediate implants placed at no. 8 and failure. The final decision about
no. 10. C. Connective-tissue grafting in pontic area no. 9 and over implant no. 10. D. Final
restoration after grafting: a three-unit zirconia prosthesis consisting of an implant abutment which modality is best suited for
at no. 8, a pontic at no. 9 and an abutment at no. 10. success will be based on the
esthetic requirements created by
If removal of all four incisors incisors as ovate pontics. The the lip line and mobility and the
is required and good periodontal second is placement of the condition of the remaining teeth.
support exists, the clinician has implants in the central incisor If the adjacent teeth are unre-
two equally acceptable options locations with a mediating space stored, it may be preferable to
for implant prostheses. One is of at least 3.0 mm; the lateral conserve tooth structure by
placement of implants in both incisor ovate pontics then can be using implants rather than
lateral incisor locations, with cantilevered from the central preparing unrestored teeth.
the replacement of both central incisors. Both options produce Some esthetic compromise may

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 PERSPECTIVES C L I N I C A L D I L E M M A S

be in the patient’s best interest

and should not be dismissed
without serious consideration
and discussion.
Slow orthodontic eruption
before extraction is another
option to consider when it is
necessary to remove multiple
adjacent teeth with periodontal
disease.15 Although eruption of a A
single tooth that is to be ex-
tracted does not alter the final
papillary heights, because those B
heights are dictated by the bone
on the adjacent teeth, the erup-
tion of multiple teeth before
extraction may move interprox-
imal bone coronally. This move-
ment of the bone is not highly
predictable, however, so the C
clinician must inform the
patient that a perfect esthetic
result is unlikely and that short
papillae, long contacts and more
rectangular final restorations
could be expected (Figure 6). D
Tooth replacement in the
presence of a flattened ridge.
The final two manifestations,
both involving a flattened ridge,
are the most difficult to manage
esthetically. When multiple
teeth are removed, the bony
ridge tends to flatten rapidly
unless the clinician does some- E
thing to alter the process. In F
cases in which the teeth have
been missing for a significant Figure 6. A. A patient requiring extraction of teeth nos. 8 and 9 because of extensive
bone loss. Note excellent papillary levels. B. Significant bone loss has occurred, creating an
time, the interproximal osseous esthetic dilemma regarding soft-tissue position. C. Orthodontic eruption was used to
crest will be gone completely. attempt to move the bone coronally. D. After the eruption, there has been minimal if any
Recreating vertical bone height improvement. E. Implant placement. F. Final restorations. Note the minimal gingival scallop
caused by an apically placed papilla and a long contact. This esthetic compromise was
in situations in which multiple expected owing to the patient’s significant interproximal bone loss before implant place-
teeth have been removed is diffi- ment. Photographs courtesy of Dr. David Mathews and Dr. Vince Kokich.
cult and unpredictable. For this
reason, when the teeth are cent implants. Therefore, the minimize esthetic compromises
missing before any treatment, clinician must inform the and can achieve an excellent
use of adjacent implants results patient that the best esthetic esthetic result (Figure 7).
in inadequate papillary height. result may involve pontics
Using a connective graft and rather than implants in some CONCLUSION
pontics, however, can create and sites. Selection of the most Patients who have multiple
maintain significantly more soft appropriate sites for using missing anterior teeth, or
tissue above the interproximal connective-tissue grafting and a patients for whom removal of
bone than is possible with adja- pontic next to an implant will multiple anterior teeth is

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PERSPECTIVES C L I N I C A L D I L E M M A S

A B C
Figure 7. A. A patient with a significant ridge defect and previously placed adjacent implants in the lateral and canine position.
B. The lateral incisor implant has been covered with soft tissue rather than used and the canine implant uncovered after soft-tissue grafting.
C. The final restoration: the lateral incisor is now cantilevered off of a canine implant. Photographs courtesy of Dr. David Mathews.

required to restore dental
health, bring with them signifi-
cant issues in ensuring an
acceptable esthetic result.
Careful evaluation of the bone
available; the periodontal health
when teeth are still present; the
amount of tooth displayed
during normal activities; the
functional and structural
requirements of the restora-
tions; and the patient’s esthetic
concerns, demands and expecta-
tions will lead the dentist and
the patient through a thera-
peutic decision tree, each branch
requiring a choice. This series of
thoughtful choices ultimately
ensures that the clinician will
achieve the best solution for
each patient. The solution may
include compromises in the
interest of giving greater impor-
tance to a portion or portions of
the desired outcome, but they
will be compromises made with
the full knowledge and under-
standing of all parties. In the
end, investing the time, thought
and communication necessary to
make the right choice creates
two beautiful smiles—in a
pleased patient and a happy
dentist. ■
Dr. Spear is the founder and director,
Seattle Institute for Advanced Dental Educa-
tion, 600 Broadway, Suite 490, Seattle, Wash.
98122. Address reprint requests to Dr. Spear.
Disclosure. Dr. Spear did not report any
disclosures.
The views expressed are those of the author
and do not necessarily reflect the opinions or
official policies of the American Dental
Association.
The author thanks Dr. Greggory Kinzer for
the photographs in Figure 3; Dr. David
Mathews and Dr. Vince Kokich for the pho-
tographs in Figure 6; and Dr. David Mathews
for the photographs in Figure 7.
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