Volume 71 Number 4

The Effect of Inter-Implant Distance on

the Height of Inter-Implant Bone Crest*
D.P. Tarnow, S.C. Cho, and S.S. Wallace
546
Background: The biologic width around implants has been
well documented in the literature. Once an implant is uncovered,
vertical bone loss of 1.5 to 2 mm is evidenced apical to the
newly established implant-abutment interface. The purpose of
this study was to evaluate the lateral dimension of the bone loss
at the implant-abutment interface and to determine if this lat-
eral dimension has an effect on the height of the crest of bone
between adjacent implants separated by different distances.
Methods: Radiographic measurements were taken in 36
patients who had 2 adjacent implants present. Lateral bone loss
was measured from the crest of bone to the implant surface. In
addition, the crestal bone loss was also measured from a line
drawn between the tops of the adjacent implants. The data were
divided into 2 groups, based on the inter-implant distance at
the implant shoulder.
Results: The results demonstrated that the lateral bone loss
was 1.34 mm from the mesial implant shoulder and 1.40 mm
from the distal implant shoulder between the adjacent implants.
In addition, the crestal bone loss for implants with a greater than
3 mm distance between them was 0.45 mm, while the implants
that had a distance of 3 mm or less between them had a cre-
stal bone loss of 1.04 mm.
Conclusions: This study demonstrates that there is a lateral
component to the bone loss around implants in addition to the
more commonly discussed vertical component. The clinical sig-
nicance of this phenomenon is that the increased crestal bone
loss would result in an increase in the distance between the base
of the contact point of the adjacent crowns and the crest of
bone. This could determine whether the papilla was present or
absent between 2 implants as has previously been reported
between 2 teeth. Selective utilization of implants with a smaller
diameter at the implant-abutment interface may be benecial
when multiple implants are to be placed in the esthetic zone so
that a minimum of 3 mm of bone can be retained between them
at the implant-abutment level. J Periodontol 2000;71:546-549.
KEY WORDS
Dental implants; dental implantation; bone loss; alveolar bone;
papilla.
* Department of Implant Dentistry, New York University College of Dentistry, New York, NY.
T
he existence of the biologic width
around teeth has been documented
in the literature. It was a study by
Gargiulo et al.
1
in 1961 that gave us a
dimensional understanding of this physio-
logic attachment apparatus. The average
distance from the base of the sulcus to the
crest of the bone was found to be 2.04 mm.
The epithelial attachment averaged 0.97
mm and the connective tissue attachment
averaged 1.07 mm in length. Another
cadaver study by Vacek et al.
2
in 1994 con-
rmed the consistency of these dimensions
while showing the connective tissue attach-
ment to average 0.77 mm and the epithe-
lial attachment to average 1.14 mm.
The presence of a biologic width around
implants has also been investigated. Multiple
research groups have veried that a biologic
width also exists around implants.
3-8
This is
true for implants of all shapes after uncov-
ering (stage 2) surgery. For 1-piece non-sub-
merged implants
4,7,8
or 2-stage implants
used with a single-stage non-submerged pro-
tocol, the biologic width will form at the time
of implant placement. This phenomenon is
not related to loading and it will occur
whether the implant is unloaded or loaded.
7
The biologic rationale is that the bone
exposed to the oral cavity will always cover
itself with periosteumand connective tissue.
Additionally, connective tissue will always
cover itself with epithelium. If a chronic irri-
tant, such as bacteria, reaches the implant-
abutment interface through screw-access
channels,
9-12
or if the abutment is removed
after initial healing,
6
the bone will resorb to
create a distance from this chronically
exposed or irritated area. Tarnowet al.
13
have
previously histologically documented a sim-
ilar bone response to subgingival crown
preparations that violate the attachment
apparatus on human teeth.
9046_IPC_AAP_553150 4/20/00 3:19 PM Page 546
J Periodontol April 2000 Tarnow, Cho, Wallace
Two-stage implants are usually placed at or near
the crest of bone. Once they are uncovered, an implant-
abutment interface is established and the bone resorbs
about 1.5 to 2.0 mm apically.
8
This vertical bone loss
has been well researched. The purpose of this paper
was to evaluate the lateral bone loss at the implant-
abutment connection and to see if this lateral dimen-
sion has an effect on the height of the crest of bone
between 2 implants separated by different distances.
MATERIALS AND METHODS
Thirty-six patients were utilized for this radiographic
study. These patients were part of a longitudinal study
conducted at the New York University Department of
Implant Dentistry on machined titaniumimplants. Radi-
ographic measurements were taken at a minimum of
1 and a maximum of 3 years after implant exposure.
Only areas with 2 adjacent implants were utilized for this
study. All radiographs were taken with a parallel tech-
nique utilizing a customized XCP bite block as a posi-
tioning index for consistency and reproducibility of the
radiographic images. The radiographs were computer
scanned, imaged, and magnied for measurement. Fig-
ure 1 illustrates the measurements taken for this study.
The lateral distances from the crest of the inter-
implant bone to the implants were recorded (A and B
in Fig. 1). In addition, the radiographs were divided
into 2 groups: those where the inter-implant distance
(D in Fig. 1) was 3 mm or less, and those where the
inter-implant distance was greater than 3 mm.
RESULTS
The lateral distance from the implant to the crest of the
ridge was 1.34 mm (SD = 0.36 mm) for A and 1.40
mm (SD = 0.60) for B. The crestal bone loss (C) for
implants with a 3 mm or less distance between them
(as measured by D) was 1.04 mm, while the crestal
bone loss (C) for implants that were more than 3.0
mm apart was 0.45 mm. These data are presented in
Table 1.
DISCUSSION
These ndings demonstrate two important facts. The
rst is that there is a lateral component to the bone loss
after abutment connection of a 2-stage implant. The
second is that this lateral component of bone loss can
result in greater inter-implant crestal bone loss if the
two implants are not spaced more than 3 mm apart
(measurement D). The lateral dimension of the defect
is readily observed in Figures 2 and 3.
547
Figure 1.
Radiographic measurements recorded. A and B represent the lateral
distance (bone loss) from the implant to bone crest; C, vertical crestal
bone loss; and D, the distance between implants at the implant-
abutment interface.
Figure 2.
Inter-implant distance greater than 3 mm. Lateral bone loss from
adjacent implants (A and B from Figure 1) does not overlap, with
minimal resultant crestal bone loss (C from Figure 1).
Table 1.
Recorded Data for Lateral and Crestal Bone
Loss (see Figure 1)
Bone Loss (mm)
Lateral A (n = 36) B (n = 36)
Mean 1.34 1.40
SD () 0.36 0.60
Bone Loss (mm)
Crestal D C
3 mm (n = 25) 1.04
>3 mm (n = 11) 0.45
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Inter-Implant Distance in the Alveolar Bone Crest Volume 71 Number 4
In 1978 Waerhaug
14
demonstrated that there was a
1.78 mm distance between plaque on teeth and the
surrounding bone. In addition, in 1984 Tal
15
examined
the presence or absence of intrabony defects when
roots were at different distances apart. It is interesting
to note that the minimum distance between roots for
2 separate angular defects to be present on adjacent
teeth was 3.l mm. In other words, the lateral aspect of
each angular defect appears to be at least 1.55 mm
on each root. This distance correlates with the present
nding of 1.34 mm and 1.40 mm of bone loss (Fig.
1A and B, respectively) in the lateral direction from an
implant to the crest of bone.
Separating the data into 2 groups, with the inter-
implant distance of the rst group being 3 mm or less
and that of the second group being greater than 3 mm,
was based on the hypothesis that 2 adjoining implants
with 3 mm or less of separation should have increased
inter-implant bone loss as a result of the horizontal
distance that bone will be lost on each side of the inter-
implant crest. The scatter graph shown in Figure 4
demonstrates the clear trend of increased crestal bone
loss as the inter-implant distance decreases.
CONCLUSIONS
This paper demonstrates that there is a lateral com-
ponent to the bone loss around implants once the bio-
logic width has formed.
The clinical signicance of this phenomenon is that
the increased crestal bone loss results in an increase
in the distance between the base of the contact point
of the adjacent crowns and the crest of bone. This
could determine whether the papilla will be present or
absent between 2 implants, as has been reported by
Tarnow et al.,
16
between 2 teeth. In that study, a small
difference of 1 mm was clinically signicant. When the
distance from the contact point to the crest was 5 mm,
the papilla was almost always present. When this dis-
tance increased to 6 mm, the papilla completely lled
the embrasure space in only 55% of the observed
cases.
It is commonly observed that it is more difcult to
maintain or create a papilla between 2 adjacent
implants than it is to maintain or create the papilla
between an implant and a natural tooth. This may indi-
cate that the selective utilization of implants with a
smaller diameter at the implant-abutment interface
may be benecial when multiple implants are to be
placed in the esthetic zone so that a minimum of 3
mm of bone can be retained between them at the
implant-abutment level. It may also indicate that wide-
bodied implants adjacent to one another may be of
limited use in the esthetic zone, since they would dimin-
ish the inter-implant distance and potentially lead to
increased crestal resorption. Measurements are pres-
ently underway to evaluate whether the papillae are
affected by this crestal resorption between adjacent
implants.
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548
Figure 3.
Inter-implant distance 3 mm or less. Lateral bone loss from adjacent
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Figure 4.
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Send reprint requests to: Dr. Dennis Tarnow, 205 E. 64th
Street, Suite 402, New York, NY 10021. Fax: 212/754-6753.
Accepted for publication August 19, 1999.
549
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