Space Between Implant Fixture and Natural Teeth: How Much Is Enough?

Anon. asks:

I have treatment planned a patient to place a dental implant in #12 area. I have a Tomographic view of the site and there is adequate occlusogingival dimension to place an 11mm long implant in the site. However, there is only 5.8mm mesiodistal space between #11 and #13. I would like to place a 3.8mm wide implant there. That will leave me only 1mm of space on each side. Will this be enough space between the implant fixture and the adjacent natural teeth? If I do not place the 3.8mm wide implant, I will have to drop down to the next narrowest implant which is only 3.4mm. What should I do?

32 thoughts on “Space Between Implant Fixture and Natural Teeth: How Much Is Enough?

  1. Hey it feels great to know that you are a “Friadent Xive S cell plus ” user like me! You could be a Frialit user too! Anyway why do you want to put a 3.8 mm wide implant in the first place any way? 3.4 mm wide is suited for premolars so go for it. Remember the measurements you do on the Intra oral films may carry distortioned proportions and 3.8 mm may prove to be way too big. 3.4 is perfect for partially edentulous jaws with missing premolars.

    You could use 3.8 if you had a larger edentulous segment, say for example, in a completely edentulous jaw.

    If you want, put a longer implant, if you wish to compensate the width with height.

    By the way be careful while using your physio to screw in the 3.4 mm implant you are likely to over do it, rather use the the ratchet quite early during the screwing so you get primary stability.

    I hope this helps!

  2. Always remember Tarno’s rule” 2mm on eachside on all 5-D”.
    Any way Too large implant will create lack of embrasures.That will lead to deficient pappilla (an esthetic issue), and perio problems (hygiene issue).
    Also will lack emergence profile, again esthetic issue.It may look like a squarish block of porcelain due to proximal under contour.

    3.25 mm implant would be better in your case.
    I would rather explore orthodontic remedy to increase mesio-distal space if possible.Good luck.

  3. Tarno’s rule in 5 dimensions means if i am still remembering it right that you will have to leace 2 mm of space mesially, distally buccal and lingual and have the implant placed if submerged 2mm apical to the CEJ.
    Belser studies suggest a minimum of 1mm so using a 3.8mm implant may be fine if you have really 5.8mmm but ask yourself the following questions:
    1-Is there really 5.8mm space?in such cases i never mesure on radiographies…i set all my implant diameters, i open my flap, mesure with my caliper and probe and decide which implant i have to use.
    2-whatever the space is and you have an implant that matches that space leaving 1 mm between it and the tooth, is that space is enough for a good esthetic outcome or the crown will be square? if the esthetic outcome is not fine i may think about orthodontics to open the space or maybe do a bridge and not and implant…
    3-Are you sure you can put your implant exactly in the midle so that you keep your 1mm space?
    i am not used to the Xive frialit implant but in the zimmer that i use i will put 3.7, 3.3 and a 3 mm one piece aside and i will choose my implant during the surgery…
    Nothing better than visual observation.

  4. Dr.Serge is right in explanation.
    I made a mistake in spelling in rush.It is Tarnow not Tarno.
    Dr. Dennis Tarnow’s rule.
    Some expert may advise for 1mm space between fixture and natural teeth, but if you listen to other masters of aesthetic implant dentistry like Drs. Salama brothers, Dr. David Garber, Dr. Jhon Kois,they will agree with Dr. Tarnow.
    Apart from lack of proper hygiene by patient,due to lack of embrasures and aesthetic issue,main problem I see with 1mm space is,You may damage adjacent roots during osteotomy prep,unless you use pecisely made surgical guide or you are an experienced surgeon.

  5. I would go fo a 3mm diameter implant top, you may have problems with blood flow and bone regeneration if you go over that size
    In such small spaces i sually recomend a ull ceramic thee unit bridge, it will allow a better cosmetic result, better papillae management and easier space distribution.

  6. I concur with the comments made. I use the rule of 2 mm or you really can expect a defect there even if it does work out. I won’t assume here that the reason you “want” to use the 3.8 is it is the smallest you have in inventory, but you are wanting to maximize strength.
    It is easy to get into what I call the fear factor of wanting the implant to mimick a tooth root as nearly the same as possible. This is fine, but ironically, due to the many issues alluded to here for example, it is usually a healthier situation to have a smaller diameter implant, placed a little deeper to allow for proper contours as the abutment exits the tissue gradually from small to proper size than trying to match root size with the body of the implant.
    another hint: use simple calipers that FOR SURE you can measure the space intraorally as mentioned.
    In other words, this is a relatively straightforward procedure, but not when you allow your tools or “implant you have in the box” to determine what you place :-)
    fmn

  7. I never had a problem regarding bone quantity around the neck of the implant i have been using for 13 years now . It has a convergent shoulder where whatever the diameter of implant is ; the implant abutment connection is 3mm . Even if the implant is 6 mm in diameter I will have at least 1.5 mm of space on each side .That is an american implant from Boston called bicon . Yes it has an odd shape but believe me it worked very well for me the last 13 years (it was called stryker implant and has been in the market for 23 years without change of design ).

  8. According to C.E.misch idea minimum distance between implant and adjacent teeth is 1.5 mm, so you must gain necessary space (1 mm in your case) through reshaping the adjacent teeth(0.5 mm on each side).Then you are able to insert 3.8 mm wide implant.

  9. Dear colleague I have had similar situations and I noticed that I could not calculate the tenth of a millimeter distance three two teeth when I put a plant. Like ‘I found myself well with a fixture from 3.5 mm nobel biocare. Distance of three years I have not had any kind of problem.
    Thanks

  10. I have had several similar situations with upper second incisors with even less space between first incisors and canines. Each situation was solved using orthodontics to create 6.0-6.2 mm space between the roots and I placed Xive 3.0 mm implants. No problems with esthetics nor function. Intrasurgical measurements with caliper will serve you fine if you are measuring distances between the tooth crowns. However, the problems are usually not there, but in the distance between the roots. The surest thing is to control intrasurgically with the RVG after each drill. No mistakes made that way.
    I would not suggest going under 1,5 mm between implant surface and lamina dura of the periodontium of adjacent teeth.

  11. Please don’t take this the wrong way.You have no business placing implants if you don’t have the basic diagnostic skills and didactics down pat.You would benefit from Carl Misch’s Contemporary Implant Dentistry.This book should be required reading from cover to cover before they sell any surgical kits.Get the book ,no joking.

  12. I personally follow the 1,2,3,7 rule, wherein 1 stands for 1mm cortical bone thickness on the buccal & lingual/palatal aspect, 2 for 2mm clearance from the adjacent tooth(thats 2mm + the radius of the implant), 3 for a 3mm inter-implant distance(assuming multiple implants are placed, again the thumb rule of 3+the radius of the implant), & 7 for 7mm of inter-arch clearance…a Utopian dream often, but that should be the basic approach..

  13. When we are talking about measurements from teeth we must specify which part of the teeth
    We measure space available from a perpendicular dropped from contact point of tooth to gum
    But when we measure distance of implant to tooth we tend to measure to the CEJ not the contact point
    This is a VERY big and important difference
    All the above recommendatons are accurate rules of thumb but this point has to be clear

  14. I need to add thus that the 2mm from edge of implant to tooth is to the perpendicular dropped from the contact point
    This will also apply if the tooth is tilted towards the implant

  15. I agree with Dr. R. Mosery that you should not be placing impalnts if you do not understand the basic knowledge. Taking a few courses or reading a few books is not an adequate substitute for experience and training.

  16. What is the minimum distance between an implant and a tooth? Tarnow suggested the 1.5 mm distance based on his studies on implants with smooth collar crest module. Other practitioners like Misch picked this number and listed it in his book as the golden rule! Same for the inter-implant minimum distance of 3 mm.
    Remember that Tarnow’s research was done on implants with smooth collar crest module which result in peri-implant bone loss. This rule doesn’t apply to implants with bone level crest module such as Astra, Xive, Bicon, …and the newer versions of the bone level implants of all big companies!! So even if you have 1 mm of distance between the implant and the tooth, or 2 mm distance between 2 implants, you will not have a problem surgically. However, placing implants too close to the adjacent teeth or to each other may impose a restorative and esthetic problem. In you case you can use either 3.4 mm or 3.8 mm implant without any surgical problem (I’m assuming that you are using Frialit or Friadent implant which has a bone level crest module). The decision on which one to use should be based on the patient’s occlusion. If you have good canine guidance, no mobility in adjacent teeth, no parafunctional habits, the 3.4 mm is more than enough.
    In your case you should pay attention to the esthetic concerns more than the surgical concerns of bone loss and disappearing of the interdental papilla. How will a 5.8 mm first premolar look like compare to the adjacent 2nd premolar and canine? You may have to do some stripping if the mesio-distal width of these teeth is 7 mm and above.
    * Regarding the 2 mm rule; how often you have 2 mm of bone B and L of the implant??!! Tarnow is a great implantologist and one of the best, however, every statement is subject to analysis and criticism.

  17. While adherence to the “rules” regarding distances between implants and natural teeth are important guides for success in our cases, there is one more important area that is almost always overlooked. That area is the role of biotype and the dento-gingival complex. Thin biotypes tend to exhibit more crestal bone remodeling regardless of the distances quoted. This is why Tarnow, et al, have had to modify their distances originally quoted. If you do CT grafts at the time of implant placement, you will preserve more crestal bone. Once a tooth has been extracted, if an implant is not placed immediately, you will lose the orientation of the transverse and circumferential fibers, leading to a thinning of the biotype and loss of papilla height. This is why, when you attend lectures, you will find that the most exquisite finishes of cases are usually where there is extraction, immediate placement as a one stage procedure.

  18. I’m disappointed with the comments of Dr.’s Mosery and Wright. This sounds like someone getting started with implants. He is planning and asking colleagues for input. He has a ct scan for an upper premolar, a good area to start with. “Please don’t take this the wrong way, you have no business placing implants…” Wow.
    Personally, I enjoy reading the questions and comments and I don’t want to discourage conversations by being judgemental.

  19. I am not trying to be judgemental, but honest. PATIENTS always deserve the best care possible. I have seen too many complications from G.P.’s who are not experienced. As a specialists who has placed implants for over ten years, I have witnessed the decline of quality care, all because most doctors don’t know their limitations.He is obviously new at placing implants and the patient should know that prior to any surgical procedure. I have no problem giving advice and support, but patients need to be informed.

  20. If these questions are NOT asked then we will kill these forums.
    Why is this question a lessor one than …a grafting technique or an oppinion on ….platform switching or …indications for Wide body or narrow implants Immidiate or delayed load one or two stage etc etc..
    I guarantee there are several “experienced “implantologists who have learned a few things from this question
    I teach Implantology to many practitioners of varying experience ..always remarkable what many do not understand
    Better to discuss and repeat and learn …
    Even a basic /obvious question will have several opinions

  21. 1.5mm measuring from the CEJ to the collar or coronal aspect of the implant. 3mm between implants. Esthetic outcome may be compromised by limited space. Whatever company you are using should have a Surgical manual that spells out clearly what parameters work best for their system. They will also define the distances based on anatomy. It may not be the same for all systems just as drilling speeds vary. It is best to ask the rep for this manual and follow it to a certain degree.

  22. Dr. Wright I’m sorry to hear that “you’ve seen ‘too many’ complications from GPs who are not experienced”. Why do you feel compelled to single out and attack GPs? Your statement is unfair, unprofessional and offensive. Complications are not the exclusive domain of GPs. As a GP who does Implant Sx. and Pros. I have seen complications from specialists as well as GPs. Did you inform your first surgical patient that you had never before reflected a flap?
    Dr. Anon you can also consider using a one piece implant. They are available in 3.0 mm diameters. However if you are inexperienced this may not be a good option because it does require greater surgical precision as well as immediate loading.

  23. Gee, whiz! Should I mention the the “Oral Surgeon placed” implants that out CT scan has shown in sinuses without benefit of grafts or the one that perfed the sinus and into the nasal cavity? Or maybe the implants that don’t sit underneath where the restorations need to go? No one is perfect!

    I believe we all benefit from rethinking our answers and re-examining even the simpliest questions. This simple question reminded us to think about numerous factors from bone width to soft tissue and final aesthetics of the crown shape.

  24. For all the years I spent in the profession, I have some findings which all dentists the GPs and the specialists would agree.

    Practitioners of Clinical dentistry can be divided into “conscientious” Dentists and “non-conscientious” Dentists.

    There are umpteen GPs who are as “Conscientious” as their specialist colleagues. And this group contains both the GPs and the specialists. These dentists have submitted themselves to the path of “lifelong continuing dental education”, specialists or GPs who so ever they are. They value knowledge and respect the patient’s right to the best advise and best treatment. They equip themselves with the best equipment and the best courses and retain the best mentors.They have a positive attitude and a goal oriented life. Their only solace for justification to be in practice, nay I say, to be alive
    comes from having given their patients the best treatment posible.

    The other group of “non Conscientious” dentists is also equally populated with GPs and specialists both. I should know. As a “lowly GP” I have spent 90% of my private practicing career repairing patient’s dental work done by “highly elevated” specialist Dentists.

    I have, like my estemed colleagues, also been irrevocably, positively influenced by some specialists. Some of the specialists have been a perpetual source of inspiration, hope and kindness. I run out of words to describe their kindness. A story, I hope, will inspire the next generation.

    I request all members of the forum, please don’t waste your own valuable keyboard time as well as that of the esteemed members of the forum by trying to divide us into a “non-viable” division of GP or specialist. It’s one of the most abhorring and painful discussion never ever founded on facts. Come off it!

    My patients presume I must be a “post graduate specialist of something” in dentistry because they are satisfied with my services, when I have to politely draw attention to the fact that I am only “an average GP”. They like the way I give them exclusive time and attention.

    For all the patient cares, “the coscientous dentist is a specialist” and a “non-conscientous dentist is a GP”!

    So specialists on an ego-trip WATCHOUT!!!!!!!!

    Dr SDJ

  25. I used to frequent these forums until every discussion thread became exactly like this thread… a turf war on who can and should place implants. Leave your personal opinions and judgemental comments aside and answer the question posed. Be constructive in your comments, not critical. Be colleagues not competitors.

  26. thanks everyone it’s beeing very helpful. i practice general dentistry 2 years now, and yes i am inexperienced. i am from a place where the line between specialist and gp is not clear but yet, the gp is free to practice the whole range (FDI-Vienna,2002). i put myself well on the conciencious side and the concious gp has to work very hard because he has to be “expert” in all ……

  27. Accoeding this article:
    Effect of the Vertical and Horizontal Distances Between Adjacent Implants and Between a Tooth and an Implant on the Incidence of Interproximal Papilla

    Jose Fabio Gastaldo
    Department of Periodontics and Implantology, School of Dentistry, University of Santo Amaro, Santo Amaro, Brazil.

    The ideal distance from the base of the contact point to the bone crest between adjacent implants is 3 mm and, between a tooth and an implant, 3 mm to 5 mm. The ideal lateral spacing between implants and between tooth and implant is 3 mm to 4 mm. Further, there is an interaction between horizontal and vertical distances when the lateral spacing is greater than 3 mm. J Periodontol 2004;75:1242-1246.

  28. Anyone have good bone coverage coronally at placement but exposure of the apical portion of the implant? I grafted over this with mineralized bone and HA mixture and a 6-8 week membrane (Biomend). IV abx during surgery and f/u PO abx. Any comments? The area exposed was apical to a previous block graft that could have been more apical (my fault).

  29. This kind of situation arise some times in maxillary lateral incisors and bicuspids region due to acute post apical concavity of labial plate(ridge).
    Your remedy should be sufficient.Only extra thing I would suggest is fixating membrane with periosteal suturing or tacs and of course decotication.

  30. The general guideline seems to be at least 2mm space in every direction! The principle is to have as much healthy well nourished(well vascularised) bone and soft tissue around the implant as possible. Therefore place in as small diameter and as long an implant as possible. Then you will have healthy bone and papillas all round. Plus you will be unlikely to hit the adjacent roots when you drill. Put in a reduced diameter implant/small diameter implant. Yeah, put in a mini.

    Cheers.

  31. I have been in the process of getting an implant and after 13 months my second temp tooth has been placed. Last week I went to have my third and final tooth placed and there are large gaps on both sides of the final tooth. It looks hidious and it is no. 7 tooth. My peri doctor who has been doing the implant has done a terribel job. After 2 gum graphs I asked for a third and he refused. I am quite unhappy with this outcome. Anyone, am I doing the right thing by asking for a 2nd consult from another doctor to see if this can be fixed. My smile is important to me and the gaps are quite obvious One gap goes over on top of my front rightr side tooth. When he went to do the 3rd graph he changed his mind after giving me shots and antibiotic and pain pills. Told me it looked fine.

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