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Open contacts adjacent to dental implant
restorations
Etiology, incidence, consequences, and correction
Gary Greenstein, DDS, MS; Joseph Carpentieri, DDS;
John Cavallaro, DDS
Development of an open contact between a
restored dental implant and a contiguous
tooth, where initially there was a firm prox-
imal contact, occurs more often than
expected (Figures 1and 2).
1-5
An interproximal gap
can result in a food trap, caries, and periodontal issues
and precipitate the need for prosthetic repairs.
1-5
These untoward consequences are disconcerting for
the patient and clinician.
Occlusal forces are transmitted via contact areas,
and mesial migration compensates for proximal tooth
wear, thereby maintaining intra-arch continuity.
1-5
Failure to maintain a firm contact after an implant
restoration is placed often happens on the mesial aspect
of the crown, but it can occur distally (Table).
2,4
An
open contact in an adult dentition adjacent to an
implant restoration is usually due to physiological
mesial drifting of teeth while the implant remains sta-
tionary.
1,2,4
In this article, we address the etiology,
incidence, consequences, and repair of open contacts
between dental implant restorations and adjacent nat-
ural teeth.
ANTERIOR COMPONENT OF FORCE
There are 4primary forces that influence the dentition’s
arrangement: tongue and lips, personal behavior (for
example, habits) or orthodontic appliances, periodontal
membrane, and occlusal forces.
6
The last factor pro-
vides the major force vector associated with physio-
logical tooth migration.
7-9
The main muscles of mastication involved with jaw
closure are the medial pterygoid, masseter, superior
division of the lateral pterygoid, and temporalis
Dr. Greenstein is a clinical professor, College of Dental Medicine, Columbia University, New York, NY, and maintains a private practice in
surgical implantology and periodontics in Freehold, NJ. Address correspondence to Dr. Greenstein at 900 W. Main St., Freehold, NJ 07728,
e-mail ggperio@aol.com.
Dr. Carpentieri is a clinical assistant professor, College of Dental Medicine, Columbia University, New York, NY, and maintains a private practice
in surgical implantology and prosthodontics in White Plains, NY.
Dr. Cavallaro is a clinical professor, College of Dental Medicine, Columbia University, New York, NY, and maintains a private practice in surgical
implantology and prosthodontics in Brooklyn, NY.
Copyright ª2015 American Dental Association. All rights reserved.
ABSTRACT
Background. The aim of this investigation was to evaluate
the potential causes, clinical significance, and treatment of
open contacts between dental implant restorations and
adjacent natural teeth.
Types of Studies Reviewed. The authors searched the
dental literature for clinical trials in humans that addressed
the incidence of open contacts that develop after implant
restorations are placed next to teeth.
Results. The authors found 5 studies in which the in-
vestigators addressed the incidence of open contacts after
implant restorations are inserted next to teeth. Results from
these studies indicated that an interproximal gap developed
34% to 66% of the time after an implant restoration was
inserted next to a natural tooth. This event occurred as early
as 3 months after prosthetic rehabilitation, usually on the
mesial aspect of a restoration.
Conclusions. The occurrence of an interproximal sepa-
ration next to an implant restoration was greater than
anticipated. It appears that force vectors cause tooth move-
ment and an implant functions like an ankylosed tooth.
Practical Implications. Clinicians should inform pa-
tients of the potential to develop interproximal gaps adjacent
to implant restorations, which may require repair or
replacement of implant crowns or rehabilitation of adjacent
teeth. Furthermore, steps should be taken to check the
continuity of the arch periodically. If the clinician detects an
open contact, it is prudent to monitor for signs or symptoms
of pathosis so that prosthetic repair of the gap can be initi-
ated, if needed. These problems could add to treatment costs
and decrease overall patient satisfaction related to implant
treatment.
Key Words. Implants; restorative dentistry; operative.
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muscles.
10
On mandibular closure, forces created by
these muscles are directed in different directions by the
teeth’s inclined planes. The forward vector is referred
to as the anterior component of force (ACF), and it drives
teeth mesially.
7-9
There also is a force that pushes teeth
distally, but the mesial vector is 5times stronger than
the posterior force.
11
The strength of the ACF increases
proportionally to the magnitude of the bite force.
8,12
In 1923, Stallard
13
suggested that the arc of mandibular
closure caused an ACF on mandibular posterior teeth
that was transmitted via interproximal contacts between
the teeth and that this vector drove teeth mesially as
the contact points wore because of friction. Subse-
quently, Conroy
12
subjected all the teeth individually
in a mandibular quadrant to a controlled force (a custom
bite force transducer was fabricated and connected to a
strain indicator) and assessed the magnitude of the ACF.
He noted that the ACF was transmitted via the inter-
proximal contacts and that its strength decreased with
increased distance from the posterior teeth. In addition,
he also confirmed that there was a posterior component
of force.
PROXIMAL CONTACTS
Arrangement of interproximal interfaces among
human teeth. The size and location of contact areas vary
with age, tooth position, biting force, and crowding of
teeth.
14
The contour of the contact interfaces is pre-
dominantly oval and usually found toward the buccal
aspect of interproximal areas. In the incisal region, their
outline is more vertical than horizontal, and in the
posterior sextants of the arch, the shape of an inter-
proximal contact is more horizontal than vertical.
15
Sarig
and colleagues
14
reported that normally the interprox-
imal interface with or without wear decreases in size
from molars to incisors. They suggested that larger
contact areas are needed in the posterior teeth to resist
attrition where there is increased biting force.
14
Over time, the morphology of contact areas changes
because of attrition and physiological drifting. The oval
contacts often become kidney shaped. This change is
associated with flattening of the contact area, which
creates room for the dentition to move mesially. To
reduce this change, Sarig and colleagues
14
suggested
enlarging the interproximal interfaces of restorations
to increase tooth position stability.
From another perspective, the contact area between a
tooth and an implant restoration needs to be modified
after an extraction. Tooth removal results in reduction of
the interdental tissue volume because of shrinkage of the
papilla and bone loss between the tooth and a future
implant restoration. To compensate for a larger embra-
sure or concave shape of an adjacent tooth, the clinician
often needs to use a longer, broader, wider contact in an
occlusogingival dimension.
Reasons for premature loss of contact between
teeth. Intact contact areas prevent tooth migration, allow
dissipation of ACF, and avoid food impaction. Prema-
ture loss of interproximal contacts can occur because of a
variety of factors: caries, early loss of a tooth, inauspi-
cious sequence of eruption, ankylosed teeth, congenital
issues, and trauma.
14
Loss or alteration of contact areas
can result in interproximal black triangles, food impac-
tion, periodontal problems (such as loss of clinical
attachment, gingival inflammation, or reduction of
interproximal bone), and misalignment of teeth.
14
Figure 1. Radiograph showing delivery of an implant-supported resto-
ration at site no. 30 on November 29, 2010. A broad, wide contact was
confirmed clinically with floss.
Figure 2. Radiograph showing open contact that developed approxi-
mately 1 year after restoration insertion (November 2, 2011) on the
mesial aspect of the implant restoration at site no. 30. No interdental
pathosis was present.
ABBREVIATION KEY. ACF: Anterior component of force.
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Craniofacial growth: a factor for loss of interproximal
contact between teeth. Besides the ACF, adult craniofacial
growth can alter tooth positions.
16,17
Historically, Odman
and colleagues
18
demonstrated that dental implants func-
tion like ankylosed teeth and do not move with additional
jaw growth. Thus, implants usually are not inserted in
patients who are still growing. With respect to adults,
Daftary and colleagues
16
reported that uncommonly there
is craniofacial growth in some people beyond adulthood.
This growth can result in occlusal alterations. Subtle facial
growth may occur mesially, buccally, and vertically.
19
Others also have discussed how facial growth after
adulthood can affect the position of teeth.
17,20-22
RESULTS AND DISCUSSION OF LITERATURE SEARCH
We searched the dental literature for human studies in
which the investigators addressed the incidence of open
contacts that develop after implant restorations are
inserted next to natural teeth. In this review, we included
all detected clinical trials in which the investigators
described how they assessed the size of open contacts
and defined the length of the monitoring period. We
found 5investigations. Investigators in 1study evaluated
only 3contact points in 1patient; the other investigations
had 28 to 105 patients (Table).
1-5
We conducted the
following searches on PubMed: proximal contact loss
adjacent to implant prostheses (2of 6articles included),
loss of interproximal contact adjacent to implant pros-
theses (2of 3articles included), migration of teeth
because of occlusal forces (1of 36 articles included),
and implant prostheses and adjacent tooth migration
(2of 12 articles included).
INCIDENCE OF OPEN CONTACTS BETWEEN DENTAL
IMPLANTS AND NATURAL TEETH
The table
1-5
lists how often we found reports of open
contacts adjacent to restored implant restorations in
different studies. Byun and colleagues
4
differentiated
between development of open contacts (floss passes be-
tween teeth unimpeded) and creation of loose contacts
(floss encounters weak resistance). They reported open
contacts at 38% of assessed sites and loose contacts at
20% of the proximal surfaces monitored over a mean
57-month period (range, 3-156 months). They found
the first open contact 8months after a restoration was
inserted. Koori and colleagues
2
recorded an increased
incidence of interproximal gaps (43% of study popula-
tion) over 1to 123 months. Wei and colleagues
1
docu-
mented a larger occurrence of open proximal contacts
(58%), and they occurred within a short period (up to
2.2years). They noted the first open contact 3months
after crown insertion. In a multipatient study, Wong and
colleagues
5
reported the largest incidence of open con-
tacts (65%) during a monitoring period of 0.5to 12 years.
They also found that the amount of open contacts was
similar among prostheses that were screw or cement
retained.
With increased time, the size of the space between
teeth and an implant restoration may enlarge,
3,5
and the
number of open contacts increased with the passage of
time.
1,2,4,5
The prevalence of interproximal open contacts varied
between studies.
1-5
Factors that could contribute to
different findings are patient age, different study pop-
ulations, types of adjacent restorations, occlusal forces,
TAB L E
Percentage of restored dental implants manifesting open proximal contact areas
adjacent to natural teeth.
STUDY TOTAL
PERCENTAGE OF
OPEN CONTACT
AREAS
NO. OF
PATIENTS
MONITORED
TOTAL
NO. OF
CONTACT
AREAS
PERCENTAGE
OF OPEN
CONTACTS ON
THE MESIAL
ASPECT
PERCENTAGE
OF OPEN
CONTACTS ON
THE DISTAL
ASPECT
DEVICE*TIME
Wei and
Colleagues,
1
2008
58 (32/55) 28 55 58 (32/55)
†
50-
m
m
‡
strip Up to 2.2 y
Koori and
Colleagues,
2
2010
43 (80/186) 105 186 52 (73/141) 16 (7/45) 50-
m
m strip Range, 1 to 123 mo
Wat and
Colleagues,
3
2011
66 (2/3) 1 3 67 (2/3) Not assessed Dental floss 2 y
Byun and
Colleagues,
4
2015
34 open
20 loose
§
(65/191)
94 191 38 (51/134) 25 (14/57) Dental floss Mean, 57 mo
(range, 3-156 mo)
Wong and
Colleagues,
5
2015
65 (43/66) 45 66 65 (43/66) Not assessed 38-
m
m Toffelmire
matrix bands
Mean, 3.9 y
(range, 0.5-12 y)
* Different devices were used to assess for the presence of open contacts.
†The authors did not clearly state whether open proximal contacts occurred mesially or distally, so we interpreted the data to indicate that it occurred
mesially.
‡
m
m: Micrometer.
§ Floss could pass through, but there was a weaker contact than originally determined. These data were from part of the group listed: 94 patients, 191
contacts.
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opposing dentition, monitoring time, and the methods
used to assess the integrity of the interproximal areas.
Mesial versus distal development of open contacts.
Byun and colleagues
4
reported that mesial contact
areas of implant restorations next to a natural tooth
manifested a gap more often than did distal aspects.
They found 38%(51 of 134) of the mesial contacts opened
versus 25%(14 of 57) of the distal contacts (Table).
1-5
This
finding was less than that observed by Koori and col-
leagues,
2
who reported 52%(73 of 141) of the mesial and
16%(7of 45) of the distal contacts were open by the end
of the assessment period (Table).
1-5
Koori and colleagues
2
also indicated that loss of
contact occurred more frequently in the mandible than
the maxilla. The reason for this finding is unclear. In
addition, they demonstrated that more migration of teeth
was seen when the opposing dentition was composed of
natural teeth rather than a partial or full denture because
natural teeth generate greater occlusal forces.
2
However,
the investigators in the studies we assessed used different
methodologies to evaluate the tightness of contact areas
(Table).
1-5
MAGNITUDE OF ALTERED TOOTH POSITION
BECAUSE OF MESIAL MIGRATION OF TEETH
Investigators reported different amounts of actual tooth
migration, which could be affected by the duration of
the assessment time, bite force, and so on. By age 40
years, the ACF results in 0.5centimeters (5millimeters)
of mesial migration of teeth.
23
These alterations oc-
curred gradually, with periods of activity and remission.
In addition, as teeth moved mesially, the alveolar bone
was altered. Bone resorption occurred on the mesial
aspect because of pressure, and bundle bone formed
on the distal surfaces of teeth because of tension.
23
However, among Swedish adults, investigators found
a smaller proximal wear rate (1mm per arch over
9years).
24
Carter and McNamara
25
noted a slightly
larger wear rate in people aged 17 to 48 years. Among
males, the mandibular arch perimeter was reduced
2.4mm, and in the maxilla it decreased 1.86 mm. Fe-
males demonstrated an alteration of 1.76 mm in the
mandible and 2.06 mm in the maxilla. Carter and
McNamara
25
concluded that changes over years usually
were not clinically significant because the adjustment
of a full-cusp Angle Class II molar relationship is
approximately 5mm.
Other factors also can influence mesial migration of
teeth. Wei and colleagues
1
suggested that high occlusal
forces on teeth adjacent to an implant restoration could
affect the degree of mesial migration. In addition, Koori
and colleagues
2
stated that age, condition of the opposing
dentition, vitality of adjacent teeth, and splinting of the
adjacent teeth may affect the rate of proximal contact
loss of a fixed dental prosthesis adjacent to an implant
restoration.
ADVERSE CONSEQUENCES CAUSED BY LOSS OF
PROXIMAL CONTACT
Open contacts can have negative effects on the dentition:
food impaction, caries, migration of teeth, periodontal
issues, and additional prosthetic repairs. Several authors
stated that subsequent to developing open contacts, pa-
tients experienced trapping food.
2,4,5
This trapped food
can result in an increased caries rate (Figures 3and 4).
26
With respect to developing periodontal issues, Byun and
colleagues
4
reported no increased incidence of inflam-
matory peri-implant problems associated with open
contacts, whereas Koori and colleagues
2
described a
greater amount of clinical attachment loss and deeper
probing depths. Others noted adverse affects with respect
to periodontal issues when there were open contacts
between teeth.
27,28
Different findings concerning peri-
odontal health or caries could be attributed to the level
of personal and professional maintenance that was per-
formed and the duration that sites were monitored.
Detection of an open contact area between an implant
restoration and an adjacent tooth may not lead to
negative consequences. Therefore, a clinician should
consider the risk-benefit ratio of only monitoring such
sites. It may be prudent to eliminate an open contact area
to preclude potential problems, such as root caries that
can result in tooth loss. However, some patients or cli-
nicians may elect to monitor these situations. In these
circumstances, patient compliance with respect to being
assessed periodically is important. If a decision is made
to close an open contact, the clinician must choose to
modify or replace the implant crown or restore the
adjacent tooth.
CORRECTION OF ISSUES CREATED BY MESIAL
MIGRATION OF TEETH
The average movement of molars during mastication in
the horizontal plane is 56 to 75 micrometers and in the
vertical plane is 28
m
m.
29
In contrast, dental implants
demonstrated 5
m
m in the vertical plane and 12 to 66
m
m
in the horizontal plane.
29
Mesial drifting is not found
with respect to dental implants,
30,31
which makes them
analogous to ankylosed teeth. However, it is hypotheti-
cally possible that an open contact could develop be-
tween implants because of facial growth.
After 2years, Wat and colleagues
3
noted 0.5-mm
gaps had developed between some restored implants
(mesial aspect) and adjacent teeth. They removed the
affected prostheses and made a new working impression.
They added porcelain to the mesial aspect of the dental
implants to reestablish proximal contacts. In this
regard, there are 2major issues that require consider-
ation concerning implant crown fabrication: selecting
a screw- versus a cement-retained restoration and choice
of the restorative material. Selection of a screw- or a
cement-retained restoration should provide retrievability
to facilitate repair of an open contact. Thus, it would be
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beneficial if cement-retained crowns were inserted with a
temporary luting agent. With respect to the restorative
format, it will be based on several factors: the clinician’s
preference, 3-dimensional location of the implant (posi-
tion, depth, and angulation), and restorative space
measured from the implant platform to the opposing
arch. Minimally, approximately 5mm of vertical space is
needed for a screw-retained crown and approximately
7mm for a cement-retained restoration.
32,33
When screw-
retained restorations are used, implants should be placed
as parallel as possible to the adjacent surfaces because
screw-retained prostheses need a line of draw (that is,
path of insertion) that allows crowns to be fabricated
with contacts of proper shape and size.
32,33
With respect to selecting a restorative material to
fabricate the implant crown, there are several options:
porcelain fused to metal or porcelain fused to zirconia
with feldspathic ceramic, lithium disilicate glass ceramic
(used with computer-aided design and computer-aided
manufacturing or press techniques), or full zirconia
restorations.
34-36
The choice of the material is an im-
portant clinical decision because of differences in each
material (such as esthetics, fracture resistance, and cost)
and their ability to be modified. When implant restora-
tions are removed, ceramics can be reapplied to restore
the contact area for both the porcelain-fused-to-metal
and lithium disilicate crowns. Similarly, zirconia
monolithic (full-contour zirconia) or bilaminar crowns
(zirconia copings layered with feldspathic porcelain)
can undergo additive correction as long as they can be
retrieved from the mouth. Ultimately, the decision to
modify or replace an existing restoration to close an open
space needs to be made with respect to the following
factors: ease of retrievability, the choice of materials,
finances, esthetics, and the size and predictability of the
potential modification, as well as the expertise of the
laboratory technician.
OCCLUSAL EQUILIBRATION TO MODIFY DISTAL
OPEN CONTACTS
Kurthy
37
advocated occlusal adjustment to reverse the
development of open contacts between natural teeth
and implants if the open contact develops distal to an
implant. However, his technique cannot be used uni-
versally because most open contacts develop on the
mesial aspect of an implant and his technique applies to
specific situations in which the implant would have to be
next to the last tooth in the arch.
RETAINERS OR NIGHT GUARDS
Occlusal forces can have a detrimental effect on natural
teeth and restorations on teeth or implants, particularly
in patients with bruxism. An easy technique to preserve
tooth patterns and porcelain and to relieve masticatory
stress is to fabricate a retainer or night guard.
38,39
Conceptually, use of a retainer should decrease attrition
of tooth contacts and reduce open contacts. However,
this outcome has not been documented in the
literature.
CRITIQUE AND OPINION
The investigations in which the authors assessed the
incidence of open contacts were observational studies.
1-5
They were not experimental or controlled studies, and the
authors did not investigate any type of therapy that may
improve outcomes.
40
The investigators assessed partic-
ular populations of patients over time; therefore, the
studies are considered longitudinal cohort investigations.
Figure 3. Radiograph showing open contact still present at tooth no. 30
mesial (November 4, 2014), but now there is extensive caries on distal
aspect of tooth no. 29, which precipitated the need for a full-coverage
restoration on tooth no. 29.
Figure 4. Radiograph illustrating an open contact on the mesial of
the implant at site no. 31. Subsequently, caries developed on the distal
of tooth no. 30 due to food impaction, and tooth no. 30 needed to be
replaced with an implant.
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Prospective observational studies are conducted to collect
descriptive information, such as the incidence of open
contacts adjacent to dental implants, and to assess asso-
ciations with respect to causes of a problem. However,
confounding variables exist that limit data interpretation.
For instance, in all 5articles in which the authors
addressed the incidence of open contacts,
1-5
other quad-
rants without implants were not used as control groups;
therefore, we do not precisely know whether the inci-
dence of open contacts was statistically significantly
greater adjacent to implants than when an implant was
not placed. This information would facilitate calculation
of the absolute and relative risks of developing an open
contact with or without implant placement.
The available data indicate a high incidence of open
contacts developing subsequent to insertion of implant
restorations adjacent to natural teeth. We have noticed
this phenomenon but not at the level of occurrence re-
ported in the table.
1-5
As previously listed, possible ex-
planations for dissimilar findings include unlike study
populations, disparate methods of assessing contact
tightness, duration of monitoring, different opposing
dentitions, biting force, prosthesis design, and bucco-
lingual and occlusogingival dimensions of restoration
contact areas. Another factor that could account for
discrepancies between study populations is the use of
different statistical methods. For example, Byun and
colleagues
4
used a generalized estimating equation so
that multiple sites could be considered from each patient,
whereas others did not address this issue.
1-3,5
It appears
that they had multiple sites per patient, but they did not
account for a person’s individual biological makeup.
Despite our critical examination of the methods and
material in the addressed studies, it was not possible to
identify precisely why the reported frequency of open
contacts
1-5
seemed greater than that in our experiences.
Contrastingly, it could mean that we might need to
quantify the occurrence of open contacts in our private
practices to validate or refute these findings. Also, some
of the open contacts recorded over time in the reviewed
studies may have been present at the time of prosthesis
placement. Regardless of the precise incidence of open
contacts, these phenomena deserve additional attention
from clinicians.
One additional point of information: the question
could be asked as to why a tooth mesial to an implant
would move anteriorly, because forces are not being
transmitted via a contact point on the distal of the tooth
where the implant remains motionless. The answer is
that continued movement mesially is due to occlusal
vector forces provided by the opposing dentition.
CONCLUSIONS
Development of open contacts generally does not occur
between natural teeth because of physiological drift,
14
so
the finding that this occurs among patients with implants
indicates that there is something more than mesial
migration occurring. The probable reason that an open
contact occurs is that an implant is “ankylosed”and
cannot shift like the other teeth.
The precise etiology of an open contact adjacent to an
implant is unclear; it may be due to the ACF, or it may be
multifactorial and related to changes in occlusion.
1,2
In
this regard, physiological migration does not explain the
occurrence of open distal contacts adjacent to implant
restorations.
The data indicate that open contacts occur more often
than expected between restored implants and natural
teeth, which creates a dilemma for restorative practi-
tioners. Accordingly, clinicians should monitor patients
to determine whether they are developing open contacts.
If this occurs, they may require modification of existing
implant restorations or adjacent teeth. Implant restora-
tions should be retrievable so that contact points can be
restored as needed.
3
Furthermore, retainers may help
reduce the incidence of open contacts between restored
implants and teeth; however, as indicated, there are no
data in the literature addressing this specific issue. Koori
BOX
Suggested guidelines for management of open contacts adjacent to an implant
restoration.
-
The possibility of future open contacts should be communicated to patients before treatment, and this information should be included in a
medicolegal consent form.
-
Retrievability of implant restorations is strongly recommended because loss of interproximal contact is fairly common.
-
Before impression procedures for implant restorations, modify both adjacent contacts with minor recontouring so they are flatter in profile and
rounded, with minor undercuts and rough edges removed.
-
If there is an open contact with no food impaction, provide no treatment and carefully monitor patient compliance.
-
If there is an open contact with food impaction without pathosis, the first choice is modification of the implant restoration; the second choice is
restoring the adjacent tooth.
-
If there is an open contact with food impaction and caries, modify the adjacent tooth with a conservative restoration or a new full-coverage
restoration to address the caries. If there is a periodontal or peri-implant problem, address it.
-
Eliminate open contact areas to preclude potential problems, especially in patients with high caries rates or history of periodontitis.
-
For maintenance and monitoring, use a peri-implant maintenance protocol (3 to 6 months), observe contacts surrounding implants, and reexamine
occlusion in the area of the implant restoration.
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and colleagues
2
advised that clinicians should include in
their informed consent statements comments advising
patients that development of open contacts adjacent to
implant restoration is an unpredictable event and that its
occurrence may dictate the need for prosthetic repair of
the contact area. As a final thought, there are no precise
guidelines with respect to the management of an open
contact associated with implant restorations; however,
closing the gap is an approach that reduces potential
complications. The box lists suggested guidelines for
management of open contacts between an implant and
an adjacent tooth. n
Disclosure. Dr. Carpentieri is a consultant and speaker for Zimmer
Biomet. Dr. Cavallaro is a consultant and speaker for Implant Direct In-
ternational. Dr. Greenstein did not report any disclosures.
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535-540.
3. Wat PY, Wong AT, Leung KC, Pow EH. Proximal contact loss be-
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