Received: 24 July 2022 Revised: 30 August 2022 Accepted: 15 September 2022

DOI: 10.1111/cid.13135

ORIGINAL ARTICLE

Suggested mesiodistal distance for multiple implant placement

based on the natural tooth crown dimension with digital design

Wenwen Liu DDS, MSD, PhD 1 | Fangyu Zhu DDS 1 | Ankita Samal BDS 2 |
2
Hom-Lay Wang DDS, MSD, PhD

1
Department of Geriatric Dentistry, Peking
University School and Hospital of Abstract
Stomatology, Beiijng, China
Purpose: The purpose of this investigation was to identify a mesiodistal algorithm for
2
Department of Periodontics and Oral
Medicine, The University of Michigan School
multiple posterior implant placement based upon an ideal prosthetically restoration
of Dentistry, Ann Arbor, Michigan, USA design.

Correspondence
Methods: One hundred one cases of posterior free-end edentulous arches were
Hom-Lay Wang, Department of Periodontics selected for digital crown designs and measurements. Cone bean computed tomo-
and Oral Medicine, The University of Michigan
School of Dentistry, 1011 North University gram and digital fabricated crown were applied. DICOM files were exported to a
Avenue, Ann Arbor, MI 48109-1078, USA. viewer software (BlueSkyPlan4) to generate digital crown and measurement. The
Email: [email protected]
mesiodistal space between roots of adjacent teeth and center of the potential
implant horizontally, from both cross-section and coronal plane were measured.
Comparisons were performed using t-tests.
Results: No significant difference was found in the distances of the maxillary and
mandibular posterior implants to adjacent natural teeth (p > 0.05). For interdental/
implant distances, premolars are around 4.2 mm and molars are 5.4 mm, correspon-
dently. The second premolar interimplant distance is around 7–7.4 mm. The distance
of interimplant of the first molar is about 8–8.5 mm. For the maxillary second molar,
the interimplant distance is 9.26 ± 0.29 mm and the mandibular second molar inter-
implant distance is 9.58 ± 0.19 mm, which is significantly different. No difference
was found between the two different measurement methods.
Conclusion: A mesiodistal algorithm of 4–4.6 (implant to adjacent canine tooth), 7–
7.4, 8–8.5, and 9–9.5 mm was recommended for interimplant/tooth distance from
first premolar to second molar when placing implants with or without case-specific
prosthetic planning prior to surgery.

KEYWORDS
CBCT, dental implants, digital dentistry, implant prosthetic design

What is known
Few studies gave evidence of the acknowledged distance for posterior implant requirement.
Meanwhile, biologic width (e.g., supracrestal tissue adhesion) was often disrupted and led to
multiple clinical outcomes.

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any
medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2022 The Authors. Clinical Implant Dentistry and Related Research published by Wiley Periodicals LLC.

Clin Implant Dent Relat Res. 2022;24:801–808. wileyonlinelibrary.com/journal/cid 801

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802 LIU ET AL.

What this study adds

This study showed the appropriate size and spacing of dental implants in the posterior by using
digital method. We would like to provide clinician with guidance to enhance implant success,
prosthesis survival and patient satisfaction.

1 | I N T RO DU CT I O N level, interdental papilla as well as ability to clean) using cone bean

computed tomogram (CBCT) and digital fabricated prosthesis. These
Implant dentistry is a prosthetic endeavor with a biological founda- mesiodistal distance resulting data are promising to be used by clini-
tion. To attain an optimal prosthetic construct and soft tissue profile, cians and provide references for implant placement with or without
implants should be placed according to the final prosthetic prosthesis case-specific prosthetic planning before surgery.
and this should be planned before initiating implant placement.1,2 For
the posterior edentulous teeth, the appropriate size and spacing of
dental implants in the posterior could be affected by multi factors 2 | M A T E R I A L S A N D M ET H O D S
such as the restorative space available, the anatomy of the ridge, and
the ability for implant maintenance in order to achieve long-term 2.1 | Study design
implant stability. The presence of a supracrestal tissue height (STH)3
or supracrestal tissue adhesion (STA)4 around implants has been This investigation was performed in accordance with the STROBE
investigated.3–8 Studies have verified that a STH/STA exists around guidelines,24 approved by the University of Michigan School of Den-
implants which determines the vertical dimension of the prosthetic tistry Institutional Review Board for Human Studies (HUM00210043)
crown on implant.5–9 For the horizontal space between adjacent with exemption for obtaining the patient's consent form.
tooth-implant, a distance of at least 1.5–2 mm from the adjacent We went through the database of CBCT from the year of 2021
teeth has been advocated especially for the anterior teeth.10 In addi- to 2020 and selected posterior free-end edentulous maxillary and
tion, implants should have 3–4 mm of space between them.11,12 mandibular arches in chronological order. All images were obtained
Nonetheless, due to the issue of emergence profile and access for from the same CBCT machine. Two authors (W.L. and A.S.) searched
proper hygiene, the minimal gap distance required for the posterior and included the cases according to the inclusion and exclusion cri-
implant is often set for at least 3 mm.12 By keeping a minimum 3 mm teria. Disagreements were resolved by discussion with the third senior
distance from the adjacent tooth and a distance of 3–4 mm between author.
adjacent implants, implants can often be maintained longitudi- The inclusion criteria were:
10,12
nally. It is because these considerations, the interimplant/tooth
algorithm of 5–5.5 (implant-tooth), 8, 8, and 9 mm of first premolar to • Posterior free-end edentulous maxillary and mandibular arches.
second molars' horizontal distance has been proposed in the lecture • One side or two sides of the arch with at least two to three poste-
circuit without evidence. This formular is based upon above principles rior teeth lost.
2
(3–4 mm of interimplant distance as well as 3 mm of space that is • No obvious malformation or pathological disease.
required for establishing a nice emergency contour for implant crown
as well as patient's ability to clean).13 CBCT will be excluded if:
The size of the prosthetic tooth must be considered when placing
implants. If an implant placed for a premolar restoration is placed too • Edentulous area without enough space for digital crown design.
close to the adjacent tooth, compromised contours, loss of hard and
soft tissue and inability for patients and clinicians to clean the area
might occur. Placing the restoration too far from the adjacent tooth 2.2 | CBCT data acquisition
also resulted in unfavorable contours of crown as well as resulting in
unfavorable cantilever type of forces on the implant.14 The natural CBCT scans were obtained from Department of Periodontics and Oral
maxillary first and second premolars, and first molars have an average Medicine at the University of Michigan, School of Dentistry. The
mesiodistal size of 7.1, 6.8, and 10.4 mm, respectively.15–20 The aver- DICOM files were exported to a viewer software (BlueSkyPlan4;
age dimensions of these teeth at the cementoenamel junction (CEJ) BlueSkyBio) to generate digital crown and measurement.
are 4.8, 4.7, and 7.9 mm.21–23 Thus, a proper implant restorations
design should consider the natural tooth dimension and contour.
Therefore, the purpose of this investigation was aimed at identi- 2.3 | Measurements and variables
fying a mesiodistal algorithm for multiple posterior implant placement
based upon an ideal prosthetically restoration design (e.g., ideal pros- Before recording measurements for each potential implant site (tooth
thetic contour, proper distance for maintaining the interproximal bone position), the examiner oriented the image in the software, using
 17088208, 2022, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/cid.13135 by Cochrane Costa Rica, Wiley Online Library on [16/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
LIU ET AL. 803

anatomic landmarks such as the occlusal plane, adjacent teeth, and mandibular arches. The mean ± SD of the distance between implant
then aligned the tooth of interest with the vertical reference line. The to natural teeth or between implants of the maxillary and mandibular
14–19
antagonists, same-named teeth and reported data were took as posterior teeth were presented in Table 1 and Figures 3–5. The data
reference when designing the crowns' size and morphology. The were measured from cross-section in CBCT, while data measured
virtual crowns were depicted harmoniously with patients' occlusion from coronal plane in CBCT was showed in Supporting
relationship as well as mesiodistal and vertical space. The long axes of Information S1. Data from both two planes were similar. Since the
implants were decided on the basis of standard data and adjacent measurement from cross-section is easy to locate the center of the
teeth. Three millimeters apical to the midfacial CEJ, the examiner hori- implant, these data were used as the main reference in measurement.
zontally measured the mesiodistal space between roots of adjacent For the first and second premolar, the distance implant to teeth
teeth and center of the potential implant. Two authors (W.L. and A.S.) distal surface is in the range of 4–4.6 mm. The second premolar inter-
designed crowns and measured the mesiodistal distances together. implant distance is around 7–7.4 mm. The distance of interimplant of
Disagreements were resolved by discussion with the third senior the first molar is about 8–8.5 mm. For the maxillary second molar, the
author (H.L.W.) (Figure 1 shows the Schematic drawing while Figure 2 interimplant distance is 9.3 ± 0.3 mm and the mandibular second
shows the screenshot for the cases). molar interimplant distance is 9.6 ± 0.19 mm. There is significant dif-
ference between the maxillary and mandibular second molar
(p < 0.001).
2.4 | Statistical analysis Comparing the distances of the maxillary and mandibular poste-
rior implants to adjacent natural teeth, there is no significant differ-
The average horizontal distance from cross-section and coronal plane ence in each related tooth position. Moreover, the two different
were analysis and expressed as a mean ± standard deviation (SD) in measurement methods showed no significant difference.
millimeters. Statistically significant differences (p < 0.05) were ana-
lyzed using Student t-tests.
4 | DI SCU SSION

3 | RESULTS Implant prosthetic factors affecting peri-implant health such as the

prosthetic crown's type, contour and the emergency profile are the
One hundred one cases were chosen from 635 CBCT documents potential factors which influence peri-implant health.25,26 Adequate
(49 males, 51 females, 1 unknown; age: 64.3 ± 10.4 years). A total of space and bone volume are imperative for dental implant therapy.
450 implants were installed in 101 cases of posterior free-end arches. Several studies have attempted to rationalize the minimum spacing
Among them, 65 were maxillary arches and the remaining 70 were and bone volume needed for a dental implant.27 The mesiodistal tooth

F I G U R E 1 Schematic
drawing of the measurement of
the horizontal distance between
the implant edge and an adjacent
natural tooth (A, maxilla. C,
mandible). Top view with (D) or
without soft tissue (B). D1,
distance between the implant
(second premolar) to adjacent
natural tooth (first premolar); D2,
distance between the first molar
implant to the second premolar
implant; D3, distance between
the second molar implant to the
first molar implant.
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804 LIU ET AL.

F I G U R E 2 Radiographic
illustration of the meausrement of
horizontal distance between the
implant edge and an adjacent
natural tooth, measured in maxilla
and mandible (A and C: cross-
section measurement. B and D:
coroanl plane measurement. E
and F: 3D modeling).

T A B L E 1 Mean and standard

Implant-natural teeth Implant-implant
deviation (SD) of the distance (mm)
Maxilla Mandible p Value Maxilla Mandible p Value between implant to teeth or interimplant
for each posterior tooth site and the
First premolars 4.3 ± 0.3 4.2 ± 0.2 ns
result of t-test
Second premolars 4.2 ± 0.2 4.2 ± 0.2 ns 7.0 ± 0.2 7.1 ± 0.3 ns
First molars 5.4 ± 0.2 5.5 ± 0.3 ns 8.4 ± 0.3 8.5 ± 0.2 ns
Second molars 5.4 ± 0.2 5.4 ± 0.2 ns 9.3 ± 0.3 9.6 ± 0.2 ***

Note: Measured from cross-section.

Abbreviation: ns, no significant.
***p < 0.001.

sizes of the maxillary and mandibular arches should have a harmoni- on implant platform depth. Because the horizontal dimension of the
ous relationship to obtain a proper occlusion at the completion of cone-shaped circumferential peri-implant bone modeling widens cres-
implant restoration with adequate bone support. The inadequate tally, deeper implants require greater interimplant and implant-to-
restorative spacing could result in a structurally weak rehabilitation, tooth distances.29 Although many studies have demonstrated the
poor physiological contours, inadequate esthetics, reduced interocclu- implant position from the point of view of obtaining sufficient bone
sal rest space, and decreased implant long-term stability.28 Studies volume, nonetheless the fundamental requirement of implant is to
reported a horizontal distance requires at least 2 mm space between provide the occlusion functions and esthetics. Thus, restorations
27
the implant platform and the tooth. Regarding the optimal buccal should be functional and as close to the natural dentition as possible,
bone dimension required, it has been suggested to have a buccal bone to allow proper development of occlusion and embrasure forms for
plate of at least 2 mm.29,30 The minimum distance required depends patient comfortable. Thus, in this study we design ideal prosthetic
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LIU ET AL. 805

F I G U R E 3 (A) Distance
between implant and adjacent
teeth in maxilla, measured from
cross-section. (B) Distance
between implant and adjacent
teeth in mandible, measured from
cross-section.

F I G U R E 4 Distance between
implant to natural teeth.

prosthesis to measure the mesiodistal position of the potential implant mesiodistal distance (second molar implant position) will be
implants on the posterior free-end edentulous area which could pro- 9–9.5 mm for the maxillary and mandibular, respectively. The distance
vide data reference for clinicians working with or without case- coincides with the maxillary and mandible mesiodistal tooth sizes in
specific prosthetic planning prior to surgery. order to obtain a harmony occlusion.17 Slightly longer distance is
Results obtained from this study showed the distance from adja- needed for mandibular tooth than maxillary tooth.
cent tooth to the first implant drill site position—most likely first or Based on the measurements, if we are placing a dental implant
second premolars is 4–4.6 mm. The second implant mesiodistal dis- right next a tooth, a distance of 4–4.6 mm for premolars and 5–
tance (first molar implant position) will be 8–8.5 mm and the third 5.5 mm for molars is recommended. When considering the distance
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806 LIU ET AL.

F I G U R E 5 Distance between
implants. ***p < 0.001.

between two implants osteotome drill location, a 7–7.4 mm for pre- soft tissue. Placing the restoration too far from the adjacent tooth also
molars, 8–8.5 mm for first molars, and 9–9.5 mm for second molars results in unfavorable contours and development of cantilever type
are recommended. forces on the implant which might lead to implant marginal bone
The presence of a STH around implants has been investigated. loss.14,27 The improper distance to the adjacent tooth or implants may
However, the term should be STA to better reflect the biology behind lead to over-contoured implant prosthesis which is a critical local con-
the dimension.4 Multiple research groups have verified that a STA also founder for peri-implant mucositis33 or peri-implantitis.34 Moreover,
exists around implants. Once an implant is uncovered, a distance of the proper distance around implant is important for the sufficient
3 mm is often needed to establish the needed implant-abutment access to remove the access cement and avoid the residual cement
interface (so called STA). Literature has also reported the minimum which will lead to peri-implant diseases.33,35 In most cases, it is virtu-
distance between roots for two separate angular defects to be pre- ally impossible for the restorative dentist to achieve an ideal restora-
sent on adjacent teeth was 3.1 mm.31 In other words, the lateral tion if the implant is not properly placed mesiodistally by the surgeon.
aspect of each angular defect appears to be at least 1.0 mm on each Therefore, the proper restorative emergence profile design is essential
31
root leaving behind of 1 mm bone peak. This is in agreement with to maintain peri-implant health.36 The ideal prosthesis could provide
12
what Tarnow et al. reported, in order to maintain an interproximal proper self-hygiene and mechanism properties for implant support
papilla between two adjacent implants, a minimal distance of 3 mm is crown and decrease the complication such as food impaction. Insuffi-
needed. In our study, considering about the regular posterior implant cient or excessive mesiodistal space between implant or adjacent
diameter is between 4 and 5 mm. Our results of the distances tooth could lead to difficulty for patient to perform daily hygiene. The
between neighboring teeth and/or implants are consisted with the ease of maintenance is important for implant service life which
other researches13 which investigated from the bone biological prop- depend, to a great extent, on the prosthesis design.
erties. The consistency proved that the prosthesis following natural For the most distally positioned implant-supported single crowns,
tooth morphology and position could direct the implant position. The study has reported the statistically significant relationship between
biological principle of the physiological position of crown and implant horizontal distance and the occurrence of mechanical complications
is therefore supported. (p = 0.009).37 Horizontal distance values in success group were 3.1
From the prospective prosthetic design aspect, the mesiodistal ± 0.1 mm while for complications group they were 3.8 ± 0.2 mm. The
position of the gingival profile on the posterior teeth was also consid- horizontal distance refers to the distal implant position which should
ered. Though esthetics is secondary in restoring the posterior areas of consider the occlusal force distribution. Clinically, the optimal horizon-
the oral cavity, care should be taken with implant position to allow tal distance in the most distally placed implant-supported crown is
restorations that is functional and mimics to the natural dentition as one of the key factors underlying implant success, to prevent implant
14
possible. As posterior implant-supported crowns serve as a guide failure and mechanical complications caused by an unfavorable canti-
for proper implant placement, adequate mesiodistal positioning of the lever prosthesis and bending movements.38
implant could allow proper development of occlusal function, embra- This study is not without limitations. In this study, all measure-
sure forms and proper establishment of interproximal hard and soft ments were based on the same vertical level implant. Nonetheless,
tissue dimension. The interproximal bone is predominately flat in the some studies have reported that the deeper the implant is placed, the
posterior regions of the maxilla and mandible.32 The implant must be more the peri-implant bone loss may occur.29,39 Hence, it will be nice
placed sufficiently away from the adjacent tooth or implant to allow if we can also assess different vertical level to examine if this modifi-
the proper prosthetic emergence profile as well as access to hygiene. cation actually change the recommended mesiodistal algorithm. Fur-
If an implant placed for a posterior restoration is placed too close to thermore, we are planning the crown dimensions based upon
the adjacent tooth, not only can it not be cleaned but it also compro- published data.14–19 It is our goal to clinically assess the actual implant
mised prosthetic contours resulting in unnecessary loss of hard and prosthesis placement and check how the above proposed mesiodistal
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LIU ET AL. 807

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