Journal of Periodontology; Copyright 2015 DOI: 10.1902/jop.2015.

150322

Food Impaction and Periodontal/Peri-Implant Tissue Conditions

in Relation to the Embrasure Dimensions Between Implant-
Supported Fixed Dental Prostheses and Adjacent Teeth: A
Cross-Sectional Study

Jin-Seok Jeong*, Moontaek Chang*†

* Department of Periodontology, School of Dentistry and Institute of Oral Bioscience,

Chonbuk National University, Jeonju, S. Korea.

† Research Institute of Clinical Medicine of Chonbuk National University-Biomedical

Research Institute of Chonbuk National University Hospital, Jeonju, S. Korea.
Background: We evaluated food impaction and periodontal/peri-implant tissue conditions in
relation to the embrasure dimensions between implant-supported fixed dental prostheses (FDPs) and
adjacent teeth.

Methods: A total of 215 embrasures of 150 FDPs in 100 patients (55 males and 45 females;
mean age, 56 years; range, 27–83 years) were included in the study. Clinical assessments of the
periodontal/peri-implant mucosa conditions, radiographic assessments of embrasure dimensions and
overall patient satisfaction were used as explanatory variables for the food impaction and
periodontal/peri-implant tissue conditions adjacent to the implant-supported FDPs in the generalized
estimating equations (GEE) analysis.

Results: Food impaction was reported in 96 (44.7%) of 215 embrasures between implant-
supported FDPs and adjacent teeth. Food impaction was more frequently reported in the embrasures with
proximal contact loss than that with tight contact (p = 0.009). Overall patient satisfaction was negatively
influenced by food impaction in the proximal embrasures (p = 0.012). Among embrasure dimensions,
only the embrasure surface area (ESA) significantly influenced food impaction (p = 0.034). Significant
influences of various embrasure dimensions on the periodontal/peri-implant mucosa conditions and bone
level at the implant were found in the univariate and multivariate GEE analyses.

Conclusions: Food impaction between implant-supported FDPs and adjacent teeth occurred
more frequently when proximal contact was lost and ESA increased. Food impaction negatively affected
overall patient satisfaction. Embrasure dimensions influenced the periodontal/peri-implant mucosa
conditions and bone level at the implant.

KEY WORDS:
Alveolar bone loss; dental prosthesis, implant-supported; patient outcome assessment;
cross-sectional studies

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Journal of Periodontology; Copyright 2015 DOI: 10.1902/jop.2015.150322

Food impaction is defined as the forceful wedging of food into the interproximal space
by chewing pressure (vertical impaction) or the forcing of food interproximally by
tongue or cheek pressure (horizontal impaction).1 Proximal contact loss, location and
area of the proximal contact, marginal ridge integrity, plunger cusp mechanisms, severe
attrition and lack of papilla fill as a consequence of gingival recession or periodontal
disease have been suggested as potential factors associated with food impaction.2, 3, 4
Food impaction may be associated with periodontal/peri-implant mucosa inflammation,
pain, and halitosis.3, 5, 6

A high incidence of proximal contact loss and frequent food impaction are found
between implant-supported fixed dental prostheses (FDPs) and adjacent teeth.7, 8 Mesial
and/or vertical migration of the adjacent tooth in relation to an osseointegrated implant
has been attributed to proximal contact loss and eventual food impaction.7 In addition,
the lack of papilla fill in the embrasure space between implant-supported FDPs and
adjacent teeth has been blamed for “horizontal” food impaction.9 Various embrasure
dimensions have been evaluated with respect to the degree of papilla fill between
implant-supported FDPs and adjacent teeth from an esthetic perspective.9-11 However,
embrasure dimensions have not been investigated in relation to food impaction.

Based on the finding that proximal contact loss, food impaction, and periodontal
tissue conditions are related, proximal contact loss between implant-supported FDPs
and adjacent teeth has been suggested as a factor inducing food impaction and an
adverse effect on peri-implant tissues.3, 4, 12 The embrasure dimensions newly created
after placing implant-supported restorations have been a concern to clinicians with
respect to the adjacent periodontal/peri-implant tissue conditions. Insufficient proximal
space due to close proximity of an implant to the adjacent tooth or implant and
overcontoured crowns hamper oral hygiene, and negatively affect periodontal/peri-
implant tissue conditions.13-15 Embrasure dimensions have been analyzed in relation to
papilla fill and height from an esthetic perspective, but the influence of embrasure
dimensions on periodontal/peri-implant tissue conditions have not been evaluated.11

The aim of the present study was to evaluate the food impaction and
periodontal/peri-implant tissue conditions in relation to embrasure dimensions between
implant-supported FDPs and adjacent teeth.

MATERIALS AND METHODS

Patient Sample
The study patients were recruited consecutively from patients who had received
implant-supported FDPs and were scheduled for a regular 3–12-month recall

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Journal of Periodontology; Copyright 2015 DOI: 10.1902/jop.2015.150322

examination at the Department of Periodontology, Chonbuk National University Dental

Hospital, Jeonju, South Korea from September 2010 to May 2013. A total of 100
patients (55 males and 45 females; mean age, 56 years; range, 27–83 years) were
included in the study. Implants were placed according to the manufacturer’s instructions
and the implant-supported FDPs were fabricated after 3–6 months of healing. Among
the 150 FDPs supported by 204 implants, 97 FDPs were supported by a single implant,
43 by two implants, nine by three implants, and one by four implants. The proximal
contact surfaces of the implant-supported FDPs were adjusted by a prosthodontist at the
Department of Prosthodontics when the prosthesis was delivered.16

The majority of the 215 proximal embrasures between implant-supported FDP and
teeth were positioned in the posterior region (56 premolar positions; 141 molar
positions). The mean follow-up period after FDP delivery was 55 months (range, 3–156
months). This study protocol was approved by the institutional review board of
Chonbuk National University Hospital, Jeonju. All patients provided informed consent.
This study was conducted in accordance with the 1975 Declaration of Helsinki, as
revised in 2000.

Clinical Assessments
Periodontal/peri-implant mucosal conditions assessed at the mesial/distal site of the
implant and adjacent tooth in the proximal embrasure included oral hygiene status
determined as the presence/absence of visible plaque at the soft tissue margin, probing
depth measured to the nearest 0.5 mm with a calibrated periodontal probe‡ with 1 mm
markings, and bleeding on probing assessed following probing with 0.25 N pressure.
The degree of papilla fill was determined at the proximal areas using the Papilla Index
scoring system.17 Proximal sites with a papilla index score of 1 and 2 were grouped as
“deficient papillae” (n = 189), and those with an index score of 3 were defined as
“complete papillae” (n = 26). In addition, the degree of proximal contact tightness was
judged as (1) tight, definite resistance to passing dental floss; (2) loose, minimal
resistance; and (3) open, no resistance when all proximal contacts between a tooth and
an implant-supported FDP were tested with waxed dental floss§.18 The tight and loose
proximal contacts were combined as the proximal contact group (n = 142), and the open
contacts were defined as the proximal contact loss group (n = 73).

Radiographic Assessments
Digital radiographs|| were taken at the recall examination with the digital X-ray sensor
parallel and the X-ray beam perpendicular to the proximal embrasure between the
implant-supported FDP and the tooth. The assessments were made using an image

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Journal of Periodontology; Copyright 2015 DOI: 10.1902/jop.2015.150322

measurement program#,19 and digitized images of the radiographs. Known implant

length and diameter were used to calibrate magnification. The following linear distances
and surface areas of the embrasure dimensions were assessed to the nearest 0.1 mm
using a reference line drawn at the implant/abutment level (Fig. 1). The linear distances
included horizontal implant-tooth distance (distance between implant and adjacent tooth
at the reference level), contact point level (vertical distance from the reference level to
the apical border of the contact area between the implant-supported crown and the
adjacent tooth), bone level at tooth (vertical distance between the reference level and the
most coronal level at which the width of the periodontal ligament space of the adjacent
tooth was normal), and bone level at implant (vertical distance between the reference
level and the bone-to-implant contact, measured at the tooth-facing site of the implant).
The surface area between the lateral margins of the implant-supported crown/adjacent
tooth and the alveolar bone crest was calculated as embrasure surface area (ESA). One
calibrated examiner (J.J.), who was not involved in patient treatment, performed all
radiographic assessments.

Patient Assessments
At the follow-up examination, the patients were asked to report whether they had
experienced food impaction in the proximal embrasure between the tooth and implant-
supported FDP.4 If the patient reports food impaction, he/she was asked to locate the
food impacted embrasure, i.e., mesial, distal or both in relation to the implant-supported
FDP. In addition, the patients were asked to express their degree of overall satisfaction
with the implant-supported restorations on a 10-cm visual analogue scale (VAS),
labeled with “not at all satisfied” at the left and “completely satisfied” at the right end
point. The distance (mm) from the left end point to the sign marked by the patient on
the 10-cm line was measured and expressed as a percentage.

Data Analyses
The primary outcome for the data analysis was “food impaction” or “no impaction”.
Mean values, standard deviations, and proximal contact loss rate of the descriptive
variables including age, gender, previous periodontal treatment, smoking, follow-up
periods, implant positions, jaw positions (maxilla/mandible), and embrasure positions
(mesial/distal) were calculated with proximal embrasure as the statistical unit. Because
the data were cluster-correlated, i.e., each patient provided different numbers of
proximal embrasures (1–6 cases), the potential factors influencing food impaction and
periodontal/peri-implant tissue conditions were analyzed using the generalized
estimating equation (GEE) procedure.20 Descriptive variables, clinical and radiographic

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Journal of Periodontology; Copyright 2015 DOI: 10.1902/jop.2015.150322

assessments, and patient’s overall satisfaction were included as explanatory variables

for food impaction in a univariate GEE analysis. The influences of embrasure
dimensions on food impaction and periodontal/peri-implant tissue conditions at the
proximal embrasure were also estimated by the univariate GEE analysis. In addition,
multivariate GEE analysis to identify factors influencing peri-implant bone loss was
performed in a model that included all embrasure dimensions as explanatory variables.
Odds ratios and 95% confidence intervals were calculated as multivariate GEE analysis
results. Data analyses were performed using statistical software**. A p-value < 0.05 was
considered significant.

RESULTS
Food impaction was reported in 96 (44.7%) embrasures. The highest food impaction
rate was observed in periodontally healthy patients who had no previous periodontal
treatment (55.6%), and the lowest rate was observed in the distal aspect of the proximal
embrasures (33.3%) among the descriptive variables included in the univariate GEE
analysis. Although embrasure position (mesial/distal) was borderline significant (p =
0.052), no descriptive variables significantly influenced food impaction.

The clinically assessed parameters, i.e., the periodontal/peri-implant mucosal

conditions, were not different between food impaction and no impaction groups in the
univariate analysis (Table 1). Bleeding on probing at the implant site was more frequent
and pocket depth was deeper than that of the adjacent teeth. Food impaction was not
influenced by the degree of papilla fill, i.e., deficient or complete papilla, whereas
proximal contact loss significantly influenced food impaction (p = 0.009). In addition,
patient’s overall satisfaction was significantly influenced by food impaction in the
proximal embrasures (p = 0.012) (Table 2).

Among the embrasure dimensions that were assessed on digital radiographs, ESA
was the only significant factor influencing food impaction (p = 0.034) (Table 3).
Various embrasure dimensions significantly influenced the periodontal/peri-implant
mucosal conditions and bone level at the implant in GEE analyses (Tables 4 and 5).

DISCUSSION
Food impaction was reported in 96 (44.7%) of 215 embrasures between implant-
supported FDPs and adjacent teeth. Food impaction was not frequently reported
between teeth (2.9–4%) of periodontally healthy patients; however, the food impaction
rate between implant-supported FDPs and adjacent teeth has been reported to be 42%,
which was similar to the present study.3, 4, 8 As more frequent food impaction is found in
the open contacts between teeth than in the closed contacts, it has been reported that the

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Journal of Periodontology; Copyright 2015 DOI: 10.1902/jop.2015.150322

proximal contact loss caused by movement of adjacent teeth in relation to an

osseointegrated implant may result in more frequent food impaction than that of a tight
proximal contact.4, 7, 8, 12 Indeed, our results show that embrasures judged as proximal
contact loss were more frequently impacted with food than those with a tight proximal
contact (p = 0.009). Proximal contact loss seems to induce “vertical” food impaction
along with other occlusal morphology factors, such as uneven marginal ridges and
prominent opposing cusps. 21

Food impaction occasionally occurs even in at proximal sites where the proximal
contacts are tight.21 In the present study, 37% of embrasures with a tight proximal
contact were food impacted. The lack of papilla fill between implants and teeth has been
suggested as a possible explanation for “horizontal” food impaction in embrasures with
a tight proximal contact.9 However, the degree of papilla fill did not influence the food
impaction rate in our study (Table 2). Most of our study patients (79%) were recruited
from patients who were under supportive periodontal therapy (SPT) after active
periodontal treatment. They were instructed to use proximal brushes between the tooth
and implant, and, consequently, only 12% of the proximal embrasures were completely
filled with papilla. The degree of papilla fill was clinically assessed and dichotomized as
“complete” or “deficient” regardless of the actual size of the empty proximal space. The
ESA bordered by the lateral margins of the implant-supported crown/adjacent tooth and
the alveolar bone crest in the radiographic assessment significantly influenced food
impaction (p = 0.034). The chance for food impaction may increase when ESA
increases, since it is more difficult to fill a larger embrasure space completely with
papilla. However, a future study may need to measure the empty proximal embrasure
area rather than dichotomize papilla fill, i.e., complete or deficient fill to determine the
influences of papilla fill on food impaction.

Food impaction is a cause of periodontal or peri-implant mucosa inflammation.3, 6

However, periodontal/peri-implant mucosal conditions and implant bone level at the
follow-up examination were not influenced by food impaction in the univariate GEE
analysis. As mentioned earlier, our study patients were recruited from a patient pool
under regular SPT, and had < 20% plaque around the tooth/implant (Table 1). Hence,
food impaction may not negatively influence the periodontal/peri-implant mucosal
conditions or implant bone level, as shown in the patients who were not under SPT.3, 4

Various embrasure dimensions have been investigated with reference to the papilla
height and fill from an esthetic perspective.22 Implant position in relation to the adjacent
tooth, i.e., vertical and horizontal implant-tooth distance, influences the bone level at the
adjacent tooth, which dictates the papilla level between implants and teeth.13, 23 In

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Journal of Periodontology; Copyright 2015 DOI: 10.1902/jop.2015.150322

addition, the distance between the contact point and bone crest also influence the degree
of papilla fill between implants and adjacent teeth.9, 11 The horizontal distance between
teeth is correlated with the papilla fill in the proximal embrasures.24, 25 Hence, a square-
shaped crown with broad and flat proximal surfaces and contact points positioned as
gingival as possible is favored by restorative dentists, because it is more predictable to
fill the embrasure space completely with papilla when the embrasure area is
smaller.22,26, 27

Various embrasure dimensions significantly influenced periodontal/peri-implant

mucosal conditions (Table 4). However, our cross-sectional study design only allowed
us to determine the influence of embrasure dimensions on the periodontal/peri-implant
tissue conditions at the follow-up. A prospective study design is warranted in future
studies to elucidate the cause and effect relationship between embrasure dimensions and
periodontal/peri-implant tissue conditions.
We evaluated the clinical condition of the periodontal/peri-implant mucosa at the
follow-up. However, the bone level at the implant may have indicated bone loss at the
implant on the follow-up radiographic assessments because the implants were placed at
the bone crest level according to the manufacturer’s instructions. Bone level at the
implants was significantly influenced by the horizontal implant-tooth distance, tooth
bone level, and the contact point level in the univariate GEE analysis, and horizontal
implant-tooth distance, tooth bone level, ESA in the multivariate GEE model (Table 5).
Bone loss at the tooth adjacent to the implant increases as the horizontal implant-tooth
distance decreases.13, 23 In contrast to the present study, no relationship between bone
loss at the implant and horizontal tooth-implant distance was found in other studies.28, 29
However, different implant systems, implant positions, and statistical analyses
employed between studies hamper a direct comparison of the results between studies.

Patient-oriented evidence will improve study quality; hence, there is a need to assess
patient-based outcomes.30 Dichotomous judgements, despite their lower efficiency than
continuous judgements, were employed to assess the primary outcome of this study, i.e.,
the presence/absence of food impaction, because additional categories may add noise or
error to the data. On the other hand, patient’s overall satisfaction about the implant-
supported FDP was assessed with the VAS which is a continuous judgement and the
essence of simplicity.31

The result of the VAS showed that 82.3% (range, 0–100%) of the patients were
satisfied. Overall satisfaction of the food impaction group was significantly lower than
that of the no impaction group, as food impaction significantly influenced patient’s
overall satisfaction in the univariate GEE analysis (p = 0.012) (Table 2). Therefore,

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Journal of Periodontology; Copyright 2015 DOI: 10.1902/jop.2015.150322

some measures to prevent food impaction between implants and adjacent teeth should
be taken during fabrication of implant-supported restorations, as food impaction affects
patient-perceived outcome, i.e., overall satisfaction. A retrievable design in which
clinicians resurface the contact area after removing the FDP could be an option to treat
the discomfort due to food impaction related to proximal contact loss between implants
and adjacent teeth.32 Occlusal modification of a crown adjacent to a tight proximal
contact manifesting food impaction due to the lack of adequate food escape grooves
may also be considered.21

In conclusion, food impaction between implant-supported FDPs and adjacent teeth

occurred more frequently when the proximal contact was lost and ESA increased. Food
impaction negatively affected patient’s overall satisfaction. Embrasure dimensions
influenced periodontal/peri-implant mucosal conditions, and bone level at the implant.
Hence, the emergence profile of an implant-supported crown and proximal contact
between implant-supported FDPs and adjacent teeth should be properly formed to
prevent food impaction and maintain healthy periodontal/peri-implant tissue conditions.

ACKNOWLEDGEMENT
This paper was supported by Fund of Biomedical Research Institute, Chonbuk National University
Hospital.

CONFLICT OF INTEREST STATEMENT

The authors declare that they have no conflict of interests.

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16. Kim DS, Suh KW. A proximal contact adjustment and interproximal relief method. J Prosthet Dent
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20. Begg MD. Analysis of correlated data. In: Emmanuel Lesaffre E, Feine J, Leroux B, Declerck D.
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22. Chang M. The peri-implant tissues from an esthetic perspective. [Thesis]. Göteborg, Sweden:
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25. Martegani P, Silvestri M, Mascarello F, et al. Morphometric study of the interproximal unit in the
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implants restored 3 weeks after 1-stage surgery. Int J Oral Maxillofac Implants 2001;16:182-192.

29. Urdaneta RA, Seemann R, Dragan IF, Lubelski W, Leary J, Chuang SK. A retrospective radiographic
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30. Ebell MH, Siwek J, Weiss BD, et al. Simplifying the language of evidence to improve patient care:
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31. Streiner DL, Norman GR. Scaling responses. In: Streiner DL, Norman GR, eds. Health Measurement
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Correspondence to: Dr. Moontaek Chang, Department of Periodontology, School of

Dentistry, Chonbuk National University Tel: +82-63-250 2216, Jeonju, 561-756 Fax:
+82-63-250 2259, Republic of Korea E-mail: chang@chonbuk.ac.kr
Submitted May 27, 2015; accepted for publication July 12, 2015.

Fig. 1.

Radiographic assessments of embrasure dimensions performed on the scanned image of radiograph;

Horizontal tooth-implant distance (HTID), bone level at the implant (BLI), bone level at the tooth (BLT),
contact point level (CPL) and embrasure surface area (ESA), and reference level (REF).

Table 1.

Differences of clinical assessments between food impaction (n=96) and no impaction (n=119)
groups.
Variable Food impaction No impaction P value*
At the adjacent tooth
Presence of plaque (%) 11.6 % 19.1 % 0.241
Bleeding on probing (%) 20.0 % 20.9 % 0.446
Pocket depth (mm ± SD) 2.54 ± 0.72 2.46 ± 0.81 0.784
Width of keratinized gingiva (mm ± SD) 2.88 ± 1.51 3.10 ± 1.72 0.298
At the implant
Presence of plaque (%) 11.5 % 14.3 % 0.495
Bleeding on probing (%) 47.9 % 42.9 % 0.470
Pocket depth (mm± SD) 3.46 ± 1.24 3.29 ± 0.98 0.099
Width of keratinized mucosa (mm ± SD) 2.71 ± 1.51 2.59 ± 1.54 0.707

* P values in generalized estimating equations analyzing the influences of variables on food impaction.

Table 2.

Differences of degrees of papilla fill and proximal contact, and patients overall satisfaction (visual
analogue scale:VAS) between food impaction (n=96) and no impaction (n=119) groups.
Variable Food impaction No impaction P value*
Papilla fill
deficient 82 (43.4%) 107 (56.6%)
0.552
complete 14 (53.8%) 12 (46.2%)
Proximal contact
loss 44 (60.3%) 29 (39.7%)
0.009
contact 52 (36.7%) 90 (63.3%)
Patient’s overall satisfaction (VAS) 77.3 ± 20.3 86.3 ± 13.2 0.012

* P values in generalized estimating equations analyzing the influences of variables on food impaction.

Table 3.

Differences of radiographic assessments between food impaction (n=96) and no impaction groups
(n=119).
Variable Food impaction No impaction P value*

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Journal of Periodontology; Copyright 2015 DOI: 10.1902/jop.2015.150322

Horizontal implant-tooth distance 3.90 ± 1.80 3.61 ± 1.61 0.403

Bone level at tooth 1.72 ± 1.80 1.89 ± 1.80 0.715
Bone level at implant -0.86 ± 1.02 -0.83 ± 1.02 0.957
Contact point level 7.28 ± 2.29 7.36 ± 2.15 0.200
Embrasure surface area 12.62 ± 6.42 11.35 ± 5.20 0.034

* P values in generalized estimating equations analyzing the influences of variables on food impaction.

Table 4.

Influences of various embrasure dimensions on periodontal/peri-implant soft tissue conditions.

Variable HITD BLT BLI CPL ESA
At the adjacent tooth
Presence of plaque NS NS NS * NS
Bleeding on probing * NS NS NS *
Pocket depth (mm ± SD) NS * NS NS *
Width of keratinized gingiva (mm ± * NS * NS NS
SD)
At the implant
Presence of plaque NS NS NS NS NS
Bleeding on probing NS NS NS * NS
Pocket depth (mm± SD) NS NS NS NS *
Bone level (mm ± SD) * * - * NS
Width of keratinized mucosa (mm ± * NS NS NS NS
SD)

*P values <0.05, NS (not significant) in generalized estimating equations. HITD: Horizontal implant-
tooth distance. BLI: Bone level at implant. BLT: Bone level at tooth. CPL: Contact point level. ESA:
Embrasure surface area.

Table 5.

Influences of embrasure dimensions on the implant bone level. Odds ratio, 95% confidence interval
(CI), and p value of the variables included in the univariate and multivariate generalized estimating
equations (GEEs).
Variables Univariate GEE Multivariate GEE*
Odds ratio (95% CI) P value Odds ratio (95% CI) P value
Embrasure dimensions
Horizontal implant- tooth 0.917 (0.852-0.988) 0.022 0.884 (0.820-0.953) 0.001
distance (mm)
Bone level at tooth (mm) 0.848 (0.793-0.906) 0.000 0.882 (0.814-0.955) 0.002
Contact point level (mm) 0.921 (0.789-0.974) 0.004 0.979 (0.914-1.048) 0.539
Embrasure surface area (mm2) 1.011 (0.980-1.043) 0.482 1.039 (1.005-1.074) 0.026

* P < 0.001

* Department of Periodontology, School of Dentistry and Institute of Oral Bioscience, Chonbuk National University,

Jeonju, S. Korea

† Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of

Chonbuk National University Hospital, Jeonju, S. Korea

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Journal of Periodontology; Copyright 2015 DOI: 10.1902/jop.2015.150322

‡ Hu-Friedy, Chicago, IL, USA

§ Oksan Preden Ltd., Seoul, Korea

|| Heliodentvario, Sirona Dental System Inc., Long Island, NY, USA

# Image J, U.S. National Institutes of Health, Bethesda, MD, USA

** Stata 11.1, Stata Corp., College Station, TX, USA

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Journal of Periodontology; Copyright 2015 DOI: 10.1902/jop.2015.150322

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