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Emergence Profile Design Based on Implant Position in the Esthetic Zone
Abstract
One of the most challenging tasks in implant dentistry is to fulfill the esthetic expectations of patients. While implant positioning and adequate amounts of soft and hard tissues are essential for achieving an esthetic outcome, the emergence profile of an abutment/restoration also plays an important role in the definitive appearance of implant prostheses. Therefore, the purpose of this paper is to propose a clinical guideline for designing an abutment/prosthesis based on implant position. By customizing the emergence profile, the overlying soft tissues could be properly contoured and maintained, and pleasing implant prostheses could be achieved.
... [5][6][7][8][9] The three-dimensional (3D) position of the implant and quantity of soft tissues available are factors that influence the shape of the EP. 5,[10][11][12] The final contour of the provisional restoration is essential to achieve an esthetic result. 10,13 The concept of the critical and subcritical contours of the implant emergence profile was described by Su et al., 14 who focus on the importance of shaping two different areas of the EP to achieve the desired outcome in the peri-implant tissues. ...
... 5,[10][11][12] The final contour of the provisional restoration is essential to achieve an esthetic result. 10,13 The concept of the critical and subcritical contours of the implant emergence profile was described by Su et al., 14 who focus on the importance of shaping two different areas of the EP to achieve the desired outcome in the peri-implant tissues. However, there is still much confusion about the subcritical contour design when different soft tissue environments are present. ...
... 16 Without a connective tissue graft, a convex design in this zone can help create the illusion of thicker tissues. 10,14 The B zone design is also influenced by the position and design of the implant neck. 12 ...
Objective
Emergence profile design is important for stable peri‐implant tissues and esthetically pleasing results with dental implant restorations, influenced by factors, such as, implant position and surrounding soft tissues. Different aspects of the emergence profile have been described, but detailed explanations of the different zones and corresponding designs are missing. This article describes the esthetic biological contour concept (EBC), differentiating important areas of the emergence profile and recommending particular designs for those zones.
Overview
The EBC concept considers specific parameters for proper design of the emergence profile of implant‐supported restorations. Understanding the different zones of the emergence profile and their relation to factors like implant position, implant design, and soft tissue thickness is key. The suggested guidelines are geared toward providing more stable and esthetic results when restoring dental implants in the esthetic zone.
Conclusions
Each of the zones described in the EBC concept have a specific function in the design of the emergence profile. Understanding the importance and specific design features of the EBC zones facilitates esthetic and biologically sound treatment outcomes with interim and definitive implant restorations.
Clinical significance
Proper emergence profile design supports esthetic outcomes and provides favorable biological response to implant‐supported restorations.
... 32 Furthermore, the emergence profile of implant restoration could also have an effect on the facial gingival tissue thickness. 33 Over-contouring facial gingival profile of implant restoration had been shown to cause horizontal and vertical gingival tissue loss. 33 On the other hand, horizontal and vertical facial gingival tissues are generally well preserved in implant restoration with under-contoured emergence profile. ...
... 33 Over-contouring facial gingival profile of implant restoration had been shown to cause horizontal and vertical gingival tissue loss. 33 On the other hand, horizontal and vertical facial gingival tissues are generally well preserved in implant restoration with under-contoured emergence profile. 33 It was widely agreed that plaque accumulation may induce a negative mucosal response. ...
... 33 On the other hand, horizontal and vertical facial gingival tissues are generally well preserved in implant restoration with under-contoured emergence profile. 33 It was widely agreed that plaque accumulation may induce a negative mucosal response. 4 The mPI and mBI scores observed at T 12m , with the majority scores either 0 or 1, implied that patients had been able to maintain a good level of oral hygiene over the course of this study. ...
This 1-year prospective study evaluated horizontal and vertical facial gingival tissue changes following immediate implant placement and provisionalization (IIPP) with and without bone graft in the implant-socket gap (ISG). During IIPP, 10 patients received bone graft material in the ISG (G group), while the other 10 patients did not (NG group). The implants were evaluated for implant stability quotient (ISQ), modified plaque index (mPI), modified bleeding index (mBI), marginal bone level (MBL), facial gingival level (FGL) and facial gingival profile (FGP) changes. The mean ISQ value at 9-month follow upwas statistically significantly greater than on the day of implant surgery ( p <.05). The mPI and mBI scores demonstrated that patients were able to maintain a good level of hygiene. There were no statistically significant differences in the mean MBL changes between the G and NG groups ( p >.05). There were statistically significant differences in FGL changes between the G (-0.77 mm) and NG (-1.35 mm) groups ( p =.035). There were no statistically significant differences in FGP changes between the G and NG groups (p>.05). However, statistically significant differences were noted in FGP change between the 3-12 and 0-12 month intervals in both groups (p<.05). Within the limitations of this study, although no significant differences were noted in FGP changes between groups, G group experienced significantly less FGL changes than NG group. Bone graft material placement into ISG seems to be advantageous for tissue preservation during IIPP. However, future long-term studies, with larger sample size, are needed to validate the efficacy of such procedure.
... However, all of the patients received values of PES/WES above 12 points, which is considered to be acceptable [39]. In order to achieve an esthetic restoration, the prosthetic factors also play a key role [40,41]. The emergence profile of the abutment should be palatal to that of the adjacent teeth at the mucosal margin, and the provisional restoration should be used for shaping the peri-implant soft tissues. ...
... The emergence profile of the provisional restoration can easily be modified so that the peri-implant soft tissues can be contoured. Once the desired condition is reached, the definitive restoration can be fabricated based on the contour of the provisional restoration, thereby achieving a congruent and esthetic restorative outcome [40]. ...
The purpose of this clinical research was to evaluate peri-implant marginal changes around immediate implants placed either with the application of SCTG or XCM or without soft tissue grafting. A total of 48 patients requiring a single implant-supported restoration in the anterior jaw were selected for inclusion. Three surgical procedures were performed, as follows: type 1 implant with subepithelial connective tissue graft (SCTG), type 1 implant with xenogenic collagen matrix (XCM), and type 1 implant without soft tissue augmentation (NG) (control group). The marginal change of peri-implant soft tissue, facial soft tissue thickness (FSTT), peri-implant health status, esthetics, and patient satisfaction were assessed at one year after surgery. All of the placed implants showed a survival rate of 100%. No significant differences in FSTT were recorded between the SCTG group and the XCM group after treatment ( P > 0.05 ), while the NG group presented a significant difference ( P < 0.05 ). Patients in the NG group lost significantly more in the buccal marginal level than did patients in the SCTG group and those in the XCM group ( P < 0.05 ). The favourable success rate recorded in all groups confirmed immediate tooth replacement as a choice of treatment for a missing anterior single tooth. The NG group presented significant changes of FSTT and buccal marginal level, while XCM constituted a viable alternative to SCTG.
... 13 The abutment contour design might be based on facial-lingual implant position. 14 Depending on the implant location, the emergence angle may range from 15 • in incisal position, 30 • in cingulum position to 45 • in palatal position. 15 The intricate relationships between the implant positioning and axis, abutment and crown contours, and the surrounding tissue characters determine the mucosal level and its stability overtime. ...
... It was suggested that a concave abutment enables superior soft tissue outcomes over a convex design because the former provides space for tissue ingrowth, which potentially increases tissue volume and stability. 14,15,26 Su and coworkers classified the implant abutment and crown contour into two zones that can be individually operated to condition and manipulate periimplant soft tissue, namely the critical and subcritical contours. 13 While the subcritical zone provides the runway for soft tissue infiltration and maturation; the critical zone ultimately determines the soft tissue margin location. ...
Background:
Immediately placed single implants with either immediate provisionalization (test) or delayed restoration (control) were followed for up to 1 year in our previous randomized clinical trial. Peri-implant tissues continue to remodel after implants are in function. Therefore, the primary aim of this study was to evaluate the facial mucosal level changes in the intermediate term between the two groups and to study potential factors influencing the mucosal level change.
Methods:
Patients who had already completed the previous clinical trial by receiving a single immediately placed implant were re-invited to this study. The facial mucosal level as well as the other peri-implant hard and soft tissue dimensions and conditions were measured clinically, radiographically and with ultrasound. These data were compared between the test and control implants. The mucosal level change as the function of the final crown contour, measured as the abutment-crown angle (ACA), was estimated with a linear regression model.
Results:
Twenty-eight patients (n of test/control = 16/12) with a mean 30-month follow-up were recruited. The mean mucosal level change was -0.38 mm (control) and 0.06 mm (test), without statistical difference between the two groups. The other clinical, radiographic, and ultrasound parameters were not statistically different. ACA was statistically significant associated with the recession (P = 0.02). The estimate effect was 0.25 mm per 10° increase (adjusted R2 = 0.18; 95% CI, 0.02 to 0.49 mm). After adjusting for vertical implant position, implant abutment angle and the group, the effect became borderline significant (P = 0.09).
Conclusions:
Peri-implant tissues, including the mucosal level change of immediately placed implants with either immediate provisionalization or delayed restoration remained stable and did not differ between the groups in the intermediate term. The final crown angle, influenced by implant position and abutment angle, might be associated with mucosal margin level change.
... The final crown was then created by replicating the final shape of the provisional restoration with an S-shaped profile, which gave the ideal concavity to accommodate the soft tissue, as indicated in the decision tree of Steigmann et al 29 for implants centrally located in the bone crest. 29 Furthermore, a concave profile associated with an emergence angle of < 30 degrees, such as the one achieved in this case, has a significantly lower chance of developing peri-implantitis. 30 The crowns were screwed in, which means that if changes of color occur or replacements become necessary in future, they can easily be unscrewed and replaced. ...
The esthetic success of a case requiring implant therapy mainly depends on both the correct planning and the surgical-prosthetic execution. However, planning and surgical implementation according to prosthetically guided criteria are not always possible due to contingent anatomical limitations. When this is further complicated by the presence of mucogin-gival deficiencies in a highly visible esthetic area, the management of the case can become very complex. The present case report describes the presurgical and surgical management of a case of maxillary lateral incisor agenesis in the absence of sufficient vertical space. Through orthodontic therapy, the opening of the deep overbite and the alignment of the maxillary and mandibular arches were obtained, allowing for an implant positioning without compromises dictated by anatomical limitations. Finally, through mucogingival surgery and careful management of the provisional prosthetic phase, an optimal esthetic profile was achieved. (Int J Esthet Dent 2022;17:42-56) 43 CLINICAL RESEARCH
... For example, implants placed in the esthetic zone outside of the bony envelope have to be compensated by soft-tissue grafting and/ or concave emergence profiles in order to satisfy esthetics. 19 Despite advances in the esthetics of pink porcelain, certain situations are unmanageable esthetically without implant removal, despite the fact that the implants have successfully osseointegrated. Implant removal differs significantly from tooth extraction. ...
Inappropriate and unnecessary implant therapy driven by an erroneous belief that dental implants provide enhanced function and esthetics over diseased or failing teeth has led to a growing burden of implant complications across the globe. Specifically, esthetic and biological complications frequently lead to the unfavorable prognosis of dental implants. Often, these cannot be managed predictably to improve the condition or satisfy patients' demands. In such circumstances, implant removal needs to be considered. Currently, minimally invasive methods based on reverse torque engineering are key to preserve peri‐implant soft and hard tissues. Implant replacement is now feasible, as evidenced by the high survival rates of implants placed at previously failed sites. Notwithstanding these data, clinicians should still consider carefully the expendability of an implant and whether its replacement will satisfy the prosthetic, biomechanical, and esthetic demands of the patient. In the scenario where future implant placement is desired, protocols undertaken for soft/hard tissue grafting and implant placement should be based upon defect morphology and soft and hard‐tissue characteristics. Currently, however, a lack of knowledge of the biological events and dimensional changes that arise following implant removal renders decision‐making complex and challenging, and recommendations remain largely based upon empirical speculation. This chapter will review the indications for implant replacement for prosthetic, biomechanical, and esthetic complications, alongside considerations in decision‐making, planning, implementation, and outcomes of implant replacement.
... Multiple clinical reports have demonstrated the ability to design and fabricate ceramic abutments and crowns using titanium base to achieve the optimum emergence profile and improve the esthetic outcomes. [64][65][66] Martínez-Rus et al 65 assessed clinically the impact of different abutments and soft tissue thickness on the optical properties of lithium disilicate implant single crowns. Twenty patients were recruited in this study where 17 had thin (≤ 2 mm) and 3 had thick (> 2 mm) soft tissue thickness. ...
Implant abutments are essential components in restoring dental implants. Titanium base abutments were introduced to overcome issues related to existing abutments, such as the unesthetic appearance of titanium abutments and the low fracture strength of ceramic abutments. This study aimed to comprehensively review studies addressing the mechanical and clinical behaviors of titanium base abutments. A search was performed on PubMed/MEDLINE, Web of Science, Google Scholar, and Scopus databases to find articles that were published in English until December 2020 and that addressed the review purpose. A total of 33 articles fulfilled the inclusion criteria and were included for data extraction and review. In vitro studies showed that titanium base abutments had high fracture strength, adequate retention values, particularly with resin cement, and good marginal and internal fit. Although the clinical assessment of titanium base abutments was limited, they showed comparable performance with conventional abutments in short-term evaluation, especially in the anterior and premolar areas. Titanium base abutments can be considered a feasible treatment option for restoring dental implants, but long-term clinical studies are required for a better assessment.
... Furthermore, the variability and unpredictability observed in the various studies as well as in the investigated groups validate the hypothesis that the implant papilla is dictated by the height of the alveolar ridge in the interproximal areas [74,75]. In addition, it is also influenced by the gingival morphology of the prosthesis and its emergence profile [76][77][78]. ...
IntroductionPreserving peri-implant tissues after immediate implant placement (IIP), especially in aesthetic zones, is a topic of interest.Objectives
This systematic review investigated the effects of currently available surgical procedures for preserving peri-implant tissue or ensuring dimensional stability following immediate implant placement.Materials and methodsThe Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement’s guidelines were followed, and articles were sought on the PubMed and Cochrane databases with no date restrictions. Only randomised clinical trials that evaluated changes in soft and hard tissues around immediately placed implants were included. Statistical analyses were performed, and the studies´ quality was assessed using the Cochrane Collaboration tool. The agreement between reviewers was assessed based on Cohen’s kappa statistics.ResultsOf the 14 studies that met the inclusion criteria, 11 were analysed in the meta-analysis (kappa = 0.814; almost perfect agreement). The use of connective tissue grafts resulted in a significantly greater improvement of the facial gingival level (MD = −0.51; 95% CI: −0.76 to −0.31; p = < .001), and the placement of bone grafts significantly reduced the horizontal resorption of the buccal bone (MD = −0.59; 95% CI: −0.78 to −0.39; p < .001).Conclusion
Connective tissue grafts and bone grafts positively influence tissue preservation around immediately placed implants. Neither the flapless technique nor palatal implant positioning resulted in significant improvements to any of the investigated parameters. Additional longitudinal studies are required.Clinical relevanceThis meta-analysis is useful for discerning the effects of soft tissue augmentation, bone grafting, the flapless technique, and palatal implant positioning on preserving peri-implant tissues after immediate implant placement.
... 9,10 Prefabricated circular healing abutments promote nonanatomic soft-tissue maturation that must be remedied at the restorative stage by the judicious and clinically sensitive addition of resin to the interim crown and abutment. 6,[11][12][13] However, the soft tissue healing time 14,15 and the limits of immediate tissue compression 16,17 make the task of developing a clinically correct emergence profile a time-consuming, demanding, multistep process both chairside and in the dental laboratory. [18][19][20] Incompletely polymerized shape-modifying resin may also cause soft tissue irritation in some patients. ...
Statement of problem. A custom emergence profile offers the ideal horizontal dimensions for an anatomic healing abutment. However,
developing such an emergence profile can be a time-consuming and complex process.
Purpose. The purpose of this study was to develop a mathematical formula defining horizontal cervical tooth geometry to design
prefabricated, tooth-specific, healing abutments.
Material and methods. Cone beam computed tomography (CBCT) horizontal cross sections of 989 teeth on 54 participants were measured.
For anterior and premolar teeth, 2 perpendicular ellipses were fitted onto the cervical tooth cross section that was defined by 3 parameters.
The lingual ellipse followed the lingual outline of the tooth, and its diameter was the largest mesiodistal diameter of the tooth (parameter
“a”); its buccolingual radius became parameter “b.” The buccal ellipse was perpendicular to the lingual ellipse and followed the buccal outline
of the tooth. The buccolingual radius of the smaller ellipse became parameter “c.” For molars, the first ellipses followed the mesial outline of
the tooth, and its larger diameter (parameter “a”) matched the largest buccolingual diameter of the tooth. Its smaller radius became
parameter “h1.” The second ellipse was parallel to the first ellipse and followed the distal outline of the tooth. Its larger diameter
became parameter “b”, and its mesiodistal diameter became parameter “h2”. Statistical differences between parameters were evaluated
by the linear mixed model (a=.05 after Bonferroni adjustment). Pairwise comparisons were made separately for each parameter of the
molars and separately for each parameter for the anterior teeth plus premolars. Teeth were put into the same parameter cluster if no
significant differences were found between them for a specific parameter. If neither parameter (4 for molars and 3 for the other teeth)
was different for 2 teeth, they were put into the same abutment cluster. The abutment clusters determined the type of anatomic
healing abutment. The areas were calculated from the developed mathematical formula by using the parameters. In addition, cervical
areas of 106 randomly chosen teeth were measured directly with a photo-editing software program. A computer algorithm was used to
select 5 CBCT scans from the 54 by using the simple randomization method. The agreement between the 2 methods was evaluated by
Bland-Altman analysis.
Results. The lower and upper limits of agreement between the 2 methods were -8.57 and 7.36 mm2, respectively, with no bias (-0.61 mm2,
P=.224). Significant differences were found between most parameters among the 14 tooth types (P<.001). Based on the parameters, 12
specifically distinct clusters were defined. Two tooth types were pooled into 1 abutment cluster: the maxillary first and second premolars
and the mandibular first and second molars.
Conclusions. The cervical tooth cross section can be accurately defined by combining 2 elliptical elements. A comprehensive array of tooth
specific emergence profiles can be provided by just 12 different prefabricated abutments, designed as per the recommended parameters.
... In clinical practice, the proper diagnosis of labial gingiva thickness (GT) and alveolar crest thickness (ACT) of the anterior teeth is important to inform decisions regarding esthetic implant dentistry, periodontal therapies, and orthodontics [1][2][3]. Studies have documented that a good implant esthetic outcome is easily obtained with a thick rather than a thin soft and hard tissue [4,5]. Therefore, awareness of the initial GT and ACT is vital for treatment and prognosis. ...
Background
Knowledge of gingival thickness (GT) and alveolar crest thickness (ACT) is essential when performing surgical and non-surgical procedures in the maxillary anterior teeth region. This study aimed at evaluating the GT and ACT in the maxillary anterior teeth region using 15-MHz B-mode Ultrasonic (US).
Methods
A total of 300 teeth from 50 healthy participants, comprising 25 women and 25 men, aged between 18 and 35 years were analyzed. We measured labial periodontal tissue structures of maxillary anterior teeth, including GT and ACT, at 3 mm apical to the gingival margin (GT3) and the crestal level, respectively. The GT and ACT measurements were correlated.
Results
The mean labial GT3 of the maxillary central incisors, lateral incisors, and canines were 1.24 ± 0.03 mm, 1.21 ± 0.03 mm and 1.11 ± 0.03 mm, respectively. Canine GT3 was significantly thin than those in the central and lateral incisors ( P < 0.05). With regards to labial ACT, we recorded 0.79 ± 0.03 mm, 0.76 ± 0.02 mm and 0.73 ± 0.02 mm for maxillary central incisors, lateral incisors and canines, respectively. There were no significant differences in ACT of maxillary anterior teeth ( P > 0.05). GT3 of men was greater than that of women ( P < 0.05). In addition, GT and ACT were positively correlated ( r = 0.32, P < 0.01).
Conclusion
15-MHz B-mode US is an effective tool for measuring labial GT and ACT of anterior teeth. There are sex-associated differences in GT3 and the correlation between the GT3 and ACT of anterior teeth is moderately positive.
... (Int J Esthet Dent 2020; 15:2-11) texture, and various other aspects of the implant-associated soft tissue need to look similar to the surrounding soft tissue to maximize the esthetic outcomes. 19,20 To achieve this, provisional implant prostheses help to create and form the ideal peri-implant tissue. 21 The timing of the placement of provisional implant restorations (immediate as opposed to 6 months, for example) is informed by many factors such as the implant stability and the amount of graft applied. ...
Objective:
The combination of partial edentulism and a worn anterior tooth in the esthetic zone can be a challenge for the dentist. This clinical situation requires extensive knowledge of soft and hard tissue management, surgical planning and execution for implant therapy, and conservative tooth preparation with ideal bonding protocols for the tooth-supported prosthesis. Moreover, an optimal selection of the final restorative materials is imperative to manage occlusal forces and fulfill the patient's esthetic demands.
Materials and methods:
The patient presented with partial edentulism on site 11, a worn incisal edge, and facial defects on tooth 21. Minimally invasive implant therapy for site 11 was performed with a papilla-sparing flap design that only included the edentulous site, and the soft tissue contouring was started for an immediate provisional restoration. A suturing technique was executed that aimed at maintaining an interproximal papilla. Conservative veneer preparation was performed on tooth 21 in order to bond the restoration to the enamel structure. Final restorations included a custom abutment with a lithium disilicate fused to zirconia crown for the implant on site 11 and a lithium disilicate veneer on tooth 21.
Conclusions:
A well-planned single implant and a ceramic veneer restoration was able to fulfill the patient's esthetic expectations. The selection of materials for the final restoration was crucial to manage the occlusal forces and to mimic the shade and shape of the adjacent teeth.
... (Int J Esthet Dent 2020; 15:2-11) texture, and various other aspects of the implant-associated soft tissue need to look similar to the surrounding soft tissue to maximize the esthetic outcomes. 19,20 To achieve this, provisional implant prostheses help to create and form the ideal peri-implant tissue. 21 The timing of the placement of provisional implant restorations (immediate as opposed to 6 months, for example) is informed by many factors such as the implant stability and the amount of graft applied. ...
Objective: The combination of partial edentulism and a worn anterior tooth in the esthetic zone can be a challenge for the dentist. This clinical situation requires extensive knowledge of soft and hard tissue management, surgical planning and execution for implant therapy, and conservative tooth preparation with ideal bonding protocols for the tooth-supported prosthesis. Moreover, an optimal selection of the final restorative materials is imperative to manage occlusal forces and fulfill the patient’s esthetic demands.
Materials and methods: The patient presented with partial edentulism on site 11, a worn incisal edge, and facial defects on tooth 21. Minimally invasive implant therapy for site 11 was performed with a papilla-sparing flap design that only included the edentulous site, and the soft tissue contouring was started for an immediate provisional restoration. A suturing technique was executed that aimed at maintaining an interproximal papilla. Conservative veneer preparation was performed on tooth 21 in order to bond the restoration to the enamel structure. Final restorations included a custom abutment with a lithium disilicate fused to zirconia crown for the implant on site 11 and a lithium disilicate veneer on tooth 21.
Conclusions: A well-planned single implant and a ceramic veneer restoration was able to fulfill the patient’s esthetic expectations. The selection of materials for the final restoration was crucial to manage the occlusal forces and to mimic the shade and shape of the adjacent teeth.
... Studies by Linkevicius et al. have focused on the importance of a thick or thin biotype to improve immediate implant success and prevent future mucosal recession [6], as soft tissue will always adapt to the condition of the local setting [7,8]. Meanwhile, Steigman et al. defined the importance of the emergence profile to manage soft tissue adjacent to dental implants [9]. Thus, soft tissue management at the prosthetic and surgical stages is considered essential to gain predictable and aesthetic results [10,11]. ...
Background:
Optimal aesthetic implant restoration is a combination of a visually pleasing prosthesis and adequate surrounding peri-implant soft tissue architecture. This study describes the influence of the residual buccal bone thickness (BBT), measured at the time of implant placement, on the soft tissue maturation during three years of follow-up.
Methods:
Seventy-eight implants were enrolled in the present study. The BBT was assessed at the surgical stage and each case assigned to Group 1 (BBT values ≤0.5 mm), Group 2 (BBT values >0.5 and <1.5 mm), or Group 3 (BBT values ≥1.5 mm). Only native bone and healed sites were included. The tooth height (TH), based on the distance between the buccal free gingival margin at the zenith level and the crown incisal edge, according to the main axis of the tooth, was monitored at one, two, and three years from the final prosthodontic rehabilitation to determine any occurrence of recession or coronal repositioning of the gums over time. A Pearson Two-Tailed test was applied and the significance level set at p ≤ 0.05.
Results:
For BBT values ≤0.5 mm, the buccal gum at three years showed an average recession of 1.22 ± 0.41 mm. For BBT values >0.5 and <1.5 mm, the buccal gum also showed recession of 0.64 ± 0.29 mm. In contrast, for BBT values ≥1.5 mm, the buccal gum showed coronal growth of 0.77 ± 0.22 mm. The differences between the groups were significant (p ≤ 0.01) at all times.
Conclusion:
The BBT at the time of implant placement was found to affect the buccal gingival margin stability over three years of observation.
La rehabilitación de la zona estética anterior es sin duda un reto importante para el odontólogo, ya que tiene que conocer y manipular la reacción y relación de tejidos blandos periimplantarios, así como la correcta transferencia mediante una copia fiel de la posición de éstos y el estado que guardan con las estructuras adyacentes mediante una impresión que también tendrá que ser personalizada. El objetivo de este artículo es presentar una alternativa en la rehabilitación de implantes mediante la personalización de nichos con la finalidad de obtener mejores resultados funcionales y estéticos, pero sobre todo conservar la posición que guardan los tejidos blandos periimplantarios.
This article describes an alternative digital approach for fabricating an implant-supported interim prosthesis. An interim prosthesis with an appropriate emergence profile and esthetics was fabricated before surgery and connected to the interim abutment immediately after implantation guided by a prosthetic template.
Resorption of the alveolar bone after tooth extraction is an irreversible process due to biological bone remodeling. It will greatly complicate the further treatment of patients for dental implantation, since for the latter a prerequisite is a sufficient volume of bone tissue. It leads to a protracted treatment process: the volume and timing of interventions increases. The literature review has shown possible methods of preservation of the alveolar ridge after tooth extraction and the results of their application.
The placement of dental implants in the anterior maxilla is a challenge for clinicians because of patients' exacting esthetic demands and difficult pre-existing anatomy. This article presents anatomic and surgical considerations for these demanding indications for implant therapy. First, potential causes of esthetic implant failures are reviewed, discussing anatomic factors such as horizontal or vertical bone deficiencies and iatrogenic factors such as improper implant selection or the malpositioning of dental implants for an esthetic implant restoration. Furthermore, aspects of preoperative analysis are described in various clinical situations, followed by recommendations for the surgical procedures in single-tooth gaps and in extended edentulous spaces with multiple missing teeth. An ideal implant position in all 3 dimensions is required. These mesiodistal, apicocoronal, and orofacial dimensions are well described, defining "comfort" and "danger" zones for proper implant position in the anterior maxilla. During surgery, the emphasis is on proper implant selection to avoid oversized implants, careful and low-trauma soft tissue handling, and implant placement in a proper position using either a periodontal probe or a prefabricated surgical guide. If missing, the facial bone wall is augmented using a proper surgical technique, such as guided bone regeneration with barrier membranes and appropriate bone grafts and/or bone substitutes. Finally, precise wound closure using a submerged or a semi-submerged healing modality is recommended. Following a healing period of between 6 and 12 weeks, a reopening procedure is recommended with a punch technique to initiate the restorative phase of therapy.
Purpose:
The aim of this cone beam computed tomography (CBCT) study was to investigate the incidence of fenestration and associated risk factors with virtual placement of an implant in the maxillary incisor region.
Materials and methods:
Edentulous ridges missing a maxillary central or lateral incisor and amenable for single implant placement were included. Root-form implants (4×12 mm and 3.5×12 mm for the central and lateral incisors, respectively) were placed virtually in the edentulous space following the axis of the ipsilateral crown. Buccolingually, the implants were placed in the ideal prosthetic cingulum position. The angles of the ridge (RA) and implants (IA) in relation to the hard palate and the incidence of fenestration were recorded.
Results:
A total of 48 CBCT scans were analyzed. The mean RA and IA were 124.32 degrees and 110.91 degrees, respectively. Nine cases resulted in fenestration, equivalent to 18.75% of the total cases. The discrepancy between the RA and IA was statistically significantly larger in the fenestration sites (19.93 degrees) than in the nonfenestration sites (13.05 degrees). The concavity depth of the alveolar ridge was statistically significantly higher in the fenestration sites (4.79 mm) than in the nonfenestration sites (3.40 mm).
Conclusion:
Within the limitations of this study, it can be concluded that the occurrence of fenestration is common (approximately 20%) if an implant is placed in the cingulum position with the axis following that of its restoration.
Objective:
The aim of the present systematic review was to determine the peri-implant tissue response to different implant abutment materials and designs available and to assess the impact of tissue biotype.
Materials and methods:
Relevant literature published between December 2009 and August 2012 was searched to identify studies dealing with different implant abutment designs and materials, as well as the response of different tissue biotypes. The search terms used, in simple or multiple conjunctions, were 'implant abutment', 'interface', 'material', 'peri-implant', 'soft tissue' and 'esthetic'. Studies were selected according to pre-determined inclusion and exclusion criteria.
Results:
The initial search yielded 2449 titles. After a subsequent filtering process, 23 studies were finally selected. The included studies revealed different factors responsible for the stability of peri-implant tissue and the esthetic outcome. These factors include tissue biotype and architecture, implant abutment material and implant abutment design. Several designs were suggested to prevent marginal bone loss and soft tissue recession. These included scalloped implants, platform-switched implants and gingivally converged or concave implant abutments. Due to the limited number of studies and the heterogeneity in their designs, it was not possible to perform a statistical analysis of the data.
Conclusions:
The current literature provides insufficient evidence about the effectiveness of different implant abutment designs and materials in the stability of peri-implant tissues.
Tissue biotypes have been linked to the outcomes of periodontal and implant therapy. The purpose of this study is to determine the dimensions of the gingiva and underlying alveolar bone in the maxillary anterior region and to establish their association.
Tissue biotypes of 22 fresh cadaver heads were assessed clinically and radiographically with cone-beam computed tomography (CBCT) scans. Maxillary anterior teeth were atraumatically extracted. The thickness of both soft tissue and bone were measured using a caliper to the nearest 0.1 mm by two calibrated examiners. Probing depths and gingival recession were measured at two points (mid-labial and mid-palatal). Clinical and CBCT measurements of both soft tissue and bone thickness were subsequently compared and correlated.
No statistically significant differences were observed between the clinical and CBCT measurements of both soft tissue and bone thickness except the palatal soft tissue measurements. The labial gingival thickness was moderately associated with the underlying bone thickness measured with CBCT (R = 0.429; P <0.05). Gingival recession was not associated with the thickness of both labial gingiva and bone.
CBCT measurements were an accurate representation of the clinical thickness of both labial gingiva and bone. In addition, the thickness of the labial gingiva had a moderate association with the underlying bone radiographically.
Full-thickness periosteal flap surgery is often accompanied by potential marginal bone loss and/or soft tissue recession. This is critical, particularly for the single-unit implant-supported restoration in the anterior maxilla, where the harmony of the soft and hard tissue architecture is of paramount importance to the development of natural aesthetics and function. This article demonstrates a flapless implant surgery technique in the anterior maxilla for optimal aesthetic results. The indications and limitations of this procedure are also discussed.
Attempts have been made to evaluate the biologic dimension of osseointegrated implants, however, most are histologic studies in animals, and the effect of soft tissue support from adjacent teeth on the interproximal dimension of the peri-implant mucosa for anterior single implants has not been addressed. This study clinically evaluated the dimensions of the peri-implant mucosa around 2-stage maxillary anterior single implants in humans after 1 year of function. The influence of the peri-implant biotype was also examined.
Forty-five patients (20 males and 25 females) with a mean age of 47.3 years were included in this study. A total of 45 maxillary anterior single implant crowns with a mean functional time of 32.5 months (range, 12 to 78) were evaluated. The dimensions of peri-implant mucosa were measured by bone sounding using a periodontal probe at the mesial (MI), mid-facial (F), and distal (DI) aspects of the implant restoration and the proximal aspects (MT, DT) of adjacent natural teeth. In addition, the peri-implant biotype was evaluated and categorized as thick or thin. Statistical analysis was performed using an independent t test (P<0.05).
The means and standard deviations of the dimensions of peri-implant mucosa at MT, MI, F, DI, and DT were 4.20 +/- 0.77 mm, 6.17 +/- 1.27 mm, 3.63 +/- 0.91 mm, 5.93 +/- 1.21 mm, and 4.20 +/- 0.64 mm, respectively. The dimensions of peri-implant mucosa in the thick biotype were significantly greater than the thin biotype at MT, MI, and DT (P<0.05).
The mean facial dimension of peri-implant mucosa of 2-stage implants is slightly greater than the average dimension of the dentogingival complex. The level of the interproximal papilla of the implant is independent of the proximal bone level next to the implant, but is related to the interproximal bone level next to the adjacent teeth. Greater peri-implant mucosal dimensions were noted in the presence of a thick peri-implant biotype as compared to a thin biotype.
The use of osseointegrated implants provides predictable, long-term aesthetics, providing that the implant housing and peri-implant gingivae are adequately maintained. Restoration-driven implant placement must, therefore, result in the development of harmonious peri-implant soft tissue contour as compared to the adjacent natural teeth. This article analyzes the implant housing features that influence aesthetics in implant therapy. Case presentations that include surgical and restorative innovations are described to illustrate methods used to achieve aesthetics with single-tooth implant restorations.
There are biologic limits of the soft tissue dimension around implants; therefore, the limiting factor for the esthetic result of implant therapy is the bone level at the implant site. Clinicians must focus on the 3-D bone-to-implant relationship to establish the basis for an ideal and harmonic soft tissue situation that is stable over a long period. In some situations, missing bone is a limiting factor for esthetics; in others, it is possible to regenerate new bone around implants. As a certain amount of bone resorption occurs around implants as soon as the implant is in contact with the oral environment, the distance between an implant and adjacent tooth, as well as the distance between two implants, is as important as the bone volume on the buccal side of the implant head and in the papillary area, especially for the long-term result. This article discusses the 3-D bone-to-implant relationship and its influence on soft tissue esthetics around implants.
A crucial factor influencing implant esthetics is the color of the peri-implant mucosa. This in vitro study analyzed the effect of titanium and zirconia with and without veneering ceramic on the color of mucosa of three different thicknesses. Ten pig maxillae were used, and the palatal area was chosen as the test region. To simulate different mucosa thicknesses, connective tissue grafts, 0.5 mm and 1.0 mm thick, were harvested from three additional jaws. Defined mucosa thicknesses were created by placing the grafts under a palatal mucosa flap. Four different test specimens (titanium, titanium veneered with feldspathic ceramic, zirconia, and zirconia veneered with feldspathic ceramic) were placed under the mucosa, and the color of the tissue was evaluated with a spectrophotometer for three different soft tissue thicknesses (1.5, 2.0, and 3.0 mm). The color was compared to mucosa without test specimens, and the color difference (DeltaE) was calculated. All restorative materials induced overall color changes (DeltaE), which diminished with increases in soft tissue thickness. Titanium induced the most prominent color change. Zirconia did not induce visible color changes in 2.0-mm-thick and 3.0-mm-thick mucosa, regardless of whether it was veneered. However, with a mucosa thickness of 3.0 mm, no change in color could be distinguished by the human eye on any specimen. Mucosa thickness is a crucial factor in terms of discoloration caused by different restorative materials. In patients with thinner mucosa, zirconia will show the least color change.
During the treatment planning process, it is important to recognize differences in gingival tissue can affect treatment outcomes. The concept that thick and thin gingival biotypes have different responses to inflammation and trauma was previously introduced. In this paper, this concept is expanded in that gingival biotypes dictate different procedures for implant site preparation. With appreciation of these differences, preparatory steps can be taken to create a more ideal implant placement site.
Background:
Procedures to improve peri-implant soft-tissue outcomes of single, immediately placed implants are a topic of interest. This systematic review investigates the effect of various surgical and restorative interventions on implant mid-buccal mucosal level.
Methods:
An electronic search of five databases (January 1990 to December 2012) and a manual search of peer-reviewed journals for relevant articles were performed. Randomized controlled clinical trials (RCTs), prospective cohort studies, and case series with at least nine participants were included, with data on midfacial mucosal recession (MR) of immediately placed implants following various surgical and restorative interventions with a follow-up period of at least 6 months.
Results:
Thirty-six studies, eight RCTs, one cohort study, and 27 case series were eligible. Six interventions were identified and reviewed: 1) palatal/lingual implant position; 2) platform-switched abutments; 3) flapless approach; 4) bone grafts to fill the gap between buccal plate and fixture; 5) connective tissue grafts; and 6) immediate provisionalization. Three studies consistently showed that palatally/lingually positioned implants had significantly less MR when using tissue-level implants. Mixed results were reported for interventions 2, 3, 5, and 6. One study was available for intervention 4 and did not show a benefit.
Conclusions:
Some interventions might be adopted to reduce the amount of MR on implants with the immediate placement approach, as suggested by the included studies, with various levels of evidence. The conflicting results among studies might be a result of differences in patient and site characteristics, e.g., tissue biotype and buccal plate thickness. Therefore, the use of these interventions might be reserved for patients with moderate to high risk of esthetic complications.
Purpose:
: Periodontal biotype is considered to be a significant factor related to successful dental treatments. The purpose of this study was to determine the relationship between gingival thickness (GT) and width with respect to the underlying bone thickness in the maxillary and mandibular anterior sextant.
Materials and methods:
: Overall, 180 anterior teeth within healthy patients were assessed. GT and buccal bone thickness (BT) were measured at 3 locations: crestal/gingival margin, tooth apex, and a midpoint between the 2. In addition, the apicoincisal gingival width (GW) was recorded. Clinical and cone beam CT measurements were compared and correlated.
Results:
: No statistically significant relations were observed between GT and BT measures at any of the 3 positions. The mean GT at crestal mid and apical position for the maxillary teeth was 1.01 (±0.58) mm, 1.06 (±0.48) mm, and 0.83 (±0.47) mm, respectively, and the corresponding mean BT was 1.24 (±0.90) mm, 0.81 (±0.33) mm, and 2.78 (±1.62) mm, respectively. The GW is directly related (R = 0.007; P < 0.05) to the crestal BT.
Conclusion:
: In this study, the GT is not linked to the BT. However, the GW seems to be associated with the crestal BT.
The aim of the study was to evaluate soft-tissue coverage and patient aesthetic satisfaction of a novel surgical–prosthetic approach to soft tissue dehiscence (STD) around single endosseous implant.
Twenty patients with buccal soft tissues dehiscence around single implants in the aesthetic area were consecutively enrolled. Treatment consisted in: removal of the implant supported crown, reduction in the implant abutment, coronally advanced flap in combination with connective tissue graft (CTG) and final restoration. The unrestored contralateral tooth normally positioned without recession defect was used as a reference. The soft tissue coverage and patient satisfaction were evaluated 1 year after the final restoration.
One-year mean STD coverage was 96.3%, and complete coverage was achieved in 75% of the treated sites. The increase (1.54 ± 0.21 mm) in buccal soft tissue thickness (STT) at 1 year was significantly correlated with CTG thickness at time of the surgery. The mean difference between graft thickness and STT increase was 0.09 ± 0.14 mm, corresponding to the 5.8% of the original graft thickness. The aesthetic analysis showed a significant improvement between the baseline (median, 3.8; 95% CI, 2–4) and the 1-year (median, 8.0; 95% CI, 8–10) visual analogue scale (VAS) scores.
The results from the present study demonstrated that the proposed bilaminar technique was effective in the coverage of buccal STD around single dental implant and the suggested prosthetic–surgical approach was aesthetically successful.
Purpose: The location of the gingival zenith in a medial-lateral position relative to the vertical tooth axis of the maxillary anterior teeth remains to be clearly defined. In addition, the apex of the free gingival margin of the lateral incisor teeth relative to the gingival zeniths of the adjacent proximal teeth remains undetermined. Therefore, this investigation evaluated two clinical parameters: (1) the gingival zenith position (GZP) from the vertical bisected midline (VBM) along the long axis of each individual maxillary anterior tooth; and (2) the gingival zenith level (GZL) of the lateral incisors in an apical-coronal direction relative to the gingival line joining the tangents of the GZP of the adjacent central incisor and canine teeth under healthy conditions.
Background:
It is generally believed that implants placed in extraction sockets have a tendency to shift in the facial direction during insertion. The purpose of this study is to investigate the effect of different thread designs on the final implant position in immediate implant placement.
Methods:
In a split-mouth design involving 11 cadaver heads, each specimen received two implants, one with a square and one with a V-shaped thread design, in maxillary incisor extraction sockets. The facio-lingual locations of the drills and the implant were tracked, and the displacements were compared between the two groups.
Results:
No statistically significant differences were observed between the square and V-shaped thread design groups. The mean displacements of the different groups showed a general tendency of the implants to be positioned facially compared with the initial drill trajectory. This tendency was greater for implants with square thread design.
Conclusion:
There was no significant effect of implant thread design on the positioning of implants in extraction sockets.
Implant dentistry has come a long way since 1981, with great improvements made to achieve primary implant stability and improve bone-to-implant contact. The focus has since shifted toward creating an esthetic restoration that is indistinguishable from natural teeth and is stable over time. This paper proposes a management triad that enhances soft tissue thickness around implant-supported restorations while discussing distinct differences between thin and thick tissue biotypes. In addition, the effect of tissue biotype on implant esthetics is highlighted.
Adequately contoured implant restorations need to transition from the circumferential design of the implant head to the correct cervical tooth anatomy. The implant abutment may be used to effect this transition provided there is sufficient running room. Implant restorations have been described as overcontoured, flat, and undercontoured. It has been shown that overcontouring will generally cause apical positioning of the gingival margin, while undercontouring will induce the opposite effect. However, these terms have been applied arbitrarily and without allocating specific determinants. Furthermore, the concept of "contour" as originally adapted from tooth-supported restorations needs to be redefined as it pertains to implant dentistry. Two distinct zones within the implant abutment and crown are defined as critical contour and subcritical contour. Any alteration of critical or subcritical contour can modify the soft tissue profile. The purpose of this paper is to determine the effect of abutment contour modifications at these zones on the peri-implant soft tissues, including the gingival margin level, papillae height, gingival architecture, labial alveolar profile, and gingiva color.
Among the factors that contribute to the papilla formation and crestal bone preservation between contiguous implants, this animal study clinically and radiographically evaluated the interimplant distances (IDs) of 2 and 3 mm and the placement depths of Morse cone connection implants restored with platform switch. Bilateral mandibular premolars of 6 dogs were extracted, and after 12 weeks, the implants were placed. Four experimental groups were constituted: subcrestally with ID of 2 mm (2 SCL) and 3 mm (3 SCL) and crestally with ID of 2 mm (2 CL) and 3 mm (3 CL). Metallic crowns were immediately installed with a distance of 3 mm between the contact point and the bone crest. Eight weeks later, clinical measurements were performed to evaluate papilla formation, and radiographic images were taken to analyze the crestal bone remodeling. The subcrestal groups achieved better levels of papillae formation when compared with the crestal groups, with a significant difference between the 3 SCL and 3 CL groups (P = .026). Radiographically, the crestal bone preservation was also better in the subcrestal groups, with statistically significant differences between the 2SCL and 2CL groups (P = .002) and between the 3SCL and 3CL groups (P = .008). With the present conditions, it could be concluded that subcrestal implant placement had a positive impact on papilla formation and crestal bone preservation, which could favor the esthetic of anterior regions. However, the IDs of 2 and 3 mm did not show significantly different results.
Flapless immediate implant surgery has been proposed as a means of reducing the surgical trauma to soft tissue and maintaining natural gingival anatomy. The aesthetic outcome in such cases may, however, be jeopardized when localized horizontal and vertical deficiencies occur. In order to correct such deficiencies, a novel flap design was developed that protected the soft tissue that had the most significant impact on the patient's appearance. This aesthetic buccal flap (ABF) was created coronally so that the supraosseous soft tissue remained undisturbed and allowed the use of guided bone regeneration techniques to correct apical dehiscences. The likelihood of obtaining an optimal aesthetic result was, therefore, enhanced.
Aesthetic restoration of single anterior teeth is one of the most difficult procedures to execute. This article discusses patient selection criteria, implant position and its relationship to the aesthetic outcome. The importance of soft tissue management in all phases of surgical and restorative phases is emphasized. Guidelines are given for the successful delivery of this service for the patient that will preserve adjacent teeth and fulfill functional and aesthetic needs.
Prosthetic planning is critical to the success of the diagnostic phase of implant therapy and is used to establish fixture numbers, position and the optimal occlusal scheme, based on the design of the definitive prosthesis. The prosthetic needs of the patient, anticipated functional and parafunctional forces, restoration fabrication and serviceability are all considered. A clear picture of the intended rehabilitation is provided to the surgical team and expedites the consultation between implant team members. Comprehensive diagnostic planning using mounted diagnostic casts and diagnostic wax-ups will provide definite parameters for fixture number, position and alignment, and permit the fabrication of radiographic and surgical templates as the treatment sequence progresses. Patients need to be informed of the time and expense involved in the diagnostic phase of implant therapy prior to the initiation of the planning process. The practitioner conducting the selection and planning phase is entitled and should expect financial remuneration commensurate with the time and effort required to achieve the objectives of this phase of implant therapy. The Planning Process Using mounted diagnostic casts and diagnostic wax-ups: 1. Establish fixture numbers and position; 2. Establish the optimal occlusal scheme; 3. Design the definitive prosthesis; 4. Fabricate a surgical template. Design Principles--Summary 1. The location and number of fixtures dictates the prosthetic design and influences restorative success. 2. A restoration must be designed to distribute forces to the fixtures without overloading the bone, and therefore be able to withstand anticipated functional and parafunctional loading. 3. Design for optimal function and esthetics with a regard for patient comfort and maintenance.
Many esthetic and functional considerations are reviewed for the partially edentulous implant candidate. With the availability of adjunctive grafting procedures, it is time for the implant team to change the traditional treatment planning approach that allows patient anatomy to dictate implant position and prosthesis design. Dimensions of the edentulous space and evaluation of occlusal relationships are discussed. Soft tissue ridge contour and creation of favorable cervical harmony are also reviewed. Functional demands unique to the partially edentulous patient are outlined in addition to the challenges of creating a prosthesis with natural cervical form and emergence profile.
With the increased awareness that optimal cosmetic dentistry can have on self-image, self-esteem, and self-confidence, patients are no longer just wanting to close gaps or whiten their smiles. Patients are becoming very conscious of the size, proportion, and position of their teeth as related to their smile and face. By incorporating the art and science of cosmetic dentistry into our enhancement therapy, we are able to create excellent results on a consistent basis. This review explores the impact that cosmetic dentistry can have on creating facial harmony. The discussion demonstrates the importance of a proper esthetic diagnosis as well as a thorough bioesthetic evaluation of each patient. This review also stresses the importance of an objective and subjective assessment and how a detailed evaluation of each patient can help create harmonious and natural smiles.
This study concluded that WDI had lower survival rates than their control (SDI). Cumulative survival rates were reported in the mandible five years following placement (94.7% for 3.5-mm implants, 84.8% for 4-mm implants, and 73% for 5-mm implants). Maxillary implant survival rates were 95.1%, 100%, and 86.3%, respectively. Based on these results, it was recommended by the authors to use wide implants cautiously and only when necessary. In addition to evaluating implant survival rates, it is important to assess the biologic responses to WDI. To date, no data that measured gingival recession around wide implants have been published. The present inves- tigation compared mean recession values of soft tissue
The aim of this study was to compare bone healing and crestal bone changes following immediate (Im) versus delayed (De) placement of titanium dental implants with acid-etched surfaces (Osseotite) in extraction sockets.
Forty-six patients were randomly allocated to the Im or De group (n = 23 per group) and received 1 implant at the incisor, canine, or premolar region of the maxilla or the mandible. The implants were placed an average of 10 days following tooth extraction in the Im group and approximately 3 months after extraction in the De group. The widths (parallel and perpendicular to the implant) and the depth of marginal bone defects around the implants were measured clinically just after placement and 3 months later at the abutment surgery. The crestal bone changes mesially and distally to the implants were evaluated radiographically by linear measurements.
The survival rates were 91% in the Im group and 96% in the De group. In the Im group, the mean reductions in parallel width, perpendicular width, and depth of the largest defect of each implant amounted to 48% (from 4.4 to 2.3 mm), 59% (from 2.2 to 0.9 mm), and 48% (from 6.9 to 3.6 mm), respectively. The corresponding mean reductions in the De group amounted to 39% (from 3.1 to 1.9 mm), 77% (from 1.3 to 0.3 mm), and 34% (from 4.4 to 2.9 mm). The reduction over time was statistically significant in both groups (P < .04). For both groups, a higher degree of bone healing was achieved in the infrabony defects (> 60% for depth) than in dehiscence-type defects (approximately 25%). Furthermore, 70% of the 3-wall infrabony defects with a parallel width of up to 5 mm, a depth of maximum 4 mm, and a perpendicular width of maximum 2 mm had a capacity of spontaneous healing within a period of 3 months.
New bone formation occurs in infrabony defects associated with immediately placed implants in extraction sockets.
Clinically, it is a tremendous challenge to create natural gingival esthetics after immediate or delayed implant placement. Hence, flapless immediate implant surgery has been proposed to overcome the shortfalls of these techniques. Nonetheless, one of the major limitations for this technique is its inability to correct localized horizontal/vertical deficiency, dehiscence, or fenestration without jeopardizing esthetic outcomes. Therefore, the aim of this paper was to present a new flap design, the esthetic buccal flap (EBF), aimed at overcoming this potential problem while maintaining the optimal esthetic appearance.
Five consecutively EBF-treated patients with simultaneous implant placement were included in this pilot case study. Clinical measurements were taken at the time of prosthesis insertion and 6 and 12 months after surgery. These included soft tissue height, papillae appearance, scar appearance, and mid-buccal probing depth.
Data obtained from this pilot case study showed that soft tissue height was preserved, and papillae appearance remained the same as at presurgery. No scar tissue was reported in any cases. Mid-buccal probing depths remained consistent throughout the study.
The results indicate that EBF, together with simultaneously guided bone augmentation, allows clinicians to correct apical buccal fenestration defects while maintaining the supraosseous soft tissue during flapless immediate implant surgery.
The objective of the present experiment was to study the morphogenesis of the mucosal attachment to implants made of c.p. titanium.
All mandibular premolars were extracted in 20 Labrador dogs. After a healing period of 3 months, four implants (ITI Dental Implant System) were placed in the right and left sides of the mandible. A non-submerged implant installation technique was used and the mucosal tissues were secured to the conical marginal portion of the implants with interrupted sutures. The sutures were removed after 2 weeks and a plaque control program including daily cleaning of the remaining teeth and the implants was initiated. The animals were sacrificed and biopsies were obtained at various intervals to provide healing periods extending from Day 0 (2 h) to 12 weeks. The mandibles were removed and placed in the fixative. The implant sites were dissected using a diamond saw and processed for histological analysis.
Large numbers of neutrophils infiltrated and degraded the coagulum that occupied the compartment between the mucosa and the implant during the initial phase of healing. At 2 weeks after surgery, fibroblasts were the dominating cell population in the connective tissue interface but at 4 weeks the density of fibroblasts had decreased. Furthermore, the first signs of epithelial proliferation were observed in specimens representing 1-2 weeks of healing and a mature barrier epithelium occurred after 6-8 weeks of healing. The collagen fibers of the mucosa were organized after 4-6 weeks of healing.
It is suggested that the soft-tissue attachment to implants placed using a non-submerged installation procedure is properly established after several weeks following surgery.
Single-rooted teeth deemed not restorable via conventional means may be candidates for implant placement at the time of tooth extraction. Immediate implant placements are believed to preserve soft and hard tissue form and contours, reduce the need for augmentation procedures, minimize surgical exposure of the patient, reduce treatment time and improve esthetic outcomes.
This retrospective review analyzed the esthetic outcomes of 42 non-adjacent single-unit implant restorations completed using an immediate implant surgical placement protocol.
The mean time in function was 18.9 months (range 6-50 months) and the majority of implants placed had a restorative platform diameter of 4.1 and 4.8 mm. A highly significant change in crown height due to marginal tissue recession of 0.9 +/- 0.78 mm (P=0.000) was recorded for all sites, with no difference seen between implant systems (P=0.837). Thin tissue biotype showed slightly greater recession than thick tissue biotype (1 +/- 0.9 vs. 0.7 +/- 0.57 mm, respectively); however, this difference was not statistically significant (P=0.187). Implants with a buccal shoulder position showed three times more recession than implants with a lingual shoulder position (1.8 +/- 0.83 vs. 0.6 +/- 0.55 mm, respectively) with the difference being highly statistically significant (P=0.000).
Immediate implant placement requires very careful case selection and high surgical skill levels if esthetic outcomes are to be achieved. Long-term prospective studies on tissue stability and esthetic outcomes are needed.