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p>In order to achieve esthetically optimal outcome with implant prosthesis, appropriate topography of emergence profile is crucial. The objective of this review is to explorer current evidence regarding this topic and relevant issue. Extent of interproximal papilla is determined not by the shape of emergence profile but the length between interproximal alveolar bone prominence and interproximal contact of crowns. There have been concerned that multiple times of disconnection and reconnection of abutment enhance peri-implant marginal bone loss, but it’s certified not to be a clinically significant level. Current digital workflow makes this step faster and easier, by copying emergence profile of contralateral tooth or extracted teeth.</p
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Review Articles
Scientific Dental Journal
Optimization of Emergence Profile of Implant Prosthesis:
A Literature Review
Minoru Sanda1,Daisuke Sato2,Kazuyoshi Baba1
1Department of Prosthodontics, School of Dentistry, Showa University Japan
2Department of Implant Dentistry, School of Dentistry, Showa University Japan
‘Corresponding Author:Kazuyoshi Baba, School of Dentistry, Showa University Japan.
Email:kazuyoshi@dent.showa-u.ac.jp
Received date:September 7, 2017.Accepted date:November 30,2017.Published date:January 25,2018.
Copyright:©2018 Sanda M, Sato D, Baba K. This is an open access article distributed under the terms of the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium provided the original author and sources
are credited.
ABSTRACT
In order to achieve esthetically optimal outcome with implant prosthesis, appropriate topography of emergence profile is
crucial.The objective of this review is to explorer current evidence regarding this topic and relevant issue.Extent of
interproximal papilla is determined not by the shape of emergence profile but the length between interproximal alveolar
bone prominence and interproximal contact of crowns.There have been concerned that multiple times of disconnection
and reconnection of abutment enhance peri-implant marginal bone loss, but it’s certified not to be aclinically significant
level.Current digital workflow makes this step faster and easier, by copying emergence profile of contralateral tooth or
extracted teeth.
Keywords : aesthetic outcome, dental implant, emergence profile, prosthodontic, provisional restoration
31
Background
An implant prosthesis is required not only to
survive, that is, remain stable inside patient’s mouth, but
also to be aesthetically pleasing, whereby the restoration
and the peri-implant tissue mimic the natural healthy
dentogingival complex.1According to the systematic
review and meta-analysis by Jung et al, survival of
implants supporting single crowns at 5years is up to
97.2% (95%CI:96.3–97.9%) and 95.2% (95%CI:91.8–
97.2%), respectively, at 10 years, whereas the cumulative
5-year aesthetic complication rate was 7.1% (95%CI:
3.6–13.6%).2In order to avoid compromised aesthetics,
the presence or absence of the papilla, level of
the mucosal margin,two-dimensional and three-
dimensional changes of the peri-implant tissues, as
well as fabrication of areconstruction that matches the
color,shape, and texture of the contralateral natural tooth
are important factors requiring consideration.3After
implant placement and uncovering surgery for abutment
connection, soft tissue around the transmucosal part
shows circular topography when observed from the
occlusal aspect, as shown in Fig.1,which is not in line
with the innate shape of the gingiva.4In order to modify
this soft tissue topography so that it resembles the
emergence profile of the soft tissue around anatural
tooth, it should be altered to an expanded shape as
shown in Fig. 2.5To accomplish this configuration,
emergence profile of the provisional restoration needs to
be modified by adding acrylic resins or grinding the
acrylic in astep-by-step manner.
SCIENTIFIC DENTAL JOURNAL 01 (2018) 31-37
Figure 1. Just after uncovering surgery, peri-implant mucosa shows a circular topography.
Figure 2. After emergence profile adjustment, peri-implant mucosa is shaped in harmony with surrounding structures.
32
Furze et al.conducted astudy that evaluated whether
tissue conditioning with provisional restoration has a
significant impact on objective aesthetic outcome.6Twenty
patients were randomly allocated two groups;the test
group received aprovisional restoration and the
emergence profile was altered, while the control group did
not receive aprovisional restoration before the final crown
was delivered.After one year, successful integration of the
implants was confirmed;the modified pink esthetic score
(modPES), which assesses the peri-implant soft tissue on
the basis of five variables (mesial and distal papilla,
curvature of the facial mucosa, level of the facial mucosa,
root convexity/soft tissue color, and texture at the facial
aspect of the implant site), and the white esthetic score
(WES), which evaluates the visible part of the implant
restoration itself with five parameters (general tooth form,
outline/volume of the crown, color, surface texture,
translucency, and characterization by ascore of 0, 1, 2),
were evaluated.7,8 The combined value of each parameter
for the test group (16.7 ±2.06)was significantly higher
than that for the control group (10.5 ±3.31,p<0.05),
suggesting that soft tissue conditioning by provisional
restorations would be highly recommended from the point
of view of aesthetics.
However, there are several concerns regarding the
methods used to achieve excellent pink and white
esthetics.First, since the favorable convexity/concavity
has not been discussed on the basis of evidence very well,
most of the clinicians or technicians design the outline of
the emergence profile empirically.In addition, it has been
demonstrated that multiple disconnections of the
provisional restoration would undermine the peri-implant
soft tissue attachment;this might lead to marginal bone
loss around the implant, which has the potential to
deteriorate esthetic outcomes.Regarding proximal papilla
formation, apart from the provisional emergence profile
considerable evidence suggests that the distance from
prominence of the bone to the proximal contact plays a
crucial role;thus, the clinician should have knowledge
about the prerequisite for papilla formation.
For all these reasons, this narrative review discusses
the basic techniques for adjustments of provisional
restorations in relation with biological considerations,
such as papilla formation, as well as the effect of abutment
disconnection on the surrounding tissue and concavity of
transmucosal part,in order to achieve aesthetically
successful outcomes.Alternative techniques by involving
specific components or digital technologies are introduced
as well
Technical Perspective:Adjusting
Emergence Profile
The emergence profile is contoured according to the
following principle steps:9
Facial emergence:Starting from the implant shoulder,
with aslightly flat/concave profile, towards the height of
convexity at the point where the mucosal margin will be
established
Interproximal emergence:Starting from the implant
shoulder, with astraight emergence, towards aslight
convexity just apical to the contact area, providing support
for the interproximal tissue.
Palatal emergence:Starting from the implant shoulder,
with astraight to slightly convex emergence, towards the
mucosal margin, focusing on matching the palatal
contours of the adjacent teeth so that there is asmooth
transition between the two.
In order to achieve the emergence profile described
by the steps above, Wittneben et al.introduced atechnique
for conditioning the soft tissue around the implant
prosthesis and the emergence profile, which is the so
called “dynamic compression technique”.10 This technique
at involves pushing and compressing the mesial and distal
proximal peri-implant papillae by means of an over
contoured provisional restoration.Selective pressure is
applied by adding the material on selected sites, thus
causing ischemic changes in the peri-implant mucosa.
After two weeks, for modifying the shape of the soft
tissue, some amount of material is removed from around
the interproximal and cervical areas.This creates space for
the soft tissue and allows the papillae to shift into the
prepared space.
Convexity at The Transmucosal Part
The latest ITI consensus statement recommends that
the provisional restoration should respect the emergence
profile of the restoration apical to the planned mucosal
margin (highest convexity) to allow for maximum tissue
volume.11
33
SCIENTIFIC DENTAL JOURNAL 01 (2018) 31-37
Several studies have been conducted to identify the
correlation between the convexity/concavity of
emergence profile and the peri-implant tissue reaction.
Huh et al.compared three types of transmucosal profiles
for different implant surfaces, straight-machined
implants
(SM), concave-machined implants (CM), or concave-
roughened implants (CR), in beagle dogs.In radiographic
and histometric evaluation, the least bone resorption was
observed for CM implants, and SM implants were
associated with the greatest bone resorption (p<0.05).
Further, histometric analysis showed that the highest
connective tissue attachment was observed around CM
implants.12
From the aesthetic point of view, astraight slope of
the emergence profile can cause apical migration of the
free gingival margin.13 Therefore, in order to obtain
symmetric mucosal margin around implant, concavity of
the root form would be suitable for the labial aspect.
However, in astudy by Sancho-Puchades et al.,
which compared two abutment designs (concave or
convex) in terms of cement remnants after cementation of
prosthesis on individualized abutments and
cement
removal,14 the concave abutments presented significantly
more cement remnants than CV abutments in the entire
abutment area.This study implies that an
emergence
profile with excessive concavity makes it difficult to
eliminate excess cement;this remaining cement may lead
to adverse effects, such as peri-implant disease.
Considering the above findings, it may be concluded that
the transmucosal part, especially the labial aspect, should
keep convexity insofar as it not too convex to cause
functional problems.
Relationship With Proximal Bone
Height, Papilla Filling, and Contact
Point
It is well known that distance from the proximal
contact point to the crest of the bone has significant effect
on the interproximal papilla adjacent to the implant
restoration.Choquet et al.conducted aclinical and
radiographic retrospective evaluation of the papilla level
around single dental implants, and their adjacent tooth
was performed in the anterior maxilla in 26 patients
restored with 27 implants.15 When the measurement from
the contact point to the crest of the bone was 5mm or
less, the papilla was present almost 100%of the time.
When the distance was 6mm, the papilla was present
50%of the time or less.Degidi et al.and Lops et al.
evaluated the incidence of inter-proximal papilla between
atooth and an adjacent immediate implant placed into a
fresh extraction socket in 1-year prospective study.16
Among forty-six patients with atotal of 46 teeth
scheduled for tooth extraction and immediate implant
placement, when inter-implanttooth distance was 3–4
mm, and the distance from the base of the contact point to
the inter-dental bone was 3–5 mm, the inter-proximal
papilla was significantly present (p<0.05). Therefore,
clinicians should predict the prospects of papilla filling
according to the patient’s clinical situation and discuss
the expected final result with patients in advance.
Effect of Abutment Disconnection
and Reconnection
Along with the adjustment of emergence profile, the
clinician needs to remove and connect the provisional
restoration several times.Some experiments suggest that
disconnection or reconnection of the provisional
restoration or abutment can jeopardize the integrity of the
peri-implant tissue.
Abrahamsson et al.in their experiment on adog
studied this effect on the marginal peri-implant tissues
following repeated abutment removal and subsequent
reconnection.17 They installed Branemark implants,
which has an external platform-matching connection, to
the beagle dog’s bilateral mandibular premolar area.On
one side, the abutment was disconnected and reconnected
5times during the 6months of observation period,
whereas the other abutment was remained as it was.
According to the histomorphometric analysis, the
reconnected group showed more apical connective tissue
attachment and marginal bone resorption compared to the
intact group.
Rodríguez et al.compared platform-switched (PS)
and platform-matched (PM) implant with regard to the
effect on horizontal and vertical bone resorption
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SCIENTIFIC DENTAL JOURNAL 01 (2018) 31-37
accompanied with 1-4 times of abutment
dis/reconnection.18 Rodríguez et al.compared platform-
switched and platform-matched implant with regard to
the effect on horizontal (H) and vertical (V) bone
resorption with abutment dis/reconnection performed 1-4
times.18 For simplicity, we have named the groups as
follows:PM-1, platform-matched (single abutment
disconnection);PM-4, platform-matched (abutment
disconnection performed 4times);PS-1, platform-
switched (single abutment disconnection);and PS-4,
platform-switched (abutment disconnection performed 4
times).The average horizontal and vertical bone
resorption were as follows:PM-1 (H: 0.31, V: 0.72), PM-
4(H: 0.98 mm, V: 1.09 mm), PS-1 (H: 0 mm, V: 0.03
mm), and PS-4 (H: 0.37 mm, V: 0.41 mm).
Comparing
PM-1 with PM-4, there were no significant differences.
Paris of PM-1/PS-1, PM-4/PS-4, and PS-1/PS-4, the
extent of bone resorption was significantly different (p
<0.05). However, the difference in bone
resorption
between PS-1 and PS-4 seems clinically insignificant.
Esposito et al.compared arepeated
disconnection
group and ano disconnection group in amulticenter
randomized controlled trial.19 Patients requiring one
single crown or one fixed partial prosthesis supported
by
amaximum of three implants were treated in four centers,
and each patient was followed up for 1year after initial
loading.They concluded that one year after loading,
although repeated dis/reconnection of the abutment
significantly increased bone loss of 0.16 mm, this
difference is clinically negligible;thus, clinicians can use
the procedure they prefer.Considering the results of these
studies, the literature generally suggests that the shape of
the connection has amore significant effect on peri-
implant tissue than the number of times dis/reconnection
of the abutments is performed.
Alternative Techniques for Emergence
Profile
Since the stepwise conditioning procedure requires
multiple sessions and prolonged chair-time, several
methods have been investigated for achieving optimal
emergence profile without involving atime-consuming
procedure.
Becker et al.introduced atechnique utilizing a
prefabricated emergence profile.20 Neoss Implant System
(Neoss Ltd, Harrogate, North Yorkshire, UK) employs a
standard root measurement of six maxillary anterior teeth
at the CEJ and duplicated in PEEK material (polyether
ether ketone), for acustomized healing abutment.This
material is flexible and fits according to the patient’s
specific anatomy.After implant placement surgery or
uncovering surgery, the abutment is seated and the height
and shape are adjusted.Thus, after the healing period, the
optimal emergence profile is already shaped according to
the customized abutment.This reduces chair-time and the
number of sessions required for stepwise conditioning of
the provisional restoration.
Joda et al.introduced atechnique to fabricate
individualized CAD/CAM healing abutment prior to
uncovering surgery.21 According to their method, the
shape of the emergence profile of the contralateral tooth
is copied from the DICOM data.After implant placement,
digital impression with an intra-oral optical scan (IOS) is
performed to identify the final three-dimensional position
of the implant.Digitally flipped (mirrored) DICOM data
of contra-lateral tooth and the STL-file of the IOS are
superimposed to fabricate an individualized healing
abutment using CAD/CAM from PMMA-based material,
which is delivered to the patient at the uncovering
surgery.
Vafiadis et al.introduced adigital fabricating method
for immediate implant placement and immediate loading
protocol.22 Their method involves copying the shape of
the tooth to be extracted and its emergence profile using
the preoperative CBCT image.The data obtained is used
to fabricate acrown-root matrix (resin shell) by
CAD/CAM.The matrix is connected with the temporary
abutment intra-orally and used as an immediate
provisional restoration.
However, in order to administer these protocols, the
clinician must predict the tissue volume changes
precisely;this requires more advanced knowledge and
experience compared to the straightforward method.23
35
SCIENTIFIC DENTAL JOURNAL 01 (2018) 31-37
Conclusion
Aclinician is responsible for determining the
treatment needs and establishing aesthetically and
functionally optimal implant prosthesis by
conditioning
of the emergence profile at the provisional state.
According to the currently available evidence, labial
emergence should have some concavity to
accommodate sufficient peri-implant mucosa, while the
palatal emergence may be convex in order to align
harmoniously with neighboring teeth.Proximal profile
should be controlled with regard to the height of the
proximal bone because it has acritical role in papilla
formation. Although it has been suggested that
repeated disconnection of the abutments should be
avoided in view of peri-implant soft tissue
preservation,17 literature suggests its effects in terms of
causing peri-implantitis are limited.Within the
limitations of this narrative review, it is evident that
comprehension of aesthetics, peri-implant tissue
biology, and prosthetic procedure is crucial.
References
1. Papaspyridakos P, Chen C-J, Singh M, Weber H-P,
Gallucci GO.Success criteria in implant dentistry:
A
systematic review. J Dent Res.2015:242–8. DOI:
10.1177/0022034511431252
2. Jung RE, Zembic A, Pjetursson BE, Zwahlen M,
Thoma
DS.Systematic review of the survival rate and the
incidence of biological, technical, and aesthetic
complications of single crowns on implants reported in
longitudinal studies with amean follow-up of 5years.
Clin Oral Implants Res.2012;23:2–21.DOI:
10.1111/j.1600-0501.2012.02547.x
3. Cosyn J, Thoma DS, Hämmerle CHF, De Bruyn H.
Esthetic assessments in implant dentistry:objective and
subjective criteria for clinicians and patients.Periodontol
2000.2017;73:193202.
4. Gallucci GO, Belser DMDUC, Dent PM.Modeling and
characterization of the cej for optimization of esthetic
implant design.Int JPeriodontics Restorative Dent.
2004;24:1929.
5. Priest G. Developing optimal tissue profiles with implant-
level provisional restorations.Dent Today.2005;
24(11):96,98,100.
6. Furze D, Byrne A, Alam S, Wittneben JG.Esthetic
outcome of implant supported crowns with and without
peri-implant conditioning using provisional fixed
prosthesis: A randomized controlled clinical trial.Clin
Implant Dent Relat Res.2016;24:115362.DOI:
10.1111/cid.12416
7. Belser UC, Grütter L, Vailati F, Bornstein MM, Weber H-
P, Buser D. Outcome evaluation of early placed maxillary
anterior single-tooth implants using objective esthetic
criteria: A cross-sectional, retrospective study in 45
patients with a 2-to 4-year follow-up using pink and white
esthetic scores. J Periodontol.2009;80:14051.DOI:
10.1902/jop.2009.080435
8. Fürhauser R, Florescu D, Benesch T, Haas R, Mailath G,
Watzek G. Evaluation of soft tissue around single-tooth
implant crowns:the pink esthetic score.Clin Oral
Implants Res 2005;16:63944.DOI:10.1111/j.1600-
0501.2005.01193.x
9. Chappuis V, Martin W. Implant therapy in the esthetic
zone – current treatment modalities and materials for
single-tooth replacements. In:Barter S, Chen S, Wismeijer
D, editors.ITI Treatment Guide.Volume 10.Basel:
Quintessence Publishing Company;2017.
10. Wittneben J-G, Buser D, Belser UC, Brägger U. Peri-
implant soft tissue conditioning with provisional
restorations in the esthetic zone:the dynamic compression
technique. Int J Periodontics Restorative Dent.
2013;33:44755.DOI:10.11607/prd.1268.
11. Morton D, Chen ST, Martin WC, Levine RA, Buser D. 5th
ITI consensus statements and recommended clinical
procedures regarding optimizing esthetic outcomes in
implant dentistry. Int J Oral Maxillofac Implants.2014;29
Suppl:216-20.DOI:10.11607/jomi.2013.g3.
12. Huh J-B, Rheu G, Kim Y, Jeong C, Lee J, Shin S-W.
Influence of implant trans mucosal design on early peri-
implant tissue responses in beagle dogs.Clin Oral
Implants Res.2014;25:962–8. DOI:10.1111/clr.12179
13. Kinsel RP, Pope BI, Capoferri D. A review of the positive
influence of crown contours on soft-tissue esthetics.
Comped Contin Educ Dent.2015;36(5):352–7.
14. Sancho-Puchades M, Crameri D, Őzcan M, Sailer I, Jung
RE, Hämmerle CHF, et al.The influence of the emergence
profile on the amount of undetected cement excess after
delivery of cement-retained implant reconstructions.Clin
Oral Implants Res.2017;28(12):1515-22.DOI:
10.1111/clr.13020
15. Choquet V, Hermans M, Adriaenssens P, Daelemans P,
Tarnow DP, Malevez C. Clinical and radiographic
evaluation of the papilla level adjacent to single-tooth
36
SCIENTIFIC DENTAL JOURNAL 01 (2018) 31-37
dental implants.aretrospective study in the maxillary
anterior region. J Periodontol.2001;72(10):1364–71.DOI:
10.1902/jop.2001.72.10.1364
16. Lops D, Chiapasco M, Rossi A, Bressan E, Romeo E.
Incidence of inter-proximal papilla between atooth and an
adjacent immediate implant placed into afresh extraction
socket: 1-year prospective study.Clin Oral Implants Res.
2008;19(11):113540.DOI:10.1111/j.1600-
0501.2008.01580.x
17. Abrahamsson I, Berglundh T, Lindhe J. The mucosal
barrier following abutment dis/reconnection.
anexperimental study in dogs. J Clin Periodontol.
1997;24:56872.
18. Rodríguez X, Vela X, Méndez V, Segalà M, Calvo-
Guirado
JL, Tarnow DP.The effect of abutment dis/reconnections
on peri-implant bone resorption: a radiologic study of
platform-switched and non-platform-switched implants
placed in animals.Clin Oral Implants Res.
2013
Mar;24(3):30511.DOI:10.1111/j.1600-
0501.2011.02317.x
19. Esposito M, Bressan E, Grusovin MG, D'Avenia F,
Neumann K, Sbricoli L, et al.Do repeated changes of
abutments have any influence on the stability of peri-
implant tissues? one-year post-loading results from amulti
centre randomised controlled trial.Eur JOral Implantol.
2017;10:5772.
20. Becker W, Doerr J, Becker BE. A novel method for
creating an optimal emergence profile adjacent to dental
implants. J Esthet Restor Dent.2012;24(6):395400.DOI:
10.1111/j.1708-8240.2012.00525.x
21. Joda T, Ferrari M, Brägger U. A digital approach for one-
step formation of the supra-implant emergence profile with
an individualized CAD/CAM healing abutment. J
Prosthodont Res.2016;60(3):220–3. DOI:
10.1016/j.jpor.2016.01.005
22. Vafiadis D, Goldstein G, Garber D, Lambrakos A.
Immediate implant placement of asingle central incisor
using acad /cam crown-root form technique:provisional
to final restoration. J Esthet Restor Dent.2017;29(1):13-21.
DOI:10.1111/jerd.12265
23. Shiota M. Design guide of implant superstructures in the
esthetic zone.Ann Jpn Prosthodont Soc.2012;4(1):3–9.
DOI:10.2186/ajps.4.3
37
SCIENTIFIC DENTAL JOURNAL 01 (2018) 31-37
Article
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A estética com implantes em regiões anteriores atualmente está muito associada ao uso de implantes com conexão cone Morse e plataforma reduzida para diminuir a saucerização, fenômeno comum em implantes de plataforma hexagonal externa. Este artigo relata um caso clínico onde foram instalados 4 implantes HE com o objetivo de criar papilas pela formação da remodelação óssea esperada nesse tipo de plataforma, com acompanhamento de 7 anos comprovando estabilidade dos tecidos peri-implantares. Um bom posicionamento tridimensional dos implantes, aliado à experiência do profissional, ainda parece ser mais importante que o sistema de implantes escolhido.
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Purpose: To evaluate the influence of at least three abutment changes in conventionally loaded implants against placement of a definitive abutment in immediately non-occlusal loaded implants on hard and soft tissue changes. Materials and methods: Eighty patients requiring one single crown or one fixed partial prosthesis supported by a maximum of three implants were randomised, after implants were placed with more than 35 Ncm, according to a parallel group design to receive definitive abutments which were loaded immediately (definitive abutment or immediate loading group) or transmucosal abutments. These were delayed loaded after 3 months and were removed at least three times: 1) at impression taking (3 months after implant placement); 2) when checking the zirconium core on titanium abutments at single crowns or the fitting the metal structure at prostheses supported by multiple implants; 3) at delivery of the definitive prostheses (repeated disconnection or conventional loading group). Patients were treated in four centres and each patient contributed to the study with only one prosthesis followed for 1 year after initial loading. Outcome measures were: prosthesis failures, implant failures, complications, pink esthetic score (PES), buccal recessions, patient satisfaction, peri-implant marginal bone level changes and height of the keratinised mucosa. Results: Forty patients were randomly allocated to each group according to a parallel group design. Two patients dropped out from the definitive abutment group but no implant failed. Four provisional and one definitive single crowns had to be remade (due of misfitting) and one definitive crown (due to ceramic fracture) in the repeated disconnection group versus one provisional prosthesis of the immediate loading group due to frequent debondings (difference = 12%; CI95%: 0%, 25%; P = 0.109). Eight patients were affected by complications: four patients from each group (difference = 1%; CI95%: -13%, 14%; P = 1). PES scores assessed at 1 year post-loading were 11.4 (1.5) mm for the definitive abutment group and 11.0 (2.0) mm for the repeated abutment changes group (difference = 0.4; CI95%: -0.4, 1.2; P = 0.289). Buccal recessions at 1 year post-loading amounted to 0.07 (0.35) mm for the definitive abutment group and 0.12 (0.65) mm for the repeated abutment changes group (actually it was a soft tissue gain; difference = 0.05 CI 95%: -0.19, 0.29; P = 0.659). All patients declared to be very satisfied or satisfied with the function and aesthetics of the prostheses and would undergo the same procedure again. Mean peri-implant marginal bone loss at 1 year after loading was 0.06 (0.12) mm for the definitive abutment group and 0.23 (0.49) mm for the repeated abutment changes group (difference = -0.16; CI95%: -0.33,-0.00; P = 0.046). The height of the keratinised mucosa at 1 year post-loading was 2.8 (1.5) mm for the definitive abutment group and 2.8 (1.7) mm for the repeated abutment changes group (difference = -0.0; CI 95%: -0.8, 0.7); P = 0.966. Up to 1 year after initial loading, there were no statistically significant differences between the two procedures, with the exception of 0.16 mm more marginal bone loss at implants subjected to three abutment removals. Conclusions: One-year post-loading data showed that repeated abutment changes significantly increased bone loss of 0.16, but this difference cannot be considered clinically relevant, therefore clinicians can use the procedure they find more convenient for their specific patient. In addition, immediately non-occlusally loaded dental implants are a viable alternative to conventional loading. Conflict-of-interest statement: This trial was partially funded by Dentsply Sirona Implants, the manufacturer of the implants and other products evaluated in this investigation. However, data belonged to the authors and by no means did the manufacturer interfere with the conduct of the trial or the publication of the results with exception of rejecting the proposal of changing the protocol, after the trial was started, allowing the use of indexed abutments.
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Background: Achieving an optimal esthetic result using dental implants is challenging. Fixed implant-supported provisional crowns are often used to customize the emergence profile and to individualize the surrounding peri-implant soft tissue. Purpose: The objective of this study is to evaluate whether the use of a provisional implant-supported crown leads to an esthetic benefit on implants that are placed in the esthetic zone. The null hypothesis is that there is no-difference between the two study groups. Material and methods: Twenty single implants (Bone Level, Straumann AG, Basel, Switzerland) were inserted in consecutive patients. After reopening, a randomization process assigned them to either cohort group 1: a provisional phase with soft tissue conditioning using the "dynamic compression technique" or cohort group 2: without a provisional. Implants were finally restored with an all-ceramic crown. Follow-up examinations were performed at 3 and 12 months including implant success and survival, clinical, and radiographic parameters. Results: After 1 year all implants successfully integrated, mean values of combined modPES and WES were 16.7 for group 1 and 10.5 for Group 2. This was statistically significant. Mean bone loss after 1 year was -0.09 and -0.08 for groups 1 and 2, respectively, without being statistically significant. Conclusion: A provisional phase with soft tissue conditioning does improve the final esthetic result.
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Purpose: This Technical Procedure describes a novel workflow for a one-step formation of the supra-implant emergence profile in the esthetic zone - the 'Digitally Flip Technique' (DFT). Methods: After implant placement, a post-operative intra-oral optical scan (IOS) was performed to capture the final three-dimensional implant position. Based on the superimposition of the digitally slice-wise DICOM-segmentation of the digitally flipped (mirrored) contra-lateral tooth and the STL-file of the IOS, an individualized healing abutment was CAD/CAM-fabricated out of PMMA-based restoration material in a fully digital workflow and seated at the stage of reopening surgery. One single treatment step was necessary for final modulation of the supra-implant mucosa architecture in order to mimic the morphological emergence profile of the contra-lateral tooth within a short-span time frame of four days after insertion of the individualized healing abutment. Conclusions: The implant crown emergence profile could be shaped immediately after reopening according to the three-dimensional radiographic contour of the digitally flipped contra-lateral tooth. Estimating the emergence profile or time-consuming step-by-step conditioning of the mucosa through an additionally produced implant provisional was therefore avoided.
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Successful crown restorations duplicate the natural tooth in hue, chroma, value, maverick colors, and surface texture. Equally important is the visual harmony of the facial and proximal soft-tissue contours, which requires the collaborative skills of the restorative dentist, periodontist, and dental technician. The treatment team must understand the biologic structures adjacent to natural dentition and dental implants. This report describes the potential for specifically designed restorative contours to dictate the optimal gingival profile for tooth-supported and implant-supported crowns. Showing several cases, the article explains how esthetic soft-tissue contours enhance the definitive crown restoration, highlights the importance of clinical evaluation of adjacent biologic structures, and discusses keys to predicting when the proximal papilla has the potential to return to a favorable height and shape.
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Objective: To test whether or not one of two emergence profile designs (concave or convex) is superior to the other in terms of remaining cement following cementation of reconstructions on individualized abutments and careful cement removal. Materials and methods: A central incisor with a single implant-supported reconstruction was selected as a model. Six types of abutments (n = 10) with two different emergence profile designs (concave (CC) and convex (CV)) and three crown-abutment margin depths (epimucosal, 1.5 mm submucosal, 3 mm submucosal) were fabricated through a CAD/CAM procedure. Lithium disilicate reinforced ceramic crowns were cemented with chemically polymerized resin cement. A blinded investigator attempted to remove all cement excess. Thereafter, the entire reconstruction was unscrewed and analyzed for the overall amount and the depth of cement excess. Kruskal-Wallis and Mann-Whitney tests were used to investigate differences between groups. When more than two groups were compared between each other, a Bonferroni correction of the P value was performed. Results: Concave abutments presented significantly more cement remnants than CV abutments when the entire abutment area of the epimucosal margin groups was evaluated (CC0 mm: mean 2.31 mm(2) (SD 0.99) vs. CV0 mm: mean 1.57 mm(2) (SD 0.55); P = 0.043). A statistically significant increase in remnants was detected when the crown-abutment margin was located more submucosally for every abutment studied (0 mm vs. 1.5 mm: P < 0.000, 0 mm vs 3 mm: P < 0.000, 1.5 mm vs. 3 mm: P < 0.000). The buccal quadrant demonstrated the least, whereas the oral and interdental quadrants showed the greatest amount of cement excess. Conclusions: Concave emergence profile abutments and deep crown-abutment margin positions increased the risk of cement excess. Oral and interdental areas are more prone to cement remnants than other surface areas.
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In recent years the scientific community has shown a clear interest in the esthetic outcome of implant treatment. The present paper provides an overview of the esthetic ratings that have been used in implant dentistry. A distinction can be made between objective evaluations by clinicians and subjective evaluations by patients. The former mainly include: midfacial and interproximal soft-tissue levels; two-dimensional/three-dimensional soft-tissue alterations; assessment of the color match between the natural dentition, on the one hand, and the peri-implant tissues and the reconstruction, on the other hand; and ordinal indices, such as the pink and white esthetic score. Patient's needs and judgment may differ from objective indicators of implant success and esthetics. As a result, assessing treatment on the basis of patient-reported outcomes measures should be considered important. Validated questionnaires have been used that mainly assess the impact of oral health on the overall well-being of individuals. The esthetic judgment of patients is usually based on nonstandardized questions with varying scoring methods, including visual analog scales, Likert and other category scales and open questions. The heterogeneity in scoring systems between studies may compromise proper comparison of objective and subjective esthetic outcomes between studies and therapeutic concepts.
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Objective Preserving soft and hard tissues after extraction and implant placement is crucial for anterior esthetics. This technique will show how the information gathered from a cone‐beam computed tomography (CBCT) scan of the maxillary left central incisor and an intra‐oral digital impression can be merged to fabricate a CAD/CAM crown‐root matrix to be used as an immediate provisional restoration that mimics the natural anatomy. Clinical Considerations Due to trauma, a left central incisor appeared to be fractured and was scheduled for extraction and implant placement. The crown‐root configuration captured by the CBCT scan was merged with the digital files from an intra‐oral digital impression. A CAD/CAM crown‐root matrix was fabricated. Because the matrix shell was fabricated with the exact anatomy of the natural tooth, it replicated the position and three dimensional anatomy of the soft and hard tissue. It was connected to the implant with a customized provisional abutment. A digital impression of a coded healing abutment was made to fabricate the final implant abutment and final restoration. Throughout the treatment time and 36 months after completion, the thickness of tissue, emergence profile, and adjacent papilla was analyzed by clinical evaluation and photography and seemed to be maintained. Conclusion The use of a pre‐operative intra‐oral digital scan of the clinical crown‐root architecture and the CBCT scan of the bone/root anatomy, can be used together to fabricate a CAD/CAM crown‐root form provisional matrix. This digital design helps in the preservation of the 3D tissue topography, as well as the final restoration. Clinical Significance The preservation of soft and hard tissue after extraction and implant placement has always been paramount for ideal anterior implant esthetics. Using the information from digital files from CBCT scans and intra‐oral scans may help the clinician identify critical anatomical features that can be replicated in the provisional and final CAD/CAM restoration. (J Esthet Restor Dent 29:13–21, 2017)
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抄録 インプラント補綴は支台の周囲組織の形態や支台の配置といった従来の補綴では不可侵だった領域に関与している.また,コンピュータテクノロジーの進歩はバーチャル空間での診療設計とその口腔内リアリティ空間での実現を可能にした.したがってインプラント上部構造を設計するにあたって補綴医は従来と全く異なるスタンスをとることとなった.またそれに伴って,従来的な意味での補綴医の担当領域は少なからず縮小している. この小論では審美領域におけるインプラントに関与する補綴医のスタンスを,個々のインプラント,口元,顔貌という三つの対象領域に焦点を当てて解説し,そこから導かれる指針の紹介を試みる.