ESTHETIC CONSIDERATIONS ESTHETIC CONSIDERATIONS IN DENTAL IMPLANT IN DENTAL IMPLANT

Under the guidance of: Dr. Arun Kumar Gupta(Prof. &Head) Dr. Jyoti Paliwal(Prof.) Dr. Sumit Bhansali(Asso.Prof.)

Presented by: Dr. Ravinder(PG-2nd yrs)

CONTENTSCONTENTS

DEFINITIONDEFINITION INTRODUCTIONINTRODUCTION ESTHETIC CONSIDRATIONESTHETIC CONSIDRATION TREATMENT PLANINGTREATMENT PLANING

Esthetics from the Greek Esthetics from the Greek aisthesis (perception)aisthesis (perception)

Is the theory of experienced – Is the theory of experienced – based judgement by which an based judgement by which an optical stimulus is not simply optical stimulus is not simply perceived as an object of perceived as an object of conciousness but evaluated as conciousness but evaluated as pleasant or un pleasant ,beautiful pleasant or un pleasant ,beautiful or ugly.or ugly.

It is the philosophy ,psychology and sociology of It is the philosophy ,psychology and sociology of the beautiful in art and nature.the beautiful in art and nature.

In DentistryIn Dentistry, , EstheticsEsthetics can be defined as the can be defined as the theory and philosophy that deals with beauty and theory and philosophy that deals with beauty and beautiful especially with respect to the appearance beautiful especially with respect to the appearance of a dental restoration as achieved through its of a dental restoration as achieved through its form and or colour.form and or colour.

Introduction Introduction

To achieve a successful esthetic result To achieve a successful esthetic result and good patient satisfaction, implant and good patient satisfaction, implant placement in the esthetic zone placement in the esthetic zone demands a thorough understanding ofdemands a thorough understanding of

AnatomicAnatomic BiologicBiologic SurgicalSurgical

Prosthetic principlesProsthetic principles. .

Guidelines are presented for ideal Guidelines are presented for ideal implant positioning and for a variety of implant positioning and for a variety of therapeutic modalities that can be therapeutic modalities that can be implemented for addressing different implemented for addressing different clinical situations involving replacement clinical situations involving replacement of missing teeth in the esthetic zoneof missing teeth in the esthetic zone. .

DIAGNOSIS AND TREATMENTDIAGNOSIS AND TREATMENT

To achieve a successful esthetic result, implant To achieve a successful esthetic result, implant placement in the esthetic zone demands placement in the esthetic zone demands thorough pre operative diagnosis and treatment thorough pre operative diagnosis and treatment planning combined with excellent clinical skills.planning combined with excellent clinical skills.

Preoperative assessment of the patient’s Preoperative assessment of the patient’s expectations is also of paramount importance.expectations is also of paramount importance.

If the patient is found to have unrealistic If the patient is found to have unrealistic expectations, a careful explanation might be expectations, a careful explanation might be necessary to clarify what the patient should necessary to clarify what the patient should expect. expect.

Data collection Data collection The data base must include the patients chief The data base must include the patients chief

complaint, comprehensive medical history, complaint, comprehensive medical history, dental history, results of extra oral and intra oral dental history, results of extra oral and intra oral clinical examinations, radiographic examination clinical examinations, radiographic examination results, documentation of patient expectations, results, documentation of patient expectations, and an assessment of risk factors for implant and an assessment of risk factors for implant failure (esthetic or functional). failure (esthetic or functional).

For ideal implant placement and optimal esthetic For ideal implant placement and optimal esthetic restorations, a comprehensive evaluation of the restorations, a comprehensive evaluation of the edentulous site must be performed. Facial, dental, edentulous site must be performed. Facial, dental, and periodontal status must be evaluated. and periodontal status must be evaluated.

A facial evaluation provides general esthetic A facial evaluation provides general esthetic parameters, such as orientation of occlusal plane, parameters, such as orientation of occlusal plane, lip support, symmetry, gingival scaffold, and smile lip support, symmetry, gingival scaffold, and smile lineline

Esthetic ConsiderationsEsthetic ConsiderationsThe Course of the alveolar ridge The Course of the alveolar ridge The course and state of the health of The course and state of the health of

mucosamucosaThe crown marginThe crown marginThe crown formThe crown formThe inter dental spacesThe inter dental spacesLip supportLip supportSmile lineSmile line

Alveolar ridgeAlveolar ridge Adequate widthAdequate width well rounded.well rounded.

Status of mucosaStatus of mucosa Loss of architecture Loss of architecture

of gingiva and its papillaof gingiva and its papilla

due to loss of tooth-due to loss of tooth-

Diminishes appearance.Diminishes appearance.

Gingival recession and Gingival recession and biotypesbiotypes

The gingival biotype should be assessed because The gingival biotype should be assessed because

such an assessment will partly determine the risk for such an assessment will partly determine the risk for post surgical recession. post surgical recession.

A thin, highly scalloped gingival biotype is much less A thin, highly scalloped gingival biotype is much less resistant to trauma from surgical or restorative resistant to trauma from surgical or restorative procedures and, consequently, is more prone to procedures and, consequently, is more prone to recession in comparison with a thick, flat gingival recession in comparison with a thick, flat gingival biotype. biotype.

A thin gingival biotype dictates placement of the A thin gingival biotype dictates placement of the

implant in a slightly more palatal position to implant in a slightly more palatal position to

reduce the chance of recession and prevent a reduce the chance of recession and prevent a

titanium “shadow” from showing through the thin titanium “shadow” from showing through the thin

gingival tissue. gingival tissue.

Similarly, the implant should be placed somewhat Similarly, the implant should be placed somewhat

more apically to achieve a proper emergence more apically to achieve a proper emergence

profile and avoid a ridge lap restorations. profile and avoid a ridge lap restorations.

The long term stability of esthetic soft tissue The long term stability of esthetic soft tissue around an implant restorations depends largely on around an implant restorations depends largely on the presence of adequate soft tissue volume in a the presence of adequate soft tissue volume in a vertical and buccolingual direction. vertical and buccolingual direction.

An adequate volume of soft tissue provides a good An adequate volume of soft tissue provides a good emergence profile of the implant restoration and emergence profile of the implant restoration and serves to mask the underlying metal implant, A sub serves to mask the underlying metal implant, A sub epithelial connective tissue graft may be epithelial connective tissue graft may be considered to augment soft tissue volume when considered to augment soft tissue volume when insufficient tissue volume is present.insufficient tissue volume is present.

Crown marginCrown marginFabrication Of supra structureFabrication Of supra structure

for implants to be symmetrical for implants to be symmetrical

to the adjacent teeth.to the adjacent teeth.

Crown FormCrown FormSelection of proper implant Selection of proper implant

diameter helps in design of diameter helps in design of

single missing natural toothsingle missing natural tooth. .

Inter dental spacesInter dental spaces Successful placement of the implant at Successful placement of the implant at

the site at Which the crown unit is to be the site at Which the crown unit is to be built up is the prerequisite for correct built up is the prerequisite for correct formation of inter dental spaces.formation of inter dental spaces.

The supporting bone influences the establishment The supporting bone influences the establishment of overlying soft tissue compartments and the of overlying soft tissue compartments and the bone quality and quantity must be carefully bone quality and quantity must be carefully assessed. assessed.

The vertical bone height in the inter proximal sites, The vertical bone height in the inter proximal sites, as well as the horizontal thickness and vertical as well as the horizontal thickness and vertical height of the buccal bone wall in the edentulous height of the buccal bone wall in the edentulous site, are important determinants of esthetic site, are important determinants of esthetic success. success.

The bone crest should be within a physiological The bone crest should be within a physiological distance of 2 to 3 mm of the cemento-enamel distance of 2 to 3 mm of the cemento-enamel junction or, when recession is present, 2 to 3 mm junction or, when recession is present, 2 to 3 mm of the buccal gingival margin. of the buccal gingival margin.

The distance between the underlying interproximal The distance between the underlying interproximal

bone height on the adjacent natural teeth and the bone height on the adjacent natural teeth and the final prosthetic contact point dictates the formation final prosthetic contact point dictates the formation and spontaneous regeneration of the inter dental and spontaneous regeneration of the inter dental papillae associated with the implant .papillae associated with the implant .

If this distance is more than 5 mm, the complete If this distance is more than 5 mm, the complete papilla formation will be compromised.papilla formation will be compromised.

This often leads to the so called “blank triangle”. This often leads to the so called “blank triangle”. This effect may differ according to whether the This effect may differ according to whether the implants is adjacent to another implant or a natural implants is adjacent to another implant or a natural tooth.tooth.

Tarnow ,etal in 2003Tarnow ,etal in 2003

Investigated the clinical problem of the Investigated the clinical problem of the difficulty of maintaining or reforming a difficulty of maintaining or reforming a papilla between two implantspapilla between two implants

One reason for this difficulty is that the One reason for this difficulty is that the biological width around an implant is apical biological width around an implant is apical to the implant abutment connection to the implant abutment connection

Lip SupportLip Support

The lost tissue must be built into the The lost tissue must be built into the reconstruction in such a way that lip reconstruction in such a way that lip support,profile , function, esthetics and support,profile , function, esthetics and phonetics are reproduced while placing phonetics are reproduced while placing the implants. the implants.

Resting lip position

RELAXED SMILE

FULLY ANIMATED SMILE

Smile LineSmile Line

o It is a decisive factor It is a decisive factor in the evaluation of the in the evaluation of the patients esthetics patients esthetics requirements .requirements .

o The lower margin of The lower margin of the upper lip also the upper lip also called the smile called the smile line ,serves as an line ,serves as an orientation guide for orientation guide for the limits of visibility of the limits of visibility of the teeth.the teeth.

Three possible esthetic situations may arise Three possible esthetic situations may arise according to according to REITHERREITHER

Incisal EffectIncisal EffectCervical EffectCervical EffectGingival Effect Gingival Effect

Four main factors directly affect the Four main factors directly affect the esthetic outcome of implant supported esthetic outcome of implant supported restorations:restorations:

implant placementimplant placement soft tissue managementsoft tissue management bone grafting considerationsbone grafting considerations prosthetic considerations. prosthetic considerations.

TREATMENT CONSIDERATIONS TREATMENT CONSIDERATIONS

Implant Placement Implant Placement

Implant placement is divided into Implant placement is divided into two aspects:two aspects:

positioning positioning implant sizing. implant sizing.

Positioning Positioning Positioning of an implant is the first step in Positioning of an implant is the first step in

gaining prime esthetic results. Fabrication gaining prime esthetic results. Fabrication of the proper surgical guide (template) is of the proper surgical guide (template) is the key to such an achievement. the key to such an achievement. Positioning involves three planes; Positioning involves three planes;

apico-occlusal,apico-occlusal, mesio-distal, mesio-distal, labio-palatal planes.labio-palatal planes.

Positioning of implants-Positioning of implants-esthetic criteriaesthetic criteria

Buccolingual positioning of implantsBuccolingual positioning of implants

Vertical positioning of implantsVertical positioning of implants

Apico-occlusal positioningApico-occlusal positioning.. Apico-occlusal positioning of the implant in an Apico-occlusal positioning of the implant in an

axial direction must be 2 to 3 mm above an axial direction must be 2 to 3 mm above an imaginary line connecting the cementoenamel imaginary line connecting the cementoenamel teeth. teeth.

Less than 2 mm will lead to a short crown (which Less than 2 mm will lead to a short crown (which is impossible to correct), and more than 3 mm is impossible to correct), and more than 3 mm will hinder proper hygienic maintenance because will hinder proper hygienic maintenance because of increased pocket depth around the of increased pocket depth around the transmucosal insert.transmucosal insert.

Placing the implant 3 mm below is mandatory to Placing the implant 3 mm below is mandatory to allow transfer in cross section from the implant allow transfer in cross section from the implant head diameter to the natural tooth diameter at head diameter to the natural tooth diameter at the point of emergence from the gingival crest. the point of emergence from the gingival crest.

Placing the implant too far palatally will result in a Placing the implant too far palatally will result in a “ditched in “ restoration. This is over come by “ditched in “ restoration. This is over come by using a modified ridge lap design for the final using a modified ridge lap design for the final restoration, which is unfavorable from hygienic restoration, which is unfavorable from hygienic and esthetic points of view; it may also create and esthetic points of view; it may also create increased strain on the implant when loaded.increased strain on the implant when loaded.

Placing the implant too far labially will result in an Placing the implant too far labially will result in an

esthetically bulky crown that is impossible to esthetically bulky crown that is impossible to correct, even with the use of angulated abutments. correct, even with the use of angulated abutments.

Labiopalatal positioningLabiopalatal positioning..

In screw retained anterior restorations, the In screw retained anterior restorations, the implant is generally placed slightly lingual implant is generally placed slightly lingual or palatal to the long axis of the crown. or palatal to the long axis of the crown.

In all cemented restorations and posterior In all cemented restorations and posterior screw retained restorations, the implant screw retained restorations, the implant should be located exactly in the center of should be located exactly in the center of the long axis of the crown. the long axis of the crown.

Mesiodistal positioning. Mesiodistal positioning.

Through case design and Through case design and preoperative planning, preoperative planning, an implant positioning an implant positioning in a mesio-distal in a mesio-distal dimension that has a dimension that has a proper relationship proper relationship between the teeth can be between the teeth can be achievedachieved

. .

The middle orientation in a mesio-distal The middle orientation in a mesio-distal direction is mandatory to avoid placing direction is mandatory to avoid placing the implant in the inter dental papillary the implant in the inter dental papillary position and subsequent approximation position and subsequent approximation of the neighboring roots. of the neighboring roots.

Mesio distal dimension of the tooth root Mesio distal dimension of the tooth root which determines the size of the which determines the size of the appropriate implant.appropriate implant.

TOOTH ROOT AS A TOOTH ROOT AS A DETERMINANT FORDETERMINANT FOR OPTIMAL IMPLANT OPTIMAL IMPLANT SIZE:SIZE:

In young individuals-attachment In young individuals-attachment mechanism for natural tooth is mechanism for natural tooth is near CEJ.near CEJ.

With age-recession is seenWith age-recession is seen Thus, it has been concluded Thus, it has been concluded

that CEJ minus 2mm is a good that CEJ minus 2mm is a good location to assess the average location to assess the average size of a tooth root to determine size of a tooth root to determine the optimal implant size for the optimal implant size for replacing the tooth.replacing the tooth.

MesiodistMesiodistalal

CrownCrown

MesiodistMesiodistal CEJal CEJ

(mm)(mm)

MesiodistMesiodistal CEJ – al CEJ – 2mm2mm

RecommendRecommended implanted implant

CENTRALCENTRAL 8.68.6 6.46.4 5.55.5 4.1,4.1,

4.3,5.04.3,5.0

LATERALLATERAL 6.66.6 4.74.7 4.34.3 3.25,3.5,3.25,3.5,

4.1,4.34.1,4.3

CANINECANINE 7.67.6 5.65.6 4.64.6 4.1,4.34.1,4.3

I PREMOLARI PREMOLAR 7.17.1 4.84.8 4.24.2 4.1,4.34.1,4.3

MESIODISTAL CROWN AND ROOT MESIODISTAL CROWN AND ROOT DIAMETER OF MAXILLARY TEETH AND DIAMETER OF MAXILLARY TEETH AND

IMPLANT RECOMMENDATIONSIMPLANT RECOMMENDATIONS

Implant sizingImplant sizing Selecting an implant diameter Selecting an implant diameter

that almost matches that of that almost matches that of the natural tooth at the the natural tooth at the cervical area will improve the cervical area will improve the esthetic outcome. esthetic outcome.

Failure to use the proper Failure to use the proper implant size must be implant size must be compensated for by sinking compensated for by sinking the implant 3 mm below the the implant 3 mm below the CEJ of the neighboring teeth. CEJ of the neighboring teeth.

CERAMIC IMPLANTCERAMIC IMPLANT

The PURE Ceramic Implant offers you a unique The PURE Ceramic Implant offers you a unique esthetic solution to treat patients with specific esthetic solution to treat patients with specific needs. While some patients have a thin gingiva needs. While some patients have a thin gingiva biotype, which requires a specific treatment biotype, which requires a specific treatment approach, other patients express their explicit wish approach, other patients express their explicit wish for a metal-free alternative.for a metal-free alternative.

High predictability with revolutionary osseointegration High predictability with revolutionary osseointegration features equivalent to the established SLA® surfacefeatures equivalent to the established SLA® surface2,3,42,3,4

100 % proof test ensuring reliable implant strength100 % proof test ensuring reliable implant strength High end esthetic solution thanks to ivory-colored High end esthetic solution thanks to ivory-colored

materialmaterial

Soft tissue management Soft tissue management

Delicate handling of the soft tissue is considered to Delicate handling of the soft tissue is considered to be the main factor in gaining a pleasant esthetic be the main factor in gaining a pleasant esthetic out come. out come.

Soft tissue management includes handling of the Soft tissue management includes handling of the soft tissue at the time of implant placement, soft tissue at the time of implant placement, abutment connection, and soft tissue grafting (if abutment connection, and soft tissue grafting (if needed). Soft tissue management should be needed). Soft tissue management should be considered in the following treatment steps. considered in the following treatment steps.

Mucoperiosteal flap Mucoperiosteal flap : : The horizontal incision should be made along a line The horizontal incision should be made along a line

connecting the palatal line angles of the adjacent connecting the palatal line angles of the adjacent teeth, and the vertical incision should be made at the teeth, and the vertical incision should be made at the adjacent teeth (ie, a normal marginal incision should adjacent teeth (ie, a normal marginal incision should be made with complete mobilization of the inter be made with complete mobilization of the inter dental papillae). dental papillae).

The incision should allow optimal mobilization of the The incision should allow optimal mobilization of the mucoperiosteal flap. A preservative inter dental mucoperiosteal flap. A preservative inter dental papillae incision is advantageous because it helps to papillae incision is advantageous because it helps to prevent dropping of the mucoperiosteal flap with prevent dropping of the mucoperiosteal flap with subsequent shrinkage (partial marginal section). subsequent shrinkage (partial marginal section).

Preservation of the interdental papillaePreservation of the interdental papillae

Second stage surgery. Second stage surgery.

At this stage, the gingival margin around the At this stage, the gingival margin around the implant can be corrected or improved to a great implant can be corrected or improved to a great extent. extent.

Bulking the keratinized tissue labially around Bulking the keratinized tissue labially around the healing heads is one technique used to the healing heads is one technique used to enhance the esthetic outcome. A modified enhance the esthetic outcome. A modified palatal roll flap is commonly used to bulk up palatal roll flap is commonly used to bulk up tissue labially. tissue labially.

Soft tissue management at abutment Soft tissue management at abutment connection. connection.

Lack of soft tissue Lack of soft tissue bulking over the labial bulking over the labial plateplate

Bulking up of the Bulking up of the keratinized tissue keratinized tissue labially during second labially during second stage surgerystage surgery

Gingival grafting.Gingival grafting.

Soft tissue deficiencies can be corrected at this Soft tissue deficiencies can be corrected at this stage of treatment (eg. A lack of keratinized stage of treatment (eg. A lack of keratinized tissue would be corrected by means of free tissue would be corrected by means of free gingival grafting or sliding flaps) . gingival grafting or sliding flaps) .

Small tissue dimples or labiocrestal concavities Small tissue dimples or labiocrestal concavities

can be corrected by sub epithelial connective can be corrected by sub epithelial connective tissue grafting to bulk up the tissue labially if tissue grafting to bulk up the tissue labially if needed (note the soft tissue drop and needed (note the soft tissue drop and mishandling). Also, gingivoplasty, using a mishandling). Also, gingivoplasty, using a diamond bur, is used to correct flat or ledged diamond bur, is used to correct flat or ledged margins. margins.

Soft tissue drop due to improper design ofSoft tissue drop due to improper design of

the incisionthe incision

Papillary illusion, by allowing a substantial Papillary illusion, by allowing a substantial excess of keratinized tissues to be stabilized at excess of keratinized tissues to be stabilized at the implant site, can also be created. the implant site, can also be created.

Preservation of the papillae is the most Preservation of the papillae is the most important factor in creating a natural looking important factor in creating a natural looking implant supported restorations. Papillae can be implant supported restorations. Papillae can be created surgically by using several techniques. created surgically by using several techniques.

Coronally repositioned flapCoronally repositioned flap A C-shaped incision is made at the implant site A C-shaped incision is made at the implant site

with the convexity toward the labial surface. with the convexity toward the labial surface. The circumference of the incision should be The circumference of the incision should be deeper than that of the abutment.deeper than that of the abutment.

Thus, when the flap is repositioned coronally, Thus, when the flap is repositioned coronally,

excess tissue will be present between the excess tissue will be present between the abutment and the adjacent teeth. This excess abutment and the adjacent teeth. This excess tissue will create tissue will create a papillary illusiona papillary illusion. The . The disadvantages of this technique is a reduction in disadvantages of this technique is a reduction in labio-attached gingiva. labio-attached gingiva.

Lateral compression of the gingivaLateral compression of the gingiva..

An incision is made over the cover screw (after An incision is made over the cover screw (after it is carefully localized using a probe). The it is carefully localized using a probe). The incision should imitate an extraction wound so incision should imitate an extraction wound so that the cover screw will be partly covered by that the cover screw will be partly covered by tissue after the incision. tissue after the incision.

This tissue should be compressed before This tissue should be compressed before removal of the cover screw. After abutment removal of the cover screw. After abutment connection, the surrounding tissue will be connection, the surrounding tissue will be compressed and raised to create natural looking compressed and raised to create natural looking papillae. papillae.

Gingival recontouringGingival recontouring

Several clinician technique have been proposed Several clinician technique have been proposed for reshaping the gingival profile, provided that a for reshaping the gingival profile, provided that a sufficient volume of soft tissue is present. sufficient volume of soft tissue is present.

Wide, temporary healing abutment are used to Wide, temporary healing abutment are used to allow gingival maturation around a wide cap. allow gingival maturation around a wide cap. Gingival electro-surgery is used to cut the Gingival electro-surgery is used to cut the desired gingival contour. desired gingival contour.

Bone Grafting Considerations Bone Grafting Considerations

Does the final restorations Does the final restorations determine the implant site, or determine the implant site, or does bone availability does bone availability determine the implant sitedetermine the implant site??

Prosthetically driven implant placement

Amount of bone formed after guided tissue regeneration

Restoration driven implant placement is the Restoration driven implant placement is the ultimate goal regardless of the amount of ultimate goal regardless of the amount of available bone. available bone.

Bone grafting procedures (autogenous, Bone grafting procedures (autogenous, allogenous, or synthetic ) have given the allogenous, or synthetic ) have given the clinician a wide range of treatment modalities clinician a wide range of treatment modalities (note the proper positioning of the implant (note the proper positioning of the implant despite the lack of labial bone and the despite the lack of labial bone and the achievement of a good bulk of bone by means achievement of a good bulk of bone by means of current grafting techniques. of current grafting techniques.

Prosthetic Considerations Prosthetic Considerations –– Esthetic Esthetic ImplantImplant

EVALUATION of prospective implant site should EVALUATION of prospective implant site should arise primarily from prosthetic point of view.arise primarily from prosthetic point of view.

The time long past when implants were inserted The time long past when implants were inserted correctly from surgeons point of view but turned correctly from surgeons point of view but turned to be unusable prosthetically.to be unusable prosthetically.

This principle is doubly important for esthetically This principle is doubly important for esthetically demanding situations.demanding situations.

Implant must be understood as an extension of Implant must be understood as an extension of the optimally located super structure.the optimally located super structure.

GARBER and BELSER have described this GARBER and BELSER have described this constraint as RESTORATION-DRIVEN IMPLANT constraint as RESTORATION-DRIVEN IMPLANT PLACEMENT AND RESTORATION-DRIVEN SITE PLACEMENT AND RESTORATION-DRIVEN SITE DEVELOPMENTDEVELOPMENT

Soft tissue profile or prosthetic recipient site from Soft tissue profile or prosthetic recipient site from which the restoration emerges should be which the restoration emerges should be identical to that around the contralateral tooth is identical to that around the contralateral tooth is the basis for all the esthetic restorations.the basis for all the esthetic restorations.

Numerous restorative materials, technologies, Numerous restorative materials, technologies, and clinical procedures have been developed.and clinical procedures have been developed.

for example – tooth colored abutments, for example – tooth colored abutments, anatomical abutments, tapered but wide anatomical abutments, tapered but wide healing heads. healing heads.

Cervical contour-Cervical contour-

Cervical contouring is one factor Cervical contouring is one factor responsible for the proper configuration of responsible for the proper configuration of the peri implant soft tissues. It also the peri implant soft tissues. It also corrects the discrepancies between the corrects the discrepancies between the diameter of the implant body and that of diameter of the implant body and that of the natural teeth.the natural teeth.

This ideal design is transferred to vital oral This ideal design is transferred to vital oral tissue through the abutment and the provisional tissue through the abutment and the provisional restorations, which are fabricated to guide the restorations, which are fabricated to guide the soft tissue to initiate the replica model. soft tissue to initiate the replica model.

Cervical contouring also focuses on shaping the Cervical contouring also focuses on shaping the abutment and the cervical crown region abutment and the cervical crown region following the previous design of the surrounding following the previous design of the surrounding tissues.tissues.

Anatomical abutments- Anatomical abutments- Because of the discrepancy in the diameter Because of the discrepancy in the diameter

between the implant head and the natural tooth between the implant head and the natural tooth diameter at the CEJ level the anatomically diameter at the CEJ level the anatomically shaped abutments dramatically improve the shaped abutments dramatically improve the emergence profile.emergence profile.

Also reduces stress on the connecting screw, Also reduces stress on the connecting screw, improve mechanical properties, increase improve mechanical properties, increase prosthetic stability, and avoid use of the ridge prosthetic stability, and avoid use of the ridge lap design. lap design.

Use of traditional narrow abutments will usually Use of traditional narrow abutments will usually lead to an inability to fulfill esthetic goals that it, it lead to an inability to fulfill esthetic goals that it, it could necessitate a modified ridge lap design, could necessitate a modified ridge lap design, which is unpleasant esthetically, make hygienic which is unpleasant esthetically, make hygienic procedures difficult, and causes undue stress on procedures difficult, and causes undue stress on the implant.the implant.

By using anatomical abutments, the soft tissue By using anatomical abutments, the soft tissue will be displaced to create the same diameter as will be displaced to create the same diameter as the natural tooth at the CEJ area the natural tooth at the CEJ area

Abutments available Abutments available

ANGULATED ABUTMENTS ANGULATED ABUTMENTS

CERAMIC ABUTMENTS.CERAMIC ABUTMENTS.

Abutments with wider cervical marginAbutments with wider cervical margin Improves emergence profileImproves emergence profile Provides greater surface area for Provides greater surface area for

retention.retention. Permits the crown preparation to the Permits the crown preparation to the

needs.needs.

Ceramic abutmentsCeramic abutments

are used to enhance the esthetic quality of are used to enhance the esthetic quality of implant supported restorations in the anterior implant supported restorations in the anterior maxilla. They are usually used in cases in which maxilla. They are usually used in cases in which the labial soft tissues is thin to allow passage of the labial soft tissues is thin to allow passage of reflective light from a non metallic abutment. reflective light from a non metallic abutment. Ceramic abutments are fabricated by suing Ceramic abutments are fabricated by suing partially stabilized alumina-Zirconia machinable partially stabilized alumina-Zirconia machinable abutments. abutments.

After preparation of the abutment, it is After preparation of the abutment, it is glass infiltrated and polished. The final glass infiltrated and polished. The final restoration can them be delivered to the restoration can them be delivered to the patient as an all ceramic crown cemented patient as an all ceramic crown cemented over the abutment, or the abutment itself over the abutment, or the abutment itself can be procelainized with the abutment can be procelainized with the abutment acting as the final restorations. acting as the final restorations.

THE UCLA TYPE ABUTMENTTHE UCLA TYPE ABUTMENT The UCLA-Type Abutment is attached directly to the The UCLA-Type Abutment is attached directly to the

implant. It provides a pattern for the creationimplant. It provides a pattern for the creation

of a screw retained veneered crown.of a screw retained veneered crown. UCLA-Type Abutments are available in single-UCLA-Type Abutments are available in single-

implant (hexed) and multi-implant (non-hexed) implant (hexed) and multi-implant (non-hexed) designs. designs.

This abutment is well suited for This abutment is well suited for sites with minimal sites with minimal thickness of soft tissuethickness of soft tissue. It is available in traditional . It is available in traditional plasticconfigurations, gold alloy, gold base with plasticconfigurations, gold alloy, gold base with plastic sleeve, and in a titanium version for plastic sleeve, and in a titanium version for provisional restorations.provisional restorations.

Healing heads- Healing heads- Wide, temporary healing head are used to Wide, temporary healing head are used to

transfer the narrow cross section of the implant transfer the narrow cross section of the implant head into the triangular cross section of the head into the triangular cross section of the upper anterior teeth by gradually pressing upper anterior teeth by gradually pressing against the gingival tissue.against the gingival tissue.

This should conform to the nearest cross section This should conform to the nearest cross section of tooth structure to allow enough room for the of tooth structure to allow enough room for the anatomical abutments to be placed. anatomical abutments to be placed.

TemporizationTemporization Temporization is a major clinical step in the Temporization is a major clinical step in the

achievements of a proper esthetic result in anterior achievements of a proper esthetic result in anterior tooth restorations . Proper and adequate stimulation tooth restorations . Proper and adequate stimulation of the gingival tissue must take place because of the gingival tissue must take place because exaggerated pressure could lead to sloughing and exaggerated pressure could lead to sloughing and necrosis. necrosis.

After second stage surgery, the tissue must be After second stage surgery, the tissue must be given time to heal and mature to stabilize the gingival given time to heal and mature to stabilize the gingival margin before the final abutment is selected or final margin before the final abutment is selected or final impressions are made. impressions are made.

The provisional restorations allows for soft tissue The provisional restorations allows for soft tissue maturation. This usually take 6 to 8 weeks. The maturation. This usually take 6 to 8 weeks. The final soft tissue profile should be replicated on final soft tissue profile should be replicated on the model, so the provisional restorations should the model, so the provisional restorations should be fabricated according to the desired gingival be fabricated according to the desired gingival contour. contour.

By adding and shaping the acrylic resin on the By adding and shaping the acrylic resin on the sub gingival portion of the temporary restoration, sub gingival portion of the temporary restoration, an esthetic emergence profile and tooth an esthetic emergence profile and tooth dimension can be achieved dimension can be achieved

Fabrication of provisional Fabrication of provisional restoration restoration

Impression made at stage I surgery - Impression made at stage I surgery - Fabrication of provisional restoration.Fabrication of provisional restoration.

Placement of customized provisional Placement of customized provisional restoration instead of healing abutment.restoration instead of healing abutment.

Advantages of placing custom Advantages of placing custom provisional restorationprovisional restoration

Exact desired emergence profile can be Exact desired emergence profile can be generated .generated .

Surgical procedures or soft tissue Surgical procedures or soft tissue management can be avoided.management can be avoided.

Acts as a guide to fabricate final Acts as a guide to fabricate final restoration.restoration.

IMPLANT PLACEMENT IN IMPLANT PLACEMENT IN EDENTULOUS SITESEDENTULOUS SITES

When an edentulous site in the esthetic zone is When an edentulous site in the esthetic zone is planned for implant placement, the site must be planned for implant placement, the site must be thoroughly evaluated. thoroughly evaluated.

Garber has proposed a classification for such Garber has proposed a classification for such sites. This classification depends on the type of sites. This classification depends on the type of reconstruction needed to get good positioning reconstruction needed to get good positioning of the implant. of the implant.

Garber Class IGarber Class I

When favorable horizontal and vertical levels of When favorable horizontal and vertical levels of both soft tissue and bone are present, ideal both soft tissue and bone are present, ideal implant positioning is a straight forward implant positioning is a straight forward procedure. procedure.

A concomitant soft tissue augmentation at the A concomitant soft tissue augmentation at the same time of implant placement is preferred in same time of implant placement is preferred in patients with a thin gingival biotype to prevent patients with a thin gingival biotype to prevent the risk of soft tissue recession and buccal the risk of soft tissue recession and buccal bone resorption. bone resorption.

Garber Class IIGarber Class II

Sites with no vertical bone loss and slight Sites with no vertical bone loss and slight horizontal bone deficiency measuring about 1 to horizontal bone deficiency measuring about 1 to 2 mm narrower than normal can be expanded 2 mm narrower than normal can be expanded by using serial osteotomes instead of drilling.by using serial osteotomes instead of drilling.

This technique will permit slight expansion of the This technique will permit slight expansion of the

bony ridge horizontally while simultaneously bony ridge horizontally while simultaneously compressing the maxillary cancellous bone to compressing the maxillary cancellous bone to improve the bone quality. improve the bone quality.

Garber Class IIIGarber Class III

For sites with no vertical bone loss and For sites with no vertical bone loss and horizontal bone loss greater than Class II, horizontal bone loss greater than Class II, implant placement can be attempted, implant placement can be attempted, provided an initial stability is achieved. provided an initial stability is achieved. Guided bone regeneration is necessary. Guided bone regeneration is necessary.

Garber Class IV Garber Class IV

In sites with no vertical bone loss but significant In sites with no vertical bone loss but significant horizontal loss, it is necessary to use a staged horizontal loss, it is necessary to use a staged approach in which the ridge is widened with approach in which the ridge is widened with guided bone regeneration.guided bone regeneration.

Implants are later placed after a suitable Implants are later placed after a suitable healing period of several months, using block healing period of several months, using block bone grafts or guided bone regeneration bone grafts or guided bone regeneration techniques. techniques.

Sites with extensive apicocoronal bone loss Sites with extensive apicocoronal bone loss present a significant challenge to the surgeon. present a significant challenge to the surgeon. As noted above, there are no well documented As noted above, there are no well documented surgical approaches available to predictably surgical approaches available to predictably augment bony ridge height. augment bony ridge height.

Some case reports suggest a surgical approach Some case reports suggest a surgical approach of guided bone regeneration using a non of guided bone regeneration using a non restorable membrane and delayed implant restorable membrane and delayed implant placement. placement.

Garber Class V Garber Class V

REFERENCESREFERENCES Soft tissue and Esthetic consideration in implant Soft tissue and Esthetic consideration in implant

therapy: Anthony G Sclartherapy: Anthony G Sclar Esthetics in dentistry – vol 1: Ronald e Esthetics in dentistry – vol 1: Ronald e

Goldstein.Goldstein. Abd EI Salam EI Askary. Esthetic considerations Abd EI Salam EI Askary. Esthetic considerations

in anterior single tooth replacement.Implant Dent in anterior single tooth replacement.Implant Dent 1999;8:61-661999;8:61-66

Avishai sadan, Markus B ,Mike Bellerino,Michael Avishai sadan, Markus B ,Mike Bellerino,Michael Block.Prosthetic design considerations for Block.Prosthetic design considerations for single-implant restorations. J Esthet Restor Dent single-implant restorations. J Esthet Restor Dent 16:165-175,2004. 16:165-175,2004.