MASTERS OF ESTHETIC DENTISTRY

Objective Criteria: Guiding andEvaluating Dental Implant Esthetics

LYNDON F. COOPER, DDS, PhD*

I N T R O D U C T I O N

The evolution of dental implanttherapies is fully apparent. Fromthe introductory concepts of thetissue integrated prostheses withremarkable functional advantages,innovations have resulted in dentalimplant solutions spanning thespectrum of dental needs. Currentdiscussions concerning the relativemerit of an implant versus a three-unit fixed partial denture fullyillustrate the possibility that singleimplants represent a bona fidechoice for tooth replacement.1

Interestingly, when delving into thedetailed comparisons between theoutcomes of single-tooth implantversus fixed partial dentures or theintentional replacement of a failingtooth with an implant instead ofrestoration involving root canaltherapy, little emphasis has beenplaced on the relative estheticmerits of one or another therapeu-tic approach to tooth replacementtherapy.2 An ideal prosthesisshould fully recapitulate orenhance the esthetic features of thetooth or teeth it replaces. Although

it is clearly beyond the scope ofthis brief article to compare thevarious methods of esthetic toothreplacement, there is, perhaps, suf-ficient space to share some insightsregarding an objective approach toplanning, executing, and evaluatingthe esthetic merit of single-toothimplant restorations.

Therapeutic success for dentalimplants has largely been describedin terms of implant survival. Ante-rior single-tooth implant survival ishigh.3 Further documentationprovides implant success criteria,defined by the reporting of mar-ginal bone level data.4 Occasionally,prosthetic or restorative outcomeshave been reported. Here, margin-ally less favorable data are reportedfor abutment complications of loos-ening or screw fracture.3 Less often,biologic data concerning the peri-implant mucosal responses are pro-vided. A biologic width developsaround implant crowns, and theassociated peri-implant connectivetissue inflammatory cell infiltratereacts to plaque accumulation.5

P R O F I L E

Lyndon F. Cooper,DDS, PhD

Current Occupation

Chair, Department of ProsthodonticsDirector, Graduate Prosthodontics

Education

NYU, 1983, DDSEastman Dental Center, 1990,

Certificate in Prosthodontics,Rochester, NY

University of Rochester, 1990, PhDNIH, 1991–1993, Fellowship,

Bethesda, MD

Academic and Other Affiliations

UNC Chapel Hill School of Dentistry,Chapel Hill, NC

Professional Memberships

American College of ProsthodonticsAcademy of OsseointegrationInternational Association of Dental

ResearchAmerican Association for

Advancement of Science

Positions Held

Vice president—American College ofProsthodontics

Chairperson—research division,Academy of Osseointegration

Honors/Awards

ACP Clinician/Scientist AwardNIH First Award

Publications

Over 75 articles published in peerreviewed journals with over 200presentations given worldwide

Hobbies/Personal Interests

“Ex”-marathon and now casualrunner, history of science, classicand sport auto enthusiast

Notable Contribution(s) to Dentistry

Early adoption and investigation ofearly and immediate loading ofunsplinted dental implants

Study of adult stem cells for alveolarbone repair *Chair, Department of Prosthodontics, UNC School of Dentistry,

Chapel Hill, NC 27599, USA

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The incidence of peri-implantitisand its effect on implant estheticsmay not be fully appreciated.Recently, two different estheticscoring systems have beendescribed.6,7 These or possibly otheresthetic evaluations have not beenwidely deployed. Although Changand colleagues8 examined patient-based outcomes for anterior single-tooth implants, there remain manyunanswered questions regarding theesthetic requirements and relatedpatient satisfaction concerninganterior single-tooth implants. In2008, esthetic concerns dominatediscourse surrounding dentalimplants. An objective approach toplanning, executing, and evaluatingtherapy is warranted.

Meeting the goal of providing asingle-tooth implant crown thatequals or exceeds the esthetic valueof the tooth it replaces requiresidentifying and addressing easilyrecognized anatomic constraints.The hypothesis underscoring anobjective approach to single-toothdental implant esthetics is that themajority of unresolved estheticproblems are because of the dis-crepancies of implant crowndimension and orientation. Mostoften, these reflect improper clini-cal management of peri-implantand peri-coronal soft tissue archi-tecture.9 The application of time-proven and well-documentedobjective criteria for dental esthet-ics to the anterior single-tooth

implant scenario can guide plan-ning and assure execution ofimplant placement, abutmentdesign, and crown formation toachieve the highest and mostreproducible esthetic goals of theclinician and patient. The aim ofthis report was to describe howobjective criteria can guide plan-ning and execution of implanttherapy and, importantly, how asingle aspect of dental implantplanning and placement can nega-tively impact half of these objectivecriteria and lead to unacceptableimplant-supported restorations.

O B J E C T I V E C R I T E R I A F O R

D E N TA L E S T H E T I C S A N D T H E

I M P L A N T S C E N A R I O

In a classic (now out of print) text-book entitled Esthetic Guidelinesfor Restorative Dentistry,10 Dr.Urs Belser described the objectivecriteria for dental esthetics. More

recently, an updated list and illus-tration of these criteria were pub-lished as a chapter in the textbookBonded Porcelain Restorations inthe Anterior Dentition.11 Thesecriteria (Table 1), together with theadditional significance of identify-ing the midline and plane of occlu-sion as a prerequisite for idealanterior dental esthetics, canprovide an indelible guidancesystem for dental esthetics. In theprocess of evaluating single-toothdental implant restorations inprospective and retrospectivestudies,11–14 it became apparent thatthese criteria were equally valid tothe dental implant restoration. Theform of the dental implant-supported tooth requires carefulconsideration of these objectivecriteria (Figure 1).

Dental implant placement is neitherfully intuited from the anatomy of

TA B L E 1 . O B J E C T I V E C R I T E R I A F O R D E N TA L E S T H E T I C S .

• Gingival health• Balance of gingival levels• Gingival zenith• Interdental closure• Interdental contact location• Tooth axis• Basic features of tooth form• Relative tooth dimensions• Tooth characterization• Surface texture• Color• Incisal edge configuration• Lower lip line• Smile symmetry• Midline and occlusal plane orientation

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the residual alveolar ridge nor canit be divined from the existingvolume of bone. Desired tooth posi-tion dictates implant placement andinforms the clinician regardingpotential requirements for tissueaugmentation. In considering therole of the objective criteria in plan-ning for dental implant placementand recognizing that the depth ofimplant placement can dramaticallyaffect one-half of these criteria, apotential objective strategy toesthetic planning for dental implant

placement emerges. That strategyrequires the evaluation of the eden-tulous alveolar ridge and adjacentteeth in the context of the objectivecriteria for dental esthetics. Simplystated, dental implant placementcan be guided by the location of thegingival zenith.

T H E G I N G I VA L Z E N I T H

A S A G U I D E F O R D E N TA L

I M P L A N T P L A C E M E N T

The gingival zenith represents themost apical part of the clinical

crown. It also represents both thefaciolingual and the mesiodistallocation of the crown in relation-ship to the edentulous ridge. Assuch, it has a remarkable influenceon the morphology of the plannedrestoration. The gingival zenithaffects other objective criteria,including the balance of gingivallevels (too inferior or superior), thetooth axis (too distal or mesial),the tooth dimension (too inferioror superior), and the tooth form(triangular becomes ovoid if tooinferior). Without the control ofthe gingival zenith, the clinician’sability to define dental implantesthetics is vastly diminished(Figure 2).

D E N TA L I M P L A N T C O N T R O L AT

T H E Z E N I T H

At least four factors affect the gin-gival zenith. One is, of course, therelative location of the tissues tothe planned gingival zenith. Secondis the depth of the dental implantplacement. Third is the response ofthe buccal bone and mucosa to theimplant procedure and compo-nents. The fourth is the prostho-dontic management of the gingivalzenith architecture.

The Relative Locations of Tissuesand the Planned Gingival ZenithIdeally, the planned gingival zenithis symmetric with the contralateraltooth and harmonious with thegingival levels of adjacent teeth.Unfortunately, most residual

Figure 1. Tooth form is objectively defined. The objectivecriteria for dental esthetics (Table 1) help to guidedecisions concerning ideal tooth form. The clinical photo ofthis implant crown replacing the central incisor #8 revealsthe significance of the many soft tissue items present ascriteria defining dental esthetics. Note that much of thecrown form is defined by the peri-implant mucosa. The lackof symmetry between the central incisors is due to the incor-rect depth of implant placement and the 1-mm apical loca-tion of the gingival zenith. The incorrect soft tissue contouris represented by a more oval or triangular tooth form and alonger clinical crown when compared with the left centralincisor. The more mesial location of the zenith has beencompensated by the enhancement of the line angles andtooth character to correct the appearance of the tooth longaxis. The loss of attachment at tooth #7 results in theabsence of gingival closure and cannot be accommodated bymodifications of the implant procedure or the crown #8.These objective limitations reduce the overall esthetic valueof this tooth display.

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alveolar ridges are significantlyresorbed.15 Important objectiveclassification16 is useful and adiagnostic waxing permits theexact determination of the extentof resorption and permits plan-ning to the key esthetic param-eters. Interproximal tissuecontours (papillae) appear to besupported by adjacent teethconnective tissue contacts, butperi-implant facial tissuecontours are dependent on facialbone and co-dependent softtissue morphology.

Controlling the Depth ofImplant PlacementDecisions concerning the depth ofimplant placement should bebased on the biologic understand-ing of the tissue responses to theimplanted device. Assuming asteady state peri-implant bone

level, it is well known that abiologic width forms at the dentalimplant17 and that the buccaldimension of the biologic widthformed at an abutment isapproximately 3 mm.18 The idealdepth of the implant placement issuggested to be 3 mm apical tothe planned gingival zenith. Theimplant/abutment interface shouldalso reside 2 mm palatal to thezenith to assure that there isadequate thickness of bone andmucosa to support tissue form.19

This “three/two” rule further sug-gests to the clinician when bonegrafting or soft tissue augmenta-tion should be performed. If boneis not present at approximatelythis position from the gingivalzenith, bone grafting proceduresshould be considered inpreparation for ideal esthetics(Figure 3).

Without apology for the followingcircular logic, controlling the depthof placement is achieved by defin-ing the gingival zenith. Managingthe gingival zenith at the time ofimplant placement sets the stagefor ideal anterior single toothesthetics. Whether or not William’stheory of tooth form has merit,20

the characterization of teethas square, ovoid, or triangularis based on the peri-coronalarchitecture. An often unrecog-nized truth about dental implantesthetics is that tooth form islargely defined by the peri-implantmucosal architecture.

Controlling Peri-ImplantMucosal ArchitectureA reproducible procedure shouldbe imposed onto the artistic phi-losophy of each clinical exercise.For the single tooth dental implant,

A B

Figure 2. In the left (A) and right (B) views, the retained c and f teeth reflect the absence of permanent cuspidteeth. The retained deciduous teeth have aided in the preservation of alveolar bone, but the location of thegingival contours are not correct and are unattractive. Using the present bone and gingival locations to guideimplant placement would result in short clinical crowns. Redefining the gingival zeniths of the permanent cuspidteeth is required.

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this process begins with an estheticdiagnosis. The diagnosis is nothingmore than the assessment of theobjective criteria as displayed bythe preoperative condition of thepatient. Suggested is the use ofclinical digital photographs uponwhich simple evaluations can besuperimposed (Figure 4).

Perhaps, the most prognostic indi-cator of eventual esthetic successthrough symmetry is gained byevaluation of the connective tissueattachment at the adjacent teeth.

Careful assessment using a peri-odontal probe and diagnostic peri-apical radiographs are needed.Loss of attachment of greater than1.0 mm is clinically discernible anddifficult to regenerate. This step isessential because interproximalperi-implant mucosal contours(papillae) are greatly dependent onadjacent tooth contours. Togetherwith study casts indicating theextent of alveolar ridge resorption,a thorough prognosis and treat-ment plan can be provided tothe patient.

For the situation of the single ante-rior missing tooth, it is not pos-sible to fully appreciate thesecriteria unless a fully contouredcrown is waxed in the edentulousspace (Figure 5). Following thediagnostic waxing, it is thenpossible to understand the relation-ship between the proposedgingival zenith location and theexisting mucosa. The relationshipof the gingival zenith to theunderlying bone can only be deter-mined by bone sounding with adiagnostic template in place or,

Figure 3. The location of the gingival zenithshould be symmetrical with thecontralateral tooth and in harmony with theadjacent teeth. As revealed in thisillustration, the gingival zenith should belocated approximately 3 mm from theimplant/abutment interface. This permits asubgingival crown margin at the facialaspect of the implant and provides at least2.5 mm for the development of the biologicwidth in a supercrestal position. Placementof the implant/abutment interface in adeeper location will result in loss of boneand facial peri-implant mucosal recession.

Figure 4. A simple photograph (representing the situation illustrated inFigure 2) can be used to objectively evaluate the clinical situation to makea complete esthetic diagnosis. Note that the mirror image of the right andleft gingival contours do not match. Note also that the orthodontist hasprovided good spacing for the central and lateral incisors; it is clear thatrelative to #10, tooth #7 is distal in its location. The gingival zenith ontooth #11 has been marked to indicate how its position guides overallesthetic value of the implant restoration, presently represented byprovisional crowns without occlusion.

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preferably by use of volumetricimaging (e.g., cone beam computedtomography) with a radiopaqueimage of the gingival zenith inplace (Figure 6). This assessment iscritical. Without underlying bone

to support the buccal contour infull dimension, the esthetic volumeof the edentulous space ultimatelywill be deficient (Figure 7). Basedon the location of the plannedgingival zenith, therefore, decisions

regarding the need for boneaugmentation, socket preservation,and/or soft tissue augmentationprocedures can be prudentlyaccessed.

A B

Figure 5. Study casts of the interim situation and the diagnostically waxed cast. The location of the gingival zenith isdirected by the process of diagnostic waxing. This is confirmed by the evaluation of the intraoperative study cast.

A B

Figure 6. A, Detailed evaluation of the diagnostically waxed cast reveals that the conceptsrevealed by the objective esthetic evaluation have been translated to the cast. This includes theharmonious arrangement of the gingival zeniths and the proper location of the cuspid zenith inthe buccolingual as well as the apicoincisal direction. Bone should be present 3 mm apical tothe gingival zenith. B, An unrelated cone beam computed tomography image of a canine siteexemplifies the examination of the required gingival zenith/bone relationship. In this example,insufficient bone for an esthetic restoration exists. The planned restoration’s zenith is 8 mmfrom the alveolar crest. The resulting crown would be approximately 14 to 15 mm in length(versus the average of 10–11 mm). Bone augmentation would be indicated.

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Prosthodontic Management ofPeri-Implant Mucosal ArchitectureWith an implant positioned prop-erly in the alveolus, the control ofperi-implant tissues is enhancedmorphologically by enforcing theremodeling of tissues using prop-erly contoured abutments andprovisional crowns (Table 2). Toassure proper healing and to limitinflammation, properly polishedabutments of titanium or zirconia

should be sculpted to support thesoft tissue form, and thus, the cer-vical contour of the crown. Typi-cally, the abutment will possessconcave features with the possibleexception being a convexity of thebuccal surface. This is particularlyimportant in developing thecontours of any provisionalrestoration for a dental implant.Morphologic refinement is estab-lished using the provisional crown

and again, the submucosal con-tours should be refined to bemore root-like (concave inter-proximally) to support ideal tissueform. No particulate materialsshould be introduced into thesulcus and all debris should becarefully washed from theimplant and sulcus prior to thedelivery of the abutment andcrown. The provisional crownshould be highly polished, well

A B

C

Figure 7. A, Intervening veneer preparations for teeth #7 to #10 were performed in the enamel only. Theprovisional crowns are removed and impression copings are placed for fixture level impressions of the AstraTechdental implants. B, ZirDesign abutment delivery in the well-formed residual alveolar mucosa. The provisionalcrown should aid in the creation of the gingival contours. The form of the provisional crown should reflect boththe clinical crown marginal contours as well as provide ideal submucosal transition contour. In most cases, theinterproximal surfaces of the abutment and crown should be concave or flat, whereas the buccal contours areslightly convex in support of the buccal architecture. The interproximal contours must accommodate sufficientinterproximal tissue mass to support contours. C, Provisional crowns reflect the contours of the diagnostic waxingand have been used to direct soft tissue changes at the implants as well as the mesial aspects of tooth #7 and #9.

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adapted to the abutment margin,and free of extruded cement(Figure 7).

A S S E S S M E N T AT T H E

P R O V I S I O N A L P H A S E O F

I M P L A N T R E S T O R AT I O N

Excellent esthetics frequentlyinvolves iterative processes. Forimplant crowns, attempts toprovide highly esthetic crowns toproperly contoured peri-implantmucosa directly from a fixture

level impression is not likely toachieve great expectations. It isimportant to provisionalizeimplants with provisional ordefinitive abutments and achievethe planned tissue architecturedescribed earlier. After aperiod of tissue healing (6–8weeks) or adaptation (3–4 weeks),objective assessment should beperformed. Only after reviewingpotential opportunities for refine-ment should the final impression

of the implant or abutment bemade. Several suggestions for cap-turing the form of the peri-implant mucosa include theplacement of rigid materials intothe sulcus. This is not recom-mended if the peri-implant tissuesdisplay little inflammation andtissue prolapsed (Figure 8).Regardless of the method chosen,the sulcus should be carefullyexamined and debrided afterthe impression is made. The

A B

C

Figure 8. A, Facial view of final restorations on implants #6 and #11, and teeth #7 to 10. All ceramiccrowns were bonded to ZirDesign implant abutments and veneers were bonded to #7 to #10. The photo-graph was made 3 months after delivery of the definitive prostheses. B, One-year evaluation of therestoration/tissue relationships #6 to #8 and (C) #9 to #11. The form and color of the peri-implant mucosais in part due to the choice of the zirconia abutments and modification of the tissues during the immediateprovisionalization period. The thick biotype contributes to the predictability of tissue responses illustratedhere. The definitive restorations were artfully produced by Mr. Lee Culp, CDT.

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provisional restoration should bereplaced with little or no displace-ment or disruption of theperi-implant mucosa.

D E L I V E RY A N D A S S E S S M E N T O F

T H E F I N A L P R O S T H E S I S

The goal of the laboratory proce-dures includes the preservation andpossible directed enhancement ofthe peri-implant mucosal form

created by the clinician, mainte-nance of the designated incisaledge position and incisal embra-sures, and the creation of the des-ignated abutment and crown. Theprepared abutment and crownmay be delivered to complete therestorative procedure.

With a major goal being to pre-serve the peri-implant mucosal

architecture with the gingivalzenith as a reference point, it isimportant to evaluate possibletissue displacement when a finalabutment is placed. Only modest,if any, blanching should be evidentusing this protocol following acareful provisionalization process.If tissues are displaced apically, itsuggests that the abutment isimproperly contoured and is mostlikely convex in form. Theabutment can be modified and thetissue contours can be evaluatedagain. Abutment delivery is, there-fore, a critical step in the controlof the peri-implant mucosal form.

Finally, the crown can be evaluatedin the usual and customarymanner. Applying the objective cri-teria for dental esthetics, here is avery useful checklist for this proce-dure.6,7 It will focus attentionbeyond the issues of delivering animplant crown, and it reaffirms themaintenance of peri-implantmucosal architecture.

A P R O C E D U R A L R E V I E W

Integration of the concepts dis-cussed earlier indicates that for allanterior implants, there is a set ofprocedures that can assure estheticsuccess (Table 3). The processbegins with an esthetic diagnosis toreveal the limitations present andto suggest steps to overcomeesthetic limitations before initiatingimplant therapy. The key featuresto observe include adjacent tooth

TA B L E 3 . P R O C E D U R A L C O N T R O L O F P E R I - I M P L A N T M U C O S A L

A R C H I T E C T U R E .

• Esthetic diagnosis using objective criteria• Determination of the adjacent connective tissue attachment• Diagnostic waxing with emphasis on peri-implant mucosal architecture

(evaluation of the residual alveolar ridge)• Assessment of bone-to-prosthesis relationship (CBCT/bone sounding)• Possible bone and/or soft tissue augmentation to support objectively defined

crown form• Ideal placement of the implant relative to the planned gingival zenith• Creating the ideal peri-implant mucosal architecture using well-formed

provisional crowns and abutment• Selection of abutment and crown materials to support peri-implant mucosal

health• Removal of cement from the sulcus

TA B L E 2 . FA C T O R S C O N T R O L L I N G B U C C A L P E R I - I M P L A N T T I S S U E S .

• Initial presentation (Seibert classification)• Implant position capability (relative to planned gingival zenith)• Bone formation and resorption at the implant• Peri-implant mucosa integration

� Character of the implant abutment interface� Inflammation� Local factors (plaque, etc.)� Patient factors (e.g., biotype)

• Abutment form• Submucosal contour of the provisional crown• Bone modeling/remodeling• Potential adjacent tooth eruption

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connective tissue attachments.Further evaluation requires that adiagnostic waxing is performed tosuggest the ideal restorative form.The designated gingival zenith canthen be used to identify the criticalcrown-to-bone relationship, todayusing volumetric radiographicimaging techniques. If the idealgingival zenith is greater than3 mm incisal and 2 mm buccalfrom the existing bone crest, thenthe bone augmentation proceduresmay be considered. The gingivalzenith, therefore, becomes thetherapeutic reference point. A posi-tive esthetic result is suggestedwhen the adjacent tooth attach-ment levels are intact and there isadequate bone relative to the refer-ence point. Using a surgical guide,the implant can be accurately posi-tioned to the zenith referencepoint. At the appropriate time(following immediate placement,one-stage surgery, or two-stagesurgery), an abutment can beplaced to permit the formation ofbiologic width along the abutmentand to begin to properly contourthe peri-implant tissues. The provi-sional crown should be used todirect proper morphologic develop-ment of the peri-implant mucosaand control the crown’s ultimateform. Finally, the definitive restora-tion should impart color, translu-cency, contour, and surface texturethat embellish or match theadjacent and contralateralanterior teeth.

C O N C L U S I O N S

An objective approach to dentalimplant therapy is warranted.Recent application of objectivecriteria suggests that furthercontrol of the anterior dentalesthetics might be achieved. Forexample, the level of the peri-implant soft-tissue margin came tolie within 1 or 2 mm of the refer-ence tooth in no more than 64%of the implant-supported replace-ments. The color of the peri-implant soft tissue matched that ofthe reference tooth in no morethan just over one-third of cases.6

More recently, Meijndert and col-leagues9 reported that only 66%of single-implant crowns in 99patients were rated acceptable bya prosthodontist, despite highpatient satisfaction. This may bethe result of soft tissue changes.For example, the measured meanapical displacement of facial softtissue was 0.6 mm 1 year aftercrown placement on abutments atflat-to-flat dental implants (Card-aropoli and colleagues).21 In con-trast, Cooper and colleagues13

reported the stability of the facialsoft tissue contour at conus designimplant/abutment interfacesthroughout a 3-year periodfollowing dental implant place-ment and provisionalization.

It may be possible to exert clinicalcontrol over the facial soft tissuecontours that control single-implant esthetics. Recognizing the

initial limitations and guidingtreatment planning by the use ofthe objective criteria for dentalesthetics are essential to thisprocess. Targeting the clinical andbiologic factors affect these crite-ria, particularly, the buccal tissuecontour may improve single-dentalimplant esthetics. The influence ofcomponent selection is suggestedbut remains unproven. Nonethe-less, the controlling depth ofimplant placement, managing peri-implant mucosal biology by limit-ing inflammation, and managingperi-implant mucosal morphologythrough ideal abutment selectionand provisionalization extend theclinical control of single-toothdental implant esthetics.

R E F E R E N C E S

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2. Tortopidis D, Hatzikyriakos A, Kokoti M,et al. Evaluation of the relationshipbetween subjects’ perception and profes-sional assessment of esthetic treatmentneeds. J Esthet Restor Dent 2007;19:154–62; discussion 163.

3. Lindh T, Gunne J, Tillberg A, Molin M.A meta-analysis of implants in partialedentulism. Clin Oral Implants Res1998;9:80–90.

4. Roos J, Sennerby L, Lekholm U, et al. Aqualitative and quantitative method forevaluating implant success: a 5-yearretrospective analysis of the Brånemarkimplant. Int J Oral Maxillofac Implants1997;12:504–14.

5. Zitzmann NU, Berglundh T, MarinelloCP, Lindhe J. Experimental peri-implantmucositis in man. J Clin Periodontol2001;28:517–23.

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6. Fürhauser R, Florescu D, Benesch T, et al.Evaluation of soft tissue around single-tooth implant crowns: the pink estheticscore. Clin Oral Implants Res2005;16:639–44.

7. Meijer HJ, Stellingsma K, Meijndert L,Raghoebar GM. A new index for ratingaesthetics of implant-supported singlecrowns and adjacent soft tissues—theImplant Crown Aesthetic Index. Clin OralImplants Res 2005;16:645–9.

8. Chang M, Wennström JL, Odman P,Andersson B. Implant supported single-tooth replacements compared to contralat-eral natural teeth. Crown and soft tissuedimensions. Clin Oral Implants Res1999;10:185–94.

9. Meijndert L, Meijer HJ, Stellingsma K,et al. Evaluation of aesthetics of implant-supported single-tooth replacements usingdifferent bone augmentation procedures: aprospective randomized clinical study. ClinOral Implants Res 2007;18:715–19.

10. Kopp FR, Belser UC. Esthetic checklist forthe fixed prosthesis. In: Sharer P, Rinn LA,Kopp FR, editors. Esthetic guidelines forrestorative dentistry. Chicago (IL): Quin-tessence Publishing Co.; 1982. p. 187–92.

11. Mange P, Belser U. Bonded porcelainrestorations in the anterior dentition: a

biomimetic approach. Chicago (IL):Quintessence Publishing Co.; 2002.

12. Cooper L, Felton DA, Kugelberg CF, et al.A multicenter 12-month evaluation ofsingle-tooth implants restored 3 weeksafter 1-stage surgery. Int J Oral MaxillofacImplants 2001;16:182–92.

13. Cooper LF, Ellner S, Moriarty J, et al.Three-year evaluation of single-toothimplants restored 3 weeks after 1-stagesurgery. Int J Oral Maxillofac Implants2007;22:791–800.

14. De Kok IJ, Chang SS, Moriarty JD,Cooper LF. A retrospective analysis ofperi-implant tissue responses at immediateload/provisionalized microthreadedimplants. Int J Oral Maxillofac Implants2006;21:405–12.

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Reprint requests: Lyndon F. Cooper, DDS,PhD, Department of Prosthodontics, UNCSchool of Dentistry, Chapel Hill, NC 27599,USA; email: Lyndon_Cooper@dentistry.unc.edu

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