Review of literature:

Orban F et al. (Dimensions and Relations of the Dentogingival Junction in

Humans. J. Periodontol (1961 32:261))

In their study measured dimensions of tissues involved in Biological Width

considerations. Used histologic sections to measure average dimensions of

biologic width. These are not clinically accurate due to distortion with

histologic processing. This study said width of junctional epithelium plus

connective tissue width was Biologic width; i.e.approximately 2 mm. If a

subgingival crown margin is placed in the middle of the gingival sulcus, the

crest of bone should be a minimum of 2 mm apically positioned. mean depth

of the histologic sulcus is 0.69 mm,mean junctional epithelium measures 0.97

mm (0.71 to 1.35 mm),mean supraalveolar connective tissue attachment is

1.07 mm (1.06 to 1.08 mm).The total of the attachment is therefore 2.04

millimeters (1.77 to 2.43 mm) and is called the biologic width.

James s Marcum et al, J Prosthet Dent. 1967 May;17:479-487

studied the effect of crown marginal depth upon gingival tissue.,

Sixty six crowns were placed and finished above, below, and even with the

gingival crest in 6 dogs. the crowns were left in place until the dogs were put to

death at time intervals of one ,two, and three months. two dogs were sacrificed

at each interval, block specimens of the teeth and gingiva were taken at this

time. Control specimens of unoperated teeth were also taken. The block

specimens were decalcified,sectioned,stained,histologically examined,and

graded for severity of inflammatory response.six hundred histological slides of

the tissue sections were graded as having evidence of none,slight,moderate or

severe gingival inflammation.

The investigation showed that crowns with margins located at or even with the

gingival crest caused the least inflammatory response; that crowns with margins

located above and below the crest cause the most severe inflammatory response.

The length of time a restoration was in place had little if any effect upon the

severity or degree of inflammation.

Choosing the proper crown marginal depth depends upon many factors.however

it appears from the results of this investigation that crowns with the gingival

crest would be least likely to cause gingival inflammation.

Yuodelis et al,

J Prosthet Dent. 1973 jan;29:61-6

Studied about the esthetics and hygiene in crowns given after periodontal

therapy that involves osseous resection procedures or following gingival

recession,we are often confronted with longer than normal clinical

crowns.these lengthened clinical crowns are much more difficult to keep

plaque free due to the exposed furcations and root flutings. If plaque is

allowed to accumulate for long periods of time ,demineralization of the

cemental surfaces will rapidly cause increased sensitivity and root caries. If

root portions must be covered by complete artificial crowns ,the gold castings

should not frustrate the oral hygiene efforts of patients.

The final restoration should not follow the original anatomic crown and should

recreate the original contours of the root portion.the modification of the

anatomic coronal form entails reduction of unnecessary bulges in order to

create additional accessibility to gingival third of the fluted and furcation

regions.this will eliminate the triangular region that is created by the roots and

cervical bulge and which is the area most difficult to maintain in a plaque-free

condition by normal brushing.for this reason we endeavour to flatten the facial

and lingual contours of restorations and have observed excellent gingival

response.most probably the cervical region is made more accessible for

routine home care.

D. Tarnow et al( Journal of Clinical Periodontology Volume 13, Issue 6, pages

563–569, July 1986)

Studied Human gingival attachment responses to subgingival crown placement

and marginal gingival remodelling.

13 teeth in block were extracted from 2 patients. Their facial periodontal

condition was essentially within normal clinical limits. Temporary crowns

covering the bevel were placed below the base of the crevice 1 to 8 weeks prior

to extraction. At time of extraction, all blocks were decalcified, the temporary

crown dissolved, and the blocks prepared for histologic examinations using

bucco-lingual cut, step serial sections.

Histologic data revealed reformation of a new supracrestal attachment unit

within 1 week following crown placement. The reformation of the gingival unit

consisted of marginal recession with apical and lateral migration of the

junctional epithelium to the level of remaining cementum inserted fibers. With

gingival recession and migration of junctional epithelium, resorption of crestal

portions of the facial plate occurred. However, periodontal fibers anchored into

cementum opposite the resorbed bone were not lysed. Rather, the attached

fibrillar ends appeared to interdigitate with fibers from the corium of the facial

gingiva at this site, thereby forming a more apically located crestal attachment.

This response may be one mechanism of reformation of the gingival attachment

unit taking place following mechanical and/or surgical injury to this site and is

completed often, within 2 weeks after injury.

Geoffrion J.et al 1989.

[Transformation of a lateral incisor to a central incisor with a ceramometal

crown].

They gave guidelines to change a maxillary lateral incisor into a central incisor

by using a ceramo-metallic crown. It is required to schedule a rational plan of

treatment. All the different pre-prosthetic (orthodontic, periodontic, and

endodontic) and prosthetic steps are described and justified. In order to

achieve a compromise between esthetic and a stable periodontium the mesial

profile of emergence of the ceramic should be conceived to prevent any

overcontour.

Croll BM.et al

(J Prosthet Dent. 1990 Apr;63(4):374-9.)

In their study showed that Selection of the straight emergence profile in

designing artificial crowns for teeth has been shown to improve the

effectiveness of oral hygiene near the gingival sulcus. The axial profile of teeth

can be viewed as a series of straight lines with curved transitions.

Reproduction of these geometric patterns facilitates fabrication of restorations

that appear natural.

Ferencz JL.

(J Prosthet Dent. 1991 May;65(5):650-7.)

Reviewed about Maintaining and enhancing gingival architecture in fixed

prosthodontics.

The long-term success of fixed prosthodontic restorations is greatly dependent

upon the health and stability of the surrounding periodontal structures. This

article deals with the interrelationship between fixed prosthodontic

procedures and the stability and health of the periodontium. The commonly

encountered problem of alterations in gingival architecture is examined in

relation to tooth preparation as well as soft tissue preparation. In addition, the

ability of the provisional restoration to guide soft tissue form is discussed as

well as the role of the final restoration in providing long-term tissue

maintenance. Key factors such as margin placement, tissue damage during

tooth preparation, the role of the provisional restoration, tissue injury during

impression procedures, crown contour, pontic design, and embrasure design

are all important factors to be considered to achieve a good emergence profile.

Donald F. Reikie et al (J Prosthet Dent 1993;70:433-7)

Did a review of esthetic and functional considerations for the partially

edentulous implant candidate. Stated that with the availability of adjunctive

grafting procedures, it is time for the implant team to change the traditional

treatment planning approach that allows patient anatomy to dictate implant

position and prosthesis design. Dimensions of the edentulous space and

evaluation of occlusal relationships are discussed by the author. Soft tissue

ridge contour and creation of favorable cervical harmony are also reviewed.

Functional demands unique to the partially edentulous patient are outlined in

addition to the challenges of creating a prosthesis with natural cervical form

and emergence profile.

David Neale et al (J Prosthet Dent 1994;71:364-8)

Describes a technique to help predict, develop, and evaluate implant

prostheses and their soft tissue contours at the provisional restoration stage.

This technique records the planned and subsequently proven contours, which

are then used to guide fabrication of the final prosthesis and produce a

predictable esthetic result.

Shavell et al

(Pract Periodontics Aesthet Dent. 1994 Jan-Feb;6(1):33-44; )

Suggested that the delicate dento-gingival attachment apparatus must be

treated with utmost respect during all preparational maneuvers in the

crevicular region. There is little room for error within these minute dimensions.

To avoid irreparable harm during chemo-mechanical manipulation of the

attachment apparatus, the dentist must always think on a histologic level in

order to respect the cellular integrity of the periodontium.

C. YOUNGSON et al. 1996

They studied about the preparation form and emergence profiles of maxillary

metalloceramic crowns .

The aim of their study was to compare the emergence profiles of crowns with

their contralateral tooth, in vitro, and determine if there is any association

between the design of tooth preparations and the resultant emergence profile.

In this study 50 models used for single crown construction were examined.

Measurements of the faciolingual width of the crowns and contralateral teeth

were taken using digital calipers. Internal line angles and the margin width of

dies and the emergence profile of the corresponding crowns were measured

from longitudinally sectioned polyvinylsiloxane indices of preparations and

associated crowns mounted on a flat-bed scanner using image analysis

software.

In this in vitro study, they concluded that the emergence profiles of crowns

were higher than the contralateral teeth. Maxillary metalloceramic crown

preparations had shoulder widths that did not conform to recommendations in

standard texts but line angles were within a satisfactory range. The margin

width exerts a weak effect upon the emergence profile of the crown.

Davidoff SR et al

(J Prosthet Dent. 1996 Sep;76(3):334-8)

Described a procedure for late stage soft tissue modification for achieving

anatomically correct implant-supported restorations. Author presents a simple

method of modifying soft tissues coronal to the implant head that will allow

the development of a restoration with correct emergence profile and anatomic

contour.

Reeves WG.et al 1996

Studied the restorative margin placement and periodontal health.

Subgingival restorative margins are associated with the development of

plaque-related inflammatory periodontal disease, primarily because of a shift

in the subgingival microflora from a profile associated with health to one

associated with disease. The degree and extent of the marginal inflammation is

influenced by four factors: failure to maintain proper emergence profile,

inability to adequately finish and/or close subgingival margins, placement of

subgingival margins in an area with minimum to no attached gingiva, and

violation of the biologic width. Supragingival margin placement is the location

of choice for all restorative margins to avoid iatrogenic periodontal disease.

However, consideration of these four factors will help reduce the adverse

impact of restorative margins that must be carried subgingivally.

Souheil Hussaini et al (J Prosthet Dent 1997;77:630-2)

Describes a procedure that enables the clinician to fabricate a full-arch

maxillary provisional restoration for a fully edentulous patient, which can be

delivered at second-stage surgery at the time of uncovering the implants. It

satisfies the patient's esthetics, phonetics, and functional demands and helps

create a good emergence profile for the healing gingival tissue.

Kleber BM et al 1997

Studied about the Influence of marginal and submarginal restoration margins

on periodontal tissues.

They concluded that Subgingival and irregular restoration margins have an

unfavourable influence on the marginal periodontal tissues. The margins close

to the gingiva of 206 restorations (age of restorations mean = 49.4 months)

showed incorrectnesses in most cases with marginal inflammation as a result.

That's why the demand of high precision, supragingival positioning of margin

restoration and removal of all potential plaque-retentive or mechanic irritated

surface is raised.

Salinas TJ et al

(Pract Periodontics Aesthet Dent. 1998 Jan-Feb;10(1):35-42)

Establishing soft tissue integration with natural tooth-shaped abutments.

Stated that the disparity in dimensions between implant fixtures and the

exposed extraction sockets has resulted in the development of anatomically

shaped abutments. Systems have been recently introduced that facilitate the

fabrication of abutments to the configuration of natural teeth in the anterior

maxilla. These systems permit development of an aesthetic emergence profile

and contours for easy access in maintenance of oral hygiene of maxillary

anterior single-tooth implant-supported restorations. The rationale for the

development, indications, advantages, and clinical utilization of a recently

introduced abutment system is discussed by the author.

Papazian S et al (J Prosthet Dent. 1998 Feb;79(2):232-4)

Described a laboratory procedure to facilitate development of an emergence

profile with a custom implant abutment.when an implant abutment must be

customized,access to coronal portion of the implant analog requires ditching of

the artificial stone on the master cast.In this procedure the author uses an

orthodontic elastic band with a square cross section to produce space around

the coronal aspect of the analog and eliminate the need for ditching.

Tung FF

( J Prosthet Dent. 2000 Jun;83(6):681-5.)

Describes a procedure for simultaneous registration of gingival emergence

profile and maximal intercuspal position for metal ceramic restorations. The

materials used in this procedure are inexpensive, readily available, and easy to

use. The clinician can inspect the framework, cast, and tissue profile before

sending them to the laboratory. When this method is properly used, it allows

better communication with the dental technician, saves chair time, and

reduces the number of laboratory procedures as currently practiced.

Schätzle M et al

(J Clin Periodontol. 2001 Jan;28(1):57-64.)

Studied the influence of margins of restorations of the periodontal tissues

over 26 years.The aim of this study was to examine the long-term relationship

between dental restorations and periodontal health.The data was derived

from a 26-year longitudinal study of a group of Scandinavian middle-class

males characterized by good to moderate oral hygiene and regular dental

check-ups. At each of 7 examinations between 1969 and 1995, the mesial and

buccal surfaces were scored for dental, restorative and periodontal

parameters. The mesial sites of premolars and molars of 160 participants were

observed during 26 years (1969-1995). A control group with 615 sound

surfaces or filling margins located more than 1 mm from the gingival margin in

all 7 surveys was compared with a test cohort with 98 surfaces which were

sound or had filling margins located more than 1 mm from the gingival margin

at baseline (1969) and had a subgingival filling margin 2 years after (1971).

The study confirmed the long held concept that restorations placed below the

gingival margin are detrimental to gingival and periodontal health. In addition,

this study suggests that the increased loss of attachment found in teeth with

subgingival restorations started slowly and could be detected clinically 1 to 3

years after the fabrication and placement of the restorations. A subsequent

"burn-out" effect was suggested.

Davarpanah M,

(Pract Proced Aesthet Dent. 2001 Nov-Dec;13(9):761-7; quiz 768, 721-2.)

Described about a three-stage approach to aesthetic implant restoration:

emergence profile concept. The three-stage approach of the emergence profile

concept guides the selection of implant, healing abutment, and provisional

prosthesis. Adaptation of the implant, provisional prosthesis, and crown

restoration stages and their harmonious integration with the soft tissues

enable the development of an optimal aesthetic result.The author

demonstrates the incorporation of the emergence profile concept for aesthetic

implant placement.

Song-bor kuo et al (J Prosthet Dent 2002;88:646-8)

Describes a method for fabricating an optimal emergence profile for the

definitive restoration of an ITI solid abutment when the implant is installed

subgingivally. Here the definite restoration for ITI solid abutment is fabricated

by waxing on the plastic coping ,casting the metal coping and adding

porcelain on the metal coping. The soft tissue model is used to adjust and

finalize the emergence profile during these different laboratory procedures. As

the subgingival configuration of the modified impression cap is performed in

the lab ,this technique may reduce chair time. The result of the peri implant

mucosal health serves to verify that the emergence profile is acceptable. This

technique cannot be applied to the narrow neck implant abutment and angle

abutment because they do not use a similar impression cap.

Michael Tischler et al. 2004

Dental Implants in the Esthetic Zone Considerations for Form and

Function .The concept of emergence profile is important when dealing with

implant esthetics. The emergence profile can be obtained three different ways.

One way is for the healing abutment to form the surrounding soft tissue. The

second way to sculpt the tissue around an implant is to have the implant

abutment create ideal form. This can be done with a custom abutment at

either first or second stage. If the abutment is used to create the emergence

profile at first stage, then the criteria for immediate loading must be

considered. The third way to create the emergence profile is to allow a

provisional restoration to sculpt it. This can be done either with an ovate

pontic or with the contours of a cemented restoration at either first- or

second-stage surgery.

Daniel C.T.Macintosh et al. (J Prosthet dent 2004 ;91:289-92)

The author describes a method for creating an improved emergence profile

with single-tooth, implant-supported restorations. An easily trimmed silicone

gingival substitute is used to allow polymerization of acrylic resin provisional

restorations to achieve control of the emergence profile. Gingival trauma is

minimized by eliminating intraoral use of monomer and minimizing surgical

procedures. Provisional restorations can be assessed to ensure the contour is

acceptable and the trimmed gingival substitute can be used to fabricate a

similar profile in the definitive prosthesis. The provisional restorations may be

used instead of standard prefabricated healing abutments to guide the healing

contours of the peri-implant gingival tissue.

Mario R. Ganddini et al. (J Prosthet Dent 2005;94:296-8)

Suggested that the fabrication of provisional restorations is an important stage

in implant treatment. In the esthetic zone, the potential for error without the

use of provisional restorations in the selection of the abutments, framework

design, appropriate vertical dimension of occlusion, occlusal profile, and the

esthetic interpretation may be significant. Provisional restorations are

indicated in esthetic zones, for the contouring of the gingiva, to achieve an

acceptable emergence profile, to have custom-guided tissue healing, and to

induce appropriate soft-tissue topography. They described the fabrication of a

provisional restoration for a single-unit implant-supported crown.

Sundh B et al.2005

Did an in vivo study of the impact of different emergence profiles of procera

titanium crowns on quantity and quality of plaque.The purpose of this study

was to evaluate the effect of crowns with different emergence profiles on

marginal plaque formation.

Seven crown preparations were performed on premolar teeth in six patients.

Four titanium crowns for each tooth--with different marginal emergence

angles--were manufactured according to the Procera technique. The three

experimental crowns and the final permanent tooth were cemented with

phosphate permanent cement. Plaque samples were collected from the

marginal area after 1 week with normal oral hygiene, and again after refraining

from oral hygiene for 2 days. The contralateral tooth served as a control. The

quantity and quality of plaque were registered. The restoration was removed,

the next crown version cemented, and the protocol repeated.

All experimental crowns, irrespective of emergence profile, showed a

significantly lower (P = .01) plaque quantity than controls. No intraindividual

differences were found regarding the accumulation of mutans streptococci at

the different experimental emergence profiles. No differences in quality

between experimental and control sides were found.

Within the limitations of this study, it was found that titanium crowns with

emergence profiles of up to 40 degrees formed less plaque than healthy

controls. There was no higher accumulation of mutans streptococci in relation

to increasing emergence profiles.

Yotnuengnit B et al

(Quintessence Int. 2008 )

Did a study to find the geometric values of emergence angles in human natural

anterior teeth and to study their influence on periodontal status.

Fifty anterior teeth with full-crown restorations and homologous contralateral

sound teeth were examined for clinical parameters: Plaque Index, Gingival

Index, probing depth, and clinical attachment loss. Impressions and stone casts

were made and then separated along the midline of the teeth. All cut-surface

specimens were photocopied, scanned, and transferred into graphic form with

a special program. The emergence angles of both restored and natural teeth

were processed and recorded. Paired t test and multivariate linear regression

analysis were used for statistical analysis.

Mean supragingival emergence angles for facial and lingual surfaces of natural

anterior teeth were 11.13 +/- 7.92 and 15.58 +/- 9.16 degrees, respectively.

The corresponding values for subgingival emergence angles were 9.93 +/- 5.68

and 14.35 +/- 8.44 degrees. The periodontal parameters were higher in

restored teeth than in natural teeth. When Plaque Index and gender were

controlled, a correlation was shown between the lingual subgingival

emergence angle of the restored teeth and probing depth. A correlation was

also found between the lingual supra- and subgingival emergence angles, as

well as between both angles of the restored teeth and the attachment loss.

They concluded that the mean values of emergence angles obtained may aid

clinicians and dental technicians in more easily designing the definitive

emergence profile of restorations. The emergence profile of the restored teeth

may affect periodontal status on the lingual aspect.

Nihon Hotetsu et al. 2006

Presented a case of interdental papilla reconstruction with prosthodontic

treatment of maxillary central incisor.

A 20-year-old female whose chief complaint was esthetic disturbance of a

crown placed on the maxillary left central incisor.

The interdental papilla was reconstructed only by the prosthodontic treatment

of maxillary left central incisor. This case suggests that the proximal and

subgingival contours of provisional crown is very important to the

reconstruction of interdental papilla, and also suggests that the transmission of

the information regarding the configuration of a provisional crown to the lab

side is very important.

This case showed that the emergence profile of a single crown, especially of its

proximal aspect, is important to reconstruct the interdental papilla.

Saad A. Al Harbi et al (J Prosthet Dent 2007 ;98:329-332)

Describes a proceduce for a patient with a missing or failing maxillary anterior

tooth desiring for immediate tooth replacement.Here the fabrication of a

provisional restoration can be challenging. Due to individual anatomical

variations in tooth shape, size, and supporting soft and hard tissue structures,

there are no premanufactured components with an anatomical emergence

profile that universally suits all individual situations. The author describes the

fabrication of a screw-retained immediate provisional restoration that fulfills

anatomic, biologic, and esthetic requirements.

Nicolas Elian et al (J Prosthet Dent 19:306-315,2007)

Described a method of accurate transfer of peri-implant soft tissue emergence

profile from the provisional crown to the final prosthesis using an emergence

profile cast.

The use of impression copings to make the final impression results in a master

cast in which the soft tissue configuration around the implant platform is

circular. Therefore, any soft tissue sculpting developed clinically by the

provisional restoration is squandered.

The purpose of this report was to present a method for the precise transfer of

the peri-implant soft-tissue developed by a customized provisional restoration

to an emergence profile cast.The emergence profile cast is obtained from an

impression of the implant-supported provisional restoration and poured with a

soft tissue model material. It is used for the fabrication of the emergence

profile of the implant abutment and the cervical section of the crown.The

technique described was simple, accurate, predictable, and does not require

additional chair time for the customization of the impression coping or the

fabrication of a new provisional restoration.

This article describes a technique that results in an implant restoration that

mimics accurately in its emergence profile that of the carefully crafted and

customized provisional restoration. The reproduction of the soft tissue contour

from the provisional to the final restoration results in an improved esthetic

outcome of the final restoration.

Amina Mohamed Hamdy et al. Jan 2008

18 patients were selected from the out patient dental clinic of Faculty of

Dentistry , Ain – Shams University according to certain criteria . patients were

randomly divided into 3 groups ( n = 6) . In the first group patients received

fibre reinforced composite full coverage crown (FRC) , in the second groups ,

they received full coverage metal ceramic crowns , with metal collar margin

(MCR) , while in the third group , they received full coverage all – ceramic

crown (In ceram ) . These groups were further subdivided into two equal

subgroups (n = 3 ) , in subgroup A , the finish line was placed 0.5-1 mm

subgingivally , while in subgroup B , it was placed 0.5 – 1 mm supragingivally.

After proper assessment of the crowns , they were cemented using adhesive

resin cement (panavia F) . Gingival health was investigated according to plaque

index (PI) , sulcus bleeding index (BI) and pocket depth (PD) . The

measurements were taken immediately after crown cementation (baseline, o )

then after 3 month (3), at the mesial , distal , buccal and lingual surfaces for

each crown. Also, control teeth ( contra lateral teeth with no restorations) ,

were assessed similarly . statistical analysis was carried using Graphpad Prism

version 4.03. Fisher’s exact test and Chi square test were performed to

compare between categorical data . Results . Regarding plaque index group I

( FRC) ,subgroup A (Subgingival) showed higher significant difference (P =

0.015) after 3 months than at baseline , while no significant differences were

observed in any of the other groups or subgroups regarding sulcus bleeding

index (BI) or pocket depth (PD) . Also , all control teeth showed no significant

changes rather than tested crowned teeth or after 3 months from baseline

regarding the three different parameters . Conclusions . Plaque index has

increased significantly around subgingival margins of fibre reinforced

composite full coverage corwns while no changes in the sulcus bleeding index

or pocket depth was observed after 3 months of crown placement regardless

the material of construction or margin location .

Athanasios Ntounis et al.(2008)

This article describes an indirect impression technique that accurately captures

the soft tissue contours around an implant-supported provisional restoration.

Customized impression copings are used to transfer the soft tissue architecture

created by the interim prosthesis. The definitive restoration is shaped like the

provisional restoration, maintaining the emergence profile and optimizing

esthetics.

Alexander shor et al. (J esthet restor Dent 20:82-97,2008)

Suggested that fixed provisional restoration can also seve as an esthetic and

functional blue print in the fabrication of the definitive restoration.this article

presents a production technique and treatment workflow of a laboratory

fabricated ,screw retained fixed provisional restoration.provisional restoration

is fabricated using layering technique and internal stain charecterization.the

soft tissue profile of the working cast is modified according to the coronal

contour of diagnostic wax up.the developed emergence profile of provisional

restoration is transferred to master cast via customized impression coping.

Den Hartog L et al (J Prosthet Dent. 2009 Oct;102(4):211-5)

describes a treatment in which an anterior maxillary implant was immediately

restored with a provisional restoration. During the provisional phase, an

optimal emergence profile was created by adjusting the provisional

restoration. An impression was made with an individually fabricated

impression post for an accurate reproduction of the established emergence

profile and, finally, a screw-retained all-ceramic crown was placed. By

implementing this protocol, an optimal definitive result could be achieved,

together with immediate patient satisfaction. However, cooperation among

several disciplines and careful patient selection were required.

Panagiota eirini et al (J Prosthet Dent 2009;102:345-347)

Suggested that Obtaining an accurate representation of the soft tissue

contours developed around an implant in the esthetic zone is crucial to the

success of a restoration. The technique presented emphasizes “guiding” of the

soft tissue by modifying a provisional restoration to obtain an emergence

profile that appears natural and blends with the gingival contour of the

adjacent teeth. The technique provides an accurate impression of the soft

tissue through the intraoral use of autopolymerized acrylic resin supported by

the impression coping and vinyl polylsiloxane impression material. The

eventual restoration uses an esthetic zirconia custom abutment and an

implant-supported single crown to fulfill the esthetic and functional

expectations of the patient and the provider.

Azer SS. Et al

(J Prosthodont. 2010 Aug;19(6):497-501)

Described a simplified technique for creating a customized gingival emergence

profile for implant-supported crowns.This is also an economical technique to

direct gingival tissue healing, as well as create a removable gingival replica of

the customized gingival emergence profile. The created profile can then be

used in the dental laboratory to achieve a superior and predictable esthetic

outcome for implant-supported fixed restorations.

Jofre et al 2010

In their clinical report concluded that, Immediate provisionalization is

considered to be an advantageous procedure for aesthetic results in

immediate implant placement. Despite reports of

techniques and procedures that use the patient’s teeth,

these cannot always be recovered. The method

described offers a chairside alternative for fabricating

an immediate provisional for a single implant, replicating

the pre-existing anatomical crown with acrylic. Acrylic

is easier to handle for this procedure, and allows the

periodontal structures to be preserved.

The applications of this technique are extensive,

and can be used on anterior and posterior teeth as

well as fixed partial prosthetics and bridges.

Takahiko Sugiyama et al 2010

Used a system called friction system to achieve a esthetic emergence profile.

The Friction Retention System has many considerable advantages

and plays an important role in achieving perfect

treatment results. The indication is restricted to single tooth

replacement and that the limit is a three unit bridge.

In addition, implant placement conditions and securing

suffi cient tissue volume surrounding the implant are fundamental

to its success. ■

Beitlitum L et al 2011

Did a review on teeth replacement in the esthetic zone . Dental implants are

usually the preferred treatment alternative for tooth replacement.in this

review they discussed several clinical issues concerning implant placement in

the esthetic area. It is still unclear whether raising a flap at the time of implant

placement enhances alveolar crest remodeling. However, a flapless surgical

procedure could avoid changes in the free gingival margin and maintain the

the attached gingiva width. A submarginal approach not involving the free

gingival margin can be applied to treat bone defects with the GBR technique.

Implants should be placed as palatal as possible while maintaining optimal

restoration emergence profile and the horizontal bone defect filled with a non

resorbable material such as bovine bone mineral. Thick periodontal biotype

and coronally positioned free gingival margin usually lead to better results.

Immediate implant placement in presence of a periapical lesion may be

performed, however, sites should be thoroughly debrided prior to implant

placement.

Degidi M et al

(J Periodontol. 2011 May;82(5):708-15. Epub 2010 Dec 7)

Did a histologic and histomorphometric evaluation of nine equicrestal and

subcrestal dental implants retrieved humans.they did this study considering

that the stability of peri-implant crestal bone plays a relevant role relative to

the presence or absence of interdental papilla. Several factors can contribute

to the crestal bone resorption observed around two-piece implants, such as

the presence of a microgap at the level of the implant-abutment junction, the

type of connection between implant and prosthetic components, the implant

positioning relative to the alveolar crest, and the interimplant distance.

Subcrestal positioning of dental implants has been proposed to decrease the

risk of exposure of the metal of the top of the implant or of the abutment

margin, and to get enough space in a vertical dimension to create a

harmoniously esthetic emergence profile.

A retrospective histologic study was performed to evaluate dental implants

retrieved from human jaws that had been inserted in an equicrestal or

subcrestal position. A total of nine implants were evaluated: five of these had

been inserted in an equicrestal position, whereas the other four had been

positioned subcrestally (1 to 3 mm).

In all subcrestally placed implants, preexisting and newly formed bone was

found over the implant shoulder. In the equicrestal implants, crestal bone

resorption (0.5 to 1.5 mm) was present around all implants.

They concluded that the subcrestal position of the implants resulted in bone

located above the implant shoulder and thus a good emergence profile can be

achieved.

Avinash S. Bidra et al (Journal of Oral and Maxillofacial Surgery june 2011)

Omega-Shaped (Ω) Incision Design to Enhance Gingival Esthetics for Adjacent

Implant Placement in the Anterior Region.

Describes a technique to achieve a papilla-like tissue using an omega-shaped

(Ω) incision design when implants are placed adjacent to each other in partially

edentulous ridges. This incision design is intended to spare an area of soft

tissue of approximately 4 mm × 4 mm between the anticipated positions of the

adjacent implants. The area of soft tissue that is free from surgical insult later

helps in the creation of a papilla-like tissue through interim restorations.