implant, dental implant

1. Maxillary Anterior Single Tooth
Replacement with Implant
Presented By:
Dr Mujtaba Ashraf
MDS 3rd Year
Seminar Presentation
Department of Prosthodontics

2. Contents
• Introduction
• History
• Alternate treatment options
• Esthetic challenges
• Stage II Surgery and soft tissue emergence contours
• Immediate implant insertion after extraction
• Extraction and delayed implant placement
• Prosthetic phase

3. Introduction

4. • In early years of modern implantology, the chief concern was
tissue health and implant survival.
• Over the last decade, there has been an increasing
appreciation that esthetics is just as important to the success
of final restoration as health.
• Single tooth implants are now one of the most common
implant procedures performed around the world.
• In 2010, one of the three teeth replaced in several countries
was with an implant.
• It should be noted that the maxillary single-tooth
replacement is often the most difficult procedure to perform
in all of implant dentistry.

5. History
• Stock, in 1942, reported on a
replacement of maxillary lateral
incisor with a cylinder implant
• Before 1989, the most common
maxillary single-tooth used the
existing bone volume. When bone
width was not ideal, narrow-blade
form or pin implants were used to
support the crown

6. • When root form implants became the primary implant type
used by the profession, osteoplasty to increase bone width
followed by implant placement was the treatment of choice

7. • By 1995, bone augmentation procedures permitted
implants in the esthetic zone to be less compromised
related to esthetics.
• The soft tissue drape around the implant crown was often
deficient and not addressed.

8. • Since 2000, the exponential growth of the field of implant
dentistry has been paralleled by an exciting growth of esthetic
dentistry and soft tissue plastic regenerative surgery.
• The profession now realized that the restoration of the peri-
implant soft and hard tissue to an optimal architecture is the
key to a successful implant restoration.

9. Alternate Treatment options for Anterior Single-
tooth Replacement
Maxillary
Single tooth
replacement
Traditional
FPD
Cantilever
FPD
(missing LI)
Removable
partial
denture
Acid-etched,
resin-bonded
prosthesis

10. Esthetic challenges
Most difficult challenge in restorative dentistry
Even more difficult on an implant abutment
• The implant is often 5 mm
or less in diameter and
round in cross-section.
• A natural maxillary anterior
crown cervix region is 4.5
to 7 mm in mesiodistal
cross-section and is never
completely round

11. A key for ideal anterior esthetic implant restorations is the soft
tissue drape
There are six different times the complexities of soft tissue may
be addressed:

12. To ideally restore an esthetic maxillary anterior tooth, the
implant should be positioned in three dimensions within the
prosthetic contour requirements of the final restoration. Hence,
the ideal implant body position is first identified. This is
followed by the prosthetic aspects of developing the soft tissue
contour after integration.

13. Implant body position
Mesiodistal position
• The maxillary anterior single-tooth implant should be located
precisely in three planes.
• From a mesiodistal aspect, the implant most often is placed in the
middle of the space, with an equal amount of interproximal bone
toward each adjacent tooth
• The goal is to remain 1.5 mm or more from the adjacent CEJ of
each tooth.

14. • The incisive foramen is variable in size and position.
• The foramen may be larger than usual or expand on one side of
the midline within the bony canal.
• With such variances, the implant may encroach on the canal
and result in lack of bone on the mesiopalatal surface of
implant.

15. Faciopalatal Position
• The faciopalatal position of the implant in adequate bone width
is in the middle to slightly palatal of the edentulous ridge.
• The crestal bone ideally should be at least 1.5 mm wide on the
facial aspect of the implant and 0.5 mm or more on the palatal
aspect.
• In this scenario, if bone loss occurs on the implant, the facial
plate will remain intact and not cause recession on the facial of
the implant crown

16. Implant body angulation
The implant center at the crest has been addressed relative to
the faciopalatal and the mesiodistal positions of the edentulous
ridge. The implant body angulation from this point is
considered next.
Three faciopalatal angulations of the implant body are suggested:
1. Similar to the facial position of the adjacent natural teeth
2. Under the incisal edge of the final restoration
3. Within the cingulum position of the implant crown

18. Facial Implant body angulation
• In theory, a maxillary anterior
implant body angulation should be
positioned at the facial emergence
of the final crown, and this position
should be in the same position as a
natural tooth.
• The facial crown contour of a
natural tooth has two planes, and its
incisal edge is palatal to the facial
emergence of the natural tooth by
12 to 15 degrees.

19. • In addition, because the implant is narrower in diameter than the
faciopalatal root dimension, when the implant body is oriented
as a natural tooth and has a facial emergence, a straight
abutment is not wide enough to permit the two- or three-plane
reduction to bring the incisal edge of the preparation more
palatal.
• As a result, the incisal edge of the preparation remains too
facial.

20. Cingulum Implant body angulation
• A second angulation suggested in the literature is more
palatal, with an emergence under the cingulum of the
crown
• This position is also often the goal when a screw-retained
crown is used in the final restoration.
• This position also is suggested to increase the bone
thickness on the facial of the implant body.

21. • The cingulum implant position may cause a considerable
hygiene compromise
• The labial cervical contour of the implant crown must be
similar to the adjacent teeth for the ultimate esthetic effect.

22. • The modified ridge lap
crown has become a
common solution to correct
the esthetics of the
restoration when the
implant is placed in narrow
bone or follows a palatal
angulation position

23. Ideal Implant angulation
• The third implant angulation in the literature describes the most
desirable implant angulation. A straight line is determined by
connecting two points
• The center of the implant is located directly under the incisal
edge of the crown.
• With the incisal edge more palatal than the cervical portion, the
incisal edge position is ideal for implant placement and
accommodates some of the facial bone loss that often occurs
before implant placement.

24. • The implant abutment selected for a maxillary anterior single-
tooth implant is usually for a cemented restoration.
• A greater range of corrective prosthetic options exists with a
cement-retained crown for implants not well positioned. Single
anterior crowns do not require readily retrievable restorations.
• The abutment almost always should be greater than 5 mm in
height.
• The location of the cervical margin of a cemented crown can
be anywhere on the abutment post or even on the body of the
implant, provided it is 1 mm or more above the bone and less
than 1.5 mm below the FGM.

25. A surgical template for a maxillary anterior single tooth, with a
guide hole under the incisal edge of the implant crown.

26. • The implant body angulation under the incisal edge may also
be used for screw-retained restorations.
• In these cases, an angled abutment for screw retention is
inserted, and the coping screw for the crown may be located
within the cingulum. This method does not require a facial
ridge lap of the final crown, which decreases the risk of
compromised hygiene
Complications:
• Prosthetic screw loosening.
• When this occurs, there is an increased risk of marginal bone
loss as a result of crown movement and microgap created by
the loose screw.

27. Implant Depth Position
• Some authors have suggested that the implant be counter sunk below
the crestal bone more than 4 mm below the facial CEJ of the adjacent
teeth to develop a crown emergence profile similar to a natural tooth.
• This concept was originally developed for a 4-mm-diameter implant,
and the diameter of a central incisor root is 4 mm at a position 4 mm
below the CEJ.
>4mm from adjacent CEJ/ Too Deep

28. • Very esthetic restorations may be fabricated with this implant depth
position because the bulk of subgingival porcelain provides good color
and contour for the crown.

29. • Several concerns arise regarding the long-term sulcular
health around the implant when it is seated 4 mm or more
below the CEJ
• The first year of function often corresponds to a mean bone
loss range of 0.5 to 3.0 mm, depending partly on implant
design.
• This may lead to facial sulcular probing depths of 7 to 8
mm or greater.

30. Less than 2mm below the FGM / Too Shallow
• When the implant body is positioned less than 2 mm below
• the facial FGM of the crown, the cervical esthetics of the restoration are
at an increased risk because limited space is present subgingivally to
develop the facial emergence profile of the crown.
• The porcelain of the crown may not be subgingival enough to mask the
titanium color of the abutment or implant below the crown margin.

31. • To solve the problem of an implant body placed too shallow,
the restoring dentist may need to prepare the implant crest
module and place the margin of the crown directly on the
implant body

32. At 3 mm Below the Free Gingival Margin (Ideal Depth)
• The best platform level for a two-stage implant is similar to the most
desirable bone level before the loss of a natural tooth, which is 2 mm
below the adjacent tooth CEJ.
• The FGM of the adjacent teeth are easier to help determine the depth
than attempting to observe to the CEJ.
• It should be noted that the FGM of a lateral incisor may be 1 mm more
incisal than the adjacent central and canine natural tooth.

33. Stage II Surgery and Soft Tissue Emergence Contours
• The clinician should use radiographs to evaluate the crestal
mesial and distal bone–implant interface relative to an
absence of crestal bone loss before the abutment post is
added to the implant body.
• Probing is necessary to evaluate the facial and palatal
conditions.
• If bone loss is suspected, then the soft tissue should be
reflected for direct evaluation.

34. Bone loss
H O R I Z O N T A L
V
E
R
T
I
C
A
L
• Local autogenous grafts covered with a barrier membrane
and reapproximation of the soft tissue.
• a vertical bone defect less than 2 mm,
autogenous bone may be added and the uncovery
of the implant may proceed because bone growth
is more probable in the presence of the lateral
walls of bone.
VERTICAL

35. • When the implant–bone interface is acceptable, the
exposure of the implant body should be accomplished
with the soft tissue final architecture in mind.
• To achieve the proper soft tissue architecture, several
options are available, depending on the soft tissue
appearance before stage II uncovery.
• These soft tissue procedures may be classified as
subtractive, additive, or a combination of each.

36. Subtractive Technique
• The ideal goal of the soft tissue drape in a two-stage
surgical approach after the implant insertion is for the
soft tissue to be at the height of the desired interdental
papillae.

37. The transitional crown maintains
and helps improve the soft tissue
drape.
Soft tissue drape after 2 months

38. Addition Technique
• If the gingival contour at stage II uncovery is insufficient for
the proper architecture for the interdental papillae, then an
additive surgery is performed to gain tissue thickness and
height.
• An incision is made on the palatal aspect of the ridge, from
the palatal line angle of each adjacent tooth. The tissue is
elevated from the crest of the ridge, and the first-stage cover
screw is identified.

39. • A connective tissue graft or acellular tissue graft (AlloDerm)
is placed around the low-profile healing cap. The crestal
tissues are then draped over the healing cap and sutured to the
palatal tissue. In other words, the PME acts as a soft tissue
elevator to obtain space.
• The tissue heals by secondary intention in the palatal area, and
excess tissue forms on the facial and interproximal regions, to
the height of the interdental papilla

40. • An alternative addition technique at the stage II uncovery
procedure is developed and called the split-finger technique.
An incision is made in the sulcus of the adjacent teeth and
continues from the palatal aspect of each tooth for 1.5 to 2 mm
and loops to the facial parallel to the adjacent interproximal teeth.
The incisions then connect on the facial aspect at the desired
midfacial emergence of the crown.

41. The facial fingers are elevated facially

42. The palatal finger is reflected palatally and exposes the implant.

43. The palatal finger is split into two sections (mesial and
distal)

44. The full-thickness elevation exposes the implant, and
the cover screw is removed.

45. The implant abutment (or permucosal extension) is
added, and each split palatal finger is positioned under
the facial corresponding finger.

46. The implant abutment and elevated facial fingers
are in position.

47. The temporary crown is cemented, and the fingers are
sutured into position.

48. The final crown in position with properly developed
interdental papillae.

49. Immediate Implant Insertion after Extraction
• According to Kois, five diagnostic keys exist for
predictable single-tooth peri-implant esthetics when an
immediate extraction and implant insertion is
contemplated:
1. The tooth position relative to the FGM,
2. The form of the periodontium,
3. The biotype of the periodontium,
4. The tooth shape
5. The position of the osseous crest before extraction
• The soft tissue and bone comprise three of the five
factors for predictable esthetics.

50. An improved preservation of the soft tissue drape and
the bone architecture compared with their collapse after
tooth extraction.
Bone augmentation and soft tissue grafts after socket
healing and before implant insertion may be avoided.
Because there are fewer surgeries, there is less treatment
time and a reduced patient discomfort and cost.
More bone is present for implant fixation, and less void
is present between the implant and the extraction
socket.
Has been described as a preservation technique aiming
at maintaining the harmonious gingival architecture

51. The implant size is often 4 to 5 mm in diameter for a central
incisor, and the extraction socket is often greater than 6 mm so a
surgical defect as large as 2 mm remains around the implant.
An increased risk of failure is present when the implant is
inserted immediately after tooth extraction even under ideal
conditions.
Risk of crestal bone loss
The implant may have less fixation and increased risk of
mobility during early loading.
It is one of the best methods available to have an ideal esthetic
result. But if the implant fails, the esthetics may be forever
compromised.
Altered implant position: too deep/ too facial

52. Extraction and Delayed Implant Placement
• After tooth extraction and socket grafting, the soft tissue
granulates over the extraction site, thus creating an increased
zone of attached gingiva. An improved bone interface may be
obtained if the large-diameter extraction site is grafted and
heals before implant placement.
• If the labial plate is compromised, then additional intraorally
harvested bone or guided bone regeneration (GBR) is
indicated.
• The delayed implant insertion method appears to enhance
capillary propagation and trabecular formation before implant
placement, facilitating a more ideal formation of an implant–
bone interface

53. Conclusion
• The replacement of a single tooth in the anterior maxilla is
most challenging because of highly specific soft and hard
tissue criteria in addition to all other esthetic, phonetic,
functional, and occlusal requirements.
• Unique surgical and prosthetic concepts are implemented for
proper results. In spite of all the technical difficulties that
may be faced, the anterior single-tooth implant is the
modality of choice to replace a missing anterior maxillary
tooth.

54. References
• Dental Implant Prosthetics, Carl E Misch, 2nd Edition, 2015
• Dental Implant Prosthetics, Carl E Misch, 2005
• Misch CE: Single tooth implants difficult, yet overused,
Dent Today 11(3):46–51, 1992
• Tarnow DP, Cho SC, Wallace SS: The effect of inter-
implant distance on the height of interimplant bone crest, J
Periodontol 71:546-549, 2000.
• Tarnow DP, Eskow RM: Preservation of implant esthetics,
soft tissue and restorative considerations, J Esthet Dent
8:12-19, 1996.
• Wheeler RC: A textbook of dental anatomy and physiology,
ed 4, Philadelphia, 1965, Lea & Febiger.

55. Thank You

58. Prosthetic Phase
Maxillary Anterior Single Tooth
Replacement with Implant

59. Abutment Selection
• The single-tooth implant requires an antirotational abutment feature.
• Interlocking features to stabilize the implant prosthetic abutment
connection have been designed along with a better understanding and
application of biomechanical parameters
The quest for an ideal prosthetic abutment implant
connection appears to continue

60. Prefabricatedabutment
subgingivalcontourdesigns
An abutment the same size (or
slightly smaller) in diameter as the
implant
An abutment with a 1-mm flare 1
to 2 mm above the implant body
An abutment with a 2-mm flare 1
to 2 mm above the implant body
An anatomic abutment similar in
cervical diameter and contour to
the tooth being replaced

61. • These abutments may be titanium or its alloy, titanium with a
titanium nitride coating, or ceramic (alumina or zirconium).
They may also be angled or straight. The preangled abutment
has varied angulations provided by manufacturers, usually 15
and 25 degrees off-axis.
• Abutments may also be custom in design. Three general
choices of abutments for cement retention for custom
abutments are available.
1. A plastic castable type coping.
2. A machined coping with a plastic cylinder.
3. A CAD-CAM customised abutment of titanium (alloy) or
ceramic.

62. Prefabricated Abutments
Narrow-Diameter Abutments
An abutment that is the same diameter (or more narrow) than the
implant crest module has several advantages:
1. One size of abutment may be used for almost all patients.
1. The abutment is seated on the implant platform and
engages the hexagon without circumferential hard or soft
tissue interference.

63. 3. Minimal preparation is required if the implant is not in
ideal position (i.e., too close to a tooth or facial position).
3. The emergence profile of the crown is used to create the
gingival contour and may be customized to the specific
requirement of each patient condition.
3. The margin of the crown may be a knife edge and may be
placed anywhere on the abutment.
3. The abutment can be used for direct and indirect crown
fabrication techniques.

64. 7. In the indirect (laboratory-assisted) technique, a knife-edge
margin may be extended or shortened in the laboratory after
the tissue model is fabricated.
8. The soft tissue below the crown margin is thicker and less
likely to recede.
9. The soft tissue is thicker, so a grayish line below the crown
is less observed.

65. Disadvantages of Narrow Diameter Abutments
1. The subgingival contour is only developed by the crown. This
dimension may be inadequate to fully modify the soft tissue drape.
1. The abutment is less tapered because it is more narrow at the base.
1. There is a thinner outer wall of the abutment, so less material is
present to prepare a taper or a margin.
1. There is no clear marking for the laboratory to determine the desired
crown margin location unless a small chamfer is prepared.

66. Wider-Diameter Abutments
• An abutment flare 1 to 2 mm
wider than the implant body
is the most common type
provided by manufacturers and
is the most popular abutment
used for the direct intraoral
technique.
• It is provided in a straight and
angled configuration

67. 1. The wider cervical region improves the emergence profile of
the soft tissue starting 1 to 2 mm above the bone.
1. The wider abutment also provides a greater surface area for
retention and provides a greater premade taper of the
abutment.
1. Because the implant is often positioned 1.5 mm more palatal
than the emergence of the adjacent teeth, the 1- to 2-mm
flare begins the process of developing the ideal emergence
profile of the crown 1 to 2 mm above the bone
Advantages

68. 4. The dentist can modify the abutment preparation for each patient,
condition, and site.
4. The accuracy of fit of the premade implant–abutment interface
decreases the force to the abutment screw and reduces the risk of
abutment screw loosening
5. Provided by most manufacturers at no charge when the implant
body is purchased. ( Eg: BioHorizons )

69. Disadvantages of Wider Diameter Abutments
1. The wider abutment is wider all
around the implant body. When too
close to the adjacent tooth or
implant, too facial, or too lingual,
the abutment must be modified.
2. The wider abutment creates a flare
with an undercut where it tapers
down to the implant body.

70. 3. If the implant was placed below the crestal bone, the
restoring dentist cannot seat the abutment on the implant
platform without an osteoplasty around the implant.
3. It is more difficult to seat the abutment below the tissue
margin because it must push the tissue away from the more
narrow implant body.

71. Premade Anatomic Abutment
• Appears attractive to inexperienced implant dentists as it may
seem logical to have an abutment copy a natural tooth crown
preparation.
• Present similar advantages and disadvantages as the wider
abutments.
Additional disadvantages include :
• The surgeon must more precisely position the hexagon of the
implant platform. This is in addition to the correct
faciopalatal, mesiodistal, and angulation positions. A rotation
of even 10 degrees can affect the final crown
esthetics.

72. • The emergence angle of the implant and abutment should
vary, depending on the tissue thickness. Therefore, for a
premade anatomical abutment, several abutment types must
be stored by the dentist or laboratory at increased overhead
costs.
• This abutment is designed primarily for the indirect
impression technique using implant body analogs, which
increase the cost of the restoration.

73. Ceramic Abutment
• Ceramic premade abutments have
become popular to prevent metal
below the crown margin from
causing a grayish hue to be seen
through the cervical tissues when
there is a thin biotype.
A thin biotype (or implant too facial) may result in the titanium abutment casting a
grayish hue to the cervical tissues

74. The crown and abutment allow the soft tissue drape to appear more coral pink in color

75. • Two types of ceramic abutments are generally found by
manufacturers, a milled all-ceramic abutment or a ceramic
abutment attached to a milled titanium component.
• The one-piece milled abutment does not have a metal to
ceramic connection and hence is stronger (and usually less
expensive). However, the material is harder than the implant
body connection; and any misfit will wear the antirotation
feature, which will increase the risk of screw loosening.

76. Angled Abutments
• The angled abutment may be made of titanium or its alloy
or of ceramic.
• When the implant body is not favorably positioned, the
angled abutment may be the only rational solution to
restore the patient.
The prefabricated angled abutment is provided in several different angulations, usually
ranging from 15 to 30 degrees off-axis.

77. Customized Abutments
• A trend toward laboratory-customized anatomical or esthetic
abutments has emerged.
• In the past, a custom-made abutment usually was fabricated
from a plastic castable pattern or machined cylinder and
plastic castable coping (UCLA abutment).
• The primary advantage of the custom abutment is that the
abutment is fabricated for each specific patient condition.
• The subgingival crown margin position and contours can be
extended only where necessary.

78. • Another major advantage of the customized abutment is that
the abutment may be fabricated with crown and bridge
precious metal, so the facial region may be covered with
porcelain (the color of the tooth, the root, or the soft tissue)
and may be extended close to the implant– abutment
connection for improved facial esthetics.
• The facial crown margin on this abutment is usually a
porcelain butt joint 1 mm below the tissue that is fabricated
and developed in the laboratory.

79. • If tissue shrinkage occurs
in the long term, a metal
margin of the abutment is
not seen. This is most
beneficial when placing a
single-tooth crown in a
young patient to account
for a potential remodeling
of the gingival profile
over time.

80. Disadvantages of customised abutments
• The disadvantages of the custom-made abutment are related
primarily to the laboratory phase. With the castable plastic
pattern, the abutment can be fabricated out of any precious
metal (to decrease corrosion risk between the coping and cast
metal) without a two-metal interface.
• The abutment- to-implant connection is less precise.

81. CAD/CAM Abutments
• The CAD-CAM abutment may be customized and
fabricated from almost any material and to almost any
angulation
• The dentist makes an implant body impression (using a
closed- or open-tray technique) that uses an impression
transfer that engages the antirotational feature of the
implant body.
• After the abutment is designed in the laboratory with the
computer, it is milled or fabricated by digital technology

82. Final Preparation
• Primarily two methods are used to restore an implant prosthesis:
direct and indirect crown (prosthesis) fabrication.
• The direct crown fabrication technique is most similar to the
fabrication of a crown on a natural tooth.
• The indirect crown fabrication requires use of an implant
analog, and the laboratory performs the majority of the work
related to abutment preparation and crown fabrication directly
on the implant abutment.

83. Direct Technique
A maxillary right canine implant with a permucosal extension (PME) to be restored with
a direct technique

84. The manufacturer-premade two-piece straight abutment for cement is inserted. A
radiograph confirms its complete seating.

85. The incisal edge is prepared, then the facial incisal third, and then the cervical portion
to the height of the free gingival margin

86. The adjacent tooth interproximal contacts are modified on the palatal aspect so that
they are elongated toward the interdental papillae.

87. A temporary crown is fabricated level with the soft tissue margin.

88. The abutment is removed, and a PME inserted to prevent the soft tissue contour from
collapsing over the implant platform.

89. The abutment for cement retention is inserted onto an implant body analog (and handle).
The margin on the abutment is extended 1 to 1.5 mm below the free gingival margin

90. The temporary crown is inserted onto the lubricated abutment extraorally, and acrylic is
added to extend the crown margin to the subgingival margin

91. The prepared abutment is placed onto another implant body analog (without the handle),
and an impression is made. The abutment and analog are inserted into a dappen dish. This
impression represents an exact duplicate of the abutment. A full-arch intraoral impression
will be used for occlusion and interproximal contacts and emergence contours.

92. The margins on the crown can be fabricated from this abutment impression because it
represents the die of the abutment

93. The prepared abutment is reinserted into the implant body.

94. The temporary crown with proper subgingival contour is seated. The tissue blanches
because the temporary crown displaces the tissue around the margin.

95. After the tissue returns to normal color, the transitional crown may be removed, and a
final impression made of the abutment, soft tissue emergence, and surrounding teeth.

96. A soft tissue model is made from the traditional closed-tray impression. The coping for
the crown may be fabricated on the individual die made from the dappen dish
impression of the abutment. The coping then is placed on the full-arch cast for final
reconstruction of the crown.

97. At the final delivery appointment, the temporary crown is removed, and the abutment
and soft tissue drape are evaluated

98. The final crown is seated and has adequate contour, color, and soft tissue drape.

99. Indirect Technique
• This has become more popular in recent years. As in the
direct technique, the PME is removed and the soft tissue
contoured to the desired emergence.
• Here, instead of inserting an abutment, a two-piece
impression transfer, which engages the hexagon of the
implant body, is attached and radiographically confirmed. An
implant body impression then is made with an elastic
material.

100. A maxillary right central incisor implant with a customized
permucosal extension (PME) during one-stage implant healing.

101. The customized PME allows the interdental papilla height to be maintained

102. A two-piece impression transfer coping which engages the antirotational hex
is inserted into the implant body

103. A closed-tray impression is made of the impression transfer and surrounding teeth

104. he impression transfer is inserted into an implant body analog and then reinserted into the
final closed- tray impression

105. A soft tissue model is prepared from the final impression, with the implant analog in position.

106. The laboratory selected a premade ceramic abutment and prepared the finish lines for
the crown

107. The coping is made for the final crown on the implant abutment.

108. The crown is fabricated on the coping

109. The final crown contour is developed with the soft tissue model.

110. This crown represents the emergence profile similar to the adjacent teeth at the
free gingival margin

111. The indirect technique first seats the final abutment prepared by the laboratory.

112. The final crown is evaluated for the shade, contours, and occlusion

113. A periapical radiograph confirms that no residual cement is present.

114. Complications
Complications of maxillary anterior single-tooth
implants primarily include:
• Interproximal papilla deficiencies
• Abutment screw loosening
• Crestal bone loss

115. Conclusion
• The replacement of a single tooth in the anterior maxilla is
most challenging because of highly specific soft and hard
tissue criteria in addition to all other esthetic, phonetic,
functional, and occlusal requirements.
• Unique surgical and prosthetic concepts are implemented for
proper results. In spite of all the technical difficulties that
may be faced, the anterior single-tooth implant is the
modality of choice to replace a missing anterior maxillary
tooth.

116. References
• Dental Implant Prosthetics, Carl E Misch, 2nd Edition, 2015
• Dental Implant Prosthetics, Carl E Misch, 2005
• Misch CE: Single tooth implants difficult, yet overused,
Dent Today 11(3):46–51, 1992
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117. Thank You