This document summarizes a presentation on implant esthetics and techniques for achieving optimal soft tissue outcomes. Key points include: differences between natural tooth anatomy and implants can impact esthetics; factors like tissue biotype, bone levels, and papillae height influence outcomes; and techniques like immediate placement, bone/soft tissue grafting, and sculpted provisionals can be used to preserve hard and soft tissues and achieve esthetic goals. Case examples demonstrate applying these principles to complex esthetic zone cases.

1. First Mondays Study Club
Robert C. Cain, DDS
March 3, 2014

2. • To understand the differences between
implants and natural teeth and how these
differences can effect esthetics
• To understand the factors associated with
hard and soft tissues around implants that can
effect the outcome of the restoration
• To understand some of the different
techniques that can be used to achieve hard
and soft tissue goals

3. • Why are implant esthetics often more
challenging than natural teeth?
• What can we do to ensure the best possible
esthetic and functional outcome?
• What do we tell a patient who needs one or
more teeth replaced in the esthetic zone?

4. • Implants preserve bone and soft tissue just as
a natural tooth would.
• Implants do not rely on adjacent teeth for
support
• Implants do not decay
• Implants appear to be less susceptible to
periodontal diseases than natural teeth
• Looks, acts and feels like the real thing

5. • Cost
• Time
• Involves surgery
• Insurance often does not cover implant
procedures, especially some the more
advanced grafting techniques

6. Natural Teeth
• Roots made of cementum
and dentin
• Ovoid in cross section
• Connection to bone by
periodontal ligament
• Connective tissue attachment
to cementum
• Gingival fibers run
perpendicular to tooth
surface
Implants
• Made of Titanium with
textured surface
• Round in cross section
• Direct connection to bone by
osseointegration
• No connective tissue
attachment
• Gingival fibers are circular

7. • Roots made of cementum
and dentin
• Ovoid and cross section
• Connection to bone by
periodontal ligament
• Connective tissue attachment
to cementum
• Gingival fibers run
perpendicular to tooth
surface

8. • Made of Titanium with
textured surface
• Round in cross section
• Direct connection to bone by
osseointegration
• No connective tissue
attachment
• Gingival fibers are circular

9. • Tissue Biotype – Thick or Thin?
• Smile Line – High or Low?
• Amount of Tissue Scallop – High or Low?
• Interproximal Bone Levels – Normal or
Reduced?
• Facial – Lingual Bone Dimensions – adequate
or reduced. How much is enough?

10. • Bone Loss Around Tooth/Teeth to be
Replaced?
• Amount of Infection Around Tooth/Teeth to be
Extracted
• Restorations on Adjacent Teeth – could effect
the overall outcome
• Patient Expectations!

11. • Careful Treatment Planning
– Study models (diagnostic waxups), x-rays (including
CBCT), photos, occlusal analysis
• Preserve Hard and Soft Tissue
– Atraumatic extractions, Immediate implant placement
where possible
– Bone and soft tissue grafting to rebuild lost tissue
– Proper provisional design
• It’s the surgeon’s job to build the foundation for the
restoration

12. • Proper Implant Placement
– Must allow for ideal emergence profile, functional
occlusion and esthetic contours
• Understand Limitations of Tissue Contours
around Implants
– What determines papillae height and shape
– Use of ovate pontics where needed

13. • The Soft Tissue Around the Implant
• Specifically the Buccal Tissue and the
Interproximal Papillae
• “The Tissue Is The Issue”

14. • Two Scenarios
– Implant – Implant
– Implant – Tooth
• A series of articles by Dennis Tarnow
– The Effect of the Distance From the Contact Point to the
Crest of Bone on the Presence or Absence of the
Interproximal Dental Papilla. J. Perio 1992; 63:995-996
– Vertical Distance from the Crest of Bone to the Height
of the Interproximal Papilla Between Adjacent
Implants. J. Perio 2003; 74: 1785-1788

15. • In 1992 Tarnow, et al.
showed complete
papillae formation if
you had a distance of
5mm or less from the
interproximal contact
point to the crest of
the interproximal
bone between teeth.

16. • In 2003 Tarnow
showed that only
2 – 4mm of
papillae height can
be expected
between two
implants.

17. • Fortunately,
between an
implant and a
tooth, the
papillae behave
the same as
between two
teeth. The tooth
supports the soft
tissue.

18. • Extraction with Immediate Placement
– Immediate fixed provisionalization
– Delayed fixed provisionalization
• Extraction with Delayed Placement
– Ridge preservation/regeneration
– Provisionalization
– Placement with fixed provisionalization

19. • Delayed Placement
– Hard and/or soft tissue regeneration
– Placement with provisionalization
• Immediate Placement
– Simultaneous hard and soft tissue regeneration
– Immediate or Delayed Provisionalization

20. • Preserving bone and soft tissue at time of
extraction
• Regenerating lost hard and soft tissue
• Sculpting papillae using provisional restoration

21. • Atraumatic
extraction using
Benex Extractor

25. • Pilot hole prepared
into root canal space
• Anchor is attached to
root
• Takes advantage of
Regional Acceleratory
Phenomenon (RAP)

26. • Cable is attached to
anchor
• Ratchet is attached
to cable
• Tooth is extracted
without
compromising bone
or soft tissue

27. • Intact socket is
debrided
• Osteotomy is
prepared

28. • Implant is placed

29. • Temporary
abutment is
prepared
• Patient’s existing
permanent crown
is re-used as a
temporary

30. • Temporary crown
and abutment are
contoured
• Using the Zimmer
transfer coping as
temporary
abutment

31. • Today I would use
the Zimmer
Plastic Provisional
Abutment
• New materials
make a stronger
restoration

32. • Temporary
abutment and
crown are seated
• Expect hard and
soft tissue contours
to remain the same
over time.

33. • Thin tissue
biotype
• High lip line
• History of RCT
and apico #7
• Pain with
slight buccal
swelling

36. • Tooth was
extracted
atraumatically
• Buccal and lingual
flaps undermined
without elevating
the papillae

37. • Dermis membrane
shaped to cover
apical buccal
defect
• This will also
increase the
thickness of the
keratinized tissue
on the facial and
improve the
biotype

38. • Puros allograft is
prepared with
doxycycline and calcium
sulfate

39. • Membrane is placed
under flap
• Bone graft is placed

40. • Membrane is
tucked under
palatal flap
• Note that the
papillae are still
intact

41. Root is removed and crown
is prepped Crown is splinted using Ribbond

42. • Tooth is bonded in
place
• Papillae will remain
intact knowing what
we know from the
Tarnow articles.

43. • Previously missing tooth or teeth
• No attempt was made to maintain bone or soft
tissue
• Teeth were often extracted many years prior
• Much more challenging than maintaining bone
and soft tissues
• Often requires multiple procedures

44. • 19 year old female
• #8 was avulsed by
a baseball when
she was 12
• Recently
completed
orthodontic
treatment

45. • CBCT shows adequate bone height and width
for implant placement

46. • Adequate ridge width, Implant placed

47. • Connective Tissue Graft Added to Facial

48. • Provisional Placed at 3 months using polycarbonate
crown and composite

49. • Final Healing of Provisional, ready to return to
restoring dentist

50. Very “gummy” smile Severe resorption and abscess

51. • Very large abscess with facial
swelling
• Extreme apical root resorption
• Teeth were supra-erupted and
crestal bone was “too high”
• Adequate width of bone apical to
apices of teeth
• “Gummy Smile” very evident
• Large amount of keratinized
tissue
• Teeth were very lingually tilted

52. •Place implants 4 – 5mm
apical to existing CEJ
•Utilize extraction with
immediate implant
placement
•Sculpt soft tissue to achieve
ideal contours
•Immediately temporize
using custom temporary
abutment and crowns to
preserve hard and soft
tissue.

53. •Less “gummy” appearance
•Better relationship to lip line

54. • Missing #’s 9 and 10 for many years
• #’s 7 and 8 have failed
• Large horizontal ridge defect

55. • Zimmer J-Block used for Ridge Augmentation

56. • Block is prepared, attached with bone screws

57. • CBCT shows block is intact with adequate
width for implant placement

58. • Implants Placed. Pt. wanted 4 implants, I would have
preferred 2 with an FPD for esthetics

59. • Permanent Restorations in Place

60. • “Can you crown lengthen these teeth for new 6-
unit splinted crowns?”

61. • After extraction of the
teeth and
debridement of the
multiple abscesses

62. • Grafting with bone putty
• Dermis membrane over graft
• Primary closure of flaps

63. • Fabricated an immediate maxillary Essix partial

64. • Essix partial
– Completely tooth
borne
– No pressure on the
bone graft
– Allows for modification
of ovate pontics to
form papillae

65. • Implants placed after 4 months of healing
• Note the amount and quality of bone allowed for
placement of 4.7mm diameter implants

66. • Soft tissue healing
• Beginning to develop
tissue contours using
ovate pontics on the
Essix partial

67. • Fabrication of fixed
temporary
restorations
• Will further help
develop tissue
contours prior to
permanent
restoration

68. • Temporary abutments
seated
• Temporary crowns
seated and healed for
1 week

69. • Tissue healing ready to return to her restoring
dentist

70. • Implant Restorations in the Esthetic Zone
present difficult challenges
• Knowledge and Experience allow us to manage
not only our patient’s expectations but also
our own.