1. Anterior single implant-
supported restoration in
esthetic zone
Maxillary Anterior Single-Tooth Replacement
Misch, Chapter 22, Pages 368-410
Dr. Mohammed Alshehri BDS, AEGD, SSC-ARD

2. Therapeutic modalities for
tooth replacement in the
esthetic zone
• Conventional fixed partial dentures (FPDs), comprising
cantilever units
• Resin-bonded ("adhesive") bridges
• Conventional removable partial dentures (RPDs)
• Tooth-supported overdentures
• Orthodontic therapy (closure of edentulous spaces)
• Implant-supported prostheses (fixed, retrievable or removable
suprastructures)

3. Single implant-supported
restoration
• Maxillary central incisor single-tooth replacement is
often the most difficult procedure in all of implant
dentistry.
• The highly esthetic zone of the premaxilla often
requires both hard (bone and teeth) and soft tissue
restoration.
• single-tooth implant has the highest success rate
compared with any other treatment option to
replace missing teeth with an implant restoration

4. Fundamental objective
esthetic criteria (Magne & Belser 2002)
1. Gingival health
2. Interdental closure
3. Tooth axis
4. Zenith of the gingival contour
5. Balance of the gingival levels
6. Level of the interdental contact
7. Relative tooth dimensions
8. Basic features of tooth form
9. Tooth characterization
10. Surface texture
11. Color
12. Incisal edge configuration
13. Lower lip line
14. Smile symmetry
• Subjective criteria (esthetic integration)
• Variations in tooth form
• Tooth arrangement and positioning
• Relative crown length
• Negative space
• dentures

5. Challenging esthetics
Bone height
• Midcrest position of the edentulous site should be 2
mm below the facial CEJ of the adjacent teeth.
• The interproximal bone should be scalloped 3 mm
more incisal than the midcrest position.
• Becker et al. 1997 classified the rang of
interpmximal bone height above the midfacial
scallop from less than 2.1 mm (flat) to scalloped 2.8
mm to pronounced scalloped < 4.1 mm.
flat anatomy square-shaped
tooth
scalloped ovoid-shaped
tooth

6. Under perfect conditions, the
implant body should not be
inserted until the bone and soft
tissue are within normal limits.

7. Challenging esthetics
Mesiodistal
space
• Two-piece implant should be at least 1.5 mm from
an adjacent tooth.
• When the implant is closer than this to an adjacent
tooth bone loss related to the microgap, biological
width violation , and/or stress.
• one-piece implant should be at least 1 mm from an
adjacent tooth. “microgap eliminated and the vertical defect
is narrower than most two-piece implant systems so they can be
placed closer”

8. Challenging esthetics
Faciopalatal Width
• A 25% decrease in faciopalatal width occurs within
the first year of tooth loss and rapidly evolves into a
30% to 40% decrease within 3 years.
• The bone width loss is primarily from the facial
region, because the labial plate is very thin
compared with the palatal plate, and facial
undercuts are often found over the roots of the
teeth.

9. Challenging esthetics
Implant size
• first factor that influences the size of an implant is
the mesiodistal dimension of the missing tooth. ”2
mm below CEJ”
• The second factor that determines the mesiodistal
implant diameter is the necessary distance from an
adjacent tooth root. ”due to this the implant is
usually smaller in diameter than natural tooth”

10. Challenging esthetics
Implant size
• Distance between an adjacent teeth roots in
comparison with implants distance.
0.5 – 1.5 3 mm
2 mm 4 mm

11. Challenging esthetics
Implant size
• The width of bone should allow at least 1.5mm on
the facial aspect of the implant.
• The faciopalatal width dimension is not as critical
on the palatal aspect of the implant, because it is
dense cortical bone, more resistant to bone
loss, and not within the esthetic zone.
• Facial bone grafting at the time of implant insertion
is frequently needed, because the bone volume in
width is often compromised.

12. Implant body position
Mesiodistal position
• The best implant position is
under the incisal edge of the
final crown, or slightly more
palatal (A). The ideal
mesiodistal implant position
for a central incisor is 0.5 to
1.0 mm more distal than the
midtooth position. This
decreases the risk of (A) (B)
encroachment on the incisive
canal (B). The best
mesiodistal position for a
cuspid is centered in the
cuspid position.

13. Implant body position
Mesiodistal position
• When the central incisor implant is placed, the
implant may encroach on the canal and result in a
probing pocket depth of 10 mm or greater on the
mesiopalatal surface of the implant.
• On occasion, the contents of the foramen must be
removed and a bone graft inserted, to decrease the
size of the incisive canal.

14. Implant body position
Faciopalatal position
• The crestal bone should be at least 1.5 mm wider
on the facial aspect of the implant and 0.5 mm on
the palatal aspect.
• The thickness of bone on the facial aspect of a
natural root is usually 0.5 mm thick. As a result, the
implant is1mm or more palatal than the facial
emergence of the adjacent crowns at the free
gingival margin.

15. Implant body position
Implant angulation
• In the literature, three faciopalatal angulations of
the implant body are suggested:
(1) a facial angulation so that emergence of the final
crown will be similar to adjacent teeth.
(2) under the incisal edge of the final restoration.
(3) within the cingulum position of the implant crown.

16. Miami 2007

17. Implant body position
Implant angulation
• A, a position below the incisal edge is best used for a
cemented crown in the esthetic zone. B, an implant is in the
position of the natural root of the tooth. Although this makes
sense, it places the implant too facial, and an angled
abutment is usually necessary, C, an implant in the
cingulum position that is used when a screw-retained
crown is the trea ment of choice. This position requires a
facial ridge lap of porcelain when used for FP-l prostheses

18. Implant body position
Facial Implant body angulation
• The facial implant position is predicated on the
concept that the facial emergence of the implant
crown at the cervical should be in the same
position as a natural tooth.
• The crown 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. Implant body position
Facial Implant body angulation
• 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. Therefore when
the implant is angled to the facial emergence of a
tooth, an angled abutment of 15 degrees must be
used to bring the incisal edge more palatal.

20. Implant body position
Facial Implant body angulation
• Most two-piece angled abutments have a design
flaw that compromises facial cervical esthetics.
• The metal flange facial to the abutment screw is
thinner than a straight abutment and may result
in fracture (especially because angled loads are
placed on thefacial-positioned implant).
• No single method exists to restore proper
esthetics when the implant abutment is located
above the free gingival margin of the adjacent
teeth. At best, the final crown appears too long
and too facial. Soft tissue grafts and/or bone
augmentation do not improve the condition.

21. Implant body position
Facial Implant body angulation
• The natural maxillary anterior teeth are loaded at
a12- to I5 degree angle, because of their natural
angulation in comparison with the mandibular
anterior teeth. This is one reason the maxillary
anterior teeth are wider in diameter than
mandibular anterior teeth (which are loaded in
their long axis).
• The facial angulation of the implant body often
corresponds to an implant body
angulation, which leads to I5 degrees off axial
loads and increases the force to the abutment
screw-implant-bone complex by
25.9%, compared with a long axis load.

22. Implant body position
Facial Implant body angulation
• These offset loads increase the risks of abutment
screw loosening, crestal bone loss, and cervical
soft tissue marginal shrinkage. As a
result, implants angled too facially compromise
the esthetics and increase the risk of
complications.

23. Implant body position
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 often the goal when a screw-
retained crown is used in restoration. The
prosthesis fixation screw (to retain a maxillary
anterior crown) cannot be located in the incisal or
facial region of the crown for obvious reasons.

24. Implant body position
Cingulum implant body angulation
• This most often requires a facial projeaion of the
crown or "buccal correction" facing away from the
implant body. The facial ridge lap must extend 2
to 4 mm and is often similar in contour to the
modified ridge lap pontic of three-unit fixed
prosthesis.
• Although an acceptable esthetic restoration may
be developed, especially with the additional
cervical porcelain, the hygiene requirements and
present implant dentistry standards render this
approach unacceptable.

25. Implant body position
Cingulum implant body angulation
• Some authors argue that an improved contour
may be developed subgingivaUy with a palatal
implant position. To create this contour, the
implant body must be positioned more apical
than desired. This position may prevent food from
accumulating on the cervical "table" of the crown.
However, the subgingival ridge lap does not
permit access to the facial sulcus of the implant
body for the elimination of plaque, as well as to
evaluate the bleeding index or facial bone loss.

26. Implant body position
Cingulum implant body angulation
• Greater interarch clearance is often needed with
an implant palatal position, because the
permucosal post exits the tissue in a more palatal
position. Inadequate interarch space may
especially hinder the restoration of Angle's Class
II, division 2 patients, with the implant in this
position. The bony ridge should be augmented if
too narrow for the model implant diameter and
position, or an alternate treatment option should
be seleaed. The anterior single-tooth implant
should use a cement-retained crown, so the
cingulum screw position is not necessary.

27. Implant body position
Ideal implant body angulation
• A straight line is determined by connecting two
points. The clinician determines the line for the
best angulation by the point of the incisal edge
position of the implant crown and the
midfaciopalatal position on the crest of the bone.
• The center of the implant is located directly under
the incisal edge of the crown so that a straight
abutment for cement retention emerges directly
below the incisal edge. Because the crown profile
is in two planes, with the incisal edge more
palatal than the cervical portion, the incisal edge
position is perfea for implant placement and also

28. Implant body position
Ideal implant body angulation
• The facial emergence of the crown mimics the
adjacent teeth, proceeding from the implant body
under the tissue. The angle of force to the
implant is also improved, which decreases the
crestal stresses to the bone and abutment
screws.
• It is easier to correct a slight palatal position in
the final crown contour compared with the
implant body angled too facial.

29. Implant body position
Ideal implant body angulation
• The implant abutment selected for a maxillary
anterior single-tooth implant is almost always for
a cemented restoration. Single anterior crowns
do not require readily retrievable restorations. In
addition, a greater range of corrective options
exists with a cement-retained crown for implants
not well placed.
• 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.

30. Implant body position
Ideal implant body angulation
• The incisal edge of the template may be notched
for the drills, because the best placement of the
drill is directly through the incisal edge.
However, most often the surgeon does not
require a template, because the adjacent teeth
provide a guide for a single-tooth implant. In
addition, the integrity of facial cortical plate is
more readily assessed during the surgery when a
template is not used.

31. Miami 2007

32. Implant position “depth”
Too Deep (> 4 mm)
• The implant countersunked 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.
• The bulk of subgingival porcelain provides
good color and contour for the crown.
However, several concerns arise
regarding the long-term sulcular health
around the implant.

33. Implant position “depth”
Too Deep (> 4 mm)
• The first year of function often
corresponds to a mean bone loss range of
0.5 to 3.0 mm, dependent in part on
implant design.
• Malevez et al.32 noted more pronounced
bone loss for conical implants that had a
long, smooth, tapered crest module. The
bone is lost at least 0.5 mm below the
abutment to implant body connection and
extends to any smooth or machined
surface beyond the crest module
(depending on the implant design). This
may lead to facial probing depths of 7 to 8

34. Implant position “depth”
Too Deep (> 4 mm)
• Grunder evaluated single-tooth implants in
function for 1 year and noted the bone
levels were 2 mm apical to the implant-
abutment connection and sulcular probing
depths were 9.0 to 10.5 mm using a
Branemark implant design.
• The attachment mechanism of the soft
tissue above the bone is less tenacious
compared with a tooth, and the defense
mechanism of the peri-implant tissues
may be weaker than that of teeth. The
clinician, to err on the side of safety for the
best sulcular health conditions, should

35. Implant position “depth”
Too shallow (> 2 mm)
• The implant body is positioned less than 2
mm below the facial free gingival margin
of the crown, the cervical esthetics of the
restoration are at an increased risk.
• The porcelain of the crown may not be
subgingival enough to mask the titanium
color of the abutment below the margin.
• Periodontal surgical procedures to
position soft tissue over the titanium roots
are unpredictable.

36. Implant position “depth”
Too shallow (> 2 mm)
• The crestal bone height is coronal to the
perfect height. The two most common
conditions that result in this finding are (1)
when the adjacent teeth are closer than 6
mm (in agenesis of a lateral incisor) and
(2) when a block bone graft regenerated
width and height of bone.
• Ideally, the interproximal bone is 3 mm
above the midcrestaI bone.

37. Implant position “depth”
Too shallow (> 2 mm)
• When a single-tooth implant replaces this
missing tooth, an osteoplasy should be
performed so that the midcrestal region is
3 mm apical to the free gingival margin of
the future crown. The same conditions
may occur when bone augmentation gains
height to the interproximal height of bone.
• 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

38. Implant position “depth”
Ideal depth (3 mm)
• This positions the platform of the implant 3 mm
below the facial free gingival margin of the
implant crown. In addition, it provides 3 mm of
soft tissue for the emergence of the implant
crown on the midfacial region and more as the
soft tissue measurements proceed toward the
interproximal. This depth also increases the
thickness of the soft tissues over the titanium
implant body, which masks the darker color
above the bone. It should be noted that the free
gingival margin of a lateral incisor is often 1 mm
more incisal than the adjacent central and canine

39. Soft tissue incision
different approaches to enhance the soft tissue appearance

40. Soft tissue incision
Surgical additive techniques
• Pouch procedures.
• Interpositional grafts.
• Sliding flaps.
• connective tissue grafts (autogenous or
acellular dennal matrix).

41. Soft tissue incision
interproximal soft tissue in the implant site classified into
three categories
• The papillae have an acceptable height in the
edentulous site.
• The papillae have less than acceptable height.
• One papilla is acceptable and the other papilla is
depressed and requires elevation.

42. Soft tissue incision

43. Transitional prosthesis
• Resin-bonded fixed restorations strongly
suggested to be fabricated to provide improved
speech and function, especially when crestal
bone regeneration is performed and for extended
healing time.
• Transitional cantilevered prosthesis from
adjacent tooth requiring crown.
• When the patient requires orthodontics, a denture
tooth and an attached bracket may be added to
the orthodontic wire.

44. Transitional prosthesis
• A removable device may be used as short term
for cosmetic emergencies.
(1) An Essix appliance is an acrylic shell, similar to a
bleaching tray, that has a denture tooth attached
to replace the missing tooth. This device is the
easiest for tooth replacement after surgical
procedures.
(2) A cast clasp RPD with indirect rest seats to
prevent rotation movements on the surgical site.
(3) Flipper.

45. 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 free gingival
margin.
(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.

46. Immediate implant
insertion after extraction

47. Stage II uncovery and soft
tissue
A. Subtraction technique (canine soft tissue drape)
• When the soft tissue along the edentulous crest
is at the level of the desired interdental papillae
and is of sufficient quality and volume, a
subtraction technique (e.g., gingivoplasty with a
coarse diamond) sculpts the crestal gingival
tissues to reproduce the cervical emergence
contour of the crown, complete with interdental
papillae and proper labial gingival contour. The
contour of the mid facial position of the tissue is 1
mm more incisal than the contour of the adjacent
teeth to allow for the gingival shrinkage
commonly observed during the first year of
implant loading. The interdental papilla zones are
also made slightly larger than the final desired

48. Stage II uncovery and soft
tissue
B. Addition technique
• 1. Split-finger approach

49. Stage II uncovery and soft
tissue
B. Addition technique
• 1. Split-finger approach

50. Stage II uncovery and soft
tissue
B. Addition technique
• 1. Split-finger approach

51. Stage II uncovery and soft
tissue
B. Addition technique
• 1. Split-finger approach

52. Stage II uncovery and soft
tissue
B. Addition technique
• 1. Split-finger approach

53. Stage II uncovery and soft
tissue
B. Addition technique
• 1. Split-finger approach

54. Stage II uncovery and soft
tissue
B. Addition technique
• 2. Crest elevated and PME “permucosal
extention” added as "tent pole" for soft tissue

55. Summary
• The replacement of a single tooth in the
premaxilla is challenging because of the highly
specific soft and hard tissue criteria, in addition to
all other esthetic, phonetic, functional and
occlusal requirements. Anterior tooth loss usually
compromises ideal bone volume and position for
proper implant placement. Implant diameter,
compared with that of natural teeth, results in
challenging cervical esthetics.

56. Summary
• Unique surgical and prosthetic concepts are
implemented for proper results. In spite of all the
technical difficulties that the restoring dentist may
face, the anterior single-tooth implant is the
modality of choice to replace a missing anterior
maxillary tooth.

57. Anterior single implant-
supported restoration in
esthetic zone
Implants In The Esthetic Zone
Lindhe V 2 , Chapter 53, Pages 1146-1166

58. Patient expectations related to
maxillary anterior edentulous
segments
• Long-lasting esthetic and functional result with a
high degree of predictability
• Minimal invasiveness (preservation of tooth
structure)
• Maximum subjective comfort
• Minimum risk for complications associated with
surgery and healing phase
• Avoidance of removable prostheses
• Optimum cost effectiveness

59. Therapeutic modalities for tooth
replacement
in the esthetic zone
• Conventional fixed partial dentures
(FPDs), comprising
cantilever units
• Resin-bonded ("adhesive") bridges
• Conventional removable partial dentures (RPDs)
• Tooth-supported overdentures
• Orthodontic therapy (closure of edentulous spaces)
• Implant-supported prostheses (fixed, retrievable or
removable suprastructures)
• Combinations of the above

60. Criteria favoring implant-borne
restorations
• Normal wound healing capacity
• Intact neighboring teeth
• Unfavorable ("compromised") potential abutment
teeth
• Extended edentulous segments
• Missing strategic abutment teeth
• Presence of diastemas

61. Evaluation of anterior tooth-bound
edentulous sites prior to implant
therapy
• Mesio-distal dimension of the edentulous segment,
including its comparison with existing
contralateral control teeth
• Three-dimensional analysis of the edentulous
segment
regarding soft tissue configuration and underlying
alveolar
bone crest (ref. "bone-mapping")

62. Evaluation of anterior tooth-bound
edentulous sites prior to implant
therapy
• Neighboring teeth:
• volume (relative tooth dimensions), basic features of
tooth form and three-dimensional position and
orientation of the clinical crowns
• structural integrity and condition
• surrounding gingival tissues (course/scalloping of
the gingival line)
• periodontal and endodontic status/conditions
• crown-to-root ratio
• length of roots and respective inclinations in the
frontal
plane
• eventual presence of diastemata

63. Evaluation of anterior tooth-bound
edentulous sites prior to implant
therapy
• Interarch relationships:
• vertical dimension of occlusion
• anterior guidance
• interocclusal space
• Esthetic parameters:
• height of upper smile line ("high lip" versus "low lip")
• lower lip line
• course of the gingival-mucosa line
• orientation of the occlusal plane
• dental versus facial symmetry
• lip support

64. Optimal three-dimensional implant positioning
("restoration-driven implant placement") in
anterior maxillary sites.
Implant = apical extension of the ideal future restoration
• Correct vertical position of implant shoulder (sink
depth)
using the cemento-enamel junction of adjacent teeth
as
reference:
• no visible metal
• gradually developed, flat axial profile
• Correct oro-facial position of point of emergence for
future

65. Optimal three-dimensional implant positioning
("restoration-driven implant placement") in
anterior maxillary sites.
Implant = apical extension of the ideal future restoration
suprastructure from the mucosa:
• similar to adjacent teeth
• flat emergence profile
•Implant axis compatible with available prosthetic
treatment options (ideally: implant axis identical
with "prosthetic axis")

66. Basic considerations related to
anterior
single-tooth replacement
Achievements
Predictable and reproducible results regarding both
esthetic parameters and longevity in sites without
significant vertical tissue deficienies Well defined
and well established surgical protocols:
• restoration-driven implant placement
Adequate and versatile restorative protocols
and prosthetic components:
• occlusal/transverse screw-retention
• angulated abutments
• high-strength ceramic components

67. Basic considerations related to
anterior
single-tooth replacement
Sites with buccal bone deficienie
Lateral bone augmentation using autografts
and barrier membranes:
• technique offers efficacy and predictability
• simultaneous or staged approach depending
on defect extension and defect
morphology
Lateral bone augmentation by means of
alveolar bone crest splitting and/or various
osteotome techniques:
• limited clinical long-term documentation

68. Basic considerations related to
anterior
single-tooth replacement
Limitations
Combined vertical bone and soft tissue
deficienies:
• following removal of ankylosed teeth or
failing implants
• advanced loss of periodontal tissues,
including gingival recession, on neighboring
teeth
• limited scientific documentation related to
vertical bone augmentation and distraction

69. Basic considerations related to multiple-unit
implant restorations in sites with horizontal
and/or vertical soft and hard tissue
deficiencies
Achievements
Predictable and reproducible results
regarding lateral bone augmentation
using barrier membranes supported
by autografts :
• allows implant placement in patients with a
low lip line.

70. Basic considerations related to multiple-unit
implant restorations in sites with horizontal
and/or vertical soft and hard tissue
deficiencies
Limitations
Vertical bone augmentation is difficult to
achieve and related surgical techniques
lack prospective clinical long-term
documentation
Interimplant papillae cannot predictably be re-
established as of yet

71. Conclusion
In conclusion, the concepts and therapeutic
modalities do exist nowadays to solve – by
means of implants - elegantly as well as
predictably a majority of clinical situations
requiring the replacement of missing teeth in
the esthetic zone, and the most promising
novel approaches and perspectives can
already be identified on a not too distant
horizon.