Ld implant esthetics

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1. INTRODUCTION
Esthetic implant therapy is an advanced treatment modality in today‘s field of
implantology, aiming to achieve an ideal esthetic and functional treatment outcome within
the alveolar ridge or the edentulous spaces. Esthetic implant therapy has become an
integral part of modern implant dentistry, because it complements the overall results of
oral implantology. Significant advances have been introduced recently, including novel
techniques to develop or regenerate implant recipient sites by stimulating both hard and
soft tissues and to reproduce healthy peri-implant tissue contours that resist mechanical
forces and masticatory trauma.
Despite the advances and the success seen in many clinicians practice, there is
insufficient scientific support regarding the overall success and longevity of esthetic
implant techniques in well-controlled, long-term studies. The advances in esthetic
implant therapy and soft tissue and hard tissue regeneration are more the author‘s
observations than standard protocols that are used in clinicians daily practice. Therefore, a
standard surgical and prosthetic protocol for esthetic implant therapy is mandatory.
Esthetic implant therapy demands evidence-based publications, and fewer case
reports, to establish a standard of care for every clinician. All efforts should be made to
standardize methodologies for every clinical situation, and then test those
procedures against evidence-based protocols. Past advances resulted from patient’s
unwillingness to accept dental restoration with metallic margins or unmatched. These
challenges, some of which have been extremely difficult to address, have benefited from
original plastic periodontal surgical techniques that are now used routinely to correct
various soft tissue defects such as gingival recession, mucogingival defects, and
imbalanced gingival contours.
This dissertation is a compilation based of the available literature of surgical techniques
and prosthetic options that are used in the treatment for implants in the esthetic zone.

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2. Basic Esthetic Principles
2.1 Introduction
2.2 Facial Considerations
2.2.1 Frontal View
2.2.2 Lateral View
2.3 Dentolabial View
2.1 Introduction
Dentistry has seen a significant increase in the elective treatment for better esthetics.
Webster‘s Dictionary defines esthetics as ―the branch of philosophy dealing with beauty and
taste (emphasizing the evaluative criteria that are applied to art).‖
The success of a restoration depends on sound mechanical, biological and esthetic
principles. An ideal restoration must satisfy these requirements. Ahmad has suggested the
HFA triad as an esthetic guide (Fig 1). According to this, careful dental treatment must be
directed to optimise the Health, Function and Aesthetics for the patient [1]. It is important to
undertake the treatment in the sequence where health is first, followed by function and lastly
esthetics. Health can be achieved without function and esthetics. However, to achieve optimal
esthetics the restoration must be in function and healthy. Hence esthetic treatment is a
combination of both systematic principles and artistic skills. People with dental deformities
such as missing, carious, or unsightly teeth, hideous restorations, and misshapen dark spaces
generally make every effort to hide their embarrassment by covering the unsightly part with
the lips. These people rarely smile or laugh. These patients consciously or unconsciously
forcibly cover the teeth with the lips.
Fig1: HFA Triad

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Construction of an esthetically pleasing restoration involves harmonizing the size, shape,
position and colour of each prosthetic tooth with the adjacent teeth and also establishing peri-
implant soft tissue compatibility with the surrounding gingiva and mucosa. This is
particularly important in the anterior maxilla; also known as the ―esthetic zone of the oral
cavity.‖
The first step in esthetic treatment is communication with the patient. Each patient electing
for esthetic treatment has certain expectations. The treatment objectives need to be discussed
in detail and a thorough examination must be done. Various techniques described to do a
consultation for an esthetic rehabilitation treatment include before-and-after photographs of
patients, diagnostic models with wax ups, composite resin mock-ups on the patient and
computer-imaging simulations. Of the mentioned options the computer-imaging simulations
offer the best idea to the patient regarding the treatment outcomes [2]. The goal of the
treatment must be to meet these expectations keeping in mind the HFA triad. Communication
with the dental technician also proves vital in fabrication of the restorations.
This would result in a balance between the esthetic needs and the functional requirements
of the patient. Each patient presents with unique characteristics with respect to the patients
facial and dental esthetics. Effective communication helps the dentist and the technician to
achieve these characterizations for individual patients.
The concept of esthetics cannot be considered relative. There are many straightforward
and universally accepted principles that decide the esthetic value pertaining to dentistry. For
the ease of understanding, these principles will be divided as:
a) Facial considerations
b) Dentolabial considerations
c) Dental considerations
d) Gingival considerations
The understanding of each of these principles will help us in evaluating the pre-treatment
esthetics of the patients and at the same time help us in the treatment planning.
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2.2 Facial Considerations
Lee Mildon rightly quoted ―People seldom notice old clothes if you wear a big smile.‖
A pleasing face is always accompanied with an esthetic smile. However, generally one never
notices a smile at a close distance as routinely done in dentistry. Hence it is important that the
smile is always analysed in relation to the face of the patient. The facial features have an
important influence on the perception of an individual‘s personality. A through facial analysis
is mandatory for any patient undergoing an esthetic treatment. Matthews suggested the use of
a smile anatomy chart to document the findings during a facial analysis. He was of the
opinion that an examination of the patient must be done without the patient's knowledge,
because the forced smile is an unnatural smile.This analysis should be done in the frontal
view and the lateral view of the patient. This extra-oral examination is made using horizontal
and vertical reference lines which correlate the patient‘s face and dentition in space.
2.2.1 Frontal view
The frontal view of the patient allows adequate identification of the reference guides that are
vital in the esthetic treatment planning. The ideal head position for the evaluation is when the
observer is in front of the patient, and when the patient holds the head in a natural posture. As
mentioned before, various reference lines must be identified during the examination.
THE INTERPUPILLARY LINE: The line passes through the centre of the eyes. If parallel to
the horizontal plane, it is the most suitable reference for carrying out correct analysis [2]. The
interpupillary line is often used as a reference to orient the incisal plane, occlusal plane and
the gingival contours. Amra Vukovic reported a parallelism of interpupillary line to the
interincisal line in 90% of the subjects [3]. Facial harmony is seen when the interpupillary
line is seen to be parallel to the ophriac line (eyebrows), interalar line and the commissural
line of the lips. However, the eyes or even the corners of the mouth are not always positioned
at the same height. In such cases, the horizon is taken as the plane of reference.
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Fig 2: A – Ophriac line, B-Intepupillary line, C-Commisural line
Using the above mentioned horizontal reference planes, a face can be divided into three
portions. The upper third of the face is between the hairline and the ophriac line, the middle
third of the face is between ophriac line and the interalar line and the lower third extends
from the interalar line to the tip of the chin. These thirds vary in sizes from individual to
individual. The lower third is crucial dental point of view. The lower third could be further
divided into thirds; the base of the nose till the lower edge of the upper lip occupying the
upper third and the bottom lip and the chin occupying the lower two thirds.
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Fig 3: The face can be divided into three portions. The
upper third of the face is between the hairline and the
ophriac line, the middle third of the face is between
ophriac line and the interalar line and the lower third
extends from the interalar line to the tip of the chin.
In patients with decreased vertical dimensions, the diminished height of the lower third of the
face is apparent. These patients present with reduced labial visibility, edges of the lips folding
inward and deepening of the concavity below the lower lip.
THE INTERCOMMISSURAL LINE: When a patient‘s mouth is in a broad smile position, an
imaginary line can be marked through the corners of the mouth. This line is known as the
inter commissure line, or ICL. The amount of maxillary tooth reveal below the ICL interacts
with the viewer‘s perception of the patient‘s age. In a youthful smile, approximately 75 % to
100 % of the maxillary teeth would show below this line.
THE MIDLINE: It is a crucial vertical reference line. It not only locates the position of the
facial midline but also determines the direction of the midline.It is traced by joining the
glabella, the tip of the nose, the philtrum and the tip of the chin. Some also refer it to as the
imaginary line that runs vertically from the nasion, subnasal point, interincisal point and the
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pogonion. As a rule, the midline is perpendicular to the interpupillary line. However the
dental midline need not always coincide with the facial midline. AmraVukovic reported an
81% coincidence in the dental and facial midlines [3]. Miller and co-workers stated that the
dental midline coincides with the philtrum midline in only 70 % of the cases [4]. However
they also stated that slight deviations in the midline does not compromise the overall
esthetics. This was not in agreement with G Soares who stated that half of his study subjects
had deviations of the midline [5]. Miller had also documented the relation of the maxillary
midline with the mandibular midline. The maxillary and mandibular midlines didn‘t coincide
in 72 % of the documented cases. Hence in absence of the maxillary central incisors the
dentist should avoid using the mandibular midline to establish the maxillary midline.
Stephen Rosenstiel conducted a web-based study to find out the preference of general
public on esthetic parameters. According to his results almost 80% of the patients preferred
no midline discrepancy [6]. Hence an attempt must always be made to keep the dental midline
as close to the facial midline as possible.
Some patients have their nose or chin deviated from the centre resulting in asymmetric
faces.The visual junction of maxillary central incisors could be at an angle to the facial
midline. It is referredto as a canted midline. In such cases the maxillary midline does not
coincide with the dental midline resulting in a slant. This could have a negative effect to the
overall esthetics of the smile. For this reason, the centre of the upper lip or the labial philtrum
can be used as the ideal reference for determining the patient‘s facial midline.
PROFILE
2.2.2 Lateral View
An evaluation of the lateral view is a determining factor of an esthetic evaluation. In the
lateral view, the patient‘s head is held erect with the eyes gazing towards the horizon. This
position gets the Frankfort plane to an angle of 8 degrees with the horizontal plane, which is
referred to as the esthetic plane. The lateral examination is presented as normal, convex and
concave profiles. It is evaluated by measuring the angle formed by the glabella, subnasion
and the tip of the chin (soft tissue pogonion).
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Normal profile: The lines joining the mentioned points generally form an angle of roughly
170 degrees.
Fig 4: Normal
profile
Convex profile: the angle formed is substantially reduced creating a posterior divergence.
This is generally because of the relative posterior placement of the tip of the chin.
Fig 5: Convex profile

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Concave profile: the angle formed is greater than 180 degrees creating an anterior divergence.
This is generally because of the anterior positioning of the tip of the chin.
Fig 6: Concave profile
Excessive concave and convex profiles are generally associated with skeletal Class II or
Class III conditions. However these profiles don‘t indicate which jaw is retruded or
protruded; the maxilla or mandible. At times the patient profiles are associated with
psychological characteristics. Rufenacht reported that a convex profile is associated with a
dominant and ambitious personality and a concave profile may show opposite attributes [2,
7].
E- LINE
It is a useful evaluation tool for determining the profile. It is the line that joins the tip of the
nose to the tip of the chin. In a normal profile the upper lip is 4 mm posterior to the E-line
and the lower lip is 2mm posterior to the E-line. However significant variations have been
seen in the sexes and different races. Hence it was reported by Ricketts that is was normal to
have lips posterior to the E-line irrespective to its position.

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NASOLABIAL ANGLE
The nasolabial angle is at the subnasale region and is formed by the tangent to the base of
the nose to the tangent to the outer edge of the upper lip. The angle varied with the position of
the upper lip. In patients with normal profiles, males have an average angle of 90-95 degrees
while females have an average of 100-105 degrees.
The nasolabial angle and the E-line can change significantly following the prosthetic
treatment. Care must be taken not to make changes to the dental positions that would interfere
with the nasolabial angle and the E-line.
THE LIPS
The contour of the lips identifies the limits within which the prosthetic treatment must be
finalized. It also helps to establish the correct dental position. Based on the size and shape,
lips can be classified as thick, medium and thin. The height of the upper lip should be half the
height of the lower lip although differences are seen. The shape and size of the lips also have
some psychological characteristics. Thick lips are associated with extroversion, subjectivity
and materialism. However thin lips are associated with introversion, objectivity and self-
control.
The Glossary of Prosthodontic terms defines a high lip line as the greatest height to which
the inferior border of the upper lip is capable of being raised by muscle function. And the low
lip line is the lowest position of the inferior border of the upper lip when it is at rest.
LABIAL PHILTRUM
The labial philtrum is measured from the base of the nose to the bottom edge of the upper lip.
The labial commissure, which is also measured from the base of the nose, is about 2-3 mm
longer than the labial philtrum. As a result of this, in young patients the labial philtrum is
shorter and hence there is more visibility of the maxillary central incisors. However there are
morphological changes that occur through the course of life due to the changes in soft tissue
such as flattening of the lips.
George Latta studied facial features and found that the width of labial philtrum is
significantly more in males (11.70mm) as opposed to females (10.6mm). A racial pattern was
also observed where Blacks had an average width of 12.1mm and the Whites had an anerage
width of 9.85mm [8].

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The dominance of the anterior teeth must be established keeping the profile and the size
and shape of the lip in mind. For patients with concave profiles and thick lips a marked
dominance of the anterior teeth must be established. A moderate dominance of the anterior
teeth must be established for patients with concave profiles and thicker lips.
2.3 Dentolabial Considerations
The area of attention in this consideration is on the lower third of the face, mainly lips and
teeth. This evaluation helps the dentist to re-establish the correct position of the incisal edges
and to evaluate and determine the lengths of the anterior teeth. The dentolabial analysis must
be done with the lips in both static and dynamic positions. The lip movements of the patients
must be studied by interacting with the patient prior to any treatment in a relaxed atmosphere.
The conversation must be spontaneous, with the patient not being conscious of his smile. The
observation must be made prior to any anaesthesia since administration of the same would
distort the finding. If the interpupillary line is parallel to the horizontal plane, it is the most
important parameter in determining the incisal plane and the level of gingival contours. The
lips can undergo substantial amount of alteration in their tonicity which would affect their
movement. It is not uncommon to see marked variation in a same individual. For example for
the same patient during smiling the maxillary teeth may be exposed and during speech there
is more show of the mandibular incisors.
Many patients limit the width of their smile to hide discoloured restorations or even other
clinical situations like crowding and malposed teeth that are not ideal from an esthetic point
of view.
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TOOTH EXPOSURE AT REST
Fig 7: A-Increased maxillary incisal visability, B-Normal maxillary incisal visibility, C-
mandibular incisal visibility.
The determination of what portion of the maxillary incisor is visible at rest is a key
parameter to evaluate if any variation is required in the tooth length. When the mandible is in
a rest position the teeth don‘t contact, the lips are slightly apart and the incisal thirds of the
maxillary incisors are visible. The visibility of the teeth varies from 1 to 5 mm, depending on
the length of the lip and the age and sex of the patient. Vig and Brundo in their study
suggested that more incisal show was seen in women (3.4 mm) compared to men (1.91mm)
and also younger patients had more show(3.37mm) compared to middle aged patient
(1.58mm) [9]. Also the portion of the maxillary incisor visible is diminished with age. The
reason for the same could be abrasion of the incisal margins and also due to the reduction in
the perioral muscle tone. Al Wazzan studied the amount of tooth visibility when the lips were
at rest. His documentation was in agreement with Vig‘s observation that females have more
incisal show when compared to males with respect to the central incisors. However, the males
significantly displayed more from themaxillary lateral, canine, and mandibular anteriorteeth
than the females. Also the amount of tooth exposed with an increase in age was studied by Al
Wazzan. With the increasing age, the amount of maxillarycentral incisor exposed when the
lips are at rest decreased from 3.13 mm at age 20 to 0.93 mm at age 60 [10].
INCISAL EDGE
The position of the incisal edges is critical in esthetic evaluation. The evaluation must be
done in both apico-coronal (the incisal curve) and the antero-posterior (incisal profile)
directions.
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INCISAL CURVE
The ideal incisal curve when observed in the frontal view is a convex curve that
follows the natural concavity of the lower lip during smiling. David Sarver referred to this as
the incisal arc. He defined it as the relationshipof the curvature of the incisal edges of the
maxillaryincisors and canines to the curvature of the lower lip inthe posed smile. The ideal
smile arc has the maxillary incisal edge curvature parallel to the curvature of thelower lip
upon smile; the term consonant is used to describe this parallel relationship. A
nonconsonantor flat, smile arc is characterized by the maxillary incisal curvature being flatter
than the curvature of the lower lip on smile [11].
A high percentage of individuals show parallelism between a convex incisal curve and
the lower lip. Studies have reported about 85 % of the cases showing this parallelism [12].
Soares documented that the straight and the convex incisal curves were more prevalent than
the reverse incisal curves [5]. This was in accordance with the results obtained by Dong (a
parallel smile was seen in 60% subjects, some with a straight smile (34%), and only a few
subjects with a reverse smile that is 5%). When Al-Johany studied 50 celebrity smiles that
were considered to be esthetic he found 78% had an anterior incisal curve that was parallel
with the lower lip, and 22% showed a straight rather than curved line. None of the subjects
showed a reverse curvature in relation to the lower lip [13].
The curvature is slightly evident in dental Class I patients. It tends to flatten out
considerably in Class III patients and it noticeably convex in Class II patients.
Depending on the relationship between the upper incisal margins and the lower lip, the
relationship could be termed as contacting, covering and not contacting. A study carried out
by Dong suggested that majority of the patients are included in the not contacting category
(54%). Tjan found that 47% subjects showed the maxillary anterior teeth touching the lower
lip, 35% were not touching the lower lip, and16% had the incisal portions of the anteriorteeth
covered by the lower lip.
Fig 8: A-The maxillary anterior teeth touching the lower lip, B-were not touching
the lower lip, C- had the incisal portions of the anterior teeth covered by the lower
lip.

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However abrasion of the incisal edges could lead to a flat of reverse incisal curvature
where the convex curve is lost. This is unpleasant from the esthetic point of view. A flat
incisal plane produces a sense of an ―aged‖ smile.
Whenever possible the clinician must try creating a convex incisal curve. This not only
improves the esthetics of the smile but also helps in establishing the incisal guidance.
However the lower lip is not always similar in its curvature on right and left sides. Hence it is
important that dentist decides to what plane the maxillary incisal edges are made parallel. It is
better to use the horizontal plane as the stable reference in such cases rather than the
curvature of the lower lip.
INCISAL PROFILE
The incisal profile is the position of the incisal edges in the anteroposterior direction. As a
rule it must be placed within the confines of the inner border of the lower lip. This allows
proper closure of the lips without any interference keeping them competent. It is
recommended to have the incisal edges remain inside the vermilion border of the lower lip.
SMILE LINE
The amount of tooth display is very critical. The smile line is the position of the inferior
border of the upper lip at maximum smile. On the basis of the amount of show of the teeth
and the gingiva, Tjan and Dong divided smile lines into low, average and high smile lines
[12, 14].
Fig 9: A- average, B-low and C-high smile lines.
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Low smile line: The anterior teeth are exposed by not more than 75%. This is found in
about20.5 % according to a study by Tjan and 15 % according to dong. Here the clinician can
avoid any treatments that are indicated for idealizing the gingival contours. Also priority must
be given to have supragingival margins.
Average smile line: 75% to 100% of the anterior teeth as well as the interproximal
gingival papillae are visible. This was found in 69% of the subjects [12]. and in about 56%
of the subjects reported according to dong [14].
High smile line: a band of gingiva of differing height is seen with the entire anterior tooth.
Goldstein examined 60 female subjects and found out that 32% of the subjects had high smile
line [15]. However this was visible in only 10.5% of the patients [12] and in 29% in
accordance to the study by Dong. The high smile line has a greater prevalence in the female
population with the incidence being twice as much. This may be due to the difference in
height of the upper lip (20 to 22 mm in women and 22 to 24 mm in male).These cases may
require corrective treatment in case the curvature of the gingival margins is not ideal. One
must ensure that in cases if intrasulcular margins are given the biological integrity of the
restoration is maintained.
With increase in age, there is loss of lip volume and architecture. This results in a
reduced tooth display. Hence some display of gingiva is often considered to be pleasing
since it is consistent with a youthful appearance.
Kourkouta evaluated 15 subjects that had undergone implant treatment in the upper anterior
region of the mouth and concluded that 46.6% of the subjects had an average smile line while
26.7% had a high and 26.7% had a low lip line [16]. This study also had results in accordance
to the previous work by Tjan and Dong respectively in terms of number of subjects compared
to the total sample size.
The high smile line showing a band of gingiva of more than 3 to 4 mm is termed as a gummy
smile. It is judged to be esthetically unattractive by many. The reasons for the same could be
1. Short upper lip
2. Labial hypermobility.
3. Anterior dentoalveolar extrusion
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While smiling the anterior teeth are generally exposed with the premolars. In few cases the 1s
4. Excessive vertical development of the upper maxilla.
Correction of a gummy smile could involve orthodontic treatment and/or crown lengthening
procedures. The idea of the treatment is to establish the ideal tooth length and also reduce the
amount if visible gingiva.
UPPER LIP CURVATURE
Upper lip curvature was divided into 3 categories. Upward curvature means that the corner
of the mouth is higher than the center of the lower border of the upper lip. Straight means that
the corner of the mouth and the center of the lower border of the upper lip are on a straight
line. Downward curvature means that the corner of the mouth is lower than the center of the
lower border of the upper lip.
An upward smile was rare (12%). Straight (45%) and downward (43%) smiles were
relatively numerous according to Dong. He also stated that an upward our straight smile is
more esthetic compared to a downward smile. This was confirmed by Al-Johany. He
compared 50 smiles that were considered to be esthetic and found the upward curvature in
62% of those subjects. [13].
SMILE WIDTH
Fig 10: A- smile width upto 1st premolar, B-smile width upto 2nd premolar, C-smile width
beyond 1st molar.
molars are exposed as well. The width of the smile varies from individual to individual.
According to Dong a majority of subjects (57%) had a smile width up to the 2nd
premolars. About 20% of the subjects had smile widths up to the 1stmolar [14].
Prior analysis of the smile width will help the clinician decide the type of preparation to be
performed. In the posterior areas, keeping the principles of tooth preparations in mind, a
conservative chamfer margin is generally considered to maintain the tooth structure. However
this could mean that the metal margin will be seen in cases with wider smile widths. Through
analysis and treatment planning must be done in such cases.
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LABIAL CORRIDOR
It is the space seen on either sides of the mouth during smiling between the buccal
walls of the maxillary teeth and the corners of the mouth. This slight gap is always seen in a
harmonious smile. However if the prosthetic restorations are placed too far buccal the entire
labial corridor could be obliterated. This would alter the harmony of the smile. If the labial
corridor is absent it gives an artificial appearance. The smile progression can be altered in a
way to maintain the harmony of the labial corridor. This can be achieved by providing the
correct inclination to the posterior teeth.
Patients who have narrow arch form a wide lip extension; tooth reveal behind the
canines can be in shadow or disappear completely. This condition has been called deficient
vestibular reveal, or DVR [17].This may have negative esthetic consequences in certain
patients.
RELATION OF INTERINCISAL LINE TO MIDLINE
Fig 11: A-Coinciding and B-Deviated
One of the most reliable references to identify the facial midline is using the midline
of the philtrum of the upper lip. Similarly the most reliable reference to identify the dental
midline is the maxillary interincisal line. However, any inclination of the incisors in the
mesiodistal direction could prove a problem in determining the dental midline. In such cases
stable landmarks like the papilla distal to the central incisors is taken. If there is a
discrepancy between the interincisal line and the midline and it is limited no treatment must
be carried out to correct it unless it is the patient‘s request. In such cases orthodontic
correction must be considered. It must be noted that the axial inclination can be altered
using prosthetic

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treatment. One must establish the interincisal line to be as vertical as possible not considering
any discrepancy with the facial midline into account.
RELATION OF OCCLUSAL PLANE TO COMMISSURAL LINE
The occlusal plane is formed by joining the incisal surfaces of the anterior teeth with the
occlusal surfaces of the posterior teeth. When viewing from the lateral aspect, this is parallel
to the ala-tragus line (Camper‘s line).
Fig 12: A-Coinciding and B-Deviated
These facial and dentolabial considerations must be evaluated in the treatment planning
phase. Ignorance to these features could lead to an unesthetic final outcome inspite of having
a successfully integrated implant in the anterior maxilla.

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References
1. Irfan Ahmad. Protocols for Predictable Aesthetic Dental Restorations. Blackwell
Munksgaard.
2. Almog D, Sanchez Marin C, Proskin HM, Cohen MJ, Kyrkanides S, Malmstrom
H. The effect of esthetic consultation methods on acceptance of diastema-closure
treatment plan: a pilot study. J Am Dent Assoc. 2004 Jul;135(7):875-81; quiz
1035-6, 1038.
3. Amra Vukovic, Selma Jakupovic, Selma Zukic, Sadeta Secic, Anita Bajsman.
Computer Aided Photogrammetry for Evaluation of Facial and Dental Symmetry
Jada 2010 Jun;18:876-881.
4. Miller EL, Bodden WR Jr, Jamison HC. A study of the relationship of the dental
midline to the facial median line. J Prosthet Dent. 1979 Jun;41(6):657-60.
5. Soares. Esthetic analysis of the smile. Braz J Oral Sci. 6(21):1313-1319
6. Rosensteil, Land, Fujimoto. Contemporary Fixed Prosthodontics 4th edition.
7. Rufenacht
8. Latta GH Jr. The midline and its relation to anatomic landmarks in the edentulous
patient. J Prosthet Dent. 1988 Jun;59(6):681-3.
9. Vig RG, Brundo GC. The kinetics of anterior tooth display. J Prosthet Dent. 1978
May;39(5):502-4.
10. Al Wazzan KA. The Visible Portion of Anterior Teeth at Rest. J Contemp Dent
Pract 2004February ;( 5)1:053-062.
11. Sarver DM. The importance of incisor positioning in the esthetic smile: the smile
arc. Am J Orthod Dentofacial Orthop. 2001 Aug;120(2):98-111.
12. Tjan AH, Miller GD, The JG. Some esthetic factors in a smile. J Prosthet Dent.
1984 Jan;51(1):24-8.
13. Al-Johany SS, Alqahtani AS, Alqahtani FY, Alzahrani AH. Evaluation of
different esthetic smile criteria. Int J Prosthodont. 2011 Jan-Feb;24(1):64-70.
14. Dong JK, Jin TH, Cho HW, Oh SC. The esthetics of the smile: a review of some
recent studies Int J Prosthodont. 1999 Jan-Feb;12(1):9-19.
15. Ronald Goldstein. Esthetics in Dentistry, Volume 1: Principles, Communications,
Treatment Methods.
16. Stella Kourkouta.Implant therapy in aesthetic zone: Smile line assessment Int J
Periodontics Restorative Dent 2011;31:195-201

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17. Matthews TG. The anatomy of a smile. J Prosthet Dent. 1978 Feb;39(2):128-34.
18. Mauro Fradeani. Esthetic Rehabilitation in Fixed Prosthodontics. Esthetic
Analysis. Volume 1. Quintessence Publishing Co.

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3. Soft and Hard Tissue Diagnostic Considerations
3.1 Introduction
3.1.1Presurgical Considerations
3.2 Soft Tissue Quality and Quantity
3.2.1 Gingival Biotype
3.3 Hard Tissue Quality and Quantity
3.3.1The Bone Morphology
3.4 Emergence Profile
3.1 Introduction
The current concept of implant dentistry deals with prosthetically driven implant fixture
implant placement. This means that the implant will occupy the position as the apical
extension of the restoration. This would however depend on the amount of hard and soft
tissue available for the procedure for implant placement. Thorough diagnosis of the available
hard and soft tissue is mandatory prior to the implant surgery.
3.1.1Presurgical Considerations
The quintessence of an optimal postsurgical aesthetic outcome is presurgical
planning. This crucial preplanning stage aims at fulfilling the patient's expectations at both
the functional and aesthetic levels. Therefore, the patient's expectations are in most cases
what the clinician might seek to realize. However, the clinician must be prudent to be able to
visualize what is feasible and realistic based on the existing clinical condition.
The dentist and his team make use of all available investigative tools to recommend
and display all treatment options. It is necessary that the final implant-supported restoration
and related soft tissue margins should match and harmonize with the remaining natural
counterparts. In this regard, selection of a clinical option that will ensure the best possible
aesthetic result is of foremost importance.
21

[23]
Implant success thus requires a personalized approach, based on the functional,
anatomical, aesthetic, and psychological needs of the implant candidate. Diagnosis and
treatment planning are the starting point for achieving the treatment goals. Type of occlusion;
number, shape, and condition of the remaining dentition; and amount of interdental and
interarch space available for replacement of teeth must be considered. This information is
crucial in making critical decisions on the many aspects of treatment. These conditions
mandate the position, size, type, and design of the future implants; the need for undertaking
any grafting or bone augmentation procedures; the surgical approach; the positioning of the
implant in the alveolar ridge; the selection of the prosthetic components; and the type of
future restoration. Therefore, the diagnostic information obtained prior to treatment initiation
can provide valuable insight into the appropriate sequence that is to be followed during the
surgical and restorative phases of treatment.
The modern clinician never depends only on visual and palpable examination of the
visible oral vital structures. The underlying investing structures also must be thoroughly
examined. Radiographic, modern diagnostic evaluation tools are essential for ensuing
successful treatment. Various available radiographic views can help assess the quantity,
quality, and inclination of the residual alveolar ridge. Such related anatomical details as the
nasal floor, maxillary sinus, and anterior mental looping may also be identified. Any
pathology or bone disease related to the working site may be detected and dealt with before
treatment commencement. Preoperative radiographs may be of assistance when reviewing
with the patient the progress made during the course of the treatment and for comparison
postoperatively.
Therefore, it is imperative that the clinician seek to obtain the most information possible
before starting the treatment. There are several means of acquiring this information. The first
of these is similar to a background check, where the patient's medical and dental history is
investigated.
3.2 Soft Tissue Quality and Quantity
Aesthetics in the anterior region relies heavily on healthy keratinized gingival tissue
(Fig1). This fact applies to both natural dentition and implant-supported restorations [1].
22

[24]
Gingival components that contribute to an aesthetically pleasing implant-supported
restoration are the marginal radicular form, the interdental tissues, and the color and texture
of healthy keratinized tissues.
Meticulous assessment of the soft tissue status related to the future implant site should
be established during the clinical examination at the presurgical stage. Seibert suggested that
the healthy soft tissue profile plays a critical role not only in establishing optimal aesthetics,
but also in facilitating long term maintenance of implant-supported restorations. [2]. The
absence of a keratinized mucosa might jeopardize the implant survival. In addition, some
authors have stated that a minimum of 2 mm of keratinized tissue width is needed to achieve
optimal health of the tissues surrounding natural dentition [3]. It has been reported that less
than 1 mm of keratinized tissue can be adequate, provided the bacterial plaque is well
controlled [4]. The presence of a sufficient band of keratinized mucosa will surely improve
the aesthetic outcome of the definitive implant-supported restoration. The presence of the
keratinized band can also minimize postoperative gingival recession, endure the trauma of
brushing, resist masticatory muscle pull, and reduce the probability of soft tissue dehiscence
above implant fixtures. Because soft tissues have the tendency to recede almost 1 mm after
surgical and restorative implant procedures, a sufficient amount of healthy keratinized
gingival tissue should exist prior to implant placement for compensation. Therefore,
optimizing the soft tissue quality and quantity before commencing on implant therapy
becomes a vital prerequiste. In the presurgical planning stage, the timing of soft tissue
augmentation therapy whether it is to be performed before, during, or after implant placement
should be determined.
Figure 1: Amount of Keratinized Tissue
23

[25]
3.2.1 Gingival Biotype
Two different periodontal patterns that are present in the human oral cavity are the
thin scalloped biotype and the thick flat biotype (Fig. 2 and 3). The thick flat type is more
prevalent (85%) than the thin scalloped biotype (15%) [5]. Each type has morphological
characteristics of its own with its distinctive adjoining structures. Recognizing and
distinguishing these basic types is essential in selecting the implant size, implant type, and
surgical approach, and in predicting the overall prognosis that will result in biological
harmony between the dental implants and the existing dentogingival structures.
The thick flat biotype is characterized by adequate amounts of masticatory mucosa. It
is dense and fibrous in nature with minimal height difference between the highest and lowest
points on the proximal and facial aspects of the marginal gingiva. Larger sized teeth that are
most likely square shaped characterize this type of periodontium. This bulkiness of the tooth
shape results in a broader, more apically positioned contact area, a cervical convexity that has
greater prominence, and an embrasure that is completely filled with the interdental papilla.
The root dimensions are broader mesiodistally, almost equal to the width of the crown at the
cervix, which causes a diminution in the amount of bone interproximally. The typical
reaction of this tissue biotype to trauma such as tooth preparation or impression making is
inflammation and apical migration of the junctional epithelium with a resultant pocket
formation. The thick flat tissue type is ideal for placing dental implants. Here the gingival and
osseous scalloping is normally parallel to the cementoenamel junction (CEJ). This type of
periodontium is less likely to exhibit soft tissue shrinkage postoperatively.
On the other hand, the thin scalloped biotype of periodontium exhibits its own
distinctive features. These include thin, friable gingiva with a narrow band of attached
masticatory mucosa, and a thin facial bone that usually exhibits dehiscence and fenestration.
The tooth crown shape usually exhibits a triangular or thin cylindrical form, and the contact
areas are smaller and located in a further incisal location. The cervical convexity is less
prominent than that of the thick biotype, while the interdental papilla is thin and long but
does not fill the embrasure space completely, resulting in a scalloped appearance.
Additionally, this biotype possesses a root that is narrow with an attenuated taper allowing
for an increased amount of inter-radicular bone. When inflicted with trauma, this tissue type
undergoes gingival recession both facially and interproximally. Placing dental implants in the
aesthetic zone becomes a critical task with this particular tissue biotype because it is difficult
24

[26]
to achieve symmetrical soft tissue contours probably due to the proximity of the implant to
the natural tooth periodontium next to it, and the reduced amount of masticatory mucosa. The
resultant recession and bone resorption leave a flat profile between the roots, with marginal
exposure of the restoration and subsequent partial loss of the interproximal papilla [6].
A proper appraisal of the periodontium should be performed prior to commencing any
implant therapy in the aesthetic zone. Each tissue type reacts differently to surgical
intervention, thereby warranting a specific treatment protocol. The thin scalloped tissue type
should be treated with an exceptional caution and utmost care (especially for patients with a
high smile line).
Figure 2: Thin periodontal biotype
Figure 3: Thick periodontal biotype
25

[27]
3.3 Hard Tissue Quality and Quantity
Replacing missing dentition with dental implants demands both optimized bone
quantity and bone quality at the edentulous site. Optimal osseous volume has a positive
influence on osseointegration. Therefore, emphasis should be placed on inserting an implant
in a sufficient osseous foundation when a predictable, successful aesthetic and functional
outcome is to be achieved.
It has been reported that the alveolar bone loses almost 30% of its size within two
years following tooth extraction. Both maxilla and mandible have distinctive resorption
patterns that affect both the width and height of the alveolar bone. Subsequently, bone
dimensions become insufficient to host the implant fixture, thus negatively affecting the
overall prognosis of the implant-supported prosthesis. It follows that alveolar bone quantity
and quality are an absolute necessity for dental implant success on both levels—aesthetically
and functionally.
The significance of the quantitative and qualitative parameters of the osseous
structure is immense; consequently, the subject has been discussed at length in most
textbooks. Many authors have classified the remaining alveolar bone differently in order to
assess and diagnose the remaining alveolar bone.
Misch has classified the available alveolar bone into four distinct divisions [7]:
Division A (Abundant Bone). Alveolar bone width is more than 5 mm, height greater than 10-
13 mm, and mesiodistal length greater than 7 mm, and the load's angulation does not exceed
30 degrees between the occlusal plan and the implant body. In addition, the crown-implant
body ratio is less than one. This type of bone is optimal for hosting an implant with a
diameter between 4 and 5 mm.
Division B (Barely Sufficient Bone). A slight to moderate atrophy has occurred, leading to a
decrease in the width of the available bone at the expense of only the facial cortical bone. The
height remains stable at a minimum of 10 mm. The remaining available bone width varies
between 3 and 5 mm and is thus able to accommodate an implant of 4 mm maximum width.
The load's angulation may not exceed 20 degrees. Treatment options presented for this type
26

[28]
are osteoplasty, bone augmentation, or the use of narrower diameter root form dental
implants.
Division C (Compromised Bone). Moderate to advanced atrophy is present, with the width
less than 2.5 mm, height less than 10 mm, load angulation greater than 30 degrees, and
crown-implant body ratio equal to or greater than one. The posterior maxillary and
mandibular regions demonstrate this type of alveolar bone more than the anterior segments.
Division D (Deficient Bone). This type demonstrates severe atrophy, accompanied by basal
bone loss. Therefore, the use of autogenous bone grafts is strongly recommended to augment
the deficient alveolar bone. This kind of bone usually results in complications related to soft
tissue management, grafting, and early implant failure.
The above classification can help the practitioner to precisely determine the specific
bone category of each particular patient. This, in turn, enables the clinician to select the
appropriate treatment protocol. The necessity of undergoing a bone grafting procedure exists
in many conditions, and subsequently, a surgical technique can be chosen that provides a
treatment prognosis with maximum predictability from either an aesthetic or functional
aspect.
Salama and Salama have introduced another classification that considers the available bone
according to the socket condition that will host the future implant fixture [8] .This
classification can be helpful when an immediate implant placement is the treatment of choice,
because the condition of the alveolar socket will dictate the treatment plan.
Lekholm and Zarb (1985) classified the residual jaw shape into five categories or types
ranging from A to E (Fig. 4), with decreasing amounts of bone remaining. In type A residual
ridges, there has been little residual ridge resorption, intermaxillary space is minimal, and
fabrication of the prosthesis may be compromised accordingly. Type B and C residual ridges
27

[29]
are found with moderate to advanced resorption and are usually ideal for placement of
osseointegrated fixtures and fabrication of the prosthesis. Type D and E residual ridges have
advanced resorption and may require onlay bone grafts in advance of or in conjunction with
fixture placement, especially in the maxilla.
The International Team of Implantology (I.T.I.) classify the patients in a classification system
known as the SAC classification.
In the SAC classification system, the ―S‖ represents simple, ―A‖ represents advanced, and
―C‖ represents complex treatment procedures. The system highlights the different clinical
conditions that often present in the anterior maxilla and the frequent need for bone
augmentation procedures. The classification states the treatment protocol according to the
clinical condition either in sites without osseous defects or in sites that has osseous defects.
Several techniques are now available for evaluation of bone quantity and quality.
Radiographic examination, especially tomograms or CT scans, can provide the accurate
dimension for the alveolar ridge at a specific predetermined location, as well as the bone
density. Bone density in the aesthetic zone generally falls into the D3 category, where 65% of
the anterior maxilla constitutes this category[9].
In many conditions, it is extremely important to assess the bone architecture using a
CT scan or a ridge mapping method because the anterior maxilla usually exhibits labial
concavities that might necessitate bone grafting procedures or placing the implant fixture at
an angle and using a pre-angled abutment. The macroscopic description of the Misch bone
density classification (Fig 5.)
D1 =bone is primarily dense cortical bone.
D2 =bone has dense-to-thick porous cortical bone on the crest and
within coarse trabecular bone.
D3= has a thinner porous cortical crest and fine trabecular bone.
D4= bone has almost no crestal cortical bone. The fine trabecular bone comprises almost all
of the total volume of bone next to the implant.
28

[30]
A very soft bone, with incomplete mineralization, may be considered D5 bone. This usually
describes immature bone.
Figure 4: Lekholm and Zarb’s Classification
Figure 5: Misch classification of bone density
29

[31]
Figure 6:Siebert’s Classification
3.3.1The Bone Morphology
The housing of a standard 3.75-mm-diameter implant requires 6 mm of bone in a
buccolingual dimension and 5–6 mm in a mesiodistal dimension. Periodontal disease,
endodontic infection and the bone remodeling process after tooth extraction may reduce the
bone volume available for implant placement. The loss of the vertical height of the bone at
the implant site represents a limiting factor for achieving an aesthetic outcome. Orthodontic
forced eruption, block bone grafting (J-graft) and osseous distraction have been proposed to
correct the vertical bone height at the implant site. An edentulous area with extensive vertical
loss of osseous structure may not be suitable for single-tooth aesthetic implant restoration.
Limitations in bone quantity in the mesiodistal dimension may be due to the root position of

31
the adjacent teeth. Orthodontic movement should be used to change the root position
providing the space for implant insertion. A reduced horizontal distance between the tooth
and the neighboring implant may adversely affect the bone level at the tooth surface. A
minimum of 1.5 mm of bone between the implant surface and the root surface should be
present. The bone volume at the implant site is measured on computed tomographic films
taken with a radiographic template reproducing the proposed position of the final restoration.
Periapical radiographs are used to evaluate the mesiodistal position of the roots adjacent to
the implant site.
3.4 Emergence Profile
The ability of the clinician to understand and control the relationship between the
implant and its associated gingival structures is extremely important in achieving an aesthetic
final implant-supported restoration. The position of the gingival margin following stage-two
surgery represents a collapsed state, until it finds support by the prosthetic components
against which it comes to rest. The gingival tissues around dental implant components should
be enhanced, influenced and developed to acquire the same dimensions and configurations as
the original tissues around natural dentition. The original soft tissue configuration around
natural teeth possesses a flat profile at the point where they erupt from the marginal mucosa .
The use of the different prosthetic components after the second-stage surgery will
allow the maturation of peri-implant soft tissue to develop a peri-implant dimension in the
subgingival area that gradually develops the emergence profile of the final prosthesis
matching the dimensions of the tooth to be replicated. The use of an accurately fabricated
surgical template can help ensure accurate implant positioning in relation to the adjacent
dentition, which directly influences the resultant emergence profile. Therefore, precise
implant placement and careful soft-tissue manipulation will allow the clinician to enhance the
peri-implant soft-tissue contours with the use of provisional restorations. Provisional
restoration will encourage gingival maturation to provide an ideal frame for the implant-
supported prosthesis. The cervical third of the labial aspect of the provisional prosthesis is
responsible for stimulating peri-implant tissues and developing the natural emergence. The
basic requirements for successful guided provisional soft-tissue modeling are sufficient
keratinized gingiva, provisional abutments, gradual atraumatic provisionalization, and
realistic size of the amount of gingival expansion.

32
Achieving a flat emergence profile around implant supported prostheses warrants obtaining
sufficient information on the specific tissue biotype, tooth form, soft tissue health condition,
adjacent periodontal health condition, and the type of future prosthetic components to be
used. Since an implant differs from a natural tooth in its morphological characteristics, the
cylindrical shape of the implant has to be improved upon in the subgingival compartment. It
rarely corresponds to that of a tooth. This compels the clinician to compensate for this
discrepancy by developing the soft tissue through the precise fabrication of a provisional
restoration that transfers the cylindrical shape of the implant to the shape of the root of the
natural tooth at the gingival margin that gradually influences the peri-implant soft tissue to
the desired configuration. When an edentulous site in the esthetic zone is planned for implant
placement, the site must be thoroughly evaluated. Garber has proposed a classification for
such sites [10]. This classification depends on the type of reconstruction needed to get good
positioning of the implant.
Garber Class I
When favorable horizontal and vertical levels of both soft tissue and bone are present, ideal
implant positioning is a straightforward procedure. A concomitant soft tissue augmentation at
the same time of implant placement is preferred in patients with a thin gingival biotype to
prevent the risk of soft tissue recession and buccal bone resorption.
Garber Class II
Sites with no vertical bone loss and slight horizontal bone deficiency measuring about I to 2
mm narrower than normal can be expanded by using serial osteotomes instead of drilling.
This technique will permit slight expansion of the bony ridge horizontally while
simultaneously compressing the maxillary cancellous bone to improve the bone quality.
However, this technique has not been investigated and insufficient evidence exists to make
evidence-based recommendations. As always, one alternative is to get sufficient initial
stability of the implant and lateral augmentation of the ridge using bone grafting techniques
or bone generation techniques .

33
Garber Class III
For sites with no vertical bone loss and horizontal bone loss greater than Class II, implant
placement can be attempted, provided an initial stability is achieved. Guided bone
regeneration is necessary.
Garber Class IV
In sites with no vertical bone loss but significant horizontal loss, it is necessary to use a
staged approach in which the ridge is widened with guided bone regeneration. Implants are
later placed after a suitable healing period of several months using block bone grafts or
guided bone regeneration techniques. Autogenous bone has generally been the graft material
of choice in these procedures.
Garber Class V
Sites with extensive apicocoronal bone loss present a significant challenge lo the surgeon.
As noted above, there are no well-documented surgical approaches available to predictably
augment bony ridge height. Some case reports suggest a surgical approach of guided bone
regeneration using a nonresorbable membrane and delayed implant placement, while other
investigators suggest tenting barrier membranes with an immediately placed, submerged
implant as a space-making device under the membrane. Distraction osteogenesis has been
used to augment the ridge height, but no long-term clinical data is available on outcomes in
this application.
Regardless of the type of procedure planned for the mature site, proper flap management is
critical for success. Careful attention should be paid to incision design and flap extension in
an effort to preserve the blood supply of the flap. A papillae sparing incision (parapapillary
incision) may be used to preserve blood supply to the delicate interdental papillae and to
minimize the potential of postsurgical recession. Implant placement without incision is
mentioned in the literature. In this procedure, the implant is placed into predetermined
abundant bone through an opening made by a soft tissue punch. There is insufficient, data to
properly evaluate this procedure, also this approach does not permit adequate visualization of
the bone. Such visualization is necessary for proper three-dimensional positioning of the
implant.

34
To achieve a successful esthetic result and good patient satisfaction, implant
placement in the esthetic zone demands a thorough understanding of anatomic, biologic,
surgical, and prosthetic principles. The ability to achieve harmonious, indistinguishable
prosthesis from adjacent natural teeth in the esthetic zone is sometimes challenging.
Placement of dental implants in the esthetic zone is a technique-sensitive, procedure with
little room for error. Guidelines are presented for ideal implant positioning and for a variety of
therapeutic modalities that can be implemented for addressing different clinical situations
involving replacement of missing teeth in the esthetic zone

35
References:
1. Berglundh T, and Lindhe J. Dimension of the periimplant mucosa: Biological width
revisited. J Clin Periodontol 1996(23): 971-973.
2. Seibert JS and Salama H. Alveolar ridge preservation and reconstruction. Periodontol
2000 1996(6): 69-84
3. Lang NP and Loe H. The relationship between the width of keratinized gingiva and
gingival health. J Periodontol 1972(43): 623-627
4. Stetler KJ and Bissada NF. Significance of the width of keratinized gingiva on the
periodontal status of teeth with submarginal restorations. J Periodontol 1987(58): 696-
700.
5. Olsson M and Lindhe J. Periodontal characteristics in individuals with varying forms
of the upper central incisors. J Clin Periodontol 1991(18): 78-82
6. Tarnow D, Magner A, and Fletcher P. The effect of the distance from the contact
point to the crest of bone on the presence or absence of the interproximal papilla. J
Periodontol 1992(63): 995-996.
7. Carl Misch. Contemporary Implant dentistry. 3rd Edition.
8. Salama H and Salama M. The role of orthodontic extrusive remodeling in the
enhancement of soft and hard tissues profiles prior to implant placement: A
systematic approach to the management of extraction site defects. Int J Periodont
Rest Dent 1993(13): 313-333.
9. Misch EC. Bone density: A key Determinant for clinical success. In Misch CE, ed.
Contemporary Implant dentistry, St. Louis: Mosby, 1999, 109-118.
10. Garber DA, Rosenberg ES. The edentulous ridge in fixed prosthodontics. Compend
Contin Educ Dent1981;2(4):212–23.

36
4. Implant and abutment design considerations in the esthetic zone
4.1 Introduction
4.2 Cement vs Screw Retention
4.3 Abutment Selection
4.4 Treatment Procedures
4.5 Use of Pink Porcelain
4.1 Introduction
Implant-based therapy has advanced clinically, with improvements primarily associated with
implant morphology and increased knowledge with regard to the biological basis for
treatment. Treatment involving replacement of teeth missing in the anterior maxilla has
arguably shown the most benefit as a result of the enhancements. True progress has been
made when considering the quality of outcome from both the functional and aesthetic
perspectives.
When considering the use of single-stage implants for treatment of missing teeth in the
anterior maxilla, the following factors [1] are of importance:
1) Implant morphology and surgical considerations
a. Biologic compatibility with bone healing and long-term bone maintenance.
b. Biologic compatibility with long-term soft-tissue health.
c. Implant macromorphology (shape) compatible with the development of appropriate
emergence.
d. Capacity to support restorations on the implant margin.
e. Implant range with regard to diameter, providing appropriate dimensions for a range of
missing teeth
f. Consistent internal connection for a variety of restorative components (indicated for both
screw and cement retention)
g. Reduction of trauma to bone and peri-implant soft tissues
h. Maturation of the sulcular epithelium from the time of implant placement

37
2) Restorative considerations
a. Mature soft tissues are present for abutment connection and margins are accessible and
conveniently located to increase simplicity of provisional restoration and impression-making
procedures.
b. No introduction of an active micro-gap at prosthesis connection ensuring the coronal
extension of bone around the implant.
c. Consistent support for soft tissues provides for long-term proximal tissue support when
coordinated correctly with the prosthesis.
d. Retention flexibility for the prosthesis and availability of components consistent with
screw and cement retention of provisional and definitive prosthesis.
e. Compatibility with conventional, early, and immediate loading protocols
The factors discussed have a strong relationship to both the surgical and restorative aspects of
implant dentistry. The rationale for a roughened surface included maximizing attachment and
stability, minimizing bone loss associated with site preparation, and minimizing implant
volume [2]. In other words, improvements in anchoring capacity with maintenance of bone,
no loss in bone contact area, and no reduction in mechanical strength. In addition, several
authors have attributed improved bone healing and apposition adjacent to dental implants
to the character of roughened surfaces [3-5]. Implants with surface characteristics of this
nature have been recommended in the aesthetic zone, and have proven successful. Initially
typified by titanium plasma-sprayed or hydroxyapatite surfaces, roughened surfaces have
altered the clinical practice of implant-based dentistry in recent years. Improvements in the
nature of the implant surface may improve the prospects of implant survival and/or reduce the
prospects of implant failure for any given healing period. This makes it safer to load implants
earlier. Buser evaluated bone-to-implant contact for a variety of implant surface
morphologies [5] They found the greatest bone-to implant contact occurred adjacent to
implants typified by either a sand-blasted, large-grit, acid-etched surface or implants with a
hydroxyapatite coating. The bone formed around the single-stage 1-part implant can be, by
design, protected from the influence of the bacterial micro-gap. This protection is provided
by a trans-mucosal portion of the implant being an integral component of the implant itself
and sized to comply with biologic width. This ensures the microgap is positioned
approximately 2 mm from the roughened surface on the implant body, a distance at which
bone remains stable [6, 7]. The location of the microgap and the implant surface morphology

38
were evaluated by Hermann [6] and associated with bone healing and crestal bone
characteristics [7]. The authors found that single-stage 1-part implants supported bone to the
junction between the rough and smooth components of the implants. In contrast, 2-part
implants (1- or 2-stage) were unable to support bone within approximately 2 mm of the
component junction.
Treatment procedures cannot be discounted as possible factors bearing positive
influence on the biologic status of this region. After all, single-stage implant placement saves
implant sites from at least 1 invasive procedure. Secondly, as no active gap results from
abutment connection, no responsive reaction of bone can be anticipated. Perhaps most
important of all, the restorative procedures of abutment connection, provisional restoration,
and impression making can be performed with a minimum of trauma to the tissues and a
maximum of simplicity.
Single-stage 1-part implants are capable of maintaining bone at the rough-smooth
junction. Bone height, in turn, has been related (with 2-stage implants) to the presence of an
interdental papillae, and the distance to the contact point between the restorations above.[8]
The success of implant-based restorations in the anterior maxilla is dependent on the aesthetic
quality of the soft tissues (height, contours, color, and symmetry), the vertical position (or
coronal extension) of bone is intimately related to this outcome.; however, clinicians should
be cognizant of the differences between this implant design and that considered conventional
(Machined Implants).
4.2 Cement vs Screw Retention
The connection of the final restoration to the implant maybe accomplished via a screw
connection or by cementation. Both methods have their benefits and short comings and
should be selected case by case. Limited scientific evidence is available for cement vs screw
retention [9].
In the anterior zone, screw retention is easier is the position of the screw access hole is
planned below the incisal edge position on the lingual aspect. In addition the implant must be
in the correct prosthodontic position.

39
Extended edentulous areas are usually an indication for fixed dental prosthesis. What matters
in this case is the prosthodontics position of the implant. Standard abutments can be used for
cemented restorations, which simplify the procedure from a technical point of view and
reduces cost. The advantages of cementation are simplicity, passivity of fit, improved
esthetics, increased control of occlusion and economy [10]. Cement can also act like a shock
absorber [11]. A major disadvantage of cement retained is the difficulty in removing the
excess cement leading to peri-implant mucositis (Wilson 2009).[10] It is recommended to
position the cement margins at the level of the mucosa of upto 2 mm below this level.
Lack of retrievability is another disadvantage. An adequately tapered abutment will usually
suffice for effective restoration of the abutment by temporary cement. The use of temporary
cement may be indicated. Hebel Gajjar[12] suggested the use of temporary cement mixed
with petroleum jelly for multiple units and of non modified temporary cement for single unit
restorations.
Screw retained restorations are recommended as the method of choice in the esthetic zone as
the screw access hole do not interfere with occlusion. Furthermore screw retention eliminates
the risk of mucositis due to absence of cement residues.
Screw retained prosthesis will require the use of customized abutments thus involving
technique sensitive and demanding fabrication steps. Michiklais [9]. It is important that all
screw be torqued according to manufacturer‘s instructions and the screw holes be obturated
with a PTFE tape and composite resin. If the interocclusal space is limited, screw retained
restorations are the technique of choice.
In recent long temr evaluation of implant supported restoration, the patients reported no
difference between the 2 types. 5 year survival was 96 % of implants with no difference in
the type of retention [13]. Soft tissue health might be better in screw retained restorations.

40
4.3 Abutment Selection
This is an quintessential aspect of implant treatment in esthetic zone. The advantage of bone
level implants is that they offer prosthodontic freedom of creating custom emergence profiles
of defining the final position of the restorative margin
Eligible materials for final abutments include
Titanium
Gold
Alumina based ceramics
Studies have shown that titanium and Zirconia abutments are well tolerated by the soft tissue
and both offer similar soft tissue integration. Gold may have their disadvantages. Apical
shifts of the barrier epithelium and margin bone were noted around gold abutments as
opposed to titanium abutments.
Dental implant abutments may be prefabricated or customized, prefabricated are indicated
when the implants are placed in an ideal position. They are time efficient as they only need to
be modified by milling and the crown can be immediately finalised. The collar height in the
aesthetic zone is not uniformly 360 degrees as the interproximal position of the crown margin
would be placed too far submucosally. If the implants are placed shallow ceramic abutments
would be the ideal choice as opposed to titanium or gold abutments. Clinical observations
have shown use of zirconia abutments when the clinicians have waited too long before re
torqueing the screw the implant abutment connection may have worn out. Implant abutments
may be engaging or non-engaging. An internal connection will preclude all rotational
movement and is therefore indicated for single restorations or short span FDP`s. Non
engaging abutments are indicated for screw retained multiple unit FDP`s to ensure a passive
fit . Multi-base standard titanium abutments are indicated for screw retained implant
supported bridges.

41
4.4 Treatment procedures:
In the esthetic zone, patient expectations of the definitive prosthodontics esthetic outcome are
the highest compared to other regions of the dentition. Important concerns include the overall
duration of treatment, morbidity, cost consideration and psychological stress of having lost
anterior teeth. Compensation for these concerns should be offered in the form of a final
prosthodontics design that will offer a satisfactory esthetic outcome.
Difficult decisions are required with regard to retention type, abutment selection,
prosthodontic design and restorative materials. A prosthodontics design depends on the
selected material and mode of retention.
In the esthetic zone, the selected material should be optimal from the esthetic as well as the
functional viewpoints. Both all ceramic and PFM reconstructions should be considered. Some
of the factors to be considered include bruxing habits, space requirements for the abutments
and the super structure and posterior support. If the patient is a bruxer, the occlusal or incisal
contact areas should be fabricated in gold, thus indicating that a metal ceramic design should
be selected. If space is limited a metal ceramic design is also recommended. Regardless of
materials and designs, posterior support must be present to equalise the load distribution
evenly throughout the dental arch.
All ceramic restorations offer excellent esthetic outcomes. In a randomised clinical trial color
differences between midfacial peri-implant mucosa and the gingival margins of the
corresponding neighbouring teeth were evaluated in a group of patients with all ceramic
crowns on alumina based abutments and compared to a group of PFM crowns on titanium or
gold abutments (Jung 2008).[14] The color changes were less prominent in the all ceramic
than the PFM group.
With posterior support ensured and no history of bruxism, all ceramic restorations are
recommended in the esthetic zone .Screw retained are the first choice depending on the
restorative positions of the implants. If screw retention is precluded by these positions,
cementation is an option that can be used. If two missing teeth are replaced by two implants,
screw retained single restorations with the implant abutments covered with no more than 2
mm of veneering ceramic are recommended.
Once soft tissue conditioning has been completed to its final shape via fixed provisional
restorations, final impression with customised impression post should be made. The

42
provisional restoration offers esthetic guidance by helping to evaluate the final prosthetic
design. An additional mock-up is recommended if the patient is dissatisfied with the
provisional restoration or more esthetic analysis is necessary.
One way of fabricating the final reconstruction is by CAD/CAM technology. Zirconia is
recommended for all ceramic frameworks.
4.5 Use of pink ceramics in the extended edentulous space:
The prosthetic design of the final restoration depends on the pre-existing situation, the
outcome of the surgical procedures, and the risk factors involved. If vertical and horizontal
deficiencies of the partially edentulous ridge are present, gingiva-coloured pink ceramics are
used to optimize the esthetic result [15]
They may be indicated whenever patients with a low or medium-high smile line present with
vertical and horizontal hard or soft tissue defect. In patients with a very high lip line, the use
of pink ceramics is not always an option [16]. Bone augmentation may be performed to
augment the bone and gingiva vertically and horizontally. Since the decision to use artificial
gingiva is highly case sensitive, proper treatment planning is essential.
A radiographic template is required to evaluate the bone height and width and to correlate
these parameters with the desired prosthetic position. A diagnostic mock up helps determine
this prospective position. A major focus of this mock-up should be on correct incisal and
labial positions of the future restorations through phonetic and profile analysis. This
information is then transferred to a radiographic template and a CBCT may be obtained.
The provisional restoration serves to replace the missing teeth on an interim basis. The
position of the mucosa and the soft tissue morphology observed by the end of the provisional
phase are important guides for designing the final prosthesis. The provisional restoration does
not offer information about the position of the transition line. The provisional restoration
must be designed to offer easy access for hygiene. The gingival shade most precisely should
match the surrounding gingiva.

43
An intraoral diagnostic wax up is recommended to determine three important aspects relative
to the prosthetic design.
1. Morphology of the future pink portion of the implant supported prosthesis by
evaluating the exact position of the transition zone between the plan pink ceramic and
the existing mucosa.
2. Cervical height of the planned gingival level.
3. Maintenance and access to the future restoration by oral hygiene devices.
In addition the intra oral diagnostic wax-up helps evaluate the overall dental esthetic
appearance, including tooth length, width and form as well as other intraoral and
extraoral parameters such as the facial and dental midline, vertical dimension of
occlusion and smile. It also helps in eliciting the patient‘s esthetic expectations and
acceptance of the suggested design.
The bisque try in with the use of pink ceramics can be divided into two steps:
1. Elaboration of exact tooth form :
Only if the correct tooth form is evident can the decision of the dimension of the
future pink portion of the restoration can be made. Pink ceramics is therefore not
finalised at the first bisque try in so that position and thickness of `pink ` and the
planned transition line can be assessed directly by the patient.
2. Elaboration of pink ceramics after the first try in:
This step is accomplished in accordance with the tooth forms and the
neighbouring teeth. The decision exactly where the transition line should be
placed is key to a successful outcome. One can readily visualise the correct level
during smile and phonetic movements.
The shape of the prosthesis should offer good access for hygiene in the absence of
any concavities underneath and should allow superfloss to pass through the entire
interface between the artificial and natural mucosa along the abutments.
(Coachman 2010)[15]
The patient should be able to use the floss without assistance and that the pressure
level between the artificial and natural mucosa is similar to the one inside an
interproximal tooth contact. Superfloss should be able to pass through the by

44
overcoming mild resistance. Oral hygiene instructions should be given and
explained in front of the mirror.

45
References:
1. Dean Morton, BDS, MS,* William C. Martin, DMD, MS,† and James D.
Ruskin,Single-Stage Straumann Dental Implants in the Aesthetic Zone:
Considerations and Treatment Procedures J Oral Maxillofac Surg 62:57-66, 2004,
Suppl 2
2. Scacchi M: The development of the ITI Dental Implant System. Part 1: A review of
the literature. Clin Oral Implants Res 11:8, 2000 (suppl)
3. Thomas K, Cook S: An evaluation of variables influencing implant fixation by direct
bone apposition. J Biomed Mater Res 19:875, 1985
4. Wilke H-J, Claes L, Steinemann S: The influence of various titanium surfaces on the
interface shear strength between implants and bone, in Heimke G, Soltesz U, Lee AJC
(eds): Advances in Biomaterials—Clinical Implant Materials. Amsterdam, Elsevier
Science, 1990, pp 309–314
5. Buser D, Schenk RK, Steinemann S, et al: Influence of surface characteristics on bone
integration of titanium implants. A histomorphometric study in miniature pigs. J
Biomed Mater Res 25:889, 1991
6. Hermann JS, Cochran DL, Nummikoski PV, et al: Crestal bone changes around
titanium implants. A radiographic evaluation of unloaded non-submerged and
submerged implants in the canine mandible. J Periodontol 68:1117, 1997
7. Cochran DL: The scientific basis for and clinical experiences with Straumann
implants including the ITI Dental Implant System: A consensus report. Clin Oral
Implants Res 11:33, 2000
8. Tarnow DP, Magner AW, Fletcher P: 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
Periodontol 63: 995, 1992
9. Michalakls, Hirayama H. Cemennt retained versus screw retained implant
restorations: A critical review. Int J Oral Maxillofac implants 2003 sept-oct 18(5):
719-728
10. Wilson TG. The positive relationship between excess cement and peri-implant
disease: a prospective clinical endoscopic study. J periodontal. 2009 Sep;80(9) 1388-
1392.
11. Guichet DL Load transfer in screw and cement retained implant fixed partial denture
design J Prosth Dent 1994;72:631

46
12. Hebel K S, Gajjar R. Cement retained versus srew retained implant restoration:
achieving Optimal occlusion and esthetics in implant dentistry. J. prosthet. Dent. 1997
jan:77(1):28-35
13. Sherif S, Susarla s, Hwang J. Clinician and patient reported long term evaluation of
Screw and cement retained Implant Restorations: A 5 year prospective Study. Clin
oral Investig 2011 Dec15(6):993-999.
14. Jung R, Hammerle C H, Sailer I et al the effect of all ceramic and porcelain fused to
metal restorations on marginal peri-implant soft tissue colour Int J Periodontics
Restorative Dentistry 2008 Aug;28(4):357-365.
15. Coachman C, Salama M, Garber D,Calamita et al Prosthetic gingival
Reconstructionin fixed restorations Part 3 : Laborotory Proceduresand maintenance.
Int J Periodontics Restorative Dent 2010 Feb;30(1):19-29
16. Salama M, Coachman C, Garber et al. Prosthetic gingival reconstruction in the fixed
partial restoration. Part 2 Diagnosis and treatment planning. Int J periodontics and
restorative dentistry 2009Dec;29(6):521-527.

47
5. Optimal Implant Position
(General Surgical Considerations for Implantology in the Esthetic
Zone.)
5.1 Introduction
5.2 Ideal Implant Position
5.2.1 Buccolingual position
5.2.2 Mesiodistal position
5.2.3 Apicocoronal position
5.2.4 Implant angulation
5.1 Introduction
The implant must be considered as the apical extension of the restoration. The planned design
of the restoration should guide the surgical placement of the implant [1]. This concept is
known as prosthetically driven implant placement. Previously the concept was based on
anatomy-driven implant placement. Prosthetically driven implantology dictates that the
implant to be placed where it can be properly restored. If the desired site is lacking in bone or
soft tissue, then hard and soft tissue augmentation procedures must be employed to create an
acceptable site for implant fixture placement. Optimal esthetic implant restoration depends on
proper three-dimensional implant positioning. Frank L. Higginbottom has suggested the use
of three dimensional template for the placement of the implants in the ideal position [2].
5.2 Ideal Implant Position
Four parameters contribute to the success of the restoration and all must be carefully
considered during implant placement. These are the buccolingual, mesiodistal, and

48
apicocoronal positions relative to the platform of the implant, as well as the angulation of the
implant [3].
5.2.1 Buccolingual position
An implant generally placed too far buccally often results in a dehiscence of the
buccal cortical plate. This increases the incidence of gingival recession. This placement is
also known to complicate the restoration of the implant. However when an implant is placed
too far to the palatal it often requires a ridge-lap restoration to accommodate for the excess
buccal contour. This results in a prosthesis that is both unhygienic and unesthetic [4]. Proper
buccolingual positioning of the implant simplifies the restorative procedure, results in a
proper emergence profile, and makes maintaining the oral hygiene easy. The buccal wall
must maintain a thickness of at least 1 mm to prevent recession and improve esthetics. Spray
reported that as the bone thickness approached 1.8 to 2 mm, bone loss decreased significantly
[5]. Adequate labial bone also helps in creating good emergence profile. The placement
should be such that the crown emerges naturally from the soft tissue cuff to create the illusion
of a natural tooth. To achieve this, the center line of the implant must often be located at or
near the center of the tooth it replaces. The implant must be positioned in such a way that the
buccal aspect of the implant platform just touches an imaginary line that touches the incisal
edges of the adjacent teeth (Fig. 1). There are, however, situations requiring that the implant
be placed in a more palatal position like in patients with a thin gingival biotype to avoid
esthetic failures in terms of recession. The type of final abutment to be used somehow
governs the labiopalatal positioning of the implant as well as its angulation. The final
abutment and the final restoration should be determined before starting implant placement.
There are two main types of final abutments, screw-retained abutments and cement-retained
abutments. The choice of positioning the implant fixture will depend on the space needed to
gain accessibility to the abutment. For example, when cement-retained abutments are used,
the implant is positioned exactly in the centre of the long axis of the future implant-supported
crown. On the other hand, when screw retained abutments are used, the implant should be
placed slightly palatal to the long axis of the crown, in order to access the connecting screw
from the palatal side.

49
Figure 1: Safe zone depicted for buccolingual position of the tooth.
5.2.2 Mesio-distal position
The available mesio-distal space must be carefully measured so that an implant of the proper
size may be selected and proper implant spacing planned. Placement of an implant too close
to adjacent implants or teeth may result in interproximal bone loss with subsequent loss of
papilla. Apart from the vertical component, there is a lateral component to the crestal bone
loss around the implant [6, 7]. It is recommended that a minimum distance of 1.5 to 2 mm
should be maintained between implants and neighbouring teeth (Fig. 2) and, in the case of
multiple implants, a space of 3 to 4 mm should be maintained between implants [6, 7]. In the
case of a maxillary central incisor site, it may be desirable to place the implant slightly to the
distal to mimic the natural asymmetry of the gingival contour often seen in these teeth.
Failure to maintain the mesial-distal position results in a proximal overhang on the restoration
which could be detrimental to the success of the implant prosthesis.
Figure 2: Safe zone depicted for mesio-distal position of the tooth.

50
5.2.3 Apicocoronal position
Apical positioning of the implant is also referred to as the countersink. It is important to mask
the metal of the implant as well as the abutment for superior esthetics. This positioning may
involve countersinking the osteotomy site. The amount of countersinking required is
somewhat dependent upon the implant diameter [8]. The wider the implant, the less distance
is needed to form a gradual emergence profile. In such cases, less countersinking will be
required. The distance from the platform to the mucosal margin is sometimes referred to as
‗‗running room.‘‘ The running room is critical in providing a good emergence profile.
Without apical placement to compensate for the difference in diameter, the transition from
implant to tooth can be abrupt. In general, the more apical the placement of the implant, the
better the emergence profile. However, locating the implant-abutment interface more apically
means losing more crestal bone for establishing the peri-implant biological width [9, 10]. It is
generally accepted that the crestal bone is re-established 1.5 mm apical to the implant-
abutment interface. The apicocoronal position of the implant should provide a balance
between health and esthetics. The more apical the implant placement, the more esthetic the
restoration and the less healthy the tissue. Excessive countersinking of the implant can cause
saucerization, which is the undesirable circumferential vertical and horizontal crestal bone
loss, and subsequent gingival recession after loading. Conversely, superficial placement of
the implant can lead to visible metal margin. In a patient without gingival recession, it is
generally acceptable to use the cemento-enamel junction (CEJ) location of adjacent teeth as a
point of reference to determine the apicocoronal position of the implant platform. The sink
depth of the implant shoulder should be 1 to 2 mm for a one-stage implant or 2 to 3 mm for a
two-stage implant apically to the imaginary line connecting mid-buccal of CEJs of the
adjacent teeth without gingival recession (Fig. 3). It is essential to take into consideration the
varying CEJs of the adjacent teeth. For example, the CEJ of the maxillary lateral incisor is
usually located 1 mm more coronally than the CEJs of the adjacent central incisor and canine.
In patients with gingival recession, the mid-buccal gingival
margin can be used as a reference in lieu of the CEJ.

51
Figure 3: Countersink of the implant fixture
5.2.4 Implant angulation
Ideally, implants should be placed so that the abutment resembles the preparation of a natural
tooth [3]. In screw-retained prostheses, poor angulation can alter screw placement, which
may have a significant effect on esthetics [11]. Implants positioned with too much angulation
either toward the palatal or the buccal often compromise esthetics due to the access of the
screw opening. It is generally accepted that the implant angulation should mimic the
angulation of adjacent teeth if the teeth are in reasonably good alignment. Most implant
systems include a provision for some type of angled or custom abutments to compensate for
situations where ideal alignment may not be possible. Surgical stents can help provide the
right angulation, as this may be difficult to visualize at the time of surgery. In the maxillary
anterior regions, a subtle palatal angulation is sometimes recommended to increase labial soft
tissue bulk and to avoid the problems with thin buccal walls.

52
References:
1. Garber DA, Belser UC. Restoration-driven implant placement with restoration-
generated site development. Compend Contin Educ Dent 1995;16(8):796, 798–802,
804.
2. Higginbottom FL, Wilson TG Jr. Three-dimensional templates for placement of root-
form dental implants: a technical note. Int J Oral Maxillofac Implants
1996;11(6):787–93
3. Mohanad Al-Sabbagh. Implants in the Esthetic Zone. Dent Clin N Am 50 (2006)
391–407.
4. Buser D, Martin W, Belser UC. Optimizing esthetics for implant restorations in the
anterior maxilla: anatomic and surgical considerations. Int J Oral Maxillofac Implants
2004; 19(Suppl):43–61.
5. Spray JR, Black CG, Morris HF, et al. The influence of bone thickness on facial
marginal bone response: stage 1 placement through stage 2 uncovering. Ann
Periodontol 2000;5(1): 119–28.
6. Tarnow DP, Cho SC, Wallace SS. The effect of inter-implant distance on the height
of interimplant bone crest. J Periodontol 2000;71(4):546–9.
7. Esposito M, Ekestubbe A, Grondahl K. Radiological evaluation of marginal bone loss
at tooth surfaces facing single Branemark implants. Clin Oral Implants Res
1993;4(3):151–7.
8. Jansen CE, Weisgold A. Presurgical treatment planning for the anterior single-tooth
implant restoration. Compend Contin Educ Dent 1995;16(8):746
9. Hermann JS, Cochran DL, Nummikoski PV, et al. Crestal bone changes around
titanium implants. A radiographic evaluation of unloaded nonsubmerged and
submerged implants in the canine mandible. J Periodontol 1997;68(11):1117–30.
10. Hermann JS, Buser D, Schenk RK, et al. Biologic width around titanium implants. A
physiologically formed and stable dimension over time. Clin Oral Implants Res
2000;11(1):1–11.
11. Sullivan DY, Sherwood RL. Considerations for successful single tooth implant
restorations. J Esthet Dent 1993;5(3):118–24.

53
6. Provisional Restorations
6.1 Introduction
6.2 Procedures for Provisionalization
6.3 Immediate Implant Placement and Provisionalization
6.4 Recommended Options
6.5 Current Clinical Guidelines
6.1 Introduction
The conventional 2 stage protocol for implant placement ensures that the implant is
submerged underneath the mucosa for the duration of a specified healing period of about 3 to
6 months. The advantage of the two-stage method lies in the primary closure of the wound
and the adaptation of bone to the implant in a sterile and stress-free environment. However
the need for a second stage surgery and the unpredictable nature of the soft tissue healing
around the healing abutment causes some amount of uncertainty with respect to the gingival
emergence profile around the implant prosthesis. The use of provisional restorations at the
time of implant placement or the second stage surgery could help with the customization of
the emergence profile.
When vertical site enhancement procedures are performed, it is important to design a
provisional restoration that will eliminate any pressure in the vertical direction. Removable
prosthesis depends on the palatal tissues for retention and resistance. This could lead to
unavoidable pressure in the area causing vertical loss of graft. It is recommended to design an
interim prosthesis that will eliminate these pressures.
6.2 Procedures for Provisionalization
Provisional restorations help confirm the design of the definitive restorations with respect to
whether it is screw retained or cement retained, and also the abutment selection. They also
help to evaluate the esthetics and phonetics of the final restoration. In addition, the oral
hygiene and periimplant soft tissue response of the patient can be monitored. Any need for

54
modifying the soft tissue contour at the pontic areas can also be confirmed. The provisional
restorations may also help the patient in communicating with the dentist the requirements of
the final restoration.
S. J. Markus (1999) suggested the use of interim esthetic restorations for anterior implants
[1]. He suggested the use of a ―T BAR‖ temporary restoration immediately after the implant
placement. The ―T BAR‖ restoration was fabricated by first making a customized incisal
edge that was matching the adjacent central incisor, using microfilled resin within a stent
made on a diagnostic cast. Then a short piece of 4-mm width Ribbond was soaked in unfilled
resin and blotted with a 2 ´ 2-inch gauze. A low viscosity resin was worked into the mesh,
and then placed on a piece of waxed paper. A second, shorter piece of 2-mm Ribbond was
treated in a similar manner, crossed (to form a ―T‖) with the longer piece, and light cured for
20 seconds. That rigid ―T‖ was then embedded in the resin within the stent at the midpoint
labiolingually, and then light cured, removed from the stent, and this incisal third of the tooth
was highly polished. This ―T BAR‖ restoration was then stabilized in the mouth after the
surgery using periodontal dressing. The dressing was carved out incisally to expose the
edges. He also suggested the use of a claspless, acrylic resin temporary removable partial
denture. He suggested the use of Ribbond ribbon to stabilize the provisional that the ridge lap
area. He also suggested that the labial flange could be eliminated.
Periklis Proussaefs (2002) suggested the use of healing abutments as abutments for cement
retained provisional restorations [2]. He suggested the use of a vacuum formed stent made
from the diagnostic wax-up as the guide for fabricating the provisional restorations. The stent
provided a guide for the amount of reduction required for the healing abutment. The healing
abutments were reduced using carbide burs and the access holes were blocked using
temporary restorative material. An irreversible hydrocolloid impression was made and using
the stent provision restorations were made. The disadvantage of using a screw retained
prosthesis is the access of the screw hole could be incisal or buccal in mal-aligned implants.
Use of such an indirect fabricated cement retained implant is thus helpful.
Mario R. Ganddini (2005) suggested a technique where they utilized an implant carrier mount
as an impression post and a provisional abutment [3]. Following the healing period after

55
second stage surgery the healing abutment was removed and an implant carrier was placed. A
plastic sprue was placed in the screw access hole. An impression was made and the cast was
removed. On the cast the implant carrier was prepared and a polycarbonate crown was relined
using autopolymerising resin. The provisional crown was then cement retained. This was a
simple cost effective technique as the implant carrier (used as a provisional abutment) was
provided with the implant.
Wei-Shao Lin and Carlo Ercoli (2009) suggested fabrication of a screw retained provisional
restoration using the indirect method [4]. An implant level impression was made and the
casts were mounted. Teeth arrangement was done on the basis of esthetics and phonetics. A
facial matrix was made using lab putty to preserve the spatial arrangement of the teeth.
Temporary abutments were attached to the working model and they were prepared to have 3-
4 mm clearance from the matrix. The denture teeth were reduced and were made to adapt on
the matrix. Autopolymerising resin was injected between the acrylic teeth and the temporary
abutments. This temporary was then finished and polished. The indirect technique allowed
more control and precision, and autopolymerising acrylic resin was easier and required less
time to use than heat-polymerizing acrylic resin. In addition, the use of denture teeth
laminates allowed long term colour stability and better esthetics in the provisional
restorations. However this technique was not suitable when the multiple implants were
misaligned or were placed facially as the screw opening would then compromise the
esthetics.

56
The following technique has been described by the authors. It is carried out at the second
stage surgery appointment. This method of provisionalization allows the clinician to mould
the peri-implant soft tissue to provide with better emergence profile. Conservative U shaped
incisions are made around the implants to uncover them. Following de-epithelization of the
tissues, these flaps are rolled into the pouch created on the labial aspect to bulk up the soft
tissue. Temporary Biotemp® abutments were attached to the implants and the labial surface
was marked and transferred to the laboratory analog. The build-up for the provisional
restoration is done on the laboratory analog to achieve the desired emergence profile and the
provisional restoration is screwed onto the implant.

57
6.3 Immediate Implant Placement and Provisionalization
The idea of immediate placement of implants after extraction and restoring the implant with a
provisional restoration was first documented by Wohrle in 1998 [5]. The advantages of
immediate implant placement and provisionalization are the reduction in the treatment
duration as the extraction healing time and the healing phase post implant placement are
coincidental. Also the hard and soft tissue can be maximally preserved. The provisional
restoration provides with support to the interdental papilla and the midfacial gingival tissue.
The success of immediate implant placement and provisionalization depends on various
factors. Joseph Kan classified these factors as intrinsic and extrinsic factors [6]. The intrinsic
factors were the patient dependant factors like hard and soft tissue relationship and the
gingival biotype. The extrinsic factors are the 3 dimensional implant position and angulation
and the contour of the abutment and the provisional restoration.
Tim De Rouck (2008) gave a review on single anterior tooth Immediate Implant Placement
and Provisionalization [7]. They suggested that the clinician must be reserved while
considering immediate implant placement and provisionalization. They suggested that a few
guidelines and prerequisites must be followed. They suggested the guidelines that had to be
followed included:
 The implant surgery must include filling the marginal void between the implant body
and the buccal wall of the extraction socket.
 The use of surface treated implants as they provide with better bone to implant contact
which is essential for osseointegration.
 The use of screw type tapered implants as they make it easier to achieve primary
stability.

58
According to them the prerequisites were
 Good primary stability of the implant
 Immediate provisionalization must not be performed in cases where buccal bone
defect extends to the buccal crest
 The provisional restoration must be clear of all occlusion contacts
Linda Grutter and Urs Belser (2009) suggested loading protocols in partially edentulous
regions in the esthetic zone [8]. The criteria they used to describe immediate restoration was
within 48 hours after placement of implants. According to them
 Immediate restoration and loading was to be performed if the implant is more than
8mm in length and more than 4 mm in diameter and if the implant has good primary
stability.
 The restoration had to be out of centric and eccentric contacts
 The restoration had to be not removed for at least 6 weeks
 Screw retained restorations were preferred
 Immediate restoration and loading was to be carried out only when the bone volume
at the site was close to normal. This meant that there had to be either minimal or no
simultaneous guided bone regeneration procedures around the implants
Eitan Mijiritsky (2009) evaluated the success of 24 single tooth implants in 16 patients that
underwent immediate provisionalization in fresh extraction sites [9]. They included only
those cases where the insertion torque values were 32 N cm or greater. Each implant was
connected to a prefabricated plastic provisional abutment. The fixed provisional restorations
were cemented to the abutments and the provisional restoration was cleared of all contacts
resulting in a non-functional loading of implants. They reported an implant survival rate of
95.8%. The only implant that failed was due to unscrewing of the provisional abutment that
resulted in an implant overload. They suggested that the soft-tissue reaction was very
favourable due to the presence of a provisional crown during the healing phase.
Pascal Valentini (2010) studied 40 patients receiving 43 implants placed in fresh extraction
sockets and provisionalized within 7 days [10]. They went ahead and documented the
condition of the buccal bone defect that followed the extraction and divided them into two
types of peri-implant defects: a circumferential defect that resulted from the discrepancy
between the implant and the residual bone socket, and a buccal dehiscence, that resulted from

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