Techniques for Success With Implants in the Esthetic Zone E-Book

Arndt Happe

• Herausgeber: Quintessence Publishing Co, Inc
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 407

Veröffentlichungsjahr: 2019

Beschreibung

Implant restoration in the anterior region represents a particular challenge for dentists because even the most functional implant cannot be considered a success if the patient is still unhappy with their smile. Attention must be given to ensuring a high survival rate and a low complication rate, without sacrificing esthetics. In this book, the authors pass on their experience based on well-documented clinical cases and discuss all relevant aspects from the biologic basics and planning to surgery to prosthetic restoration in this challenging area. Modern microsurgical procedures for the augmentation of hard and soft tissue and plastic periodontal surgery are a special focus. Through numerous clinical photographs and schematic drawings, each procedure, whether simple or complex, is reproduced in comprehensive detail.

Leseprobe

Techniques for Success with Implants in the Esthetic Zone

I would like to thank my parents Dr Gabriele and Dr Herwig Happe

For Marlene and Paula

This book was originally published in German under the title Erfolg mit Implantaten in der ästhetischen Zone: Parodontale, implantologische und restaurative Behandlungsstrategien in 2018 by Quintessenz Verlags-GmbH, Berlin, Germany.

Library of Congress Cataloging-in-Publication Data

Names: Happe, Arndt, editor. | Körner, Gerd, editor.

Title: Techniques for success with implants in the esthetic zone / edited by Arndt Happe and Gerd Körner.

Other titles: Erfolg mit Implantaten in der ästhetischen Zone.English.

Description: Batavia, IL : Quintessence Publishing Co, Inc, [2019] | Includes bibliographical references and index.

Identifiers: LCCN 2019019189 | ISBN 9780867158229 (hardcover) | 9780867159752 (ebook)

Subjects: | MESH: Dental Implantation | Esthetics, Dental

Classification: LCC RK667.I45 | NLM WU 640 | DDC 617.6/93--dc23

LC record available at https://lccn.loc.gov/2019019189

© 2019 Quintessence Publishing Co, Inc

Quintessence Publishing Co, Inc

411 N Raddant Road

Batavia, IL 60510

www.quintpub.com

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All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without prior written permission of the publisher.

Editor: Marieke Zaffron

Design: Sue Zubek

Production: Kaye Clemens and Christine Cianciosi

Printed in China

Contents

Foreword

Preface

Contributors

1Introduction

/ Arndt Happe, Gerd Körner

2Requirements

/ Arndt Happe

3Microsurgery

/ Arndt Happe, Gerd Körner

4Immediate Implant Placement in theEsthetic Zone

/ Arndt Happe, Gerd Körner

5Implant Position, Planning, and Esthetic Analysis

/ Arndt Happe, Christian Coachman, Tal Morr, Vincent Fehmer, Irena Sailer

6Tooth Preservation Versus Extraction and Implant Placement

/ Gerd Körner, Arndt Happe

7Adjacent Implants

/ Tomohiro Ishikawa, Arndt Happe

8Soft Tissue Augmentation

/ Arndt Happe, Gerd Körner

9Bone Augmentation

/ Arndt Happe, Daniel Rothamel, Gerd Körner

10Implant Exposure Techniques

/ Arndt Happe, Gerd Körner

11Implant Abutments

/ Anja Zembic, Arndt Happe

12Superstructure and Peri-Implant/ Restorative Interface

/ Arndt Happe, Pascal Holthaus

13Complications

/ Arndt Happe, Gerd Körner

14Complex Cases

/ Tomohiro Ishikawa, Gerd Körner, Arndt Happe

Index

Foreword

There is a common misconception that implant placement and restoration in the esthetic zone is a “slam dunk,” a more or less simple procedure— especially compared with more demanding full-mouth implant-supported reconstructions. The anterior regions are easy to access for surgery and restoration, hard and soft tissue defects are often limited, and patients are likely younger, meaning greater healing potential. However, this doesn’t mean the esthetic zone is easy to treat— quite the opposite, especially in extenuating circumstances.

Although anterior treatment sites are easier to access, the esthetic outcomes of implant-supported restorations and the adjacent hard and soft tissue framework require the implant positioning to be extremely accurate. Even minor aberrations in implant location and angulation (as well as prosthetic inaccuracies) may have devastating effects. Preoperative bone and tissue defects may indeed be limited in these cases. However, when these defects do occur, they are in the most visible zone, and their treatment therefore requires significantly more attention to detail and a minimally invasive approach, preferably involving microsurgical techniques to restore these defects indiscernibly. In addition, the fact that implant treatment in the esthetic zone is more prevalent in younger patients actually makes these cases significantly more challenging. The procedures themselves may not be more difficult, but the established esthetic and functional outcomes have to be maintained not just for a few years but potentially for decades.

In the past few years alone, we have gained a tremendous amount of new information on how to treat esthetically debilitated patients in need of implant-support restorations. We have learned from the past, when we were often overzealous and too concerned with trying and implementing the “latest and greatest” techniques—often without sufficient scientific evidence and clinical rigor—rather than truly addressing patients’ needs. Therefore, it is extremely difficult to find a comprehensive up-to-date publication that summarizes the current knowledge and clinical techniques and technologies that provide predictable and long-lasting outcomes. In this book, Drs Happe and Körner, with their team of well-known coauthors, have achieved just that and compiled a unique and exhaustive guide for both the beginning as well as the seasoned surgical and restorative implantologist, explaining and illustrating in a most understandable and beautiful manner how implant treatment should be carried out in the esthetic zone today. From treatment planning and fundamental esthetic guidelines to microsurgical techniques and CAD/CAM technologies, the authors guide the reader through current surgical and restorative principles and techniques, ultimately leading up to more complex and challenging implant-supported restorations in the esthetic zone. The thorough list of cited scientific publications exemplifies the evidence-based approach that was chosen to compile the information and select the most appropriate techniques and technologies.

I have been a great admirer of Dr Happe’s scientific contributions, deep knowledge, and clinical skills, wonderfully compiled in this book. The comprehensiveness, scientific diligence, and clinical excellence displayed will make this title an indispensable guide for any dentist with ambitions for excellence in implant dentistry. Congratulations to the authors for creating this state-of-the-art piece of literature and to the reader who, without a doubt, will greatly enjoy the journey mapped out by Dr Happe and his coauthors.

Markus B. Blatz, DMD, PhD

Chairman and Assistant Dean for Digital Innovation Department of Preventive and Restorative Sciences University of Pennsylvania School of Dental Medicine

Preface

“If there’s a book that you want to read, but it hasn’t been written yet, then you must be the one to write it.”

TONI MORRISON

Since I started placing implants as part of my oral surgery training in the mid-1990s, I have been especially interested in attempting to copy nature as perfectly as possible. Anyone familiar with the subject will appreciate that this has led to some frustrating experiences, especially if you set a high esthetic standard. I quickly found that good results cannot be achieved without taking into consideration the disciplines of periodontology as well as restorative and esthetic dentistry, and so I attended conferences and courses on these subjects. The problem is that a whole universe of information opens up as soon as you start dedicating yourself more to a discipline. Furthermore, you realize that other specialties such as orthodontics, function, and dental technology are also extremely important and must be incorporated, which means you can feel rather overwhelmed in the beginning.

Over time, however, you gain experience and are better able to prioritize the wealth of information and assess the clinical relevance of the different techniques for yourself. This gives rise to certainty, professionalism, and practiced expertise. However, it is not an easy path, and I thank all my readers and mentors for their invaluable support and confidence in me. We often speak in an abstract way about a “learning curve” and readily forget that this is underpinned not only by successes but obviously by failures as well. Failures with implants in the esthetic zone can be extremely frustrating, expensive, and painful for everyone involved.

As a young dental practitioner, I would have greatly appreciated a book devoted specifically to the subject of implant therapy in the esthetic zone—and this was precisely our motivation for producing this title. When Dr Körner and I decided to write it, there were hardly any reference books that dealt specifically with implants in the esthetically sensitive area. Yet, while we were working on the book, several publications by reputable authors appeared that handled exactly this subject—or at least touched on it in one or more chapters. As a consequence, we asked ourselves whether it really made sense to continue working on the project. Naturally, we looked at these works with enormous interest. Each of these books enthused and intrigued us in their own particular way. Nevertheless, it seemed to us that the kind of book we had in mind might be an appropriate addition to the range of existing literature in that it would also incorporate related areas of dentistry. After all, every book reflects the experiences and personality of the author or authors in a very specific way.

I am therefore delighted that we managed to attract fascinating contributors, some of whom were already friends, who agreed to provide their unique expertise and have enormously enhanced the book. With this text, we would like to invite all interested colleagues to engage with our understanding and our philosophy of periodontology, implant therapy, and restorative dentistry but also with our approaches to implant therapy in the esthetic zone. We hope our passion and enjoyment of the work will light a spark in our readers.

Arndt Happe

Contributors

Christian Coachman, DDS, CDT

Founder

Digital Smile Design

São Paulo, Brazil

Vincent Fehmer, MDT

Division of Fixed Prosthodontics and

Biomaterials

Clinic of Dental Medicine

University of Geneva

Geneva, Switzerland

Pascal Holthaus, ZTM

Master Dental Technologist

Münster, Germany

Tomohiro Ishikawa, DDS

Private Practice

Hamamatsu, Japan

Tal Morr, DMD , MSD

Private Practice Limited to

Prosthodontics

Miami, Florida

Daniel Rothamel, MD , DMD , PHD

Professor

Department of Maxillofacial and

Plastic Surgery

University Hospital of Düsseldorf

Düsseldorf, Germany

Head of the Division of Maxillofacial

Surgery

Protestant Hospital Bethesda

Mönchengladbach, Germany

Irena Sailer, Prof Dr Med Dent

Head

Division of Fixed Prosthodontics

and Biomaterials

Clinic of Dental Medicine

University of Geneva

Geneva, Switzerland

Anja Zembic, PD, DMD

Consultant

Department of Fixed and Removable

Prosthodontics

University of Zürich

Zürich, Switzerland

Assessment of the esthetic quality of implant treatment has long been ignored in academia. The traditional way to evaluate the success of implants has been to document survival rates, but these only describe whether or not an implant remains functional in the oral cavity. Factors such as clinical immobility and minimal crestal bone level change in defined periods of time have been accepted as measures of osseointegration and consequently of implant success.1 However, individual criteria for achieving an esthetic appearance in the dentofacial area have been proposed by several authors in the dentistry literature, systematized, and discussed with particular regard to implant treatment.2–8

From the patient’s point of view, the appearance of the peri-implant soft tissue and the prosthetic superstructures is a very important criterion for successful treatment with implants (Fig 1-1). In 2003, Vermylen et al8 published a study on patient satisfaction with single-tooth implant restorations and stressed that an esthetically satisfactory outcome was a principal concern of patients receiving this type of treatment.

Fig 1-1 / While the implants at the maxillary left lateral incisor and canine sites have been functioning for several years, the result is not a success for the patient because the esthetics are so poor.

In ancient Greece, Plato and Aristotle debated the subject of beauty and esthetics and focused on symmetry in this context. Yet how much symmetry or asymmetry is actually perceived? In 2006, Kokich and Kokich9 examined this topic and compared the esthetic perception of dental deviations among laypeople, dentists, and orthodontists. For this purpose, the smiles of seven women were deliberately manipulated using an image-processing program. Minimal changes were made to crown length, crown width, midline deviation, diastema, papilla height, and the relationship of the mucosa to the lips. The images were then assessed by orthodontists, dentists, and laypeople. It emerged that the orthodontists’ assessment of the dental condition was more critical than that of the dentists and laypeople. All three groups were able to identify unilateral discrepancies in crown width of 2 mm. A unilateral alteration of the gingival margin at a central incisor was recognized by trained dentists when the discrepancy was only 0.5 mm. Laypeople did not notice this change until the difference was 1.5 mm. None of the study groups classified a diastema as unattractive. A unilateral reduction of papilla height was judged less attractive than the same change bilaterally. Orthodontists as well as laypeople rated gingival exposure of more than 3 mm as unattractive.9

Gehrke et al10 conducted a similar study to investigate the influence of papilla length and position of interproximal contact in symmetric and asymmetric situations, comparing the esthetic sensitivity of dentists and laypeople. Starting from a reference image of an anterior dentition that had been digitally idealized, further image processing was carried out to make changes to papilla length and position of the coronal contact point. The digitally manipulated photographs of the anterior dentition were assessed by 105 dental practitioners and 106 laypeople using a questionnaire, and these questionnaires were then analyzed. The authors concluded that the phenomenon of papillary loss associated with the “black triangle” in the midline was recognized early by laypeople and dentists alike but judged differently in terms of its esthetic impact. Laypeople tolerated the gradual loss of the papilla, provided the remaining interproximal space was completely filled with mucosa due to lengthening of the contact point, thus avoiding a black triangle. Clinicians were significantly more critical in their assessment of asymmetric changes to contact point or papillary length.

In 2004, Belser et al11 criticized the fact that the appearance of implant prosthetic restorations had been neglected in clinical trials and, in their review article on the outcome of anterior implant restorations, concluded that although “the use of dental implants in the esthetic zone is well-documented in the literature . . . most of these studies do not include well-defined esthetic parameters.”11 This indicates that the esthetic outcome is for the most part poorly documented in scientific studies and is not a criterion of success.

Dental Scores

Various measurable criteria have been sought in dentistry to provide an objective method of addressing this esthetic deficit. In 2005, Meijer et al12 proposed a white esthetic score (WES) to assess the esthetic result of implant restorations. This index was intended to evaluate and document the appearance of crown and soft tissue based on nine parameters. At the same time, Fürhauser et al13 published an index designed solely to assess the peri-implant soft tissue, known as the pink esthetic score (PES) (Fig 1-2). This involves evaluating seven parameters that describe the soft tissue situation and rating them from 0 to 2 so that a maximum score of 14 points can be achieved. In 2009, Belser et al14 proposed their own simplified index that assesses both the soft tissue and the prosthetic superstructure. Their combined PES/ WES score includes five parameters each for crown and peri-implant soft tissue, allowing a maximum score of 10.

Fig 1-2 / Pink esthetic score: index for assessment of peri-implant soft tissue according to Fürhauser et al.13

Patient-Related Factors

It is currently a matter of course for the diagnostic assessment of new patients to include some form of screening to check for various diseases. For instance, there is the periodontal screening index (PSI) for identifying or excluding periodontitis, and temporomandibular screening to evaluate the situation of the temporomandibular joints and involved musculature has also been proposed.15 However, it makes sense for patients to also be screened for esthetic risk factors prior to implantology treatment so that at-risk patients can be identified. One classification for risk assessment of implant treatment that has become established internationally is known as the SAC classification, which divides cases into straightforward, advanced, and complex.16

Lip dynamics

The smile line naturally plays a role in this risk assessment. According to Fradeani,17 a low smile line reveals a maximum of 75% of the maxillary anterior teeth, a medium smile line reveals 75% to 100% of the maxillary anterior teeth plus the papillary apices, and a high smile line exposes 100% of the maxillary anterior teeth plus the facial soft tissues. About 20% of people have a low smile line, 70% have a medium smile line, and 10% have a high smile line. Women have a greater tendency toward high smile lines.18 Because patients with a high smile line expose their facial soft tissue, recessions or other esthetically problematic alterations in this area are instantly visible, whereas they remain unnoticed in patients with a low smile line (Fig 1-3).

Fig 1-3 / A patient with a high smile line exposes the esthetically and functionally inadequate peri-implant soft tissue situation in the region of the maxillary central incisors.

Tissue phenotype

Another typical patient-related factor is the periodontal tissue phenotype, also known as the periodontal morphotype or periodontal biotype. According to Müller et al,19 the thickness of marginal periodontal tissue (masticatory mucosa) is less than 1 mm in roughly 75% of patients. Only about 25% have a tissue thickness of more than 1 mm. Kois4 and Kan et al20 postulated that the different tissue types also react differently to an iatrogenic or inflammatory trauma, which therefore has an influence on the predictability of treatment protocols. Clinical experience shows that thin tissue tends to react to surgical trauma with scarring and recession with more frequency than does thick, fibrous soft tissue.

Kan et al20 showed in a clinical trial that the dimension of the peri-implant tissue around single-tooth implants (eg, the tissue thickness in the interproximal papillary area) is larger in patients with thick biotypes, thereby influencing the esthetic appearance. Regarding immediate implant placement, patients with a thin periodontal biotype clearly have a stronger tendency to severe recession than patients with a thick biotype.21

As a rule, it is not realistic to measure the thickness of the tissue type directly. In clinical practice, this measurement is instead based on the transparency of the periodontal probe through the gingival margin (Fig 1-4a). De Rouck et al22 proposed this method in 2009 and demonstrated a strong correlation with direct measurement in 100 patients. In 2010, Kan et al23 showed in a prospective clinical trial that visual determination of the biotype alone, without the aid of a periodontal probe, is not a reliable method. Tissue thickness also has a considerable influence when selecting restorative materials (see chapter 11).

Fig 1-4 / (a) The biotype can be reliably determined clinically with the aid of a periodontal probe. Two different illustrative tissue types: (b) thick biotype with tough, fibrous tissue and flat papillary contour (scalloping); (c) thin biotype with delicate, transparent tissue and high papillary contour.

Interdental papillae and scalloping

The interdental papillae or so-called scalloping play an important role in all of the scores used to assess the peri-implant soft tissue. Scalloping describes how great the difference in level is between the facial gingival margin and the apex of the papilla and therefore how much the gingival contour undulates. In implantology, flat and wide papillae (Fig 1-4b) are easier to reconstruct than high and narrow papillae4 (Fig 1-4c). Jemt24 proposed a papilla index to assess and systematize the papillary situation:

• Score 0: No papilla present

• Score 1: Less than half of the embrasure filled

• Score 2: Half or more of the embrasure filled

• Score 3: All of the embrasure filled (ie, optimal papilla)

• Score 4: Hyperplastic papilla

In 2001, Choquet et al25 reported that reconstruction of papillae in single-tooth implant restorations is highly dependent on the vertical location of the peri-implant bone and can only be performed predictably if the distance between the contact point of the crowns and the bone is 5 mm or less. Kan et al20 also showed that the tissue height in the area of the papillae is highly dependent on the attachment of adjacent teeth in the case of single-tooth implants; they additionally investigated the influence of the individual tissue phenotype. It emerged that thick tissue phenotypes are likely to have greater tissue height than thin phenotypes. As a result of these interdependences, loss of attachment at adjacent teeth means significant limitations for peri-implant soft tissue. As the foundation, bone codetermines the vertical position of the soft tissue. Therefore, a compromised bony situation that cannot be surgically remedied and affects adjacent teeth will always lead to soft tissue compromise later on. For the most part, these are local prognostic factors.

Predictable reconstruction of a papilla is particularly problematic between adjacent implants,26 especially if three-dimensional (3D) bone augmentation measures are required.27 While crown shape and localization of the contact point also influence the esthetic prognosis of implant restorations, lack of an interdental papilla often spells esthetic failure. Whereas the lack of this papilla can be concealed by a long contact surface in the case of rectangular teeth, this is not possible with triangular teeth and quickly leads to a black triangle in this area.4

Biologic Factors

An understanding of biologic principles with respect to peri-implant tissues is essential when planning for esthetic implant restorations (Fig 1-5). These principles are primarily patient independent. For instance, consider postrestorative remodeling. After reopening of two-part, two-stage implant systems, a biologic width is established around implants in the same way as the biologic width of natural teeth.28,29 This means that the crestal bone is positioned 1.3 to 2.6 mm apical to the interface or the microgap between implant and abutment.30,31 The supporting bone, which ultimately determines the position of the soft tissue, therefore retracts. This can lead buccally to recessions and interproximally to insufficient papilla height Figs 1-6a to 1-6f).26 The latter effect usually does not occur with single-tooth implants because the attachment of adjacent teeth determines papilla height. However, it is a major problem with adjacent implants and makes the reconstruction of papillae between adjacent implants highly unpredictable Figs 1-6g to 1-6j) andFig 1-7).26 These circumstances and their influence on esthetics were described graphically by Grunder et al26 as early as 2005 and motivated the use of platform switching to exert a positive effect on the peri-implant bone situation. As a result, components reduced in diameter came to be used to move the microgap away from the bone in a central direction (see Fig 1-5b).

Fig 1-5 /(a) Unlike natural teeth, implants have no attachment: The collagen fibers of the connective tissue do not integrate with the implant, and no supracrestal fibrous tissue exists. Because the implant has no periodontal space, its vessels are absent, and the peri-implant tissue is poorer in blood vessels. Then there is the added influence of the microgap. All of these circumstances make it difficult to reconstruct soft tissues and papillae around implants. (b) Comparison of structures around implants with non-platform-switched connection (left) and platform switching (right).

Fig 1-6 / (a and b) Anatomy around non-platform-switched implants. (c and d) Excessively large diameter and malpositioning distally lead to loss of papilla. (e and f) Excessively large diameter and malpositioning buccally lead to recession. (g and h) Recommended distances for adjacent implants. (i and j) Adjacent implants placed too close together lead to loss of papilla. (Adapted with permission from Grunder et al.26)

Fig 1-7 / (a) Implant design with smooth (ie, machined) 1.4- mm shoulder. (b) All-ceramic restorations after full-mouth reconstruction, including implants placed at the maxillary right lateral incisor and canine sites and the mandibular right canine site. The interproximal soft tissue between the maxillary lateral incisor and canine is deficient. (Laboratory work performed by A. Nolte.)

Loss of attachment to adjacent teeth poses another limitation. Here again bone height or attachment level determines the expected soft tissue height, which can cause interproximal deficits if there is preexisting periodontal damage (Fig 1-8). The soft tissue situation at the adjacent teeth can only rarely be improved with considerable time and effort (Figs 1-9 and 1-10).

Fig 1-8 / (a) Single-tooth gap at the maxillary left central incisor with adverse preoperative situation due to 3D ridge defect, scarring, triangular tooth shape, and loss of mesial attachment at the rotated maxillary left lateral incisor. (b) Implant restoration 10 years after placement of an all-ceramic crown. (c) The patient has a medium smile line. (Laboratory work performed by A. Nolte.)

Fig 1-9 / (a) Adverse preoperative situation at the left central incisor due to a vertical defect at the central incisor and loss of attachment at the lateral incisor. (b) Vertical augmentation by distraction osteogenesis. / (c) Final appearance after restoration with an implant and veneers. (Laboratory work performed by K. Muterthies.)

Fig 1-10 / (a) Condition after microsurgical exposure of two implants at the central incisors with papilla reconstruction. (b) Soft tissue situation after several months of contouring with provisional crowns. (c) Customized zirconia abutments in situ. (d) All-ceramic restorations of the central incisor implants. Note the harmonious peri-implant soft tissue with sufficient interdental papilla. (e) Superimposed radiograph. The implants were placed with platform switching. Nevertheless, some interimplant crestal bone resorption has occurred. The arrow illustrates the distance from the crestal bone level to the apex of the papilla. (Laboratory work performed by A. Nolte.

Table 1-1 summarizes vertical soft tissue limitations.7,32 A multicenter study by Tarnow et al33 showed that the soft tissue height between implants is 3.4 mm on average, with a wide variation. The authors took measurements of 33 patients and 136 papillae and reported papilla heights of up to 7 mm. However, the most common heights were 2 mm (16.9%), 3 mm (35.3%), and 4 mm (37.5%). Unfortunately, the publication provided no information on the patients’ tissue types or the surgical protocol used. One-part and two-part implant systems as well as single-stage and two-stage procedures have also been compared.

Table 1-1 Vertical soft tissue limitations*

–, not applicable.

*Data from Salama et al.7 Reprinted with permission from Salama et al.32

Tymstra et al27 studied 10 patients with adjacent implants in the anterior dentition who required bone augmentation before implants could be placed. After prosthodontic restoration, the esthetic outcome was assessed by patients and dentists on a scale from 0 to 10. The results showed that the patients’ satisfaction with the esthetic outcome was higher than that of the dentists. Overall, it was concluded that the papillary situation is often unsatisfactory when adjacent implants are placed following prior augmentation.

However, buccal recession at implants is also a problem that can cause esthetic difficulties. In a 1-year study involving a total of 63 implants, Small and Tarnow34 investigated the changes to the peri-implant soft tissue after the exposure procedure. In their study, 80% of the implants exhibited buccal recession, which was 0.75 mm on average after 3 months, 0.85 mm after 6 months, and 1.05 mm after 12 months. The authors concluded that clinicians should wait a minimum of 3 months after exposure before fabricating the definitive prosthesis for implants in the esthetic zone.

In a prospective 1-year study with 11 patients, Cardaropoli et al35 also investigated the tissue changes around single-tooth implants in the anterior maxilla and reported buccal recessions of 0.6 mm after 1 year and papillary growth within the same observation period. These results coincide with those of Grunder,36 who in a 1-year study on 10 patients measured an average of 0.5 mm of buccal recession for 70% of the implants and found increased papillary volume at all implant sites.

Surgical Factors

Uncorrected alveolar ridge defects are a common cause of esthetic problems. The literature makes it clear that despite a variety of treatment options, correction of 3D ridge defects is difficult and cannot always be fully achieved.37,38 Especially in the esthetically sensitive anterior dentition, microsurgical techniques are recommended to attain an esthetically attractive, natural soft tissue appearance39,40 (Fig 1-11). Particularly in the interdental papillary area, deficits in the millimeter range can mean the difference between esthetic success and failure. Microsurgical techniques are already well established in periodontal surgery and result in less tissue trauma and better healing.41,42 It is particularly important in the esthetic zone to avoid complications of implant placement or augmentation that can impair the esthetics.

Fig 1-11 / (a) Unharmonious smile caused by diastema, agenesis of the maxillary right lateral incisor, and recession at the right central incisor, which is not worth preserving. (b) Unfavorable preoperative view due to ridge defect, scars, and difficult overall esthetic situation. The right central incisor will be replaced by an implant. (c) 3D augmentation of the implant site. Vertical releasing incisions are not used to avoid producing additional scars and because the blood supply to the flap is more favorable. (d) Microsurgical suturing. A connective tissue graft was harvested palatally for soft tissue augmentation at the implant site. (e) Preparation of the adjacent teeth according to the wax-up created in advance, checked with a silicone key. (f) All-ceramic implant restoration with marginally veneered, customized zirconia abutment and all-ceramic crown. (g) Clinical situation with all-ceramic abutment in situ. (h) Final appearance 6 months after restoration. (i) Smile after treatment. (Laboratory work performed by A. Nolte.)

The therapeutic concept of immediate implant placement was reevaluated after Botticelli et al43 and Araújo et al44 showed in an animal model that while the placement of implants into extraction sockets did not lead to preservation of bony structures, the remodeling processes of the bony socket nevertheless proceeded.45 According to Schropp et al,46 the horizontal loss of volume after extraction can be as high as 50% 1 year postextraction. However, augmentation of the buccal areas of the socket with xenograft material can markedly reduce this loss of volume.47 It is therefore advisable to immediately place implants only if the buccal lamella is intact and in thicker periodontal biotypes; furthermore, the implant should be inserted in the palatal/lingual region of the socket, and the buccal area should be augmented using validated methods45 (see chapter 4). Aside from bone augmentation, connective tissue grafts are also recommended to compensate for imminent or existing volume deficits.48–50

3D positioning of the implant is a fundamentally important factor in the esthetic outcome (see chapter 5). This must be guided by the planned restoration.3 Chen et al47 studied the influence of gingival biotype, implant position, and the design of two different implant systems on the degree of buccal recession at 42 immediate implant sites. They concluded that implant position has the greatest influence. What this means clinically is that the implant should be placed slightly palatally, and a buccal angulation must be avoided. If the implant is placed too far buccally or there is an excessive buccal angulation of the implant axis, later attempts at corrective surgery in terms of covering recession are not very promising.

Restorative and Material-Related Factors

The restorative materials have a major influence on the esthetic appearance of implant restorations. Abutments made of titanium can show through the vestibular soft tissues, and these effects are particularly noticeable in the thin marginal soft tissue region.51 In their much-quoted article on the PES, Führhauser et al13 reported that 60% of the studied restorations exhibited distinct color deviations in the peri-implant soft tissue. Jung et al52 conducted an in vitro study in an animal model to analyze the color change in oral mucosa caused by translucent materials. Titanium and zirconia, each without veneer and veneered with dental ceramic, were tested under different tissue thicknesses. The mucosal color differences were measured using a spectrophotometer. The results showed that titanium causes significant color differences even at a tissue thickness of 3 mm (Fig 1-12). By contrast, zirconia ceases to cause color differences above a tissue thickness of 2 mm. Based on the results, it may be concluded that all-ceramic abutments produce better esthetic outcomes, especially in patients with thin facial tissue.

Fig 1-12 / The soft tissue in the region of the right central incisor shows recession and transparency to the abutment material.

A clinical trial conducted at Harvard University using a spectrophotometer showed that anterior implants with titanium abutments produced visibly perceptible discoloration of the soft tissue compared with the natural adjacent teeth.51 The same study group53 demonstrated in a second clinical trial that the colors light orange and light pink are most suitable for color masking of abutments. They also showed that white performs poorly as an abutment color.

In a prospective, randomized, controlled trial conducted at Zurich University involving 30 patients, porcelain-fused-to-metal restorations were compared directly with all-ceramic restorations on implants.54 The results showed that both materials cause color changes. However, the all-ceramic restorations performed markedly better. Because the light optical effect of abutments can influence the esthetics of implant restorations depending on tissue thickness, an entire chapter is dedicated to this topic (see chapter 11).

Conclusion

The following are key factors for the esthetic success of implant restorations:

1. Correct 3D position of the implant

2. Appropriate bone architecture and stable bone volume

3. Adequate thickness and quality of soft tissue

4. Transmucosal form, material, and surface of abutment and restoration

5. Development and preservation of the soft tissue contour

Each of these aspects is described in detail in the following chapters, and practice-based concepts with the appropriate evidence are presented. Typical risk factors with respect to the esthetic outcome are summarized in Table 1-2.55,56

Table 1-2 Classification for risk assessment of implant treatments *

–, not applicable.

*Adapted from Belser et al55 and Renouard and Rangert.56

†ASA Physical Status Classification of the American Society of Anesthesiologists.

‡Central incisor, canine, and premolar at least 7 mm, lateral incisor at least 5 mm.

References

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2. Chiche GJ, Pinault A. Esthetics of Anterior Fixed Prosthodontics. Chicago: Quintessence, 1994.

3. Garber DA. The esthetic dental implant: Letting restoration be the guide. J Oral Implantol 1996;22:45–50.

4. Kois JC. Predictable single tooth peri-implant esthetics: Five diagnostic keys. Compend Contin Educ Dent 2001;22:199–206.

5. Kokich VO Jr, Kiyak HA, Shapiro PA. Comparing the perception of dentists and lay people to altered dental esthetics. J Esthet Dent 1999;11:311–324.

6. Magne P, Belser U. Bonded Porcelain Restorations in the Anterior Dentition: A Biomimetic Approach. Chicago: Quintessence, 2002.

7. Salama M, Salama H, Garber D. Guidelines for aesthetic restorative options and implant site enhancement. Pract Proced Aesthet Dent 2002;14:125–130.

8. Vermylen K, Collaert B, Lindén U, Björn AL, De Bruyn H. Patient satisfaction and quality of single-tooth restorations. Clin Oral Implants Res 2003;14:119–124.

9. Kokich VG, Kokich VO. Ästhetische Korrekturen im Frontzahnbereich – Teil 1: Wann und warum? Inf Orthod Kieferorthop 2006;38:236–246.

10. Gehrke P, Degidi M, Lulay-Saad Z, Dhom G. Reproducibility of the implant crown aesthetic index: Rating aesthetics of singleimplant crowns and adjacent soft tissues with regard to observer dental specialization. Clin Implant Dent Relat Res 2009;11:201– 213.

11. Belser UC, Schmid B, Higginbottom F, Buser D. Outcome analysis of implant restorations located in the anterior maxilla: A review of the recent literature. Int J Oral Maxillofac Implants 2004;19(suppl):30–42.

12. Meijer HJ, Stellingsma K, Meijndert L, Raghoebar GM. A new index for rating aesthetics of implant-supported single crowns and adjacent soft tissues: The Implant Crown Aesthetic Index. Clin Oral Implants Res 2005;16:645–649.

13. Fürhauser R, Florescu D, Benesch T, Haas R, Mailath G, Watzek G. Evaluation of soft tissue around single-tooth implant crowns: The pink esthetic score. Clin Oral Implants Res 2005;16:639–644.

14. Belser UC, Grütter L, Vailati F, Bornstein MM, Weber HP, Buser D. Outcome evaluation of early placed maxillary anterior singletooth implants using objective esthetic criteria: A cross-sectional, retrospective study in 45 patients with a 2- to 4-year follow-up using pink and white esthetic scores. J Periodontol 2009;80:140– 151.

15. Ahlers MO, Jakstat HA. Evidence-based development of a diagnosis-dependent therapy planning system and its implementation in modern diagnostic software. Int J Comput Dent 2005;8:203– 219.

16. Dawson A, Chen S (eds). The SAC Classification in Implant Dentistry. Berlin: Quintessence, 2009.

17. Fradeani M. Esthetic Rehabilitation in Fixed Prosthodontics. Volume 1: Esthetic Analysis: A Systematic Approach to Prosthetic Treatment. Chicago: Quintessence, 2004.

18. Owens EG, Goodacre CJ, Loh PL, et al. A multicentre interracial study of facial appearance. Part 1: A comparison of extraoral parameters. Int J Prosthodont 2002;15:273–282.

19. Müller HP, Heinecke A, Schaller N, Eger T. Masticatory mucosa in subjects with different periodontal phenotypes. J Clin Periodontol 2000;27:621–626.

20. Kan JY, Rungcharassaeng K, Umezu K, Kois JC. Dimensions of peri-implant mucosa: An evaluation of maxillary anterior single implants in humans. J Periodontol 2003;74:557–562.

21. Evans CD, Chen ST. Esthetic outcomes of immediate implant placements. Clin Oral Implants Res 2008;19:73–80.

22. De Rouck T, Eghbali R, Collys K, De Bruyn H, Cosyn J. The gingival biotype revisited: Transparency of the periodontal probe through the gingival margin as a method to discriminate thin from thick gingiva. J Clin Periodontol 2009;36:428–433.

23. Kan JY, Morimoto T, Rungcharassaeng K, Roe P, Smith DH. Gingival biotype assessment in the esthetic zone: Visual versus direct measurement. Int J Periodontics Restorative Dent 2010; 30:237–243.

24. Jemt T. Regeneration of gingival papillae after single-implant treatment. Int J Periodontics Restorative Dent 1997;17:326–333.

25. Choquet V, Hermans M, Adriaenssens P, Daelemans P, Tarnow DP, Malevez C. Clinical and radiographic evaluation of the papilla level adjacent to single-tooth dental implants. A retrospective study in the maxillary anterior region. J Periodontol 2001;72:1364– 1371.

26. Grunder U, Gracis S, Capelli M. Influence of the 3-D bone-toimplant relationship on esthetics. Int J Periodontics Restorative Dent 2005;25:113–119.

27. Tymstra N, Meijer HJ, Stellingsma K, Raghoebar GM, Vissink A. Treatment outcome and patient satisfaction with two adjacent implant-supported restorations in the esthetic zone. Int J Periodontics Restorative Dent 2010;30:307–316.

28. Gargiulo AW, Wentz FM, Orban B. Mitotic activity of human oral epithelium exposed to 30 per cent hydrogen peroxide. Oral Surg Oral Med Oral Pathol 1961;14:474–492.

29. Berglundh T, Lindhe J. Dimension of the periimplant mucosa. Biological width revisited. J Clin Periodontol 1996;23:971–973.

30. Hermann JS, Buser D, Schenk RK, Schoolfield JD, Cochran DL. Biologic width around one- and two-piece titanium implants. Clin Oral Implants Res 2001;12:559–571.

31. Hermann JS, Schoolfield JD, Schenk RK, Buser D, Cochran DL. Influence of the size of the microgap on crestal bone changes around titanium implants. A histometric evaluation of unloaded non-submerged implants in the canine mandible. J Periodontol 2001;72:1372–1383.

32. Salama M, Ishikawa T, Salama H, Funato A, Garber D. Advantages of the root submergence technique for pontic site development in esthetic implant therapy. Int J Periodontics Restorative Dent 2007;27:521–527.

33. Tarnow D, Elian N, Fletcher P, et al. Vertical distance from the crest of bone to the height of the interproximal papilla between adjacent implants. J Periodontol 2003;74:1785–1788.

34. Small PN, Tarnow DP. Gingival recession around implants: A 1-year longitudinal prospective study. Int J Oral Maxillofac Implants 2000;15:527–532.

35. Cardaropoli G, Lekholm U, Wennstrom JL. Tissue alterations at implant-supported single-tooth replacements: A 1-year prospective clinical study. Clin Oral Implants Res 2006;17:165–171.

36. Grunder U. Stability of the mucosal topography around singletooth implants and adjacent teeth: 1-year results. Int J Periodontics Restorative Dent 2000;20:11–17.

37. Aghaloo TL, Moy PK. Which hard tissue augmentation techniques are the most successful in furnishing bony support for implant placement? Int J Oral Maxillofac Implants 2007;22(suppl):49–70.

38. Esposito M, Grusovin MG, Coulthard P, Worthington HV. The efficacy of various bone augmentation procedures for dental implants: A Cochrane systematic review of randomized controlled clinical trials. Int J Oral Maxillofac Implants 2006;21:696–710.

39. Zadeh HH, Daftary F. Minimally invasive surgery: An alternative approach for periodontal and implant reconstruction. J Calif Dent Assoc 2004;32:1022–1030.

40. Shanelec DA. Anterior esthetic implants: Microsurgical placement in extraction sockets with immediate plovisionals. J Calif Dent Assoc 2005;33:233–240.

41. Cortellini P, Tonetti MS. Microsurgical approach to periodontal regeneration. Initial evaluation in a case cohort. J Periodontol 2001;72:559–569.

42. Burkhardt R, Lang NP. Coverage of localized gingival recessions: Comparison of micro- and macrosurgical techniques. J Clin Periodontol 2005;32:287–293.

43. Botticelli D, Berglundh T, Lindhe J. Hard-tissue alterations following immediate implant placement in extraction sites. J Clin Periodontol 2004;31:820–828.

44. Araújo MG, Sukekava F, Wennström JL, Lindhe J. Ridge alterations following implant placement in fresh extraction sockets: An experimental study in the dog. J Clin Periodontol 2005;32:645– 652.

45. Hämmerle CH, Chen ST, Wilson TG Jr. Consensus statements and recommended clinical procedures regarding the placement of implants in extraction sockets. Int J Oral Maxillofac Implants 2004;19(suppl):26–28.

46. Schropp L, Wenzel A, Kostopoulos L, Karring T. Bone healing and soft tissue contour changes following single-tooth extraction: A clinical and radiographic 12-month prospective study. Int J Periodontics Restorative Dent 2003;23:313–323.

47. Chen ST, Darby IB, Reynolds EC. A prospective clinical study of non-submerged immediate implants: Clinical outcomes and esthetic results. Clin Oral Implants Res 2007;18:552–562.

48. Mankoo T. Contemporary implant concepts in aesthetic dentistry—Part 2: Immediate single-tooth implants. Pract Proced Aesthet Dent 2004;16:61–68.

49. Chung S, Rungcharassaeng K, Kan JY, Roe P, Lozada JL. Immediate single tooth replacement with subepithelial connective tissue graft using platform switching implants: A case series. J Oral Implantol 2011;37:559–569.

50. Grunder U. Crestal ridge width changes when placing implants at the time of tooth extraction with and without soft tissue augmentation after a healing period of 6 months: Report of 24 consecutive cases. Int J Periodontics Restorative Dent 2011;31:9– 17.

51. Park SE, Da Silva JD, Weber HP, Ishikawa-Nagai S. Optical phenomenon of peri-implant soft tissue. Part I. Spectrophotometric assessment of natural tooth gingiva and peri-implant mucosa. Clin Oral Implants Res 2007;18:569–574.

52. Jung RE, Sailer I, Hämmerle CH, Attin T, Schmidlin P. In vitro color changes of soft tissues caused by restorative materials. Int J Periodontics Restorative Dent 2007;27:251–257.

53. Ishikawa-Nagai S, Da Silva JD, Weber HP, Park SE. Optical phenomenon of peri-implant soft tissue. Part II. Preferred implant neck color to improve soft tissue esthetics. Clin Oral Implants Res 2007;18:575–580.

54. Jung RE, Holderegger C, Sailer I, Khraisat A, Suter A, Hämmerle CH. The effect of all-ceramic and porcelain-fused-to-metal restorations on marginal peri-implant soft tissue color: A randomized controlled clinical trial. Int J Periodontics Restorative Dent 2008;28:357–365.

55. Belser U, Buser D, Wismeijer D. ITI Treatment Guide. Vol 1: Implant Therapy in the Esthetic Zone for Single-Tooth Replacements. Berlin: Quintessence, 2007.

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There are certain requirements that must be met by practices that offer implant dentistry. These relate to building design as well as the level of organization in the practice and the qualifications of practitioners and support staff.

Implant and periodontal surgery requires appropriate surgical skills from the dental practitioner and demands high standards of hygiene and organization from the team. Sterile care must be guaranteed to ensure safe and successful treatment (Fig 2-1). Dentists and assistants should regularly attend postgraduate courses so that the latest hygiene regulations are rigorously put into practice. Appropriate quality management is another prerequisite.

Beyond high hygiene standards, it must be remembered that patients come to the practice with certain anxieties and expectations. For areas such as waiting and consulting rooms, consider warm materials and color schemes. First impressions play a key role in building a trusting relationship between the patient and the clinician. The environment is part of external communication and should convey a sense of quality and be esthetically appealing. It is beneficial to keep a separate room for consultations, and this space should have room for the patient as well as spouses or caretakers who may accompany them to appointments (Figs 2-2 and 2-3). Rooms used for medical functions, on the other hand, should exude professional order and cleanliness (Figs 2-4 to 2-6).

Fig 2-1 / Outpatient operations require certain hygiene standards, which are a prerequisite for safe and successful treatment.

Fig 2-2 / Example of a waiting room that is comfortable yet professional.

Fig 2-3 / Consulting room for treatment planning and interviews with patients. This is a private space with room for several people.

Fig 2-4 / Treatment room for dental treatments and implantology procedures.

Fig 2-5 / Clear, streamlined, and well-arranged layout of the treatment room surfaces conducive to patient care.

Fig 2-6 / Functional space should be available for storing sterile supplies.

Precare and Aftercare

In addition to the clinician’s surgical expertise and scrupulous compliance with hygiene standards, the precare and aftercare of patients is a key point in the treatment approach. Good and excellent results can only be achieved in the long term if patients receive precare and aftercare as part of a systematic preventive concept. All of the therapeutic approaches depicted in this book require the tissues of the oral cavity to be healthy and free of inflammation. Not only must the patient be instructed on how to practice oral hygiene, but the clinical situation must allow for this cleaning. If it does not, this must be remedied during precare.

The dental practice must provide the premises, equipment, and staff resources for this purpose. Trained staff (eg, dental hygienists, dental assistants) and an efficient recall system are important requirements for therapeutic success. If a referral system is being used, it is essential to ensure that patients receive appropriate care in the referring practice before and after the implant therapy.

The absence of periodontal and peri-implant inflammatory processes is a basic precondition for a sustained esthetic and—above all—healthy outcome. Tissue stability can only be expected if the peri-implant tissues as well as the periodontal tissues of adjacent teeth are free from inflammation. The spectrum of bacteria and the pathogenesis of periodontitis and peri-implantitis are known to be very similar.1 The overwhelming majority of periodontal and peri-implant diseases are caused by colonization with microorganisms that form a biofilm on nonexfoliating surfaces, including teeth and implants. This biofilm causes a local inflammatory reaction of the surrounding soft tissues (ie, gingiva and peri-implant mucosa). If the biofilms are not removed regularly by proper oral hygiene measures at home, this results in overgrowth of microorganisms pathogenic to the periodontium, which ultimately leads to chronic inflammation of the soft tissues (ie, gingivitis or peri-implant mucositis). In patients who are predisposed to periodontal disease, this chronic inflammation can result in the formation of periodontitis or peri-implantitis.2,3

The etiopathogenesis of periodontitis and peri-implantitis illustrates the key role of the biofilm in the development of these diseases. Patients with poor oral hygiene have a significantly higher risk of developing peri-implantitis.4 Patients who suffer from periodontitis also have a significantly higher risk.2,4 Like periodontitis and peri-implantitis, smoking is an additional risk factor that must be taken into consideration.

The statistical risk of developing peri-implantitis is increased by several factors.4–8 The odds ratio (OR) for each factor describes its relative impact on peri-implantitis (eg, an OR of 2 would indicate that this factor results in a doubled likelihood of developing peri-implantitis):

These values illustrate that precare and aftercare as well as patient education play an important role in the success of implant treatment.

Precare

One purpose of precare is to thoroughly inform patients what part they themselves have to play in the long-term success of their implant therapy and what oral hygiene measures they should implement at home to remove the biofilm regularly and adequately. Secondly, precare should result in tissue that is free of inflammation. Patients with preexisting periodontal damage generally have an increased risk of developing peri-implantitis.9–12 There is a scientific consensus that existing periodontitis must be treated before implant placement.2,3

In a clinical trial, it was found that patients with preexisting periodontal damage with just one localized probing depth ≥ 5 mm at natural abutments have a significantly higher risk of peri-implantitis than patients with preexisting periodontal damage without such deep residual pockets.8 More than 50% of adults suffer from periodontitis, and 11% are affected by a particularly severe form; this demonstrates how many potential implant patients actually carry an increased risk of peri-implantitis due to preexisting damage to their periodontium.2 Patients must be educated on the relationships between plaque, peri-implantitis, and long-term prognosis. Patients with periodontal damage (as well as patients who smoke or patients who have diabetes) must be told about their increased risk.3 For patients who smoke, tobacco/nicotine withdrawal should be considered, where appropriate, or the individual risk should be assessed.7

As part of precare, teeth not worth preserving must be extracted and periodontal infections controlled by systematic periodontal therapy. The periodontal situation must be reevaluated before the actual implant planning and after an appropriate healing phase.

The consensus conference of the European Workshop in Periodontology issued the following recommendations on steps to take prior to implant therapy13:

• Patients should be informed about the risk of peri-implantitis and the need for preventive measures.

• An individual risk analysis should be prepared that identifies systemic and local risks. Where appropriate, this will include tobacco withdrawal, smoking cessation, and elimination of periodontal pockets.

•