implant dentistry in esthetic zone

IMPLANT DENTISTRY IN ESTHETIC ZONE

DR FARIBORZ VAFAEE DDS MS

Multidisciplinary approach

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Pre surgery considerationsprosthetic overview

Supporting bone influence (Garber DA, Belser UC. Compend Contin Educ Dent 1995;16(8):796, 798802, 804.)

Periodontal overview

Site evaluationGraber classification (garber DA, rosenberg ES. Compend contineduc dent 1981;2(4):21223.)Garber class i : Favorable horizontal and vertical levels of both soft tissue and bone are present.Garber class ii: Sites with no vertical bone loss and slight horizontal bone deficiency measuring about 1 to 2 mm narrower than normal.Garber class iii:For sites with no vertical bone loss and horizontal bone loss greater than class II.Garber class iv:In sites with no vertical bone loss but significant horizontal loss.Garber class v:Sites with extensive apicocoronal bone loss present a significant challengeto the surgeon

Timing of implant placement following tooth removalHammerele et al:type 1:immidiate after extractiontype 2:4-8 weeks later(soft tissue healed)type 3:12-16 weeks later(bone formation in clinic and radiographic evaluation)type 4:more than 16 weeks

Hammerele et al Int J Oral Maxillofac Impl. 2004; 19(supp):43-61

Alveolar bone resorption after tooth extractionFollowing tooth removal, a variable amount of ridge collapse takes place in either buccal-lingual or apicocoronal dimensionsAn average of 40% to 60% original height and width is expected to be lost after tooth extraction with the greatest loss happening within the first 2 yearsThin buccal ,more resorption had to result in a vertical reduction .Wider lingual bone, less resorption

Socket bone wall in relation to immediate implant placementIt has been suggested that immediate placement of implants into extraction sockets may preserve the bony architecture Denissen & kalk 1991; denissen et al. 1993; sclar 1999

Implants placed immediately into extraction sockets will not prevent the occurrence of ridge alterations Botticelli et al. 2004a, 2004b; covani et al. 2004; araujo & lindhe 2005 ferrus et al. 2009; sanz et al. 2009

Implant size selectionCommonly depends on Dimension of the edentulous crestProximity of the adjacent rootsMaintain at least 3mm of inter implant distance to decrease the chance of crestal bone lossIdeal diameter usually are 3.75-4 mmBoudrias P et al. J Dent Que 2003;40:301-302

Multidisciplinary approach

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Tischler guideline (Tischler M.NY State Dent J 2004;70(3):226.)

Employ a conservative flap design; Evaluate the existing bone and soft tissue; Time the placement correctly; Visualize the three-dimensional position of the implant; Consider healing time before implant loading; Consider the determinants of emergence profile Select a proper abutment and final restoration design.

Buccolingual position

Ideal position of implant depends on:desired crown locationdesign of the implantdesign of the abutment

Implant positioning The centerline 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

Implant placement

An implant placed too far buccally

An implant placed too far to the palataly

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Implant positioning Spray et al ( Spray JR, Black CG, Morris HF, et al. An Periodontol 2000;5(1):11928.)As the bone thickness in buccal area approached 1.8 to 2 mm, bone loss decreased significantly and some evidence of bone gain was seen

Buser et al (Buser D, Martin W, Belser UC. Int J Oral Maxillofac Implants 2004; 19(Suppl):4361.)in patients presenting with a thin gingival biotype some palatoversion is desirableGraber et al (Garber DA, Belser UC. Compend Contin Educ Dent 1995;16(8):796, 798802, 804.)Occlusal considerations occasionally necessitate labioversion, particularly in cases involving excessive vertical overlap.

Mesiodistal positionevaluating mesiodistal space available for:select a proper implant sizegood esthetic out comepreservation of interdental bone and papillaa minimum distance of 1.5 to 2 mm should be maintained between implants and neighboring teeth. (Esposito M, Ekestubbe A, Grondahl K. Clin Oral Implants Res 1993;4(3):1517.) in multiple implants, a space of 3 to 4 mm at the implant abutment level should be maintained between implants.(Tarnow DP, Cho SC, Wallace SS. J Periodontol 2000;71(4):5469.)

Mesiodistal positionGraber et al (Garber DA. J Am Dent Assoc 1995;126(3):31925. )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.

Apicocoronal position or countersinkneed to mask the metal of implantdepends on implant diameterThe wider the implant, the less distance is needed to form a gradual emergence profile ( Jansen CE, Weisgold A. Compend Contin Educ Dent 1995;16(8):74852).esthetic VS biology (Cochran DL, Hermann JS, Schenk RK, et al. J Periodontol 1997;68(2):18698.)

Apicocoronal position or countersinkNot deep enough

Too deep

In a patient without gingival recession, cemento-enamel junction (CEJ) location of adjacent teeth is a point of reference to determine the apicocoronal position of the implant platform and In patients with gingival recession, the mid-buccal gingival margin can be used as a reference in lieu of the CEJ

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 recessionHermann JS, Buser D, Schenk RK, et al. Clin Oral Implants Res 2000;11(1):111.

Implant angulationsIdeally, implants should be placed so that the abutment resembles the preparation of a natural tooth; implant angulation should mimic the angulation of adjacent teethpoor angulation can:alter screw access holepoor esthetic resultdifficult home caresome undesirable cantilevers

Sullivan DY, Sherwood RL. J Esthet Dent 1993;5(3):11824.

Multidisciplinary approach

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Emergence profile importanceProper emergence profile can obtained with 3 different methodsproper implant positioning and using healing abutment or special gingival former)khoury K,happe A.Quintessence Int 2000;31:483-499.)using ovate pontic or an acrylic resin restoration (jemt T.int j periodontics restorative dent 1999;19:20-29.)cervical contouring method(using custom healing abutments). (bichacho N,Landsberg CJ.pract periodontics aesthet dent 1994;6:35-41.)

Healing abutmentsHealing abutments were good for implants in no esthetic zones, but lacked appropriate esthetics for implants in esthetic zones (Chee WW: Periodontol 27:139, 2000)

AdvantagesHealing abutments are usually chosen preoperatively by the implant surgical cliniciansThese designs greatly simplify implant levelPre design emergence profile developing

Provisional restorationimproved tissue contours related to emergence profile (Higginbottom F, Belser U, Jones JD, et al:. Int J Oral Maxillofac Implants 19:62, 2004 (suppl))

development of an interdental or interimplant papillae (Small PN, Tarnow DP: Int J Oral Maxillofac Implants 15:527, 2000)

potential avoidance of a third surgical procedure ( Byrne D, Houston F, Cleary R, et al: J Prosthet Dent 80:184, 1998)

customization during the healing process to form an esthetically contoured prosthesis (Biggs WF. J Prosthet Dent 1996;75:231-3

Immediate Implant Restoration and Loading protocolImmediate restoration and loading can be used when the implant is of adequate length ( 8 mm)and diameter ( 4 mm) and the implant achieves good primary stability.The restoration should be taken out of any functional occlusal contacts both in centric occlusion and during excursive mandibular movements.The restoration should not be removed during the healing period of approximately 6 weeks. The patient should be instructed in how to function during the healing period and how to perform adequate oral hygiene.Screw-retained provisional restorations are recommended.Patients with parafunctional occlusal habits should be fitted with a habit appliance.Immediate restoration and loading can be used when the bone volume at the site is close to idealGrutter.INT JORAL MAXILLOFAC IMPLANTS 2009;24(SUPPL):169179

Papilla consideration

Existence of a predictable papilla length usually can be predictable in 4.5mm inter implant distance5mm inter natural teeth distance5.5 mm inter tooth implant distance

(salama H,salama M ,graber D.pract periodont aesthet dent 1998;10(9):1131-1141.)

Emergence profile play a role in papillary formation

Proximal restorationcontours &contact play a role in papillary formation

Multidisciplinary approach

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General rulesColor TextureGingival contourRestoration contour

Impression techniqueinterim restoration as an abutment for the definitive impression. custom impression coping for the replication of the healed tissue around the implant Bain and Weisgold inserted autopolymerizing acrylic resin directly into the sulcus during impression making Chee and Donovan advise performing gingivoplasty procedures to re contour the tissues before making provisional restorations

Abutment material

Abutment material influencetitanium alloy (asperini, et al: Clin Oral ImplantsRes 9:357, 1998) high noble ceramicszirconia abutments (Piconi C, Maccauro G Biomaterials 20:1, 1999)biocompatibilitytoughness (Kucey BKS, Fraser DC: J Can Dent Assoc 66:445, 2000)esthetic demands (Yildirim M, Fischer H, Marx R, et al: J Prosthet Dent 90:325, 2003)

Ceramic abutments vs metal abutmentsbiocompatibility (Abrahamsson et al: J Clin Periodontol 25:721, 1998) color change in surrounding tissue? 2mm vs 3 mm soft tissue thickness (Jung RE, et al: Int J Periodont Restor Dent 27:251, 2007)future gingiva resection (Jung RE, et al: Int J Periodont Restor Dent 28:357, 2008)survival ratemetal>=zirconia> alumina in 3-5 years follow up (Glauser et al: Int J Prosthodont 17:285, 2004)metal>>zirconia>>alumina more than 5 years follow up (Glauser R: Osseointegration Res 4:41, 2004)

Abutment fabricationPrefabricatedCustomPorcelain application

CAD/CAM custom abutments

superior material homogeneitymaterial propertiescustom designease of fabrication

Multidisciplinary approach

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soft tissueSmall and Tarnow reported that the majority of recession occurred within the first 3 months. (Small PN, Tarnow DP. Int J Oral Maxillofac Implants 2000;15:527532.)Deangelo et al showed that peri-implant soft tissue seemed to be stable at about 4 weeks after mucoperiosteal flap surgery. (DeAngelo SJ, J Periodontol 2007;78:18781886).

Lai et al reported that the esthetic outcome of soft tissue around a single-tooth implant had improved significantly after 6 months compared with baseline according to PES assessment. (Lai HC, Zhang ZY, Wang F, Zhuang LF, Liu X, Pu YP. Clin Oral Implants Res 2008;19:560564.)

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