76

DENTISTRYTODAY.COM • MARCH 2014

INTRODUCTIONAlthough perfection is never attainable,excellence is always expected. As dentists, weare faced with complicated situations involv-ing both diagnostic and treatment complexi-ties. We attempt to simplify our proceduresso we do not overlook details that sacrificepredictability, longevity, or aesthetics.

At the Kois Center we are taught, “intel-lectualize simplification,” and we system-ize protocols for all procedures. Throughthe American Academy of Cosmetic Den -tistry (AACD), we are presented establishedaccreditation examination criteria to evalu-ate the parameters for aesthetic excellence,giving us a checklist for optimal outcomes.The journey through the AACD examina-tion process trains your eyes to see thenuances first, followed by the discerningimplementation of manual skills.

Many dentists find implant placement,bone grafting, and socket preservation proce-dures exciting, challenging, and fun. I am notone of those dentists. I have taken a multi-tude of implant courses, watched and partic-ipated in implant surgeries (fixture place-ment and bone grafting), and nonetheless am

happy outsourcing the surgical aspects ofthis care. I believe in leveraging the skills andcore competencies of my team that includesperiodontists, endodontists, orthodontists,and oral and maxillofacial surgeons.

The team approach centers around thecoordination of care with a comprehensivetreatment plan understood by all parties,especially the patient. It is the teamworkand synergy among these individuals thatallows the realization of the visualizedtreatment result.

Dealing with more complex cases in -volving defects in bone, compromised softtissue, space management, and high smile-lines (aesthetic zone challenges) will test the

team’s ability to manage and deliver a natu-ral appearing reconstruction. The ultimateaesthetic outcome requires ideal hard- andsoft-tissue topography. The restoration musthave natural anatomy and components ofcolor. The patient’s expectations must beunderstood and managed. Educating thepatient about the risks and prognosis facili-tates trust in the team and understanding ofthe proposed outcome. The restorative chal-lenges must be identified and communicat-ed to all team members.

Training, anticipation, planning, andcommunication are paramount. For the finalrestoration to meet the highest standard, itmust be placed precisely both vertically andhorizontally. The restorative dentist mustunderstand minimum space requirementsfor implant placement. This often requiresan orthodontic referral. Deficiencies in hardand soft tissue must be addressed and oftenrequire a surgical solution. Once these issuesare addressed, proper placement of the im -plant is possible so the final restoration willhave sufficient tissue and result in a naturalform. Ideally, the emergence profile isdesigned to reflect the morphology of thecontralateral natural tooth.

CASE REPORTDiagnosis and Treatment Planning

A 17-year-old female patient (Figure 1) pre-sented with an unsightly composite bond-ed to her right lateral incisor (tooth No. 7)and a congenitally missing left lateral inci-sor (tooth No. 10). Her initial goal was toattain a “natural, beautiful appearance.”Her main questions related to whether shewas ready for implant placement.

She was referred from the orthodontistand presented wearing an Essex appliancewith a plastic denture tooth to replace themissing tooth (No. 10). The edentulous sitecorresponding to tooth No. 10 was not idealin terms of soft tissue or bone volume. Theright central was disproportionally largerthan the left central incisor, and asymmetrywas visual at the free gingival margin. Herdental midline was concentric with herfacial midline. On smiling she displayed aguarded Cupid’s bow gingival smile-line,defined by the absence of display of the

Joyce L.Bassett, DDS

Predictable Tooth Replacement in the Aesthetic Zone

continued on page 78

Figure 1. Patient presented with an Essex appli-ance with a denture tooth to replace tooth No. 10.

Figure 2. Pre-op smile. Tooth No. 7 was triangularshaped at gingiva with a high scallop and guardedCupid’s bow smile (high-risk assessment).

Figure 3. Incisal view. Note: tooth No. 10 showing adeficient/compromised ridge and inadequate soft-tissue topography.

AESTHETICS

Many dentists find implant place-ment, bone grafting, and socketpreservation procedures exciting....I am not one of those dentists.

For ed

ucati

onal

use o

nly

midfacial gingival tissue of the cen-tral incisors (low smile-line) com-bined with the display of midfacialzenith gingival tissue on other maxil-lary teeth in the aesthetic zone(Figure 2).1 This illustrated a high-risk assessment with a poor progno-sis, since everything in the visualfield (Nos. 7 and 10) needed to berestored. She presented with thin gin-gival tissue, and the gingival biotype,critical to a successful result, was inneed of volumetric enhancement.She exhibited high gingival scallop,and the contralateral tooth, whichwould be mimicked in the final res -toration, exhibited triangular toothshape. The hard-tissue morphologywas inadequate from a horizontal andlabial perspective and in need of aug-mentation (Figure 3). The treatmentgoal would be to decrease the risk andincrease the prognosis.2

The orthodontic workup includedlateral cephalometric tracings (datedSeptember 2007 and July 2009). Thesewere evaluated and compared, and itwas confirmed that no facial growthhad occurred during the observed peri-od. The patient also had symptomaticthird molars that needed removal.

A surgical consult was recom-mended and scheduled after therestorative dentist solved the spacemanagement quandary. The patient’sfather was present for this consulta-tion and was firm in his opposition tothe placement of veneers on virginteeth (Nos. 8 and 9). He requested a

minimally invasive solution. The pa -tient’s determination to preserve hernatural smile established the parame-ters for planning the case.

Measuring the width of the con-tralateral incisors was the most logicalfirst step. In all cases like this one,shape and form of the teeth must beassessed. Removal of the unattractivecomposite and replacement with a newimperceptible composite veneer thatwould duplicate the aesthetics of herexisting teeth was recommended(Figure 4).

The remaining spaces would thenbe equalized, by performing additionaldirect bonding on the distal of the leftcentral to achieve central incisor sym-metry. After the entire direct compos-ite has been placed and idealized, deter-mination of additional tooth move-ment can be made. If minor toothmovement were necessary, it could beimplemented, followed by implantplacement. The patient agreed withthis approach and was scheduled.

Space Management and Restorative Execution

Extrinsic stain was removed from alltooth surfaces using plain pumice on asoft prophy cup. The unsightly com-posite on tooth No. 7 was removed andspace evaluation was performed bymeasuring the space with a caliper(Figure 5). Shade selection occurredimmediately to avoid any possibility ofdesiccation of the teeth that would leadto a mismatch after the tooth rehydrat-

ed. A small increment of compositewas light cured, previewed, and thenverified for color. The tooth was micro -etched (Micro Etcher II [DanvilleMaterials]),3 rinsed, and a 37% phos-phoric etch was agitated with a micro-brush for 15 seconds. The tooth wasrinsed for 5 seconds and lightly air-dried. A fifth-generation adhesive(Scotch bond Universal [3M ESPE]) wasapplied and agitated for 20 seconds andair-dried for 5 seconds in order toremove the ethanol solvent. The areawas then light cured for 10 seconds.This total-etch and adhesive techniquewas used on all surfaces of tooth towhich composite was augmented.

Composite placement on the distalfacial of No. 9 followed by recontouringuntil both centrals measured identical-ly in the width of the teeth and from afrontal view appeared contralaterallysymmetrical in outline form.

A direct composite veneer on No. 7was bonded using a freehand tech-nique, and a nanofilled composite (Fil -tek Supreme Ultra [3M ESPE]) wasselected due to its strength, sculptabil-ity, and shade matching capabilities. Amicrofilled composite resin (Durafill[Heraeus Kulzer]) was selected as thethinnest final facial layer. The silicaparticles are .04 µm in size, the fillersbeing 35% of the weight. This micro-fill composite is translucent and pro-vides excellent polishability and long-term color retention.

The depth of color and vitalitynecessary to mimic the adjacent tooth

was complex and required manyshades of composite. Shade WE (3MESPE) was placed as the lingual shelf,followed by dentin lobe formationwith shade A1D (3M ESPE). Kolor +Plus Modifier (lavender shade) (Kerr)was painted in between the lobes toprovide internal characterization,color saturation, and diffusion oflight. When creating this layer, thecentral incisor was examined and theincisal effects were mimicked, butlessened. A thin layer of Filtek Su -preme Ultra AT (3M ESPE) filled inthe space between the lobes and creat-ed the incisal translucency effect.

Shade A1B (3M ESPE) was placedin a very thin increment on the body(middle) of the tooth, and then thefinal facial layer (Durafill VS B1[Heraeus Kulzer]) was carried acrossthe whole facial of the tooth, extend-ing to the free gingival margin. Thislayer created the translucency of theenamel and an illusion of depth. Thisstratification technique modulatedthe shades and allowed depth of colorto come through from within therestoration, yielding an undetectable,lifelike restoration. Finish ing and pol-ishing discs (Sof-Lex [3M ESPE]) werethen used to refine primary anatomy,which consists of the facial profile,outline form, and the incisal embra-sures. The anatomy of a lateral incisortooth shape and form ranges fromsquare to ovoid to triangular. In orderto decrease the risk and increase the

AESTHETICS78

DENTISTRYTODAY.COM • MARCH 2014

continued from page 76

Figure 4. Right maxillary peg lateral underunsightly composite and asymmetrical centrals.

Figure 5. Measuring the mesiodistal widthof teeth Nos. 8 and 9. Note: No. 9 is thinner.

Figure 6. No. 7 composite veneer and spaceequalization finalized; harmonized and balanced aesthetically.

Figure 7. Post-op labial view, bone graft andimplant placement completed.

Figure 8. Lab-fabricated prototype. Note:tooth form is too square and apical in the gingival third compared to No. 7.

Figure 9. Developing the outline formshape, height, and level of zenith to mirrorthe contralateral tooth.

Figure 10. Submergence profile on the facialis flattened and undercontoured subgingivallyunder the zenith area, allowing for movement inan incisal direction of the free gingival margin.

Figure 11. Lateral pressure was attainedinterproximally by recontouring the mesialand distal portion of the crown, offeringsupport to the papilla.

continued on page 80

Predictable Tooth Replacement...

DEVELOPING SUBGINGIVAL EMERGENCE PROFILE TO SUPPORT AND SHAPE THE SOFT TISSUE

For ed

ucati

onal

use o

nly

AESTHETICS80

prognosis, ovoid shape was chosen atthe gingival third.2,4,5

Secondary anatomy, which con-sists of line angles and reflective sur-faces, was created using fine diamondburs (8889.31.009 [Brasseler USA]). Afinal luster was attained using spiralfinishing wheels (3M ESPE), followedby placing a polishing paste on a feltwheel (Enamelize [Cosmedent]).

Measurements of the remainingspace were accomplished, and verifi-cation of spacing equalization wasattained (Figure 6). The patient wasreferred to the oral surgeon.

Surgical Treatment and Strategies Successful implants must serve as afoundation for a naturally aestheticprosthesis that provides both formand function as close to the naturaldentition as is possible. Proper posi-tioning of the implant, adequate sta-ble bone volume and architectureand adequate soft-tissue thickness atthe transmucosal connection (tissuebiotype) are all significant factorsaffecting stability, health, and aes-thetics. The ideal implant position isdictated by the balance between thedesired final form and function of theprosthesis and the physiology andanatomy of the available hard andsoft tissues. Because of the significantbone atrophy on the crestal and labialsurfaces of the maxilla, a corticocan-cellous block onlay bone graft wasperformed on this patient.

The bone was harvested from theleft external oblique ridge at the timeher wisdom teeth were removed, 4months prior to placement of theimplant. The underside of the graftwas shaped so that it sat passively inthe crestal and labial defects. The con-tact with the underlying bone wasintimate. It was secured with a single10-mm x 1.7-mm titanium lag screw,placed in an incisal to apical angula-tion. This was done so that minimalsoft-tissue dissection would be neces-

sary at the time of implant placementwhen the lag screw was removed.

Of significant importance at thetime the graft is placed is the estab-lishment of a passive, well-vascular-ized primary closure with a rigidly fix-ated bone graft. This is accomplishedduring the establishment of the labialflap. The adjacent papillas are pre-served, and trapezoidal releasing inci-sions are made. A subperiosteal dissec-tion is then completed. In a transversedirection, the periosteum is anatomi-cally dissected from the overlyingmuscle, taking great care to preservethe vascular pedicle to the flap. It isthen anatomically incised. With gen-tle blunt traction, the flap is then easi-ly mobilized. This creates the volumeneeded to accommodate the underly-ing bone graft and permits eventualenhancement of the tissue biotype,while at the same time accomplishinga passive vascularized primary clo-sure. The flap tends to swell for thefirst couple of days after surgery; con-sequently, the placement of the provi-sional prosthesis was delayed to avoidischemia to the flap during the earlypostoperative period.

After 4 months of healing, a bonelevel 4.1 x 10-mm SLActive (Strau -mann) implant was placed. The roughosseoconductive surface and horizon-tal offset (Straumann’s Bone ControlDesign) is felt to be a very effectivedesign in maintaining bone againstfunctional load. The crestal bone levelis critical to the preservation of themucosal barrier, and therefore to thelong-term health and success of theimplant/prosthetic unit. The depth ofthe implant placement is dictated bythe facial height of the contour of thebone at the contralateral incisor. Thepatient’s age should be taken into con-sideration, understanding that naturaldegrees of bone and tissue recessionthat may occur with time.

The flap was then developed,starting with the palatal aspect of thecrestal incision. The incision was car-ried in a labial direction, preservingthe papilla while making minimal

trapezoidal releases. This allowed foradequate exposure to identify andremove the lag screw, which was usedto secure the bone graft.

A vacuum-formed surgical guide(fabricated by the restorative dentist)was employed to assure proper posi-tioning of the implant. The implantwas placed toward the palatal aspectof the maxillary alveolus at a 15° in -clination. A healing abutment wasthen placed. The aspect of the flapthat covered the crestal area of thegraft was then de-epithelialized androlled underneath the proximal as -pect of the flap. This served as a vas-

cularized connective tissue graft andwas done to enhance the labial con-tour of the cortical bone and to con-tribute to the perception of a root emi-nence. The wound was then closedanatomically (Figure 7).

Transitional ProsthesisWhile grooming soft tissue is notessential to achieving gingival aes-thetics, the technique utilized in thiscase simplifies the fabrication of thedefinitive porcelain while eliminat-ing the guesswork on shape and formfor the ceramist.6 The interproximalbone levels on adjacent teeth dictatethe papillary height.7 Predicting thelevel of facial tissue can be accom-plished 85% of the time by probing tothe osseous crest of the adjacenttooth. The goal is to develop andguide the rebound of the soft tissue soas to mimic the root of the tooth andcreate scalloped forms identical tothe contralateral area.8

The healing abutment was re -moved, the reverse torque test at 20Ncm verified integration, and theimpression coping was screwed intoplace. Radiographic confirmation ofcomplete seating was accomplished.

A fixture level impression wasdone, a photo taken for the documen-tation of color, followed by fabrica-tion of a laboratory fabricated provi-sional screw-retained compositecrown (Symphony [3M ESPE]). Consis -tent evaluation of every step in the proce-dure is paramount to the success of thecase. The case was returned from theceramist and, on evaluation of themodel (Figure 8), it was noted that thezenith and scallop of the compositeprototype was more apical and widerat the apical third than the compositeveneer on the right lateral. Immedi -ate recontouring of the height of the

composite prosthesis was accom-plished to mimic the contours of thecontralateral tooth (Figure 9).

The healing abutment was re -moved, and the interproximal con-tacts were adjusted to ensure com-plete seating of the crown. This wasthen verified with a radiograph. Next,the submergence profile on the facialwas flattened and undercountouredsubgingivally (Figure 10). Lateralpressure was attained interproximal-ly by recontouring the mesial and dis-tal portion of the crown to offer sup-port to the papilla (Figure 11). Thisfacilitated proper molding of the tis-sue with the composite prototype bymanipulation of concavity to formand guide the tissue. This created anabutment form that was scalloped atthe gingiva, mimicking the level ofthe scallop of the contralateral tooth.Primary anatomy was evaluated froma frontal perspective and compared tothe facial outline form of the rightlateral incisor.

The facial height of contour wasflattened on the mesial, length wasadjusted, and incisal embrasure formswere checked (Figure 12); when the

DENTISTRYTODAY.COM • MARCH 2014

continued from page 78

continued on page 82

Predictable Tooth Replacement...

Figure 12. Flattening of the facial height ofcontour on the mesial facial outline form followed by adjusting the length and incisalembrasure. Note the contralateral symmetry.

Figure 13. Custom shade tabs fabricatedwith composite resin (Venus Pearl [HeraeusKulzer]). (The tab is placed in the sameplane as the tooth being matched.)

Figure 14. Depth-gauge cuts establish theamount of facial reduction.

Figure 15. A concave transmucosal profile(occlusal view). Note the bilateral symmetry,augmentation of the osseous volume, andexact lingual positioning of the implant.

Consistent evaluation of every step in the procedure is paramount to the success of the case.

For ed

ucati

onal

use o

nly

AESTHETICS82

outline form mimicked the contralat-eral tooth, the occlusion was checked.Verification of clearance from occlu -sal, protrusive, and cross overloadingwas achieved to control the earlyfunctional stress to the implant.

The patient was instructed tonever allow food to be placed be -tween this restoration and any oppos-ing tooth.9 A 20 Ncm torque force wasemployed to secure the abutmentscrew in the access opening. It wasthen covered with cord and compos-ite. The occlusion was then checkedon all postoperative visits to verifythat supereruption of the opposingdentition did not occur.

The precise anatomy should in -corporate normal root contours andproperly placed cemento-enamel junc-tions. These contours support the tis-sue at the proper levels mirroring thecontralateral anatomy. Adjust ment tothe contours will affect the gingivalshape and scallop form. On postoper-ative visits, composite can be added orsubtracted to gain the desired result.The soft tissues adapt to the compres-sions of the composite prototype; ifthe composite is too full, this formwill position the tissue apically. If thetissue at the zenith (the height of con-tour on the free gingival margin onthe facial of the tooth) needs to bemoved incisally, the composite proto-type is flattened under the zenith.10

At-home bleaching trays were fabricat-ed and 14% H2O2 bleach (Philips ZoomDay White) was dispensed. Month lyevaluation and recontouring occurred,and once symmetry was attained, theprovisional restoration will functionas a template for the porcelain.

RecordsColor matching was accomplished byfabricating custom composite resin(Venus Pearl [Heraeus Kulzer]) tabslabeled with different colors andadded to a wax spatula. The photo-graphs were taken in the same plane

as the facial surface of the tooth beingused for comparison. These pieceswere sent to the ceramist as part ofthe records needed for duplication ofvalue and chroma (Figure 13).

Local anesthesia was adminis-tered, then a clear matrix vinyl poly-siloxane (VPS) (Crystal [CLINICIAN’SCHOICE]) impression was taken ofthe maxillary quadrant from teethNos. 5 to 9. This record was used atthe end of this visit to fabricate a newcomposite prototype to provisional-ize the upper right lateral incisor. Inorder to establish the amount offacial reduction, depth gage cuts(828.31.030 [Brasseler USA]) weremade across the upper middle and

lower middle third of tooth No. 7(Figure 14). Next, 2.0 mm was re -moved from the previously approvedincisal edge length, and then theveneer preparation was finalized.

The provisional screw-retainedcomposite crown was then removed(Figure 15) and an impression copingwas screwed into place, followed byradiographic verification of completeseating. The subgingival envelopemust be reproduced so the ceramistcan duplicate it in the final restora-tion. One technique is to duplicatethis area using a customized impres-sion coping. This coping is then takento the mouth to support the soft tis-sue when taking the final impression.An alternative technique involves

fabricating an impression of the pro-visional by seating it into the light-body VPS impression (Figure 16). Thisallows a cast of the soft-tissue emer-gence profile, which communicatesthe exact support of soft tissue to repli-cate the papillary and free gingivalmargin height and contour.11,12

A hemostatic, atraumatic, cord-free retraction putty (Expasyl [Kerr])was placed intrasulcular on tooth No.7 and then, as directed, rinsed withwater. A fixture-level full-arch im -pression (Imprint 3 [3M ESPE]), face-bow (Panadent), opposing impres-sions, and bites were recorded.

The provisional screw-retainedcomposite implant abutment wastorqued 20 Ncm into place. A bis-acryl composite (shade B1 Luxatemp[DMG America]) was loaded into theprovisional matrix; the No. 7 proto-type was fabricated and the cementa-tion technique employed used a com-bination of 2 cements. Next, spotetching, then bonding with expiredveneer cement (RelyX [3M ESPE]) inthe tooth center, TempBond Clear(Kerr) temporary resin cement (em -ployed at the periphery of the restora-tions), was followed by light curing.Milled zirconia abutments providebetter optical properties over castgold or titanium, but proper facialthickness must be present. Uponevaluation, adequate bulk (2.0 mm)was verified, and since zirconia hasproven tissue biocompatibility,13 azirconia abutment with titaniuminserts was chosen. Lithium disilicate(IPS e.max [Ivoclar Vivadent]) wasselected as the veneering ceramic dueto its aesthetic properties and highflexural strength (400 mPa).

This patient is young and, eventhough all known parameters for suc-cess had been fulfilled, a screw-retained design was selected due to theoption of retrievability. Gingival reces-sion is the most common complica-tion of anterior tooth implants.2 In thefuture, if minor corrections to the pros-thesis would be required, the fix couldeasily be done. The patient’s provision-al was also archived in her records box.

CementationAnesthesia was administered, the com-posite prototypes were removed, andthe No. 7 veneer was tried in and eval-uated for marginal fit and aesthetics. Itwas then cemented using the total-etch technique, adhesive (OptiBond FL[Kerr]), and a light-cured veneercement (RelyX Veneer [3M ESPE]). A35-Ncm torque force was employed ina wet environment to secure the titani-um abutment screw. Ten minutes later,

continued from page 80

Predictable Tooth Replacement...

Figure 16. An impression of the provisionalby seating it into the light body vinyl polysiloxane impression; used to fabricate acast with the exact support papilla and freegingival margin height and contour.

Figure 17. The patient’s goal was attained: a natural, beautiful appearance.

Figure 18. Post-op smile. Note the bigCupid’s bow smile, normal root contours,papilla, and free gingival margin mirroring.This becomes “imperceptible dentistry.”

Figure 19. Post-op retracted view. Lifelike emergence profiles, tooth contours, andcolor.

DENTISTRYTODAY.COM • MARCH 2014

For ed

ucati

onal

use o

nly

AESTHETICS

it was torqued again to 35 Ncm. Theaccess opening was covered with cordand composite.14

The recare protocol has includedbone and soft-tissue monitoring every6 months at the patient’s recare visits.

CLOSING COMMENTSThis AACD Accreditation Fellowshipcase demonstrates that even high-risk case types can result in an excel-lent outcome. Key principles includ-ing interdisciplinary treatment plan-ning, meticulous attention to detail,and skillful execution, can be tediousand time consuming. However, thesedifficulties are overshadowed by theexcellent results achieved and in -creased patient satisfaction.

A letter from the patient, alongwith a photo (Figure 17), was sent tothe entire treatment team, stating thefollowing:

We just wanted to send over a pic-ture of Nicole with her final results. It hasbeen a long journey that includes you andyour team, but it was well worth it.Nicole loves her new smile and is alwayssmiling from ear to ear. We are so grate-ful for all the work you did!

When the postoperative photosare displayed at the AACD scientificsession Showcase of Excellence(Figures 18 and 19), the conferenceattendees (mostly dentists and somedental technicians) evaluate all thedisplayed cases with a very discern-ing eye. They focus on:

lWhat is right? lWhat is wrong? lWhat is perceptible? and lWhat dentistry has been per-

formed?Yes, there is a shadow of a scar

and, yes, there are slight differencesin opacities be tween the veneer andthe implant crown. In the end, wemust remember that perfection maynot be possible, but excellence is!�

AcknowledgmentThe concepts demonstrated werelearned from the Kois Center andthrough many courses presented by theAACD. The author would like to thankDr. Karel DeLeeuw of Mayo Clinic forhis surgical expertise, Dr. HowardHenry for orthodontic alignment, andRick Durkee and Brad Patrick for thelaboratory work and support.

References1. Hochman MN, Chu SJ, Tarnow DP. Maxillary ante-

rior papilla display during smiling: a clinicalstudy of the interdental smile line. Int JPeriodontics Restorative Dent. 2012;32:375-383.

2. Kois JC. Predictable single tooth peri-implantaesthetics: five diagnostic keys. CompendContin Educ Dent. 2001;22:199-206.

3. Onisor I, Bouillaguet S, Krejci I. Influence of dif-

ferent surface treatments on marginal adapta-tion in enamel and dentin. J Adhes Dent.2007;9:297-303.

4. Bassett J. To plan or not to plan: that is thequestion! Aesthetically guided transitional bond-ing for space management quandaries. DentToday. 2012;31:128-131.

5. Bassett J. Conservativerestoration of a traumati-cally involved central inci-sor. Compend Contin EducDent. 2012;33:264-267.

6. Leziy SS, Miller BA.Aesthetics in implanttherapy: a blueprint forsuccess and change. AnnR Australas Coll DentSurg. 2010;20:28-35.

7. Choquet V, Hermans M,Adriaenssens P, et al.Clinical and radiographicevaluation of the papillalevel adjacent to single-tooth dental implants. Aretrospective study in themaxillary anterior region.J Periodontol.2001;72:1364-1371.

8. Wood RA, Mealey BL.Histologic comparison ofhealing after tooth extrac-tion with ridge preservationusing mineralized versusdemineralized freeze-driedbone allograft. J Perio -dontol. 2012;83:329-336.

9. Block M, Finger I, Cas -tellon P, et al. Single toothimmediate provisionalres toration of dentalimplants: technique andearly results. J OralMaxillofac Surg.2004;62:1131-1138.

10.Phillips K, Kois JC.Aesthetic peri-implant sitedevelopment. The re -storative connection.Dent Clin North Am.1998;42:57-70.

11.Jemt T. Restoring the gin-gival contour by means ofprovisional resin crownsafter single-implant treat-ment. Int J PeriodonticsRestorative Dent.1999;19:20-29.

12.Neale D, Chee WW.Development of implantsoft tissue emergence pro-file: a technique. J ProsthetDent. 1994;71:364-368.

13.Linkevicius T, Apse P.Influence of abutmentmaterial on stability ofperi-implant tissues: asystematic review. Int JOral Maxillofac Implants.2008;23:449-456.

14.Siamos G, Winkler S,Boberick KG. Relationshipbetween implant preloadand screw loosening onimplant-supported pros-theses. J Oral Implantol.2002;28:67-73.

A graduate of The OhioState University, Dr. Bas -sett practices compre-hensive restorative andaesthetic dentistry inScottsdale, Ariz. She isvice president and anAccredited Fellow of theAmerican Academy ofCosmetic Dentistry. Sheis an associate memberof the American Academyof Esthetic Dentistry, aKois mentor, an activemember in the Academyof Fixed Prosthodontics,and a Fellow in the AGD.Dr. Bassett is adjunct fac-ulty where she teachesthe aesthetic continuumat the Arizona School of

Dentistry. She is a national lecturer, pub-lished author, and is a member of the edito-rial board of several peer-reviewed publica-tions. She is also a Catapult speaker. Dr.

Bassett can be reached via e-mail at the ad -dress drmouthy@aol.com.

Disclosure: Dr. Bassett reports no disclosures.

83

For ed

ucati

onal

use o

nly