Ten tips that everyone should know before performing a treatment involving implants in the aesthetic zone.

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Ten tips that everyone should know before performing a treatment involving implants in the aesthetic zone. Introduction Francisco Teixeira Barbosa. Private practice. Barcelona. Spain.

1 Ten tips that everyone should know before performing a treatment involving implants in the aesthetic zone. Introduction Francisco Teixeira Barbosa. Private practice. Barcelona. Spain. Nowadays, implantology is a predictable area and well-accepted by scientific community for missing or doubtful prognosis tooth reposition. More than 30 years ago, Brånemark and col. published the first articles that presented implantology as a safe and predictable method to rehabilitate edentulous patients if a rigid protocol is performed, in which one of the key factors were the time the implant was submerged until loading (3 months for the jaw and 6 months to the maxilla)(bränemark 1977). Years later, Albrektsson establishes a success criteria for every treatment involving implants, where implants should be absent of mobility, pain, radioluscence around the implant, and the bone loss should never be more than 1,5 mm and 0,2 mm per year (Albrektsson 1986). Although this is a prevailing criteria, at that time treatment involving implants were mainly functional and aesthetics were at most at the time not a mandatory requirement. Smith et al. just three years later established that aesthetic have also an important role on a successful implant treatment (Smith 1989). For that there are some golden rules that every implantologist should manage in order to achieve predictable results on the aesthetic zone and in this article there will be described ten rules that everyone should consider: 1) Edentulous gap in the anterior zone: When there will be papilla? Presence of papilla between an implant and a teeth depends mainly on the presence of inter proximal bone of the adjacent teeth. If there is a bone defect there will not be papilla (Kan 2003). There is also a relation between the presence of the papilla and the distance between the contact point and the bone crest (Tarnow 1992), where there will be a probability of complete presence if this distance is 5mm or less (98%), and less probability if that distance is 6 mm (56%) and 7 mm (27%). Fig. 1-3.Different distance from the contact point to the bone crest will represent different soft tissue contour. The more distance the less probability there will be papilla at the inter proximal contact.

2) Placing 2 adjacent implants. What should we expect? Placing two implants adjacent is always a big challenge.

aesthetic result (Tarnow 2003). This issue can be solved by placing one implant to substitute two anterior teeth.

Aesthetic results when two adjacent implants are placed adjacent is always a challenging issue.

It is important to choose the right abutment when an aesthetic restoration is performed.

2 2) Placing 2 adjacent implants. What should we expect? Placing two implants adjacent is always a big challenge. The mean papillary height between to implants will be 3,4 mm, which is in the most of the cases insufficient to achieve an optimal aesthetic result (Tarnow 2003). This issue can be solved by placing one implant to substitute two anterior teeth. This way it is expected to achieve a higher papilla level between an implant and a pontic (5,5mm) (Salama 1998). Fig Aesthetic results when two adjacent implants are placed adjacent is always a challenging issue. The average of papilla height we should expect is 3.4 mm. 3) Selecting the correct abutment. It is important to choose the right abutment when an aesthetic restoration is performed. If there is a thin mucosa with less than 2 mm width, zirconia should be the option cause metallic abutments will show a color alteration of the peri-implant soft tissue (Jung 2007,2008). Fig. 6-8.When the width of the buccal soft tissue is more than 2 mm, a metallic abutment can be used without altering the soft tissue color.

4) Immediate implants and aesthetic results. What we should know? Although this is a very discussed topic, there are some basic knowledge about immediate implants in the aesthetic zone.

extraction (Botticelli 2004, Araujo & Lindhe 2006).

3 4) Immediate implants and aesthetic results. What we should know? Although this is a very discussed topic, there are some basic knowledge about immediate implants in the aesthetic zone. Unavoidable bone resorption happens when a tooth is extracted (Cardaropoli 2003, Schropp 2003, Araujo & Lindhe 2005) and this events are not avoidable if the implant is placed at the time of the extraction (Botticelli 2004, Araujo & Lindhe 2006). There are some protocols published to overcorrect this events, like performing a connective tissue graft at the time of the immediate implant (Kan 2000, Kan 2005), but recession of the gingival margin is likely to occur (Evans 2007). This facial recession will be more pronounced on a thin biotype rather than a thick biotype (Kan 2011), so there could be stated that immediate implants in a thin biotype is not a predictable treatment and other treatment options should be consider, like ridge preservation (Jung 2012). Fig Immediate implants is a predictable method in some cases. It has some advantages like decreasing the global treatment time but should be avoided on patients with thin biotype. 5) Early implant placement. A predictable alternative. The time when the implant is placed has been a topic of discussion (Hämmerle 2004). One option is perform the extraction and after one month place the implant with simultaneous ridge augmentation (Buser 2013). This method as been proved to be a reliable way to achieve predictable aesthetic results. 6) Provisional restoration. Is it mandatory? After extraction of the teeth, it is important to preserve the papilla architecture. Some authors stated that placing an implant at the same time the teeth is extracted somehow helps to preserve the shape and the papillary architecture. Even if there is no provisional after the surgery, it is important to reshape the soft tissue before placing the definitive prosthesis. The provisional restoration is also a way to achieve the final periimplant shape and then transfer this emergence profile to the lab (Elian 2007).

It is mandatory to design natural emergence profiles before finishing the treatment. 7) Managing provisionals. Current concepts.

- Subcritical contour: Is the contour below the critical contour.

4 Fig Every demanding esthetic treatment involving implants should have a provisional phase before the definitive prothesis is delivered. It is mandatory to design natural emergence profiles before finishing the treatment. 7) Managing provisionals. Current concepts. During the provisional phase of the treatment, a correct and natural emergence profile should be create in accordance with the adjacent teeth. In every emergence profile it can be identify two contours (Su 2010): - Critical contour: The contour 1 mm immediately below the gingival margin. This contour when modified can displace apically the gingival margin. - Subcritical contour: Is the contour below the critical contour. When properly managed, this contour can create soft tissue volume (concave) and once this volume is created it can be displaced where is needed. There are some other ways to manage the provisionals during the healing phase but always regarding the concepts posted before (Wittneben 2013). Fig. 15. Critical contour and sub critical contour is a recent concept that explain the behavior of the peri-implant soft tissue when it is modified.

8) Implant three dimensional position. Where to place the implant.

of 1,5 mm from the adjunct teeth. This is the minimal distance although there are some articles that even showed that 2 mm would be an improvement (Gastaldo 2004).

If there is no teeth previously, a wax- up should create a reference of the future restoration.

Placing the implant in the comfort zone is a requisite when implants are placed in the aesthetic zone. 9) Choosing the right implant.

5 8) Implant three dimensional position. Where to place the implant. When an implant is placed in the anterior aesthetic zone, there are some rules that should be a guide for every implant placement (Buser 2004): - Mesio-distally: The implant should be at a distance of 1,5 mm from the adjunct teeth. This is the minimal distance although there are some articles that even showed that 2 mm would be an improvement (Gastaldo 2004). - Apico-coronally: This distance should be 3-4 mm distance from the gingival margin of the future restoration. In immediate implants the reference is the gingival distance of the removed teeth. If there is no teeth previously, a wax- up should create a reference of the future restoration. - Buccal- palatal: The buccal part of the implant should be 1-2 mm palatal to the emergence profile of the adjacent teeth. Fig Placing the implant in the comfort zone is a requisite when implants are placed in the aesthetic zone. 9) Choosing the right implant. Nowadays there is an increasing implant market in almost all countries with some new implants brands. This is something positive to the clinician but we have to be well aware if the different implants companies can fulfill our expectations and also the treatment and patient goals. Platform switching is a biological concept well implemented in almost all the implant brands (Lazzara 2006), but we should know that although it is an important issue, platform switching is not the only factor that can contribute to less bone remodeling after implant placement. Lately, Zipprich (Zipprich 2007) proved that the stability between the implant and the abutment is crucial to avoid the pumping effect which leads to bone resorption. Fig. 19. Knowing the behavior of the implants that are used in the daily practice will allow the clinician to have an extra confidence with the treatment options offered to the patient.

6 10) New techniques to avoid buccal bone resorption. Several methods have been described to avoid the negative effect of an extraction like immediate implants (Botticelli 2004, Araujo & Lindhe 2006), barrier membranes (Lekovic 1997) although the most suitable technique advocated to preserve the volume of the socket is the ridge preservation (Araujo 2009). Lately a new technique is being described as an option to perform an immediate implant without the negative consequences of the bone remodeling after an extraction (Hürzeler 2010), and the rationale behind this technique is preserving a tooth fragment that will avoid the resorption that takes place after the extraction. Although this technique is quiet promising we should be aware of the incoming publications about a larger follow up of this technique and the predictability of leaving a fragment inside the socket after an extraction (Baumer 2013, Kan 2013). Fig. 20. The socket shield technique is a recent method to avoid buccal bone resorption when immediate implants are performed. We should wait for new literature about this technique with larger follow ups before applying it on our daily practice.

7 Conclusions Today we can find in the literature an important number of reliable protocols to achieve a satisfactory aesthetic results in our treatments. But we should consider that the success is most likely to happen if a correct diagnose and treatment plan is carried out. There are some important tools that we should use daily in our daily practice in order to asses and to help clinician to identify the complexity of a case before a treatment plan is defined (Buser 2009). Clinicians also should perform protocols that are well described at the literature and with a follow up that categorize that treatment option as a predictable in long term. Nowadays there is sufficient data and scientific background to establish clear guidelines when demanding aesthetic treatments involving implants are required.

8 Bibliography Albrektsson, T., Zarb, G., Worthington, P., & Eriksson, A. R. (1986). The long-term efficacy of currently used dental implants: a review and proposed criteria of success. The International Journal of Oral & Maxillofacial Implants, 1(1), Araújo, M. G., & Lindhe, J. (2005). Dimensional ridge alterations following tooth extraction. An experimental study in the dog. Journal of Clinical Periodontology, 32(2), doi: /j x x Araújo, M. G., Sukekava, F., Wennstrom, J. L., & Lindhe, J. (2006). Tissue modeling following implant placement in fresh extraction sockets. Clinical Oral Implants Research, 17(6), doi: /j x Araújo, M. G., & Lindhe, J. (2009). Ridge preservation with the use of Bio-Oss collagen: A 6-month study in the dog. Clinical Oral Implants Research, 20(5), doi: /j x Bäumer, D., Zuhr, O., Rebele, S., Schneider, D., Schupbach, P., & Hürzeler, M. (2013). The Socket-Shield Technique: First Histological, Clinical, and Volumetrical Observations after Separation of the Buccal Tooth Segment - A Pilot Study. Clinical Implant Dentistry and Related Research, n/a n/a. doi: /cid Buser, D., Chappuis, V., Bornstein, M. M., Wittneben, J.-G., Frei, M., & Belser, U. C. (2013). Long-Term Stability of Contour Augmentation With Early Implant Placement Following Single Tooth Extraction in the Esthetic Zone A Prospective, Cross-Sectional Study in 41 Patients With a 5- to 9-Year Follow-Up. Journal of Periodontology, doi: /jop Buser, D., Martin, W., & Belser, U. C. (2004). Optimizing esthetics for implant restorations in the anterior maxilla: anatomic and surgical considerations. The International Journal of Oral & Maxillofacial Implants, 19 Suppl, Buser, D., Cordaro, L., & Martin, W. (2009). The SAC Classification in Implant Dentistry. Quintessence Publishing Company. Botticelli, D., Berglundh, T., & Lindhe, J. (2004). Hard-tissue alterations following immediate implant placement in extraction sites. Journal of Clinical Periodontology, 31(10), doi: /j x x Brånemark, P. I., Hansson, B. O., Adell, R., Breine, U., Lindström, J., Hallén, O., & Ohman, A. (1977). Osseointegrated implants in the treatment of the edentulous jaw. Experience from a 10-year period. Scandinavian Journal of Plastic and Reconstructive Surgery. Supplementum, 16, Cardaropoli, G., Araujo, M., & Lindhe, J. (2003). Dynamics of bone tissue formation in tooth extraction sites. An experimental study in dogs. Journal of Clinical Periodontology, 30(9), Elian, N., TABOURIAN, G., JALBOUT, Z. N., CLASSI, A., Cho, S.-C., Froum, S., & TARNOW, D. P. (2007). Accurate Transfer of Peri-implant Soft Tissue Emergence Profile from the Provisional Crown to the Final Prosthesis Using an Emergence Profile Cast. Journal of Esthetic and Restorative Dentistry, 19(6), doi: /j x Evans, C. D. J., & Chen, S. T. (2007). Esthetic outcomes of immediate implant placements. Clinical Oral Implants Research, 0(0), ??? doi: /j x Gastaldo, J. F., Cury, P. R., & Sendyk, W. R. (2004). Effect of the Vertical and Horizontal Distances Between Adjacent Implants and Between a Tooth and an Implant on the Incidence of Interproximal Papilla. Journal of Periodontology, 75(9), doi: /jop Hämmerle, C. H. F., Chen, S. T., & Wilson, T. G. (2004). Consensus statements and recommended clinical procedures regarding the placement of implants in extraction sockets. (Vol. 19, pp ). Presented at the The International journal of oral & maxillofacial implants. Jung, R. E., Sailer, I., Hämmerle, C. H. F., Attin, T., & Schmidlin, P. (2007). In vitro color changes of soft tissues caused by restorative materials. The International Journal of Periodontics & Restorative Dentistry, 27(3),

9 Jung, R. E., Holderegger, C., Sailer, I., Khraisat, A., Suter, A., & Hämmerle, C. H. F. (2008). The effect of all-ceramic and porcelain-fused-to-metal restorations on marginal peri-implant soft tissue color: a randomized controlled clinical trial. The International Journal of Periodontics & Restorative Dentistry, 28(4), Jung, R. E., Philipp, A., Annen, B. M., Signorelli, L., Thoma, D. S., Hämmerle, C. H. F., et al. (2012). Radiographic evaluation of different techniques for ridge preservation after tooth extraction: a randomized controlled clinical trial. Journal of Clinical Periodontology, 40(1), doi: /jcpe Kan, J. Y. K., Rungcharassaeng, K., Umezu, K., & Kois, J. C. (2003). Dimensions of peri-implant mucosa: an evaluation of maxillary anterior single implants in humans. Journal of Periodontology, 74(4), doi: /jop Kan, J. Y., & Rungcharassaeng, K. (2000). Immediate placement and provisionalization of maxillary anterior single implants: a surgical and prosthodontic rationale. Practical Periodontics and Aesthetic Dentistry : PPAD, 12(9), quiz 826. Kan, J. Y. K., Rungcharassaeng, K., & Lozada, J. L. (2005). Bilaminar subepithelial connective tissue grafts for immediate implant placement and provisionalization in the esthetic zone. Journal of the California Dental Association, 33(11), Kan, J. Y. K., Rungcharassaeng, K., Lozada, J. L., & Zimmerman, G. (2011). Facial gingival tissue stability following immediate placement and provisionalization of maxillary anterior single implants: a 2- to 8-year follow-up. The International Journal of Oral & Maxillofacial Implants, 26(1), Kan, J. Y. K., & Rungcharassaeng, K. (2013). Proximal socket shield for interimplant papilla preservation in the esthetic zone. The International Journal of Periodontics & Restorative Dentistry, 33(1), e doi: /prd.1346) Lazzara, R. J., & Porter, S. S. (2006). Platform switching: a new concept in implant dentistry for controlling postrestorative crestal bone levels. The International Journal of Periodontics & Restorative Dentistry, 26(1), Lekovic, V., Kenney, E. B., Weinlaender, M., Han, T., Klokkevold, P., Nedic, M., & Orsini, M. (2012). A Bone Regenerative Approach to Alveolar Ridge Maintenance Following Tooth Extraction. Report of 10 Cases. Dx.Doi.org, 68(6), doi: /jop Salama, H., Salama, M. A., Garber, D., & Adar, P. (1998). The interproximal height of bone: a guidepost to predictable aesthetic strategies and soft tissue contours in anterior tooth replacement. Practical Periodontics and Aesthetic Dentistry : PPAD, 10(9), Schropp, L., Wenzel, A., Kostopoulos, L., & Karring, T. (2003). Bone healing and soft tissue contour changes following single-tooth extraction: a clinical and radiographic 12-month prospective study. The International Journal of Periodontics & Restorative Dentistry, 23(4), Smith, D. E., & Zarb, G. A. (1989). Criteria for success of osseointegrated endosseous implants. The Journal of Prosthetic Dentistry, 62(5), Su, H., Gonzalez-Martin, O., Weisgold, A., & Lee, E. (2010). Considerations of implant abutment and crown contour: critical contour and subcritical contour. The International Journal of Periodontics & Restorative Dentistry, 30(4), Tarnow, D. P., Magner, A. W., & Fletcher, P. (1992). The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla. Journal of Periodontology, 63(12), doi: /jop Tarnow, D., Elian, N., Fletcher, P., Froum, S., Magner, A., Cho, S.-C., et al. (2003). Vertical distance from the crest of bone to the height of the interproximal papilla between adjacent implants. Journal of Periodontology, 74(12), doi: /jop Zipprich, H., Weigl, P., Lange, B., & Lauer, H. C. (2007). Erfassung, Ursachen und Folgen von Mikrobewegungen am implantat-abutment-interface. Implantologie.

Wittneben, J.-G., Buser, D., Belser, U. C., & Brägger, U. (2013).

university Alfonso X El Sabio, Madrid, Spain in 2004.

finished the post graduated studies of Oral Implantology at Santiago de Compostela University,

Moved his practice to Barcelona where he continued his education at Escuela Superior de

Advanced Oral Implantology at Loma Linda University, LA, California, USA.

10 Wittneben, J.-G., Buser, D., Belser, U. C., & Brägger, U. (2013). Peri-implant soft tissue conditioning with provisional restorations in the esthetic zone: the dynamic compression technique. The International Journal of Periodontics & Restorative Dentistry, 33(4), doi: /prd.1268) About the Author: Francisco Teixeira Barbosa Francisco Barbosa graduated from the university Alfonso X El Sabio, Madrid, Spain in After finishing his graduation, he started the post graduation studies where one year later he finished the post graduated studies of Oral Implantology at Santiago de Compostela University, Santiago, Spain. Moved his practice to Barcelona where he continued his education at Escuela Superior de Implantologia in Barcelona and as a Dentist at the Maxillofacial department of Hospital del Mar at Barcelona. At the same time he started his private practice in Barcelona and also finished his degree in Advanced Oral Implantology at Loma Linda University, LA, California, USA. At the moment he lectures all around Spain, Portugal and Italy and participates in many research protocols. He is also the author of the ibooks about oral implantology Immediate implants immediately restored and Immediate loading and immediate restoration with CAD/CAM technology. Publications: Immediate Loading with CAD/CAM prothesis Social network: Immediate Implants Immediately Restored Twitter: cisco_research Facebook: Francisco Teixeira Barbosa Instagram: tuminha_dds LinkedIn: Francisco Teixeira Barbosa Google+: Francisco Teixeira Barbosa

Planning for esthetics Part II: adjacent implant restorations

C L I N I C A L Planning for esthetics Part II: adjacent implant restorations William C Martin, 1 Emma Lewis, 2 Dean Morton 3 1 DMD, MS, Associate Professor & Clinical Director, Center for Implant Dentistry,