MAXILLARY ANTERIOR

SINGLE-TOOTH
REPLACEMENT AND
IMPLANT ESTHETICS
PRESENTED BY:
Dr DIPIKA GARG
MDS 1ST YEAR
DEPT. OF PRSOTHODONTICS
 CONTENTS
-ALTERNATE TREATMENT OPTIONS FOR ANTERIOR SINGLE-TOOTH
-REPLACEMENT
-SINGLE-TOOTH IMPLANT
-FACTORS INFLUENCING TREATMENT
-SPECIFIC SINGLE-TOOTH IMPLANT INDICATIONS
-THE PERIIMPLANT FRAME AND SOFT AND HARD TISSUE
CONSIDERATIONS
-IMPLANT POSITION : DEPTH
-IMMEDIATE IMPLANT INSERTION AFTER EXTRACTION
-SOFT TISSUE EMERGENCE CONTOUR
-PROSTHETIC PHASE
-COMPLICATIONS
 Causes of max. anterior single tooth loss
• Agenesis
• Trauma
• Endodontic failure
• Fracture
• Resorption
• Caries
 Replacement options

• Traditional FPD
• Cantilever FPD
• RPD
• Acid- etched resin bonded FPD
• Implant supported crown
 Traditional FPD: complications and
reasons for failure

• Caries
• Endodontic therapy
• Uncementation
• Fracture
-porcelain
-tooth
• Esthetics
 Contraindications to anterior FPD

• Poor abutment teeth support

• Inadequate edentulous bone for pontic
contour
• Anterior diastemas
• Patient desire
• Young patient
 RPD
• No clinical studies support
• Instability of the restoration
-Speech
-Function
• Patient acceptance
• Used only as interim treatment modality
• Only indication is economics
 Contraindications to Resin-Retained FPD

• Thin enamel on abutment teeth

• Mobile abutment(s)
• Vertical overlap
• Bruxism
• Anterior diastemas
• Short clinical crown
• Poor occlusal relationship
 Single tooth implant

• The primary reason to suggest or

perform a treatment is often not related
to the cost, time, or difficulty to
perform the procedure,
but lies in the best possible long-term
solution for each patient.
 Factors influencing treatment
(1) Patient age,
(2) patient desires,
(3) patient compliance (orthodontics) and fears (surgery, especially
autogenous grafts),
(4) time for the procedure,
(5) consequences of failure,
(6) cost,
(7) the transitional prosthesis,
(8) challenging esthetics,
(9) adjacent tooth mobility,
(10) crown height space,
(11) amount of mesio-distal space,
(12) amount of available bone height,
(13) amount of available bone width, and
(14) the soft tissue in the edentulous site
 Local contra-indications to the anterior
single-tooth implant

• Inadequate bone volume

Faciopalatal (<5mm)
Mesiopalatal (<6mm for a 3.2mm implant to allow 1 to 2mm
from adjacent roots)
Height
• Inadequate crown height
• Mobility of two or four adjacent teeth greater than
+1
Insufficient inter-radicular space for
implant
Inadequate bone height for crown
Specific Single-Tooth Implant Indications

• Anodontia
• Root resorption
 The Peri-implant Frame And Soft And
Hard Tissue Considerations

• Remaining max. anterior teeth

• Tooth position
• Crown size
• Tooth shape
Remaining max. anterior teeth
Tooth Position
Crown Size
 Tooth Shape
• The three basic shapes of maxillary anterior teeth
are square, ovoid, and triangular.
• .The tooth shape influences the interproximal
contact and the gingival embrasure.
• The square tooth shape is the most favorable for
proper soft tissue drape and papillae around the
crown because the interproximal contact is more
apical and more tooth structure fills the
interproximal region.
 MAXILLARY SOFT TISSUE
CONSIDERATIONS

• Soft tissue drape : interproximal papilla

• Surgical considerations
• Position of the osseous crest
• Implant crest module design
• Implant size
Soft Tissue Drape: Interproximal Papilla
• Under ideal conditions, soft tissue completely
fills the interproximal space, with no, dark
triangles.

black triangle
• The distance from the facial free gingival margin
to the height of the interproximal papilla is
usually 4 to 5 mm, and therefore the inter dental
papilla height is about 50% of the exposed tooth
length.
• The biotype of the gingiva usually is called thick or thin.
• Thicker tissue is more resistant to the shrinkage or
recession and more often leads to the formation of a
periodontal pocket after bone loss.
• Thin gingival tissues around the teeth are more prone to
shrinkage after tooth extraction and more difficult to
elevate or augment after tooth loss.
• Gingival recession is the most comrnon esthetic
complication after anterior single-tooth extraction and is
also a concern after implant surgery and uncovery.
 Surgical Considerations

• Several techniques have been described to minimize soft

tissue recession and allow optimal papilla healing.
• If the mesial and distal papillae are in the ideal position,
they should be left intact, and a papilla-saving incision
should be made with facial vertical release incisions
joining a crestal incision.
• To reduce the incidence of scarring, the vertical release
incision should be short of the muco-gingival junction.
Intact Papilla
• If the papillae are depressed already, the crestal incision
is made to the palatal aspect of the adjacent teeth and a
sulcular incision is carried on the proximal aspect of the
adjacent teeth, and the papillae are reflected as part of
the mucoperiosteal facial flap.
• The soft tissue crestal incision is made from the
cingulum position of each adjacent tooth (palatal to the
midcrestal position or at the proximopalatal angle) to
increase the amount of tissue reflected facially.
• This additional tissue may be used to improve the
interdental papillae height and the facial soft tissue
contour.
Depressed Papilla
 Position of the Osseous Crest

• The dentist should evaluate closely the available bone

for implant insertion in esthetic regions because it will
influence greatly the soft tissue drape, implant size,
implant insertion (angulation and depth), and ultimately
the final outcome. A hard tissue topography as close to
ideal as possible is, pre-requisite to an esthetic implant
restoration.
• The ideal midcrestal position
of the edentulous site should
be 2 mm below the CEJ of
the facial position of the
adjacent teeth.
• On occasion bone crest may
be above this position and at
the level of the adjacent CEJ,
when the interproximal bone
height is higher or a socket
preservation bone graft was
performed.
• Bone and soft tissue changes after maxillary anterior
tooth loss are rather rapid and of considerable
consequence.
• As a result, many maxillary anterior edentulous sites
require at least some bone and soft tissue augmentation
before, along with, or at implant uncovery.
• Under ideal conditions, the implant body should not be
inserted until the bone and soft tissue are within normal
limits.
 Implant Crest Module Design
• The two most common complications of anterior single tooth implant
replacement are abutment screw loosening and crestal bone loss.
• Both of these conditions are related in part to the implant crest nodule design.
• An implant body with an antirotational feature is used for the single-tooth
implant.
• The greater the dimension of the external or internal hexagon (or anti rotational
feature, the greater the resistance to shear forces once the abutment is inserted,
which corresponds to a decrease in abutment screw loosening.
• The crest module also should be designed to transmit some compression and
tensile forces to the crestal bone. Smooth metal on the crest module transmits
shear forces to bone that increase the risk of crestal bone loss.
• Therefore smooth metal should be limited to 0.5 mm to reduce the amount of
shear load to the bone.
 Implant Size
• The implant body obviously should not be as wide as the natural
tooth or clinical crown.
Otherwise, the emergence contour and interdental papillary
region cannot be established properly.
• The height of the interseptal (interimplant) bone in part
determines the incidence of presence or absence of the interdental
papillae between the teeth.
• Therefore the intraseptal bone height is relative to the
maintenance of the interdental papilla, and the dentist should do
everything to preserve it.
• As a result, the implant should be at least 1.5 mm from the
adjacent teeth whenever possible.
• The larger-diameter implant decreases abutment screw loosening,
crestal bone loss, and the risk of implant body failure in the long
term
When the distance from the interproximal contact
is 5 mm or less, the papilla fills the space
When the distance is 6 mm, a partial absence
of papilla exists 45% of the time, and at 7
mm the risk of a compromise in the
interproximal space is 75%.
 IMPLANT BODY POSITIONS
• Mesiodistal position
• Faciopalatal position
• Implant angulation
• Facial implant body angulation
• Cingulum implant body angulation
Mesio-distal Position
Minimum 1.5 mm
• On occasion, the central incisor implant is positioned
slightly to the distal of the intratooth space. The incisive
foramen varies in size and position.
• As a precaution, the surgeon should reflect the palatal
tissue when placing a maxillary central incisor implant,
probe the foramen, and if necessary, place the implant in
a more distal position. This usually requires a 4-mm
diameter implant, rather than the ideal 5 mm, to stay
clear of the lateral incisor.
 Facio-palatal Position
• The mid-faciopalatal position of the implant is in
the middle of the edentulous ridge of adequate
contour.
• This approach permits the use of the greatest
diameter implant.
• The crestal bone should be at least 1 mm wider
than the implant on facial and palatal aspects.
Ideal implant placement should be palatal to an
imaginary line that outlines the
curvature of the teeth.
 Too palatal implant placement
The restoration for the same requires too
facial a cantilever
 Too facial an implant placement
will result in facial bone
resorption and apical migration of the soft tissue.
The resulting restoration will appear long in
comparison to the contra lateral tooth
 Implant Angulation
• The natural maxillary anterior teeth are loaded at a
12-degree angle because of their natural angulation
compared with the mandibular anterior teeth.
• The facial angulation of the implant body often
corresponds to an implant body angulation, which leads
to greater than 30 degrees off axial loads.
• These offset loads increase abutment screw loosening,
crestal bone loss, and the risk of cervical marginal
shrinkage.
• As a result, implants angled too facially compromise
esthetics and increase the risk of complications.
Cingulum Implant Body Angulation

• A second angulation suggested in the literature is more palatal

with an emergence under the cingulum of the crown.
This position also may be the result of an implant insertion in a
width-deficient ridge (Division B).
• The cingulum implant position may cause a considerable health
compromise.
• The implant body is round and usually 4 to 5.5 mm in diameter.
• The labial cervical contour of the implant crown must be similar
to the adjacent teeth for ideal esthetics.
• Because the long axis of the implant for a screw-retained crown
must emerge in the cingulum position, this most often requires a
facial projection of the crown or buccal correction facing away
from the implant body
 Implant Position : DEPTH
• The literature usually reports two positions for
the depth of the implant.
The facial bone of a healthy natural tooth is about
2 mm below the CEJ and the soft tissue from the
free gingival margin to the bone is 3mm
An implant inserted 4mm
or below CEJ often is
countersunk below the
crestal bone 2mm or more.
This gives “running-room”
for the porcelain on the
crown to create a natural
looking emergence profile.
 Disadvantage
• Bone loss is likely to occur beyond the implant-
abutment connection and often proceeds to the
first thread beyond the crest module.
• As a result, an increase in the probing depth and
growth of the anaerobic bacteria are more likely.
• An implant placed
2mm below the
adjacent facial CEJ
provides 3mm of soft
tissue which gives
ideal appearance.
• An implant placed
too shallow causes
severe emergence
profile angles and
compromises esthetics.
 Immediate Implant Insertion After
Extraction
• According to Kois, the five diagnostic keys for
predictable single-tooth periimplant esthetics when an
immediate extraction and implant insertion are
contemplated are
(1) relative tooth position,
(2) form of the periodontium,
(3) biotype of the periodontium,
(4) tooth shape, and
(5) the position of the osseous crest before extraction.
Tooth has been extracted.

Osteotomy done in the

palatal aspect of the socket.
Implant has been inserted into osteotomy and a 4 mm healing
abutment has been placed onto the implant.
Arrow points to gap between mucosal tissue and healing abutment.
BONE AUGMENTATION DONE
USING SYNTHETIC BONE

SITE SUTURED.
• The bone regenerated over the facial aspect of the
implant with guided bone regeneration (GBR) is often
immature woven bone, which is more prone to occlusal
overload.
• The inability to achieve proper esthetic and health
parameters constitutes a compromised result and
increased risk of esthetic or implant failure.
• When the implant is countersunk below the facial bone,
the implant platform may be up to 4 mm apical to the
CEJ of the adjacent teeth, which increases the
anatomical crown height.
• In addition, synthetic grafts placed around the titanium
implant grow less dense bone, which also is limited in
implant contact.
• The risk of postoperative infection
around the implant also is increased
with an immediate insertion because
of the bacteria associated with the
cause of tooth loss when judicious
case selection has not been
exercised.
• The presence of exudate lowers the
pH, which causes a solution-
mediated resorption of the grafted
bone and contaminates the implant
body with a bacterial smear layer,
which in turn reduces bone contact .
• The benefits of immediate implant insertion after tooth
extraction are related to an improved preservation of the
soft tissue drape and the bone architecture, compared
their collapse after tooth extraction.
• As a result, bone augmentation and soft tissue grafts can
be avoided.
• Therefore under ideal conditions that include lack of
pathologic conditions, thick gingival tissues, ideal bone
contours, ideal soft tissue contours, and square tooth
forms, the dentist may consider an immediate implant
insertion after tooth extraction.
SOFT TISSUE EMERGENCE CONTOUR

• The dentist should evaluate the crestal bone- to -

implant interface closely by radiographs to
ensure an absence of crestal bone loss before
adding the abutment post to the implant body.
• If the dentist suspects bone loss, the dentist
should reflect tissue for direct evaluation.
• Correction of a cervical horizontal defect
includes local autogenous grafts covered with a
barrier membrane and reapproximation of the
soft tissue
• For a vertical defect less than 2 mm, autogenous
bone may be added, and the uncovery of the
implant proceeds because bone growth is more
probable in the presence of the lateral walls of
bone.
• When the soft tissue along the edentulous crest is
at the level of the desired interdental papilla and
of sufficient quality and volume, the dentist uses
a subtraction technique such as gingivoplasty
with a coarse diamond tool and sculpts the
crestal gingival tissues to reproduce the cervical
emergence contour of the crown, complete with
interdental papillae and proper labial gingival
contour.
• If the gingival contour at Stage II uncovery is insufficient for the
proper architecture for the interdental papillae, an additive surgery is
performed to gain tissue thickness.
• Several addition techniques have been proposed, for example,
making an incision on the palatal aspect of the ridge, from the
palatal angle of each adjacent tooth, and making a release incision in
the midline to the height of the facial gingival contour desired. The
tissue is elevated from the crest of the ridge, and the first-stage
cover screw is identified.
• Once removed, a low-profile healing cap of 2 mm is inserted. A
connective tissue graft or Alloderm is placed around the low-profile
healing cap.
• The crestal tissues then are draped over the healing cap and sutured
to the palatal with tissue.
• The tissue heals by second intention in palatal areas, and excess
tissue forms on the facial and interproximal regions .
• An alternative Stage II uncovery procedure
developed by the author is called the
"split finger technique."
Split finger technique selected, when the
desired papilla height is almost ideal
The split palatal fingers are rotated The palatal tissue heals by
and support the appropriate facial second intention.
finger.
 PROSTHETIC PHASE
VARIOUS STAGES ARE
-Timing of prosthetic treatment
-Selection of the type of restoration
-Abutment selection
-Impression techniques
-Lab fabrication
-Try-in of prosthesis
-delivery of final prosthesis
 1. Timing of prosthetic treatment.
• It is generally recommended that wherever possible it is
better to leave the healing abutments in place until the
gingival tissue around them has matured.
• A minimum of
approximately
4 weeks from the time
of second-stage surgery
is recommended.
 2. Selection of the type of restoration.

There are 2 principal alternatives

1. A screw-retained prosthesis secured direct to the implant.
2. A cement-retained prosthesis secured direct to abutment.
 Screw retained Cement retained
ADVANTAGE ADVANTAGE
• Retrievability • Can compensate for
change in alignment

DISADVANTAGE DISADVANTAGE
• Expansion of cingulum • if margins of abutment
are subgingival, excess
cement may lodge.
• Retrievability is
extremely difficult
 3. Abutment selection.

• The role of the abutment is to connect the final

prosthesis to the implant body.

Most manufacturers provide a range of designs;

however, these are usually product specific.
• Minimum flare
• Wide flare
• Anatomic/ esthetic
• Ceramic
• Preangled
• Custom abutment
• Plastic castable UCLA
• Plastic/machined coping UCLA
 STANDARD PREFORMED ABUTMENTS
Material of manufacture
• Titanium

Advantages
• Simple to use
• Minimal chairside and laboratory time
• Predictable fit with implant-prosthesis components and anti-rotation feature
already present.
• Good retention
• Wide range of collar sizes
Disadvantages
• Design may increase bulk, limiting aesthetic
outcome
• Donot follow gingival contour
• Cannot be customized.
 PREPABLE ABUTMENTS

Material of manufacture
• Titanium
• Gold alloy
• Ceramic
Advantages
• Suitable for all cases
• Allows for angulation changes
• Modification allows for good gingival contour
Disadvantages
• Increases clinical and laboratory time
 CUSTOMIZED ABUTMENTS
Material of manufacture
• Gold alloy
• Titanium
• Zirconium
• Ceramic
Advantages
• Suitable for all cases
• Allow for angulation changes
• Modification allows for good gingival contour
Disadvantages
• Increases clinical and laboratory time
• Material choice influenced by occlusal loads
 Assessment of abutment choice

• The height from the head of the implant to the opposing

teeth, i.e. the interocclusal space.
• The amount of soft tissue from the head of the implant
body to the gingival margin of the mucosal cuff (both in
depth and thickness).
• The aesthetic requirements of the patient.
• The orientation of the implant body to the proposed
prosthetic crown.
• Preference for cement- or screw-retained prosthesis.
 FINAL PREPARATION AND
IMPRESSION

• OPTION 1: DIRECT TECHNIQUE

• OPTION 2: INDIRECT TECHNIQUE
OPEN TRAY IMPRESSION TECHNIQUE
CLOSED TRAY IMPRESSION TECHNIQUE

• OPTION 3: DIRECT-INDIRECT APPROACH

 Impression of the implant head

REMOVAL OF HEALING IMPRESSION COPING IS SCREWED

CAP TO THE FIXTURE
INDIRECT IMPRESSION COPING
• RADIOGRAPHS SHOULD BE TAKEN USING
LONG CONE TECHNIQUE TO ENSURE
PROPER SEATING OF THE IMPRESSION
COPING AND THEN TIGHTENED AND
AGAIN CHECKED WITH RADIOGRAPHS
 PERIODONTAL PROBE IS
RUBBER BASE INPRESSION MADE
USED TO MEASURE THE DEPTH
OF GINGIVAL COLLAR
 CAST IS POURED
AFTER ATTACHING
IMPLANT ANALOG
AND GINGIVAL
MIMIC IS ADDED
TO THE
IMPRESSION.
 TRANSITIONAL PROSTHESIS
• Progressive bone loading of the implant can reduce implant
failure, and bone density increases have been reported while
minimizing early crestal bone loss, especially in softer bone
types.
• Therefore the acrylic provisional delivered at- the impression
appointment is not placed in function during the next 4 to 6
weeks.
• The patient is instructed to avoid the area while eating.
• When soft tissues are not ideal and require manipulation at the
initial prosthetic appointment, the transitional prosthesis may be
used for 2 to 3 months before making the final impression.
• In this way, the interproximal papillae height and width may be
elevated before the final impression along with the emergence of
the soft tissue drape.
 Final Prosthesis
• Implant crowns are most often porcelain to metal, fabricated from
noble alloys, which are less likely to cause metal corrosion,
especially with sub-gingival margins on a metal implant.

• When all-porcelain crowns are fabricated, the higher impact force

on implants is more likely to cause fracture. In addition, because
the implant post is most often metal color, little advantage accrues
from a full-porcelain crown.

• The contours of the final crown are dictated by the surrounding

hard and soft tissue characteristics. Therefore by the time the final
crown is fabricated, all parameters for a harmonious, well-
integrated crown should be in place. The crown should follow the
normal criteria for an anterior tooth, independent from the support
system in the bone, implant, or natural tooth.
 Danger signs at a review appointment
The following is a list of the possible damage that may
occur to single-tooth implant-retained prostheses.
• interdental papilla deficiency
• cement failure
• loosening of abutment screws
• fracture of veneering material, ceramic or resin
• fracture of abutment screws
• increased bone loss around an implant
• fracture of the implant.
• abutment- crown crevice
Interdental papilla deficiency
Excess cement in the soft tissues
Loosening of abutment screw due to failure to tighten
it correctly.
Fracture of the implant body
The most common causes of these problems are:
• occlusal overload: careful review of all occlusal
contacts in all patterns of mandibular movement
and their refinement may be needed;
• failure to use a prescribed nocturnal occlusal
guard;
• faulty construction;
• off-axis loading of an implant.
 CONCLUSION
• Contrary to what they feel concerning missing
posterior teeth, most patients have an emotional
response regarding a maxillary anterior missing
tooth.
• No question exists regarding the need to replace
the tooth, and financial constraints are less
important.
 REFERENCES

• Dental implant prosthetics- CARL E.

MISCH
• Oral & maxillofacial surgery, Vol 7 -
FONSECA
• Introducing dental implants -HOBKIRK
• BRITISH DENTAL JOURNAL VOLUME 201 NO. 4
AUG 26 2006
• BRITISH DENTAL JOURNAL VOLUME 201 NO. 2
JUL 22 2006