Anterior Single-Tooth Implants in the Esthetic zone

Doreen Leigh BelloGerwin Seco

• Implants in the anterior esthetic zone are most difficult to perform.

• When attempting an implant in the esthetic zone, clinician is adviced to place and restore 100 implants less in challenging areas.

Levels of difficulty for implant successLevels:

Level1 •Extraction performed by clinician•Good 5-wall bony housing•Great papilla or thick-flat periodontal biotype•Low smile line

Level2 •Extraction performed previously and grafted•Good 5-wall bony housing•Great papilla or thick-flat periodontal biotype•Low smile line

Level3 •Extraction performed previously and not grafted•Good 5-wall bony housing•Great papilla or thick-flat periodontal biotype•Medium smile line

Level4 •Extraction performed previously and not grafted•4-wall bony housing•Good papilla or thick-flat periodontal biotype•Medium smile line

Levels of difficulty for implant successLevels:

Level5 •Extraction performed previously and not grafted•4-wall bony housing•Good papilla or thick-flat periodontal biotype•High smile line

Level6 •Extraction performed previously and not grafted•3-wall bony housing•Inadequate papilla mesially of distally•High smile line

Level7 •Extraction performed previously and not grafted•2-wall bony housing•Inadequate papilla mesially of distally•Moderate or High smile line

PRETREATMENT GUIDELINES

• Soft Tissue Considerations• Bone Dimension• Root Morphology

Soft Tissue Considerations

• Anatomy of soft tissue depends on bone contours

• Type of Periodontium:Thin and Scalloped Thick and Flat

Square crowns Triangular crowns

Contact areas more apical Contact areas more incisal and occlusal

> Incisogingival and faciolingual < incisogingival and faciolingual

Bulbuous convexities at cervical 3rd More sublte convexities

Prone to gingival recession on adjacent

• Several adjacent teeth in anterior maxilla are removed >labial bony plate can collapse > longer implants

• Gingival recession occurs or adjacent when implants are placed upon extraction.

• SOLUTION? Conservative Flap Design– Labial flap extension of 3mm or less beyond the

alveolar crest may eliminate gingival recession of teeth adjacent to implant sites

Soft Tissue Considerations

Bone Dimension

• Determined height and width of bone• Implants should be placed soon after initial

socket healing to maintain internal stimulation of the bone and prevent collapse of facial plate

• Traumatic tooth(avulsion) loss can cause resorption of ridge.

Bone Dimension

• Minimum- 1mm bone required around the implant

• Standard- 6mm bone bed necessary buccolingually

Root Morphology

• Root form is evaluated before implant placement

Thin and Scalloped Thick and FlatNarrow and Tapered Roots Wider and less tapered Roots

SITE PREPARATIONS USING OSTEOTOMES

• DRILLS are used to remove bones on implant placements

• OSTEOTOMES are used as a better alternative technique:– Compress the bone literally– Allow bone preservation, condensation, and

expansion– Widen thin ridges which facilitate implant

placement

IMPLANT PLACEMENT

• Accurate placement of single-tooth implants is very important because it determines the tooth form, emergence profile,location of the screw hole, and dimensions of the interproximal papillae.

Incision design

• within the attached keratinized gingiva• Minimal incision should be made for single -tooth implant• Allows for placement of regenerative materials without

coronal displacement of the labial flap• Palatal ridge crest- a horizontal releasing incision is made

that does not penetrate down to the bone• Perpendicular to the ridge crest• Two beveled labial vertical releasing incisions are

extended apically and flared mesially an distally beyond mucogingival junction

Prosthetic considerations

• depends on the atomy and surgical parameters• Implant shoulder should be located subgingivally in the

anterior• The restoration profile can be developed gradually using an

acrylic temporary with appropriate contours at the time of second-stage surgery

• Placed as far to the labial aspect as possible and more apically

• Three dimensional positioning of implants• The facial contours of the crown should be slightly palatal

as compared with adjacent teeth

In px with resorbed ridges• Adequate flap cover and

maintenance of muccogingival junction may be difficult

- regenerative materials are placed to correct ridge resorption

Subtantial releasing and coronal positioning of the labial flap are necessary to primary coverage

• spiral tomogrpahy

-precise planning and placementof endosseous implant

-surgical guide fabriction- Evaluate implant position

and inclination

Final restoration

• All –ceramic or ceramometal crown• Final restoration is constructed on a cast with

implant position recorded• Metal casting to accept porcelain is

constructed on the final modified abutment

Current two –stage approach to single-tooth implants in the anterior maxilla

• A single- tooth implant on the same arch always provide a provisional restoration first - healing of tissues in two levels

(coronal and bone interface)

Tissue enhancement and precise implant placement

• Impression and indexing techniques performed at stage 1 or 2 implant surgery- satisfying px expectation- decreasing chair time-enhancing implant function and esthetics- provide optimal fitting of the abutment and finished restoration

• Singe tooth restoration in max may be complicated by improper crown shape, emergence profile, soft tissue contoursshape of the alveolar ridge, and crown position

Sometimes the implant must be angled for proper anchorage in compromised bone

When the abutment are placed at second-stage surgery- gingival tissue could collapse, making the fitting of the crown problematic.

Always bear in mind the functional and esthetic needs of px

Traditional approach for providing restorations after stage two surgery

• First take impressions for fabrication of a provisional crown

• Once provisional crown is in place, the soft tissue adapts to crown surface, which has been fabricated on the basis of the indexing and impression information given to the laboratory

• Either closed-tray or an open tray procedure can be used at stage two surgery to make a master impression of the px dentition.

• Along with soft tissue casts, these impressions provide information for the laboratory to use when fabricating the abutments and crowns for the restoration

• Accurate records of implant-abutment positions and gingival contours is manufactures, the restoration can be cemented into a place using conventional crown and bridge procedure

Usual sequence for the restoration begins during or after stage 2 surgery

• Impression is taken when the implant is exposed, or approximately 10 days later, when stitches are removed

• Clinician can remove the healing collar and put on the transfer coping, often using closed tray, and send the impression to the laboratory for the fabrication of the costum abutment and a provisional plastic crown

• When the final impressions are taken, the provisional plastic crown is removed and the screw of the implant is topped off

• Tighten the abutment by hand• After 3mos tighten it up mechanically• Then try on the metal abutment again to make sure it is placed

just below the tissues

• An impression can be taken with the abutment in place, allowing the laboratory technician to provide the optimal crown.

• At the time that the costum abutment is dilivered, the clinician tries on the metal casting. Assuming that it fits well, he or she moves to the final crown

Immediate placement and loading of implants in extraction sites in the esthetitc zone

• Advantages- faster restoration-minimal invasive surgery and minimum pain-natural healing process is mobilized- bone growth toward the implant-absence of bone loss-simplified maintenance of the natural design and contour of the gingiva- positive, immediate psychological effect on the px

Single-tooth implant

• Complete preservation of enamel and dentinal tissue• One piece screw-retained provides good esthetic,

easy to retrieve

• Longer treatment time• Necessity for additional surgical procedures• Increased costs• Esthetic result that may be more technically difficult

to achieve