Tạp chí implant IPUS tháng 3& 4/2013 Vol 6 No2

Tạp chí implant tháng 3& 4/2013 Vol 6 No2

PAYING SUBSCRIBERS EARN 24

CONTINUING EDUCATION CREDITS

Preventing the dreaded black

triangle during implant placement in the esthetic

Volume 6 Number 2 Implant practice 1

March/April 2013 - Volume 6 Number 2

EDITORIAL ADVISORS

Steve Barter BDS, MSurgDent RCS

Anthony Bendkowski BDS, LDS RCS, MFGDP, DipDSed, DPDS,

MsurgDent

Philip Bennett BDS, LDS RCS, FICOI

Stephen Byfield BDS, MFGDP, FICD

Sanjay Chopra BDS

Andrew Dawood BDS, MSc, MRD RCS

Professor Nikolaos Donos DDS, MS, PhD

Abid Faqir BDS, MFDS RCS, MSc (MedSci)

Koray Feran BDS, MSC, LDS RCS, FDS RCS

Philip Freiburger BDS, MFGDP (UK)

Jeffrey Ganeles, DMD, FACD

Paul Tipton BDS, MSc, DGDP(UK)

Clive Waterman BDS, MDc, DGDP (UK)

Mali Schantz-Feld Email: mali@medmarkaz.com

Tel: (727) 515-5118 ASSISTANT EDITOR

Kay Harwell Fernández Email: kay@medmarkaz.com

PRODUCTION MANAGER/CLIENT RELATIONS

Kim Murphy Email: kmurphy@medmarkaz.com

NATIONAL SALES/MARKETING MANAGER

Drew Thornley Email: drew@medmarkaz.com

Tel: (619) 459-9595 NATIONAL SALES REPRESENTATIVE

Sharon Conti Email: sharon@medmarkaz.com

Tel: (724) 496-6820 E-MEDIA MANAGER/GRAPHIC DESIGN

Greg McGuire Email: greg@medmarkaz.com

PRODUCTION ASST./SUBSCRIPTION COORDINATOR

Lauren Peyton Email: lauren@medmarkaz.com

consent must be obtained before any part of this publication may

be reproduced in any form whatsoever, including photocopies

and information retrieval systems While every care has been

taken in the preparation of this magazine, the publisher cannot

be held responsible for the accuracy of the information printed

herein, or in any consequence arising from it The views

expressed herein are those of the author(s) and not necessarily

the opinion of either Implant Practice or the publisher.

Having recently celebrated my 27th year in private practice as a periodontist, I have been reflecting on the changes that have occurred in the profession It is hard to believe that at the beginning of my career I was a “full-time” specialist limiting my practice

to the prevention, diagnosis, and treatment of periodontal disease As a resident, implant dentistry was not a part of our curriculum, and discussions involving this topic were relegated to lunch hour debates in the cafeteria At that time, it was performed by a select few who later became known as pioneers in the field

In the mid- to late 1980s, many clinicians, including myself, were taking the courses necessary to place dental implants and recognized the fact that one can change people’s lives by simply restoring form and function However, at that time, patients with hopelessly involved dentitions often had treatment plans that were in excess of 18 months Patient acceptance was often difficult to obtain, as they did not necessarily understand the advantages of implant dentistry

With time, several innovations, some of which include an internal hex connection and a second-generation roughened surface technology (micro and macro roughness), improved the predictability of patient care and addressed some of the patient’s resistance

to time-intensive treatment plans This led to wider acceptance of implant dentistry and

a paradigm shift in the 1990s, making this a treatment of choice in clinical situations that would require sophisticated, less predictable procedures to salvage failing dentitions

In response to market demands, esthetics became the focus of our profession

It was no longer enough to simply restore form and function Our endpoint had to be

an esthetically pleasing restoration As a result, the last 10 to 15 years found clinicians changing their mantra from surgically driven implant placement to restoratively driven implant placement Often, this would require one- and two-stage hard and soft tissue grafting procedures to satisfy the esthetic demands of a consumer-educated patient population There was, and always will be, a percentage of the population who is comfortable with an “at any cost” treatment approach However, due to motivation, time, and financial constraints, many patients would seek treatment alternatives that also resulted in an esthetic restoration Implant companies responded with a number of innovations centering on surface technology and the introduction of new implant materials (alloys) developed specifically for narrow interdental spaces, expanding our treatment options

More recently, another surface technology was introduced that enhanced osseointegration through its hydrophilic and chemically active properties, resulting in

an improved surface chemistry This is noteworthy, as these properties enable faster osseointegration, reducing the overall loss of implant stability, which is typical after mechanical stability due to an osteopenia This technology is designed to give clinicians the confidence to proceed with immediate placement in extraction sites A byproduct

of the improved surface chemistry is the ability to load the fixture sooner, increasing the appeal and patient acceptance of implant treatment

Another technology that is allowing for more and more implant candidates is the advent of new implant materials There is a titanium-zirconium alloy that has shown higher strengths when compared to implants made of grade 4 titanium manufactured by the same company Smaller diameter implants can now be placed with confidence, as fixture fracture is less of a concern This is clinically relevant, as often patients will not accept treatment recommendations if large grafting procedures are necessary to create an environment for successful implant placement

When I graduated from my residency, I had no idea that the profession would change

as much as it has I feel blessed to be practicing in a time when dentistry continues

to evolve where we now have the ability to meet and exceed patient expectations with respect to restoring form and function — as well as replacing teeth that are indistinguishable from those lost I can only hope that the innovations that will occur in the next 27 years will be as noteworthy as those in the past

Dr Robert MillerMiami and Boca Raton, Florida

Reflections on an ever-evolving profession

Practice profile 6

Dr Coury Staadecker: The art of harnessing synergy

Dr Staadecker discusses the many facets of his practice that set the stage for

guiding and maintaining true patient wellness.

Straumann: Shaping the future together

Straumann® – a global leader in implant dentistry offering surgical, restorative,

regenerative, and digital solutions for the dental and lab business – is a pioneer

Guided surgery – understanding the risks

Dr Peter Sanders explains the importance of gaining experience in conventional implant placement prior

to using CT guided surgery 18

Continuing education

Preventing the dreaded black triangle during implant placement in the esthetic zone: part 1

Dr Scott M Blyer examines ways

to avoid a frustrating complication of dental implant therapy 22

Treatment planning of implants

in the esthetic zone: part 1

In the first part of a series of articles, Drs Sajid Jivraj, Mamaly Reshad, and Winston Chee look

at the diagnostic factors that affect the predictability of peri-implant esthetics .28

ORTHOPHOS XG 3D

ORTHOPHOS XG 3D The right solution for your diagnostic needs.

Implantologists

will appreciate the seamless clinical workflow from initial diagnostics, to treatment planning, to ordering surgical guides and final implant placement.

Endodontists

will enjoy instantly viewable 3D volumetric images for revealing and measuring canal shapes, depths and anatomies.

Orthodontists

will benefit from high- quality pan and ceph images for optimized therapy planning.

For more information, visit www.Sirona3D.com

or call Sirona at: 800.659.5977

The advantages of 2D & 3D in one comprehensive unit

ORTHOPHOS XG 3D is a hybrid system that provides clinical workflow advantages, along with the lowest possible effective dose for the patient Its 3D function provides diagnostic accuracy when you need it most: for implants, surgical procedures and volumetric imaging of the jaws, sinuses and other dental anatomy

For standard 2D images, it offers the most comprehensive selection

of pan and ceph programs to meet virtually all needs, from standard panoramic programs for adults and children, to extraoral bitewing, sinus, TMJ options and many more.

Automatic patient positioning The new Auto-Positioner measures the exact tilt of the patient’s occlusal plane and automatically adjusts the height for an optimal panoramic image within the sharp layer, thereby preventing incorrect positioning and reducing re-takes.

Fast, profitable, and

patient-friendly denture stabilization

3M™ ESPE™ MDI Mini Dental Implants

34

Technology

Trabecular Metal™ implants

from orthopedics to dental

implantology

Dr Suheil M Boutros focuses on the

applications for a new type of implant

Event preview

4th annual NYU College of Dentistry Global Implantology Week . 52

Diary .56

Materials &

equipment .62

Small-diameter implant

treatment

34

Abutments as individual

as your patients

ATLANTIS BioDesign Matrix™

The four features of the ATLANTIS BioDesign Matrix™

work together to support soft tissue management for ideal functional and esthetic result This is the true value of ATLANTIS™ for you and

your patients.

ATLANTIS VAD ™

Designed from the

fi nal tooth shape

Custom Connect ™

Strong and stable fi t – customized connection for all major implant systems

Soft-tissue Adapt ™

Optimal support for soft tissue sculpturing and adaptation to the

fi nished crown

Natural Shape ™

Shape and emergence profi le based on individual patient anatomy

CAD/CAM abutments help to eliminate the need for inventory management of stock components and simplify the restorative procedure.

Find out how ATLANTIS™ can bring simplicity and esthetics

to your practice Just take an implant-level impression, send it to your laboratory and ask for ATLANTIS today.

800-531-3481 • www.dentsplyimplants.com

DENTSPLY Implants_ATLANTIS_Implant Practice_DEC.indd 1 12/21/2012 6:06:37 PM

What can you tell us about your

background?

I earned my dental degree from Ohio State

University in 1997 and my Periodontics

Certificate from the Naval Postgraduate

Dental School in Bethesda, Maryland

While pursuing my periodontics certificate,

I also earned a Master of Science degree

from George Washington University When

on staff at the Naval Medical Center San

Diego, I mentored numerous general

practice residents and lectured extensively

While in private practice in Seattle,

Washington, I continued my involvement

with academics as a Clinical Instructor

and Affiliate Professor at the University

of Washington, Department of Graduate

Periodontics Additionally, I am the former

Senior Clinical Editor of the Seattle Study

Club Journal, reaching over 8,000 dentists

worldwide I am a Diplomate of the

American Board of Periodontology and an

Accredited Fellow of the American Society

of Dental Anesthesiology

Is your practice limited to

implants?

As a periodontist, there are three distinct

facets of my practice that include (1)

treatment of periodontal disease, (2) implant

therapy, and (3) periodontal plastic surgery

Being well versed in all three areas sets the

stage to guide and maintain true patient

wellness Additionally, these facets blend

seamlessly not only to establish health,

but also to maintain optimal function and

esthetics

Why did you decide to focus on

implantology?

While I was attending dental school during

the mid-1990s, it was the birthplace of

modern day implantology Implant design

and technology have continued to evolve,

but with all the different manufacturers,

implants have become similar We can

now provide our patients with a tooth

replacement that predictably makes them

“whole” again I can emotionally identify

with the innate and powerful sense of

self-preservation With prosthetic treatment

other than implant therapy, the treatment

is either collaterally destructive or foreign

to the patient Patients simply perceive

implants as being a part of themselves

and therefore self-preserving Having the opportunity to return a sense of self-esteem and confidence is just as joyful for

me as it is for my patients

How long have you been practicing, and what systems do you use?

I have been practicing dentistry for more than 15 years I exclusively use Straumann® and Nobel Biocare® dental implant products

What training have you undertaken?

Following graduation from Dental School

at The Ohio State University, I continued

my training in an Advanced Education General Dentistry (AEGD) Residency in the U.S Navy The AEGD Residency piqued

my interest in periodontics and implants Shortly thereafter, I applied and graduated from a 3-year residency in periodontics from the Naval Postgraduate Dental School Over the course of the following

8 years, I was a didactic instructor and Affiliate Professor at the Naval Medical Center, San Diego and the University of Washington, respectively I also had the good fortune of becoming part of the Seattle Study Club “university without walls” continuing education organization

as a co-director and Senior Clinical Editor

Who has inspired you?

After I had reached my goals within the military and was ready to pursue private practice, I was introduced to Dr Michael Cohen, founder of the Seattle Study Club

Dr Cohen invited me to become partner

PRACTICE PROFILE

in his practice, co-director in the Seattle

Study Club and Senior Clinical Editor in the

SSC Journal

The Seattle Study Club is recognized

as one of the most advanced and exciting

dental continuing education groups today

Dr Cohen is one of the few practitioners

in the country to have constructed a

successful bridge between didactic and

clinical programming Building on the

traditional study club model, he has added

original and more powerful programming to

maximize member interest

I then had the good fortune to return

to California in Newport Beach and partner

with Dr Donald C Dornan in private

practice Dr Dornan is the most skilled,

humble, and accomplished periodontist

I know The proof of Dr Dornan’s deft

clinical abilities resides in our hygiene

maintenance program for over 40 years

What is the most satisfying aspect

Professionally, what are you most proud of?

I have been blessed often with being in the right place at the right time In my professional training and in life, I have had the opportunity to be guided by gifted mentors that have molded the way I think and approach patients As an Affiliate Professor at the University of Washington

in the Graduate Periodontics Department,

I had the chance to give back to the dental community The residents at UW were intelligent, eager, and passionate to learn Passing along the techniques that

I have developed throughout my career is like opening my heart Years later, I have continued to stay in touch with many of my former residents

What do you think is unique about your practice?

There is a great deal of diversity, innovation, and experience within our practice Pairing sound clinical knowhow with new technology and materials is an art form Critically evaluating and reevaluating yourself and each other allows us to grow

in a positive direction from which our patients benefit most

Dr Staadecker and his partner Dr Donald C Dornan

positive direction from

which our patients

benefit most.

Humanitarian operation while Dr Staadecker was in the Navy in Mombasa, Kenya

What has been your biggest

challenge?

I believe that dentists are often

perfectionists I am no exception to this,

which is both a blessing and a curse Even

with all of the advances in technology

that we have available to us, there are still

limitations in our biology Accepting these

limitations can be challenging

What would you have become if

you had not become a dentist?

An architect

What is the future of implants and

dentistry?

The future of dentistry resides in molecular

biology and the capability to harvest cells

Stem cell research has come a long way

but has not made it to our practices yet

Influencing stem cells to down or up

regulate in the presence of disease is also

becoming more noteworthy Clinicians

and the general population are becoming

more aware of the periodontal-systemic

relationship

What are your top tips for

main-taining a successful practice?

My top tip for maintaining a successful

practice is to find what makes you

passionate, and leverage off of that

passion I found myself involved in many

cases that required a comprehensive

approach, which led me to becoming

involved with interdisciplinary study clubs

The challenging nature of these cases and

the opportunity to work closely with astute

clinicians is a joy! Now, I have started a study club, Apres Continuum, based upon interdisciplinary treatment planning

The doctors involved in Apres Continuum are dedicated to the advancement of team treatment planning and total case management as the ultimate tool for achieving ideal comprehensive care

They have also committed themselves to excellence in their profession and in the management of their practices

As we settle into the 21st century, technological advances continue to shape

a challenging and innovative future for the dental health care profession How can the demands of this rapidly changing field be met? What skills and knowledge will be necessary to move comfortably into the future? How can all aspects of dentistry, whether periodontics, oral surgery, or endodontics, be incorporated into one’s practice, thereby “bridging the disciplines?”

The answers to these questions are crucial

to comprehending the role that continuing education will play in the future of our profession

What advice would you give to budding implantologists?

First, know your strengths, work within your strengths, and pass those gifts along

to your patients

Secondly, develop a strong level of communication between the restorative dentist and implant surgeon Working together as a team will benefit your patients and practice immensely

Finally, work with an interdisciplinary

team that values treatment planning

What are your hobbies, and what

do you do in your spare time?

I am an avid outdoorsman and former triathlete Ski trips with my friends and family are always the highlight of the year

TOP FAVORITES

1 Periolase ® by Millennium

2 Acellular Dermal Matrix

3 Tunneling Instrument (KMIS1) by G Hatzell & Son

4 DASK Lateral Wall Sinus Bur by Dentium USA

5 SonicWeld by KLS Martin

6 Straumann ® immediate temporary abutment

7 Molly Moon’s Salted Caramel Ice Cream, Seattle, WA

8 Paseo’s Caribbean Roast Plato, Seattle, WA

9 Thurman Café’s Thurman Burger, Columbus, OH

10 Ikko’s Sweet Shrimp in Miso Soup, Costa Mesa, CA

11 Juliette Kitchen & Bar’s Pork Cheek small plate, Newport Beach, CA

12 W Hotel, South Beach (Miami Beach), FL

13 Earl Grey at Uva’s in Vancouver, BC

14 Backcountry at Whistler Blackcomb, BC

15 Ohmi Filet at The Met, Seattle, WA

16 Osso Bucco at Caffé dei Poeti in Madrid, Spain

17 Portola Coffee in Costa Mesa, CA

IP

During a Half Ironman—swimming, biking, and running

Designed to give you confidence in all cases through the combination of advanced material and surface technology

the Loxim™ Transfer Piece

Roxolid implants with Loxim can increase your treatment options, expand your prosthetic options and make implant

insertion and restoration as easy as 1–2–3

www.straumann.us 800/488 8168

Straumann Shaping the future together

Who we are

Straumann® – a global leader in implant

dentistry offering surgical, restorative,

regenerative, and digital solutions for the

dental and lab business – is a pioneer

of innovative technologies We are

committed to Simply Doing MoreSM

for dental professionals and patients With

world-class customer service, highly

skilled technical support, and a team of

experienced professionals readily available

to you, our vision is to be the commercial

partner of choice in implant, restorative,

and regenerative dentistry

With its corporate headquarters in

Basel, Switzerland, and North American

headquarters in Andover, Massachusetts,

Straumann’s products and services are

available in more than 70 countries Having

pioneered many influential technologies

and techniques in dentistry, the company’s

mission is to enable dental professionals to

restore their patients’ dental function and

overall oral health

What drives us – our core beliefs

Reliability is our trademark

We deliver peace of mind Our customers

and patients trust us for consistent quality

and service excellence

Simplicity is our strength

In an increasingly complex world, we

seek solutions that make life simpler for

customers and patients

Customers are our inspiration

We are dedicated to the success of all our

customers We always seek to understand their perspective and to deliver what we promise

People are our successOur success depends on skilled, caring, trustworthy, and diverse individuals who work as a team and share our passion for innovative solutions and service excellence

Achieving more is our future

We strive relentlessly for better solutions and to create value for our stakeholders

We must always believe in our ability to achieve more

Why dental professionals trust in our products

Straumann has won the confidence

of its customers with this promise: a strong foundation of scientific and clinical evidence supporting the specialization, reliability, and simplicity that define every Straumann solution With more than 3,000 published peer-reviewed studies, along with what has been learned in more than 50 years of research in various scientific fields, Straumann products have demonstrated their long-term effectiveness through research studies following good clinical practice This reliability made the Straumann® Dental Implant System one of the most widely used systems in the world with more than 9 million implants sold

Straumann’s 30-year relationship with the International Team for Implantology (ITI®) unites more than 11,000 dental professionals from all fields of implant dentistry and dental tissue regeneration

Straumann has won the confidence of its customers with this promise: a strong foundation of scientific and clinical evidence supporting the specialization, reliability, and simplicity that define every Straumann solution.

CORPORATE PROFILE

An independent academic association,

ITI actively promotes networking and

exchange among its members at meetings,

courses, and congresses with the objective

of improving treatment methods and

outcomes for the benefit of their patients

Our tradition of innovation

The number of innovations Straumann

has produced continues to grow, from

the SLA® implant surface in 1998 to the

hydrophilic SLActive® implant surface in

2006, the Roxolid® material in 2009 to a

new generation of small diameter implant

– the Narrow Neck CrossFit® – in 2012

Beginning April 2013, Straumann makes

Roxolid available in all implant diameters

with the introduction of Roxolid® for All –

Straumann strength, simplified Roxolid for

All with the new Loxim™ transfer piece is

designed to provide you with confidence

in all cases through the advanced material

and surface combination with the flexibility

of more treatment options and efficient

implant placement through simplified

handling

Straumann’s dedication to innovation

provides clinicians the products they need

to meet the clinicial demands in daily

practice

The Straumann® Dental Implant

System – surgical and restorative

solutions

What does simplicity mean? One

system One kit A variety of indications

Straumann offers a complete line of both

Soft Tissue Level and Bone Level implants

for maximum flexibility and efficiency with

SLA and SLActive surface technologies

designed for treatment predictability and

your choice of titanium grade 4 or Roxolid

material, which is designed to provide more

confidence when placing small diameter

implants

With characteristics such as double

roughness treatment for greater implant contact, the SLA implant surface

bone-to-is designed to allow loading in just 6 weeks after implant placement in healthy patients with sufficient bone quality and quantity The SLActive surface takes the topography of the SLA surface to the next level Through its surface chemistry, it is designed to deliver faster osseointegration1

to enhance confidence in all treatments, reduce healing times from 6-8 weeks to 3-4 weeks,2 and increase predictability in stability-critical treatment protocols

The Roxolid material enabled the design of the Narrow Neck CrossFit Implant Roxolid – the first Titanium Zirconium alloy developed specifically for the needs of dental implantology

— features higher tensile3 and fatigue4strengths and osseointegration when compared to Straumann SLActive titanium implants5 The CrossFit Connection is designed to provide a secure and precise fit between the Straumann implant and authentic Straumann abutments

This year, Roxolid for All offers you the advanced material of Roxolid and the surface technology of SLActive combined with simplified handling with the development of the Loxim transfer piece

Loxim is pre-mounted to the implant, self-retained and designed for clockwise and counter-clockwise rotations with one-step implant insertion The additional treatment options offered by Roxolid for All may result in a less invasive procedure

or fewer procedures, helping to increase the acceptance of implant treatment to patients

Excellent restorative outcomes – authenticity

As the company that pioneered single-stage tissue-level implants, Straumann has a strong track record

in, and vision for, dental implantology

Precision is the hallmark

of the Straumann product portfolio

From Bone Control Design® to the implant-abutment connections, Straumann products are manufactured to exacting specifications

Look-alike implant and abutment systems attempt to copy the original manufacturer’s design, but cannot give assurance of equal precision or material quality Compromises, such as a poor connection between the implant and abutment, can lead to complications

When it comes to long-term stability and excellent restorative outcomes, providing genuine Straumann components from our complete prosthetic portfolio is important

Now you can eliminate all doubt with the Straumann Online Verification Tool and NEW Laser Etched Titanium Abutments that enable you to confirm that you have purchased and received an original Straumann component.* Straumann Implants Straumann Abutments

Straumann Authenticity

Straumann regeneration solutions

Straumann offers a complete portfolio of oral tissue regeneration solutions for various treatment situations Some of the most exciting research and development within the dental market is being conducted on regeneration, showing the body’s potential

to rebuild lost structures Straumann is on the forefront of this research with the use

of the polyethylene glycol (PEG) technology

in dental applications and more expansive research on enamel matrix derivative (EMD)

With over 400 scientifically supported clinical publications, including results over

10 years, Straumann® Emdogain™ is a protein-based gel designed to promote predictable regeneration of lost periodontal hard and soft tissue, helping to save and stabilize teeth Clinicians have learned that treating gingival recession cases may be

an important strategy in practice growth, and the use of Emdogain6 may decrease

tooth sensitivity to hot and cold, support

the regeneration of lost bone and tissue,7

and boost confidence by providing a more

natural-looking appearance.8 Emdogain

was recently featured on Lifetime TV’s The

Balancing Act as a treatment of choice to

fight the effects of gum disease

Straumann® Bone Graft Solutions

provide a choice of quality products

designed to support the regeneration of

the patient’s own vital bone Straumann®

AlloGraft is processed with LifeNet

Health®‘s proprietary and patented

Allowash XG® technology, designed to

remove and inactivate viruses and bacteria

with a Sterility Assurance Level (SAL) of

10-6, and maintain the biomechanical and/

or biochemical properties of the tissue

Straumann delivers several AlloGraft

products, each designed to meet a specific

clinical and patient need

Straumann® MembraGel®, an

advanced technology hydrogel membrane

used in treatment with Guided Bone

Regeneration (GBR), is a precise, simple

and quick application – a next generation

membrane With its gel-like consistency

and its formation in situ, MembraGel is

adaptable to various types and sizes of

bone defects and can be precisely applied

to the surgical site MembraGel is designed

to function as a barrier to prevent ingrowth

of soft tissue into the defect region

and stabilize the underlying bone graft

material, confining it to the site of bone

augmentation Straumann MembraGel

was launched in conjunction with a

well-received, specialized education program

that includes hands-on product trainings

and covers all aspects of the application

On the cutting edge of digital

dentistry

What will shape the future of dentistry?

Digitalization Straumann’s complete

digital package is designed for seamless

connectivity to simplify workflows and

offer interdisciplinary care amongst the

treatment team

Straumann® CARES® Digital Solutions

delivers a full prosthetic digital workflow

across guided surgery, intraoral scanning,

and CADCAM technology that is reliable,

precise, and dedicated to the needs of

clinicians and laboratory technicians

Straumann® CARES® digital

solutions

Guided Surgery offers a clear view of

patient bone structure, nerve position,

RefeRences

*Straumann recommends that you use only original Straumann prosthetic components to restore Straumann implants.

1 Compared to SLA ® in an animal model.

titanium-Clin Imp Dent Relat Res 2012;14(4);538-545.

6 In combination with coronally advanced flap.

7 McGuire MK, Nunn M Evaluation of human recession defects treated with coronally advanced flaps and either enamel matrix derivative or connective tissue Part 2: histologic

evaluation J Periodontol 2003;74:1126-1135.

8 McGuire MK, Nunn M Evaluation of human recession defects treated with coronally advanced flaps and either enamel matrix derivative or connective tissue Part 1:

comparison of clinical parameters J Periodontol

on computerized 3D treatment planning software, is designed to offer the surgeon more predictable outcomes and more accurate financial estimates for the patient

Guided Surgery and 3D treatment planning has expanded the ability to communicate with referrals and patients This can lead

to improved case acceptance and practice growth

Straumann® CARES® CADCAM is

an integrated prosthetic design system, including a state-of-the-art scanner, software, and a leading material offering an applications range Through alliances with industry leaders such as Ivoclar Vivadent

AG®, 3M ESPE, and VITA, Straumann offers high-performance ceramic materials for first-class esthetic restorations From customized abutments to screw-retained bar and bridge solutions, applications are available for a multitude of patient situations

Intraoral scanning can replace conventional impression taking and enables the lab to digitally design CADCAM crowns, bridges, or customized abutment restorations without the need for

a stone model Straumann’s goal is to help you reduce time to the final restoration, eliminate manual processes, and decrease remakes via a CADCAM production process by employing a digital workflow

Simply Doing MoreSM

Straumann is not only a commercial partner for premium products Even more importantly, we strive to help you grow your practice From a wide range of patient education materials to practice growth tools that are developed based on your needs, we will work with you every day

to differentiate your practice When you work with Straumann, you have a network

of dental professionals who are by your side every day We are committed to your success – and the esthetic results your patients demand

Today Tomorrow Together

Straumann invites you to grow with us

We are working on multiple initiatives that will help shape the future of dentistry Dedication to research has allowed Straumann to deliver meaningful innovations that help clinicians improve

the quality of care and life for patients.9Straumann values the longstanding trust

of customers, working with clinicians

to help grow their practices through a variety of channels From comprehensive continuing education courses designed to deliver the latest technologies and clinically relevant scientific information for surgical and restorative clinicians, office staff, and dental labs to customer loyalty programs, Straumann stands behind more than just their products – Straumann stands behind their customers

With a full pipeline of innovative technologies, products, services, and solutions to address the changing trends in dentistry, clinicians should want to choose Straumann as their commercial partner of choice At Straumann, the future is today

This information was provided by Straumann.

IP

Dental Implant ComplICatIons:

Providing SolutionS for your Practice

friday, May 17, 2013 ■ the Westin St francis ■ San francisco, ca

Mark your calendars! Back by popular demand, this year’s event

will take place friday, May 17, 2013 in San francisco, ca our

group of seven speakers will come together at the Westin St francis

to provide you information from their experiences on this topic that

is coming to the forefront of the dental world.

“Your program was terrific! The speakers were knowledgeable and their material

was outstanding! You even arranged great weather! Please let me know when I

can sign up for next year’s program.”

–Dr Kenneth R Levine

Location:

The Westin St Francis

335 Powell StreetSan Francisco, CA 94102

agenda:

7:00am – 8:00am Registration8:00am – 5:00pm Program5:00pm – 6:00pm Cocktail Reception

speakers:

Sang-Choon Cho, DDSStuart J Froum, DDSRonald E Jung, DMD, PhDDean Morton, BDS, MS Kirk L Pasquinelli, DDSPaul S Rosen, DMD, MS Ray C Williams, DMD

Visit http://straumann.cvent.com/dic2013 to learn more and register

*$20 off cannot be combined with other available discounts

Please see website for complete program details and pricing.

discount code “ImplantUS”

“Course was amazing Engaging speakers and was able to apply things I learned

the next day I was in my office! As a restorative dentist who works in the same office

as my surgical team, I have always enjoyed learning the surgical end so that it can

enhance my ability to communicate the complete treatment to patients during case

presentations.”

–Dr Jay Freedman

Straumann would like to thank the following sponsors:

What is peri-implantitis – and how does it differ from periodontitis?

Peri-implantitis is a disease affecting the tissues around a dental implant, whereas periodontitis is a disease affecting the tissues surrounding a natural tooth They share a lot of common clinical features

in terms of pocket formation, bleeding upon probing, inflammation, and bone loss However, at a recent consensus conference of the European Federation

of Periodontology (EFP), it has been shown that despite similarities in terms

of clinical features and etiology between peri-implantitis and periodontitis, critical histopathological differences exist between the lesions created by these diseases

How can dentists diagnose it?

It is usually by a combined clinical and radiographic diagnosis During clinical examination, pockets and bleeding upon probing might be seen In this case, a radiographic evaluation is needed – you can compare the bone loss in association with the clinical signs that have occurred during the intervals between X-rays

It is recommended by the EFP that in order to establish baseline, a radiograph should be taken to determine alveolar bone loss after physiologic remodeling has been completed In the same report,

it is suggested that time of prosthesis installation is the point to establish baseline criteria

Should it be treated differently than periodontitis?

There is usually a two-step procedure: a nonsurgical treatment initially, and finally a surgical treatment

While it has been shown that nonsurgical treatment might be adequate

to treat the clinical symptoms for implant mucositis, this is often not the case with peri-implantitis Furthermore, today we are not in a position to claim that

peri-we have a predictable surgical approach that will eliminate or resolve the disease

Unfortunately, there are studies indicating that even after a surgical procedure, a number of peri-implantitis cases continue

to progress with the loss of implant as a result

Nevertheless, there are two surgical

approaches: the resective and the regenerative approach

The resective approach aims to eliminate the pockets around the implants and expose the contaminated implant surface, in order for the patient to perform oral hygiene procedures and control the plaque formation

The regenerative approach, when the defect configuration allows it, leads

to bone regeneration around the implant (with a significant variability, if any, of

Uncovering peri-implantitis

Dr Nikos Donos talks about the growing importance of peri-implant disease and explains how the latest research is shaping treatment

Figure 1: Simulated canal injected with ink

Nikos Donos, DDS, MS, FHEA, FRCSEng PhD, has held the positions of Head and Chair

of Periodontology, as well as the Director

of Research, and Chair of Department of Clinical Research, and Director of Eastman Clinical Investigation Centre, UCL-Eastman Dental Institute in London, England.

reosseointegration) through the use of

membranes and bone grafts, according

to the treatment principle of guided bone

regeneration

Again, there is no long-term data

discussing/evaluating the efficacy of these

two surgical approaches

It is important to add that we often

need to use antibiotics for both surgical

and nonsurgical techniques

Is peri-implantitis a growing

problem?

Peri-implant disease could well become a

bigger issue in the future, given that many

patients wish to be treated with dental

implants As they become more accessible

to more people, there is the possibility that

we’ll see more cases of peri-implantitis in

the future But there is also the possibility

that dentists are becoming more aware of

the disease and case selection, whereas

peri-implantitis was not previously thought

of as a common problem

Does it only affect those with a previous diagnosis of periodonti- tis?

There is a significant amount of literature indicating that patients with periodontitis are definitely more susceptible to developing biologic complications (peri-implantitis)

The important element in these cases is appropriate case selection by the dentist;

the complete resolution of the periodontal disease by the specialist in periodontics

prior to the placement of implants; and, at the end, the regular maintenance of these patients There is a lot of discussion about identifying these susceptible patients, but unfortunately, there is still no easy way

to define who, within the compromised population, will be more susceptible to further complications than others

periodontally-Can improperly managing the soft tissues lead to implant failure?

Soft tissue management is a very important element to consider within implant treatment

But when we discuss implant failure,

we are usually talking about the complete loss of the implant

Therefore, as far as complete failure, I

do not think that solely managing the soft tissues in a non-optimal manner will always lead directly to failure However, if we talk about failure in terms of making cosmetic compromises, then this can, of course, result directly from improper management

“When we discuss implant failure, we are usually talking about the complete loss of the implant.”

CERTIFIED PRE-OWNED CONE BEAM

Call 888.246.5611 or visit renewdigital.com.

Claffey N, Clarke E, Polyzois I, Renvert S

Surgical treatment of peri-implantitis J Clin

Periodontol 2008;35(suppl):316-332.

Dereka X, Mardas N, Chin S, Petrie A, Donos N

A systematic review on the association between genetic predisposition and dental implant

biological complications Clin Oral Implants Res

dilemma Periodontol 2000 2012;59(1):89-110.

Donos N, Mardas N, Buser D An outline of competencies and the appropriate postgraduate

educational pathways in implant dentistry Eur J

Dent Educ 2009;13(suppl 1):45-54

Lang NP, Berglundh T Periimplant diseases: where are we now? Consensus of the Seventh

European Workshop on Periodontology J Clin

of the soft tissues

The dentist needs to be very well

trained in managing the soft tissues

because the esthetic demands these days

are very high – patients being treated with

dental implants often expect to have the

same smiles as “the models in the implant

brochures.” There is a very high level of

expectation in this field on the part of

patients

Is this a mistake inexperienced

implant dentists are more likely to

make?

I think that any inexperienced dentist in any

type of dental discipline is more likely to

make mistakes, but experienced dentists

can make mistakes, too As with all

disciplines, it’s important to have the right

training for the safety of your patients

Is peri-implantitis only an issue for

dentists treating complex cases?

All dentists who do implant dentistry – but

also those who do not – should be mindful

of peri-implantitis, and be able to advise

their patients on how to avoid it Treatment

of peri-implantitis, though, is a condition

that forms part of the official curriculum for

the specialty of periodontology, and it is regarded as a complex level of treatment

The ADEE (Association for Dental Education

in Europe) held a workshop in Prague in

2008 that decided the treatment of implantitis is a major competency where

peri-a significperi-ant level of trperi-aining is required (specialist level)

What does the future hold for implant dentistry?

I think that an understanding of implantitis and periodontitis will become very important in the future

peri-A significant number of dental implants will continue to be placed on a global level, and the data so far shows that a proportion

of these patients will present biologic complications with their implants, and they will require treatment with predictable outcomes The demand for very good esthetic results, and the fact that patients wish to have faster treatments, will, most probably, lead to further exciting research

in terms of implant surfaces I also think

we will see exciting developments in the restorative components, too, where new materials will appear that allow better esthetics and better resistance to fracture

Address the implant complexities you face everday with

3 EASY WAYS TO SUBSCRIBE

VISIT www.implantpracticeus.com

EMAIL kmurphy@medmarkaz.com

CALL 1.866.579.9496

$99 1 year

$239 3 years

Lowest Payments Help Patients Say YES

Our Extended Plan “The Other Guy’s” 12-Month Case Size LOWEST Payment Lowest Payment (@ 14.9%)** No-Interest Payment

You’re saving smiles.

They’ll smile at the savings!

No-Interest * Plans PLUS Extended Plans as low as 3.99% *

Let’s Talk!

800-630-1663

Learn more at hellospringstone.com

* For plan details, please visit springstoneplan.com ** Based on publicly available as of 2/7/13

It is commonly known that cone beam

computed tomography (CBCT) and

computed tomography (CT) guided surgery

can improve the placement of implants, with

great precision and accuracy Technologies

such as cone beam scanning, 3D imaging

software, and surgical guides can achieve

a level of precision that up until recent years

was unheard of

When planned and executed well,

the use of CT guided surgery improves

comfort in treatment, lowers the volume of

local anesthetic required, reduces surgical

trauma, and cuts down on chair time for

the patient But while the potential for

complication decreases and higher levels

of precision are achieved, there are certain

risks associated with surgical guidance

that remain These risks are related to the

tactile feedback we sacrifice when relying

on such technology

Earning experience

To successfully place a dental implant

using CT guided surgery, a strong

knowledge of the anatomy is critical But

as more and more dental surgeons are

using guided surgery, many (especially

those new to implants) are foregoing the

vital foundation of experience gained

through manual or conventional implant

procedures Consequently, the anatomical

knowledge and experience gained through

such procedures may be missing

CT guided surgery has relieved the

surgeon of making many decisions that

are commonly experienced in conventional

placement during surgery However

without this experience, the risk relating

to anatomical hazards can increase and therefore precision can be compromised – potentially leading to iatrogenic damage or implant failure

In actual fact, the use of guided surgery requires the same skills, experience, and anatomical knowledge as manual placement, to ensure any potential risks are recognized and avoided

For example, if during the osteotomy protocol a higher or lower level of resistance occurs while drilling the bone, previous experience of manual implant placement will alert you to the unpredicted resistance, indicating bone density or alignment issues Conversely, little prior experience of conventional surgical placement may leave this warning sign unheeded

be supported with experience to achieve the precision the technology is capable of

Mucosa-supported guides are often misconstrued as the easiest to use, but they can be the least accurate in terms

of positioning If a guide is positioned, but there is a slight misalignment in the initial stages, or the guide is moved from its original position, this could potentially make the implant’s proximity to adjacent nerves, teeth, or blood vessels a hazard Additional tissue pressure on seating the guide may also result in implants being placed more deeply than planned The use

of a tissue punch approach during guided surgery may also lead to the permanent loss of useful or critical attached mucosa, potentially compromising the final outcome

Bone-supported guides are very stable, and therefore accurate, but require

a much larger flap to be raised than may otherwise be desirable, with the inherent consequences of increased trauma and risks

When using a guide, the surgeon is compelled to follow the path of the drilling sleeves, without being able to visually verify the accuracy of the guide, which can also obscure the view of the implant position This may mean that errors such as

Guided surgery – understanding the risks

Dr Peter Sanders explains the importance of gaining experience in conventional implant placement prior to using CT guided surgery

Figure 1: Planning in SimPlant

Dr Peter Sanders is the clinical director and

lead implant dentist at Dental Confidence

He was recently awarded the Fellowship of

the Faculty of General Dental Practice by the

Royal College of Surgeons (RCS) in London

and regularly attends implant conferences and training

events across the globe

Dr Sanders is also responsible for delivery of the

FGDP(UK) Implant Diploma program at Leeds Dental

School and examining at the Royal College of Surgeons

of England.

For more information visit www.dentalconfidence.com.

©2012 Zimmer Dental Inc All rights reserved * Data on file with Zimmer Dental

Please check with a Zimmer Dental representative for availability and additional information.

www.zimmerdental.com

to view a special bone ingrowth animation and

request a Trabecular Metal Technology demo.

I am the Zimmer® Trabecular Metal™ Dental Implant, the first dental implant

to offer a mid-section with up to 80% porosity—designed to enable bone INGROWTH as well as bone

ONGROWTH Through osseoincorporation, I harness the tried-and-true technology of Trabecular Metal

Material, used by Zimmer for over fifteen years in orthopedics My material adds a high volume of

ingrowth designed to enhance secondary stability and I am Zimmer.

Artistic Rendering

Figures 2A-2D: Screenshots showing the planning stages This ensures that not only are the implants placed in the ideal position from surgical and prosthetic perspectives, but also that the abutment angles and collar heights can be preselected

Figures 3A-3B: Stereolithographic drill guides with metal collars to control drill angle and depth

Figures 4A-4C: Bone level drill guide in position and in use Figure 5: Pre-selected abutments aligned

as planned

control over the depth of the drilling may

be more difficult to assess as visual access

is impaired In such cases, conventional

implant experience is critical

A lack of knowledge may lead one to

accept a misaligned guide position that

an experienced surgeon (with a history

of manual implant placement) would

recognize as incorrect

Stereolithographic surgical guides can

improve accuracy and precision, but they

can sometimes present certain limitations

For example, a guide may only be used

when there is sufficient ridge width This

means that some conservative techniques

such as ridge expansion, ridge splitting, or

bone condensing are not possible

Guided surgery is also incompatible

with techniques such as internal sinus lifts

and deep implant placements Without the

experience of manually placing implants, a

good knowledge of these techniques may

not have been acquired If primary stability

is an issue, a surgeon may need to be

able to improvise using such techniques, if

treatment is to be successful

Hot under the collar

Overheating is also a risk Inadequate cooling from irrigation of the surgical area can cause necrosis of the bone, leading

to implant failure By using a guide, the likelihood of overheating the bone can often be increased

Most systems use external irrigation, whereby coolant saline is used to reduce the temperature of the external area of the drill, but with this, there is an increased risk

of the bur and bone overheating

The most effective way of cooling the drill is through internal irrigation, where the possibility of overheating is significantly reduced The alternative is to continually remove the drill completely in order to cool it, but this will lead to a less accurate osteotomy, as the hole gets larger and less precise with each reinsertion

Without a background of conventional methods of placement, a surgeon increases his/her chances of overheating

bone as his/her frame of reference – in terms of understanding when irrigation has not been effective is limited

Acknowledging experience

Overall, CT guidance can greatly enhance precision and accuracy, but in order to eliminate possibilities of risk, hazards, or potential failure, first-hand experience of manual implant procedure should always

be gained prior to its use

While the advances of technology should be embraced, it is important that

we do not forget the value of first-hand knowledge and experience

Using CT/CBCT guided surgery is often perceived as the “easier” way to place implants, which in many cases may be true However, as with any form of surgery,

it is vital to have a thorough understanding

of all of the potential risks and hazards so they can be both recognized and avoided before damage or failure occurs IP

now available in two versions

The art of flexible fields of view

Let’s redefine experTise

Workflow integration | Humanized technology | diagnostic excellence

Call 800.944.6365 or visit www.carestreamdental.com/cs9300ip

© Carestream Health, inc 2013

8697 Pe Ad 0213

the Cs 9300 extraoral imaging system combines outstanding image quality, low dose exposure and high flexibility through selectable fields of view in one compact and versatile solution now with every angle, you get a better, more accurate view of your patients’ dental anatomy, allowing you to diagnose with confidence and ease

• 5 x 5 to 17 x 13.5 cm fields of view—

including a new 10 x 10 cm for the Cs 9300 select

• Panoramic, 3d and optional cephalometric imaging

As the evolution of dental implant therapy

in terms of technology and technique

marches on, still one of the greatest

challenges remains — the achieving of

predictable esthetic results The implant

practitioner must have a strong grasp

conceptually, surgically, and prosthetically

to deliver not only what patients want,

but what they expect in the esthetic zone

As a specialist, barriers to an esthetically

pleasing result should be identified and

related to the patient and the restoring

dentist When they are explained before

they occur, they are a warning; when

explained after they occur, they become

an excuse

The focus of this article is the

avoidance of a frustrating complication, the

open gingival embrasure, also referred to as

the black triangle Preventive interventions

for the black triangle should be considered

(1) preoperatively, (2) surgically, and (3)

postoperative prosthetically (Figure 1)

1 Preoperative

assessment/interven-tions:

Always when planning on implantation in

the esthetic zone, gingival biotype should

be identified before continuing further

Patients with a thin biotype often have long

narrow maxillary central incisors This type

of gingival support is more susceptible

to recession and open embrasures

When a thin biotyped patient requiring a

tooth extraction and implant placement

is identified, there should be meticulous

Preventing the dreaded black triangle during implant

placement in the esthetic zone: part 1

Dr Scott M Blyer examines ways to avoid a frustrating complication of dental implant therapy

Dr Blyer is a dual-degree, double

board-certified oral and maxillofacial surgeon with

offices in Islandia and New York City He

has teaching positions in multiple hospitals,

authored textbook chapters and books,

written numerous research papers, and lectured around

the globe He is a reviewer for two well-respected

medical publications, and his resume reflects numerous

awards in leadership, research, patient care, and

compassion He was voted one of America’s 80 top

oral and maxillofacial surgeons by his peers in 2010 He

is a certified speaker for Straumann ® Dental Implants.

Educational aims and objectives

This article aims to identify preventative interventions for the black triangle preoperatively, surgically, and postoperative prosthetically.

Expected outcomes

Correctly answering the questions on page 26, worth 2 hours of CE, will demonstrate the reader can:

• Identify the importance of gingival biotypes when planning implantation in the esthetic zone.

• Learn about surgical considerations such as flap design, supporting bone, angulation, and mesio-distal relationships

• Realize the various aspects of prosthetic planning such as platform switching, contact points, temporization, tooth shape, and final crown position.

Figure 1: To avoid creating an open gingival embrasure during implant placement and restoration, many consid-erations must be in place from before one starts until final restoration

attention to performing an “atraumatic extraction.” Considering a hard and/

or soft tissue graft and a 3- to 6-month consolidation period should be considered prior to implant placement.1

Patients with a thicker biotype typically have short and wide central incisors.2 They have thicker osseous structure with thick and wide papilla These thicker biotype patients have less recession, better vasculature to the papilla, and better tissue resilience

If a tooth with poor gingival support is planned for an extraction and implant placement, this tooth can be orthodontically extruded over a period of 4

weeks The extrusion should be parallel to the long axis of the tooth to advance the buccal and interdental bone supporting the papilla coronally (Figures 2A and 2B) This should be considered in those areas with an apically positioned gingival margin, and flat gingival scallop.3 A 2 mm coronal overcorrection is ideal anticipating some recession over time.4 Cochran, et al., (2002) reported that soft-tissue changes (e.g., recession) of approximately 1

mm take place in the first year after the restorative therapy is performed on a one-stage implant.5 Anticipating this with overcorrection is ideal

CONTINUING EDUCATION

2 Surgical considerations:

Fabricating a surgical guide prior to implant

placement can help determine the need for

site development and help assist proper

angulation and positioning of an implant in

the esthetic zone

A) Flap design: Numerous interdental

papilla-preserving incisions have been

described Most of these incisions restrict

the vertical release component in the

papilla area (Figure 3) Restricting flap

elevation can minimize the amount of bone

resorption,6 thus helping in the preservation

of the interdental papilla Different variations

of techniques for papilla preservation have

been described, most of them emphasizing

limiting the vertical releasing incisions in the

papillary area.7

B) Supporting bone: To quote Dr

D Garber, “Soft tissue is the issue, but bone sets the tone.” Bone loss around an implant will increase the distance from the contact point to the bone, resulting in an inadequate papilla For a two-piece implant, changes occur after placement of the abutment Biological width is reestablished

as 1.5 to 2 mm of bone resorption occurs circumferentially If proper spacing were not respected, the resultant interproximal bone resorption will not support the papilla, and it will be evident in papilla loss

Bone resorption along the gingival margins has been most pronounced when the facial thickness was less than 1.4 mm, while the possibility of bone gain has been seen at a 2 mm thickness This is why the authors concluded that 2 mm is a critical thickness for the integrity of facial plate

after stage 2.8

C) Angulation: Proper angulation

of implant placement will preserve supporting gingival tissue around the implant This angulation should resemble the angulation of the long access of the adjacent teeth In the maxilla, a slight palatal inclination can help preserve thin buccal bone.2

bone-D) Buccolingual position is critical for

a proper esthetic result (Figure 1) This can best be estimated on a model The center

of the implant should be 4 mm from an imaginary line connecting the incisal edges

of adjacent teeth The buccal aspect of the implant should touch that imaginary incisal edge line There are times when slight variations of this can be favored (Figure 4)

E) Mesio-distal relationship: Implants

Figure 2B: Orthodontic extrusion (after)

Figure 3: Papilla-sparing incision

Figure 2A: Orthodontic extrusion (before)

To quote Dr D Garber, “Soft tissue is the

issue, but bone sets the tone.” Bone loss

around an implant will increase the distance

from the contact point to the bone, resulting

in an inadequate papilla.

should be placed no closer than 1.5 mm

to a natural tooth Two adjacent implants

should be placed no closer than 3 mm.9

F) Apically: The implant should be

placed 3 to 5 mm below the gingival margin

of the adjacent teeth10 (Figure 5)

3 Prosthetic planning

A) Platform switching: Platform

switching is another technique employed

to preserve crestal bone height around the

implant which helps support the papilla

At the implant abutment interface, also

referred to as the microgap, 1.2 to 1.3 mm

of horizontal and vertical bone loss can be

anticipated Platform switching has been

a proven method for minimizing or even

eliminating this unwanted loss11 (Figure 6)

B) Contact point: Tarnow, et al.,12

examined the existence of interdental

papillae in humans, and this study has

been duplicated multiple times since.13

The authors found that when the distance from the contact point to the alveolar bone was less or equal to 5 mm, the papilla was present 98% of the time, while at 6

mm, it dropped to 56%, and at 7 mm it was only present 27% of the time between natural teeth and implants In two adjacent implants, the distance between contact point to alveolar bone was <3.5 mm to maintain papilla formation9 (Figure 7)

The mean papilla length for an tooth relationship was found to be 6.5 mm; for an implant-implant relationship, the mean papilla length was 4.5 mm.14

implant-In another study, the papilla length was determined to be 3.4 mm between adjacent implants.15

The importance of the alveolar bone

to contact point distance is of colossal importance in maintaining or creating proper interdental papilla formation

C) Temporization: The provisional

restoration placed in the edentulous space will also impact the gingival architecture

If a pontic should be placed, it should be ovoid and not overbulked on the facial The pontic should extend initially 2.5 mm below the free gingival margin This will allow the pontic to be situated within 1

mm of the facial and interproximal bone and will give support to the surrounding facial gingiva and the interdental papilla After a 4-week healing period, the height

of the pontic should be adjusted to extend approximately 1.5 mm below the tissue.16 If

a removable appliance should be placed, it should lay passive and not impinge on the tissues

Placement of a provisional restoration

at the time of stage 2 can also reshape the interdental papilla tissue favorably When possible, a provisional restoration is helpful

in prosthetically guiding the soft tissue into its final position for a 4- to 6-week period.17

Figure 5: Implant placement should be 3 to 5 mm apical

to the gingival margin of adjacent teeth

Figure 4: The center of the implant should be 4 mm from

an imaginary line drawn from the incisal edges of the adjacent teeth

Figure 6: The platform matched side (A) of the implant shows an abutment with the same diameter implant This implant/abutment interface will result in bone loss around the microgap The platform switched side (B) shows a smaller diameter abutment which shifts the microgap medially, preserving crestal bone attachment and papilla support

1 Park J, Tai K, Morris J, Modrin D Clinical

considerations of open gingival embrasures In:

Buduneli N, ed Pathogenesis and treatment of

periodontitis New York, NY: InTech; 2012:113-126.

2 Al-Sabbagh M Implants in the esthetic zone Dent

Clin North Am 2006;50(3):391-407, vi.

3 Sclar AG Esthetic implant complications:

Prevention and management J Oral Maxillofac Surg

2006;64(suppl 9):4-5.

4 Brindis MA, Block MS Orthodontic tooth extrusion

to enhance soft tissue implant esthetics J Oral

Maxillofac Surg 2009;67(suppl 11):49-59.

5 Cochran DL, Buser D, ten Bruggenkate CM,

Weingart D, Taylor TM, Bernard JP, Peters F, Simpson

JP The use of reduced healing times on ITI implants

with a sandblasted and acid-etched (SLA) surface:

early results from clinical trials on ITI SLA implants Clin

Oral Implants Res 2002;13(2):144–153.

6 Wilderman MN, Pennel BM, King K, Barron JM

Histogenesis of repair following osseous surgery J

Periodontol 1970;41(10):551–565.

7 Nemcovsky CE, Artzi Z, Moses O, Gelernter I

Healing of dehiscence defects at delayed-immediate

implant sites primarily closed by a rotated palatal flap

following extraction Int J Oral Maxillofac Implants

2000;15(4):550–558.

8 Spray JR, Black CG, Morris HF, Ochi S The influence of bone thickness on facial marginal bone response: stage 1 placement through stage 2

uncovering Ann Periodontol 2000;5(1):119-128.

9 Tarnow D, Elian N, Fletcher P, Froum S, Magner

A, Cho SC, Salama M, Salama H, Garber DA Vertical distance from the crest of bone to the height of the

interproximal papilla between adjacent implants J

Periodontol 2003;74(12):1785-1788.

10 Park J, Tai K, Morris J, Modrin D Clinical considerations of open gingival embrasures In:

Buduneli N, ed Pathogenesis and treatment of

periodontitis New York, NY: InTech; 2012:113-126.

11 Gardner DM Platform switching as a means

to achieving implant esthetics N Y State Dent J

radiographic evaluation of the papilla level adjacent

to single-tooth dental implants A retrospective

study in the maxillary anterior region J Periodontol

2001;72(10):1364–1371.

14 Salama H, Salama MA, Garber D, Adar P The interproximal height of bone: a guidepost to predictable aesthetic strategies and soft tissue contours in anterior

tooth replacement Pract Periodontics Aesthet Dent

1998;10(9):1131-1142.

15 Hartmann R, Müller F Clinical studies on the appearance of natural anterior teeth in young and old adults Gerodontology 2004;21(1):10-16

16 Spear, FM Maintenance of the interdental papilla

following anterior tooth removal Pract Periodontics

Aesthet Dent 1999;11(1):21-28, 30.

17 Rocci A, Martignoni M, Gottlow J Immediate loading in the maxilla using flapless surgery, implants placed in predetermined positions, and prefabricated provisional restorations: a retrospective 3-year clinical

study Clin Implant Dent Relat Res 2003;5(suppl

1):29-36.

18 Kois JC Predictable single tooth peri-implant

esthetics: five diagnostic keys Compend Contin Educ

Dent 2001;22(3):199-206, 208.

The shape and contours of this provisional will have a tremendous impact on the final position of the soft tissue Excessive contouring on the facial aspect will cause the free gingival margin to migrate apically

Adding interproximal contour will help create an ideal papillary shape

D) Tooth shape: When the tooth shape is considered, square-shaped teeth may have a more favorable esthetic outcome than ovoid or triangular-shaped teeth because of a longer interproximal contact and implicitly a less amount of papilla to fill in the space.18

E) Final crown position: The final crown should be centered no farther than

Figure 7: Mesio-distal spacing of implants in

relationship to natural teeth and adjacent implants to

maintain the interdental papilla The contact point

be-tween alveolar bone and crown is also demonstrated

half of the abutment radius from the center

of the implant This will prevent thin buccal bone recession

Having too much tissue is like having too much money It is usually a good problem to have When placing implants

in the marginally tissued individual, one must properly plan and respect the biological ecosystems that have been well established Having a surgical guide

on hand can quicken surgical time and improve surgical results in the esthetic zone Fighter pilots will always map out their coordinates before aiming at their targets, and implant surgeons should do the same

Having too much tissue is like having too much money It is usually a good problem to have When placing implants in the marginally tissued individual, one must properly plan and respect the biological ecosystems that have been well established.

1 Preventive interventions for the black

triangle should be considered _

a preoperatively

b surgically

c postoperative prosthetically

d all of the above

2 Always when planning on implantation in

the esthetic zone, _should be identified

before continuing further

a gingival biotype

b flap design

c flap elevation

d bone support

3 Patients with a thin biotype often have

maxillary central incisors

b better vasculature to the papilla

c better tissue resilience

d all of the above

6 If a tooth with poor gingival support

is planned for an extraction and implant placement, this tooth can be orthodontically extruded for a period of _ weeks

a Restorative therapy

b Bone loss

c Overcorrection

d Vertical releasing incisions

9 At the implant abutment interface, also referred to as , 1.2-1.3 mm of horizontal and vertical bone loss can be anticipated

a the minigap

b the microgap

c the gingival scallop

d the micro triangle

10 The final crown should be centered no farther than _of the abutment radius from the center of the implant

Each article is equivalent to two CE credits Available only to paid subscribers Free

subscriptions do not qualify for the CE credits Subscribe and receive up to 16 CE

credits for only $99 To receive credit, complete the 10-question test by circling

the correct answer, then either:

n Post the completed questionnaire to:

Implant Practice US CE

15720 N Greenway-Hayden Loop #9

Scottsdale, AZ 85260

n Fax to (480) 629-4002

To provide feedback on this article and CE, please email us at education@implantpracticeus.com

Legal disclaimer: The CE provider uses reasonable care in selecting and providing accurate content The CE

provider, however, does not independently verify the content or materials Any opinions expressed in the

ma-terials are those of the author and not the CE provider The instructional mama-terials are intended to supplement,

but are not a substitute for, the knowledge, skills, expertise and judgement of a trained healthcare professional.

Full Name AGD REGISTRATION NUMBER LICENSE NUMBER

ADDRESS CITY, STATE, AND ZIP CODE EMAIL

TELEPHONE/FAX

REF: IP V6.2 BLYER

Please allow 28 days for the issue of the certificates to be posted

CONTINUING EDUCATION BROUGHT TO YOU BY

Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by

a state or provincial board of dentistry or AGD endorsement 12/1/2012 to 11/30/2016 Provider ID# 325231

The PREVAIL ® Implant System

Please contact us at 561.776.6700 or visit us online at www.biomet3i.com to learn more.

† Aforementioned have financial relationships with BIOMET 3i LLC resulting from speaking engagements, consulting engagements and other retained services.

The key to achieving long-term sustainable aesthetic outcomes

is preservation of hard and soft tissues The PREVAIL Implant System’s unique features are designed for preservation.

Implants designed for primary stability with

two well-researched surface options for

bone apposition

Optimized aesthetics with as little as

0.37mm of bone recession1

Higher seal strength as compared

to the competitive average2,3

Seal integrity test was performed by BIOMET 3i on December

2011 Testing was done under testing standard ISO 14801

Five (5) BIOMET 3i PREVAIL Implant Systems and five (5) of

three (3) competitors’ implant systems were tested Bench test

results are not necessarily indicative of clinical performance.

1 Östman PO †, Wennerberg A, Albrektsson T Immediate occlusal loading of NanoTite Prevail Implants: A prospective 1-year clinical and radiographic study Clin Implant

Dent Relat Res 2010 Mar;12(1):39–47

2 Baumgarten H † , Meltzer A † Improving outcomes while employing accelerated treatment protocols within the aesthetic zone: From single tooth to full arch restorations

Presented at the Academy of Osseointegration, 27th Annual Meeting; March 2012; Phoenix, AZ

3 Suttin Z † , Towse R † , Cruz J † A novel method for assessing implant-abutment connection seal robustness Poster Presentation 188: Academy Of Osseointegration, 27th

Annual Meeting: 2012 March 1–3; Phoenix, Arizona http://biomet3i.com/Pdf/Posters/Poster_Seal%20Study_ZS_AO2012_no%20logo.pdf Testing done by BIOMET 3i,

Palm Beach Gardens, FL; n = 20.

4 Byrne D, Jacobs S, O’Connell B, Houston F, Claffey N Preloads generated with repeated tightening in three types of screws used in dental implant assemblies

J Prosthodont 2006 May–Jun;15(3):164-71

5 Boitel N, Andreoni C, Grunder U † , Naef R, Meyenberg, K † A three year prospective, multicenter, randomized-controlled study evaluating platform-switching for the

preservation of peri-implant bone levels Poster presentation P83: Academy of Osseointegration, 26th Annual Meeting: 2011 March 3–5; Washington DC.

6 Lin A, Wang CJ, Kelly J, Gubbi P, Nishimura I The role of titanium implant surface modification with hydroxyapatite nanoparticles in progressive early bone-implant

fixation in vivo Int J Oral Maxillofac Implants 2009 Sep–Oct;24(5):808–816.

7 Zetterqvist et al A prospective, multicenter, randomized controlled 5-year study of hybrid and fully etched implants for the incidence of peri-implantitis J Periodontol

April, 2010.

8 Östman PO † , Wennerberg A, Ekestubbe A, et al Immediate occlusal loading of NanoTite™ Tapered Implants: A prospective 1-year clinical and radiographic study

Clin Implant Dent Relat Res 2012 Jan 17 [Epub ahead of print]

9 Block MS † Placement of implants into fresh molar sites: Results of 35 cases J Oral Maxillofac Surg 2011 Jan;69(1):170-4

PREVAIL is a registered trademark of BIOMET 3i LLC Preservation By Design and Providing Solutions - One Patient At A Time are trademarks of BIOMET 3i LLC ©2013 BIOMET 3i LLC.

Achieving esthetics with implant

restorations is significantly more

challenging than with conventional

restorations Diagnosis and appropriate

treatment planning are critical in obtaining a

successful outcome Many manufacturers

will identify their systems as esthetic —

from an objective perspective, components

in and of themselves are not esthetic

There is not a single component available

that would be the ideal replacement

for a maxillary central incisor Esthetic

outcomes are based on many variables It

is not the specific implant design, surface

characteristics, or type of abutment that

will guarantee an esthetic result It is the

time spent on data collection in reaching

a correct diagnosis that pays dividends in

terms of function and esthetics (Sullivan,

2001)

Root form cylindrical implants placed

following surgical techniques described

by Branemark, et al., have proven to

be a predictable method for anchoring

replacement teeth to the jaw bone

(Branemark, et al., 1990; Naert, et al.,

1992) Today, clinicians can prescribe

the use of implants with the knowledge

and confidence that they will predictably

integrate into the jawbone The successful

integration of an implant, however, is not

sufficient to declare success; implants

placed in poor restorative positions result

in unesthetic restorations that provide little

satisfaction for the clinician or the patient

Figures 1-3 demonstrate the complexity

of implant use in esthetic zones and the

Treatment planning of implants in the esthetic zone: part 1

In the first part of a series of articles, Drs Sajid Jivraj, Mamaly Reshad, and Winston Chee look at the

diagnostic factors that affect the predictability of peri-implant esthetics

Sajid Jivraj, DDS, MSEd, is clinical associate professor

at Herman Ostrow USC School of Dentistry in Los

Angeles, California He is a board member of the British

Academy of Restorative Dentistry and honorary clinical

teacher at Eastman Dental Institute London, England

He owns a private practice in Ventura, California.

Mamaly Reshad, BDS, MSc, is honorary clinical teacher

at Eastman Dental Institute London, England He works

in private practice at 30a Wimpole Street, London.

Winston WL Chee, DDS, FACP, is Ralph and Jean

Bleak professor of restorative dentistry, director of

implant dentistry at the School of Dentistry, University

of Southern California in Los Angeles, California,

co-director of the advanced prosthodontics program and

Herman Ostrow USC School of Dentistry.

Educational aims and objectives

The aim of this article is to discuss the fundamental considerations of treatment planning implants in the esthetic zone

Expected outcomes

Correctly answering the questions on page 32, worth 2 hours of CE, will demonstrate the reader can:

• Learn the factors that affect predictability.

• See the aspects that affect the esthetics of the final outcome.

• Understand the major indications for dental implant treatment.

Figure 1: Laboratory photograph of implant in poor tion angled labially

posi-importance of proper treatment planning prior to implant placement

Providing an esthetic outcome requires understanding of the objective and subjective criteria related to hard and soft tissue esthetics (Belser, 1982) Both dental and gingival esthetics act together to provide a smile with harmony and balance

The clinician must be aware of parameters related to gingival morphology, form and dimension, characterization, surface texture, and color (Magne, Belser, 2002) [Figure 4]

Ceramists can often produce restorations to match adjacent teeth in terms of color However, if the surrounding tissues are not reconstructed, an esthetic outcome is not likely (Figures 5A and

5B) The ultimate aim is for the implant restoration to harmonize into the frame of the smile, face and, more importantly, the individual

Treatment planning must address hard and soft tissue deficiencies and combine this with precision in implant placement; only with this approach can implant restorations be indistinguishable from the adjacent teeth (Figure 6)

Recreating what nature provided can

be a formidable challenge The physiology

of wound healing after tooth extraction creates an unfavorable soft tissue complex The remaining mucosa often recedes palatally and apically Often this results in

a restoration that appears long, and this is compounded by the absence of interdental

Figure 2: Smile view of restoration fabricated for implant

in Figure 1

Figure 3: Labial view of restoration for implant on Figure

1 Pink ceramics used to disguise poor implant position

CONTINUING EDUCATION

papilla (Figure 7)

The predictability of the esthetic

outcome of an implant restoration is

dependent on many variables including,

but not limited to:

1 Patient selection and smile line

2 Tooth position

3 Root position of the adjacent teeth

4 Biotype of the periodontium and tooth

shape

5 The bony anatomy of the implant site

6 The position of the implant

Patient selection and smile line

Patients who are candidates for

replacement of an anterior tooth with

an implant-supported restoration must

understand its benefits They must also

understand the additional length of time

required for treatment and additional costs

that will be incurred The clinician must

also understand the patient’s desires In

most cases, the patient’s primary demand

is an esthetic tooth replacement With

this in mind, it is important to establish

sound clinical concepts with clearly

defined parameters that lead to successful esthetics with long-term stability of the peri-implant tissues

The major indication for a single tooth implant restoration is preservation (nonpreparation) of one or more of the adjacent teeth (Figure 8), and reduction in the rate of alveolar resorption Additional indications would be restoration of a missing tooth to maintain a diastema and preservation of extensive fixed restorations that are intact

A patient’s esthetic expectations must also be evaluated together with his/her lip activity and lip length In an average smile, 75-100% of the maxillary incisors and the interproximal gingiva are displayed In a high smile line, additional gingival tissue

is exposed Less than 75% of the incisors are exposed in a low smile line (Figures 9-11) [Tjan, Miller, The, 1984] The clinician should be aware that the patient who presents with unacceptable tooth health, shade, or position may not give a full smile when asked Previous photographs may aid in determining the natural position of

the patient’s lip when smiling

A high smile line poses considerable challenges when planning for implant-supported restorations in the esthetic zone because the restoration and gingival tissues are completely displayed In these types of clinical situations, maximal efforts towards maintaining peri-implant tissue support throughout the planning, provisional, surgical, and restorative phases will be required

The low smile line is a less critical situation because the implant restoration interface will be hidden behind the upper lip However, this cannot be assumed, and the patient’s input must be sought to confirm this

Tooth position

The tooth needs to be evaluated in three planes of space: apicocoronal, faciolingual, and mesiodistal The existing tooth position will significantly influence the presenting gingival architecture In many instances, teeth with a poor prognosis are thoughtlessly extracted These teeth can

Figure 4: Restoration of implants must satisfy objective

and subjective esthetic criteria There should be sufficient

interradicular space for placement of the implant

and sufficient intertooth distance for fabrication of an

esthetically pleasing restoration

Figure 5A: Implants in lateral incisor position placed too buccally Note how position of implant affects position of gingival margin

Figure 5B: Cemented implant restorations placed on custom abutments Note asymmetrical gingival margins

Figure 6: Implant restoration on right lateral incisor in

harmony with the existing hard and soft tissue Figure 7: Wound healing following extraction of a tooth can result in apical and palatal migration of the interdental

papilla

Figure 8: A perfect indication for a dental implant is preparation of the adjacent teeth

non-Figure 9: Low smile line Figure 10: Average smile line Figure 11: High smile line The color and contour of the

restorations and associated hard and soft tissues become very visible to the observer

significantly influence both the hard and

soft tissue configuration

Apico-coronal

On assessment of the apico-coronal

position of the tooth, it may be more

apical, more coronal, or ideal, and mimic

the level of the adjacent gingival margin

(Figure 12) Numerous authors have shown

that following extraction and insertion of an

ovate pontic, there is likely to be up to 2 mm

of gingival recession, and on extraction and

placement of an implant immediately the

migration of the gingival margin is likely to

approximate 1 mm (Kois, 1998; Saadoun,

et al., 1999)

The implication of this is that if there is a

hopeless tooth positioned ideally or apically,

and this is extracted, the gingival margin is

likely to migrate apically Restoratively, long

clinical crowns, pink porcelain, or visible

metal margins will compromise the esthetic

outcome These teeth can benefit from

orthodontic extrusion (Figure 13) prior to

extraction, which will serve to position the

gingival level at a more harmonious level

(Kois, 2004; Salama, Salama, Kelly, 1996)

Faciolingual

In this dimension, the tooth position may

present with different concerns The tooth

may be positioned too far facially; this often

results in very thin or nonexistent labial

bone These teeth are not good candidates

for orthodontic extrusion because of

inadequate underlying bone Extraction

of these teeth results in significant vertical bone loss and collapse of the gingival architecture This type of situation would benefit from bone augmentation procedures prior to implant placement

A tooth positioned more lingually would benefit from the presence of an increased amount of facial bone This situation is more favorable prior to extraction since the resultant discrepancy in the facial free gingival margin may be minimal (Kois, 2004)

Mesiodistal

The proximity of the adjacent teeth necessary to provide proximal support and volume of interdental papillae should

be evaluated Ideally, the mesiodistal tooth width should be equal to that of the contra lateral tooth so that an esthetic outcome can be achieved (Figures 14 and 15) Excess or deficiencies in this dimension should be addressed through the use of orthodontics, enameloplasty, or restorations For patients with diastemas, it

is imperative that the decision to maintain

or close the space be made prior to implant placement If the patient refuses the above options to close the space and insists on closing the space with the implant restoration, there is a likelihood that

a black triangle may ensue This results from inadequate support from the adjacent tooth to maintain the papilla It is important that the clinician discusses this with the patient ahead of time so disappointment

Figure 12: The right lateral incisor has

been treatment planned for an implant

restoration The level of the soft tissues

mimic that of the contra lateral tooth

Figure 13: Immediate extraction of the right lateral incisor would result in apical migration of the soft tissue Orthodontic extrusion will allow the clinician to position the tissue more coronally so that on extraction there is a margin of error

Figure 14: The mesiodistal width of the tooth requiring replacement must equal that of the contra lateral tooth

Figure 15: Implant restoration replacing the right central incisor

Figure 16: Excessive mesiodistal space in

the region of the tooth requiring an implant

restoration

Figure 17: Implant restoration in the region

of the right central incisor Note absence of interdental papilla as a result of inadequate support of the soft tissue by the restoration

with the final outcome is avoided (Figures

18 and 19 desired implant restorations

to replace congenitally missing maxillary lateral incisors, orthodontic therapy would

be necessary to move the roots of the cuspid and central incisor to allow room for ideal implant placement

Teeth with root proximity also possess very little interproximal bone, and this thin bone creates a greater risk of lateral resorption, which will decrease the vertical bone height after extraction or implant placement When teeth are present, the use

of orthodontics serves as a valuable adjunct

to create space This can be advantageous for support of proximal gingival architecture (Tarnow, Cho, Wallace, 2000; Tarnow, Magner, Fletcher, 1992)

Biotype of periodontium and tooth shape

The position of the gingival tissue around

a tooth is determined by the connective tissue attachment and by the bone level Two different periodontal biotypes have been described in relation to the

Figure 18: Clinical presentation of patient with congenitally missing maxillary lateral incisors post orthodontic treatment

Figure 19: Radiograph of patient in Figure

18 revealing that there is insufficient inter radicular space for implants

Belser UC Esthetic checklist for the fixed prosthesis Part II: Biscuit bake try-in In: Schärer

P,Rinn LA, Kopp FR, eds Esthetic guidelines for

restorative dentistry Chicago, IL: Quintessence;

1982:188-192.

Becker W, Ochsenbein C, Tibbetts L, Becker BE

Alveolar bone anatomic profiles as measured

from dry skulls Clinical ramifications J Clin

Periodontol 1997;24(10):727-731.

Adell R, Eriksson B, Lekholm U, Brånemark

PI, Jemt T Long term follow-up study of osseointegrated implants in the treatment of

totally edentulous jaws Int J Oral Maxillofac

Implants 1990;5(4):347-359.

Kois JC Esthetic extraction site development:

The biological variables Contemp Esthet

Restorative Pract 1998;2:10-18.

Kois JC Predictable single tooth peri-implant

esthetics: five diagnostic keys Compend Contin

Educ Dent 2004;25(11):895-896, 898, 900,

906-907.

Magne P, Belser U Natural oral esthetics In:

Bonded porcelain restorations in the anterior dentition: a biomimetic approach Chicago, IL:

Quintessence; 2002:57-99.

Naert I, Quirynen M, van Steenberghe D, Darius P A study of 589 consecutive implants supporting complete fixed prostheses

Part II: Prosthetic aspects J Prosthet Dent

1992;68(6):949-956.

Phillips K, Kois JC Aesthetic peri-implant site

development The restorative connection Dent

Clin North Am 1998;42(1):57-70.

Saadoun AP, LeGall M, Touati B Selection and ideal tridimensional implant position for soft

tissue esthetics Pract Periodontics Aesthet Dent

Sullivan RM Perspectives on esthetics in

implant dentistry Compend Contin Educ Dent

2001;22(8):685-692.

Tarnow DP, Cho SC, Wallace SS The effect

of inter-implant distance on the height of

inter-implant bone crest J Periodontol

2000;71(4):546-549

Tarnow DP, Magner AW, Fletcher P The effect

of the distance from the contact point to the crest of bone on the presence or absence of

the interproximal dental papilla J Periodontol

1992;63(12):995-996

Tjan AH, Miller GD, The JG Some esthetic

factors in a smile J Prosthet Dent

1984;51(1):24-28.

morphology of the interdental papilla

and the osseous architecture — the thin

scalloped periodontium and the thick flat

periodontium (Becker, et al., 1997)

The thin scalloped periodontium,

found in less than 15% of cases, is

characterized by a delicate soft tissue

curtain, a scalloped underlying osseous

form, and often has dehiscences and

fenestrations, and a reduced quantity and

quality of keratinized mucosa Generally,

interproximal tissue does not completely

fill the space between adjacent teeth This

form of gingiva reacts to insults by receding

facially and interproximally As recession

occurs and the interroot bone resorbs, the

subsequent soft tissue loss compromises

the overall esthetic result (Figure 20)

The tooth form in this type exhibits

a contact point towards the incisal third

essentially triangular anatomic crowns

and contact areas of teeth that are small

faciolingually and apico-coronally Due

to extreme taper of the roots, the bone

interproximally tends to be thicker

Characteristics of the soft tissue

biotype will play a prominent role in final

planning for the shoulder position of the

implant A thin biotype with highly scalloped

tissue will require the implant body and

shoulder to be placed more palatal to mask

any titanium show-through When implants

are placed toward the palate, a slightly

deeper placement is required to allow for

proper emergence profile

Combining previous factors in a

patient with a high lip line and a thin biotype

is extremely difficult to treat Patients who

fit into these treatment categories should

be made aware of the challenges involved

in obtaining an esthetic result before

treatment begins

The thick flat periodontal biotype is

characterized by a denser more fibrotic

soft tissue curtain, a flat thicker underlying

osseous form, and an increased quantity

and quality of attached keratinized gingiva

This tissue often reacts to insults by pocket

formation Flat gingiva is associated with a tooth form that is more bulbous; contact areas are located more toward the middle third of the tooth primarily square anatomic crowns and contact areas that are wide faciolingually and apico-coronally (Figure 21)

The tooth morphology appears to

be correlated with the soft tissue quality

The triangular tooth shape is associated with the scalloped and thin periodontium

The contact area is located in the coronal third of the crown, underlining a long and thin papilla The square anatomic crown shape combines with a thick and flat periodontium The contact area is located

at the middle third, supporting a short and wide papilla

Loss of interproximal tissue in the presence of a triangular tooth form will display a wider black triangle than in a situation when a square tooth is present (Figure 21) In some cases when the adjacent teeth are to be restored, the crown form can be modified prosthetically to compensate for partial interproximal tooth loss The contact area of the prosthetic tooth is positioned more cervically, reducing the volume of the interdental space

The presenting tooth shape will also influence the implant restoration shape

The implant restoration should mimic its contra lateral natural tooth coronal to the free gingival margin (Figure 22) However, apical to the free gingival margin, the implant restoration will not be an anatomic replica A delicate balance must be developed that provides adequate support

of the gingival architecture, yet does not provide excessive pressure Ideally, the facial contour should be slightly flatter than the contra lateral natural tooth to minimize apical displacement of the free gingival margin after insertion (Figure 23) [Phillips, Kois, 1998]

Parts of this article were reprinted with permission from the British Dental Journal

Figure 21: Biotype 2 periodontium, not thick and flat tissues Implant provisional restoration in the position of left central incisor

Figure 22: Loss of interproximal soft tissue

in the presence of a triangular tooth form can result in unsightly black triangles

Figure 23: Over contour of the implant restoration as it emerges from the free gingival margin can result in apical migration of the soft tissuesFigure 20: Biotype 1 periodontium, note

thin and scalloped tissue