Rodriguez and RosenstielIn recent years the frequency of and esthetic demand for implant restorations in the esthetic zone has increased. Recent literature has revealed numerous consistent trends which may aid the clinician in achieving predictable esthet- ics. Maintaining generous facial bone by judicious placement as well as by using implants with diameters of less than 4 mm appears to be beneficial. Avoiding adjacent implants in the esthetic zone while maintaining an implant to tooth distance of between 2 mm and 4 mm seems to aid in bone and soft tissue maintenance. Abutment connections in which the abutment is narrower than the implant offer distinct advantages, most notably increased bone heights. Also, provisional restoration, especially early in treatment provides long-term esthetic benefits. (J Prosthet Dent 2012;108:259-267) Esthetic considerations related to bone and sof t tissue maintenan ce and development aroun d dental implants: Report of the C ommit tee on Researc h in Fixed Prosthodo ntics of the American Academy of Fixed Prosthodontics Arthur M. Rodriguez, DMD, MS aand Stephen F . Rosenstiel BDS, MSD b University of Pittsburgh School of Dental Medicine and Veterans Affairs Medical Center , Pittsburgh, Pa; The Ohio Stat e Univer sity, College of Dentistry, Columbus, Ohio a Staff Prosthodontist and Assistant Program Dir ector , Veterans Affairs Medical Center; and Assistant Professor , Depar tment of Prosthodontics, University of Pittsburgh School of D ental Medicine. b Professor Emeritus, Division of Restorative and Prosthetic Dentistry, The Ohio State Universit y. Implant-retained restoration in the esthetic zone have long been difficult for reasons which are well document- ed in the literature and anecdotally acknowledged by many clinicians. 1-4 Most prevalent among these are a lack of facial bone and inadequate interproximal tissue. However, the es- thetic demands of clinicians as well as the expectations of patients continue to grow along with advances in com- ponent design and clinical technique. The following discussion summarizes relevant current literature in an at- tempt to establish evidence-based guidelines for esthetic implant resto- rations. Bone availability and maintenance Inadequate facial bone is a com- mon problem that can present itself at any time following extraction and often leads to a more lingual implant placement and an anterior ridge lap restoration. 5 In an attempt to avoid this situation, osseous grafting or regeneration techniques are used. 6,7 However, these can be both time consuming and unpredictable. Even when an implant can be placed, a thin plate of facial bone is often all that re- mains, leading to thread exposure or unpredictable future tissue height. 8 Huynh et al 9 found the average max- illary anterior bony wall thicknesses following maxillary anterior extrac- tion to be approximately 0.8 mm with 87% less than 1 mm. Recent trends by clinicians to use wider diameter implants (4 mm or greater) have also contributed to inadequate facial bone thickness or facial tissue recession. 10 Recession often occurs following the initiation of the restorative phase as thin attached tissue supported by inadequate bone cannot withstand the stress created by restorative con- tours. The theoretical advantage of wider diameter implants is not well supported in the literature. A finite element analysis by Petrie et al 11 did show a decrease in crestal bone strain as implant diameter and length in- creased while modeling a 20 mm mandibula r sec tion. However, clinical data demonstrating the advantages of wide diameter implants are scarce. In fact clinical studies showed similar or somewhat lower success rates for wider diameter implants 12-15 Degidi et al 15 showed a 99.4% success rate for 510 narrow diameter implants (<3.75 mm) over 8 years, with some evidence of increased success for implants wider than 3.4 mm. A clinical study of 182 3.3-mm-diameter implants in severely resorbed maxillae revealed a survival rate of 99.4%. 16 Zinsli et al 17 reported a 98.7% 5-year survival rate for 298 of the same reduced diameter implants, over a 10-year period. In this study the implants were restored with a variety of restorations, includ- ing single teeth, fixed prostheses, and overdentures. It has also been suggested that the amount of remaining facial or lingual bone following osteotomy is critical for implant success 1 (Fig. 1). Even af- ter implant placement in fresh extrac-
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8/18/2019 Esthetic Considerations Related to Bone and Soft Tissue
http://slidepdf.com/reader/full/esthetic-considerations-related-to-bone-and-soft-tissue 1/9Rodriguez and Rosenstiel
In recent years the frequency of and esthetic demand for implant restorations in the esthetic zone has increased.Recent literature has revealed numerous consistent trends which may aid the clinician in achieving predictable esthet-ics. Maintaining generous facial bone by judicious placement as well as by using implants with diameters of less than4 mm appears to be beneficial. Avoiding adjacent implants in the esthetic zone while maintaining an implant to toothdistance of between 2 mm and 4 mm seems to aid in bone and soft tissue maintenance. Abutment connections inwhich the abutment is narrower than the implant offer distinct advantages, most notably increased bone heights.Also, provisional restoration, especially early in treatment provides long-term esthetic benefits. (J Prosthet Dent2012;108:259-267)
Esthetic considerations related to bone and
soft tissue maintenance and development
around dental implants: Report of the
Committee on Research in Fixed Prosthodontics
of the American Academy of Fixed Prosthodontics
Arthur M. Rodriguez, DMD, MSa and Stephen F. Rosenstiel
BDS, MSDb University of Pittsburgh School of Dental Medicine and VeteransAffairs Medical Center, Pittsburgh, Pa; The Ohio State University,College of Dentistry, Columbus, Ohio
aStaff Prosthodontist and Assistant Program Director, Veterans Affairs Medical Center; and Assistant Professor, Department ofProsthodontics, University of Pittsburgh School of Dental Medicine.bProfessor Emeritus, Division of Restorative and Prosthetic Dentistry, The Ohio State University.
Implant-retained restoration in the
esthetic zone have long been difficult
for reasons which are well document-
ed in the literature and anecdotally
acknowledged by many clinicians.1-4
Most prevalent among these are a
lack of facial bone and inadequate
interproximal tissue. However, the es-
thetic demands of clinicians as well as
the expectations of patients continue
to grow along with advances in com-
ponent design and clinical technique.
The following discussion summarizes
relevant current literature in an at-
tempt to establish evidence-based
guidelines for esthetic implant resto-
rations.
Bone availability and maintenance
Inadequate facial bone is a com-
mon problem that can present itself
at any time following extraction and
often leads to a more lingual implant
placement and an anterior ridge lap
restoration.5 In an attempt to avoid
this situation, osseous grafting or
regeneration techniques are used.6,7
However, these can be both time
consuming and unpredictable. Even
when an implant can be placed, a thin
plate of facial bone is often all that re-
mains, leading to thread exposure or
unpredictable future tissue height.8
Huynh et al9 found the average max-
illary anterior bony wall thicknesses
following maxillary anterior extrac-
tion to be approximately 0.8 mm with
87% less than 1 mm. Recent trends
by clinicians to use wider diameter
implants (4 mm or greater) have also
contributed to inadequate facial bone
thickness or facial tissue recession.10
Recession often occurs following the
initiation of the restorative phase as
thin attached tissue supported byinadequate bone cannot withstand
the stress created by restorative con-
tours. The theoretical advantage of
wider diameter implants is not well
supported in the literature. A finite
element analysis by Petrie et al11 did
show a decrease in crestal bone strain
as implant diameter and length in-
creased while modeling a 20 mm
mandibular section. However, clinical
data demonstrating the advantages
of wide diameter implants are scarce.
In fact clinical studies showed similar
or somewhat lower success rates for
wider diameter implants12-15 Degidi et
al15 showed a 99.4% success rate for
510 narrow diameter implants (<3.75
mm) over 8 years, with some evidence
of increased success for implants
wider than 3.4 mm. A clinical study
of 182 3.3-mm-diameter implants in
severely resorbed maxillae revealed a
survival rate of 99.4%.16 Zinsli et al17
reported a 98.7% 5-year survival rate
for 298 of the same reduced diameter
implants, over a 10-year period. In
this study the implants were restoredwith a variety of restorations, includ-
ing single teeth, fixed prostheses, and
overdentures.
It has also been suggested that the
amount of remaining facial or lingual
bone following osteotomy is critical
for implant success1 (Fig. 1). Even af-
ter implant placement in fresh extrac-
8/18/2019 Esthetic Considerations Related to Bone and Soft Tissue
The Journal of Prosthetic Dentistry Rodriguez and Rosenstiel
volving implants placed immediately
into extraction sites, Canullo et al63,64
showed generally less bone loss than
previously described in the literature
after a mean follow-up of 22 months.
Also they noted significantly less buc-
cal tissue recession and greater papil-
la height in an experimental platform
switched group than in a nonplat-
form switched group. The treatment
protocol for both groups included
immediate provisional restoration
and placement of the definitive res-
toration 2 months following implant
placement. Vela-Nebot et al77 also
reported dramatically less bone loss
when using implant systems incorpo-
rating a narrower diameter of restor-
ative components relative to implant
diameter. A comprehensive literature
review of 10 studies and 1239 im-
plants by Atieh et al67 showed strong
evidence of less bone loss around the
platform switched implants, although
there was no difference in overall im-plant survival. The authors also noted
that a more favorable bone response
was seen when the platform switch
was 0.4 mm or greater. Wagenberg
and Froum68 followed 94 platform
switched connections over 11 years
and found that approximately 75%
showed no radiographic bone loss
with 88% displaying 0.8 mm or less
bone loss. Conversely a 2 year study
by Crespi et al,78 which compared ex-ternal hexagon regular platform im-
plants to platform switched implants
placed in fresh extraction sites andimmediately loaded, showed no dif-
ference in bone loss.
In an attempt to mimic platform
switching, some implant manufac-
tures offer implant designs in which the
coronal portion of the implant flares
to accommodate an abutment that is
roughly the same diameter as the im-
plant body but narrower than the flared
neck.54 Using this concept, it has been
stated that a residual ridge width of at
least 6.3 mm is necessary to accommo-
date the flared design.79 For example,
Cocchetto et al80 followed 15 implants
with a 5.8 mm diameter receiving a 4.1
mm abutment healing cap and showed
an average bone loss of only 0.3 mm
at 18 months. However, this study re-
quired a minimum bone width of 8
mm for inclusion. Because bone width
of this dimension is exceptional in the
esthetic zone, this design may have lim-
ited application. Neck diameters of thisdimension will most likely necessitate
removal of the same critical coronal
bone that the clinician is trying to pre-
serve. Also the resulting distance from
the implant to the adjacent tooth will
be minimal at best, preventing the es-
tablishment of a desirable interproximal
distance. Therefore, given the above, a
parallel walled implant of standard or
slightly narrow diameter with reduced
diameter restorative componentsseems preferable.
A distinct advantage of the im-
plant/abutment diameter difference
is the ability to place the implant
subcrestally, encouraging bone and
soft tissue at the superior edge of the
implant circumference to remain and
even grow to or over the edge of the
implant and remain there undisturbed
by restorative components.59,60,81,82
Novaes et al59,60 found this to be true,
while noting greater papilla fill and
less bone loss for subcrestal place-
ment than for crestal placement in
2 dog studies of platform switched
implants. They also concluded that
the presence of a microgap did not
adversely affect tissue health. Weng
et al81 compared a platform switched,
Morse taper design placed subcrest-
ally to an external hexagon design. They demonstrated bony overgrowth
only in the former. Veis et al82 com-
pared 193 regular platform implants
to 89 platform switched implants
and found that the platform switched
design resulted in less bone loss only
when placed subcrestally. Conversely,
Cochran et al83 found slightly more
bone loss for platform switched im-
plants placed 1 mm subcrestally than
for those placed crestally or 1 mm su-
pracrestally.
Tenenbaum et al84 showed a great-
er number and greater length of con-
nective tissue fibers around implants
which incorporated a nonflared neck
with reduced diameter abutments
than other designs. Attached tissue
thickness of greater than 2 mm has
been associated with a decreased ten-
dency for buccal bone loss and tissue
recession around platform switched
implants.85- 87 This effect was even moredramatic when implants were placed
supracrestally. Interestingly, when the
mucosa was considered thin (less than
2 mm), the authors found no advan-
tage with regard to bone level for the
platform switched design.88 Subcrestal
placement leads to other esthetic
advantages. The distance from the
top of the implant to the emergence
of the restoration is maximized, al-
lowing adequate vertical length forthe development of anatomic con-
3 Platform switched implant-abutment connection. Notenarrower diameter of abutment relative to implant allowingbone to remain undisturbed throughout restorative phase.
8/18/2019 Esthetic Considerations Related to Bone and Soft Tissue
The Journal of Prosthetic Dentistry Rodriguez and Rosenstiel
also concluded that less interproximal
bone loss occurs as interimplant dis-
tance increases, while recommending a
minimum of 3 mm, lending further sup-
port to their earlier mentioned recom-
mendation of using standard to narrow
diameter implants in the esthetic zone.
Garber et al105 have recommended in
order to maintain interproximal boneheight and the accompanying papilla,
that the implant should be placed at
least 1.5 mm from adjacent teeth and
3 mm from adjacent implants. Traini et
al106 also recommend a minimum of 3
mm interimplant distance to provide
optimum alveolar bone health. They
observed a more desirable orienta-
tion of collagen fibers and significantly
increased marrow spaces for interim-
plant distances of 3 mm in a histologi-cal dog study of 48 implants, sacrificed
24 months after implant placement. In
a similar follow-up study, they observed
that an interimplant distance of 3 mm
allowed for an increase in the develop-
ment of blood vessels.107
While it is difficult to isolate clini-
cal variables scientifically, the litera-
ture seems to indicate that the risk
to interproximal bone increases for
tooth-to-implant distances less than
3 mm.108 Conversely, in a 5-year study
of interproximal bone changes be-
tween implants, Chang et al109 found
that interimplant distance played a
minor role in final bone levels and
that the coronal height of bone to
implant contact was a better predic-
tor. Lee et al110 found that both inter-
implant distance and bone to implant
contact level had minimal effect on
papilla height and that the width of
keratinized tissue exerted a greaterinfluence. However, the literature is
fairly consistent in showing that the
maintenance of proximal bone height
and associated papilla height seems
to be more difficult between adjacent
implants than in the tooth-implant
situation.111-113 In a retrospective study
evaluating previously mentioned vari-
ables, Kourkouta et al112 followed 35
implants in 15 participants and found
bone crest and papilla heights to be4.6 mm and 2 mm lower, respectively,
for the implant-implant clinical situa-
tion than for the tooth-implant situ-
ation. They also found only 1 mm of
missing papilla height when the inter-
implant distance was 3 mm and that
immediate provisional restoration
reduced papilla loss from 2 mm to
1 mm. It is also noteworthy that, in
this study, 87.5% of participants werepleased with their esthetic result even
with a papilla height discrepancy of 2
mm. Because most of these changes
have been found to occur within the
first 6 months following placement, the
advantages of early and long term pro-
visional restoration seem clear. Tarnow
et al113 also recommended caution,
while reporting mean papillary tissue
heights of only 3.4 mm for 136 adja-
cent implant sites in 33 participants. While 3 to 4 mm appears to be the
ideal interimplant distance, the use of
a platform switched design may allow
more bone and soft tissue maintenance
for enhanced esthetics, effectively in-
creasing the interabutment distances
for implants in close proximity 65,105 In a
study of 41 pairs of platform switched
implants in 37 participants, Rodri-
guez-Ciurana et al65 demonstrated
bone maintenance to be an average of
2.4 mm above the implant/abutment
interface at interimplant distances
less than 3 mm. As stated previously,
Novaes et al59,60 also found improved
papilla fill for subcrestally placed plat-
form switched implants than for those
placed crestally. However, the papilla
height was not influenced by interim-
plant distance, which varied from 1
to 3 mm.59,60 In addition to his previ-
ously mentioned recommendation of
a 3 mm distance from implant to ad- jacent gingival margin zeniths, Priest 61
similarly recommended 3 mm of in-
terimplant distance as well as orient-
ing the center of the implant 3 mm
palatal to the future facial restorative
margin. Therefore, because of the es-
thetic challenges detailed above, the
placement of adjacent implants in the
esthetic zone should be avoided when-
ever possible.114
SUMMARY
A review of the current literature
suggests that the use of standard to
narrow diameter implants, a plat-
form switched design, and early pro-
visional restoration should be con-
sidered when long term esthetics are
paramount. Also, maintaining inter-implant and tooth-to-implant dis-
tances of approximately 3 mm is desir-
able with regard to crestal bone main-
tenance and papilla development.
Subcrestal placement may afford ad-
equate space to develop restorative
contours from the top of the implant
to restoration emergence while avoid-
ing facial thread exposure. This may
be even more effective in combina-
tion with a platform switched design.In addition, abutment to implant
connections, which are extremely in-
timate and allow little to no relative
movement, seem to offer distinct ad-
vantages with regard to tissue health.
Lastly, the use of noncustomizable
abutments and abutment level restor-
ative techniques provides for ease of
provisional restoration and treatment
sequencing while avoiding multiple
exposures of the implant/abutment
junction, although the biological ad-
vantages this may offer have yet to be
investigated.
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Corresponding author:Dr Arthur M. Rodriguez1834 Liberty Way