Volume 6/Issue 2/2010 195 194 Forum Implantologicum

Use of dental implants in the esthetic zone is well docu-

mented in the literature
1
. The SAC classication system
classifies tooth replacement in the esthetic zone as an
advanced or complex process
2
. This means that the patients
esthetic demands, lip mobility, periodontal health, and
implant system design can all play a critical role in creating
an excellent restorative outcome. The focus of this article
will be to introduce criteria for utilization of soft-tissue
level and bone-level implants in the esthetic zone as single
tooth replacement.
Focus on the Clinic:
Bone and Tissue Level Implant
Esthetics, the Case for Each
Frank Lozano
Frank E. Lozano Jr.
DMD, MS is a clinical
faculty member at
the University of Florida
in the Department
of Oral and Maxillofacial
Surgery and teaches
in the Center for Implant
Dentistry. He joined the faculty in 2008 and also
maintains a full time private practice in Gainesville, FL.
Dr. Lozano is a board eligible member of the American
College of Prosthodontics and is a Member of the ITI.
The gingival biotype is one patient-specic
factor that can have a signicant impact
on the restorative outcome in the esthetic
zone
1
. Thick at and thin scalloped types
have been dened, with subtypes discussed
in the literature
3, 4
. Papilla must be sup-
ported by bone in any healthy situation,
however the bony response around implants
and teeth must be considered when plan-
ning treatment prior to surgery.
Implant positioning can also inuence
the esthetic outcome with implants. Optimal
implant position in coronal-apico, bucco-
lingual, and mesio-distal dimensions will
impact the result of most esthetic outcomes.
There are relative comfortand danger
zones for implant placement
5
and are
dependent on the site and implant design.
In the esthetic zone, errors in implant body
positioning relative to the danger zones
may result in inferior outcomes. These
danger zones are also inuenced by the
implant design. The coronal-apico depth of
placement of a soft-tissue level Straumann
implant would differ when compared to
a bone-level implant. The design of these
two implants is reported to play a role
in bone response to microgaps. Microgaps
are gaps between the dental implant and
restorative abutment
6
. Interproximal bone
will remodel differently in the presence
of a horizontal offset, as is the case of the
bone level implant
7
.
Soft-tissue level and bone-level implant
designs present different challenges for plan-
ning and restoration in the esthetic zone.
In the presence of thick, highly keratinized
tissue, a shorter transition zone may be
advantageous when prosthetic reconstruc-
tion has begun, but may place a higher
demand on the surgical phase of treatment.
The polished collar of the implant provides
a built-in emergence through tissue for
1.8 mm (Fig. 1). Thin delicate tissue may
lend itself more readily to shaping during
provisionalization, and the additional exibil-
ity with the more apically positioned bone
level design without the polished collar may
prove benecial (Fig. 2). Lack of this polished
collar yields more exibility, however it
requires that more tissue be shaped during
the provisional phase in the transition zone.
Two patient treatments of anterior single-
tooth replacement utilizing two differing
implant designs will be presented and
discussed.
PATIENT #1
A 32-year-old male patient presented with
a root fracture of tooth #21 (#9) on the
palatal aspect with four millimeters of
re cession on that side (Figs 35). The area
was sensitive to occlusion and cold. After
data collection and template fabrication,
the patient was referred back to the perio-
dontist for extraction and immediate place-
ment with a regular neck implant (Strau-
mann

RN SP SLA 4.1 x 12 mm). Clinical

ndings included a non-contributory medical
history, thick, at periodontal tissues, and
a gingival margin on the tooth to be treated
1 mm coronal to the adjacent tooth. Findings
that put the patient in a high esthetic risk
category
8
were the 15-year-old crown with
wide post (greater than 1/3 of MD width
of the root), high esthetic expectations
of treatment, and high lip line at full smile.
Following a periotome extraction of the
tooth and removal of remaining soft tissue
remnants from the socket, increasing
diameter osteotomy drills were utilized
to prepare the site. Restoration-driven
three-dimensional implant placement was
performed mindful of the possible danger
zones. Correct bucco-lingual, mesial-distal,
FOCUS ON THE CLINIC
Fig. 1
Fig. 4
Fig. 2
Fig. 5
Fig. 3
Fig. 6
196 Forum Implantologicum Volume 6/Issue 2/2010 197
FOCUS ON THE CLINIC FOCUS ON THE CLINIC
Fig. 7
Fig. 10
Fig. 8
Fig. 11
Fig. 9
Fig. 12
Fig. 13
Fig. 14 Fig. 15 Fig. 16 Fig. 17
Fig. 18
PATIENT #2
The 55-year-old female patient reported
for pain and loosenessassociated with
tooth #11 (8) (Fig. 14). Peri-apical radiographs
did not show apical pathology, however,
probing revealed 4 mm vertical defects at
the mesial and distal palatal line angles.
The tooth had been endodontically treated
20+ years prior and had a large disto-lingual
composite (Fig. 15). Clinical ndings included
a non-contributory medical history. Findings
which pushed the case into a high esthetic
risk included high smile line, coincident
gingival margin positions, thin scalloped
gingival biotype, vertical bony defects, and
very high esthetic expectations.
Upon referral to the surgeon for extraction,
the fractured tooth crown and root were
removed utilizing a periotome (Fig. 16).
Due to the width of the mid-root and thin
soft tissue, it was decided to use a delayed
approach with a bonded acrylic resin pro-
visional. Eight weeks after extraction,
a bone-level implant was placed utilizing a
surgical template (Straumann

RC SLActive
4.1 x 10 mm). The implant was placed in
a submerged fashion and an essix provisional
was delivered for ease of adjustment and to
keep forces off the soft tissues. The implant
was uncovered at 12 weeks and a bottle-
shaped healing abutment was placed to start
the tissue-maturation phase. Two weeks
after uncovering, a screw-retained provisional
restoration was delivered (Fig. 17). Tissue
maturation progressed quickly and nal im-
pression was made after six weeks (Fig. 18).
A customized impression coping was then
fabricated to capture and record the transi-
tion zone contour generated by the pro-
visional restoration (Fig. 19). Shade photos
were used to communicate accurate color
to the lab. The screw access position allowed
for the use of a one-piece restoration.
A zirconia abutment was fabricated using
the CAD/CAM by Straumann

scanning
design milling service from a cast and full
cutback wax-up. Feldspathic porcelain (Vita
VM9, Brea CA) was added to the abutment
subgingivally to ensure that no zirconia show
through occurred in this patient due to her
and coronal-apico placement were aided
with the use of a surgical template rst
described by Higginbottom et al
9
.
Following a 12-week healing period, the
patient presented for provisionalization
and tissue shaping. Adequate soft tissue
was maintained on the facial aspect of the
beveled healing cap (Fig. 6). The extra tissue
afforded by this cap allowed the creation
of a more pleasing and full soft tissue con-
tour during provisionalization. Proper im-
plant placement allowed optimal sub gingival
contour to be obtained in the provisional.
A synOcta

PEEK provisional abutment

was utilized along with Luxatemp

(DMG,
Hamburg Germany) to create the provi-
sional and sculpt the emergence through
the transition zone. Shade characterization
was accomplished using Orbit Stain

(GC America, Alsip IL) mixed with Palaseal

(Kulzer, Southbend IN) and then light cured
on the provisional (Fig. 7). After eight weeks
of tissue maturation, the nal impression
was then made (Fig. 8). A customized impres-
sion coping was fabricated with an open tray
synOcta

impression coping and owable

composite resin to duplicate the submucosal
contour developed by the provisional
10
. This
procedure allowed the transfer of the precise
tissue shape of the transition zone to the lab
for duplication in the nal restoration. The
denitive abutment selected was a synOcta

1.5 mm with a CAD/CAM zirconia abutment
(CARES, Straumann AG). To ensure that no
zirconia show-through occurred gingivally,
it was decided to add pink feldspathic porce-
lain over the facial portion of the abutment.
Try-in of the abutment was accomplished
and the margins veried before scanning
for coping fabrication (Fig. 9). The porcelain
fused to zirconia crown was fabricated
for cementation on the zirconia abutment
(Fig. 10) and delivered to the patient. He
was very pleased with the esthetic outcome
of the treatment and the tissue response
was excellent at the three-month follow-up
(Figs 1113). The laboratory shade match
and characterization were well executed and
patient home care was adequate to maintain
health throughout the treatment phase.
Fig. 19 Fig. 20
Fig. 21 Fig. 22 Fig. 23
198 Forum Implantologicum Volume 6/Issue 2/2010 199
FOCUS ON THE CLINIC
1. Belser U, Buser D, Higginbottom F. Consensus statements and recommended
clinical procedures regarding esthetics in implant dentistry. Int J Oral Maxillofac
Implants. 2004; 19 Suppl:73- 4.
2. Dawson A, Chen S. The SAC classication in implant dentistry. 2007 Quintessence
Publishing Ltd. Berlin.
3. Kois JC. Predictable single-tooth peri-implant esthetics: ve diagnostic keys.
Comend Contin Educ Dent. 2004 Nov; 25(11): 895-6, 898, 900; quiz 906-7.
4. Cardaropoli D, Re S, Corrente G, Abundo R. Reconstruction of the maxillary
midline papilla following a combined orthodontic-periodontic treatment in adult
periodontal patients. J Clin Periodontol. 2004 Feb; 31(2): 79-84.
5. Buser D, Martin W, Belser UC. Optimizing esthetics for implant restorations
in the anterior maxilla: anatomical and surgical considerations. Int J Oral Maxillofac
Implants. 2004; 19 Suppl: 43- 61.
6. Hermann JS, Schooleld JD, Schenk RK, Buser D, Cochran DL. Inuence
of the size of the microgap on crestal bone changes around titanium implants.
A histometric evaluation of unloaded non-submerged implants in the canine
mandible. J Periodontol 2001 Oct;72(10):1372-83.
7. Cochran DL, Bosshardt DD, Grize L, Higginbottom FL, Jones AA, Jung RE,
Wieland M, Dard M. Bone response to loaded implants with non-matching implant-
abutment diameters in the canine mandible. J Periodontol. 2009 Apr; 80(4):
609-17.
8. Buser D, Belser UC, Wismeijer D. ITI Treatment Guide Vol. 1: Implant treatment
in the esthetic zone Single tooth replacement. 2007. Quintessence Publishing
Co Ltd. Berlin.
9. Higginbottom FL, Wilson TG Jr. Three-dimensional templates for placement
of root-form dental implants: a technical note. Int J Oral Maxillofac Implants.
1996 Nov- Dec; 11(6): 787-93.
10. Hinds, K. Custom impression coping for an exact registration of the healed
tissue in the esthetic implant restoration. Int J Periodontics Restorative Dent.
1997 Dec; 17(6): 584-91.
REFERENCES
KISUAHELI BLINDTEXT
thin soft-tissue biotype. The abutment was
veried for shape and tissue support prior
to stacking of porcelain (Fig. 20). The nal,
one-piece, all-ceramic crown is shown prior
to connection, illustrating the subgingival
contour (Fig. 21). After try-in and color
correction by the lab, the nal crown was
delivered to the patient and tightened to
35 Ncm. The follow-up pictures and delivery
radiograph demonstrate excellent bone re-
tention and good overall esthetic integration
(Figs 22, 23). The patient was very pleased
with the overall outcome.
DISCUSSION
Both soft-tissue level and bone-level im-
plants have been used successfully to treat
partial and complete edentulism. Both
designs have strengths and challenges for
implementation. As highlighted in the
patient treatments presented, proper
planning and implant selection were instru-
mental in achieving esthetically acceptable
outcomes. The soft-tissue level treatment
was for a patient who presented with excess,
thick, keratinized mucosal tissues. During
the tissue-maturation phase of treatment,
the use of an implant with a collar was
a benet. Due to the trumpet-shaped design,
the rst 1.8 mm of transition zone was built
in. In the treatment example using the bone-
level implant, the tissue was much thinner,
and interproximal bone loss more likely. The
deeper placement of the head of the implant
also made it less likely that any gray color
would appear through the tissue. In addition,
in the thinner tissue it would have been
easier if necessary to change the emergence
prole to alter tissue height on the midfacial
aspect because of the longer transition zone.
These advantages and disadvantages must
be weighed and considered when selecting
between soft-tissue level and bone-level
implants in the esthetic zone.
The author would like to thank Dr. Richard
Oliver and Dr. Emma Lewis for their work
during the surgical aspect of the presented
treatments and to Mitchell Jim for his
expertise in the technical fabrication of
the prostheses.
ITI SCHOLARS
A Dental Jackpot in Bern
Vedrana Braut
With todays surfeit of expensive, marketing-driven courses,
it is difcult for young academics to nd an evidence-based
program that is worth the time and effort invested. From that
point of view, the ITI Scholarship program is one of a kind.
Two years ago, I decided to apply for
a research grant at the University of Geneva,
which turned out to be a very rewarding
experience. It was during that time that
I came in contact with the ITI philosophy
when I met Professor Urs Belser and his
team of ITI Scholars. Right from the start, the
research, clinical and educational standards
championed by the ITI came through clearly
and inspired me to apply for a Scholarship
and point my further education in that
direction. Looking back, it was by far one
of my best decisions.
I am very grateful to have been accepted
as an ITI Scholar in the Department of Oral
Surgery and Stomatology at the University
of Bern. At the end of my Scholarship year,
all I can say is that I truly consider it to
be the dental jackpot. My primary interest
in applying for the Scholarship was to get
an overview of prosthetically-driven and
evidence-based implant dentistry. And for
these reasons it seems I couldnt have come
to a better place. The University of Bern
is one of the most prominent centers in
implant dentistry for both clinical practice
and research. The extent of interdisciplinary
knowledge in implant dentistry I managed
to obtain over this relatively short period
of time goes far beyond any postgraduate
education I had got up to that point.
Given my background in prosthodontics,
in my Scholarship year I hoped to expand
my understanding of the principles and
possibilities of implant surgery and loading
protocols for prosthetic implant treatment.
I anticipated some difculties in exploring
the new clinical area that implant surgery
presents for a prosthodontist, but due to the
meticulous way procedures are documented
at the clinic it turned out to be easier than
anticipated to get a comprehensive overview
of surgical treatment options.
I spent most of my time assisting Professor
Daniel Buser in numerous surgeries as well
as case planning sessions. Soon, I was able
to understand complex clinical treatment
protocols, not just in terms of the sequence
of the procedures, but the sound biologic
principles behind them.
The close collaboration between the Depart-
ments of Oral Surgery, Periodontology
and Fixed Prosthodontics at the University
of Bern enabled me to get an all-round view
of implant treatment. This enriched my
prosthodontic skills, especially in the area
of soft tissue conditioning with provisional
restorations, where I observed and learned
from Dr. Julia Wittneben.
I was also involved in research and I am very
proud to have performed a radiographic
study, mentored by Prof. Buser, on the thick-
ness of the facial bone wall at teeth in the
anterior maxilla using cone beam computed
tomography. It received an award at the
10th International Symposium on Periodon-
tics & Restorative Dentistry in Boston, USA
and is soon to be published. Additionally,
I participated in ongoing clinical and animal
studies. I was also able to attend various
international meetings.
Throughout the year I attended lectures
and Masters courses in esthetic implant
dentistry, GBR and sinus grafting procedures
organized by the Department as well as
excellent Masters courses in regenerative
periodontal therapy organized by the Depart-
ment of Periodontics.
When I return to Croatia I intend to pass on
the knowledge and experience I have gained
to dental students and in everyday practice.
I also hope to have the opportunity to spread
the ITI philosophy by contributing to exist-
ing and establishing new evidence-based,
continuing education programs.
Finally, I would like to express my gratitude
to Professor Daniel Buser for his invaluable
guidance and encouragement as well as
to all the colleagues at the University of Bern
for making my stay so pleasurable.
Dr. Vedrana Braut
graduated in 2004 from
the University of Rijeka,
Croatia where she has
worked as an Assistant
Lecturer in the Depart-
ment of Prosthodontics
since 2005. She re-
ceived her training in Prosthodontics at the University
of Zagreb, Croatia and a Research Doctorate at the
University of Geneva, Switzerland. Her clinical focus
is on prosthetic treatment options and use of dental
materials in the esthetic zone.