RECONSTRUCTIVE

AESTHETIC
IMPLANT
SURGERY
RECONSTRUCTIVE
AESTHETIC
IMPLANT
SURGERY

Abd El Salam El Askary

Blackwell
Munksgaard

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El Askary, Abd El Salam
Blackwell Publishing Asia Pty Ltd, Reconstructive aesthetic implant surgery / Abd El Salam
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Tel: +61 (0)3 9347 0300 Includes bibliographical references and index.
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Contents

FOREWORD, vii

PREFACE, ix

ACKNOWLEDGMENTS, xi
1 Introduction, 3
Abd El Salam El Askary
2 Presurgical Considerations, 8
Abd El Salam El Askary
3 Aesthetic Implant Placement, 45
Abd El Salam El Askary
4 Soft Tissue Management, 60
Abd El Salam El Askary
5 Aesthetic Bone Grafting, 115
Luc Huys and Abd El Salam El Askary

INDEX, 139
Foreword

The Kubler Ross emotional progression of anger, Today, in order to achieve the aesthetic results that our
denial, despair, bargaining, and finally acceptance when patients rightfully demand, many foundational cosmetic
facing serious illnesses or even death applies also to sig- procedures are now recognized as being necessary. Dr. El
nificant loss of teeth and related oral-facial structures. Askary's text traces the history of, describes, and illus-
The advances that have been made in implant dentistry trates the hard and soft tissue manipulations for optimal
allow us to interrupt this downward spiral for many results with implant-supported prostheses.
patients and virtually reconstruct their hard and soft tis- Personally, we both feel that in the arena of "cosmetic
sue deficits. dentistry" there is too much emphasis placed on signature
Originally, implants were devised to restore function, cases, tooth preparation, cementation and finishing of
and aesthetics was secondary. Soldiers suffering from the veneers, metal-free bridges, etc. and not enough emphasis
ravages of World War II and later conflicts cried out for placed on our ability to create the necessary bone support
effective therapies. Dental implants, devised by multiple and gingival architectures that are the sine qua non for
clinicians and investigators from around the world, often aesthetic case outcomes.
provided the foundation for functional prostheses. Dr. El Askary has confronted these scientific and prac-
As the field matured, many cases required a multidisci- tical clinical training problems head on. He has given the
plinary approach with identification of complex etiologic profession a treatise on how we should proceed when
factors. This central issue was often ignored or not appre- approaching simple as well as definitively complex cases.
ciated. Challenges were met with compromise. End goals His work is to be admired in the original meaning of the
were not clear. No one or everyone wanted to be the word, i.e., "wondered at." He is to be congratulated.
"captain of the ship." An educational revolution with Our patients need no longer sink to despair.
significant cross-training was the result. The upheaval of With our best personal and professional regards, we
commitment to excellence is still raging full force. remain
Sincerely,

Carl E. Misch, DDS, MDS, FACD, FICD

Co-Chairman, ICOI
Beverly Hills, Michigan, USA

Kenneth WM. Judy, DDS, FACD, FICD

Co-Chairman, ICOI
New York, New York, USA

VII
Preface

In the name of God, the Beneficent, the Merciful. with a step-by-step clinical manual to aid practitioners in
achieving optimum clinical results.
The fashioning of modern dental implantology in the The first chapter of this book highlights the importance
hands of pioneers like Branemark, Linkow, Judy, of art in human life and its relation to implant dentistry. It
Niznick, Straumann, Misch, and others has solved many shows how implant dentistry uniquely combines science
chronic clinical problems that were heretofore untreat- and art to achieve a functional, aesthetic result. It is worth
able. Dental implants are becoming sometimes the only noting that this field requires not only clinical knowledge
predictable alternative treatment for many clinical situa- but also artistic talent to provide satisfactory results.
tions, and their long-term success over time has been well The second chapter concentrates on the presurgical
established. New implant designs with improved surgical planning for aesthetic cases, from evaluations of the
and prosthodontic options have extended the benefits of study cast to the fabrication of the surgical template. The
implant dentistry to patients previously excluded from chapter highlights the available treatment options and
therapy due to anatomical limitations or other reasons. explains why one treatment option should be selected
Today, countless numbers of patients with partial and over another. It also covers the provisional stage prepara-
full edentulism have experienced dramatic improvements tion for the patient receiving an implant-supported pros-
not only in clinical function, but also in their appearance, thesis in the aesthetic zone; hence, the chapter focuses on
social interactions, and personal self-confidence as a much more than aesthetic case planning.
direct result of successful implant therapy. In that vein, The third chapter of this book addresses dental
modern dental implantology may be considered the implant anatomy, the importance of implant positioning
treatment modality of the twentieth century, and it on the alveolar ridge, and how the three-dimensional
promises to yield even greater advancements in the new placement of an implant can be vital to the final treat-
millennium. ment outcome. It also addresses the clinical challenges
Concurrent with the refinement of the scientific aspects and options for addressing implant misplacements.
of dental implants, many renowned clinicians around the The fourth chapter of this book concerns soft tissue
world, such as Lazara, Bragger, Potashnick, Hurzeler, management around dental implants. It is the largest
Belser, Tarnow, Salama, Bengazi, Sclar, Wohrle, Saadoun, chapter of the book and presents most of the soft tissue
Grunder, Bitchacho, Geovanovick, Kan, Zitzmann, and techniques that are currently available. I have divided the
others, have made invaluable advancements in the science topic into four categories, each of which relates to the
of aesthetic implantology. Through the contributions of timing of clinical intervention. The chapter focuses on
these master artists, dentists no longer need to make the many clinical techniques that can be important for the
painful compromise between providing the patient with reader and includes guidelines for second-stage surgery,
function at the expense of appearance, or vice versa. I soft tissue grafting, papilla regeneration, and soft tissue
have greatly benefited from their contributions. enhancement procedures.
I offer in this present work an overview of the beauty The fifth chapter of this book provides information on
and artistic qualities that may be achieved with dental aesthetic bone reconstruction and presents the methods
implants. The surgical and reconstructive aspects of aes- for grafting the alveolar ridge to attain an optimal aes-
thetic dental implant restorations are presented, along thetic result. The chapter emphasizes the use of titanium

IX
 PREFACE

mesh to help solve many clinical problems related to aes- It is hoped that the information and clinical tech-
thetics and function as a predictable treatment option. It niques included in the present work will provide clini-
also discusses why certain procedures may be preferable cians with sufficient knowledge to help them achieve
to others, and highlights most of the available bone graft- aesthetic implant-supported restorations and provide
ing materials. their patients with beauty as one result of the treatment.
Acknowledgments

As instructed by my God to work and provide a quality I must thank my friend and colleague Dr. Luc Huys,
work as much as possible, because he shall see my work, who agreed to coauthor the last chapter of this book with
I thank him first for giving me the strength and inspiring me. His efforts were an extreme asset to the book.
me with vision to write this book. I would also like to thank deeply my laboratory tech-
nicians, Mr. Walter Lummer (my master technician) and
This book reflects the influences of many mentors and Dr. Raffat Mahfooz for their art work provided in this
scholars, all of whom I would like to acknowledge per- book. Their contributions have added a great dimension.
sonally and offer my debt of gratitude. As for my start in I would like to thank the Centerpulse, dental division
the field of dental implants long ago, I would like to employees who offered unlimited support for me in the
express my profound appreciation for the remarkable early stages of this book: the maestro of the firm, Mr.
educators who guided me with extreme and selfless dedi- Steven Hanson, as well as Celine Cendras-Maret, Robin
cation: Prof. Dr. Roland M. Meffert of San Antonio, Marx, and Werner Grotz.
Texas, who taught me the A-B-C's and mindset of oral Prosthodontists who helped me along the way by
implantology; Prof. Dr. Griffin of Boston, Massachusetts, enlightening me with their knowledge were Drs. Abul-
who showed me the way to soft tissue handling and naga, El Ibrashi, Sameh Labib, El Sharkawy, Garana, and
inspired me as his hands worked with the scalpel during El Tenneer in Cairo, Egypt.
his famous soft tissue grafts; Prof. Dr. Besada of Cleve- I must raise my hat and salute the editors who helped
land, Ohio, who helped me with my unceasing periodon- me with this book, as I sometimes gave them a hard time
tal inquiries; and Prof. Dr. Morton L. Perel of (as my first language is Arabic and not English). I would
Providence, Rhode Island, who taught me how to pro- like to thank Mrs. Inas, Dr. Bassant, and Dr. Zahran of
vide a publication that is readable! Furthermore, being Cairo, Egypt, Mrs. Bonnie Harmon of USA and a special
honored with the ICOI's prestigious Ralph McKinney thanks goes to my friend Mr. Mike Werner from the Cen-
Award in 1999 had a tremendous impact on my life. I terpulse dental division team. His dedicated work cannot
must also acknowledge that the personal advice provided be forgotten and is highly appreciated.
by Dr. Perel and his wife, Jane, was highly valuable in my In the early stages of this book, I collected a large
career. number of articles from the literature and I acknowledge
Other inspiring mentors that I would like to thank are Dr. Racha Fouad of Pennsylvania, Dr. M. Hassan of
Prof. Dr. Kenneth Judy of New York, who gave me Boston, Dr. Zaher of Alexandria, and Dr. Thomas Oates
tremendous support, and Prof. Dr. Carl Misch (whom I of San Antonio for providing scientific materials; without
count as a great scientist and a personal friend). One of their help this book would not be as it is today.
the remarkable moments of my life came when Dr. There were also many friends all over the world who
Misch stood up in the conference lecture room in Istan- supported the idea of this book wholeheartedly. Thanks
bul, Turkey, after one of my presentations and acknowl- to all of you, especially to my personal friends: the
edged the work that I presented before I even knew him famous Arab actress Yosra, my dear friend Ahmad
personally. I would also like to acknowledge Prof. Dr. Bakry, Dr. Mona Al Sane, Ms. Dina Ezzat, and Dr.
Peker Sandalli, president of the ICOI, and Dr. Eddi Palti, Ameed Abdeulhamid of London.
president of the DGZI, who have long supported me by My family support was immense, and I thank my
their continuous encouragement. mother, father, and brother Hesham, who focused their

XI
XII ACKNOWLEDGMENTS

prayers towards asking God that this book come to real- A special note of appreciation also goes to those who
ity. Thanks to all of you. did the graphic work of this book: Ms. Nilly Ali and Mr.
I also would like to offer a special thanks to my execu- Khaled Eldawy.
tive team: Ms. Enjy Mohammad, my secretary; Mr. Finally, I would like to thank every single person from
Ahmad Hanafy, my office manager; Dr. El Hefnawy, my the working team of Iowa State Press who contributed to
assistant in Cairo; Dr. Hayati, my assistant in Alexandria; the success of this book especially Mrs. Lynne Bishop, the
and Dr. Shawkat, my senior assistant, who all provided a project manager of this book.
sincere effort to this work.
RECONSTRUCTIVE
AESTHETIC
IMPLANT
SURGERY
 1
Introduction

Abd El Salam El Askary and makeup found buried with the dead, we know that
these were indispensable funerary gifts.1
So far, no one has ever found a sample of ancient
Egyptian lipstick. However, the Louvre Museum in Paris
ANCIENT COSMETICS gives us an indication that Nefertiti had perhaps
attempted painting her lips. Surprisingly, both men and
"The beauty has come" is what her name meant, and yet women of the upper classes used ground ants' eggs to
Nefertiti did not rely on her natural looks alone.1 Her paint their eyelids. The dye from the Henna plant was
darkened eyebrows and boldly outlined eyes are as popu- used to color hair and fingernails and to adorn the palms
lar today as they were in the pharaonic times. and soles of their feet. To freshen their breath they
The art of cosmetic beautification has roots dating chewed on natron, a naturally occurring sodium carbon-
back to antiquity; famous pop star Billy Idol's distinctive ate.3 Ancient chemists synthesized the black or gray
hairdo (spikes) can be dated back to the end of the Iron makeup, referred to as mesdemet by the ancient Egyp-
Age (1000 B.C. to 50 B.C.), when Celts and Gauls used to tians, that later acquired the name kohl from Arabs.4
wash their hair with limewater—a white, chalky sub- Raw essences were brought from neighboring
stance—in an attempt to create striking white spikes of Mediterranean countries to be utilized for making per-
hair. Tattooing the whole body with blue pigments was a fumes, creams, and lotions, which were then exported.
common practice in the late thirteenth century as Scents constituted a large percentage of Egypt's exports
depicted in the famous movie Braveheart. at one time. Beauty inventions of the pharaohs spread so
The use of cosmetics in history was not restricted to far that women belonging to the Roman Empire began to
the pharaohs' times; it can also be seen during the Pale- rely on cosmetics brought from Egypt and the other parts
olithic Age.2 The curlers used by women today are actu- of the region.
ally an ancient beauty ritual followed by men and women Records have shown that the Sumerians, Babylonians,
alike. One of the earliest examples of hair curling is seen and Hebrews employed these compounds as much as the
in Venus of Willendorf, a mummy belonging to the Pale- Egyptians for ceremonial, medicinal, and ornamental
olithic Age.2 purposes. Locally, however, their use was most often con-
Archeological evidence suggests that prehistoric peo- fined to mummification rituals.
ple contrived their own techniques for preparing pig- According to researchers, the apparent beauty of royal
ments for cosmetics. As many as seventeen different women in ancient times was essentially due to their abil-
colors were reported to have been created from a few pri- ity to use natural resources to enhance their appearance.4
mary sources: lead, chalk, or gypsum (for white); char- They believed that makeup was only an adjuvant to one's
coal (for black); and manganese ores (for shades of red, own natural beauty.
orange, and yellow). These pigments were blended with Beautification and adornment are mutually inclusive
greasy substances to acquire the right consistency for terms that involve the use of cosmetics, clothing, jewelry,
painting on bodies. body piercing, tattooing, and so forth. They are fueled by
For the ancient Egyptians, life was not as important as a subconscious drive to look attractive and to feel good
the afterlife, and their desire to look appealing extended about ourselves. We also enjoy the attention we get from
beyond the grave. From the large amounts of perfumes others when they notice our attractiveness,5 which
 CHAPTER 1

explains the contemporary high demand for cosmetics by Like artists in their paintings, clinicians should
all classes of society. attempt to maintain a balance of proportions in their
work. Perfection cannot exist in isolation: each element
of beauty must harmonize with all other related elements
COSMETICS VERSUS to create the whole. For example, a beautiful face cannot
AESTHETICS be called so unless all facial features are in harmony.

The term cosmetic refers to substances and procedures

that are used to enhance or correct defects in the appear- HARMONY IS THE KEY
ance. Cosmetics are the preparations used to change the
appearance or enhance the beauty of the face, skin, or The philosophy of beauty and beautification is so wide-
hair. Aesthetics, on the other hand, signifies "natural ranging throughout history to the present time that it has
beauty," a quality that comes from within. It can be attracted people of all kinds: artists, musicians, and even
defined as the science of beauty that is applied in nature common man. It makes the clinician's task of attaining
and in art. perfect aesthetics even more challenging. Like a musician
composing the different elements that will orchestrate his
music, a successful clinician integrates the treatment ele-
BEAUTY IN ART ments for a particular patient before executing the treat-
ment plan (Fig. [Link],b).
Beauty is generally described as "a pleasurable psycho-
logical reaction to a visual stimulus," while the word art
is derived from the Latin ars, meaning "skill."6 For an
artwork to be valued as good, it has to be satisfactory to
the senses—what is referred to in the visual arts as "the
relationships among colors, lines, and masses in space."7
People usually interpret beauty differently; each defin-
ing it according to his own conception. Prominent artistic
figures have expressed their viewpoints about beauty in
ways that are worth mentioning. In his Vision of the
Prophet, Kalil Gibran manipulated magnificent pieces of
poetry and prose to express his view of natural beauty:
"Beauty is that which attracts your soul, and that which
loves to give and not to receive."8
Dante also viewed art to as a natural imitation: "Art
as far as it is able, follows nature, as a pupil imitates his
master." FIGURE [Link]. Preoperative view of a patient with a
missing left central incisor.
Leonardo da Vinci's famous Mona Lisa, the enigmatic
woman whose identity remains a mystery to this day,
reveals his perspective on beauty.9 In the Mona Lisa, da
Vinci finds real "natural" beauty. The mysterious smile
on her face—which could be interpreted as either angel-
like or quite devilish—was the secret of her everlasting
beauty.10
Most artists have one thing in common: they use their
talent to imitate reality—the real beauty they find in a
certain thing, such as nature or the beauty of a face or
soul. In this way, Peter Paul Rubens expressed his true
feelings towards his beloved, Susanna Fourment, by imi-
tating her beauty in "a portrait of my love."10
Art has always been instrumental in the imitation of
beauty or nature. When Honore de Balzac was once
asked what art is, his reply was "nature concentrated."
Thus, artists derive their inspiration from God's magnifi- FIGURE [Link]. Postoperative view of the patient
cent creation of nature and of us, and all artistic endeav- restored. Note the harmony between the implant-sup-
ors are compared to nature as the standard of excellence. ported restoration and the remaining natural dentition.
INTRODUCTION

Beauty in dentistry does not differ widely from the Dental implants have proven to be a predictable
general art concepts that have been discussed earlier. Cos- method of restoring function in the oral cavity over the
metic dentistry as defined by Philips11 is an elective proce- past thirty-five years.13'16 The late 1980s and early 1990s
dure aimed at altering the existing natural or unnatural witnessed the expansion of the use of dental implants to
periodontium to a configuration perceived by the patient include treatment of partially edentulous patients with
to enhance the appearance; on the other hand, aesthetic fixed, implant-supported restorations. These new clinical
dentistry is a rehabilitative procedure that corrects a applications include the treatment of missing anterior
functional problem using techniques that will be least single dentition, which has become a treatment option
apparent in the remaining natural periodontium and/or with documented success rates in excess of 90%.17~20 As
associated tissues.11 A successful aesthetic dental treat- awareness of this treatment modality has improved,
ment should help the patient to regain his/her self-image, restoration of missing maxillary anterior single teeth with
revive social skills, and experience professional success. implant-supported restorations is quickly becoming the
In evaluating an aesthetic treatment as successful, the preferred treatment modality, despite the fact that it still
clinician's visual judgment becomes very significant. That remains one of the most aesthetically difficult and chal-
is, the success of an aesthetic procedure can be deter- lenging of all implant restorations. Efforts by clinicians to
mined only when the eye moves along the object to be improve the aesthetic dimension of dental implants and
corrected and perceives its cohesion and harmony with achieve restorations that exactly mimic the appearance of
all the other relevant aesthetic elements.12 Any aesthetic natural teeth have played a significant role in improving
restoration requires imaginative skills, superior clinical the awareness and popularity of dental implants.
talents, and the comprehension of all facial relationships Success in achieving an aesthetic implant-supported
that will influence the treatment success. Logic and imag- restoration that mimics the natural tooth appearance
ination are both necessary in analyzing the available ele- requires very meticulous treatment procedures. The
ments that are required to ensure a harmonious aesthetic process involves careful, detailed presurgical planning,
result. optimal three-dimensional implant placement, meticu-
There is a social dimension that complements the lous soft tissue management, the use of predictable bone
image of every person. Natural teeth are not mere physi- grafting techniques when required, and skillful use of
cal structures with only a functional role to perform. various prosthetic components.
They have social attributes as well, which are vital to Many researchers have dedicated their efforts to
one's self-image, social interaction, and physical attrac- improving and developing techniques that help achieve
tiveness (Fig. 1.2). Restoring missing natural dentition, predictable, aesthetic results with dental implants. Some
especially in the anterior area, has a complementary have laid out the fundamentals of presurgical planning,21
impact on the individual's personal and social counte- and others22'23 have set the guidelines for aesthetic
nance. Experience has proven that most patients not only implant positioning to achieve a natural-looking final
perceive the functional improvements provided by restoration.
prosthodontic rehabilitation, but also note remarkable Soft tissue sculpture,24 the use of connective tissue
improvements in their social and spiritual well-being as a grafts25 and free gingival grafts,26 improvement of soft tis-
result of the changes in their appearance. sue contours,27 the use of enhanced conservative new
mucoperiosteal flap designs,28 and methods to improve
soft tissue topography at the time of second-stage surgery29
were all invented to benefit the aesthetic outcome.
To achieve adequate height and width of the alveolar
bone to obtain an optimal natural emergence profile,
many techniques have been introduced.30'31 Jovanovic32
defined the term aesthetic bone grafting as the regenera-
tion of the lost osseous structure to its original biological
dimensions, not only to serve function but also to favor
aesthetics.
Unlike natural dentition, restoring a single missing
tooth with an implant-supported prosthesis can be a dif-
ficult task, never like restoring multiple missing teeth in
the aesthetic zone.33 In cases where only a single tooth is
to be restored, the establishment of the peri-implant
FIGURE 1.2. View of a woman with missing anterior papillae and surrounding tissues is highly predictable,34
dentition; she used to cover her mouth while laughing whereas in the case of multiple implant placements the
to hide her edentulous status. interimplant papilla is unpredictable. Some authors3j~38
 CHAPTER 1

have suggested soft tissue surgical interventions as a solu- 14. Adell R, Lekholm U, Rockier B. A 15 Year study of
tion for this problem, while others33'39 have utilized hard osseointegrated implants in the treatment of the edentu-
tissue reconstructive procedures. Tarnow40 and Salama41 lous jaw. Int J Oral Surg 1981(10): 387-416.
have proposed helpful tools for predicting the inter- and 15. Engquist B, Bergendal T, Kallus T, et al. A retrospective
peri-implant papillae with classifications that have multicenter evaluation of osseointegrated implants sup-
porting overdentures. Int J Oral Maxillofac Implants
assisted in the assessment of clinical papillary conditions.
1988(3): 129-134.
Misch42 stated that aesthetic enhancement techniques are
16. Schnitman PA, Rubenstein JE, Whole PS, et al. Implants
very often accomplished at the expense of sulcular health, for partial edentulism. J Dent Educ 1988(52): 725-736.
as some of the clinical procedures can be invasive to peri- 17. Schmitt A and Zarb GA. The longitudinal clinical effec-
implant tissues. For example, creating deep soft tissue tiveness of osseointegrated dental implants for single
pockets around abutments can jeopardize the long-term tooth replacement, Int J Prosthodont 1993(6): 187-202.
survival of the implant and its surrounding structures. 18. Engquist B, Nilson H, and Astrand P. Single tooth
Aesthetic implant dentistry should not be a separate replacement by osseointegrated Branemark implants: A
discipline but rather an integral part of all other treat- retrospective study of 82 implants. Clin Oral Implant
ment modalities.43 Function should complement aesthet- Res 1995(6): 238-245.
ics and vice versa: the final objective of aesthetic implant 19. Anderson B, Odman P, Lidvall AM, et al. Single tooth
dentistry is a perfect prosthetic outcome that simulates restoration supported by osseointegrated implants: Results
the natural tooth appearance. Simple principles of design and experience from a prospective study after 2 to 3 years.
applied to anterior dental aesthetics that create harmony Int J Oral Maxillofac Implants 1995(10): 702-711.
20. Ekfeldt A, Carlsson G, and Borgesson G. Clinical evalu-
while maintaining natural beauty can turn an average
ation of single tooth restorations supported by osseoin-
restorative case into an ideal one.44
tegrated implants. A retrospective study. Int J Oral
There is no right or wrong when it comes to an aes- Maxillofac Implants 1994(9): 179-183.
thetic restoration. It is the clinician's own responsibility 21. Jansen C, and Weisgold A. Presurgical treatment plan-
to analyze the available treatment options and utilize the ning for the anterior single-tooth implant restoration.
best possible working strategy that will provide a pre- Compendium 1995(16): 746-762.
dictable long-term prognosis. 22. Spielman HP. Influence of the implant position on the
aesthetics of the restoration. Pract Periodont Aesthet
Dent 1996(8): 897-904.
23. Parel SM, and Sullivan, DY. Aesthetics and Osseointe-
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9. Corson, Richard. Fashions in Makeup. London: Peter 2000(11): 83-90.
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10. Gunn, Fenja. The Artificial Face: A History of Cosmet- ized alveolar ridge augmentation. Int J Periodontics
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tological aspects. J Dent Res 1979 58(10): 1953-1969. 1994(14): 497-511.
INTRODUCTION

32. Jovanovic SA. Bone rehabilitation to achieve optimal aes- 39. Salama H, Salama MA, Garber D, and Adar P. Develop-
thetics. Pract Periodont Aesthet Dent 1997(9): 41-52. ing optimal peri-implant papilla within the esthetic
33. El Askary AS. Interimplant papilla reconstruction by zone: Guided soft tissue augmentation, J Esthet Dent
means of a titanium guide. Implant Dent 2000(9) 85-89. 1995(7): 125-129.
34. Petrungaro PS. Smilanich MD, and Windmiller NW. 40. Tarnow D, Magner A, and Fletcher P, The effect of the
The formation of proper interdental architecture for sin- distance from the contact point to the crest of the bone
gle tooth implants. Contemp Esthet Rest Pract 1999(3): on the presence or absence of the interproximal dental
14-22. papilla. J Peridontol 1992(63): 995-996.
35. Beagle JR. Surgical reconstruction of the interdental 41. Salama H, Salama M, Garber D, and Adar P. The inter-
papilla: Case report. Int J Periodontics Restorative Dent proximal height of bone—a guide post to predictable
1992(12): 145-151. esthetic strategies and soft tissue contours in anterior
36. Shapiro A. Regeneration of the interdental papillae tooth replacement. Pract Periodont Aesthet Dent
using periodic curettage. Int J Periodontics Restorative 1998(10): 1131-1141.
Dent 1985(5): 27-33. 42. Misch EC. Single tooth implant. In Misch CE, ed. Con-
37. Jemt T. Regeneration of gingival papillae after single temporary Implant Dentistry. St. Louis: Mosby, 1999,
implant treatment, Int J Periodontics Restorative Dent 397-428.
17(1997): 327-333. 43. Sorensen JA. Aesthetics at what cost? Pract Periodont
38. Hurzeler MB, and Dietmar W. Peri-implant tissue man- Aesthet Dent 1997(9): 969-970.
agement: Optimal timing for an aesthetic result. Pract 44. Golub-Evans J. Unity and variety; essential ingredients
Periodont Aesthet Dent 1996(8): 857-869. of a smile design. Curr Opin Cosmet Dent 1994:1-5.
2
Presurgical Considerations

Abd El Salam El Askary foundation of diagnosis, treatment planning, and case

preparation. Bone and soft tissue volume, topography, and
quality, differ, as do implant designs, surfaces, and surgical
The quintessence of an optimal postsurgical aesthetic protocols. Each patient also has different requirements,
outcome is presurgical planning. One cannot imagine any desires, expectations, and a unique array of health con-
difficult task being undertaken without thinking the cerns. Implant success thus requires a personalized
whole procedure out very thoroughly prior to commenc- approach, based on the functional, anatomical, aesthetic,
ing on it. This crucial preplanning stage aims at fulfilling and psychological needs of the implant candidate. Diagno-
the patient's expectations at both the functional and aes- sis and treatment planning are the starting point for
thetic levels. achieving the treatment goals.
In general the patient goes to the dentist for help and The patient must be notified of the benefits and poten-
guidance and for an honest opinion about what lies in tial complications of implant therapy. As mentioned ear-
his/her best interest. Therefore, the patient's expectations lier, the patient's expectations of the proposed treatment
are in most cases what the clinician might seek to realize. plan must be attended to conscientiously. It is the clini-
However, the clinician must be prudent to be able to visu- cian's responsibility to inform the patient prior to treat-
alize what is feasible and realistic based on the existing ment initiation about the extent of probable realization
clinical condition. of his/her expectations.
The dentist and his team make use of all available Presurgical planning is not just limited to setting the
investigative tools to recommend and display all treat- groundwork for the patient. The treatment team must be
ment options. It is the patient's right to be made aware well versed on everything related to the patient and the
not only of the possible use of dental implants but also of work required from every one of them. A well-prepared
all other available treatment alternatives. diagnostic study is one that will shed light on fundamental
Imagination is a sign not only of creativity but also of aspects of the oral cavity's anatomical structures and clini-
farsightedness. The ability to envision the final treatment cal condition. Areas of condition include type of occlusion;
outcome before starting on it will help the dentist assess number, shape, and condition of the remaining dentition;
what is needed to restore the dentition and/or its support- and amount of interdental and interarch space available
ing structures. If dental implants are to be considered, it for replacement of teeth. The detection of any existing
is necessary that the final implant-supported restoration pathological lesion, parafunctional habits, or abnormal
and related soft tissue margins should match and harmo- physiology should be underscored. This information is
nize with the remaining natural counterparts. In this crucial in making critical decisions on the many aspects of
regard, selection of a clinical option that will ensure the treatment, each of which is important in its own right.
best possible aesthetic result is of foremost importance. These conditions mandate the position, size, type, and
Implant replacement therapy is not a traditional treat- design of the future implants; the need for undertaking any
ment option that can be taken lightly, or for granted, either grafting or bone augmentation procedures; the surgical
in its course or in its final outcome. Successful long-term approach; the positioning of the implant in the alveolar
function of dental implant restorations requires a solid ridge; the selection of the prosthetic components; and
PRESURGICAL CONSIDERATIONS

the type of future restoration. Therefore, the diagnostic or may wish to hide some deformity or abnormality that
information obtained prior to treatment initiation can pro- he/she might used to have. Learning the patient's desires
vide valuable insight into the appropriate sequence that is and expectations using old previous pictures as a refer-
to be followed during the surgical and restorative phases ence can be very helpful in anterior oral rehabilitations.
of treatment. Study casts are yet another useful tool in this stage of
A patient undergoing a comprehensive aesthetic planning. They are made preoperatively from casting a
reconstruction in the oral cavity has to be provided with preliminary impression. The type of occlusion and the
a detailed description of the treatment procedures. The available interarch space are the two major important
patient has his/her own crucial role in this whole treat- benefits of study casts.
ment process. It is only fair that he/she know the extent Therefore, it is imperative that the clinician seek to
of the required participation and what is expected of obtain the most information possible before starting the
him/her during and after treatment. Another point of treatment. There are several means of acquiring this
importance is the time frame and costs involved, which information. The first of these is similar to a background
must also be presented and discussed at this time. check, where the patient's medical and dental history is
The patient must be informed of any possible discom- investigated.
fort, pain, or temporary compromise in function that he/
she might experience, and a patient seeking implant
replacement therapy requires reassurance to attain the MEDICAL EVALUATION
patience and endurance demanded for investigating,
preparing, and executing the selected treatment plan that A complete medical and dental history provides insight
will pay off at the end of the treatment. Consequently, it into the patient's current state of health. It highlights
is only humane for the clinician to try to minimize the contraindications or important areas of concern for den-
time of the actual treatment. The ideal presurgical plan- tal implant therapy,1'2 and it can also provide useful
ning can significantly reduce the time required for treat- information on the potential success of implant treat-
ment, and subsequently minimizes unnecessary financial ment.3'4'5 The following areas of medical risks6 associ-
burdens and strains. ated with dental implant placement can be evaluated
A clinician of these days may not depend only on through a detailed medical history. Surgical and anes-
visual and palpable examination of the visible oral vital thetic risks including cardiovascular, respiratory, and
structures; the underlying investing structures also must renal diseases are major concerns that should be first
be thoroughly examined. Radiographic, modern diagnos- carefully evaluated through the medical history.6 Because
tic evaluation tools are thus reckoned as stepping-stones the human body is a precise interrelated mechanism,
for the ensuing treatment. These are the necessary ingre- there are many medical conditions that negatively affect
dients for any successful aesthetic project, and this pre- osseointegration, and they should be noted.6 These con-
treatment appraisal influences not only treatment ditions include blood dyscrasias (e.g., anemia, leukemia,
modality selection but also treatment timing, sequence, bleeding/clotting disorders, etc.), severe endocrine sys-
and prognosis. Various available radiographic views can temic diseases (e.g., uncontrolled diabetes, hyperthy-
help assess the quantity, quality, and inclination of the roidism, pituitary/adrenal disorders, etc.), severely
residual alveolar ridge. Such related anatomical details as compromised immune systems (e.g., AIDS), severe gas-
the nasal floor, maxillary sinus, and anterior mental loop- trointestinal diseases (e.g., hepatitis, malabsorption,
ing may also be identified. Any pathology or bone disease etc.), and severe musculoskeletal diseases (e.g., osteo-
related to the working site may be detected and dealt porosis, osteopetrosis, etc.).
with before treatment commencement. Preoperative radi- Other conditions that may require consideration in
ographs may be of assistance when reviewing with the decision making are musculoskeletal diseases (e.g., severe
patient the progress made during the course of the treat- osteoarthritis) and neurologic disorders (e.g., stroke,
ment and for comparison postoperatively. In the event of palsy, mental retardation, etc.), which may render a
future medicolegal problems, radiographs are used as patient incapable of maintaining adequate oral hygiene
evidence of the patient situation at present and both pre- on a daily basis.6
and postoperatively. Some situations or predicaments preclude the success
Besides radiographs, old photographs or slides the of implant therapy because they compromise the body's
patient might provide are regarded as fairly important health either generally or locally. Pregnancy, persistent
tools in constructing the treatment plan. The patient may oral infections, and malignancies are examples of such
yearn to duplicate what he or she previously looked like, contraindicating situations for dental implant therapy.7
10 CHAPTER 2

Relative contraindications to dental implant therapy, senile dementia, etc.); and (c) chronic, severe alcohol or
on the other hand, are conditions that are debilitating to drug addiction (because of a high propensity for poor
the body's immune system. Although they do not directly motivation, inadequate nutrition, and lack of compliance
pose a potential threat to dental implant survival, these with oral hygiene regimen).22 As always, it is best to select
contraindications would eventually be the cause of failure candidates whose level of understanding and cooperation
of implant acceptance within the host body. These rela- is superior, for that guarantees a successful end result.
tive contraindications include prolonged corticosteroid or Registering information and taking notes on past his-
immunosuppressive drug therapy, chemotherapy, colla- tory is only one aspect of the presurgical stage of implant
gen diseases, and a history of osteomyelitis or irradiation therapy. A thorough physical examination prior to
in the region of the proposed implant receptor site.7 implant placement is imperative in order to assess the
Patients are urged to reveal any ongoing medical treat- patient's present health status and detect early signs of an
ment and/or any medications they are taking as well as undiagnosed disease.22 Recording the patient's vital signs
any influencing habits. Smoking is increasingly cited in (pulse, blood pressure, respiratory rate, and temperature)
the literature as a risk factor in soft tissue healing,8 peri- can be important in assessing the patient's present overall
odontal health,9'10 and implant therapy.11"15 health. Other medical tests and/or consultation with the
Allergies are yet another source of concern. A thor- patient's physician may be necessary when compromised
ough medical and dental history is important in identify- medical conditions exist.
ing allergies that could dictate the use or avoidance of A comprehensive hard and soft tissue examination
certain drugs or other substances in dental implant ther- should be performed in order to rule out undiagnosed
apy. Due to its high passivity and biocompatibility, no malignancies or dysplastic oral, head, and neck lesions.22
allergies to titanium or titanium alloy have been reported Inspection and bidigital palpation of the lips, buccal
in the dental literature.16"18 However, allergies to denture mucosa, hard and soft palates, the oral pharynx and the
resin19 and such restorative base metals as chromium- submental, submandibular, and cervical lymph nodes
cobalt,16'19 nickel,18"19 and palladium-copper-gold alloys20 should be made to assess the presence of any masses.22 By
have appeared in research abstracts. gently grasping and lifting the tongue forward, upward
It is important to note that the literature suggests eval- and laterally, the floor of the mouth and the tongue can
uating medically compromised implant candidates on a also be examined.22
patient-by-patient basis, as compromised medical status The salivary glands and ducts must be inspected for
alone is not necessarily indicative of implant failure.20 unobstructed asymptomatic salivary flow that might
Physical conditions and symptoms are not the only cause lack of lubrication to any oral prosthesis and may
aspects an oral surgeon should evaluate and assess. A mandate a change in the proposed prosthodontic plan.
patient's psychological ability to commit to long-term
treatment and maintenance programs must be an integral
part of the examination and selection process. During the STUDY CAST
consultation, the clinician should determine whether the
patient is psychologically capable of making the neces- The study cast is considered to be a valuable diagnostic
sary long-term commitment. For example, phobic or tool that assists in developing and executing the treatment
highly anxious individuals may have low pain thresholds plan (Fig. 2.1).23 This is primarily due to the fact that the
and refuse to present for treatment follow-ups. On the patient can only be examined for a limited time per visit.
other hand, patients whose dental complaints stem from The study cast provides an almost exact replica of the oral
somatization disorders will probably not be satisfied with conditions prevailing at the time the impression is made.
the results of implant therapy.21 Transferring the patient's intraoral condition to a dental
It is unfortunate that not every person may be consid- cast is a vital prerequisite to presurgical planning; it
ered mentally, psychologically, physically, and emotion- enables the clinician to study and comprehend the treat-
ally sound. As a result, some cases may contraindicate for ment elements needed to satisfy all the aesthetic and func-
dental implant therapy. Persons afflicted with acute psy- tional demands in subsequent treatment phases.24 The
chiatric or psychological disorders are one such exam- master study cast may be duplicated two or three times for
ple.6 These disorders may be subdivided into (a) inability various clinical applications. One duplicate may be used in
to understand information, follow instructions, or make fabricating the surgical template, another in constructing a
reasonable decisions (e.g., psychotic syndromes, severe provisional restoration for the patient, and another may be
neurotic conditions, or character disorders, etc.); (b) retained and preserved as a record for any future demand.
impaired memory or motor coordination necessary for The uses of study casts are numerous, especially since
routine oral hygiene (e.g., cerebral lesion syndromes, pre- they provide information that is measurable and verifi-
PRESURGICAL CONSIDERATIONS 11

FIGURE 2.1. Study casts mounted on a simple hinge

articulator showing a missing maxillary right central FIGURE 2.2. An illustration showing the use of a
incisor. reduced number of implants to enable enhanced peri-
implant soft tissue architecture.
able. They are helpful in determining the interarch space
and sulcus depth. These measurements are necessary in
order to calculate the future crown-implant ratio, the
type of implant used, the type of the final abutment, and
the extent of the final restoration.27
Study casts can also lend a hand in determining the
number and size of implants to be used in supporting a
given prosthesis. In areas where function is of prime
importance, as in replacing missing posterior dentition, a
maximum number of implants should be used to provide
a larger surface area for support. This procedure is rec-
ommended as a safety factor so that the implants can
withstand the magnified stresses at these particular areas,
ensuring a better prognosis. Whereas, in areas where aes-
thetics are desirable and biting forces are at a minimum,
it is the personal experience of the author that sometimes FIGURE 2.3a. A master cast showing the use of three
reducing the number of implants used (without compro- implants to restore five missing anterior teeth; note the
mising the function) can strikingly improve the aesthetic sculpture of the pontic area on the model.
outcome by enhancing peri-implant soft tissue architec-
ture. The availability of a pontic space between the views, study casts aid in the accurate selection of implant
implants allows the clinician to perform pontic develop- size by determining the bone width at a given section of
ment techniques, resulting in a papillary-like architecture the alveolar ridge using a technique called ridge map-
that simulates natural appearance (Figs 2.2, 2.3a-c).25>26 ping.28'29 This involves inserting a thin needle or a tissue
When a reduced number of implants is used to execute gauge into the soft tissue investing the alveolar ridge fol-
pontic development techniques, longer and surface- lowing a vertical line drawn in the middle of the edentu-
enhanced implants should be used to provide a reason- lous area or at the area of intrest. The measurement is
able support for the long-term success of the repeated at two or three locations along the vertical line
implant-supported prosthesis. both facially and lingually. The collected depth readings
Study casts can occasionally give a valuable indication are then transferred onto the corresponding locations on
of the nature of available osseous support. They can be the sectioned study cast at the same vertical line. These
useful in assessing the amount of bone required from a readings furnish the thickness of the soft tissue. Addition-
proposed grafting procedure to contribute to the long- ally, the underlying bone width can be calculated by sub-
term serviceability and improved aesthetics of the dental traction (Figs 2.4a-d). This technique can be used to
implants. In conjunction with the available radiographic reduce the cost of the treatment (by eliminating the fees
FIGURE 2.3b. Final clinical result after pontic devel-
opment technique. Note the formed papillary-like archi- FIGURE 2.4b. Three pin markings labially and three
tecture. pin markings palatally are made. A needle punching the
soft tissue at the markings place to record the soft tissue
depth is shown.

FIGURE 2.3c. Final restoration cemented in place

restoring the natural emergence and papillary architec-
ture.

FIGURE 2.4a. Incisal view of a missing right central FIGURE 2.4c. A sectioned model showing the actual
incisor showing labial bone defect due to postextraction thickness of bone after tracing the collected data; the
resorption. blue color represents the soft tissue thickness.

12
PRESURGICAL CONSIDERATIONS 13

FIGURE 2.5. A wax-up of two missing anterior teeth

on the study model.

around the teeth, by painting, or using tooth-colored and

pink base plate wax to simulate gingival appearance.31
Sometimes adding a lip impression to the pink matrix on
the study cast will provide a three-dimensional vision for
the patient.32 After the patient approves the wax-up, the
locations of the future implants are marked on the cast.
A surgical template constructed on the study cast accord-
ing to the markings of these locations will aid in transfer-
ring the planned first stage of surgery onto the surgical
site.
In conclusion, the study cast is the main diagnostic
tool in the presurgical phase, as it aids in evaluating the
edentulous space in relation to the number, location,
and/or size of the missing dentition. It also helps in ana-
FIGURE 2.4d. A tissue gauge caliper can be used in- lyzing the biomechanical forces exerted, detecting the
stead of the needle puncture to measure soft tissue depth.
type of occlusion, and determining the prosthetic compo-
nents to be used in the future. Other nondiagnostic func-
for CT scans) and to eliminate the exposure to radiation tions include fabrication of the surgical template as well
(to satisfy some patients' preferences). as any provisional prostheses. Additionally, the study cast
The study cast is not limited in its use to obtaining may be used as a reference guide for comparison between
information and taking measurements; after studying the the different stages of the treatment, thus evaluating the
available edentulous space and determining the number treatment progress. If medicolegal problems should arise,
of implants required, a wax-up (Fig. 2.5) is subsequently the study cast may be considered and used as a material
fabricated to replace the missing natural dentition, and of evidence.
reestablish the missing biological contours. In effect, the
wax-up on the study cast is very much like a dress
rehearsal. It is then shown to the patient so he/she can RADIOGRAPHIC ASSESSMENT
evaluate it personally and directly on the study cast. This
makes the whole treatment process more tangible for the Implant positioning in the alveolar ridge is dependent on
patient. However, evaluation of the wax-up is usually the location and morphology of the potential osseous
complicated for the patient because it is difficult for receptor site and its contiguous structures. Because the
him/her to imagine and visualize him-/herself with a new contour and thickness of the oral mucosa can mask the
prosthesis from simply observing a wax-up.30 Examples actual dimensions of the underlying osseous structure, a
of attempts made to enhance the realistic appearance of thorough radiographic examination is essential for diag-
the wax-up for the patient include placing a pink matrix nosis and treatment. This examination is to make note of
14 CHAPTER 2

what is and is not radiographically present, with any

deviation from normality duly recorded.33
Radiographic assessment is a significant tool in evalu-
ating the quantity and the quality of the alveolar bone,
locating any anatomical landmarks, and/or detecting
pathological lesions. It helps the clinician to visualize and
judge the likelihood of executing the proposed treatment
plan. In addition to determining bone dimensions accu-
rately,34 the available technical advancements in radiogra-
phy have helped improve case design and treatment
planning, thus conferring upon clinical results a measure
of predictability.35 This, in turn, has helped the dental
team select the proper candidate for implant therapy;
implant size and design; surface texture and angulation;
and the surgical technique to be utilized for implant FIGURE 2.6. Periapical radiographic view.
placement.
There are numerous radiological techniques and views
available, and each has its own merits and drawbacks. Modern periapical digital radiographs have reduced
The clinician should be able to select the most suitable 90% of the radiation exposure. They have eliminated the
method for each patient particularly. Sophisticated radi- need for films and subsequent film processing. The regu-
ography, as digital computed scans, is not mandatory for lar film is replaced with a sensor that is connected to a
every single alveolar ridge evaluation. However, some computer, where the image can be viewed instanta-
patients require sophisticated radiographic investigations neously.36 The radiation reduction has benefited both the
for assurance of attaining a successful treatment plan. clinician and the patient, where digitalization has
Periapical and panoramic views are examples of two allowed for taking several views in a shorter time without
very commonly used views in dental treatment. They fear of radiation hazard. It is thought to be cost effective
offer only a two-dimensional image, where bone height in comparison with the regular radiographic views.
and density may be gauged.35 These views can also be Occlusal views have very limited applications because
helpful in evaluating the condition of the periodontium of superimposition of anatomical structures, changes in
or pulp. They are also used to assess the location of the the x-ray tube angulation that can lead to distortion in
roots relative to the neighboring anatomical structures most of the images, and difficulties encountered in
and/or a particular future implant receptor site. Acquir- accessing the posterior regions of the oral cavity (Fig.
ing periapical and panoramic x-ray views is cost effective, 2.7).37
as the radiographic devices can be readily available in the
dental office, are easy to use, and involve minimal addi-
tional expense for the patient.
The periapical view has a unique advantage over other
types and views of x rays. It is the only available method
for routine monitoring of crestal bone levels around pre-
viously restored dental implants. It can also be a valuable
reference that the clinician can resort to at the time of
surgery to determine the depth of drilling (Fig. 2.6).
Conversely, periapical radiography has some inherent
shortcomings. These inadequacies are represented in a
slight magnification of images that is not consistent and
that varies according to the technique used. Conse-
quently, an image in a periapical film doesn't represent
the actual size of an object. Another disadvantage is the
small size of the film, which restricts the viewed area,
thus limiting its clinical applications. Periapical radi-
ographs, however, are considered valuable in the treat-
ment planning for single tooth implants. FIGURE 2.7. Occlusal radiographic view.
PRESURGICAL CONSIDERATIONS 15

lizes a lower dose of radiation, presents precise measure-

ments directly without magnification, and provides a dig-
ital image that can be stored on the computer for future
comparisons.37
Computerized tomography (CT) is based on a soft-
ware program that constructs a three-dimensional
model. It creates clear tomographic sections for the
alveolar bone, and differentiates between soft and hard
tissues clearly as never before. It reformats the image
data to create a tangential and cross-sectional tomo-
graphic image of the future implant site; it also verifies
the bone quality precisely. This three-dimensional
model is computed using several radiographic views
from specific angles (Fig. 2.9a-e).38 Because of its ability
FIGURE 2.8. Panoramic view showing all the denti- to provide a complete three-dimensional image, CT pro-
tion and tracing of the maxillary sinus floor level with vides a highly sophisticated format for precisely defin-
some anatomical landmarks (note the image magnifica- ing jaw structure and locating critical anatomical
tion). structures.23'39"42
Dentascan (MPDI, Torrance, California) is consid-
ered to be one of the most modern applications of com-
Panoramic radiography (Fig. 2.8) is believed to be the puterized tomography (CT) in implant dentistry. It
standard technique for radiographic examination in the generates a referenced cross-sectional and tangential
treatment planning for patients receiving dental panoramic image of the alveolar bone along with three-
implants.38'39 It shows the hard and soft tissue anatomy dimensional images of the arch. It consists of a software
and the related structures of the maxilla and mandible in modification of the CT data to produce images specifi-
a single film. However, although it is considered the most cally helpful for preoperative assessment of the alveolar
popular two-dimensional view in oral implantology bone before implant placement. It provides serial slices
treatment, it has its own shortfalls: it fails to show the through the alveolar ridge at specific intervals. The sur-
width of the object. Panoramic views also have lower res- geon is then able to visualize the alveolar bone in a
olution (especially in the anterior zone) than intraoral three-dimensional image and measure the size of the
radiographs. Moreover, when these radiographs are mag- ridge directly from the scan. This method has its limita-
nified to 15-22%, it is difficult to calculate the exact tions in terms of high cost, critical head tilting position
bone height, or mesiodistal distance, without performing of the patient, requiring a compensation for magnifica-
a mathematical calculation to eliminate the magnifica- tion, and the increased time needed for generation of the
tion factor. In spite of its disadvantages, however, images.43
panoramic radiography will remain the radiographic Magnetic resonance imaging may be used to appraise
examination tool of choice in dental implant treatments the existing alveolar bone, especially for use with dental
because of its simplicity and affordability. implants. It is a useful scanning method that may be uti-
Periapical and panoramic views are not the only lized in areas where CT software programs are not avail-
views that are applicable in dental implantology. Lat- able, or for patients who don't desire or cannot be
eral cephalometric radiographs are usually used in exposed to further radiation.44
order to focus on the anterior maxilla and mandible. To date, digital subtraction radiography (DSR) is the
Here, the trajectory and angulation of the residual most versatile and sensitive method for measuring bone
alveolar ridge are required. Therefore, cephalographs loss. It can detect both bone height and changes in bone
provide information regarding the angulation of the mass surrounding dental implants. DSR addresses the
implants to be placed. They are, however, limited in limitations in detecting postoperative changes that are
their application in dental implantology to completely present in other radiographic modalities. By eliminating
edentulous patients. information that has not changed, DSR allows the clini-
Dental implants in general have benefited from com- cian's eye to focus on actual changes that have occurred
puted dental radiography. Computerized tomography between the recordings of two images.35'37 This feature
(CT), specifically, offers several advantages. It produces makes comparison easier, and any uncertainties about the
sharp images, eliminates the need for film processing, uti- procedure's success can be laid to rest.
16 CHAPTER 2

FIGURE 2.9a,b,c,d. Four different views of a computerized tomography (CT) of the maxilla.

ticated and expensive radiographic procedures may

sometimes not be helpful in detecting the various para-
meters needed to make a precise diagnosis, and the reg-
ular readily available radiographic techniques may be
sufficient.

TREATMENT OPTIONS
Making sensible decisions is one of the most important
daily activities of any clinician's practice. Currently
obtainable data, statistical analysis methods, and techno-
logical advancements give the practitioner the facility to
select a specific treatment path in a more thorough and
FIGURE 2.9e. Three-dimensional simulation of the predictable manner than ever before. When treating a
premaxilla from a CT. partially or completely edentulous patient with dental
implants, the primary target of the treatment should be
determined: functional, aesthetic, or both. When aesthet-
Selection of the most suitable radiographic view ics is a priority in the treatment plan, the patient should
requires rational decision and sound judgment. Sophis- be actively involved in the details of the treatment plan,
PRESURGICAL CONSIDERATIONS 17

so as to accurately ascertain his/her aesthetic expecta- natural teeth: dental implants are used to replace the
tions.45 It is crucial to conceive and comprehend what is missing tooth/teeth without resorting to including
in the patient's best interest prior to any aesthetic recon- neighboring abutment teeth that are in a relatively good
structive methods being undertaken, in order to avoid condition.
any future medicolegal problems. Many disappointments Using general standards that exist in the literature, the
may occur when a final prosthetic outcome does not sat- average lifetime of a fixed bridge is 8.3-10.3 years.51'52
isfy the patient's wishes or meet his/her expectations. The This might raise the question of how many restorations a
reason may be due to poor clinician-patient communica- young patient might require over a lifetime. Alternatively,
tion, a misunderstanding of the patient's demands, if the teeth adjacent to an edentulous space have either
and/or the dentist's inability to fulfill them. severe attrition or a gross restoration, dental implants
All the available treatment options should be pain- may not be a feasible treatment option. In this case, it
stakingly explained to the patient prior to embarking would be better to consider protecting and splinting these
on any clinical treatment procedures. The patient's compromised teeth within a bridge framework. Thus, the
gender, physical appearance, age, personality, cultural condition of the remaining dentition, the number of
and ethnic background, profession, lifestyle require- remaining dentition, parafunctional habits, type of occlu-
ments, and financial capability are all factors that will sion, and leverage are all determinant factors that assist
eventually influence the selection of a suitable treat- selection of this treatment modality.
ment modality.46
There are various methods for restoring lost anterior
teeth; these encompass conventional bridges, resin-
Adhesive Bridges
bonded bridges, implant-supported restorations, remov- An alternative treatment option that has been suggested
able partial dentures, or a combination of all of these in conserving and restoring missing dentition in the aes-
various options. thetic zone is adhesive bridges. They eliminate the need
for substantial destruction of natural abutments. Adhe-
sive bridges were originally introduced by Rochette to be
Conventional Fixed Bridges used as periodontal splints.53 However, adhesive bridges
Fixed bridges have been for a long time the most ideal present a treatment option that is different from conven-
treatment modality for restoring natural dentition. They tional bridges. Adhesive bridges require greater clinical
represented the school of thought in which aesthetics was skills than do conventional bridges, and another point
of prime importance, even if the structure of the remain- worth mentioning is the possibility of recurrent dental
ing natural teeth was compromised. caries occurring around the bridge margins and line
Conventional bridges have exhibited clinically proven angles. De-bonding of adhesive bridges, which leads to
high success rates with their excellent aesthetics and long- loosening of the bridge, tends to occur at a frequency rate
term functional serviceability.47 However, in spite of their as high as 25-31%.54>55 De-bonding tendency is consid-
outstanding clinical performance, there is a significant ered the major complication of this type of bridge, which
variation in their success rates as documented in the liter- limits its regular daily use. Resin-bonded restorations
ature, ranging from 97 to 80%.48'49 These variations are have shown a wide range of clinical results as cited in the
probably due to differences in clinical performance, pre- literature, from a failure rate of 54% in eleven months
cision of the bridge fabrication, and the type of the metal (when used in the absence of mechanical retentive meth-
alloy used. ods) to a success rate of 92.9% in 127 cases (with a mean
The main reason for failure of conventional bridges is longevity of five years), as reported by Barrack.56'57
attributed to endodontic failure of the abutment teeth Resin-bonded bridges can only be suggested to a
after an unknown period of time.30 The extensive patient who is seeking a temporary, inexpensive aesthetic
destruction of the abutment teeth through tooth prepara- solution for a particular period of time. The specific
tion for conventional bridges is now considered to be a nature of this treatment option should be explicitly
clinical drawback, especially when the teeth are sound. explained to the patient.
The immense loss of tooth structure during tooth prepa-
ration can be the actual reason for unsatisfactory results
with this treatment option.
Dental Implants
With the evolution of dental implants, preservation Unlike the previous alternatives, dental implants as a
of natural teeth that would normally be used to serve as predictable treatment option have been investigated
abutments for a fixed bridge has been emphasized. In exhaustively over the past few years under controlled
other words, dental implants have paved the way for a parameters, especially in completely edentulous
shift in thought towards preservation of the remaining patients.58"60 Since the late eighties, continuous research
18 CHAPTER 2

and sophisticated statistical analysis have shown dental tion, certain parts of the denture framework or acrylic
implants to be a predictable treatment option for dental resin can sometimes become visible while talking or smil-
restoration in totally and partially edentulous patients.58 ing, which may not be aesthetically pleasing and thus
The scope of dental implants later expanded to may negatively contribute to the social dimension.67 The
include the treatment of missing single teeth; this treat- aesthetic and functional outcome of fixed partial den-
ment has shown consistent success rates ranging from tures, that is, conventional bridges, is regarded as being
91 to 97.4% over a 3-6 year period.59'60 However, a few usually superior to that of a removable partial denture.68
complications were encountered with this treatment In conclusion, making a removable partial denture is a
modality; screw loosening has been reported most often feasible solution for patients who are unable to afford
as an uninvited event associated with single-tooth other treatment alternatives due to financial limitations
implant-supported restorations.61 This drawback has or for whom other treatment modalities are contraindi-
been overcome to a great extent by the introduction of cated. It is also convenient for those who prefer not to
new implant-abutment connections that provide greater undergo sophisticated treatment procedures that might
surface areas, stability against lateral displacement, and involve soft and hard tissue grafting.
a predictable retention.
Implant dentistry has dramatically changed the con-
ventional routine of restorative dentistry. It has inspired
Points of Consideration
many clinicians who, in turn, have contributed to Prior to the final selection of the course of treatment to be
improving the clinical aesthetic outcome of this treatment undertaken, the patient must be made aware of the
modality. New soft and hard tissue augmentation proce- approximate total cost and time for the treatment
dures were developed to optimize the long-term aesthetic involved. There are several steps required not only to
outcome of dental implants.62 In partially edentulous insert an implant and its prosthetic components, but also
patients, dental implants offer the advantage of eliminat- to construct the overlying restoration and maintain the
ing the necessity of natural abutment preparation. They implant and its related components. The patient must
are considered to be the best tooth replacement alterna- have an active role in selecting a specific treatment plan
tive for both young and old patients because they pre- from among several proposed ones; this role comes after
serve the structural integrity of the natural dentition. If thorough explanation of the pros and cons of each proce-
the dental implant treatment should fail at any time, dure proposed; this procedure splits the responsibility for
other treatment options would still be available as a next treatment choice morally between the patient and the
line of treatment, which makes this treatment modality clinician.
unique in its kind. Moreover, retrospective and prospec- An anterior implant-supported prosthesis invariably
tive studies have reported that dental implants have a requires the clinician to spend more time, effort, and skill
positive effect on the recipient's well-being and quality of than replacements in the posterior zone. Sometimes addi-
life, which has added a new social dimension to this treat- tional corrective peri-implant soft tissue surgeries in the
ment modality.63 aesthetic zone are necessary; these consequently increase
the overall cost of single anterior implant-supported
restorations up to one-third of the total cost, and the time
Removable Partial Dentures required for treatment completion is eventually doubled.
Removable partial dentures have been a treatment of Therefore, to avoid any disappointments or misunder-
choice when there are multiple missing teeth that may be standings between the patient and the clinician, the
dispersed throughout the dental arch and are not neces- approximate time and cost required for each treatment
sarily next to each other. This treatment option is also option should be a distinctive part of the doctor-patient
indicated when the remaining teeth are mobile and future preoperative communication that is confirmed with a
extractions are expected. In addition, when patient signed consent by the patient.
resources are limited and the cost of treatment is a deter- It is also possible that the dentist may be biased
mining factor, the relative inexpensiveness of removable towards a particular treatment plan, rather than follow-
partial dentures becomes a good incentive for choosing ing an objective approach.69 This can happen when a
this line of treatment. clinician prefers certain procedures or is capable of per-
However, as with other treatment options, partial den- forming some procedures better than others. Although
tures are not exempt from drawbacks. The possible this is not a recommended attitude, it is the clinician who
occurrence of periodontal disease and natural tooth is, at the end, responsible for the treatment choice and its
decay adjacent to the abutment teeth is one of the major results. Therefore, the clinician is urged to select a rea-
disadvantages. Resorption of the alveolar ridge due to sonable treatment option that both suits the patient's best
pressure from the fitting surface is another.64"66 In addi- interest and is compatible with the clinician's skills. This
PRESURGICAL CONSIDERATIONS 19

means catering to each patient's needs on an individual

basis. Trustful dentist-patient communication remains
critical and should be maintained throughout the course
of treatment on both sides.
Patients seeking aesthetic treatment should be encour-
aged to understand and evaluate the entire scope of the
clinical task to be carried out. When patients fully com-
prehend the extent of the work entailed, they will be able
to appreciate it and convey a good impression to their
personal contacts. In conclusion, the patient's positive
attitude and greater willingness to cooperate during the
treatment will surely lead to a better working environ-
ment for the dental team.

PROVISIONALIZATION
PLANNING
As the word provisional suggests, provisionalization
involves something that is used temporarily, to serve for a
short period of time, until the permanent service is ren-
dered. In this regard, its application to dental treatment is
no exception. A critical stage in tooth replacement in the
aesthetic zone is in the interim between implant insertion
and surgical uncovering at the second-stage surgery. At
this time, a provisional prosthesis may be used to tem-
porarily restore the missing dentition and to maintain the
social appearance of the patient. In fact, many patients, FIGURE 2.10a,b. Removable partial denture is used to
especially those who are "aesthetically conscious," ask a provisionally restore four missing anterior teeth during
common question: Will I stay without teeth during the the grafting and implant integration period.
treatment? Although these patients may have been edentu-
lous for years, their question can be explained as a turning
point in their lives and a starting point for a new social Removable partial dentures can be indicated when
and aesthetic era to be fulfilled. The provisional prostheses there are adjacent or scattered multiple missing teeth (Fig.
should be designed to sustain or improve the quality of life 2.10a,b). Being removable can be an advantage by itself:
for patients undergoing implant therapy.70 this facility is important during surgical intervention, as
A provisional prosthesis can be a valuable aid in deter- the partial dentures can be removed and then replaced
mining the final tooth position, exact tooth shade, and once the procedure has been completed without any clin-
occlusal scheme of the definitive prosthesis. Moreover, it ical complexity. Removable dentures also act as a stimu-
can reveal any additional requirements for improved aes- lus for bone remodeling around dental implants in totally
thetics and patient comfort.70 The type of provisional edentulous patients and can be used to confirm osseointe-
prosthesis should be determined during the presurgical gration before the final prosthesis is constructed.73 This
planning phase by the dental team.70 A provisional type of provisional solution provides an inexpensive pro-
restoration can be necessary to guide healing of the soft visional modality that must be taken into account based
tissues around dental implants to develop the emergence on the patient's financial status. The patient may feel psy-
profile until it reaches the original anatomical dimensions; chologically improved with the edentulous area tem-
this can minimize the need for further soft tissue manipu- porarily restored and other related facial structures being
lation.71 The main advantage of the interim prosthesis is supported. However, the patient should be reminded that
that it acts as a reference in designing the final prosthesis.72 the prosthesis is only a temporary alternative for the
When considering a provisional prosthesis for a missing space.
patient who will receive an implant-supported restora- Removable partial dentures can be limiting in their
tion, the available options are removable partial denture, function, especially during speaking or chewing, due to
resin-bonded bridge, or temporary implants. instability. Furthermore, some precautions need to be
20 CHAPTER 2

observed when removable partial dentures are used as a

provisional modality for totally or partially edentulous
patients; the appliance must be relieved from its fitting
surface on top of the implant heads to avoid any biting
load being exerted on the implants during the healing
period. In addition, the material lining of the denture
tends to dry out or become stiff over a period of use. This
can be handled by changing the lining material at
monthly intervals to maintain the elasticity of the fitting
surface of the denture.
A resin-bonded bridge, on the contrary, does not exert
any pressure on the implant area. It is better tolerated by
the patient and may be more reassuring than a removable
partial denture because of the improved aesthetic results,
stability and fixation. However, a resin-bonded bridge
FIGURE [Link]. Provisional resin-bonded bridge
can be a deterrent when multiple reentries to the surgical cemented in place after implant placement, thus restor-
site are required (Fig 2.11a-c). ing the patient aesthetics and function.
Temporary implants are bringing in a new era for pro-
visionalization. They are commercially available from
several companies and have solved many clinical prob- lems, especially for totally edentulous patients. They are
self-tapping screws that have a diameter ranging between
1.8 and 2.8 mm and come in an assortment of various
lengths. They are fabricated from either grade one com-
mercially pure titanium or tritium alloy. These implants
are inserted through a one-stage drilling procedure (only
a pilot drill) with minimal surgical intervention. They
should be placed at least 1 mm from the site of the per-
manent implants to avoid interrupting osseointegration
around the implant-bone interface. They can be easily
removed by reversed torque or by using a small diameter
trephine drill after completion of the healing period for
the permanent implants. They can be a reliable treatment
alternative for patients who refuse to wear a removable
prosthesis.74 Temporary implants exhibit several advan-
tages, including the possibility of providing immediate
function after implant placement, uneventful soft tissue
FIGURE [Link]. Resin-bonded bridge.
healing on top of the permanent implants, and restora-
tion of phonetics and aesthetics.75
Improper placement of transitional implants can cause
damage to a previously reconstructed alveolar ridge or
jeopardize osseointegration around permanent implants.
Another drawback is the difficulty of using these
implants in the restoration of a single missing tooth due
to lack of space (Fig. 2.12a,b ). Transitional implants can
be an ideal treatment option when more than two
implants are to be inserted. This can be accomplished by
placing a temporary implant positioned between the per-
manent fixtures or in a lingual position if the width of the
alveolar bone allows.
The previously mentioned interim restorations are
considered as a major part of the whole definitive treat-
ment plan for patients receiving dental implants. Patients
FIGURE 2.11b. A long-span resin-bonded bridge on a seeking aesthetic treatment should be encouraged to
study cast. understand the entire scope of the clinical task to be car-
PRESURGICAL CONSIDERATIONS 21

FIGURE 2.12a. Two transitional implants used to sup-

port a provisional restoration along with the temporary
abutment.
FIGURE 2.13a. An edentulous area showing soft tis-
sue defects at the future implant sites that mandates cor-
rection before implant placement.

FIGURE 2.12b. The provisional restoration in place;

note that it has its support mainly on the two transi-
tional implants and partially on the temporary abut-
ment. FIGURE 2.13b. A subepithelial soft tissue graft com-
bined with the coronally repositioned flap is performed
in order to improve the soft tissue status.
ried out. When patients fully comprehend the extent of
work entailed, they will be able to appreciate it and Meticulous assessment of the soft tissue status related
accept the difficulties that might occur during the period to the future implant site should be established during the
of the treatment. clinical examination at the presurgical stage. The healthy
soft tissue profile plays a critical role not only in estab-
lishing optimal aesthetics, but also in facilitating long-
SOFT TISSUE QUALITY AND term maintenance of implant-supported restorations.78
QUANTITY Some authors have shown conclusive results concerning
the relationship between the condition of soft tissue and
Aesthetics in the anterior region relies heavily on healthy the implant survival; they concluded that neither the
keratinized gingival tissue; this fact applies to both nat- absence of inflamed soft tissue nor a specific amount of
ural dentition and implant-supported restorations.76 Gin- keratinized mucosa is required to ensure a successful
gival components that contribute to an aesthetically osseointegration.79'80 On the contrary, some authors have
pleasing implant-supported restoration are the marginal confirmed that the absence of a keratinized mucosa might
radicular form, the interdental tissues, and the color and jeopardize implant survival.81'82 In addition, some authors
texture of healthy keratinized tissues (Fig 2.13a-c).77 have stated that a minimum of 2 mm of keratinized tissue
22 CHAPTER 2

Two different distinctive periodontal patterns are pre-

sent in the human oral cavity: the thin scalloped biotype
and the thick flat biotype. The thick flat type is more
prevalent (85%) than the thin scalloped biotype
(15%).88'89'90 Each type has morphological characteristics
of its own with its distinctive adjoining structures. Recog-
nizing and distinguishing these basic types is essential in
selecting the implant size, implant type, and surgical
approach, and in predicting the overall prognosis that
will result in biological harmony between the dental
implants and the existing dentogingival structures.
The thick flat biotype (Figs 2.14a,b) is characterized
by adequate amounts of masticatory mucosa. It is dense
and fibrous in nature with minimal height difference
FIGURE 2.13c. The final soft tissue condition after between the highest and lowest points on the proximal
clinical intervention; note the continuity of the kera- and facial aspects of the marginal gingiva; therefore, it is
tinized band.

width is needed to achieve optimal health of the tissues

surrounding natural dentition.83'84 Others have suggested
that less than 1 mm of keratinized tissue can be adequate,
provided the bacterial plaque is well controlled.85
Generally speaking, the presence of a sufficient band
of keratinized mucosa will surely improve the aesthetic
outcome of the definitive implant-supported restoration.
The presence of the keratinized band can also minimize
postoperative gingival recession, endure the trauma of
brushing, resist masticatory muscle pull, and reduce the
probability of soft tissue dehiscence above implant fix-
tures. Because soft tissues have the tendency to recede
almost 1 mm after surgical and restorative implant proce-
dures,86 a sufficient amount of healthy keratinized gingi-
val tissue should exist prior to implant placement for FIGURE 2.14a. Thick flat tissue biotype clinically;
note the square shape of the crown and the width of the
compensation. Therefore, optimizing the soft tissue qual-
keratinized tissue band.
ity and quantity before commencing on implant therapy
becomes a vital prerequiste. In the presurgical planning
stage, the timing of soft tissue augmentation therapy
(whether it is to be performed before, during, or after
implant placement) will be determined.
Note that Chapter 4 will cover all the soft tissue
manipulations around dental implants.

TISSUE BIOTYPES
Healthy human periodontium is comprised of radicular
cementum, periodontal ligament, gingiva, and investing
alveolar bone.87 It is the integration of all these biological
elements that maintains the periodontium in a state of
harmony that makes it unique. The natural morphology
of the healthy periodontium is characterized by a rise and FIGURE 2.14b. Periapical view showing the morpho-
fall of the marginal gingiva following the underlying alve- logical characters of the thick flat tissue biotype. Note
olar crest contour both facially and proximally. the reduced inter-radicular bone thickness.
PRESURGICAL CONSIDERATIONS 23

called flat. Larger sized teeth that are most likely square
shaped characterize this type of periodontium. This bulk-
iness of the tooth shape results in a broader, more api-
cally positioned contact area, a cervical convexity that
has greater prominence, and an embrasure that is com-
pletely filled with the interdental papilla. The root dimen-
sions are broader mesiodistally, almost equal to the width
of the crown at the cervix, which causes a diminution in
the amount of bone interproximally. The typical reaction
of this tissue biotype to trauma such as tooth preparation
or impression making is inflammation and apical migra-
tion of the junctional epithelium with a resultant pocket
formation.
The thick flat tissue type is ideal for placing dental
implants. Here the gingival and osseous scalloping is nor-
mally parallel to the cementoenamel junction (CEJ).91
The minimal undulation of the CEJ between adjacent
teeth, which predictably follows the natural contour of
the alveolar crest, makes the gingival tissues more stable.
Consequently, this type of periodontium is less likely to
exhibit soft tissue shrinkage postoperatively.91
On the other hand, the thin scalloped biotype of peri-
odontium exhibits its own distinctive features. These
include thin, friable gingiva with a narrow band of
attached masticatory mucosa, and a thin facial bone that
usually exhibits dehiscence and fenestration (Fig
2.15a,b). The tooth crown shape usually exhibits a trian-
gular or thin cylindrical form, and the contact areas are
smaller and located in a further incisal location. The cer-
vical convexity is less prominent than that of the thick
biotype, while the interdental papilla is thin and long but FIGURE 2.15b. A view showing the root shape of the
does not fill the embrasure space completely, resulting in thin scalloped dentition.
a scalloped appearance.92 Additionally, this biotype pos-
sesses a root that is narrow with an attenuated taper,
allowing for an increased amount of interradicular bone.
When inflicted with trauma, this tissue type undergoes
gingival recession both facially and interproximally. Plac-
ing dental implants in the aesthetic zone becomes a criti-
cal task with this particular tissue biotype because it is
difficult to achieve symmetrical soft tissue contours prob-
ably due to the proximity of the implant to the natural
tooth periodontium next to it, and the reduced amount
of masticatory mucosa.93 The resultant recession and
bone resorption leave a flat profile between the roots,
with marginal exposure of the restoration and subse-
quent partial loss of the interproximal papilla.94
A proper appraisal of the periodontium should be per-
formed prior to commencing any implant therapy in the
aesthetic zone. Each tissue type reacts differently to surgi-
cal intervention, thereby warranting a specific treatment
FIGURE 2.15a. Clinical picture of the thin scalloped protocol. The thin scalloped tissue type should be treated
tissue biotype. Note the reduced crown width and the with an exceptional caution and utmost care (especially
apically located interdental papillae. for patients with a high smile line).
24 CHAPTER 2

BONE QUANTITY AND of bone is optimal for hosting an implant with a

diameter between 4 and 5 mm.
QUALITY Division B (Barely Sufficient Bone). A slight to moder-
ate atrophy has occurred, leading to a decrease in the
Replacing missing dentition with dental implants
width of the available bone at the expense of only the
demands both optimized bone quantity and bone quality
facial cortical bone. The height remains stable at a
at the edentulous site. Optimal osseous volume has a pos-
minimum of 10 mm. The remaining available bone
itive influence on osseointegration.95"97 Therefore, empha-
width varies between 3 and 5 mm and is thus able to
sis should be placed on inserting an implant in a sufficient
accommodate an implant of 4 mm maximum width.
osseous foundation when a predictable, successful aes-
The load's angulation may not exceed 20 degrees.
thetic and functional outcome is to be achieved.
Treatment options presented for this type are osteo-
It has been reported that the alveolar bone loses
plasty, bone augmentation, or the use of narrower
almost 30% of its size within two years following tooth
diameter root form dental implants.
extraction.98 Both maxilla and mandible have distinctive
Division C (Compromised Bone). Moderate to advanced
resorption patterns that affect both the width and height
atrophy is present, with the width less than 2.5 mm,
of the alveolar bone (Fig. 2.16)."~101 Subsequently, bone
height less than 10 mm, load angulation greater than
dimensions become insufficient to host the implant fix-
30 degrees, and crown-implant body ratio equal to or
ture, thus negatively affecting the overall prognosis of the
greater than one. The posterior maxillary and
implant-supported prosthesis. It follows that alveolar
mandibular regions demonstrate this type of alveolar
bone quantity and quality are an absolute necessity for
bone more than the anterior segments.
dental implant success on both levels—aesthetically and
Division D (Deficient Bone). This type demonstrates
functionally.
severe atrophy, accompanied by basal bone loss.
The significance of the quantitative and qualitative
Therefore, the use of autogenous bone grafts is
parameters of the osseous structure is immense; conse-
strongly recommended to augment the deficient alve-
quently, the subject has been discussed at length in most
olar bone. This kind of bone usually results in com-
textbooks. Many authors have classified the remaining
plications related to soft tissue management,
alveolar bone differently in order to assess and diagnose
grafting, and early implant failure.
the remaining alveolar bone. Misch has classified the
available alveolar bone into four distinct divisions95:
The above classification can help the practitioner to
Division A (Abundant Bone). Alveolar bone width is precisely determine the specific bone category of each par-
more than 5 mm, height greater than 10-13 mm, and ticular patient. This, in turn, enables the clinician to select
mesiodistal length greater than 7 mm, and the load's the appropriate treatment protocol. The necessity of
angulation does not exceed 30 degrees between the undergoing a bone grafting procedure exists in many con-
occlusal plan and the implant body. In addition, the ditions, and subsequently, a surgical technique can be cho-
crown-implant body ratio is less than one. This type sen that provides a treatment prognosis with maximum
predictability from either an aesthetic or functional aspect.
Salama and Salama have introduced another classifi-
cation that considers the available bone according to the
socket condition that will host the future implant fix-
ture.102 This classification can be helpful when an imme-
diate implant placement is the treatment of choice,
because the condition of the alveolar socket will dictate
the treatment plan. Details of this classification are pro-
vided later in this chapter.
Several techniques are now available for evaluation of
bone quantity and quality. Radiographic examination,
especially tomograms or CT scans, can provide the accu-
rate dimension for the alveolar ridge at a specific prede-
termined location, as well as the bone density. Bone
density in the aesthetic zone generally falls into the D3
FIGURE 2.16. View of anterior maxilla showing severe category, where 65% of the anterior maxilla constitutes
bone resorption that hinders implant placement. this category.103
PRESURGICAL CONSIDERATIONS 25

In many conditions, it is extremely important to assess

the bone architecture using a CT scan or a ridge mapping
method29 because the anterior maxilla usually exhibits
labial concavities that might necessitate bone grafting
procedures or placing the implant fixture at an angle and
using a pre-angled abutment.104
Reconstruction of the deficient alveolar bone in the
aesthetic zone will be discussed in detail in Chapter 5.

ORTHODONTIC AND
ENDODONTIC
CONSIDERATIONS FIGURE 2.17b. Panoramic view confirming the
absence of the congenitally missing tooth in the maxil-
The increased demand for the use of dental implants to lary bone.
restore missing dentition and enhance aesthetics has led
orthodontics to become an integral part of a multidisci-
plinary approach to implant therapy. This approach can
help solve certain clinical dilemmas and reduce the ten-
dency for performing invasive surgical procedures.
As a result of tooth loss, especially due to premature
extraction of deciduous dentition, drifting of the remain-
ing teeth occurs. Therefore, there will be a demand to
recreate or develop the lost space to its original optimal
dimensions.105 The use of a narrower implant diameter is
not always considered a preferred treatment modality in
most of these conditions because narrow implants often
result in compromised aesthetic and functional results.
Developing space (Fig. 2.17a-e) for the missing dentition
therefore becomes valuable in regaining the original nat-
ural dimensions.
Salama and Salama106 were the first to describe the FIGURE 2.17c. Panoramic view showing the space
applications of the conventional orthodontic techniques created with orthodontic movement where the upright
position of the roots is evident.

FIGURE 2.17a. A study cast showing a congenitally FIGURE 2.17d. The space developed is clinically
missing maxillary right central incisor. noticed.
26 CHAPTER 2

Orthodontic extrusive remodeling or extrusion com-

bined with tooth extraction is used currently in regular
orthodontic treatments.102 This procedure is originally
performed to gain access to deep carious cavities or in the
treatment of crown and root fractures below gingival
margins. In this technique, slow eruption of teeth using a
light eruptive force of 25-30 g will result in a coronal
migration of the entire attachment apparatus.110 As a
result, new bone is deposited in the apical area above the
root apex, and is accompanied by an increase in the
width of the attached mucosa and the proximal papillae
at the cervical area (Fig. 2.18b-k).m
FIGURE 2.17e. A pontic attached to the orthodontic
wire to be used as a provisional prosthesis.

to facilitate implant placement.102 They made use of the

so-called restorative orthodontics to develop the
supragingival restorative space (space development).
They applied this technique in situations where the resid-
ual space was not sufficient for placing a dental implant.
In some cases selecting the venue of implants as a
treatment of choice must be disregarded. This is espe-
cially the case when a space may not be created ortho-
dontically, either because orthodontic treatment is not
indicated or because the patient refuses to go through
with it.
The periodontic-orthodontic management is yet
another clinical treatment approach that has been sug-
gested for achieving greater osseous support.107'108 This
method entails forced eruption of unsalvageable residual
roots that will be replaced by dental implants (Fig.
2.18a). In other words, soft and hard tissues may be
manipulated to favor the placement of an aesthetic
restoration.109

FIGURE 2.18b,c,d. Three different clinical views of

unsalvageable severely compromised anterior teeth with
FIGURE 2.18a. Illustration showing forced eruption. loss of the natural height of the interdental papillae.
PRESURGICAL CONSIDERATIONS 27

FIGURE 2.18e. Orthodontic appliance on the cast to FIGURE 2.18h. Forced eruption occurred to the roots
move the remaining roots in an occlusal direction. with remarkable movement of the interdental papillae in
an incisal direction.

FIGURE 2.18f. The appliance in place; note the hook FIGURE 2.181. Implants in place.
with the rings attached together.
direction. Thus, an increase in the available alveolar bone
height is to be expected.112 Subsequently, the coronal
migration of the attachment complex promotes regenera-
tion of the papilla and adjacent gingival contours, thus
enhancing the aesthetic outcome. The tooth to be
removed must be allowed to move only in an axial direc-
tion without tipping, which might cause penetration of
the labial plate. Extrusion should be brought about at a
speed that does not exceed the rate of bone deposition. It
usually requires three to four months to occur. This is
only half the waiting time needed for a bone-grafting pro-
cedure, bearing in mind that this procedure is less trau-
matic to the patient than others. On the other hand,
patient selection and motivation are important factors to
be considered before undertaking these procedures.
FIGURE 2.18g. A device that measures the optimal The local surrounding environment of the proposed
force used to activate forced eruption. implant sites can be an issue of concern during the
presurgical stage of implant therapy. Any endodontic
During extrusive orthodontic movement, the alveolar lesion should be eliminated before any implant surgery
bone attached to the root surface by periodontal fibers takes place, because it can lead to a possible implant fail-
migrates along with the investing soft tissues in an incisal ure.113 During the initial stage of osseointegration, the
28 CHAPTER 2

FIGURE 2.18j,k. The case restored finally.

implant can be particularly vulnerable if placed in closer anatomy, lip line, lip curvature, nasolabial angle, lip
proximity to an endodontic pathological lesion.114 This thickness, smile line, and facial complexion.
thought was raised in a case report by Sussman in which The outline of the lip, or lip-frame, that surrounds nat-
he suggested that an implant does not have the ability to ural dentition is a major facial element that contributes
withstand any bacterial challenge during the healing dramatically to dental aesthetics; consequently, it
period.115 demands careful inspection.118 Several authors have
However, Novaes and Novaes116 later argued that described the anatomical landmarks of the lip in order to
placement of an implant into a socket that has a chronic diagnose facial deformities and assist in defining an opti-
endodontic lesion does not necessarily result in failure, mal treatment plan (Fig. 2.19); the Burstone line is a refer-
provided certain precautions are taken.116 The authors ence line that connects the subnasale point to the
suggested complete removal of the causative factor (the pogonion point. The upper and lower lips are compressed
unsalvageable tooth) with careful and thorough debride- by this reference line (ideally +3.5 and +2.2 mm, respec-
ment of the socket. Administration of antibiotics to begin tively, above this line).119 The Steiner line is a line joining
at least two days prior to surgery and to be maintained the midpoint of the nose to the chin, where the patent's
ten days postoperatively was recommended. This was lips touch this line.120 The Ricketts' E-plane describes a
intended to reduce or eliminate the likelihood of bacterial line that extends from the tip of the nose to the chin, in
contamination; after the course of antibiotics was com- which the maxillary and mandibular lip positions mea-
pleted the host cells could take control. The decision sure 4 and 2 mm, respectively.121 For the most favorable
whether to remove the lesion before or with the implant facial aesthetics, the distance between the subnasale point
placement remains dependent on the clinician's judgment. (base of the nose) and the upper lip should be approxi-
mately half the distance measured from the lower lip to
the menton (lowest chin) point.122
FACIAL ANALYSIS
Patients electing to go through aesthetic reconstructive
surgery have certain expectations. These expectations
revolve around an improvement in the way they look,
specifically their smile; patients focus not particularly on
the new restoration itself as a separate entity, but rather
on what it has done for their final overall appearance.117
Therefore, the smile is considered a major component
that should be involved in the presurgical evaluation and
should be emphasized in any aesthetic treatment plan.
For any aesthetic reconstruction of the oral cavity to
be regarded as being comprehensive in nature, an in-
depth analysis of the facial morphology and structures is
mandatory to ensure a harmonious treatment outcome.
The facial structures that are considered integral to the
examination, as related to the dental assembly, are the lip FIGURE 2.19. Lip anatomy.
PRESURGICAL CONSIDERATIONS 29

Lip size and thickness may sometimes influence the

aesthetic perspective of the patient, and consequently, the
treatment plan to be embarked upon. It is the author's
opinion that a thick lip can mask the marginal artifacts of
the final prosthesis to some extent, and it can also influ-
ence the restoration design. (Fig. 2.20). On the other
hand, a patient with a thin lip tends to exhibit a greater
display of the entire restoration, which in most cases has
lingually inclined margins. Additionally, the thinner the
lip, the shorter the tooth and more lingual its position.123
Therefore, careful evaluation of lip size, thickness, and
character will define what shape and form the future
restoration should have. At the same time, it will deter-
mine how much of the restoration should be displayed
while smiling or with the lip in any other position. FIGURE 2.21a. A view showing missing anterior teeth
The teeth and the alveolar bone support the outward that led to drop of the lip, due to losing its support.
position of the lips. Once loss of dentition has occurred,
it is followed by typical bone resorption on the facial
aspect of the maxilla. As a result, the lip loses its support
and tonicity, and appears wrinkled or dropped or sunken
in (Fig. 2.21a,b). To regain the original state of the lip's
tone, dental implants should be placed at the original site
of the missing tooth to be replaced and not where the
bone is available. A carefully fabricated wax-up on the
study cast will indicate the amount of osseous structure
required facially to support the lip and return it to its
original position. Note that the cervical and middle thirds
of the crown contour are to a great extent mostly respon-
sible for determining the lip support.124
Changes in the facial musculature that occur as a
result of the incumbent emotional state lead to the smile
effect. It is the manner in which the lips, teeth, and sil-
houettes blend to create harmony that gives a smile its
FIGURE 2.21b. The lip support is restored after com-
own unique magical character.125 The profound psycho- prehensive oral reconstruction.
logical effect that smiling has on a human being explains
its value.126 The development of the smile, from the quar-
ter smile, to the half smile, to the full smile, in relation to
the amount of tooth displayed will suggest to the clini-
cian whether to display or hide the morphological devia-
tion in tooth-gingival relationships.127 A smile line is
defined by Philips as a line that shows a dark or negative
space when both jaws separate (Fig. 2.22a-c).128 In other
words, the silhouettes of the incisal edges of the maxillary
teeth in comparison to the mandibular incisal edges can
also define the smile line.
In young individuals, only 3-4 mm of the incisal edges
of the maxillary central incisors are usually displayed at
the rest or repose position of the lips. With a full smile,
the maxillary lip is required to translate approximately
6-8 mm to expose almost 10-11 mm of the clinical
crown. A patient with a hyperactive maxillary lip, how-
FIGURE 2.20. Thick lip can mask many prosthetic ever, may translate 1.5-2 times the normal distance.131 In
artifacts. older patients the upper lip loses its muscle tone and
 30 CHAPTER 2

Rubin has classified smiles into five categories: a max-

illary smile showing only the maxillary teeth; a maxillary
smile showing more than 3 mm of gingiva, also often
referred to as a gummy smile; a solely mandibular smile;
a smile with both maxillary and mandibular teeth
appearing; and lastly, a smile which is neither maxillary
nor mandibular.129 It is noteworthy to mention that a
gummy smile or an increased bite over jet does not neces-
sarily warrant reconstructive correction. Sometimes, if
the gingival tissue that is exposed during a smile is mod-
erate, it can add a touch of beauty to the facial complex,
thereby giving a distinctive appearance to the person (Fig.
2.23).
Rubin also stated that there are three basic styles of
FIGURE 2.22a. Low smile line. smiles. A commissure smile is the most common type
(67%); the corners of the mouth are initially pulled
upward and outward, followed by rising of the upper lip
to exhibit only the maxillary teeth. A cupid smile, occur-

FIGURE 2.22b. High smile line.

FIGURE 2.22c. Medium smile line.

tends to lengthen, hiding more of the maxillary dentition

and exposing more of the mandibular dentition; this FIGURE 2.23. A picture of a famous Egyptian actress
observation can be valuable when a totally edentulous showing a slight gingival display that can add to the
patient is to receive restorative rehabilitative treatment. beauty of the face.
PRESURGICAL CONSIDERATIONS 31

ring in 31% of the population, exposes the canines and face, to obtain complete harmony of the dentofacial
then the corners of the mouth. A complex smile, how- complex.133"135
ever, appears in only 2% of the population; it shows all The shape of the central incisors can arbitrarily reveal
the maxillary and mandibular teeth simultaneously dur- a patient's age or gender. A longer, rectangular-shaped
ing elevation of the upper lip and contraction of the central incisor, gives a more youthful appearance.133 On
lower lip.129 the other hand, incisal wear and attrition that occur with
Smile design is a novel expression introduced by Mor- age result in a short and square central incisor, which
ley.130 He defined smile design as a discipline involving characterizes old age. Lateral incisors can reveal the gen-
the diagnosis and subsequent planning for primarily the der of a person. A feminine lateral incisor possesses a
aesthetic component of the overall dental treatment. In more constricted neck with rounded incisal edges, while
other words, it is the modification of the amount of tooth masculine lateral incisors tend to be flatter and wider,
displayed while smiling, using the available tools and with square incisoproximal angles, and sometimes attain
applying the principles of design to anterior dental aes- a width closer to that of the neighboring central incisors
thetics. This approach can turn an average restorative job (Fig. 2.24a,b).133'134
into an outstanding one while at the same time preserv- All these observations should be gathered from range
ing the existing natural beauty.131 of facial expressions as well as during various forms of
Aesthetic factors that contribute to smile design and the patient's speech. Since individuals are conditioned to
can be influenced in the treatment consist of the incisal conceal aesthetic discrepancies with pretentious rather
and occlusal plane; size and inclination of the central than natural demeanors, these extreme facial expressions
incisors; midline position; axial alignment of the remain- or poses must be carefully recorded before the treatment
ing teeth; size and form of the arch; lip line to the incisal commences.135
edge position; form and morphology of the dentition;
position of the contact points; and gingival height, zenith
color, and contour.136"138 EMERGENCE PROFILE
The maxillary central incisors play an important role
in smile design. They represent the gateway to the oral The ability of the clinician to understand and control the
cavity and are invariably apparent in any smile. It is no relationship between the implant and its associated gingi-
wonder that a missing central incisor is best restored val structures is extremely important in achieving an aes-
when a method that focuses on duplicating the original thetic final implant-supported restoration. The position
natural tooth's appearance is selected. Therefore, infor- of the gingival margin following stage-two surgery repre-
mation about the original position, shape, and size of the sents a collapsed state, until it finds support by the pros-
central incisors is vital to restoring a patient's smile.132 thetic components against which it comes to rest.111 The
Moreover, in major aesthetic reconstructive procedures, gingival tissues around dental implant components
it is important that the midline be adjusted centrally to should be enhanced, influenced and developed to acquire
coordinate with the other anatomical landmarks in the the same dimensions and configurations as the original

FIGURE 2.24a. Showing an unpleasant smile due to FIGURE 2.24b. Showing the remarkable improvement
improper position and morphology of the prosthesis. of the smile after replicating the original tooth form and
position.
32 CHAPTER 2

tissues around natural dentition. The original soft tissue condition, and the type of future prosthetic components to
configuration around natural teeth possesses a flat profile be used. Since an implant differs from a natural tooth in its
at the point where they erupt from the marginal mucosa morphological characteristics, the cylindrical shape of the
(Fig. 2.25).139'140 implant has to be improved upon in the subgingival com-
The use of the different prosthetic components after partment. It rarely corresponds to that of a tooth. This
the second-stage surgery will allow the maturation of compels the clinician to compensate for this discrepancy by
peri-implant soft tissue to develop a peri-implant dimen- developing the soft tissue through the precise fabrication of
sion in the subgingival area that gradually develops the a provisional restoration that transfers the cylindrical
emergence profile of the final prosthesis matching the shape of the implant to the shape of the root of the natural
dimensions of the tooth to be replicated. The use of an tooth at the gingival margin, that gradually influences the
accurately fabricated surgical template can help ensure peri-implant soft tissue to the desired configuration.142
accurate implant positioning in relation to the adjacent
dentition, which directly influences the resultant emer-
gence profile.141 Therefore, precise implant placement
and careful soft-tissue manipulation will allow the clini- SURGICAL TEMPLATE
cian to enhance the peri-implant soft-tissue contours with
the use of provisional restorations. Provisional restora- Optimal placement of dental implants becomes a vital
tion will encourage gingival maturation to provide an clinical prerequisite in fulfilling the patient's desires and
ideal frame for the implant-supported prosthesis. The expectations.143 The precise placement of dental implants
cervical third of the labial aspect of the provisional pros- is essential to designing a prosthesis that satisfies the aes-
thesis is responsible for stimulating peri-implant tissues thetic and functional requirements and simultaneously
and developing the natural emergence. The basic require- allows clear phonetics and facilitates oral hygiene.
ments for successful guided provisional soft-tissue model- Prosthetic-driven implant placement is the golden rule
ing are sufficient keratinized gingiva, provisional that ensures predictable treatment results. Thus, transfer
abutments, gradual atraumatic provisionalization, and of the information regarding optimal position and angu-
realistic size of the amount of gingival expansion. lation for the implant fixture from the study cast onto the
Achieving a flat emergence profile around implant- surgical site becomes mandatory. A precisely fabricated
supported prostheses warrants obtaining sufficient infor- surgical template or guide has an active role in executing
mation on the specific tissue biotype, tooth form, soft tis- the treatment plan at the first stage of surgery and deter-
sue health condition, adjacent periodontal health mining the position of the implants at the second-stage
surgery. Furthermore, this presurgical step in implant
treatment aids in the preservation of the required biolog-
ical space between the implant and the neighboring roots.
Besides that, it assists in keeping the recommended dis-
tance between implant fixtures themselves. All of these
advantages ultimately assist in an increase in the preci-
sion of aesthetic implant positioning and an improved
final outcome of the prosthesis.
Several factors must be taken into consideration
before deciding on the design of the future template to be
used. These encompass the future implant position, num-
ber of implants to be used, the existing occlusion, the
amount of available bone, the soft tissue status, the type
of implant prosthetic components, and the type of future
definitive prosthesis.144
The basic simplest surgical template is fabricated from
a clear resin duplicate of the diagnostic wax-up. It has
guiding grooves or cutouts at the location of the potential
implant sites. These are usually fabricated according to
the original position of the missing dentition; the exact
amount of hard and soft tissue that should be regener-
ated to provide a healthy biological contour will be auto-
FIGURE 2.25. Flat emergence profile of the natural matically identified after the template construction.145
maxillary anterior teeth. The template is placed on the working cast, and drill
PRESURGICAL CONSIDERATIONS 33

holes of 3 mm diameter are prepared through the cingula factor of the panoramic image can be calculated for each
of the anterior teeth and/or on the center of the occlusal proposed implant location.35 The actual height of the
surfaces of posterior teeth.146 These guide holes will be residual ridge can then be calculated by multiplying the
used to guide the pilot drill in the bone. distortion factor by the distance from the crest of the
Most fabricated surgical templates are limited to two ridge to any anatomical landmark. This procedure assists
planes, excluding the apicoincisal plane of the implant.147 in the selection of accurate implant length. After radi-
However, there are available surgical templates that can ographic diagnosis is made, the ball bearings are removed
also be used to indicate the distance required to counter- and the template is perforated and sterilized to be used
sink the implant. This is accomplished by making room during the implant surgery.35
for a gradual emergence from the relatively narrow Another advanced technique used to construct a pre-
implant platform to the comparatively wide cervical por- cise surgical template is integration of a stainless steel
tion of the restoration.92'148 The greater the accuracy of sleeve into the acrylic resin body of the template around
the surgical template fabrication, the more precise the the drill hole.151'152 This type of template permits exact
implant positioning obtained. implant positioning with accurate parallelism. The
The design of the surgical template differs according sleeves help maintain parallel holes throughout the
to the complexity of the case. In partially edentulous drilling procedure; they also prevent the acrylic resin
cases, where the edentulous area is bounded by remain- from being distorted or chipped off at the surgical site
ing dentition, the template need not be extended antero- (from the sharp friction of the surgical drill with the sides
posteriorly more than two teeth on each side of the of the template). Presence of the sleeves provides a stable
edentulous space and can be trimmed accordingly.146 position for the drill and fixed angulation throughout the
The commonly used surgical template can either be a drilling procedure (Fig. 2.27a-c).
partial denture with indented markings on the acrylic A dual-purpose template is another precise surgical
teeth indicating the site of the future implants (with template that maintains a correct labiopalatal position
palatal or lingual relief) or a transparent template with a of dental implants.153 It offers not only precise informa-
guiding hole that allows the drill to penetrate into the tion about the location and angulation of the implant
bone.149'150 Both types lack precise implant positioning but also, subsequent to a tomographic evaluation, infor-
because the template does not provide a control for the mation on the anticipated abutment relative to the pre-
buccolingual movement of the drill. For that reason, any designed suprastructure.154
deviation in the direction of the drilling angulation will Recently, the terms computer-guided surgery and com-
subsequently alter the future implant position (Fig. 2.26). puter-milled surgical templates have been introduced.155
A panoramic radiograph can be taken with the surgical The computer-milled surgical template (Compu-surge
template in place to help determine the best location and Template, Implant Logic Systems, Cedarhurst, New
angulation of implants relative to the proposed prosthe- York, U.S.A.) provides a connection between the CT scan
sis.35 Radiopaque ball bearings of a known diameter are
luted into the template and appear suspended over poten-
tial implant placement sites on the radiograph. By divid-
ing the actual diameter of the ball bearing by the
diameter of its image on the radiograph, the distortion

FIGURE 2.27a. The acrylic template can show the

FIGURE 2.26. The commonly used surgical template amount of bone to be regenerated to regain the original
that has guiding grooves lacks axial control of the drill. contours.
34 CHAPTER 2

implants.156 It is fabricated from the wax-up on the diag-

nostic cast. Precise determination of the implant angula-
tion is obtained by providing a guide sleeve on the 0.8
mm Kirschner wires within the template. The template is
placed in position over the intact mucosa surface. The
template guides the Kirschner wires to pierce through the
mucosa into the bone. The wires are attached to a special
insert using a dental coupling fitted into the dental hand-
piece. The insert facilitates easy insertion of the wires into
the bone. The wires are then trimmed 5-7 mm above the
bone level; then incisions are made to connect the wires
to each other or to the adjacent natural tooth. After the
insertion of the wires, the implant osteotomies are pre-
pared with a trephine drill guided over the wires alone or
FIGURE 2.27b. Wax-up of the case. over wires combined with a special guidance cylinder fit-
ting the trephine drill (Fig. 2.28a-e). This method may
alleviate some of the problems common to conventional

FIGURE 2.27c. The stainless steel sleeves are attached

to the acrylic template for accurate implant positioning.
FIGURE 2.28a. Illustration showing a missing central
incisor.
and the surgical template. It utilizes reformatted CT data
in combination with a three-dimensional simulation of
the implant position to produce a computer-milled surgi-
cal template. The simulated implant position is created
via SIM/Plant software (SIM/Plant, Columbia Scientific,
Columbia, Maryland, U.S.A.). The three-dimensional
coordinates of the simulated implant position will be
transferred to a five-axis computer-controlled milling
machine that creates an appliance with the SIM/Plant
plan. Drill guide components are then installed in the
milled surgical template to direct the drilling procedure.
The Novel guide template is one of the most recently
introduced surgical templates that eliminates the problem
of template slippage on the flap. With no slippage, the
risk of plastic or metal debris from the template entering
into the wound is eliminated because the template itself
does not have an active role in the drilling procedure. FIGURE 2.28b. The Novel guide is put in the place of
This guide template is best used when placing multiple the missing tooth.
PRESURGICAL CONSIDERATIONS 35

FIGURE 2.28e. The remaining Kirschner wire is the

FIGURE 2.28c. The Kirschner wire being introduced guide for the trephine drill. Note that in using the Novel
through the mucosa. guide, the pilot drill is replaced with a small-diameter
trephine drill.

PLANNING FOR SURGICAL

INTERVENTION
Appropriate timing of the implant placement in the alve-
olar ridge is essential. It can influence aesthetic soft tissue
contours around dental implants, especially when the
anterior maxilla is concerned.
The decision whether to insert the implant immedi-
ately upon unsalvageable tooth extraction or to delay its
placement until complete socket healing occurs is based
on many factors.157 These determining factors include
soft tissue health and integrity, tissue biotype, the need
for preservation of interdental papillae, prevention of the
alveolar ridge resorption, the pathological and morpho-
logical condition of the alveolar socket immediately after
extraction, patient demands, and the predictability of
osseointegration. It must be duly noted that the decision
on the timing of dental implant placement is critical and
can significantly affect treatment results from the aes-
thetic standpoint and/or that of serviceability.
The standard protocol for placing dental implants
requires an alveolar ridge that is completely healed before
inserting the implant fixture.158 It is called the delayed
implant placement protocol and requires a healing period
varying between five and nine months post-tooth extrac-
tion before implant placement.80 The healing period not
only allows the placement of the implant fixture in mature
osseous architecture, but also permits the maturation of
the associated soft tissue in the future implant site. This
FIGURE 2.28d. The wire trimmed off.
ultimately minimizes the need for excessive soft tissue
manipulative procedures required to achieve primary soft
template techniques, where the template usually directly tissue closure (Fig. 2.29a-c). The need for bone grafting
guides the drill, whereas the guiding wires allow for pre- procedures is also minimized especially in the posterior
cise implant positioning in the alveolar ridge. areas because greater implant-bone contact is ensured.
36 CHAPTER 2

This in turn eliminates the possibility of epithelial down-

growth into the osteotomy site. However, delayed implant
placement may not be the treatment of choice in all
regions. In the maxillary anterior zone, in particular, delay-
ing implant placement results in alveolar ridge resorption,
both in the buccolingual and apicoincisal directions,159
which usually necessitates the use of guided tissue regener-
ative techniques, in order to maintain maximum aesthet-
ics. Furthermore, studies have shown that as much as 3-4
mm of alveolar ridge resorption can occur during the first
six months after tooth extraction (if no bone-grafting pro-
cedures have been performed at the time of tooth extrac-
tion).160 Other reports have indicated that 23% of the
anterior alveolar ridge resorption takes place within the
FIGURE 2.29a. Six months postextraction allowing first six months following tooth extraction.161 This process
for delayed implant placement. significantly affects the topography of the hard and soft
tissues, which in turn may hinder the aesthetic three-
dimensional positioning of the implant (Fig. 2.30).
Some clinicians, for more than one reason, prefer the
delayed implant placement technique. These reasons
include reducing the risk of infection and reducing soft
tissue manipulations.179 Postextraction bone resorption
remains as an issue of controversy to be reckoned with.
Immediate implant placement has been extensively
documented in the literature.162"164 In this approach, the
implant fixture is inserted immediately following the
unsalvageable tooth extraction. This procedure may be
performed with or without bone grafting of the space
between the implant body and the alveolar socket walls.
Immediate implant insertion can be an effective method
to prevent the alveolus from undergoing postextraction
resorption.165'166
Several studies have shown success rates using imme-
FIGURE 2.29b. The implant inserted and the flap diate implants comparable to those of implants inserted
closed without any soft tissue modification procedure in into healed sites.167"169 However, there are some prevail-
delayed implant placement.
ing conditions that increased this technique's credibility;

FIGURE 2.29c. The case restored with no soft tissue FIGURE 2.30. Two years postextraction bone resorp-
compromise. tion.
PRESURGICAL CONSIDERATIONS 37

these include absence of infection, good mechanical

anchorage and primary stability of the implant fixture,
atraumatic removal of the unsalvageable tooth with
preservation of the labial plate of bone, use of the appro-
priate implant size and design that corresponds to the
socket's configuration, and proper implant placement in
terms of angulation and position. Unfortunately, most of
the studies have measured success in terms of osseointe-
gration, but have not considered soft tissue changes. The
soft tissue compromise resulting from the attempt to
achieve primary closure on top of the socket is the only
primary concern that directly influences the final aes-
thetic results. A recent study recommended the use of
wide-diameter implants with caution in aesthetically FIGURE 2.31c. The soft tissue modified to allow for
demanding areas.170 This was based on the conclusion complete closure.
that after the second stage of surgery the soft tissue
recedes around wide-diameter implants an average of
1.58 mm, compared with 0.57 mm around small-diame-
ter implants (Fig. 2.31a-d).170 Therefore, the use of the
wide-diameter implants should be approached with cau-
tion in the case of the immediate aesthetic implant place-
ment protocol.
Extraction of a tooth leaves behind a socket that has
its own characteristics. Many authors have classified
extraction sites at the time of implant placement and

FIGURE 2.31d. The case restored with some scar tis-

sue formation due to excessive soft tissue manipulations.

have suggested clinical solutions for each class.102'171'175

The classifications of the socket condition can provide
the clinician with an accurate diagnostic tool to deal with
the different clinical situations. Salama and Salama have
classified the socket state into three individual classes102:
FIGURE 2.31a. Immediate implant placement. Class One describes a socket that has intact walls and is
favorable for immediate implant placement with or with-
out bone grafting. Class Two has a socket with a missing
labial wall, necessitating the use of guided tissue regener-
ation (GTR) and a bone graft in conjunction with
implant placement. Class Three refers to a socket that
does not provide any implant anchorage and requires the
application of a staged implant insertion as well as bone-
grafting procedures.
Garber and Reiser have categorized immediate
implant sites after tooth extraction into three different
classes.173 Their classification was as follows: Type I is a
socket having dehiscence of less than 5 mm; this type is
almost equivalent to the first class in Salama and
FIGURE 2.31b. The area is grafted with demineralized Salama's classifications. A Type II socket has a dehiscence
freeze-dried bone (DMDB) combined with tetracycline equal to 5 mm; it requires autogenous bone grafting and
powder. GTR. Type III is a socket with a dehiscence of more than
38 CHAPTER 2

5 mm; it offers no primary stability for the implant fix-

ture and warrants a staged approach for implant inser-
tion and bone-grafting procedures.
Meltzer described four classes of socket conditions174:
A Class I socket possesses intact walls all over. A Class II
socket has a fenestrated wall. A Class III socket has suffi-
cient bone height, but not enough width, or has two
missing osseous walls. Class IV describes a socket with
insufficient or no vertical dimension.
A recent classification included, in addition to a three-
dimensional classification for the osseous defect, the sta-
tus of the soft tissues surrounding the immediate dental
implants. This classification yields a more accurate
description of the status of the socket at the time of
immediate implant placement.175 FIGURE 2.32a. Unsalvageable remaining root that
The advantages an immediate implant procedure will be extracted for implant placement.
offers are many. They include optimal implant placement
(i.e., the original tooth place), which thus minimizes the
need for severely angulated abutments, and alveolar ridge
preservation due to prevention of the postextraction
resorption, which permits the use of longer and wider
implants. Other advantages are (1) minimizing the possi-
bility for injury of anatomical landmarks, (2) limiting
postdrilling bone resorption by reducing heat generation
during drilling, and (3) reducing treatment time to almost
half. Additionally, there is a positive psychological
impact on the patient in relation to dental implants since
immediate replacement of the extracted root/tooth takes
place without the patient going through a lapse waiting
for socket healing.
Methods of soft tissue closure for immediate implant
placement will be explained in detail in Chapter 4. FIGURE 2.32b. Eight weeks after extraction; note the
A nonsubmerged protocol for immediate implantation soft tissue closure.
was proposed.176 In this protocol, the implant and heal-
ing abutment are connected at the time of implant place- made to achieve primary closure in immediate implant
ment without attempting any soft tissue modifications. placement cases (Fig. 2.32a,b).
This technique minimizes soft tissue trauma and plays a Interestingly, a study described another method for
significant role in the maturation of the soft tissue around delayed implantation.178 This technique employs an
the site. Using an implant diameter that corresponds to implant osteotomy followed by wound closure without
the socket orifice will eventually reduce the need for bone actually inserting the implant. Two weeks later, the
grafting and prevent the in-growth of soft tissue along the patient undergoes another surgery to place the implant.
socket walls.177 On the other hand, soft tissue closure is The authors found that many new thin trabeculae and
still a questionable guarantee for long-term osseointegra- capillaries formed around the osteotomy walls during the
tion. Lack of direct visibility of the labial plate of the waiting period, and the surrounding fibrous tissue encap-
alveolar bone raises some serious concerns over this pro- sulation appeared to a lesser extent, thus enhancing
cedure and its clinical success. osseointegration. This approach makes the technique
The immediate delayed protocol of implant place- clinically and practically inapplicable.
ment, on the other hand, permits soft tissue granulation The one-stage implant placement technique is another
on the socket orifice. It takes six to ten weeks after tooth implant placement protocol; it refers to the insertion of a
extraction to mature. This approach aids in developing a one-piece implant in a single surgical procedure, elimi-
soft tissue seal on top of the socket by secondary inten- nating the second-stage surgery. The technique is similar
tion, after which the implant is placed, as is the case of to the nonsubmerged protocol of implant placement. The
the standard delayed method. The newly formed kera- implant penetrates the soft tissue through the flared
tinized tissue helps minimize soft tissue complications implant neck itself. The method can be used in delayed
that might arise from excessive surgical manipulations and immediate cases. The use of nonsubmerged, one-
PRESURGICAL CONSIDERATIONS 39

piece implants has shown immense clinical success, espe- 2. Sabes WR, Green S, and Craine C. Value of medical
cially at the functional level, with the ease of prosthetic diagnostic screening tests for dental patients. J Am Dent
management.180-181 The one-stage system eliminates the Assoc 1970(80): 133-136.
possibility of microgap formation between the abutment 3. Halstead C, ed. Physical Evaluation of the Dental
and the implant fixture at the level of the bone crest. Patient. St. Louis: Mosby, 1982, 74-81
4. Misch CE. Medical evaluation of the implant candidate.
While these advantages certainly increase the popularity
Part II. Int J Oral Implant 1982(2): 11-18.
of this type of implant, it must be noted that the tech-
5. Little JW and Palace DA, eds. Dental Management of
nique must be restricted to areas where aesthetics are not the Medically Compromised Patient, 4th ed. St Louis:
of chief concern.182 Mosby, 1993.
Selecting a particular method of implantation will 6. Matukas VJ. Medical risks associated with dental
remain the clinician's decision to make after the required implants. J Dent Educ 1988(52): 745-747.
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174. Meltzer A. Non-resorbable membrane-assisted bone Eight-year life table analysis of a prospective multicenter
regeneration: Stabilization and the avoidance of micro- study with 2359 implants. Clin Oral Implant Res
movement. Dent Implantol Updatel995(6): 45-48. 1997(8): 161-172.
175. Tehemar SH. Classification and treatment modalities for 181. Buser D, Mericske-Stern R, Dula K, and Lang NP. Clin-
immediate implantation. Part I: Hard and soft tissue sta- ical experience with one-stage, non-submerged dental
tus. Implant Dent 1999(8): 54-60. implants. Adv Dent Res 1999(13): 153-161.
176. Saadoun AP and La Gall M. Periodontal implications in 182. Cornelini R, Scarano A, Covani U, Petrone G, and Piat-
implant treatment planning for aesthetic results. Pract telli A. Immediate one-stage postextraction implant: A
Periodont Aesthet Dent 1998(11): 655-664. human clinical and histologic case report. Int J Oral
177. Wheeler SL, Vogel RE, and Casellini R. Tissue preserva- Maxillofac Implants 2000(15): 432-437.
tion and maintenance of optimum esthetics: A clinical 183. Misch C.E. Single tooth implant. In Misch CE, ed. Con-
report. Int J Oral Maxillofac Implants 2000(15): 265-271. temporary Implant Dentistry. St. Louis: Mosby, 1999,
397-428.
3
Aesthetic Implant Placement

Abd El Salam El Askary

In the aesthetic zone, accurate implant positioning pro-

vides a delicate balance between appearance and func-
tion. When the missing dentition in the posterior jaw is
being replaced, the balance falls heavily on the functional
aspect, which represents the primary concern due to the
extreme and magnified biting loads that characterize this
region.1 Thus, implant positioning in the posterior alveo-
lar ridge will be governed by particular factors such as
occlusion, biting loads, opposing dentition, parafunc-
tional habits, quality and quantity of the available bone,
and the existing location of the anatomical landmarks.
In the "aesthetic zone," such as the anterior maxilla, or
wherever the patient perceives to be aesthetically impor- FIGURE 3. la. Preoperative view of a missing maxil-
tant, implant positioning will be governed by the need to lary right central incisor with postextraction alveolar
maximize both the aesthetics and function of the implant- bone resorption in horizontal direction.
supported restorations. In conjunction with the variables
cited in the preceding paragraph, a number of additional implant palatal to the more buccal contour of the
factors regarding implant positioning in the aesthetic zone extracted root (Fig. 3.1b).5 Such a placement in most
should be emphasized; these include smile line, lip support, cases negatively affects the morphological characteristics
lip thickness, facial symmetry, quantity and quality of the of the final prosthesis as well as the interproximal papil-
soft tissues, emergence profile, type of prosthetic compo- lae and their surrounding gingival contours (Fig. 3.1c).
nents to be used, and the future contour of the final Therefore, it is necessary to first reconstitute the lost sup-
restoration. porting structures to their original size so that the origi-
In the case of restoring missing maxillary anterior nal tooth position may be replicated at the time of
teeth, aesthetics is considered as a major concern, implant placement.6
because the dental complex becomes visible in the vast To precisely position an implant in the alveolar ridge,
majority of people during speech or smiling. Therefore, thorough preliminary case planning is mandatory in
the implant should be placed in the exact location of the order to determine the exact location of the implant fix-
missing tooth to attain its original appearance. ture. A complete wax-up of the edentulous area on the
Unfortunately, inserting the implant in its natural pre- study cast should first be fabricated to establish the origi-
decessor's location is not frequently a clinical option due nal location of the missing dentition.7'8 An accurate surgi-
to alveolar ridge resorption (30-40%) subsequent to cal template is then fabricated from the wax-up, thereby
tooth loss.2^ After tooth extraction in the anterior max- identifying the optimal position of the implant relative to
illa, alveolar bone resorption usually takes on a horizon- the proposed final prosthesis.9'10 The main purposes of
tal pattern (Fig. [Link]). This necessitates placement of the the surgical template are to transfer the position of the

45
46 CHAPTER 3

minimizing heat generation to the bone, achieving pri-

mary implant stability,11"13 and avoiding direct biting
loads at the bone-implant interface during a sufficient
healing period.14"16 Secondly, extreme care should be
exercised not to compromise sulcular depth or gingival
biological health in an attempt to achieve optimal
implant placement.17
Consequently, implant placement in the aesthetic zone
should be approached with extra caution to provide a
harmonious implant supported restoration and to reduce
the risks of morbidity and implant failure.18'19 Implant
failure is not limited to the breakdown of the integration
between the implant and investing bone, but also encom-
passes failure to achieve aesthetic, functional, and pho-
FIGURE 3.1b. Note the palatal placement of the
netic goals. In other words, successful implant
implant.
integration does not necessarily result in a satisfied
patient.20 On a more profound note, many authors con-
sider the failure to achieve aesthetically pleasant implant-
supported restorations as a complete implant failure
condition (Fig. 3.2).18>19

DENTAL IMPLANT
MORPHOLOGY AND
TOOTH ANATOMY
When restoring natural dentition with conventional pros-
theses, the anatomy of the existing natural teeth and peri-
odontia serve as a guide for replicating the natural form
and contours. Unfortunately, dental implants do not have
the same valuable guides that are available when restor-
ing natural dentition, especially when more than one
tooth is missing. Consequently, before inserting dental
implants, the clinician should develop an image in his/her
FIGURE 3.1c. The final restoration with the modified mind that acts as a guide or reference. This is accom-
labial contour as a result of palatal placement of the plished by visualizing the original shape of the osseous
implant. bed and the biological dimensions of the missing denti-
tion and relating them to the restorative components that
will be used.6 Being familiar with and following the orig-
implant from the study cast accurately to the surgical site, inal anatomy of the natural architecture will assist the
and to serve as a drill guide in the preparation of the clinician in selecting the optimal size and position of the
osteotomy. Furthermore, It can aid in the selection of future dental implant and its related components.
prosthetic components for restoring the case. Therefore, understanding the basic morphology of the
Optimizing clinical results through aesthetic implant implant fixture and its related components in relation to
positioning is predicated on several factors that cannot the dental anatomy is an absolute necessity for achieving
be ignored. These factors embrace two very important successful aesthetic results. On the other hand, the
themes. Firstly, strict adherence to clinical guidelines for anatomical character of the existing periodontium is of
achieving predictable osseointegration should be main- great relevance to dental implant predictability, as the
tained. These guidelines include using a relatively gentle type of periodontium determines the prognosis of the
surgical technique, preparing a precise osteotomy, avoid- implant and the future condition of its surrounding
ing exerting too much pressure to the alveolar bone, structures.
AESTHETIC IMPLANT PLACEMENT 47

wide root diameter in this biotype can have the same

width as the widest part of the crown. Wide contact areas
are located more apically, and eventually the interproxi-
mal papillae fill all of the embrasure space.
Based on the foregoing, when a missing single tooth
with thin scalloped tissue biotype is to be restored with a
dental implant, the final aesthetic result might not be
entirely predictable, because recession of the interproxi-
mal papilla and its surrounding gingival structures might
be a likely event. This is due to the reduced amount of
keratinized tissues and the fragile nature of the soft tissue
that characterizes this biotype. Also, the greater vertical
distance of undulation between the edge of the implant's
cervix and the interproximal bone margin stimulates
mild bone resorption, which leads to unsymmetrical peri-
implant tissue margins when compared with the con-
tralateral side.29 Any additional osseous remodeling will
result in further shortening of the already short papillae,
thus complicating aesthetics.30
On the other hand, when a dental implant is placed
in the thick tissue biotype, the vertical undulation space
located between the edge of the implant's cervix and
the margin of the interproximal bone is minimized.
This will not be of any serious significant clinical con-
cern.29 The thick flat tissue biotype certainly offers
more predictable aesthetic treatment outcome than the
thin scalloped biotype. Therefore, patients with the
thick flat biotype are generally considered more favor-
able candidates for achieving and maintaining accept-
able aesthetic results with implant placement and
restorative therapy. That being the case, recognition
FIGURE 3.2. El Askary-Meffert failure checklist, show- and assessment of the tissue biotype before commenc-
ing that an unacceptable aesthetic result with dental ing implant therapy is important. The proper assess-
implants is considered a failed condition. ment of the tissue biotype preoperatively will mandate
a specific surgical approach that suits each type. For
example, in the thin scalloped tissue biotype, it seemed
The unique human periodontium is divided into two that a flapless approach to implant placement can
basic biotypes: the thin scalloped biotype and the thick reduce the tendency for postoperative soft tissue
flat biotype.21"23 Each biotype has its own particular shrinkage and healing complications.
tooth anatomy and osseous topography.24'25
Thin scalloped tissue biotype is characterized by nar-
row, tapered roots and a triangular or cylindrical crown AESTHETIC IMPLANT DESIGN
shape; the contact areas are located more incisally with a
reduced cervical convexity. Therefore the interproximal The newly designed dental implants offer several modi-
papillae are located in an incisal position and do not fications compared with the old classic ones; the
totally fill the whole embrasure space, which explains changes involve new implant surface treatments, new
their designation as "scalloped." Due to the relatively interface connections, versatile sizes, and new implant-
small diameter and tapered form of the roots of the thin related prosthetic components. This has led to increased
scalloped biotype, the interradicular bone is wider than awareness of the clinicians to challenge the clinical out-
in the thick flat biotype.26"28 come of dental implants and to take dental implants to
The thick flat biotype is characterized by a bulbous a new horizon. The newly introduced dental implant
root form and a square crown shape. In some areas the designs have led the clinicians to dramatically improve
48 CHAPTER 3

the clinical outcome of dental implants from the

aesthetic standpoint and to take implant-supported
restorations to new levels. Thus, selection of the opti-
mum implant design and size is now becoming an inte-
gral part of every treatment plan that seeks a superior
aesthetic outcome.
The implants of choice that are available to restore
missing teeth are either endosseous screws or cylinders.
The standard screw-type body is 3.75 mm in diameter,
and the diameter of its platform flares up to 4.1 mm.31
The cylinder design of endosseous implants usually has a
4-mm body diameter and the same platform dimensions
as the screw type.6
The abutments for the cylindrical and screw type
implants start with the same diameter as the implant's FIGURE 3.3. An implant replacing the mandibular
platform and then flare out to 4.5 or 5 mm. While these lateral incisor is wider than the original missing tooth
dimensions might vary somewhat among implant man- dimension at the crestal bone level; this leads to a bulky
ufacturers or due to laboratory modifications of the restoration at the emergence level compared with its
abutment, generally most of the standard implant diam- adjacent natural tooth.
eters will require a crown with a diameter of a mini-
mum of 5.5 mm at the CEJ level and 7 mm at the level
of the contact points when a missing central incisor is patient. The width of the implant dictates its position in
being restored,29 for instance. In order to obtain natural the alveolar ridge; wider implants are less apically posi-
biological contours of implant supported restorations, tioned while narrow diameter implants are more api-
the difference in the diameter of the implant and the cally placed in order to allow for "running room" to
cervical dimension of the missing tooth should be com- stack the prosthetic components in.
pensated for. This is accomplished either by tissue It is noteworthy that any attempt to follow a specific
expansion procedures through the provisional prosthe- formula for selecting a particular implant diameter for a
sis to allow a smooth transition from the implant head specific tooth will be very unsatisfactory, because there
diameter to that of the natural tooth or by using wide are many other variables that must be considered in the
implants with abutments that have a diameter approxi- implant diameter selection process. Some of these
mately similar to that of missing tooth. Selecting include variations in the tissue biotype, differences in
implant diameter that is wider than the tooth to be the size of the same tooth's diameter among different
replaced will result in a crown that is incorrect in its size individuals, changes that occur to the remaining bone
and does not biologically fit with the surrounding tis- after extraction, the altered soft tissue contours, and the
sues (Fig. 3.3). In conclusion, the use of a wide implant variation in implant diameters. Thus, the clinician's per-
diameter that exceeds the natural biological dimensions sonal evaluation will be the best tool for selecting the
will jeopardize not only aesthetics but also function. proper implant size. Adhering to specific ready-made
The implant diameter is directly related to the root charts may not work well in many clinical conditions
diameter at the crest of the alveolar ridge. For example, and can sometimes lead to confusion.
if a missing maxillary central incisor to be replaced with
a dental implant has a diameter that ranges between 7
and 8.5 mm at the CEJ level and between 5 and 6 mm at AESTHETIC
the bone level, the diameter of the implant to be used IMPLANT POSITIONING
may vary from 4 to 6 mm, and so forth.26 Therefore the
diameter of the implant should be related to the diame- Accurate implant positioning enhances natural aesthet-
ter of the root at the bone emergence level and not the ics; an implant should not be inserted into the alveolar
CEJ level, because if the diameter of the implant exceeds ridge at random wherever there is a space available
the diameter of the root at the bone level, this will even- because the implant requires sufficient osseous dimen-
tually cause crestal bone resorption. The diameter of the sions and restorative dimensions. These dimensions are
missing tooth can be verified by measuring the dimen- not always related to one another, and sometimes one
sions of the same tooth on the contralateral side, or by dimension may be adequate while the other is not; the
studying an old study cast or photograph for the balance between these two dimensions will lead to the
AESTHETIC IMPLANT PLACEMENT 49

FIGURE 3.4a. Optimal mesiodistal positioning of an

implant.

optimal implant positioning.6 Certain guidelines are pre-

sented to assist in placing the implant in a three-dimen-
sional fashion; the three dimensions are related to the FIGURE 3.4b. Improper mesiodistal positioning of an
lateral axis (mesiodistal dimension), the sagittal axis implant.
(labiopalatal dimension), and the coronal axis (apicoin-
cisal dimension).

MESIODISTAL POSITIONING
The mesiodistal position of the implant in relation to the
adjacent teeth has a direct impact on the aesthetic out-
come and the integrity of the future restoration contours.
It also directly affects postoperative hygiene maintenance
around dental implants. In ideal soft and hard tissue con-
ditions, the implant should be positioned midway in the
center of the mesiodistal space in order to obtain a cen-
tralized restoration if a missing single tooth is being
restored (Fig. 3.4a). Care should be exercised to avoid
placing the implant in a position too close to the inter-
dental papilla (Fig. 3.4b). Failure to heed this precaution
can induce pressure on the papillary soft tissue that hin- FIGURE 3.5. Healing abutment in place, exerting pres-
ders hygiene measures and potentially jeopardizes aes- sure on the interdental papilla due to the improper
thetics (Fig. 3.5). Improper mesiodistal positioning may mesiodistal placement of the implant body.
50 CHAPTER 3

also affect the periodontium of the adjacent tooth to the

implant site; it can compromise the blood supply, thus
leading to possible external root resorption.32 This last-
mentioned complication might underscore the impor-
tance of using cylindrical root form dental implants. The
use of tapered implant design may reduce the chance of
adjacent root approximation (Fig. 3.6).
The presence of diastemas demands more careful
mesiodistal positioning of dental implants. Here, the
available mesiodistal space will be greater in width than
the required space for the definitive restoration (Fig. 3.7).
In such cases, the fabrication of a precise surgical tem-
plate is valuable to ensure optimal implant positioning.33
The misplacement of the implant in the space where
diastema exists may cause irreversible aesthetic problems. FIGURE 3.7. Preoperative view of a missing left maxil-
For single-tooth replacements, the formula for calcu- lary central incisor with preexisting median diastema
lating the minimum space required for mesiodistal posi- that mandates accurate mesiodistal positioning of the
tioning of the implant should include the width of the implant.
periodontal ligament (average 0.25 mm) and a 1 mm
zone of sound bone between the implant and the peri-
odontal ligament of the adjacent natural tooth.34 It must
be remembered that the measurements accounting for the
periodontal ligament and sound bone should be doubled
to calculate both the mesial and distal aspects of the
implant. Simply stated, the required distance for placing a
4 mm diameter implant between two teeth would be cal-
culated by adding 1 mm + 0.25 mm + 4 mm + 0.25 mm
+ 1 mm. The resultant sum of 6.5 mm is the minimal
space needed to position the implant mesiodistally. When
multiple implants are used, the previous equation may be
used by adding a distance of 2 or 3 mm between each
implant.35 However, these measurements are only recom-
mended as a guideline, since every case should be
approached on an individual basis. The mesiodistal posi-
tion of an implant depends on the mesiodistal dimension
of the edentulous space, the presence or absence of
diastemas, and the adjacent root proximity.

LABIOPALATAL POSITIONING
The labiopalatal orientation of the implant directly influ-
ences the emergence profile of the final restoration. In
order to ensure an implant-supported restoration with a
flat emergence profile (Fig. 3.8), it is necessary to leave 1
mm of intact labial bone covering the implant surface
(Fig. 3.9).32 In perfect bone situations, the implant should
be placed as close to the buccal contour as the volume of
the available bone permits, rather than being centered
along the residual ridge (Fig. 3.10).5 Therefore, 6 mm of
bone width is necessary to place a 4 mm diameter
FIGURE 3.6. Paragon tapered screw vent implant, 4.7 implant labiopalatally; this will leave a minimum amount
mm (Centerpulse, Dental Division, Carlsbad, California). of bone surrounding the implant fixture to keep it
AESTHETIC IMPLANT PLACEMENT 51

FIGURE 3.9. Illustration of the ideal labiopalatal posi-

FIGURE 3.8. Side view of maxillary teeth showing the tioning of the implant fixture.
natural flat emergence profile.

healthy. If the labiopalatal dimension is less than 6 mm, a

small diameter implant may be used; if a large diameter
implant is to be used, the bone dimension will need to be
increased accordingly.6
If the implant is placed too far labially, it will violate
the integrity of the labial plate of bone, leading to a final
implant-supported restoration possessing bulky, overcon-
toured margins (Fig. 3.11a-c). This situation is clinically
impossible to correct, even with the use of angulated
abutments. In fact, angulated abutments might further
complicate the situation, as their metallic gingival collar
can potentially displace the soft tissue in a more labial
direction, resulting in soft tissue recession or grayish, dis-
colored gingiva.
Placement of the implant too far palatally will result in
an increased distance between the labial edge of the
implant and the highest point of the future crown con- FIGURE 3.10. The ideal labiopalatal placement of an
tour at the emergence level (Fig. 3.12a-c). In other words, implant fixture restoring a missing right maxillary cen-
the final restoration will appear to be severely "ditched- tral incisor clinically; note the remaining labial bone in
in" when viewed sagittally. Consequently, fabrication of relation to the fixture position.
52 CHAPTER 3

FIGURE [Link]. A sagittal section of a study cast show-

ing an implant fixture that is placed too far labially; note
the violation of the labial plate of bone.

a restoration with a ridge-lap design at its labial margin

to be aligned with the adjacent natural teeth is necessary.
A ridge-lap design will hinder hygiene maintenance
around the restoration labial contour, thereby facilitating
plaque accumulation and leading to possible inflamma-
tion and apical migration of the gingival margin. This
may be a potential threat to the implant's very existence,
as pocket formation may ensue, resulting in implant fail-
FIGURE 3.11a. An illustration showing too far labial ure. As a result of the modified ridge-lap design, there
placement of the implant fixture. will be an increased strain on the implant surface due to
an off-axis loading (Fig. 3.13a,b).36
Positioning the implant in relation to the sagittal axis
within the labiopalatal dimension influences the implant
angulation in the alveolar ridge as well. Some authors
classify labiopalatal implant angulation in terms of its
relation to the occlusal plane.37 The implant may be
inserted perpendicular to the occlusal plane, which pro-
vides a far more palatal positioning of the final restora-
tion, resulting in a ridge-lap design of the restoration
(Fig. 3.14a). An angulation of approximately 65 degrees,
or 45 degrees to the occlusal plane, results in the most
labial positioning of the implant head with optimal aes-
thetic results; this placement often requires using an
angulated abutment (Fig. 3.14b).
The type of final abutment to be used somehow gov-
erns the labiopalatal positioning of the implant as well as
FIGURE [Link]. A view showing a too far labially its angulation. The final abutment and the final restora-
placed implant fixture on the study cast. Note the differ- tion should be determined before starting implant place-
ence between the position of the natural tooth and the ment. There are two main types of final abutments,
implant fixture. screw-retained abutments and cement-retained abut-
AESTHETIC IMPLANT PLACEMENT 53

FIGURE 3.12c. A modified ridge-lap design of the

crown to compensate for the too far palatal placement of
the implant.

ments are used, the implant is positioned exactly in the

center of the long axis of the future implant-supported
crown (Fig. 3.15). On the other hand, when screw-
retained abutments are used, the implant should be
placed slightly palatal to the long axis of the crown, in
order to access the connecting screw from the palatal side
(Fig. 3.16).38

APICOINCISAL POSITIONING
FIGURE 3.12a. An illustration showing too far palatal One of the most critical areas in implant-supported
placement of an implant fixture. restorations is the cervical region. Here lies the breaking
point between an ordinary implant-supported restoration
and an aesthetically superior implant-supported restora-
tion; the latter is what demands skill and experience. The
emergence profile and functional/mechanical requirements
of the restorative components dictate the correct apicoin-
cisal orientation of the implant to a great exent.6 Apicoin-
cisal positioning is no less important than the mesiodistal
and labiopalatal positioning aspects of the implant, as this
dimension determines the amount of exposure the final
restoration will receive. This exposure dramatically affects
the aesthetic outcome of the restoration.
Apicoincisal positioning of the implant allows the con-
tours of the restoration to be developed in a progressive
manner within the gingival sulcus so that the final
FIGURE 3.12b. Too far palatally placed implant fix- restoration will appear to emerge naturally through the
ture on the study cast; note the distance between the
marginal gingival tissues (Fig. 3.17).39 To create an
implant fixture to the labial plate of bone.
implant-supported restoration that is successful from
both the aesthetic and functional standpoints, several
ments. The choice of positioning the implant fixture will considerations must be weighed. These include the loca-
depend on the space needed to gain accessibility to the tion and amount of space available for restoration, the
abutment. For example, when cement-retained abut- topography of remaining bone, and the size and type of
54 CHAPTER 3

FIGURE 3.14a. Perpendicular placement of the

implant to the occlusal plane that mandates slight
palatal positioning.

FIGURE 3.13a. Final restoration with a ridge-lap

design to overcome palatally placed implant fixture.

FIGURE 3.14b. Implant angulation of 65 degrees that

provides optimal aesthetic results.

rounding the new restorations exists. These implants

should be placed at the alveolar crest within the circum-
ference of the CEJ of the missing teeth to be restored.
This will enable the clinician to develop appropriate
embrasures on both sides adjoining the restorations as
well as to develop the emergence profile.5
A difference exists between the fixture morphology
and that of the natural tooth at the cervical level. There-
fore, a transition from the narrow circular implant neck
FIGURE 3.13b. Clinical view showing unpleasant aes- form to the natural tooth form is required. The ideal api-
thetic final result of an implant-supported crown (restor- coincisal implant positioning will place the implant head
ing upper right missing lateral incisor) due to the too far 2-3 mm below a line connecting the gingival zeniths of
palatal placement of the implant fixture.
the adjacent teeth. "Running room" should be allowed
throughout the biological width of the implant when it is
implant to be chosen. When multiple implants are to be correctly positioned in an apicoincisal plane.36 This
used, a greater urgency for restoring gingival tissues sur- "running room" is a space or leeway that lies 2-3 mm
AESTHETIC IMPLANT PLACEMENT 55

FIGURE 3.15. Illustration showing the long-axis posi- FIGURE 3.16. Illustration showing the long-axis posi-
tioning of the implant fixture in case of using a cement- tioning of the implant in case of using a screw-retained
retained abutment. abutment.

apical to an imaginary line connecting the gingival the screw design ranks first: its mechanical character
zeniths of the neighboring dentition (Fig. 3.18). This allows control of the depth while threading the fixture in
room allows for stacking and building up of prosthetic the bone. The cylinder design, on the other hand,
components to create the natural contours of the final requires the use of an implant retrieval tool to adjust the
restoration. The use of anatomical abutments to provide implant's optimal vertical position, which makes the
the same cross-sectional triangular shape as the missing procedure difficult to control. Additionally, implants
natural tooth did not benefit the aesthetic outcome to a with wide diameters of 5-6 mm will eventually require
great extent (as it is supposed to do) due to the nature of less space for transitioning into a natural tooth form
the peri-implant soft tissue. When an anatomical abut- than narrow-diameter implants (Fig. 3.19).
ment is used, it will give the required original missing It is recommended that the location of the implant neck
tooth configuration at the emergence level while it is in should be related to a line connecting the gingival zenith of
place, but upon its removal for any clinical reason, the the adjacent remaining natural dentition rather than to a
peri-implant soft tissue tends to collapse and regain its line connecting the CEJ or the crest of the ridge. Therefore,
original circular shape. Therefore, the final prosthesis when the implant-supported restoration is completed, it
that possesses natural biological contours seems to fulfill will attain the same marginal level as those existing around
the same purpose without the need for the use of natural dentition. The gingival zenith is not a constant ref-
anatomical abutments. With regard to which implant erence point; it sometimes moves apically in case of reces-
type permits ease of control of apicoincisal positioning, sion, and it reflects the actual clinical marginal level of the
56 CHAPTER 3

FIGURE 3.19. Illustration showing that wider

implants require less apical positioning.

a wavy course that has a rise and fall on both buccolingual

and interproximal margins; this scalloped line does not
move when gingival recession occurs.
The crest of the ridge also is not an ideal reference
point, since the very nature of bone resorption makes it
sometimes variable in its height, and also the soft tissue
thickness on top of it can be variable. For that reason,
FIGURE 3.17. Illustration showing the difference in when implant placement is in an area afflicted with mild
cross section between implant and natural tooth and the vertical ridge resorption and a remarkably thick mucosa,
running room. the implant neck should be situated above the level of the
bone crest in order to keep the "running room" within
the required average level (2-3 mm). On the other hand,
in restoration of a missing single tooth for a patient that
exhibits nonpathological gingival recession, the only
ideal reference line will be the line connecting the gingival
zeniths of the adjacent teeth.
Lastly, there is a relationship between the apicoincisal
and labiopalatal positioning. Labiopalatal placement of
the implant is directly proportional to its apicoincisal posi-
tioning. Potashnick stated that, for every millimeter the
implant is placed palatally, the implant should be sunken 1
mm apically for compensation, in order to maintain a nat-
ural emergence profile.5 This relationship was found to be
helpful in obtaining an optimal implant position.5

CORRECTIONS OF IMPLANT
MISPLACEMENT
Any deviation from the optimal position of the implant in
FIGURE 3.18. The ideal apicoincisal positioning of any dimension will surely result in an aesthetic problem.
the implant.
Some of the problems can be treated, while for others,
implant removal will be the only possible resort. An
implant that is placed in an incorrect position in the alveo-
soft tissue at the time of implant placement. In contrast, lar ridge may be due to the use of an imprecise surgical
the CEJ is a constant landmark. It follows a uniformly template, instability of the angulation of the handpiece,
fixed scalloped path along the root surface. It also pursues and the lack of knowledge or experience. As in the case of
AESTHETIC IMPLANT PLACEMENT 57

any positioning error, there is always a consequence or

repercussion. Therefore, it is essential that the clinician
should be familiar with the various unfortunate clinical sit-
uations that may arise in order to be able to deal with
them.
The problem associated with positioning the implant
too far apically is the formation of a deep gingival sulcus.
This creates a favorable environment for several types of
bacteria, including anaerobic bacteria, to colonize and
populate, due to the inaccessibility for cleaning (Fig.
3.20).17 Gingival bleeding upon tooth brushing or when
the prosthetic components are to be retrieved is a com-
mon event with too far apical placement. Moreover,
accessibility to the prosthetic margins of a deeply seated
implant becomes difficult, especially when the restora-
tion is to be cemented. It becomes increasingly exigent to
ensure complete removal of the luting cement from the
interface between the abutment and the restoration.40
The correction of this clinical dilemma is almost impossi-
ble because gingival recession usually occurs as a result; FIGURE 3.21. Too far incisal positioning of an
strict oral hygiene procedures should be maintained to implant fixture.
reduce the tendency for gingival inflammation.
The implant placed too far incisally, in contrast, often or incisally. Even using the pre-angulated abutments in
results in a short crown with constricted margins due to too far labial implant placement will not be effective in
the reduced space for "running room." This makes stack- most situations because the pre-angled abutment usually
ing the prosthetic components difficult. This clinical requires a larger restorative dimension than other types.
predicament is impossible to amend or rectify. The diffi- The protruding gingival collar of the pre-angled abut-
culty remains in handling the margins of the final pros- ment will encroach upon the peri-implant soft tissue and
thesis and hiding the abutment collar sublingually (Fig. violate its integrity. Interestingly, Nishimura et al. have
3.21). In this particular condition, implant removal can described an alternative approach for patients with mis-
be the treatment of choice. placed dental implants that are difficult to restore with
The chances to restore a misplaced implant with an the regular commercially available abutments.41 This
acceptable aesthetic result are minimal. This is especially approach suggests the use of a custom-fabricated abut-
the case if the implant has been positioned too far labially ment that is specially designed to meet the aesthetic and
functional needs of each particular patient.
Other attempts have been made to correct implant
misplacement by performing an osteotomy around the
osseous housing of the implant fixture, moving the seg-
ment to the required correct position, and stabilizing it
with microplates and screws.42 This procedure can save
the patient the distress of going through several surgical
procedures to remove the misplaced implant and replace
it, which involves longer treatment time. This technique
has its limitations: limited space between the existing nat-
ural root and the implant fixture that sometimes makes
the osteotomy clinically inapplicable; insufficient kera-
tinized tissues to cover the surgical site; anatomical limi-
tations; and risk of morbidity or other unforeseen
surgical difficulties. However, despite all these hin-
drances, sometimes removal of the implant may be the
only reliable solution to treat implant misplacement.
In conclusion, the balance between function and aes-
thetics must be maintained, and since delicate viable tissue
FIGURE 3.20. Too far apical placement of an implant is being dealt with in the oral cavity, the necessity to
fixture; note the increased pocket depth. achieve accurate and precise implant placement is empha-
58 CHAPTER 3

sized. Tipping of the balance is a price that cannot be paid! 18. El Askary AS, Meffert RM, and GriffinT. Why do dental
implants fail? Part I. Implant Dent 1999(8): 173-185.
19. El Askary AS, Meffert RM, and GriffinT. Why do Dental
Implants Fail? Part II. Implant Dent 1999(8): 265-277.
REFERENCES 20. Meffert RM. Treatment of failing dental implants. Curr
Opin Dent 1992(2): 109-144.
1. English CE. Biomechanical concerns with fixed partial 21. Seibrt J. Surgical management of osseous defects. In
dentures involving implants. Implant Dent 1993( 2): Gorman HM and Cohen DW, eds. Periodontal Therapy,
221-242. 5th ed. St. Louis: CV Mosby Co., 1973, 765-766.
2. Atwood DA and Coy DA. Clinical, cephalometric and 22. Oschsenbein C and Ross S. A concept of osseous surgery
densitometric study of reduction of residual ridge. J and its clinical applications. In Ward HL and Chas C eds.
Prosthet Dent 1971(26): 280-293. A Periodontal Point of View. Springfield, IL: Charles C.
3. Johnson K. A study of the dimensional changes occur- Thomas, 1973).
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healing. Aust Dent J 1963(8): 428-433. individuals with varying forms of the upper central
4. Carlsson GE, Bergman B, and Headegard B. Changes in incisors. J Clin Periodontol 1991(18): 78-82.
contour of the maxillary alveolar process under immedi- 24. Morris ML. The position of the margin of the gingiva.
ate dentures. A longitudinal clinical and x-ray cephalo- Oral Surg Oral Med Oral Pathol 1958(11): 722-734.
metric study covering 5 years. Acta Odontol Scand 25. Wheeler RC. Complete crown form and the periodon-
1967(25): 45-75. tium. J Prosthet Dent 1961(11): 722-734.
5. Potashnick SR. Soft tissue modeling for the esthetic sin-
26. Wheeler RC. A Text Book of Dental Anatomy and Phys-
gle-tooth implant restoration. J Esthet Dent 1998(10):
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27. Glickman I. Clinical Periodontology, 4th ed. Philadel-
6. Jansen CE and Weisgold A. Presurgical treatment plan-
phia: W. B. Saunders Co., 1972, 21.
ning for the anterior single-tooth implant restoration.
28. Seibert J and Lindhe J. Esthetics and periodontal ther-
Compendium 1995(16): 746-763.
apy. In Lindhe J, ed. Text Book of Clinical Periodontol-
7. Chiche GJ and Aoshima H. Functional versus aesthetic
articulation of maxillary anterior restorations. Pract ogy, 2nd ed. Copenhagen: Munksgaard, 1988.
Periodont Aesthet Dent 1997(9): 335-342. 29. Zitzman NU and Marinello CP. Anterior single-tooth
8. Spiekerman HS. Special diagnostic methods for implant replacement: Clinical examination and treatment plan-
patients. In Implantology. Stuttgart: Thieme Verlag, ning. Pract Periodont Aesthet Dent 1999(11): 847-858.
1995, 91-124. 30. Esposito M, Ekestubbe A, and GrondahK. Radiological
9. Garber DA. The esthetic dental implant: Letting the evaluation of marginal bone loss at tooth surfaces facing
restoration be the guide. J Am Dent Assoc 1995(126): single Branemark implants. Clin Oral Impl Res 1993(4):
319-325. 151-157.
10. Palacci P. Optimal implant positioning. In Palacci P and 31. Jansen CE. Restorative options with implant dentistry. J
Ericsson I. Esthetic Implant Dentistry. Soft and Hard Calif Dent Assoc 1992(20): 30-31.
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11. Buser D, Mericske-Stern R, Dula K, and Lang NP. Clin- 33. Kennedy B.D, Collins TA, and Kline PC. Simplified
ical experience with one-stage, non-submerged dental guide for precise implant placement: A technical note.
implants. Adv Dent Res 1999(13): 153-161. Int J Oral Maxillofac Implants 1998(13): 684-688.
12. Burger EH and Klein-Nulend J. Responses of bone cells 34. Ohenell L, Palmquist J, and Branemark PI. Single tooth
to biomechanical forces in vitro. Adv Dent Res replacement. In Worthington P and Branemark P-I, eds.
1999(13): 93-98. Advanced Osseointegration Surgery Applications in the
13. Herrmann G. Primary stability of oral implants. Int Mag Maxillofacial Region. Carol Stream, IL: Quintessence
Oral Implantol 2000(1): 22-24. Publishing Co., 1992, 211-232.
14. Szmukler-Moncler S, Salama H, Reingewirtz Y, and 35. Askary AS. Why do dental implants fail? Part I. Implant
Dubruille JH. Timing of loading and effect of micromotion Dent 1999(8): 173-185.
on bone-dental implant interface: Review of experimental 36. Parel SM and Sulivan DY. Esthetics and Osseointegra-
literature. J Biomed Mater Res 1998(43): 192-203. tion. Dallas, TX: Taylor Publishing, 1989.
15. Block MS, Kent JN, and Guerra LR. Implants in Den- 37. Daftary F. Natural esthetics with implant prosthesis. J
tistry. Philadelphia: W. B. Saunders Co., 1997. Esthet Dent 1995(7): 9-17.
16. Brunski JB, Puleo DA, and Nanci A. Biomaterials and 38. Davidoff D. Developing soft tissue contours for implant
biomechanics of oral and maxillofacial implants: Cur- supported restorations: A simplified method for
rent status and future developments. Int J Oral Maxillo- enhanced aesthetics. Pract Periodont Aesthet Dent
fac Implants 2000(15): 15-46. 1996(8): 507-513.
17. Misch CE. The maxillary anterior single tooth implant aes- 39. Wheeler RC. Dental Anatomy, Physiology and Occlu-
thetic health compromise,. Int J Dent Symp 1995 (l):4-9 . sion. 5th ed. Philadelphia: W. B. Saunders Co., 1974.
AESTHETIC IMPLANT PLACEMENT 59

40. Agar J, Cameron S, Hughbanks J, and Parker M. 41. Nishimura RD, Chang TL, Perri GR, et al. Restoration of
Cement removal from restorations luted to titanium partially edentulous patients using customized implant
abutments with simulated subgingival margins. J Pros- abutements. Pract Periodont Aesthet Dent 1999(11): 669-
thet Dent 1997(78): 43-47. 676.
42. Warden P J . Surgical repositioning of a malposed, unser-
viceable implant: Case report. Int J Oral Maxillofac Surg
2000(58): 433-435.
4
Soft Tissue Management

Abd El Salam El Askary Unlike the natural dentition, a dental implant is a

metallic body inserted into the jawbone. Therefore, its
The soft tissue in the oral cavity may be likened to an collar does not receive any blood supply from a sur-
outer frame that magnifies and complements the beauty rounding periodontal ligament or any other vessels.
of the natural teeth within. Without this outer frame the Rather, it acquires a fibrous connective tissue band
color, contrast, and luster of the teeth will not attain around its collar that is more dense and acellular.15"19 In
maximum attractiveness. If one were to imagine the teeth addition, the very fragile nature of the oral mucosa
without the surrounding soft tissue, one would be aghast makes its ability to withstand excessive clinical manipu-
at the image of just teeth coming out of the bone. That lations unpredictable, which can lead sometimes to asym-
image is one that shows how important the soft tissue is, metrical final implant prostheses (Fig. 4.1).20 In view of
in simply giving life to the total image. It is this total the above, clinicians are required to handle peri-implant
image of teeth with healthy surrounding soft tissue that soft tissues with exceptional care because of their reduced
clinicians seek to replicate in oral implantology to give a blood circulation and delicate nature. Mastering the tech-
natural tooth appearance. niques of manipulating the delicate peri-implant soft tis-
The soft tissue that closely surrounds the implant col- sue architecture in the aesthetic zone is therefore
lar (the peri-implant soft tissue) is delicate in nature. considered mandatory. It can lead to a remarkable
Understandably, it is impossible to achieve satisfactory improvement in the aesthetic outcome of implant-sup-
aesthetic results without peri-implant soft tissue that is ported restorations when the other treatment steps are
harmonious with the adjacent tissues in color, form, and properly fulfilled.
contour.1'2 Peri-implant architecture thus takes a major
share in the aesthetic setup of any implant-supported
restoration.3"6
Currently available soft tissue manipulations of the
peri-implant soft tissue can solve a number of minor clin-
ical problems that prosthetic simulated soft tissue
restorations attempted to handle in the past. For exam-
ple, connective tissue grafts can amend minor alveolar
ridge defects and restore original contours by increasing
the soft tissue height and width.7"9 Soft tissue expansion
by means of a provisional restoration is yet another mod-
ern application in soft tissue management; it is used to
enhance the aesthetic outcome or help solve an existing
soft tissue clinical problem.10'11 A provisional restoration
also can compensate for a palatally positioned implant by
expanding the peri-implant soft tissue margin in a labial
direction until it levels and harmonizes with the adjacent FIGURE 4.1. Nonsymmetrical implant-supported
tissues.12"14 restoration, due to soft tissue mismanagement.

60
SOFT TISSUE MANAGEMENT 61

Aesthetic implant positioning has a direct influence on stages of implant treatment. Soft tissue can be influenced
the soft tissue profile and final appearance.21 The more during many stages of implant treatment. The second-
precisely the implant is positioned, the easier it will be to stage surgery is an example where the labial mucosa
obtain a natural-looking, implant-supported restoration exists in a collapsed state.20 It would require support
in its soft tissue housing. With optimal implant position- from the prosthetic components to develop natural-look-
ing, any gingival discrepancy will be avoided, thus mini- ing peri-implant soft tissue contours. Mucogingival sur-
mizing the need for further corrective surgeries and soft gical corrections can also be used before or after implant
tissue reconstruction. placement to reconstruct the missing aesthetic biological
Accurate diagnosis and treatment planning set the contours surrounding already existing implant-sup-
stage for the timing of all the events to follow. This has its ported restorations.24"26
direct impact on the precision of the work and the pre- Correction of edentulous ridge defects can be per-
dictability of the final results. It is important to be able to formed at any time during the period of the treatment
identify and classify the existing clinical conditions, plan. Soft tissue correction of a deficient edentulous ridge
whether they are related to hard or soft tissue origin. is best performed before implant placement; this can help
Ridge defects have a wide range of descriptions with improve aesthetics, phonetics, and oral hygiene mainte-
numerous variations in size, severity, and extent. Allen et nance.27 Soft tissue management at the time of tooth
al. identified three categories of ridge defects in relation to extraction can be determinative to the final aesethtic out-
the healthy soft tissue margins: (a) mild, a defect of less come as well. Soft tissue refining and profiling, on the
than 3 mm; (b) moderate, a defect of 3-6 mm; and (c) other hand, are intermediate clinical procedures in
severe, a defect greater than 6 mm.22 Seibert and Salama, implant treatment that can be executed after the abut-
on the other hand, classified volumetric deformity ment connection.
changes of the edentulous ridge into three general cate- The time allowed for soft tissue healing after cosmetic
gories: Class I, buccolingual loss of tissue with normal reconstruction is important. Lazara recommends that
ridge height in an apicocoronal dimension; Class II, apic- consideration should be given to the healing period after
ocoronal loss of tissue with normal ridge width in a buc- any soft tissue manipulation occurred, as oral soft tissues
colingual dimension; and Class III, combination require an ample time to heal and mend.28 A stable soft
buccolingual and apicocoronal loss of tissue, resulting in tissue clinical condition must be attained before begin-
loss of normal ridge height and width.23 These classifica- ning or continuing with other clinical procedures. This is
tions not only facilitate the assessment of any given clini- also reaffirmed by Small and Tarnow, who recommend a
cally compromised situation, but also help the dental three-month waiting period for the soft tissue to stabilize
team to identify the existing soft tissue status and describe before selecting the final abutment or making the final
it in a more specific and scientific manner that contributes impression after the second-stage surgery.29
to better communication among the dental team. In their longitudinal study of gingival recession
In many situations, after classifying the existing hard around dental implants, Small and Tarnow measured the
and/or soft tissue defects, the clinician may have to resort soft tissue level around implants following surgery to
to surgical reconstruction of these tissues from the outset. determine if a predictable pattern of soft tissue changes
The surgical reconstruction enables the clinician to could be identified. They evaluated sixty-three implants
restore the alveolar ridge to its original biological dimen- in eleven patients. Baseline measurements were recorded
sions. This, in turn, will help the clinician to restore the at the second-stage surgery in two different submerged
missing dentition with greater precision and predictabil- implant systems. Subsequent measurements were
ity. It is important to note, however, that these cosmetic recorded at one week, one month, three months, six
surgical procedures may result in additional discomfort months, nine months, and one year after baseline mea-
and financial cost for the patient as well as additional surements. The majority of the recession occurred within
chair time for the dentist. the first three months, and 80% of all sites exhibited
recession on the buccal surface. It is therefore recom-
mended to allow three months time for the tissue to sta-
bilize and mature before either selecting a final abutment
TIMING IN RELATION TO SOFT or making a final impression in order to avoid any unpre-
TISSUE MANAGEMENT dictable tissue behavior around the final prosthesis.29
The author has classified management of the soft tis-
There is no specific time when management of peri- sues around dental implants in the aesthetic zone accord-
implant soft tissue should take place. Proactive soft tissue ing to the timing of clinical intervention into four
management can be performed throughout the various categories: (1) before implant placement, (2) during
62 CHAPTER 4

implant placement, (3) at the time of abutment connec- This technique provides sufficient keratinized mucosa
tion, and (4) at postabutment connection.30 for a soft tissue closure procedure on top of the implant.
This new regenerated tissue subsequently minimizes sur-
Soft Tissue Management before gical trauma that occurs due to attempts to achieve pri-
mary closure in immediate implant placement. In
Implant Placement addition, the new regenerated tissue preserves the
After the future surgical site for implant placement is anatomical mucogingival integrity at its biological level
carefully examined in order to identify any defects or dis- (Fig. 4.2a-e) and eliminates the chance for postextraction
crepancies in the keratinized band. Any corrective soft tis- alveolar bone resorption.36"38
sue surgery (if needed) should be performed two to four Generally speaking, the regenerated oral tissues
months before the first-stage implant placement surgery should be in excess of what is required so as to compen-
takes place, to allow ample time for the soft tissue to sate for ensuing tissue shrinkage or remodeling39'40 (espe-
reach a stable remodeling state, as mentioned earlier.31 cially following multiple surgical interventions). After
Soft tissue therapy prior to implant placement utilizes sufficient healing time has elapsed and a stable tissue con-
various techniques to enhance the quantity or the quality tour is established, any excessive tissue can then be
of the soft tissue or to eliminate any existing soft tissue trimmed or sculptured to the desired level.
pathology at the area of interest. Free gingival grafting,32
connective tissue grafting,33 or a combination of both can SOCKET SEAL TECHNIQUES This technique is
also be used at this stage to enhance the final aesthetic used prior to implant placement to improve the condi-
results as well as minimize the complications that might tion of the soft tissue on top of the socket orifice, to pre-
arise at the time of the first- and second-stage surgeries.34 vent postextraction bone resorption of the alveolar
The methods of dealing with the soft tissue before
implant placement follow below.

OPTIMIZING KERATINIZED TISSUES The

general biological nature of the oral mucosa is fragility.
The mucosa can be easily torn and traumatized during
intraoperative procedures, leading to postoperative
sloughing and a subsequent delay in healing that might
jeopardize the future aesthetics. This explains the need
to improve the soft tissue status prior to surgery.
Improving the condition of the keratinized mucosa
prior to implant surgery can be a safeguard for the future
health of the implant and its surrounding tissues. Pres-
ence of a sufficient zone of keratinized mucosa can mini-
mize the soft tissue manipulations (especially in
immediate implant placements) needed to achieve pri-
mary closure over the future implant site. FIGURE 4.2a. A patient with unsalvageable remaining
Immediate implant placement into a freshly extracted root of the maxillary left central incisor.
socket presents an especially difficult challenge to achiev-
ing soft tissue coverage, especially with patients that have
the thin scalloped tissue biotype. To overcome these clin-
ical difficulties, a technique for developing keratinized
tissues on top of the socket orifice has been introduced.35
The technique entails the use of a round bur to reduce the
tooth height below the crestal bone level without trauma-
tizing the surrounding gingival margin.35 The presence of
residual roots of the reduced teeth will prevent epithelial
downgrowth along the socket walls and provide scaffold-
ing for the regeneration of keratinized tissues on top of
the socket orifice. The soft tissues will take only few
weeks to regenerate and fill the socket orifice as part of FIGURE 4.2b. Reduction of the root level below the
the healing process. crest of the alveolar bone with a rose-head bur.
SOFT TISSUE MANAGEMENT 63

ridge, and to enhance the quality of bone at the future

implant site. The technique of socket sealing aims to
block off the socket of an extracted tooth immediately
after tooth extraction. Socket seal surgery was first
described by Landsberg41 and Bichacho42 as a treatment
method for preserving the integrity of the alveolar ridge
and inhibiting apical epithelial migration into the
socket.43
The procedure involves atraumatic, flapless tooth
extraction, followed by debridement and decortication of
the socket walls to enhance osteogenic activity. The free
gingival margins surrounding the socket are circumferen-
tially deepithelialized with a water-cooled, round coarse
diamond bur or with a sharp scalpel in order to provide
vascularity for the future free gingival graft and to pro-
FIGURE 4.2c. A four weeks postoperative view show- mote clot formation. The socket is then packed with the
ing regeneration of new keratinized tissues. bone graft of choice.
Since any bone-grafting material must be kept in place
and protected from the hostile oral environment,43 a 3
mm thick free gingival graft is harvested from the palate
to cover the bone-grafting material. The free gingival
graft is then adapted and fitted to the freshly deepithelial-
ized gingival margins on top of the bone graft and
sutured, to completely seal the socket orifice. The pur-
pose of the socket sealing technique is to prevent physi-
cal, chemical, or bacterial contamination of the
organizing blood clot and bone-grafting material until
healing occurs (Fig 4.3a-c).
The technique is considered to be a simple clinical pro-
cedure that can be performed along with tooth extrac-
tion. However, this technique has its shortcomings. The
soft tissue graft lies on the bone graft particles and not on
the periosteum. Therefore, the surrounding gingival tis-
FIGURE 4.2d. Clinical view after root extraction, sue located on the rim of the socket becomes the only
showing reflection of the muccoperiosteal flap with the source of vascularity to the free gingival graft. As a result,
implant in place. the soft tissue graft is prone to thinning, necrosis, and
infection, due to the poor blood supply to the graft. If the

FIGURE 4.2e. Postinsertion view of the final restora-

tion in place, showing an excellent soft tissue condition FIGURE 4.3a. The socket condition after tooth extrac-
with zero scar tissues. tion and bone grafting.
64 CHAPTER 4

epithelium on top of the socket with an exact color and

texture similar to that of the surrounding original tis-
sues. Also, the use of the autogenous bone is found to be
more predictable for bone regenerative procedures.45"47
Misch et al.44 have also used platelet-derived growth
factor (PDGF) from the patient's own blood that func-
tions as a chemoattractant for mesenchymal cells to
enhance cartilage and bone formation rate.48
The procedure entails a flapless atraumatic extraction
of the unsalvageable tooth, followed by curettage and
decortication of the socket walls, and the soft tissue
around the rim of the extraction socket is then deepithe-
FIGURE 4.3b. Keratinized tissue graft is adapted and lialized with a diamond bur or a sharp scalpel (Fig. 4.4a-
sutured to the socket orifice. c). A trephine drill that has a diameter almost the same as
or larger than that of the socket orifice is used to harvest
the composite graft from the tuberosity. Care must be
exercised not to cause excessive heat generation to the

FIGURE 4.3c. Unfavorable graft healing occurred

(sloughing) due to decreased blood supply to the graft.

soft tissue graft survives, it generally does not come to

possess the same texture or color as the surrounding soft
tissues.
FIGURE 4.4a. A patient with an unsalvageable
remaining root of the maxillary first premolar.
MODIFIED SOCKET SEAL SURGERY Misch et
al. have modified the previously mentioned technique of
socket sealing in order to eliminate its drawbacks and
improve its clinical predictability.44 The modified socket
seal surgery is performed prior to implant placement in
order to enhance the quantity and quality of bone and
soft tissue as well as to preserve the original biological
architecture of the alveolar ridge at the place of tooth
extraction. It is preferably performed when the socket
walls are intact. In this technique, a composite graft,
consisting of epithelial tissue, connective tissue, perios-
teum, cortical bone, and cancellous bone, is harvested
from the tuberosity area to fill and seal the socket.
There are several advantages to using a composite graft.
For one, the connective tissue part of the graft has an
advantage over the keratinized tissue graft: it merges
and blends with the adjacent keratinized tissues after FIGURE 4.4b. Deepithelialization of the soft tissue
completion of the healing process, providing keratinized margins.
SOFT TISSUE MANAGEMENT 65

FIGURE 4.4c. Flapless atraumatic extraction of the

remaining root with intact labial plate of bone.
FIGURE 4.4e. The composite graft after harvesting
(cancellous bone, connective tissue, and keratinized tis-
graft. This is accomplished by using a slow-speed hand- sue).
piece with copious saline irrigation during the harvesting
procedure.
A green stick fracture of the composite graft is per-
formed at its base to separate it from the donor site. Here,
caution must be exercised not to perforate the maxillary
sinus; an x-ray film or digital radiography can help deter-
mine the extent of drilling procedure (Fig. 4.4d,e). The
keratinized layer of the graft core is then shaved to
remove only the surface epithelium, leaving almost 3 mm
of connective tissue thickness attached to the bone core
(Fig. 4.4f). If the bone core is found to be larger than the
socket orifice, it should be pared so that it will fit snugly in
the socket. The apical third of the extraction socket is sub-
sequently filled with demineralized freeze-dried bone and

FIGURE 4.4f. Removal of the keratinized epithelium

from the composite graft.

a puffy coat containing PDGF (Fig. 4.4g). Afterwards the

composite graft is introduced into the socket (Fig. 4.4h)
and tapped gently into place using a mallet and blunt
instrument. Upon seating, the surface of the composite
graft should conform to the crestal contour of the socket
and be positioned slightly below the surrounding mar-
ginal gingiva (Fig. 4.4i). This is to allow for epithelial
migration on top of the connective tissue graft. The con-
nective tissue portion of the graft is then sutured to the
surrounding gingival tissues (Fig. 4.4j).
When this technique is used, a provisional removable
prosthesis should not be allowed during the first few
weeks after surgery because the composite graft may
move upon pressure and become sequestrated due to pre-
FIGURE 4.4d. Harvesting a composite graft from the mature loading of the bone resulting from the pressure of
maxillary tuberosity region using a wide trephine drill fitting surface of the prosthesis. The osteotomy hole of the
that is almost the same diameter as the socket orifice. donor site can be filled with any bone-grafting material,
66 CHAPTER 4

FIGURE 4.4g. Condensation of freeze-dried bone

inside the apical third of the socket. FIGURE 4.4 j. The graft is sutured in its final place-
ment.

and primary wound closure can be achieved by undermin-

ing the soft tissue edges, or an acrylic template may be
used to seal the area of the defect until it heals by sec-
ondary intention.
The numerous advantages of this technique include the
great enhancement of the soft tissue quality and quantity
over the socket (which attains the exact color and texture
of the surrounding tissues) (Fig. 4.4k) and the promotion
of faster and more predictable bone regeneration in the
socket (Fig. 4.41), so that the width and height of the alve-
olar bone are maintained after extraction (Fig. 4.4m), thus
improving the overall prognosis for any future implant
placement. This method is considered a highly predictable
technique among all the techniques used to enhance
socket condition prior to implant therapy (Fig. 4.4n).

FIGURE 4.4h. The prepared graft is being introduced Soft Tissue Management during
into the socket and tapped. Implant Placement
Surgical techniques utilized during implant placement at
the first-stage surgery are numerous; the techniques

FIGURE 4.4k. Healing of the area with the contour of

the labial plate of bone intact and with no postoperative
FIGURE 4.41. The graft is positioned below the gingi- resorption (note the color match of the soft tissue part of
val margin to allow epithelial growth on its surface. the graft to the surrounding tissues).
SOFT TISSUE MANAGEMENT 67

FIGURE 4.41. Periapical radiographic view of the area

showing bone regeneration in the socket with improved
bone density. FIGURE 4.4n. Post crown insertion view.

On the other hand, nonsubmerged implant placement

requires a different surgical approach than submerged
implant placement. Nonsubmerged implant placement
does not require a second-stage surgery because the access
to the implant is maintained above the soft tissue from the
time of its placement.54"56 Buser et al.54 stated that osseoin-
tegration showed high predictability in the one-stage,
nonsubmerged surgical protocol; this referred to the elim-
ination of the subgingival implant-abutment connections.
However, it is the author's opinion that when aesthetics is
a priority, the nonsubmerged one-stage implant place-
ment protocol should be restricted. The reasoning is
grounded in the inherent character of the design of the
one-stage implant system. The flaring of the transmucosal
part of the implant handicaps the use of the provisional
restoration to develop the "running room" within which
the natural emergence through the soft tissues can be
replicated. The nonsubmerged (two-stage) implant place-
FIGURE 4.4m. The final soft tissue healing after the ment protocol entails the attachment of the healing abut-
second-stage surgery with the contour of the labial plate ment to the implant fixture at the time of implant
of bone intact. insertion; the implant is permitted to heal in a nonsub-
merged mode to provide greater latitude for proper soft
tissue contouring. However, submerging the implant
should all aim at fulfilling the standard operative recom- beneath the soft tissue for a two-stage surgical protocol is
mendations in mucoperiosteal flap management as well still the method most preferred by clinicians, probably
as closure. Incision design, mucoperiosteal flap handling, because there is extensive long-term documentation in the
careful soft tissue manipulation, and tension-free flap literature57 and the implant is not subjected to any biting
closure contribute to providing a healthy environment loads while it is undergoing osseointegration.58"60
around dental implants and minimizing postoperative The standard submerged protocol for placing dental
complications.49"51 The first-stage surgery involves the implants might be indicated when the aesthetic outcome
placement of the dental implant either in an immediate or of the implant restoration is significantly important,
a delayed fashion.52'53 Surgical procedures utilized to when the implant is placed in poor bone quality or in a
achieve delayed implant placement will surely differ from site that has been previously augmented, and when peri-
those used in immediate placement, and postoperative odontal therapy has not been concluded at the time of
soft tissue healing will accordingly not be the same. implant placement.
68 CHAPTER 4

SOFT TISSUE MANAGEMENT IN DELAYED the site accompanied by an inflammatory reaction (which
IMPLANT PLACEMENT can be a potential risk of infection).68
Another flap design for submerged implant placement
Mucoperiosteal Flap Design Flap design is an is the crestal approach. This approach has shown many
important clinical step in dental implant placement; some advantages. It is simple, does not require professional
clinicians prefer to design the flap in the presurgical stage surgical experience, can be easily sutured, offers faster
on the study cast because of its value in the success of the healing, does not compromise the blood supply to the
treatment. The flap should be designed to gain access and site, and exhibits a mild inflammatory reaction.68'69
visibility with minimal soft tissue trauma and to facilitate Various studies have been conducted to judge the effi-
maintenance of the attached tissues. This in turn will help cacy of vestibular versus crestal approaches used for sub-
achieve favorable healing and minimize postoperative merged dental implant placement. A study by Casino et
complications .6l-64 al. compared the vestibular and crestal approaches in
The concept behind selecting one flap design over relation to the success rate of osseointegration. The clini-
another is mainly to achieve optimal wound healing that cal success of osseointegration was evaluated at the sec-
contributes positively to implant survival.65 Because ond-stage surgery.70 In this study, a crestal incision was
the oral cavity harbors numerous microorganisms, it used for 1,705 implants in 381 patients, and a vestibular
becomes a hostile environment for dental implants, espe- approach was used for placing 593 implants in 141
cially in the healing period.66 Therefore, placing a dental patients. The outcome showed no statistically significant
implant in such an environment warrants special atten- difference in the clinical success of osseointegration
tion. Esposito et al. expressed an important fact that between the two approaches.
links wound healing with implant survival; he stated that A similar retrospective study by Scharf and Tarnow
clinical signs of oral tissue infection during the postoper- weighed the clinical success rate of osseointegrated
ative period of a submerged implant insertion can indi- implants at the time of the second-stage surgery using the
cate an increased risk of implant failure.67 Systemic same two surgical approaches.68 A total of 386 implants
conditions such as uncontrolled diabetes mellitus, severe was placed in 92 patients; 265 implants were placed in
anemia, uremia, and jaundice can also be considered 60 patients using a vestibular incision and showed a suc-
aggravating factors that impair wound healing.65 There- cess rate of 98.8%; 121 implants were placed in 32
fore, special emphasis should be directed towards deli- patients using a crestal incision and showed a success rate
cate soft tissue manipulation and handling. of 98.3%. They concluded that there was no statistically
Obviously, there is no strict recommendation in the significant difference in the success rates of dental
literature for selecting a particular flap design over implants between the vestibular incision and crestal inci-
another; the incision and flap design are usually selected sion approaches.
according to the clinician's preference following the rule Another study by Hunt attempted to demonstrate
that says, "Whatever works best in the clinician's hands which incision, crestal or vestibular, is more suitable for
works best for the patient." However, the general health placing dental implants.71 Hunt also found that no single
condition of the patient, quality and quantity of the ker- flap design was optimal for implant surgery.71 More
atinized soft tissues, tissue biotype, width of the importantly, he recommended that basic factors like flap
vestibule, presence of osseous defects, the design of the design, blood supply, visibility, access, atraumatic han-
implant used, and the location of anatomical landmarks dling, and primary tension-free closure on healthy bone
are all factors that must be considered when choosing be carefully considered in implant placement.
any flap design.
There are several flap designs used for dental implant Preservative Interproximal Papilla Incision
placement with various surgical approaches. The classic Aesthetic and functional placement of dental implants
vestibular approach to accessing the alveolar ridge in requires a flap design that provides accessibility, visibil-
implant placement surgery was first described by Brane- ity, and workability without jeopardizing soft tissue
mark et al.53'57 The design involves a horizontal incision health or integrity. Including the interproximal papillae
in the vestibular mucosa parallel to the gingival margin. in the mucoperiosteal flap is not recommended in aes-
A lingually or palatally pedicled mucoperiosteal flap is thetic areas; therefore, excluding the interproximal
next obtained through two vertical incisions. The objec- papillae from the mucoperiosteal flap will help to
tive of this design is to position the incision line away achieve good aesthetic results. Some authors stated that
from the head of the implants. This particular approach raising the interproximal papillae along with the rest of
has several disadvantages, especially in patients with the mucoperiosteal flap might lead to an unpleasant aes-
shallow vestibules. These disadvantages include severe thetic outcome.72'73 This can be related to the tendency
postoperative edema and compromised blood supply to of the soft tissue to shrink or recede after raising a
SOFT TISSUE MANAGEMENT 69

mucoperiosteal flap, because a slight bone resorption can be used as an alternative to the classic full thickness
occurs each time a full mucoperiosteal flap is raised.74 mucoperiosteal design used for submerged implant
It is the author's experience that the preservative inter- placement. The original Elden-Mejchar77 vestibulo-
proximal papilla approach during the first- and/or sec- plasty was modified by Hertel78 and applied to totally
ond-stage surgery will favor aesthetics because the edentulous cases receiving dental implants. However, it
preservation of the papillae stabilizes the adjacent mar- can be used in partially edentulous patients as well.
gins of the implant-supported prosthesis, reduces postop- The technique starts with a shallow incision made
erative soft tissue recession, and reduces the tendency for approximately 10 mm from the alveolar crest and at least
marginal bone loss (Fig. 4.5a,b).75'76 15 mm distal to the site of the last implant to be placed (in
An added advantage to the flap design that safeguards the case of placing implants in totally edentulous areas).
the interproximal papillae is a lessened tendency to lacer- Care should be taken to ensure that the incision does not
ate the interdental papillae during surgery. The smaller end exactly where the implants will be located. A partial
size of the interproximal papillae, added to their delicate thickness flap subsequently is reflected towards the crest,
nature, makes them easy to tear or lacerate during the leaving the attached fibrous tissue over the periosteum in
different stages in flap handling. place, and then dissected with a scalpel to the lingual side
The preservative interproximal papilla flap design to expose the crest of the alveolar bone. The periosteum is
allows better flap adaptation upon closure; in other incised buccally and lingually next to the fibrous tissue
words, when the preservative design is used, each vertical band at the crest of the ridge. The buccal periosteum is
incision of the mucoperiosteal flap meets with the adja- again cut approximately 10 mm from the crest of the
cent tissues in a soft-tissue-to-soft-tissue manner (at the mandible (at the height of the first incision); the remain-
mesiocervical angle of the adjacent natural teeth), while in ing fibrous tissue at the ridge crest is best removed with a
nonpreservative flap designs, the vertical incision rests on rose-head bur. The implants should be placed under the
the mesiocervical aspect of the tooth structure; therefore, crestal bone level in order not to perforate the thin
the preservative design adapts in a soft-tissue-to-soft-tis- remaining attached mucosa. The flap is repositioned and
sue manner, while the nonpreservative design adapts in a sutured with resorbable suture material to the buccal
soft-tissue-to-tooth manner at the mesiocervical area. periosteum at its base; buccal edges of the incision are
The preservative interproximal papilla flap design can then sutured to the adjacent mucosa (Fig. 4.6a-k).
be used in several clinical applications; it can be used in The advantages of this technique are as follows: the
placing dental implants routinely, at the second-stage thickness of the mucosa is reduced to a minimal level
surgery, and in bone-grafting procedures. around dental implant prosthetic components; the band
of keratinized tissues is well preserved; insertion of the
Modified Elden-Mejchar Technique The modi- muscles close to the future implant site is eliminated (in
fied Elden-Mejchar technique is a flap design that is the case of totally edentulous patients); primary wound
used for implant placement to create an optimal closure on top of the implants is achieved, which favors
mucosal condition with maximum stability and reduced healing; no additional surgical procedures are necessary
pocket depth around dental implants. The flap design to repair excessive soft issue height; more interarch space

FIGURE 4.5a. Reflection of a mucoperiosteal flap FIGURE 4.5b. Closure of the flap showing the intact
through a preservative interdental papilla incision. interdental papillae attachment on both sides.
70 CHAPTER 4

FIGURE 4.6a. An illustration showing the outline of

the vestibular approach of the mucoperiosteal flap for
the modified Elden & Mej char technique for implant
placement in a partially edentulous case.

FIGURE 4.6c. An illustration showing the primary

reflection of a partial thickness flap.

FIGURE 4.6b. The outline of the flap design marked

on the soft tissue next to the space of the missing tooth.

will be provided for the prosthesis; and there is reduced

postoperative pain for the patients because no raw areas
are allowed postoperatively.
On the other hand, the procedure poses a greater risk FIGURE 4.6d. The partial thickness flap reflected,
with the horizontal incision marked.
of mucosal perforation during raising of the partial thick-
ness flap, and possible soft tissue sloughing because the
absence of the buccal periosteum reduces blood supply to techniques have been used to achieve complete soft tis-
the flap. sue closure with a satisfactory clinical outcome, either
by undermining and releasing the soft tissue margins to
SOFT TISSUE MANAGEMENT IN IMMEDIATE approximate the wound edges or by applying a special
IMPLANT PLACEMENT Immediate placement of surgical procedure to achieve the same goal.61'92"97 Early
dental implants in freshly extracted sites has been devel- exposure of immediately placed implants in fresh sock-
oped to save time and preserve the integrity of the alve- ets was a common event until these new techniques
olar ridge from postextraction bone resorption (Fig. offered predictable soft tissue closure results; this early
4.7).79~87 As a consequence, primary soft tissue closure exposure of dental implants might have a negative
in immediate implant procedures became a vital clinical impact on osseous regenerative procedures and jeopar-
prerequisite for many authors.88"91 Therefore, many dize implant survival rates.91'98"102
SOFT TISSUE MANAGEMENT 71

FIGURE 4.6e. An illustration showing the excision of

the buccal periosteum leaving the crestal periosteum FIGURE 4.6g. An illustration showing the final place-
intact. ment of the implant.

FIGURE 4.6f. The removal of the periosteum on the FIGURE 4.6h. View of the surgical site with the
crest of the ridge using a large round bur and marking implant in place.
the osteotomy hole.
special attention. It influences the width, position, and
Adherence to the standard successful protocol for sub- configuration of the attached mucosa as well as the
merging dental implants that was introduced by Brane- future emergence profile.104 The most common methods
mark103 and the need to protect the bone-grafting of achieving primary soft tissue closure in immediate
material from the oral environment and delay the migra- implant placement are the palatal rotated flap, the buccal
tion of epithelial tissues into the socket walls have rotated flap, rehermanplasty, the pedicle island flap, and
emphasized the importance of soft tissue closure. Yet, the use of guided tissue regenerative barriers.
there is neither available scientific data to substantiate the
use of one procedure over another, nor strict indications Palatal Rotated Flap The palatal rotated flap tech-
for the use of a specific surgical approach. nique was introduced by Nemkovesky et al.105 It origi-
Complete socket closure in immediate implant place- nally aimed at achieving primary closure on top of an
ment is a technique-sensitive procedure that warrants immediate implant without modifying or altering the
72 CHAPTER 4

FIGURE 4.6k. Final restoration in place.

FIGURE 4.6i. Illustration showing soft tissue closure

on top of the implant.

FIGURE 4.7. A patient presented with remarkable

postextraction labial bone resorption in the area of the
left maxillary central incisor.

the implant is placed, a sharp, deep, internally beveled

FIGURE 4.6j. Three months after implant placement, incision is made to delineate a full thickness palatal pedi-
at the time of the second-stage surgery; note the reduced cle flap. The pedicle flap is carefully elevated from the
gingival thickness on top of the implant head. underlying bone and rotated towards the socket orifice.
Bone-grafting material is used to fill socket voids between
the implant and socket walls and a GTR membrane might
buccal contour of keratinized mucosa, which can be vital be placed. The pedicle flap is rotated gently using surgical
to the final aesthetic outcome of implant-supported pliers, then tucked and sutured to the buccal keratinized
prostheses. A palatal pedicle flap is rotated towards the gingival margin of the socket. This procedure has shown
buccal mucosa to cover the socket orifice (Fig. 4.8 a-e). great clinical success due to improved blood supply to the
The technique entails an intrasulcular incision made pedicle from the palatal mucosa. Therefore, the technique
around the maxillary tooth to be extracted and the proxi- offers a good quality soft tissue closure while preserving
mal palatal aspect of the adjacent teeth; then the unsal- the buccal integrity of the keratinized soft tissue band.
vageable tooth is extracted atraumatically, and the
implant osteotomy is prepared according to a three- Buccal Rotated Flap Becker and Becker88 devel-
dimensional aesthetic implant placement protocol. After oped the buccal rotated flap technique to obtain a ten-
SOFT TISSUE MANAGEMENT 73

FIGURE 4.8a. An illustration showing the design of FIGURE 4.8b. Illustration showing rotation of the flap
the rotated palatal flap. to the labial side to cover the implant site.

FIGURE 4.8c. An implant placed by the flapless tech- FIGURE 4.8d. A palatal rotated flap is made to cover
nique, restoring missing maxillary canine. the implant and sutured to the labial mucosa.

mucoginigival discrepancies; however, the procedure

requires advanced surgical skills in soft tissue handling.
Becker and Becker originally recommended a split thick-
ness flap from the tooth adjacent to the donor tooth to
cover the exposed bone on the donor tooth itself,88 while
Novaes106 has modified this technique by incorporating
various incisions that improved the clinical outcome and
reduced postoperative complications (Fig. 4.9a,b).
Novaes's technique starts by placing a vertical releas-
ing incision at the mesial line angle of the adjacent tooth
anterior to the implant site, and a second vertical releas-
ing incision is executed at mesial line angle of the tooth
lying immediately distal to the implant site. A split thick-
ness flap is raised, starting at the first vertical incision
FIGURE 4.8e. Six weeks after healing. mesially and extending to the distal line angle of the same
tooth (Fig. 4.9c,d). Another deep vertical incision is then
sion-free closure on top of dental implants placed in made in the periosteum, extending down to the bone to
freshly extracted sockets. The technique can achieve a change the mode of partial thickness reflection to a full
complete tension-free closure without creating any thickness reflection. All along, the elevation of the full
74 CHAPTER 4

FIGURE 4.9d. Clinical view of the reflected split

FIGURE 4.9a. An illustration showing the design of
thickness flap.
the buccal rotated flap.

FIGURE 4.9e. An illustration showing the complete

FIGURE 4.9b. A patient with an unsalvageable
mobilization and reflection of the full thickness flap.
remaining root of the maxillary second premolar, with
the outlines of the flap marked using a blue marker.
thickness flap is started (Fig. 4.9e-h). Any tension
exerted on the flap should be avoided; a flap-relaxing
incision can be made by making a small horizontal inci-
sion on the mesial aspect and most-apicovestibular part
of the flap to release any possible tension. After the flap is
pulled distally and coronally to cover the socket area, it is
sutured to the palatal tissue (Fig. 4.9i-k). The excessive
•-I- soft tissue on the distal aspect is carefully excised to facil-
itate closure of the distal vertical incision. The excised tis-
sue is then used as a free gingival graft to cover the
exposed periosteum over the donor tooth. Fig. 4.91).
The main advantage of this method is that it avoids
harvesting a palatal pedicled flap, which might be incon-
venient for many patients (Fig. 4.9m).

Rehermanplasty Rehermanplasty is considered the

FIGURE 4.9c. Illustration showing the split thickness most common method among clinicians for primary
flap raised from the mesial side. soft tissue closure in the oral cavity. It was originally
FIGURE 4.9f. Clinical view of the flap, consisting of a FIGURE 4.9i. View of the rotation of the buccal flap
partial thickness segment and a full thickness segment. to cover the implant site.

FIGURE 4.9g. Illustration showing the implant in FIGURE 4.9j. Illustration showing the rotated buccal
place. flap sutured over the implant.

FIGURE 4.9h. Clinical view of the implant in place. FIGURE 4.9k. The rotated buccal flap is sutured.

75
76 CHAPTER 4

FIGURE 4.91. A free gingival graft excised from the

excessive soft tissue distally covers the exposed perios-
teum.

FIGURE 4.10a. A mucoperiosteal flap designed for

immediate implant placement.

FIGURE 4.9m. The final restoration in place.

developed to close oroantral fistulae.107'108 It is currently

used successfully to achieve primary soft tissue closure
in immediate implant placement cases. This method
entails raising a full thickness mucoperiosteal flap
through two vertical parallel incisions that are made
along both sides of the extraction socket and extended
vestibularly (Fig. 4.10a). The flap is then reflected and
extended farther vestibularly (Fig. 4.1 Ob). A periosteal
slitting incision is then made horizontally at the base of
the flap, after which multiple incisions in the periosteum
can be made to lengthen and release the flap if required.
The flap is then released and extended to cover the
socket and sutured to the palatal or lingual mucosa.
This method provides an excellent predictable socket
seal but is not satisfactory from an aesthetic point of view
because the attached buccal mucosa shifts from its origi-
nal position to the crest of the ridge, thus losing its conti-
nuity (Fig. 4.10c). Nevertheless, this mucogingival
discontinuity can be corrected during second-stage FIGURE 4.10b. Immediate placement of an implant.
SOFT TISSUE MANAGEMENT 77

FIGURE 4.10d. Apically repositioned flap at the sec-

ond-stage surgery with the healing abutment in place.
FIGURE 4.10c. Complete soft tissue closure.
apex of the flap covers the socket and then sutured to the
surgery. This can be achieved by apical repositioning the attached free gingiva from the palatal side of the socket
keratinized tissues from the crest of the ridge to the labial (Fig. 4.11i,j). Finally, the vestibular wound is approxi-
side, thus restoring soft tissue integrity (Fig. 4.10d,e). mated and sutured (Fig. 4.11k,l).
The base of the mucosal extension exhibits a rich
Pedicle Island Flap The pedicle island flap is used blood supply, which enhances the predictability of the
to achieve soft tissue closure in immediate implant technique.109 It also provides proper tissue seal on top of
placement procedures. It offers a predictable socket clo- the socket (Fig. 4.11m). However, the delicate nature of
sure and achieves an excellent aesthetic postoperative the mobile soft tissue making up the mucosal extension
result: in this technique the attached buccal mucosa is may create difficulty in clinical handling. The mucosa can
not altered or repositioned, and therefore the mucogin- easily be torn or lacerated, especially during the dissec-
gival integrity is kept intact. tion or deepithelialization of the tongue-like mucosal
After the implant is placed in the fresh extraction extension. The color difference between the extension
socket (Fig. 4.11a,b), two parallel horizontal incisions and the surrounding attached mucosa makes it a distinct
are made in the vestibular mucosa, creating a tongue-like island of vestibular tissues to be identified and excised at
extension (Fig. 4.11c,d). The base of the mucosal exten- the second-stage surgery (Fig. 411n,o).
sion is placed posterior or distal to the socket opening.
The flap is made approximately 20 mm long and as wide Guided Tissue Regeneration Soft tissue manage-
as the socket width. The surface of the mucosal extension ment to achieve primary closure in immediate implant
is thereafter deepithelialized, except for the apical portion placement can sometimes be a difficult clinical task that
that corresponds to the surface of the extraction socket has an increased potential postoperative risk of compli-
(Fig. 4.11e,f). A subperiosteal tunnel connecting the mar- cations. Using guided tissue regenerative (GTR) barriers
ginal keratinized mucosa is then made, buccal to the to close the socket orifice has been claimed to help elim-
extraction socket and the corresponding site in the inate the need for soft tissue closure.
vestibule (Fig. 4.11g,h). The flap extension is subse- The technique involves a horizontal incision extending
quently pulled through the tunnel until the epithelialized along the marginal gingiva of two teeth adjacent to the
78 CHAPTER 4

FIGURE [Link]. Flapless placement of an implant into

the fresh extraction socket.

FIGURE 4.10e. View of the final restoration cemented

in place.

FIGURE [Link]. Illustration showing the tongue-like

extension dissected from the vestibular mucosa.

FIGURE 4.1 la. A patient with a remaining root of a

maxillary second premolar.

extraction site from both buccal and lingual sides.110 The

mucoperiosteal flap is then reflected without vertical FIGURE [Link]. The tongue-like extension on the buc-
releasing incisions, and the implant is placed (the socket cal side after being released.
FIGURE [Link]. Illustration showing the partial deep- FIGURE 4.1 111. An illustration showing the subpe-
ithelialization of the extension except for its apical part. riosteal tunnel created.

FIGURE 4.1 If. The mucosal extension is partially FIGURE 4.111. An illustration showing the mucosal
deepithelialized. extension being tucked underneath the tunnel to cover
the socket.

FIGURE 4.11g. Creation of the subperiosteal tunnel FIGURE 4.11). The mucosal extension appearing from
using a scalpel. the tunnel after being pulled.

79
80 CHAPTER 4

FIGURE 4.11k. Illustration showing the mucosal

extension sutured to the palatal free gingival margins of
the socket. FIGURE 4.1 In. Second-stage surgery using the punch
technique, only removing the soft tissue pedicle island.

FIGURE 4.111. View of the socket closed.

FIGURE 4.11o. The final restoration in place. Note
the continuity of the keratinized tissue band.

voids may be grafted). A homologous cortical bone mem-

brane (Lambone™, Pacific Coast Tissue Bank, Los Ange-
les, California, U.S.A.) is tucked above the implant head
and underneath the flap at least 5-6 mm under the
mucoperiosteum, buccally and lingually; this type of
membrane is preferred due to its high biocompatibility.
The membrane should fit precisely to the bone from
each side. The flap is then returned to its place with the
membrane secured in place, and sutured. The central area
of the membrane is left exposed, allowing tissues to
migrate over it and, given ample of time, to heal com-
pletely.
Using GTR instead of the soft tissue techniques to
close freshly extracted sites can be questionable, as this
FIGURE 4.11m. Four weeks after surgery, showing technique is considered highly susceptible to infection
favorable healing; note the color distinction between the because the hostile environment of the oral cavity favors
tongue-like extension and the surrounding attached tis- bacterial population on top of or underneath the mem-
sue that gives the shape of an island. brane. Furthermore, the possible formation of granula-
SOFT TISSUE MANAGEMENT 81

tion tissue underneath the membrane can lead to its loos- nia) is placed on top of the graft in order to prevent loss
ening, which can compromise the predictability of the of the graft particles during clinical handling; then a tem-
bone-grafting procedure or the osseointegration. porary abutment (Centerpulse, Dental Division, Carls-
bad, California) is connected to the implant and trimmed
Socket Seal Template Technique The use of soft to the required height.
tissue closure procedures in immediate implant cases Self-cure acrylic resin in its rubbery stage of curing is
can be tedious and increases the risk of postoperative introduced to the socket and packed around the tempo-
complications; in most cases it can result in postopera- rary abutment. It is withdrawn along with the temporary
tive discomfort for patients. In an attempt to provide a abutment just before final curing occurs to prevent tissue
treatment alternative to the (sometimes) complicated exposure to the heat emitted from the polymerization reac-
soft tissue closure procedures, a new technique is intro- tion (Fig. 4.12b). Once polymerization is completed extra-
duced to achieve the same purpose. The new socket seal orally, the template is trimmed and polished to remove the
template technique aims at isolating the implant and the excess material and to snugly fit into the socket (Fig.
bone graft in immediate implant placement from the 4.12c), then secured in place with the temporary abutment
oral environment. This technique is particularly recom-
mended for use when a flapless immediate implant
placement technique is performed.111'112 A custom-made
acrylic template is fabricated and placed on top of the
implant and the bone graft, thus sealing the socket.
Using this method may reduce the likelihood of soft tis-
sue complications. The procedure can be of great bene-
fit to patients possessing a thin scalloped tissue biotype,
where soft tissue shrinkage can be a common postoper-
ative event. Lastly, but most importantly, it preserves
both the soft and hard tissue architecture.113'114
The technique entails a thorough and precise clinical
performance with utmost regard for the nature of the
existing oral tissues at the time of implant placement. The
procedure involves atraumatic extraction of the unsal-
vageable tooth to ensure intact undamaged socket walls.
After debridement of the socket walls is performed, the
implant is placed according to the aesthetic placement
protocol. The voids between the implant and the socket
walls (if they exist) are filled with the bone-grafting mate-
rial of choice. Using maximum implant size is recom-
FIGURE 4.12b. Self-cure acrylic resin attached to the
mended to ensure a greater primary anchorage of the temporary abutment before trimming.
implant (Fig. 4.12a). A tailored collagen pack (Cola
Tape, Centerpulse, Dental Division, Carlsbad, Califor-

FIGURE 4.12c. The temporary abutment ready for

FIGURE 4.12a. An immediate implant placement insertion after trimming and polishing the excess resin
with the socket voids filled with bone grafting material. material.
82 CHAPTER 4

connecting screw. An antibiotic and antianaerobic oint- Using the socket seal template technique has several
ment may be applied on its fitting surface before it is advantages. It may prevent the apical migration of the
secured in place. The seated template should be at approx- gingival epithelium into the socket and the bone graft.
imately the same level as or slightly below the marginal Additionally, it favors tissue healing from the periodontal
gingiva. It is possible to remove the template at any later ligament site,115 as periodontal ligament cells are capable
time to clean it and put it back in place. of migrating only for short distances.116'117
After the recommended healing period for the implant In immediate implant placement, the regular soft tis-
and the bone graft has elapsed, a natural-looking emer- sue manipulations around dental implants, especially in
gence profile around the implant site that attains the thin scalloped tissue biotypes, can result in a greater
same cervical dimension as the original missing tooth is amount of soft tissue shrinkage.76'118 The possibility of
replicated (Fig. 4.12d). The need for emergence profile soft tissue shrinkage around the socket seal template dur-
development using a provisional prosthesis or wide heal- ing clinical manipulation is much less likely to occur.119'120
ing abutments at this time is eliminated; therefore, this The use of GBR (guided bone regenerative) mem-
procedure is considered to be time saving. Impressions branes or GTR (guided tissue regenerative) membranes in
are made using transfer copings at the time of the conjunction with implant placement has been highly con-
removal of the template in order to obtain the exact pro- troversial. It has not been confirmed that there is conclu-
file before the soft tissue collapses, and a provisional sive evidence of improved survival of bone grafts when
restoration is fabricated and fitted to the temporary abut- GTR membranes are used, especially in small osseous
ment after the acrylic resin material is removed (Fig. defects around implants.93'97'121 Therefore, the application
4.12e). of a barrier membrane may not be mandatory in any
immediate implant placement procedures. Others have
strictly recommended the use of a barrier membrane to
help stabilize both the blood clot and bone graft mater-
ial122 before epithelial migration occurs. It has been
claimed that the socket seal template can provide a func-
tion that is similar to GBR membranes.
Advantages of the socket seal template technique may
be summarized as follows:

• It protects the bone grafting material around the

dental implant.
• It eliminates soft tissue trauma.
• It minimizes patient discomfort postoperatively.
• It isolates the implant from the hostile environment
of the oral cavity.
• It supports the marginal surrounding soft tissues and
FIGURE 4.12d. The final abutment in place. Note the
prevents postextraction bone resorption.
natural soft tissue profile devolved.
• It provides an exact replica of the emergence profile of
the missing tooth for the future implant-supported
prosthesis.
• It reduces the treatment time as it eliminates the time
required for doing a second-stage surgery.
• It reduces treatment cost.
• It satisfies the patient's aesthetics.
• If an immediate loading protocol is the treatment of
choice, it can allow an immediate provisional pros-
thesis to be fabricated on top of the template.

The socket seal template technique should be limited

to patients with excellent oral hygiene, areas that allow a
placement of a minimum 13 mm long implant, a mechan-
ically well stabilized implant in the socket, and small
osseous defects around the dental implant that do not
FIGURE 4.12e. The case finally restored. exceed 1 mm circumferentially.
SOFT TISSUE MANAGEMENT 83

FLAPLESS TECHNIQUE FOR IMPLANT PLACE-

MENT The flapless, immediate placement technique is
utilized to maintain the natural soft tissue contours, pre-
serve alveolar ridge integrity, and avoid additional soft
tissue trauma by raising a mucoperiosteal flap. Preserva-
tion of the delicate vascular network adjacent to implant
receptor sites may be an important factor in maintaining
facial bone height and aesthetics. In edentulous regions
where the vascular network is compromised by tooth
loss, the associated periosteum and soft tissues may
serve as primary blood sources for the area. Some
authors111'112'123 have reported the use of a flapless
approach for immediate and delayed dental implant
placement in the alveolar ridge. A study124 evaluated the
clinical success of osseointegration achieved with nine FIGURE 4.13a. Preoperative view of four unsalvage-
immediate implants placed without incisions in fresh able maxillary anterior teeth to be replaced with dental
extraction sites, and without any guided bone regenera- implants; note the thin scalloped tissue biotype of the
tive membranes being used; the only allowed grafting patient that warrants flapless implant placement.
material to fill the socket gaps was autogenous bone
chips harvested from the drilling procedure. Interestingly,
the results showed high clinical success without soft tis-
sue primary closure. The study was based on the fact that
there is no absolute necessity for either bone augmenta-
tion or primary flap closure when placing implants in
freshly extracted sites.124 In other words, the absolute
need for soft tissue closure for dental implants placed in
fresh extracted sites has not yet been proven.
Another study125 used nonsubmerged implants in
healed sites and exposed the alveolar bone with a
mucosal punch; the authors stated that placing an
implant without raising a mucoperiosteal flap reduces
surgical morbidity and postoperative bone resorption.
Furthermore, it stabilizes the papillary height after
surgery and has an increased patient acceptance.
In the case of immediate implant placement, the clini- FIGURE 4.13b. Postoperative view showing the
abutments connected; the interimplant papillae are
cal procedure for the flapless placement technique starts preserved.
with an atraumatic extraction of the unsalvageable teeth.
Drilling is then performed through a surgical template
with the use of a buccally placed guiding finger, to avoid
perforating the labial plate of bone. Autogenous bone
chips are collected from the drill flutes and packed back
into the surgical site around the implant fixture to fill any
existing gaps. Finally, the wound edges are approximated
and may be sutured.
This approach is utilized to avoid soft tissue complica-
tions, including postoperative recession. It also helps to
simplify the implant surgery for both the patient and clin-
ician, as achieving primary closure with immediate
implant placement sometimes may be considered a diffi-
cult task. In the delayed implant placement protocol
where gum punching is used to expose the bone for the
drilling procedure and implant placement, the flapless
technique may help achieve acceptable aesthetic results FIGURE 4.13c. The case finally restored showing
and reduce postoperative complications (Fig. 4.13a-c). intact peri-implant architecture.
84 CHAPTER 4

Factors that are considered to be detrimental to this The surgical procedure for grafting an intraoral defi-
treatment modality include lack of direct visibility, diffi- cient osseous site commences with a crestal incision
culty in assessing any labial osseous defects at the time of placed slightly to the palatal or lingual side and extending
implant placement, the absolute necessity of using axial at least one tooth mesial and distal to the site to be regen-
tomography or a CT scan preoperatively to evaluate the erated. This is followed by two vertical releasing incisions
osseous topography, the limited ability to augment extending to the buccal vestibule (Fig. 4.14a-f). Another
implant sites due to lack of visibility, and the potential
loss of almost 4 mm of keratinized tissue at the time of
implant placement due to gum punching (in case of the
delayed implant placement protocol). In addition, the
potential contamination of the implant surface by the
soft tissue surrounding the surgical site might complicate
the overall prognosis. A conservative palatal flap may be
reflected during implant placement, which can reveal the
condition of the labial plate of bone; it can be viewed
through the palatal side at a 45 degree angle to the
occlusal plane. This modified palatal approach adds
more predictability by helping to detect any labial
osseous defect before implant placement.
In conclusion, the flapless approach is still a blind sur-
gical procedure that should be approached with caution FIGURE 4.14a. Preoperative view of maxillary alveo-
and performed only by skillful experienced clinicians.123 lar bone resorption.

MUCOPERIOSTEAL FLAP CLOSURE IN CRITI-

CAL CONDITIONS Osseous grafting of the alveolar
ridge is always required to increase the height or width of
a deficient alveolar ridge. Therefore, primary soft tissue
closure on top of the graft is a major concern and should
be permitted to protect the graft because it favors uninter-
rupted healing and contributes positively to the graft suc-
cess. Furthermore, failure to achieve tension-free closure of
the mucoperiosteal flap might negatively affect graft sur-
vival or implant osseointegration.67'126'127 Therefore, com-
plete tension-free closure should be achieved to accomplish
an uneventful wound healing. Excessive clinical manipula-
tions performed to achieve tension-free primary closure
can lead to soft tissue trauma, which negatively affects the
quantity and quality of regenerated bone.127 Consequently, FIGURE 4.14b. Illustration showing two vertical inci-
many atraumatic surgical approaches to soft tissue cover- sions made.
age over grafted sites have been developed over the past
twenty years.35'99'128
Fugazzotto,127 detailed the surgical management and
closure of mucoperiosteal flaps on top of grafted sites
with GBR techniques. This surgical protocol of soft tissue
closure is considered the most reliable method of achiev-
ing primary closure on top of grafted sites, and it helped
many practitioners to solve many clinical problems. The
broad outlines of the clinical procedures are as follows:
(1) extend the vertical incisions from the crest of the ridge
to the vestibular mucosa, (2) undermine the flap with
another two horizontally placed vestibular incisions, and
(3) make a deep periosteal slitting incision at the base of
the flap. FIGURE 4.14c. Two vertical incisions clinically.
SOFT TISSUE MANAGEMENT 85

Two horizontal releasing incisions are made, starting

from the most apical extent of the vertical releasing inci-
sions and extending 3-4 mm anteriorly and posteriorly in
the buccal vestibule (Fig. 4.14g,h). After a full thickness
flap is raised, a horizontal incision at the deepest part of
the base of the flap is made on the periosteum to release
the flap and allow for further stretching (Fig. 4.14i,j).
The incisions can be repeated in other areas of the perios-
teum until a sufficient flap lengthening is acquired, so
that both edges of the flap can be approximated without
tension (Fig. 4.14k,l). These surgical manipulations will
consequently alter the mucogingival continuity (Fig.

FIGURE 4.14d. The mucoperiosteal flap reflected

revealing the nature of the defect.

FIGURE 4.14g. An illustration showing the two

vestibular horizontal incisions.

FIGURE 4.14e. Titanium mesh carrying bone-grafting

material is used to treat the osseous defect (note the
change of the alveolar ridge size).

FIGURE 4.14f. The mucoperiosteal flap could not be FIGURE 4.14h. The two horizontal incisions intrao-
stretched to achieve edge-to-edge closure. rally.
86 CHAPTER 4

FIGURE 4.141. The flap sutured.

FIGURE 4.141. An illustration showing a deep hori-

zontal periosteal slitting incision.

FIGURE 4.14m. One month after healing occurs; note

FIGURE 4.14J. Deep horizontal slitting incision made the discontinuity of the attached mucosa.
intraorally.
4.14m), which can be corrected later with another repo-
sitioning corrective surgery (Fig. 4.14n).
Other attempts128'129 to allow tension-free soft tissue clo-
sure on top of grafted sites while maintaining the position
of the labial mucogingival junction at its original level have
been introduced. A palatal flap approach is used to over-
come this clinical situation: the palatal flap is elongated
through a split thickness dissection; as a result of the split
thickness incision, a connective tissue extension is reflected
with the palatal flap over the crest of the ridge. The flap
with the connective tissue pedicle is then slid in a labial
direction to cover the augmented area without interrupt-
ing the continuity of the labial keratinized tissue band. The
palatal connective tissue extension is then sutured to the
labial soft tissue margin. However, this procedure has lim-
FIGURE 4.14k. The flap is mobilized and stretched to itations when thin palatal tissue exists, which complicates
achieve tension-free primary edge-to-edge closure. the partial thickness reflection procedure. Additionally, the
SOFT TISSUE MANAGEMENT 87

ing the selection of an optimal flap design, that ensure

sufficient blood supply and allow for better access and
visibility must be strictly observed to maintain uneventful
healing. The use of cosmetic incisions is highly recom-
mended in the second-stage surgery130 because they are
beveled toward the center of the flap at a 45 degree angle,
thereby minimizing the chances of postoperative soft tis-
sue scarring, while at the same time favoring healing.
Two basic surgical protocols are used to expose the
implant head at the second-stage surgery. The first is con-
servative and is basically performed by reflecting a
mucoperiosteal flap next to the implant to be restored. The
second is excisional: the soft tissue on top of the implant
head is excised to reveal the cover screw. This second pro-
FIGURE 4.14n. Free gingival graft combined with tocol can be called the soft tissue punching technique.
vestibuloplasty is performed to improve the attached
mucosa condition. This step is taken to improve the clin-
ical results for the second-stage surgery. RULES OF SECOND-STAGE
SURGERY
amount of tissue gained from the palatal flap lengthening
might not always be sufficient. To improve the soft tissue status around the implant
prosthetic components at the time of second-stage
Soft Tissue Management at the Time surgery, some clinical guidelines for reducing postopera-
of Abutment Connection tive complications and maximizing the aesthetic outcome
can be helpful. These "rules" are not obligatory, because
The form and quality of the soft tissue adjoining the the decision to use them will ultimately be the clinician's
implant components are vital prerequisites for ensuring a to make. Rather, they are clinical recommendations that
natural-looking implant-supported restoration. The can be applied separately in different clinical situations or
nature of the alveolar mucosa mandates an excellent sec- together in a single surgery. By using these guidelines as a
ond-stage surgery protocol to help regain the missing bio- clinical reference, the clinician can obtain satisfactory
logical emergence profile and related soft tissue contours. aesthetic results. The goal of creating natural-looking
Due to an increasing demand for natural-looking soft tissue profiles around dental implants may be
implant-supported restorations by both clinicians and achieved by adhering to the following "rules": bulking
patients, new surgical techniques have been introduced, keratinized or connective tissues facially, scalloping the
especially those pertaining to the aesthetic zone. keratinized tissues, limiting the incision to the keratinized
Soft tissue manipulation at the time of abutment con- tissues, preserving intact interproximal papillae, and
nection is conceptual. There are no strict recommenda- using connective tissue grafts in conjunction with second-
tions that can be applied to the protocol of the stage surgery.
second-stage surgery. The techniques vary according to
the future vision, experience, and preference of the clini- Bulking Keratinized or Connective
cian. In selecting from the many techniques available, the
clinician should consider all those techniques that aim at
Tissues Facially
modifying the soft tissue contours and simulating natural This rule aims at the displacement of soft tissues from the
appearance. Also to be chosen are those techniques in palatal to the labial aspect, which in turn leads to soft tis-
which the adjacent papillae are manipulated to accom- sue bulking and overprofiling around the prosthetic com-
modate the future implant-supported restoration in a ponents. Technically speaking, this procedure can be
natural-looking manner. described as a reverse Rehermanplasty (Fig. 4.15a,b).
The second-stage surgery in the aesthetic zone is not Increasing the amount of keratinized tissues on the
only performed to expose the implant interface for exe- facial aspect of the prosthetic components is necessary to
cuting restorative procedures, but also to create a healthy develop the future biological width and to compensate
marginal attached mucosa around the implant compo- for any postoperative soft tissue remodeling or gingival
nents.103 All the basic intraoperative precautions, includ- recession. A longitudinal study conducted by Bengazi
88 CHAPTER 4

eration and connective tissue grafting. One year after

prosthesis insertion, 0.6 mm of soft tissue shrinkage was
recorded on the buccal side of the implant-supported
prosthesis.
It is not inconceivable that soft tissue shrinkage is
expected around implant-supported dental restorations
in the first six months following abutment connection.
These findings favor the concept of bulking the kera-
tinized mucosa as much as possible on the labial aspect to
compensate for any soft issue shrinkage. It also supports
the use of a provisional prosthesis for six months after
abutment connection, until a stable gingival margin is
obtained.
Following complete maturation of the soft tissue after
the second-stage surgery, when the gingival margins have
reached a stable level, any excessive soft tissue that
exceeds the adjacent natural contour can be trimmed off
FIGURE 4.15a. Sketch on a study model showing the and removed. At the time of the second-stage surgery, not
incision design at the second-stage surgery that moves only should keratinized tissues be bulked around the
the palatal keratinized mucosa to the labial side. abutment, but also connective tissue grafts can be used to
treat minor osseous defects around dental implants or to
provide a root-eminence-like profile. A connective tissue
graft is placed underneath the mucoperiosteal flap and
secured with resorbable sutures to improve the soft tissue
profile (Fig. 4.16a,b,c).

Scalloping the Keratinized Tissues

To ensure proper soft tissue adaptation to the circular
shape of the prosthetic components a C-shaped incision
is made palatal to the implant head, with the convexity
of the C directed buccally, during the second-stage
surgery. At the end of the C scallop, two small (1-2 mm)
vertical relieving incisions are made to allow for flap

FIGURE 4.15b. Clinical application of bulking the

keratinized mucosa labially around healing abutments.

et al. that measured the alterations in the position of peri-

implant soft tissue margin on partial and full arch
implant-supported prostheses after the second-stage
surgery.119 The study revealed a gingival recession of 0.4
mm on the labial aspect of implant-supported prostheses
in the maxilla after six months, and 0.7 mm after twenty-
four months in nongrafted sites. It was proposed that the
recession of the peri-implant soft tissue margin may be
mainly the result of a remodeling of the soft tissue in
order to establish an appropriate biological dimension.
Another confirming study conducted by Grunder120 eval- FIG 4.16a. A clinical view showing a minor alveolar
uated the soft tissue stability around ten single-tooth ridge deficiency around an implant replacing a maxillary
implants. All cases were treated with guided bone regen- left central incisor.
SOFT TISSUE MANAGEMENT 89

Limiting the Incision to the

Keratinized Tissues
It is the author's experience that extending the vertical
relieving incisions to the vestibular tissues should be
avoided at the second-stage surgery in order to avoid any
possible postoperative soft tissue scarring (Fig. 4.19).
Hertel et al.103 advocated a second-stage surgery design
that provides incisions only in the keratinized mucosa and
maintains a proper amount of keratinized tissue around
the implant collar (see Fig. 4.20a,b). They described the
placement of an incision on the crest of the ridge. This
incision is followed by bisection of the attached mucosa
with two small proximal vertical incisions around the
FIGURE. 4.16b. Connective tissue graft is used at the implant to release the tension on the flap.
time of the second-stage surgery to bulk the soft tissue
profile.
Preserving Intact Papillae
Preserving the interproximal papillae in the second-stage
surgery or keeping them intact is a strict recommendation
for preventing further drop down or recession of the
adjacent marginal soft tissues, as recommended in cos-
metic periodontal surgeries.131"134 Therefore, the decision
not to displace the papillae from their original location is
conceivable and will contribute positively to the stability
of the soft tissue margins. This approach averts postoper-
ative soft tissue shrinkage around natural dentition as
well as the implant prosthetic components (see Fig. 4.21).
Preserving the interproximal papillae might also reduce
soft tissue trauma during the surgery.

Using Connective Tissue Grafts in

FIGURE 4.16c. Clinical view six weeks after abutment
Conjunction with Second-Stage
connection showing an improved peri-implant soft tis- Surgery
sue contour imitating the bulging root shape, which Many authors have used connective tissue grafts at the
gives a natural appearance to the implant-supported
time of the second-stage surgery to treat minor soft tissue
prosthesis.
deficiencies or simulate a rootlike bulging around the
neck of the implant-supported prosthesis.135"137 Abrams135
introduced an interesting method for augmenting minor
mobility. The flap is then raised, the abutment is con- edentulous alveolar defects. The technique involved strip-
nected, and the flap is pushed backward until the scal- ping the epithelium from a palatal connective tissue pedi-
lop is adapted to embrace the buccal aspect of the cle and rolling it under the buccal mucosa; this procedure
abutment collar (Fig. 4.17a,b). This method ensures has shown high clinical predictability for improving the
tighter adaptation of the soft tissue to the abutment, alveolar ridge topography at the defective area. Scharf
thus reducing the tendency for developing a dead space and Tarnow138 introduced a modification of Abrams'
and minimizing any possible soft tissue marginal dis- technique. A "trap-door" approach is used to reflect and
crepancy around the abutment. preserve the epithelium that overlies the connective tissue
Hertel et al.103 described another procedure that serves pedicle; the epithelial pedicle is used to cover the donor
a similar purpose. They called it the cervical folding tech- site, thus eliminating any raw area at the donor site.
nique. This technique achieves an intimate flap abutment The technique requires reflecting an epithelial flap with
adaptation around the prosthetic components as well a connective tissue extension or pedicle from the palate
(Fig. 4.18). and moving it to the site to be augmented labially. Two
90 CHAPTER 4

FIGURE 4.17a. Illustration showing the scalloped FIGURE 4.17b. Clinical view of the scalloping of kera-
incision design around healing collars. tinized mucosa around healing collars.

as much as possible. The length of the incisions is depen-

dent on the length of connective tissue required. The two
vertical incisions are joined with a shallow horizontal
incision along the crest of the ridge to be a starting point
for the partial thickness reflection of the epithelial flap.
Once the epithelial flap is reflected, an incision is made
along the connective tissue pedicle, down to the bone.
The connective tissue pedicle is now bounded laterally by
the two vertical incisions made initially for the epithelial
pedicle and apically at its base by another horizontal inci-
sion to separate it. The connective tissue pedicle is then
FIGURE 4.18. Tying the keratinized tissues around the reflected in an apicocoronal direction. A pouch between
abutment to help proper adaptation. the buccal mucosa and the alveolar ridge is made. The
connective tissue pedicle is then rolled into the buccal
pouch and secured with sutures. The epithelial pedicle is
replaced over the bone and secured.(Fig. 4.22a-h).
The use of the modified roll flap technique for soft tis-
sue enhancement therapy prior to implant placement
increased the amount of connective tissue at the defective
area, which in turn improved peri-implant soft tissue
contours and reduced patient discomfort to a great extent
by preventing denudation of the palatal bone.
The author139 introduced the use of the modified roll
flap technique at the time of the second-stage surgery. It is
proposed that healing abutments can provide support for
the rolled connective tissue pedicle, which in turn improves
the final soft tissue profile and simulates the rootlike emi-
nence. Using the modified roll flap at the time of the sec-
ond-stage surgery is indicated only when minor defects
FIGURE 4.19. Example of soft tissue scarring, due to
extending the incision line to the vestibular mucosa dur- exist; larger defects mandate surgical corrective procedures
ing second-stage surgery. before starting the implant therapy (see Fig. 4.23a-f).

full thickness vertical parallel releasing incisions are made

Soft Tissue Punching
from the crest of the ridge toward the palate to outline the Soft tissue punching is another surgical alternative for
pedicle, preserving the papillae in both sides of the defect exposing the implant cover screw at the second-stage
SOFT TISSUE MANAGEMENT 91

FIGURE 4.20a. Incision design for nonresorbable

membrane removal during the second-stage surgery to FIGURE 4.20b. Removal of the nonresorbable mem-
avoid extending the two vertical incisions to the vestibu- brane from the buccal vestibule; note the limited vertical
lar tissues. incision.

FIGURE 4.21. Preservation of the interdental papillae

in second-stage surgery to avoid postoperative shrinkage.
Note the amount of keratinized tissues being bulked on
the labial side.

surgery. The technique entails excising a circular area of

the keratinized mucosa on top of the implant cover
screw, which makes the technique excisional in nature.
The technique has limited indications; it is only indicated
when a wide and stable keratinized band is present, and
it can be applied safely in the posterior zone where aes-
thetics are not of prime concern.
The use of the soft tissue punching procedure can offer
some advantages. It is a simplified clinical technique, less FIGURE 4.22a. Illustration showing the modified roll
traumatic to the tissues, and does not require an exten- flap in second-stage surgery.
sive surgical inventory to be applied, as it can be per-
formed with a scalpel, a gum-punching tool, or a and the attendant subsequent loss of almost 3-4 mm of
diamond bur. keratinized tissue limits its application in the aesthetic
On a precautionary note, punching of soft tissues has zone. Furthermore, tissue punching sometimes involves
its drawbacks. Imperfect positioning of the tissue punch guesswork in locating the implant head unless the origi-
may jeopardize the labial peri-implant contour integrity, nal surgical template is used; the implant cover screw can
92 CHAPTER 4

FIGURE 4.22d. The connective tissue pedicle attached

to the labial mucosa after dissection.

FIGURE 4.22b. Illustration showing rolling of the

palatal flap extension underneath the labial flap.

FIGURE 4.22e. Suturing of the flap after the connec-

tive tissue pedicle has been rolled underneath the labial
soft tissues.

FIGURE 4.22c. Two vertical incisions with the reflec-

tion of the partial thickness palatal flap.

be located by searching the area with a sharp probe until

it catches the cover screw (sound of metal scratching can FIGURE 4.22f. Postoperative view showing a remark-
be heard). When an implant is placed below the bone able improvement of the labial contour.
SOFT TISSUE MANAGEMENT 93

FIGURE 4.22g. The final abutment in place. FIGURE 4.23b. The two vertical incisions made along
the reflection of the palatal partial thickness flap.

FIGURE 4.22h. The case finally restored.

FIGURE 4.23c. Mobilization of the connective tissue

pedicle.

FIGURE 4.23a. Preoperative view showing minor

labial defect.

crest level, bone contouring may be recommended, as it

creates a funnel-like shape in the bone to accommodate
the flaring of the prosthetic component, but with the FIGURE 4.23d. The flap sutured.
94 CHAPTER 4

Miller was the first to introduce mucogingival surgery,

or periodontal plastic surgery.140 Such surgical procedures
are used to correct or eliminate anatomic, developmental,
and/or traumatic deformities of the gingiva and alveolar
mucosa. These surgical procedures are currently applied
in conjunction with implant therapy to help achieve an
enhanced peri-implant soft tissue appearance. Using plas-
tic soft tissue surgery around dental implants eliminated
the use of soft-tissue-colored prosthetic devices that were
used to mask soft tissue defects.
Corrective procedures may involve one or more of
the following treatment options: onlay grafting; inlay
grafting; connective tissue pouch procedures; and gingi-
val recontouring procedures, which involve (a) modify-
FIGURE 4.23e. The labial contour is improved and ing and expanding the gingival margin with the use of a
the final abutment connected. provisional restoration, (b) plastic soft tissue grafting to
treat soft tissue grooves or deficiencies, (c) sculpting the
excessive soft tissues, and (d) contouring of the mar-
ginal gingiva.

Onlay Grafting
Onlay soft tissue grafting techniques, including their clin-
ical modifications, are becoming popular methods
among clinicians for treating peri-implant soft tissue
defects. The techniques have been extensively described
in the literature.32'141"144 These techniques originally
aimed at increasing the width of keratinized tissues, treat-
ing mucogingival defects, and arresting gingival recession
around natural teeth.145 Onlay soft tissue grafting may be
performed prior to implant placement (Fig. 4.24) or after
connection of the final abutment, to improve the integrity
FIGURE 4.23f. The case finally restored.
of soft tissue contours, stabilize soft tissue margins, and
treat minor deficiencies.146 Moreover, it can be used to
punching technique, it may be difficult to apply particu- mask undesirable soft tissue pigmentation, such as amal-
lar bone-contouring tools. Care should be exercised not gam tattoos (Fig. 4.25a,b).
to injure the surrounding soft tissue while removing any
excess bone on top of the implant head.

STM POSTABUTMENT
CONNECTION
Manipulating the soft issue after the prosthetic compo-
nents are connected to the implant fixture can be called
peri-implant tissue refining and profiling. After the sec-
ond-stage surgery, when complete tissue healing has
occurred, the peri-implant soft tissues can be reshaped or
augmented to attain a satisfactory aesthetic outcome, to
overcome some resultant tissue defects, and/or to treat
some tissue deformity (e.g., dimples, ditched-in tissues,
grooves); therefore, this stage of implant therapy can be FIGURE 4.24. Onlay graft to treat an alveolar ridge
called plastic implant soft tissue surgery. defect.
SOFT TISSUE MANAGEMENT 95

FIGURE 4.2Sa. Onlay graft has been performed to FIGURE 4.25b. Postoperative view showing the heal-
treat a keratinized tissue discontinuity. ing of the graft and the recovered keratinized tissue con-
tinuity.

Adherence to the basic intraoperative principles of soft

tissue grafting, such as determining the amount of soft rating the graft as it moves. A tissue forceps is used to
tissue required to cover the defect, the clinical condition retract the graft distally until it is finally separated. The
of the recipient site, and the availability of donor tissues, graft should be trimmed to remove any fatty, glandular tis-
detecting the location of any anatomical landmark in the sues, or tissue irregularities, which might inhibit the graft-
area of grafting, and assessing the patient's oral hygiene take. After the graft is prepared, it is adapted and fitted to
condition can be considered important clinical steps that the underlying periosteum and sutured. Five minutes pres-
favor the final clinical results.7 The final soft tissue sure with saline-wetted gauze will permit fibrin clot forma-
dimensions gained from any onlay grafting procedure are tion and prevent postoperative bleeding. Coverage of the
directly related to the thickness of the graft used and the grafted area with rubber dam material (to prevent the
amount of tissue that survives the grafting procedure.23 sutures from adhering to the dressing) followed by a surgi-
But it is generally accepted that a thin graft is used for cal dressing on top may be recommended.147 Coverage of
increasing the zone of attached tissues, whereas a thick the raw area of the donor site relieves patient's postopera-
graft is recommended for ridge augmentation proce- tive discomfort; it can be achieved by fitting a previously
dures. If greater tissue height is required from an onlay fabricated acrylic template to the palate.
soft tissue grafting procedure, the procedure may be The clinical drawbacks and complications encoun-
repeated after a two- to three-month interval until an tered with onlay grafts include the color and texture mis-
optimal tissue contour is achieved (Fig. 4.26a-d). match between the graft and the surrounding tissues (tire
The procedure entails two surgical sites: the recipient patch appearance), the difficulty of graft adaptation to
site, and the donor site. The recipient site is prepared by an the recipient site, graft mobility due to hematoma forma-
incision that starts at the distal end of the defect with the tion, graft shrinkage (approximately 30%) from its origi-
blade held parallel to the alveolar process; then the blade nal size after healing is complete,148 and the difficulty of
is drawn in a mesial direction to the end of the defect. achieving proper adherence of the graft to titanium abut-
Another horizontal incision (equal in length to the first) is ments, which has caused some clinicians to abandon this
made just below the mucogingival junction. The residual grafting procedure after the abutment connection.149
band of keratinized tissues will be removed to allow for A recent development in onlay grafting procedures is
epithelial denudation, which can be achieved with a the introduction of the acellular dermal matrix (Allo-
scalpel or high-speed bur. A sharp dissection is performed derm, Lifecore Biomedical). Grafting with autogenous
apically to separate the alveolar mucosa and muscle fibers tissue or freeze-dried skin can be an accepted method for
from the periosteum, and it is preferred to overextend the increasing and/or restoring the width of attached gin-
periosteal bed to compensate for any expected future [Link] method was originally used to treat burn
shrinkage of the graft. The graft size is then determined patients. When used as a gingival graft, it possessed
using a tin foil cut to the exact size of the recipient bed. major potential advantages over the traditional onlay
The donor site (usually the palate) is prepared by mak- grafts, including improved color and contour match to
ing a beveled incision, starting along the occlusal aspect of the original tissues, elimination of donor site surgery, and
the palate and continuing apically, while lifting and sepa- unlimited availability.150
96 CHAPTER 4

FIGURE 4.26b. Bilateral pedicle graft from the palate

FIGURE 4.26a. Severe soft tissue defect due to several to enhance the quantity and quality of tissue on the
failed bone grafting attempts. crest of the alveolar ridge.

FIGURE 4.26c. Onlay graft is utilized with vestibulo- FIGURE 4.26d. The case six weeks after healing. Note
plasty to improve the labial contour and vestibular the improvement in the pontic area as well as in the sul-
status. cus depth.

tissue or (2) a graft composed of connective tissue that

Inlay Grafting has an epithelial rim (a composite graft). The connective
Langer and Calagna33'137 were the first to outline the clini- tissue grafts are used for aesthetic ridge augmentation
cal indications and description for the use of subepithelial procedures, while the composite grafts are used for treat-
connective tissue grafts to cover a denuded root surface or ing denuded root surfaces and masking gingival discol-
to augment the alveolar ridge for aesthetic reasons. The oration around dental implants.
technique was later modified and improved by others.137'140 The inlay grafts have an advantage over the onlay
The technique of using inlay grafting showed success and grafts because they combine the characters of the soft tis-
predictability in treating one-, two-, and three-dimensional sue autograft and the pedicle flap procedure.152 This com-
soft tissue defects around natural teeth and dental bination doubles the blood supply to the graft, thus
implants. Interestingly, 2-6 mm of root coverage has been increasing its chances of survival; also, inlay grafts attain
documented in cases where subepithelial grafts are used to the same color and texture of the tissues surrounding the
treat denuded root surfaces.137 This technique is now used recipient site after healing has occurred. Grayish gingival
routinely by many clinicians to enhance soft tissue profile discoloration around dental implants is a result of the
with implant-supported dental restorations. metallic reflection (of the prosthetic components)
Connective tissue grafts are applied clinically in two through a thin mucosa; it affects the aesthetic outcome of
different forms: (1) a graft composed solely of connective the implant-supported prostheses negatively, especially in
SOFT TISSUE MANAGEMENT 97

patients with a high smile line. Connective tissue inlay

grafts can treat the condition successfully, as the inlay
graft masks gingival discoloration by increasing the
thickness of the peri-implant soft tissues (Fig. 4.27a-d).
In this particular case, the graft should be proximally
extended farther from the implant site to compensate for
the reduced blood supply to the graft, thereby allowing
peripheral anastomosis from the adjacent tissues.
The procedure involves two main clinical steps: (1)
preparation of the recipient site and (2) harvesting the
graft. A horizontal intrasulcular incision is made on the
marginal gingiva with the scalpel angle parallel to the
tooth long axis; another two vertical incisions are made

FIGURE 4.27c. The connective tissue graft secured in

place underneath the labial tissue. Note that no vertical
incisions are made.

FIGURE 4.27a. Preoperative view showing soft tissue

grayish discoloration related to an implant-supported
restoration replacing the maxillary left lateral incisor.

FIGURE 4.27d. Six weeks after healing, showing clini-

cally improved soft tissue that masks the metallic collar
of the abutment.

to facilitate mucoperiosteal flap release. A partial thick-

ness flap is then raised by blunt dissection until it reaches
the vestibule. Care must be exercised not to perforate the
flap during dissection and thus jeopardize the overall
blood supply.
The connective tissue graft can be harvested from the
palate or from the tuberosity. A straight, horizontal inci-
sion parallel to the alveolar ridge starts posteriorly at
approximately 5-6 mm from the free gingival margin
and is extended anteriorly. A second, more coronally
positioned, parallel incision is made approximately 3 mm
FIGURE 4.27b. One-line sulcular incision made at from the free gingival margin and is continued to the
the recipient site with the scalpel parallel to the long same distance as the first incision. Then two small verti-
axis of the teeth. cal incisions are made mesially and distally to connect the
98 CHAPTER 4

two horizontal incisions. Another horizontal incision is

made at the apical border of the graft to completely sepa-
rate the graft from the underlying bone. This will finally
provide a 2-3 mm wide connective tissue wedge with an
epithelial rim. Finally, the palate is sutured with continu-
ous basting sutures.
The graft is then trimmed and introduced into the
recipient site, drawn underneath the partial thickness
flap, and secured with a sling suture to the labial mucosa.
In aesthetically demanding areas where only increased
tissue height is required, no vertical relaxing incisions
should be made at the recipient site, to avoid any possi-
bility of future scar tissue formation.

Connective Tissue Pouch Procedures

The connective tissue pouch procedure is another clinical
modification for using connective tissue grafts; it is used
to correct confined minor ridge deficiencies, where the
color and surface characteristics of the area after grafting
should not differ from the original tissue character (Fig.
4.28a-e).22'23'136'137
The procedure is indicated when the alveolar defect is
not large in size and does not jeopardize the function of the

FIGURE 4.28b. Illustration showing the use of con-

nective tissue graft to improve the labial contour.

FIGURE 4.28c. Illustration showing the pouch created

in the labial mucosa with a one-line vertical incision.

implant. However, the long-term clinical results of the

FIGURE 4.28a. Illustration showing minor labial graft are still questionable. Initially, this procedure exhibits
defect related to the implant. remarkable postoperative results, but graft shrinkage as a
SOFT TISSUE MANAGEMENT 99

FIGURE 4.28d. Illustration showing the connective

tissue graft being introduced to the pouch.

FIGURE 4.29a. Clinical view showing labial defect

around an implant-supported restoration replacing a
missing maxillary first premolar.

FIGURE 4.28e. Illustration showing the final closure.

result of postoperative tissue remodeling has a tendency to

occur over time. The procedure can also be called a
"closed connective tissue grafting procedure" because the FIGURE 4.29b. The pouch is created through a one-
graft is totally embedded under the soft tissues, thus pro- line vertical incision.
viding more predictable graft survival.
The procedure involves making a supraperiosteal
pouch at the deficient area; a one-line vertical incision,
extending apically and bypassing the deformity through
the attached gingiva and the mucogingival junction, is
made. Blunt dissection is used to extend the pouch. The
maxillary tuberosity and the palate are readily accessible
donor sites for harvesting the connective tissue graft to
repair the alveolar defect. A 2 to 3 mm thick connective
tissue graft is carefully dissected, deepithelialized, intro-
duced to the pouch, and placed underneath the flap. The
graft is then stabilized with resorbable sutures. A suture
is first passed through the base of the pouch to the end of
the graft, then another suture is made in the middle of the
graft, which helps stabilize the graft to the underlying
periosteum; the pouch is then closed with interrupted FIGURE 4.29c. The connective tissue graft is har-
sutures (Fig. 4.29a-f). vested.
100 CHAPTER 4

sue volume, while the epithelial graft can stabilize

mucosal margins and increase the width of the attached
mucosa. Combining two types of grafting procedures
increases soft tissue height and stability. However, post-
operative soft tissue remodeling remains an issue for con-
cern (Fig. 4.30a-f).

Gingival Recontouring Techniques

Gingival recontouring techniques154 are plastic surgical
procedures used to reshape or refine peri-implant soft tis-
sues, and they are usually performed after the implant is
restored. The techniques require a favorable keratinized
tissue condition, in terms of quality and quantity. The
techniques include cosmetic laser resurfacing, electrosur-
FIGURE 4.29d. The connective tissue graft is intro-
duced into the pouch.

FIGURE 4.30a. A remarkable loss of the interimplant

papilla between two implant-supported crowns replacing
FIGURE 4.29e. The pouch is closed and sutured.
the maxillary right central and lateral incisors.

FIGURE 4.29f. Postoperative view showing improve-

ment of labial contour.

In extremely compromised defects where bone grafts FIGURE 4.30b. A connective tissue graft is being
are not indicated, a connective tissue graft can be used in introduced and tucked underneath the defect from a
combination with another onlay graft.153 The connective vestibular approach in order to provoke a downward
tissue graft is placed underneath the defect to restore tis- movement of the interimplant papilla.
SOFT TISSUE MANAGEMENT 101

FIGURE 4.30e. Six weeks postoperative healing, show-

FIGURE 4.30c. The connective tissue graft is secured ing an improvement of the interimplant papilla height.
and sutured to the underlying periosteum.

FIGURE 4.30f. Final crown inserted.

FIGURE 4.30d. An onlay graft is used to compensate

for the downward movement of the vestibular tissue as better than any other traditional method, it allows for
well as to stabilize its new position. precise tissue trimming, it offers a bloodless field, and it
emits less heat generation to the underlying tissues than
do rotary instruments.
gical sculpturing, gingivoplasty, and the use of provi-
sional restorations. ELECTROSURGICAL SCULPTURING Electro-
surgery can be used to remove the excess bulky gingival
COSMETIC LASER RESURFACING130 Peri- contours or smoothen tissue scars, as is done in laser
implant soft tissue irregularities sometimes occur after resurfacing. Tissue warming due to the heat emitted
the completion of the implant therapy as a result of from the electrodes sometimes delays healing. This
multiple surgical procedures or due to uneventful soft method should be applied with caution because there is
tissue healing. They can be soft tissue dimples or irregu- an increased risk of implant failure if the electrode con-
larities that affect the aesthetic outcome of the implant- tacts the implant surface.
supported restoration negatively, especially if the
patient possesses a high smile line. It clinically appears GINGIVOPLASTY Minor plastic surgical proce-
as soft tissue nodes or white elevated scar lines in the dures known as gingivoplasty can be used to treat unde-
peri-implant soft tissue area. Cosmetic laser soft tissue sirable aesthetic gingival contours, provided a sufficient
resurfacing is widely used by plastic surgeons because it amount of keratinized tissue is present. It is usually lim-
has been shown to control the depth of tissue removal ited to patients with the thick flat tissue biotype, where
102 CHAPTER 4

FIGURE 4.3la. Excess keratinized mucosa around an FIGURE 4.31b. The excess gingival tissues were
implant-supported restoration after the insertion of the excised with a scalpel.
final prosthesis.

the condition of the soft tissue can withstand further desired configuration, a provisional restoration is fabri-
surgical manipulations. It is used when final maturation cated accordingly and transferred to the implant site.
of the soft tissue around the implant-supported restora- The provisional prosthesis is then seated. Digital pres-
tion has occurred. The procedure entails removal of the sure is exerted to compress the peri-implant tissue in an
excessive facial gingival tissues using either a sharp outward labial direction. Temporary blanching of the
scalpel (Fig. 4.31a,b) or a high-speed diamond bur (Fig. soft tissue occurs as a result of the pressure, resulting in
4.32). changing of the soft tissue contours to the future final
implant-supported restoration dimension.154
USE OF PROVISIONAL RESTORATIONS An
implant-supported provisional restoration is considered
an important tool for reshaping and profiling the peri-
implant soft tissues without performing any surgical THE REAL PAPILLAE
intervention after the second-stage surgery is completed
and soft tissue is healed. It is considered the most Creating an aesthetic implant-supported restoration in
important factor responsible for a natural appearance the oral cavity depends to a great extent on the presence
of implant-supported restorations. It stimulates peri- of healthy peri-implant soft issue architecture.155 The
implant tissues to attain the same configuration and presence of the interproximal papillae around implant-
dimensions as missing original natural soft tissue con- supported restorations allows symmetrical soft tissue
tours. After the peri-implant tissues are duplicated on margins and a state of harmony between natural and
the working cast, envisioned, and carved to the optimal dental implant components.31 The slightest change in the
level of the interproximal papillae around dental
implants due to pathologic reasons or poor soft tissue
handling during implant treatment can lead to major aes-
thetic and phonetic complications.
After tooth extraction, the thin adjacent alveolar bone
(interradicular bone) starts to undergo a rapid process of
resorption, probably due to the thin nature of the alveo-
lar bone (which allows faster resorption), reduced blood
supply to the crest of the interradicular bone due to the
tooth extraction procedure, the possible direct exposure
of the interradicular bone to oral bacteria as a result of
tooth extraction, and most importantly, the absence of
the Sharpey's fibers that stimulate continuous bone
remodeling and thus maintain healthy marginal levels. As
a result of tooth extraction, the interdental papilla
FIGURE 4.32. Trimming of keratinized tissue dimple remodels in a sloping fashion from the palatal to the
with a diamond bur. more apical facial osseous plate, and becomes depressed
SOFT TISSUE MANAGEMENT 103

in comparison with the healthy adjacent marginal tis-

sue.156 Unfortunately the lost interdental papilla is not
capable of self-regeneration to regain its original dimen-
sions.157 This complicates the overall clinical prognosis
and mandates special reconstructive procedures.
The greatest challenge today in implant and periodon-
tal plastic surgery is the reconstruction of lost or incom-
plete interproximal papillae. Many clinical efforts have
attempted to reconstruct the missing interproximal papil-
lae by using guided tissue regenerative procedures,158 aug-
menting procedures,159 free gingival grafts,160 coronally
positioned flaps,161 pedicle grafts,151 and pontic develop-
ment techniques.1 Unfortunately, no single technique for
papilla regeneration offers predictable long-term clinical
success.
To assess and classify the different clinical conditions
of the interdental papillae, Nordland et al. have classified
the clinical condition of the interdental papillae accord-
ing to their marginal level.162 They subdivided the inter-
dental papillae into three classes (Fig. 4.33a-d):
• Class I. Tip of the interdental papilla lies between the
interdental contact point and the most coronal

FIGURE 4.33b. Class II Nordland classification.

extent of the interproximal CEJ (space is present, but

interproximal CEJ is not visible).
• Class II. Tip of the interdental papilla lies at or apical
to the interproximal CEJ (interproximal CEJ visible).
• Class HI. Tip of the interdental papilla lies level with
or apical to the facial CEJ.
Tarnow et al.163 developed a useful classification for
clinically identifying the predictability of the presence of
interdental papillae. They concluded that when the
measurement from the contact point of the natural
tooth to the crest of the bone was 5 mm or less, the
papilla was present almost 100% of the time; when the
distance was 6 mm, the papilla was present 56% of the
time; and when the distance was 7 mm or more, the
papilla was present in only 27% of the time or less (Fig.
4.34).
Salama et al.164 proposed another interesting classifica-
tion that furnished a prognostic classification system for
the peri-implant papillae. Their three classes are based on
the available interproximal height of bone (IHB) in rela-
tion to the prognosis of the peri-implant papillae. In
Class 1, IHB is 4-5 mm (measured from the apical extent
FIGURE 4.33a. Class I Nordland classification. of future contact point of the restoration to the crest of
104 CHAPTER 4

FIGURE 4.33d. Nordland classification legend.

FIGURE 4.33c. Class III Nordland classification.

bone), suggesting an optimal prognosis; Class 2 shows an

IHB of 6-7 mm with a guarded prognosis; and in Class 3
IHB is greater than 7 mm, indicating a poor prognosis
(Fig. 4.35).

Basic Morphology of the

Iiiterproxinial Papillae
The clinical configuration of the interdental papilla basi-
cally depends on the volume of the underlying osseous
support and the morphology of the proximal surfaces of
the adjacent teeth. The osseous structure of the interden-
tal papilla is composed of two crests or peaks from the
FIGURE 4.34. Tarnow et al. classification to assess pre-
labial and lingual sides. The labial crest is slightly higher dictability of interdental papillae.
than the lingual one, with an intervening distance of 2-6
mm. The two crests are connected by the so-called gingi-
val col, which may be convex or concave in shape, or gingiva closely adherent to the neck of the tooth; thus
have a sawlike appearance.165 these fibers are responsible for maintaining both the
Histologically, the interdental papilla is composed of shape and the position of the papilla. The connective tis-
stratified squamous epithelium covering its crest,157 with sue contains lymphocytes and plasma cells.
abundant bundles of collagenous fibers running through Different terms have been coined to identify or distin-
the lamina propria. The collagenous fibers, which run in guish between the interproximal papillae located at dif-
a buccolingual direction through the lamina propria,166" ferent sites. The papilla that exists between natural
168
may have a significant role in keeping the marginal dentition is called interdental papilla, that located
SOFT TISSUE MANAGEMENT 105

grafts,171 coronally positioned palatal sliding flaps,172 and

Interproximal bone profile Beagle's technique.173
(levels 1,2,3) Beagle's technique entails a palatal pedicle flap that is
folded and tied on itself on the facial side in order to
Soft tissue contours increase the height of the interimplant papilla. Regret-
tably, this method did not attain a high success rate
because of the compromised blood supply of the small-
sized pedicle (Fig. 4.36).
Alternatively, Han and Takei171 described a technique
Class 1 lHB=Optimal prognosis
that makes use of a pedicle graft with a semilunar inci-
Class2 lHB=Guarded prognosis sion and total coronal displacement of the gingival unit.
Class3 lHB=Poor prognosis Others have disclosed several methods for minimizing
gingival recession around dental implants to improve the
interimplant papilla contours.51
FIGURE 4.35. Salama et al. classification of the inter- Azzi et al.174 employed a connective tissue graft to be
proximal height of bone. placed on the defective area then tucked under buccal
and palatal flaps, thus providing the graft with an ade-
between an implant and a natural tooth is peri-implant quate blood supply (Fig. 4.37a-e). The method requires
papilla, and if papilla exists between two adjacent
implants, it is called interimplant papilla. When papilla is
used in a generalized term (unspecified), it can be called
interproximal papilla.
The soft tissue histological characteristics of interim-
plant papillae and interdental papillae are similar,
except that interimplant papillae have a connective tis-
sue fiber orientation,18 have a high percentage of colla-
gen fibers with fewer fibroblasts, and attain a less
adequate blood supply because of the absence of the
periodontal ligament.169 This makes the interimplant
papillae more like scar tissue, which may complicate
any attempts for surgical repair or reconstruction.
When the interimplant papilla is missing or does not
1 2
totally fill the embrasure space, the condition looks like FIGURE 4.36. Beagle's technique.
and is called a black triangle.
Peri-implant papillae are more clinically achievable
than the interimplant papillae because the CEJ at the
proximal surface of the adjacent natural tooth follows a
reverse scalloping toward the incisal edge; this keeps the
interproximal bone at the same height by means of
Sharpey's fibers,170 which is not the same as the situation
for adjacent multiple implants.

Soft Tissue Procedures for

Reconstruction of the Interimplant
Papillae
The interimplant papillae are characterized by dimin-
ished blood supply, because of the histological nature of
the peri-implant soft tissue and because of its marginal
location. This explains the poor prognosis of any surgical
reconstruction attempt. Several surgical procedures have
been introduced in an attempt to solve the problem; FIGURE 4.37a. Illustration showing Azzi et al. tech-
among these soft tissue surgical procedures are coronally nique for regenerating the interdental papilla with a
positioned flaps in combination with connective tissue connective tissue graft.
106 CHAPTER 4

FIGURE 4.37b. Illustration showing the crestal inci- FIGURE 4.37e. The graft secured in place.
sion.

trimmed to obtain two connective tissue extensions with

an epithelial crest on the center. When both flaps cover
the connective tissue ends of the graft, the epithelial crest
stays exposed to increase the height of the interimplant
papilla.

Osseous Regenerative Methods

for Interimplant Papillae
Based on Holmes findings,157 the therapeutic techniques
utilizing only soft tissue intervention to regenerate inter-
implant papillae did not attain predictable clinical results.
It makes more sense to first regenerate the underlying
FIGURE 4.3 7c. Illustration showing the labial and lin- osseous support. Hence, attention is turned towards
gual partial thickness flaps reflected. regenerating the osseous structure of the interimplant
papillae to regain the overall lost tissue height medially
between implants.155 This conclusion is confirmed by
Salama et al.: "successful and predictable aesthetic results
can be accomplished only when underlying labial and
interproximal osseous support has been therapeutically
provided."164
In an attempt to regenerate the osseous support of a
deficient interimplant papilla, an interimplant papilla
regenerative template has been introduced recently.
Although the template is still in its preliminary experi-
mental stages, it showed an acceptable clinical success.

FIGURE 4.3 7d. Illustration showing the preparation

Interimplant Papilla Regenerative
of the composite connective tissue graft. Template
The interimplant papilla regenerative template155 (Fig.
two buccal and lingual marginal partial thickness inci- 4.38) is a carrier fabricated from pure titanium. It acts as
sions at the compromised site. A wedge-shaped graft is a housing that supports the bone-grafting material on the
harvested from the tuberosity. It is then shaped and alveolar ridge, and it is placed between two implants to
SOFT TISSUE MANAGEMENT 107

FIGURE 4.38. Interimplant papilla regenerative tern-

plate. FIGURE 4.39a. The template carrying the bone-grafting
material and secured in place with two fixation screws.

regenerate an osseous foundation for the interimplant

papilla.
The template is to be placed at the time of implant
insertion, therefore eliminating the need for any addi-
tional surgical procedure. Other advantages of the tem-
plate are that it carries and protects the bone graft
material and also separates the bone-grafting mix from
the undesired fibroblast and epithelial cells, which favors
graft predictability.
The use of the template requires a space of not less
than 3 mm between two adjacent implants. After the
implants are inserted, the interimplant bone is decorti-
cated, to provide sufficient blood supply to the graft.
[The grafting mix that is commonly used with the tem-
plate is 50% autogenous bone chips harvested from
the drilling procedure and 50% mineralized freeze- FIGURE 4.39b. The bone regenerated between the
dried bone (Pacific Coast Tissue Bank, California, two implants after template removal in second-stage
U.S.A.). Recently, however, the author has found that surgery.
use of 100% autogenous chips can provide a more pre-
dictable clinical outcome. The template is then placed
on the ridge with its two perforated ends facing the The long-term prognosis of this method is still under
alveolar ridge. Two GBR fixation pins (IMTEC Corp., investigation, as postoperative bone remodeling will be an
Ardmore, Oklahoma, U.S.A.) are fitted into the perfo- important factor to be considered. This method requires
rated ends of the template to stabilize the template and further assessment and maybe a new generation of bone-
secure it in place. Soft tissue closure can be performed grafting materials will help ensure more predicable results.
according to the previously mentioned protocol for
soft tissue closure in critical conditions in this chapter
(Fig. 4.39a-d). Prosthetic Solutions for Papillary
At the time of the second-stage surgery, the template is
removed, revealing the regenerated bone, and the flap is
Creation
then sutured and left to heal. After soft tissue healing is Soft-tissue-colored acrylic stents were utilized long ago
complete, the provisional prosthesis is used to develop to solve many aesthetic problems associated with ante-
the emergence profile, as mentioned earlier. Use of rior fixed restorations on natural teeth; they might be
smooth thin margins on the provisional prosthesis is used now to improve aesthetic and phonetic problems
mandatory in order to not exert pressure on the newly associated with losing interimplant papillae. Papillary
formed bone. illusions are yet another method used to modify the
108 CHAPTER 4

FIGURE 4.40. Papillary illusion.

FIGURE 4.39c. The interimplant papilla is formed
between the two implants.
Noninvasive Methods for Papillary
Reconstruction
Interestingly, Jemt176 observed that the peri-implant
papillae can regenerate without any clinical manipula-
tion of the soft tissue to some extent one to three years
after completing the implant therapy. He reasoned that
plaque accumulation in the proximal areas causes gingi-
val inflammation and hyperplasia, which sequentially
leads to overgrowth of the papilla to fill the interproxi-
mal space. Creeping of interdental papilla on the tooth
surface171 as well as onto porcelain crowns177'178 has been
reported in the literature. Scaling and root planing also
may induce proliferation of the gingival tissues (referred
FIGURE 4.39d. Postoperative view showing the case to as inflammatory hyperplasia).179 This can lead to
finally restored. regeneration of the interdental papilla after nine months
time. However, creeping of the interdental papilla
around the root surface is not clinically predictable in
final prosthesis by moving the contact area in an apical many clinical conditions. Forced eruption180'181 is
direction, thus making the gingival embrasures smaller another noninvasive method for regenerating interdental
in size and giving the impression that the interimplant or peri-implant papillae. Development of the interdental
papilla fills most of the gingival embrasure space. Pros- papillae can be achieved by the application of a continu-
thetic papillary illusion can be used in small and moder- ous light force; after a few months, coronal migration of
ate losses of interimplant papillae. This method gives an the attachment apparatus occurs, as explained earlier in
acceptable clinical result without the need to perform Chapter 2.
any invasive surgical procedure (Fig. 4.40).
An alternative method, which requires a highly experi- Future Methods for Papillary
enced dental technician, is the use of pink porcelain175 to Reconstruction
mimic the natural appearance of the papilla. With this
method oral hygiene might be compromised, and the Recently the soft tissue ballooning concept has been
porcelain color usually does not match the color of the investigated as a technique for developing a subgingival
adjacent natural tissues. tissue space that can be filled later with any commercially
A removable provisional prosthesis can influence the available silicon material or bone cement. Also, titanium
underlying gingival tissues at the pontic areas to create a papilla inserts were inserted subgingivally to regain the
papilla-like shape; this can be achieved by adding acrylic shape of the interimplant papilla.155 Unfortunately, the
resin to the fitting surface of the pontic in order to press delicate nature of the oral mucosa did not allow any suc-
and conform the alveolar mucosa, forming a papilla cess for these trials.
between the two pontics. (Fig. 4.41a,b). The current thought is to use mini osteodistraction
devices to increase bone height in the future interimplant
SOFT TISSUE MANAGEMENT 109

FIGURE 4.41a. Prosthetic solution to enhance the FIGURE 4.41b. The postconfiguration effect of the
interdental papilla by adding a resin material to the fit- alveolar ridge pontic development.
ting surface of the removable partial denture, in order to
press and reshape the pontic area.
tered titanium or stainless steel surfaces. Biomaterials
1986(7): 201-205.
papilla areas, or to distract all of the bone segment that
4. Buser D, Schenk RK, Steinemann S, Fiorellini JP, Fox
will receive the implants to a higher level than the CEJ of
CH, and Stich H. Influence of surface characteristics on
the adjacent teeth. The distracted bone at the place of the bone integration of titanium implants. A histomorpho-
future implants is reduced to its optimal height, while the metric study in miniature pigs. J Biomed Mater Res
bone sites for the future interimplant papillae are left as 1991(25): 889-902.
is, thus maintaining the required height of the interim- 5. Sennerby L, Thomsen P, and Ericson LE. Early bone tis-
plant papillae.183 This method is still under investigation sue response to titanium implants inserted in rabbit cor-
because the construction of mini osteodistractors will be tical bone. I. Light microscopic observations. J Mat Sci
expensive and the treatment time will be doubled, which Mat Med 1993(4): 240-250.
is considered a handicapping factor. 6. Strid KG. Radiographic procedures. In Branemark P-I,
Zarb KG, and Albrektsson T, eds. Tissue Integrated
Prostheses. Osseointegration in Clinical Dentistry.
Chicago: Quintessence, 1985.
CONCLUSION 7. Seibert J. Reconstruction of the partially edentulous
ridge: Gateway to improved prosthetics and superior aes-
Developing and regenerating the interimplant papillae is thetics. Pract Periodont Aesthet Dent 1993(5): 47-55.
a challenging and difficult clinical task. Further research 8. Garber DA. The edentulous ridge and fixed prosthodon-
efforts are required to test and improve the current tech- tics. Compend Contin Educ Dent 1981(2): 212.
niques. Most of the published data are case reports that 9. Wennstrom JL. Mucogingival therapy. Ann Periodontol
lack long-term evaluations and predictable clinical 1996(1): 671-701.
results.182 Careful treatment planning, optimal implant 10. Chee WWL, Cho GC, and Donovan TE. Restoration of
positioning, proper use of the provisional prostheses, and the anterior edentulous space. J Calif Dent Assoc
development of appropriate surgical skills are all factors 1997(25): 381-385.
that should be considered during dental implant therapy 11. Chee WWL and Donovan TE. Treatment planning and
in the aesthetic zone. soft tissue management for optimal implant aesthetics.
Ann Acad Med Singapore 1995(24): 113-117.
12. El Askary AS. Esthetic considerations in anterior single
tooth replacement. Implant Dent 1999(8): 61-67.
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5
Aesthetic Bone Grafting

Luc Huys tion resorption. It loses almost 25% of its volume during
Abd El Salam El Askary the first year and up to 40-60% in width within the first
three years after tooth loss.1'2 Therefore, many osseous
reconstructive techniques have been introduced to help
INTRODUCTION restore alveolar ridge defects. Recently, the term aesthetic
bone-grafting procedures was introduced to define the
Healthy osseous structure of the alveolar ridge maintains aesthetic dimension of bone-grafting prodecures; it refers
the aesthetic soft tissue appearance around natural denti- to the regeneration of the missing osseous structure to
tion and provides a framework for peri-implant soft tis- support the future aesthetic gingival contours while
sue contours. Lack of alveolar bone, especially in the maintaining long-term implant success at the same
maxilla due to postextraction bone resorption, can result time.3'4 Therefore, restoring the lost volume of the under-
in functional and aesthetic problems that necessitate the lying hard tissues either prior to or simultaneously with
use of augmenting procedures to reestablish the missing the implant placement can maintain and support not
original dimensions. The advent of novel osseous regen- only an aesthetic implant-supported restoration but also
erative techniques has significantly increased the func- the related facial structures.5'6
tional and aesthetic potential of dental implants by The variations in maxillary alveolar bone resorption
restoring alveolar ridge defects to their original dimen- patterns require different treatment approaches; the size
sions, which allows for optimal implant placement1'2 and, and type of each particular osseous defect influence the
in turn, increases the credibility of dental implant therapy selection of the most suitable grafting procedure. For
as a unique treatment alternative. example, minor alveolar ridge defects suggest the use of
Osseous reconstruction of the alveolar ridge can be an allografting material in a nonstaged surgical
classified according to its goal, either functional or aes- approach, while moderate horizontal ridge defects
thetic. Jovanovic3 has divided the locations in the oral require the use of more predictable grafting procedures
cavity into (1) aesthetically visible locations where ade- such as autogenous grafts in a staged treatment
quate osseous structure (that supports the peri-implant approach.3'7'9 In cases of combined severe horizontal and
soft tissue to develop a natural emergence profile) is vertical alveolar ridge defects, the use of reconstructive
important in obtaining aesthetic and functional results devices will be mandatory to ensure more predictable
and (2) nonaesthetically visible locations where adequate regenerative results.10'11
osseous support is required to ensure long-term func- The technological advancements in intraoral bone-
tional success. grafting procedures are immense. One of the current
The underlying osseous structure influences the shape developments in bone-grafting techniques involves using
and appearance of the investing soft tissues. Unfortu- bone morphogenetic proteins (BMPs), such as BMP-2, on
nately, in the anterior maxilla the osseous structure of the a collagen carrier12 to enhance the predictability of the
alveolar bone undergoes a rapid process of postextrac- regenerated bone and to increase the bone density
through a slow resorption and remodeling process. The
Dr. Luc W.S. Huys, is a professor at the Flemish Institute for BMP-2 helps increase local stem cell mitosis to recruit
Orthomolecular Sciences in Belgium. Dr. Huys is also the cofounder undifferentiated mesenchymal cells to the grafted site.
of the International Acacemy of Replacement Therapy. These cells may be transformed to osteoblasts, by the

115
116 CHAPTER 5

appropriate morphogenetic cytokine, and start the bone and the patient's general health condition are some fac-
matrix formation process.13'14 This process is called the tors that influence the decision making in bone-grafting
multiple type mitogen-morphogen mechanism for stimu- procedures.
lating osseous healing. It may become the ideal bone-
grafting procedure in the near future.15
Technical advancements have also taken place in the
manufacture of the guided bone regenerative barriers16'17; THE REPAIR PROCESS
these advancements have been mainly focused on the
enhancement of the physical characteristics and biocom- Surgical intervention always produces a trauma that is
patibility of the barrier materials. Many types of barriers repaired via a complex biological process that consists of
are available in the market and are made either resorbable three phases that will overlap one another in time: (1) the
(e.g., collagen membranes or membranes of polylactic inflammatory (or exudative phase), (2) the proliferative
acid alone, polylactic acid combined with polyglycolic phase, and the (3) repair phase.40 The first phase starts
acid, or polylactic acid in its polymer form) or nonre- with homeostasis, which is triggered by the interaction of
sorbable (e.g., polytetrafluoroethylene or its expanded or vessel walls, platelets, and coagulation factors. The result
reinforced forms). The resorbable biodegradable mem- of this interaction is a "coagulum" that becomes colo-
branes require less tissue manipulation and seem to elicit nized by inflammatory cells within two to four hours, fol-
less tissue reaction due to their biological nature.18"21 The lowed by fibroblasts within twenty-four to thirty-six
nondegradable membranes stay longer in the grafted site, hours. The three-dimensional fibrin net, which consti-
thus providing a long-term regenerative effect, but require tutes the framework of the coagulum, acts as a guide for
a second surgery for removal.22"24 However, the litrature cellular colonization.40'41 During this phase, cellular
did not provide a definite answer on which of the two necrosis (resulting from the surgical trauma) and home-
material types is more predictable.25 Selection of suitable ostasis (resulting from the hemorrhage) produce and lib-
guided bone regenerative barriers should be based on a erate numerous factors that trigger the migration of
thorough understanding of the inherent benefits and limi- inflammatory cells into the defect, creating the necessary
tations of the material in relation to the functional conditions for healing. Chemotactic factors that act on
requirements of the specific clinical applications.26 the leucocytes, present in the extravascular spaces, will
Autogenous bone grafting in any reconstructive proce- influence the migration of inflammatory cells toward of
dure is considered to be the gold standard of all bone- the inflammatory stimulus.40'41 Lysosomal enzymes pro-
grafting procedures, because it provides proteins such as voke vasodilatation, which in turn provokes slowing of
bone-enhancing substrates, minerals, and vital bone cells the blood flow that permits the leucocytes to migrate
to the recipient site, which enhance the overall success of towards the vessel walls, adhere to them, and penetrate
the grafting procedure, resulting in high success rates.27"30 through them. Growth factors, produced by
Sites used for harvesting autogenous bone for alveolar macrophages (derived from the transformation of mono-
bone grafting can be either extraoral or intraoral. Extra- cytes) during their function of cellular debris removal
oral harvesting sites include the posterior iliac crest of the induce the second phase.40"42
hip and the calvaria,31'32 but unfortunately, extraoral The proliferative phase is characterized by the repro-
grafts showed a higher rate of morbidity than intraoral duction of the fibroblasts as a result of the chemotactic
grafts and required complex surgery.33 On the other attraction by the growth factors. It also has a role in syn-
hand, intraoral sites, such as the maxillary tuberosity, the thesizing collagen. Platelets assist the macrophages to
ascending ramus, and particularly the symphysis of the secrete factors that favor tissue repair. Platelets act indi-
mandible, offer better quality of cancellous and cortical rectly by attracting macrophages and fibroblasts, and
bone and more predictable postoperative results 34 directly by stimulating replication of fibroblasts and col-
Recently, in 1996, distraction osteogenesis was intro- lagen synthesis.40"42
duced as a promising method for restoring a defecient The third phase, repair, is characterized by a marked
alveolar ridge to its size.35'37 The technique has been taken increase in the synthesis of collagen with the complete
from orthopedic surgery, as used in the elongation of formation of fibrous tissue as a substitute for the tissue
tubular bone in children, and now is predictably used in damaged during the surgical procedure.40"42
restoring severe atrophy of the alveolar ridge.36>38 It elim- In the presence of an implanted graft material the
inates the need for donor site surgery and reduces the risk repair process undergoes a different tissue reaction that
of morbidity in comparison with the autogenous grafting deviates from the normal process, especially in its inten-
procedures.39 sity and duration.42 An accumulation of extracellular
Selection of the appropriate grafting technique or fluid that contains proteins and inflammatory cells sur-
grafting material influences the success and predictabil- rounds the implanted material. The proteins are
ity of the final treatment outcome. Defect size and type absorbed at the surface of the implanted graft and
AESTHETIC BONE GRAFTING 117

undergo a variation of their configuration to an extent grafts act are normally determined by their origin and
that they condition the functional response of the peri- composition.
implant cells.42 The inflammatory cells can then modify
the structure, the physical and chemical properties, of the
surface of the graft material, usually causing a foreign
body giant cell reaction, which activates the macrophages TYPES OF BONE-GRAFTING
and leads to the production of cytokines that stimulate MATERIALS
the production of collagen and bone tissue.40"*2
A layer of fibrous connective tissue will surround graft There are four forms of bone-grafting material: autoge-
material as it will any other device that remains for a cer- nous grafts, allografts, xenografts, and alloplasts.
tain time in the body. The surrounding fibrous tissue
layer attains different thicknesses and shapes depending
on its location, the mechanical stimuli, and the chemical Autogenous Grafts
characteristics of the graft interface.40"42
Of all the bone-grafting materials, autogenous bone is
If the implanted graft material is biocompatible, the
still regarded as the "gold standard," because it is the
alterations in the repair process are limited, and the pres-
only osteogenic grafting material.43'46 Grafted autogenous
ence of fibrosis (which typically characterizes the final
bone heals through osteogenesis, osteoinduction, and
phase) is minimal. Biocompatibility can be defined as the
osteoconduction, and those stages overlap during the
capacity of a material to function in a specific application
healing process.43 Autogenous bone grafts can be har-
and provoke an appropriate reaction by the host.42
vested from extraoral sites such as the iliac crest, the cra-
Therefore, biocompatibility should involve the chemical
nial bones, or the ribs; from intraoral sites such as the
and physical characteristics of the bone grafting material
mandibular symphysis, the maxillary tuberosity, the
in order to avoid systemic or local toxicity and carcino-
ramus, and bone exostoses; and sometimes from the
genic or genotoxic reactions.40"42
osteotomy drilling procedure. Its organic component, col-
lagen, which provides the resilience, strength, and stabil-
ity for the graft, whereas the inorganic component,
MECHANISMS OF BONE hydroxyapatite, contributes to the rigidity of the graft.
Grafted autogenous bone can be trabecular, cortical, or
REGENERATION corticotrabecular. Trabecular grafts provide numerous
osteogenic cells in their structure, while a cortical graft
Bone regeneration can be accomplished through three
has fewer surviving osteogenic cells but provides the most
different mechanisms: osteogenesis, osteoinduction, and
bone morphogenetic protein (BMP), the essential agent
osteoconduction.43"46 Osteogenesis is the formation and
for bone formation.47 BMP differentiates host mesenchy-
development of bone, even in the absence of local undif-
mal cells into osteoblasts.47"49 In addition, BMP provides
ferentiated mesenchymal stem cells.43 Osteogenic grafts
more resistance to the graft structure, which impedes soft
can facilitate the different phases of bone regeneration,
tissue in-growth but also may prolong the time needed for
thus activating a faster osseous regeneration rate in most
blood vessels to infiltrate the graft.47"49 Corticotrabecular
of the cases. An osteogenic graft is an organic material
grafts can be shaped and trimmed to fit the recipient bed,
that is derived from, or composed of, living human tissue
and the trabecular part is placed to face the recipient bed.
and is harvested from the individual in whom it will be
The healing process follows one of three paths: (1) the
used.43 Osteoinduction is the transformation of undiffer-
graft becomes viable, acquiring in time the characteristics
entiated mesenchymal stem cells into osteoblasts or chon-
of adjacent bone, (2) the graft resorbs partially or com-
droblasts through growth factors that exist only in living
pletely, resulting in instability, or (3) the graft becomes
bone. Osteoinductive grafts enhance and facilitate nor-
sequestrated and is treated by the host as a foreign
mal bone regeneration, or even extend the regenerative
body.43'46
process sometimes in places where it is not normally
Autogenous bone grafts are highly osteogenic and
found.43 Osteoconduction is the process that provides a
best fulfill, in theory, the requirements for bone regenera-
bioinert scaffold, or physical matrix, suitable for the
tion. However, they possess some important practical
deposition of new bone.43"46 Osteoconductive grafts
shortcomings:
(which are often inorganic) allow bone apposition from
the surrounding bone or encourage differentiated mes- • Harvesting of the graft requires an additional surgery,
enchymal cells to grow along the graft surface. They do which increase the patient postoperative inconvenience.
not stimulate bone formation when placed in soft tissues. • Another osseous defect at the donor site is created,
All grafting materials have one or more of these three which presents an extra risk of infection and/or mor-
mechanisms of action. The mechanisms by which the bidity.
118 CHAPTER 5

• Extensive graft resorption can be expected, especially

with iliac grafts, but less with mandibular grafts
(because they are from the same embryonic origin as
the recipient site).
• Only limited amounts of graft material can be har-
vested from the intraoral donor sites.
• The possibility of apical root injury (in chin grafts)
or sensory nerve damage exists.
These shortcomings have led to the development and
use of other readily available grafts (allografts,
xenografts, and alloplasts) that can be treatment alterna-
tives used routinely and safely in the dental office (Fig.
5.1 a-g).
FIGURE 5.1c. An implant (Twist MP1, Centerpulse,
Dental Division, Carlsbad, California) is placed within a
dehiscent labial bone, with the cortical bone being
decorticated.

FIGURE [Link]. Intraoperative view of a patient with an

immediate implant (TSV Paragon, Centerpulse, Dental
Division, Carlsbad, California) replacing the maxillary
right central incisor; the place of the missing left central
incisor shows an osseous defect that warrants grafting.
FIGURE [Link]. A corticocancellous graft is harvested
from the chin and fixed on top of the implant with two
fixation screws. Note the place of the screws (lateral to
the implant body).

FIGURE 5.1b. A conservative mucoperiosteal flap is

used to place an implant to restore the missing left cen-
tral incisor and simultaneously graft the area. Note the
conservation of the interimplant papilla and the peri-
implant papilla in the flap design. FIGURE 5.1e. Primary tension-free wound closure.
AESTHETIC BONE GRAFTING 119

FIGURE 5. If. Seven months postoperative view show- FIGURE 5.1g. The case finally restored.
ing a remarkable improvement in the labial bone con-
tour.

Allografts bone.46 The expense and morbidity involved with autoge-

nous extraoral grafts made irradiated cancellous bone the
Allografts are obtained from other individuals of the
most effective, readily available graft material that he has
same species, but from disparate genotypes.43'45 Donors
used.46
can be living related persons, living unrelated persons, or
The advantages of allografts include ready availability,
cadavers. The grafts are processed under completely ster-
elimination of donor site surgery, reduced anesthesia and
ile conditions and stored in bone banks. Transplanted
surgical time, and decreased blood loss.43 Disadvantages
bone allografts always induce a host immune response. consist primarily of the history of the obtained grafting
To reduce this response, the nature of the bone graft is material. The quality of the graft material depends
altered; three types of grafts are used: freeze-dried bone mainly on the donor's health condition; for example, not
allografts (FDBAs), demineralized freeze-dried bone allo- having a history of infection, cancer, degenerative bone
grafts (DFDBA), and irradiated cancellous bone allo-
disease, hepatitis B or C, sexually transmitted disease,
grafts (ICBA). In a FDBA, the graft is dried at low autoimmune deficiency, or other medical problems that
temperature (lyophilized) without any liquid phase in the
might lead to cross infection.43"45 Therefore, first priority
whole process. In a DFDBA the mineral phase of the must be given to thorough donor screening, which
FDBA is removed, exposing the collagen and the BMP.
involves a traceable medical, demographic, and social
Without removal of this mineral phase, no bone induc-
history. Other disadvantages of allografts include the risk
tion process will be seen. Cortical bone chips are mostly of rejection, high rate of infection, nonunion, risk of
preferred because of their low antigenic activity and the rapid resorption, and problems related to the consider-
relatively large quantity of collagen. However, steriliza-
able technical precision required to pack and hold the
tion by gamma radiation kills most of the BMP present.45
graft in place in bleeding sites (Figs. 5.2 and 5.3).45>51
A DFDBA may regenerate bone by osteoinduction, by its
To minimize the above-mentioned risks, Puros™ Allo-
effect on the host's undifferentiated mesenchymal cells
graft with Tutoplast® processing (Centerpulse, Dental
while blood vessels penetrate the graft. DFDBAs may
division, Inc., Carlsbad, California, U.S.A.) recently has
also regenerate bone by osteoconduction, by serving as a
been introduced. The processing of the graft material
scaffold for the host bone while resorbing. However,
consists of five stages (delipidization, osmotic contrast
Rummelhart et al. did not find any significant differences treatment, oxidation, solvent dehydration, and limited-
between the efficacy of FDBAs and DFDBAs in promot- dose of gamma irradiation), which are claimed to signifi-
ing bone repair of human periodontal defects six months cantly reduce antigens and reactive agents.
postoperative.50
In stage one, the graft is bathed in acetone and agi-
Irradiated cancellous bone has been used more
tated with ultrasound. This removes fat (which interferes
recently. In its initial preparation, the bone was exposed
with healing), inactivates viruses, and prepares the graft
to 6-8 million rads of radiation. Nowadays trabecular
so that the subsequent treatments penetrate the graft
bone obtained from the spinal column can be treated
more effectively. In stage two, the osmotic contrast treat-
only with 2.5 million rads.46 Tatum reported that this
ment, which is considered unique to the Tutoplast® pro-
material provided a response closest to autogenous cessing, the graft receives alternating baths of distilled
120 CHAPTER 5

FIGURE 5.2. Placement of two immediate implants in

fresh extracted sockets. FIGURE 5.3. Radiographic view after application of a
demineralized freeze-dried bone allograft; note that there
is no grafting material around the neck of the implants
water and saline. This might disrupt the cell wall integrity or in the extraction sockets; the graft is held in place via
and exposes intracellular material. Bacteria are killed, a resorbable membrane.
undesirable cells are destroyed and removed (and as a
result, so is most antigenicity), and the viral load is fur-
osteoconductive, and regenerative potential of allograft
ther reduced. During stage three, the graft is bathed in a
materials after such bone preparations.52"54
hydrogen peroxide (H2O2) wash, destroying the remain-
ing proteins, removing the residual antigenicity, inactivat-
ing any remaining viruses, and minimizing the potential
Xenografts
for graft rejection. In stage four, the graft receives no less Xenografts are obtained from a species other than the
than seven acetone baths. This removes all the water, host species. The representative materials are natural
making the graft storable at room temperature, and pre- hydroxyapatite and deorganified bovine bone. Natural
serves the dense collagen fibrous structure and its original hydroxyapatite is synthesized (by hydrothermal process-
strength. Finally, during the last stage, the graft receives a ing) from the calcium carbonate (CaCO3) skeleton of
low-dose (17.8 kGy) gamma radiation, inactivating all coral.44 It has the three-dimensional microstructure of
remaining viruses and guaranteeing sterility following natural bone with average pore sizes of 200 u-. It has
cutting and packaging. approximately 60% void spaces and a calcium to phos-
Nevertheless, a rapidly increasing body of evidence phorus ratio of 10:6. The material is highly biocompati-
questions the clinical relevance and the osteoinductive, ble and bonds readily to adjacent hard and soft tissues.
AESTHETIC BONE GRAFTING 121

Thanks to its highly organized and permeable porous

structure, with an interconnected three-dimensional
architecture, the graft and the ingrown bone are remod-
eled in response to the same chemical and biomechanical
forces that remodel normal bone. Its compressive
strength increases following tissue ingrowth and is
claimed to be sufficient to withstand masticatory forces
exerted by dentures.55'56 Reported disadvantages of this
material are that the strength decreases exponentially
with the increase in porosity, it is brittle and difficult to
handle, the material migrates under stress during the
healing period, and the material can only be used in non-
infectious sites.46
Deorganified bovine bone is an inorganic bone of
bovine origin. The graft is chemically treated to remove FIGURE 5.6. Figure demonstrating the integration of
all organic components (calcium deficient carbonate- deorganified bovine bone (Bio-Oss®) eight months post-
apatite) by heat processing. This process differs accord- operative. Graft particles (violet) are included in newly
ing to the material processed. That is, Osteograf/N® formed bone.
(CeraMed Dental, Lakewood, Colorado, U.S.A.) uses a
high heat (1100°C) sintering process, resulting in fusion reportedly considered to be the most physiological bone
of bone crystallites, with decreased porosity and surface substitute; it becomes completely incorporated and inte-
area. To enhance the cell-binding activity of this material, grated into the human bone after remodeling (Figs. 5.6
a new synthetic peptide analogous to a potent cell-bind- and 5.7).57 Another commercially available product is
ing domain in type I collagen, PepGen P-15™ (CeraMed Colloss®, a collagen type I lyophilisate in a triple helix
Dental, Lakewood, Colorado, U.S.A.), is now promoted structure (Ossacur GmbH, Oberstenfeld, Germany).
for use in combination with Osteograf®. The other chem- Disadvantages of deorganified bovine bone grafts are
ical extraction process is done at low heat (300°C), and (besides their bovine origin) the increased risk of a host
as a result, the exact trabecular architecture and porosity immune response, brittleness, easy migration, the recom-
are maintained. When the graft is processed at low heat mendation to be combined with autogenous bone, and
(Bio-Oss®; Geistlich AG, Wolhusen, Switzerland), it the mandatory use of GTR membranes with it.43-45'58
maintains the same compact apatite crystalline natural Xenografts appear to incorporate into bone, but their
structure (Figs. 5.4 and 5.5). This similarity is important slow resorption rates may have a negative impact on the
for remodeling (substitution of bone for bone as part of quality of the newly formed bone and consequently on
the natural growth process), which is needed for any their clinical relevance. Public perception of the materials
graft to attain a degree of permanency.57 Bio-Oss® is used as allografts and xenografts reduces the acceptance

FIGURE 5.4. Three-dimensional architecture of FIGURE 5.5. Figure clearly showing the same architec-
human cancellous bone. ture in deorganified bovine bone (Bio-Oss8).
122 CHAPTER 5

porous (greater than 350 jx), or nonporous; crystalline or

amorphous; or granular or molded in form. There is a
consensus about their advantages: they are readily avail-
able, sterile, easily stored, safe, and well tolerated. But
their main advantage is the elimination of the possibility
of cross-infection.
They are osteoconductive materials, but all differ from
each other in some chemical and physical properties;
these differing properties will determine which material is
best for a specific clinical application.43'64 There are three
main groups of alloplasts:
1. Ceramics (synthetic hydroxyapatite, tricalcium
phosphate, glass)
FIGURE 5.7. Magnification of a part of Figure 5.6 2. Calcium carbonate
shows one particle that is part of the process of natural 3. Composite polymers (resorbable and nonresorbable)
remodeling by osteoclasts (light).
CERAMICS
of these materials. Furthermore, the potential for
Synthetic Hydroxyapatite (HA) Hydroxyapatite
immunologic reactions can limit the use of these graft
(HA), Ca10(PO4)6(OH)2, is the primary inorganic nat-
materials. The recent worldwide developments concern-
ural component of bone, comprising 60-70% of the cal-
ing bovine spongiform encephalopathy (BSE) disease
cified skeleton and 98% of dental enamel. It has a
strengthen the fear of disease transmission. BSE is not a
calcium to phosphorus ratio of 10:6. It is biocompatible
disease caused by bacteria, fungi, or viruses; it is a prion
and bonds readily to adjacent hard and soft tis-
disease. A prion is a modification of a protein into a
sues.43'55'65 The clinical applications of this material are
prion-protein (PrPSc or proteinaceous infectious particle
determined by the physical and chemical properties of
protein) that accumulates in the central nervous system
the graft type used. The physical forms include porous
and spleen. The outcome is inevitably lethal. To date, pri-
(micro- or macro-) and nonporous forms, resorbable
ons are highly resistant to all traditional chemical and
and nonresorbable forms, and blocks and particles.
physical procedures of inactivation, and no decontamina-
Chemical properties depend on the calcium to phospho-
tion procedure existing today has been shown to be capa-
rus ratio, the pH of the surrounding area, ionic substi-
ble of inducing complete deactivation of the infectious
tution, and elemental impurities.66 Large crystalline
agents, in spite of what manufacturers claim. In fact,
particles will take a very long time to resorb and are
these prions are not destroyed either by methods utilizing
called nonresorbable; small-sized crystalline HA and
hot or cold treatments or by chemical or enzymatic meth-
amorphous HA will break down more quickly.65 There-
ods. UV radiation, ionizing radiation, heat sterilization,
fore, the nature of the crystalline structure of the mater-
and methods utilizing formaldehydes have also proven to
ial determines the degree of resorption. On the other
be ineffective.59"61 The acquired form of BSE disease in
hand, porosity will determine the extent of blood per-
humans (CJD or Creutzfeld-Jacob Disease) can be trans-
meability and vessel ingrowth into the graft. Pores of
mitted by surgical instruments, EEC electrodes, grafts, or
250-350 |x are reported to be ideal for bone ingrowth.
growth hormones and has been found in health care pro-
But unfortunately the strength decreases exponentially
fessionals such as neurosurgeons, dentists, nurses, and
with the increase in porosity, which is considered a
histopathologists. At the present time, there is no effec-
major disadvantage.28'43"45'55 Solid, dense blocks have
tive treatment or cure.62'63
high compressive strength, but they are brittle, migrate
under stress during the healing period, and are not suit-
Alloplasts able for load bearing. Strong and porous HA, with a
To avoid the previously mentioned complications and compressive strength similar to that of bone, can be pre-
drawbacks of allografts and xenografts, biocompatible pared in laboratories, but this material becomes clini-
synthetic materials have been used over the past two cally difficult to handle and contour. Currently available
decades. High expectations have been placed on their use examples of this type of material are Calcitite® 2040
in clinical applications, and recent advances have greatly and 4060 (dense, nonresorbable particulates; Center-
improved their clinical outcome. They can be resorbable pulse, Dental Division, Carlsbad, California, U.S.A.);
or nonresorbable; microporous (less than 350 |x), macro- Osteograf/LD® (low density particles) and Osteograf/
AESTHETIC BONE GRAFTING 123

D® (dense particles) (CeraMed Dental, Lakewood, Col-

orado, U.S.A.); Osteogen® (highly porous, resorbable
particles; Impladent Ltd., Holliswood, New York,
U.S.A.); and Orthomatrix® (dense, nonresorbable parti-
cles), which comes in 420-840 jx (HA-1000) and 250-
420 JUL (HA-500) sizes (Lifecore Biomedical, Chaska,
Minnesota, U.S.A.). However, an important main disad-
vantage of these materials is that HA makes dental
implant placement impossible or difficult to perform.
The current use of HA as a grafting material is becom-
ing limited, since it may be just an osseous defect filler
(Figs. 5.8a,b and 5.9).
To overcome some of the material's difficult handling
characteristics and physical properties, a combination
product was developed: Hapset® (Lifecore Biomedical,
Chaska, Minnesota, U.S.A.). It is 65% Orthomatrix®
HA-500 and 35% calcium sulfate (CaSO4) hemihydrate
(medical-grade plaster of Paris). Dreesman, in 1892,
reported the use of calcium sulfate in filling a variety of
human osseous defects.67 The calcium sulfate acts as a
resorbable binder and helps to prevent the initial loss of
HA particles. It is recommended that the surgical site be
free of bleeding to promote initial hardening of the graft
mass. The plaster resorbs within one month, leaving a
scaffold of HA. The rationale for using medical-grade
calcium sulfate is that (1) it acts as a barrier for three to
four weeks, preventing undesirable soft tissue ingrowth,
and (2) it helps to stabilize the bone graft, preventing
excessive particle loss.68 A controlled study of human
periodontal defects filled with calcium sulfate alone
showed no improvement over the controls.69

Tricalcium Phosphate (TCP) Tricalcium phos-

phate is chemically similar to HA, but it does not have
the same chemical composition as natural bone. It has a
calcium to phosphorus ratio of 3:2 and is converted
partially into HA in the body.70 Resorption rate is vari-
able and is very dependent on the material's chemical
structure. During the past few years, the a- and (3-
phases of TCP have been subjected to increasing atten-
tion. Variation of the sintering temperature allows the
production of different crystalline phases. A tempera-
ture of 900°C allows the production of (3-TCP; a further
increase in temperature (greater than 1180°C) leads to a
restructuring of the TCP to its a analogue. Alpha (a) or
beta (P) refers to the particular orientation of the TCP FIGURES 5.8a,b. These figures show the difficulty of
crystals. Alpha-TCP resorbs very slowly and remains completely filling extraction sockets with hydroxyap-
detectable in bone after many years, whereas [3-TCP is atite.
fully resorbed and replaced by natural bone after eight
to twelve months.71 Clinical use of a-TCP is obviously
not recommended, although there are such products since the resorption rate of (3-TCP is synchronous with
commercially available (e.g., BioBvse®; BioVision, the bone remodeling rate, one can expect full bone regen-
Freiburg, Germany). TCP thus provides a physical eration at the defect site, provided it is used in the proper
matrix suitable for the deposition of new bone, and clinical indication.70'71 Note that the use of TCP is only
124 CHAPTER 5

FIGURE 5.9. Figure showing the lack of integration

between hydroxyapatite and host bone.

indicated for nonpathologic sites,70'71 preferably com-

bined with autogenous bone grafts or allografts (to
improve its handling properties and osteoinductivity)
and guided tissue regenerative techniques.43 Commer-
cially available TCP products include Augmen®, Syn-
thograf®, Fortoss Resorb™, and Cerasorb® (Curasan
Pharma GmbH, Kleinostheim, Germany) (Figs. 5.10
and 5.11).

Bioactive Glass Bioactive glass grafts are a mixture

of calcium salts and phosphate (in the same propor-
tions as in bone and teeth), sodium salts, and silicon
(which is essential for bone to mineralize). This mixture
FIGURE 5.10. One p-tricalcium phosphate particle of
or composition is known as 45S5. The sizes of the 200 IJL (Cerasorb®).
granules vary between 90 and 710 JJL, with an average
of 300-355 |x. The material bonds to bone by forming
a hydroxycarbonate apatite (HCA) layer on the surface
of the glass,72 closely imitating bone as a result of the enhanced prognosis, thus the graft will have an
incorporation of host material. A mechanically compli- increased therapeutic effect.40'41 However, other
ant collagen layer approximately 0.3 JJL thick, which is authors reported a rapid breakdown and loss of the
very similar in dimensions to the natural periodontal graft material when it was exposed to oral fluids, with
ligament,73'74 is created on the graft-bone interface; this a very high risk for infection.44'74 Commercially avail-
is how this graft material is thought to help in the able products include Bioglass®, Perioglass® (U.S. Bio-
repair of ligaments. Bone transformation and regenera- materials, Baltimore, Maryland U.S.A.) and Biogran®
tion occur within the hollow calcium phosphate cham- (3i, Palm Beach Gardens, Florida, U.S.A.).
bers, at multiple sites, rapidly filling the defect with
new bone that continuously remodels in its normal CALCIUM CARBONATE The CaCO3 graft mater-
physiological manner.73'75 This controlled bioactivity ial is made of aragonite (more than 98% CaCO3),
permits material transformation and bone remodeling which is not altered by laboratory processing and has a
to occur at the same time (Figs. 5.12 and 5.13 ). In an porosity greater than 45%. The average pore size is
animal study76 and another human study,75 Schepers et 150 u,, and the granules are 300-450 |x and 630-1000
al. reported that bioactive glass granules are easier to IJL in diameter. The material resorbs slowly and needs
manipulate than HA granules and did not show any no surface transformation to start the bone formation
tendency to disperse into the surrounding tissues.76 It cascade: other materials must undergo a surface trans-
formed a cohesive mass when contacting blood and did formation, from HA to carbonate, but CaCO3 appar-
not float with bleeding. The possible differentiation of ently eliminates this step, which may permit more rapid
osteoprogenitor cells to osteoblasts might create an bone formation at the grafting site.77 Calcium carbon-
AESTHETIC BONE GRAFTING 125

FIGURE 5.13. Calcium phosphate hollow chamber

formed by phagocytes, where progenitor cells differenti-
ate into osteoblasts.

under stress during the healing period.44 The commer-

cial available product is called Biocoral® (Inoteb s.a.,
Saint-Gonnery, France).

COMPOSITE POLYMERS

Resorbable Synthetic biologically resorbable poly-

mers have been known in medicine for a long time.64
For many years products composed of either polylactic
or polyglycolic acid have been used as a suture material,
fixation screws, bone patches, and in many other clini-
FIGURE 5.11. Newly formed bone (red) in and around cal applications. Most of these polymers have a high
the pores of the [3-tricalcium phosphate graft (black), molecular weight, yielding a breakdown time of up to
with simultaneous resorption of the graft.
three years, which is sometimes necessary for a particu-
lar clinical purpose, as in certain spinal column surg-
eries. Many factors play a role in the biological
degradation of the polymers, including the age of the
patient, the condition of the immune system, tissue tol-
erance, the location of the defect, and configuration of
the exposed surface.78 The final by-products of the enzy-
matic degradation of these polymers are carbon dioxide
and water.78 Recently, a low-density copolymer of poly-
lactic acid and polyglycolic acid that permits an esti-
mated degradation time of between a minimum of three
to four months and a maximum of six to eight months
was made available in three different forms (powder,
sponge, and gel) that can be combined to permit the fill-
ing of every possible type of bone defect. The powder is
more indicated for three-wall osseous defects, the
FIGURE 5.12. A 300-350 JJL bioactive glass granule sponge for two- or three-wall defects; they are damp-
(Biogran®). ened slightly with physiological solution or the patient's
own blood and formed into the correct shape by a
ate grafts appear to have good hemostatic properties scalpel or any sharp instrument prior to insertion. The
and are not readily displaced from the treatment site. gel can be used for deep defects, where it is "injected"
However, this material is also brittle and migrates directly via a syringe. The small mass and large surface
126 CHAPTER 5

area of this graft material permits the fibroblasts to easily

penetrate into it and initiate absorption and cell coloniza-
tion. This graft material is easy to work with. It is com-
mercially available as Fisiograft® (GHIMAS spa. Bolognia,
Italy). However, the use of guided tissue regenerative bar-
riers is often necessary. Histological findings seem very
promising, but all data are very recent and available clini-
cal follow-up is only within a few months.

Nonresorbable This bone alloplast material is a

patented nonresorbable chemically pure mixture of
polymethylmethacrylate (PMMA) and polyhydrox-
ylethylmethacrylate (PHEMA), with small amounts of
barium sulfate for radiopacity and an outer surface of
calcium hydroxide graft material, which makes the FIGURE 5.14. Precursor cells are attracted immedi-
direct interface with the host bone and forms CaCO3 ately to the surface of a nonresorbable copolymer parti-
apatite in the presence of the bleeding marrow. Since the cle (Bioplant HTR8).
polymerization reaction occurs in the laboratory, there
is no heat generated to the tissues and no chance of
monomer contamination: these two important side
effects are totally eliminated.
PMMA is a synthetic polymer used extensively for
years in a variety of implantable and other medical
devices, including intraocular lenses, prosthetic heart
valves, reconstructive prosthetic dental devices; in cranio-
plasty implants; and to encase intracranial aneurysms.
The first inner layer is coated with a layer of PHEMA, a
hydrophilic polymer that also has an extensive history of
use in medical devices, for example, contact lenses and
burn dressings (Hydron®). The material has a unique hol-
low, spherical architecture with a pore size opening of
approximately 350 JJL and a particle size of 750 JJL, which
allows bone growth into and around the material and FIGURE 5.15. Intimate contact and immediate prolif-
creates a matrix with increased surface area and greater eration of precursor cells on the surface of the graft due
ingrowth possibilities. Following healing, only 10-12% to its negative (-10 mV) charge.
of the volume fill of a defect consists of this graft mater-
ial, while 88-90% is regenerating, remodeling bone.79
The synergy of graft components results in unique form osteoblasts on its surface (Figs. 5.14 and 5.15); and
properties and physical characteristics. The most impor- to adhere to metal82 (Fig. 5.16), enhancing osseointegra-
tant and unique characteristic of the material is its nega- tion (Fig. 5.17) around metal implants.79'83"85 Further-
tively charged surface (-10 mV). Wolff showed that such more, the material does not undergo any migration under
a negative surface charge facilitates and enhances bone loads. Most of the commercially available bone grafting
healing and bone formation.80 Studies on salamanders materials require GTR membranes for ensuring pre-
proved that they use an extremely weak current to regen- dictable results,84'85 but with the use of this material, the
erate completely lost body parts.81 When the same nega- need for the membrane may be eliminated, because it is
tive charge is used in bone diseases (e.g., osteomyelitis), claimed that the material itself acts as a membrane. The
healing of the bone occurs.81 Although the material is nei- nonresorbable polymer material, when wetted with
ther bacteriostatic nor even bactericidal, bacteria do not bleeding marrow, initially forms dense fibrous tissue
easily colonize on the surface of the polymer because under the mucosal flap and develops a substantial com-
both the material and bacteria have a negative surface pressive strength (up to 1800 psi).79'83"85
charge; thus, the material might impede the development In animal studies, new bone, PDL, and new cementum
of infection.81 This negative charge also allows the poly- were formed around and in the material. Sharpey's fibers
mer to adhere to bone (because of the positively charged also were observed without other intervening tissues.86
cells); to attract the pluripotential precursor cells that will And in human studies, an author reported a 65% regen-
AESTHETIC BONE GRAFTING 127

regularly in all intraoral grafting procedures.84'85'87 The

commercially available product is called Bioplant HTR®
(Bioplant, Inc., South Norwalk, Connecticut, U.S.A.)

REGENERATIVE BARRIERS
Barrier membranes were first tested in the late 1950s for
the healing of cortical defects in orthopedic research and
were first described by Hurley et al.88 However, this pio-
neer study did not lead to broad clinical applications of
the membrane techniques for similar defects. Nyman et
al., who examined barrier membranes in periodontal
wound regeneration in the early 1980s,89 recognized the
FIGURE 5.16. A 100% fill of every extraction socket. potential of this technique. The barrier is basically used
to prevent invasion of competing soft tissue cells from the
overlying mucosa.
Critical work by Karring et al. and Buser et al.90'91 has
explored different membrane devices that separate tis-
sues during healing. This technology has been termed
guided bone regeneration (GBR). The principles of GBR
are derived from the knowledge generated by guided tis-
sue regeneration (GTR). GBR shares with GTR the use
of barrier membranes to achieve regeneration of new tis-
sues. But where the goal of GTR is to regenerate bone,
cementum, new attachment, and periodontal ligament
contiguous with root structure(s), the only goal of GBR
is to regenerate bone.92 It seems reasonable to assume
that GBR procedures are even more predictable than
GTR procedures for osseous regeneration, because the
regeneration in GTR occurs in a hostile healing environ-
ment due to the proximity of root surfaces contaminated
with plaque, calculus, and toxins. This hostile environ-
ment is contrary to the situation in GBR procedures.
Additional use of bone-grafting materials for space
maintenance tends to improve GBR outcomes.93 GBR
today is a widely accepted regenerative treatment modal-
ity in the implant dentistry. Guided bone regenerative
membranes are used to
• Separate tissues during healing,
• Retard apical migration of epithelium to the site,
• Maintain the necessary space for bone ingrowth
(tenting), and
• Protect the graft material in the defect.92
GBR barriers are of two types, nonresorbable and
resorbable.
FIGURE 5.17. Complete integration of grafting mater-
ial and newly formed bone. Nonresorbable
EXPANDED POLYTETRAFLUOROETHYLENE
eration rate for new cementum, new bone, and normal Expanded polytetrafluoroethylene (ePTFE) is sintered,
PDL.55 A possibility of slow material resorption (twelve and has pores between 5 and 30 JJL in the structure of the
years) also was reported.86 The material can be applied material itself. The most popular commercial type is
128 CHAPTER 5

Gore-Tex® (W. L. Gore 8t Assoc., Flagstaff, Arizona, (resorption time fifteen to eighteen weeks) (Center-
U.S.A.). pulse, Dental Division , Carlsbad, California, U.S.A.).
• Bovine collagen tendon (resorption time sixteen to
NANO POLYTETRAFLUOROETHYLENE (NPTFE) twenty-four weeks): BioSorb® (Imtec Corp, Ard-
With nano polytetrafluoroethylene (nPTFE), there is no more, Oklahoma, U.S.A.).
sintering, making the material quite pliable, allowing • Bilayer collagen from pigs (resorption time six to
easier tenting and adaptation; the pores are between 0.2 eight months): Bio-Gide® and Perio- Gide® (Geistlich
and 0.3 |x, and the smaller pore size is believed to limit Pharma AG, Wolhusen, Swizerland).
epithelial ingrowth and bacterial infiltration.94 Commer- • Collagen from porcine dermis (resorption time four
cially available products are TefGen-FD and TefGen- months): AlloDerm® P (Lifecell Corp., Branchburg,
Plus (Lifecore Biomedical, Chaska, Minnesota, U.S.A.). New Jersey, U.S.A.)
• Collagen from human dermis (resorption time four
TITANIUM Most of the membranes are made of tita- months): AlloDerm® H. (Lifecell Corp., Branchburg,
nium foil with micropores (e.g., Frios® BoneShield, and New Jersey, U.S.A.). Donated human skin is asepti-
JMP Titanium Mesh™; Friadent GmbH, Mannheim, cally processed to become a framework without any
Germany). Sometimes the surface is also treated to attain human cells, creating an acellular, biocompatible
a titanium oxide surface (e.g., Ti TitaniumOxid Mesh). human connective tissue matrix.

COMBINATION Sometimes ePTFE membranes are Collagen membranes have become the subject of
reinforced with titanium, for example, Gore-Tex® Tita- research lately, mainly because of their favorable biologi-
nium Reinforced (W. L. Gore & Assoc., Flagstaff, Ari- cal properties.97 Type I collagen is a predominant compo-
zona, U.S.A.). nent found in periodontal connective tissue and forms the
The major disadvantage of these types of nonresorbable main component of this type of membrane (Bio-Gide® has
membranes is the need for a second surgical procedure to types I and III). In addition, collagen possesses extra
remove them. This second surgery can sometimes be a advantages, including weak immunogenicity, hemostasis,
tedious undertaking and can also disturb healing and soft and chemotaxis for fibroblasts.97 When implanted into
tissue integrity.95 Patients today are not eager to accept this the body, collagen is absorbed at a rate that can be con-
type of treatment.95 Another disadvantage is that mem- trolled by the degree of chemical treatment or cross-link-
brane exposure rates of up to 31%,% caused by flap age. Various cross-linking techniques have been
sloughing or incision-line opening, have been the cause of developed, such as ultraviolet light, hexamethylenediiso-
postsurgical complications and failures. Membrane expo- cyanate(HMDIC), diphenylphosphorylazide (DPPA), and
sure provides a channel of communication between the glutaraldehyde (GA) or formaldehyde (FA) plus irradia-
oral environment and newly forming tissues, increasing tion. But cross-linkage seems to inhibit epithelial migra-
the chance for infection and decreasing bone regeneration tion effectivly.97
potential. These disadvantages and other minor problems In conclusion products that resorb very slowly seem to
led to the development of resorbable barriers. favor bone-grafting success.

Resorbable SYNTHETIC

NATURAL • Poly DL-lactide dissolved in N-methyl-2-pyrrolidone.

This material is commercially obtained as a liquid that
• Polylactic and citric acid ester (resorption time eight to sets to a firm consistency when contacted with water
ten weeks): Guidor® (Butler, Chicago, Illinois, U.S.A.). or other aqueous solutions. It can be shaped extrao-
• Glycolate and lactate polymers (resorption time ten rally and adheres to the defect without sutures. Resorp-
weeks): Vicryl-mesh™ (Johnson & Johnson, Som- tion time is twelve months, and the commercial name
merville, New Jersey, U.S.A.). is Atrisorb® (Atrix Labs, Fort Collins, Colorado,
• Glycolate and lactate polymers, arranged in a ran- U.S.A.).
dom fiber, trilayer matrix lacking large holes (resorp- • Calcium sulfate (plaster of Paris). As stated earlier,
tion time ten weeks): Gore Resolut XT™ (W. L. CaSO4 has been used since 1892.67 This material (For-
Gore & Assoc., Flagstaff, Arizona, U.S.A.). toss Cema™, Capset®; Lifecore Biomedical, Chaska,
• Polyglycolic acid, polylactic acid, trimethylene car- Minnesota, U.S.A.) is mixed and then placed over the
bonate (resorption time twelve to fourteen months): graft material. Resorption time is four weeks.
Gore Osseoquest (W. L. Gore & Assoc., Flagstaff,
Arizona, U.S.A.). Although GBR membranes are a widely accepted
• Bovine Achilles tendon collagen: BioMend™ (resorp- treatment modality, their clinical application should be
tion time six to eight weeks) or BioMend™ Extend approached with caution. In many instances, they
AESTHETIC BONE GRAFTING 129

showed compromised wound closure, with the risk of All growth factor types modulate healing events by
membrane exposure and bacterial infiltration, either due stimulating the migration and proliferation of a broad
to clinical mishandling or unknown reasons. range of mesenchymal cells.103 They also stimulate
When resorbable membranes are used, degradation osteoblast-like cells to proliferate and synthesize colla-
occurs mostly via hydrolysis. This creates an acid environ- gen. This is the rationale behind the new commercially
ment, which can have a negative effect on bone forma- available platelet rich plasma (PRP). Platelets or throm-
tion.92'96'97 Only collagen membranes seem to be absorbed bocytes contain numerous GFs that are released during
through catabolic processes resembling those involved in the natural healing process.104 The growth of new blood
normal tissue turnover.67 On the other hand, an animal vessels (angiogenesis), especially, is stimulated through
study reported the fast degradation of three types of colla- PRP, and this is the first and most important step
gen membranes (BioGide, AlloDerm porcine-derived, and towards rebuilding the defect area. The use of the
AlloDerm human-derived) that puts in question the effec- patient's own PRP seems to improve the safety and
tiveness of these types of resorbable membranes when quality of the newly formed bone.104 Usually, PRP is
they are to be used as physical barriers beyond one produced by the techniques of "plasmapheresis" or
month.98 "thrombopheresis" via a centrifuge collection system.
PRP is prepared from just half a liter of the patient's
own blood. It has to be considered that the activity of
CYTOKINES platelets rapidly decreases after harvesting, so the
period of time between harvesting and the clincal use of
Levander made one of the earliest suggestions of the the PRP has to be kept as short as possible (maximum
presence of protein extracts that induce new bone for- forty-five minutes). However, most of the growth fac-
mation when implanted subcutaneously or intramuscu- tors including PRP seem to be more active in the soft tis-
larly.99 He proposed that the implanted bone material sue regeneration as well as in bone formation.
contains soluble stimulating agents that promote new Therefore, research must be directed toward developing
bone formation. Lacroix confirmed these findings by site-specific effects. Today, PRP concentrate can be
showing that an alcoholic extract of bone cartilaginous advantageous for patients with reduced wound
epiphyses promoted bone formation. He termed this healing.104 New technology has recently been introduced
substance osteogenin.100 Urist, in 1965, observed that by Harvest® SmartPReP™ (Harvest Technologies Corp.,
protein extracts could induce the local formation of Plymouth, MA, U.S.A.) to produce a bioactive platelet
new cartilage and bone when implanted at nonbony gel called "SmartClot™." It provides a revolutionary
sites. He later showed that protein extracts from decal- platelet-harvesting process while preserving platelet via-
cified bone matrix were responsible for new bone for- bility with its bioactive properties.
mation and could be separated.101 However, clinical
application was very restricted because of the difficulty Bone Morphogenetic Proteins
of the extraction process. The advent of molecular biol-
ogy and, in particular, recombinant DNA technology Actually, more than twenty structurally unique BMPs
permitted the production of relatively large quantities have been identified, all of which can produce ectopic
of these proteins. bone formation.48 The advent of molecular biology tech-
The family name of all these proteins is cytokines; niques and, in particular, recombinant DNA technology
these can be divided into two major categories: growth has substantially increased the possibility of producing
factors (GFs) and bone morphogenetic proteins (BMPs). relatively large quantities of these proteins.47 The use of
Their activity is significantly different: GFs cause several recombinant BMP offers some critical advantages over
general activities, whereas BMPs focus only on differenti- the use of BMPs derived from human cadaver bones:
ating cells.47'102 GFs also change the growth rate of preex- there are no contaminating proteins and no risk of trans-
isting bone, while BMPs induce new bone formation mitting infectious disease. Thirteen proteins have already
limited to the site of implantation. been purified and cloned; they are called BMP-1 through
BMP-13.47 One of these, recombinant human BMP-2
Growth Factors (rhBMP-2), has been assayed in several systems and has
been found to have very high osteogenic activity, making
The available growth factors types are
rhBMP-2 most promising.48'49'105 BMPs induce formation
• Transforming growth factor beta (TGF-|3), of new bone that has all the characteristics of normal
• Insulinlike growth factors I and II (IGF-I; IGF-II), bone, including cartilage formation followed by endo-
• Fibroblast growth Factor (FGF), chondral ossification. BMPs accelerate the time of
• Epidermal growth factor (EGF), and implant-bone integration and have excellent therapeutic
• Platelet derived growth factor (PDGF). potential in dental and periodontal attachment complex
130 CHAPTER 5

repair.49'105 However, they are all highly active, which traction phase, a retention or consolidation period of
leaves the question still unanswered of how to control three months must be observed. The average gain in ver-
their activity. The full potential and safety of BMPs will tical height after a completed treatment can reach up to
require further clinical studies. 10.2 mm (Figs. 5.18-5.20). Implants can then be
How to deliver cytokines to the graft site still remains inserted. This procedure gains a time advantage of
debatable. All need an appropriate carrier for regular approximately nine weeks over the conventional aug-
clinical use. The ideal carrier must maximize host tissue menting techniques, where a consolidation of at least six
exposure to the cytokines and ensure uniform delivery months is required. Contraindications to this type of
without allowing spread of the substance beyond the treatment are in general the same as for implant treat-
boundaries of the graft site. The carrier should be safe ment (bone diseases, radiotherapy of greater than 60 Gy,
and biocompatible. Several carriers have been tested, and smoking habits, etc.) and include negative perception by
from the latest results it seems that synthetic polymers the patient; however, a specific contraindication is a start-
may prove to be a reasonable carrier.47'49 ing height of less than 6 mm of remaining bone, due to
the high risk of jaw fracture.108'110

DISTRACTION OSTEOGENESIS
Besides conventional bone grafting methods to treat the
lack of bone, distraction osteogenesis can become a
viable alternative.106The technique is based on the "float-
ing bone principle": the natural tendency of fractured
bone to bridge defects by immediate callus formation.107
A directed distraction of the fracture ends by means of
microplates (distractors) will activate bone growth to fill
up the gap. The distracters are made exclusively of pure
titanium and carry a slide mechanism with attached
microplates. Following adjustment of the microplates,
the buccocortical osteotomy is performed to mobilize an
adequate section of the alveolar crest.. The distraction is
then carried out, one week after the surgery, by activating
the device about 1 mm a day (0.5 mm, two times) until
the desired gain in height is obtained. Following the dis- FIGURE 5.19. Radiographic view after placement of
the distractor.

FIGURE 5.20. Radiographic view at the end of the dis-

FIGURE 5.18. Distraction device (TRACK 1.5, Tissue traction phase, showing approximately 12 mm of bone
Regeneration by Alveolar Callus distraction Koln). height gained.
AESTHETIC BONE GRAFTING 131

TITANIUM MESH decorticated to enhance the cellular flow to the graft. The
placement of the titanium mesh requires sequential place-
Severe alveolar bone resorption can sometimes be a clini- ment steps: first the palatal side of the mesh (Mondeal
cal dilemma that impairs optimal implant placement in Medical Systems GmbH, Tuttlingen, Germany) is fixed in
the alveolar ridge; it mandates particular bone-grafting place and tightened with two microscrews), then another
procedures that can offer predictable results. Autogenous two screw holes are drilled in the labial side in the corti-
corticotrabicular grafts used in treating severe osseous cal bone and marked with the naked eye in order to not
defects have clinical short comings: the blood supply to lose their original place.
the graft can be minimized (especially when using large The grafting material is prepared and introduced to
grafts),111 there is an increased risk of surgical morbidity, the area of the defect (the preferred grafting material is
and the graft may lose 30% or more of its overall size due particulated bone marrow with allogenous bone parti-
to postoperative bone remodeling.30'112 Guided bone cles), and the space is overfilled (Fig. 5.23a-f). The tita-
regenerative membranes can help in treating larger verti- nium mesh is then laid to the labial side and fixed to the
cal osseous defects, but the inherited physical property of
the membrane to collapse towards the defect due to the
pressure of the overlying soft tissues (thus reducing the
space required for regeneration) makes the overall
amount of regenerated bone questionable. The physical
characteristics of the GBR membranes could be
improved by the application of titanium strips. This pro-
cedure allows the preservation of the space for regenera-
tion by what is called tenting. 9
The use of titanium mesh can be a predicable and reli-
able treatment modality for regenerating and recon-
structing a severely deficient alveolar ridge.10'113"118 A
study118 that involved the use of a titanium mesh to pro-
tect the regenerating tissues and to achieve a rigid fixa-
tion of autogenous bone segments was conducted with
twenty-five patients. It concluded that the use of titanium
mesh can assist bone regeneration in non-space-making
defects, since it probably does not interfere with the
blood flow to the underlying tissues because of the pres- FIGURE 5.21a. Preoperative view of a forty-five-year-
ence of microholes within the mesh. The study also con- old woman showing excessive bone loss in both vertical
firmed that the quantity of bone regenerated under the and horizontal dimensions.
membranes is directly related to the amount of space pre-
sent underneath. The main advantages of the titanium
mesh are that it maintains and preserves the space to be
regenerated without being collapsed or bent, it provides
blood supply for the bone-grafting material directly from
the periosteum through its micropores, and it is com-
pletely biocompatible to oral tissues.119
The preoperative steps for using the titanium mesh
entail a thorough presurgical planning,120 which includes
a proper assessment of the size and nature of the osseous
defect121 and making preoperative working casts for tail-
ing and fitting the titanium mesh sheet to the space of the
osseous defect (Figs. 5.21a-d and 5.22a-d). The intraop-
erative steps involve a midcrestal incision extended
mesially and distally beyond the area to be grafted.
Another two vertical incisions are made at both ends of
the crestal incision on the buccal side, with complete FIGURE 5.21b. Intraoperative view showing a 6 mm
mucoperiosteal flap mobilization. The osseous defect is osseous defect.
132 CHAPTER 5

FIGURE 5.22t>. Autogenous bone chips harvested

from the chin to be particulated with the allogenous
graft particles.
FIGURE 5.21c. Seven months after grafting, view
showing the complete bone regeneration in the area
using the titanium mesh.

FIGURE 5.22c. The titanium mesh (Mondeal Medical

Systems GMBH, Tuttlingen, Germany) fixed in place
with the bone graft placed underneath.
FIGURE 5.21d. Six weeks after abutment connection,
showing remarkable improvement of the papillary height.

FIGURE 5.22a. Preoperative view of severe alveolar FIGURE 5.22d. Seven months postoperative view
ridge resorption. showing improved bone topography.
AESTHETIC BONE GRAFTING 133

FIGURE 5.23a. A fifty-two-year-old man with missing FIGURE 5.23d. The labial end of the mesh is stabi-
maxillary right central and lateral incisors. lized to the labial plate. Note the sequential steps of the
mesh fixation.

FIGURE 5.23b. The area after flap reflection showing FIGURE 5.23e. Seven months postoperative view
severe bone loss in the horizontal plane. Note that the showing the regenerated bone after removal of the
labial plate is being decorticated. mesh.

FIGURE 5.23c. The titanium mesh being stabilized

palatally with two micro fixation screws (Mondeal Med-
ical Systems GMBH, Tuttlingen, Germany ).The particu-
lated bone-grafting mix is introduced to the site (human FIGURE 5.23f. Post- and preoperative models show-
allograft bone tissue, Allosource, Denver, Colorado). ing the improvement of the osseous topography after
Note the sequential steps of the mesh fixation. the treatment.
134 CHAPTER 5

labial plate with the microscrews and tightened to its pre-

viously prepared place. Care should be exersised to not
expose the margins of the titanium mesh through the mar-
gins of the mucoperiosteal flap. The importance of the
sequence in stabilizing the mesh is that it saves the partic-
ulate bone graft from being dispersed or displaced during
the drilling procedure for making the labial screw holes.
Optimal soft tissue closure on top of the titanium mesh
is a vital clinical step that contributes to the success of the
grafting procedure, because any opening of the incision
line can jeopardize graft success.122 (Refer to the method
of soft tissue closure in critical conditions in Chapter 4).
Titanium mesh can be used before placing dental
implants (staged approach) or in conjunction with dental
implant placement (nonstaged approach). The choice FIGURE 5.24c. The titanium mesh (Modeal Medical
depends primarily on the amount of bone available to Systems GMBH, Tuttlingen, Germany) stabilized in
stabilize the implant (Figure 5.24a-d). place, protecting the bone graft.

FIGURE 5.24a. Intraoperative view of a thirty-year- FIGURE 5.24d. The case finally restored; note the
old patient with missing right central incisor with the improved profile.
mucoperiosteal flap reflected, showing horizontal bone
loss.

CONCLUSION
The decision to use any particular grafting material or
grafting technique should be based on the
• Nature and size of the defect,
• Physical properties of the graft,
• Chemical properties of the graft,
• Mechanism(s) of action of the graft,
• Assumed rehabilitation planning, and
• Required final result.
Today's practitioner has a wide array of grafting mate-
rials available that can be used in several clincal applica-
FIGURE 5.24b. The implant placement (TSV Paragon, tions. The use of these materials has widened
Centerpulse, Dental Division, Carlsbad, California). Labial tremendously the scope and expectations for implant
dehiscence occurred to reduced bone width. surgery. Research and clinical experience have shown
AESTHETIC BONE GRAFTING 135

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Index

Page references in italics denote photographs or Ball bearing, 33

illustrations. Ballooning, soft tissue, 108
Barrier membranes. See Regenerative barrier
membranes
Abutment Beauty
soft tissue management in art, 4
postconnection, 94-102 cosmetics and, 3—4
at time of connection, 87 in dentistry, 5-6
temporary, 81-82 Biocompatibility, 117
Aesthetic implant placement, 45-57 Bio-Oss®, 121, 121
apicoincisal positioning, 53-56, 56 BMPs (bone morphogenetic proteins), 115-117,
corrections of misplacement, 56-57, 57 129-130
design, implant, 47-48 Bone. See also Bone grafting
labiopalatal positioning, 50-53, 51-53 classification of available alveolar, 24
mesiodistal positioning, 49-50, 49-50 deorganified bovine bone, 121, 121
overview, 45-46 evaluation
positioning, 48-49 quantity and quality, 24-25
tooth anatomy and implant morphology, 46-47 radiographic assessment, 13-16
Aesthetics study cast use of, 11
defined, 4 regeneration, mechanisms of, 117
implant, 5-6 resorption, 24
Aesthetic zone, 45-46 horizontal pattern, 45
Allergies, 10 postextraction, 36, 36, 115
Allografts, 119-120,120 with dentures, 18
Alloplasts, 122-127 width, calculating, 11
calcium carbonate, 124-125 Bone banks, 119
ceramics, 122-124 Bone grafting, 115-135
glass, bioactive, 124, 125 aesthetic, 5
synthetic hydroxyapatite, 122-123, 123-124 choosing materials and techniques, 134-135
tricalcium phosphate, 123-124, 124-125 cytokines and
polymers bone morphogenetic proteins, 115-116, 129-130
nonresorbable, 126-127,126-127 growth factors, 129
resorbable, 124-125 distraction osteogenesis, 116, 130, 130
Angiogenesis, 129 harvesting autogenous bone, 116-117
Antibiotics, 28, 82 materials
Apicoincisal positioning, 53-56, 56 allografts, 119-120, 120
Art, beauty in, 4 alloplasts, 122-127
Autogenous grafts, 116-118 calcium carbonate, 124-125

139
140 INDEX

Bone grafting, materials, alloplasts (continued) inlay grafting, 96-98, 97

ceramics, 122-124 for interdental papilla reconstruction, 105-106,
glass, bioactive, 124,125 105-106
polymers, nonresorbable, 126-127,126-127 second-stage surgery and, 88-90, 89, 91-93
polymers, resorbable, 124-125 Connective tissue pouch procedure, 98-100
synthetic hydroxyapatite, 122-123, 123-124 Contraindications, to dental implant therapy, 9-10
tricalcium phosphate, 123-124,124-125 Cortical bone, 117
autogenous grafts, 116-118 Cosmetics
xenografts, 120-122, 121 aesthetics compared, 4
overview, 115-116 ancient, 3-4
regenerative barrier membranes, 116,127-129 defined, 4
nonresorbable Creutzfeld-Jacob Disease (CJD), 122
combination, 128 Cross-linking, 128
expanded polytetrafluoroethylene (ePTFE), CT (computerized tomography), 15, 16, 24-25, 84
127-128
nano polytetrafluoroethylene (NPTFE), 128
titanium, 128 Delayed implant placement, 67-70
resorbable modified Elden-Mejchar technique, 69-70, 69-71
natural, 128 mucoperiosteal flap design, 68
synthetic, 128-129 preservative interproximal papilla incision,
titanium mesh and, 131-134, 131-134 68-69, 69
Bone morphogenetic proteins (BMPs), 115-117, protocol, 35-36, 36
129-130 Demineralized freeze-dried bone allografts (DFDBAs),
Bovine spongiform encephalopathy (BSE), 122 119,120
Bridges Dentascan, 15
adhesive, 17 Dentures, removable partial
conventional fixed, 17 choosing, 18
as provisional prosthesis, 20, 20 as provisional prosthesis, 19, 19-20
resin-bonded, 20, 20 Deorganified bovine bone, 121,121
BSE (bovine spongiform encephalopathy), 122 Dermal matrix, acellular, 95
Buccal rotated flap technique, 72-74, 74-75 Design, aesthetic implant, 47-48
Burstone line, 28 Diamond bur, 102, 102
Diastema, 50, 50
Digital subtraction radiography (DSR), 15
Calcitite, 122 Distraction osteogenesis, 116, 130, 130-131
Calcium carbonate, 124-125
Calcium sulfate, 123, 128
Caliper, tissue gauge, 13 Elden-Mejchar technique, modified, 69-70, 69-71
Cancellous bone, 119,121 Electrosurgical sculpturing, 101
Cast. See Study casts Emergence profile, 31-32, 32
Cementoenamel junction (CEJ), 23, 55-56,103 Endodontics, 27-28
Cephalographs, 15 Epidermal growth factor (EGF), 129
Ceramics, 122-124 Eruption, forced, 26-27, 26-27
glass, bioactive, 124,125 Examination of patients, physical, 9-10
synthetic hydroxyapatite, 122-123, 123-124 Expanded polytetrafluoroethylene (ePTFE), 127-128
tricalcium phosphate, 123-124,124-125
Chemotactic factors, 116
Coagulum, 116 Facial analysis, 28-31, 28-31
Collagen, 116-117,124,128-129 Failure checklist, El Askary-Meffert, 47
Colloss, 121 Fibrin, 116
Computerized tomography (CT), 15, 16, 24-25, 84 Fibroblast growth factor (FGF), 129
Connective tissue grafts Fibroblasts, 116
harvesting, 97-98, 99 Fibrosis, 117
INDEX 141

Flap design success rate, 18

buccal rotated flap, 72-74, 74-75 temporary, 20, 21
closure in critical conditions, 84-87, 84-87 as treatment option, 17-18
connective tissue graft use, 88-89, 91-93 Incisors
interproximal papilla, preserving, 68-69, 69 age and gender, differences in, 31
modified Elden-Mejchar technique, 69-70, 69-71 smile design and, 31
palatal rotated flap, 71-72, 73 Inlay grafting, 96-98, 97
pedicle island flap, 77, 78-80 Insulinlike growth factors (IGFs), 129
for reconstruction of interimplant papillae, 105,105 Interproximal papilla
rehermanplasty, 74-77, 76-78 classification
scalloping, 88-89, 90 Nordland, 103,103-104
Flapless placement techniques, 83, 83-84 Salama, 103-104, 105
Foreign body giant cell reaction, 117 Tarlow, 103, 104
Freeze-dried bone allografts (FDBAs), 119 histology, 104-105
morphology, basic, 104-105
osseous regenerative methods, 106
Gingival zenith, 55-56 preserving, 68-69, 69, 89, 91
Gingivoplasty, 101-102, 102 prosthetic papillary illusion, 107-108, 108-109
Glass, bioactive, 124, 125 reconstruction, 105-106, 105-106
Grafts. See Bone grafting; Connective tissue grafts; noninvasive methods, 108-109
Soft tissue management template, regenerative, 106-107, 107-108
Growth factors, 116, 129 Interradicular bone, 102
Guided bone regeneration (GBR), 82, 127. See also Irradiated cancellous bone allografts (ICBAs), 119
Regenerative barrier membranes
Guided tissue regeneration (GTR)
barriers, 77-82 Keratinized tissue
guided bone regeneration (GBR) compared, 127 assessment of, 21-22
socket classification and, 37 bulking tissues facially, 87-88, 88
incisions into, limiting, 89, 90-91
optimizing, 62, 62-63
Hapset, 123 scalloping, 88-89, 90
Harmony, 4, 4 trimming, 102, 102
Homeostasis, 116 Kirschner wires, 34, 35
Hydroxyapatite, synthetic, 122-123,123-124

Labiopalatal positioning, 50-53, 51-53

Immediate implant placement, 70-87 Laser resurfacing, 101
buccal rotated flap, 72-74, 74-75 Lips
in critical conditions, 84-87, 84-87 anatomy, 28, 28
flapless technique, 83, 83-84 impressions on study cast, 13
guided tissue regeneration, 77-82 size and thickness, 29, 29
palatal rotated flap, 71-72, 73 smile, 29-31,29-31
pedicle island flap, 77, 78-80 support and tonicity, 29, 29
protocol, 36-38, 37 Lysosomal enzymes, 116
rehermanplasty, 74-77, 76-78
socket seal template technique, 81-82, 81-82
Implants Macrophages, 116
aesthetics of, 5-6 Magnetic resonance imaging, 15
number of, 11 Medical evaluation, of patients, 9-10
placement Mesiodistal positioning, 49-50, 49-50
aesthetic, 45-57 Modified Elden-Mejchar technique, 69-70, 69-71
delayed, 67-70 Mucoperiosteal flap design, 68. See also Flap design
immediate, 70-87 Multiple type mitogen-morphogen mechanism, 116
142 INDEX

Nano polytetrafluoroethylene (NPTFE), 128 surgical template, 32-35, 33-35

Novel guide template, 34, 34 tissue biotypes, 22-23, 22-23
treatment options, 16-19
bridges, adhesive, 17
One-stage implant placement technique, 38-39 bridges, conventional fixed, 17
Onlay grafting, 94-95, 94-96 dentures, removable partial, 18, 19
Orthodontic techniques, 25-27, 25-27 implants, 17-18
Orthomatrix, 123 points of consideration, 18-19
Osseointegration, 24, 27 Prion, 122
Osteoconduction, 117 Provisional prosthesis, 102
Osteogen, 123 dentures, removable partial, 19, 19-20
Osteogenesis, 117 planning, 19-21
Osteograf/D®, 122-123 resin-bonded bridges, 20, 20
Osteograf/LD®, 122 temporary implant, 20, 21
Osteograf/N®, 121 Punch technique, 80, 90-94
Osteoinduction, 117

Radiation exposure, 14
Palatal rotated flap technique, 71-72, 73 Radiography
Papilla. See Interproximal papilla cephalographs, 15
Papillary illusions, 107-108,108-109 computerized tomography, 15,16
Patients digital subtraction radiography (DSR), 15
communicating with, 8-9,16-17, 19 occlusal view, 14, 14
expectations, 8-9, 17 panoramic view, 14-15, 14
medical evaluation of, 9-10 Radiography (continued)
Pedicle island flap, 77, 78-80 periapical view, 14, 14
PepGen P-15™, 121 presurgical assessment, 13-16, 14-15
Periodontal ligament, width of, 50 of surgical template, 33
Periodontium. See Soft tissue evaluation; Tissue biotypes Regenerative barrier membranes, 116, 127-129
Planning. See Presurgical considerations nonresorbable
Plasmapheresis, 129 combination, 128
Platelet derived growth factor (PDGF), 64-65, 129 expanded polytetrafluoroethylene (ePTFE),
Platelets, 129 127-128
Polyglycolic acid, 125 nano polytetrafluoroethylene (NPTFE), 128
Polyhydroxylethylmethacrylate (PHEMA), 126 titanium, 128
Polylactic acid, 125 resorbable
Polymers natural, 128
nonresorbable, 126-127,126-127 synthetic, 128-129
resorbable, 124-125 Rehermanplasty, 74-77, 76-78, 87
Polymethylmethacrylate (PMMA), 126 Repair process, 116-117
Pontic development techniques, 11, 12 Resorption, bone, 24
Presurgical considerations, 8-39 with dentures, 18
bone evaluation, 24., 24-25 horizontal pattern, 45
emergence profile, 31-32, 32 postextraction, 36, 36, 115
facial analysis, 28-31, 28-31 Resurfacing, cosmetic laser, 101
medical evaluation, 9-10 Ricketts' E-plane, 28
orthodontic and endodontic, 25-28, 25-28 Ridge defects, categories of, 61
overview, 8-9 Ridge-lap design, 52, 53-54
patient expectations, 8-9 Ridge mapping, 11, 25
provisional planning, 19-21
radiographic assessment, 13-16,14-15
soft tissue evaluation, 21-22 Sculpturing, electrosurgical, 101
study casts, 10-13, 11 -13 Sharpey's fibers, 102
surgical intervention, planning for, 35-39, 36-38 SIM/Plant software, 34
INDEX 143

Smile, 29-31,29-31 secondary-stage surgery, rules of, 87-94

Social attributes, of dentition, 5 bulking keratinized or connective tissues facially,
Socket, classification of, 37-38 87-88, 88-89
Socket seal techniques, 62-64, 63-64 connective tissue grafts, use of, 89-90, 91-93
modified, 64-66, 64-66 interproximal papillae, preserving, 89, 91
template techniques, 81-82, 81-82 limiting incision of keratinized tissues, 89, 90-91
Soft tissue evaluation punching, 90-94
depth measurement, 11, 12 scalloping keratinized tissues, 88-89, 90
presurgical considerations, 21-22 at time of abutment connection, 87
quality and quantity, assessment of, 21-22 Steiner line, 28
tissue biotypes, 22-23, 22-23 Study casts
Soft tissue management, 60-109 lip impression on, 13
for aesthetics, 5-6 uses of, 10-13, 11-13
before implant placement, 62-66 wax-up, 13, 13, 34, 45
modified socket seal surgery, 64-66, 64-66 Surgery. See also Soft tissue management; specific
optimizing keratinized tissues, 62, 62-63 techniques
socket seal techniques, 62-64, 63-64 implantation techniques
during implant placement, 64-87 delayed placement, 35-36, 36
delayed implant placement, 67-70 immediate placement, 36-38, 37
modified Elden-Mejchar technique, 69-70, 69-71 nonsubmerged, 38
mucoperiosteal flap design, 68 one-stage, 38-39
preservative interproximal papilla incision, planning for, 35-39, 36-38
68-69,69 repair process and, 116-117
immediate implant placement, 70-87 Surgical template, 32-35, 33-35, 45
buccal rotated flap, 72-74, 74-75
in critical conditions, 84-87, 84-87
flapless technique, 83, 83-84 Tapered implant design, 50, 50
guided tissue regeneration, 77-82 Template
palatal rotated flap, 71-72, 73 interimplant papilla regenerative, 106-107,
pedicle island flap, 77, 78-80 107-105
rehermanplasty, 74-77, 76-78 surgical, 32-35, 33-35, 45
socket seal template technique, 81-82, 81-82 Tissue biotypes
overview, 66-67 thick flat, 22, 22-23, 47
mismanagement, 60 thin scalloped, 23, 23, 47
overview, 60-61 Tissue gauge caliper, 13
papillae, interproximal, 102-109 Titanium
classification of, 103-104,103-105 interimplant papilla regenerative template, 106
importance of, 102-103 mesh, 131-134, 132-134
morphology, 104-105 in regenerative barriers, 128
prosthetic illusions, 107-108, 108-109 Trabecular bone, 118-119
reconstruction, 105-106, 105-106, 108-109 Transforming growth factor beta (TGF-(3), 129
template, regenerative, 106-107, 107-108 Trephine drill, 34, 35, 64
postabutment connection, 94-102 Tricalcium phosphate, 123-124
connective tissue pouch procedures, 98-100,
98-100
gingival recontouring techniques, 100-102 Ultrasound, 119
cosmetic laser resurfacing, 101
electrosurgical sculpturing, 101
gingivoplasty, 101-102, 102 Wax-up, 13,13, 34, 45
inlay grafting, 96-98, 97
onlay grafting, 94-95, 94-96
provisional restoration, 102 Xenografts, 120-122, 121