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Tooth-supported overdentures
Orthodontic therapy (closure of edentulous spaces) Implant-supported prostheses (fixed, retrievable or removable suprastructures)
Challenging esthetics
Bone height
Midcrest position of the edentulous site should be 2 mm below the facial CEJ of the adjacent teeth. The interproximal bone should be scalloped 3 mm more incisal than the midcrest position. Becker et al. 1997 classified the rang of interpmximal bone height above the midfacial scallop from less than 2.1 mm (flat) to scalloped 2.8 mm to pronounced scalloped < 4.1 mm. flat anatomy square-shaped tooth scalloped ovoid-shaped tooth
Under perfect conditions, the implant body should not be inserted until the bone and soft tissue are within normal limits.
Challenging esthetics
Mesiodistal space Two-piece implant
should be at least 1.5 mm from
an adjacent tooth. When the implant is closer than this to an adjacent tooth bone loss related to the microgap, biological width violation , and/or stress. one-piece implant should be at least 1 mm from an adjacent tooth. microgap eliminated and the vertical defect
is narrower than most two-piece implant systems so they can be placed closer
Challenging esthetics
Faciopalatal Width
A 25% decrease in faciopalatal width occurs within the first year of tooth loss and rapidly evolves into a 30% to 40% decrease within 3 years. The bone width loss is primarily from the facial region, because the labial plate is very thin compared with the palatal plate, and facial undercuts are often found over the roots of the teeth.
Challenging esthetics
Implant size
first factor that influences the size of an implant is the mesiodistal dimension of the missing tooth. 2 mm below CEJ The second factor that determines the mesiodistal implant diameter is the necessary distance from an adjacent tooth root. due to this the implant is usually smaller in diameter than natural tooth
Challenging esthetics
Implant size
Distance between an adjacent teeth roots in comparison with implants distance.
0.5 1.5
2 mm
3 mm
4 mm
Challenging esthetics
Implant size
The width of bone should allow at least 1.5mm on the facial aspect of the implant. The faciopalatal width dimension is not as critical on the palatal aspect of the implant, because it is dense cortical bone, more resistant to bone loss, and not within the esthetic zone. Facial bone grafting at the time of implant insertion is frequently needed, because the bone volume in width is often compromised.
(A)
(B)
Miami 2007
A, a position below the incisal edge is best used for a cemented crown in the esthetic zone. B, an implant is in the position of the natural root of the tooth. Although this makes sense, it places the implant too facial, and an angled abutment is usually necessary, C, an implant in the cingulum position that is used when a screw-retained crown is the trea ment of choice. This position requires a facial ridge lap of porcelain when used for FP-l prostheses
Miami 2007
The implant countersunked below the crestal bone more than 4 mm below the facial CEJ of the adjacent teeth to develop a crown emergence profile similar to a natural tooth. The bulk of subgingival porcelain provides good color and contour for the crown. However, several concerns arise regarding the long-term sulcular health around the implant.
The first year of function often corresponds to a mean bone loss range of 0.5 to 3.0 mm, dependent in part on implant design. Malevez et al.32 noted more pronounced bone loss for conical implants that had a long, smooth, tapered crest module. The bone is lost at least 0.5 mm below the abutment to implant body connection and extends to any smooth or machined surface beyond the crest module (depending on the implant design). This may lead to facial probing depths of 7 to 8
Grunder evaluated single-tooth implants in function for 1 year and noted the bone levels were 2 mm apical to the implantabutment connection and sulcular probing depths were 9.0 to 10.5 mm using a Branemark implant design. The attachment mechanism of the soft tissue above the bone is less tenacious compared with a tooth, and the defense mechanism of the peri-implant tissues may be weaker than that of teeth. The clinician, to err on the side of safety for the best sulcular health conditions, should
The implant body is positioned less than 2 mm below the facial free gingival margin of the crown, the cervical esthetics of the restoration are at an increased risk. The porcelain of the crown may not be subgingival enough to mask the titanium color of the abutment below the margin. Periodontal surgical procedures to position soft tissue over the titanium roots are unpredictable.
The crestal bone height is coronal to the perfect height. The two most common conditions that result in this finding are (1) when the adjacent teeth are closer than 6 mm (in agenesis of a lateral incisor) and (2) when a block bone graft regenerated width and height of bone. Ideally, the interproximal bone is 3 mm above the midcrestaI bone.
When a single-tooth implant replaces this missing tooth, an osteoplasy should be performed so that the midcrestal region is 3 mm apical to the free gingival margin of the future crown. The same conditions may occur when bone augmentation gains height to the interproximal height of bone. To solve the problem of an implant body placed too shallow, the restoring dentist may need to prepare the implant crest module and place the margin of the crown
Pouch procedures. Interpositional grafts. Sliding flaps. connective tissue grafts (autogenous or acellular dennal matrix).
Transitional prosthesis
Resin-bonded fixed restorations strongly suggested to be fabricated to provide improved speech and function, especially when crestal bone regeneration is performed and for extended healing time. Transitional cantilevered prosthesis from adjacent tooth requiring crown. When the patient requires orthodontics, a denture tooth and an attached bracket may be added to the orthodontic wire.
Transitional prosthesis
A removable device may be used as short term for cosmetic emergencies. (1) An Essix appliance is an acrylic shell, similar to a bleaching tray, that has a denture tooth attached to replace the missing tooth. This device is the easiest for tooth replacement after surgical procedures. (2) A cast clasp RPD with indirect rest seats to prevent rotation movements on the surgical site. (3) Flipper.
Summary
The replacement of a single tooth in the premaxilla is challenging because of the highly specific soft and hard tissue criteria, in addition to all other esthetic, phonetic, functional and occlusal requirements. Anterior tooth loss usually compromises ideal bone volume and position for proper implant placement. Implant diameter, compared with that of natural teeth, results in challenging cervical esthetics.
Summary
Unique surgical and prosthetic concepts are implemented for proper results. In spite of all the technical difficulties that the restoring dentist may face, the anterior single-tooth implant is the modality of choice to replace a missing anterior maxillary tooth.
Optimal three-dimensional implant positioning ("restoration-driven implant placement") in anterior maxillary sites.
Implant = apical extension of the ideal future restoration
Correct vertical position of implant shoulder (sink depth) using the cemento-enamel junction of adjacent teeth as reference: no visible metal gradually developed, flat axial profile Correct oro-facial position of point of emergence for future
Optimal three-dimensional implant positioning ("restoration-driven implant placement") in anterior maxillary sites.
Implant = apical extension of the ideal future restoration
suprastructure from the mucosa: similar to adjacent teeth flat emergence profile Implant axis compatible with available prosthetic treatment options (ideally: implant axis identical with "prosthetic axis")
Basic considerations related to multiple-unit implant restorations in sites with horizontal and/or vertical soft and hard tissue deficiencies
Achievements Predictable and reproducible results regarding lateral bone augmentation using barrier membranes supported by autografts :
allows implant placement in patients with a low lip line.
Basic considerations related to multiple-unit implant restorations in sites with horizontal and/or vertical soft and hard tissue deficiencies
Limitations
Vertical bone augmentation is difficult to achieve and related surgical techniques lack prospective clinical long-term documentation Interimplant papillae cannot predictably be reestablished as of yet
Conclusion
In conclusion, the concepts and therapeutic modalities do exist nowadays to solve by means of implants - elegantly as well as predictably a majority of clinical situations requiring the replacement of missing teeth in the esthetic zone, and the most promising novel approaches and perspectives can already be identified on a not too distant horizon.