Implant supported single-tooth replacements compared to contralateral natural teeth. Crown and soft tissue dimensions

Aesthetic perception of single implants placed in the anterior zone. A cross-sectional study

BACKGROUND

Several aesthetic indexes have been described to assess implant aesthetics. The aim of this study was to compare the aesthetic assessment made by dental professionals and students of single-tooth implants placed in the upper incisors.

MATERIALS AND METHODS

A cross-sectional survey study using a subjective questionnaire to assess the aesthetics in 3 implant supported single-tooth cases in the anterior maxilla was performed. The interviewed subjects were divided into 4 groups: dentist with experience in implant treatment, dentists without experience in implants and 3rd and 5th year dental students. The questionnaire consisted of 2 visual analogue scales (VAS) to evaluate aesthetics, the pink esthetic score (PES), the white esthetic score (WES) and the simplified papilla index (PI).

RESULTS

One-hundred dentists and one-hundred dental students filled the aesthetic assessment questionnaire. The results showed that the subjects were more critical than reference values, specially concerning prosthetic issues. The differences between groups were more obvious in the case with the best result. On the other hand, few differences were detected in the remaining cases. Regarding soft tissue and crown features, experienced dentists in implant dentistry were the most demanding. Cronbach's Alpha showed values ≥ 0,8 in the questionnaire in every case, which indicates an adequate reliability.

CONCLUSIONS

Dentists and dental students have different opinions when assessing aesthetics of single tooth implant supported cases. Experience and area of expertise seem to influence the evaluation of aesthetics in the anterior region.

Soft tissue augmentation procedures at second-stage surgery: a systematic review

OBJECTIVES

The aim of this systematic review was to evaluate the efficacy of different soft tissue augmentation/correction methods in terms of increasing the peri-implant width of keratinized mucosa (KM) and/or gain of soft tissue volume during second-stage surgery.

MATERIALS AND METHODS

Screening of two databases, MEDLINE (PubMed) and EMBASE (OVID), and hand search of related articles, were performed. Human studies reporting on soft tissue augmentation/correction methods around submucosally osseointegrated implants during second-stage surgery up to July 31, 2015 were considered. Quality assessment of the selected full-text articles was performed according to the Cochrane collaboration's tool to assess the risk of bias.

RESULTS

Overall, eight prospective studies (risk of bias: high) and two case series (risk of bias: high) were included. Depending on the surgical technique and graft material used, the enlargement of keratinized tissue (KT) ranged between -0.20 and 9.35 mm. An apically positioned partial-thickness flap/vestibuloplasty (APPTF/VP) in combination with a free gingival graft (FGG) or a xenogeneic graft material (XCM) was most effective. Applying a roll envelope flap (REF) or an APPTF in combination with a subepithelial connective tissue graft (SCTG), mean increases in soft tissue volumes of 2.41 and 3.10 mm, respectively, were achieved. Due to the heterogeneity of study designs, no meta-analysis could be performed.

CONCLUSIONS

Within the limitations of this review, regarding the enlargement of peri-implant KT, the APPTF in the maxilla and the APPTF/VP in combination with FGG or XCM in the lower and upper jaw seem to provide acceptable outcomes. To augment peri-implant soft tissue volume REF in the maxilla or APPTF + SCTG in the lower and upper jaw appear to be reliable treatment options.

CLINICAL RELEVANCE

The localization in the jaw and the clinical situation are crucial for the decision which second-stage procedure should be applied.

Agenesis of Maxillary Lateral Incisors: Treatment Involves Much More Than Just Canine Guidance

Objective:

In this study, we aimed highlight some clinical features present in patients whose maxillary lateral incisors are missing, and proposed more logical, rational and predictable solutions to inform decision making in rehabilitation procedures.

Methods:

Literature review and discussion.

Conclusion:

Choosing the best possible treatment for congenital absence of maxillary lateral incisors depends on the multidisciplinary diagnosis of facial, occlusal, functional and periodontal features. It also depends on the individual long-term stability, and it does not only rely on canine-guided disocclusion.

The influence of professional competence on the inter- and intra-individual esthetic evaluation of implant-supported crowns in the anterior maxilla

OBJECTIVES

Evaluation of the influence of professional competence on esthetic predictability of implant-supported crowns in the anterior maxilla and identification of objective factors allowing predictable planning for esthetic results.

MATERIALS AND METHODS

Sixty patients with 82 implants in the esthetic zone were included in this study. Width of keratinized mucosa, biotype, recessions, and papilla index according to Jemt as well as radiological bone loss were assessed. Study casts and photographs were obtained. Each patient as well as people with different level of expertise (laypersons, students and dentists) rated the esthetic satisfaction after final restoration on a scale (1-10). Correlations between esthetic assessments and previously documented clinical parameters were tested.

RESULTS

The study failed to show a significant relationship between the raters' level of dental expertise and their subjective esthetic evaluation. However, patients rated themselves much more favorable than the three evaluator groups did. A comparison of the clinical parameters with the esthetic evaluation revealed significantly more favorable ratings by the lay group in the presence of a wide attached gingiva (P = 0.021) than by the other groups and by the laypersons (P = 0.002), the dentists (P = 0.003), and students (P = 0.009) in the absence of recessions. The ratio of the implant crown length to the length of the contralateral crown had a negative effect on ratings for all three groups ([laypersons P < 0.001], [students P < 0.001] and [dentists P = 0.001]). The papilla index of the mesial papilla correlated significantly with laypersons' ratings (P = 0.036).

CONCLUSION

Earlier investigations are confirmed. Width of keratinized mucosa is a risk factor for esthetic predictability of implant-supported crowns in the anterior maxilla in laypersons' ratings. Furthermore, there is an association between the discrepancy of lengths of implant-supported single crowns to their contralateral natural teeth and esthetic satisfaction for all expertise levels.

Radiological and Biological Assessment of Immediately Restored Anterior Maxillary Implants Combined with GBR and Free Connective Tissue Graft

OBJECTIVES

Radiologic and biologic assessment of immediately restored Implants combined with guided bone regeneration (GBR) and free connective tissue graft.

METHODS

1-4 year retrospective study involving 34 patients treated with maxillary immediately restored anterior single-implants. Soft tissue dimensions, radiographic bone loss, and biological and prosthetic complications were assessed.

RESULTS

During the mean follow up period of 29 months the study group presented a mean mesial bone loss of 1.10 ± 0.39 mm (range: 0.5-2.4 mm), and mean distal bone loss of 1.19 ± 0.41 mm (range: 0.4-2.1 mm). Mean periimplant probing depth of 3.49 mm (SD ± 1.06) and 2.35 (SD ± 0.52) for the contralateral tooth (highly significant p < 0.001). Bleeding on probing was present in 29.4% of the examined implant supported crown sites and 10.4% of the contralateral teeth (p < 0.001).

CONCLUSIONS

Anterior maxillary single-tooth replacement, using GBR and connective tissue graft according to the concept of immediate implant placement, and non-functional restoration is an accepted treatment modality achieving favorable peri-implant soft tissue condition.

Survival rates and complication types for single implants provided at the Melbourne Dental School

BACKGROUND

Single implants and implant-supported single crowns (ISSCs) have become popular treatment modalities for single tooth replacement. Studies have identified high implant survival rates, but also many complications. The aim of this five-year retrospective study was to assess the survival rates, complication types and occurrences for single implants and ISSCs at the Melbourne Dental School (MDS) in Victoria, Australia.

METHODS

A search of the Royal Dental Hospital of Melbourne (RDHM) database was conducted for data on all implant treatment and reported complications during the period between 1 January 2005 and 31 December 2009. Complications were categorized into surgical, biological and restorative types.

RESULTS

A total of 622 implant fixtures and 444 ISSCs were inserted into 406 patients. Seventeen implants failed during the mean follow-up time of 2.18 years, yielding a 2.7% failure rate and an estimated one- and five-year survival rate of 98.8% and 93.9%, respectively. The cumulative surgical, biological and restorative complication incidences were 11.9%, 17.6% and 14.1%, respectively.

CONCLUSIONS

This study confirmed that single tooth replacement using implant therapy within a teaching environment had a high survival rate. However, complications frequently occurred. This article only provides a descriptive analysis. Correlation analysis between variables would provide greater insight into the causes of complications.

Interdental Implant Papillae Grow up with Temporary Abutment displaced at Monthly Intervals

Interdental papillae regeneration remains a challenge in implant dentistry in cases in which papillae are lost following tooth extraction. This report presents an implant case with missing 1st and 2nd premolars and total papillary loss. We performed immediate provisionalization to the first premolar implant with a temporary abutment and crown, whereas the second premolar was submerged. Crown contouring and modifications to the shape and size were performed once every month (the temporary abutment and crown disconnected three times during the 3-month healing period). At the end of the 3-month healing period, papillae regeneration was observed between the implant and the adjacent tooth and between the adjacent implants. Papillae regeneration is possible with temporary abutment and a composite material crown that is properly contoured and polished, even with several abutment removals during the healing period.

Missing upper incisors: a retrospective study of orthodontic space closure versus implant

Background

The aim of this retrospective study was to compare the esthetic, periodontal, and functional outcomes of orthodontic space closure versus implant substitution in patients with missing maxillary incisors 5 years after completion of treatment.

Methods

The study group consisted of ten patients treated with orthodontic space closure (six males, four females, mean age 19 ± 2.1 years at the completion of treatment) and ten patients treated with implant insertion (five males, five females, mean age 20 ± 1.4 years at the time of implant insertion). Tooth mobility, plaque index, probing depth, infraocclusion, open gingival embrasure (black triangle), and temporomandibular joint function were recorded at the 5.6 years follow-up. Self-perceived dental esthetic appearance was also evaluated through a visual analog scale (VAS) questionnaire. T-test was used to evaluate the data.

Results

All patients were equally satisfied with the appearance of their teeth 5.6 ± 0.4 years after the completion of treatment. No statistically significant differences were found in relation to the VAS scores of the subjects (P < 0.857). No significant differences were found in tooth mobility, plaque index (P < 0.632), and the prevalence of signs and symptoms of temporomandibular disorders. However, significant infraocclusion was noticed in all implant patients (P < 0.001). Probing depth was also significantly higher in implant patients (P < 0.001).

Conclusions

Orthodontic space closure and implant of missing maxillary incisors produced similar, well-accepted esthetic results. None of the treatments impaired temporomandibular joint function. Nevertheless, infraocclusion was evident in implant patients. Space closure patients also showed better periodontal health in comparison with implant patients.

Congenitally missing maxillary lateral incisors: update on the functional and esthetic parameters of patients treated with implants or space closure and teeth recontouring

Maxillary lateral incisor agenesis (MLIA) is a condition that affects both dental esthetics and function in young patients, and represents an important challenge for clinicians. Although several treatment options are available, the mesial repositioning of the canines followed by teeth recontouring into lateral incisors; or space opening/maintenance followed by implant placement have recently emerged as two important treatment approaches. In this article, the current and latest literature has been reviewed in order to summarize the functional and esthetic outcomes obtained with these two forms of treatment of MLIA patients in recent years. Indications, clinical limitations and the most important parameters to achieve the best possible results with each treatment modality are also discussed. Within the limitations of this review, it is not possible to assert at this point in time that one treatment approach is more advantageous than the other. Long-term followup studies comparing the existing treatment options are still lacking in the literature, and they are necessary to shed some light on the issue. It is possible, however, to state that adequate multidisciplinary diagnosis and planning are imperative to define the treatment option that will provide the best individual results for patients with MLIA.

Flap approaches in plastic periodontal and implant surgery: critical elements in design and execution

AIM

To identify critical elements in design and execution of coronally advanced flap, lateral positioned flap and their variations for the treatment of facial gingival recessions or peri-implant soft tissue dehiscences.

MATERIALS AND METHODS

Clinical studies were identified with both electronic and hand searches, and examined for the following aspects: flap design and incision techniques, flap elevation, root conditioning, flap mobility, flap stability and suturing. Moreover, prognostic factors for complete recession coverage were identified.

RESULTS

Some critical elements are evident in flap design and execution: the dimension and the thickness of tissue positioned over the denuded roots; the use on root surface of enamel matrix derivate; the stability and suturing of the flap in a position coronal to the cemento-enamel junction. The pre-determination of the clinical cemento-enamel junction, smoking status, operator surgical skills and the compliance to a supportive care programme have a role in obtaining and maintaining a complete root coverage.

CONCLUSIONS

Different flap approaches are available when performing periodontal plastic surgery, resulting in a great variability in clinical outcomes. The possibility of using pedicle flaps alone to achieve complete soft tissue coverage of facial implant dehiscence has not yet been investigated.

Evaluation of the influence exerted by different dental specialty backgrounds and measuring instrument reproducibility on esthetic aspects of maxillary implant-supported single crown

OBJECTIVE

To evaluate the influence exerted by different dental specialty backgrounds as well as the validity and reproducibility of the Pink Esthetic Score/White Esthetic Score (PES/WES) and the modified Implant Crown Aesthetic Index (mod-ICAI) on the assessment of esthetic aspects of maxillary implants supported single-tooth prosthesis.

MATERIAL AND METHODS

A total of fourteen examiners (Two orthodontists, two prosthodontists, two oral surgeons, two periodontists, two dental technicians, two dental assistants, and two postgraduate students in Implant Dentistry evaluated 20 photographs of single-implant-supported crowns and five photographs of unrestored teeth of esthetic zone in a two part study. The examiners assessed the photographs with each index (Pink Esthetic Score/White Esthetic Score and modified Implant Crown Aesthetic Index), twice with a week's interval. Orders of photographs were rearranged in the second assessment.

RESULTS

Kruskal-Wallis test results showed significant differences among all the six specialties (P ≤ 0.001). DAs and periodontists had significantly better ratings than other specialties with both indices. Prosthodontists had the lowest mean rank scores regardless of the index. Interobserver agreement was also lowest between the two prosthodontists (4-28%), rest of the groups had low-to-moderate agreement (20-80%) when limited allowance was accepted. With mod-ICAI, more interobserver agreement was noted within the specialty group than with PES/WES.

CONCLUSIONS

The PES/WES and the modified ICAI can be reliable estimates of esthetic outcomes. The assessor degree of specialization affected the esthetic evaluation with both the PES/WES and the modified ICAI. DAs and periodontists were identified to provide more favorable ratings than other specialties while prosthodontists were most critical in this study. With modified ICAI, more interobserver agreement within specialty resulted. The interexaminer agreement may be increased if more tolerance of 1-2 points is considered.

Optimal parameters for final position of teeth in space closure in case of a missing upper lateral incisor

Background

The aim of this study was to provide clinical indications for the correct management of appliances in space closure treatment of patients with agenesis of the upper lateral incisors.

Methods

Virtual setup for space closure was performed in 30 patients with upper lateral incisor agenesis. Tip, torque and in-out values were measured and compared with those of previous authors.

Results

In the upper dentition, the tip values were comparable to those described by Andrews (Am J Orthod 62(3):296-309, 1972), except for at the first premolars, which require a greater tip, and the first molars, a lesser tip. The torque values showed no differences except for at the canines, where it was greater, and the in-out values were between those reported by Andrews and those by Watanabe et al. (The Shikwa Gakuho 96:209-222, 1996) (except for U3 and U4).

Conclusions

The following prescriptions are advisable: tip 5°, torque 8° and in-out 2.5 for U1; tip 9°, torque 3° and in-out 3.25 for U3; tip 10°, torque −8° and in-out 3.75 for U4; and tip 5°, torque −8° and in-out 4 for U5. Andrews' prescription is suitable for the lower jaw, except for at L6. It is also advisable to execute selective grinding (1.33 ± 0.5 mm) and extrusion (0.68 ± 0.23 mm) on the upper canine during treatment, and the first premolar requires some intrusion (0.56 ± 0.30 mm).

Soft tissue conditions and marginal bone levels of implants with a laser-microtextured collar: a 5-year, retrospective, controlled study

AIM

To compare clinical and radiographic outcomes of implants with a Laser-Lok®-microtextured collar to implants with a resorbable blast textured (RBT) collar after a 5-year follow-up period.

MATERIALS AND METHODS

Thirty-four implants with a Laser-Lok®-microtextured collar (test group [TG]) and 31 implants with an RBT collar (control group [CG]) were placed in 45 non-smoking, periodontally healthy patients. The full-mouth plaque score, full-mouth bleeding score, number of sites with plaque, and the number of sites with bleeding on probing (BOP) were recorded at baseline, and at 1-, 2-, 3-, 4-, and 5-year follow-up. Probing depth (PD) and mucosal recession were assessed at baseline and after the 5-year follow-up period. The radiographic marginal bone loss (MBL) was calculated by subtracting the bone level at the time of crown insertion from the bone level at the 5-year follow-up.

RESULTS

An implant survival rate of 94% and of 90% was reported for the TG and the CG, respectively. No statistical differences were found between the study groups for presence of plaque (10.1% vs. 25%) or for number of sites with BOP (10.3% vs. 23%). The differences between both study groups were statistically significant for mean MBL (0.81 ± 0.24 vs. 2.02 ± 0.32 mm), mean PD (2.32 ± 0.44 vs. 4.25 ± 0.87 mm), and mean mucosal recession (0.16 ± 0.3 vs. 0.22 ± 0.3 mm).

CONCLUSIONS

Within the limitations of this study, results suggest that the laser-microtextured implant collar surface may provide more favorable conditions for the attachment of hard and soft tissues, and reduce the level of MBL.

Papilla dimension and soft tissue level after early vs. delayed placement of single-tooth implants: 10-year results from a randomized controlled clinical trial

AIM

To present the10-year esthetic outcome data for single-tooth implants placed early or delayed after tooth extraction.

MATERIAL AND METHODS

Forty-four patients randomly allocated to two equal size groups were treated with a single-tooth implant approximately 10 days (Ea; N = 22), or 3 months (De; N = 22) after tooth extraction. Healing abutments were mounted after 3 months of submerged healing, and metal-ceramic crowns cemented after one additional month. Presence of buccal bone defects was registered at the second-stage surgery. Patients attended control visits 1 week and 1-1.5 years after mounting of the crown and 5 and 10 years after implant placement. Marginal bone level at the implant and the adjacent teeth as well as the distance between the implant and the teeth were measured in standardized periapical radiographs. The papilla dimension and clinical crown height (CCH) were assessed on clinical photographs by an experienced prosthodontist.

RESULTS

Two Ea and one De implants failed to osseointegrate. Twenty-eight patients (13 Ea and 15 De) who attended all four control visits were included in the data analysis. Complete papilla fill interproximally was achieved in one-third of the cases and an appropriate clinical crown height in <60% after 10 years. Although not statistically significant, early-placed implants tended to be superior to delayed-placed implants regarding soft tissue appearance just after crown delivery and after 10 years. An improvement in papilla dimensions was seen during the follow-up period for both groups while the CCH was unchanged. The implant region (anterior vs. posterior) did not significantly influence the papilla or CCH scores while younger patients (<50 years of age) received significantly better papilla scores than older patients (≥ 50 years). An apically located bone level at the tooth neighboring the implant influenced negatively the papilla dimension. In contrast, the presence of a bone defect buccally to the implant at second-stage surgery did not have a negative impact on the CCH 10 years after implant placement.

CONCLUSION

Early placement of single-tooth implants after tooth extraction performed equally to delayed placement in regard to the esthetic outcome of the soft tissues after 10 years in function.

Interdisciplinary rehabilitation of a root-fractured maxillary central incisor: A 12-year follow-up case report

Single-tooth implantation has become a common treatment solution for replacement of a root-fractured maxillary incisor in adults, but the long-term esthetic results can be unfavorable due to progressive marginal bone loss, resulting in gingival recession. In this case report, a maxillary central incisor with a root fracture in its apical one-third was orthodontically extruded and extracted in a 21-year-old female. Implant surgery was performed after a 3-month healing period, and the final crown was placed about 12 months after extraction. After 12 years, favorable osseous and gingival architectures were visible with adequate bone height and thickness at the buccal cortical plate, and no gingival recession was seen around the implant-supported crown. Although modern dentistry has been shifting toward simplified, clinical procedures and shorter treatment times, both general dentists and orthodontists should be aware of the possible long-term esthetic advantages of orthodontic extrusion of hopelessly fractured teeth for highly esthetically demanding areas and should educate and motivate patients regarding the choice of this treatment solution, if necessary.

Impact of cone-beam computed tomography on implant planning and on prediction of implant size

The aim was to investigate the impact of cone-beam computed tomography (CBCT) on implant planning and on prediction of final implant size. Consecutive patients referred for implant treatment were submitted to clinical examination, panoramic (PAN) radiography and a CBCT exam. Initial planning of implant length and width was assessed based on clinical and PAN exams, and final planning, on CBCT exam to complement diagnosis. The actual dimensions of the implants placed during surgery were compared with those obtained during initial and final planning, using the McNemmar test (p < 0.05). The final sample comprised 95 implants in 27 patients, distributed over the maxilla and mandible. Agreement in implant length was 50.5% between initial and final planning, and correct prediction of the actual implant length was 40.0% and 69.5%, using PAN and CBCT exams, respectively. Agreement in implant width assessment ranged from 69.5% to 73.7%. A paired comparison of the frequency of changes between initial or final planning and implant placement (McNemmar test) showed greater frequency of changes in initial planning for implant length (p < 0.001), but not for implant width (p = 0.850). The frequency of changes was not influenced by implant location at any stage of implant planning (chi-square test, p > 0.05). It was concluded that CBCT improves the ability of predicting the actual implant length and reduces inaccuracy in surgical dental implant planning.

Peri-implant soft tissue colour around titanium and zirconia abutments: a prospective randomized controlled clinical study

OBJECTIVES

To objectively determine the difference in colour between the peri-implant soft tissue at titanium and zirconia abutments.

MATERIALS AND METHODS

Eleven patients, each with two contralaterally inserted osteointegrated dental implants, were included in this study. The implants were restored either with titanium abutments and porcelain-fused-to-metal crowns, or with zirconia abutments and ceramic crowns. Prior and after crown cementation, multi-spectral images of the peri-implant soft tissues and the gingiva of the neighbouring teeth were taken with a colorimeter. The colour parameters L*, a*, b*, c* and the colour differences ΔE were calculated. Descriptive statistics, including non-parametric tests and correlation coefficients, were used for statistical analyses of the data.

RESULTS

Compared to the gingiva of the neighbouring teeth, the peri-implant soft tissue around titanium and zirconia (test group), showed distinguishable ΔE both before and after crown cementation. Colour differences around titanium were statistically significant different (P = 0.01) only at 1 mm prior to crown cementation compared to zirconia. Compared to the gingiva of the neighbouring teeth, statistically significant (P < 0.01) differences were found for all colour parameter, either before or after crown cementation for both abutments; more significant differences were registered for titanium abutments. Tissue thickness correlated positively with c*-values for titanium at 1 mm and 2 mm from the gingival margin.

CONCLUSIONS

Within their limits, the present data indicate that: (i) The peri-implant soft tissue around titanium and zirconia showed colour differences when compared to the soft tissue around natural teeth, and (ii) the peri-implant soft tissue around zirconia demonstrated a better colour match to the soft tissue at natural teeth than titanium.

Single implant-supported crowns in the aesthetic zone: patient satisfaction with aesthetic appearance compared with appraisals by laypeople and dentists

OBJECTIVE

To appraise the patients' satisfaction with aesthetic outcomes following an implant restoration in the anterior maxilla as compared to appraisals made by dentists and laypeople.

MATERIAL AND METHODS

Randomly selected patients (n = 116) restored with an implant-retained crown in the anterior maxilla were invited to rate their satisfaction with aesthetic outcomes using a questionnaire containing seven criteria, each graded from excellent to poor. Projected images of the patient smiles were appraised by dentists (n = 8) and laypeople (n = 6) using the same assessment criteria in a room setting. In addition, the laypeople judged the same cases on printed 10 × 15 cm photographs in a separate setting. Jemt papilla scores, pink aesthetic score (PES) and white esthetic score (WES) were assigned by the dentists. Differences in the levels of satisfaction between the patient, and appraisals by the dentists and the laypeople were compared using non-parametric statistical tests.

RESULTS

Patients' opinions of their aesthetic appearance following the placement of a single implant-supported crown in the aesthetic zone were in general very favourable. The laypeople were more critical than the dentists when the aesthetic outcomes were appraised on magnified images projected onto a screen. Laypeople became less critical when evaluating the aesthetic outcomes on printed photographs compared to appraisals on a screen. Patient satisfaction with their aesthetic appearance differed from dentists' and laypeople's appraisals.

CONCLUSION

Factors other than the actual aesthetic outcome itself appear to influence patients' satisfaction with their end results. Laypeople's appraisal is influenced by the magnification and method used for appraising the aesthetic outcomes.

Smile attractiveness of patients treated for congenitally missing maxillary lateral incisors as rated by dentists, laypersons, and the patients themselves

STATEMENT OF PROBLEM

Esthetic judgments can help dental professionals better understand how attentive people are to their own smiles and those of others.

PURPOSE

The purpose of this study was to evaluate the smile attractiveness of patients treated for maxillary lateral incisor agenesis compared with that of individuals with a complete dentition.

MATERIAL AND METHODS

Photographs were made of the smiles of patients with maxillary lateral incisor agenesis who were treated with space closure and teeth recontouring (n=26) or space opening and implants (n=20) and of a control group with a complete dentition (n=22). Both laypersons and dentists assessed smile attractiveness by using a visual analog scale. Patients and controls also assessed the level of satisfaction with their own smile. Assessments were performed twice, and the reliability of the method was determined with Cronbach α and intraclass correlation. Multifactorial and 1-way ANOVA were used to analyze smile attractiveness and participant satisfaction, followed by the Bonferroni post hoc test (α=.05).

RESULTS

Attractiveness ratings by dentists and laypersons did not differ significantly among the study groups (P=.64). The ratings of male dentists and female laypersons differed significantly from those of other evaluators (P=.01). Patients with space closure and teeth recontouring were significantly more satisfied than controls (P=.002). No significant differences were found between the patients with implants and controls or between the patients with implants and those with space closure and teeth recontouring.

CONCLUSIONS

The smiles of patients with maxillary lateral incisor agenesis were judged to be as attractive as those of the controls. Male dentists were the most critical raters, closely followed by female laypersons. All participants had high levels of satisfaction with their own smile; patients treated with space closure and teeth recontouring were the most satisfied.

Is buccolingual angulation of maxillary anterior implants associated with the crestal labial soft tissue thickness?

We aimed to examine the relationship between crestal labial soft tissue thickness (CLSTT, measured with a digital calliper at the crestal level of casts) and implant buccolingual angulation (IBLA). The records of 22 females and 10 males treated with two bone-level implants (3.3-4.6mm) between the maxillary canines were evaluated. IBLA was recorded as cingulum, incisal, or labial based on the screw access hole position on provisional restorations. Postoperative implant labial bone thickness (ILBT) at the crestal (2mm from crest) and mid-implant levels were measured on sectional cone beam computed tomography scans. The mean (SD) ridge width at the crestal level was 6.81 (0.98) mm. Mean (SD) CLSTT for implants with cingulum, incisal, and labial angulations were 2.98 (0.84), 2.24 (0.51), and 1.71 (0.72) mm, respectively. Significant differences were detected between CLSTT of implants with cingulum and incisal, as well as cingulum and labial angulations (P<0.01). Of implants with cingulum, incisal, and labial angulations, 3.4%, 20%, and 53.3%, respectively, had a CLSTT<2mm. Overall, 74.2% of CLSTT variance could be predicted by IBLA and ILBT at the crestal and mid-implant levels. A significant association between CLSTT and IBLA was noted when ILBT (crestal level) was <2mm (P<0.01). Implants with labial angulations carry a higher risk of soft tissue complications when the crestal implant labial bone thickness is <2mm.

Dimensions of the healthy gingiva and peri-implant mucosa

OBJECTIVE

To determine the dimensions of the soft tissue cuff present at various aspects of teeth and to compare these dimensions to those of the mucosa surrounding single implants.

MATERIAL AND METHODS

Fifty volunteers were recruited that were ≥25 years of age and exhibited no signs of (i) untreated caries; (ii) loss of periodontal tissue support in the incisor, canine, and premolar regions; (iii) systemic or local disease. Furthermore, among the 50 patients recruited (iV), 27 had one single implant in the maxilla with teeth present mesial and/or distal to the implant. Probing pocket depth (PPD) and transmucosal sounding depth (TS) were assessed by five experienced, carefully calibrated examiners and with the use of a periodontal probe at the proximal (mesial, distal) and flat (facial, buccal and palatal/lingual) surfaces of all teeth/implants. The width of the keratinized mucosa (KM) was also determined.

RESULTS

It was demonstrated that (i) PPD and TS were greater at proximal than at flat surfaces at both tooth and implant sites. In addition, both PPD and TS were deeper at implant than at tooth sites. The TS values documented that the cuff of healthy soft tissue that surrounded a tooth varied between 2 mm at flat surfaces and 4 mm at proximal surfaces, while at implant sites, the mucosa at proximal as well as flat surfaces was 1-1.5 mm greater.

CONCLUSION

The probing pocket depth (PPD) and the transmucosal sounding depth (TS) values were greater at proximal than at flat, that is, facial/palatal (lingual) surfaces at tooth sites and frequently also at implant sites. Furthermore, the PPD and the TS dimensions were greater at implant than at adjacent tooth sites.

Fresh-Socket Implants of Different Collar Length: Clinical Evaluation in the Aesthetic Zone

BACKGROUND

The aim of this clinical study was to compare clinical evaluations of implants in the aesthetic zone with smooth collars of different length.

MATERIALS AND METHODS

Sixty-six patients requiring extractions of one, two, or three teeth in the aesthetic zone of the maxilla were enrolled in this study. Ninety-four implants were positioned and were loaded immediately after tooth extraction. Forty-seven implants with a short smooth collar of 0.5 mm (SCI) and 47 implants with a long smooth collar of 1.8 mm (LCI) were utilized in this study and were placed using a nonsubmerged approach. Clinical (gingival index, modified plaque index, modified bleeding index, probing depth, gingival recession) and intraoral digital radiographic parameters were measured at baseline and after 6, 12, 24, and 36 months of healing to evaluate crestal bone loss levels over time.

RESULTS

After a follow-up period of 36 months, a survival rate of 100% was reported. The SCI group showed a mean bone loss of 1.07 ± 0.38 mm at 12 months and 1.09 ± 0.38 mm at 36 months. The LCI group showed a mean bone loss of 0.46 ± 0.14 mm at 12 months and 0.53 ± 0.12 mm at 36 months. After the 36-month follow-up period, both groups showed stable bone levels over time. Statistically significant differences were found between groups (p < .05). No statistically significant differences were found between SCI and LCI groups with regard to clinical parameters over time.

CONCLUSIONS

This study revealed significant differences in radiographically observed marginal bone loss between the two types of implant with different smooth-collar lengths, but no differences in gingival vestibular margin outcome were observed.

Soft Tissues Changes After Immediate and Delayed Single Implant Placement in Esthetic Area: A Systematic Review

The aim of the present study was to conduct a systematic review of the literature to compare soft tissue aspects of immediate and delayed implant placement in esthetic areas. This review of literature was conducted in the following databases: MEDLINE (PubMed), Lilacs, Scielo, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL). For those studies that met the inclusion/exclusion criteria, the results were analyzed and summarized according to the treatment protocol used for implant placement. The primary parameters taken into consideration were papilla level (PL) and marginal mucosa level (MML) around implants. Four randomized controlled trials (RCT) were selected for analysis, but all were deemed as being of poor quality according to quality assessment. No studies reported any statistically significant differences concerning the soft tissue esthetic parameters analyzed around immediate or delayed implants at any follow-up periods reported. However, PL results seemed to be more reliable than were MML results, due to the PL standardization of the method of analysis, which showed a tendency for poorer results around immediately placed implants. In conclusion, although the results are based on only a few poor quality RCTs, both treatment options for implant placement demonstrated similar outcomes in the esthetic area, especially when PL was considered.

Patient satisfaction and esthetic outcome after immediate placement and provisionalization of single-tooth implants involving a definitive individual abutment

OBJECTIVES

To assess patient satisfaction and esthetic outcome after immediate placement and provisionalization of single-tooth implants involving a definitive individual abutment and a provisional crown followed by later placement of a definitive crown.

MATERIALS AND METHODS

In private practice, a single-tooth implant was placed immediately after tooth extraction in the esthetic zone of 54 patients. A definitive individual abutment and a provisional crown were mounted in the same visit. The definitive crown was placed after a mean period of 7 months. After a mean follow-up period of 33 months, the subjective and professional evaluation of the total implant treatment, peri-implant soft tissues, and implant crown were assessed on a 10-cm visual analog scale (VAS). The professional esthetic treatment outcome was also evaluated using pink esthetic score (PES), white esthetic score (WES), and total score of PES/WES.

RESULTS

The evaluation of total implant treatment, peri-implant soft tissues, and implant crown demonstrated a significantly higher subjective than professional score for all 3 parameters (P < 0.001), for example, for the overall treatment, the mean scores were 9.4 and 7.0, respectively. A significant positive correlation was revealed between the professional VAS scores and the PESs and WESs.

CONCLUSIONS

Immediate placement and provisionalization of single-tooth implants involving a definitive individual abutment and provisional crown followed by later placement of a definitive crown demonstrated high subjective and professional satisfaction. Generally, the professionals seem to be more critical than the patients. A strong correlation was observed between the professional VAS scores and the PES and WES scoring systems.

Aesthetic Analysis of an Implant-Supported Denture at the Cleft Area

Objective

To evaluate the aesthetics of an implant-supported denture at the cleft area, comparing the peri-implant tissues and prosthetic crown with the contralateral tooth.

Settings

Hospital for Rehabilitation of Craniofacial Anomalies, Bauru, São Paolo, Brazil.

Patients

A total of 39 individuals of both genders, with complete unilateral cleft lip and palate, who received secondary alveolar bone graft and were rehabilitated with single implant-supported dentures at the area of the missing maxillary lateral incisor after completion of orthodontic treatment.

Interventions

The following parameters were analyzed in follow-up sessions: length and width of prosthetic crown and contralateral tooth, characteristics of implants, filling of interproximal space by the papilla, and smile height of the patients.

Results

The implant-supported prosthetic crowns were longer than the contralateral tooth ( p < .001). Among the 78 papillae analyzed, 29 (37.17%) received a score of 3; 32 (41.02%) papillae had a score of 2; and 17 (21.79%) received a score of 1. Concerning the smile height, among the 39 patients analyzed, 23 (56.41%) had a medium smile, 15 (38.46%) had a high smile, and two (5.12%) presented a low smile.

Conclusion

The use of dental implants to rehabilitate the edentulous cleft area is an excellent option. However, adequate evaluation of the bone quantity and quality, positioning and shape of adjacent teeth, smile height, and patient expectations should be considered to achieve success and avoid aesthetic deformities such as elongated teeth and absence of gingival papillae.

Correlation between subjective and objective evaluation of peri-implant soft tissue color

PURPOSE

While extensive references are present in the literature dealing with the correlation between subjective and objective evaluation of tooth shade, there is a lack of information on this correlation regarding the soft tissue color. The purpose of this experimental study was to verify whether a correlation between the objective and subjective evaluation exists in analyzing soft tissue color.

MATERIAL AND METHODS

A total of 39 patients with at least one implant-supported restoration in the anterior maxilla were included in the study. The shade of the peri-implant mucosa was compared with the shade of the gingiva at the adjacent tooth in a subjective and in an objective manner. The subjective evaluation was performed by five dental professionals (prosthodontist, periodontist, general dentist, dental hygienist, and dental assistant) in a subjective scale (ranging from 1 to 4). The objective evaluation was obtained by means of a spectrophotometer in a CIELAB* Color Scale, and the differences were evaluated through formula ΔE=[(ΔL)²+(Δa)²+(Δb)²]¹/². To correlate the subjective and the objective evaluation, for each arithmetical median value of the subjective evaluation, a mean value of objective evaluation has been calculated, and the Spearman's rank correlation coefficient has been used. The differences have been also analyzed for thin and thick tissue biotypes.

RESULTS

The mean ∆E value for the subjective evaluation between peri-implant soft tissue and adjacent tooth gingival tissue was ∆E = 9.74. Also, mean ∆E values of 10.35 and 7.54 have been reported for thin and thick biotypes, respectively. Mean values of ∆E = 6.63, 8.54, and 15.54 were presented by median values of 1 (perfect matching), 2 (good matching), and 3 (clinically distinguishable), respectively. The threshold for the distinction of differences of mucosal color by the human eyes between perfect or good matching and distinguishable values has been calculated in ∆E = 8.74.

CONCLUSIONS

Within the limitation of this study, a correlation between the subjective and the objective evaluation of the peri-implant soft tissue exists and the threshold for the distinction of mucosal color differences between perfect or good matching and distinguishable subjective values has been calculated in ∆E = 8.74 in the objective evaluation.

Papillae alterations around single-implant restorations in the anterior maxillae: thick versus thin mucosa

To evaluate the papilla alterations around single-implant restorations in the anterior maxillae after crown attachment and to study the influence of soft tissue thickness on the papilla fill alteration. According to the inclusion criteria, 32 patients subjected to implant-supported single-tooth restorations in anterior maxillae were included. The patients were assigned to two groups according to the mucosal thickness: (i) group 1, 1.5 mm s mucosal thickness 3 mm; and (ii) group 2, 3 mm<mucosal thickness 4.5 mm.Assessments of interproximal papillae at the time of crown placement (baseline) and at 6-month post loading (follow-up) were made by two prosthodontists using papilla fill index (PFI). The mean mucosal thickness was (2.49±_0.31) mm (group 1) and (3.81±_0.31) mm(group 2) for the two groups respectively. A significant difference in PFI between the groups was detected at the baseline (P<0.001).PFI improvements over time occurred after 6-month follow-up irrespective of the groups. When compared to group 1, the likelihood to obtain papilla fill was significantly higher for group 2 with an odds ratio of 6.05 (P<0.001). The interproximal papilla level around single-implant restorations could improve significantly over time after 6-month restoration according to PFI assessment. The thicker mucosa before implant placement implied a more favorable esthetic outcome in papilla alteration.

Congenitally missing maxillary lateral incisors: functional and periodontal aspects in patients treated with implants or space closure and tooth re-contouring

To evaluate functional and periodontal aspects in patients with unilateral or bilateral congenitally missing maxillary lateral incisors, treated with either implants or space closure and tooth re-contouring. The sample consisted of 68 volunteers, divided into 3 groups: SCR - space closure and tooth re-contouring with composite resin (n = 26); SOI – implants placed in the area of agenesis (n = 20); and CG - control group (n = 22). A modified Helkimo questionnaire and the Research Diagnostic Criteria for Temporomandibular Disorders were used by a single, previously calibrated evaluator to assess signs and symptoms of temporomandibular joint disorder. The periodontal assessment involved the following aspects: plaque index, bleeding upon probing, pocket depth greater than 3 mm, gingival recession, abfraction, periodontal biotype and papilla index. The data were analyzed using Fisher's exact test and the nonparametric Mann-Whitney and Kruskal-Wallis tests (α=.05). No differences in periodontal status were found between treatments. None of the groups were associated with signs and symptoms of temporomandibular joint disorder. Both treatment alternatives for patients with congenitally missing maxillary lateral incisors were satisfactory and achieved functional and periodontal results similar to those of the control group.

Immediate placement and restoration of implants in the aesthetic zone with a trimodal approach: soft tissue alterations and its relation to gingival biotype

PURPOSE

The aim of this prospective study was to evaluate the soft tissue changes around implants in the aesthetic zone, placed under a trimodal approach (immediate post-extraction placement, flapless, and immediate provisional restoration) and its relationship to gingival/periodontal biotype of the patient.

MATERIALS AND METHODS

The sample consisted of 14 patients from two private practices that were in need of a tooth extraction in the anterior maxillary region (cuspid to cuspid) and were candidates to a replacement with a dental implant. An initial measurement (baseline) of the position or the mesial and distal papillae and gingival zenith was made at this time, with a rigid dental-supported stent and an electronic precision caliper, able to the second tenth of a millimeter; after careful tooth extraction, the periodontal thickness, at a point 5 mm apical to de gingival buccal margin, with an analogical thickness gauge, able to one tenth of a millimeter. Once the implant was inserted an immediate provisional restoration was delivered. To evaluate the soft tissue changes measurements were repeated at 3, 6, and 12 months. A statistical analysis was performed to evaluate the changes in the gingival margin around the implant restorations and to identify a possible correlation to patient's periodontal thickness.

RESULTS

All 14 patients received Straumann (®) implants (9 Tissue Level [TL] Regular Neck [RN], 2 TL Narrow Neck [NN], 2 Bone Level [BL] Narrow Crossfit [NC], and 1 BL Regular Crossfit [RC]). All implants integrated and none had any biological complications. Three provisional restorations presented screw loosening and retightened once and one loss retention and was recemented once. In one patient, with a severe bruxing habit, the final restoration suffered screw loosening and was retightened. Of the final restorations, 12 were screw-retained and 2 cemented on custom-made Zirconia abutments. A mean recession of the buccal margin of 0.45 mm was recorded at 12 months ( ± 0.25 mm). An acceptable papilla level was present in all cases at 1 year, with mean changes of 0.38 mm ( ± 0.60) for the mesial and 0.80 mm ( ± 0.90) of the distal papilla, respectively. No correlation could be established between the soft tissue changes and the periodontal biotype of the patient.

CONCLUSIONS

Within the limitations of this study, the good aesthetic outcome and minimal complications seem to validate the trimodal approach protocol as a reliable and simple protocol to place and restore immediate implants in the aesthetic zone. No correlation between the patient's gingival biotype and the soft tissue alterations could be established. Additional studies are needed to verify long-term aesthetic results with this approach and to better define and quantify biotypes.