Developing optimal peri-implant papillae within the esthetic zone: guided soft tissue augmentation

Aesthetic outcomes of different materials for delayed, single-tooth restorations for immediately placed implants. A randomized controlled clinical trial

OBJECTIVES

The aim of this study is to compare the aesthetic outcomes of metal porcelain (C), lithium disilicate (T1) and porcelain-layered zirconium (T2) immediate implant-supported single crowns in the anterior maxilla.

MATERIALS AND METHODS

Forty-five immediate dental implants were provided for 45 patients that required the extraction of a single tooth in the anterior maxilla. A temporary prosthesis was provided at 8 weeks after placement followed by the final prosthesis at 24 weeks post-implantation. The patients were randomly allocated into 3 groups: 15 patients in the control group (C) received a metal-porcelain restoration, 15 patients (T1) received a lithium disilicate (LD) restoration and 15 patients (T2) received a porcelain-layered, zirconium (Z) restoration. Pink (PES) and White (WES) esthetic scores, radiographic bone levels, periodontal parameters and patient's esthetic satisfaction using a visual analogue scale (VAS) were evaluated at the time of final restoration placement (t0) and at 12-months post-loading (t12).

RESULTS

No implants were lost during the duration of this study. Statistically significant higher WES and VAS scores (p < 0.05) were recorded in T1 vs C and T1 vs T2 groups respectively. Similar radiographic bone levels and periodontal parameters were recorded in all groups.

CONCLUSION

Within the limitations of this study, it was concluded that T1 restorations provided better WES outcomes when compared to C restorations and better VAS scores when compared to T2 restorations at 12 months post-loading. Besides, different material interphases did not have an impact in PES, bone levels or periodontal parameters.

CLINICAL RELEVANCE

There is limited data comparing aesthetic outcomes of implant supported single crowns made of different ceramic materials based on accepted and comparable indexes and the evaluation of the patient's perspective regarding these aesthetic outcomes.

Smile Design: Mechanical Considerations

Smile designing refers to the cosmetic and esthetic dental reconstruction that is visible during smiling. The use of modern digital tools requires adequate knowledge about the tooth shape and shade principles. Mechanical, biological, and psychological factors should be understood and tailor an individualized treatment accordingly to achieve pleasing esthetic outcomes. Dental therapy is becoming more appearance-driven, and thus, both patients and dental clinicians mainly emphasize on cosmetic dental and facial aspects of treatments.

In situ soft tissue regeneration using periosteal distraction: A preliminary study in the rat calvarial model

Aim

In this study, we aimed to evaluate soft tissue generated by periosteal distraction.

Background

Management of soft tissue defects represents a challenge in dentistry. Previous periosteal distraction studies documented partial fill of the distraction space with newly-generated bone and fibrous connective tissue.

Material and methods

Titanium meshes were inserted in subperiosteal tunnels in the calvaria of 20 rats through coronal incision. The devices were immediately activated after insertion by elevation of one side at 1 mm/day for 3 days. Rats were then divided into two groups (n = 10). Animals were sacrificed after 2 weeks (Group 1) and after 4 weeks (Group 2). Distraction sites specimens were embedded in paraffin and analyzed histologically and histomorphometrically.

Results

In both groups, new periosteum was regenerated and covered the original bone surface in the distraction site. Distraction spaces showed a predomination of hyper-vascularized connective tissue and little new bone formation near to the stable end of the device. The 4-week findings showed more organized collagen fibers with less vascularity compared to the 2-week findings.

Conclusion

The periosteal distraction technique can effectively regenerate connective tissue. It may open a new modality in the guided tissue regeneration for soft tissue augmentation.

Immediate implant placement in fresh alveolar sockets with a minimal split-thickness envelope flap: A randomised controlled clinical trial

OBJECTIVES

Comparing PES/WES scores, modified success rate, survival, success, buccal bone thickness and patient-reported outcomes of immediate dental implants placed in fresh alveolar sockets using a flap or a minimal split-thickness envelope flap (MSTEF).

MATERIALS AND METHODS

Implants following random assignment into a flap or MSTEF group were placed immediately in anterior and premolar areas. Guided bone regeneration and autogenous connective tissue graft were used in all cases. A temporary prosthesis was provided followed by the final prosthesis at 16-18 weeks. Success and survival rates together with radiographic buccal bone thickness and patient satisfaction were evaluated at 12-month post-loading. The aesthetic outcome was evaluated through the Pink (PES) and White (WES) Aesthetic Score by 8 blind clinicians of different training background and incorporated in modified success criteria.

RESULTS

28 implants were placed on 28 patients. No statistically significant differences were noted in PES (10.54 control versus 10.80 test), WES scores (6.97 control versus 6.95 test) or success criteria including aesthetic parameters (modified success criteria) for the different specialty groups (Range 69%-92%). In addition, no statistically significant differences were noted in survival (100%), success (100%), buccal wall thickness between control (0.72 ± 0.22) and test group (0.92 ± 0.31) and patients' reported outcomes.

CONCLUSIONS

Immediate dental implant treatment with flap/ MSTEF provided similar mean PES/WES scores, modified success rate, survival, mean buccal bone levels and patients' satisfaction. However, aesthetic failures were common in both groups.

A Novel Solution to Treat Unesthetic Implant Restorations in the Esthetic Zone: A Case Report

INTRODUCTION

Soft tissue dehiscences and deficiencies can occur around implants especially when they are malpositioned. There is a dearth of information on burying these fixtures and bridging over them to improve the prosthetic result. The patient presented with a very functional fixed dental prosthesis (FDP) from #7 to #10 which had been in place for 20 years. The patient requested replacement of the restoration for a better esthetic outcome.

CASE PRESENTATION

The FDP was intact and did not need replacement other than for esthetic improvement. Implants were placed in the #8,9 sites and complications developed. After multiple hard and soft tissue surgeries, the case worsened. It was referred to a periodontist who reconstructed the site to ideal tissue levels. The patient had a very high smile line showing all of the soft tissue framework around the missing teeth. The prosthodontist and periodontist decided to leave the implants buried and bridged over them which resulted in an excellent esthetic outcome.

CONCLUSION

This case points out the importance of considering all possible treatment plans and involving the patient in the final decision. The seemingly apparent obvious plan would have been to restore the implants and try to achieve an esthetic result. However, after the implants were placed and developed complications, the decision to bury them improved the probability of a better esthetic outcome. The gingival levels and height of papillae were esthetically more acceptable with an FDP than what would have resulted if the fixtures were re-uncovered and restored.

Comparison between two different techniques for peri-implant soft tissue augmentation: Porcine dermal matrix graft versus tenting screw

BACKGROUND

The thickness of the soft tissues around dental implants is crucial for both the preservation of the marginal bone and esthetic profile. Many authors have showed the thickened soft tissues favor a better peri-implant bone stability; however, different thickening techniques can be used for this aim.

METHODS

Forty-seven patients were enrolled in this study, each one had one implant included in this analysis. According to the thickening procedure, patients were assigned into group A (porcine dermal matrix, n = 24) or B (healing abutment used as tenting screw to sustain the soft tissues, n = 23), soft tissue thickness was measured after flap elevation in a standardized way. Six months after implant placement, implants were uncovered and soft tissue thickness measured again.

RESULTS

At second stage, 6 months after implant placement, the mean vertical thickness was 3.01 ± 0.58 mm in group A and 2.25 ± 0.53 mm in group B. The difference between the two groups at 6 months was significant (P < 0.001). The mean vertical gain in group A was 1.33 ± 0.71 mm, whereas it was 0.43 ± 0.55 mm in group B. This difference was also statistically significant (P < 0.001).

CONCLUSION

The use of a healing abutment for "tenting effect" has limited efficacy to obtain a significant increase in soft tissue thickness. The use of a porcine dermal matrix at time of implant placement is effective to thicken peri-implant tissues.

Regenerative Surgical Flap to Maintain Interdental Papilla around Dental Implant

The modified surgical flap technique for placement of implant in the anterior maxilla has been described. The flap design has been used to achieve optimal soft-tissue contour for implant restoration. A modification in the surgical technique has been employed with the intention to preserve the interdental papilla, which is the key to the maintenance of hygiene and esthetics around anterior implants. This, in turn, prevents black triangles and improves soft-tissue contours. The modified surgical flap method maintains both functional and esthetic values.

[Treat or prevent the loss of inter-dental papillae]

INTRODUCTION

Contemporary literature agrees that orthodontic results can no longer be limited to occluso-functional success. The integration of the teeth into a healthy periodontium is essential to good treatment finish and durability.

MATERIALS AND METHODS

This article proposes to describe the orthodontic physiopathological and iatrogenic lesions leading to the opening of black triangles in place of the inter-dental papillae. It goes on to discuss different periodontal, prosthetic as well as orthodontic reconstruction protocols.

RESULTS

This last point, supported by a biological rationale well-known to periodontologists, is described using clinical cases.

Comparison of interdental papilla around single implants in the anterior maxilla between two implant systems: A cohort study

Background. In successful replacement of a tooth with a dental implant, soft tissue esthetic is as important as stability and function of the implant. Quality and quantity of the peri-implant mucosa can influence esthetic outcomes. This study assessed implant esthetic success of two different implant systems. In this regard the interdental papilla was evaluated and the relation-ship between implant type and crestal bone loss adjacent to implant was assessed.

Methods. Eighteen patients (11 males, 7 females) with a total of 18 implants participated in this historical cohort study. Patients were divided into two groups based on the type of implants: Implantium group and SPI group; 36 interproximal papillae were evaluated photographically, using Jemt’s papillary presence index (PPI). Radiographic analysis was carried out to find out the relation between bone loss and type of implant. Analysis of data was performed with SPSS 18, using Fisher's exact test, independent t-test, Spearman's correlation coefficient and ANOVA.

Results. Comparison of photographs did not show a statistically significant difference in PPI between the two groups (P=0.94). Radiographic evaluation of crestal bone loss adjacent to implant shoulder did not reveal significant differences between the two groups (P=0.30).

Conclusion. Implant therapy in the anterior maxilla, using Implantium or SPI system, did not result in significant differences in esthetics. In this study, there was an inverse relationship between the distance of contact point to bone crest and papilla index (P=0.002 in the SPI group) (P=0.02 in the Implantium group).

Interdental papilla regeneration around implants: A novel window technique (2 years follow-up)

Reconstructing predictable and esthetic papilla is the most complex and challenging aspect of implant dentistry. To obtain an esthetic and predictable gingival architecture and implant restoration, interdental papilla plays an important role. The main objective of the surgeon during the second stage of implant treatment should be the creation of interdental papilla prior to prosthetic restoration. The aim of this case report was to demonstrate a novel window technique for developing predictable and esthetic papilla around dental implants, which was followed for 2 years with excellent esthetic results.

Flapless implant surgery: a 2-year follow-up study of 40 implants

OBJECTIVES

Flapless implant surgery is fast gaining popularity because of several advantages, such as reduced surgical time, postoperative bleeding, and swelling. Studies have shown that flap elevation results in some amount of bone loss. The aim of the current study was to compare the amount of bone loss in procedures using the flapless technique and those where flap elevation was done. Papillary fill was also compared in both techniques, which is unique to this study.

STUDY DESIGN

Forty patients, selected according to certain inclusion and exclusion criteria, were randomly assigned to 1 of 2 groups: Flap (F), or Flapless (FL). The amount of crestal bone loss was measured from standardized radiographs at baseline, 6 months, 1 year, and 2 years after implant placement. Papillary fill was evaluated using the Papillary presence index, which was measured 6 months after loading.

RESULTS

The bone loss was greater for the F group during all time periods and the mean papillary fill was greater for the FL group.

CONCLUSIONS

In conclusion, the results of the current study show that flapless implant surgery results in less crestal bone loss both during the healing period and after loading. In addition, it can produce better papillary fill. The cases selected for this study were ideal cases in terms of bone volume and the operator was well experienced, however. Care should be taken during case selection for flapless implant surgery.

The effect of peri-implant bone exposure on soft tissue healing and bone loss in two adjacent implants

PURPOSE

The purpose of this study was to evaluate the soft tissue and bone change around two adjacent implants in one-stage implant surgery.

METHODS

Eleven subjects (7 males, 4 females) who were needed placement of 2 adjacent implants in the molar area were included. The two implants were placed with the platform at the level of the alveolar crest. The interproximal bone between the 2 implants was not covered with gingiva. After surgery, an alginate impression was taken to record the gingival shape and radiographs were taken to evaluate implant placement. Using a master cast, the gingival height was measured at baseline, 4 weeks, and 12 weeks. In the radiograph, the alveolar bone level was measured at the mesial and distal side of both implants at baseline and 12 weeks.

RESULTS

The exposed bone was covered with gingiva at both 4 and 12 weeks. Loss of alveolar bone around implants was found in all areas. The alveolar bone level in the exposed bone area did not differ from that in the non-exposed area.

CONCLUSIONS

This study showed that the alveolar bone level and gingival height around 2 adjacent implants in the exposed bone area did not differ from that in unexposed bone area.

Small Diameter Implants: Specific Indications and Considerations for the Posterior Mandible: A Case Report

The field of implant dentistry continues to grow globally as clinicians embrace the evolution of various endosseous implant technologies and the array of enhanced surgical and prosthetic products. The utilization of small diameter implants in limited osseous regions increases patients' ability to choose implants as a viable restorative option. Although small diameter implants have been indicated in the incisor region for the maxilla and mandible primarily, their usage should be considered in select posterior regions. These 2 case reports demonstrate the incorporation of small diameter implants to replace missing mandibular posterior teeth.

Scalloped Dental Implants: A Retrospective Analysis of Radiographic and Clinical Outcomes of 17 NobelPerfectTM Implants in 6 Patients

BACKGROUND

The scalloped dental implant (NobelPerfect, Nobel Biocare, Yorba Linda, CA, USA) is designed to biologically guide and facilitate interproximal bone remodeling during healing and to maintain bone height and papillae during functional loading. The design features of the scalloped implant include hard and soft tissue apposition areas, which are parallel to each other and mirror the cementoenamel junction. The hard tissue surface area is intended for osseointegration. The soft tissue surface area is meant to support the connective tissue zone and to provide a space for the subgingival margin of the restoration. Current literature on the clinical performance of the scalloped dental implant is limited.

PURPOSE

The aim of this study was to evaluate whether the scalloped dental implant maintains interproximal bone and the overlying soft tissue.

MATERIALS AND METHODS

Radiographs for six patients (mean age 40.5 years) treated with 17 implants (NobelPerfect) were reviewed for an 18-month follow-up evaluation of bone response. Orthodontic movement and/or autogenous bone augmentation had been provided to obtain the best possible soft and hard tissue dimensions prior to implant placement. A surgical guide was used for an optimal implant placement. No surgical flap was reflected, and implants were placed a minimum of 2 mm and a maximum of 3 mm apical (midbuccally) to the most apical portion of the surgical guide. Final optimal rotational alignment was achieved in all cases by not exceeding 45 Ncm. Implants were immediately restored with provisional crowns. Photographic documentation provided the basis for analysis of papillary response. Radiographic change in the interproximal bone level was obtained by computer analysis (ImageJ for Windows, National Institutes of Health, Bethesda, MD) by measuring the distance from the interproximal shoulder of the scalloped implant to the crest of the bone.

RESULTS

When the scalloped implants were placed adjacent to existing natural dentition, the average bone level at placement and at 6, 12, and 18 months was -1.7, -3.5, -3.8, and -3.9 mm, respectively, compared with -1.0, -3.6, -4.3, and -4.4 mm respectively, when placed adjacent to other scalloped implants. Papillae formation exhibited no differences from the configuration that typically results after placement of conventional dental implants. Moreover, bone loss around the scalloped implants was notably greater than that expected after traditional implant placement.

CONCLUSION

This chart review of 17 scalloped implants, followed for 18 months, determined that the scalloped implant design resulted in bone loss that was more severe than that associated with properly placed conventional dental implants. Further, the design showed no evidence of exceptional capacity to increase or maintain soft tissue height.

Adjacent Implant-Supported Restorations in the Esthetic Zone: Understanding the Biology

Traditionally, whe n considering adjacent implants in the esthetic zone, clinicians have encountered problems associated with deficient interproximal soft tissues. These discrepancies were often solved either by fabricating restorations with long interproximal contacts or by adding pink ceramics, both of which represent an esthetic compromise in today's demanding standard of care for restorative dentistry. This challenge has led to the recent introduction of scalloped implants. An understanding of the biology of wound healing of bone and soft tissue around implants and the remodeling process with implant-supported restorations allows the dental team to offer patients an alternative restorative solution consisting of combining conventional flat prosthetic table implants and scalloped implants.

CLINICAL SIGNIFICANCE

This article illustrates the biologic behavior of wound healing associated with dental implants and shows a step-by-step clinical case in which a patient received four adjacent implants in the esthetic zone. It also describes key elements in laboratory communication when dealing with the aforementioned restorations.

Management of inter-dental/inter-implant papilla

OBJECTIVES

The aims of this paper are to review and compare existing techniques for creation of interdental/interimplant papillae, to address factors that may influence its appearance and to present an approach that authors developed that could help clinicians to manage and recreate the interproximal papillae.

METHODS

Papers related to interdental and interimplant papillae published over the last 30 years were selected and analyzed.

RESULTS

Thorough treatment planning is essential for maintenance of the height of the interproximal papillae following tooth removal. The key for achieving an esthetically pleasing outcome is the clinicians' ability of properly managing/creating interdental/interimplant papillae. Bone support is the foundation for any soft tissue existence, techniques such as socket augmentation, orthodontic extrusion, guided bone regeneration, onlay graft and distraction osteogenesis are often used for this purpose. Soft tissue grafts as well as esthetic mimic restorations can also be used to enhance the esthetic outcomes.

CONCLUSIONS

An esthetic triangle is developed to address the foundations that are essential for maintaining/creating papilla. These include adequate bone volume, proper soft tissue thickness as well as esthetic appearing restorations.

Multifaceted aspects of implant esthetics: the anterior maxilla

Presurgical planning, implant positioning, soft tissue management, esthetic bone grafting, provisionalization, and prosthetic management are the treatment considerations that affect the treatment outcomes that are associated with dental implants in the anterior maxillary area of the oral cavity. Each should be approached with caution to help avoid postoperative esthetic complications and to maximize the esthetic outcome. This article reviews most of the current techniques that help to maximize the esthetic results and introduces a new classification for soft tissue management according to the time of clinical intervention.

Clinical and radiographic evaluation of the papilla level adjacent to single-tooth dental implants. A retrospective study in the maxillary anterior region

BACKGROUND

The regeneration of gingival papillae after single-implant treatment is an area of current investigation. This study was designed to determine: 1) whether the distance from the base of the contact point to the crest of the bone would correlate with the presence or absence of interproximal papillae adjacent to single-tooth implants, and 2) whether the surgical technique at uncovering influences the outcome.

METHODS

A clinical and radiographic retrospective evaluation of the papilla level around single dental implants and their adjacent teeth was performed in the anterior maxilla in 26 patients restored with 27 implants. Six months after insertion, 17 implants were uncovered with a standard technique, while 10 implants were uncovered with a technique designed to generate papilla-like formation around dental implants. Fifty-two papillae were available for clinical and radiographic evaluation. The presence or absence of papillae was determined, and the effects of the following variables were analyzed: the influence of the 2 surgical techniques; the vertical relation between the papilla height and the crest of bone between the implant and adjacent teeth; the vertical relation between the papilla level and the contact point between the crowns of the teeth and the implant; and the distance from the contact point to the crest of bone.

RESULTS

When the measurement from the contact point to the crest of bone was 5 mm or less, the papilla was present almost 100% of the time. When the distance was > or = 6 mm, the papilla was present 50% of the time or less. The mean distance between the crest of bone and the most coronal papilla level (interproximal soft tissue height) was 3.85 mm (SD = 1.04). When comparing the conventional and modified surgical technique, the relation shifted from 3.77 mm (SD = 1.01) to 4.01 mm (SD = 1.10), respectively.

CONCLUSIONS

These results clearly show the influence of the bone crest on the presence or absence of papillae between implants and adjacent teeth. The data also show a positive influence for the modified surgical technique, aimed at reconstructing papillae at the implant uncovering.

Clinical evaluation and prosthetic complications of single tooth replacements by non-submerged implants

The aim of the present study was to evaluate single tooth replacements by non-submerged implants. In the time period from 1990 to 1998, 72 patients were consecutively admitted for treatment with a total of 109 solid screw ITI-implants supporting single crowns. All crowns were ceramic to metal fused with a ceramic occlusal surface and mounted to the octa-abutment. The mean observation time was 4.3 years, ranging from >1 to 9 years. The implants were monitored regularly by periimplant parameters. Periapical radiographs using the parallel technique were taken after the healing period and in 1999 for comparative measurements. No implant was lost during the healing phase, while 3 failures occurred after a loaded period of 2.5 and >5 years, respectively. The 5-year cumulative survival rate was 99.1%. In the course of the study, only 2 implants exhibited marginal inflammation that required treatment. The radiographically measured distance (DIB) from the implant shoulder to the first implant-bone contact was significantly increased in 1999 and different between the two readings. However, this difference in DIB was not significant between implants with a short (1 year) and long (>5 years) observation period. It was concluded that changes in the crestal bone level occur mostly in the first postsurgical year. Prosthetic complications were rare, mostly encountered in the first year after loading and often limited to re-tightening of the occlusal screw.

Fifty years of interdisciplinary site development: lessons and guidelines from periodontal prosthesis

Just as "osseointegration" became synonymous with successful restoration of function in the fully edentulous patient during the 1980s, the term "implant site development" has become intricately associated in the 1990s with the techniques used to achieve esthetic results with implants in the partially edentulous patient. This article explores the roots of the concept of site development within the philosophy and principles of periodontal prosthesis. In addition, the myriad of techniques that are presently collectively referred to as site development are systematically classified into a sequential four-tiered approach that optimizes their efficient application as well as overall success.

Treatment planning 2000: an esthetically oriented revision of the original implant protocol

Soft and hard tissue ridge deformities are prevalent in areas of tooth loss and trauma and can compromise esthetic outcomes. Only a full understanding of the severity of the dimensional defects, the reconstructive techniques available, and the functional and esthetic needs of the final implant restoration will allow the design of a treatment approach that will achieve the desired outcome. This article emphasizes the synergistic relation of the osseous, gingival, and restorative triad in treatment planning. In addition, a systematic approach to the enhancement of this triad, in the partially edentulous patient, is outlined as part of a revised protocol for achieving optimal esthetics in implant therapy.

The esthetic dental implant: letting restoration be the guide

Dental implants originally were placed according to the availability of supportive bone structures. This article describes a new way of approaching implant placement: envisioning the ideal ultimate restoration and developing the treatment plan--and the implant site--to achieve that goal.