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Peri-Implant and Restorative Considerations for Aesthetic Implant Dentistry

Aesthetic implant dentistry is becoming increasingly popular due to the increased general use of implants in the aesthetic zone. Awareness of their predictability and adaptability has caused implants to be considered as the standard of care for the replacement of missing teeth.

The biological principles of soft tissue and bone on adjacent teeth as well as in the implant site must be considered for single-tooth replacement using osseointegrated dental implants. The placement of an implant between periodontally healthy natural teeth is a unique situation whereby the bone and soft tissue are assisted in maintaining their levels of health, in part, by the teeth. While this seems to be especially true for the interproximal areas, the facial and lingual regions of these implant sites may behave in a slightly different way. Studies by Gargiulo have shown the width of the dentogingival complex surrounding natural teeth to be approximately 3mm.1 A similar study by Cochran assimilated the peri0implant tissues to a similar dimension.2 Additional articles in the literature have further illustrated these biologic axioms.3,4 Based on these principles, the suggested depth of placement of an implant below the free margin of soft tissue should be approximately 3mm to 4mm. this distance provides space for biologic width, proper emergence, and aesthetics. This distance should also allow for bone remodeling, which occurs after 1 year.

Regardless of the configuration of the implant placed, successful treatment will result in a maximum of 0.2mm of recession each year.5 Since bone functions as a scaffold for the soft tissue, the gingival tissues often recess to a more apical position and expose the abutment-restoration connection. It has been postulated that the type of periodontium will influence the extend of this remodeling process.6 Thin, scalloped gingival will, therefore, recede more extensively than thick, nonscalloped gingival. Although these axioms may be well established, clinicians have entered the 21st century with a refreshing look at immediate placement and restoration in the aesthetic zone.7 Additional studies are required to address the different rules that govern the complex criteria and timing associated with implant placement following tooth extraction.

It is desirable to keep metal restorative interfaces below the free gingival margin in anticipation of soft tissue remodeling following implant placement. Because of this remodeling, the use of tooth-colored, ceramic abutment connections has been widely advocated. Aluminous oxide has been used as a restorative and abutment material for many years. This material has high strength, is aesthetic, and maintains an epithelial attachment similar to titanium. Zirconium has also become increasingly popular due to the configuration required for cemented mechanics and its improved strength over alumina. The zirconium surface has also demonstrated reduced bacterial colonization when compared to titanium.8 Perhaps use of these materials, combined with strict attention to the biologic principles described, will further our understanding of this challenging area of dentistry. Dynamic as it has been in the distant and recent past, dentistry will continue to change and address the new paradigms with biomaterial development, clinical challenges of immediate surgery, and the increased union of restorative and surgical sciences.

*Assistant Professor, Department of Otolaryngology, University of Nebraska Medical Center, Omaha, Nebraska.

 

References:

  1. Gargiulo AW, Wentz FM, Orban B. Dimensions and relations of the dentogingival junction in humans. J Periodontal 1961;32:261-267.
  2. Cochran DL, Hermann JS, Schenk RK, et al. Biologic width around titanium implants. A histometric analysis of the implanto-gingival junction around unloaded and loaded nonsubmerged implants in the canine mandible. J Periodontol 1997;68(2):186-198.
  3. Touati B. The double guidance concept. Pract Periodont Aesthet Dent 1997;9(9):1089-1094.
  4. Salma H, Salma MA, Garber D, Adar P. The interproximal height of bone: A Guidepost to predictable aesthetic strategies and soft tissue contours in anterior tooth replacement. Pract Periodont Aesthet Dent 1998;10(9):1131-1141.
  5. Albrektsson T, Zarb G, Worthington P, Eriksson AR. The long-term efficacy of currently used dental implants: A review and proposed criteria of success. Int J Oral Maxillofac Impl 1986;1(1):11-25.
  6. Sanavi F, Weisgold AS, Rose LF. Biologic width and its relation to periodontal biotypes. J Esthet Dent 1998;10(3):157-163.
  7. Kan JY, Shiotsu G, Rungcharassaeng K, Lozada JL. Maintaining and attenuating periodontal tissues for aesthetic implant placement. J Oral Implantol 2000;26(1):35-41.
  8. Rimondini L, Cerroni L, Carrassi A, Torricelli P. Bacterial colonization of zirconia ceramic surfaces: An in vitro and in vivo study. Int J Oral Maxillofac Impl 2002;17(6):793-798.
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