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Case Study
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Clinical Considerations for Preservation of the Gingival Architecture in Hopeless Adjacent Anterior Teeth

Case Report

Learning Objectives:

This case study evaluates factors that may influence the dynamics of peri-implant gingival aesthetics in the event of adjacent anterior failing teeth; it also describes a surgical and prosthodontic technique that may assist the restorative team in achieving a predictable objective. Upon completing this case study, the reader should:

  • Understand the role of interdental papillae on restorative success.
  • Recognize the importance of accurately managing the soft peri-implant architecture during surgical procedures in order to avoid the remodeling and resorption of the soft tissues.


Traditionally, one of the primary objectives of implant therapy was to ensure osseointegration and to deliver a restoration that would reconstruct the form and improve function. While these objectives remain a priority in contemporary restorative treatment, alternative concerns include the preservation of tissue and optimization of the soft tissue contour, simplification of treatment, reduction of sequences, patient comfort, and development of an optimal aesthetic result.  

 When treating failing adjacent teeth in the aesthetic zone with an otherwise healthy periodontium and complete dentition in patients with a high smile line, the development of optimal gingival aesthetics is paramount. Bone resorption, unfortunately, is common following the removal of adjacent anterior teeth, and it is extremely difficult to avoid remodeling of gingival tissue levels and interproximal papillae. A combination of improper implant placement and/or inadequate osseous-gingival support may similarly result in compromised aesthetic outcomes. This article evaluates factors that may influence the dynamics of peri-implant gingival aesthetics in the event of adjacent anterior failing teeth; it also describes a surgical and prosthodontic technique that may assist the restorative team in achieving a predictable objective.  

To obtain ideal implant aesthetics, the role of the interdental papilla is essential. The papilla height and form should be restored to the original situation observed in natural teeth in cases of adjacent failing teeth. In the case presented herein, various techniques were used to establish the ideal situation. This included atraumatic extraction procedures, immediate implant insertion, concave profile of the provisional abutment, and the root submergence technique. However, the most important factor in these cases is the management of the soft peri-implant architecture during the procedure in order to avoid soft tissue remodeling and resorption.


*Associate professor, Postgraduate Studies, Conservative and Esthetic Department, Complutense University; private practice, Madrid, Spain.


Related Reading:

  1. Kois J, Kan J. Predictable peri-implant gingival aesthetics: Surgical and prosthodontic rationales. Pract Proced Aesthet Dent 2001;13(9):691-698.
  2. Kois, J. Predictable single-tooth peri-implant esthetics: Five diagnostic keys. Compend Contin Educ Dent 2004;24(11):895-902.
  3. Belser U, Buser D, Higginbottom F. Consensus statements and recommended clinical procedures regarding esthetics in implant dentistry. Int J Oral Maxillofac Impl 2004;19(suppl):73-74.
  4. Funato A, Salama M, Ishikawa T, Garber D, Salama H. Timing, positioning and sequential staging in esthetic implant therapy: A four-dimensional perspective. Int J Periodont Rest Dent 2007;27: 313-323.
  5. Elian N, Jalbout ZN, Cho SC, et al. Realities and limitations in the management of the interdental papilla between implants: Three cases reports. Pract Proced Aesthet Dent 2003;15(10):737-744.  
  6. Mankoo, T. Contemporary implant concepts in aesthetic dentistry – Part I: Biological width. Pract Proced Aesthet Dent 2003;15(10):737-744.
  7. Choquet V, Hermans M, Adriaenssens P, et al. Clinical and radiographic evaluation of the papilla level adjacent to single-tooth dental implants. A retrospective study in the maxillary anterior region. J Periodontol 2001;72(10):1364-1371.
  8. Vailti F, Belser U. Replacing four missing maxillary incisors with regular or narrow-neck implants: Analysis of treatment options. European J Esthet Dent 2007;2(1):42-57.
  9. Tarnow DP, Elian N, Fletcher P, et al. Vertical distance from the crest of bone to the height of the interproximal papilla between adjacent implants. J Periodontol 2003;74(12):1785-1788.  
  10. Tarnow DP, Cho SC, Wallace SS. The effect of inter-implant distance on the height of inter-implant bone crest. J Periodontol 2000;71(4):546-549.
  11. Testori T, Bianchi F, Del Fabbro M et al. Implant aesthetic score for evaluating the outcome: Immediate loading in the aesthetic zone. Pract Proced Aesthet Dent 2005;17(2):123-130.
  12. Leziy S, Miller B. Replacement of adjacent missing anterior teeth with scalloped implants: A case report. Pract Proced Aesthet Dent 2005;17(5):331-338.
  13. Mankoo T. Contemporary implant concepts in aesthetic dentistry – Part 3: Adjacent immediate implants in the aesthetic zone. Pract Proced Aesthet Dent 2004;16(4);327-334.
  14. Lazzara RJ, Porter SS. Platform switching: A new concept in implant dentistry for controlling postrestorative crestal bone levels. Int J Periodont Rest Dent 2006;26:9-17.
  15. Baumgarten H, Cocchetto R, Testori T, et al. A new implant design for crestal bone preservation: Initial observations and case report. Pract Proced Aesthet Dent 2005;17(10):735-740.  
  16. Rungcharassaeng K, Kan JYK. Aesthetic implant management of multiple adjacent failing anterior maxillary teeth. Pract Proced Aesthet Dent 2004;16(5):365-369.
  17. Gamborena I, Blatz MB. Current clinical and technical protocols for single-tooth immediate implant procedures. Quint Dent Technol 2008;31:49-60.
  18. Leziy S, Miller B. Prefabricated zirconia abutments: Surgical and restorative advantages, handling considerations, and clinical outcomes. Quint Dent Technol 2008;31:95-104.
  19. Salama M, Ishikawa T, Salama H, Funato A, Garber D. Advantages of the root submergence technique for pontic site development in esthetic implant therapy. Int J Periodont Rest Dent 2007;27:521-527.
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