Interdisciplinary Management of Single-Tooth Implants Frank M. Spear, David M. Mathews, and Vincent G. Kokich Orthodontists treat many patients who are missing maxillary lateral incisors, and/or mandibular second premolars. In the past, if the canines could not be substituted for lateral incisors, conventional full-coverage bridges were the common restoration. Recently, resin-bonded Maryland bridges became a popular substitute for conventional bridges to avoid crowns on the nonre- stored abutments, However, resin-bonded bridges have a poor long-term prognosis for retention, lasting on average about 10 years. Since implants were introduced into dentistry by Swedish researchers in the mid-1980s, ‘they have become a promising substitute for conventional or resin-bonded bridges. Howe) to successfully place and restore single-tooth implants in young orthodontic patients several questions must be answered. Thisarticio will discuss the many interdisciplinary issues that are Involvedin placing and restoring single-tooth impiants in orthodontic patients. (Semin Orthod 1997; 3:45-72,) Copyright»: 1997 by W.B. Saunders Company Cia erases eciinachcion missing teeth, Some of these individuals se adults who have lost teeth because of ea by periodontal disease. However, many’ partially edentulous orthodontic patients have enngeni- tally: missing maxillary lateral ineitor and man. dibular second premolar teeth. In the past. if sputce closure was not an orthodontic treatment ‘option, restoration of the edentulous space was the alternative. Previous options for edentulous spaces have cither been. conven- tional fll coverage bridges or resin-bonded Mary land bridges. Today, most young patients are cariestiee. Therefore, fulleoverage bridges are inappropriate. Resinvbouded bridges have ahigh failure rate. Therefore, most dentists as well as patients ate considering a rephice congenitally missing permanent ( Implants require interdisciphnary interaction hetween orthocontis, surgeon, and lentist, This article will discuss the tical ius is, Stal of Det, Frm the Dipartaeed of Ort nat of Wingo, Sole, Wa Adres cormponience Kone (Reith Lifetime if Orthontc, Sc of Ret Washinon, Sata, WA ON95 Coprght ©1997 by Waar Campy U3 8746/7 /OHOL ONES DH Vaile af that must be auldressed to achieve an optimal result with single-tooth implants Space Requirement Maxillary Lateral Incisors Ifa patient is congenitally missing one maxillary Jateral incisor, the amount of space for the implint and crown is eletermined by the contra tateral lateral incisor. However, in some patients, the existing hiteral incisor may be peg-shaped. Int ‘othersituations, hoth lateral incisors are congeni- tally absent, In the Tater instance what then determines the amount of space for the implant and crown? The amount of space is determined Iby two factors: esthetics and occlusion. An esthetic relationship exists between the size of the maxillary central and lateral ineisor eth. This size ratio hasbeen called the "golden proportion.” Ideally, the maxillary | should be about two-thirds the width of the central incisor.’ Most central incisors are be- tween 8 and 10 crm wide, IFthe central incisor is $ mum in width, then the kaweral ineisor should be 5.5 mm wide. If the central incisor is mm in. width, then the width of the late: should be 6 mm. Ifthe central Incisor is 10 mm wide then the lateral incisor should be 6.7 mm. 1 incisor Seminars i Orthotentis, Vol 3: No (Maney), 1997; pe A872 4546 Spas Matha nd Kohich wide sors will range Ins ate less thn ideal width for the lateral incisor implant and crown because of ocelusal conside ations (Figs and 2). The orthodontist should be assessing the posterior intercuspation, as well as the appropriate amount af averbite and ove Ithe corteet occlusion has been achieved, the space for the implant crown is too narrow, the orthodontist should remove ei Therefore, the wideh of most Literal inei- ne situations, the orthodontist may eve proximally froth the central Jnelsors and eanines to provide uddlitional width for the lateral incisor exown, The traditional width of an implant is 3. mm. The platform on the implant is about 40 mum wide surement is important be cause the platform must fit interproxintally be: nyeen the central ineisor and canine at the crest of the alveolar ridge. IF the orthodentist has created 5.5 mm of space for the lateral ineisor, id the plato of te implant 64 mum wide, Figure 1, This patient wn congenitally smiaing dhe wasillay sight lite [reatient, space wasopened for an implant to replace the ‘nin implant was placed between the cen the left lateral incisor, the space was 5 mun (CAS result, the papilla's positioned more ieably (Eand F five (D), When a wider implant is placed iat anteow space, the amount of space tor the incisor (A). During orttiataute To match thesizr of sl incisor an pillais educed. As axillary right laeral incor (B)Iuverscipinary Manage 7 Figure 2. This patient way congenitally missing dhe maxilla lel lateral incor (A). A. enn spaces was exeaed for the Tet lateral incisor to match the sze of theesisting right kateral (B). this narrowcsprace at 241 mm implant way placed (Gand D), With the marvower fmplaat, mere ypace remained between the iryplant sil the adjcent tooth and permitted a more esthetic regeneration of aati papillae aroutid the implana crown (E atl FY Jess than [mm space will remain between the provide more than 1mm of space berween the P P ¥ implant aud the adjacent central incisor and platform and the adjacent weth, canine teeth (Fig 1). Previous articles have sig- Another important area that is often over- gested that the space beaween the implant and looked during orthodontic finishing is the space the adjacent tooth should be at least min for between the Toots of the central Ineisor and proper healing and fo ensure adequate space for canine teeth, If space has been created tor the the development of a papilla. In narrower spaces, implant by moving the central incisor and canine stualler iimplants could be used io provide addi+ apart, the roo1s may have moved into closer tional space between the implant and the adje proximity. In the latter situation, there may be cent teeth (Fig 2). Ifthe size of the lateral incisor inadequate space to fi the implant berween the is (7 mm, the wadivional 8.79 smn implani will — apices of the central incisor and camine teeth48 Shei Mather rad Rohl During fi the apices of the teeth apart co provide adequate spice fo beaveen the shing, the orthodontist must move the surgeon t© position the implant the teeth, Mandibular Premolars mandibular premolars are heween 7 and 1 wide. If the premolar is congenitally absent space er nined primarily by the posterior occlu 1 or intercuspation (Fig 4). IF the edentulous space is 75 mm, and the implant has a 4-mm platform, greater than 1 mum of ted for the implant and crown sill be de bemeen the implantand theadiacent teeth. This, amount of space is sulficient 1 permit proper bone-fill around the impkintand leave adequate space lor a papilla benveen the implant crown and the adjacent weih. ‘Timing of Placement Adolescent Patients Most orthodontic patients are about M4 10 15 years of age at the end of arthodontie treatment Ia male adolescent completes his arthadontic treatment at 15 years of age, ane a maxillary Figure 3. This patient was congenitally missing the mandibular see Implant besseen the frst premolar and f placed in the seceand pesiolar site (E) and ventoreld with a mike (18 nel nel premolar (A). Spc ‘onthodonge weaunent chInuendsriplinary Mangement 4a nteral incisor is congenitally ‘Teeth erupt in response to growth, The ques: can the impkant be phe plant is on that the orthodontist must answer isiwhether phiced and restored too early, relative to the ot the patient has completed dhe majority of patient's woth eruption, the reaction of the — theit fucial growth. A handawrist radiograph is mnplant will be similar to thar of 3 nkylosed inappropriate for the tawer assessment because tt tooth. The adjacent teeth may erupt, and a isnot specific enough for each patient, The best crepancy will be created beaween the gingival — method of evaltating the completion of facial gins of the implant and the natural teeth" growth is by superimposing sequential cephalo- @ patient with a high fip line, ais could be metic radiographs (Fig 4). Mest boys have no enthetieally unacceptable, For these reasons pa completed their facial growth qnutil the late tiemts should have co1 teenage years, A He or Liye their tooth eruption before the pl bavegone throngh their implant eis advisable to wait until an adolescent vale has lel bey may now lolescent growl spurt YS wl Figure 4. 0 are, HT mainthe of age and completed at 1% years. 8 months « amen, the patient urew significantly (C). Sequersial Cephalumeic supermpositions made afer orthodonic ireaunent (D, Fane F) inehcated that ihe patent hae ‘nok compleied facial growth and was therefore not teady for impkant placement until 18 years, 10 mnths of age50 Spas, aes, andl Rekich completed growth in height. AL that point, a cephalomeuic radiograph should be taken. Ane other radiograph should be taken at least 6 wonths w a year luer If these radiographs are superimposed and there are no changes in ettical facial height (nasion to menton), then this indicates that most of the facial growth has been completed. Ian implant is placed at dhat time, significant eruption ofadjacent teeth would not be expected. In girls, the growl’ of the face is often completed by 15 years oF age. Therefore, it may be possible to place implants for congenitally missing teeth as early as 15 years in girls without the risk of eruption of adjacent teeth. However, sequential cephalometric radiographs should be compared to verily that vertical Facial growels has ceased. Adults Implants can be placed in adult patients at any time alter the edentulous space has been opened. In mest situations, itis easier to wait until the appliances have been removed betore placing theimplant, However, in some patients, itmay be advisable to place an implant immediately after extraction of tractured or hopeless tooth (Fig 3). For example, if a maxillary lateral incisor has a sertical fracture oF an untreatable periodontal defectand must be extracted, the implant can be placed immechiately (Fig 5). 11 these situations, if orthodontics hats been initiated to align adjacent Jeeth, the extraction of the hopeless tooth, and the placement of the implant may be secom- plished during the orthodontic weament to ensure that the alveokir ridge does not tesorb, Final resoration of the implant may be detaved until after the orthodontic appliances have been removed Changes in Ridge Width If an adolescent male completes orthodontic treatment at age 15, and fan implant replacing 4 lateral incisor will not he phiced unul age 20, the buceolingual thickness of the alveolar ridge could decrease over that period of time. Signifi cant narrowing of the sidge could jeopardize placement of an implant. Previous research has shown that after tooth extraction, the ma anterior buecolingual width is reduced by 29% fn the first 6 months (Fig 6). After 5 years an illary acalitional 11% loss in. ide width ocenrs. There: fare, after tooth extraction, the ridge width will narrow by approximately 14%, aver 3 years.! When the maxillary lateral incisor is congeni- tally absent, the canine may eruptadjacentto the central incisor. AS the permanent canine is moved distally to ereate space fora lateral incisor implant, an alveolar ridge is created (Fig 7) What happens to the buccolingual width of this hone over time? This question wasaddressed ina uals A sample of 20 patients with congenitally rahiated missing lateral ineicors were the end of orthodontic treaunent and ut an average of 4 years after appliance removal. All patients were congenitally missing ar least one lateral incisor wootl, Space was ereated for restorations in all edentulous sites. Tomograms through the eden made at the A4year recall sectioned across the edentulous ridge. Comparison of posttreanment and long-term measaremonts of the dental exsts und tomogranis revesded the amount of change that occurred across these edentulous ridges with ime The amount of bone loss inthis sample was less than 14 over years. IFtecth are extracted, the ridge will narrow by 34%." If the dentulous alveolar ridge has been created by the 1 of wo teeth, Tile resorptive change will occur over time. Based on this information, the orthodontist should allow the permanent canines to erupt medially if the maxillary lateral incisors are con- genitally absent (Fig 8). As the canines are moved distally, an edentulous ridge will be cre ated. Over time, this ridge will not resorb as muchas a ridge resorbs following woth extraction. Timing Extraction of Primary Teeth Maxillary Arch Ie the maxillary lateral incisor tooth is conge tally absentand the maxillary eanine has erupted distal us the central incisor, the pr y sill he present distal to the permanent ea When should the primary canine be ex tracted (Fig 0)? If it ie extracted too warly, the ridge will umelergo resorption and the buccelin gual thicknesewill decrease, However, the perma. a must he moved into the primary ex tine space. Ta jan, the pp should be extracted just before moving the52 Spit, Maths, and KkichJatenseiplinary Management 53 c il frieidor (A). "The ania ane cera re 7; THis patient i manillary sight b scent to one another, Dating octhiodontics, the central and eanine were moved apart (1) incisor Thad erupted Asthe weth were separated, the alveolar reige was created for placement at an implant (C and 0). permanent canine distally, This will ensure that rmuintained and placement of the implant may significant resorption af the ridge will not ocew he simplerand more predictabh Ifthe mandibular second premolariscongent 6 tally absent, and the primary molar is ankylosed, Miandiulee Arch: itssill he progressively submerged as theadjacent I the mandibul: smolarsare cong ate a vertical. defec tally absent, the primarysecond molars may still — between. the aaljacent second ie teeth erupt. This will ist premokie and first be presentinthe dental arch, Should these teeth molar th implant at could complicate the phicement of an be extracted early to permit placement of ter time. In this situation, the implant? If the primary molar is extracted, the ankylosed primary molar should be extracted ridge thickiiess will decrease by about 30%. — eaily, Studies have shown that the alveolar eres There is another alternative, If the primary will follow the adjacent first molar and first second mehr isnot ankylosed, itean be reduced — premolar as they erupt This will prevent alelefeet in the edentulous ridge. Ia 1 old girl has an ankylosed primary second in width by interproximal removal ofenameland vert D4 fin (Fig 10). Mandibular primary second 134% molars ate approximately 10 10 12 mm wide, By mol Feducing the mesialalistal width, the tooth ca ave Timited growth of the mandible remaining wee to abent 8 mm, By rettining the and, therefore, the arljacear teeth vill have primary seconel molar, but reducing its wicth, — reduced erieption potential, ke buccolingual thickness of the alveolus will be Ha primary molar isextracted at a young age maintained. Whe nal thickness of the riilge growth, the prinntry mokir may be extracted, and decreases, the ridge may need augmentation an implant can be pliced, By reining the — before placing an impl primary molar dhe width of the alveolus will be orthodontics ean be used 10 aug be extracted. A girl may rhe patient has completed and the huee cn the ridge.54 Figure 8. If xi Aueral incisors are congenitally absent (A). iis intageons to allow the canines to erupt uljaceni to the entra incisors (B). As the canines are moved distally (C), the edentulous rage isercated (D) This will provide anv adequate te In other eases, bone grafting may be necessary 1 build up a rie hefore placing the implant Orthodontic Ridge Augmentation ded Eruption It & primary second molar is ankylosed: and submerged, and the second premolar is congent tallyalsent, it isimportant to extract the primary molar cially. tre I the pat young, By extracting the pi first premolar will erupt by the primary This is e5) nto the space occupied 1), The first premor innplants to be placed and restored (Band F) As the tweth continue to erupt, the ridge will develop, Ata ba piaic treatment is init ated, the first premolar ane mokar can be: moved lian will bring bone as it erupts apart to create the edentulons ridge for place ment of the implant (Fig: 1 Orthodontic Movement In some patients, extraction of an anklyosed primary second moktr may have been delayed The primary second molar becomes submerged as the adjacent teeth erupt. When the primary inolaris eventually extracted, a significant vertIntrtucsptnery Management Figure 9, “nis patient was congenitally anssnng the masta sight aan! Jet permanent casilues (A), "The pelanury fines. the irplants were plied (C). After orth the space helare uncovering the implants (F cal and buceolingual defect may be produced, Because of the rediiced bucealingual thickness, ot be placed in this (ype of ridge One option for correcting this problem is 10 phe bone graft in the area, The other option is tw move the fist premolar into the edentulous space and to place the implant in the position previously occupied by the first prem A potential consequence of this type of woth movement is that recession will occur as premolar is moved into the edentulous § However, previous studies have shown tha lar cortical hone will he deposited ahead of the ined (Ui). Two months after extraction af the pr Mller un exit (D) a shusilay retainer as piel to asaintain wring, crus were placed on both implants (F) tooth, if the tooth is moved slowly and if the gingival tissue is healthy. By moving the tootly slowl, the periosteum a the buceal and lingual of the: alveolus will form bone as teeth e moved inty the edentuloussite. Irthe toath is moved tou rapidly, a dehiscence may ovcun In some patients, permanent teeth may have been extracted berate of etries or tratimt, The edenmulous space may close and ereaie a dental asymmetry (Fig 13), In these sitations. instead. of extracting three resohe the asymmetry, it may be more advisable to reopen the space and placean implant. When her permanent tweet to56 Spey Melony, wil Raich Figure 10. ‘This patient molar was not arkslosed (A the primary mur was reclaced in with (Cane D), Two second molar isstill in place, helping to mainiain the alveolar width as well as space to teetl are moved pari orthodontically,alveo lar bone will be deposited behind the teeth. This will reer ous rielge and allow an implant © be placed without bone grafting, (Fig | fe ann elon Surgical Ridge Augmentation Ridge Resorption Ridge resorption cant dimension When the ridge cur in a buccolingwal acl in is less than 4 mim in width is congenitally imidaing the manalihularsight secenidjirernntar anil the peimary sere nil B), To ercate the appropriate amount of space lara second premolar inp the primary carsales ortedontic He placement of the implant (Fig 130). Significant apicocoronall ridge jon procedures ave required betore curred and will ako require augmentation, This can he accomplished before implant placement (rat the time of implant placement, so that the head of the fixture will be positioned in the proper location for ideal restoration and esthet ies. When the ridge width i in the 4 to. mm range, it may be possible to place the implant even though the fenestration or dehiscence buccal aspect tnay Nave The deficient area ean be augmented at the time of plementInserisciplinary Managesent 37 (Fig 6), However, if the ridge is wo narrow to stabilize the implant or place itin an appropriate functional and esthetic location, then pre- implant ridge augmentation will be necessary (Fig 18) ‘Timing of Ridge Augmentation Aker the acjacent teeth ate in proper alignment, ridge augmentation and/or implant placement can be accomplished When grafting procedures are required to augment a ridge, ittakes about 9 months for the bone graft to be stable enough to place an implant. In this situation, it is most advantageous to plan the procedure as soon as the proper tooth alignment is achieved by the orthodontist. This may mean that the procedure could be accomplished 1 year before band re- moval. This would allow the surgeon to proceed with placement of the implan} near the end of orthodontic treatment or shortly after the appli- ances have been removed and a Hawley appli- ance, or other space maintaining device has heen placed. Alter the graft has matured, an implant should be placed soon to avoid resorp- tion of the grafted ridge (Fig HME). Ridge Augmentation Techniques Membranes. Resorbable sand nonresorbable branes have been used to augment implant sites cither before implant placement or at the time of implant placement if a dehisees present” Augieentition can be accomplished in a buccal, Hingual and incisal dimension, The honresorbabe membranes (Gore-Tes, Ws Gor & Assoriates Ine, Flagstall, AZ) fend 10 give Heiter results because the harrier effect is more long-lasting, The resorbahie membranes (Lame bone [Litimaties, Ine, Springdale, AR}, collages Resolut [W.L. Gore & Associates) wil Last only a few months, and after that period of time the barrier effect is diminished. This could have an «verse effect on the eventual amount of bone augmentation, The tise of tiantum reinforced. Gore-Tex has improved the technique by allow ing greater incisal (vertical) augnnentation” (Fig 14). The reinforcement with titanium prevents collapse of th ne which could ako, diminish the amount of bone growth The surgery involves a full thickness Map, decortication of the area to be grafied with a small round bur, and placement of graft material ora spane making device!" (Fig 13), Grafting, merbra material is placed over the decorticated bone surface.!? When a nonresorbable membrane (Gore-Tex) is used, itis preferable to stabilize the membrane at the periphery with screws or tacks (Memphis. Strauman, USA. Cambridge, MA) (Fig, 140). Mets ration plays an tant part in achieving maximum hone growth, from the flap sal location and seals this ar which is returned to its orig sutured, Autogenous bone which can be obtained from the ithernsity, the ramus, or the symphysis area is the traditional choice. However, other types of materials such as freeze-dried bone and other allograft materials have been shown t0 accomplish adequate results (Fig 13). Allograft may require longer maniration time to achiewe 3 solic! bony base for placement of the implant I. ic preferable to leave the nonrocorhable me be toachieve optimum results. The disadvantage of resorbable membrane is that it must be le men fe for at least 9 mouths or preferably longer removed! surgically, Resor sorb in about 2 months, When the surgeon ean place an implant and simply augment a small buceal dehiscence or fenestration, itis common a resorbable membrane. However, if 3 ls to be anginented before implant “orbable membra mount of bone growth ow a more ridge placement, fora yreater predictable basis. Bune grafts. Another methou of augmenting the rilge in a bucea, lingual, in isto use blocks of bones!" These bone blocks can obu crest, the mandibular symphysis, or from the mandibular ramus! A full-thickness flap is reflected, the area is decort: cated, and the block graft is shaped and screwed into the site. The flap is returned (0 its original location and sutured. These grafts have been al direction ned from the ili specially for vertical augmenta tion. The disidvantage is the additional surgery, and expense. Bone blocks only require about 3 Gmonth healing period before the implant can be phicee Occasionally, ifthe tidge is wide e plant can be placed at the same: time block is stabilized!" This is accomplished by ing, he using exiting bone ane the in » the site ‘Osteotome Ridge Splitting Technique ‘The oseotome technique for ridge augment. tion can he used if the ridge i 8 to 4 man wide.”5 Spe ‘ani Kolieh Figure 11 second premolar was malfor etl erupted (C, Dana F This patient was ce Narrower ridges can abo be widened with the addition of bone tiferdge this technique will be pro! ails, the ridgein ise of sequentially larger il the ridge so an implant can be placed. This is a slow wedging process 1 avoid splitiing the ridge A similar technique involves actual ridge split ting. A fillthickness flap is reflected and a erosscut fissure bur is used to make a miderestal cut, Small vertical cutsave made, and the ridge 1s split gently with aw esteotome or chisel. A green: stick fracture is made, and the ridge is widened Variations of this technique can invohe either nally mnising the mandibular right-second premolar. The mandibular tel (A), The primary teeth were ankyh the fen premolar erupted disully i contact with te frst mbar (F sf an (xt (15). As the remaining placement of the fixture and/or placement of gnifhing materials within the splitto maintain the widening of the ridge, The flap is returned 10 its original location andl sutured. Approximately 6 months healing is required before either place ment or uncovering oF the unplants, Space Maintenance During Orthodonties U space hus been created for an implant, it mast be maintained during the orthotonne weat- ment. Ly the maxillary anterior region, plasticInteraiseiplinary Management 59 ‘K 5 a duce the nd J). Afi eth Figure 1. (Cont ereneny (Kaa L) vl premolar inp veth can be shaped to fit into the edentulous. space (Fig 15). Lateral incisor prosthetic teeth should he contoured to avoid impinging on the ingiva. [tis impo on the tissue mesial and distal to the pontic because this area will became the papilla after implant placement. A bracket can be phwced on that it can he attached to the archwire andl ligated! to the adjacent teeth, This alveolar hot to impinge Will maintain the space during the complevon of the arthod tie therapy In the mandibular posterior region, esthetics is not as critical. Therefore a prosthetic tooth is hot neéedsary, In thivsituation, a pices of ek werjer (G) and mai 2 upper lip support (H}. xpac wa opened treatment, the implants were vestared with porertain coil spring may be phiced on the archwire 1 keep the first premolarand first molar apart dur- ing the finishing phase of orthoconties (Fig 3). After Orthodontics Maxillary lareral incisor implants usually are not placed! until ater orthodontics. I only a short period of time is anticipated between app Femoval and amplant placement, teal (Fig 13) implant and the implant while the re This will permit placement of the being worn, Ivis important just the rerainierPuterdsiptiviary Management a ingement of the interproximal tissue and a jon and iransmucosal loadting of the implant. The plastic tooth on the retainer must be contoured to permit development of an. adequate papilla around the implant (Fig 15D) The plastic tooth should be reinforced with wire to avoid breakage when the implant is uncor ered,and the healing eap is placed. Ifa period of 1 or 5 years is anticipated before implant plac meat. it might be advisable 0 place a resin- bonded bridge as at maintain the space. It is not reasonable to, sider that the appliance ever that period of dine. A removable retainer with prosthetic tooth will gradually deteriprate and become less esthetic over time. Afver orthodontic treatment, mandibular pos terior edermulous spaces shoulel be maintained with a fixed rather than «removable retainer: It is difficult to construct adequate occlusal rests ‘on the teeth to avoid impinging on the tissue witht removable retainer, In addition, younger patients may not wear the mandibular retainer and adjacent teeth could move. A fixed buccal retainer with a mesh pad that is bonded to the th iy an excellent method of retaining this space (Fig 16), The wire should not interfere \ith the occlusion, tt also must not interfere with the final impression for the implant crown. This ype of retainer ean be removed when the crown hasbeen placed on the implant, Implant Placement Presurgical Planning and Stent Fabrication Premugical planning req fal under standing of how implant placement affects the ‘outcome of the final restoration. Three di sions are considered when placing buccolingual position of the body of buccolingual angulation, and depth of plac ment below tissue, Ty identity the correct locas tion for placement in each of these areas, the Ideal resontion muse be envisioned, Fiyt, It should haye a smooth labial emergence profile to provide support to the gingiva, and should be easy to clean, A ridge lap design should be avoided, because the esthetics are dependent on. ho change in the underlying soft tissue. The el allow for minitnal metal thickness helow tissue so that no graying of the gingiva oceurs. The depth sila allow for a smooth contour, but not t00 far below tise, $0 the technical aspects of impression making, tem porization, and seating of the abutment and rowan are facilitated By visualizing these ideal goals, the following guidelines ean be used for presurgieal planning and stent fabrication. The buceolingual position of the body of the implant shoulel be as far to the abil as peties is a ce This provides the 1 emergence profile fromimplant heal 1 cervical contour ofthe testorse tion. The more lingual the implant is placed, the more abrupt this emergence profile will be. The angle ofthe implant should be directed at the incisal ‘edge of anterior teett oF the central foxstof poste- rior teeth. For incisors, this angulation provides smooth emergence profile, an the opportunity to ereate the thinnest posible metal collar on the abnitinent. The move facially the implant & angled, the thicker the metal collar must be to correct the angulation problem. The more paktal the implant is placed, the more abrapt the emer gence profile becomes on the facial ‘The depth ofthe implant should be 3104 mm below the desired fee gingival margin of the final restoration. This allows for 210 $ mm of porcelain below the tissue to provide the best color of the gingiva surrounding the implant. Tealso allen for minimal suleutar depth to avoid biological problems It isthe restorative dentist who is respon sible for ereating 2 stent that gprs the surgeon $0 that these placement objectives can bie met, Th nos critieal areas that rust bene to accomplish these goals are: the desired ine eige position of the final restoration andthe de- sired free gingival margin of the inal restoration. The simplest way te accomplish these objee tives is to start with a diagnostic east with the correct tooth position. Then a composte tooth with corrcet contour and gingival outli created in the edentulous space using a light material Triad, Dentsply Trubyte, Trubyte Diviion, York, PA). After the woth form is completed, the cast is Inbricited and a clear pressure formed matrix i created. from heavy stent material (Copyphist LO. % 129 mm, Great Lakes Ortho, Tonawancia, NY). Then this stent is tvimmed to cover the incisal hall of the ad-62 Spear, Mathews: tend. Bokich Figure 13. This patient was con implant (B). Because the sd ne (F) 10, 1 the ridge jacent te teeth on euch side of the edentulous area, and carefully adjusted 1 maintain the ire labial surface including the free margin in the implant site (Fig 17) edge is then pertorated in the center of the toothy mesiowlistally with a iva The incisal uanber 8 round bar te allow phase guicle drill to fic through ie (Fig This simple stent providesall the key elements needed for implant placement, and can be used to index the fixture afler i has been placed by simply cutting the incisal half of the tooth off the implant area, and luting an impression vitally missing the emailary right La al incivoe (A) and space Was opened for 1s too narrow (Ch, a bone graft was placed (D and B) and covered with a coping Pattern Resin, GC America Ine, Chicago, TL) > the stent with quicksetting acrylic (GC Implant Placement The advent of multiple implant systemsanel sizes of fixtures has greath facilitated the surgical process, When a patient is congenital maxillary lateral incisor, the space req) missing. a fe crllical, Often, the mesiodistal wid may be 5.010 mam, A sta wide at the top plait 1 size implant iy 4mm im, This leaves a narrovyIitetsciptinany Manone 63 Figure 13, space herween the head of the implant and the ueljacent tooth, which makes resto difficult and creation of peoper papilkary form, more challenging (Fig 1). With narrower jm plants (9.040 8.9 mmasillary haters ad a still le nim) it is postible to replace distance bewween the h (Fig re narrower bucealitr fe more than | nt and the adjacent 2). Also, in ridges which gually, the smaller implanis are very useful in preventing dehiseenees ilelitional grafting and possible head of the impl et require tase of ment (Conv), Aer 8 mnontls (Gat Kmyplant was placeel (H) and the retainer was adjusted io penn andl J)» Air 6 months the final eresen was cemented (and L) In the maxillary stabilization can be achieved if the proper length ‘of fixture is used, The apical end of the fixtire can be stabilized in the cortieal bone that bor ders the nasal spine amerior region, bicertical vnd the plattarm of the Fisture can be stabilized in cortical bone on tye erest of the ridge (F The surgical technique is usually accom plished with a fill thickness flap. [fan implant is placed jnto an extraction site, minimal reflection or Hinggually."* Sequentially larger ovis drills are used to pre pare the of tise is necessary. buceally plant site. His extremely important6 Speer: Maas, ant Raich Figure 14. This patient had avulsed the lateral jnncisor and eanine (A) and the ridge was decorticated. Reinforced prevent elle he ot membrane wast Innplanes could be plaved widh sufficient k gation and cooling is: main that adequate ir buriing of the bane” which can prevent integration and AS surgics place the fixture at the best functig cause implant failure sent is often used help the surges 1 angle and esthetic restoration (Fig 17) Proper vertical placement of the implant is paramount in facilitating the restorative proce dures, Some surgeons recommend plicing the ical 10 the adjacent cemen: al ‘optimy 1 fa implant 3104 mm 3 tocnamel junction, However, this would place a maxillary lateral ineiser implant too deep api during hive augmentation (B, Gand D) so that cally and would create a sulcular depth of 6 mm 1 from the gingival he imp Jems and. potenti This may cause maintenance prob- A beter gingival abscess guideline for vertical placement of implants isto place the head of the fixture about 4 mun apical fw the desired glagivall margin, (Fig 7) This will produce an ideal emergence profile for the Festorutive dentist and also will create a maintain: able 310 4 mm sulcular depity around. the implant crown, Alier plicementof the implant, « caver serew is placed and the flaps are sutured to achieve“akeieipines Mawdigeoenit 65 tre 15, This patient iscony (8). To malmain the space duiring orthodontics, plastic teeth were c ‘maxillary retainer with wo prosthetic teeth was placed to hold the arch wire. Alter orthodontic teaument (E the space before implant placement (F) primary closure, Optimum healing time in the maxillary arch is 6 to 8 months. This will vary depending on the type of bone and whether or not bone gralting and membranes were placed In the mandible 4 to 6 equate to allow months is usually ad isseointegration. ‘Temporary Restoration For shortterm temporization after implant place- ment, a removable retiner with an atiched tooth is an acceptable option for most anterior tecth. However, more precise bonded tempo- sstaly mrssing both maxillary lateral inci 2 (A) Space wa lance toned (C), bracketed rary restoration can be easily constructed. It is very stable, and is easy to remove and replace for any subsequent surgical procedures, The bonded temporary eliminates the risk of tissue impinge- ner. P. bonded temporary restoration. It is more e% thetic and comfortable, and it will maintain interproximal tissue levels hetter than a remot able retain A study A piece of The construction is relatively simple model is made of the edentulous are the lingual surface of the weth adjacent to the66 Mathe Spee gure 16, ‘This patient was congenitally missing the mandibular right second premolar treattnent, abonded wire and mesh retainer was pliced to maintain the edentulous space (B ut iw anil Koki A). Alter orthodontic ©). Thisis avery ellective vay of providing access for the surgeon And restorative dentist during implant placement and restoration 1D, E,and F edentulous space without interfering with the ‘occlusion, In addition, the bendsextend the wire facially. into the edentulous area so it is com- pletely wrapped by the restorative material, Once the wire is bent, it ean he held in place on the model with sticky wax, and then colored composite can be modeled around the The wire t0 the correct tooth color and form, wire is chosen over the current re systems because it makes the temporary much eagier to remave and replace The temporary is tried in the mouth, anc then Ined to the adjacent teeth with tooth: colored composite and acic-etch bonding emove it without damaging the ad 7902 finishing bur is used to open up the facial embrasures. Then a highspeed brownie point (Shofo, Menlo Park, GA) is used to remove the composite around the wire. This point will take the composite off without abrading the tooth surkice. Alter removal, the high-speed brownie is used to remi ese composite on the adjacentPater nary Managenent 67 Figure 17, After orthodontic treatment (A), stent yas constructed to duplicate the eve sal WH {B), Fhis stent used to establisty the corres level art (Cand D) teeth, At uncovering, this same temporary ean be used by simply reshaping its undersusface 10 adapt tothe healing abutment and tissue changes. Surgical Uncovering Surgical Uncovering of the Implant Alter the implant has had adequate time to ossepintegrate, itcan be uncovered, In the orth: ‘odontic patient, ustally the hands and brackets have been removed, sine the patient has either a removable or fixed retainer to maintain the ceclentutlous space. Two different techniques ean bensed ro uncover implanss, ‘The mest common technique is to reflect a full-thickness flap, place a temporary titanium healing abutment, and suture the flap around the abutment, In the maxillary areh, the full thickness flap originates teward the palatal sur Face to gain acmuch attached gingiva as posible (Fig 18), Vertical incisions are male ever the adjacent teeth and the fullthiekness flap is re flected. Often, bone must be removed from the uyula anil Nex heal pest cover serew to allow for its removal. The proper size and length of the temporary heal ment is selected and seated on top of the implant. Additional buecal augmentation ean alo be plished for improved esthetics ‘This can be done with either connective tissue taken from the palate or allogralt materials. The fap is sutured slightly over the occlusal aspect of the healing abutment to permit maximum sg- ‘mentation in a vertical direction (Fig 18). This will also permit reconstruction of the interproxi- ral papillae. By using the palatal approach, the restorative dentist will haye an optimum amount of thick attached gingiva which can be motded during the provisional stage, The flaps are st tured with resorhable sutures. In ahout A weeks the restorative dentist can begin the restorative FP Rrehrtecinijuetn umoege nplimaidtie punch technique” (Fig 19), This technique is, ot used olten because it requires an ideal alveolar ridge. The ridge must have adequate thickness, adequuie attached gingiva, Weal ime phunt placement with properangulation and not68 Spar, Mah, anal BokehIntatavaptinery Management “9 Figure 19. An uncorering stent (A) sets ereated trom an index of tas seral ineisor implant during initial placement, A tissue pastich (2) was wed ty precisely uncover tn: heaet of the implant (C) anel ase darnaging the papillae (1) and require any further buccal augmentation, I this technique is used, an additional procedure will be necessey when the iayplant is placed. Ac the dened, Hime of surgery, the fixture can be This index ean be uséd by the restorative dentist to makea study model with san implant analogue that duplicates the intrioral implant Ie F profabricate « tempor uncovering surgery (Fig 19). g wo he made sm this model the retoritive dentist can restoration before the ide-sleeve ean for precise placement of the surgical punch to uncover the top of the fixture rylie material THhisalyo failitatedimanediawe placement of the temporary crown (F) which fits over the teeth like a for proper plicemen panel is placed the erest of the ridge, and ther pressed ins the head of the fixture (Fig 19) .¢ plug of tissue excised, snd the cover serew stent and allows of the surgical purich, The » the sleeve, maved dowe tiastte down is removed. An appropriate abutment cat be phiced and the temp. iene the same time snatic andl This technique is with proper contouring and temporization, the gaationt can have am in pal fests: inte pre ration at the tin Again. Of the imicovering sungery, this teeh 1 only be used in the70 yore Mathias, end Kohich ideal ridge. The ndvantages of this technique reduced trauma, no temporary heating abut- ments, and the patient leaves the office with a contoured, esthetic, temporary restoradon. Implant Restoration Implant Temporization “Temporization of the implant is ary area which tionales given for the use of termporaries are the sequential loading of the implant t6 allow in: cacased bone density before placing the final restoration, and soft tissue healing to a predict able level before the fi S months are allowed for im) sential Joa for single anterior implants, The concerns over soft tissue healingzare more critical ies some confusion. The most 1 inipression. Sinee 6 to \ healing before uncovering, se Soft Tissue Management After Implant Uneovering The primary concern after the uncovering pro- cess is when to start the restorative phase treatment, Ty achieve the best result inthe finished restoration, the soft tissue should be healed to its ideal form aroun a temporary restoration. Afier healing iy complete, a final impression can be made that captures the healeel tissue so that the final restoration properly eo forms to the gingiva. For the restorative dentist, the major issue regarding temporization 's timing. Should the Implant be indexes! at the time of placement and a temporary placed at uncovering, or showlel some tissue healing occur after tncoveting, but before placing the temporary? Certain criteria should be assessed (0 answer these questions, I the edentulous ridge has inadequate facial bulk, ate interproxinral tissue height, or tn equate vertical height in the free gingival margin area, the uncovering technique must sso ang ‘ment the inadequate areas. Whenever soft tise augmentation is performed! during the uncoxer= ing process, the temporary should not be plicedt ar the same time, Instead, «healing abutment should be placed and the fap surtired partially over the abutment to tent the tissue above the bone (Fig INE). A temporary restoration wil not permit this ype of uncovering technique, After 4+ to 6 weeks of healing, an excess amount at tissue isustally prese snporary can be placed 10 properly shape tltiy soft tissue tissue should not be excised, because the tempor rary contour will help correct the tissue for, ‘To accomplish ts, the patient Is evaluated 4 to 6 weeks alter uncovering and an impression imaele of te fisture. A study avodel is snade ane all the gingiva is removed fom this motel c/the implant, A temporary is fabricated af lighteured composite on a temporary abutment This temporary ts contoured to the deal shape ‘ofa (woth, ignoring the patient’seurrentgingival form, I de augmentation way successful, there will be excess tissue around the implant and 1 will be difficult io seat the tempo Rather than modify the wemporary pr the dssue, the temporary is forced into position until i is seated completely, This may cause significant blanching of the Usue, Over the next 4 8) weeks, the tissue will remodel to fit dhe ideal crown form, After the dssue his reached the desired form, the temporary is removed and a mal impression made of the fixture and the healed gingiva. The final restorion may then, be complete, Tf no soft tissue augmentation iy necesstry at uncovering, then a temporary cu be placed om the same day that the implant is uncovered. To ucilitate this, dhe implant can be indexed by the surgeon at time of plicement using some for of stent (Fig 17C). The restorative dentist uses the index to produce a model with the implant analog properly oriented to the adjacent teeth. ‘This model will serve wo purposes. First. a temporary ean be fabricated on the model be fore the uncovering process, Second, a surgical guide can be created that will enhance the uncovering process (Fig 19). Because ney augmen: fatton is necessary, the ideal uncovering only ssposes the implant without any risk of damags ‘ng the soft tissue. This type of uncovering is best performed by a surgical punch approach (Fig 19), The difficulty is knowing where to aim the punch, This is where te analog, model is used. The dlesirerl punch is seated over the head ofthe Implant analog on the model, The punch is held so that its approach will be slightly from the palatal to avoid damaging the labial papilla, With the puneh in the proper inclination alight-cured resin Seve is created and extends around ke cireumference of the punch and omo the adja cent teeth (Fig 19), A clear pressure-formed The excessInte tary Management 7 stentis then made of the composite sleeve to ald in seating, dhe sleeve i the mouth. TL saving access for the punch 10 igh the guide. Then, the punch, and the guide stent are used to expose the implant without damaging the Facial or inter proximal tissue. After exposure of the implant, the preconstructed temporary is seated, Healing lime before the final impression is now reduced, tod to Sweeks. Final Implant Restoration ‘The biggest decision Facing the tist iswhether the final erown on the single-tooth implant will he cemented or sereweretainedd When amuiple implants are heing restored and splinted, the cemented approach offers several advantages. However, for single teeth, bath ers mented and sereweretained crowns ean be used The advamtages of the serew-retained system are Known re retrievability: The disadvantage is the anesthetic access hole, The advantage of the cemented crow Ihecause it has no ace The d of'a cemented crosen an unknown rettiewability. Th A temporary cement (Temp Bond, Kerr Corp, Orange, CA), which works well for both ret tian and kno Actually, the decision beqween a cemented of screwretained crown is usually dictated by the angle of the implant, A screwretained restone: tion is only possible in the maxillary anterior when the screw access hole exits lingns incisal edge. If the implant access exits labial to the incisal edge a serew-retainedl erown will result In severe esthetic compromise In the posterior area, itis advantageous to use a serewtetained crown front a mechanical per spective, However, from esthetic and occlusal perspectives, the screw access opening isa probe Jem, Por these reasons, it iy ideal to use cement Fetained restorations in ihe posterior quadrans, The method of securing the crown alyo alfeets abutment design and_ placement retained restoration the prianaty concern is create ing the correct subgingival contour, However, In a cemented restoration, It is also important to, consider how far the cement margin will extend, The abutment should be shaped so tht the coment margin is 2 fo $ num below the free al margin. [the marginis any deeper than this, dhe cement cleanup becomes very diffieul IF itis any shallower, esthetics may be compro mised Te is abo important seat the ab completely on the head of the fixs effective to we an antibacterial paste (E Value Dental, Auburn, WA) on the end of the abutment at the time of seating. The implant abutment is dipped in a drop of paste and the seated. Complete seating is verified wid a radio- graph before final tighte driver, The use of this paste has been a great aid in rapidly achieving excellent tissue health, around the final restoration. Long-Term Success Rate Swedish researchers have been placing titanium implants in completely edentulous patients for ‘more than 30 years. In these patients, five or six implants were placed in an edentulous maxilla or mandible, A denture was fixed (0 the top of the implants. These fixtures have been evaluated after 15 years of function. The longterm success rates for implanis placed in this manner are very high! Implants have also heen used as abut- ments for fixed bridges. A 20 year followup of these types of restorations: was performed by Swedish researchers. In their stuely, the contin ‘ous prosthesis stability rate was over 95%. Single-tooth implantshave only been used for about the last years. Long-term studiesare not available. However, some followarp studies have been published.!! The five year suecess rate for single-tooth implants is well above 90%. Thete- fore, it seems that implant replacement of miss- ing teeth is a viable and desirable option in the appropriate patient ‘Summary ‘This article has highlighied the various consider- ations that ate necessary iF implants are used as sinigle-tooth replacements int orthodontic pax tients, Implants require interdisciplinaary inter tion, Orthodontists, surgeons, and restorative dentists mustwork together to produce a excel lent result, Without interdisciplinary interaction, the final esthetic and functional result may be unacceptable, With 3 team approach, manage ment of the single-tooth implant becomes more: predictable and suceessfl2 ‘She, Mehenss, n Kokioh References Roki Siiglenoths Insp in soning Nyman S, Lang NP, Thses D, Kkeh Ve Anterior dental etheties: An. orthodontic espective I Mediolateral relationships, J Esthet Dent Toussnex dian J, Grondahl K. Leboim tmseointeyrae imps on tele etal The elteet 0 colar develop: iment clinical radiographic way greseng pigs Eu | Other! 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