1. Anterior Single-Tooth
Implants in the Esthetic
zone
Doreen Leigh Bello
Gerwin Seco

2. • Implants in the anterior esthetic zone are
most difficult to perform.
• When attempting an implant in the esthetic
zone, clinician is adviced to place and restore
100 implants less in challenging areas.

3. Levels of difficulty for implant success
Levels:
Level1
•Extraction performed by clinician
•Good 5-wall bony housing
•Great papilla or thick-flat periodontal biotype
•Low smile line
Level2
•Extraction performed previously and grafted
•Good 5-wall bony housing
•Great papilla or thick-flat periodontal biotype
•Low smile line
Level3
•Extraction performed previously and not grafted
•Good 5-wall bony housing
•Great papilla or thick-flat periodontal biotype
•Medium smile line
Level4
•Extraction performed previously and not grafted
•4-wall bony housing
•Good papilla or thick-flat periodontal biotype
•Medium smile line

4. Levels of difficulty for implant success
Levels:
Level5
•Extraction performed previously and not grafted
•4-wall bony housing
•Good papilla or thick-flat periodontal biotype
•High smile line
Level6
•Extraction performed previously and not grafted
•3-wall bony housing
•Inadequate papilla mesially of distally
•High smile line
Level7
•Extraction performed previously and not grafted
•2-wall bony housing
•Inadequate papilla mesially of distally
•Moderate or High smile line

5. PRETREATMENT GUIDELINES
• Soft Tissue Considerations
• Bone Dimension
• Root Morphology

6. Soft Tissue Considerations
• Anatomy of soft tissue depends on bone
contours
• Type of Periodontium:
Thin and Scalloped
Thick and Flat
Square crowns
Triangular crowns
Contact areas more apical
Contact areas more incisal and occlusal
> Incisogingival and faciolingual
< incisogingival and faciolingual
Bulbuous convexities at cervical 3rd
More sublte convexities
Prone to gingival recession on adjacent

7. Soft Tissue Considerations
• Several adjacent teeth in anterior maxilla are
removed >labial bony plate can collapse >
longer implants
• Gingival recession occurs or adjacent when
implants are placed upon extraction.
• SOLUTION? Conservative Flap Design
– Labial flap extension of 3mm or less beyond the
alveolar crest may eliminate gingival recession of
teeth adjacent to implant sites

9. Bone Dimension
• Determined height and width of bone
• Implants should be placed soon after initial
socket healing to maintain internal stimulation
of the bone and prevent collapse of facial
plate
• Traumatic tooth(avulsion) loss can cause
resorption of ridge.

10. Bone Dimension
• Minimum- 1mm bone required around the
implant
• Standard- 6mm bone bed necessary
buccolingually

11. Root Morphology
• Root form is evaluated before implant
placement
Thin and Scalloped
Thick and Flat
Narrow and Tapered Roots
Wider and less tapered Roots

12. SITE PREPARATIONS USING
OSTEOTOMES
• DRILLS are used to remove bones on implant
placements
• OSTEOTOMES are used as a better alternative
technique:
– Compress the bone literally
– Allow bone preservation, condensation, and
expansion
– Widen thin ridges which facilitate implant
placement

14. IMPLANT PLACEMENT
• Accurate placement of single-tooth implants is
very important because it determines the
tooth form, emergence profile,location of the
screw hole, and dimensions of the
interproximal papillae.

19. Incision design
• within the attached keratinized gingiva
• Minimal incision should be made for single -tooth
implant
• Allows for placement of regenerative materials without
coronal displacement of the labial flap
• Palatal ridge crest- a horizontal releasing incision is
made that does not penetrate down to the bone
• Perpendicular to the ridge crest
• Two beveled labial vertical releasing incisions are
extended apically and flared mesially an distally
beyond mucogingival junction

20. Prosthetic considerations
• depends on the atomy and surgical parameters
• Implant shoulder should be located subgingivally in the
anterior
• The restoration profile can be developed gradually
using an acrylic temporary with appropriate contours
at the time of second-stage surgery
• Placed as far to the labial aspect as possible and more
apically
• Three dimensional positioning of implants
• The facial contours of the crown should be slightly
palatal as compared with adjacent teeth

21. In px with resorbed ridges
• Adequate flap cover and
maintenance of
muccogingival junction may
be difficult
- regenerative
materials are placed to
correct ridge resorption
Subtantial releasing and
coronal positioning of the
labial flap are necessary to
primary coverage
• spiral tomogrpahy
-precise planning and
placementof endosseous
implant
-surgical guide fabriction
- Evaluate implant position and
inclination

22. Final restoration
• All –ceramic or ceramometal crown
• Final restoration is constructed on a cast with
implant position recorded
• Metal casting to accept porcelain is
constructed on the final modified abutment

23. Current two –stage approach to singletooth implants in the anterior maxilla
• A single- tooth implant on the same arch
always provide a provisional restoration first
- healing of tissues in two levels
(coronal and bone interface)

24. Tissue enhancement and precise
implant placement
• Impression and indexing techniques
performed at stage 1 or 2 implant surgery
- satisfying px expectation
- decreasing chair time
-enhancing implant function and esthetics
- provide optimal fitting of the abutment and
finished restoration

25. • Singe tooth restoration in max may be complicated by
improper crown shape, emergence profile, soft tissue
contours
shape of the alveolar ridge, and crown position
Sometimes the implant must be angled for proper
anchorage in compromised bone
When the abutment are placed at second-stage surgerygingival tissue could collapse, making the fitting of the
crown problematic.
Always bear in mind the functional and esthetic needs of
px

26. Traditional approach for providing
restorations after stage two surgery
• First take impressions for fabrication of a
provisional crown
• Once provisional crown is in place, the soft
tissue adapts to crown surface, which has
been fabricated on the basis of the indexing
and impression information given to the
laboratory

27. • Either closed-tray or an open tray procedure can
be used at stage two surgery to make a master
impression of the px dentition.
• Along with soft tissue casts, these impressions
provide information for the laboratory to use
when fabricating the abutments and crowns for
the restoration
• Accurate records of implant-abutment positions
and gingival contours is manufactures, the
restoration can be cemented into a place using
conventional crown and bridge procedure

28. Usual sequence for the restoration
begins during or after stage 2 surgery
• Impression is taken when the implant is exposed, or
approximately 10 days later, when stitches are removed
• Clinician can remove the healing collar and put on the
transfer coping, often using closed tray, and send the
impression to the laboratory for the fabrication of the
costum abutment and a provisional plastic crown
• When the final impressions are taken, the provisional
plastic crown is removed and the screw of the implant is
topped off
• Tighten the abutment by hand
• After 3mos tighten it up mechanically
• Then try on the metal abutment again to make sure it is
placed just below the tissues

29. • An impression can be taken with the
abutment in place, allowing the laboratory
technician to provide the optimal crown.
• At the time that the costum abutment is
dilivered, the clinician tries on the metal
casting. Assuming that it fits well, he or she
moves to the final crown

30. Immediate placement and loading of
implants in extraction sites in the
• Advantages esthetitc zone
- faster restoration
-minimal invasive surgery and minimum pain
-natural healing process is mobilized
- bone growth toward the implant
-absence of bone loss
-simplified maintenance of the natural design and
contour of the gingiva
- positive, immediate psychological effect on the
px

31. Single-tooth implant
• Complete preservation of enamel and dentinal
tissue
• One piece screw-retained provides good esthetic,
easy to retrieve
•
•
•
•
Longer treatment time
Necessity for additional surgical procedures
Increased costs
Esthetic result that may be more technically
difficult to achieve