ACCREDITATION ESSENTIALS

Tooth Replacement
in the Esthetic Zone
Synergy and Success for Accreditation Case Type III

Mohan Bhuvaneswaran, MDS, AAACD

Key Words: implant esthetics, soft tissue grafting, anterior implant restoration, abutment solutions,
subgingival contouring, Accreditation Case Type III

Introduction
The field of cosmetic dentistry has gained new dimen-
sions from numerous advances in the fields of mate-
rials science and soft tissue techniques. Undetectable
replacement of a missing anterior tooth has become
more predictable; however, such procedures remain a
challenge in day-to-day dental practice.
One of the clinical options for the replacement of
a missing tooth involves the use of a dental implant.
With the expanded knowledge we have gained about
bone and soft tissue reactions to tooth extraction and
implant placement, we can now fabricate implant-
retained restorations with an outcome that is beauti-
ful and natural in appearance. A successful outcome
depends upon a number of factors, including implant
position, gingival biotype, restoration emergence, and
communication with the ceramist and specialists.
Figure 1: Preoperative; full-face smile view.

A successful outcome depends upon a

number of factors, including implant
position, gingival biotype, restoration
emergence, and communication with the
ceramist and specialists.

30 Summer 2014 Volume 30 Number 2

 Bhuvaneswaran

Figure 2: Preoperative frontal 1:2 view, showing the unesthetic Figure 3: Preoperative 1:1 view, clearly showing that the acrylic
acrylic bridge. bridge has impinged on the gingival tissues, resulting in an
unhealthy site in relation to #8 and #9.

Patient History
A 20-year-old female was referred to us by her general dentist due
to a missing upper anterior tooth. Her history revealed trauma
to her maxillary central incisors 10 years earlier during a school
sporting event. Both #8 and #9 had been treated with a light-
cured composite to restore the significant fractures, after end-
odontic treatment. Five years later, because there were frequent
failures with composite, temporary acrylic crowns were placed.
Subsequently, the patient experienced moderate discomfort in
this area. Tooth #8 was deemed non-restorable and was extract-
ed, while #9 was retreated endodontically. An acrylic cantilever
bridge was then placed by her general dentist.
She was in excellent health, with an unremarkable medical his-
tory and good preventive dental care. Her oral hygiene was good
and the soft tissue was in good shape. Clinical and radiographic
examinations were within normal limits and there were no tem-
poromandibular joint (TMJ) abnormalities. For many years, the
patient had been unhappy about her appearance; her dream was
to have a beautiful smile (Fig 1).

Diagnosis and Treatment Planning

A thorough clinical examination including study models,
photographs, and radiographs was completed. For precise
implant planning, a CT scan was also done to evaluate the bone
morphology of the edentulous area. The examination revealed
a poor acrylic temporary cantilever bridge replacing tooth #8
(Fig 2). The bridge was totally out of contour, impinging on the
tissues, and was highly unesthetic. The soft tissue surrounding
the bridge was highly inflamed (Fig 3). There was an obvious Figure 4: Preoperative radiograph shows the extracted site
extraction site defect in the region of #8 and radiographic and the satisfactory endodontic treatment in #9.
examination revealed that the endodontic treatment of #9 was
without any periapical pathology (Fig 4). The patients other
teeth were all in good condition.

Journal of Cosmetic Dentistry 31

ACCREDITATION ESSENTIALS

Treatment options for this patient included a tra-

ditional fixed bridge or an implant crown for replace-
ment of #8. Considering the age and overall status
of the patient, it was decided to place an implant.
Implants are a conservative treatment modality for
a missing anterior tooth and the level of esthetics
achieved can be exceptionally good.1

Biological Considerations
Clinical and radiographic examinations and a scan
report revealed acceptable bone quality for implant
placement. The site required only soft tissue augmen-
tation (Fig 5). It was also noted that there was loss of
keratinized attached gingiva in the region of #8.

Esthetic Considerations
The challenge was to achieve a symmetrical smile with
reference to hard and soft tissues. All-ceramic crowns Figure 5: Note defect and loss of attached keratinized tissue.
would be sufficient, but the main issue was to mirror
#8 with #9 both anatomically and at the gingival in-
terface. This required careful implant placement, pro-
visionalization, abutment selection, customizing of
the abutment, and final crown placement.

Functional Considerations
The patient did not have any occlusal discrepancy or
TMJ problems. Hence, a carefully designed restoration
in harmony with the existing dentition was enough to
address functional considerations. A good diagnostic
wax-up was done on a semi-adjustable articulator, and
a provisional template and surgical stent were fabri-
cated. The same wax-up also served as a guide for the
permanent restorations.
After correlating the data, a precise treatment plan
was formulated with the help of additional key team
members, including the oral surgeon, periodontist,
and ceramist. The esthetic importance of achieving a
correct emergence profile was discussed with the sur-
geon and the periodontist. The surgeons plan ensured
that the implant was placed correctly, bearing in mind
the incisal edge position of the final restoration and
the bone morphology.2 Correct placement and an-
gulation of the implant are important in achieving
good soft tissue architecture.3 The grafting procedure
was planned after the implant placement to take into
consideration the final soft tissue morphology after
wound contraction.4 The tissue was harvested from the
palatal mucosa instead of using Alloderm, since the
former generally yields predictable results.5 Consider-
ing the esthetic requirements of the case, the techni- Figure 6: Radiograph three months after implant
cian preferred a glass ceramic instead of oxide ceramic. placement.
Glass ceramic can provide a better esthetic outcome.6

32 Summer 2014 Volume 30 Number 2

 Bhuvaneswaran

The treatment time required to achieve an excellent expose the implant, and a temporary abutment and provisional were
result was discussed, as soft tissue management can placed for #8 (Fig 6). After two weeks, soft tissue grafting was completed
require significant time.7,8 using the connective tissue from the palate, which served as the donor
site (Figs 7 & 8). Vicryl 5-0 suture (Ethicon; Blue Ash, OH) was placed to
Treatment Plan Sequence secure the graft in position. Care was taken to maximize soft tissue thick-
The treatment plan sequence was as follows: ness around the implant (Fig 9); this allowed ideal gingival contour, to
1. placement of temporary crown in #9 achieve the required emergence profile.11
2. placement of a two-stage implant for #8 Ten days later, sutures were removed and the bone levels of the teeth
3. placement of temporary abutment and provision- adjacent to the implant were evaluated (Fig 10). The bony crest was
al crown for #8 sounded using a periodontal probe to ensure that the proximal contacts
4. connective tissue grafting for soft tissue augmen- of the provisional were within 4 to 5 mm of the interdental bone of the
tation in the region of #8 adjacent natural tooth (this will minimize the occurrence of black tri-
5. provisionalization of #8 and #9 angles). The provisional crown of #8 was removed and reshaped using
6. functional and esthetic evaluation of provisionals flowable composite in order to train the peri-implant soft tissue for a
7. fabrication of customized abutments and perma- proper emergence profile. The gingival third of the crown was well pol-
nent crowns using lithium disilicate glass ceramic ished to avoid any irritation to the soft tissue. In subsequent appoint-
(IPS e.max, Ivoclar Vivadent; Amherst, NY) ments, small amounts of composite were added in the gingival third to
8. observation and follow up. establish the required emergence profile (Figs 11a & 11b). This tissue
training was repeated every two weeks to achieve the desired contours.12,13
Description of Treatment During the entire procedure of soft tissue grafting, it was always kept in
mind to match #8 and #9 with regard to the symmetry of hard and soft
Surgical Procedure tissues. Once the ideal contours were developed with provisional crowns,
The temporary acrylic bridge was removed, a new the tissue was allowed to mature for six weeks. During the healing phase,
temporary crown was placed in #9, and the tissue was the soft tissue responded very well to treatment and a good keratinized
allowed to heal in the region of #8. Our surgical treat- mucosa formed in the region of #8 (Fig 12).
ment was simple, predictable, and respected the biol-
ogy of hard and soft tissues. The surgeons goal was to
create an ideal prosthodontic environment,9 allowing
the dental technician to create an implant restoration
with ideal soft tissue support and long-term stability.
The surgeon used the template from the diagnostic
wax-up as a surgical stent for the placement of a 3.7
mm x 14 mm implant (Hexacone, IHDE Dental; Uet-
liberg, Switzerland). After achieving complete local
anesthesia, the implant was placed, an esthetic heal- Implants are a conservative
ing cap was placed, and the soft tissue was sutured.
The surgical guide helped the surgeon to determine treatment modality for a
the angulation of the implant.10 Instructions for home missing anterior tooth and the
care were given and the patient was discharged after level of esthetics achieved can
postoperative radiographs were taken. The primary
stability of the implant was satisfactory and the radio- be exceptionally good.
graph revealed correct placement.

Tissue Grafting
The patient was recalled one week later for suture re-
moval and the healing was found to be acceptable.
A temporary partial denture was fabricated without
impinging on the soft tissue and the patient was ex-
amined monthly for three months.
Clinical and radiographic examinations during the
follow-up appointments verified satisfactory healing.
After three months, laser gingivectomy was done to

Journal of Cosmetic Dentistry 33

 ACCREDITATION ESSENTIALS

Figure 7: The connective tissue graft was taken from the palatal Figure 8: The connective tissue graft was tucked into an envelope,
region. to preserve the papilla and any related wound contraction.

Figure 9: Note the significant bulk of soft tissue that was gained after Figure 10: The postoperative period was uneventful. This image
the initial grafting procedure. shows the maturation of the tissues.

Figure 11a: Labial view of the provisional was contoured to obtain the Figure 11b: Mesial view of the provisional.
emergence profile.

34 Summer 2014 Volume 30 Number 2

 Bhuvaneswaran

milled to achieve the required contour and then customized

using lithium disilicate (IPS e. max), which was cemented
onto the titanium abutment using Mutilink Hybrid Abut-
ment (Ivoclar Vivadent) (Fig 13).
The crowns for both #8 and #9 were fabricated using IPS
e.max pressable glass ceramic, replicating the diagnostic
wax-up in the permanent restorations. The laboratory sent
the custom abutment and crowns in the pre-glaze stage for
clinical evaluation. The custom abutment was placed and
required no further adjustment, as the expected soft tissue
contour was achieved. The crowns were placed using the try-
in cement and evaluated esthetically and functionally. The
shade match to the natural dentition was excellent, as were
all contours and contacts. Radiographs were used for seat-
ing verification. When the patient and all the team members
Figure 12: An ideal soft tissue profile was obtained. Note the soft were happy with the results, the crowns were returned to the
tissue bulk and the healthy site for prosthetic rehabilitation. laboratory for final finishing.

Delivery
On delivery day, the provisionals were removed, the im-
plant was rinsed with chlorhexidine gluconate (0.2%), and
the custom abutment was torqued into place (20 Ncm).
Radiographs were taken to verify seating of the abutment.
The screw access hole of abutment was then sealed and the
abutment and tooth were cleaned thoroughly before cement-
ing the crowns with Multilink Speed (Ivoclar Vivadent). The
crowns were held firmly in place and light-curing (Bluephase
G2, Ivoclar Vivadent) was done using a quarter-cure tech-
nique. This facilitated the easy removal of the cement. The
restorations were then carefully examined under magnifica-
tion and radiographed to ensure there was no excess cement.
Finally, the occlusion of crowns was verified and was found
to be in proper alignment with rest of the dentition. The pa-
Figure 13: Custom abutment during the try-in stage. tient was examined after one week, at which time the resto-
rations had completely blended with the existing dentition
(Figs 14 & 15). Postoperative photographs and radiographs
were taken during this visit (Fig 16). The emergence profile
Prosthetic Management and Crown Fabrication proved to be in the zone of excellence (Fig 17).
After complete evaluation and discussion with the technician, it
was decided that the NiTi abutment would be milled and used Summary
as a base for the final abutment. Lithium disilicate glass (IPS Replacement of missing teeth in the esthetic zone with an
e.max) was selected to customize the abutment to the tissue implant-supported restoration provides patients with a con-
contours using computer-aided design/computer-aided manu- servative treatment modality. In this case, an interdisciplin-
facturing (CAD/CAM) technology, making it easy to replicate ary approach to treatment was the key to success. Needless
the tissue contours that were achieved.14 The provisionals were to say, an excellent treatment plan is essential for a predict-
removed, the temporary abutment of #8 was replaced with the able outcome. Improving the perio-prosthetic interface with
custom titanium abutment, and #9 was carefully prepared for connective tissue grafting is one of the most efficient surgical
an all-ceramic crown. An open tray impression was made using treatments for obtaining long-term stability, as seen in this
an addition silicone impression material (Virtual, Ivoclar Viva- type of esthetic case.
dent). The opposing arch impression and bite registration were This case was managed via a multidisciplinary team effort
made. An impression of the gingival third of the provisional of that proved to be successful for the patient and all who were
#8 was also sent to the laboratory to transfer the exact replica clinically involved (Fig 18).15 The patient was extremely satis-
of the soft tissue contour that was achieved. The abutment was fied with the treatment outcome (Figs 18-20).

Journal of Cosmetic Dentistry 35

 ACCREDITATION ESSENTIALS

Figure 14: Note the blending of the ceramics with the existing Figure 15: The ideal soft tissue contour and the beautiful restorations
dentition. that were achieved through a multidisciplinary team effort.

Figure 17: The right lateral view showing good emergence profile.

Figure 16: Postoperative radiograph showing perfect fit of the Figure 18: Postoperative full smile.
restorations with no excess cement.

36 Summer 2014 Volume 30 Number 2

 Bhuvaneswaran

Figures 19 & 20: The happy patient.

Acknowledgments 8. Chen ST, Wilson TG, Hammerle CF. Immediate or early placement of implants fol-
lowing tooth extraction: review of biologic basis, clinical procedures, and outcomes.
The author thanks his team members: oral and maxillofa-
Int J Oral Maxillofac Implants. 2004;19 Suppl:12-25.
cial surgeon P. Suresh Kumar, periodontist P.M. Archana,
and N. Dhanasekar, CDT, all of Tamil Nadu, India, for 9. Chiche GJ, Pinault A. Esthetics of anterior fixed prosthodontics. Hanover Park (IL):
their tireless efforts leading to the success of this case. The Quintessence Pub.; 1996.
author also extends his gratitude to his mentor, Rebecca
Pitts, DMD, FAACD, for her continuous support and en- 10. Buser D, Martin W, Belser UC. Optimizing esthetics for implant restorations in the
couragement to pursue Accreditation. anterior maxilla: anatomic and surgical considerations. Int J Oral Maxillofac Im-
plants. 2004;19 Suppl:43-61.
References
11. Funato A, Ishikawa T. 4D implant therapy: esthetic considerations for soft tissue
1. Fradeani M. Esthetic rehabilitation in fixed prosthodontics. Vol. management. Hanover Park (IL): Quintessence Pub.; 2011.
1: esthetic analysisa systematic approach to prosthetic treat-
ment. Hanover Park (IL): Quintessence Pub.; 2004. 12. Murphy KG. 10 key steps in immediate implant placement: delivering a screw-re-
tained provisional. J Cosmetic Dent. 2012 Summer;28(2):74-82.
2. Kois JC. Predictable single-tooth peri implant esthetics, five diag-
nostic keys. Compend Contin Educ Dent. 2004 Nov;25(11):895- 13. Nealon FH. Acrylic restorations by operative nonpressure procedure. J Prosthet
6, 898. Dent. 1952 Jul;2(4):513-27.

3. Spear FM. Maintenance of the interdental papilla following an- 14. Culp L, McLaren EA. Lithium disilicate: the restorative material of multiple options.
terior tooth removal. Pract Periodontics Aesthet Dent. 1999 Jan- Compend Contin Educ Dent. 2010 Nov-Dec;31(9):716-25.
Feb;11(1):21-8.
15. Spear FM, Mathews DP, Kokichi VG. Interdisciplinary management of single-tooth
4. Sclar A. Soft tissue and esthetic considerations in implant thera- implants. Semin Ortho. 1997 Mar;3(1)45-72. jCD
py. Hanover Park (IL): Quintessence Pub.; 2003. p. 243-61.

5. Wie PC, Laurell L, Eivelis G, Lingen, Maddalozzo D. Acellular

dermal matrix allografts to achieve increased attached gingiva. Dr. Bhuvaneswaran is associate dean, professor, and head of the
Part 1. A clinical study. J Periodontol. 2000 Aug;71(8):1297-305. Department of Conservative Dentistry, SRM Kattankulathur Dental
College, Chennai, Tamil Nadu, India. He also is an instructor at the
6. Shenoy A, Shenoy N. Dental ceramics: an update. J Conserv Center for Advanced Dental Education and Training in Tamil Nadu,
Dent. 2010 Oct;13(4):195-203. where he maintains a practice specializing in restorative dentistry.

7. Fagan MC, Owens H, Smaha J, Kao RT. Simultaneous hard and Disclosure: The author did not report any disclosures.
soft tissue augmentation for implants in the esthetic zone: report
of 37 consecutive cases. J Periodontol. 2008 Sep;79(9):1782-8.

Journal of Cosmetic Dentistry 37

 Examiners Commentary

Synergy and Success

Clinical Case Type III: Tooth Replacement (Implant)
James H. Peyton, DDS, FAACD

A ccreditation Case Type III can be very difficult to

blend seamlessly with the surrounding dentition.
Careful attention to the gingival profile and soft tissue
Careful attention to the contours is of the utmost importance. The restoration
gingival profile and soft needs to be made to mimic the adjacent teeth. This
tissue contours are of the all calls for a tremendous team effort! The cosmetic
dentist must properly treatment plan the case in
utmost importance. conjunction with the implant surgeon/periodontist,
laboratory technician, and the patient. A result such
as that obtained by Dr. Bhuvaneswaran could have
been achieved only by selecting a first-rate team.
There was a significant esthetic improvement in
The examiners main comments were as follows: this case. The soft tissue was healthy and the extraction
site was handled very well. However, even though all
Criterion #53: Is the color (hue, value, five examiners passed the case, it was not perfect. The
chroma) selection appropriate/natural, not examiners comments were almost the same, and the
monochromatic? The restored teeth #8 and #9 scores they awarded were identical.
were lower in value. It is important to note that sometimes a fault
can be categorized as belonging to several different
Criteria #64/#84/#87: These criteria are criteria. However, in each instance here, the examiners
related to a wide contact area. The incisal did not double dip and just deducted for one
embrasure was underdeveloped and the fault that related to the similar issue. Overall, Dr.
distal line angle was underdeveloped. Bhuvaneswaran obtained an excellent result and his
case was deemed worthy of Accreditation. jCD

Dr. Peyton is an AACD Accredited Fellow and has been an AACD Accreditation Examiner since 2000.
A part-time instructor at the UCLA School of Dentistry, he practices in Bakersfield, California.

Disclosure: The author did not report any disclosures.

38 Summer 2014 Volume 30 Number 2