ANTERIOR SINGLE

TOOTH IMPLANT
RESTORATIONS-PART 1

Presented by: Guided by:

Dr. Anuradha G. Mohite Dr.Amit Jagtap
 Contents
 Introduction
 Alternate treatment options for anterior
single implants
 Limiting factors influencing treatment
 Specific single tooth implant indications
 Reference article
 References
 Contents
 Implant crest module design
 Implant body position
 Ideal implant angulation
 Soft tissue incision
 Soft tissue closure
 Immediate implant insertion after extraction
 Stage II surgery and soft tissue emergence contours
 Complications
 Reference article
 Conclusion
 References
 Introduction
 Emotional response regarding maxillary
anterior missing tooth.

Posterior missing teeth Anterior missing teeth

 Introduction

Congenitally missing Missing central incisors

lateral incisors
 Introduction
 Maxillary central incisor the most difficult
procedure.

 The highly esthetic zone of the premaxilla

hard tissue restoration soft tissue restoration.

Causes of maxillary anterior tooth
loss

 Agenesia

 Trauma

 Endodontic failure

 Fracture

 Resorption

 Caries
Alternate treatment options for anterior
single tooth implant replacement

• Conventional fixed partial dentures (FPDs)

• Cantilever fpds ( for missing laterals )

• Resin-bonded ("adhesive") bridges

• Conventional removable partial dentures (RPDs)

• Implant-supported crown
Conventional fixed partial dentures
 3 unit FPD fabricated in shorter time,
satisfies criteria of normal contour,
comfort, function, esthetics, speech and
health.

 More complications
Caries
Endodontic complications
Fractured porcelain
Uncemented restorations
 Advantages of FPD

1. Patient compliance and patient fear

Patient’s desire, compliance or fear of

surgery  contraindication to implant
procedures

Nonsurgical procedures ( FPD) indicated

 Advantages of FPD
2. Time of treatment

Total time for implants restorations  6 months

to 1 year

FPD less time

 Advantages of FPD
3. Consequence of failure

Consequences of bone graft, implant, or

prosthetic failure are greater for single tooth
implant compared with a 3 unit FPD

Most common contraindication for FPD and

indication for single tooth implant in anterior
region is patient’s desire.
 Advantages of FPD
4. Cost to patient

FPD less expensive than implants

5. Unfavorable tooth size and position

 Advantages of FPD
6. Adjacent tooth mobility

Single tooth implant surrounded by anterior

mobile teeth are not indicated

FPD  treatment of choice

Cantilever fpds ( for missing laterals )
Cantilever fpds ( for missing laterals )
Resin-bonded ("adhesive") bridges
Conventional removable partial
dentures
 A traditional option  an RPD.

 The term “flipper”  causes instability of the

restoration during both speech and function.

 The usual indication  economics.

 The easiest interim treatment modality for

implants
Implant-supported crown- Single tooth
implant
 Factors influencing Maxillary Anterior
Single Tooth
1.Patient compliance and patient fear

2.Patient desires

3.Consequences of failure- potential damage to adjacent teeth

4.Treatment time

5.Cost

6.Patient’ s age

7.Esthetics
 Factors influencing Maxillary Anterior
Single Tooth
8.Adjacent tooth mobility

9.Crown height and occlusal relationship

10.Mesiodistal space at crown and bone level

11.Available bone height

12.Available bone width

13.Soft tissue drape type – surrounding gingival tissue

14.Transitional prosthesis
 Age Limitations
 Congenitally missing teeth

 Fpd Resin bonded restoration

 Implant Affects Growth and

development
 Age Limitations
 Infraposition implant-
 Age Limitations

 Thilander et al. concluded that fixed

chronological age is not an adequate
guideline.
 Growth of maxilla

Growth of
Maxilla

Transverse Sagittal Vertical

 Age Limitations
 Sagittal growth- suture and maxillary

tuberosity

 It is the most variable growth of concern.

 Complete growth

 No splinting of implants
 Age Limitations

 Impedement of mesial shift

Asymmetrical arch
 Age Limitations
Vertical growth of maxilla

Displacement and Drift

orbits, nasal cavity, maxillary sinus

&
Deposition of bone on palatal and

alveolar surface
 Age Limitations

 Lateral incisor inserted at

younger age than central incisor or
canine.

 Less obvious to the eye

Guidelines for implant placed in
younger patients
1.Chronological age

2.Endocrine changes

3.Size of the child

4.No growth in last 6-month period

1 .Chronological Age

Boys –
11- 17 Girls-
9 - 15
2. Endocrine changes

• Should be able to
Female menstruate

• Body hair
• Voice changes
Male • Need to shave
3. Size of the child

Height of Implant patient > same sex parent

Size of patient is more important than age of

patient.
4. No growth in last 6 month period

cephalograms
2 year evaluation
period
hand wrist films
 Two criteria that make implant site most
at risk are

Male
patient Central
incisor
Challenging Esthetics
 Crown Height Space
 Angle’s class II division II skeletal
patterns

 Inadequate maxillomandibular
relationship

 Severe deficiency in vertical dimension

Mesiodistal space
 Mesiodistal space

 Two-piece implant should be at least 1.5 mm

from an adjacent tooth.

 One-piece implant should be at least 1 mm from

an adjacent tooth.

 Congenitally missing tooth

with narrower contralateral implant
anterior teeth contraindicated
and angled roots
 Bone height
• Midcrest position of the edentulous site should be 2
mm below the facial CEJ of the adjacent teeth.

• The interproximal bone should be scalloped 3 mm

more incisal than the midcrest position.

Under ideal conditions, the implant body

should not be inserted until the bone and
soft tissue are within normal limits.
 Bone height

• Becker et al. 1997 classified the range of

interproximal bone height above the midfacial
scallop from less than 2.1 mm (flat) to scalloped 2.8
mm to pronounced scalloped < 4.1 mm.

flat anatomy square-shaped

tooth
scalloped ovoid-shaped

tooth
pronounced scalloped triangular-
shaped
 Bone height
 Maxillary anterior edentulous sites require
some bone or soft tissue modification

- When osseous crest is more apical than

ideal

- After tooth loss when bone and soft

tissue changes are rapid
 Bone height

 Bone grafting for height adjacent to a

tooth is more difficult and less
predictable than grafting for width .

 Orthodontic extrusion

 Endodontic therapy and crown

Bone height
Faciopalatal Width
 Faciopalatal Width

• A 25% decrease in faciopalatal width occurs within the

first year of tooth loss and rapidly evolves into a 30% to
40% decrease within 3 years.

• The bone width loss is primarily from the facial region.

Faciopalatal Width
 Faciopalatal Width
 Abnormally long clinical crown

compromised maintenance

bone graft

Ideal cervical esthetics & hygiene

 Faciopalatal Width

 Amount of available bone width

2 mm greater than the implant diameter, so

3.5 mm implant requires at least 5.5 mm of
bone width.
 Soft tissue drape
 Same color and form as adjacent teeth.

 Bone remodels in a sloping fashion.

 Interdental papillae are often depressed.

 Transitional prosthesis
 The transitional restoration a
removable prosthesis the term
flipper.

 Resin bonded fixed restoration

suggested.
Transitional prosthesis
 Transitional prosthesis
 Options to the resin bonded device

An Essix appliance

Cantilevered transitional FPD with pontic over the

surgical site

Denture tooth and an attached bracket

A cast clasp RPD with indirect rest seats

SPECIFIC SINGLE-TOOTH
IMPLANT INDICATIONS
 Anodontia

 The most common maxillary anterior

tooth replaced by an implant is a central
incisor lost from trauma (e.g. endodontic
failure fracture, root resorption )and / or
a lateral incisor lost as result of agenesis
 Anodontia
 When the patient is missing maxillary
lateral incisor, space closure is less
often indicated.

 Limitations

 Space opening and maintenance

followed by implant and single crown
restoration.
 Root resorption
 Root resorption may cause the loss of a
single anterior tooth.

 Two major categories of root resorption

(1) external and (2) internal.
 Root resorption

 Orthodontic extrusion
 Root resorption
 Bone fills in previous apical region

 No void exists around implant at the

time of extraction and implant insertion.

 Soft tissue drape follows coronal

migration of tooth.

 Less time for orthodontic extraction

 Root resorption
 External root resorption orthodontic
extrusion not possible

 Extensive labial bone loss and resultant

bony wall defects.

 Delaying extraction as long as possible

Remaining maxillary anterior teeth

 Evaluate not only the edentulous site but

also the remaining anterior teeth.

 The adjacent teeth most often dictate its

length, contour, shape and position.

 Parameters for a healthy esthetic anterior

restoration have been established.
 Tooth size
 The two maxillary central incisors
should appear symmetrical and or
similar size.

 Orthodontic correction.

 Veneer for existing central incisor

 Tooth size
 Maxillary central incisor length
males 10.2mm
Females 9.4mm

 Implant crown is longer than the corresponding

natural tooth crown lengthening on
natural tooth
 Tooth size
 Maxillary central incisor width
males 8.6mm
Females 8.1mm

 When the anterior teeth are made longer

and both centrals have the same width an
acceptable result may be obtained.
 Tooth size
 Maxillary lateral incisor length

Males & females 8.7mm

 An implant crown on the lateral incisor

should not be longer than the central or
canine.
 Tooth size
 Maxillary canine
Clinical crown Width
length

Males 10.1mm 7.6mm

Females 8.9mm 7.2mm

 Regardless of sex the central incisor is 2

mm wider than the lateral incisor and 1mm
wider than the canine
 Tooth Shape
 Three basic shape of maxillary anterior teeth
exist.

(1) square
(2) ovoid and
(3) triangular.

 The tooth shape will influence the

interproximal contact and the gingival
embrasure.
 Tooth Shape
 Square tooth shape most favorable

interproximal contact is more tooth structure fills the

more apical interproximal region
 Triangular tooth shape less ideal

interproximal contact is Farther from interproximal

more incisal bone
 Tooth Shape
 Topography of the underlying hard
issues
 Triangular tooth Square tooth

Less crestal greater crestal

bone loss bone loss

Favorable for less favorable

for immediate immediate
insertion insertion
 Soft Tissue Drape
 Height of maxillary lip when smiling

 Its position is usually related to age

 Ideal height of maxillary lip

 Higher the high lip line is, the more ideal

the esthetic requirement.
 Soft Tissue Drape
 The soft tissue drape of the remaining
teeth.

 Ideally, soft tissue completely fills the

interproximal space with no dark triangle.

 Interproximal contact for maxillary central

incisors.
Soft Tissue Drape
 Soft Tissue Drape

 Contact point to bone  3 to 5mm

 Contact point to bone  6 mm

 Loss of height of interproximal bone or

interproximal contact is more incisal
 Soft Tissue Drape

 Higher risk of gingival loss after extraction.

 Less likely to restore ideal soft tissue

contour.

 A flatter gingival scallop and an

interproximal tissue close to the osseous
crest
 Soft Tissue Drape

 The least desirable gingival contour is

seen when the anterior tooth is higher
than the rest.

 Common occurrence with an implant

crown
 Soft Tissue Drape
 The color and texture of the tissue in the
edentulous tooth site

 Similar around the implant abutment

compared with the healthy adjacent

 Thicker gingiva

 Thinner gingiva
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 Reference article
“Vertical Distance from the Crest of Bone
to the Height of the Interproximal Papilla
Between Adjacent Implants” -The Journal
of Periodontology 2003;74:1785-1788.

 Results: The mean height of papillary

tissue between two adjacent implants was
3.4 mm, with a range of 1 mm to 7 mm.
 Reference article
 Conclusions: Clinicians should proceed
with great caution when placing two
implants adjacent to each other in the
esthetic zone. In most cases, only 2, 3,
or 4 mm of soft tissue height (average
3.4 mm) can be expected to form over
the inter-implant crest of bone. These
results showed that modification of
treatment plans may be necessary when
esthetics are critical for success.
 References
Thank Joining
youedition; Carl Misch

me
Contemporary implant dentistry: 2 nd

 Contemporary implant dentistry: 3rd

edition; Carl Misch

 Atlas of oral implantology: Cranin

ext seminar by Dr. Priyanka Bansal on Diagnosis and

reatment planning for complete dentures on Friday 10-06-2011 81