A Review of the Functional and Esthetic Requirement

Background. The esthetic replacement of teeth has become an impor-tant standard for implant dentistry. While defining this goal has not beendifficult, the ability to restore implants esthetically has been fraught withobstacles and sometimes has not been attainable. The purpose of thisreview is to summarize essential anatomical and surgical considerationsfor cosmetic implant dentistry.Methods. This article provides a summary of the predominant findingsfrom clinical studies and case reports that help develop implant surgicalguidelines for better esthetic outcomes. Results. Soft- and hard-tissue requirements for placing an implant inan ideal position are defined. The authors discuss the best treatmentapproaches as well as the limitations associated with esthetic implantplacement. They evaluate the available data specifically for the maxillaryanterior sextant, since this anatomical region has higher estheticdemands.Conclusions. Several parameters and various surgical techniqueshave been developed to manipulate soft- and hard-tissue contours and tocontrol the esthetic outcome for implant-supported restorations.Clinical Implications. It is essential for practitioners to understandthe anatomical basis for and limitations of implant dentistry in theesthetic zone. Key Words. Alveolar bone; gingiva; dental implant; regeneration.JADA 2007;138(3):321-9.

Esthetic demands posed bydental implant-supportedrestorations are in-creasing in the maxillaryanterior region. In this

sextant, the natural dentition issurrounded with a scalloped gin-gival margin and a pyramid-shapedinterdental papilla. Gingival archi-tecture is determined mainly by theanatomy of the teeth and the posi-tion and the size of the contact sur-faces,1,2 and all of these features areframed by the lip line.3

Seibert4 defined the limitations ofsoft-tissue grafting for a betteresthetic appearance around anteriorfixed partial dentures by creating aclassification for alveolar ridgedefects. This was modified byPalacci and Ericson5 to classify theamount of vertical and horizontalloss of soft tissue, hard tissue orboth in the maxillary anteriorregion (Figure 1). Therefore, it isimportant that the clinician takeinto account soft-tissue considera-tions—including the height of thepapilla and the presence of attachedgingiva—to fulfill the patient’sesthetic needs.6-9

Consequently, a preoperativetreatment plan for implants in theanterior maxilla requires an evalu-

A B S T R A C T

Dr. Leblebicioglu is an assistant professor,, Section of Periodontology, College of Dentistry, The OhioState University, Columbus.Dr. Rawal is assistant professor, Department of Periodontology, College of Dentistry, The University ofTennessee, Memphis.Dr. Mariotti is the chairperson, Section of Periodontology, College of Dentistry, The Ohio State Univer-sity, 305 West 12th Ave., Columbus, Ohio 43210, e-mail “[email protected]”. Address reprintrequests to Dr. Mariotti.

A review of the functional and estheticrequirements for dental implants

Binnaz Leblebicioglu, DDS, PhD; Swati Rawal, BDS, MS; Angelo Mariotti, DDS, PhD

C L I N I C A L P R A C T I C E

JADA, Vol. 138 http://jada.ada.org March 2007 321

Copyright ©2007 American Dental Association. All rights reserved.

ation of the hard and soft tissue to determine thetype and size of fixture needed. The dentistshould visualize the expected restorative outcomeby means of a temporary restoration with thedesired emergence profile. Both the restorativedentist and dental implant surgeon should usethis template and work out all the steps involvedin reaching expected treatment outcomes. In thisarticle, we characterize soft- and hard-tissue pre-requisites for placing an implant in an ideal posi-tion in the maxilla so that it can be restored withesthetically acceptable soft-tissue contours.

THE ANATOMICAL BASIS FOR IMPLANTSELECTION

Osseous structure and architecture. Alveolarprocess of the maxilla. The clinician shouldexamine the alveolar process of the patient’s max-illa in relation to the nasal cavity, the floor of themaxillary sinus and the incisive canal.10 In gen-eral, the canine occupies a neutral positionbetween the two cavities, while incisors are belowthe floor of the nasal cavity and the premolars andmolars are below the maxillary sinus.10 The rela-tionships of the apexes of teeth to the nasal floordepend on two factors: the height of the face andlength of the roots. In people with a relativelyshort alveolar process and long roots, the centralincisor actually may reach the thin compact bonyplate that forms the floor of the nasal cavity.10

Thus, the dentist should examine the height of thealveolar process and the length of the roots beforedeciding on the appropriate implant length.

Alveolar sockets are placed eccentrically. Theaxis of the root and the socket are more nearlyvertical than is the axis of the alveolar process as

a whole.10 Therefore, the alveolar bone proper onthe labial surface of the roots fuses with theexternal plate of the alveolar bone. In addition, awedge-shaped area of spongy bone generally isfound between the alveolar bone proper and thepalatine plate of the alveolar process.10 As aresult, the buccal plate often is fractured and col-lapses during tooth extraction and may need to beregenerated for a better implant diameter selec-tion and correct localization.

Owing to the proximity of the incisive canaland its contents to the maxillary central incisors,positioning an implant in this area requirescareful consideration.11 Terminal branches ofnasopalatine nerves and the greater palatineartery, together with the nasopalatine artery,pass through the incisive canal. Investigators12

have reported difficulties and anatomical limita-tions regarding the location of the incisive canalin relation to maxillary implants replacing cen-tral incisors.

Quality of available bone. The maxilla has thinporous bone on the labial aspect, very thinporous-to-dense compact bone in the nasal regionand thick cortical bone on the palatal aspect. Thetrabecular bone often is less dense than themandible.13 Classically, bone quality of edentu-lous jaws is classified as type I through type IV.14

Type I bone has homogeneous cortical bone withno cancellous bone, whereas type IV bone has anextremely thin compact layer and cancellous boneof reduced density. Type II carries mostly cortical


322 JADA, Vol. 138 http://jada.ada.org March 2007

Figure 1. Palacci’s classification for vertical and horizontal loss of soft tissue, hard tissue or both in the maxillary anterior region. On thebasis of vertical loss, Class I is an intact or slightly reduced papilla (A). Class II has limited loss of papillae. Class III has severe loss of papillae.Class IV represents absence of the papillae (B). On the basis of horizontal loss, Class A shows intact or slightly reduced buccal tissue (A).Class B has limited loss of buccal tissue. Class C has severe loss of buccal tissue (B). Class D has extreme loss of buccal tissue, often in combina-tion with a limited amount of attached mucosa.

ABBREVIATION KEY. GBR: Guided bone regeneration.

A B


bone and some cancellous bone, while TypeIII presents cancellous bone surrounded witha 3- or 4-millimeter–thick layer of compactbone. Researchers have reported predomi-nance of Type III bone in the anterior andpremolar regions of the maxilla.15

Quantity of available bone. The alveolarbone reacts to dental extraction by remod-eling its structures, removing bone at itsouter surfaces and depositing bone in theempty sockets. The various factors affectingalveolar bone resorption can be classified asmechanical, biological and anatomical. Fivegeneral groups of diverse jaw shapes encoun-tered after extraction are as follows16-18

(Figure 2):dmost of the alveolar ridge is present;dmoderate residual ridge resorption hasoccurred;dadvanced residual ridge resorption hasoccurred and only basal bone remains;dsome resorption of the basal bone has occurred;dextreme resorption of the basal bone has takenplace.

Tooth-related considerations. The maxil-lary lateral incisor crown is more slender thanthe central incisor and may lean more medially.19

The labial surface is more convex than is the cen-tral incisor; frequently, the root is bent distally ordistolingually near the apex.19

The maxillary permanent canine is at thecorner of the dental arch, and its anatomyreflects the beginning transition from anterior toposterior tooth forms.19 The root of the canine isthe longest and strongest in the humandentition.19 For an acceptable esthetic outcome,the clinician should keep the crown height and

length proportions of implant-supported restora-tions similar to those of the natural teeth(Table).20 Also, the anatomical location of maxil-lary canines in relation to ipsilateral and con-tralateral dental arches creates additional chal-lenges for implant placement and formanipulation of the gingiva around implant-supported restorations.

Relationship of lips to teeth and gingiva.In the average smile, the lip is positioned to show75 to 100 percent of the maxillary central incisorand the interproximal gingiva. A high smile linereveals the total cervical-incisal length of themaxillary anterior teeth and a contiguous band ofgingiva. A low smile line displays less than 75percent of the anterior teeth.21



Figure 2. Diverse jaw shapes encountered in the maxilla after extraction.

TABLE

Various dimensions of teeth in the maxillary anterior sextant. DIMENSION MAXILLARY TOOTH DIMENSION

Central Incisors

LateralIncisors

Canines

* mm: Millimeters.

Overall Length ofTooth

Height of Crown

Greatest Mesial-distal Diameter of Crown

Cervical Mesial-distal Diameter of Crown

Greatest Labial-lingual Diameter of Crown

24 mm*

11.6 mm

8.4 mm

6.7 mm

7.3 mm

22.5 mm

9 mm

6.5 mm

5.1 mm

6 mm

27 mm

10 mm

7.6 mm

5.6 mm

8.1 mm


ANATOMY AND MORPHOLOGY OF SOFTTISSUES

Periodontal biotypes. The soft-tissue pheno-type (that is, shape and thickness) contouring acrown can be defined as the “periodontal biotype.”Researchers22,23 have described two periodontalbiotypes: the thick-flat biotype and the thin-scalloped biotype. Different biotypes have a ten-dency to respond differently to inflammation andsurgical injury. In a patient with a thin-scallopedperiodontium, the surgical and restorative inter-vention involved in esthetic implant therapy mayresult in some degree of soft-tissue recession.24

Also, the thin maxillary buccal plate is predis-posed to defect formation secondary to remodelingand resorption of bone after extractions and/orimplant therapy. On the other hand, the thick-flat periodontium resists recession and reacts tosurgical and restorative therapy with pocket for-mation.24 This type of tissue is predisposed toforming notches and scars that can jeopardize the final esthetic and functional results. Re-searchers21,24 have evaluated the peri-implant biotype and categorized it as thick or thin, similarto periodontal biotype.

Biological width concept and dentalimplants. The physiological dentogingival junc-tion of natural teeth includes the length of theepithelial attachment, the length of the connec-tive-tissue attachment and the depth of thesulcus. This also is known as “the biologicalwidth.”25 The mean value of the biological widtharound a natural tooth is 2.73 mm.25 The implant-epithelium junction is similar to that in the nat-ural dentition, except that it is shorter andthinner than the tooth-epithelium junction.26

Because of the absence of a cementum layeraround an implant, most connective-tissue fibersin supracrestal region are oriented in a directionparallel to the implant surface.27,28 Furthermore,investigators have observed the presence of anavascular zone, 50 to 100 micrometers wide, ofdense circular connective-tissue fibers that are indirect contact with the implant post at thesupracrestal area.29 The biological width aroundimplants can have significant influence on thecharacter of soft tissues and depends on a varietyof characteristics that include implant design,presence of adjacent teeth and quality of softtissue. For example, one-piece implant designshave been implicated in more closely mimickingthe biological width around natural teeth.30,31 Sim-

ilarly, platform switching (as in controlling thedimension of the abutment) during the period ofosseointegration affects biological width byaltering the position of the microgap and control-ling circumferential bone loss around dentalimplants.30 In addition, a scalloped implant plat-form is available that follows the osseous struc-ture of the maxillary anterior teeth and may pre-vent interproximal crestal bone resorption duringhealing.32 These results may have importantimplications when dealing with esthetic implant-borne restorations, considering that long-termesthetic survival depends on soft-tissue dimen-sions that remain healthy and vertically constantover time.

Anatomical basis for optimal implantpositioning. The extent of alveolar bone resorp-tion that follows tooth extraction depends on anumber of factors, including existing periodontaldisease, trauma, time after the extraction and thequality of alveolar bone.33 The reduction in widthof the maxillary alveolar ridge after tooth extrac-tion is greater than the loss in height.34 Severityof resorption also depends on whether the patientis wearing a removable denture.35 A transforma-tion from skeletal Class I or II to a Class III rela-tion between maxillary and mandibular jaws rou-tinely can be seen in totally edentulous patients34

and can affect the maxillary esthetic result owingto implant angulation in the upper jaw.

Guided bone regeneration (GBR) proceduresare performed routinely before or during dentalimplant placement to increase the width and theheight of the alveolar ridge.36 Particulate bonegraft materials37 in the presence or absence ofresorbable or nonresorbable membrane38 can beused to augment bone, whereas bone blocks fixedwith miniscrews and a barrier membrane may beindicated in areas with more extensive bonedefects.39

Creating alveolar bone height usually is morechallenging than creating alveolar bone width,and it almost always requires placement of a boneblock.39 This can be obtained from the chin, themandibular ramus, the rib or the hip of thepatient, or it can be purchased from a tissuebank.40 Although controversial, it has been sug-gested that vertical bone length should be able tosupport at least a 10-mm implant with a crown-to-root ratio of 1:1.41

One of the main requirements for a GBR sur-gical approach is the availability of keratinizedtissue to cover the wound and to allow bioma-


324 JADA, Vol. 138 http://jada.ada.org March 2007Copyright ©2007 American Dental Association. All rights reserved.

terial stability. Scar tissue often makes woundcoverage difficult, and onlay- or inlay-type soft-tissue grafts may be required to cover bone graftmaterial.42

Soft-tissue support for papilla reconstruc-tion and preservation. The bony supportbetween a tooth and an implant or between twoimplants has been shown to be an important cri-terion in creating or preserving the papilla.43,44

For example, when the measurement from theinterproximal coronal contact point to the crest ofbone is 5 mm or less, the papilla is present almost100 percent of the time.45 When the distance is 6mm or greater, the papilla is present 50 percentof the time or less. Tarnow and colleagues46

reported a mean papillary height between twoadjacent implants as 3.4 mm. One difficulty inmaintaining or re-forming a papilla between two

implants is that the biological width around animplant usually is located apical to the implantabutment connection. In the esthetic zone, thedistance from alveolar crest to the adjacent toothcementoenamel junction should be 3 to 5 mm toachieve ideal implant localization47 and appro-priate space for the peri-implant sulcus to form(Figure 3). This location places the biologicalwidth subcrestally, whereas in a natural tooth,biological width always forms supracrestally.

The localization of the alveolar crest is impor-tant not only for partially edentulous patients butalso for those who are totally edentulous.Depending on the type of restoration (fixedbridge, hybrid or bar/ball attachment–supportedoverdenture) adequate vertical space should beavailable for different restorative parts to beplaced.48-50 Thus, alveolar bone height reductionmay be required before implant placement cantake place.

Mesial-distal position of implant in bone.A minimum of 1.25 mm of clearance is requiredbetween the implant fixture and adjacent teethfor proper osseointegration and decreased risk ofdamage to adjacent natural teeth (Figure 4).51

However, an average creastal bone loss of 1.04mm has been reported when interimplant space is3 mm or less compared with 0.45 mm crestal boneloss when this distance is greater than 3 mm.52

When calculating the mesial-distal distance toselect the appropriate implant diameter, one alsohas to consider the space required for the fabrica-tion of contact points between crowns. Thus, aminimum of 1.5 to 2 mm of clearance from theadjacent tooth is recommended to obtain optimumesthetics with appropriate space for prostheticdevices related to various implant designs andalso for peri-implant tissue health.50,52



Figure 3. Distance from alveolar crest to adjacent tooth cementoe-namel junction (CEJ). A. Initial presentation. Notice buccal concavityand papilla covering interproximal area. B. Implant location afterguided bone regeneration. Implant was placed 3 millimeters api-cally to the adjacent tooth CEJ without reducing alveolar boneheight. C. Final restoration with ideal implant localization and accu-rate space for peri-implant sulcus to form.

A

C

B


Buccolingual positioning of implant inbone. Two factors play an important role in clin-ical decisions regarding buccolingual positioningof an implant: bone thickness with adequateblood supply and the appropriate implant angula-tion for the proper emergence profile (Figure 5).An implant should be surrounded with bone atleast 1 mm thick on both the buccal and lingualaspects. When a mean facial bone thickness of 1.8 mm or larger remains after site preparation,the potential for bone loss decreases significantly

and bone apposition is more likely to occur(Figure 6).53 In addition, the implant body shouldbe aligned with adjacent teeth as well as with thedentition in the opposing arch.54 One researcherhas recommended that the implant be oriented 5degrees palatally and closer to the palatal corticalaspect to minimize buccal angulation and to openup space for screw retention.55 If an implant mustbe placed palatally, for each millimeter of palatalinclination, the implant should be placed an addi-tional millimeter apically to correct angulation.55


326 JADA, Vol. 138 http://jada.ada.org March 2007

Figure 4. Calculation of mesial-distal distance to select appropriate implant diameter. A. A minimum of 1.5 to 2 millimeters of clearance (dand b) is required between implant and adjacent tooth for proper osseointegration and decreased risk of damage to adjacent teeth. B. A minimum of 3 to 4 mm clearance (a) is required between two adjacent implants to decrease crestal bone loss. This space also is important for the fabrication of contact points between crowns.

Figure 5. Buccolingual positioning of the implant. Bone thickness with adequate blood supply and appropriate implant angulation for theproper emergence profile. A. Implant placed too far to the buccal aspect, leaving thin buccal bone and a poor emergence profile. B. Implant placed too far to the lingual aspect, leaving a more than ideal space on the buccal aspect and jeopardizing the occlusal space.

A

A B

B


If the buccolingual dimension of the maxillaryarch is compromised, GBR should be consideredto allow implant placement at the appropriatebuccal or lingual position.

Trajectory of the implant = emergence profile. The emergence profile of a dentalimplant depends on both implant body angulationand the existing status of the periodontal tissues.The clinical parameters that have been reportedearlier should be considered for an optimal emer-gence of the implant restoration. In regard toimplant angulation, implant bodies should beplaced at angles less than 25 degrees sinceesthetic needs cannot be fulfilled easily withimplants placed with wider angles.56,57 The clini-cian should carefully evaluate the soft-tissuecharacteristics—including the amount of kera-tinized tissue, biotype and papilla form—beforeperforming implant surgery. It is important toremember that soft-tissue augmentation is notpossible without hard-tissue support.58 Therefore,a ridge deficiency at the implant site should bewithin 3 mm of its optimal contour to allow theclinician to modify the soft tissues suitably. Tohave ideal localization, implant placement inbone requires placement of the implant platform3 to 5 mm from the cementoenamel junction of



Figure 6. Buccolingual bone walls and immediate implant place-ment. A. Removing remaining nonrestorable root by using burs. B.Intact buccal and lingual bone walls after root removal. C. Imme-diate placement, using an implant of a diameter larger than thenatural root diameter. D. One-stage healing. E. Final restorationwith acceptable esthetic presentation.

A

C

E

D

B


the adjacent tooth.30,43 Furthermore, both buccaland lingual bone walls should be at least 1 to 2 mm in thickness (Figure 6).

Hard- and soft-tissue remodeling duringthe first year. Up to the mid-1990s, alveolarbone loss at the crest was considered to be a phys-iological response to healing during the first yearafter dental implant placement.59 This wasthought to occur as a result of mechanical stresscaused by the implant body at alveolar crest leveland was defined as “saucerization.”60 Currently, itis accepted that this phenomenon occurs not onlyowing to mechanical stress created by the implantbody at the crest but also owing to lack of a spacefor biological width61 and the existence ofmicrogap62 at the alveolar crest level. Cochranand colleagues61 reported that a space of approxi-mately 3 mm in height is required for peri-implant sulcus formation around dental implantswithout alveolar bone loss. Thus, several implantdesigns have been modified to allow a polishedcollar to create biological width at the alveolarcrest. The dilemma is that existence of a polishedcollar may create esthetic problems due to metalcolor showing through the gingiva. Some dentalimplant surgeons have recommended embeddingthe polished collar into alveolar bone, especiallyat esthetic regions. This should not be consideredas a routine practice, since bone will not integrateon a polished titanium surface and the alveolarcrest will have a higher risk of resorption. Also,soft-tissue changes can occur; an additional 0.75mm and 0.9 mm of tissue recession can occur atsix months and one year, respectively, after abut-ment connection.63-65

CONCLUSION

Surgical and restorative concepts related toimplant dentistry have been modified tremen-dously through the years. The ultimate goal ofimplant-supported restorative therapy is toreplace a tooth with a structure that will mimicwhat is lost functionally and esthetically. Severalsurgical techniques have been developed to regen-erate soft and hard tissue with the aim ofimproving esthetics. These procedures allow thedentist to increase tissue support around dentalimplants. In addition, several parameters havebeen developed to control the esthetic outcome ofthe treatment. The initial trend of case reportsand personal communications has been replacedby clinical studies, though there still is a need forwell-controlled, longitudinal investigations. Gen-

eral dentists and specialists who would like toinclude implant dentistry in their practicesshould be familiar with the current improvementsand limitations of this fast-developing discipline. ■

The authors thank Dr. Maria Lavda (University of Illinois, Chicago)and Dr. Selim Pamuk (Istanbul University, Turkey) for allowing themto document the restorative treatment performed by these doctors.

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A Review of the Functional and Esthetic Requirement

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