1

Single Implant Supported Cantilever Prosthesis in the esthetic zone –

A new treatment approach.

Mauricio Barreto, DDS, DMD, MSc1

Carlos Eduardo Francischone, DDS, MSc, PhD2

Hugo Nary Filho, DDS, MSc, PhD3

1Doctorate Student, Course on Implantology, Sagrado Coração University, Bauru, São Paulo, Brazil.

2Titular Professor, Coordinator, Master of Science Degree Course on Implantology, Sagrado

Coração University, Bauru, São Paulo, Brazil.

3Assistant Professor, Coordinator, Master of Science Degree Course on Oral and Maxillofacial

Surgery, Sagrado Coração University, Bauru, São Paulo, Brazil.

Correspondence to:

MAURICIO ANDRADE BARRETO

AV.ACM,585 ED. ODONTOMEDICO LJ 35

SALVADOR, Bahia 41850-000

Telephone: (71) 3354 - 3344

e-mail – mauriciobarreto@implo.com.br

www.implo.com.br

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ABSTRACT

Background: Esthetic complications due to non harmonious periimplant soft tissue profiles

are common in the anterior maxilla, especially when two adjacent implants are found. This

controlled clinical studies evaluatied soft and hard tissue stability of a ten single implant supported

cantilever prosthesis.

Methods: Ten patients, 5 men e 5 women, with absence of the maxillary central and lateral

incisors were treated with a single implant supported cantilever prosthesis. The soft peri- implants

tissues were assessed using the Pink Esthetic Score (PES) described by Fürhauser et al. Assessment

of the level of peri- implant bone support were performed on radiographs taken 4 months after

implant placement, but immediately before implant exposition (baseline), and at the 6-months

follow-up (immediately after seating definitive prosthesis).

Results: The Pink Esthetic Score (PES) based on clinical photographs obtained 1 week after

seating definitive prosthesis is 9,22 (SD = 0,63). The crestal bone loss was - 0, 92 mm (SD = 0,8) at

6-moth follow-up (immediately after seating definitive prosthesis). The crestal bone level changes

for time interval was 1,42 mm (SD = 0,7).

Conclusions: The insertion of a single implant to replace two maxillary anterior teeth can

provide a more acceptable esthetic appearance of the periimplant soft tissue profile. The single

implant supported cantilever prosthesis was not able to prevent crestal bone loss More controlled

clinical studies are necessary to address soft and hard tissue stability in this treatment modality, as

well as studies to evaluate the mechanical performance of a single implant supported cantilever

prosthesis.

Keywords : dental papilla, gingival tissue, titanium implants, esthetic zone, implant-supported

prosthesis, cantilever

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INTRODUCTION

Presence or absence of papillary tissue between adjacent teeth,1 implants or tooth-implant

interface2 has received a great deal of attention from clinicians over the last 15 years, since filling

most of the interproximal embrasure space by papillae is fundamental for achieving a pleasant

dentogingival composition3.

Reformation of natural-appearing sulcular and papilla anatomy between adjacent implants in

the esthetic zone presents a complex challenge for the implant team. The replacement of multiple

adjacent missing teeth in the anterior maxilla with fixed implant restorations is poorly documented.

In this context, esthetic restoration is not predictable, particularly regarding the contours of the

interimplant soft tissue4.

Tarnow et al.2 measured papillary height between adjacent implants and found an average of

3.4mm, ranging from 1 to 7mm. When these results are compared with the papillary height between

natural teeth (5mm)1, this represents a lack of 1-2mm, which leads to important esthetic issues in the

anterior maxillary zone2.

To overcome this problem, several suggestions have been made for preserving or regaining

soft tissue integrity in the esthetic zone, through surgical5-8 or prosthetic9,10 procedures. However,

there is still an increasing demand for scientific investigation in this area.

The clinical situation in this article refers to the absence of two contiguous teeth in the

esthetic zone: the upper central and lateral incisors (Figs 1a and b). The therapeutic suggestion is to

insert two implants, but keeping the implant from the upper lateral incisor submerged and unloaded

prosthetics. The hypothesis to be proved is that this procedure can generate a better clinical

performance.

The biological rationale for this recommendation is based on the understanding of the

formation of the biologic space around titanium implants11. It is known that after the titanium

implant is exposed to the oral medium, a rapid reabsorption of the bone crest around the platform is

observed. Therefore, the exposure to the oral environment of single implant supported cantilever

prosthesis could make it possible to preserve the interdental papilla and gingival outline, there would

be at the crest bone reabsorption around the platform of the second implant.

4

a b

Figs 1a and 1b - Treatment of the absence of two adjacent teeth in the anterior maxilla, with

titanium implants. In the clinical case on the left (a) two contiguous implants were inserted and a

deficiency of the interdental papilla was observed. In the clinical case on the right (b) a single

implant exposed to the oral cavity and the presence of interdental papilla and a more harmonious

gingival outline were observed.

Therefore, clinicians must be careful during implant treatment planning in partially

edentulous patients, because two adjacent implants pose a greater esthetic risk due to gingival tissue

contours being less predictable.

The aim of this article is evalue soft/ hard implant tissue of a ten single implant supported

cantilever prosthesis in the anterior maxilla.

M ATERIAL AND METHODS

Clinical procedures

Ten patients, 5 men e 5 women, with absence of the maxillary central and lateral incisors are

randomly select (Fig 2). After adequate surgical and prosthetic planning, a bone graft was made to

augment the width of the alveolar bone crest, using the mandibular ramus as a donor site (Fig 3).

Four months later, a commercially pure titanium implant (PI Philosophy™, São Paulo, Brazil) was

placed in the maxillary central and lateral incisor region (Fig 4). The average distance between the

implants installed is of 3.58 mm (SD = 0.62).

The implant complied with the following specifications: platform diameter: 4.1mm, external

hexagon width: 2.7mm, external hexagon height: 0.71mm.

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Fig 3- Bone graft in the surgical area

a b

Fig 4 a and b – (a) Two implants placed in the maxillary left central and lateral incisor region.

A new bone graft was made to cover the entire implant (b) Periapical radiograph taken after five

month. Note the presence of bone crest in the maxillary lateral incisor region.

Two month later implants insertions, a sub-epithelial connective tissue graft was performed

(Fig.5) with the object of obtaining a more voluminous alveolar crest.

Fig 2 - Initial clinical situation in the anterior

maxillary zone.

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a b c

Four months later, the implant in the maxillary central incisor region was exposed and a

provisional cantilever fixed partial denture (FPD) (Fig 6) was made, using a titanium prosthetic

component screwed into the implant platform (UCLA Titanium, PI Philosophy ™ , São Paulo,

Brazil) and self-polymerizable acrylic (Jet Classic, São Paulo- Brazil). To obtain the plaster model, a

mold was made using a polyether based material (3M ESPE Impregum Soft), and a personalized

individual mold made of self-polymerizable acrylic (Jet Classic, São Paulo- Brazil). The opposing

dentition impression was made using an irreversible hydrocolloid. The soft tissue was conditioned

by means of successive compression cycles by adding self-polymerizable acrylic resin to the cervical

portion of the FPD (Fig 7).

a b c

Fig. 6 a to c- Clinical photograph showing the implant exposed (a), a fabricated FDP (b and c) in

a laboratory situation.

Fig. 5 a to c. Sub-epithelial connective tissue graft procedure performed

with the object of obtaining a more voluminous alveolar crest.

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a b c

When a period of 90 days after performing the subepithelial connective tissue graft had

elapsed, procedures to make the definitive denture were started. Thus a new polyether mold (3M

ESPE Impregum Soft) of the maxillary arch and a personalized individual mold were made. For

correct molding of the peri-implant soft tissue, the provisional denture was used to personalize an

impression coping with self-polymerizable acrylic (Duralay II, Reliance, Worth, IL) (Fig 8).

a b

Figs 7a and b – Clinical photographs showing the emergency profile in the central incisor

region (a) and a fabricated FDP inserted (b). Periapical radiograph taken 3 months after the FDP

was inserted. Note the presence of bone crest in the maxillary lateral incisor region (c).

Fig. 8a and b - Molding for making the definitive denture. Observe that the correct

molding of the peri- implant soft tissue was obtained by means of personalizing the

molding component.

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A screw retained zirconia metal- free framework was made (ZircozanT M Italy) (Fig 9). The

screw retained definitive prosthesis (Fig. 10) was inserted 5 months after the surgical procedures.

Occlusal adjustment was made in order to maintain a slight occlusal contact in the maximum

intercuspation position, and an anterior guide with concomitant contacts on the two central incisors.

An endeavor was made to avoid occlusal contacts on the maxillary left lateral incisor (cantilever).

a b

Figs 10a and b – Final prosthesis inserted. Note that the interdental papilla is more coronal in

relation to the contra lateral counterpart.

Fig. 9 - All-ceramic zirconia framework in position.

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Fig 11 - Periapical radiograph taken 1 immediately after the definitive prosthesis was inserted. Note

the presence of bone crest in the maxillary lateral incisor region.

Evaluation of soft peri-implants tissues:

The soft peri- implants tissues were assessed using the Pink Esthetic Score (PES) described

by Fürhauser et al12. The PES is based on seven variables: mesial papilla, distal papilla, soft-tissue

level, soft-tissue contour, alveolar process deficiency, soft-tissue color and texture (Fig. 12). Each

variable was assessed with a 2-1-0 score, with 2 being the best and 0 the poorest score. Clinical

photographs (20 D digital camera, Cannon, 100 mm lens and circular flashes) of ten single implant

supported cantilever prosthesis in the anterior maxilla were evaluated. All of them replaced central

and lateral incisor. Photographs were obtained 1 week after seating definitive prosthesis (10

photographs). For assessing anterior teeth replacements, the contra lateral reference teeth had to be

visible well enough to ensure comparability. The photographs were magnified to twice the original

size, printed out on A4 sheets together with the list of variables. Implant-supported crows were

marked by arrows. All photographs were developed and processed by the same person. Blinded

evaluation of clinical photographs was carried out by specialists who had not been involved in the

treatment. The questionnaire was handed to 3 individuals of variable specialization (1 prosthodontist,

1 oral surgeon and 1 dental student). Assessments were made twice at an interval of 4 weeks. To

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reduce any bias, from the first viewing, the order of the photographs was reversed for the second

viewing.

Fig. 12 – Illustrative view of pink esthetic score variables.

Statistical analysis

Differences between the two assessments were evaluated with the X2 test. Differences

between the three specialists were evaluated with the Wilcoxon test. P< 0.05 was considered to be

significant.

a. Evaluation of hard peri-implants tissues.

Intraoral dental radiographs were taken to assess hard peri- implants tissues by the technique

for standardized evaluation suggested by MEIJNDERT et al13. A cast model of the dentition was

used to construct a custom made acrylic splint to the occlusal surface (Fig. 13). A prefabricated,

acrylic small film holder is connected on the palatal side to the splint.

Assessment of the level of peri- implant bone support were performed on radiographs taken 4

months after implant placement, but before implant exposition (baseline), and at the 6-months

follow-up (immediately after seating definitive prosthesis). Intraoral radiographs were obtained

using a bissetris technique. The radiographs were digitalized using a scanner (UMAX, Astra 4000 U,

Korea) at 600 dpi, 256 gray scales.

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In the clinical radiographs, it was used, as a horizontal reference, a line from the most coronal

proximal margin of the implants platform (Fig. 14). The apical area to the line was considered

negative and the coronal area, positive. Using the middle point of the line as the reference and the

coronal point of crestal bone, the distance was measured to the nearest 0.01 mm with the UTHSCSA

Image Tool (version 3.00 for windows, University of Texas Health Science in San Antonio, TX).

a b

a b

Fig. 13 a and b – Intraoral dental x-ray film on the place of the scheduled implant position and of surrounding teeth in the laboratory (a) and in a clinical situation (b).

Fig. 14 a and b – a) radiographic image showing the horizontal reference line (proximal margin of the implants platform) and the measurement of the most coronal point of crestal bone between the implants (vertical line) b) Measurement of crestal bone loss on a radiographic image using UTHSCSA Image Tool Software.

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RESULTS

Soft peri- implants tissues:

In each two assessment, 3 observers rated 10 cases, i.e. a total of 30 PESs/assessments. All in

all, 60 PESs with 420 single variables were available for analysis. The mean PES based on clinical

photographs obtained 1 week after seating definitive prosthesis was 9,22. The standard derivation

was + 0,63 for observers and + 2,94 for patients. No significant differences between observers and

assessment were found (P < .05). These data are presented in table 1.

Table 1 The Pink Esthetic Score (PES) - (see Figure 12)

Pacients Observer 1 Observer 2 Observer 3 Mean SD 1 8 6,5 8,5 7,67 1,00 2 6 7 7 6,67 0,19 3 9 7,5 7,5 8,00 0,29 4 11 11 10 10,67 0,51 5 13,5 13 13,5 13,33 0,25 6 7,5 6,5 8,5 7,50 1,00 7 5 2 5 4,00 1,53 8 9,5 11 10 10,17 0,54 9 11,5 12 11 11,50 0,50

10 12 12,5 13,5 12,67 0,54 Mean 9,3 8,9 9,45 9,22 0,63

SD 2,73 3,54 2,73 2,94

The single-variable analysis show that the score 0 was signed to the seven variables in 8,33

% of cases, the score 1 was signed in 51,18 % and the score 2 was signed 40,48%. The highest

possible score of 2 was signed to distal papilla in 35% of cases, the score 1 was signed 51,66 and the

score 0 was signed 13,33%. These data are presented in table 2.

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Table 2 Frequency of variable assessment of score s 0, 1 and 2.

Variable Score 0 Score 1 Score 2 No. % No. % No. %

Mesial papilla 10 16,66 26 43,33 24 40 Distal Papilla 8 13,33 31 51,66 21 35

Alveolar process 5 8,33 19 31,66 36 60 Soft-tissue texture 5 8,33 34 56,66 21 35 Soft-tissue contour 5 8,33 31 51,66 24 40 Soft-tissue collor 0 0 37 61,66 23 38,33

Level of Soft-tissue margin 2 3,33 37 61,66 21 35 Mean 5,00 8,33 30,71 51,18 24,29 40,48

SD 3,37 5,61 6,45 10,75 5,35 8,91

b. Hard peri-implants tissues.

The crestal bone loss was - 0, 92 mm (+ 0,8 SD) at 6-moth follow-up (immediately after

seating definitive prosthesis). The crestal bone level changes for time interval was 1,42 mm (+ 0,7

SD). These data are presented in table 3. ,

Table 3 Crestal Bone Level (mm) Changes for Different Time Interval (see Figure 14)

Pacients Baseline Follow-up 6-month Difference 1 1,27 -1,18 2,45 2 0,98 0,88 0,1 3 0,54 -1,06 1,6 4 0,27 -0,58 0,85 5 0 -1,12 1,12 6 0,7 -1,6 2,3 7 1,39 -0,42 1,81 8 0 -0,93 0,93 9 -0,53 -2,19 1,66

10 0,41 -1 1,41 Mean 0,50 -0,92 1,42 SD 0,6 0,8 0,7

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DISCUSSION

Soft tissue behavior

The soft tissue profile is a fundamental factor in the esthetic appearance of implant

prostheses. But how can a single implant replacing two adjacent teeth contribute to stabilizing the

gingival tissue contours? This explanation is perhaps found when one understands the biologic width

around implants.11 It is well known that bone loss near the implant platform is observed just after the

second stage surgery.14 The bone resorption process takes place in an apical and lateral direction15;

magnitude of bone loss is dependent on several factors, among others, the periodontal biotypes 16,

prosthetic load17 implant type14 and initial implant position18.

Why is the gingival contour difficult to maintain in the presence of two adjacent implants

exposed? First, we have to consider that the edentulous alveolar ridge is flat and no bone crest is

observed under the gingival papilla, as seen between two adjacent natural teeth. Thus, a second

exposed adjacent implant is problematic, because it contributes to the lateral bone loss in the implant

platform, thus decreasing the bone crest height between the implants even further15. In the single-

implant technique, the chance of a more stable alveolar ridge increases.

In the present study, the evaluation of ten single implant supported cantilever prosthesis in

the anterior maxilla, there was a PES average of 9.22 (+ 2.94 SD). In 2000, Fürhauser et all12

showed the mean PES at first assessment (n = 600) was 9.46 (+ 3.81 SD) and 9.24 (+ 3.8 SD) at the

second one to assess 30 single-tooth implant crows. Thus we can conclude, based on the sample

submitted, that insertion of one implant to replace two adjacent teeth demonstrates the same effects

as those observed at implant-supported single-tooth replacements. This hypothesis, if proved

scientifically in the future based on more randomized controlled clinical studies, could represent a

new esthetic parameter for the treatment of absence of two contiguous teeth in the anterior maxilla.

The single-variable analysis showed the lowest possible score of 0 was assigned to the mesial

papilla in 16.66% of cases and to the distal papilla in 13.33%. These data are in agreement with

other publications19, 20 that reported the achievement of gingival papilla as the major obstacle of

osseointegration. However, in this study, most patients received scores 1 and 2 in the gingival

papillae, demonstrating that a single implant supported cantilever prosthesis can provide satisfactory

cosmetic results.

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Hard tissue behavior

The crestal bone loss was - 0, 92 mm (+ 0.8 SD) at 6-moth follow-up (immediately after

seating definitive prosthesis) and the crestal bone level changes for time interval was 1,42 mm (+ 0.7

SD). Based on these data, we can say that single implant supported cantilever prosthesis was not able

to prevent crestal bone loss. It is important to emphasize that the second implant installed in the

upper lateral incisor was kept covered by gingival tissue, and is not therefore subject to load

prosthetics.

These data are consistent to those seen by Tarnow et all15 in 2000 that assessed the effect of

inter- implant distance on height of inter- implant bone crest when we have two adjacent implants

exposed to the oral cavity. In Tarnow’s study, the crestal bone loss for implants with a greater than 3

mm distance between them was 0,45mm, while the implants that had a distance of 3mm or less

between them had a crestal bone loss of 1.04 mm. Therefore, we can say that single implant

supported cantilever prosthesis made a crestal bone loss similar to that observed when two implants

had a distance of 3 mm or less between them. How to explain this fact? Firstly, it is important to

remember that most patients were subjected to increased bone vertical through autogenous bone

graft. For the concept of vertical ridge augmentation to enable dental implant placement, there are

clinical and histological data supporting its potential use. However, this procedure in order to

improve the aesthetics is poorly documented21, 22. Another possibility is bacterial contamination of

the implant covered by gingival tissue23. Furthermore, the surgical trauma of insertion of the second

implant may explain the crestal bone loss.

Despite the crestal bone loss observed, this study showed that the aesthetic end of treatment

was satisfactory. To speculate that it may, under the conditions of the study, the implant installed in

the upper lateral Incisor played the mechanical support of soft tissue, thus keeping the volume of soft

tissue compatible with an aesthetically pleasing result.

The validity of the use of the second implant submerged

In the present study, 2 implants were installed: one in the upper central incisor and another in

the region of upper lateral incisor. The second implant was left submerged and unloaded prosthetics.

It is the use of the implant submerged for two reasons: first, by a lack of scientific evidence to

recommend the use of single implant supported cantilever prosthesis in humans, during a

16

complication of biomechanics, we would have the second available to support prosthetic implant.

The second justification is based on clinical observation: It is observed that around fixing screws

bone graft, bone has a lower degree of bone resorption (Fig.15). Thus, it was this same effect with

the implant submerged. In the present study, bone loss occurred around the implant covered by

gingival tissue in some patients (Fig. 16).

a b

Fig . 15 - Clinical photographs showing bone graft surgery. b) Upon the establishment of the graft.

b) After 4 months. Note the large bone resorption and maintenance of bone tissue around the screws

for fixing the graft.

Fig 16. Periapical radiograph taken immediately after the definitive prosthesis was inserted. Note

bone loss around the implant in the left lateral incisor.

17

Thus, one can say that the implant not exposed to the oral cavity was not effective in

preventing bone resorption. Moreover, as discussed earlier, the final aesthetic result of the treatment

was satisfactory. It is speculated, then, that the submerged implant may play the role of mechanical

support of soft tissues. If this hypothesis is proven in the future, you can construct solid cylinders of

titanium for mechanical support of soft tissues, which in theory would be less susceptible to bacterial

contamination.

Implant connection type

In the periapical radiographs of the two clinical cases described in this article, it was possible

to observe a circumferential radiolucent area close to the implant platform, compatible with the

biologic width around titanium implants11. Several advances have been described to maintain the

bone crest around implants by macro and microanatomic implant modifications.24, 25, 26.

Several implant manufacturers evoke their clinical superiority for maintaining optimal bone

crest levels, but there is a lack of extensive clinical documentation on this topic.27 Despite this, it is

expected that new designs will be able to keep desirable bone levels around the implant platforms.

Thus, unless new implant designs demonstrate the same bone crest/coronal root portion

relationships, the clinician should consider the use of a single implant to replace two lost adjacent

teeth in the anterior maxilla, because it is thought that this procedure could result in better clinical

performance.

Framework

High-strength all-ceramic systems for fixed partial dentures (FPDs) are available for

replacing missing teeth. New core/framework materials have been developed and have evolved in

the last decade28. All-ceramic systems are a focus of interest, because they offer aesthetic results

that may be difficult to achieve with metal-ceramic systems. Nowadays, the new ceramics associate

good esthetic and mechanical qualities, biocompatibility and accurate marginal fit.29, 30. But what is

the best material for making the framework of single implant supported cantilever prosthesis? From

the mechanical point of view, one could speculate that metal-ceramic bridges are preferably

indicated due to their predictable characteristics of long-term strength. All-ceramic systems can be

recommended for anterior bridges, especially if highly satisfactory esthetic results are required.

18

There are no studies that make reference to the use of implant-supported all-ceramic restorations

applied in a single implant supported cantilever prosthesis. Further studies should be conducted for

detailed evaluation of the clinical performance of all-ceramic systems for fixed partial dentures

(FPDs)31 and single implant supported cantilever prosthesis.

Biomechanical risks

The number of implants and their length, as well as bone quality, occlusal pattern and

prosthesis design are fundamental to the biomechanical integrity of an implant prosthesis.32 With

regard to the possible biomechanical risks, is it safe to plan a single implant supported cantilever

prosthesis in the anterior maxilla?

Barreto et al33 assess the unscrewing and alignment torque of the screw of an implant

supported denture with pillar and cantilever by means of a fatigue test. Torque and detorque were

measured before cycling fatigue three times, with intervals of two minutes between measurements

and a single time after cycling. In the screwed group, the mean initial detorque value was 25.2 +

2.9N/cm and final detorque value was 22.7 ± 0.9N/cm (p=0.049 Wilcoxon Test). In the cemented

group, the mean initial detorque value was 27.67 + 1.92N/cm and final detorque value was 24.7 +

1.55N/cm. (p=0.002 paired t-Test). Significant difference was observed between the pre-fatigue

mean detorque values and the post-fatigue detorque value in both groups. No significant alterations

were found in the denture screw alignment. In spite of the reduction in the unscrewing torque, there

was no slackening and loosening of screws.

Even with the lack of scientific evidences, some factors point out to a favor their treatment

option: The occlusal forces in the anterior region are less than half the value observed in the

posterior region;34 manufacturers constantly seek to develop implants that present more bone to

implant contact, which could increase due to their anchorage35; a thorough occlusal adjustment with

slight contact in the maximum intercuspation, with unimpeded lateral and protrusive excursive

movements around the implant; and excluding patients with parafunctional habits and class II and

class III malocclusion36 from this type of treatment, are factors that can determine the

biomechanical longevity of single implant supported cantilever prosthesis.

19

CONCLUSION

The insertion of a single implant to replace two maxillary anterior teeth can provide a more

acceptable esthetic appearance of the periimplant soft tissue profile. The single implant supported

cantilever prosthesis was not able to prevent crestal bone loss More controlled clinical studies are

necessary to address soft and hard tissue stability in this treatment modality, as well as studies to

evaluate the mechanical performance of a single implant supported cantilever prosthesis.

REFERENCES

1. Tarnow DP, Magner AW, Fletcher P. The effect of the distance from the contact point to the

crest of bone on the presence or absence of the interproximal dental papilla. J Periodontol

1992;63: 995-996.

2. Tarnow DP, Elian N, Fletcher P, Froum S, Magner AW, Cho S et al. Vertical distance from

the crest of bone to the height of the interproximal papilla between adjacent implants. J

Periodontol 2003;74:1785-1788.

3. Leblebicioglu B, Rawal S, Mariotti A. A review of the functional and esthetic requirements

for dental implants. J Am Dent Assoc. 2007 Mar;138(3):321-9. Review.

4. Belser UC, Schmid B, Higginbottom F, Buser D. Outcome analysis of implant restorations

located in the anterior maxilla: a review of the recent literature. Int J Oral Maxillofac

Implants. 2004;19 Suppl:30-42. Review.

5. Steigmann M, Wang HL. Esthetic buccal flap for correction of buccal fenestration defects

during flapless immediate implant surgery. J Periodontol;77:517-22, 2006.

6. Oh TJ, Shotwell JL, Billy EJ, Wang HL. Effect of flapless implant surgery on soft tissue

profile: a randomized controlled clinical trial. J Periodontol;77:874-82, 2006.

7. Nasr HF. Current methods for soft tissue enhancement of the esthetic zone. Atlas Oral

Maxillofac Surg Clin North Am 2006;14:39-49.

8. Scarso J, Barreto M, Tunes U. Planejamento estético, cirúrgico e protético em

implantodontia. Ed. Artes Médicas, 2001.

9. Lesage BP. Improving implant aesthetics: prosthetically generated papilla through tissue

modeling with composite. Pract Proced Aesthet Dent 2006;18:257-63.

20

10. Donitza A. Prosthetic procedures for optimal aesthetics in single-tooth implant restorations: a

case report. Pract Periodontics Aesthet Dent 2000;12:347-52.

11. Hermann JS, Buser D, Schenk RK, Higginbottom FL, Cochran DL. Biologic width around

titanium implants. A physiologically formed and stable dimension over time. Clin Oral

Implants Res 2000;11:1-11.

12. Fürhauser R, Florescu D, Benesch T, Haas R, Mailath G, Watzek G. Evaluation of soft tissue

around single-tooth implant crowns: the pink esthetic score. Clin Oral Implants Res 2005

Dec; 16(6) :639-44.

13. Meijndert L, Meijer HJ, Raghoebar GM, Vissink A. A technique for standardized evaluation

of soft and hard peri- implant tissues in partially edentulous patients. J Periodontol. 2004

May;75(5):646-51.

14. Hermann JS, Buser D, Schenk RK, Schoolfield JD, Cochran DL. Biologic Width around one-

and two-piece titanium implants. Clin Oral Implants Res. 2001 Dec;12(6):559-71.

15. Tarnow DP, Cho SC, Wallace SS. The effect of inter- implant distance on the height of inter-

implant bone crest. J Periodontol. 2000 Apr;71(4):546-9.

16. Sanavi F, Weisgold AS, Rose LF. Biologic width and its relation to periodontal biotypes. J

Esthet Dent. 1998;10(3):157-63.

17. Duyck J, Rønold HJ, Van Oosterwyck H, Naert I, Vander Sloten J, Ellingsen JE. The

influence of static and dynamic loading on marginal bone reactions around osseointegrated

implants: an animal experimental study. Clin Oral Implants Res. 2001 Jun;12(3):207-18.

18. Hartman GA, Cochran DL. Initial implant position determines the magnitude of crestal bone

remodeling. J Periodontol. 2004 Apr;75(4):572-7.

19. Pradeep AR, Karthikeyan BV. Peri- implant papilla reconstruction: realities and limitations. J

Periodontol. 2006 Mar;77(3):534-44

20. Elian N, Jalbout ZN, Cho SC, Froum S, Tarnow DP. Realities and limitations in the

management of the interdental papilla between implants: three case reports.. Pract Proced

Aesthet Dent. 2003 Nov-Dec;15(10):737-44; quiz 746. Review

21. Clinical outcomes of vertical bone augmentation to enable dental implant placement: a

systematic review. Rocchietta I, Fontana F, Simion M. J Clin Periodontol. 2008 Sep;35(8

Suppl):203-15. Review.

21

22. Esposito M, Grusovin MG, Coulthard P, Worthington HV. The efficacy of various bone

augmentation procedures for dental implants: a Cochrane systematic review of randomized

controlled clinical trials.. Int J Oral Maxillofac Implants. 2006 Sep-Oct;21(5):696-710.

Review

23. Barboza EP, Caúla AL, Carvalho WR. Crestal bone loss around submerged and exposed

unloaded dental implants: a radiographic and microbiological descriptive study. Implant

Dent. 2002;11(2):162-9.

24. Holt RL, Rosenberg MM, Zinser PJ, Ganeles J. A concept for a biologically derived,

parabolic implant design. Int J Periodontics Restorative Dent. 2002 Oct;22(5):473-81

25. Glauser R, Schüpbach P, Gottlow J, Hämmerle CH. Periimplant soft tissue barrier at

experimental one-piece mini- implants with different surface topography in humans: A light-

microscopic overview and histometric analysis. Clin Implant Dent Relat Res. 2005;7 Suppl

1:S44-51.

26. Hermann F, Lerner H, Palti A. Factors influencing the preservation of the periimplant

marginal bone. Implant Dent. 2007 Jun;16(2):165-75.

27. Eckert SE, Choi YG, Sánchez AR, Koka S. Comparison of dental implant systems: Quality

of clinical evidence and prediction of 5-year survival. Int J Oral Maxillofac Implants

2005;20:406-415.

28. Raigrodski AJ. Contemporary materials and technologies for all-ceramic fixed partial

dentures: a review of the literature. J Prosthet Dent. 2004 Dec;92(6):557-62. Review

29. Sadan A, Blatz MB, Lang B. Clinical considerations for densely sintered alumina and

zirconia restorations: Part 1. Int J Periodontics Restorative Dent. 2005 Jun;25(3):213-9.

30. Sadan A, Blatz MB, Lang B. Clinical considerations for densely sintered alumina and

zirconia restorations: part 2. Int J Periodontics Restorative Dent. 2005 Aug;25(4):343-9.

31. Wassermann A, Kaiser M, Strub JR. Clinical long-term results of VITA In-Ceram Classic

crowns and fixed partial dentures: A systematic literature review. Int J Prosthodont. 2006 Jul-

Aug;19(4):355-63. Review.

32. Adell R, Lekholm U, Rockler B, Brånemark PI. A 15-year study of osseointegrated implants

in the treatment of the edentulous jaw. Int J Oral Surg, 1981;10:387-416.

33. Barreto M, Francischone CE, Rosseti P, Laurenti JA. Mechanical evaluation of an single

implant supported cantilever prosthesis by a cyclic load test. Quintecensse Int. In press.

22

34. Gibbs CH, Mahan PE, Mauderli A, Lundeen HC, Walsh EK. Limits of human bite strength.J

Prosthet Dent. 1986 Aug;56(2):226-9.

35. Albrektsson T, Wennerberg A. Oral implant surfaces: Part 1--review focusing on topographic

and chemical properties of different surfaces and in vivo responses to them. Int J

Prosthodont. 2004 Sep-Oct;17(5):536-43.

36. Kim Y, Oh TJ, Misch CE, Wang HL. Occlusal considerations in implant therapy: clinical

guidelines with biomechanical rationale. Clin Oral Implants Res. 2005 Feb;16(1):26-35.

Review