Advances in Esthetic, Immediate Tooth Replacement Therapy Aimed at Improving Clinical Outcomes.

The criteria for successful tooth replacement in the esthetic zone is comprehensive and often complex. Merely achieving osseointegration is no longer the bar for which clinicians strive to reach in this endeavor. Achieving and maintaining hard- and soft-tissue stability as well as physiologic, scalloped soft-tissue architecture to frame cosmetic restorations is the ultimate goal of esthetic, immediate tooth replacement therapy (EITRT).

A comparative analysis of dual-axis implants placed into maxillary anterior extraction sockets versus virtual planning with uniaxial implants: A simulated cone beam computed tomography study of implant length and diameter.

OBJECTIVE: The biaxial nature of the anterior maxilla poses a surgical and restorative challenge in implant dentistry. The present study sought to investigate the apical socket perforation rate (ASPR) from a simulated uniaxial implant placement and to determine the effect of implant length and diameter on ASPR when a uniaxial implant was placed compared with the orientation of the pre-existing dual-axis implant. MATERIAL AND METHOD: Cone beam computed tomography (CBCT) scans from the database of three private practices were searched for patients who received dual-axis implants within the esthetic zone in immediate tooth replacement therapy. A uniaxial implant was virtually placed using the pre-existing screw access channel of the dual-axis implant as a reference. The closest length and diameter were selected for the simulated implant. ASPR by the uniaxial implant was recorded. In addition, the affordable maximum length of a corresponding uniaxial implant that would avoid apical socket perforation was measured. RESULT: Eighty-one patients with a total of 101 dual-axis dental implants were selected for analysis. A simulated virtual surgical planning with uniaxial implants revealed high ASPR (48.51%). When the length of the uniaxial implant was reduced to 11 and 9 mm, ASPR was decreased to 41.58% and 20.79%, respectively. CONCLUSION: Dual-axis implant design effectively evades anatomical challenges in the anterior maxilla (esthetic zone). Considering the current evidence, efforts should be made to carefully consider the angular disparity between the extraction socket-alveolus complex and the future restorative emergence so that a harmonious biologic-esthetic result may be more predictably and consistently obtained.

Changes in Peri-Implant Soft Tissue Thickness with Bone Grafting and Dermis Allograft. Part III: A Case Series Using a Novel, Hybrid Implant Design with a Subcrestal Angle Correction.

This comparative case series presents 16 consecutively placed and temporized immediate implants in the maxillary esthetic zone. The implants have a novel, inverted body-shift design, intended to achieve high levels of primary stability via the tapered apical portion. The coronal narrow cylinder provides greater space between the implant platform and facial socket wall and adjacent teeth/implants, allowing a greater opportunity for augmentation. The restorative platform also features a subcrestal angle correction, which facilitates screw retention. The wider, facial platform-shift thus creates more room for augmentation via dual-zone bone grafting and the application of a dermal allograft, which yields greater soft tissue thickness after initial healing. This case series aimed to evaluate soft tissue thickness and compare the results to two previously published cohorts where implant design served as the only variable between groups.

What Are the Three Most Essential Elements to Implants in the Esthetic Zone?

There are many essential elements to achieving long-lasting esthetic and physiologic outcomes in implant dentistry in the esthetic zone. Here are three specialists take on the three most essential elements to implants in the esthetic zone.

Long-Term Esthetic Complications Associated With Anterior Implant-Supported Restorations.

Having demonstrated high average survival rates, osseointegrated endosseous dental implants are considered a predictable solution for the replacement of missing teeth. Most studies and case reports have concentrated on the success and/or failure of dental implant-supported restorations in the posterior regions of the mouth, while fewer reports have investigated the performance of such treatments in the esthetic segment. Today, it is recognized that in addition to implant survival, other parameters of implant dentistry are considerations when evaluating success or failure in the esthetic zone. These include numerous patient and operator assessments of peri-implant soft-tissue level, prosthesis level, subjective smile and esthetic appearance, and phonetic changes. Implant dentistry in the esthetic zone is highly challenging because of not only the immediate postoperative appearance, but also the potential changes that might occur in the long term, such as soft- and hard-tissue recessions, infraocclusion of single implants adjacent to natural teeth, and the unpredictable development of peri-implantitis. Thus, the aim of this article is to identify possible long-term biologic complications that may develop around dental implant in the esthetic zone and discuss their effect on treatment decisions.

Outcomes of a 1-Year Prospective Single-Arm Cohort Study Using a Novel Macro-Hybrid Implant Design in Extraction Sockets: Part 1.

A novel macro-hybrid implant design was introduced to afford high apical primary stability and more coronal space to preserve the circumferential extraction socket architecture. This study presents 1-year data from a prospective single-arm cohort study. The data was distilled based on the following criteria: (1) single-tooth immediate tooth replacement therapy (ITRT) in the maxillary anterior and premolar regions in intact (Type 1) extraction sockets that were (2) treated with the dual-zone grafting technique. The clinical and radiographic outcomes of 48 ITRT implants were evaluated. The mean ± SD labial plate dimension changes were 0.33 ± 0.41 mm at the implant abutment interface (L1) and 0.34 ± 0.40 mm at 5.0 mm below (L2). The mean labial plate dimension (thickness) at the 1-year recall was 2.27 ± 0.88 mm (L1) and 1.95 ± 0.95 mm (L2). At ITRT, the ridge contour at the free gingival margin and 3.0 mm below it were 7.54 ± 0.93 mm and 9.44 ± 2.36 mm, respectively; after final restoration delivery, the corresponding values were 7.45 ± 0.95 mm and 10.23 ± 2.30 mm, respectively. The peri-implant soft tissue thickness (PISTT) at the time of implant-level impression-making was 3.29 ± 0.73 mm, with an average Pink Esthetic Score of 12.79. A macro-hybrid implant design showed high levels of primary stability (~60 Ncm), stable ridge contour at 1 year, a labial plate dimension between 1.5 and 2.0 mm, and PISTT > 3.0 mm, which may be a critical factor in providing stable, long-term esthetic outcomes.

A Novel Implant Design for Immediate Extraction Sites: Determining Primary Stability.

Achieving primary stability is a critical challenge presented by immediate implant therapy. Surgeons often utilize wider, tapered implants for this purpose, or they use longer implants to achieve primary stability. Both strategies are associated with negative ramifications. Prosthetically guided implant placement must respect biologic principles, such as tooth-implant and implant-implant distance, gap space between the implant and the facial cortex, and, when possible, screw-retention of the prosthesis. A novel implant design geared toward achieving a predictable level of primary stability while adhering to the aforementioned physiologic principles was recently introduced. Both primary and secondary implant stability, along with hard and soft tissue stability, are demonstrated in this study of 107 consecutively placed implants. Rotational and axial stability can be produced with this newly designed implant, along with predictable osseointegration and tissue preservation.

Rehabilitation of an Esthetic Compromise in a Patient Previously Treated With Maxillary Anterior Implants.

Over time, patients treated in developmental stages of implantology may need additional treatment,as teeth adjacent to implants may fail and require replacement themselves with new implants. Blending newer implant rehabilitations into a dentition with existing implant-supported restorations can be challenging. The use of implants with a subcrestal angle correction (SAC) enables predictable screw-retained anchorage of temporary and definitive restorations. An SAC implant often can be placed into the palatal bone of an extraction socket, along the incisal angle of the crown, allowing screw retention of the prosthesis. This case report demonstrates the use of both straight and SAC implants combined with hard- and soft-tissue augmentation and serial provisionalization to replace hopeless teeth adjacent to pre-existing implants and improve esthetics in the anterior maxilla.

Use of a Novel Implant with an Inverted Body-Shift and Prosthetic Angle Correction Design for Immediate Tooth Replacement in the Esthetic Zone: A Clinical Case Series.

A clinical case series of three patients is presented using a novel implant design to not only address primary stability but also to prevent damage to the labial bone plate and improve the interdental space for papillae preservation with immediate tooth replacement therapy. This unique implant design features an apicocoronal inverted body-shift in diameter (wide to narrow), shape (tapered to cylindrical), thread depth (deep to shallow), and thread pattern (V-shaped to square) to achieve uncompromised primary stability and esthetics, particularly in extraction sockets, in a singular body form. In addition, the implant possesses a prosthetic angle correction within the implant body to facilitate screw-retention of the restoration and avoid the risk of apical socket perforation.

The Importance of Interdisciplinary Treatment in an Esthetically Challenging Case.

A single missing tooth is a common occurrence among young patients and impacts esthetics and long-term oral health in terms of compromised bone, gum tissue, and, if warranted, an implant and final prosthesis. In this case report, after years of poorly executed orthodontic therapy, the patient's dental growth complicated the development of an esthetically pleasing smile. An interdisciplinary approach was utilized comprising periodontal surgery, a second course of orthodontics, and prosthodontics to provide comprehensive patient care that included evaluation of occlusion and esthetics. Orthodontic treatment was performed to position the teeth in the most esthetic, functionally optimal position. An implant crown in the maxillary left central incisor position and direct bonding on the maxillary right central incisor were indicated to treat a large edentulous area. Final orthodontic treatment achieved a substantial reduction of incisor protrusion and proper mesial-distal distance between the future implant and adjacent teeth. An ideal emergence profile, appealing esthetics, and a provisional restoration were created before the final crown. Optimal alignment of teeth relative to the arch was achieved, and adequate tissue dimensions were created by combining surgical augmentations with provisional restorative therapy.

Immediate Tooth Replacement Therapy in Postextraction Sockets: A Comparative Prospective Study on the Effect of Variable Platform-Switched Subcrestal Angle Correction Implants.

Immediate tooth replacement therapy (ITRT), ie, immediate implant placement and provisional restoration in postextraction sockets, has been shown to achieve favorable outcomes in reference to soft tissue stability and esthetics. However, avoiding socket perforation with uniaxial implants in the anterior maxilla can be challenging due to the inherent anatomy. Dual or co-axis subcrestal angle correction (SAC) implants have been developed to change the restorative angle of the clinical crown restoration subcrestally at the implant-abutment interface to enhance the incidence of screw-retained definitive restorations. An additional benefit of this macrodesign implant feature is variable platform switching (VPS) that increases soft tissue gap distance above the implant platform. The purpose of this prospective study on ITRT in maxillary anterior postextraction sockets was to investigate the effect of SAC with VPS (SAC/VPS) compared to conventional platform-switch-design implants (PS) relative to ridge dimension stability and peri-implant soft tissue thickness. A total of 29 patients had undergone ITRT and received either a PS or SAC/VPS implant; previously described measurements were made compared to the contralateral natural tooth sites. When the comparison of buccal soft tissue thickness was made, SAC/VPS showed a greater increase compared to PS (3.12 mm vs 2.39 mm, respectively) with statistical significance (P = .05). The increase was independent from periodontal phenotype. Therefore, SAC/VPS may increase peri-implant soft tissue thickness and help minimize recession following ITRT.

Tapered Versus Inverted Body-Shift Implants Placed Into Anterior Post-extraction Sockets: A Retrospective Comparative Study.

BACKGROUND: A retrospective comparative radiographic and clinical studywas performed to evaluate primary stability, bone volume, and esthetic outcomes of tapered (T) implants (control group) versus inverted body-shift (INV) implants (test group). METHODS: A total of 42 platform-switched implants, 21 T and 21 INV, were used to replace nonrestorable teeth in maxillary central incisor post-extraction sockets. Implant primary stability and insertion torque values in addition to radiographic differences in labial plate dimension, tooth-to-implant distance, and marginal bone levels were correlated with clinical outcomes using the pink esthetic score (PES). RESULTS: Statistically significant differences (P ≤ .05) were found between groups, with T implants having not only lower primary stability at immediate implant placement than INV implants but also less circumferential bone volume at recall. Consequently, lower PESs were seen in the T implant group that equated to an increased frequency of midfacial recession, tissue discoloration, and papilla loss. CONCLUSIONS: INV implants, which feature a unique macro hybrid design, may offer advantages over T implants in maxillary anterior post-extraction sockets with regard to achieving both higher primary stability and superior esthetic outcomes.

Simultaneous Crestal Sinus Elevation and Implant Placement Using a Ribose Cross- Linked, Collagen Bone Graft Material: Case Series of 28 Consecutive Patients.

The anatomic proximity of the maxillary sinus to the apices of molar and premolar teeth is a significant factor when considering implant therapy to replace maxillary posterior teeth. An emerging field within tissue engineering is the application of xenografts capable of stimulating de novo bone regeneration. This article presents a technique using a crestal approach to sinus grafting utilizing a novel bone graft material composed of porcine, ribose cross-linked collagen seeded with a nanocrystalline hydroxyapatite mineral. This highly cohesive biomaterial is able to minimize graft migration, which is particularly important in case of undetected Schneiderian membrane perforations. The material also has been demonstrated in animal studies to be capable of osteoconduction, resulting in increased bone volume in ridge augmentation procedures.

Changes in Peri-implant Soft Tissue Thickness with Bone Grafting and Dermis Allograft. Part II: A Comparative Retrospective Case Series Using a Subcrestal Angle Correction Implant Design.

Immediate tooth replacement therapy (ITRT) in the maxillary anterior sextant is an increasingly frequent treatment option sought by patients and performed by clinicians worldwide. Achieving long-term results that are predictable, stable, esthetic, and healthy is the ultimate goal. This trend also lends itself to minimally invasive surgery as well as defining the procedure to a singular surgical intervention. Preserving and augmenting hard and soft tissues at the time of immediate implant placement provides the best opportunity to achieve these goals. Incorporating an implant with a subcrestal angle correction [SAC] or biaxial feature facilitates screw-retention of both provisional and definitive restorations through the cingulum portion of the crown. Compared to uniaxial implants, these implants also feature an extended or variable platform switch [VPS] facially. Measurements of the peri-implant soft tissue thickness 2.0 mm apical to the facial free gingival margin were compared between two groups of 15 consecutively treated patients with different implant designs to evaluate the effect of SAC/VPS for ITRT. The null hypothesis was that there is no difference between uniaxial and biaxial implants with bone grafting and dermis allograft. These authors contend that using a combined hard and soft tissue grafting approach along with SAC/VPS biaxial implants has a synergistic effect on increasing peri-implant soft tissue thickness compared to uniaxial implants.

A Paradigm Change in Macro Implant Concept: Inverted Body-Shift Design for Extraction Sockets in the Esthetic Zone.

An innovative macro hybrid implant design is aimed at enhancing labial plate dimension and tooth-implant distance while achieving consistent esthetic outcomes. This unique "body-shift" concept in diameter and shape combines a tapered apical portion with a cylindrical coronal portion in a singular implant body design. The overall configuration of the implant is inverted and "convergent" in form toward the implant-abutment interface where bone is thinnest. Conversely, the tapered apical portion is wider where the bone is greatest in volume and vascularity. By reducing the coronal portion of the implant with the inverted body-shift design, a coronal circumferential chamber is created, thereby allowing larger amounts of graft material to be placed labially and interdentally to create a net increased bone dimension. Use of the implant is demonstrated in a case report.

Prosthetic and Surgical Management of Atypical Space When Teeth Are Missing.

When a patient presents with congenitally missing teeth, early diagnosis and comprehensive treatment planning are critical to effective restorative management. Interdental space allocation must be identified to accommodate proper clinical crown proportion(s) through a surgical-prosthetic solution. This article, which presents two case reports describing situations that clinicians may commonly face, demonstrates the management of atypical tooth spacing caused by congenitally missing teeth. The implementation of interdisciplinary therapy resulted in successful outcomes from both functional and esthetic perspectives.

Changes in Peri-implant Soft Tissue Thickness with Bone Grafting and Dermis Allograft: A Case Series of 15 Consecutive Patients.

Immediate implant placement and provisional restoration has become a popular and well-supported method of tooth replacement in the maxillary anterior dentition. Aside from achieving osseointegration, esthetic demands have grown with better understanding of the behavior of hard and soft tissues following this mode to therapy. Stability of gingival contours, texture of the surrounding tissues, and blending of prosthetic components with the natural dentition are critical for successful outcomes to be maintained long-term. Increasing soft tissue thickness at the time of therapy plays an important role in this regard. A technique combining the proven principles of immediate implant placement and provisional restoration with hard and soft tissue augmentation using nonautogenous materials is demonstrated with comparisons to nongrafted, temporized historical controls.

Framing the Restorative Result: How Tissue Augmentation and Preservation Maximizes Implant Therapy Outcomes.

The role of hard- and soft-tissue augmentation as it pertains to dental implant therapy is often underestimated. If this restorative aspect is neglected during the natural healing process and subsequent remodeling following extraction(s), the long-term outcome of treatment can be catastrophic. Three of the most common opportunities for surgeons to enhance outcomes with regenerative therapy are: reconstruction of edentulous segments of the alveolus, management of extraction sockets, and immediate implant placements. Each has its own unique nuances, which can be quite confounding without an appreciation for the potential biomaterials and techniques currently available for use in these situations. This article will focus on novel methods aimed toward the reconstruction and maintenance of hard- and soft-tissue volumes needed to support functional, hygienic, and esthetic implant restorations.

Ridge Augmentation Simultaneous With Immediate Implant Placement: The Subperiosteal Tunneling Technique.

The efficacy of immediate implant placement has made it an appealing treatment modality in dentistry. Over the past several decades various surgical techniques to minimize the ridge collapse and other adverse changes that occur after tooth extraction have been advocated. This case series proposes a method of soft-tissue augmentation when multiple implants are being immediately placed. The authors describe a subperiosteal tunneling technique that achieves the dual purpose of graft containment/guided bone regeneration and soft-tissue augmentation around maxillary anterior implants.

Use of a Sugar Cross-Linked Collagen Membrane Offers Cell Exclusion and Ossification.

Resorbable barrier membranes are advantageous for use in guided bone regeneration for treatment of peri-implant defects, eliminating the need for surgical re-entry. Ribose, a natural sugar-based material that has been used to cross-link collagen, is able to be utilized in high concentrations to extend barrier function for long periods without eliciting inflammation or foreign body reactions in situ. A unique finding with a ribose cross-linked collagen membrane is the in situ ossification of the material upon re-entry. This article presents two cases that clinically demonstrate the efficacy of a sugar cross-linked collagen membrane in peri-implant and site development type defects and suggest its ability to ossify and achieve bone regeneration.