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2 Proceedings of the Third ITI Consensus Conference: Esthetics in Implant Dentistry

2.1 Consensus Statements and Recommended Clinical Procedures Regarding Esthetics in Implant Dentistry

3 Pre-operative Analysis and Prosthetic Treatment Planning in Esthetic Implant Dentistry

4.1 Surgical Considerations for Single-Tooth Replacements in the Esthetic Zone: Standard Procedure in Sites Without Bone Deficiencies

4.2 Prosthetic Management of Implants in the Esthetic Zone: General Principles and Scientific Documentation

4.4 Replacement of an Upper Right Central Incisor with a Regular Neck Implant, Restored with an All-Ceramic Crown, Transocclusally Screw-Retained

4.5 Replacement of an Upper Right Central Incisor with a Regular Neck Implant, Restored with (1) an All-Ceramic Crown, Transocclusally Screw-Retained, and (2) an Auro-Galvano Crown, Cemented, Seated on CAD/CAM Custom Mesostructures (ZrO2 and Titanium)

4.6 Replacement of an Upper Right Central Incisor with a Regular Neck Implant, Restored with an All-Ceramic Crown, Cemented

4.7 Replacement of an Upper Right Central Incisor with a Regular Neck Implant, Restored with an All-Ceramic Crown, Cemented

4.8 Replacement of an Upper Left Central Incisor with a Regular Neck Implant, Restored with a Ceramo-Metal Crown, Transocclusally Screw-Retained

4.9 Replacement of an Upper Left Central Incisor with a Regular Neck Implant, Restored with a Ceramo-Metal Crown, Transocclusally Screw-Retained

4.10 Replacement of an Upper Right Central Incisor with a Regular Neck Implant Restored with a Ceramo-Metal Crown, Transocclusally Screw-Retained

4.11 Replacement of an Upper Left Persisting Deciduous Canine with a Regular Neck Implant, Restored with a Ceramo-Metal Crown, Horizontally Screw-Retained

4.12 Replacement of a Congenitally Missing Upper Left Lateral Incisor with a Narrow Neck Implant, Restored with a Ceramo-Metal Crown, Transocclusally Screw-Retained

4.13 Replacement of Congenitally Missing Upper Lateral Incisors with Narrow Neck Implants, Restored with Ceramo-Metal Crowns, Cemented

4.14 Replacement of an Upper Right Lateral Incisor with a Narrow Neck Implant, Restored with a Ceramo-Metal Crown, Cemented

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All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without prior written permission of the publisher.

Medical Editing: Dr. Kati Benthaus, CH-Basel
Illustrations: Ute Drewes, CH-Basel, www.drewes.ch
Copyediting: Triacom Dental, D-Barendorf, www.triacom-dental.de
Graphic Concept: Wirz Corporate AG, CH-Zurich
Production: Bernd Burkart, D-Berlin
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Printed in Germany

ISBN: 185097344x

The materials offered in the ITI Treatment Guide are for educational purposes only and intended as a step-by-step guide to treatment of a particular case and patient situation. These recommendations are based on conclusions of the ITI Consensus Conferences and, as such, in line with the ITI treatment philosophy. These recommendations, nevertheless, represent the opinions of the authors. Neither the ITI nor the authors, editors and publishers make any representation or warranty for the completeness or accuracy of the published materials and as a consequence do not accept any liability for damages (including, without limitation, direct, indirect, special, consequential or incidental damages or loss of profits) caused by the use of the information contained in the ITI Treatment Guide. The information contained in the ITI Treatment Guide cannot replace an individual assessment by a clinician, and its use for the treatment of patients is therefore in the sole responsibility of the clinician.

The inclusion of or reference to a particular product, method, technique or material relating to such products, methods, or techniques in the ITI Treatment Guide does not represent a recommendation or an endorsement of the values, features, or claims made by its respective manufacturers.

All rights reserved. In particular, the materials published in the ITI Treatment Guide are protected by copyright. Any reproduction, either in whole or in part, without the publisher’s prior written consent is prohibited. The information contained in the published materials can itself be protected by other intellectual property rights. Such information may not be used without the prior written consent of the respective intellectual property right owner.

Some of the manufacturer and product names referred to in this publication may be registered trademarks or proprietary names, even though specific reference to this fact is not made. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain.

With the exception of Fig 13a in section 4.7 and Figs 6, 7, 23, 24, 25, 27, 29, 30a, 30b, 31, 32, 33, 34, and 37 in section 5, the components of the implant system shown are part of the Straumann® Dental Implant System.

The tooth identification system used in this ITI Treatment Guide is that of the FDI World Dental Federation.

“... to promote and disseminate knowledge on all aspects of implant dentistry and related tissue regeneration through research, development and education to the benefit of the patient.”

Preface

In the past 15 years, the use of osseointegrated implants has become the standard of care for the rehabilitation of fully and partially edentulous patients, leading to a rapid expansion of implant therapy in dental offices.

This positive development was supported by several factors and trends. Firstly, implant therapy is meeting with much greater acceptance—not only by patients, but also by dentists. The excellent documentation of osseointegrated implants in prospective clinical studies (with up to ten years of follow-up) and good clinical results have both contributed to this increased acceptance. Secondly, the prosthodontic aspect of implant therapy has been simplified by precise prefabricated components, so general practitioners can easily treat patients with implant-supported restorations. Thirdly, there has been significant progress in bone-augmentation procedures (techniques to overcome local bone deficiencies such as guided bone regeneration or sinus grafting). These surgical procedures are routinely used for implant patients today; they have broadened the indications for oral implant therapy, particularly in partially edentulous patients.

As a result, the single-tooth replacement has become the most common indication for implant therapy in recent years. Parallel to this, “novel techniques,” such as immediate implants (with or without flap elevation) and immediate loading, have been promoted to make implant therapy more patient-friendly. Most of these new techniques, however, have not yet been sufficiently documented clinically. Carefully designed, randomized, controlled clinical studies are required to evaluate their value for daily practice.

With this rapid expansion of implant therapy, involving more than 100,000 clinicians worldwide, quality control in implant dentistry has become an increasing challenge. Universities and scientific associations have been asked to make efforts to assure that the implant therapy provided is of high quality in order to maintain the good reputation of dental implants.

The International Team of Implantology (ITI) has responded by establishing the ITI Education Committee. The main objectives of this committee are to discuss and define the standards of care in the surgical and prosthetic aspects of implant dentistry, to integrate these standards into high-quality continuing-education courses, and to coordinate the worldwide educational efforts. Over the past eight years, the ITI has significantly increased its efforts in the area of implant education, including the establishment of the ITI Scholarship Program, which offers stipends to young clinicians and financial support for Centers of Implant Dentistry in the U.S., Europe, and Japan. In addition, the ITI organized its third ITI Consensus Conference in 2003 to discuss clinical topics of interest to implant dentistry. The proceedings were published in a special supplement of JOMI (Proceedings of the Third ITI Consensus Conference 2004).

The ITI Education Committee has decided to use these consensus proceedings to establish an ITI Treatment Guide. This guide will offer detailed clinical guidelines for specific problems in implant dentistry. The first volumes will discuss the following topics: (i) esthetic implant dentistry; (ii) loading protocols in implant dentistry; and (iii) implant placement in extraction sockets.

These topics will be comprehensively presented with detailed recommendations for step-by-step procedures. Each treatment option will be discussed objectively, taking into account the following parameters:

The first volume of the ITI Treatment Guide is devoted to single-tooth replacements in the esthetic zone, a topic of great interest within implant dentistry. It should be of great help to the clinician dealing with esthetic indications in implant patients.

Acknowledgment

The authors thank Ms. Ute Drewes for her beautiful artwork and illustrations and Dr. Kati Benthaus for her excellent support and outstanding commitment to the timely completion and high quality of this ITI Treatment Guide.

Editors and Authors

Urs C. Belser, DMD, Professor
University of Geneva
Department of Prosthodontics
School of Dental Medicine
Rue Barthélemy-Menn 19, 1211 Genève 4, Switzerland
E-mail: urs.belser@medecine.unige.ch

Daniel Buser, DMD, Professor
University of Berne
Department of Oral Surgery and Stomatology
School of Dental Medicine
Freiburgstrasse 7, 3010 Bern, Switzerland
E-mail: daniel.buser@zmk.unibe.ch

Daniel Wismeijer, DMD, Professor
Academic Center for Dentistry Amsterdam (ACTA)
Free University
Department of Oral Function
Section of Implantology and Prosthetic Dentistry
Louwesweg 1, 1066 EA Amsterdam, Netherlands
E-mail: dwismeijer@acta.nl

Christoph Hämmerle, DMD, Professor
University of Zurich, Center for Dental and
Oral Medicine, Clinic for Fixed and
Removable Prosthodontics
Plattenstrasse 11, 8032 Zürich, Switzerland
E-mail: hammerle@zzmk.unizh.ch

Ronald Jung, DMD
University of Zurich, Center for Dental and
Oral Medicine, Clinic for Fixed and
Removable Prosthodontics
Plattenstrasse 11, 8032 Zürich, Switzerland
Email: jung@zzmk.unizh.ch

William C. Martin, DMD, MS
University of Florida, Gainesville
Center for Implant Dentistry
Department of Oral and Maxillofacial Surgery
1600 W Archer Road, D7-6, Gainesville, FL 32610, USA
E-mail: wmartin@dental.ufl.edu

Dean Morton, BDS, MS
University of Florida, Gainesville
Center for Implant Dentistry
Department of Oral and Maxillofacial Surgery
1600 W Archer Road, D7-6, Gainesville, FL 32610, USA
E-mail: dmorton@dental.ufl.edu

Bruno Schmid, DMD
Bayweg 3, 3123 Belp, Switzerland
E-mail: brunoschmid@vtxmail.ch

1 Introduction

D. Buser, U.C. Belser, D. Wismeijer

Over the past 15 years, implant dentistry has progressed faster than many other disciplines in dental medicine. Whereas osseointegration was the primary goal two decades ago, it is nowadays taken for granted and implants are expected to remain functional for decades.

The success of implant therapy is no longer judged mainly by the osseointegration of the implant. In recent years, esthetics has become an inseparable part of oral rehabilitation as patients not only expect implant-supported restorations to be functional long-term, but also to be esthetic, especially in regions of the oral cavity that are visible when the patient smiles.

Supported by new academic curricula as well as by statements from clinical dentistry, such as the Proceedings of the Third ITI Consensus Conference published in a special 2004 supplement of JOMI, we believe that we are coming closer to creating the “perfect illusion” and maintaining it over time.

This is on one hand due to our increased knowledge of biological principles such as biologic width. On the other hand, our increasing awareness of the implementation of biomimetic principles, derived from a growing understanding of the key anatomic and optical parameters of the natural dentition, supports this goal as well.

Nevertheless, predictable optimum results in the esthetic region can only be achieved through application of a comprehensive clinical concept based on experience, sound pre-operative examination and treatment planning, and a team approach that unites patients, surgeons, prosthodontists, and dental technicians.

It is logical to use the 2004 Consensus Proceedings for drawing up and publishing detailed clinical guidelines regarding diagnosis, treatment planning, and the management of patients requiring implant therapy in the esthetic zone.

Sound, evidence-based clinical concepts that produce successful treatment outcomes are needed.

The present first volume of the ITI treatment guide provides comprehensive details on all aspects of implant therapy in the esthetic zone.

2 Proceedings of the Third ITI Consensus Conference: Esthetics in Implant Dentistry

The International Team for Implantology (ITI) is a nonprofit academic organization of professionals in implant dentistry and tissue regeneration with over 2000 fellows and members in more than 40 countries. The ITI organizes consensus conferences at 5-year intervals to discuss relevant topics in implant dentistry.

The first and second ITI Consensus Conferences in 1993 and 1997 (Proceedings of the ITI Consensus Conference 2000) primarily discussed basic surgical and prosthetic issues in implant dentistry. For the Third ITI Consensus Conference in 2003, the ITI Education Committee decided to focus the discussion on four special topics that had received much attention in recent years, “Esthetics in Implant Dentistry” being one of them (Proceedings of the Third ITI Consensus Conference, published in 2004).

A working group was elected for the exploration of each topic. Working Group 2, exploring the topic of “Esthetics in Implant Dentistry,” consisted of the following ITI fellows:

Participants:    Daniel Buser
                            Jean-Paul Martinet Douteau
                            Javier G. Fabrega
                            Timothy W. Head
                            Joachim S. Hermann
                            Frank L. Higginbottom
                            John D. Jones
                            Hideaki Katsuyama
                            Scott E. Keith
                            William C. Martin
                            Stephen Rimer
                            Johannes Röckl
                            Bruno Schmid
                            Alwin Schönenberger
                            David Shafer
                            Christian ten Bruggenkate
                            Dieter Weingart

The group was asked to arrive at a consensus position related to the esthetic dimension of implant dentistry in the anterior maxilla, based on its discussion of and subsequent deliberation on three position papers that had been prepared regarding the following fields:

The subsequent text gives an overview of the consensus statements developed by the group (Belser and coworkers, 2004).

2.1 Consensus Statements and Recommended Clinical Procedures Regarding Esthetics in Implant Dentistry

In esthetic dentistry, difficulties arise in generating evidence-based statements regarding clinical procedures. Therefore, any clinical recommendations given with regard to esthetics in implant dentistry are primarily based on the expert opinion of the Esthetics consensus group. The group worked on each statement until a unanimous opinion was reached.

2.1.1 Statements A: Long-Term Results

2.1.2 Statements B: Surgical Considerations

2.1.3 Statements C: Prosthodontic and Restorative Procedures

In this volume of the ITI Treatment Guide, the above-listed Consensus Statements will be exemplified by clinical case documentations.

3 Pre-operative Analysis and Prosthetic Treatment Planning in Esthetic Implant Dentistry

W.C. Martin, D. Morton, D. Buser

The goal of risk assessment is to identify patients whose implant therapy carries a high risk of a negative outcome. Therefore, for each patient, a detailed preoperative analysis should be performed to assess the individual risk profile and the level of difficulty of the planned therapy.

The initial examination of the patient requiring dental implants in the anterior maxilla should commence with a general treatment risk assessment. Risk assessment in the anterior maxilla of potential implant patients includes several aspects. The patient’s past medical history, current medications, allergies, smoking habits, periodontal status and occlusal function should be examined (Buser and coworkers, 2004). Table 1 lists the superordinate, general risk factors in implant patients:

With regard to implant success, high-risk patients should be informed of the challenges associated with the treatment. Alternative restorative methods should be duly considered before planning for dental implant therapy. Patients who qualify for surgical implant procedures from a medical point of view and whose esthetic demands are high should always undergo a detailed examination not only of the edentulous space, but also of the supporting hard and soft tissues. Adjacent teeth, periodontal support, and existing hard and soft tissues are all critical factors when planning for a predictable esthetic result. Together, these factors constitute an assessment of esthetic risk.

In simple terms, the esthetic quality of implant-supported restorations should not differ from that of restorations supported by teeth. They should be in harmony with perioral facial structures, be associated with a healthy surrounding dentition and represent a successful imitation of the missing tooth or teeth with regard to color, form, texture, size, and optical properties (Belser and coworkers, 2004). Achieving such an outcome presupposes a clear understanding of dental esthetics and general esthetic principles, and depends on the treatment team developing an acute diagnostic acumen.

3.1 Diagnostic Factors for Esthetic Risk Assessment

Diagnostic factors of significance to the pre-treatment examination of the esthetic risk to the treatment outcome include:

*Table 1 Risk factors in candidates for implant therapy (Buser and coworkers, 2004)*
General Risk Factors in Candidates for Implant Therapy
Risk Factor	Remarks
Medical	Severe bone disease causing impaired bone healing Immunologic diseases Medication with steroids Uncontrolled diabetes mellitus Irradiated bone Others
Periodontal	Active periodontal disease History of refractory periodontitis Genetic disposition
Oral Hygiene/Compliance	Home care measured by gingival indices Personality, intellectual aspects
Occlusion	Bruxism

These criteria can be used to create an Esthetic Risk Profile that will help the clinician and patient determine the potential of achieving esthetic results through dental implant therapy.

3.1.1 The Patient’s Treatment Expectations

The recent rise in public awareness of the benefits of dental implant therapy has had both positive and negative effects on daily clinical practice. We benefit from the increasing numbers of patients who desire dental implant treatment, but most patients are unaware of what the process entails. Access to the Internet has helped educate patients on how dental implants are used to replace missing teeth. Unfortunately this education may lead to unrealistic expectations that the treatment team cannot attain. During the consultation visit, it is imperative to determine the patient’s ultimate desires. Discussion of the oral rehabilitation project should focus on three aspects: form, function, and esthetics (Garber and coworkers, 1995; Morton and coworkers, 2004). Reviewing these areas with the patient may help generate an initial risk profile for the esthetic outcome and patient acceptance.

Form

Can the edentulous span be restored at all? An evaluation of the restorative space in relationship to adjacent or contralateral teeth will determine if orthodontic or restorative procedures are necessary before or along with implant therapy (Figs 1a, b). Visualizing the planned restoration will also provide information on the available hard and soft-tissue support, whether deficient, adequate, or excessive. Accepted dental procedures, including diagnostic wax-ups and photographs, are important to this visualization.

Function

An occlusal evaluation is necessary to incorporate the implant-supported restoration into a harmonious and functional environment. In the case of long-standing edentulism, supereruption of the opposing dentition into the free space may make restoration of the implant(s) difficult (Fig 2).

Diagnostic wax-ups help establish a plan for modifying the positions of those teeth and will often be a mandatory component of pre-treatment esthetic analysis.

Esthetics

What are the patient’s esthetic expectations? And are they realistic? A detailed discussion with the patient concerning the potential outcome may help avoid disappointing outcomes for patients with high esthetic expectations. Such patients should be considered “high esthetic risks.”

3.1.2 Patient’s Smoking Habits

When determining the potential for the esthetic success of a given course of implant treatment, potential complications secondary to the local and general factors should also be considered. Smoking habits may have deleterious effects on grafting procedures, implant integration, or long-term peri-implant tissue health (Buser and coworkers, 2004). Several clinical studies have shown smoking to have a negative impact on the short-term and long-term integration of dental implants (Bain and Moy, 1993; De-Bruyn and Collaert, 1994; Lambert and coworkers, 2000; Wallace, 2000). Patients who smoke should be educated on or directed to cessation programs before implant therapy is initiated. Heavy smokers (>10 cig/d) should be considered “high esthetic risks.”

3.1.3 Height of the Lip Line on Smiling

The lip line is associated with the amount of tooth substance and supporting tissues visible when the patient chews, speaks, or smiles.

Low Lip Line

Patients who exhibit a low lip line display a predominance of mandibular teeth or an equal mix of maxillary and mandibular teeth. For these patients, the quality of the esthetic outcome is related mostly to the appearance of the incisal half of the maxillary teeth (Fig 3).

Here the “esthetic risk” is reduced as the lips effectively mask sub optimal outcomes associated with the appearance of the gingival tissues, tooth proportions, and the apical aspects of the restoration.

Medium Lip Line

Patients who exhibit a medium lip line typically display most of their anterior maxillary teeth and only very little, if any, of the supporting periodontal structures (Fig 4). Here the esthetic risk is increased and is associated with factors affecting the appearance of these teeth and restorations, such as tooth size, color, shape, texture, optical properties, relative proportions, as well as the shape and appearance of the incisal and gingival embrasures and the presence of convexity in the teeth and the surrounding structures.

High Lip Line

Patients characterized by a high lip line often display their maxillary anterior teeth in their entirety, as well as a significant portion of the supporting soft tissues (Fig 5). The esthetic risk for these patients is greatly increased, mostly associated with the gingival tissue display. It can be difficult to develop healthy, symmetric, and contoured soft tissues, and any failures will be readily visible—particularly when restoring adjacent missing teeth (Buser and coworkers, 2004). Moreover, the display of gingival structures increases the relevance of tooth proportions and their emergence profile. The esthetic contours of the gingival margins are also critical to the outcome in patients with high esthetic demands.

3.1.4 Gingival Biotype in the Treatment Area

Thick-Gingiva Biotype

A thick-gingiva biotype can be low-risk when replacing single missing teeth in the anterior area. The gingival tissues in these patients are characterized by a predominance of a thick, broad band of attached gingiva, typically resistant to recession (Cardaropoli and coworkers, 2004; Kan and coworkers, 2003; Kois and coworkers, 2001; Weisgold, 1977) (Fig 6).

The thickness of the gingival tissue effectively masks the color of the implant(s) and any subgingival metallic components, reducing the risk of not achieving a pleasing esthetic result. This biotype clearly favors the long-term stability of esthetic peri-implant soft tissues. Special surgical consideration should be given to thick-gingiva biotype patients, as they are more prone to post-surgical scarring subsequent to augmentation procedures.

For patients with multiple adjacent missing anterior teeth, a thick-tissue biotype can be both favorable and detrimental. Thick gingiva remains predictable in terms of position and appearance and resistant to recession. However, the character of the tissue reduces the likelihood of papillae developing when multi-tooth edentulous areas are present (Fig 7).

Medium-Gingiva Biotype

For patients with a medium-gingiva biotype, esthetic restoration of missing teeth is more challenging in the long term, and the esthetic risk is increased. Medium-gingiva biotypes display some characteristics of a thick biotype—most often the presence of thick attached gingival tissues. In addition, however, they can display characteristics of a thin-gingiva biotype, including long, thin, and blunted dental papillae (Fig 8).

In these cases, esthetic restorations are more challenging and less predictable over the long term.

Thin-Gingiva Biotype

Athin-gingiva biotype can be associated with excellent esthetic single-tooth restorations if the adjacent teeth are periodontally healthy and have sufficient bone-crest heights (Fig 9).

Inhaltsverzeichnis

ITI Treatment Guide

Implant Therapy in the Esthetic Zone Single-Tooth Replacements

Volume 1

Authors:

U. Belser

W. Martin

R. Jung

C. Hämmerle

B. Schmid

D. Morton

D. Buser

Editors:

D. Buser

U. Belser

D. Wismeijer

Quintessence Publishing Co, Ltd

Berlin, Chicago, London, Tokyo, Barcelona, Beijing, Istanbul, Milan, Moscow, Mumbai, Paris, Prague, São Paulo, Seoul, Warsaw

Preface

Acknowledgment

Editors and Authors

1 Introduction

D. Buser, U.C. Belser, D. Wismeijer

2 Proceedings of the Third ITI Consensus Conference: Esthetics in Implant Dentistry

2.1 Consensus Statements and Recommended Clinical Procedures Regarding Esthetics in Implant Dentistry

2.1.1 Statements A: Long-Term Results

2.1.2 Statements B: Surgical Considerations

2.1.3 Statements C: Prosthodontic and Restorative Procedures

3 Pre-operative Analysis and Prosthetic Treatment Planning in Esthetic Implant Dentistry

W.C. Martin, D. Morton, D. Buser

3.1 Diagnostic Factors for Esthetic Risk Assessment

3.1.1 The Patient’s Treatment Expectations

Form

Function

Esthetics

3.1.2 Patient’s Smoking Habits

3.1.3 Height of the Lip Line on Smiling

Low Lip Line

Medium Lip Line

High Lip Line

3.1.4 Gingival Biotype in the Treatment Area

Thick-Gingiva Biotype

Medium-Gingiva Biotype

Thin-Gingiva Biotype