ITI Treatment Guide
Volume 10

ITI

Editors:
D. Buser, S. Chen, D. Wismeijer

Treatment

Guide

Authors:
V. Chappuis, W. Martin

Volume 10

Implant Therapy
in the Esthetic Zone:

Current Treatment Modalities
and Materials
for Single-tooth Replacements

Berlin, Barcelona, Chicago, Istanbul, London, Milan, Moscow, New Delhi, Paris, Prague, São Paulo, Seoul, Singapore, Tokyo, Warsaw

German National Library CIP Data

The German National Library has listed this publication in the German National Bibliography. Detailed bibliographical data are available at http://dnb.ddb.de.

© 2017 Quintessenz Verlags-GmbH

Ifenpfad 2–4, 12107 Berlin, Germany

www.quintessenz.de

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, whether electronic, mechanical, photocopying, or otherwise, without prior written permission of the publisher.

Illustrations:	Ute Drewes, Basel (CH), www.drewes.ch
Copyediting:	Triacom Dental, Barendorf (DE), www.dental.triacom.
Graphic concept:	Wirz Corporate AG, Zürich (CH)
Production:	Juliane Richter, Berlin (DE)

ISBN (ebook): 978-3-86867-406-4

ISBN (print): 978-3-86867-343-2

The materials offered in the ITI Treatment Guide are for educational purposes only and intended as a step-by-step guide to the 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, or 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, whether 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.

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

The ITI Mission is …

“… to serve the dental profession by providing a growing global network for life-long learning in implant dentistry through comprehensive quality education and innovative research to the benefit of the patient.”

Acknowledgment

The authors would like to express their gratitude to Dr. Kati Benthaus for her excellent support in the preparation and coordination of this Treatment Guide. We would also like to thank Ms. Ute Drewes for the professional illustrations, Ms. Juliane Richter (Quintessence Publishing) for the typesetting and for the coordination of the production workflow and Mr. Per N. Döhler (Triacom Dental) for the language editing. We also acknow ledge Institut Straumann AG, the corporate partner of the ITI, for its continuing support.

Editors and Authors

Editors:

Daniel Buser

DDS, Dr med dent, Professor

Chair, Department of Oral Surgery and Stomatology

School of Dental Medicine

University of Bern

Freiburgstrasse 7

3010 Bern

Switzerland

E-mail: daniel.buser@zmk.unibe.ch

Stephen Chen

MDSc, PhD, FRACDS

Clinical Associate Professor

School of Dental Science

University of Melbourne

720 Swanston Street

Melbourne, VIC 3010

Australia

E-mail: schen@periomelbourne.com.au

Daniel Wismeijer

DMD, Professor

Head of the Department of Oral Implantology and

Prosthetic Dentistry

Section of Implantology and Prosthetic Dentistry

Academic Center for Dentistry Amsterdam (ACTA)

Free University

Gustav Mahlerlaan 3004

1081 LA Amsterdam

Netherlands

E-mail: d.wismeijer@acta.nl

Authors:

Vivanne Chappuis

DDS, Dr med dent, PD, Assistant Professor

Department of Oral Surgery and Stomatology

School of Dental Medicine

University of Bern

Freiburgstrasse 7

3010 Bern

Switzerland

E-mail: vivianne.chappuis@zmk.unibe.ch

William Martin

DMD, MS, Clinical Professor

The University of Florida

Center for Implant Dentistry

1395 Center Drive, Room D7-6

Gainesville, FL 32610-3003

United States of America

E-mail: wmartin@dental.ufl.edu

Contributors

Urs Belser

DMD, Dr med dent

Professor emeritus, University of Geneva

Guest Professor, University of Bern

Freiburgstrasse 7

3010 Bern

Switzerland

E-mail: urs.belser@unige.ch

Dieter Bosshardt

PhD, Associate Professor

University of Bern

Head, Robert K. Schenk Laboratory of Oral Histology

School of Dental Medicine

Freiburgstrasse 7

3010 Bern

Switzerland

E-mail: dieter.bosshardt@zmk.unibe.ch

Allen Russell Burgoyne

BSc, DDS, MSD, Cert Prostho

966 King Street West

Suite 101

Kitchener, ON N2G 1G4

Canada

E-mail: dr.burgoyne@sympatico.ca

Daniel Buser

DDS, Dr med dent, Professor

Chair, Department of Oral Surgery and Stomatology

School of Dental Medicine

University of Bern

Freiburgstrasse 7

3010 Bern

Switzerland

E-mail: daniel.buser@zmk.unibe.ch

Paolo Casentini

DDS, Dr med dent

Via Anco Marzio 2

20123 Milano

Italy

E-mail: paolocasentini@fastwebnet.it

Stephen Chen

MDSc, PhD, FRACDS

Clinical Associate Professor

School of Dental Science

University of Melbourne

720 Swanston Street

Melbourne, VIC 3010

Australia

E-mail: schen@periomelbourne.com.au

Wagner Duarte

DDS, PhD

University of Brasilia

SCN Quadra 2 Bloco D Sala 516/517

Edificio Liberty Mall, Asa Norte

Brasília, DF

70712-903

Brazil

E-mail: duartew@yahoo.com

Michael Gahlert

Dr med dent

High Tech Research Center

University Hospital Basel

Spitalstrasse 21

4031 Basel

Switzerland

E-mail: mgahlert@uhbs.ch, m.gahlert@knihagahlert.de

Jason Gillespie

DDS, PA

4118 McCullough Ave

San Antonio, TX 78212-1905

United States of America

E-mail: jrgillespiedds@sbcglobal.net

Adam Hamilton

BDSc, FRACDS, DCD

Harvard School of Dental Medicine

Restorative Dentistry and Biomaterials Sciences

Division of Regenerative and Implant Sciences

188 Longwood Avenue

Boston, MA 02115-5819

United States of America

E-mail: adam_hamilton@hsdm.harvard.edu

Alessandro Januario

DDS, MS, PhD

Aria Institute

Centro Médico Lúcio Costa

SGAS 610 Lote 74 Bloco II Sala 307

Brasília, DF

70200-700

Brazil

E-mail: januarioal@gmail.com

Scott Keith

DDS, MS

1111 Civic Drive

Suite 320

Walnut Creek, CA 94596-3894

United States of America

E-mail: skeithdds@hotmail.com

Chatchai Kunavisarut

DDS, MS, Assistant Professor

Mahidol University

School of Dentistry

Advanced General Dentistry Department

6 Yothee Road

Bangkok 10400

Thailand

E-mail: drjub@hotmail.com

Eduardo R. Lorenzana

DDS, MS

3519 Paesano’s Parkway

Suite 103

San Antonio, TX 78231-1266

United States of America

E-mail: drlorenzana@yahoo.com

Dean Morton

BDS, MS, Professor

Professor and Chair, Department of Prosthodontics

Assistant Dean for Strategic Partnerships and Innovation

Director, Center for Implant, Esthetic and Innovative Dentistry

Indiana University School of Dentistry —

Prosthodontics

1121 W Michigan Street, DS-S316

Indianapolis, IN 46202-5186

E-mail: deamorto@iu.edu

Paulo Eduardo Pittas do Canto

DDS

Prosthodontics

Contento – Odontologica Especializada

Rua Marcelo Gama, 1148

Porto Alegre, RS

90540-041

Brazil

E-mail: pittasdocanto@gmail.com

Waldemar D. Polido

DDS, MS, PhD

Clinical Professor and Program Director,

Predoctoral Oral and Maxillofacial Surgery

Co-Director, Center for Implant, Esthetic and

Innovative Dentistry, Indiana University

School of Dentistry

1050 Wishard Boulevard, Room 2200

Indianapolis, IN 46202-2872

United States of America

E-mail: cirurgia.implantes@polido.com.br

Simon Storgård Jensen

DDS

Department of Oral and Maxillofacial Surgery

Copenhagen University Hospital

Blegdamsvej 9

2100 København Ø

Denmark

E-mail: simon.storgaard@jensen.mail.dk

Daniel S. Thoma

PD, Dr med dent, Head of Academic Unit

Clinic of Fixed and Removable Prosthodontics and

Dental Material Science

Center for Dental Medicine, University of Zürich

Plattenstrasse 11

8032 Zürich

Switzerland

E-mail: daniel.thoma@zzm.uzh.ch

Table of Contents

1	Introduction W. Martin, V. Chappuis
2	Consensus Statements: Statements and Recommendations Obtained from the 5th ITI Consensus Conference V. Chappuis, W. Martin
2.1	Contemporary Surgical and Radiographic Techniques in Implant Dentistry
2.2	Restorative Materials and Techniques for Implant Dentistry
2.3	Optimizing Esthetic Outcomes in Implant Dentistry
2.4	Implant-loading Protocols
2.5	Prevention and Management of Biological and Technical Implant Complications
3	Preoperative Risk Assessment and Treatment Planning for Optimal Esthetic Outcomes W. Martin, V. Chappuis, D. Morton, D. Buser
3.1	Patient Selection
3.1.1	SAC Classification for Single-tooth Replacement
3.2	Esthetic Risk Assessment
3.2.1	Medical Status
3.2.2	Smoking Habit
3.2.3	Gingival Display at Full Smile
3.2.4	Width of the Edentulous Span
3.2.5	Shape of Tooth Crowns
3.2.6	Restorative Status of Adjacent Teeth
3.2.7	Gingival Phenotype
3.2.8	Infection at the Implant Site
3.2.9	Soft-tissue Anatomy
3.2.10	Bone Level at the Adjacent Teeth
3.2.11	Facial Bone-wall Phenotype
3.2.12	Anatomy of the Alveolar Crest
3.2.13	Patients’ Esthetic Expectations
3.3	Treatment Planning
3.3.1	Anatomical Considerations
3.3.2	Indications for CBCT in the Esthetic Zone
3.3.3	Digital or Conventional Planning
3.3.4	Surgical Templates for Implant Placement
4	Selecting Biomaterials for Implant Procedures V. Chappuis, S. S. Jensen, D. D. Bosshardt, D. Buser
4.1	Ceramic vs. Titanium Implant Materials
4.1.1	Commercially Pure Titanium Implants
4.1.2	Titanium-alloy Implants
4.1.3	Ceramic Implants
4.2	Bone Grafts and Bone Substitute Materials
4.2.1	Autologous Bone Grafts
4.2.2	Allografts
4.2.3	Xenografts
4.2.4	Alloplastic Bone Substitutes
4.3	Biologics
4.3.1	Growth Factors
4.3.2	Enamel Matrix Derivative
4.3.3	Autologous Platelet Concentrates
4.4	Membranes
4.4.1	Non-resorbable Membranes
4.4.2	Resorbable Membranes
4.4.3	New Development in Membranes with a Functionally Graded Structure
5	Surgical Considerations for Optimal Esthetic Outcomes V. Chappuis, S. Chen, D. Buser
5.1	Post-extraction Dimensional Ridge Alterations in the Esthetic Zone
5.1.1	Flapless Low-trauma Tooth Extraction to Reduce Dimensional Alterations
5.1.2	Post-extraction Dimensional Alterations of the Hard Tissues
5.1.3	Post-extraction Dimensional Alterations of the Soft Tissues
5.2	Indications for Post-extraction Ridge Preservation
5.2.1	Ridge Preservation by Root Maintenance
5.2.2	Ridge Preservation by Socket Grafting
5.3	Indications for Soft-tissue Grafting
5.3.1	Increasing the Band of Keratinized Mucosa
5.3.2	Improving the Soft-tissue Volume
5.4	Flap Design and Suture Techniques
5.4.1	Flapless Approach
5.4.2	Elevation of a Mucoperiosteal Flap
5.5	Implant Selection
5.5.1	Selection Criteria for Soft-tissue-level (STL) vs. Bone-level (BL) Implants in the Anterior Maxilla
5.5.2	Implant Diameters in the Anterior Maxilla
5.5.3	Implant Lengths in the Anterior Maxilla
5.6	Correct Three-dimensional Implant Positioning
5.6.1	Mesiodistal Dimensions
5.6.2	Orofacial Dimensions
5.6.3	Coronoapical Dimensions
5.6.4	Implant Angulation
5.7	Surgical Approach: Simultaneous vs. Staged GBR
5.7.1	Simultaneous GBR
5.7.2	Staged GBR
5.8	Surgical Approach: Immediate vs. Early vs. Late Implant Placement
5.8.1	Immediate Implant Placement (Type 1)
5.8.2	Early Implant Placement (Type 2 and 3)
5.8.3	Late Implant Placement (Type 4)
6	Prosthetic Management for Optimal Esthetic Outcomes W. Martin, A. Hamilton
6.1	Evaluation of Esthetic Outcomes in Single-tooth Replacement
6.2	Interim Prostheses
6.2.1	Before Implant Placement
6.2.2	After Implant Placement
6.3	Management of Peri-implant Tissue
6.3.1	Shaping the Transition Zone
6.3.2	Capturing the Transition Zone
6.4	Laboratory Communication
6.4.1	Photography
6.4.2	Records
6.4.3	Prescription
6.5	Screw-retained vs. Cemented Restorations
6.6	Material Selection for Abutments and Crowns
6.6.1	Prefabricated Abutments
6.6.2	Cast Custom Abutments
6.6.3	CAD/CAM Custom Abutments
6.6.4	Original vs. Non-original
6.6.5	Abutment Materials
6.6.6	Biocompatibility
6.6.7	Influence on Esthetics
6.6.8	Physical Properties
6.7	Prosthetic Design
6.7.1	Crown/Veneer Materials
6.8	Handling of Abutments and Restorations
7	Clinical Case Presentations
7.1	Replacement of a Failing Upper Left Central Incisor: Immediate Placement of an RC Bone Level Implant and Provisionalization E. R. Lorenzana, J. Gillespie
7.2	Replacement of a Perforated Upper Left Central Incisor: Early Placement of an RC Bone Level Implant A. Januário, W. Duarte
7.3	Replacement of an Upper Right Central Incisor with a Root Fracture: Early Placement of an RC Bone Level Implant, Variobase Abutment C. Kunavisarut
7.4	Replacement of a Failing Upper Right Central Incisor: Ridge Preservation and Late Placement of a NC Bone Level Implant W. D. Polido, P. E. Pittas do Canto
7.5	Replacement of an Upper Right Central Incisor with Root Resorption: Ridge Preservation, Delayed Placement of an NC Bone Level Roxolid Implant P. Casentini
7.6	Replacement of an Upper Right Central Incisor with Root Resorption: Ridge Preservation, Early Placement of an RC Bone Level Implant S. Chen
7.7	Replacement of an Ankylosed Central Incisor with a Gingival Recession: Tooth Extraction with Socket Grafting and Late Implant Placement with Simultaneous Contour Augmentation D. Buser, U. Belser
7.8	Replacement of a Compromised Upper Right Central Incisor: Hard- and Soft-tissue Augmentation, Late Placement of an RC Bone Level Implant P. Casentini
7.9	Replacement of a Failing Restored Upper Right Central Incisor: Ridge Preservation and Early Placement of an RC Bone Level Implant D. Thoma
7.10	Replacement of a Fractured Upper Left Central Incisor: Delayed Placement of a Bone Level Tapered Implant Using a Staged Approach S. Keith
7.11	Replacement of an Ankylosed Upper Left Central Incisor: Bone Augmentation and Socket Grafting, Late Placement of an RC Bone Level Implant A. Burgoyne
7.12	Replacement of a Missing Upper Left Central Incisor: Late Placement of an RC Bone Level Implant, CAD/CAM Zirconia Abutment E. R. Lorenzana, J. Gillespie
7.13	Replacement of a Missing Upper Left Central Incisor: Late Placement of an RC Bone Level Implant and Adjacent Tooth Restoration A. Hamilton
7.14	Replacement of a Fractured Upper Left Central Incisor: Early Placement of a Monotype Zirconia Implant, Semi-submerged Transmucosal Healing M. Gahlert
8	Esthetic Complications V. Chappuis, W. Martin, D. Buser
8.1	Causes of Esthetic Complications
8.1.1	Incorrect 3D Implant Position
8.1.2	Implant Selection
8.1.3	Insufficient Facial Bone Wall
8.1.4	Esthetic Failure Due to Late Facial Growth
8.1.5	Esthetic Failure Due to Implants and Third-party Implant Components Lacking Scientific Validation
8.2	Management of Esthetic Complications
8.2.1	Decision Criteria for Salvaging Esthetic Implants
8.2.2	Criteria for Implant Removal
9	Conclusions W. Martin, V. Chappuis
10	References

The history of successful dental implant treatment has led to its large-scale use in today’s clinical practice, providing patients with solutions for the treatment of all forms of edentulism. Clinicians and patients alike benefit from the possibility to use these implants to retain prostheses in a variety of situations, ranging from anterior to posterior tooth replacement to fully edentulous situations. Several authors have reported long-term survival rates of > 90%, leading to a higher acceptance of the dental implant as a primary option for tooth replacement (Adell and coworkers 1990; Lindquist and coworkers 1996; Wennström and coworkers 2005; Buser and coworkers 2012; Chappuis and coworkers 2013a). Of critical note, implant survival does not necessarily correlate with successful esthetic rehabilitation, since success criteria have varied over time. For esthetically sensitive areas, success criteria must include measurements of the peri-implant mucosa as well as the restoration and its relationship to the surrounding dentition (Belser and coworkers 2004; Smith and Zarb 1989).

Patients with failing or missing teeth in the esthetic zone present with their own set of clinical challenges for the clinician to achieve a natural-looking outcome. Any esthetic rehabilitation has to be predictable, which requires a reproducible and stable outcome in the short and long term. The ability to achieve this depends on the interaction between clinicians and technicians (experience) as well as biologic (anatomic factors, host response), surgical (procedures, materials, techniques), implant (dimensions, compositions, surface characteristics, designs), and prosthetic factors (techniques and materials).

The ITI has recognized the challenge of treating patients with esthetic needs and focused attention on them in its numerous publications (SAC Classification, ITI Treatment Guides) and the Proceedings of the 1st through 5th ITI Consensus Conferences over the past sixteen years. The SAC Classification provides information on the degree of restorative and surgical difficulty in the treatment of patients with dental implants and incorporates the use of the Esthetic Risk Assessment (ERA) in determining the risks to achieving an esthetic outcome based upon clinical factors associated with individualized treatment situations. Several ITI Treatment Guides have described the influence of treatment protocols on esthetic outcomes, beginning with Volume 1, Implant Therapy in the Esthetic Zone: Single-tooth Replacements and continuing with volumes 2 through 8. The Proceedings of the (1st to 5th) Consensus Conferences with its consensus statements and clinical recommendations have focused on the treatment of patients with high esthetic needs through treatment guidelines focusing on patient evaluation and treatment, timing of implant placement, loading protocols, and complications related to restorative materials.

In 2007, the ITI published the first volume of the ITI Treatment Guide series, focusing on single-tooth replacement in the esthetic zone. Since then there have been many advances in patient evaluation, implant design, surgical techniques and materials, abutment design and restorative materials, necessitating a revisit to this timely topic.

This volume of the ITI Treatment Guide series begins with the most recent consensus statements and clinical recommendations of the 5th ITI Consensus Conference, followed by a detailed protocol for evaluation and treatment planning for patients with esthetic needs requiring single-tooth replacement with a dental implant and restoration. The ERA table will be reviewed, and an updated version will be presented that is in line with current evaluation procedures and techniques incorporating digital technology.

Implant therapy performed in the esthetic zone requires careful attention to surgical procedures and materials utilized to regain lost tissue support for placing implants in ideal three-dimensional positions based upon the restorative plan. Implant materials, bone grafts, bone substitutes, biologics, and membranes will be presented and indications and techniques for their use outlined. Various surgical situations commonly encountered in the esthetic zone will be presented and treatment recommendations provided.

Prosthetic treatment in the esthetic zone requires advanced knowledge of clinical techniques and materials that can contribute to creating predictable and long-term esthetic outcomes. This volume will highlight the clinical management of the proposed implant site before and after implant placement through the use of interim prostheses, laboratory communication, abutment design, restorative material selection, and prosthesis delivery.

A unique characteristic of all ITI Treatment Guides has been the incorporation of clinical case presentations contributed by clinicians from all over the world that embrace the ITI’s philosophy of an evidence-based approach to treatment and treatment planning. This volume will present several clinical cases highlighting various approaches, both surgical and restorative, in the treatment of patients requiring single teeth to be replaced with a dental implant. In addition, causes and case management approaches related to esthetic implant complications will be reviewed, highlighting surgical and prosthetic options to recover from compromised outcomes.

Our goal with this Treatment Guide has been to present a comprehensive, evidence-based approach to assist practitioners in the successful treatment of their patients who desire esthetic outcomes, from the initial consultation to follow-up.