Download Anterior Implant Esthetics

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Joseph Y K Kan, DDS, MS
Professor, Department of Restorative Dentistry, Advanced Education in Implant Dentistry,
Loma Linda University School of Dentistry, Loma Linda, California, USA
Kitichai Rungcharassaeng, DDS, MS
Associate Professor, Department of Orthodontics and Dentofacial Orthopedics,
Loma Linda University School of Dentistry, Loma Linda, California, USA
Michael Fillman, DDS, MS
Associate Professor, Department of Orthodontics and Dentofacial Orthopedics,
Loma Linda University School of Dentistry, Loma Linda, California, USA
Joseph Caruso, DDS, MS, MPH
Chair and Associate Professor, Department of Orthodontics and Dentofacial Orthopedics,
Loma Linda University School of Dentistry, Loma Linda, California, USA
Correspondence to: Dr Joseph Kan
Center for Prosthodontics and Implant Dentistry, Loma Linda University School of Dentistry, Loma Linda, CA 92354, U.S.A;
phone: (011) 1-909-558-4980; fax: (011) 1-909-558-4803; e-mail: [email protected]
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Tissue Architecture Modification
for Anterior Implant Esthetics:
An Interdisciplinary Approach
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Abstract
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Replacing multiple adjacent failing teeth
an interdisciplinary approach (orthodon-
with compromised osseous and gingival
tics, periodontics, and prosthodontics) for
architecture with implants in the esthetic
tissue architecture modification in multiple
zone is often challenging and demanding
adjacent failing teeth with osseous and gin-
for the clinician. Multiple procedures are
gival tissue discrepancies in the esthetic
usually required and entail a preservation
zone. The rationale and limitations are also
technique, a re-creation approach, or a
discussed.
combination of both. This article describes
(Eur J Esthet Dent 2009;4:104–117.)
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Bone sounding on teeth 9 and 10 revealed
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Introduction
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a low crest osseous–gingival tissue relaIn recent years, achieving optimal implant
tionship facially (> 3 mm), and interproxi-
esthetics has been the Holy Grail of implant
mally (> 4.5 mm) of the immediate adjacent
dentistry. As the peri-implant tissue archi-
dentition (teeth 8 and 11).7-9
tecture is the essence of the implant esthet-
The periapical radiograph displayed se-
ics, techniques have been devised to pre-
vere
serve and/or re-create its natural form. To
around the maxillary left central and lateral
replace failing anterior maxillary teeth, the
incisors (teeth 9 and 10), but with no peri-
preservation technique (immediate implant
apical radiolucency (Fig 2). Upon occlusal
placement and provisionalization) is usual-
examination, an excessive anterior vertical
1-3
localized
periodontal
bone
loss
Nevertheless, it
overlap (80%) was observed. In addition, a
is indicated only with the presence of ide-
low incisal position of maxillary incisors
al pre-existing tissue conditions; eg, an ap-
and average gingival exposure were evi-
propriate gingival level and osseous-gin-
dent during smile analysis (Fig 3).10
ly the preferred method.
1
gival relationship. When tissue discrepancy
The patient was advised that teeth 9 and
is apparent, a re-creation approach, which
10 were hopeless and required extraction.
entails periodontal and/or orthodontic in-
The patient requested that the failing teeth
tervention, might be required.4-6 This article
be replaced with implant-supported restora-
describes an interdisciplinary approach for
tions. The patient also expressed the desire
tissue architecture modification in multiple
to improve overall dental esthetics in the an-
adjacent failing teeth with osseous and gin-
terior region. After a thorough diagnosis and
gival tissue discrepancies in the esthetic
planning, a comprehensive treatment plan
zone. The rationale and limitations are also
that addressed all the patient’s concerns
discussed.
was devised. The treatment sequence entailed: (1) tissue architecture modification
with orthodontic and periodontal interven-
Case presentation,
treatment planning,
and discussion
tion; (2) full coverage provisionalization of
A 45-year-old female patient presented with
visionalization of teeth 9 and 10.
teeth 7 to 10 to determine appropriate esthetics, phonetics, and implant position; and
(3) immediate implant placement and pro-
discomfort on the left maxillary central and
lateral incisors (teeth 9 and 10). Clinically,
both teeth were presented with root caries,
super-erupted and the facial free gingival
Tissue architecture
modification
margins were more than 2 mm apically positioned than that of the contralateral denti-
A harmonious relationship between intra-
tion (the right central and lateral incisors
oral components (tooth shape, size, shade,
[teeth 7 and 8, Fig 1]). Furthermore, the lat-
and position; and gingival architecture, lev-
eral incisor was labially and distally dis-
el, and condition) and extra-oral compo-
placed with Class II mobility. The presence
nents (active/inactive lip/smile lines) is fun-
of a thick periodontal biotype was apparent.
damental to dental esthetics, and must
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always be thoroughly evaluated during ex-
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amination. The ability to identify the prob-
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lems/challenges and to envision the treatment goal as well as the final outcome is
an essential step in achieving anterior implant esthetics. Recognizing appropriate
treatments and their limitations is also
equally important. Therefore, in complicated situations, an interdisciplinary approach
is, more often than not, warranted.
The patient presented with discrepancies at multiple levels: (1) incisal position to
Fig 1
lip/smile line, (2) gingival level/architecture
lateral incisors. Note the increased clinical crown length
and tooth length, and (3) osseous–gingival
Facial view of failing maxillary left central and
of the failing teeth due to super-eruption and gingival
level discrepancy.
relationship (Figs 1 to 3). Furthermore,
these discrepancies were not uniformly expressed across the maxillary anterior teeth,
warranting different/individualized managements/treatments on each involved
tooth. The maxillary left incisors (teeth 9
and 10) were hopeless and were replaced
with implant restorations, whereas only
new restorations were needed for esthetic
rehabilitation of maxillary right incisors
(teeth 7 and 8). The maxillary canines
(teeth 6 and 11) were in an acceptable condition both functionally and esthetically and
Fig 2
did not require treatment.
central and lateral incisors showing severe localized
Periapical radiograph of failing maxillary left
periodontal bone loss.
Orthodontic procedure
Orthodontic treatment is the least invasive
procedure for tissue architecture modification. Slow controlled vertical orthodontic
tooth movement causes the entire attachment, which includes gingival and osseous
tissues, to shift in unison with the tooth.11-14
As the patient’s maxillary incisal level was
low in relation to lip/smile line, especially at
teeth 9 and 10, it seemed logical that orthodontic intrusion should be used to attain
ideal incisal level. However, the gingival level of teeth 9 and 10 were significantly more
apical when compared with that of con-
Fig 3
A low incisal position of maxillary incisors and
average gingival exposure were evident during smile
analysis.
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Fig 4
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b
a
(a) Loss of interdental papilla between teeth 9 and 10 due to (b) extensive
horizontal bone loss and increased inter-radicular space.
b
a
Fig 5
(a) Space closure of teeth 9 and 10 using an elastomeric chain improved the
height of the interdental papilla and (b) created a more favorable condition for orthodontic tooth extrusion. Note the root parallelism after space closure.
tralateral dentition. Furthermore, a low-crest
minimal intrusion of tooth 8 were optimal
osseous–gingival relationship (> 4.5 mm)
treatments in this situation.
was observed at teeth 9 and 10. Since 9
While the facial tissue improvement by or-
and 10 were to be replaced with implants,
thodontic extrusion has been well docu-
the goal was to create an optimal osseous
mented,11,15-17 similar results have not been
and gingival condition for immediate im-
replicated for the interproximal tissue. There-
plant placement and provisionalization
fore, prior to vertical orthodontic tooth move-
(preservation approach). Orthodontic intru-
ment, the involved teeth should first be
sion of teeth 9 and 10 would have resulted
aligned in appropriate horizontal positions.
in greater tissue discrepancies. Therefore,
In the presented situation, there was a large
orthodontic extrusion of teeth 9 and 10 and
inter-radicular space between teeth 9 and
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Fig 6
Orthodontic extrusion of teeth 9 and 10. The
Fig 7
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More extrusion of tooth 10 was carried out as
multiple-loop design provides light continuous extru-
planned along with intrusion of tooth 8. The incisal
sive force and direction control.
edges of the extruded teeth were adjusted periodically
to avoid occlusal interference.
Fig 8
Orthodontic appliances were removed after an
Fig 9
Periapical radiograph after orthodontic treat-
8-month period of stabilization. Minor gingivectomy
ment. Note the coronal osseous migration of bone
was performed for esthetic reasons. While the results
around teeth 9 and 10.
from orthodontic extrusion (teeth 9 and 10) were stable, some relapse was observed with the intruded tooth
(tooth 8).
10, possibly due to a periodontal problem
tic tooth extrusion is performed to allow for
and/or trauma from occlusion (Figs 4a and
a predictable direction of tooth movement
b). Interproximal bone in such a situation
and osseous tissue migration (Fig 5b).
does not seem to respond well to vertical or-
It should be noted that the primary ob-
thodontic tooth movement. Not only did the
jective of tissue architecture modification
space closure of teeth 9 and 10 using an
by orthodontic intervention is to attain an
elastomeric chain improve the height of the
ideal osseous level rather than a gingival
interdental papilla, it also created a more fa-
level (Figs 6 and 7). Since the osseous–gin-
vorable condition for orthodontic tooth extru-
gival relationship remains fairly constant
sion (Figs 5a and b). Root parallelism
after orthodontic extrusion, and the initial
should also be observed before orthodon-
osseous-gingival relationship is known
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teDental on
polymerizing acrylic resin (Jet, Lang
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approximate osseous level can be calcu-
n
(measured through bone sounding), the
MFG, Wheeling, IL, USA). The periodontal
lated from the gingival level. Overtreatment
surgical guide outlined the pre-determined
is, however, recommended to compensate
free
for potential tissue loss during subsequent
restorations indicated by the diagnostic
surgeries. Once the desired gingival tissue
wax patterns. In addition, the silicone ma-
level was reached, the involved teeth were
trix was also used as a guide to form the
stabilized for 8 months with a non-active
contour of acrylic resin provisional shells
orthodontic appliance. Although 4 weeks
(teeth 7 to 10). The provisional shells were
to 6 months of retention time has been rec-
fabricated by initially lining them with au-
ommended,11,18-20 it is the authors’ opinion
topolymerizing acrylic resin (Jet, Lang Den-
and clinical experience that a minimal re-
tal MFG) for resiliency and were sub-
tention time of 6 to 8 months be enforced
sequently overlayed with light polymerizing
in this kind of situation. This long (> 6
acrylic resin (Gradia™, GC America, Alsip,
months) stabilization period allows for the
IL, USA) for esthetics.
gingival
margin
of
the
definitive
maturation of the evaginated gingival tis-
Following the administration of local
sue as well as the repositioned osseous
anesthesia, the facial gingiva around teeth
tissue. Nevertheless, while the results from
7 to 10 was first re-contoured using a #15c
orthodontic extrusion were stable, some
blade (Kei, Japan) with the aid of the peri-
relapse could be observed with the intrud-
odontal surgical guide (Fig 10). While an
ed tooth 8 (Fig 8). This phenomenon must
inverse bevel incision21,22 around the free
be taken into consideration during treat-
gingival margin is recommended for con-
ment planning and retention.
ventional crown lengthening procedures
(teeth 7 and 8) to improve marginal adap-
Periodontal crown lengthening
and provisionalization
tation, in the authors’ opinion, a butt joint in-
While the osseous tissue discrepancies
preparing the gingiva for implant place-
can be resolved by orthodontic interven-
ment (teeth 9 and 10), as it minimizes the
tion, the optimal gingival architecture is
thinning of the facial gingival tissue, which
generally accomplished with delicate peri-
may increase the risk of peri-implant gin-
odontal plastic procedures (Fig 9). Follow-
gival recession.8
cision
is
more
advantageous
when
ing the completion of orthodontic therapy,
The detrimental effects of biologic width
a diagnostic impression was made to pre-
violation from improper placement of
pare teeth 7 to 10 for crown lengthening
restoration margin have been suggest-
surgery and provisional restorations. A di-
ed.23,24 Therefore, to establish a healthy bi-
agnostic waxup was first performed on
ologic width during the crown lengthening
teeth 7 to 10 to create the desirable gingi-
procedure of teeth 7 and 8, an apicocoro-
val outline, levels, tooth contours, and in-
nal distance of 2.5 to 3 mm between the fa-
cisal edge positions. The cast was then du-
cial bone and the margin of the provision-
plicated and a full contour silicone matrix
al
(Sil-Tech, Ivoclar North America Amherst,
(Fig 11).25-27 On the other hand, upon bone
NY, USA) was made for the fabrication of
sounding, a high crest situation (< 3 mm
the periodontal surgical guide using auto-
bone-gingiva relationship) was observed
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Fig 10
Esthetic facial gingiva recontouring using a #15
Fig 11
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To establish a healthy biologic width, during
blade and using the periodontal surgical guide outlining
the crown lengthening procedure of teeth 7 and 8, an
the pre-determined free gingival margin of the definitive
apicocoronal distance of 3 mm between the facial bone
restorations indicated by the diagnostic wax patterns.
and the provisional restoration margin of teeth 7 and 8
was accomplished.
Fig 12
High crest (< 3 mm osseous-gingiva relation-
ship) was noted on the facial aspect of tooth 9 as a result
Fig 13
After 2 months of healing, an acceptable lev-
el of gingival esthetic was observed.
of orthodontic tooth extrusion and gingival re-contouring.
a
Fig 14
b
Immediate implant placement of maxillary left (a) central incisor (9) and (b) lateral incisor (10).
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interproximal
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on the facial aspect of failing teeth 9 and
single tooth replacement,
10. (Fig 12). This favorable condition was
bone level on the adjacent tooth is criti-
the result of tissue architecture modifica-
cal to the maintenance of the interproxi-
tion via a combination of orthodontic tooth
mal papilla.8 In multiple adjacent failing
extrusion and gingival re-contouring. As
teeth situations, it has been suggested
labial bone developed by orthodontic ex-
that immediate implant placement and
trusion is often thin and is prone to resorp-
provisionalization should be done in an
tion following flap surgeries,
fo r
28,29
flap reflec-
alternate manner (one carried out after
tion was avoided on teeth 9 and 10. The
the other implant has completely inte-
facial high crest situation of teeth 9 and 10,
grated).33 The alternate approach avoids
along with the flapless procedure,30 may
simultaneous extraction of multiple adja-
mitigate the inherent facial bone resorption
cent teeth, which may compromise the
and gingival recession often encountered
integrity and stability of the interproximal
with immediate implant placement and
bone and papilla, as well as maintain the
provisionalization procedures.
proximal bone on one side of the implant
Teeth 7 to 10 were then prepared for
while the other side is healing. In the pa-
metal-ceramic restorations. The provision-
tient situation presented, since the treat-
al shells were then re-lined with autopoly-
ment was rendered prior to the concep-
merizing acrylic resin (Jet, Lang Dental
tion of the alternate approach, both failing
MFG), and cemented with temporary ce-
teeth (9 and 10) were removed simulta-
ment (Temp-Bond™, Kerr, Orange, CA,
neously with immediate tooth replace-
USA). The gingiva was allowed to heal for
ment. Fortunately, the stability of intere-
6 months,25 at which point the patient was
proximal bone and papilla between teeth
re-evaluated for periodontal and esthetic
9 and 10 was observed throughout the
status to determine if more reconstructive
provisionalization period (6 months after
procedures were required. An acceptable
periodontal tissue architecture modifica-
esthetics and osseous-gingiva relationship
tion; 14 months after orthodontic inter-
was observed, prompting immediate im-
vention). In addition, the minimal root
plant placement and provisionalization at
structure remaining in the socket follow-
the subsequent treatment (Fig 13).
ing orthodontic procedure would render
extraction minimally traumatic to the in-
Tissue preservation procedure
terproximal bone and papilla. Neverthe-
Immediate implant placement and provi-
less, the alternate approach should al-
sionalization has been shown to be an ef-
ways
fective preservative procedure, especial-
especially in thin biotype situations.
be
considered
as
an
option,
ly in the single failing tooth situation in the
this technique, which involves atraumat-
Preparation of surgical template
and provisional prosthesis
ic tooth extraction, flapless surgery, and
Prior to implant surgery, provisional shells
immediate implant placement, is intend-
of teeth 9 and 10 were fabricated using a
ed for osseous preservation. Likewise,
combination of autopolymerizing (Jet,
immediate artificial tooth replacement
Lang Dental MFG) and light-cured acrylic
aims to maintain the gingival tissue.1 For
resin (Gradia, GC America). The implant
esthetic zone.2,3,31,32 The surgical aspect of
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the periapical radiograph and study cast.
n
dimensions were selected with the aid of
visional restorations were re-lined to retro-
The implant length was estimated by
fit onto the abutments, they were adjusted
measuring
from
the
desired
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teproretention and resistance form. After the
ss e n c e
cervical
to clear all centric and eccentric functional
depth of the implant (~3 mm apical to the
contacts and were subsequently cement-
pre-determined free gingival margin of
ed with provisional cement (Temp-bond,
the definitive restoration).9 The implant
Kerr) (Fig 15). Periapical radiographs were
platform diameter should correspond to
made to verify the fit of the abutments and
or be slightly less than the dimension of
the provisional prosthesis as well as com-
the failing tooth at the desired cervical
plete removal of the provisional cements
depth, to allow for a minimal distance of
(Fig 16).
2.0 mm between the implant and adja-
Appropriate antibiotic and analgesic
cent teeth and 3.0 mm between adjacent
were prescribed for postoperative use. The
implants to minimize marginal bone loss
patient was instructed not to brush the sur-
due to encroachment.34,35 A surgical tem-
gical site, but rinse gently with 0.12%
plate was fabricated to identify the pre-
chlorhexidine gluconate (Peridex, Procter &
determined facial gingival margin.
Gamble, Cincinnati, OH, USA). The patient
was advised against any activities that
Immediate implant placement
and provisionalization
might compromise the surgical site. A liq-
After administration of local anesthesia, the
et for the remaining duration of the implant-
remaining tooth structures of 9 and 10 were
healing phase were recommended.
uid diet during the first week and a soft di-
removed atraumatically with the aid of the
periotome (Nobel Biocare, Yorba Linda,
Definitive restoration
CA, USA). A periodontal probe was used to
The gingival architecture around implant 9
verify the integrity of the labial bone of the
and 10 was well preserved after 8 months
extraction sockets. Implant osteotomies for
following implant surgery (Fig 17). The de-
teeth 9 and 10 were sequentially prepared
finitive impression for metal-ceramic crowns
to completion (manufacturer’s recommen-
(7 and 8) and implants 9 and 10 was made
®
dation, Replace , Nobel Biocare), and the
using vinyl poly-siloxane (Aquasil™ Mono-
socket was thoroughly debrided with nor-
phase, Dentsply Caulk, Milford, IL, USA). A
mal saline rinse before the implants (Re-
hexed direct abutment (Replace, Nobel
place, Nobel Biocare) were inserted with
Biocare) was waxed and cast in type IV
35 Ncm torque (Figs 14a and b). After the
gold (Monogram IV, Leach & Dillon, Cran-
titanium temporary abutment (Replace,
ston, RI, USA), duplicating the gingival
Nobel Biocare) was hand tightened onto
emergence established by the customized
the implant, low viscosity flowable light-
temporary abutment. The finished abut-
cured polymerizing resin (Revolution™,
ments were torqued to 35 Ncm (manufac-
Kerr) was applied subgingivally to capture
turer’s recommendation, Nobel Biocare)
the cervical gingival emergence of the ex-
and the definitive metal-ceramic restora-
tracted teeth. The coronal portions of the
tions (Creation®, Jensen, North Haven, CT,
customized temporary abutments were
USA) were cemented with permanent ce-
then prepared extra-orally for appropriate
ment (RelyX™, 3M, St. Paul, MN, USA)
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Fig 16
Periapical
radiograph of immediate implant placement and provisionalization of teeth 9
and 10 at the day of
surgery.
Fig 15
Provisionalization of teeth 9 and 10 immedi-
ately following implant placement.
Fig 17
Well preserved gingival architecture around implants 9 and 10, eight months after implant placement.
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b
a
Fig 18
Fig 19
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(a) Facial and (b) palatal views of the definitive restorations.
The custom gold alloy abutments were
torqued to 35 Ncm.
Fig 20
Healthy and well-developed gingival archi-
tecture presents an optimal recipient site for definitive
metal-ceramic restorations 8 months following implant
surgery.
Fig 21
Facial view of definitive restorations at time of
placement.
Fig 22
A significantly higher smile line and more
harmonious gingival architecture following esthetic reconstruction of maxillary anterior teeth were apparent
compared with initial smile examination.
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Facial view of the definitive restorations at 7 years follow-up.
Fig 24
Periapical radiograph of definitive restorations at 7 years.
(Figs 18 to 22). Clinical and radiographic
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Fig 23
Acknowledgements
follow-up at 7 years showed a stable gingival architecture around restorations on
The authors declare no financial interests in any of the
both natural dentition and implants (Figs 23
products cited within this article. Dr Kan is grateful to the
and 24).
master ceramicist, Hatate Katsuhiro RDT, for the fabrication of the definitive restorations displayed in this article.
Conclusions
Achieving anterior dental esthetics requires not only the understanding of the
anatomy of the hard and soft tissues/organs involved, but also their physiology
and interwoven dynamics when subjected
to different treatments. While proper diagnosis and treatment planning as well as
precise execution of the treatment are important for the interdisciplinary approach, it
is the good communication and rapport
among the specialists that is the key to the
success of the final outcome.
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References
1.
Kan JY, Rungcharassaeng K. Site Development
for Anterior Single Implant Esthetics: The Dentulous Site. Compend Contin Educ Dent
2001;22:221–232.
2. Kan JY, Rungcharassaeng K. Immediate placement and provisionalization of maxillary anterior
single implants: a surgical and prosthodontic
rationale. Pract Periodontics Aesthet Dent
2000;12:817–824.
3. Kan JY, Rungcharassaeng K, Lozada JL. Immediate placement and provisionalization of maxillary
anterior single implants: 1-year prospective study.
Int J Oral Maxillofac Implants 2003;18:31–39.
4. Spears FM, Kokich VG, Mathews DP. Interdisplinary management of anterior dental esthetics. J
Am Dent Assoc 2006;137:160–169.
fo r
16. Levine RA. Force eruption in
the esthetic zone. Compend
Contin Educ Dent
1997;18:795–804.
17. Celenza F. Orthodontically
induced gingival and alveolar
augmentation: Clinical and
histological findings. Pract
Proced Aesthet Dent
2001;13:173–175.
18. Ingber JS. Forced eruption:
Alteration of soft tissue cosmetic deformities. Int J Periodontics Restorative Dent
1989;9:417–425.
19. Mantzikos T, Shamus I. Case
report: Forced eruption and
implant site development.
Angle Orthod
1998;68:179–186.
20. Park YS, Yi KY, Moon SC, Jung
YC. Immediate loading of an
implant following implant site
development using forced
eruption: A case report. Int J
Oral Maxillofac Implants
2005;20:621–626.
21. Litch JM, O’Leary TJ, Kafrawy
AH. Pocket epithelial removal
via crestal and subcrestal scalloped internal bevel incisions.
J Periodontol
1984;55:142–148.
22. Fisher MR, Bowers FM,
Bergquist JJ. Effectiveness of
the reverse bevel incision used
in the modified Widman procedure in removing pocket
epithelium in humans. Int J
Periodontics Restorative Dent
1982;2:32–43.
23. Reeves WG. Restorative margin placement and periodontal
health. J Prosthet Dent
1991;66:733–736.
24. Tarnow D, Stahl SS, Magner A,
Zamzok J. Human gingival
attachment responses to subgingival crown placement.
Marginal remodelling. J Clin
Periodontol 1986;13:563–569.
25. Bragger U, Lauchenauer D,
Lang NP. Surgical lengthening
of the clinical crown. J Clin
Periodontol 1992;19:58–63.
n
5. Mathews DP. Soft tissue management around implants in
the esthetic zone. Int J Periodontics Restorative Dent
2000;20:141–149.
6. Mathews DP. The pediculated
connective tissue graft: A technique for improving unaesthetic implant restorations. Pract
Proced Aesthet Dent
2002;14:719–724.
7. Kois J. Altering gingival levels:
The restorative connection,
Part I: Biologic variables. J
Esthet Dent 1994;6:3–9.
8. Kan JY, Rungcharassaeng K,
Umezu K, Kois JC. Dimensions
of peri-implant mucosa: An
evaluation of maxillary anterior
single implants in humans. J
Periodontol 2003;74:557–562.
9. Kois J, Kan JY. Predictable
peri-implant gingival aesthetics: Surgical and prosthetic
rationales. Pract Proced Aesthet Dent 2001;13:691–698.
10. Tjan AH, Miller GD, The JG,
Some esthetic factors in a
smile. J Prosthet Dent
1984;51:24–28.
11. Reitan K. Clinical and histologic observations on tooth movement during and after orthodontic treatment. Am J Orthod
1967;53:721–745.
12. Stern N, Becker A. Forced
eruption: Biological and clinical considerations. J Oral
Rehabil 1980;7:395–402.
13. Linde J. Textbook of Clinical
Periodontology. Copenhagen,
Denmark: Munksgaard, 1983.
14. Buskin R, Castellon P, Hochstedler JL. Orthodontic extrusion
and orthodontic extraction in
preprosthetic treatment using
implant therapy. Pract Periodontics Aesthet Dent
2000;12:213–219.
15. Salama H, Salama M, Kelly J.
The orthodontic-periodontal
connection in implant site
development. Pract Periodontics Aesthet Dent
1996;8:923–932.
ot
Q ui
by N
ht
KAN ET ALopyrig
No C
t fo
rP
ub
lica
tio
n
te
26. Pontoriero R, Carnevale G.
e
s
s
c
e
n
Surgical crown lengthening: A
12-month clinical wound healing study. J Periodontol
2001;72:841–848.
27. Lanning SK, Waldrop TC, Gunsolley JC, Maynard JG. Surgical crown lengthening: Evaluation of the biological width. J
Periodontol 2003;74:468–474.
28. Pennel BM, King KO, Wilderman MN, Barron JM. Repair of
the alveolar process following
osseous surgery. J Periodontol
1967;38:426–431.
29. Wilderman MN, Pennel BM,
King K, Barron JM. Histogenesis of repair following osseous
surgery. J Periodontol
1970;41:551–565.
30. Kan JY, Rungcharassaeng K,
Ojano M, Goodacre CJ. Flapless Anterior Implant Surgery:
A Surgical and Prosthodontic
Rationale. Pract Periodontics
Aesthet Dent 2000;12:467–474.
31 Wohrle PS. Single-tooth
replacement in the aesthetic
zone with immediate provisionalization: Fourteen consecutive case reports. Pract Periodontics Aesthet Dent
1998;10:1107–1114.
32. Kan JY, Rungcharassaeng K,
Lozada JL. Bilaminar subepithelial connective tissue grafts
for immediate implant placement and provisionalization in
the esthetic zone. J Calif Dent
Assoc 2005;33:865–671.
33. Kan JY, Rungcharassaeng K.
Interimplant papilla preservation in the esthetic zone: a
report of six consecutive cases.
Int J Periodontics Restorative
Dent 2003;23:249–259.
34. Esposito M, Ekestubbe A,
Grondahl K. Radiological evaluation of marginal bone loss at
tooth surfaces facing single
Branemark implants. Clin Oral
Implants Res 1993;4:151–157.
35. Tarnow DP, Cho SC, Wallace
SS. The effect of inter-implant
distance on the height of interimplant bone crest. J Periodontol. 2000;71:546–549.
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THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 2 • SUMMER 2009