Contents

Foreword

Per-lngvar Branemark
Introduction Chapter 1 Biology and Pathology of Peri-implant Soft Tissues Ingvar Ericsson Chapter 2 Practical Guidelines Based on Biomechanical Principles Bo Rangert Chapter 3 Implant Placement Patrick Palacci, Ingvar Ericsson, Per Engstrand Chapter 4 Optimal Fixture Positioning Patrick Palacci, Ingvar Ericsson, Per Engstrand Chapter 5 Peri-implant Soft Tissue Management: Papilla Regeneration Technique Patrick Palacci Chapter 6 Clinical Applications Patrick Palacci

11

21

35

41

59

71

CHAPTER 1

Biology and Pathology of Peri-implant Soft Tissues

Ingvar Ericsson

Teeth are anatomically unique because lesions were minute and located adjacent they are the only structures of the body and along a junctional epithelium. Lekholm that penetrate a lining or covering epitheli- et al (1986b) examined clinically healthy um. Thus, teeth and dental implants are and slightly inflamed gingiva and peritwo isolated examples of structures that implant mucosa obtained from partially pierce the integument. While proper an- edentulous patients enrolled in an indivichorage of an implant in the bone (osseo- dually designed maintenance care prointegration) is a prerequisite for its stabil- gram, and concluded that the two types of ity, long-term retention of an implant seems tissues harbored inflammatory-cell infilto depend on the epithelial and connec- trates with similar locations and extensions. tive tissue attachment to the titanium surSeveral animal and in vitro experiments face, ie, a complete soft tissue seal pro- have stressed that similarities obviously tecting the bone from the oral environ- exist between the gingiva and the periment (eg, Branemark 1985, Gould 1985, implant mucosa with respect to both Ten Gate 1985, McKinney et al 1988, Carmichael et al 1989). structures and connective tissue epithelial components (Gould et al 1981, Schroeder et al 1981, Jansen et al 1985, McKinney et It has been proposed that the free marginal gingiva and the peri-implant al 1985, Hashimoto et mucosa al 1988, van Drie et demonstrate many clinical and histological features in common (Adell et al 1986, al 1988, Buser et al 1989). However, the Lekholm et al 1986a and b, Akagawa et al absence of a root cementum layer on the 1989, Seymour et al 1989). Adell et al implant surface creates basic differences ;1986) and Lekholm et al (1986a) harvested biopsybetween specimens of the soft tissues implants and teeth regarding consurrounding successful implant sites in nective tissue fiber orientation and attachedentulous patients who had been treated ment (Buser et al 1989). The importance with Branemark System implants. The of the soft tissue seal at implant sites with authors reported that this peri-implant respect to its "functional success" has not mucosa was frequently absent of inflam- yet been completely evaluated. However, matory lesions, but when present the well-controlled experimental studies in this field have been performed by a research team at the Department of Periodontology

11

Biology and Pathology of Peri-implant Soft Tissues

Fig 1-1 Anatomy of the soft and hard tissues surrounding titanium dental implants ad modum Branemark (left) and teeth (right) in termination of the junctional epithelium; AFJ - abutment-fixture junction; BC = marginal bone crest; GM = gingival margin; CEJ = cernentoenamel junction.

(Chairman: Professor Jan Lindhe), Faculty of Odontology, Goteborg University (Berglundh et al 1991, 1992, 1994; Ericsson and Lindhe 1993; Ericsson et al 1992; Leonhardt et al 1992; Lindhe et al 1992, Marinello et al [in press]). Berglundh et al (1991) compared clinically healthy peri-implant mucosa and free marginal gingiva in the beagle dog with respect to structure and composition. Histological analysis revealed that the two soft tissue units both had a keratinized oral epithelium and a junctional epithelium with a length of approximately 2 mm. The height of the gingival supracrestal connective tissue portion was approximately 1 mm where the orientation of the collagen fiber bundles were fan-shaped, with the acellular root cementum serving as a center (Figs 1-1 and 1-2). Titanium implants, however, lack root cementum, and

therefore the collagen fiber bundles in the peri-implant mucosa run mainly parallel with the implant surface and originate from the bone surface (Figs 1-1 and 1-3). The supracrestal implant surface facing the connective tissue, defined coronally by the apical cells of the junctional epithelium and apically by the bone surface, was found to be approximately 2 mm in height, ie, two times that of the gingival supracrestal connective tissue attachment (Fig 1 -1). Within this zone that is free from epithelium, a "reaction" must have occurred between the connective tissue and the titanium dioxide abutment surface. This "reaction" will, in one way or another, limit the proliferation possibility of the junctional epithelium. Evidently, this "zone of interaction" is not apprehended as a wound surface. This must have a significant effect on adhesion of the peri-implant

Biology and Pathology of Peri-implant Soft Tissues

CEJ; aJE

BC

Fig 1-2 Supracrestal connective tissue attachment at teeth. aJE = apical termination of the junctional epithelium; CEJ = cementoenamel junction.

Fig 1 -3 Apical portion of the supracrestal connective tissue at titanium implants. BC = marginal bone crest. The empty space to the left represents the titanium implant surface.

mucosa to the titanium abutment, and thus also on the soft tissue defense against an exogenous irritation. The qualitative analysis of the connective tissue portion subjacent to the junctional epithelium and within the supracrestal region revealed that the peri-implant mucosa contained significantly more collagen and fewer fibroblasts than corresponding gingival connective tissue portions (Fig 1-4). Berglundh et al (1994) studied the vascular topography of the periodontium and the peri-implant soft and hard tissues using the beagle-dog model. The authors observed that the gingiva and the supracrestal connective tissue at teeth are supplied by (1) supraperiosteal vessels lateral to the alveolar process and (2) vessels from the periodontal ligament. The periimplant mucosa, on the other hand, was found to be supplied by terminal branches

of larger vessels originating from the periosteum of the bone at the implant site. In both situations, the blood vessels built a characteristic "crevicular plexus" lateral to the junctional epithelium (Egelberg 1966). At teeth, the supracrestal connective tissue portion demonstrated a rich vascularization, while at the corresponding implant sites very few, if any, vessels were observed (Fig 1-5). These observations support the suggestion made by Buser et al (1992) that the peri-implant soft tissue may have an impaired defense capacity against exogenous irritation. Ericsson and Lindhe (1993), using the beagle-dog model, examined the resistance to mechanical probing offered by clinically healthy gingival tissues and periimplant mucosa at titanium dental implants. The authors reported that the probe penetration was more advanced at implants

13

Biology and Pathology of Peri-implant Soft Tissues

Fig 1-4 Composition of the supracrestal connective tissue at implants and teeth. Co = collagen; V = vessels; Fi - fibroblasts; R = residual tissue.

PM

GM

aJE-

aJE;CEJ BC

AFJ BC

Fig 1-5 Vascular topography of the peri-implant soft and hard tissues (left) and of the penodontium (right). PM - peri-implant soft tissue margin; aJE - apical termination of the junctional epithelium; AFJ = abutment-fixture junction; BC = marginal bone crest; GM - gingival margin; CEJ = cementoenamel junction.

Biology and Pathology of Peri-implant Soft Tissues

than at teeth {- 2.0 mm and ~ 0.7 mm, respectively). Thus, at the implant sites the probe tip displaced the junctional epithelium as well as the connective tissue portion facing the abutment surface in the lateral direction and stopped close to the bone crest (Fig 1-6). The tip of the probe thus stopped within the supracrestal connective tissue portion, and occasional rupture of some blood vessels resulted in bleeding. At the tooth sites, however, the tip of the probe consistently terminated coronally to the apical portion of the junctional epithelium, thus roughly identifying the bottom of the gingival pocket (Fig 1-6). Bleeding on probing is an important tool to properly diagnose the condition of the apical portion of the periodontal soft tissues. In this study, however, bleeding on probing was sometimes observed at im-

plants, but rarely at teeth. Based on current knowledge, the importance of such an observation at implants is doubtful. The effects of de novo (Berglundh et al 1992) and long-standing (Ericsson et al 1992) plaque formation on the gingiva and the peri-implant mucosa have been evaluated using the beagle-dog model. Berglundh et al (1992) reported that both tissues responded to a 3-week plaque formation period with the development of an inflammatory lesion. The size and composition of these two lesions had many features in common (Fig 1-7). The gingiva and peri-implant mucosa thus had a similar host defense potential to de novo plaque formation. Ericsson et al (1992) evaluated the response of the gingival and peri-implant tissues to a 3-month period of undisturbed plaque accumulation. Mar-

Fig 1-6 Results of probe penetration at Branemark System implants (left) and teeth (right). PM - periimplant soft tissue margin; aJE = apical termination of the junctional epithelium; AFJ - abutment-fixture junction; BC = marginal bone crest; GM = gingival margin; CEJ = cementoenamel junction.

Biology and Pathology of Peri-implant Soft Tissues

Fig 1-7 Anatomical landmarks of the peri-implant soft and hard tissues (left) and the periodontium (right) following de novo plaque formation. PM = peri-implant soft tissue margin; alCT = apical termination of the infiltrated connective tissue; aJE = apical termination of the junctional epithelium; AFJ abutment-fixture junction; BC - marginal bone crest; GM = gingival margin; CEJ = cementoenamel junction.

Fig 1-8 Anatomical landmarks of the peri-implant soft and hard tissues (left) and the periodontium (right) following long-standing plaque formation. PM = peri-implant soft tissue margin; alCT = apical termination of the infiltrated connective tissue; aJE = apical termination of the junctional epithelium; AFJ = abutment-fixture junction; BC - marginal bone crest; GM - gingival margin; CEJ = cementoenamel junction.

Biology and Pathology of Peri-implant Soft Tissues

Fig 1-9 Anatomical landmarks of the peri-implant (left) and the periodontal (right) tissues following experimental breakdown. PM = peri-implant soft tissue margin; AFJ = abutment-fixture junction; ICT = infiltrated connective tissue; aJE = apical termination of the junctional epithelium; BC = marginal bone crest; GM - gingival margin; CEJ - cementoenamel junction.

ginal soft tissue bleeding upon gentle touching was observed at both implants and teeth. The authors reported that the prolonged period of plaque accumulation resulted in a development of an inflammatory-cell infiltrate in the gingiva and the peri-implant mucosa. The two infiltrates had many features in common, but the apical extension was more pronounced in the peri-implant mucosa than in the corresponding lesion in the gingiva (Fig 1-8). The data reported above indicated the following: (1) for teeth, 3 weeks to 3 months of undisturbed plaque accumulation resulted in no further extension of the inflammatory lesion, but (2) at implants, under identical experimental conditions, a further spread in apical direction of the inflammatory-cell infiltrate was consistently observed. This implies that the defense mechanism of the gingiva may be more effective than that of the peri-implant

mucosa in preventing further apical propagation of the pocket microbiota. This hypothesis is further supported by Lindhe et al (1992) and Marinello et al (in press). Lindhe and coworkers (1992) induced experimental breakdown of peri-implant and periodontal tissues in dogs by placing cotton-floss ligatures submarginally and reported that 1 month following ligature removal, (1} "the resulting tissue destruction was more pronounced at implants than at teeth, (2) the size of the soft tissue lesion was larger at implants than at teeth, and (3) the lesion at implants but not at teeth frequently extended into the bone marrow" (Fig 1-9). Using the same animal model, Marinello et al (in press) examined the "spontaneous" healing capacity of an advanced, destructive peri-implantitis lesion. The authors reported that the most common observation 3 months following ligature removal was that the soft and

Biology and Pathology of Peri-implant Soft Tissues

Progression

Encapsulation

Fig 1-10 Schematic drawing demonstrating the "spontaneous" healing capacity (resolution) of periirnplantitis lesions durin junction; aJE = apical termination of the junctional epithelium; ICT - infiltrated connective tissue; BC = marginal bone crest.

hard tissue lesion at most implant sites had converted to a resting and encapsulated lesion separated from the bone surface by a dense stroma of fibrous connective tissue. However, in one of the dogs monitored, three of four implants placed demonstrated continuing loss of supporting bone, became unstable, and were consequently lost during the observation period (Fig 1-10). Finally, it should be noted that the microbial colonization and establishment on titanium implants (fixture + standard abutment) in dogs in a healthy situation, as well as in diseased situations, follow essentially the same pattern as on teeth (Leonhardt et al 1992). Looking into clinical follow-up studies of dental implant treatment (eg, Adell et al 1981, 1990; van Steenberghe et al 1990; Lekholm et al 1994), peri-implantitis does not seem to be a frequent complication.

However, it has to be considered that peri-implant bone loss may occur as a result of occlusal overload (eg, Strub 1986, Rangert et al 1989, Quirynen et al 1992), submarginally located plaque formations (eg, Mombelli et al 1987; Nakou et al 1987; Sanz et al 1990; Leonhardt et al 1992, 1993), or a combination of reasons. In conclusion, the periodontal and periimplant soft tissues demonstrate many features in common but also some differences, such as the orientation of the collagen fibers and the fact that the periimplant mucosa is characterized by a high collagen content and a low number of fibroblasts. The peri-implant mucosa has the character of scar tissue, which will probably result in an impaired defense capacity towards exogenous irritation such as plaque infection. This in turn makes it extremely important to create a soft tissue

Biology and Pathology of Peri-implant Soft Tissues

anatomy around implants and to design superstructures to facilitate a high standard of oral hygiene, thus providing a healthy soft tissue barrier.

Studie am Beagle-Hund. Zeitschrift fur Zahnarztliche implantolo

Buser, D., Weber, H. P, Donath, K., Fiorellini, J., Paquette, D. W., Williams, R. (1992). Soft tissue reactions to nonsubmerged unloaded titanium implants in beagie-dogs. Journal of Periodontology 63: 226-23 Carmichael. R. P., Apse, P., Zarb, G. A., McCulloch, C. A. G. (1989). Biological, microbiological and clinical aspects of the peri-implant mucosa. In: T. Albrektsson, G. A. Zarb (eds.). The Branemark Osseointegrated Imp/ant (pp. 39-78). Chicago: Quintessence. Egelberg, J. (1966). The blood vessels of the dentogingival junction. Journal of Periodontal Hesearch 1: 163-179.

References

Adell, R., Lekholm. U., Rockier, B.. Branemark, R-l. (1981). A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. international Journal of Oral Surgery 6: 387-416. Adell, R., Lekholm, U., Rockier, B.,Branemark, P-1, Ericsson, L, Berglundh, T., Marinello, C. P., Liljenberg. B., Lindhe, J. ( Lindhe, J., Eriksson, B., Sbordone, L. (1986). plaque and gingivitis at implants and teeth in the Marginal tissue reactions at osseointegrated dog. Clinical Oral Implants Research 3: 99-103. titanium fixtures (I). A 3-year longitudinal prospective study, international Journal of Oral & Ericsson, I., Lindhe, J. (1993). Probing at implants Maxillofacial Surgery 15: 39-52. and teeth. An experimental study in the dog. Adell, R., Eriksson, B., Lekholm, U., Branemark, Journal of Clinical Periodontology 20: 623-627. P-I, Jemt, T. (1990). A long-term follow-up study Gould, T. R. L (1985). Clinical implications of the of osseointegrated implants in the treatment of attachment of oral tissue to permucosal imtotally edentulous jaws. International Journal of plants. Exerpta Medica 29: 253-270. Oral & Maxillofacial Implants 5: 347-359. Gould, T R. L., Brunette, D. M., Westbury. L. (1981). Akagawa, Y, Takata, T., Matsumoto, T., Nikai, H., The attachment mechanism of epithelial cells to Tsuru, H. (1989). Correlation between clinical titanium in vitro. Journal of Periodontal Research and histological evaluations of the peri-implant 16:611-616. gingiva around single-crystal sapphire endosHashimoto, M., Akagawa, Y.. Nikai. H., Tsuru. H. seous implant. Journal of Oral Rehabilitation 16: (1988). Single-crystal sapphire endosseous den581-587. tal implant loaded with functional stress - cliniBerglundh, T., Lindhe, J., Ericsson. L, Marinello, cal and histological evaluation of peri-implant C.P, Liljenberg, B., Thomsen, P. (1991). The soft tissues. Journal of Oral Rehabilitation 15: 65-76. tissue barrier at implants and teeth. Clinical Oral Jansen, J. A., de Wijn, J. R., Wolters-Lutgerhorst, Implants Research 2: 81-90. J. M. L., van Mullein, P. J. (1985). Ultrastructural Berglundh, T, Lindhe, J., Marinello, C.P, Ericsson, study of epithelial cell attachment to implant I., Liljenberg, B. (1992). Soft tissue reactions to material. Journal of Dental Research 64: de novo plaque formation at implants and teeth. 891-896. An experimental study in the dog. Clinical Oral Lekholm, U., Adell, P., Lindhe, J.. Branemark, P-I, Implants Research 3: 1-8. Eriksson, B., Rockier, B., Lindvall, A.-M., Yoneyama, T. (1986a). Marginal tissue reactions at Berglundh, T., Lindhe, J., Jonsson, K., Ericsson, I. osseointegrated titanium fixtures. A cross-sec(1994). The topography of the vascular systems tional retrospective study. International Journal in the periodontal and peri-implant tissues in the of Oral & Maxillofacial Surgery 15: 53-61. dog. Journal of Clinical Periodontology 21: 189-193. Lekholm, U., Ericsson, I., Adell, R., Slots, J. (1986b). Branemark, P-l. (1985). Introduction to osseointeThe condition of the soft tissues at tooth and gration. In: P-l. Branemark, G. A. Zarb, T. fixture abutments supporting fixed bridges. A Albrektsson (eds.). Tissue-Integrated Prostheses: microbiological and histologicai study. Journal of Osseointegration in Clinical Dentistry (pp. 11-76). Clinical Periodontology 13: 558-562. Chicago: Quintessence. Lekholm, U., van Steenberghe, D.. Herrmann, I., Bolender, C., Folmer, T., Gunne, J., et al (1994). Buser, D., Stich, H., Krekeler, G., Schroeder, A. Osseointegrated implants in the treatment of (1989). Faserstrukturen der periimplantaren Mukosa bei Titanimplaniaten. Eine experimentelle partially edentulous jaws. A prospective 5-year

Biology and Pathology of Peri-implant Soft Tissues Ranged, B., Jernt, T, Jorneus, L. (1989). Forces and moments on Branemark implants. International Journal of Oral & Maxillofacial Implants 4:241-247. Sanz, M., Newman, M. G., Nachnani, S., Holt, R., Stewart, R.. Flemmig, T. (1990). Characterization of the subgingival microflora around endosteal sapphire dental implants in partially edentulous Leonhardt, A., Adolfsson, B., Lekholm, U., Wikstrom, M. Dahlen, G. (1993). A longitudinal patients. International Journal of Oral & Maxil/omicrobiological study on osseointegrated titanifacial Implants 5: 247-253. um implants in partially edentulous patients. CliSchroeder, A., van derZypen, E., Stich, H., Sutter, nical Oral Implants Research 4: 113-120. F. (1981). The reaction of bone, connective tissue and epithelium to endosteal implants with Lindhe, J., Berglundh, T., Ericsson, I., Liljenberg, sprayed titanium surfaces. Journal of MaxilioB., Marinello, C. P. (1992). Experimental breakfadal Surgery 4: 191-197. down of peri-implant and periodontal tissues. A study in the beagle dog. Clinical Oral Implants Seymour, G. J., Gemmel, E., Lenz, L. J., Henry. R, Research 3: 9-16. Bower, R., Yamazaki, K. (1989). Immunohistologic analysis of t sociated with osseointegrated implants. InterMarinello, C. P., Berglundh, T.. Ericsson, I., Klinge, national Journal of Oral & Maxillofacial Implants B., Glantz, R-O., Lindhe, J. Resolution of ligature 4: 191-197. induced periimplantitis lesions in the dog. Journal of Clinical Periodontology, in press. McKinney, R. V, Steflik, D. E., Koth, D. L. (1985). Strub, J. R. (1986). Langzeitprognose von enossaEvidence for junctional epithelial attachment to len oralen Irnplantaten unter spezjeller Beruckceramic dental implants, a transmission electron sichtigung von periimplantaren, materialkundmicroscope study. Journal of Periodontology 6: lichen und okklusalen Gesichtspunkten. Thesis. 425-436. Berlin: Quintessenz. McKinney R. V, Steflik. D. E., Koth, D. L. (1988). Ten Gate, A. R. (1985). The gingival junction. In: R-l. Branemark, G. A. Zarb, T. Albrektsson, (eds.). The epithelium-dental implant interface. Journal Tissue-Integrated Prostheses: Osseointegration of Oral Implantology 13: 622-641. in Clinical Dentistry (pp. 145-153). Chicago: Mombelli, A., van Osten, M. A. C., Schurch, E., Quintessence. Lang, N. P. (1987). The microbiota with successful or failing osseointegrated titanium implants. van Drie, H. J. Y., Beertsen. W., Grevers. A. (1988). Oral Microbiology and immunology 2: 145-151. Healing of the gingiva following installment of Biotes implants in beagle dogs. Advances in Nakou, M., Mikx, F. H. M., Oosterwaal, P. J. M., Biomaterials 8: 485-490. Kruijsen, J. C. W. M. (1987). Early microbioal colonization of permucosal implants in edentulvan Steenberghe, D., Lekholm, U., Bolender, C., ous patients. Journal of Dental Research 66: Folmer, T., Henry, P., Herrmann, I., et al. (1990). 1654-1657. The applicability of osseointegrated oral implants in the rehabilitation of partial edentulism: Quirynen, M., Naert, L, van Steenberghe, D. (1992). A prospective multicenter study on 558 fixtures. Fixture design and overload influence on marInternational Journal of Oral & Maxillofaciai Imginal bone loss and fixture success in the Braneplants 5: 272-281. mark system. Clinical Oral Implants Research 3:104-111. multicenter study. International Journal of Oral & Maxillofacial Implants, 9: 621-635. Leonhardt, A., Berglundh, T., Ericsson, I., Dahlen, G. (1992). Putative periodontal pathogens on titanium implants and teeth in experimental gingivitis and periodontitis in beagle dogs. Clinical Oral Implants Research 3: 112-119.

In any structure subjected to functional ported by three implants than for those loads, there may be situations leading to supported by two implants. In a retrooverload and subsequent complications. spective clinical study, Quirynen et al (1992) Implant treatment defines a structure claimed that overload may lead to marbased on both biological tissue (bone) and ginal bone resorption. This suggestion is mechanical components (implant and in agreement with results reported by superstructure). Overload in this biomechanical system Hoshaw can et be al defined (1994)as from a conan experimental dition where chewing forces exert a study in dogs. In an analysis of clinically repeated bending of a part of this struc- fractured fixtures, Rangert et al (1995) ture leading to marginal bone loss and/or demonstrated the importance of sufficient component failure (Rangert et ai 1995). An number of implants for predictable longimportant consequence of this detrimental term results. In addition, the authors illusnature of excessive bending is that the trated the influence of implant position, partially edentulous situation is more sus- geometry of the prosthetic reconstruction, ceptible to overload than the full-arch and the patient's chewing habits. restoration, due to the more linear implant Based on this clinical documentation, configuration in the partially edentulous combined with engineering analysis of the case. loading conditions, it is possible to preThe most comprehensive prospective clinical long-term study on implant treatment of partially edentulous patients is a 5-year multicenter study presented by Lekholm et al (1994). From this material and from the 3-year report of the study (Gunne et al 1994), it can be concluded that a sufficient number of fixtures is essential for minimizing potential complications. The authors showed a significantly lower rate of failures for protheses sup-

sent clinical guidelines on how to reduce the risk of overload in partially edentulous situations. The foundation for these recommendations is the

Practical Guidelines Based on Biomechanical Principles

Transverse Force, Lever Arm, and Bending Moment During chewing, forces are generated on the prosthesis. If a chewing force is acting along the axis of an implant (axial force), the stress will be evenly distributed through the implant cross-section and the fixture threads (Fig 2-1). This means a high loadbearing capacity for the implant and supporting bone. However, if the force, or a component thereof, is acting in a transverse direction relative to the implant axis, it will result in a bending moment on the implant (Fig 2-2). In bending, only a small portion of the cross-section of the implant will counteract the load, and the bone will be loaded mainly at the terminal portions of the fixture, giving rise to higher stress

levels in both implant and bone (Rangert et al 1989). The bending moment is defined as the force multiplied by the lever arm (the orthogonal distance) between the direction of force and the cross-section (Fig 2-2); the larger this lever arm, the larger the bending moment and the larger the stress. Thus, the acting force itself may be of reasonable magnitude, but the forces needed to counteract the bending may be excessive due to the leverage effect. Therefore, axial loading most likely is preferable. The full-arch restoration is based on the use of multiple implants, positioned on a curved line dictated by the residual jawbone. This curved line creates an inherently high capacity to counteract a transverse force with axial forces; any

Fig 2-1 When a force is acting along the axis of an implant (axial force), the stress will be evenly distributed through the implant cross-section and the fixture threads.

Fig 2-2 When a force is acting in a transverse direction relative to the fixture axis, a bending moment is introduced. Only a small portion of the implant cross-section and only a few threads will counteract the load, leading to higher stress levels in implant and bone.

Practical Guidelines Based on Biomechanical Principles

potential bending around a line combining any two implants will effectively be counteracted by the axial forces of implants placed off of that line (Fig 2-3). When restoring posterior edentulous spaces in partially dentate jaws, however, the implants often are placed in a more linear configuration and the compensating effect of an offset implant is thus not automatically produced (Fig 2-4); the straighter the alignment, the greater the potential bending of the implants. For the one- or two-implant-supported prostheses, no such compensating effect can be produced. Posterior implant-supported prostheses are, therefore, more frequently exposed to bending moments. The leverage effect as described above can be caused by a variety of geometric conditions. An extension beyond the implant support (Fig 2-5), or implants offset buccolingually relative to the prosthesis (Fig 2-6) are commonly encountered ex-

Figs 2-3a and b In the full-arch restoration, implants are positioned on a curved line. Any potential bending around a line through any two implants will be effectively counteracted by the axial forces of the implants offset from that line.

Figs 2-4a to c When restoring posterior edentulous spaces in partially dentate jaws, the implants are often placed in a linear configuration. The capacity of an offset implant to counteract a transverse force with an axial force is not automatically produced.

Practical Guidelines Based on Biomechanical Principles

Fig 2-5 An extension beyond the implant support leads to an increased bending moment from a transverse force acting on the pontic.

Fig 2-6 Implants offset buccolingually relative to a prosthesis may lead to a bending moment from the axial force component acting on the prosthesis.

Practical Guidelines Based on Biomechanical Principles

amples of such leverage situations. One particular condition is the single-implant molar replacement, in which the dimension of the tooth crown is substantially larger than the diameter of the fixture, leading to possible bending in all directions (Fig 2-7).

Occlusion, Articulation Occlusion is important for the load distribution; the lesser resilience of the implant segments relative to the adjacent teeth may force the implants to take the major share. If cuspal contact is allowed (Fig 2-8), higher cusp inclination leads to higher relative magnitude of the transverse force component and the position of the lateral excursive contact determines the position of the force; the more lateral the contact, the greater the leverage. By centering the occlusal contacts, the lever arm will be

Fig 2-7 In a single-implant molar replacement, the dimensions of the tooth crown are substantially larger than the diameter of the fixture, leading to possible bending in all directions.

Fig 2-8 When cuspal contact is allowed, cusp inclination and position of the lateral excursive contact determines the leverage; the more lateral the contact and the larger the inclination, the greater the bending moment.

Practical Guidelines Based on Biomechanical Principles

reduced. Careful consideration of the each end of the fixture leads to an esdesign of the occlusal surfaces and the sentially greater capacity for withstanding contact pattern is therefore important for bending, as stronger cortical bone will be limiting the stress on implant and bone. As present where the forces are greatest the basic design of the occlusal surfaces (Fig 2-2). is created by the dental technician, it is Healing time is important for achieving important for him or her to be involved at optimal strength of the implant-bone interan early stage of treatment. face. It is well established that following Furthermore, it is important to diagnose implant placement the maxillary jawbone any parafunctional habits. Such habits generally needs a longer healing time than may contribute to bending overload, as the mandibular bone. In special cases, they increase both load magnitude and like unicortical anchorage in the posterior frequency. Observations of excessive occlusal wear mandible and/or a with history soft of fracturing and spongious bone natural teeth or veneering material should tissue underneath the cortical plate, probe considered indicators of increased longed healing time is also beneficial. loading. However, there is a need for further documentation on the effect of healing time on bone strength before more precise recommendations can be given. Fixture Anchorage Angulation of a fixture may lead, in certain situations, to better anchorage and/or Besides minimization of stress, parameters better implant position. A mesiodistal ininfluencing the load capacity of the bone clination in a multiple implant arrangement itself must be considered, from the view- usually does not lead to increased loadpoint of both initial stability and long-term ing, as bending in the plane defined by the strength. Cortical support is an important prosthesis long axis and the implant direcfactor, as the engagement of the fixture tion will be counteracted by the superstructhreads in strong compact bone offers an ture (Fig 2-10). Furthermore, the potential increased load-carrying capacity. In the problems with bending occur mainly in the posterior mandible, where it is usually not possible to obtain bicortical fixture anchorage, it is essential not to countersink excessively, which reduces the support. In the maxilla, where the bone is often soft and the cortical plates are thin, initial anchorage is important and countersinking should be minimized. Fixture thread interlocking with cortical bone is important for load transfer (Fig 2-9).

Bicortical anchorage should be striven for whenever possible, as it adds not only greater cortical bone support, but also greater bending resistance; support at

Fig 2-9 The fixture threads should interlock with cortical bone for optimal load transfer.

Practical Guidelines Based on Biomechanical Principles

Figs 2-10a to d A moderate mesiodistal inclination in a multiple-implant arrangement does not lead to increased loading, as bending in the plane defined by the long axis of the prosthesis and the implant direction will be counteracted by the superstructure. This biomechanical situation is exemplified by a clinical case with a three-unit bridge.

buccolingual direction. However, an implant inclination in buccolingual direction may still be used tor better anchorage and positioning. As long as the position of the fixture head is not changed, a limited inclination of the fixture itself is of minor importance regarding load transfer to the bone (Fig 2-11). Problems with buccolingual implant inclination are more likely

to occur in situations in which the prosthetic reconstruction becomes offset relative to the fixture head, which introduces a bending moment on the fixture (Fig 2-12). The aim should thus be to place the fixture head as close as possible to the acting direction of the force, reducing the lever arm and bending moment.

Practical Guidelines Based on Biomechanical Principles

Figs 2-11 a and b As long as the position of the fixture head is maintained, limited inclination has minor influence on load transfer to the fixture. No additional bending of the fixture is induced, and only a slight increase of bone stress will take place.

Fig 2-12 Problems with implant buccolingual inclination may occur in situations when the prosthetic reconstruction becomes offset relative to the fixture head, which introduces a bending moment on the fixture. The reason for the increased bending is not the inclination per se but the distance between the force direction and the fixture head.

Practical Guidelines Based on Biornechanical Principles

Practical Guidelines Given the above background, it is possible to present guidelines, mainly from a biomechanical point of view, for designing implant-supported restorations. First, it is important to visualize the design of the final prosthetic reconstruction with regard to dimension, occlusal contacts, and function. Next, consideration must be given to the anatomical limitations related to implant number and position, and how these match the expected support requirements. There should be a balance between demands and possibilities at the initial stage of the treatment planning.

In the case of a three-unit prosthesis, the ideal situation from a biomechanical point of view is three implants placed in a slightly curved configuration, with the middle implant offset a minimum of 2 to 3 mm in the buccolingual direction (Fig 2-13). This tripod implant configuration allows the load response to bending forces to be mostly axial, minimizing the stress level (Fig 2-14). It can be estimated that the stress level will be reduced approximately 50% by tripodization, compared to a straight-line configuration with the same number of implants. The tripod should be related to where the fixture heads penetrate the anchoring bone. A

Figs 2-13a and b For a three-unit prosthesis, the ideal situation from a biomechanical point of view is three implants placed in a slightly curved configuration with the middle implant offset 2 to 3 mm buccolingually.

Practical Guidelines Based on Biomechanical Principles

slight inclination of the implant may be a useful way to achieve such placement (Fig 2-15). If only two implants can be placed, they should preferably be placed as end supports, eliminating extensions (Fig 2-16). A three-unit prosthesis with one cantilever pontic doubles the stress level at the implant closest to the extension (Fig 2-5), in comparison to the situation in which the pontic is placed between the two implants. As two implants cannot prevent a possible bending moment (Fig 2-4), it is important to diagnose the patient's functional habits and, if needed, reduce the consequences of any parafunction. Centering the occlusal contacts and eliminating lateral excursive
Fig 2-14 The tripod implant configuration allows a mostly axial load response to bending forces, which minimizes the stress level.

Fig 2-15 The fixture head defines the position of the prosthesis support in the bone; slight inclination of the implant may be a useful means for optimizing its location. This situation is clinically illustrated in Fig 2-11.

Practical Guidelines Based on Biomechanical Principles

Fig 2-16 When only two implants can be placed, they should preferably be placed as end supports, eliminating extensions.

engagements should be considered (Fig 2-8). There could be as much as a sixfold stress difference between the most adverse load situation (two implants with an extended pontic) and the most optimal one (tripod placement) due only to implant support (Fig 2-17). Considering occlusal control possibilities would lead to even greater difference between the worst and the best situation. Currently, the single-tooth molar replacement supported by a single implant has limited long-term clinical documentation. As this situation has a high susceptibility to bending overload, the occlusion should be developed so that only centric contacts exist. Due to the potential high level of stress, fixtures with a diameter of 4 mm or more are recommended for singlemolar replacements. Bruxism, clenching, and the periodontal condition of the adjacent teeth should be carefully evaluated, as such conditions may contraindicate

single-implant molar restorations. In many situations, two implants might be needed to sufficiently support a single molar.

Conclusion To a large extent, the biomechanical considerations for implants follow simple mechanical rules, based on the leverage principle. By considering the patient's functional behavior, limiting the extension of the prosthesis, and controlling the occlusal pattern and contacts, possible overload situations can be minimized. Placing the implants in position and number like tooth roots rather than bridge posts combines biomechanical and esthetic aspects harmoniously. The main biomechanical recommendations for implant treatment in the posterior positions can be listed as follows:

Practical Guidelines Based on Biomechanical Principles

Fig 2-17 There could be a sixfold difference in stress level between the most adverse load situation (two implants with a cantilever) compared to the most optimal one (three implants in a tripod arrangement).

1. Strive for a minimum of three implants with one offset a minimum of 2 to 3 mm to provide for axial loading. 2. If only two fixtures can be placed, eliminate cantilevers and minimize buccolingual prosthesis contact and cuspal inclinations. 3. Slight implant inclination may be used to position the fixture head for optimal support. 4. The use of only one free-standing implant to support a fully functioning molar should be approached cautiously. In addition, the occlusion should be centered and light, and a fixture diameter of at least 4 mm should be used. 5. Occlusal forces may be difficult to control in situations of reduced periodontal tissue support around neighboring

teeth. Treatment planning of such cases should be done cautiously. 6. Increased risk of exceeding component and/or bone strength is present in patients with parafunctional habits. Optimal implant support, elimination of cantilevers, and minimization of occlusal contacts should be striven for in these situations. 7. Sufficient precision of the fit between prosthesis and abutment and appropriately tightened screw joints are important factors for obtaining the full mechanical strength of components. 8. Observation of screw loosening or fracture should be looked upon as overload indicators and should lead to immediate evaluation and correction of the cause to avoid further complications.

Practical Guidelines Based on Biomechanical Principles

References
Gunne, J., Jemt, T., Linden, B. (1994). Implant treatment in partially edentulous patients. A report on prostheses after 3 years. International Journal of Prosthodontics 7:143-148. Hoshaw, S., Brunski, J., Cochran, G. (1994). Mechanical loading of Branemark implants affects interfacial bone modeling and remodeling. International Journal of Oral & Maxillofacial Implants 9:345-360. Lekholm, U., van Steenberghe, D., Herrmann, I., Bolender, C., Folmer, T., Gunne, J., et al. (1994). Osseointegrated implants in the treatment of partially edentulous jaws. A prospective 5-year multicenter study. International Journal of Oral & Maxillofacial Implants 9: 627-635. Quirynen, M., Naert, I., van Steenberghe, D. (1992). Fixture design and overload influence marginal bone loss and fixture success in the Branemark system. Clinical Oral Implants Research 3: 104-111. Rangert, B., Jemt, T., Jorneus, L. (1989). Forces and moments on Branemark implants. International Journal of Oral & Maxillofacial Implants 4: 241-247. Rangert, B., Krogh, P. H. J., Langer, B., Van Roekel, N. (1995). Bending overload and implant fracture. A retrospective clinical analysis. International Journal of Oral & Maxillofacial Implants 10: 326-334.

In occlusal rehabilitation using implants as ing figures still differ, but to a lesser anchors for the reconstruction, the implant degree. Thus, in the maxilla the average unit (the titanium fixture and the abutment) width of the tooth crowns in the mesiodistal direction rang must be looked upon as a tooth root. From incisor) to 8.5 rnm (central incisor), and in a prosthodontic point of view, the implants the mandible between 5.0 (central incisor) are replacing the roots as supports for the and 7.0 mm (canine and premolars). These superstructure and consequently the implants must values, be placed representing to make it possible different tooth dimento obtain the expected treatment outcome. sions, must be compared with the design The degree of bone resorption and other of the implant components (Figs 3-1 and anatomical characteristics also have to be 3-2). The diameter of the threaded portion considered. Furthermore, it is important to of the most frequently used fixtures is keep in mind that implant components of either 3.75 or 4 mm. At the fixture head, approximately the same dimension are in- ie, at the collar, the diameter is increased tended to serve as supports for teeth of to 4.1 mm. The design of the standard, different sizes (Fig 3-1).
ESTHETlCONE, CERAONE, a n d MlRUSCONE

Root and crown width vary greatly among different teeth. According to Wheeler (1984) (Table 3-1), the mesiodistal and buccolingual average extension of the roots at the cementoenamel junction varies between 3.5 (mandibular central incisor) and 10.0 mm (maxillary molars). The mean width of the tooth crowns in the mesiodistal direction varies between 5.0 (mandibular central incisor) and 10.5 rnm (mandibular molars). When considering only the incisors, canines, and premolars, the regions that are most important from an esthetic point of view, the correspond-

abutments results in a further increase of the implant width (Fig 3-3). To reach a satisfactory esthetic outcome when connecting the superstructure to the implants, the most coronal extension of the crown-abutment junction must be located about 0.5 to 3.0 mm submarginally. This means that in partially edentulous cases in which the neighboring teeth demonstrate intact periodontal-tissue support, the crownabutment junction (CAJ) has to coincide more or less with the most apical extension of the cementoenamel junction (CEJ) of these teeth (Fig 3-4). Deeper placement

Implant Placement

Figs 3-1 a and b Relationship between the fixture and the roots to be replaced (a; maxillary central incisor; b: maxillary canine).

(~ 3 mm) of the crown-abutment junction has to be used when neighboring teeth demonstrate a big difference in position of the cementoenamel junction at buccolingual vs proximal sites. Consequently, in dentitions with reduced periodontal tissue support and exposed root surfaces, the crown-

abutment junction most often will be placed more superficially than in a periodontally intact situation, but still at a submarginal position ( 0.5 to 1 mm) (Fig 3-5). A suggested rationale for fixture placement to obtain this crown-abutment junction location will be presented in detail in Chapter 4.

Implant Placement

Fig 3-2

The relationship between different tooth crowns and an implant (fixture diameter: 3.75 mm).

Fig 3-3 Width of different abutment types for the BRANEMARK SYSTEM. From left to right: standard abutment, ESTHETlCONE, CERAONE, and MlRUSCONE.

Implant Placement

Figs 3-4a and b Ideal fixture position in a situation in which neighboring teeth demonstrate intact periodontal tissue support. The crown-abutment junction (CAJ) of the implant-supported restoration coincides more or less with the most apical extension of the cementoenamel junction (CEJ) of the neighboring teeth. GM = gingival margin.

Figs 3-5a and b Ideal fixture position in a situation in which neighboring teeth demonstrate reduced periodontal tissue support. The crown-abutment junction (CAJ) is placed slightly submargmally. CEJ = cementoenamel junction.

Implant Placement

When replacing teeth in the anterior and premolar regions, except in the anterior mandibular region, the idea! distance in the mesiodistal direction between supporting fixtures usually is about 7, 14, or 21 mm (Table 3-1). The shortest distance (7 mm) is used when each individual implant serves as an anchor for one crown; the longer distances are used when one or two pontics are placed between two implants. This concept can be applied in totally as well as in partially edentulous situations. The coordination of the surgical and prosthetic treatment-planning procedures is certainly one of the most important factors in obtaining an ideal esthetic result. In the anterior region, fixtures must be placed so that the screw-access holes are located lingual or palatal to the incisal edge of the crown restoration. Pronounced variances in implant angulation can jeopardize a good final esthetic result. Therefore, an individually designed surgical guide stent will facilitate correct and optimal fixture placement (Fig 3-6). This in turn will enable prediction of a good esthetic outcome for the implant treatment. When two or more fixtures are placed it is often a necessity and an advantage from an esthetic point of view to place them more or less parallel to each other. Thus, the position and angulation of the first fixture placed will influence the placement of the following ones. These guidelines for implant placement are also applicable in the premolar and molar regions.

Fig 3-6 Surgical guide stent used to determine the location of an implant site.

New surgical components have been developed to facilitate optimal fixture placement based on biological, biomechanical, and esthetic considerations, keeping within individual anatomical limitations. Descriptions of these components, as well as methods of use, are presented in the following chapter.

References
Wheeler, R. C. (1984). Wheeler's Atlas of Tooth Form, ed. 4. R. C. Wheeler, M. Ash (eds.). Philadelphia: Saunders.

Proper planning is important for obtaining an acceptable final result when providing implant treatment. A complete treatment plan needs to consider both surgical and prosthetic aspects. From a surgical point of view, a careful analysis of fixture positioning is essential. Surgeons have relied mainly on the use of a guide stent in combination with direction indicators. However, even when using these tools there are still difficulties visualizing the final restorative result. Therefore, new surgical components have been designed by Dr P. Palacci together with Nobelpharma AB to enhance proper fixture placement. These tools will simplify and facilitate optimal fixture placement based on biological, biomechanical, and esthetic considerations.

It is important to obtain optimal position and angulation when placing fixtures. These parameters must be viewed as the keys for success, especially in partially edentulous situations, as the room for error is more limited than in a completely edentulous situation. For example, 1 mm in positioning and/or 10 degrees in angulation can completely final result (Figs 4-2 and 4-3). Figure 4-4 lists different implant positions and their influences on the final esthetic, biomechanical, and phonetic result, as well as the possibilities for good oral hygiene. Figures 4-5 to 4-24 illustrate how these new surgical components facilitate optimal fixture placement.

These newly designed components complement currently available direction indicators. The Fixture Positioning Guides are available in three different shapes: "Milestone" (Guide 1), "Short Flag" (Guide 2), and "Long Flag" (Guide 3), with guidepin diameters to fit in either a 2- or 3-mm-diameter preparation (Figs 4-1 a to c). The Milestone is primarily intended to give an image of the final prosthetic restoration, and the e the surgeon to place fixtures at a proper distance (> \7 mm) from each other.

Optimal Fixture Positioning

Fig 4-1 a Milestone: Guide 1,02 mm (left), to be used following preparation with 0 2 mm twist drill. Guide 1,03 mm (right), to be used following preparation with 0 3 mm twist drill.

Fig 4-1 b Short Flag: Guide 2, 0 2 mm (left), or 0 3 mm (right), to be used following preparation with the twist drills.

Fig 4-1 c Long Flag: Guide 3, 0 2 mm (left), or 0 3 mm (right), to be used following preparation with the twist drills.

Optimal Fixture Positioning

Fig 4-2 Potential implant site positions. The green zone indicates correct position and the red zone indicates more unfavorable impiant position. This fact has to be considered in mesiodistal (left), and in buccolingual (right) aspects.

Fig 4-3 Potential implant angulations. The green zone represents correct implant-site angulation and the red zone more unfavorable implant angulation (positioning). This fact has to be considered in the mesiodistal as well as buccolingual directions.

Fig 4-4 Influence of implant position on final results. Green circles indicate good prerequisites to obtain an acceptable result of the treatment, while yellow circles indicate difficulties in obtaining such a result. Red circles indicate greater problems in obtaining an acceptable treatment result.

Fig 4-5 Individually designed guide stent placed in an edentulous area distal to a mandibular left canine. The stent will facilitate placement of the starting point for the implant site preparation in the exposed cortical layer of the alveolar bone. A guide drill (round bur) is used for this preparation. The position of the starting point is more crucial in situations with advanced bone resorption.

Optimal Fixture Positioning

Fig 4-6 Use of the guide stent with the twist drill (0 2 mm). The stent and the remaining left mandibular canine will guide the surgeon in reaching an acceptable position and angulation for the implant-site preparation.

Figs 4-7a and b Use of the Guide 1 (D=2 mm) facilitates confirmation of acceptable position and angulation of the initial implant-site preparation (at the D= 2-mm level). If corrections are necessary, it is preferable to use the guide drill and the twist drill (D=2 mm) instead of a D= 3-mm twist drill.

Optimal Fixture Positioning

Fig 4-8a The Guide 1 can show the embrasure as well as the image of the final crown restoration when the position and angulation of the implantsite preparation is optimal.

Fig 4-8b For situations in which the Guide 1 is touching the neighboring tooth, the embrasure, as well as the shape of the final crown restoration, will be compromised.

Fig 4-8c For situations in which the space between the remaining tooth and the Guide 1 is too wide, difficulties in creating a good crown anatomy and embrasure may occur.

Fig 4-8d Unfavorable angulation of the fixture site will be revealed when using the Guide 1. Such an angulation may create difficulties in placing the implant-supported prosthetic restoration.

Optimal Fixture Positioning

Figs 4-9a to c The Guide 1 gives the surgeon an image of the future outline of the crown restoration in the mesiodistal direction (see also Figs 4-8a to d), as well as an image of the embrasure. Turning the Guide 1 90 degrees will present an image of the buccal crown outline.

Optimal Fixture Positioning

Fig 4-10 Use of the Guide 1 can be of great help in the anterior maxilla, where esthetic requirements are most important. If the implant-site preparation is too buccally angulated, the screw-access hole will appear on the buccal surface and thus create a potential esthetic complication. If the implant angulation is too palatal, then esthetic and hygienic complications may occur. A correct inclination of the implantsite preparation is thus of great importance, and will also reduce the need to use angulated abutments.

Fig 4-11 Width in the mesiodistal direction of the Guide 1 in relation to the mean width of incisors, canines, and premolars.

Fig 4-12a to d Dimensional relationships between maxillary anterior teeth and the Guide 1 in mesio-distai and buccopalatal directio Table 1 in Chapter 3.

Optimal Fixture Positioning

Figs 4-13a and b Use of the short flag (Guide 2) to begin implant-site preparation in an adequate position. Use of the short flag as shown results in a center-to-center distance of 7 mm between the implant-site preparations, which allows a good design of the final fixed prosthesis. Furthermore, at the abutment-connection procedure, this 7-mm distance between the centers will make it possible to manipulate the soft tissues adequately. If needed, the amount of tissues will allow the surgeon to create interimplant papillae with favorable anatomy and proper blood supply. This tissue manipulation is described in detail in Chapter 5.

Figs 4-14a and b Use of flags (either short or long) will not only help the surgeon to find an acceptable position for a fixture but also will facilitate a parallel implant-site preparation.

Optimal Fixture Positioning

Fig 4-15 The procedure can be repeated for all the following fixtures to be placed. After preparation of all implant sites using the twist drill (0 2 and 3 mm) and pilot drill fixtures can be placed according to the standard technique (Adell et al 1985).

Fig 4-16

Final implant-supported restoration.

Optimal Fixture Positioning

Figs 4-17 a and b

Missing maxillary central incisors to be replaced by two implant-supported restorations.

Optimal Fixture Positioning

Figs 4-17c to i indicators.

Clinical use of the Fixture Positioning Guides in combination with conventional direction

Optimal Fixture Positioning

Figs 4-18a and b Use of the long flag (Guide 3) when a pontic is to be placed between two implants. The use of the long flag, in accordance with the description above for the short flag, will result in a minimum center-to-center distance of 12 mm between the implant-site preparations. This is a minimum distance for placing a pontic between two implants to obtain a good esthetic result and for proper oral hygiene. For situations in which a distance greater'than 14 mm between the centers of the sites is available, it is preferable to place another fixture rather than extending another pontic. Such a treatment approach is preferable from both biomechanical and esthetic points of view.

Fig 4-19a Four-unit prosthesis supported by three implants.

Fig 4-19b Three-unit prosthesis supported by two implants.

Optimal Fixture Positioning

Figs 4-20a and b Use of the long and short flag to visualize the occlusal plane.

Fig 4-21

Technique for visualizing a tripod (see Chapter 2) using the flags.

Optimal Fixture Positioning

Figs 4-22a and b Technique for using the flags to visualize a controlled interimplant inclination in the mesiodistal and buccolingual directions. The biomechanical importance of inclination and tripodization is discussed in Chapter 2.

Optimal Fixture Positioning

Figs 4-23a to d Implant site with a bony defect (eg, extraction socket, dehiscence, etc). In such a situation, the potential implant site must be widened to 3 mm before proper stability of the Fixture Positioning Guides (0 3 mm) can be achieved.

Optimal Fixture Positioning

Figs 4-24a and b Use of Guide 1 (0 3mm) following countersinking to enhance vertical fixture positioning related to cementoenamal junction of adjacent teeth demonstrating intact (top) and reduced (bottom) periodontal tissue support. CEJ cementoenamel junction; AFJ - abutment-fixture junction; CAJ = crown-abutment junction. This topic is discussed in Chapter 3.

References
Adell, R., Lekholm, U., Branemark, P.-l. (1985). Surgical procedures. In: P.-l. Branemark, G. A. Zarb, T- Albrektsson (eds.). Tissue-Integrated Prostheses: Osseointegration in Clinical Dentistry (pp. 211 -232). Chicago: Quintessence.

Abutment connection has historically been performed using the tissue-punch technique or full-thickness flaps (Adell et al 1985). Moy and coworkers (1989) reported on a scalloping adjustment of the flaps resulting in a better soft tissue adaptation to the titanium abutments. Several other techniques have been described over the years (eg, Israelsson et al 1993, Hertel et al 1994). However, when applying these techniques it may be difficult to achieve a papilla-like formation at the implants. This experience has support from Sullivan et al (1994), who have claimed that "while the ability to regenerate lost contour has improved during the past 10 years, the unpredictability of the final result has led to the need, in many cases, for multiple surgical procedures to reach an esthetic result. Each procedure adds to the time and expense of the final result and significantly increases the risk of undesirable complications." Sullivan et al (1994) have also claimed that "the ability to regenerate or augment tissue in a coronal direction is more difficult to perform successfully than in other directions. Unfortunately, there is usually a need to replace lost tissue in that coronal dimension. Improved surgical procedures to recreate the appearance of

an interdental papilla are needed to address this common shortcoming." It is often recommended that clinicians perform an evaluation of the ridge mucosa prior to fixture placement to judge whether surgical augmentation procedures of the covering mucosa are needed. However, Wennstrom et al (1994) discussed the importance of an attached portion of masticatory mucosa as a border tissue around implants. The authors reported that their clinical study "failed to support the concept that the lack of an attached portion of masticatory mucosa may jeopardize the maintenance of soft tissue health around dental implants." These observations are in agreement with findings presented by Strub et al (1991) from an experimental study in the dog. A surgical technique has been developed to move the attached mucosa at the top of the ridge in a buccal direction at the second-stage surgery in order to obtain papilla-like formations (Palacci 1992, Andreasen et al 1994). Following flap elevation and abutment connection, the moved mucosa increases the volume at the buccal aspect of the implants. The increased tissue volume is also used to promote papilla-like formations between

Peri-implant Soft Tissue Management; Papilla Regeneration Technique

implants, as well as between implants and teeth. This technique results in a harmonious soft tissue architecture adjacent to implant-supported prostheses, providing that the implants are properly positioned

(see Chapters 3 and 4). This in turn will result in better esthetics, phonetics, and opportunity for good oral hygiene. The papilla regeneration technique is described below and is illustrated in Figs 5-1 to 5-17.

Papilla Regeneration Technique: 1. Identify the location of the cover screws through the covering mucosa. 2. Make an incision at the palatal/lingual aspect of the cover screws, followed by vertical releasing incisions in the buccal direction. It is important to preserve the gingival cuff at neighboring teeth. 3. Elevate a full-thickness flap in the buccal direction. 4. Remove the cover screws. 5. Select proper abutments and connect them to the fixtures. 6. Make semilunar bevel incisions in the buccal flap towards each abutment. Start at the distal aspect of the most mesially located implant. 7. Disengage the pedicle, then rotate it 90 in the palatal direction to fill in the interimplant space. 8. Suture the tissues, allowing no tension within the pedicles.

Peri-implant Soft Tissue Management: Papilla Regeneration Technique

Fig 5-1 b Technique for identifying the cover Fig 5-1 a Edentulous area distal to the first premolar in the first quadrant, in which fixtures have screws by the use of the probe tip. The dotted line already been placed. indicates the top of the alveolar crest; the solid line outlines the incisions to be made. The horizontal incision must be made at the palatal aspect of the cover screws and the vertical releasing incisions in the buccal direction. The gingival cuff at the distal aspect of the first premolar must be preserved.

Figs 5-2a and b

The situation following the incisions and the beginning of flap elevation.

61

Peri-implant Soft Tissue Management: Papilla Regeneration Technique

Figs 5-3a and b

Elevated full-thickness flap with the cover screws exposed.

Figs 5-4a and b

Cover screws are removed and the fixture heads are exposed.

Figs 5-5a and b

Healing abutments are selected and connected to the fixtures.

Peri-implant Soft Tissue Management: Papilla Regeneration Technique

Fig 5-6 The selected healing abutments should have sufficient length to support the flap. The increased soft tissue volume at the buccal aspect of the implants is clearly shown.

Figs 5-7a and b A semilunar bevel incision is made in the flap in relation to each implant. The first incision is made starting at the distal aspect of the most mesially located implant.

Fig 5-8 The incision creates a pedicle that is rotated 90 toward the mesial aspect of the abutment. The semilunar bevel incision must be extended enough to allow the pedicle to be rotated and placed in the interproximal area without tension.

63

Peri-implant Soft Tissue Management: Papilla Regeneration Technique

Figs 5-9a and b

The semilunar bevel incision and rotation of the pedicle is repeated for each implant.

Figs 5-1 Oa and b

Pedicle rotation from an occlusal view.

Peri-implant Soft Tissue Management: Papilla Regeneration Technique

Figs 5-11 a to c The rotated pedicles occupy the interproximal areas, resulting in gain of soft tissue height. This soft tissue portion will become a papilla-like formation.

Peri-implant Soft Tissue Management: Papilla Regeneration Technique

Figs 5-12a and b The suturing procedure starts at the mesial aspect of the flap, with a single suture at the releasing incision (step 1).

Peri-implant Soft Tissue Management: Papilla Regeneration Technique

Figs 5-13a and b Mattress sutures are made starting buccally and running to the palatal aspect and back (steps 2, 3, and 4). Such a suture design stabilizes the pedicle in the interproximal area and adapts this tissue portion to the underlying bone. Furthermore, this suture technique minimizes the risk of rupturing the pedicle.

Pen-implant Soft Tissue Management: Papilla Regeneration Technique

Fig 5-14 Healing result from an occlusal aspect 8 weeks following abutment connection. Note the increased tissue volume obtained at the buccal aspect.

Fig 5-15 Eight weeks following second-stage surgery, the healing abutments are replaced by the final abutments (EsthetiCone ). At this stage of the treatment, it is obvious that the surgical soft tissue manipulation used has created a perimucosal soft tissue contour matching the gingival architecture.

Fig 5-16

Prosthesis in place.

Peri-implant Soft Tissue Management: Papilla Regeneration Technique

Figs 5-17a and b Condition and architecture of the perimucosal soft tissues 2 years following placement of the fixed prosthesis.

Peri-implant Soft Tissue Management: Papilla Regeneration Technique

References
Adell, R., Lekholm, U., Branemark, P.-l. (1985). Surgical procedures. In: P.-l. Branemark, G. A. Zarb, T. Albrektsson (eds.). Tissue-Integrated Prostheses: Osseointegration in Clinical Dentistry (pp 211-232). Chicago: Quintessence. Andreasen, J. O., Kristerson, L, Nilson, H., Dahlin, K., Schwartz, O., Palacci, R, Jensen, J. (1994). Implants in the anterior region. In J. O. Andreasen, F. M. Andreasen (eds.). Textbook and Color Atlas of Traumatic Injuries to the Teeth, ed. 3 (Ch 20). Copenhagen: Munksgaard. Hertel, R. C., Blijdorp, P. A., Kalk, W., Baker, D. L. (1994). Stage 2 surgical techniques in endosseous implantation. International Journal of Oral & Maxillofacial Implants 9: 273-278. Israelson, H., Plemons, J. M. (1993). Dental implants, regenerative techniques, and periodontal plastic surgery to restore maxillary anterior esthetics. International Journal of Oral & Maxillofacial Implants 8: 555-561. Moy, P. K., Weinlaender, M., Kenney, E. B. (1989). Soft tissue modifications of surgical techniques for placement and uncovering of osseointegrated implants. Dental Clinics of North America 33: 665-681. Palacci, R (1992). Amenagement des tissus periimplantaires interet de la regeneration des papilles. Realites Cliniques 3: 381-387. Strub, J. R., Garberthuel, T. W., Grunder, U. (1991). The role of attached gingiva in the health of periimplant tissues in dogs. Part I. Clinical findings. International Journal of Periodontics & Restorative Dentistry 11:317-333. Sullivan, D., Kay, H., Schwarz, M., Gelb, D. (1994). Esthetic problems in the anterior maxilla. International Journal of Oral & Maxillofacial Implants 9 (Supplement): pp. 64-74. Wennstrom, J. L., Bengazi, R, Lekholm, U. (1994). The influence of the masticatory mucosa on the peri-implant soft tissue condition. Clinical Oral Implants Research 5:1-8.

Figs 6-1 and 6-2 In the treatment of edentulous arches, the use of a surgical guide stent in combination with the Fixture Positioning Guides is recommended. A general recommendation is to start the implantsite preparation in the canine region, using the guide stent. When the flags are used, they can be turned in the mesial and distal directions to guide the preparations of additional implant sites.

Figs 6-3 and 6-4 In partially edentulous arches, optimal implant positioning is more crucial than in completely edentulous arches. The Fixture Positioning Guides are designed to facilitate such an implant placement. These radiographs demonstrate clinical examples of this type of treatment.

Clinical Applications

Figs 6-5a and b Use of the long flag to position two fixtures in the mandibular prernolar-molar region. The flag allows the surgeon to evaluate different design possibilities for the final prosthetic reconstruction at the time of fixture placement.

Fig 6-6 Laboratory model demonstrating multiple implant placement with good parallelism and distances between the fixtures, as well as favorable tripodization.

Fig 6-7 Laboratory model showing a superstructure to be placed in the maxilla. The favorable implant positioning facilitates an optimal design of the prosthetic reconstruction. (Surgeon: Peter K. Moy, Los Angeles, California)

Clinical Applications

Figs 6-8a to f Replacement of mandibular right first molar and second premolar with a two-unit implant-supported prosthesis. Following preparation of the most mesial implant site, the short flag can be used to guide the surgeon in placing the next fixture. In this case, the optimal distance between the two fixtures was found to be 9 mm. Two millimeters were added to the 7-mm short flag, resulting in a center-to-center fixture distance of 9 mm. This allowed design of a two-unit prosthesis with favorable anatomy, facilitating proper oral hygiene.

Clinical Applications

Case B
Figs 6-9a to I Different treatment phases in restoring a partially edentulous mandible with bilateral implant-supported fixed prostheses. This patient has been treated in accordance with the guidelines given in Chapters 2, 3, 4, and 5. (Surgical and Prosthetic treatment: Patrick Palacci/Jean-Luc Vionnet, Monthey, Switzerland).

Clinical Applications

Clinical Applications

Figs 6-10a and b

Clinical appearance of a patient with advanced periodontal disease.

Figs 6-10c and d Radiograph taken following extraction of all teeth (left). After soft and hard tissue healing, Branemark System fixtures were placed in the maxilla and the mandible (right).

Figs 6-10e and f To facilitate design of fixed restorations with natural-appearing incisors, placement of fixtures in the most anterior segment of the arches has been avoided. The most posterior fixture on the maxillary right side was found to be non-integrated and thus had to be removed, but a sufficient number of fixtures remain to support a fixed bridge.

Clinical Applications

Figs 6-10g to I Laboratory models showing the maxillary and mandibular bridges respectively. In the maxilla a gold-acrylic bridge was fabricated and in the mandible porcelain fused to gold was used. Attachments were used to connect the bridges (two segments in the maxilla and three segments in the mandible).

Clinical Applications

Fig 6-11 a The natural left central and lateral incisors were restored with cemented crowns.

Fig 6-11b In the maxillary right quadrant, six implants were properly placed and a six-unit prosthesis was connected. In the maxillary left quadrant distal to the lateral incisor, a four-unit fixed prosthesis, supported by three implants, was placed.

Fig 6-11c

Figs 6-11 d and e

Good esthetic results of the peri-impiant mucosa closing the interimplant spaces-

Clinical Applications

Fig 6-12a Maxillary right central incisor with a root fracture due to trauma was scheduled for extraction.

Fig 6-12b A 13-mrn-long Branemark System fixture was immediately placed in the extraction site. Following healing, a CERAONE abutment was connected to the fixture.

Figs 6-12c and d A ceramic single-tooth restoration was fabricated using the

CERAONE

ceramic cap.

Fig 6-12e

Incision at stage II surgery.

Fig 6-12f Clinical appearance 3 years after prosthesis placement.

Clinical Applications

Figs 6-13a and b

Placement of fixture to restore a missing maxillary left canine.

Fig 6-13c Implant-supported single-tooth restoration, fabricated using a CERAONE abutment and ceramic cap.

Fig 6-13d Clinical appearance 3 years following restoration placement. The papilla regeneration technique (see Chapter 5) has been used to create harmonious soft tissue architecture.

Clinical Applications

Case G
Figs 6-14a to n A 25-year-old woman with congenital aplasia of the permanent maxillary lateral incisors. The remaining deciduous lateral incisors, showing signs of severe root resorption, were extracted and replaced with implant-supported single restorations. Following healing, CERAONE abutments were connected to fixtures, and ceramic crowns were fabricated and placed.

Figs 6-14a

Fig 6-14b Pronounced gingival recession at the buccal aspect of the maxillary right lateral incisor before treatment.

Clinical Applications

Clinical Applications

Figs 6-14i to I Clinical result 1 year after prosthetic treatment. Note the harmonious soft tissue architecture at the buccal aspects, compared to the situation before implant treatment (see Fig 6-14b).

Fig 6-14m and 6-14n Clinical appearance 3 years after prosthetic treatment. Orthodontic treatment had also been performed.