Implant Aesthetics Keys to Diagnosis and Treatment

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vi Preface

I wish to thank each of the authors for their time and patience in creating
this publication. It certainly has been a labour of love and an exhaustive but
rewarding process which I could not foresee when I embarked upon this
project.
Lastly, I wish to offer my sincere gratitude to everyone at Springer for
offering this opportunity to me and for their efforts in making it become a
reality. My professional ‘bucket list’ has now become one item shorter in
length.

Chicago, IL, USA E. Dwayne Karateew

Acknowledgements

This book is lovingly dedicated to those key individuals in my life who not
only have inspired me to reach for new heights but exhibited great restraint
and tolerance to many of my unique characteristics.
First and foremost, to my wife, Mitra. She is always at the ready for a new
challenge and does not know how to give less than 100 % of herself to any
project she signs onto.
Your unending love, encouragement and support have made this publica-
tion possible. Thank you for being the individual that you are and for both the
love and guidance you have expressed over the years we have shared together.
To my departed parents, Marni and Ed. The self-sacrifice for the better-
ment of my education which you unselfishly bestowed upon me was perhaps
never acknowledged directly, but is never forgotten. Thank you for teaching
me not only how to love, smile and laugh but to also study and work hard. You
may be gone, but are never out of my mind.
To my in-laws, Dr. Ali, Masoudeh and Dr. Mahtab. One could not wish for
a better, more considerate and loving extended family.
To the memory of our dog Kuma. He was an integral component of our
family and embodied unconditional love. His ‘smile’ is missed.
Special recognition is warranted for my residents and colleagues,
Drs. A. Narvekar, F. Gholami, E. Kaminsky, C. Traxler, T. Newman, H. Aljewari
at the University of Illinois at Chicago (UIC), Department of Periodontology,
who tirelessly aided me in the proof reading of this book.

E. Dwayne Karateew

vii
Contents

Part I Diagnostic and Treatment Considerations

1 Recognition of Risk Factors and Patient Assessment �������������������� 3

Lyndon F. Cooper and Homayoun H. Zadeh
2 Determination of the Sequence of Therapy ���������������������������������� 19
Michael S. Block
3 Osseointegration and the Biology of Peri-implant Hard and
Soft Tissues �������������������������������������������������������������������������������������� 31
Clark M. Stanford
4 Revisiting the Role of Implant Design and Surgical
Instrumentation on Osseointegration�������������������������������������������� 43
Paulo G. Coelho, Estevam A. Bonfante, and Ryo Jimbo
5 Anatomic Considerations in Dental Implant Surgery������������������ 57
Mitra Sadrameli
6 The Aesthetic Challenge: Three-Dimensional Planning
Concepts for the Anterior Maxillary Aesthetic Zone ������������������ 79
Scott D. Ganz
7 Clinical Assessment of the Gingiva and Alveolus ���������������������� 103
Yung-Ting Hsu and Hom-Lay Wang
8 Interdisciplinary Planning, Development, and Treatment�������� 117
Keith M. Phillips
9 Flap Design, Suturing, and Healing �������������������������������������������� 135
Praveen Gajendrareddy, Sivaraman Prakasam,
and Satheesh Elangovan
10 Digital Photography and Digital Asset Management ���������������� 151
Steven H. Goldstein

Part II Tissue Augmentation Considerations

11 Preservation of Alveolar Dimensions at the Time

of Tooth Extraction������������������������������������������������������������������������ 171
Robert A. Horowitz

ix
x Contents

12 Development of Hard Tissues with Block

Grafting Techniques���������������������������������������������������������������������� 189
John Russo
13 Guided Bone Regeneration for Aesthetic Implant
Site Development���������������������������������������������������������������������������� 203
Bach Le
14 Development of the Soft Tissue with Gingival Grafting������������ 233
David H. Wong
15 Tissue Engineering Approach to Implant Site
Development ���������������������������������������������������������������������������������� 247
Dan Clark, Igor Roitman, Mark C. Fagan,
and Richard T. Kao

Part III Implant Placement and Restoration

16 Optimal Implant Position in the Aesthetic Zone������������������������ 261

Jae Seon Kim, Lance Hutchens, Brock Pumphrey,
Marko Tadros, Jimmy Londono, and J. Kobi Stern
17 Parameters of Peri-Implant Aesthetics���������������������������������������� 287
Henriette Lerner
18 The Single Implant-Crown Complex
in the Aesthetic Zone: Abutment Selection
and the Treatment Sequencing ���������������������������������������������������� 301
Stavros Pelekanos
19 Implant Provisionalization: The Key to Definitive
Aesthetic Success���������������������������������������������������������������������������� 337
Edward Dwayne Karateew
20 Biomaterials Used with Implant Abutments
and Restorations���������������������������������������������������������������������������� 353
Toru Sato, Kazuhiro Umehara, Mamoru Yotsuya,
and Michael L. Schmerman
21 Digital Implant Abutment and Crowns
in the Aesthetic Zone �������������������������������������������������������������������� 369
Nesrine Z. Mostafa, Chris Wyatt, and Jonathan A. Ng
22 Challenging Maxillary Anterior Implant-Supported
Restorations: Creating Predictable Outcomes
with Zirconia���������������������������������������������������������������������������������� 383
Michael Moscovitch

Part IV Complications and Their Management

23 Peri-implantitis: Causation and Treatment�������������������������������� 407

Michael L. Schmerman and Salvador Nares
Contents xi

24 Laser-Assisted Treatment of Peri-implantitis������������������������������ 417

Edward A. Marcus
25 Prosthetic Solutions to Biological Deficiencies: Pink
and White Aesthetics �������������������������������������������������������������������� 427
Pinhas Adar
Appendix: Implant Checklist���������������������������������������������������������������� 439
Index�������������������������������������������������������������������������������������������������������� 441
Contributors

Pinhas Adar, MDT, CDT Adar Dental Laboratory, Atlanta, GA, USA
Gustavo Avila-Ortiz, DDS, MS, PhD Department of Periodontics,
University of Iowa College of Dentistry, Iowa City, IA, USA
Christopher A. Barwacz, DDS Department of Family Dentistry & Craniofacial
Clinical Research Program, The University of Iowa College of Dentistry & Dental
Clinics, Iowa City, IA, USA
Michael S. Block, DMD Center for Dental Reconstruction, Metairie, LA, USA
Estevam A. Bonfante, DDS, MS, PhD Department of Prosthodontics,
University of São Paulo – Bauru College of Dentistry, Bauru, SP, Brazil
Daniel Clark, DDS Orofacial Sciences, Postgraduate Periodontology,
UCSF School of Dentistry, San Francisco, CA, USA
Paulo G. Coelho, DDS, PhD Biomaterials and Biomimetics, Hansjorg Wyss
Department of Plastic Surgery, New York University College of Dentistry,
New York University College of Medicine, New York, NY, USA
Lyndon F. Cooper, DDS, PhD Department of Oral Biology, University
of Illinois at Chicago College of Dentistry, Chicago, IL, USA
Satheesh Elangovan, BDS, ScD, DMSc The University of Iowa College
of Dentistry and Dental Clinics, Iowa City, IA, USA
Mark C. Fagan, DDS, MS Private Practice, San Jose, CA, USA
Praveen Gajendrareddy, BDS, PhD Department of Periodontics, University
of Illinois, Chicago, IL, USA
Scott D. Ganz, DMD Department of Restorative Dentistry, Rutgers School
of Dental Medicine Private Practice, Fort Lee, NJ, USA
Steven H. Goldstein, DDS Private Practice Scottsdale, AZ, USA
Robert A. Horowitz, BS, DDS NYU College of Dentistry. Private Practice
Scarsdale, NY, USA
Yung-Ting Hsu, DDS, MDSc, MS Department of Periodontology and Dental
Hygiene, University of Detroit Mercy School of Dentistry, Detroit, MI, USA
Lance Hutchens, DDS Department of Periodontics, The Dental College
of Georgia, Augusta, GA, USA
xiii
xiv Contributors

Ryo Jimbo, DDS, PhD Department of Oral and Maxillofacial Surgery and Oral
Medicine, Faculty of Odontology, Malmö University, Malmö, Sweden
Georgia K. Johnson, DDS, MS Department of Periodontics, Iowa City, IA, USA
Richard T. Kao, DDS, PhD Private Practice, Cupertino, CA, USA
Department of Orofacial Sciences, University of California, San Francisco,
CA, USA
Department of Orofacial Sciences, University of Pacific, Cupertino, CA, USA
E. Dwayne Karateew, DDS Advanced Education in Periodontics, University of
Illinois at Chicago, Chicago, IL, USA
Jae Seon Kim, DDS Restorative Dentistry, University of Washington,
Seattle, WA, USA
Bach Le, DDS, MD, FICD, FACD Oral and Maxillofacial Surgery,
Los Angeles County USC Medical Center, Whittier, CA, USA
Henriette Lerner HL-Dentclinic, Baden-Baden, Germany
Jimmy Londono, DDS Department of Oral Rehabilitation, College of Dental
Medicine, Augusta University, Augusta, GA, USA
Edward A. Marcus, DDS Periodontics and Periodontal Prosthesis, University
of Pennsylvania School of Dental Medicine, Philadelphia, PA, USA
Michael Moscovitch, BSc, DDS, CAGS (Prosthodontics) Division of
Restorative Sciences, Boston University, Boston, USA
McGill UniversityMontreal, Quebec, Canada
Nesrine Mostafa, BDS, MSc, PhD Faculty of Dentistry, University of British
Columbia, Vancouver, BC, Canada
Salvador Nares, DDS, PhD Department of Periodontics, The University of
Illinois at Chicago, Chicago, IL, USA
Jonathan A. Ng, DDS, MSc, Dip Pros, FRCD(C) University of British
Columbia, Vancouver, British Columbia, Canada
Stavros Pelekanos, DDS, Dr med dent Department of Prosthodontics,
Dental School of Athens, University of Athens, Athens, Attica, Greece
Keith M. Phillips, DMD, MSD, CDT, FACP Department of Restorative
Dentistry, University of Washington School of Dentistry, Fife, WA, USA
Sivaraman Prakasam, BDS, MSD, PhD Periodontics, Oregon Health and
Science University, Portland, OR, USA
Brock Pumphrey, DMD Pumphrey Periodontics, Atlanta, GA, USA
Igor Roitman, DMD, MS UCSF School of Dentistry, Department of Dentistry,
San Francisco VA Hospital, Menlo Park, CA, USA
John Russo, DDS, MHSc Division of Periodontics, Medical University of
South Carolina, Sarasota, FL, USA
Contributors xv

Mitra Sadrameli, DMD, MS, Dipl. ABOMR University of British

Columbia Faculty of Dentistry and Private Practice, Chicago, IL, USA
Toru Sato, DDS, PhD Department of Crown and Bridge Prosthodontics,
Tokyo Dental College, Tokyo, Japan
Michael L. Schmerman, DDS Department of Periodontics, University of
Illinois College of Dentistry, Chicago of Dentistry, Chicago, USA
Illinois Masonic Medical Center, Chicago, USA
Department of Dentistry, Chicago, IL, USA
Clark M. Stanford, DDS, PhD College of Dentistry, The University of
Illinois at Chicago, Chicago, IL, USA
J. Kobi Stern, DMD, MSc Advanced Education in Periodontics, Department
of Periodontics, Augusta University, Evans, GA, USA
Marko Tadros, DMD Oral Rehabilitation – Prosthodontics, Augusta University,
Augusta, GA, USA
Kazuhiro Umehara, DDS, PhD Umehara Dental Office, Aomori, Japan
Hom-Lay Wang, DDS, MSD, PhD Department of Periodontics and Oral
Medicine, School of Dentistry, University of Michigan, Ann Arbor, MI, USA
David H. Wong, DDS Private Practice Tulsa, OK, USA
Chris Wyatt, BSc, DMD, MSc, Dip Pros, FRCD(C) Division of
Prosthodontics & Dental Geriatrics, Department of Oral Health Sciences,
University of British Columbia, Vancouver, BC, Canada
Mamoru Yotsuya, DDS, PhD Department of Crown and Bridge Prosthodontics,
Tokyo Dental College, Tokyo, Japan
Homayoun H. Zadeh, BS, DDS, PhD Advanced Education Program in
Periodontology, Division of Diagnostic Sciences, Ostrow School of Dentistry
of University of Southern California, Laboratory for Immunoregulation and
Tissue Engineering (LITE), Los Angeles, CA, USA
List of Videos

Videos can be found in the electronic supplementary material in the online

version of the book. On http://springerlink.com enter the DOI number given
on the bottom of the chapter opening page. Scroll down to the Supplementary
material tab and click on the respective videos link. In addition, all videos to
this book can be downloaded from http://extras.springer.com. Enter the ISBN
number and download all videos.
Video 18.1 Video showing the correct implant positioning according to
the guide stent
Video 18.2 
Video showing how to customize the impression coping
according to the emergence profile
Video 18.3 Video showing the customization of the emergence profile of a
single implant in the lab
Video 18.4 Video showing the digital design of a customized zirconia
abutment for a cemented restoration
Video 18.5 Video showing the customization of the emergence profile,
zirconia abutment and provisional crown fabrication prior to
extraction and implant placement on a stereo-lithographic
model
Video 18.6 Video showing tooth extraction and implant placement with
the use of a stereo-lithographic stent. “One time-final abut-
ment” and provisional crown insertion
Video 18.7 Video showing the customization of the healing abutment. The
concave shape of the abutment does not exceed the dimensions
of the extraction socket, thus protecting the blood clot and
leaving space for the soft tissue to grow
Video 18.8 Video showing only one disconnection of the final abutment
and extra-oral cementation of the final crown
Video 18.9 Video showing the correction of the screw access with the use
of The LTS abutment
Video 18.10 Video showing the extraoral cementation of the veneer on the
lithium disilicate implant-abutment
Video 18.11 Video showing the final cement-screw retained crown insertion

xvii
xviii List of Videos

Video 18.12 Video showing a double digital impression of the implant and

the achieved emergence profile
Video 18.13 Video showing the digital design of a LS2 abutment to fit in the
customized emergence profile
Video 18.14 Video showing the milling of the abutment from a pre-crystal-
ized Lithium disilicate block (IPS e.max CAD) with a pre-
manufactured connection
Video 18.15 Video showing the laboratory procedure for the cementation
of LS2 abutment on the titanium sleeve
Video 18.16 Video showing the Insertion of the final lithium disilicate abut-
ment and cementation of the final e.max crown
 Part I
Diagnostic and Treatment Considerations
 Recognition of Risk Factors
and Patient Assessment
1
Lyndon F. Cooper and Homayoun H. Zadeh

Abstract
Esthetic outcomes are of central importance to most patients. To ensure
that patients’ expectations are aligned with expected outcomes, a system-
atic risk assessment is required. Communication of the risk factors and
expected outcomes is important to ensure the patient has realistic expecta-
tions. Risk reduction for implant therapy begins with collection of diag-
nostic information and sharing a comprehensive esthetic diagnosis with
the patient. Esthetic risks for dental implants are often associated with the
tissues that surround the implant, specifically the lack of interproximal
tissue fill and the recession of buccal tissues following implant restoration.
Diagnostic information regarding connective tissue attachment levels at
adjacent teeth can clarify the risk for incomplete interproximal tissue fill,
and steps to overcome buccal tissue recession include both augmentation
procedures and proper dental implant placement. The establishment of
ideal tooth contours for the implant crown is easily achieved when the
proper volume of the supporting bone and soft tissue is provided.
Integrating an ideal implant-supported restoration into a beautiful smile
requires a comprehensive esthetic diagnosis, a broad approach to implant
site development, and careful execution of the planned implant therapy.

1.1 Introduction

Dental implants are often preferred as a method of

L.F. Cooper, DDS, PhD (*)
Department of Oral Biology, College of Dentistry, tooth replacement. The success of dental implants
University of Illinois at Chicago, and the restorations they support are favorably
Chicago, IL 606112, USA reported in a large body of literature representing
e-mail: [email protected] a broad spectrum of evidence. For example, sin-
H.H. Zadeh, DDS, PhD gle-tooth dental implant outcomes have been sys-
Herman Ostrow School of Dentistry of USC, tematically reviewed to have high success at
925 West 34th Street, Los Angeles,
CA 90089-0641, USA multiple levels. Full arch restorations subjected to
e-mail: [email protected] this scrutiny in the literature have similar high

© Springer International Publishing AG 2017 3

E.D. Karateew (ed.), Implant Aesthetics, DOI 10.1007/978-3-319-50706-4_1
4 L.F. Cooper and H.H. Zadeh

reported success rates. Multiunit anterior restora- cal capabilities are aligned than to conduct a
tions, particularly restricted to the anterior maxil- comprehensive esthetic diagnosis (one extending
lary arch, where esthetics is paramount, have not beyond the dental implant) prior to providing any
received this level of direct evaluation. The sur- implant-related prognosis.
vival of implants and prostheses in the anterior
maxilla is reported to be high. Unfortunately,
these large datasets regarding single, multiunit, 1.2 Comprehensive Esthetic
and complete arch implant restorations are lack- Diagnosis: A First Step
ing of outcomes regarding esthetics. in Dental Implant Success
Before embarking on a discussion of risk fac-
tors and patient assessment with regard to dental A comprehensive esthetic diagnosis requires
implant esthetics, it is worthwhile to consider ­several tools, as well as a checklist to obtain suf-
what is known regarding patient-based outcomes ficient information to complete this task. In addi-
regarding this facet of implant therapy (Yao et al. tion to intraoral instruments (mirror, periodontal
2014). Over a decade ago, it was reported that probe, explorer), a suitable intraoral camera and
“patient satisfaction with implant position, resto- impression materials are needed. The meaningful
ration shape, overall appearance, effect on introductory patient visit should result in obtain-
speech, and chewing capacity were critical for ing a complete clinical record, high-quality clini-
patient overall acceptance of the dental implant cal intraoral and extraoral photographs, screening
treatment”(Levi et al. 2003). It has been reiter- radiographs (revealing potential pathology or
ated that esthetic outcomes are of central impor- aberrant anatomy), and ideal study casts. Esthetic
tance to our patients and that their expectations implant therapy requires deployment of a compre-
may be high (even unrealistic). Yao et al. (2014) hensive esthetic diagnostic toolkit (Table 1.1).
summarized the following regarding patient An esthetic evaluation should be performed on
esthetic expectations for dental implants: an objective basis to avoid untoward meaning or
misunderstanding between the patient and clinical
1. An inverse correlation was found between age
and functional expectations, and negative cor-
relations were found between satisfaction and Table 1.1 An esthetic diagnosis toolkit
age. Extraoral photographs
2. Patient expectations before treatment were  Oblique view
higher than satisfaction after treatment, but  Facial view
this difference was significant only for esthet-  At rest, speaking, smiling, and laughing
ics in patients who had received implant-­ Intraoral photographs
supported fixed partial dentures (FPDs).  Fully retracted facial view (molar to molar)
3. Participants expected implants to restore their  Oblique view
oral-related quality of life to “normal.”  Region(s) of interest (three-tooth view)
4. Patient expectations on implant success and  Occlusal view
predictability are high compared with their  Facial view
Mounted study casts
reluctance toward treatment costs.
 Full representation of teeth and alveolar ridges
 Careful articulation revealing interocclusal distances
It is vitally important to establish expectations
Clinical chart
in the context of the patients’ understanding of  Tooth inventory
esthetics. Patients seeking replacement of their  Caries charting
tooth may expect esthetic improvement over their  Periodontal disease
existing tooth or teeth. It is the authors’ opinion Screening radiographs (PA or panoramic)
that there is no better way to assure that the  Revealing potential pathology or aberrant anatomy
patient’s esthetic expectations and the likely Consolidating information in HIPAA compliant, central
­outcomes based on biological realities and clini- location
1 Recognition of Risk Factors and Patient Assessment 5

team. For example, “my tooth is too big” requires specifically for the purpose of guiding single-
understanding if it is too far facially displaced, too tooth implant therapy (Cooper 2008). Several
long incisally, too wide mesiodistally, or exposed parameters overlap with the macroesthetic deter-
due to gingival recession. The objective diagnosis minants of esthetics described above. Collectively,
begins with review of the extraoral photographs. the objective analysis of the many esthetic deter-
The macroesthetic elements of smile design minants of the smile provides sufficient informa-
include factors influencing “the relationship tion to (a) characterize any esthetic limitations,
between teeth, the surrounding soft tissue, and the (b) describe these objectively for presentation
patient’s facial characteristics”. Included are the with the patient, and (c) provide a framework
facial midline, tooth display (the amount of tooth for discussion what possible features can and
and/or gingiva displayed in various views and lip cannot be changed by the intervention proposed
positions); the position of the intercommissure (Table 1.2).
line, vestibular (negative space); the orientation of
the smile line; and the orientation of the lower lip Table 1.2 An esthetic checklist to reduce dental implant
frame (Morley and Eubank 2001). These factors esthetic risk
can be clearly discerned from carefully oriented
Macroesthetic keys Fourteen objective criteria for
clinical photographs made using the simplest of (Morley and Eubank dental esthetics (Mange et al.
digital cameras and black-and-white desktop 2001) 2003)
printer images (Fig. 1.1). Midline Gingival/periodontal health
Any esthetic diagnosis for implant therapy Occlusal plane Interdental closure
involving single-tooth replacement, multiunit orientation
prosthesis, or full arch tooth replacement must be Tooth/gingival display Tooth axis
Intercommissure line Zenith of the gingival contour
comprehensive in nature. The placement of an
Lower lip framea Balance of the gingival levels
ideal single-tooth implant crown amidst medio-
Level of the interdental
cre restorations and aberrant anatomical relation- contact
ships of other teeth can lead to disappointment, Relative tooth dimensions
despite the quality of the implant therapy. Basic features of tooth form
Similarly, replacement of tooth/teeth, in the pres- Tooth characterization
ence of periodontitis, may lead to increased Surface texture
­likelihood of biologic complications. A compre- Color
hensive diagnosis is best performed objectively Incisal edge configuration
using a conceptual framework such as the “14 Lower lip linea
fundamental objective criteria” proposed by Smile symmetry
Mange et al. (2003) that have been repurposed Equivalent clinical parameters
a

a b

Fig. 1.1 (a) A simple color retracted photograph should ­discussions. (b) The final result realized for a complex
be made, archived, and used for discussion with the situation involving immediate implant placement (tooth
patient. This can be printed and illustrated or shown on a #6) replacing a missing lateral incisor
simple monitor, but serves as a point of reflection in