Tissue-Directed Plcement of Dentl Implnts in the Esthetic Zone for Long-Term Biologic Synergy: A Clinicl Report Richrd P. Kinsel, DDS 1 /Roert E. Lm, DDS, MSD 2 Implnt dentistry stedily evolves s more is lerned out the unique iologic interreltionship of the dentl implnt restortion nd the surrounding hrd nd soft tissues. Importnt fctors include the impct of the surfce microtopogrphy on iochemiclly-medited cell differentition, the unvoidle cteril coloniztion of the implnt-utment (or crown) microgp, the verticl nd horizontl dimensions of iologic width, nd the histology of surrounding structures. The recipient site, implnt design, surgicl technique, nd loction of the restortive pltform significntly influence the optiml esthetics nd iologic stility of implnt restortions. There re differing opinions mong clinicins regrding the pproprite positioning of the implnt restortive pltform in the verticl nd sgittl plnes reltive to the lveolr crest. An picl nd pltl orienttion of the coronl pltform reltive to the lveolr crest in the esthetic zone is generlly dvocted for fvorle fcil nd proximl emergence profiles of the definitive crown. Tissue-directed implnt plcement primrily considers the long-term consequences of the implnt restortion upon the surrounding hrd nd soft tissues. The gol is to develop optiml gingivl contours nd definitive restortion in the esthetic zone tht coexist in stle iologic synergy. The rtionle nd the specific prosthodontic nd surgicl protocols inherent in the tissue-directed concept re discussed in this report. INT J ORAL MAXILLOFAC IMPLANTS 2005;20:913 922 Key words: iologic width, dentl implnts, gingivl morphology, implnt-supported dentl prostheses, interdentl ppill, osseous morphology, ovte pontics, single-stge implnts Clinicins hve relized tht it is importnt to hve n optiml gingivl frme surrounding implnt restortions to complete the illusion of nturl teeth in the esthetic zone. 1 8 The osseous rchitecture surrounding helthy nturl dentition follows the cementoenmel junction (CEJ) of teeth terminting, pproximtely 2 mm piclly, with 3-mm gingivl tissue overly. Although the interdentl one is typiclly 3 mm coronl to the midfcil one, this scffold lone does not ccount for the mesured soft tissue height of 4.5 to 5.5 mm, discrepncy of 1.5 to 1 Assistnt Clinicl Professor, Deprtment of Restortive Dentistry, Division of Prosthodontics, nd Director, Implnt Dentistry Progrm, Buchnn Dentl Center, University of Cliforni, Sn Frncisco, Cliforni; Privte Prctice, Foster City, Cliforni. 2 Assistnt Professor, Deprtment of Periodontology, University of the Pcific, Sn Frncisco, Cliforni; Visiting Assistnt Professor, Grdute Periodontics, University of Wshington, Settle; Privte Prctice Limited to Periodontics, Sn Mteo, Cliforni. Correspondence to: Dr Richrd P. Kinsel, 1291 Est Hillsdle Boulevrd, Foster City, CA 94404. Fx: +650 573 8280. E-mil: drcycle@ol.com 2.5 mm of gingivl scllop. This dditionl height is relted to the presence of djcent tooth ttchments nd the volume of the gingivl emrsure. The clssic study of Vn der Veldon 9 found tht denuded interdentl ppille of helthy dentition consistently showed reound of n verge of 4.3 mm into the gingivl emrsure.the greter the distnce from the coronl pex of the interdentl ppill to the underlying one, the less predictle complete oturtion of the gingivl emrsure ecomes. 10 Preservtion of interproximl hrd nd soft tissues is profoundly influenced y the verticl nd horizontl components of iologic width. 11 18 The necessity of one to estlish physiologic iologic width in the verticl dimension requires tht the implnt-crown interfce e locted t lest 2 mm coronl to the osseous crest. 14 In nturl dentition, Werhug 19 nd Tl 20 demonstrted tht interseptl one will resor pproximtely 2 mm piclly nd 1.5 mm lterlly from cteril plque on the tooth surfces. Similrly, the cteril coloniztion ssocited with djcent implnt microgps 21 23 would e expected to ffect the preservtion of interproximl one nd soft tis- The Interntionl Journl of Orl & Mxillofcil Implnts 913
Figs 1 nd 1 () Circumferentil crestl one loss of t lest 2 mm cused y the effects of estlishing iologic width picl to the implnt-utment (crown) microgp. This physiologicl response occurs with oth 1- nd 2-piece implnts. () A rdiogrph of djcent 1-piece single-stge implnts plced more thn 8 yers go demonstrtes the stility of the osseous structure when the implnt-crown microgp respects the proper dimensions of lterl nd verticl iologic width. The interproximl one pek is importnt for support nd mintennce of the overly ppill. sue ppillry height. Therefore, to preserve the interproximl one scffold, the recommended distnce etween djcent implnt-crown microgps is t lest 3 mm. 24 Choquet nd ssocites 25 evluted the ppill height etween single implnt restortions nd nturl teeth. When the distnce from the most coronl interproximl one to the contct point etween the implnt restortion nd nturl tooth exceeded 4 mm, they found significnt loss in ppill height. This is sutle difference from Trnow nd collegues 26 recognized study in nturl dentition, which showed complete oturtion of the interdentl spce when the one to contct-point height ws 5 mm or less. Of more significnce is the ppill height reltive to the proximl one of djcent implnts, which Trnow nd ssocites 27 hve shown to verge 3.4 mm from the interimplnt one crest. Excessive picl plcement of the interfce microgp will cuse circumferentil one loss of t lest 2 mm nd could potentilly cuse picl recession of the fcil mrginl gingiv nd reduction in ppillry height, with susequent esthetic compromises (Fig 1). A more coronl loction of the microgp results in long-term stility of the surrounding osseous scffold nd the overlying soft tissue (Fig 1). OPTIMIZING THE IMPLANT RECIPIENT SITE IN THE ESTHETIC ZONE In response to the need for fvorle soft tissue profiles round implnt restortions, mny surgicl techniques hve een presented to enhnce the interproximl ppille. Andresen nd coworkers 28 nd Plcci 29,30 reported on rotted pedicle grft technique to increse the interproximl volume t the trnsmucosl utment connection in the 2-piece sumerged implnt. Adrienssens nd collegues 31 descried gingivl flp design they hve leled the pltl sliding strip flp, performed t the secondstge surgery of the 2-piece dentl implnt to enhnce the ppill etween implnts in the nterior mxill. Kinsel nd ssocites 32 illustrted surgicl technique to increse the mount of ttched gingiv in the interproximl region for the completely edentulous ptient during the plcement of multiple single-stge implnts. The excess crestl kertinized tissue remining in the nonsumerged protocol is retined nd rotted mesilly into the spce etween the djcent implnts. Unfortuntely, despite these innovtive surgicl procedures, the finl ppillry heights etween djcent implnts re often less thn stellr, even with dequte underlying osseous support. One possile explntion my e relted to the histologic fetures of the structures surrounding dentl implnts. Buser nd ssocites 33 nd Berglundh nd collegues 34 compred the vsculr supply round teeth nd implnts. Around teeth, the vsculr supply is derived from the suprperiostel vessels lterl to the lveolr process nd from within the periodontl ligment. However, the implnt soft tissue lood supply origintes from the terminl rnches of lrger vessels from the one periosteum t the implnt site. While peri-implnt soft tissues lterl to the implnt hd sprse lood vessels, soft tissue lterl to root cementum ws highly vsculrized. A zone of vsculr connective tissue ws found directly djcent to the implnt surfce. In ddition, connective tissue fiers insert into the dentin coronl to the one, which provides support for the soft tissues surrounding teeth. These histologic fetures my explin why the interproximl ppill, which consistently fills the 914 Volume 20, Numer 6, 2005
interdentl spce in nturl dentition when the underlying one is 5 mm or less to the contct point, is difficult to duplicte surgiclly in the cse of djcent dentl implnts. All successful soft tissue grfting nd regenertive procedures must hve dequte lood supply to mintin grft vitlity. Any compromise in the vsculrity of the recipient site my cuse necrosis. Periodontl procedures to correct esthetic deficiencies tht re predictly successful in nturl dentition my hve n incresed risk of filure round implnts, with the potentil for result worse thn the originl defect. Therefore, the preservtion or ugmenttion of the soft tissue prior to implnt plcement is of prmount importnce to otining optiml gingivl contours surrounding the definitive restortions. Once fvorle recipient site is developed, modified tissue-punch technique tht minimlly disrupts lood supply, s opposed to the reflection of full-thickness flp, cn e used to uncover the underlying one prior to the implnt osteotomy. THE SCALLOPED IMPLANT RESTORATIVE PLATFORM Currently, there is considerle interest in prolic 1-piece implnt tht would minimize proximl one loss cused y iologic width impingement while llowing intrsulculr plcement of the pltl nd fcil mrgins. 35,36 Holt nd collegues 35 presented series of hypotheticl implnts with prolic restortive pltforms tht conformed to the osseous rchitecture found in the esthetic zone. The uthors recognized tht predictle, long-term mintennce of the surrounding hrd nd soft tissues is prolemtic with the rottionl restortive pltforms of current dentl implnts, s opposed to the norml sclloped CEJ of nturl teeth. It ws postulted tht one loss nd picl recession of the gingivl mrgins could e reduced y redesign of the coronl pltform of implnts. Unfortuntely, 1-piece implnt with coronl pltform tht follows the prolic osseous structure typiclly found surrounding nturl teeth leds to certin compromises. The osseous rchitecture vries in coronl height etween the mid-fcil, proximl, nd mid-pltl one. Therefore, severl vritions of the implnt s coronl pltform would hve to e mnufctured. Secondly, proper orienttion of the prolic pltform requires either press-fit cylinder or nrrow thred-pitch screw tht llows t lest 90-degree rottion of the implnt ody without excessive picl movement of the implnt ody. A press-fit implnt my lck sufficient primry stility following plcement, preventing immedite provisionl restortion. Both the cylindric press-fit nd nrrow thred-pitch designs hve limited resistnce to sher forces etween the one-implnt interfce, which my compromise the long-term survivl of the implnt. Vrious dentl implnt mnufcturers hve developed sclloped utments tht re connected to the coronl portion of the implnt ody. Although the prolic shpe of the restortive pltform more closely follows the curviliner profile of the hrd nd soft tissues, the implnt-utmnt interfce will cuse crestl one resorption s iologic width is estlished, irrespective of the loction of the crown mrgins. TISSUE-DIRECT PLACEMENT OF THE SINGLE-STAGE IMPLANT Currently, there re implnt designs tht re rottionlly symmetricl ut llow the clinicin to modify oth the implnt utment nd ody while mintining the crown microgp t lest 2 mm from the underlying osseous crest. However, the concept of introrl preprtion of the solid utment nd implnt shoulder requires return to prosthodontic protocols tht hve een consistently successful in full-coverge crown restortions of the nturl dentition. A comprison etween Strumnn stndrd single-stge implnt (Institut Strumnn, Wldenurg, Switzerlnd) nd mxillry centrl incisor is shown in Fig 2. The most pprent differences re the fcilpltl dimension (4.8 mm versus 7 mm) nd the sence of curviliner CEJ. However, the tpered coronl neck fvorly simultes the emergence profile of nturl tooth. In the sgittl view, n otuse ngle is formed when line is drwn from the root pex to the proximl midpoint of the CEJ to the fcil-incisl line edge. This ngle must e compensted for in the friction of the implnt restortion (Fig 3). If the implnt ody were plced prllel to the tooth root, then the solid utment would penetrte through the incisl fcil third of the crown. However, this ngultion hs the dvntge of duplicting the fcil emergence profile of the nturl tooth nd loctes the microgp in more coronl position reltive to the proximl one crest. Altertion of the ngultion of the implnt, which positions the coronl shoulder pltlly, would hve dverse consequences (Fig 4). The fcil-gingivl contour of the crown would need to e excessively oversized to simulte nturl tooth. This would result in plque retention prolems, possile picl migrtion of the mrginl gingiv, nd esthetic compromises t The Interntionl Journl of Orl & Mxillofcil Implnts 915
Fig 2 A comprison of stndrd single-stge dentl implnt nd mxillry centrl incisor. The implnt hs rough, threded surfce tht rnges from 8 mm to 14 mm in length (A). The polished neck is 2.8 mm in length (B) nd 4.8 mm in dimeter (C). The verge mxillry centrl incisor tooth hs n overll length of 24 mm (D), prolic CEJ tht is 2 mm coronl to the lveolr crest (E), nd midpltl to midfcil width of 7 mm (F). Fig 3 Generlly, the soft tissue structures surrounding the single-stge implnt re similr to nturl dentition. Also importnt is the otuse ngle tht is formed when line is drwn from the root pex to the proximl midpoint of the CEJ to the fcil-incisl line edge. CTC = connective tissue contct, JE = junctionl epithelium, CTA = connective tissue ttchment Figs 4 nd 4 () Pltl inclintion of the implnt to position the center xis of the solid utment through the incisl edge of the crown leds to n excessively convex fcil emergence profile with the ssocited periodontl nd esthetic complictions. () If the restortive pltform were plced piclly to llow more grdul fcil emergence of the crown, circumferentil crestl one loss would e expected ecuse of the impingement of the microgp upon iologic width. the crown-gingivl contct. Additionlly, the junction etween the rough nd smooth surfces would e picl to the proximl one, leding to resorption. Plcing the pltform more piclly improves the rupt chnge in the fcil emergence profile ut leds to susequent circumferentil one loss s iologic width is estlished 2 mm from the microgp (Fig 4). Clinicins commonly recommend tht the coronl portion of the implnt ody e positioned 3 mm picl to the CEJ of the contrlterl nturl tooth. 37,38 The impct upon the surrounding one nd soft tissue is illustrted in Figs 5 to 5d. The lveolr crestl one resors t lest 2 mm piclly nd 1.4 mm lterlly. The clinicl ppernce of this process in the single implnt restortion is often not ffected ecuse of the mintennce of the proximl one y the djcent teeth (Fig 5). However, the inevitle one resorption hs more potentil negtive esthetic consequences with djcent implnt restortions (Figs 5 to 5d). Proximl one loss reduces the verticl support for the interdentl ppill. Should this tissue recede piclly, the result is n open gingivl emrsure (Fig 5c) or restortions with excessively long proximl contcts (Fig 5d). Both re devitions from the clinicl ppernce of helthy nturl dentition. PREPARATION OF THE IMPLANT ABUTMENT AND RESTORATIVE PLATFORM IN SITU Clinicins hve recognized tht the 1-piece, singlestge implnt design is prticulrly well suited to utment nd implnt coronl pltform modifiction. 39 41 Introrl preprtion of the solid utment nd, if necessry, the implnt pltform provides dequte spce for properly contoured crown restortion, helps the mintennce of physiologic iologic width, nd controls the precise loction of the intrsulculr crown mrgin. 916 Volume 20, Numer 6, 2005
c d Figs 5 to 5d The lterl nd verticl components of iologic width led to predictle one resorption. ( nd ) Although recession of the interproximl soft tissue is lessened y the one support from the djcent teeth, the potentil consequences re more pronounced with djcent implnt restortions. (c) The inevitle loss of interdentl one reduces the ppillry scffold with picl recession of the soft tissue. (d) To close the gingivl emrsure, the restortions must hve excessively long proximl contct. c d Figs 6 to 6d () The implnt ody is oriented t the sme ngultion s nturl tooth root. () The recipient site is flttened so tht the rough surfce is completely surrounded y one. In the mxillry nterior region, where the osseous rchitecture is highly sclloped, the fcil nd pltl spects of the restortive pltform my e coronl to the mrginl gingiv. (c) The solid utment nd the implnt ody re prepred introrlly. (d) The gingivl mrgin is t lest 2 mm coronl to the osseous crest, follows the prolic rchitecture, nd mintins proper iologic width. The Interntionl Journl of Orl & Mxillofcil Implnts 917
c Figs 7 to 7c Clinicl cse of multiple single-stge implnts with solid utments plced into the mxillry rch t the sme ngultion s nturl dentition. () Note the intrsulculr loction of the implnt shoulders interproximl to the soft tissue levels. () The implnts nd solid utments re prepred with the gingivl mrgins plced t fcil tissue levels. (c) The definitive fixed prosthesis shows fvorle gingivl helth nd esthetics. The fcil nd interproximl mrgins of the restortive pltform cn e prepred to within 2 mm of the osseous crest. The tissue-directed plcement of single-stge implnt with 2.8-mm-high polished collr nd susequent preprtion re shown in Fig 6 through 6d. In the sgittl plne, the implnt is plced prllel to the root of nturl tooth. The proximl surfce of the restortive pltform is positioned t lest 2 mm coronl to the lveolr one (Fig 6). If the osseous rchitecture is highly sclloped, the fcil nd pltl mrgins my e suprgingivl (Fig 6). In situ preprtion of the solid utment nd implnt ody llows the development of prolic shpe tht follows the circumferentil outline of the osseous crest nd is unique to the ptient (Fig 6c). The restoring clinicin hs control over the picl extension of the intrsulculr mrgin. The definitive crown hs the fcil nd pltl contours tht simulte nturl centrl incisor tooth while mintining the loction of the implnt-crown microgp within 2 mm of the surrounding crestl one (Fig 6d). A clinicl exmple of the preprtion of singlestge implnts with solid utments in the mxillry rch is shown in Figs 7 through 7c. The implnts were plced prllel to the corticl one with the restortive pltforms in the proper fcil nd picl positions (Fig 7). Using 16-fluted finishing urs (#H375R-023, #7408-023, #ETUF 6.014; Brsseler USA, 918 Volume 20, Numer 6, 2005
Figs 8 nd 8 () The verticl position of the implnt s restortive pltform is prllel with the midfcil CEJ of the contrlterl nturl tooth. () The typicl mesiodistl distnce is 8.5 mm (A), while the width of the implnt restortive pltform is 4.8 mm (B). The implnt shoulder is centered etween the djcent teeth with the fcil position in line with the norml tooth root. Note tht the pltl extension of the crown restortion will e deficient ecuse of the inherent discrepncy in the root dimeter. Figs 9 nd 9 () In the cse of djcent implnts, loss of one occurs lterlly when the microgp of the djcent restortive pltforms is within 3 mm, compromising the osseous support for the interproximl ppill. () Two centrl incisors hve comined width of 17 mm (A). The seprtion etween the restortive pltforms should e etween 3 to 4 mm (B); the fcil extension should e in line with the norml position of the centrl incisors. The center-to-center distnce of the implnts will rnge from 8 to 9 mm (C). Svnnh, GA), the restoring clinicin completes the preprtion of the solid utments nd intersulculr gingivl mrgins (Fig 7). The cooling spry from the dentl hndpiece dequtely controls the het generted through the metl nd does not cuse dverse ffects to the djcent peri-implnt tissues. 42,43 The definitive fixed prosthesis shows fvorle gingivl helth (Fig 7c). A mximum of 0.8 mm of the stndrd single-stge implnt shoulder cn e removed while mintining the crown-implnt interfce within 2 mm of the osseous crest. Therefore, loss of the one supporting the overlying soft tissue would not e expected to occur. An implnt plced into the centrl incisor position hd the fcil extent of the coronl pltform in line with the contrlterl tooth nd ws centered etween the djcent teeth (Fig 8). The fcil mrgin of the pltform ws plced in line with the CEJ of the djcent tooth. This my result in coronl position of the mrgin if the osseous rchitecture is thin nd highly sclloped (Fig 8). When 2 or more djcent implnts re plced, estlishing optiml fcil nd interproximl gingivl contours of the recipient sites prior to implnt plcement is especilly importnt. The reduced lood supply of the tissue djcent to the coronl portion of the implnts jeoprdizes the regenertive cpilities of the surrounding gingiv. Agin, the fcil extent is in line with the nturl tooth, nd the interproximl distnce should e etween 3 to 4 mm (Figs 9 nd 9). The loction of the restortive pltform preserves the underlying fcil nd proximl one, which supports the soft tissue contours. SURGICAL TECHNIQUE TO PRESERVE AND ENHANCE THE GINGIVAL PROFILE Becuse of the difficulty of correcting gingivl deficiencies following implnt plcement, fvorle soft tissue contours must exist prior to surgery (Fig 10). The ovte pontic of either fixed or removle pros- The Interntionl Journl of Orl & Mxillofcil Implnts 919
c d e f g h i Figs 10 to 10i () Becuse of the compromised vsculrity surrounding dentl implnts, the prospective implnt sites should e optimlly developed prior to implnt plcement. () The tissue-punch technique ws used insted of the reflection of full-thickness fcil flp, minimizing the disruption of the lood supply. (c) The fcil tissue incision ws plced over the center of the implnt site nd connected with the pltl incision. (d) The gingivl tissue nd periosteum were completely removed nd the one flttened. (e,f) The djcent implnts in the centrl incisor region were seprted y 3 mm nd the lengths of the implnts were determined y sutrcting the tissue thickness from the depth of the guge to the gingivl mrgin. The ellipticl incision llowed fcil movement of the excess kertinized tissue once the implnts were seted, which ws evident y the lnching of the gingiv. (g) The lterl incisors nd second molrs tht hd served s interim utments for the provisionl fixed prosthesis were extrcted the dy of implnt plcement. (h) The solid utments nd implnts were prepred, nd the definitive fixed prosthesis ws delivered. (i) The rdiogrph shows the positive osseous rchitecture supporting the soft tissue tht is found surrounding nturl dentition. 920 Volume 20, Numer 6, 2005
thesis ids in ccomplishing this gol. 44 50 Use of surgicl technique without flp reflection conserves crestl tissue nd minimizes disruption of lood supply to mintin the gingivl frme (Figs 10 to 10d). Adjcent implnts re seprted y 3 mm (Fig 10e). Following the finl osteotomy, the tpered coronl neck of the implnt displces the excess kertinized soft tissue fcilly s the implnt is seted. The incresed thickness of fcil tissue cretes the ppernce of nturl root prominence, reduces the risk of picl migrtion of the fcil gingiv, nd elimintes the potentil gry show through of the implnt ody (Fig 10f). Once the implnts re plced nd the solid utments inserted, the lterl incisors nd second molrs tht served s interim utments for the fullrch provisionl fixed prosthesis were extrcted. The completed preprtion hs dequte reduction nd mrgin plcement for the definitive porcelin fixed prosthesis (Figs 10g nd 10h). The positive osseous rchitecture supports the overlying soft tissues (Fig 10i). When the implnt recipient site is optimlly prepred nd the supporting one level remins stle, the gingivl contours do not hve propensity to recede piclly over time. The present stte of the rt of implnt dentistry, coupled with the ever-incresing esthetic expecttions of ptients, continully chllenges the tretment tem. Successful implnt therpy is no longer judged simply y whether or not the implnt ecomes osseointegrted. Precise dupliction of the color, contour, nd vitlity of nturl dentition my ultimtely result in n esthetic filure if the optiml gingivl profile nd underlying supporting osseous structures re sent or recede piclly over time. Dentl implnts do not lend themselves to the unique prolic shpe nlogous to the CEJ of nturl teeth tht follows the norml osseous rchitecture. Attempts to develop n implnt with curviliner (prolic) coronl pltform re prolemtic ecuse of the compromises tht must e mde for proper orienttion nd the inherent vritions of individul lveolr one contours. However, mny implnts currently mnufctured hve the design properties necessry to llow the clinicin to modify introrlly oth the implnt utment nd ody for precise plcement of the intercreviculr mrgin, thus ensuring long-term iologicl synergy. CONCLUSION Tissue-directed implnt dentistry represents prdigm in conventionl protocols. Tht is, the finl form of the prosthesis is envisioned first, nd ll susequent procedures re designed to ccommodte optiml implnt plcement, hrd nd soft tissue support, nd proper gingivl contours to chieve long-term iologic synergy. Importnt considertions include: Recognizing tht the reduced vsculrity of the soft tissue structures surrounding dentl implnts my compromise susequent corrective gingivl surgicl procedures following plcement of the restortion Developing nd mintining the soft tissue contours t the prospective implnt site prior to surgicl plcement Using surgicl technique tht minimizes disruption of the lood supply of the optimized gingivl contours 3-dimensionl positioning of the implnt ody nd restortive pltform tht lessens the iologic width influences on lveolr one loss, therey preserving support for the overlying soft tissues Incorporting n implnt design with restortive pltform nd smooth surfce collr plced significntly coronl to llow selective removl of the implnt shoulder without dversely ffecting the structurl integrity of either the implnt or its restortive components. REFERENCES 1. Trnow D, Eskow R. Considertions for single-unit esthetic implnt restortions. Comp Cont Educ Dent 1995;16:778 784. 2. de Lnge GL. Aesthetic nd prosthetic principles for single tooth implnt procedures: An overview. Prct Periodontics Aesthet Dent 1995;7:51 61. 3. Dvidoff SR. Developing soft tissue contours for implnt-supported restortions: A simplified method for enhnced esthetics. Prct Periodontics Aesthet Dent 1996;8:507 513. 4. Stein JM, Nevins M.The reltionship of the guided gingivl frme to the provisionl crown for single-implnt restortion. Compendium 1996;17:1175 1182. 5. Trnow DP, Eskow RN, Zmzok J. Aesthetics nd implnt dentistry. Periodontol 2000 1996;11:85 94. 6. Trnow DP, Eskow RN. Preservtion of implnt esthetics: Soft tissue nd restortive considertions. J Esthet Dent 1996;8: 12 19. 7. Myenerg KH, Imoerdorf MJ.The esthetic chllenges of single tooth replcement: A comprison of tretment lterntives. Prct Periodont Aesthet Dent 1997;9:727 735. 8. Phillips K, Kois JC. Aesthetic peri-implnt site development.the restortive connection. Dent Clin North Am 1998;42:57 70. 9. vn der Velden U. Regenertion of the interdentl soft tissue following denudtion procedures. J Clin Periodontol 1982; 9:455 459. 10. Trnow DP, Mgner AW, Fletcher P.The effect of the distnce from the contct point to the crest of one on the presence or sence of the interproximl dentl ppill. J Periodontol 1992;63:995, 996. 11. Berglundh T, Lindhe J. Dimension of the peri-implnt mucos: Biologicl width revisited. J Clin Periodontol 1996;23:971 973. The Interntionl Journl of Orl & Mxillofcil Implnts 921
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