What is supracrestal fiberotomy extent
The anterior implant restoration - like a natural tooth Part 1
The single tooth implant is part of the repertoire of treatment planning in the anterior area, especially when the substance is to be treated gently with intact neighboring teeth, non-abutments or only minimally worthy of restoration neighboring teeth. The high survival rates of dental implants with single tooth gaps in the upper jaw prove that osseointegration can almost be assumed. In contrast, the data on success rates related to aesthetic success is less clear.
Fig. 1: The five critical steps in replacing an anterior tooth with an implant-supported restoration.
Diagnostic and pre-treatment phase
Fig. 2: Aesthetic risk analysis for edentulous alveolar ridge sections, slightly modified. Original in: ITI Treatment Guide, Volume 1, Implant Therapy in the Esthetic Zone - Single tooth replacement, Quintessenz Publishing Co, Ltd 2007.
Fig. 3: Risk factor gingival infection, strongly curved gingival course. Fig. 4: Risk factor high smile line, apical infection. Fig. 5: Risk factor of interproximal attachment loss, uneven gingival course.
As early as 1967, Pietrokovski reported a significant resorption of the alveolar process after tooth extraction . Van der Weijden  reports an average horizontal reduction of the alveolar ridge of 3.9 mm and an average vertical reduction of the alveolar ridge of up to 2 mm after anterior or premolar extractions. Schropp  describes an apical displacement of the buccal alveolar margin by 1.2 mm. The connection between the resorption of the buccal alveolar wall and the removal of the tooth could lie in the close connection during the development process of bundle bone, periodontal ligament and root cement and therefore cannot be influenced so much.
Many studies have shown that neither one of the many ridge preservation techniques nor the insertion of immediate implants is able to prevent the resorptive processes on the alveolar ridge, especially the buccal wall, after extraction [3, 4, 7, 10, 16]. What remains, however, is the possibility of preventing additional trauma by protecting the structures during the extraction process. This applies to the buccal bone wall, the periosteum and the adjacent gingival structures. The use of periotomes - alternating with slightly rotating pulling movements using pliers - helps here. Special ultrasonic cutting devices offer new substance-friendly options. To prevent additional resorption, pressure peaks during luxation and the formation of a mucoperiosteal flap should be avoided. Following an extraction, for example, in the sense of guided tissue healing, mechanical protection of the blood clot and support of the proximal and buccal soft tissue can be achieved by integrating a temporary with ovate pontic design . However, if you start with a tissue minus before the extraction, simultaneous augmentation - be it in the sense of a ridge preservation technique, guided bone regeneration or a soft tissue build-up - can be useful at the time of extraction. The main aim is to preserve the vertical dimension after extraction, as this is very difficult to reconstruct (Fig. 6 and 7).
- Fig. 6: Adhesive anchoring of the tooth crown with ovate pontic design for mechanical protection of the blood clot and as a soft tissue support.
- Fig. 7: Filling of the alveolus with xenogenic, mineralized bone substitute material and insertion of a membrane.
Precise implant position
Stable volume ratios are the prerequisite for a long-term biological aesthetic appearance of an implant-supported anterior crown. Ono  describes an undulating course of the mucosa, an adequate crown length adapted to neighboring teeth, convex shaped, sufficiently thick buccal mucosa and a papilla that harmonizes with the natural dentition as factors for aesthetic soft tissue contours. In this context, especially with regard to the papilla height and the stability of the buccal mucosa, the concept of the biological width on the implant should be mentioned. Due to the flat implant shoulder and the associated, partly subcrestal localization, it differs from the concept of biological width on the tooth, which is supracrestal . Thus, the bony foundation for the proximal soft tissue for the formation of a papilla in the implant is not guaranteed. Spear  and Kois  concluded that in addition to the proximal bone level, the presence of an adjacent dental soft tissue attachment and sufficient volume for the interproximal gingival soft tissue are also important. For the implant position, this means that all three dimensions, namely the mesio-distal, the bucco-lingual and the apico-coronal, must be included in the planning.
In the mesio-distal direction, an implant diameter should be selected that allows approx. 1.5 mm space for interradicular bone. Adell  demands this with consideration of the periodontal ligament of the neighboring tooth for undisturbed osseointegration. Tarnow  reports about 1.3–1.4 mm bone loss in the lateral direction after exposure of an implant. In order to avoid resorption of the bone on the neighboring tooth, a minimum distance of 1.5 mm should be maintained.
The buccal-lingual position of an implant should be chosen so that even after remodeling of the bone (as mentioned above, a lateral component of 1.3–1.4 mm must be anticipated) the buccal bone wall remains intact in the vertical direction and thus remains intact does not form the basis for recessions. If an average of 0.7 mm resorption due to the surgical trauma is added , this assumes a buccal bone thickness of approx. 2 mm  and in most cases requires augmentative procedures. The thickness of the mucosa influences the supracrestal height of the peri-implant soft tissue . Augmentation with connective tissue or homologous substitute materials offers additional protection in order to locally positively influence the underlying biotype.
Fig. 8: Precise implant position buccolingual ... Fig. 9:… vertical and… Fig. 10:… mesio-distal.
The implant crown - many functions
The functional, aesthetic and biological properties of the implant crown should imitate the lost natural tooth as well as possible. From a periodontological point of view, the submucosal portion of the implant abutment and the implant crown has the greatest influence on the apico-coronal position and the facial course of the free marginal mucosal border. Here, too, a sufficient supply of soft tissue is a prerequisite. The key to a predictable and stable red result in the anterior zone is the screw-retained temporary in combination with a slight excess of tissue. If a natural emergence profile from the implant shoulder to the marginal tissue margin has been achieved through sequential adaptation of the temporary, this can be obtained by precisely converting the submucosal functional area into the definitive abutment-crown combination. Small and Tarnow assume that a three-month waiting period after the end of the shaping process gives sufficient time for tissue stabilization and that no further apical displacement of the free mucosal margin is to be expected .
Fig. 11: Submucosal shaping and design using a functional, screw-retained, provisional crown. Implementation of the emergence profile achieved in an individual abutment with a 1 mm submucosal preparation margin.
Record reference data and define the implant recall
Fig. 12 and 13: Probing 2 weeks after incorporation of the definitive restoration.
Summary and conclusion
The treatment of a single tooth gap with an implant in the aesthetically relevant area is a challenge for the practitioner. It requires a high level of know-how and meticulous planning and implementation. Often, a quick path cannot be implemented and several preparatory treatment steps are required before the treatment goal is aesthetically achieved. Ergo, this is a time-consuming and costly treatment with very different levels of risk depending on the case. Observing the five treatment phases shown here will help to realistically assess the risk, to carry out the treatment gently and correctly and to keep the result permanent.In this way, we are able to provide the patient with a long-term stable single-tooth implant restoration that harmonizes with their perioral facial structures.
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