Esthetics in Implants

Contents

Introduction Glossary Implant Selection & Positioning Inter-implant papilla Complications Conclusion References

Introduction

Beautification and adornment are mutually inclusive terms that involve cosmetics, clothing, e!elry, "ody piercing, tattooing, and so forth# $hey are fueled "y our su"conscious drive to loo% attractive and feel good a"out ourselves & also en oy the attention !e get from others !hen they notice our attractiveness &Boucher '()*+, !hich e,plains the contemporary high demand for cosmetics "y all classes of society#

$he esta"lishment of optimal and predicta"le aesthetics is one of the most important and challenging aspects of reha"ilitation !ith dental implants# -esthetic reha"ilitation is important, not only "ecause achieving the ..perfect smile// is demanded "y our "eautyoriented society, "ut also "ecause individual impairment and disa"ility may result from aesthetic deficiencies# $he goal of aesthetic reha"ilitation is to alleviate or eliminate deficiencies and to o"tain optimal aesthetics#

0ptimal aesthetics should "e defined as the patient/s perception of ..visually pleasing or satisfying,// and the clinician/s assessment of accepta"le anatomic architecture coupled !ith proper function of the masticatory system &mastication, speech, s!allo!ing+# -esthetic reha"ilitation has to "e predicta"le, implying reproduci"ility and sta"ility of the outcome in the short and long term#

-chieving these characteristics depends on the interaction "et!een multiple varia"les, namely, "iologic &anatomic factors, host response+, surgical &procedure, technical s%ills+, implant &dimensions, surface characteristics, design+, and prosthetic factors# It is o"vious that analy1ing, selecting, and integrating each of these factors is challenging# Esthetic implant therapy has "ecome an integral part of modern implant dentistry, "ecause it complements the overall results of oral implantology#

Significant advances have "een introduced recently, including novel techni2ues to develop or regenerate implant recipient sites "y stimulating "oth hard and soft tissues and to reproduce healthy peri-implant tissue contours that resist mechanical forces and masticatory trauma# 3espite the advances and the success seen in many clinicians practices, there is insufficient scientific support regarding the overall success and longevity of esthetic implant therapeutical techni2ues in !ell-controlled, longterm studies#

$he advances in esthetic implant therapy and soft tissue and hard tissue regeneration are more the author/s o"servations than standard protocols that are used in clinicians/ daily practices# $herefore, a standard surgical and prosthetic protocol for esthetic implant therapy is mandatory#

Glossary
Esthetics4 &GP$-5+ Pertaining to the study of "eauty and the sense of "eautiful# 3escriptive of a specific creation that results from such study6 o" ectifies "eauty and attractiveness, and elicits pleasure Pertaining to sensation

3ental Esthetics4 $he application of the principles of esthetics to the natural or artificial teeth and restorations

Implant Selection & Positioning

7actors influencing8 Implant morphological & design considerations Rationale of implant positioning

7actors influencing according to -s%ary8 $he grip4 3uring the drilling procedure, the grip of the hand-piece influences the implant/s optimal position to a great e,tent# $he control of the clinician/s hand !hile drilling, using either a palm grip or pen-grasping grip, optimi1es the positioning procedure# $he palm grip sometimes provides "etter control over the other grips, especially in the ma,illary premolars locations#

It is the author/s personal opinion that the palm grip offers greater control of the drilling procedure in the ma,illary posterior areas# $his preference is due to the nature of the drilling procedure, !hich differs from the regular tur"ine handpiece grip that is used for cavity preparation# $he nature of the slo! speed and high tor2ue during dental implantology procedures, as !ell as the "one resistance, allo!s the palm grip to assist in achieving "etter positioning control#

-ccuracy of the surgical template4 $he more accurate the surgical template, the more accurate the implant positioning# 9e! types of templates are "eing fa"ricated !ith computer-aided design: computer-aided manufacturing &C-3:C-;+ technology that offers precise positioning in terms of locating the a,ial location of the implant head !ithin the alveolar ridge# $hese precise surgical templates are "eing used !ith a computed tomography &C$+ scan-"ased planning system &$ardieu et al# <==>+ !hich allo!s the surgeon to select the optimal location for implant placement, ta%ing into account specific anatomic characteristics of the patient and thus using the optimal "one densities#

$he precision of the perpendicular reconstruction images along the a,is of the arch &orthogonal frontal o"li2ue sections+ is almost (*?# $hus, the precision of these reconstruction sections is amply sufficient for clinical application in implant therapy# $he goal of this technology is to allo! the clinician to use an individuali1ed drill guide that fits e,actly on the "one crest of the patient# - C-3:C-; program uses the shape of the scanning template and the >-3 information of the plan#

- stereolithographic drill guide allo!s a physical transfer of the implant planning to the patient/s mouth# $he scannographic template is designed so that it can "e transformed into a temporary fi,ed or final prosthesis for immediate loading# $his su"se2uently transfers most of the surgical and prosthetic planning and fa"rication outside the patient/s mouth and allo!s the planning to "e done prior to implant installation#

$his revolutionary treatment planning and surgical implementation system transfers e,traoral planning into the mouth !ith accuracy and ease# $herefore, placing implants, a"utments, and restorative components is simultaneous "y using either conventional modeling or computer aided >-3 design# $his system gives the e,act position and depth of the implants prior to surgery# $he la"oratory can then produce a surgical template that guides the surgical procedure from the start to a completely successful placement#

$he case is planned in a computer "ased on C$ scan data, !hich offers a more precise picture of anatomy, compared to model-"ased planning# - customi1ed surgical template and the re2uired implantrelated components then can "e ordered and used according to the preplanned case#

Sharpness of the cutting drills4 Because drills "ecome "lunt !ith use, each implant manufacturer states the num"er of times a set of drills should "e used, after !hich they should "e discarded# $he sharpness of the drill prevents it from !o""ling in the surgical site and the su"se2uent deviation from the intended angulation or position# In fact, the sharpness of the rosette or the pilot drill that is used for the pilot osteotomy is the most valua"le "ecause it guides the primary path for the other drill to follo!#

$he use of positioning devices4 Some positioning devices are no! availa"le to help %eep an optimi1ed distance "et!een the implant and the natural teeth# - novel implant positioning system called IPS set &Stor1 am ;ar%t G;B@, Emmingen-Aiptingen, Germany+ !as introduced to assist in maintaining the proper implant position and angulation during the preparation of the surgical site# It consists of a series of sleeves and spreaders that maintain the proper interpro,imal dimensions and help determine the proper apical level of the implant head during surgery#

$he system facilitates selection of the implant diameter and a,is, maintains e,act spacing "et!een the ad acent tooth and the implant or "et!een ad acent implants, is compati"le !ith any implant system, is useful for orthodontists in determining prospective implant positions in cases in !hich teeth are missing as a result of a congenital defect, and is suita"le for use as seating tips in spacing templates#

$he use of computeri1ed navigation surgery4 Computeri1ed navigation surgery is a developing technology for intraoperative trac%ing and guidance of surgical instruments to enhance minimally invasive procedures# It is considered to "e a ne! era in perfecting implant positioning !ithin the alveolar ridge, and it has evolved to facilitate minimally invasive procedures# $his surgery, also called image guided implantology, can "e used !ith flapless or flapped implant placement protocols in cases of flapless implant placement !here the surgery may "e perceived as a "lind procedure that includes a ris% of cortical plate perforation#

$he computeri1ed navigation system provides real-time imaging of the drill and transforms flapless implant surgery into a fully monitored procedure# $he surgeon can rely on the computeri1ed navigation to ad ust the position and angulation of the drill in a"solute coordination !ith the pre-surgical digital implant plan# $he highly accurate intraoperative navigation ena"les precise transfer of the detailed pre-surgical implant plan to the patient#

Intraoperative computeri1ed navigation in implant dentistry mandates that an interfacing template "e firmly attached to the operated a! throughout the surgery# In the partially edentulous patient, this template may "e an acrylic resin splint that is mounted over the e,isting natural teeth, and in fully edentulous a!s, sta"ili1ing "one scre!s might "e used#

Implant ;orphological & 3esign Considerations4 $he modern implant design has several additional morphological modifications than the original standard classic designs and !as originally made to simulate the original tooth morphology in most of the designs# Bnfortunately, all missing teeth in the same dental arch cannot "e restored !ith the same implant design due to the uni2ue and versatile nature of human tooth roots# Some roots possess anti-rotational characters, some have stronger anchorage characters, and still others have a greater load-"earing capacity#

$herefore, the comparison "et!een natural teeth and dental implants is unfair, and dental implants should not "e called third dentition# Chen restoring natural dentition !ith conventional prostheses, the anatomy of the e,isting natural teeth and periodontium serve as guides for replicating the original natural form and contours# Bnfortunately, dental implants do not provide the same valua"le guides that are availa"le !hen restoring natural dentition, especially !hen multiple teeth are missing#

Conse2uently, "efore inserting dental implants, the clinician should develop an imaginary picture that !ill act as a guide or reference during the treatment plan# $his is accomplished "y properly assessing the original shape of the osseous "ed and the "iological dimensions of the missing dentition and relating them to the restorative components that !ill "e used# Bnderstanding the "asic morphology of the missing tooth in relation to the implant fi,ture design along !ith its related components "ecomes an a"solute necessity for achieving successful esthetic results#

;any scholars study the technical advancements in implant designs, as a result, a "etter understanding of "one "ehavior and cellular activities has led to the invention of ne! designs# $he changes involved include implant surface treatments, predicta"le interface connections, versatile uni2ue implant si1es, and ne! implant-related prosthetic components# $he ne!ly introduced dental implant designs have led many clinicians to dramatically improve the clinical outcome of dental implants from "oth the esthetic and functional standpoints and to ta%e implantsupported restorations to ne! levels#

$hus, selection of the optimum implant design and si1e is no! an integral part of every treatment plan that see%s a superior esthetic outcome# $he elements of implant design are4
'+

$he implant surface topography &micro characters+

<+

$he overall physical geometry &macro characters+, such as length, diameter, and macroscopic threads, vents, and grooves

>+

$he implant material composition

- tapered form for root-shaped implant design presents uni2ue physical characteristics4
It reduces the tendency for apical perforation !hen an immediate

placement method is selected, as compared !ith those that are parallel-!alled#

It might avoid damaging the ad acent roots#

It offers greater initial sta"ility#

It compresses "one against its !alls#

Implant positioning rationale4 Placing an implant in the esthetic 1one re2uires accurate attention to all treatment details not only to achieve clinically accepted results "ut also to preserve the e,isting natural details# -n optimum osseous dimension and restorative dimension should "e %ey in any accurate >-3 positioning procedure# $he natural "alance "et!een these t!o dimensions should "e preserved in implant therapy#

It contri"utes to the complete "iological integration of the dental implant !ithin its housing# Certain guidelines to assist in placing the implant in a >-3 fashionDthe interpro,imal dimension, !hich represents the relationship anterio-posteriorly "et!een the implant and the natural teeth mesiodistally, and the la"iopalatal dimension, !hich relates to the mediolateral a,is and the sagittal dimensional a,is, !hich is the apico-incisal dimension#

;esiodistal positioning4 $he mesiodistal position of the implant in relation to the ad acent teeth or "et!een ad acent implants has a direct impact on the esthetic outcome and the interpro,imal marginal integrity of the future restorative contours# It directly affects hygiene maintenance around the implantsupported restorations and its ad acent natural components# In ideal soft and hard tissue conditions, the implant should "e positioned mid!ay in the center of the availa"le mesiodistal space to o"tain a centrally positioned prosthesis#

$he potential ris% of improper mesiodistal positioning of the implant is the appro,imation to the interdental papilla or, !orse, impinging on it# $his can cause "lunting of the papilla and possi"le damage to the periodontium of the ad acent tooth to the implant site "y compromising the "lood supply, !hich could lead to e,ternal root resorption# E,ternal root resorption highlights the importance of not using parallel !alled roots for dental implants# $he use of a tapered implant design may reduce the chance of ad acent root appro,imation, especially !hen restoring areas !ith limited mesiodistal space or !ith curved roots#

-,ial positioning4 $he la"iopalatal position of the implant !ithin the alveolar ridge influences the emergence point of the implantsupported restoration as !ell as its contagious marginal contours and the profile of the final restoration# Generally, a proper emergence profile is desira"le, for "oth esthetic and hygienic reasons# $herefore, the la"ial contour of the implant head has to emerge, as do ad acent natural teeth# In perfect "one situations, the implant should "e placed as close to the "uccal contour as the volume of the availa"le "one permits, leaving '#*mm from the "uccal edge of the "one#

7or e,ample, in ) mm of "one !idth, a >#E*-mm-diameter implant should "e placed la"iopalatally to leave sufficient "one on the la"ial aspect of the implant "ody to maintain an optimal osseointegration# If the la"iopalatal dimension of "one is less than ) mm, a smaller diameter implant may "e used# Several methods can treat a deficient "one !idth6 "one dilators and "one splitting methods can "e used to increase or e,pand the amount of availa"le "one accordingly# $he placement of the implant in this dimension is critical#

- misplaced implant can violate the integrity of the la"ial plate of "one !ith su"se2uent "one fenestration or dehiscence, leading to a final implant-supported restoration !ith "ul%y, over-contoured margins# $his situation is clinically impossi"le to correct, even !ith the use of angulated a"utments# In fact, angulated a"utments might further complicate the situation "ecause their metallic gingival collar can potentially displace the soft tissue in a more la"ial direction, resulting in soft tissue recession or grayish, discolored gingiva at the emergence level#

-,ial positioning4 Implant positioning in relation to its a,ial level influences the amount of e,posure the final restoration !ill receive, !hich in turn dramatically affects the esthetic outcome of the restoration# -picoincisal positioning is no less important than the mesiodistal and la"iopalatal positioning aspects of the implant# Bnfortunately, surgical templates that offer apicoincisal positioning guidance for functional or esthetic implant placement are fe!#

Several factors control the location of the implant head in an a,ial dimension,
$he amount of space availa"le for restoration,

$he topography of the remaining "one,

$he marginal gingival location of the ad acent natural teeth, and

$he selected implant diameter#

$he reference location of all a,ial implant positioning is an imaginary line connecting the gingival 1eniths of the ad acent natural teeth# $here is a greater urgency for restoring natural gingival contours surrounding the ne! restorations !hen a natural tooth reference is missing and multiple ad acent implants are to "e used# $hese implants should "e placed at the alveolar crest !ithin the circumference of the missing teeth to "e restored#

$his ena"les the clinician to develop appropriate natural em"rasures on "oth sides ad oining the restorations and duplicate a natural gingival profile# $he ideal apicoincisal implant positioning places the implant head <mm to > mm apical to the line connecting the gingival 1eniths of the ad acent natural teeth# $his su"se2uently allo!s Frunning roomG throughout the "iological !idth of the implant !hen it is correctly positioned in an apicoincisal plane# $he Frunning roomG is a space of <mm to >mm in depth and it surrounds the implant head circumferentially#

Gingival 1enith of the ad acent natural teeth is considered to "e the landmar% or the reference in apico-incisal implant positioning# $herefore, for a num"er of reasons, it is recommended that the location of the implant head "e related to a line connecting the gingival 1enith of the ad acent remaining natural dentition rather than to a line connecting the CEH or the crest of the ridge#

Inter-implant papilla

$he presence of the interpro,imal papillae around implant-supported restorations allo!s symmetrical soft tissue margins and a state of harmony "et!een natural teeth and dental implant components# $his harmony and tissue symmetry leads to a natural-loo%ing restoration that does not o"scure vision# 0n the other hand, the slightest change in the level of the interpro,imal papillae around dental implants due to pathologic reasons or poor soft tissue handling during implant treatment can lead to ma or esthetic and phonetic complications that are often difficult to correct# $hat is !hat ma%es the peri-implantIsupported tissues a delicate clinical issue to handle#

$he se2uence of losing the interpro,imal papilla starts immediately after tooth e,traction# $he thin ad acent alveolar "one &interradicular "one+ starts to undergo a rapid process of resorption, pro"a"ly due to the follo!ing reasons4

$he thin nature of the alveolar "one &!hich allo!s faster resorption+, Reduced "lood supply to the crest of the interradicular "one at this particular area, $he possi"le direct contamination of the interradicular "one "y oral "acteria as a result of tooth e,traction, and ;ost importantly, the a"sence of the Sharpey/s fi"ers that stimulate continuous "one remodeling and thus maintain healthy marginal levels#

-s a conse2uence of tooth e,traction, the interdental papilla remodels in a sloping fashion from the palatal to the more apical facial osseous plate, and "ecomes depressed in comparison !ith the healthy ad acent marginal tissue# Bnfortunately, the lost interdental papilla usually cannot regenerate to regain its original dimensions# $he nature of the inter-implant &scar-li%e+ soft tissues also complicates the overall clinical prognosis and mandates special reconstructive procedures# $he greatest challenge today in implant and periodontal plastic surgery is the reconstruction of lost or incomplete interpro,imal papillae#

$o assess and classify the different clinical conditions of the interdental papillae, 9ordland and $arno! &'((5+ have reported the deferent clinical conditions of the interdental papillae according to their marginal level# $hey su"divided the interdental papillae into three classes4
Class I4 $ip of the interdental papilla lies "et!een the interdental contact

point and the most coronal e,tent of the interpro,imal cementoenamel unction &CEH+ &space is present, "ut interpro,imal CEH is not visi"le+#
Class II4 $ip of the interdental papilla lies at or apical to the interpro,imal

CEH &interpro,imal CEH is visi"le+#

Class III4 $ip of the interdental papilla lies level !ith or apical to the facial

CEH#

$arno! and others &'((<+ developed a useful classification for clinically identifying the predicta"ility of the presence of interdental papillae# $hey concluded that !hen the measurement from the contact point of the natural tooth to the crest of the "one !as * mm or less, the papilla !as present almost '==? of the time6 !hen the distance !as ) mm, the papilla !as present *)? of the time6 and !hen the distance !as Emm or more, the papilla !as present only <E? of the time or less#

$his classification is considered to "e the ultimate clinical parameter for predicting the presence of the papilla around dental implants in single-tooth situations and not in-"et!een t!o ad acent implants situations#

Salama and others &'((5+ proposed another interesting classification that furnished a prognostic classification system for the peri-implant papillae# $heir three classes are "ased on the availa"le interpro,imal height of "one &I@B+ in relation to the prognosis of the periimplant papillae# In Class ', I@B is JI*mm &measured from the apical e,tent of the future contact point of the restoration to the crest of "one+, suggesting an optimal prognosis6 in Class <, an I@B of )IEmm sho!s a guarded prognosis6 and in Class >, the I@B is greater than E mm, indicating a poor prognosis#

7actors affecting the peri-implant tissues4

Initial presentation &Sei"ert classification+ Implant position capa"ility &relative to planned gingival 1enith+ Bone formation and resorption at the implant Peri-implant mucosa integration Character of the implant a"utment interface Inflammation Aocal factors &pla2ue, etc#+ Patient factors &"iotype+ -"utment form Su"mucosal contour of the provisional cro!n Bone modeling:remodeling Potential ad acent tooth eruption

&'(5>+ Sei"ert classified alveolar crestal defects4 Class I4 Buccolingual loss !ith crestal height maintained Class II4 Kertical loss !ith "uccolingual !idth maintained Class III4 Com"ination of "uccolingual and vertical loss

Papilla reconstruction procedures4 Reconstructing the inter-implant papilla is one of the most techni2uesensitive procedures in dental implantology# It re2uires greater surgical s%ills and optimal scientific "ac%ground# $he nature of the inter-implant papilla &scar tissues+ also might compromise an optimal surgical reconstructive procedure6 ho!ever, there are general factors that influence the treatment outcome !hen one is to reconstruct the inter-implant papilla#

'+

Blood supply is the %ey factor in predicting the treatment outcome# - sufficient "lood supply should "e maintained in any flap design, especially in comple, grafting procedures that involve "oth soft and hard tissues# Relative tooth orientation "ecomes an important factor in predicting the peri-implant papilla, "ecause restoring t!o missing central incisors is unli%e restoring unidentical anterior teeth, such as a central and ad acent lateral incisor# 0ptimal implant position "ecomes an important factor in determining the future cro!n contours# $he three-dimensional &>-3+ implant positioning in the alveolar ridge "ecomes an influential factor, especially the a,ial position8

<+

>+

that influences the distance from the contact point to the osseous crest# $issue "iotypes should "e carefully evaluated and recorded "efore the treatment "egins# 7or e,ample, in the thin scalloped tissue "iotypes, the soft tissue volume is usually insufficient and more lia"le to slough !hen surgical procedures are "eing underta%en# -lso, the postoperative response to trauma &recession+ might complicate the overall treatment fate# In thic% flat tissue "iotypes, reconstruction procedures seem to "e more predicta"le due to the sturdy nature of the soft tissue and the underlying osseous structure#

J+

*+

In tooth morphology, the triangular cro!n shape seems to negatively influence the volume and height of the gingival em"rasure, thus affecting the overall si1e of the inter-implant papilla# 0n the other hand, s2uare cro!n shapes sho! "etter prognosis# -ttenuated tapered roots seem to allo! more interradicular "one than !ider roots, !hich influences the diameter of the future implant to "e used# Chen revie!ing the status of the osseous crestal level, the height of the osseous crest determines the predicta"ility of the inter-implant papilla# In cases of severe osseous resorption, the papillary morphology as !ell as the soft tissues !ill "e compromised6 therefore a staged approach should "e underta%en# $he current thought is to improve the

)+

osseous topography until a sta"le level is reached, and then proceed !ith implant installation procedures# Recently platform s!itching has "een introduced to many esthetic implantology procedures# S!itching the platform of the implant diameter to a smaller diameter at the interface level favors the "iological !idth development in the hori1ontal direction to compensate for the vertical one, there"y minimi1ing postoperative "one resorption and helping to maintain sta"le soft tissue margins# Platform s!itching seems to ma%e sense "ecause !ith e,perience, osseous levels !ere found to "e more sta"le !ith the use of narro! platforms# $his current thought has led to many ne! implant designs# -lso, shaping the su"gingival prosthetic

)+

components to "e narro!er and constricted su"gingivally has led to "etter soft tissue marginal results#

5+

Leeping an optimal distance "et!een ad acent implants and "et!een natural teeth and ad acent implants is vital in restoring natural soft tissue margins and prosthetic contours# $here is no definite guideline that dictates a certain distance to "e %ept "et!een dental implants, and nor should there "e "ecause the variations in teeth shape as !ell as the implant diameters are countless# Chen possi"le, a logical spacing should "e maintained that !ill not eopardi1e or infringe on any "iological areas#

(+

Recently several attempts have "een made to introduce ne! implant designs !ith scalloped features# Chile clinicians !orld!ide do not yet find this to yield predicta"le results, it is the author/s opinion that the designs !ill sho! promising results in the future# Scalloped designs can "e helpful in maintaining pro,imal osseous contours at sta"le levels in immediate implant placement6 ho!ever, in delayed implant placement therapy, it is necessary for the "one-grafting procedure to regenerate "one on the scalloped margins#

Complications

Implant failure is defined as the total failure of the implant to fulfill its purpose &functional, esthetic, or phonetic+ due to mechanical or "iological reasons# $reatment complications can range from fracture of the prosthetic components to a transient inflammatory condition6 ho!ever, this chapter addresses the possi"le complications in the esthetic 1one, !hich involves the possi"ility of failure due to esthetic reasons# -n implant !ith successful osseointegration might still "e considered a failure if the final prosthesis does not provide the optimal re2uired esthetics#

Such a failure could "e due to several reasons, some of !hich are untreata"le# $he esthetic outcome of an implantsupported restoration is affected "y four main factors4
Implant placement,

Soft tissue condition,

0sseous condition, and

Prosthetic & Biomechanical condition#

Implant Positioning Complications4

Peri-implant Soft $issue Complications4

Peri-implant @ard $issue Complications4

$he decision to use any particular grafting material or grafting techni2ue should "e "ased on the follo!ing4
9ature and si1e of the defect

Physical properties of the graft

Chemical properties of the graft

;echanism&s+ of action of the graft

-ssumed reha"ilitation planning

Conclusion

$o achieve a successful esthetic result and good patient satisfaction, implant placement in the esthetic 1one demands a thorough understanding of anatomic, "iologic, surgical, and prosthetic principles# $he a"ility to achieve harmonious, indistinguisha"le prosthesis from ad acent natural teeth in the esthetic 1one is sometimes challenging# Placement of dental implants in the esthetic 1one is a techni2ue-sensitive procedure !ith little room for error#

Guidelines are presented for ideal implant positioning and for a variety of therapeutic modalities that can "e implemented for addressing different clinical situations involving replacement of missing teeth in the esthetic 1one !hich should "e follo!ed "y the dental practitioner and:or the implant team# Aast "ut not the least BEGIN WITH THE END IN MIND.

References

-s%ary -ESE# 7undamentals of esthetic implant dentistry# <nd edition# @ong Long4 Blac%!ell6 <==E#p# '=(-<),<<*-*J,>='-<5# Buser 3, ;artin C, Belser C# optimi1ing esthetics for implant restorations in the anterior ma,illa4 anatomic & surgical considerations# Int H 0ral ;a,illofac Implants4<==J6'(#J>-)'# Sonic% ;, @!ang 3# Ley Principles of Implant 3entistry in the Esthetic Mone# -EGIS4 &online+ -l-Sa""agh ;# Implants in the Esthetic Mone# 3ent Clin 9 -m *= &<==)+ >('IJ=E#

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