treatment guidelines for aesthetic implant therapy · key words: aesthetics, treatment guidelines,...

SPECIAL REPRINT, JIRD® CE Article No. 1, 2015

Inside this issue:Treatment guidelines for aesthetic implant therapy 1Carl Drago, DDS, MS

Immediate implant placement and provisional restoration: A case report 9Pär-Olov Östman, DDS, PhD

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Official Publication of BIOMET 3i LLC. 2015 | CE No. 1

CE-1A R T I C L E

† The author has a f inancial relationship with BIOMET 3i LLC resulting from speaking engagements, consulting engagements, and other retained services.

Earn 2 CE Credits—Written for dentists, hygienists and assistants.

EDUCATIONAL OBJECTIVES

The overall goal of this course is to provide the reader with a greater understanding of some of the many factors affecting the development of optimal anterior aesthetic implant restorations in partially edentulous patients.

Upon completion of the course, participants should be able to:

1. Refine their implant-treatment protocols to better incorporate such factors as the central incisor-proportions, facial and dental midlines, axial inclinations, maxillary incisal edge and lower lip contours, maxillary interproximal contact areas, arch form, crown heights, and anterior gingival symmetry.

2. Identify three planes of space that are important in planning implant treatment.

3. Understand how peri-implant soft-tissue biotypes affect overall treatment outcomes.

4. Discuss how the position of the osseous crest affects anterior aesthetics.

ABSTRACT

Thorough and accurate diagnoses are essential for providing optimal, state-of-the-art dental treatments that have predictable prognoses and long-term clinical success. Over the past 40 years, osseointegrated dental implants have proven to be a clinically successful treatment for edentulous and partially edentulous patients. Due to various advances, implants are now used in clinical situations that were once unimaginable. This paper outlines treatment guidelines for achieving aesthetically and functionally optimal maxillary an-terior implant restorations.

Treatment guidelines for aesthetic implant therapyCarl Drago, DDS, MS†

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JOURNAL OF IMPLANT AND RECONSTRUCTIVE DENTISTRY® 2015 | CE No. 1

guidelineCarl Drago, DDS, MS†

Key Words: aesthetics, treatment guidelines, implants

Treatment guidelines for aestheticimplant therapy

Introduction Medical and dental treatment commences with obtaining medical/dental histories via questionnaires and/or verbal interviews. Questions regarding patients’ past dental history should be aimed at determining the rate and progression of intraoral processes, including periodontal disease, pulpal disease, dental caries, and tooth loss. Past dental records, treatment notes, radiographs, casts, and photographs can be extremely helpful in identifying tooth positions, lip lines, and symmetries/asymmetries. They can also help determine what patients liked and/or disliked about their restorations.

Aesthetics are certainly subjective, but some established principles can be applied by clinicians and patients in order to achieve aesthetically optimal results. Knowingly or unknowingly, clinicians and patients use a framework

of aesthetic parameters. Rufenacht described the relationship between objects made visible by contrasts as “composition.”1 He identified dental, dentofacial, and facial compositions. Dental compositions might include images of anterior teeth in centric occlusion (Fig. 1). Dentofacial compositions could be close-up images of patients smiling without lip retractors (Figs. 2-4). Facial compositions could be full-faced photographs.

One factor in facial/dental aesthetics is symmetry, i.e. regularity in the arrangement of forms or objects. Two types of symmetry have been identified: horizontal and radiating. Horizontal symmetry contains similar elements from left to right or right to left in a defined sequence. Figures 5-7 are examples of asymmetrical elements.Radiating symmetry is a design that extends from a central

horough and accurate diagnoses are essential for providing optimal, state-of-the-art dental treatments that have predictable prognoses and long-term clinical success. Over the past 40 years, osseointegrated dental implants have proven to be a clinically successful treatment

for edentulous and partially edentulous patients. Advances in hard- and soft-tissue grafting, membranes, bone morphogenic proteins, and implant macrogeometry and surfaces have enabled implants to be used in clinical situations today that were once unimaginable. Patient expectations have also increased as the science has advanced; however, ill-planned and non-optimally placed implants still pose challenges for both patients and clinicians alike. This article outlines treatment guidelines for achieving aesthetically and functionally optimal maxillary anterior implant restorations.

T

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point, with symmetry on the right and left sides. Aesthetic smiles may have components of both.

Pythagoras defined a formula that provided a ratio between two parts in a harmonious relationship. He called this ratio (1:1.618) the Golden Proportion. Much more recently (1993), Preston reported that less than 20% of a study population had dental relationships that fell within the Golden Proportion.2 Although teeth may have shapes and relationships relative to adjacent teeth in the vertical and frontal planes that do not conform to the Golden Proportion, they may still be aesthetically pleasing. Ultimately, Preston considered that a viewer’s attention is drawn to proportions. The beauty of a smile will be affected by a number of relationships and elements linked to perceived aesthetic concepts.

An individual patient’s ability to have a pleasant, aesthetically pleasing smile depends on the quality of the dental and soft-tissue elements, the relationships that exist between teeth and lips during smiling, and how all of the above integrate into the facial composition. Matthews stated that the anatomy of a smile is an integral part of dentistry.3 Understanding and achieving aesthetic smiles involve close scrutiny of all elements of the oral region. It is not enough to establish the size of teeth based on high and low lip lines, the size of the mouth, and the best shade to blend with the patient’s age and complexion. In order to create harmonious smiles, dentists must maintain

or create normal curvature of the lips, proper exposure of the red zone of the lips, an undistorted philtrum, and undisturbed naso-labial grooves. These entities, maintained in harmony with teeth that are visible during smiling, constitute the anatomy of a smile. In order to develop optimal smiles, the smile must be understood, recorded, and analyzed so that desirable aspects may be preserved and undesirable components changed into desirable components. Preoperative photographs are essential to obtaining these goals.

The amount of tooth exposure during rest, speaking, and smiling, as well as the amount of gingival tissues (if any) exposed under the same conditions, are critical to creating and maintaining aesthetic smiles. The amount of exposure depends on body posture, muscle tone, tooth size, and arrangements. Vig and Brundo reported the results of a population survey in which they noted significant decreases in the amount of maxillary incisor display with advancing age (3.92mm exposed for people 10-15 years of age versus 0.25mm exposed for people 31-36 years of age).4 Decreasing maxillary incisor exposure contributed to the perception of aging of individuals in their 40s. Teeth may be lengthened but only within the parameters of other aesthetic and functional factors. The researchers also reported that tooth exposure for female participants averaged 3.4mm as compared to an average of 1.91mm for males. Vig and Brundo suggested that clinicians take these findings into account when designing smiles.

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According to Rufenacht,5 the perfect smile is characterized by a tooth/lip relationship with approximately half of the maxillary incisors visible at rest, the maxillary incisal edges parallel to the upper border of the lower lip, and an upper lip with an upward curvature. These specifications do not take into account Vig and Brundo’s results regarding the age-dependent nature of incisal display.4 The commissures should be symmetrically aligned with the inter-pupillary line, according to Rufenacht. Tooth proportions are also important in smile evaluation. Ward stated that the width/length ratio should be between 75 and 80% and recommended a Golden Proportion width ratio of 60%.6 Ward cautioned that these ratios are separate and distinct and should not be considered synonymous.

Dental and gingival aesthetics are separate, inter-dependent entities. A defect or fault in one cannot be compensated for with excellence in the other. Treatment

protocols must consider periodontal, aesthetic, and prosthetic factors. Clinicians must take into account the total picture, including the amount of gingival tissue displayed during speaking, smiling, and at rest.

1. Central incisor proportions: Generally, the width of maxillary central incisors should be 75-80% of their lengths (Fig. 8). The classical “Golden Proportion” of 1:1.618 (about 62%) is now thought to be the exception rather than the rule.2,7 The average length of central maxillary incisors is 11.3mm, average mesiodistal width is 9mm, and average mesiodistal width at the CEJ is 6.5mm. The average length of maxillary lateral incisors is 10.1mm, average mesiodistal width is 7mm, and average mesiodistal width at the CEJ is 5mm.8

2. Facial and dental midlines: The maxillary midline should be consistent with the facial midline (Fig. 9).

Carl Drago, DDS, MS (continued)

Established principles can be applied to achieve aesthetically optimal results.

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3. Axial inclinations: Maxillary central incisors are generally the most vertical of the anterior teeth. Figure 10 is an example of an inconsistent vertical alignment of the maxillary anterior teeth.

4. Maxillary incisal edge and lower lip contours: The incisal edges of the maxillary incisors typically should follow the contours of the lower lip, as exemplified in Figure 11.

5. Maxillary interproximal contact areas: Interproximal contacts should be closest to the incisal edges of the maxillary central incisors and then move apically as one progresses posteriorly from the maxillary midline (Fig. 12). The interproximal contacts in Figure 13 do not conform to this principle and thus are less aesthetic.

6. Arch forms: In many cases, drawing a line through the cusp tips of the maxillary canines can provide

valuable information about the likely aesthetic results. The right and left sides should be symmetrical, as is seen in Figure 14. In Figure 15, a line connecting the cusp tips of the maxillary canine teeth would be tilted, indicating an asymmetrical smile. More of the patient’s right canine would be visible to someone standing in front of the person.

7. Maxillary posterior crown heights: Clinical crowns should decrease in height distally, as is illustrated in Figure 16. In contrast, when the clinical crown heights do not decrease in height posteriorly, the result will be unaesthetic. The maxillary canine in Figure 17 is shorter than the lateral incisor, and the first premolar is as long as the lateral incisor and much longer than the canine.

8. Anterior gingival symmetry: Several principles can be formulated pertaining to this area.

Fig. 1. Anterior centric occlusion.

Fig. 7. The vertical orientation of the lateral incisors is not parallel.

Fig. 2. Low smile line.

Fig. 5. The maxillary and mandibular midlines are not symmetrical.

Fig. 4. The maxillary incisal edges follow the contour of the patient’s lower lip.

Fig. 8. The width of the maxillary central incisor is approximately 80% of the vertical height.

Fig. 3. Medium smile line.

Fig. 6. The incisal edges of the maxillary lateral incisors are at different heights and hence are asymmetrical.

Fig. 9. The facial midline aligns with the maxillary dental midline.

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a. Anterior gingival symmetry is generally more critical for teeth closer to the midline.

b. It is more critical in patients with high lip lines. c. Clinical crown heights for maxillary lateral incisors

should be shorter than those for maxillary central incisors and canines.

d. The greatest vertical height of the maxillary central incisors should be just distal to the middle of the maxillary incisors.

The maxillary canine teeth are the longest anterior teeth, the maxillary lateral incisors are the shortest, and the maxillary central incisors are longer than the lateral incisors but shorter than the canine teeth. Although the clinical crown heights in Figure 18 are slightly inconsistent, the overall result appears symmetrical. In contrast, the uneven gingival margin levels in Figure 19 significantly compromise the aesthetics.

Anterior Aesthetic ConsiderationsSingle-tooth replacement in contemporary dentistry is often accomplished with osseointegrated implant-supported restorations. Predictable peri-implant aesthetics require an understanding and preservation of the osseous and gingival tissues surrounding the failing teeth. Patients have become increasingly demanding regarding anterior aesthetics, even though the size of the defects and number of teeth

lost may be substantial. Achieving acceptable aesthetics requires a thorough course of treatment, including diagnosis, treatment planning, surgery, and restorative and preventive care (Figs. 20 and 21).9

Kois identified the following key elements as requisites for developing predictable anterior aesthetics with endosseous dental implants:10

• Relative tooth position • Gingival contours • Biotype • Tooth shape • Position of the osseous crest

Relative Tooth PositionClinicians need to be aware of three planes of space in diagnosing and planning implant treatment: incisal/apical, mesial/distal, and facial/lingual. Up to 2mm of apical migration of the facial peri-implant soft tissues may be expected after tooth extraction. Teeth with adequate attached gingiva have a more favorable prognosis than do teeth with minimal attached gingiva. The proximity of adjacent teeth is also critical during the diagnostic and treatment-planning phases, especially for maintaining interdental papillae. Teeth with root proximity have thinner interproximal bone and may be more susceptible to crestal bone loss postoperatively. If teeth are labially inclined, little


Fig. 10. The long axes of the anterior teeth are not parallel to each other.

Fig. 11. Maxillary incisal edges follow the contours of the lower lip.

Fig. 12. Interproximal contacts move apically as one moves mesio-distally.

Fig. 13. Interproximal contacts are not consistently located in a vertical direction.

Fig. 14. Cusp tips of the canine teeth are at the same level in the bucco-lingual plane.

Fig. 15. Cusp tips of the canine teeth are not at the same level in the bucco-lingual plane.

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or no alveolar bone may exist. This worsens the prognosis for maintaining the peri-implant soft tissues. Such patients would likely benefit from bone and/or soft-tissue grafting prior to or in conjunction with implant placement.

Gingival ContoursGingival shapes have been classified as high, normal, and flat. Kois reported in a clinical study of 100 patients that the average normal scallop was 4-5mm apical to the free gingival margin of natural teeth and that bone crests were more than 2mm apical to the cemento-enamel junctions. He postulated that as the gingival scallop increased, so did the risk of peri-implant soft-tissue recession and post-extraction bone loss.10

Choquet et al, reporting on the results of a retrospective evaluation of papilla levels adjacent to single-tooth implants in the anterior maxillae,11 found that when measurements from the interproximal contact areas to the interproximal heights of bone (IHB) were 5mm or less, papillae were present almost 100% of the time. When the distances were greater than or equal to 6mm, papillae were present 50% of the time or less. The mean distance between the IHB and the most coronal papilla level (interproximal soft-tissue height) was 3.85mm (SD=1.04). When comparing conventional and modified surgical techniques, the relation shifted from 3.77mm (SD=1.01) to 4.01mm (SD=1.10),

respectively. The researchers concluded that the results clearly demonstrated the influence of the location of the IHB on the presence or absence of papillae between implants and adjacent teeth.

BiotypePeri-implant soft-tissue biotypes have been defined as being either thick or thin. Cosyn et al reported on the results of a three-year clinical study that assessed the overall outcomes of immediate single-implant treatment in anterior maxillae.12 Thirty consecutively treated patients with thick gingival biotypes, ideal gingival levels/contours, and intact socket walls at the time of tooth extraction were treated with single-tooth replacement in the aesthetic zone by two experienced clinicians. The results included 25 patients at the three-year recare appointments. One early implant failure occurred; the cumulative implant-survival rate was 96%. Radiographic examinations revealed average interproximal crestal bone loss of 1.13mm mesially and 0.86mm distally. Mean mesial/distal papilla shrinkage and midfacial soft-tissue recession relative to the preoperative conditions were 0.05, 0.08, and 0.34mm respectively. Advanced midfacial recession (more than 1mm) was found in two cases (8%). Five cases (21%) were considered to be aesthetic failures, while the outcomes for five were judged to be (almost) perfect. The remaining 14 (58%) demonstrated acceptable aesthetics.

Fig. 16. Crown heights decrease from anterior to posterior.

Fig. 17. The inconsistent clinical crown heights contribute to the unaesthetic appearance of this maxillary left quadrant.

Fig. 18. An example of aesthetic symmetry. The clinical crown height of the lateral incisors is shorter than that of the central incisors.

Fig. 19. Macroscopic asymmetries. Although the incisal edges are more or less on the same plane, the gingival margin levels of the incisors are at different heights.

Fig. 20. Despite subtle asymmetries, thorough treatment made it possible to achieve an acceptable aesthetic result in this case.

Fig. 21. The aesthetic result was also acceptable for this patient, who has a medium smile line.

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The authors concluded that their protocol provided predictable outcomes for well-selected patients over at least a 3-year time frame, with almost full papillary re-growth and low risks for midfacial recession. Lee et al also concluded that soft-tissue biotype is an important parameter to consider in achieving aesthetic implant restorations, improving immediate implant survival, and preventing future mucosal recession.13

However, Kan et al reported on the results of a 2-8 year clinical study regarding facial gingival tissue stability following immediate placement and provisional restoration of maxillary anterior single implants and noted that peri-implant soft-tissue responses seemed to be limited to facial gingival recession and did not influence the volume or heights of interproximal papillae or proximal bone levels.

Tooth ShapeKois identified tooth shapes as square, tapered, and triangular.10 He stated that tooth shapes may impact soft-tissue contours both coronal and apical to the free gingival margins. Coronally, clinical crowns may affect the volume and heights of gingival embrasures. Kois considered square teeth to have the most favorable impact on soft-tissue contours due to the likelihood of such teeth being larger, with greater interproximal contact areas. He believed that square teeth have less of a risk of black triangles post-extraction. Kois stated that triangular teeth have the highest risks of black triangles because their interproximal contact areas tend to be more incisal and generally require more tissue to completely fill the gingival embrasures. However, he also noted that triangular teeth tend to have greater separation between roots and therefore may have more and thicker interproximal bone. He did not know whether this correlated with a greater

Treatment Guidelines• Thorough and complete physical and radiographic

examinations are required for optimal and predictable treatment.

• Preoperative clinical photographs are extremely helpful regarding locations and volumes of gingival interdental papillae and gingival symmetry (or lack thereof).

• Preoperative identif ication of maxillary and mandibular incisal edge locations and the amount of tooth display during speaking, smiling, and resting is critical. These factors should be taken into account during treatment planning and consultation.

• When adjacent implants are being placed, consideration must be given to identifying the amount of space available for both the implants and restorations, as well as the location of the implants relative to the teeth adjacent to the edentulous site. In some cases, it may be more appropriate to place one implant and cantilever an ovoid pontic in order to achieve optimal gingival contours.

• The interproximal bone height of teeth adjacent to edentulous sites is one of the major determinants of maintaining interproximal papillae. Assessment of this may be done with local anesthesia and bone sounding, clinical probing, and accurate radiographs.

• A meticulous surgical technique is mandatory when extracting hopeless teeth. Every effort must be made to maintain the integrity of the extraction socket walls and preserve interdental papillae.

• Vertical positioning of implants must be made relative to the interproximal bone height and cemento-enamel junctions of the adjacent teeth. Generally, coronal positions are more favorable than apical positions.

• It may be harder to achieve optimal aesthetics when the preoperative gingival tissue is scalloped, rather than flat.

• Thin biotypes are associated more with the potential for midfacial gingival recession than they are with preservation of gingival papillae.

• Screw-retained provisional restorations are the more likely treatment of choice for immediate restorations, as these eliminate the potential for leaving cement in the surgical wounds. Retained cement is one of the main causes of peri-implantitis.15

• If immediate restorations are planned, customized gingival contours can be developed within the contours of stock, provisional components.

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tendency for vertical crestal bone loss or maintenance of interproximal bone heights.

Kois concluded:a. Implant crowns should mimic the contours of the

contralateral teeth.b. A balance should be struck between supporting the

peri-implant soft tissues and putting too much pressure on them.

c. The facial contours of implant restorations should be flatter than natural tooth contours to minimize apical displacement of the peri-implant soft tissues.

Position of the Osseous CrestAccording to Kois, one of the key factors in anterior aesthetics relative to implant placement is the vertical distance from the osseous crest to the peri-implant soft-tissue margins, especially the height of the interdental papillae. He thought greater distances increased the risk of peri-implant soft-tissue loss (recession) and stated that if the vertical distance in the midfacial region from the soft tissues to the osseous crest was less than 3mm, one could expect less than 1mm of soft-tissue recession after extraction and immediate implant placement. He also stated that distances of up to 4mm from the interproximal bone height to the interproximal contact areas presented less risk of decreased soft-tissue volume and a gingival black triangle. He noted that these measurements should be based on the adjacent teeth, not the missing tooth.

Nisapakultorn et al reported on the results of a clinical study in which they identified factors affecting soft-tissue levels around anterior maxillary single-tooth implants.15 They followed 40 single-tooth implants in anterior maxillae, 75% of which replaced maxillary central incisors. Postoperatively, the facial mucosal margins were 0.5±0.9mm more apical than those of the contralateral natural teeth. Half or more of papillae were filled in 89% of the cases. Consistent with Kan et al’s findings, Nisapakultorn et al reported that the midfacial regions were more influenced by biotype than the interproximal areas. Papillae levels around single-tooth anterior maxillary implant restorations appeared to be mainly influenced by the interproximal height of bone of the adjacent teeth.

Clinical RelevanceThis article identified some of the factors pertinent to developing optimal anterior aesthetic implant restorations in partially edentulous patients. Treatment guidelines were suggested. However, for greater insight into anatomy,

surgical protocols, and implant loading protocols, readers are urged to review current textbooks and literature.

References1. Rufenacht C. Introduction to esthetics. In: Fundamentals of

Esthetics. Chicago: Quintessence, 1990:15. 2. Preston J. The golden proportion revisited. J Esthet Dent

1993;5:247-251.3. Matthews TG. The anatomy of a smile. J Prosthet Dent

1978;39:128-134.4. Vig RG, Brundo GC. The kinetics of anterior tooth display. J

Prosthet Dent 1978;39:502-504. 5. Rufenacht C. Introduction to esthetics. In: Fundamentals of

Esthetics. Chicago: Quintessence, 1990:85. 6. Ward D. Proportional smile design using the recurring esthetic

dental (RED) proportion. Dent Clin North Am 2001;45:143-154.7. Levin EL. Dental esthetics and the golden proportion. J Prosthet

Dent 1978;40:244-252.8. Wheeler RC. Dental Anatomy, Physiology and Occlusion. 5th ed.

Philadelphia: Saunders, 1974.9. Tarnow D, Eskow R. Considerations for single-unit esthetic implant

restorations. Compend Contin Educ Dent 1995;16:778-780.10. Kois J. Predictable single-tooth peri-implant esthetics: 5 diagnostic

keys. Compend Contin Educ Dent 2004;25:895-905.11. Choquet V, Hermans M, Adriaenssens P, et al. Clinical and

radiographic evaluation of the papilla level adjacent to single tooth dental implants. A retrospective study in the maxillary anterior region. J Periodontol 2001;72:1364-1371.

12. Cosyn J, Eghbali A, De Bruyn H, et al. Immediate single-tooth implants in the anterior maxilla: 3-year results of a case series on hard and soft tissue response and aesthetics. J Clin Periodontol 2011;38:746-753.

13. Lee A, Fu JH, Wang HL. Soft tissue biotype affects implant success. Implant Dent 2011;20:38-47.

14. Kan JY, Rungcharassaeng K, Lozada JL, et al. Facial gingival tissue stability following immediate placement and provisionalization of maxillary anterior single implants: A 2-to 8-year follow-up. Int J Oral Maxillofac Implants 2011;26:179-187.

15. Nisapakultorn K, Suphanantachat S, Silkosessak O, et al. Factors affecting soft tissue level around anterior maxillary single-tooth implants. Clin Oral Implants Res 2010;21:662-670.

In support of their research or for preparation of their work, one or more of the authors of the publications cited in the references may have received financial remuneration from BIOMET 3i LLC.

Carl J. Drago, DDS, MS†

Dr. Drago received his dental degree from The Ohio State University College of Dentistry and a Master’s Degree from the University of Texas Graduate School of Biomedical Sciences at San Antonio, Texas. Dr Drago is a Diplomate of the American Board of Prosthodontics and a

Fellow in the American College of Prosthodontists and the American College of Dentists. Dr. Drago lectures nationally and internationally and has published approximately 75 papers on various subjects in conventional and implant prosthodontics. He also has written four textbooks on dental implants and currently serves as the Clinical Science section editor for the Journal of Prosthodontics. Dr. Drago maintains a private practice limited to fixed, removable, and implant prosthodontics in LaCrosse, Wisconsin. Email: [email protected]

† The contributing clinician has a financial relationship with BIOMET 3i LLC resulting from speaking engagements, consulting engagements, and other retained services.

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CE Quiz N°1Treatment guidelines for aesthetic implant therapy Carl Drago, DDS, MS†

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Official Publication of BIOMET 3i LLC. This continuing education activity has been planned and implemented in accordance with the standards of the ADA Continuing Education Recognition Program (ADA CERP) through joint efforts between Dental Learning, LLC and BIOMET 3i LLC.

CE Quiz N°1

Treatment guidelines for aesthetic implant therapyDr. Carl Drago, DDS, MS

1. Which of the following preoperative steps are crucial to obtaining a good aesthetic result?

a. Identification of the maxillary and mandibular incisal edge locations

b. Evaluation of tooth display during speaking, smiling, and resting

c. Taking preoperative clinical photographs d. All of the above

2. For most people, the width of the maxillary central incisor should be what percentage of the length?

a. 75-80% b. Just under two-thirds (the classical “Golden Proportion”

of 1:1.618) c. Roughly equal d. It is not possible to generalize

3. What proportion of dental relationships have been found to fall within the classical Pythagorean "Golden Propor-tion”?

a. 75% b. 50% c. Less than 20% d. Less than 6%

4. As most people age, the amount of their maxillary incisor display:

a. Increases slightly b. Decreases significantly c. Remains fairly consistent d. Is greater for males than females

5. The aesthetic quality of most smiles will be higher if crown heights in the posterior maxilla, relative to the maxillary canines, are:

a. Symmetrical with those in the anterior b. About the same height as those in the anterior c. Higher than those in the anterior d. None of the above

6. For most patients: a. The maxillary central incisors should have the longest

clinical crowns b. The maxillary lateral incisors should have the longest clini-

cal crowns c. The maxillary canines should have the longest

clinical crowns d. None of the above

7. What is the normal reported height of the gingival scallop apical to the free gingival margin of natural teeth?

a. 1-2mm b. 2-3mm c. 4-5mm d. 3-6mm

8. To preserve the papillae in the natural dentition, what dis-tance between the interproximal bone height and the inter-proximal contact area has been reported to be optimal?

a. Between 3mm and 6mm b. 5mm or less c. 6mm or more d. Less than 7mm

9. Which tooth shape is considered to have the most favor-able impact on soft-tissue contours?

a. Tapered b. Triangular c. Ovoid d. Square

10. An aesthetically pleasant smile depends on: a. The quality of the dental and soft-tissue elements b. The relationships between the teeth and lips

during smiling c. The way a) and b) are integrated into the facial composi-

tion d. All of the above

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EDUCATIONAL OBJECTIVES• Refine their implant-treatment protocols to better incorporate such factors as the central incisor-proportions,

facial and dental midlines, axial inclinations, maxillary incisal edge and lower lip contours, maxillary interproximal contact areas, arch form, crown heights, and anterior gingival symmetry.

• Identify three planes of space that are important in planning implant treatment.• Understand how peri-implant soft-tissue biotypes affect overall treatment outcomes.• Understand how the position of the osseous crest affects anterior aesthetics.

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AGD Codes: 254, 255

Price: $29 CE Credits: 2Save time and the environment by taking this course online.

COURSE EVALUATIONPlease evaluate this course using a scale of 3 to 1, where 3 is excellent and 1 is poor.

1. Clarity of objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 2 1

2. Usefulness of content . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 2 1

3. Benefit to your clinical practice . . . . . . . . . . . . . . . . . . . . 3 2 1

4. Usefulness of the references . . . . . . . . . . . . . . . . . . . . . . 3 2 1

5. Quality of written presentation . . . . . . . . . . . . . . . . . . . . 3 2 1

6. Quality of illustrations . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 2 1

7. Clarity of quiz questions . . . . . . . . . . . . . . . . . . . . . . . . . 3 2 1

8. Relevance of quiz questions . . . . . . . . . . . . . . . . . . . . . . 3 2 1

9. Rate your overall satisfaction with this course . . . . . . . . 3 2 1

10. Did this lesson achieve its educational objectives? Yes No

11. Are there any other topics you would like to see presented in the future? __________________________________________________________________________

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Treatment guidelines for aesthetic implant therapyDr. Carl Drago, DDS, MS

SPONSOR/PROVIDER: This continuing education activity has been planned and implemented in accordance with the standards of the ADA Continuing Education Recognition Program (ADA CERP) through joint efforts between Dental Learning, LLC and BIOMET 3i LLC. DESIGNATION STATEMENTS: Dental Learning, LLC is an ADA CERP recognized provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Dental Learning, LLC designates this activity for 2 CE credits. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/goto/cerp. Dental Learning, LLC is also designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by AGD for Fellowship, Mastership, and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 2/1/2012 - 1/31/2016. Provider ID: #346890. Dental Learning, LLC is a Dental Board of California CE provider. The California Provider number is RP5062. This course meets the Dental Board of California’s requirements for 2 units of continuing education. EDUCATIONAL METHODS: This course is a self-instructional journal and web activity. Information shared in this course is based on current information and evidence. REGISTRATION: The cost of this CE course is $29.00 for 2 CE credits. PUBLICATION DATE: January, 2015. EXPIRATION DATE: December, 2017. REQUIREMENTS FOR SUCCESSFUL COMPLETION: To obtain 2 CE credits for this educational activity, participants must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%. AUTHENTICITY STATEMENT: The images in this course have not been altered. SCIENTIFIC INTEGRITY STATEMENT: Information shared in this continuing education activity is developed from clinical research and represents the most current information available from evidence-based dentistry. KNOWN BENEFITS AND LIMITATIONS: Information in this continuing education activity is derived from data and information obtained from the reference section. EDUCATIONAL DISCLAIMER: Completing a single continuing education course does not provide enough information to result in the participant being an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. PROVIDER DISCLOSURE: Dental Learning does not have a leadership position or a commercial interest in any products that are mentioned in this article. No manufacturer or third party has had any input into the development of course content. CE PLANNER DISCLOSURE: The planner of this course, Casey Warner, does not have a leadership or commercial interest in any products or services discussed in this educational activity. She can be reached at [email protected]. TARGET AUDIENCE: This course was written for dentists, dental hygienists, and assistants, from novice to skilled. CANCELLATION/REFUND POLICY: Any participant who is not 100% satisfied with this course can request a full refund by contacting Dental Learning, LLC in writing or by calling 1-888-724-5230. Please direct all questions pertaining to Dental Learning, LLC or the administration of this course to [email protected]. Go Green, Go Online to www.dentallearning.net to take this course. © 2015

500 Craig Road, First Floor, Manalapan, NJ 07726

DENTAL LEARNING

† Dr. Drago has a financial relationship with BIOMET 3i LLC resulting from speaking engagements, consulting engagements, and other retained services.

treatment guidelines for aesthetic implant therapy · key words: aesthetics, treatment guidelines,...

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