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Are the most demanding implant

restorations requiring extreme skill and
proper planning
Are divided into:
-Anterior Single Implants
-Posterior Single Implants

Causes of single tooth loss

Endodontic failure
-maxillary central or lateral region is
often the commonest site for tooth
replacement in a restorative practice

Why single tooth implants?

Options for replacing single tooth include:
-Removable partial Denture
-Resin Bonded Prosthesis
-Space Maintainers
-Fixed Partial Denture
However, single tooth implants has highest
survival rate with success ranging from
94.6-100% according to schmitt and Zaib

Advantages of single tooth implants

1)Adjacent teeth do not require splinted
-Less risk of Caries
-Less risk of endodontics
-Less risk of porcelain fracture
-Less risk of uncemented restorations
-Less risk of fracture of tooth
2) Psychological need of patient
addressed. Patient does not desire two
adjacent teeth-often virgin prepared and
splinted to restore missing teeth

Advantages cont.
3) Improved hygiene conditions
-less decay risk
-floss versus floss threader
-less pontic overhang
4) Decreased cold or sensitivity
a) prepared teeth more temperature
b) Cement of tooth removed by tooth
preparation, toothbrush or scaler

Advantages cont.

5) Improved esthetics
6)Maintains bone in site 30%
decreasing width within 3 years after
7) Decreases adjacent tooth loss
-35% versus 0.05% risk at 10 years

Indications for single tooth implants

Endodontic failure
Root resorption

Missing lateral incisor-congenitaly

with radiographs showing less
interadicular space

Inadequate bucco-lingual width and

its augmentation


Factors influencing
treatment in single tooth

-patient selection
-smile line
-biotype of the periodontium
-patients age
-Tooth shape
-Bone anatomy of the implant site
-position of the implant
-Tooth position
-Root position of the adjacent teeth


Status of the adjacent teeth

Soft tissue profile
High standard of prosthetics
Crown height and occlussal relationships
Mesiodistal space at crown bone level

Generally the greatest problem is high

patient expectations, high esthetic
requirements and sensitive soft and hard
tissue management

Missing central in an area with

poor bone
Short crowns make bridge a
poor choiceimplants are
best here
A large diastema makes
fabrication of bridge a
daunting task


Whereas it is important to place implant

early before bone loss-it is critical to
understand that growth and development
are affected by implant which acts as
ankylosed teeth
Implants do not erupt along with
adjacent teeth hence many implants
placed in adolescent with residual growth
maybe infraposition after 10 years or the
implant may impede mesial shift resulting
in assymetrical arch


Ceasation for growth ranges from 11-15 years

and 11-17 years for boys
Generally implants insertion in females should
be done after 15 years and 18 years for males
even then other factors indicative of growth
completion should be assesssed before implant
Secondly, endocrine changes must be assesed
menstruation in females and body hair and
voice changes in men
Size is also important prospective implant
patient should have greater height than same
sex parents
Patient should not have grown over the last six
months-one can use lateral ceph of two years
with no changes


Lateral incisor can be inserted at a

younger age than central incisor or
canine; it is less obvious to the eye
when lateral incisors are at a
different position compared to the
central incisor
It is also not unusual for the lateral
to be shorter

Challenging esthetics

The esthetics of a maxillary anterior

single crown a natural tooth is often
one of the most difficult
The implant is often 5 mm or less in
diameter and round in cross section. A
natural maxillary anterior crown cervix
region is 4.5 to 7.0 mm in mesiodistal
cross section and is never completely
In fact the natural central incisor and
canine teeth are often larger in their
faciopalatal dimension at the CEJ than
the mesiodistal dimension.


In addition, because the bone is lost first

in faciopalatal width, the greater width
implants in this dimension would require
even greats augmentation than
presently advocated.
As a result the cervical esthetics of a
single-implant crown must accommodate
a round-diameter implant and balance
hygiene and esthetic Parameters.
Augmentation may be needed and a soft
tissue model is often required to transfer
the soft tissue clinical condition to the

Crown height space

The interocdusal space should be

assessed carefully. Patients with Angle's
Class II Division II skeletal patterns, an
inadequate maxillomandibuiar
relationship, or a severe deficiency in the
vertical dimension are contraindicated for
dental implants without prior corrections.
Main problem is short implant abutment
that may not retain crown
Correct through orthognathic surgery,
orthodontic treatment or both


An adequate mesiodistal space is necessary for

an esthetic outcome of an implant restoration
and the interproximal soft tissue of the
adjacent teeth.
A traditional two-piece implant should be at
least 1.5 mm from an adjacent tooth. When the
implant is closer than this to an adjacent tooth,
any bone loss related to the microgap, the
biological width, or stress will cause the implant
and adjacent tooth to lose bone. This may
compromise interproximal esthetics and
sulcular health of the implant and natural tooth.
The smallest-diameter implant body offered by
commercial companies is 3.2 mm with a
module of 3.5 or more. Therefore the
mesiodistai edentulous space for a two-piece
implant should be 6.5 mm or greater.


One piece implant may be fabricated in a

2.5mm-3mm diameter to accommodate a
reduced mesiodistal dimension
These implants design do not have a
micro-gap and the vertical defect is
narrower than most two piece implants
Such implants can therefore be placed as
close as 1mm from adjacent teeth and can
accommodate a 5mm mesiodistal missing

Available bone will influence soft tissue drape,
implant size, implant position (angulation and
depth) and final esthetic outcome

Important is 1) adequate bone volume.

2)Position of osseus crest-ideal
mid creastal position of the edentolous site
should be 2mm bellow the facial CEJ of the
adjacent teeth and the interproximal bone
should be scalloped 3mm more incisal than
midcrestal position-to allow development of of
good interproximal soft tissue height


Bone and soft tissue changes after

maxillary anterior tooth loss are rather
rapid and of considerable consequence.
As a result, many maxillary anterior
edentulous sites require at least some
bone and/or soft tissue modification
before, in conjunction with, or at implant
Under ideal conditions, the implant body
should not be inserted until the bone and
soft tissue are within normal limits


The crestal height of bone is one of the more

important considerations for an implant in the
esthetic zone.

Overall bone height in an apical direction is not

a problem in the anterior regions, it is often
deficient at the crest of the ridge and greatly
affects the position of the implant in relation to
the adjacent teeth and the related soft tissue
Bone grafting for height adjacent to a tooth is
more difficult and less predictable than grafting
for width or in extraction sockets.


It is a clinical challenge when a singletooth site has inadequate bone height

at the crest and the adjacent roots also
have lost bone, because it is not
predictable to grow bone on a natural
tooth root.
Therefore growing bone height both in
the edentulous site and growing bone
on the roots of the adjacent teeth is
not predictable.

To grow crestal bone height on the

adjacent roots, in relation to the ideal
crest of the ridge, orthodontic extrusion of
the teeth may be considered.
However, in cases of significant crestal
bone height loss, endodontic therapy and
a crown on the affected tooth is often
indicated after treatment.
After the bone on the adjacent teeth is at
an ideal height, the edentulous- site may
be augmented with increased success.

Facio -palatal Width

Single-tooth loss often result in the loss

of some or all of the facial bone in the
region of the missing tooth .
In addition, a 25% decrease in
faciopalatal width occurs within the first
year of tooth loss and a 30% to 40%
decrease within 3 years.
As a result even an intact alveolus 6 to 8
mm wide is often adequate in width after
1 year for a root form implant in a central
incisor position.
The bone width loss is primarily from the
facial region, because the labial plate is
very thin compared with the palatal plate,
and facial undercuts are often found over
the roots of the teeth


Therefore the majority of edentulous

maxillary central incisor single-tooth
sites require bone grafting for ideal
cervical esthetics and hvgiene.
The amount of available bone width
(faciopalatal) should be at least 2.0 mm
greater than the implant diameter at
implant insertion and ideally more 3 mm
greater in width; a 3.5mm implant
requires least 5.5 mm of bone width.
Bone augmentation on width is very
predictable and should be performed
before implant placement but also at the
time of implant insertion, especially
when no dehiscence of implant is visible.

Soft Tissue Drape

The position and
architecture of
the interdental" papillae are noted
before developing the implant
treatment plan.
The soft tissue in the region of the
edentulous site should ideally have
the same color and form as that of
adjacent teeth.
When a tooth is lost, the interdental
papillae are often depressed
compared with their level between
healthy adjacent teeth


The use of a soft tissue removable

prosthesis often accelerates the
collapse of the soft tissue and its
apical migration.
Therefore once the tooth is
extracted, inter-dental papillae are
rarely at the desired height and are
most often apically depressed.
Soft tissue manipulation to restore
their proper contour is often
required in conjunction with implant

Transitional Prosthesis
The transitional restoration tor a
single-tooth implant is often a
removable prosthesis, which lacks
stability and retention (hence the
name flipper).
Instead, it is strongly suggested that
a resin-bonded fixed restoration be
fabricated to provide lmproved
function, especially when crestal
bone regeneration ls performed.
The device should be bonded to the
tooth region s below the centric
occlusal contacts of the teeth

The soft tissue-borne transitional

restoration enhances crestal bone
loss during the graft healing, may
cause bone loss around the implant
during Stage I healing or even
implant failure from early loading
and may depress the interdental
papilla of adjacent teeth
Other transitional devices include
Essix appliance, cantilevered
transitional PD with pontic over the
surgical site, or a cast clasp RPD with
indirect rest seats to prevent rotation


The two most common complications of

anterior single-tooth implant
replacement are abutment screw
loosening and crestai bone loss.
The crestal bone loss causes an
increased risk of peri-implantitis or
shrinkage of the tissue and poor
cosmetic results.
Both of these conditions are in part
related to the implant crest module

An implant body with an antirotational

feature should be used for the singletooth implant.
The greater the dimension of the
external or internal hex for
antirotational feature), the greater the
resistance to shear forces once the
abutment is inserted, which corresponds
to a decrease in abutment screw

Smooth metal on the crest module

increases the crestal bone loss of the
biological width (once the implant is
uncovered) and transmits shear forces to
the bone

Therefore smooth metal collars on the

implant crest module should be limited to
approximately 0.5mm.

Implant Size

The first factor that influences the size of

an implant is the mesio-distal dimension
of the missing tooth. The average mesiodistal dimension of a central incisor is 8.6
mm for a male patient and 8.1 mm for a
female patient.
However, the implant body should
obviously not be as wide as the natural
tooth or clinical crown. Otherwise, the
emergence contour and interdental
papillae region cannot be properly

The bone level on natural teeth is 2 mm

below the CEJ, and the natural tooth
dimensions is 5.5 mm for central
This dimensions most closely resemble
an ideal implant diameter to mimic the
emergence profile of a natural tooth.
However, this ideal diameter is usually
too large to adequately restore the soft
drape of the missing anterior tooth.


The second factor that determines

implant diameter is the necessary
distance from an adjacent tooth root.
When the implant is closer than 1.5m
to adjacent tooth root, bone loss on the
adjacent tooth root may occur.
The distance from the interseptal bone
to interproximal contact SHOULD be 5
mm or less,to allow papilla to
completely fill the space.

At 7 mm the risk of a compromise in the

interproximal space is 75%. Therefore
intraseptal bone height is relative to the
maintenanc of the interdental papilla
and should be preserved.
In consequence, the implant should be
at least 1.5 m from the adjacent teeth
whenever possible, and the interseptal
bone on the adjacent teeth should be
within 5 mm of the eventual
interproximal crown contact position.

In summary, two mesio-distal parameters

determine the ideal implant size. The
ideal width of the single-tooth implant
should ideally correspond to the width of
the missing natural tooth 2mm below CEJ
However, distance between the roots of
the adjacent teeth should also be
measured. The implant diameter plus 3
mm (1.5 mm on each side) should be
equal to or less than the distance
between the adjacent roots at the crest
of the ridge (which is 2 mm below the
inter-proximal CEJ).

The next dimension that determines the

width of an anterior implant is the
faciopalatal dimension of bone
The ideal width of bone would allow at
least 1.5 mm on the facial aspect of the
implant so that if a vertical defect forms
around the crest module, that defect
would not become horizontal and change
the cervical contour of the facial gingiva.
Therefore the feciopalatai width of bone
at the crest for an anterior Implant
should have at least 1.5 mm on the facial
plus dimension of the implant at the crest
module, plus 1mm on the palatal.

The dimension of the implant reflect the size

of the crest module, not the implant body
dimension for example, a 4.1-mm crest
module (on a 3.75-mm |mplant body) needs
7.1 mm of mesiodistal bone, a 3.5 mm
crest module (on a 3.25-mm imolant bodv)
should have 6.5 mm of bone.
The natural intraroot distance of the two
central incisors distance is approximately 2
mm. However, the natural roots of the central
to lateral and lateral to canine are often less
than 1.5 mm apart, and often only 0.5 mm
separates them. As a consequence, the ideal
size of the single-tooth imolant is usually
smaller in diameter than the natural tooth

Often, the implant ideal diameters used to

replace the average-size tooth result in a 4.15.2-mm implant for a central incisor, a 3.0-to
3.5-mm implant for a lateral incisor, and a 3.7to 4,2-mm implant for a canine.
when in doubt, the clinician should use an
implant with a smaller diameter.
As such, a 4-mm-diameter implant may often
be used in the central implant position for a
single-tooth replacement.
Likewise, a.3.0- to 3.5-mm implant is often
used for a lateral incisor single-tooth
Though generally larger-diameter implant will
decrease abutment screw loosening, crestal
bone loss, and risk of long-term implant body

A) Extra-oral Examination:
Examine the area of the dental arch
and sorrounding gingiva that is
displayed when patient smiles or
laughslip line and smile line
B) Intra-oral Examination
-There should be no evidence of
bleeding and increased probing depth
- Do palpation and ridge mapping
Examine level of ridge crest or form
- Examine position and form of frenum

Hard tissues
Examine teeth on either side of the
-Are they restored with a crown or large
-Is there exposure of the root surface?
-is the root crown ration favourable?
-is there any mobility
-What is the alignment of the clinical


Assess both in ICP and RCP which

should be as close as possible
If there is any discrepancies eliminate
any deflective contact before planning
Assess where the guidance is and
avoid situation where the implant is
the one providing guidance
Assess any para-functional habits
-provide at least 7mm between
implant head and opposing tooth

Specific tests
Radiographic assesments






Realistic expectations ?
Needs to discuss potential outcomes

Lip line
a) Low lip line-display a predominance of
mandibular teeth or equal mix of
maxillary and mandibular teeth. Low
aesthetic risk as gingiva not seen

B) medium lip line-display most of their anterior

maxillary teeth and only very little, if any , of
supporting periodontal structures . Medium risk
Appearance of teeth and gingival embrasures is
of importance.

c) high lipline display entire maxillary

anterior teeth and significant portion of
supporting soft tissue. High aesthetic
Display of gingival structures increases
the relevance of tooth proportion and
emergence profile

A) Thick gingiva biotype-predominance of
thick broad band of attached gingva
(>6mm), resistant to recession. Low risk
for single tooth replacement
Can mask subgingival metallic
Favours long term stability of periimplant soft tissue

However thick gingiva biotype prone to postsurgical scarring subsequent to augmentation

For multiple teeth replacement, thick gingiva
biotype can be both favorable and detrimental
Favorable because tissue stability predictable,
however less chances of papillae developing.

B) Thin gingival biotype-highly scalloped

gingival architecture, reduced soft tissue
thickness. Width of keratinized gingiva
3.5-5mm. High risk
Then and friable nature of soft tissues is
conducive to formation and maintenance
of papillae but risk of gingival recession.
Adjacent teeth need to be periodontally
healthy and with sufficient bone-crest
height to maintain papillae


Square teeth-with thick gingival biotype. Low

Triangular teeth-with thin gingival biotype. High
When assoc with localized periodontal defects
and loss of interproximal papillae-implant crown
restored is square shaped with large contact
areas-compromised aesthetics

Infection at Implant Site

Local infections assoc with periodontal disease,
endo lesions can reduce quantity and quality of
hard and soft tissue at implant sites and adjacent
sites. Acute infection is a high risk, chronic
infections medium risk.
Bone level at adjacent teeth
Support for interproximal papilae is related to
the height of bone crests on adjacent teeth
Contact point to bone rest in relation to implant
papilla (Tarnow)
<4mm 100%
5mm 88%
>6mm 59%

Distance of 6mm or more from alveolar

crest to contact point reduces probability
of intact papilla.
Restorative status of adjacent teeth
Adjacent teeth with subgingival
restoration pose a threat as can cause
recession subsequent to placement of
Width of edentulous span

Width of hard and soft tissue in

Horizontal bone deficit-need to consider
augmentation procedure
Soft tissue deficits-need to consider soft
tissue grafting eg connective tissue graft

Height of hard and soft tissue in


Vertical hard tissue deficiencies are difficult to correct

and not predictable. High risk
Mostly regenerative procedures increase the width of
the implant sites but do not capture adequate height.
Vertically deficient sites usually assoc with adjacent
periodontally involved teeth

These sites cannot be enhanced without

addressing the periodontal d/s itself

Minimum for single tooth implants

in anterior region
Standard Implants(3.6-4.1)
ideal for upper centrals,upper and
lower canines and lower premolars
-requires a mesiodistal space of about
7mm and vertical height of 7mm
Narrow Implants(3.3 mm or less)
-Usually weak and provides smaller area
of contact between bone and implants
-needs 5mm between adjacent crowns
and roots and 7mm vertical space
-suited for upper lateral incisors and
lower incisors

Wide implants

Maximize potential bone implant

contact and enable primary stability
by engaging both buccal and lingual
cortical plate
-needs 9mm mesiodistal space and
7mm vertical space
Not ideal for single anterior implants


Use longest implant possible

Implant length to crown ration
should be greater than 1
Align implants with overlying crowns
so that load is directed along the
long axis of the implant
Do not use single implants to support
a cantilever