CASE REPORT
Implant-supported anterior tooth restoration
H.-J. Hartmann and A. SteupPrivate Dental Practice, Tutzing, Germany(Received for publication on July 25, 2005)(Revised for publication on November 16, 2005)(Accepted for publication on November 24, 2005)

Abstract. Various options are available for restoring anterior teeth. Their choice is dictated by theseverity of infection of the teeth to be extracted and the pocket depth. Immediate single-stage implant
placement proved to be the least traumatic option, which best preserved the soft tissue. A differential
use of surgical and prosthodontic techniques is indispensable to account for conditions in the individualcase. Given an adequate amount of hard tissue, soft tissue contours can be expected to return to normal. Immediate implants combined with a soft tissue support have been found to ensure that the depthof even larger pockets is stable for years. (Keio J Med 55 (1): 23–28, March 2006)
Key words: dental implants, immediate implantation, delayed implantation, implant supported, immediate loading

With delayed immediate implant placement, some
soft and hard tissue loss is inevitable despite the shortinterval of 6 to 8 weeks. The severity of ostitis orperiodontitis following tooth extractions is one of thedeterminants of tissue loss.2 Thanks to improved prosthodontic materials like zirconium oxide, electroplated
crowns or ceramic suprastructures, less than optimal
conditions post surgery can still be turned into a satisfactory or at least acceptable prosthodontic outcome.
However, this requires the availability of an adequate
amount of soft tissue. Temporary crowns help to contour and stabilize the soft tissue for subsequent deﬁnitive rehabilitation after an appropriate healing time.11
Various options are available for successfully replacing
the upper anterior teeth:

Esthetic implant-supported anterior tooth restoration is the greatest challenge both surgeons and prosthodontists are confronted with. Ever since immediate
implants have been available, there is conclusive scientiﬁc evidence showing that soft and hard tissue loss canonly be prevented by implants. Although their indications are limited in the anterior maxilla, immediate
implants should invariably be considered whenever anupper anterior tooth is extracted. However, esthetic
aspects or periodontal infections may rule out immediate implant placement so that the risk of minor hardand soft tissue loss associated with delayed immediate
implant placement may have to be put up with.1,2,3
The surgeon is called upon to keep in mind the subsequent prosthodontic work when placing implants andto make sure that implant positioning or bone grafting
permit an optimal crown design and restoration of thepapilla.4 Implant systems are designed for differential
diameters. Because of the tapering roots of upper anterior teeth, the placement of screw-shaped implants
may be more difﬁcult in the anterior maxilla than thatof conical implants. The implant – to – tooth distanceand the inter-implant distance as well as the hard tissue
support of the mucosa also need to be attended to.5,6,7
The recommendations for immediate implant placement reported by Schulte continue to be valid and arestill being followed in minimal invasive surgery today.1,8,9

1. Single-stage immediate implants with(a) customized tissue contouring abutments(b) deﬁnitive crowns
2. Delayed immediate implants placed 6 to 8 weeks
post extraction with(a) immediate impression taking and insertion of
the deﬁnitive crown after implant exposure(b) soft tissue contouring with provisional crowns
followed by later deﬁnitive crown insertion.
For these four options, long-term results are presented
on the basis of case reports.

Reprints requests to: Dr. H.-J. Hartmann, Zahnärztliche Gemeinschaftspraxis, Graf-Vieregg-Str. 2, D-82327, Tutzing, Germany, e-mail:hartmann.tutzing@t-online.de23

24

Hartmann H-J and Steup A: Implant replacement

Fig. 1

22, 11 and 12 extracted.

1. (a) Immediate implants with customized tissue contouring abutments
A female patient aged 68 years was referred for
implants. 12, 11 and 22 showed grade 2 loosening. On
probing, the pocket depth around all teeth was 11 mm
causing exudation of pus and recurrent periodontal
abscesses. The patient presented with a deep bite. The
non-removable bridge she had been rehabilitated with
was partly supported by implants.
Following periodontal pretreatment to control theacute infection, ﬁxed bridgework was recommended forthe time the implants would need to heal. 21 was trimmed to accommodate a crown with the neighboring
teeth 22, 11 and 12 as pontics. Metal rests were bonded
on 13 and 23 palatally in terms of a Maryland bridge
without prior trimming. The metal bridge was veneered
with plastic. One week later 12, 11 and 22 wereextracted in local anesthesia and implants were placed
despite the deep pockets. The inﬂammatory periodontal lesions had largely healed. Following Schulte’s recommendations the implants, i.e. FRIALIT-2 Synchro
screws with a Cellplus surface (Dentsply/Friadent,Mannheim, Germany), were placed palatally (Fig. 1).
Implant diameters were 4.5 mm for 12, 5.5 mm for 11
and 4.5 mm for 22. Implant length was 15 mm throughout. All implants were anchored in the cortical bone of
the nasal ﬂoor (Fig. 2).
The implants were closely spaced in the bone with aninter-implant distance of no more than 1 to 1.5 mm.
Implants with a smaller diameter did not achieve primary stability and had to be replaced by larger ones.
Alternatively, the periodontal lesions could have been
curetted to the point of healing. However, this would
have caused substantial resorption of the mucosa andthe alveolar process. Despite a pocket depth of 11 mm
around 21, 9 mm around 12 and 9 mm around 22, theFig. 2

Condition after appr. 1 week.

implants were seated down to the limbus. As tissue
contouring abutments of adequate length to support themucosa together with the papillae to the level of themucogingival junction were not available, ProTect
abutments were customized to the right size. All
implants achieved primary stability.
On the day of implant placement impressions weretaken and the lab technician fabricated plastic-coated,highly polished tissue contouring abutments matching
the ovoid diameters of the teeth. While he was atwork, transfer copings were attached for 1 to 2 hours
to maintain stable mucosal conditions and prevent
mucosal collapse.
When ready, the customized tissue contouring abutments were put in place, the Maryland bridge wasbonded with Panavia1 (Kuraray Dent) and antibiotics
were administered.
The customized tissue contouring abutments werechecked for stability at weekly intervals and the mucosa
was examined for alterations, shape and color. As thesmall inter-implant distances prevented papilla regeneration, the original tissue contouring abutments werereplaced by other customized highly polished, plasticveneered abutments with the diameters reduced byplatform switching. With these, papilla-like soft tissue
developed within the mucosa and persisted to the timeof deﬁnitive management. Platform switching was also
used for the deﬁnitive restoration, i.e. the 4.5 mm implant in 12 was ﬁtted with a 3.8 mmD abutment and the5.5 mm implant in 11 with a 4.5 mmD abutment. Bothof these abutments were custom-designed. By the timeof deﬁnitive management, the mucogingival junction
was only slightly lower than around the natural tooth
21. The 3 implant-supported electroplated crowns weremounted on customized ﬁnal abutments and retainedwith a horizontal screw. An electroplated crown wasalso used on 21 to avoid a translucency mismatch.

Keio J Med 2006; 55 (1): 23–28

25Fig. 3 Patient has been occlusally stable for the past year. Mucosal
level matches that around natural tooth 21.
Fig. 422 extracted. Note apical granuloma.

Fig. 5Transfer coping in place for impression.

At the follow-up visits scheduled at regular intervals
in the subsequent 2 years, the vestibular probing depths
dropped to 7 mm around 12, 8 mm around 11 and 6 mmaround 22. Compared to 21, which was vital, the reduction of the mucogingival junction was negligible.
The papillae between the implant-supported crowns
were stable (Fig. 3).
1. (b) Immediate implants with deﬁnitive crowns
This patient, a 38-years-old female, presented with aroot canalled, loosened (grade 2) 22. The pocket depthof 4 mm was not yet signiﬁcantly abnormal. After duly
considering all alternative treatments the patient opted
for an immediate implant with an immediate deﬁnitive
crown. 22 was extracted in local anesthesia. For implant
placement Schulte’s recommendations for tooth extraction, implant inclination and positioning to support thefacial cortical plate were followed. Immediately after
the FRIALIT – 2 Synchro implant (Dentsply/Friadent,Mannheim, Germany) with a grit-blasted acid-etchedsurface, a diameter of 4.5 mm and a length of 15 mm
was placed, an impression was taken, a tissue contouring abutment was mounted on the implant and the patient was sent home for the day (Figs. 4–5).
In the meantime, the lab technician fabricated ahorizontally screw-retained electroplated crown, which
was veneered with ceramic. Rather than glaze-baked,
the crown surface was polished mechanically to leavesome scope for subsequent esthetic and functional
crown ﬁnishing, i.e. baking the ceramic on metal, which
increases the compressive force applied to the papillaand promotes papilla repair.
In the evening of the same day, the horizontallyscrew-retained electroplated crown matched in shape to
22 was mounted. The mucosa had meanwhile been sta-bilized by the tissue contouring abutment. On accountof the compressive force generated by the permanentcrown the supracoronal tissue brieﬂy became anemic.
The anemic reaction ought to subside within 8 to 10
minutes. If it does not, the compromised nutritive supply of the soft tissue is bound to lead to recessions.
Crown contacts were avoided during maximal intercuspidation, protrusion and lateral shift. The patient
was recalled weekly and instructed to clean the tooth
gently and not to bite or chew with it. The crown waschecked for stability throughout the healing time of theimplant. It was never taken off. The mucosa was soundwithout any loss in height or papillary volume.
After about 3 months, the crown was removed andﬁnalized esthetically and functionally in the lab. Twoyears post management the mucosa was at the samelevel as that around the neighboring teeth. The dis-

26

Fig. 6

Hartmann H-J and Steup A: Implant replacement

Labial view of implant-supported crown in 22, 12 year later.

tances of the papilla from the contact points, the incisaledge and the implant base were also unchanged. All of
the soft tissue had successfully been preserved (Fig. 6):
2. (a) Delayed immediate implants with immediate impression taking and insertion of the deﬁnitive crownafter implant exposureThis 34-years-old female, who had lost 22 and wasprovided with a removable temporary partial, came forimplant treatment. The tooth had been extracted elsewhere about 8 weeks ago. Even during this short interval, substantial hard and soft tissue loss had occurred byclinical evidence. The patient reported that the extraction had been very difﬁcult and that she developed aninfection after it.
Treatment alternatives were discussed with her andimplant-supported restoration combined with bone
grafting was agreed upon.
The neighboring teeth were caries-free. The alveolar
process was exposed through a palatal incision in local
anesthesia. The bone atrophy, which had already been
noted on palpation, was conﬁrmed intra-operatively(Fig. 7).
The pre-implant diagnostic workup had indicated theneed for an implant with a diameter of 3.8 mm and alength of 15 mm. A FRIALIT-2 Synchro implant with agrit-blasted and acid-etched surface was chosen. The
bone from the intended implant site was removed witha trephine. Implant placement itself was uneventful.
One third of the implant surface was not buried in thehost bone.
With due attention to the subsequent prosthodontic
work, an impression was taken immediately after implant placement. This left the lab technician more than
3 months’ time for fabricating the crown. After impres-Fig. 7

Alveolar process exposed. Note extensive bone loss.

sion taking the area of bone loss was grafted with bone
harvested from the retromolar region and with bonechips from the bone collector and the trephine. The
graft was covered with a titanium mesh secured withscrews before primary tension-free wound closure(Figs. 8a, 8b).
Healing was uneventful and the implant was uncovered after about 3 months. The titanium mesh wasremoved through the original incision. The quality of
the alveolar process had substantially improved. The
originally exposed implant surface was now covered bybone. The ﬁnal abutment had a collar height of 0.5 mm
and the crown, which had meanwhile been fabricated in
the lab, was immediately mounted and retained with ahorizontal screw. With interdental and inter-implant
sutures in place, the wound was allowed to heal.
After about 4 weeks, the bland mucosa had become
attached to the implant. At 2 years peri-implantmucosal conditions were stable despite the loss of about
1 mm in mucosal height compared to the neighboring
tooth. The papillae were well preserved (Fig. 9).
3. (b) Delayed immediate implants with soft tissue
contouring by temporary crowns and subsequentdeﬁnitive management
This patient, a 34-years-old female, presented withloosening of 11 and 12. (Fig. 10a) As these teeth were
not salvageable because of periodontal abscesses, they
were extracted and the patient was temporized with aremovable partial. Implants were placed about 8 weeks
post extraction. In local anesthesia, a mucoperiosteal
ﬂap was raised through a palatal incision spanning 11and 12. Alveolar bone loss was apparent both verticallyand horizontally. Two FRIALIT-2 Synchro implants
were placed, i.e. a 4.5 mmD in 12 and a 5.5 mmD in 11.

Keio J Med 2006; 55 (1): 23–28

Fig. 8Fig. 9a) Retromolar bone graft applied to alveolar process.
b) Graft covered with titanium mesh secured with screws.

Crown in 22 appr. 1 year after abutment was mounted.

27

Fig. 10 a) Periodontally compromised 11 and 12 in need ofextraction.
b) Vestibular view showing stable mucosal conditions
around horizontally screw-retained crowns appr. 2 years postinsertion.

Both implants were 15 mm long. They were not fullyburied in bone, but left exposed about 2 mm above
the alveolar process for augmentation with a bone substitute. The vertical 2-mm defect and the horizontal
defect were grafted with BIO-OSS1 (Geistlich, Wohlhusen, Switzerland). The grafts were covered with aresorbable membrane (Vycryl, Ethicon, Norderstedt,Germany), which was secured with the occlusal screwsof the implants. Following submucosal vestibuloplasty
the wound was closed with tension-free sutures. The
patient was prescribed an anti-inﬂammatory (diclofenac) and an antibiotic (clindamycin) to prevent swellingand infection. Healing was uneventful. About 3 months
later the implants were uncovered through the original

28incision, tissue contouring abutments were mounted onthem and stabilized with inter-implant sutures. The
mucoperiosteal ﬂap was repositioned and sutured
against the abutments. For adequate mucosal support
extra-high tissue contouring abutments were chosen.
Loading by the denture was not allowed for about 1week. About 8 days later, an impression was taken andtemporary crowns were inserted on the same day.
These were originally intended to be left in place forabout 3 to 6 months for satisfactory soft tissue contouring. However, the soft tissue support provided by thecrowns was found to be inadequate. As the patient
spent some time abroad, she was prevented fromshowing up for crown recontouring. As a result, deﬁnitive rehabilitation was done after about 1 year. The inadequate soft tissue support had caused mucosal loss
both vertically and horizontally. Electroplated crowns
retained with horizontal screws were chosen for deﬁnitive restoration. The shoulder of the ﬁnal abutments for
the FRIALIT-2 implants was reduced to 0.5 mm forrecontouring the mucosa to match the natural ovoid
crown shape. In addition, the abutments were extended
in length to counteract the leverage on the crowns. Asmall ischemic area just above the crown margin wasseen after the crowns were mounted. This disappeared
within approximately 8 to 10 minutes. Deﬁnitive management was completed by readjusting the ceramiccrowns to provide more support for the papillae and thesoft tissue.
At about 2 years after crown insertion the soft tissue
was stable. (Fig. 10b)

Hartmann H-J and Steup A: Implant replacement

References
1. Gomez-Roman G, Schulte W, d’Hoedt B, Axman-Krcmar D:The Frialit-2 implant system: ﬁve-year clinical experience insingle-tooth and immediately postextraction applications. Int J
Oral Maxillofac Implants 1997; 12: 299–309
2. Wohrle PS: Single-tooth replacement in the aesthetic zone withimmediate provisionalization: fourteen consecutive case reports.
Pract Periodontics Aesthet Dent 1998; 10: 1107–1114
3. Romanos G: Sofortbelastung von enossalen Implantaten im Seitenzahnbereich des Unterkiefers, Tierexperimentelle und klinische Studien, Quintessenz Verlags GmbH 2005
4. Tarnow DP, Magner AW, Fletcher P: The effect of the distancefrom the contact point to the crest of bone on the presence orabsence of the interproximal dental papilla. J Periodontol 1992;
63: 995–996
5. Saadoun AP, Le Gall MG: Periodontal implications in implant
treatment planning for aesthetic results. Pract Periodontics Aesthet Dent 1998; 10: 655–664
6. Tarnow DP, Cho SC, Wallace SS: The effect of inter-implantdistance on the height of inter-implant bone crest. J Periodontol
2000; 71: 546–549
7. Hartmann H-J: Sofortimplantation mit Sofortbelastung, Identity
2004; 5: 14–16
8. Hartmann H-J: Ästhetische Frontversorgung mit sofortbelasteten Implantaten, DZW, Orale Implantologie, 1/04, 47–51
9. Lazzara RJ: Immediate implant placement into extraction sites:
surgical and restorative advantages. Int J Periodontics Restorative Dent 1989; 9: 332–343
10. Hugo O: Prothetische Sofortversorgung nach einzeitiger
Chirurgie – Experiment oder etabliertes Verfahren. Oralchirurgie Journal, 5. J, März 2005, Heft 1: 20–24
11. Bragger U, Pasquali L, Kornman KS: Remodelling of interdental
alveolar bone after periodontal ﬂap procedures assessed bymeans of computer-assisted densitometric image analysis(CADIA). J Clin Periodontol 1988; 15: 558–564