esthetic considerations related to bone and soft tissue

8/18/2019 Esthetic Considerations Related to Bone and Soft Tissue

http://slidepdf.com/reader/full/esthetic-considerations-related-to-bone-and-soft-tissue 1/9Rodriguez and Rosenstiel

In recent years the frequency of and esthetic demand for implant restorations in the esthetic zone has increased.Recent literature has revealed numerous consistent trends which may aid the clinician in achieving predictable esthet-ics. Maintaining generous facial bone by judicious placement as well as by using implants with diameters of less than4 mm appears to be beneficial. Avoiding adjacent implants in the esthetic zone while maintaining an implant to toothdistance of between 2 mm and 4 mm seems to aid in bone and soft tissue maintenance. Abutment connections inwhich the abutment is narrower than the implant offer distinct advantages, most notably increased bone heights.Also, provisional restoration, especially early in treatment provides long-term esthetic benefits. (J Prosthet Dent2012;108:259-267)

Esthetic considerations related to bone and

soft tissue maintenance and development

around dental implants: Report of the

Committee on Research in Fixed Prosthodontics

of the American Academy of Fixed Prosthodontics

Arthur M. Rodriguez, DMD, MSa and Stephen F. Rosenstiel

BDS, MSDb University of Pittsburgh School of Dental Medicine and VeteransAffairs Medical Center, Pittsburgh, Pa; The Ohio State University,College of Dentistry, Columbus, Ohio

aStaff Prosthodontist and Assistant Program Director, Veterans Affairs Medical Center; and Assistant Professor, Department ofProsthodontics, University of Pittsburgh School of Dental Medicine.bProfessor Emeritus, Division of Restorative and Prosthetic Dentistry, The Ohio State University.

Implant-retained restoration in the

esthetic zone have long been difficult

for reasons which are well document-

ed in the literature and anecdotally

acknowledged by many clinicians.1-4

Most prevalent among these are a

lack of facial bone and inadequate

interproximal tissue. However, the es-

thetic demands of clinicians as well as

the expectations of patients continue

to grow along with advances in com-

ponent design and clinical technique.

The following discussion summarizes

relevant current literature in an at-

tempt to establish evidence-based

guidelines for esthetic implant resto-

rations.

Bone availability and maintenance

Inadequate facial bone is a com-

mon problem that can present itself

at any time following extraction and

often leads to a more lingual implant

placement and an anterior ridge lap

restoration.5 In an attempt to avoid

this situation, osseous grafting or

regeneration techniques are used.6,7

However, these can be both time

consuming and unpredictable. Even

when an implant can be placed, a thin

plate of facial bone is often all that re-

mains, leading to thread exposure or

unpredictable future tissue height.8

Huynh et al9 found the average max-

illary anterior bony wall thicknesses

following maxillary anterior extrac-

tion to be approximately 0.8 mm with

87% less than 1 mm. Recent trends

by clinicians to use wider diameter

implants (4 mm or greater) have also

contributed to inadequate facial bone

thickness or facial tissue recession.10

Recession often occurs following the

initiation of the restorative phase as

thin attached tissue supported byinadequate bone cannot withstand

the stress created by restorative con-

tours. The theoretical advantage of

wider diameter implants is not well

supported in the literature. A finite

element analysis by Petrie et al11 did

show a decrease in crestal bone strain

as implant diameter and length in-

creased while modeling a 20 mm

mandibular section. However, clinical

data demonstrating the advantages

of wide diameter implants are scarce.

In fact clinical studies showed similar

or somewhat lower success rates for

wider diameter implants12-15 Degidi et

al15 showed a 99.4% success rate for

510 narrow diameter implants (<3.75

mm) over 8 years, with some evidence

of increased success for implants

wider than 3.4 mm. A clinical study

of 182 3.3-mm-diameter implants in

severely resorbed maxillae revealed a

survival rate of 99.4%.16 Zinsli et al17

reported a 98.7% 5-year survival rate

for 298 of the same reduced diameter

implants, over a 10-year period. In

this study the implants were restoredwith a variety of restorations, includ-

ing single teeth, fixed prostheses, and

overdentures.

It has also been suggested that the

amount of remaining facial or lingual

bone following osteotomy is critical

for implant success1 (Fig. 1). Even af-

ter implant placement in fresh extrac-


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60 Volume 108 Issue 4

The Journal of Prosthetic Dentistry Rodriguez and Rosenstiel

tion sites, thinning of the buccal and

lingual walls occurs within the firstfew weeks with an associated decrease

in buccal wall height.18 In a study on

dogs, Qahash et al19 concluded that

buccal bone width strongly influ-

enced alveolar ridge resorption and

recommended a buccal bone width

of 2 mm or greater following implant

placement. Thicknesses of 1.5 to 2.0

mm on both the buccal and lingual

surfaces have been associated with

high success rates.20,21 It is also rea-

sonable to assume that initial implant

stability, often stated as a prime fac-

tor for implant success, can only be

enhanced when substantial facial and

lingual walls remain after osteotomy

site preparation.22-24 A narrower im-

plant also allows the surgeon to avoid

bony defects more easily or to tra-

verse them with less thread exposure.

In these instances, the implant could

still be placed with excellent stability

and perhaps augmented with a mi-nor graft or guided tissue procedure

as opposed to separate graft and im-

plant placement procedures. In addi-

tion, a narrower implant may allow

placement to be shifted slightly lin-

gually, while still providing relatively

anatomic lingual contours in the final

restoration. Given this, the use of a

standard or slightly narrow diameter

implant of 3.75 mm or less to prevent

perforation or thinning of the buccalbone and associated attached tissue

loss or implant exposure has been

suggested.25,26

Preserving interproximal bone and

associated soft tissue is obviously also

central to achieving optimum esthet-

ics. Crestal bone loss adjacent to the

implant has been long observed and

even expected in clinical practice.27,28

Rigid criteria for determining implant

success have even included an expec-

tation of initial bone loss up to 1 mm

with continued yearly bone loss of up

to 0.2 mm per year.29 Many clinicians

and authors have observed bone loss

progressing to the first thread of the

implant and then slowing.30,31 Recent

implant and prosthetic component

design as well as clinical technique

have focused on preventing or reduc-

ing this crestal loss.

Abutment connection

The nature and location of the

abutment to implant connection andits effect on crestal bone loss and in-

flammation have been frequently dis-

cussed.32,33 Some studies have shown

that the mere presence of this me-

chanical junction, in addition to poor

oral hygiene, has led to increased

inflammation of the marginal tis-

sues.33,34 Hermann et al35 in a study

of submerged and nonsubmerged im-

plants in dogs observed that bone loss

and remodeling always occur apicalto the abutment/implant interface.

Piattelli et al36 evaluated bone loss in

regard to the location of the implant/

abutment junction. They found that

bone resorption occurred when the

junction was placed below the bone

crest and that less bone loss occurred

when the junction was placed su-

pracrestally. Hammerle et al37 found

similar results while studying a rough/smooth implant abutment connec-

tion placed at the alveolar crest rather

than at 1 mm below the crest, with

the subcrestally placed implants dis-

playing significantly greater bone loss.

It should be noted that in both of

these studies the implant/abutment

connection extended to the outer

circumference of the implant. Wang

et al38 found no difference in bone

loss between crestally and subcrest-ally placed implants for both external

hexagon and Morse taper abutment

connections. Conversely, Todescan et

al39 and Welander et al40 in dog stud-

ies found that subcrestal placement

of the implant/abutment junction led

to less bone loss and a tendency to-

ward thicker epithelium and connec-

tive tissue than crestal or supercrestal

placement. In addition multiple au-

thors have shown that eliminating the

microgap by incorporating a 1-piece

implant/abutment design decreased

inflammatory response.41-43 Finne et

al42 followed 152 1-piece implants in

87 participants for up to 2 years and

reported a 97.9% success rate, mini-

mal bone loss, and an excellent soft

tissue response. While, biologically,

1-piece designs are promising, the lack

of restorative flexibility seems to be a

challenge.

It is well established that a stableinternal abutment connection is bio-

mechanically advantageous for long

term prosthodontic success.44 Cur-

rently there are multiple internal con-

figurations, including various internal

hexagons, an internal triangulated or

cloverleaf design, and conical con-

nections (Fig. 2). In addition, there

are many variations of the previously

mentioned connections as well as

systems which combine elements ofmore than one design. Recently, some

1 Remaining buccal and lingual bone width followingosteotomy preparation. Widths of 1.5 to 2.0 millimetershave been recommended.



261October 2012

Rodriguez and Rosenstiel

definite advantages of the conical

connection have surfaced.45-50 Tesmer

et al45 have shown a decreased ten-

dency for bacterial colonization given

the intimate fit afforded by the coni-

cal connection. Biomechanical com-

plications, such as screw loosening or

component fracture, also seem to oc-

cur less with the conical connection,

theoretically because of decreased

micromovement at the implant/abut-

ment junction.46-48 Schwarz49 notedthat the conical Morse taper has virtu-

ally eliminated abutment screw loos-

ening and fracture. In a finite element

analysis study comparing multiple

systems and examining stress trans-

mission to the crestal bone during

multiple loading conditions, the coni-

cal Morse taper connection with plat-

form switch demonstrated the most

favorable stress transmission during all

nonaxial loading simulations.50

In addition to the specific configu-

ration of internal fit, the intimacy of

fit and, therefore, the movement of

the abutment relative to the implant

may also affect stress transmission

as well as tissue health and subse-

quent crestal bone loss.51,52 In fact,

connection stability may have a more

important role than the presence of

a microgap with regard to inflamma-

tion and bone loss. Hermann et al53

showed that welded 2-piece implants

displayed less bone loss than conven-tionally joined 2-piece implant/abut-

ment connections regardless of the

size of the microgap. King et al,52 in a

follow-up study, also concluded that

stability or lack of movement at the

abutment/implant junction was more

important than microgap size. They

compared welded 1-piece connec-

tions to 2-piece connections, while

varying the microgaps for each group

between 10 and 100 µm and foundthat the size of the microgap had no

significant effect on bone loss, while

the nonwelded groups consistently

showed higher levels of bone loss.

Heijdenrijk et al51 compared 2-piece

abutment/implant connections with

the connections placed above and

below the tissues to a 1-piece system

and found no association between

the presence of a microgap and in-flammation.

Platform switching

Locating the abutment/implant

connection internally or away from

the bone/tissue to implant interface

has also been attempted. This con-

cept, which involves an abutment of

decreased diameter relative to the

implant, is sometimes referred to asplatform switching.54, 55 While many

consider platform switching to be

a new concept, it has been incorpo-

rated into various systems for over 20

years.20,47,48 Platform switching moves

the abutment-implant interface in-

ward, away from the outer circum-

ference of the implant (Fig. 3). This

has been reported to decrease crestal

bone loss, preserve tissue height,

and promote soft tissue health.56-74

Whether this advantage is gained me-

chanically or biologically is debatable.

Some theorize that this configuration

shifts the inflammatory infiltrate in-

ward, encouraging soft tissue and/or

bone to biologically seal off the outer

circumference of the implant from

the oral environment.56 Becker et al74

found no histological advantage to a

0.3-mm platform switch with respect

to bone remodeling in a dog study

over 24 weeks, suggesting that theadvantage may be a consequence of

a physical barrier. Other authors75,76

have reported a more favorable stress

distribution within the bone for plat-

form switched connections.

Hurzeler et al62 showed signifi-

cantly less bone loss 1 year after res-

toration placement for 14 platform

switched implant single crowns than

for 8 similarly restored implants

that did not incorporate a platformswitch. In a pair of clinical studies in-

2 A, Conical internal abutment connection; B, Internalhexagon abutment connection.

A

B





volving implants placed immediately

into extraction sites, Canullo et al63,64

showed generally less bone loss than

previously described in the literature

after a mean follow-up of 22 months.

Also they noted significantly less buc-

cal tissue recession and greater papil-

la height in an experimental platform

switched group than in a nonplat-

form switched group. The treatment

protocol for both groups included

immediate provisional restoration

and placement of the definitive res-

toration 2 months following implant

placement. Vela-Nebot et al77 also

reported dramatically less bone loss

when using implant systems incorpo-

rating a narrower diameter of restor-

ative components relative to implant

diameter. A comprehensive literature

review of 10 studies and 1239 im-

plants by Atieh et al67 showed strong

evidence of less bone loss around the

platform switched implants, although

there was no difference in overall im-plant survival. The authors also noted

that a more favorable bone response

was seen when the platform switch

was 0.4 mm or greater. Wagenberg

and Froum68 followed 94 platform

switched connections over 11 years

and found that approximately 75%

showed no radiographic bone loss

with 88% displaying 0.8 mm or less

bone loss. Conversely a 2 year study

by Crespi et al,78 which compared ex-ternal hexagon regular platform im-

plants to platform switched implants

placed in fresh extraction sites andimmediately loaded, showed no dif-

ference in bone loss.

In an attempt to mimic platform

switching, some implant manufac-

tures offer implant designs in which the

coronal portion of the implant flares

to accommodate an abutment that is

roughly the same diameter as the im-

plant body but narrower than the flared

neck.54 Using this concept, it has been

stated that a residual ridge width of at

least 6.3 mm is necessary to accommo-

date the flared design.79 For example,

Cocchetto et al80 followed 15 implants

with a 5.8 mm diameter receiving a 4.1

mm abutment healing cap and showed

an average bone loss of only 0.3 mm

at 18 months. However, this study re-

quired a minimum bone width of 8

mm for inclusion. Because bone width

of this dimension is exceptional in the

esthetic zone, this design may have lim-

ited application. Neck diameters of thisdimension will most likely necessitate

removal of the same critical coronal

bone that the clinician is trying to pre-

serve. Also the resulting distance from

the implant to the adjacent tooth will

be minimal at best, preventing the es-

tablishment of a desirable interproximal

distance. Therefore, given the above, a

parallel walled implant of standard or

slightly narrow diameter with reduced

diameter restorative componentsseems preferable.

A distinct advantage of the im-

plant/abutment diameter difference

is the ability to place the implant

subcrestally, encouraging bone and

soft tissue at the superior edge of the

implant circumference to remain and

even grow to or over the edge of the

implant and remain there undisturbed

by restorative components.59,60,81,82

Novaes et al59,60 found this to be true,

while noting greater papilla fill and

less bone loss for subcrestal place-

ment than for crestal placement in

2 dog studies of platform switched

implants. They also concluded that

the presence of a microgap did not

adversely affect tissue health. Weng

et al81 compared a platform switched,

Morse taper design placed subcrest-

ally to an external hexagon design. They demonstrated bony overgrowth

only in the former. Veis et al82 com-

pared 193 regular platform implants

to 89 platform switched implants

and found that the platform switched

design resulted in less bone loss only

when placed subcrestally. Conversely,

Cochran et al83 found slightly more

bone loss for platform switched im-

plants placed 1 mm subcrestally than

for those placed crestally or 1 mm su-

pracrestally.

Tenenbaum et al84 showed a great-

er number and greater length of con-

nective tissue fibers around implants

which incorporated a nonflared neck

with reduced diameter abutments

than other designs. Attached tissue

thickness of greater than 2 mm has

been associated with a decreased ten-

dency for buccal bone loss and tissue

recession around platform switched

implants.85- 87 This effect was even moredramatic when implants were placed

supracrestally. Interestingly, when the

mucosa was considered thin (less than

2 mm), the authors found no advan-

tage with regard to bone level for the

platform switched design.88 Subcrestal

placement leads to other esthetic

advantages. The distance from the

top of the implant to the emergence

of the restoration is maximized, al-

lowing adequate vertical length forthe development of anatomic con-

3 Platform switched implant-abutment connection. Notenarrower diameter of abutment relative to implant allowingbone to remain undisturbed throughout restorative phase.



263October 2012


tours and proper emergence profiles.

Priest 61 recommended providing at

least 3 mm from the implant margin

to the zenith of the facial margins

of adjacent teeth, while noting that

provisional restoration is essential in

developing optimum esthetics. This

is especially critical when soft tissue

thickness is minimal.

Provisional Restoration

As in conventional restorative and

fixed prosthodontics, provisional res-

torations are an invaluable esthetic

and diagnostic tool. Provisional resto-

ration of implants is often neglected

probably because provisional compo-

nents are often time consuming and

cumbersome. Also many provisionalcomponents do not readily accom-

modate angle correction. Attached

gingiva can be sculpted and molded

by means of the provisional restora-

tion to help create the illusion of inter-

dental papillae as well as contributing

to more stable, predictable overall es-

thetics and providing increased func-

tion.89-92 Providing anatomic fixed

provisional restorations also avoids

the introduction of dramatically differ-

ent restorative contours at the time of

final restoration placement, decreas-

ing the likelihood of postplacement

recession.63,93 Lai et al94 and Gallucci

et al95 showed that dramatic soft tis-

sue changes, both in dimension as well

as health, occur following the initial

establishment of anatomic contours.

Although bone response was similar

to delayed provisional restoration,

Block et al92 found an average increase

in tissue height of 1 mm for immedi-ately provisionally restored implants

following their placement in fresh ex-

traction sites. Establishing these con-

tours immediately, either at placement

or during second stage uncovering

has been shown to be especially effec-

tive.63,79,93,95 DeRouck et al93 compared

the postrestoration soft tissue con-

tours of 24 immediately provisionally

restored implants to 25 restored with

a conventional 2-stage approach. Theyfound 2.5 to 3 times less midfacial re-

cession and better predictability of pa-

pilla heights in the immediately provi-

sionally restored group.

The use of definitive stock abut-

ments placed intraorally by the clini-

cian as opposed to laboratory pre-

pared custom abutments would seem

to offer distinct advantages in the es-

thetic zone. Provisional restoration issimplified, allowing the establishment

of a proximal contact point early in

the restorative phase to initiate pa-

pilla formation. The use of cumber-

some, interim, partial removable den-

tal prostheses is also obviated. Most

of all this technique eliminates the

multiple switching of various compo-

nents during the restorative phase. Al-

though such evidence in the literature

could not be found, it is these authors’opinion that the techniques afforded

by this type of abutment offer distinct

biologic and clinical advantages.

Parameters influencing papillary

tissue development

The possibility of papilla fill is

greatly enhanced when interproximal

bone is preserved, creating a reason-

able opportunity to provide a desir-

able distance of 5 mm or less from

the proximal contact to the intersep-

tal bone as described in the literature

for natural teeth as well as recently

for implants immediately adjacent

to natural teeth.96-99 Lops et al98 and

Gastaldo et al99 recommend 3 to 4

mm and 3 to 5 mm, respectively, be-

tween proximal contacts and bone

crest when the implant is adjacent

to a natural tooth. However, papilla

fill was observed, in some instances,where the bone to contact distance

was as great as 9 mm, suggesting, not

surprisingly, that multiple factors in-

fluence soft tissue response.97 Palmer

et al100 also found, in a study of 46

participants with platform switched

implants, that papilla fill was ob-

served when the proximal contact to

bone distance exceeded 4 to 5 mm.

It should be noted that both of these

studies involved implants adjacentto natural teeth. In addition, Kwon

et al66 observed that in the tooth-im-

plant-tooth clinical scenario, the criti-

cal distance is that from the proximal

contact to the bone level adjacent to

the natural tooth, termed tooth side

bone level. In this study of 17 im-

plants and 37 papillae, they found

virtually complete papilla fill when the

average bone to contact distance was4.88 mm or less and a lack of papilla

fill when this distance exceeded 6 mm.

The situation becomes much more

challenging when adjacent implants

are present. In a dog study of plat-

form-switched implants, de Oliveira

et al101 found that a 5 mm bone to

proximal contact distance proved to

be the critical factor for papilla devel-

opment between implants, regardless

of interimplant distances, which var-ied between 1 and 3 mm. Other inves-

tigators have observed that to achieve

papilla fill between implants, a proxi-

mal contact to bone crest distance

of 3 mm or less is desirable, while a

distance of 3 to 5 mm can provide

papilla fill between an implant and a

natural tooth.98

As previously mentioned, interim-

plant distance and tooth-to-implant

distance have been shown to play a

role and possibly interact with bone

to proximal contact distance. In a

more recent study involving the same

type of implants, de Oliveira et al102

reported increased bone remodeling

when interimplant distance was 1 mm

or less than in groups with 2 to 3 mm

interimplant distance. In the natural

dentition, Martegani et al103 found

that papilla loss increased dramatical-

ly when interradicular distances were

2.4 mm or less and that this factorhad both an independent and com-

bined effect with proximal contact

distance. Degidi et al104 examined 152

implants and 99 interimplant sites

and found that optimum interim-

plant distance for papilla develop-

ment was greater than 2 mm but less

than 4 mm. They also found that op-

timum bone to contact height should

be 3 to 4 mm and that papilla height

decreased dramatically when this dis-tance exceeded 6 mm. Tarnow et al25





also concluded that less interproximal

bone loss occurs as interimplant dis-

tance increases, while recommending a

minimum of 3 mm, lending further sup-

port to their earlier mentioned recom-

mendation of using standard to narrow

diameter implants in the esthetic zone.

Garber et al105 have recommended in

order to maintain interproximal boneheight and the accompanying papilla,

that the implant should be placed at

least 1.5 mm from adjacent teeth and

3 mm from adjacent implants. Traini et

al106 also recommend a minimum of 3

mm interimplant distance to provide

optimum alveolar bone health. They

observed a more desirable orienta-

tion of collagen fibers and significantly

increased marrow spaces for interim-

plant distances of 3 mm in a histologi-cal dog study of 48 implants, sacrificed

24 months after implant placement. In

a similar follow-up study, they observed

that an interimplant distance of 3 mm

allowed for an increase in the develop-

ment of blood vessels.107

While it is difficult to isolate clini-

cal variables scientifically, the litera-

ture seems to indicate that the risk

to interproximal bone increases for

tooth-to-implant distances less than

3 mm.108 Conversely, in a 5-year study

of interproximal bone changes be-

tween implants, Chang et al109 found

that interimplant distance played a

minor role in final bone levels and

that the coronal height of bone to

implant contact was a better predic-

tor. Lee et al110 found that both inter-

implant distance and bone to implant

contact level had minimal effect on

papilla height and that the width of

keratinized tissue exerted a greaterinfluence. However, the literature is

fairly consistent in showing that the

maintenance of proximal bone height

and associated papilla height seems

to be more difficult between adjacent

implants than in the tooth-implant

situation.111-113 In a retrospective study

evaluating previously mentioned vari-

ables, Kourkouta et al112 followed 35

implants in 15 participants and found

bone crest and papilla heights to be4.6 mm and 2 mm lower, respectively,

for the implant-implant clinical situa-

tion than for the tooth-implant situ-

ation. They also found only 1 mm of

missing papilla height when the inter-

implant distance was 3 mm and that

immediate provisional restoration

reduced papilla loss from 2 mm to

1 mm. It is also noteworthy that, in

this study, 87.5% of participants werepleased with their esthetic result even

with a papilla height discrepancy of 2

mm. Because most of these changes

have been found to occur within the

first 6 months following placement, the

advantages of early and long term pro-

visional restoration seem clear. Tarnow

et al113 also recommended caution,

while reporting mean papillary tissue

heights of only 3.4 mm for 136 adja-

cent implant sites in 33 participants. While 3 to 4 mm appears to be the

ideal interimplant distance, the use of

a platform switched design may allow

more bone and soft tissue maintenance

for enhanced esthetics, effectively in-

creasing the interabutment distances

for implants in close proximity 65,105 In a

study of 41 pairs of platform switched

implants in 37 participants, Rodri-

guez-Ciurana et al65 demonstrated

bone maintenance to be an average of

2.4 mm above the implant/abutment

interface at interimplant distances

less than 3 mm. As stated previously,

Novaes et al59,60 also found improved

papilla fill for subcrestally placed plat-

form switched implants than for those

placed crestally. However, the papilla

height was not influenced by interim-

plant distance, which varied from 1

to 3 mm.59,60 In addition to his previ-

ously mentioned recommendation of

a 3 mm distance from implant to adjacent gingival margin zeniths, Priest 61

similarly recommended 3 mm of in-

terimplant distance as well as orient-

ing the center of the implant 3 mm

palatal to the future facial restorative

margin. Therefore, because of the es-

thetic challenges detailed above, the

placement of adjacent implants in the

esthetic zone should be avoided when-

ever possible.114

SUMMARY

A review of the current literature

suggests that the use of standard to

narrow diameter implants, a plat-

form switched design, and early pro-

visional restoration should be con-

sidered when long term esthetics are

paramount. Also, maintaining inter-implant and tooth-to-implant dis-

tances of approximately 3 mm is desir-

able with regard to crestal bone main-

tenance and papilla development.

Subcrestal placement may afford ad-

equate space to develop restorative

contours from the top of the implant

to restoration emergence while avoid-

ing facial thread exposure. This may

be even more effective in combina-

tion with a platform switched design.In addition, abutment to implant

connections, which are extremely in-

timate and allow little to no relative

movement, seem to offer distinct ad-

vantages with regard to tissue health.

Lastly, the use of noncustomizable

abutments and abutment level restor-

ative techniques provides for ease of

provisional restoration and treatment

sequencing while avoiding multiple

exposures of the implant/abutment

junction, although the biological ad-

vantages this may offer have yet to be

investigated.

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Corresponding author:Dr Arthur M. Rodriguez1834 Liberty Way

Valencia, PA 16059Fax: 412-527-4616E-mail: [email protected]

Copyright © 2012 by the Editorial Council forThe Journal of Prosthetic Dentistry.

esthetic considerations related to bone and soft tissue

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