A Multidisciplinary Approach to Single-Tooth
Replacement
Sergio Rubinstein, DDS*
Alan J. Nidetz, DDS*
Masayuki Hoshi, RDT**
O ver the last several decades, dentistry
has focused on more conservative treat-
ment modalities and preventive tech-
niques. This has been possible not only because
of improved techniques and materials, but also
because of the understanding that tooth prepara-
tion, regardless of how conservative it may be, is
an irreversible procedure.
A missing tooth in the anterior region is not
only a physical loss, but also may be an emotional
experience for the patient as well. To remove
healthy tooth structure of adjacent teeth to re-
place a congenitally missing tooth or a tooth lost
to decay, trauma, root fracture, failed root canal
*Oral Rehabilitation Center, Skokie, Illinois, USA.
**Oral Rehabilitation Institute, Skokie, Illinois, USA.
Correspondence to: Dr Sergio Rubinstein, Oral Rehabilitation
Center, 64 Old Orchard, Suite 420, Skokie, IL 60077, USA.
E-mail: oralrehab1@aol.com
treatment, or pathology is, for some patients and
dentists, a very aggressive treatment option. In-
fection in any of these situations creates an envi-
ronment in the hard and soft tissues that makes
regeneration procedures more difficult, thereby
complicating the ability to create a natural ap-
pearance in the definitive restoration.
While a conventional three-unit fixed partial den-
ture is a predictable technique to replace a missing
tooth, the invasive nature of the treatment can lead
to other complications throughout the life of the
restoration. Complications may include mechanical
overload of the abutment teeth with weakening or
fracture, risk of endodontic treatment, periodontal
problems, decay, and cement failure. If any of these
complications occurs on one of the abutment
teeth, the entire prosthesis will fail. Splinting teeth
can overload the supporting structures because
teeth function individually, and oral hygiene tech-
niques become more cumbersome.
QDT 2004 1
 RUBINSTEIN ET AL
HISTORY OF SINGLE-TOOTH
RESTORATIONS
For more than 50 years, dentistry has sought a
more conservative approach to replacing a single
missing tooth with a conventional fixed prosthesis,
which involves the cutting of sound tooth struc-
ture. Treatment possibilities have evolved from
bonding a natural extracted tooth or composite
resin restoration to the adjacent teeth,1–3 to the
Rochette bridge,4,5 to the Maryland bridge,6–8 and
currently to the single-implant–supported crown.
It is debatable which technique is the most con-
servative, and in many instances the patient’s pref-
erence dictates the restoration of choice. The clin-
ician must also evaluate the advantages and
disadvantages of such techniques in order to pro-
vide the patient with the best clinical result since
not all patients should be treated with the same
restoration type or design.
While the Rochette bridge replaced the miss-
ing tooth without any tooth preparation, it was, at
best, considered a temporary solution, and its
framework was designed with a gold substructure
and hence resulted in a thick metal framework.
Such restorations were designed with macrome-
chanical retentions (Figs 1a to 1c) to lock the com-
posite into the gold and through the bonded lin-
gual surface. This technique met the patient’s
conservative requirements of replacing the miss-
ing tooth, even though it required the patient’s
compliance not to overload the prosthesis during
masticatory function and necessitated a modified
flossing technique because of the splinted pros-
thesis (Fig 1d).
Proven over the years through the achievement
of acceptable clinical results, such resin-bonded
prostheses continued to improve, and their evolu-
tion led to the development of the Maryland
bridge.6,7 For this technique, the tooth required a
conservative preparation in the enamel only8 with a
gingival rest to create a definite seat. The prepara-
tion design included an interproximal wraparound
to help prevent lingual displacement and to in-
crease stability on a bondable surface area
(enamel) with a solid, nonperforated, metal sub-
2 QDT 2004
structure that could be as thin as 0.2 mm. Use of a
non-noble metal alloy significantly increases the
mechanical retention of the etched framework and
more easily prevents degradation of the luting
resin in the oral cavity. Care must be exercised so
the framework does not involve the incisal third of
the abutment teeth, since this could block translu-
cency and result in a graying effect (Figs 2a to 2h).
While use of a resin-bonded retainer involves a
very conservative technique and preparation of
the enamel is minimal, the mechanical retentive
properties of the prosthesis, by design, have a
wraparound effect of 180 degrees. Still, care must
be exercised to prevent occlusal overload during
function.
Presently, the single-implant–supported crown
is a predictable method of tooth replacement,
and it has several improvements over resin-
bonded prostheses: preparation of adjacent teeth
is not needed; the tooth replacement will function
individually; a conventional oral hygiene tech-
nique can be used; preservation and stimulation
of existing bone and soft tissues occur, including
recreation of the interproximal papillae; and sta-
bility and function are improved because of the
implant supporting the crown.
While osseointegration around implants is a
well-documented phenomenon, the implant de-
signs will continue to undergo structural modifica-
tions to fulfill the prosthetic requirements one
faces as the practice of dentistry evolves. Such
changes include the transitions from the standard-
diameter implant to wider-diameter implants;
from the external-hexagon, antirotational device
to the internal morse taper connections; and from
the two-stage surgical approach to the now more
frequently used one-stage techniques that include
immediate loading. These are just a few of the
factors that complicate the analysis of implant de-
signs with respect to failure or success. The area
often considered the most critical is the implant-
abutment interface, and because of evolving de-
signs, this is where dentistry may see some signifi-
cant changes to obtain the best possible fit and
improved tissue response.
 A Multidisciplinary Approach to Single-Tooth Replacement

Rochette Bridge

1a 1b 1c

Fig 1a Lingual view of the waxup for the Rochette bridge.

Fig 1b Cast framework on the stone model.

Fig 1c Framework showing mechanical undercuts to lock the bonded pros-

thesis.

Fig 1d Buccal view of the bonded Rochette bridge. (Prosthetics and labora-
tory work by Alexander H. Chan, DDS.)
1d

Maryland Bridge

Figs 2a and 2b The maxillary right central incisor and supporting bone Fig 2c A connective tissue graft was
have been lost as a result of trauma. The rotation of the left central incisor placed to correct the soft tissue de-
and the vertical bone loss required a multidisciplinary treatment approach. fect, and orthodontics corrected the
rotation of the left central incisor.
(Orthodontics by Sergio Rubinstein,
DDS; surgery by Sergio Rubinstein
and Patrick J. Pierre, DDS; 1981.)

2d 2e 2f

Fig 2d Lingual view of the Mary-

land bridge. The incisal extension
required slight trimming to avoid
blocking translucency.

Figs 2e and 2f Views of the Mary-

land bridge replacing the maxillary
right central incisor.

Figs 2g and 2h Views of the pa-

tient’s smile. 2g 2h

QDT 2004 3
 RUBINSTEIN ET AL
IMPLANT PROSTHODONTICS
Since the endosseous implant was introduced in
the United States, the prosthetic indications have
grown from the mandibular, fixed, bone-anchored
prosthesis to the single-tooth replacement. 9–16
While many clinicians still resist the application of
endosseous implants, preferring the more tradi-
tional restorations, one could argue the relative
morbidity of preparing the adjacent teeth for fixed
partial dentures compared with the two-stage,
one-stage, or immediate-loading implant surgical
and prosthetic protocol. Clearly not only can im-
plant prosthodontics offer excellent cosmetic out-
comes, but it also allows for bone preservation
and stimulation, and the restoration most closely
resembles an actual tooth during function.
DIAGNOSIS
When a patient needs replacement of a missing
tooth (Figs 3a to 3c), the clinician must perform a
series of clinical and radiographic evaluations (Fig
3d) to visualize and offer the available treatment
options. The patient must be made aware of these
options, which generally include some form of re-
movable partial denture, resin-bonded retainers,
fixed partial prosthesis, or an implant-supported
restoration. If a single-tooth implant restoration is
considered, the clinician must first determine
whether an adequate recipient bed, or site, for the
implant exists. Once this has been determined
clinically and radiographically, the function, esthet-
ics, and contours of the final prosthesis, as well as
peri-implant health, should be considered. Treat-
ment should proceed only if all prerequisites are
fulfilled. It is important that the site to be treated
be evaluated along with the complete dentition to
formulate a comprehensive treatment plan.
CLINICAL EXAMINATION
Definitive tooth replacement must follow active
disease control and some type of provisionaliza-
4 QDT 2004
tion of the missing tooth (Fig 3e). Several clinical
concerns need to be addressed: measurement of
interproximal space and adjacent teeth, the oc-
clusal relationships, anterior and canine guidance,
and esthetic demands. The esthetic demands in-
clude the lip profile, alveolar height and buccolin-
gual dimensions, and the quality of the overlying
gingiva.9
There must also be enough mesiodistal clear-
ance for the implant in order to avoid risk to adja-
cent structures such as the nasopalatine or
mandibular nerve, nasal cavity, neighboring teeth,
or the maxillary sinus. In most cases, the implant
and prosthetic components will require a mini-
mum of 6 to 8 mm of mesiodistal clearance de-
pending on the location in the dental arch.15–18 A
congenitally missing tooth will most likely have a
normal osseous ridge, both in height and width,
whereas alveolar atrophy always follows the ex-
traction of teeth. Its severity depends on several
factors, including (1) quantity and quality of bone,
(2) existing or previous pathology, (3) length of
time following tooth loss, and (4) trauma incurred
during the extraction and the loading of the tis-
sues. The collapse of the facial plate and alveolar
height subsequent to tooth loss19 can impact the
position and angulation of an implant. The ideal
implant placement and how alternative positions
affect prosthetic design and morphology has
been described at length; however, this will vary
from case to case and depending on the implant
system selected.
Occlusal relationships will influence the design
of the crown. A minimum of 7 to 8 mm is required
from the coronal aspect of the implant to the op-
posing occlusion. 15,16 When determining the
occlusal clearance for an implant, it is important to
remember that implants are often intentionally
placed below the crest of the ridge about 2 to 4
mm apical to the cementoenamel junction of adja-
cent teeth to provide a sufficient emergence profile
for the crown.20 Incisal relationships that subject
teeth to heavy occlusal loads must be carefully
evaluated, because an esthetic result must be
achieved while the teeth and implant are protected
from undesirable forces.21,22 While parafunctional
 A Multidisciplinary Approach to Single-Tooth Replacement

Restoration of Lateral Incisors

Figs 3a to 3c Pretreatment views of Maryland bridges. The lateral incisor prostheses are improperly contoured be-
cause of the malpositioned maxillary central incisors and canines.
Fig 3d Initial radiograph showing inadequate space to place implants in the
position of the congenitally missing lateral incisors.

Fig 3e Orthodontic treatment in progress with provisional prostheses bonded

only to the mesial of the canines while the root position of the central incisors is
being adjusted. Once the centrals are in the correct position, the provisionals
are bonded to them while the position of the canines is adjusted. Treatment
can then proceed to implant surgery. (Orthodontics by Howard Spector, DDS.)

Fig 3f Incisal view of premachined, 15-degree angulated abutments. Note

that the implants have been placed slightly palatal to the incisal edge so the
abument screws can be placed in the cingulum area. (Surgery by Douglas V.
Gorin, DDS.)

Fig 3g Acrylic resin, implant-supported, provisional restorations 4 months

after insertion. Soft tissue contouring and tooth bleaching have been accom-
3d
plished at this stage.

3e 3f 3g

Fig 3h Final crowns in solid stone model with soft tissue duplication.

Fig 3i Horizontal lingual screws allow for improved lingual contours and
ease of retrievability.

Fig 3j Final implant-supported crowns on the maxillary left and right lateral
incisors. (Prosthetics by Sergio Rubinstein, DDS; laboratory work by
Masayuki Hoshi, RDT.)
3h

3i 3j

QDT 2004 5
 RUBINSTEIN ET AL
Soft Tissue Management with a Fixed Provisional Restoration
Fig 4a The patient was unhappy with the esthetics of
the maxillary right central incisor crown. Supereruption
of the tooth could have predictably corrected the gingi-
val recession, but the patient declined the treatment.
The prognosis was hopeless, and the tooth was ex-
tracted.
Fig 4c Composite resin provisional restoration bonded
in place. Even though the soft tissue discrepancy will
have to be corrected during second-stage surgery, note
the interproximal papillae preservation with the fixed
provisional.
activities are not a contraindication for implants,
they do influence treatment planning. 23 It is
paramount to have a passive fit between the im-
plant, component(s), and crown.24–28
Because esthetic demands have an enormous
impact on the treatment planning of implant-sup-
ported prostheses, a high lip position that exposes
the gingiva will affect the requirements of implant
6 QDT 2004
Fig 4b Healing site showing gingival height discrep-
ancy between the central incisors 7 days after tooth ex-
traction. (Surgery by Leslie B. Heffez, DDS.)
Fig 4d Incisal view of the fixed bonded provisional.
(Prosthetics by Sergio Rubinstein, DDS; laboratory work
by Orly Farahmandpour.)
placement, soft tissue management (Figs 4a to
4d), and design of the final prosthesis. Loss of cre-
stal bone requires a longer clinical crown usually
with larger gingival embrasure spaces. A narrow
implant diameter placed into a site with minimal
alveolar bone loss can lead to unesthetic results
with improper contours, such as a bulky implant-
prosthetic connection with a cantilever effect.
 A Multidisciplinary Approach to Single-Tooth Replacement
Soft Tissue Management with Supereruption
Fig 5a Preoperative photograph showing a 3-
mm apical migration of the gingiva at the right
central incisor compared with that at the left
central incisor.
Fig 5c The labial root is torqued to bring the
palatal bone labially.
SOFT TISSUE CONSIDERATIONS
It is well-documented that soft tissue architecture
is influenced by the underlying bony architec-
ture.29–31 It is further documented that tooth loss
results in a loss of alveolar bone height and loss of
soft tissue architecture in both the facial and api-
cal directions.32 When a tooth must be extracted,
changes in bone loss and soft tissue architecture
can be controlled by using orthodontic supererup-
tion prior to extraction.3 This technique can pro-
vide solutions to very difficult situations (Fig 5a).
On average, anterior tooth loss will result in a 3-
mm apical migration of the soft tissue. Supererup-
tion of 3 mm prior to extraction will compensate
for this loss.33 When a defect in soft tissue archi-
tecture already exists, it can be predictably cor-
Fig 5b Orthodontic brackets positioned to
achieve 6 mm of supereruption. (Orthodontics,
restorative dentistry, and laboratory work by
Alan J. Nidetz, DDS; surgery by David Barack,
DDS.)
Fig 5d Supereruption is complete. Note the
overcorrection of the gingival height.
rected by adding the amount of the defect in mil-
limeters to the “3-mm rule.” For instance, a 3-mm
defect would require 6 mm of supereruption (Figs
5b to 5d). After supereruption is complete, the
clinician should wait 3 months before proceeding
with extraction and implant placement. This al-
lows for complete maturation of both the bone
and the soft tissue. Once the tooth is extracted
and the implant is placed, an ovate pontic is used
to provide scaffolding for the soft tissue during
the healing process34,35 (Figs 5e to 5l). The implant
is uncovered, and an immediate provisional
restoration engaging the implant is placed to
allow for tissue maturation36 (Figs 5m to 5p). The
final prosthetic restoration is fabricated and deliv-
ered after the hard and soft tissues have healed
(Fig 5q).
QDT 2004 7
 RUBINSTEIN ET AL

Soft Tissue Management with Supereruption (continued)

Fig 5e Radiograph taken immediately after implant

placement.

Figs 5f to 5h Fabrication of a fixed provisional Mary-

land bridge.

Figs 5i and 5j The provisional Maryland bridge is

placed immediately following implant placement.

Figs 5k and 5l Clinical and radiographic views after 4

months of healing.
5e

5f 5g 5h

5i 5j

5k

5l

8 QDT 2004
 A Multidisciplinary Approach to Single-Tooth Replacement

Fig 5m Appearance of the soft tissue immediately Fig 5n Tissue appearance immediately after implant
upon removal of the fixed provisional. uncovering and placement of the second provisional.

Figs 5o and 5p Tissue appearance 4 weeks after implant uncovering.

Fig 5q Final restoration. (Figs 5a to 5q: Orthodontics, restorative dentistry,

and laboratory work by Alan J. Nidetz, DDS; surgery by David Barack, DDS.)

QDT 2004 9
 RUBINSTEIN ET AL
Radiographic Stents
Figs 6a and 6b Radiographic and surgical stent with barium sulfate to delineate buccal contours. Gutta-percha
markers are placed on the occlusal surface to suggest the ideal implant inclination.
RADIOGRAPHIC EXAMINATION
Radiographs will provide information regarding
the bone available for implant placement and the
position of vital structures, as previously de-
scribed, in order to help prevent disappointing
postoperative results. Determining the need for
specific radiographs depends to some degree on
the patient’s clinical presentation as well as the
dental team’s philosophy.
Periapical radiographs will provide a fairly accu-
rate assessment of interdental clearance (see Fig
3d); however, maxillary anterior radiographs are
subject to frequent elongation as a result of film
angulation. Panoramic radiographs are also sub-
ject to significant distortion both horizontally and
vertically.37,38 As much as radiographic markers,
such as metal balls of known dimensions, can help
to calibrate the films for improved accuracy, the
lack of dimensional reliability combined with the
two-dimensional quality of traditional radiographs
underscores the value of digital reformatted com-
puterized tomography. These diagnostic films pro-
vide a three-dimensional cross-sectional view
through the maxilla or mandible with a 1.1:1 or
1:1 magnification ratio.38–40 Linear tomograms can
be useful for isolated areas while minimizing radi-
ation and expense to the patient.41,42 This type of
tomogram will clearly demonstrate the quality of
cortical and trabecular bone as well as the bound-
aries of the facial or linguopalatal plate, the maxil-
lary sinus, nasal cavity, and mandibular nerve.
10 QDT 2004
Radiographic stents with radiopaque markers
such as gutta-percha or barium sulfate can be
helpful (Figs 6a and 6b). These will produce a
cross-sectional image indicating the desired incli-
nation of the implant with its possible correspond-
ing contours. This position can then be evaluated
in terms of available bone to determine whether
the desired position is surgically realistic. Clearly,
the osseous architecture will not always allow for
ideal implant position. The information provided
by cross-sectional images will enable the clinician
to anticipate any limitations and determine how to
correct defects surgically or identify acceptable al-
ternative implant positions. With careful planning,
the surgeon and restorative dentist can eliminate
what otherwise might be an unpleasant surprise
and then communicate to the patient possible
prosthetic designs as a function of the ultimate
implant position.
Once all the diagnostic data have been ob-
tained, the surgeon and restorative dentist must
anticipate the design of the final restoration to
achieve an optimum functional and esthetic clini-
cal result. The final position of the implant de-
pends not only on the hard and soft tissue topog-
raphy, but also on the implant diameter, the
desired emergence profile, and the contours of
the neighboring teeth. The simplest restorative
design to date places the abutment screw
through the cingulum in anterior teeth and
through the central groove in posterior teeth. To
achieve this result, the surgeon must position the
 A Multidisciplinary Approach to Single-Tooth Replacement
implant slightly palatal to the incisal edge for an-
terior teeth and close to the central groove for
posterior teeth. If the surgeon and restorative
dentist determine that a facial angulation is re-
quired, then some form of substructure, such as a
premachined angled abutment (see Fig 3f) or cus-
tom abutment, will be necessary to maintain an
esthetic result.
STENT CONSTRUCTION
Once the initial clinical and radiographic findings
have been established, a clear acrylic resin or
plastic stent with radiographic markers should be
fabricated. Such a stent should demonstrate the
ideal prosthetic position and indicate the pre-
ferred implant placement as well as acceptable al-
ternatives that will facilitate an optimum final pros-
thesis.
Clinicians may be tempted to place implants
for single-tooth replacements without a stent, be-
lieving that the neighboring teeth will serve as a
reference for implant inclination and position.
However, once the flap has been raised, the sur-
geon will focus on the osseous architecture to de-
termine optimum implant support. The stent can
serve to prevent prosthetic failures resulting from
overangulation, especially to the facial. Generally,
the stent used for preoperative radiographs can
also be used during surgery to guide implant
placement and to help in uncovering the implant
after the primary healing period.
Stents used for single-tooth replacement are
simple in design and easy to fabricate. A stent
that replicates the buccal profile with the palatal
portion cut out will prevent screw access to the fa-
cial and will aid in centering the implant mesiodis-
tally.43 Some clinicians prefer stents that restrict
the implant placement to a specific position (using
a 2- to 3-mm hole in the stent), as this will clearly
indicate the desired position for the primary drill.
Once the surgeon increases the bur size, this stent
is no longer usable. It is possible for the surgeon
to slightly redirect bur angulation (especially in
softer bone), but it does not allow for alternative
positions or angulations that may be clinically ac-
ceptable. Alternatively, the stent should be en-
tirely open in its lingual aspect to facilitate the sur-
geon with additional options.
When stents are created, the radiographic stent
can be designed first, and if necessary it can be
modified to correspond to the computerized to-
mogram. Such computerized tomogram–assisted
stents will help to place the implant not only in its
planned buccolingual and mesiodistal positions,
but also at the desired depth.
PROVISIONALIZATION
The patient will want to wear some form of provi-
sional tooth replacement during the primary heal-
ing period, especially in an esthetic area. Primary
healing can range from 2 to 8 months depending
on the clinical situation. The type of provisional
selected can be a removable appliance; a resin-
bonded fixed provisional, if adjacent teeth allow
for bonding; or a passive acrylic resin provisional
using the implant, with the restoration being out
of occlusion. The advantages of the resin-bonded
provisional are that it is cosmetic, noninvasive,
and fixed; it maintains occlusion and adjacent
teeth positions; and it allows for tissue contouring
and papillae preservation.
It is important that the appliance does not
transmit any load to the healing implant site and
thus increase the risk of failure. The provisional
restoration must maintain a passive fit and provide
for soft tissue support.
SURGICAL PLACEMENT OF IMPLANTS
While placing the implant, the surgeon will focus
on avoiding injury to vital structures or adjacent
teeth, maximizing bony support for the implant,
engaging cortical bone for implant stability (for
certain systems), and placing the implant in the
ideal prosthetic position. These considerations
must be factored into planning the direction of
the implant placement, the chosen length and di-
QDT 2004 11
 RUBINSTEIN ET AL
ameter of implant to be used, the depth of im-
plant placement (including whether the implant
must be countersunk, for some systems), the
height relative to the osseous crest and adjacent
teeth, and whether or not bone grafting is to be
implemented.
A position that is centered between the neigh-
boring teeth, with note to the anatomic struc-
tures, usually best fulfills these considerations.
The buccolingual orientation depends on the
presence of intact bone and the ability to engage
the palatal or buccal plate, while keeping in mind
the desired prosthetic position of the implant. If
there is a conflict between the most stable posi-
tion of the implant and the desired prosthetic po-
sition, then the surgeon must refer to the range
of alternative acceptable positions. Some sur-
geons will intentionally engage the floor of the
maxillary sinus or nasal cavity, but care must be
taken not to perforate these vital structures be-
cause the predictability of osseointegration will
be diminished.44 The vertical position of the im-
plant will depend on the desired emergence pro-
file of the final crown. It has been recommended
that the implant be placed 3 to 4 mm apical to
the neighboring cementoenamel junction.9,20 If
minimal resorption of the osseous crest has oc-
curred, the crest may require some resection to
create the required space for countersinking the
implant to the suggested depth. Any resection
should be postponed until the implant is uncov-
ered to prevent excessive resorption of the crest
and subsequent exposure of the implant surface.
A wider implant diameter or narrower diameter of
the tooth to be replaced can reduce the amount
of countersinking needed to account for proper
emergence profile.20,45
The indications for osseous grafting include
augmentation of the ridge for implant stability or
esthetic concerns. Bone grafting may be per-
formed, in some instances, 3 to 6 months before
implant placement. In selective cases, osseous
grafting can be performed at the time of implant
placement. If minor bone modification is needed,
the osteotome can help stretch the existing bone.
While ridge augmentation procedures have been
12 QDT 2004
employed for several years,38 the predictability of
crestal augmentation in the coronal direction is
questionable.46
OSTEODISTRACTION AND BONE GRAFTING
According to Samchukov et al,47 “Most significant
new ideas, concepts, or products go through a
four-stage evolution in their infancy. They are ini-
tially rejected by almost all potential users who
claim that it cannot be done or it is too much trou-
ble. Shortly thereafter, it is accepted by a few; the
vast majority, however, contend that it is just not
there yet or maybe later. After a period of time,
most people adopt the new technique, and begin
to question why their colleagues are not using it.
Finally, after years of clinical and experimental
documentation, it becomes the standard of
care—the technique by which all others are com-
pared.”
Osteodistraction has many clinical applications
and facilitates different treatment modalities in a
more conservative and predictable manner. As
distractors become smaller and more efficient,
distraction osteogenesis is becoming a viable
technique to build up bone in a vertical direction.
However, guided tissue regeneration techniques
have improved the predictability for increasing the
ridge thickness, especially in smaller areas48–53 (Figs
7a to 7d). Sinus lift procedures are currently being
performed with a high degree of predictability
and are enabling treatment options that once
were not imaginable. It is important to remember
that smoking has been shown to increase the rate
of dental implant failure.54
Presently, the choice of osseous grafting mate-
rials includes autologous bone, freeze-dried bone
allograft, demineralized freeze-dried bone allo-
graft, resorbable bone substitutes, and nonre-
sorbable bone alloplast. Allografts can be placed
into fresh extraction sites and then covered with
membranes for guided tissue regeneration to pre-
serve ridge height prior to the implant
placement.48 Researchers do not agree on the
ideal grafting material to be used around en-
 A Multidisciplinary Approach to Single-Tooth Replacement
Bone Grafting
Fig 7a The patient was unhappy with the
Maryland bridge because of the need to floss
laterally with a threader. The patient was not
interested in correcting the malposition of the
canine with orthodontics.
Fig 7c Final implant-supported crown.
dosseous implants.55–60 Many clinicians prefer de-
mineralized freeze-dried bone allografts in the
treatment of infrabony periodontal defects. How-
ever, this grafting material appears to be subject
to rapid resorption when used in sites not rich in
mesenchymal cells58; therefore, the use of rich
plasma cells mixed with autogenous bone is in-
creasing in popularity. In time researchers will be
able to evaluate its long-term stability. While bone
growth into grafted sites has been reported,59,61 a
Fig 7b The maxillary lateral incisor was con-
genitally missing. Note the loss of the buccal
plate, complicating ideal implant placement. A
bone graft was required.
Fig 7d Lingual view of the final crown with a
horizontal screw, which improves the lingual
contour and ease of retrievability. (Prosthetics
by Sergio Rubinstein, DDS; laboratory work by
Masayuki Hoshi, RDT.)
fibrous connective tissue around grafted hydrox-
yapatite has also been documented.55 If grafted
sites are infected, there may be a chance for the
infection to disseminate.61 Autogenous bone is
widely used, but volume may be limited by avail-
able donor sites. A variety of materials have been
used with implant placement, but they appear to
be most predictable when used with membranes
for guided tissue regeneration.48,49,51,52
QDT 2004 13
 RUBINSTEIN ET AL
TOOTH EXTRACTION WITH IMMEDIATE
IMPLANT PLACEMENT
Implants can be placed into fresh extraction sites
when adequate bone exists to immobilize the im-
plant62–67; this generally requires that about 40% of
the implant be embedded in firm bone tissue.
Some benefits are improved preservation of alve-
olar bone and decreased treatment time. Implants
should not be placed into sites where there is in-
adequate bone to stabilize the implant; to do so
will risk micromovement of the implant and inter-
fere with the tissue’s ability to integrate around
the implant.16 Implants should also not be placed
into sites with a remaining infection associated
with a diseased tooth. This would interfere with
tissue healing, risking dissemination of the infec-
tion as well as implant failure.68
For placement of an implant into a fresh ex-
traction site, the implant site should be prepared
beyond the apex of the extraction site and quite
often along an axis not parallel to the long axis of
the extracted tooth (Figs 8a to 8f). The coronal
aspect of the implant will be either partially or
completely exposed without direct contact to the
socket walls. Therefore, the cells of the bone tis-
sue must travel a significant distance to reach the
implant surface and mature into a supporting tis-
sue. This is in contrast to the surgical principles
described in which a tight bone fit was consid-
ered critical for osseointegration to occur.69 To en-
courage bone fill of the remaining socket space,
steps must be taken to prevent the gingival flap
from contributing to the healing of this potential
space.
One way to reduce the distance the bone cells
must travel is to place an implant that resembles
the anatomy of the extraction site, either conical
or cylindrical in shape. The implant will thus fill
more of the socket or be slighter larger to engage
healthy bone for its stability.
A bone graft will act as scaffolding for the
bone-forming cells to travel and reach the implant
surface. Graft materials also support the flap and
may act as a barrier to the soft tissue. Expanded
polytetrafluoroethylene membranes used for
14 QDT 2004
guided tissue regeneration also support the over-
lying flap and thereby preserve the space to be
occupied by bone.62,64,66–68,70
One- and Two-Stage Surgery
In selective cases, second-stage surgery is not
needed when a taller healing cap is placed, thus
preventing the soft tissue from covering the im-
plant. Such cases will depend on ease of the surgi-
cal technique, occlusion, oral hygiene, and the pa-
tient’s ability to follow postoperative instructions.
For other cases second-stage surgery is re-
quired. The time allotted for the primary healing
period depends on the site of implant placement,
the quality of bone, whether bone grafting has
been performed, or whether the implant has been
placed into a fresh extraction site. Generally, this
ranges from 2 months71 to 8 months. At the time of
implant uncovering osseointegration must be veri-
fied by radiographic and clinical means.
Implant Uncovery
The desired esthetic result will influence soft tis-
sue management during all surgical phases as
well as during implant uncovering72 (see Figs 3g to
3j). Posterior implants are frequently uncovered by
use of linear incisions or a circular tissue punch.
Anterior procedures should focus on the preserva-
tion of keratinized tissue, color match of the gin-
giva, and the ultimate height of the soft tissue fa-
cial and interproximal to the implant. The need for
a wide zone of keratinized tissue around implants
has been argued for some time. While many
agree that minimal to no attached tissue is neces-
sary to maintain peri-implant health,73 esthetics
demands a healthy, wide zone of gingival tissue
around natural teeth and implants. If an inade-
quate zone of tissue exists prior to implant place-
ment, soft tissue grafting can be performed prior
to placement of the implant. However, either
pedical flaps or connective tissue grafts are pre-
ferred because these procedures tend to provide
the best color match of grafts to the recipient tis-
sues.
 A Multidisciplinary Approach to Single-Tooth Replacement

Immediate Implant Placement

Fig 8a Healing cap over the implant. The tooth was lost Fig 8b Tissue healing around the implant. (Surgery by
as a result of vertical fracture, and a fixed provisional Kenneth H. Peskin, DDS.)
was not used. Note the loss of the papillae.

Fig 8c Radiograph showing impression post–implant

transition. Note the bone loss around the neck of the
implant subsequent to a previous infection.

Fig 8d Angled, screw-retained abutment with perfora-

tion to accept a lingual screw.

8c 8d

Fig 8e Buccal view of the final crown. Fig 8f Lingual view of the final crown with the lingual
screw parallel to the axis of the implant. (Prosthetics by
Sergio Rubinstein, DDS; laboratory work by Masayuki
Hoshi, RDT.)

Follow-up care should include suture removal if gins when the healing cap is exposed into the oral
a flap was raised, plaque control, and evaluation of cavity and will continue throughout treatment until
healing prior to initiation of prosthetic procedures. after the implant-supported crown is in place. Oral
Oral hygiene with a soft brushing technique be- rinses for plaque control have been shown to pro-

QDT 2004 15
 RUBINSTEIN ET AL

Implant-Supported, Cemented Crown

9a 9b 9c

Fig 9a Incisal view of a screw-retained abutment.

Fig 9b Buccal view of an implant-supported, permanently cemented crown

on the maxillary right lateral incisor.

Fig 9c Lingual view of an implant-supported, permanently cemented crown.

Fig 9d The maxillary right lateral incisor crown looks natural in the patient’s
smile. (Prosthetics by Sergio Rubinstein, DDS; surgery by Robert A. Bress-
man, DDS; laboratory work by Masayuki Hoshi, RDT.)
9d

mote healing in the early postoperative period; in-
definite use of chlorhexidine is typically prescribed
as part of the oral hygiene regimen for implants. A
3-month maintenance program has been shown to
effectively maintain peri-implant health.74 The sur-
geon’s responsibility for the health of the implant
does not end with second-stage surgery, but joins
with the patient’s and the restorative dentist’s ef-
forts for a long-term successful result.
PROSTHODONTIC ALTERNATIVES
For many clinicians, fabrication of an implant-sup-
ported crown as either a screw-retained or ce-
mented restoration is a personal preference. Each
technique has its advantages and disadvantages.
The screw-retained restoration allows more simple
retrieval if any modifications, repairs, or alterations
to the existing tooth contours or adjacent teeth are
needed. While traditionally the screw will be in a
vertical direction along the axis of the implant, a
horizontal or transversal placement of the screw in
the lingual surface of an anterior restoration will
allow for better lingual anatomy on its lingual sur-
face along with the improved esthetics (see Fig 7d).
Another option is to have the abutment screw
retained on the implant with the final restoration
temporarily cemented to the abutment to allow
for some retrievability. However, in some cases re-
trievability of a temporarily cemented crown can
be a challenge. An additional problem can occur
when the crown is permanently cemented and
there is uncertainty of whether the cement has
been removed entirely. Two of the most favorable
advantages of the cementable crown are its simi-
larity to conventional prosthodontics and the elim-
ination of the screw through the crown, hence
better contours and esthetics (Figs 9a to 9d).
Designs of implant restorations have evolved to
accommodate the width of the different teeth
they can replace, not only wider anterior teeth but
also posterior teeth (Figs 10a to 10f). With the ex-
isting variations of teeth and the mesiodistal
space between teeth in direct correlation to the
available supporting bone, it is necessary to have
implants of different diameters to solve the chal-
lenges faced in implant dentistry.

16 QDT 2004
 A Multidisciplinary Approach to Single-Tooth Replacement

Posterior Single-Tooth Restoration

10a 10b 10c

10d 10e 10f

Fig 10a Occlusal view of a customized abutment, with interproximal grooves, milled at 2 degrees of convergence.

Fig 10b Lingual view of the abutment with mesiolingual tapping to allow for a screw-retained crown.

Fig 10c Porcelain-fused-to-metal crown retained with a lingual screw. Note the narrow buccolingual contours to
minimize undesirable occlusal loads.

Fig 10d Lingual view of final crown.

Fig 10e Buccal view of final crown.

Fig 10f Radiograph of final crown. While a mesial cantilever is present, it is diminished by the use of the widest
available implant. (Prosthetics by Sergio Rubinstein, DDS; surgery by Jeffrey K. Bressman, DDS; laboratory work by
Toshiyuki Fujiki, RDT.)

CONCLUSION ACKNOWLEDGMENTS

We would like to thank Dr Tatiana Quintiliano for her tireless

The ultimate goal of the single-tooth implant
effort in helping us prepare this article for publication.
restoration is to restore the lost tooth with both
optimum function and esthetics. The definitive
restoration should ideally resemble the original
REFERENCES
tooth in contour and shade while both restoring
and preserving the bone and soft tissues. Long- 1. Ibsen RL. One-appointment technic using an adhesive
term health will only be possible if treatment is composite. Dent Surv 1973;49:30–32.
2. Ibsen RL. Fixed prosthetics with a natural crown pontic
followed by a proper maintenance program.
using an adhesive composite: Case history. J South Cal
Dent Assoc 1973;41:100–102.

QDT 2004 17
 RUBINSTEIN ET AL
3. Jordan RE, Suzuki M, Sills PS, Gratton DR, Gwinnett JA.
Temporary fixed partial dentures fabricated by means of the
acid-etch resin technique: A report of 86 cases followed for
up to three years. J Am Dent Assoc 1978;96:994–1001.
4. Rochette AL. Attachment of a splint to enamel of lower
anterior teeth. J Prosthet Dent 1973;30:418–423.
5. Howe DF, Denehy GE. Anterior fixed partial dentures uti-
lizing the acid-etch technique and a cast metal frame-
work. J Prosthet Dent 1977;37:28–31.
6. Livaditis GJ, Thompson VP. Etched castings: An improved
retentive mechanism for resin-bonded retainers. J Pros-
thet Dent 1982;47:52–58.
7. Simonsen R, Thompson V, Barrack G. Etched Cast Restora-
tions: Clinical and Laboratory Techniques. Chicago:
Quintessence, 1983.
8. Rubinstein S, Jekkals V. Preparation for anterior resin-bonded
retainers. Compend Cont Educ Dent 1986;7:631–632.
9. Parel SM, Sullivan DY. Esthetics and Osseointegration.
Dallas: Osseointegration Seminars, 1989.
10. Ohrnell L-O, Hirsch J, Ericsson I, Brånemark P-I. Single-
tooth rehabilitation using osseointegration. A modified
surgical and prosthodontic approach. Quintessence Int
1988;19:871–876.
11. Lewis SG, Beumer J III, Perri GR, Hornburg WP. Single-
tooth implant restorations. Int J Oral Maxillofac Implants
1988;3:25–30.
12. Jemt T, Lekholm U, Grondahl K. A 3-year follow-up study
of early single implant restoration ad modum Brånemark.
Int J Oral Maxillofac Implants 1990;5:341–349.
13. Andersson B, Odman P, Carlsson L, Brånemark P-I. A new
Brånemark single-tooth abutment: Handling and early
clinical experiences. Int J Oral Maxillofac Implants
1992;7:105–111.
14. Weiner RE. A comparison of the UCLA abutment to the
Cera-One technique [abstract from the 7th annual meeting
of the Academy of Osseointegration, February 1992]. Int
J Oral Maxillofac Implants 1992;7:126.
15. Interpore IMZ Technique Manual, Revision 3. Irvine, CA:
Interpore International, 1987.
16. Hobo S, Ichida E, Garcia LT. Osseointegration and Occlusal
Rehabilitation. Chicago: Quintessence, 1990:105–132.
17. Priest GF. Single-tooth implants and their role in preserv-
ing remaining teeth: A 10-year survival study. Int J Oral
Maxillofac Implants 1999;14:181–188.
18. Priest GF. Failure rates of restorations for single-tooth re-
placement. Int J Prosthodont 1996;9:38–45.
19. Atwood DA. Bone loss of edentulous alveolar ridges. J
Periodontol 1979;50(4 special no):11–21.
20. Saadoun AP, Le Gall MG. Periodontal implications in im-
plant treatment planning for aesthetic results. Pract Peri-
odontics Aesthet Dent 1998;10:655–666.
21. Graf H. Bruxism. Dent Clin North Am 1969;13:659–665.
22. Hobo S, Ichida E, Garcia LT. Osseointegration and Occlusal
Rehabilitation. Chicago: Quintessence, 1990:257–259.
23. Ramfjord SP, Ash MM. Occlusion, ed 2. Philadelphia:
Saunders, 1971:99–140.
24. Brånemark P-I, Zarb GA, Albrektsson T. Tissue-Integrated
Prostheses. Osseointegration in Clinical Dentistry.
Chicago: Quintessence, 1985.
18 QDT 2004
25. Zarb GA, Symington JM. Osseointegrated dental im-
plants: Preliminary report on a replication study. J Pros-
thet Dent 1983;50:271– 276.
26. Laney WR, Tolman DE, Keller EE, Desjardins RP, Van
Roekel NB, Brånemark P-I. Dental Implants: Tissue-Inte-
grated Prosthesis Utilizing the Osseointegration Concept.
Mayo Clin Proc 1986;61:91–97.
27. Worthington P, Bolender CL, Taylor TD. The Swedish sys-
tem of osseointegrated implants: Problems and complica-
tions encountered during a 4-year trial period. Int J Oral
Maxillofac Implants 1987;2:77–84.
28. Sones AD. Complications with osseointegrated implants.
J Prosthet Dent 1989;62:581–585.
29. Gargiulo AW, Wentz FM, Orban B. Dimensions and rela-
tions of the dentogingival junction in humans. J Periodon-
tol 1961;31:6261–6267.
30. Vacek JS, Gher ME, Assad DA, Richardson AC, Giambar-
resi LI. The dimensions of human dentogingival junction.
Int J Periodontics Restorative Dent 1994;14:154–165.
31. Becker W, Ochsenbein C, Tibbetts L, Becker BE. Alveolar
bone anatomic profiles as measured from dry skulls. Clini-
cal ramifications. J Clin Periodontol 1997;24:727–731.
32. Kois JC. Esthetic extraction site development: The geologic
variables. Contemp Esthet Restorative Pract 1998;2:10–18.
33. Salama H, Salama M. The role of orthodontic extrusive re-
modeling in the enhancement of soft and hard tissue pro-
files prior to implant placement: A systematic approach to
the management of extraction site defects. Int J Peri-
odontics Restorative Dent 1993;13:312–333.
34. Kan JY, Rungcharassaeng K. Site development for ante-
rior single implant esthetics: The dentulous site. Com-
pend Contin Educ Dent 2001;22:221–232.
35. Spear FM. Maintenance of the interdental papilla follow-
ing anterior tooth removal. Pract Periodontics Aesthet
Dent 1999;11:21–28.
36. Jemt T. Restoring the gingival contour by means of provi-
sional resin crowns after single-implant treatment. Int J
Periodontics Restorative Dent 1999;19:21–29.
37. Klinge B, Petersson A, Maly P. Location of the mandibular
canal: Comparison of macroscopic findings, conventional
radiography, and computed tomography. Int J Oral Max-
illofac Implants 1989;4:327–332.
38. McGivney GP, Houghton V, Strandt JA, Eichholz JE, Lubar
DM. A comparison of computer-assisted and data-gather-
ing modalities in prosthodontics. Int J Oral Maxillofac Im-
plants 1986;1:55–68.
39. Schwarz MS, Rothman SLG, Rhodes ML, Chafetz N. Com-
puted tomography, Part I: Preoperative assessment of the
mandible for endosseous implant surgery. Int J Oral Max-
illofac Implants 1987;2:137–141.
40. Schwarz MS, Rothman SLG, Rhodes ML, Chafetz N. Com-
puted tomography, Part II: Preoperative assessment of
the maxilla for endosseous implant surgery. Int J Oral
Maxillofac Implants 1987;2:143–148.
41. Lindh C, Petersson A. Radiologic examination for location
of the mandibular canal: A comparison between panoramic
radiography and conventional tomography. Int J Oral Max-
illofac Implants 1989;4:249–253.
 A Multidisciplinary Approach to Single-Tooth Replacement
42. Clark DE, Danforth RA, Barnes RW, Burtch ML. Radiation
absorbed from dental implant radiography: A comparison
of linear tomography, CT scan, and panoramic and intra-
oral techniques. J Oral Implantol 1990;16:156–164.
43. Parel SM, Funk JJ. The use and fabrication of a self-retain-
ing surgical guide for controlled implant placement: A tech-
nical note. Int J Oral Maxillofac Implants 1991;6:207–210.
44. Brånemark P-I, Adell R, Albrektsson T, Lekholm U, Lindstrom
J, Rockler B. An experimental and clinical study of osseoin-
tegrated implants penetrating the nasal cavity and the max-
illary sinus. J Oral Maxillofac Surg 1984;42:497–505.
45. Jensen OT, Brownd C, DeLorimier J. Esthetic maxillary
arch vertical location for the osseointegrated cylinder im-
plant. J Am Dent Assoc 1989;119:735–736.
46. Santoro F, Maiorana C, Rabagliati MI. Long-term results
with autogenous onlay grafts in maxillary and mandibular
atrophy. J Long-Term Eff Med Implants 1999;9:215–222.
47. Samchukov ML, Cope JB, Cherkashin AM. Craniofacial
Distraction Osteogenesis. St Louis: Mosby, 2001.
48. Seibert J, Nyman S. Localized ridge augmentation in
dogs: A pilot study using membranes and hydroxyapatite.
J Periodontol 1990;61:157–165.
49. Becker W, Becker BE, Handlesman M, et al. Bone forma-
tion at dehisced dental implant sites treated with implant
augmentation material: A pilot study in dogs. Int J Peri-
odontics Restorative Dent 1990;10:93–101.
50. Nyman S, Lang NP, Buser D, Bragger U. Bone regenera-
tion adjacent to titanium dental implants using guided tis-
sue regeneration: Report of two cases. Int J Oral Maxillo-
fac Implants 1990;5:9–14.
51. Wachtel HC, Langford A, Bernimoulin JP, Reichert P. Guided
bone regeneration next to osseointegrated implants in hu-
mans. Int J Oral Maxillofac Implants 1991;6:127–135.
52. Zablotsky M, Meffert RM, Caudill R, Evans G. Histological
and clinical comparisons of guided tissue regeneration on
dehisced hydroxyapatite-coated and titanium endosseous
implant surfaces: A pilot study. Int J Oral Maxillofac Im-
plants 1991;6:294–303.
53. Mentag PJ, Kosinski T. Hydroxyapatite-augmented sites
as receptors for replacement implants. J Oral Implantol
1989;15:114–123.
54. Bain CA. Effects of smoking on failure rates of dental im-
plants [abstract from the 7th annual meeting of the
Academy of Osseointegration, February 1992]. Int J Oral
Maxillofac Implants 1992;7:123.
55. Kramer G, Mattout P, Mattout C, Mellonig JT. Clinical and
histological responses to a mixed bone/hydroxyapatite
graft: Report of a case. Int J Periodontics Restorative
Dent 1989;9:9–21.
56. Aspenberg P, Kalebo P, Albrektsson T. Rapid bone healing
delayed by bone matrix implantation. Int J Oral Maxillo-
fac Implants 1988;3:123–127.
57. Hoen MM, Strittmatter EJ, LaBounty GL, Keller DI, Ne-
speca JA. Preserving the maxillary alveolar ridge contour
using hydroxyapatite. J Am Dent Assoc 1989;118:739–741.
58. Toriumi DM, Larrabee WF, Walike JW, Millay DJ, Eisele
DW. Demineralized bone. Arch Otolaryngol Head Neck
Surg 1990;116:676–680.
59. Hjorting-Hansen E, Worsaa N, Lemons JE. Histologic re-
sponse after implantation of porous hydroxyapatite ceramic
in humans. Int J Oral Maxillofac Implants 1990;5:255–263.
60. Holden CM, Bernard G. Ultrastructure in vitro characteri-
zation of a porous hydroxyapatite/bone cell interface. J
Oral Implantol 1990;16:86–95.
61. Marshall SG. The combined use of endosseous dental im-
plants and collagen/hydroxyapatite augmentation proce-
dures for reconstruction/augmentation of the edentulous
and atrophic mandible. A preliminary report. Oral Surg
Oral Med Oral Pathol 1989;68:517–526.
62. Lazzara RJ. Immediate implant placement into extraction
sites. Int J Periodontics Restorative Dent 1989;9:333–342.
63. Ashman A. An immediate tooth root replacement. An im-
plant cylinder and synthetic bone combination. J Oral Im-
plantol 1990;16:28–38.
64. Becker W, Becker BE. Guided tissue regeneration for im-
plants placed into extraction sockets and for implant de-
hiscences: Surgical techniques and case reports. Int J Pe-
riodontics Restorative Dent 1990;10:377–391.
65. Barzilay I, Graser GN, Iranpour B, Natiella JR. Immediate
implantation of a pure titanium implant into an extraction
socket: Report of a pilot procedure. Int J Oral Maxillofac
Implants 1991;6:277–284.
66. Caudill RF, Meffert RM. Histologic analysis of the osseointe-
gration of endosseous implants in simulated extraction sock-
ets with and without E-PTFE barriers. Part I. Preliminary find-
ings. Int J Periodontics Restorative Dent 1991;11:207–215.
67. Becker W, Becker BE, Handelsman M, Ochsenbein C, Al-
brektsson T. Guided tissue regeneration for implants
placed into extraction sockets: A study in dogs. J Peri-
odontol 1991;62:703–709.
68. Simion M, Baldoni M, Polcan M. Effectiveness of GTAM
membranes with and without early exposure: A compara-
tive study [abstract from the 7th annual meeting of the
Academy of Osseointegration, February 1992]. Int J Oral
Maxillofac Implants 1992;7:121.
69. Carlsson L, Rostkund T, Albrektsson B, Albrektsson T. Im-
plant fixation improved by close fit. Acta Orthop Scand
1988;59:272–275.
70. Hurzeler MB, Quinones CR. Installation of endosseous
oral implants with guided tissue regeneration. Pract Peri-
odontics Aesthet Dent 1991;3:21–29.
71. Lazzara RJ, Porter SS, Testori T, Galante J, Zetterqvist L. A
prospective multicenter study evaluating loading of Os-
seotite implants two months after placement: One-year
results. J Esthet Dent 1998;10:280–289.
72. Palacci P. Optimal Implant Positioning and Soft Tissue Man-
agement for the Brånemark System. Chicago: Quintessence,
1995.
73. Krekeler G, Schilli W, Diemer J. Should the exit of the arti-
ficial abutment tooth be positioned in the region of the
attached gingiva? Int J Oral Surg 1985;14:504–508.
74. Flemming TF, Berwick RHF, Newman MG, et al. Effect of a
3-month maintenance program on osseointegrated im-
plants. Microbiological observations. Z Zahnarztl Implan-
tol 1990;6:45–51.
QDT 2004 19