C O N T I N U I N G E D U C A T I O N 3 4
SELECTION AND IDEAL
TRIDIMENSIONAL IMPLANT POSITION
FOR S OFT T ISSUE A ESTHETICS
André P. Saadoun, DDS, MS*
Marcel LeGall, DDS*
Bernard Touati, DDS, DSO†
While single-tooth replacement can be accomplished
with predictability using implant therapy, this procedure
is challenging in the anterior region where numerous
criteria must be evaluated by the restorative team. The
available height of bone, soft tissue volume, and three-
dimensional position of the anticipated implant restora-
tion are among the numerous concerns that must be
addressed prior to the initiation of treatment. This article
provides a comprehensive review for the selection and
placement of implants in the aesthetic region and illus-
trates these principles with a case presentation.
Key Words: implant, aesthetic, provisional, soft tissue,
emergence profile
T he single-unit implant-supported restoration has proven
to be an efficacious means of replacing a missing
tooth.1 Although this procedure appears simple to perform,
the restoration of an anterior tooth — particularly a maxil-
lary central incisor — is quite challenging. In order to
be considered successful, an implant-supported restoration
must achieve a harmonious balance between functional,
aesthetic, and biological imperatives. This concept has
resulted in the development of “restoration-driven implant
placement,”2 in which implants are positioned in relation
to the anticipated requisites of the restorative phase rather
than the availability of bone.
*Private practice, Paris, France.
†Editor-in-Chief, Practical Periodontics & Aesthetic Dentistry;
private practice, Paris, France.
André P. Saadoun, DDS, MS
12 Avenue Paul Doumer
75116 Paris, France
Tel: (011) 33-1-47-27-17-57
Fax: (011) 33-1-47-55-00-96
E-mail: andre.p.saadoun@wanadoo.fr
Pract Periodont Aesthet Dent 1999;11(9):1063-1072
SAADOUN
11
9
Restoration-driven implant therapy often requires the
NOVEMBER/DECEMBER
development of an adequate volume of osseous struc-
ture to support the implant and the soft tissue to sculpt
the prosthetic site. This restoration-generated site devel-
opment presumes that the three-dimensional configura-
tion of the prosthesis will affect the anatomical form and
tone of the free gingival margin. If implant selection and
placement are dictated by the definitive crown, then the
healing and maturation of the soft tissues are guided by
the placement of the provisional restoration at stage II to
promote ideal scalloping and papillae reformation
according to the “double-guidance concept.”3
As the ceramic crown emerges from the implant, it
should support the most coronal 4 mm of the soft tissue
— including the free gingival margin of the restoration-
gingival interface. The components of the aesthetic pro-
file comprise the osseous, gingival, and restorative triad
and their relationship to the adjacent dentition. The criti-
cal interdependence of these three components and the
necessity of systematic reconstruction of the deficiencies
within the triad cannot be underestimated if aesthetic
results are to be achieved with consistency.4
2.5 mm
1.8 mm
8.6 mm
4.3 mm
5 mm
3.6 mm
Figure 1. Diagram of ideal tooth/bone relationship with
optimal interdental alveolar bone.
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Practical Periodontics & AESTHETIC DENTISTRY

The hard tissue, however, remains the principal deter-

minant of the aesthetic outcome. Therefore, successful
and predictable results can be accomplished if the opti- 2.5 mm
mal osseous dimension is initially reconstructed to achieve 1.8 mm 2 mm
implant stability and to support the optimal gingival con-
tours that, consequently, can sustain the development of
an aesthetic restorative profile.5
Prior to implant placement, the following factors 8.6 mm
4.3 mm
should be analyzed by the implant team:
• Type of smile (ie, high, medium, or low).
• Biotype of adjacent periodontium (quality
and quantity of keratinized gingiva). 3.6 mm
• Osseous topography of the edentulous ridge
(Seibert’s Class I, II, or III). Figure 2. Diagram indicates that the minimum interproxi-
• Anticipated form, position, and type of mal bone between two adjacent implants should not be
restoration (screwed or cemented). less than 3 mm and 2 mm from the adjacent teeth.

• Surgical procedures involved in ridge

augmentation.
Failure to consider these factors will compromise the Buccal 2 mm +
aesthetic result.6 convexity implant radius

Implant Selection, Position, and Angulation G.M. Level

As the objective of implant treatment is the accurate repli-
cation of the natural dentition,7 it is critical to possess an
understanding of crown and root anatomy (Figure 1). Since
the placement of the implant within the edentulous space
significantly impacts the functional, periodontal, and aes-
thetic result, the implant must be perfectly aligned with Bone level Crown enamel
the anticipated restoration, adapted to the site, and posi-
tioned in the tridimensional space.
Figure 3. Diagram demonstrates ideal positioning of an
implant buccopalatally.
Implant Selection
Since the implant replaces the root of the missing tooth,
the transition between the properly sized implant and the Too buccally Optimal Too palatally
anatomic crown must be harmonious in order to establish
an aesthetic emergence profile. To determine the shape
and width of the crown to be replaced, the dimensions
of the contralateral tooth should be analyzed and the
root size and anatomy at the level of implant placement
should be evaluated. Implant diameter is dictated by the
corresponding root anatomy at the crest of bone. Under
normal conditions, the crest of bone appears to be 1.5 mm
to 2 mm apical to the crest of the cementoenamel junction
(CE J) of the extracted tooth or adjacent teeth. Following
the determination of crown/root size, interdental crest
width, and periodontal prerequisites, an implant of cor-
responding dimensions can be selected to provide a nat- Figure 4. Illustration of optimal implant position on the
ural emergence profile for an aesthetic restoration (Table). buccopalatal axis.

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Table
Implant Recommendation Based on Crown/Root Diameter of Maxillary Teeth
Mesiodistal at
Mesiodistal Cementoenamel
Tooth (mm) Crown Junction
Central incisor 8.6 6.4
Lateral incisor 6.5 4.7
Canine 7.6 5.6
First premolar 7.1 4.8
Second premolar 6.6 4.7
First molar 10.4 7.9
Second molar 9.8 7.6
Angulation
Angulation refers to the proper orientation of an implant
in three-dimensional space (ie, mesiodistal, buccolingual,
apicocoronal).8 In addition, the exact rotation of the hexa-
gon can be regarded as the fourth dimension — the flat
surface of the hexagonal implant should be parallel to
the buccocortical plate to allow optimal positioning when-
ever an asymmetrical prosthetic abutment is utilized. In
order to ensure proper implant angulation, a surgical
template should be utilized to transfer prosthetic para-
meters (eg, tooth position, emergence profile, gingival
margin, arch form, vertical dimension) to the surgical site.
Mesiodistal Placement
According to Adell et al,9 an implant with a diameter of
4.1 mm requires a minimum mesiodistal space of 7 mm
between two adjacent teeth (ie, 4.1 mm for the implant
and 1.5 mm of clearance on each side). The mesiodistal
position of the implant, however, also depends on the
coronal and cervical width of the replaced tooth, the prox-
imity of the adjacent roots, and the presence or absence
of diastemata. The mesiodistal implant axis should pass
by the center of the future crown and the bisecting line
angle of the adjacent roots. Moreover, a direct relation-
ship exists between the height of the interproximal bone
and the height and shape of the papillae.10
In order to develop and/or maintain the integrity
of the interdental papillae, a distance of 2 mm at the
cervical implant level is suggested as appropriate
between an implant and the adjacent teeth; this distance
should be a minimum of 3 mm between two implants.11
If the interproximal distance between tooth/implant and
two implants is less, horizontal bone loss will occur and
increase the vertical distance between the remaining cres-
tal bone and the apical proximal contact of the adja-
cent crowns. Consequently, this phenomenon jeopardizes
Saadoun
Mesiodistal at Buccolingual at
Cementoenamel Cementoenamel Recommended
Junction – 2 mm Junction Implant (mm)
5.5 6.4 4.1, 4.3, 5.0
4.3 4.7 3.25, 3.5
4.6 7.6 4.1, 4.3
4.2 8.2 4.1, 4.3
4.1 8.1 4.1, 4.3
7.0 10.7 4.1, 4.3, 5.0, 6.0
7.0 10.7 4.1, 4.3, 5.0, 6.0
the existence or may prevent the formation of the inter-
dental papilla, which compromises the definitive aesthe-
tic result. All this information should allow the selection of
the proper implant diameter by subtraction (Figure 2).
Faciolingual Placement
This orientation varies with the type of restoration con-
nection (ie, screwed or cemented). This placement deter-
mines the proximal dimensions of the crown and its
anticipated aesthetic appearance. Occlusally, the collar
of the implant should remain inside the virtual line that
connects the incisal borders of the adjacent teeth.
Cervically, the longitudinal axis of the implant should be
4 mm inside the cervical envelope of the adjacent teeth
and the external implant collar surface should be 2 mm
from the buccal contour of the adjacent teeth (Figure 3).1,8
If the implant axis is aligned with the axis of the
restoration, the crown height is the same as that of the
tooth it replaces (Figure 4). If the implant axis has a
palatal inclination, the crown exhibits a facial ridge lap
that impairs proper hygiene. In order to achieve an
acceptable aesthetic result, a palatally positioned implant
should generally be placed to a greater apical extent.
For every 1 mm of palatal positioning, the implant should
be placed an additional 1 mm apically.12 If the implant
axis exhibits a facial inclination, the implant emergence
is located coronally to the cervical contour of the adja-
cent teeth. This results in an excessively long crown,
and the collar is misaligned with that of the adjacent
contralateral tooth.13 In order to prevent a buccal angu-
lation and an improper implant/crown ratio and occlusal
relationship, it is recommended to orient the implant 5°
palatally and to place the implant closer to the palatal
cortical aspect. This also prevents and/or limits the pre-
mature resorption of the buccocortical plate, which may
occur in instances where it is too thin.9
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Day 1 implant placement 1 year postoperatively

C.T.A. 1.2 mm C.T.A. 1.5 mm

J.E. 1 mm J.E. 1.5 mm
Sulcus: 1 mm Sulcus: 1 mm

Biological width 2 mm Biological width 3 mm

Figure 5. Diagram of apicocoronal position at implant placement following tooth extraction and 1 year postoperatively.

Day 1 insertion 1 year

Apicocoronal Placement
The exact apicocoronal location of the implant shoulder
is dependent upon the cervical bone resorption mor-
phology, the diameter of the implant, the size discrep-
ancy between the root and the diameter of the implant,
the thickness of the marginal gingiva, and the proximal
tissue. The implant collar should be 2 mm apical to the
line of CEJ of the neighboring tooth if no gingival reces-
sion is evident and 3 mm from the gingival margin when
gingival recession is present. Consequently, the optimal
reference line in all instances is not the CEJ, but the bucco-
gingival contour.14 The implant should be at a maximum
of 3 mm from the gingival margin displayed in the sur-
gical guide or on the adjacent teeth (Figure 5) to allow
space for the crown to emerge from a round implant to
a triangular emergence profile and for the development
of the biological volume.15 If the discrepancy between
the tooth and the implant diameter increases, the implant
shoulder must be placed more apically to achieve an
aesthetically acceptable emergence profile.
The height of soft tissues determines the length avail-
able for the emergence profile. Long-term peri-implant
considerations, however, dictate that the sulcus should
remain shallow. While soft tissue heights of less than
2 mm are challenging for aesthetic restoration, a height
of more than 4 mm establishes satisfactory aesthetics but
has been noted to result in a deep sulcus with long-term
soft tissue complications.16
postoperatively
Gingival
recession
0.7 mm
to 1 mm C.A. 1.5 mm
3 mm J.E. 1.5 mm
Bone S.D. 1 mm
resorption
0.9 mm to
1.6 mm
Figure 6. Relationship of biological volume and gingival margin
on submerged implant at insertion and 6 months following the
subsequent abutment connection.
If the position is too apical, it will subsequently result
in the formation of an infrabony defect, a peri-implant
pocket, complications in the second phase, difficulty at
abutment connection, and excess cement at seating of
the restoration. If the position is too occlusal, it can induce
by vertical overcontour pressure a recession of the soft
tissue, a limitation in the emergence profile, and an unaes-
thetic result. A more ideal emergence profile can be
obtained when the diameter of the implant is similar to
the diameter of the tooth to be replaced.17 Therefore,
the elimination of the variations in apicocoronal implant
placement, due to emergence profile considerations and
periodontal defects, can be obtained with a properly
selected implant diameter.

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Figure 7. Orthodontic treatment can be utilized to develop or
improve implant sites (as depicted for appropriate mesiodistal
placement).
Figure 8. Buccal view of implant-supported restoration. Soft tissue
integration has been prepared by the provisional restoration placed
at implant exposure.
Since the biological height in submerged implants
is approximately 3 mm and the sulcus depth 1 mm,18 it
is critical to position the platform of the implant in rela-
tion to these biological dimensions. It is also important
to consider that the majority of the submerged implants
lose approximately 0.9 mm to 1.6 mm of crestal bone
during the first year of function.19 Care should also be
taken to maintain or reestablish a minimum of 2 mm of
buccal bone thickness.9 The apicocoronal position of the
implant and its long-term gingival marginal stability is dic-
tated by the balance between the crestal level of bone,
the biological height of the junctional epithelium and con-
nective attachment (at implant placement and 1 year
postoperatively), and the sulcus depth. It is therefore
Saadoun
necessary to augment the hard and soft tissue and place
the implant platform at 3 mm to maintain the 4 mm of
soft tissue required to allow the development of an ade-
quate emergence profile and obtain an optimal aesthetic
result (Figure 6).
Occlusal Considerations
Obtaining and maintaining a nontraumatic occlusal rela-
tionship with the opposing dentition is a decisive factor
in preserving osseointegration and, consequently, the
aesthetics of the implant prosthesis. In the authors’ expe-
rience, if the occlusal forces developed between the pros-
thetic occlusal surfaces are excessive axially or laterally,
they may induce cervical bone loss around the implant
collar, increase the gingival recession, or compromise
the gingival level and the definitive aesthetic result.20
In order to accommodate axial forces during func-
tion, an aesthetic implant position and orientation must
consider the future occlusal relation with the opposing
dentition. This can be achieved by aligning the implant
axis as close as possible to the one of the opposing teeth.
The palatal orientation of a maxillary anterior implant is
more favorable than a buccal position, which consider-
ably increases the lateral forces to be dissipated on a thin
buccal bone. In addition, an appropriate accommoda-
tion for axial forces can be made by avoiding an unfa-
vorable vertical ratio between the prosthetic crown and
the osseointegrated portion of the implant by limiting the
prosthetic overbite and overjet and by establishing a non-
traumatic occlusal relation during maximum intercuspi-
dation, incision, and mastication. This correct axis could
be achieved by reestablishing the normal bone morphol-
ogy prior to or in conjunction with implant placement.
Soft Tissue Management
In order to achieve natural soft tissue aesthetics, the con-
tour, height, and width of the gingiva at the implant site
must correspond to the soft tissues that surround the adja-
cent natural teeth. Adequate bone must exist for place-
ment of the implant, along with proper soft tissue framing
that consists of interproximal papillae and an adequate
zone of attached gingiva with the potential for tissue
augmentation. The status of the gingiva must be evalu-
ated for the diagnosis and treatment planning in order
to determine its quantity, quality, color, texture, and bio-
type (ie, scalloped or flat). It is also a prerequisite to mea-
sure the thickness of the gingiva that encompasses the
maxilla (ie, buccal 1 mm to 2 mm; palatal 3 mm to 4 mm)
and the mandible (ie, buccal and lingual 1 mm). This
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examination allows the restorative team to decide if kera-

tinized peri-implant gingiva is adequate for a single-unit
implant restoration in the aesthetic zone.
Although the presence of alveolar mucosa free of
inflammation around the submerged implant does not
appear to be required for long-term osseointegration,9
the presence of a band of keratinized gingiva appears
to be conducive to the establishment and maintenance
of aesthetics. Recession can be prevented by keratinized
gingiva, which may be less sensitive to tooth brushing
than the alveolar mucosa. While keratinized tissue is no
less sensitive to inflammation, it is less likely to recede
due to its thickness, which can also conceal the metallic
Figure 9. Occlusal view of definitive metal-ceramic implant-supported
appearance of the corresponding abutment.
crown restoration (Laboratory: Jean-Marc Etienne, MDT).
The presence of keratinized gingiva is not sufficient
in itself to ensure an aesthetic result postoperatively, but
it is a prerequisite to achieve this objective. Sufficient hard
tissue must be present, however, to support the 4 mm of
soft tissue that is required to develop and maintain the
biologic width around implants. In order to develop a
natural emergence profile for the definitive restoration, it
is essential — if soft tissue is at an adequate level or defi-
cient — to increase the keratinized tissue. It is necessary
to overcontour the soft tissues by a minimum of 2 mm to
3 mm, as they tend to recede by 1 mm during surgical
and restorative procedures.21 The guideline for this level
is an imaginary line drawn from the papillary height to
the papillary height of the proximal teeth.22 Due to 1 mm
of soft tissue recession that occurs in the 6 months fol-
lowing implant exposure, tissue volume must be increased
by an additional 20% to achieve an aesthetic gingival Figure 10. Facial view of two unaesthetic restorations on the central
marginal contour around a restoration to prevent marginal incisors following initial periodontal preparation.
level discrepancies between adjacent teeth.11 Conse-
quently, the primary objectives in the restoration of gingi-
val aesthetics are to establish an excess of hard and soft
tissues, to compensate for future resorption, and to fabri-
cate a restoration that will dictate the shape and form of
the gingiva. This overcontouring of the tissues can be per-
formed prior to stage I surgery or through hard and soft
tissue augmentation at implant insertion. Soft tissue aug-
mentation procedures can also be utilized 3 to 4 months
following implant placement and after implant exposi-
tion with a connective tissue graft or a roll technique. At
every surgical phase, the possibility of using connective
tissue grafting should be evaluated and potentially per-
formed to prepare for the aesthetic emergence profile with
limited incision or gingivoplasty and provisional restora-
tion guidance. When the definitive restoration has been
Figure 11. Surgical stent with the pilot drill in place in the socket
completed, however, the surgical potential of aesthetic following atraumatic extraction.
tissue management is severely limited.23

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Figure 12. Occlusal view demonstrates immediate placement of
5 mm abutments (Bioesthetic, Nobel Biocare, Yorba Linda, CA).
Figure 13. Postoperative retroalveolar radio-
graph demonstrates the optimal connection
between implants (Replace, Nobel Biocare,
Yorba Linda, CA) and healing abutments.
Figure 14. Facial view of marginal gingival contour after removal of
both abutments. Note the scalloping of the tissue and maintenance
of the central interdental papilla.
Saadoun
In certain instances, orthodontics may be utilized
to provide an alternative solution (Figures 7 through 9).
This can be achieved when the root socket is moved
coronally to allow bone regeneration in the defect. The
resultant modification in soft tissue topography is con-
comitant with the change in the osseous configuration.
The proximal papilla can be preserved at implant
placement by excluding them from the flap design using
two proximal divergent incisions (although healing scars
could remain) or by immediate implant placement after
extraction without flap elevation through sulcular incision.
Implant exposure is more complex to realize in the
aesthetic area. Uncovering the implant can be accom-
plished by using the palatal flap design or by using a
soft tissue punch to minimize tissue reflection. The soft
tissue punch is primarily indicated when adequate ker-
atinized attached gingiva and intact papillae are pre-
sent to achieve optimal soft tissue architecture.24 Gradual
tissue expansion can be performed with a small abut-
ment and then the provisional restoration at the subse-
quent treatment stage to transfer the gingival margin to
the master model. The expansion ensures that restorative
dimensions are increased progressively below the gin-
gival tissues to provide for a proper emergence profile
and to establish contours that are aesthetic and con-
ductive to hygiene procedures.5
Immediate placement of the implant in a single-
stage surgery should be considered when the tooth to
be replaced is still in the socket because the potential of
successful peri-implant tissue management is optimal. The
implant and a contoured healing abutment can also be
placed in a single-stage approach to facilitate margin
closure, maintain ideal soft tissue morphology, and pre-
vent soft tissue collapse.25 As this one-stage surgical
approach also minimizes surgical trauma and decreases
the duration of treatment, this procedure has a significant
role in the soft tissue development and restoration of the
site. The use of a one-stage nonsubmerged implant with
an anatomical healing abutment (eg, Bioesthetic, Nobel
Biocare, Yorba Linda, CA) can also achieve a proper
three-dimensional fit that may aid in the support and shap-
ing of the gingival tissues (Figures 10 through 13).
Provisionalization and Prosthetic Stage
The patient’s goal for treatment is not the implant place-
ment itself, but the functional and aesthetic restoration.
Since aesthetics is critical, the placement of a customized
provisional restoration allows the tissue to heal in the exact
cervical contour and emergence profile of the definitive
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prosthesis. When the soft tissues are not adapted to the

provisional restoration, the incision should facilitate del-
icate exposure to provide for any necessary augmen-
tation or adjustment of soft tissue defects (Figures 14
through 16). All biological, functional, and aesthetic objec-
tives must be achieved in the provisional phase prior to
the placement of the definitive restoration.
The objective of the prosthetic phase is to use a pro-
visional restoration that has the optimal form of the desired
restoration to develop the restorative gingival interface
and the prospective prosthetic recipient site. Once the
soft tissues have been molded by the refined provisional
crown and have become stable following 6 months of
Figure 15. The prosthetic abutments (Bioesthetic, Nobel Biocare,
healing, the subgingival peri-prosthetic envelope is trans- Yorba Linda, CA) are subsequently screwed in correct orientation.
ferred to the final laboratory model using a customized
impression coping, flowable composite resin, and low-
viscosity polyvinylsiloxane according to the “prototype
duplication concept.”5 A well-adapted cervical contoured
metal-ceramic abutment is subsequently screwed to the
implant, and the definitive ceramic restoration is cemented
(Figures 17 and 18).

Discussion
An understanding of the biological variables and perio-
dontal implications enables the precise selection and
placement of the implant and the determination of the
timed sequences of peri-implant tissue management. A
correlation between marginal bone loss at adjacent teeth
and the horizontal distance between the implant and
the tooth has been established by radiological evalua-
tion. As this distance is decreased, bone loss is increased Figure 16. Facial view of nonfunctional provisional composite
— particularly in the lateral maxillary incisor region.26 restorations at insertion 6 weeks following surgery (Laboratory:
Marc Leriche, CDT).
With a horizontal distance of 0 mm to 1 mm, the aver-
age vertical bone loss was 2.22 mm postoperatively
and 0.14 mm 1 year following the placement of the
crown restoration (Figure 19).
A positive correlation between the interproximal dis-
tance and the presence of infrabony pockets has also
been noted. The frequency of infrabony pocketing is
higher with increasing interdental distance.27 Two infra-
bony pockets in the same region were present only if the
interdental distance was greater than 3.1 mm. When the
distance exceeded 4.6 mm, no further increase of
infrabony pocket frequency was observed (Figure 20).
Therefore, crestal bone loss increases by 1 mm when
the interdental distance between two implants is equal
to or less than 3 mm,11 and less than 2 mm between the
implant and the adjacent tooth.26
Figure 17. Customized metal-ceramic abutments were screwed
Consequently, it would be necessary to maintain a onto the implants.
minimum of 2 mm of bone between the implant collar

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 Saadoun

and the proximal cervical surface of the adjacent teeth

and provide a minimum of 3 mm of bone between the
lateral surfaces of two adjacent implants.11 Implant diam-
eter selection would then be determined by the interproxi-
mal distance, which can be observed on well-aligned
natural teeth with healthy periodontia. The vertical aspect
of implant placement should be established 3 mm apical
of the anticipated buccogingival margin.
It has been demonstrated that the crestal peri-implant
bone changes around submerged and nonsubmerged
implants were not significantly different following a period
of osseointegration and abutment connection.28 With non-
submerged implants, the greatest bone loss occurred
Figure 18. Postoperative facial view of the definitive implant-
supported restorations. Note the buccogingival contour, the height, immediately after implant placement; bone levels remained
and the position of the central proximal papilla. consistent following the osseointegration period. Using
submerged implants, minimal bone loss was evident fol-
lowing insertion and osseointegration. Following reentry
surgery and attachment of the transmucosal abutment,
additional bone resorption had occurred. The rate of
peri-implant bone loss was similar to the trends docu-
mented during the postsurgical healing period. When
2.4 mm 1.2 mm the coronal extent of the soft tissue and the bone level
around the submerged and nonsubmerged implants were
compared, no statistically significant differences were
detected. The apical extension of the epithelium and
the quantity of connective tissue, however, did differ
between implant types. In submerged implants, the api-
cal extension of the epithelium was always located below
≤ 1 mm ≤ 2 mm the implant-abutment gap, which resulted in a greater
connective tissue contact at the implant surface. It was
Figure 19. Illustration of interproximal bone resorption 1 year
following implant placement. speculated that this apical position of the junctional epithe-
lium was the result of microbiological contamination by
microleakage and/or micromovements. In contrast, the
connective tissue surrounding the nonsubmerged implants
Day 1 insertion 1 year postoperatively resembled the dimensions of the natural dentition. The
combined epithelium and connective tissue contact was
2.95 mm on the submerged implant and slightly greater
than the 2.62 mm observed on nonsubmerged implants.18
The interproximal height of bone and the presence
or absence of a full papilla are related to each other
and contribute to the definitive aesthetic outcome. The
distance between the bone crest and apical contact point
between the teeth or crown restorations should not exceed
Interproximal Vertical bone loss 5 mm.10 These values can be applied as a guide for the
implant distance Infrabony defect bone regeneration process and the restorative phase in
> 3.1 mm implant patients with anatomical deficiencies. Conse-
quently, the level of the bone itself — due to the expected
Figure 20. Diagram of implant in site with 3.1 mm of proximal bone
at placement and 1 year postoperatively. Note the two shallow resorption — must be increased by 2 mm in order to
infrabony defects present. support the gingival margin and the interproximal papilla

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that are necessary for aesthetic development. The flat
regenerated marginal bone could be reshaped in sub-
sequent stages to establish a normal scalloping prior to
implant placement.
In addition, the soft tissue generally recedes at each
stage of implant surgery. The buccal recession of the gin-
gival margin three months following abutment connection
in first- or second-stage surgery reaches 0.75 mm at six
months and 0.90 mm at one year.11 Therefore, the soft tis-
sue should be overcontoured during the provisional phase
(approximately 6 months following abutment connection
surgery) which, along with keratinized soft tissue attach-
ment around the implant site, have been proven to be
necessary to establish a stable long-term gingival margin.
Conclusion
The development and maintenance of the aesthetic hard
and soft tissue complex are important — particularly
when implant treatment is performed in the aesthetic
zone. The site selected for the implant must be guided
in the mesiodistal, apicocoronal, and buccolingual dimen-
sions by the anticipated restoration. The essence of any
aesthetic implant restoration remains the initial site devel-
opment.29 The volume of the osseous support must allow
the implant to be placed in the ideal situation, while the
soft tissue morphology must mimic that of the adjacent
teeth following the anticipated recession.
Implant selection and the interdental papilla volume
(height and width) are determined by the implant’s
mesiodistal position. The length of the crown restoration is
indicated by its buccopalatal orientation. The emergence
profile and peri-implant pocket depth are influenced by the
apicocoronal location. The histological variation of the
biological volume at bone level and the clinical change
of the gingival margin between the phase of the implant
placement and 6 months after implant exposition should
be considered in the selection of the implant diameter
and for adequate treatment planning to achieve an opti-
mal aesthetic aspect for the implant-supported restoration.
The cervical contour of the provisional restoration
determines the shape of the buccal gingiva and height of
the interdental papillae. Finally, the ceramic restoration
must possess a form that complements the surrounding
tissues, facilitates proper plaque control and occlusal
function, and presents a harmonious natural appearance.
Acknowledgment
The authors mention their gratitude to Dr. Mario Groisman,
Brazil, for his contribution in the discussion.
1072 Vol. 11, No. 9
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CONTINUING EDUCATION CE 34
CONTINUING EDUCATION

(CE) EXERCISE NO. 34 NEW YORK UNIVERSITY

College of Dentistry
Center for Continuing Dental Education
New York City, NY

To submit your CE Exercise answers, please use the answer sheet found within the CE Editorial Section of this issue and
complete as follows: 1) Identify the article; 2) Place an X in the appropriate box for each question of each exercise; 3) Clip
answer sheet from the page and mail it to the CE Department at Montage Media Corporation. For further instructions,
please refer to the CE Editorial Section.
The 10 multiple-choice questions for this Continuing Education (CE) Exercise are based on the article “Selection and
ideal tridimensional implant position for soft tissue aesthetics” by André P. Saadoun, DDS, MS, Marcel LeGall, DDS,
and Bernard Touati, DDS, DSO. This article is on Pages 1063-1072.

Learning Objectives:
This article reviews and describes the importance of utilizing restoration-driven therapy for accurate implant placement.
Upon reading and completion of this exercise, the reader will possess:
• A heightened awareness of the role of the soft tissues in aesthetic implant restorations.
• An understanding of the functional and aesthetic factors that influence implant placement.

1. As the ceramic crown emerges from the
implant, it should support:
a. The most coronal 4 mm of the soft tissue.
b. The most incisal 7 mm of the soft tissue.
c. The most coronal 7 mm of the soft tissue.
d. The most incisal 4 mm of the soft tissue.
6. Faciolingual placement and orientation
determines:
a. Length of the implant collar surface.
b. Definitive aesthetic result.
c. The proximal dimensions of the crown.
d. Implant emergence.

2. All the following factors must be considered
prior to implant placement EXCEPT:
a. Type of smile.
b. Potential height of the replacement crown.
c. Osseous topography of the edentulous ridge.
d. Surgical procedures necessary for adequate
site preparation.
3. The dimensions of the contralateral dentition
must be analyzed in order to:
a. Determine the length of the crown to be
replaced.
b. Analyze the root position.
c. Analyze the edentulous ridge.
d. Determine the shape and width of the crown
to be replaced.
4. Cervical bone resorption morphology is a
factor in determining the:
a. Mesiodistal placement of the implant collar.
b. Faciolingual placement of the implant shoulder.
c. Gingival placement of the implant collar.
d. Apicocoronal placement of the implant shoulder.
5. Optimal implant placement within an edentu-
lous site affects all the following EXCEPT:
a. Facial aesthetics.
b. Periodontal health.
c. Implant longevity.
d. Occlusal function.
7. In order to maintain the integrity of the inter-
dental papillae:
a. 1 mm must be maintained at the cervical
implant level.
b. A distance between 3 mm and 4 mm must be
maintained between two implants.
c. 5 mm must be maintained at the cervical
implant level from the adjacent teeth.
d. A distance between 5 mm and 7 mm must be
maintained between two implants.
8. If the soft tissue is at an adequate or deficient
level, keratinized tissue must be increased to:
a. Develop a natural emergence profile.
b. Support the 6 mm of soft tissue required
to maintain biologic width.
c. Prevent bone loss.
d. Ensure an aesthetic result.
9. Proper angulation involves orientation of the
implant with regard to all the following EXCEPT:
a. Ridge morphology.
b. Hexagonal rotation.
c. Mesiodistal placement.
d. Apicocoronal orientation.
10. What is the objective of the prosthetic phase?
a. To achieve the definitive restoration.
b. To develop the restorative-gingival interface.
c. To support contoured healing.
d. To achieve cementation of the crown molding.

1074 Vol. 11, No. 9