Damned if we do and damned if we don´t

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Damned if we do and damned if we don ́ t part
II. Adverse effects of implant treatment in the
combined orthodontic-restorative...
Working Paper · April 2017
DOI: 10.13140/RG.2.2.11793.02409/2
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Katja Kritzler, DDS; Ulrich Kritzler, DDS; Theodosia Bartzela, DDS, PhD
1
Topical Review
Damned if we do and Damned if we don ́t Part II.
Adverse Effects of Implants in the Combined Orthodontic-Restorative Treatment
of Maxillary Lateral Incisor Agenesis. Review of an Esthetic Dilemma.
Objectives: To document and evaluate the literature regarding esthetic outcomes of
implant restorations in the anterior maxilla in cases of missing teeth, to provide
guidelines for clinicians and to articulate questions to be answered by future research.
Data Sources: The available dental literature in English language was scrutinized in
MEDLINE and a hand search was conducted by two independent reviewers in order to
isolate articles published between January 1970 and January 2017.
Results: Treatment failures and complications of dental implant treatment should be of
special consideration in circumstances where esthetic is the overriding concern. At
present, it seems not possible to predict when, in what extend, or which patients will
have soft- and hard-tissue changes around implants in cases of maxillary lateral incisor
agenesis. If esthetic complications occur, they are usually difficult or impossible to
manage. Conclusion: In order to avoid failures and complications and to establish
optimal treatment goals and results the planning for implant placement in the anterior
maxilla should be done with caution not only in adolescents but also in adults prior to
the fourth decade of life. Implants in the anterior maxilla should be generally avoided in
females and cases of males with narrow teeth and therefore short distance between a
planned implant and the adjacent teeth. Current therapeutic concepts have to be
considered as not being based on high levels of evidence. We need more research on
basic level and clinical follow-up studies of large samples to make evidence-based
decisions.

Introduction
The management of maxillary lateral incisor agenesis plays an important role in
dentistry because of the value of the anterior teeth in smile esthetics and function. The
clinical management requires a complex and multidisciplinary treatment approach.
Missing or peg-shaped maxillary incisors can be present both unilaterally and

2
bilaterally. A genetic contribution to agenesis is well recognized, with geographic
variation and a female predilection.1,2

The reestablishment of esthetics is a challenging process in the oral rehabilitation of
children/adolescents with maxillary lateral incisors agenesis. The treatment goal
should be to establish a good situation from an esthetic as well as a functional and
psycho-social viewpoint with the need of minimal replacement of the missing teeth by
prosthodontic treatment.3 Preservation of the deciduous canines or autologous
transplantation of teeth3, or space closure by early extraction of the deciduous lateral
incisors and guided eruption of permanent canines followed by orthodontic treatment
should be some treatment alternative (or the proposed treatment). However, several
new treatment modalities have been introduced, including canine substitution and
mesialization of the complete posterior dentition faciliated by skeletal anchorage or
space opening and replacement with dental implants. This implies early
multidisciplinary treatment planning. In order to cover the dental and esthetic needs of
the patient with missing laterals several dental specialities (the general dentist,
prosthodontist, periodontologist, oral maxillofacial surgeon, and orthodontist) have to
work together in order to determine the treatment approach. The interaction between
the patient/ parent, and the previous mentioned dental disciplines is the key factor for
satisfactory results.4-20

Current therapeutic concepts have to be considered as not being based on high levels of
evidence. RCT studies and alas systematic reviews on the treatment of agenesis of
maxillary lateral incisor are missing and the published narrative reviews are inconclusi-
ve.8,21-23

In literature treatment alternatives for agenesis of maxillary lateral incisors have been
extensively discussed. Clinicians nowadays may choose between two main treatment
approaches:

• Opening of the space created by the congenital absence followed by the
placement of some type of prosthodontic intervention (removable partial
dentures or fixed bridgework, or implants)4,12,20,24-42 or autotransplantation of
the developing maxillary premolar(s)43-47 or

3
• Space closure via canine substitution. Canine(s) and first premolar(s) should be
reshaped to resemble and function as lateral incisor(s) and canine(s),
respectively.14-16,48-62

The dental and skeletal maturation, occlusion, number and location of existing teeth and
facial and dental esthetics have been postulated as important factors for decisions on
space closure or replacement. Each treatment option has been reported to have its own
advantages, disadvantages, indications, and limitations.

Featuring the treatment of maxillary lateral incisor agenesis in the existing literature the
best available evidence on long term stability of single tooth implants in the anterior
maxilla in terms of the level of occlusion and health of the periodontal tissue has not
been critically appraised. In order to provide the best information for clinical decision-
making all knowledge previously available from retrospective studies or animal
experiments as well as knowledge based on years of clinical experience should be
included. The appraised literature must enclose all available evidence in the field of
orthodontics and the fields of prosthodontics, periodontics and craniofacial growth
when making clinical decisions.

Materials and methods

The focused PICO (population, intervention, comparison and outcome) question of the
present topical review was whether the aesthetic outcome of implant treatment is
similar to that obtained by canine substitution, where hard and soft tissue ar-
chitectures “remain in a natural state that can better respond to the change over
time”.40

It was the intention of the authors to determine whether or not the available literature
offers enough scientific data to qualify both treatment approaches as equivalent.

4
Search strategy and study selection
An electronic MEDLINE search was conducted by two independent reviewers in order to
isolate English language articles, published in dental journals between January 1970 and
January 2017, reporting on treatment of missing maxillary incisors, accomplished by
prosthodontic intervention with implants. The following search limits were activated:
human; anterior maxilla; missing tooth; single tooth implants; clinical trial; systematic
review; meta-analysis; randomised controlled trial; controlled clinical study;
prospective / retrospective study; review; case reports. The search was supplemented
with manual searches of full-text articles identified by the electronic-search. Hand
search from journals (orthodontic, prosthodontic, periodontal) published between
January 2012 and January 2017 were perused to identify additional relevant
publications.

All available evidence was appraised. No randomised controlled trials could be
identified. Prospective, retrospective, cross-sectional and case series studies retrieved
through the electronic- and hand-searches were the basis of this topical review. All
studies that did not meet the above-set criteria, including in vitro studies, animal
studies and clinical studies reporting on implant treatment in other locations, were
excluded.

Full texts were obtained, when the abstracts met the inclusion criteria.

Results

Crown Esthetics / Implant Submersion
It is undisputed that the processes of facial growth and changes in the dental arches
continue post adolescent into adulthood.63,64 In adults, in the dentoalveolar region,
significant increments of all dimensions except overjet and overbite can be found,
indicating an eruptive movement of the teeth and a vertical development of their
investing tissues. At the same time posterior rotation of the mandible (especially in
females) and uprighting of the upper incisors may occur.65,66

5
A continuous increase of palatal height up to adulthood seems to be an effect of a slow
continuous eruption of the teeth.67
In adults facial development, continuous tooth eruption, and mesial drift of teeth have
been identified as compromising factors for implant placement.23,67 Therefore, occlusion
should be regarded as a dynamic rather than a stable interrelationship between facial
structures.67
Osseointegrated dental implants, like ankylosed teeth, alter position as growth-related
changes occur within the jawbones. In the upper incisor region infraocclusion may
occur, especially for lateral incisors, due to slight continuous eruption of adjacent teeth
and craniofacial changes postadolescence.68 Adults who had received single implants
may exhibit major vertical steps resulting from osseointegrated fixtures.69
Various signs of infraposition of single-implant restorations were observed in long-term
follow-up studies.70,71 Females seem to be at a higher risk of implant infraposition.72,73
They show a significantly higher incidence of tooth movements adjacent to implants and
significantly greater increase of anterior face height and posterior rotation of the
mandible.72,74 Infraposition scores and facial shape may be related, indicating a link
between “long-face” appearance and a higher risk of infraposition.72

Fig 1. Typical clinical photo of a submerged implant supported restoration at 6 year follow up (after below),
courtesy Dr. Devorah Schwartz-Arad, Ph.D., DMD | Schwartz-Arad Surgical Centers, Ramat Hasharon /
Ha'saron / Israel

6

The rate of implant submersion varies with age. This phenomenon is much more
conspicious during the second and third decade of life as compared with the fourth and
fifth.70 Little knowledge is available on the biological mechanism behind this pattern.
In implant supported prosthodontic rehabilitation the most common reason for crown
replacement was infraposition of the implant crown.75 Based on objective parameters
baseline esthetics was considered poor.76,77

Health care providers should inform patients about the compromise intraoral esthetics
and function induced by continued growth and may require unpredictable future
corrective action.78

Mucosa Esthetics / Periodontal Health
It has been postulated that orthodontic space closure patients had better periodontal
health in comparison with implant substitution patients.71,79 Furthermore it is obvious
that the peri-implant mucosa has a significant influence on the esthetic result of the
dental implants.80

In the literature, there is a great diversity regarding parameters, methods and
measurement units used for assessment of esthetics in implant dentistry and there is a
strong need for a consensus on objective and well defined criteria.81

It should be undisputed that mucosa esthetics should be judged by the following esthetic
parameters 82:
• inter-dental papilla shape: papilla filling in the entire proximal space and/or in
good harmony with the adjacent papillae
• free gingival margin: accurate form in harmony with adjacent teeth
• attached gingiva appearance: occlusal-gingival height of attached gingiva similar
to neighboring teeth with stippled appearance
• smile line: in harmony with restorations.

7
For maximal esthetics, the soft tissue thickness at the buccal aspect of the implant sites
and the height of the papillae appear to be the key factors.83

There is general consensus that the papillae adjacent to the single-unit implant
supported crown should mimic those of a healthy tooth, both in height and embrasure
fill. In addition, a harmonious gingival line without abrupt changes in tissue height and
intact papillae should be preserved.84

Because the dimensions of peri-implant soft tissues are relatively constant, the
underlying bone structure plays a key role in the establishment of esthetic soft tissues in
the anterior maxilla. Two anatomic structures are important: the bone height of the
alveolar crest in the interproximal areas and the height and thickness of the facial bone
wall. The interproximal crest height is playing a role in the presence or absence of peri-
implant papillae.84,85

Papillary height is therefore dependent on interdental bone crest preservation. The
chance of a complete papilla fill will be improved with increased facio-lingual thickness
of the papilla base and decreased distance between the contact point between the
crowns and the bone level at the tooth.85 In single tooth gaps, the bone height at
adjacent teeth determines the status of the papilla.84

The reported periodontal problems include recessions, black triangles, and the color and
texture of the peri-implant soft tissue. If esthetic complications occur, they are usually
difficult or impossible to manage.26,86,87

Regarding soft tissue stability and contours around anterior implant restorations buccal
soft tissue shrinkage can lead to black triangles, which are even more pronounced
between adjacent implants (17). This soft tissue deficiency of 1 to 2 mm arises from the
biological width around an implant being in some types of implants apical to the
platform for the abutment,88 which is then found subcrestally instead of supracrestally,
as is the case in natural teeth.89

Marginal bone loss around the adjacent teeth and bone loss buccally to the implants may
occur.68,73 Bone level alterations may be associated with different implant types

8
containing an internal conical implant-abutment connection, a rough neck surface
design, including microthreads, and platform switching.90-92

Mean marginal bone level changes of 0.24mm (Astra Tech Dental Implant System), 0.48
mm (Straumann Dental Implant System) and up to 0.75 mm (Branemark System), have
been reported.92 A possible reason for this difference might be micro movements
between abutment and implant 93 or the design of the implant shoulder (different
retention elements and roughness of neck surface).94-97

Although rough surface implants induce statistically significant more bone loss the
clinical impact of surface roughness on bone loss seem to be limited.98 A tendential
higher bone loss might be expected by implants with a reduced diameter in the anterior
region when they are placed below the bone crest.99 Independent of surface or implant
brand, bone loss above 3 mm occurs in less than 5% of all implants after at least 5 years
in function. Moreover, a recent meta-analysis indicates that co-factors such as smoking
or periodontal disease increase the risk for bone loss.98

Assessing the long-term soft tissue height changes on the facial surfaces of dental
implants the majority of implants may show 1 mm or more of soft tissue recession.100
The evaluation of a tooth-bound edentulous site should include periodontal examination
and probing, ridge mapping, bone sounding, and gingival biotype.101 Soft-tissue
examination before implant procedures is of great importance in determining the
predictability of a treatment approach.102 It should include the assessment of the
gingival biotype of the implant site and adjacent teeth. Gingival thickness, keratinized
tissue, and bone morphology showed a positive association with biotype categories.103,
104,105

A soft tissue thickness threshold of 2mm is required to mask the appearance of
prosthetic materials on implant-supported restorations.106-108

A thin biotype, with a highly scalloped gingival architecture, has a reduced soft tissue
thickness when compared with a thick biotype featuring blunted contours of the
papillae. There is a strong correlation of thin biotype with the presence of bone

9
fenestrations and dehiscence. Moreover, a thin biotype is susceptible to soft-tissue
recession after surgical procedures.101 Patients with a thin gingival morphotype are
more difficult to treat because the implants will need to be placed closer to the palate
and deeper to provide for proper emergence. Thus, the potential for loss of inter-
implant tissue is increased and results in a “black triangle” and/or broad contact
points.84

Fig. 2 Fig. 3
Fig 2. and Fig 3. Adverse effects on soft tissue esthetic by bone loss, papilla loss, discoloration of gingiva
and dehiscence in a young adult.

In patients with thin biotype implant supported restorations may cause more visible
color changes of the peri-implant mucosa.79,109-113 This peri-implant soft tissue
discoloration is due to the shine through effects of restorative materials (Titanium
abutments, crown margins) in the anterior maxilla, with the thickness of the buccal bone
plate and/or soft tissue having a major impact. The resulting esthetic deficiencies may
be unacceptable to patients and clinicians. In cases involving thin gingival biotypes,
abutment color can help to restore the correct color match between peri-implant
mucosa and natural teeth, thus avoiding additional surgery.114

The peri-implant soft tissue around zirconia abutments demonstrate a better color
match to the soft tissue at natural teeth than titanium. This underlines that the abutment
as part of the final reconstruction offers options to optimize the esthetic outcome.115
Further efforts need to be undertaken to to minimize the soft tissue discoloration at
implant sites independent of the soft tissue thickness.

10
Conversely, a thick gingival biotype has a low-scalloped thick soft tissue, square teeth,
small gingival embrasure spaces, and long contact surfaces positioned at the middle
third of teeth. This biotype is more resistant to recession after surgical manipulation of
soft tissue.101 The thicker mucosa implies a significantly more favorable papilla fill.116

Unfortunately, the final peri-implant biotype after implantation may be influenced by
several factors including implant type, implant orientation, and possible hard and soft
tissue augmentation.117 Soft tissue changes at the site level may occur irrespective of
the possibly thick biotype at the patient level, thus impairing the final esthetic outcome
at the implant site.117

Fig 4. Adverse effects of implant treatment in the esthetic zone of the anterior maxilla regarding inter-
dental papilla shape, free gingival margin, attached gingiva appearance and smile line which are difficult or
impossible to manage

It can be concluded that proper management of soft tissue around implants may be a
key factor to improve esthetics and long term-maintenance. The presence of at least 1-2
mm of keratinized peri-implant tissue may be beneficial to reduce plaque accumulation,
gingival inflammation and the risk of mucosal recession.118
Assessing the long-term soft tissue height changes on the facial surfaces of dental
implants the majority of implants may show 1 mm or more of soft tissue recession.100
Sites with congenitally missing teeth often have deficient thickness and width of
keratinized mucosa. Augmentation of both the keratinized mucosa and osseous tissues
is frequently necessary.101

11
Implant Positioning / Space Requirements
Patients with missing maxillary lateral incisors have reduced mesio-distal tooth widths.
Especially Caucasian females may be showing smaller anterior maxillary teeth
compared to control subjects.2,119,120 In patients with ideal occlusal relationships and
agenesis of the maxillary lateral incisor, space creation for prosthodontic restoration of
the lateral incisor might be difficult to obtain.120
Narrow-diameter implants of 3.3 to 3.5 mm are well documented in all indications.
Smaller implants of 3.0 to 3.25 mm and mini-implants < 3.0 mm in diameter are well
documented only for single-tooth non-load-bearing regions. Success rates, long-term
follow-up times > 1 year and information on patient specific risk factors (bruxism,
restoration type) are missing.121
Because of the smaller edentulous space, it may be difficult to obtain an ideal mesio-
distal distance for implant placement in the anterior region with any type of
contemporary implants.122

Discussion

Esthetic failures can be caused by inappropriate implant positioning and/or improper
implant selection. Placement of implants in a correct 3-dimensional position is a key to
an esthetic treatment outcome regardless of the implant system used.84

It has been a general consensus that a precise preoperative evaluation of alveolar
dimension at the future implant site is very important to develop an appropriate
placement strategy and to preserve adjacent anatomical structures. In the anterior
maxilla, implant placement presents more challenges due to the demand for well-
anchored implant as well as for satisfactory esthetic result.84,124
The average alveolar dimension at anterior maxilla is approximately 18-19 mm in height
and 8-9 mm in width. Further tissue deficiencies in the anterior maxilla of patients with
lateral incisor agenesis may be related to a narrow alveolar crest and/or undercut of
alveolar process. At least one third of maxillary anterior teeth have buccal undercut
with various depth and location. Careful treatment planning with CBCT has been
recommended for successful implant placement, especially at the lateral incisor region
due to limited availability of alveolar bone125 and it can be concluded that cone beam

12
computed tomography imaging is an established radiographic modality in treatment
planning for dental implants.126

When available, multiple patient-related data sets (e.g., CBCT, intraoral and laboratory
scans, virtual planning of implants and restorations) should ideally be integrated to
maximize their synergistic diagnostic value. This procedure can also be used to virtually
visualize specific patient outcomes. This can be helpful in exploring patient’s
expectations and providing information regarding limitations to the clinical outcome. To
allow exchange and integration of various data sets, clinicians should preferably use
devices and software applications that offer fully compatible data transfer.127
It has to be ensured that the implant is placed in the correct restoratively determined 3D
position. The implant should be placed: (i) in the mesiodistal direction, at least 1.5 mm
away from the roots of adjacent teeth; (ii) in the coronoapical direction, between 2 and 3
mm (depending upon the design of the implant) apical to the anticipated mucosal
margin of the implant restoration; (iii) in the orofacial direction, at least 1.5–2.0 mm
palatal to the facial curvature of the arch or point of emergence at the level of the
mucosal margin.122

One increasing complication around osseointegrated implants in function is the
development of peri-implant mucosal recessions. Despite the fact that, in most cases,
mucosal recessions do not significantly influence long-term implant maintenance, their
presence can affect the esthetic outcome and patient satisfaction.128 Several factors,
such as the thickness of hard and soft tissues surrounding the osseointegrated implant,
incorrect implant positioning122 and/or the quality of prosthetic reconstructions, appear
to play a role in the etiology of mucosal recessions.128
Improper orofacial positioning with the implant shoulder to far facially will result in a
potential risk for soft tissue recession, because the thickness of the facial bone wall is
reduced by the malpositioned implant. Implants placed too far palatally can result in
emergence problems. Placing the implant in mesiodistal direction too close (<1,5 mm)
to the adjacent tooth may cause resorption of the interproximal alveolar crest to implant
level leading to a reduction in papillary height. The resulting poor embrasure will
require a restoration with a long connector and compromised esthetics. If the implant is
not inserted deep enough into the tissues, the metal shoulder may be visible. If it is

13
positioned too deep it can cause recession of the facial mucosa in cases with a thin
buccal wall or lead to a persistent inflammation of the peri-implant mucosa.122
In females, because of the smaller edentulous space in cases with maxillary incisor
agenesis it may be difficult to obtain an ideal mesio-distal distance for implant
placement in the anterior region with any type of contemporary implants.2,120,122
Dental tissues are unforgiving when it comes to achieving ideal esthetic results with
dental implants, and seemingly minor errors in judgment and execution of treatment
regarding to implant position and soft and/or hard tissue augmentation procedures can
have profound negative implications.122

In conclusion esthetic complications can be caused either by malpositioned implants, by
an inappropriate size of the utilized implant, by a peri-implant infection progressively
leading to the destruction of peri-implant bone, or by pre-existing bone or soft tissue
deficiencies in the alveolar process.122,128

There is a risk of long-term biological and technical complications accompanying the
prosthodontic implant rehabilitation. Sufficient clinical training to achieve advanced
skills and experience level for daily practice with implant surgery may be needed to
avoid implant complications or failures. Experience, skills and judgement seem to affect
the clinical outcome of implant surgery.128,129

Last but not least disuse bone atrophy under semipermanent partial denture prosthesis
may develop because several years must elapse between completion of orthodontic
treatment in adolescence and implant placement.84 Aſter successful orthodontic
opening of the implant space, the central incisor and canine roots may reapproximate
during retention and prevent implant placement and retreatment and orthodontic space
reopening may be needed.123

At present it seems not possible to discuss or predict either when, to what degree, or in
which patients long term unesthetic soft- and hard-tissue changes around implant-
supported crowns in the anterior maxilla will occur in cases of maxillary lateral incisor
agenesis treated with implants.58

14
If there is a need for space opening in young patients, it may be preferable to open the
spaces posteriorly and place implants in the premolar region of the maxilla.

In addition the best available evidence on long term esthetic stability shows that
patients with congenitally missing maxillary lateral incisors treated with space closure,
first premolar intrusion, and canine extrusion are periodontally healthy 10 years after
treatment. It could be confirmed that the intrusion of the first premolar and the
extrusion of the canine in these patients did not increase the risk of periodontal tissue
destruction and attachment loss in the long term and no significant difference with
regard to occlusal function was found between the patients whose premolars and
canines were moved mesially and vertically to close spaces and the orthodontically
treated patients with intact dentitions.130

Conclusions

Awareness of the risk of treatment failures and complications is required as implant
treatment outcomes are not as predictable as treatment outcomes of conventional
therapies, particularly, in circumstances where esthetic considerations are of overriding
concern. Due to eruptive movement of the teeth, vertical development of their investing
tissues, posterior rotation of the mandible and uprighting of the upper incisors
throughout life, clinicians should refrain from placing implants in the anterior maxilla of
females. Males are less prone to implant submersion but cases with narrow teeth should
be treated with caution. Esthetic failures can also be caused by inappropriate implant
positioning and/or improper implant selection and minor errors in judgment and
execution of treatment regarding the position of the implant and the soft and/or hard
tissue augmentation procedures can have negative implications. If esthetic
complications occur, they are usually difficult or impossible to manage. In order to avoid
failures and complications and to establish optimal treatment goals and results implant
placement in the anterior maxilla should be done with caution not only in adolescents
but also in adults prior to the fourth decade of life. In cases of missing (lateral) incisors
in children / adolescents with demand for orthodontic treatment a predictable long-
term aesthetic and functional outcome with a natural, healthy tooth-like appearance in
the anterior maxilla seems to be easier achievable without implants. Proper orthodontic

15
space closure using skeletal anchorage is a low risk procedure, and from a periodontal
standpoint is safer than prosthetic replacements. In comparison to implant treatment
canine substitution may be accompanied by only minor adverse effects. With the aid of
esthetic dentistry the appearance of a natural intact dentition can be delivered, both
functionally and esthetically with predictable long-term stable results.129

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