Implantes Dentales

ESTHETICS
J Oral Maxillofac Surg 65:2-12, 2007, Suppl 1

The Esthetic Challenge of Adjacent Implants
George F. Priest, DMD*
Reformation of natural-appearing sulcular and papilla anatomy between adjacent implants in the esthetic zone presents a complex challenge for the implant team. Guidelines for implant placement of adjacent implants and soft tissue development are introduced that optimizeesthetic results. The rule of 3x3x3 PIE is a mnemonic, based on biologically and prosthetically driven implant placement, which maximizes the potential for optimal esthetics between adjacent implants. The 4 interdependent principles of the 3x3x3 PIE rule are as follows: 1) the platforms of the implants should be located 3 mm apical to the zeniths of the predetermined facial-gingival margins ofthe planned restorations, 2) the centers of the implants should be placed at a distance at least 3 mm palatal to the anticipated facial margins, 3) interimplant spacing of 3 mm is required between adjacent implant platforms, and 4) the implants should emerge through the palatal incisal edge of the ensuing crown positions. After placement of adjacent implants by the surgeon according to the rule of3x3x3 PIE, the restorative dentist must then develop the remaining soft tissue beginning with a provisional restoration. The reformed peri-implant gingiva is then supported by the subgingival contours of the definitive abutments and crowns. If ideal gingival esthetics are not achievable, pontics or gingival-colored porcelain can be acceptable alternatives. New technologies, including platformswitching, are enhancing clinicians’ abilities to deliver consistent esthetic results with adjacent implants. © 2007 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 65:2-12, 2007, Suppl 1 Replacement of multiple missing teeth in the esthetic zone presents a complex challenge for the implant team due to the difficulty in reformation of natural-appearing sulcular and papillaanatomy surrounding adjacent implants. Optimal esthetics are predicated on meticulous execution of sequential steps beginning with treatment planning, a welldesigned surgical guide, site development and preservation, implant placement, and abutment and crown contours. When treating patients with visible display of gingival architecture, the clinician must use protocols that optimize sulcular andpapilla forms around adjacent implants. However, limitations with present protocols preclude ideal gingival contours in many instances, and some ridge
*Formerly, Clinical Instructor, Department of Graduate Prosthodontics, Emory University, Atlanta, GA. Dr Priest is a paid consultant for Biomet 3i (formerly Implant Innovations, Inc). Address correspondence and reprint requests to Dr Priest: 999Peachtree Street NE, Suite 795, Atlanta, GA 30309; e-mail: georgepriest@bellsouth.net
© 2007 American Association of Oral and Maxillofacial Surgeons

0278-2391/07/6507-0102$32.00/0 doi:10.1016/j.joms.2007.03.015

defects are too substantial to allow normal gingival architecture. Therefore, the purpose of this report is to review current surgical placement and prosthetic techniques that deal withthe esthetic shortcomings of insufficient soft tissue profiles around adjacent implants and to offer guidelines for optimizing the esthetic outcome. In a review of recent literature, Belser and colleagues noted that predictable soft tissue anatomy around single implant restorations is likely because of tissue support of adjacent teeth, but soft tissue profiles around multiple implants are oftencompromised.1 The potential for ideal soft tissue of single implant restorations is primarily due to preservation of crestal bone heights of teeth adjacent to implant sites where only 1 tooth has been lost (Figs 1-3).2 Inevitable interimplant bone resorption following multiple teeth extractions and implant placement is largely responsible for altered soft tissue architecture surrounding adjacent...