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Presence or absence of papillary tissue
between adjacent teeth,
1
implants, or a tooth-
implant interface
2
has received a great deal of
attention from clinicians over the last 15 years.
Filling most of the interproximal embrasure
space by papillae is fundamental for achieving
a pleasant dentogingival composition.
3,4
Tarnow et al
2
measured papillary height
between adjacent implants and found a mean
of 3.4 mm, ranging from 1.0 to 7.0 mm. When
compared with the papillary height between
natural teeth (5.0 mm),
1
these results repre-
sent a lack of 1.0 to 2.0 mm, which leads to
important esthetic issues in the anterior maxil-
lary zone.
2
To overcome this problem, several sugges-
tions have been made for preserving or
regaining soft-tissue integrity in the esthetic
zone through surgical
58
or prosthetic
9,10
pro-
cedures. However, there is still an increasing
demand for scientific investigation in this area.
The clinical situation in this article refers to
the absence of 2 contiguous teeth in the
esthetic zone: the maxillary central and later-
al incisors (Figs 1a and 1b). The therapeutic
suggestion is to insert only 1 implant
2
in the
maxillary central incisor region, because it is
speculated that this procedure can generate
a better clinical performance. The biologic
rationale for this recommendation is based
on the understanding of the formation of the
biologic space around titanium implants.
11
It
is known that after a titanium implant is
exposed to the oral medium, a rapid reab-
sorption of the bone crest around the plat-
form is observed. Therefore, the insertion of
a single-implant-supported cantilever pros-
thesis could make it possible to preserve the
interdental papilla and gingival outline, as
there would be no bone crest reabsorption
around the platform of the second implant.
Clinicians must be careful during implant
treatment planning for partially edentulous
patients: Two adjacent implants pose a
greater esthetic risk because the gingival tis-
sue contours are less predictable.
The aim of this article is to present a sur-
gical and prosthetic treatment modality by
means of a single-implant-supported can-
tilever prosthesis to replace 2 adjacent natu-
ral teeth in the anterior maxillary zone.
Two prosthetic crowns supported by a single
implantAn esthetic alternative for restoring
the anterior maxilla
Mauricio Barreto, DDS, DMD, MSc
1
Carlos Eduardo Francischone, DDS, MSc, PhD
2
Hugo Nary Filho, DDS, MSc, PhD
3
Esthetic complications due to nonharmonious peri-implant soft tissue profiles are common
in the anterior maxilla, especially when 2 adjacent implants are found. This article suggests
the use of a single implant to replace 2 lost adjacent teeth in this region and demonstrates
the treatment with 2 clinical cases. The main advantage is preservation of the interdental
papilla and gingival contours, compensating for the alveolar bone crest resorption at the
platform of a second implant. (Quintessence Int 2008;39:717725)
Key words: cantilever, dental papilla, esthetic zone, gingival tissue, implant-supported
prosthesis, titanium implants
1
Doctorate student, Course on Implantology, Sagrado Corao
University, Bauru, So Paulo, Brazil.
2
Titular Professor, Coordinator, Master of Science Degree Course on
Implantology, Sagrado Corao University, Bauru, So Paulo, Brazil.
3
Assistant Professor, Coordinator, Master of Science Degree
Course on Oral and Maxillofacial Surgery, Sagrado Corao
University, Bauru, So Paulo, Brazil.
Correspondence: Dr Mauricio Andrade Barreto, AV.ACM,585 ED.
Odontomedico LJ 35, Salvador, Bahia, Brazil 41850-000. E-mail:
mauriciobarreto@implo.com.br
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CLINICAL CASE 1
The patient was a 25-year-old woman with
missing maxillary left central and lateral inci-
sors (Fig 2). After adequate surgical and
prosthetic planning, a bone graft was made
to augment the width of the alveolar bone
crest using the mandibular ramus as a donor
site (Fig 3). Five months later, a commercial-
ly pure titanium implant (Titanium Fix, AST
Technology) was placed in the maxillary left
central incisor region (Fig 4). The implant
complied with the following specifications:
platform diameter, 4.1 mm; external hexagon
width, 2.7 mm; and external hexagon height,
0.7 mm.
Six months later, the implant was exposed,
and a provisional cantilever fixed partial den-
ture (FPD) (Figs 5a and 5b) was made using
a titanium prosthetic component screwed
into the implant platform (UCLA Titanium,
Titanium Fix) and self-polymerizable acrylic
resin (Jet Classic, Clssico Odontolgico).
To obtain the plaster cast, an impression was
made using a polyether-based material
(Impregum Soft, 3M ESPE), and a custom-
ized individual tray was made of self-poly-
merizable acrylic resin (Jet Classic). The
opposing dentition impression was made
using an irreversible hydrocolloid.
After the provisional FPD was inserted, a
subepithelial connective tissue graft was per-
formed, and the soft tissue was conditioned by
means of successive compression cycles by
adding self-polymerizable acrylic resin to the
cervical portion of the FPD (Figs 6a and 6b).
Ninety days after the subepithelial con-
nective tissue graft was performed, proce-
dures to make the definitive denture were
started. Thus, a new polyether impression
(Impregum Soft) of the maxillary arch and a
personalized individual tray were made. For
correct molding of the peri-implant soft tis-
sue, the provisional denture was used to per-
sonalize an impression coping with self-poly-
merizable acrylic resin (Duralay II, Reliance)
(Figs 7a and 7b).
In the plaster cast obtained, a titanium pil-
lar with parallel walls (CeraOne abutment,
Titanium Fix) was inserted, and a metal-free
framework was made of aluminum oxide
(Vita In-Ceram alumina, Vident) (Fig 8).
Figs 1a and 1b Treatment of 2 adjacent
missing teeth in the anterior maxilla with tita-
nium implants. In the first clinical case (a), 2
contiguous implants were inserted, and a
deficiency of the interdental papilla was
observed. In the second clinical case (b), a sin-
gle implant was inserted, and the presence of
interdental papilla and a more harmonious
gingival outline were observed.
a
b
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Fig 2 Initial clinical situa-
tion in the maxillary anterior
zone.
Fig 3 Bone graft in the surgical area. Fig 4 A single implant placed in the maxillary
left central incisor region.
Figs 5a and 5b A provisional cantilever
fixed partial denture was inserted.
Figs 6a and 6b
Subepithelial connective
tissue graft procedure
performed to obtain a more
harmonious emergence
profile.
Figs 7a and 7b Impression for mak-
ing the definitive denture. Observe that
the correct impression of the peri-
implant soft tissue was obtained by
means of customizing the impression
coping.
a b
a b
a b
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The cemented definitive prosthesis (Figs
9a, 9b, and 10) was inserted 5 months after
the surgical procedures. Zinc phosphate
(Hy-Bond Zinc Phosphate Cement, Shofu)
was used as the cementing agent. Occlusal
adjustment was made to maintain a slight
occlusal contact in the maximum intercuspa-
tion position, as well as an anterior guide
with concomitant contacts on the 2 central
incisors. An effort was made to avoid
occlusal contacts on the maxillary left lateral
incisor (cantilever).
Fig 8 All-ceramic alumina framework in position.
Figs 9a and 9b Definitive prosthesis inserted. A labial deficiency was maintained in the maxillary central incisor region, and
the interdental papilla is more coronal to the contralateral counterpart.
Fig 10 Periapical radiograph taken 1 year after
the definitive prosthesis was inserted. Note the
presence of bone crest in the maxillary lateral inci-
sor region. The gap at the abutment prosthesis is a
technical artifact from x-ray angulation.
a
b
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CLINICAL CASE 2
The second case was performed in the max-
illary anterior region and presents 11-year fol-
low-up documentation. This 35-year-old
patient had a history of root resorption in the
maxillary left lateral incisor and canine
region (Figs 11a and 11b).
After surgical and prosthetic planning,
these teeth were removed, and after 60 days,
an implant (Nobel Biocare) was inserted in
the maxillary left canine region using the sur-
gical guide as a prosthetic reference. Six
months later, the implant was exposed and a
CeraOne abutment (Nobel Biocare) was
connected (Figs 12a to 12c) to fabricate the
provisional cantilever FPD. To obtain a har-
monious emergence profile, successive
compression cycles of the peri-implant tis-
sue were performed by the addition of self-
polymerizable resin (Jet Classic) in the cervi-
cal portion of the denture.
The impression procedure for making the
definitive denture was performed in a similar
manner to that used in clinical case 1. Next, a
framework was constructed of noble alloy
(Pors-on 4, Degussa Dental), and a definitive
denture (see Fig 12c) was cemented with zinc
phosphate cement (Hy-Bond Zinc Phosphate
Cement). Occlusion was adjusted to maintain
the canine guide and to avoid touching the
maxillary left lateral incisor (cantilever).
After an 11-year follow-up period, no pros-
thetic complications, such as denture screw
loosening or ceramic fracture, were observed.
The peri-implant tissues, interdental papilla,
and gingival outline remained stable (Figs 13a
and 13b).
Figs 11a and 11b Initial
presentation. The maxillary
left lateral incisor and canine
were scheduled for extrac-
tion.
Figs 12a to 12c CeraOne abutment (a), noble alloy framework (b), and the definitive prosthesis (c).
a
b
c b a
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DISCUSSION
Soft tissue behavior
The soft tissue profile is a fundamental factor
in the esthetic appearance of implant pros-
theses. But how can a single implant replac-
ing 2 adjacent teeth contribute to stabilizing
the gingival tissue contours? This explana-
tion is perhaps found when one understands
the biologic width around implants.
11
It is well
known that bone loss near the implant plat-
form is observed just after second-stage sur-
gery.
12
The bone resorption process takes
place in an apical and lateral direction
13
; the
magnitude of bone loss depends on several
factors, such as the periodontal biotypes,
14
prosthetic load,
15
implant type,
12
and initial
implant position,
16
among others.
Why is the gingival contour difficult to
maintain in the presence of 2 adjacent
implants? First, the edentulous alveolar ridge
is flat, and no bone crest is observed under
the gingival papilla, as seen between 2 adja-
cent natural teeth. Thus, a second adjacent
implant is problematic, because it con-
tributes to lateral bone loss in the implant
platform, decreasing the bone crest height
between the implants even more.
13
In the sin-
gle-implant technique, the chance of a more
stable alveolar ridge increases.
Cardoropoli et al
17
evaluated 11 patients
who received the Brnemark implant system
to treat a single missing tooth in the esthetic
zone. The results showed 0 to 6 mm of apical
migration in the gingival margins (P < .05).
Also, papillary deficiencies were 50% or more,
being 32% during definitive crown insertion
and 86% after 1 year. The 2 clinical cases pre-
sented in this article demonstrate a similar
behavior to that described by Cardoropoli et
al,
17
since a deficiency of the interproximal
papilla and discrete apical migration of the
gingival margin were observed. Therefore, it is
possible that insertion of 1 implant to replace
2 adjacent teeth demonstrates the same
effects as those observed at implant-support-
ed single-tooth replacements. This hypothe-
sis, if scientifically proven, could represent a
new esthetic parameter for the treatment of
2 missing contiguous teeth in the anterior
maxilla.
Mesiodistal space available
Many authors recommend that the distance
between 2 adjacent implants and between
tooth and implant should be 3.0 mm and 2.0
mm, respectively.
13,18
The goal of this recom-
mendation is to maintain the bone crest
between implants and consequent bone sup-
port for the interproximal papilla. Tarnow et
al
13
demonstrated that the crestal bone loss
for implants with a distance greater than 3.0
mm between them was 0.45 mm, while
implants that had a distance of 3.0 mm or less
between them had a crestal bone loss of 1.04
mm. Thus, the mesiodistal space required for
inserting 2 standard-diameter implants is
approximately 15.2 mm, as depicted in Fig 14.
Figs 13a and 13b
Clinical and radiograph-
ic presentation 11 years
after treatment. Note
the presence of bone
crest in the maxillary left
lateral incisor region.
(Clinical case performed
by Prof Dr Carlos
Eduardo Francischone).
a b
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On the other hand, spaces of less than
15.0 mm are found between the central and
lateral incisor regions because of crowding
or teeth with reduced mesiodistal distances.
Therefore, for a space equal to or smaller
than 15.2 mm, the use of a single implant to
replace 2 lost adjacent teeth in the anterior
maxilla, from an esthetic point of view, is a
therapeutic suggestion to be considered.
Also, for spaces larger than 15.2 mm, one
could consider the use of 2 implants, that is
to say, 1 implant for each lost tooth.
Proceeding in this manner, the bone crest
and the interproximal papilla could be main-
tained,
13
because the distance between the
implants would be greater than 3.0 mm.
Moreover, the use of 2 implants improves the
conditions of biomechanical support for the
definitive prosthesis.
Implant connection type
In the periapical radiographs of the 2 clinical
cases described in this article, a circumferen-
tial radiolucent area was observed near the
implant platform, compatible with the biologic
width around titanium implants.
11
Several
advances have been described to maintain
the bone crest around implants by macro- and
microanatomic implant modifications.
1921
Several implant manufacturers claim clini-
cal superiority for maintaining optimal bone
crest levels, but clinical documentation on
this topic is lacking.
22
Nevertheless, it is
expected that new designs will be able to
keep desirable bone levels around the
implant platforms. Thus, unless new implant
designs demonstrate the same bone
crest/coronal root portion relationships, the
clinician should consider the use of a single
implant to replace 2 lost adjacent teeth in the
anterior maxilla, because it is thought that
this procedure could result in better clinical
performance.
Framework
High-strength all-ceramic systems for FPDs
are available for replacing missing teeth.
New core/framework materials have been
developed and have evolved in the last
decade.
23
All-ceramic systems are a focus of
interest, because they offer esthetic results
that may be difficult to achieve with metal-
ceramic systems. Nowadays, the new ceram-
ics associate good esthetic and mechanical
qualities, biocompatibility, and accurate mar-
ginal fit.
24,25
But what is the best material for
making the framework of a single-implant-
supported cantilever prosthesis? From the
mechanical point of view, one could specu-
late that metal-ceramic FPDs are preferable
because of their predictable characteristics
of long-term strength. All-ceramic systems
can be recommended for anterior FPDs,
especially if highly satisfactory esthetic
results are required. No studies refer to the
use of implant-supported all-ceramic restora-
tions applied in a single-implant-supported
cantilever prosthesis. Further studies should
Fig 14 Ideal space distribution
between teeth and implants.
2 mm
4.1 mm 3 mm
2 mm
15.2 mm
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be conducted for detailed evaluation of the
clinical performance of all-ceramic systems
for FPDs
26
and single-implant-supported can-
tilever prostheses.
Biomechanical risks
The number of implants and their length, as
well as bone quality, occlusal pattern, and
prosthesis design, are fundamental to the
biomechanical integrity of an implant pros-
thesis.
27
With regard to the possible biome-
chanical risks, is it safe to plan a single-
implant-supported cantilever prosthesis in
the anterior maxilla? Even with the lack of
scientific evidence, some factors indicate a
particular treatment option: (1) The occlusal
forces in the anterior region are less than half
the value observed in the posterior region
28
;
(2) manufacturers constantly seek to devel-
op implants that present more bone-to-
implant contact, which could increase
because of their anchorage
29
; (3) a thorough
occlusal adjustment with slight contact in
maximum intercuspation, with unimpeded
lateral and protrusive excursive movements
around the implant; and (4) excluding
patients with parafunctional habits and Class
II and Class III malocclusion
30
from this type
of treatment, are factors that can determine
the biomechanical longevity of the single-
implant-supported cantilever prosthesis.
CONCLUSION
The insertion of a single implant to replace 2
maxillary anterior teeth can provide a more
acceptable esthetic appearance of the peri-
implant soft tissue profile. However, more
controlled clinical studies are necessary to
address soft and hard tissue stability in this
treatment modality, as are studies to evaluate
the mechanical performance of a single-
implant-supported cantilever prosthesis.
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