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The International Journal of Oral & Maxillofacial Implants 73

INTRODUCTORY REMARKS

The group was asked to come to a consensus posi-tion related to the esthetic dimension of implantdentistry in the anterior maxilla, based on its discus-

sion of and subsequent deliberation on 3 previouslywritten position papers regarding the followingfields: (1) outcome analysis of implant restorationslocated in the anterior maxilla; (2) anatomical andsurgical considerations of implant therapy in theanterior maxilla; and (3) practical prosthodontic pro-cedures related to anterior maxillary fixed implantrestorations. These reports were critically reviewedand thoroughly discussed within the group, leadingto a first draft of consensus statements. These weresubsequently presented during a plenary session thatincluded the members of the other 3 consensus

groups. After their respective input, the statementswere refined and then presented again to the plenarysession for final approval.

CONSENSUS STATEMENTS AND CLINICALRECOMMENDATIONS

In esthetic dentistry, difficulties arise in generatingevidence-based statements regarding clinical proce-dures. Therefore, any clinical recommendationsgiven in this section are primarily based on the expert

opinion of this group. The group worked on eachstatement until a unanimous opinion was reached.

Long-Term Results

From the discussion of the Belser et al review of long-term results of implant treatment in the esthetic zone,the following consensus statements were drafted.

Evidence from the Literature. The use of dentalimplants in the esthetic zone is well documented inthe literature. Numerous controlled clinical trialsshow that the respective overall implant survival andsuccess rates are similar to those reported for other

segments of the jaws. However, most of these stud-ies do not include well-defined esthetic parameters.

Single-Tooth Replacement. For anterior single-tooth replacement in sites without tissue deficien-cies, predictable treatment outcomes, includingesthetics, can be achieved because tissue support isprovided by adjacent teeth.

Multiple-Tooth Replacement.The replacement ofmultiple adjacent missing teeth in the anterior max-illa with fixed implant restorations is poorly docu-mented. In this context, esthetic restoration is notpredictable, particularly regarding the contours of

the interimplant soft tissue.Newer Surgical Approaches. Currently, the liter-

ature regarding esthetic outcomes is inconclusivefor the routine implementation of certain surgicalapproaches, such as flapless surgery and immediateor delayed implant placement with or withoutimmediate loading in the anterior maxilla.

Surgical Considerations

From the discussion of the Buser et al review of surgi-cal considerations of implant treatment in the estheticzone, the following consensus statements were drafted.

Planning and Execution. Implant therapy in theanterior maxilla is considered an advanced or com-plex procedure and requires comprehensive preop-erative planning and precise surgical executionbased on a restoration-driven approach.

Patient Selection. Appropriate patient selectionis essential in achieving esthetic treatment out-comes. Treatment of high-risk patients identifiedthrough site analysis and a general risk assessment(medical status, periodontal susceptibility, smoking,and other risks) should be undertaken with caution,since esthetic results are less consistent.

Consensus Statements and Recommended Clinical

Procedures Regarding Estheticsin Implant Dentistry

Primary authors: Urs Belser, Daniel Buser, Frank Higginbottom

Correspondence to: Dr Urs Belser, University of Geneva, School

of Dental Medicine, Rue Barthlemy-Menn 19, CH-1205 Geneva,

Switzerland. Fax: + 41 22 372 94 97. E-mail: urs.belser@medi-

cine.unige.ch

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Implant Selection. Implant type and size shouldbe based on site anatomy and the planned restora-tion. Inappropriate choice of implant body andshoulder dimensions may result in hard and/or softtissue complications.

Implant Positioning. Correct 3-dimensionalimplant placement is essential for an esthetic treat-

ment outcome. Respect of the comfort zones inthese dimensions results in an implant shoulderlocated in an ideal position, allowing for an estheticimplant restoration with stable, long-term peri-implant tissue support.

Soft Tissue Stability. For long-term esthetic softtissue stability, sufficient horizontal and verticalbone volume is essential. When deficiencies exist,appropriate hard and/or soft tissue augmentationprocedures are required. Currently, vertical bonedeficiencies are a challenge to correct and often leadto esthetic shortcomings. To optimize soft tissue

volume, complete or partial coverage of the healingcap/implant is recommended in the anterior max-illa. In certain situations a nonsubmerged approachcan be considered.

Prosthodontic and Restorative Procedures

From the discussion of the Higginbottom et alreview of prosthodontic and restorative proceduresfor implant treatment in the esthetic zone, the fol-lowing consensus statements were drafted.

Standards for an Esthetic Fixed Implant Restora-

tion. An esthetic implant prosthesis was defined as

one that is in harmony with the perioral facial struc-tures of the patient. The esthetic peri-implant tis-sues, including health, height, volume, color, andcontours, must be in harmony with the healthy sur-

rounding dentition. The restoration should imitatethe natural appearance of the missing dental unit(s)in color, form, texture, size, and optical properties.

Definition of the Esthetic Zone. Objectively, theesthetic zone was defined as any dentoalveolar seg-ment that is visible upon full smile. Subjectively, theesthetic zone can be defined as any dentoalveolar

area of esthetic importance to the patient.Measurement of Esthetic Outcomes.The follow-

ing esthetic-related soft tissue parameters are pro-posed for use in clinical studies:

Location of the midfacial mucosal implant mar-gin in relation to the incisal edge or implantshoulder

Distance between the tip of the papilla and themost apical interproximal contact

Width of the facial keratinized mucosa Assessment of mucosal conditions (eg, modified

Gingival Index, bleeding on probing) Subjective measures of esthetic outcomes, such as

visual analog scales

Use of Provisional Restorations. To optimizeesthetic treatment outcomes, the use of provisionalrestorations with adequate emergence profiles isrecommended to guide and shape the peri-implanttissue prior to definitive restoration.

Location of the Implant Shoulder. In mostesthetic areas, the implant shoulder is located sub-gingivally, resulting in a deep interproximal margin.

This shoulder location makes seating of the restora-tion and removal of cement difficult. Therefore ascrew-retained abutment/restoration interface isadvisable to minimize these difficulties.

74 Volume 19, Supplement, 2004

GROUP 2: CONSENSUS STATEMENT