Review of literature:

Orban F et al. (Dimensions and Relations of the Dentogingival Junction in Humans. J. Periodontol(1961 32:261)) In their study measured dimensions of tissues involved in Biological Width considerations. Used histologic sections to measure average dimensions of biologic width. These are not clinically accurate due to distortion with histologic processing. This study said width of junctional epithelium plus connective tissue width was Biologic width; i.e.approximately 2 mm. If a subgingival crown margin is placed in the middle of the gingival sulcus, the crest of bone should be a minimum of 2 mm apically positioned. mean depth of the histologic sulcus is 0.69 mm,meanjunctional epithelium measures 0.97 mm (0.71 to 1.35 mm),mean supraalve olar connective tissue attachment is 1.07 mm (1.06 to 1.08 mm).The total of the attachment is therefore 2.04 millimeters (1.77 to 2.43 mm) and is called the biologic width .

James s Marcum et al, J Prosthet Dent. 1967 May;17:479-487 studied the effect of crown marginal depth upon gingival tissue., Sixty six crowns were placed and finished above,below, and even with the gingival crest in 6 dogs. the crowns were left in place until the dogs were put to death at time intervals of one ,two, and thre e months. two dogs were sacrificed at each interval, block specimens of the teeth and gingiva were taken at this time. Control specimens of unoperated teeth were also taken. The block

specimens were decalcified,sectioned,stained,histologicallyexamined,and graded for severity of inflammatory response.six hundred histological slides of the tissue sections were graded as having evidence of none,slight,moderate or severe gingival inflammation. The investigation showed that crowns with margins located at or even with the gingival crest caused the least inflammatory response; that crowns with margins located above and below the crest cause the most severe inflammatory response. The length of time a restoration was in place had little if any effect upon the severity or degree of inflammation. Choosing the proper crown marginal depth depends upon many factors.however it appears from the results of this investigation that crowns with the gingival crest would be least likely to cause gingival inflammation.

Yuodelis et al,
J Prosthet Dent. 1973 jan;29:61-6 Studied about the esthetics and hygiene in crowns given a fter periodontal therapy that involves osseous resection procedures or following gingival recession,we are often confronted with longer than normal clinical crowns.these lengthened clinical crowns are much more difficult to keep plaque free due to the exposed furcations and root flutings. If plaque is allowed to accumulate for long periods of time ,demineralization of the cemental surfaces will rapidly cause increased sensitivity and root caries. If root portions must be covered by complete artificial crowns ,the gold castings should not frustrate the oral hygiene efforts of patients.

The final restoration should not follow the original ana tomic crown and should recreate the original contours of the root portion.the modification of the anatomic coronal form entails reduction of unnecessary bulges in order to create additional accessibility to gingival third of the fluted and furcation regions.this will eliminate the triangular region that is created by the roots and cervical bulge and which is the area most difficult to maintain in a plaque -free condition by normal brushing.for this reason we endeavour to flatten the facial and lingual contours of restorations and have observed excellent gingival response.most probably the cervical region is made more accessible for routine home care. D. Tarnow et al(Journal of Clinical Periodontology Volume 13, Issue 6, pages 563 569, July 1986) Studied Human gingival attachment responses to subgingival crown placement and marginal gingival remodelling.

13 teeth in block were extracted from 2 patients. Their facial periodontal condition was essentially within normal clinical limits. Temporary crowns covering the bevel were placed below the base of the crevice 1 to 8 weeks prior to extraction. At time of extraction, all blocks were decalcified, the temporary crown dissolved, and the blocks prepared for histologic examinations using bucco-lingual cut, step serial sections.

Histologic data revealed reformation of a new supracrestal attachment unit within 1 week following crown placement. The reformation of the gingival unit consisted of marginal recession with apical and lateral migration of the junctional epithelium to the level of remaining cementum inserted fibers. With gingival recession and migration of junctional epithelium, resorption of

crestalportions of the facial plate occurred. However, periodontal fibers anchored into cementum opposite the resorbed bo ne were not lysed. Rather, the attached fibrillar ends appeared to interdigitate with fibers from the corium of the facial gingiva at this site, thereby forming a more apically located crestal attachment. This response may be one mechanism of reformation o f the gingival attachment unit taking place following mechanical and/or surgical injury to this site and is completed often, within 2 weeks after injury. Geoffrion J.et al 1989. [Transformation of a lateral incisor to a central incisor with a ceramometal crown].
They gave guidelines to change a maxillary lateral incisor into a central incisor by using a ceramo-metallic crown. It is required to schedule a rational plan of treatment. All the different pre-prosthetic (orthodontic, periodontic, and endodontic) and prosthetic steps are described and justified. In order to achieve a compromise between esthetic and a stable periodontium the mesial profile of emergence of the ceramic should be conceived to prevent any overcontour. Croll BM.et al (J Prosthet Dent. 1990 Apr;63(4):374-9.) In their study showed that Selection of the straight emergence profile in designing artificial crowns for teeth has been shown to improve the effectiveness of oral hygiene near the gingival sulcus. The axial profile o f teeth can be viewed as a series of straight lines with curved transitions. Reproduction of these geometric patterns facilitates fabrication of restorations that appear natural.

Ferencz JL. (J Prosthet Dent. 1991 May;65(5):650-7.) Reviewed about Maintaining and enhancing gingival architecture in fixed prosthodontics. The long-term success of fixed prosthodontic restorations is greatly dependent upon the health and stability of the surrounding periodontal structures. This article deals with the interrelationship between fixed prosthodontic procedures and the stability and health of the periodontium. The commonly encountered problem of alterations in gingival architecture is examined in relation to tooth preparation as well as soft tissue preparation. In addition, the ability of the provisional restoration to guide soft tissue form is discussed as well as the role of the final restoration in providing long -term tissue maintenance. Key factors such as margin placement, tissue damage during tooth preparation, the role of the provisional restoration, tissue injury during impression procedures, crown contour, pontic design, and embrasure design are all important factors to be considered to achieve a good emergence profile.

Donald F. Reikie et al (J Prosthet Dent 1993;70:433-7) Did a review of esthetic and functional considerations for the partially edentulous implant candidate.Stated that with the availability of adjunctive grafting procedures, it is time for the implant team to change the traditional treatment planning approach that allows patient anatomy to dictate implant

position and prosthesis design. Dimensions of the edentulous space and evaluation of occlusal relationships are discussed by the author. Soft tissue ridge contour and creation of favorable cervical harmony are also reviewed. Functional demands unique to the partially edentulous patient are outlined in addition to the challenges of creating a prosthesis with natural cervical form and emergence profile.

David Neale et al (J Prosthet Dent 1994;71:364-8) Describes a technique to help predict, develop, and evaluate implant prostheses and their soft tissue contours at the provisional restoration stage. This technique records the planned and subsequently proven contours, which are then used to guide fabrication of the final prosthesis and produce a predictable esthetic result.

Shavell et al (Pract Periodontics Aesthet Dent. 1994 Jan-Feb;6(1):33-44; )

Suggested that the delicate dento-gingival attachment apparatus must be treated with utmost respect during all preparationalmaneuvers in the crevicular region. There is little room for error within these minute dimensions. To avoid irreparable harm during chemo -mechanical manipulation of the

attachment apparatus, the dentist must always think on a histologic level in order to respect the cellular integrity of the periodontium.

C. YOUNGSON et al. 1996 They studied about the preparation form and emergence profiles of maxillary metalloceramiccrowns . The aim of their study was to compare the emergence profiles of crowns with their contralateral tooth, in vitro, and determine if there is any association between the design of tooth preparations and the resultant emergence profile. In this study 50 models used for single crown construction were examined. Measurements of the faciolingual width of the crowns and contralateral teeth were taken using digital calipers. Internal line angles and the margin width of dies and the emergence profile of the corresponding crowns were measured from longitudinally sectioned polyvinylsiloxane indices of preparations and associated crowns mounted on a flat-bed scanner using image analysis software. In this in vitro study, they concluded that the emergence profiles of crowns were higher than the contralateral teeth. Maxillary metalloceramic crown preparations had shoulder widths that did not conform to recommendations in standard texts but line angles were within a satisfactory range. The margin width exerts a weak effect upon the emergence profile of the crown.

Davidoff SR et al (J Prosthet Dent. 1996 Sep;76(3):334-8)

Described a procedure for late stage soft tissue modification for achieving anatomically correct implant-supported restorations.Author presents a simple method of modifying soft tissues coronal to the implant head that will allow the development of a restoration with correct emergence profile and anatomic contour.

Reeves WG.et al 1996 Studied the restorative margin placement and period ontal health. Subgingival restorative margins are associated with the development of plaque-related inflammatory periodontal disease, primarily because of a shift in the subgingivalmicroflora from a profile associated with health to one associated with disease. The degree and extent of the marginal inflammation is influenced by four factors: failure to maintain proper emergence profile, inability to adequately finish and/or close subgingival margins, placement of subgingival margins in an area with minimum to no attached gingiva, and violation of the biologic width. Supragingival margin placement is the location of choice for all restorative margins to avoid iatrogenic periodontal disease. However, consideration of these four factors will help reduce the adv erse impact of restorative margins that must be carried subgingivally.

SouheilHussaini et al (J Prosthet Dent 1997;77:630 -2)

Describes a procedure that enables the clinician to fabricate a full -arch maxillary provisional restoration for a fully edentulo us patient, which can be delivered at second-stage surgery at the time of uncovering the implants. It satisfies the patient's esthetics, phonetics, and functional demands and helps create a good emergence profile for the healing gingival tissue.

KleberBM et al1997 Studied about the Influence of marginal and submarginal restoration margins on periodontal tissues. They concluded that Subgingival and irregular restoration margins have an unfavourable influence on the marginal periodont al tissues. The margins close to the gingiva of 206 restorations (age of restorations mean = 49.4 months) showed incorrectnesses in most cases with marginal inflammation as a result. That's why the demand of high precision, supragingival positioning of margin restoration and removal of all potential plaque -retentive or mechanic irritated surface is raised.

Salinas TJ et al (Pract Periodontics Aesthet Dent. 1998 Jan-Feb;10(1):35-42) Establishing soft tissue integration with natural tooth-shaped abutments. Stated that the disparity in dimensions between implant fixtures and the exposed extraction sockets has resulted in the development of anatomically shaped abutments. Systems have been recently introduced that facilitate the fabrication of abutments to the configurati on of natural teeth in the anterior

maxilla. These systems permit development of an aesthetic emergence profile and contours for easy access in maintenance of oral hygiene of maxillary anterior single-tooth implant-supported restorations. The rationale for the development, indications, advantages, and clinical utilization of a recently introduced abutment system is discussed by the author.

Papazian S et al (J Prosthet Dent. 1998 Feb;79(2):232-4) Described a laboratory procedure to facilitate development of an emergence profile with a custom implant abutment.when an implant abutment must be customized,access to coronal portion of the implant analog requires ditching of the artificial stone on the master cast.In this procedure the author uses an orthodontic elastic band with a square cross section to produce space around the coronal aspect of the analog and eliminate the need for ditching.

Tung FF ( JProsthet Dent. 2000 Jun;83(6):681-5.) Describes a procedure for simultaneous registration of gingival emergence profile and maximal intercuspal position for metal ceramic restorations.The materials used in this procedure are inexpensive, readily available, and easy to use. The clinician can inspect the framework, cast, and tissue profile before sending them to the laboratory. When this method is properly used, it allows better communication with the dental technician, saves chair time, and reduces the number of laboratory procedures as currently practiced.

Schtzle M et al (J ClinPeriodontol. 2001 Jan;28(1):57-64.) Studied the influence of margins of restorations of the periodontal tissues over 26 years.The aim of this study was to examine the long-term relationship between dental restorations and periodontal health.The data was derived from a 26-year longitudinal study of a group of Scandinavian middle -class males characterized by good to moderate oral hygiene and regular dental check-ups. At each of 7 examinations between 1969 and 1995, the mesial and buccal surfaces were scored for dental, restorative and periodontal parameters. The mesial sites of premolars and molars of 160 participants were observed during 26 years (1969-1995). A control group with 615 sound surfaces or filling margins located more than 1 mm from the gingival margin in all 7 surveys was compared with a test cohort with 98 surfaces which were sound or had filling margins located more than 1 mm from the gingival margin at baseline (1969) and had a subgingival filling margin 2 years after ( 1971). The study confirmed the long held concept that restorations placed below the gingival margin are detrimental to gingival and periodontal health. In addition, this study suggests that the increased loss of attachment found in teeth with subgingival restorations started slowly and could be detected clinically 1 to 3 years after the fabrication and placement of the restorations. A subsequent "burn-out" effect was suggested.

Davarpanah M,

(PractProcedAesthet Dent. 2001 Nov-Dec;13(9):761-7; quiz 768, 721-2.) Described about a three-stage approach to aesthetic implant restoration: emergence profile concept.The three-stage approach of the emergence profile concept guides the selection of implant, healing abutment, and provisional prosthesis. Adaptation of the implant, provisional prosthesis, and crown restoration stages and their harmonious integration with the soft tissues enable the development of an optimal aesthetic result.The author demonstrates the incorporation of the emergence profile concept for aes thetic implant placement.

Song-borkuo et al (J Prosthet Dent 2002;88:646-8) Describes a method for fabricating an optimal emergence profile for the definitive restoration of an ITI solid abutment when the implant is installed subgingivally.Here the definite restoration for ITI solid abutment is fabricated by waxing on the plastic coping ,casting the metal coping and adding porcelain on the metal coping.The soft tissue model is used to adjust and finalize the emergence profile during these different laboratory procedures.As the subgingival configuration of the modified impression cap is performed in the lab,this technique may reduce chair time.The result of the peri implant mucosal health serves to verify that the emergence profile is acceptable.This technique cannot be applied to the narrow neck implant abutment and angle abutment because they do not use a similar impression cap.

Michael Tischler et al. 2004

Dental Implants in the Esthetic Zone Considerations for Form and Function .The concept of emergence profile is important when dealingwith implant esthetics. The emergence profile can be obtainedthree different ways. One way is for the healing abutment to formthe surrounding soft tissue. The second way to sculpt the tissuearound an implant is to have the implant abutment create ideal form.This can be done with a custom abutment at either firstor second stage. If the abutment is used to create the emergenceprofile at first stage, then the criteria for immediate loading mustbe consid ered.The third way to create the emergence profile is to allow a provisionalresto ration to sculpt it. This can be done eitherwith an ovate pontic or with the contours of a cemented restorationat either first- or second-stage surgery.

Daniel C.T.Macintosh et al. (J Prosthet dent 2004 ;91:289-92) The author describes a method for creating an improved emergence profile with single-tooth, implant-supported restorations. An easily trimmed silicone gingival substitute is used to allow polymerization of acrylic r esin provisional restorations to achieve control of the emergence profile. Gingival trauma is minimized by eliminating intraoral use of monomer and minimizing surgical procedures. Provisional restorations can be assessed to ensure the contour is acceptable and the trimmed gingival substitute can be used to fabricate a similar profile in the definitive prosthesis. The provisional restorations may be used instead of standard prefabricated healing abutments to guide the healing contours of the peri-implant gingival tissue.

Mario R. Ganddini et al. (J Prosthet Dent 2005;94:296 -8) Suggested that the fabrication of provisional restorations is an important stage in implant treatment. In the esthetic zone, the potential for error without the use of provisional restorations in the selection of the abutments, framework design, appropriate vertical dimension of occlusion, occlusal profile, and the esthetic interpretation may be significant. Provisional restorations are indicated in esthetic zones, for the contouring o f the gingiva, to achieve an acceptable emergence profile, to have custom -guided tissue healing, and to induce appropriate soft-tissue topography. Theydescribed the fabrication of a provisional restoration for a single-unit implant-supported crown.

Sundh B et al.2005 Did an in vivo study of the impact of different emergence profiles of procera titanium crowns on quantity and quality of plaque.The purpose of this study was to evaluate the effect of crowns with different emergence profiles on marginal plaque formation. Seven crown preparations were performed on premolar teeth in six patients. Four titanium crowns for each tooth--with different marginal emergence angles--were manufactured according to the Procera technique. The three experimental crowns and the final permanent tooth were cemented with phosphate permanent cement. Plaque samples were collected from the marginal area after 1 week with normal oral hygiene, and again after refraining from oral hygiene for 2 days. The contralateral tooth served as a control. The quantity and quality of plaque were registered. The restoration was removed, the next crown version cemented, and the protocol repe ated.

All experimental crowns, irrespective of emergence profile, showed a significantly lower (P = .01) plaque quantity than controls. No intraindividual differences were found regarding the accumulation of mutans streptococci at the different experimental emergence profiles. No differences in quality between experimental and control sides were found. Within the limitations of this study, it was found that titanium crowns with emergence profiles of up to 40 degrees formed less plaque than healthy controls. There was no higher accumulation of mutans streptococci in relation to increasing emergence profiles.

Yotnuengnit B et al (Quintessence Int. 2008 ) Did a study to find the geometric values of emergence angles in human natural anterior teeth and to study their influence on periodontal status.

Fifty anterior teeth with full-crown restorations and homologous contralateral sound teeth were examined for clinical parameters: Plaque Index, Gingival Index, probing depth, and clinical attachment loss. Impressions and stone casts were made and then separated along the midline of the teeth. All cut -surface specimens were photocopied, scanned, and transferred into graphic form with a special program. The emergence angles of both restored and natural teeth were processed and recorded. Paired t test and multivariate linear regression analysis were used for statistical analysis.

Mean supragingival emergence angles for facial and lingual surfaces of natural anterior teeth were 11.13 +/- 7.92 and 15.58 +/- 9.16 degrees, respectively. The corresponding values for subgingival emergence angles were 9.93 +/ - 5.68 and 14.35 +/- 8.44 degrees. The periodontal parameters were higher in restored teeth than in natural teeth. When Plaque Index and gender were controlled, a correlation was shown between the lingual subgingival emergence angle of the restored teeth and probing depth. A correlation was also found between the lingual supra- and subgingival emergence angles, as well as between both angles of the restored teeth and the attac hment loss. They concluded that t he mean values of emergence angles obtained may aid clinicians and dental technicians in more easily designing the definitive emergence profile of restorations. The emergence profile of the restored teeth may affect periodontal status on the lingual aspect.

Nihon Hotetsu et al. 2006 Presented a case of interdental papilla reconstruction with prosthodontic treatment of maxillary central incisor. A 20-year-old female whose chief complaint was esthetic disturbance of a crown placed on the maxillary left central incisor. The interdental papilla was reconstructed only by the prosthodontic treatment of maxillary left central incisor. This case suggests that the proximal and subgingival contours of provisional crown is very important to the reconstruction of interdental papilla, and also suggests that the transmission of the information regarding the configuration of a provisional crown to the lab side is very important.

This case showed that the emergence profile of a single crown, especially of its proximal aspect, is important to reconstruct the interdental papilla.

Saad A. Al Harbi et al (J Prosthet Dent 2007 ;98:329-332) Describes a proceduce for a patient with a missing or failing maxillary anterior tooth desiring for immediate tooth replacement.Here the fabrication of a provisional restoration can be challenging. Due to individual anatomical variations in tooth shape, size, and supporting soft and hard tissue structures, there are no premanufactured components with an anatomical emergence profile that universally suits all individual situations. The author describes the fabrication of a screw-retained immediate provisional restoration that fulfills anatomic, biologic, and esthetic requirements .

Nicolas Elian et al (J Prosthet Dent 19:306-315,2007) Described a method of accurate transfer of peri-implant soft tissue emergence profile from the provisional crown to the final prosthesis using an emergence profile cast. The use of impression copings to make the final impression results in a master cast in which the soft tissue configuration around the implant platform is circular. Therefore, any soft tissue sculpting developed clinically by the provisional restoration is squandered. The purpose of this report was to present a method for the precise transfer of the peri-implant soft-tissue developed by a customized provisional restoration

to an emergence profile cast.The emergence profile cast is obtained from an impression of the implant-supported provisional restoration and poured with a soft tissue model material. It is used for the fabrication of the emergence profile of the implant abutment and the cervical section of the crown. The technique described was simple, accurate, predictable, and does not require additional chair time for the customization of the impression coping or the fabrication of a new provisional restoration. This article describes a technique that results in an implant restoration that mimics accurately in its emergence profile that of the carefully crafted and customized provisional restoration. The reproduction of the soft tissue contour from the provisional to the final restoration results in an improved esthetic outcome of the final restoration.

Amina Mohamed Hamdy et al. Jan 2008

18 patients were selected from the out patient dental clinic of Faculty of Dentistry , Ain Shams University according to certain criteria . patients were randomly divided into 3 groups ( n = 6) . In the first group patie nts received fibre reinforced composite full coverage crown (FRC) , in the second groups , they received full coverage metal ceramic crowns , with metal collar margin (MCR) , while in the third group , they received full coverage all ceramic

crown (In ceram ) . These groups were further subdivided into two equal subgroups (n = 3 ) , in subgroup A , the finish line was placed 0.5 -1 mm subgingivally , while in subgroup B , it was placed 0.5 1 mm supragingivally.

After proper assessment of the crowns , they were cemented using adhesive

resin cement (panavia F) . Gingival health was investigated according to plaque index (PI) , sulcus bleeding index (BI) and pocket depth (PD) . The measurements were taken immediately after crown cementation (baseline, o ) then after 3 month (3), at the mesial , distal , buccal and lingual surfaces for each crown. Also, control teeth ( contra lateral teeth with no restorations) , were assessed similarly . statistical analysis was carried using Graphpad Prism version 4.03. Fisher s exact test and Chi square test were performed to compare between categorical data .Results . Regarding plaque index group I ( FRC) ,subgroup A (Subgingival) showed higher significant difference (P = 0.015) after 3 months than at baseline , while no si gnificant differences were observed in any of the other groups or subgroups regarding sulcus bleeding index (BI) or pocket depth (PD) . Also , all control teeth showed no significant changes rather than tested crowned teeth or after 3 months from baseline regarding the three different parameters . Conclusions . Plaque index has increased significantly around subgingival margins of fibre reinforced composite full coverage corwns while no changes in the sulcus bleeding index or pocket depth was observed after 3 months of crown placement regardless the material of construction or margin location .

AthanasiosNtounis et al.(2008) This article describes an indirect impression technique that accurately captures the soft tissue contours around an implant-supported provisional restoration. Customized impression copings are used to transfer the soft tissue architecture created by the interim prosthesis. The definitive restoration is shaped like the provisional restoration, maintaining the emergence profile and optimizing esthetics.

Alexander shor et al. (J esthetrestor Dent 20:82-97,2008) Suggested that fixed provisional restoration can also seve as an esthetic and functional blue print in the fabrication of the definitive restoration.this article presents a production technique and treatment workflow of a laboratory fabricated ,screw retained fixed provisionalrestoration.provisional restoration is fabricated using layering technique and internal stain charecterization.the soft tissue profile of the working cast is modified according to the coronal contour of diagnostic wax up.the developed emergence profile of provisional restoration is transferred to master cast via customized impression coping.

Den Hartog L et al (J Prosthet Dent. 2009 Oct;102(4):211-5) describes a treatment in which an anterior maxillary implant was immediately restored with a provisional restoration. During the provisional phase, an optimal emergence profile was created by adjusting the provisional restoration. An impression was made with an individually fabricated impression post for an accurate reproduction of the established emergence profile and, finally, a screw-retained all-ceramic crown was placed. By implementing this protocol, an optimal definitive result could be achieved, together with immediate patient satisfaction. However, cooperation among several disciplines and careful patient selection were required.

Panagiotaeirini et al (J Prosthet Dent 2009;102:345-347) Suggested that Obtaining an accurate representation of the soft tissue contours developed around an implant in the esthetic zone is crucial to the success of a restoration. The technique presented emphasizes guiding of the soft tissue by modifying a provisional restoration to obtain an emergence profile that appears natural and blends with the gingival contour of the adjacent teeth. The technique provides an accurate impression of the soft tissue through the intraoral use of autopolymerized acrylic resin supported by the impression coping and vinyl p olylsiloxane impression material. The eventual restoration uses an esthetic zirconia custom abutment and an implant-supported single crown to fulfill the esthetic and functional expectations of the patient and the provider.

Azer SS. Et al (J Prosthodont. 2010 Aug;19(6):497-501) Described a simplified technique for creating a customized gingival emergence profile for implant-supported crowns.This is also an economical technique to direct gingival tissue healing, as well as create a removable gingival repl ica of the customized gingival emergence profile. The created profile can then be used in the dental laboratory to achieve a superior and predictable esthetic outcome for implant-supported fixed restorations.

Jofre et al 2010 In their clinical report concluded that, Immediate provisionalization is considered to be an advantageous procedure for aesthetic results in immediate implant placement. Despite reports of techniques and procedures that use the patient s teeth, these cannot always be recovered. The method described offers a chairside alternative for fabricating an immediate provisional for a single implant, replicating the pre-existing anatomical crown with acrylic. Acrylic is easier to handle for this procedure, and allows the periodontal structures to be preserved. The applications of this technique are extensive, and can be used on anterior and posterior teeth as well as fixed partial prosthetics and bridges.

Takahiko Sugiyama et al 2010

Used a system called friction system to achieve aesthetic emergence profile. The Friction Retention System has many considerable advantages and plays an important role in achieving perfect treatment results. The indication is restricted to single tooth replacement and that the limit is a three unit bridge. In addition, implant placement conditions and securing sufficient tissue volume surrounding the implant are fundamental to its success.

Beitlitum L et al 2011

Did a review on teeth replacement in the estheticzone .Dental implants are usually the preferred treatment alternative for tooth replacement.in this review they discussed several clinical issues concerning implant placement in the esthetic area. It is still unclear whether raising a flap at the time of implant placement enhances alveolar crest remodeling. However, a flapless surgical procedure could avoid changes in the free gingival margin and maintain the the attached gingiva width. A submarginal approach not involving th e free gingival margin can be applied to treat bone defects with the GBR technique. Implants should be placed as palatal as possible while maintaining optimal restoration

emergenceprofile and the horizontal bone defect filled with a non resorbable material such as bovine bone mineral. Thick periodontal biotype and coronally positioned free gingival margin usually lead to better results. Immediate implant placement in presence of a periapical lesion may be performed, however, sites should be thoroughly debri ded prior to implant placement.

Degidi M et al (J Periodontol. 2011 May;82(5):708-15. Epub 2010 Dec 7) Did a histologic and histomorphometric evaluation o f nineequicrestaland subcrestal dental implants retrieved humans.they did this study considering that the stability of peri-implant crestal bone plays a relevant role relative to the presence or absence of interdental papilla. Several factors can contribute to the crestal bone resorption observed around two-piece implants, such as the presence of a microgap at the level of the implant -abutment junction, the type of connection between implant and prosthetic components, the implant positioning relative to the alveolar crest, and the interimplant distance. Subcrestal positioning of dental implants has been proposed to decrease the risk of exposure of the metal of the top of the implant or of the abutment margin, and to get enough space in a vertical dimension to create a harmoniously esthetic emergence profile. A retrospective histologic study was performed to evaluate dental implants retrieved from human jaws that had been inserted in an equicrestal or subcrestal position. A total of nine implants were evaluated: five of these had been inserted in an equicrestal position, wherea s the other four had been positioned subcrestally (1 to 3 mm).

In all subcrestally placed implants, preexisting and newly formed bone was found over the implant shoulder. In the equicrestal implants, crestal bone resorption (0.5 to 1.5 mm) was present around all implants. They concluded that t he subcrestal position of the implants resulted in bone located above the implant shoulder and thus a good emergence profile can be achieved.

Avinash S. Bidra et al (Journal of Oral and Maxillofacial Surgery june 2011 ) Omega-Shaped ( ) Incision Design to Enhance Gingival Esthetics for Adjacent Implant Placement in the Anterior Region . Describes a technique to achieve a papilla -like tissue using an omega-shaped ( ) incision design when implants are placed adjacent to ea ch other in partially edentulous ridges. This incision design is intended to spare an area of soft tissue of approximately 4 mm 4 mm between the anticipated positions of the adjacent implants. The area of soft tissue that is free from surgical insult lat er helps in the creation of a papilla-like tissue through interim restorations.