The biaxial nature of the anterior maxilla poses a surgical and restorative challenge in implant dentistry. The present study sought to investigate the apical socket perforation rate (ASPR) from a simulated uniaxial implant placement and to determine the effect of implant length and diameter on ASPR when a uniaxial implant was placed compared with the orientation of the pre-existing dual-axis implant.
Cone beam computed tomography (CBCT) scans from the database of three private practices were searched for patients who received dual-axis implants within the esthetic zone in immediate tooth replacement therapy. A uniaxial implant was virtually placed using the pre-existing screw access channel of the dual-axis implant as a reference. The closest length and diameter were selected for the simulated implant. ASPR by the uniaxial implant was recorded. In addition, the affordable maximum length of a corresponding uniaxial implant that would avoid apical socket perforation was measured.
Eighty-one patients with a total of 101 dual-axis dental implants were selected for analysis. A simulated virtual surgical planning with uniaxial implants revealed high ASPR (48.51%). When the length of the uniaxial implant was reduced to 11 and 9 mm, ASPR was decreased to 41.58% and 20.79%, respectively.
Dual-axis implant design effectively evades anatomical challenges in the anterior maxilla (esthetic zone). Considering the current evidence, efforts should be made to carefully consider the angular disparity between the extraction socket-alveolus complex and the future restorative emergence so that a harmonious biologic-esthetic result may be more predictably and consistently obtained.

This article describes a comprehensive step-by-step protocol for immediate implant placement and restoration in the esthetic zone. Clinical Considerations Immediate implant placement into fresh extraction sockets and immediate restoration have become widely accepted, demonstrating long-term success rates that are comparable with traditional delayed implant protocols. However, they are technique sensitive and require proper treatment planning as well as meticulous execution to be predictable and successful in the long term. This is particularly important in the esthetic zone, where even minor aberrations and mistakes can have devastating consequences, and especially in younger patients, where esthetic and functional outcomes should remain stable for years and possibly decades to come. The eight critical steps for predictable immediate implant placement include: provisional restoration of the failing tooth and presurgical phase, atraumatic tooth extraction, initial implant osteotomy, 3D bone graft packing, guided implant placement with a surgical guide, customized abutment insertion, provisional crown relining, and placement of a connective tissue graft from tuberosity. Immediate implant protocols in the esthetic zone require thorough planning and execution in the proper sequence. Each one of the critical steps discussed in this article has its own importance and challenges, which are critically assessed based on current scientific evidence.

OBJECTIVE: To address the myths and realities of soft tissue grafting with the tunnel technique in the mandibular anterior region.
METHODS: Myths associated with use of the tunnel technique for soft tissue grafting in the mandibular anterior region are identified and examined. Explanations for the misunderstandings are presented and documented with case examples and evidence from scientific studies.
RESULTS: Six myths are described and the realities are presented.
CONCLUSIONS: This report demonstrates that the tunnel technique can be successfully used in the mandibular anterior region in the presence of anatomic features thought to favor the use of more invasive surgical methods.
CONCLUSIONS: Soft tissue grafting in the mandibular anterior region has complicating anatomical features including a strong frenal attachment, shallow vestibule and thin tissue. These features may be successfully managed with a free gingival graft, but that procedure results in an uncomfortable experience for the patient. The tunnel technique, especially when combined with an acellular dermal matrix, dramatically improves the patient experience and esthetic outcome without compromising the clinical outcome.

The long-term stability of soft tissue augmentation in treatment of localized severe maxillary anterior ridge deformities.
OBJECTIVE: Severely deformed edentulous ridges in the esthetic zone (EZ) are very difficult to restore with an esthetic fixed dental prosthesis (FDP). Soft tissue augmentation of these deformed ridges can dramatically improve the esthetics of the restoration. The long-term stability of soft tissue grafting used alone to treat severe localized alveolar ridge deformities will be reported.
UNASSIGNED: Three different soft tissue augmentation techniques, connective tissue graft (CTG), keratinized gingival graft (KGG), and pediculated connective tissue graft (PCTG) used to treat severe ridge deformities in the maxillary anterior region in five patients will be described. The stability of the augmentation will be shown at follow-up periods ranging from 5-30 years.
CONCLUSIONS: All three soft tissue grafting techniques demonstrated long-term stability following the six-month post-treatment result.
CONCLUSIONS: Edentulous ridges in the esthetic zone, with severe hard and soft tissue deformities, are very difficult to restore esthetically. The development of soft tissue augmentation techniques has allowed clinicians to enhance the esthetics of their fixed dental prostheses (FDP). Restorative clinicians need to be assured that soft tissue shrinkage under the pontics will not occur after the final prosthesis is seated. The stability of these soft tissue augmentations over an extended period of time, will be demonstrated in the presented cases.

To review the historical and current periodontal phenotype classifications evaluating methods and characteristics. Moreover, to identify and classify the methods based on periodontal phenotype components.
Several gingival morphology studies have been frequently associated with different terms used causing confusion among the readers. In 2017, the World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions recommended to adopt the term \"periodontal phenotype\". This term comprises two terms, gingival phenotype (gingival thickness and keratinized tissue width) and bone morphotype (buccal bone plate thickness). Furthermore, gingival morphology has been categorized on \"thin-scalloped\", \"thick-scalloped\" and \"thick-flat\" considering the periodontal biotype. However, by definition, the term phenotype is preferred over biotype. Periodontal phenotype can be evaluated through clinical or radiographic assessments and may be divided into invasive/non-invasive (for gingival thickness), static/functional (for keratinized tissue width), and bi/tridimensional (for buccal bone plate thickness) methods.
\"Thin-scalloped,\" \"thick-scalloped,\" and \"thick-flat\" periodontal biotypes were identified. These three periodontal biotypes have been considered in the World Workshop but the term periodontal phenotype is recommended. Periodontal phenotype is the combination of the gingival phenotype and the bone morphotype. There are specific methods for periodontal phenotype evaluation.
The term periodontal phenotype is currently recommended for future investigations about gingival phenotype and bone morphotype. \"Thin-scalloped,\" \"thick-scalloped,\" and \"thick-flat\" periodontal phenotypes can be evaluated through specific methods for gingival thickness, keratinized tissue width, and buccal bone plate thickness evaluation.

When pigmentations appeared in the esthetic zone and were visible during the patient\'s smile, they were very disconcerting. There are multiple techniques to eradicate or ameliorate these discolorations. This article will address those pigmentations caused by amalgam particles.
Keratinized gingival grafts were used to cover and mask these pigmentations. In addition, connective tissue grafts were used to aid in the elimination of the external pigmentation.
Both techniques were shown to be very effective in masking or eliminating these unesthetic pigmentations. Long-term follow-up has shown these results to be stable with no recurrence of the pigmentation.
Unesthetic pigmentations in the esthetic zone that are visible during a patient\'s smile are very disconcerting. Elimination of these unesthetic discolorations can make a dramatic improvement in the patient\'s smile.