The esthetic challenge of adjacent implants.

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 optimize esthetic 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 of the 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 of 3x3x3 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 platform switching, are enhancing clinicians' abilities to deliver consistent esthetic results with adjacent implants.