ESTHETICS AND IMPLANT DENTISTRY

Esthetics is the fundamental consideration of clinical dentistry. Various parameters have been offered to define the esthetic characteristics of teeth and their investing structures. Management of the investing structures is greatest challenge to the clinician in replacement of tooth. A partial denture or an implant often replaces missing teeth. Dental implant provides several advantages over the conventional tooth-borne fixed prosthesis. New requirements have emerged for surgical and prosthetic requirements when implants are involved. The use of an implant avoids unnecessary sacrifice of intact tooth structure and avoids long span dentures. Cylindrical shaped implants provide long lasting support to the prosthesis and also provide better survival rates. Studies on the longevity of implants consider the survival time and esthetic consideration of the implant. Functional and esthetic success is essential to long term successful outcome(Sabbagh MA 2006193).

DIAGNOSTIC METHODS1. Esthetics begins with conceptualizing the final implant restoration existing in harmony with the rest of the dentition. 2. The gingiva around each tooth must exhibit a symmetry and harmony that results in a continuity of form. To achieve this, the gingival form and the marginal height of each tooth must be considered. In addition, the root eminence and the cervical width are important in developing an appropriate intertooth relationship.3. The diagnostic process is initiated by developing a diagnostic wax-up. This provides the conceptual basis for the placement of the implant and the tissue requirements. This wax-up is used to fabricate a template that serves several roles.4. The implant placement is preceded by a three-dimensional analysis of the implant site (mesiodistal, facio1ingua1 and apicocoronal). 5. Similarly the bone and soft tissue form is deficient due to resorption occurring in the site of the missing teeth. Furthermore in cases of congenitally missing teeth: the alveolar ridge is deficient faciolingually and possibly mesiodistally.6. Considering the potential aberrations, implant site development is an inherent part of treatment planning process. 7. Information regarding thickness of the soft tissue and configuration of the underlying bone can be done by bone sounding. This is done after administration of local anesthesia, using needle, explorer, periodontal probe or calipers. 8. These findings are enhanced by radiographic studies using IOPA, OPG and CT scans. CT scans are particularly helpful when taken with a radiographic template. Radio opaque markers permit a correlation to be made between the bone and coronal position and form of the future restoration as well as the angle, length and diameter of the implant. 9. Consideration must be given to the faciolingual location of the implant. This varies based on whether the final restoration will be retained by screws or cement. A more labially placed cemented restoration for the maxillary anteriors provides support for the buccal soft tissue esthetic contours, but is not easily retrievable.10. If a screw retained restoration is used and the implant is more palatal then the facial eminence can be created with connective tissue or bone graft. STAGE I SURGERY: Normal Ridge Anatomy1. Placement of an implant in a site that has no deficiencies requires a surgical design that provides access without inducing a deformity in the adjacent papillae or gingival margins. 2. The implant is placed 3 mm apical to the gingival margin of the proximal teeth. 3. Furthermore a ridge with minimal deformity that possesses a sufficient quantity of bone for implant placement can be corrected either prior to or at the time of the stage I surgery. 4. Soft tissue grafting can precede the stage I surgery. 5. The placement of a subepithelial connective tissue graft can be accomplished during the stage I surgery. The incision for the latter procedure should traverse the ridge at the linguoproximal line angles. This facilitates placement, retention and wound healing of the graft.

STAGE II SURGERY 1. Soft tissue management in stage II surgery aids in creating the appropriate inter and intra tooth relationships. 2. Repositioning of the tissue may be necessary to create the appropriate dimensions of keratinized tissue and align the mucogingival junction. 3. The incision is placed slightly lingual to the implant, permitting a greater bulk of tissue to be established in the facial surface. 4. The tissue should be incised, not punched in a effort to conserve tissue volume

Ridge Augmentation Procedures54Aesthetic considerations have expanded the surgical scenario of implant dentistry. Placement of an implant in a site that has an adequate complement of soft and hard tissue requires surgical techniques that will maintain them. However when deficiencies exist they must be recreated. Evaluation of the edentulous site resulting in knowledge of tissue deficiency will aid in determining the surgical sequence and the number of procedures that will precede and follow stage I & II surgery.Minor DeficienciesA mild bone defect may be managed at the time of the stage I surgery. The use of a membrane with bone graft will correct the deformity. Soft tissue augmentation may be required in the facial aspect to create root eminence. Similarly the emergence profile of the temporary and the final restoration is contingent on the soft tissue profile of the marginal tissues. To achieve this, a Nonresorbable alloplast may be placed, a free soft tissue autograft, or pedicle graft can be performed at stage II surgery. The latter is similar to the procedure described by Abrams to manage deformities of an edentulous ridge. The palatal tissue must be de-epithelialized before being rolled beneath the facial flap. A variation suggested by Scharf & Tarnow involves dissecting the palatal connective tissue from the internal aspect of the palatal flap, which remains continuous with the facial flap, and rolling it into the facial aspect to be situated between the flap and the facial bone. Major Deficiencies When a substantial amount of bone is absent from the prospective implant site, it is possible that there is insufficient bone to stabilize the fixture, ensuring integration or achieving the appropriate position of the fixture. In these instances, GTR is used to create the necessary quantity of bone in the desired location. Techniques using autogenous blocks of bone and membranes with and without bone graft material, sometimes secured in place with pins and screws have been described. These approaches can be applied to the area that has been edentulous or at the time of extraction. Correction should be accomplished by preparatory surgery 6-9 months prior to fixture placement. Contingent on the size of the initial defect and the quantity of tissue regenerated, more than one procedure may have to be performed before stage I surgery. At times the quantity of bone regenerated is insufficient to achieve the desired goals. In such instances additional bone grafting procedures may be performed at stage I surgery. Management of Papillae64A critical aspect in achieving the appropriate soft tissue symmetry and harmony around an implant supported restoration is preserving their existing interdental papillae or creating them if they are absent. In both stage I & II surgery, incision placement is a fundamental consideration. In single tooth replacement, if the proximal teeth are less than 6 mm apart, the incision is made mesiodistally at the linguoproximal line angles, preserving the faciolingual dimensions of the papillae and including them as apart of the facial flap. If the teeth are more than 6 mm apart, the papillae are left in place and access is achieved by the use of vertical incisions. When the papillae are missing or insufficient, a dilemma exists, as there are no methods that can predictable create or enhance them. A free soft tissue onlay graft can be placed prior to stage I surgery, at the time or after the healing of stage II surgery. Furthermore before stage I surgery if soft tissue augmentation has not been performed, the placement of an ovate pontic on the ridge is an effective means by which papillae can be maintained.Restorative Sculpturing of the Crevice Ridge laps can and should be avoided by proper placement of the implant and sculpturing of the crevice. The crevice can be sculptured at or after the stage II surgery. Placement of a temporary restoration at the time of the stage II surgery can influence the size and shape of the crevicular space. Even though conventional healing abutments are available in various diameters, they do not reflect differences between mesiodistal and faciolingual dimensions. An appropriately shaped crevice can be facilitated if the temporary is prefabricated and inserted at the time of the stage II surgery. This results in a crevice that anticipated the final shape of the final restoration. Incremental addition to a temporary placed into a healed crevice can change its shape as well as influence the interdental tissue.

Tooth Movement to modify Ridge formGraber and Salama87 have demonstrated that a hopeless tooth present in a site where a implant is to be laced can be orthodontically repositioned to alter both the soft tissue and underlying bone in the absence of infection and inflammation. Mesiodistal; movement of the tooth can aid in development of a papilla. Moving the tooth facially can alter the direction off the socket, thus enabling a fixture to be placed to optimize transmission of occlusal forces and providing a proper emergence profile for the restoration. Extrusion of the tooth, in addition to increasing the volume of bone will aid in positioning the osseous crest, facilitates placing the top of the implant in its ideal position 2-3 mm apical to the facial gingival margin of the adjacent teeth. Tooth movement to correct the position of the adjacent teeth may be required to provide adequate space for the fixture as well as a desirable soft tissue and osseous environment. Frequently, the mesiodistal dimensions between the roots and! or crowns of the maxillary central and canine. Adjacent to the congenitally missing lateral is too narrow for the fixture placement, crown contour and soft tissue form. Tipped teeth proximal to an edentulous area may result in a soft and hard tissue form that makes the development of the papillae approximating the implant restoration impossible.

Factors to be considered for implant aesthetics while placement include1931. Anatomy of the recipient site.2. Position of the implant in the jaw.3. Soft tissue management during the various stages of placement and restoration. The soft tissue that frames the restoration contributes greatly to esthetics. Prevention of hard and soft tissue loss is of primary importance during the surgical procedure.The need for bony augmentation is decided during the pretreatment phase, based on radiographic examination, CT or tomography. Various methods to rebuild the lost hard and soft tissue have been developed. Shaping the peri-implant tissues begins immediately after extraction of the tooth. In the pre implant placement phase, the provisional restorations often constitute an ovate pontic placed immediately in the extraction site. The pontic extends into the extraction socket this maintaining the naturally appearing soft tissue contours. The pontic can be attached to a removable prosthesis or Maryland type prosthesis. If a removable prosthesis is used to retain the pontic, the patient is advised to wear it all the times except during oral hygiene maintenance. Since it is virtually impossible to fabricate naturally looking esthetic restorations on implants placed on non-ideal positions, the implant must be considered in all the dimensions and in relation to the adjacent teeth. During surgical implant placement, the implant is best positioned by using a surgical guide to indicate the site of tooth replacement. Typically, the base of a two-phase dental implant is placed 3-5 mm apical to the gingival margin of the contralateral tooth in the arch, and as far labially as possible. This allows for smooth transition of contours from the narrow cross section of the implant to the natural contours of the replacement tooth. In implants placed immediately after extraction, the provisional restoration is prepared without contact, maintaining 1.5 mm of distance between the base of the pontic and the cover screw of the implant. Chlorhexidine rinses for 30 seconds, twice daily is prescribed for 2 weeks after placement of the implant.For implant placement various surgical flap designs and soft tissue management procedures aimed at preserving the contours of the soft tissue have been devised. To limit the disruption of the soft tissue, an implant is often placed with tooth form incision rather then surgical flap. After implant integration, the cover screw may be replaced with a provisional abutment that is attached to the pontic on the existing provisional restoration. Alternatively, provisional restorations can be made from a stage I impression obtained immediately after implant insertion. The provisionals are inserted after uncovering the implant to allow for adequate time or integration. The soft tissue contours around the fixed provisional restorations as well as the implant position must be detailed to the technician. With screw-retained provisionals, the provisional restorations can be used as an impression coping and incorporated into the impression. The soft tissue cast poured against the provisional restoration provides a good replication of the soft tissue morphology from which the definitive restoration can be made and placed with minimal disruption of the soft tissues. If the implant surgeon and the restorative dentist collaborate closely and provisional restorations are used appropriately, pen-implant soft tissue can be formed and minimally disrupted to allow for esthetic implant supported restorations.

Soft Tissue Enhancement Implant Therapy(Palacci P and Nowzarr H 2008165 )Soft tissue profiles play a critical role in establishing optimal aesthetics as well as facilitating long-term maintenance of implant- supported restorations. When deficiencies in this area compromise the desired restorative outcome, soft tissue enhancement procedures become an integral component in the comprehensive approach of implant site development. Depending on the specific needs of the patient, the sequence of therapy may dictate that soft tissue augmentation be performed before, during or after implant placement. For severe soft tissue deficiencies, as well as one stage implant system, it is more predictable to augment the sites before or during implant placement. Onlay gingival graft and subconnective tissue graft are the most common techniques used in this approach to early enhancement. The popular use of two stage implant systems and the need to consolidate surgical procedures however have necessitated the sequencing of most soft tissue enhancement procedures in conjunction with stage II implant exposure surgery. The authors used a palatal or lingual incision to acquire the maximum amount of keratinized tissue into the flap. The principle benefit is to position the flap buccally and apically to gain optimal harmony with the adjacent teeth and restorations. Recovery of any previously compromised vestibular depth or asymmetry with adjacent mucogingival junctions is easily established. When necessary, roll techniques or subconnective tissue grafts are also utilized in conjunction with this buccally-rotated flap to enhance esthetics.

ESTHETIC CONSIDERATION IN GERIATRIC PATIENT

The excellence of every art is its intensity, capable of making all disagreeables evaporate, from their being in close relationship with beauty and truth. John KeatsEsthetic as appreciative of, responsive to, or zealous about the beautiful; having a sense of beauty or fine culture. Each of us has a general sense of beauty. However, our own individual expression, interpretation, and experience make it unique, however much it is influenced by culture and self-image. Adult patients require different treatment approach from adolescents. Eli et al. found that when sets of photographs of intact and decayed teeth were viewed by both males and females, significant differences in perceptions of esthetic, social, and professional traits associated with the photographs were evident. Beall reported, Teeth alone can have an impact on overall attractiveness and perceptions of personality attributes.

ISSUES TO BE CONSIDERED97Various factors must be given considerations, which demand special consideration for adults._ Psychosocial factors_ Perio-restorative problems_ Age related considerations_ Lack of growth potential_ Aging of tissues_ Vulnerability to Root resorption_ Vulnerability to TMDTo take care of these important issues, adult orthodontics often requires interdisciplinary approach to deliver efficient treatment outcome involving many healthcare providers viz. Periodontist, Restorative Dentist, Prosthodontist, Endodontist, TMJ specialist, Oral & Maxillofacial Surgeon.

ORTHODONTICSFor adult orthodontic patients with missing teeth or insufficient numbers of teeth for orthodontic anchorage, palatal implants are being used to assist with the necessary support. Orthodontically repositioning teeth may prevent the need for more aggressive crown and bridge coverage. In baby boomers who may not have as many restored teeth as the previous generation, preserving the natural enamel through orthodontics may be preferable to removing enamel and dentin for crowns or veneers. The orthodontics may also be less costly in the long run than the prosthodontic procedures.

PERIODONTAL THERAPYEsthetic dentistry procedures require a foundation of good periodontal support. Periodontal tissues frame the teeth and need to be healthy and in harmony with the teeth. Age is not a contraindication for periodontal plastic surgery or periodontal surgery of any type. New periodontal regeneration procedures are providing older adults who have lost periodontal bone support with new options for retaining teeth. Esthetic surgery, whether periodontal or oral surgical, should be offered to the older adult if surgery provides the best option for an esthetic result. Frequently, interdisciplinary therapy is necessary to achieve the most esthetic result. E.g. gingivsal recontouring. Gingival veneers are a cosmetic replacement for missing gingival tissue.They do not replace any kind of periodontal therapy that may be indicated in these patients. It is very important that patients who receive such veneers be on very close recalls to ensure that the patients are able to maintain good oral hygiene around these veneers as well as to ensure that their periodontal disease is under control.

PROCELAIN VENEERING(de Carvolo Cardoso 201262)Prosthodontic procedures can restore function and an esthetic appearance to a worn dentition. Prosthodontic treatment may last longer than composite resin bonding. Often, the bonding procedures serve to introduce the patient to how esthetic dentistry can improve his or her smile. Later, when it needs to be redone, the patient may opt for the longer-lasting prosthodontic procedures. Porcelain veneers are by far one of the most effective and yet conservative methods to achieve an esthetic result, especially when 8 or more teeth are involved. If the patients goal is to improve his or her smile, the dentist should first note how many teeth are involved in this smile improvement. Generally, the patient should smile to his or her fullest, and then which of the posterior teeth shows at the corner of the mouth can be noted. Sometimes, it may be a second molar. If so, the esthetic result the patient desires will not be achieved if only 8 teeth are included in the treatment plan. Since the upper lip line varies considerably in older adults, this assessment will be critical to achieving an esthetic result pleasing to the patient. The most artificial result occurs when only the 6 anterior teeth are restored in a lighter shade, with 8 or 10 teeth showing when the patient smiles. The unrestored posterior teeth now appear even darker than previously and detract from the anterior teeth. When the patient requires complete oral rehabilitation, the full crown is still the restoration of choice. It can be expected to provide a greater functional life than bonding. It can be combined with porcelain veneers to accomplish an esthetic result.In many cases of bite problems that require an esthetic solution, the full crown, rather than porcelain onlays, will offer the most occlusal support against fracture.

IMPLANT235Implant treatment is increasing in older adults. Again, age, in and of itself, is not a contraindication to implant therapy. Many older adults are trading their complete dentures for implant supported prostheses. Implant therapy is expected to increase as implants become the treatment of choice for replacement of a single missing tooth. Implant therapy often requires a team approach with excellent communication between the surgical and the prosthodontic teams.

ESTHETIC DENTAL CONSULTATION AND ESTHETIC FACIAL SURGERYEsthetic dentistry can be part of an overall appearance makeover. When a younger appearance is desired through plastic surgery, esthetic dental services should be considered prior to the esthetic facial surgery. The reasons for this include the following: (1) creating a younger-looking smile may be sufficient to please the patient so that plastic facial surgery may not be necessary or less surgery may be sufficient and (2) oral pathology such as caries or severe periodontal disease subsequent to facial surgery will compromise the esthetic surgical result. Another issue that may occur when esthetic dental services are provided after facial surgery involves the use of retractors. When dentists provide esthetic dental services, they may use retractors during the course of treatment. If esthetic dental services are provided after facial surgery, patients may perceive the use of retractors as contributing to new wrinkle development that the plastic surgery had removed. In truth, these wrinkles were present prior to the dental treatment, but the patients did not notice them until after the dental procedures. When treating a patient who has had plastic facial surgery, the patient should be photographed in repose and smiling close up and full face without make-up to record any existing facial wrinkling prior to dental treatment. For a patient considering facial surgery, the consultation with the dentist regarding smile enhancement should occur prior to the facial surgery to maximize the final facial esthetics.

Vital Tooth BleachingTeeth darken and become more yellow as they age. Teeth also tend to take on stain throughout the enamel and cementum surfaces. Vital tooth bleaching performed either in office or at home has been demonstrated to be effective in older adults. In older adults, sensitivity does not appear to occur as frequently as in younger patients. This is thought to be due to the gradual receding of the pulpal tissue with age. Because aging effects darken teeth in the yellow color range, this color range has been shown to achieve the best results with vital tooth-whitening procedures. In-office and at-home whitening with trays work equally well. Products containing 10 to 35% peroxide have been shown to work in mature adults. The main determinant is whether the patient desires the whitening results immediately or can wait longer for the at-home whitening agents to begin to work. If a patient has anterior teeth with prominent microcracks, he or she should be advised of these cracks and monitored carefully to ensure that there is no streaking in the whitened teeth.

Cosmetic Contouring and Bonding247The teeth of 60-, 70-, and 80-year-old people often exhibit the wearing away of hard tissue by erosion, abrasion, or parafunctional habits such as bruxism. Shortened anterior teeth, particularly in the maxilla, result in less of the teeth being seen when one talks or smiles. This shortening of teeth in the maxilla contributes significantly to an older appearance. As hard tissues wear away, patients will lose vertical dimension, resulting in the mandible becoming more anteriorly positioned. The reverse, the so-called longin- tooth phrase that Shakespeare used to describe the aging process, results from periodontal disease. With age, one shows less of the maxillary teeth and more of the mandibular teeth. The patient at age 50 who wishes to change only the color or shape of the maxillary teeth by age 60 may be requesting similar changes in the mandibular teeth. Both of these age-related changes can add years to an individuals appearance and inhibit oral function. However, esthetic dental treatment can easily transform the patients appearance, in effect turning back the clock on the aging process. Cosmetic contouring provides an excellent introduction to esthetic dentistry for patients who are unsure about making significant changes in their smile. It also provides a lower cost option for those patients with limited financial resources. With minimal preparation, the tooth or teeth can be altered to achieve an esthetic result. Bonding also enables the dentist to easily repair chipping and fractures that occur in the teeth of older adults. Although manufacturers have made cosmetic shades lighter to reflect the increasing range of whiter shades of bleached teeth, older patients may require darker composite shades to restore erosion or root caries. Currently, when a patient needs a restoration on a tooth darker than existing composite shades, the dentist may need to use modifiers to make the restoration more natural in appearance and blend with the surrounding teeth. An overlay technique or partial veneer can be used when a spot match is not possible.

COMPLETE DENTURE3Complete denture esthetics can no longer be considered solely a function of tooth selection and arrangement or the colors and contours and contours of the denture bases. Denture esthetics must also include the entire face in which the expression of inner feelings, personality, comfort, image, well-being, and perceptions of past dental experiences are all very evident. These hard and soft components all contribute to the complete denture esthetics results; they are inseparable and should be given every consideration when developing a successful complete denture esthetic restoration.

DENTURE ESTHETICS is defined as the cosmetic effect produced by a dental prosthesis which affects the desirable beauty, attractiveness, character and dignity of the individual. The tooth problem was an esthetic problem and to avoid disharmony, one should in the initial stages of tooth selection, use a tooth form similar to the patients face form. After Williams work, many researchers continued to build on this beginning, broadening the esthetic area to include the anatomic variants of mesiodistal and cervicoincisal contours and surface texture, the interrelations of tooth form, arch form, face form, alignment form and achieving a harmonious balance. Refinements in determining tooth form, size and color harmony were developed and was followed later by an entirely different and divergent concept basing tooth selection and arrangement on sex, personality and age. Even though it has been subsequently demonstrated that experts cannot accurately differentiate the sex of individuals when shown only their natural teeth, the SPA factor or Dentogenics concept contributed much in achieving a more natural, esthetic appearance to complete denture restorations. FISHER states that Utilize the approach of an artist while analyzing the patient first as to sex, i.e. Male or female, then as to personality i.e. Vigorous or delicate, & then as to age, i.e. young, middle aged or old.Another significant esthetic contribution was the molding of artificial teeth made from impressions of natural teeth and individually color characterized. In this same era, others duplicated natural gingiva and mucosal contours and colors which they transferred to the polished surface for improved esthetics, facial contours and food management6. Tooth arrangement was always considered important from Nelsons arch form and face form, facial contours and support to refinement that followed which included phonetics, tooth display, harmony and the functional elements of occlusal vertical dimension, incisal guidance and centric relation.