Esthetics in Implants

Esthetics in ImplantsContentsIntroduction

Glossary

Implant Selection & Positioning

Inter-implant papilla

Complications

Conclusion

ReferencesIntroductionBeautification and adornment are mutually inclusive terms that involve cosmetics, clothing, jewelry, body piercing, tattooing, and so forth.

They are fueled by our subconscious drive to look attractive and feel good about ourselves & also enjoy the attention we get from others when they notice our attractiveness (Boucher 1965), which explains the contemporary high demand for cosmetics by all classes of society.The establishment of optimal and predictable aesthetics is one of the most important and challenging aspects of rehabilitation with dental implants.

Aesthetic rehabilitation is important, not only because achieving the perfect smile is demanded by our beauty-oriented society, but also because individual impairment and disability may result from aesthetic deficiencies.

The goal of aesthetic rehabilitation is to alleviate or eliminate deficiencies and to obtain optimal aesthetics.Optimal aesthetics should be defined as the patients perception of visually pleasing or satisfying, and the clinicians assessment of acceptable anatomic architecture coupled with proper function of the masticatory system (mastication, speech, swallowing).

Aesthetic rehabilitation has to be predictable, implying reproducibility and stability of the outcome in the short and long term.Achieving these characteristics depends on the interaction between multiple variables, namely, biologic (anatomic factors, host response), surgical (procedure, technical skills), implant (dimensions, surface characteristics, design), and prosthetic factors.

It is obvious that analyzing, selecting, and integrating each of these factors is challenging.

Esthetic implant therapy has become an integral part of modern implant dentistry, because it complements the overall results of oral implantology.Significant advances have been introduced recently, including novel techniques to develop or regenerate implant recipient sites by stimulating both hard and soft tissues and to reproduce healthy peri-implant tissue contours that resist mechanical forces and masticatory trauma.

Despite the advances and the success seen in many clinicians practices, there is insufficient scientific support regarding the overall success and longevity of esthetic implant therapeutical techniques in well-controlled, long-term studies.The advances in esthetic implant therapy and soft tissue and hard tissue regeneration are more the authors observations than standard protocols that are used in clinicians daily practices.

Therefore, a standard surgical and prosthetic protocol for esthetic implant therapy is mandatory.GlossaryEsthetics: (GPT-8)

Pertaining to the study of beauty and the sense of beautiful. Descriptive of a specific creation that results from such study; objectifies beauty and attractiveness, and elicits pleasure

Pertaining to sensation

Dental Esthetics: The application of the principles of esthetics to the natural or artificial teeth and restorationsImplant Selection & PositioningFactors influencing

Implant morphological & design considerations

Rationale of implant positioningFactors influencing according to Askary

The grip: During the drilling procedure, the grip of the hand-piece influences the implants optimal position to a great extent.

The control of the clinicians hand while drilling, using either a palm grip or pen-grasping grip, optimizes the positioning procedure.

The palm grip sometimes provides better control over the other grips, especially in the maxillary premolars locations.It is the authors personal opinion that the palm grip offers greater control of the drilling procedure in the maxillary posterior areas.

This preference is due to the nature of the drilling procedure, which differs from the regular turbine hand-piece grip that is used for cavity preparation.

The nature of the slow speed and high torque during dental implantology procedures, as well as the bone resistance, allows the palm grip to assist in achieving better positioning control.

Accuracy of the surgical template: The more accurate the surgical template, the more accurate the implant positioning.

New types of templates are being fabricated with computer-aided design/ computer-aided manufacturing (CAD/CAM) technology that offers precise positioning in terms of locating the axial location of the implant head within the alveolar ridge.

These precise surgical templates are being used with a computed tomography (CT) scan-based planning system (Tardieu et al. 2003) which allows the surgeon to select the optimal location for implant placement, taking into account specific anatomic characteristics of the patient and thus using the optimal bone densities.The precision of the perpendicular reconstruction images along the axis of the arch (orthogonal frontal oblique sections) is almost 95%.

Thus, the precision of these reconstruction sections is amply sufficient for clinical application in implant therapy.

The goal of this technology is to allow the clinician to use an individualized drill guide that fits exactly on the bone crest of the patient.

A CAD/CAM program uses the shape of the scanning template and the 3-D information of the plan.A stereolithographic drill guide allows a physical transfer of the implant planning to the patients mouth.

The scannographic template is designed so that it can be transformed into a temporary fixed or final prosthesis for immediate loading.

This subsequently transfers most of the surgical and prosthetic planning and fabrication outside the patients mouth and allows the planning to be done prior to implant installation.This revolutionary treatment planning and surgical implementation system transfers extraoral planning into the mouth with accuracy and ease.

Therefore, placing implants, abutments, and restorative components is simultaneous by using either conventional modeling or computer aided 3-D design.

This system gives the exact position and depth of the implants prior to surgery.

The laboratory can then produce a surgical template that guides the surgical procedure from the start to a completely successful placement.The case is planned in a computer based on CT scan data, which offers a more precise picture of anatomy, compared to model-based planning.

A customized surgical template and the required implant-related components then can be ordered and used according to the preplanned case.Sharpness of the cutting drills: Because drills become blunt with use, each implant manufacturer states the number of times a set of drills should be used, after which they should be discarded.

The sharpness of the drill prevents it from wobbling in the surgical site and the subsequent deviation from the intended angulation or position.

In fact, the sharpness of the rosette or the pilot drill that is used for the pilot osteotomy is the most valuable because it guides the primary path for the other drill to follow.The use of positioning devices: Some positioning devices are now available to help keep an optimized distance between the implant and the natural teeth.

A novel implant positioning system called IPS set (Storz am Markt GMBH, Emmingen-Liptingen, Germany) was introduced to assist in maintaining the proper implant position and angulation during the preparation of the surgical site.

It consists of a series of sleeves and spreaders that maintain the proper interproximal dimensions and help determine the proper apical level of the implant head during surgery.The system facilitates selection of the implant diameter and axis, maintains exact spacing between the adjacent tooth and the implant or between adjacent implants, is compatible with any implant system, is useful for orthodontists in determining prospective implant positions in cases in which teeth are missing as a result of a congenital defect, and is suitable for use as seating tips in spacing templates.

The use of computerized navigation surgery: Computerized navigation surgery is a developing technology for intraoperative tracking and guidance of surgical instruments to enhance minimally invasive procedures.

It is considered to be a new era in perfecting implant positioning within the alveolar ridge, and it has evolved to facilitate minimally invasive procedures.

This surgery, also called image guided implantology, can be used with flapless or flapped implant placement protocols in cases of flapless implant placement where the surgery may be perceived as a blind procedure that includes a risk of cortical plate perforation.The computerized navigation system provides real-time imaging of the drill and transforms flapless implant surgery into a fully monitored procedure.

The surgeon can rely on the computerized navigation to adjust the position and angulation of the drill in absolute coordination with the pre-surgical digital implant plan.

The highly accurate intraoperative navigation enables precise transfer of the detailed pre-surgical implant plan to the patient.Intraoperative computerized navigation in implant dentistry mandates that an interfacing template be firmly attached to the operated jaw throughout the surgery.

In the partially edentulous patient, this template may be an acrylic resin splint that is mounted over the existing natural teeth, and in fully edentulous jaws, stabilizing bone screws might be used.Implant Morphological & Design Considerations:

The modern implant design has several additional morphological modifications than the original standard classic designs and was originally made to simulate the original tooth morphology in most of the designs.

Unfortunately, all missing teeth in the same dental arch cannot be restored with the same implant design due to the unique and versatile nature of human tooth roots.

Some roots possess anti-rotational characters, some have stronger anchorage characters, and still others have a greater load-bearing capacity.Therefore, the comparison between natural teeth and dental implants is unfair, and dental implants should not be called third dentition.

When restoring natural dentition with conventional prostheses, the anatomy of the existing natural teeth and periodontium serve as guides for replicating the original natural form and contours.

Unfortunately, dental implants do not provide the same valuable guides that are available when restoring natural dentition, especially when multiple teeth are missing.Consequently, before inserting dental implants, the clinician should develop an imaginary picture that will act as a guide or reference during the treatment plan.

This is accomplished by properly assessing the original shape of the osseous bed and the biological dimensions of the missing dentition and relating them to the restorative components that will be used.

Understanding the basic morphology of the missing tooth in relation to the implant fixture design along with its related components becomes an absolute necessity for achieving successful esthetic results.Many scholars study the technical advancements in implant designs, as a result, a better understanding of bone behavior and cellular activities has led to the invention of new designs.

The changes involved include implant surface treatments, predictable interface connections, versatile unique implant sizes, and new implant-related prosthetic components.

The newly introduced dental implant designs have led many clinicians to dramatically improve the clinical outcome of dental implants from both the esthetic and functional standpoints and to take implant-supported restorations to new levels.Thus, selection of the optimum implant design and size is now an integral part of every treatment plan that seeks a superior esthetic outcome.

The elements of implant design are:

The implant surface topography (micro characters)

The overall physical geometry (macro characters), such as length, diameter, and macroscopic threads, vents, and grooves

The implant material compositionA tapered form for root-shaped implant design presents unique physical characteristics:

It reduces the tendency for apical perforation when an immediate placement method is selected, as compared with those that are parallel-walled.

It might avoid damaging the adjacent roots.

It offers greater initial stability.

It compresses bone against its walls.Implant positioning rationale:

Placing an implant in the esthetic zone requires accurate attention to all treatment details not only to achieve clinically accepted results but also to preserve the existing natural details.

An optimum osseous dimension and restorative dimension should be key in any accurate 3-D positioning procedure.

The natural balance between these two dimensions should be preserved in implant therapy.It contributes to the complete biological integration of the dental implant within its housing.

Certain guidelines to assist in placing the implant in a 3-D fashionthe interproximal dimension, which represents the relationship anterio-posteriorly between the implant and the natural teeth mesiodistally, and the labiopalatal dimension, which relates to the mediolateral axis and the sagittal dimensional axis, which is the apico-incisal dimension.Mesiodistal positioning: The mesiodistal position of the implant in relation to the adjacent teeth or between adjacent implants has a direct impact on the esthetic outcome and the interproximal marginal integrity of the future restorative contours.

It directly affects hygiene maintenance around the implant-supported restorations and its adjacent natural components.

In ideal soft and hard tissue conditions, the implant should be positioned midway in the center of the available mesiodistal space to obtain a centrally positioned prosthesis.The potential risk of improper mesiodistal positioning of the implant is the approximation to the interdental papilla or, worse, impinging on it.

This can cause blunting of the papilla and possible damage to the periodontium of the adjacent tooth to the implant site by compromising the blood supply, which could lead to external root resorption.

External root resorption highlights the importance of not using parallel walled roots for dental implants. The use of a tapered implant design may reduce the chance of adjacent root approximation, especially when restoring areas with limited mesiodistal space or with curved roots.

Axial positioning: The labiopalatal position of the implant within the alveolar ridge influences the emergence point of the implant-supported restoration as well as its contagious marginal contours and the profile of the final restoration.

Generally, a proper emergence profile is desirable, for both esthetic and hygienic reasons. Therefore, the labial contour of the implant head has to emerge, as do adjacent natural teeth.

In perfect bone situations, the implant should be placed as close to the buccal contour as the volume of the available bone permits, leaving 1.5mm from the buccal edge of the bone.For example, in 6 mm of bone width, a 3.75-mm-diameter implant should be placed labiopalatally to leave sufficient bone on the labial aspect of the implant body to maintain an optimal osseointegration.

If the labiopalatal dimension of bone is less than 6 mm, a smaller diameter implant may be used.

Several methods can treat a deficient bone width; bone dilators and bone splitting methods can be used to increase or expand the amount of available bone accordingly.

The placement of the implant in this dimension is critical.A misplaced implant can violate the integrity of the labial plate of bone with subsequent bone fenestration or dehiscence, leading to a final implant-supported restoration with bulky, over-contoured margins.

This situation is clinically impossible to correct, even with the use of angulated abutments. In fact, angulated abutments might further complicate the situation because their metallic gingival collar can potentially displace the soft tissue in a more labial direction, resulting in soft tissue recession or grayish, discolored gingiva at the emergence level.

Axial positioning: Implant positioning in relation to its axial level influences the amount of exposure the final restoration will receive, which in turn dramatically affects the esthetic outcome of the restoration.

Apicoincisal positioning is no less important than the mesiodistal and labiopalatal positioning aspects of the implant.

Unfortunately, surgical templates that offer apicoincisal positioning guidance for functional or esthetic implant placement are few.Several factors control the location of the implant head in an axial dimension,

The amount of space available for restoration,

The topography of the remaining bone,

The marginal gingival location of the adjacent natural teeth, and

The selected implant diameter.The reference location of all axial implant positioning is an imaginary line connecting the gingival zeniths of the adjacent natural teeth.

There is a greater urgency for restoring natural gingival contours surrounding the new restorations when a natural tooth reference is missing and multiple adjacent implants are to be used.

These implants should be placed at the alveolar crest within the circumference of the missing teeth to be restored.This enables the clinician to develop appropriate natural embrasures on both sides adjoining the restorations and duplicate a natural gingival profile.

The ideal apicoincisal implant positioning places the implant head 2mm to 3 mm apical to the line connecting the gingival zeniths of the adjacent natural teeth.

This subsequently allows running room throughout the biological width of the implant when it is correctly positioned in an apicoincisal plane.

The running room is a space of 2mm to 3mm in depth and it surrounds the implant head circumferentially.

Gingival zenith of the adjacent natural teeth is considered to be the landmark or the reference in apico-incisal implant positioning.

Therefore, for a number of reasons, it is recommended that the location of the implant head be related to a line connecting the gingival zenith of the adjacent remaining natural dentition rather than to a line connecting the CEJ or the crest of the ridge.

Inter-implant papillaThe presence of the interproximal papillae around implant-supported restorations allows symmetrical soft tissue margins and a state of harmony between natural teeth and dental implant components.

This harmony and tissue symmetry leads to a natural-looking restoration that does not obscure vision.

On the other hand, the slightest change in the level of the interproximal papillae around dental implants due to pathologic reasons or poor soft tissue handling during implant treatment can lead to major esthetic and phonetic complications that are often difficult to correct. That is what makes the peri-implantsupported tissues a delicate clinical issue to handle.The sequence of losing the interproximal papilla starts immediately after tooth extraction.

The thin adjacent alveolar bone (interradicular bone) starts to undergo a rapid process of resorption, probably due to the following reasons:

The thin nature of the alveolar bone (which allows faster resorption),Reduced blood supply to the crest of the interradicular bone at this particular area,The possible direct contamination of the interradicular bone by oral bacteria as a result of tooth extraction, andMost importantly, the absence of the Sharpeys fibers that stimulate continuous bone remodeling and thus maintain healthy marginal levels.As a consequence of tooth extraction, the interdental papilla remodels in a sloping fashion from the palatal to the more apical facial osseous plate, and becomes depressed in comparison with the healthy adjacent marginal tissue.

Unfortunately, the lost interdental papilla usually cannot regenerate to regain its original dimensions.

The nature of the inter-implant (scar-like) soft tissues also complicates the overall clinical prognosis and mandates special reconstructive procedures. The greatest challenge today in implant and periodontal plastic surgery is the reconstruction of lost or incomplete interproximal papillae.To assess and classify the different clinical conditions of the interdental papillae, Nordland and Tarnow (1998) have reported the deferent clinical conditions of the interdental papillae according to their marginal level. They subdivided the interdental papillae into three classes:

Class I: Tip of the interdental papilla lies between the interdental contact point and the most coronal extent of the interproximal cementoenamel junction (CEJ) (space is present, but interproximal CEJ is not visible).Class II: Tip of the interdental papilla lies at or apical to the interproximal CEJ (interproximal CEJ is visible).Class III: Tip of the interdental papilla lies level with or apical to the facial CEJ.

Tarnow and others (1992) developed a useful classification for clinically identifying the predictability of the presence of interdental papillae.

They concluded that when the measurement from the contact point of the natural tooth to the crest of the bone was 5 mm or less, the papilla was present almost 100% of the time; when the distance was 6 mm, the papilla was present 56% of the time; and when the distance was 7mm or more, the papilla was present only 27% of the time or less.This classification is considered to be the ultimate clinical parameter for predicting the presence of the papilla around dental implants in single-tooth situations and not in-between two adjacent implants situations.

Salama and others (1998) proposed another interesting classification that furnished a prognostic classification system for the peri-implant papillae.

Their three classes are based on the available interproximal height of bone (IHB) in relation to the prognosis of the peri-implant papillae.

In Class 1, IHB is 45mm (measured from the apical extent of the future contact point of the restoration to the crest of bone), suggesting an optimal prognosis; in Class 2, an IHB of 67mm shows a guarded prognosis; and in Class 3, the IHB is greater than 7 mm, indicating a poor prognosis.

Factors affecting the peri-implant tissues:

Initial presentation (Seibert classification)Implant position capability (relative to planned gingival zenith)Bone formation and resorption at the implantPeri-implant mucosa integrationCharacter of the implant abutment interfaceInflammationLocal factors (plaque, etc.)Patient factors (biotype)Abutment formSubmucosal contour of the provisional crownBone modeling/remodelingPotential adjacent tooth eruption(1983) Seibert classifiedalveolar crestaldefects:

Class I: Buccolingual loss with crestal height maintained

Class II: Vertical loss with buccolingual width maintained

Class III: Combination of buccolingual and vertical lossPapilla reconstruction procedures:

Reconstructing the inter-implant papilla is one of the most technique-sensitive procedures in dental implantology.

It requires greater surgical skills and optimal scientific background.

The nature of the inter-implant papilla (scar tissues) also might compromise an optimal surgical reconstructive procedure; however, there are general factors that influence the treatment outcome when one is to reconstruct the inter-implant papilla.Blood supply is the key factor in predicting the treatment outcome. A sufficient blood supply should be maintained in any flap design, especially in complex grafting procedures that involve both soft and hard tissues.

Relative tooth orientation becomes an important factor in predicting the peri-implant papilla, because restoring two missing central incisors is unlike restoring unidentical anterior teeth, such as a central and adjacent lateral incisor.

Optimal implant position becomes an important factor in determining the future crown contours. The three-dimensional (3-D) implant positioning in the alveolar ridge becomes an influential factor, especially the axial positionthat influences the distance from the contact point to the osseous crest.

Tissue biotypes should be carefully evaluated and recorded before the treatment begins. For example, in the thin scalloped tissue biotypes, the soft tissue volume is usually insufficient and more liable to slough when surgical procedures are being undertaken. Also, the postoperative response to trauma (recession) might complicate the overall treatment fate. In thick flat tissue biotypes, reconstruction procedures seem to be more predictable due to the sturdy nature of the soft tissue and the underlying osseous structure.In tooth morphology, the triangular crown shape seems to negatively influence the volume and height of the gingival embrasure, thus affecting the overall size of the inter-implant papilla. On the other hand, square crown shapes show better prognosis. Attenuated tapered roots seem to allow more interradicular bone than wider roots, which influences the diameter of the future implant to be used.

When reviewing the status of the osseous crestal level, the height of the osseous crest determines the predictability of the inter-implant papilla. In cases of severe osseous resorption, the papillary morphology as well as the soft tissues will be compromised; therefore a staged approach should be undertaken. The current thought is to improve theosseous topography until a stable level is reached, and then proceed with implant installation procedures.

Recently platform switching has been introduced to many esthetic implantology procedures. Switching the platform of the implant diameter to a smaller diameter at the interface level favors the biological width development in the horizontal direction to compensate for the vertical one, thereby minimizing postoperative bone resorption and helping to maintain stable soft tissue margins. Platform switching seems to make sense because with experience, osseous levels were found to be more stable with the use of narrow platforms. This current thought has led to many new implant designs. Also, shaping the subgingival prostheticcomponents to be narrower and constricted subgingivally has led to better soft tissue marginal results.

Keeping an optimal distance between adjacent implants and between natural teeth and adjacent implants is vital in restoring natural soft tissue margins and prosthetic contours. There is no definite guideline that dictates a certain distance to be kept between dental implants, and nor should there be because the variations in teeth shape as well as the implant diameters are countless. When possible, a logical spacing should be maintained that will not jeopardize or infringe on any biological areas.Recently several attempts have been made to introduce new implant designs with scalloped features. While clinicians worldwide do not yet find this to yield predictable results, it is the authors opinion that the designs will show promising results in the future. Scalloped designs can be helpful in maintaining proximal osseous contours at stable levels in immediate implant placement; however, in delayed implant placement therapy, it is necessary for the bone-grafting procedure to regenerate bone on the scalloped margins.

ComplicationsImplant failure is defined as the total failure of the implant to fulfill its purpose (functional, esthetic, or phonetic) due to mechanical or biological reasons.

Treatment complications can range from fracture of the prosthetic components to a transient inflammatory condition; however, this chapter addresses the possible complications in the esthetic zone, which involves the possibility of failure due to esthetic reasons.

An implant with successful osseointegration might still be considered a failure if the final prosthesis does not provide the optimal required esthetics.Such a failure could be due to several reasons, some of which are untreatable. The esthetic outcome of an implant-supported restoration is affected by four main factors:

Implant placement,

Soft tissue condition,

Osseous condition, and

Prosthetic & Biomechanical condition.Implant Positioning Complications:

Peri-implant Soft Tissue Complications:

Peri-implant Hard Tissue Complications:

The decision to use any particular grafting material or grafting technique should be based on the following:

Nature and size of the defect

Physical properties of the graft

Chemical properties of the graft

Mechanism(s) of action of the graft

Assumed rehabilitation planningConclusionTo achieve a successful esthetic result and good patient satisfaction, implant placement in the esthetic zone demands a thorough understanding of anatomic, biologic, surgical, and prosthetic principles.

The ability to achieve harmonious, indistinguishable prosthesis from adjacent natural teeth in the esthetic zone is sometimes challenging.

Placement of dental implants in the esthetic zone is a technique-sensitive procedure with little room for error.Guidelines are presented for ideal implant positioning and for a variety of therapeutic modalities that can be implemented for addressing different clinical situations involving replacement of missing teeth in the esthetic zone which should be followed by the dental practitioner and/or the implant team.

Last but not the least BEGIN WITH THE END IN MIND.ReferencesAskary AESE. Fundamentals of esthetic implant dentistry. 2nd edition. Hong Kong: Blackwell; 2007.p. 109-26,225-54,301-28.

Buser D, Martin W, Belser C. optimizing esthetics for implant restorations in the anterior maxilla: anatomic & surgical considerations. Int J Oral Maxillofac Implants:2004;19.43-61.

Sonick M, Hwang D. Key Principles of Implant Dentistry in the Esthetic Zone. AEGIS: (online)

Al-Sabbagh M. Implants in the Esthetic Zone. Dent Clin N Am 50 (2006) 391407.

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