Figure 1: Note the proper implant positioning in apico-occlusal direction.
Figure 2: A free gingival graft to correct for scarring around a restored dental implant.
Figure 3: A connective tissue graft to increase the quality of the keratinized tissues around a restored dental implant.
Figure 4: Using a diamond bur to reshape the excess gingival tissues around a restored dental implant.
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Dental Implants in the Esthetic Zone
Abdel El Salam El Askary, BDS
Placing dental implants in the esthetic zone is considered to be the ultimate challenge for many dentists. The use of dental implants in the esthetic zone has overcome many of the disadvantages of conventional restorative techniques that used anterior natural teeth as abutments. Professionals aimed at creating an implant-supported restoration that replicated natural teeth1. That is why the single-tooth, implant supported restoration in the anterior region remains a challenge.2
Successful placement of implant-supported restorations in edentulous and partially edentulous patients has been reported by several authors. Esthetic implant placement has become a well recognized, documented branch of science due to the efforts of both scientists and manufacturers to offer new solutions and treatment modalities.
Patient acceptance of dental implants in the esthetic zone is increasing due to many factors, including the outstanding results shown in the media. In the past, available bone often restricted placement of implants into areas such as the anterior mandible. Today prosthetic requirements dictate, to a great extent, the placement of dental implants.
Bone regenerative materials, soft tissue augmentation techniques, wide temporary healing abutments, natural profile abutments, and tooth colored abutments are the main tools used in the creation of an optimal emergence profile of an implant-supported prosthesis in the esthetic zone.
In addition, acceptable esthetics often requires repeated interventions, prolonged waiting periods, multiple visits and high costs.3
Factors affecting the esthetic outcome include:
1 - Implant placement: Accurate use of the surgical stent guides the placement of the implant in three different main directions — apico-occlusal, or mesio-distal, or labio-palatal (Figure 1). Each implant should be positioned properly in all three directions. The implant orientation in the alveolar ridge dictates the emergence profile of the tooth to be replaced.
2 - Implant size: Selecting the proper implant size in relation to the size of the missing tooth is a valid rule. In other words, the more the similarity between the diameter of the implant and the diameter of the missing tooth at the bony crest, the greater the esthetic outcome.
3 - Soft tissue profiling: Creation of a soft tissue contour with intact papillae and a gingival outline that is harmonious with the gingival silhouette of the adjacent dentition is the most difficult factor in achieving an optimal esthetic result. Mismanagement of the soft tissue often results in esthetically unacceptable restorations, and such situations are difficult to correct.4
3A - Standard operative techniques: The basic principles of the flap reflection, tissue handling and wound closure should be considered in order to prevent post operative complications.
3B - Second stage surgery: An important step in obtaining a soft tissue topography around the implant, making the incisions exclusively in the attached tissues definitely decreases scarring. Transposing the palatal keratinized tissues labially also enhances the emergence contour.
3C - Soft tissue grafting: There are numerous methods to increase the attached tissues or to modify the gingival contour, such as: free gingival grafting (Figure 2); subepithelial (connective tissue grafting - Figure 3); and coronally repositioning flaps.
3D - Papilla reconstruction: Reconstruction of the interdental papilla is a very unpredictable application in the oral cavity. There are many ways to regenerate the papilla, but none of them provide a reasonable percentage of success.
3E - Gingival recontouring techniques: Techniques can be used to reshape the gingival tissues provided that there are enough keratinized tissue (Figure 4). For example, electro-surgery is utilized to remove scarring and the gingivoplasty by using a diamond bur to remove the excess tissue.
4 - Bone grafting considerations: In the past available bone often dictated placement of implants in areas such as the anterior mandible5. These days prosthetic requirements dictate, to a great extent, the precise placement of the dental implants.
Advancements in the manufacturing of the bone substitutes, the bio-compatibility of the grafting materials, the extended knowledge of bone physiology, and a wider variety of GTR materials, are all factors making the bone grafting techniques more predictable. Therefore, implant placement is now prosthetically driven.
5 - Prosthetic considerations: There is a consensus that prosthetic restoration is the ultimate objective of implant procedures. Each potential implant site should be considered from the perspective of achieving the optimal restoration.6
The are many different factors affecting the prosthodontic phase, including:
• healing abutments and their influence to create the gingival collar
• the abutment connection
• the shape of the abutments (e.g. angled abutments, anatomical abutments)
• the color of abutments
• temporary abutments.
The provisional stage of the treatment is another important factor that influences the emergence profile. It creates the papilla or the papillary illusion, etc., resulting in the final restoration.
Finally, each step of the treatment should be managed carefully in order to obtain the desired esthetic outcome, which will satisfy both the patient and the dentist.
References
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