Importance of esthetics in implant dentistry

1. Dr. BALAGANESH BDS,
PGCOI.

2. Esthetic Dentistry
“Art and science of dentistry applied to create or enhance beauty of an
individual within functional and physiological limits.
In Implant Dentistry,
• Esthetic component – Critical for successful outcome and
Pt’s satisfaction
• Proper treatment planning
• Multidisciplinary approach

3. ESTHETIC CRITERIA ( Sarver & Ackerman) :
Macro - esthetics Mini - esthetics Micro - esthetics
Profile Incisor display Gingival heights
Vertical proportions Transverse smile Triangular holes
Lip fullness Smile symmetry Emergence profiles
Chin projection Crowding Spacing
Nasal projection Smile arc Tooth shade
Ears Tooth space
Incisor angulations

4. Factors influencing the Esthetic outcome :
 Patient selection
 Smile line
 Tooth position
 Root position of the adjacent teeth
 Biotype of the periodontium
 Bony anatomy of the implant site
 Position of Implant

5. Esthetic troubles after errors in implant positioning :
Implant placed,
 Too shallowly – Ridge lap – Compromise soft tissue health
 Too deep – Instrumentation problem - Compromise adjacent teeth health
 Too palatally – Biomechanical compromises
 Too close together – Compromise future implant prosthetics – Papilla loss
 Too facially – Thinning of bone – Tissue recession

6. (2)
(3)
(1)
(5)
(4)

7. Factors related to Peri-implant bone loss :
 Surgical trauma
 Stress at coronal region of implant after loading
 Bacterial leakage – Implant-abutment microgap
 Localised inflammation - Implant-abutment interface
 Biological width theory
 Repeated screwing and unscrewing of Abutment
 Peri-implantitis
 Implant neck geometry

8. Possibilities to minimize Peri-implant bone loss :
 Altering the implant neck design
 Microthreads at coronal aspect of the implant
 Altering the implant surface characteristics
 Diameter of implant
 Use of one-piece implants
 Placing implants in relation to alveolar crest

9. Esthetic factors in multiple implant supported restorations :
 Ridge Width
 Soft tissue volume
 Smile line

10. Implant placement in the Esthetic zone demands thorough
understanding of ,
 Anatomic
 Biologic
 Surgical
 Prosthetic principles

11. Esthetic Considerations
 Course of the Alveolar ridge
 Course and state of the health of mucosa
 Crown margin
 Crown form
 Interdental Spaces
 Lip support
 Smile line

12. Alveolar ridge
• Adequate width
• Well rounded
Status of mucosa
• Loss of Gingival architecture & its papilla
• Gingival recession & Biotype

13. Crown margin
• Fabrication of supra-structure for implants to be symmetrical
to the adjacent teeth
Crown Form
• Selection of proper implant diameter helps in design of single missing
natural tooth
Inter dental spaces
• Successful placement of the implant at the site at which the crown unit is
to be buildup is the prerequisite for correct formation of inter dental
spaces
• Vertical bone height – determinants of esthetic success
• Bone crest – 2 to 3mm to CEJ >5mm – Compromised papilla

14. Lip support
• The lost tissue must be built into the reconstruction in such a way
that lip support, profile, function, esthetics and phonetics are
reproduced while placing the implants
Smile line
• Decisive factor – patient’s esthetic success
• Lower margin of upper lip – Guide – Visibility of the teeth & Gingiva
• Three possible situations ( REITHER ) – Incisal, Cervical, Gingival
effect

15. TREATMENT CONSIDERATIONS
1. Implant placement
2. Soft tissue management
3. Bone grafting considerations
4. Prosthetic considerations

16. 1. Implant placement
• Positioning
Apico – Occlusal
Mesio – distal
Labio – palatal
• Implant sizing
Tooth root as a determinant – Optimal implant size
Diameter almost matches – natural tooth at cervical
area

17. 2. Soft tissue management
• Delicate handling – implant placement & Abutment connection
• Soft tissue grafting (if needed)
• Mucoperiosteal flap – Papilla preservation
• Second stage surgery – Bulking the keratinized tissue labially – Modified palatal roll
flap
• Deficiencies – Free gingival grafting or sliding flaps
• Papilla regeneration – Coronally repositioned flap
Lateral compression of gingiva

18. 3. Bone grafting Considerations
Does the final restorations determine the implant site or
Does bone availability determine the implant site
• Restoration driven implant placement – ultimate goal regardless of amount of
available bone
• Grafting procedures – Autogenous, allogenous or synthetic

19. 4. Prosthetic considerations – Esthetic implant
• EVALUATION of prospective implant site – Prosthetic point of view
• Implant must be understood as an extension of the optimally located super
structure
• GARBER & BELSER – Restoration-driven implant placement
Restoration-driven site development
• Newer techniques – Tooth colored abutments
Anatomical abutments – improve the emergence profile
Wide healing abutments
Ceramic abutments
• Cervical Contouring – Periimplant tissue configuration
• UCLA Abutment – Hexed & Non-hexed

21. Temporization – Major step in anterior tooth restorations
Proper and adequate stimulation of gingival tissue
Advantages – Custom provisional restoration :
1. Exact desired emergence profile can be generated
2. Surgical procedures or soft tissue management can
be avoided
3. Acts as a guide to fabricate final restoration

22. GARBER CLASSIFICATION

23. CASE REPORT-1

24. CASE REPORT-2

25. CASE REPORT-3

26. CASE REPORT-4