Dental Implants in the Aesthetic Zone

Michael Tischler, DDS


Coordination of all these required steps is not only performed by the implant surgeon and restorative dentist, but also requires communication with the dental laboratory team that creates possibly the provisional and final restoration. Clearly many tasks have to come into play to create success.

Replacing an anterior tooth (or teeth) in the aesthetic zone requires that every aspect of implant dentistry align with perfection. As Dr. Carl Misch says, “You don’t want your first implant to be an anterior tooth on an attorney with a high lip-line.” That is surely good advice!

Many factors and clinical disciplines come into play when replacing teeth with dental implants. When the teeth being replaced are clearly visual, the bar is raised to a very high level. All implants placed require correct spacing between them, ideal soft tissue around each implant, and adequate bone support. With dental implants in the aesthetic zone, these criteria for success become even more important.

In this issue, an article by our esteemed Dentistry Today Implant Advisory Board member Dr. Michael Sonick, and his co-author Dr. Debbie Hwang, discusses the key points of creating soft-tissue excellence in the aesthetic zone. Their techniques dealing with forming the soft tissue when uncovering an implant are based on important principles of soft-tissue manipulation, vascularity, bone grafting, and more. Creating an ideal aesthetic result to replace a missing tooth mandates that the clinician have a firm understanding of sound biologic principles, and, in addition, the knowledge of how these principles all coordinate and meet together in harmony.

Treatment planning for aesthetic zone tooth replacement from a surgical standpoint entails the following: the principles of correct implant spacing; ensuring adequate keratinized tissue; providing atraumatic extractions; assuring the correct implant depth apically; assessment of a high smile-line; bone grafting (presurgical, during surgery, and uncovery); choosing the correct implant length, shape, and geometry; and having the correct surgical skills to allow all of this (and more!) to happen. From a prosthetic standpoint, implants in the aesthetic zone require the following: choosing the correct abutment from a material and morphology standpoint; choosing the correct healing cap at uncovery; taking accurate impressions either with a tray or digitally with a scanning jig; choosing the right provisional restoration during implant healing; creating an ideal occlusal scheme; choosing the right shade; and choosing the correct final material that creates aesthetic and clinical excellence.

Coordination of all these required steps is not only performed by the implant surgeon and restorative dentist, but also requires communication with the dental laboratory team that creates the provisional and final restoration. Clearly many tasks have to come into play to create clinical and aesthetic success.

While replacing one or more teeth in the aesthetic zone with implants is a challenge, replacing an entire arch of teeth offers a different set of challenges. When replacing a full arch of teeth, larger scale issues become more evident. For example, the surgical and prosthetic issues not only concern the aesthetic zone, but the issues become larger and treatment planning issues change. As a result, the focus becomes more macro and less micro. While the same principles for the soft tissue and hard tissue are in play to achieve success, with a full arch they become more related to facial, speech, TMJ/muscle, and occlusal issues. Prosthetically, the steps for success and material choices also become more critical.

Treatment planning is the key to success in implant dentistry, and this is especially true when implants support teeth in the anterior region. One key concept of treatment planning is site development for implant placement. Site development entails hard- and soft-tissue augmentation so that the end result looks similar to natural teeth. Dr. Carl Misch has categorized tooth replacement for fixed prosthetics as fixed prosthetics 1 to 3 (FP1, FP2, FP3). The FP1 situation is tooth replacement that looks similar in size to a natural tooth or teeth with no pink gingival areas. An FP3 situation has prosthetic teeth that replace the pink gingival areas as well as the teeth.

When treatment planning an FP1 clinical situation, the natural gingiva must be very carefully assessed to predict the chance of recession. The patient’s lip-line is very crucial for an FP1 situation so that any soft-tissue/implant deficiencies are not shown. The main clinical and surgical issues with FP1 concern augmenting the bone and soft tissue to allow for a natural tooth position. With an FP3 situation, the exact opposite is true. Instead of augmenting bone, it is crucial to reduce bone through alveoloplasty to gain an ideal aesthetic result with regards to a patient’s high smile-line. Instead of creating natural tissue, the clinician is creating artificial tissue with acrylic, porcelain, or zirconia. These are 2 opposite bone level approaches have the same clinical result in mind. The common factors for success, though, are the same principles of basic osteotomy preparation, and fundamental prosthetic steps of impression-taking, laboratory steps, and material choices. In the end, the principles related to the soft tissues that Drs. Sonick and Hwang have outlined in their article are crucial for every situation in the anterior of the mouth. While the bone supports the tissue that is seen, the tissue itself drapes and supports the implants.

Guided Gingival Growth: Improving Aesthetics During Second-Stage Surgery

Michael Sonick, DMD, and Debby Hwang, DMD, describe a new approach to augment soft tissue at the time of second-stage surgery without secondary gingival grafting.

Technology to Control Excessive Occlusal Contact Force: Enhancing Implant Restoration Longevity
Christopher J. Stevens, DDS, centers a discussion on principles of occlusion and aesthetics as related to implant dentistry.

Achieving Anterior Aesthetics in a Full-Arch Implant Case
Dino Javaheri, DDS, presents a large full-arch case that emphasizes the importance of a smile design analysis for aesthetic success.