ESTHETIC CONSIDERATIONS

IN DENTAL IMPLANT

Under the guidance of:

Dr. Arun Kumar Gupta(Prof.
&Head)
Dr. Jyoti Paliwal(Prof.)
Dr. Sumit Bhansali(Asso.Prof.)
Presented by:
Dr.
Ravinder(PG-2nd yrs)
 CONTENTS
 DEFINITION
 INTRODUCTION
 ESTHETIC CONSIDRATION
 TREATMENT PLANING
Esthetics from the Greek
aisthesis (perception)
Is the theory of experienced –
based judgement by which an
optical stimulus is not simply
perceived as an object of
conciousness but evaluated as
pleasant or un pleasant ,beautiful
or ugly.
 Itis the philosophy ,psychology and sociology of
the beautiful in art and nature.

 In Dentistry, Esthetics can be defined as the

theory and philosophy that deals with beauty and
beautiful especially with respect to the appearance
of a dental restoration as achieved through its
form and or colour.
 Introduction
To achieve a successful esthetic result
and good patient satisfaction, implant
placement in the esthetic zone
demands a thorough understanding of
 Anatomic
 Biologic
 Surgical

 Prosthetic principles.
 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.
 DIAGNOSIS AND TREATMENT
To achieve a successful esthetic result, implant
placement in the esthetic zone demands
thorough pre operative diagnosis and treatment
planning combined with excellent clinical skills.

Preoperative assessment of the patient’s

expectations is also of paramount importance.

If the patient is found to have unrealistic

expectations, a careful explanation might be
necessary to clarify what the patient should
expect.
Data collection
The data base must include the patients chief
complaint, comprehensive medical history,
dental history, results of extra oral and intra oral
clinical examinations, radiographic examination
results, documentation of patient expectations,
and an assessment of risk factors for implant
failure (esthetic or functional).
 For ideal implant placement and optimal esthetic
restorations, a comprehensive evaluation of the
edentulous site must be performed. Facial, dental,
and periodontal status must be evaluated.

A facial evaluation provides general esthetic

parameters, such as orientation of occlusal plane,
lip support, symmetry, gingival scaffold, and smile
line
 Esthetic Considerations
The Course of the alveolar ridge
The course and state of the health of
mucosa
The crown margin
The crown form
The inter dental spaces
Lip support
Smile line
 Alveolar ridge
 Adequate width
 well rounded.

Status of mucosa
 Loss of architecture

of gingiva and its papilla

due to loss of tooth-
Diminishes appearance.
 Gingival recession and
biotypes
The gingival biotype should be assessed because
such an assessment will partly determine the risk for
post surgical recession.

A thin, highly scalloped gingival biotype is much less

resistant to trauma from surgical or restorative
procedures and, consequently, is more prone to
recession in comparison with a thick, flat gingival
biotype.
 A thin gingival biotype dictates placement of the
implant in a slightly more palatal position to
reduce the chance of recession and prevent a
titanium “shadow” from showing through the thin
gingival tissue.

Similarly, the implant should be placed somewhat

more apically to achieve a proper emergence
profile and avoid a ridge lap restorations.
 The long term stability of esthetic soft tissue
around an implant restorations depends largely on
the presence of adequate soft tissue volume in a
vertical and buccolingual direction.
An adequate volume of soft tissue provides a good
emergence profile of the implant restoration and
serves to mask the underlying metal implant, A sub
epithelial connective tissue graft may be
considered to augment soft tissue volume when
insufficient tissue volume is present.
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
built up is the prerequisite for correct
formation of inter dental spaces.
The supporting bone influences the establishment
of overlying soft tissue compartments and the
bone quality and quantity must be carefully
assessed.
The vertical bone height in the inter proximal sites,
as well as the horizontal thickness and vertical
height of the buccal bone wall in the edentulous
site, are important determinants of esthetic
success.
The bone crest should be within a physiological
distance of 2 to 3 mm of the cemento-enamel
junction or, when recession is present, 2 to 3 mm
of the buccal gingival margin.
 The distance between the underlying interproximal
bone height on the adjacent natural teeth and the
final prosthetic contact point dictates the formation
and spontaneous regeneration of the inter dental
papillae associated with the implant .

If this distance is more than 5 mm, the complete

papilla formation will be compromised.

This often leads to the so called “blank triangle”.

This effect may differ according to whether the
implants is adjacent to another implant or a natural
tooth.
 Tarnow ,etal in 2003
Investigated the clinical problem of the
difficulty of maintaining or reforming a
papilla between two implants
One reason for this difficulty is that the
biological width around an implant is
apical to the implant abutment connection
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.
Resting lip RELAXED FULLY
position SMILE ANIMATED
SMILE
 Smile Line
o It is a decisive factor
in the evaluation of the
patients esthetics
requirements .
o The lower margin of
the upper lip also
called the smile line
,serves as an
orientation guide for
the limits of visibility of
the teeth.
 Three possible esthetic situations may arise
according to REITHER
 Incisal Effect
 Cervical Effect
 Gingival Effect
 TREATMENT CONSIDERATIONS

Four main factors directly affect the

esthetic outcome of implant supported
restorations:
 implant placement
 soft tissue management
 bone grafting considerations
 prosthetic considerations.
 Implant Placement
Implant placement is divided into
two aspects:
 positioning
 implant sizing.
 Positioning
Positioning of an implant is the first step in
gaining prime esthetic results. Fabrication
of the proper surgical guide (template) is
the key to such an achievement.
Positioning involves three planes;
 apico-occlusal,
 mesio-distal,
 labio-palatal planes.
 Positioning of implants-
esthetic criteria
Buccolingual positioning of implants

Vertical positioning of implants

Apico-occlusal positioning.
Apico-occlusal positioning of the implant in an
axial direction must be 2 to 3 mm above an
imaginary line connecting the cementoenamel
teeth.
Less than 2 mm will lead to a short crown (which
is impossible to correct), and more than 3 mm
will hinder proper hygienic maintenance because
of increased pocket depth around the
transmucosal insert.

Placing the implant 3 mm below is mandatory to

allow transfer in cross section from the implant
head diameter to the natural tooth diameter at
the point of emergence from the gingival crest.
 Labiopalatal positioning.
Placing the implant too far palatally will result in a
“ditched in “ restoration. This is over come by
using a modified ridge lap design for the final
restoration, which is unfavorable from hygienic
and esthetic points of view; it may also create
increased strain on the implant when loaded.

Placing the implant too far labially will result in an

esthetically bulky crown that is impossible to
correct, even with the use of angulated abutments.
 In screw retained anterior restorations, the
implant is generally placed slightly lingual
or palatal to the long axis of the crown.
In all cemented restorations and posterior
screw retained restorations, the implant
should be located exactly in the center of
the long axis of the crown.
Mesiodistal positioning.

Through case design and

preoperative planning,
an implant positioning
in a mesio-distal
dimension that has a
proper relationship
between the teeth can be
achieved
.
The middle orientation in a mesio-distal
direction is mandatory to avoid placing
the implant in the inter dental papillary
position and subsequent approximation
of the neighboring roots.
Mesio distal dimension of the tooth root
which determines the size of the
appropriate implant.
 TOOTH ROOT AS A
DETERMINANT FOR
OPTIMAL IMPLANT
SIZE:
 In young individuals-attachment
mechanism for natural tooth is
near CEJ.
 With age-recession is seen
 Thus, it has been concluded
that CEJ minus 2mm is a good
location to assess the average
size of a tooth root to determine
the optimal implant size for
replacing the tooth.
 MESIODISTAL CROWN AND ROOT
DIAMETER OF MAXILLARY TEETH AND
IMPLANT RECOMMENDATIONS
Mesiodist Mesiodist Mesiodist Recommend
al al CEJ al CEJ – ed implant
Crown (mm) 2mm

CENTRAL 8.6 6.4 5.5 4.1,

4.3,5.0
LATERAL 6.6 4.7 4.3 3.25,3.5,
4.1,4.3
CANINE 7.6 5.6 4.6 4.1,4.3

I PREMOLAR 7.1 4.8 4.2 4.1,4.3

 Implant sizing
Selecting an implant diameter
that almost matches that of
the natural tooth at the
cervical area will improve the
esthetic outcome.

Failure to use the proper

implant size must be
compensated for by sinking
the implant 3 mm below the
CEJ of the neighboring teeth.
 CERAMIC IMPLANT
 The PURE Ceramic Implant offers you a unique
esthetic solution to treat patients with specific
needs. While some patients have a thin gingiva
biotype, which requires a specific treatment
approach, other patients express their explicit wish
for a metal-free alternative.

 High predictability with revolutionary osseointegration

features equivalent to the established SLA® surface2,3,4
 100 % proof test ensuring reliable implant strength
 High end esthetic solution thanks to ivory-colored
material
 Soft tissue management
Delicate handling of the soft tissue is considered to
be the main factor in gaining a pleasant esthetic
out come.
Soft tissue management includes handling of the
soft tissue at the time of implant placement,
abutment connection, and soft tissue grafting (if
needed). Soft tissue management should be
considered in the following treatment steps.
Mucoperiosteal flap :
The horizontal incision should be made along a line
connecting the palatal line angles of the adjacent
teeth, and the vertical incision should be made at the
adjacent teeth (ie, a normal marginal incision should
be made with complete mobilization of the inter
dental papillae).
The incision should allow optimal mobilization of the
mucoperiosteal flap. A preservative inter dental
papillae incision is advantageous because it helps to
prevent dropping of the mucoperiosteal flap with
subsequent shrinkage (partial marginal section).
Preservation of the interdental papillae
 Soft tissue management at abutment
connection.
Second stage surgery.
At this stage, the gingival margin around the
implant can be corrected or improved to a great
extent.
Bulking the keratinized tissue labially around
the healing heads is one technique used to
enhance the esthetic outcome. A modified
palatal roll flap is commonly used to bulk up
tissue labially.
Lack of soft tissue
bulking over the labial
plate

Bulking up of the
keratinized tissue
labially during second
stage surgery
 Gingival grafting.
Soft tissue deficiencies can be corrected at this
stage of treatment (eg. A lack of keratinized
tissue would be corrected by means of free
gingival grafting or sliding flaps) .

Small tissue dimples or labiocrestal concavities

can be corrected by sub epithelial connective
tissue grafting to bulk up the tissue labially if
needed (note the soft tissue drop and
mishandling). Also, gingivoplasty, using a
diamond bur, is used to correct flat or ledged
margins.
Soft tissue drop due to improper design of
the incision
 Papillary illusion, by allowing a substantial
excess of keratinized tissues to be stabilized at
the implant site, can also be created.

 Preservation of the papillae is the most

important factor in creating a natural looking
implant supported restorations. Papillae can be
created surgically by using several techniques.
 Coronally repositioned flap
 A C-shaped incision is made at the implant site
with the convexity toward the labial surface.
The circumference of the incision should be
deeper than that of the abutment.

 Thus, when the flap is repositioned coronally,

excess tissue will be present between the
abutment and the adjacent teeth. This excess
tissue will create a papillary illusion. The
disadvantages of this technique is a reduction in
labio-attached gingiva.
 Lateral compression of the gingiva .
An incision is made over the cover screw (after
it is carefully localized using a probe). The
incision should imitate an extraction wound so
that the cover screw will be partly covered by
tissue after the incision.
This tissue should be compressed before
removal of the cover screw. After abutment
connection, the surrounding tissue will be
compressed and raised to create natural looking
papillae.
 Gingival recontouring
Several clinician technique have been proposed
for reshaping the gingival profile, provided that a
sufficient volume of soft tissue is present.

Wide, temporary healing abutment are used to

allow gingival maturation around a wide cap.
Gingival electro-surgery is used to cut the
desired gingival contour.
 Bone Grafting Considerations

Does the final restorations

determine the implant site, or
does bone availability
determine the implant site?
Prosthetically driven Amount of bone
implant placement formed after guided
tissue regeneration
 Restoration driven implant placement is the
ultimate goal regardless of the amount of
available bone.

Bone grafting procedures (autogenous,

allogenous, or synthetic ) have given the
clinician a wide range of treatment modalities
(note the proper positioning of the implant
despite the lack of labial bone and the
achievement of a good bulk of bone by means
of current grafting techniques.
Prosthetic Considerations – Esthetic
Implant
 EVALUATION of prospective implant site should
arise primarily from prosthetic point of view.

 The time long past when implants were inserted

correctly from surgeons point of view but turned
to be unusable prosthetically.

 This principle is doubly important for esthetically

demanding situations.
Implant must be understood as an extension of
the optimally located super structure.

GARBER and BELSER have described this

constraint as RESTORATION-DRIVEN IMPLANT
PLACEMENT AND RESTORATION-DRIVEN SITE
DEVELOPMENT
Soft tissue profile or prosthetic recipient site from
which the restoration emerges should be
identical to that around the contralateral tooth is
the basis for all the esthetic restorations.

Numerous restorative materials, technologies,

and clinical procedures have been developed.
for example – tooth colored abutments,
anatomical abutments, tapered but wide
healing heads.
Cervical contour-
Cervical contouring is one factor
responsible for the proper configuration of
the peri implant soft tissues. It also
corrects the discrepancies between the
diameter of the implant body and that of
the natural teeth.
 This ideal design is transferred to vital oral
tissue through the abutment and the provisional
restorations, which are fabricated to guide the
soft tissue to initiate the replica model.

Cervical contouring also focuses on shaping the

abutment and the cervical crown region
following the previous design of the surrounding
tissues.
Anatomical abutments-
Because of the discrepancy in the diameter
between the implant head and the natural tooth
diameter at the CEJ level the anatomically
shaped abutments dramatically improve the
emergence profile.

Also reduces stress on the connecting screw,

improve mechanical properties, increase
prosthetic stability, and avoid use of the ridge
lap design.
 Use of traditional narrow abutments will usually
lead to an inability to fulfill esthetic goals that it, it
could necessitate a modified ridge lap design,
which is unpleasant esthetically, make hygienic
procedures difficult, and causes undue stress on
the implant.

By using anatomical abutments, the soft tissue

will be displaced to create the same diameter as
the natural tooth at the CEJ area
Abutments available

ANGULATED ABUTMENTS

CERAMIC ABUTMENTS.
Abutments with wider cervical margin
 Improves emergence profile
 Provides greater surface area for
retention.
 Permits the crown preparation to the
needs.
Ceramic abutments
are used to enhance the esthetic quality of
implant supported restorations in the anterior
maxilla. They are usually used in cases in which
the labial soft tissues is thin to allow passage of
reflective light from a non metallic abutment.
Ceramic abutments are fabricated by suing
partially stabilized alumina-Zirconia machinable
abutments.
 After preparation of the abutment, it is
glass infiltrated and polished. The final
restoration can them be delivered to the
patient as an all ceramic crown cemented
over the abutment, or the abutment itself
can be procelainized with the abutment
acting as the final restorations.
 THE UCLA TYPE ABUTMENT
 The UCLA-Type Abutment is attached directly to
the implant. It provides a pattern for the creation
of a screw retained veneered crown.
 UCLA-Type Abutments are available in single-
implant (hexed) and multi-implant (non-hexed)
designs.
 This abutment is well suited for sites with
minimal thickness of soft tissue. It is available in
traditional plasticconfigurations, gold alloy, gold
base with plastic sleeve, and in a titanium
version for provisional restorations.
Healing heads-
Wide, temporary healing head are used to
transfer the narrow cross section of the implant
head into the triangular cross section of the
upper anterior teeth by gradually pressing
against the gingival tissue.
This should conform to the nearest cross section
of tooth structure to allow enough room for the
anatomical abutments to be placed.
 Temporization
 Temporization is a major clinical step in the
achievements of a proper esthetic result in anterior
tooth restorations . Proper and adequate stimulation
of the gingival tissue must take place because
exaggerated pressure could lead to sloughing and
necrosis.

 After second stage surgery, the tissue must be

given time to heal and mature to stabilize the gingival
margin before the final abutment is selected or final
impressions are made.
The provisional restorations allows for soft tissue
maturation. This usually take 6 to 8 weeks. The
final soft tissue profile should be replicated on
the model, so the provisional restorations should
be fabricated according to the desired gingival
contour.

By adding and shaping the acrylic resin on the

sub gingival portion of the temporary restoration,
an esthetic emergence profile and tooth
dimension can be achieved
 Fabrication of provisional
restoration
 Impression made at stage I surgery -
Fabrication of provisional restoration.

 Placement of customized provisional

restoration instead of healing abutment.
Advantages of placing custom
provisional restoration

 Exact
desired emergence profile can be
generated .

 Surgical
procedures or soft tissue
management can be avoided.

 Actsas a guide to fabricate final

restoration.
 IMPLANT PLACEMENT IN
EDENTULOUS SITES
When an edentulous site in the esthetic zone is
planned for implant placement, the site must be
thoroughly evaluated.
Garber has proposed a classification for such
sites. This classification depends on the type of
reconstruction needed to get good positioning
of the implant.
 Garber Class I
When favorable horizontal and vertical levels of
both soft tissue and bone are present, ideal
implant positioning is a straight forward
procedure.
A concomitant soft tissue augmentation at the
same time of implant placement is preferred in
patients with a thin gingival biotype to prevent
the risk of soft tissue recession and buccal
bone resorption.
 Garber Class II

Sites with no vertical bone loss and slight

horizontal bone deficiency measuring about 1 to
2 mm narrower than normal can be expanded
by using serial osteotomes instead of drilling.

This technique will permit slight expansion of the

bony ridge horizontally while simultaneously
compressing the maxillary cancellous bone to
improve the bone quality.
 Garber Class III
For sites with no vertical bone loss and
horizontal bone loss greater than Class II,
implant placement can be attempted,
provided an initial stability is achieved.
Guided bone regeneration is necessary.
 Garber Class IV

In sites with no vertical bone loss but significant

horizontal loss, it is necessary to use a staged
approach in which the ridge is widened with
guided bone regeneration.

Implants are later placed after a suitable

healing period of several months, using block
bone grafts or guided bone regeneration
techniques.
 Garber Class V
Sites with extensive apicocoronal bone loss
present a significant challenge to the surgeon.
As noted above, there are no well documented
surgical approaches available to predictably
augment bony ridge height.

Some case reports suggest a surgical approach

of guided bone regeneration using a non
restorable membrane and delayed implant
placement.
 REFERENCES
 Soft tissue and Esthetic consideration in implant
therapy: Anthony G Sclar
 Esthetics in dentistry – vol 1: Ronald e
Goldstein.
 Abd EI Salam EI Askary. Esthetic considerations
in anterior single tooth replacement.Implant Dent
1999;8:61-66
 Avishai sadan, Markus B ,Mike Bellerino,Michael
Block.Prosthetic design considerations for
single-implant restorations. J Esthet Restor Dent
16:165-175,2004.