Esthetics In dental

implant
Under Supervision of Prof.Dr.Sameer Koheil
Presented by:
Rowane Hassan
Sherief Aymen
John Asham
Sanaa Youssef
Outline

2
Introduction
•Oral prosthetic restoration on dental
implants is a predictable procedure
in most cases.
•Current implantology is concerned
not only with the long-term success
of dental implants (survival on the
arch, or bone integration), but also
with the functional and esthetic
outcomes of the oral rehabilitation
on dental implants (the prosthetic
restoration and its dentomaxillofacial
harmony).
•Placement of implants, especially in
cases of partial edentation, requires
functional tridimensional location
identification, which ensures long-
term implant survival, at the same
time requiring the consolidation of
the bone and gum structures, which
ensures long-term esthetic results.
Esthetics and functionality should go
hand in hand in all dental and
periodontal zones, not just in some
• From the classical point of view, the esthetic zone is the
anterior maxilla, although most of the upper
dentoperiodantal structures actually participate in overall
facial harmony.
• The prosthetic restorations in this area are a challenge for
the oral rehabilitation team, especially because of the
maximum involvement in the general physiognomic aspect
of the patient.
• The esthetic aspect requires a correlation of the hard tissue
parameters and the soft tissue that need to be harmonized.
Both dental and gingival esthetics interlace for a nice smile
and a balanced, harmonious facial appearance. The
clinician should be well practiced and also consider the
gingival factors (morphology, texture, color, shape, and size)
• Implicitly, the bony support must be assessed for quantity
and quality. The maxillary bone is both the infrastructure on
which the gum develops and shapes, and the receiver of the
dental implant. 5
DIAGNOSIS AND TREATMENT PLANNING

To achieve a successful esthetic result, implant

placement in the esthetic zone demands
thorough pre operative diagnosis and
treatment 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.
 Clinical situation

• This patient should determine

• If this “gummy smile” is a
• Concern so that it should be
• Treated before implant
• Placement.
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.
Establishing the
diagnosis and
planning the
therapeutic sequence

10
• The therapeutic outcome in uni- or multidental upper anterior edentation
is a challenge, especially when several teeth are missing. Preserving or
reconstructing a gingival morphology that gives the illusion of natural
teeth is hard, and very often small technical slips will ruin the esthetic
outcome and lead to patient dissatisfaction
• A good esthetic result of prosthetic reconstructions on implants placed in
esthetic zones depends on a judicious preoperative diagnosis and
adequate therapeutic planning.
• Preoperative anamnesis is important both for the patient assessment
and for his/her esthetic expectations. The patient should undergo an
overall health assessment. Possible medical problems that could
contraindicate surgical operations could be evidenced. The patient’s
dental state and history of dental and periodontal conditions should be
assessed, and an oral and cervicofacial examination should be
performed. 11
• The results of the imaging tests (dental radiographs, cone beam computer
tomography [CBCT] scans) are analyzed and evaluated in the light of the clinical
findings and esthetic expectations. Study models and oral and facial photos will be
taken to complete the perioperative documentation. This comprehensive
examination may establish a number of esthetic risk factors for the prosthetic
restoration supported by dental implants
• A number of general pathological states, parafunctions (eg, bruxism), smoking, or
poor oral hygiene should also be taken into account as potential risk factors for the
functional and esthetic outcome of implants in the esthetic zone.
• The ideal placement of implants, and the optimal prosthetic result, requires the
evaluation of the edentulous space in relation to the facial, dental and periodontal
examination.
• The success of the bone integration involves achieving a balance between
functional and esthetic factors, with an asymptomatic interface between bone and
implant and permanently healthy peri-implant gingival tissues
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 • Absence of implant mobility.
Criteria of • Radiograph examination does not
successful evidence peri-implant
implants radiotransparency.
• Vertical bone lysis is less than 0.2
mm/year after the first year of
functional prosthesis.
• No signs of gum inflammation,
bone infection, pain, neuropathy,
or paresthesia.
• A success rate of 85% after 5
years and 80% after 10 years are
the minimum accepted criteria
•Another objective of implant treatment is to preserve the bony
and gummy structures and fulfill the esthetic purpose in
accordance with the patient’s objective and subjective
demands
•The predictability of the esthetic outcome in the anterior
maxillary zone depends on a number of factors, among which
the most important are the esthetic parameters referring to the
smile line, dental position, status, and morphology of the
crowns and roots of neighboring teeth, the gingival biotype, the
level of gum recession in the edentation, the morphology of the
bone support and its spatial position, and the implant position
Esthetic Considerations

 The Course of the alveolar ridge

 The course and state of the health of The

mucosa

 The crown form

 The inter dental spaces

 Lip support
Alveolar ridge

 Adequate width

 well rounded.
Status of
mucosa

• Loss of normal
architecture of
gingiva and papilla
should be noted and
treated
The position of the remaining teeth and roots, and
the periodontal condition of the teeth that limit the
edentulous zone:

The remaining teeth should be assessed clinically and radiologically in order to establish their relation with
the edentulous space. The position of the roots inclined toward the edentation limit the correct placement of
the implant. Distancing the implant from the interproximal space in order to avoid contact with the
neighboring root will place it outside the ideal site, and may limit the spontaneous recovery of the dental
papillae by provisional crowns. These patients should undergo preoperative orthodontic treatment .

An important factor in the prediction of the therapeutic and esthetic outcome is the level of the interproximal
bone. Teeth with marked lyses of the proximal bony septum represent an increased risk for the esthetic
result, and even for the success of the implant. Local vertical augmentations of the interproximal bone are
not too predictable due to the local conditions (avascular root or sepsis due to the impossibility of sealing the
periodontal space). More predictable and recommended are augmentations of the soft tissues, by soft tissue
grafts
The shape of the gum line and the
interdental papillae:

The gum line may have a normal, marked, or flat shape, usually following the bone
structure. In the case of a normal and healthy periodontium, the underlying bone is
situated 2 mm below the cementoenamel junction (CEJ), and at 3.5 mm at the
central incisor. Thus, in the case of a markedly high gum line, there will be more
gingival tissue interproximally, and more coronary positioned, than in the vestibular
tooth neck area. The flat gum line is easier to reproduce as it follows the bone level
more closely.

The interdental papilla is supported by the proximal bone at the level of the teeth,
limiting the edentulous space. The height of both the interproximal bone and the
edentulous spaces determines the esthetic outcome. The bone in the edentulous
area should be at a physiological distance of 2 to 3 mm from the gingival margin
The periodontal biotype:

• This is one of the essential parameters determining the esthetic outcome of dental restorations in the
maxillary anterior zone. The periodontal biotype determines the surgical approach and establishes the
esthetic limitations. Two main periodontal biotypes are described: thin-scalloped and thick-flat.
• In the case of the thin-scalloped biotype, the periodontal architecture is pronounced and frail. It is
characterized by bone fenestrations and minimal gingival attachments. Surgical operations often entail gum
recession. Minimal surgical interventions are recommended, and the flaps created should not touch the
blood supply in the implanted bone bed.
• In a case such as this, the patient should be informed regarding possible gum and bone recessions and the
necessity of augmentation procedures. One way to prevent such periodontal reactions is to place the
implant more palatally and the implant neck more apically.
• In the case of a thick-flat, firm biotype, the periodontal tissue mass is fibrous and dense, with an increased
amount of keratinized gum. The periodontal tissue bears trauma better, and gum recession is minimal. This
periodontal type reacts to trauma by forming periodontal pockets
• Also, postoperative scars are more obvious, which might affect the final esthetic appearance. Nevertheless,
long-term tissue stability is predictable, once the esthetic objectives have been achieved
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

senstive 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 of the implant in a
slightly more palatal position to implant
to reduce the chance of recession and
prevent a titanium “shadow” from
showing through the the thin gingival
tissue.
Crown Form

Fabrication Of supra
structure for implants to
be symmetrical to the
adjacent teeth.

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.
Bone morphology of
the alveolar crest:
•The bony support is one of the defining factors of
the success of implant therapy, as well as its long-
term survival and esthetic outcome. The ideal
tridimensional configuration of the alveolar ridge
ensures a functional and stable placement of
dental implants. At the same time, adequate bone
morphology represents an infrastructure that helps
preserve the soft tissues sufficiently to ensure
esthetic success. Thus, besides the bone
integration of the implants, there is also the
premise of a well-located fibromucosa, which limits
the prospect of gum recession.
• If the bone anatomy and/or volume are inadequate, additional surgical procedures are necessary to
restore the lost bone contour and volume. The patient must be informed and understand the
therapeutic requirements for bone and soft tissue augmentation before the treatment so as to obtain
the expected results
• The bone architecture is analyzed tridimensionally, clinically, and by imaging. Current imaging
techniques, such as cone beam scanning, have become accessible, and are very useful in
tridimensional bone analysis. Clinical examination should not be dismissed as it plays a major role
in establishing diagnosis and therapy.
• As the bony substrate is a basis for gum volume and position, often bone augmentation also
requires soft tissue augmentation. This aspect is particularly important in vertical bone defects,
which are less predictable and more difficult to manage.
• The loss of bone volume may also be assessed before extraction. Kois considers that the level of
the anterior cervical bony ridge of the tooth in relation to the free gum margin is defining in the
assessment of the bone deficit that will occur after extraction. The greater the distance, the greater
the bone deficit will be after invasive procedures. Generally, the vertical distance between the free
gum margin and the bone ridge is 3 mm, and a 1 mm bone resorption may be expected after the
implant placement immediately after extraction. A distance larger than 3 mm may determine greater
resorption. Thus, measurement before the operation may help the decision: a distance of more than
3 mm of the dentogingival complex requires orthodontic extrusion before the extraction.
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 edentuloush site, are
important determinants of esthetic of
success.
The bone crest should be within a
physiological distance of 2 to 3 mm of the
cemento-enamel junction to allow for
convenience emergence profile of the final
prothesis

We should also preserve at least 2mm of

sound bone adjacent to the implant.
The distance between the underlying
interproximal natural teeth and the bone
height on the adjacent natural teeth and the
final prosthetic contact point dictates the
formation and spontaneous regeneration of the
inter dental and 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.
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
The smile line
 1 2 3 4

The shape of the On average, a smile Clearly, a high smile The line of the lower
upper lip and its reveals about 75% to line calls for more lip is an element of
relation to the dental 100% of the anterior attention to esthetics facial harmony, its
and periodontal incisors’ height and than one revealing relationship with the
structures are adjacent gum. If the less than 75% of the maxillary incisors
extremely important upper lip line is lower, teeth. In a high upper allowing the
in the assessment of less than 75% of the lip line, the smile will assessment of the
dental esthetics. This incisors’ height will uncover the tooth curvature and
relationship is the show . neck margins and the inclination of the
starting point for gum, and the gum-, incisal plane, the
esthetic restorations tooth relation is an position of the incisal
in the anterior important esthetic margin, and the
maxillary zone. At the factor in the maxillary vestibular inclination
same time, this aspect anterior zone. of the anterior teeth.
determines the
therapeutic methods
for the reconstruction
of dentoperiodontal
harmony.
In the case of a relaxed smile, the incisal margin of the maxillary anterior teeth should follow the line
of the lower lip. If the incisal margin is too anterior or posterior in relation to the internal margin of the
red lip portion, there is a supposition of abnormality.

The mucogingival line is also assessed, and a marked pattern is corrected by gingivectomy. The
lateral incisor may be at a slightly different level from the central incisor, or have the same level. The
patient should be informed of an exaggeration of the uneven level or asymmetries of the gum line.
Even if not perceived, the existing gum line will be a reference for the esthetic restoration.

The anterior teeth provide the support for the upper lip. If there are many anterior teeth missing,
patients may request a more labial position of the prosthetic reconstruction in order to have more
labial support. Besides the fact that the general esthetic effect may be affected, the positioning of the
teeth outside the neutral muscular balance zone will cause an abnormal stress on the implant, with
repercussions for the bone and gums. The anterior teeth should be situated inside the “functional
envelope” determined by the muscular balance between the lip and tongue. Repercussions are felt at
the functional, esthetic, and phonetic levels, but also at the morphological level.
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
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 2 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.
 Placing the implant too far labially will
result in that is impossible to esthetically
bulky crown .
 We should preserve 2mm of bone buccal
and linual to the implant.
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 2 mm
below the CEJ of the neighboring teeth.
Mucoperiosteal flap

A preservative inter dental papillae incision is

advantageous because it helps to prevent
dropping of the mucoperiosteal flap with
subsequent recession
Immediate Esthetic Implant Therapy

The high clinical success rates that have been reported

when implants placed in standard situations have,
especially for implants that are placed in more
demanding esthetic situations.

One of these improvements is the procedure for

immediate tooth replacement with dental implants in
fresh extraction sockets.
 Immediate implant placement is particularly challenging in
the esthetic zone .
Only limited number of patients with low esthetic risk, intact
bone walls, thick facial bone wall (at least 1 mm), with no
infection at the extraction site and bone volume providing
sufficient primary implant stability, and are candidates for
such approach.
Despite the reduced treatment time and optimal bone volume
available for the implant placement, immediate protocol is
associated with increased risk of gingival recession.
Approximately 30 % of such sites have gingival recession of
at least 1 mm.
Protocol of immediate implant placement in conditions of
unfavourable gingival biotypes, the lack of bone or soft tissue
in patients with a high smile line lead to esthetic failure which
20XX
is very important in the esthetic region.
PRESENTATION TITLE 54
In the maxillary anterior region, it is important to avoid
placing the implant directly into the extraction socket.

Placing the implant in this position will invariably cause

the implant to perforate the buccal plate and jeopardize
the survival of the implant or cause a poor esthetic
result.
Impressions can be made immediately after
implant placement, which facilitates
fabrication of prosthetic abutments and
provisional
restorations.

The abutments and provisional restorations

can be inserted in place post-healing.
 Flapless Implant
Installation

Recently the flapless implant placement

technique has been increasingly used to offer
several clinical advantages
Some factors are considered to be detrimental
to this treatment modality, including :

lack of direct visibility because it is considered

to be a blind surgical technique.

the difficulty in assessing any existing labial

osseous defects at the time of implant
placement.

the absolute necessity for using axial

tomography or a CT scan preoperatively to
evaluate the osseous topography
A flapless approach for immediate and delayed
dental implant placement in the alveolar ridge
to:

 maintain the natural soft tissue contours.

 reduce intraoperative bleeding.
 reduce post-operative patient discomfort.
 preserve alveolar ridge integrity, and avoid
additional soft tissue trauma by raising a
mucoperiosteal flap.
In the case of immediate implant
placement, the clinical procedure for the
flapless placement technique starts with
an atraumatic extraction
Preserving Biological Soft Tissue

Contours Socket Seal Template Due to the significant

advancements in dental implantology,new titanium or
ceramic abutments have been developed for esthetic
implant restorations.

Anatomical abutments that replicate tooth morphology

have been introduced to create a better emergence
profile .
The method is used when immediate implant
therapy is being conducted, by applying an
immediate, delayed, or nonfunctional type of loading
.

This method is aimed at preserving natural tissue

contours post-operatively,.
 Timing of implant placement

• Following tooth extraction,

• Implant can be placed immediately
(Type 1)
• Early after soft tissue healing (Type 2)
• Partial bone healing (Type 3),
• After complete socket healing (Type
4).
• Clinician should bring the important
decision on the appropriate time of implant
placement.
• Patient desire for reduced treatment time
should be weighed against the possible risk
20XX PRESENTATION TITLE 63
 The recommended protocol for the esthetic zone is Type 2 placement,
4 to 8 weeks following tooth extraction
At that time the soft tissue is healed and a slight
flattening of the buccal wall is present as a result of a
bundle bone resorption .
The main aim of this protocol is the soft tissue healing
that would provide its sufficient volume and the
wide zone of keratinized mucosa allowing the
primary tension-free closure following guided bone
regeneration procedure.
In this way risk of esthetic complications is minimized.
This approach is suitable for the most cases with low to
high esthetic risk.
20XX PRESENTATION TITLE 64
 • Deviation from this protocol is necessary in cases of
large apical bone defects that compromise primary
implant stability.
• In this situation, early implant placement with partial
bone healing following 12 to 16 weeks (Type 3) is
indicated.
• Although newly formed bone in the extraction socket
supports implant and provides sufficient primary
stability, at the same time flattening of the facial bone
wall occurs as a result of bone remodelling and requires
contour augmentation using bone filler with slow
20XX resorption rate for acceptable esthetic result
PRESENTATION TITLE 65
 Implant selection

• For the regions of central incisor and canine where the

tooth width is at least 7 mm regular neck implants are
recommended
• For lateral incisor region narrow neck implants should be
used.
• Implants of reduced diameter with new titanium zirconium
alloy that exhibit high mechanical resistance can be a
viable alternative to extensive bone augmentation
procedures.
• Wide-neck and wide-platform implants should be avoided in
the esthetic zone since implant shoulder positioned to
facially causes resorption of facial wall and gingival
20XX
recession PRESENTATION TITLE 66
 Implant placement:
• After proper treatment planning and tissue grafting, a
recipient site is prepared for implant placement.

• Prior to implant placement, various things should be

considered to increase the chances of an ideal implant
esthetic result.

• The interproximal bony architecture should be within 5

mm of the proposed contact point, and adequate
soft tissue should be present.

• Having ideal bony and soft tissue architecture to

support the soft tissue of an implant recipient site is a
20XX key step to obtaining ultimate implant esthetic results
PRESENTATION TITLE 67
• During osteotomy preparation, care should be taken to
adequately space the implants from adjacent teeth or
other implants.
• A minimum of 1.5 mm should be allowed for the space to
an adjacent tooth and a minimum of 3 mm should be
allowed to an adjacent implant.
• A slight lingual angulation of an implant is preferred in the
anterior region, to allow for increased soft tissue bulk.
• These measurements allow for adequate blood supply to
support the overlying papillae. Careful consideration to
angulations of adjacent structures should also be made, to
avoid perforations.
• Detailed treatment planning that includes guide stents
should avoid spacing and perforation problems
 • After implant placement, the decision to submerge the
implant or leave it exposed transmucosally must be
made.
• A submerged implant requires uncovering at some point
after implant osteointegration.
• Leaving an implant submerged is usually done in softer
bone when there is simultaneous grafting being done, or
if the pressures of a provisional restoration could create
overloading on an implant.
• An advantage to leaving an implant exposed with a
transmucosal extension (healing abutment) is the ability
to form the surrounding soft tissue and to create an
emergence profile.
• A healing abutment can be used if the bone is stable and
20XX if provisional prosthetic pressures allow for it.
PRESENTATION TITLE 69
Referenc
e:
• Forna N. Tratat de Protetică Dentară (Treatise of Dental Prosthetics). București: Editura
Enciclopedică; 2011: pp. 2. 2.
• Jivraj S, Reshad M. Esthetic implant dentistry: diagnosis and treatment planning. In: Frost
RJ (ed) Oral and Maxillofacial Surgery. Elsevier; 2018: pp. 391-409. 3.
• Reshad M, Jivraj S. The influence of posterior occlusion when restoring anterior teeth. J
Calif Dent Assoc. 2008;36:567- 574. 4.
• Jivraj S, Chee W. Treatment planning of implants in the aesthetic zone. Br Dent J.
2006;201:77-89. 5.
• Jivraj S. Treatment planning: An art or a science? J Calif Dent Assoc. 2008;36:563-564. 6.
• Mankoo T. Maintenance of interdental papillae in the esthetic zone using multiple
immediate adjacent plants to restore failing teeth—a report of ten cases at 2 to 7 years
follow-up. Eur J Esthet Dent 2008; 3(4):304–322. 7.
• Sullivan RM. Perspective on esthetics in implant dentistry. Compend Contin Educ Dent.
2001;22:685–692; quiz 694. 8.
• Magne P, Belser U. Natural oral esthetics. In: Bonded porcelain restorations in the
anterior dentition. A biomimetic approach. Chicago: Quintessence; 2002: pp. 57-99. 9.
• Sarver DM, Ackerman MB. Dynamic smile visualization and quantification: part 1.
Evolution of the concept and dynamic records for smile capture. Am J Orthod Dentofacial
Orthop. 2003;124:4-12. 10. Bhuvaneswaran M. Principles of smile design. J Conserv Dent.
2010;13:225–232. 11.
• Khzam N, Mattheos N, Roberts D, Bruce WL, Ivanovski S. Immediate placement and