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Dental implants in the aesthetic zone – Mr. Matthieu Dupui Biomedical engineer TBR

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  Posted by: The Probe      22nd December 2019

The restoration of anterior teeth with implant-supported restorations is arguably one of the most difficult procedures to execute. This not only relates to the clinical aspect of treatment, but also to patient demands and expectations regarding implant placement in an area of particular aesthetic significance. The ultimate aim is to provide a long-lasting restoration that enhances the aesthetic of a patient’s smile and complements the overall appearance of their face. There are various factors that clinicians should consider in order to ensure a highly satisfactory outcome.

Smile line

It is important to evaluate a patient’s aesthetic aspirations in combination with their smile line. The implant restoration interface is hidden by a low smile line, but this must be confirmed upon assessment of the patient. It is typical for 75-100% of the maxillary incisors and the interproximal gingiva to be displayed in an average smile, but additional gingival tissue is exposed by a high smile line.[i] This can pose a challenge to implant placement in the aesthetic zone, as the restoration and the gingival tissue will be completely visible when the patient smiles. In these cases, maximal effort should be given towards maintaining peri-implant tissue support throughout treatment.

Implant site

To restore an implant to an excellent aesthetic standard, the bony anatomy at the proposed implant site should permit placement of the implant in a restoratively ideal position. The hard and soft tissue in the area of an extracted tooth may need to be reconstructed to achieve optimal function and aesthetics. Bone grafting procedures can be performed to ensure that there is adequate bone quality and quantity for the implant to be placed, but this is not the only element that is key to the success of the implant site. Good surgical execution – especially using atraumatic techniques – can also lead to a more favourable outcome. 

Adjacent teeth

As they provide an immediate comparison to the implant prosthesis, the adjacent teeth should be assessed in relation to morphology and colour to ensure the provision of a natural-looking restoration. Radiographs are essential to determining the root position of the adjacent teeth, which can potentially preclude placement of the implant. There is often very little interproximal bone surrounding tooth roots in close proximity to each other. This poses a greater risk of resorption and reduction of the vertical bone height after tooth extraction or implant placement. In this case, orthodontic therapy can be provided to reposition malposed teeth and create sufficient space that is ideal for implant placement and the support of proximal gingival structures.[ii], [iii]

Implant position

The aesthetic quality of an implant restoration depends heavily on correct three-dimensional positioning of the implant, taking into account apico-coronal, mesial-distal and facio-lingual dimensions, as well as the angulation of the implant. Ideally, the implant should be placed at a distance of 1.5mm to 2mm from the adjacent teeth, otherwise bone resorption can occur. A lack of sufficient space between the implant and the adjacent teeth can also make it more difficult to create the ideal emergence profile for the final prosthesis. This could lead to oral hygiene and soft tissue complications – including reduced papilla height – which could negatively affect the visual result of treatment and increase implant morbidity.[iv], [v]

Gingival biotype

The patient’s gingival biotype should be fully considered during treatment planning for an anterior implant. Thick gingival biotypes offer greater flexibility with regard to implant placement and can be easier to manage from an aesthetic perspective, in comparison to thin and highly scalloped gingival biotypes. Patients with thin gingival biotypes are more prone to recession and the issue of the metal implant components becoming visible through the soft tissue, which can compromise the overall aesthetic of treatment.[vi] The choice of implant can make all the difference to mitigating this risk. TBR’s Z1® implant combines a titanium body with a tooth-coloured zirconia collar in one seamless component, which features excellent osseointegrative properties. The unique design of the Z1® also encourages the soft tissue to heal around the implant in a manner that closely resembles natural gingival growth to ensure it is indistinguishable from the adjacent teeth once placed.

Aesthetics have become increasingly important in modern implant dentistry. Implant placement in the aesthetic zone – where the visual end result is of great concern to many patients – presents a unique challenge. Both dental and gingival aesthetics must work harmoniously to create a truly beautiful and balanced smile. With a complete understanding of the various biological factors and clinical parameters that influence the success of treatment – and by selecting a top-quality solution – practitioners can place anterior implants in the optimal position to achieve a highly functional and aesthetic restoration.

For more information on the Z1® implant, visit tbr.dental, email support@denkauk.com or call 0800 707 6212

  

[i] Christensen, G. J., Guyer, S. E., Lefkowitz, W., Malone, W. F. P. and Sproull, R. C. (1984) Some esthetic factors in a smile. The Journal of Prosthetic Dentistry. 51(1): 24-28. DOI: 10.1016/s0022-3913(84)80097-9.

[ii] Tarnow, D. P., Cho, S. C. and Wallace, S. S. (2000) The Effect of Inter-Implant Distance on the Height of Inter-Implant Bone Crest. Journal of Periodontology. 71(4): 546–549. DOI: 10.1902/jop.2000.71.4.546.

[iii] Tarnow, D. P., Magner, A. W. and Fletcher, P. (1992) The Effect of the Distance From the Contact Point to the Crest of Bone on the Presence or Absence of the Interproximal Dental Papilla. Journal of Periodontology. 63(12): 995–996. DOI: 10.1902/jop.1992.63.12.995.  

[iv] Misch, C. E. (2015). Maxillary Arch Implant Considerations. Dental Implant Prosthetics. 615–649. DOI: 10.1016/b978-0-323-07845-0.00025-7.  

[v] Buser, D., Martin, W. and Belser, U. C. (2004) Optimizing Esthetics for Implant Restorations in the Anterior Maxilla: Anatomic and Surgical Considerations. The International Journal of Oral & Maxillofacial Implants. 19(Suppl): 43-61.

[vi] Jivraj, S. and Chee, W. (2006) Treatment planning of implants in the aesthetic zone. British Dental Journal. 201(2): 77-89. DOI: 10.1038/sj.bdj.4813820.


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