Overcoming aesthetic challenges in implantology – Mr. Matthieu Dupui TBRFeatured Products Promotional Features
Posted by: The Probe 14th February 2019
Many patients now seek dental implants in order to restore the function and appearance of their smile. As patients’ demands and expectations continue to grow, greater consideration towards the various aesthetic elements of implant treatment has become vital to achieving desired results. However, the replacement of missing teeth with dental implants – particularly in the smile zone – is a procedure that poses many aesthetic challenges.
It is not enough that the restoration functions well and looks like a natural tooth. The supporting bone structure and gingival tissue must appear aesthetical in shape and colour. Some studies have reported aesthetic failure in an estimated 20% of implants placed in the anterior maxilla.[i]This emphasises the importance of aesthetics as a determinant of implant success and patient satisfaction. The bone and tissue anatomy resulting from implant placement must be optimal to achieve the best outcome.
Bone tissue enhancement
A comprehensive evaluation of the edentulous site must be performed so as to ensure the patient has adequate bone quality and sufficient bone quantity for implant placement. Bone resorption typically occurs in the vacated area of a missing tooth and this condition can gradually worsen the longer the tooth remains absent. In fact, as much as 3mm to 4mm of alveolar bone resorption can occur during the first six months following tooth extraction.[ii]The greater the bone loss, the more difficult it can become to reach the ideal visual result. As such, complex regeneration may be required to correct any bone defects.
Soft tissue management
The patient’s gingival biotype should be assessed in order to help determine the risk of post-surgical recession, which can compromise aesthetics by revealing the metal components of the implant. For example, patients with a thin, highly scalloped gingival biotype are more prone to gingival recession, which is an issue that becomes exposed by a high smile line. Ultimately, the long-term stability of the soft tissue around an implant restoration is largely dependent on the presence of adequate soft tissue volume. This provides a good emergence profile of the restoration and serves to hide the underlying metal components of the implant, particularly when combined with suitable apical placement.[iii]As such, soft tissue grafts may be necessary to improve the condition of the gingiva. Although this adds another step in the restorative process, it can lead to an enhanced aesthetic result.
Placing an implant in the most optimal location is essential to achieve osseointegration, address any soft tissue deficiencies, ensure good occlusion, and provide enough space around the implant for a suitable restoration to be fitted. The aesthetic result of the restoration depends on proper three-dimensional positioning, taking into account the faciolingual, mesiodistal, and apico-coronal positions, as well as the angulation of the implant.[iv]For example, in the case of a patient with a thin gingival biotype, the implant may need to be placed further to the palatal aspect to ensure the implant components do not become visible. Some partially edentulous patients might even require orthodontic work to move dentition that have drifted as a result of tooth loss. This may be viable as an alternative to bone grafting procedures, but orthodontics can also improve spacing of the teeth adjacent to the future implant, thereby reducing the risk of diastema issues.[v]
Choice of implant
Selecting the most appropriate implant solution can be difficult and requires thoughtful preplanning. Titanium implants are regarded as the gold standard choice due to their durability, strength, and high biocompatibility.[vi]However, there is a risk that the dark greyish colour of the implant’s metal components could become visible through the gingiva.[vii]Consequently, zirconia is growing in popularity as an alternative implant material, due to the fact that it exhibits similar mechanical benefits to that of titanium, and looks like a natural tooth. Practitioners must be wary, however, that zirconia is less “flexible” than titanium and can be more prone to fracture.[viii]
Ideally, practitioners should use an implant solution that offers the best functional and aesthetic advantages. TBR’s Z1 implant, for instance, combines a titanium body with a zirconia collar in one seamless component. This unique system generates effective adhesion and proliferation of fibroblast and osteoblast cells for excellent osseointegration and epithelial healing.[ix]Soft and hard tissues are supported as the implant promotes a creeping attachment of the gingiva and reconstruction of the papillae in a way that mimics natural gingival growth. This ensures superior aesthetic management can be achieved for a truly exceptional visual outcome.
Placement of dental implants in the smile zone is a technique-sensitive procedure with little room for error, so it is essential that practitioners have a thorough understanding of anatomic, biologic, surgical, and prosthetic principles. Ensuring that the implant-supported restoration is indistinguishable from the adjacent natural teeth is particularly challenging, but practitioners that do so successfully are able to help patients achieve a smile they can be proud to wear.
For more information on the Z1 implant, visit tbr.dental, email email@example.com call 0800 707 6212
[i]Chen, S. T. and Buser, D. (2014) Esthetic Outcomes Following Immediate and Early Implant Placement in the Anterior Maxilla – A Systematic Review. The International Journal of Oral & Maxillofacial Implants. 29(Suppl): 186-215. doi: 10.11607/jomi.2014suppl.g3.3.
[ii]Van der Weijden, F., Dell’Acqua, F. and Slot, D. E. (2009) Alveolar bone dimensional changes of post-extraction sockets in humans: a systematic review. J Clin Periodontol. 36: 1048-1058. doi: 10.1111/j.1600-051X.2009.01482.x.
[iii]Kao, R., Fagan, M. C. and Conte, G. (2008) Thick vs. thin gingival biotypes: A key determinant in treatment planning for dental implants. Journal of the California Dental Association. 36: 193-198. Link: https://www.researchgate.net/publication/5408806_Thick_vsthin_gingival_biotypes_A_key_determinant_in_treatment_planning_for_dental_implants/. [Last accessed: 23.08.18].
[iv]Balasubramaniam, A. S., Raja, S. V. and Thomas, L. J. (2013) Peri-implant esthetics assessment and management. Dental Research Journal. 10(1): 7-14. Link: http://doi.org/10.4103/1735-3327.111757. [Last accessed: 23.08.18].
[v]Cabbar, F., Nur, R. B., Dikici, B., Canpolat, C. and Capar, G. D. (2016) New bone formation by orthodontic tooth movement for implant placement. Annals of Maxillofacial Surgery. 6(2): 316–318. Link: http://doi.org/10.4103/2231-0746.200332. [Last accessed: 23.08.18].
[vi]Osman, R. B. and Swain, M. V. (2015).A Critical Review of Dental Implant Materials with an Emphasis on Titanium versus Zirconia. Materials. 8(3): 932–958. Link: http://doi.org/10.3390/ma8030932. [Last accessed: 23.08.18].
[vii]Gupta, S. (2016) A Recent Updates on Zirconia Implants: A Literature Review. Dent Implants Dentures. 1: 113. Link: https://www.omicsonline.org/open-access/a-recent-updates-on-zirconia-implants-a-literature-review-.php?aid=82588. [Last accessed: 23.08.18].
[viii]Cionca, N., Hashim, D. and Mombelli, A. (2016) Zirconia dental implants: where are we now, and where are we heading? Periodontology 2000. 73(1):241-258. Link:https://onlinelibrary.wiley.com/doi/full/10.1111/prd.12180. [Last accessed: 23.08.18].
[ix]Bianchi, A. & Bosetti, Michela & Dolci, G & T Sberna, M & Sanfilippo, S & Cannas, Mario. (2004) In vitro and in vivo follow-up of titanium transmucosal implants with a zirconia collar. Journal of applied biomaterials & biomechanics. 2:143-50. Link: https://www.researchgate.net/publication/46037726_In_vitro_and_in_vivo_follow-up_of_titanium_transmucosal_implants_with_a_zirconia_collar. [Last accessed: 23.08.18].
Mr. Matthieu Dupui Biomedical engineer TBR Marketing Product Manager since 2013
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