A comprehensive and highly illustrated reference on current topics in esthetic dental implant therapy
Advances in Esthetic Implant Dentistry provides a current, comprehensive overview of esthetic implant therapy. Offering innovative step-by-step protocols for surgical techniques and case studies, the book presents practical, clinically oriented guidance firmly anchored in solid scientific research. A companion website provides videos of clinical procedures and follow-up case studies.
The book emphasizes the physiology of labial plate of bone and its influence to the overall fate of implant placement in fresh extraction sites, including several cutting-edge techniques to restore and treat deficient labial plate of bone. A novel chapter offers a solid protocol to diagnose, categorize, and treat implant-related gingival recession predictably.
* Highlights novel esthetic protocols in dental implantology, applying the latest advances in clinical techniques to real-world dentistry
* Follows up on treatment outcomes, presenting results up to seven years later
* Provides reliable, evidence-based bone regenerative methods
* Illustrates procedures step by step, with more than 2500 clinical photographs
* Features a companion website with videos of clinical procedures and follow-up case studies
Advances in Esthetic Implant Dentistry is an indispensable clinical companion for practitioners and students of periodontics, prosthodontics, oral and maxillofacial surgery, and general dentistry, bringing the reader new horizons in esthetic dentistry.
Modern Trends in Esthetic Implant Therapy
1.1 Predictability of Esthetic Implant Therapy
The journey of the sun and moon is predictable. But yours is your own ultimate art.
Suzy Kassem (2011)
This quote also applies to your future esthetic treatment plan. Scientific breakthroughs have rapidly changed the practice of implant prosthetics in dentistry today with fascinating inventions. Just as structural engineering principles must be combined with artistic skills to build an accurate building, so the same applies to implant dentistry, which should offer suitable (durable) prosthesis, using optimal designs and fabrication. Implant dentistry has come a long way from the era of the incidental discovery of osseointegration (Branemark et al. 1969). With high implant survival rates relished in the field, the focus has shifted toward creating an esthetic restoration that is indistinguishable from the adjacent natural teeth and that has stable long-lasting adjoining tissues over time. Yet the longevity of the esthetic outcome in implant therapy is now becoming the main focus for many clinicians because the current understanding is to provide not only an immediate fabulous esthetic result but also long-term success. The chauvinistic standard of having an immediate esthetic result that is promoted to conference audiences and in textbooks and publications is no longer sufficient without showing the actual outcome for patients in the long term. Therefore, more emphasis should be placed on the long-term follow-up for esthetic cases to offer clinicians predictable treatment protocols. The current shift in the understanding of esthetic implant therapy is the longevity of the treatment outcome that is documented year after year and which shows stable, healthy peri-implant tissue architecture and astonishingly durable esthetics.
In the early years of practicing oral implantology, the chief concerns were tissue health and implant survival. Over the past decade there has been a paradigm shift of increasing appreciation from long-lasting esthetics to the success of the final restoration. However, a modern affluent society often demonstrates an obsessive interest in achieving unrealistic forms of beauty, which may be detrimental to the final outcomes and perceptions of the patient. The role of the clinician is to smoothly direct the patient to her/his best interest and prescribe the best treatment protocol that can predictably work for longer while also giving the best possible esthetic result.
Market research has identified esthetics as one of the major reasons why clinicians advocate dental implants over conventional restoration methods for partial or complete edentulism. However, achieving an esthetic outcome with implant-supported restorations is significantly more challenging than with conventional restorations on natural teeth. Enhancement of the esthetic appearance supports effective and successful interactions among the soft and hard tissues (Palacci 2000). Indeed, the rationale for peri-implant plastic surgery should go well beyond pure esthetics to address issues concerning the quality of life and the psychological well-being of patients. Esthetic outcomes are based upon many variables. It is not just the implant design, surface characteristics, or type of abutment that will guarantee an esthetic result; it is rather the time spent on data collection in reaching a correct diagnosis that pays dividends in terms of function and esthetics (Jivraj and Chee 2006). This gives the patient a complete understanding of their desires by formulating the right treatment protocol. Thus, comprehending the patient's demands, and transforming them into a deliverable plan will be the best forward for the patient.
Though duplicating what nature has provided can be a formidable challenge, the placement of a dental implant in the esthetic zone is a technique-sensitive procedure with little room for error. A subtle mistake in the positioning of the implant or the mishandling of soft or hard tissue can lead to esthetic failure and patient dissatisfaction or a disastrous esthetic outcome. Since both dental and gingival esthetics act together to provide a smile with harmony and balance, the clinician must be aware of parameters related to gingival morphology, form and dimension, characterization, surface texture, and color. Therefore, the ultimate aim should be for the implant restoration to fit harmonically with the frame of the natural smile.
A preoperative assessment of the patient's expectation is of paramount importance to depict the predictability of the esthetic vector. To achieve a successful esthetic result, implant placement in the esthetic zone demands a thorough preoperative diagnosis and treatment plan combined with excellent clinical skills. The predictability of the esthetic outcome of an implant restoration is dependent on many variables, including but not limited to the following: (1) patient selection, (2) tooth position, (3) root position of adjacent teeth, (4) phenotype of periodontium and tooth shape and the osseous crest height, (5) the available osseous anatomy of the implant site, (6) position of the implant, and (7) the related facial anatomy, which impacts the overall fate of the treatment plan (Elaskary 1999).
Garber (1995) and David, Garber and Salama (2000) described restoration-driven implant placement as a process where the final form of the restoration is decided upon first and then backwards, while the implant fixture is seen merely as an apical extension of the restoration. It emphasizes the importance of providing high-quality and esthetically demanding fixed prosthodontics. Since the ideal placement of dental implants should be determined by prosthetic parameters, the exact positioning of the implant with respect to location and angulation is often a delicate procedure (Misch 1997). In complete hybrid prosthetics supported with multiple fixtures, implant positioning might be more forgiving than in single or partial implant supported restorations with single tooth implant-supported restorations where a minimal error might be magnified and might lead to a serious esthetic outcome (Misch 1997).
With increasing demand toward patient-driven esthetics, numerous types of radiological and surgical innovations have been proposed. For example, CAD/CAM-assisted (Computer Aided Design/Manufacture) implant placement provided a major leap in reducing implant alignment problems and ensures better esthetics, with many studies emphasizing the radiographic diagnostics (Engelman et al. 1988), computed tomography ()-based prosthetic treatment planning, or precise bone-mapping (Pesun 1997) and then guidance for the surgical implant placement (Minoretti, Merz, and Triaca 2000).
1.2 Where We Were
Esthetic implant therapy started many years ago, taking advantage of the ever flourishing nonstop human need for esthetics and adornment (Elaskary 2003). Although some of the procedures used were groundbreaking in their day, several have now become obsolete.
Over the years clinicians have thrived by reproducing only natural tooth shape, color, with gingival contours as close as possible to natural oral conditions. Surgical advancements started to evolve using esthetic surgical protocols that enabled esthetic implant-supported restorations to duplicate the original contours and profile characters of the natural teeth from all aspects. Elaskary (2008) consequently made several attempts to provide a protocol for 3D implant positing along with several soft tissue sculpturing procedures.
In esthetic sites, the goal of surgical therapy was to achieve successful implant-tissue integration and to sustain healthy esthetic peri-implant tissue contours that re-establish both function and esthetics. Therefore, a clear understanding of the specific needs of a patient in a given clinical situation and the need to master the necessary surgical techniques to achieve the treatment objectives were considered paramount. In non-esthetic sites, however, the primary goal of surgical therapy was to achieve a predictable hard and soft tissue integration of the implant to re-establish a long-lasting function with the implant-supported prosthesis.
Many factors were used to the optimize the implant fixture position in relation to its adjacent tissue contours (either when placed with guided assistance or non-guided), including the available soft tissue thickness, the overall original tissue volume prior to surgery, the degree of accuracy of the fabrication of the surgical template, the condition of the adjacent natural teeth and its relationship to the gingival architecture, the available occlusion, and the ability of the dental technician to develop natural-looking prosthetic contours (Elaskary 2003).
It has also been learned that the gingival tissues around dental implant fixture components should be enhanced and developed, at several phases to acquire the same dimensions and configurations of the original tissues around natural dentition. The original soft tissue configuration around natural teeth possess a flat profile at the point where they emerge from the free gingival margin after implant fixture placement. The subgingival area, and particularly the biological width, is the part that harbors the development of the emergence profile of the final prosthesis to match the dimensions of the tooth...