What Are the Three Most Essential Elements to Implants in the Esthetic Zone?
Barry P. Levin, DMD; Stephen L. Jacobs, BDS, FDS RCPS(Glas), MJDF RCS(Eng) and Andre Hattingh, BChD, MChD(OMP)(Pret)
There are many essential elements to achieving long-lasting esthetic and physiologic outcomes in implant dentistry in the esthetic zone. But, as a surgical specialist, there are three especially critical steps that, in my opinion, cannot be overlooked or underestimated.
First, proper implant selection is crucial and can single-handedly determine whether treatment will be successful or a total failure. As a huge advocate for immediate implant placement and immediate temporization, I believe implant design must be predictable in terms of achieving primary stability. Additionally, the implant must not encroach upon the facial socket wall or periodontal attachment apparatus of adjacent teeth. If possible, the position of the prosthetic connection should be aligned with the cingulum region of the restoration, favoring screw retention over the use of cement. Novel implants have recently come into play that satisfy most if not all of these criteria in anterior cases.
Second, and probably a bit predictably, I utilize the dermal apron technique® (DAT) in 100% of my anterior immediate implant cases.1 After introducing the technique in 2016, and following several years of successful implementation in practice, our group has published two comparative studies that demonstrate the efficacy of DAT to increase the facial mucosal thickness. First, in 2018, we demonstrated the improvements in this regard compared to nongrafted sites, and in 2020 we showed almost 1 mm increase in soft-tissue thickness when DAT was combined with an implant with a subcrestal angle correction versus uniaxial implants. Currently, the group is working on part 3, using a new, inverted body design implant with the subcrestal angle correction.
Third, a newer and wonderful approach has been the use of custom healing abutments when full-contour provisional crowns are contraindicated. Not only does this facilitate DAT, but in the same manner that temporary restorations preserve soft-tissue contours and "seal the socket," this approach falls perfectly in line with minimally invasive and maximum preservation concepts all clinicians strive to achieve.
Having practiced implant dentistry for more than 30 years, with many of my original patients returning for review or, indeed, for further implants, our practice gets the chance to critique its work. This sometimes can be a sobering experience, especially when assessing treatments in the esthetic zone. However, it also shows us how much we have learned over the years, along with what we didn't know or thought we didn't know at the time.
The three essential elements to implants in the esthetic zone, in my opinion, are hard tissue (bone), soft tissue (keratinized mucosa), and implant position. They could be termed the "holy trinity" of esthetic implant therapy.
Hard tissue-In the late 1980s and early to mid 1990s, the use of bone biomaterials was very limited, and clinicians' ability to regenerate alveolar bone was, likewise, extremely restricted. Autogenous bone, in blocks and particulates, was used to some extent, but resorption was common and success of these techniques was limited. Over the past three decades, the advent of xenografts, allografts, and synthetics, in various forms, has changed the way dentists work and the results they can predictably obtain. One vital thing dentists have learned is that the labial plate of alveolar bone overlying a tooth root is extremely thin in most cases. This means that if this bone is retained during extraction, and even if ongoing resorption is minimal, greater width augmentation alongside implant therapy will still need to be achieved.
Soft tissue-Achieving adequate bone thickness buccally to a dental implant is important, but so is the thickness and type of tissue. The connective tissue graft (CTG) has become a mainstay in treating esthetic implant cases, and the use of free gingival grafts (FGGs) is also becoming more common. Using simple subepithelial CTGs is a relatively straightforward procedure that can boost the gingival phenotype. In some cases where the keratinized band of tissue is deficient (eg, when an initial bone graft has previously been carried out), a FGG may be required to widen the band of more fibrous tissue.
Implant position-Three-dimensional implant positioning is a complex subject that requires a much more detailed discussion than this roundtable article will allow. However, suffice it to say there are only two positions in which an implant can be placed: the perfect position and everywhere else. In implant dentistry, a millimeter might as well be a mile.
To summarize, this triad of factors goes a long way in achieving long-term predictable success with esthetic implants. None of these factors are mutually exclusive.
What is interesting is that among the cases from all those years ago, many of which today would be regarded as esthetic failures, virtually none of the patients expressed any concern about the appearance of their restorations. This can probably be explained by the phrase "patient expectations." In years past, the ability of an implant to osseointegrate was enough to satisfy patients, while today it is not, and esthetics play a vital role. Perhaps the dental profession, utilizing many technological advances and a greater understanding of what is required, has set an extremely high bar for itself to meet.
Implantology is a restorative procedure with a critical surgical component, and planning should therefore start with the end goal in mind. The first essential element (following comprehensive planning) is the precise 3-dimensional positioning of the implant in relation to the planned restoration and/or the removed tooth in the case of immediate implant placement.
It is generally accepted, and has been overwhelmingly agreed, that the positioning of the implant is the main factor determining the design (shape/form) of the final restoration. If the implant placement position is imperfect, modifications have to be made to the restoration, which generally results in esthetic compromises. The more ideal the placement position of the implant is (in terms of buccolingual, mesiodistal, and apicocoronal dimensions), the easier the design and placement of the final restoration and attainment of an optimal esthetic result will be.
The second most essential element is achieving a good soft-tissue profile. Matching contours and buccal/labial volume while maintaining the presence of full interdental papillae are goals that all implant clinicians strive and hope for. The natural-looking soft-tissue profile should match the adjacent teeth and the original tooth and complement the final esthetic result perhaps more than the final restoration itself. Without an ideal emergence profile and a precise soft-tissue component, the definitive restoration is unlikely to pass esthetic scrutiny. One of the most reliable prosthetic criterion used to assess esthetic rehabilitations in the anterior maxillary zone-not only for dental implants but also for natural teeth-is the PES/WES (pink esthetic score/white esthetic score) index. An optimal PES is synonymous with the second most essential element.
The third most essential element is achieving a screw-retained restoration that can simulate the exact characteristics of the original tooth. If, and only if the first two essential elements are already in place can the final restoration (the only components controlled in the laboratory) be the "icing on the cake." With an ideally positioned implant and a preserved or well-developed soft-tissue profile, the final restoration can be perfected to reach the highest WES.
These three elements are interwoven, and they represent the main elements in the esthetic zone. However, they could also be regarded as the "tip of the iceberg," whereby a multitude of additional factors included in the equation of "esthetically pleasing" are considered.
1. Levin BP. The dermal apron technique for immediate implant socket management: a novel technique. J Esthet Restor Dent. 2016;28(1):18-28.
Barry P. Levin, DMD
Clinical Associate Professor in Periodontology, University of Pennsylvania, Philadelphia Pennsylvania; Private Practice in Periodontology and Dental Implant Therapy, Jenkintown, Pennsylvania
Stephen L. Jacobs, BDS, FDS RCPS(Glas), MJDF RCS(Eng)
Clinical Director and Principal Dentist, Dental FX, Glasgow, Scotland; Past President, Association of Dental Implantology;
Member, Board of Directors, and Fellow,
Academy of Osseointegration
Andre Hattingh, BChD, MChD(OMP)(Pret)
Periodontist, Private Practice,