When a dental implant case is planned, there are important aesthetic considerations. Not only must the dental restoration be naturally beautiful, but also the supporting bone and gingival tissue must appear naturally aesthetic in shape and color.
One of the reasons I choose to refer my patients to a dental implant specialist is because the replacement of missing teeth with implants in the smile zone can pose difficult challenges. The bone and tissue anatomy resulting from implant placement must be optimal to ensure the most satisfactory aesthetic results…a smile the patient is proud to wear.
Here are some of the major considerations.
The greater the amount of bone and soft tissue loss, the more difficult it becomes to produce an ideal aesthetic result. When a tooth is missing, bone resorption occurs in the vacated area, and the longer the tooth has been missing, the greater the potential for bone resorption to occur. When there is inadequate bone to support the implant(s) the bone must be augmented through a bone graft, which depending on the location may be part of a surgical sinus lift procedure or bone ridge enhancement procedure. The volume and placement of the bone graft and today’s advanced surgical techniques require special training and technology.
Restoring natural gum tissue dimensions, tooth coverage and contours is especially challenging when there are multiple missing teeth in the aesthetic zone. Often in these situations, the bone substructure requires augmentation.
The physiology of wound healing after tooth extraction often results in receding gum tissue. After an implant is restored, the restoration can appear longer than natural and also abnormal due to the absence of interdental papilla (gum tissue extending between teeth). In addition to placing an implant in the optimal position for osseointegration (bone healing around the implant) and stable function, it must also be placed to optimally address soft tissue deficiencies, for optimal occlusion (how the upper and lower teeth come together), and to provide for enough space around the implant for an aesthetically pleasing restoration.
Sometimes, orthodontics may be recommended prior to implant placement to move teeth that have drifted due to missing teeth and/or to improve spacing of teeth adjacent to the future implant. And, sometimes this respacing of teeth eliminates the need for bone enhancement procedures.
In the case of thin gum tissue with highly scalloped contour, the implant will need to be placed more palatally than facially to make sure the titanium of the implant does not show through the gum tissue. This is just an example of many placement considerations.
In my practice, dental implant cases are always “interdisciplinary” with both the surgical specialist my dental laboratory technicians and me collaborating to form the treatment plan. Selecting the right number of implants and the optimal type of implants and restorations for patients with multiple missing adjacent teeth can be challenging and take thoughtful preplanning. For example, a challenging situation is replacement of an upper canine and adjacent lateral incisor because the empty space is relatively small. Consideration, in this instance, will be given to possibly placing a single implant in the canine region and cantilevering a lateral prosthetic incisor from it.
A dental implant specialist can surgically manage wound healing to improve the gingiva and, when needed, can reconstruct gum tissue with soft tissue grafts. The latter adds a step to the restorative process but can lead to a beautiful smile.
In some cases, when adjacent teeth are to be restored, the crowns can be designed to reduce the volume of the interdental space. This is especially desirable if a “black triangle” space would be left between the front teeth due to an absence of an adequate papilla.
Sometimes it is better to restore the tooth with an ovate crown (also known as an ovate pontic). A depression is surgically created in the gum ridge so that the prosthetic tooth is made to appear as if it is emerging out of the gum tissue—and not as if the front of the tooth is resting on top of the gum tissue. When done well, the crown looks like an original tooth instead of a prosthetic one.
Many people, including my own patients, assume implant surgery is a simple procedure. This is understandable given the recent high success rate of dental implants and their long longevity for 30 or more years. But, the high success rate is largely due to the fact that most implants have been placed by highly skilled specialists (most commonly, oral surgeons and periodontists), who have completed surgical residency programs.
I want the best for my patients, including high satisfaction with both the appearance and function of their restored smiles. I believe referring patients to a specialist with surgical expertise and in-depth experience in diagnosing, treatment planning, and performing dental implant related oral surgery is in my patients’ best interest. I tend to use the adage, “what would I do if this were my mother or grandmother”. Therefore, I only refer my patients to the same specialists that I actually do trust to treat my family members.
If you decide you want dental implants to replace missing teeth, I will refer you to a specialist who can assess your situation and custom design a personalized treatment plan. I will collaborate to ensure you receive the surgical treatment that is ideal for the restoration of your smile. Once an appropriate foundation for health, function and beauty is established by the specialist, I will complete your dental implant treatment by designing and placing your custom restoration(s) on your implants. Together, we will then maintain your dental implant(s) for years to come.