|Year : 2012 | Volume
| Issue : 1 | Page : 37-40
Getting it right in the esthetic zone!
Kamal Kiswani1, Deepinder Duggal2, Poonam Rohra3
1 Professor and HOD, Department of Oral Pathology, Bhabha College of Dental Sciences, Bhopal, India
2 Reader, Department of Oral Pathology, Shri Aurbindo College of Dentistry, Indore, India
3 Lecturer, Bhabha College of Dental Sciences, Bhopal, India
|Date of Web Publication||23-Apr-2014|
Dev's Oral Care, D/237, 2nd Floor, Clover Centre, 7, Moledina Road, Pune - 411 001, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction of osseointegration by Branemark and coworkers and replacement of missing teeth by implants has revolutionized oral rehabilitation. As a result, restoration of form and function has shown a paradigm shift. Implant-supported restorations in completely or partially edentulous patients have proven to be highly predictable in numerous studies. Patients increasingly demand prosthesis that are not only functional but are equally esthetic; hence, implants placed in the anterior esthetic zone, pose a huge challenge. At times thorough planning and diligent execution can spare the patient from elaborate procedures of grafting. One such case report of restoring the esthetic zone in a female patient has been reported here with a 5-year follow-up.
Keywords: Aesthetic zone, delayed implant placement, morse taper connection, platform switch, soft tissue emergence
|How to cite this article:|
Kiswani K, Duggal D, Rohra P. Getting it right in the esthetic zone!. J Int Clin Dent Res Organ 2012;4:37-40
| Introduction|| |
Implant placement and restoration to replace single or multiple teeth in the esthetic zone is a challenging job for the clinician, particularly in sites with deficiencies in soft tissue and bone.  It is imperative to get everything right in the esthetic zone - from diagnosis and planning to surgical and prosthetic therapy. Not only correct implant positioning, but also preservation or creation of a soft tissue scaffold that is needed to create the illusion of a natural tooth is often difficult to achieve.  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. 
| Case Report|| |
A 46-year-old female healthy patient with no systemic history, reported to the clinic in 2008 with a chief complaint of mobile upper anterior bridge. Anamnesis and detailed history revealed that she had lost her #21 due to trauma from accident in childhood. Subsequently, she had prosthetic replacement (thrice) in the form of a long span bridge since 1984. Intraoral examination revealed a long span bridge extending from #14, 13, 12, 11, 21, 22. The fixture was mobile [Figure a].
|Figure a: Crown and bridge in anterior zone, right and left posterior maxilla|
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Patient also had a bridge from #17, 16, 15 and #25, 26, 27.
The gingiva phenotype was thick and keratinized. The alveolar ridge in #21 area was very thin, with marked buccal bone concavity [Figure b].
Preop orthopantomogram (OPG) revealed both the maxilla and mandible, the maxillary sinus, inferior alveolar canal (IAC) with good contrast and symmetry. Upper anterior teeth depicted failed endodontic treatment. Periapical lesion and marked bone loss was noted in teeth number #13, 12, 11, 22 [Figure c] and [Figure d].
Denta scan findings revealed intact buccal and lingual cortical plates with buccal bone dehiscence in #22. In the region of #12, 11 buccal bone plate was missing at the crest, but was present at the middle and apical area.
Pictorial representation of management of case [Figure e], [Figure f], [Figure g], [Figure h], [Figure i], [Figure j], [Figure k], [Figure l].
|Figure e: Pictorial representation of management of case- Impression for study casts: Mobile #11 exfoliated at the time of primay impression|
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|Figure f: Provisory prosthesis: Acrylic denture without a labial flange, to avoid impinging on to the labial bone|
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|Figure g: Eight weeks post healing: Soft tissue closed and more fuller because of use of abgel|
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|Figure h: Surgical phase: Ankylos implant placed sub crestally, in #16, 13, 21, 22 region. Xive implant in #14 region|
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|Figure i: Prosthetic phase: After the osseointegration period of 3 months|
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| Discussion|| |
For an acceptable esthetic result, implant placement in the anterior zone demands thorough preoperative diagnosis and treatment planning combined with excellent clinical skills.
The above-discussed case, of a middle-aged lady, had a long span bridge because of loss of anterior teeth due to trauma. The bridge that served for more than 20 years was finally failing along with the teeth that served as abutments. Hence, implants were the only treatment option.
Implants for #14 and #16 were planned as well, since the posterior bridge was failing as well.
For an ideal implant placement and optimal esthetic restoration, a comprehensive evaluation of the edentulous site should always be done. Facial, dental, and periodontal status should be evaluated. Facial evaluation for esthetic parameters, such as orientation of occlusal plane, lip support, symmetry, gingival scaffold, and smile line is of utmost importance. Dental evaluation should include information about the edentulous site in three dimensions, as well as information about the occlusion, adjacent teeth, and interarch relation. ,,
Along with all the above guidelines, the real challenge was loss of buccal bone contour especially in #22 region. Also in #11, 12 region, there was crestal bone loss. However, a thick gingiva phenotype helped to overcome the challenge posed by dehiscent buccal bone.
The long-term stability of soft tissue around an implant restoration depends largely on the presence of adequate soft tissue volume in a vertical and buccolingual direction.  An adequate volume of soft tissue provides a good emergence profile especially when combined with apical placement.  Subcrestal placement of the implant along with thick soft tissue gives good emergence profile. 
A subepithelial connective tissue graft to augment soft tissue volume is done, whenever soft tissue is deficient. However, the present case did not warrant any soft tissue manipulation, since the soft tissue was very thick and adequate in volume.
Timing of the implant placement is another important factor to meet the challenges in the anterior zone.  In this particular case, no immediate implantation was planned so as to allow the soft tissue to close primarily. In the extraction sockets, resorbable collagen was placed which helped to maintain the volume. Because of allowing the ridge to heal naturally, the overall dimension of the edentulous span was optimal enough to place delayed implants after 4 months. No major bone manipulation techniques were needed, except for bone expansion in #22.
The major challenge during surgery was to precisely position the implants according to the tooth assigned, so as to achieve good emergence.
Because of subcrestal positioning and choice of the implant system (Ankylos) used, very stable crestal bone around the implants was noted in the follow-up panoramic radiographs (5 years follow-up) [Figure m].
|Figure m: Lip profile: Esthetic result obtained that satisfied the patient's objectives OPG: Immediately after cementing the prosthesis, 5 - years follow – up: Very stable soft tissue, good emergence. OPG depicts very stable crestal bone around the implants|
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Implants placed subcrestally do not have a polished collar, which allows the bone at the crest to grow over the head of the implant.
Another important factor to note is the kind of connection between the implant and the abutment. A conical (Morse taper) connection always creates a bacteria proof seal that helps to minimize crestal bone loss after loading of implants. It is always desirable to have such a bacteria proof connection in the anterior zone for the long-term stability of the crestal bone and the soft tissue associated with it.
Follow-up clinical picture in the case mentioned here depicted very stable soft tissue. The ridge dimension also appeared fuller, than what it was before the implant therapy (visible in the 5 years follow-up clinical photograph).
| Conclusion|| |
To meet the challenges in the esthetic zone; proper planning, precise placement of implants, deft and delicate handling of soft tissue is mandatory. Timing of placement, subcrestal positioning, and choice of implant system are also important to get it right in the esthetic zone.
In the case described here, following strict protocols helped to overcome the challenges of esthetic zone. No major grafting procedures were needed. The timing of placement (delayed), choice of implant system (Ankylos), positioning of implants (subcrestal and in the appropriate tooth position) in the surgery, and deft and diligent handling of the soft tissue helped to achieve optimum esthetic result.
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[Figure a], [Figure b], [Figure c], [Figure d], [Figure e], [Figure f], [Figure g], [Figure h], [Figure i], [Figure j], [Figure k], [Figure l], [Figure m]