Cirugía Mucogingival

Key Principles of Implant Dentistry in the Esthetic Zone
Michael Sonick, DMD; Debby Hwang, DMD
Kerr University Online Learning Center
Abstract
Garnering a pleasing smile using implant therapy taxes even the most accomplished clinical team. There are certain relationships between the implant and its adjacent restorations, bone, mucosa, and lip line that result in a serviceable prosthesiscomplementary to the natural dentition. As importantly, the dentist must submit to the patient a realistic appraisal of potential cosmetic outcomes after treatment based on the individual’s tissue biotype, smile, and intensity of concern regarding appearances. This article reviews the major factors that affect the esthetic success of maxillary anterior implant treatment in partially edentuloussituations.
Triggering at once the most gratifying, frustrating, and fearsome sentiments, dentistry in the visible section of the mouth is a complex undertaking, sometimes subtly but occasionally blatantly so. Cases involving implants disturb not only the dental architecture but also that of bone and gingiva, structures that change shape easily upon violation, further complicating matters. Despitestrides in regenerative surgery and prosthetic manipulation, a natural-appearing relationship between papilla, surrounding mucosa, native teeth, and implant crowns is exasperatingly difficult to achieve. A functional, long-lasting anterior implant restoration is probable but one that is, moreover, indistinguishable from its indigenous neighbors is less feasible. Blame the extended epithelial connectionbetween titanium alloy and mucosa, any inherent dearth of osseous or soft tissue and possibly capricious healing.1,2 Thus, the most pressing question is also the most superficial: how much tooth and gum does the patient expose upon smiling? To put things bluntly, what can the patient put up with (and his or her clinicians get away with) cosmetically? The combination of physical boundaries andpatient tolerance determines the appropriate restorative solution for partial edentulism in the esthetic zone. The lip line is the primary determinant of esthetic success; a low lip line (exposure of less than 75% of teeth upon smiling) covers a multitude of sins.3 This notion is tempered by the fact that certain patients demand perfection regardless of whether anyone else sees their teeth. Thesepatients possess a high esthetic concern and must be treated as if they had high smile lines. For them as well as those with average (exposure of 75% to 100% of teeth and only interproximal gingiva) and high (exposure of all teeth and a contiguous band of gingiva) smiles, treatment consists of possible augmentation of bone and/or mucosa, non-buccally-oriented implant placement, delivery andprogressive alteration of interim restorations to refine tissue draping, and a precisely hued final prostheses. This article reviews treatment steps and decision points that the healthcare team and patient must undergo to reach a satisfactory, agreed-upon implant resolution to partial edentulism in the anterior area.
Patient-Doctor Harmony
Recognition of the limits of dentistry—the boundaries of currenttechnology as well as those of the individual clinician—is imperative. Total honesty with the patient and with oneself with respect to the predictability of care encourages trust, eases the treatment process, and, most importantly, preserves the patient–doctor relationship regardless of therapeutic particulars or even the eventual outcome. In the midst of persuading a patient to commit totreatment, it is all too tempting to overpromise results and gloss over the efforts required to accomplish them. There are, however, always temporal, psychological, and monetary costs to the patient, but the more thoroughly these are attended to or at least delineated in the beginning, the less the chance for untoward surprises, exasperation, and subsequent crumbling confidence during treatment.
The...