Richard M. Palmer, Paul J. Palmer & J. Timothy Newton The esthetic and functional demands in the replace- ment of missing teeth have always been a major focus of oral rehabilitation. The introduction of osseointegrated implants increased the possibility of providing xed restorations in extensive edentu- lous zones. Treatment initially concentrated on func- tion and long-term success, and there is ample scientic literature to support these goals. Esthetics initially subsumed a somewhat secondary require- ment and there is unfortunately a paucity of scien- tic data in this area, with no randomized controlled trials. It would seem that much of the current demand for `esthetics' appears to be fuelled by the profession and there is a reluctance to admit that not all cases will result in good esthetics, even in cases where there are no compromising factors to begin with. Developments in implant components, materi- als, fabrication technology and increased sophistica- tion in planning and surgical procedures have enabled provision of more esthetic restorations. Most modern implant systems have a range of compo- nents designed to deal with esthetic demands, and professional literature to demonstrate the effective- ness of the system. In most cases, however, the results of treatment which are publicized are close to ideal and do not address the difculties of the compromised case. The term esthetic means pertaining to beauty or to the improvement of appearance (Dorland's Medical Dictionary) and this is often a prime goal of the clinician and patient when replacing missing teeth in the anterior maxilla. The anterior maxillary teeth in the `esthetic zone' usually extend from rst pre- molar to rst premolar, but in some individuals can extend as far distally as the rst molar. In many patients a shortened dental arch will satisfy esthetic and functional demands (12). The judgment of esthetics is subjective, and difcult to test or evaluate in a scientic way. The treating clinician's idea of a good esthetic result may be quite different to that of the patient (6, 21). It is therefore important to get the correct balance between these demands and to have adequate discussion, planning and preview of the potential end result to reach agreement. To achieve good esthetics in cases of simple tooth loss may simply require the services of a skilled technician/ ceramist. In contrast, in cases where there is exten- sive loss of teeth, bone and soft tissue there is a need to develop a plan to deal with these compromises using more sophisticated surgery, prosthetic solu- tions or both. It is essential to involve the patient in the decision process with the whole clinical/tech- nical team in deciding the nal treatment strategy. Patients' expectations and psychological aspects Patients' expectations of health and healthcare are key determinants of their satisfaction with the out- come of treatment, or their adherence to treatment recommendations (2, 3). Their expectations of treat- ment may be a better predictor of perceived outcome and quality of life than functional or clinical status (4). Matching treatments to patient expectations has been shown to have a marked impact not only upon patient satisfaction but also upon behavioral markers of outcome. Lefer et al. (20) found that patients who were involved in the choice of their dentures were less likely to complain or to reject them, and made fewer visits for corrections. This was despite the fact that patients were more likely to choose dentures that were less than clinically optimal. The expectations patients hold regarding the appearance of the mouth may be either specic to their own mouth, or general based on perceptions of the `ideal' appearance of the mouth, lips, teeth and gums. Patients express their specic expectations of the oral cavity in terms of appearance, function and the absence of certain stimuli, most notably pain. Established norms for oral and facial appearance do not vary widely among the industrialized nations 105 Periodontology 2000, Vol. 33, 2003, 105118 Copyright # Blackwell Munksgaard 2003 Printed in Denmark. All rights reserved PERIODONTOLOGY 2000 ISSN 0906-6713 and extreme deviations are viewed as unacceptable (7). All clinicians will be aware of the extent of variation to which patients are willing to tolerate abnormalities. Some patients may place undue emphasis on minor oral abnormalities, and have unrealistic expectations of the impact that the cor- rection of such abnormalities might have upon their lives. This may be a symptom of body dysmorphic disorder (8). The general public hold expectations regarding the characteristics associated with an `Ideal' dentition. Individuals use facial appearance as a guide to infer a variety of characteristics of a person including per- sonality, integrity, social and intellectual competence and mental health (11). The impact of appearance on perceptions of personal characteristics is not limited to initial meetings such perceptions may have a lasting effect (1). Moreover, individuals rated as facially attractive tend to earn more, have more suc- cessful life outcomes and have greater self-worth than less attractive individuals (9, 22). Good oral appearance is thought to be a requirement of pres- tigious occupations among some professional groups (17). It is unsurprising therefore that a dento-facial appearance that differs from the `Ideal' produces negative perceptions of personal characteristics (18, 2527). These negative social perceptions may also exert a negative inuence on an individual's self perception (19). Previous research examining the impact of orofa- cial abnormalities on the perceptions of others has tended to focus on anomalies of occlusion and severe orofacial anomalies such as cleft lip and palate (28). However, minor abnormalities in oral appearance may inuence the appraisal made of an individual's social adjustment (10, 13). In brief, patients have specic expectations of their treatment and the end product of their oral rehabi- litation. In general, there is little variation in what constitutes the `Ideal' orofacial appearance. Failure to match these expectations is associated with dis- satisfaction in patients, and negative social apprai- sals on the part of observers. Range of cases which may lead to compromise The compromised case can range from a patient with a missing single tooth unit to an edentulous jaw with advanced resorption. The extent of the site may not be the most important factor. A single tooth site can provide as big an esthetic challenge as a more exten- sive defect. The main problem with missing single teeth is achieving harmony with adjacent healthy uncompromised teeth. This was highlighted in a study by Chang et al. (6) of single tooth implant restorations in routine cases. Experienced clinicians were able to recognise the implant restoration in the majority of patients and were most critical of the soft tissue form, rather than the crown. The patients were less critical of the result. The compromised site can be decient in soft tissue and bone in the ver- tical, horizontal or combined planes. Lack of these tissues on adjacent natural teeth in the esthetic zone may be even more difcult to deal with because the clinician may have to improve conditions around the natural teeth as well as the edentulous zone (Fig. 1A). Duration of tooth loss Alveolar resorption follows tooth loss. The gradual resorption with time has been well described (5) and in many patients reaches a point where an esthetic problem results. Trauma Even minor trauma leading to avulsion of a tooth can cause loss of alveolus and gingiva. More major trauma can cause extensive vertical and horizontal bone loss, loss of arch form and derangement of the occlusion (Fig. 1). Developmental Cleft lip and palate Most cleft patients are currently treated to a high level by expert teams (28) and may not be classied as compromised cases where tooth replacement is required. Secondary alveolar bone grafting per- formed at 911 years of age should allow eruption of the maxillary canine into a continuous alveolar ridge form accompanied by vertical growth of the alveolar process (23, 24). In approximately half of affected patients the maxillary lateral incisor is absent or malformed. If the orthodontist makes space for the lateral incisor (rather than achieving space closure), then replacement should be straight- forward. However, older patients treated before these highly successful protocols often had primary bone grafting at a much earlier age, which led to impairment of growth. Residual deformities and sometimes multiple missing teeth following failure Palmer et al. 106 of conventional bridges in these patients make man- agement difcult (Fig. 2). Hypodontia Minor degrees of hypodontia involving a few teeth do not normally present a challenge. However, major forms can present difculties because the remaining teeth are often small and closer in size to the primary dentition (Fig. 3). In addition, the jaws and alveolar processes are small and lack of development of sec- ondary dentition results in thin angled alveolar pro- cesses. There is often spacing and orthodontics is Fig. 1. Traumatic loss of anterior maxillary teeth in a female in her 30's. (A) Intraoral appearance showing loss of all incisors, a vertical ridge deformity and gingival reces- sion on the proximal surfaces of the canines. (B) Dental panoramic tomogram showing extent of vertical bone loss. Bone plates from previous maxillofacial surgery are visi- ble. (C) The patient wearing an acrylic prosthesis with a large labial ange to compensate for missing gingiva and bone. (D) The patient wearing the acrylic prosthesis and smiling. The gingiva is not visible. (E) An intraoral diag- nostic set-up with long acrylic teeth set on the ridge. (F) The patient smiling with the diagnostic prosthesis in place. (G) An intraoral view of the completed implant supported bridge, which has addition of pink porcelain to compen- sate for missing marginal gingiva and papillae. (H) The patient smiling with the nal implant supported prosthe- sis in place. (I) Radiograph of the prosthesis which is sup- ported by two Astra Tech ST implants. 107 Esthetic demands in the anterior maxilla required. Diagnostic set-ups have to take account of the pre-existing small permanent teeth and the implications of providing larger adult-sized teeth have to be evaluated. In some cases, skeletal discre- pancies may also be present and further complicate management. Periodontitis The periodontitis case (Fig. 4) may be the most dif- cult compromise case of all as the anterior teeth are often affected by: Recession and thin soft tissue morphotype Loss of papillae Flat gingival prole Large interdental spaces Loss of bone Drifting, overeruption and rotations Exposure of root surface Functional compromise of stability and mobility Many clinicians hesitate over whether to advise early extraction of periodontitis-affected teeth to pre- serve esthetics. There is insufcient scientic evi- dence to help in making this decision. In order to facilitate esthetic requirements in many instances, the patient would have to lose teeth at a stage in the disease process when periodontal treatment and tooth retention would not present a difculty. This is clearly not in the interests of the patient. Replacement of teeth with implants in the patient who has suffered from advanced periodonti- tis is usually a compromised situation even in cases where it is a single tooth replacement. In most situations the adjacent teeth are affected by bone loss and gingival recession. Replacement of a single unit in an arch form of affected teeth has to accept this compromise as it is impossible to reconstruct a ridge form coronal to the adjacent affected teeth. The single tooth replacement there- fore mimics the adjacent teeth (Fig. 5). Loss of most of the maxillary incisor teeth through advanc- ed periodontitis will result in considerable ridge resorption and compromise (Fig. 6). In addition, the periodontitis-affected maxillary incisor teeth may have drifted to a Class 2 division 1 relationship, which will often need to be corrected in the nal result. Endodontic lesions Teeth with poor endodontic status may give rise to large areas of apical bone loss or exhibiting residual scars of previous apical surgery, such as amalgam tattoos (Fig. 7). Diagnosis and assessment of features which affect esthetics Lips Esthetics of the anterior teeth may not be an important issue for some patients if their teeth and gingiva are never exposed during normal activities Fig. 1. continued 108 Palmer et al. such as smiling and laughing. However, most sub- jects expose their gingiva to some degree during these activities and may be very conscious of their compromised appearance (30). Contrary to a generally held opinion, this also may occur in the lower anterior region. The most demanding cases expose large amounts of tooth and gingiva at rest (Figs 8 and 9). The teeth also provide im- portant support to the lips and facial tissues which should be assessed in frontal and prole views (Fig. 2A,B). Residual ridge The edentulous ridge should be evaluated clinically onstudy casts and radiographically to measure mesio- distal space, buccolingual widthandheight. The thick- ness and health of the soft tissue must be assessed. Fig. 2. A middle aged male who had cleft lip and palate treated in childhood by primary bone grafting and repla- cement of missing lateral incisor and canine with a con- ventional bridge which subsequently failed. (A) The patient with lips at rest showing asymmetry. (B) A lateral view showing maxillary retrognathism. (C) An intraoral view showing missing teeth, class 3 incisor relationship, buccal crossbite and mobile, enlarged, non-keratinized soft tissue overlying the repaired cleft in the upper left lateral incisor region. (D) Dental panoramic tomogram showing evidence of residual cleft and retained roots. (E) Diagnostic prosthesis showing need for replacement teeth buccal to existing ridge. (F) Lips at rest with patient wear- ing diagnostic prosthesis. 109 Esthetic demands in the anterior maxilla Diagnostic set-ups Diagnostic wax-up on study casts are of value in treatment planning but do not allow assessment of the appearance in the mouth of the patient. Diag- nostic prostheses are probably the most useful, espe- cially in the compromised case as the clinician can provide multiple set-ups to allow evaluation of Fig. 3. A female in her early 20's with severe hypodontia. (A) The patient smiling showing poor esthetics in the canine/premolar regions. (B) An intraoral view showing retained deciduous canines and molars. The maxillary lateral incisors are replaced by Maryland bridges. (C) Den- tal panoramic tomogram showing retained primary teeth with advanced root resorption and relative submer- gence. (D) The patient smiling wearing a diagnostic and transitional removable prosthesis. (E) An intraoral view of the transitional prosthesis which replaces the maxillary lateral incisors, canines and rst premolars. (F) An intraoral view after completion of the implant treat- ment without grafting. The bridges are cemented onto customised abutments, which are necessary because of the labial angulation of the implants in the narrow ridge forms of these patients. (G) The patient smiling following completion of treatment. (H) Radiographs of the com- pleted treatment. On the patients' right side there are two standard Branemark system implants. The left side has been treated with a Astra Tech implants. A 3.5 mm diameter implant has been placed at the lateral incisor site and a 4 mm diameter implant at the canine site. The premolar is replaced with a cantilever pontic. This compromised approach has avoided onlay grafting on the buccal aspect of the ridge and a sinus elevation on the left side. 110 Palmer et al. changes in appearance, e.g. with and without pros- thetic gumwork to permit assessment of the degree of missing soft and hard tissue and lip support/smile line (Figs 1 and 2). The patients should be thoroughly informed so that they are able to participate in the decision making process leading to an agreed treat- ment strategy. The main advantages of a diagnostic removable prosthesis are summarized as follows: Inexpensive/ cost effective Easy to modify Major changes possible/multiple set ups for com- parison Fig. 3. continued Fig. 4. A female patient in her early 40's with advanced periodontitis. (A) The patient holding her lips together to hide her teeth. (B) The lips at rest showing incompetent lip morphology. (C) The patient smiling exposing 34 mm of gingiva and a class 2 division 1 incisor relationship. She had noticed drifting and spacing of the incisors. (D) The intraoral view showing spacing between her central incisors, loss of papillae, recession and inammation. 111 Esthetic demands in the anterior maxilla Can be worn for extended periods of time to allow a real life evaluation Efcient interim/provisional prosthesis However, there are also disadvantages. The fact that they are removable is not liked by some patients and production of good esthetics may be too easy and the conversion to xed implant prosthesis may not be possible. Radiographs Radiographic examination is a crucial part of any assessment for implant treatment. In the compro- mised case it is usually performed to conrm the extent of the clinically obvious deciency. Imaging which utilizes a radiographic stent of the planned tooth position will permit a more accurate estimate of the degree of mismatch with the position of the residual jaw bone and the difculty of reconstruction (32). Treatment strategies choice of restoration and limitations There are two basic ways of dealing with the compromised case, surgical and prosthodontic, although in many cases a combination of the two is required. Surgical: Reconstruct the decient bone and soft tissue. This may be achieved with guided bone regeneration, bone grafting and soft tissue grafting or distraction osteogenesis (31). The reconstructive procedure should be predictable and the patient made aware of the risks involved, including the pos- sibility that there may still be some deciency and level of compromise. Vertical reconstruction of per- iodontal tissues around adjacent natural teeth is unpredictable or impossible in many cases despite advances in guided tissue regeneration/grafting/ microsurgery. In some instances it may be necessary to extract more natural teeth to facilitate the recon- struction and further improve the esthetic result. The vertical augmentation of bone and soft tissue in the absence of teeth should be more predictable. The fact that the graft can be buried and sealed beneath the mucosa reduces the chance of infection. It is more predictable to surgically rebuild decient tissue rst before placing implants, rather than attempting combined procedures. Prosthodontic: Accept the deformity and provide a compromise prosthetic reconstruction. In this situa- tion there has to be sufcient bone to allow provision of an adequate number of implants to full the bio- mechanical requirements, thereby assuring a good long-term prognosis (14). The patient should be aware and accept the compromised esthetics. Whatever restoration is chosen to solve the esthetic problem it is axiomatic that it should not Fig. 5. Replacement of a single tooth in the periodontitis patient. (A) An intraoral view of a single tooth implant replacing the maxillary rst premolar (bicuspid). The adja- cent teeth have 3-mm of recession circumferentially and the replacement tooth mimics the recession. (B) A radio- graph of the single tooth implant showing that the implant head level with the apical third of the adjacent tooth root which has lost over half of its support. 112 Palmer et al. compromise the health or the remaining dentition or associated oral structures. It is unacceptable to provide a patient with a restoration that is impossible to clean with normal oral hygiene proce- dures. Removable dentures A conventional removable denture can provide ideal esthetics as it readily replaces missing gingiva and the teeth can be placed in any desired arrangement without concern for the position of the residual ridge or implants (29). A labial (buccal) ange on the den- ture also gives good lip support (Fig. 1C,D). The major disadvantage is that it is removable and may have compromised stability, retention and function. These disadvantages can be largely overcome when providing a removable implant-retained overden- ture. Overdentures with a bar and clip arrangement compare very favorably with xed bridges when eval- uated by patients (33). More sophisticated types have a precision-made milled bar to connect the implants, which is then used to support a precisely tting patient-removable bridge with a very high degree of stability and retention. Fixed bridges (partial dentures) Conventional tooth-supported and implant-sup- ported xed bridges may provide equivalent esthetics (Fig. 10). In the natural tooth-supported bridge the location of crown margins is dictated by the periodontal health of the abutment teeth and the preparation of the tooth structure. Tooth-supported bridges may be compromised by the strength of the remaining tooth structure and the potential for development of caries or periodontitis. The form and appearance of bridge pontics is the same for tooth and implanted supported bridges and both are amenable to augmentation of the tissue beneath the pontic to improve appearance. If there has been extensive recession around natural teeth or bone Fig. 6. Replacement of all maxillary incisors in the period- ontitis patient. (A) An intraoral view showing missing maxillary incisors and healthy remaining teeth which exhibit marked recession. (B) The existing removable par- tial denture, which has a labial ange to replace missing gingivae. (C) The patient following treatment with four single tooth implants. There are no papillae between the implant crowns, which is a similar situation to that in the mandibular incisor segment following succ- essful periodontal treatment. (D) The patient smiling, showing acceptable esthetics of the completed implant treatment. 113 Esthetic demands in the anterior maxilla resorption prior to implant placement, the abutment crowns will be longer and therefore provide a compromised appearance. `Pink porcelain' can be used at the cervical margins to help disguise this Fig. 7. An endodontic lesion leading to compromise. (A) The patient smiling, showing slight discoloration of the maxillary left central incisor. (B) The intraoral view show- ing extensive loss of labial gingival and a restored root surface. There is likely to be a marked deformity in the ridge following extraction of this tooth. (C) A radiograph showing the central incisor which has a hopeless prog- nosis. Fig. 8. The smile line. (A) The subject holding her lips together. (B) The subject at rest showing incompetent lips and a short upper lip, which is level with the gingival margin. (C) The subject smiling, exposing all of the attached gingiva, a very demanding case if incisor tooth replacement were required. 114 Palmer et al. (Fig. 11A) or a Gumslip (a removable gingival pros- thesis or veneer) used (15). These are removable and often relatively fragile, not hard-wearing and needing regular replacement. The periodontist may consider, on agreement with the dentist, transition to implant supported xed bridgework via transitional tooth supported bridges. The teeth that are to be retained need to be free of infection and in good strategic locations. The advan- tage to the patient is that they can avoid wearing a removable denture during the treatment schedule. The main advantages and disadvantages are sum- marised below. Advantages No removable denture worn during the treatment schedule Avoidance of loading the residual ridge mucosa/ implants/grafts Trial esthetics of a xed bridge reconstruction Disadvantages More complex and expensive More time consuming/longer treatment schedule Provisional bridge needs to be robust to allow removal, replacement Retained supporting teeth may occupy best poten- tial implant sites The alternatives to this approach are: Extraction of the remaining teeth and provide removable provisional denture. Provision of a temporary bridge on temporary implants. This has more or less the same advan- tages/disadvantages as the transitional tooth sup- ported bridge with additional cost and surgery of temporary implants. Provision of permanent implants in an immediate extraction /implantation protocol with construc- tion of an immediate bridge. The third approach is being promoted by some clinicians (16). It may be more difcult to provide good esthetics if implant placement is compromised by position of tooth sockets. In addition, it is not easy to show the patient a provisional intraoral set-up of the planned appearance. If esthetics is a prime con- sideration, this strategy is not recommended. Achiev- ing good esthetics takes time and planning and does not easily lend itself to rapid/condensed treatment protocols. Effects of accepting the compromise on implant placement This section applies to those cases which have not been adequately surgically reconstructed, a compro- mised outcome has been accepted and there is suf- cient bone to allow implant placement. The result is that the implant may be placed too apically, palatally or angled. Fig. 9. Favorable smile line. (A) The patient smiling only reveals the coronal two-thirds of the incisors, with no exposure of gingiva. The esthetics are entirely acceptable to the patient. (B) The same patient with lips retracted showing extensive labial recession and loss of the midline papilla. This would not be acceptable in many patients with a high smile line. Fig. 10. Prosthetic compensating tactics 1. A patient with a natural tooth supported bridge on their right side and an implant supported bridge on their left side. The prosthetic teeth on the implant side are much longer due to extensive ridge resorption following loss of the teeth. The patient accepts the compromised esthetics which do not show in normal function. 115 Esthetic demands in the anterior maxilla Vertical level of the implant Placement of the implant head 3 mm apical to the level of the adjacent natural tooth cementoenamel junction is commonly advised to allow for adequate emergence prole (Fig. 12A,B)). Thus in case of minimal resorption the head of the implant may have to be countersunk. This is clearly not the case in compromised sites with vertical loss of bone. The implant head should be left level with the crest of the ridge or even supercial to it depending upon the implant design. This strategy will also help to minimise unfavorable implant/crown ratios (Fig. 12CE). Buccal/palatal position and angle of the implant The compromised ridge will be positioned more palatally. The treatment plan should have decided upon whether a xed bridge or a removable denture is to be provided (32). With a removable denture the sites offering the best bone quantity and stability should be chosen and sufcient space provided between implants if a clip system is planned. In the case of the xed bridge, the implants should be placed to enhance the appearance and reduce canti- lever forces as much as possible (Fig. 12CE). There- fore they should be: Placed under teeth they are to replace. This may be difcult with large horizontal and vertical discre- pancies. Angled labially to the appropriate degree (Fig. 12E). Labial angulation can overcome some of the horizontal discrepancy and the surgeon should take into account whether it is desirable to project the implant long axis through the cingulum area to enable screw retention (most likely with severe discrepancy) or through the incisal tip or labial face to produce a better labial emergence prole in a cemented prosthesis. These strategies cannot provide optimum esthetics in the compromised case but they may allow treat- ment where an esthetic compromise has been accepted. Fig. 11. Prosthetic compensating tactics 2. (A) An intraoral view of a full arch implant supported bridge in a patient who has undergone extensive maxillary onlay grafting and sinus augmentation. This has allowed placement of sufcient implants but she still required provision of porcelain `gum-work'. (B) The patient smiling, showing a good appearance. 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