Professional Documents
Culture Documents
DIAGNOSTIC METHODS
1. Esthetics begins with conceptualizing the final implant restoration existing in
harmony with the rest of the dentition.
2. The gingiva around each tooth must exhibit a symmetry and harmony that results in a
continuity of form. To achieve this, the gingival form and the marginal height of each
tooth must be considered. In addition, the root eminence and the cervical width are
important in developing an appropriate intertooth relationship.
3.
2. The implant is placed 3 mm apical to the gingival margin of the proximal teeth.
3. Furthermore a ridge with minimal deformity that possesses a sufficient quantity of
bone for implant placement can be corrected either prior to or at the time of the stage I
surgery.
4.
of
the
graft.
STAGE II SURGERY
1. Soft tissue management in stage II surgery aids in creating the appropriate inter and
intra tooth relationships.
2. Repositioning of the tissue may be necessary to create the appropriate dimensions of
keratinized tissue and align the mucogingival junction.
3. The incision is placed slightly lingual to the implant, permitting a greater bulk of
tissue to be established in the facial surface.
4. The tissue should be incised, not punched in a effort to conserve tissue volume
bone and membranes with and without bone graft material, sometimes secured in place with
pins and screws have been described. These approaches can be applied to the area that has
been edentulous or at the time of extraction. Correction should be accomplished by
preparatory surgery 6-9 months prior to fixture placement. Contingent on the size of the
initial defect and the quantity of tissue regenerated, more than one procedure may have to be
performed before stage I surgery. At times the quantity of bone regenerated is insufficient to
achieve the desired goals. In such instances additional bone grafting procedures may be
performed at stage I surgery.
Management of Papillae64
A critical aspect in achieving the appropriate soft tissue symmetry and harmony
around an implant supported restoration is preserving their existing interdental papillae or
creating them if they are absent.
In both stage I & II surgery, incision placement is a fundamental consideration. In
single tooth replacement, if the proximal teeth are less than 6 mm apart, the incision is made
mesiodistally at the linguoproximal line angles, preserving the faciolingual dimensions of the
papillae and including them as apart of the facial flap. If the teeth are more than 6 mm apart,
the papillae are left in place and access is achieved by the use of vertical incisions.
When the papillae are missing or insufficient, a dilemma exists, as there are no
methods that can predictable create or enhance them. A free soft tissue onlay graft can be
placed prior to stage I surgery, at the time or after the healing of stage II surgery. Furthermore
before stage I surgery if soft tissue augmentation has not been performed, the placement of an
ovate pontic on the ridge is an effective means by which papillae can be maintained.
Restorative Sculpturing of the Crevice
Ridge laps can and should be avoided by proper placement of the implant and
sculpturing of the crevice. The crevice can be sculptured at or after the stage II surgery.
Placement of a temporary restoration at the time of the stage II surgery can influence the size
and shape of the crevicular space. Even though conventional healing abutments are available
in various diameters, they do not reflect differences between mesiodistal and faciolingual
dimensions. An appropriately shaped crevice can be facilitated if the temporary is
prefabricated and inserted at the time of the stage II surgery. This results in a crevice that
anticipated the final shape of the final restoration. Incremental addition to a temporary placed
into a healed crevice can change its shape as well as influence the interdental tissue.
the
adjacent
teeth.
Tooth movement to correct the position of the adjacent teeth may be required to provide
adequate space for the fixture as well as a desirable soft tissue and osseous environment.
Frequently, the mesiodistal dimensions between the roots and! or crowns of the maxillary
central and canine. Adjacent to the congenitally missing lateral is too narrow for the fixture
placement, crown contour and soft tissue form. Tipped teeth proximal to an edentulous area
may result in a soft and hard tissue form that makes the development of the papillae
approximating
the
implant
restoration
impossible.
and
placed
with
minimal
disruption
of
the
soft
tissues.
If the implant surgeon and the restorative dentist collaborate closely and provisional
restorations are used appropriately, pen-implant soft tissue can be formed and minimally
disrupted
to
allow
for
esthetic
implant
supported
restorations.
The excellence of every art is its intensity, capable of making all disagreeables
evaporate, from their being in close relationship with beauty and truth. John Keats
Esthetic as appreciative of, responsive to, or zealous about the beautiful; having a sense of
beauty or fine culture. Each of us has a general sense of beauty. However, our own
individual expression, interpretation, and experience make it unique, however much it is
influenced by culture and self-image. Adult patients require different treatment approach
from adolescents. Eli et al. found that when sets of photographs of intact and decayed teeth
were viewed by both males and females, significant differences in perceptions of esthetic,
social, and professional traits associated with the photographs were evident. Beall reported,
Teeth alone can have an impact on overall attractiveness and perceptions of personality
attributes.
ISSUES TO BE CONSIDERED97
Various factors must be given considerations, which demand special consideration for adults.
_ Psychosocial factors
_ Perio-restorative problems
_ Age related considerations
_ Lack of growth potential
_ Aging of tissues
_ Vulnerability to Root resorption
_ Vulnerability to TMD
To take care of these important issues, adult orthodontics often requires interdisciplinary
approach to deliver efficient treatment outcome involving many healthcare providers viz.
Periodontist, Restorative Dentist, Prosthodontist, Endodontist, TMJ specialist, Oral &
Maxillofacial Surgeon.
ORTHODONTICS
For adult orthodontic patients with missing teeth or insufficient numbers of teeth for
orthodontic anchorage, palatal implants are being used to assist with the necessary support.
Orthodontically repositioning teeth may prevent the need for more aggressive crown and
bridge coverage. In baby boomers who may not have as many restored teeth as the previous
generation, preserving the natural enamel through orthodontics may be preferable to
removing enamel and dentin for crowns or veneers. The orthodontics may also be less costly
in the long run than the prosthodontic procedures.
PERIODONTAL THERAPY
Esthetic dentistry procedures require a foundation of good periodontal support. Periodontal
tissues frame the teeth and need to be healthy and in harmony with the teeth. Age is not a
contraindication for periodontal plastic surgery or periodontal surgery of any type. New
periodontal regeneration procedures are providing older adults who have lost periodontal
bone support with new options for retaining teeth. Esthetic surgery, whether periodontal or
oral surgical, should be offered to the older adult if surgery provides the best option for an
esthetic result. Frequently, interdisciplinary therapy is necessary to achieve the most esthetic
result. E.g. gingivsal recontouring. Gingival veneers are a cosmetic replacement for missing
gingival tissue.
They do not replace any kind of periodontal therapy that may be indicated in these patients. It
is very important that patients who receive such veneers be on very close recalls to ensure
that the patients are able to maintain good oral hygiene around these veneers as well as to
ensure that their periodontal disease is under control.
Prosthodontic procedures can restore function and an esthetic appearance to a worn dentition.
Prosthodontic treatment may last longer than composite resin bonding. Often, the bonding
procedures serve to introduce the patient to how esthetic dentistry can improve his or her
smile. Later, when it needs to be redone, the patient may opt for the longer-lasting
prosthodontic procedures. Porcelain veneers are by far one of the most effective and yet
conservative methods to achieve an esthetic result, especially when 8 or more teeth are
involved. If the patients goal is to improve his or her smile, the dentist should first note how
many teeth are involved in this smile improvement. Generally, the patient should smile to his
or her fullest, and then which of the posterior teeth shows at the corner of the mouth can be
noted. Sometimes, it may be a second molar. If so, the esthetic result the patient desires will
not be achieved if only 8 teeth are included in the treatment plan. Since the upper lip line
varies considerably in older adults, this assessment will be critical to achieving an esthetic
result pleasing to the patient. The most artificial result occurs when only the 6 anterior teeth
are restored in a lighter shade, with 8 or 10 teeth showing when the patient smiles. The
unrestored posterior teeth now appear even darker than previously and detract from the
anterior teeth. When the patient requires complete oral rehabilitation, the full crown is still
the restoration of choice. It can be expected to provide a greater functional life than bonding.
It can be combined with porcelain veneers to accomplish an esthetic result.
In many cases of bite problems that require an esthetic solution, the full crown, rather than
porcelain onlays, will offer the most occlusal support against fracture.
IMPLANT235
Implant treatment is increasing in older adults. Again, age, in and of itself, is not a
contraindication to implant therapy. Many older adults are trading their complete dentures for
implant supported prostheses. Implant therapy is expected to increase as implants become the
treatment of choice for replacement of a single missing tooth. Implant therapy often requires
a team approach with excellent communication between the surgical and the prosthodontic
teams.
Teeth darken and become more yellow as they age. Teeth also tend to take on stain
throughout the enamel and cementum surfaces. Vital tooth bleaching performed either in
office or at home has been demonstrated to be effective in older adults. In older adults,
sensitivity does not appear to occur as frequently as in younger patients. This is thought to be
due to the gradual receding of the pulpal tissue with age. Because aging effects darken teeth
in the yellow color range, this color range has been shown to achieve the best results with
vital tooth-whitening procedures. In-office and at-home whitening with trays work equally
well. Products containing 10 to 35% peroxide have been shown to work in mature adults. The
main determinant is whether the patient desires the whitening results immediately or can wait
longer for the at-home whitening agents to begin to work. If a patient has anterior teeth with
prominent microcracks, he or she should be advised of these cracks and monitored carefully
to ensure that there is no streaking in the whitened teeth.
easily transform the patients appearance, in effect turning back the clock on the aging
process. Cosmetic contouring provides an excellent introduction to esthetic dentistry for
patients who are unsure about making significant changes in their smile. It also provides a
lower cost option for those patients with limited financial resources.
With minimal
preparation, the tooth or teeth can be altered to achieve an esthetic result. Bonding also
enables the dentist to easily repair chipping and fractures that occur in the teeth of older
adults. Although manufacturers have made cosmetic shades lighter to reflect the increasing
range of whiter shades of bleached teeth, older patients may require darker composite shades
to restore erosion or root caries. Currently, when a patient needs a restoration on a tooth
darker than existing composite shades, the dentist may need to use modifiers to make the
restoration more natural in appearance and blend with the surrounding teeth. An overlay
technique or partial veneer can be used when a spot match is not possible.
COMPLETE DENTURE3
Complete denture esthetics can no longer be considered solely a function of tooth
selection and arrangement or the colors and contours and contours of the denture bases.
Denture esthetics must also include the entire face in which the expression of inner feelings,
personality, comfort, image, well-being, and perceptions of past dental experiences are all
very evident. These hard and soft components all contribute to the complete denture esthetics
results; they are inseparable and should be given every consideration when developing a
successful complete denture esthetic restoration.
The tooth problem was an esthetic problem and to avoid disharmony, one should in
the initial stages of tooth selection, use a tooth form similar to the patients face form. After
Williams work, many researchers continued to build on this beginning, broadening the
esthetic area to include the anatomic variants of mesiodistal and cervicoincisal contours and
surface texture, the interrelations of tooth form, arch form, face form, alignment form and
achieving a harmonious balance. Refinements in determining tooth form, size and color
harmony were developed and was followed later by an entirely different and divergent
concept basing tooth selection and arrangement on sex, personality and age. Even though it
has been subsequently demonstrated that experts cannot accurately differentiate the sex of
individuals when shown only their natural teeth, the SPA factor or Dentogenics concept
contributed much in achieving a more natural, esthetic appearance to complete denture
restorations.
FISHER states that Utilize the approach of an artist while analyzing the patient first
as to sex, i.e. Male or female, then as to personality i.e. Vigorous or delicate, & then as to age,
i.e. young, middle aged or old.
Another significant esthetic contribution was the molding of artificial teeth made from
impressions of natural teeth and individually color characterized. In this same era, others
duplicated natural gingiva and mucosal contours and colors which they transferred to the
polished surface for improved esthetics, facial contours and food management6.
Tooth arrangement was always considered important from Nelsons arch form and
face form, facial contours and support to refinement that followed which included phonetics,
tooth display, harmony and the functional elements of occlusal vertical dimension, incisal
guidance and centric relation.