Implant teeth in cosmetic area: not easy at all!
Although implanted teeth have many advantages over traditional dental restorative techniques, implant placement in the cosmetic area is always a challenge for clinicians and is a major concern of patients. As a surgeon with many years of experience in implant dentistry and having treated many complex and challenging cases, I would like to give a more in-depth look at implants in the cosmetic area. At the same time, analyze some causes leading to failure as well as the factors and solutions to achieve success.
Modern implant placement, since its development in the 1960s, dental implant has become an increasingly popular treatment for dental patients around the world, with an annual estimated number of implant placed worldwide is 6.8 million implants, in the US is 910,000 implants*. In Vietnam, the first implant was placed in 1992 for a 54-year-old man who can still eat and chew well. It is estimated that in Viet Nam, about 20,000 to 40,000 implants are placed per year. In the past 22 years, dental implant has developed quite rapidly in Vietnam, Vietnamese doctors timely update the world implant techniques and perform all the techniques from simple to complicated. From easy cases with enough bone to complex cases with severe bone-deficiency, it is necessary to restore the bone by performing autografts with bone taken from the chin or pelvic area. In particular, lower alveolar nerve reposition and placing implants were successfully performed by Dr. Vo Van Nhan and reported at the Conference of Dental Implant in 2013. This is considered to be a breakthrough in Vietnamese dental industry .
Today, implant success in bone integration, meaning the implant fixed into bone after implantation is evident and has been proven in many studies, such as Lorenzoni's 100%  or Fugazzotto's 98.3 % . However, a successful implant placement for cosmetic is a great challenge for clinicians. According to Jempt 1997 (JPRD journal) in the United States, studied 21 patients who were implanted in cosmetic areas (incisors of the upper jaw). The result after one year showed that only 58% of implants achieved cosmetic results, 42% of implants failed cosmetically, but all these implants were successful in bone integration (the implants still sit firmly in the bone).
One thing to note is that Dr. Jempt's research was conducted in the United States which is one of the most advanced dental education countries in the world, and the condition for physicians to be qualified is very strict and harsh. However, the rate of failure for cosmetic implants by the US doctors is very high at 42%, which means implants in the incisor area is very difficult to achieve cosmetic results, this is a tremendous challenge. So where does the problem come from and how to overcome it? What conditions should be fulfilled to achieve the desired cosmetic result when placing implants in the maxillary region?
Clinical signs of failure in cosmetic implant placement:
The first type is missing the interdental papilla, forming a gap between the two teeth (Figure 1). This is a common type, but this complication affects only patients with the gummy smile without significant effect on patients with low laughing lines, only expose teeth when laughing.
The second most severe cosmetic complication is the recession of gums exposing the implant (Figure 2). This is a completely cosmetic failure, upset both the doctors and patients. These cases also make doctors reluctant or have difficulty appointing implant treatment for the incisor area. This is a trap, a challenge for dentists in implant surgery.
The results and methods may vary depending on the individual's condition
There are three main types of causes of cosmetic failure: (1) indications errors, (2) technical errors, and (3) anatomical disadvantages. Causes (1) and (2) are due to the fault of the doctor, cause (3) is due to the adverse clinical condition of the patient.
- Indication errors: Due to the lack of careful examination of the patient's clinical condition resulting in immediate implant placement after extraction in patients with an cortical plate recession, patients with thin gum tissue, patients with dental infections, patients with low alveolar crest.
- Technical errors: Due to the inexperienced surgeon, placing the implant too close to the outside bone, too deep, tilt too much, etc., placing the implant in the wrong position in the 3 dimensions orientational space. Do not graft bone when there is insufficient bone density to ensure that there is at least 2mm of bone surrounding the implant.
- Anatomical disadvantages: Patients with thin gum tissue, thin cortical plate, triangular teeth, infection, patients with many clinical diseases that reduce the ability to heal, etc.
Solutions: According to Dr. Nhan, there are 5 important solutions: (1) Accurate clinical evaluation and careful treatment planning, (2) proper indications, (3) proper techniques, (4) ensure sufficient bone volume and gums, (5) experienced doctors, (6) cosmetic dental restoration.
- Clinical evaluation:This is a job that is often overlooked before the start of an implant, but in my opinion the most important link affects all decisions and treatment techniques. Clinical evaluation of the bone status, type of bone defect, gingival tissue condition, inflammation of the implants as well as adjacent areas should be considered. Coagulation may be widespread and implant failure. In addition, it is important to consider the shape of the adjacent denture for the impiceplant as well as the correlation between the bite and the opposite tooth. Thus imlant teeth can later be matched and harmonious with the entire jaw as well as the smile of the patient. In addition, attention should be paid to general diseases and the patient's healing ability to select appropriate implants and materials. It is necessary to identify favorable factors to utilize as well as to detect the disadvantages and pitfalls to overcome the solution. These must be discussed in advance with the patient so that the patient understands and knows in advance the optimal aesthetic level that he can give them, but he can not always deliver excellent results. Usually the following two trends when the clinical situation is too complex, too many disadvantages: one is that the patient has to perform many complicated procedures, using special materials should increase costs and prolonged treatment time; Second, the patient has to lower his or her desired expectation to accept a simple and inexpensive solution in terms of cost and time. However, the third possibility is to accept a peaceful solution,
- Proper indication: Immediate implant placement immediately after tooth extraction and not flip flops, although the technique does not flip flickering to the patient but it is difficult to predict the aesthetic results should be very cautious. This is done only when the following conditions are met: patients with thick gingival epithelium, intact bone, intestinal skeleton, square or oval teeth, and most Asian patients in general. Male in particular has thin gum tissue so be very careful in implantation immediately.
In other cases implantation should be delayed 2-4 months after extraction. Depending on the shape of the bones, combine bone grafts or grafts to increase the thickness, ensuring at least 2mm of bone around the implant to ensure successful implantation and stability in the long run.
Implants need to be implanted in the correct space in relation to the adjacent teeth, while the direction of the implant should also be careful not to place the implant too directional or in. When implanted too far outside, it will cause the teeth to be too long, too into the teeth will cause 2 short cases that cause aesthetic.
Elasticity of the bone and gums: This is a very important factor to ensure that the implant is successful and that aesthetic results are stable in the long run. If enough bones and thick gums are good factors for good prognosis.
In case of lack of bone or gum graft supplement these two types of tissue to ensure that there are 2mm bones covering the implant and gum tissue at least 1.1mm thick and have gingival hyperkeratosis around the implant. For this reason, most cases of implant placement in the aesthetic area require the addition of bone and extra gums.
- About bone grafting material: Until now, the patient's real bone is still the best material because it contains growth factors that help heal wounds, have live bone cells, and limit the ability to react. . Thus, in cases where there is a large bone defect, the bone mass must choose the graft material is the patient's real bone can be taken from the chin, jaw area, pelvic area. In cases where minor bone defects require less bone grafting, artificial materials that replace bone can be used.
- Doctors with experience: This is an extremely important condition that determines the success of the entire treatment process rather than the type of implant because each implant has its own advantages and disadvantages depending on the clinical situation of the patient that he selected. It does not mean that the implant as expensive as possible. Because the development of an accurate treatment plan is important depending on the experience of the therapist. Based on examining and assessing the condition of the gums and jaw bone status of the patient to determine the following issues: the number of implants and the type of implant to be inserted into the implant with certainty Surface treatment of the implant for quick healing and prosthetic restoration. He or she also decided to have a bone graft and what type of graft is appropriate, for example: In the case of severe bone defects and severe bone loss, bone grafts of the patient should produce good results. Artificial bone can not be used in this case because artificial bone does not have growth factors. As bone grows in itself, the process of bone growth is slow, sometimes without bone healing. Adhere to the principle of 2mm bone covering the implant for long-term success. Therefore, bone grafting in implant implants should be taken care of properly. In addition, gingival tissue should be focused, even grafting implants in the implant to ensure the implants are not inflammation later. Thus, implant treatment is a complementary sequence of complementary processes including the development of treatment plans, implant placement in the correct position and direction,
- Artistic porcelain restorations: The general aesthetic of the teeth or the teeth on the implant in particular can be divided into two parts: pink aesthetic or cosmetic aesthetic and aesthetic white aesthetic. Porcelain on the implant is an exposing part for everyone to see, so it is important to ask for a cosmetic toothpaste if this part fails to meet all of the above treatment procedures as wasted. The porcelain teeth must have the shape, color, and characteristics of the similarity and harmony with the adjacent teeth, with the patient's lips and smile as well as the fitting of the bite to be able to eat well.
After the introduction of some cases of aesthetic failure due to non-compliance implant conditions in the cosmetic area:
Case 1 (Figure 1) is a clinical case cited from Dr. Buser's paper. The mistake is due to: Implant placement in the wrong position, implant too close to the outer bone blade, not enough 2mm bone The implant is placed too deep, the patient has a thin gum tissue and the result is an osteophytosis, gum recession, and implant exposures.
The second case (Figure 2) is the clinical case of the Rapoport BS Highway exposed to the same cause. Thus, these complications are also commonplace among new colleagues starting implant treatment in the world, not in Vietnam alone.
Here are two successful cases of compliance with the principles of implant treatment in the aesthetic area:
- Case 3 (Figure 3) is a clinical case done by Dr. Vo Van Nhan. This is a difficult case because patients have a clinical condition that is unfavorable: bone loss, gum tissue, and two vertical implant. adjacent. Therefore, the treatment plan in this case is implantation of bone-implanted bone grafts of patients with artificial bone, but grafted with special technique using real bone of the patient grafted between the two implants to Support the gingival papilla between 2 implants, while surgery 2 increases the thickness of the gingival tissue and gingival papilla between the two implants. This case was successful because it properly assess the initial condition, have a good treatment plan, adhere to the principles of bone grafting, using the correct self-grafting material, implant placement in place The treatment increases the thickness of the gum tissue.
- Case 4 (Fig. 4): This is a case study done by Dr. Vo Van Nhan. It is extremely difficult for patients with severe bone loss in the longitudinal and transverse dimensions. Osteoporosis is clearly visible in the clinic.
The treatment plan in this case is to have the best bone and bone graft in this case, the bone of the patient being taken from the posterior area rather than the artificial bone graft because of too large a defect. This case also has successful results because of good plan to treat the right principles of bone grafting, using the correct grafting materials, implant placement in the right place, and have increased the degree of treatment. thick tissue gum.
* Conclude:Based on the above analysis, implant implants in the aesthetic area are extremely difficult and challenging requiring physicians to have more knowledge, experience as well as supportive clinical skills such as bone grafting, gum implants. Not just implant implants. In addition, the examination of the patient's clinical condition must be carefully and carefully conducted to identify the factors that should be taken advantageously, but more importantly, to detect any factors. Benefits and pitfalls can lead to failure to work out practical and practical solutions to overcome these adverse factors before initiating treatment. Therefore,
Last of all patients and colleagues happy and successful career and life.
Ho Chi Minh City on 8/8/2014
Vo Van Nhan DDS.PhD
1. Vo Van Nhan (2014), "Lower abdominal neuromuscular implant surgery and dental implants implantation: Clinical case report", Journal of Medical Research, Vol. 89-99. http://www.thanhnien.com.vn/pages/20131206/dot-pha-moi-ngong-nganh-implant-nha-khoa-viet-nam-in-thong-duoc-rang-nho-phau-thuat-doi- day-than-kinh.aspx.
2. Jemt T. (1997), "Regeneration of gingival papillae after single implant treatment", Int J Periodontics Restorative Dent, 17, pp.326-333.
Lorenzoni M, Pertl C, Polansky R, Wegscheider W. Guided bone regeneration with clinical barrier and radiographic follow-up study after 24 months. Clin Oral Implants Res 1999; 10 (1): 16-23.
4. Fugazzotto PA. Osseointegrated implants in function in regenerated bone for 72 to 133 months. Int J Oral Maxillofac Implants 005; 20 (1): 77-83.
5.D. Buser, U. Belser (2007), Implant therapy in the Esthetic Zone, Single Tooth Replacement, ITI Treatmet Guide, Quintessence Publishing Co.Ltd.
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