Esthetic Implant Restoration In The Edentulous Maxilla A Simplified Protocol Karim Dada, Marwan Daas

Mục đích chính của cuốn sách này là cung cấp cho độc giả một hướng dẫn lâm sàng đơn giản để giúp họ điều trị răng hàm trên hoàn toàn bằng công nghệ mới hiện có và đối mặt thành công với thách thức thực sự của tình trạng lâm sàng này: đạt được sự tích hợp thẩm mỹ của các phục hình với kết quả có thể đoán trước được. Cuốn sách này không phải là một mô tả đơn giản về các phương pháp điều trị có sẵn; ngược lại, nó thúc đẩy một chiến lược điều trị dựa trên các phân tích thẩm mỹ được tiêu chuẩn hóa. Phương thức điều trị này tập trung vào tầm quan trọng của giai đoạn chuẩn bị và chất lượng của bộ phận giả tháo lắp ban đầu, vốn thường bị bỏ qua trong các phương pháp điều trị thông thường và thường có thể là lý do gây thất vọng về mặt thẩm mỹ hoặc chức năng. Đó là điều kiện tiên quyết quan trọng tạo nên sự thành công của liệu pháp này. Cuốn sách này cũng mô tả các khả năng tải ngay lập tức, cung cấp một bộ phận giả cố định ngay sau khi phẫu thuật và sử dụng phẫu thuật không vạt, tất cả đều có thể được sử dụng để hạn chế càng nhiều càng tốt những khó khăn sau phẫu thuật cho bệnh nhân. Các hình ảnh minh họa rộng rãi tương xứng với văn bản có thể khiến người đọc ngạc nhiên. Chúng tôi chọn bài trình bày này vì nó có vẻ phù hợp hơn với mục đích lâm sàng của cuốn sách. Chúng tôi cũng nghĩ rằng đó là cách hiệu quả nhất để truyền đạt những điểm chính cần thiết để bắt đầu thực hiện loại điều trị này. Tuy nhiên, ngay cả khi cuốn sách này cung cấp một thông tin tổng hợp thì cũng không phải là không có cơ sở khoa học. Phác đồ điều trị đã được xác nhận bởi một số ấn phẩm được đánh giá ngang hàng và được hỗ trợ bởi các kết quả ban đầu của quá trình theo dõi lâu dài. Phân tích thẩm mỹ tiêu chuẩn là một công cụ giao tiếp thiết yếu giữa các thành viên của nhóm điều trị, bao gồm bác sĩ phục hình răng, kỹ thuật viên nha khoa, bác sĩ phẫu thuật, trợ lý nha khoa và bệnh nhân, trong số những người khác. Các nguyên tắc làm việc nhóm mà chúng tôi đã coi trọng trong nhiều năm là rất quan trọng đối với bệnh nhân ngày nay. Làm việc nhóm đòi hỏi sự phối hợp hoàn hảo và đó là nền tảng của cuốn sách này. Với tinh thần làm việc nhóm này, chúng tôi đã hợp tác trong dự án này với Tiến sĩ Paulo Malo và nhóm của ông, những người có kinh nghiệm lâm sàng vô song và không ngừng phát triển các chiến lược điều trị mới cho những bệnh nhân hoàn toàn lành mạnh. Trọng tâm của họ là giảm số lượng mô cấy được sử dụng, đơn giản hóa các quy trình phẫu thuật và phục hình, tránh ghép xương và phát triển các chiến lược điều trị có thể áp dụng cho số lượng bệnh nhân lớn nhất và số lượng bác sĩ lớn nhất. Kết quả của sự hợp tác này là chương cuối cùng về khái niệm điều trị cả bốn, một đóng góp mà chúng tôi vô cùng biết ơn.

Quintessence Publishing Co, Inc

Chicago, Berlin, Tokyo, London, Paris, Milan, Barcelona, Beijing, Istanbul, Moscow, New Delhi, Prague, São Paulo, Seoul, Singapore, and Warsaw

A Simplified Protocol

First published as Esthétique et implants pour l’édenté complet maxillaire in French in 2011 by

Quintessence International in Paris, France

Library of Congress Cataloging-in-Publication Data

Dada, Karim, author

[Esthétique et implants pour l’édenté complet maxillaire English]

Esthetic implant restoration in the edentulous maxilla : a simplified protocol / Karim Dada, Marwan Daas ; with collaboration by Paulo Malo

p ; cm

Includes bibliographical references

ISBN 978-0-86715-645-4 (hardcover)

I Daas, Marwan, 1968- author II Malo, Paulo, 1961- author III Title

[DNLM: 1 Dental Implantation, Endosseous methods 2 Jaw, Edentulous rehabilitation 3 tal Implants 4 Dental Prosthesis, Implant-Supported methods 5 Esthetics, Dental 6 Maxil-la surgery WU 640]

RK667.I45

617.6’93 dc23

2014011123

© 2014 Quintessence Publishing Co, Inc

Quintessence Publishing Co, Inc

lenge of this clinical situation: obtaining an esthetic integration of the restorations with predictable results This book is not a simple description of the available therapeutic options; on the contrary,

it promotes a treatment strategy based on standardized esthetic analysis This treatment modality focuses on the importance of the preparatory phase and on the quality of the original removable prosthesis, which is often neglected in conventional treatments and can frequently be the reason for esthetic or functional disappointments It is a crucial prerequisite to the success of this therapy.This book also describes the possibilities of immediate loading, providing a fixed prosthesis short-

ly after the surgery, and the use of flapless surgery, all of which can be used to limit as much as possible the postoperative difficulties for the patient

The extensive illustrations in proportion to the text may surprise the reader We chose this tation because it seems to better correspond to the clinical aim of the book We also thought it was the most effective way to convey the key points needed to begin performing this kind of treatment However, even if this book provides a synthesis of information, it is not without scientific basis The treatment protocol has been validated by several peer-reviewed publications and is supported by the initial results of long-term follow-up

presen-A standardized esthetic analysis is an essential communication tool between members of the treatment team, which includes the prosthodontist, dental technician, surgeon, dental assistant, and patient, among others The principles of teamwork that we have valued for so many years are crucial for today’s patients Teamwork demands perfect coordination, and that is the foundation of this book

In this spirit of teamwork, we have collaborated on this project with Dr Paulo Malo and his team, who have unparalleled clinical experience and never stop developing new treatment strategies for the fully edentulous patient Their focus is on reducing the number of implants used, simplifying surgical and prosthetic protocols, avoiding bone grafting, and developing treatment strategies that will be applicable to the largest number of patients and by the largest number of clinicians The result of this collaboration is the final chapter on the all-on-four treatment concept, a contribution for which we are deeply grateful

This phenomenon can be explained by a longer life expectancy, which is estimated to be rising by 1.5

to 3 months every year, and the proportional increase in edentulous patients In 2050 in the United States, there should be more than 50 million people older than 65 years, and people more than 60 years old should represent more than one-third of the population In 2050, there will be three times more people older than 75 years and four times more people older than 85 years than there were in 2000 In

2010, almost a quarter of the United States population older than 65 years was fully edentulous Today, there is also limited access to health care for certain segments of the population who are in precarious

circumstances or have inadequate insurance

cov-erage

However, aged and poor people are not the

only ones who are fully edentulous Every social

class is affected, as are many young people The

rise of patient numbers coincides with increased

expectations in terms of treatment comfort and

efficiency, despite a deteriorating oral situation

While an edentulous mandible is functionally

more difficult for the patient than an edentulous

maxilla, the latter is more difficult for the

clini-cian to treat and obtain a good esthetic result

Indeed, there are multiple parameters to take

into account that can be challenging for the

in-experienced clinician Regardless of how

com-fortable and functional a maxillary prosthesis

may be, patients are often not satisfied unless it

is also meets their esthetic expectations Hence,

there is a high demand for an implant-supported

restoration in the edentulous maxilla However,

implant placement has to respect certain

condi-tions to guarantee a high success rate

Therapeutic Options

The therapeutic approach to treating the fully

Removable complete denture

Box 1 presents the indications and advantages

as well as the disadvantages of treatment with

a removable complete denture Within the adigm of implant-supported treatment,2 fab-rication of a provisional removable complete denture allows:

par-• Validation of the planned occlusal scheme in conjunction with the mandible

• Assessment of the interocclusal space able for the surgical and prosthetic stages

avail-• Facilitation of the continuity of the surgical and prosthetic treatment

• Preview of the definitive esthetic result

• Assurance that the provisional restoration

of the implants will create fewer ments

micromove-Implant-supported overdenture

Although implant-supported overdentures have been described extensively in the literature,3

in the authors’ opinion their only indication

is cases in which implants have already been placed in the anterior maxilla and, because of their position, cannot be restored with a fixed

• Prior use of a removable denture

• Favorable ridge for support and retention

• Absolute contraindications for surgery

Advantages:

• Simple and reversible treatment

• Low cost

• Negative psychologic impact

• Low control over ridge resorption

• Lower functional efficiency

Box 2 Implant-supported overdenture

maintenance (2) Prevalence of peri-implantitis

is significantly higher than with a fixed denture

Furthermore, failure rates reported in the

liter-ature for implants supporting maxillary

overden-tures are significantly higher than those

clas-sically allowed for this kind of treatment in the

mandible4: When combined, the results of recent

studies showed failure rates around 19%.5

As a general rule, when four implants are sidered to treat a fully edentulous maxilla, the au-thors prefer to place the implants so that a fixed solution may be offered to the patient Figure 2 presents the clinical case of a patient treated with a removable implant-supported overdenture

con-Fig 2 (a) Initial intraoral view The patient presents with an implant-supported bar with three ball attachments to

sta-bilize an overdenture (b) Occlusal view of the prosthesis, which has been reinforced with a metal portion, in which the

matrix of the ball attachments are embedded (c) View of the intaglio, which shows many instances of relining

result-ing from the separation of the matrix from the attachments At this stage, the attachments are no longer retentive, and

the patient wants to improve her comfort during chewing while maintaining an identical prosthetic scheme (d)

Intra-oral view after removal of the bar Despite an unfavorable mucosal environment in the right sector, the implants were

clinically osseointegrated and did not show peri-implant disease (e) View of the abutments supporting the bar

Be-cause of the decrease in the available prosthetic space generated by these abutments, the planned retention bar will

need to be placed directly on the implants (f) Mixed impression in polyether and plaster that will be used to fabricate

the planned implant-supported prosthesis

Fixed implant-supported prosthesis

Box 3 presents the advantages and

disadvantag-es of treatment with a fixed implant-supported

prosthesis Currently, the fixed implant-supported

prosthesis is the authors’ gold standard for

treating a fully edentulous maxilla

However, there are different types of fixed

implant-supported prostheses that can be used

depending on the defect caused by the loss of

teeth (and often of the alveolar process) The

conventional fixed implant-supported

prosthe-sis lacks artificial gingiva and is used in cases

presenting a minimal tissue defect (Fig 3) The hybrid fixed implant-supported prosthesis is in between the conventional prosthesis and the classic implant-supported prosthesis described

by Brånemark; this prosthesis can support tificial gingiva and is used in cases where there

ar-is an average tar-issue defect or when there are specific esthetic demands (Fig 4) The fixed implant-supported prosthesis (Brånemark-type prosthesis) has the most clinical experience and

is especially recommended when the tissue fect is severe (Fig 5)

de-Advantages:

• Stable and retentive

• Less obstruction

• Positive psychologic impact

• Optimal restoration of masticatory capacities

Disadvantages:

• Demanding hygiene and maintenance

• Very high initial cost

a

b

Fig 4 Hybrid prosthesis (a) Framework (b) Esthetic ceramic.

Fig 3 Conventional prosthesis.

Fig 5 Brånemark type of prosthesis.

An Approach Based on

Degree of Resorption

The use of osseointegrated implants has

great-ly evolved from the puregreat-ly mechanical, where

osseointegration was the ultimate goal, to

in-corporate prosthetic aims in which implant

positioning must be compatible with an

esthet-iologic puzzle is a modern view of treatment that considers any restoration in terms of its integration from a biologic, biomechanical, functional, and esthetic perspective

At the same time, it is becoming

increasing-ly important to limit treatment morbidity and

to favor simple and efficient treatment that duces the number of surgeries The emergence

re-of treatment without grafts and a high level re-of evidence and associated success to support it

Table 1 Data supporting a treatment approach without bone grafting

Provisional prosthesis

Occlusally adapted custom tray

Esthetic analysis

Prosthetic plan

Surgical guide

1 Douglas CW, Shih A, Ostry L Will there be a need for

complete dentures in the United States in 2020? J

Prosthet Dent 2002;87:5–8.

2 Postaire M, Daas M, Dada K Prothèses et implants

pour l’édenté complet mandibulaire Paris:

Quintes-sence, 2006.

3 Chan MF, Narhi TO, de Baat C, Kalk W Treatment of the

atrophic edentulous maxilla with implant-supported

overdentures: A review of the literature Int J

Prostho-dont 1998;11:7–15.

4 Sadowsky S Treatment considerations for maxillary

implant overdentures: A systematic review J Prosthet

Dent 2007;97:340–348.

5 Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JY

Clinical complications with implants and implant

pros-theses J Prosthet Dent 2003;90:121–132.

6 Magne P, Belser U Bonded Porcelain Restorations in

the Anterior Dentition: A Biomimetic Approach

Chica-go: Quintessence, 2002.

7 Krekmanov L, Kahn M, Rangert B, Lindström H

Tilt-ing of posterior mandibular and maxillary implants for

improved prosthesis support Int J Oral Maxillofac

Im-plants 2000;15:405–414.

8 Aparicio C, Perales P, Rangert B Tilted implants as an

alternative to maxillary sinus grafting: A clinical,

radio-logic, and Periotest study Clin Implant Dent Relat Res

2001;3:39–49.

9 Tawil G, Mawla M, Gottlow J Clinical and

radiograph-ic evaluation of the 5-mm diameter regular-platform Brånemark fixture: 2- to 5-year follow-up Clin Implant Dent Relat Res 2002;4:16–26.

10 Malo P, de Araújo Nobre M, Rangert B Short implants placed one-stage in maxillae and mandibles: A retro- spective clinical study with 1 to 9 years of follow-up Clin Implant Dent Relat Res 2007;9:15–21

11 Malo P, Rangert B, Nobre M All-On-4 tion concept with Brånemark System implants for com- pletely edentulous maxillae: A 1-year retrospective clin- ical study Clin Implant Dent Relat Res 2005;7(Suppl 1):S88–S94.

immediate-func-12 Malo P, Nobre Mde A, Petersson U, Wigren S A pilot study of complete edentulous rehabilitation with im- mediate function using a new implant design: Case series Clin Implant Dent Relat Res 2006;8:223–232.

13 Agliardi E, Panigatti S, Clericò M, Villa C, Malo P mediate rehabilitation of the edentulous jaws with full fixed prostheses supported by four implants: Interim results of a single cohort prospective study Clin Oral Implants Res 2010;21:459–465.

14 Bedrossian E, Rangert B, Stumpel L, Indresano T mediate function with the zygomatic implant: A graft- less solution for the patient with mild to advanced atrophy of the maxilla Int J Oral Maxillofac Implants 2006;21:937–942.

Im-15 Malo P, Nobre Mde A, Lopes I A new approach to bilitate the severely atrophic maxilla using extramaxil- lary anchored implants in immediate function: A pilot study J Prosthet Dent 2008;100:354–366

reha-The protocol presented in this book (and

summarized in Fig 6) starts with a thorough

esthetic analysis that allows the clinician to

pro-pose solutions to the patient It continues with a

logical and standardized therapeutic approach

that ensures the final success of the treatment

and meets the various goals previously

estab-lished for the prosthetic restorations:

• Avoid bone grafting

• Ensure a high success rate

• Reestablish esthetics and function

• Allow correct hygiene and maintenance

• Provide the patient with an immediate fixed

of a provisional removable complete denture that meets specific quality criteria and clinical valida-tion This is the keystone of the prosthetic treat-ment Indeed, the provisional removable com-plete denture will be essential to the creation of the surgical guides used to position the implants

as well as the fabrication of the definitive fixed implant-supported prosthesis

to further illustrate how the esthetic checklist can be implemented into clinical practice.

Several situations can justify the use of dental implants to treat an edentulous maxilla:

• Patient dissatisfaction with a removable complete denture

• Prevention of bone resorption and preservation of the bone in a young patient, or prevention of severe resorption in an older patient

• Limiting psychologic trauma and ensuring continuity in terms of comfort and esthetics in a tate patient who is becoming edentulous

den-Each edentulous patient is different and will have different expectations and demands The cian has to identify each patient’s needs to avoid overtreatment and propose the most appropriate therapeutic approach according to the clinical situation In addition to different treatment options, and in some cases in response to certain expectations, it is possible to immediately load the pros-thesis and even apply a protocol of extraction followed by implant placement Because there are so many possible therapeutic options, it is important to have a standardized sequence of treatment with a therapeutic approach that can help avoid failures that occur from lack of planning

clini-Goals of the Esthetic Analysis

At the end of this phase, it is important to obtain the best compromise between the patient’s sires; the clinician’s capabilities; and the anatomical, medical, and prosthetic possibilities

de-The clinician should always acquire a full patient history (including expectations and motivations), prior medical and surgical records, and a comprehensive clinical examination with additional exam-inations as needed

The comprehensive clinical examination is

followed by the analysis of the casts poured

from secondary impressions and mounted on

an articulator in correct maxillomandibular

relation (vertical dimension of occlusion and

centric relation) This gives crucial information

regarding the relationship of the ridges and

the available prosthetic space It cannot be

ne-glected because the definitive restoration will

be guided by the amount of bone resorption

Mounting the denture teeth at this point

pro-vides important indications regarding the

oc-clusal treatment of the opposing mandible

After key steps of treatment, it is important

to reevaluate the therapeutic approach using

the esthetic checklist.1 Key steps include the

re-lining of the new complete denture, immediate

loading of an implant-supported provisional

restoration, and try-ins of the definitive implant-

supported prosthesis This checklist has been

put together as an instructional tool, and it is

important to keep in mind that the majority

of the analytic parameters are interdependent

and therefore cannot be studied in isolation It

is only with experience and practice with these

treatments that the clinician will be able to put

these criteria together for a global perspective

col-It is important to be aware that the term

den-togenic (to be taken along the same lines as togenic) was introduced during a time that was

pho-significantly different than today A 60-year-old patient cannot be considered an elderly individual Patients in this age group are mainly asking for a rejuvenation of their smile to match the standard set by the mass media One may consider that

a modern dentogenic approach would be to give these patients a smile optimizing their esthetics based on criteria appropriate to their age

Patient demands and expectations

Being able to understand patients’ tions and demands is critical in the clinical interview (Fig 1-2) It is crucial to explain to patients what to expect in terms of the pos-sibilities and limitations of implant treatment

expecta-in their case Each case is different, and it is not possible to be exhaustive Boxes 1-1 and 1-2 present the main questions and concerns

to address with patients in order to understand

Thin Athletic

Build

Introverted Extroverted

Fig 1-1 Basic information.

Patient answers have to be correlated with

the clinical examination to evaluate the quality

of the existing prosthesis

Contraindications to implant

surgery

It is important to understand the potential for

contraindications (Fig 1-3) The goal is not to

make an exhaustive list of the absolute and

po-tential contraindications for implant surgery

However, during the first interview, it is

import-ant to be able to detect patients who should

be classified in the risk category—patients for

whom the risk of implant failures or

compli-cations is clearly above average For example,

smokers have 10% less chance for implant

os-seointegration if they present one or more

rela-tive contraindications The implant options may

be reconsidered if the risks of complications

are too high

In contrast, for a nonsmoking patient

pre-senting one or two relative contraindications,

the clinician should consider a minimally

in-vasive protocol such as a flapless surgery The

border between absolute and relative

contrain-dications is often unclear; therefore, the

clini-cian has to use common sense and experience

to balance safety with expected benefit ever, any absolute contraindication should halt consideration of treatment with an implant- supported prosthesis

How-The Face

Eye color and face shape

Eye color and face shape must be considered next (Fig 1-4) “An oval-shaped face means oval-shaped teeth” Many clinicians probably heard this kind of axiom (Williams’ theory7) in dental school when studying removable prostheses, but it is important not to fall into a dogmatic vision of esthetic restoration This process has

to do with an esthetic harmony that is guided

by the clinician’s perception and that respects patient desires (Fig 1-5) It is difficult to pre-cisely define the shape of a patient’s face, which often falls in between two categories In addition, when the morphology is clear, under-lining it with a similar tooth shape can make the restoration monotonous Playing with in-

Box 1-1 Basic first questions

• What is the prosthetic demand?

• Are the patient’s expectations realistic?

• Is there a functional challenge or an esthetic

goal that can be solved with a specific

treat-ment?

• Is the patient already involved in a conventional

treatment?

• What are the patient’s complaints?

• Is the patient aware of the specifications of

im-plant treatment in terms of duration, follow-up,

cost, and maintenance?

Box 1-2 Common sources of complaint

• Mobility or prosthetic instability

Contraindications to implant surgery

Fig 1-3 Contraindications to implant surgery.

a b

d

c

Fig 1-4 Eye color and face shape.

Face shape

Harmony with teeth? Yes No

terdental transition lines can enhance the

pa-tient’s smile However, purposely choosing a

shape that widely differs from the face shape

of the patient or ignoring this parameter puts

the clinician at risk of fabricating an unesthetic

definitive restoration Finally, in many cases the

shape of patients’ teeth may not be in absolute

harmony with their face shape but is also not

the cause of their esthetic complaints

Balance between the face and

the smile

To study the balance between the face and the

smile, it is helpful to mask the middle part of

the face (Figs 1-6 and 1-7) As with the other

parameters of this esthetic analysis, it is

im-portant to collaborate with patients to mine what they want and what the possibilities are for change The therapeutic decision process starts with balancing what is wanted with what

deter-is possible At thdeter-is point, it deter-is important to termine if the face and the smile are balanced

de-or if one is prominent over the other When the face is less dominant it is important to explain that the dental rehabilitation alone will not solve the problem and that to do so the patient may require cosmetic treatment or plastic surgery (if desired) The easiest way to treat a lackluster smile is to choose a brighter shade for the teeth

It is also possible to emphasize the tooth phology with longer and squarer teeth However,

mor-it is important not to introduce restorative ments that could dominate the smile too easily

Fig 1-7 (a and b) The implant-supported provisional prosthesis restored a balance

between the look and the smile of the patient.

Fig 1-6 Balance between the face and the smile.

Balanced Imbalanced

Mark the dominant and nondominant areas on the image

Horizontal lines

It is essential to determine the horizontal lines

of the face and whether they are harmonious

with one another and perpendicular to the

me-dian sagittal line (Fig 1-8) It can be useful to

superimpose a grid on the picture to detect

thetic occlusal plane should be parallelized to give a global sense of harmony Finally, inside the esthetic occlusal plane, it is important to have harmony between the gingival plane and the dental plane, especially if the transition be-tween the two planes is visible in the smile.Harmony between the main horizontal lines

Fig 1-9 The parallelism between the occlusal plane and the

pupil-lary line, which contributes to the overall harmony of the restoration,

can be detected by any observer during an extraoral examination.

Parallel Anomaly due to the orientation of the

esthetic occlusal plane

Mark asymmetry of the smile on the drawing

Fig 1-8 Horizontal lines.

Diverging

perpendicular to the median sagittal line When

the pupillary line is the only one diverging, it is

important to orient the esthetic plane

perpen-dicularly to the median sagittal line in order to

minimize the imbalance When the

comissur-al line comissur-alone is diverging, there is a true smile

asymmetry that can only be corrected with

plastic surgery (as opposed to an asymmetry

from the incorrect orientation of the

esthet-ic plane that can be easily corrected) In this

case, the dental rehabilitation should only try

to compensate for the visual effect induced by

this asymmetry Once again, it is important not

to accentuate the anomaly but to try to create

harmony with the rest of the face

Facial thirds

The division of the face into three equal parts that was introduced by Leonardo da Vinci is still valid today (Figs 1-10 and 1-11) It is import-ant at this point to measure the three different

parts of the face: (1) the upper third, from the crown of the head to glabella; (2) the middle third, from the glabella to subnasal; (3) and the

lower third, from subnasal to gnathion

Dental treatment applies directly to the lower third of the face only Indeed, three essential vertical dimensions define it:

Fig 1-11 Various parts of the face according to Lejoyeux 8 ; morphopsychology is based on relating a

patient’s facial feature to an aspect of his or her personality to better understand the individual as a

INTELLECTUAL

EMOTIONAL

PHYSICAL

Ideals Conscience Fulfillment

State of mind Feelings Impulses

Sensitivity Sensuality Instinct

Fig 1-10 Facial thirds.

Balanced Imbalanced

Mark on the image + or –

Fig 1-13 (a) Initial view of a young patient who is completly

edentulous (b) Profile view showing the obvious collapse of

the vertical dimension as well as the loss of soft tissue

sup-port The patient’s aspect is typical of that of a fully

edentu-lous patient There is a difference between her actual age and

her apparent age (c) While smiling, the patient does not

show the edentulous ridge; there is therefore no indication for

bone reduction

a

c b

1 Vertical dimension of occlusion This is the

dimension of the lower third of the face when

the mandible is in occlusion This is the

es-sential dimension that will be transferred to

the laboratory; the two other vertical

dimen-sions are only used to determine it

Fig 1-12 Profile.

Fig 1-13 (cont) (d and e) Initial intraoral views (f) Although this patient is highly motivated for implant placement, the treatment

begins with the fabrication of high-quality complete dentures for both arches (g) Particular attention is paid to reestablishing a proper maxillomandibular relationship (h) Because the edentulous ridges do not need to be modified, computer-guided implant

placement is indicated to treat both arches in one appointment In the maxilla, eight implants are planned and will be

immediate-ly loaded with a provisional prosthesis supported by multi-unit abutments (i) Maxillary planning The right maxillary sinus is passed by angulating the implant position (j) The treatment of the mandible will be achieved by placing six implants to support a

by-definitive prosthesis (Procera Implant Bridge, Nobel Biocare) with guided abutments (Nobel Biocare) immediately after surgery

In a concave profile, the face looks older The

nose seems longer and the cheeks recessed

This type of profile is typical of the completely

edentulous patient when there is little or

insuffi-cient correction (Fig 1-13) Usually, the need for

correction and the amount of support is

dictat-ed by each arch’s resorption (significant

resorp-tion means the need for significant support and

vice versa)

When the patient is dentate or is fully restored, the profile can also be adjusted to highlight par-ticular aspects of the personality For example, a protrusive profile is usually associated with mas-culinity and an energetic nature

Finally, since the shape of the teeth can be influenced by the shape of the face, there is a tendency to match the shape of the teeth with the shape of the face

Fig 1-13 (cont) (k) This view of the duplicate denture in occlusion reveals the vertical defect in the maxillary arch It is not

possible to treat this situation with a fixed prosthesis A prosthesis with artificial gingiva is indicated (l) Maxillary arch after surgery (m) An impression of the implant positions is taken for immediate loading of the prosthesis (n to p) Final intraoral

view showing the reestablishment of a proper maxillomandibular relationship after surgery

o

m

p n

Fig 1-13 (cont) (q) Final panoramic radiograph showing that the surgical plan has been followed (r)

Final extraoral view The provisional restorations will now be critically examined and optimized to

ob-tain fully satisfactory definitive restorations (s) At this stage of treatment, the improvement in the

profile of the patient is clear, and the architecture of the lower third of the face is restored.

Lip support

The lip support is under the direct influence of

the position of the interincisal point in the

sag-ittal plane as well as the shape and the length

of the lips (Fig 1-14) Furthermore, the upper

lip position in the anteroposterior direction has

a direct influence on the visual perception of the nose: It will appear more prominent when there is a deficit of support, which is often the case when the profile is concave in a completely edentulous patient

Normal Deficient Excessive

Lip support

Fig 1-14 Lip support.

Depending on the amount of resorption, the

lip support is influenced by different elements

When the bone resorption is minimal, the lip

support is determined by the position of the

prosthetic teeth When the bone resorption is

severe, the lip support will be determined by

the artificial gingiva of the prosthetic

resto-ration It is important to consider the angle

be-tween the buccal plate and the artificial gingiva

to obtain the needed support (Fig 1-15) If this

angle is more than 45 degrees, the artificial

gingiva must begin well before the crest and

will compromise the architecture,10 which may

whereas thick lips are a contraindication to any anterior displacement The displacement of the upper lip should not be accentuated by the po-sition of the incisors When the upper lip is in-clined backward, a lowering of the point flattens the lip When the upper lip is inclined forward, anterior displacement of the point may provide excessive support; on the contrary, the inter-incisal point should be translated posteriorly Short lips are not affected by displacement of the interincisal point

Fig 1-15 (a and b) A vertical osteotomy is indicated as soon as the angle formed by the artificial gingiva/prosthetic tooth

and the alveolar ridge is greater than 45 degrees It allows restoration of a normal relationship and avoids food retention and discomfort for the patient (Modified from Malo et al 11 with permission.)

Smile line

Fig 1-16 Smile line.

Resorption < 45 degrees Resorption > 45 degrees

Fig 1-17 A gingival smile is not automatically considered

un-esthetic if there is a harmonious un-esthetic occlusal plane and

the visible gingiva has no imperfections.

Fig 1-18 (a and b) For this patient, immediate implant

place-ment after extraction has been planned She has a particularly

high smile line Resection of alveolar tissue was indicated after

the immediate implant placement procedure to hide the

tran-sition between the natural gingiva and the prosthesis and to

remove the unesthetic aspect of her smile (c) The amount of

tissue to remove is visualized by marking the future location of

the esthetic occlusal plane and comparing it with the smile

line (d) Extraoral view of the definitive result The smile of the

patient looks normal again through the application of a

rela-tively simple surgical procedure (e) It is important to notice

any exposure of the edentulous ridge in the smile that may

indicate a need for aveolar resection This can help avoid any

risk of failure of the esthetic restoration.

Statistically, 10% of the population has a

high smile line13 (Figs 1-17 and 1-18) This is

a delicate situation to manage because of the

esthetic risk In cases where the planned

resto-ration does not include artificial gingiva, there

is no resorption to compensate It is ant to respect a strict correlation between the normal tooth placement and the implant posi-

import-tioning Otherwise, the implant could emerge

in a gingival embrasure and there would be no

artificial gingiva to mask it In cases where the

planned restoration includes artificial gingiva,

the transition line between artificial gingiva and

natural gingiva should not be visible Therefore,

when the patient’s lip is short, a vertical

oste-otomy should be made to mask this transition

Because the bone resorption cannot be

con-trolled when a patient transitions to an

eden-tulous state, it is important to measure the

amount of tissue to remove to make the

transi-tion line invisible

For a dentate patient, it is also important to

check that the posterior sectors are not

visi-ble during the smile If they are, an osteotomy

should be made in the posterior sectors to avoid

an unsightly appearance during the smile

When implants are placed correctly in a case

of severe resorption or when the transition

be-tween the artificial gingiva and natural gingiva

is masked, a high smile line can be compatible

with an esthetic restoration The esthetic plane

should harmonize with the teeth, gingiva, and

lip curvature (Fig 1-19)

For 70% of the population the smile line is

average.13 The teeth are then in an ideal

posi-tion in relaposi-tion to the upper lip: All the surfaces

Esthetic occlusal plane

The esthetic occlusal plane is formed by the alignment of the incisal edges and the cusps of the teeth visible during the smile The esthetic oc-clusal plane is crucial to the smile because it is directly visible when looking at the full face (Fig 1-20) Its correct position usually depends on op-timal positioning of the interincisal point Even if

it is possible to make an esthetic compromise to enhance the smile, it is important to keep in mind its role in speech and anterior guidance

When the esthetic occlusal plane is mally high, it evokes an aging smile because it underscores any sagging of the face Two main

abnor-anomalies can cause this phenomenon: (1) terior teeth are too short or (2) the upper lip

an-is abnormally long In cases in which the rior teeth are too short, the mandibular teeth are often found to have overerupted Therefore, there is an insufficient vertical overlap and an-terior guidance When the upper lip is abnor-mally long, the clinician may be tempted to lower the interincisal point to show more of the restoration during the smile However, in this situation, the lower the interincisal point is, the more the incisal guidance is augmented and the more the restoration is exposed to exces-

ante-For patients with a high smile line who wear a removable denture, is the edentulous crest

visible during the smile?

es of severe attrition of the anterior

mandib-ular teeth that have not compensated through

overeruption The resulting anterior guidance is

once again too pronounced, and the

generat-ed mechanical stress puts the prosthetic

res-toration at risk When there is a skeletal cause

for a gingival smile, such cases are frequently

reinforced by a short upper lip The option of

a vertical osteotomy is legitimate and should

be favored if there is another abnormality or when it is necessary to include artificial gingiva

in the definitive restoration (eg, when the bone resorption is mainly horizontal)

Any divergence of the esthetic plane in relation

to the horizontal lines of the face needs to be rected and align with the pupillary line (Fig 1-21)

cor-Fig 1-20 Esthteic occlusal plane.

Diverging

Mark the movement needed to obtain harmony with the facial lines

Fig 1-21 (a) Divergence of the esthetic occlusal plane with the horizontal references of the face brings a feeling of general

disharmony (b) The restoration of a harmonious esthetic occlusal plane has a direct impact on the harmony of a face despite

the presence of other anomalies of the horizontal lines.

b a

When the esthetic plane is inverse,

rehabilita-tion of the opposing arch should be considered

(Fig 1-22) Indeed, the complete rehabilitation

of the maxilla requires harmonious occlusal

curves An inverse occlusal curve is

unesthet-ic and mechanunesthet-ically incompatible with a fixed

implant-supported maxillary prosthesis

The curvature in an esthetic plan (which must

provide a smooth disocclusion in all lateral and

Length of the upper lip

The length of the upper lip must be considered (Fig 1-23) The visibility of the maxillary teeth increases when the lip shortens, which can give the smile a more feminine look At this point in the esthetic analysis, there should be an under-standing that the parameters for correct posi-tioning of the interincisal point are numerous

Fig 1-22 (a to c) For this patient, the esthetic occlusal plane is completely reversed; only the mandibular incisors are visible

while smiling In all such cases, both arches have to be treated (d) Extraoral view at the end of the treatment, in which the

maxillary esthetic has been restored through the establishment of ideal mandibular curves.

a

c

b

d

Fig 1-24 (a) Initial extraoral view of a patient with a long upper lip who is dissatisfied with her maxillary restoration The lip

length was not considered when locating the interincisal point, which is the cause of her dissatisfaction She felt that her

teeth were not visible enough in her smile (b) The new restoration includes a lower interincisal point It is important in this

type of treatment to find a balance between esthetics and biomechanical integration because the incisal guidance has to be more pronounced to increase the visibility of the maxillary anterior teeth.

1 The phonetic aspect The maxillary incisal

edge needs to have only a slight contact with

the lower lip when the patient is

pronounc-ing phonemes like “FE” and “VE”

2 The esthetic aspect For a 30-year-old patient

with a regular lip length, the incisal edges of

the maxillary incisors at rest need to be 2

mm lower than the upper lip This should be

adapted depending on the upper lip length

The shorter the lip is, the more this distance

can be augmented Conversely, the longer

the lip is, the higher the esthetic occlusal

plane should be placed The age of the

pa-tient also needs to be considered The older

the patient, the less muscular tone and the

more abrasion there is; therefore, the incisal

edges will be less visible For a 50-year-old

patient, a mean of a 1- to 1.5-mm distance

of the incisal edges beyond the upper lip is acceptable However, in some cases, it can

be useful to go the opposite way to give a younger look to the smile Once again, it is all about individual perception and compro-mise, and the patient’s expectations should

be considered (Fig 1-24)

Thickness of the upper lip

The thickness of the upper lip has a direct influence on the perception of the smile (Fig 1-25) Thinner lips will give an impression of

an aged and less visually pleasant smile It is our role to introduce elements into the smile

to counteract this tendency Conversely, thicker lips will be associated with more femininity and sensuality It is important to note that when the

Fig 1-23 Length of the upper lip.

lips are thick, the dental composition will be

less visible, whereas a thin lip (and especially

when it is short) will put the dental and gingival

composition at the forefront, which should be

in perfect harmony with the curvature of the

upper lip

The position of the interincisal point in the

anteroposterior direction is crucial in patients

with a short lip; recession of the upper lip

should not be accentuated Likewise, to have a

pleasant outcome, the support of the thick lip

should not be overaccentuated (Fig 1-26)

Curvature of the upper lip

• Type 1 Stomion is below the comissural line

This is the ideal situation, which brings more femininity and sensuality in the smile In this type of smile, particularly for women, the oc-clusal esthetic plane should parallel this cur-vature

• Type 2 Stomion is on the comissural line

This is the most frequent type of smile for men The esthetic occlusal plane should parallel the curvature, whereas for women it should be slightly curved

• Type 3 Stomion is above the comissural line

This is the most difficult situation because this type of curvature accentuates the gingiva and produces an unesthetic smile Further-more, the curvature of the esthetic occlusal

Fig 1-26 (a and b) Profile and intraoral views For this patient with a thick lip, the upper lip support appears to be quite

satis-factory In this case, the correct location of the interincisal point in the sagittal plane is crucial to avoid excessive upper lip

support (c) Profile view of the implant-supported restoration.

Fig 1-25 Thickness of the upper lip.

Tooth shape, shade, and size

As previously discussed, there are no set rules

when choosing tooth shape In case of a

tran-sition to complete edentulism, it is important

to document the shape and the shade of the

existing teeth (Figs 1-28 to 1-30)

Choosing the anterior teeth means

deter-mining the shape, shade, and size to obtain a

harmonious result proportionate to the face

Several elements can guide the clinician:

pho-tographs taken before tooth extraction or tooth

loss, morphotype of the patient, available

space for the esthetic plane, and of course the

patient’s demands

Position of the interincisal point

The position of the interincisal point is

prob-ably the most crucial element of the smile It

is influenced esthetic and phonetic factors and

must be adapted to the smile environment to

compensate for imperfections

The position of the interincisal point in the

vertical plane has already been discussed;

however, its position in the frontal plane and its relationship with the sagittal median axis needs to be specified (Fig 1-31) First of all, the main abnormality of the interincisal axis

in the frontal plane is obliqueness, meaning

a divergence in relation to the sagittal median axis It is almost the only abnormality that can

be seen from the extraoral examination, and it needs to be corrected If it deviates minimally toward the left or right, it can stay uncorrected because it often does not affect the smile It must be corrected when the deviation is very visible (Fig 1-32)

The correct position of this point in the ittal plane also affects the lip support, profile, and smile In a complex case transitioning from

sag-a dentsag-ate to sag-an edentulous stsag-ate, there is ususag-ally

a need for anterior or posterior displacement of the interincisal points In these cases, the imme-diate placement of dental implants can be risky since the esthetic changes are significant Deliv-ering an immediate removable complete denture can be useful to test the new esthetic appearance and confirm its relationship to the osseous crest

Fig 1-27 Curvature of the upper lip based on Hulsey 14

Fig 1-28 Tooth shape, shade, and size.

Square Oval Triangular

In harmony with the shape of the face?

Tooth shape

Initial shadeTooth size –––––– mm (reference tooth)

Sex, personality, and age

It is important to study the factors of sex,

per-sonality, and age (SPA) as they affect tooth

shape before restoring the smile (Fig 1-33) The

main rules are that anything feminine is

round-ed, brighter, lighter, and smoother, whereas

anything masculine would be angled, darker,

less luminous, and with surface irregularities

This is true for the tooth shape but also for the

arrangement of the esthetic plane

Several tricks can be used during esthetic

mounting15 (Fig 1-34) The central incisors can

be slightly lengthened to break the linear

as-pect of the esthetic plane, whereas when they

are widened and dominating the lateral incisors

they express more masculinity In addition,

me-sioversion of the lateral incisors can

accentu-ate a more masculine expression of the smile

When the mesial edge of the lateral incisor

overlaps the distal edge of the central incisor, it reduces the importance of this tooth and gives the smile a more feminine aspect The canine, which is normally strictly perpendicular to the occlusal plane, evokes a more blunt form when

it is in buccoversion, whereas a slight lingual orientation gives more softness

Finally, calculated placement and rotation of certain teeth allows characterization of patients’ smiles to harmonize with their personality

Regarding age, older teeth are usually more worn and less bright and have concavities They also start to be affected by different pigments.Following these guidelines can prevent com-pletely off-target esthetic try-in, but it must be adapted to meet the expectations of the pa-tient The most important point is that these guidelines allow reduction or emphasis of any particular trait that the patient wishes to re-move or highlight

Too high Deviated to the left Correct Too low Deviated to the right

Divergence from the median sagittal axis?

Anterior Correct Posterior

Frontal plane

Sagittal plane

Fig 1-31 Position of the interincisal point.

Fig 1-33 SPA concept and tooth shape.

Fig 1-32 (a) When the interincisal axis is not vertical, it is unesthetic and easy to see during extraoral examination (b)

Re-storing an interincisal axis to agree with the major axis of symmetry of the face is essential, whereas a mismatch between the interincisal points is minor and can easily be left untouched if it is not too severe.

Harmonious To be modified

SPA concept

Periodontal biotype

The periodontal biotype of the patient will

deter-mine treatment options and can require the

cli-nician to use more caution in adressing the

ante-rior area (Fig 1-35) For example, a thin biotype

represents a risk of recession when immediate

Usually, a thin biotype does not require a ferent treatment option However, in situations where the gingival and dental compositions are

dif-in the foreground and where artificial gdif-ingiva will not be used, it is important be extra careful.Finally, the presence of keratinized tissue in adequate quantity is a deciding factor for con-sidering the use of guided flapless surgery, which requires a significant amount of kerati-nized gingiva

Fig 1-34 Illustration of SPA concept by Frush and Fisher 2–6 : the shape of maxillary incisors and canines should correlate with the sex, age, and personality of a patient.

Sex Age

In the absense of keratinized tissue, note the area(s) requiring regeneration

Periodontal biotype

Fig 1-35 Periodontal biotype.

periodontal health is stabilized (Fig 1-37) Also,

it is essential to remember that patients who

have a history of periodontal disease should

still be considered at risk and require a strict

maintenance program, especially if the

oppos-ing arch is still marked by periodontal disease

Ridge resorption and quality of

supporting tissues

Palpation of the edentulous ridges is one of

the first diagnostic procedures to consider the

feasibility of placing implants (Fig 1-38) This

important step must be carried out carefully to

discover any sharp ridges, a buccal or lingual

concavities, or localized defects It is also perative to assess the depth of the vestibule

im-As a general rule, a shallow vestibule indicates advanced bone resorption and a wide interoc-clusal space

The location of the anterior wall of the lary sinus can be used to determine the approx-imate posterior limit for implant placement when bone height under the sinus is limited

maxil-Similarly, the quality of the supporting sues for the denture is important It is essential

tis-to check for a flabby ridge, which is a major contraindication to guided surgery because it alters the accuracy of the transfer of the surgi-cal guide (Fig 1-39)

Fig 1-37 (a) A history of periodontal disease often has a strong impact on the gingival composition and is frequently followed

by a loss of the “pink esthetics.” (b) The prosthesis of such patients must include esthetic artificial gingiva to restore

harmo-ny to the gingival composition A fixed prosthesis is not indicated because of the risk of ending up with long denture teeth, which is particularly unattractive.

Fig 1-36 Oral hygiene and periodontal health.

Good Poor History of periodontal disease

Periodontal health

Good Flabby ridge

If defect is present, what type?

Ridge resorption

Quality of supporting tissues

Fig 1-38 Ridge resorption and quality of supporting tissues.

Mouth opening

A mouth opening of less than 34 mm (less than

two fingers) is an absolute contraindication for

any implant surgery because the handpiece

with the shortest drill cannot access the

sur-gical site With an opening between 35 and 45

mm, angulated posterior implant placement

along the anterior wall of the sinus will be

sig-nificantly complicated because guided surgery

is not an option The minimum mouth opening

is 45 mm to allow guided surgery in all

situa-tions During the first clinical examination, do

not hesitate to simulate drilling at the most

pos-terior site with the chosen system (Fig 1-40)

Articulation

Any abnormality found during the evaluation

of articulation (painful areas, joint noises, or dyskinesia) is an indication for a thorough oc-clusal examination before any implant surgery (Fig 1-42)

Interocclusal relationship

The accuracy of the interocclusal ship must be assessed (Fig 1-43) To do this, the tests described in chapter 2 must be per-formed It is important not to start implant treatment without validating the patient’s in-terocclusal relationship; otherwise it can affect the entire prosthetic treatment In addition, for guided surgery procedures, the correct transfer

relation-of the surgical plan should be completed under

Fig 1-39 (a) Low resorption (b) Average resorption (c)

Palpa-tion of masticatory mucosa can identify a flabby ridge.

a

c

b

Occlusal scheme

The complete rehabilitation of the maxilla

im-plies restoring harmonious occlusal curves to a

specific occlusal scheme (Fig 1-44) In addition

to the accuracy of the interocclusal

relation-ship, developing an occlusal scheme

guaran-tees a favorable long-term prognosis of

treat-ment

The chosen occlusal scheme will depend

mainly on the nature of the antagonist arch,

with a simple rule in mind: The less stable

pros-thesis dictates the choice When the opposing

arch is a complete removable denture, the

max-illary restoration must respect the occlusal

scheme of the denture, and special attention

should be given to the placement of the

poste-rior teeth

When the opposing arch is dentate or restored

with an implant-supported prosthesis, the

oc-clusal scheme will follow that of the fixed

pros-thesis With widespread contacts in maximal

intercuspation, it is preferable to set a group

function and a posterior disocclusion in

protru-sive movements Take care to obtain gentle

oc-clusal curves, which allow for a smooth sion that generates as little stress as possible.The occlusal context will also determine the material chosen for the restoration In the ab-sence of bruxism, the authors favor the use of ceramic to allow the long-term conservation of the chosen occlusal-prosthetic scheme In case

disocclu-of bruxism, the restoration must include

res-in denture teeth This precaution is essential because a maxillomandibular rehabilitation in which the two arches are restored with ceramic denture teeth requires substantial maintenance and also poses a significant mechanical risk

In all cases, a rigid occlusal splint must be realized at the same time the prosthesis is fab-ricated, and both appliances are given to the patient at the same time

If examination of the opposing arch reveals that it is not possible to create correct occlusal curves, it is important to rebuild those prior to any surgical procedure and especially before immediate loading The correct management

of the occlusion is a key to success in this type

of protocol

Fig 1-40 Mouth opening.

Fig 1-41 Parafunctions and dysfunctions.

Fig 1-42 Articulation.

Fig 1-43 Interocclusal relationship.

Fig 1-44 Occlusal scheme.

Requires rehabilitation Adequate