Osseointegration and prosthodontic considerations

Introduction

According to the Greek philosopher Plato, “beauty lies in the eye of the beholder.” Although this may be true, there are certain aspects of beauty that are universally accepted. Numerous scientific publications have addressed the topic “facial aesthetics.” Manufacturers and practitioners alike spend considerable time and money developing, advertising, and making use of products and techniques directed to this end. The public, in turn, spends considerable resources availing themselves of these—all in the pursuit of facial beauty.

There are established norms of proportion, shape, size, and orientation that guide surgeons in their pursuit of aesthetic facial outcomes, and a number of chapters of this book specifically address these from multiple perspectives. This chapter will focus on the prosthodontic consideration when utilizing osseointegration to optimize facial aesthetics.

Prosthodontics is the dental specialty pertaining to the diagnosis, treatment planning, rehabilitation, and maintenance of the oral function, comfort, appearance, and health of patients with clinical conditions associated with missing or deficient teeth and/or maxillofacial tissues with the use of biocompatible substitutes. More simply stated, it is the art and science of the aesthetic and functional restoration of the hard and soft tissues of the oral cavity. These tissues may be missing due to a congenital condition, dental caries, periodontal disease, ablative surgery, or trauma. Rehabilitation may be performed by using autogenous, allogeneic, or alloplastic materials or a combination of these. Most directly, it is the “aesthetic zone” that it impacted. This is the area of teeth, gingivae, mucosa, and lips. Outcomes in this critical region will certainly affect the entire facial appearance.

A healthy smile is an integral part of facial aesthetics. It not only affects one’s psychologic and emotional well-being but also has a functional, physical, and health-related component. To achieve success in this area, a team approach should to be employed. The aesthetics team should include a plastic and reconstructive surgeon and a prosthodontist but may also include other dental specialists, such as an orthodontist and a periodontist, to address all aesthetic concerns, such as the oral soft tissues and natural tooth alignment and position. It is also important that the patient be considered as part of the team because his or her input is valuable. Each smile and the related facial aesthetics are as unique as each individual.

Osseointegration and facial aesthetic

Osseointegration refers to a “direct structural and functional connection between ordered, living bone and the surface of a load-carrying implant.” This phenomenon was first described by Dr. P-I. Brånemark in 1985 in his landmark textbook Tissue-Integrated Prostheses. Although implants had been used in dentistry for many years, it was Brånemark’s work that brought science and evidence-based predictability to dental implantology. Since its introduction to clinical care, the use of dental implants has expanded exponentially. It is arguably the most significant contribution to the art and science of prosthetic dentistry and has become a routine consideration in any dental treatment plan that involves tooth replacement. As of January 2016, more than 100 manufacturers of dental implants exist.

The initial application of osseointegrated implants was in the anterior mandible as a way of resolving the age-old problem of an unstable removable complete denture. In short order, applications were expanded to the maxilla to address not only missing complete dentition but partially edentulous areas as well. The use of osseointegrated implants has greatly improved the ability to restore facial aesthetics and normal function in the presence of tooth loss.

Although the technical aspect of placing an implant into bone is fairly straightforward, it is the planning of the placement of the implant and its restoration that determines the aesthetic outcome. As is true of so many procedures, the care, skill, judgment, and experience of the operator are critical. Equally true of osseointegration and facial aesthetics, as of reconstructive surgery in general, the more the structures missing and needing replacement, the more challenging it is to achieve an ideal aesthetic outcome. A cardinal rule of implant placement is that there must be adequate bone volume at an edentulous site to place the implant and achieve initial stability.

The aesthetic zone

Many articles in the dental literature address tooth appearance, the smile, and the “aesthetic zone” as they relate to facial aesthetics. This zone takes into consideration the position and appearance of the maxillary anterior teeth, their periodontal hard and soft tissues, the incisal and middle thirds of the mandibular anterior teeth, and the upper and lower lip positions and contours ( Fig. 31.1 ).

When restoring the aesthetic zone to complement and enhance facial aesthetics, the following points need to be considered. The degree to which each is employed will depend on the extent of the rehabilitation that is required. All of these points contribute to an aesthetic dentition, which, in turn, affects facial aesthetics. These points related to an aesthetic smile whether restored with natural dentition or an implant prosthesis:

• 1.

  The midline of the maxillary dentition

• 2.

  The individual tooth characteristics: the length, size, shape, contour, position, alignment, surface texture, and color of an individual tooth

• 3.

  The smile line

• 4.

  The tooth and the dentogingival display at rest, while speaking, and during casual and wide smiles

• 5.

  The levels of the margins of the gingival soft tissue

• 6.

  The health of the periodontal tissues

• 7.

  The vertical dimension of the facial height and facial profile

• 8.

  Contour of the lips and adjacent perioral soft tissue