Dental Implant Soft Tissue Aesthetics
“Restoring the appearance of the soft tissues surrounding implants is one of the most difficult aesthetic challenges in modern dentistry. While perhaps less obvious than the hard, white surfaces of teeth and restorations, the presence and condition of the gingiva greatly modifies the overall result.”
Beyond the considerable functional advantages that implants provide, patients also value the exceptional improvement that can be achieved in aesthetics. The face is the most closely scrutinised area during interactions with others, and the mouth is a key focus. Though appreciable in its own right, appearance is no trivial thing. People consciously and unconsciously scrutinise each other’s faces for subtle cues to mood and intent, and we do so constantly and quickly. It has been observed that attention is increased when we find physical stimuli either more interesting or attractive, and also when the stimuli is perceived negatively. In fact, we appear to dwell longer on negative stimuli than positive.i The central triangle (eyes, nose, mouth) is the area we pay the closest attention to. Aspects that the observer finds unattractive, especially in this region, which can include disfigurement and signs of aging (such as recessed gums), can illicit negative emotional responses and increase the amount of attention paid to them.ii
Aesthetic factors can also have a deep impact on the patient’s own emotional and psychological wellbeing, including their self-esteem and confidence. Negative self-perception can in turn influence behaviour, such as becoming less outgoing and less expressive. These changes can further influence how others perceive a person, which can create a vicious circle. Research indicates that particular psychological traits a patient can modify this. For instance, being a perfectionist results in lower self-esteem in patients with poor dental aesthetics, than those without.iii
Soft tissue management plays a major role in achieving satisfactory aesthetics in the mouth. Insufficient soft tissue can expose the grey titanium of the abutment, which can create a disconcerting discoloration or make the presence of the implant obvious to observers. The appearance of a healthy mouth has no particularly dark colours in the aesthetic zone, whereas metal appears very dark in contrast to the reds, pinks and whites of the natural tissues. This can create the impression that the area above the implant is dirty or diseased. There have been attempts to mitigate this by implant designers, for example, using a zirconia sheathe or anodising the titanium to a more neutral colour to better disguise the metal.iv However, there is only so much that can be achieved from the design side, without good gingival health. Gingival recession not only exposes the abutment, but it can also cause the base of the restoration to appear free floating, which makes it very clear that it is artificial. Maintaining good gingival health is critical, not only to prevent peri-implant disease but also to maintain aesthetic success.
Restoring the appearance of the soft tissues surrounding implants is one of the most difficult aesthetic challenges in modern dentistry. While perhaps less obvious than the hard, white surfaces of teeth and restorations, the presence and condition of the gingiva greatly modifies the overall result. The interdental papilla, in particular, is comparatively sensitive to insult, has little blood supply, and can be lost during periodontal disease and iatrogenically. In some cases, it is possible to halt receding interdental papilla surgically, or restore with grafting. However, results are variable and the priority should be on protecting and preserving the existing papilla where possible.v Patients should be advised not to use excessive force while brushing and flossing, as interdental gingiva can be damaged by doing so.vi
Aesthetic success and how to achieve it is a huge topic and there is a lot to be learned. If you are interested in furthering your understanding of soft tissue management and aesthetics, you should consider attending the upcoming Soft Tissue Around Dental Implants course. Brought to you by BPI Dental Education & Training and held in Birmingham, the course provides hands-on tuition from Dr Boota Singh Ubhi – a Specialist Periodontist with more than 25 years of experience with dental implants. Delegates will be trained to diagnose potential soft tissue complications prior to implant treatment, so that they can be minimised or avoided completely. Various plastic periodontal surgical techniques will also be taught to optimise aesthetics and the longevity of outcomes. Remaining spaces for this year are going fast, so secure your place as soon as possible to avoid disappointment.
Achieving the best aesthetic results requires good co-operation between the dental team and patient. At every step of the treatment there are factors that can influence the level of aesthetic success that will ultimately be attained, from the design of the implant and the management of the soft tissues, through to how the patient maintains their oral hygiene and general health. Where excellent results are attained, the patient does not simply benefit from a prettier smile, it can have a decided impact on their mental wellbeing, confidence and how they are perceived by others.
i Pritsch C., Telkemeyer S., Mühlenbeck C., Liebal K. Perception of facial expressions reveals selective affect-biased attention in humans and orangutans. Scientific Reports. 2017; 7: 7782. https://doi.org/10.1038/s41598-017-07563-4 June 4, 2021.
ii Frautschi R., Dawlagala N., Klingemier E., England H., Sinclair N., Zins J. The use of eye tracking technology in aesthetic surgery: analyzing changes in facial attention following surgery. Aesthetic Surgery Journal. 2020; 40(12): 1269-1279. https://doi.org/10.1093/asj/sjaa008 June 4, 2021.
iii Venete A., Trillo-Lumbreras E., Prado-Gascó V., Bellot-Arcís C., Almerich-Silla J., Montiel-Company J. Relationship between the psychological impact of dental aesthetics and perfectionism and self-esteem. Journal of Clinical and Experimental Dentistry. 2017; 9(12): 1453-1458. https://dx.doi.org/10.4317%2Fjced.54481 June 4, 2021.
iv Wang T., Wang L., Lu Q., Fan Z. Influence of anodized titanium abutments on the esthetics of the peri-implant soft tissue: a clinical study. The Journal of Prosthetic Dentistry. 2021; 125(3): 445-452. https://doi.org/10.1016/j.prosdent.2019.12.023 June 5, 2021.
v Shenoy S., Punj A., Ramesh A., Talwar A. Salvaging the lost pink triangle: a case series of papilla reconstruction. Case Reports in Dentistry. 2020; 2020: 9735074. https://doi.org/10.1155/2020/9735074 June 5, 2021.
vi Singh V., Uppoor A., Nayak D., Shah D. Black triangle dilemma and its management in esthetic dentistry. Dental Research Journal. 2013; 10(3): 296-301. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3760350 June 5, 2021