Optimizing esthetics for implant restorations in the anterior maxilla: anatomic and surgical considerations

The placement of dental implants in the anterior maxilla is a challenge for clinicians because of patients' exacting esthetic demands and difficult pre-existing anatomy. This article presents anatomic and surgical considerations for these demanding indications for implant therapy. First, potential causes of esthetic implant failures are reviewed, discussing anatomic factors such as horizontal or vertical bone deficiencies and iatrogenic factors such as improper implant selection or the malpositioning of dental implants for an esthetic implant restoration. Furthermore, aspects of preoperative analysis are described in various clinical situations, followed by recommendations for the surgical procedures in single-tooth gaps and in extended edentulous spaces with multiple missing teeth. An ideal implant position in all 3 dimensions is required. These mesiodistal, apicocoronal, and orofacial dimensions are well described, defining "comfort" and "danger" zones for proper implant position in the anterior maxilla. During surgery, the emphasis is on proper implant selection to avoid oversized implants, careful and low-trauma soft tissue handling, and implant placement in a proper position using either a periodontal probe or a prefabricated surgical guide. If missing, the facial bone wall is augmented using a proper surgical technique, such as guided bone regeneration with barrier membranes and appropriate bone grafts and/or bone substitutes. Finally, precise wound closure using a submerged or a semi-submerged healing modality is recommended. Following a healing period of between 6 and 12 weeks, a reopening procedure is recommended with a punch technique to initiate the restorative phase of therapy.