Review Article

Implant esthetics
Ritu Batra, mds*, Sanjay Kalra, mds**, Hemant Batra, mds†
*Senior Lecturer, **Principal and Head, Department of Prosthodontics, BRS Dental College and Hospital, Sultanpur, Panchkula, †Professor and Head,
Department of Oral and Maxillofacial Surgery, Dr HS Judge Institute of Dental Sciences, Punjab University, Chandigarh, India.

Abstract

The recent concepts of implant dentistry are not only to restore the function of mastication, but the newly applied surgical and prosthetic
techniques are enabling dentists to fulfill patients’ esthetic expectations as well. A diagnostic wax-up of planned final restoration is crucial
as it establishes the final goal toward which all treatment is directed. The esthetic restoration must possess a form that compliments the sur-
rounding tissues and facilitates proper plaque control and occlusal function. It often presents reconstructive and restorative challenges and
requires a comprehensive treatment plan. Implants used to replace missing teeth in the esthetic zone have many advantages ranging from
preservation of unrestored adjacent teeth, halting the resorption of edentulous spaces to provide support for the prosthesis. Advanced papilla
reconstruction procedures can enable the dentist in achieving the ultimate and most sophisticated goal of ideal esthetic restoration both in
anterior and in posterior regions of human dentition. Hence, this is helping patients smile with confidence and dignity.

Keywords: Abutments, emergence profile, implant esthetics

INTRODUCTION Scientific investigations have resulted in the formulation

In a population that is becoming increasingly aware of the
benefits of esthetic surgery, implant dentistry is among the
most frequently requested procedures for both esthetic and
functional purposes. The recent concepts of implant den-
tistry are not restricted to the basic needs, but newly applied
surgical and prosthetic techniques are enabling dentists to
approach patients’ esthetic expectations. The philosophy
behind successful esthetic implant restoration is restoration-
driven implant placement. Thus, the restoration itself becomes
immediately involved in the correct development of soft-
tissue profile, similar to conventional prosthetic restoration in
which the restoration on remaining tooth structure is involved
in soft-tissue support.1–3 A diagnostic wax-up of planned final
restoration is crucial as it establishes the final goal toward
which all treatment is directed. The esthetic restoration must
possess a form that compliments the surrounding tissues and
facilitates proper plaque control and occlusal function.4,5
It often presents reconstructive and restorative challenges
and requires a comprehensive treatment plan.
Correspondence: Ritu Batra, Senior Lecturer, Department of
Prosthodontics, BRS Dental College and Hospital, Sultanpur, Panchkula,
India.
E-mail: ritubatra71@gmail.com
Received: 05.08.2011
Accepted: 16.11.2011
doi: 10.1016/S0975-962X(12)60006-9
and verification of a set of laws or principles of visual per-
ception. These provide a basis for an introduction to the ele-
ments of esthetics that are part of essential and natural
beauty. These principles were first introduced to the dental
fraternity by Richard E Lombardi1,6; by combining artistic
creativity with scientific discretion, an esthetically appeal-
ing smile window can emerge4,7:
1. Composition: The relationships existing between objects
made visible by contrasts in color, line, and texture is
called composition; it is the dental composition, dentofa-
cial composition, and facial composition.
2. Unity: It gives the different parts of the composition the
effects of a whole, which can be
(a) Static: As seen in inanimate objects such as snow-
flakes and crystals. They are passive and inert based
on a regular, repetitive pattern.
(b) Dynamic: Active, living, and growing as in plants
and animals.
3. Cohesive and segregative forces:
(a) Cohesive forces: Elements that tend to unify a com-
position, represented by elements arranged according
to a principle.
(b) Segregative forces: Elements that break the monotony
of the composition to provide a variety in the unity.
These are required to make a design effective.
Harmony depends on the equilibrium created by
cohesive and segregative forces.

© 2012 Indian Journal of Dentistry. Published by Elsevier Ltd. 15

 Batra, et al
4. Symmetry: The regularity in the arrangement of forces or
objects.
(a) Horizontal/running: Occurs when a design contains
similar elements from left to right in a regular sequence.
(b) Radiating: Occurs as a result of the design of objects
extending from a central point with the left and right
sides being mirror images; it is used to create a posi-
tive psychologic response.
5. Proportion and repeated ratio: It is the percentage or
measure in its numerical determination. Various philoso-
phers have desired to prove the hypothesis that beauty
could also be expressed mathematically.8–11
For example,
Golden proportion (Pythagoras): 1/1.618 = 0.618
Beautiful proportion (Plato): 1/1.733 = 0.577
6. Balance: The causative element must be moved toward
the line of forces or midline to relieve visual tension. An
opposite element must be introduced along the same line
of forces to promote equilibrium.
7. Lines: The parallel relationship between two lines is the
most harmonious as it does not exhibit conflict com-
monly used as the equals sign. The strongest psychologic
relationship that lines can engender is a perpendicular
relationship as a plus or a cross sign.
8. Dominance: Implies the presence of subsequent similar
elements. The stronger the subsequent element, the stron-
ger the dominating element and more vigorous the com-
position will be. Color, shape, and lines are factors that
can create dominance.
This can be achieved by increasing the size of the tooth in
question, making it lighter or placing it forward.12
UNDERSTANDING THE NORMAL ESTHETIC ZONE
The ultimate esthetics at smile depends on the interplay among
the three components of esthetic zone, that is, the teeth, the
lips, and the gingiva. It is the lip line which in turn deter-
mines the extent of display of teeth and the gums depending
upon this; it is categorized whether a particular smile has a
high, medium, or a low lip line.
High Lip Line
A lip line is high, if it reveals the total cervico-incisal length
of the maxillary anterior teeth and a continuous band of gin-
giva. It is most critical during smiling, as patient exposes the
entire restoration, the restorative gingival frame, the implant
prosthetic interface, and the extent of soft-tissue below the
inferior border of the upper lip. It becomes more demanding
area to restore if lost in such patients.
Medium Lip Line
It reveals 75–100% of the maxillary anterior teeth and the
interproximal gingiva. Teeth are entirely visible, along with
16
interdental papillae and often a couple of millimeters of the
free gingival margin.
Low Lip Line
Less than 75% of the anterior teeth are displayed. The inter-
face between implant and restoration is hidden behind the
drape of the lip. Thus, it is not that critical.
Once the perimeter has been defined and smile is designed
with harmony and symmetry, the esthetic workup should be
focused on matching the tooth in its most natural form, that
is, shade (e.g. value, hue, and chroma), shape, surface, tex-
ture, and luster of the restoration to that of the adjacent natu-
ral teeth.13 The success or failure also depends on the
emergence profile—the transition zone from the top of the
implant shoulder through the soft-tissue to the margin area.
Diagnostic Keys for Predicting Peri-implant Esthetics
The ultimate aim is for the implant restoration to harmonize
with the frame of the smile, face, and more importantly the
individual. Treatment planning must address hard and soft-
tissue deficiencies and combine this with the precision in
implant placement. Only with this approach can implant res-
toration be undistinguished from the adjacent teeth. To more
accurately predict the peri-implant esthetic outcome before
removing a failing tooth, an understanding of five diagnostic
keys (smile line, relative tooth position [implant position],
form and biotype of the periodontium, emergence profile,
and position of the osseous crest) are essential.14 The diag-
nostic keys are described below:
Smile Line: The ultimate esthetics at smile depends on the
interplay among the three components of esthetic zone, that
is, the teeth, the lips, and the gingiva. It is the lip line which
in turn determines the extent of display of teeth and the
gums. Depending upon this, it is categorized whether a par-
ticular smile has a high, medium, or a low lip line.
A high smile line poses considerable challenges when
planning for implant supported restorations because the res-
toration and gingival tissues are completely displayed.
Relative Tooth Position (Implant Position): Dictates the
emergence profile of the tooth to be replaced. The apico-
coronal position of the implant should be evaluated in rela-
tion to the adjacent teeth. A hopeless tooth for extraction
should be orthodontically extruded to migrate the marginal
gingiva coronally prior to extraction so that gingival level is
in harmony and prevent metal display. Faciolingual defi-
ciency in the labial bone can be either augmented with a
graft or implant can be placed more palatally with ovate
pontic so that the health of the facial free gingival margin
may be preserved. Mesiodistal deficiency in this dimension
can be addressed through the use of orthodontics, enamelo-
plasty, or restorations, as there is likelihood that black tri-
angles may occur if there is discrepancy in this relation teeth
© Indian Journal of Dentistry 2012/Volume 3/Issue 1
 Implant esthetics
with root proximity also possess very little interproximal
bone; this thin bone creates a great risk of lateral resorption
which will decrease the vertical bone height.
Form and Biotype of the Periodontium: Implants should
be inserted keeping in mind the form (scalloped or straight)
of the periodontal structures. The type of periodontium or
periodontal biotype should be determined before surgery as
it has got a direct bearing on the esthetics owing to factors
like the display of metal through the gums, response to sur-
gical insult and filling up of interimplant/dental spaces.
Broadly, periodontal biotypes can be thin and translucent,
scalloped and thick, opaque, and flat.
The thin scalloped periodontium reacts to insult by reces-
sion, facially, and interproximally. This type of periodontium is
more demanding and tends to recede after implant placement.1
Thick, opaque, and flat periodontium is dense, fibrotic
soft-tissue curtain of periodontium and a flat, thick underly-
ing osseous form tends to be more forgiving and favorable
for implant placement and health and integration of peri-
implant tissues.
A thick biotype is prone to pocket formation, whereas a
thin biotype is prone to gingival recession following surgical
manipulation. A study by Kan and colleagues in 2003 has
stated that the implant papilla may be maintained at or re-
established to the normal level (4.5 mm from the underlying
bone) with the thick biotype, but it can seldom be created
beyond 4 mm with the thin biotype.
Emergence Profile: Implant restorations in the esthetic
zone should mimic the emergence profile (flat) of the natu-
ral teeth. One method is by proper implant positioning and
the use of a healing abutment or special gingival former with
coronal holes on which the flap is adapted at the desired
level with a single-knot suture. The second method is to use
an ovate pontic or an acrylic resin restoration to sculpt the
gingival tissues. The third method is to employ a cervical
contouring concept used in the case of an edentulous ridge,
wherein cervical contouring is done on a model. Later, an
acrylic resin crown is fabricated to fill the carved space
around the abutment and placed intra-orally to press against
the peri-implant soft-tissue to form the required emergence
profile. Moreover, the emergence profile of the final pros-
thesis should be carefully created. If the profile is too nar-
row, no contralateral pressure or support for the gingiva will
exist, and the interdental papilla will diminish. If the profile
is too wide, papillae will be vertically compressed, oral
hygiene will be difficult or impossible to perform, and papil-
lae will collapse. The soft-tissue cast (gingival mimic) is
used to finalize the emergence profile during the different
laboratory steps.12,15,16 Once this parameter has been defined
and smile is designed with harmony and symmetry, the
esthetic workup should be focused on matching the tooth in
its most natural form and profile, that is, shade (e.g. value,
hue, and chroma), shape, surface, texture, and luster of the
restoration to that of the adjacent natural teeth.17
© Indian Journal of Dentistry 2012/Volume 3/Issue 1
Position of the Osseous Crest: Position of the crestal bone
is a determining factor for implant placement as it deter-
mines the soft-tissue architecture after healing.18,19 Pro-
fessional acceptance of implants in the esthetic zone can be
increased with better presurgical planning guidelines, under-
standing options in the diameter of implant fixtures, know-
ing variety of abutments, ensuring better fit of the abutment
to the implant fixture, ensuing better placement of the fix-
tures accurately with surgical guides, using better techniques
for preparing the edentulous site and employing prosthetic
techniques to produce a highly esthetic final restoration.
Deficient alveolar crest width will require a bone aug-
mentation procedure to allow the implant to be placed in
an ideal position. Mesiodistal space should be equal to the
contralateral tooth.18
Use of a diagnostic template highlights the proposed
gingival margin of the implant restoration. Measuring the
distance from the free gingival margin to the osseous crest
prior to extraction is an important diagnostic predictor of the
anticipated final position of the free gingival margin.
The important diagnostic factor in the predictability of
the post-placement level of the papillae is the crestal bone of
the teeth adjacent to the edentulous site.19,20 It has been
shown that the papillae will predictably form and maintain
if the distance between the crest of the bone and the inter-
proximal contact area is 5 mm or less. Inadequate interim-
plant spacing (<3 mm) may result in exaggerated bone loss
and increased distance from the proximal contact points to
the associated alveolar bone crests.15 This may result in
decreased papillary volume and accompanying ‘black tri-
angles’ within the esthetic zone.
Implant Position: Mesiodistal position: The mesiodistal
position depends on the width of the coronal tooth to be
replaced; adjacent root proximity and the presence or absence
of diastema. It should approximate the position from which
the natural tooth originally emerged from the gingival sulcus.
The mesiodistal implant axis should pass by the center of the
future crown or the bisecting line angle of the adjacent roots.
A minimal mesiodistal, coronal, and radicular space must be
1.5–2 mm from the root of the adjacent tooth (Figure 1).
Buccopalatal position: The body of the implant should be
placed as far labially as the buccal bone allows. Orientation
at 45° to the occlusal plane provides the best facial contour
and lip support and requires the fewest compromises in terms
of oral hygiene and maintenance. The principle behind this
requirement is that the implant angulations relates to the orig-
inal tooth structure more than the original root of the tooth
and to some extent the type of restoration being planned
(Figure 2).
Apico-coronal position: Implant can be placed 1.5–2 mm
from cementoenamel junction (CEJ) of adjacent teeth, if
there is no gingival recession for better emergence profile
and to accommodate the abutment and porcelain restoration
17
 Batra, et al
Figure 1 A minimal mesiodistal, coronal, and radicular space must be
1.5–2 mm from the root of the adjacent tooth.
Figure 2 The implant angulations relate to the original tooth structure
more than the original root of the tooth.
Figure 3 Implant can be placed 1.5–2 mm from cementoenamel junction
of adjacent teeth, if there is no gingival recession for better emergence
profile.
subgingivally (Figure 3). But if gingival recession is observed,
then the implant head should be positioned 3 mm from the
adjacent gingival margins. Successful implant placement
must be accomplished in three planes. If a screw-retained
abutment is used, the implant needs to be placed on the pala-
tal aspect of the extraction socket or more palatal within the
18
edentulous ridge because the abutment screw access needs
to be in the cingulum area to avoid the incisal edge and
facial aspect of the restoration. This palatal placement of
implant will lead to either a ridge-lap on the labial aspect of
the restoration or to more apical placement, which results in
a deeper peri-implant sulcus. Therefore, in most cases, ideal
implant placement in nonresorbed premaxilla may necessi-
tate the use of angled abutments to overcome the problems
associated with implant placement and its relationship to the
screw hole access. The cement retained restoration directs
long axis of implant toward incisal edge and the screw-
retained restoration directs long axis of implant toward the
cingulum. If the buccopalatal position of the implant is too
palatal, the shape of the final restoration will be overcontoured;
it will overlap the ridge, increase the cantilever and compli-
cate oral hygiene. In such cases, a ridge-lap pontic needs to
be fabricated to compensate for poor implant placement.
Steps to Achieve Desired Esthetic Outcome
Site Preservation: After the loss of an anterior tooth, the nor-
mal sequelae of wound healing will create an unfavorable
esthetic soft-tissue complex. The remaining facial mucosa
often recedes apically and palatally. Typically, this cervical
recession results in a restoration that appears too long and
may be compounded with the loss of the interdental papilla.
Optimal implant soft-tissue esthetics depends much on the
optimal implant site preservation after the extraction of the
natural tooth. In the simplest terms, site preservation involves
the use of surgical and prosthetic techniques to preserve
both the volume and the architecture of the hard and soft-
tissues at the implant site. Surgical factors including flap
design and surgical approaches applicable to the respective
case, thereby reducing further damage or shrinkage of the
soft-tissues, can be considered to be site preservation tech-
niques. Soft-tissue integration refers to the establishment
and long-term maintenance of soft-tissue health and esthetics.
Soft-tissue integration is influenced by several factors such
as surgical/clinical technique, macro- and micro-surface
design, biocompatibility of the transmucosal component
(Figure 4), as well as soft-tissue morphology, including bio-
type, papilla volume (fill), and degree of scalloped gingival
margin. Clinical handling may jeopardize the soft-tissue
integration, during repeated disconnection and reconnection
of the transmucosal abutment. This has been reported to
result in a more apical position of the connective tissue.
Interdental Papillary Esthetics: Papillary volume is
inversely proportional to the distance from the interproximal
contact area to the bone crest.19 At a distance of < 5 mm, the
papillae fill 100% of the time; when the distance measures
5–7 mm, the papillae fill the space 56% of the time (Figure 5).
Finally, when the distance exceeds 7 mm, the space is filled
only 27% of the time. Implants must be placed in the so-called
‘safe zone’ for best esthetic results. In an apical–coronal
position, it is recommended that the implant be positioned
© Indian Journal of Dentistry 2012/Volume 3/Issue 1
 Implant esthetics
Figure 4 Soft-tissue integration influenced by biocompatibility of the
transmucosal component.
Figure 5 Papillary volume is inversely proportional to the distance from
the interproximal contact area to the bone crest.
2–3 mm below the CEJ of adjacent teeth. When optimal
implant positioning is achieved, the transitional tissue could
be altered using a customized abutment to create an emer-
gence profile that mimics the natural teeth and provides
adequate support to the surrounding soft-tissue. This can be
performed with a provisional restoration at the time of
uncovering the implant and could be transferred at a later
stage to the definitive restoration. Using the patient’s natural
tooth as a provisional can help maintain the volume and
support of the papilla.
Techniques to Achieve Optimum Soft-tissue Esthetics
with Implants: To verify these results, different methods
of measuring the lengths of papilla have been introduced.
Some authors used photographs to assess the length; others
introduced indices to measure the length. Few authors used
a rather invasive technique called ‘bone sounding’ to relate
papilla with the interdental bone. Latest techniques rely on
radiographic measurement of bone level, and measuring the
height of papilla with respect to the pitch of the implant
inserted. Modification includes placing a radio-opaque mate-
rial at the tip of the papilla before exposure to radiograph.
© Indian Journal of Dentistry 2012/Volume 3/Issue 1
Figure 6 Contact point position altered to give illusion to papilla.
Bone probing has been confirmed as a valid method of
reporting the papilla length.19 However, it is rather an invasive
method since administrating the local anesthesia is likely to
cause the patient some discomfort and pain. Radiography
on the other hand has been regarded a valuable diagnostic
method, noninvasive, and often requires minimum patient
cooperation.
The following four surgical choices provide a better
esthetic outcome for a particular implant treatment21–26:
1. Papilla saving incision (flap reflection).
2. Second-stage surgery: making the incisions exclusively
in the attached tissues, this definitely decreases scarring.
Transposing the palatal keratinized tissues labially
enhances the emergence contour.
3. Soft-tissue grafting: free gingival grafting; subepithelial
connective tissue grafting; and coronally repositioning
flaps.
4. Gingival recontouring techniques: electrosurgery is uti-
lized to remove scarring and the gingivoplasty by using
a diamond bur to remove the excess tissue.
Considerable knowledge has been gained in surgical
management of facial gingival recession. The procedures
described in the literature include free gingival grafts, coro-
nally positioned flaps, free gingival grafts combined with
coronally positioned flaps, different types of pedicle grafts,
free connective tissue grafts combined with pedicle grafts,
and the guided tissue regeneration procedure. Although
these techniques give predictable solutions to the coverage
of the denuded roots, they are not directed to the reconstruc-
tion of truncated papillae.27
CONCLUSION
The change in dentistry from the need-based to elective den-
tistry has made a significant impact on the profession and
the public perception of dentists. It is estimated that up to
one-half of the dentistry accomplished at this time is elective.
Much of this treatment is what could be considered to be
19
 Batra, et al
esthetic dentistry including procedures like implant place-
ment. As health professionals have increased their ability to
change faces, the necessity to understand what is and is not
beautiful has intensified.
Prosthetic-driven implantology has been suggestive of
more accurate depicter of the esthetic outcome. As with any
extensive oral rehabilitation, esthetic concerns will require
consideration both in treatment planning and in restoration
completion. The addition of an osseo-integrated component,
particularly in the esthetic zone, may both enhance ultimate
stability and provide the opportunity to utilize many of the
esthetic concepts described previously.26 With better scien-
tific approach and improved knowledge, what was impossi-
ble previously can be achieved in reality with ease in the
esthetic zone.
Implants used to replace missing teeth in the esthetic
zone have many advantages from preservation of unrestored
adjacent teeth, halting the resorption of edentulous spaces,
and providing support. Restoratively by altering the position
of contact points to give illusion of papilla can be done to
achieve optimum esthetic outcome (Figure 6).28
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© Indian Journal of Dentistry 2012/Volume 3/Issue 1