You are on page 1of 14

Dealing with esthetic demands in

the anterior maxilla


Richard M. Palmer, Paul J. Palmer & J. Timothy Newton
The esthetic and functional demands in the replace-
ment of missing teeth have always been a major
focus of oral rehabilitation. The introduction of
osseointegrated implants increased the possibility
of providing xed restorations in extensive edentu-
lous zones. Treatment initially concentrated on func-
tion and long-term success, and there is ample
scientic literature to support these goals. Esthetics
initially subsumed a somewhat secondary require-
ment and there is unfortunately a paucity of scien-
tic data in this area, with no randomized controlled
trials. It would seem that much of the current
demand for `esthetics' appears to be fuelled by the
profession and there is a reluctance to admit that not
all cases will result in good esthetics, even in cases
where there are no compromising factors to begin
with. Developments in implant components, materi-
als, fabrication technology and increased sophistica-
tion in planning and surgical procedures have
enabled provision of more esthetic restorations. Most
modern implant systems have a range of compo-
nents designed to deal with esthetic demands, and
professional literature to demonstrate the effective-
ness of the system. In most cases, however, the
results of treatment which are publicized are close
to ideal and do not address the difculties of the
compromised case.
The term esthetic means pertaining to beauty or to
the improvement of appearance (Dorland's Medical
Dictionary) and this is often a prime goal of the
clinician and patient when replacing missing teeth
in the anterior maxilla. The anterior maxillary teeth
in the `esthetic zone' usually extend from rst pre-
molar to rst premolar, but in some individuals can
extend as far distally as the rst molar. In many
patients a shortened dental arch will satisfy esthetic
and functional demands (12). The judgment of
esthetics is subjective, and difcult to test or evaluate
in a scientic way. The treating clinician's idea of a
good esthetic result may be quite different to that of
the patient (6, 21). It is therefore important to get the
correct balance between these demands and to have
adequate discussion, planning and preview of the
potential end result to reach agreement. To achieve
good esthetics in cases of simple tooth loss may
simply require the services of a skilled technician/
ceramist. In contrast, in cases where there is exten-
sive loss of teeth, bone and soft tissue there is a need
to develop a plan to deal with these compromises
using more sophisticated surgery, prosthetic solu-
tions or both. It is essential to involve the patient
in the decision process with the whole clinical/tech-
nical team in deciding the nal treatment strategy.
Patients' expectations and
psychological aspects
Patients' expectations of health and healthcare are
key determinants of their satisfaction with the out-
come of treatment, or their adherence to treatment
recommendations (2, 3). Their expectations of treat-
ment may be a better predictor of perceived outcome
and quality of life than functional or clinical status
(4). Matching treatments to patient expectations has
been shown to have a marked impact not only upon
patient satisfaction but also upon behavioral markers
of outcome. Lefer et al. (20) found that patients who
were involved in the choice of their dentures were
less likely to complain or to reject them, and made
fewer visits for corrections. This was despite the fact
that patients were more likely to choose dentures
that were less than clinically optimal.
The expectations patients hold regarding the
appearance of the mouth may be either specic to
their own mouth, or general based on perceptions
of the `ideal' appearance of the mouth, lips, teeth and
gums. Patients express their specic expectations of
the oral cavity in terms of appearance, function and
the absence of certain stimuli, most notably pain.
Established norms for oral and facial appearance
do not vary widely among the industrialized nations
105
Periodontology 2000, Vol. 33, 2003, 105118 Copyright
#
Blackwell Munksgaard 2003
Printed in Denmark. All rights reserved
PERIODONTOLOGY 2000
ISSN 0906-6713
and extreme deviations are viewed as unacceptable
(7). All clinicians will be aware of the extent of
variation to which patients are willing to tolerate
abnormalities. Some patients may place undue
emphasis on minor oral abnormalities, and have
unrealistic expectations of the impact that the cor-
rection of such abnormalities might have upon their
lives. This may be a symptom of body dysmorphic
disorder (8).
The general public hold expectations regarding the
characteristics associated with an `Ideal' dentition.
Individuals use facial appearance as a guide to infer
a variety of characteristics of a person including per-
sonality, integrity, social and intellectual competence
and mental health (11). The impact of appearance on
perceptions of personal characteristics is not limited
to initial meetings such perceptions may have a
lasting effect (1). Moreover, individuals rated as
facially attractive tend to earn more, have more suc-
cessful life outcomes and have greater self-worth
than less attractive individuals (9, 22). Good oral
appearance is thought to be a requirement of pres-
tigious occupations among some professional groups
(17). It is unsurprising therefore that a dento-facial
appearance that differs from the `Ideal' produces
negative perceptions of personal characteristics (18,
2527). These negative social perceptions may also
exert a negative inuence on an individual's self
perception (19).
Previous research examining the impact of orofa-
cial abnormalities on the perceptions of others has
tended to focus on anomalies of occlusion and severe
orofacial anomalies such as cleft lip and palate (28).
However, minor abnormalities in oral appearance
may inuence the appraisal made of an individual's
social adjustment (10, 13).
In brief, patients have specic expectations of their
treatment and the end product of their oral rehabi-
litation. In general, there is little variation in what
constitutes the `Ideal' orofacial appearance. Failure
to match these expectations is associated with dis-
satisfaction in patients, and negative social apprai-
sals on the part of observers.
Range of cases which may lead to
compromise
The compromised case can range from a patient with
a missing single tooth unit to an edentulous jaw with
advanced resorption. The extent of the site may not
be the most important factor. A single tooth site can
provide as big an esthetic challenge as a more exten-
sive defect. The main problem with missing single
teeth is achieving harmony with adjacent healthy
uncompromised teeth. This was highlighted in a
study by Chang et al. (6) of single tooth implant
restorations in routine cases. Experienced clinicians
were able to recognise the implant restoration in the
majority of patients and were most critical of the soft
tissue form, rather than the crown. The patients
were less critical of the result. The compromised site
can be decient in soft tissue and bone in the ver-
tical, horizontal or combined planes. Lack of these
tissues on adjacent natural teeth in the esthetic zone
may be even more difcult to deal with because
the clinician may have to improve conditions around
the natural teeth as well as the edentulous zone
(Fig. 1A).
Duration of tooth loss
Alveolar resorption follows tooth loss. The gradual
resorption with time has been well described (5)
and in many patients reaches a point where an
esthetic problem results.
Trauma
Even minor trauma leading to avulsion of a tooth can
cause loss of alveolus and gingiva. More major
trauma can cause extensive vertical and horizontal
bone loss, loss of arch form and derangement of the
occlusion (Fig. 1).
Developmental
Cleft lip and palate
Most cleft patients are currently treated to a high
level by expert teams (28) and may not be classied
as compromised cases where tooth replacement is
required. Secondary alveolar bone grafting per-
formed at 911 years of age should allow eruption
of the maxillary canine into a continuous alveolar
ridge form accompanied by vertical growth of the
alveolar process (23, 24). In approximately half of
affected patients the maxillary lateral incisor is
absent or malformed. If the orthodontist makes
space for the lateral incisor (rather than achieving
space closure), then replacement should be straight-
forward. However, older patients treated before these
highly successful protocols often had primary
bone grafting at a much earlier age, which led to
impairment of growth. Residual deformities and
sometimes multiple missing teeth following failure
Palmer et al.
106
of conventional bridges in these patients make man-
agement difcult (Fig. 2).
Hypodontia
Minor degrees of hypodontia involving a few teeth do
not normally present a challenge. However, major
forms can present difculties because the remaining
teeth are often small and closer in size to the primary
dentition (Fig. 3). In addition, the jaws and alveolar
processes are small and lack of development of sec-
ondary dentition results in thin angled alveolar pro-
cesses. There is often spacing and orthodontics is
Fig. 1. Traumatic loss of anterior maxillary teeth in a
female in her 30's. (A) Intraoral appearance showing loss
of all incisors, a vertical ridge deformity and gingival reces-
sion on the proximal surfaces of the canines. (B) Dental
panoramic tomogram showing extent of vertical bone loss.
Bone plates from previous maxillofacial surgery are visi-
ble. (C) The patient wearing an acrylic prosthesis with a
large labial ange to compensate for missing gingiva and
bone. (D) The patient wearing the acrylic prosthesis and
smiling. The gingiva is not visible. (E) An intraoral diag-
nostic set-up with long acrylic teeth set on the ridge. (F)
The patient smiling with the diagnostic prosthesis in place.
(G) An intraoral view of the completed implant supported
bridge, which has addition of pink porcelain to compen-
sate for missing marginal gingiva and papillae. (H) The
patient smiling with the nal implant supported prosthe-
sis in place. (I) Radiograph of the prosthesis which is sup-
ported by two Astra Tech ST implants.
107
Esthetic demands in the anterior maxilla
required. Diagnostic set-ups have to take account of
the pre-existing small permanent teeth and the
implications of providing larger adult-sized teeth
have to be evaluated. In some cases, skeletal discre-
pancies may also be present and further complicate
management.
Periodontitis
The periodontitis case (Fig. 4) may be the most dif-
cult compromise case of all as the anterior teeth are
often affected by:
Recession and thin soft tissue morphotype
Loss of papillae
Flat gingival prole
Large interdental spaces
Loss of bone
Drifting, overeruption and rotations
Exposure of root surface
Functional compromise of stability and mobility
Many clinicians hesitate over whether to advise
early extraction of periodontitis-affected teeth to pre-
serve esthetics. There is insufcient scientic evi-
dence to help in making this decision. In order to
facilitate esthetic requirements in many instances,
the patient would have to lose teeth at a stage in
the disease process when periodontal treatment
and tooth retention would not present a difculty.
This is clearly not in the interests of the patient.
Replacement of teeth with implants in the
patient who has suffered from advanced periodonti-
tis is usually a compromised situation even in
cases where it is a single tooth replacement. In
most situations the adjacent teeth are affected by
bone loss and gingival recession. Replacement of a
single unit in an arch form of affected teeth has
to accept this compromise as it is impossible to
reconstruct a ridge form coronal to the adjacent
affected teeth. The single tooth replacement there-
fore mimics the adjacent teeth (Fig. 5). Loss of
most of the maxillary incisor teeth through advanc-
ed periodontitis will result in considerable ridge
resorption and compromise (Fig. 6). In addition,
the periodontitis-affected maxillary incisor teeth
may have drifted to a Class 2 division 1 relationship,
which will often need to be corrected in the nal
result.
Endodontic lesions
Teeth with poor endodontic status may give rise to
large areas of apical bone loss or exhibiting residual
scars of previous apical surgery, such as amalgam
tattoos (Fig. 7).
Diagnosis and assessment of
features which affect esthetics
Lips
Esthetics of the anterior teeth may not be an
important issue for some patients if their teeth and
gingiva are never exposed during normal activities
Fig. 1. continued
108
Palmer et al.
such as smiling and laughing. However, most sub-
jects expose their gingiva to some degree during
these activities and may be very conscious of
their compromised appearance (30). Contrary to a
generally held opinion, this also may occur in the
lower anterior region. The most demanding cases
expose large amounts of tooth and gingiva at
rest (Figs 8 and 9). The teeth also provide im-
portant support to the lips and facial tissues which
should be assessed in frontal and prole views
(Fig. 2A,B).
Residual ridge
The edentulous ridge should be evaluated clinically
onstudy casts and radiographically to measure mesio-
distal space, buccolingual widthandheight. The thick-
ness and health of the soft tissue must be assessed.
Fig. 2. A middle aged male who had cleft lip and palate
treated in childhood by primary bone grafting and repla-
cement of missing lateral incisor and canine with a con-
ventional bridge which subsequently failed. (A) The
patient with lips at rest showing asymmetry. (B) A lateral
view showing maxillary retrognathism. (C) An intraoral
view showing missing teeth, class 3 incisor relationship,
buccal crossbite and mobile, enlarged, non-keratinized
soft tissue overlying the repaired cleft in the upper left
lateral incisor region. (D) Dental panoramic tomogram
showing evidence of residual cleft and retained roots. (E)
Diagnostic prosthesis showing need for replacement teeth
buccal to existing ridge. (F) Lips at rest with patient wear-
ing diagnostic prosthesis.
109
Esthetic demands in the anterior maxilla
Diagnostic set-ups
Diagnostic wax-up on study casts are of value in
treatment planning but do not allow assessment of
the appearance in the mouth of the patient. Diag-
nostic prostheses are probably the most useful, espe-
cially in the compromised case as the clinician can
provide multiple set-ups to allow evaluation of
Fig. 3. A female in her early 20's with severe hypodontia.
(A) The patient smiling showing poor esthetics in the
canine/premolar regions. (B) An intraoral view showing
retained deciduous canines and molars. The maxillary
lateral incisors are replaced by Maryland bridges. (C) Den-
tal panoramic tomogram showing retained primary
teeth with advanced root resorption and relative submer-
gence. (D) The patient smiling wearing a diagnostic
and transitional removable prosthesis. (E) An intraoral
view of the transitional prosthesis which replaces the
maxillary lateral incisors, canines and rst premolars.
(F) An intraoral view after completion of the implant treat-
ment without grafting. The bridges are cemented onto
customised abutments, which are necessary because of
the labial angulation of the implants in the narrow ridge
forms of these patients. (G) The patient smiling following
completion of treatment. (H) Radiographs of the com-
pleted treatment. On the patients' right side there are
two standard Branemark system implants. The left side
has been treated with a Astra Tech implants. A 3.5 mm
diameter implant has been placed at the lateral incisor
site and a 4 mm diameter implant at the canine site.
The premolar is replaced with a cantilever pontic. This
compromised approach has avoided onlay grafting on
the buccal aspect of the ridge and a sinus elevation on
the left side.
110
Palmer et al.
changes in appearance, e.g. with and without pros-
thetic gumwork to permit assessment of the degree
of missing soft and hard tissue and lip support/smile
line (Figs 1 and 2). The patients should be thoroughly
informed so that they are able to participate in the
decision making process leading to an agreed treat-
ment strategy. The main advantages of a diagnostic
removable prosthesis are summarized as follows:
Inexpensive/ cost effective
Easy to modify
Major changes possible/multiple set ups for com-
parison
Fig. 3. continued
Fig. 4. A female patient in her early 40's with advanced
periodontitis. (A) The patient holding her lips together to
hide her teeth. (B) The lips at rest showing incompetent lip
morphology. (C) The patient smiling exposing 34 mm of
gingiva and a class 2 division 1 incisor relationship. She
had noticed drifting and spacing of the incisors. (D)
The intraoral view showing spacing between her central
incisors, loss of papillae, recession and inammation.
111
Esthetic demands in the anterior maxilla
Can be worn for extended periods of time to allow
a real life evaluation
Efcient interim/provisional prosthesis
However, there are also disadvantages. The fact
that they are removable is not liked by some patients
and production of good esthetics may be too easy
and the conversion to xed implant prosthesis may
not be possible.
Radiographs
Radiographic examination is a crucial part of any
assessment for implant treatment. In the compro-
mised case it is usually performed to conrm the
extent of the clinically obvious deciency. Imaging
which utilizes a radiographic stent of the planned
tooth position will permit a more accurate estimate
of the degree of mismatch with the position of the
residual jaw bone and the difculty of reconstruction
(32).
Treatment strategies choice of
restoration and limitations
There are two basic ways of dealing with the
compromised case, surgical and prosthodontic,
although in many cases a combination of the two
is required.
Surgical: Reconstruct the decient bone and soft
tissue. This may be achieved with guided bone
regeneration, bone grafting and soft tissue grafting
or distraction osteogenesis (31). The reconstructive
procedure should be predictable and the patient
made aware of the risks involved, including the pos-
sibility that there may still be some deciency and
level of compromise. Vertical reconstruction of per-
iodontal tissues around adjacent natural teeth is
unpredictable or impossible in many cases despite
advances in guided tissue regeneration/grafting/
microsurgery. In some instances it may be necessary
to extract more natural teeth to facilitate the recon-
struction and further improve the esthetic result. The
vertical augmentation of bone and soft tissue in the
absence of teeth should be more predictable. The
fact that the graft can be buried and sealed beneath
the mucosa reduces the chance of infection. It is
more predictable to surgically rebuild decient tissue
rst before placing implants, rather than attempting
combined procedures.
Prosthodontic: Accept the deformity and provide a
compromise prosthetic reconstruction. In this situa-
tion there has to be sufcient bone to allow provision
of an adequate number of implants to full the bio-
mechanical requirements, thereby assuring a good
long-term prognosis (14). The patient should be
aware and accept the compromised esthetics.
Whatever restoration is chosen to solve the
esthetic problem it is axiomatic that it should not
Fig. 5. Replacement of a single tooth in the periodontitis
patient. (A) An intraoral view of a single tooth implant
replacing the maxillary rst premolar (bicuspid). The adja-
cent teeth have 3-mm of recession circumferentially and
the replacement tooth mimics the recession. (B) A radio-
graph of the single tooth implant showing that the implant
head level with the apical third of the adjacent tooth root
which has lost over half of its support.
112
Palmer et al.
compromise the health or the remaining dentition
or associated oral structures. It is unacceptable
to provide a patient with a restoration that is
impossible to clean with normal oral hygiene proce-
dures.
Removable dentures
A conventional removable denture can provide ideal
esthetics as it readily replaces missing gingiva and
the teeth can be placed in any desired arrangement
without concern for the position of the residual ridge
or implants (29). A labial (buccal) ange on the den-
ture also gives good lip support (Fig. 1C,D). The
major disadvantage is that it is removable and may
have compromised stability, retention and function.
These disadvantages can be largely overcome when
providing a removable implant-retained overden-
ture. Overdentures with a bar and clip arrangement
compare very favorably with xed bridges when eval-
uated by patients (33). More sophisticated types have
a precision-made milled bar to connect the implants,
which is then used to support a precisely tting
patient-removable bridge with a very high degree
of stability and retention.
Fixed bridges (partial dentures)
Conventional tooth-supported and implant-sup-
ported xed bridges may provide equivalent
esthetics (Fig. 10). In the natural tooth-supported
bridge the location of crown margins is dictated by
the periodontal health of the abutment teeth and the
preparation of the tooth structure. Tooth-supported
bridges may be compromised by the strength of the
remaining tooth structure and the potential for
development of caries or periodontitis. The form
and appearance of bridge pontics is the same for
tooth and implanted supported bridges and both
are amenable to augmentation of the tissue beneath
the pontic to improve appearance. If there has been
extensive recession around natural teeth or bone
Fig. 6. Replacement of all maxillary incisors in the period-
ontitis patient. (A) An intraoral view showing missing
maxillary incisors and healthy remaining teeth which
exhibit marked recession. (B) The existing removable par-
tial denture, which has a labial ange to replace missing
gingivae. (C) The patient following treatment with four
single tooth implants. There are no papillae between
the implant crowns, which is a similar situation to
that in the mandibular incisor segment following succ-
essful periodontal treatment. (D) The patient smiling,
showing acceptable esthetics of the completed implant
treatment.
113
Esthetic demands in the anterior maxilla
resorption prior to implant placement, the abutment
crowns will be longer and therefore provide a
compromised appearance. `Pink porcelain' can be
used at the cervical margins to help disguise this
Fig. 7. An endodontic lesion leading to compromise. (A)
The patient smiling, showing slight discoloration of the
maxillary left central incisor. (B) The intraoral view show-
ing extensive loss of labial gingival and a restored root
surface. There is likely to be a marked deformity in the
ridge following extraction of this tooth. (C) A radiograph
showing the central incisor which has a hopeless prog-
nosis.
Fig. 8. The smile line. (A) The subject holding her lips
together. (B) The subject at rest showing incompetent lips
and a short upper lip, which is level with the gingival
margin. (C) The subject smiling, exposing all of the
attached gingiva, a very demanding case if incisor tooth
replacement were required.
114
Palmer et al.
(Fig. 11A) or a Gumslip (a removable gingival pros-
thesis or veneer) used (15). These are removable and
often relatively fragile, not hard-wearing and needing
regular replacement.
The periodontist may consider, on agreement with
the dentist, transition to implant supported xed
bridgework via transitional tooth supported bridges.
The teeth that are to be retained need to be free of
infection and in good strategic locations. The advan-
tage to the patient is that they can avoid wearing a
removable denture during the treatment schedule.
The main advantages and disadvantages are sum-
marised below.
Advantages
No removable denture worn during the treatment
schedule
Avoidance of loading the residual ridge mucosa/
implants/grafts
Trial esthetics of a xed bridge reconstruction
Disadvantages
More complex and expensive
More time consuming/longer treatment schedule
Provisional bridge needs to be robust to allow
removal, replacement
Retained supporting teeth may occupy best poten-
tial implant sites
The alternatives to this approach are:
Extraction of the remaining teeth and provide
removable provisional denture.
Provision of a temporary bridge on temporary
implants. This has more or less the same advan-
tages/disadvantages as the transitional tooth sup-
ported bridge with additional cost and surgery of
temporary implants.
Provision of permanent implants in an immediate
extraction /implantation protocol with construc-
tion of an immediate bridge.
The third approach is being promoted by some
clinicians (16). It may be more difcult to provide
good esthetics if implant placement is compromised
by position of tooth sockets. In addition, it is not easy
to show the patient a provisional intraoral set-up of
the planned appearance. If esthetics is a prime con-
sideration, this strategy is not recommended. Achiev-
ing good esthetics takes time and planning and does
not easily lend itself to rapid/condensed treatment
protocols.
Effects of accepting the compromise on
implant placement
This section applies to those cases which have not
been adequately surgically reconstructed, a compro-
mised outcome has been accepted and there is suf-
cient bone to allow implant placement. The result is
that the implant may be placed too apically, palatally
or angled.
Fig. 9. Favorable smile line. (A) The patient smiling only
reveals the coronal two-thirds of the incisors, with no
exposure of gingiva. The esthetics are entirely acceptable
to the patient. (B) The same patient with lips retracted
showing extensive labial recession and loss of the midline
papilla. This would not be acceptable in many patients
with a high smile line.
Fig. 10. Prosthetic compensating tactics 1. A patient with a
natural tooth supported bridge on their right side and an
implant supported bridge on their left side. The prosthetic
teeth on the implant side are much longer due to extensive
ridge resorption following loss of the teeth. The patient
accepts the compromised esthetics which do not show in
normal function.
115
Esthetic demands in the anterior maxilla
Vertical level of the implant
Placement of the implant head 3 mm apical to the
level of the adjacent natural tooth cementoenamel
junction is commonly advised to allow for adequate
emergence prole (Fig. 12A,B)). Thus in case of
minimal resorption the head of the implant may
have to be countersunk. This is clearly not the case
in compromised sites with vertical loss of bone.
The implant head should be left level with the crest
of the ridge or even supercial to it depending
upon the implant design. This strategy will also help
to minimise unfavorable implant/crown ratios
(Fig. 12CE).
Buccal/palatal position and angle of the implant
The compromised ridge will be positioned more
palatally. The treatment plan should have decided
upon whether a xed bridge or a removable denture
is to be provided (32). With a removable denture the
sites offering the best bone quantity and stability
should be chosen and sufcient space provided
between implants if a clip system is planned. In
the case of the xed bridge, the implants should be
placed to enhance the appearance and reduce canti-
lever forces as much as possible (Fig. 12CE). There-
fore they should be:
Placed under teeth they are to replace. This may be
difcult with large horizontal and vertical discre-
pancies.
Angled labially to the appropriate degree
(Fig. 12E). Labial angulation can overcome some
of the horizontal discrepancy and the surgeon
should take into account whether it is desirable
to project the implant long axis through the
cingulum area to enable screw retention (most
likely with severe discrepancy) or through the
incisal tip or labial face to produce a better
labial emergence prole in a cemented prosthesis.
These strategies cannot provide optimum esthetics
in the compromised case but they may allow treat-
ment where an esthetic compromise has been
accepted.
Fig. 11. Prosthetic compensating tactics 2. (A) An intraoral
view of a full arch implant supported bridge in a patient
who has undergone extensive maxillary onlay grafting
and sinus augmentation. This has allowed placement of
sufcient implants but she still required provision of
porcelain `gum-work'. (B) The patient smiling, showing a
good appearance. (C) Intraoral radiographs of the com-
pleted bridge after 3 years showing good marginal bone
levels around the Branemark system implants.
116
Palmer et al.
Conclusion
Ideal esthetics may not be achievable in the compro-
mised case. The goals of treatment should be realistic
and achievable and take account of function, com-
fort, phonetics, longevity and cost. The patient
should be fully involved in the treatment outcome
decisions.
References
1. Berscheid E. An overview of the psychological effects of
physical attractiveness and some comments upon the psy-
chological effects of knowledge of the effects of physical
attractiveness. In: Lucker W, Ribbens K, McNamera JA, eds.
Logical aspects of facial form. Ann Arbor: University of Mi-
chigan Press, 1981.
2. Brody DS, Miller SM, Lerman CE, Smith DG, Lazaro CG,
Blum MJ. The relationship between patients' satisfaction
with their physicians and perceptions about interventions
they desired and received. Med Care 1989: 27: 10271035.
3. Calman KC. Quality of life in cancer patients an hypoth-
esis. J Med Ethics 1984: 10: 124127.
4. Carr AJ, Gibson B, Robinson PG. Is quality of life determined
by expectations or experience? Br Med J 2001: 322: 1240
1243.
5. Cawood JI, Howell RA. Reconstructive preprosthetic sur-
gery. 1. Anatomical considerations. Int J Oral Maxillofac
Surg 1991: 20: 7582.
6. Chang M, Odman PA, Wennstrom JL, Andersson B. Esthetic
outcome of implant supported single-tooth replacements
assessed by patient and prosthodontist. Int J Prosthodont
1999: 12:335341.
7. Cons NC, Jenny J, Kohout FJ. Perceptions of occlusal con-
ditions in Australia, the German Democratic Republic and
the United States of America. Int Dent J 1983: 33: 200206.
8. Cunningham SJ, Harrison SD, Feinman C, Hopper C.
Body dysmorphic disorder involving the facial region:
a report of 6 cases. J Oral Maxillofac Surg 2000: 58:
11801183.
9. Dion K, Berscheid E, Walster E. What is beautiful is good. J
Personality Soc Psychol 1972: 24: 285290.
10. Dunn WJ, Murchison DF, Broome JC. Esthetics: patients'
perceptions of dental attractiveness. J Prosthod 1996: 5:
166171.
Fig. 12. Surgical compensating tactics in the compromise
case Prole diagrams of the maxillary incisor region A
and B with minimal resorption and CE with resorption
which causes compromise. (A) This diagram depicts the
situation where there has been minimal bone resorption.
(B) In the case shown in A it is easy to produce the ideal
implant placement. The implant is in the long axis of the
crown, projecting through the incisor tip. It could be
angled slightly more labially or palatally as there is suf-
cient bone to allow considerable variation according to
whether the clinician wants to provide a cemented or
screw retained prosthesis. The implant head has to be
placed sufciently apically to allow a good emergence
prole and a subgingival esthetic location of the crown
margin. Case with minimal resorption therefore often
require countersinking of the implant head. (C) This dia-
gram depicts moderate resorption. The ridge is narrower
and located more palatally and apically. (D) The implant
restoration fromdiagram B has simply been superimposed
on the resorbed ridge to demonstrate the vertical and
horizontal discrepancy. The clinician does not need to
place the head of the implant apically to establish an
emergence prole. The implant head should not be coun-
tersunk so that unfavorable crown/implant ratios are
minimized. The angulation of the implant in this diagram
also creates a considerable labial cantilevering of the
crown. (E) This diagram shows that the clinician should
consider angling the implant head towards the labial to
reduce cantilevering and keeping the implant head super-
cial to reduce unfavorable crown/implant ratios.
117
Esthetic demands in the anterior maxilla
11. Eagly AH. What is beautiful is good, but. . . ..a meta-analytic
review of research on the physical attractiveness stereotype.
Psychol Bull 1991: 110: 109128.
12. Elias AC, Sheiham A. The relationship between satisfaction
with mouth and number and position of teeth. J Oral Rehab
1998: 25: 649661.
13. Feng XP, Newton T, Robinson PG. The impact of dental
appearance on perceptions of personal characteristics
among Chinese people in the United Kingdom. Int Dent J
2001: 51: 282286.
14. Gotfredsen K. Treatment concepts for partially dentate pa-
tients. In: Lang NP, Karring T, Lindhe J, eds. Proceedings of
the 3
rd
European Workshop on Periodontology. Berlin:
Quintessence, 1999: 408420.
15. Greene PR. The flexible gingival mask: an aesthetic solution
in periodontal practice. Br Dent J 1998: 184: 536540.
16. Grunder E. Immediate functional loading of immediate im-
plants in edentulous arches: two year results. Int J Period-
ontics Restorative Dent 2001: 21:545553.
17. Jenny J, Proshek J. Visibility and prestige of occupations and
the importance of dental appearance. J Can Dent Assoc
1986: 52: 987989.
18. Kerosuo H, Hausen H, Laine T, Shaw WC. The influence of
incisal malocclusion on the social attractiveness of young
adults in Finland. Eur J Orthod 1995: 17: 505512.
19. Kiesler SB, Baral RL. The Search for a romantic partner: The
effects of self esteem and physical attractiveness on roman-
tic behaviour. In: Gergen K, Marlowe D, eds. Personality and
social behavior. Reading, MA: Addison Wesley, 1970.
20. Lefer L, Pleasure M, Rosenthal L. A psychiatric approach to
the denture patient. Psychosom Res 1962: 6: 199207.
21. Locker D. Patient-based outcomes of implant therapy: A
review of the literature. Int J Prosthod 1998: 11: 453461.
22. Loh ES. The economic effects of physical appearance. Soc
Sci Quart 1993: 74: 420438.
23. Schultes G, Gaggl A, Karcher H. A comparison of growth
impairment and orthodontic results in adult patients with
clefts of palate and unilateral clefts of lip, palate and alveo-
lus. Br J Oral Maxillofac Surg 2000: 38: 2632.
24. Shashua D, Omnell ML. Radiographic determination of the
position of the maxillary lateral incisor in the cleft and
parameters for assessing its habilitation prospects. Cleft
Palate Craniofac J 2000: 37: 2125.
25. Shaw WC. The influence of children's dentofacial appear-
ance on their social attractiveness as judged by peers and
lay adults. Am J Orthod 1981: 79: 399415.
26. Shaw WC, Humphreys S. Influence of children's dentofacial
appearance on teacher expectations. Community Dent Oral
Epidemiol 1982: 10: 313319.
27. Shaw WC, Rees G, Dawe M, Charles CR. The influence of
dentofacial appearance on the social attractiveness of
young adults. Am J Orthod 1985: 8: 2126.
28. Shaw WC, Dahl E, Asher-McDade C, Brattstrom V, Mars M,
McWilliam J, Molsted K, Plint DA, Prahl-Andersen B,
Roberts C. A six centre international study of treatment
outcomes in patients with clefts of lip and palate. Part 5:
General discussion and conclusions. Cleft Palate Craniofac J
1985: 29: 413418.
29. Smith BJ. Chapter 6 In: Palmer RM, Smith BJ, Howe
LC, Palmer PJ, eds. Diagnosis and treatment planning
for implant dentures. London: Martin Dunitz, 2002:
6981.
30. Tjan AH, Miller GD, The JG. Some esthetic factors in a smile.
J Prosthet Dent 1984: 51: 2428.
31. Triplett RG, Schow SR, Laskin DM. Oral and maxillofacial
advances in implant surgery. Int J Oral Maxillofac Surg
2000: 15: 4755.
32. Zitzman NU, Marinello CP. Treatment plan for restoring the
edentulous maxilla with implant supported restorations:
Removable overdenture versus fixed partial denture design.
J Prosthet Dent 1999: 82:188196.
33. Zitzman NU, Marinello CP. Treatment outcomes of fixed
and removable implant-supported prostheses in the eden-
tulous maxilla. J Prosthet Dent 2000: 83:424433.
118
Palmer et al.