Symposia
Orthodontists often left without orthognathic surgery as
a treatment option are forced to settle for less than ideal
treatment results.
In order to reverse this trend and make orthognathic
surgery more available to patients several things must
happen. First, the oral and maxillofacial surgery profes-
sion needs to reinforce the importance and value of
orthognathic surgery to insurance providers, patients,
referring doctors and to surgeons within our own pro-
fession. Alternatives for providing high quality surgical
services at a reasonable cost must be explored including
negotiating for better financial arrangements with hos-
pitals and providing options for outpatient surgical care.
This presentation will outline strategies to rebuild
orthognathic surgery within the oral and maxillofacial
surgery profession.
References
Lombardo GS, Karakourtis MH, White RP Jr: The impact of clinical
practice patterns on hospital charges for orthognathic surgery. Int J
Adult Orthodon Orthognath Surg 9:251, 1994
SYMPOSIUM ON DENTAL IMPLANT FAILURES: HOW TO AVOID
THEM
Thursday, October 5, 2006, 3:00 pm—5:00 pm
Moderator: Craig Misch, DDS, MDS, Sarasota, FL
Esthetic Implant Complications:
Prevention and Management
Anthony G. Sclar, DDS, Miami, FL
In its simplest terms, an esthetic complication in im-
plant therapy is defined as the failure to deliver an
inconspicuous functional dental replacement in an area
of high esthetic concern, as defined by the patient.
Although the course of action required to deliver a nat-
ural appearing implant restoration may, in certain in-
stances, be simple, a series of surgical and prosthetic
procedures methodically sequenced and closely coordi-
nated is most commonly required for the bulk of patients
who desire esthetic dental implant replacements for
failing or missing dentition. A smaller set of patient’s
present with advanced complexity case scenarios that
require multiple treatment modalities and the use of
camouflage techniques in order to achieve an accept-
able, albeit less than perfect, esthetic outcome. Despite
all the advancements in procedures and technologies
related to dental implant therapy, achieving predictable
esthetic results remains the greatest challenge and a
significant source of frustration in implant dentistry.
Nevertheless, cumulative clinical experience and cur-
rent scientific knowledge provide the basis to prevent
the majority of esthetic implant complications that is
occurring. Therefore, it is imperative that clinicians in-
4 AAOMS • 2006
Dolan P, White, RP Jr, Tulloch JF: An analysis of hospital charges for
orthognathic surgery. Int J Adult Orthodon Orthognath Surg 2:9, 1987
Dolan P, White RP Jr: Community charges for orthognathic surgery.
Int J Adult Orthodon Orthognath Surg 11:253, 1996
Outpatient Surgery/Managed Care
Jerry L. Jones, DDS, MD Albuquerque, NM
Orthognathic surgery is a part of oral and maxillo-
facial surgery that helps define our speciality. Unfor-
tunately, decreased reimbursement or denial of cover-
age by third party payers has significantly reduced the
performance of these procedures. This presentation
will discuss approaches that have kept orthognathic
surgery a viable and significant portion of this OMS’s
practice. These include use of a surgery center for
outpatient orthognathic surgery and hospital facilities
with a global fee.
volved in esthetic implant therapy not only fully grasp
the factors known to contribute to complications but
should posses in-depth knowledge of the treatment mo-
dalities, surgical approaches, and prosthetic techniques
required to prevent esthetic complications.
Achieving predictable success and avoiding complica-
tions in esthetic implant therapy require a familiarity
with smile esthetics, specific patient evaluation and in-
terview skills, prophylactic employment of certain sur-
gical and prosthetic measures, and a sense of artistry not
required for success when dental implant therapy is
performed in areas of low esthetic concern.
To begin with, implant team members must be able to
identify those elements present in each prospective pa-
tient’s smile that enhance or detract from the existing
smile esthetics and visualize the desired final esthetic
result following implant therapy. Furthermore, they
must be able to develop priority based treatment plan-
ning options that are balanced in terms of the patient’s
desires and the treatment outcomes that can realistically
be achieved. In order to do so, a systematic dentofacial
and dentoperiodontal evaluation focused on identifying
the currently recognized special treatment planning con-
siderations that are associated with esthetic implant fail-
ures must also be performed. These special treatment
planning considerations include; unfavorable past dental
history that potentially diminishes the regenerative po-
tential of the site, the patient’s periodontal biotype,

vertical maxillary deficiency, compromised bone volume
or malposition of adjacent natural dentition, insufficient
surgical or restorative dimension, and an unfavorable
occlusal scheme. While the presence of any of the above
mentioned considerations has the potential to cause an
esthetic compromise, pretreatment identification allows
the implant team to develop suitable treatment options
that most often lead to successful esthetic outcomes.
Accordingly, with advanced recognition of factors that
are associated with compromised esthetic outcomes, the
implant team will be able to select and sequence the
appropriate treatment modalities required to achieve an
acceptable esthetic result in the majority of cases. Suc-
cess in esthetic implant therapy also requires advanced
patient interview and patient education skills. Following
the initial interview and pretreatment evaluation pro-
cess, a problem list is assembled and details of the avail-
able treatment options are outlined and presented to the
patient including strategies for management of the lim-
iting factors identified during clinical evaluation. Realis-
tic patient expectations are established via this co-dis-
covery process prior to proceeding with treatment.
Notwithstanding the above, a small number of es-
thetic complications and failures are inevitable. Al-
though management of patients with esthetic complica-
tions requires that the clinician follow the same pre-
treatment evaluation and patient education process
described above, it should be recognized that these
patients have been traumatized and they lack confidence
in implant therapy and related procedures. The impor-
tance of psychological management of these patients
should not be overlooked. The first step involves estab-
lishing how the patient’s current situation compares to
the pretreatment situation. In many cases, alternative
options for treatment initially included traditional fixed
or removable partial dentures and these options often
remain possible despite the complication or failure that
has occurred. The patient’s willingness to accept a fixed,
or in some cases, a removable partial denture as a desir-
able outcome sets the stage for moving forward with the
understanding that reasonable efforts will be made to
deliver an esthetic implant restoration. The patient
should also be educated about diminished vitality of the
site as a result of previous complications and the nega-
tive effect that this may have on planned reparative
procedures. A plastic and reconstructive surgery ap-
proach is adhered to in the treatment of patients who
have already experienced complications or failures re-
sulting in a loss of soft and hard tissue ridge volume in
areas of high esthetic concern. Soft tissue augmentation
procedures are typically performed as the first proce-
dure at the involved sites as a means of testing the
regenerative potential of the site and to improve the
volume and quality of the soft tissue envelope in prepa-
ration for subsequent hard and soft tissue grafting pro-
cedures. Pedicle soft tissue flaps such as the VIP-CT flap
AAOMS • 2006
Symposia
are useful for improving tissue volume and circulation at
compromised sites with diminished regenerative poten-
tial secondary to unfavorable past history. In certain
cases, vertical ridge defect morphology requires consid-
eration for distraction osteogenesis or osteotomy/sand-
wich bone graft techniques in addition to traditional
bone grafts. Increased healing times should be allotted in
between each planned procedure in this patient popu-
lation. Should a significant treatment setback occur, con-
sideration is given to finalizing pontic site development
and proceeding with a fixed partial denture. In advanced
complexity cases, camouflage techniques such as es-
thetic crown lengthening and cosmetic restoration of
adjacent dentition are often required in order to deliver
a harmonious final prosthesis, whether traditional or
implant borne. In some cases, a removable partial den-
ture, either tooth borne or implant assisted is indicated.
References
Chiche G, Pinault A: Artistic and scientific principles applied to
esthetic dentistry, in Chiche G, Pinault A (eds): Esthetics of Anterior
Fixed Prosthodontics. Chicago: Quintessence 13, 1994
Sclar AG: Esthetic Implant Therapy: A Comprehensive Approach, in
Sclar AG, Soft Tissue and Esthetic Considerations in Implant Therapy.
Chicago: Quintessence 189, 2003
Sclar AG: Esthetic Implant Therapy: Vascularized Interpositional
Connective Tissue (VIP-CT) Flap, in Sclar AG, Soft Tissue and Esthetic
Considerations in Implant Therapy. Chicago: Quintessence 163, 2003
Failures: Prosthodontic
Joseph Y. K. Kan, DDS, MS, Loma Linda, CA
Achieving predictable anterior implant esthetics is of-
ten challenging for the clinicians. To create anterior
implant restorations with harmonious gingival contour
that emulate nature is a fusion of science and art. Under-
standing the biologic and physiologic limitations of the
soft and hard tissue along with proper implant position-
ing and prosthetic design will facilitate predictability in
simple to complex esthetic situations.
This presentation will focus on current implant treat-
ment philosophies and methodologies for diagnosis and
management of failures in the esthetic zone. Equal em-
phasis will be placed on the periodontal plastic proce-
dures and adjunctive orthodontic maneuvers and pros-
thetic management of soft and hard tissue for optimal
anterior implant esthetics.
References
Kan JYK, Rungcharassaeng K, Umeuz T, Kois JC: Dimensions of
Peri-implant Mucosa: An evaluation of maxillary anterior single im-
plants in humans. J Periodontal 74:563, 2003
Kan JYK, Rungcharassaeng K, Lozada JL: Immediate placement and
provisionalization of Maxillary anterior single implants: 1 year prospec-
tive study. Int J Oral Maxillofac Implants 18:31, 2003
Kan JYK, Rungcharassaeng K: Inter-implant papillary preservation in
the esthetic zone: A report of 6 consecutive cases. Int Periodont Rest
Dent 23:245, 2003
5