08 January 2025

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Periodontics, Implantology, and Prosthodontics Integrated: The Zenith-Driven Rehabilitation

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A customized treatment plan is important to reach results that will satisfy the patient providing esthetics, function, and long-term stability. This type of oral rehabilitation requires professionals from different dental specialties where communication is a major key point. Digital Smile Design allows the practitioners to plan and discuss the patient’s condition to establish the proper treatment plan, which must be driven by the desired zenith position. The ideal gingival position will guide the professionals and determine the need to perform surgical procedures or orthodontic movement before placing the final restorations. In this article, the zenith-driven concept is discussed and a challenging case is presented with 4-year follow-up where tooth extraction, immediate implant placement, bone regeneration, and a connective tissue graft were performed.

Multidisciplinary integration is necessary to achieve esthetical and functional results in simple and complex dental rehabilitations. Planning and establishing the correct timing of the involved procedures increase treatment predictability. To perform the oral rehabilitation, it is possible to mimic contralateral teeth form, alignment, and proportion or design it based on esthetical principles and the characteristics of all teeth. Creating a harmonious smile might need interventions from different dental specialties, which will indicate surgical, orthodontic, or restorative procedures. To verify the necessity of such interventions, the gingival contour must be evaluated and establishing the correct gingival zenith aids the treatment planning as well as the following dental procedures.

Gingival zenith is the most apical portion of the gingival margin and is usually distally displaced in maxillary central incisors and centralized in maxillary lateral incisors and canines. Contour of the gingival margins must be in harmony with the smile and facial components so existing alterations or asymmetries require surgical or orthodontic interventions if the patient presents a high lip line or is willing to correct the gingival tissue format. Even after clinical, photographical, and study cast analysis discrete or more complex alterations may not be visualized in the day-to-day practice so a method to boost treatment planning possibilities must be used.

Digital Smile Design (DSD) is a planning tool used to facilitate the detection of alterations, individual case planning, and communication between involved personnel. A set of static and dynamic images are acquired from the patient and used to design several reference lines and shapes in the computer to detect alterations and disharmonies. The virtual treatment plan allows that both personnel and patients visualize the main goals and expected results after the treatment as well as its risks and limitations. Furthermore, the communication by digital methods favors treatment sequential procedures as the orthodontist, periodontist, and the restorative team may prospectively progress with the treatment increasing its predictability.

Establishing the ideal position for the gingival zenith with DSD is the first step to recreate a smile. Orthodontic movements are usually indicated whenever it is necessary to perform large horizontal movements in the zenith position. As for smaller horizontal movements and in vertical modifications, periodontal plastic procedures such as crown lengthening or root/implant coverage are good indications. Surgically moving the zenith position coronally with gingival grafts is a more sensitive situation but predictable if properly indicated. This graft also increases the soft tissue volume and prevents gingival or peri-implant tissue recession.

Rehabilitation of esthetic areas with implants increased integration between the surgical and restorative procedures. Both treatment phases, performed isolated or concomitantly, have to be in agreement so satisfactory results can be achieved. Whenever a tooth must be removed and replaced by an implant it is important to limit the tissue losses and the collapse of the soft tissue after extraction. If the patient’s systemic and local conditions permit, an immediate implant and provisional can be placed in an intact or compromised socket to perform an immediate tooth replacement (ITR). This procedure presents esthetical, psychological, functional, and biological advantages to the patient but must be well indicated in order to achieve treatment success. Despite the limitations and risks reported in the past, ITR combined with bone and gingival grafts present good results maintaining the ridge format and soft tissue contour if the appropriate surgical protocol is employed.

Before performing ITR, the ideal zenith position must be established to guide the surgeon in the tridimensional position of the dental implant and in the grafting process. The aim of this paper is to demonstrate an interdisciplinary clinical protocol in order to obtain the better functional and aesthetic results. The protocol was based on the position of the gingival zenith as a starting point and the prediction of the DSD to obtain predictable results.

Authors: Fausto Frizzera, Mateus Tonetto, Guilherme Cabral, Jamil Awad Shibli, Elcio Marcantonio Jr.

Source: https://onlinelibrary.wiley.com/doi/full/10.1155/2017/1070292