Biologically Driven Implant Aesthetics: Escaping the Single Tooth Solution

Dr. Melissa Seibert: Hey, I want to tell you about something I put together for you. I created a free PDF guide that walks you step-by-step through the injection molding technique.I love this technique because it is one of the best ways to get predictable, beautiful, and highly aesthetic anterior composites. You're actually injecting the composite directly into the tooth using a clear template which makes it far more consistent and efficient. If you like this guide, I've made it super easy. Just head over to TheElevatedGP.com forward slash IMPDF. And to make it even simpler, I've included the link for you right here in the show notes.

Hey, welcome to Dental Digest. This is a podcast with the mission of enabling you to stay on the cutting edge of evidence-based dentistry. And I'm your host, Dr. Melissa Seibert. This is part two of my series with Dr. David Attia.In this episode, we'll build on last week's conversations and dive deeper into how partial extraction therapies, biologically respectful implant placement, and digital workflows are changing the long-term outlook for our aesthetic cases. Dr. Attia shares real-world insights on collaborations and how digital tools, when used wisely, can elevate results across the entire interdisciplinary team.

Dr. David Attia earned his dental degree from Griffith University and went on to complete a postgraduate diploma in orthodontics and dentofacial orthopedics at the City of London Dental School. He then pursued a master's in oral implantology at Goethe University in Frankfurt, focusing his thesis on full-arch implant rehabilitation techniques while serving as a surgical mentor for Australian students. As a core faculty instructor for the Australian College of Dental Practitioners graduate diploma in oral implants, Dr. Attia brings a multidisciplinary approach to patient care and actively teaches and mentors dentists in advanced surgical implant techniques.

I've got something that you're going to love. If you've been loving the podcast and want to dive deeper into mastering implant dentistry, this is your chance. I'm giving away access to one of my on-demand courses completely free. This course is packed with everything you need to know about implant occlusion, platform switching, and creating that stunning aesthetic emergence profile that sets your work apart. Here's how to grab it. Leave a rating for the podcast, take a quick screenshot, and send it my way. You can either direct message me on Instagram. My Instagram handle is dr.melissaseibert or send it to me in an email at dr.melissaseibert at gmail.com. Once you get the screenshot, I will send you access to the course so you can start learning right away. It's my way of saying thank you for supporting the podcast and being part of this amazing community, and I can't wait to hear what you think.

So let me ask you this, I'm going to say something which, based on which circles you run in, may or may not be controversial. In my circles, this is very well accepted. But if I'm in a situation where I'm in the anterior aesthetic zone, predominantly the maxillary anterior aesthetic zone, although this can be done in the mandibular aesthetic zone, and I have a missing tooth, what I love to do is actually devitalize the root of an adjacent hopeless structure, bury it, and then do a resin-bonded fixed dental prosthesis (FDP) on the adjacent tooth.Some people call it a resin-bonded bridge, some people call it a Maryland bridge, although that's not technically correct, but that's a good description. And so have the root keep all the hard and soft tissue in place, and then just put a pontic on the adjacent tooth. As a master of implantology, what would you say to that?

Dr. David Attia: I have no problem with that. I spent a lot of time with Tony Rotondo, who a lot of people who listen to this podcast will know. And there are very, very few people that can manage the aesthetic zone like Tony does. And the more we do implants, the more we realize implants aren't always the solution. In the lateral incisor position, we're doing less and less implants. And I think we spoke about this last time we spoke, four years ago. Lateral incisor implants, when there is bone loss, the mesiodistal distance between the central and the canine is limited. As that interproximal bone loss, for whatever reason, extends to the adjacent proximal bony peaks, you will lose papilla. So in young patients, in patients that have a very, very narrow mesiodistal distance, in patients who are open to the idea of a resin-bonded bridge, lateral incisors are great for resin-bonded bridges. Centrals are a little bit different. A lot of patients will say, "I want something as close to my natural tooth as possible. I want something that I can bite on with confidence," et cetera. And maybe the treatment planning changes for a central incisor. But I have absolutely no problem at all with resin-bonded bridges in the aesthetic zone, provided the occlusal factors are controlled.Coupling it with partial extraction therapy, that's music to my ears. It's not anything that I wouldn't implement in my own practice.

But of course, case selection is everything, right? Do you have a patient with a deep bite? That's not a good case for a resin-bonded FDP. These patients have broken down their teeth for a reason, right? And the number of times patients come in with a fractured central or lateral incisor down to the gumline, and you check the bite and they've got a 100% deep bite to the palate, and suffer from sleep apnea and all sorts of other things that are really the prerequisite to these fractures.It's a conversation with the patient. I can treat your tooth in isolation and we probably end up here in a few years' time with bone loss around an implant because an implant doesn't have a PDL. You're going to be overloading the bone without realizing, et cetera. If they've fractured that tooth because of occlusal disharmony, if they've fractured that tooth because of overloading their natural dentition, they're going to do the same thing to your implant. So your implant is less forgiving than the tooth. It's then about educating the patient on the importance of orthodontics, the importance of aesthetic rehabilitation, or bite opening.

If you have a deep bite, are you in high-contact sports? We have to modify the treatment plan. I don't put provisional teeth on patients who have high-contact sports regularly involved or high-contact vocations. I treat a lot of police officers. They're usually in a lot of high-impact type activities. So I will provisionalize them with a customized healing abutment, but I will not put a provisional tooth sometimes because during that critical zone, that critical period of integration, if they get hit, there goes my implant, the socket shield, the soft tissues, the hard tissues—everything I've worked so hard to preserve would be out the window. So we really have to customize and tailor the treatment plan to the patient factors as well as the clinical scenario and the underlying etiology.

I can use a customized healing abutment to hold all the tissue contours for me and a fixed Maryland bridge to give them something fixed in place. They know it's not for chewing during that initial three months. You can wear it, you can smile with it, you can go about your business with it—just don't eat on it. Occasionally in these deep bite patients, a tip that I've learned over the years is that if I am planning on provisionalizing them and they do have that moderately deep bite, I crank open the bite for two months. I put blobs of composite on the palatal aspect of the maxillary canines or on the facial aspect of the mandibular canines. That's what we call a canine riser, and it discludes the bite anteriorly for six to eight weeks. We know from an orthodontic perspective that's going to have minimal effect on tooth movement in that short period of time. Then when it comes to restoring them, we take them off and we can then restore them if the bite permits.

In the cases where they bite 100% of the palate, I will not place the implant unless there is a definitive restorative plan in place. Because if I go ahead and place that implant and they haven't committed to opening up the bite, then my implant is going to be restored in a very, very traumatic environment. When that implant fails, who do you think they're going to call?

When patients walk in for an anterior tooth, they want to walk out with a fixed tooth every single time. And a fixed tooth can be a screw-retained provisional, or it can be a Maryland bridge. The way in which I design my provisionals is I will get a Maryland bridge with a hole in the back of it. We place the implant. That bridge is designed with the critical contour exactly where the proposed final gingival margin needs to be. If we get great primary stability and the occlusion is favorable, we pick up that Maryland bridge, chop the wings off, shape the subcritical contour, and they walk out with a fixed provisional. If we can't get primary stability, we will then create a custom healing abutment preserving the subcritical contours in their entirety. That very same Maryland bridge that has a hole in the back of it—we fill up that hole, chop one of the wings off, and bond it to the adjacent tooth, and they walk out with a fixed provisional.My custom healing abutment is nowhere near it. I create a one-millimeter clearance between the healing cap and the intaglio of the pontic, which means that I'm getting the benefits of a full provisional without loading the fixture.

Pivoting to a softer topic, this over-treatment is a global epidemic. I do not think it's just North America. We are seeing a lot more over-treatment restoratively, and even worse still, a lot more over-treatment surgically. For me, I look at the work that we're doing, and I always ask myself, how long is this going to last, and what can I do when it doesn't last? It's way more lucrative to go ahead and take everything out and provide someone with immediate final teeth in 24 hours. However, when this fails—not if, because we're not immune to failure—what are we going to do to fix it? If there is the hope of saving teeth without compromising aesthetics, that is always our first approach. When you practice the right dentistry, the money will always follow. If you are actually practicing ethical dentistry to a very high level, it takes longer and requires more work, but you are doing right by those patients. If you can really bridge the gap between what they see on social media, what they hear about from their family and friends, and what is actually true, then really we've mastered the art of communication.