Anterior Implant Esthetics, Emergence Profile, and Tissue Stability with Dr. Jonathan Esquivel

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Hey, welcome to Dental Digest. I'm your host, Dr. Melissa Seibert, and this is a podcast with a mission of enabling you to stay on the cutting edge of evidence-based dentistry.

This is part one of a two-part series with Dr. Jonathan Esquivel, a prosthodontist and educator known for his work in implant aesthetics and biologically driven restorative dentistry. In this first episode, we'll dive into the challenges of restoring implants in the aesthetic zone, where even the smallest variations in tissue or bone can have a huge impact on long-term results.

Dr. Esquivel shares his framework of space, volume, and time, and how it can help clinicians achieve predictability in complex aesthetic cases.

Dr. Jonathan Esquivel is a prosthodontist in private practice who completed his specialty training at LSU School of Dentistry in 2013, followed by an aesthetic and implant fellowship in 2014. A former LSU faculty member, he's been recognized with multiple teaching honors, including the Golden Apple Award, the Dr. Allen A. Copping Award for Excellence in Teaching, and the 2023 Claude Baker Award from the American Academy of Fixed Prosthodontics.

Widely published and an invited national and international speaker, Dr. Esquivel is passionate about advancing prosthodontics while delivering individualized, aesthetically driven care at the highest level.

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Dr. Melissa Seibert: So why is restoring a single implant in the anterior aesthetic zone often considered the ultimate test of restorative dentistry?

Dr. Jonathan Esquivel: I think that the bigger difference or the biggest challenge in restoring a single implant or an implant in the aesthetic sector is twofold. The first one is, of course, trying to achieve that natural look with tissues that are constantly changing, or in constant change.

And the second one is dealing with a device that is not a root and does not have the same biological protection or the biological assets that a root has. Achieving that balance between an aesthetically pleasing restoration and a biologically stable restoration is a challenge because of that.

It's two different beasts. Tissues around teeth are so resilient. Not so much around implants. This is why for us as dentists, we really have to be double or triple careful when we're dealing with an implant restoration per se.

Dr. Melissa Seibert: What are the key biological and anatomical factors that make the anterior zone so difficult compared to the posterior? This is just so important because so often we think if you can comfortably restore a mandibular molar, you can restore anything, and that's just not the case. There's a lot of thoughtfulness that goes into restoring implants in the anterior aesthetic zone.

Dr. Jonathan Esquivel: I think that some of the things that we have to consider is, one, the anatomical position of the bone. In your anterior maxilla, you have that naturally tilted anatomy, that natural inclination of the maxillary arch, that already sets you at a little disadvantage when it comes to your prosthetic design.

I always like to say that the three most important things are always space, volume, and time. If that implant is misplaced in the aesthetic sector and you start violating the space requirement, that is going to alter, for example, your material selection for your abutment. It's going to alter the shape of your emergence profile.

I was asked a couple of weeks ago by one of the colleagues I work with, “Jonathan, what do you think are some of the most important things to have long-term success in implant therapy?” And I said, “I'm going to talk to you about four.”

The first one was luck, because in an implant, there's a lot of factors that we can't control: the human response, the biological response, the innate response of the patient, your patient's behavior, and all the other things that you cannot see that you try to control through proper management of the implant placement, proper management of the abutment design, et cetera.

But in reality, you're limited to some degree. The second important thing for me was three-dimensional position of the implants, because that's going to directly dictate your emergence profile design. The third one is emergence profile. The fourth one would be the patient's capacity to clean and the patient's capacity to maintain this environment.

This is why it's so hard. We're dealing with an evolving or changing set of tissues in an aesthetically demanding area of the mouth, in which the minor changes that happen to the tissues are going to be so easily seen. Not only that, we're dealing with smaller dimensions of bone, and as this bone changes, we're leaving those implants in a not-so-favorable position compared to the posterior.

Dr. Melissa Seibert: Can you please describe where the implants should be placed so that we can achieve the most aesthetic outcome, versus where the implant might be placed where we're facing a lot of aesthetic challenges?

Dr. Jonathan Esquivel: That's a very good question. A couple of years ago, I wrote an article that was called The Impact of the Three-Dimensional Position of the Implant and Emergence Profile Design, and this is directly linked to aesthetics too.

I think the first thing that we need to think about is that every single case that we do in implant dentistry has to be reverse engineered. For me to answer that question, first I need to know where the tooth is supposed to be, and I have to have a proper position of the tooth.

Once I have that incisal edge, that cingulum point rather, I want to have the platform of that implant about four millimeters apical to that. In an ideal situation, I want to have that platform of the implant not only four millimeters apical, but emerging closer to the cingulum of the tooth.

For that to happen, you need a plethora of things. You need good volume of bone, good volume of tissues, and also a proper environment with the neighboring teeth too. One of the things that's important to consider in anterior implants is not only the position of the implant's neck or the implant's platform, but also the surrounding structures.

How is the crest of the bone maintained by the neighboring teeth? Are we placing two implants side by side? How is this going to affect my aesthetic outcome? What implants are we replacing side by side? Am I dealing with a central implant and another central incisor implant, or am I dealing with a central incisor and a missing lateral incisor?

One of my very best friends, whom I consider one of my mentors, has a beautiful quote that says, “We oftentimes spend too much effort trying to learn the complex when the basis of excellence is to master the basics.”

Going back to this and taking this phrase and putting it into what you just asked me, for me, the most important thing to consider when placing an implant in the three-dimensional position is to position that tooth first in the right three-dimensional position. If I have to move neighboring teeth around with orthodontics, if I have to do periodontal surgery around, I'll do it.

That's going to set the tone for that proper position on the implant, not the physical act of just putting a screw in the bone, essentially.

Dr. Melissa Seibert: What are the challenges when you are restoring adjacent implants?

Dr. Jonathan Esquivel: There's quite a few. Going back to that quote I just said, we have to think about the aesthetic basics or aesthetic fundamentals. For me, the most important fundamental in the anterior sector is to achieve symmetry.

Depending on where I'm restoring these adjacent implants, the bigger challenge between two adjacent implants is to have beautiful soft tissue between them, a nice papilla between the two implants. It's not the same to have a shortened papilla between two centrals as having a short papilla between a central and a lateral where I can compare to the contralateral side.

That becomes a challenge because you're then playing with symmetry, which is, like I said, one of the most important fundamentals. If you ask me, that's the number one task. That's the hardest thing to achieve: to have a symmetrical outcome.

If I have the two centrals, I'm a little bit less worried. Nevertheless, I want to achieve a good aesthetic outcome. The bigger challenge is maintaining what I have achieved in time because I know these tissues are going to change.

We try to sometimes overcompensate the soft tissue with soft tissue grafting. Many times, in situations where we need orthodontic extrusion, we orthodontically extrude teeth before placing implants to have a vertical overcompensation and position the bone and the crest of the bone where we want them to be.

A lot of things have to come into play for us to be able to get this outcome to be what we want. That's the bigger challenge: finding the patient, one, that is willing to go through all this process; two, that understands that we're in a limitation when we place an implant to get these perfect outcomes; and three, that is also willing to undergo additional procedures like orthodontics many times or tissue grafting and taking a little bit of the palate, a little bit of the tuberosity, and putting it in these future implant sites.

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Dr. Melissa Seibert: Can you speak about when soft tissue grafting is utilized? How important is soft tissue for achieving a really good aesthetic outcome with the implant? I think that there's a lot of healthy discussion going on about this over the course of the last five years, and we've really recognized the importance of really good healthy soft tissue.

Dr. Jonathan Esquivel: Absolutely. When we started talking just a few minutes ago, we talked about three fundamentals that I said are critical. We talked about space and how the 3D position of the implant, emergence profile design, and material selection are three things that influence this.

The second fundamental is volume. We need to have a good volume of tissues, bone, and soft tissue. Depending on the case, we're going to need more or less of that additional grafting procedure.

We like to divide the treatments into margin preservation therapies and margin reestablishment therapies. In a margin preservation therapy, the name is very descriptive. You want to maintain the existing soft tissue outline.

In many of these cases, which is a typical patient that comes to your practice and needs a tooth extracted, immediate implant placement, immediate provisionalization, if this patient has a thick phenotype, if this patient has thick bone, many times you may say, “In this particular case, I may not need a connective tissue graft.”

But this is not the norm. Many or a lot of the patients that come to our practice do not have a perfect soft tissue outline or very thick phenotype. Oftentimes, they will benefit from soft tissue grafting. This is for many reasons, biological and aesthetic reasons.

From the aesthetic standpoint, the fact that I have thicker tissues gives me more margin stability in time. It allows me to mask dental materials that I'm going to use in this future implant site or future implant site. And from the biological standpoint, less chance of recession.

Also, the association of thicker tissues and more stability of the bone crest, and the association of soft tissue grafted sites and the dimensions of that ridge after the tooth has been extracted, the implant has been placed, and the tissues mature.

In my opinion, most of the cases in the aesthetic sector benefit from a connective tissue graft. We cannot say all because there are situations that won't need it, like very thick phenotypes and ideal soft tissue outlines with thick phenotype associated with it. But that's not the vast majority of cases.

Now, if we're talking about margin reestablishment therapies where your patients have lost vertical and horizontal soft tissues, in those cases, I think it's almost an absolute must to have a connective tissue graft associated, not only the bone regeneration done.

Dr. Melissa Seibert: You talked about the ridge stability after extraction, and this isn't talked about enough. What happens to the bone after we take a tooth out? Sometimes patients will not want to go through extensive restorative treatment, and so they'll say, go ahead and just take the tooth out. But you're largely a part of creating a really aesthetic outcome. Can you comment a little bit more about what it is about tooth loss that leads to a lot of ridge instability?

Dr. Jonathan Esquivel: Essentially, if you go back and read the literature about what happens or what percentage of sites get resorption, it's pretty interesting. Don't ask me to quote you the authors right now, but some authors talk about sites that have extraction are highly associated with ridge dimensional changes.

In sites that these dimensional changes happen, they tend to be what we classify as severe, with a vertical and a horizontal component, which makes it really, really tough. You've lost that root. You've lost that PDL. The moment you extract the tooth, the bundle bone goes away. There's a series of biological changes that are happening in the sites that need to be addressed.

One of the things I'd like to emphasize is you're going to have patients that are not going to be ready to get an implant immediately for many reasons: financial, biological, or simply they're not emotionally ready, which is one of the bigger things.

What we do in that site in the meantime will help diminish or alleviate the rate at which these changes happen, or will cause them to move faster into those dimensional changes. What I refer to here is provisionalizing the sites.

One of the things that I like to emphasize is to tell dentists that flippers may not be the best resource for that future implant site. Yes, they're easy to do. Yes, they look much nicer than an Essix and your patients are going to be happier with you. But the problem is that they may be causing or exacerbating or accelerating the rate at which these dimensional changes happen on both the hard and soft tissue.

Before, I used to do a lot of Maryland bridges. I don't do many anymore. I do a lot of Essix retainers now because of time and cost and all that stuff. But I think they serve a purpose, which is not to accelerate my bone and tissue dimensional changes because we know that they will happen to some degree.

It will happen to most people. The literature says that 91% of the sites with dimensional changes are associated with that extraction too. It's very, very important that we as dentists take note of this.

I'm not a surgeon. I'm a restorative dentist. My task as a restorative dentist that today does not do any surgery is to try to prevent how fast these tissues change.

Dr. Melissa Seibert: Talk a little bit more about why an Essix-type option or even a provisional RPD might not be the greatest thing for the hard and soft tissue.

Dr. Jonathan Esquivel: I think Essix retainers are not a problem. I do a lot of Essix, to be honest with you.

A provisional RPD is a problem because they don't have any rest seats. It's not like a regular RPD where you have built-in rest seats in your teeth that are going to get that vertical load when you bite down. The problem with the RPD is you bite down and the pressure of that interim partial is going to be extrapolated to the residual tissues.

That's going to make this remodeling happen much faster. On an Essix, in a properly done Essix, as long as you keep it off the tissues, it should be just fine.

Of course, it really depends what situation you have too. If I have a patient that gets a tooth extracted and gets a bone graft and a large connective tissue graft done, I always tell my patients, “My first Essix is going to be ugly. It's going to be really short. I don't want anything touching these tissues. Then I can make you something that looks prettier.”

I know that's not what patients want to hear many times or most of the time. Nobody wants to go around life with a short tooth that does not look nice. But I try to build the importance into these patients of time, letting tissues heal.

This would be our third important principle: space, volume, and time. We have to let those tissues heal, whether it is in the initial stages after extraction and grafting, if you replace the implant, or if you place them in an outloader, or even after you've provisionalized that implant. Let those tissues heal. Give them the right amount of space and patience.

All of these little things that we do are going to protect the tissue and bone from a faster deterioration or from deterioration caused by our prosthetic designs in our interim restorations or our final restorations.

Dr. Melissa Seibert: I love that you mentioned this. Todd Schoenbaum, I know he's your good friend. You both have immense respect for one another. He talks about how the provisional stage is not optional. It's a mandatory part of the procedure and it's integral to the long-term success. Can you speak a little bit more about why this is? Because it is hard to prepare patients for this.

Dr. Jonathan Esquivel: Absolutely. Think about the moment you extract the tooth. Most of the dimensional changes are going to happen within the first three to six months according to the literature. However, they can happen within the first year.

Let's think about this from a logical standpoint. Where do you want these dimensional changes to happen? In the interim restoration, where you can still modify and make changes, or in the final restoration, where once you've delivered it, if some change happens, you have to redo it again?

That's from the business standpoint and from the patient comfort standpoint. From the biological standpoint, we have to think and understand that a lot of these tissues take a lot of time to heal. I want to give these tissues the proper environment. I want to guide their healing.

A lot of people envision an immediate provisional on a post-extraction socket as an aesthetic benefit because you maintain the soft tissue outline, the papilla, et cetera. I also envision it as a biological advantage because I am maintaining or preserving the existing aesthetics, but I'm letting the tissue heal around the proper anatomy.

Once these tissues heal, if everything is proper and correct, all I have to do is disconnect this crown once from the patient's mouth, put in an impression coping or scan body, scan, and put my provisional back on. If I'm lucky and I have a great ceramist, next appointment I'm delivering a crown.

This little amount of disconnections is a great biological advantage for the site because I'm maintaining, or at least not disturbing, that very weak mucosal seal constantly. That's the biological purpose.

Second, once we extract the tooth and put a provisional in, many times you're going to see that the tissues are going to change. You're going to have maybe little black triangles every now and then. If you let these tissues heal, and in many occasions the crest of the bone is at the right level, you're going to see the soft tissue creep into these spaces and stabilize itself following the anatomy of the restoration you've given previously.

What happens if we move fast? I have a friend from Brazil who gave this a name. We call it a restorative curse. If we see a little space in our mind, the first thing we want to do is block it and close it with ceramic or close it with plastic or something. But if we do that, we're not letting those tissues creep into these spaces.

You don't want to take on that challenge. You don't want to take on that risk of those tissues not moving into these spaces in your final restoration. You want to take them into the provisional restoration, let them creep, let them move into these spaces. If they don't after some long period of time, then you know that they're probably going to stay there, and then you can move to your final.

The other thing is when I'm restoring the aesthetic sector, I need to give information to my lab technician. If I establish my parameters adequately, if I give this beautiful soft tissue outline, but also manage the subgingival spaces with a biologically thought-of process, then I can extrapolate this information to the ceramist to turn this into a titanium or zirconia abutment and a ceramic crown.

For me, this is just a personal opinion. I don't want to give all the responsibility to my ceramist to design what's under the gums, under that free gingival margin.

The number one task of the ceramist is to make that crown look beautiful. That's why I believe that we should not take credit for the white because we don't do the white. I, as a dentist, as a restorative dentist, should take credit for the transition between the pink and the white and the stability of that tissue and how we design the emergence profile.

But if I don't provisionalize my cases, then my laboratory is going to have to do this, and they're going to have to do it somewhat in an arbitrary mode because they don't have the patient in front of them. They just have either a stone model with a platform of an analog or an STL file that has a digital platform of the implant that comes from the scan made with a scan body.

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