Single Implant Supported Crowns in the Aesthetic Zone. Patient Evaluation of Aesthetic ...

185 Pages·2011·15.18 MB·English

by  Dr. Joseph Fava

Single Implant Supported Crowns in the Aest hetic
Zone. Patient Evaluation of Aesthetic Appearance
Compared to Laypersons and Dentists.

by
Joseph Anthony Bernard Fava

A thesis submitted in conformity with the requirements
for the degree of Masters of Science
Graduate Prosthodontics
Faculty of Dentistry
University of Toronto

© Copyright by Joseph Fava 2011
Single Implant Supported Crowns in the Aest hetic
Zone. Patient Evaluation of Aesthetic Appearance
Compared to Laypersons and Dentists.
Joseph Fava
Masters of Science
Graduate Prosthodontics
University of Toronto
2011

Abstract
OBJECTIVE: To appraise the patients’ aesthetic awareness following an implant
restoration in the anterior maxilla as compared to dentists and laypeople. MATERIALS
AND METHODS: Patients (n=139) restored with an implant-retained crown in the anterior
maxilla were invited to rate their satisfaction. Projected magnified images of the crowns
were appraised by dentists (n=8) and laypeople (n=6) in room settings. The laypeople
judged also printed 10x15cm photographs. Differences in the levels of satisfaction between
the actual patient, dentists, and laypeople were compared. PES/WES and Jemt papilla
scores were also assigned. RESULTS: Laypeople were less critical than the dentists when
judging from printed photographs and vice versa when same images were magnified and
projected onto screen. CONCLUSION: Patient satisfaction and awareness of aesthetic
appearance following an implant treatment in the aesthetic zone appears to differ from
dentists’ and laypeople’s observations. Laypeople’s evaluation is influenced by the
method used for appraising the aesthetic outcomes.
ii
Acknowledgments

I would like to start by thanking my family; to my wife Laura, and my daughters
Sophia and Elise your love, understanding and unwavering support have made this
journey possible. To my mom and dad, thank you for teaching me that with hard work
and perseverance, anything is possible. To my siblings; Nick, Vince and Maria, thank
you for your help and support during this very busy time in my life.
I would like to thank my committee members Dr. Laura Tam, and Dr. Jim Lai for
their time, effort and guidance. I would especially like to thank Dr. Asbjorn Jokstad for
his support, guidance, and leadership. Without your efforts this project would not have
been possible.
I would like to thank my fellow residents in the program for their friendship, and
support. I would in particular like to thank Dr. Mark Lin, and Dr. Mohammed Zahran for
the help and wisdom they provided. It is greatly appreciated and will not be forgotten.
I would also like to thank the Department of Prosthodontics and IPU clinical and
administrative staff for all your help, and for making the program enjoyable.
I would also like to thank our clinical instructors for all of the wisdom, and clinical
judgment they imparted.
Finally, I would like to thank God for giving me the courage, strength, and
determination to follow my dreams.
It is often said that time fly’s when you are having fun. It seems 3 years have
gone in the blink of an eye.

iii
Table of Contents

Abstract.……………………………………………………………………………………………. ii.
Acknowledgements………………………………………………………………………………... iii.
List of Tables……………………………………………………………………………………….. v.
List of Figures………………………………………………………………………………………. vi.
List of Appendices………………………………………………………………………………….. viii.
Introduction…………………………………………………………………………………………, 1.
Hypothesis………………………………………………………………………………………….. 7.
Material and Methods………………………………………………………………………………. 8.
Participants and Recruitment……………………………………………………………………. 8.
Data Collection………………………………………………………………………………….. 9.
Statistical Analysis………………………………………………………………………………. 13.
Results………………………………………………………………………………………………. 14
Discussion……………………………………………………………………………………………2 4
Conclusions…………………………………………………………………………………………. 32
References…………………………………………………………………………………………… 3 3
iv
List of Tables
Table 1. Studies reporting on single implants in the aesthetic zone that do not discuss
Aesthetics and/or Patient Satisfaction……………………………………………… 2
Table 2. Studies reporting on single implants in the aesthetic zone that discuss Aesthetics
and/or Patient Satisfaction…………………………………………………………. 3
Table 3. Patient Questionnaire…………………………………………………………..…… 9
Table 4. Patient overall satisfaction versus the scores of the dentists and laypersons……….. 18

v
List of Figures
Figure 1. www.dentalpbrn.ca web shot (accessed Feb 2010)…………………………………………1 0
Figure 2. Layout of images viewed by dentists and laypersons (both projected on a screen and
printed on photo paper)…………………………………………………………………….. 11
Figure 3. Jemt Score Classification………………………………………………………….……… 12
Figure 4. PES/WES Criteria………………………………………………………………………..…1 3
Figure 5. Age groups of participants ……………………….…………………………….………….1. 4
Figure 6. Year of single tooth implant restoration ………………………………….…….............….1 5
Figure 7. Distribution of single tooth implant crown locations...………………………………….…1 5
Figure 8. Overall esthetic appearance according to patient (n=139)…………………………...…….1. 6
Figure 9. Level of Patient Satisfaction dichotomized for gender……………………………..….…..1 6
Figure 10. Levels of Patient Satisfaction categorized based on age groups………….…………..……1 7
Figure 11. Patient overall satisfaction compared to non-dentist average overall satisfaction when
viewing images on screen (left), or when viewing printed images (centre) and to dentist
average overall satisfaction (right)………………………………………………………..
18
Figure 12. Overall Aesthetic Appearance score. Sorted first by patients' satisfaction (blue horizontal
line), next by the dentists best to worse (red). The green lines indicates the lay-persons
average score on photographic paper……………………………………………………..
19
Figure 13. Extreme examples of what patients judged as an excellent (left) and fair (right) overall
result……………………………………………………………………………………… 19
Figure 14. Scatterplots of the aesthetic satisfaction scores by the dentists and laypersons………….. 20
Figure 15. Wilcoxon signed ranks tests for the scatterplots…………………………………………. 20
vi
Figure 16. Distribution of observed Jemt Papillary Index (left: mesial, right: distal side)…….....……2 1
Figure 17. Patient Satisfaction vs. Jemt Papilla scores…………………………………………………2 1
Figure 18. Jemt index scores vs PES scores (mesial and distal papilla)………………………………. 22
Figure 19. Scatterplots of the aesthetic satisfaction scores by the patient vs. the PES/WES scores….. 22
Figure 20. PES-WES scores versus non-dentist average overall satisfaction when viewing images on
screen (left), or when viewing printed images (centre) and dentist average overall
satisfaction (right)………………………………………………………………………….. 23

vii
List of Appendices

Appendix I Photographs, Questionnaire and PES/WES data…………………………...…… 39

viii
Introduction

Replacing a missing tooth in the anterior maxilla with a single dental
implant was introduced in the early nineties (Jemt 1991). It has since become a
mainstream treatment modality that has enjoyed a documented high level of
osseointegration as well as long-term functional success (Naert et al. 2002).
Unlike in the past however, when meeting functional demands were sufficient, it is
assumed that patients today have greater expectations of the implant
reconstruction. It may no longer be enough to simply restore the edentulous
space with a functioning tooth. It has been suggested that patients today
measure their final restoration using the contralateral natural tooth as the gold
standard (Chang et al. 1999b). In order to satisfy a patient’s perceived
expectations, the clinician should strive to achieve an “ideal” aesthetic result by
focusing on the subtle interplay between the implant and adjacent tooth position
in the buccal-lingual, mesial-distal and apical-coronal dimension. The gingival
parameters, such as soft tissue drape and ideal papillae form, should also be
considered in order to enhance dental implant aesthetics. Much has been written
on this topic, and the theoretical parameters for aesthetic success have been
elucidated (Kois 2001; Meijndert et al. 2007; Teughels et al. 2009). As a
consequence, patients and clinicians alike have become much more aesthetically
conscious.
This shift in aesthetic consciousness is reflected in the tools and indices
used today to determine implant success. The traditional criterion for success
(Albrektsson et al. 1986), while still commonly used, falls short in aesthetically
sensitive cases. As such, Smith and Zarb 1989 included in their criteria the
necessity for an aesthetic appearance that both the patient and clinician finds
acceptable in order to have a successful result. Many indexes have since been
created to help quantify an aesthetic result. (Furhauser et al. 2005, Meijer et al.
2005, Gehrke et al. 2008) For example, the PES/WES, which has been proposed
1
by Belser and coworkers (2009) is gaining in popularity in research publications.
Although much emphasis is placed on achieving aesthetic restorations, an
area that requires further investigation is the relationship between the appearance
of the restored tooth and patient satisfaction. Moreover, how does the dental
profession’s aesthetic expectation of single tooth implant supported restoration
compare to that of the patient’s? Does the dental profession have lower standards
with respect to aesthetic outcome compared to that of patients and laypeople, or
is the profession more critical?
Studies reporting on single tooth implant-supported restorations in the
anterior maxilla are included in Tables 1 and 2. The tables highlight that while
many papers have been written on the topic, relatively few include aesthetic or
patient satisfaction parameters in their outcome measures.

Table 1. Studies reporting on single implants in the aesthetic zone that do not discuss Aesthetics
and/or Patient Satisfaction
Patient
Aesthetics
YR Study Objective as stated satisfaction
(range)
(range)
Palmer et To evaluate the Astratech implant clinically and
1997 NR NR
al. radiographically after 2 years in function
to evaluate the clinical survival rate after rapid
Cooper et loading of unsplinted endosseous root-form
2001 NR NR
al. implants replacing the loss of 1 or 2 teeth in the
anterior maxilla.
To design a technique to monitor changes of
alveolar crest contour in follow- up situations and
Jemt &
2003 to use this technique to measure volume changes NR NR
Lekholm
of the alveolar crest at single-implant restorations
during a 2-year follow-up period.
Verify that the clinical outcome of immediately
Lorenzoni loaded unsplinted FRIALIT-2 Synchro stepped
2003 NR NR
et al. screw implants in the maxillary incisal region is a
predictable treatment approach
To measure changes in buccal tissue volume after
Henriksson
2004 placing restorations with single-implant crowns NR NR
& Jemt
using two different abutment systems and to
2