Implant therapy is currently a better alternative in replacing a loss tooth as compare to a bridge due to better force distribution, bone preservation/avoid bone atrophy in the pontic area, and ease of oral hygiene (flossing) to ensure healthy periodontal support.  Implant therapy usually involved two stages, i.e., implant placement, and implant restoration.  In order to fabricate a natural, life like, esthetic implant restoration that lasts a life time, the following considerations must be made toward the implant placement phase: the size and length of the implant,  the location of the implant, the implant system, the placement technique, and finally the need of using soft tissue and/or bone graft must be determined.  Size wise, the implant diameter should mimic that of the lost tooth.  Since the largest size  implant diameter available is only 5.5-6.0 mm, the largest possible implant  diameter should be used.  The large size, combined with the length of at least 11mm, should provide enough surface area for osseointegration (bone binding into the implant) that would ensure the implant function for a life time.  The implant should be placed at correct position to allow for optimal interarch relationship (the relationship of upper to lower arch).  The implant system should allow for a  versatile or diversified restorative option, with esthetic zirconia abutment available for maximal esthetic color result.  The use of soft tissue graft (connective tissue graft with/without the aid of platelet rich plasma (PRP)therapy and/or bone graft (with or without PRP) should be determined before the start of the procedure.  The placement technique involved should be chosen in order to preserve as much bone as possible, and thus bone expansion technique should be considered at all time.  The implant will remained in place after placement for at least six months prior to begin restorative stage.  Many researches and efforts have tried to legitimate the early and/or immediate loading (restoring) an implant, however, it has been established that the longevity of the delay loading  (six months) always is more predictable than the early and/or immediate loading.  In the delay loading,  the implant can be torque with a shear force up to 32Ncm to ensure osseointegration, whereas in the immediate and/or early loading, NO torquing is done on these implants.  In the delay loading,  the implant restoration always will have a true contact with its opposing tooth, whereas in early and/or immediate loading, contacts are avoid or eliminated if possible.  Esthetically,  it is more predictable to achieve esthetics in the delay loading because the soft tissue crest is already then established and the tissue is healed fully around the implant.  Early and/or immediate loading is offered to patient for the sole purpose of increasing acceptance and early payment collection.  In my opinion,  early and/or immediate loading should be avoid when considered implant therapy.  Finally, in the restoration phase, an all porcelain implant crown should be placed over an all porcelain abutment (yttria zirconia abutment) to achieve the beautiful, translucent, life like restoration.  The following ten cases studies of real life patient will explain these concepts in more details.

Case 1:  Patient presents with a bridge which involved six units  from upper right to upper left canine in order to replace a missing upper left lateral incisor.  After one year, the localized gingival irritation of the bridge (compromising oral hygiene effort) leads to bleeding gums, halitosis (bad breath), gingival recession and infllammation, with the gingiva exhibits hypoxic reaction with the color turns bluish around the restorative margins.  Dr. Bui proceeds to replace the bridge with all single crowns restoration to allow for better oral hygiene effort in term of flossing.  Moreover, the all porcelain restorations allow for better translucency, more natural and life like color, and elimination of the hypoxic reaction of the gingiva due to the presence of the chromium nickel alloy in the porcelain fused to metal restoration.  An Astra 4.0mm diameter implant is placed in the area of upper left lateral incisor using bone expansion technique.  Bone graft is placed, followed by placement of biomend XP membrane to prevent epithelial migration into the graft.  After six months, the implant is uncovered, torque with a force of 32Ncm to ensure osseointegration occured, and restored using an yttria zirconia abutment and an all porcelain restoration design and fabricated by Dr. Bui.  The implant is restored with correct occlusal relationship and optimal force distribution in the upper and lower arch.  Needless to say, we guarantee the function of this implant for lifetime.

Case 2:  The patient presents with the missing of lower right first molar.  Patient had her tooth extracted when she were very young.  Moderate ridge atrophy noted buccolingually, thus a graft should be anticipated.  An implant therapy is suggested.  A 5.5 mm Noble Biocare implant is placed, with Biogran bone graft is simultaneously placed, and covered by Biomend XP membrane.  Implant remains submerged for six months, then was uncovered and restored with yttria zirconia abutment and the all porcelain crown.  Again, excellent esthetic and function is achieved in this case.

Case 3:  A young, 13 years old girl presents with a missing central incisor, with bite collapse as the adjacent teeth migrates into the area.  Dr. Bui first proceeds with Orthodontic therapy to prepare for the implant site and correct her occlusion, then followed with implant placement in the central incisor using platelet rich plasma since the parents wants the best esthetic result.  Photographs shows excellent healing even at one day post surgery due to the use of platelet rich plasma in the surgical stage.  Six months later, the implant is restore with Yttria zirconia abutment and an all porcelain crown.

Case 4:  Patient is a forty five year old man with missing central incisor and has been wearing his flipper (removable partial) for the last twenty one years.  Clinical examination shows poor occlusal interarch relationship, with impacted upper left premolar.  Dr. Bui proceeds to correct his bite with Orthodontic therapy, then followed with implant therapy to replace missing tooth. The impacted premolar was uncovered and bring into occlusion with braces.  Patient is very happy with the result.

Case 5:  Patient is a sixty seven years old lady presents with fracture upper right central incisor.  Dr. Bui proceed to remove the tooth, wait for 3 weeks prior to place a 5.0 diameter Astra implant into the area.  Six months later, her implant is uncovered, torque, and restore with Yttria Zirconia abutment and an all porcelain restoration.

Case 6:  Patient is a female dentist missing her lower right second premolar.  Upon examination, Dr. Bui decided to place a 4.5 mm diameter implant, grafting Biogran and covering with Biomend XP membrane in the area, and the implant remained submerge for six months.  An all porcelain restoration is then placed over the Yttria Zirconia abutment to achieve a natural, life like, esthetic result.

Case 7:  Patient is a twenty five years old lady who loss her posterior support and due to her bite collapse, she demonstrated an excessive overjet.  As the result, she is an open mouth breather since she has to strain to close her lips during relaxation.  Dr. Bui proceeds to treat her orthodontically using implant as anchorage.  Four implants were placed posteriorly and provided anchorage to pull the maxillary anterior teeth lingually to treat her overjet problems.  Final results shows much better lip closure during relaxation and her open mouth breathing problem is eliminated.  Patient can now function with her implants for life time.

Case 8: Patient is a 72 years old man from Kentucky who is missing lower left molars and premolars.  Minor tooth movement to reclaim the space for the implant, and implant placement to replace the missing teeth.  Patient is very happy with the result, knowing these implants will last a life time.

Case 9:  Patient presents to our clinic missing his upper left and lower right canine.  The adjacent teeth migrates into the implant area, thus orthodontic therapy is needed to reclaim the space.  Implants are then placed and remained submerge for six months.  Finally, the implants are restored.

Case 10:  Patient is a pharmacy student who presents to our clinic with upper right canine missing and teeth migration resulting in poor occlusal interarch relationship.  Again, Dr. Bui corrected her occlusion orthodontically and replaced her missing canine with a 5.5mm diameter implant.  The implant is submerged for six months, and is restored with an all porcelain restoration.

 The success of the implant therapy is very predictable if the clinician planned out every phase of the implant therapy, i.e. the diagnostic phase, the surgical phase, and the restorative phase.  The beautiful result reflects the sum of all the small parts, i.e., the correct diagnostic, the excellent execution of the surgical phases concerning the size, location, technique, and the use of grafts, and finally the esthetic restoration with correct occlusion.  If all these factors are considered, the implant esthetic and function could easily be guaranteed for a life time of an individual.