Anterior Implants Aren't Always the Gold Standard with Dr. Ashley Hoaders

Episode Overview In part two of this two-part series on Dental Digest, host Dr. Melissa Seibert and dual-boarded periodontist/prosthodontist Dr. Ashley Hoders challenge the conventional assumption that implants are always the gold standard in the anterior aesthetic zone . They explore why maxillary laterals and mandibular incisors are biologically hazardous sites for implants, how to choose mechanical over biologic failure, and how root submergence preserves vital bundle bone and papilla architecture .

Guest Information

• Guest: Dr. Ashley Hoders, DDS, MS

• Credentials & Affiliations: Dual board-certified diplomate and fellow of the American Board of Periodontology and the American Board of Prosthodontics; MS from the University of Texas Health Science Center at San Antonio . Clinical researcher with the McGuire Institute, co-creator of Spear Hygiene, visiting faculty at the University of Washington Graduate Periodontics Department, and active member of the American Academy of Restorative Dentistry .

Key Clinical Takeaways

1. The Fallacy of the Anterior Implant "Gold Standard"

• Maxillary lateral incisors and mandibular incisors represent non-strategic implant locations due to narrow space, thin facial bone, and continuous lifetime craniofacial changes .

• Natural adjacent teeth and jaws continue to move, erupt, and remodel across a patient's lifespan, whereas ankylosed/osseointegrated implants remain static, causing mismatched incisal edges and uneven gingival zeniths over time .

2. Mechanical Complications vs. Biologic Disasters

• Conservative cantilevered or single-retainer resin-bonded bridges achieve a $\approx 98\%$ success rate over 10+ years in properly managed occlusal schemes .

• Fixed tooth-supported alternatives fail through mechanical inconvenience (e.g., wing debonding or connector fracture), which is easily repaired .

• Implants carry biologic risk: at least 50% of implants exhibit inflammation or peri-implant disease, introducing chronic inflammatory challenges into an avascular environment where treatment is unpredictable .

3. Two-Layer Diagnostic & Treatment Planning

• Dual perio-prosthodontic diagnostics require planning not just for the immediate edentulous site, but predicting what happens when adjacent teeth compromise (e.g., adjacent traumatized central incisors) .

• 3D planning dictates restorative pathways before surgery, verifying whether crestal morphology necessitates cement-retained versus screw-retained solutions .

• Placing an anterior implant too shallow or too facial is the ultimate "kiss of death" for long-term peri-implant tissue stability .

4. Biologic Tension and Muscular Equilibrium

• Bone stability relies on eliminating tension from the surrounding musculature (lips, cheeks, and tongue) and establishing a robust collar of keratinized mucosa .

• Genetic cell turnover rates and masticatory function continuously challenge crestal bone margins .

5. Root Submergence & Partial Extraction Therapy

• Anterior facial bone is frequently $ thick; removing the tooth and its periodontal ligament (PDL) causes rapid resorption of the bundle bone, resulting in horizontal and vertical ridge collapse .

• Root submergence retains the submerged root structure inside the alveolus, tricking the body into maintaining the PDL, preserving bundle bone volume, and sustaining interproximal papilla height for adjacent restorations .

• "Pro-tooth" dentistry prioritizes buying time with natural root structures (via posts, ferrule optimization, or partial extraction therapies) over premature implant placement .

Notable Mentions & Literature

• Bill Robbins, DDS: Commentary in the International Journal of Periodontics & Restorative Dentistry (IJPRD) on avoiding lateral incisor implants; single-retainer RBFDP designs utilizing the mesial of the canine .

• Matthias Kern, Dr. med. dent.: Long-term evidence supporting single-wing cantilever resin-bonded bridges (using the distal of the central incisor) .

• Frank Spear, DDS, MSD: Clinical philosophy on valuing natural tooth retention: "I'm not anti-implant, I'm pro-tooth."

• Mike Gunson, DDS, MD: Research surrounding facial aging, craniofacial growth, and implant positioning discrepancies .