Implant Aesthetics Unpacked: Biologic Design & Power of Provisionalization with Dr. Jonathan Esquivel

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In this episode of Dental Digest, Dr. Melissa Seibert sits down with prosthodontist and educator Dr. Jonathan Esquivel for part one of an enlightening two-part series that explores the biologic and aesthetic complexities of implant restoration. Known for his meticulous approach and his evidence-based framework of space, volume, and time, Dr. Esquivel brings clarity to one of dentistry's most challenging frontiers: the anterior aesthetic zone.

They begin by examining why restoring a single anterior implant is often considered the ultimate test of restorative mastery. Dr. Esquivel explains that implants behave fundamentally differently from natural roots—they lack the periodontal ligament and its vascular support—making soft tissue far less forgiving. Even slight changes in tissue contour or bone volume can compromise long-term success. He introduces his four cornerstones for implant predictability: luck (biologic variability), three-dimensional positioning, emergence-profile design, and patient maintenance, emphasizing that precision and patient education are inseparable.

The conversation then turns to three-dimensional implant positioning and the role of reverse-engineered planning. Dr. Esquivel insists that every implant must begin with the end in mind—by first visualizing where the tooth should be. He details how ideal placement, roughly 4 mm apical to the planned incisal edge and aligned toward the cingulum, forms the foundation for natural emergence and long-term stability. But true success, he notes, depends equally on interdisciplinary collaboration—sometimes requiring orthodontic repositioning or periodontal modification before an implant is ever placed.

Dr. Esquivel and Dr. Seibert next tackle the aesthetic challenge of adjacent implants and the pursuit of symmetry. Perfect papillae between centrals are notoriously difficult to maintain, and Dr. Esquivel discusses techniques—from soft-tissue grafting to orthodontic extrusion—to preserve harmony between the pink and the white. He stresses that treatment planning is as much about patient selection and expectation management as it is about surgical technique: "The hardest part isn't the implant—it's finding a patient willing to go through the process."

The discussion deepens into the critical role of soft tissue in achieving lasting aesthetics. Dr. Esquivel explains his distinction between margin-preservation therapies (maintaining existing tissue contours) and margin-re-establishment therapies (rebuilding lost dimensions). He makes a compelling case that most anterior implants benefit from connective-tissue grafting, since thicker tissue phenotypes promote margin stability, mask restorative materials, and protect against recession.

From there, the episode explores ridge dimensional changes after extraction—why bone and soft-tissue collapse are inevitable without intervention, and how provisional restorations can slow this process. Dr. Esquivel cautions against relying on removable flippers, which may accelerate resorption, and instead advocates for properly designed Essix retainers or fixed provisionals that maintain space without transmitting occlusal pressure. His guiding principle: space, volume, and time—allowing tissue to heal in an environment that supports both biological inte