I was again fortunate to be able to attend a wonderful continuing education lecture recently. The presenter was Dr. Maurice Salama a periodontist and implantologist from Atlanta Georgia. He  along with Drs. Henry Salama, David Garber and Ronald Goldstein are Team Atlanta, a world famous group that both teaches and practices cutting edge dentistry. The lecture centered primarily on  dental implant related issues. It was Dr. Salama who said our definition of failure has evolved from clinical failure to esthetic failure. This is especially true in what we term the esthetic zone which means anywhere in the mouth that can be seen by the patient or the casual observer when the patient speaks, laughs eats or otherwise funcions in the presence of others. It really goes beyond that though. As those of us in practice know, our patients cosmetic expectations have evolved with our ability to perform these wonderful tooth saving and replacement services. If we replace or restore a tooth in the front of the mouth and where it emerges from the gums is covered by the lip, most people will pull up the lip with their finger to see what it looks like. They want it to look natural even if no one else can ever see it.  Dr. Goldstein, the first  to use the term cosmetic dentistry in his seminal textbook on the subject in the early seventies, was ridiculed by his peers for insinuating that our healing profession had anything to do with esthetics. As it turns out he was prophetic. Now everytrhing we do in restorative dentistry has a cosmetic component to it and the public has come to expect it. Much has evolved over thr past three decades regarding implant therapy. The design of both the shape and the surface covering of the implants we use has changed greatly. The time it takes for implants to integrate, that is to take hold in the bone, has been reduced tremendously in many cases. Our ability to place implants in sites previously thought to be unacceptable has improved because of greatly advanced techniques and materials. Our analytical approach to implant placement and success has changed resulting in better soft tissue (gums) management and predictability. And because of the extremely high cosmetic expectations we and our patients place upon us, sometimes we will recommend a bridge rather than implants because we know we can better satisfy our patients cosmetic demands. This idea represents a full circle change in the way we have thought about tooth replacement. For a number of years we recommended an implant for a missing tooth in most instances because of the better long term prdictability  among other reasons, of implants versus a bridge.  But now because of the tremendously high cosmetic expectations, if a potential implant site is compromised a bridge might be a better option for some patients. There are many factors we must consider when we make recommendations to our patients. Their needs, their expectations, the amount of treatment, the cost, the ability of the doctors involved and the willingness and ability of the patient to properly maintain their proposed restorations are all considerations. Our clinical ability as well as our  expectations have evolved very much over the years and will continue to do so over time. This is one of the many reasons dentistry is so challenging and stimulating. What a great profession!