American Dental Implant Association
The Miami Implant Update
Dr. James McAnally – April 25, 2009
Strategies for Boosting Implant Case Acceptance
· In Times Like These… How do we succeed
· We are in the business of Marketing and Sales
· What do we do at meetings?
o Learn Techniques
o Dr. Atcha uses McNally
· Business
o Non-dental sales course last 2 years?
§ Yep
o Dental Sales Book
§ Yep
o Non-dental sales book
§ Yep
· 80% of success is just showing up – Woody Allen
· 2003 – Aron Ralston
o More focus, more purpose AFTER getting stuck under a boulder and knowing off his hand
o Today 80% is thinking, 20% is Practical
§ Global changes at work – recession is going on… economics
§ Why get better at sales (Case acceptance)
§ Common worldwide dentist sales frustrations
§ Capabilities vs Opportunities
· Economics and History 801
o The World is Flat
§ While we were fighting terrorism for 10 years, the world kept moving
o Slumdog
§ Many people motivated to work harder
· Creative Destruction
o Look at Kmart, Sears
o Kodak, Plaroid
o Seattle Times, San Fran Chronicle
o ALL GONE
· Law of Accelerating Return
o Progress is EXPONENTIAL, not LINEAR
o Technology is 10 times as fast
o EVERYONE is going to be around a LOT longer
§ 1900: 48 yrs avg life expectancy, now 78
· Get a FLIP
o Testimonials
· What about dentistry?
o It’s only going to get more complex
o Teeth will be needed/wanted longer
o Cost will always go up
o BUT… Patients will want even more SIMPLICITY
· Overview
o Selling (better case acceptance) as a dentist requires
§ Modifying you/your team’s actions
§ Acknowledging that persuasion is a science
§ Altering dr, staff, and pt mindset
· Why get better at selling cases?
o Greed… do more tx
· Why get better at case acceptance for elective tx?
o The dental economy is changing RADICALLY
· New rules emerging in the business of dentistry
o Big chunk of bread and butter middle class is leaving (because of flattening of the globe)
o More tx’s fall outside of insurance
o Dental insurance will become even more obsolete
o Global trends are unchangeable
· It’s the BEST golden age EVER in dentistry
o Newer, better, faster, more esthetic, more predictable
o Training has never been easier or faster
o Equipment, Training
o Rebuild a smile for anyone: it’s life changing
· Reasons to get better
o The economis
o The new dental economy
o The golden age
§ MOST dentistry is ELECTIVE
· Dirty dozen of Universal Case Acceptance Frustrations
o Not knowing what to present with cases
o Pts not owning their problems
o Not having financial ability
o Presenting to pts who aren’t ready for tx
o Difficulty getting large case acceptance
· Sales pyramid
o Close sales (Top)
o Make “NOISE” in the market
o Practice management systems
o Clinical education and technical competence (Bottom)
· Underlying factors
o Capabilities vs Opportunities
§ We have 2 sets
· Clinical Capabilities
o Dental School
o CE
o Residencies
· Non-clinical Capabilities
o Practice Marketing systems
o Case acceptance systems
§ Opportunities
· Patchwork versus Full Mouth
o Capabilities
§ Take a course
§ Easy to get there
o Opportunities don’t get bigger by increasing the capabilities
o To increase our opportunities
§ He have to improve our setup
· How do we get setups?
· 7 common fallacies in thinking that further hinder case acceptance
o #1: Misunderstanding Credentials
§ If I get more letters after my name… I’ll get more credentials
§ Must use, describe the credentials in ways that actually MEAN something to pts
o #2: I need more CE
§ Most dentists need to READ more books
o #3: Believing technology sells
§ They don’t buy the technology, they buy the solutions
o #4: Bigger menu’s are the answer
§ Lava, Procera… Pts don’t care
§ Dental menu’s are TOO complex
· Maximize benefits, minimize losers by KEEPING IT SIMPLE
o #5: Believing Patients are Logical
§ Not really, unless they are engineers or teachers
§ Behavior is the same for most
o #6: Being good at sales means high pressure
§ It doesn’t work for high-cost products
§ Sandler, Gitomer, Sandler, Ziglar
o #7: Not understanding the magic bullet
§ Competition is minimal… Must master the COMPLICATED
§ 20% MAX
· 8 Strategies for next week
o #1 Caveat: NO MAGIC BULLETS
§ Make your marketing messages
§ Match the problem you wish to treat
· Why does this boost results?
o Getting the right pt dramatically boosts case acceptance
o Pts seeking answers to their problem
§ Undertsand Branding
· Pts with problems wanting implants don’t care about you as the brand
§ Freat FREE examples of Medical Messgae Matching
· Cynergenics
o #2: Always remember, The Fear of Loss…
§ Proof:
· Recent financial panic
· Robert Cialdini
§ I (Heart) Dentures
· No one wats them…
· Easy image to sell
o #3: For BIG $$$ implant cases, separate the exam and case presentation visits
§ All in one
· Consult
· Disgnostics
· Fee presentation
§ Effective intervals between visits BOOSTS sales
o #4: Screening systems to find those more likely to say yes to tx
§ Low odds…
§ The “Funnel” principle of marketing
§ Qualifying: Only working with pts that are going to buy from you
§ Extra No’s
· Don’t need to talk all about opening vertical
· How much time Is wasted?
o #5: he larger the $$$ amount, the more professional we should look
§ Got to have PERFECT teeth
o #6: Dr. and staff communicate only in ways that reduce complexity
§ Must practice… forever
§ LOSE all dental Jargon
§ Even applies to marketing
§ Goal: Reduce complexity in the pt’s world
§ As case complexity goes up, tx discussion must be reduced
· 30min max
§ Patients want:
· Respect
· Simple explanantion
· 2-3 options
§ Must monitor yourself
o #7: Develop systems to prevent fee sticker shock
§ I didn’t know it would cost that much
§ Pts have no idea what the cost reference point is for dentistry
§ Use FEE FRAMIMG
· Tell them the range of what stuff costs
· My range is higher because I know how to sell
· Verbally… during diagnostics
· Preemptive… written materials as part of the financial “screening/qualifying”
· Also verbal range of $ during diagnostics
§ BIGGEST problem
· Present fess CORRECTLY
o 1 dr closes the case
o #8: Use appropriate case acceptance technology
§ “What if” imaging is CRITICAL
· http://www.smilevision.net/
o Reduces complexity
o 24” monitor for effect
o Image single teeth, quadrants, everything…
· Permanent solution
o Understand how you arrived at your frustrations
o Acknowledge fallacies in your thinking
o Change your thinking
o Study those who have already fixed their frustrations
o COPY THOSE WHO ARE SUCCESSFUL
o Systems are:
§ Step by step, tested and proven actions
§ 1 or 2 implants: Simple (Single engine plane)
§ More and more specialized (Jet)
o Define your expectations for case acceptance
§ Short term patches and long term systems
Saturday, April 25, 2009
Renzo Casellini, MDT – April 25, 2009
American Dental Implant Association
The Miami Implant Update
Renzo Casellini, MDT – April 25, 2009
A New Dimension of Esthetics
· CRAZY introductory video…. Neat!
· 22 yr old in a bar fight lost #8,9
o BAD result of tissue (fired and inflamed) and papillae are flattened
o Needed to use esthetic caps – creates the emergence profile
§ Cut off the chimney and have flipper stay off of the tissue
§ TEMPORIZATION IN anterior zone is VERY important
o Gingiva came back to health
· Teamwork = Success
o Surgeon, Dentist, CDT or MDT, hygienist
· Newest technique in Zirconium
o Full arch fixed: ZirkonZahn
o 1 piece Zirconium bridge
o Connect implant abutments with GC resin… not duralay
o Screw in, cotton plugs, Composite plugs made by lab which get bonded in with flowable
o New zirconium full mouth cases, carved like a key
· http://www.renzoswissquality.com/
· Immediate case
o Index teeth, Immediate ext, place implant, grind extracted tooth, place cover screw, reline extracted tooth with composite, use impressing abutment with composite to get gingival contour and emergence profile à send to lab for temp fabrication, bond ext tooth relieved on cervical by 1.5mm to the adjacent teeth so that there is no load on implant
· Multiple Single Implant Crowns
o Esthetic caps to be used to maintain papillae
o NEED diagnostic wax up
· Titanium CAD/CAM
o Great for Haider bars
· Teeth in an hour
o Reverse engineering
o Need anesthetic and exact depths of gingiva all around missing tooth sites
o Can make porcelain corwns… but don’t fit great
o Would rather recommend temps in a day
· Dentsply makes Esthetic Caps
The Miami Implant Update
Renzo Casellini, MDT – April 25, 2009
A New Dimension of Esthetics
· CRAZY introductory video…. Neat!
· 22 yr old in a bar fight lost #8,9
o BAD result of tissue (fired and inflamed) and papillae are flattened
o Needed to use esthetic caps – creates the emergence profile
§ Cut off the chimney and have flipper stay off of the tissue
§ TEMPORIZATION IN anterior zone is VERY important
o Gingiva came back to health
· Teamwork = Success
o Surgeon, Dentist, CDT or MDT, hygienist
· Newest technique in Zirconium
o Full arch fixed: ZirkonZahn
o 1 piece Zirconium bridge
o Connect implant abutments with GC resin… not duralay
o Screw in, cotton plugs, Composite plugs made by lab which get bonded in with flowable
o New zirconium full mouth cases, carved like a key
· http://www.renzoswissquality.com/
· Immediate case
o Index teeth, Immediate ext, place implant, grind extracted tooth, place cover screw, reline extracted tooth with composite, use impressing abutment with composite to get gingival contour and emergence profile à send to lab for temp fabrication, bond ext tooth relieved on cervical by 1.5mm to the adjacent teeth so that there is no load on implant
· Multiple Single Implant Crowns
o Esthetic caps to be used to maintain papillae
o NEED diagnostic wax up
· Titanium CAD/CAM
o Great for Haider bars
· Teeth in an hour
o Reverse engineering
o Need anesthetic and exact depths of gingiva all around missing tooth sites
o Can make porcelain corwns… but don’t fit great
o Would rather recommend temps in a day
· Dentsply makes Esthetic Caps
Bruce McKay – April 25, 2009
American Dental Implant Association
The Miami Implant Update
Bruce McKay – April 25, 2009
Smile Reminder
· Communicating information to patients
· E-mail and text messaging technologies
· Avoid using Mail to deliver
· Publish video testimonials from patients
· Cell phone:
o You can reach them at a critical time frame
o Helps with no shows
o Can fill a cancellation
· Birthday greetings
o Can make a big impact
The Miami Implant Update
Bruce McKay – April 25, 2009
Smile Reminder
· Communicating information to patients
· E-mail and text messaging technologies
· Avoid using Mail to deliver
· Publish video testimonials from patients
· Cell phone:
o You can reach them at a critical time frame
o Helps with no shows
o Can fill a cancellation
· Birthday greetings
o Can make a big impact
Friday, April 24, 2009
Dr. A. Burton Melton – April 24, 2009
American Dental Implant Association
The Miami Implant Update
A. Burton Melton – April 24, 2009
Prosthodontic and Surgical Considerations for the Edentuous Maxilla
· Talked about NeoOss system
· “If you don’t take a look at this system, you’re doing yourself an injustice”
· Begin with the end in mind
· GET DIAGNOSTIC CASTS
· Well made overextended impressions
· You want as much of the anatomic detail
10 Questions that demand answers
1. What are the pt’s wants, needs, expectations?
a. ASK!
2. What type of restoration fulfills these requirements?
a. Offer multiple options
b. Do nothing à High end dentistry
3. What are its support needs?
a. Supported by alveolar ridges & soft tissues
b. Bone?
4. How much interarch space is available?
5. What are the soft tissue needs?
a. Big issue in the aesthetic zone
6. What are the esthetic, phonetic, and functional requirements specific to the restoration?
7. What are the surgical solutions required for periodontal success?
8. How will the prosthesis be retained?
a. Screw retained? Cemented?
9. What is the cost to fabricate the restoration?
10. How much do I have to charge to be profitable?
· The problem with edentulism
· Loss of teeth, bone, vertical height, lip support
· Bone
· Must evaluate maxilla with ct scan
· Why am I lisping?
· You have encroached the lateral border of the tongue
· If we graft after ext, it’s a good day
· You can recreate self-cleansing
· Stage I: Minor ridge remodeling
· Can do anything you want
· Stage IV: Major ridge remodeling
· Limited choices
· The more divergent implants are, CONNECT them with a bar
· Lower jaw: At LEAST 3 implants to create a tripod
· 4 on the floor is better
· Upper jaw: 6 implants ideal, 8 at most
· If you are putting things together with duralay, index it with bite registration for 30 sec just so lab doesn’t need redo
· Cantilever section in a Haider should not exceed 1.5x the distance between the front 2 and back 2 implants
· Bredent C-Attachements allow you to connect F/ without compensating vertical attachments
The Miami Implant Update
A. Burton Melton – April 24, 2009
Prosthodontic and Surgical Considerations for the Edentuous Maxilla
· Talked about NeoOss system
· “If you don’t take a look at this system, you’re doing yourself an injustice”
· Begin with the end in mind
· GET DIAGNOSTIC CASTS
· Well made overextended impressions
· You want as much of the anatomic detail
10 Questions that demand answers
1. What are the pt’s wants, needs, expectations?
a. ASK!
2. What type of restoration fulfills these requirements?
a. Offer multiple options
b. Do nothing à High end dentistry
3. What are its support needs?
a. Supported by alveolar ridges & soft tissues
b. Bone?
4. How much interarch space is available?
5. What are the soft tissue needs?
a. Big issue in the aesthetic zone
6. What are the esthetic, phonetic, and functional requirements specific to the restoration?
7. What are the surgical solutions required for periodontal success?
8. How will the prosthesis be retained?
a. Screw retained? Cemented?
9. What is the cost to fabricate the restoration?
10. How much do I have to charge to be profitable?
· The problem with edentulism
· Loss of teeth, bone, vertical height, lip support
· Bone
· Must evaluate maxilla with ct scan
· Why am I lisping?
· You have encroached the lateral border of the tongue
· If we graft after ext, it’s a good day
· You can recreate self-cleansing
· Stage I: Minor ridge remodeling
· Can do anything you want
· Stage IV: Major ridge remodeling
· Limited choices
· The more divergent implants are, CONNECT them with a bar
· Lower jaw: At LEAST 3 implants to create a tripod
· 4 on the floor is better
· Upper jaw: 6 implants ideal, 8 at most
· If you are putting things together with duralay, index it with bite registration for 30 sec just so lab doesn’t need redo
· Cantilever section in a Haider should not exceed 1.5x the distance between the front 2 and back 2 implants
· Bredent C-Attachements allow you to connect F/ without compensating vertical attachments
Harold Meredith – April 24, 2009
American Dental Implant Association
The Miami Implant Update
Harold Meredith – April 24, 2009
Marketing and Patient Education and Building Your Practice
· Likes Hockey
· Asked everyone to take out their business cards
· Women make the buying decision
· Asked me to get up and show off my suit
· Complimented our office
· Target audience: Women
· We are visually stimulated
o “Put your hand on your chin”, but he put his on his cheek
· Who buys?
o Women buy
· Abercrombie & Fitch emit a nice smell from their store
· Our logo is our brand
· Why use an extracted tooth?
· Nothing in our office WELCOMES patients
· Why did he take that from me?
o Because I handed it to him
o “I just wanted to give this to you to have you give it to your friends and family”
· For a referral, send out a gift card for Starbucks or Outback
· “Do you know we are offering implant therapy?”
· Implement a proper referral program
· Get involved with:
o Gymnasiums
o Tanning salons
o Nail salons
o Spas
· Every years, an outdoor event
o Rock climbing
o Corousel
· TOO MUCH TALKING
o Let the patient talk
o 4 minutes of crap
o No system
· What is the number of ACTIVE patients?
· What is the value of a patient?
· Where did you hear about us?
· Business Hours
o Lunchtime: GET the phone
o Have to answer the phone
· Coaching Excellence
o Roxanne Moulden
o Roxannem@cogeco.ca
o 905-746-8326
· Experience
o Have an internet café in the welcome area
o Hot towels
§ 866-938-8693
§ http://www.whitetowelservices.com/
o Neck pillows
o Massage chairs
o Flowers
o READ “Raving Fans”
o Ceramic bowl of ice cream
· Sign outside
· Dr. Matkovich
o Check out his website
o http://www.drmatkovich.com/
· McDonalds started asking “Would you like Fries with that?”
o Increased by 23%
· Smiles for Life
o Let pts know
· Websites
o Get video on there
o Understand keywords
o Link to dental associations
o Get multiple domain names
o Change the site regularly
The Miami Implant Update
Harold Meredith – April 24, 2009
Marketing and Patient Education and Building Your Practice
· Likes Hockey
· Asked everyone to take out their business cards
· Women make the buying decision
· Asked me to get up and show off my suit
· Complimented our office
· Target audience: Women
· We are visually stimulated
o “Put your hand on your chin”, but he put his on his cheek
· Who buys?
o Women buy
· Abercrombie & Fitch emit a nice smell from their store
· Our logo is our brand
· Why use an extracted tooth?
· Nothing in our office WELCOMES patients
· Why did he take that from me?
o Because I handed it to him
o “I just wanted to give this to you to have you give it to your friends and family”
· For a referral, send out a gift card for Starbucks or Outback
· “Do you know we are offering implant therapy?”
· Implement a proper referral program
· Get involved with:
o Gymnasiums
o Tanning salons
o Nail salons
o Spas
· Every years, an outdoor event
o Rock climbing
o Corousel
· TOO MUCH TALKING
o Let the patient talk
o 4 minutes of crap
o No system
· What is the number of ACTIVE patients?
· What is the value of a patient?
· Where did you hear about us?
· Business Hours
o Lunchtime: GET the phone
o Have to answer the phone
· Coaching Excellence
o Roxanne Moulden
o Roxannem@cogeco.ca
o 905-746-8326
· Experience
o Have an internet café in the welcome area
o Hot towels
§ 866-938-8693
§ http://www.whitetowelservices.com/
o Neck pillows
o Massage chairs
o Flowers
o READ “Raving Fans”
o Ceramic bowl of ice cream
· Sign outside
· Dr. Matkovich
o Check out his website
o http://www.drmatkovich.com/
· McDonalds started asking “Would you like Fries with that?”
o Increased by 23%
· Smiles for Life
o Let pts know
· Websites
o Get video on there
o Understand keywords
o Link to dental associations
o Get multiple domain names
o Change the site regularly
Dr. Zhimon Jacobson – April 24, 2009
American Dental Implant Association
The Miami Implant Update
Dr. Zhimon Jacobson – April 24, 2009
Current Concepts in Implant Prosthodontics
· Zirconia abutments for maxillary anteriors
· If you don’t have much room, 1.5mm porcelain will get you complete blockage of metal of abutment
· Can intrude teeth with mini-screws and wires to create space for lower bicuspids
· Can do a hybrid when resecting mandible
· Implantology is integral to dentistry
· Should be a specialty
The Miami Implant Update
Dr. Zhimon Jacobson – April 24, 2009
Current Concepts in Implant Prosthodontics
· Zirconia abutments for maxillary anteriors
· If you don’t have much room, 1.5mm porcelain will get you complete blockage of metal of abutment
· Can intrude teeth with mini-screws and wires to create space for lower bicuspids
· Can do a hybrid when resecting mandible
· Implantology is integral to dentistry
· Should be a specialty
Dr. Arun Garg - April 24, 2009
American Dental Implant Association
The Miami Implant Update
Dr. Arun Garg – April 24, 2009
Maxillary Sinus Bone Grafting – An innovative, Predictable, and Efficient Method for Crestal Approach
· 3 Techniques
o Lateral Window (1-5mm Crestal Bone)
o Sinu-Drill (5-13mm Crestal Bone)
o Osteotomes (13mm + Crestal bone)
· Need a panorex at minimum
o What you SHOULD do is a CT Scan
· Don’t go higher than 15 above the crestal bone
o Otherwise you’ll go into the maxillary artery – LOTS of bleeding
· Bone maturation is 4-10 months
· Particulate graft material gets a LOT more vascularity than block grafting
· The only time you would ever consider a block is for structural stability
· Bone grafting NEEDS primary closure for it to heal, unlike extractions and unlike perio surgery
· Tears occur 10-50% of the time
o Use a membrane
· Sinu-Drill – SLS system by IIT (Sinu-Drill)
o Expensive, but less invasive
o Drill goes in without tearing membrane
· Osteotomes (13mm +)
o To get 1-3mm more bone
· Eventually bone replaces the graft: takes 4-12 months
· PRP alone is not enough to grow bone predictable… should use graft material as well
The Miami Implant Update
Dr. Arun Garg – April 24, 2009
Maxillary Sinus Bone Grafting – An innovative, Predictable, and Efficient Method for Crestal Approach
· 3 Techniques
o Lateral Window (1-5mm Crestal Bone)
o Sinu-Drill (5-13mm Crestal Bone)
o Osteotomes (13mm + Crestal bone)
· Need a panorex at minimum
o What you SHOULD do is a CT Scan
· Don’t go higher than 15 above the crestal bone
o Otherwise you’ll go into the maxillary artery – LOTS of bleeding
· Bone maturation is 4-10 months
· Particulate graft material gets a LOT more vascularity than block grafting
· The only time you would ever consider a block is for structural stability
· Bone grafting NEEDS primary closure for it to heal, unlike extractions and unlike perio surgery
· Tears occur 10-50% of the time
o Use a membrane
· Sinu-Drill – SLS system by IIT (Sinu-Drill)
o Expensive, but less invasive
o Drill goes in without tearing membrane
· Osteotomes (13mm +)
o To get 1-3mm more bone
· Eventually bone replaces the graft: takes 4-12 months
· PRP alone is not enough to grow bone predictable… should use graft material as well
Dr. Rolf Ewers - April 24, 2009
American Dental Implant Association
The Miami Implant Update
April 24, 2009
Dr. Rolf Ewers
Bone Forming Materials to Enhance Missing Bone
· Oral Surgeon from University of Vienna and has CMF Institute Vienna
· MAJOR facial surgeries
o 21 hour surgery example on lady from Romania
o Full facial reconstruction of gentleman where accessory nerve was preserved: skydive
· Bone replacement material (BRM) vs Bone forming Material (BFM)
· BFM vs. Foreign Body Material
o FBM – Bio-Oss never resorbs… even after 7, 14 yrs
o FBM – Interpore after 26 yrs… still there
· PAR
o Porosity
o Absorption
o Resorption
· Must be biocompatible
· Algisorb
o Very porous
o Histomorphology
§ Hydrolytic alteration of the scaffold
§ Creeping substitution by new bone
§ Even see nuclei in the tubules of Algisorb
o Copies nature
§ More elegant than cadaver
· Augmentation techniques
o Bone quality
§ Class I – Revascularized bone: Never resorbed, can maybe add in BMP
§ Class II – Distracted bone (vascularized)
§ Class III – Pedicled inlay bone (not vascularized)
§ Class IVa – Autogenous Onlay bone (not vascularized)
§ Class IVb – Augmented allograft (not vascularized)*
· *The one they are always trying to sell is 5th
o Never extracts tooth w/o filling the root
o Need to place a membrane to prevent mesenchymal cells from inving bon e graft
· What is best membrane?
o 1. Thin cortical bone,
o 2. Titanium membrane
o 3. E-PTFE membrane
o 4. Slowly resorbing membrane
· Algisorb – after 7 months, the histomorphology is 23% newly formed bone and 33% algisorb
· Algiorb with PRP – after 7 mo 31% newly formed bone and 21% residual algisorb
o The PRP is activating the osteoclasts
· Johansson et al 2001
o Algisorb has 14% replacement versus 30% with iliac crest
· Only a 4.4% failure with algisorb and maxillary sinus lifts
· The Bow Tie Book
o Oral and Implant Surgery Dunsche, Ewers, Filippi
o By Quintesscence
· Future
o Rehumanization of resorbable material
o Bioactivating of the bone forming material
o PAR – Porosity, Absorption, Resorption
o Autogenous stem cell products
· Tenting
o BMP2 with good scaffolding and bone (just implants sticking out)
· It’s not the bone, it’s the SOFT TISSUE coverage
o That’s how you get true success of bone grafts
The Miami Implant Update
April 24, 2009
Dr. Rolf Ewers
Bone Forming Materials to Enhance Missing Bone
· Oral Surgeon from University of Vienna and has CMF Institute Vienna
· MAJOR facial surgeries
o 21 hour surgery example on lady from Romania
o Full facial reconstruction of gentleman where accessory nerve was preserved: skydive
· Bone replacement material (BRM) vs Bone forming Material (BFM)
· BFM vs. Foreign Body Material
o FBM – Bio-Oss never resorbs… even after 7, 14 yrs
o FBM – Interpore after 26 yrs… still there
· PAR
o Porosity
o Absorption
o Resorption
· Must be biocompatible
· Algisorb
o Very porous
o Histomorphology
§ Hydrolytic alteration of the scaffold
§ Creeping substitution by new bone
§ Even see nuclei in the tubules of Algisorb
o Copies nature
§ More elegant than cadaver
· Augmentation techniques
o Bone quality
§ Class I – Revascularized bone: Never resorbed, can maybe add in BMP
§ Class II – Distracted bone (vascularized)
§ Class III – Pedicled inlay bone (not vascularized)
§ Class IVa – Autogenous Onlay bone (not vascularized)
§ Class IVb – Augmented allograft (not vascularized)*
· *The one they are always trying to sell is 5th
o Never extracts tooth w/o filling the root
o Need to place a membrane to prevent mesenchymal cells from inving bon e graft
· What is best membrane?
o 1. Thin cortical bone,
o 2. Titanium membrane
o 3. E-PTFE membrane
o 4. Slowly resorbing membrane
· Algisorb – after 7 months, the histomorphology is 23% newly formed bone and 33% algisorb
· Algiorb with PRP – after 7 mo 31% newly formed bone and 21% residual algisorb
o The PRP is activating the osteoclasts
· Johansson et al 2001
o Algisorb has 14% replacement versus 30% with iliac crest
· Only a 4.4% failure with algisorb and maxillary sinus lifts
· The Bow Tie Book
o Oral and Implant Surgery Dunsche, Ewers, Filippi
o By Quintesscence
· Future
o Rehumanization of resorbable material
o Bioactivating of the bone forming material
o PAR – Porosity, Absorption, Resorption
o Autogenous stem cell products
· Tenting
o BMP2 with good scaffolding and bone (just implants sticking out)
· It’s not the bone, it’s the SOFT TISSUE coverage
o That’s how you get true success of bone grafts
Dr. Richard Sable - April 24, 2009
American Dental Implant Association
The Miami Implant Update
Dr. Richard P. Sable – April 24, 2009
Current Concepts and Access to Care Issues for CBCT (Cone Beam Computerized Tomography) Scanning
· Mobile CT Scan Center
· Quality of bone, shape of bone, dentsity of bone
· Tx planning software
· What is a CT?
o Come Beam Computerized Tomogram
· Why do we use them?
o Evaluate max and mand
o Extent of alveolar ridge resorption
o Location of Mandibular nerve
o Invagination of Maxillary sinuses
o Evaluate undercuts and anomalies
o Evaluate anomalies (Pathology)
o Evaluate bone density
o Implant tx planning software
· Other uses
o TMJ Evaluation
o Airway space
· When to order it?
o Diagnostic purposes
o In every implant case?
§ Yes
o Pre-tx planning
o Post-implant placement
· Distortion… or the lack thereof
o Periapicals: 1.5-3.5mm
o Panoramic: 2.5-7.5mm
o CT Scan: 0.2-0.5mm – Essentially a 1:1 ratio
· AAOMR: 70% of case- implant sizes have been changed when tx planning with a CT Scan
· Where?
o Hospital – Medical CT Scans
o Scan centers – Medical CT Scan
o Colleague’s office
o Own one in an office - $180,000
o Precision Dx – Affordable and convenient
· How?
o Proprietary download
§ iCAT vision
o DICOM 3 file
o Tx planning software
§ PVS, Bite – Send to lab and they do waxup and make a scannable waxup with barium sulfate teeth
· Beneficiaries
o The surgeon
§ See things in 3D
§ Width of ridge
§ Height of idge
§ Bone density
§ Bone grafting success
§ Location of mandibular nerve
§ Location of maxillary sinus
o Measures bone density in Hounsfield units
o Tx planning w/o surprises
§ Grafting?
§ Type of graft?
§ Harvesting sites
§ Exact placement and parallelization of dental implants
o The restorative dr
§ Optimal occlusion
· Esthetics
o Emergence profile
o Allows you to control the case and the implant team
o The patient!
§ Low post-op pain
§ Heals quicker
§ Pt can understand tx plan
· Is 3D imaging the standard of care
o Now at the pt of informed refusal level
The Miami Implant Update
Dr. Richard P. Sable – April 24, 2009
Current Concepts and Access to Care Issues for CBCT (Cone Beam Computerized Tomography) Scanning
· Mobile CT Scan Center
· Quality of bone, shape of bone, dentsity of bone
· Tx planning software
· What is a CT?
o Come Beam Computerized Tomogram
· Why do we use them?
o Evaluate max and mand
o Extent of alveolar ridge resorption
o Location of Mandibular nerve
o Invagination of Maxillary sinuses
o Evaluate undercuts and anomalies
o Evaluate anomalies (Pathology)
o Evaluate bone density
o Implant tx planning software
· Other uses
o TMJ Evaluation
o Airway space
· When to order it?
o Diagnostic purposes
o In every implant case?
§ Yes
o Pre-tx planning
o Post-implant placement
· Distortion… or the lack thereof
o Periapicals: 1.5-3.5mm
o Panoramic: 2.5-7.5mm
o CT Scan: 0.2-0.5mm – Essentially a 1:1 ratio
· AAOMR: 70% of case- implant sizes have been changed when tx planning with a CT Scan
· Where?
o Hospital – Medical CT Scans
o Scan centers – Medical CT Scan
o Colleague’s office
o Own one in an office - $180,000
o Precision Dx – Affordable and convenient
· How?
o Proprietary download
§ iCAT vision
o DICOM 3 file
o Tx planning software
§ PVS, Bite – Send to lab and they do waxup and make a scannable waxup with barium sulfate teeth
· Beneficiaries
o The surgeon
§ See things in 3D
§ Width of ridge
§ Height of idge
§ Bone density
§ Bone grafting success
§ Location of mandibular nerve
§ Location of maxillary sinus
o Measures bone density in Hounsfield units
o Tx planning w/o surprises
§ Grafting?
§ Type of graft?
§ Harvesting sites
§ Exact placement and parallelization of dental implants
o The restorative dr
§ Optimal occlusion
· Esthetics
o Emergence profile
o Allows you to control the case and the implant team
o The patient!
§ Low post-op pain
§ Heals quicker
§ Pt can understand tx plan
· Is 3D imaging the standard of care
o Now at the pt of informed refusal level
Monday, April 20, 2009
Dr. Paul Petrungaro – April 18, 2009
Implant Seminars
Anterior Tooth Replacement, High Aesthetic Demand
Dr. Paul Petrungaro – April 18, 2009
List of what to look for
· Edentulous Site
· Suturing
· Sinus Block
· Posteriors
· Temp stent
Overview of Last Case Yesterday
· Start with diagnostic waxup
· Silicone Bite Index
· Atraumatic tooth removal
· Debridement
· Use implant
· Large particle graft with heavy condensation
· Place abutment, make temp with index
· 3 months later, restore
Edentulous Site
· Make sure that there is no frenum pull – Likely need frenectomy before working
o Use Laser
o Use periosteal tacks if concerned with retraction
· Carve out the tissue using a tempstent
o Use #8 round bur through tempstent
o Create the extraction socket using a football bur
o Create the biological width in the bone
· Create a facial pouch with a elevator = Go EASY
o Need to remove periosteum
· Place Implant
· For adjacent recession
o Create puch for dermis
o Scale and root plane surface
o Citric acid pH1 for 1 minute
· Place cover screw and Place bone graft with PRP: heavy condensation
· Place abutment, then reline tempstent with coping
· Cement temp with tempbond clear
· Place DERMIS on buccal of #8,9
o Tack it in with 6-0 polypropylene
· Use sling sutures
o Kenneth Krebs (AAP Periodontist who was AMAZING with sutures)
· USE A BLOCK if the implant can’t go in
· Make sure you evaluate the papillae AND the adjacent teeth including CONTACT points, angulation and rotation of adjacent teeth
TEMP STENT: Lab - Edgar
· Needs a study model
· He virtually extracts the tooth
· He brings the tissue down or up with WAX
o Creates the emergence profile
o Look at line angles and buccal contours
· Fabricate the temp, make a hole on lingual for surgical guide
· Create a vacuum form over the temp, but the temp needs to have some undercut to lock in the temporary into the vacuum form
o Remove all undercuts on adjacent teeth
o 1mm thickness vacuum form
Multiple Units with Temp Stent
· For multiple units, need a lot more info
· Models, Bite, Bitestick/Facebow
Congenitally missing Laterals
· For small spaces, use 1 piece implants
· Need at least 5.5mm between teeth for an implant
· Place, graft bone with pouch, make temp
Sinus Lift
· Palatal crestal incision (not mid-crestal) internal bevel incision (the cut is toward palate) and the release is distal line angle of tooth anterior to sinus
· Use #8 round diamond and do the osteotomy until its purple
· If you get a bleeder, clamp the bone
· To control bleeding in sinus, use Gauze with Xylocaine with 1:50,000 Epi
· Go from the distal on the floor with dull instruments and then zip it up
· Regenoform bone
· Place membrane in sinus whether or not you have a tear
· Slits in corners of membrane
· Pack in bone
o If you ever have an infection in the sinus graft and it doesn’t heal in 7 days, you have to REMOVE the graft, debride, close, heal (at least for 3 months)
o Purulence, pain, swelling under the eye
· Place implants, build out buccals with bone graft
· Fabricate temporary bridge, cement it, suture flap toward the bridge
· If nose bleed occurs, watch out for profuse
o If profuse – Arterial… go to hospital
o If very light, 1:50,000 xylocaine on gauze 10 minutes
Internal Socket Lift
· Section tooth at CEJ
· Trifurcate or bifurcate the teeth
· Debride the defects
· #8 round diamond
· Osteotomes to elevate sinus only 3-4mm up
· Place implant
· Healing cap, Bone graft in defect, suture closed
Tunnel Graft
· Can use Alloderm or Dermis
· Shiny side to tissue
· Width never more than 8mm (top to bottom)
· Root planning of surface
· Diamond to level off root
· Burnish roots over and over
· EDTA or citric acid for 1 minute
· Activate with PRP without thrombin
· ½ Orban Knife between cervical to cervical subpapillary
· Slide through the Alloderm
o Tack in all of the mesials and loop through the palatal under the papillae, then pass thru the distals and tie it on the anterior with 6-0 polypropylene (Biohotizons)
o Then do interrupted slings with 5-0 monocryl
o Do a periosteal tack with 4-0 vicryl in the vestibule
Puros Block Grafting
· Advantages:
o No need for secondary surgical site
o No donor site morbidity
o Decrease resorption of cortical plate
o Ample supply
o Osteoconductive
· Disadvantages
o Technique sensitive procedure
o Additional cost (Block $700-900) (Pericardium $400)
o Requires use of a regenerative membrane (Pericardial tissue)
o Must have adequate keratinized tissue prior to placement
§ MUST HAVE PRIMARY CLOSURE – IT WILL FAIL IF IT OPENS
o Posterior mandible requires highly proficient block grafting system (DON’T DO POSTERIOR MANDIBLE)
· Human corticocancellous bone
· Must be aggressive with blocks
· Must advance the flap 2 teeth each way with releasing incisions
· Must OVERBUILD due to chance of sequestra at cortical walls
· Must do deep inlay prep in bone
· Must adjust the block
· Use #8 round bur to countersink the screw
· If the wound opens in the first 30 days, you will not get epithelial migration and you will get failure
· Horizontal mattress first and vertical sling next
· Wait 5 months
· 5 months later, remove screws, REMOVE CORTICAL plate, place implant and temp
Anterior Tooth Replacement, High Aesthetic Demand
Dr. Paul Petrungaro – April 18, 2009
List of what to look for
· Edentulous Site
· Suturing
· Sinus Block
· Posteriors
· Temp stent
Overview of Last Case Yesterday
· Start with diagnostic waxup
· Silicone Bite Index
· Atraumatic tooth removal
· Debridement
· Use implant
· Large particle graft with heavy condensation
· Place abutment, make temp with index
· 3 months later, restore
Edentulous Site
· Make sure that there is no frenum pull – Likely need frenectomy before working
o Use Laser
o Use periosteal tacks if concerned with retraction
· Carve out the tissue using a tempstent
o Use #8 round bur through tempstent
o Create the extraction socket using a football bur
o Create the biological width in the bone
· Create a facial pouch with a elevator = Go EASY
o Need to remove periosteum
· Place Implant
· For adjacent recession
o Create puch for dermis
o Scale and root plane surface
o Citric acid pH1 for 1 minute
· Place cover screw and Place bone graft with PRP: heavy condensation
· Place abutment, then reline tempstent with coping
· Cement temp with tempbond clear
· Place DERMIS on buccal of #8,9
o Tack it in with 6-0 polypropylene
· Use sling sutures
o Kenneth Krebs (AAP Periodontist who was AMAZING with sutures)
· USE A BLOCK if the implant can’t go in
· Make sure you evaluate the papillae AND the adjacent teeth including CONTACT points, angulation and rotation of adjacent teeth
TEMP STENT: Lab - Edgar
· Needs a study model
· He virtually extracts the tooth
· He brings the tissue down or up with WAX
o Creates the emergence profile
o Look at line angles and buccal contours
· Fabricate the temp, make a hole on lingual for surgical guide
· Create a vacuum form over the temp, but the temp needs to have some undercut to lock in the temporary into the vacuum form
o Remove all undercuts on adjacent teeth
o 1mm thickness vacuum form
Multiple Units with Temp Stent
· For multiple units, need a lot more info
· Models, Bite, Bitestick/Facebow
Congenitally missing Laterals
· For small spaces, use 1 piece implants
· Need at least 5.5mm between teeth for an implant
· Place, graft bone with pouch, make temp
Sinus Lift
· Palatal crestal incision (not mid-crestal) internal bevel incision (the cut is toward palate) and the release is distal line angle of tooth anterior to sinus
· Use #8 round diamond and do the osteotomy until its purple
· If you get a bleeder, clamp the bone
· To control bleeding in sinus, use Gauze with Xylocaine with 1:50,000 Epi
· Go from the distal on the floor with dull instruments and then zip it up
· Regenoform bone
· Place membrane in sinus whether or not you have a tear
· Slits in corners of membrane
· Pack in bone
o If you ever have an infection in the sinus graft and it doesn’t heal in 7 days, you have to REMOVE the graft, debride, close, heal (at least for 3 months)
o Purulence, pain, swelling under the eye
· Place implants, build out buccals with bone graft
· Fabricate temporary bridge, cement it, suture flap toward the bridge
· If nose bleed occurs, watch out for profuse
o If profuse – Arterial… go to hospital
o If very light, 1:50,000 xylocaine on gauze 10 minutes
Internal Socket Lift
· Section tooth at CEJ
· Trifurcate or bifurcate the teeth
· Debride the defects
· #8 round diamond
· Osteotomes to elevate sinus only 3-4mm up
· Place implant
· Healing cap, Bone graft in defect, suture closed
Tunnel Graft
· Can use Alloderm or Dermis
· Shiny side to tissue
· Width never more than 8mm (top to bottom)
· Root planning of surface
· Diamond to level off root
· Burnish roots over and over
· EDTA or citric acid for 1 minute
· Activate with PRP without thrombin
· ½ Orban Knife between cervical to cervical subpapillary
· Slide through the Alloderm
o Tack in all of the mesials and loop through the palatal under the papillae, then pass thru the distals and tie it on the anterior with 6-0 polypropylene (Biohotizons)
o Then do interrupted slings with 5-0 monocryl
o Do a periosteal tack with 4-0 vicryl in the vestibule
Puros Block Grafting
· Advantages:
o No need for secondary surgical site
o No donor site morbidity
o Decrease resorption of cortical plate
o Ample supply
o Osteoconductive
· Disadvantages
o Technique sensitive procedure
o Additional cost (Block $700-900) (Pericardium $400)
o Requires use of a regenerative membrane (Pericardial tissue)
o Must have adequate keratinized tissue prior to placement
§ MUST HAVE PRIMARY CLOSURE – IT WILL FAIL IF IT OPENS
o Posterior mandible requires highly proficient block grafting system (DON’T DO POSTERIOR MANDIBLE)
· Human corticocancellous bone
· Must be aggressive with blocks
· Must advance the flap 2 teeth each way with releasing incisions
· Must OVERBUILD due to chance of sequestra at cortical walls
· Must do deep inlay prep in bone
· Must adjust the block
· Use #8 round bur to countersink the screw
· If the wound opens in the first 30 days, you will not get epithelial migration and you will get failure
· Horizontal mattress first and vertical sling next
· Wait 5 months
· 5 months later, remove screws, REMOVE CORTICAL plate, place implant and temp
Dr. Paul Petrungaro – April 17, 2009
Implant Seminars
Immediate Restoration of Dental Implants in Extraction, Edentulous, and Sinus Grafted Sites: Keys to Successful Outcomes in Immediate Tooth Replacement
Dr. Paul Petrungaro – April 17, 2009
State of the Art Regenerative Therapy: Clinical Realities Versus Marketing Hype
• He uses an ad in a Michigan Ave magazine
• He backs up his work for 15 yrs in writing
• He is doing marketing in Chicago
• Loves CT Scans – But used models to look at ST emergence profiles
• He liked my question: ROADMAP – Diagnostic tx plan
• Need to build the restoration from the foundation
Enhancing the Natural Tooth Space with Dental Implants
• Can’t have less than 5.5mm at an ext site if you want to restore it ideally
• To create nice papillae, the only way is to place a temporary at the time of implant placement
• It takes a LONG time to make temporaries properly
• You need space to graft: need surface area for mesenchymal cells to get in there
• ST: Dermis
• Block grafting for ridges: J-Block instead of removing from mandible (3 month reentry)
Implant Reconstruction
• Surgically Driven Implant placement: 1970’s – 2000
• Prosthetically Driven Implant placement: 2000 – 2003
• Esthetically Driven Implant placement: 2003 – Present
1. Creating the Aesthetic Implant Restoration
• Cosmetic Periodontal Surgical Principals
o Thick Biotype vs Thin Biotype
Need to have THICK biotype
If you don’t have it, MAKE it happen
Reestablish the proper volume and thickness
• May need ST Graft
o Keratinized gingiva vs Nonkeratinized tissue
• Get a WAX-UP (This is an example)
o Centrals: 11.5mm
o Laterals: 10.5mm
o Length, Width, Biological Width, Contour, Contact Point, Line Angle, Tooth shape
• Need the Foundation
o AAP: 72% have fenestrations or dehescence on the buccal of maxillary anteriors
o Treat every pt as if they have a fenestration or dehescense
• Must convert the gums before the implant OR during implant placement (NOT after placement)
• Use ALLODERM (DERMIS) instead of palatal CT
o How much quantity and quantity of tissue do we have
2. Periodontal-Prosthetic Implications
• Look at tissue and bone (Gummy Smile Case)
o Short anteriors, chipped with multiple diastemata
o Posteriors are short with bulbous buccal bone
• START with
o Diagnostic wax up
Study models (want to lengthen the teeth)
o Sounding with anesthetic (to evaluate biological width)
Go all around the buccal aspect
If sounding is 2mm and you need to lengthen the tooth 2mm, you need the bone to be 5mm from original facial height of contour to new depth of bone
Biological width is normally 3mm (avg)
• See if frenectomy is required
• Can use Football diamond to plasty the gums where there is hyperplastic tissue
• Round #4-interprox,6,8-buccal diamond for bone removal to crown lengthen
3. PRP
• Draw blood: 20cc
• Harvest Centrifuge
o Spins for 14 minutes
o Separate out the Platelets
o Platelets call in more stem calls for healing
o Jump-starts the healing
o He does not use steroids because it counters what PRP does
Classification System for Loss of Papillary Height
1. Interdental papilla
a. When you have papillary loss due to bone loss, after surgery, you are going to have more papillary loss
b. Let pt know what can happen, let them know what needs to be done and have them sign
2. Diagnostic assessment of a hopeless tooth (John Kois 12.2004 Compendium)
a. Tooth position FGM: Coronal, Ideal
b. Ginigval Form: Flat scallop, High Scallop
c. Biotype: Thick, thin
d. Position of osseous crest: High <3mm>4mm from adjacent teeth and facilly
i. Favorable/Low risk peri-implant esthetics: More coronal, Flat scallop, Thick biotype, High Crest
ii. Unfavorable/High risk peri-implant esthetics: Ideal
3. Classification of Interproximal Height of Bone (IHB: Salama’s, Garber): Bone to apical extent of future contact point
a. Class 1 IHB – 4-5mm Optimal prognosis
b. Class 2 IHB – 6-7mm Guarded prognosis
c. Class 3 IHB – More than 7mm Poor prognosis
• NOTE: Never use anything more than a 3.7 from #7-10
• J-Block: 3 mo later, remove screws, place implant, recontour bone and remove buccal bone
The immediate Restoration of Dental Implants: Petrungaro’s Prinicpals
• Guidelines for success
• Diagnostic Wax-up
o Contours are planned, Contact points are planned
o SO IMPORTANT for multiple implants
The waxup gives you provisionals, and gives you the interproximal papillae and the buccal gingiva
• TempStent II Surgical Guide/Aesthetic Temporary System
• I-Cat Cone Beam Image, Diagnostic Radiology
• Administration of Pre-op Antibiotics starting day before surgery
o Augmentin 875, 20 tabs, 1 tab PO q12h
o Levoquin 500mg, 10 tabs, 1 tab PO qd til done
• Atraumatic Ext, minimally invasive surgery
• Implant design:
o HA Coated Root form or Tapered Screw Implant
o Apical 1/3 of implant must have aggressive cutting pattern with deep thread pitch
Stronger initially
o .5-1mm collar with thread design that blends into the collar
Soft tissue migrates to the collar
o Internal hex
• Buccal plate evaluation, bone graft “pouch” between the buccal flap and the buccal plate
• Stock metal abutment
• Bio-engineering at surgical site
o Platelet rich plasma use to coat implant and osteotomy site
o PRP and PPP as a bioactive sealer/barrier
• Provisional restoration that respects the biological width environment and creates an esthetic emergence profile, and is non-functional in centric, protrusive, and rt and lt lateral excursive movements
• Final abutment hand tightened
Example of Immediate Ext Implant Temp
• Index with bite registration or PVS for temp later
• Ext as atraumatically as possible
• Retain ALL circumferential gingiva, ESPECIALLY the papillae
• Debride the ext site with Molt, high speed and triple stripe diamond, #8 long round diamond
• Create a POUCH 2-3mm beyond the facial dehiscence
• Implant depth
o Placement of implant collar is equal to a line drawn from the facial height of the contralateral tooth
o Collar at alveolar crest
o Place it LINGUALLY
• Place cover screw
• 98% of graft is 1-2mm cancellous (larger partical size) – SALVIN Mineralized LifeNet Bone
o This is for implant surface to buccal plate
• If thinner biotype .25mm-1mm cancellous at cervical area – SALVIN Mineralized LifeNet Bone
o Use it with PRP or Keystone’s Dynablast (Like a Gel – Sticks together)
o HEAVY condensation
• Thickness of Buccal Plate
o If there is >1.8mm buccal plate: Spray, T (J Perio 2000) – No graft
o If 1-2mm – No incision required – Graft/Membrane required
o If no buccal plate, 2 stage – Graft/Membrane + Flap
o No buccal plate/dehesence/fenestration – Graft/Membrance
• Cut original tooth, hollow it out, etch bond, reline with composite
• Then place bone graft, cement temp
• Wait 3 months, then final crown
Immediate Restoration of Dental Implants in Extraction, Edentulous, and Sinus Grafted Sites: Keys to Successful Outcomes in Immediate Tooth Replacement
Dr. Paul Petrungaro – April 17, 2009
State of the Art Regenerative Therapy: Clinical Realities Versus Marketing Hype
• He uses an ad in a Michigan Ave magazine
• He backs up his work for 15 yrs in writing
• He is doing marketing in Chicago
• Loves CT Scans – But used models to look at ST emergence profiles
• He liked my question: ROADMAP – Diagnostic tx plan
• Need to build the restoration from the foundation
Enhancing the Natural Tooth Space with Dental Implants
• Can’t have less than 5.5mm at an ext site if you want to restore it ideally
• To create nice papillae, the only way is to place a temporary at the time of implant placement
• It takes a LONG time to make temporaries properly
• You need space to graft: need surface area for mesenchymal cells to get in there
• ST: Dermis
• Block grafting for ridges: J-Block instead of removing from mandible (3 month reentry)
Implant Reconstruction
• Surgically Driven Implant placement: 1970’s – 2000
• Prosthetically Driven Implant placement: 2000 – 2003
• Esthetically Driven Implant placement: 2003 – Present
1. Creating the Aesthetic Implant Restoration
• Cosmetic Periodontal Surgical Principals
o Thick Biotype vs Thin Biotype
Need to have THICK biotype
If you don’t have it, MAKE it happen
Reestablish the proper volume and thickness
• May need ST Graft
o Keratinized gingiva vs Nonkeratinized tissue
• Get a WAX-UP (This is an example)
o Centrals: 11.5mm
o Laterals: 10.5mm
o Length, Width, Biological Width, Contour, Contact Point, Line Angle, Tooth shape
• Need the Foundation
o AAP: 72% have fenestrations or dehescence on the buccal of maxillary anteriors
o Treat every pt as if they have a fenestration or dehescense
• Must convert the gums before the implant OR during implant placement (NOT after placement)
• Use ALLODERM (DERMIS) instead of palatal CT
o How much quantity and quantity of tissue do we have
2. Periodontal-Prosthetic Implications
• Look at tissue and bone (Gummy Smile Case)
o Short anteriors, chipped with multiple diastemata
o Posteriors are short with bulbous buccal bone
• START with
o Diagnostic wax up
Study models (want to lengthen the teeth)
o Sounding with anesthetic (to evaluate biological width)
Go all around the buccal aspect
If sounding is 2mm and you need to lengthen the tooth 2mm, you need the bone to be 5mm from original facial height of contour to new depth of bone
Biological width is normally 3mm (avg)
• See if frenectomy is required
• Can use Football diamond to plasty the gums where there is hyperplastic tissue
• Round #4-interprox,6,8-buccal diamond for bone removal to crown lengthen
3. PRP
• Draw blood: 20cc
• Harvest Centrifuge
o Spins for 14 minutes
o Separate out the Platelets
o Platelets call in more stem calls for healing
o Jump-starts the healing
o He does not use steroids because it counters what PRP does
Classification System for Loss of Papillary Height
1. Interdental papilla
a. When you have papillary loss due to bone loss, after surgery, you are going to have more papillary loss
b. Let pt know what can happen, let them know what needs to be done and have them sign
2. Diagnostic assessment of a hopeless tooth (John Kois 12.2004 Compendium)
a. Tooth position FGM: Coronal, Ideal
b. Ginigval Form: Flat scallop, High Scallop
c. Biotype: Thick, thin
d. Position of osseous crest: High <3mm>4mm from adjacent teeth and facilly
i. Favorable/Low risk peri-implant esthetics: More coronal, Flat scallop, Thick biotype, High Crest
ii. Unfavorable/High risk peri-implant esthetics: Ideal
3. Classification of Interproximal Height of Bone (IHB: Salama’s, Garber): Bone to apical extent of future contact point
a. Class 1 IHB – 4-5mm Optimal prognosis
b. Class 2 IHB – 6-7mm Guarded prognosis
c. Class 3 IHB – More than 7mm Poor prognosis
• NOTE: Never use anything more than a 3.7 from #7-10
• J-Block: 3 mo later, remove screws, place implant, recontour bone and remove buccal bone
The immediate Restoration of Dental Implants: Petrungaro’s Prinicpals
• Guidelines for success
• Diagnostic Wax-up
o Contours are planned, Contact points are planned
o SO IMPORTANT for multiple implants
The waxup gives you provisionals, and gives you the interproximal papillae and the buccal gingiva
• TempStent II Surgical Guide/Aesthetic Temporary System
• I-Cat Cone Beam Image, Diagnostic Radiology
• Administration of Pre-op Antibiotics starting day before surgery
o Augmentin 875, 20 tabs, 1 tab PO q12h
o Levoquin 500mg, 10 tabs, 1 tab PO qd til done
• Atraumatic Ext, minimally invasive surgery
• Implant design:
o HA Coated Root form or Tapered Screw Implant
o Apical 1/3 of implant must have aggressive cutting pattern with deep thread pitch
Stronger initially
o .5-1mm collar with thread design that blends into the collar
Soft tissue migrates to the collar
o Internal hex
• Buccal plate evaluation, bone graft “pouch” between the buccal flap and the buccal plate
• Stock metal abutment
• Bio-engineering at surgical site
o Platelet rich plasma use to coat implant and osteotomy site
o PRP and PPP as a bioactive sealer/barrier
• Provisional restoration that respects the biological width environment and creates an esthetic emergence profile, and is non-functional in centric, protrusive, and rt and lt lateral excursive movements
• Final abutment hand tightened
Example of Immediate Ext Implant Temp
• Index with bite registration or PVS for temp later
• Ext as atraumatically as possible
• Retain ALL circumferential gingiva, ESPECIALLY the papillae
• Debride the ext site with Molt, high speed and triple stripe diamond, #8 long round diamond
• Create a POUCH 2-3mm beyond the facial dehiscence
• Implant depth
o Placement of implant collar is equal to a line drawn from the facial height of the contralateral tooth
o Collar at alveolar crest
o Place it LINGUALLY
• Place cover screw
• 98% of graft is 1-2mm cancellous (larger partical size) – SALVIN Mineralized LifeNet Bone
o This is for implant surface to buccal plate
• If thinner biotype .25mm-1mm cancellous at cervical area – SALVIN Mineralized LifeNet Bone
o Use it with PRP or Keystone’s Dynablast (Like a Gel – Sticks together)
o HEAVY condensation
• Thickness of Buccal Plate
o If there is >1.8mm buccal plate: Spray, T (J Perio 2000) – No graft
o If 1-2mm – No incision required – Graft/Membrane required
o If no buccal plate, 2 stage – Graft/Membrane + Flap
o No buccal plate/dehesence/fenestration – Graft/Membrance
• Cut original tooth, hollow it out, etch bond, reline with composite
• Then place bone graft, cement temp
• Wait 3 months, then final crown
Dr. Andre Saadoun – March 28, 2009
Implant Seminars
Aesthetic Management of the Gingival Tissue Around Implants
Dr. Andre Saadoun – March 28, 2009
· The concern is less about integration, and more about gingival management around the implant/restoration
· High demand from patients
· Harmony between gingival contour, height of tooth, point of contact
· Papillary height is 40% compared to height of incisal
· LONG TERM STABILITY from gingival margin
· Fxnal and aesthetic success of implant tx in the anterior zone depend not only on the aesthetic quality of the restoration, but also on the final aspect of the gingiva and papillae
· Keys to success in implant aesthetics:
o Detailed pre-surgical dx of smile and site
o Precise and non-traumatic surgical technique
o Pre- or per- surgical bone augmentation
o Pre- per- or post- surgical gingival soft tissue management
· Once you reopen a 2 stage implant, you start to lose 1.5mm of bone around the collar
· Peri-implant recession is 0.7-1mm as well
· There is vertical and horizontal resorption around an implant circumferentially
o Bone saucerization around implants
§ Horizontal 1-1.5mm
§ Vertical 2mm
· Get earlier loss of buccal attachment in non-keratinized area
o Higher susceptibility to tissue breakdown due to p[laque accumulation
o Understand that marginal/proximal bone loss is an unavoidable biological process and soft tissue recession will occur
Peri-Implant Soft Tissue Recession
· Implant design / Collar / Surface / Diameter
o Internal abutments are better
o Remember that the root is flat and the buccal contour is curved
o Microthreads at the collar maintain the marginal bone level against gingival recession because they increase the bone interface
o Platform switching reduced stress to a greater degree in the microthread model compared to the smooth neck model
o YOU WANT microthread, rough surface collar
o It is necessary today to have TAPERED, ROUGH, MICROTHREAD COLLAR
o No advertising…
· Patient’s biotype
o Schropp 1999
§ The thicker the buccal plate, the LESS bone resorption
§ The thicker the gingiva, the less gingival recession
o Warrer 1995; Saadoun Touati 2007
§ The necessity of a zone of keratinized tissue adjacent to dental implants is especially important
o Bouri 2008
§ Implants with a narrow zone had 3x higher chance of probing and bleeding
o All of these parameters predict the peri-implant esthetic outcome before removing a tooth
§ Thin tissue: harder to develop a papilla
§ Thick tissue: easier
§ Biotype – Thick, Thin
§ Gingival Form – flat scalloped, high scalloped
§ Tooth shape – triangular, square
o Rompen 2003
§ If you have a thick biotype: no real problems
· Safe if you respect the rules
§ Thin biotype: You will have gingival recession
· You must to something more
o Biotype and management of single and multiple implants
§ Class I Single tooth, Thick biotype
· Minimally invasive, simple placement
· Flat contour
§ Class II Single tooth, Thin Biotype
· Preservation and augmentation
· Minimally invasive, BUT must increase length of bone, and increase soft tissue
· Flat, to undercontoured, to concave
§ Class III Multiple teeth, Thick biotype
· Two stage surgery
· Must develop the site with bone
§ Class IV Multiple teeth, Thin Biotype
· Two stage surgery
· Must develop the site with bone and CT
· Biological width
o On a tooth, you have hemi-desmosomes and sharpey’s fibers that attach the tissue to the bone and the teeth
o On an implant in 1992: no cementum; more collagen than fibroblasts; no seal
o Now, May 2008, with rough surfaces on implants, you will get CT attachment with pores (on Biohorizons)
o Thickness and height of mucosa is proportional
o Rough surface is much better than machined in terms of biological width
o The height of a papilla between #8,9 will never be as tall if both #8,9 are replaced with implants
§ 2 implants: you get double resorption
§ You must move the contact point
· Extraction timing / Implant placement
o Once you extract a tooth, you remove the PDL
o Araujo 2005
§ Loss of PDL vasculararization
§ Removal of circumferential transeptal fibers
§ Cervical bundle bone is lost
§ Where bone is thin, vertical crestal height is lost
§ 0.5-1mm post-ext recession
o More pronounced alterations occur in the 1st 3 months
§ So if you have an abscess, do the implant with a couple of weeks
§ Lose 2-4.5mm vertically
§ Lose 5-7mm bucco-libgually
· 2/3 of that in 1st 3 mo
o After 8 weeks, buccal bone collapses after ext
o So what do we do?
§ Once we extract, you should decide on bone graft
o Drakos 2006
§ The thinner the buccal plate, the more likely a buccal concavity will occur
§ Sound the bone before extraction and AFTER the extraction
o Check the bone to see if bone augmentation is required
§ If dehiscence, fenestration, or thin bone wall observed
o Cardaropoli 2006
§ Bone loss can still occur with immediate ext/placement
o Fill with bone at most 1 week after ext
o Wait 6-8 weeks for soft tissue to heal
o Socket Types
§ Class I Have good ST and good bone
· Easiest to treat
· Class IA Bone intact, thick biotype; flapless immediate placement, optimal immediate loading
· Class IB Bone intact, thin biotype; immediate with CTG, good for immediate loading
§ Class II Have good ST, but some bone loss
· Need to do bone augmentation
· Cannot do immediate loading
§ Class III Have ST Loss and Bone loss
· Need to do CT augmentation and bone augmentation (Most difficult)
· NA Immediate loading
· Needs to be multiple staging
o Site development prior to implant placement
§ Take 2g Amoxicillin 1 hr before implant placement to decrease the failure of placement
§ Bone graft with ST, takes 2 yrs for allograft to disappear
§ Can use cone shaped membrane, inside buccal bone, pack in bone graft, suture to palatal wall
§ Graft, wait 6 months, flapless Implant, healing abutment, wait 2 months, temp crown, 2 weeks, permanent crown
o Submerged 2 stages
§ Pt with already extracted tooth
§ Start with deformed ridge
§ Let ext site heal for 3 months; Combine ST management, use a rolled CT graft from the palatal side, get a lot of excess tissue on buccal, may need to make a more convex temp to help push away some tissue at time of implant placement
§ Leave suture for 2 weeks
o Nonsubmerged 1 stage
§ Can place healing abutment directly
§ Stay away from buccal plate (since it is SO important esthetically
· Put a bone graft if it is more than 2mm away at cervical region (Kan 2000) and prevents gingival recession
§ Araujo 2006
· The gap of less than 2mm will fill with new bone during the healing process
§ Saadoun 2004
· In immediate implant placement after ext, place the implant to the palatal aspect in order to avoid trauma to the buccal plate and allow the filling of the gap with an allograft material
· The Implant should not at all touch the cortical plate
· Do not use autogenous bone, use pur-oss; because autologous will resorb almost immediately
§ The objective is to MAINTAIN the buccal plate
§ Place a membrane over the bone graft
o Immediate Placement
§ Drill-cone technique
· Cut gingiva with drill-cone, middle m-d, slightly palatally
· If you have 35Ncm, you can go ahead and restore
· No occlusion in centric and lateral excursives on the temp
· Refine abutment in 2 months, final impression
§ Immediate ext
· Loosen fibers with 15C blade
· Sound the bone
· Rotational ext, not buccal-lingual
· Ext, then sound AGAIN
· Place implant palatally
· Place cover screw, THEN place bone
· Place abutment and temp crown
§ If extracting #8,9 that are seriously peridontally involved:
· Ext 1, and use the other as a reference point for making temps
· Bichacho, Landsberg 1997
o 2 weeks after temps, can reshape temporary crowns ‘ proximal contacts to help shape the papillae
· Forced eruption
o Orthodontic eruption can prevent bone resorption after extraction, enhance ST
o Active movement is 8 weeks to increase ST and bone by 4-5mm
o Then do ext and implant placement 3 months after ST stability
· Flap design
o Can do partial drill-cone on lingual and slightly creastal
§ Use that gingiva, remove epithelium with diamond, roll it in buccally, and place healing cap to hold gingiva in place
· Tridimensional implant position
o Buccal positioning of the implant is an irreversible complication
o Palatal positioning is a less critical complication
o Horizontal plane: Horizontal Biological Criteria for implant placement
§ Mesiodistally
· 2mm bone from implant to adjacent teeth (minimum is 1.5mm due to bone necrosis)
· 3-4mm bone between implants (4.5mm between #8,9)
§ Bucco-lingual (Determines Length of restoration)
· 2-3mm from cervical height of contour
§ Corono-apical
· 2.5-3mm from bucco-gingival margin
o 2.5 for thick biotype
o 3mm for thin biotype
§ Selection of implant diameter must be based upon distance between teeth
o Vertical Biological criteria for single or multiple implant restorations
§ Bone crest/Dental-dental contact point restoration – 5mm
§ Bone crest/Dental-implant contact point restoration – 4.5mm
§ Bone crest/Implant-Implant contact point restoration – 3.5mm
§ Bone crest/Implant-pontic contact point restoration – 5.5mm
§ Bone crest/Tooth-pontic contact point restoration – 6.5mm
§ Bone crest/Pontic-pontic contact point restoration – 6mm
· Connective Tissue Graft
o A large thick inter-positional CT graft at time of ext over a bone graft will:
§ Preserve graft
§ Secure the bone graft
§ Changes biotype from thick to thin
o Can use CT graft: at time of ext with or without implant placement, before implant placement, at implant exposition w ith or without roll technique, after implant placement
o Can place a CT graft after ext similar to a cone shaped membrane except that it is between the periosteum and buccal gingiva
o When doing 2 stage, cut from palatal, roll tissue onto buccal in order to bulk up the buccal contour
o You can ALWAYS have too much tissue
· Implant / Abutment
o
· Temporary / Final Restoration
o
· Occlusal Trauma
Aesthetic Management of the Gingival Tissue Around Implants
Dr. Andre Saadoun – March 28, 2009
· The concern is less about integration, and more about gingival management around the implant/restoration
· High demand from patients
· Harmony between gingival contour, height of tooth, point of contact
· Papillary height is 40% compared to height of incisal
· LONG TERM STABILITY from gingival margin
· Fxnal and aesthetic success of implant tx in the anterior zone depend not only on the aesthetic quality of the restoration, but also on the final aspect of the gingiva and papillae
· Keys to success in implant aesthetics:
o Detailed pre-surgical dx of smile and site
o Precise and non-traumatic surgical technique
o Pre- or per- surgical bone augmentation
o Pre- per- or post- surgical gingival soft tissue management
· Once you reopen a 2 stage implant, you start to lose 1.5mm of bone around the collar
· Peri-implant recession is 0.7-1mm as well
· There is vertical and horizontal resorption around an implant circumferentially
o Bone saucerization around implants
§ Horizontal 1-1.5mm
§ Vertical 2mm
· Get earlier loss of buccal attachment in non-keratinized area
o Higher susceptibility to tissue breakdown due to p[laque accumulation
o Understand that marginal/proximal bone loss is an unavoidable biological process and soft tissue recession will occur
Peri-Implant Soft Tissue Recession
· Implant design / Collar / Surface / Diameter
o Internal abutments are better
o Remember that the root is flat and the buccal contour is curved
o Microthreads at the collar maintain the marginal bone level against gingival recession because they increase the bone interface
o Platform switching reduced stress to a greater degree in the microthread model compared to the smooth neck model
o YOU WANT microthread, rough surface collar
o It is necessary today to have TAPERED, ROUGH, MICROTHREAD COLLAR
o No advertising…
· Patient’s biotype
o Schropp 1999
§ The thicker the buccal plate, the LESS bone resorption
§ The thicker the gingiva, the less gingival recession
o Warrer 1995; Saadoun Touati 2007
§ The necessity of a zone of keratinized tissue adjacent to dental implants is especially important
o Bouri 2008
§ Implants with a narrow zone had 3x higher chance of probing and bleeding
o All of these parameters predict the peri-implant esthetic outcome before removing a tooth
§ Thin tissue: harder to develop a papilla
§ Thick tissue: easier
§ Biotype – Thick, Thin
§ Gingival Form – flat scalloped, high scalloped
§ Tooth shape – triangular, square
o Rompen 2003
§ If you have a thick biotype: no real problems
· Safe if you respect the rules
§ Thin biotype: You will have gingival recession
· You must to something more
o Biotype and management of single and multiple implants
§ Class I Single tooth, Thick biotype
· Minimally invasive, simple placement
· Flat contour
§ Class II Single tooth, Thin Biotype
· Preservation and augmentation
· Minimally invasive, BUT must increase length of bone, and increase soft tissue
· Flat, to undercontoured, to concave
§ Class III Multiple teeth, Thick biotype
· Two stage surgery
· Must develop the site with bone
§ Class IV Multiple teeth, Thin Biotype
· Two stage surgery
· Must develop the site with bone and CT
· Biological width
o On a tooth, you have hemi-desmosomes and sharpey’s fibers that attach the tissue to the bone and the teeth
o On an implant in 1992: no cementum; more collagen than fibroblasts; no seal
o Now, May 2008, with rough surfaces on implants, you will get CT attachment with pores (on Biohorizons)
o Thickness and height of mucosa is proportional
o Rough surface is much better than machined in terms of biological width
o The height of a papilla between #8,9 will never be as tall if both #8,9 are replaced with implants
§ 2 implants: you get double resorption
§ You must move the contact point
· Extraction timing / Implant placement
o Once you extract a tooth, you remove the PDL
o Araujo 2005
§ Loss of PDL vasculararization
§ Removal of circumferential transeptal fibers
§ Cervical bundle bone is lost
§ Where bone is thin, vertical crestal height is lost
§ 0.5-1mm post-ext recession
o More pronounced alterations occur in the 1st 3 months
§ So if you have an abscess, do the implant with a couple of weeks
§ Lose 2-4.5mm vertically
§ Lose 5-7mm bucco-libgually
· 2/3 of that in 1st 3 mo
o After 8 weeks, buccal bone collapses after ext
o So what do we do?
§ Once we extract, you should decide on bone graft
o Drakos 2006
§ The thinner the buccal plate, the more likely a buccal concavity will occur
§ Sound the bone before extraction and AFTER the extraction
o Check the bone to see if bone augmentation is required
§ If dehiscence, fenestration, or thin bone wall observed
o Cardaropoli 2006
§ Bone loss can still occur with immediate ext/placement
o Fill with bone at most 1 week after ext
o Wait 6-8 weeks for soft tissue to heal
o Socket Types
§ Class I Have good ST and good bone
· Easiest to treat
· Class IA Bone intact, thick biotype; flapless immediate placement, optimal immediate loading
· Class IB Bone intact, thin biotype; immediate with CTG, good for immediate loading
§ Class II Have good ST, but some bone loss
· Need to do bone augmentation
· Cannot do immediate loading
§ Class III Have ST Loss and Bone loss
· Need to do CT augmentation and bone augmentation (Most difficult)
· NA Immediate loading
· Needs to be multiple staging
o Site development prior to implant placement
§ Take 2g Amoxicillin 1 hr before implant placement to decrease the failure of placement
§ Bone graft with ST, takes 2 yrs for allograft to disappear
§ Can use cone shaped membrane, inside buccal bone, pack in bone graft, suture to palatal wall
§ Graft, wait 6 months, flapless Implant, healing abutment, wait 2 months, temp crown, 2 weeks, permanent crown
o Submerged 2 stages
§ Pt with already extracted tooth
§ Start with deformed ridge
§ Let ext site heal for 3 months; Combine ST management, use a rolled CT graft from the palatal side, get a lot of excess tissue on buccal, may need to make a more convex temp to help push away some tissue at time of implant placement
§ Leave suture for 2 weeks
o Nonsubmerged 1 stage
§ Can place healing abutment directly
§ Stay away from buccal plate (since it is SO important esthetically
· Put a bone graft if it is more than 2mm away at cervical region (Kan 2000) and prevents gingival recession
§ Araujo 2006
· The gap of less than 2mm will fill with new bone during the healing process
§ Saadoun 2004
· In immediate implant placement after ext, place the implant to the palatal aspect in order to avoid trauma to the buccal plate and allow the filling of the gap with an allograft material
· The Implant should not at all touch the cortical plate
· Do not use autogenous bone, use pur-oss; because autologous will resorb almost immediately
§ The objective is to MAINTAIN the buccal plate
§ Place a membrane over the bone graft
o Immediate Placement
§ Drill-cone technique
· Cut gingiva with drill-cone, middle m-d, slightly palatally
· If you have 35Ncm, you can go ahead and restore
· No occlusion in centric and lateral excursives on the temp
· Refine abutment in 2 months, final impression
§ Immediate ext
· Loosen fibers with 15C blade
· Sound the bone
· Rotational ext, not buccal-lingual
· Ext, then sound AGAIN
· Place implant palatally
· Place cover screw, THEN place bone
· Place abutment and temp crown
§ If extracting #8,9 that are seriously peridontally involved:
· Ext 1, and use the other as a reference point for making temps
· Bichacho, Landsberg 1997
o 2 weeks after temps, can reshape temporary crowns ‘ proximal contacts to help shape the papillae
· Forced eruption
o Orthodontic eruption can prevent bone resorption after extraction, enhance ST
o Active movement is 8 weeks to increase ST and bone by 4-5mm
o Then do ext and implant placement 3 months after ST stability
· Flap design
o Can do partial drill-cone on lingual and slightly creastal
§ Use that gingiva, remove epithelium with diamond, roll it in buccally, and place healing cap to hold gingiva in place
· Tridimensional implant position
o Buccal positioning of the implant is an irreversible complication
o Palatal positioning is a less critical complication
o Horizontal plane: Horizontal Biological Criteria for implant placement
§ Mesiodistally
· 2mm bone from implant to adjacent teeth (minimum is 1.5mm due to bone necrosis)
· 3-4mm bone between implants (4.5mm between #8,9)
§ Bucco-lingual (Determines Length of restoration)
· 2-3mm from cervical height of contour
§ Corono-apical
· 2.5-3mm from bucco-gingival margin
o 2.5 for thick biotype
o 3mm for thin biotype
§ Selection of implant diameter must be based upon distance between teeth
o Vertical Biological criteria for single or multiple implant restorations
§ Bone crest/Dental-dental contact point restoration – 5mm
§ Bone crest/Dental-implant contact point restoration – 4.5mm
§ Bone crest/Implant-Implant contact point restoration – 3.5mm
§ Bone crest/Implant-pontic contact point restoration – 5.5mm
§ Bone crest/Tooth-pontic contact point restoration – 6.5mm
§ Bone crest/Pontic-pontic contact point restoration – 6mm
· Connective Tissue Graft
o A large thick inter-positional CT graft at time of ext over a bone graft will:
§ Preserve graft
§ Secure the bone graft
§ Changes biotype from thick to thin
o Can use CT graft: at time of ext with or without implant placement, before implant placement, at implant exposition w ith or without roll technique, after implant placement
o Can place a CT graft after ext similar to a cone shaped membrane except that it is between the periosteum and buccal gingiva
o When doing 2 stage, cut from palatal, roll tissue onto buccal in order to bulk up the buccal contour
o You can ALWAYS have too much tissue
· Implant / Abutment
o
· Temporary / Final Restoration
o
· Occlusal Trauma
Dr. Andre Saadoun – March 27, 2009
Implant Seminars
Gingival Recession Coverage
Dr. Andre Saadoun – March 27, 2009
Finest periodontist in the world: from Paris, France
See the real articles on http://www.implantarticles.com/ with full color photos
· High level of perio surgery
o 40% of the face is a smile
o Beautiful smile: healthy dentition, harmonious gingival contour
· Aslund, Suvan J Periodontal 2008:79:1031-1040
o The periodontal health of the subjects affects their smiling pattern and their smile-related to their quality of life
o Poor perio health may prevent adults from smiling…
· Periodontal Biological Parameters
o Lip Line
o Gingiva
o Bone
o Teeth
o Interdental papilla
o Biological width
· Lip Line
o Fxn: rest, speech, smile
§ Low lip line: 20%; Medium:70%; High:10% (Beyond 3mm)
· Gingiva
o Look at gingival level
o Form: Scalloped, flat
o Biotype: thin, thick
§ Thick – flat contour of gingiva
o Quantity: small, large
· The amount of keratinized gingival extends from the FGM (Free Gingival Margin) to the MGL (Muco-Gingival Line) minus the pocket depth in the absence of inflammation
· Stetler and Bissada 1987
o Higher chance of gingival inflammation wih subgingival restorations
· Bone
o In healthy patients, the gingival follows the underlying osseaous/CEJ contours
· Chu’s Aesthetic Gauges Proportions: (Hu-Friedy)
o See drawing for esthetic proportions
· In-line tip
o Another esthetic gauge
· Maxillary teeth
o Women have longer teeth than men due to aggressiveness of men
o Tell lab about gender (especially anteriors)
· Interdental papilla (Note IHB – Interproximal bone height)
o Class 1 IHB – Optimal prognosis 2mm from CEJ
o Class 2 IHB – Guarded prognosis 4mm from CEJ
o Class 3 IHB – Poor prognosis >5mm from CEJ
· Tamow et al 1991 2008
o The height of the contact decreases from the central to the molar
§ 4mm at cental incisors, 3mm at laterals, 2mm cuspids, 1.5mm premolars, 1mm molars (Chu, Tamow)
§ The ideal length of the ID papillae is about 40% of the length of the tooth from the gingival zone
o The mesial and distal papilla are about equal height
o The apical pt of the contact surface area determines the height
· Biological width
o Junction of epithelium and connective tissue (Not gingival sulcus)
o See drawing for Biological width
o Also see drawing for Chu’s biological width instruments
o 3mm from gingival crest to bone
Crown Lengthening
· Use this when you have THICK tissue
· Without osseous resection
o No flap elevation
o Initial display: excessive gingiva when she smiles (AA Female who models)
§ Models, x-rays, photos
§ CEJ to bone 1mm (normal) – but 6mm from gingiva to bone: can remove 3 mm
§ Internal bevel gingivectomies (Blade 15C)
· Vicryl 5-0 to hold the papillae in place and to slow down the bleeding
· Continuous vertical mattress sutures throughout
§ Must suture this kind of case to maintain papillae when cutting papillae
o If you can not touch papillae - e.g. for long, triangular teeth OR diastema
§ Crescent incisions (like croissant leaving papillae alone)
§ Zenith on canine is on distal, lateral in middle, centrals slightly distal
· With osseous resection and no flap (use bur in sulcus on bone)
o Short teeth, chipped edges but only 3mm sounding
o Must sound the bone
o Need to remove some bone: use fine diamond – don’t touch papillae
§ Leave 2-3 months before doing final restorations
§ No flap elevation during bone removal
o Can do this with moderate and thick type gingiva
· Want to achieve predictability
o Plan PROPERLY
o Everything in the body needs to work in HARMONY
o Think before jumping
o NEVER touch the palate on the esthetic zone
· With osseous resection and flap elevation
o Lip line uneven: will need perio with laminates
o Do a wax-up
o Do a full thickness flap
o Papillae will take 6-8wks to drop back down
· If you do single tooth crown lengthening: DO NOT INCLUDE THE PAPILLAE
· When probing: CEJ should be 1.2mm incisal to bone
· From diagnosis comes multiple treatment plans
Treatment of Gingival Recession
· Use this when you have THIN tissue
o The demand on thin tissue increases – demand is increasing
· Miller’s gingival recession classification
o I No extension to MGJ: no periodontal loss in the interdental bone/papilla
o II Extension to or beyond the MGJ, no periodontal loss in the interdental papillae
o III Extension to or beyond the MGJ, partial periodontal loss in the interdental papillae
o IV Extension beyond the MGJ, full periodontal loss in the interdental papillae
· Success rates per diagnosis
o Class I – Can 100% cover the recession
o Class II – Can get 100% coverage
o Class III – Can get 50-75% coverage
o Class IV – Only get 0-10%: Not worth even trying
· Zuchelli et al J Perio 2006; 4:714-721
o The line of root coverage is predetermined by calculating
· Restore cervical region AFTER perio surgery
· Connective tissue graft
o Get CT from palate
o Place it, and let it heal
o Tell pt in advance about prognosis
· Alloderm grafts will not work with no bone present
· Submerged Connective Tissue Graft
o Bridge with pink acrylic
o Do surgeries in stages if needed
o You can use pouch or flap
§ Pouch: Apical to MGJ
§ Make sure you loosen circumferentially
· Horizontal tunneling
o Premedication: Prednisone 40mg/50kg morning of; Antibiotics day before; Chlorhexidine; Ibuprofen 600mg 1 hr before
o Prepare bed with ophthalmic blade or 15C
§ Tie suture around 1 end, pull through, suture it into place
· Enamel matrix derivative (alloderm) emdogain
o Report the recession length on the papillae with perio probe
o 1mm deep full thickness, then do partial thickness flap
o Keep the papillary tips
o Emdogain – embryonic acid gel on for 3 minutes after scaling and root planning/acid/wash and then emdogain
§ Must use suspensory sling vertical sutures
· Knot is on occlusal
§ Excellent results
§ Circular incisions
§ Fine diamond burs to root plane
§ Keep the tip of the papilla
§ Use round diamond to decrease root abrasion and remove epithelium interproximally
§ Vicryl 5-0 is used with 19 needle (instead of 13)
· Alloderm Free Gingival Graft – Acellular dermal graft material
o Lower incisor case
o Use Blade 15C
o Need to see patient every 3 days for 6 weeks
o The alloderm needs to be VERY firmly bound down
§ Basal side goes toward roots
§ Alloderm dermal side goes toward the flap
§ Must suture the alloderm in a specific way to steady the flap
§ Never allow the alloderm to be visible at the end
o There will be a lot of gingival deformities
§ Heals very slowly
· Combining alloderm and emdogain
o To increase the length and the thickness
o Emdogain with alloderm increases the amount of keratinized tissue
o Emdogain is injected underneath the alloderm
· After alloderm: WAIT 10 weeks – for ortho, or restorative tx
· I’m not going to cut your gums… I’m going to raise your gums
· Smokers have less root coverage than non-smokers (58% versus 83%)
o Smoking destroys grafts
o No sinus elevations on smokers
o No grafts on smokers
· Can create membranes with PRF
o Platelet rich plasma is the best membrane
o EXCELLENT results with PRP, PRF
Conclusions
· If there is less than 3mm of gingiva around the recession, you must augment the qulity and quantity with emdogain and alloderm
o Suture any mistakes early
· Tunnel: Less complications, less discomfort, minimally invasive
· Beauty: Based on culture
· Details make perfection
· Smiles are important ways to communicate to people
· In perio-plastic surgery: you can improve the smile of a patient
o Gingival disharmony
o Gingival Excess
o Buccal Gingival recessions
· Know the classifications
· mailto:andre.p.saadoun@wanadoo.fr
Gingival Recession Coverage
Dr. Andre Saadoun – March 27, 2009
Finest periodontist in the world: from Paris, France
See the real articles on http://www.implantarticles.com/ with full color photos
· High level of perio surgery
o 40% of the face is a smile
o Beautiful smile: healthy dentition, harmonious gingival contour
· Aslund, Suvan J Periodontal 2008:79:1031-1040
o The periodontal health of the subjects affects their smiling pattern and their smile-related to their quality of life
o Poor perio health may prevent adults from smiling…
· Periodontal Biological Parameters
o Lip Line
o Gingiva
o Bone
o Teeth
o Interdental papilla
o Biological width
· Lip Line
o Fxn: rest, speech, smile
§ Low lip line: 20%; Medium:70%; High:10% (Beyond 3mm)
· Gingiva
o Look at gingival level
o Form: Scalloped, flat
o Biotype: thin, thick
§ Thick – flat contour of gingiva
o Quantity: small, large
· The amount of keratinized gingival extends from the FGM (Free Gingival Margin) to the MGL (Muco-Gingival Line) minus the pocket depth in the absence of inflammation
· Stetler and Bissada 1987
o Higher chance of gingival inflammation wih subgingival restorations
· Bone
o In healthy patients, the gingival follows the underlying osseaous/CEJ contours
· Chu’s Aesthetic Gauges Proportions: (Hu-Friedy)
o See drawing for esthetic proportions
· In-line tip
o Another esthetic gauge
· Maxillary teeth
o Women have longer teeth than men due to aggressiveness of men
o Tell lab about gender (especially anteriors)
· Interdental papilla (Note IHB – Interproximal bone height)
o Class 1 IHB – Optimal prognosis 2mm from CEJ
o Class 2 IHB – Guarded prognosis 4mm from CEJ
o Class 3 IHB – Poor prognosis >5mm from CEJ
· Tamow et al 1991 2008
o The height of the contact decreases from the central to the molar
§ 4mm at cental incisors, 3mm at laterals, 2mm cuspids, 1.5mm premolars, 1mm molars (Chu, Tamow)
§ The ideal length of the ID papillae is about 40% of the length of the tooth from the gingival zone
o The mesial and distal papilla are about equal height
o The apical pt of the contact surface area determines the height
· Biological width
o Junction of epithelium and connective tissue (Not gingival sulcus)
o See drawing for Biological width
o Also see drawing for Chu’s biological width instruments
o 3mm from gingival crest to bone
Crown Lengthening
· Use this when you have THICK tissue
· Without osseous resection
o No flap elevation
o Initial display: excessive gingiva when she smiles (AA Female who models)
§ Models, x-rays, photos
§ CEJ to bone 1mm (normal) – but 6mm from gingiva to bone: can remove 3 mm
§ Internal bevel gingivectomies (Blade 15C)
· Vicryl 5-0 to hold the papillae in place and to slow down the bleeding
· Continuous vertical mattress sutures throughout
§ Must suture this kind of case to maintain papillae when cutting papillae
o If you can not touch papillae - e.g. for long, triangular teeth OR diastema
§ Crescent incisions (like croissant leaving papillae alone)
§ Zenith on canine is on distal, lateral in middle, centrals slightly distal
· With osseous resection and no flap (use bur in sulcus on bone)
o Short teeth, chipped edges but only 3mm sounding
o Must sound the bone
o Need to remove some bone: use fine diamond – don’t touch papillae
§ Leave 2-3 months before doing final restorations
§ No flap elevation during bone removal
o Can do this with moderate and thick type gingiva
· Want to achieve predictability
o Plan PROPERLY
o Everything in the body needs to work in HARMONY
o Think before jumping
o NEVER touch the palate on the esthetic zone
· With osseous resection and flap elevation
o Lip line uneven: will need perio with laminates
o Do a wax-up
o Do a full thickness flap
o Papillae will take 6-8wks to drop back down
· If you do single tooth crown lengthening: DO NOT INCLUDE THE PAPILLAE
· When probing: CEJ should be 1.2mm incisal to bone
· From diagnosis comes multiple treatment plans
Treatment of Gingival Recession
· Use this when you have THIN tissue
o The demand on thin tissue increases – demand is increasing
· Miller’s gingival recession classification
o I No extension to MGJ: no periodontal loss in the interdental bone/papilla
o II Extension to or beyond the MGJ, no periodontal loss in the interdental papillae
o III Extension to or beyond the MGJ, partial periodontal loss in the interdental papillae
o IV Extension beyond the MGJ, full periodontal loss in the interdental papillae
· Success rates per diagnosis
o Class I – Can 100% cover the recession
o Class II – Can get 100% coverage
o Class III – Can get 50-75% coverage
o Class IV – Only get 0-10%: Not worth even trying
· Zuchelli et al J Perio 2006; 4:714-721
o The line of root coverage is predetermined by calculating
· Restore cervical region AFTER perio surgery
· Connective tissue graft
o Get CT from palate
o Place it, and let it heal
o Tell pt in advance about prognosis
· Alloderm grafts will not work with no bone present
· Submerged Connective Tissue Graft
o Bridge with pink acrylic
o Do surgeries in stages if needed
o You can use pouch or flap
§ Pouch: Apical to MGJ
§ Make sure you loosen circumferentially
· Horizontal tunneling
o Premedication: Prednisone 40mg/50kg morning of; Antibiotics day before; Chlorhexidine; Ibuprofen 600mg 1 hr before
o Prepare bed with ophthalmic blade or 15C
§ Tie suture around 1 end, pull through, suture it into place
· Enamel matrix derivative (alloderm) emdogain
o Report the recession length on the papillae with perio probe
o 1mm deep full thickness, then do partial thickness flap
o Keep the papillary tips
o Emdogain – embryonic acid gel on for 3 minutes after scaling and root planning/acid/wash and then emdogain
§ Must use suspensory sling vertical sutures
· Knot is on occlusal
§ Excellent results
§ Circular incisions
§ Fine diamond burs to root plane
§ Keep the tip of the papilla
§ Use round diamond to decrease root abrasion and remove epithelium interproximally
§ Vicryl 5-0 is used with 19 needle (instead of 13)
· Alloderm Free Gingival Graft – Acellular dermal graft material
o Lower incisor case
o Use Blade 15C
o Need to see patient every 3 days for 6 weeks
o The alloderm needs to be VERY firmly bound down
§ Basal side goes toward roots
§ Alloderm dermal side goes toward the flap
§ Must suture the alloderm in a specific way to steady the flap
§ Never allow the alloderm to be visible at the end
o There will be a lot of gingival deformities
§ Heals very slowly
· Combining alloderm and emdogain
o To increase the length and the thickness
o Emdogain with alloderm increases the amount of keratinized tissue
o Emdogain is injected underneath the alloderm
· After alloderm: WAIT 10 weeks – for ortho, or restorative tx
· I’m not going to cut your gums… I’m going to raise your gums
· Smokers have less root coverage than non-smokers (58% versus 83%)
o Smoking destroys grafts
o No sinus elevations on smokers
o No grafts on smokers
· Can create membranes with PRF
o Platelet rich plasma is the best membrane
o EXCELLENT results with PRP, PRF
Conclusions
· If there is less than 3mm of gingiva around the recession, you must augment the qulity and quantity with emdogain and alloderm
o Suture any mistakes early
· Tunnel: Less complications, less discomfort, minimally invasive
· Beauty: Based on culture
· Details make perfection
· Smiles are important ways to communicate to people
· In perio-plastic surgery: you can improve the smile of a patient
o Gingival disharmony
o Gingival Excess
o Buccal Gingival recessions
· Know the classifications
· mailto:andre.p.saadoun@wanadoo.fr
Subscribe to:
Posts (Atom)
