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
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· Temporary / Final Restoration
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· Occlusal Trauma