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