Implant Seminars

Esthetic Outcomes in Implant Dentistry

Dr. David Garber – May 8, 2009

 

Dr. Garber

·         Periodontist and prosthodontist

·         “Change Your Smile” Ronald Goldstein

Topics

·         Implants 2009 (What are the main concerns)

o   Rapidity

§  Design

·         Microgeometry

·         Macrogeometry

§  Tissue Engineering

o   Esthetics

§  Labial

§  Proximal

Illusion of Reality

·         Esthetics is about beauty

·         The soft tissue is the biggest factor

·         The CHALLENGE

o   The porcelain is no longer the challenge

o   Redeveloping bone is tougher than porcelain

o   The REAL challenge is THE ZONE: 3mm Papillae, Keratinized tissue

·         PINK, WHITE, LIPS, FACE

Components of Implant Esthetics

·         If the ZONE is intact, the restoration is simple

o   Look at buccal gingival contour compared to contralateral tooth

·         In order to avoid esthetic failure, you need to DEVELOP the site

ALL IS AVAILABLE ONLINE: www.dentalxp.com

·         Type 1 Site

o   Ideal

o   Great bone

o   No loss of buccal plate

o   Normal interproximal contact

·         Type 2 Site

o   Labial plate is gone

o   Great Interproximal bone

·         Type 3 site

o   Interproximal bone loss

§  No way to regenerate interproximal bone

o   Horizontal/Vertical

·         Timing, Positioning and Sequential Staging (Funato, Salama, Garber, Int J Perio Rest Dent 2007; 27:313-323)

o   Look at Table 1: Timing, when to do immediate, staged surgeries

o   Look at Table 2:

Type 1 Case

·         You want to prevent the loss of the buccal plate

o   Use BioOss outside of the buccal plate to have slow resorption and prevent the loss of buccal plate

·         Ronal Jung: 2mm rule – Need 2mm of gingival thickness to prevent visualization of implant abutment (titanium or zirconia)

·         Grimdau (sp?) Another 2mm rule: Need 2mm buccal bone to prevent loss of buccal plate

 

ONE ABUTMENT, ONE TIME

·         Due to bone loss around gingival collar: Occurs within 1 hour

·         Misch claims that the loading stress causes the circumferential bone loss

·         IN REALITY: BACTERIA coming out of the screw hole cause the circumferential loss

o   Affects the biologic width

o   Abraham: check it on DENTALXP.com

·         HOW TO AVOID IT:

o   Platform switching

§  3I and Ankylos do it

§  A way to compensate for bone loss

o   Dentomycin (must get it from Canada)

§  It’s acromycin in a gel form

·         Less Bacteria

§  Sometimes need to use cortisone as well

·         Less inflammation

·         Best abutment connections for bone preservation: BICON (but no way to index the abutment, need to hammer it in, and no threads to implant)

·         NOTE: You need 2mm buccal bone to preserve the buccal plate

CRITICAL THINKING IN ANTERIOR IMPLANT PLACEMENT

·         Avoid stressing the labial plate’

·         Graft the xt socket whether or not you place the implant abutment

·         Allograft/Xenograft for longer term maintenance of scaffolding effect

·         Minimum 2mm of Soft Tissue thickness

·         Minimum 2mm of Buccal bone thickness

·         BIOTYPE

o   If thick biotype: No flap, Atraumatic ext, place implant, try in different types of contoured abutments, find the best one, and seat that one PERMANENTLY (eg Zimmer HLA abutments), Make a temp

o   If thin biotype: Flap it, graft it with bone AND Soft tissue from the palate

·         Submergence profile

o   Don’t see it, but has a HUGE impact on buccal gingiva – should make it concave

o   Concave preserves buccal tissue

o   If convex – Will cause recession (NOT GOOD)

o   If concave – Will cause growth of tissue

·         Emergence profile

o   If you want more tissue, make it less convex

o   If you want to push down the tissue, make it more convex

2 QUESTIONS TO CONSIDER WHEN TX PLANNING

1.       Smile Line?

a.       Is it high?

                                                               i.      Better Make sure you look at things VERY carefully

2.       What are the patient’s expectations?

a.       Not only of the implant, but of ALL the teeth

Type 2 Case

·         Loss of buccal bone

·         USE A BLOCK GRAFT from the ramus or the symphysis

·         Use a pieso: nice clean cut

·         Check bone with sounding: use a #30 endo file

·         These kinds of grafts require Bio-Oss bone as well

·         Wait 3 months before implant placement

Type 3 Case

·         Loss of interproximal bone height

o   CANNOT regenerate interproximal bone height with surgery

o   Need to use ORTHODONTICC EXTRUSION TO GAIN INTERPROXIMAL BONE HEIGHT

·         A hopeless tooth is not useless, it’s actually quite useful

o   Orthodontic extrusion

·         SALAMA & GARBER 1998

o   Papillae presence based upon Interproximal Height of Bone next to the NATURAL TOOTH (Not the implant)

·         Orthodontic extrusion

o   Can extrude a tooth 1mm every 10 days

o   Nitenol wire 012-014 (for lighter forces)

o   Must keep shaving the incisal edge

o   Once at the right level, WAIT for 3 months before ext and implant

LARGE Block Grafts to build mandibular posterior height

·         Wait 4 months before placing implants

Smile Design

·         Make sure you have gingival contours related to the upper smile line

·         G+L+I=Case Type

o   G=Gingival Harmony

o   L=Labial Plate

o   I=Interproximal Height of bone

·         Patient expectations

o   Periodontal

o   Occlusal

o   Structural

o   NOTE: Biotype (if thin, add in costs)

·         Lip Line

o   How it relates to teeth

·         Age

o   Make sure epiphyses are closed (Female: 16y/o)

·         Do an initial SMILE ANALYSIS

o   Look at gingival contours

Semilunar Grafts

·         Semilunar incision at MGJ

·         Sulcular incision Sharp Opthalmic blade

·         Slide down the tissue

Tunnel Technique

·         Use Brassler Tunnel technique

·         Use palatal tissue

·         NO brushing for 10 days

·         KIRK PASQUINELLI on Dental XP

Frenectomy

·         Laser

Loss of Papillae

·         ALWAYS DO ORTHODONTIC EXTRUSION

·         Note: There is a COL between the buccal and palatal papillae – that’s where the contact point is

·         Sounding witn an endodontic #30

On Congenitally Missing Teeth

·         Must recontour the bone before placing the implant

·         Use soft tissueto help the contour of the buccal

·         Place implants deep, especially on buccal side

·         Lateral incisors

o   Missing bone buccally

o   Look at Hand Film to see if the epiphyses have formed (Thick Lamina Dura at the end)

o   See if they changed shoe size, or if they’re growing

o   Too much bone interproximally

o   Need to recontour bone, AND need to augment the buccal with palatal graft

Immediate Placement after Ext

·         Periotomes ONLY to be used on the Palatal, NEVER on buccal

·         Be as atraumatic as possible

·         Schein sells the TITAN EASY EXTRACT: Amazing extraction technique

o   Brasseler is excellent

o   Flatten the root

o   Use the drills in ORDER (White, Red, Blue)

o   Torque it in all the way to the base

o   See the line on the drill bit

o   Try in the tray without the putty

·         ANKYLOSIS

o   Drill through the apex with implant drills, and LOTS of water

o   Drill all the way until you see blood

o   Then use the periotome

o   If you see external root resorption

§  CUT the crown off

§  Core it out

Pieso Surgery

·         Wonderful way to remove teeth

o   Split root with Pieso

o   Infracture the lingual’Then infracture the buccal

·         Also great for harvesting bone form chin, mandible

Technique

·         After extracting atraumatically, Prognastically evaluate the site

·         KNOW YOUR SOUNDING DEPTHS

·         Selection of Implant Diameter & Position

o   1990’s: BIGGEST implant possible

o   2005: Smaller is better

·         Less than 2.25mm between implant and buccal plate: don’t need to graft

Immediate

·         Loading

o   Cross arch stabilization

o   OK

·         Temp Single tooth

o   OK

·         Unilateral bridges

o   DON’T DO IT!

·         40Ncm is OK to load with temporary

·         If you undercontour papillae, the get shorter

o   You need positive connection

·         If you undercontour the buccal emergence profile, the gingiva grows occlusally

o   You need negative contour

Gingival optical Esthetics

·         Zirconium needs fluorescence to make it more natural