Implant Seminars

Esthetic Outcomes in Implant Dentistry

Dr. David Garber – May 9, 2009

Sinus Lift

Use Metronidazole (Flagyl) in the sinus

Chin Block

Simplant will fabricate a Stereolithographic model out of the DICOM

If you want a LARGE bone block graft, you go through the mandible with Pieso through and through – bicortical cut

Fit the bone to the model, drill through

Vestibule goes back to normal within 2 years

Terminology

EFFICACIOUS – Defined as the probability of benefit of a tx when provided under ordinary conditions by the avg practitioner for the typical pt

He wants to give guidelines to think it though

Multiple Missing Teeth within the Esthetic Zone

Pts don’t come in for implants, they come in for: Esthetics, function, and normalcy

When missing centrals and Laterals, you lose bone buccally, palatally

Lose the arch form

Need to do narrower teeth, placed more lingually

Often times end up with LONG, skinny teeth with BROAD, LONG contacts

They end up being very rectangular teeth

The incisal edge starts to change cervically and lingually

The zenith changes from distal to slightly mesial

Get shortening of the perimeter of the ridge

Lip collapses

Showed us a case with 3 crowns and 3 implants

Difficult to maintain papillae between 2 implants

In retrospect: Instead of 3 in a row, do 2 with a pontic

BIG anterior defect around 3 implants

Salama, Garber 1995 JED: Use 3mm healing abutment with LOTS of CT graft over it acts like tent (The longer the tent pole, the more tissue you get)

Use ovate pontics to develop the site

Bone sounding IHB to visualize

PUT THE MIDDLE implant to sleep, don’t yank it!!!

Just don’t use it

Make sure you look at the entire arch: look for any need for tissue treatment

Crown lengthening?

Essex retainers are excellent for temps

Don’t do a flipper

Vertical bone is MUCH harder to rebuild than horizontal bone

Can get horizontal bone very predictably

Bone between implants and teeth

Esposito 1992: 1.5mm tooth to implant interproximal

Tarnow 2000: 3mm implant to implant

Avg: 3.4mm height of a papilla between 2 implants

That’s an average… 30% will have less than 3mm of papillary height

At centrals… you may want to consider platform switching to maintain the bone

Novaes (Bazilain): Shows that bone comes up between implants when they are 3mm apart, NEVER less than 3mm

Abutment/Implant Junction Inflammatory Cell Tissue Infiltrate (ICT)

2mm down and 1mm outward: Ericsson

Staging

If you have 2 centrals that need to be removed

Take 1 out and pace 1 implant, wait for healing

Then do the next a couple of months later

Platform Switching

Palotrisi: Platform switching

If you have platform switching, you need at least 1mm difference

Protect the developed site

ZEKRYA: Gingival retraction during prepping to save the meat

Trisi Vris: 2 pice platform switching makes a HUGE difference, but 1 piece does NOT

2 or 3 Implants

Do 2 instead of 3 in a row: you will have papillary loss

SOFT TISSUE HARVEST

Go from mesial of 1^st molar distal of canine

1^st Cut 15C is right angle all the way down to bone

2^nd cut 15C is parallel to palate

4-0 silk in X Form

Use 15C blade

Tunneling technique protects the gingiva

If you can’t get coverage, you must use autogenous CT

If you can’t harvest enough tissue, start using dermis

NOTE TO SELF: JOIN AGD, DOCS

Endodontically treated teeth

Can cut them at the gingiva or sub-G and cover it with CT to help MAINTAIN bone

JUST cover it up and put it to sleep

Notched teeth (V-Shaped)

USE GLASS IONOMER: Shofu (no hybrid)

THEN place C or dermis

Management of Fully Edentuous site

Can use his existing denture

Cover with Barium, take a CT

Drill thru the denture

Block it with Barricade (DENTSPLY) – It’s actually a periodontal dressing

For screw access holes

Punch holes on rubber dam

Reline with locators

The zone in the fully edentulous case

SURGICALLY GUIDED stents and model

Place 6 implants, parallel, and make a denture with gold copings

Titanium screw retained substructure

Surgically guided stent

Make titanium substructure

Pink composite

Use Panavia to cement the crowns

Severe Periodontal Disease

Upper, save whatever you can by splinting for now, 1^st visit: PUT IN LOTS OF BONE

1^st Visit: Temp supported by 5 teeth

2^nd Visit: Then a few months later, place 6 implants

3^rd Visit: 6 more fixtures into ext sites

Lower: Keep 3 teeth to maintain inter-arch relationships

2^nd Visit: Get bite relationships

2^nd Visit: EXT all except 3 at first, do a pick up temp denture on all but 3 implants

Screw retained hybrid

2^nd Visit: Place 8 fixtures, do a lower hybrid

3^rd Visit: Finalize and do cermic/metal

For immediate loading you can do it on roundhouse

Primary stability – Purely mechanical (Putting a screw into wood: NO biomechanical)

Secondary Stability – Osseointegration: this IS biomechanical

Cumulative Stability – The total stability of primary and secondary combined

Terrible decay on a Failed Roundhouse bridge

Ext 3 remaining uppers, place 12 implants

Cross arch stabilization

This took him 14 hours to do (first time)

Digital Rendering

Use Simplant

Get Atlantis Abutments made

Severe perio, partially edentulous (lot like Mr. DC)

1: Remove severely compromised teeth, make an essex

Essex uses denture teeth

1: Use Essex with Barium Sulfate and take a CT (Could use TempBond)

2: Plan bone grafting

Sinus lifts, bone blocks

Use laser to open up the short vestibule

3: Roughen snapcaps with prophyjet

Make temp and cement with tempbond

Multiple Teeth Missing

Judge needs them ASAP

Use available bone

Ext’s, guide, place implants

Barricaid

Fill into a syringe, place, wipe off excess with alcohol

PRGF

$1000 for unit, less than $14 per use

Papillae

Can partially recreate papillae AS AN ALTERNATIVE

Orthodontic extrusion if horizontal bone loss

CANTILEVERS MUST BE SCREW RETAINED

PINK CERAMICS: Christian Coachman

Look for his tough pink ceramic cases, look up Christian Coachman

MAKE SURE YOU HIDE THE SEAM WHERE THE PINK CERAMIC/COMPOSITE INTERFACES WITH GINGIVA AND THE LIPLINE!!!

Pink Ceramic, roughen it, create space for FGM, Etch with Hydrofluoric acid, Cover porcelain, Silanate

Then DIRECT PINK COMPOSITE

Needs to be considered IN ADVANCE!!!

Photography

Draw lines on the pictures!!!

Evaluate gingival margins!!!

Evaluate papillae

Evaluate smile line

Do a diagnostic waxup too!

Use this for Essex