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C A S E S T U D Y Bone Sculpting to Achieve Papilla Regeneration Around Dental Implants Michael Sonick, Assistant Clinical Professor of Surgery ideal implant restoration. likely to fill the embrasure space DMD Yale School of Medicine Substantial alveolar bone in the and a black triangle would Private Practice New Haven, Connecticut Limited to Periodontics proper position allows the clini- appear. If the vertical distance and Dental Implants Guest Lecturer cian to place the implant in the from contact point to alveolar Fairfield, Connecticut International Program New York University ideal mesial-distal, facial-palatal, bone measured 5 mm or less, a Phone: 203.254.2006 Fax: 203.254.9201 School of Dentistry and occlusal-apical positions.2 papilla would be present almost Email: New York, New York Thus, an ideal soft tissue profile 100% of the time. The same has Boomerdent@aol.com may be achieved. In addition, the been found true with dental ental implants have moved If adequate bone for implant proper dental-gingival relation- implants. To assure that a papillaD into mainstream dentistry. They are now part and par-cel of routine dental practice. The placement is not present (Figures 2 and 3), the clinician must decide whether to graft at ships can be created between the implant crown and the gingiva, and between the implant crown is present, the distance from the contact point of adjacent crowns to bone should be around 5 mm.predictable success of dental the time of implant placement or and the adjacent crowns. Dental The horizontal relationshipimplant therapy1 has led to a to bone graft before implant gingival harmony is the thera- between teeth has not beenrise in the number of dental placement. Grafting at the time peutic endpoint. addressed in papilla regenera-implants being placed. Osseo- of implant placement has the fol- Last, but not least, a papilla tion. However, with adjacentintegration is now almost taken lowing advantages: must be present to ensure an implants, it has been determinedfor granted. However, the esthetic • The patient does not have to esthetic restoration. The pres- that a distance of 3 mm is neces-success of dental implants is not go through a separate surgical ence or absence of a papilla sary to prevent bone loss andso predictable, and is therefore not procedure. between implants or between an hence loss of papilla.4 In antaken for granted. • The amount of time from implant and a natural tooth attempt to make papilla regener- Achieving successful esthetic surgery to the final restoration is depends on two variables, per ation between dental implantsimplants begins with a proper diminished. the author’s experience: more predictable, the followingbony foundation in which to place • There is less cost to the • the vertical distance be- rules apply:the dental implant. Adequate patient. tween the contact point of the • Allow for a distance of atbone must be present if one is to However, the major disad- adjacent crowns and the crest of least 3 mm between adjacentdevelop the proper emergence vantage is surgical complication. the alveolar bone implants.profile, soft tissue contour, crown- Should the graft become infected • the horizontal distance be- • A distance of approximatelyto-gingival relationships, and or heal less optimally, the tween the implants at the 5 mm should exist between thepapilla formation (Figures 1A implant may fail. Worse yet, the implant–abutment interface or contact point of adjacent crownsthrough 1C). Three possible situ- implant may integrate but with between the implant and natural and the crest of the alveolar bone.ations are possible when implant less than optimal bone forma- tooth at the level of the alveolar The reformation of papillatherapy is considered: tion. An integrated implant with bone. between prosthetically restored• Bone is present at the time of significant bone loss is not an Tarnow and colleagues3 dem- teeth has become a relatively pre-implant placement. ideal starting point for an esthetic onstrated that as the vertical dictable procedure. Similarly, the• Bone is grafted before implant restoration. In fact, it is a pre- distance between the contact reformation of a papilla between aplacement (site development). scription for esthetic failure. point of adjacent crowns and the single implant and a natural tooth• Bone is grafted at the time of An adequate bony founda- crest of the alveolar bone is much more straightforward.implant placement. tion is the starting point for an increased, the papilla was less However, the reformation andFigure 1A—The patient was missing Figure 1B—Ideal papilla formation was Figure 1C—A smile view reveals the Figure 2—An osteotome was used to pre-tooth No. 9. seen in this patient with tooth No. 9 beautiful harmony and esthetics of the cen- pare the implant site of tooth No. 8. The replaced with a dental implant. tral incisors. (Restoration courtesy of Dr. atrophied ridge was expanded with the Stephen Rothenberg, Darien, Connecticut.) osteotome, allowing an implant to be placed in the area of tooth No. 8.46 June 2002 CONTEMPORARY ESTHETICS AND RESTORATIVE PRACTICE
Case Study continuedFigure 3—Implants were placed in ideal Figure 4—View of the patient 3 days after Figure 5—Intraoral view of the provisional Figure 6—Radiograph taken 3 days afterpositions. Implants were 3 to 4 mm from being hit in the mouth by a 2 × 4 during an restoration. the accident. Note that tooth No. 9 wasthe anticipated CEJ and from each other. industrial accident. His lip had been horizontally fractured. The patient lostNote the amount of bone present between recently sutured and he was wearing a new tooth No. 8 more than 20 years earlier.the implants that would eventually sup- provisional restoration—a one-tooth can-port the interdental papilla. tilever with tooth No. 9 as a lone abutment.maintenance of a papilla between planning template is provided in Implants (3i Implant Innovations Bone Graftingadjacent implants is often consid- Table 1. It serves as a guide Inc.) were placed in the areas of Bone regeneration is neces-ered much more difficult. The for implant dentistry. Alterations teeth Nos. 8 and 9. They were sary around both implants topurpose of this article is to to the protocol may occur because placed approximately 4 mm apical have a predictable stable result.demonstrate a predictable way to of individual variations. However, to the anticipated cemento- Autogenous bone was harvestedregenerate papilla between adja- the basic sequence is useful. enamel junctions (CEJs) of the from the osteotomy sites using acent implant crowns. In addition, implant crowns. This would bone trap (Osseous Coagulumthe concept of bone sculpting Surgical Treatment allow a proper emergence profile Trap, Quality Aspirators) andwill be discussed along with the Tooth No. 9 was determined for the final restoration.2 From a placed into sterile saline. A com-following case, which is used to to be hopeless because it had restorative perspective, both bination of 50% autogenous bonedemonstrate these concepts. a vertical root fracture. It implants were in good positions. and 50% demineralized freeze- was determined that it would However, they were not com- dried bone allograft (AmericanCASE STUDY be extracted and an implant pletely in bone. Implant No. 8 Red Cross) was then placed over The patient, a high school would be placed into the extrac- was stable but had nine threads the labial surface of implant No. 8woodworking instructor, was tion site. Immediate implants exposed on the labial (Figure 3). and into the extraction site ofreferred for evaluation 3 days have been shown to have a suc- Implant No. 9 was embedded in tooth No. 9, filling the voidafter trauma to the anterior max- cess rate similar to that of bone, but had a circumferential around the implant (Figure 8). Anilla (Figure 4). He had sustained delayed implant placement.5 defect (Figure 8). expanded polytetrafluoroethylenea traumatic injury to the lip, Tooth No. 8 was also to receive (e-PTFE) membrane (Gore-Tex®maxillary anterior alveolus, and an implant. Before surgery it was TABLE 1—TREATMENT oval 6, W.L. Gore & Associatesmaxilla left central incisor when not known whether an implant PLAN TEMPLATE Inc.; distributed by Nobela 2 × 4 piece of wood catapulted could be placed, because the 1. Clinical and radiographic Biocare USA) was placed over thefrom a table saw to his face. tooth had been lost for more evaluation. graft and stabilized with two The patient had lost his max- than 20 years and it was not 2. Joint consultation miniscrews (Figure 9). Stability ofillary right central incisor 20 known how much ridge resorp- between periodontist and the use of a membrane in con-years earlier. This had been tion might have occurred during restorative dentist. junction with a bone graft is oftenrestored with a single cantilever this time. A therapeutic contin- 3. Fabrication of provisional the most predictable method totooth off a restored left central gency involved grafting the tooth restoration. obtain bone regeneration.7 Theincisor. As an emergency proce- No. 8 site for a future implant. 4. Implant placement and author has found that the use of adure, a new provisional restora- After local anesthesia, a full- bone regeneration, if membrane in conjuction with ation was made (Figures 4 and 5) thickness flap was elevated to necessary. bone graft is the most predictablebefore his referral. Radiographs expose the underlying alveolar 5. Two to 6 months of healing. method to obtain bone regenera-revealed that tooth No. 9 had a ridge (Figure 7). Significant atro- 6. Second-stage surgery tion around implants.midroot horizontal fracture and phy of the alveolar ridge was including bone sculpting Primary closure is also essen-was hopeless (Figure 6). noted in the area of tooth No. 8. and placement of EP tial to eliminate the possibility of Bone augmentation with ridge Temporary Healing bacterial infiltration and subse-The Treatment Plan expansion was indicated. Using a Abutments®. quent infection (Figure 10). A Treatment planning is the sine Summers Osteotome Kit (3i 7. One month of healing. connective tissue graft was har-qua non of predictable esthetic Implant Innovations Inc.) the 8. Implant level impression. vested from the hard palate anddentistry. The treatment plan is ridge was expanded according 9. Placement of permanent placed over the membrane andthe template on which the to Summers’6 principles. The abutments and provision- occlusal surfaces of the implants. Itclinician can develop an ideal ridge was too narrow to com- alization. was stabilized with a 5-0 gutrestoration. The development plete expansion with an 10. Papillary maturation. suture (Ethicon Inc.) to prevent itsof the treatment plan allows osteotome. However, the use of 11. Final impressions of abut- egress. Primary closure was thenfor excellent communication be- an osteotome would allow ments and impression of achieved using Gore-Tex® CV-5tween the restorative dentist and enough increase in ridge volume provisional restoration. sutures. These sutures allow forthe periodontist. This is essential for an implant to be placed and 12. Temporary cementation of synching of the flap and excellentto predictably create a restoration stabilized (Figure 3). the final prosthesis. adaptation. The e-PTFE suturesthat will be esthetic. A treatment- Machine Titanium Threaded also do not wick bacteria. Wound48 June 2002 CONTEMPORARY ESTHETICS AND RESTORATIVE PRACTICE
in alveolar mucosa. Healing was pass before the implants were necessary to remove bone to extremely rapid in this tissue. uncovered, thus allowing for opti- access the cover screws of the Nonresorbable sutures can be very mal bone regeneration. A full- implants, and additional bone difficult to remove when within thickness flap was elevated and also would have to be removed to alveolar mucosa because of the the e-PTFE membrane removed create a smooth emergence pro- rapidity of the healing. Therefore, (Figure 11). Complete bone file. The removal of bone to a resorbable suture was used. regeneration was noted beneath achieve the proper soft tissue con- the membrane. The immediate tour (bone sculpting) can be ac- Second-Stage Surgery Including implant placed within the alveo- complished three ways (Table 2).Figure 7—Surgical view on the day tooth Bone Sculpting lar bony housing was completely All three bone sculptingNo. 9 was extracted and implants placedat teeth Nos. 8 and 9. A large full-thick- Six months were allowed to regenerated (Figure 11). It was methods work. Hand instru-ness flap has been elevated, providing ade-quate access for implant placement andbone grafting.Figure 8—Occlusal view of the implants inplace before placement of the bone graftingmaterial. The implant in the area of toothNo. 9 was completely housed within bone.However, a circumferential defect was pre-sent and regenerated with the application ofa bone graft. A membrane was not needed.Figure 9—Facial view of the e-PTFEmembrane in place. Note that the mem-brane does not cover the implant in thearea of tooth No. 9. Two mini-screws wereused to stabilize the membrane.Figure 10—Primary closure was achievedusing e-PTFE sutures. The vertical inci-sions allowed the flap to be elevatedocclusally. A connective tissue graft alsowas harvested from the palate and placedbeneath the flap to assure primary closure.healing is much improved,because these sutures cause mini-mal irritation to the epithelium.The vertical incisions were closedwith 5-0 gut sutures, as they were Circle 32 on Reader Service CardCONTEMPORARY ESTHETICS AND RESTORATIVE PRACTICE June 2002 49
Case Study continuedmentation is the most tedious Inc.) create a smooth emergenceand time consuming. If the bone profile efficiently and safely. This TABLE 2—BONEis thick, it is not always practi- is the author’s bone sculpting SCULPTING TECHNIQUEScal to rely solely on hand instru- technique of choice.mentation. High-speed rotary Bone profilers were used to • Hand instrumentationinstruments such as finishing burs create a smooth emergence pro- with chisels and curets.and Neumeyer burs are very effi- file (Figure 12). The bone was • High-speed rotary instru-cient. However, the platform of sculpted; this was possible mentation using finishingthe implant is not protected and because the implants were burs and Neumeyer bursmay be damaged during the pro- placed a little greater than 3 mm (Brasseler USA®). Figure 11—Second-stage surgery was per-cedure. Bone profiling instru- from each other and slightly • Bone profiling instruments. formed at 6 months. Complete bone regener-ments (3i Implant Innovations beneath the crest of bone. A peak ation occurred on the facial surface of the implant in the area of tooth No. 8. Seven previously exposed labial threads were now covered with bone. The implant in the area of tooth No. 9 also was well integrated. Figure 12—The platforms of the dental implants after bone removal, removal of the cover screws, and bone sculpting. There is a peak of bone between the implants. A smooth emergence profile could now be achieved. Figure 13—Temporary healing abutments were placed. Resultant papilla would form between the implants. of bone was created to guide the soft tissues of the gingiva to form a papilla. If the implants were placed within 3 mm of each other, it was likely that the bone would resorb and the peak of bone (Figures 12 and 13) would be lost, per the author’s experi- ence. Hence, the papilla would shrink and a dark triangle would form between the implant crowns. After the completion of the bone sculpting, EP Temporary Healing Abutments® (3i Implant Innovations Inc.) were placed (Figure 13). The wound was sutured and allowed to heal for 4 weeks. Four weeks after implant exposure, a Circle 33 on Reader Service Card papilla was already beginning to form, despite the absence of a50 June 2002 CONTEMPORARY ESTHETICS AND RESTORATIVE PRACTICE
Case Study continuedFigure 14—View 4 weeks after the sec- Figure 15—Permanent abutments were Figure 16—The provisional restoration Figure 17—The final restoration in place, 2ond-stage surgery. The soft tissue was placed and the patient was about to receive in place. Papillae were maturing and the days after temporary cementation. The gin-healing and a papilla was beginning to the provisional restoration. A piece of floss appropriate dental-gingival relationships gival tissues were still slightly inflamed andform, despite the absence of a provisional was used to help visualize the dental gingi- were achieved. The patient had been complete papillary regeneration had not yetrestoration. val-marginal relationships. wearing the provisional restoration for 2 been achieved. Within 1 year, the papilla months. He was now ready for final and soft tissue would be stable. (Laboratory impressions. work courtesy of Precision Dental CeramX: Jim Mallick, CDT, and Tim Anrico, CDT, both of Fairfield, Connecticut.)fixed provisional restoration UCLA abutments (3i Implant then allowed to heal in the pro- an impression of the provisional.(Figure 14). Innovations Inc.) were made, or visional until the dentist and The provisional impression serves machined prepable abutments patient were both satisfied with as a template for the laboratory toProvisionalization could be chosen. A provisional the tooth-to-soft-tissue relation- make the final restoration. The patient was now ready restoration was made to fit the ships. During this phase of care, The final restoration wasfor provisionalization. Initial soft custom or machined abutments the provisional restoration can made with a high degree of pre-tissue healing was now complete and delivered to the restorative be modified to help guide the dictability. This sequence ofand the gingival tissues were sta- dentist. The permanent abut- soft tissue. The goals of therapy events minimizes laboratory make-ble. An impression was made of ments were placed (Figure 15), of the provisional phase are: overs. It saves time for the patient,the implants at the level of the followed by placement of the • development of a dental dentist, and laboratory, and makesplatform. This was transferred to acrylic provisional restoration papilla esthetic rehabilitation predic-the laboratory and custom (Figure 16). The patient was • obtaining a smooth emer- table and hence, more enjoyable. gence profile The final restoration became a • achieving dental-gingival recapitulation of the provisional harmony restoration (Figure 17). Papilla • creation of proper tooth reformation had been achieved shape, size, and contour. between the implant crowns as The above requirements well as between the implant must be met before impressions crowns and the natural teeth. The are taken for the final restora- height of contour of the central tion. In no instance should final incisors was equal to the height of impressions be taken until an contour of the canines and apical ideal provisional restoration has to that of the lateral incisors been achieved. The provisional (Figures 17 and 18). All this is restoration is a template for the possible because the treatment final restoration. All too often, plan template was followed. too little attention is paid to the provisional restoration. If ideal one profilers esthetics are not achieved in the provisional, it is unlikely that ideal esthetics will be obtained in B were used to create a smooth the final restoration. FINAL IMPRESSIONS AND emergence profile. THE FINAL RESTORATION Final impressions included Radiographically, a smooth impressions of the permanent emergence profile was evident abutments and of the soft tissue. (Figure 19). In addition, the peak A soft tissue model should of alveolar bone between the be fabricated to allow the labora- implants could be visualized; this tory to create a restoration with supported the papilla. The the proper emergence profile. distance from implant crown con- In addition, final impressions tact point to bone was 5 mm and should also include an impres- the distance between implants sion of the provisional restora- was between 3 and 4 mm. The ini- Circle 35 on Reader Service Card tion. The laboratory now has the tial parameters of papilla regenera- abutment impression as well as tion between implants were fol-52 June 2002 CONTEMPORARY ESTHETICS AND RESTORATIVE PRACTICE
recede during the first year after the implant crown is cemented.8 Product References Six years after the cementation of Product: Summers Osteotome Kit, Product: Gore-Tex® oval 6, Gore-Tex® the restoration, the patient Machine titanium threaded CV-5 suture implants, Bone profiling instru- Manufacturer: W.L. Gore & Associates Inc. showed about 1 mm of labial gin- ments, EP Temporary healing Distributor: Nobel Biocare USA abutments®, UCLA abutments Address: 22985 Eastpark Drive gival recession and complete fill Manufacturer: 3i Implant Innovations Inc. Yorba Linda, CA 92887 Address: 4555 Riverside Drive Phone: 800.891.9191 and maturation of the papilla Palm Beach Gardens, FL 33410 Fax: 800.451.9047 between the implants (Figure 20). Phone: 800.342.5454 Fax: 561.776.1272 Product: 5-0 plain gut suture Manufacturer: Ethicon Inc. Product: Osseous Coagulum Trap Address: US Route 22 WestFigure 18—Smile view of the patient CONCLUSION Manufacturer: Quality Aspirators Inc. Somerville, NJ 08876with the new implant crowns. Compare Address: 1419 Goodwin Lane Phone: 800.225.2500to Figure 2. Ideal dental-gingival rela- Predictability in esthetic Duncanville, TX 75116 Fax: 732.562.2212 Phone: 800.858.2121tionships were achieved. implant dentistry is possible. Fax: 972.298.6592 Product: Neumeyer burs Manufacturer: Brasseler USA® This article outlines a treatment Product: Demineralized freeze-dried Address: 1 Brasseler Boulevard plan template that should serve bone graft Savannah, GA 31419 Manufacturer: American Red Cross Tissue Phone: 800.841.4522 as a guide for communication, as Services Fax: 912.927.8671 Address: 7401 Lockport Place well as treatment. The concept of Lorton, VA 22079 Phone: 800.693.6272 bone sculpting and its clinical significance is essential in laying the foundation for an esthetic, functional restoration. Excellent communication between restorative dentist,Figure 19—Radiograph of the implants implant surgeon, dental labora-with the final restoration. Note the peak tory, and patient is essential ifof bone between the implants. This would predictable results are to beserve as support for the gingival papilla. achieved. Each step of the treat-Also note the smooth emergence profile,from the platform of the implants to the ment planning process is only asCEJs of the implant crowns. strong as the preceding step. The success of the final crown rests on the quality of the provisional, which in turn rests on the quality of the laboratory-fabricated crown and abutment—which rests on the quality of the bone and soft tissue, the quality of the surgical technique, and the quality of the treatment plan. All elements of the dental treatment plan should beFigure 20—Intraoral view of the implantrestorations 1 year after cementation. strong to allow for an estheticNote that there has been about 1 mm of implant restoration.labial gingival recession. The gingival tis-sues have matured and the papillae now REFERENCESfill the embrasure space between the 1. Adell R, Eriksson B, Lekholm U, et al: Long-term fol-implants and between the implants and low-up study of osseointegrated implants in thenatural teeth, an ideal esthetic result. treatment of totally edentulous jaws. Int J Oral(Restoration courtesy of Dr. Stephen Guss Maxillofac Implants 5(4):347-359, 1990.of Fairfield, Connecticut.) 2. Sonick M: Hard and soft tissue regeneration for implants in the esthetic zone. Contemp Esthet Rest Pract 5(10):64-76, 2001. Figure 21— 3. Tarnow DP, Magner AW, Fletcher P: The effect of the Postoperative view, distance from the contact point to the crest of bone full-face smile. on the presence or absence of the interproximal den- tal papilla. J Periodontol 63(12):995-996, 1992. 4. Tarnow DP, Cho SC, Wallace SS: The effect of inter- implant distance on the height of inter-implant bone crest. J Periodontol 71(4):546-549, 2000. 5. Gelb DA: Immediate implant surgery: three-year ret- rospective evaluation of 50 consecutive cases. Int J Oral Maxillofac Implants 8(4):388-399, 2000. 6. Summers RB: The osteotome technique: Part 2—the ridge expansion osteotomy (REO) procedure. Compend Contin Educ Dent 15(4):422-436, 1994.lowed. The result is an esthetically 7. Buser D, Dula K, Hirt HP, et al: Localized ridge aug- mentation using guided bone regeneration. In: Buserpleasing restoration (Figures 17, D, Dahlin C, Schenk R, Guided Bone Regeneration in18, and 20) and a happy, smiling Implant Dentistry. Chicago, Quintessence Publishingpatient (Figure 21). Co., 189-233, 1994. 8. Small PN, Tarnow DP: Gingival recession around Over time, soft tissues contin- implants: a 1-year longitudinal prospective study.ue to mature. Soft tissues may Int J Oral Maxillofac Implants 15(4):527-532, 2000. Circle 50 on Reader Service CardCONTEMPORARY ESTHETICS AND RESTORATIVE PRACTICE June 2002 53