Anterior implants building the foundation
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Anterior implants building the foundation

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    Anterior implants building the foundation Anterior implants building the foundation Presentation Transcript

    • First Mondays Study Club Robert C. Cain, DDS March 3, 2014
    • • To understand the differences between implants and natural teeth and how these differences can effect esthetics • To understand the factors associated with hard and soft tissues around implants that can effect the outcome of the restoration • To understand some of the different techniques that can be used to achieve hard and soft tissue goals
    • • Why are implant esthetics often more challenging than natural teeth? • What can we do to ensure the best possible esthetic and functional outcome? • What do we tell a patient who needs one or more teeth replaced in the esthetic zone?
    • • Implants preserve bone and soft tissue just as a natural tooth would. • Implants do not rely on adjacent teeth for support • Implants do not decay • Implants appear to be less susceptible to periodontal diseases than natural teeth • Looks, acts and feels like the real thing
    • • Cost • Time • Involves surgery • Insurance often does not cover implant procedures, especially some the more advanced grafting techniques
    • Natural Teeth • Roots made of cementum and dentin • Ovoid in cross section • Connection to bone by periodontal ligament • Connective tissue attachment to cementum • Gingival fibers run perpendicular to tooth surface Implants • Made of Titanium with textured surface • Round in cross section • Direct connection to bone by osseointegration • No connective tissue attachment • Gingival fibers are circular
    • • Roots made of cementum and dentin • Ovoid and cross section • Connection to bone by periodontal ligament • Connective tissue attachment to cementum • Gingival fibers run perpendicular to tooth surface
    • • Made of Titanium with textured surface • Round in cross section • Direct connection to bone by osseointegration • No connective tissue attachment • Gingival fibers are circular
    • • Tissue Biotype – Thick or Thin? • Smile Line – High or Low? • Amount of Tissue Scallop – High or Low? • Interproximal Bone Levels – Normal or Reduced? • Facial – Lingual Bone Dimensions – adequate or reduced. How much is enough?
    • • Bone Loss Around Tooth/Teeth to be Replaced? • Amount of Infection Around Tooth/Teeth to be Extracted • Restorations on Adjacent Teeth – could effect the overall outcome • Patient Expectations!
    • • Careful Treatment Planning – Study models (diagnostic waxups), x-rays (including CBCT), photos, occlusal analysis • Preserve Hard and Soft Tissue – Atraumatic extractions, Immediate implant placement where possible – Bone and soft tissue grafting to rebuild lost tissue – Proper provisional design • It’s the surgeon’s job to build the foundation for the restoration
    • • Proper Implant Placement – Must allow for ideal emergence profile, functional occlusion and esthetic contours • Understand Limitations of Tissue Contours around Implants – What determines papillae height and shape – Use of ovate pontics where needed
    • • The Soft Tissue Around the Implant • Specifically the Buccal Tissue and the Interproximal Papillae • “The Tissue Is The Issue”
    • • Two Scenarios – Implant – Implant – Implant – Tooth • A series of articles by Dennis Tarnow – The Effect of the Distance From the Contact Point to the Crest of Bone on the Presence or Absence of the Interproximal Dental Papilla. J. Perio 1992; 63:995-996 – Vertical Distance from the Crest of Bone to the Height of the Interproximal Papilla Between Adjacent Implants. J. Perio 2003; 74: 1785-1788
    • • In 1992 Tarnow, et al. showed complete papillae formation if you had a distance of 5mm or less from the interproximal contact point to the crest of the interproximal bone between teeth.
    • • In 2003 Tarnow showed that only 2 – 4mm of papillae height can be expected between two implants.
    • • Fortunately, between an implant and a tooth, the papillae behave the same as between two teeth. The tooth supports the soft tissue.
    • • Extraction with Immediate Placement – Immediate fixed provisionalization – Delayed fixed provisionalization • Extraction with Delayed Placement – Ridge preservation/regeneration – Provisionalization – Placement with fixed provisionalization
    • • Delayed Placement – Hard and/or soft tissue regeneration – Placement with provisionalization • Immediate Placement – Simultaneous hard and soft tissue regeneration – Immediate or Delayed Provisionalization
    • • Preserving bone and soft tissue at time of extraction • Regenerating lost hard and soft tissue • Sculpting papillae using provisional restoration
    • • Atraumatic extraction using Benex Extractor
    • • Pilot hole prepared into root canal space • Anchor is attached to root • Takes advantage of Regional Acceleratory Phenomenon (RAP)
    • • Cable is attached to anchor • Ratchet is attached to cable • Tooth is extracted without compromising bone or soft tissue
    • • Intact socket is debrided • Osteotomy is prepared
    • • Implant is placed
    • • Temporary abutment is prepared • Patient’s existing permanent crown is re-used as a temporary
    • • Temporary crown and abutment are contoured • Using the Zimmer transfer coping as temporary abutment
    • • Today I would use the Zimmer Plastic Provisional Abutment • New materials make a stronger restoration
    • • Temporary abutment and crown are seated • Expect hard and soft tissue contours to remain the same over time.
    • • Thin tissue biotype • High lip line • History of RCT and apico #7 • Pain with slight buccal swelling
    • • Tooth was extracted atraumatically • Buccal and lingual flaps undermined without elevating the papillae
    • • Dermis membrane shaped to cover apical buccal defect • This will also increase the thickness of the keratinized tissue on the facial and improve the biotype
    • • Puros allograft is prepared with doxycycline and calcium sulfate
    • • Membrane is placed under flap • Bone graft is placed
    • • Membrane is tucked under palatal flap • Note that the papillae are still intact
    • Root is removed and crown is prepped Crown is splinted using Ribbond
    • • Tooth is bonded in place • Papillae will remain intact knowing what we know from the Tarnow articles.
    • • Previously missing tooth or teeth • No attempt was made to maintain bone or soft tissue • Teeth were often extracted many years prior • Much more challenging than maintaining bone and soft tissues • Often requires multiple procedures
    • • 19 year old female • #8 was avulsed by a baseball when she was 12 • Recently completed orthodontic treatment
    • • CBCT shows adequate bone height and width for implant placement
    • • Adequate ridge width, Implant placed
    • • Connective Tissue Graft Added to Facial
    • • Provisional Placed at 3 months using polycarbonate crown and composite
    • • Final Healing of Provisional, ready to return to restoring dentist
    • Very “gummy” smile Severe resorption and abscess
    • • Very large abscess with facial swelling • Extreme apical root resorption • Teeth were supra-erupted and crestal bone was “too high” • Adequate width of bone apical to apices of teeth • “Gummy Smile” very evident • Large amount of keratinized tissue • Teeth were very lingually tilted
    • •Place implants 4 – 5mm apical to existing CEJ •Utilize extraction with immediate implant placement •Sculpt soft tissue to achieve ideal contours •Immediately temporize using custom temporary abutment and crowns to preserve hard and soft tissue.
    • •Less “gummy” appearance •Better relationship to lip line
    • • Missing #’s 9 and 10 for many years • #’s 7 and 8 have failed • Large horizontal ridge defect
    • • Zimmer J-Block used for Ridge Augmentation
    • • Block is prepared, attached with bone screws
    • • CBCT shows block is intact with adequate width for implant placement
    • • Implants Placed. Pt. wanted 4 implants, I would have preferred 2 with an FPD for esthetics
    • • Permanent Restorations in Place
    • • “Can you crown lengthen these teeth for new 6- unit splinted crowns?”
    • • After extraction of the teeth and debridement of the multiple abscesses
    • • Grafting with bone putty • Dermis membrane over graft • Primary closure of flaps
    • • Fabricated an immediate maxillary Essix partial
    • • Essix partial – Completely tooth borne – No pressure on the bone graft – Allows for modification of ovate pontics to form papillae
    • • Implants placed after 4 months of healing • Note the amount and quality of bone allowed for placement of 4.7mm diameter implants
    • • Soft tissue healing • Beginning to develop tissue contours using ovate pontics on the Essix partial
    • • Fabrication of fixed temporary restorations • Will further help develop tissue contours prior to permanent restoration
    • • Temporary abutments seated • Temporary crowns seated and healed for 1 week
    • • Tissue healing ready to return to her restoring dentist
    • • Implant Restorations in the Esthetic Zone present difficult challenges • Knowledge and Experience allow us to manage not only our patient’s expectations but also our own.