Anterior implants building the foundation

1,857 views

Published on

Published in: Health & Medicine, Technology
  • Be the first to comment

Anterior implants building the foundation

  1. 1. First Mondays Study Club Robert C. Cain, DDS March 3, 2014
  2. 2. • 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
  3. 3. • 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?
  4. 4. • 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
  5. 5. • Cost • Time • Involves surgery • Insurance often does not cover implant procedures, especially some the more advanced grafting techniques
  6. 6. 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
  7. 7. • 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
  8. 8. • Made of Titanium with textured surface • Round in cross section • Direct connection to bone by osseointegration • No connective tissue attachment • Gingival fibers are circular
  9. 9. • 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?
  10. 10. • 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!
  11. 11. • 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
  12. 12. • 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
  13. 13. • The Soft Tissue Around the Implant • Specifically the Buccal Tissue and the Interproximal Papillae • “The Tissue Is The Issue”
  14. 14. • 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
  15. 15. • 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.
  16. 16. • In 2003 Tarnow showed that only 2 – 4mm of papillae height can be expected between two implants.
  17. 17. • Fortunately, between an implant and a tooth, the papillae behave the same as between two teeth. The tooth supports the soft tissue.
  18. 18. • Extraction with Immediate Placement – Immediate fixed provisionalization – Delayed fixed provisionalization • Extraction with Delayed Placement – Ridge preservation/regeneration – Provisionalization – Placement with fixed provisionalization
  19. 19. • Delayed Placement – Hard and/or soft tissue regeneration – Placement with provisionalization • Immediate Placement – Simultaneous hard and soft tissue regeneration – Immediate or Delayed Provisionalization
  20. 20. • Preserving bone and soft tissue at time of extraction • Regenerating lost hard and soft tissue • Sculpting papillae using provisional restoration
  21. 21. • Atraumatic extraction using Benex Extractor
  22. 22. • Pilot hole prepared into root canal space • Anchor is attached to root • Takes advantage of Regional Acceleratory Phenomenon (RAP)
  23. 23. • Cable is attached to anchor • Ratchet is attached to cable • Tooth is extracted without compromising bone or soft tissue
  24. 24. • Intact socket is debrided • Osteotomy is prepared
  25. 25. • Implant is placed
  26. 26. • Temporary abutment is prepared • Patient’s existing permanent crown is re-used as a temporary
  27. 27. • Temporary crown and abutment are contoured • Using the Zimmer transfer coping as temporary abutment
  28. 28. • Today I would use the Zimmer Plastic Provisional Abutment • New materials make a stronger restoration
  29. 29. • Temporary abutment and crown are seated • Expect hard and soft tissue contours to remain the same over time.
  30. 30. • Thin tissue biotype • High lip line • History of RCT and apico #7 • Pain with slight buccal swelling
  31. 31. • Tooth was extracted atraumatically • Buccal and lingual flaps undermined without elevating the papillae
  32. 32. • 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
  33. 33. • Puros allograft is prepared with doxycycline and calcium sulfate
  34. 34. • Membrane is placed under flap • Bone graft is placed
  35. 35. • Membrane is tucked under palatal flap • Note that the papillae are still intact
  36. 36. Root is removed and crown is prepped Crown is splinted using Ribbond
  37. 37. • Tooth is bonded in place • Papillae will remain intact knowing what we know from the Tarnow articles.
  38. 38. • 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
  39. 39. • 19 year old female • #8 was avulsed by a baseball when she was 12 • Recently completed orthodontic treatment
  40. 40. • CBCT shows adequate bone height and width for implant placement
  41. 41. • Adequate ridge width, Implant placed
  42. 42. • Connective Tissue Graft Added to Facial
  43. 43. • Provisional Placed at 3 months using polycarbonate crown and composite
  44. 44. • Final Healing of Provisional, ready to return to restoring dentist
  45. 45. Very “gummy” smile Severe resorption and abscess
  46. 46. • 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
  47. 47. •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.
  48. 48. •Less “gummy” appearance •Better relationship to lip line
  49. 49. • Missing #’s 9 and 10 for many years • #’s 7 and 8 have failed • Large horizontal ridge defect
  50. 50. • Zimmer J-Block used for Ridge Augmentation
  51. 51. • Block is prepared, attached with bone screws
  52. 52. • CBCT shows block is intact with adequate width for implant placement
  53. 53. • Implants Placed. Pt. wanted 4 implants, I would have preferred 2 with an FPD for esthetics
  54. 54. • Permanent Restorations in Place
  55. 55. • “Can you crown lengthen these teeth for new 6- unit splinted crowns?”
  56. 56. • After extraction of the teeth and debridement of the multiple abscesses
  57. 57. • Grafting with bone putty • Dermis membrane over graft • Primary closure of flaps
  58. 58. • Fabricated an immediate maxillary Essix partial
  59. 59. • Essix partial – Completely tooth borne – No pressure on the bone graft – Allows for modification of ovate pontics to form papillae
  60. 60. • Implants placed after 4 months of healing • Note the amount and quality of bone allowed for placement of 4.7mm diameter implants
  61. 61. • Soft tissue healing • Beginning to develop tissue contours using ovate pontics on the Essix partial
  62. 62. • Fabrication of fixed temporary restorations • Will further help develop tissue contours prior to permanent restoration
  63. 63. • Temporary abutments seated • Temporary crowns seated and healed for 1 week
  64. 64. • Tissue healing ready to return to her restoring dentist
  65. 65. • 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.

×