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15 “Esthetic Periodontal Plastic Surgical
Procedures for Teeth / Implants”... .Advanced Periodontics and Implant Center
72780 Country Club Dr. #402, Rancho Mirage, CA
g o a l s / o b j e c t i v e s o f t r e a t m e n tS e s s i o n 1
•Discuss Advantages Of Interdisciplinary Therapy •Surgical Procedures That Improve Esthetic Restorative Results W i t h Te e t h A n d I m p l a n t s - C r o w n L e n g t h e n i n g Gingival Augmentation - Teeth And Pontic Sites
•Orthodontic Site Development Procedures
g o a l s / o b j e c t i v e s o f t r e a t m e n tS e s s i o n 2
•Discuss Concepts With Esthetic Implant Cases. •How Altering Gingival Levels With Adjacent Teeth In Esthetic Implant Cases Should Be Planned.
•Preventing Dental Implant Complications.
The Interdisciplinary Team • Restorative Dentist • Periodontist • Orthodontist • Lab Technician • Oral Surgeon • Endodontist • Dental Hygienist • Staff Members
optimal clinical results obtained through collaborative services of highly ski l led
dental clinicians
t h e - T E A M Common Goals Communication Clinical Skills Ideal Sequencing
c o n c l u s i o n st h e i n t e r d i s c i p l i n a r y
t e a ma c h i e v e s o p t i m a l
r e s u l t s w i t h
Procedures That Enhance Restorative Outcomes
Crown Lengthening (restorative access / esthetics) Root Coverage (teeth / implants) Soft Tissue Ridge Augmentation (pontic sites) Esthetic Implant Procedures
• Surgical Resective Procedures (Crown Lengthening)
• Surgical Regenerative Procedures (Connective Tissue Grafting)
• Orthodontic Extrusion or Intrusion of the entire attachment apparatus
Treatment Modalities for Irregular Gingival Arrangement
Gingival Augmentation
Why?
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Increase the Zone of Keratinized Gingiva Achieve Root Coverage
Why Do You Need Keratinized Gingiva?
A. Improves Esthetics B. Protects Better Than Mucosa From Abrasive Agents. Examples: Restorative procedures / Aggressive Oral Hygiene Techniques
• Freedman AL, Green K, Salkin LM, Stein MD, Mellado JR. An 18-year longitudinal study of untreated mucogingival defects. J Periodontol. 1999 Oct;70(10):1174-6
When?Documented Progressive Recession
Restorative Margins Planned (Sub-gingival)
Orthodontic Treatment Planned
Treatment of Isolated Dentinal Sensitivity
Cosmetic Concerns
Coverage of Root Caries
How? Lateral Pedicle Grafts
Free Gingival Grafts
Free Gingival CT Graft
Subepithelial CTGs
Tunnel Collagen Grafts
Acellular Dermis Grafts
Guided Tissue Regeneration
Coronolly Postioned Flaps with EMD
Which Procedure and Where?•Goal of Procedure
•Local Anatomy
•Modifications of Procedures for Different Sites
•Implant Selection
•Placement of Implants in the Esthetic Zone
•Minimal Traumatic Extraction Techniques
Esthetic Implants Sites
Current Concepts
•Connective Tissue Grafts with Immediate Implants
•Options for Interim Tooth Replacement - Pros and Cons of Immediate Provisionalization
•Combination Procedures Interdisciplinary Team Therapy with Esthetic Implants
Esthetic Implant Selection and
Current Concepts
Superhydrophilic SLActive implants M. de Wild Abstract: Surface chemistry influences both surface charge and wettability. The purpose of this study was to investigate initial hydrophilicity of SLActive implants compared to standard SLA.
Bioactive Surfaces
Titanium SurfacesCriteria For Implant Selection
•Restorative Issues / Flexibility –Internal Connection –Platform Switch / Horizontal Offset Abutment –Digital Design Process –Fixture Level Impressions - (CAD-CAM, Screw Retained,Custom Abutments)
Horizontal Offset Abutment Designs•Straumann BL Implants •Crestal bone maintenance !Respecting the biological distance is a key factor for preserving the crestal bone level (horizontal offset abutment) "microgap "bacterial contamination "inflammation (peri-implantitis) !The conical connection is designed to provide a seal and minimize issues with lateral forces 17
Microgap origin of bacterial
contamination
0.4 mm*
TreatmentPlanning
•Guidelines •Sequencing
Esthetic Sites
Keep implant approximately 1-1.5 mm lingual to facial plate
Facial - Lingual
Andre P Saadoun DDS MS et al Practical Procedures Aesthetic Dentistry
1999: 1063-1072
•≥1.8 mm from Tooth to Implant Surface
•≥ 3mm from Implant to Implant (Crestal Bone Needed for Papillae
Support)
Andre P Saadoun DDS M et al Practical Procedures Aesthetic Dentistry 1999: 1063-1072
Mesial - Distal
•Mean Lateral Bone Loss 1.38 mm
•Mean Crestal Bone Loss <3mm =1.04mm >3mm =0.45mm
The Effect of Inter-Implant Distance on the Height of Inter-Implant Bone Crest Tarnow, D J Periodontal 2000, 71:546-549
Adjacent Implants Anterior Sites
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R e s o r p t i o n B i o l o g yThe Buccal Plate and
Papillae Issues Change How We Sequence and Do
Therapy To Preserve The Esthetics!
Extraction
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Amler, M.H. (1969) The time sequence of tissue regeneration in human extraction wounds. Oral Surgery Oral Medical Oral Pathology 27: 309–318.
Nevins, M., Camelo, M., De Paoli, S., Friedland, B., Schenk, R.K., Parma-Benfenati, S., Simion, M., Tinti, C. & Wagenberg, B. (2006) A study of the fate of the buccal wall of extraction sockets of teeth with prominent roots. The International Journal of Periodontics & Restorative Dentistry 26: 19–29.
l i t e r a t u r e
The most significant bone resorption occurs during the first month after tooth extraction: 3–5 mm in width at 6 months
why consider immediate placement ?- preservat ion
- does not prevent resorpt ion of the buccal p late?
cervical sof t t issue form
papi l la form
Literature immediate - placement
46 Studies Reviewed - 9 of the studies were > 3 years in duration.
A systematic review on survival and success rates of implants placed immediately into fresh extraction sockets after at least 1 year Niklaus P. Lang etal. Clinical Oral Implants Research Special Issue: Osteology Foundation, 6th Expert Meeting Volume 23, Issue Supplement s5, pages 39–66, February 2012
98.4% Success for Immediate Placement
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C o m p e n d i u mJ u l y / A u g 2 0 1 4Vo l 3 5 ; 7
B o b b y B u t l e r D D S
Do Not Elevate Base of Papilla in a Thin Biotype
Incision designs.... Dr Ken Hinds Compendium 2014. Laguna Hills, CA
Custom Scan Bodies
Before Afterprovisional options
i m m e d i a t e p l a c e m e n t
- r e m o v a b l e r e t a i n e r
- f i x e d b o n d e d r e t a i n e r
- c u s t o m h e a l i n g a b u t m e n t
- immediate implant provisionalkey:key s u p p o r t s o f t t i s s u e
The In terd i sc ip l inary Re lat ionsh ip Of A l l Team Members Summar i ze The Per iodonta l Surg ica l P rocedures Which Improve Restorat ive Outcomes
I n t e r d i s c i p l i n a r y a n d C o m b i n a t i o n P r o c e d u r e s
Closing Points•Interdisciplinary Team
Collaboration Improve Results •Know when Crown Lengthening
Can be Beneficial •Understand the Various Soft Tissue
Grafting Procedures •Preventing Esthetic Implant
Complications is Key! •All Therapy Should Focus on
Collecting Appropriate Findings - A Clear Diagnosis and Treatment Planning
“Peri-Implant Disease and Dental Implant Complications”
“Implant Maintenance” Bobby Butler DDS
Affiliate Faculty UW Advanced Periodontics and Dental
Implants Rancho Mirage
February 6th, 2016