Anterior Implant Esthetics:Building the Foundation

First Mondays Study ClubRobert C. Cain, DDS

March 3, 2014

Objectives• 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

Questions

• 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?

Advantages of Implants

• 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

Disadvantages of Implants

• Cost• Time• Involves surgery• Insurance often does not cover implant

procedures, especially some the more advanced grafting techniques

Differences between Implants and Natural Teeth

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

Natural Teeth

• 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

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

Considerations

• 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?

Considerations

• 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!

How do we get the best possible outcome?

• 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

How do we get the best possible outcome?

• 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

What Makes an Implant Look Like a Tooth?

• The Soft Tissue Around the Implant• Specifically the Buccal Tissue and the

Interproximal Papillae

• “The Tissue Is The Issue”

How Do We Know Whether We Will Have a Papilla?

• 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

How Do We Know Whether We Will Have a Papilla?

• 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.

How Do We Know Whether We Will Have a Papilla?

• In 2003 Tarnow showed that only 2 – 4mm of papillae height can be expected between two implants.

How Do We Know Whether We Will Have a Papilla?

• Fortunately, between an implant and a tooth, the papillae behave the same as between two teeth. The tooth supports the soft tissue.

Treatment Options – Tooth Present

• Extraction with Immediate Placement– Immediate fixed provisionalization– Delayed fixed provisionalization

• Extraction with Delayed Placement– Ridge preservation/regeneration– Provisionalization– Placement with fixed provisionalization

Treatment Options – Tooth Missing

• Delayed Placement– Hard and/or soft tissue regeneration– Placement with provisionalization

• Immediate Placement– Simultaneous hard and soft tissue regeneration– Immediate or Delayed Provisionalization

Review of Techniques

• Preserving bone and soft tissue at time of extraction

• Regenerating lost hard and soft tissue• Sculpting papillae using provisional restoration

Preserve Hard and Soft Tissue

• Atraumatic extraction using Benex Extractor

Benex Extraction System

Benex Extraction System

Benex Extraction System

Extraction with Immediate Placement and Provisionalization

• Pilot hole prepared into root canal space

• Anchor is attached to root

• Takes advantage of Regional Acceleratory Phenomenon (RAP)

Extraction with Immediate Placement and Provisionalization

• Cable is attached to anchor

• Ratchet is attached to cable

• Tooth is extracted without compromising bone or soft tissue

Extraction with Immediate Placement and Provisionalization

• Intact socket is debrided

• Osteotomy is prepared

Extraction with Immediate Placement and Provisionalization

• Implant is placed

Extraction with Immediate Placement and Provisionalization

• Temporary abutment is prepared

• Patient’s existing permanent crown is re-used as a temporary

Extraction with Immediate Placement and Provisionalization

• Temporary crown and abutment are contoured

• Using the Zimmer transfer coping as temporary abutment

Extraction with Immediate Placement and Provisionalization

• Today I would use the Zimmer Plastic Provisional Abutment

• New materials make a stronger restoration

Extraction with Immediate Placement and Provisionalization

• Temporary abutment and crown are seated

• Expect hard and soft tissue contours to remain the same over time.

Hard and Soft Tissue Preservation

• Thin tissue biotype

• High lip line• History of RCT

and apico #7• Pain with

slight buccal swelling

Hard and Soft Tissue Preservation

Hard and Soft Tissue Preservation

• Tooth was extracted atraumatically

• Buccal and lingual flaps undermined without elevating the papillae

Hard and Soft Tissue Preservation• 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

Hard and Soft Tissue Preservation• Puros allograft is

prepared with doxycycline and calcium sulfate

Hard and Soft Tissue Preservation

• Membrane is placed under flap

• Bone graft is placed

Hard and Soft Tissue Preservation• Membrane is

tucked under palatal flap

• Note that the papillae are still intact

Hard and Soft Tissue PreservationRoot is removed and crown is prepped Crown is splinted using Ribbond

Hard and Soft Tissue Preservation

• Tooth is bonded in place

• Papillae will remain intact knowing what we know from the Tarnow articles.

Regenerating Lost Tissues

• 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

Soft Tissue Regeneration

• 19 year old female• #8 was avulsed by

a baseball when she was 12

• Recently completed orthodontic treatment

Soft Tissue Regeneration• CBCT shows adequate bone height and width

for implant placement

Soft Tissue Regeneration

• Adequate ridge width, Implant placed

Soft Tissue Regeneration

• Connective Tissue Graft Added to Facial

Soft Tissue Regeneration• Provisional Placed at 3 months using polycarbonate

crown and composite

Soft Tissue Regeneration• Final Healing of Provisional, ready to return to

restoring dentist

Implants and Crown Lengthening

Very “gummy” smile Severe resorption and abscess

Problem List:• 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

Solution:•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.

Final Result•Less “gummy” appearance•Better relationship to lip line

Guided Bone Regeneration• Missing #’s 9 and 10 for many years• #’s 7 and 8 have failed• Large horizontal ridge defect

Guided Bone Regeneration• Zimmer J-Block used for Ridge Augmentation

Guided Bone Regeneration• Block is prepared, attached with bone screws

Guided Bone Regeneration• CBCT shows block is intact with adequate

width for implant placement

Guided Bone Regeneration• Implants Placed. Pt. wanted 4 implants, I would have

preferred 2 with an FPD for esthetics

Guided Bone Regeneration• Permanent Restorations in Place

Maxillary Anterior Implants with Pontics

• “Can you crown lengthen these teeth for new 6-unit splinted crowns?”

Maxillary Anterior Implants with Pontics

• After extraction of the teeth and debridement of the multiple abscesses

Maxillary Anterior Implants with Pontics

• Grafting with bone putty• Dermis membrane over graft• Primary closure of flaps

Maxillary Anterior Implants with Pontics

• Fabricated an immediate maxillary Essix partial

Maxillary Anterior Implants with Pontics

• Essix partial– Completely tooth

borne– No pressure on the

bone graft– Allows for modification

of ovate pontics to form papillae

Maxillary Anterior Implants with Pontics

• Implants placed after 4 months of healing• Note the amount and quality of bone allowed for

placement of 4.7mm diameter implants

Maxillary Anterior Implants with Pontics

• Soft tissue healing• Beginning to develop

tissue contours using ovate pontics on the Essix partial

Maxillary Anterior Implants with Pontics

• Fabrication of fixed temporary restorations

• Will further help develop tissue contours prior to permanent restoration

Maxillary Anterior Implants with Pontics

• Temporary abutments seated

• Temporary crowns seated and healed for 1 week

Maxillary Anterior Implants with Pontics

• Tissue healing ready to return to her restoring dentist

Conclusions

• 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.

THANK YOU!