PEOPLE with a high level of personal mastery live in a continual...

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complicationreferencenote

imperio+ 12 modulesto successful patient treatment

TREATMENT PLANNINGFOR SUCCESS

make knowledge

hard tissues 2

make knowledge constructive

resective procedures … crown lengthening additive procedures … guided tissue & bone regeneration some of the basic surgical tools used to idealize the tissue framework

hard tissues 2

make knowledge constructive

complications

surgical treatment is increasingly microsurgical … emerging biologics reduce the need for secondary sites… how is this affecting our outcomes and success rates? … hard tissues …. hard job …

constructivehard tissues2

• ideal root form for crown lengthening

• Ingber FJS, Rose LF, Coslet JG. The biologic width. A concept in

periodontics and restorative dentistry. Alpha Omegan 1977;70:62-65.

• Tarnow DP, Magner AW, Fletcher P. 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 Periodontol 1992;63:995-996.

• Melker DJ Richardson CR. Root reshaping: an integral component of

periodontal surgery. Int J Periodontics Restorative Dent 2001;21:297-304.

reference

• establish the desired soft tissue level

• bone sound to assess the bone crest level

• correct the bone level to establish biologic width

• root/tooth surface modifications

conventional periodontal surgery

• Deas DE, Moritz HT, Poell CA, Mealey BL. Osseous surgery for crown lengthening: a 6-month clinical study. J Periodontol. 2004;75:1288-1294.

• establish the desired soft tissue level

• bone sound to assess the bone crest level

• blindly correct the bone level to establish b.w.

laser (minimally invasive) surgery

• Sonic M, Hwang D. Periodontal plastic surgery II: Esthetic crown lengthening. Inside Periodontics. 2007;65-72.

• Flax H. Maximizing esthetic transformations using a closed flap Er,Cr:YSGG modality. Compend Contin Educ Dent 2005;26:172-174.

• Dyer B. Minimally invasive osseous crown lengthening procedure using an erbium laser. Clinical case and procedure report. J Cosmetic Dent 2008;23(4):72-78.

i m m e d i a t e p o s t - o p e r a t i v e v i e w

h e a l i n g a t 2 1 d a y s

• McGuire MK, Schreyer ET. Laser-assisted flapless crown lengthening: a case series. Int J Periodontics Restorative Dent. 2011;31:357-364.

• plaque control problems

• invasion of biologic width

• retained cement

aetiology of post-restoration inflammation?

• inadequate bone level correction ?

• root damage . charring . impact?

• inadequate bone removal & bone toughing

inevitable treatment failure

Nevins M, Camelo M, De paoli S et al. Int J Perio & Rest Dent 2006 !Ferrus J, Cecchinato D, Pjetursson EB et al. Clin Oral Implants Res 2010 !Lee Sl, Kim HJ, Son MK, Chung CH. J Adv Prosthodont 2010 !Lau SL, Chow J, Li W, Chow LK. J oral Maxillofac Surg 2011 !Braut V, Bornstein M, Belser U, Buser, D. Int J Perio Rest Dent 2011

• facial bone 90% < 1mm thick

• facial bone at crest missing or thin 90%. • mid-root thickness 0.9 +/- 0.4mm

• roots often buccally angulated

incisor buccal plate thickness (thin <1mm . thick >1mm)

• Nissan J, Mardinger O, Calderon S et al. Cancellous bone block allografts for augmentation of the anterior atrophic maxilla. Clin Implant Dent Relat Res 2009 Sept.

• Waasdorp J, Reynolds MA. Allogenic bone onlay grafts for alveolar ridge augmentation: a systematic review. Int J Oral Maxillofac Implants. 2010;25:525-531.

surgery 1

• condition complicates flap handling.

• treatment: anti-fungal medication, new transitional

prosthesis & laser tissue abrasion/removal.

inflammatory papillary hyperplasia (type 3)

surgery 2

• uneventful healing 4 weeks post-surgery

• soft tissue dehiscence

• bone graft failure

• significant implant thread exposure

8 weeks post-surgery

surgery 3

• in search of less ‘risky’ materials

• SonicWeld Rx (KLS martin)

• resorbable poly-dl-lactic acid pins and membrane

i n f u s e B M P 2 ( m e d t r o n i c )

m i n e r o s s a l l o g r a f t ( b i o h o r i z o n s )

• Iglhaut G, Schwarz F et al. Shell technique using a rigid resorbable barrier system for localized alveolar ridge augmentation. Clin Oral Impl Res. 2012; 00: 1-6.

• Burger B. Use of ultrasound-activated resorb able poly-d-l-lactide pins (sonicpins) and foil panels (resorb-x) for horizontal bone augmentation of the maxillary and mandibular

alveolar ridges. J Oral Maxillofac Surg. 2011.

surgical & restorative strategies 3

make knowledge applicable

Understand the implant placement and restoration strategies that can be used following tooth extraction. Explore the case selection criteria, rationale for and techniques used in the aesthetic zone.

surgical & restorative strategies 3

make knowledge applicable

complications

immediate implant placement and restoration are increasingly used protocols …

some literature … and some opinions state that these are of high aesthetic risk, especially in the thin biotypes and high gingival scallops

applicablesurgical & restorative strategies3

• moderately thick gingival biotype

• adequate palatal & apical bone for stability

• favorable occlusion . cooperative patient

• grafting the residual horizontal defect

• goal: 4mm buccal bone & tissue

• outcome: reduce buccal resorption

• Grunder U, Gracis S, Capelli M. Influence of the 3-D bone-to-implant relationship on esthetics. Int J Periodontics Restorative Dent 2005;25:113-119.

• Capelli M, Testori T et al. The implant-buccal plate distance: A diagnostic parameter. A prospective cohort study on implant placement in fresh extraction sockets. J Periodontol 2013.

day of surgery

reference

• De Rouck T, Collys K, Wyn I, Cosyn J. Instant provisionalization of immediate single-tooth

implants is essential to optimize esthetic treatment outcomes. Clin Oral Implants Res. 2009.

20(6):566-570

• Cosyn J, Eghball A, De Bruyn H, Collys K, et et. Immediate single-tooth implants in the anterior

maxilla: 3-year results of a case series on hard and soft tissue response and aesthetics. J Clin

Periodontol 2011;38(8):746-753.

• Peng M, Fei W, Hosseini M, Gotfredsen K. Influence of implant position on clinical crown length

and peri-implant soft tissue dimensions at implant-supported single crowns replacing maxillary

central incisors. Int J Periodontics Restorative Dent. 2013;33(6):785-793.

• mid-facial tissue height - better with immediate

placement vs. delayed restoration (0.75mm).

• papilla similar, but took longer to reform with

delayed placement.

10 days post-surgery

d e f i c i e n t d i s t a l p a p i l l a

very thin gingival biotype!

screw-retained provisional restoration natural tooth veneered to peek abutment

immediate post-op

• limit papilla-opening procedures/bone recontouring

• idealize implant position

• idealize contact point positions

optimizing soft tissue levels

post-op 8 weeks

post-op 8 weeks immediate post-op post-op 1 week post-op 8 weeks

implant position 4

make knowledge relative

The determinants for correct 3D implant placement are clearly defined in today’s literature, as are the guidelines to ensure idealized placement for aesthetic and restorative success.

implant position 4

make knowledge relative

complications

The guilty (and rationalizing) surgical team member … Avoid the pitfalls of improper implant position and recognize which positional errors can be managed surgically and/or prosthetically, and which ones need to be removed.

relativeimplant position4

consequences of placement errors

relativeimplant position4

implant removal . several techniques & instruments

gingival biotype 6

make knowledge cumulative

Connective tissue and dermal grafts are routinely used in the management of gingival recession in the natural dentition. These techniques are pivotal in implant surgery to enhance tissue volume and improve post-restoration tissue levels.

gingival biotype 6

make knowledge cumulative

complications

Gingival or dermal graft options… Similar treatment outcomes Unique technical handling Dentist-guided … Patient decision

cumulativegingival biotype6

p r e - o p p o s t - o p

volume

enhancement

cumulativegingival biotype6 cumulativegingival biotype6

g r a f t q u a l i t y i m p a c t o n l o n g - t e r m s t a b i l i t y

i m p a c t o f f i b r o u s v s . f a t t y g r a f t s

cumulativegingival biotype6 cumulativegingival biotype6

7-0 vicryl with spatula blade. ethiconalloderm (BioHorizons)

3 w e e k s p o s t - o p

non-passive suturing/closure

post-operativepre-operative

6 months post-op

alloderm (BioHorizons)

• Alloderm (BioHorizons) • Dermis (Zimmer) • PerioDerm (Dentsply) • Mucograft (Osteohealth)

do all dermal grafts produce similar gains in

keratinized tissue?

provisionalization 7

make knowledge functional

Provisionalization can be viewed as the fine-tuning of tissue architecture around implants and in adjacent pontic sites. It is an essential step in the restoration of implants in the esthetic zone and is a pivotal step in the transfer of information from the restorative team to the technician.

provisionalization 7

make knowledge functional

complications

A natural step in the treatment of the natural dentition … An integral step to success in the restoration of dental implants….

c h a n g e s t r u c t u r e

functionalprovisionalization7

36 months

day of insertion 8 weeks later definitive restoration

revised restoration

overcontoured crown

abutment materials & designs 9

make knowledge compatible

Material options range from titanium, gold-hued titanium to today's increasingly used aesthetic materials zirconia and lithium disilicate. This module will touch on abutment strength, biocompatibility, impact on tissue colour and the influence on cementation.

abutment materials & designs 9

make knowledge compatible

complications

There are numerous material options in the transmucosal area that offer aesthetic solutions . Some of these materials are proving to have structural weaknesses. Clinicians and patients suffer the consequences …

compatibleabutment materials & designs9

• Garine WN, Funkenbusch PD, Ercoli C, Wodenscheck J, Murphy WC. Measurement of the rotational misfit and implant-abutment gap of all-ceramic abutments. Int J Oral Maxillofac

Implants. 2007;22:928-938.

• Sailer I, Sailer T, Stawarczyk B, Jung RE, Hammerle CH. In vitro study of the influence of the type of connection on the fracture load of zirconia abutments with internal and external

implant-abutment connections. Int J Oral Maxillofac Implants. 2009 Sep-Oct; 24(5):850-858.

sulcus%

epithelial%a,achment%

connec0ve%%0ssue%

sulcus%

epithelial%a,achment%

connec0ve%%0ssue%

JE stops

• Nevins M, Kim DM, Jun SH, Guze K, Schupbach P, Nevins ML. Histologic evidence of a connective tissue attachment to laser microgrooved abutments: a canine study. Int J Periodontics

Restorative Dent. 2010;30:245-255.

• demonstrated consistent soft tissue integration

(uncommon on smooth surface abutments)

• but … clinical parameters comparable

• plaque . gingival health . probing depths

laser ablated abutments

Guers NC, O’Neil SJ, Reddy MS. Plaque, mucosal health and probing depth around laser ablated

abutments. Oral presentation Wash State Dental Convention March 2013.

ceramics 10

make knowledge appealing

Choosing a restorative material is often decided upon by technical team members. This module is designed to foster the participant's involvement in the material selection process and will review current options, strengths and limitations of the new restorative materials.

ceramics 10

make knowledge appealing

complications

Teamwork between the dentist and technician . Ceramic restorations demand careful handling and an understanding of material properties. Cementation … the make-you or break-you step.

appealingceramics10

• Alikhasi M, Monzavi A, Bassir SH et al. A comparison of precision of fit, rotational freedom, and torque loss with copy-milled zirconia and prefabricated titanium abutments. Int J Oral

Maxillofac Implants. 2013;28(4):996-1002.

• Buzayan M, Baig MR, Yunus N. Evaluation of accuracy of complete-arch multiple-unit abutment-level dental implant impressions using different impression and splinting materials. Int J

Oral Maxillofac Implants. 2013;28(6):1512-1520.

appealingceramics10

ceramic fracture appears to be the most common clinical

failure mechanism of all-ceramic crowns

• Wassermann A et al. Clinical long-term results of Vita In-Ceram Classic crowns and fixed partial dentures. A

systematic literature review. Int J Prosthodont 2006; 19:355-363

• Jung RE et al. A systematic review of the 5- year survival and complication rates of implant-supported single

crowns. COIR 2008;19:119-30.

• White SN et al. Flexural strength of a layered zirconia and porcelain dental all-ceramic system. J Prosthet

Dent 2005;94: 125-31.

• Scherrer SS et al Failure analysis of ceramic clinical cases using qualitative fractography. Int J Prosthodont

2006;19: 185-92.

• Koenig V et al. Clinical risk factors related to failures with zirconia-based restorations: An up to 9-year

retrospective study. J Dent 2013.

appealingceramics10

!104EMAX EMAX full contour zirconia. M feldspathic cusp

!105 restoration try-in

appealingceramics10

• de Brandao ML, Vettore MV, Vidigal Junior GM. Peri-implant bone loss in cement- and screw-retained prostheses: systematic review and meta-analysis. J Clin Periodontol. 2013;40(3):287-295.

• Chen CJ, Papaspyridakos P, Guze K, Singh M, Weber HP, Gallucci GO. Effect of misfit of cement-retained implant single crowns on crestal bone changes. Int J Prosthodont. 2013;26(2):135-137.

appealingceramics10

Pette GA, Ganeles J, Norkin. Radiographic appearance of commonly used cements in implant dentistry. Int J Periodontics Restorative Dent 2013;33:61-68.

Wadhwani C, Hess T, Faber T, Pineyro A, Chen CSK. A descriptive study of the radiographic density of implant restorative cements. J Prosthet Dent 2010;103:295-302.

Tarica DY, Alvarado VM, Truong ST. Survey of United States dental schools on cementation protocols for implant crown restorations. J Prosthet Dent. 2010;103:68-79.

Wilson TG. The positive relationship between excess cement and peri-implant disease: a prospective clinical endoscopic study. J. Periodontol. 2009 Sep;80(9):1388-92.

appealingceramics10

n a t u r a l t o o t h p r e p a r a t i o n a b u t m e n t p r e p a r a t i o n

The performance of luting cements in maintaining a minimum film thickness over a suitable period of time

setting time & film thickness (um)

luting cement 1 min !2min

!3 min

FujiCem RelyX Luting Plus

7.3 (3.4) 19.7 (5.6)

8.9 (3.9) 25.4 (7.7)

28.6 (9.3) 53.6 (12.2)

RelyX ARC Panavia 21

12.3 (3.2) 20.9 (2.0)

16.4 (4.2) 24.3 ( 1.6)

28.6 (9.3) 26.3 (2.4)

Maxcem RelyX Unicem

19.3 (3.5) 15.1 (2.3)

19.6 (2.1) 16.0 (4.6)

21.0 (2.1) 19.4 (4.8)

RelyX Ultimate 12 ? ?

appealingceramics10

• Chee WW, Duncan J, Afshar M, Moshaverinia A. Evaluation of the amount of excess cement around the margins of cement-retained dental implant restorations: the effect of the cement

application method. J prosthet Dent 2013;109(4): 216-221.

appealingceramics10

• bone . resective & additive procedures

• implant protocols . new thoughts on outcomes

• tissue volume . enhancement for success

• provisionalization & tissue form

• restorative materials . interesting & challenging

• the difference between failure & success …

doing something nearly right … or doing it

exactly right

PRODUCTIVEyah yah…

just gimmie the credits

12 easy modules you say?

visit www.imperioplus.ca to find out how

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