The Art of Healing ÒDynamic Biologic Transformation of ... · 2. Orthodontic Extrusion Tx Plan...

“Dynamic Biologic Transformation of Hard & Soft Tissue”

2008 Dental Implant ConferenceDecember 5, 2008

Kenneth F. Hinds DDS

The Art of Healing

Wednesday, November 13, 13

History

Age 56“Patient does not like the black spaces at her gum line and would like to improve the appearance of her

front teeth.” Wednesday, November 13, 13

Maxilla: History of Advanced Periodontal DiseaseWednesday, November 13, 13

Treatment Options & Sequence?

Fixed Prostheses?

Regenerate 5-6mm Crest Height?

1. Orthodontic Extrusion – Full Arch?2. Sinus Augmentation – Bilateral, Iliac Crest 3. Immediate Implants – When & Where?4. Custom Healing Abutments – Where?5. Provisionals – Type?6. Definitive Prostheses – Design?

3. Sinus Augmentation4. Implants & Provisionals

1. Tuberosity Implants 2. Orthodontic Extrusion

Tx PlanPhase I:Posterior

8. Provisionals9. Metal-Ceramic Prostheses

5. Orthodontic Extrusion 6. Anterior Immediate Implants7. Custom Healing Abutments

Tx PlanPhase II:Anteriors

Treatment Plan: “Implant Mapping”1. 12 Total Implants planned2.Determine Tooth Sizes3. Implant Targets Locations

Custom Abutment / Ceramic collar / Cementable Prostheses

4 5 7 12 13 13 13 13 12 7 5 4 7 7 6 6 6 6 6 6 6 6 7 7

8 9 7 7.5 6 8.5 8.5 6 7.5 7 9 8

Planned Tooth SizesWednesday, November 13, 13

8 9 7 7.5 6 8.5 8.5 6 7.5 7 9 8

Target Implant Sites

6.0 6.07.5 7,57.0 7.0

9.0 8.0

8.5 8.5

Planned Tooth Sizes

Prosthetic TemplateRadiographic TemplateSurgical Template

6.0 6.07.5 7,57.0 7.0

9.0 8.0

8.5 8.5

Radiographic Template

5 4 4 4 4 5Wednesday, November 13, 13

Orthodontic Extrusion

Tuberosity Implants

Bilateral SinusAugmentation

Treatment: Phase I “Posteriors”Implant

Provisionals

The Role of Orthodontic Extrusive Remodeling in the Enhancement of Soft and Hard Tissue Profiles Prior to Implant Placement: A Systematic Approach to the Management of Extraction Site Defects.

H. Salama, M. Salama, Int J Perio Rest Dent 1993;13:4,313-333Wednesday, November 13, 13

3. Sinus Augmentation4. Implants & Provisionals

1.Tuberosity Implants 2. Orthodontic Extrusion

Tx PlanPhase I:Posterior

Orthodontic Extrusion - Posteriors1. Endodontic Therapy2. Provisionals

Before BeforeAfter

Before

Provisionals & Retention 3-4 monthsWednesday, November 13, 13

Extractions, Sinus grafts(Iliac Crest) &Expose Implants

Provisionals: Tuberosity Implants

New Metal Reinforced, Precision, Provisionals

5 4 4 4 4 5

Posterior Implants

ImmediateImplants

Custom Healing

Abutments

Treatment: Phase II “Anteriors”

Metal Ceramic Definitive Prostheses

Custom Impression

Coping

Orthodontic Extrusion: AnteriorsDynamic Biologic Transformation

Elastic Thread Technique

Sequence: 1. Splint Anteriors 2. Reduce 8 & 9 3. Extrude two teeth

Elastic ThreadOrmco,

Glendora, CAFile Cemented in Root

Ortho Wire in #55 K File

1. Reduce roots 2. Reset Hook3. Change Elastic

Provisional Attach to Brackets

ImmediateImplants

ImmediateCustom Healing

Abutments

Treatment: Phase II “Anteriors”Custom

Impression Coping

Extractions Implant Sites

Immediate

ISQ StabilityTest 65-70

Fixture Placement Preserve Soft

Tissue?

Preserve Soft Tissue?

Custom Healing Abutments1. Plastic Temp Cylinders2. Line with Composite3. Attach to Implants4. Add Composite &Light

Cure.Wednesday, November 13, 13

Plastic Temporary Cylinders

Add Composite ResinWednesday, November 13, 13

Fill Voids

Smooth & PolishWednesday, November 13, 13

Immediate Custom Healing Abutments

Reduce to Tissue Wednesday, November 13, 13

6 Months

Definitive Impresssions?

orProvisionals?

6 Months

Provisionals

6 Months

Accurate Transfer to Technician?

ImmediateImplants

ImmediateCustom Healing

Abutments

Treatment: Phase II “Anteriors”Custom

Impression Coping

Fabrication?

Custom Impression Coping

“Custom Impression Coping For An Exact Transfer in The Esthetic Implant Restoration” . International Journal of Periodontics and Restorative Dentistry, NOV-DEC 1997; Vol 17, No#6: Pages 585-591. Hinds, K

Fabrication?Custom Impression Coping

“Custom Impression Coping For An Exact Transfer in The Esthetic Implant Restoration” . International Journal of Periodontics and Restorative Dentistry, NOV-DEC 1997; Vol 17, No#6: Pages 585-591. Hinds, K

Direct or Indirect

Fabrication Direct: “Custom Impression Coping”

Add Composite ResinWednesday, November 13, 13

Transfer Technique: “Custom Impression

Connect to Implant & Light Cure Composite ResinWednesday, November 13, 13

Remove Abutment Attach to Analog

Fabrication Indirect: “Custom Impression Coping”

Attach Implant Replica into a small container 6 7 8 9 10 11

Connect Provisional AbutmentsInject Regisil to fill containerRemove AbutmentsConnect Pickup Impression CopingInject Composite Resin Around Imp Coping

Custom Impression Coping

IndividualSplinted SplintedWednesday, November 13, 13

Ceramic?Titanium?Gold?

Master Cast

Abutment Selection?

Strength & EstheticWednesday, November 13, 13

Custom Abutment / Ceramic Collar

A procedure for a modified cylindric titanium abutment.J Prosthet Dent. 1997 May;77(5):546-9. Marchack CB, Yamashita T

Metal Ceramic Fixed Prosthesis

Before Provisionals

Definitive ProsthesesBefore

Female, Age 55Patient History:

Hx: Tooth #7 Apical LesionWednesday, November 13, 13

Orthodontic Extrusion RX: Antiobiotics

Custom Healing Abutment at One Week

Extraction and Immediate Implant

Provisional

Definitive Prosthesis

Single Site Multiple Implant Sites

Dynamic Biologic

PotentialPatients

4 5 7 12 13 13 13 13 12 7 5 4 7 7 6 6 6 6 6 6 6 6 7 7

8 9 7 7.5 6 8.5 8.5 6 7.5 7 9 8

“Initial BluePrint”Custom Abutment / Ceramic collar / Cementable Prostheses

Metal Ceramic Prosthetic Template8.5 8.5 8.5 8.5

6.0 6.0 6.0 6.07.5 7,5 7.5 7,57.0 7.0 7.0 7.0

9.0 8.0

9.0 9.0 9.0

8.0 8.0 8.0

• Interdisciplinary Team• Sequencing•Do not be in a hurry to remove teeth•Do not be in a hurry to remove teeth

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