d e n t a l b i o - a r c h i t e c t u r e

Dr. Sonia Leziy

implant positioning accuracy gingival phenotype bone volume . flap design guiding marginal tissues

RNCPsurgical concepts & soft tissue success

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ERA esthetic risk assessment analysis ITI pretreatment assessment tool Levine RA, Huynh-Ba G, Cochran DL. Soft tissue augmentation procedures for mucogingival defects in esthetic sites. IJOMI 2014;29(suppl):155-185.

clinical decisions guidelines better planning & reducing complications

• assess the risk of achieving an unesthetic result in given clinical conditions.

• communication between treating clinicians/technicians.

• communicate risk factors to patient . avoid misunderstandings/unmet expectations.

• avoid/minimize complications.

era risk assessmentmedical status healthy - reduced immune competencesmoking habit non-smoker light smoker (<10) heavy smoker (> 10)

patient’s esthetic expectations low medium highlip line low medium high

width of span 1 tooth ≥ 7mm 1 tooth ≤ 7mm 2 or more teethshape of tooth/crown rectangular slightly triangular triangular

infection at treatment site none chronic acuteadjacent teeth bone level ≤ 5mm to contact 5.5-6.5mm to contact 7mm to contact point

adjacent restoration status virgin - restoredgingival phenotype low scallop/thick medium scallop/medium thickness high scalloped/thinsoft tissue anatomy intact soft tissue - soft tissue defectssite bone anatomy no deficiency horizontal deficiency vertical deficiency

esthetic risk factors low medium high

implant position . the key to success? the role of digital technology/guided surgery

�surgical concepts & soft tissue success

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treatment planning & execution errors . esthetic impact

reduced provisional contour & ct graft (22) new provisional contour (12)

numerous remedial steps to correct treatment errors

the digital workflow . streamlining planning . communication . minimizing errors and improving outcomes in the surgical and restorative fields . case documentation

DIGITAL WORK-FLOW

implant position relative to virtual tooth

‘planned’ restorative running room

position for screw-retention

pilot drill guide full guidance

Lopez-Lopez PJ, Mareque-Bueno J, Boquete-Castro A et al. The effects of healing abutments of different size and anatomic shape placed immediately in extraction sockets on peri-implant hard and soft tissues. A pilot study in foxhound dogs. Clin Oral Implants Res. 2016. 27:90-96.

Crespi R, Cappare, P, Crespi G et al. Tissue remodelling in immediate versus delayed prosthetic restoration in fresh socket implants in the esthetic zone. Int J Periodontics Restorative Dent 2018;38 (suppl): S97-S103.

prefabricated provisional restorations or custom healing abutmentsKOOGFKCVG�VTCPUOWEQUCN�IWKFCPEG�

provisional and definitive restorations how do the micro/macro-design features influence tissue stability?

anatomy design virtual crown & implant position

designing abutment tissue pressure gingival anatomy-healing abutment design

‘analogue’ modifications by technician

prefabricated custom healing abutments & PMMA bonded restorations Proussaefs P. Custom CAD-CAM healing abutment and impression coping milled from a poly (methylmethacrylate) block and bonded to a titanium insert. J Prosthet Dent. 2016;116:657-662.

� is it about the phenotype & it’s modification ? reducing post-restoration soft tissue esthetic tissue complications

surgical concepts & soft tissue success

evaluation methods transgingival probing . probe visibility • thin . probe can be seen through tissue (≤ 1mm)

• thick . probe cannot be seen through tissue (>1mm)

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terminology gingival biotype … actually phenotype (observed properties)

thin phenotype prevalence relative to tooth type 11% premolars 24% canines 23% lateral incisors 7% central incisors

thin phenotype in < 1/3rd of patients

predominantly ̦

slender tooth form, narrow zone of kt, high scallop

less vascular . more labile /risk for change ? suggestion that response to plaque ↑

12 years post-surgery inadequate bone grafting . thin phenotype. size of edentulous space. adjacent implant placement . connection type. transmucosal material

circum-implant tissue grafting

�24 post-op 5 years

bone-contact point 5-6mm

extraction related tissue retraction

14 days healing

2 month post-restoration . deficient distal papilla

• mesial papilla regeneration @ 3-6 months

• distal papilla regeneration @ 6-12 months

• 10% of distal papilla deteriorated

• distal papilla - better preservation in delayed protocol

• Cosyn J, BeBruyn H, Cleymaet R. Soft tissue preservation and pink aesthetics around single immediate implant restorations: a 1-year prospective study. Clin Implant Dent Relat Res 2013;15:847-857.

• Kinaia BM, Ambrosio F, Lamble M et al. Soft tissue changes around immediately placed implants: A systematic review and meta-analyses with at least 12 months of follow-up after functional loading. J

the evolution of flap design

• significant association between flap thickness & coronal advancement

• split thickness - 35% CRC

• split-full-split thickness - 80% CRC

CRC = complete root coverage

Zadeh HH. Minimally invasive treatment of maxillary anterior gingival

recession defects by vestibular incision subperiosteal tunnel access and platelet-derived growth factor bb. Int J Periodontics Restorative Dent. 2011;31:653-660.

Chao JC. A novel approach to root coverage: the pinhole surgical technique. Int

J Periodontics Restorative Dent. 2012; 32(5): 521-531.

the evolution of flap design

tunnelling/vestibular approaches

Leziy S, Miller B. The dermal ARC protocol. Acellular dermal tissue augmentation procedures for teeth and implants:

Manuscript in preparation.

Ņ#T%ņ acellular dermal matrix graft

alloderm gbr

alloderm acellular matrix graft . selective 7-0 prolene sling sutures

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Mago VK, Mago A, Sharma P, Mago J. Fuzzy logic based expert system for the treatment of mobile tooth. Chapter 62. In:

Software tools and algorithms for biological systems. Ed. Arabnia HR, Tran QN. Adv Exp Med Biol 696; Springer. 2011

pre-op immediate post-op post-op 12 weeksnatural tooth veneered

to temp abutment

CASE ILLUSTRATION ��

� pre-op

� 4 years post-op palatal

� 4 years post-op facial

1. 2.

3.

post-op 3 yearsCASE ILLUSTRATION ��

7 years post-opbone & tissue defect corrected by ortho extrusion

CASE ILLUSTRATION ��

�surgical concepts & soft tissue success is it all about the bone volume?smaller implant diameters

bone graft volume target

‘protective’ customized healing abutments

thin phenotype 0.7mm thick labial cortical plate

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VGEJPKSWG���graft horizontal defect & external grafting

IQCN���3-4mm buccal bone & soft tissue

QWVEQOG���reduce buccal resorption & increase soft tissue supportCapelli M, Testori T, Galli F et al. Implant-buccal plate distance as diagnostic parameter: a prospective cohort study on implant placement in fresh extraction sockets. J Periodontol 2013; 84(12): 1768-74. Pluemsakunthai W, Le B, Basugai S. Effect of buccal gap distance on alveolar ridge alteration after immediate implant placement: a microcomputed tomographic and morphometric analysis in dogs. Implant Dent 2015;24(1): 70-76. DeGroot BS, Villar CC, Mealey BL et al. Osseous healing around immediate implants placed using contour augmentation: A prospective case series. Int J Periodontics Restorative Dent 2017;37(6):883-891.

healing abutments shape/size/handling

Lopez-Lopez PJ, Marque-Bueno J, Boquete-Castro A et al. The effects of healing abutments of different size and anatomic shape placed immediately in extraction sockets on peri-implant hard and soft tissues. A pilot study in foxhound dogs. Clin Oral Implants Res. 2016. 27:90-96.

anatomic healing abutments protect soft and hard tissues and reduce crestal bone resorption compared

with concave-straight healing abutments

1. 2.

3. post-extrusion site development

failing 21 & 22 probings circumferential up to 8mm

extrusion assessment #1

extrusion assessment #2

labial root torque . facial tissue loss on 22

1. 2.

3.

� post-extraction

� lateral tunnelling instrument

� vestibular incision access to dehiscence defects

fully guided implant placement . H2-H6 stop

Miron RJ, Zucchelli G, Pikos MA et al. Use of platelet-rich fibrin in regenerative dentistry: a systematic review. Clin Oral Investig. 2017; 21(6): 1913-1927.

iPRF & aPRF- platelets recruit osteoblasts, endothelial cells, fibroblasts sustained growth factor release for 7-14 days improve cell migration/proliferation, support hemostasis subjective bone quality shift D4 → D3 soft tissue healing & time benefits trend > new bone formation . active super-cells (osteogenic . BMP2). enhance bone graft handling properties

12 weeks post-op 12 weeks post-op

1. 2.

3.

� radiographs . day of surgery

� buccal contour enhancement

� limited flap for effective debridement

post-op 2 weeks

inadequate proximal supportchair-side revision

additive

subtractive

rethinking bone/tissue graft flaps

3 months post-surgery . immediate 13 (6) & delayed 14 (5)

• smaller implant diameters & maximize buccal bone volume

• limit papilla-opening procedures/bone recontouring

• idealize implant position bucco-lingually

• custom healing abutments . superior soft tissue response

• idealize provisional contour & contact point positions

• phenotype enhancement (?)

6 key points to optimize soft tissue outcomes

VJQWIJVUsurgical concepts & soft tissue success digital dentistry/guided surgery . minimize error

soft tissue phenotype . often but not always important

facial bone volume . 3-4mm target for stability

full thickness & apical flap approaches

transitional soft tissue support

obrigadoelevating knowledge www.elatus.ca