dental implant replacement of central incisor · pdf fileclassification- cologne orientation...

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Bethesda, MD

Dental Implant Replacement of

Central IncisorKey Surgical Considerations and

Site Development for a Successful

Restorative Outcome

H. Ryan Kazemi, DMD

Oral & Maxillofacial Surgery

Bethesda, MD

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Site Characteristics

Site

Development

Implant

Placement

Tissue

Management

Unique

Requirements for

Central Incisors

Site

Characteristics

•Type and degree of bone deficiency

•Soft tissue biotype

•Tissue health

•Tooth missing / to be extracted?

•Location and size nasopalatine nerve

•Gingival harmony

•Smile line

Site

Development

Extraction site graft

GBR

Inlay bone graft

Onlay bone graft

Mesh / rhBMP2

SonicWeld

Distraction

Soft tissue graft

PDGF

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Implant

Placement

Implant diameter

Platform switch

Bucco-palatal placement

Position of the platform

Immediate implant / graft / provisional

CT-Guided planning and placement

Midline / symmetry / smile line

Tissue

Management

Connective tissue graft

Customized healing abutments

Implant uncovering designs

Immediate implant provisional

Delayed implant provisional

classification- cologneorientation

H: horizontal

V: vertical

C: combination

S / +S: sinus

graft needs

1: low < 4 mm

2: medium 4-8 mm

3: high > 8 mm

relation graft to defect

i: internal, inside the

contour

e: external, outside the

ridge

h.2.e

C.2.e.S.1combined defect of 4-8 mm, outside the

envelope, with sinus defect < 4 mm

V.2.i.+S.2vertical defect 4-8 mm, inside the contour

with sinus defect 4-8 mm

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Defect-Specific Treatment Options

Central Incisor: #8

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classification- cologneorientation

H: horizontal

V: vertical

C: combination

S / +S: sinus

graft needs

1: low < 4 mm

2: medium 4-8 mm

3: high > 8 mm

relation graft to defect

i: internal, inside the

contour

e: external, outside the

ridge

c.2.e

Horizontal deficiency of 6 mm

Vertical deficiency of 3 mm

Thick tissue biotype

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🚩 🚩Aesthetic zone

Vertical deficiency

Thick tissue biotype

Good interseptal bone

Low smile line

Vertical def. 3mm

Mostly horizontal def.

What is the best bone augmentation technique?

“No single technique or biomaterial is

optimum for every clinical application.

Instead, surgeons should consider the

advantages an disadvantages of

each alternative in a given clinical

situation, and select the approach with

lowest overall cost and morbidity, and

the highest likelihood of success”

Rogers, Greene 2012

What is the best bone augmentation technique?

Bone Augmentation Axiom #1“The morphology of a bone defect should influence

our choice of material or technique for repair”

Bone Augmentation Axiom #2“Sites with less bone (fewer walls, > atrophy) are

more demanding and require materials and/or

techniques that offer greater biologic activity and

regenerative capacity.”

Craig Misch

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GBR

Bone Blocks

Ridge Split

Mesh

+ Growth factors

Horizontal Bone Augmentation

Gain (Avg.)

Ridge Split 2.9 mm

GBR 3.1 mm

Block Autograft 4.3 mm

Milinkovic, I, Cordaro L, Int J Oral Maxillofac Surg 2014

Gain (Avg.)

GBR: Non-resorb memb 2.5 - 3.5 mm

GBR: Resorb memb 3.2 - 4.6 mm

Block Autograft 4.0 - 5.7 mm

Jensen SS, Terheyden H, Int J Oral Maxillofac Surg 2009

GBR

Bone Blocks

Ridge Split

Mesh

+ Growth factors

Horizontal Bone Augmentation

Minimal: < 2.0 mm

GBR, Split

Moderate: 2.0 - 4.0 mm

GBR, Split, Block, Mesh

Maximum: > 4.0 mm

Block, Mesh

Gain

Craig Misch

GBR

Bone Blocks

Ridge Split

Mesh

+ Growth factors

Horizontal Bone Augmentation

Minimal: < 2.0 mm

GBR, Split

Moderate: 2.0 - 4.0 mm

GBR, Split, Block, Mesh

Maximum: > 4.0 mm

Block, Mesh

Gain

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GBR

Bone Blocks

Distraction

Mesh

Interpositional

Tent pole

+ Growth factors

Vertical Bone Augmentation

< / = 5 mm•GBR (resorb/PTFE + autograft or bone substitute)

•Intraoral bone blocks

•Ti mesh + oral autograft or bone substitute

•Inlay graft

•Distraction

5 - 10 mm•GBR (resorb/PTFE + autograft)

•Extraoral bone blocks

•Ti mesh + oral autograft

•Inlay graft

•Tent pole

•Distraction osteogenesis

> 10 mm• Iliac block bone grafts

• Ti mesh + extraoral autograft

• Distraction osteogeneis

GBR

Bone Blocks

Distraction

Mesh

Inlay graft

Tent pole

Combination Bone Augmentation

< / = 5 mm•GBR (resorb/PTFE + autograft)

•Intraoral bone blocks

•Ti mesh + oral autograft or bone substitute

•Inlay graft

•Distraction

5 - 10 mm•GBR (resorb/PTFE + autograft)

•Extraoral bone blocks

•Ti mesh + oral autograft

•Inlay graft

•Tent pole

•Distraction osteogenesis

> 10 mm• Iliac block bone grafts

• Ti mesh + extraoral autograft

• Distraction osteogeneis

Consider

Staged

Bone

Grafting

Horizontal deficiency of 6 mm

Vertical deficiency of 3 mm

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Horizontal: Onlay graft

Vertical: GBR- autogenous

Space maintenance is

critical in GBR techniques

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Membrane selection

for space maintenance

Implant

Placement

• Implant diameter based on bucco-palatal

dimension

•Allow 3 mm between implant and outer surface of

buccal bone wall - José Carlos Martins da ROSA Dental Pres Implantol. 2014

Apr-June;8(2):80-9

•Palatal implant placement

Maintain proper buccal tissue

thickness and stability

•Position of the platform- 3 mm apical to CEJ

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6 months

Inadequate

Space

Maintenance??

?

Modified block

Extended resorb memb

Non-resorb reinforced memb

Ti-mesh

SonicWeld

6 months

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Maxillary Anterior: #6 - #9

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#6 #7-8 #8-9 #10

Non-restorable 6 & 8

Horizontal defect 7

Combination defect 9

classification- cologneorientation

H: horizontal

V: vertical

C: combination

S / +S: sinus

graft needs

1: low < 4 mm

2: medium 4-8 mm

3: high > 8 mm

relation graft to defect

i: internal, inside the

contour

e: external, outside the

ridge

c.2.e

Staged Treatment

1. Ext 6

2. Bone graft 9

3. Fixed provisional

1. Implant 6 & 9

2. Tissue graft

1. Provisional 6-9

2. Ext 8 / site graft

Implant-supported

bridge 6-9

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Central Incisor: #8

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classification- cologneorientation

H: horizontal

V: vertical

C: combination

S / +S: sinus

graft needs

1: low < 4 mm

2: medium 4-8 mm

3: high > 8 mm

relation graft to defect

i: internal, inside the

contour

e: external, outside the

ridge

v.1.i

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Central Incisor: #8

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Central Incisor: #8

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classification- cologneorientation

H: horizontal

V: vertical

C: combination

S / +S: sinus

graft needs

1: low < 4 mm

2: medium 4-8 mm

3: high > 8 mm

relation graft to defect

i: internal, inside the

contour

e: external, outside the

ridge

h.2.e

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Maxillary Incisors: #7 - #9

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#6 #7-8 #8-9 #10

Missing 7

Horizontal defect #7

Perio #9

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Maxillary Incisors: #9 - #10

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classification- cologneorientation

H: horizontal

V: vertical

C: combination

S / +S: sinus

graft needs

1: low < 4 mm

2: medium 4-8 mm

3: high > 8 mm

relation graft to defect

i: internal, inside the

contour

e: external, outside the

ridge

c.1.e

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Dr. Ben Watkins has a financial relationship with BIOMET 3i LLC, resulting from speaking engagements, consulting

engagements and other retained services.

Ben Watkins, DDS, FICDProsthodontist

www.drbenwatkins.com

Planning for Implant Restorations

Ben Watkins, DDS, FICDProsthodontist

www.drbenwatkins.com

12/2/2014

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Keys To Successful Implant Esthetics

1. A Diagnosis That Reflects Endpoint Thinking.

2. Precise Surgical and Prosthetic Execution.

Gingival Health

Interdental Closure

Gingival Zenith Gingival Level Equilibrium

Interdental Contact Levels

Patient Evaluation and Implant Site Assessment

1. Biologically Acceptable

2. Functionally Enduring & 3. Esthetically Pleasing

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Running room

Space for components

Emergence profile

In the Facial Plane

Langer and Sullivan I.J.P.R.D. Vol. 9 no. 3, 1989

How can we control the position and direction of tissue?

Think Water Balloons

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Thick Biotype

Moves tissue apically.

FACIALTISSUE

Thin Biotype

Moves tissue incisally.

FACIALTISSUE

Interproximal Shaping

Moves papillae incisally

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Interproximal Shaping

Moves papillae apically

Cylindrical vs. AnatomicEmergence

7 wks healing

“Maintenance of the (tissue) depth range allows clinicians to establish an esthetic, natural-appearing emergence profile .”

--William Becker, DDS, MSD

J Esthet Restor Dent 24:395-401, 2012

Creation of Emergence Profile

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Custom Provisional Technique

Creation of Emergence Profile

Creation of Emergence Profile

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Once the soft tissue has been shaped to our satisfaction, how do we

communicate this to our laboratory for customized abutment fabrication ?

Custom Impression Coping

TechniqueMark Buccal

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Custom Healing Abutment Technique

Technique by Joseph Kan, DDS, MSLoma Linda University

Custom lmpression Coping for an Exact Registration of the Healed Tissue in the Esthetic lmplant Restoration

lnt J Periodont Rest Dent. 1997;17:585-591Kenneth F. Hinds, DDS

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Encode®

Zirconia Abutments

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Zirconia Copingsveneered with

Noritake CZR Porcelain

Ceramics—Rick Bishop, CDTDiplomate Dental Lab

Washington, DC

tissue response13 wks post

implant placement

day of delivery

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CEMENT DELIVERY JIG

Salama H,Salama MA,Garber D,Adar P. The Interproximal Height of Bone: A Guidepost to Esthetic Strategies and Soft Tissue Contours in Anterior Tooth Replacement

Prac Periodontics Aesthet Dent 1998;10:1131-1141

Class Restorative

Environment

Proximity

Limitations

Vertical Soft

Tissue

Limitations

1 Tooth-Tooth

2 Tooth-Pontic

3 Pontic-Pontic

4 Tooth-Implant 1.5 mm 4.5 mm

5 Implant-Pontic N/A 5.5 mm

6 Implant-Implant 3 mm 3.5 mm

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13 mos post delivery1-14-13

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Take-home PointCustom Healing Abutment

+ Custom Impression Coping

+ Custom Abutment (CAD/CAM)

+ World-class Lab Support

+ Application of the Literature

= Best Chance For Superior Esthetic Results