Esthetic Consideration for Implant Restorations3/13/20 2 Use of a CBCT for pre-planning and...
Transcript of Esthetic Consideration for Implant Restorations3/13/20 2 Use of a CBCT for pre-planning and...
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Esthetic Consideration for Implant Restorations
Suphachai Suphangul DDS.
Hard Tissue Foundations
Soft Tissue Transitional Zone
Dental Prosthesis Zone
Spray JR et al. Ann Periodontol 2000;5:119–128.
Sites with > 3 mm of bone loss showed the lowest mean facial bone thickness at 1.3 mm. Whereas sites with no change in facial bone response had a mean thickness of 1.8 ± 1.10 mm at implant placement
A critical thickness to help in clinical decision-making to reduce facial bone loss was determined at 2 mm.
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Use of a CBCT for pre-planning and evaluation of buccal plate thickness along with sagittal root position is helpful in establishing an appropriate treatment plan and in guiding proper 3D placement.
Levine et al. Int J Oral maxillofac Implants 2014;29(suppl):155–185.
Hard Tissue Foundations
Soft Tissue Transitional Zone
Dental Prosthesis Zone
A minimum of 3 mm of keratinized gingiva in the esthetic zone is
recommended to allow for the biologic width to reform with a minimal gingival thickness of 2 mm.
Levine et al. Int J Oral maxillofac Implants 2014;29(suppl):155–185.
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Landsberg CJ, Bichacho N. A modified surgical/prosthetic approach for optimal
single implant supported crown. Part I—The socket seal surgery. PractPeriodontics Aesthet Dent 1994;6:11–17.
Langer B, Langer L. Subepithelial connective tissue graft technique for root coverage. J Periodontol 1985;56:715–720.
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Why Does Treatment Plan is Matter?
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Buser D et al Int J Oral Maxillofac Implants. 2004;19 Suppl:43-61.
Buser D et al Int J Oral Maxillofac Implants. 2004;19 Suppl:43-61.
Buser D et al Int J Oral Maxillofac Implants. 2004;19 Suppl:43-61.
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What is happen when loss teeth in esthetics zone ?
Anatomy of Socket
Navin M. et al Int J Periodontics Restorative Dent. 2006 ;26 :19-29
“The alveolar process is a tooth dependenttissue that develops in conjunction
with the eruption of the teeth.” Schroeder 1986
Anatomy of Socket
Navin M. et al Int J Periodontics Restorative Dent. 2006 ;26 :19-29
“The alveolar process is a tooth dependenttissue that develops in conjunction
with the eruption of the teeth.” Schroeder 1986
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Physiology of Socket Healing
Schropp L et al. Int J Periodontics Restorative Dent. 2003 Aug;23(4):313-23)
Materials and Methods:
46 patients Dimensional changes
evaluated at 3,6, and 12 months
post-extraction
Socket dimensional change
Stephen T. Chen et al. ,Immediate or Early Placement of Implants Following Tooth Extraction: Review of Biologic Basis, Clinical Procedures, and Outcomes,The International Journal of Oral & Maxillofacial Implants
Volume 19, Supplement, 2004
Physiology of Socket Healing
P – Provisional MatrixC – ClotL – LingualB – BuccalWB – Woven Bone Araujo 2005; JClinPerio
1 week 2 weeks 4 weeks 8 weeks
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Physiology of Socket Healing
Atwood et al. J Prosthet Dent 1971
Physiology of Socket Healing
Physiology of Socket Healing
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Chen S, Buser D. Implants in post-extraction sites: A literature
update. In: Buser D, Belser U, Wismeijer D (eds). ITI Treatment Guide. Vol 3: Implants in extraction sockets. Berlin: Quintessence, 2008.
Horizontal Augmentation Technique
• Guided Bone Regeneration• Onlay/Inlay Bone Graft • Ridge Expansion• Distraction Osteogenesis
What is Guided Bone Regeneration(GBR)?
Bone regenerative technique that uses physical means (e.g., barrier membranes) to seal off an anatomical site where bone is to be regenerated.
The goal is to direct bone formation and prevent other tissues (e.g., connective tissue) from interfering with osteogenesis.
Jalbout Z, Tabourian G, eds. Glossary II of Im plant Dentistry International Congress of Oral Im plantologists; 2008:41
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Guide Bone Regeneration• First published “Guide Tissue Regeneration” (GTR) By Dahlin
in 1988• Expanded polytetrafluoroethylene (ePTFE) • Create space and excluded fibroblast form healing • Has been used regenerate peri-implant defects
Guide Bone Regeneration
• Collapse of ePTFE membranes • Reduce the volume and quality of regenerated tissue• Bone filler: autografts or allografts• Bioresorbable membranes– Polymeric membranes – Collagen membranes
Modern Essentials of Bone Formation
Scaffolds(Collagen, bone matrices, synthetics)
Blood Clot
Cells(Osteoblasts, endothelial cells)
Signaling Molecules(Growth Factors)
Time
Blood Supply
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Bone Grafts in Modern Implant Dentistry
Autograft(autotransplant)
Intra-oral-Chin-Ramus-Tuberosity-Torus
Extra-oral- Hip- Rib- Calvaria- Tibia
Xenograft(different species)
Sources-Bovine-Equine-Canine
Alloplast(synthetics)
Materials-Hydroxyapatite-Calcium Phosphate-Calcium Sulfate-Calcium Carbonate
Allograft(same species)
Mineralized-FDBA-M axgraft
- Cortical- Cancellous- Blocks
Demineralized-DFDBA
Biologics(proteins & GFs)
- EM D- PDGF
- BM P-2
Bone graft materials: differences
composition
porosity
biologic activity
resorptionorigin
risk of infection
scientific evidence
mixability appplication form mechanical stability
volume stability
Properties of Bone Grafts
Particle Size Mechanical Handling Compaction Absorption
X-Small <500 - - +++ ++++ ++++
Small 0.5 – 1mm + +++ +++ +++
Large 1 – 2 mm +++ ++ ++ +
X-Large >2mm ++++ - - -
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Biologic potential: maxgraft®
3 6 9 12 months
maxgraft®
100
75
25
50%
Bone formation
maxgraft®
biologic activity
& resorption rate
Volume stability
Regeneration
Rem
odeli
ngm
axgr
aft®
0
Barrier Membranes in Dentistry
Non-absorbablePTFECytoplast
Tenting only(no barrier function)
- Ti mesh- Ti screws
- PGA/PLA plates- Bone pins
AbsorbableFast-BioGide-BioM end-Collprotect
Slow- Biomend Extend
- Pericardium- CopiOs- Jason M embrane
PTFE &Tenting
Cytoplast Ti Reinforced
months
100
75
25
50%
Barrier function
0 4
Vascularisation
2 6
Healing
RegenerationGTR / GBR
IntegrationResorption collprotect®
membrane
Protection
Collprotect® membrane : optimal barrier function over 3 monthswith parallel integration and vascularisation
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Guide Bone Regeneration
Wang HL, Boyapati L. Implant Dent. 2006;15:8-17.
TRAPEZOIDAL FLAP WITH VERTICAL INCISIONS- One Tooth Mesial and Distal.
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Surgical Flap Elevation
INTRAMARROW PENETRATION
TO PREPARE DEFECT FOR GRAFT
PERIOSTEAL RELEASING INCISION FOR TENSION FREE CLOSURE OF FLAP
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TENSION FREE RELEASE OF FLAP
Membrane Trimmed to Fit Defect
BONE GRAFT PLACED TO AUGMENT SITE
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Membrane PLACED FOR B-Li AND
VERTICAL AUGMENTATION
FLAP CLOSED & SUTURED
TENSION FREE CLOSURE
Horizontal Bone Deficiency
Implant Placement &GBR
Site Development (GBR)
Implant Stability with Proper position
Implant Placement
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Ridge Preservation
Socket and ridge preservation
Socket preservation: no bony wall defect- filling extraction socket with bone graft, Jason® fleece or collacone®
Ridge preservation: bony wall defect after tooth extraction- coverage of defect with membrane and filling of the alveolarvsocket
Tooth extraction Filling with collacone® Suturing
Insertion of membrane Filling with bone granules Suturing
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7 months later
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Final Prosthesis
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3 Months follow up
2 years follow up
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5 years follow up
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Site Development Horizontal GBR
International Journal of Periodontics and Restorative Dentistry 2004;24:232-245
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7 months later
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2 weeks after implant placement and provisional
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Final Prosthesis
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2 years follow up
Implant Placement Simultaneous GBR
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Second Stage 4 months Post Implant Placement with GBR
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Er,Cr:YSGG (Erbium, Chromium: Yttrium, Scandium, Gallium, Garnet)
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Post Op Second Stage 3 weeks
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