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.



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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


P – Provisional MatrixC – ClotL – LingualB – BuccalWB – Woven Bone Araujo 2005; JClinPerio

1 week 2 weeks 4 weeks 8 weeks

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Atwood et al. J Prosthet Dent 1971



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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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esthetic consideration for implant restorations3/13/20 2 use of a cbct for pre-planning and...

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