people with a high level of personal mastery live in a continual...
TRANSCRIPT
PEOPLE with a high level of personal mastery live in a continual learning mode
complicationreferencenote
imperio+ 12 modulesto successful patient treatment
TREATMENT PLANNINGFOR SUCCESS
make knowledge
hard tissues 2
make knowledge constructive
resective procedures … crown lengthening additive procedures … guided tissue & bone regeneration some of the basic surgical tools used to idealize the tissue framework
hard tissues 2
make knowledge constructive
complications
surgical treatment is increasingly microsurgical … emerging biologics reduce the need for secondary sites… how is this affecting our outcomes and success rates? … hard tissues …. hard job …
constructivehard tissues2
• ideal root form for crown lengthening
constructivehard tissues2
note
• Ingber FJS, Rose LF, Coslet JG. The biologic width. A concept in
periodontics and restorative dentistry. Alpha Omegan 1977;70:62-65.
• Tarnow DP, Magner AW, Fletcher P. The effect of the distance from the
contact point to the crest of bone on the presence or absence of the
interproximal dental papilla. J Periodontol 1992;63:995-996.
• Melker DJ Richardson CR. Root reshaping: an integral component of
periodontal surgery. Int J Periodontics Restorative Dent 2001;21:297-304.
reference
constructivehard tissues2
3+mm
4.5mm
• establish the desired soft tissue level
• bone sound to assess the bone crest level
• correct the bone level to establish biologic width
• root/tooth surface modifications
conventional periodontal surgery
constructivehard tissues2
• Deas DE, Moritz HT, Poell CA, Mealey BL. Osseous surgery for crown lengthening: a 6-month clinical study. J Periodontol. 2004;75:1288-1294.
constructivehard tissues2
• establish the desired soft tissue level
• bone sound to assess the bone crest level
• blindly correct the bone level to establish b.w.
laser (minimally invasive) surgery
constructivehard tissues2
• Sonic M, Hwang D. Periodontal plastic surgery II: Esthetic crown lengthening. Inside Periodontics. 2007;65-72.
• Flax H. Maximizing esthetic transformations using a closed flap Er,Cr:YSGG modality. Compend Contin Educ Dent 2005;26:172-174.
• Dyer B. Minimally invasive osseous crown lengthening procedure using an erbium laser. Clinical case and procedure report. J Cosmetic Dent 2008;23(4):72-78.
constructivehard tissues2
i m m e d i a t e p o s t - o p e r a t i v e v i e w
constructivehard tissues2
h e a l i n g a t 2 1 d a y s
constructivehard tissues2
• McGuire MK, Schreyer ET. Laser-assisted flapless crown lengthening: a case series. Int J Periodontics Restorative Dent. 2011;31:357-364.
constructivehard tissues2
• plaque control problems
• invasion of biologic width
• retained cement
aetiology of post-restoration inflammation?
• inadequate bone level correction ?
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• root damage . charring . impact?
• inadequate bone removal & bone toughing
inevitable treatment failure
constructivehard tissues2
Nevins M, Camelo M, De paoli S et al. Int J Perio & Rest Dent 2006 !Ferrus J, Cecchinato D, Pjetursson EB et al. Clin Oral Implants Res 2010 !Lee Sl, Kim HJ, Son MK, Chung CH. J Adv Prosthodont 2010 !Lau SL, Chow J, Li W, Chow LK. J oral Maxillofac Surg 2011 !Braut V, Bornstein M, Belser U, Buser, D. Int J Perio Rest Dent 2011
• facial bone 90% < 1mm thick
• facial bone at crest missing or thin 90%. • mid-root thickness 0.9 +/- 0.4mm
• roots often buccally angulated
incisor buccal plate thickness (thin <1mm . thick >1mm)
constructivehard tissues2
• Nissan J, Mardinger O, Calderon S et al. Cancellous bone block allografts for augmentation of the anterior atrophic maxilla. Clin Implant Dent Relat Res 2009 Sept.
• Waasdorp J, Reynolds MA. Allogenic bone onlay grafts for alveolar ridge augmentation: a systematic review. Int J Oral Maxillofac Implants. 2010;25:525-531.
constructivehard tissues2
constructivehard tissues2
constructivehard tissues2
surgery 1
• condition complicates flap handling.
• treatment: anti-fungal medication, new transitional
prosthesis & laser tissue abrasion/removal.
inflammatory papillary hyperplasia (type 3)
constructivehard tissues2
surgery 2
constructivehard tissues2
• uneventful healing 4 weeks post-surgery
constructivehard tissues2
• soft tissue dehiscence
• bone graft failure
• significant implant thread exposure
8 weeks post-surgery
surgery 3
constructivehard tissues2
constructivehard tissues2
• in search of less ‘risky’ materials
• SonicWeld Rx (KLS martin)
• resorbable poly-dl-lactic acid pins and membrane
constructivehard tissues2
constructivehard tissues2
constructivehard tissues2
i n f u s e B M P 2 ( m e d t r o n i c )
m i n e r o s s a l l o g r a f t ( b i o h o r i z o n s )
constructivehard tissues2
• Iglhaut G, Schwarz F et al. Shell technique using a rigid resorbable barrier system for localized alveolar ridge augmentation. Clin Oral Impl Res. 2012; 00: 1-6.
• Burger B. Use of ultrasound-activated resorb able poly-d-l-lactide pins (sonicpins) and foil panels (resorb-x) for horizontal bone augmentation of the maxillary and mandibular
alveolar ridges. J Oral Maxillofac Surg. 2011.
surgical & restorative strategies 3
make knowledge applicable
Understand the implant placement and restoration strategies that can be used following tooth extraction. Explore the case selection criteria, rationale for and techniques used in the aesthetic zone.
surgical & restorative strategies 3
make knowledge applicable
complications
immediate implant placement and restoration are increasingly used protocols …
some literature … and some opinions state that these are of high aesthetic risk, especially in the thin biotypes and high gingival scallops
applicablesurgical & restorative strategies3
• moderately thick gingival biotype
• adequate palatal & apical bone for stability
• favorable occlusion . cooperative patient
applicablesurgical & restorative strategies3
applicablesurgical & restorative strategies3
• grafting the residual horizontal defect
• goal: 4mm buccal bone & tissue
• outcome: reduce buccal resorption
• Grunder U, Gracis S, Capelli M. Influence of the 3-D bone-to-implant relationship on esthetics. Int J Periodontics Restorative Dent 2005;25:113-119.
• Capelli M, Testori T et al. The implant-buccal plate distance: A diagnostic parameter. A prospective cohort study on implant placement in fresh extraction sockets. J Periodontol 2013.
applicablesurgical & restorative strategies3
day of surgery
applicablesurgical & restorative strategies3
reference
• De Rouck T, Collys K, Wyn I, Cosyn J. Instant provisionalization of immediate single-tooth
implants is essential to optimize esthetic treatment outcomes. Clin Oral Implants Res. 2009.
20(6):566-570
• Cosyn J, Eghball A, De Bruyn H, Collys K, et et. Immediate single-tooth implants in the anterior
maxilla: 3-year results of a case series on hard and soft tissue response and aesthetics. J Clin
Periodontol 2011;38(8):746-753.
• Peng M, Fei W, Hosseini M, Gotfredsen K. Influence of implant position on clinical crown length
and peri-implant soft tissue dimensions at implant-supported single crowns replacing maxillary
central incisors. Int J Periodontics Restorative Dent. 2013;33(6):785-793.
• mid-facial tissue height - better with immediate
placement vs. delayed restoration (0.75mm).
• papilla similar, but took longer to reform with
delayed placement.
10 days post-surgery
applicablesurgical & restorative strategies3
applicablesurgical & restorative strategies3
d e f i c i e n t d i s t a l p a p i l l a
applicablesurgical & restorative strategies3
very thin gingival biotype!
screw-retained provisional restoration natural tooth veneered to peek abutment
applicablesurgical & restorative strategies3
applicablesurgical & restorative strategies3
immediate post-op
applicablesurgical & restorative strategies3
• limit papilla-opening procedures/bone recontouring
• idealize implant position
• idealize contact point positions
optimizing soft tissue levels
post-op 8 weeks
applicablesurgical & restorative strategies3
post-op 8 weeks immediate post-op post-op 1 week post-op 8 weeks
implant position 4
make knowledge relative
The determinants for correct 3D implant placement are clearly defined in today’s literature, as are the guidelines to ensure idealized placement for aesthetic and restorative success.
implant position 4
make knowledge relative
complications
The guilty (and rationalizing) surgical team member … Avoid the pitfalls of improper implant position and recognize which positional errors can be managed surgically and/or prosthetically, and which ones need to be removed.
relativeimplant position4
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relativeimplant position4
relativeimplant position4
consequences of placement errors
relativeimplant position4
relativeimplant position4
implant removal . several techniques & instruments
gingival biotype 6
make knowledge cumulative
Connective tissue and dermal grafts are routinely used in the management of gingival recession in the natural dentition. These techniques are pivotal in implant surgery to enhance tissue volume and improve post-restoration tissue levels.
gingival biotype 6
make knowledge cumulative
complications
Gingival or dermal graft options… Similar treatment outcomes Unique technical handling Dentist-guided … Patient decision
cumulativegingival biotype6
cumulativegingival biotype6
p r e - o p p o s t - o p
volume
enhancement
cumulativegingival biotype6
cumulativegingival biotype6 cumulativegingival biotype6
g r a f t q u a l i t y i m p a c t o n l o n g - t e r m s t a b i l i t y
i m p a c t o f f i b r o u s v s . f a t t y g r a f t s
cumulativegingival biotype6 cumulativegingival biotype6
cumulativegingival biotype6
7-0 vicryl with spatula blade. ethiconalloderm (BioHorizons)
cumulativegingival biotype6
3 w e e k s p o s t - o p
cumulativegingival biotype6
non-passive suturing/closure
cumulativegingival biotype6
post-operativepre-operative
cumulativegingival biotype6
6 months post-op
cumulativegingival biotype6
alloderm (BioHorizons)
cumulativegingival biotype6
• Alloderm (BioHorizons) • Dermis (Zimmer) • PerioDerm (Dentsply) • Mucograft (Osteohealth)
do all dermal grafts produce similar gains in
keratinized tissue?
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provisionalization 7
make knowledge functional
Provisionalization can be viewed as the fine-tuning of tissue architecture around implants and in adjacent pontic sites. It is an essential step in the restoration of implants in the esthetic zone and is a pivotal step in the transfer of information from the restorative team to the technician.
provisionalization 7
make knowledge functional
complications
A natural step in the treatment of the natural dentition … An integral step to success in the restoration of dental implants….
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c h a n g e s t r u c t u r e
functionalprovisionalization7
36 months
functionalprovisionalization7
day of insertion 8 weeks later definitive restoration
functionalprovisionalization7
functionalprovisionalization7
functionalprovisionalization7
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functionalprovisionalization7
revised restoration
functionalprovisionalization7
overcontoured crown
abutment materials & designs 9
make knowledge compatible
Material options range from titanium, gold-hued titanium to today's increasingly used aesthetic materials zirconia and lithium disilicate. This module will touch on abutment strength, biocompatibility, impact on tissue colour and the influence on cementation.
abutment materials & designs 9
make knowledge compatible
complications
There are numerous material options in the transmucosal area that offer aesthetic solutions . Some of these materials are proving to have structural weaknesses. Clinicians and patients suffer the consequences …
compatibleabutment materials & designs9
• Garine WN, Funkenbusch PD, Ercoli C, Wodenscheck J, Murphy WC. Measurement of the rotational misfit and implant-abutment gap of all-ceramic abutments. Int J Oral Maxillofac
Implants. 2007;22:928-938.
• Sailer I, Sailer T, Stawarczyk B, Jung RE, Hammerle CH. In vitro study of the influence of the type of connection on the fracture load of zirconia abutments with internal and external
implant-abutment connections. Int J Oral Maxillofac Implants. 2009 Sep-Oct; 24(5):850-858.
compatibleabutment materials & designs9
sulcus%
epithelial%a,achment%
connec0ve%%0ssue%
sulcus%
epithelial%a,achment%
connec0ve%%0ssue%
compatibleabutment materials & designs9
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Text
JE stops
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compatibleabutment materials & designs9
!
• Nevins M, Kim DM, Jun SH, Guze K, Schupbach P, Nevins ML. Histologic evidence of a connective tissue attachment to laser microgrooved abutments: a canine study. Int J Periodontics
Restorative Dent. 2010;30:245-255.
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compatibleabutment materials & designs9
• demonstrated consistent soft tissue integration
(uncommon on smooth surface abutments)
• but … clinical parameters comparable
• plaque . gingival health . probing depths
laser ablated abutments
Guers NC, O’Neil SJ, Reddy MS. Plaque, mucosal health and probing depth around laser ablated
abutments. Oral presentation Wash State Dental Convention March 2013.
ceramics 10
make knowledge appealing
Choosing a restorative material is often decided upon by technical team members. This module is designed to foster the participant's involvement in the material selection process and will review current options, strengths and limitations of the new restorative materials.
ceramics 10
make knowledge appealing
complications
Teamwork between the dentist and technician . Ceramic restorations demand careful handling and an understanding of material properties. Cementation … the make-you or break-you step.
appealingceramics10
appealingceramics10
appealingceramics10
appealingceramics10
• Alikhasi M, Monzavi A, Bassir SH et al. A comparison of precision of fit, rotational freedom, and torque loss with copy-milled zirconia and prefabricated titanium abutments. Int J Oral
Maxillofac Implants. 2013;28(4):996-1002.
• Buzayan M, Baig MR, Yunus N. Evaluation of accuracy of complete-arch multiple-unit abutment-level dental implant impressions using different impression and splinting materials. Int J
Oral Maxillofac Implants. 2013;28(6):1512-1520.
appealingceramics10
appealingceramics10
ceramic fracture appears to be the most common clinical
failure mechanism of all-ceramic crowns
• Wassermann A et al. Clinical long-term results of Vita In-Ceram Classic crowns and fixed partial dentures. A
systematic literature review. Int J Prosthodont 2006; 19:355-363
• Jung RE et al. A systematic review of the 5- year survival and complication rates of implant-supported single
crowns. COIR 2008;19:119-30.
• White SN et al. Flexural strength of a layered zirconia and porcelain dental all-ceramic system. J Prosthet
Dent 2005;94: 125-31.
• Scherrer SS et al Failure analysis of ceramic clinical cases using qualitative fractography. Int J Prosthodont
2006;19: 185-92.
• Koenig V et al. Clinical risk factors related to failures with zirconia-based restorations: An up to 9-year
retrospective study. J Dent 2013.
appealingceramics10
!104EMAX EMAX full contour zirconia. M feldspathic cusp
!105 restoration try-in
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appealingceramics10
appealingceramics10
• de Brandao ML, Vettore MV, Vidigal Junior GM. Peri-implant bone loss in cement- and screw-retained prostheses: systematic review and meta-analysis. J Clin Periodontol. 2013;40(3):287-295.
• Chen CJ, Papaspyridakos P, Guze K, Singh M, Weber HP, Gallucci GO. Effect of misfit of cement-retained implant single crowns on crestal bone changes. Int J Prosthodont. 2013;26(2):135-137.
appealingceramics10
appealingceramics10
Pette GA, Ganeles J, Norkin. Radiographic appearance of commonly used cements in implant dentistry. Int J Periodontics Restorative Dent 2013;33:61-68.
Wadhwani C, Hess T, Faber T, Pineyro A, Chen CSK. A descriptive study of the radiographic density of implant restorative cements. J Prosthet Dent 2010;103:295-302.
Tarica DY, Alvarado VM, Truong ST. Survey of United States dental schools on cementation protocols for implant crown restorations. J Prosthet Dent. 2010;103:68-79.
Wilson TG. The positive relationship between excess cement and peri-implant disease: a prospective clinical endoscopic study. J. Periodontol. 2009 Sep;80(9):1388-92.
!
appealingceramics10
appealingceramics10
appealingceramics10
n a t u r a l t o o t h p r e p a r a t i o n a b u t m e n t p r e p a r a t i o n
The performance of luting cements in maintaining a minimum film thickness over a suitable period of time
setting time & film thickness (um)
luting cement 1 min !2min
!3 min
FujiCem RelyX Luting Plus
7.3 (3.4) 19.7 (5.6)
8.9 (3.9) 25.4 (7.7)
28.6 (9.3) 53.6 (12.2)
RelyX ARC Panavia 21
12.3 (3.2) 20.9 (2.0)
16.4 (4.2) 24.3 ( 1.6)
28.6 (9.3) 26.3 (2.4)
Maxcem RelyX Unicem
19.3 (3.5) 15.1 (2.3)
19.6 (2.1) 16.0 (4.6)
21.0 (2.1) 19.4 (4.8)
RelyX Ultimate 12 ? ?
appealingceramics10
appealingceramics10
• Chee WW, Duncan J, Afshar M, Moshaverinia A. Evaluation of the amount of excess cement around the margins of cement-retained dental implant restorations: the effect of the cement
application method. J prosthet Dent 2013;109(4): 216-221.
appealingceramics10
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appealingceramics10
appealingceramics10
appealingceramics10
appealingceramics10
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appealingceramics10
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• bone . resective & additive procedures
• implant protocols . new thoughts on outcomes
• tissue volume . enhancement for success
• provisionalization & tissue form
• restorative materials . interesting & challenging
• the difference between failure & success …
doing something nearly right … or doing it
exactly right
PRODUCTIVEyah yah…
just gimmie the credits
12 easy modules you say?
visit www.imperioplus.ca to find out how