the art of healing Òdynamic biologic transformation of ... · 2. orthodontic extrusion tx plan...
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“Dynamic Biologic Transformation of Hard & Soft Tissue”
2008 Dental Implant ConferenceDecember 5, 2008
Kenneth F. Hinds DDS
The Art of Healing
Wednesday, November 13, 13
History
Age 56“Patient does not like the black spaces at her gum line and would like to improve the appearance of her
front teeth.” Wednesday, November 13, 13
Maxilla: History of Advanced Periodontal DiseaseWednesday, November 13, 13
5-6mm
Wednesday, November 13, 13
Treatment Options & Sequence?
Fixed Prostheses?
Regenerate 5-6mm Crest Height?
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1. Orthodontic Extrusion – Full Arch?2. Sinus Augmentation – Bilateral, Iliac Crest 3. Immediate Implants – When & Where?4. Custom Healing Abutments – Where?5. Provisionals – Type?6. Definitive Prostheses – Design?
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3. Sinus Augmentation4. Implants & Provisionals
1. Tuberosity Implants 2. Orthodontic Extrusion
Tx PlanPhase I:Posterior
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8. Provisionals9. Metal-Ceramic Prostheses
5. Orthodontic Extrusion 6. Anterior Immediate Implants7. Custom Healing Abutments
Tx PlanPhase II:Anteriors
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Treatment Plan: “Implant Mapping”1. 12 Total Implants planned2.Determine Tooth Sizes3. Implant Targets Locations
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Custom Abutment / Ceramic collar / Cementable Prostheses
4 5 7 12 13 13 13 13 12 7 5 4 7 7 6 6 6 6 6 6 6 6 7 7
8 9 7 7.5 6 8.5 8.5 6 7.5 7 9 8
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8 9 7 7.5 6 8.5 8.5 6 7.5 7 9 8
Planned Tooth SizesWednesday, November 13, 13
8 9 7 7.5 6 8.5 8.5 6 7.5 7 9 8
Target Implant Sites
6.0 6.07.5 7,57.0 7.0
9.0 8.0
9.0 8.0
8.5 8.5
Planned Tooth Sizes
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Prosthetic TemplateRadiographic TemplateSurgical Template
6.0 6.07.5 7,57.0 7.0
9.0 8.0
9.0 8.0
8.5 8.5
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Radiographic Template
5 4 4 4 4 5Wednesday, November 13, 13
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Orthodontic Extrusion
Tuberosity Implants
Bilateral SinusAugmentation
Treatment: Phase I “Posteriors”Implant
Provisionals
The Role of Orthodontic Extrusive Remodeling in the Enhancement of Soft and Hard Tissue Profiles Prior to Implant Placement: A Systematic Approach to the Management of Extraction Site Defects.
H. Salama, M. Salama, Int J Perio Rest Dent 1993;13:4,313-333Wednesday, November 13, 13
3. Sinus Augmentation4. Implants & Provisionals
1.Tuberosity Implants 2. Orthodontic Extrusion
Tx PlanPhase I:Posterior
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Orthodontic Extrusion - Posteriors1. Endodontic Therapy2. Provisionals
Before BeforeAfter
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Before BeforeAfter
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Before
Provisionals & Retention 3-4 monthsWednesday, November 13, 13
Extractions, Sinus grafts(Iliac Crest) &Expose Implants
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Provisionals: Tuberosity Implants
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New Metal Reinforced, Precision, Provisionals
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5 4 4 4 4 5
Posterior Implants
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Orthodontic Extrusion
ImmediateImplants
Custom Healing
Abutments
Treatment: Phase II “Anteriors”
Metal Ceramic Definitive Prostheses
Custom Impression
Coping
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Orthodontic Extrusion: AnteriorsDynamic Biologic Transformation
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Elastic Thread Technique
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Sequence: 1. Splint Anteriors 2. Reduce 8 & 9 3. Extrude two teeth
Elastic Thread Technique
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Elastic ThreadOrmco,
Glendora, CAFile Cemented in Root
Ortho Wire in #55 K File
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1. Reduce roots 2. Reset Hook3. Change Elastic
Elastic Thread Technique
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Provisional Attach to Brackets
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Orthodontic Extrusion
ImmediateImplants
ImmediateCustom Healing
Abutments
Treatment: Phase II “Anteriors”Custom
Impression Coping
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Extractions Implant Sites
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Immediate
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ISQ StabilityTest 65-70
Fixture Placement Preserve Soft
Tissue?
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Preserve Soft Tissue?
Custom Healing Abutments1. Plastic Temp Cylinders2. Line with Composite3. Attach to Implants4. Add Composite &Light
Cure.Wednesday, November 13, 13
Plastic Temporary Cylinders
Add Composite ResinWednesday, November 13, 13
Fill Voids
Smooth & PolishWednesday, November 13, 13
Immediate Custom Healing Abutments
Reduce to Tissue Wednesday, November 13, 13
6 Months
Definitive Impresssions?
orProvisionals?
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6 Months
Provisionals
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6 Months
Accurate Transfer to Technician?
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Orthodontic Extrusion
ImmediateImplants
ImmediateCustom Healing
Abutments
Treatment: Phase II “Anteriors”Custom
Impression Coping
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Fabrication?
Custom Impression Coping
“Custom Impression Coping For An Exact Transfer in The Esthetic Implant Restoration” . International Journal of Periodontics and Restorative Dentistry, NOV-DEC 1997; Vol 17, No#6: Pages 585-591. Hinds, K
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Fabrication?Custom Impression Coping
“Custom Impression Coping For An Exact Transfer in The Esthetic Implant Restoration” . International Journal of Periodontics and Restorative Dentistry, NOV-DEC 1997; Vol 17, No#6: Pages 585-591. Hinds, K
Direct or Indirect
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Fabrication Direct: “Custom Impression Coping”
Add Composite ResinWednesday, November 13, 13
Transfer Technique: “Custom Impression
Connect to Implant & Light Cure Composite ResinWednesday, November 13, 13
Remove Abutment Attach to Analog
Fabrication Indirect: “Custom Impression Coping”
Wednesday, November 13, 13
Attach Implant Replica into a small container 6 7 8 9 10 11
Connect Provisional AbutmentsInject Regisil to fill containerRemove AbutmentsConnect Pickup Impression CopingInject Composite Resin Around Imp Coping
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Custom Impression Coping
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IndividualSplinted SplintedWednesday, November 13, 13
Ceramic?Titanium?Gold?
Master Cast
Abutment Selection?
Strength & EstheticWednesday, November 13, 13
Custom Abutment / Ceramic Collar
A procedure for a modified cylindric titanium abutment.J Prosthet Dent. 1997 May;77(5):546-9. Marchack CB, Yamashita T
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Metal Ceramic Fixed Prosthesis
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Before Provisionals
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Definitive ProsthesesBefore
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Female, Age 55Patient History:
Hx: Tooth #7 Apical LesionWednesday, November 13, 13
Orthodontic Extrusion RX: Antiobiotics
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Custom Healing Abutment at One Week
Extraction and Immediate Implant
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Provisional
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Definitive Prosthesis
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Single Site Multiple Implant Sites
Dynamic Biologic
PotentialPatients
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4 5 7 12 13 13 13 13 12 7 5 4 7 7 6 6 6 6 6 6 6 6 7 7
8 9 7 7.5 6 8.5 8.5 6 7.5 7 9 8
“Initial BluePrint”Custom Abutment / Ceramic collar / Cementable Prostheses
Wednesday, November 13, 13
Metal Ceramic Prosthetic Template8.5 8.5 8.5 8.5
6.0 6.0 6.0 6.07.5 7,5 7.5 7,57.0 7.0 7.0 7.0
9.0 8.0
9.0 9.0 9.0
8.0 8.0 8.0
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• Interdisciplinary Team• Sequencing•Do not be in a hurry to remove teeth•Do not be in a hurry to remove teeth
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Thank You for the Opportunity to Share This
Time With You
The Art of Healing
Wednesday, November 13, 13