2020 GPVFDC Surgical-Restorative Connection Working Copy · Surgical Planning Considerations 49 ... §Crowns have anatomical emergence profiles §Implants have hemi-desmosomal (no

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The Surgical/Restorative Connection in Dental ImplantTreatment for the

General Practitioner: Why, Where, When and How for a Successful Outcome

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What are the Keys to Success?

What are the Fundamental Rules and Guidelines?

The Surgical/Restorative Connection in Dental Implant Treatment

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The Surgical/Restorative Connection in Dental Implant Treatment: Where We Were!

Surgically Driven (by the presence of adequate bone)

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The Surgical/Restorative Connection in Dental Implant Treatment: Where We Were!

Surgically Driven (by the presence of adequate bone)

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The Surgical/Restorative Connection in Dental Implant Treatment: Where We Are Now!

Restoratively Driven Treatment Planning = Restorative Success

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Remember:

The tissue is the issue

The bone sets the tone

The mission is the dentition

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The long term prognosis is affected differently by different treatment options for the same diagnosis

The goal is always to minimize risk and maximize the long term prognosis

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Patients don’t attend our offices for implants but rather for teeththat function, look good and have a long term prognosis

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What are the Criteria for Case Selection?

How Do I Plan for Success?

Diagnosis and Treatment Planning

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§ CORRECT diagnosis!

§ Carefully thought out treatment planning

§ Proper management of occlusal forces

§ Successful management of the bacterial challenge(short maintenance interval, i.e., 3-4 mos. )

§ Understand the patient’s wishes: Are they realistic??

What are the Criteria for Success for Implant Therapy?

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What are the Minimum Requirements for Successful Implant Treatment?

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Suitable materialViable boneStability of the bone/implant material interface during healingCorrect position of the implant

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What are the Differences We Need to Know BetweenTeeth and Implants?

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Tooth vs. Implant

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What are the Conditions Favoring Peri-Implant Papillae?

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Conditions Favoring Peri-Implant Papillae

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Treatment Planning in Implant Dentistry:

What is the Prosthetic Situation?

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Incorrect m-d implant position results in…Patient Selection and Treatment

Planning in Implant Dentistry


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Incorrect m-d implant position results in…What is the Patient’s Medical and

Dental History?


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§ Does the patient’s present state of health

influence your decision? ASA I-IV ?

§ Is there a history of osteoporosis related

medications: injectable or oral?

§ What medications is the patient taking?

Medical History

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Medical History

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§ What if the patient has an INR of >3.0? Is the patient taking an anti-coagulant?

§ Are there other medical conditions, e.g. Sjogren’s or medications inhibiting salivary flow which influence a positive outcome?

Medical History

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Medical History

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§ Has the patient received regular dental care in thepast?

§ Does the patient have regular maintenance?

§ What is the history of the previous tooth loss, andwhat was the recommended treatment?

Dental History

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Are there adjacent teeth present?:

§ Periodontal condition

§ Angulation

§ Length of edentulous space

§ Inter-arch space

Treatment Planning

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§ Implant position: RESTORATIVELY DRIVEN !!

§ Reconstruction for Site Preparation?§ Bone and/or Soft Tissue if required:

§ At time of implant placement?§ As a separate procedure?

Treatment PlanningHow Do I Determine the Best Implant Position?:

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DISCUSS with your patient:§ Multiple stages may be required

§ Deficiencies may need to be disguised prosthetically

§ Implants may require replacement in the future!

Treatment Planning

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How Do I Evaluate Potential Implant Sites?

§ Single tooth space§ Tooth or root present§ Normal ridge form§ No inflammation§ No recession at adjacent teeth§ Low lip line

Positive Factors Negative Factors§ Multiple teeth missing§ Atrophy of edentulous space§ Inflammation of soft tissue§ Recession at adjacent teeth§ Highly visible site

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Radiography and Imaging:What areToday’s Standards for Implant

Treatment?

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§ Digital panorex

§ Digital periapical

§ CBCT scan

§ CAD/CAM technology

§ Treatment planning software

Radiography and Imaging

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§ Digital radiographs are useful, however, are still two dimensional

§ CBCT scan gives accurate three dimensional model of the implant site

§ CBCT scans can be used with software designed to allow implants to be placed in the computer model, e.g.,

Radiography and Imaging

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Radiographic Examination

§ Bone quality§ Bone quantity§ Anatomical structures§ Inferior alveolar nerve

§ Maxillary sinuses and nasal cavity

§ Roots of adjacent teeth

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Radiographic Examination

The AAOMR recommends that cross-sectional imaging be used in the assessment of all dental implant sites and that CBCT is the imaging method of choice

Tyndall, D et al. Oral Surg Oral Med Oral Pathol Oral Radiol, 2012

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Incorrect m-d implant position results in…

3D Imaging: CBCT Scan

What is the Rationale?

Does it Impact the Surgical/Restorative Connection?

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Mental foramenMental

nerve

Mandible nerve

Maxillary sinus

Problematic Areas!!!

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Rationale for 3D Imaging

The Surgical/Restorative Connection in Dental ImplantTreatment

Dr. D Chenin

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Surgical Guide: Is it Necessary??

The Surgical/Restorative Connection

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§ Provide a means of communication between the restorative dentist, surgeon and laboratory technician

§ In some cases, function as a radiographic guide

§ Should not interfere with flap elevation

The Surgical Guide Should:

Surgical Guide

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Pre-Surgical Planning: Set Up/Wax Up or Scan (intra oral or model) ??

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Surgical Guide

A diagnostic set-up or scan is essential to assist the surgeon and restorative dentist in deciding proper implant placement

Restoratively Driven Implant Placement

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What are the Principles for Correct Implant Placement?

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Restoratively Driven Treatment Plan: Clinical Case

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Restoratively Driven Treatment Plan

Hopeless #21, 22 #21, 22 extracted

Impression Working model

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Merging CBCT & Scan Data

Virtual Fixture Placement

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Surgical Template Design

Surgical Guide & Abutment Temporary Crowns

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Checking Surgical Guide Fit CRITICAL!

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Guided Surgery

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The Surgical/Restorative Connection in Dental ImplantTreatment

Surgical Planning Considerations

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Classification and Descriptive Terms for the Timing: Implant Placement after Tooth Extraction

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Esthetic Risk Assessment (ERA)

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What are the Advantages and Disadvantages of the Different Treatment Options for Implant

PlacementTiming?

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Advantages:

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Disadvantages:

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What is the Surgical/Restorative Connection in Dental Implant Treatment and How do We Achieve Success?

Natural Teeth and Implant/Restorations:Are There Differences?

Dr. Dennis Smith, Graduate Periodontics LLU School of Dentistry

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§ Teeth possess a scallopedconnective tissue attachment

§ Root forms vary in length and shape

§ Crowns have anatomicalemergence profiles

§ Implants have hemi-desmosomal(no CT) attachment§ Implants are round, cylindrical or tapering§ Implant crowns have variable emergence profiles

Natural Teeth and Implant/Restorations:What are There Differences?

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§ Bony contours—volume and quality§ Implant-crown contours and position§ Bone crest to proximal crown contact§ Biotypes/phenotypes§ Presence of periodontal disease§ Harmony with facial profiles/arch forms

What Factors Influence Gingival Architecture: Around Implants/Crowns ?

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Labial thicknesses vary

Implant-crown contours and position determine gingival form

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Natural root forms varyImplants are consistently

smaller and round!

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Labial thicknesses vary

Implant crown form assumes an unnatural contour

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Loss of oral structures:A surgical and prosthetic problem

(1) For the implant surgeon and restorative dentist, the challenge is to restore lost dental and periodontal structures to the “normal” with a smaller, round, cylindrical implant and a modified crown form.

What are the Challenges ?

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(2) With the use of implants and crowns, how can one restore to normal gingival architecture and pleasing esthetics?

All treatments should be RESTORATIVELY OR PROSTHETICALLY DRIVEN !!

Loss of oral structures:A surgical and prosthetic problem

What are the Challenges ?

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Staged implant surgery: where there is insufficient bone/gingiva quality or quantity, but augmentation potential is good

Implant Borne RestorationsA Restoratively Guided Treatment Plan

Immediate implant surgery: where existing bone/gingiva contours and volume are good, treatment can be expedited

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A Restoratively Guided Treatment PlanProvisional Restoration

Cho S et al Compendium 2007;28(11):604-609

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Immediate Tooth Replacement??

Dr. Joseph Kan, LLUSchool of Dentistry, Graduate Implant Program

What is the Surgical/Restorative Connection in Dental ImplantTreatmentand How do We Achieve Success?

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Immediate Implant PlacementImmediate Tooth Replacement Problems

§ Recession

§ Discoloration

§ Facial Contour

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The Surgical/Restorative Connection:The Critical Zone!

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Sclar A 2003

IMPLANT:

§ Lack of CT

§ Hypovascular, hypocellular zone adjacent to the implant

§ Absence of PDL blood supply

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The socket-shield technique to support the buccofacial

tissues at immediate implant placement

What is the Socket Shield Procedure: Does it Work?The Surgical/Restorative Connection

Gluckman H et al. , International Dentistry Vol.5 No.3 2018

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Procedures to Manage Post Extraction Resorption

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Literature Review on the Socket Shield Technique

Conclusion: At present the technique is highly promising and holds significant potential for the field of aesthetic and restorative implant dentistry

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Proximal Socket Shield for Inter-implant Papilla Preservation in the Esthetic Zone

The Surgical/Restorative ConnectionWhat is the Socket Shield Procedure: Does it Work?

Kan J & Runcharassaeng K, Int’l J of Perio. & Restor. Dent. Jan 33(1) 2013

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Conclusions:

§ Maintaining inter-implant papillae is one of the most challenging tasks in anterior implant esthetics

§ The proximal socket shield procedure with immediate implant placement maintains the bone level and dento-gingival fibers attached to the proximal supracrestal cementum

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Conclusions:

§ This is a technique sensitive procedure

§ There is limited long term evidence

§ Large scale closely monitored studies are needed to validate this procedure

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Platform Switching: Is it Beneficial and Is it Necessary?

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Platform Switching for Marginal Bone Preservation Around Dental Implants; A Systematic Review and Meta-Analysis

Atieh MA et al. J Periodontol. Oct. 81(10), 2010

CONCLUSIONS:§ The marginal bone loss around platform switched implants was

significantly less than around platform matched implants

§ No statistically significant difference was detected for implant failures between PS and PM implants

§ Subgroup analysis showed that an implant abutment diameter difference > or = 0.4mm was associated with a more favorable bone response

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Peri-implant Bone Levels Around Implants With Platform Switched Abutments Preliminary Data From a Prospective Study

Hurzeler M et al. J Oral Maxillofac. Surg. July 65(7 suppl 1) 2007

CONCLUSIONS:§ The concept of platform switching appears to limit crestal

resorption and seems to preserve peri-implant bone levels

§ The reduction of the abutment of 0.45mm on each side (5mm implants and 4.1mm abutment) seems sufficient to avoid peri-implant bone loss

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Systematic Review: Platform Switch and Dental Implants

Chrcanovic BR et al. J Dent. Jun 43 (6) 2015

CONCLUSIONS:§ There was less marginal bone loss with platform switching than at

implants with platform matching (mean difference 0.29)

§ An increase of the mean difference of MBL between the procedures was observed with: (a) increase in the follow up time and (b) increase of the mismatch between the implant platform and the abutment

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Impact of Platform Switching on Marginal Peri-implant Bone Level Changes: A Systematic Review and Meta-Analysis

Strietzel F et al. Clin Oral Implants Research 2015

CONCLUSIONS:§ The meta-analysis revealed a significantly less mean MBL change

at implants with a PS compared to PM implant abutment configuration

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Impact of Platform Switching on Marginal Peri-implant Bone Level Changes: A Systematic Review and Meta-Analysis

Strietzel F et al. Clin Oral Implants Research 2015

CONCLUSIONS:What do we need?

§ Platform switch of at least 0.4mm

§ Strong material for platform switch implant and abutments

§ A very stable conical connection

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Screw vs. Cement Retained Implant Prosthesis

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Choice of retention type might not have a crucial influence on the overall prosthesis but may increase chances of complications

Wittenben JG et al. IJOMI Jan 2:29, 2014

Screw vs. Cement Retained Implant Prosthesis

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Screw vs. Cement Retained Implant ProsthesisDecision Making Tree

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Predictable Single Tooth Peri-Implant Esthetics: Five Diagnostic Keys

Kois, J. Vol. 22 No. 3 Compendium March 2001

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Papilla maintenance is determined by the proximal bone on adjacent teeth and not by the tooth to be extracted, i.e., bone level on the tooth side determines the presence of papilla not the implant!!

Strategic Point

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1. Tooth Position/FGM Coronal2. Gingival Form Flat Scallop3. Biotype Thick4. Tooth Shape Square5. Position of the Osseous Crest:Measures <3mm fromteeth and facially High Crest

SummaryLOW RISK:

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1. Tooth Position/FGM Ideal or Apical2. Gingival Form High Scallop3. Biotype Thin4. Tooth Shape Triangular5. Position of the Osseous Crest:Measures <3mm fromteeth and facially Low Crest

SummaryHIGH RISK:

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Documents

2020 GPVFDC Surgical-Restorative Connection Working Copy · Surgical Planning Considerations 49 ... §Crowns have anatomical emergence profiles §Implants have hemi-desmosomal (no