Nicholas Caplanis DMD MS 6/13/2012 - OCACD · Nicholas Caplanis DMD MS 6/13/2012 Periodontal and Peri-Implant Considerations in Esthetic Dentistry 4 Esthetic crown lengthening –

Nicholas Caplanis DMD MS 6/13/2012

Periodontal and Peri-Implant Considerations in Esthetic Dentistry 1

Periodontal and Peri-Implant Considerations In The Esthetic Zone

Nick Caplanis DMD MSPrivate Practice Periodontics and Implant Surgery

Mission Viejo, [email protected]

Assistant Professor Loma Linda University

Presentation Outline• Anatomic concerns• Procedures to improve restorative outcomes• Periodontal and Peri-implant disease management

Presentation Outline• Anatomic concerns

• Periodontal biotype

• Biologic width

• Bone crest position

• Gingival display and smile line

Periodontal Characteristics in Individuals with Varying form of the Upper Central Incisor

• 113 subjects in long term periodontal surgery study

• Thin “biotypes” had more buccal recession

Olsson M, Lindhe J. J Clin Periodontol 1991;18(1):78-82.

Periodontal Biotype

Thick

• Short square teeth

• Thick robust gingiva

• Wide blunted papilla

• Resistant to recession

Thin

• Long Tapered teeth

• Thin friable gingiva

• Long pointy papilla

• Susceptible to recession

Dimensions of the Dentogingival Junction in Humans• Gingival sulcus

– 0.69mm

• Junctional epithelial attachment– 0.97mm

• Connective tissue attachment– 1.07mm

Garguilo AW, Wentz FM, Orban B. J Perio 1961;32:261-267

Sulcus

JE

CT

TOOTH

Biologic Width

Periodontal considerations in restorative and implant therapy

• Subgingival margins should be considered a compromise

• 2-3mm of healthy, natural, supra-alveolar tooth needed for attachment

• Margins should not be placed deeper than 0.5mm

Goldberg PV, Higginbottom FL, Wilson TG. Periodontol 2000. 2001;25:100-109

Tissue reactions around artificial crowns• Minimum distance required for

periodontal health, between restorative margin and “biologic width” 0.5mm

Waerhaug J. J Periodontol 1953;24:172-185

Sulcus

JE

CT

TOOTH

The Restorative Periodontal Interface: Biologic Parameters

• Crestal bone positions– Normal

– Low

– High

• The location of a restorative margin in relationship to the alveolar bone crest is more important for preserving gingival health than its distance below the free gingival margin

Kois J. Periodontology 2000. 1996;11:29-38



Biologic Width and its Importance in Periodontal and Restorative Dentistry

Figures copied from - Nugala B, Kumar BS, Sahitya S, Krishna PM. J Conserv Dent 2012;15(1):12-17.

Normal Crest High Crest Low Crest

Tooth vs. Implant Histology• Tooth

– Sulcus

– Epithelial Attachment

– Connective Tissue Attachment

– Bone Attachment via Sharpy’sfibers

• Implant– Sulcus

– Epithelial Adhesion

– No Connective Tissue Attachment

– Direct Bone to Implant Union LM (Osseointegration)

Peri-implant biologic width

• Junctional Epithelium• Connective Tissue

Sulcus

Junctional Epithelium

Connective Tissue

Probing around implants: a standard of care• Rationale for probing around implants

– Probing reveals level of inflammation through BOP and presence of suppuration

– Pocket depth changes can indicate bone loss

– Deep pockets increase risk of harboring pathogens

– Deep pockets increase risk of developing bone loss

Smile Lines Smile Lines

Understanding Biologic Width is Important to Avoid Complications with Restorative Dentistry Presentation Outline

• Anatomic concerns• Periodontal biotype

• Biologic width

• Bone crest position

• Gingival display and smile line




Presentation Outline•Procedures to improve restorative outcomes

• Esthetic crown lengthening• Mucogingival surgery

– root recession repair– procedures to increase AG– ridge defect repair– biotype enhancement during implant

placement

• Root reshaping• “reverse crown lengthening”

• Site preservation• Orthodontic extrusion• Papilla management

Esthetic Crown Lengthening Techniques• Gingivectomy• Gingivectomy with osseous surgery

– with or without flap elevation

• Apically repositioned flap with osseous surgery• Orthodontics

Camargo PM, Melnick PR, Camargo LM. CDA Journal 2007;35(7):487-98

25 y/o female normal to high crest medium biotype

Gingivectomy using Ellman™ Radiosurgery Flapless osseous reduction through tunnel flap 6 week post op evaluation

42 y/o female high crest thick biotype Osseous surgery with full thickness flap 3 month post op evaluation



Esthetic crown lengthening – Gingivectomy guided by stent Osseous surgery with full thickness flap 1 year post op evaluation

Contemporary Crown Lengthening Therapy: A Review

• Results and Conclusions– Final prosthetic treatment should wait at least 3 months and up to 6

months for esthetically critical areas

Hempton TJ, Dominici JT. JADA 2010;14(6):647-655

Root coverage procedures Treatment Options For Recession

• Free gingival graft• Interpositional connective

tissue graft• Coronally advanced flap

– with or without connective tissue

• Pedicle graft– lateral

– semi lunar

• Regeneration– bone grafts, membranes,

growth factors

Treatment of Gingival Recession

Purpose•To evaluate the outcome of various gingival grafting techniques to assess which provides optimal results

Materials and Methods•Review of controlled clinical trials

Kassab MM, Cohen RE. JADA 2002;133(11):1499-1506

Treatment of Gingival Recession

Kassab MM, Cohen RE. JADA 2002;133(11):1499-1506

• Results and Conclusions– Autogenous connective tissue grafts in conjunction with a coronally

repositioned flap is most effective in achieving predictable root coverage

Miller Recession ClassificationClinical Presentation Expectation Success rates

Class I Recession above MGJ – No AL Complete root coverage 100%Class II Recession to or beyond MGJ – No AL Complete root coverage 100%Class III Recession to or beyond MGJ – Minor

interproximal ALPartial root coverage to the height of interproximal tissues

50-70%

Class IV Recession to or beyond MGJ –Severe interproximal AL

Unpredictable root coverage <10%

Miller, PD. A classification of marginal tissue recession. Int J Perio Rest Dent 1985; 5(2):8-13



Mucogingival surgery – interpositional CT graft Mucogingival surgery – interpositional CT graft Mucogingival surgery – Free gingival graft + CTG

Root coverage procedures Placement of interpositional CT graft guided by stent 3 month post op evaluation

58 y/o female with failing maxillary anterior 3 unit bridge Debridement and Regeneration surgery Interpositional CT graft via tunnel approach



Interpositional CT Graft with coronally repositioned flap Inerpositional CT Graft via Tunnel Flap Semi-Lunar Pedicle Graft

Ridge Defect RepairAutologous Connective Tissue Graft can function as a membrane

to contain graft as well as to repair soft tissue deficit Provisional prosthesis with ovate pontic design used to guide healing

Connective tissue graft harvest Successful site preservation allows for prosthetically driven implant placement Radiographic case progression



Final Outcome 37 y/o female. Congenitally missing lateral incisors with constricted arch formLost left central incisor due to trauma as a child

First procedure - extraction of teeth, site preservation with Bio-Oss + DBM and connective tissue graft

Second procedure – site development usinga symphyseal block graft and membrane

Third procedure – implant placement with connective tissue graft and healing abutments used as space maintainers Ridge Defect Repair

Facial gingival tissue stability after connective tissue graft with single immediate tooth replacement in the esthetic zone

• 20 consecutive patients• Immediate implant placement

with associated connective tissue graft

• Follow up 1-4 yrs

• Preservation of papilla• Biotype enhanced• Bone and soft tissue stability

Kan JY et.al. J Oral Maxillofac Surg. 2009:67(11);40-48

Biotype Enhancement followed by Implant Placement Site preservation with socket and CT Graft



Root reshaping: an integral part of periodontal surgery

Procedure•Alternative to conventional osseous surgery involving reshaping of the existing tooth and root surface with conservative removal of supporting bone to create the width needed for biologically acceptable restorations

Melker DJ, Richardson CR. Int J Perio Rest Dent 2001;21(3):296-304

Combination Esthetic Crown Lengthening, Root Reshaping, and Root Coverage Procedure

Root Coverage Required to Reduce Anterior Tooth Length Esthetic Crown Lengthening in Posterior and Root Reshaping of the Anterior Teeth Root Reshaping Eliminates Existing Restorative Margins

Placement of Interpositional CT Graft Guided by Stent Esthetic Crown Lengthening, Root Reshaping and Root Coverage A Prospective Randomized Clinical Study of Changes in Soft Tissue Position Following Immediate and Delayed Implant Placement

Purpose•To compare efficacy of immediate vs. delayed implant placement in maintaining soft tissue margin position following tooth extraction

Materials and Methods•24 patients randomly received either immediate or delayed implant placement•Delayed sites received FDBA and collagen membrane and re-entered for implant placement 3-6 months later

van Kesteren CJ, Schoolfield J, West J, Oates T. Int J Oral Maxillofac Implants 2010:25(3);562-570.



A Prospective Randomized Clinical Study of Changes in Soft Tissue Position Following Immediate and Delayed Implant Placement

van Kesteren CJ, Schoolfield J, West J, Oates T. Int J Oral Maxillofac Implants 2010:25(3);562-570.

• Results and Conclusions– No differences between immediate or delayed approaches with respect to

midbuccal and interproximal soft tissue margins

Site preservation• Socket graft with a membrane improves ridge height

and width following extraction but may interfere with normal healing/bone fill within defect

• Artzi Z et.al. J Perio 2000. 71(6): 1015-23.• Iasella JM et.al. J. Perio 2003 74(7): 990-9.• Lew DW et.al. Int J Oral Maxillofac Implants 2009;24(4): 609-15.• Araujo MG, Lindhe J Clin Oral Implant Res 2009;20(5):433-40.

Extraction, Socket Debridement, Bone Graft Placement

Resorbable Membrane, Ovate Pontic Site preservation biomaterialsBone Grafts likely minimize clot shrinkage and thus alveolar resorption

Membranes serve to contain the graft and minimize epithelial downgrowth

Maintenance of alveolar ridge morphology

Site Preservation

Orthodontic Extrusion Orthodontic Extrusion 44 y/o female with chronic alveolar abscess of maxillary left lateral incisor Papilla Management through CTG and adjacent restorations pre planned



Biotype Enhancement Prior to surgery, patient prepared for additional adjacent restorations as needed

Prototype development

Laboratory Phase Papilla Management CDA Journal Nov 2005

Papilla Management• Interproximal bone to tooth contact

point

• <5mm 100% papilla presence

• 6 mm 56%

• 7mm 27%

• Tarnow et. Al. J Perio 1992

Implant placement guidelines - spacing

Tooth to Implant 2mmEsposito et al. Clin Oral Imp Res 1993

Implant to Implant 3mmTarnow et al. J Perio 20003mm2mm

2mm

Implant placement guidelines - position

Avoid adjacent implants in the esthetic zone



Implant placement guidelines –Emergence Profile3 mm below restorative margin

Esthetics vs. HealthExcessive platformdepth compromisesmaintenance

Communication Devices- Surgical guides Presentation Outline•Procedures to improve restorative outcomes

• Esthetic crown lengthening• Mucogingival surgery

– root recession repair– procedures to increase AG– ridge defect repair– biotype enhancement during implant

placement

• Root reshaping• “reverse crown lengthening”

• Site preservation• Orthodontic extrusion• Papilla management


Presentation Outline• Periodontal and Peri-implant disease management

• Diagnosis

• Treatment

• Maintenance

Classification of periodontal disease and conditions

• Previous classification– 1989 world workshop

• Current classification– 1999 international workshop

• A standard classification provides a framework for the scientific study of disease etiology, pathogenesis and treatment as well as a standard mean of communication

Weakness of 1989 classification• Criteria for diagnosis unclear• Disease categories overlapped• Too much emphasis on age of disease onset and rate of

progression which are difficult to determine• No classification for diseases limited to gingiva

1999 Gingival and Periodontal Disease Classification

Armitage GC. Ann Periodontol 1999;4:1-6

Periodontal disease classification “Key Changes”Previous

• No section on gingival diseases• “Adult” Periodontitis• “Early-onset” Periodontitis• “Refractory” Periodontitis• “Localized Juvenile” Periodontitis

Current• Entire new section on gingival diseases • “Chronic” Periodontitis • “Aggressive” Periodontitis• Additions

– Periodontal abscess

– Perio-endo lesions

– Acquired deformities and conditions




Classification of periodontal disease and conditions• Chronic periodontitis

– Typical adult onset plaque induced

– Previously referred to as “adult” perio

• Aggressive periodontitis– Previously known as pre-pubertal, juvenile perio, localized juvenile perio, rapidly progressive perio,

early onset perio


Classification of periodontal disease and conditionsChronic and Aggressive Periodontitis

– Distribution• Localized < 30% sites

• Generalized > 30% sites

– Severity• Slight 1-2mm CAL

• Moderate 3-4mm CAL

• Severe > 5mm CAL


Systemic Connections• Periodontal disease increases CRP levels• Link between Periodontal disease and

cardiovascular disease; MI, CVA• Link between periodontal disease and the delivery of

premature, underweight babies• Link between Periodontal disease and Diabetes• Recent link with Alzheimer’s disease• Periodontal Pathogens are transmissible

Biofilm and inflammation management Gingivitis• Clinical Signs

– Gingival erythema– Edema– Bleeding on probing– PPD’s up to 3mm (unless pseudo

pocket)– Soft tissue contour changes– Increased GCF– No attachment loss

• Treatment– Scaling/Prophy with

OHI

– Phase I Re-eval

– 4-6 mo PST

Slight Periodontitis• Clinical Signs

– Gingival erythema– Edema– Bleeding on probing

– Slight attachment loss

– Pocket depths 4mm

• Treatment– SRP + behavior mod

– Rx Periostat

– Phase I Re-eval

– 3-6mo PST

Moderate Periodontitis• Clinical Signs

– Gingival erythema– Edema– Bleeding on probing

– Moderate attachment loss

– Slight furcation invasion

– Pocket Depths 5mm

• Treatment– SRP + behavior mod– Rx Periostat– Phase I Re-eval– Additional RP + Arrestin– Pocket reduction surgery

if needed– Phase II Re-eval – 3-4 mo PST

Severe Periodontitis• Clinical Signs

– Severe Attachment Loss

– Pocket Depths >6mm

– Moderate to Advanced

Furcation involvement

– Inflammation, BOP

• Treatment– SRP + behavior modification

– Phase I Re-eval

– Pocket Elimination Surgery

– Phase II Re-eval

– Bacterial Culture and Sensitivity

– Localized and Systemic Antibiotics

– 3mo PST

Manual vs. Powered tooth brushing for oral healthMaterials and Methods

• 42 trials involving 3855 participants included in review

Results and conclusions

• Powered brushes removed plaque and reduced gingivitis more effectively than manual brushes

Robinson PG, et.al. Cochrane Database 2005;18(2):CD002281



The efficacy of interdental brushes on plaque and parameters of periodontal inflammation: a systematic review

Materials and Methods

• 218 Medline-PubMed and 116 Cochrane papers identified

• 9 studies met eligibility criteria

Results and conclusions

• As an adjunct to brushing interdental brushes remove more plaque than brushing alone.

• Clinical improvements noted in PI, BOP, PD

• Improvement in PI better than using floss

Slot DE. Dorfer CE, et.al Int J Dent Hyg 2008;6(4):253-64

56y/o male generalized chronic severe periodontitis

Prior to treatment Jan 2002


Post Perio, Restorative and Ortho Treatment Jan 2007


Jan 2011


Periodontal and Peri-Implant Considerations In The Esthetic Zone

Nick Caplanis DMD MS

Documents

Nicholas Caplanis DMD MS 6/13/2012 - OCACD · Nicholas Caplanis DMD MS 6/13/2012 Periodontal and Peri-Implant Considerations in Esthetic Dentistry 4 Esthetic crown lengthening –