Présentation de cas

MEOUCHY Peter-CES Paro

Nom: HAKIM Dolly Date de naissance: 1971 Date de consultation: 18-05-09

Motifs de la consultation: -changement des couronnes 11-12-16-25 à cause de leur

aspect inesthétique -fétidité d’haleine -mobilité 11-12

Anamnèse: couronnes réalisées depuis 10 ans (accident de la voie publique)

Etat général: rien à signaler

Examen endobuccal: -couronnes: 11-12-16-17-25 46 -restaurations: 13-14-15-18-26-27-28 34-35-36-37-44-45-47

Diagnostic :parodontite chronique marginale lésion endo-parodontale site 11 sévère

Plan de traitement: 1. phase initiale 2. évaluation (11), extraction et remplacement par implant avec greffe osseuse 3. traitement endodontique(reprise)+prothèse fixée: 12-24

BILAN RADIOGRAPHIQUE18-05-09

ETAPES DU TRAITEMENT ETABLI : sites 11-12

1-Extraction

2-Greffe osseuse en bloc (prélèvement ramique)

3-Pose d’implant: Branemark

4-Echec: 4.1.greffe régénération osseuse guidée (ROG) 4.2.implant (cause infectieuse)

5-Greffe osseusse en bloc (prélèvement symphysaire)

6-Pose d’implant: Bone Level + greffe conjonctif enfoui (2 temps chirurgicaux)

7-Traction orthodontique lente(site 12)

Extraction11-06-09

Extraction (11) et curetage du tissu inflammatoire avec une suture simple croisée

1-Extraction

2-Greffe osseuse en bloc (prélèvement ramique)

3-Pose d’implant: Branemark

4-Echec: 3.1.greffe régénération osseuse guidée (ROG) 3.2.implant (cause infectieuse)

5-Greffe osseusse en bloc (prélèvement symphysaire)

6-Pose d’implant: Bone Level + greffe conjonctif enfoui (2 temps chirurgicaux)

7-Traction orthodontique lente(site 12)

Greffe osseuse en bloc (14-10-09)

Prélèvement ramique

branche horizontale mandibulaire beaucoup d’os (épaisseur confirmée par CBCT) réduction en épaisseur possible 4-5 mm d’épaisseur 1 cm en hauteur

28-10-09 04-03-10(2 sem post op) (5 mois environ)

4 principes pour le succès des greffes osseuses en bloc:

1-préparation site receveur pour apport vasculaire, cellules ostéogéniques et FDC

2-stabilisation de la greffe

3-fermeture sans tension du lambeau

4-placement des implants après incorporation de la greffe

littérature

Fernando Verdugo, Krikor Simonian, Hessam Nowzari.Periodontal Biotype Influence on the Volume Maintenance of Onlay Grafts. J Periodontol 2009;80:816-823

40 patients receiving autogenous block transplants prior to implant placement clinical parameters: BOP, mobility, suppuration, mucosal recession and buccal tissue transparency,

recorded at yearly intervals (CT) scan was taken at an average of 42 months (n = 20) postaugmentation

clinical examination: no implant transparency, mucosal recession, mobility, BOP or suppuration (n = 40) at 48 months

(CT) scans: varying thicknesses (0.5 to 4 mm) of buccal cortical bone around the implants the increased width at the recipient site postgraft was 7.6 mm, maintaining, on average, 98% of the

augmented width the buccal osseous thickness at the implant sites averaged 2.0 mm compared to 0.7 mm for the

adjacent teeth (P <0.0001) even when adjacent teeth had a thin biotype, the transplanted sites maintained statistically

significant thicker buccal cortical plate at all sites (P <0.0001)

Conclusion:

grafted site phenotype did not seem to be influenced by the adjacent teeth biotype autogenous osseous transplants can predictably reconstruct function and esthetics and seemed to

maintain stable bone volume around implants at an average of 3.5 years

Liran Levin, Daniel Nitzan, Devorah Schwartz-Arad.Success of Dental Implants Placed in Intraoral Block Bone Grafts. J Periodontol 2007;78:18-21

retrospective study conducted from 1999 to 2001 50 healthy patients who received 129 implants in augmented sites reviewed implant

survival, radiologic implant success (marginal bone loss), and complications recorded.

follow-up from time of implantation ranged from 6 to 67 months (mean: 24.3 months) the overall survival rate was 96.9% (4 implants were removed) MBL around implants ranged from 0 to 3.3 mm (average: 0.22 mm) Only 5% of the implants presented marginal bone loss more than 1.5 mm over the

follow-up time

Conclusion:

intraoral bone block graft surgery is a predictable operation for the use of dental implants

implant placement in augmented areas presents high survival and radiologic success rates with minimal bone loss

1-Extraction

2-Greffe osseuse en bloc (prélèvement ramique)

3-Pose d’implant: Branemark

4-Echec: 3.1.greffe régénération osseuse guidée (ROG) 3.2.implant (cause infectieuse)

5-Greffe osseusse en bloc (prélèvement symphysaire)

6-Pose d’implant: Bone Level + greffe conjonctif enfoui (2 temps chirurgicaux)

7-Traction orthodontique lente(site 12)

Pose d’implant (zone esthétique)

littérature

Hae-Lyung Cho, Jae-Kwan Lee, Heung-Sik Um, Beom-Seok Chang. Esthetic evaluation of maxillary single-tooth implants in the esthetic zone. J Periodontal Implant Sci 2010;40:188-193 • doi: 10.5051/jpis.2010.40.4.188

41 adult patients, 41 implant-supported single restorations pink esthetic score (PES)/white esthetic score (WES) twice with an interval of 4

weeks (8 observers) visual analog scale (VAS)

Summarized the PES and WES of the 41 implants(Belser):

PES Mesial papilla

Distal papilla

Curvature of facial mucosa

Level of facial mucosa

Root convexity Soft tissue color and texture

Total PES (max 10)

Mean SD

0.630.12

0.620.09

1.310.21

1.330.13

1.160.13

5.170.45

WES Tooth form Tooth volume

color Surface texture

Translucency Total WES(max 10)

MeanSD

0.590.17

0.610.14

1.220.16

1.390.34

1.120.17

6.020.70

Hae-Lyung Cho, Jae-Kwan Lee, Heung-Sik Um, Beom-Seok Chang. Esthetic evaluation of maxillary single-tooth implants in the esthetic zone. J Periodontal Implant Sci 2010;40:188-193 • doi: 10.5051/jpis.2010.40.4.188

in the PES/WES, very good and moderate intraobserver agreements were noted between the first and second rating.

mean total PES/WES = 11.19 ± 3.59, mean PES was 5.17 ± 2.29 and mean WES was 6.02 ± 1.96.

in the total PES/WES, no significant difference; in the WES, significant difference prosthodontists assigned poorer ratings than the other groups; periodontists gave higher

ratings than prosthodontists and senior dental students; orthodontists were clearly more critical than the other observers

statistical analysis revealed statistically significant correlation between patients’ esthetic perception and dentists’ perception of the anterior tooth (except for the first premolar)

Conclusion:

the PES/WES is an objective tool in rating the esthetics of implant supported single crowns and adjacent soft tissues

orthodontists were the most critical observers, while periodontists were more generous than other observers

Joseph Y.K Kan, Kitichai Rungcharassaeng, Kiyotaka Umezu, John C. Kois. Dimensions of Peri-Implant Mucosa: An Evaluation of Maxillary Anterior Single Implants in Humans. J Periodontol 2003;74:557-562

45 patients, 45 maxillary anterior single implant crowns, mean functional time of 32.5 months

dimensions of peri-implant mucosa by bone sounding at (MI), (F), (DI) aspects of the implant restoration and the proximal aspects (MT, DT) of adjacent natural teeth(in mms)

Conclusion: the level of the interproximal papilla of the implant is independent of the proximal

bone level next to the implant, but is related to the interproximal bone level next to the adjacent teeth

MT MI F DI DT

4.20 6.17 3.63 5.93 4.20

Nisapakultorn K, Suphanantachat S, Silkosessak O, Rattanamongkolgul S. Factors affecting soft tissue level around anterior maxillary single-tooth implants. Clin. Oral Impl. Res. 21, 2010; 662–670

40 single-tooth implants, anterior maxilla, 75% upper central incisors variables possibly associated with the soft tissue level were obtained from clinical

measurements, study models, peri-apical radiographs, and computerized tomograms

Conclusion:

the papilla level around single-tooth implants in the anterior maxilla was mainly influenced by the interproximal bone crest level of the adjacent tooth

facial marginal mucosal level, on the other hand, was affected by multiple factors

including the peri-implant biotype, the facial bone crest level, the implant fixture angle, the interproximal bone crest level, the depth of implant platform, and the level of first bone to implant contact.

Règles d’or # récession péri- implantaire

a-axe de forage +/- palatinb-diamètre adéquatc-table osseuse vestibulaire suffisante

26-05-10

!! Première complication!!

Implant BK (3.75 х 11.5 mm)

Déhiscence vestibulaire

1-Extraction

2-Greffe osseuse (prélèvement ramique)

3-Pose d’implant: Branemark

4-Echec: 3.1.greffe régénération osseuse guidée (ROG) 3.2.implant (cause infectieuse)

5-Greffe osseusse (prélèvement symphysaire)

6-Pose d’implant: Bone Level + greffe conjonctif enfoui (2 temps chirurgicaux)

7-Traction orthodontique lente (site 12)

Régénération osseuse guidée

Membrane ACE (R) + bio-oss®

littérature

Lillian Carpio, Juan Loza, Samuel Lynch, Robert Genco. Guided Bone Regeneration Around Endosseous Implants With Anorganic Bovine Bone Mineral. A Randomized Controlled Trial Comparing Bioabsorbable Versus Non-Resorbable Barriers. J Periodontol 2000; 71:1743-1749

porcine-derived bioabsorbable collagen membrane v/s ePTFE membrane (NR) +bovine bone xenograft/autograft bone composite in defects surrounding dental implants effect of primary barrier fixation on GBR 48 subjects, 23 collagen membrane, 25 ePTFE, 34 sites+barrier fixation (polylactic

resorbable pins) (6months)

postoperative complications when barrier fixation was lacking at initial surgery

Conclusion:

both barriers are suitable for achieving GBR of osseous defects surrounding dental implants importance of barrier fixation at the time of initial surgery

Membrane Width length circumferences

collagen 1.95 2.65 57.7ePTFE 2.65 2.26 80.2

Avantages des greffes osseuses(P/R aux ROG)

augmentation horizontale jusqu’à 7.5 mm (v/s 4.5 mm)

cicatrisation rapide d’environ 4-5 mois (v/s 6-9 mois)

densité osseuse optimale pour la stabilité implantaire

stabilité du bloc pendant la cicatrisation et perte osseuse postop réduite

augmentation verticale jusqu’à 4 mm

1-Extraction

2-Greffe osseuse en bloc (prélèvement ramique)

3-Pose d’implant: Branemark

4-Echec: 3.1.greffe régénération osseuse guidée (ROG) 3.2.implant (cause infectieuse)

5-Greffe osseusse en bloc (prélèvement symphysaire)

6-Pose d’implant: Bone Level + greffe conjonctif enfoui (2 temps chirurgicaux)

7-Traction orthodontique lente(site 12)

!! Deuxième complication!! 16-06-10

dépose sutures

perte de l’implant site 11 pour cause d’infection apicale et vestibulaire

tissu inflammatoire cureté

comblement avec du bio-oss® et double membrane ACE

1-Extraction

2-Greffe osseuse en bloc (prélèvement ramique)

3-Pose d’implant: Branemark

4-Echec: 3.1.greffe régénération osseuse guidée (ROG) 3.2.implant (cause infectieuse)

5-Greffe osseusse en bloc (prélèvement symphysaire)

6-Pose d’implant: Bone Level + greffe conjonctif enfoui (2 temps chirurgicaux)

7-Traction orthodontique lente(site 12)

Greffe osseuse en bloc -2-prélèvement symphysaire04-05-11

greffe réalisée après essayage de pose d’implant mais pas de stabilité

prélèvement d’un bloc osseux du site symphysaire droit:

facile, épaisseur ≤ 4 mm, loi ou règle des 5 mm

fixation du bloc avec 2 vis

1-Extraction

2-Greffe osseuse en bloc (prélèvement ramique)

3-Pose d’implant: Branemark

4-Echec: 3.1.greffe régénération osseuse guidée (ROG) 3.2.implant (cause infectieuse)

5-Greffe osseusse en bloc (prélèvement symphysaire)

6-Pose d’implant: Bone Level + greffe conjonctif enfoui (2 temps chirurgicaux)

7-Traction orthodontique lente(site 12)

Pose d’implant et greffe conjonctif enfoui en deux temps chirurgicaux23-02-12 et 23-05-12

Implant Bone Level (ITI) (4.1 х 12 mm)

16-02-12 23-02-12(9 mois post onlay graft-2) (1e tps.chir.)

Suivi post opératoire après pose d’implant Bone Level

Amoxicilline® (500 mg)

Ponstan forte®

Paro-ex®

littérature

Yoav Grossmann, Liran Levin. Success and Survival of Single Dental Implants Placed in Sites of Previously Failed Implants. J Periodontol 2007;78:1670-1674.

75 patients experienced the failure of 96 implants. Of those, 31 implants in 28 patients were replaced by a similar implant placed in the same location. Follow-up ranged from 6 to 46 month

9 of the replacement implants failed, resulting in an overall survival rate of 71%

replacement of maxillary and mandibular failed implants was similar

on average, implant replacement occurred 5.8 months after original implant removal

3 implants were placed immediately after implant removal

a third attempt for single implant replacement was made in two patients. However, one failed.

Yoav Grossmann, Liran Levin. Success and Survival of Single Dental Implants Placed in Sites of Previously Failed Implants. J Periodontol 2007;78:1670-1674.

Conclusion:

replacement of a failed implant presents a challenge to achieve osseointegration in a healed bone site and may result in a decline in the survival rates

patients and clinicians should be aware of these results before a replacement attempt is considered

the success of replacement may be increased by the use of wider implants or with improved surfaces.

David A.Garber, Henry Salama, Maurice Salama. Two-Stage Versus One–Stage: Is There Really a Controversy? J Periodontal March 2001

Placement of bone grafts and/or GBR

”While the osseous support may in fact be adequate to develop implant primary stability and functional restoration, there may be resultant esthetic deficiences […] in either the horizontal or vertical dimension”

”In these cases, particularly where a significant amount of vertical osseous component is lost, it may become necessary to use the 2-stage combination approach to restore esthetic soft tissue profiles. Depending on the degree of compromise, this 2-stage approach may be used on its own or in conjunction with a connective tissue graft over the buccal or incisal aspect of the fixture”

”The benefit of maintaining a submerged environment in GBR clearly illustrates that a 2-stage procedure is essential”

Rami Guiha, Soheir El Khodeiry, Luis Mota, Raul Caffesse. Histological Evaluation of Healing and Revascularization of the Subepithelial Connective Tissue Graft. J Periodontol 2001; 72:470-478

6 female beagle dogs (experimental study)

7 daysa clot at the demarcation zones vascularization originated from the periodontal plexus and the overlying flap 14 daysa clot more organized(granulation tissue) graft completely vascularized 28 daysJE formed + demarcation zones not delineated anymore

60 daysoral epithelium regaining its normal appearance At 28 and 60 days, normal vascularization present

Conclusion:

Vascularization: periodontal plexus, supraperiosteal plexus, and the overlying flap Attachment of the graft:-combination of epithelial downgrowth and CT attachment -little potential for new cementum and new bone formation

Terrence J. Griffin, Wai S. Cheung, Athanasios I. Zavras, Petros D. Damoulis. Postoperative Complications Following Gingival Augmentation Procedures. J Periodontol 2006;77:2070-2079

75 FSTG (Free Soft Tissue Grafting), 256 SCTG (Subepithelial Connective Tissue Grafting procedures), 228 patients

duration of surgical procedures highly correlated with pain or swelling post-surgically

current smokers were 3 times more likely to experience post-surgical swelling

patients who underwent FSTG procedures were 3 times more likely to develop post-surgical pain or bleeding compared to those who received SCTG procedures

07-11-12

Peter:” Dolly s’il te plait on doit prendre une radio de contrôle et réévaluer ton cas”

Dolly:” OK je viens mais peux-tu demander Pr TAWIL si on peut faire une 3ème greffe de gencive”

??? 3ème greffe conjonctif enfoui???

Evaluation clinique et radiologique 14-11-12

1-Extraction

2-Greffe osseuse en bloc (prélèvement ramique)

3-Pose d’implant: Branemark

4-Echec: 3.1.greffe régénération osseuse guidée (ROG) 3.2.implant (cause infectieuse)

5-Greffe osseusse en bloc (prélèvement symphysaire)

6-Pose d’implant: Bone Level + greffe conjonctif enfoui (2 temps chirurgicaux)

7-Traction orthodontique lente (site 12)

Traction orthodontique site 12

Traction lente (12) coronairement = “essai” pour gagner un niveau plus coronaire de la gencive vestibulaire et interproximale

MERCI DE VOTRE ATTENTION