What is the Surgical/Restorative Connection in Dental ... · Tooth Extraction Treatment Approach –Timing of Implant Placement after Tooth Extraction Favourable Clinical Conditions

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The Surgical/Restorative Connection in Dental ImplantTreatment for the

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

§ Diagnosis and treatment planning for a successful surgical/restorative connection

§ What are the differences between natural teeth restorations and implant restorations?

§ What is a restoratively driven treatment plan?

§ When is site preparation indicated and does it affect the surgical/restorative connection?

§ Does the timing of implant placement affect the restorative plan?

§ Surgical and prosthetic considerations for successful implant/restorative therapy summary

Course Objectives

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

What are the Keys to Success?

Fundamental Rules and Guidelines

The Surgical/Restorative Connection in Dental Implant Treatment

The Surgical/Restorative Connection in Dental Implant Treatment: Where We Were!Surgically Driven (by the presence of adequate bone)

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

Team Approach: Who are the Players?


Restorative Dentist Implant Surgeon Lab Technician

Team Approach: Who are the Players?


Implant Company Hygienest Patient

§ The tissue is the issue

§ The bone sets the tone

§ The mission is the dentition

Remember:


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


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


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Diagnosis andTreatment Planning

§ Science of diagnosis and treatment planning: literature defining the parameters that should be considered when making a final diagnosis

§ Art of diagnosis and treatment planning: results when the clinician combines objective science with a subjective component based on personal experience

§ Integration of both is science and art

Rationale for Treatment Planning

Diagnosis Basis

Treatment Planning

§ Visibility of site§ Availability of bone

§ Models, radiographs§ Occasionally other investigations

§ Soft tissue§ Periodontal status of adjacent teeth§ Patient expectations

Evaluate:

Problematic Areas: Mandible

MENTAL FORAMENMENTAL NERVEINFERIOR ALVEOLAR NERVE

MAXILLARY SINUS/SCHNEIDERIAN MEMBRANE

Problematic Areas: Maxilla Evaluation of Implant Site(s)

§ 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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Criteria for Case Selection

Planning for Success

Diagnosis and Treatment Planning

Basic Patient Selection and Treatment Planning in Implant

Dentistry

Treatment Planning

What is the prosthetic situation?§ Completely edentulous

§ Partially edentulous

§ Single tooth

Treatment Planning

General Considerations§ Maxilla or mandible

§ Anterior or posterior

§ Fixed or removable

Local Soft Tissue Condition:§ Pathology?

§ Inflammatory§ Neoplastic§ Keratinized vs non-keratinized mucosa

§ Tissue Phenotype/Biotype:Thick or thin?

Treatment Planning

Residual Ridge Form:

§ Height?

§ Width?

§ Facial and lingual contours?

Treatment Planning

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Adjacent Teeth:

§ Periodontal condition

§ Angulation

§ Length of edentulous space

§ Inter-arch space

Treatment Planning Esthetic ZoneDoes it show?

§ Consider smile line

§ Consider appearance of other teeth

§ Consider patient demands

Treatment Planning

Surgical placement

§ Implant position: restoratively driven

§ Reconstruction (Bone? Soft tissue?) if required:• At time of implant placement?• As a separate procedure?

DISCUSS thoroughly with your patient:

§ Multiple stages may be required§ Deficiencies may need to be disguised

prosthetically

§ Treatment may have to be repeated

Treatment Planning

§ Where ?

§ When ?

§ How ?

Immediate Implants

Surgical Planning

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

Factors Influencing Treatment Outcomes with ImplantTherapy and Their Relationship with Each Other

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

Esthetic Risk Assessment (ERA)

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

PlacementTiming?

Advantages:

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Disadvantages:

Favorable and Unfavorable Conditions for the Four Timing

Options for Implant Placement after Tooth Extraction

Treatment Approach – Timing of Implant Placement after Tooth

Extraction

Favourable Clinical Conditions Unfavourable Clinical Conditions

Immediate Placement(Type 1)

• In the esthetic zone, sites with a low esthetic risk based on the ERA- Thick tissue biotype- Intact thick facial bone wall- Low lip line- Single-tooth gap

• Intact bone walls• Single-rooted sites• Sites with no infection

• In the esthetic zone, sites with a high esthetic riskbased on the ERA- Thin tissue biotype - Thin facial bone wall (≤ 1 mm)- High lip line- Facial bone defect- Multi-tooth gaps

• Bone wall defects• Multi-rooted sites• Local infection at the extraction site• Large apical bone defects where initial stability may

be compromised

Early Placement with Soft-Tissue Healing (Type 2)

• In the esthetic zone with a low to high esthetic risk, most cases can be managed with a Type 2 approach

• Single-rooted sites• Local infection involving the tooth

• Large apical bone defects where initial stability may be compromised

Early Placement with Partial Bone Healing (Type 3)

• Multi-rooted sites• Local infection involving the tooth• Large apical bone defects where initial stability with a Type 1 or Type 2

approach is compromised

• Initially wide defects of the facial bone where extended flattening of the facial bone surface is expected

Late Placement (Type 4) • In growing patients• In situations where increased time for bone healing and modelling is

desired, e.g., large cystic lesions, sinus floor• Medical or other patient-related factors that may require treatment

after extraction to be significantly delayed

• Narrow orofacial dimensions of the socket at extraction where a delay of over 4 months will lead to an insufficiently wide crest

• Initially wide defects of the facial bone where extended flattening of the facial bone surface is expected

Restoratively Driven Treatment Plan: Clinical Case

Restoratively Driven Treatment Plan

Merging CBCT & Scan Data

Virtual Fixture Placement


Surgical Template Design

Surgical Guide & Abutment Temporary Crowns

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Incorrect m-d implant position results in…


Checking Surgical Guide Fit CRITICAL!

When implants and crowns are used to replace lost oral structures, the factors influencing gingival architecture around implant crowns are different from those factors for natural teeth

§ Teeth possess a scallopedconnective tissue attachment

§ Root forms vary in length and shape

§ Crowns have anatomical forms

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

Natural Teeth and Implant/Restorations:Are There Differences?

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

What Factors Influence Gingival Architecture: Implants/Crowns?

Bony contours: volume and quality determine gingival form


Facial Bony Contours

Labial thicknesses vary

Facial Thickness Varies


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Implant/crown contours and position determine gingival form

Natural root forms are varied

Implants are consistently smaller and round

Labial thicknesses vary

Implant-crown contours and position determine gingival form

Crown form assumes an unnatural contour

The crown attaches to a small fixture and emerges quickly to a larger form:“Emergence profile”

Loss of oral structures: both a surgical and prosthetic problem

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.

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

Ideally, all treatments should be restoratively or prosthetically guided

Loss of oral structures: both a surgical and prosthetic problem

A prosthetically guided plan for implant-borne restorations

A Restoratively Guided Treatment Plan for Implant Borne Restorations

(1) Staged treatments: where there is insufficient bone/gingiva quality or quantity, but augmentation potential is good

(2) Immediate treatments: where existing bone/gingiva contours and volume are good, treatment can be expedited

A Restoratively Guided Treatment Plan for Implant Borne RestorationsAdequate diagnostics (CBCT Scan) and Surgical Guide

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Incorrect implant placement (crown position?)


Incorrect mesial-distal implant position results in…

Incorrect crown form



Implant to the facial

Example of buccal implant placement

Example of facial implant placement




Implant in vertically deficient bone…

Results in long crown formResults in longcrown form




Implant positioned too far to the lingual…

RESULTS IN POOR CROWN FORM AND

INCLEANSABILITY

Results in poor crown form and uncleansibility



Vertical root fracture: tooth # 21

Mesial and distal bone levels are acceptable


Soft Tissue Augmentation


Soft tissue augmentationAfter tooth removal, bone grafting, and implant placement, a ridge with horizontal and vertical gingival deficiency remains


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Provisional restoration of implants

Papillae are fully mature, 3 months

Favorable gingival contours, ready for final crown


Radiography and Imaging:What areToday’s Standards for Implant

Treatment?

§ Digital panorex

§ Digital periapical

§ CBCT scan

§ CAD/CAM technology

§ Treatment planning software

Radiography and Imaging

§ 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

Radiographic Examination

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

§ Maxillary sinuses and nasal cavity

§ Roots of adjacent teeth


3D Imaging: CBCT Scan

What is the Rationale?

Does it Impact the Surgical/Restorative Connection?

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What is the Rationale for 3D Imaging?

Surgical Guide: Is it Necessary??

§ For pre-surgical determination of ideal location and angulation of the implant sites

§ Developed by the restorative dentist to visualize the final restoration and provide a guide for the surgeon

Surgical Guide

Rationale:§ Provide a means of communication between the

restorative dentist, surgeon and laboratory technician

§ In some cases, functions as a radiographic guide

§ Should not interfere with flap elevation

The Surgical Guide Should:

Surgical Guide

§ Mounted study casts for diagnostic work-up and determining implant location or scan models or intra-oral scan: “crown down/restoratively driven implant placement”

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

Mounted Study Casts and Diagnostic Wax-UpSurgical Guide

Why Guided Surgery?

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Non-Guided Surgery

Correct Implant Positioning

The Surgical/Restorative Connection

Principle 1: Fixture must be in the bone housing



Principle 2: Establish the abutment G/H -3mm for Posterior, 4mm for Anterior



Principle 3: Establish the Occlusal Space - 9mm for Posterior, 10mm for Anterior



Principle 3: Establish the Occlusal Space - 9mm for Posterior, 10mm for Anterior

* If the occlusal height is less than 9mm, adjust the fixture depthIncorrect m-d implant

position results in…

Immediate Implant PlacementImmediate Tooth Replacement Problems

§ Recession

§ Discoloration

§ Facial Contour

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The Surgical/Restorative Connection:The Critical Zone!


Sclar A 2003

IMPLANT:

§ Lack of CT

§ Hypovascular, hypocellular zone adjacent to the implant

§ Absence of PDL blood supply

Tissue seal=position stability


As narrow as possible=soft tissue thicknessAs wide as necessary=maintenance of gingival stability

Ikiru A et al. Journal of Prosth Res 60:3–11, 2016




Decision Making Process for Restoring Single Implants Clavijo V and Blasi A (2017)



Decision Making Process for Restoring Single Implants Clavijo V and Blasi A (2017)

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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


Procedures to Manage Post Extraction Resorption


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

Platform Switching: Is it Beneficial and Is it Necessary?


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


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


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


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

Screw vs. Cement Retained Implant Prosthesis??


Screw vs. Cement Retained Implant Prosthesis


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


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When do we choose cement retention?

§ Adequate inter-ridge space

§ Areas where esthetics are of concern

§ Implant is not positioned in the prosthetically ideal location


When do we choose screw retention?

§ Brannemark system validated screw retention

§ Screws are used to attach the prosthesis to an implant and the abutment to the crown

§ Different screws have different properties, size, design and composition


When do we choose screw retention?

§ Limited inter-ridge space (Chee et al. British Dental Journal Oct 21:201, 2008)

§ Implant is placed in the prosthetically ideal position



Screw vs. Cement Retained Implant ProsthesisDecision Making Tree

Types of Cementation

§ Permits retrievability

§ Risk of leakage and loss of retention is higher


Provisional Cementation:

Definitive Cementation:§ Very difficult to retrieve

§ Prosthesis may be lost in the case of a failure

What Factors Need to be Considered During Decision Making?

§ Retrievability

§ Esthetics and provisionalization


§ Clinical performance

§ Occlusion

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What Factors Need to be Considered During Decision Making?

§ Retention

§ Implant placement


§ Passivity

Summary

§ Single, short span§ Narrow diameter crowns§ Inadequate inter-occlusal space

§ Cantilevered prosthesis (may require more maintenance)§ Patients who are at higher risk for gingival recession


§ Large, full arch cases (complications can be more common)

Cement Retention Preferred When:

Screw Retained Preferred When:

Chee et al. British Dental Journal Oct 21:201, 2008

Summary

§ Restoring mal-aligned implants

§ Periodontally compromised cases when expected to lose more teeth

§ Minimal occlusal space <4mm


§ Removal of excess cement would be very difficult§ Cases in which biologic complications are anticipated

Cement Retention Preferred When:

Screw Retained Preferred When:

Chee et al. British Dental Journal Oct 21:201, 2008

ConclusionScrew vs. Cement Retained Implant Prosthesis

No clear evidence that one system of retention is better than the other however several authors suggest screw retained over cement retained

The overall survival of the implant is not dictated by the type of prosthesis retention but may be a predisposing factor for certain biological and technical complications

Documents

What is the Surgical/Restorative Connection in Dental ... · Tooth Extraction Treatment Approach –Timing of Implant Placement after Tooth Extraction Favourable Clinical Conditions