8years later

EAO CERTIFICATION PROGRAMME 2016

C A S E Number: 1 Dr Emmanouil Symeonidis

Hamad Medical Corporation Al Wakra hospital Dental department periodontics clinic # 3 82228 Al Wakra

QATARMobile phone: +30 6932223074 /+97433299012Email address: [email protected]

CERTIFICATION PROGRAMME 2016 case #1

mailto:[email protected]

General introduction

M.K. female 32 y.o.a. Architect.Medical History : Clear , No Known Drug Allergies CC: “I don’t like my Anterior Tooth”

Medical History : Clear smoking up to 7 cigarettes per day

Dental History : Previously RCT surgery ….. “with some kind of grafting” in a hospital in Athens Greece




Standardised Documentation for Implant Treatment 9E AO

Pre-operative assessment: periodontal status

Bleeding on probing

Bleeding on probingPlaque

Tooth number

Pocket depth

Plaque

Pocket depth

Tooth number

labial

lingual

labial

linguallabial

lingual

labial

lingual

labial

lingual

labial

lingual

Date: 10/04/2010

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3 3 3 3 3 3 3 2 3 3 3 3 2 1 2 3 3 3 3 3 4 5 6 7 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 5 5 6 6 4 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

55 54 53 52 51 61 62 63 64 65

85 84 83 82 81 71 72 73 74 75

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 3 3 4 4 3 3 3 3 3 3 3 3 4 2 2 2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

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CBCT Axial view at the level of the CEJs distance of cuts 2 mm (#31-40 )real dimensions


CBCT Panoramic views Planes 2 & 4 including the area of interest #21


CBCT Sagittal view of 21 Periapical pathos isPossible fenestration Buccal plate not visible


• Thick Flat Periodontium • Altered passive eruption Coslet classification 1A normal distance CEJ bone crest wider keratinized mucosa • Inflamed papilla and gingival margin• Bleeding on Probing • Class V composite restoration extending below the gingival margin


Treatment planInitial assessment Initial ImpressionsIndexing of the anterior teeth/ bite registration Radiographic examination Scaling Oral Hygiene Instructions Lab processed/ Self carved provisional: removable or fixed provisional crown supported on neighboring teethExtraction Depending on the presence abscense of the buccal plate (Dscan vs clinical )Implant placement

NO ? YES ? Install the implant immediately ? Wait ?

Primary stability ? TIME Ridge Augmentation ?

Comfort Would the implant support the ridge by itself ? Need for bone graft material ? Provisional ? Screw Retained ? Cemented? Soft tissue Management ? Second Stage uncovering the implant ? Restorative Treatment ? Metal Free?


Albrektsson T, Brånemark P-I, Hansson H-A, Lindström J. Osseointegrated titanium implants: requirements for ensuring a long-lasting direct bone-to-implant anchorage in man. Acta Orthop Scand 1981; 52:155–170.

1) status of the bone (or, better, the implant site)2) loading conditions3) surgical technique4) implant design (or macrostructure)5) implant finish (surface)6) implant material


Are there Risks into choosing the immediate implant as intervention of choice ?

In patients with an intact buccal bone wall and thick gingival biotype, treated by means of flapless surgery and an immediate implant crown, the frequency of advanced midfacial recession was low (<10%)A systematic review on the frequency of advanced recession following single immediate implant treatment J.Cosyn,N.Hooghe, H.Bruyn J Clin Periodontol. Vol. 39(6)2012 pp.582–589

Would the single tooth implant in the anterior Maxilla be a predictable result in the course of time ?immediate single implant treatment in the anterior maxilla after a 3-year observation period. thick gingival biotype, ideal gingival level/contour and intact socket walls at the time of tooth extraction.• minimal mucoperiosteal flap elevation, • immediate implant placement• insertion of a grafting material between the implant and the socket wall • connection of a screw-retained provisional restoration. • Not immediately loaded • cemented crown 6 months thereafter. • implant survival 96% • hard and soft tissue conditions mid facial recession 8% • PES < 8 & WES <6 : 21% (failures) 58% acceptable 21% perfect C:valuable and predictable treatment option for right case selection with almost full papillary re-growth and a low risk for advanced midfacial recession.

Immediate single-tooth implants in the anterior maxilla: 3-year results of a case series on hard and soft tissue response and aestheticsJan Cosyn,A. Eghbali, H. Bruyn, K. Collys, R. Cleymaet, T. Rouck Jclin. Periodontol.. 38(8), 2011 pp746–753


Placing and loading a single implant in a fresh extraction socket in the Anterior Maxilla, is it a total or calculated risk? Immediate restoration/loading of immediately placed single implants: is it an effective bimodal approach?MA. Atieh,AT. Payne, WJ. Duncan, MP. Cullinan COIR 20(7), 2009 pp.645–659

A systematic comparison meta analysis of survival and radiographic marginal bone level changesimmediate implant protocols in the aesthetic region; immediate single implantrestoration/loading in extraction sockets (the bimodal approach) VS. same in healed sites.

C: bimodal approach adds a certain risk may offer an advantage with respect to the favorable changes in marginal bone levels.


Wilson & Weber (1993) Immediate Same day as extraction Recent 30–60 days after extraction Delayed Following hard tissue maturation Mature Months to years after extraction

Mayfield (1999) Immediate Same day as extraction Delayed 42–70 days after extraction Late 6 months after extraction

Immediate restoration/loading of immediately placed single implants: is it an effective bimodal approach?MA. Atieh,AT. Payne, WJ. Duncan, MP. Cullinan COIR 20(7), 2009 pp.645–659

Hämmerle et al. (2004) Type I In fresh extraction sockets Type II After soft tissue coverage ( 4- 8 weeks) Type III Radiographic bone fill (12-16 weeks) Type IV Healed socket (>16 weeks)

Esposito et al. (2006) Immediate In fresh extraction sockets Immediate-delayed < 8 weeks post extraction Delayed > 8 weeks post extraction

Immediate implants following tooth extraction. A systematic reviewJ.Ortega-Martínez, T.Pérez-Pascual, S. Mareque-Bueno , F.Hernández-Alfaro, E. Ferrés-Padró Med Oral Patol Oral Cir Bucal. 2012 Mar 1;17 (2):e251-61

.


Implant placement protocols

• Immediate restoration or immediate non-functional (non-occlusal) loadingWithin 48 h of implant placement but not in centric or eccentric occlusal contact with the opposing dentition during healing• Immediate loading or immediate functional loadingInto occlusal loading within 48 h of implant placement• Progressive loadingIn light occlusal contact initially and then gradually adjusted into full occlusal contact• Early loading Between at least 48 h and not later than 3 months after implant placement• Conventional loading • In a second procedure after a healing period of 3–6 months• Delayed loading • After a conventional healing period of 6 months

Cochran, D.L., Morton, D. & Weber, H.P. (2004) Consensus statements and recommended clinical procedures regarding loading protocols for endosseous dental implants. International Journal of Oral & Maxillofacial Implants 19 (Suppl.): 109–113. Implant loading Protocols


TYPE 1: Implant placement immediately following tooth extraction and as part of the same surgical procedure

Advantages • Reduced number of surgical procedures • Reduced overall treatment time • Optimal availability of existing bone

Disadvantages • Site morphology may complicate optimal placement and anchorage • Thin tissue biotype may compromise optimal outcome • Potential lack of keratinized mucosa for flap adaptation• Adjunctive surgical procedures may be required• Procedure is technique-sensitive

Consensus Statements and Recommended Clinical Procedures Regarding the Placement of Implants in Extraction SocketsChristoph H. F. Hämmerle, Stephen T. Chen, Thomas G. Wilson Jr IJOMI Vol 19 Supplement 2004

Certification Programme Exam case #1

TYPE 2 : Complete soft tissue coverage of the socket (typically 4 to 8 weeks)

Advantages • Increased soft tissue area and volume facilitates soft tissue flap

management • Resolution of local pathology can be assessed

Disadvantages• Site morphology may complicate optimal placement and anchorage • Treatment time is increased • Socket walls exhibit varying amounts of resorption • Adjunctive surgical procedures may be required • Procedure is technique sensitive



TYPE 3 : Substantial clinical and/or radiographic bone fill of the socket (Typically 12 to 16 weeks)

Advantages • Substantial bone fill of the socket facilitates implant placement • Mature soft tissues facilitate flap management

Disadvantages • Treatment time is increased • Adjunctive surgical procedures may be required • Socket walls exhibit varying amounts of resorption



TYPE 4 : Healed Site (typically 12 to 16 weeks)

Advantages • Clinically healed ridge • Mature soft tissues facilitate flap management

Disadvantages • Treatment time is increased • Socket walls exhibit varying amounts of resorption • Large variations are present in available bone



Full thickness flap was raised Composite Resin violating biological with altering the bone crest contour Altered Passive Eruption Coslet type 1A (normal distance of CEJ to bone crest/ wider keratinized mucosa)


Type 1 classification CHF Hammerle 2004:• Extraction of #21 • Immediate placement of dental implant


Type 1 classification CHF Hammerle 2004:• Extraction • Immediate placement • Buccal bone present thickness of 1 mm aprox.


A prospective, controlled clinical trial evaluating the clinical radiological and aesthetic outcome after 5 years of immediately placed implants in sockets exhibiting periapical pathology.R.E. Jung,B. Zaugg,A.O. H. Philipp,TC. Truninger,DW. Siegenthaler, CHF Hammerle COIR 24: (8)2013 Pp :839–846


• Presence of buccal plate with 1 mm of thickness approximately

• Atraumatic extraction with the help of Nobel Biocare periotome was achieved

• No Rotational movements • Effort and Care was made to respect the

socket’s dimensions• Remnants of the RCT are obvious at the

palatal wall of the socket

Correct Implant PositionMD dimensioncomfort zone away from danger zones which are located close to adjacent root surfaces 1-1.5mm OF dimension Implant shoulder is positioned about 1 mm palatal to the point of emergence of adjacent teeth Too facially will place the implant in danger of recession Too palatally will need the crown to have ridge lap design

AC dimension 1 mm apically than the adjacent CEJ Too deep will created a deep sulcus difficult maintenance * cemented crowns !! Too coronally shoulder exposure and mechanics revelation with shoulder exposure


Buser D, Martin W, Belser UC.Optimizing Esthetics for Implant Restorations in the Anterior Maxilla: Anatomic and Surgical Considerations.International Journal of Oral & Maxillofacial Implants . 2004 Supp., Vol. 19 Issue 7, p43-61

• primary stability • the presence of a buccal plate• filling of the gap between the buccal plate and the implant or jumping distance • tissue biotype, • implant design.

A NEW PROTOCOL FOR IMMEDIATE IMPLANTS. THE RULE OF THE 5 TRIANGLES: A CASE REPORT (PAGES 4 & 5)J. Jiménez García, D.Sanguino Dec. 2014http://www.eao.org/new-protocol-immediate-implants-rule-5-triangles-case-report-pages-4-5-0#sthash.llMbGKrP.dpuf


• atraumatic extraction prevents pronounced bone loss.• the void should always be grafted with biomaterial.• compensate soft tissue remodeling, by overbuilding• Biomaterial• soft tissue graft.• Provisional crowns in immediately placed implants can help

maintain soft tissue contours.• Implant design is recommended to be self-tapered, so it can

favor reaching primary stability

Primary Stability–first tringle • sufficient bone apical to the extracted tooth’s alveolus. • approximate 2-4 mm of bone apical to the alveolus is necessary to obtain primary

stability This can be enhanced by the type of implant used, which is of a tapered design.



Schwartz D, Chaushu. The ways and wherefores of immediate placement of implants into fresh extraction sites: a literature review. J Periodontol 1997;68:915-923

1) high rate of survival, ranging between 93.9% to 100%; 2) implants must be placed 3 to 5 mm beyond the apex in order to gain a maximal degree of stability; 3) implants should be placed as close as possible to the alveolar crest level (0 to 3 mm); 4) there is no consensus regarding the need for gap filling and the best grafting material; 5) membranes do not imply better results-on the contrary, membrane exposure may carry complications 6) the absolute need for primary closure remains to be established


Buccal bone-second triangle • 2mm buccal plate is crucial to avoid soft tissue recession, and • an inter-implant distance of 3mm should always be present in order to allow papilla formation• implant adjacent-tooth distance of 1.5 mm maintained to • preserve bone tissue • fiber attachment • the presence interproximal papillae.

Grunder U, Gracis S, Capelli M. Influence of the 3D bone-to-implant relationship on esthetics. Int J Periodontics Restorative Dent. 2005 Apr; 25(2):113-9

implant position will dictate the emergence profile of the final restorationKois JC. Predictable single-tooth peri-implant esthetics. five diagnostic keys. Compend Contin Educ Dent. 2004 Nov;25(11):895-6, 898, 900



Fill the gap-third triangle horizontal resorption of bone dimension that amounts up to 56%void created between the buccal wall and the implant. Araújo et al. • They state that filling the gap with deproteinized bone mineral has beneficial outcomes: • hard tissue healing process is modified• additional hard tissue is present at the re entrance of the socket after a period of bone healing• soft tissue recession is prevented• improvement of the marginal BIC • xenogenic material in the void between the buccal wall and the implant surface, compensates for the

hard tissue lost after a tooth is extracted.



Tissue Biotype- fifth triangle

Thick-flat vs Thin scalloped periodontium Interproximal osseous position and thus, the overall soft tissue architectureprocess of remodeling following implant placementKois JC. Predictable single-tooth peri-implant esthetics. five diagnostic keys. Compend Contin Educ Dent. 2004 Nov;25(11):895-6, 898, 900

compensate this remodeling. 1. GrunderSubepithelial Connective Tissue Graft Control: 1.063mm vs. No Change in Test Group no soft tissue dimension changes in the test group. Flapless no compromise of blood supply 2. Capelli et al., graft internallyplace biomaterial between the soft tissue and the buccal plate to maintain the ridge contour., and thus, “overbuilding” the buccal aspectDe Rouck et al. single immediate implants with instant provisionalization, can help optimize esthetics. this can limit the amount of midfacial soft tissue lossimplant position will dictate the emergence profile of the final restoration



Implant Design-fifth triangle • influence the biomechanics of the environment where an immediate implant is

placed• self-tapping implants for achiening primary stability as their design compress the

alveolar bone as the implant is inserted.



• facilitation of progenitor cells influx• improvement local formation of angiogenesis• formation of new boneHämmerle CH1, Schmid J, Lang NP, Olah AJ.Temporal dynamics of healing in rabbit cranial defects using guided bone regeneration.J.Oral Maxillofac Surg. 1995 Feb;53(2):167-74.

Cortical / Intramarrow Penetrations D1mm :Mellonig JT, Bowers GM, Bright RW, Lawrence JJ.Clinical evaluation of freeze-dried bone allografts in periodontal osseous defects. J Periodontol 1976;47: 125-131

Sepe WW, Bowers GM, Lawrence JJ, Friedlaender GE, Koch RW. Clinical evaluation of freeze-dried bone allografts in periodontal osseous defects — Part II.J Periodontol 1978;49:9-14.

Froum SJ, Coran M, Thaller B, Kushner L, Scopp IW,Stahl SS. Periodontal healing following open debridement flap procedures. I. Clinical assessment of softtissue and osseous repair. J Periodontol 1982;53:8-14.

.Yukna RA, Harrison BG, Caudill RF, Evans GH, Mayer ET, Miller S. Evaluation of Durapatite ceramic as an alloplastic implant in periodontal osseous defects. II.Twelve month reentry results. J Periodontol 1985;56: 540-547.

Rompen EH, Biewer R, Vanheusden A, Zahedi S, Nusgens B.The influence of cortical perforations and of space filling with peripheral blood on the kinetics of guided bone generation. A comparative histometric study in the rat. Clin Oral Implants Res. 1999 Apr;10(2):85-94.

Zybutz MD, Laurell L, Rapoport DA, Persson GR.Treatment of intrabony defects with resorbable materials, non-resorbable materials and flap debridement. J Clin Periodontol 2000;27:169-178.

Crea A1, Deli G, Littarru C, Lajolo C, Orgeas GV, Tatakis DN.Intrabony defects, open-flap debridement & decortication: a randomized clinical trial.J Periodontol. 2014 Jan;85(1):34-42.


• 5mm BAT X 13.0 (Southern Implants SLA ) external Hex implant

• 4 mm of implant anchorage into native bone Lazarra RJ. Immediate implant placement into extraction sockets:surgical and restorative advantages IJPRD 1989;9:333-343

Lioubavina–Hack N, Lang NP, Karring T., Significance of primary stability for osseointegration of dental implants. COIR 2006; 17:244-250

Froum SJ. Immediate placement of implants into extraction sockets :Rationale, outcomes, technique Alpha Omegan 2005; 2005 98 :20-35


Optimizing Esthetics for Implant Restorations in the Anterior Maxilla: Anatomic and Surgical Considerations DM Buser; UC. Belser. IJOMI 2004 Suppl, 19(7), p43-61

IMPLANT PLACEMENT POSITION MD: within the comfort zone 1.5 mm OF: placement :palatal AC: surpassed the root apex > primary stability.

Double layer of resorbable membranePrimary stability was achieved and no countertorque device was used to removed itImmediate Loading of the implant will be triedImplant mount was used to register the implant position


was fabricated by block negative carving with acrylic resin and covered with composite resin interproximal areas were over contoured and flattened so that tissue would fall without tension and fill the area


Single-Tooth Anterior Implant: A Word of Caution, Part II AS. WEISGOLD, J-P ARNOUX, J. LU JERD Vol 9(6), Nov 1997 pp.285–294

Single-Tooth Anterior Implant: A Word of Caution, Part I AS. WEISGOLD, J-P ARNOUX, J. LU JERD Vol 9(5), Sept 1997 pp.225–233

Pin point interrupted non resorbable 4-0 sutures were usedPrimary closure periosteal separation released any possible tension on the covering flapScrew Retained Provisional crown (no cement)


1 week

Special care was given to the interproximal emergence toallow tissue to heal without pressure



Immediate post operative Panoramic Xray


4mm abutment was used switching the 5 mm implant head platform

1 month

• Oral Hygiene is fair • Soft tissue management of right central incisor Slight manipulation of the

provisional crown • Gingival Margin of #11 was corrected with gingivectomy and bone

reconturing with hand instrument . Kois JC. The restorative-periodontal interface: biological parameters. Periodontol 2000. 1996;11:29-38.


Final Provisional . 5 to 4 platform switching The running room has been adjusted with Jet Acrylic In order to support the soft tissues and recreated an new anterior Zenith Healing time will the chance for tissues to mature more and registration of the peri-implant sulcus will follow in order to communicate with the Ceramist Mr. Nontas Vlachopoloulos , Aesthetic Lab Athens Greece


Tissue Maturation


ABUTMENT/CROWN MATERIAL SELECTION

Metalic Abutments vs. Ceramic Abutments (approx. 5 years observation)1. 97.4 % 99.1% 2. Supporting Ceramic crowns same survival rate (Cer. Abtm /Cer. Cr. better)3. Technical Complications : Abutment screw loosening 4. Biological Complications : Similar

Is the performance of Ceramic Abutments similar to that of Metallic Abutments? Sailer I, Philipp A., Zembic A., Pjetursson BE, Hammerle CHF, Zwallen M COIR 20 (Suppl. 4): 4-31


Abutment Material Selection


For Cementation temporary cement was used, after retraction cord was inserted in order to prevent escape of excess cement into the per-implant tissues


Final Case inserted 2010 ! Zirconia Custom Abutment and Cementable Zirconia Crown


Furhauser R., Florescu D., Benesh T., Haas R., Mailah G., Watzek G. Evaluation of Soft Tissue around single-tooth implant crowns: the pink esthetic score COIR 16, 2005: 639-644


1 23

4

5

6 7

PES: 2-1-0M pap : 2 completeD pap : 2 completeLSM : 1 minor 1-2 mmSTC : 1 fairly natural Alv Pr : 2 none Softissue C: 2 no diff. Softissue T: 2 no diff.

Sum: 12/14



April 2010 Nov 2010 May 2016

Final Case inserted 2010 ! Zirconia Custom Abutment and Cementable Zirconia Crown



2010


MAY 2016


2016

2010 2016

PES:13?

2010 2016 2010


MAY 2016


May 2016 full smile





Treatment Plan Since 04-2010 on to 11- 2010 final recall05-2016

Impressions Radiographic examination Scaling (gingivitis) Oral Hygiene Instructions Surgical ApptCHX .2%, Local Anesthesia Sulcular Incisions Vertical incision distal of 22 maintaining the papilla Full thickness flap was raised supra level of Apex#21 was surgically and atraumatically extractedRCT remnants removed. Socked with saline, waited for bleeding and implant placed with 15rpm at 70 Nm Southern Implants BAT 5mm 11.5 mm, tapered by SLA external Hex .Position, palatal portion of the socket engaging the palatal wall surpassing the level of root apex . Relatively to adjacent CEJs of 11 and 22 , 2-3 mm deeper (Weisgold). Excellent primary stability. Visual of the adjacent CEJs , along with visualization of defect diagnosed on CBCT.Duralay indexing, fabrication Provisionalcortically penetrated with 1 mm surgical bur bone grafted and buccally (Araujo) with bovine allograft (BioOss) and covered with Collagen resorbable MembraneVickyl sutures interrupted / pin point to maintain papilla position for one week. Healing Abutment covered the implant.lab processed screw retained provisional was fabricated and corrected slightly intraorally for no functional occlusion. Implant was immediately loaded.06/07-2010Maturation additional 3 months . soft tissue manipulation correction of alered passive eruption new lab processed provisional 10-2010Final impressionZirconium cement retained Crown Last recall May 2016

THANK YOU EMMANOUIL SYMEONIDIS Manos


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8years later