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15 “Esthetic Periodontal Plastic Surgical

Procedures for Teeth / Implants”... .Advanced Periodontics and Implant Center

72780 Country Club Dr. #402, Rancho Mirage, CA

g o a l s / o b j e c t i v e s o f t r e a t m e n tS e s s i o n 1

•Discuss Advantages Of Interdisciplinary Therapy •Surgical Procedures That Improve Esthetic Restorative Results W i t h Te e t h A n d I m p l a n t s - C r o w n L e n g t h e n i n g Gingival Augmentation - Teeth And Pontic Sites

•Orthodontic Site Development Procedures

g o a l s / o b j e c t i v e s o f t r e a t m e n tS e s s i o n 2

•Discuss Concepts With Esthetic Implant Cases. •How Altering Gingival Levels With Adjacent Teeth In Esthetic Implant Cases Should Be Planned.

•Preventing Dental Implant Complications.

The Interdisciplinary Team • Restorative Dentist • Periodontist • Orthodontist • Lab Technician • Oral Surgeon • Endodontist • Dental Hygienist • Staff Members

optimal clinical results obtained through collaborative services of highly ski l led

dental clinicians

t h e - T E A M Common Goals Communication Clinical Skills Ideal Sequencing

c o n c l u s i o n st h e i n t e r d i s c i p l i n a r y

t e a ma c h i e v e s o p t i m a l

r e s u l t s w i t h

Procedures That Enhance Restorative Outcomes

Crown Lengthening (restorative access / esthetics) Root Coverage (teeth / implants) Soft Tissue Ridge Augmentation (pontic sites) Esthetic Implant Procedures

• Surgical Resective Procedures (Crown Lengthening)

• Surgical Regenerative Procedures (Connective Tissue Grafting)

• Orthodontic Extrusion or Intrusion of the entire attachment apparatus

Treatment Modalities for Irregular Gingival Arrangement

Gingival Augmentation

Why?

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Increase the Zone of Keratinized Gingiva Achieve Root Coverage

Why Do You Need Keratinized Gingiva?

A. Improves Esthetics B. Protects Better Than Mucosa From Abrasive Agents. Examples: Restorative procedures / Aggressive Oral Hygiene Techniques

• Freedman AL, Green K, Salkin LM, Stein MD, Mellado JR. An 18-year longitudinal study of untreated mucogingival defects. J Periodontol. 1999 Oct;70(10):1174-6

When?Documented Progressive Recession

Restorative Margins Planned (Sub-gingival)

Orthodontic Treatment Planned

Treatment of Isolated Dentinal Sensitivity

Cosmetic Concerns

Coverage of Root Caries

How? Lateral Pedicle Grafts

Free Gingival Grafts

Free Gingival CT Graft

Subepithelial CTGs

Tunnel Collagen Grafts

Acellular Dermis Grafts

Guided Tissue Regeneration

Coronolly Postioned Flaps with EMD

Which Procedure and Where?•Goal of Procedure

•Local Anatomy

•Modifications of Procedures for Different Sites

•Implant Selection

•Placement of Implants in the Esthetic Zone

•Minimal Traumatic Extraction Techniques

Esthetic Implants Sites

Current Concepts

•Connective Tissue Grafts with Immediate Implants

•Options for Interim Tooth Replacement - Pros and Cons of Immediate Provisionalization

•Combination Procedures Interdisciplinary Team Therapy with Esthetic Implants

Esthetic Implant Selection and

Current Concepts

Superhydrophilic SLActive implants M. de Wild Abstract: Surface chemistry influences both surface charge and wettability. The purpose of this study was to investigate initial hydrophilicity of SLActive implants compared to standard SLA.

Bioactive Surfaces

Titanium SurfacesCriteria For Implant Selection

•Restorative Issues / Flexibility –Internal Connection –Platform Switch / Horizontal Offset Abutment –Digital Design Process –Fixture Level Impressions - (CAD-CAM, Screw Retained,Custom Abutments)

Horizontal Offset Abutment Designs•Straumann BL Implants •Crestal bone maintenance !Respecting the biological distance is a key factor for preserving the crestal bone level (horizontal offset abutment) "microgap "bacterial contamination "inflammation (peri-implantitis) !The conical connection is designed to provide a seal and minimize issues with lateral forces 17

Microgap origin of bacterial

contamination

0.4 mm*

TreatmentPlanning

•Guidelines •Sequencing

Esthetic Sites

Keep implant approximately 1-1.5 mm lingual to facial plate

Facial - Lingual

Andre P Saadoun DDS MS et al Practical Procedures Aesthetic Dentistry

1999: 1063-1072

•≥1.8 mm from Tooth to Implant Surface

•≥ 3mm from Implant to Implant (Crestal Bone Needed for Papillae

Support)

Andre P Saadoun DDS M et al Practical Procedures Aesthetic Dentistry 1999: 1063-1072

Mesial - Distal

•Mean Lateral Bone Loss 1.38 mm

•Mean Crestal Bone Loss <3mm =1.04mm >3mm =0.45mm

The Effect of Inter-Implant Distance on the Height of Inter-Implant Bone Crest Tarnow, D J Periodontal 2000, 71:546-549

Adjacent Implants Anterior Sites

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R e s o r p t i o n B i o l o g yThe Buccal Plate and

Papillae Issues Change How We Sequence and Do

Therapy To Preserve The Esthetics!

Extraction

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Amler, M.H. (1969) The time sequence of tissue regeneration in human extraction wounds. Oral Surgery Oral Medical Oral Pathology 27: 309–318.

Nevins, M., Camelo, M., De Paoli, S., Friedland, B., Schenk, R.K., Parma-Benfenati, S., Simion, M., Tinti, C. & Wagenberg, B. (2006) A study of the fate of the buccal wall of extraction sockets of teeth with prominent roots. The International Journal of Periodontics & Restorative Dentistry 26: 19–29.

l i t e r a t u r e

The most significant bone resorption occurs during the first month after tooth extraction: 3–5 mm in width at 6 months

why consider immediate placement ?- preservat ion

- does not prevent resorpt ion of the buccal p late?

cervical sof t t issue form

papi l la form

Literature immediate - placement

46 Studies Reviewed - 9 of the studies were > 3 years in duration.

A systematic review on survival and success rates of implants placed immediately into fresh extraction sockets after at least 1 year Niklaus P. Lang etal. Clinical Oral Implants Research Special Issue: Osteology Foundation, 6th Expert Meeting Volume 23, Issue Supplement s5, pages 39–66, February 2012

98.4% Success for Immediate Placement

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C o m p e n d i u mJ u l y / A u g 2 0 1 4Vo l 3 5 ; 7

B o b b y B u t l e r D D S

Do Not Elevate Base of Papilla in a Thin Biotype

Incision designs.... Dr Ken Hinds Compendium 2014. Laguna Hills, CA

Custom Scan Bodies

Before Afterprovisional options

i m m e d i a t e p l a c e m e n t

- r e m o v a b l e r e t a i n e r

- f i x e d b o n d e d r e t a i n e r

- c u s t o m h e a l i n g a b u t m e n t

- immediate implant provisionalkey:key s u p p o r t s o f t t i s s u e

The In terd i sc ip l inary Re lat ionsh ip Of A l l Team Members Summar i ze The Per iodonta l Surg ica l P rocedures Which Improve Restorat ive Outcomes

I n t e r d i s c i p l i n a r y a n d C o m b i n a t i o n P r o c e d u r e s

Closing Points•Interdisciplinary Team

Collaboration Improve Results •Know when Crown Lengthening

Can be Beneficial •Understand the Various Soft Tissue

Grafting Procedures •Preventing Esthetic Implant

Complications is Key! •All Therapy Should Focus on

Collecting Appropriate Findings - A Clear Diagnosis and Treatment Planning

“Peri-Implant Disease and Dental Implant Complications”

“Implant Maintenance” Bobby Butler DDS

Affiliate Faculty UW Advanced Periodontics and Dental

Implants Rancho Mirage

February 6th, 2016