b i o - a r c h i t e c t u r e SEATTLE STUDY CLUB 2018

La QuintaLEGACY TOUR • CALIFORNIA

d e n t a l b i o - a r c h i t e c t u r e SEATTLE STUDY CLUB 2018

La QuintaLEGACY TOUR • CALIFORNIA

“ Architecture is not so much a knowledge of form, but a form of knowledge

- Bernard Tschumi

SIGNIFICANT ADVANCES IN THE SURGICAL & RESTORATIVE FIELDSFACILITATED COMMUNICATION FOR HIGH-END PLANNING, SURGERY & DEFINITIVE RESTORATIONS

Dr. Sonia Leziy Dr. Brahm Miller

www.elatus.caFOLLOW ALONG WITH .PDF GUIDE

Advances in thread structure allow for better healing or some kind of text

OPTICAL SCANNINGAPPLICATIONS / BENEFITS1 BRIGHT IDEAS,

MATERIALS & INNOVATIONS

www.elatus.ca

scan body/flag . identifying 3D implant position metal interface . accurate and confirmed seating

not all scan body designs are good

dentist . technician . surgical team members quick and accurate communication

iOSBENEFITS

1 data fusion with cbct * key for diagnosis/treatment planning/guide generation2 ease of communication (clinicians and laboratory)3 real time visualization 4 virtual analysis of preparation & abutment/restoration design 5 color models . virtual shade measurements6 ease of repeatability vs impression7 selective repeatability & capture of relevant areas8 archivable9 virtual monitoring10 no disinfection steps

9

early identification of inaccuracies

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12

laboratory as a service provider. not only a producer

preliminary plan as defined by the dentist executed by the technician

revised plan as defined by the clinician

COLLABORATION & TRAINING THE DESIGNER

pilot drill guide full guidance

printed guides: high accuracy of fit . generated from optical scans or lab-scanned impressions

lateral access - limited vertical opening

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guided surgery is not easier… it is more accurate or precise

demands experience & appropriate steps

increased clinical time efficiency … but more data collection & planning time

useful in simple and complex cases … including bone reduction guides

specific drills . access limitations

insertion torque . difficult to evaluate due to contact friction

bone overheating concerns . more heat, but subcritical

factors affecting accuracyintraoral scan

cbct scan

planning software

printer

instrumentation tolerances

fully guided prep + implant insertion

support (tooth vs soft vs hard tissue) flapless (vs flap)

single vs multiple guides

human error

innovators early adapters early majority late majority laggards

16.00

34.0034.00

13.50

2.50

2016 market

customers that want technology/ performance customers that want solutions/convenience

MARKET INFORMATION CAD/CAM - SCANNER PENETRATION

digital impressions ∼25% of cases 2017

VANCOUVER PRODUCTION LAB 11/2015- 09/2017

Trios growth 10 %

Itero growth 2 %

Sirona growth 1 %

conventional impressions -13%

THE IMPLANT DIGITAL WORK-FLOW

WHAT / HOW Lava C.O.S. (DS) vs PVS (CI) experience with either technique sophomore dental students who used video lecture instructor demo

Marti AM, Harris BT, Metz MJ et al. Comparison of digital scanning and polyvinyl siloxane impression techniques by dental students: instructional efficiency and attitudes towards technology. Eur J Dent Edu 2016;9. pub ahead of print.

comparison of digital scanning and PVS impression techniques by dental students

despite the results 96% expressed an expectation that digital scanning will become their predominant impression technique

OUTCOME time spent greater for DS vs CI after instruction and practice CI proved significantly easier

Technology to document & track outcomes

MATERIAL & TREATMENT INNOVATIONS A FOCUS ON BIOLOGICS & CHANGING PROTOCOLS2 BRIGHT IDEAS,

MATERIALS & INNOVATIONS

www.elatus.ca

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TISSUE MANAGMENT & MATERIAL OPTIONS IN CLINICAL PRACTICE• Kim DM, Neiva R. Periodontal soft tissue non-root coverage procedures: a systematic review from the AAP Regeneration Workshop. J Periodontol. 2015;86(2 Suppl): S56-72. • Chambrone L, Tatakis DN. Periodontal soft tissue root coverage procedures: a systematic review from the AAP Regeneration Workshop. J Periodontol. 2015; 86(2): S8-51. • Wu Q, Qu Y, Gong P, Wang T et al. Evaluation of the efficacy of keratinized mucosa augmentation techniques around dental implants: a systemic review. J Prosthet Dent. 2015;113(5): 383-390. • Zuhr O, Baumer D, Hurzeler M. The addition of soft tissue replacement grafts in plastic periodontal and implant surgery: critical elements in design and execution. J Clin Periodontol. 2014;41(s15): 123-142.

ROOT COVERAGE PROCEDURES (recession improvement, CAL gain, KT gain)

subepithelial connective tissue grafts - gold standard

coronally advanced flap + acellular dermal graft

coronally advanced flap + enamel matrix derivative

coronally advanced flap + collagen matrix

NON-ROOT COVERAGE PROCEDURES study heterogeneity … no conclusive results

viable alternatives to palatal donor tissue

FGGs have disappeared from the esthetic zone … limited to esthetically irrelevant applications

DONOR SITE CLINICAL CONSIDERATIONS

1st molar region -thinnest tissue

canine/premolar area - greatest width/shallow harvest

tuberosity - thickest tissue/limited width

palatal vaults . graft procurement considerations

shallow vs deep . fibrous vs fatty & glandular

subepithelial ct vary substantially between patients

reiser gm, bruno jf et al 1996 studer sp, allen ep et al 1997 muller 2000

harris 2003 bert et al 2015

the evolution of flap design & material selection

Zadeh HH. Minimally invasive treatment of maxillary anterior gingival recession defects by vestibular incision subperiosteal tunnel access and platelet-derived growth factor bb. Int J

Periodontics Restorative Dent. 2011;31:653-660. Chao JC. A novel approach to root coverage: the pinhole surgical technique. Int J Periodontics

Restorative Dent. 2012; 32(5): 521-531.

preop post-op 5 weeks

set of 4 tunnelling instruments . available from www.pronorthsolutions.ca

short papilla tunnelling

long papilla tunnelling

long facial tunnelling

short facial tunnelling

‘arc’ acellular dermal matrix graft

Leziy S, Miller B. Acellular dermal tissue augmentation procedures for teeth and implants: the dermal ARC

protocol. Manuscript in preparation.

alloderm gbr

alloderm acellular matrix graft . selective 7-0 prolene sling sutures

1 year postop

UR prior to grafting UR post-grafting 2 weeks

the evolution of documentation

UL prior to grafting UL post-grafting 6 weeks

OPTICAL SCANNING

• progressive tissue level & volume changes

• track wear/NCCL changes

• track stability of treated/untreated sites

A NEW METHOD TO TREATMENT PLAN MONITOR ASSESS TISSUE STABILITY

superimposition of scans time points 1 and 2 (1 year apart)

heat map - green indicates high scan correlation

significant soft tissue volume changes (red) pt’s R- 3 weeks after dermal-ARC graft vs 1 year

pt’s L - prior to dermal-ARC graft vs 1 year

• accurately positioned implants • anticipating required tissue changes • transmucosal guidance

SUCCESSFUL IMPLANT PROTOCOLS PLANNING & TREATMENT EXECUTION3 BRIGHT IDEAS,

MATERIALS & INNOVATIONS

www.elatus.ca

CASE ILLUSTRATION #1

fully guided preparation and implant insertion

Miron RJ, Zucchelli G, Pikos MA et al. Use of platelet-rich fibrin in regenerative dentistry: a systematic review. Clin Oral Investig. 2017; 21(6): 1913-1927.

iPRF & aPRF- platelets recruit osteoblasts, endothelial cells, fibroblasts sustained growth factor release for 7-14 days improve cell migration/proliferation, support hemostasis subjective bone quality shift D4 → D3 soft tissue healing benefits trend - > new bone formation may decrease the healing time

indexing jig & crown form & temp ti abutment

telio or nano ceramic bondable bridge custom healing abutment

1.

2.

1. 2.

3. custom ha

4. temp abutment

&4. implant supported provisional restoration

&3. tooth supported provisional restoration

THE COMPLETE PROSTHETIC SOLUTION

p r e f a b r i c a t e d c u s t o m h e a l i n g a b u t m e n t

non-engaging titanium base/pmma form

anatomy design virtual crown & implant position

designing abutment tissue pressure gingival anatomy-healing abutment design

‘analogue’ modifications by technician

7 days post-opbonded nano-ceramic bridge over custom healing abutment

24 month follow-up

7 (12) 9 (21)case illustration #2 tunnel defect bucco-lingual thin/deficient facial bone

infuse BMP2

ti-reinforced PTFE membrane root coverage / sockets sealed with ct graftinfuse/allograft combination

post-op 4 months

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implant surgery

predictableimplant positioning & accuracy3

Leziy S, Miller B. Rethinking gingival tissue augmentation around implants: 3-dimensional augmentation techniques. Manuscript in preparation.

tissue passivation and advancement tenting over healing abutments

fixed provisional partial denture

predictableimplant positioning & accuracy3

laser de-epithelization

glustitch periacryl adhesive bandage

geistlich mucograft

predictableimplant positioning & accuracy3definitive restoration try-in

preop

osteotomy preparation

DYNAMIC GUIDED SURGERY (gps)

executed 2d position

• high set-up cost • optical tracking of jaw & drill • no lab fabricated guides • can alter plan within the surgery • comparable accuracy to static guides

• entry point . mean error 0.62mm-3.4mm • apex point . mean error 0.68mm to 3.5mm

ROBOTIC SURGERY REDUCING HUMAN ERROR

moving from 2d planning to 3d planning

ESTHETICS FACIALLY GENERATED TREATMENT PLANS & MATERIALS4 BRIGHT IDEAS,

MATERIALS & INNOVATIONS

www.elatus.ca

smile design. merging photos/iOS & radiographs (2D/3D)

2d planning process

photorealistic 3D digitalization of the face

technicians create the restoration on the basis of the face, accurate arch positioning &

precise arch movements

dentists/patients can preview the planned restoration

FORWARD-LOOKING SOLUTIONSFACE-IN DESIGN FINDERS & HUNTERS

FORWARD-LOOKING SOLUTIONS

position of the upper arch inclination of the occlusal plane ..horizontal, inter-pupillary, frontal plane bite position, (upper/lower arch relationship) occlusal surface design tooth set-up lower arch functional analysis

CAPTURING & MEASURING PATIENT-SPECIFIC OCCLUSAL INFORMATION

PS1

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FORWARD-LOOKING SOLUTIONSWHAT IS COMING NEXT?

TRACER (presently in beta version)

virtual tracing of jaw movements….. a digital gnathological tracing for a fully functional articulation

ARTIFICIAL INTELLIGENCE (AI - intelligence exhibited by machines or software)

(a digital platform equipped with AI) Just tap in your preferences and the machine handles all the complexities. Machines - make them intelligent . teach them reasoning & prioritization, problem solving and deduction

SCREW vs CEMENT RETENTION

Why we have moved from cementation to screw retention where possible …but what’s next?

PROS / CONS TO EACH METHOD5 BRIGHT IDEAS,

MATERIALS & INNOVATIONS

www.elatus.ca

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cement removal challenges . even with good design & technique

CEMENTATIONmany techniques to minimize excess cement: dual cord, venting, dummy abutment. Begum et al IJOMI 2014.

high number of cemented restorations - sulcular cement excess. Kosrch et al Int J Prosthodont 2015.

excess cement - signs of peri-implant disease in 81% of cases. Wilson et al J Periodontol 2009.

undetected excess … varies with cement type. Korsch et al. CIDRR 2014.

removal of excess cement is difficult. with training, only success at removal of ZOE cements from models. Behr et al IJOMI 2014.

retentiveness of luting cements varies. Garg et al J Oral Implant 2014.

retentiveness of provisional luting cements is not predictable. Schiessl et al. Clin Oral Investig. 2013.

ideal biofilm niche - abutment-cement-suprastructure interface. Papavasileiou et al Int J Prosthod 2015.

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TECHNOLOGIES WITH THE ABILITY TO DISRUPT6 BRIGHT IDEAS,

MATERIALS & INNOVATIONS

www.elatus.ca

• RODO medical • the smileloc abutment system • no cement • no screws • no access holes

RODO ABUTMENT with silicone gasket/seal

SMILELOCNITINOL sleeve

COPINGTi or Zr copings

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Dudley JE, Richards LC, Abbott JR, Retention of cast crown copings cemented to implant abutments. Australian Dental Journal, Vol. 53, pp. 332-9, 2008 Mundt T et al. Retention force of secondary crowns to copings after temporary cementation: the effect of crown material and luting agent. Biomed Tech 2010, Vol. 55, pp. 335-40, 2010.

Average Retention Force (N)

336

473

476

• Equivalent or better static and fatigue strength • No micro-leakage found in all samples tested in fatigue testing • No effects on performance or loosening observed due to thermal cycling

Improv

Panavia-F (Kuraray Medical)

Smileloc (unused)

Smileloc (after 6 mo use)

FATIGUE TESTING SMILELOC RETAINED CROWN SCREW RETAINED CROWN

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all-on-4 or similar prostheses

• no screw holes affecting occlusion • less prosthesis complications - teeth breaking etc. • easy clinician-directed prosthesis removal /

replacement • less chair time for hygiene appts

• remove prosthesis • hygiene appointment • replace prosthesis/seal access holes

CONCLUSIONS AN OPENNESS FOR CHANGE

BRIGHT IDEAS, MATERIALS & INNOVATIONS

www.elatus.ca7 • optical scans • face-in planning/treatment • bone & soft tissue grafting innovations • accurate implant surgical & restorative

protocols • today’s CAD-CAM restoration design • screw retention vs cement retention vs

other forms of retention

2018

leziy education hands-on seminars

vancouver british columbia

visit our website for more information www.elatus.ca

dr. Sonia Leziyperiodontist

thank youelevating knowledge

www.elatus.ca