the clinical application of regenerative technique and muco-gingival surgery in implant therapy

8/3/2019 The Clinical Application of Regenerative Technique and Muco-gingival Surgery in Implant Therapy

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(Jehng S M) D.D.S., M.S.,http://www.periojehng.com


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Esthetic Dental Implant

The most challenging work


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The value of implant therapy


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The development of dental implant

Need by

Bone - driven scientist

Restoration - driven esthetics

Soft -tissue driven esthetics


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Bone - driven restoration


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Restoration-driven implant placement

implant the apical extensionof the ideal future restoration


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Soft - tissue driven implant placement

Soft-tissue integration

Supported by bony tissue

Presence of inter-dental papilla

Absence of gingival recession


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Biological aspects ofPeriodontal and peri-implant

tissues


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The key factor

Tissue-Natural tooth Interface Tissue-Implant Interface


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Interface Epithelium Connective tissue Bone


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Implant-bone interface ----

The philosophy of osseointegration

P.-I. Brnemark

Provides a stable and immobile support of a prosthesis under

functional loads, without pain, inflammation, or loosening.


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Osseointegration : a reality

A direct structural and functional connection between ordered,living bone and the surface of a load-carrying implant


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Principles of bone regeneration

Basic bone biology

Bone modeling: sculpting and shapingBone remodeling: bone multicellular unit


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Bone healing


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Bone healing


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Bone healing


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Biologic width-Vertical dimension of the dento-gingival junction

(soft tissue)The distance of bone to external environment


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Clinical implication of biologicwidth


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Violation of biological width

Gingival Inflammation

Bone Resorption


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Soft tissue - Implant Interface

Junctional epithelium Connective tissue attachment


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A biological widthexists aroundunloaded andloaded non-submerged one-part titaniumimplants.


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Different types of inflammatoryreactions in peri-implant soft tissues

Ericsson I, Persson LG, Berglundh T, Lindhe J, Marinello CP, Klinge

J Clin Periodontol 1995; 22:255-2


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Implant design

Implant surface

Time of implantation

Bone grafting

Future trend


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Pathophysiology of edentulous jaws


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Factors influencing edentulous bone loss

Trauma Extraction Infection Systemic diseases

Mechanical and functional stress and overloading


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Bone shape and bone quality classification

according to Lekholm and Zarb (1985)

I II III IV


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Periodontal regeneration for

implant therapy

Goal of regenerative therapy


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Goal of regenerative therapy

Long term implant function

Optimal esthetic result of the finalreconstruction

High efficacy and predictability


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Patient- centered Treatment Plan


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Evidenced-based approach in implant treatment

Guidelines to help the clinician make anintelligent decision

randomizedcontrolledlong-term study


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Pre-surgical planning

Patient evaluation

General health status

Motivation and compliance

Oral hygiene status

Financial situation


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Extraoral examination

Smile line

Facial harmony and profile

Facial soft tissue appearance and consistency


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Intraoral examination Edentulous area evaluation

Natural teeth evaluation

Esthetic needs

Choice of the type of prosthetic rehabilitation


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Accessory procedures

Orthodontics Periodontal surgery

Advanced concepts in implant therapy


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Preservation of alveolar bone

Site enhancement procedures Alveolar bone augmentation

Soft tissue augmentation



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Site enhancement procedures Alveolar bone augmentation


Extraction socket preservation


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Atraumatic tooth removal

Do not reflect the interdental papilla, especiallyin the esthetic zone

Controlling the process of tooth removal

Eliminate all soft tissue fragments and pathology Stabilizing blood clot

Extraction socket preservation


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Five-wall socket with or without

GBR

Four- and three-wall sockets withGBR

Two- and one-wall sockets withGBR ormonocortical block graft


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Imp lan t p lac ement a f te r too th ex t rac t i on Immediate implant placement bone grafting(+)

membrane(+)

soft tissue grafting(+) Delayed implant placement bone grafting(+)

< 2 months membrane(+)

soft tissue grafting(+) Staged implant placement bone grafting(+)

4 ~ 6 months membrane(+)

soft tissue grafting(+)

#36 37 ith d d i d titi


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#36, 37 with advanced periodontitis


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Site enhancement procedures

Alveolar bone augmentation Soft tissue augmentation

Implant site development


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Implant site development

the essence of the esthetic implant

Build up hard tissue and soft tissue for esthetic implant placement


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Bone regeneration strategies


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Guided Bone Regeneration


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g

Procedures attempting to regenerate lostperiodontal structure through differential

tissue responses. GBR typically refers to ridgeaugmentation or bone regenerationprocedures

(AAP Glossary of Periodontal Terms;2001 4th Edition)

GBRGTR


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Regeneration ofsupporting boneRegeneration ofperiodontal tissue ofnatural teeth

Animal study


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Foxhound dog

2 month

Control defectTest defect

Test defect control defect


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Test defect control defect

Membrane requirements for GBR of the


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Membrane requirements for GBR of thealveolar ridge

Biocompatibility Cell occlusion

Tissue integration

Space-making

Clinical manageability

Generation of new bone around titanium


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Generation of new bone around titanium

implant using a membrane technique: Anexperimental study in rabbits.

Dahlin 1989

Expanded polytetrafluoroethylene( e-PTFE

Types of membranes


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Types of membranes

Non-resorbable membranes

ePTFETitanium-reinforced ePTFE

Bioresorbable membranes

Collagen membrane

Polylactic acid (PLA) membrane

Calcium sulfate

Bone-grafting Materials


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Autogenous

Extraoral donor sites

intraoral donor sites

Allogenic

DFDBA

FDBA

Alloplastic

Xenograft


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Successful GBR depends on:


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Successful GBR depends on:

Space Making

Complete Soft Tissue Coverage Membrane Placement and Stabilization

Sufficient Time to Regenerate Bone



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Site enhancement procedures

Alveolar bone augmentation Soft tissue augmentation

Alveolar bone augmentation


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Horizontal ridge augmentationDehiscences and fenestrations

Monocortical block graft

Vertical ridge augmentation

Distraction osteogenesis

Ridge expansion(ridge splitting)

Maxillary sinus bone augmentationLateral-wall technique

Osteotome technique

Distraction Osteogenesis


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Growth factor


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Growth factor

Platelet- rich plasma (PRP)

PDGF, TGF-, EGF, VEGF

Block bone grafting


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Ridge expansion(ridge splitting)


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Preservation of alveolar bone Site enhancement procedures

Alveolar bone augmentation



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Soft tissue management

and

esthetic considerations in implant therapy


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Soft tissue consideration

symmetric with contralateral tooth

1: gingival contour

2: interdental papilla

3: root prominence12 23

Esthetic anterior maxilla classification


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The Palacci Ericsson Classification

Esthetic anterior maxilla classification


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The Palacci Ericsson Classification

Esthetic Dental Implant


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Submucosal positioning of the implant shoulder adequate 3-D implant positioning

long-term stability of esthetic and peri-implant softtissue contours

symmetry of clinical crown volumes between theimplant site and contra-lateral teeth

Key factor is the boneheight of adjacent teeth

Accurate axis is importanto buccal plate


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preservation


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Pre-surgical planningTiming of implant placement

Immediate same time with extraction

Delayed < 2 monthsStaged > 2 months


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Pre-surgical planningNumber of missing teeth

Single

Multiple


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Pre-surgical planningImplant size selection

NP 3.3 mm

RP 4.0 mmWP 5.0 mm


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Pre-surgical planningProvisional selection

Removable partial denture

Resin bonded bridgeImmediate provisionalization

Loss of interdental papilla immediately


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after adjacent tooth extraction

Interdental papilla support using


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flangeless removable prosthesis


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Support with ponticafter atraumatic

extraction


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Pre-surgical planningPeriodontic and orthodontic consideration

Extraction using orthodontic extrusion

Clinical and radiographic evaluation of the


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papilla level adjacent to single-toothdental implants. A retrospective study in

the maxillary anterior region Choquet 200152 papillae

Distance in mm from contact point to crest of bone

3 4 5 6 7 8 9 10

% papilla 100 100 88 50 75 50 50 75present



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Implant positioning

Apico-coronal



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Implant positioning

Mesio-distal

Facio-palatal


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Single tooth gap


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Implant Bone Dimension

Mesio-distal: 6-7 mm (RP),1-1.5 mm away fromadjacent teeth

Apicocoronal: 3-4 mm

apical from CEJ


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Buccolingual: 6 mm, At least 1- 2mm on buccal

and palatal side

Multiple, adjacent missing teeth


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Multiple, adjacent missing teeth

as shallo as possible as deep as necesssar


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as shallow as possible, as deep as necesssary

Th ff t f i t i l t di t


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The effect of inter-implant distance onthe height of inter-implant bone crest

Tarnow, 2000

36 pairs implants: < 3 mm increased crest bone loss

Vertical distance from the crest of bone to

the height of the interproximal papilla


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the height of the interproximal papillabetween adjacent implants

Tarnow, 2003

136 interimplant papillary heights 3.4 m m


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Bone saucerization


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M di l


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Medical

Severe bone disease causing impaired bone healing

immunologic disease

medication with steroids

uncontrolled diabetes mellitus

irradiated bone

others

P i d t l


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Periodontal

Active periodontal disease

History of refratory periodontitis

Genetic disposition

S ki h bit


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Smoking habits

Light smoking (< 10 cigarettes per d )

Heavy smoking (> 10 cigarettes per d )

O l h i / li


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Oral hygiene/ compliance

Home care measured by gingival indices

Personality, intellectual aspects

O l i


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Occlusion

Bruxism


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Peri-implant plastic surgery

Importance of keratinized mucosa


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Importance of keratinized mucosa

Prevents spread of inflammation to deeptissue

May prevent recession of marginal gingiva

Prevent excessive movement of freegingiva

Resists damage from brushing


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Nevins and coll.


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Nevins and coll.


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Nevins and coll.

Peri-implant plastic surgical techniques

F ft ith li l / ti


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Free graft epithelial / connective

Pedicled flaps apical repositioncoronal reposition

rotated mixed grafts bilayer technique

simple incision punch

T- shaped

Predictable site development


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Subepithelial Connective Tissue Grafting

Subepithelial Connective Tissue Graft

Histology


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gy

Epithelium

Lamina propria (papillarylayer)

Lamina propria (reticularlayer)

Submucosa

Donor site selection


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Donor site selection

Palate Tuberosity

Edentulous areas

Advantages of CTG

Predictable


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Predictable

Esthetic Economic

Enhancing gingival thickness

prevent post-op gingival recession

enhance oral hygiene

Favorite donor site


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How to harvest a CTG

Surgical Technique


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A single-incision technique to harvest

subepithelial connective tissue graftsfrom the palate

Markus B.HUZERLER, Dietmar Weng

IJPRD 1999;19:279-287


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Advantages of single-incision technique


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g g q

Primary intention healing

No post-operative stents

Variable graft sizes are obtainable

Severe traumatic bony defect of a

19 y/o female


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y

Guided Bone Regeneration


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A ridge concavity remained after

GBR and implant restored


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p

Soft tissue management


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Subepithelial Connective Tissue Grafting

Subepithelial connective tissue

grafting procedures


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g g p


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Papilla Regeneration Technique


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Modified roll flap


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2nd stage: Rolling

technique to fold palatalconnective tissue graftonto buccal side of impla


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the clinical application of regenerative technique and muco-gingival surgery in implant therapy

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