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

com

Esthetic Dental Implant

The most challenging work

The value of implant therapy

The development of dental implant

Need by

Bone - driven Restoration - driven Soft -tissue driven

scientist esthetics esthetics

Bone - driven restoration

Restoration-driven implant placement

implant the apical extension

of the ideal future restoration

Soft - tissue driven implant placement

Soft-tissue integration Supported by bony tissue Presence of inter-dental papilla Absence of gingival recession

Biological aspects of Periodontal and peri-implant tissues

The key factor

Tissue-Natural tooth Interface Tissue-Implant Interface

Interface Epithelium
Connective tissue Bone

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.

Osseointegration : a reality

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

Principles of bone regeneration Basic bone biology Bone modeling: sculpting and shaping Bone remodeling: bone multicellular unit

Bone healing

Bone healing

Bone healing

Biologic widthVertical dimension of the dento-gingival junction (soft tissue) The distance of bone to external environment

Clinical implication of biologic width

Violation of biological width

Gingival Inflammation Bone Resorption

Soft tissue - Implant Interface

Junctional epithelium Connective tissue attachment

A biological width exists around unloaded and loaded nonsubmerged onepart titanium implants.

Different types of inflammatory reactions in peri-implant soft tissues

Ericsson I, Persson LG, Berglundh T, Lindhe J, Marinello CP, Klinge B J Clin Periodontol 1995; 22:255-261

 Implant design Implant surface Time of implantation Bone grafting Future trend

Pathophysiology of edentulous jaws

Factors influencing edentulous bone loss

Trauma Extraction Infection Systemic diseases Mechanical and functional stress and overloading

Bone shape and bone quality classification according to Lekholm and Zarb (1985)

II

III

IV

Periodontal regeneration for implant therapy

Goal of regenerative therapy

Long term implant function Optimal esthetic result of the final reconstruction High efficacy and predictability

Patient- centered Treatment Plan

Evidenced-based approach in implant treatment

Guidelines to help the clinician make an intelligent decision randomizedcontrolledlong-term study

Pre-surgical planning

Patient evaluation
General health status

Motivation and compliance Oral hygiene status Financial situation

Extraoral examination

Smile line Facial harmony and profile Facial soft tissue appearance and consistency

Intraoral examination

Edentulous area evaluation

Natural teeth evaluation Esthetic needs Choice of the type of prosthetic rehabilitation

Accessory procedures

Orthodontics Periodontal surgery

Advanced concepts in implant therapy

Preservation of alveolar bone Site enhancement procedures Alveolar bone augmentation Soft tissue augmentation

Advanced concepts in implant therapy

Preservation of alveolar bone Site enhancement procedures Alveolar bone augmentation Soft tissue augmentation

Extraction socket preservation

Atraumatic tooth removal Do not reflect the interdental papilla, especially in the esthetic zone Controlling the process of tooth removal Eliminate all soft tissue fragments and pathology Stabilizing blood clot

Extraction socket preservation

Five-wall socket

with or without GBR

Four- and three-wall sockets with GBR Two- and one-wall sockets with GBR or monocortical block graft

Implant placement after tooth extraction Immediate implant placement bone grafting(+) membrane(+) soft tissue grafting(+) bone grafting(+) membrane(+) soft tissue grafting(+) bone grafting(+) membrane(+) soft tissue grafting(+)

Delayed implant placement < 2 months Staged implant placement 4 ~ 6 months

#36, 37 with advanced periodontitis

Advanced concepts in implant therapy

Preservation of alveolar bone Site enhancement procedures Alveolar bone augmentation Soft tissue augmentation

Implant site development the essence of the esthetic implant

Build up hard tissue and soft tissue for esthetic implant placement

Bone regeneration strategies

 Guided Bone Regeneration Procedures attempting to regenerate lost periodontal structure through differential tissue responses. GBR typically refers to ridge augmentation or bone regeneration procedures (AAP Glossary of Periodontal Terms; 2001 4th Edition)

GTR
Regeneration of periodontal tissue of natural teeth

GBR
Regeneration of supporting bone

Animal study Foxhound dog

2 month
Test defect
Control defect

Test defect

control defect

Membrane requirements for GBR of the alveolar ridge

Biocompatibility Cell occlusion Tissue integration Space-making Clinical manageability

Generation of new bone around titanium implant using a membrane technique: An experimental study in rabbits.
Dahlin 1989

Expanded polytetrafluoroethylene( e-PTFE)

Types of membranes
Non-resorbable membranes ePTFE Titanium-reinforced ePTFE Bioresorbable membranes Collagen membrane Polylactic acid (PLA) membrane Calcium sulfate

Bone-grafting Materials
Autogenous
Extraoral donor sites intraoral donor sites Allogenic DFDBA FDBA Alloplastic Xenograft

Successful GBR depends on:

Space Making Complete Soft Tissue Coverage Membrane Placement and Stabilization Sufficient Time to Regenerate Bone

Advanced concepts in implant therapy

Preservation of alveolar bone Site enhancement procedures Alveolar bone augmentation Soft tissue augmentation

Alveolar bone augmentation Horizontal ridge augmentation

Dehiscences and fenestrations Monocortical block graft Vertical ridge augmentation Distraction osteogenesis Ridge expansion(ridge splitting)  Maxillary sinus bone augmentation Lateral-wall technique Osteotome technique

Distraction Osteogenesis

Growth factor Platelet- rich plasma (PRP) PDGF, TGF-, EGF, VEGF

Block bone grafting

 Ridge expansion(ridge splitting)

Advanced concepts in implant therapy

Preservation of alveolar bone Site enhancement procedures Alveolar bone augmentation Soft tissue augmentation

Soft tissue management and esthetic considerations in implant therapy

 Soft tissue consideration

symmetric with contralateral tooth

1: gingival contour 2: interdental papilla 3: root prominence

2

3
1 2

Esthetic anterior maxilla classification The Palacci Ericsson Classification

Esthetic anterior maxilla classification The Palacci Ericsson Classification

Esthetic Dental Implant

Submucosal positioning of the implant shoulder adequate 3-D implant positioning long-term stability of esthetic and peri-implant soft tissue contours symmetry of clinical crown volumes between the implant site and contra-lateral teeth

Key factor is the bone height of adjacent teeth

Accurate axis is important to buccal plate preservation

Pre-surgical planning Timing of implant placement

Immediate Delayed Staged same time with extraction < 2 months > 2 months

Pre-surgical planning
Number of missing teeth
Single Multiple

Pre-surgical planning
Implant size selection
NP RP 3.3 mm 4.0 mm

WP 5.0 mm

Pre-surgical planning
Provisional selection
Removable partial denture Resin bonded bridge Immediate provisionalization

Loss of interdental papilla immediately after adjacent tooth extraction

Interdental papilla support using flangeless removable prosthesis

Support with pontic after atraumatic extraction

Pre-surgical planning
Periodontic and orthodontic consideration
Extraction using orthodontic extrusion

Clinical and radiographic evaluation of the papilla level adjacent to single-tooth dental implants. A retrospective study in the maxillary anterior region
Choquet 2001 52 papillae
Distance in mm from contact point to crest of bone 3 4 5 6 7 8 9 10 % papilla present 100 100 88 50 75 50 50 75

Pre-surgical planning
Implant positioning
Apico-coronal

Pre-surgical planning
Implant positioning
Mesio-distal

Facio-palatal

Single tooth gap

Implant Bone Dimension
Mesio-distal: 6-7 mm (RP), 1-1.5 mm away from adjacent teeth Apicocoronal: 3-4 mm apical from CEJ

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

Multiple, adjacent missing teeth

Multiple, adjacent missing teeth

as shallow as possible, as deep as necesssary

The effect of inter-implant distance on the 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 between adjacent implants
Tarnow, 2003

136 interimplant papillary heights 3.4 mm

Bone saucerization

Medical
Severe bone disease causing impaired bone healing immunologic disease medication with steroids uncontrolled diabetes mellitus irradiated bone others

Periodontal
Active periodontal disease History of refratory periodontitis Genetic disposition

Smoking habits
Light smoking (< 10 cigarettes per d ) Heavy smoking (> 10 cigarettes per d )

Oral hygiene/ compliance

Home care measured by gingival indices Personality, intellectual aspects

Occlusion
Bruxism

Peri-implant plastic surgery

Importance of keratinized mucosa

Prevents spread of inflammation to deep tissue May prevent recession of marginal gingiva Prevent excessive movement of free gingiva Resists damage from brushing

Nevins and coll.

Nevins and coll.

Nevins and coll.

Peri-implant plastic surgical techniques

Free graft Pedicled flaps epithelial / connective apical reposition coronal reposition rotated mixed grafts simple incision bilayer technique punch T- shaped

Predictable site development Subepithelial Connective Tissue Grafting

Subepithelial Connective Tissue Graft Histology

Epithelium Lamina propria (papillary layer) Lamina propria (reticular layer)

Submucosa

Donor site selection

Palate Tuberosity Edentulous areas

Advantages of CTG Predictable Esthetic Economic Enhancing gingival thickness

prevent post-op gingival recession enhance oral hygiene

Favorite donor site

How to harvest a CTG

Surgical Technique
A single-incision technique to harvest subepithelial connective tissue grafts from the palate
Markus B.HUZERLER, Dietmar Weng IJPRD 1999;19:279-287

Advantages of single-incision technique

Primary intention healing No post-operative stents Variable graft sizes are obtainable

Severe traumatic bony defect of a 19 y/o female

 Guided Bone Regeneration

A ridge concavity remained after GBR and implant restored

Soft tissue management

Subepithelial Connective Tissue Grafting

Subepithelial connective tissue grafting procedures

Papilla Regeneration Technique

Modified roll flap

2nd stage: Rolling technique to fold palatal connective tissue graft onto buccal side of implant