1 The Single Tooth Implant The Ultimate Aesthetic Challenge by Daniel G. Pompa, D.D.S. 2 Before starting any Maxillary Anterior Single Implant, or any case in the esthetic zone: TAKE A PHOTO OF YOUR PATIENT WITH A SMILE! 3 Preventative Dentistry Operative Dentistry Restorative Dentistry Reconstructive Dentistry 4 T 5 JADA: 2008 6 JADA: 2008 7 Distance from contact point to crest of bone (mm) 3 4 5 6 7 8 % of papilla filling in the embrasure 100 100 98 56 27 10 8 The Tissue is the Issue especially if the
8 The Tissue is the Issue especially if the Bone is Gone 9 Biologic Width and Mechanical Stress 10 Biology Rules... 11 12 Platform Matching 13 Now we know there is a Horizontal component to Biologic Width 14 2 mm 15 Implant/Implant: no synergistic biologicic contribution 16 17 18 Why Platform Switching.. The extent of bone resorption is related to both the texture of the surfaces of the implant and abutment at and the morphology of the implant-abutment junction (IAJ). A number of investigators have zeroed in on the proposed inflammatory cell infiltrate that forms a zone around the IAJ. Although not yet fully understood, the current theory of the benefit of platform switching is related to the physical repositioning of the IAJ away from the outer edge of the implant and the surrounding bone, thereby containing the inflammatory infiltrate within the width of the platform switch. It is the MAGNITUDE of the platform switch that really makes the difference in that when the difference is greater than 0.8mm there was a statistically significant difference in the level of bone maintenance. 19 Articles published.. Lazzara RJ, et al. Platform switching: A new concept in implant dentistry for controlling postoperative crestal bone levels. Int J Perio Rest Dent 2006;26:9-17 Ericsson I, et al. Different types of inflammatory reactions in peri-implant soft tissues. J Clin Perio 1995;22:255-261.
Ericsson I, et al. Different types of inflammatory reactions in peri-implant soft tissues. J Clin Perio 1995;22:255-261. Atieh MA, et al. Platform switching for marginal bone preservation around dental implants: A systematic review and meta-analysis. J Perio 2010;81:1350-1366. 20 Block MS, 2009; Nov. 67(11):89-107 J Oral Maxillofacial Surgery Prospective evaluation of immediate and delayed provisional single tooth restorations ------------------------------------- Buser D, 2014; 29: 186-215 Int J Oral Maxillofacial Implants Esthetic Outcomes following immediate and early implant placement in the anterior region - a systematic review 21 Recession as it relates to Implants 22 23 24 25 25 year follow up 26 15 Years Follow up 27 If no Buccal Plate - No Implant - Graft and Membrane If you have a good Buccal Plate: and want to maintain papillae igap i=immediate Implant G=Graft the Gap-Bio Oss - Xenograft A=Abutment-clean/sterile - Do not remove
G=Graft the Gap-Bio Oss - Xenograft A=Abutment-clean/sterile - Do not remove P=Provisional-Reestablish the contact point 28 Vertical Augmentation 29 30 31 32 Bone Morphogenic Protein BMP-2 33 BMP Mechanism of Action 34 BMP Mechanism of Action 35 36 37 38 39 40 41 42 43 44 45 46 47 48 Pre Op - Severe Atrophy 49 Meshwork to support bone graft with BMP 50 Post op with mesh
49 Meshwork to support bone graft with BMP 50 Post op with mesh 51 Pre/Post op CBCT Scan 52 Golden Rules 22.5 23.5 53 Guide pins placed 2+,2+,3+,2+,2+ = 11 3.75 X 4 = 15 11 + 15 = 26 mm 54 Post op 55 Pre-Treatment Planning measurements from the palate with immediate implants 56 57 58 59 60 If space is compromised or ridge is deficient place 3 of 4 with one Maxillary Central Multiple reasons -to create an ideal midline -to avoid the nasopalantine canal -for more ideal phonetics 61 Immediate Placement and Provisionalization 62 63 64
63 64 65 66 67 68 69 Using the actual Tooth as a Temp 70 71 72 73 74 75 Indications for Immediate Implant and/or Removal 76 Early indications for removal, especially if younger (over 20y/o) 77 78 79 80 81 Vertical Oblique Fracture 82 83 If no Buccal Plate.No implant - Graft and Membrane. If Buccal Plate: and want to maintain papillae.. igap i=immediate Implant
83 If no Buccal Plate.No implant - Graft and Membrane. 84 If Buccal Plate: and want to maintain papillae.. igap i=immediate Implant G=Graft the Gap- Bio Oss - Xenograft A=Abutment-clean/sterile - do not remove P=Provisional-reestablish the contact point 85 Alternative options? 86 How to maintain gingival margin 87 88 89 90 Today, that last case could have been perfect for orthodontic super-eruption 91 92 93 94 95 96 97 98 99 100 101 Use of CAT Scan Technology Cone Beam Computerized Tomography (CBCT)
101 Use of CAT Scan Technology Cone Beam Computerized Tomography (CBCT) 102 Today with CBCT analysis the risk/benefit prior to surgery clearly shows that periapical surgery is contraindicated 103 Here we can see that the option of an orthograde and/or retrograde approach is acceptable, AND that the surgical approach has minimal risk of post op paresthesia 104 The difference in width for the buccal plate at the 2nd Molar vs. the 1st Molar position is both clinically and radiographically significant 105 106 107 What will that look like on a Periapical Radiograph? 108 109 110 111 112 with 1 1/2 mm on either side 113 Maxillary Central Why?? 114 1) Due to widened M-D width possibly requiring a Porclein Laminate be placed on the opposite Central 115 2) To avoid placement of the medial side of the implant against the nasopalantine canal 116 Prosthetics 117 Provisional options 118 119
118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 With Clasps... 134 Without Clasps 135 136 137 When you see and recognize a mistake.. correct it immediatly, as you own it until it s fixed 138 139 140 141
139 140 141 142 143 144 145 146 As a general rule, if you create a contact point 5mm or less from the crestal bone you will insure a papilla will exist in that embrasure 147 Distance from contact point to crest of bone (mm) 3 4 5 6 7 8 % of papilla filling in the embrasure 100 100 98 56 27 10 148 149 150 Soft Tissue Management 151 152 153 154 155 156 Contact Point Index CPI Impression
156 Contact Point Index CPI Impression Impression to record and index the point of contact for maintenance of dental papallae 157 Soft Tissue Considerations 158 159 160 161 162 163 164 165 166 167 168 169 170 Live as if you were to die tomorrow. Learn as if you were to live forever Mahatma Gandhi 171 For the PDF of To Pull or Not to Pull or The Single Tooth Implant
171 For the PDF of 172 email: To Pull or Not to Pull or The Single Tooth Implant DPompaOMS@gmail.com or visit the website: NVDS.org