LES JOURNÉES DENTAIRES INTERNATIONALES DU QUÉBEC 2016

Transcription

1 LES JOURNÉES DENTAIRES INTERNATIONALES DU QUÉBEC 2016 PRESENTS SMILE LINE ESTHETICS WITH CROWNS, VENEERS AND IMPLANTS BY DOCTOR GEORGE PRIEST SUNDAY, MAY 29, 2016 FROM 8:30 A.M. TO 3:30 P.M. ROOM 513EF ENDORSEMENT AND RESPONSIBILITY DISCLAIMER The Journées dentaires internationales du Québec (JDIQ) and their sponsor, the Ordre des dentistes du Québec (ODQ), make every effort to present high calibre clinicians in their respective areas of expertise. The presentations of the speakers in no way imply endorsement of any opinion, product, technique or service presented in the courses. The JDIQ and the ODQ specifically disclaim responsibility for any material presented.

2 Smile line esthetics with crowns veneers and implants Part 2 Board Certified Prosthodontist Hilton Head Island, SC Veneer Preparation Technique Priest GF. Benefits of proximal extensions for ceramic veneer preparations. Pract Proced & Aesthet Dent 2004;16: Veneer technique sequence 1. Begin with facial depth cuts using wider burs for larger teeth 2. Blend depth cuts both mesiodistally and incisogingivally 3. Use narrow diameter diamond to prepare proximal surfaces 1

3 Veneer technique sequence 4. Prepare butt joint at right angle to palatal surface and round over to incisal edge, 1 ½ mm from anticipated final incisal edge 5. Smooth preparations with finishing diamonds of matching diameter Veneer technique sequence 6. Use smaller diameter diamonds for smaller teeth 7. On posterior teeth, extend chamfer ½ distance down palatal incline of buccal cusp 8. Verify preparation depth with clear matrix if needed Veneer technique sequence 9. Retract and refine margins and impress 10. Silicon matrix, bis-acryl resin and flowable composite resin for provisional veneers 11. Notch placed between central incisors in silicone matrix for orientation 2

4 Veneer technique sequence 12. Timer set 13. Inject bis-acryl and seat 14. Remove and let bench set for a few minutes 15. Fill voids with flowable composite resin of same shade Veneer technique sequence 16. Trim with Universal Polishing wheels, knife edge disks and double-sided diamond disk 17. Polish with slurry of wet pumice and rag wheel 18. Seat provisional restorations with self-etching cement, like RelyX Unicem Removal of provisional veneers Hemostat against gingival margin and grasp incisal edge Torque incisogingivally Remove remnants with curette Clean with sanding strip and fluoride free prophy paste 3

5 Veneer cementation Try all veneers in to examine relative fit, esthetics and confirm patient approval Try in veneer and adjacent mesial veneer Check and adjust contact areas Reconfirm complete seating from gingival and palatal aspects Veneer cementation Remove excess with brush and floss 2 second light cure, remove excess with scaler and floss Complete cure, clean again with scaler and metal sanding matrix Check and refine occlusion and finish margins Veneer cement Empress veneers on 20 bovine teeth Divided into light cure and dual cure No differences found between them in color change Both demonstrated perceptible, but clinically insignificant color changes with aging Magalhães APR et al. Influence of activation mode of resin cement on the shade of porcelain veneers. J Prosthodont 2014;23:

6 Veneer seating sequence Seat one veneer at a time Work from distal to mesial Verify fit, then bond distal veneer Contact area serves as guide Spot cure while holding adjacent veneer in place Recheck fit and contacts before proceeding to next veneer Finishing proximal margins Open proximal areas conservatively when possible: Finishing then done on palatal aspect Where contacts closed, open slightly with metal sanding strip: More accurate die separation Make well define margins: chamfer or butt joint: Result is better fitting and tighter margins Finish with think, fine, metal sanding strip only Cord retraction is procedure and biotype specific Crowns Two cords for thicker biotype, one for thin Thinner biotype retracts more apically than thick May leave the single cord when impressing Thinner cords for thinner biotype Two cords when hemorrhage control an issue Cord always need with subgingival restorations 5

7 Cord retraction is procedure and biotype specific Veneers If little or no color change, retraction may be unnecessary Rarely retract for lower anterior teeth One continuous cord, usually lesser diameter than for crown Thinner cords for thinner biotypes Cord versus chemical retraction 1-2 mm subgingival preparation: Cord with no aluminum chloride Cord with aluminum chloride Traxodent with retraction cap Cord and Traxodent cap Except nonimpregnated group, all groups comparable Traxodent much easier Acar Ö, et al. A clinical comparison of cordless and conventional displacement systems regarding clinical performance and impression quality. J Prosthet Dent 2014;111: Feldspathic vs. glass ceramic Estimated veneer survival 89% in 9 year follow-up Estimated survival of glass-ceramic veneers, 94% Estimated survival of feldspathic porcelain veneers, 87% Morimoto S et al. Main clinical outcomes of feldspathic porcelain and glass-ceramic veneers: a systematic review and metaanalysis of survival and complication rates. Int J Prosthodont 2016;29:

8 A consonant smile line may be the most critical factor in smile esthetics Conclusions: Ceramic veneers Veneers are an integral part of an esthetically focused restorative practice Preparations must be conservative Progressive veneer preparation design offers significant advantages over conventional techniques Provisional restorations are key in understanding patient expectations Lithium disilicate offers esthetic and functional advantages Intraoral scanning provides clinical advantages Agenda Esthetic integration of dental implants 7

9 Implant Esthetic Hierarchy Priest GF. The art of collaboration for predictable aesthetic results. Pract Procedures & Aesthet Dent 2005;17(10, Suppl, Perio/Implant Showcase):14. Rule of 3x3 PIE 1. The implant platform should be located 3 mm apical to the zenith of the predetermined facialgingival margin of the planned restoration 2. The center of the implant should be placed at a distance of at least 3 mm palatal to the anticipated facial margin 3. The implant should emerge through the palatal incisal edge (PIE) of the ensuing crown position Priest GF. The esthetic challenge of adjacent implants. J Oral Maxillofac Surgery 2007 (Suppl.): 2007:65(7): Anticipated free gingival margin more important than root position in implant placement Make surgical guide with tooth replacement at planned gingival level; work backwards from here 8

10 Risk factors for facial recession Thin tissue biotype Facial malposition of implant Thin or damaged facial bone wall Grütter L, Belser UC. Implant loading protocols for the partially edentulous esthetic zone. Int J Oral Maxillofac Implant 2009:24(suppl): The umbrella effect Magne P, Magne M, Belser U. The esthetic width in fixed prosthodontics. J Prosthodont 1999;8(2): Refer to separate handout for implant provisional restoration technique 9

11 Advantages of Polymer Provisional Components Less costly than metal alloy temporary cylinders Easier and quicker to prepare Warmer gingival tones Natural appearance to provisional restoration No heat generation or metal filings Can be prepared directly on implant Subtle sulcular modifications Priest, GF. Esthetic potential of single implant provisional restorations. J Esthet Restorative Dent 2006;18(6): Immediate extraction and provisional restoration 40 patients and 43 implants in extraction sites Provisional restorations within 1 week After 1 year, 78% of papillae completely preserved Valentini P, Abensur D, Albertini JF, Rocchesani M. Immediate provisionalization of single extraction-site implants in the esthetic zone: a clinical evaluation. Int J Periodontics Restorative Dent 2010;30:

12 Value of implant provisional Based on the reviewed studies, the literature does not identify strong scientific evidence that esthetic outcomes are influenced positively or negatively by utilization of a provisional prosthesis A provisional prosthesis remains strongly recommended in order to test the planned final prosthesis, to facilitate maturation of healing tissue, and for patient convenience Martin WC et al. The influence of restorative procedures on esthetic outcomes in implant dentistry: a systematic review. Int J Oral Maxillofac Implants 2014;29 (suppl): Recommendations for immediate implant restoration Immediate restoration should be considered when bone volume at site is close to ideal 40 Ncm or more initial seating torque Screw-retained provisional restoration recommended, out of functional occlusal contacts Restoration not removed during healing period of 6 weeks modified from: Grütter L, Belser UC. Implant loading protocols for the partially edentulous esthetic zone. Int J Oral Maxillofac Implants 2009;24(suppl): Recommendations for immediate implant restoration Soft diet for 8 weeks No brushing in area for a few days, then soft brushing for 2 weeks. Flossing gently after 1 week Chlorhexidine gluconate, 60 second rinse at least once a day, preferably at bedtime, until completed 11

13 Torque Value Smile line esthetics with crowns and veneers Why screw-retained provisional restorations for soft tissue development? Easier to remove one component during adjustment rather than abutment and crown Emergence profile begins at implant level with screwretained restoration Difficult to get smooth emergence profile from prepared margin to crown with cement retained No cement margin to be concerned with using screwretained Gently expand tissue by slowly tightening screw Single implants inserted in fresh extraction sockets and immediately provisionalized Bone-to-implant gap grafted with bovine bone After 3 months, ceramic crowns placed. No statistical differences found between baseline and 1 year Cardaropoli D, et al. Soft tissue contour changes at immediate postextraction single-tooth implants with immediate restorations: a 12-month prospective cohort study. Int J Periodontics Restorative Dent 2015;35: Primary and Secondary Stability Time (weeks) 12

14 Soft tissue impression technique Remove screw-retained provisional restoration Attach implant analog Seat provisional and analog in silicone putty at least 1/3 way up the crown Unscrew provisional after silicone sets Soft tissue impression technique Attach pick-up impression coping to analog in matrix Inject flowable composite resin into void left by provisional, capturing sides of impression coping Remove impression coping from matrix and seat on implant Make open-tray implant impression Ceramic screw-retained crowns Esthetics of a ceramic restoration Potential of residual cement eliminated Access opening easily masked Deeper ceramic margin accommodates recession One margin instead of two Predictable retrievability Open contacts more easily corrected Particularly useful with shallow sulcus or thin biotype 13

15 Open contacts and dental implants Mesial drift occurs throughout life Because implants are ankylosed, they remain in place while teeth mesial to them drift, therefore open contacts, particularly on mesial, sometimes occurs Greenstein G, Carpentieri J, Cavallaro J. Open contacts adjacent to dental implant restorations. J Amer Dent Assoc 2016;147: Ceramic screw-retained crowns Electronic search from Although no statistical difference was found between cement- and screw-retained reconstructions for survival or failure rates, screw-retained reconstructions exhibited fewer technical and biologic complications overall. Wittneben J-G, et al. Clinical performance of screwversus cement-retained fixed implant-supported reconstructions a systematic review. Int J Oral Maxillofac Implants 2014;29 (Suppl): Implant placement and soft tissue levels Greater than 3 mm inter-implant spacing required to minimize interseptal bone loss Tarnow DP, Cho SC, Wallace SS. The effect of interimplant distance on the height of the inter-implant bone crest. J eperiodontol 2000;71:

16 The rule of 3x3x3 PIE: Adjacent implants 1. The platforms of the implants should be located 3 mm apical to the zeniths of the predetermined facial-gingival margins of the planned restorations 2. The centers of the implants should be placed at a distance of at least 3 mm palatal to the anticipated facial margins Priest GF. The esthetic challenge of adjacent implants. J Oral Maxillofac Surgery 2007:65(7) Supplement 1, Practical Advances in Implant Dentistry: The rule of 3x3x3 PIE: Adjacent implants 3. At least 3 mm interimplant spacing is required between adjacent implant platforms 4. The implants should emerge through the palatal incisal edges (PIE) of the ensuing crown positions Must have skilled technician to achieve optimal contours without provisional 15

17 Restorative potential between adjacent implants Preservation of crestal and interseptal bone Optimal support of available soft tissue with crown and abutment contours Long contact areas Elimination of black triangles Fluorescent ceramics on proximal surfaces of restorations Asymmetric papilla levels Altered images of women s smiles rated by general dentists, orthodontist and laypersons Unilateral reduction of papillary height rated less attractive than bilateral alteration by dentists Laypersons did not find discrepancies of 2 mm unattractive Kokich VO et al. Perceptions of dental professionals and laypersons to altered dental esthetics: Asymmetric and symmetric situations. Am J Ortho Dentofacial Orthop 2006;130: Implant timing Failing teeth are to be placed alternatively to ensure periimplant tissue stability Kan JYK, Rungcharassaeng K. Interimplant papilla preservation in the esthetic zone: A report of six consecutive cases. Int J Periodontics Restorative Dent 2003;23:

18 Splinting versus nonsplinting U. Padova, Italy 132 implants placed in 44 patients At 10 years, 0.1 mm more bone loss in non-splinted group not considered clinically meaningful Vigolo P, et al. Clinical evaluation of marginal bone level change around multiple adjacent implants restored with splinted and nonsplinted restorations: a 10-year randomized controlled trial. Int J Oral Maxillofac Implants 2015;30: Zirconia core fdp Patient charts from , mean followup 21 months 26 complete-arch implant supported zirconia framework prostheses 100% survival of all 154 implants No framework fractures Venezia P, et al. Retrospective analysis of 26 complete-arch implantsupported monolithic zirconia prostheses with feldspathic veneering limited to facial surface. J Prosthet Dent 2015;114: Scanning and articulation/occlusion Occlusion captured digitally No material interspersed between teeth, no bubbles and no distortion Face bow and occlusal record may be needed if change in OVD Virtual face bow programs available Articulators have added much precision and engineering to a relatively sloppy joint (i.e. Bennett shift) 17

19 Scanning and articulation/occlusion If occlusal schemes of canine guidance and group function so important, why is denture occlusion so different Do orthodontists plan for precise articulation when aligning teeth Virtual occlusal record Direct acquisition of the position of the maxillary and mandibular casts considered more accurate than the positions obtained by using an occlusal record because material introduced between arches could change their relative position Solabererieta E, et al. Comparison of a conventional and virtual occlusal record. J Prosthet Dent 2015;115: Lab protocols for intraoral scanning: Full contour Zirconia crowns Complete virtual design and manufacture Model needed only for verification Lithium disilicate crowns Virtual design and computer milled; e.max CAD or waxing milled and pressed; e.max Press E.max CAD does not provide detail of e.max Press (1:1 milling) Model only need for verification 18

20 Lab protocols for intraoral scanning: Layered Layered zirconia Virtual design and computer milled coping Model needed for layering Layered lithium disilicate for crowns and veneers Virtual design and computer milled coping; e.max CAD Virtual design and waxed coping computer milled; e.max Press Model needed for layering Conclusions Optimal implant esthetic outcomes are a culmination of many subtleties in techniques and materials The esthetic potential is primarily determined at the surgical stage, by the site and implant placement Most implants are placed in the esthetic zone and continuity with teeth, crowns and veneers is critical Overall objective in esthetic rehabilitation is seamless integration of all treatment modalities For a listing of the products and materials shown in this presentation, visit our website, under menu heading For Dentists/Recommendations 19

21 Implant & Esthetic Dental Presentations Visit 20