Don t Gamble in the Anterior Zone

Transcription

1 ACCREDITATION ESSENTIALS Don t Gmle in the Anterior Zone Executing Successful Peri-Implnt Esthetics Bone resorption following mxillry nterior tooth extrction is common nd often compromises gingivl tissue levels for implnt restortion. Pul E. VreNon, DDS, MAGD Astrct Executing successful esthetic implnt-supported restortion for n nterior tooth is one of the most chllenging procedures in cosmetic dentistry, requiring n interdisciplinry pproch etween the surgeon, restortive dentist, nd lortory technicin. To chieve the optiml predictle clinicl outcome, n understnding of risk fctors is essentil, from periodontl surgicl procedures to the reproduction of nturl tooth chrcteristics on the implnt. The gol of this rticle is to enhnce the clinicin s knowledge of the risks nd techniques tht will ffect the restortion s success. Key Words: implnt-supported restortion, implnt plcement, custom utment, implnt crown, esthetic zone, Accredittion Cse Type III 28 Winter 2016 Volume 31 Numer 4

2 VreNon Introduction During the lst decde, implnts hve ecome predictle tretment modlity for replcing missing or nonrestorle teeth with high clinicl success nd survivl rte. 1,2 In the esthetic zone, there re severl fundmentl components tht dictte the definitive outcome; these include the estlishment of periodontl soft nd hrd tissue tht will thoroughly support the implnt crown nd the reproduction of nturl tooth chrcteristics on the implnt utment. Bone resorption following mxillry nterior tooth extrction is common nd often compromises gingivl tissue levels for implnt restortion. 3,4 An implnt tht is osseointegrted does not lwys trnslte into esthetic success. Understnding the five dignostic keys of peri-implnt esthetics reltive tooth position, form of the periodontium, iotype of the periodontium, tooth shpe, nd position of osseous crest height will enle the clinicin to develop tretment options nd clinicl procedures to more predictly chieve the desired therpeutic outcome. 3 Cse Presenttion A 31-yer-old femle presented desiring to definitively replce her missing left mxillry centrl incisor. Her dentl history reveled tht she hd lost tooth #9 two yers previously due to trumtic ccident. She reported tht she ws in excellent helth, nd her medicl history ws unremrkle. Clinicl findings in the mxillry nterior edentulous re included loclized moderte horizontl one loss, loclized moderte verticl one defects, moderte loss of gingivl ttchment, nd moderte loss of lil one. Moderte horizontl one loss ws oserved in the rdiogrphic exmintion on the edentulous re (Figs 1-1c). A tretment option ws presented tht included three-unit fixed restortion. Becuse this would require tooth preprtion on the djcent teeth, the ptient declined this option. Insted, she ccepted pln to hve single tooth implnt tht involved surgiclly stged tretment pproch with soft tissue ugmenttion to mximize n esthetic nd functionl tretment outcome. c Figures 1-1c: Clinicl imges, ll t initil presenttion: () Fcil view. () Occlusl view. (c) Rdiogrph of nterior mxillry re. Journl of Cosmetic Dentistry 29

3 ACCREDITATION ESSENTIALS Figures 2 & 2: Clinicl photogrphs, fcil view, where soft tissue evlution ws completed: () Before. () After. Note tht lck of horizontl nd verticl height is evident. Tretment A comprehensive orl exmintion ws completed to estlish predictility in the periodontl soft tissue nd determine the est mode of ction (Figs 2 & 2). When determining the need for surgicl ugmenttion, the ptient s smile is n importnt fctor to consider. The trnsition from the restortive mrgin to the mucos or the rtificil ppille is visile in ptients with high or verge smile lines, so ttempts to ugment the height of the tissues cn e eneficil. 5 Thin iotypes nd sites with no kertinized tissue hve demonstrted more recession thn thick iotypes, 6-8 nd the ddition of soft tissue grft my e eneficil in providing improved esthetic outcomes. Severl studies hve utilized freeze-dried cellulr derml mtrix llogrft s n lterntive to utogenous-free gingivl grfts to chieve incresed ttchment of kertinized gingiv round nturl teeth or implnts, root coverge, nd for ridge preservtion procedures. 9,10 Preliminry impressions were mde with n irreversile hydrocolloid impression mteril (Jeltrte Chrom, Dentsply Int.; York, PA). Dignostic csts for oth the mxillry nd mndiulr rches were fricted with Type III dentl stone (Microstone Golden Stone, Hereus Kulzer; South Bend, IN) nd were mounted in mximl intercuspl position on semidjustle rticultor (Pndent; Pndent Corp.; Colton, CA) fter Kois Dento-Fcil Anlyzer (Pndent) ws used. A dignostic nlysis of the occlusl plne nd dignostic wx-up were completed. A surgicl templte ws then fricted with cler utopolymerizing polymethyl methcrylte resin (Teets Cold Cure Denture Mteril, Co-Orl-Ite Dentl Mfg Co.; Dimond Springs, CA). A surgicl guide, creted y the restortive dentist in collortion with the surgeon, ws used to plce the 4.6 x 12 mm implnt with 3.5-mm pltform (Tpered Plus, BioHorizons; Birminghm, AL) in proper position with cover screws nd sumerged. To compenste for the horizontl nd verticl ridge resorption, freeze-dried cellulr derml mtrix (AlloDerm GBR, BioHorizons) ws plced to enhnce the soft tissue to crete n idel gingivl contour nd emergence profile. The implnt remined in plce for three months to llow osseointegrtion. During this period, the ptient wore n interim prtil removle dentl prosthesis relieved in the ridge re to void ny tissue contct t the surgicl site. Severl options of interim prtil removle dentl prostheses re ville (Figs 3-3h) tht llow enhnced ptient esthetics nd functionlity throughout tretment. A heling period of three months is dequte if the implnt ws plced in good-qulity one. 30 Winter 2016 Volume 31 Numer 4

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5 Achievement Deserves recognition Nominte Your Collegues for n Evy! The AACD wnts to recognize outstnding individuls who hve mde significnt contriutions to the field of cosmetic dentistry or to the Acdemy. These individuls re dvncing the AACD s mission nd mking n impct, nd YOU know who they re. For everything they ve lredy done, let s let them know how much it hs ment. Nominte your exceptionl collegue(s) for n Evy wrd, so their ccomplishments, dediction, nd pssion cn e recognized nd pprecited during the Celertion of Excellence Gl t AACD For more informtion, visit Akir Send, Andrew Co, DDS Arthur Chl, DDS, J. Olson, DDS, FAACD FAACD Bruce Crispin, DDS, DDS, AAACD Byoung Suh Cry DDS Andy Hites AAACD Brdley Brin LeSge, DDS, AAACD Bruce Singer, Crlos Pug Behle, DDS, FAACD Chrles Cox Chrles Vittitow, Jr., DMD, AAACD Clude Seier, MDT Corky Willhite, DDS, FAACD Dn Fischer, DDS Dniel Mterdomini, CDT Dniel Myed, DDS, FAACD Dvid Hornrook, DDS, Den Lodding, DDS, AAACD AAACD Dentl XP Din Jckson Terry, DDS, AAACD Drio Adolfi, Edwrd Lowe, DMD, AAACD DuCoin, DMD Frnk Sper, DDS Gry Drke, DDS, AAACD Gry George Hites Gordon Christensen, DDS Ivoclr Vivident (for their work Jck Kmmer, DDS, FAACD Jmes Hstings, DDS, AAACD Jeff Morley, DDS, Jeffrey Shpiro, DDS, AAACD Jerry Bellen, Joe Crrick, DDS, FAACD John Clmi, DMD John Sullivn, DDS, AAACD John FAACD Jun Olivier, CDT K. Willim Kenneth Glick, DDS, FAACD Lrry AAACD Lur Kelly, CDT, AAACD Lee Lorin Berlnd, DDS, FAACD Mrilyn DDS, AAACD Mrty Zse, DMD, AAACD Behle Michel Ap, DDS Michel Miller, Mickey Bernstein, DDS, AAACD Mike Nthniel Hill, DDS Newton Fhl Jr., DDS, FAACD Normn Feigenum, Peter Auster, DMD Peter Dwson, Attipoe, DDS Rndy Mitchmore, Roert Nixon, DMD, FAACD DDS, AAACD Ronld Goldstein, Sndr Roth Scott Finly, CDA, CDD Sidney SUNY t Bufflo FAACD Tes Berry, DDS II, DDS, Yrovesky, Vincent Lierto, Cohen, FAACD Dennis Wells, DDS, Giesler, DDS Dougls DDS & Muro Frdeni, DDS Elizeth Bkemn, DDS, FAACD Frncis Frederick Aeles, DDS Frederick McIntyre, DDS Rdz, DDS George Freedmn, DDS, FAACD DDS Hugh Flx, DDS, AAACD Irwin Smigel, with e-mx) J. Fred Arnold III, DMD, FAACD Dunn, DDS Jmes Elis, DDS, AAACD Jmes FAACD Jeffrey Golu-Evns, DDS, FAACD DDS, AAACD Jimmy Eunk, DDS, FAACD DMD John Derngo, DDS, FAACD John Kois, Weston, DDS, FAACD Jonthn Schrf, DMD, Mopper, DDS, FAACD Ken Bnks, DDS, AAACD Addleson, DDS, FAACD Lrry Rosenthl, DDS, Culp, CDT, AAACD Lorenzo Vnini, DDS, MD Clvo, DDS, AAACD Mrk Willes Mrtin Prger, Mshiro Kuwt Murice Slm, DMD Meg DDS, FAACD Michel Sesemnn, DDS, FAACD Mlone, DDS, AAACD Nthn Blitz, DDS, AAACD DDS Nichols Dvis, DDS, FAACD Nils Olson, DDS, FAACD Pul Lndmn, DDS, FAACD DDS Philip Kemp, DDS, AAACD Quincy DDS Ren Vky, DDS, AAACD Rick Simeone Roger Levin, DDS, AAACD Ron Goodlin, DDS Roy Hmmond, DDS DDS, FAACD Shnnon Brinker, Mrkowitz, DDS, FAACD Susn Hollr, DDS, Reeves, DDS Thoms Thoms Nors, AAACD Uri CDT DDS Willim DDS, AAACD Willim Dorfmn, DDS, FAACD Willim J. Rowe, Jr., DDS, AAACD Wynn Okud, DMD, FAACD AACD Executive Office Stff

6 VreNon c d e f g h Figures 3-3h: During implnt uncovering, severl types of interim prtil removle dentl prostheses re ville for the ptient: (,) Essix retiner. (c,d) Hwley retiner. (e,f) Sty plte. (g,h) Smile trnsition. Journl of Cosmetic Dentistry 33

7 Reproduction of Nturl Tooth Chrcteristics Figure 4: Clinicl photogrph, fcil view, fter three months of heling. Note tht the horizontl nd verticl dimensions of the ridge pper significntly improved. After three months of heling, the horizontl nd verticl dimensions of the ridge showed significnt improvement (Fig 4). A heling period of three months is dequte if the implnt ws plced in good-qulity one. 11 A peripicl rdiogrph ws evluted for ny one loss (Fig 5). The heling utment ws then removed nd n impression coping ws inserted on the implnt (Fig 5). The definitive polyether impression (Impregum, 3M ESPE; St. Pul, MN) ws mde on the impression nlog with closed-try impression technique efore determining the shde color for the definitive restortion (Figs 6 & 6). Next, the gingivl contour ws poured with elstomeric mteril (Softissue Moulge, Kerr Dentl Lortory; Ornge, CA) round the implnt nlog, nd definitive cst with Type IV dentl stone (GC Fujirock EP, GC Americ; Alsip, IL) ws fricted. Figures 5 & 5: Rdiogrphs of: () Implnt fter three months of plcement with cover screw nd sumerged. () Impression coping on implnt to verify tht it is completely seted efore impression for custom utment nd implnt crown. Figures 6 & 6: Shde communiction: () Hue nd chrom (color). () Vlue (lck nd white). 34 Winter 2016 Volume 31 Numer 4

8 VreNon To develop definitive soft tissue rchitecture round the implnt with correct ntomicl emergence profile, it is essentil to understnd the esthetic gingivl components. These components include gingivl horizontl symmetry from cnine to cnine nd scllop form tht follows the interproximl emrsures. Generlly, the fcil level of the gingivl tissue mimics the rchitecture of the underlying osseous crest. Predicting the level of fcil tissue dimension cn e ccomplished with 3.0 mm referenced from the osseous crest nd with 4.0 mm mesured from the free gingivl mrgin to the osseous crest t the interproximl osseous scllop. 12 A definitive crown with reltively nrrow ntomicl emergence profile my result in soft tissue complictions due to unsupported soft tissue components. As result, it my trp plque nd cn e difficult for the ptient to mintin hygieniclly (Figs 7-7h). In this cse, when plcing the ntomiclly correct utment, the tissue ws impeding the set of the utment on the pltform. To preserve the fcil tissue, lingul relesing incision ws plced cliniclly to llow seting. Susequently, n ll-cermic zirconi custom utment (Atlntis, Dentsply Int.) ws fricted nd lithium disilicte crown (IPS e.mx, Ivoclr Vivdent; Amherst, NY) ws het-pressed to fit with the utment, using cut-ck lyering technique. The utment screw ws torqued nd tightened to 35 Ncm nd the hole ws filled with wrm gutt perch (Otur Sprtn Endodontics; Algonquin, IL). The crown ws cemented with elstomeric resin cement (Premier Implnt Cement, Premier Dentl; Plymouth Meeting, PA) nd excess cement ws removed with #12 lde. The occlusion ws then refined using 200-µ rticulting pper (Busch Dentl; Nshu, NH) efore the crown ws polished with polishing pste (DiShine, VH Technologies; Lynnwood, WA). The ptient expressed her stisfction with the esthetic nd functionl outcomes. There were no mechnicl complictions t the two-month follow-up ppointment (Figs 8-8c). c e g Figures 7-7h: Definitive implnt utment: (-d) Indequte displys nrrow ntomicl emergence profile. (e-h) Adequte displys norml ntomicl emergence profile tht supports soft tissue rchitecture. Note tht the occlusl view shows the lingul relesing incision. d f h Journl of Cosmetic Dentistry 35

9 ACCREDITATION ESSENTIALS c Figures 8-8c: Definitive implnt-supported restortion for the nterior tooth t the two-month follow-up ppointment. 36 Winter 2016 Volume 31 Numer 4

10 VreNon Summry This cse report descried the correction of difficult clinicl sitution presenting loss of horizontl nd verticl ridge volume. By evluting nd estlishing the periodontl soft tissue from oth surgicl nd restortive perspective, stisfctory nd enhnced predictle clinicl outcome ws chieved. Acknowledgment The uthor thnks Dr. Curry Levitt (Red Rock Periodontics; Ls Vegs, NV) for his surgicl procedure on implnt plcement; nd Mr. Sm Lee (Cliforni Smile Dentl Studio; Grden, CA) for his lortory work on the definitive restortion. References 1. Bidr AS, Rungrungnunt P. Clinicl outcomes of implnt utments in the nterior region: systemtic review. J Esthet Restor Dent Jun;25(3): Ch HS, Kim YS, Jeon JH, Lee JH. Cumultive survivl rte nd compliction rtes of single-tooth implnt; focused on the coronl frcture of fixture in the internl connection implnt. J Orl Rehil Aug;40(8): Kois JC. Predictle single tooth peri-implnt esthetics: five dignostic keys. Compend Contin Educ Dent Mr; 22(3): Kn JY, Rungchrsseng K, Lozd JL, Zimmermn G. Fcil gingivl tissue stility following immedite plcement nd provisionliztion of mxillry nterior single implnts: 2- to 8-yer follow-up. Int J Orl Mxillofc Implnts Jn- Fe;26(1): Henderson RD, Greenwell H, Drisko C, Regennitter FJ, Lm JW, Mehluer MJ, Goldsmith LJ, Reitski G. Predictle multiple site root coverge using n cellulr derml mtrix llogrft. J Periodontol My;72(5): Fowler EB, Breult LG, Reitski G. Ridge preservtion utilizing n cellulr derml llogrft nd deminerlized freeze-dried one llogrft: Prt I. A report of 2 cses. J Periodontol Aug;71(8): Buser D, Mericske-Stern R, Bernrd JP, Behneke A, Behneke N, Hirt HP, Belser UC, Lng NP. Long-term evlution of non-sumerged ITI implnts. Clin Orl Implnts Res Jun;8(3): Phillips K, Kois JC. Aesthetic peri-implnt site development. The restortive connection. Dent Clin North Am Jn;42(1): jcd To develop definitive soft tissue rchitecture round the implnt with correct ntomicl emergence profile, it is essentil to understnd the esthetic gingivl components. 4. Kois JC, Kn JY. Predictle peri-implnt gingivl esthetics: surgicl nd prosthodontic rtionles. Prct Proced Aesthet Dent Nov-Dec;13(9): Hochmn MN, Chu SJ, Trnow DP. Mxillry nterior ppill disply during smiling: clinicl study of the interdentl smile line. Int J Periodontics Restortive Dent Aug;32(4): Dr. VreNon is clinicl instructor t the Kois Center in Settle, Wshington. He owns privte prctice in Ls Vegs, Nevd. 6. Bengzi F, Wennström JL, Lekholm U. Recession of the soft tissue mrgin t orl implnts. A 2-yer longitudinl prospective study. Clin Orl Implnts Res Dec;7(4): Disclosure: The uthor did not report ny disclosures. 7. Chen ST, Buser D. Clinicl nd esthetic outcomes of implnts plced in postextrction sites. Int J Orl Mxillofc Implnts. 2009;24 Suppl: Journl of Cosmetic Dentistry 37

11 Exminers Commentry Replicting Nture with Dentl Implnt Jmes H. Peyton, DDS, FAACD Cse selection is very importnt; it is essentil to hve sufficient soft tissue nd one ville in the edentulous spce. Cse Type III consists of restoring mxillry nterior tooth with either fixed ridge or dentl implnt. For the implnt cse, the preopertive x-rys nd photogrphic views must show the edentulous spce or the filing tooth prior to implnt plcement. 1 Cse selection is very importnt; it is essentil to hve sufficient soft tissue nd one ville in the edentulous spce. When there is deficiency in the edentulous ridge, ugmenttion must e done (connective tissue or one grft). This my tke long time to hel nd dd significnt cost to the cse. It is lso importnt to hve good mentor, preferly n Accredited AACD memer who is n Accredittion Exminer. Tht wy the memer in the process (MIP) will know whether they hve cse tht is pproprite for Accredittion. It is importnt to hve excellent communiction with the lortory technicin, periodontist (implnt surgeon), orthodontist (if necessry), nd the ptient. The MIP should e prepred y tking study models, doing dignostic wx-up, creting the necessry surgicl stent, mking temporry implnt (to crete the idel tissue contour), nd ny other steps needed to ensure the est possile result. 2,3 When selecting the fixed ridge option, it is very difficult to crete pontic site tht ppers to emerge from the gingiv nturlly. It is helpful to fricte temporries tht re shped in the sme contour tht is plnned for the finl restortion (i.e., ovte pontic). 4 The second mjor concern is the size of the connectors nd how well the lortory technicin cn mke this re pper s if it were nturl tooth spce interproximlly. It is importnt not to mke the connectors too long. Choosing n implnt restortion for Cse Type III minimizes these concerns. 38 Winter 2016 Volume 31 Numer 4

12 Peyton Dr. Pul VreNon did n excellent jo of restoring missing tooth #9 with dentl implnt (Figs 1 & 2). The min focus of the Accredittion Exminers on Cse Type III is to evlute how the MIP hndled the soft tissue in the edentulous site. Dr. VreNon did very nice jo with the soft tissue round the implnt crown. There is good emergence profile round the restortion nd the gingivl crest of #8 mtches the implnt crown in the #9 site. As with lmost ll restortive cses, this cse ws not perfect nd the Accredittion Exminers noted fults (see sider). These were judged to e minor fults (-2 deduction). Two of the exminers commented tht the distl of #9 hd lunted/constricted emrsure. The Accredittion process provides frmework to chieve excellence in cosmetic nd restortive dentistry. Once this level of excellence is chieved, the dentist hs this skill nd knowledge for the rest of their creer. This will e tremendous enefit not only to the dentist, ut lso to ll their ptients. Figure 1: Preopertive retrcted 2:1 view showing the edentulous site t #9. References 1. Americn Acdemy of Cosmetic Dentistry (AACD). A guide to Accredittion criteri. Mdison (WI): AACD; Chn D. Emulting nture with dentl implnts. J Cosmetic Dent Winter;27(4): Schoenum TR, Swift EJ Jr. Autment emergence contours for single-unit implnts. J Esthet Restor Dent Jn-Fe;27(1): Peyton JH. Evlute, study, nd select. J Cosmetic Dent Winter;27(4): Figure 2: Postopertive retrcted 2:1 view demonstrting nice jo in hndling the soft tissue. The exminers found the following fults: Criterion #53: Is the color (hue, vlue, chrom) selection pproprite/nturl, not monochromtic? All five exminers stted tht the vlue of #9 ws slightly lower thn the djcent teeth. Criterion #89: Are the cervicl emrsures proper? No drk tringles? All five exminers stted tht there ws drk tringle etween #8 nd #9. Dr. Peyton is n AACD Accredited Fellow nd hs een n AACD Accredittion Exminer since A prt-time instructor t the UCLA School of Dentistry, he prctices in Bkersfield, Cliforni. Disclosure: The uthor did not report ny disclosures. Journl of Cosmetic Dentistry 39