Nicholas Caplanis DMD MS 6/13/2012

Transcription

1 Considerations In The Esthetic Zone Nick Caplanis DMD MS Private Practice Periodontics and Implant Surgery Mission Viejo, California Assistant Professor Loma Linda University Anatomic concerns Procedures to improve restorative outcomes Periodontal and Peri-implant disease management Anatomic concerns Periodontal biotype Biologic width Bone crest position Gingival display and smile line Periodontal Characteristics in Individuals with Varying form of the Upper Central Incisor 113 subjects in long term periodontal surgery study Olsson M, Lindhe J. J Clin Periodontol 1991;18(1): Thin biotypes had more buccal recession Thick Short square teeth Thick robust gingiva Wide blunted papilla Resistant to recession Periodontal Biotype Thin Long Tapered teeth Thin friable gingiva Long pointy papilla Susceptible to recession Dimensions of the Dentogingival Junction in Humans Gingival sulcus 0.69mm Junctional epithelial attachment 0.97mm Biologic Width Connective tissue attachment 1.07mm Garguilo AW, Wentz FM, Orban B. J Perio 1961;32: T O Sulcus O T H JE CT Periodontal considerations in restorative and implant therapy Subgingival margins should be considered a compromise 2-3mm of healthy, natural, supra-alveolar tooth needed for attachment Margins should not be placed deeper than 0.5mm Goldberg PV, Higginbottom FL, Wilson TG. Periodontol ;25: Tissue reactions around artificial crowns T Minimum distance required for O O periodontal health, between T H restorative margin and biologic width 0.5mm Waerhaug J. J Periodontol 1953;24: CT JE Sulcus The Restorative Periodontal Interface: Biologic Parameters Crestal bone positions The location of a restorative Normal margin in relationship to the Low alveolar bone crest is more important for preserving High gingival health than its distance below the free gingival margin Kois J. Periodontology ;11:29-38 Considerations in Esthetic Dentistry 1

2 Biologic Width and its Importance in Periodontal and Restorative Dentistry Normal Crest High Crest Low Crest Figures copied from - Nugala B, Kumar BS, Sahitya S, Krishna PM. J Conserv Dent 2012;15(1): Tooth vs. Implant Histology Tooth Implant Sulcus Sulcus Epithelial Attachment Epithelial Adhesion Connective Tissue Attachment NoConnective Tissue Attachment Bone Attachment via Sharpy s Direct Bone to Implant Union LM fibers (Osseointegration) Peri-implant biologic width Junctional Epithelium Connective Tissue Sulcus Junctional Epithelium Connective Tissue Probing around implants: a standard of care Rationale for probing around implants Smile Lines Smile Lines Probing reveals level of inflammation through BOP and presence of suppuration Pocket depth changes can indicate bone loss Deep pockets increase risk of harboring pathogens Deep pockets increase risk of developing bone loss Understanding Biologic Width is Important to Avoid Complications with Restorative Dentistry Anatomic concerns Periodontal biotype Biologic width Bone crest position Gingival display and smile line Anatomic concerns Procedures to improve restorative outcomes Periodontal and Peri-implant disease management Considerations in Esthetic Dentistry 2

3 Procedures to improve restorative outcomes Esthetic crown lengthening Mucogingival surgery root recession repair procedures to increase AG ridge defect repair biotype enhancement during implant placement Root reshaping reverse crown lengthening Site preservation Orthodontic extrusion Papilla management Esthetic Crown Lengthening Techniques Gingivectomy Gingivectomy with osseous surgery with or without flap elevation Apically repositioned flap with osseous surgery Orthodontics Camargo PM, Melnick PR, Camargo LM. CDA Journal 2007;35(7): y/o female normal to high crest medium biotype Gingivectomy using Ellman Radiosurgery Flapless osseous reduction through tunnel flap 6 week post op evaluation 42 y/o female high crest thick biotype Osseous surgery with full thickness flap 3 month post op evaluation Considerations in Esthetic Dentistry 3

4 Esthetic crown lengthening Gingivectomy guided by stent Osseous surgery with full thickness flap 1 year post op evaluation Contemporary Crown Lengthening Therapy: A Review Results and Conclusions Final prosthetic treatment should wait at least 3 months and up to 6 months for esthetically critical areas Hempton TJ, Dominici JT. JADA 2010;14(6): Root coverage procedures Treatment Options For Recession Free gingival graft Interpositional connective tissue graft Coronally advanced flap with or without connective tissue Pedicle graft lateral semi lunar Regeneration bone grafts, membranes, growth factors Treatment of Gingival Recession Purpose To evaluate the outcome of various gingival grafting techniques to assess which provides optimal results Materials and Methods Review of controlled clinical trials Kassab MM, Cohen RE. JADA 2002;133(11): Treatment of Gingival Recession Results and Conclusions Autogenous connective tissue grafts in conjunction with a coronally repositioned flap is most effective in achieving predictable root coverage Kassab MM, Cohen RE. JADA 2002;133(11): Miller Recession Classification Clinical Presentation Expectation Success rates Class I Recession above MGJ No AL Complete root coverage 100% Class II Recession to or beyond MGJ No AL Complete root coverage 100% Class III Recession to or beyond MGJ Minor Partial root coverage to the 50-70% interproximal AL height of interproximal tissues Class IV Recession to or beyond MGJ Severe Unpredictable root coverage <10% interproximal AL Miller, PD. A classification of marginal tissue recession. Int J Perio Rest Dent 1985; 5(2):8-13 Considerations in Esthetic Dentistry 4

5 Mucogingival surgery interpositional CT graft Mucogingival surgery interpositional CT graft Mucogingival surgery Free gingival graft + CTG Root coverage procedures Placement of interpositional CT graft guided by stent 3 month post op evaluation 58 y/o female with failing maxillary anterior 3 unit bridge Debridement and Regeneration surgery Interpositional CT graft via tunnel approach Considerations in Esthetic Dentistry 5

6 Interpositional CT Graft with coronally repositioned flap Inerpositional CT Graft via Tunnel Flap Semi-Lunar Pedicle Graft Ridge Defect Repair Autologous Connective Tissue Graft can function as a membrane to contain graft as well as to repair soft tissue deficit Provisional prosthesis with ovate pontic design used to guide healing Connective tissue graft harvest Successful site preservation allows for prosthetically driven implant placement Radiographic case progression Considerations in Esthetic Dentistry 6

7 Final Outcome 37 y/o female. Congenitally missing lateral incisors with constricted arch form Lost left central incisor due to trauma as a child First procedure - extraction of teeth, site preservation with Bio-Oss + DBM and connective tissue graft Second procedure site development using a symphyseal block graft and membrane Third procedure implant placement with connective tissue graft and healing abutments used as space maintainers Ridge Defect Repair Facial gingival tissue stability after connective tissue graft with single immediate tooth replacement in the esthetic zone 20 consecutive patients Immediate implant placement with associated connective tissue graft Follow up 1-4 yrs Preservation of papilla Biotype enhanced Bone and soft tissue stability Kan JY et.al. J Oral Maxillofac Surg. 2009:67(11);40-48 Biotype Enhancement followed by Implant Placement Site preservation with socket and CT Graft Considerations in Esthetic Dentistry 7

8 Root reshaping: an integral part of periodontal surgery Procedure Alternative to conventional osseous surgery involving reshaping of the existing tooth and root surface with conservative removal of supporting bone to create the width needed for biologically acceptable restorations Combination Esthetic Crown Lengthening, Root Reshaping, and Root Coverage Procedure Melker DJ, Richardson CR. Int J Perio Rest Dent 2001;21(3): Root Coverage Required to Reduce Anterior Tooth Length Esthetic Crown Lengthening in Posterior and Root Reshaping of the Anterior Teeth Root Reshaping Eliminates Existing Restorative Margins Placement of Interpositional CT Graft Guided by Stent Esthetic Crown Lengthening, Root Reshaping and Root Coverage A Prospective Randomized Clinical Study of Changes in Soft Tissue Position Following Immediate and Delayed Implant Placement Purpose To compare efficacy of immediate vs. delayed implant placement in maintaining soft tissue margin position following tooth extraction Materials and Methods 24 patients randomly received either immediate or delayed implant placement Delayed sites received FDBA and collagen membrane and re-entered for implant placement 3-6 months later van Kesteren CJ, Schoolfield J, West J, Oates T. Int J Oral Maxillofac Implants 2010:25(3); Considerations in Esthetic Dentistry 8

9 A Prospective Randomized Clinical Study of Changes in Soft Tissue Position Following Immediate and Delayed Implant Placement Results and Conclusions No differences between immediate or delayed approaches with respect to midbuccal and interproximal soft tissue margins van Kesteren CJ, Schoolfield J, West J, Oates T. Int J Oral Maxillofac Implants 2010:25(3); Site preservation Socket graft with a membrane improves ridge height and width following extraction but may interfere with normal healing/bone fill within defect Artzi Z et.al. J Perio (6): Iasella JM et.al. J. Perio (7): Lew DW et.al. Int J Oral Maxillofac Implants 2009;24(4): Araujo MG, Lindhe J Clin Oral Implant Res 2009;20(5): Extraction, Socket Debridement, Bone Graft Placement Resorbable Membrane, Ovate Pontic Site preservation biomaterials Bone Grafts likely minimize clot shrinkage and thus alveolar resorption Membranes serve to contain the graft and minimize epithelial downgrowth Maintenance of alveolar ridge morphology Site Preservation Orthodontic Extrusion Orthodontic Extrusion 44 y/o female with chronic alveolar abscess of maxillary left lateral incisor Papilla Management through CTG and adjacent restorations pre planned Considerations in Esthetic Dentistry 9

10 Biotype Enhancement Prior to surgery, patient prepared for additional adjacent restorations as needed Prototype development Laboratory Phase Papilla Management CDA Journal Nov 2005 Interproximal bone to tooth contact Papilla Management Implant placement guidelines - spacing Implant placement guidelines - position point <5mm 100% papilla presence 6 mm 56% Tooth to Implant 2mm Esposito et al. Clin Oral Imp Res mm 2mm 3mm Implant to Implant 3mm Tarnow et al. J Perio 2000 Avoid adjacent implants in the esthetic zone 7mm 27% Tarnow et. Al. J Perio 1992 Considerations in Esthetic Dentistry 10

11 Implant placement guidelines Emergence Profile 3 mm below restorative margin Esthetics vs. Health Excessive platform depth compromises maintenance Communication Devices- Surgical guides Procedures to improve restorative outcomes Esthetic crown lengthening Mucogingival surgery root recession repair procedures to increase AG ridge defect repair biotype enhancement during implant placement Root reshaping reverse crown lengthening Site preservation Orthodontic extrusion Papilla management Anatomic concerns Procedures to improve restorative outcomes Periodontal and Peri-implant disease management Periodontal and Peri-implant disease management Diagnosis Treatment Maintenance Classification of periodontal disease and conditions Previous classification 1989 world workshop Current classification 1999 international workshop A standard classification provides a framework for the scientific study of disease etiology, pathogenesis and treatment as well as a standard mean of communication Weakness of 1989 classification 1999 Gingival and Periodontal Disease Classification Periodontal disease classification Key Changes Criteria for diagnosis unclear Disease categories overlapped Too much emphasis on age of disease onset and rate of progression which are difficult to determine No classification for diseases limited to gingiva Armitage GC. Ann Periodontol 1999;4:1-6 Previous No section on gingival diseases Adult Periodontitis Early-onset Periodontitis Refractory Periodontitis Localized Juvenile Periodontitis Armitage GC. Ann Periodontol 1999;4:1-6 Current Entire new section on gingival diseases Chronic Periodontitis Aggressive Periodontitis Additions Periodontal abscess Perio-endo lesions Acquired deformities and conditions Considerations in Esthetic Dentistry 11

12 Classification of periodontal disease and conditions Chronic periodontitis Typical adult onset plaque induced Previously referred to as adult perio Aggressive periodontitis Previously known as pre-pubertal, juvenile perio, localized juvenile perio, rapidly progressive perio, early onset perio Armitage GC. Ann Periodontol 1999;4:1-6 Classification of periodontal disease and conditions Chronic and Aggressive Periodontitis Distribution Severity Localized < 30% sites Slight 1-2mm CAL Generalized > 30% sites Moderate 3-4mm CAL Severe > 5mm CAL Armitage GC. Ann Periodontol 1999;4:1-6 Systemic Connections Periodontal disease increases CRP levels Link between Periodontal disease and cardiovascular disease; MI, CVA Link between periodontal disease and the delivery of premature, underweight babies Link between Periodontal disease and Diabetes Recent link with Alzheimer s disease Periodontal Pathogens are transmissible Biofilm and inflammation management Clinical Signs Gingival erythema Edema Bleeding on probing PPD s up to 3mm (unless pseudo pocket) Soft tissue contour changes Increased GCF No attachment loss Gingivitis Treatment Scaling/Prophy with OHI Phase I Re-eval 4-6 mo PST Slight Periodontitis Clinical Signs Treatment Gingival erythema SRP + behavior mod Edema Rx Periostat Bleeding on probing Phase I Re-eval Slight attachment loss 3-6mo PST Pocket depths 4mm Moderate Periodontitis Clinical Signs Treatment Gingival erythema SRP + behavior mod Edema Rx Periostat Bleeding on probing Phase I Re-eval Additional RP + Arrestin Moderate attachment loss Pocket reduction surgery Slight furcation invasion if needed Pocket Depths 5mm Phase II Re-eval 3-4 mo PST Severe Periodontitis Clinical Signs Treatment SRP + behavior modification Severe Attachment Loss Phase I Re-eval Pocket Depths >6mm Pocket Elimination Surgery Moderate to Advanced Phase II Re-eval Furcation involvement Bacterial Culture and Sensitivity Inflammation, BOP Localized and Systemic Antibiotics 3mo PST Manual vs. Powered tooth brushing for oral health Materials and Methods Results and conclusions 42 trials involving 3855 participants Powered brushes removed plaque included in review and reduced gingivitis more effectively than manual brushes Robinson PG, et.al. Cochrane Database 2005;18(2):CD Considerations in Esthetic Dentistry 12

13 The efficacy of interdental brushes on plaque and parameters of periodontal inflammation: a systematic review Materials and Methods Results and conclusions 56y/o male generalized chronic severe periodontitis 56y/o male generalized chronic severe periodontitis 218 Medline-PubMed and 116 Cochrane papers identified As an adjunct to brushing interdental brushes remove more plaque than brushing alone. 9 studies met eligibility criteria Clinical improvements noted in PI, BOP, PD Slot DE. Dorfer CE, et.al Int J Dent Hyg 2008;6(4): Improvement in PI better than using floss Prior to treatment Jan 2002 Post Perio, Restorative and Ortho Treatment Jan y/o male generalized chronic severe periodontitis Anatomic concerns Procedures to improve restorative outcomes Periodontal and Peri-implant disease management Considerations In The Esthetic Zone Nick Caplanis DMD MS Jan 2011 Considerations in Esthetic Dentistry 13