Smile Line Rehabilitation with Dental Implants Board Certified Prosthodontist Hilton Head Island, SC Agenda Implant placement and esthetic potential Single immediate implant placement Soft tissue preservation Soft tissue development Multiple adjacent implants and soft tissue form Agenda Implant placement and esthetic potential 2018 Priest Prosthodontics, LLC 1
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: Single Implants The implant platform should be located 3 mm apical to the zenith of the predetermined facial-gingival margin of the planned restoration The center of the implant should be placed at a distance of at least 3 mm palatal to the anticipated facial margin The implant should emerge through the palatal incisal edge (PIE) of the ensuing crown position Priest GF. An interdisciplinary approach to esthetic single implant outcomes in young patients. Pract Proced Aesthet Dent 2008;20(3):167-175. 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):169-179 2018 Priest Prosthodontics, LLC 2
The umbrella effect Magne P, Magne M, Belser U. The esthetic width in fixed prosthodontics. J Prosthodont 1999;8(2):106-118. Agenda Single immediate implant placement Soft tissue preservation Subtle sulcular modifications Priest, GF. Esthetic potential of single implant provisional restorations. J Esthet Restor Dent 2006;18(6):326-338. 2018 Priest Prosthodontics, LLC 3
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 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 screw-retained restoration Difficult to get smooth emergence profile from prepared margin to crown with cement retained No cement margin to be concerned with using screw-retained 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;35:191-198. 2018 Priest Prosthodontics, LLC 4
Torque Value Smile line revitalization with implants Agenda Single immediate implant placement Soft tissue development Young patients and implant placement Waiting too long after tooth loss can result in inevitable bone resorption of the site and inadequate osseous support for implant placement. Op Heij DG et al. Facial development, continuous tooth eruption, and mesial drift as compromising factors for implant placement. Int J Oral Maxillofac Impl 2006, 21(6):867-878. Primary and Secondary Stability Time (weeks) 2018 Priest Prosthodontics, LLC 5
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 Particularly useful with shallow sulcus or thin biotype Priest, G. A current perspective on screw-retained single-implant restorations. J Esthet Restorative Dent 2017;29(3):161-171. 2018 Priest Prosthodontics, LLC 6
Implants and open contacts Columbia U, literature review Mesial drift occurs throughout life Because implants act as ankylosed teeth, they remain in place while teeth mesial to them drift If implants are placed in growing individual, continued growth can result in open contact Greenstein G, Carpentieri J, Cavallaro J. Open contacts adjacent to dental implant restorations. J Amer Dent Assoc 2016;147:28-34. Ceramic screw-retained crowns Electronic search from 2000-2012 Although no statistical difference was found between cement- and screwretained reconstructions for survival or failure rates, screw-retained reconstructions exhibited fewer technical and biologic complications overall. Wittneben J-G, et al. Clinical performance of screw- versus cement-retained fixed implant-supported reconstructions a systematic review. Int J Oral Maxillofac Implants 2014;29(Suppl):84-98. Agenda Multiple adjacent implants and soft tissue form 2018 Priest Prosthodontics, LLC 7
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 inter-implant distance on the height of the inter-implant bone crest. J eperiodontol 2000;71:546-549. 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: 2-12. 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 2018 Priest Prosthodontics, LLC 8
Must have skilled technician to achieve optimal contours without provisional 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;130:141-151. 2018 Priest Prosthodontics, LLC 9
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;23:249-259. Jaw relations and articulation U Basque Country, Spain Conventional procedure, 6 sets of casts in maximal intercuspal positon without interocclusal record. Then the occlusal contacts determined with articulating paper. Subsequently, occlusal relationships and stone cast were digitized with 3D scanner and occlusal contacts compared. Conclusions: The accuracy provided by a virtual occlusion procedure is greater than that of the traditional physical interocclusal record. The casts were mounted without any interocclusal record because many authors have stated that the use of the occlusal records changes the relative position of the maxillary and mandibular casts. In other words, the direct acquisition of the relative position of the maxillary and mandibular casts is considered more accurate than the relative positons obtained by using an occlusal record, because material introduced between arches could change their relative position. Solabererieta E, Otegi JR, Goicoechea N, Brizuela A, Pradies G. Comparison of a conventional and virtual occlusal record. J Prosthet Dent 2015;114(1):92-97. Lab protocols for intraoral scanning Full contour restorations Zirconia crowns Complete virtual design and manufacture Model only needed 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, compared with zirconia) Model only needed for verification 2018 Priest Prosthodontics, LLC 10
Lab protocols for intraoral scanning Layered restorations Layered zirconia crowns Virtual design and computer milled coping Model needed for completion of layered ceramic 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 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 Implant & Esthetic Dental Presentations Visit www.georgepriest.com 2018 Priest Prosthodontics, LLC 11