Minimally Invasive Dental Implant Surgery E-Book

Daniel R. Cullum

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 1063

Veröffentlichungsjahr: 2015

Beschreibung

Minimally Invasive Dental Implant Surgery presents a new clinical text and atlas focused on cutting edge and rapidly developing, minimally invasive treatment modalities and their applications to implant dentistry. Centered on progress in imaging, instrumentation, biomaterials and techniques, this book discusses both the "how to" as well as the "why" behind the concept of minimally invasive applications in implant surgery. Drawing together key specialists for each topic, the book provides readers with guidance for a broad spectrum of procedures, and coalesces information on the available technologies into one useful resource. Minimally Invasive Dental Implant Surgery will be a useful new guide to implant specialists and restorative dentists seeking to refine their clinical expertise and minimize risk for their patients.

Leseprobe

Minimally Invasive Dental Implant Surgery

Edited by

Daniel R. Cullum DDS

Oral and Maxillofacial Surgeon Private Practice Coeur d’Alene, ID, USA Guest Lecturer Loma Linda University Department of OMS Loma Linda, CA, USA Guest Lecturer UCLA Department of OMS Los Angeles, CA, USA

Douglas Deporter DDS, Dipl Perio, PhD

Discipline of Periodontics Faculty of Dentistry University of Toronto Toronto, ON, Canada

Copyright © 2016 by John Wiley & Sons, Inc. All rights reserved

Daniel R. Cullum, Aldo Leopardi (Chapter 4), Bach T. Le (Chapter 14), and Earl Ness (Chapter 21) retain the copyright of all the figures in their chapters that are not otherwise the copyright of another third party.

Published by John Wiley & Sons, Inc., Hoboken, New Jersey Published simultaneously in Canada

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Library of Congress Cataloging-in-Publication Data:Minimally invasive dental implant surgery / edited by Daniel R. Cullum, Douglas Deporter.       p. ; cm.    Includes bibliographical references and index.    ISBN 978-0-8138-1452-0 (cloth)    I. Cullum, Daniel R. (Daniel Ray), editor. II. Deporter, Douglas, editor.    [DNLM: 1. Dental Implantation—methods. 2. Minimally Invasive Surgical Procedures—methods. 3. Patient Care Planning. WU 640]    RK667.I45    617.6'93—dc23

2015025339

Cover images courtesy of Daniel R. Cullum.

Contents

Contributors

Memorial

Foreword

Preface

Acknowledgments

Copyright note

Section I: Technology, Diagnosis, and Treatment Planning

Chapter 1 Diagnosis and Treatment Planning for Minimally Invasive Dental Implant Treatment

Introduction

The diagnostic process

Informed consent

Comprehensive evaluation and risk assessment

The esthetic zone: pink and white esthetic concepts

Planning for ideal implant position

Treatment planning

Conclusions

Acknowledgments

References

Chapter 2 Diagnostic Imaging for Patient Evaluation and Minimally Invasive Treatment Planning

Introduction

Cone beam computed tomography data set and software

3-D anatomic evaluation

Clinical applications for diagnostic and restorative driven treatment planning

Screw-retained versus cement-retained positioning concepts

Clinical applications: surgical phase

Conclusions

References

Chapter 3 Risk Assessment and Avoiding Complications

Introduction

Risks associated with patient health and habits

Anatomic risk factors

Prosthetic risk factors

Surgical risks

Conclusions

References

Chapter 4 The Provisional Restoration: A Diagnostic, Functional, and Esthetic Template

Introduction

Bone and soft tissue considerations

Biologic width

Adjacent implants

“Platform switching or shifting”

Provisional restoration

Provisional abutments

Provisional fabrication and impression techniques

Tissue manipulation and sculpting

Conclusions

References

Section II: Technology and Surgery

Chapter 5 Extraction Site Management for Ridge Preservation and Implant Site Development

Introduction

Rationale for alveolar ridge preservation

The biology of extraction socket healing

Guided bone regeneration applied to extraction sites

Minimally invasive surgical protocol

The “modified” Bio-Col technique for ridge preservation

Open-barrier techniques

The Cytoplast® (hd-PTFE) ridge preservation technique

Conclusions

References

Chapter 6 Engineering Biologic Width and Tissue Levels with Implant and Abutment Surface Preparation

Introduction

The laser-ablated surface

Human histologic evidence of a connective tissue attachment to a dental implant

Conclusions

References

Chapter 7 Recombinant Human Bone Morphogenetic Protein-2 or Recombinant Human Platelet-Derived Growth Factor BB in Extraction Site Preservation and Bone Augmentation

Introduction

Recombinant human bone morphogenetic protein-2 for extraction socket defects

Recombinant human bone morphogenetic protein-2–absorbable collagen sponge socket repair technique

Recombinant human platelet-derived growth factor BB for extraction socket defects

Discussion

Conclusions

References

Chapter 8 Periodontal and Peri-Implant Soft Tissue Surgery

Introduction

Anatomic considerations

Surgical considerations

Flap design principles

Surgical techniques

Tunnel flaps

Vascular pedicle “plastic” techniques

Conclusions

References

Chapter 9 Minimally Invasive Implant Surgery Using Computer-Guided Technology

Introduction

History

Computer-guided technology overview

Computerized-tomography-guided surgery indications

Applications in complicated situations

Implant-specific instrumentation

Benefits to patients and clinicians

Conclusions

References

Section III: Optimizing Anatomical Limits with Short, Narrow and Angled Implants

Chapter 10 Short Implants

Introduction

Literature review

Conclusions

References

Chapter 11 Narrow Implants

Introduction

Literature review

Clinical results

Clinical applications of narrow-diameter dental implants

Prosthetic considerations

Conclusions

References

Chapter 12 Minimally Invasive Complete Arch Treatment: The Versatility of Angled Implants

Introduction

Achieving biomechanical fixation into cortical bone

Facilitating splinted complete arch immediate function

Improving biomechanical distribution

Economy of implant placement

Increasing resistance form by angulation

Avoiding vital structures

Avoiding bone grafting

Increasing use of immediate function

Increasing patient acceptance to treatment

Favorable psycho-social factors

Discussion

Conclusions

References

Chapter 13 Wedge Implants and Piezoelectric Surgery: A Minimally Invasive Implant Concept for the Treatment of Narrow Alveolar Ridges

Introduction

Ultrasonic bone surgery: an overview

Minimally invasive treatment of narrow ridges

Wedge implant design

Wedge implant site preparation

Clinical case studies

Conclusions

References

Section IV: Implant Site Development

Chapter 14 Single-Stage Implant Placement and Simultaneous Grafting: The “Esthetic Contour Graft”

Introduction

Single-stage implants with simultaneous guided bone regeneration: “esthetic contour graft”

Defect configuration

Flap design

Surgical technique

Bone graft materials

Barrier membranes

The role of bone and soft tissue augmentation

Implant position and labial soft tissue thickness

Conclusions

References

Chapter 15 Trans-Alveolar Sinus Elevation and Contiguous Sinus Floor Elevation

Introduction

Anatomic considerations

Surgical considerations

Advanced trans-alveolar sinus elevation techniques

Procedures

Avoiding and managing complications

Conclusions

References

Chapter 16 Ridge Expansion

Introduction

Literature review

Anatomic considerations

Surgical considerations

Procedures

Avoiding complications

Summary

References

Chapter 17 Ridge Expansion Combined with Trans-Alveolar Sinus Elevation

Introduction

Literature review

Anatomic considerations

Surgical considerations

Ridge expansion and trans-alveolar sinus elevation procedures for maxillary horizontal and vertical deficiency

Avoiding complications

Summary

References

Section V: Immediate Implant Reconstruction

Chapter 18 Immediate Implant Placement for Single- and Multi-Rooted Teeth

Introduction

Literature review

Prosthetic considerations

Anatomic considerations

Surgical considerations

Procedures with single-rooted teeth

Immediate procedures for multi-rooted teeth

Conclusions

References

Chapter 19 Immediate Esthetic Zone Tooth Replacement

Introduction

Literature review

Provisional abutment design

Preoperative evaluation and planning

Surgical techniques

The provisional restoration

Conclusions

References

Section VI: Comprehensive Applications of Minimally Invasive Surgery

Chapter 20 Skeletal Anchorage and Orthodontics in Implant Site Development

Introduction

Temporary anchorage devices

The anterior–posterior dimension

The vertical dimension

The transverse dimension

Interdisciplinary treatment with orthodontic and implant site development

Conclusions

References

Chapter 21 Minimally Invasive Comprehensive Treatment: Case Studies

Outline of case studies

Introduction

Case study 21.1

Case study 21.2

Case study 21.3

Case study 21.4

Case study 21.5

Case study 21.6

Index

EULA

List of Tables

Chapter 1

Table 1.1

Chapter 2

Table 2.1

Chapter 4

Table 4.1

Chapter 8

Table 8.1

Chapter 13

Table 13.1

Table 13.2

Chapter 15

Table 15.1

Chapter 16

Table 16.1

List of Illustrations

Chapter 1

Figure 1.1

(a) Facial perspectives and proportions. (b) Facial perspectives and proportions projected over face.

Figure 1.2

(a) Parallelism between interpupillary plane and overall anterior incisal plane. (b) Parallelism between Frankfort plane and posterior occlusal plane.

Figure 1.3

(a) Midline and anterior incisal plane discrepancies. (b

)

New midline and anterior incisal plane after correction.

Figure 1.4

(a) Anterior smile view of preoperative disharmony. (b) Anterior smile view after camouflage of disharmony harmony.

Figure 1.5

(a) Esthetic dento-gingival presentation demonstrating the free gingival margin of maxillary anterior dentition. (b) Same as (a) with teeth outlines drawn. Imaginary lines joining gingival margins of canines to centrals; ­laterals should ideally be shorter or even with this line. Note that the planes slope downward towards the midline. (c) Diagrammatic representation of (b). (d) Variation #1 (of gingival levels): the right canine is longer gingivally, but perspective is maintained. (e) Variation #2: the right canine and central incisor are longer gingivally, but the gingival plane remains in relative harmony as it slants downward. (f) Dysharmony #1: the right central incisor is significantly longer than in (c), creating a more significant unilateral asymmetry because of the upward plane toward midline. (g) Dysharmony #2: right central incisor is very long gingivally creating visual tension away from ideal plane.

Figure 1.6

(a) Anterior smile view demonstrating significant white and pink disproportions of the right lateral incisor. (b) Right lateral smile view. (c) Esthetic analysis on laboratory study cast. (d) Esthetic superimposition of the left canine and lateral incisor mirror images over the right canine and lateral incisor sites. (e) Same as (d) but with preoperative right canine and lateral incisor teeth eliminated. (f) Anterior retracted dentition of provisional crowns immediately post-insertion; note slight tissue recontouring with diamond gingivoplasty at the right lateral incisor.

Figure 1.7

(a) Ideal width-to-length ratio of maxillary central incisors (75–80%). (b) Short tooth width-to-length ratio (larger than 75–80%). (c

)

Long tooth width-to-length ratio (smaller than 75–80%).

Figure 1.8

(a) A youthful incisal embrasure anatomy. (b) Variation in incisal embrasure anatomy and depth of incisal planes; the flatter the embrasures (top of figure), the more worn/aged teeth will look. The deeper the embrasures (bottom of figure), the younger the dentition will appear.

Figure 1.9

(a) Mesio-distal contours: given a particular width for a tooth to occupy a desired space, moving the facial height of contours inward will “round” a tooth, making it look “narrower” (and vice versa). (b) Gingivo-incisal contours: given a particular length for a tooth to occupy a desired space, accentuating the labial planes will also “round” a tooth, making it look “shorter” (and vice versa).

Figure 1.10

(a) Anterior retracted preoperative image demonstrating a hopeless maxillary left central incisor with a large midline diastema. (b) Esthetic analysis on laboratory study cast; idealized right and left centrals incisors superimposed over the existing sites. (c) Planning for dental implant position with planned tooth proportion changes. (d) Retracted anterior view of definitive results right and left centrals incisors. The patient accepted slightly larger than ideal central incisor restorations in order to avoid having to restore the lateral incisors.

Figure 1.11

(a) Anterior smile view presents a patient with significant occlusal and esthetic compromise resulting from parafunctional occlusal habits combined with chemical erosion and periodontal recession. (b) Right lateral smile view. (c) Retracted view of the maxillary teeth. (d) Retracted maxillary anterior “mock-up” with rapid freehand addition of composite resin (without bonding agent). (e) Retracted maxillary anterior “mock-up” with white orthodontic wax pressed into gingival embrasures. (f) Anterior smile view of completed rapid “mock-up.” (g) Anterior retracted view of completed definitive restorations with modified shape and proportions. (h) Right lateral smile view of completed definitive restorations.

Figure 1.12

(a, b) Inter-arch and vertical space requirements for prosthesis design need to account for the vertical height of the abutment, major connector, and restorative materials.

Source:

Nobel Biocare. Reproduced with permission of Nobel Biocare, Yorba Linda, CA.

Figure 1.13

(a) Clinical and (b) periapical radiographic images show a significant bone and soft tissue defect after traumatic injury with the loss of the right lateral incisor, canine, and first premolar teeth. (c) It was possible to reconstruct this large defect with an implant-supported restoration using a pink esthetic fixed prosthetic with excellent white and pink balance.

Figure 1.14

(a) Anterior smile view preoperative resin-bonded PFM bridges replacing teeth 7 and 10. (b) Anterior retracted view with superimposed proposed implants 7 and 10 (red lines represent free gingival margins of preoperative restorations; pink lines represent desired height of free-gingival zeniths; dotted white lines represent desired outlines of new restorations 7 and 10). (c) Anterior retracted view of provisional implant crowns 7 and 10 after soft tissue maturation.

Figure 1.15

(a) Retracted anterior preoperative view of failing maxillary right central incisor. (b) Occlusal view of root fragment aft er removal of the failing crown. (c) Preoperative periapical radiograph showing intact interproximal bone. (d) Anterior retracted view with superimposed mirror image tracing for tooth shape analysis. (e) Superimposed mirror image tracing for tooth shape analysis with proposed midline and the shaded outline of the proposed restoration. (f) Occlusal view of dangerous bucco-lingual positioning for implant placement in the esthetic zone (too facial). (g) Occlusal view of idealized bucco-lingual positioning for implant planning in the esthetic zone, maintaining at least 2 mm facial gap. (h) Occlusal view of analysis of bucco-lingual angulation with the access hole location for planned restoration through the incisal edge of the future crown. (i) Occlusal view of analysis of bucco-lingual angulation with the access hole location for planned restoration through the cingulum of future crown. (j) Lateral view of the study cast with a sagittal view representation of (i) showing implant angulation relative to desired restored crown anatomy. Th e location of the access hole for screw retention is visualized through the cingulum. (k) Occlusal view of the implant and peri-implant soft tissues 4 months post-extraction with an immediate fi xed provisional restoration. (l) Anterior retracted view of defi nitive implant crown at the central incisor. (m) Periapical radiograph of defi nitive implant restoration.

Figure 1.16

(a) Smile view of this female patient after traumatic loss of her maxillary left central incisor. (b) Anterior retracted view of an implant-supported restoration at the maxillary left central incisor, with anterior dental asymmetry and compromised bone and soft tissue levels. (c) Esthetic analysis of treatment option 1 with restoration of gingival recession defect at the left lateral incisor and restorations with proposed contour modifications at the left central and lateral incisors as well as composite gingivo-mesially at the right central incisor. (d) Esthetic analysis of treatment option 2 maintains a longer left lateral incisor to avoid further surgery/orthodontics to correct gingival recession defect. This also partially compensates for the slightly longer gingival (apical) margin at the left central incisor. (e) Anterior retracted view of definitive results after restorations with contour modifications at the left central (implant-supported crown) and lateral incisors (conventional laminate) as well as composite gingivo-mesially at the right central incisor. (f) Anterior smile view of definitive results.

Figure 1.17

(a) Anterior smile view of patient with a failing right maxillary central incisor. (b) Retracted anterior view showing adequate contours of hard and soft tissues present. (c) Periapical radiograph demonstrating a large lesion secondary to internal resorption of the right maxillary central incisor and adequate interproximal bone heights. (d) Extraction and immediate implant reconstruction was completed with placement for screw retention of an immediate non-functional provisional crown. (e) Th e frontal and (f) occlusal views demonstrate the excellent soft tissue response on removal of the provisional crown 4 months aft er immediate implant placement with immediate provisional restoration. (g) Definitive porcelain-fused-to-zirconia screw-retained crown displays the emergence contours typical of this anatomic location. (h) Defi nitive screw-retained crown, and the ideal screw access location is shown on the master cast. (i) Periapical radiograph of defi nitive restoration at the right central incisor shows excellent bone contours and implant positioning with screw retention. (j) A retracted anterior view demonstrates the defi nitive result with excellent bone and soft tissue contours and implant positioning aft er immediate implant placement with immediate provisional restoration.

Figure 1.18

(a) Preoperative smile and (b) retracted view revealed implantsupported fi xed restorations at the right lateral and central, and left central incisor locations, with a restored natural left lateral incisor. Apparent tooth shape and size discrepancies and asymmetry were noted, contributing to an overall displeasing esthetic result. (c) Clinical right lateral view of provisional anterior restorations 1 week aft er placement, designed to correct the esthetic defi ciencies, with the contact points 3.0.3.5 mm crestal to the interproximal bone peaks. (d) Anterior and (e) lateral views of customized master cast demonstrating peri-implant tissue profi les on individual implant crowns (right and left central and right lateral incisors) and conventional crown (left lateral incisor). (f, g) Clinical lateral smile views and (h) retracted anterior view of the defi nitive restorations in position with improvement of the white and pink esthetic balance. (i) Periapical radiograph of defi nitive restoration aft er insertion.

Figure 1.19

(a–c) Panoramic radiographic series demonstrating sequential implant reconstruction of the maxilla maintaining fixed esthetic provisional restoration through the treatment phases. © Daniel R. Cullum.

Figure 1.20

(a, b) Clinical images of an implant-supported maxillary precision bar prosthesis design secured with plungers in the bilateral molar regions. Restoration by Earl Ness DDS MSD. © Daniel R. Cullum.

Figure 1.21

Preoperative (a) clinical and (b) radiographic views of a patient with severe attrition and non-restorable caries with loss of vertical dimension with wear of tooth structure and simultaneous alveolar extrusion. This resulted in limited vertical space available for the restoration and increased mandibular incisor display. (c) Residual alveolar height prior to 12 mm bone reduction for adequate prosthetic space. (d) The immediate post-treatment image with implant placement and immediate prosthesis fabrication demonstrating the corrected maxillary incisal edge position. (Restoration Dr K Hintz.) (e) The 10-day post-treatment clinical result with implant placement and immediate prosthesis insertion. (f) The 3-month post-treatment radiograph with implant placement and immediate prosthesis fabrication demonstrating six implants placed for maximum anterior–posterior spread. © Daniel R. Cullum.

Flowchart 1.1

Flowchart 1.2

Flowchart 1.3

Flowchart 1.4

Chapter 2

Figure 2.1

(a, b) A 3-D reconstructed view of the remaining mandibular teeth and knife-edged alveolar ridge seen in relation to the volumetric posterior bone loss.

Figure 2.2

(a) The cross-sectional view of the buccal bone. (b) At the midline of the symphysis, lingual perforating vessels are often found (arrow).

Figure 2.3

(a) Cross-sectional view of the nerve (orange) exiting the mental foramen. (b) The posterior mandible exhibits a severe lingual undercut (arrow) undetected with conventional periapical or panoramic radiography. (c) The topography of the posterior mandible illustrated by slicing or “clipping” through the 3-D reconstructed image.

Figure 2.4

(a, b) Advanced software functionality allows virtual extraction of teeth helping to visualize the residual sockets as an aid in planning.

Figure 2.5

The lateral 3-D reconstructed mandibular view (a) was manipulated to alter its opacity to help inspect the mental foramen and the entire path of the underlying inferior alveolar nerve (b).

Figure 2.6

(a) An axial image of the maxilla reveals the bilateral maxillary sinus cavities, nasal turbinates, and the ethmoid and sphenoid sinuses. (b) The coronal images reveal the maxillary sinuses and the right and left alveoli.

Figure 2.7

The axial slice revealed a normal left sinus, but soft tissue pathology in the right sinus (green arrow).

Figure 2.8

(a) Cross-sectional images allow for an excellent appraisal of the lateral and medial walls of the sinus, the deficient crestal bone (red arrows), and sinus pathology (green arrow). (b) Inspection of the lateral sinus wall with undistorted measurement of distances to intra-osseous vessels seen in the cross-sectional slice. (c) Measurements made from the lateral to medial walls help to estimate bone graft volume needed to prepare the sinus for subsequent dental implant placement.

Figure 2.9

(a) The axial image revealing the location and extent of sinus septa (red arrows). (b) Cross-sectional slices are useful in visualizing septa (blue arrow) from the lateral to medial sinus walls and potential pathology within the sinus (red arrow).

Figure 2.10

Sinus pathology evident in the left axial view (yellow arrows).

Figure 2.11

Sinus pathology in the cross-sectional view (a) and axial views (b) depicted by arrows.

Figure 2.12

(a) The preoperative condition of a normal maxillary sinus. (b) Advanced software tools can simulate the graft volume required to fill the sinus (green). (c) The simulated implant site assessed in several views allows for an appreciation of the volume of bone needed to surround the body of the implant.

Figure 2.13

(a) The alveolus is clearly visualized at the junction between the nasal cavity (red arrow) and the anterior extent of the maxillary sinus (yellow arrow). (b) The “triangle of bone” (TOB) concept creates a decision tree for potential implant placement based upon the zone of available bone.

Figure 2.14

(a) This cross-sectional slice reveals the extent of bone loss surrounding adjacent teeth, the height of the facial cortical plate, and a view of the palatal bone that cannot be appreciated with conventional radiology. (b) The anterior maxilla also houses the incisive canal that varies substantially from patient to patient (yellow arrows).

Figure 2.15

(a–d) The anterior maxilla in this case exhibited severe alveolar resorption, making it impossible for dental implant placement without ancillary augmentation procedures to reconstruct the lost volume.

Figure 2.16

Preoperative photograph of the maxillary deciduous lateral incisors.

Figure 2.17

(a) Left side and (b) right side preoperative clinical appearance.

Figure 2.18

Preoperative periapical radiographs demonstrating limited residual roots and excellent apical bone height. Red arrows demonstrate the 2-D inferior position of the nasal (medial) and sinus (lateral) cavities.

Figure 2.19

Periapical versus cross-sectional CBCT images of (a) right side and (b) left side.

Figure 2.20

(a) Preoperative axial CBCT view. (b) Preoperative axial view with simulated implant placement (yellow).

Figure 2.21

(a) TOB on cross-sectional view. (b) TOB with simulated implant placement.

Figure 2.22

(a, b) Screen shots of interactive treatment planning software application.

Figure 2.23

The 3-D reconstructed maxillary volume.

Figure 2.24

(a) Using simulated abutment projections (yellow) helps to define the trajectories for the implants.(b) Selected transparency was used to reveal the roots of the adjacent teeth.

Figure 2.25

(a) Cross-sectional CBCT view with abutment projection. The red line indicates positioning of a cotton roll for the “lip lift “ technique. (b) Cross-sectional CBCT view with implant and future crown outline.

Figure 2.26

Cross-sectional 3-D model including the virtual crown.

Figure 2.27

(a) Cross-sectional 3-D model of implant and abutment. (b) Cross-sectional image of the 3-D model for the implant, abutment, and virtual crown. (c) 3-D cross-sectional image with an angled abutment within the virtual crown.

Figure 2.28

(a) Positioning for a screw-retained crown with screw emergence through the cingulum. (b) Reconstructed view shows positioning for a screw-retained crown may result in apical perforation. (c) 3-D reconstructed view shows screw-retained positioning results in perforation of the facial cortical plate.

Figure 2.29

(a) The stone cast with good surface detail. (b) Optical scan of the stone cast. (c) The digital model of stone cast merged with CBCT data.

Figure 2.30

The digital model with (a) digital “virtual” abutments and (b) abutments.

Figure 2.31

(a) Side view of the digital model with abutments. (b) Digital model with abutments.

Figure 2.32

Extracted primary teeth confirming short residual root forms per software planning.

Figure 2.33

The tooth-borne surgical template.

Figure 2.34

Sequential drilling through surgical template with the drill-specific guide key.

Figure 2.35

Clinical picture after placement of both implants.

Figure 2.36

Unprepared abutment placed onto the left implant.

Figure 2.37

Temporary restoration connected to the implant analog.

Figure 2.38

Left transitional resin temporary in place.

Figure 2.39

Clinical appearance at 2 weeks following (a) left implant placement surgery and (b) right implant placement surgery.

Figure 2.40

Preoperative and post-operative radiographs of the (a) right and (b) left lateral incisor implant.

Figure 2.41

Open-tray fixture-level impression transfer copings in position.

Figure 2.42

(a, b) Ceramo-metal restorations on the implant analogs.

Figure 2.43

Custom post for the right implant with a good soft tissue profile.

Figure 2.44

Final ceramo-metal restoration on the (a) right and (b) left lateral incisor.

Figure 2.45

Final periapical radiographs taken at 24 months post-surgery for the right and left lateral incisor implant restorations.

Chapter 3

Figure 3.1

(a) Clinical view of a fixed implant-supported prosthesis showing accumulation of food debris as well as plaque and calculus under the denture due to a poor prosthetic design (case provided by Dr David Chvartszaid, Toronto, ON). (b) Occlusal view of the implants and soft tissue. The tissue appears inflamed due to chronic irritation. (c) The intaglio surface is irregular with a poor, unhygienic prosthetic design making it difficult to clean. (d) Radiograph showing the resulting crestal bone loss that has affected most notably the second implant from the right.

Figure 3.2

(a) The implant shown fractured on the palatal aspect resulting in peri-implant inflammation and bone loss. (b) View of the fractured implant after removal.

Figure 3.3

(a) Occlusal view showing inadequate bone and soft tissue volume at the facial aspect of implants at the lateral incisor positions resulting in a compromised esthetic result and thin soft tissue. (b) A facial view of the sites shows a thin soft tissue biotype with recession and tissue color compromise, which did not present until 2 years after restoration. Late findings of bone remodeling and soft tissue volume changes can result from inadequate initial facial bone thickness (<2 mm). (c) The corresponding panoramic radiograph demonstrates good implant positioning and maintenance of the interproximal bone heights. © Daniel R. Cullum.

Figure 3.4

Tissue recession exposing implant threads. The tissue quality is of a thin biotype with visible buccal bone loss compared with the thick keratinized tissue and bone support associated with the two adjacent implants. © Daniel R. Cullum.

Figure 3.5

Clinical example of peri-implant mucositis. (a) The soft tissue is inflamed with a slight mucoid discharge. (b) As the prosthesis was being removed, heavy subgingival deposits were seen; and, (c) were found to be extensive following prosthesis removal. (d) No peri-implant bone loss was detected in this radiograph taken at the time. (case provided by Dr David Chvartszaid, Toronto, ON).

Figure 3.6

(a) A panoramic radiograph showing bone loss around the implant in the mandibular right second molar site. (b) Probing depths in excess of 10 mm were found at the buccal and lingual surfaces of the implant crown. Delayed bleeding and purulent discharge also were noted. (c) A flap was reflected showing the denuded implant surface as well as the bony trough and granulation tissue resulting from the inflammatory response.

Figure 3.7

(a) A preoperative radiograph shows tooth #3, which was removed and site preservation grafting completed. (b) At the 6-month follow-up visit, a periapical radiolucency was seen at tooth #2 and is directly communicating with the adjacent bone graft. The graft was subsequently compromised. (c) Cross-sectional CBCT views show contamination and infection of the grafted site originating from tooth #2. © Daniel R. Cullum.

Figure 3.8

(a) The stone model for an implant at site #7 shows the positioning and excessive facial angulation of the fixture. (b) Clinically, this resulted in an apical gingival margin position and an unesthetic and overly long clinical crown.

Figure 3.9

A radiograph of two adjacent implants violating the desired 3 mm inter-implant distance. Significant bone loss between the failing implants can be seen, and they were subsequently removed.

Figure 3.10

(a) A periapical radiograph showed extensive peri-implant crestal bone loss. (b) After implant removal, cement was visible on the buccal aspect.

Figure 3.11

An implant design showing both platform switching and a tapered internal connection.

Source:

Nobel Biocare. Reproduced with permission of Nobel Biocare.

Figure 3.12

(a) Compromised inter-occlusal distance secondary to extrusion of the opposing dentition and a high-riding crest. (b) Implants were placed. (c) Custom healing caps were made after integration with uncovering, to develop optimal emergence profiles. (d, e) The opposing dentition was orthodontically impacted with the use of a temporary anchorage device to increase the available inter-occlusal space. (Orthodontic treatment by Dr J. Hintz.) (f) Panoramic radiograph showing the final position of the opposing teeth after orthodontic intrusion, confirming adequate space for crown placement. © Daniel R. Cullum.

Figure 3.13

An axial CBCT image of a maxillary sinus with complete opacification of the right sinus secondary to a dental abcess and chronic sinusitis.

Figure 3.14

A panoramic radiograph showing an implant displaced into the maxillary sinus. Further apically, the cover screw is also visible.

Chapter 4

Figure 4.1

 (a) Low scalloped, thick gingival biotype with shorter clinical crowns and papilla heights. (b) High scalloped, thin gingival biotype with more triangular tooth forms are at greater risk of bone and soft tissue recession. © Aldo Leopardi.

Figure 4.2

 The use of an internal tapered connection reduces the dimension of the microgap and abutment micromotion under function.

Source:

Nobel Biocare. Reproduced with permission of Nobel Biocare.

Figure 4.3

 Platform switching moves the implant–abutment interface (microgap) medially to reduce the vertical height requirement of the biologic width.

Source:

Nobel Biocare. Reproduced with permission of Nobel Biocare.

Figure 4.4

 (a–c) Fabrication of a secondary “die” or abutment can be used as a technique with cemented crowns to seat and extrude excess cement for complete removal prior to seating in the patient. © Aldo Leopardi.

Figure 4.5

 (a, b) Healed implant sites with impression copings in place. The implants demonstrate excellent palatal positioning and angulation appropriate for screw retention. (c, d) The corresponding radiographs confirmed complete impression coping seating. (e) A closed-tray impression was used to fabricate the master cast with simulated soft tissue at the implant sites. (f) A combination PEEK polymer and titanium base provisional abutments were used. (g) Provisional abutments were seated onto the working model with removal of simulated soft tissue to produce the desired emergence profile in wax. (h) Initial abutment preparation was completed and the undercuts on the master cast blocked out with wax. (i) A vacuform template was constructed in the laboratory from a diagnostic work-up master cast. (j) Separating medium (petroleum jelly) was placed on the master cast. An indirect technique was used by filling of the vacuform template with light-cured provisional material (Triad, Dentsply) of matched shade followed by delivery to the master cast. (k) After curing, the provisional screw-retained restorations were removed from the cast and trimmed and polished to the desired contours for the maxillary lateral incisors. (l) Provisional screw-retained restorations were seated onto the cast. (m–o) These clinical and radiographic images demonstrate the soft tissue contours with provisional restorations in place for 3 weeks. © Aldo Leopardi.

Figure 4.6

 (a–d) After fabrication of the master soft tissue cast was completed, screw-retained, stock precontoured titanium abutments were placed and the case evaluated with the soft tissue mask in place and after its removal. (e, f) The desired emergence profile was produced in wax (reverse) with block-out of undercuts. The abutments were prepared with application of metal primer and bonding agent, use of resin tint opaque modifier to block out the metal and a separating medium placed on the cast.  (g) A vacuform template was filled with the desired provisional resin (Triad, Dentsply) and cured. (h, i) The provisional restorations were removed from the master cast, trimmed to appropriate contours, and polished. (j) The restorations were cleansed and delivered to the patient. Typically, blanching of the soft tissue occurs with insertion; this should resolve within several minutes. The screw-retained provisional restoration can be seen in position after 3 weeks. © Aldo Leopardi.

Figure 4.7

 (a) Custom impression posts for case study 4.1 maxillary right and left lateral incisors are shown here. The prototypes were placed back onto the cast. (b) A medium-body vinyl polysiloxane impression material was injected onto the cast to record the soft tissue profile. (c) The prototypes were removed from the cast. (d) Open-tray impression posts were placed using a light-cured or chemical-cured resin (GC pattern resin™ LS, GC America). (e) After adequate time for curing, the custom impression copings were removed and trimmed. (f) Posts now were ready to deliver to the patient during the master impression appointment. (g) Fabrication of the screw-retained final restorations included customization of precontoured stock zirconia abutments.  (h–j) Shown here are the inserted restorations and periapical radiographs 3 weeks after insertion. (k, l) Definitive restoration and pretreatment images for the patient can be seen confirming an excellent esthetic and stable clinical result. © Aldo Leopardi.

Figure 4.8

 (a) Excellent tissue contours and volume can be seen at the maxillary left central incisor site 6 months after extraction and site preservation grafting. (b) After the minimum 8 weeks of soft tissue healing, a closed-tray impression coping was inserted and the impression completed. (c) A titanium (Triad fused to titanium) screw-retained prototype was fabricated as described in case study 4.1. (d) The prototype provisional restoration was delivered to the patient. After 2 weeks of soft tissue maturation, the facial gingival margin is approximately 1.5 mm coronal to that of the contralateral tooth. (e, f) The anticipated effect of contour change on the gingival profile is demonstrated here with the addition of facial contour using a triangular pad of flowable light-cured composite resin. By adding restorative material to the mid-facial intaglio area (last 1.5 mm), the tissue was displaced coronally to achieve the desired soft tissue profile. (g) The clinical presentation after provisional modification and two more weeks for tissue maturation. Temporary veneers also were placed on the adjacent teeth. (h, i) The custom impression post technique was used to fabricate the definitive restorations. Clinical “try-in” was completed to confirm the final contours. (j–l) The clinical and radiographic images 3 weeks after delivery of the definitive restorations, which included a screw-retained porcelain fused to zirconium implant crown at the maxillary left central incisor and revised porcelain laminate veneers at the adjacent teeth. © Aldo Leopardi.

Figure 4.9

 (a) The patient presented with retained primary canines and permanent canines that had been moved into the lateral incisor positions. (b) The patient elected to proceed with adult orthodontics, removal of deciduous canines, and movement of the canines back to normal canine positions. (c) The patient is seen here after orthodontic treatment in preparation for implant placement with a surgical guide in position. Implants were placed using a single-stage protocol with a guided minimally invasive approach. (d) After 4 months healing, palatal implant positioning can be seen with excellent facial tissue volume. (e–g) Open-tray impression technique was used following radiographic confirmation of abutment seating. (h, i) The implant-level impression was used to prepare the working cast (as described previously). Implants had been placed well in the buccal–palatal dimension for screw-retained restorations. However, the placements were slightly shallow (2 mm apical to the future ­ mid-facial free gingival margins), as can be seen here on the working model. (j) This figure displays the available 3.0 mm diameter provisional abutments: titanium engaging (hex index), titanium non-engaging, and PEEK polymer engaging (BioHorizons, Birmingham, AL). The provisional restorations in this case were fabricated using the 3.0 mm diameter engaging titanium abutments.

Source:

BioHorizons, Inc. Reproduced with permission of BioHorizons, Inc. (k, l) The soft tissue contours of the provisional restorations of the maxillary lateral incisors can be seen here 1 week following insertion. (m, n) The prototype provisional abutment used for this left maxillary lateral incisor required addition of contour to the mid-facial area (i.e. the last 1.5 mm of the emergence profile). © 4.9a–i, k–n, Aldo Leopardi.

Figure 4.10

 (a, b) After 4 weeks, mid-facial contour can be seen to have shaped well. However, the prototypes are impinging on the interproximal papillae. (c) A radiograph of the right lateral incisor showed less than a 4.5 mm distance between the height of interproximal bone and the contact area of the provisional crown form. (d, e) The provisional restorations are shown here after placement onto the cast. The line indicates the areas of contour change needed. (f, g) Contact areas were opened up to a point within 5 mm from the interproximal bone height and finished. (h, i) The restorations are shown here after re-insertion (day of). (j, k) The clinical change 6 weeks after the contour adjustments, and with the papillae reformed. (l, m) The soft tissue profile development was completed at 12 weeks, and is documented here with restorations in place. (n–p) The soft tissue contours and thickness can be visualized after provisional removal showing excellent gingival architecture and health. (q) The custom post-impression technique was performed as discussed previously. (r, s) During bisque bake try-in, minor adjustments with resin were made to close the open interproximal contacts and improve the interproximal emergence profile of the definitive restoration – provisional prototype (r) and modified bisque bake (s). (t, u) The modifications were completed with the technician, and the crowns finished and delivered with the esthetic result shown in these retracted views. (v, w) Pretreatment and restoration full-smile views demonstrated significant esthetic improvement produced by using appropriate treatment planning and application of carefully prepared provisional restorations. © Aldo Leopardi.

Chapter 5

Figure 5.1

(a) “Proximator” instrument kit with specialized shapes for atraumatic root extraction (H&H Company, Ontario CA). (b–e) The radius of curvature of the Proximator-style of instrument is a significant advantage to reduce trauma and increase surgical efficiency. Instruments with a rounded and “spear” shaped tips are the most helpful in management of challenging root removal.

Source

(a): H&H Company, Ontario, CA, USA. Reproduced with permission of H&H Company.

Figure 5.2

(a–c) Instruments to facilitate access for minimally invasive grafting include mini-rongeurs and specialized instrument kit for preparing and placing the graft materials.

Source:

H&H Company, Ontario, CA, USA. Reproduced with permission of H&H Company.

Figure 5.3

The modified Bio-Col® technique is demonstrated at a non-restorable mandibular first molar region. (a) Failing mandibular right first molar occlusal view. (b) Particulate xenograft saturated in venous autologous blood (Equimatrix®, Osteohealth, Shirley, NY). (c) Sectioned collagen plug (Ora-Plug®, Salvin Dental, Charlotte, NC). (d) Extraction site following minimally invasive surgery after particulate grafting and placement of a sectioned collagen plug saturated in rhPDGF (GEM 21S®, Osteohealth, Shirley, NY) and a figure-of-eight chromic suture (4-0). (e) Healing site after 3 weeks demonstrating maturing epithelium. (f) Open exposure of the grafted site after 6 months’ healing and implant placement (5 mm diameter) demonstrating buccal bone volume. (g) Pretreatment cone beam computed tomography (CBCT) cross-sectional radiographic view of the failing molar site. (h) CBCT cross-sectional radiographic view of the grafted edentulous site after 6 months’ healing, immediately prior to implant placement. © Daniel R. Cullum.

Figure 5.4

(a) Failing maxillary right central incisor with a buccal fistula. (b) Atraumatic removal of the fractured root and socket debridement is completed. (c) The residual defect is grafted with mineralized allograft up to the surrounding bone margins. (d) Facial and (e) occlusal views showing the sectioned collagen plug saturated in rhPDGF (GEM 21S®, Osteohealth, Shirley, NY) after being placed in the crestal soft tissue defect and secured with a figure-of-eight 4-0 chromic suture. (f) Occlusal view after 10 days’ healing. (g) Occlusal view after 4 months’ healing. (h) Occlusal view of implant placement demonstrating buccal bone volume after modified Bio-Col® technique. (i) Final buccal dimensions can be visualized after restoration. (j–l) CBCT cross-sectional radiographs of the site demonstrate bone dimensions preoperative, 4 months post-operative, and after restoration. © Daniel R. Cullum.

Figure 5.5

Scanning electron microscopic comparison of expanded PTFE (ePTFE) and hd-PTFE. At 500×, the “node and fibril” structure typical of ePTFE can be seen, whereas the surface of hd-PTFE appears more dense without distinct fibrils. At 20,000×, individual ePTFE fibrils are shown, demonstrating a highly porous structure. At 20,000× the submicrometer pore size of hd-PTFE can be appreciated.

Source:

Implant Site Development and Extraction Site Grafting Technical Manual. Osteogenics Clinical Education, 2012. Reproduced with permission of Dr Barry Bartee, Osteogenics Biomedical, Inc. Lubbock, TX, USA.

Figure 5.6

(a) Clinical photograph of the symptomatic maxillary left cuspid tooth. (b)Periapical radiograph showed external root resorption. (c) A circumferential intra-sulcular incision was made to free the marginal soft tissues. (d) A micro-periosteal elevator was used in initial flap elevation to start to create a soft tissue pouch into which to insert the barrier material. (e) The buccal bone level was found to be 6 mm apical to the buccal soft tissue margin likely as a result of the external root resorptive activity. (f) A combination of particulate mineralized and demineralized allograft materials was used to graft the socket. (g) A collagen membrane was prepared to provide a first layer of protection for the grafted socket. (h) The collagen membrane was inserted onto the surrounding bone margins on the buccal, palatal, and interproximal regions. (i) The hd-PTFE barrier was trimmed to create rounded edges and with adequate length to cover the socket and rest on 3–4 mm of the peripheral bone. (j) The hd-PTFE barrier was carefully inserted to avoid bent edges and underlying dead space. (k) Sutures were used to stabilize the barrier. (l) The inserted Essix® retainer used for temporization.

Figure 5.7

(a) The site at 3 weeks of healing immediately before non-surgical removal of the barrier. (b) At 6 weeks the site has healed well with good ridge width retention and formation of abundant keratinized tissue.

Figure 5.8

(a) Four-month post-ridge preservation soft tissue profiles. Compare with the pretreatment defect Figure 5.6a and e. (b) Soft tissue profile after 4 months’ healing. (c) Four-month bone healing is shown in this radiograph. (d) Minimally invasive implant site preparation with a small, u-shaped flap elevation preserving the adjacent papillae. (e) The implant placed and soft tissue sutured. The flap was repositioned apically to retain and further thicken the keratinized tissue. (f) A radiograph of the implant after 4 months’ site healing. (g) The buccal soft tissues 4 months following implant placement. (h) The implant restoration included a custom zirconia abutment. (i) Post-restoration clinical view after 16 months. (j) A post-restoration radiograph taken after 16 months of clinical function. (k) A CBCT scan at 16 months reveals adequate retention of buccal cortical bone for the whole implant length.

Figure 5.9

(a) The healing tissue profile in the previously extracted first molar site which had not been preserved with grafting appears abnormal with likely loss of buccal bone, later confirmed with a computed tomography scan (see (c)). (b) The mandibular right second molar was deemed hopeless and showed extensive bone loss secondary to a root fracture. Evidence of recent extraction of the first molar can be seen. (c) The preop computed tomography scan shows extensive bone loss in the previously extracted mandibular first molar site. (d) The socket walls at the second molar site were largely intact, while following debridement the first molar site shows inadequate bone healing. (e) The debrided sockets were filled with a combination freeze-dried allograft that had both a mineralized and demineralized portion. (f) The graft material was covered with an hd-PTFE barrier. (g) The soft tissues were sutured with no effort being made to gain complete flap closure.

Figure 5.10

(a) A 6-month post-extraction CBCT scan showed good healing at the second molar site and regeneration of buccal plate and lost vertical height at the first molar site. (b) Cross-sectional image of right mandibular second molar. (c) Cross-sectional image of right mandibular first molar. (d) Complete soft tissue healing can be seen 6 months after extraction and socket preservation grafting. (e) A wide, flat, healed bony ridge is seen after 6 months’ healing and flap reflection. (f) Two 4.8 mm diameter threaded implants were placed. (g) The soft tissue were sutured following single-stage implant placement. (h) The histological findings following 6 months of healing at the grafted first molar site. (i) A clinical photograph of the completed implant-borne prosthesis. (j) The baseline post-treatment radiograph.

Chapter 6

Figure 6.1

The four cohorts. LL: Laser-Lok® (BioHorizons, Birmingham, AL); RBT: resorbable blast texturing; M: machined surface.

Figure 6.2

Implant platforms were placed as level as possible with the osseous crest to allow for accurate histologic assessment of crestal bone levels.

Figure 6.3

LL microgrooved healing abutment (L) and standard machined-surface healing abutments (M) were placed on the implants at the time of implant placement.

Figure 6.4

Bucco-lingual light microscopic section of a group A specimen demonstrating osseointegration and crestal bone levels.

Figure 6.5

At group A sites, the JE ended at the coronal-most LL grooved area. Apical to the JE, healthy connective tissue fibers attached perpendicularly to the laser-ablated channels.

Figure 6.6

In this group A specimen, regenerated bone was attached to the LL abutment surface and the IAJ microgap was eliminated.

Figure 6.7

Intense fibroblastic cellular activity and dense networks of connective tissue fibers occurred on the LL microgrooved areas of abutments in all group A specimens.

Figure 6.8

A light microscopic section of a group B specimen demonstrating native and new bone (darker stain) on the implant surface. This probably is the result of the correction of drilling disparity, but it is evidenced that the supracrestal connective tissue fiber has prohibited apical migration of epithelium, allowing the bone to respond in an aseptic environment.

Figure 6.9

A polarized light microscopic view of a group B specimen demonstrating perpendicularly oriented connective tissue fibers against the entire surface of the LL microgrooved area.

Figure 6.10

A group C specimen with a long JE seen along the abutment and implant MTC surfaces, preventing connective tissue fibers from forming the protective barrier seen in groups A and B.

Figure 6.11

A group D high-power specimen demonstrated apical JE migration, resulting in significant crestal bone resorption.

Figure 6.12

The LL collar of a dental implant. The most coronal zone of 0.5 mm has a machine-turned surface. The black arrow distinguishes the upper laser-ablated zone, which consists of 8 μm microgrooves that are 6 μm deep, from the lower laser-ablated zone, which consist of 12 μm microgrooves that are 12 μm deep.

Figure 6.13

A ground section showing intimate osseointegration of this implant. Note the intense remodeling activity in the area of newly formed bone (NB). OB: local old bone.

Figure 6.14

A ground section of specimen stained with toluidine blue–Azure II.

Figure 6.15

Higher magnification of Figure 6.14 identifies the apical extent of the JE (red arrow). There is a connective tissue attachment to the laser microchannel surface that extends to the point of bone attachment.

Figure 6.16

View of the connective tissue in contact with the laser microgrooves (Figure 6.14 at higher magnification and with polarized light). Note the functional orientation of the collagen fibers toward the implant surface. I: implant; AV: alveolar bone crest.

Figure 6.17

SEM image showing collagen fibers attached to the rough implant surface (original magnification ×3810).

Figure 6.18

Higher magnification of area shown in Figure 6.17 (original magnification ×9510).

Figure 6.19

Healing abutment with a 0.7 mm LL microgrooved zone.

Figure 6.20

At low magnification, peri-abutment soft tissues are healthy with no inflammatory cell infiltrate at the IAJ. A long JE is absent, and excellent bone-to-implant contact is noted at all implant threads.

Figure 6.21

At higher magnification, direct contact (arrows) is seen between the abutment microchannels and adjacent connective tissue. Evidence of a long JE is absent. LLA: LL abutment; CT: connective tissue.

Figure 6.22

Crestal bone can be seen in close contact with the implant collar surface, with no evidence of bone loss apparent, and even new bone formation (arrows). LLA: LL abutment; CT: connective tissue; B: bone.

Figure 6.23

Low power view of an en bloc specimen to show healthy connective tissue against all borders of the abutment surface. No evidence is seen of crestal bone loss on either side of the implant collar.

Figure 6.24

At higher power, dense connective tissue (arrows) is seen in intimate contact with the abutment microgrooved surface. LLA: LL abutment; CT: connective tissue.

Figure 6.25

Polarized light image to demonstrate dense, obliquely oriented connective tissue fibers inserting directly into the laser microchannel abutment surface. LLA: LL abutment; CT: connective tissue.

Figure 6.26

(a) Initial radiograph of a defect around the mandibular left central incisor. The site showed complete loss of the facial plate, and the implant was placed using a staged protocol with bone graft and resorbable barrier membrane. (b) Two-year radiograph of restored case demonstrating stable crestal bone level. (c) Two-year clinical picture of (b).

Figure 6.27

(a–c) A patient with a failed fixed partial denture in the maxillary left posterior region. A CT scan revealed a ridge width of 4–5 mm, requiring a ridge-splitting technique at the time of implant placement: (a) initial radiograph; (b) digital radiograph of the implants placed; (c) after 1 year in function. (d–f) Long-term post-restoration follow-up digital radiographs demonstrate crestal bone stability at (d) 2 years, (e) 3 years, and (f) 4 years.

Figure 6.28

(a) Radiograph at 3 years of a LL 3.5 mm platform implant (BioHorizons, Birmingham, AL) placed in a narrow ridge of a congenitally missing left maxillary lateral incisor in this 21-year-old female. (b) Clinical photograph of restored maxillary lateral incisor. Note crestal bone level at coronal aspect of LL microchannel collar.

Figure 6.29

(a) Radiograph at 2 years following immediate extraction and implant placement of the maxillary right central incisor with a 4.5 mm platform LL tapered internal implant (BioHorizons, Birmingham, AL). (b) Clinical photograph of 2-year result in 78-year-old female.

Figure 6.30

(a) Radiograph at 10 years utilizing prototype LL microtextured 1 mm collar implant. Note crestal bone levels within 0.5 mm of top of collar. (b) Clinical photograph of restored implant at 8 years with maintenance of gingival papilla height and facial contour.

Chapter 7

Figure 7.1

(a) Preoperative view of the failed maxillary left central incisor. (b) CT scan image reveals a lack of facial bone and root fracture with palatal bone loss.

Source:

Misch CM. The use of recombinant human bone morphogenetic protein-2 for the repair of extraction socket defects: a technical modification and case series report. Int J Oral Maxillofac Implants 2010; 25: 1246–1252.

8

Reproduced with permission of Quintessence Publishing Co., Inc.

Figure 7.2

(a) An occlusal view of the extraction socket and bone defect. (b) The socket was grafted with rhBMP-2–ACS and secured with cross-sutures. (c) Healing at 1 week following the extraction and grafting.

Source:

Misch CM. The use of recombinant human bone morphogenetic protein-2 for the repair of extraction socket defects: a technical modification and case series report. Int J Oral Maxillofac Implants 2010; 25: 1246–1252.

8

Reproduced with permission of Quintessence Publishing Co., Inc.

Figure 7.3

(a) Cross-sectional CT scan image of the healed graft site at 5 months. (b) An occlusal view of the implant. Note the regeneration of the buccal and palatal bone. (c) Final cement-retained implant crown. (d) Periapical radiograph of the restored implant reveals favorable integration. (a, b)

Source:

Misch CM. The use of recombinant human bone morphogenetic protein-2 for the repair of extraction socket defects: a technical modification and case series report. Int J Oral Maxillofac Implants 2010; 25: 1246–1252.

8

Reproduced with permission of Quintessence Publishing Co., Inc.

Figure 7.4

(a) Preoperative view of the failed maxillary right central incisor. (b) Cross-sectional CT scan image reveals a lack of facial bone over the endodontic treated failed incisor. (c) A probe was used to evaluate the buccal bone defect. (d) The socket was grafted with rhBMP-2–ACS and secured with cross-sutures. (e) Healing at 1 week following the extraction and grafting.

Source:

Misch CM. The use of recombinant human bone morphogenetic protein-2 for the repair of extraction socket defects: a technical modification and case series report. Int J Oral Maxillofac Implants 2010; 25: 1246–1252.

8

Reproduced with permission of Quintessence Publishing Co., Inc.

Figure 7.5

(a) Cross-sectional CT scan image of the healed graft site at 4 months. (b) Implant placement into the healed bone graft at 5 months. (c) Periapical radiograph of the implant after second stage surgery. (d) The implant is restored with a cement-retained crown. (a, b, d)

Source:

Misch CM. The use of recombinant human bone morphogenetic protein-2 for the repair of extraction socket defects: a technical modification and case series report. Int J Oral Maxillofac Implants 2010; 25: 1246–1252.

8

Reproduced with permission of Quintessence Publishing Co., Inc.

Figure 7.6

(a) Preoperative view of patient with hypodontia. (b) Missing maxillary right cuspid #6. (c) Missing maxillary left cuspid #11. (d) CT scan image of the maxillary right cuspid site. (e) CT scan image of the maxillary left cuspid site.

Figure 7.7

(a) Mucoperiosteal flap is elevated to expose the maxillary ridges. (b) A composite graft mixture of rhBMP-2–ACS plus mineralized allograft plus platelet-rich plasma. (c) The maxillary right ridge is augmented with the composite graft supported by titanium mesh. (d) The maxillary left ridge is augmented with the composite graft supported by titanium mesh.

Figure 7.8

(a) The regenerated bone is D3 quality, so the implant osteotomy is prepared with osteotomes. (b) An occlusal view of the reconstructed ridge and the implant osteotomy. (c) The tapered implant is inserted for submerged healing.

Figure 7.9

(a) Removal of the titanium mesh reveals a “pseudoperiosteum” over the maxillary left reconstructed ridge. (b) An occlusal view of the implant in the maxillary left ridge.

Figure 7.10

The healed implants are restored with single crowns.

Figure 7.11

(a) Axial view of CT scan image reveals large cyst in the right posterior mandible. (b) Preoperative cross-section view from CT scan following cyst removal and healing. (c) Flap reflected to expose the atrophic posterior mandible after healing from the cyst removal. (d) The rhBMP-2–ACS mixed with allograft is packed into the concave area of the titanium mesh. (e) The titanium mesh and graft is secured over the atrophic ridge with monocortical fixation screws. (f)After 6 months’ healing, the mesh was removed and three 4.0 mm diameter implants were inserted. (g) A lateral view of the reconstructed site and implant placement in the right posterior mandible.

Source:

Misch CM. Bone augmentation of the atrophic posterior mandible for dental implants using rhBMP-2 and titanium mesh: clinical technique and early results. Int J Periodontics Restorative Dent 2011; 31; 581–589.

12

Reproduced with permission of Quintessence Publishing Co., Inc.

Figure 7.12

(a) This extraction socket defect has 10 mm loss of buccal plate. It was grafted with a combination of rhPDGF-BB and MCBS (no membrane), and the buccal flap advanced for primary closure. (b, c) The re-entry at 5 months demonstrated robust bone formation, which was confirmed via histologic evaluation. Reprinted with permission of Quintessence Publishing Co., Inc.

Figure 7.13

(a) This radiograph demonstrates advanced vertical bone loss to the apices of the first molar and to 80% for the second molar, which had hopeless and guarded prognoses respectively. (b) The first molar extraction site was grafted with rhPDGF-BB-enhanced freeze-dried bone allograft covered by a collagen membrane. The growth-factor-enhanced healing resulted in early bone formation and graft biomaterial integration, as evidenced by this 5-week post-operative radiograph. (c) The 3.5-month CBCT scan revealed extensive bone regeneration. (d) The surgical re-entry at 8 months demonstrated the degree of bone fill and little evidence of the graft particulate. (e) The bone fill on the mesial of the second molar allows for ideal implant placement. (f) The 3-year follow-up periapical radiograph.

Figure 7.14

(a, b) Note the significant bone loss post-extraction from pressure due to an ill-fitting removable partial denture. (c) A pretreatment CBCT scan using a barium stent fabricated via a diagnostic wax-up allowed an accurate diagnosis and treatment plan. (d) A scaffold system combining a tenting screw, freeze-dried bone allograft (soaked in rhPDGF-BB), and a resorbable membrane were used successfully to regenerate the ridge, as evidenced in the 5-month post-grafting CT scan. (e) Re-entry demonstrated adequate bone for implant placement (Figure 7.3d) and allowed for implant placements. (f) Post-placement radiograph of the implants.

Figure 7.15

(a) This maxillary central incisor was planned for extraction and replacement with an implant. Note the gingival recession and thin tissue biotype in this pretreatment photograph. (b) A pretreatment CBCT scan revealed a thin buccal plate of bone with the root angled buccally. (c–f) A semilunar incision with full-thickness flap elevation was made apically at the mucogingival junction to permit adequate surgical access for removing all residual apical granulation tissue, performing a frenectomy, and placing growth-factor-enhanced bone matrix with a barrier membrane to protect an apical bony fenestration. (g) An Essix appliance avoided pressure on the healing site. (h) The periapical radiograph 3 months post-extraction. (i–k) Re-entry surgery after 5 months’ healing allowed implant placement and connective tissue grafting. (l, m) The final restoration met the patient’s functional and esthetic needs.

Chapter 8

Figure 8.1

(a) Periodontal attachment–junctional epithelium supported by strong dentogingival fibers. (b) Numerous collagenous fibrils are bundled into one fiber and each fiber is firmly anchored to the mineralized cementum. Courtesy of Dr Peter Schupbach. Nobel Biocare. Reproduced with permission of Nobel Biocare.

Figure 8.2

“O-ring” stability at the implant–gingival complex is provided by circular fibers as seen on polarized light microscopy, arranged around an implant abutment in an “O-ring” configuration. Courtesy of Dr Peter Schupbach. Nobel Biocare. Reproduced with permission of Nobel Biocare.

Figure 8.3

(a, c) Peri-implant bone remodeling and crestal bone volume.

28

Good thickness of bone on the buccal side of implant is necessary to support the gingival margin following bone remodeling for establishment of the biologic width. (b, d) Inadequate buccal bone thickness on an implant can result in vertical bone loss and recession of the gingival margin following remodeling needed for biologic width. Grunder et al. 2005.

28

Reproduced with permission of Quintessence Publishing Co., Inc.

Figure 8.4

(a) The clinical presentation of the left maxilla with loss of the facial gingiva at the lateral incisor, canine, and first premolar sites after guided bone regeneration and labial flap advancement for primary wound closure. (b) The implant-supported restorations  year after a free gingival graft was placed at the maxillary left canine and first premolar sites providing vestibular extension, frenum release, and an increase in the thickness and width of attached gingiva.

Figure 8.5

(a) A palatal connective tissue harvest was completed using a curvilinear incision (mid-palatal of the first molar to the distal aspect of central incisor) at a minimum distance of 3 mm from the palatal gingival margin; dissection was done parallel to the palatal surface deep to the vault to gain maximum tissue harvest. Adequate thickness of the overlying epithelial flap is necessary to preserve blood supply and vitality during the donor site healing interval. (b) After ensuring adequate dimensions of the graft, the incision is completed through the remaining connective tissue and the periosteum elevated. (c, d) After the final dissection and capture of the free graft have been completed, the tissue is “defatted” and stored in a saline-soaked gauze. © Daniel R. Cullum.

Figure 8.6

(a) A tuberosity connective tissue harvest using an oblique and/or semilunar incision completed from the disto-buccal aspect of the tuberosity to the palatal aspect of the second molar. (b) Joining the oblique incisions can maximize the linear dimensions of the harvested tissue and in designing the graft to fit the recipient site. (c) The harvested tuberosity connective tissue graft. (d) The trimmed connective tissue graft simulating positioning on the buccal soft tissue prior to insertion into the recipient tunnel. © Daniel R. Cullum.

Figure 8.7

(a) The immediate post-extraction condition of a maxillary right central incisor site after decortication in preparation for socket grafting. (b) A palatal connective tissue donor site demonstrating the mucosal–connective tissue plane of dissection (prior to elevation and harvest of the connective tissue). (c) A buccal supraperiosteal pouch has been prepared. The connective tissue is engaged with a monofilament horizontal mattress suture. (d and e) The connective tissue is pulled into the buccal pouch, then the lingual and sutured. (f) The post-operative view of the connective tissue graft forming a biologic plug at the time of socket grafting of the maxillary right central incisor. (g) One month healing of a socket bone graft where a connective tissue graft was utilized for socket closure and maintenance of the buccal soft tissue contour. (h) The final restoration of the maxillary right central incisor implant with esthetic gingival contours.

Figure 8.8

(a, b) Preoperative views of an edentulous maxilla with a failing mini-implant reconstruction and severe anterior bone loss and posterior soft tissue tuberosity hyperplasia. (c) Preoperative view of the atrophic edentulous maxilla after mini-implant removal. (d, e) The incision design for bilateral maxillary tuberosity connective tissue harvest/volume reduction. (f, g) The harvested connective tissue prior to recipient site development and graft placement. (h, i) An incision has been made at the mucogingival junction for a split-thickness dissection. (j, k) The split-thickness dissection has been completed uniformly into the bilateral vestibule and extended to the depth required to remove any muscle pull or instability with lip or cheek mobilization. (l) The crestal tissue was secured to the periosteum at the base of the wound for “vestibular fixation” and the connective tissue grafts were sutured in place with 4-0 Vicryl® (Ethicon, Summerville, NJ). (m) The post-operative image at 4 weeks. (n, o) The soft tissue healing prior to maxillary reconstruction with implants. © Daniel R. Cullum.

Figure 8.9