GBR at the time of Immediate Implant Placement

Factors to consider after reviewing a similar case to the one presented in this video:

1. In the presence of an edentulous space next to a tooth that is treatment planned to be extracted, you should evaluate the width of the crest at the edentulous site. This might give you an idea of how much resorption the extraction socket would have if not grafted or immediately place an implant.

2- If not planning on horizontally graft the edentulous site, place your dental implant in the extraction site 2mm lingually to the facial wall of the edentulous site. This is irrespective of the gap between the implant body and the facial wall of the socket. This way you will have a predictable result. If this case scenario would compromise the prosthetic rehabilitation of the implant, then perform GBR and place the implant at second stage.

3. Place the immediate dental implant 2mm sub-crestally to the lingual wall of the extraction socket to accommodate for height resorption, to provide space for establishment of proper emergence profile of the restoration and to establish adequate thickness/height of soft tissue around your implant for the uncovery stage.

Ioannis

Replacement of a broken dental implant

This patient was referred in our clinic for evaluation of an implant that was previously placed by another dentist.

Upon clinical and radiographic evaluation, our diagnosis was:

- Broken dental implant collar associated with occlusal parafunctional habits (bruxism)

Our treatment plan was as follow:

- Dental Implant removal & guided bone regeneration
- Placement of a new dental implant 4-6 months later
- Restoration + delivery of a biteguard for night use: 2-3 months later

Tips: A wider diameter dental implant would be preferable but the limited space mesio-distal and the triangular shape of the desired final restoration would not allow for the use of it. In order to overcome the above, the final prosthesis was kept out of contacts on lateral excursions and protrusion movements.

Ioannis

Dental implant uncovery with simultaneous free gingival graft procedure to augment keratinized gingiva

Diagnosis:
- Movable muccosal tissue around dental implant

Treatment plan for this case:
- Free gingival graft upon uncovery of the implant

Why is stable keratinized tissue important?

1. Keratinized attached tissue around a dental implant minimizes the chance of future recession and possible bone loss on the facial surface of the implant

2. Oral hygiene practices could be performed with minimal discomfort on the area and plaque removal is more predictable if done correctly.

3. Reduction on discomfort related to mastication of hard foods on that site.

Immediate implant placement

Treatment plan:

1. Extraction of teeth #22 and #12 and immediate implant placement with GBR
2. Restoration of the implants 4-6 months later r

Tips:

1. Due to the presence of a very thin buccal plate of the socket as well as on the edentulous area adjacent to the extractions (sites: #11, and 21) we anticipated more bone resorption despite the use of GBR.  An estimation of approximately 1.5-2mm vertical bone loss is expected, therefore the dental implants were placed 2mm sub-crestally.

3. The smooth collar of the implant won't be able maintain the height bone. For that reason it is better to utilize implants with full rough surface treatment in such cases.

4. We used these specific implants as requested by the restorative dentist

5. The open margins of the restoration are located far away from the crestal bone and 0.5mm subgingivally. Thus the environment is relatively aerobic and can be maintained clean with oral hygiene.

I posted this case to point out some factors that could be done better and optimize the result. It will be interesting to see how this case will hold on with time. I will keep you updated as the time passes.

Ioannis

Cosmetic crown lengthening procedure for teeth restored with full ceramic veneers and crowns

Diagnosis:
- Short clinical crown of the central incisors (old crowns present)
- Gingival asymmetry in the anterior sextant
- Malposition in the arch of the lateral incisor (#22)

Treatment plan:
1. Orthodontic treatment to align teeth (patient declined)
2. Temporary prosthesis (crowns / veneers) to establish final incisal edge position of the anterior teeth
3. Crown lengthening surgery
4. Final full ceramic crowns and veneers on anterior sextant 3 months after surgical procedure

Esthetic crown lengthening

Esthetic crown lengthening

Key points to the technique

1. Identify pre-op the location of the CEJ
2. Remove exostosis and festoon the bone for better soft tissue adaptation
3. Establish the 2mm biologic zone around the teeth
4. Apically position the flap to desired position, if necessary perform gingivectomy
(gingivectomy can be performed if zone of attached gingival is adequate)
5. inform the patient prior to the procedure that a secondary minor gingivectomy/plasty might be needed

Ioannis