This video demonstrates the use of the VPI Cervico system/concept for the selection of the proper gingival cervical profile, the accurate placement of an implant in relation to the desired custom gingival cervical profile and the development and recording of the selected custom gingival emergence and Cervical profile after implant osseointegration.

This a complicated sinus graft case where extraction of a palatally impacted tooth was performed at the same time with the sinus lift procedure. 7 months later 2 implants were placed and they were immediately loaded. 16 months post loading both implants are clinically and radiographically successful.

Dr.Vergoullis

DENTAL IMPLANTS IN THE ESTHETIC ZONE

DENTAL IMPLANTS IN THE ESTHETIC ZONE IN COMBINATION WITH CROWN LENGTHENING PROCEDURE POST ORTHODONTIC TREATMENT

POINTS OF INTEREST:

1. PATIENT WAS REFFERED FOR IMPLANT PLACEMENT BUT DURING CONSULTATION APPOINTMENT SHE WAS INFORMED FOR THE AESTHETIC ADVANTAGES OF PERFORMING A  CROWN LENGTHENING PROCEDURE OF THE CENTRAL INCISORS AND THE PATIENT AGREED ON PROCEEDING WITH A COMBINED IMPLANT PLACEMENT AND CROWN LENGTHENING APPROACH

2. THERE WAS PLENTY OF BONE FACIALLY BUT THERE WAS BONE MISSING PALATALLY. THIS IS USUALLY SEEN IN CERTAIN CASES POST ORTHODONTIC TREATMENT. IN THESE CASES IT IS IMPORTANT TO CONSIDER THE LINGUAL SIDE OF THE FINAL PROSTHESIS WHEN DECIDING ON IMPLANT POSITION

3. #12 SITE SHOWED SOME IRRITATION DUE TO GRAFT EXFOLIATION FACIALLY, WHICH IS CONSISTENT WITH PRESENCE OF THINNER SOFT TISSUE IN THE AREA. A CTG AT TIME OF GRAFTING OR AT UNCOVERY COULD PREVENT SUCH ISSUES.

IOANNIS

Bilateral Sinus graft & GBR with tenting screw Vs laminate block graft

This is a case where we performed a bilateral sinus graft and simultaneous ridge width augmentation. On both sides we utilised the bony window as a source of graft. On the right side the window broke upon use of the bony screw, so we crashed it in small pieces and we utilised the screw as a tenting screw and performed GBR. On the left side we utilised the window as a laminate graft.
Unfortunately our piezotome was broken at the time, so we had to use a high speed hand piece with a diamond bur, which made the process uneasy. I am looking forward to hearing your thoughts about the efficiency of these two different approaches.
Best,
Ioannis

Implant maintenance

This is a case of immediate extraction, implant placement and loading performed 8 years ago. We show in the video the protocol of maintenance we utilise.
1. Pocket depth probing and bleeding on probing recordings
2. Cleaning of implants with inserts with silicone tip
3. Cleaning of the prosthesis with regular cavitron inserts

Cosmetic crown lengthening with new prosthetic restorations

The patient was referred in our clinic by the GP for aesthetic crown lengthening of the maxillary anterior teeth, in order to improve the teeth proportions and re-establish bilateral symmetry.
Post crown lengthening composite resin was placed over the newly exposed root surfaces in order to support the gingival in there new position.
12 weeks post-op a new set of temporary prostheses were placed and the tissue was allowed to mature for an additional month before final restorations were placed.

Surgery: Ioannis Vergoullis, DDS, MS
Prosthetics: Claudia Stamatidou, DDS
Lab: TDK

Esthetic rehabilitation of the maxillary anterior teeth

The patient was referred to our clinic for esthetic evaluation of the maxillary anterior teeth. 

The teeth were in malposition in the arch. They also had uneven gingival margins as well as inadequate crown proportions. 

We recommended orthodontic treatment for proper teeth alignment. Followed by cosmetic crown lengthening for establishment of adequate crown proportions. Finally, prosthetic rehabilitation with full ceramic veneers and crowns.

The patient declined ortho treatment. Patient understood that esthetic results may be compromised without ortho treatment and more invasive teeth preparation might be needed.

Diagnostic wax-up was performed and a direct mock-up was done in the patient mouth. 

Based on the mock-up, cosmetic crown lengthening was performed. 

Final restorations were cemented 3 months later.

At 6 months follow up, stable results are appreciated.

Surgery: Ioannis Vergoullis, DDS, MS

Restorative treatment: Marieta Kalogirou, DDS

Immediate replacement of a primary canine with an implant

Patient presented to our clinic for removal of a long standing primary upper right canine (#53) and to be replaced with a dental implant. Clinically, the tooth to be extracted presents with class 3 mobility. 

Patient is a mild smoker (<10 cig/day) without any other contributing factors in the medical history.

We proceeded with the extraction of the primary tooth. The socket was thoroughly derided and difinfected with diamond burs and rinsing with a mixture of TTC solution and saline. 

A Legacy3 3.7x11 implant was immediately placed following the appropriate position within the existent socket.  A high insertion torque was obtained. An impression was taken and a 2 stage protocol was utilized due to the smoking habit of the patient. 

Uncovery of the implant was performed 3 months later.  A temporary crown was placed at this time in order to guide soft tissue profile during healing. 

1 month later, a final screw retained crown was placed by the GP. 

At 1 year post-implant placement, soft and hard tissues seem favorable. However, patient's interproximal oral hygiene was fair and thus mild gingival inflammation is evident on the mesial papillae. 

Oral hygiene was reinforced and an appropiate maintenance schedule was discussed with the patient to ensure gingival health around the implant.

SOCKET GRAFT WITH CYTOPLAST MEMBRANE

Patient presented in our clinic for extraction of tooth # 36 and dental implant replacement after it was diagnosed non-restorable by the patient's dentist.

Treatment plan:

- Extraction of #36 and socket graft

- Dental implant placement 3-4 months later

- Restoration of the dental implant 2-3 months later.

Upon extraction and thorough disinfection of the socket, a facial dehiscence ranging from 8-11mm was identified. Also, a 4mm deep 4-wall defect was found on mesial of tooth #37.

The #36 socket and the periodontal defect on #37 were grafted with a mixture of FDBA and tetracycline and covered with a cytoplast membrane. The membrane was left exposed. Oral hygiene instructions to the patient involved chlorhexidine gel 0.2% application 3 times per day for 7 weeks until the membrane was removed.

A Legacy3 5.2x10mm dental implant was then placed 4 months later presenting high initial stability. After 1 year post-op, good bone stability around the implant can be observed. Also, the defect on medial of #37 responded favorably as it can be observed clinically and radiographically. 

The technique used in this particular case could be utilized in posterior sites with a thick soft tissue and where large amount of bone augmentation is required. Patients medical history should be clear so proper healing could be expected. It is not recommended for patients with potentially impaired healing like diabetics and smokers.

Sinus graft complications & management

The following clinical case shows several minor complications and management during different dental implant surgical stages. 

This is the case of a  28 years old healthy male who came to our clinic for dental implant rehabilitation of the posterior left maxillary area. After clinical and radiographic evaluation, the need for vertical and horizontal ridge bone augmentation was determined. Vertical augmentation was treatment planned to be obtained through lateral window sinus lift surgery accompanied by horizontal ridge augmentation using particulate bone grafting material and membrane. 

Two dental implants were placed 8 months post sinus lift surgery. During the osteotomy for the molar site implant, a small membrane perforation was identified, managed and controlled through the osteotomy site. Dental implants were placed and primary stability was obtained for both. 

Upon dental implant uncovery, 3 months after surgical placement,  bone loss was found on the molar site implant. We reduced the exposed implant threads with Implant-plasty using a fine diamond bur and a layer of HA xenograft bone grafting material was used to graft the facial aspect of the implant. 

The 3 year follow up X-ray shows good bone stability around the implants.

Ioannis

Gingival recession treatment with connective tissue graft

Patient presented to our clinic with the chief complaint of: "Increased and persistent sensitivity on upper left central, lateral, canine and first premolar teeth (21, 22, 23, 24)"

After clinical and radiographic evaluation our Diagnosis given to those teeth was: Class I Miller recession on 21, 22, 23, 24

Etiology: Traumatic forces (applied with a hard toothbrush) over a thin tissue biotype.

Treatment plan: Connective tissue graft with a coronally positioned flap

Prognosis: Excellent (90-100% root coverage is anticipated in class I miller recessions)

Some post operative instructions given to the patient included but were not limited to: 

- Oral hygiene modification: modified Bass toothbrusing technique was instructed

- Recommended the use of a soft toothbrush 

Ioannis

Excision of a Fibroma with the use of a Nd-Yag Laser

Clinical diagnosis:
- Trauma induced Fibroma

Treatment protocol:
1. Occlusal adjustment of the uneven cusps of the teeth involved
2. Complete excision of the lesion for histologic evaluation

The excision of the lesion was performed using a Nd-Yag Laser.
Settings used: 4W, 200mJ, 20Hz

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

Immediate implant placement with 4.5 years follow up (Legacy 1 dental implant)

The case presented is an extraction with immediate implant placement of an upper right first premolar. Patient has been followed up for 4.5 years. Radiographic evidence of inter-proximal bone stability has been consistent through out the years.

In our clinical practice, we have found true that with the proper prosthetic management of soft tissues, adequate quality and quantity of hard tissues and appropriate periodontal maintenance, we could expect long term hard and soft tissue stability, even in periodontally controlled patients.

Key points of the techniques used:

Surgical
- Maintain facial wall intact
- Disinfection of the socket thoroughly
- Surgical removal of the coronal portion of the inter-radicular septum to get a more stable grip of the initial drill in the socket
- Extend 3mm apically to the existing socket to obtain adequate primary stability (therefore, extra 3mm of bone apical to the existing socket)
- Place your implant towards the palatal socket allowing at least a 4mm space between the facial wall to the implant platform and fill in the gap with bone graft material
.
Prosthetics
- Screw retained restorations to prevent the retention of cement apically towards the implant body where it would be harder able to detect.
- Torque crown to 30N/cm or as per manufacturer's recommendation to minimize microgap and micro movement
- Protected occlusion

Implant uncovery technique to correct facial soft tissue deficiency

The case presented is a 2 stage immediate dental implant placement.

Upon implant uncovery,  the top of the implant (cover screw) was covered by bone which was then removed.

The facial soft tissue presented an evident clinical deficiency. In similar cases when this type of tissue deficiencies are not corrected, this can lead to a less than acceptable esthetic result of the area restored.

We utilized a technique that we feel comfortable with to restore this type of deficiencies, in which we augment the facial soft tissue thickness at the time of implant uncover.

Steps:
1. De-epithelialize the crestal portion of the soft tissue (exposing CT)
2. Elevate a mini flap (with 2 small vertical incisions)
3. Split the CT from the mini flap without separating each other
4. Create a facial pouch with split thickness flap
5. Rotate the CT into the facial pouch
6. Place the healing abutment
7. Suture the flap into position

Materials used:
- Implant: Legacy 3 (Implant Direct)
- Sutures: Gut 4.0

Best,
Ioannis