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 

Legacy 3 Implant restoration

The patient is controlled diabetic with fair oral hygiene but stable periodontal attachment for the last 7 years (He is my father).
Due to diabetes we proceeded with staged approach for the implant placement.
Extraction+socket graft and later implant placement

The design of the prosthesis:

The lab fabricates a PFM crown keeping access to the screw of the abutment
The abutment is sandblasted and the crown is cemented on the abutment with a permanent cement extra orally

Benefits:
1. Cost ( you use the abutment that comes with the implant)
2. Factory abutment has better fit on implant platform compared to a UCLA abutment
3. Avoid cement trap in cases with deep peri-implant sulcus. This could lead to peri-implantitis development
4. Easy access in case the crown needs to be removed for any reason

Ioannis

Socket Graft of a Maxillary 1st Molar

Diagnosis
1. #16 Hopeless for endodontic and restorative reasons.
2. Odontogenic sinusitis

Treatment plan
Extraction of #16 and graft
3-4 months later
Dental implant placement with possible minor sinus lift

We utilized a cross type, double layer technique with a collagen membrane to over come major facial bone resorption.
Why?
Because the facial wall was very thin with small fenestration present. This kind of conditions might lead to up to 4mm bone resorption if GBR is not utilized at the time of extraction.
Upon re-entry the alveolar ridge width was 10.5 mm. This allows us to place a 5mm diameter implant with good amount of bone surrounding it.

Ioannis