Esthetic Dilemma

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Healthy 55 year old woman with fairly thin biotype and a very high smile line presents with failing #8. #9 implant was placed and restored 4 years ago. (for you disbelievers, it was done as an immediate placement and immediate provisional procedure which included hard and soft tissue augmentation. Papilla between 9 and 10 was blunted before I replaced #9.) Patient will reluctantly consider redoing other restorations, but no ortho.

Good ideas regarding #8?

Jeff Ganeles

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Jeff,
As far as #9. Was it done :
1.Flapless?
2.Did you just augment the gap? Or a more extensive hard tissue graft What did you place?
3. Was the soft tissue a SECTG tunneled as per Grunder?
4. Are you ever worried about using a bone level implant with the loss of the height of the facial socket? It is a very nice result..interested in your protocol.

Thanks,

Dominic

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Jeff,

My thought would be to retain the root for #8 and go with a new cantelever 9-8.
To begin, I would remove the crown #8 and convert it to an ovate pontic that you bond back into position after you seal off the root with a ct graft.
Once tissues are stable proceed with the final restoration.

Chuck

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This was done flapless, although I apparently created a pouch to place a CT graft. Augmented the gap with BioOss and autogenous chips.

Jeff

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Hi Jeff,

Given the comments related to keeping the root and redoing the crown on #9 with a cantilever: why wouldn’t you place another implant and do the same transition you did for #9?

All the best,

John

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Jeff,

Very nice. Is your final restoration screw retained?

Chuck

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No, cemented ceramic crown on Atlantis abutment on Astra Tech implant.

Jeff

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John,

I am concerned that if #8 is extracted, I will lose the papilla between 8 and 9, creating the need to lower the contact point and create 2 long rectangular crowns. Also I am not aware of any kind of “socket preservation” technique that would preserve the papilla between 8 and 9.

Nick, what kind of socket graft are you talking about that would prevent loss of the papilla between 8 and 9? Please elaborate.

Jeff Ganeles

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Jeff,

In the cases (limited) where I have done upper anterior side by side immediates with provisionals the profiles of the provisionals are what maintain the inter-implant papillae. I think the other suggested procedures pose the same risk.

Here is an example of one of my cases:
http://youtu.be/W-s2xOj79co Granted the papilla was not as long as the midline one your patient has now.

My experience with transitional stayplates with ovate pontics is that the shape of the tooth will support the papilla AND that shape is really critical. If you we do our own provisionals we have control over the contours.

All the best, John

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John,

I like your technique, and agree that crown contours are extremely important for cultivating soft tissue profiles, but still feel side by side implants in the esthetic zone are NOT the treatment of choice.
I believe in Jeff’s case the expectation’s are much higher than what you have demonstrated.
In your case, had you kept the root of #7 and performed soft tissue augmentation, you probably would have done better with a cantelever-ovate pontic solution.
Fundamentally, you seem to overestimate the capabilities of implants underestimate the value of the attachment apparatus of natural teeth.

Chuck

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I think the problem is not supporting soft tissue with contours of provisionals initially, it is the fact that to do these cases correctly in the “smile zone” implants need to be countersunk in order for the development of proper emergence profile of the final restorations. Countersinking adjacent implants–with time–leads to a loss of interdental bone, especially if the implants are too close. Once the interdental bone starts to melt away, the soft tissue follows, hence the dredded “black triangle”. Spear had a great article in which he showed that a distance of 3mm or greater allowed for a maintenance of interdental bone in spite of countersinking in the anterior. Once again, can it be done–SURE, but the risks are great and once it’s done it’s DONE. Where is Dr. Salama on this one? I’m no expert. Much of what I do is partially grounded in some of what I’ve learned by listening to him.

Nick

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Jeff, did you take a ct scan of the area and measure your distances?

By the way beautiful result on #9!

Alan

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Hi Chuck,

Thanks for your comments! It always helps me to think when I get questions and comments like yours. It always broadens my curiosity.

I’ll argue though, that the attachment of teeth and the regeneration of that attachment has been fundamental to my practice. And with the aid of the periodontal endoscope we have revolutionized disease treatment and management. There certainly are multiple ways to solve and treat any given problem and this group is wonderful in how it shares in such a collegial way (for the most part).

I look forward to your comments and here is something I just posted on YouTube: http://youtu.be/gUQmILLr7h0 Preprosthetic Soft Tissue Reconstruction

All the best,

John

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John,

I am happy to see you have a thick skin and are open minded.
In that light I would like to ask you a few questions that I hope you will not find insulting.
1. What is your understanding of the function of the PDL and it’s ability to maintain and remodel bone and more importantly what do you think happens to the bone when a tooth is extracted.
2. What is your understanding of the attachment of implant to bone and why you believe placement of an implant has the ability to maintain and remodel bone.
I certainly would understand if you don’t wish to respond to these questions, but perhaps it will give you more to think about.

Chuck

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John-

Nice results.
A trick I learned from Peter Nordland – use the N6900 blade. It is thinner and bends to assist in sharp dissection beyond the alveolar crest.
Do you soak/hydrate your Alloderm in anything “active”?

Bob

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Hi Bob,

I used the Nordland blade for years but when I watched the Pat Allen technique and started using the combo of the Orban knife and the endo spoon I found I would get more full thickness reflection. This results in just as much mobility but thicker tissue. The side benefit is that I don’t pay for the blades like I used to.

All the best,

John

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Hi Chuck,

I’m sorry that I probably won’t take the time to answer your questions (I feel somewhat like I’m being tested). However, if you have the time I’d certainly like to read your anwers. My opinions related to your need to get clarity are only time tested having placed and fixed implants since the late 80’s. I seem to have success in areas that apparently don’t work in other practices or where there is doubt that proof of concept exists. I’ll certainly keep sharing because as Dr. Atul Gawande says we should have a coach. This forum is kind of like that for me.

All the best,

John

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Then I guess I will have to order the endo spoon. Thanks for the information. Where do you get it from?
Do you use the 7-0 mono sutures for everything or just the repairs? What do you think about the 6-0 PTFE from Osteogenics?
Thanks for the information.

Bob

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John,

Please please keep sharing. I am very interested in what you are doing. We all benefit and learn from each other.
You may find it hard to believe, but my technique and philosophy of extraction – immediate implant placement – provisional crown placement is quite similar to yours. In addition, I am getting similar results.
I believe we are doing pretty much the same things (perhaps for different reasons).
I prefer to use GCT vs Alloderm and use FDDBA hydrated with anesthectic vs your tetracycline mix. Probably no significant difference. Although I am hearing that alloderm (placed single layer) is gone in 2 years.
My focus going forward is on the provisional materials and contours. I have most recently shifted to the Zimmer contoured zirconium abutments and PureForm Ceramic Copings.

Chuck

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Hi,

I have attached my instrument list which indicates what and where. I use the 7.0 vicryl for the repairs (on the list). I normally use 6.0 proline for the coronal positioning slings now. I used to use 6.0 and 7.0 gore tex all the time but now for suspensory sutures in papilla reconstruction and for pulling graft tissue into the space prn.

Is the PTFE suture from Osteogenics less cost than Gore? Once in a while I’ll use the 7.0 vicryl for other things but the needle is not big enough for getting interproximal (maybe ok in the anterior).

All the best,

John

[document redacted]

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Sorry,
I hit the send tab before finishing.
As far as the previous questions relative to comparing teeth to implants, I will try to be brief in my explaination.
Only teeth via PDL have the ability to truly REGENERATE bundle bone. Once a tooth is extracted you no longer have that ability. You now are dealing with REPAIR or RECONTRUCTION of bone.
What role an implant may play (or not play) in the repair or recontruction of bone is unclear. One thing that is clear. It is NOT bundle bone.
Rather than drone on and on. I will conclude in saying:

The unique ability of the PDL to replace and maintain bundle bone is to valuable to discard prematurely.

Chuck

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Hi Chuck,

I get it. It’s amazing what we can do with hard and soft tissue regeneration and reconstruction around teeth and implants!

All the best,

John

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Those are a few reasons I like Osteogenics.

Their needle is significantly longer than Gore’s and the sutures are much less costly. Once in a while, there’s a little “chalking” where the suture is pulled through the tissue. Otherwise, I have been very happy with them.
Thanks for sending along the supply list. More stuff to buy and store.

Bob

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