Nicholas Caplanis DMD MS 6/4/2012

Periodontal and Peri-Implant Considerations 1999 Gingival and Classification In The Esthetic Zone Nick Caplanis DMD MS Private Practice Periodontics and Implant Surgery Mission Viejo, California [email protected]

Assistant Professor Loma Linda University Armitage GC. Ann Periodontol 1999;4:1-6

Classification of periodontal disease and conditions Periodontal disease classification “Key Changes” • Previous classification • Current classification Previous Current • No section on gingival diseases • Entire new section on gingival diseases – 1989 world workshop – 1999 international workshop • “Adult” Periodontitis • “Chronic” Periodontitis • “Early-onset” Periodontitis • “Aggressive” Periodontitis • “Refractory” Periodontitis • Additions • A standard classification provides a framework for the – – Perio-endo lesions scientific study of disease etiology, pathogenesis and – Acquired deformities and conditions treatment as well as a standard mean of communication Armitage GC. Ann Periodontol 1999;4:1-6

Weakness of 1989 classification Classification of periodontal disease and conditions • Criteria for diagnosis unclear • – Typical adult onset plaque induced • Disease categories overlapped – Previously referred to as “adult” perio

• Too much emphasis on age of disease onset and rate of • progression which are difficult to determine – Previously known as pre-pubertal, juvenile perio, localized juvenile perio, rapidly progressive perio, early onset perio • No classification for diseases limited to gingiva Armitage GC. Ann Periodontol 1999;4:1-6

Periodontal and Peri-Implant Considerations in Esthetic 1 Nicholas Caplanis DMD MS 6/4/2012

Classification of periodontal disease and conditions Chronic and Aggressive Periodontitis • Clinical Signs • Treatment – Distribution – Severity – Gingival erythema – Scaling/Prophy with • Localized < 30% sites • Slight 1-2mm CAL – Edema OHI • Generalized > 30% sites • Moderate 3-4mm CAL – – Phase I Re-eval • Severe > 5mm CAL – PPD’s up to 3mm (unless pseudo – 4-6 mo PST pocket) – Soft tissue contour changes – Increased GCF Armitage GC. Ann Periodontol 1999;4:1-6 – No attachment loss

Systemic Connections Slight Periodontitis • Periodontal disease increases CRP levels • Link between Periodontal disease and • Clinical Signs • Treatment – Gingival erythema cardiovascular disease; MI, CVA – SRP + behavior mod – Edema • Link between periodontal disease and the delivery of – Periostat – Bleeding on probing premature, underweight babies – Phase I Re-eval – Slight attachment loss – 3-6mo PST • Link between Periodontal disease and Diabetes – Pocket depths 4mm • Recent link with Alzheimer’s disease • Periodontal Pathogens are transmissible

Biofilm and inflammation management Moderate Periodontitis • Clinical Signs • Treatment – Gingival erythema – SRP + behavior mod – Edema –Rx Periostat – Bleeding on probing – Phase I Re-eval – Moderate attachment loss – Additional RP + Arrestin – Pocket reduction surgery – Slight furcation invasion if needed – Pocket Depths 5mm – Phase II Re-eval – 3-4 mo PST

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Severe Periodontitis 56y/o male generalized chronic severe periodontitis • Clinical Signs • Treatment – SRP + behavior modification – Severe Attachment Loss – Phase I Re-eval – Pocket Depths >6mm – Pocket Elimination Surgery – Moderate to Advanced – Phase II Re-eval Furcation involvement – Bacterial Culture and Sensitivity – Inflammation, BOP – Localized and Systemic Antibiotics – 3mo PST Prior to treatment Jan 2002

Manual vs. Powered tooth brushing for oral health 56y/o male generalized chronic severe periodontitis Materials and Methods Results and conclusions • 42 trials involving 3855 participants • Powered brushes removed plaque included in review and reduced gingivitis more effectively than manual brushes

Robinson PG, et.al. Cochrane Database 2005;18(2):CD002281 Post Perio, Restorative and Ortho Treatment Jan 2007

The efficacy of interdental brushes on plaque and parameters of 56y/o male generalized chronic severe periodontitis periodontal inflammation: a systematic review Materials and Methods Results and conclusions • 218 Medline-PubMed and 116 Cochrane • As an adjunct to brushing interdental brushes papers identified remove more plaque than brushing alone.

• 9 studies met eligibility criteria • Clinical improvements noted in PI, BOP, PD

• Improvement in PI better than using floss Slot DE. Dorfer CE, et.al Int J Dent Hyg 2008;6(4):253-64 Jan 2011

Periodontal and Peri-Implant Considerations in Esthetic Dentistry 3 Nicholas Caplanis DMD MS 6/4/2012

Periodontal Biotype Tooth vs. Implant Histology

Thick Thin • Tooth •Implant –Sulcus –Sulcus • Short square teeth • Long Tapered teeth – Epithelial Attachment – Epithelial Adhesion • Thick robust gingiva • Thin friable gingiva • Wide blunted papilla • Long pointy papilla – Connective Tissue Attachment –NoConnective Tissue Attachment • Resistant to recession • Susceptible to recession – Bone Attachment via Sharpy’s – Direct Bone to Implant Union LM fibers (Osseointegration)

Dimensions of the Dentogingival Junction in Humans Peri-implant biologic width

T • ~1mm O Sulcus O T •Sulcus • ~1mm H • Junctional Epithelium • Connective Tissue Sulcus Attachment ~1mm JE • Connective Tissue Junctional Epithelium Connective Tissue CT Garguilo AW, Wentz FM, Orban B. J Perio 1961;32:261-267

Periodontal Biologic Width Peri-implant Histology •Sulcus • Junctional Epithelium • Junctional Epithelium – Presence of hemidesmosomes • Connective Tissue Attachment

– James R, Shultz RL JOI 1973

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Peri-implant Histology Esthetic Techniques • Connective Tissue • – Parallel Fiber arrangement around smooth titanium • Gingivectomy with osseous surgery – Perpendicular fiber arrangement can be found around – with flap elevation or without rough surfaces • Apically repositioned flap with or without osseous surgery – Adhesion – Fiber dense • Orthodontics Camargo PM, Melnick PR, Camargo LM. CDA Journal 2007;35(7):487-98

Peri-implant probing Esthetic crown lengthening – case 1

• Probe extends to base of connective tissue • Deep pockets difficult to maintain • Deep pockets increase risk for bone loss • Over contoured restorations will prevent accurate probing • Deep pockets around implants do not necessarily represent bone loss

Understanding Biologic Width is Important to Avoid Gingivectomy using Ellman™ Radiosurgery Complications with Restorative Dentistry

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Esthetic crown lengthening – flapless osseous reduction Esthetic crown lengthening – Osseous surgery w flap

Esthetic crown lengthening – case 1 Esthetic crown lengthening-case 2

Esthetic crown lengthening-case 2 Esthetic crown lengthening- case 3

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Esthetic crown lengthening – Gingivectomy guided by stent Root coverage procedures

Esthetic crown lengthening – osseous flap surgery Placement of interpositional CT graft guided by stent

Esthetic crown lengthening-case 3 Root coverage procedures

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Miller Recession Classification Mucogingival surgery – interpositional CT graft Clinical Presentation Expectation Success rates Class I Recession above MGJ – No AL Complete root coverage 100% Class II Recession to or beyond MGJ – No AL Complete root coverage 100% Class III Recession to or beyond MGJ – Minor Partial root coverage to the 50-70% interproximal AL height of interproximal tissues Class IV Recession to or beyond MGJ –Severe Unpredictable root coverage <10% interproximal AL

Miller, PD. A classification of marginal tissue recession. Int J Perio Rest Dent 1985; 5(2):8-13

Treatment of Mucogingival surgery – interpositional CT graft Purpose •To evaluate the outcome of various techniques to assess which provides optimal results

Materials and Methods •Review of controlled clinical trials

Kassab MM, Cohen RE. JADA 2002;133(11):1499-1506

Treatment of Gingival Recession Mucogingival surgery – interpositional CT graft

• Results and Conclusions – Autogenous connective tissue grafts in conjunction with a coronally repositioned flap is most effective in achieving predictable root coverage

Kassab MM, Cohen RE. JADA 2002;133(11):1499-1506

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Root reshaping: an integral part of periodontal surgery Esthetic Crown Lengthening in Posterior and Root Reshaping of the Anterior Teeth Procedure •Alternative to conventional osseous surgery involving reshaping of the existing tooth and root surface with conservative removal of supporting bone to create the width needed for biologically acceptable restorations

Melker DJ, Richardson CR. Int J Perio Rest Dent 2001;21(3):296-304

Combination Esthetic Crown Lengthening, Root Reshaping, Root Reshaping Eliminates Existing Restorative Margins and Root Coverage Procedure

Root Coverage Required to Reduce Anterior Tooth Length Placement of Interpositional CT Graft Guided by Stent

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Esthetic Crown Lengthening, Root Reshaping and Root Coverage A Prospective Randomized Clinical Study of Changes in Soft Tissue Position Following Immediate and Delayed Implant Placement

• Results and Conclusions – No differences between immediate or delayed approaches with respect to midbuccal and interproximal soft tissue margins

van Kesteren CJ, Schoolfield J, West J, Oates T. Int J Oral Maxillofac Implants 2010:25(3);562-570.

Immediate or Delayed Placement? Immediate Questions Realities • Basic Principles for Success • Is the alveolus intact? • Immediate placement more challenging • Will implant stability be achieved? • Physiologic post extraction resorption can lead – Primary stability an absolute requirement • Is pathology present? to a loss of buccal and/or crestal bone – Majority of implant should be within bone • Operator experience and comfort level driven • Is ideal implant position achievable? – Place implant 2mm lingual of buccal plate • Any hard or soft tissue deficiencies? • Implant failure can result in soft or hard tissue • Are there multiple sockets? deficit – Graft residual defect • Will the majority of implant be in bone? – Case selection • consider what may happen if implant fails

A Prospective Randomized Clinical Study of Changes in Soft Tissue Position Following Immediate and Delayed Implant Placement 44 y/o female with chronic alveolar abscess of maxillary left lateral incisor Purpose •To compare efficacy of immediate vs. delayed implant placement in maintaining soft tissue margin position following tooth extraction Materials and Methods •24 patients randomly received either immediate or delayed implant placement •Delayed sites received FDBA and collagen membrane and re-entered for implant placement 3-6 months later

van Kesteren CJ, Schoolfield J, West J, Oates T. Int J Oral Maxillofac Implants 2010:25(3);562-570.

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Small buccal plate perforation therefore immediate implant placement performed in Laboratory Phase conjunction with site preservation including an interpositional connective tissue graft

Prior to surgery, patient prepared for additional Final Outcome adjacent restorations as needed

Prototype development Delayed Placement – Site preservation • Socket graft with a membrane improves ridge height and width following extraction but may interfere with normal healing/bone fill within defect

• Artzi Z et.al. J Perio 2000. 71(6): 1015-23. • Iasella JM et.al. J. Perio 2003 74(7): 990-9. • Lew DW et.al. Int J Oral Maxillofac Implants 2009;24(4): 609-15. • Araujo MG, Lindhe J Clin Oral Implant Res 2009;20(5):433-40.

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Delayed Placement – Site preservation Site Preservation

Site preservation begins with atraumatic tooth extraction followed by Delayed Placement – Site preservation extremely thorough socket and placement of a bone graft EDS-3 Extraction Defect

Autologous Connective Tissue Graft can function as a membrane Site preservation biomaterials to contain graft as well as to repair soft tissue deficit

Bone Grafts likely minimize clot shrinkage and thus alveolar resorption

Membranes serve to contain the graft and minimize epithelial downgrowth

Maintenance of alveolar ridge morphology

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Provisional prosthesis with ovate pontic design used to guide healing Radiographic case progression

Connective tissue graft harvest Final Outcome

Facial gingival tissue stability after connective tissue graft with single Successful site preservation allows for prosthetically driven implant placement immediate tooth replacement in the esthetic zone • 20 consecutive patients • Preservation of papilla • Immediate implant placement • Biotype enhanced with associated connective • Bone and soft tissue stability tissue graft • Follow up 1-4 yrs

Kan JY et.al. J Oral Maxillofac Surg. 2009:67(11);40-48

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Ideal bone leads to Final Outcome ideal treatment outcomes EDS-1 extraction defect

Delayed Implant Placement Successful site preservation allows for prosthetically driven implant placement EDS-2 Extraction Defect

Radiographic case progression Site preservation with socket and CT Graft

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First procedure - extraction of teeth, site preservation with Bio-Oss + DBM and connective tissue graft

Site development EDS-4 Defect Second procedure – site development using a symphyseal block graft and membrane • Post extraction following Site preservation • 3 or more bony walls missing or compromised • Challenging defects require autogenous bone or BMP-2

37 y/o female. Congenitally missing lateral incisors with constricted arch form Third procedure – implant placement with connective tissue graft and Lost left central incisor due to trauma as a child using healing abutments as space maintainers

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Site development Implant placement guidelines - spacing

Tooth to Implant 2mm Implant to Implant 3mm Esposito et al. Clin Oral Imp Res 1993 2mm Tarnow et al. J Perio 2000 2mm 3mm

CDA Journal Nov 2005 Implant placement guidelines - position

Avoid adjacent implants in the esthetic zone

Papilla Preservation Implant placement guidelines –Emergence Profile • Interproximal bone to tooth contact point 3 mm below Esthetics vs. Health • <5mm 100% papilla presence restorative margin • 6 mm 56% • 7mm 27% Excessive platform depth compromises • Tarnow et. Al. J Perio 1992 maintenance

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Communication Devices- Surgical guides

Periodontal and Peri-Implant Considerations In The Esthetic Zone

Nick Caplanis DMD MS

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