Februari 21, 2017
gregg kinzer: alright, so yesterday, we spokeabout the delayed approach, which is rebuilding what's there, so you can actually have idealimplant placement and have ample soft tissue to work with, but when we evaluate those fourvariables we spoke about yesterday and you have good soft tissue and bone positions andyou have good gingival architectures, then it makes no sense to just take the tooth outand let everything collapse. so, then we go into an immediate approach,where we're gonna enhance, maintain, and support the soft tissue. and we mentioned yesterday that there's abunch of different ways to do that, i basically spoke about the immediate implant placementand the immediate provisional approach, but
that's just one way to support the soft tissue. the reality is i can use any of these methodsand i can get to the same end point, which is what i'm trying to do. i'm trying to get to the endpoint and do itpredictably. so whether i put an immediate temporary onthe day the implant goes in, or whether i support the soft tissue with another method,a lot of it depends on how the patient presents. so what i'd like to do is just go througha variety of cases to show you how each of these different treatment options can be used. so here's a patient who comes in, and youcan see radiographically that his left central
has been deemed hopeless, and needs to beextracted. these are two restored teeth, they're actuallysplinted together. so, since we're gonna have to take out theleft central, the question is going to be, "how are we going to sequence through, how'sour treatment option?" we look, we have good bone positions, we havegood gingival margin, we have good papilla, in fact we have one papilla that's actuallyalmost too good. it almost goes all the way to the incisaledge. so, i like the gingival architecture, in fact,we're gonna move this a little bit more apically, to get a little bit of symmetry.
i could do it with an immediate provisional,that would be an option, but there's always the down side if you go to an immediate provisional. jim and i don't work in the same office, wedon't work in the same city which means that he would have to do the immediate provisional,otherwise it's an hour and half drive to come to seattle, if your surgeon doesn't do theprovisional for you. but there's another way that i could supportthe soft tissue because i'd actually wanna redo this restoration as well. and since this is a full coverage restorationand i have it next to the implant, then i could cantilever the provisional, and thecantilevered provisional then could be used
to support the soft tissue, just like an ovatepontic. so that's what we're going to do for thispatient. so where the treatment would start would bein the restorative office. i would take off the old restorations, i wouldrefine the preps, but this one, i'm not gonna take it out, i'm just gonna cut it down. so i cut it, and i showed you this yesterday,i cut it down just below the soft tissue, i make a provisional, and the provisional'sjust resting upon that root, like a cantilevered bridge-lapped pontic, like that. what this does now, is it gives the surgeonthe ability to take this off, take the tooth
out, do what they need to do, and then putit back on and adjust and add to the apical surface, to be able to support the soft tissue. so the surgeon has to deal with just a littlebit of work, as opposed to making an implant provisional, 'cause i know when jim makesimplant provisionals for me, he adds a lot of treatment time to the patient. so i don't take the tooth out because we sawyesterday that when you take the tooth out, you start getting these dimensional changesin the ridge. and because we have the dimensional changesin the ridge, when the tooth comes out, we're going to follow it up with some sort of contouraugmentation, and there's a bunch of different
ways in literature to augment that contour. you can use hard tissues, you can use softtissues. so our typical protocol would be doing somesort of soft tissue facial augmentation to maintain that facial contour, otherwise youstart having components show through, you start having a concavity, and from a restorativestandpoint, it starts impacting the shape of the restoration. if the ridge is more palatal, then to getback to the ridge, i have to wind the tooth back, so it's in a different facial planethan the tooth next to it. so what we typically end up doing is somesort of a connective tissue graft.
we can grab connective tissue from a varietyof places on the palate, or even in the tuberosity, depending on what our goals are. and if you look at this patient from ueligrunder, half the patients had a connective tissue graft, half of them did not. and when they followed them, what they foundwas, that there was an average loss in the non-grafted group, but an average gain, slightgain from where they started when they put that connective tissue facially. and if you break down the non-grafted, theaverage was about a millimeter loss, but 16% had 1.5 to 2 millimeters of facial loss.
that's quite a bit, that's significant, right,in dental terms? so if you look, almost half of them had significantloss. now we used to play the game that, "let'sdo the procedure and not do the graft and we'll see what happens, we'll see if theyfall into this category, where we might not have to graft it, or if they fall in somethinglike this." don't do the graft if you don't need it. but you don't know if you don't need it untilyou wait. and the problem is that every time we didit, we ended up coming back at a subsequent appointment and doing the graft.
it's like now you're putting the patient throughtwo different surgeries. so then we said, "you know what? we're gonna be in the aesthetic zone, everybodytypically is going to get soft tissue augmentation, no matter what, because most of the patients,a majority, are going to need it, and it never hurts you." so the way it would be done is that the surgeonwould take the tooth out, put the implant in, and then do some facial contour augmentationwith soft tissue. now in this specific example, the soft tissueis also gonna be carried over to cover the recession that was on the lateral.
so just because he's in the sight, he's gonnado a little bit more good for the patient. then what he's going to do is, he's gonnahave to modify the underneath side of that pontic, 'cause remember it was a ridge-lapbefore. so he's gonna have to add material to fillin the space, and make sure that they can still support the papillae. now the benefit of doing this is, when itgets time for me to jump an implant temporary underneath there, like an implant abutment,the shape is already there. so yesterday, when you were adjusting thesoft tissue on the model of the delayed approach, there's a lot of thinking that's involved,isn't there?
'cause you have no reference points. here you have reference points. you know where the papilla heights are, youknow where the gingival margin is, in fact, you have the exact tooth form that you want. so to fill in the small blank, if you actuallytook this off and put an abutment on, it's actually quite easy to do chair-side. so way more efficient, i don't need to takean impression, make it and bring it back to the mouth. i can do this all chair-side.
so this is the same provisional that theystarted with. i just now connected it to an abutment. so the immediate approach does make us significantlymore efficient and our goal then is to maintain the soft tissue aesthetics, to maintain thesoft tissue contours, and the facial connective tissue augmentation allows us to maintainthat facial contour. bob winter: so one of the beauties of thisapproach, it's guided healing of the site. so in this workshop, obviously it's gearedtowards implants but we also have the pontic section lying in this course. so tomorrow morning, you're actually gonnado all of this work on models because controlling
an ovate pontic site is a key for a ponticbut it's also an option for a provisional and for a lot of surgeons and so forth, itcan be an easy transition. so that's why our concepts of the tissue formand support is based on obviously bone, adjacent teeth, but then the restorative object that'sthere, in this case it's a pontic. questions? attendee: i was gonna ask how far apicallyyou had to go with your... to support the tissue, it sounds like we cando that tomorrow. bob winter: we'll get into details about thattomorrow and basically you want to support having the embrasure form in contact zoneto, i'll say, mirror image the contralateral
side, if you err, you have a little bit morespace to encourage the papilla to come down. greg showed yesterday the last thing you wantis erring by having this too long 'cause then it moves the tissue apically and you may notget it back and then on the facial aspect, let's say one to two millimeters maximum,i typically go a millimeter but the apex of the ovate pontic design has to be positionedtwo to three millimeters from the facial aspect of the ridge to make sure that you have enoughsupport so the tissue doesn't collapse underneath it. we'll get into the details and you'll actuallydo that tomorrow. gregg kinzer: so about a millimeter facially,that's pretty typical but if you imagine cutting
the tooth down clinically, your provisionalstarts about a millimeter. so that the surgeon that's going to be addingin the contour already has kind of where the position is. what they're really adding is more of theovateness underneath and they just need to pay attention to these areas here, the supportof the papilla. yep. attendee: if it's not grafted, do you haveto worry about the tissue initially? bob winter: typically, as you'll see withimplants, as well as pontics, we're grafting because of the research that shows that theridge resorbs and then therefore the tissue
will collapse. if you don't graft, you're at high risk ofthose changes. so, virtually, as greg's saying in implantcases now, in the past they wait and see, well they find that you can typically comeback and graft. so the general thought now is grafting atthe time of this and with ridges, for example, and we'll go through an example of extractinga tooth, augmenting a defective site, and then dealing with one that's already augmented. we'll go through all those examples. typically grafting is required soft tissueand if it's implanted it would be hard tissue
and soft tissue. gregg kinzer: so restorative dentists, ifyou're going to have your surgeon do things for you, restorative things, make sure theyhave the equipment to do it. make sure they have something to adjust theprovisional, something to add, something to polish. 'cause the last thing you want is them toleave a very rough surface underneath now that the tissue is touching that, you'll startto get a lot of inflammation. little christmas gift, they get a provisionaltrimming kit and they pull it out to be able to do work 'cause it actually enhances thingsfor you.
now, could you have gotten to the same pointby doing an immediate provisional? absolutely. but technically now, it can be more challenging. this is a more predictable way that challengesyou, let's say less clinically but i don't run the risk of not getting integration becausethe patient functions on the implant. there's some patients i just don't trust. that you tell em, that this, no, you can'tbite into this, you can't look, you can't do much, this is just kind of to give youa tooth but they don't follow your rules. and so you end up having this risk of notgetting integration.
so this is not a bad option if you end uphaving restorations on the tooth next door. cantor-lever it over, just makes it easy. so here's the final abutment and the adjacenttooth, which is a dark tooth. so these are actually emax restorations andbob can comment that from a technical standpoint, if we have to start masking dark teeth, thepreference would be to use emax just because of the different ingot selection that's availableto us. bob winter: yeah and i think it's an importanttreatment planning consideration that greg brought up where there was a crown on thistooth and rather than doing a single central to match maybe a crown that's old.
yes, it's a little bit of an investment forthe patient initially but to replace that makes everything so much easier. and then, yeah, with e.max, the lithium disilicate,the technician has choices of opacities, and so an example, like this, it's not so severe,you might use, like, a medium opacity base, and then layer it, and you can do the twocentrals exactly the same, so you get an ideal outcome, highly predictable. gregg kinzer: so, i mean, our ideal plan wouldhave been to replace the veneers on the laterals, right? and do a connective tissue graft on this oneas well, but from a financial standpoint,
the patient goes, "i can't afford to do allthat." so, the surgery was done to cover the rooton that one, just because he was in the area. and the patient knows that at some point intime, if he wanted to restore these, and kinda make 'em look better, then we would also dothe connective tissue augmentation there. okay? so, that would be one technique to be ableto start enhancing and managing the aesthetics. but let me show you what happens when we don'tdo that facial augmentation. and as i told you, we used to play the gameof, well, let's see if we need it before we do it.
so, this is a patient who's going to be losing,because of resorption again, her right central. and given the malocclusion that she has, andthe crowding, i spoke to her about doing ortho. and the benefits of the ortho is to alignthe teeth to get the occlusion. but also, we can erupt this, and we can improvethe implant site. if we're already doing ortho, we might aswell have it benefit you. so, the tooth was erupted, and we're gonnado this one as an immediate provisional. now, we look at where the bone and the softtissue is, and we have, like, real thick bone, real thick soft tissue, so we decided, let'snot do a facial connective tissue graft, let's just see if we wouldn't have to do it, becauseremember, as you erupt the central, what are
you improving? the facial bone and tissue on the tooth. you're actually moving things more coronal. so, this is day-of-treatment. immediate extraction, immediate implant placement,and provisionalization. now, what happened to this patient is thatshe kind of left the office, and i lost track of her. she ended up having a baby, and so i didn'tsee her for two years. so, she comes back in two years.
this is what it looks like when we put itin, so i want you to look at the facial contours. this is day-of-extraction. in two years, i want you to now evaluate thefacial contour of the implant. do you see how thin it is? it's thin, it's moved apical. the gingival margin has a different form thanit was. and this is what we started to see on a lotof our patients. that we rolled the dice and said, "oh, let'sjust wait. why do surgery if they're not going to needit?"
and by far, almost all, we ended up havingto come back. and what's interesting is that when she cameback in two years, she brought this to my attention. i saw it right off the bat. but now you tell the patient, "well, she'sready to go to a final restoration, that's why she's being appointed." and all of a sudden i have to tell her that,"well, okay, well, now we have to go back and we have to do another connective tissuegraft. we've gotta let it sit in there for a fewmonths."
so, all of a sudden, we delay the treatment. but she pointed it out to me, so now we haveto come back in and do a second surgery, whereas if we were to have done it at the day-of-implant-placement,it's just a one-time deal. that's why i say nowadays we basically doit on all of our patients. now, my least favorite option, 'cause i usethese three mainly, my least favorite option would be to use something removable. whether it's on a flipper or whether it'son an essix, you can do it. i just don't prefer to do it. so, i showed you this patient yesterday, whereshe's going to be losing her canine.
and she comes in to see me as, like, a second,third opinion, because nobody wanted to do an implant on her. everybody wanted to do a bridge, because theyweren't sure if they could manage the aesthetics. and this is one of those patients where youkind of have to walk on eggshells. you know what i'm talking about? those types of patients where you don't wantanything to go wrong, because the slightest thing that happens negatively, they blow itway out of proportion. so, i get it. they didn't want to do an implant, becausethey weren't comfortable saying that, "yeah,
i can replace what's there and make it looknatural." but remember we talked about the factors thatwill influence the aesthetics, being the bone and soft tissue positions. so, this is a resorptive defect on the tooth. so, the bone positions on the distal of thelateral and the mesial of the first bi are actually good. which means that, unless i do something wrong,i should end up with nice papillae. and again, we have good facial bone and goodfacial gingival margin positions. but i, now i'm thinking, "alright, how cani replace this tooth in the interim, and minimize
the risks of something negative happening?" you could say, "well, we could do an immediateprovisional." but again, this is the patient where, if something,if i push it and something goes wrong, it's gonna be really bad. so, what we decided is, let's just do it asa flipper, because i couldn't bond anything in there, given her occlusion. i couldn't bond a tooth. i couldn't do something fixed. and i wasn't willing to do it as an immediate.
and kind of in the time zone when we did this,we weren't really doing immediate implant provisionals, right? that wasn't really a mainstay. it wasn't published a lot in the literature. so, i kinda had to go back and do a removableappliance. nowadays, i'd probably think about doing itas an immediate. bob winter: yeah, this is a great case, becausefrom a treatment planning perspective, of course, you have options, right. a lot of the people were thinking bridgesbut then you start looking at lateral as a
bridge abutment in the function going offa canine and then a question came up yesterday, cantor-levers. well, maybe you double-but bi's and cantor-leverthe cuspid, that would be the worst possible scenario. so you don't wanna go down that pathway. so the implant is actually the best option,'cause you have virgin teeth essentially next door as well. so it, but it complicates this whole processof provisionalization; because of getting something in there in a fixed perspectiveis now more challenging.
i don't have adjacent teeth that are crowningand i can cantor-lever off her bond tooth. so, it's a great treatment planning case actually. gregg kinzer: yes, so nowadays i would dothis as an immediate temporary. and i would just make sure it's not able tobe functioned on. but given the time period that this was done,we're gonna do it with the removable. so here's our implant, straumann implant,look at how nice the soft tissue looks. it's perfect right now, but if you just satand watched this, you would slowly start to see these papillaes start to slump. you would slowly start to see the facial marginsstart to come palatally.
so we wanna maintain our support of that. now you, as a surgeon, you could send thisback to me and i could do the provisional or you can help have your surgeon do it foryou. the more i can get my surgeon to do, as longas they do it correctly, it makes my life easier. so this is what i sent, this is dave matthewsdoing the surgery. what i sent him was a flipper that i fabricated,and remember we talked about, it's gotta be supported by the teeth, so i don't have itcontinually bouncing on the soft tissue. but the way i fabricated it is i took thetooth on the model, and i cut it down just
like i did clinically. but i didn't cut it below tissues; basically,cut to tissue level. imagine doing that on the model, just cuttingthe tooth off. so this is kind of a ridge-lapped, pontic. when he goes to put it in, if you were totry it in right now, it's going to scallop like the tooth but it's basically not gonnatouch the tissue at all. because it wasn't fabricated to go sub-genitivelyon the model. so what does dave have to do? dave has to pull out his restorative materialsand add to the apical portion of the pontic
to, again support the soft tissue, just likewe did on that fixed cantor-lever off of the central. so this is day-of-treatment. i can't have a lot of soft tissue bounce,so it's touching soft tissue, but if she were to occlude on it, if she were to come outto the edge of this, it's not going to push on the soft tissue. because these areas are preventing it frombouncing the soft tissue. so i saw the patient at 24 hour follow-up. i wanted to check dave's work.
i told him what i needed him to do, and ijust wanted to make sure he did it and i wanted to polish things if he didn't polish it well. so she comes back in the next day and thisis what it looks like. he did a phenomenal job. look at how nice the papilla heights are. so when you take it out, it's not ... thiskind of goes to your question about, what's the contour? how deep are you? he's just slightly below tissue on the facial,but you can see that he's supporting a lot
the papilla. it's not resting on the implant though. it actually has the ability to let tissuekind of granulate over it. bob winter: so technical tips for the restorativedentist making the flipper, if you micro-air abrade the under-surface of that pontic withaluminum oxide, to get it ready for the surgeon to add the material, we'll go through theexercises of using a little adhesive, a little bit flowable, you light cure it. and it's a pretty simple procedure. if you don't air abrade it and prep it, maybethe bond isn't as good.
so that's the way i'd have the restorativedentist help the surgeon get it ready so they have less work to do. and that's why it's set-up perfectly for whengregg does the follow-up, it looks great. he doesn't have to do anything really. gregg kinzer: so the only thing i had to dowas, i just polished it a little bit, just to get a little bit better junction betweenwhat was added and what was there. so this is now four weeks later. so at a month. and again, we have nice papilla heights, goodsymmetry to the papilla, and now we have a
nice healed tissue. now, what you'll find is, it'll never completelyclose over. there'll always be an epithelial heal so there'llalways be a way to get down to the head of the implant. but this now becomes easy to make a provisional. you could take an impression, and pour itup, and you could do it on a model, but do you really need to? 'cause you have all of the points there. you know where the papillaes are.
you have your tooth shape, you know wherethe gingival margin is, so connecting the dots between where the tooth is from somesort of a matrix and where the head of the implant is, you're talking a millimeter toa millimeter and a half of adding material to get your emergence. 'cause all of the thinking's already beendone. so chair-side now, you can come in and youcan actually fabricate the provisional. saves time, saves appointments. now, what's the down side of this? the down side of using a removable applianceis, they have to wear it all day and all night.
if she took it out at night, what's gonnahappen to soft tissue? it's gonna collapse. so then in the morning when she pulls it outand she puts it back in, it's not going to fit, is it? it's gonna be bouncing off the soft tissue,so she'd have to continually hold it 'cause the soft tissue wants to push it away. so they have to wear it all day and all night,which means you have to instruct them on how to keep it clean, 'cause if they don't takeit out routinely and clean it, the tissue starts to really look nasty.
so, as i said, this is my least preferableoption, but you can do it. and you can do the same thing with an essix,an essix with an ovate pontic in the essix, but they still have to wear it all day long. but it's easy at this point, now, to jumpinto fabricating a provisional and jumping the provisional in. although you can take an impression, do iton a model, bring the patient back, do it over two appointments, it's easy to do chair-sidein one appointment. so it does make you more efficient. so, here's the implant provisional, and nowhere is the final abutment, and we're gonna
talk about in the latter part of this morning,we're gonna talk about abutment selection. this gives you an idea of the time periodthat this was done. straumann didn't have the ability to do zirconiaat this point, so we ended up having to a metal-ceramic abutment, metal to give strengthand the ceramic sub-gingively to be able to enhance the esthetics of the tissue so wedon't start to get the tissue to be grayed out. in a cement-retained restoration. so, here is the final restoration. and again, we've maintained soft tissue architecture,soft tissue harmony.
this is one of those examples as well, wherewe didn't do any facial augmentation. back when this was done, i don't think anybodywas doing facial augmentation. actually, it wasn't part of the routine yet. but if you'll notice, given her periodontium,the thickness of her soft tissue actually still emulates the contour-lateral side. so it's a little bit deficient, but not appreciably,compared to the other side. so this would be one of those small exampleswhere you can get away without doing it, but this is really, in my opinion, nowadays it'sreally rare that i find that we do this and don't have the repercussions of the soft tissuecollapsing.
this option of using a customized healingabutment, and maybe a customized healing abutment with a fixed retainer, fixed bonded tooth,is probably the one we do most often. if we're not gonna do an immediate provisional,we're living in this world. and again, this is something that you cando, a restorative dentist, or this is something that your surgeon can do for you. i actually typically tend to have my surgeondo a lot of it for me, just because they're there at the time-of-surgery. so, this is ben, and ben was in an accident,a snowboarding accident, and he fractured his central.
you can see the fracture line here, you cansee the fistula present on his right central. so, for his treatment planning, treatmentoptions, given the malocclusion, given the position of the teeth, i thought, "you knowwhat? if we do ortho, we can fix some other problems,and we can also erupt this tooth." and in the process of erupting, i can movethat fracture line more coronal, i can get better facial bone, better facial soft tissue. so he's going through the ortho. now, when we're ready to take the tooth out,how are we going to provisionalize him? 'cause i now have good bone, i have healthysituation, i have good soft tissues, but i'm
in the middle of ortho. so i'd rather just take a pontic and stickit on the archwire. but if i have a pontic on the archwire, howam i gonna influence and support the soft tissue in that situation? if we do a custom healing abutment, it doesn'tmatter how you replace the tooth. you could use a flipper, you could use anessix, or you could stick it on the archwire, because the tooth hanging off the archwirewill have no influence on the soft tissue. it doesn't need to. so, bobby butler is the periodontist that'streating him, takes the tooth out, and again,
we're placing the implant relative to wherei need the gingival margin to be, 'cause right now, the gingival margin's about 2 millimetersplus more coronal than i want it. so, this implant's gonna probably be aroundfive plus millimeters below the tissue. you go, "that's really deep." well, it's deep because i want the gingivalmargin to be somewhere up here, and i'm anticipating this soft tissue changing. so, what bobby's gonna do is, he's going tofabricate a custom healing abutment. now, for many years, in order to do that,they had to use a stock temporary abutment. we didn't have the ability to pull somethingout of the catalog and just stick it in that
had an anatomic shape. nowadays, a lot of companies are fabricatingcustomized, or maybe even customizable, healing abutments. but, this is still a very valid option, butyou have to use an engaging temporary abutment. i need something that when the surgeon putsit on, it can only fit one way. you can't use a stock healing abutment thatonly screws in with the threads, 'cause typically if you imagine the profile of a central, it'sgoing to be wider mesial distal. so imagine when you screw something in andif it only screws in with the threads, you get this wide mesial distal that screws aroundand it actually starts wiping out facial and
palatal tissues as you get it seated. and it's typically done just by adding composite. so you can give your surgeon some compositeto use, and honestly, this can even be old, ugly colored composite that you just neveruse in practice. and it'll stick quite well to that kind ofknotted surface. now, when it's fabricated for the surgeonsthat are gonna fabricate it, i would keep the length of the abutment. it's gonna be tall, it's gonna be way tallerthan you want. but keep the length because what it enablesyou to do is it gives you a handle to hold
on to take it on and off. ideally, this would be the shape you're tryingto create. something that follows the scallop of thesoft tissue from facial, to mesial to distal. now, if you'll notice, this is a differentcustom healing abutment than what was done in the mouth because this is now flat. can you see how flat it is radiographically? in an ideal world, i would want the surgeonto actually scallop it here and scallop it here, like you would see there to supportthe papilla all the way around. but this is doing its job of supporting theapical portion of it.
so, if this is going to support the soft tissue,as i said, it doesn't matter what's on top. it's just gonna be a tooth that's bonded tothe archwire. before the patient is done, bobby's gonnado the facial connective tissue augmentation and then we just take a plastic tooth andwe stick it on the archwire. so, it has no influence on the soft tissuebut the soft tissue is being supported by what's underneath. and even though this hasn't supported thefull papilla, i have good thickness to the papilla here. so i should have pretty decent papillae.
now, if you look at the papilla, you'll noticethat the papilla on the distal here is deficient. so, why is it deficient and could you havepredicted this? and could you have improved it? well, it's deficient because of the bone levelon the mesial of the lateral. and if you think about the fracture, rememberwhere the fracture line went? fracture line went from facial kind of lineangle towards the distal. so, in the process of having the fracture,the bone on the mesial of the lateral was lost. and we said that four and half to five millimeterscoronal was where your papilla height's going
to be. so, you could look at this patient from thebeginning and say, "we're probably gonna lose some papillary height. it looked alright when we started becauseit was inflamed," inflamed tissue always looks good. but you could predict where the papilla'sgonna go. in fact, you would want to predict that 'causeyou would wanna have a discussion with the patient about what's going to happen in theend. if the patient wasn't going to be happy withthis, use some templates, use your photos,
and show where the papilla's gonna go, thenhow could you have improved it? attendee: erupt the lateral. gregg kinzer: could've erupted the lateral. you're already doing the ortho. now, if you erupt the lateral to improve themesial bone and mesial papilla, you're going to create something else to add to your treatment. 'cause as you erupt this, this will improve,this will become too coronal, which means now you're gonna have to do facial crown lengtheningat the time you do your implant surgery. and if you're going to expose root, you'reprobably gonna have to add another restoration.
but you could predict all that and the patientcould make the call for you. so, he says, "no, i'm fine. it doesn't bother me." so this was left the way it was, we have alittle deficiency, a little bit more apical than the other side. so, here he is at five years and nine years. and again, this could have been treated andimproved from the beginning. you could have predicted that that was goingto happen. so you're setting the expectation for thepatient, as we said yesterday, that's where
a lot of patients when their expectationsaren't met, even though maybe their expectations are unrealistic, that's where they becomeunhappy. so evaluating the patient before you treatcould alleviate that. yeah? attendee: since it's so minimal, would softtissue graft help ...? gregg kinzer: to do a vertical, you'd haveto deconstruct everything and do a big pedical soft tissue graft over the ridge. could you improve it? you probably could but you're taking a lotof steps backwards.
attendee: but before? gregg kinzer: yeah. yes, i think you could have. i would have probably done it with eruptionjust because predictability now having the bone support the soft tissue is, i know thatpapilla's not going anywhere. if you start to graft and get more soft tissueheight above the bone, there's always the risk that over time you start to lose thepapilla height 'cause it doesn't have the bone-y support. bob winter: one thing that it's a little difficultto appreciate when we show photos, we use
flashes to capture images. and i just saw a patient a couple of daysago that i'm redoing some dentistry that i did 15 or so years ago and it relates to pontics,so similar to what we're talking about. and the deficiency of the ridge and with hersmile, the lip goes up high enough so the two lateral pontics, the restorations lookspectacular and with flash photography everything looks great and you scratch your head andsay, "why do you wanna make a change?" but if you just see the patient stand beforeyou and smiling, what happens? the lip drape creates a shadow. and when you have areas like this or as greg'sdiscussing even a deficiency facially, that
shadow then is accentuated compared to theother side. so that's something we have to let patientsbecome aware of as greg was just describing, it's informed consent. patients have to understand if they say "no"to something, they can't come back to us at some point and say, "well, i don't like theway i look in my photos because it just looks too dark, so to speak. so sometimes that's difficult. we understand it but getting the patient tounderstand what they're saying "no" to. because ultimately, again patients may saythat's all fine, but some patients may not.
yes? attendee: and is it true, the fuller the lipsthe more that's enhanced? bob winter: you could say that or argue thatfor sure because you create more shadow 'cause most light comes from down from above, andthe fuller the lip maybe the more shadow, so i'd say it's a fair comment. attendee: okay. bob winter: yeah. gregg kinzer: so when would we divert ourselvesto do some sort of a customized healing abutment? these are kinda the things that i would thinkabout, to say, "okay, i'm not gonna do an
immediate provisional here." if there's a peri-functional activity wherei can't control the contacts on the immediate provisional. if i go this route it doesn't matter. if there's a malocclusion that doesn't allowme to clear the provisional. 'cause typically if you do an immediate provisional,you have to make sure they can't get on it, in protrusively or even in an incisal edge-to-edgeposition. i have patients who are pretty aggressiveathletes. and you could say, "well, do an immediateprovisional and just make em a mouth guard."
and that's, in theory, that sounds great untilthey arrive at the field and they don't have their mouth guard. they're not gonna go, "oh, yeah, kinzer saidi shouldn't play if i don't have it." no, they're gonna do it anyway. and then, as i said earlier, i have patientsthat maybe i just don't trust their compliance. i had a patient who was the daughter of adentist from the east coast and she was working at microsoft. she was in seattle and we had done an immediateimplant, immediate provisionalization on a so, she comes in and i'm going to take ifoff to do final impressions.
i go to unscrew it, i pull the temporary outand the implant and the temporary all come out together. and i go, "whoops." i stuck it back in. and then you say, "i think we have a problem,we need to send you back to the surgeon." but what happens for these patients that you'redoing the immediate provisionals is overtime they forget. they forget it's an implant on a provisionalthat was done immediately. they just think it's a normal tooth.
so whatever you told them from the beginning,they kinda start to just function on it normally. so there's full customized healing abutmentsand then there are customizable healing abutments. this is a piece from straumann, it's the peakmaterial that has a shape kind of just a larger cylindrical shape that the surgeon can actuallynow adjust and polish so it's easier to adjust this than to adjust metal. and they can actually support reasonably wellthe soft tissue. it's better than just putting a stock pieceon, but obviously the central isn't going to be completely round. and as i said, now you have the ability toactually buy pieces that have more of an anatomic
shape. but the difficulty is, from a surgical standpoint,you have to have a huge selection. you have to stock up your shelves and say,"okay, well, here's the size, here's the flare i want." so customizing the piece actually starts tomake sense. bob winter: yeah, and the peak material, asyou can see, it's somewhat pink in color so it blends reasonably well. and you can, we'll, actually have a chanceto, if you'd like, i can demonstrate grinding on this tomorrow.
but you can't add to it unfortunately. it's virtually impossible to add to. so we'll actually have everyone have a chanceto work with the pmma material, we can use it for a full abutment or you can modify itby cutting it down, shaping it but then you can add to it quite easily. so that could be used as an option from thepeak. so we'll work with that tomorrow. gregg kinzer: so i will say one thing forthe surgeons or if you're gonna be doing this restoratively.
'cause again, the surgeon can do the treatment,send it back to your office, and you do this. always err on under-contouring the facial. under-contouring the facial leaves more facialthickness. more facial thickness that you can now addcontour to and move it apically. if it's over-contoured here, the day-of-surgery,you're probably going to risk having the tissue move apical and then its gone. it's probably not going to come back. so under- contoured facially and you can kindof appreciate that here, if you look at where this tissue is compared to the tissue that'son the natural tooth.
it's been over-adjusted facially to allowthere to be more soft tissue lying on it. so you got a case just like that last monthwhere there's a peak or some sort of inter-temporary abutment. would you restore that directly or would youtake another step of putting a temporary to then reposition the tissue where you wantit? gregg kinzer: that's a great question becauseyou're better than you were if it was just healed around something natural but you'renot as good as you're going to be. so this now, i'm gonna say it's a clinicaljudgement call. the risk is, what's gonna happen now whenyou actually create better contours, because
what you're going to ask the technician todo or you would do it on the model is, like you did yesterday on your models, you're goingto have to adjust the soft tissue. you're gonna have to take and adjust the softtissue on that model to create the flare that you want. and when you support this papilla more, whatdo you anticipate happening to the tip of that papilla? it's gonna come down more coronal. so now, if you're planning on a cement-retainedrestoration, the technician is going to guess, "how far is it gonna come down and where shouldi place my margin?"
and they're always going to err on placingit deeper, 'cause nobody's gonna win if you can see the junction. so, the risk that you run then, is you endup having the tissue more coronal, like your margin is gonna be way way too deep and nowyou risk keeping cement, not being able to clean up the cement. so, if you were going to do this right fromthis, go to right to finals, doing it as a screw-retained restoration maybe is a littlesafer. but now the guess still is, where is the papillagoing to come down because they need to create an emergence profile, and what they don'twant is they don't want to choke the papilla
off, but they're gonna tend to err on thatside. otherwise, they leave a black space. so, you're guessing a little bit. so, in an ideal world, i would say you gomake the provisional. but now, clinical reality is, you may choosenot to do it given whatever your fees are or whatever the patient is willing to endureor whatever the patient is willing to pay for, you might end up having to go right tofinals. bob winter: so it's a great question and itleads us into the discussion we're gonna have for really the rest of the morning when weget into abutments and so forth.
but what we try and emphasize in this courseand our core philosophy is, is the dentist should be managing the tissue to get it ideal,'cause as what we're just describing and we'll talk more about it, is if we go to final fromhere, now all of those decisions really go into the hands of the technician. and then the question is, "what knowledgebase does the average technician have to make some of those decisions?" and it's safer if it's screw-retained becausethere's no margin placement to worry about, but you still deal with contour. so in this situation right now, where thegingival margin, i'll call it a millimeter
and a half to two millimeters more coronalthan the adjacent tooth, now the final restoration, whether it's an abutment or final crown, wehave to add contour to it. and then when you go to the mouth and youput it in permanently, it's the leap-of-faith that it's done precisely and the tissue'sgonna move to exactly where you want it. so, there's risk benefit to everything. the real world is, for sure this is betterthan just having a straight three-millimeter healing abutment on there and going to final,but you're still at high-risk in the esthetic zone, in particular on a central incisor. if it's a cuspid, you can get away with moreerror or asymmetry 'cause you can't see the
tooth. so, in our opinion, it's better to be in thehands of the clinician rather than the technician.
Tidak ada komentar
Posting Komentar