Nicholas Caplanis DMD MS 6/4/2012 Periodontal and Peri-Implant [PDF]

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

Nick Caplanis DMD MS

Private Practice Periodontics and Implant Surgery Mission Viejo, California Nick@drcaplanis.com Assistant Professor Loma Linda University

Classification of periodontal disease and conditions

Previous classification

– 1989 world workshop

Current classification

– 1999 international workshop

A standard classification provides a framework for the

scientific study of disease etiology, pathogenesis and treatment as well as a standard mean of communication

Weakness of 1989 classification

Criteria for diagnosis unclear
Disease categories overlapped
Too much emphasis on age of disease onset and rate of

progression which are difficult to determine

No classification for diseases limited to gingiva

1999 Gingival and Periodontal Disease Classification

Armitage GC. Ann Periodontol 1999;4:1-6

Periodontal disease classification “Key Changes”

No section on gingival diseases
“Adult” Periodontitis
“Early-onset” Periodontitis
“Refractory” Periodontitis

Current

Entire new section on gingival diseases
“Chronic” Periodontitis
“Aggressive” Periodontitis
Additions

– Periodontal abscess – Perio-endo lesions – Acquired deformities and conditions

Armitage GC. Ann Periodontol 1999;4:1-6

Classification of periodontal disease and conditions

Chronic periodontitis

– Typical adult onset plaque induced – Previously referred to as “adult” perio

Aggressive periodontitis

– Previously known as pre-pubertal, juvenile perio, localized juvenile perio, rapidly progressive perio, early onset perio Armitage GC. Ann Periodontol 1999;4:1-6

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Nicholas Caplanis DMD MS 6/4/2012 Periodontal and Peri-Implant Considerations in Esthetic Dentistry 2

Classification of periodontal disease and conditions

Chronic and Aggressive Periodontitis

– Distribution

Localized < 30% sites
Generalized > 30% sites

– Severity

Slight 1-2mm CAL
Moderate 3-4mm CAL
Severe > 5mm CAL

Armitage GC. Ann Periodontol 1999;4:1-6

Systemic Connections

Periodontal disease increases CRP levels
Link between Periodontal disease and

cardiovascular disease; MI, CVA

Link between periodontal disease and the delivery of

premature, underweight babies

Link between Periodontal disease and Diabetes
Recent link with Alzheimer’s disease
Periodontal Pathogens are transmissible

Biofilm and inflammation management

Gingivitis

Clinical Signs

– Gingival erythema – Edema – Bleeding on probing – PPD’s up to 3mm (unless pseudo pocket) – Soft tissue contour changes – Increased GCF – No attachment loss

Treatment

– Scaling/Prophy with OHI – Phase I Re-eval – 4-6 mo PST

Slight Periodontitis

Clinical Signs

– Gingival erythema – Edema – Bleeding on probing – Slight attachment loss – Pocket depths 4mm

Treatment

– SRP + behavior mod – Periostat – Phase I Re-eval – 3-6mo PST

Moderate Periodontitis

Clinical Signs

– Gingival erythema – Edema – Bleeding on probing – Moderate attachment loss – Slight furcation invasion – Pocket Depths 5mm

Treatment

– SRP + behavior mod – Rx Periostat – Phase I Re-eval – Additional RP + Arrestin – Pocket reduction surgery if needed – Phase II Re-eval – 3-4 mo PST

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

Clinical Signs

– Severe Attachment Loss – Pocket Depths >6mm – Moderate to Advanced Furcation involvement – Inflammation, BOP

Treatment

– SRP + behavior modification – Phase I Re-eval – Pocket Elimination Surgery – Phase II Re-eval – Bacterial Culture and Sensitivity – Localized and Systemic Antibiotics – 3mo PST

Manual vs. Powered tooth brushing for oral health

Materials and Methods

42 trials involving 3855 participants

included in review Results and conclusions

Powered brushes removed plaque

and reduced gingivitis more effectively than manual brushes

Robinson PG, et.al. Cochrane Database 2005;18(2):CD002281

The efficacy of interdental brushes on plaque and parameters of periodontal inflammation: a systematic review

Materials and Methods

218 Medline-PubMed and 116 Cochrane

papers identified

9 studies met eligibility criteria

Results and conclusions

As an adjunct to brushing interdental brushes

remove more plaque than brushing alone.

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

56y/o male generalized chronic severe periodontitis

Prior to treatment Jan 2002

56y/o male generalized chronic severe periodontitis

Post Perio, Restorative and Ortho Treatment Jan 2007

56y/o male generalized chronic severe periodontitis

Jan 2011

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

Periodontal Biotype

Thick

Short square teeth
Thick robust gingiva
Wide blunted papilla
Resistant to recession

Thin

Long Tapered teeth
Thin friable gingiva
Long pointy papilla
Susceptible to recession

Dimensions of the Dentogingival Junction in Humans

Gingival sulcus ~ 1mm
Junctional Epithelium ~ 1mm
Connective Tissue

Attachment ~ 1mm

Garguilo AW, Wentz FM, Orban B. J Perio 1961;32:261-267

Sulcus JE CT

T O O T H

Periodontal Biologic Width

Sulcus
Junctional Epithelium
Connective Tissue Attachment

Tooth vs. Implant Histology

Tooth

– Sulcus – Epithelial Attachment – Connective Tissue Attachment – Bone Attachment via Sharpy’s fibers

Implant

– Sulcus – Epithelial Adhesion – No Connective Tissue Attachment – Direct Bone to Implant Union LM (Osseointegration)

Peri-implant biologic width

Sulcus
Junctional Epithelium
Connective Tissue

Sulcus Junctional Epithelium Connective Tissue

Peri-implant Histology

Junctional Epithelium

– Presence of hemidesmosomes – James R, Shultz RL JOI 1973

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Nicholas Caplanis DMD MS 6/4/2012 Periodontal and Peri-Implant Considerations in Esthetic Dentistry 5 Peri-implant Histology

Connective Tissue

– Parallel Fiber arrangement around smooth titanium – Perpendicular fiber arrangement can be found around rough surfaces – Adhesion – Fiber dense

Peri-implant probing

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 Complications with Restorative Dentistry

Esthetic Crown Lengthening Techniques

Gingivectomy
Gingivectomy with osseous surgery

– with flap elevation or without

Apically repositioned flap with or without osseous surgery
Orthodontics

Camargo PM, Melnick PR, Camargo LM. CDA Journal 2007;35(7):487-98

Esthetic crown lengthening – case 1

Gingivectomy using Ellman™ Radiosurgery

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

Esthetic crown lengthening – flapless osseous reduction

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

Esthetic crown lengthening – Osseous surgery w flap

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

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Nicholas Caplanis DMD MS 6/4/2012 Periodontal and Peri-Implant Considerations in Esthetic Dentistry 7

Esthetic crown lengthening – Gingivectomy guided by stent

Esthetic crown lengthening – osseous flap surgery

Esthetic crown lengthening-case 3 Root coverage procedures

Placement of interpositional CT graft guided by stent

Root coverage procedures

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Nicholas Caplanis DMD MS 6/4/2012 Periodontal and Peri-Implant Considerations in Esthetic Dentistry 8 Miller Recession Classification

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 interproximal AL Partial root coverage to the height of interproximal tissues

50-70% Class IV

Recession to or beyond MGJ –Severe interproximal AL Unpredictable root coverage

< 10%

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

Purpose

To evaluate the outcome of various gingival grafting 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

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

Results and Conclusions

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

Mucogingival surgery – interpositional CT graft Mucogingival surgery – interpositional CT graft Mucogingival surgery – interpositional CT graft

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Nicholas Caplanis DMD MS 6/4/2012 Periodontal and Peri-Implant Considerations in Esthetic Dentistry 9

Root reshaping: an integral part of periodontal surgery

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, and Root Coverage Procedure

Root Coverage Required to Reduce Anterior Tooth Length Esthetic Crown Lengthening in Posterior and Root Reshaping of the Anterior Teeth Root Reshaping Eliminates Existing Restorative Margins Placement of Interpositional CT Graft Guided by Stent

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Nicholas Caplanis DMD MS 6/4/2012 Periodontal and Peri-Implant Considerations in Esthetic Dentistry 10

Esthetic Crown Lengthening, Root Reshaping and Root Coverage

Immediate or Delayed Placement?

Questions

Is the alveolus intact?
Will implant stability be achieved?
Is pathology present?
Is ideal implant position achievable?
Any hard or soft tissue deficiencies?
Are there multiple sockets?
Will the majority of implant be in bone?

Realities

Immediate placement more challenging
Physiologic post extraction resorption can lead

to a loss of buccal and/or crestal bone

Operator experience and comfort level driven
Implant failure can result in soft or hard tissue

deficit

A Prospective Randomized Clinical Study of Changes in Soft Tissue Position Following Immediate and Delayed Implant Placement

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.

A Prospective Randomized Clinical Study of Changes in Soft Tissue Position Following Immediate and Delayed Implant Placement

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

Results and Conclusions

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

Immediate Dental Implant

Basic Principles for Success

– Primary stability an absolute requirement – Majority of implant should be within bone – Place implant 2mm lingual of buccal plate – Graft residual defect – Case selection

consider what may happen if implant fails

44 y/o female with chronic alveolar abscess of maxillary left lateral incisor

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Nicholas Caplanis DMD MS 6/4/2012 Periodontal and Peri-Implant Considerations in Esthetic Dentistry 11

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

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

Prototype development

Laboratory Phase

Final Outcome

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.
I asella JM et.al. J. Perio 2003 74(7): 990-9.
Lew DW et.al. I nt J Oral Maxillofac I mplants 2009; 24(4): 609-15.
Araujo MG, Lindhe J Clin Oral I mplant Res 2009; 20(5): 433-40.

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Nicholas Caplanis DMD MS 6/4/2012 Periodontal and Peri-Implant Considerations in Esthetic Dentistry 12

Delayed Placement – Site preservation Delayed Placement – Site preservation

Site preservation biomaterials

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

Site Preservation

Site preservation begins with atraumatic tooth extraction followed by extremely thorough socket debridement and placement of a bone graft EDS-3 Extraction Defect Autologous Connective Tissue Graft can function as a membrane to contain graft as well as to repair soft tissue deficit

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Nicholas Caplanis DMD MS 6/4/2012 Periodontal and Peri-Implant Considerations in Esthetic Dentistry 13

Provisional prosthesis with ovate pontic design used to guide healing

Connective tissue graft harvest

Successful site preservation allows for prosthetically driven implant placement

Radiographic case progression

Final Outcome

Facial gingival tissue stability after connective tissue graft with single immediate tooth replacement in the esthetic zone

20 consecutive patients
Immediate implant placement

with associated connective tissue graft

Follow up 1-4 yrs
Preservation of papilla
Biotype enhanced
Bone and soft tissue stability

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

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Nicholas Caplanis DMD MS 6/4/2012 Periodontal and Peri-Implant Considerations in Esthetic Dentistry 14

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

Successful site preservation allows for prosthetically driven implant placement

Radiographic case progression

Final Outcome

Delayed Implant Placement EDS-2 Extraction Defect Site preservation with socket and CT Graft

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Nicholas Caplanis DMD MS 6/4/2012 Periodontal and Peri-Implant Considerations in Esthetic Dentistry 15 Site development EDS-4 Defect

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 Lost left central incisor due to trauma as a child

First procedure - extraction of teeth, site preservation with Bio-Oss + DBM and connective tissue graft Second procedure – site development using a symphyseal block graft and membrane Third procedure – implant placement with connective tissue graft and using healing abutments as space maintainers

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Nicholas Caplanis DMD MS 6/4/2012 Periodontal and Peri-Implant Considerations in Esthetic Dentistry 16 Site development

CDA Journal Nov 2005

Papilla Preservation

I nterproximal bone to tooth contact

point

< 5mm 100% papilla presence
6 mm 56%
7mm 27%
Tarnow et. Al. J Perio 1992

Implant placement guidelines - spacing

Tooth to I m plant 2 m m

Esposito et al. Clin Oral I m p Res 1 9 9 3

I m plant to I m plant 3 m m

Tarnow et al. J Perio 2 0 0 0

3mm 2mm 2mm

Implant placement guidelines - position

Avoid adjacent implants in the esthetic zone

Implant placement guidelines –Emergence Profile

3 mm below restorative margin

Esthetics vs. Health

Excessive platform depth compromises maintenance

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