Bone Regeneration

“Bone Regeneration

For Ideal

Implant Placement”

Michael Sonick

1047 Old Post Road

Fairfield, CT 06824

(203) 254-2006

Bone RegenerationFor IdealImplant Placement

implant concepts

Implants - surgical procedure driven by prosthetics
Bone is the first requirement (sets the tone)*
Surgeons focus - 3-D bone to imp relationship
Soft tissue depends on bone (is the issue)*
Missing bone is the limiting factor for esthetics
Imp-tooth & imp-imp distance is critical
Lacks of esthetics is unacceptable

Esthetic Hierarchy

Restoration
Soft Tissue Form
Implant Placement
Site Development

Why An Implant?

Segment the case
Decrease future costs
Increase strength of the restoration
Preserve bone
Patient able to floss
Cosmetics
Psychological health

Implant Success is Dependent Upon

Implant stability
Good restorative position

Implant Stability Dependent Upon

Bone quantity
Bone quality

Good Restorative Position is Dependent Upon

Bone quantity and quality
Adequate gingiva – esthetics
Ideal 3-D implant placement
Timing of implant placement

Implant Advantages

Maintenance of bone
Improved stability of prosthesis
Improved proprioception
Increased support
Direct occlusal loads
No caries or endo
Improved psychological health

Consequences of Bone Loss

Denture retention difficult
Reverse smile line
Minimal display of maxillary teeth
Upper lip does not follow mx incisal edge
Hypererupted mand anterior teeth “combination sx”
Resorbed max ridge

Loss of teeth

Decreased V.D.

Increased nasal-labial fold
Prominent chin
Pointed nose
Witch‘s profile

Which Graft

Nothing
Bone Graft?
Autograft, allograft, xenograft, synthograft, combograft
Membrane?
Non-resorbable, Resorbable – bovine, porcine, human, synth
Growth factors
PRGF, PRP, Emdogain, rhPDGF-BB (Gem 21),rhBMP-2(Infuse)
Soft tissue graft?
Autograft, Allograft, Xenograft
All or some combination of the above

Extraction Facts

General DDS extract 23 million teeth/year
First year – 25% loss of bony width
First year – multiple extractions 4 mm loss of vertical
Years 2 to 3 – 40% bone loss

Tooth Extraction Sequellae

Resorpton and remodeling
Insufficient bone for implant placement
Increased crown to root ratio
Gingival loss
Recession at adjacent teeth
Lifelong bone resorption

Tooth Extraction -classification

Simple – no flap elevation (and GFs?)

nothing
fdbg & collacote

Complex – flap elevation (and GFs?)

fdbg & membrane

–resorbable or non-resorbable

fdbg & membrane & soft tissue graft

–autogenous or allograft (alloderm TM)

fdbg & soft tissue graft

Tooth Extraction - Simple Grafting Technique

Remove tooth atraumatically
Sulcular incision
Minimal elevation
Ogram system
Consider Piezosurgery
Good degranulation – use neumeyer burs (Brassler)
Copious irrigation – saline and CHX
Hydrate FDBG with water and Growth Factor and fill defect
Place collacote plug
Suture with 4-0 gut, rapide or gortex

Post-extraction changes

Tooth removal spurs external bone resorption
Horizontal3 - 6 mm
Vertical1 - 2 mm
Must minimize loss
Via grafting extraction site
Termed “socket preservation” or “ridge preservation”
Atraumatic extraction techniques

The Excessive Loss of Branemark Fixtures in Type IV Bone: A 5 Year Analysis

1054 implants placed in 246 jaws

952 fixtures in Type I, II, III bone

Implant failure rate 3% (29/952)

102 fixtures Type IV bone

Implant failure rate 35% (36/102) in Type IV bone Jaffin and Berman 1991

Tooth Extraction - Ogram Technique

Understand dental anatomy
Section all multi-rooted teeth
Two axis bioengineering principles
Fulcrum at the level of bone – don’t position forceps apically
Micro motion relative to anatomy
Teeth removed quickly
Bone is preserved

Why a membrane?

Resorbable

Collagen
Bovine
Achilles tendon
Pericardium
Porcine
Human
Pericardium
Acelleular dermis
Fascia Lata
PLA/PGA
PRGF

Non-resorbable

Expanded PTFE
(e-PTFE Gortex)
Plain
Titanium re-enforced
Non-expanded PTFE
(n-PTFE Teflon)

What is an ideal membrane?

Space making
Allow nutrients to pass
Does not allow soft tissue cells to pass
Bio-compatible
Does not become easily infected
Maintains its barrier function for 6 months
Resorbs after 6 months
Does not have to be removed

-no second surgery

Incision Design

Sulcular circumferential incision
To adjacent palatal line angles
Extend 1 tooth distally
Vertical radicular bone
Perpendicular to bone
At right angle to mesial tooth
Full thickness reflection past MGJ
Explore the buccal plate

Membrane Preparation

Soak in sterile saline or
patient’s blood for 3 - 5 min
Trim (template provided)
Use only curved scissors
Do not tack

Membrane and Graft Placement

Hydrate graft & membrane
Pack loosely into site
Place membrane
Cover the defect
Shy of adjacent teeth
Obtain passive primary closure
Periosteal release may be needed

Membrane Surgical Considerations

Flap preparation
Site preparation
Space beneath the membrane
Lie passively over defect
No sharp edges
Adapt margins of membrane to bone
Cover the defect by 2 mm
Avoid the teeth by 1.5 mm
Stability of the membrane
Obtain primary closure

Closure

Replace flap
Maintain anatomy
Tack vertical with gore
Close vertical (5-0) gut
Pack collacote plug or CTG
Close socket with gore
No pressure on wound

Bone Grafting – Peri-implant Regeneration

Incision Design

Full thickness flap
Expose buccal plate
7 threads exposed
Verticals 1 tooth lat
Interradicular incisions
Connect with sulcus
Ideal position – 3 D

Autogenous Bone - Harvesting Options

Locally
Rounger, trephine, safescraper
Osteotomy site
Bur slow speed, spoon
Chin or Ramus
Piezosurgery, bur, chisel, trephine

Second Stage Surgery

Palatal surgical flap
Increase tissue thickness
Increase keratinized tissue
Provide proper abutment seating
Facilitate oral hygiene
Provide proper ridge contour

Growth Factors

Autologous
PRGF – Plasma Rich Growth Factors
PRP – Platlet Rich Plasma
Xenologous (Pig)
Enamel Matrix Proteins (amelogenins) - Emdogain
Synthetic
rhPDGF-BB – Gem 21
rhBMP-2 - Infuse

Bone Grafting – Site Development

Site Development

hard tissue
soft tissue

Site Development - hard tissue options

Orthodonics
Membranes & bone grafting
non-resorbable (titanium reinforced)
resorbable
Block grafts
Sinus grafts

Site Development - soft tissue options

Connective tissue grafting
1st stage surgery
Post 1st stage surgery
2nd stage surgery
Post 2nd stage surgery
Alloderm
Flap management second stage surgery
Guided gingival growth

Orthodontics

Tooth movement moves bone
Vertical defects can be reduced
Bone can be leveled
Potential implant sites created

Radiographic evaluation of marginal bone loss at tooth surfaces facing single Branemark implants

Decreased horizontal distance between implant and tooth correlated to increased bone loss

Gingival recession around implants 1-year longitudinal prospective study

63 implants in 11 patients
evaluated at baseline, 1 week, 1 month, 3 months, 6 months, 9 months, and 1 year
majority of the recession occurred within the first 3 months
80% of all sites exhibited recession on the buccal
wait 3 months for tissue to stabilize before crown

What is Osseoguard ?

Type I Bovine Collagen
Bovine Achilles Tendon
U.S.D.A Certified
Australian Bovine Source
Manufactured in U.S. by Collagen Matrix Inc

Bone Grafting – Immediate Implants

Implant Surgical Placement - When?

Post extraction

-delayed

Two months post extraction

–immediate delayed

At the time of extraction

-immediate

Site Development Implant Placement Provisionalization

Without ImplantPlacement

Six months post exo
Two months post exo
At the time of exo

With Implant Placement

•Six months post exo

•implant, heal, expose, heal, temp

•implant, heal, expose, temp

•implant and temp – immed temp

•Two months post exo

•implant, heal, expose, heal, temp

•implant, heal, expose, temp

•implant and temp – immed temp

•At the time of exo

•implant, heal, expose, heal, temp

•implant, heal, expose, temp

•implant and temp – immed temp

Implant Placement Two months post extraction - disadvantages

•No immed gratification

•May still need CTG

•Bone resorption

•Bone grafting needed

•May lose papillae

Implant Placement Two months post extraction - benefits

•Soft tissue has healed

•No need for CTG

•No anatomic distortion

•Infection has healed

•Less surgery needed

•Less technique sensitive?

•Some bony healing

Immediate Implant - benefits

•One surgical visit

•Patient committed to imp

•Shorter treatment time

•Papillae preservation

Immediate Implant - disadvantages

•Must deal with infection

•Site larger than implant

•Bone graft needed

•Gingival closure difficult

•Membrane exposure

•Provisionalization

•Technique sensitive

•Rececession

Immediate Occlusal Loading (IOL)

Provisional or final restoration is in function with contact in centric occlusion, lateral working and balancing movements.

Requires multiple implants rigidly splinted by a fixed prosthesis.

Five-year prospective study of immediate/early loading of fixed prostheses in completely edentulous jaws with a bone quality-based implant system

•Immediate load cases followed average 2.6 years

•Average bone loss first year < 0.7 mm

•No implant failures occurred

•Bone loss similar to a two staged approach

Immediate Non-Occlusal Loading

Provisional restoration is not in function, has no contact in centric or non-centric occlusion.

Can be accomplished with single tooth or multiple restorations.

Immediate Non-Occlusal Loading - Advantages

•Fewer appointments

•Stimulate bone formation

•Preserve esthetics

•Form a “niche” practice

Immediate Temporization

•Primary stability a must

•Dense cortical bone preferred

•Instability > micromovement

•Instability > fibrous ecapsulation

•Within 48 hours of implant surgery

PreFormance™ Posts And Cylinders

•For screw retained or cemented restorations

•Packaged with hexed titanium alloy screw

•Knurled surface for mechanical retention

•Titanium alloy interface

•Non-Hexed available

Five-year prospective study of immediate/early loading of fixed prostheses in completely edentulous jaws with a bone quality-based implant system

•Immediate load cases followed average 2.6 years

•Average bone loss first year < 0.7 mm

•No implant failures occurred

•Bone loss similar to a two staged approach

“25 percent of people without teeth reported

that they avoided close relationships

because of fear of rejection when their

toothlessness was discovered.”

Process for Creating CAM StructSURE™ Bars

•Make impression and pour cast

•Fabricate occlusion rim & verification index

•Set denture teeth and wax for try-in

•Scan analogs and wax try-in

•Design bar in CAD

•Mill bar from CAD design (CAM)

•Polish bar and add attachments

•Tooth/bar try-in

•Process denture with attachments in acrylic

Immediate occlusal loading of Osseotite implants in the lower edentulous jaw. A multicenter prospective study

•325 Osseotite implants inserted & loaded

•Temp prosthesis delivered within 4 hours

•Final delivered in 6 months

•Implant Success: 99.4% 12-60 months post insert

•Crestal bone loss similar to that reported for standard delayed loading protocols.

Michael Sonick DMD

1047 Old Post Road Fairfield, CT 06824

Voice (203) 254-2006

Dr. Michael Sonick is a full time practicing periodontist and implant surgeon in Fairfield, Connecticut. He is on the Editorial Board of Compendium of Continuing Dental Education, Functional Esthetics and Restorative Dentistry, Inside Dentistry, Journal of Implant and Advanced Clinical Dentistry, Journal of Implant and Reconstructive Dentistry, and Dental XP. He currently is a Guest Lecturer at New York University School of Dentistry in their international dental program was previously a Clinical Assistant Professor in the Department of Surgery at Yale University School of Medicine and University School of Dental Medicine.

He is a frequent lecturer throughout the United States and abroad. His diverse lecture topics include cosmetic periodontics, dental esthetics, periodontal surgical technique, diagnosis and treatment planning, dental implant surgery, advanced hard and soft tissue grafting, sinus grafting, and practice management.

Dr. Sonick is the founder and director of the Fairfield County Dental Club, an advanced continuing education organization with over 100 active members. Dr. Sonick is also the founder and director of Sonick Seminars, LLC, a multidisciplinary teaching institute located in his clinical office and teaching center. Courses are given on all surgical aspects of periodontics and implant dentistry. Unique to this program is the three part continuum: dentists get to observe live surgery, participate during the Hand’son portion and attend lectures. Courses are limited to 20 participants to maintain the intimacy of the group and to facilitate a great educational experience. Interested participants wishing to participate can contact Carole Brown at 203 254-2006 or visit us on our website,

Dr. Sonick is a frequent contributor to dental literature having published articles on periodontal surgical technique, esthetics, dental implants, bone grafting, gingival grafting, and radiographic protocol for predictable implant placement. Dr. Sonick is the recipient of an Honorary Membership in the Indian Society of Periodontists, Fellowship in the AmericanCollege of Dentists, Fellowship in the Pierre Fauchard Society and a member of Who's Who in Dentistry. The General Dental Practice Residents at YaleNew HavenHospital have awarded Dr. Michael Sonick the honor of “Teacher of the Year.”

Dr. Sonick completed his undergraduate college education at ColgateUniversity in 1975. He received his DMD from University of Connecticut School of Dental Medicine in 1979. He completed his residency in periodontics at EmoryUniversity in Atlanta in 1983. He received implant training at the Branemark Clinic at the University of Gotenborg in Sweden in 1986 and at Harvard.