“Implant Treatment

In The

Esthetic Zone”

Michael Sonick DMD

1047 Old Post Road

Fairfield, CT 06824

(203) 254-2006

Implant Treatment in the Esthetic Zone

Practice Made Perfect

  • Direct relationship bet person’s physical beauty and a change in self esteem
  • Pygmalion effect. . .self fulfilling prophecy people dev into type of person as they are viewed
  • Improvement of physical appearance lead to an increase in attractiveness

Psychology of Esthetics

  • What do patients want?
  • How do people see themselves?
  • What impact do dentists have on patients lives?
  • On patients’ health
  • On patients’ esthetics
  • On patients’ self esteem

“Wearing Dentures Has A Negative Affect On Their ‘Psyche’, As They Feel Singled Out In Their Largely Dentate Social Groups.”

Taché R. Demographic, Psychological, Sociological, And Economic Variables And Other Factors That Influence A Patient’s Choice Of Prosthodontic Treatment. Int J Prosthodont 2003;16:22-24

“25 percent of people without teeth reported that they avoided close relationships because of fear of rejection when their toothlessness was discovered.” Surgeon General Report on Oral Health 2000

Truth & goodness, mirrors & masks
A sociology of beauty of the face

“Person’s face is the prime symbol of the self and the principal factor in a person’s physical appearance.” A Synnott Br J Socil 1989

What Matters Most?

Order of importance on the face

Mouth 2. Eyes 3. Nose

Conclusion: “changes made to a person’s teeth and oral region are likely to yield the greatest impact upon self-esteem via in the person’s physical attractiveness.”

Areas of Growth

  • Periodontics
  • Cosmetics
  • Dental Impalnts

Nobel Biocare Survery NA Survey Nobel Biocare 2008

  • 56,680 respondents
  • 50% population >25 - 1+ missing teeth
  • Income $75,000 - 33% had missing teeth
  • 80% patients w missing teeth aware of imp
  • Fixed bridge tx, 3x more likely
  • 40% w fixed bridge felt it was permanent
  • DDS rec implants only 14%

Symmetry - A Celebration of PINK and WHITE

First Indian Dental Conference in Esthetics 1997

Esthetic Concepts

  • Symmetry
  • Balance
  • The lips frame the teeth
  • Gingiva frames the teeth
  • Dental – gingival harmony required
  • Papilla follow the contact points
  • Contact points follow the incisal edge
  • Incisal edge follows the wet/dry line
  • Gingival health essential

Smile Line - Tjan JPD 1984

Low - 20%

Medium - 69%

High - 11%

Dental gingival Harmony – Maxillary Anterior Teeth

Rufenacht Fundamentals of Esthetics; Chu et al J Esth Rest Dent 2009

Canines and Central Gingival Zenith equal

Laterals 1.5 – 2.0 mm incisal

Gingival zenith of central incisor is distal

Gingival zenith of lateral incisor is mid-facial

Esthetic Relationships - Five

Incisal edges of maxillary anterior teeth follow the wet/dry line of the lower lip

Contact points follow the incisal edges

Papilla follow the contact points

Upper lip follows the papilla

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 George Priest PPAD 2005

  • Restoration
  • Soft Tissue Form
  • Implant Placement
  • Site Development

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

Keys to Ideal Implant Placement

  1. Bone
  2. Implant Position
  3. Soft Tissue
  4. Restoration

Bone Grafting – Peri-implant Regeneration

Vertical Growth Approaches

  • Block graft
  • GBR – tenting screws
  • GBR – titanium mesh & BMP
  • GBR – titanium membrane

Second Stage Surgery

  • Surgical flap via a palatal approach
  • Roll technique a la Abrams
  • Flap with connective tissue graft
  • Mid-crestal incision - not recommended
  • Guided Gingival Growth

Esthetic Rehabilitation of the Maxillary Anterior Sextant: The Periodontal-Restorative Connection Sonick Cont Esth Rest Practice 1998

  1. Esthetic and functional exam
  2. Diagnosis
  3. Treatment plans
  4. Treatment

a)Periodontal/implant tx

b)Restorative treatment

Treatment Sequence

  • Examination
  • Diagnosis
  • Diagnostic work up
  • Treatment Plans
  • Patient options
  • Treatment

Cost, Risk Benefit Ratios

Why an Implant?

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

Implant Advantages

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

Tooth Extraction – An opportunity for bone preservation – Site Development

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

American Dental Association 1990

Carlsson and Persson Odontol Revy 1967

Misch and Tatum 1999, 2000

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

Horowitz Compendium October 2005; Christianse1996

Cawood & Howell 1988; Lekholm & Zarb 1985

Misch & Judy 1985; Atwood J Prosth Dent 1963

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

Alveolar Bone

“The alveolar process is a tooth dependant tissue that develops in conjunction with the eruption of teeth. The volume as well as the shape of the alveolar process is determined by the formation of teeth, their axis of eruption and eventual inclination.” (Schroeder 1986)

Bone Sets the Tone

Tissue is the IssueDavid Garber

The Plate Sets Your Fate Craig Misch and Jack Krauser

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

Gem 21

  • rhPDGF

–purified recombinant human platelet derived growth factor

  • stimulates cells of periodontium, blood vessels
  • binds osteoblasts, PDF fibroblasts, cementoblasts
  • leads to cellular migration
  • stimulates regeneration

Flapless Surgery

Can one evaluate the labial osseous anatomy properly without elevating a labial flap? Answer - Yes and No

Summary – Esthetics and Site Preservation

  • Dentists change self esteem
  • Complete diagnostic work up
  • Develop an esthetic treatment plan
  • Bone is the 1st requirement
  • Consider grafting all extraction sites
  • No buccal plate – membrane required
  • 2nd stage surg - opp for gingival growth

Pre-operative Concerns

  • Anxiety
  • Pain
  • Infection
  • Swelling

Anxiety Control

  • Audio analgesia
  • Nitrous oxide
  • Halcion
  • 0.25 mg hs if needed
  • 0.25 mg 1 hr pre-surgery
  • Bring to office apt
  • 0.125 – 0.25 dose sublingual in office
  • Monitor with pulse oximeter
  • IV sedation with Anesthesiologist - 2 days week

Pain Management

•Pre-med Motrin 600 mg – 1 h pre-op

•Marcaine injection end of apt

•Motrin 600 mg end of apt

•Motrin 600 mg q 3 h day one

•Motrin 600 mg q 4 h day two prn

•Vicodin ES as a supplement

Antibiotics

•Amoxicillin 500 mg tid or 875 bid

•Doxycycline 100 mg d

•Zithromax Zpak or Tri-pak

•Augmentin 875 mg bid

Swelling/Bruising

  • Begin Arnica pills 2 d prior to apt - 5 tabs t.i.d. po
  • Continue for 5 days po
  • Arnica cream to face post op qid for 5 days
  • Ice to face 20 min on 20 min off – 48 h
  • NO physical activity for 48 h

Arnica Montana

  • European meadows
  • Rare
  • 20 -60 centimetres
  • Similar to NSAIDs
  • Sprains & bruises
  • Vasodialator
  • Can cause bleeding

Keys to Ideal Implant Placement

  1. Bone
  2. Implant Position
  3. Soft Tissue
  4. Restoration

Implant Positioning In the maxillary anterior esthetic zone

Mesial – Distal Mike Sonick Inside Dentistry 2005

Place centrals slightly distal to pick up height of contour of the parabolic arch

Lateral implants align with the mid-facial

•Implant to tooth2 mm

•Implant to implant 3-4 mm

Attempt to avoid placing adjacent implants!

Implant Papilla – Depends on the Following

•Distance of implant from adjacent teeth

•Coronal level of bone

•Contact pt & proximal support of crowns

•Volume of connective tissue

Grunder, Gracis & Capelli IJPRD 2005

The Effect of the Distance From the Contact Point to the Crest of Bone on the Presence or Absence of the Interproximal Papilla Tarnow, Magner, & Fletcher, J Perio 1992

Cont pt to Bone (mm)3-45678

Papilla Present (%)10098562710

Clinical and radiographic eval of the papilla level adjacent to single-tooth dental implants.A retrospective study in the maxillary anterior region

Cont pt to Bone (mm)<5>6

Papilla Present (%)10050

Choquet et al J Perio 2001

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

Decreaed horizontal distance between implant and tooth correlated to increased bone loss.

Esposito, Ekestubbe, Grondahl Clin Oral Imp Res 1993

Implant Positioning - In the maxillary anterior esthetic zone

Buccal – Palatal

•Slightly palatal to the incisal line angle

For cemented restorations

•Thru the cingulum

For screw retained restorations

Avoid angling labially for it will result in a loss of labial gingival height and result in an uneven gingival margin.

Keys to Ideal Implant Placement

  1. Bone
  2. Implant Position
  3. Soft Tissue
  4. Restoration

2nd Stage Surgery – Opportunities

•Augment gingival tissue

•Proper abutment seating

•Control tissue thickness

•Proper ridge contour

2nd Stage Surgery – Apporaches

  • Surgical flap via a palatal approach
  • Roll technique a la Abrams
  • Flap with connective tissue graft
  • Mid-crestal incision – mandible only
  • Guided Gingival Growth

Guided Gingival GrowthM Sonick 1995/James Stein 1994

•Non-surgically grow gingiva

•Titanium is gingiva loving

•Use THA to guide gingiva

•Leave THA slightly below ging

•Wait 4-6 weeks

•Push gingiva labially

•Place final THA or do again

Non-surgical gingival GraftM Sonick 1995

•Gingiva has grown over THA

•Give anesthetic

•Push gingiva labially

•Place final THA & suture

•OR place slightly larger THA

and repeat the procedure

Implant Positioning - In the maxillary anterior esthetic zone

Apical – Coronal

•Deep restorations are difficult to remove cement and to keep clean

•Shallow restorations risk the showing of the implant.

•Apical to the gingival margin 3-4 mm

Allows for development of a proper emergence profile. . . . . “running room.”

Running Room – distance from the implant platform to the gingival margin.

Steve Potashnick

Provisional Options

  • Screw retained PEEK preformance post
  • Cement retained PEEK preformance post
  • Hexed and non-hexed

Keys to Ideal Implant Placement

  1. Bone
  2. Implant Position
  3. Soft Tissue
  4. Restoration

Running Room – connecting the circles Mike Sonick

Do Incision Designs Influence Papilla?

  • Envelope
  • Sulcular with 2 vertical
  • Sulcular with off angle

Managing the Orthodontic Patient

  • Establish good relationships with orthodontists
  • Exam, x-rays & photographic eval prior to ortho
  • Educate, educate, educate
  • Letter with space recommendations to orthodontist
  • -minimum of 7 mm for lateral incisor
  • -minimum of 8 mm for central incisor
  • Radiographic monitoring during tx
  • Don’t remove bands until x-ray shows adeq space
  • Permanent stabilization. . .no removable appliances

Summary – Implant Position

  • Idealize implant position
  • Bone regeneration first!!!
  • Minimum 1.5 mm from teeth, prefer 2.0 mm
  • Minimum 3.0 mm imp to imp, prefer 4.0 mm
  • Angle to the palatal of incisal line angle
  • Implant platform 3 – 4.0 mm from DGJ
  • 2nd stage surgery – a 2nd opp for gingival growth

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 the co-editor with Dr Debby Hwang of the implant text, Implant Site Development. 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, Journal of Implant and Advanced Clinical Dentistry, xpAPce, Journal of Cosmetic 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 Gothenburg in Sweden in 1986 and at Harvard.