Gregg Kinzer: Alright, so yesterday, we spoke about the delayed approach, which is rebuilding
what's there, so you can actually have ideal implant placement and have ample soft tissue
to work with, but when we evaluate those four variables we spoke about yesterday and you
have good soft tissue and bone positions and you have good gingival architectures, then
it makes no sense to just take the tooth out and 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 a bunch of different ways to do that, I basically
spoke about the immediate implant placement and the immediate provisional approach, but
that's just one way to support the soft tissue.
The reality is I can use any of these methods and 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 it predictably.
So whether I put an immediate temporary on the 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 through a 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 you can see radiographically that his left central
has been deemed hopeless, and needs to be extracted.
These are two restored teeth, they're actually splinted together.
So, since we're gonna have to take out the left central, the question is going to be,
"How are we going to sequence through, how's our treatment option?"
We look, we have good bone positions, we have good gingival margin, we have good papilla,
in fact we have one papilla that's actually almost too good.
It almost goes all the way to the incisal edge.
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, we don'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 the provisional for you.
But there's another way that I could support the soft tissue because I'd actually wanna
redo this restoration as well.
And since this is a full coverage restoration and I have it next to the implant, then I
could cantilever the provisional, and the cantilevered provisional then could be used
to support the soft tissue, just like an ovate pontic.
So that's what we're going to do for this patient.
So where the treatment would start would be in the restorative office.
I would take off the old restorations, I would refine 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's just resting upon that root, like a cantilevered
bridge-lapped pontic, like that.
What this does now, is it gives the surgeon the ability to take this off, take the tooth
out, do what they need to do, and then put it 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 little bit of work, as opposed to making an implant
provisional, 'cause I know when Jim makes implant provisionals for me, he adds a lot
of treatment time to the patient.
So I don't take the tooth out because we saw yesterday that when you take the tooth out,
you start getting these dimensional changes in the ridge.
And because we have the dimensional changes in the ridge, when the tooth comes out, we're
going to follow it up with some sort of contour augmentation, and there's a bunch of different
ways in literature to augment that contour.
You can use hard tissues, you can use soft tissues.
So our typical protocol would be doing some sort of soft tissue facial augmentation to
maintain that facial contour, otherwise you start having components show through, you
start having a concavity, and from a restorative standpoint, it starts impacting the shape
of the restoration.
If the ridge is more palatal, then to get back to the ridge, I have to wind the tooth
back, so it's in a different facial plane than the tooth next to it.
So what we typically end up doing is some sort of a connective tissue graft.
We can grab connective tissue from a variety of places on the palate, or even in the tuberosity,
depending on what our goals are.
And if you look at this patient from Ueli Grunder, half the patients had a connective
tissue graft, half of them did not.
And when they followed them, what they found was, that there was an average loss in the
non-grafted group, but an average gain, slight gain from where they started when they put
that connective tissue facially.
And if you break down the non-grafted, the average 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 significant loss.
Now we used to play the game that, "Let's do the procedure and not do the graft and
we'll see what happens, we'll see if they fall into this category, where we might not
have to graft it, or if they fall in something like this."
Don't do the graft if you don't need it.
But you don't know if you don't need it until you wait.
And the problem is that every time we did it, we ended up coming back at a subsequent
appointment and doing the graft.
It's like now you're putting the patient through two different surgeries.
So then we said, "You know what?
We're gonna be in the aesthetic zone, everybody typically 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 surgeon would take the tooth out, put the implant
in, and then do some facial contour augmentation with soft tissue.
Now in this specific example, the soft tissue is also gonna be carried over to cover the
recession that was on the lateral.
So just because he's in the sight, he's gonna do a little bit more good for the patient.
Then what he's going to do is, he's gonna have to modify the underneath side of that
pontic, 'cause remember it was a ridge-lap before.
So he's gonna have to add material to fill in the space, and make sure that they can
still support the papillae.
Now the benefit of doing this is, when it gets 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 the soft 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, you know 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 actually took 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 take an impression, make it and bring it back to
the mouth.
I can do this all chair-side.
So this is the same provisional that they started with.
I just now connected it to an abutment.
So the immediate approach does make us significantly more efficient and our goal then is to maintain
the soft tissue aesthetics, to maintain the soft tissue contours, and the facial connective
tissue augmentation allows us to maintain that facial contour.
Bob Winter: So one of the beauties of this approach, it's guided healing of the site.
So in this workshop, obviously it's geared towards implants but we also have the pontic
section lying in this course.
So tomorrow morning, you're actually gonna do all of this work on models because controlling
an ovate pontic site is a key for a pontic but it's also an option for a provisional
and for a lot of surgeons and so forth, it can be an easy transition.
So that's why our concepts of the tissue form and support is based on obviously bone, adjacent
teeth, but then the restorative object that's there, in this case it's a pontic.
Questions?
Attendee: I was gonna ask how far apically you had to go with your...
To support the tissue, it sounds like we can do that tomorrow.
Bob Winter: We'll get into details about that tomorrow and basically you want to support
having the embrasure form in contact zone to, I'll say, mirror image the contralateral
side, if you err, you have a little bit more space to encourage the papilla to come down.
Greg showed yesterday the last thing you want is erring by having this too long 'cause then
it moves the tissue apically and you may not get 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 positioned two to three millimeters from the facial aspect
of the ridge to make sure that you have enough support so the tissue doesn't collapse underneath
it.
We'll get into the details and you'll actually do that tomorrow.
Gregg Kinzer: So about a millimeter facially, that's pretty typical but if you imagine cutting
the tooth down clinically, your provisional starts about a millimeter.
So that the surgeon that's going to be adding in the contour already has kind of where the
position is.
What they're really adding is more of the ovateness underneath and they just need to
pay attention to these areas here, the support of the papilla.
Yep.
Attendee: If it's not grafted, do you have to worry about the tissue initially?
Bob Winter: Typically, as you'll see with implants, as well as pontics, we're grafting
because of the research that shows that the ridge resorbs and then therefore the tissue
will collapse.
If you don't graft, you're at high risk of those changes.
So, virtually, as Greg's saying in implant cases now, in the past they wait and see,
well they find that you can typically come back and graft.
So the general thought now is grafting at the time of this and with ridges, for example,
and we'll go through an example of extracting a 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 tissue and if it's implanted it would be hard tissue
and soft tissue.
Gregg Kinzer: So restorative dentists, if you're going to have your surgeon do things
for you, restorative things, make sure they have the equipment to do it.
Make sure they have something to adjust the provisional, something to add, something to
polish.
'Cause the last thing you want is them to leave a very rough surface underneath now
that the tissue is touching that, you'll start to get a lot of inflammation.
Little Christmas gift, they get a provisional trimming kit and they pull it out to be able
to do work 'cause it actually enhances things for you.
Now, could you have gotten to the same point by doing an immediate provisional?
Absolutely.
But technically now, it can be more challenging.
This is a more predictable way that challenges you, let's say less clinically but I don't
run the risk of not getting integration because the patient functions on the implant.
There's some patients I just don't trust.
That you tell em, that this, no, you can't bite into this, you can't look, you can't
do much, this is just kind of to give you a tooth but they don't follow your rules.
And so you end up having this risk of not getting integration.
So this is not a bad option if you end up having restorations on the tooth next door.
Cantor-lever it over, just makes it easy.
So here's the final abutment and the adjacent tooth, which is a dark tooth.
So these are actually Emax restorations and Bob can comment that from a technical standpoint,
if we have to start masking dark teeth, the preference would be to use Emax just because
of the different ingot selection that's available to us.
Bob Winter: Yeah and I think it's an important treatment planning consideration that Greg
brought up where there was a crown on this tooth and rather than doing a single central
to match maybe a crown that's old.
Yes, it's a little bit of an investment for the 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 two centrals exactly the same, so you get an ideal
outcome, highly predictable.
Gregg Kinzer: So, I mean, our ideal plan would have been to replace the veneers on the laterals,
right?
And do a connective tissue graft on this one as well, but from a financial standpoint,
the patient goes, "I can't afford to do all that."
So, the surgery was done to cover the root on that one, just because he was in the area.
And the patient knows that at some point in time, if he wanted to restore these, and kinda
make 'em look better, then we would also do the connective tissue augmentation there.
Okay?
So, that would be one technique to be able to start enhancing and managing the aesthetics.
But let me show you what happens when we don't do that facial augmentation.
And as I told you, we used to play the game of, 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, and the crowding, I spoke to her about doing ortho.
And the benefits of the ortho is to align the teeth to get the occlusion.
But also, we can erupt this, and we can improve the implant site.
If we're already doing ortho, we might as well have it benefit you.
So, the tooth was erupted, and we're gonna do this one as an immediate provisional.
Now, we look at where the bone and the soft tissue is, and we have, like, real thick bone,
real thick soft tissue, so we decided, let's not do a facial connective tissue graft, let's
just see if we wouldn't have to do it, because remember, 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 that she kind of left the office, and I lost track
of her.
She ended up having a baby, and so I didn't see her for two years.
So, she comes back in two years.
This is what it looks like when we put it in, so I want you to look at the facial contours.
This is day-of-extraction.
In two years, I want you to now evaluate the facial 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 than it was.
And this is what we started to see on a lot of our patients.
That we rolled the dice and said, "Oh, let's just wait.
Why do surgery if they're not going to need it?"
And by far, almost all, we ended up having to come back.
And what's interesting is that when she came back in two years, she brought this to my
attention.
I saw it right off the bat.
But now you tell the patient, "Well, she's ready 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 tissue graft.
We've gotta let it sit in there for a few months."
So, all of a sudden, we delay the treatment.
But she pointed it out to me, so now we have to 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 do it on all of our patients.
Now, my least favorite option, 'cause I use these three mainly, my least favorite option
would be to use something removable.
Whether it's on a flipper or whether it's on an Essix, you can do it.
I just don't prefer to do it.
So, I showed you this patient yesterday, where she'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 they weren't sure if they could manage the aesthetics.
And this is one of those patients where you kind of have to walk on eggshells.
You know what I'm talking about?
Those types of patients where you don't want anything to go wrong, because the slightest
thing that happens negatively, they blow it way out of proportion.
So, I get it.
They didn't want to do an implant, because they weren't comfortable saying that, "Yeah,
I can replace what's there and make it look natural."
But remember we talked about the factors that will 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 the lateral 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 good facial gingival margin positions.
But I, now I'm thinking, "Alright, how can I replace this tooth in the interim, and minimize
the risks of something negative happening?"
You could say, "Well, we could do an immediate provisional."
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 as a 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 removable appliance.
Nowadays, I'd probably think about doing it as an immediate.
Bob Winter: Yeah, this is a great case, because from a treatment planning perspective, of
course, you have options, right.
A lot of the people were thinking bridges but then you start looking at lateral as a
bridge abutment in the function going off a canine and then a question came up yesterday,
cantor-levers.
Well, maybe you double-but bi's and cantor-lever the 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 process of provisionalization; because of getting
something in there in a fixed perspective is now more challenging.
I don't have adjacent teeth that are crowning and I can cantor-lever off her bond tooth.
So, it's a great treatment planning case actually.
Gregg Kinzer: Yes, so nowadays I would do this as an immediate temporary.
And I would just make sure it's not able to be 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 sat and watched this, you would slowly start to
see these papillaes start to slump.
You would slowly start to see the facial margins start to come palatally.
So we wanna maintain our support of that.
Now you, as a surgeon, you could send this back to me and I could do the provisional
or you can help have your surgeon do it for you.
The more I can get my surgeon to do, as long as they do it correctly, it makes my life
easier.
So this is what I sent, this is Dave Matthews doing 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 it continually bouncing on the soft tissue.
But the way I fabricated it is I took the tooth 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 cutting the tooth off.
So this is kind of a ridge-lapped, pontic.
When he goes to put it in, if you were to try it in right now, it's going to scallop
like the tooth but it's basically not gonna touch the tissue at all.
Because it wasn't fabricated to go sub-genitively on the model.
So what does Dave have to do?
Dave has to pull out his restorative materials and add to the apical portion of the pontic
to, again support the soft tissue, just like we 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 out to the edge of this, it's not going to push
on the soft tissue.
Because these areas are preventing it from bouncing 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 I just 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 this is 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 ... This kind 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 tissue kind of granulate over it.
Bob Winter: So technical tips for the restorative dentist making the flipper, if you micro-air
abrade the under-surface of that pontic with aluminum oxide, to get it ready for the surgeon
to add the material, we'll go through the exercises 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, maybe the bond isn't as good.
So that's the way I'd have the restorative dentist help the surgeon get it ready so they
have less work to do.
And that's why it's set-up perfectly for when Gregg does the follow-up, it looks great.
He doesn't have to do anything really.
Gregg Kinzer: So the only thing I had to do was, I just polished it a little bit, just
to get a little bit better junction between what was added and what was there.
So this is now four weeks later.
So at a month.
And again, we have nice papilla heights, good symmetry to the papilla, and now we have a
nice healed tissue.
Now, what you'll find is, it'll never completely close over.
There'll always be an epithelial heal so there'll always 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 it up, 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 where the gingival margin is, so connecting the
dots between where the tooth is from some sort of a matrix and where the head of the
implant is, you're talking a millimeter to a millimeter and a half of adding material
to get your emergence.
'Cause all of the thinking's already been done.
So chair-side now, you can come in and you can actually fabricate the provisional.
Saves time, saves appointments.
Now, what's the down side of this?
The down side of using a removable appliance is, they have to wear it all day and all night.
If she took it out at night, what's gonna happen to soft tissue?
It's gonna collapse.
So then in the morning when she pulls it out and 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 take it out routinely and clean it, the tissue
starts to really look nasty.
So, as I said, this is my least preferable option, 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 jump into fabricating a provisional and jumping
the provisional in.
Although you can take an impression, do it on a model, bring the patient back, do it
over two appointments, it's easy to do chair-side in one appointment.
So it does make you more efficient.
So, here's the implant provisional, and now here 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 period that this was done.
Straumann didn't have the ability to do zirconia at this point, so we ended up having to a
metal-ceramic abutment, metal to give strength and the ceramic sub-gingively to be able to
enhance the esthetics of the tissue so we don'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, where we didn't do any facial augmentation.
Back when this was done, I don't think anybody was 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 examples where you can get away without doing it, but
this is really, in my opinion, nowadays it's really rare that I find that we do this and
don't have the repercussions of the soft tissue collapsing.
This option of using a customized healing abutment, 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 can do, a restorative dentist, or this is something
that your surgeon can do for you.
I actually typically tend to have my surgeon do 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 can see the fistula present on his right central.
So, for his treatment planning, treatment options, given the malocclusion, given the
position of the teeth, I thought, "You know what?
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 move that 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 healthy situation, I have good soft tissues, but I'm
in the middle of ortho.
So I'd rather just take a pontic and stick it on the archwire.
But if I have a pontic on the archwire, how am I gonna influence and support the soft
tissue in that situation?
If we do a custom healing abutment, it doesn't matter how you replace the tooth.
You could use a flipper, you could use an Essix, or you could stick it on the archwire,
because the tooth hanging off the archwire will have no influence on the soft tissue.
It doesn't need to.
So, Bobby Butler is the periodontist that's treating him, takes the tooth out, and again,
we're placing the implant relative to where I need the gingival margin to be, 'cause right
now, the gingival margin's about 2 millimeters plus more coronal than I want it.
So, this implant's gonna probably be around five plus millimeters below the tissue.
You go, "That's really deep."
Well, it's deep because I want the gingival margin to be somewhere up here, and I'm anticipating
this soft tissue changing.
So, what Bobby's gonna do is, he's going to fabricate 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 something out of the catalog and just stick it in that
had an anatomic shape.
Nowadays, a lot of companies are fabricating customized, or maybe even customizable, healing
abutments.
But, this is still a very valid option, but you have to use an engaging temporary abutment.
I need something that when the surgeon puts it on, it can only fit one way.
You can't use a stock healing abutment that only screws in with the threads, 'cause typically
if you imagine the profile of a central, it's going to be wider mesial distal.
So imagine when you screw something in and if it only screws in with the threads, you
get this wide mesial distal that screws around and 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 composite to use, and honestly, this can even be old,
ugly colored composite that you just never use in practice.
And it'll stick quite well to that kind of knotted surface.
Now, when it's fabricated for the surgeons that are gonna fabricate it, I would keep
the length of the abutment.
It's gonna be tall, it's gonna be way taller than you want.
But keep the length because what it enables you 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 trying to create.
Something that follows the scallop of the soft tissue from facial, to mesial to distal.
Now, if you'll notice, this is a different custom 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 surgeon to actually scallop it here and scallop it
here, like you would see there to support the papilla all the way around.
But this is doing its job of supporting the apical 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 to the archwire.
Before the patient is done, Bobby's gonna do the facial connective tissue augmentation
and then we just take a plastic tooth and we stick it on the archwire.
So, it has no influence on the soft tissue but the soft tissue is being supported by
what's underneath.
And even though this hasn't supported the full 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 notice that the papilla on the distal here is deficient.
So, why is it deficient and could you have predicted this?
And could you have improved it?
Well, it's deficient because of the bone level on the mesial of the lateral.
And if you think about the fracture, remember where the fracture line went?
Fracture line went from facial kind of line angle 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 millimeters coronal was where your papilla height's going
to be.
So, you could look at this patient from the beginning and say, "We're probably gonna lose
some papillary height.
It looked alright when we started because it was inflamed," inflamed tissue always looks
good.
But you could predict where the papilla's gonna go.
In fact, you would want to predict that 'cause you would wanna have a discussion with the
patient about what's going to happen in the end.
If the patient wasn't going to be happy with this, use some templates, use your photos,
and show where the papilla's gonna go, then how 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 the mesial 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 lengthening at the time you do your implant surgery.
And if you're going to expose root, you're probably gonna have to add another restoration.
But you could predict all that and the patient could 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 a little 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 and improved from the beginning.
You could have predicted that that was going to happen.
So you're setting the expectation for the patient, as we said yesterday, that's where
a lot of patients when their expectations aren't met, even though maybe their expectations
are unrealistic, that's where they become unhappy.
So evaluating the patient before you treat could alleviate that.
Yeah?
Attendee: Since it's so minimal, would soft tissue graft help ...?
Gregg Kinzer: To do a vertical, you'd have to 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 lot of steps backwards.
Attendee: But before?
Gregg Kinzer: Yeah.
Yes, I think you could have.
I would have probably done it with eruption just because predictability now having the
bone support the soft tissue is, I know that papilla's not going anywhere.
If you start to graft and get more soft tissue height above the bone, there's always the
risk that over time you start to lose the papilla height 'cause it doesn't have the
bone-y support.
Bob Winter: One thing that it's a little difficult to appreciate when we show photos, we use
flashes to capture images.
And I just saw a patient a couple of days ago 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 her smile, the lip goes up high enough so the
two lateral pontics, the restorations look spectacular and with flash photography everything
looks great and you scratch your head and say, "Why do you wanna make a change?"
But if you just see the patient stand before you and smiling, what happens?
The lip drape creates a shadow.
And when you have areas like this or as Greg's discussing even a deficiency facially, that
shadow then is accentuated compared to the other side.
So that's something we have to let patients become 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 the way 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 to understand what they're saying "no" to.
Because ultimately, again patients may say that's all fine, but some patients may not.
Yes?
Attendee: And is it true, the fuller the lips the more that's enhanced?
Bob Winter: You could say that or argue that for sure because you create more shadow 'cause
most light comes from down from above, and the 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 ourselves to do some sort of a customized healing abutment?
These are kinda the things that I would think about, to say, "Okay, I'm not gonna do an
immediate provisional here."
If there's a peri-functional activity where I 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 allow me 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-edge position.
I have patients who are pretty aggressive athletes.
And you could say, "Well, do an immediate provisional and just make em a mouth guard."
And that's, in theory, that sounds great until they arrive at the field and they don't have
their mouth guard.
They're not gonna go, "Oh, yeah, Kinzer said I shouldn't play if I don't have it."
No, they're gonna do it anyway.
And then, as I said earlier, I have patients that maybe I just don't trust their compliance.
I had a patient who was the daughter of a dentist from the East Coast and she was working
at Microsoft.
She was in Seattle and we had done an immediate implant, immediate provisionalization on a
central.
So, she comes in and I'm going to take if off to do final impressions.
I go to unscrew it, I pull the temporary out and 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're doing the immediate provisionals is overtime
they forget.
They forget it's an implant on a provisional that 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 abutments and then there are customizable healing abutments.
This is a piece from Straumann, it's the peak material that has a shape kind of just a larger
cylindrical shape that the surgeon can actually now adjust and polish so it's easier to adjust
this than to adjust metal.
And they can actually support reasonably well the soft tissue.
It's better than just putting a stock piece on, but obviously the central isn't going
to be completely round.
And as I said, now you have the ability to actually 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 to make sense.
Bob Winter: Yeah, and the peak material, as you can see, it's somewhat pink in color so
it blends reasonably well.
And you can, we'll, actually have a chance to, 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 chance to work with the PMMA material, we can use
it for a full abutment or you can modify it by cutting it down, shaping it but then you
can add to it quite easily.
So that could be used as an option from the peak.
So we'll work with that tomorrow.
Gregg Kinzer: So I will say one thing for the 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 facial thickness.
More facial thickness that you can now add contour 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 kind of appreciate that here, if you look at where
this tissue is compared to the tissue that's on the natural tooth.
It's been over-adjusted facially to allow there to be more soft tissue lying on it.
Attendee: Okay.
So you got a case just like that last month where there's a peak or some sort of inter-temporary
abutment.
Would you restore that directly or would you take another step of putting a temporary to
then reposition the tissue where you want it?
Gregg Kinzer: That's a great question because you're better than you were if it was just
healed around something natural but you're not as good as you're going to be.
So this now, I'm gonna say it's a clinical judgement call.
The risk is, what's gonna happen now when you actually create better contours, because
what you're going to ask the technician to do or you would do it on the model is, like
you did yesterday on your models, you're going to have to adjust the soft tissue.
You're gonna have to take and adjust the soft tissue on that model to create the flare that
you want.
And when you support this papilla more, what do 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-retained restoration, the technician is going to guess,
"How far is it gonna come down and where should I place my margin?"
And they're always going to err on placing it deeper, 'cause nobody's gonna win if you
can see the junction.
So, the risk that you run then, is you end up having the tissue more coronal, like your
margin is gonna be way way too deep and now you risk keeping cement, not being able to
clean up the cement.
So, if you were going to do this right from this, go to right to finals, doing it as a
screw-retained restoration maybe is a little safer.
But now the guess still is, where is the papilla going to come down because they need to create
an emergence profile, and what they don't want is they don't want to choke the papilla
off, but they're gonna tend to err on that side.
Otherwise, they leave a black space.
So, you're guessing a little bit.
So, in an ideal world, I would say you go make the provisional.
But now, clinical reality is, you may choose not to do it given whatever your fees are
or whatever the patient is willing to endure or whatever the patient is willing to pay
for, you might end up having to go right to finals.
Bob Winter: So it's a great question and it leads us into the discussion we're gonna have
for really the rest of the morning when we get into abutments and so forth.
But what we try and emphasize in this course and 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 from here, now all of those decisions really go
into the hands of the technician.
And then the question is, "What knowledge base does the average technician have to make
some of those decisions?"
And it's safer if it's screw-retained because there's no margin placement to worry about,
but you still deal with contour.
So in this situation right now, where the gingival margin, I'll call it a millimeter
and a half to two millimeters more coronal than the adjacent tooth, now the final restoration,
whether it's an abutment or final crown, we have to add contour to it.
And then when you go to the mouth and you put it in permanently, it's the leap-of-faith
that it's done precisely and the tissue's gonna move to exactly where you want it.
So, there's risk benefit to everything.
The real world is, for sure this is better than 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 more error or asymmetry 'cause you can't see the
tooth.
So, in our opinion, it's better to be in the hands of the clinician rather than the technician.
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