Dr. Patrick Yoshikane - GDIA U.S.A. Symposium 2018 - Orange, CA

Dr. Patrick Yoshikane, DDS, from Loyola University School of Dentistry in Chicago, served as president of the Academy for excellence in Dentistry. Is a graduate of the GDIA live patient surgical training program. Please help me welcome Dr. Yoshikane.

Today. I'll be talking about the single tooth for the Esthesic Zone.

Where planning is everything. Plan to be successful, proper planning and practice prevents poor performance. Proven principles to help create a successful surgical outcome. Timing of the placement, accuracy of placement, ideal time for loading of the fixture, or will you just do a staged approach? Ultimately, a cooperative compliant patient was financial resources.

The ultimate goal of dental implant therapy is the satisfy the patient's desire to replace one or more missing teeth in aesthetic and functional manner with longterm success. Before you treat, consider the issues. Each issue may increase case complexity and plan for the worst scenario. The thick or thin biotype, facial and lingual bone height, interproximal bone height, smile line, and lip position, digital contour, bone loss around teeth and implants to be replaced, the amount of infection around teeth and implants, restorations on adjacent teeth, and the mental stability of the patient may create the most complex case and worst scenario. We can't help everyone. When in doubt refer.

So, what's critical is data collection. We really need to do a comprehensive exam, radiographic evaluation to include a CBCT. Study models and diagnostic wax up photo series, occlusal analysis and accurate treatment planning fees. Estimate the total treatment time to allow for proper healing.

Current surgical techniques. Preservation of the hard and soft tissue. Build the foundation for the restoration. Implants systems with platform switching, internal connection and crown down approach. Plan for proper digital implant positioning, angulation in depth for allowing an ideal emergence profile and invest in continuing education for current restorative and surgical techniques.

A properly trained dental team is necessary for us to be successful. Invest in your staff training to support the type of care you're willing to provide and commission a qualified dental technician who understands the biologic and physiologic limitations of the rest of the restorative material. This is something that's actually from 1992, the contact point to the crest of bone by Dennis Tarnow.

This was published in 1992 in the Journal of periodontology where the effect of the distance of the contact point to the crest of bone on the presence or absence of the interproximal dental papilla. Basically, the results show that when the measurement from the contact point of the crest of the bone was five millimeters or less, the Papilla was present almost 100 percent of the time. When the distance was six millimeters, the Papilla was present 56 percent of the time and the distance was seven millimeters or more, the papilla was present 27 percent of the time.

Surgical techniques that will help us restore these implants. Utilizing autologous concentrated growth factor, enrich bone graph matrix, or sticky bone, and the CGF enrich fibrin membrane in implant dentistry. So we create the sticky bone using asilfradent medifuge. There's a huge difference in these centrifuges.

I personally haven't experienced that. I wanted to cut a corner and it's huge difference in the CGF membrane quality. We create the concentrated growth factor with the patient's blood. We spin it down and we either compress it or we leave it in the state for Sinus lifts. We use the concentrated growth factor for allograft and xenograft to create an autologous fibrin glue.

So my case is a 24 old female who had a traumatic dental injury. Her chief complaint was, "I'm self conscious and my tooth is dark, loose, and I want my smile back." This tooth was fully evolved, re-implanted, stabilized, 12 years prior. This is my CBCT prior to treating her, there's the hesitance on the buccal and no lingual bone. So how do we do this? The regenerative surgical procedure. We want to create the environment for which the dental implants survivability will be improved and limit our risk for failure, regenerate the hard tissue foundation through the use of sticky bone, improve the soft tissue quality with a resorbable Collagen Membrane, managed through tunneling, biologic stacking of CGF membrane for improved healing and creating a more favorable bio-type to restore the implant.

So our objective findings were: We had this root resorption, buccal plate to Heston's, soft tissue compromise, increased mobility, and psychological and emotional trauma. Periodontal regeneration of the alveolar socket. I utilize chromic gut sutures to assist in guiding the Collagen membrane placement and stabilization through tunneling. Resorbable collagen membrane was hydrated with CGF serum for better adaptation over hard tissue and improved manipulation. Insulating the bone graft material from the invasive epithelial tissue which will improve the tissue biotype.

So this is how we did it. We carefully managed the removal of the tooth with utilizing mini periotomes, buccal lingual sectioning and root removal. It's so critical for de-granulation of the socket with a serrated currette. I like the lucas. It's actually a two right and two left. Extra care to preserve the delicate peripheral soft tissue is paramount for future success. The regenerative surgical procedure.

This is at time of surgery. And one week post op.

So, our GBR was allowed to heal for six months. Pre surgical implant planning and surgical techniques and theories utilized in this case. So, our presurgical planning. So, I utilize digital blue sky bio and an analog information for centered positioning and sub-Crestal implant placement. X marks the spot. Actually I learned from Jin Kim. The midpoint of two cylindrical objects are intersected. Verification of the central point is visually apparent through the surgical guide. A two point two millimeter pilot drill is placed lingual to the intersection, and actual position is actually verified with a CVCT.

Duplicating adjacent root position while ensuring two millimeters of buccal bone and implant fixture is palatally positioned and placed four millimeters sub-crestal. I placed it four millimeters sub-crestal with the forecast I'm going to lose some bone. The implant fixture was allowed to integrate undisturbed for six months. The restorative techniques and theories utilized in this case: Custom abutment development, implant biologic width development, and aesthetics. Our custom provisional abutment for the development of the implant biologic width. Replacing the fixtures sub-crestal four millimeters, creating our custom abutment with composite, placing it, creating the provisional, and allow that to heal for an additional three months.

This is the provisional from the right side, straight on, incisal and left side view. Let's talk about the anatomic complex. Basically, the implant biologic width. The implant biologic width is the junctional epithelium, which is about two millimeters and also the connected tissue attachment about one point five which serves to prevent oral bacteria and the byproducts from penetrating the body. So this is our anatomic cuff.

The custom abutment development and capturing the anatomic implant, biologic width and delivery of the custom Zirconia abutment. So, let's review the procedural timeline. The extraction. We waited six months after GBR. Replaced the implant. We waited another six months and we created the provisional abutment and provisional crown. Two months later, we took the impression of the final abutment and provisional crown. I waited two more weeks and delivered the final Zirconia abutment and impression for the final crown. Two and a half weeks later, I delivered the final and CBCT because planning is everything.

Thank you so much Dr. Yoshikane for that fine presentation. Do we have any questions? Thank you.