Prof. Dr. Daniel Hernández, DDS, Prosth
University of Cartagenga, Colombia
Hi, everyone. First of all, I would like to Dr. Vincent and Dr. Mauro to open this door from Cartagena to the magical Italy and the beautiful Catania. I’m Dr. Daniel Hernandez, I am prosthodontist and professor of the several postgraduate programs in Cartagena and I collaborate with Bicon in the Congress and events in Colombia. Today, we will cover the following topics. First of all, we’re going to show you how to make a good comprehensive clinical analysis, searching the aesthetics in immediate loading in anterior zone. Thinking always in a prosthetic driven planning, and I go to explain some concepts about how to achieve the best aesthetics when you are doing the surgery in the same time that the temporary. And for finish, we go to see a clinical case that we can make a key point about the best way to use the Bicon components. Okay, so our compressive clinical analysis for these cases involves evaluation of the facial aspect, understanding on the lip tooth relationship and the assessment of the white aesthetics and pink esthetics. When we have our patient in front we can see landmarks to evaluate the asymmetrical or some facial irregularities can impact in the aesthetics of our work. For example, the midline can wait with the midline we can identify some asymmetries and the occlusal plane and its relationship with the pupillary plane can show us some asymmetrical stuff in the face of our patient. A lateral view of our patient can we need to assess to evaluate some orthopedic issues or malocclusions with our patient. Okay? If we get closer to our patient, we can evaluate the smile line because this is an important topic to assess if you have a gummy smile, maybe you need to do pre surgery procedures to after, before the implant. Okay? But we need to evaluate the incisal edge because they need to accompany the upper border of the lower teeth. We can see this aesthetically that this incisal edge show on the lip. Now let’s take an ever closer look of our patient and begin with the evaluation of the white and the pink aesthetic scores. Dr. Belser in 2009, made an objective aesthetic criteria to evaluate the aesthetic and we can use these criteria to evaluate before the treatment starts and in the time and to the following apps. We’re going to start with the white aesthetic. The white esthetic we go to evaluate five parameters and we the first parameter is a general tooth form and we need to find a correlation with all the anterior zone and specifically with the tooth that we go to work and need to be similar the shape of the adjacent or the opposite tooth. Other parameter is the outline or volume crown, this refers to the tooth proportion and it to be equal to the opposite tooth that we are working. The color detects the surface texture and the translucency and characterization, it’s another parameter of the white aesthetic evaluation. Now we go to start to assess the pink esthetics. The pink esthetics start with the evaluation of the mesial and distal papilla. We go to evaluate the shape, the level and the presence, and the interproximal space is filled by this papillae. The curvature of the facial soft tissue is important because this is the emergence profile of the tooth, so we need to be aware of this emergence profile for this final aesthetics of our implant. Needs to be correlated with the adjacent tooth. The same for the level of the facial mucosa. We need to evaluate the same point and needs to be in a triangle to be more esthetic. And for the last parameter in the pink esthetics score is the color and texture and the root convexity of the soft tissue. Look at the greener row how the healthy gum is showed and look when it’s inflamed. So the idea is we perform all this evaluation before starting the surgery to avoid undesired outcomes. For that reason, we do this evaluation to have in mind this concept, a prosthetically and a biologically driven protocol. We see yesterday all the advantage of the digital dentistry to plan our surgery. So the idea is make an oral scan, make them match with the 3D cone beam and planning our surgery from the planning software, taking in mind the next concept about the prosthesis with Bicon. So when we are preparing the surgery, we need to have in mind that the implant is a prosthetic component, and it must be placed with a clear understanding of the abutment that we use. For that reason, we need to separate our patient implant zone in three zones. First are the bone zone, the transmucosal zone, and the prosthetic zone, to understand how to use the difference abutment that Bicon has for us. In the bone zone, we go to put the implant where we have more bone availability than normally it is in the palatal. Searching the native bone to achieve primary stabilization in four or five millimeters of native bone. And the implant in this anterior zone can be placed in a deeply position to save bone around the crest. Can be placed four, five or six millimeters because we have abutments to restore a deep implant in these cases. So we need to put in the transmucosal zone the good position of the margin line. This margin line has a relationship with the connection to the implant and the hemispherical base because like we see before yesterday, the hemispherical base needs to be around the bone to activate the metabolism and stability of the bone in long time. The goal is maintain the crestal bone by preserving as much bone as possible in the crestal because you know that the bone, the buccal plate is very thin in these anterior cases. So Bicon offers us versatility in its abutments, but not all can be used in these cases because our geometry is not adequate to the deep implant position of the the deep implant position. For example, if we use a non shoulder abutment, the hemispherical base is near to the shoulder of the implant, so can the bone go to follow this hemispherical base and we can have bone loss because the titanium above of the abutment can generate bone loss of the crestal. The same thing happens when you use a universal abutment, because the profile can interference with the crestal bone. But now we have a long shaft universal abutment that maybe is not enough to achieve the connection to the implant, deep implant position. But we have in our options the stealth abutment that allow us to put the margin line in a correct position and the hemispherical base near to a good prosthetic position and save the crestal bone around the implant. With a six millimeter shaft or long post to connect the deep implant. So this is the best way to restore this deep implant position. And let’s go to see some cases, for example, this is the post operative x-ray after the surgery and the immediate loading in this lateral case. And look at the position of the crest after our our surgery, with the temporary. And three months later, after the healing period, look at the position of the bone. The bone reserve around the hemispherical base. And this hemispherical base is near to the shoulder of this implant, of this implant putting in a deep position. And this can have clinical result because maybe with the time, we cannot fill the space, interproximal space, of the papilla. Another case, we use a neutral and universal abutment and look at, after the surgery, the position of the crest, and three months later, see the shape of the bone around the hemispherical base. In some cases, you can have retraction of gum. Because this small loss of bone at the crestal. Let’s see the clinical case to see what is the correct way to use these abutments. This is Robert, Robert came to University of Cartagena because he have symptomatology in that tooth and the crown fell out every time and the tooth have problems with the endodontic treatment. And after the CT scan, we can see the fracture and the problem in the apical, periapical zone. So we decide to extract the tooth atraumatically, see the fracture, and fill the make a bone graft into the fenestration of the bone. So we put our implant deeply enough to achieve the native bone primary stabilization and then we put an abutment that allow us to put the finish line in a correct position and the hemispherical base contacting the crestal bone. And in a pro in a good prosthetic in a good prosthetic position. Then we make the graft to save the bone around the in the fenestration, and then we make the temporary. With the components of temporization of the stealth abutment. Then we bond the temporary to the adjacent tooth, to prevent the micromovement, and this is the result. This is the post operative x-ray and see where is the position of the crestal bone. So the idea is to have this position of the crestal bone longer in the time. And look at the native bone primary stabilization. So we weighed the healing period, and this is the result, the outcome after three months of healing period. Obviously, it’s a little of resorption, but it’s not clinical, but we only need to reshape the abutment a little in the buccal, in the vestibular zone, and we can start our crown. So we make the proof of the crown, the laboratory makes the crown in lithium disilicate with all the aesthetics of the crown. Okay? So this is the aesthetic outcome after the the crown. And let’s see the X-ray images. And look at the after three months of healing period and the restoration, look at the final x-ray, we have in the same position the crestal bone. That allow us to have the gum in the same position and don’t change the aesthetic of our patient. See? This is the aesthetic outcome, look at the postoperative x-ray, the day of the surgery, the position of the bone in the crest, and three months later, the same position, because the hemispherical base are in the good prosthetic position. Okay? So the idea is maintain this along the time. Okay? Remember, when we use a hemispherical base in a deep position and we put to the shoulder, we can have a bone resorption because the bone follow this shape. But you can use in a deep implant positioning the hemispherical base with a long shaft abutment. So in order to conclude, we need to do a facial, smile, and white and pink esthetic analysis to prevent aesthetic complications. The idea is have a 3D implant positioning based on available bone for primary stability and preserving the crestal bone, and you must use a correct abutment selection criteria for optimal aesthetic outcomes. Thank you very much.