Januari 03, 2017
dr. greggory kinzer: and you can try to getit as close as possible. and now let's say that you do it, and yougo, "wow! that custom healing abutment that i milledout before we did anything is, really looks good. now i wanna make it into a temporary." you already have the information. you already have the emergence profile. it's already a digital file, that you coulddo an impression, to just basically get a scan log of the implant position, and younow marry those two files, and you just add
a tooth to it, and you're done. so, it's really, the digital workflow makesthings way more efficient, and as we said yesterday, accuracy levels can go up, becauseyou can reproduce something that you have in the mouth 100%. for me to be accurate from the mouth to thelab bench requires my hands, and my skillset, and my technician's hands and skillset, butyou wanna up the accuracy? digital allows you to do that. dr. bob winter: yeah, and the future is... again, i was involved as a author in a paperlooking at the concept, 'one abutment, one
time', and it's based on these concepts. so gerhard iglhaut and some others involvedin the paper, in a perfect world, you don't wanna connect and disconnect a bunch of differenttimes, 'cause that negatively impacts the tissue. so in a perfect world, you get the abutmenton at one time. it could be the final abutment. so that's now going to the nth degree as faras planning. so where there can be risk involved with that,but maybe the future is guiding us more and more to those.
kinzer: yeah. attendee: yeah, and this image of it hereon the left side, from an esthetic standpoint, i'm a little bit more concerned about thedistal aspect (unintelligible) that papilla than the mesial aspect. and i'm just kinda wondering, what are yourthoughts about what options do you have? is the scarf graft something that would helpwith that papilla? is there something else you could do? the symmetry between those two papillas ispretty significant. kinzer: yeah, so there's been attachment losson the mesial of the lateral.
that's what he's noting and picking up. which, when you get added contour here, thispapilla will move, but i'm anticipating it may be moving only this far. maybe, but again, if i look over here, i seethat i'm deficient, so in this case, i probably wouldn't do much, because i'm deficient onthe other side. but if in fact we had a situation where wehad a unilateral papilla loss because of attachment issues, and typically what this is also associatedwith then, is facial attachment loss, so you'd have recession on the facial. that i know what jim would do, is he woulddo the scarf graft, or he would take connective
tissue over the ridge on this mesial aspect,and he would tuck it underneath on the facial, to be able to enhance both of those areas. but in that regard, now we're going to anaugmentation as opposed to a support. so we would put a smaller hemin abutment onhere and he would try to get more soft tissue gain over the entire aspect of it. but you're exactly right, if we needed toget more gain, this wouldn't be the choice for the abutment though. it would be, put something small on to getway more soft tissue. yup.
winter: so one of the simplest ways to lookat that, of course, looking radiographically an idea where the bone is, but using a periodontalprobe and probing sulcus depth, and if you probe sulcus depth on this side, let's sayit's three. its three here, three here, three here, andone here, then you have a sense that by shaping the abutment right, you'll get some coronalmovement of the tissue. so that's a simple way to have a good senseof what might happen as well. radiographic bone level and then sulcus depthis gonna be key. just one more question... kinzer: oh, yep.
attendee: i have a quick question on that,on the last photo. when you see those triangular shaped centrals,whenever i see a patient with a hopeless number eight next to a triangular shaped number nine,it's almost like i'm setting up a patient for a veneer on the tooth next door too, becausei'm always concerned that that's gonna really set me up for a black triangle. do you often go back with composite if you'renot able to kind of have the water balloon effect that you want on that pushing on thatpapilla? would you go back with direct composite maybeon the (unintelligible)? kinzer: yeah, great question.
and again, this goes into the pre-prostheticplanning. i wanna look at all aspects of the case beforei start. and one of the things that impacts us quitea bit, is trying to fill up an embrasure space, is we have triangular shaped teeth, whichwe can see from day one, and we know that there's going to be problem. maybe there is already a black space beforeyou take the tooth out, or maybe the papilla is going to fill it with the tooth intact,but when you take the tooth out, you know you're gonna lose it. my typical protocol is, unless it needs aveneer, because it has other aesthetic issues,
this is gonna be direct composite. so just a mesial composite and i have allsorts of access to be able to put it on. but i will tell the patient that from dayone. in fact, the last case i'm going to show youis similar, where it's gonna have to have a mesial composite in place. if it needed other aesthetic work then itwould be a veneer, but otherwise not. it's gonna be minimally invasive, just directcomposite. just take a strip, rough and clean the area,and then freehand some composite. good question.
okay, that leads us into the immediate provisionalization. it's a great option. what i don't know, and i can now take it tothe point where you're seeing the patient restoratively in your chair, you're goingto anticipate, the tooth's gonna be lost, and now you're talking to the patient abouthow are we going to replace the tooth in the interim? but you haven't had the patient see the surgeonyet. so i tell 'em about options. one option might be that we take the toothout and either the surgeon or myself makes
a temporary on the implant. but what i don't know is, i don't know howmuch primary stabilization the implant is going to have. that's not being able to be identified untilthe surgeon actually places the fixture and sees how tight they can get it in the bone. so i put it as an option and then i followit with another option. i say, "we're going to do something, probablyin this realm. you'll never walk out without a tooth. you'll always have a tooth there."
but then, i leave it up to the surgeon todecide. now, if we're going to do an immediate implantprovisional, we're gonna be using one of these four. and i'll actually say, probably one of thesethree to fabricate it. jim will sometimes use an existing crown,as long as you can get the crown and hollow it out without destroying it. so that means it's typically a metal ceramiccrown. the problem i find with doing this is, it'stypically ugly, and why would i want to make it ugly, when i can actually make it better?
so i either use the natural tooth, if it'sa good tooth. i use a copyplast or a putty matrix. i like to use copyplast, jim likes to useputty. i like to see what i'm doing, he just likesthe accuracy of using the putty. so how is it done with a natural tooth? this is a case where jim is going to be treatingthis central. and the reason that the central is going toneed to be extracted, is that it has a fracture. now this is also a triangular shaped tooth. so i would have the discussion that if welose this really super good papilla, and it
starts to go apical, 'cause the contact pointis so coronal, we're probably gonna want to do something onto the mesial of the othertooth. alright? and we'll make the call of what that is. we might do it as composite. so the tooth's gonna come out and he's gonnatry to take it out and maintain it. and in this case, given the obliqueness ofthe fracture, he's going to basically have to use it as a veneer. it's gonna be an enamel veneer, an enamelshell.
so yesterday, when you're working on yourmodel... i think you're at the point right now whereyou're using an index to start to hold it. you're getting there. winter: connected it to the metal opaque abutment. so we're just working on contouring. kinzer: okay, so you've used the index tohelp position it. winter: yes. the index on the incisal edge, which you'llshow us. kinzer: okay, so you used an index yesterdayto hold the little shell of a tooth to get
it in the right position, and you did it ona model. we're gonna do the same thing now. we're gonna do it clinically. because if i had to position that over theimplant, it's just a shell, so i could put it in a thousand different positions. i want it back in the position that it wasin before it was extracted. so using an index as a carrier allows youreposition it ideally. so this is gonna be the index. what this is, it's gonna give jim a surgicalguide, but then it also engages onto the incisal
edges where you could take that extractedtooth, and you could stick it into the incisal edge here, and reposition it. so, it's a dual purpose... it goes to the incisal edge, so he doesn'tlean it too far facial. and then, he's using, as far as his depth,he's using the gingival margin of the adjacent central. now, look what's happening to the soft tissue. we saw that the canine... i showed you how nice the papillas were andi said that, "if you sat and watched it, it
would in fact do this." you would start to loose the papillary supportand they would start to slump on you. in fact, even this tissue here is gonna startto fall palatally. so before the surgery you can take a stocktemporary abutment, an engaging temporary abutment, and you can opaque it. whether you use colored opaquers or whetheryou use an opaque composite, doesn't matter. but now, you're gonna take your soon to beprovisional, your enamel shell, and you're gonna hollow it out. and i would typically either remove all ofthe cementum or if you're gonna leave a little
shell of cementum... you don't want it to be cementum back in themouth, because what'll happen is, when you get it realigned and you put it in, the tissueis actually going to attach to it, 'cause it's actually a tooth structure, cementum. and it'll look phenomenal in the provisionalphase, but when you go to take it out, it's gonna bleed, because you have to sever theattachment and then you're gonna change the support of the soft tissue. so either remove it completely, grind it off,or at the least, air abrade it, etch it, and put some resin on it.
so now, it's root, but it's covered with resin,so you won't get a true attachment to it. so now, what the shell is going to be usedfor, is you're gonna set it back in the index. and it's not going to stay very well. so take a little bit of bonding resin andset it in there, hold it, put some bonding resin or some composite and cure it, so itactually stays in... it doesn't wobble around. and you're going to seat it over the abutment,which means you're gonna have to take these little papilla, and you're gonna have to moveit to the side as you take and put that in. and then, your job is to add composite andstick this to the abutment.
and once you get it stuck to the abutmentand you pull it out of the mouth, this is how much thinking you have to do. this is your emergence profile. but all of the points are there, 'cause youknow the tooth contour that you're trying to achieve. so this is, it takes the thinking out whenyou have a preformed shell, or like this, a tooth. and now it's gonna go back in the mouth. and again, look at the black spaces that arepresent, just in the short time that it took
to do that, the tissue height has been lost. but it's lost, 'cause we have no support. now, we're gonna give it the support backand we're gonna leave the space, because this tissue now is gonna start to move coronallyonce again. winter: so relating this to where we finishedyesterday afternoon, we used our bis-acryl tooth, we connected it, but we were workingon the model. we created that funnel by grinding on thetissue and most of you found that you probably didn't grind enough of the tissue, so nowyou're under contoured. so now, the next step we're gonna go throughis freehand addition to create the ideal shape,
but this is now based on conceptualizing howthat's going to support the soft tissue. so whether it's in the mouth, or on a model,or actually, what we'll show you late today, whether it's on the computer and you're designingit on the computer, it's all the same thought process, same understanding. what we're trying to do is create a shapeto support the soft tissue. kinzer: the reason we do the delayed approachfor you first, 'cause it's the most thinking, it's the most challenging. if you can adjust soft tissue, which as bobsaid, i typically underdo it. and then you have to add the contour back.
when you add the contour back, you're basicallydoing this. if you can do the delayed approach that weare doing with you, started yesterday, this becomes really, really easy. so we give you the hardest one first, 'causeit makes every other piece that much easier. rodney? attendee: what's your timing window on this? kinzer: to fabricate the provisional? attendee: from the time they do the surgery... kinzer: yeah, good question.
we would typically do this either at the dayof surgery, during the day of surgery, or the next day. that's our typical window. attendee: 48 hours? kinzer: i think you can go 48 hours, but 24hours for us is our window. attendee: sometimes the surgeons sedate, sothey can't get to their office that day. kinzer: right. so let's take his question and we'll takeit one step further. let's say your surgeon doesn't wanna do it.
they don't have enough time, they got a bunchof other surgeries, and what they're gonna get paid to make the temporary for you isn'tworth their time and energy. so you're gonna do it, but you can't see themthe same day, because maybe they had some sort of a medication, so they can't get toyour office. how would i fabricate it? imagine taking an index. remember this right here? once the implant is placed, use this indexand stick an impression coping on the implant and lock it in place.
and you're going to do this... winter: we will actually do that, in fact,i was just gonna have you come back to this image. 'cause we made this index, and i said if therestorative dentist makes this before surgery, it saves some time, but can be used multipleways. and then greg is even showing how jim usedthis as a surgical guide. the problem with this, is it doesn't showyou the soft tissue, so you probably have something else to show depth or it's basedon experience. so this, we will actually do the exercise,we'll actually lecture about it as well and
talk about indexing the position of the implant,so then as the restorative person, i can get that that same day of the surgery, i can makethe model, and then... kinzer: okay, so one sec. imagine now, they hook an impression copingto the implant and now they secure it with resin to this. so when you pull this out of the mouth, it'syour index that fits onto the teeth, and in it is an impression coping, and they're allhooked together, it's like one big piece. they send this to your office, you go havea staff member pick it up, or they send it to your office.
so that night, you take the original model,you drill a hole like you're extracting the tooth, drilling the hole out, you can seatthis on the model, and you can put an analogue on it, and you can lock an analogue onto yourstone model. and then if you had the tooth from the daybefore, you do exactly this on a stone model, which is the way you're working right now,next door. winter: yeah, exactly, and we will do that,and again, it's... we will do it, by yes, tomorrow afternoon. we'll finish that exercise and the point beingis you can use simple tools to allow you to do things.
i like to think of non-chair time, there'sless stress involved, "it's less expensive," because chair time's expensive, and you havethe capability of adding, subtracting, and so forth, without the stress of, "hey, thepatient's numb, it's wearing off," and so forth. so you're buying time and less stressful. kinzer: so when you bring the patient backthe next day, you could have this provisional already done, you're just doing it on a model. and again, i alluded to this yesterday morningwhen i began by saying that we're gonna be working on models, and sometimes it's a model,and sometimes it's a patient, and sometimes
the techniques can go either way, you cando that same technique on a model or a patient. so our goal is that things make sense to you,that you know when you can do one versus the other, and how it would play out. but you'll do this procedure, you'll actuallymake an index, and you'll actually seat an index, and lock an implant analogue into themodel. you'll do all that, and i'll show you thatagain as well. i was gonna say something very important... [laughter] but now i forgot what it was.
oh, so let's say that you do this and youbring the patient back the next day. why don't i want to wait longer than, let'ssay, 24 hours? it's because you get bony change around thefixture. and as you wait longer, the implant, althoughit might have good primary stability the day it's placed, it will start to lose some ofthat primary stability. so when you go the next day to put your implantabutment and temporary on, you're gonna wanna stabilize the tooth. 'cause if you, and i only hand tighten these. i only hand tighten any provisional restoration.
you're gonna wanna hold on to this, becauseif you were to start hand tightening it, you could have the entire tooth and the implantstart to move on you because you're having some change around the fixtures. so if you wait longer, that's the risk. so 24 hours is as long as i would wanna wait. bob, would you... winter: i would do exactly the same. attendee: you would use the index to stabilizethat where you tighten it? winter: you could.
i use this index. but you could, you could put the index backon and actually tighten it with that in place, for sure. winter: so, and little things that we tryand share with you is again, making that index before on a model. and so, if a surgeon does it directly on theteeth, there is a risk that it's not gonna transfer well to a model. so that's why my advice would be, make itbefore, 'cause i know it's gonna work on that model.
you can confirm it's gonna fit in the mouthmost cases before the surgery, so you know you're not introducing an error. that's another little tip that i try and thinkof. kinzer: alright, another clinical scenario. let's say that your plan is to do an immediatetemporary. but i told you that you don't know how gooda primary stabilization you're going to get. and who's gonna know that? the surgeon. so let's say you plan on doing this, but youget to the day of surgery, they take the tooth
out, they put the implant in, and the surgeongoes, "you know what, i can't get it stabilized enough. i can't make an immediate temporary." now what do you do? attendee: (unintelligible). kinzer: well, i always wanna send with thepatient, a backup plan. i always wanna have a backup plan, in casei can't do what i set out to do. but i don't wanna spend a lot of time andmoney on the backup plan, so the easiest thing to do is, you send them a clear essix thatyou snap over the initial model.
so as a backup, if you had to, they coulduse that clear essix, and fill it with provisional material, and do a custom healing abutment,and that's a quick interim temporary. it doesn't cost you much to fabricate, itdoesn't take you a long time to fabricate, but it can save you, if in fact, you can'tdo what you set out to do. now, if you don't use it ... to do a temporary,i'm still going to have the patient use it, 'cause i told you that i need to remove contact. i can't have the patient functioning on that. so i have to change the incisal edge and haveto grind on the palatal, but i still won't trust the patient.
so they actually wear the essix. and the reason that i'm having them wear theessix, it's a reminder that there's some dentistry that was just done. but when i fabricate that essix, i actuallyput a little bit of spacer around here, 'cause those fit ... they fit really well. and you imagine... they snap it on and off and they pull it onand off throughout the day. that's a lot of stress and movement you'reputting on here. so if i give a little spacer, it's fittingintimately everywhere else, and it slides
on and off a little bit easier. it doesn't put the same stresses on. winter: so think about that. the backup plan is an essix to put a toothin... but a second, i would personally do a secondessix with the spacer on, because if i put a bis-acryl to give 'em a tooth and all ofa sudden now i've spaced it, now it's a bigger tooth. so think about that. again, it's pretty inexpensive to suck downanother one.
almost no time, a few bucks for the sheet,but think about that as options as well for you. kinzer: just don't put so much spacer on. winter: yeah, i wanna pass (unintelligible). [chuckle] kinzer: okay, so you gotta check occlusion,you gotta make sure that they can't get on it, and you have to instruct them. and then as a reminder, the essix actuallyhelps them keep from functioning, because there's a piece of plastic in their mouth.
now i want you to watch what happens to theembrasure areas and the papilla heights as this starts to heal ... so here's the contour... this is the thinking and this is kind of whereyou're at next door with your restoration. i will almost guarantee you that you're undercontouredin what you adjusted on the soft tissue. why do i say that? 'cause i would be undercontoured. so now you're filling in this area next door,you would do the same thing clinically here, and now look at the papillary areas as thepatient starts to heal and mature. so we have really nice papilla areas, andif you look at the facial gingival margins,
it's not a huge change, but do you see thedeficiency now compared to this gingival margin role versus that side? do you see how it's flattened out? doesn't have the thickness here? so jim is gonna come back and actually doa connective tissue graft to plump the area, and in the process, he's going to do whati showed you on the very first case this morning, he's going to drag it over and cover the rooton the lateral. so now the facial connective tissue graftwas done as a second surgical procedure, and here is everything healed and ready to goto final restorative.
now, restorative dentists, you're gonna runinto a problem. when you use natural teeth that look good,your technician now is going to be very challenged trying to improve upon nature. even in provisionals, sometimes. we can do things in provisionals because ofthe translucency of provisionals that you can't emulate with ceramic materials. you have opacities and shadows that are created. so technicians can start to be very challengedtrying to now turn this into a final restoration, and you'll often hear the patient say, "well,why can't i just keep this?"
or you'll make a provisional, and then i'vehad a patient say, "well, why don't you make the final crown? you made this, it looks so nice. why don't you make it?" i said, "no, you don't want me to do that." so you have a good looking tooth or you havean ugly tooth that matches the ugly tooth next to it. as long as you have the form, this is a reallygood option. so let's say it was a resorptive area, maybean ankylosed area where the tooth looked good.
surgeons, how are you gonna get that out andkeep the crown form? what jim will do, is he'll take a burr fromthe back of the tooth and he'll start to cut horizontally towards the facial, and thenhe'll take and he'll snap the tooth off. and he's fine cutting from the palatal, becauseadding material there is not gonna be unaesthetic, and it's not really so much of a contour issue,but he'll try to preserve the aesthetics of the crown by cutting it off horizontally. so if we can't use the natural tooth, theni'm gonna rely on some sort of a copyplast matrix or a putty matrix to give me the toothform. so this patient comes in to see me.
i get a lot of second opinions, but sometimesi get 'em really late in the game. they're gonna have a procedure done next week,and they get appointed to see me a week before. and i'm like, "well, you already have yourteam in place and you already have an appointment schedule, so what do you want from me?" i said, "so what's going on here?" she gives me her history that the anteriorteeth have continually started to flare and open up the space. and so, as the space opens, she doesn't likethe space, so the dentist would add composite, close the space, pretty soon it would openup some more.
they'd add more composite. now, in the process of adding the composite,maybe the contours subgingivally weren't ideal, so they started to create a ledge. and the ledge they create now is a trap forbacteria and plaque, and calculus, and all of a sudden, you start to get a vertical defecton the tooth, and it's still starting to move facial. so what they said is, "we're gonna take thetooth out and we're gonna do an implant." that was her plan. it was gonna be set in place the followingweek.
and patients are, they're very logical. and i said, "so you're telling me that thistooth has been moving, and they add material and they have a big bony defect, and so they'regonna put an implant in. but the problem is, the implant isn't goingto move which means that as the process that created the issue continues, you're gonnahave a bigger problem, 'cause that implant is gonna break, come loose, ceramic's gonnachip, something is going to happen structurally, 'cause it's non-adaptive. and so what would make more sense to me, is,"let's fix the problem that got you in this situation."
and if you look at the way her lower anteriorsare set, stepped above the occlusal plane, crowding, tight anterior relationship, that'sthe problem. and the problem was exacerbated by the clinicaltreatment that was done to accommodate the problem. so a better option would be, "let's not takeit out yet. let's do ortho. let's fix the primary issue. let's correct the malocclusion." when you start to have patients where teethare moving and you start having diastemas
open up, it's telling you something. there's a reason why that's happening. and a lot of the reasons we state nowadays,you could say this is because of the malocclusion, but it might be that they keep wanting tomove forward, because if they move forward, they can actually breathe easier. so it's a functional issue, it's a breathingfunctional issue, not a tooth functional issue. so, my plan is, "let's do ortho." if it was me, i would say, "let's do orthofirst". and, "let's clean things up," because there'sa lot of subgingival localized factors.
and in the process of doing the ortho, wecan also erupt that central and we can improve that vertical defect. now, i told you yesterday that when you erupta single tooth, you improve the facial bone and facial soft tissue. you don't improve the papilla unless you eruptthe tooth adjacent to it. however, in this situation, when you havea vertical defect and you erupt the single tooth, what's gonna happen is the verticaldefect, this is kinda what it's gonna look like, it's going to improve to the level ofthe bone on the adjacent central. it's not gonna do this once you continue toerupt it, but i can actually get rid of that
vertical defect. so that's our plan. and she says, "well, that makes total senseto me." so i send her to the orthodontist. john moore is going to be my orthodontist,he erupts the tooth, he's cutting it down, he's aligning the arches, he's improving thissite for maybe a potential implant, and he's improving it from a biologic standpoint. he's removing the probing depths in that verticaldefect. so this is now post-ortho.
and if you look radiographically, now we havemore level bone. i don't have the longest root though. but i said that now we would re-evaluate,so you could take the tooth out, you have a good implant recipient site, you have boneand tissue more coronal than you need it, which is good, because i can control the apicalmovement. or maybe you decide to keep it. i can always take a tooth out later if i neededto, and we always get caught up on having a one-to-one crown to root ratio, which wedon't have here. but there's nothing in the literature to saythat you have to have that.
so if i look at the amount of root left inbone, and if this was my mouth, i'd probably think of keeping it. now what would that entail? it would entail facial crown lengthening,to move and reposition the hard and soft tissue, to emulate the gingival margin. my papilla is probably going to be a littlebit deficient compared to that side, but not too bad over here. in fact, if you look at where the pulps are,i probably wouldn't even have to devitalize this tooth.
if i prepped it, i probably still wouldn'tbe into the nerve. and i think that this would be a long term,really successful tooth. now, that being said, you know i'm takingthis tooth out, otherwise i would not put it in this workshop at this moment. but i spoke with her about taking the toothout and her response was, "this tooth has been a thorn in my side for many years. you have no idea what i've been through. i just wanna move on. i want to part ways and i want to forget thatsection of everything that's happened."
so we're gonna take it out, we're gonna doan immediate implant, we're gonna do an immediate provisional. now i'm not gonna use this tooth, 'cause it'skinda ugly. so i'll take an impression of that and thenon a model, i'll do a stone-ectomy, and i'll wax up the tooth form, and match the adjacenttooth. and from this, you could actually make a puttyover it, or you could duplicate it, pour it in stone, and do a copyplast matrix, whichis what i'm gonna do. so this is the day of surgery. bobby butler is the surgeon, he takes thetooth out, he places the implant.
and again, it just kills me to look at thistooth, 'cause i think that's a viable tooth long term. but here is the situation, and the nice partis bobby actually brings her over to my practice, and coming from downtown, maybe 15-20 minutedrive, so he actually hand delivers her. i thought that was really a nice touch. so what do i have ready? much like i showed you on the previous case,i have a stock temporary abutment, and on the previous case that was opaque composite,this is just composite opaquer, like a kerr kolor + plus opaquer or the estelite coloropaques.
this isn't the stock screw that comes withthe temporary abutment, 'cause that temporary abutment screw is somewhere down in here. this is an impression coping screw, a longscrew. i put it in, so when i slap on my copyplastmatrix, i can see where the screw is going to come out, and i use this screw to fabricatethe provisional. if you didn't use this and you used the temporaryabutment screw, that's fine, you'll just have to make a mental note of where you're gonnahave to drill to get down through the temporary into the screw. so all i have to do is keep this semi-dry,semi-clean.
i'm gonna put some adhesive on it, i'm gonnafill up my copyplast matrix with bis-acryl, and i'm going to seat it just like that. and the screw is going to come right throughmy copyplast, and when it sets and i take it out of the mouth, this is what i have. now this is taking what you're doing nextdoor to the nth degree, i've really undercontoured this. but if you think about it, all of my landmarksare there. i know where the gingival margin is, i knowwhere the papilla heights are, and i have my tooth form.
i also know where the head of the fixtureis. so now, out of the mouth, i can clean it,i can add more adhesive, remove the flash and then in my hand i just freehand and addin composite. yup? attendee: do you find you have to use a teflontape or vaseline on adjacent teeth? and do you ever have an issue with (unintelligible)? kinzer: the only issue that you may have,and you wouldn't have it here, 'cause you can see no material came apically becauseof how thick the soft tissue is, but surgeons that are doing this day of surgery, whereyou have a smaller diameter implant and a
larger space, let's say a central, is thatyou have the risk of this material going all the way down to the head of the fixture, goingtoo far apical. it's not gonna stick to the adjacent teeth,but it could go down around the fixture, which is not something that you want to have happen. so what jim will do is he'll use a littlecollagen, like a little collacote, and you can either cut strips of it and put it aroundthe head of the fixture, or you could even make a little hole and put a little skirtaround the abutment, so that when you put it on, it has a little bit of a natural collagenbarrier that prevents the material from being pushed too far apically.
you just take it off and throw it away whenyou're done with it, but it can prevent the material from going down. so that's especially that when the surgeryis being done, you have more chance of the material going apically. given that he did the procedure, brought herto my office, now it's probably an hour after it, so the tissue's feeling more tight aroundit, so i didn't need to do anything like that. attendee: so when i do immediate placementand immediate temporization, of course i'm grafting that buccal gap with bone grafting,and i usually put a stock healing abutment on to hold the tissue somewhat while i'm fiddlingwith things outside ... now should i be concerned
about flowing apical to the collar now thatthere's graft there, the blood's warm, the clot has stabilized? when i pull it out, i don't see anything physical,but is there... kinzer: well, so you have a barrier that,it's a different barrier. you've put your bone graft barrier in, dependingon the timing, you have a blood clot that might be formed or semi-formed in the area,so that's now your barrier. but there are times where, yeah, it's a realconcern of mine, but it's a real concern when it needs to be a concern. if you have something down there, then maybeit's not a concern at that specific patient.
but it's something to always keep in the backof your mind that if it goes down, it has no restriction. it can go quite deep. attendee: within the socket, right. kinzer: and if you left anything down thereand didn't realize it... winter: yeah, that would be my concern, isnot necessarily leaving some of the bis-acryl, but just the material contact to bone graftor tissue. you have resin now contacting those surfaces,there is gonna be some molecules left behind, and that can negatively impact healing.
so i think the safer approach is what jimdoes, is put the collacote there, because i would say, you would wanna avoid uncuredresin contacting any surgical site like that, and granted, it is hitting papilla and somesoft tissue, but we deal with that every day in restorative, i don't think that's the problem. it's now contaminating the implant and integrationand things like that. so i think it's more of a concern. kinzer: and again, it's like anything we do. the more material you stick in there, youreally, really overload it, then it might push it more apical.
if you err on the side of just having enoughto cover and connect here, then maybe the risk is less. there's also, there's a clinical experiencewith it as well, and obviously, your clinical experience is high enough that it's reallynot then so much of an issue. but the thinking now is not difficult to do,that's why i said if you can do the delayed approach, this becomes much easier for youto interpolate what you need to add and where the contour needs to be. and again, if you're going to err, you erron it being less contour. you're always more safe by less contour thatyou know you can always add more and move
winter: so it's already come up from one individualat the end of yesterday, it's like, "hey, the way i do it at home is using copyplastusing that bis-acryl tooth. and i said, "you can use the natural tooth,you could use a denture tooth, you could use a bis-acryl tooth, you could do this technique." we are actually gonna do this technique onthe molar on our models. so i try and introduce lots of different options,so you have that experience because you may have the preference of always doing it thisway anteriorly, happy day. but at least you now have more tools in yourtool belt that you can use. kinzer: okay, so same idea.
i wanna make it out of occlusion, so it'sa little bit shorter incisally. but that's what it looks like when i put itin. now, notice that there is a lot of embrasurespace still. the distal's looking quite nice, i leave alot of space. but watch what happens over the next coupleof months after i keep it in. so here's two months, and now i start to havemore of the papillary form. but there's still a black triangle, and thisgoes back to your observation earlier that if you have triangular shaped teeth, you willhave a black space. and if you don't accommodate it by addressingit on the adjacent tooth, you end up having
to morph this over, which now has asymmetrywith the other tooth, and you still might end up having a black space that just mightbe smaller. so my plan is to redo this composite to getthis shape to match the implant crown, that was always the plan. and so here's, now, the abutment, this isa metal ceramic abutment and the composite has been redone here. but now we have our papilla peak and the finalimplant restoration, with just direct composite on the other adjacent tooth. and this is something that i find that i haveto do a lot.
i have a lot of patients with triangular shapedteeth, but i also have a lot of patients, maybe you've noticed this, where you havetwo centrals that are just different widths. it's amazing to me how often i see two naturalteeth that the widths are off by three quarters of a millimeter at times. winter: yeah, it's frequently has to be addressedand i'm just like greg. if i refer to it, if it's a one-dimensionalproblem issue, you just do direct bonding. if there's an aesthetic complication overall,yeah veneer, crown, whatever your choice might be. but the key element that we're trying to addressis we frequently talk about contact point
relative to bone, but most importantly it'sdecreasing the volume of space that allows the tissue to move more coronally. it's not just the point, if you have a verywide space, it's not gonna move. so decreasing the volume and space is thecritical element. and so whether it's the composite or the provisional,that's what you're thinking about. kinzer: okay, so, using those examples, ourgoal was to illustrate, that there is... the endpoint is what we're trying to achieve. and there's multiple ways that i can get there,there's multiple techniques that i can use and we choose the technique based on the clinicalsituation, based on the patient.
and i can get to the same endpoint regardlessof how i do it. so i choose that... how is it going to be the most predictablegiven what i start with? attendee: on this particular patient, i'mconcerned about the tissue impact over time. why wouldn't it be done a little bit of afrenectomy when they did... kinzer: yeah, you could make that point of... if you're in there to do the procedure, why don't you fix this at the same time? i don't have an answer for you. i would say that the surgeon decided thatthere wasn't ... even though there's an attachment,
if you were to lift the lip, there's probablynot a lot of pull on the soft tissue, but if there was the risk would be that that couldmove the soft tissue apically over time. winter: (unintelligible). attendee: bob, maybe, i don't know, both ofyou could talk about this, but if you're having like a three-three straumann or somethingand you wanna use a zirconian style, which is not really indicated, what's another strategy,abutment-wise (unintelligible)? winter: perfect question, because the questionrelates to abutment choices, and that's gonna be our next topic, but we're going to do thatafter the break. kinzer: yeah, it's a great lead-in question.
winter: exactly. but i think... kinzer: we'll pay you later for that. winter: there was one more question that wascoming up... did you raise your hand? attendee: yeah. just back to that ... can we go back to thatpoint a little? kinzer: yup. attendee: i'm just being hypercritical here,but is there any way...
it seems to me that even in the temporaryand in the final, there's still some asymmetry on the mesial 9 of the tissue. it's almost like 9 is too far on mesial. is there any way to avoid that, or is thatjust... kinzer: this contour here? yup, if i was a more talented clinician... i would have caught that. and it's easy ... i'm kind of being funny,but it's easy to see it now, but to see it clinically is quite challenging, 'cause it'ssuch a small amount of change.
but yeah, if you want to be hypercritical,that's something that was my error in the initial adjustment. kinzer: now, it was probably in the temporization,the difficulty that i had is i didn't have this contour when i was actually making thiscontour, so you could say that i missed it twice now. i missed it in the provisional, and then imissed it when i recreated the contour here. this is going to be more difficult to do,'cause i have to work subgingivally. so that was the challenge is i have two differentcontours coming to the mesial that i'm making it two different times using two differenttechniques, and given my skill level, yeah,
i missed that emergence. but you're absolutely right. attendee: so is that the final restorationor is it the abutment that caused that? or both? kinzer: it's probably occurred in the provisionaland then it was just matched into the final restoration. winter: or you can always blame the lab... winter: that they over-contoured it, 'causethat's typically the case. kinzer: but it was present in the provisional.
winter: for a closing thought on this though,'cause everyone is here because we're trying to take everything to, i hate to use thisword but, perfection. we're trying to work with super high precision,so when we magnify these on a screen and now a quarter inch tall tooth is now 4 feet talland we can see things. so i always go back to clinically acceptablefrom a social distance in a smile. and i would argue, little imperfections makesit more believable and more real. if i restore teeth and everything is linedup like a picket fence and everything ... it looks artificial. but, in this case, i would argue, this isa better tooth form based on laterals, and
this tooth is the one that i would alter thelength on, because if i look at gingival levels, that's how you could then argue the case alittle differently. for the symmetry of the case, i think thefinal crown is better. kinzer: the other challenge is the facialconcavity. kinzer: and again, you can try to recreatethat in the provisional, i can put a concave surface at the same area and the tissue willactually fill it in and you can actually... you can almost try to emulate it but again,now that's just another piece that throws our eye off. now, bob makes a good point that, yeah, wesay that these minor imperfections make it
look real, it's just what we tell ourselvesto allow us to sleep at night, 'cause... i don't think either of us, well maybe youdo, but i know i don't... kinzer: every case that i've ever done, youmight look at and go, "wow, that's great", and i'll look at it and find three thingsthat i would do differently next time. some are in my control, some are in the technician'scontrol, and i have some cases that i think are really pretty, but i go ... this is whati see. you're always trying to improve ... winter: you're always pushing the envelopeto improve, and again, that's why we're all here, that's why we love to be with you guys,because you push us to become better, and
we are trying to, most importantly, do thingspredictably so, you look at all these cases and we want you to believe you can go homeand do this if you follow the protocols and thought process that we're setting up. 'cause the real world is, a lot of this stuffis not done and then restoration of implants can be super complicated and it's all in thelab hands and it's almost a crapshoot. and that's super frustrating, i'll say froma lab prospective, 'cause in the real world i'd say it depends on the lab of course, buton a real world perspective, 95 to 98% of the time, nothing is set up for the lab. it's all now created in the lab.
and so, you guys are all here, 'cause youguys believe in doing this, you want to do it, 'cause you want these outcomes. so that's the beauty of what we're tryingto emphasize. kinzer: what i appreciate about your statementis that you see it. winter: yeah. kinzer: if you don't see it, then you haveno way of correcting it. if you're looking right now and you saw that,then that means you're looking at these minor details that will actually help improve youwhen you get back to the practice. so that's great.
that's great. i mean, pointing out my imperfections, maybe... no, no i'm just kidding. i'm just kidding. i do appreciate the fact that you actuallysee it ... attendee: i was thinking to myself. kinzer: because it's a good discussion point. no, it's perfect. it was great.
attendee: just in case i do ... kinzer: yeah, that's what we would hope. 'cause that's the way we beat ourselves up. attendee: it seems like oftentimes even wheni use a really talented lab, and i use your lab a lot, bob, but ... winter: i'm not quite sure how to ... kinzer: but when they're using the reallytalented lab... attendee: no, but the central incisor'll comeback and it's like i need to knock a little bit of the glaze off.
it seems like maybe getting, this is so greatbecause you're able to dry it off and the surface texture really matches well but, that'sreally difficult to do... kinzer: it's amazing, we ... so his questionis, and i think this is very true if you're a digital dentist, a cerec user, then you'rehandling ceramic and you have maybe more comfort, but i think most clinicians, you get the crownback and you go, "well that's... the technician can do contour better thanme and i don't want to touch it, 'cause i might mess it up." so you just go, "well, it's a little shiny,it's a little dull, it's a little this, it's a little that."
and you go, "well, let's just put it in. i don't want to send it back to the lab, 'causethen i'll lose production time" and so on, so forth. we used to have a course that was basically,to your question. it is not difficult for you to enhance thesurface and you'll find that the one thing that technicians actually struggle with isgetting the ideal surface shine, texture, luster because they don't, they're lookingat a photo and they don't actually see it right next to the tooth. so that's something that's easy for us asclinicians to do.
and what i would say is that grabbing someof the instrumentation and taking old crowns and actually playing with an old crown allowsyou to do it on this when you're trying it in and know that you're not going to messit up. and you can take and just minor fluctuations... kinzer: it's rare. i work with a really talented technician. my technician is phenomenally talented andbob has a lot to do with that, 'cause he worked with bob, and bob helped to train him, butit's rare that i don't do something to it. it's rare that i don't touch it.
i always will do a, maybe it's a pink wheel. maybe i take it to the lathe and then i usea little pumice on it to change that surface. but you have to, 'cause you're seeing it'sright next to the natural tooth. do you want to add one piece before we signoff? winter: no, great discussions. so, we're going move into a break. so thanks for watching on facebook live andwe'll see you guys in 15 minutes. so, a couple of minutes after 10, we'll see...
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