Become a Creator today!Start creating today - Share your story with the world!
Start for free
00:00:00
00:00:01
Distally Anchored Connective Tissue Graft with Drs. Lory Abrahamian, Alvaro Blasi, and Gonzalo Blasi
149 Plays14 days ago
Listen in as Dr. Diego Velasquez interviews Drs. Lory Abrahamian, Alvaro Blasi, and Gonzalo Blasi on their case report using the distally anchored connective tissue graft platform for papilla enhancement.
Read the full article here. https://aap.onlinelibrary.wiley.com/doi/10.1002/cap.10299
This podcast is produced by the American Academy of Periodontology. To learn more visit perio.org.
The views expressed in this episode are those of the participants and not necessarily those of the AAP.
Music Credit: Groove Nation by OctoSound
Recommended
Transcript
Introduction to the Probing Period Podcast
00:00:00
Speaker
Whether you're in training, in practice, or in research, the Journal of Periodontology and Clinical Advances in Periodontics have something new for you. Hello everyone, I'm Dr. Effio Anidou and I'm the Editor-in-Chief of the Journal of Periodontology and Clinical Advances in Periodontics.
00:00:20
Speaker
Tune with our team to Probing Period, the podcast that aims to discuss advances and innovation in periodontology and implantology.
Excitement for Interdisciplinary Paper Discussion
00:00:35
Speaker
well hello everyone And this is a very special morning. I'm very excited to have this opportunity to share this space and this time with three friends and colleagues. I'm going to start with their introduction, probably. I'm going to let themselves introduce themselves.
00:00:50
Speaker
But I'm very excited because this paper that we're going to be covering today, which has been titled the Distally Anchored Connective Tissue Graph, Platform for Papilla Enhancement, a case report written by these three colleagues and friends. It's a very exciting paper. It has an an interesting opportunity to showcase true interdisciplinary care and who is going to be best to portray this type of collaboration than Gonzalo, Alvaro and Lori. But before we get started, I would like you to please share with you a ah brief
Guests Introduce Their Expertise
00:01:25
Speaker
introduction. Who are you? Where are you practicing?
00:01:28
Speaker
And I'm going to start with Lori. Ladies first, please. Thank you Diego for this introduction. My name is Lori Abrahamian. I'm an EFB accredited periodontist. I completed my master's degree at UIC Barcelona University where I'm currently pursuing my PhD and I work full-time at private practice in Barcelona as well.
00:01:52
Speaker
Fantastic. Thank you Lori Gonzalo. Well, thank you, Diego. And then also thank you for counting on us for for this podcast.
Importance of Interdisciplinary Collaboration
00:02:00
Speaker
We're really honored to be here. I'm also a periodontist. I was trained in the University of Maryland, Baltimore. I graduated in 2016.
00:02:11
Speaker
And then ah I also did a fellowship, a periodontist fellowship there for one year. After I finished that, they came back to Barcelona to practice with my brothers and my family.
00:02:23
Speaker
and I do part-time teaching and part-time prior practice. I'm the co-director of the periodontics program at UIC and I spend my time between the our office and the university.
00:02:36
Speaker
Wearing multiple hats. Thank you, Gonzalo. Álvaro, please. Good morning. Thank you, Diego. and So I'm i'm the prosthodontist. I'm the outsider. So thank you for allowing me in here.
00:02:49
Speaker
I knew Diego that they were resisting for me to be here, but I'm here. so So I did my post program at Augusta University. I graduated in 2014 and I became a board certified prosthodontist as well as certified dental technician a by the American board as well.
00:03:09
Speaker
And I did one year implant program 2014 to 2015. Then I came back to Barcelona. then i came back to barcelona and I do part-time practice and then part-time teaching at the university and I did also my PhD last year I finished my PhD so I'm very excited to be here and I'm happy we're going to be able to discuss what we do every day which is collaboration between the specialties to get the best outcome for our patients This is fantastic. and Thank you, Alvaro, for joining us. and believe it or not, when Gonzalo suggested that you could come and you could join, I was very happy. I was elated because I know that this paper was a true collaborative effort. And of course, with the
00:03:57
Speaker
interactions and the expertise of each one of you, you are able to achieve such a beautiful result. And I'm very excited. I need to mention that this paper is has free access, which is going potentiate the community being able to read and enjoy and take advantage of what you have shared with our community.
00:04:17
Speaker
But thank you again for for sharing your introductions and let's get started. I'm going to start with Gonzalo. And the first question is, Gonzalo, how did the surgical concept develop?
New Surgical Concept for Distal Papilla
00:04:29
Speaker
you're You're introducing a new concept. You're introducing a very viable way to manage some challenges and complications, especially in the aesthetic area. So what inspired you to follow that systematic approach described in your manuscript and how did the concept develop?
00:04:45
Speaker
So, thank you for your question, Diego. I think all these papers, even if it's a case report or a study, they all start with a clinical question of something that is not really working in your practice. And this is something that happened to us with immediate implants in the anterior zone. Since we started about 10 years ago in our practice,
00:05:08
Speaker
and we started doing immediate implant placement in the anterior zone, specifically on the maxillary central incisors, we always had the same issue with the distal papilla, where we had to camouflage the lack of distal papilla with prosthetics and giving a more over-contoured crown on the distal aspect to camouflage that the lack of distal papilla.
00:05:31
Speaker
And we always ask ourselves that question. and And we look into the literature, we look at the paper by Belzer in 2009, where he also looked at central incisors and 19 central incisors and the pink aesthetic score on those central incisors that were supported by implants.
00:05:49
Speaker
And he saw that the pink aesthetic score and the scoring that this papilla was significantly lower than the mesial papilla. And then we look further into literature and there's a very interesting study by Oscar Gonzalez, Martina and Gustavo Avila Ortiz talking about the fate of the distal papilla and why this issue that we were having, everybody's having elsewhere.
00:06:13
Speaker
And so it's basically the position of the lateral incisor and the position of the CJD of the lateral incisor that's dictating that papilla. And so we thought, okay, how can we again, camouflage that distal papilla, but instead of doing prosthetically, doing surgically and augmenting the height of that soft tissue. And that's why we started discussing possibilities also with Laurie about surgical strategies to improve that distal papilla. And that's how we developed the concept based on on these questions that we ask ourselves during our practice.
00:06:50
Speaker
Because ah there ah in other times what we had to do was let's say do extrusion of the lateral incisor to bring that papilla of the lateral down to have an impact on the distal papilla of the central.
00:07:04
Speaker
But then many times you have to restore that lateral after you extrude and you have to add orthodontics into the into the treatment. And as Gonzalo was mentioning, when we camouflage with prosthetic the lack of papilla, we have to also add a restoration to the lateral as well to bring that tissue or push that tissue to be able to to visually see a more papilla even if there is no papilla.
00:07:32
Speaker
I find that fascinating. And of course, you have been following the evolution of all these concepts, the identification of problems, and that you're offering now this solution inspired and based
Foundational Papers on Papillary Aesthetics
00:07:44
Speaker
on literature. And I'm going to use that segue for Laurie, your next question, which will be one of the parts that I enjoyed of reading your paper.
00:07:52
Speaker
And I always take advantage of taking a look at the introduction because in the introduction we have usually it's a literature review where we see the background the base of knowledge that we have and you did such a superb job bringing the most relevant papers that have been published that have to deal with aesthetics and especially the papilla and that the the pink score of course the white scores and and and and all these concepts that are so relevant but Laurie Looking at the literature, I was wondering what are the three papers perhaps that you would call out or what is what are the most relevant articles that you think are relevant for our community to perhaps go and pull them out and read just because they're so valuable as far as knowledge? What is your opinion as far as what would be your your top recommendations?
00:08:40
Speaker
Thank you, Diego, for the question. So when we think about papillary aesthetics, there are mainly two articles, two papers that come to mind that are foundational. The first one is the 1992 paper by Tarno, which showed how the distance between the contact point and the alveolar bone crest was important in determining the presence or not the absence of the interdental papilla in metro dentition.
00:09:08
Speaker
So this paper showed when this distance was less than 5 mm, there was 100% of the time presence of the papilla, and when it was more, then it was less probable.
00:09:21
Speaker
Then the second paper that is also very important, and it shifted this concept to implant support and restorations between natural teeth, is the one by Schoké in 2001.
00:09:33
Speaker
two thousand one where he basically showed that this concept was also true for infant supported restoration next to natural teeth but also this distance was also determined by the presence of the periodontal attachment of this adjacent tooth and not only this alveolar bone crest.
00:09:55
Speaker
And probably the third paper that I would recommend everyone to read is the one by mentioned by Gonzalo, is the commentary by Oscar Gonzales and Gustavo Avila, is the fate of the distal papilla.
00:10:12
Speaker
which is really crucial in order to understand why there is a frequent atrophy of this distus papilla and the clinical strategies in order to prevent or to reconstruct it.
00:10:24
Speaker
Fantastic, Lori. So we have a couple of papers by Tarno and the paper by Oscar and Gustavo, which you recommend. Thank you so much for that suggestion. And I believe that it is something that become very valuable for us to be able to have those those points of reference that are so valuable for our knowledge.
Decision Making: Implants vs. Prosthesis
00:10:43
Speaker
With that said, also, and again, Alvaro, so happy you're here with us because as the prosthodontist, and I see you as the quarterback of the team, all right, as the quarterback, as the leader of the team, you're going to, of course, work in collaboration with the periodontist, with the orthodontist, of course.
00:11:00
Speaker
you're going to be able to have an overview of the case, but particularly for this application, how do you make that decision as far as, okay, this is going to be a case in which we're going to follow up with an implant restoration?
00:11:16
Speaker
Or how are you going to make that decision perhaps of this is going to be too complicated? There are too many factors that probably are going to affect the the final outcome. Perhaps this is going to be much better handled with without a traditional approach such as a fixed partial prosthesis.
00:11:33
Speaker
How do you make those decisions? What type of tools, what type of diagnostics do you follow in order to make those recommendations to your team and then set a course of action? and thank Thank you for the question. And I think that question is frequently comes to my mind when I work in practice because I need to understand which, after the correct diagnosis, what are options of treatment we're gonna render to the patient or suggest to the patient so he's gonna be able to make the right decision. and
00:12:09
Speaker
one of the things that we decide after we seen that the tooth is hopeless, is to understand if the tooth is useless or not, which means could we do any treatment to that tooth before we extract or not? this In this case, we couldn't because it was a vertical fracture.
00:12:27
Speaker
So we know the tooth has to go. And the second question would be many prosthodontists place their own implants and some of the prosthodontists refer the implants to the periodontist.
00:12:41
Speaker
So even for experienced prosthodontist placing implants, you also need to understand the This situation is within your scope or of expertise, or you have to refer this to the periodontist because they are more ah capable of doing the soft tissue graft and the bone graft in combination with the implant placement.
00:13:04
Speaker
So that's the first decision also that you need to make understanding if you're going to do it yourself or you're going to build a team. And then within the team, understand if you're going involve the orthodontist or not.
00:13:17
Speaker
And as you mentioned, are we going to go we know that it is hopeless. We know that it is useless. we can do We cannot do any treatment to that tooth before we extract. So we know we're losing that tooth.
00:13:29
Speaker
Are we going to go towards a three, a a bridge, fixed partial denture between seven and and nine?
00:13:42
Speaker
And on a young patient like this, I rather to be focused on the area of problem, which is that single tooth than prepping the teeth adjacent to that area.
00:13:53
Speaker
So involving the tooth preparation to those other teeth. So we good we took that out of the picture to the three implants or two supported restoration.
00:14:05
Speaker
And we know we were gonna do place an implant. We understood there was a bone deficiency and soft tissue deficiency. So periodontists then come into play and discussing with ig Gonzalo and also with Lori, understanding that could we do this without ortho? Not because we don't like ortho, we love ortho, but if we can do less treatment and get a good outcome, that's our approach.
00:14:33
Speaker
So we normally try to just focus on the area of the problem. that would be implant placement then soft tissue graft that the case was difficult to handle and at the same time if we can just handle this with just one procedure with the distal anchor soft tissue graft and we don't have to use orthodontic extrusion or we don't have to prep the lateral that that was our decision for this for this case Thank you, Alvaro. You shared lot of good points because definitely there are so many moving moving factors, there are so many moving mechanisms that are going to affect that decision.
00:15:13
Speaker
So I appreciate your perspective on this.
Clinical Strategy for Alveolar Dehiscence and Mobility
00:15:16
Speaker
And Gonzalo, looking from a clinical point of view, you are gathering information, you are looking at a patient that has some alveolar dehiscence, you're looking at a patient that has advanced mobility on the tooth that is in trouble, and that you're also dealing with a thin phenotype.
00:15:33
Speaker
So how how do you dictate your strategy with all these red flags for this patient? mean, there are so many things that are critical. What is your train of thought as far as how you're going to address all these individual factors and how this is going to potentially affect your youre a strategy of treatment?
00:15:49
Speaker
ah Thank you, Diego. Great question. um I think when we face hopeless tooth, especially on the upper anterior, our first choice of treatment is always gonna be immediate implant if the tooth is hopeless, just to try to reduce the treatment time, reduce the number of procedures for the patient, and also give the patient something, a professional that is fixed, that is also very valuable from the patient perspective.
00:16:19
Speaker
But there are always some red flags, and and we like to go through the guidelines that the ITI provided, by Adam Hamilton and Franz Lambert.
00:16:31
Speaker
And we look when we look at the site, not the patient, but the site, we first look at the soft tissue and we look if there's a recession that can be minor, major.
00:16:42
Speaker
And if the recession is more than two millimeters, that's a red flag for an immediate implant placement. Then we looked at the bone site. We look at also, excuse me, when the soft tissue was to look at if there's enough keratinized tissue, if there's not enough keratinized tissue, meaning less than two millimeters, that's a no-go for an immediate implant placement.
00:17:05
Speaker
And then we look at the bone, if there's a presence of baccal plate, if there's the histones of menstruations, or there's enough bone to anchor our implant on the palatal and epical aspect from the socket.
00:17:21
Speaker
We also look at if there's a peripical infection in that area, if we're going to be able to debride that area properly. that These are some of the factors.
00:17:32
Speaker
And then we look at the implant site. Implants meaning, are we going to be able to place the implant on the 3D ideal position? For that, we do all the planning together. We we do our digital wax up of the tooth, and we plan the implant on the 3D ideal position.
00:17:51
Speaker
If the anatomical features on that side do not allow us to place the implant on the 3D ideal position, definitely we're not going to place the implant. um and then um the prosthetics parts as well yeah because many times we have shifted with the old the innovation with the prosthetic restorations or prosthetic possibilities with the implant components we are able to place the implant in an ideal 3d alveolar position that is not dictated by a
00:18:25
Speaker
access of the implant or the screw in the cingulum area.
Prosthetically Driven, Surgically Limited Implant Placement
00:18:30
Speaker
Now we are placing the implants more towards the incisal edge or a little bit vocally placed because prosthetically we are able to ah compensate that screw access towards the lingual.
00:18:44
Speaker
The part that we need to take into account when we are trying to bring that access to the lingual is that we need depth on the implant placement we we always uh try to place that implant a little bit towards the buckle towards the incisor ledge a little bit towards the rue but always leaving at least two millimeters of distance between the head of the implant and the buckle plate to allow us for that safe zone for for the implant um So what we always say is that everybody's mentioning that implants should be prosthetically driven placed.
00:19:21
Speaker
And we say that it should be prosthetically driven, but surgically limited because there are always some limitations surgically that are going to affect the prosthetics. So that's why we discuss this all the time. It's team driven implant placement.
00:19:35
Speaker
That is refreshing to hear because there is that is reality. That is reality and that you nailed it. Thank you again for sharing that. Those lots of pearls that you're sharing with what you just said.
00:19:46
Speaker
And, Gloria, I wanted to so switch gears a little bit and and ask you, so this patient was was very healthy, the patient that you were dealing with. But now we're talking about this approach that you follow on this in this case, but play with me a little bit.
00:20:02
Speaker
Let's pretend this patient was a heavy smoker. And for me, a heavy smoker, I don't know what he is in Spain, but for me, a heavy smoker, you're looking at somebody who's smoking more than a pack a day, okay? That is probably, it's going to raise some flags.
00:20:13
Speaker
How this situation would challenge or would modify your approach for this therapy, Lori? Thank you, od Diego. It's a great question. So absolutely, it's ah it's a great factor to consider.
00:20:29
Speaker
First of all, smoking is considered as a great modifier and a well-documented risk factor that will alter the soft tissue and hard tissue healing after any regenerative or grafting procedure.
00:20:49
Speaker
So when we have a smoking patient, the first thing we do is to have a very open conversation with him in order to explain to him all the risk that it involves.
00:20:59
Speaker
First smoking, what it entails, and then smoking, how it can affect the healing of the soft tissues and any surgeries that we do. And when we do that, we also recommend to him smoking cessation.
00:21:14
Speaker
and aiming at least to have two to four weeks of abstinence before and after the surgery in order to favor the healing of the soft tissues. And if the patient is not willing to quit or to reduce smoking,
00:21:28
Speaker
then we need to be very ah direct with him in order to explain the expectations that we have of the surgery. Maybe we can limit the extent of the soft tissue surgery or we can make it a more staged approach.
00:21:48
Speaker
Fantastic. And I think that is so critical to think about those issues, especially when we're dealing with a patient that might have some potential factors, risk factors that can complicate, especially in a case like this that you're dealing with so much crucial aspects for healing and vascularization and so on that can be compromised by smoking.
Biofilm Control Before Surgery
00:22:07
Speaker
And Laurie, I wanted to follow up with you as well, because this is a patient that has tooth that is in trouble. This is a tooth that that has a very poor prognosis. um And that you still take the time to recruit this patient and involve this patient on a six-week program for biofilm control.
00:22:26
Speaker
Tell me the rationale behind that. I found out that very attractive. Yeah. So it's always very important. to to do this first phase of infection control to reduce the local inflammation.
00:22:39
Speaker
And it basically has two advantages. So first we reduce the inflammation, we reduce the friability of the soft tissues. So that's how we can augment and the predictability of our of our surgeries because we have better handling of the soft tissues and we can have a better regenerative and integration and maturation of the tissues.
00:23:02
Speaker
And then the second factor that is also very important to consider is this period of six weeks makes it easier to see the compliance of the patient. And it's very, very important in these cases where we have an aesthetic zone and we have a complex rehabilitation and interdisciplinary approach.
00:23:21
Speaker
So these two factors are the main advantages that gives us this first infection control phase. Thank you, Laurie. Thank you so much, Laurie, for those comments. And again, so important to have plaque control to avoid inflammation, which is the cornerstone of any type of therapy.
00:23:43
Speaker
um I was wondering, because that is something that I i was questioning myself and and that reading through the paper, You're going to be removing a maxillary tooth, and this is a long haul. This is something that is going to take some some treatment stages for you to get your final outcome.
00:24:02
Speaker
As you are removing this tooth in the aesthetic area, how are you planning to replace this tooth in an interim fashion? How do you start thinking about your decision the approach that you're going to take? What are your your alternatives and what are the pros and cons of how to replace this tooth in a temporary way?
00:24:22
Speaker
Yes, this is a great question because the as a prosthodontist or as a restorative dentist, what do you need to ask the periodontist is what are the procedures that you're going to perform And what do you need from my side to make those those procedures less uncomfortable, not only for the patient, but also for the dentist?
00:24:52
Speaker
So for this specific a patient, we knew he was losing that central. We knew that the implant was not going to be placed immediately. And even when the implant was going to be placed, I was not going to be able to do i immediate provisionals implant retained or and so i knew we need a long-term provisional and i'm gonna have to be away from the grafted areas so main question is i'm not gonna be able to give something that is fixed to the implant and i'm gonna be able to be away from the grafted sites
00:25:35
Speaker
And also I'm going to have to handle and manage that soft tissue area. So first things that come into my mind and then I discuss with the patient is, do you mind using a removable prosthesis?
00:25:50
Speaker
If they don't mind to a wear removable prosthesis, the best thing to use is a ah flipper, but we have to handle that vertical movement.
00:26:04
Speaker
So we need to design that so they able the patient is able to put it in and take it out. The patient is able to eat with it, but at the same time, I'm not gonna have issues with the vertical movement because many times the flippers are not well designed and they are just punching or creating pressure on that grafted areas.
00:26:27
Speaker
So that's the first thing. Another thing you can use is a vacuum form with a tooth. but many times they are not able to eat with it because the vacuum covers the teeth.
00:26:39
Speaker
So one thing that we like to do is we just remove the occlusal aspect from premolar's back. So they're able to chew better with that is a modified vacuum. And then the last thing would be a Merlin bonded bridge, which is very comfortable for the patient.
00:26:59
Speaker
But we have two main issues. One is debonding. like an emergency. And the other thing is being debonded by the periodontist or the prosthodontist and bonded back again.
00:27:13
Speaker
ah not only that, is you need to bond that back again with all the sutures and the grafted area and some blood. So that's ah difficult. So if patient allows, we use a removable prosthesis and if they allow it's a flipper.
00:27:29
Speaker
And for the, whoever is going to do a case like this is make sure you discuss with the lab which areas you can design to avoid this vertical movement. If not, would be a vacuum and you remove the occlusal aspect of the vacuum area.
00:27:45
Speaker
Those are good because there's not going to be emergency. Handling in the office is going to be easy. And once the periodontist gives us the green light, we can add and push that tissue.
00:27:58
Speaker
And that's what you're reducing the cost as well. You're reducing the cost as well, yeah. And the last but sometimes necessary is a Maryland bonded bridge that we normally do it with a two ortho wires.
00:28:13
Speaker
So we avoid this rotation and it's easy to remove and it's easy to put back. We don't use what's the resin bonded fixed partial prosthesis or dental prosthesis that is with one wing.
00:28:27
Speaker
That would be if it's a definitive or a long-term provisional, but that with one wing is going to be very difficult to debond and bond. back again. and And as we mentioned before that we say not all hopeless teeth are useless teeth.
00:28:41
Speaker
Most of the time what we do is we session the section the root and we use the same tooth as a provisional bonded to the adjacent teeth with these two buyers. And another question would be for the surgical aspect.
00:28:55
Speaker
We you need to discuss with the, i mean, the discussion between peri and process. Are we going to touch a little bit the tissue and guide that tissue healing with the provisional or not? in what aspect or what phase of the treatment we're going to do that and one other thing that we can do and we did in this case is towards the end once the implant was placed and he gonzalo gave us the green light to to not do the second stage surgery but but open the area to to access to the screw and then do the immediate provisional we push the tissue in this case we did it with increments but
00:29:34
Speaker
Sometimes we do it in one shot. We numb the patient and we pressure until we feel there is a resistance. We know it's the implant and then we unscrew and do the pickup of the implant.
00:29:46
Speaker
That is brilliant. So many pearls and so much knowledge with that. i appreciate you taking the time to walk us through all the options, the pros and the cons, because I think it is important, especially for those novices, those individuals who are starting to get into these these type of details as far as the alternatives to replace out a natural tooth that has been lost. And of course, I like that idea of keeping the natural tooth. You're going to get the best static match, obviously, if the natural tooth allows.
00:30:14
Speaker
Now let's look at a little bit of the the surgical intervention a little bit. and I'm going to ask Gonzalo to enlighten us a little bit. the The tooth is removed and looking at the manuscript, and I'm going to refer the listeners to the figure number two. You capture that moment really well.
00:30:31
Speaker
in which you are designing a flap that it is going to be coronally advanced. That is the the main purpose of that flap design. You're going to be able to coronally advance this flap.
00:30:43
Speaker
What was the rationale of doing this? What are the the pros and cons of this technique? For instance, why not perhaps have a tunnel and that perhaps want a small vertical incision?
00:30:54
Speaker
and I would like for you to to expand on that, Gonzalo, please.
Coronal Advancement Flap Design in Surgery
00:30:57
Speaker
Thank you for your question, Diego. this ah something that we describe for quite frequently with Laurie about what technique are we going to use and and we're very much into mucotangible surgery and and root coverage and we're we're doing some research about that and and we think that we can apply and lot of the concepts of mucotangible surgery into guided bone regeneration in terms of
00:31:25
Speaker
flap design such as ah in this case. we We have mainly two possibilities. We have many possibilities, but two main ones would be a colony advanced flap or doing a tunnel technique, trying to avoid raising a flap, which we mostly, most of the time we do that when we do an immediate implant placement. But here we're talking about the damaged socket, the very damaged socket with a recession,
00:31:50
Speaker
with a buccal bone dehiscence, with an apical lesion, and we thought that we really needed to access that area well to the right if we wanted to place an implant that site.
00:32:03
Speaker
So we needed to flap that. And since we had to flap it and we had not only one recession, but multiple recession defects on the central lateral canine, we decided to do a cornea advanced flap, and which was described by Zucchelli and DeSantis. But in this situation, we're adding a other rich preserv preservation on the central.
00:32:24
Speaker
um And so but the advantage of doing a cornea advanced flap is that the access that you have on that side is much better than when we do a tunnel.
00:32:36
Speaker
The other advantage is that we can advance the flap slightly more than when we do a tunnel technique. And then we have a better access to stabilize the connective tissue graft at the area that we want.
00:32:51
Speaker
which in our case would be about 1 millimeter or 0.5 millimeters from the CEJ, apical to the CEJ. So that's the those are the main advantages.
00:33:05
Speaker
We know that this cannot apply be applied to all the cases, but in this case, we thought it was going to be the best approach to try to get that advancement and trying to achieve complete root coverage on all these sites and trying to also augment the thickness of the soft tissue on the socket not only grafting with ftba and a collagen membrane but also augmenting the soft tissue on a very thin phenotype on that area That is so important, Gonzalo, because you're trying to achieve so much with that single procedure that sometimes that can be lost, that cannot be perceived.
00:33:42
Speaker
And I do believe that it is important to emphasize that we can not but we have to avoid the mistake of trying to be conservative and sacrifice the possibilities that we have through the surgical approach, which is ultimately visualization, being able to visualize the whole field so we don't have anything left behind. We can get a good understanding of the defect that we're dealing with and we can manage it appropriately. So I thank you for that and you manage that so well.
00:34:13
Speaker
Now, Laurie, now we're going to talk a little bit about my biomaterials and you decided to choose a couple of biomaterials, an FTBA, Osseous particle graph material.
00:34:27
Speaker
and also you were combining it with a cross-linked collagen membrane. and My question is, could you please expand on why those choices, and especially try to in enlighten us a little bit about why choosing a cross-linked collagen barrier versus a non-cross-linked collagen barrier? Thank you, Diego, for your question.
00:34:46
Speaker
so First, regarding the use of FTBA in this case, we wanted an excellent scaffold that was osteoconductive in nature, but also resulted in a re-entry time that is less than six months to to place our implant. And also that could result in a good amount of vital bone, which was also shown by the systematic review by Derisi in 2015 compared to, for example, the use of xenografts.
00:35:14
Speaker
And second, why we used the cross-link membrane. So first for its mechanical stability and the low resorption rate. So in this case, we wanted ah membrane that was stable enough that could stabilize the coagulum and the graft and give us this dimensional stability.
00:35:35
Speaker
And also we wanted a membrane that did not resorbed, looking at the secondary intention healing that we chose for
Cross-Linked Collagen Membrane for Graft Stabilization
00:35:42
Speaker
this case. because even though we did, according to the advanced flat, we didn't aim for primary closure because we wanted to preserve the keratinized tissue.
00:35:51
Speaker
And if we were to use a native collagen membrane, we would have lost the membrane prematurely and resulted in the encapsulation of the graft.
00:36:03
Speaker
How much time would you like to have that barrier staying to protect that and allow for that natural tissue, for the gingival tissue to cover that on its own? How much time would you like for that barrier to stay?
00:36:16
Speaker
So I would say at least six six to eight weeks until the bone, osteoid formation starts. And so in order to prevent the encapsulation of the of the graft and the migration of the epithelial cells.
00:36:35
Speaker
That's a very good point of reference. Thank you, Lori. And now, Gonzalo, continuing with the sequence of your treatment, you are going to be harvesting tissue multiple
De-Epithelializing Tissue for Grafting
00:36:45
Speaker
times. You're going to be de-epithelializing this tissue in situ, which is a very interesting technique.
00:36:53
Speaker
You're using a diamond bird to ah to achieve this process. My question is much more geared... How critical it is to remove all that epithelium, number one, and number two, I've seen some situations in which residual epithelium can cause some problems.
00:37:09
Speaker
How do you verify, how are you 100% sure that you're not leaving any epithelium behind? with this approach. What are your thoughts on that? A great question. And this is something also that we discussed and we're actually doing research about this. We're about to publish an article about this.
00:37:28
Speaker
So mainly, i was trying to to harvest a subepithelial connective tissue graft with trapdoor technique or single incision. And then I came back to Europe and I was seeing everybody using a depithelialized free ginger graft that was described mainly by Zucchelli, but also by Bosco.
00:37:49
Speaker
And I thought to myself, okay, it looks much easier to handle, but also the the harvesting side, the donor side, probably the patients can have greater pain than when we do a sublithereal connective tissue graft.
00:38:03
Speaker
So when we looked at the visual analog scale from those patients that would have a dipithelial free ginger graft, there are actually no difference between the two techniques. And then looking at the possibility of leaving epithelium behind, that is also something that can happen with a sub-epithelial connective tissue graft, maybe not as frequent as with a dipithelial free ginger graft. But the thing about the the technique utilizing the connective tissue graft in Clorolli with the Diamond Bear, the main thing is to basically reduce the the time and making sure that we're more efficient in reducing or removing the epithelium.
00:38:47
Speaker
With that flat diamond bear, we're actually trying to remove all the epithelium. ah What we try to do is to at least make sure that our thought our diamond bear is going at at least a millimeter apical than the adjacent tissue where we've relined our incision.
00:39:07
Speaker
And the other main issue that we take into account is that we go... past the incision line because most of the time the remnants of epithelium are at the edges of our connective tissue so the harvesting side is not going to look as pretty when you do that but you're going to be much more efficient so what that's what we do we use the flat diamond bear we pass the incision lines and we deepen the the bear at least a millimeter And then when we take out that connective tissue graft, what we do is basically we we scrap that connective tissue graft with a 15C blade, a new blade, so that we remove any type of possible epithelium. But if we look at the papers that are being published, like Emilio Coso, there's actually mainly no difference in the amount of epithelial remnants that are left comparing the inter-world epithelialization and the actual epithelialization.
00:40:04
Speaker
But it's a matter of time and I would say easier technique. And also it could reduce the cost since we could sterilize the burrs more easily.
00:40:15
Speaker
Yeah, do not use too many blades. Ten blades. Very good. That's a very good point too, Lorien. Always thinking about the cost point reference is is is very relevant. That is but very valid.
00:40:27
Speaker
And Alvaro, I wanted to touch base with you. And again, in the beginning, you so gave us tons of pearls regarding the provisionalization of these cases. But one of the questions that I had is when you have you were touching already based on that, you were touching a little bit on this, and it is when you're having these intrams contact the grafted areas, how much pressure is...
00:40:50
Speaker
is tolerable, that is not going to be causing problems. For somebody who's getting into this and is going to be placing these interim pontics and that the patient is going to be occluding and you're going to see some ischemic reaction, how much is too much ischemic reaction? How much is is you feel comfortable with?
00:41:10
Speaker
Did you see that Gonzalo is smiling? You know why? You know why? Because it's a common discussion. So if Gonzalo is not seeing me, I pressure. And if I knew the soft tissue grad was well done and there's enough thickness of soft tissue would would be that would be more than two millimeters thickness,
00:41:36
Speaker
I can, I rather numb the patient and pressure and not doing an increments. Because I knew if i applied too much pressure, i would just relieve that pressure later on and that tissue will come back down.
00:41:53
Speaker
So for me, if it's more than two millimeters thickness, I do it in one shot. on applying the pressure. It's less than two and the patient is not willing to do to go through another soft tissue graft, I do it by increments.
00:42:11
Speaker
For this patient, we did it by increments because Gonzalo didn't
Managing Pressure on Interim Pontics
00:42:15
Speaker
allow me. So it's not I'm not the quarterback, you know, I just i just serve the period. He follows orders. Let me make one point is that it's not how much pressure It is important how much pressure, but it's also more important even is where you put the pressure.
00:42:35
Speaker
because we want to have that under contour area on the most cervical aspect and we can put more pressure on the most palatal aspect.
00:42:47
Speaker
So when people come into problems are when they are applying too much pressure on the most buccal aspect of the soft tissue and that's when you may have some soft tissue dehiscence.
00:42:58
Speaker
Yeah, but not only that, also that as Gonzalo was mentioning, you apply the pressure but when it's in depth the first two millimeters is where you apply a lot of the pressure vocalingually or towards the buckle after the two millimeters you're going to try to go very narrow on the diameter of your provisional so it's very important that let's say you have the patient back and you need to modify the provisional and you need to apply pressure so my trick is
00:43:33
Speaker
I mark with ah with a pencil on the provisional where the soft tissue is or the mucosal margin is. I remove, I mark with a round burr so I can make an indentation on that pencil.
00:43:50
Speaker
And then from there, apply only on the two first millimeters towards the buckle. And after the two millimeters in depth or vertically, I don't apply any more material.
00:44:01
Speaker
So that's why I don't mind doing it in one shot because I'm not going all the way to the implant hat. I'm just working in the first two millimeters, which is known as a critical contour, critical aspect or critical and area.
00:44:15
Speaker
Now, new nomenclature by Gomez Meda and Esquivel, they call it the EBC, will be the E area. So it's around 1.5 to 2 first a vertical millimeters or vertical depths.
00:44:33
Speaker
I don't know if I answer the question or not. This is very good and I think it will be very valid to perhaps start thinking about a very technical article in the future for you to describe those as well because I think that information is so valuable.
00:44:46
Speaker
But I am in agreement with what your approach is and that yeah the location of the pressure. It is also very important. so but i think I think we all get very worried when you apply the pressure, you screw the provisional in,
00:45:02
Speaker
and it's all very ischemic and white, you have marked the area and you only work in the first two millimeters from that actual mucosal margin, you don't have to be worried.
00:45:15
Speaker
If it's all white, you're gonna create ischemia because you know you have more than two millimeters thickness of mucosal thickness. And if you apply too much pressure that happened to me before, I don't allow Gonzalo in, i remove, I screw back in, I wait two weeks and the tissue is back. you know Fantastic. This is great. Now, moving on with the timing, the timing of the placement of the
Timing of Implant Placement Post-Grafting
00:45:40
Speaker
implant.
00:45:40
Speaker
And this question will be for you, Gonzalo. I believe there was a four month period of waiting for healing after the grafting. um My question was, why not going a little earlier, let's say three months or not later, letting that tissue mature a little longer, six, eight months.
00:45:58
Speaker
How did you decide to go in at four months? So that that's a great question. And and we always ask ourselves this type of questions because you go through residency and everybody's telling you know after guided bone regeneration, six months, you can place implants. Vertical bone regeneration, nine months.
00:46:19
Speaker
When you want to place the final restoration, three to four months. so when we look at the literature that's been published i think there's a great article by nelson and neely that they look at the alboreal rich preservation in in that article they do a rct comparing uh the time of entry for him for implant placement after other rich preservation The type of biomaterial they use is different than ours because they use a 70%, 30% mineralized, 30% demineralized.
00:46:51
Speaker
And they in one group, they do their reentry in eight to 10 weeks. And the other one, then they do 18 to 20, I believe. And the the amount of percentage of vital bone is doubled when they waited the 18 to 20 weeks.
00:47:08
Speaker
And the amount of residual bone particles is half compared to the other group. So that's our question right there. That's the, well what we want to have is ah as much vital information as possible in order to have not only good bone to implant contact, but also to have good primary stability when we place our implants. So that's ah that's mainly our our goal and that's why we wait at least four months after our very rich preservation. Maybe we were using xenograft, a particular xenograft, the waiting time would be a little longer because of the resorption rate of that particular bone. But in this case, that's why we waited four months.
00:47:51
Speaker
I think the challenge here when we want to wait longer to get a better result is comes to our side on the provisional part that would be have the patient comfortable.
00:48:03
Speaker
So it's not is not uncomfortable enough to keep on asking to when we are finished. But we know nowadays it's very hard because everyone wants everything for yesterday.
00:48:16
Speaker
But we understood that the waiting gives us better results. patients. that is Those expectations need to be handled so delicately with patients, of course, but that is critical.
00:48:28
Speaker
Laurie, looking at the connective tissue, what is your take on on the source of where you're harvesting that tissue? For instance, in the bicuspid area, or if you're going to the tuberosity, what applications do you see, especially for these type of aesthetically driven cases?
00:48:45
Speaker
What is your take? So in a scenario like this, when we want to augment the papillary tissue, what we want from our connective tissue graft are two main characteristics.
00:48:56
Speaker
So first, the tissue quality, that it has a good density, which is achievable either from connective tissue graft, from the lamina propria, from the palate, or from the maxillary tuberosity area.
00:49:09
Speaker
And also what we want also is a dimensional stability over time, because Papilla, as we know, is a very difficult site to preserve and to reconstruct and to regenerate.
00:49:20
Speaker
That's why we want the highest stability. So in this case, we could either harvest from the pallet or the tuberosity area. However, since we wanted the graft to be placed on the occlusal part and also to go over the buccal part, we wanted a good dimension of the graft, which is not always achievable to harvest from the tuberosity area, and that's why we opted for the premolar palatal area in this case.
Choosing Suture Materials for Surgical Procedures
00:49:50
Speaker
Thank you. that is That is beautiful, the way you're describing this. A quick question out of curiosity. You, at some point, and Gonzalo, perhaps for you, at some point during your procedures, you are combining different biotextiles. You're using EPTFE or PTFE for your suture material. You're using also polypropylene.
00:50:10
Speaker
Why those choices? That's a great question. we have We believe that you can not only focus on just one type of suture for for the same procedure.
00:50:24
Speaker
There are different ways that suture can be managed so that you can get the best out of its suture. In this situation, for example, we use a 7-0 PGA suture to fix our graft on our initial procedure.
00:50:42
Speaker
And we use that one because it's with a smaller diameter suture, we can get better vascularity around our graft. And it's going to be resorbable because going to be underneath our flap since we're going to do i only a colony advanced flap.
00:50:58
Speaker
Then we're going to use a polypropylene suture for our colonel advancement, for our sling sutures, or even the sutures in the the area where we do our cristanization, because that's the area where the vascularity is more compromised in the papilla area or at the center of the ridge.
00:51:18
Speaker
So with a less so or a reduced diameter of a suture, we can enhance the vascularity on the air that can be more compromised. And then with the PTFE suture, is a suture that has a, we use that one basically for tensile or mechanical properties. That's a suture that you can stretch the most and you can approximate the flaps better.
00:51:40
Speaker
And we use that mostly, most of the time we use that for doing our horizontal mattress sutures. or in order to approximate the borders at the at the edges of our incisions or at the distal part and mesial part of our fridge so that we can approximate the borders better. And then the rest, we're going to use a polypropane sutures because of the diameter, but also because of the properties in terms of accumulated less plaque on that critical area.
00:52:11
Speaker
Thank you. That is an important concept to understand that sometimes you need different biotextiles, different alternatives, different that are going to provide different solutions for the challenges that we have surgically.
Minimizing Enamel Damage During Bonding
00:52:24
Speaker
Alvaro, a question for you. We touched base a little bit on the Maryland Bridge and that some of the pros and the cons Specifically, I wanted to talk to you because that is something that I deal with. And it kind of bothers me as far as the bonding process, you know, having to place it back and remove it and bonding and rebonding. And how do you try to minimize preserving enamel, the enamel health when you're doing all these bonding procedures that sometimes can require multiple dislocations of these provisionals?
00:52:54
Speaker
What were are your thoughts with that? so the main approach would be do a merlin bridge but with ortho wires on the lingual that would be double i mean two ortho wires on the lingual no no circular ortho wires but rectangular in shape titanium if possible and you're gonna put it on the lingual so you're gonna aerobrate the enamel use a bonding agent and then flowable on top.
00:53:28
Speaker
So you're not preparing the enamel like you're going to bond a long-term Merlin bridge that let's say we're using now with zirconia with one wing.
00:53:40
Speaker
we are just using as a ortho retainer with the two with the two wires. That will be easier because all you have to do to remove it is just to hold it with pliers and just do rotation towards the lingual and it breaks easily.
00:53:57
Speaker
And if not, you can use the instrument from ortho to remove the resin from the braces. And it comes out very easy. And that's how we how we use it.
00:54:10
Speaker
But actually, if we are able to, we try to avoid Merlin and we try to go first phase with removable prosthesis, as mentioned, controlling the vertical movement or vertical dislocation.
00:54:24
Speaker
And from there, we tried to go directly to fix restoration over the implant. And if you can see on the paper in the figure number eight, you can see the provisional with two wings, one that goes towards the lingual and the other one goes towards the buckle.
00:54:43
Speaker
We call these anti-rotational wings. they are That allow us to pressure and it's controlled by the adjacent teeth. So you don't go too much to the vocal, too much to the lingual.
00:54:54
Speaker
So it's controlled. We designed this digitally. And it's very easy because you keep on pressuring until you see it's enough and you bond it in that area. Or if your periodontist trusts you, you just numb the patient and do the same all the way in until you pick up the implants.
00:55:14
Speaker
or you fill the implant, then you unscrew the closing screw and you do the pickup of the provisional. Then from there, you start working on the soft tissue or molding the soft tissue.
00:55:28
Speaker
And I like that answer because it's a perfect segue for the next question that I was going to ask Lori. You spent all this time building this beautiful tissue, and obviously you want to be very conservative, picking up the position of the implant and making that connection, uncovering finally the ah the implant.
00:55:45
Speaker
So how was this done, Lori, in your experience? What is the best approach to do this, to find that implant and incorporate it? So, as Alvaro was explaining, we did it in a non-surgical incremental way where we used the Maryland Bridge and we used we added some copu subpllo composite on it every week in order to reach the head of the implant.
00:56:08
Speaker
So this had two main advantages. so First, we didn't touch the papilla, we didn't traumatize it, so we didn't lose the vascularization and risked losing papilla that we saw ah did that effort to build.
00:56:24
Speaker
And then the second advantage was also to incrementally also shape the emergence profile, the critical and subcritical contour of our future implant supported provisional.
00:56:37
Speaker
So it had double advantage. Very important. And again, those are the, yeah I do believe that the devil is in the details and that type of attention to detail is what is going to make that difference. So thank you again and I compliment you for that beautiful work.
Using Autogenous Connective Tissue for Papilla Reconstruction
00:56:51
Speaker
Now, with that in mind as well, were talking about about connective tissue, mainly that's what was used. What are your thoughts, and and that that could be for Laurie or Gonzalo, what are your thoughts as far as utilizing substitutes for these type of applications, coming with a substitute for a connective tissue graph?
00:57:11
Speaker
so so we think that uh graft substitutes are ah good alternative to when we want to reduce the morbidity of the patient and we don't want to harvest the connective tissue graph from a second site however in this scenario where we want to build the papilla which is very difficult to do and we want it to be as perfect as possible the connective tissue graph from the palette or the diversity is still considered as the gold standard i think
00:57:46
Speaker
yeah so and And not only that, but we can see through literature and and and we actually published a case series a few years ago, a couple of years ago on a journal aesthetic and restorative dentistry that we evaluated the dimensional changes with a serodermal matrix and the amount of resorption that occurs not only vertically when we try to do root curve, but also in terms of thickness, in terms of volume, the amount of resorption is very significant in comparison to connective tissue graft stability over time.
00:58:18
Speaker
So in this type situation, when we're trying to augment significantly the height and the thickness, we think that connective tissue graft, autogenous connective tissue graft is the best alternative.
00:58:31
Speaker
Thank you, Gonzalo. I'm very aware of of how generous you've been with your time today, and I wanted to close this session.
Reflecting on Case Improvements
00:58:40
Speaker
and The way I wanted to close this session is I think we all realize that 2020, our vision 2020 is much more accurate when you're looking retrospectively. i do believe that myself personally, I feel like I've never done a perfect procedure, 100% satisfied. There's always something that I could have tweaked that perhaps I could have done better.
00:58:57
Speaker
And I wanted to ask you that question is in retrospect, and let's start with you, Alvaro, in retrospect, is is there something that you could have done to enhance this case, even though the the outcome was was very favorable from any point of view, was a beautiful case, um anything that you could have done better now, perhaps with the knowledge that you have since the time that you wrote this paper?
00:59:20
Speaker
And the same question will apply to Gonzalo and to Laurie, if you would like to share with your thoughts.
00:59:27
Speaker
so from a prosthetic perspective if i could if i could go back and do and treat this patient what things would i do different is i for sure would uh wait until the implant healing to move from one removal provisional to fixed but i would do it in one shot i would just go in instead of increments i would do it in one shot and pick up the implants to reduce the the the challenge technical challenge that we had and the amount of appointments that we had to go through and another thing that i would have done differently is that
01:00:10
Speaker
Before we used to, once we do the pickup of the implant, we used to slowly move and increment, do the increments by appointments as well.
01:00:22
Speaker
And I would try to it in, in, in one shot and material selection that we did a titanium custom abutment. I would do the same nowadays.
01:00:34
Speaker
And we use the CUNIA, um, generation three and layer ceramics on the vocal aspect, I will still use the same because even if we had improved on the materials and the quality of the materials, I would still use for a single central zirconia core and layer ceramics on the facial. So my changes would be more on the approach on the soft tissue management from the prosthetical aspect.
01:01:04
Speaker
So from my side, in terms of surgery, I think we actually did this in in two procedures, but at the same time, we did harvest the connective tissue graft twice from the palate. And this can be very aggressive for the patient and uncomfortable. But as we mentioned, we we don't think we could we could have have this resolved with an alternative to a connective tissue graft.
01:01:34
Speaker
At the same time, I think we could have have better aesthetic results in terms of soft tissue if we harvested maybe a thinner connective tissue graft to cover the lateral and the canine areas.
01:01:49
Speaker
but Because we can see that not only with With a thinner connective tissue graft, we you can have a better experience for the patient in terms of pain and painkiller consumption.
01:02:02
Speaker
But also we can improve also the aesthetics of the area where we have a thinner connective tissue graft to perform root coverage. So from from the surgical perspective, I think this could have been a an improvement.
01:02:14
Speaker
I agree with Gonzalo. Another idea also would be to use a soft tissue substitute only on the lateral and canine area, combining it with the connective tissue graft on the central area.
01:02:29
Speaker
And if you allow me to to add something that would be a question for ourselves would be... course. When would we suggest the reader that this distally anchored soft tissue graft is...
01:02:44
Speaker
a treatment and of choice and when would be ortho extrusion of the lateral is less than two, more than two millimeters, we don't know yet, because this would be also armamentarium for a clinician to decide, oh, this case I need this amount, I would use this technique or I would go to... Yeah, I think i think this this is a great point. and And basically when we're looking at a tooth that is hopeless, that needs an extraction and and possibly an immediate implantation cannot be performed,
01:03:21
Speaker
And the tooth form is a triangular shaped tooth, very scalloped soft tissue. Those are the type of cases that the distal papilla is going to be more compromised after the extraction. So those type of cases, I think, is the ideal cases for this type of technique, for the distally anchored connective tissue graft platform.
Conclusion and Gratitude to Guests
01:03:43
Speaker
I'm so glad you added that information because I was going to ask you as well, is there anything that you would like to add that I hadn't asked you? So I'm really happy that you you got ahead and that you contributed with that important piece of information.
01:03:56
Speaker
Well, Laurie, Gonzalo, Alvaro, it has been such a pleasure for me. it's such an honor to share this space and time with you. And again, I thank you very much for your collaboration with CAP. And I look forward to future collaborations because it is all of you bring so much to our profession.
01:04:14
Speaker
And that we're very happy, very lucky, too very fortunate to be able to work with colleagues and friends like you. Thank you so much for your time today. Thank you, Diego. Thank you. Thank you. Thank you.
01:04:28
Speaker
Thank you for joining our episodes today. If you like this episode, share with a friend. Don't forget subscribe to the podcast wherever you're listening so you get the latest episodes.