COMPLEX SITUATIONS
ON IMPLANT DENTISTRY:
SPECIALIZED CLINICAL SOLUTIONS
Editors
Paulo Henrique Orlato Rossetti
Wellington Cardoso Bonachela
ISBN: 978-85-64761-06-3
Copyright © 2013 VM Cultural
Publisher
VM Cultural
Editors
Paulo Henrique Orlato Rossetti
Wellington Cardoso Bonachela
Graphic Design
Adriana Carrer
Text Review
Vivian Priscila Arais Soares
English edition editing and production: VM Cultural Editora
Rua Gandavo, 70 - Vila Mariana
04023-000 – São Paulo – SP – Brazil
Tel.: (11) 2168-3400
All rights reserved. This book and therein any part of it cannot be
reproduced without previous permission of the Publisher.
Dados Internacionais de Catalogação na Publicação (CIP)
(Câmara Brasileira do Livro, SP, Brasil)
Situações complexas na implantodontia : soluções clínicas
especializadas / coordenadores Paulo Henrique Orlato Rossetti,
Wellington Cardoso Bonachela . -- São Paulo : VM Cultural
Editora, 2013.
Vários autores
Bibliografia
1. Clínica dentária 2. Dentes - Extração 3. Implantes dentários
4. Implantes dentários osseointegrados 5. Periodontia I. Rossetti,
Paulo Henrique Orlato. II. Bonachela, Wellington Cardoso.
13-07409
CDD-617.692
13-07409 NLM-WU 500
Índices para catálogo sistemático:
1. Implantodontia : Terapia clínica :
Odontologia 617.692
To the Almighty God, by blessing us with His courage to get up and restart every time.
To our families, for their love and support.
P. H. O. R.
W. C. B.
“I have fought the good fight, I have finished the good race, I have kept the faith”.
Timothy, 4:7.
ACKNOWLEDGEMENTS
U
ndoubtedly, this book is the outcry of many restless minds. The IN 2013 Congress has a strong
commemorative meaning. It represents the past experiences that inspire the future generations.
I would like to thank all people involved in the project of this book: to my colleague and also editor, Wellington
Cardoso Bonachela, for sharing long journeys and for the correct mindset of the text, to the invited authors (many of
them have shared their professional and personal thoughts with me along time) that made every effort to present a
high-quality update material.
To Miriam Ribalta, Cristina Sigaud, Aline Souza, Adriana Fuzo, and José Reis, for layout and project logistics. To VM
Com employees and to my contacts at the Marketing Department, Ms. Claudia Pini, William Oliveira, and Camila
Adrieli. Certainly, their friendship, support, and sharing made this project a big success.
To our dear colleague, César Arita, who passed away early.
To our masters, for their dedication and time sharing their thoughts, philosophies, and an excellent common-sense
of life.
An especial acknowledgement to our patients that represents a source of ongoing material and spiritual learning. We
hope to be able to provide the best quality of life for all of you.
Finally, to our Publisher and Executive-Director of VM Comunicacao, Haroldo Joaquim Vieira, a singular person who
soon understood that lack of learning if timeless and improvement only comes with continuous investment.
Thank you!
EDITORS
PAULO HENRIQUE ORLATO
ROSSETTI, DDS, MSc,
Doctorade (Oral Rehab)
Scientific-Editor, ImplantNews
Private Practice, Bauru, São Paulo, Brazil
WELLINGTON CARDOSO BONACHELA,
DDS, MSc, Doctorade (Oral Rehab)
Associate Professor, Department of Prosthodontics
and Periodontics
Bauru Dental School, University
of Sao Paulo, Brazil
Private Practice, Bauru, Sao Paulo, Brazil
LIST OF AUTHORS
ALBERTO BLAY
DANIEL AFONSO HIRAMATSU
Graduation course in Dentistry
MSc - Laser, IPEN-USP;
Specialist – Implantodontics - UNISA, Brazil
Graduation course in Dentistry
MSc – Oral Rehabilitation – FOB-USP
Brånemark Osseointegration Center – Sao Paulo - Brazil
ALESSANDRA CASSONI
EDGARD FRANCO MORAES JR.
Associate Professor, Post-Graduation Program in Dentistry, Restorative
Dentistry and Implantodontics, University of Guarulhos (UnG), Brazil
MSc, Doctorade, and Specialist – Restorative Dentistry, FO-USP, Brazil
Graduation course in Dentistry
MSc and Doctorade – Buccomaxillofacial Surgery and Traumatology, FOAr- UNESP,
Brazil
ALVARO FRANCISCO BOSCO
EDUARDO BATITUCCI
Graduation course in Dentistry
Professor, Department of Surgery and Integrated Clinics
Discipline of Periodontics
Araçatuba Dental School, UNESP, Brazil
Graduation course in Dentistry
MSc – Oral Rehabilitation - FOB/USP
Doctorade - Dentistry - UERJ,
Associate Professor, Department of Dental Prosthesis – UFES, Brazil
ANTONIO AZOUBEL ANTUNES
ELKEN GOMES RIVALDO
Graduation course in Dentistry
Specialist - Buccomaxillofacial Traumatology
Doctorade student, Buccomaxillofacial Surgery
Ribeirao Preto Dental School
University of Sao Paulo, Brazil
Graduation course in Dentistry
Specialist – Dental Prosthesis - UFRGS
MSc – Dental Prosthesis - ULBRA/RS
Doctorade – Biomedical Gerontology - PUC/RS
Associate Professor, Dentistry course - ULBRA/RS
Full Professor, Post-Graduation Program in Dentistry
Universidade Luterana do Brasil- RS, Brazil
ARTHUR BELÉM NOVAES JUNIOR
Titular Professor, Department of Buccomaxillofacial Surgery and Traumatology
Ribeirao Preto Dental School
University of Sao Paulo, Brazil
FELIPE RAMALHO FERREIRA
Graduation course in Dentistry
MSc – Oral Rehabilitation – FOB – USP, Brazil
CÁSSIO DE BARROS PONTES
Graduation course in Dentistry
Doctorade – Oral Rehabilitation
Ribeirao Preto Dental School
University of Sao Paulo, Brazil
FERNANDA HERRERA STANCARI
Graduation course in Dentistry
MSc, Doctorade – Oral Rehabilitation
Bauru Dental School
University of Sao Paulo, Brazil
CARLOS DOS REIS PEREIRA DE ARAUJO
Graduation course in Dentistry
Associate Professor, Department of Prosthodontics and Periodontics
Bauru Dental School
University of Sao Paulo, Brazil
FRANCO IGNÁCCIO MALAGUTI
Graduate student UNIUBE-Uberaba, MG, Brazil
FRANCO ROCHA VILLELA
JULIANO MILANEZI DE ALMEIDA
Graduation course in Dentistry
Specialist – Dental Prosthesis
Fundação Bauruense de Estudos Odontológicos
University of Sao Paulo, Brazil
Graduation course in Dentistry
Professor, Department of Surgery and Integrated Clinics
Discipline of Periodontics
Araçatuba Dental School
Paulista State University, Brazil
GABRIEL RAMALHO FERREIRA
Graduation course in Dentistry
Specialist on Buccomaxillofacial Surgery and Traumatology – AHB- Bauru
MSc, Douctorade - Buccomaxillofacial Surgery and Traumatology, Paulista
State University– Araçatuba
Surgeon, Hospital de Reabilitação de Anomalias Craniofaciais – USP, Brazil
LAÉRCIO WONHRATH VASCONCELOS
GUARACILEI MACIEL VIDIGAL JR.
LEANDRO ROTH
Graduation course in Dentistry
Specialist - Implantodontics
Specialist, MSc and Associate Professor, Periodontics
Doctorade – Materials Engineering, Brazil
GUSTAVO NARDEGAM
Graduation course in Dentistry
MSc student, Implantodontics, UnG, Brazil
JAMIL AWAD SHIBLI
Graduation course in Dentistry
Associate Professor, Post-Graduation Program in Dentistry - Implantodontics
and Periodontics, University of Guarulhos (UnG);
MSc, Doctorade and Specialist on Periodontics, FOAr-UNESP;
Associate Professor – Department of Buccomaxillofacial Surgery and
Traumatology, Department of Periodontics, FORP-USP, Brazil.
JOSÉ AUGUSTO RODRIGUES
Graduation course in Dentistry
MSc, Doctorade and Specialist on Restorative Dentistry, FOP-UNICAMP
Associate Professor, Post-Graduation Program in Dentistry - Restorative
Dentistry and Implantodontics, University of Guarulhos (UnG), Brazil
JOSÉ GERALDO MALAGUTI
Graduation course in Dentistry
Specialist – Dental Prosthesis, Periodontics and Implantodontics,
Doctorade - Implantodontics, USC, Bauru, Brazil
Graduation course in Dentistry
Specialist – Buccomaxillofacial Surgery and Traumatology - UERJ
Doctorade - Implantodontics- FOA- UNESP
Clinical Director, Brånemark Osseointegration Center – Sao Paulo - Brazil
Graduation course in Dentistry
MSc student - Implantodontics, UnG
Specialist - Implantodontics, FOAr-UNESP, Brazil
LETÍCIA HELENA THEODORO
Graduation course in Dentistry
Professor, Department of Surgery and Integrated Clinics
Discipline of Periodontics
Araçatuba Dental School,
Paulista State University, Brazil
LUIZ ANTONIO SALATA
Graduation course in Dentistry
Professor, Department of Buccomaxillofacial Surgery and Traumatology
Ribeirao Preto Dental School
University of Sao Paulo, Brazil
LUIS CARLOS DA FONTOURA FRASCA
Graduation course in Dentistry
MSc, Doctorade – Oral Rehabilitation - FOB - USP
Associate Professor, Faculty of Dentistry - UFRGS
Coordinator – Specialization course in Dental Prosthesis and
Implantodontics – ABO – RS - Brazil
LUIZ FERNANDO PEGORARO
Graduation course in Dentistry
MSc, Doctorade – Oral Rehabilitation, FOB-USP
Titular Professor, Department of Dental Prosthesis and Periodontics,
FOB-USP
Bauru Dental School, Brazil
LUIZ ROBERTO FIGUEIREDO DANTAS
RENATO OLIVEIRA FERREIRA DA SILVA
Graduation course in Dentistry
Specialist - Periodontics
Specialist, MSc - Implantodontics.
Graduation course in Dentistry
MSc, Doctorade –Oral Rehabilitation, FOB –USP, Brazil
RUBENS FLORINO PADOLFI (IN MEMORIAM)
MARIA ANGELICA REHDER DE ARAUJO
Graduation course in Dentistry
MSc- Implantodontics - UFSC
Specialist – Implantodontics - PUC-Campinas.
Private Practice, Bauru, Brazil
Graduation course in Dentistry
Titular Professor, Department of Dental Prosthesis and Periodontics
Bauru Dental School
University of Sao Paulo, Brazil
SAMUEL PORFÍRIO XAVIER
MARIO GROISMAN
Graduation course in Dentistry
Specialist - Periodontics – UERJ, Brazil
Specialist - Oral Implantology - CFO
MSc - Dental Sciences, University of Lund, Malmo, Sweden
Graduation course in Dentistry
Professor, Department of Buccomaxillofacial Surgery and Traumatology
Ribeirao Preto Dental School
University of Sao Paulo, Brazil
SAMY TUNCHEL
PAULO FUKASHI YAMAGUTI
Graduation course in Dentistry
Specialist – Dental Prosthesis –FOA- UNESP
MSc –Dental Prosthesis – FOA - UNESP
Doctorade – Oral Rehabilitation – FOB-USP, Brazil
Brånemark Osseointegration Center – Sao Paulo - Brazil
PAULO MARTINS FERREIRA
Graduation course in Dentistry
Master in Periodontics, Boston University, EUA
Doctorade – Oral Rehabilitation – FOB- USP
Professor, Department of Dental Prosthesis and Periodontics
Bauru Dental School
University of Sao Paulo, Brazil.
RAFAEL CALÇADA BASTOS VASCONCELOS
Graduation course in Dentistry
Specialist - Implantodontics
Post-graduate course on Implantodontics - ILAPEO
Brånemark Osseointegration Center – Sao Paulo - Brazil
Graduation course in Dentistry
MSc, Specialist - Implantodontics, UNISA, Brazil
VALDIR ANTONIO MUGLIA
Graduation course in Dentistry
Professor, Department of Dental Materials and Fixed Prosthesis
Ribeirao Preto Dental School
University of Sao Paulo, Brazil
VALDIR GOUVEIA GARCIA
Graduation course in Dentistry
Titular Professor, Department of Surgery and Integrated Clinics
Discipline of Periodontics
Araçatuba Dental School
Paulista State University, Brazil
Professor, Post-Graduation Program in Dental Sciences
MSc level - concentration area: Implantodontics
Fundacao Educacional de Barretos, SP, Brazil
PRESENTATION
T
his book was written for the clinician. However, there is no practice without a theoretical basis. At the same time, the history tells
us that clinical practice has overwhelmed some dogmas. Restitutio ad integrum is our great challenge and we do not have all
the answers: when the art of diagnosis is not properly exercised, no colleague can reach the desired outcomes. In a certain way,
all patients deserve to be treated by a high-skilled clinician, but even “super-heroes” also have rough days.
At the same time, dental treatment with or without dental implants means a “marriage”. Then, motivation for success has to be shared
between the patient and the professional.
There is a good chance that, throughout this book, the dental colleague can find similarities between his/her clinical cases and the
material presented here. Besides, each chapter brings classic and update literature references to guide and support treatment planning.
Although we live in the evidence-based age, the practice is of utmost importance. So answers just get strong over time.
Chapters 1, 2 and 3 deal with tooth extraction and immediate implant placement in the esthetic zone, being that immediate-loaded or
not. Curiously, this has been one of the most discussed topics in the literature and although dental implants are so popular as amalgams
and composite resins, published results still makes us apprehensive.
Chapter 4 brings a different regenerative approach at the post-extraction socket: the use of granulation tissue as a “natural membrane”.
Certainly, an interesting aspect with promising results.
Chapter 5 presents implant solutions for posterior regions with the subcrestal implant placement philosophy, which automatically involves platform-switching due to the abutment design for restoration delivery.
Chapter 6 shows two aspects on the prostho/perio/implant interface, revealing why clinical caution on regenerative biology of lesions and
the adherence to sound occlusal principles for large-span prostheses still are important steps for treatment success.
Chapter 7 poses the ravage of peri-implantitis. Being this or not a problem associated to smoking, diabetes, or lack of oral hygiene, decontamination and regeneration of implant surfaces still seems to be a global issue.
Chapter 8 demonstrates that correct 3-D implant positioning is a sine qua non condition especially at the upper central incisor situation,
and how the solution of complex cases involves several surgical procedures and a lot of prosthetic patience.
Chapter 9 brings extensive procedures for oral and maxillofacial reconstruction showing the necessary knowledge on tissue anatomy and
physiology, as well as the limits and possibilities of each donor area.
Chapter 10 provides us with the winds of a new moment: Digital Dentistry. Virtually, would it possible to integrate technologies and verify
the final result at a computer screen? How this changes our clinical practice?
Finally, Chapter 11 show correction of large defects in the esthetic zone, and why is fundamental to understand how to start and finish
each clinical case from the multidisciplinary team approach.
FOREWORD
A
long time ago, two things have echoed in our minds:
“Implants are used to replace lost teeth, not teeth” and “Be careful: teeth get older than dental implants”.
For sure, those are notes from congresses and probably they summarize the fundamental biomechanical differences between these daily issues.
Over the years, many concepts had emerged, disappeared, or been improved on Implant Dentistry. Bone quantity and quality used to
be the first surgical obstacle and more than 50% of the inaugural class context. Less importance was attributed to the esthetic aspect. Nowadays, inclined implants are placed in the maxilla and mandible to avoid noble anatomic landmarks (maxillary sinus, mental foramina) in case
of complete, fixed, screw-retained prostheses. Also, the use of shorter and narrower implants has been in evidence (an acceptable biological
response). Also, changes on implant macro- and micro-geometry are seen. Particularly at the anterior region, we have moved from large to
single-tooth prostheses and our efforts have been driven to preservation of the alveolar extraction socket (flapless procedures, platform-switching, piezosurgery, new periodontal techniques and improved biomaterials, growth factors, stem-cells, etc.). Finally, CAD/CAM and zirconia
have been incorporated for abutment and prosthesis manufacturing.
Clinically, most of the above mentioned therapies are still in their infancy (a large number of studies with short-term observation – less
than five years). Some techniques demand a change in the routine, financial investment, and significant patient cost. If one considers that
contemporary dental implant practice was developed in worse technological conditions, for sure this new battleship will be successful upon
the new storms with a reduced learning curve.
Also, there is a plethora of diagnostic technologies and the chance to make our patients understand limitations and opportunities for
each treatment modality. Some decisions and opinions are shared, but to what point can we work within safe limits and at the same time to
make come true the most delicate dreams?
Truly, we hope the next generations to be so blessed as the previous ones and that they bring solutions for issues not addressed this
moment. This is a transition period and also concepts and practices conflicts. Nevertheless, bold, curiosity and the desire to make something
better to our patients are human features that must not change over the years.
SUMMARY
Chapter 1
Prosthetically-driven alveolar reconstructions – the next step.................................................................. 16
Luiz Roberto Figueiredo Dantas, Mario Groisman, Guaracilei Maciel Vidigal Junior
Chapter 2
Challenges on the immediate implant-supported rehabilitation in the esthetic zone ................................. 32
Elken Gomes Rivaldo, Luis Carlos da Fontoura Frasca
Chapter 3
Soft tissue conditioning with esthetic implants: technique and scientific aspects ..................................... 50
Carlos dos Reis Pereira de Araujo, Maria Angélica Rehder de Araujo, Fernanda Herrera Stancari
Chapter 4
A protocol to preserve the alveolar architecture for different biotypes using the granulation tissue ............ 70
José Geraldo Malaguti, Franco Ignáccio Malaguti
Chapter 5
The subcrestal positioning for implant-supported restorations ................................................................ 86
Valdir Antônio Muglia, Arthur Belém Novaes Júnior
Chapter 6
Regenerative, therapeutic, and restorative delicate decisions: when the days are not enough ............... 114
Paulo Martins Ferreira, Felipe Ramalho Ferreira, Gabriel Ramalho Ferreira, Renato Oliveira Ferreira da Silva, Paulo Henrique Orlato
Rossetti, Wellington Cardoso Bonachela, Eduardo Batitucci, Luiz Fernando Pegoraro, Rubens Florino Pandolfi (in memoriam)
Chapter 7
Treatment of peri-implantitis using L-PRF and Er, Cr:YSGG laser in the esthetic zone: longitudinal aspects...146
Jamil Awad Shibli, Alberto Blay, Samy Tunchel, Leandro Roth, Gustavo Nardegam, Alessandra Cassoni, José Augusto Rodrigues
Chapter 8
Dental implant rehabilitation in the anterior esthetic zone: an approach to success ................................ 166
Juliano Milanezi de Almeida, Alvaro Francisco Bosco, Edgard Franco Moraes Jr., Letícia Helena Theodoro, Valdir Gouveia Garcia
Chapter 9
Reconstructive methods in the severely atrophic maxillary arch: clinical and scientific backgrounds ....... 180
Samuel Porfírio Xavier, Antonio Azoubel Antunes, Cássio de Barros Pontes, Luiz Antonio Salata
Chapter 10
The implant-supported restorative dentistry: foundations, technology, and communication .................... 200
Franco Rocha Villela
Chapter 11
Correction of large defects in the esthetic zone: why a multidisciplinary approach is mandatory? ........... 220
Laércio Wonhrath Vasconcelos, Paulo Fukashi Yamaguti, Daniel Afonso Hiramatsu, Rafael Calçada Bastos Vasconcelos