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BB: Do you have a material of choice for grafting? SJ: The most used procedure, which is evidence-based in the literature — and we have been doing this now for 20 years — is the GBR principle, which is the Guided Bone Regeneration principle. This is basically the principle where we use bone grafts based on particulate — some of it is autogenous, which is the gold standard, and some of it could be a biomaterial — and then we cover this with a barrier membrane, which could be resorbable or nonresorbable. This will, first of all, stabilize the bone graft for regeneration purposes and, secondly, exclude the soft tissue and bacteria from invading, so we don’t have a loss of that bone. BB: Another question along the line of bone grafting: If you are going to do a delayed case — say you’re going to extract a tooth and then place an implant later — would you typically graft that socket? SJ: Yes, socket grafting is something that is more of a norm today. So I would always recommend socket grafting to any clinician and to any colleague for sure in the single-rooted teeth — which basically means everything that is toward the anterior — because it will prevent collapse of the buccal plate, it will maintain more of the soft tissue, and it will improve the stability of the soft tissue dimension. I would always recommend socket grafting to any clinician and to any colleague for sure in the singlerooted teeth. Socket grafting is a very successful procedure, and various materials work. It could be a biomaterial; it could be a growth factor; it could be an autogenous bone graft. But, important as always, the extraction socket needs to be clean. The infection, which often was there with the tooth, needs to be cleaned out. So, sometimes you need to spend more time on extraction and cleaning it out than just on a grafting procedure. That’s very important because, unfortunately, I’ve seen a lot of socket grafting which came back, and the material is just laying around, and it didn’t do anything. So that is not a good idea. BB: Once you’ve cleaned out the socket and you’ve grafted, what do you typically like to cover it up with? SJ: Socket grafting, as you know, has different options. The first option, which of course most of us will look at, is to use a barrier membrane. This can be either a nonresorbable material — today there’s the dense PTFE material — or we can use a resorbable material. Then there are also some new materials. We have collagen grafts, which are thicker; they have a thickness of about 5 mm. These help us to, first of all, stabilize the soft tissue and the bone graft, and they also allow the soft tissue to creep in. And then we have a procedure that is called socket seal surgery. Socket seal surgery is a procedure that has been around for a long time. Cobi Landsberg published something on this, quite nicely, and he’s using a free gingival graft to stabilize the bone graft and the soft tissue. BB: We’ve talked a lot about hard tissue grafting. What’s the benefit of soft tissue grafting in implant cases? SJ: What you are focusing on, Brad, is really soft tissue esthetics and health. But you can see that there are a lot of things which are happening to soft tissue before we really get to it, when we are talking about bones, implants, abutments, etc. Why soft tissue grafting? Soft tissue grafting is important because whenever we remove teeth, or whenever we lose teeth, soft tissue dimension shrinks. So, we often go from gingival thickness to something thin. And implants, they don’t have that stability like a tooth has. What we try to do with soft tissue grafting is to actually increase the thickness. So we create a new gingival biotype, which is thicker. And what does that do? This could prevent recession again, improve esthetics because we won’t have that metal shadowing through, and give a more natural look. So it is resistance to recession, resistance to bone loss because the biological width is more stable, and also it gives better soft tissue esthetics and health. BB: Over the last couple of years, there have been a lot of lectures on connective tissue grafting, particularly in the esthetic zone. What’s coming across is that labial bone loss is inevitable, no matter what you do. Have you found that to be the case? And then do you have to use connective tissue grafting basically as a cosmetic Band-Aid? Or what’s been your experience as far as maintaining that labial bone? What we try to do with soft tissue grafting is to actually increase the thickness. So we create a new gingival biotype, which is thicker. 22 – www.inclusivemagazine.com –
SJ: Connective tissue grafting leads into or follows up on the question you just asked. Let me refer to a very nice study that we published in 2009, where we looked at vertical bone augmentation using the GBR principle. And what we saw there, when we did a combo — a bone graft and a connective tissue graft — is that we always had better crestal bone stability. So, you have to think about it. Soft tissue is very delicate, so when you don’t have enough soft tissue, bone has a tendency to shrink more, to lose a little bit more. What connective tissue does is it, first of all, thickens the soft tissue. It prevents bone from losing too much, so it kind of keeps it in a healthy range. And, of course, it improves again the end outcome, which is esthetics and health. BB: Very good. Then, for a final question, is a temporary restoration required for controlling the final soft tissue esthetics? SJ: Yes, absolutely. This is a tough one because, obviously, a lot of patients want to have a final restoration as fast as possible. I always say to my patients that a temporary is like a prototype. We need to shape and support the soft tissues in such a way that we know that they’re stable. We don’t want to have a situation where we now see recession. So, potentially, we have a final crown in place and the tissues are not there yet, the gingival papilla is not there yet, and then we have recession again. BB: To start wrapping things up, first I’d like to thank you for taking the time to talk with me. We went through a lot in a short period. If there are clinicians reading this who want to get more education and training on different types of hard and soft tissue grafting and esthetics, what would you recommend? SJ: Well, our field is full of needs for training and education. This is a great field. I’m very passionate about it. I love this area and have been involved in it, thankfully, for more than 20 years. If you want to get more involved with this and get more training in soft tissue grafting, choose the right partners for you. It could be one mentor whom you trust, it could be an institute that you trust, it could be a university, or it could be a mix of each. But go through training and education as much as you can. Think about it like this: For us, what’s most important is how much experience you have. Then of course there’s skill. What’s your skill level? Skill can improve and experience can improve. So, go for it; find the right partner and learn as much as you can. I’m still learning every single day. We need to shape and support the soft tissues in such a way that we know that they’re stable. So I would urge every single patient, especially in the esthetic zone, to go through a temporary phase. And, again, the same thing for the clinician; we need to have something which gives us a better result. And the better result definitely is there when we first do a prototype, create the abutment correctly, create the emergence correctly, and then let the soft tissue flow in. And this soft tissue growth and stabilization around abutments and around temporaries could go for more than 12 months. So make sure that you leave the spaces in. Make sure that you have the abrasion spaces into which soft tissues can flow. And don’t worry about the black triangles right then because we have the potential to regenerate soft tissues interproximally between 3 mm to 5 mm. But you have to give it time to fill in, and that’s the temporary phase. – Implant Q&A: An Interview with Dr. Sascha Jovanovic – 23
Page 1 and 2: Inclusive® Restorative Driven Impl
Page 3: Contents ALSO IN THIS ISSUE 32 Clin
Page 6 and 7: Publisher Jim Glidewell, CDT Editor
Page 8 and 9: CAD/CAM Technology in Implant Abutm
Page 10 and 11: So is the best transgingival design
Page 12 and 13: ■ Posterior Case Example Figure 7
Page 14: Chairside Processing of LOCATOR ®
Page 17 and 18: Figure 1: Pre-endodontic treatment
Page 19 and 20: Figure 6: CBCT saggital image taken
Page 21 and 22: Dr. Bradley Bockhorst: Before we ge
Page 23: need a minimum of 3 mm to 4 mm, whi
Page 27 and 28: Three-Dimensional Treatment Plannin
Page 29 and 30: The accuracy of each surgical guide
Page 31 and 32: Cook-Waite Lidocaine ® HCI 2% and
Page 33 and 34: with the O-ring Housings built in.
Page 35 and 36: Figure 3a: Smile line without prost
Page 37 and 38: www.glidewellce.com
Page 39 and 40: GLIDEWELL INTERNATIONAL TECHNOLOGY
Page 41 and 42: Date Course Name Instructor Course
Page 43 and 44: Discussion Figure 3: Natural facial
Page 45 and 46: Removable dentures should provide o
Page 47: SOFT PMMA Clusters BOLD YOUTHFUL UN
Page 50 and 51: or her restoration on an interim ba
Page 52: CASE 2 The following case depicts a
Page 55 and 56: Many people are unaware of the rela
Page 57 and 58: were used to visualize tooth positi
Page 59 and 60: Figure 12: Severely resorbed mandib
Page 61 and 62: Figure 19: Facial photograph of our

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