Dr. Paul Petrungaro – April 18, 2009

Implant Seminars
Anterior Tooth Replacement, High Aesthetic Demand
Dr. Paul Petrungaro – April 18, 2009

List of what to look for
· Edentulous Site
· Suturing
· Sinus Block
· Posteriors
· Temp stent
Overview of Last Case Yesterday
· Start with diagnostic waxup
· Silicone Bite Index
· Atraumatic tooth removal
· Debridement
· Use implant
· Large particle graft with heavy condensation
· Place abutment, make temp with index
· 3 months later, restore
Edentulous Site
· Make sure that there is no frenum pull – Likely need frenectomy before working
o Use Laser
o Use periosteal tacks if concerned with retraction
· Carve out the tissue using a tempstent
o Use #8 round bur through tempstent
o Create the extraction socket using a football bur
o Create the biological width in the bone
· Create a facial pouch with a elevator = Go EASY
o Need to remove periosteum
· Place Implant
· For adjacent recession
o Create puch for dermis
o Scale and root plane surface
o Citric acid pH1 for 1 minute
· Place cover screw and Place bone graft with PRP: heavy condensation
· Place abutment, then reline tempstent with coping
· Cement temp with tempbond clear
· Place DERMIS on buccal of #8,9
o Tack it in with 6-0 polypropylene
· Use sling sutures
o Kenneth Krebs (AAP Periodontist who was AMAZING with sutures)
· USE A BLOCK if the implant can’t go in
· Make sure you evaluate the papillae AND the adjacent teeth including CONTACT points, angulation and rotation of adjacent teeth
TEMP STENT: Lab - Edgar
· Needs a study model
· He virtually extracts the tooth
· He brings the tissue down or up with WAX
o Creates the emergence profile
o Look at line angles and buccal contours
· Fabricate the temp, make a hole on lingual for surgical guide
· Create a vacuum form over the temp, but the temp needs to have some undercut to lock in the temporary into the vacuum form
o Remove all undercuts on adjacent teeth
o 1mm thickness vacuum form
Multiple Units with Temp Stent
· For multiple units, need a lot more info
· Models, Bite, Bitestick/Facebow
Congenitally missing Laterals
· For small spaces, use 1 piece implants
· Need at least 5.5mm between teeth for an implant
· Place, graft bone with pouch, make temp
Sinus Lift
· Palatal crestal incision (not mid-crestal) internal bevel incision (the cut is toward palate) and the release is distal line angle of tooth anterior to sinus
· Use #8 round diamond and do the osteotomy until its purple
· If you get a bleeder, clamp the bone
· To control bleeding in sinus, use Gauze with Xylocaine with 1:50,000 Epi
· Go from the distal on the floor with dull instruments and then zip it up
· Regenoform bone
· Place membrane in sinus whether or not you have a tear
· Slits in corners of membrane
· Pack in bone
o If you ever have an infection in the sinus graft and it doesn’t heal in 7 days, you have to REMOVE the graft, debride, close, heal (at least for 3 months)
o Purulence, pain, swelling under the eye
· Place implants, build out buccals with bone graft
· Fabricate temporary bridge, cement it, suture flap toward the bridge
· If nose bleed occurs, watch out for profuse
o If profuse – Arterial… go to hospital
o If very light, 1:50,000 xylocaine on gauze 10 minutes
Internal Socket Lift
· Section tooth at CEJ
· Trifurcate or bifurcate the teeth
· Debride the defects
· #8 round diamond
· Osteotomes to elevate sinus only 3-4mm up
· Place implant
· Healing cap, Bone graft in defect, suture closed
Tunnel Graft
· Can use Alloderm or Dermis
· Shiny side to tissue
· Width never more than 8mm (top to bottom)
· Root planning of surface
· Diamond to level off root
· Burnish roots over and over
· EDTA or citric acid for 1 minute
· Activate with PRP without thrombin
· ½ Orban Knife between cervical to cervical subpapillary
· Slide through the Alloderm
o Tack in all of the mesials and loop through the palatal under the papillae, then pass thru the distals and tie it on the anterior with 6-0 polypropylene (Biohotizons)
o Then do interrupted slings with 5-0 monocryl
o Do a periosteal tack with 4-0 vicryl in the vestibule

Puros Block Grafting
· Advantages:
o No need for secondary surgical site
o No donor site morbidity
o Decrease resorption of cortical plate
o Ample supply
o Osteoconductive
· Disadvantages
o Technique sensitive procedure
o Additional cost (Block $700-900) (Pericardium $400)
o Requires use of a regenerative membrane (Pericardial tissue)
o Must have adequate keratinized tissue prior to placement
§ MUST HAVE PRIMARY CLOSURE – IT WILL FAIL IF IT OPENS
o Posterior mandible requires highly proficient block grafting system (DON’T DO POSTERIOR MANDIBLE)
· Human corticocancellous bone
· Must be aggressive with blocks
· Must advance the flap 2 teeth each way with releasing incisions
· Must OVERBUILD due to chance of sequestra at cortical walls
· Must do deep inlay prep in bone
· Must adjust the block
· Use #8 round bur to countersink the screw
· If the wound opens in the first 30 days, you will not get epithelial migration and you will get failure
· Horizontal mattress first and vertical sling next
· Wait 5 months
· 5 months later, remove screws, REMOVE CORTICAL plate, place implant and temp