Implant Seminars

Live Surgery

Dr. Arun Garg – June 27, 2009

Ramus (Autogenous… not autologous) Block Graft Exposure

After 5 months expose

Vertical releases, midcrestal incisions

Remove screws from bloc

Osteotomy for implant placement

Place implants

Horizontal mattress sutures

Square knot

3 knots, the last one, switch your hands’ directions

Marcaine at the end ½ carpule each site

5 minutes of pressure

Scrubbing In

Sterile technique

Salvin: offers scrub packs and JBlocks

Scrub in up to elbows

Chlorhexidine pre-op rinse and irrigation

Sterile gloves

J-block with BMP

Infiltration with lido w/1:100,000

Midcrestal incision with vertical releases 1 tooth over

Release all muscle apically

Use Piezo to clean off soft tissue from bone

To Decorticate

And to create inlay site

Try-in J-Block

Modify shape of J-Block to fit inlay site

BMP Mixed up

Place JBlock in BMP

Screw has to engage 5mm of natural bone for retention

Screw in J-Block, place bone and BMP collatape pieces

Suture with horizontal mattress

No Peridex 1^st week

Use Augmentin 875 or Clindamycin 300

Grafts are JUST SCAFFOLDS

If infxn: Augmentin 500 tid 10 days start day before sx, Flagyl 375 tid 10 days

FEES

Unilateral 1 tooth 3200

Bilateral 1 tooth 3800

Unilateral 2-3 teeth 4200

Bilateral 2-3 teeth 4800

Unilateral Edentulous 5800

Bilateral Edentulous 7800

I’m in the process of getting my table ordered!

Implant Seminars

Live Surgery

Dr. Arun Garg – June 26, 2009

Psychological Sedation

Garg uses an eye mask as eye pillow

PRP

BTI $5000 – Centrifuge $1000 and Packs $10-15

Harvest $6000 – Centrifuge $3000 and Packs $100

ACE $2000

CT Planning Software

Blue Sky Bio – Now available for no cost

Bone

Osteolife Biomedical: $80/bottle

50-250 microns – Best bone comes out of it

300-500 microns – Good

800-1200 microns

1000-2000 microns (1-2mm) Most difficult to condense and worst to heal, but easiest to handle

WANT MINERALIZED BONE

Dynablast is poorly demineralized

Osteoblast is half mineralized/half demineralized

Autogenous Bone in a Bottle

BMP – $850 per bottle

Wait 6-7 months

There will be a LOT of post-op swelling but no pain

Due to influx of millions of cells from BMP’s signals

1 week of swelling

BMP lasts 3 days

Maxillary Sinus Lift

Window

Superior line: 15mm

Inferior line: Ridge plus 3mm

Aseptico 1:1 Straight handpiece for Sinus Lift osteotomy

Piezo to finalize the window

Elevate sinus SLOWLY

Gauze soaked with 1:50,000 epi for hemostasis

Osteolife small particle mixed with salin

Use Cut off syringe to place bone

Use island of bone for coverage

Then cover Collatape with saline

Dental Health Products

Vicryl Type of suture

Made by LOOK

Close with horizontal mattress

½ carpule: Marcaine at the end for discomfort

Implant Placement

Midcrestal incisions

Primary closure with Vicryl

Note: Use sinus elevators as adjunct for reflection

Stage 2

Steal tissue from palate

Create papillae with palatal tissue

Papilla suture 5-0 needs to be fine

Vertical mattress suture

Flap sutures should be 3-0

Note: Use sinus elevators as adjunct for reflection

Sutures

Gut is good for vertical releases

Vicryl is good for crestal incisions

1 Wall Defect – Maxilla

Open flap, past muco-gingival jxn

Remove all soft tissue on the bone with Piezo

Mix water and BMP particulate

Impregnate collatape with BMP – 15 minutes

BMP binds to collagen

Then put BMP on bone

Place bone, pieces of BMP in collatape

Primary closure with horizontal mattress

Note: Use sinus elevators as adjunct for reflection

Heal time 8 months

Atraumatic Extraction& Socket Preservation

Raise a flap

Vertical releasing incisions

Make sure you pass the muco-gingival jxn

Release the flap so that you can get primary closure after ext and bone graft

Note: Use sinus elevators as adjunct for reflection

Piezo for creating PDL space on an ankylosed tooth

Atraumatic ext

Decorticate socket with Piezo and High speed #8 round diamond

Graft site with small particle with saline

Primary closure with 4-0 vicryl

Close the vertical releasing incisions with either the vicryl or gut

Heal time after bone graft

Molars: 16 weeks

Canines: 12 weeks

Premolars: 10 weeks

Upper centrals: 8 weeks

Lower Incisors & Upper laterals: 6 weeks

Implant Length

Length

Molar – 15mm

Canine – 13mm

Premolar – 11mm

Upper Central – 9 mm

Upper laterals and lower incisors – 7mm

Ridge Split

Raise a flap

Vertical releasing incisions

Make sure you pass the muco-gingival jxn

Release the flap so that you can get primary closure after ext and bone graft

Make it split thickness when it is apical to MGJ

Want to release muscle attachment

Note: Use sinus elevators as adjunct for reflection

Must use a Piezo for ridge split

NO OTHER OPTION

8mm vertical saw blade on Piezo

2 vertical cuts just through the cortical bone

Need at least a 3mm ridge to do this

Basically cutting bone on 3 walls, but maintaining bone at apex

Use ridge split kit to widen ridge

Place tapered implant

Posterior Mandible ridge thickening

Few options:

Ramus block

Chin block

J Block

Ridge split

BEST OPTION

Implant Seminars

Esthetic Outcomes in Implant Dentistry

Dr. David Garber – May 9, 2009

Sinus Lift

Use Metronidazole (Flagyl) in the sinus

Chin Block

Simplant will fabricate a Stereolithographic model out of the DICOM

If you want a LARGE bone block graft, you go through the mandible with Pieso through and through – bicortical cut

Fit the bone to the model, drill through

Vestibule goes back to normal within 2 years

Terminology

EFFICACIOUS – Defined as the probability of benefit of a tx when provided under ordinary conditions by the avg practitioner for the typical pt

He wants to give guidelines to think it though

Multiple Missing Teeth within the Esthetic Zone

Pts don’t come in for implants, they come in for: Esthetics, function, and normalcy

When missing centrals and Laterals, you lose bone buccally, palatally

Lose the arch form

Need to do narrower teeth, placed more lingually

Often times end up with LONG, skinny teeth with BROAD, LONG contacts

They end up being very rectangular teeth

The incisal edge starts to change cervically and lingually

The zenith changes from distal to slightly mesial

Get shortening of the perimeter of the ridge

Lip collapses

Showed us a case with 3 crowns and 3 implants

Difficult to maintain papillae between 2 implants

In retrospect: Instead of 3 in a row, do 2 with a pontic

BIG anterior defect around 3 implants

Salama, Garber 1995 JED: Use 3mm healing abutment with LOTS of CT graft over it acts like tent (The longer the tent pole, the more tissue you get)

Use ovate pontics to develop the site

Bone sounding IHB to visualize

PUT THE MIDDLE implant to sleep, don’t yank it!!!

Just don’t use it

Make sure you look at the entire arch: look for any need for tissue treatment

Crown lengthening?

Essex retainers are excellent for temps

Don’t do a flipper

Vertical bone is MUCH harder to rebuild than horizontal bone

Can get horizontal bone very predictably

Bone between implants and teeth

Esposito 1992: 1.5mm tooth to implant interproximal

Tarnow 2000: 3mm implant to implant

Avg: 3.4mm height of a papilla between 2 implants

That’s an average… 30% will have less than 3mm of papillary height

At centrals… you may want to consider platform switching to maintain the bone

Novaes (Bazilain): Shows that bone comes up between implants when they are 3mm apart, NEVER less than 3mm

Abutment/Implant Junction Inflammatory Cell Tissue Infiltrate (ICT)

2mm down and 1mm outward: Ericsson

Staging

If you have 2 centrals that need to be removed

Take 1 out and pace 1 implant, wait for healing

Then do the next a couple of months later

Platform Switching

Palotrisi: Platform switching

If you have platform switching, you need at least 1mm difference

Protect the developed site

ZEKRYA: Gingival retraction during prepping to save the meat

Trisi Vris: 2 pice platform switching makes a HUGE difference, but 1 piece does NOT

2 or 3 Implants

Do 2 instead of 3 in a row: you will have papillary loss

SOFT TISSUE HARVEST

Go from mesial of 1^st molar distal of canine

1^st Cut 15C is right angle all the way down to bone

2^nd cut 15C is parallel to palate

4-0 silk in X Form

Use 15C blade

Tunneling technique protects the gingiva

If you can’t get coverage, you must use autogenous CT

If you can’t harvest enough tissue, start using dermis

NOTE TO SELF: JOIN AGD, DOCS

Endodontically treated teeth

Can cut them at the gingiva or sub-G and cover it with CT to help MAINTAIN bone

JUST cover it up and put it to sleep

Notched teeth (V-Shaped)

USE GLASS IONOMER: Shofu (no hybrid)

THEN place C or dermis

Management of Fully Edentuous site

Can use his existing denture

Cover with Barium, take a CT

Drill thru the denture

Block it with Barricade (DENTSPLY) – It’s actually a periodontal dressing

For screw access holes

Punch holes on rubber dam

Reline with locators

The zone in the fully edentulous case

SURGICALLY GUIDED stents and model

Place 6 implants, parallel, and make a denture with gold copings

Titanium screw retained substructure

Surgically guided stent

Make titanium substructure

Pink composite

Use Panavia to cement the crowns

Severe Periodontal Disease

Upper, save whatever you can by splinting for now, 1^st visit: PUT IN LOTS OF BONE

1^st Visit: Temp supported by 5 teeth

2^nd Visit: Then a few months later, place 6 implants

3^rd Visit: 6 more fixtures into ext sites

Lower: Keep 3 teeth to maintain inter-arch relationships

2^nd Visit: Get bite relationships

2^nd Visit: EXT all except 3 at first, do a pick up temp denture on all but 3 implants

Screw retained hybrid

2^nd Visit: Place 8 fixtures, do a lower hybrid

3^rd Visit: Finalize and do cermic/metal

For immediate loading you can do it on roundhouse

Primary stability – Purely mechanical (Putting a screw into wood: NO biomechanical)

Secondary Stability – Osseointegration: this IS biomechanical

Cumulative Stability – The total stability of primary and secondary combined

Terrible decay on a Failed Roundhouse bridge

Ext 3 remaining uppers, place 12 implants

Cross arch stabilization

This took him 14 hours to do (first time)

Digital Rendering

Use Simplant

Get Atlantis Abutments made

Severe perio, partially edentulous (lot like Mr. DC)

1: Remove severely compromised teeth, make an essex

Essex uses denture teeth

1: Use Essex with Barium Sulfate and take a CT (Could use TempBond)

2: Plan bone grafting

Sinus lifts, bone blocks

Use laser to open up the short vestibule

3: Roughen snapcaps with prophyjet

Make temp and cement with tempbond

Multiple Teeth Missing

Judge needs them ASAP

Use available bone

Ext’s, guide, place implants

Barricaid

Fill into a syringe, place, wipe off excess with alcohol

PRGF

$1000 for unit, less than $14 per use

Papillae

Can partially recreate papillae AS AN ALTERNATIVE

Orthodontic extrusion if horizontal bone loss

CANTILEVERS MUST BE SCREW RETAINED

PINK CERAMICS: Christian Coachman

Look for his tough pink ceramic cases, look up Christian Coachman

MAKE SURE YOU HIDE THE SEAM WHERE THE PINK CERAMIC/COMPOSITE INTERFACES WITH GINGIVA AND THE LIPLINE!!!

Pink Ceramic, roughen it, create space for FGM, Etch with Hydrofluoric acid, Cover porcelain, Silanate

Then DIRECT PINK COMPOSITE

Needs to be considered IN ADVANCE!!!

Photography

Draw lines on the pictures!!!

Evaluate gingival margins!!!

Evaluate papillae

Evaluate smile line

Do a diagnostic waxup too!

Use this for Essex