LEVEL I - April 2018 Handout...18. Technical troubleshooting 19. Implant maintenance protocols 20....
Transcript of LEVEL I - April 2018 Handout...18. Technical troubleshooting 19. Implant maintenance protocols 20....
ESSENTIALS OF IMPLANTOLOGY AND CBCT-GUIDED IMPLANT SURGERY: LEVEL I
JAY B. REZNICK, D.M.D., M.D. DIPLOMATE, AMERICAN BOARD OF ORAL AND MAXILLOFACIAL SURGERY
TARZANA, CA
UNDERSTANDINGTHE TECHNICIAN UNDERSTANDS “THE HOW”
THE DOCTOR ALSO UNDERSTANDS! “THE WHY ! THE WHY NOT!
AND THE WHAT IF!”"2
THOUGHT FOR THE DAY…“FAMILIARITY IS THE KEY TO SUCCESS”
- GERRY RODRIGUES
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TO DO SURGERY?•WHAT IS YOUR EXPERIENCE/ COMFORT LEVEL •“HASSLE FACTOR” •30 - 60 MINUTE TIME LIMIT •DEALING WITH COMPLICATIONS
-Backup
•GP DOING SURGERY IS HELD TO THE SAME STANDARD OF CARE AS A SPECIALIST
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TO DO SURGERY?•JUST BECAUSE YOU HAVE AN IMPLANT SURGERY KIT, THAT DOESN’T MEAN YOU SHOULD NOT REFER THE PATIENT. •EVERYTHING YOU DO IN YOUR OFFICE SHOULD BE A “PRACTICE BUILDER” •REFERRING THE PATIENT TO THE RIGHT SPECIALIST MAKES YOU LOOK GREAT TO THE PATIENT •STAY WITHIN YOUR TRAINING, EXPERIENCE AND COMFORT ZONE!
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STRATEGY “THINK LIKE A SURGEON”•MENTALLY VISUALIZE THE PROCEDURE FROM START TO FINISH •ANTICIPATE WHAT INSTRUMENTS WILL BE NEEDED, AND HAVE THEM READY/ READILY AVAILABLE •ANTICIPATE COMPLICATIONS •HEADLIGHT, LOUPES •“MEASURE TWICE, CUT ONCE”
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ESSENTIALS OF IMPLANTOLOGY - LEVEL I
1. Principles of bone type/soft tissue type/ biologic width
2. Medical considerations for the implant surgical patient
3. Atraumatic extraction and ridge preservation grafting
4. Anatomical considerations in implant planning – why CBCT is standard of care
5. Planning your first (25) cases: 1st PM - 1st M, flapless, good ridge/ principles/rules of ideal implant planning
6. Concepts of implant length 7. Consultation appointment, incl. informed consent 8. Introduction to the Astra Tech EV system 9. Prepping the patient for surgery 10. Surgical suite set-up: draping/ handpiece 11. Principles of freehand implant surgery
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OUR AGENDA
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
12. ITV vs ISQ 13. Astra Tech EV-S surgical kit and drilling sequence 14. Healing abutment vs. cover screw 15. Post-op care 16. Avoiding, recognizing and managing complications 17. Peri-implant disease 18. Technical troubleshooting 19. Implant maintenance protocols 20. Hands-on with the Astra Tech EV (freehand) kit
21. Introduction to Astra Tech EV conical and profile implants
22. CBCT work-up, planning / work flow/ finalizing plan 23. EV 5.4 implant placement 24. Hands-on with the EV Guided kit 25. Guided surgery trouble shooting 26. Case planning exercises 27. Closing thoughts
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OUR AGENDA
IMPLANTOLOGY FUNDAMENTALS
•BONE •SOFT TISSUE
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RIDGE CLASSIFICATION•BRANEMARK’S CLASSIFICATION OF RIDGE SHAPE BASED ON AMOUNT OF RESORPTION •LINE-- DEMARCATES ALVEOLAR/ BASAL BONE
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BONE QUALITY CLASSIFICATIONBRANEMARK’S CLASSIFICATION, BASED ON RATIO OF CORTICAL AND CANCELLOUS BONE AND MEDULLARY DENSITY
VASCULARITY DENSITY
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IN ADDITION TO GOOD QUALITY BONE, WE ALSO NEED
•SUFFICIENT BONE VOLUME
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INSUFFICIENT BONE VOLUMEINADEQUATE BONE WIDTH
4 -0.4 mm 5 0 mm
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INSUFFICIENT BONE VOLUME• INADEQUATE BONE HEIGHT • INADEQUATE BONE WIDTH
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HOW MUCH BONE DO WE NEED SURROUNDING AN IMPLANT FIXTURE?BLOOD SUPPLY TO ALVEOLAR BONE COMES FROM: •Periosteum •Periodontal ligament
"16• Qahash M, et al. Bone healing dynamics at buccal peri-implant sites. Clin Oral Implants Res. 2008 Feb;19(2):166-72. • Spray JR et al. The influence of bone thickness of facial bone response: stage 1 placement through stage 2 uncovering. Ann
Periodontal 5(1): 119-128, 2000
HOW MUCH BONE DO WE NEED SURROUNDING AN IMPLANT FIXTURE?INADEQUATE BONE THICKNESS LEADS TO RESORPTION DUE TO COMPROMISED BLOOD SUPPLY •2 mm buccal (facial) •2 mm lingual (palatal)
"17• Qahash M, et al. Bone healing dynamics at buccal peri-implant sites. Clin Oral Implants Res. 2008 Feb;19(2):166-72. • Spray JR et al. The influence of bone thickness of facial bone response: stage 1 placement through stage 2 uncovering. Ann
Periodontal 5(1): 119-128, 2000
TISSUE CONSIDERATIONS
•TISSUE BIOTYPE •BIOLOGIC WIDTH
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SOFT TISSUE BIOTYPES•THICK !FLAT BONY ARCHITECTURE !DENSE, FIBROTIC SOFT TISSUE !LARGE AMOUNT OF ATTACHED GINGIVA !PRONE TO POCKET FORMATION •THIN !SCALLOPED BONY ARCHITECTURE !DELICATE, FRIABLE SOFT TISSUE !THIN ATTACHED GINGIVA !PRONE TO GINGIVAL RECESSION
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SOFT TISSUE BIOTYPES•THICK •MINIMAL RIDGE ATROPHY •BONE/GINGIVAL CONTOURS MORE PREDICTABLE •THIN •APICAL/LINGUAL RIDGE RESORPTION •BONE/GINGIVAL HEALING LESS PREDICTABLE
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SOFT TISSUE BIOTYPES - SO WHAT?•THICK
RIDGE MAY NOT NEED PRESERVATION GRAFT IMMEDIATE IMPLANTS MORE PREDICTABLE •THIN
ATRAUMATIC EXTRACTION/ RIDGE PRESERVATION ESSENTIAL IMMEDIATE IMPLANTS LESS PREDICTABLE
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BIOLOGIC WIDTH• MINIMUM DIMENSION OF SOUND TOOTH
STRUCTURE BETWEEN THE RESTORATIVE MARGIN AND THE ALVEOLAR CREST.
• ACCOMMODATES THE CONNECTIVE TISSUE AND EPITHELIAL ATTACHMENT
• INADEQUATE BIOLOGIC WIDTH RESULTS IN INFLAMMATION
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VIOLATION OF BIOLOGIC WIDTH
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BIOLOGIC WIDTHBiologic Width of Natural Tooth
1-2 mm Sulcus
1 mm Epithelial Attachment
1 mm Supra-Crestal Connective Tissue
Tissue Level at Placement
Biologic Width Established
Sulcus
Epithelial Attachment
Supra-Crestal Connective Tissue
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KERATINIZED GINGIVA (KG)•BIOLOGIC WIDTH = CONNECTIVE TISSUE (1MM) + JUNCTIONAL EPITHELIUM (0.5 - 1.5MM) + SULCUS DEPTH •
CTJES
BW
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1-2 mm
0.5 - 1 mm
1 mm
VIOLATION OF BIOLOGIC WIDTH
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KERATINIZED GINGIVA REQUIREMENTS•SIGNIFICANCE FOR DENTAL IMPLANTS: •THERE MUST BE A SUFFICIENT WIDTH AND THICKNESS OF KERATINIZED TISSUE AROUND AN IMPLANT. •THIS VARIES FROM TOOTH TO TOOTH, BUT ABOUT 2MM IS A GOOD RULE OF THUMB.
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ESSENTIALS OF IMPLANTOLOGY - LEVEL I
“Since I have a CBCT-based surgical guide, does that mean that I can place the implant without a flap (tissue punch)?”
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IF YOU HAVE ENOUGH…•BONE •ATTACHED GINGIVA
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SPACING/ POSITION ISSUES•IDEALLY- - Parallel to adjacent teeth - Equally spaced between adjacent teeth - Aligned with occlusal tables of adjacent
teeth
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HOW FAR APICALLY SHOULD THE CONTACT BE PLACED TO ENSURE COMPLETE FILL OF THE INTERDENTAL PAPILLA?• TARNOW DP, MAGNER AW, FLETCHER P: THE EFFECT OF DISTANCE FROM THE CONTACT POINT TO
THE CREST OF BONE ON THE PRESENCE OR ABSENCE OF THE INTERDENTAL PAPILLA. J PERIODONTOLOGY 1992; 63: 995-996
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TARNOW 1992
•Contact points closer to bone crest are more predictable, but tooth form will look more square
DISTANCE IN MM FROM CONTACT POINT TO CREST TO BONE(N)3
(2)4
(11)5
(73)6
(112)7
(63)8
(21)9
(4)10 (2)
Papilla Present 2 11 72 63 17 2 1 0
Papilla Not Present 0 0 1 49 46 19 3 2
% Present 100 100 98 56 27 10 25 0
% Not Present 0 0 2 44 73 90 75 100
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SALAMA 1998
NOT BASED ON “PLATFORM-SWITCHED” IMPLANTS
Salama et al classification of predicted height of interdental papillae
Class Restorative Environment
Proximity Limitations
Vertical soft Tissue Limitations
1 Tooth-Tooth 1.0 mm 5.0 mm
2 Tooth-Pontic N/A 6.5 mm
3 Pontic-Pontic N/A 6.0 mm4 Tooth-Implant 1.5 mm 4.5 mm
5 Implant-Pontic N/A 5.5 mm
6 Implant-Implant 3.0 mm 3.5 mm
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MAINTENANCE OF INTERDENTAL PAPILLAE•THE MAXIMUM DISTANCE BETWEEN THE CRESTAL BONE AND THE CONTACT POINT SHOULD BE 4-5 MM IN ORDER TO MAINTAIN THE INTERDENTAL PAPILLAE FILLING THE EMBRASURE SPACE.
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DISTANCE BETWEEN IMPLANTS
•TARNOW 2003 CLINICAL PERIODONTOLOGY, 11 ED."36
IMPLANT SPACING GUIDELINES
• TARNOW DP, ET AL: THE EFFECT OF INTER-IMPLANT DISTANCE ON THE HEIGHT OF INTER-IMPLANT BONE CREST. J PERIODONTOLOGY 2000; 71:546-54
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PLATFORM SWITCHING•CRESTAL BONE LOSS (1-2MM) HAS LONG BEEN ASSOCIATED WITH DENTAL IMPLANTS, ESPECIALLY WITH SMOOTH NECKS. •BONE LEVEL USUALLY RESORBS TO LEVEL OF ROUGH SURFACE. •“BIOLOGIC SEAL” FORMS AROUND NECK OF IMPLANT (1.0-1.5MM JE, 1.5-2.0MM CT). CANULLO ET AL. 2011
•IMPLANT HEAD PLACED AT CREST WILL ESTABLISH BIOLOGIC WIDTH.
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PLATFORM SWITCHING•USE OF AN ABUTMENT THAT IS NARROWER THAN THE IMPLANT FIXTURE. •DOES NOT REDUCE “MICROGAP”, BUT ALLOW TISSUE TO ATTACH TO THE ABUTMENT-IMPLANT INTERFACE AND FORMS A SEAL.
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PLATFORM SWITCHING
PLATFORM-MATCHED
Apical view from Long Axis of Implant Note: The Inflammatory Connective Tissue (ICT) Infiltration
Apical view from Long Axis of Implant Note: ICT Does Not Infiltrate Beyond Platform Dimension
PLATFORM-SWITCHED
Degidi et al. 2008 Luongo et al. 2008"40
PLATFORM SWITCHING CAN REDUCE CRESTAL BONE LOSS AND CAN SERVE AS A "MECHANICAL RETENTION FACTOR" FOR PERIODONTAL FIBER ORIENTATION
•RODRÍGUEZ X ET AL. EFFECT OF PLATFORM SWITCHING ON COLLAGEN FIBER ORIENTATION AND BONE RESORPTION AROUND DENTAL IMPLANTS: A
Schematic drawing of the fiber orientations around NPS and PS implants. (Left) On NPS implants, the first implant thread (edge thread) presents the best chance for circular fiber attachment (retainment). (Right) On PS implants, the best chance for circular fiber attachment (retainment) is at the platform level (edge discrepancy between platform and abutment).
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ESSENTIALS OF IMPLANTOLOGY AND CBCT-GUIDED IMPLANT SURGERY
PLATFORM SWITCHINGCombining a bone-level implant with platform switching and a conical seal connection seems to significantly reduce crestal bone loss.
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IMPLANT CONSULTATION• REVIEW MEDICAL
HISTORY • REVIEW CLINICAL DATA • DISCUSS TREATMENT
OPTIONS • PLAN FOR PROCEDURE
PRE-SURGICAL CONSIDERATIONS•GET A THOROUGH MEDICAL HISTORY •GET A COMPLETE LIST OF MEDICATIONS •PRIOR SURGERY •ALLERGIES
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PRE-SURGICAL EVALUATION•Diabetes - impaired wound healing, infections •Heart conditions - anticoagulants •Cancer treatment - bisphosphonates •Osteoporosis - bisphosphonates •Asthma - inhalers (impaired wound healing) •Smoking - impaired wound healing, infections •Chronic steroid use - impaired wound healing
Be especially aware of:
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MEDICATIONS•HOW DO THEY AFFECT TREATMENT? •WHICH ONES TO STOP •WHICH ONES NOT TO STOP •MODIFICATIONS OF ROUTINE MEDS
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ESSENTIALS OF IMPLANTOLOGY - LEVEL I
SELECTIVE SEROTONIN REUPTAKE INHIBITORS AND THE RISK OF OSSEOINTEGRATED IMPLANT FAILURE! SSRIs: Antidepressant- Prozac, Zoloft, Celexa, Paxil ! SSRIs reduce bone formation and increase risk of fracture !916 implants in 490 patients (94 implants in 51 patients on SSRSs) ! SSRI usage associated with an increased risk of dental implant
failure (10.6% vs. 4.6%) ! Implant diameter <4mm and smoking further increased the risk in
both groups
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WU ET AL- J DENT RES 2014(11) NOV:1054-61
JADA NOVEMBER 2003IT IS NOW RECOMMENDED
THAT PATIENTS BE LEFT ON ANTICOAGULANTS FOR MINOR PROCEDURES IF AT RISK OF THROMBOSIS
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COUMADIN THERAPYFOR MOST DENTAL IMPLANT
PROCEDURES COUMADIN THERAPY CAN USUALLY BE
MAINTAINED, IF INR IS 3.5 OR LESS
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ANTIBIOTIC PROPHYLAXIS GUIDELINES- JOINTS
AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS/AMERICAN DENTAL ASSOCIATION. PREVENTION OF ORTHOPAEDIC IMPLANT INFECTION IN PATIENTS UNDERGOING DENTAL PROCEDURES: EVIDENCE-BASED GUIDELINE AND EVIDENCE REPORT. AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS 2012. HTTP://WWW.AAOS.ORG/RESEARCH/GUIDELINES/PUDP/PUDP_GUIDELINE.PDF
Management of patients with prosthetic joints undergoing dental procedures
Clinical Recommendation:In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection.For patients with a history of complications associated with their joint replacement surgery who are undergoing dental procedures that include gingival manipulation or mucosal incision, prophylactic antibiotics should only be considered after consultation with the patient and orthopedic surgeon.* To assess a patient’s medical status, a complete health history is always recommended when making final decisions regarding the need for antibiotic prophylaxis.
Clinical Reasoning for the Recommendation: • There is evidence that dental procedures are not associated with prosthetic joint implant infections.• There is evidence that antibiotics provided before oral care do not prevent prosthetic joint implant infections.• There are potential harms of antibiotics including risk for anaphylaxis, antibiotic resistance, and opportunistic infections
like Clostridium difficile.• The benefits of antibiotic prophylaxis may not exceed the harms for most patients.• The individual patient’s circumstances and preferences should be considered when deciding whether to prescribe prophylactic
antibiotics prior to dental procedures.
* In cases where antibiotics are deemed necessary, it is most appropriate that the orthopedic surgeon recommend the appropriate antibiotic regimen and when reasonable write the prescription.
Copyright © 2015 American Dental Association. All rights reserved. This page may be used, copied, and distributed for non-commercial purposes without obtaining prior approval from the ADA. Any other use, copying, or distribution, whether in printed or electronic format, is strictly prohibited without the prior written consent of the ADA.
Sollecito T, Abt E, Lockhart P, et al. The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints: Evidence-based clinical practice guideline for dental practitioners — a report of the American Dental Association Council on Scientific Affairs. JADA. 2015;146(1):11-16.
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ANTIBIOTIC PROPHYLAXIS GUIDELINES- IEPATIENT SELECTION •THE CURRENT INFECTIVE ENDOCARDITIS GUIDELINES STATE THAT USE OF PREVENTIVE ANTIBIOTICS BEFORE CERTAIN DENTAL PROCEDURES IS REASONABLE FOR PATIENTS WITH: •PROSTHETIC CARDIAC VALVE OR PROSTHETIC MATERIAL USED FOR CARDIAC VALVE REPAIR •A HISTORY OF INFECTIVE ENDOCARDITIS •A CARDIAC TRANSPLANT THAT DEVELOPS CARDIAC VALVULOPATHY
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ANTIBIOTIC PROPHYLAXIS GUIDELINES- IEA. EXCEPT FOR THE CONDITIONS LISTED BELOW, ANTIBIOTIC PROPHYLAXIS IS NO LONGER RECOMMENDED FOR ANY OTHER FORM OF CONGENITAL HEART DISEASE. Congenital (present from birth) heart disease: •UNREPAIRED CYANOTIC CONGENITAL HEART DISEASE, INCLUDING PALLIATIVE SHUNTS AND CONDUITS •A COMPLETELY REPAIRED CONGENITAL HEART DEFECT WITH PROSTHETIC MATERIAL OR DEVICE, WHETHER PLACED BY SURGERY OR BY CATHETER INTERVENTION, DURING THE FIRST SIX MONTHS AFTER THE PROCEDURE •ANY REPAIRED CONGENITAL HEART DEFECT WITH RESIDUAL DEFECT AT THE SITE OR ADJACENT TO THE SITE OF A PROSTHETIC PATCH OR A PROSTHETIC DEVICE (THAT INHIBITS ENDOTHELIALIZATION)
B. PROPHYLAXIS IS REASONABLE BECAUSE ENDOTHELIALIZATION OF A PROSTHETIC MATERIAL OCCURS WITHIN SIX MONTHS AFTER THE PROCEDURE.
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ANTIBIOTIC PROPHYLAXIS GUIDELINES- IEDENTAL PROCEDURES
PROPHYLAXIS IS RECOMMENDED FOR THE PATIENTS IDENTIFIED
IN THE PREVIOUS SECTION FOR ALL DENTAL PROCEDURES THAT
INVOLVE MANIPULATION OF GINGIVAL TISSUE OR THE PERIAPICAL
REGION OF THE TEETH, OR PERFORATION OF THE ORAL MUCOSA.
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ADDITIONAL CONSIDERATIONS ABOUT INFECTIVE ENDOCARDITIS ANTIBIOTIC PROPHYLAXIS (WHEN INDICATED)
Sometimes patients forget to premedicate before their appointments.
The recommendation is that the antibiotic be given before the
procedure. This is important because it allows the antibiotic to reach
adequate blood levels. However, the guidelines to prevent infective
endocarditis state, “If the dosage of antibiotic is inadvertently not
administered before the procedure, the dosage may be administered
up to 2 hours after the procedure.”"54
ADDITIONAL CONSIDERATIONS ABOUT INFECTIVE ENDOCARDITIS ANTIBIOTIC PROPHYLAXIS (WHEN INDICATED)
Another concern that dentists have expressed involves patients who
require prophylaxis but are already taking antibiotics for another
condition. In these cases, the guidelines for infective endocarditis
recommend that the dentist select an antibiotic from a different class than
the one the patient is already taking. For example, if the patient is taking
amoxicillin, the dentist should select clindamycin, azithromycin or
clarithromycin for prophylaxis."55
HERBAL SUPPLEMENTSMANY OTC HERBAL SUPPLEMENTS INTERACT WITH COMMON MEDICATIONS, FOODS, OR AFFECT NORMAL PHYSIOLOGY
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ESSENTIALS OF IMPLANTOLOGY - LEVEL I
COMMON HERBALS! Coenzyme Q10
- Decreases warfarin effectiveness
! Cranberry - Enhances anticoagulants
! Valerian - May interact with pain medications, muscle relaxants, antidepressants
! St. John’s Wort - Interacts with SSRIs, TCAs, warfarin, OCPs
! Saw Palmetto - Interacts with warfarin to prolong bleeding
! Melatonin - Interacts with benzodiazepines, opiates, muscle relaxants, raise blood sugar
! Fish Oil - Increased bleeding with Plavix, Lovenox, warfarin, ASA
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ESSENTIALS OF IMPLANTOLOGY - LEVEL I
COMMON HERBALS! Ginseng
- Deceases the efficacy of warfarin, affects insulin and hypoglycemics
! Ginkgo Biloba - Affects metabolism in liver, diabetes meds, seizure meds, anticoagulants, decreases antiviral drugs efficacy
! Garlic - Affects ASA, warfarin, Plavix
! Green Tea - May contain Vit. K, interfere with warfarin
! Ginger - Can prolong ASA, warfarin, other blood thinners
! Grapefruit - Decreases CYP450 activity- erythromycin, fentanyl, verapamil, amiodarone, carbamezapine, benzodiazepines, ED
drugs, warfarin. "58
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
MEDICATION-RELATED OSSEONECROSIS OF THE JAWS (MRONJ)
! Formerly BRONJ ! Seen with: • Antiresorptive medications - IV Bisphosphonates - Oral Bisphosphonates - RANK Ligand Inhibitors (denosumab)
• Antiangiogenic medications (Bevacizumab/Avastin)
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
BISPHOSPHONATES
!Decrease bone turnover by inhibiting bone resorption by osteoclasts.
!IV bisphosphonates used in patients with metastatic bone lesions in prostate, lung and breast CA, and multiple myeloma.
!Oral Bisphosphonates are used for reducing the risk of complications of osteoporosis, and for Paget Dz.
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
IV BISPHOSPHONATES
!Aredia (pamidronate) - 2001
!Zometa (zolendronic acid) - 2002
!Decrease pain and hypercalcemia in metastatic bone disease.
!Very potent. Zometa > Aredia
!Administered monthly
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
ORAL BISPHOSPHONATES
!Fosamax (alendronate) - 1995
!Actonel (risedronate)
!Boniva (ibandronate)
!Skelid (tiludronate)
!Didronel (etidronate)
!Given daily – weekly
!About 1/5 - 1/10 as potent as IV
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
RANK LIGAND INHIBITOR
! Denosumab ! Human monoclonal antibody against RANK ligand- inhibits
osteoclastic function • Prolia- SQ q 6 mo for osteoporosis • Xgeva - administered monthly for metastatic bone disease (except
MM) ! Does not bind to bone - effects minimal 6 mo after cessation
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
MECHANISM
!Inhibit bone resorption by osteoclasts !Not metabolized !High concentrations maintained over a prolonged period of time !Adversely affect bone turnover and remodeling, especially at the site of dentoalveolar “trauma”
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
AAOMS CASE DEFINITION OF MRONJ
! Current or previous treatment with antiresorptive or antiangiogenic agents
! Exposed bone or bone that can be probed through an intramural or extraoral fistula(e) in the maxillofacial region that has persisted for > 8 weeks
! No history of radiation therapy to the jaws or obvious metastatic diseases to the jaws
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
RISK OF BRONJ DEPENDS ON:
!IV vs oral drug
!Dosage
!Duration of drug exposure
!Time since last used
!History of “trauma”
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
RELATIVE RISK AFTER DENTOALVEOLAR SURGERY!IV Bisphosphonates !14.8 - 16.4% !If > 1 year
!Oral Bisphosphonates ! 0.1 – 0.5% !If > 3 years
"Antiresorptive agents !??
•Mandible- 73% •Maxilla- 22.5% •Both - 4.5%
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
PATIENT MANAGEMENT! Patient education- patient must be aware of and accept risk
! For oral bisphosphonate patients
• “Drug holiday”: benefit controversial- no evidence of effectiveness
• Maybe if taking > 4 years
- For IV bisphosphonate patients
• AVOID elective procedures
" RANK L Inhibitors
• Antiresorptive effects dissipate after 6 mo. No data to support/refute cessation
" Antiangiogenic drugs - No data to support/refute cessation
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
PREVENTION OF BRONJPatients Taking Oral Bisphosphonates !Maintain good oral/dental health
!Patient education
!Assess risk based on dose/ duration !Thorough Informed Consent !Consider modification/ discontinuation of drug •3 months before •3 months after
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
RISK ASSESSMENT – ORAL BISPHOSPHONATES
!Serum CTx (Collagen Type I C-Telopeptide
!2006 Quest Diagnostics
!Cleavage fragment from Type I collagen due to osteoclastic activity
!Marker of bone remodeling
!Assesses degree of bone turnover supression by oral bisphosphonate use --"" Risk of BRONJ
!73
<100 pg/ml = High risk
100 – 150 pg/ml = Moderate risk
> 150 pg/ml = Low risk
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
SERUM CTX
Not even mentioned in most current AAOMS guidlines.
ATRAUMATIC TOOTH EXTRACTION•-PROXIMATORS
- “Turbo periotomes”
•-APICAL RETENTION FORCEPS •THIN BEAKS •TAPERED PROFILE •ALLOW INSTRUMENT TO PASS
DEEPER ONTO ROOT SURFACE
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RIDGE PRESERVATION GRAFTING• OPTIMIZES THE AMOUNT OF BONE PRESENT AT EXTRACTION
SITE • REDUCES EARLY (1ST 6 MONTHS) RIDGE RESORPTION BY ABOUT
75% • AFTER EXTRACTION SOCKET IS DEBRIDED AND IRRIGATED,
GRAFT MATERIAL IS PACKED INTO SOCKET • BARRIER MEMBRANE IS PLACED OVER GRAFT • SUTURED IN PLACE
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•MAJOR CHANGES TO EXTRACTION SITE OCCUR IN FIRST 12 MONTHS AFTER EXTRACTION. •2/3 OF THE RESORPTION OCCURS WITHIN THE FEW MONTHS•SCHROPP L ET AL. BONE HEALING AND SOFT TISSUE CONTOUR CHANGES FOLLOWING SINGLE-TOOTH EXTRACTION: A CLINICAL AND RADIOGRAPHIC 12-MONTH PROSPECTIVE STUDY. INT J PERIODONTICS RESTORATIVE DENT 23(4); 313-23, 2003
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RIDGE PRESERVATION GRAFTING•REVIEW OF ALL ENGLISH LANGUAGE DENTAL LITERATURE •3954 TITLES / 238 ABSTRACTS —> 104 FULL TEXT ARTICLE ANALYSIS •6 MONTHS AFTER EXTRACTION - 3.79mm (29-63%) horizontal - 1.24mm (B)/ 0.84mm (L) vertical avg. bone loss (11-22%)
Tan WL, et al. Clin Oral Implants Res; 23 Suppl 5: 1-21, 2012"78
SYMBIOS™ REGENERATIVE PRODUCTS
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MY RIDGE PRESERVATION TECHNIQUE!SYMBIOS mineralized
corticocancellous granules
!SYMBIOS OsteoShield PTFE membrane
!Cytoplast suture
" !"#$%&'%()"*+,%-./%00%1$2%2&&34
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SYMBIOS™ CORTICAL/CANCELLOUS GRANULES• A COMBINATION OF CORTICAL HUMAN BONE (80%) AND CANCELLOUS
HUMAN BONE (20%) • LARGE PARTICLE RANGE
- Mineralized: 1.0 mm – 2.0 mm
- Demineralized: 0.5 mm – 3.0 mm • INTEGRATES IN APPROXIMATELY 4-5 MONTHS • 3-YEAR SHELF LIFE
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OSTEOGRAF®/NNATURAL BOVINE ANORGANIC BONE MATRIX (ABM) – MICROPOROUS HYDROXYLAPATITE DENSE, HIGH-HEAT STERILIZED BOVINE PARTICLES AVAILABLE IN 2 PARTICLE RANGES:
- 250 – 420µ (OsteoGraf N-300) - 420 – 1000µ (OsteoGraf N-700)
RESORBS IN APPROXIMATELY 9 – 12 MONTHS 5-YEAR SHELF LIFE
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OSTEOGRAF®/NFeatures Benefits
Dense bovine bone particulate Provides dimensional stability
Hydrophilic Easy to use and place
High heat processing Safe
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Indications for use: • Extraction sites •Ridge augmentation* •Periodontal (peri-implant)
defects* • Sinus elevations
Four-pack configuration
1 gram
3 grams
OSTEOGRAF®/N
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SYMBIOS™ OSTEOSHIELD® PTFE"NON-RESORBABLE
• PROPRIETARY 100% POLYTETRAFLUOROETHYLENE SHEET • BIOLOGICALLY INERT AND TISSUE COMPATIBLE • MESH APPEARANCE IS “DIMPLES”, NOT HOLES – MAKES MEMBRANE
VIRTUALLY IMPERVIOUS TO BACTERIAL AND SOFT TISSUE PENETRATION (SMOOTH SIDE IS PLACED ON BONE)
• 4-YEAR SHELF LIFE
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Features Benefits
Primary closure is not required • By avoiding releasing incisions the membrane maintains soft tissue architecture and preserves keratinized mucosa
• Easily, non-surgical removal after 21-28 daysMedical grade PTFE • Biocompatible and non-reactive
• Can be trimmed with sharp sterile scissors for easier handling
Micro-machined surface texture • Facilitates cell adhesion • Enhances membrane stability • Reduces flap retraction • Increases pull-out strength
SYMBIOS™ OSTEOSHIELD® PTFE"NON-RESORBABLE
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Indications for use:
• Socket grafting
• When primary closure after grafting cannot be achieved
• Large bony defects
• Temporary implantable material for space-making barrier in periodontal defects
Multi-pack configuration
12 mm x 24 mm (10 pack)
25 mm x 30 mm (4 pack)
SYMBIOS™ OSTEOSHIELD® PTFE"NON-RESORBABLE
"87
SYMBIOS™ OSTEOSHIELD® PTFE"NON-RESORBABLE
"88
RIDGE PRESERVATION TECHNIQUE
"89
MIXING BONE WITH SALINE VERSUS BLOOD
•SALINE AND BLOOD ARE BOTH ISOTONIC •BLOOD CONTAINS FIBRIN, PROTEINS, STEM CELLS •PARTICULATE GRAFT IS MORE COHESIVE WHEN MIXED WITH BLOOD VERSUS SALINE •MIXING WITH BLOOD REQUIRES DRAWING BLOOD (APPROX. EQUAL VOLUMES) •CLINICAL ADVANTAGE??
"90
SYMBIOS™ REGENERATIVE PRODUCTS
"91
SYMBIOS™ OSTEOSHIELD® COLLAGEN"RESORBABLE
• RESORBABLE TISSUE MATRIX DERIVED FROM HIGHLY-PURIFIED TYPE-I BOVINE ACHILLES TENDON FOR SAFETY AND PREDICTABILITY
• GBR BARRIER FUNCTION • INTEGRATES IN APPROXIMATELY 6-9 MONTHS • 3-YEAR SHELF LIFE
"92
Features Benefits
Multi layer construction Guides healing of bone and tissue – inner layers help prevent cellular and bacterial down growth
Unique fiber orientation Provides tensile strength to accommodate sutures or tacks
Excellent wet handling characteristics and either side may be placed on site
Ease of use
SYMBIOS™ OSTEOSHIELD® COLLAGEN"RESORBABLE
"93
Indications for use:
• Around dental implants
• Bony defects
• Ridge reconstruction
• GBR/GTR
Two-pack configuration
15 mm x 20 mm
20 mm x 30 mm
30 mm x 40 mm
SYMBIOS™ OSTEOSHIELD® COLLAGEN"RESORBABLE
"94
RIDGE PRESERVATION• 88 Y.O. FEMALE •HTN, HYPOTHYROID •SYNTHROID, LOSARTAN
(COZAAR) •NKDA •LOST CROWN, SAW ENDO
--> NOT RESTORABLE
"95
RIDGE PRESERVATION
"96
PERIACRYL• COLLAPLUG • GUT FIG-8
SUTURE • PERIACRYL
"97
PANORAMIC RADIOGRAPHS
"98
THE BIRTH OF COMPUTED TOMOGRAPHY
"99
Godfrey N Hounsfield
1919 - 2004
5 4 2 4 5
54245
4
10 9 7 9 106 8 94 6 76 8 9
10 10
868
979
79 9
BACK PROJECTION IMAGE RECONSTRUCTION
"100
HOW CONE BEAM CT WORKS
"101
X - r a y source
‘Cone’ of X-rays
Detector
HOW CONE BEAM CT WORKS• X-rays are used more efficiently • Cone beam can acquire hundreds of slices per one rotation
"102
HOUNSFIELD UNITS
"103
! - ATTENUATION COEFFICIENT
•WITH CBCT, WE ARE MOST INTERESTED IN BONE DENSITY •ALL CBCT MACHINES ARE DIFFERENT, GEOMETRIES CAN VARY •X-RAY BEAMS ARE NOT MONOCHROMATIC •ATTENUATION OF BEAM DEPENDS ON THE X-RAY PHOTON ENERGY •SCATTER, BEAM HARDENING AND METAL ARTIFACTS AFFECT ATTENUATION
"104Computed Medical Imaging Nobel Lecture, 8 December 1979 Godfrey N. Hounsfield J Radiol. 1980 Jun-Jul;61(6-7):459-68
CBCT GRAYSCALE VS. HOUNSFIELD UNITS
BOTTOM LINE…•GRAY SCALE VALUE IS USEFUL TO COMPARE DENSITY IN DIFFERENT AREAS OF THE SAME PATIENT IN THE SAME SCAN. •COMPARISONS BETWEEN SCANS CAN BE UNRELIABLE.
"105
3D IMAGING- CBCTKNOWING THE PATIENT’S ANATOMY IN 3D IS CRITICAL TO:
• Accurate implant planning • Avoidance of complications • Long term implant success
"106
ANATOMICAL CONSIDERATIONS• MANDIBULAR NERVE • LINGUAL NERVE • MAXILLARY SINUSES • MYLOHYOID FOSSA
"107
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
NERVE INJURY! Nerve (IAN) injury - Drilling injury
! Drill extends 0.1 - 1.0 mm beyond fixture depth
- Fixture injury
! Pressure on IAN
! Impingement on IAN"108
ANATOMICAL CONSIDERATIONS•MANDIBULAR NERVE •Stay at least 2mm above canal •Watch anterior loop of mental nerve
"109
PREVENTING IAN INJURY - 2MM SAFETY MARGIN
•2MM SAFETY MARGIN
"110
BEWARE THE ANTERIOR LOOP
"111
ANTERIOR LOOP OF MANDIBULAR NERVE•GREENSTEIN G AND TARNOW D. •THE MENTAL FORAMEN AND NERVE: CLINICAL
AND ANATOMICAL FACTORS RELATED TO DENTAL IMPLANT PLACEMENT: A LITERATURE REVIEW. J PERIODONTAL 77(12), P 1933-1943, 2006
"112
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
RESULTS/ CONCLUSIONS
•Mental foramen location can vary from canine —1st molar
•CT scan more accurate than conventional radiographs •Incidence ranges between 0 - 88% •2mm “safety zone” should be kept from mandibular
nerve
!"##$%&#'$(!()$*(&)"$+,(*-(.(/#"'+*+$&)0(1123456(/(3788937:86(4;;<
"113
LINGUAL NERVE•VERY VARIABLE LOCATION •MAY BE ABOVE OR BELOW THE MYLOHYOID MUSCLE •AVOID LINGUAL RETRACTION AND INSTRUMENTATION
"114
MYLOHYOID FOSSA
"115
"116
"117
SOFT TISSUE BLEEDING
"118
ANATOMICAL CONSIDERATIONSMAXILLARY SINUSES •LIGHTEN SKULL •WARM, MOISTEN AIR •PNEUMATIZE AFTER EXTRACTIONS
"119
ANATOMICAL CONSIDERATIONS•MAXILLARY SINUSES: •“NORMAL” VS. “PATHOLOGICAL” PATHOLOGY •PENETRATING THE SINUS FLOOR
"120
SINUS FLOOR VIOLATION
"121
"122
SINUS FLOOR VIOLATION
"123
THIS IS A PROBLEM…
"124
MAXILLARY BONE REQUIREMENT•NEED AT LEAST 5MM OF SOLID BONE AT FLOOR OF SINUS TO STABILIZE FIXTURE •SINUS LIFT FIRST
"125
NASOPALATINE DUCT
"126
"127
PLANNING YOUR FIRST IMPLANT CASE
"128
JBR
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
KEY TO SUCCESS!We don’t want you to have complications
!We don’t want you to stop placing implants
!Progression in case complexity is based on training and experience
JBR
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
YOUR FIRST (25) CASES SHOULD BE:! Very straightforward
! Minimal risk of complications
! Adequate bone volume - no bone grafting needed
! Plenty of keratinized gingiva - flapless surgery (tissue punch)
! 1st Premolar to 1st Molar
• Easy access
• Not in the anterior esthetic zone
RULES OF ENGAGEMENT - IMPLANT PLANNING
•IMPLANT FIXTURE SHOULD BE PLACED: •PARALLEL TO OCCLUSAL FORCES •PARALLEL TO ADJACENT TEETH (IF NOT TILTED) •ALIGNED WITH CENTRAL SULCUS/ AXIS OF RESTORATION •2 MM FROM LINGUAL & BUCCAL CORTICAL WALLS •2-3 MM FROM ADJACENT IMPLANTS AND TEETH
"131
IMPLANTS ARE NOT TEETH•IMPLANTS ARE NON-VITAL •THERE IS NO PDL •IMPLANTS DON’T MOVE • If patient needs orthodontic treatment, do
not place implant until ortho is finished
"132
TOOTH MOVEMENT•USE A SPACE MAINTAINER
- ESSIX BRIDGE - BONDED BRIDGE - STAYPLATE/ FLIPPER •ORTHODONTIC EVALUATION IF
SIGNIFICANT •MAY RESULT IN REMOVAL OF TOOTH
TOOTH MOVEMENT•USE A SPACE MAINTAINER
- ESSIX BRIDGE - BONDED BRIDGE - STAYPLATE/ FLIPPER •ORTHODONTIC EVALUATION IF
SIGNIFICANT •MAY RESULT IN REMOVAL OF TOOTH
"134
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
"136
6 MM IMPLANT LENGTH OPTIONIDEAL FOR CASES WITH LIMITED VERTICAL BONE HEIGHT, THIS SHORTER IMPLANT ALSO HELPS REDUCE THE NEED FOR BONE ARGUMENTATION
"137
JBR
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
WHAT IS THE SUCCESS RATE OF A SHORT IMPLANT VS. LONGER?! 7mm long implants, loaded at 4 months, showed a 93.7% success rate at 3 years. Mean bone loss
was 1.46mm. - Malo P. 7mm long dental implants in posterior jaws: 3-year report of an ongoing prospective single cohort study. Eur J Oral
Implantol 10(1): 85-93, 2017
! 6.6mm implants have similar success rate to 9.6mm or longer implants. More complications were seen in augmented patients - Felice P, et al. Short implants versus longer implants in vertically augmented posterior mandibles: a randomized controlled trial
with 5-year after loading follow-up. Eur J Oral Implantol 7(4): 359-369, 2014
! 4mm diameter by 6mm long implants had similar results to longer implants placed in augmented bone, with fewer complications. - Pistilli R, et al. Posterior atrophic jaws rehabilitated with prostheses supported by 6mm long 4mm wide implants or by longer
implants in augmented bone. One-year post-loading results from a pilot randomized controlled trial. Eur J Oral Implant 6(4): 359-373, 2013
"139
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
CROWN-IMPLANT RATIO ! Implant 4 year survival rate was 94.1% with C/I ratio more than 2. Peri-implant bone
loss was not influenced by C/I ratio. - Blanes RJ. To what extent does the crown-implant ratio affect survival and complications of implant-supported
reconstructions? A systematic review. Clin Oral Implants Res 20(4): 67-72, 2009
! Prostheses with C/I ratios up to 2 have a high survival rate and do not result in more bone loss. - Greenstein G, Cavallao JS. Importance of crown to root and crown to implant ratios. Dentistry Today CE Course
25, 2011.
! Implant splinting does not significantly improve implant success rates - Weber HP. Sukotjo C. Does the type of implant prosthesis affect outcomes in the partially edentulous patient? Int
J Oral Maxillofac Implants 22(suppl):140-172, 2007"140
IMPLANT CONSULTATION• REVIEW MEDICAL
HISTORY • REVIEW CLINICAL DATA • DISCUSS TREATMENT
OPTIONS • PLAN FOR PROCEDURE
CASE PRESENTATION•Overall, dental implant long-term success is about 95%. •About 1 out of 20 implants fail •Dental insurance will pay to replace a bridge after 5
years •Bridge has a 90- 95% failure rate after 15 years • If an implant fails, it can be replaced by another implant
(just like a “permanent” tooth (93% success)"142
“DOCTOR, ARE DENTAL IMPLANTS PERMANENT?”
“Implants are as permanent as your permanent teeth”
567! "143
INFORMED CONSENT•A DISCUSSION WITH THE PATIENT OF THE POTENTIAL/EXPECTED-
- Risks - Benefits - Complications - Alternatives, including no treatment - Option of going to a Specialist
"144
"145
THIS IS A LONG-TERM COMMITMENT•“IMPLANTS ARE LIKE A CAR” - Not a one-time event/expense - Long-Term implant success requires “Regular
routine maintenance” •PATIENT MUST BE COMMITTED TO SUCCESS •PARTNERSHIP
"146
JBR
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
SUCCESS STRATEGY! Biofilm reduction
! Daily maintenance by patient
! Water flosser (Water-Pik) daily
! Dilute sodium hypochlorite solution - 6 drops per tank
! 6 month recall- Implant protocol
! Glycine air abrasion
! Er,Cr:YSSG laser (2780 nm)
! Piezoscaler (Ti tips)
ASTRA TECH IMPLANT SYSTEM EVA SITE-SPECIFIC, CROWN-DOWN APPROACH
Concept Follows the Principles of “Prosthetically-Driven” Implant Planning
"148
THE FOUNDATION"- ASTRA TECH IMPLANT SYSTEM BIOMANAGEMENT COMPLEX™
PROMOTES LONG-TERM BONE LEVEL MAINTENANCE AND ESTHETICS
"149
ASTRA TECH IMPLANT SYSTEM EV•EV STRAIGHT VS. CONICAL FIXTURES •CONICAL CONNECTION •IMPLANT/ COMPONENT PACKAGING •STANDARD (NON-GUIDED) SURGICAL KIT
"150
IMPLANT SIZE / TOOTH POSITIONTHE ILLUSTRATION INDICATES THE RECOMMENDED IMPLANT SIZES IN RELATION TO THE NATURAL DENTITION 3.0MM AND 5.4MM IMPLANTS ARE NON-GUIDED
"151
SYSTEM OVERVIEW – KEY POINTS SURGICALSURGICAL SIMPLICITY AND FLEXIBILITY
" VERSATILE IMPLANT DESIGNS " DRILLING PROTOCOL ALLOWS FOR
PREFERRED PRIMARY STABILITY " AN INTUITIVE, COLOR-CODED SURGICAL
TRAY
"152
VERSATILE IMPLANT DESIGNSONE SYSTEM FOR ALL INDICATIONS SUITABLE FOR BOTH ONE-STAGE AND TWO-STAGE SURGERY DESIGNED FOR IMMEDIATE AND EARLY RESTORATION
"153
IMPLANT ASSORTMENT
"154
IMPLANT DESIGN "- OSSEOSPEED™ EV
Green
1.8#mm
2.5 #mm
3.1 #mm
3.7#mm
4.3#mm
2.5#mm
3.1 #mm
"155
Ø 3.0 MM IMPLANTA TWO-PIECE IMPLANT SOLUTION OPTIMAL FOR CASES WITH LIMITED HORIZONTAL SPACE IN LOWER ANTERIORS OR UPPER LATERALS
8 mm 9 mm 11 mm 13 mm 15 mm"156
Ø 5.4 MM IMPLANTA 5.4 MM IMPLANT DIAMETER OPTION FOR TREATMENT OF THE MOLAR REGION
6 mm 8 mm 9 mm 11mm 13 mm 15 mm"157
6 MM IMPLANT LENGTH OPTIONIDEAL FOR CASES WITH LIMITED VERTICAL BONE HEIGHT, THIS SHORTER IMPLANT ALSO HELPS REDUCE THE NEED FOR BONE ARGUMENTATION
"158
ONE INTERFACE – THREE INDEXING SOLUTIONS
Six positions
Indexed abutments will seat in six available positions.
Index free
Index free abutments will be seated in any rotational.
One-position-only ATLANTIS patient-specific, CAD/CAM abutments will seat in one position only.
"159
PREPARING THE PATIENT FOR SURGERY•MEDICAL CONSIDERATIONS •MEDICATIONS •CHLORHEXIDINE ORAL RINSE •SYSTEMIC ANTIBIOTICS
"160
PERIOPERATIVE PROTOCOLS•ANTIBIOTIC USE - Systemic - Chlorhexidine 0.12% (16 oz) •PAIN MEDICATIONS
•MY REGIMEN: - Cephalexin 750 mg (Amoxicillin 875 mg) BID x 6d - CHX Rinse 0.5 oz BID x 16d
"161
PERIDEX / ABX REGIMEN•2 PRESCRIPTIONS •2 X PER DAY •STARTED 2D BEFORE SURGERY
"162
ALLERGIC TO PENICILLINS AND CEPHALOSPORINS?
#DEFINE “ALLERGIC”
•BIAXIN 500MG BID X 6 DAYS •CIPRO 500MG BID X 6 DAYS
"163
PRE-OP PATIENT INSTRUCTIONSYour appointment for _______________________________________________________ is scheduled on
_______________________ 201____ at __________o’clock, in our ______________________office.
This time is reserved specifically for you. Please try to arrive about 15 minutes prior to your scheduled
appointment. If you are late, we may need to reschedule your surgery so that our other patients can be
treated at their scheduled times.
PRE-OPERATIVE INSTRUCTIONS FOR PATIENTS HAVING INTRAVENOUS SEDATIONOR GENERAL ANESTHESIA FOR SURGERY
1. Do not eat food or drink liquids (including water) for at least eight (8) hours prior to your appointment.**Patients who take daily medication (such as blood pressure, heart, or diabetes medicine, or antibiotics)should take their medicines as scheduled (swallow with a minimal amount of water) unless toldotherwise by the surgeon or their medical doctor.**
2. Please bring the name and dosage of any medicine you are currently taking.3. Have a responsible person accompany you to drive you home. Minors must be accompanied by a parent.
We cannot allow patients to leave the office by taxi or other transportation without an escort.4. Do not drink any alcoholic beverages for 24 hours before your surgery.5. Please discontinue the use of tobacco for as long as possible prior to your appointment. Smoking may
delay healing, will create increased discomfort following surgery, and increase the risk of infection.6. Wear short-sleeved, comfortable clothing. Please remove any oral or facial rings, posts, or other facial
jewelry before your appointment. (Non-dangling earrings are acceptable.) Please leave your jewelry andvaluables at home or with your escort.
7. Contact lenses, nail polish, false eyelashes, scented lotions, perfumes, and make-up should not be worn toyour appointment.
8. It is a good idea to have a few ice compresses made for when you arrive home.9. You should have soft, bland food ready at home for the first day.10. Someone should be available to be with you for 12 to 24 hours after you arrive home.11. If there is any change in your health in the few days before surgery, such as fever, chest cold, flu or
persistant cough, please notify this office immediately.12. If you have insurance, please bring forms with you.
The estimated fee for surgery: $_________________ Due at Surgery: $_________________
We must have a signed financial agreement and assignment of benefits prior to surgery.
IF YOU ARE UNABLE TO KEEP YOUR APPOINTMENT, PLEASE NOTIFY THE OFFICE AT LEAST 24HOURS PRIOR TO YOUR SCHEDULED VISIT.
IF YOU HAVE ANY QUESTIONS REGARDING YOUR SURGERY, DO NOT HESITATE TO CALL THEOFFICE.
THANK YOU.
SOUTHERN CALIFORNIA CENTER FOR ORAL AND FACIAL SURGERYJAY B. REZNICK, D.M.D., M.D., INC.
818-996-1200
Jay B. Reznick, D.M.D., M.D., Inc.18372 Clark Street, Suite 224
Tarzana, California 91356818-996-1200 / FAX 818-996-1325
"164
• Thorough oral examination should be prior to implant planning
•Any sources of infection should be managed •Periodontal issues should be under control • There should be no sources of periapical infection • Thorough oral prophylaxis 2 weeks before implant
surgery
PREOPERATIVE PROTOCOL
"165
CLINICAL PEARL! ONCE YOU HAVE DONE THE WORK-UP FOR THE
SURGERY AND PLANNED THE SURGICAL GUIDE, ANY RESTORATIVE PROCEDURES IN THE SAME ARCH WILL CAUSE THE SURGICAL GUIDE TO NOT FIT. ! DO URGENT RESTORATIVE NEEDS BEFOREHAND, OR
WAIT UNTIL AFTER IMPLANT SURGERY IS DONE."166
FOLLOWING THAT SAME LOGIC- IF THE PATIENT NEEDS ORTHODONTIC TREATMENT OR IF THEY ARE UNDERGOING ORTHO TREATMENT, DO NOT PLAN IMPLANTS UNTIL AFTER ORTHO CASE IS FINISHED. -the surgical guide may not fit -The teeth are moving. The implant does not!
"167
ANOTHER PEARL
IMPLANT CASE CHECKLIST• IMPLANT SYSTEM • FIXTURE SIZES • GRAFTING
MATERIALS • 2ND STAGE INFO
"168
BASIC IMPLANT SURGERY TECHNIQUES•PREPARING THE PATIENT FOR SURGERY •SURGICAL DRAPING - “sterile technique” •SURGICAL TECHNIQUES - Drilling sequence - Pearls and pitfalls - Post-op management •AVOIDING AND MANAGING COMPLICATIONS
"169
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
PRINCIPLES OF SURGERY
!Wound Classification !Clean vs. Sterile technique !Protocol of Oral Surgery/ Implant Surgery
"170
SURGICAL WOUND CLASSIFICATIONS•I. CLEAN: •- UNINFECTED, NO INFLAMMATION •- RESP, GI, GU TRACTS NOT ENTERED •- CLOSED PRIMARILY •EXAMPLES: EX LAP, MASTECTOMY, NECK DISSECTION, THYROID, VASCULAR, HERNIA, SPLENECTOMY
•II. CLEAN-CONTAMINATED: •- RESP, GI, GU TRACTS ENTERED, CONTROLLED •- NO UNUSUAL CONTAMINATION •EXAMPLES: CHOLE, WHIPPLE, GASTRIC SURGERY, BRONCH, COLON SURGERY, ORAL OR ENT
"171
SURGICAL WOUND CLASSIFICATIONS•III: CONTAMINATED: •- OPEN, FRESH, ACCIDENTAL WOUNDS •- MAJOR BREAK IN STERILE TECHNIQUE •- GROSS SPILLAGE FROM GI TRACT •- ACUTE NONPURULENT INFLAMMATION •EXAMPLES: INFLAMED APPY, BILE SPILLAGE IN CHOLE, DIVERTICULITIS, RECTAL SURGERY, PENETRATING WOUNDS, TOOTH EXTRACTION
"172
SURGICAL WOUND CLASSIFICATIONS•IV: DIRTY: •- OLD TRAUMATIC WOUNDS, DEVITALIZED TISSUE •- EXISTING INFECTION OR PERFORATION •- ORGANISMS PRESENT BEFORE PROCEDURE •EXAMPLES: ABSCESS I&D, PERFORATED BOWEL, PERITONITIS, WOUND DEBRIDEMENT, POSITIVE CULTURES PRE-OP, ABSCESSED TOOTH
"173
CLEAN TECHNIQUE•Clean technique refers to the use of routine hand washing,
hand drying and use of non-sterile gloves•Use clean technique if staff or objects will touch intact skin,
intact mucous membranes or dirty (contaminated) items•Clean tech is appropriate for: •Taking blood pressures •Examining patients •Removing sutures from oral cavity
"174
INVASIVE PROCEDURES#ACTS DONE TO PATIENTS THAT COME IN CONTACT WITH THE WOUNDS, BLOOD STREAM, THE INSIDE OF THE BODY, OR NORMALLY STERILE PARTS OF THE BODY
"175
IN SUMMARY…Clean Aseptic Sterile
Procedure space In clinic or at beside
Dedicated area
Dedicated room
Gloves Clean or none
Sterile Sterile surgical
Hand hygiene before the procedures
Routine Aseptic, e.g. alcohol
Surgical scrub
Iodophors, chlorhexidine
Skin antisepsis No Alcohol Long acting agent
Sterile field No No* Yes
Sterile gown, mask, head covering
No No Yes "176
ASEPTIC TECHNIQUE •ASEPTIC TECHNIQUE IS USED FOR SHORT INVASIVE PROCEDURES.
IT INVOLVES: •ANTISEPTIC HAND HYGIENE (ALCOHOL, BETADINE OR CHLORHEXIDINE) •STERILE GLOVES •ANTISEPTIC ON PATIENT’S SKIN (IF EXTRAORAL) •USE OF CLEAN, DEDICATED AREA
"177
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
ASEPTIC TECHNIQUE
$Use aseptic technique for brief invasive procedures that may break skin or mucous membranes, or normally sterile parts of the body
$Example: placing a urinary catheter, placing an IV, penetration through mucous membranes
"178
STERILE TECHNIQUE#USE DURING SURGERY AND FOR INVASIVE
PROCEDURES WITH HIGH RATES OF INFECTION #EXAMPLES: !Any long invasive procedure !Placement of central lines and thoracic lines !Surgery of sterile parts of the body
"179
STERILE TECHNIQUE•STERILE TECHNIQUE IS USED FOR SURGERY. IT INVOLVES: •SURGICAL HAND RUB WITH LONG ACTING ANTISEPTIC •HANDS DRIED WITH STERILE TOWELS •STERILE FIELD •STERILE GOWN, MASK, GLOVES •STERILE SUPPLIES •SKIN PREP •A DEDICATED ROOM
"180
SURGICAL DRAPING FOR IMPLANTS!ORAL CAVITY IS CLASSIFIED AS
“CLEAN-CONTAMINATED” ! “STERILE” DOESN’T EXIST FOR
THE MOUTH !OPERATING ROOM STERILE
DRAPING IS A WASTE !MODIFIED DRAPING FOR DENTAL
IMPLANT SURGERY"181
ESSENTIALS OF IMPLANTOLOGY AND CBCT-GUIDED IMPLANT SURGERY - LEVEL I
SUCCESS RATES OF OSSEOINTEGRATION FOR IMPLANTS PLACED UNDER STERILE VERSUS CLEAN CONDITIONS Tarnow D, J Periodontol 1993 Oct;64(10)954-6
! Retrospective study ! “Sterile” - 61 pts/ 273 implants - OR/ strict sterile protocol
! “Clean” - 31 cases/ 113 implants - Clinic setting
! Evaluated at Stage 2 ! Sterile group: 98.9% implant success/ 95.1% case success
! Clean group: 98.2% implant success/ 93.5 case success
! No statistical difference between study groups ! Implant surgery can be performed under “clean” conditions
"182
IT DOESN’T REALLY MAKE A DIFFERENCE UNLESS YOU TOUCH OUTSIDE OF THE ASEPTIC FIELD•So, if you are new to surgery, maintaining a “OR sterile” environment is a good insurance policy
J Oral Maxillofac Surg 1996
"183
DRAPING FOR IMPLANT SURGERY•COVER PATIENT’S HAIR, CHEST WITH STERILE TOWELS •STERILE COVERS ON LIGHT HANDLES, TRAYS, HANDPIECES AND TUBING •CLEAN COVER OVER HAIR •CLEAN COVER GOWNS •EYE PROTECTION
"184
ORAL SURGERY ASEPTIC TECHNIQUE•STERILIZE EVERYTHING THAT WILL CONTACT THE ORAL CAVITY AND LOWER FACE
THAT IS NOT ALREADY PACKAGED STERILE: • Instruments/ Implant surgical Kit • Gauze • Needles • Irrigation
•YOU CAN TOUCH: • Patient • Sterile /Clean Covered surfaces • Sterile Instruments/ Implants
"185
ORAL SURGERY ASEPTIC TECHNIQUE•YOU CAN’T TOUCH: # EVERYTHING ELSE
• Replace gloves if they touch outside of aseptic field • Do not place implant if it gets contaminated
"186
WHAT ABOUT THE SURGICAL STENT?• SOAK IN CHLORHEXIDINE 0.12% ORAL
SOLUTION FOR 10 - 15 MINUTES BEFORE SURGERY
"187
STERILE FIELD SETUP
www.salvin.com
02-15-2017
Everything For Your Implant Practice But The Implants®
Reznick Sterile Kit
#REZNICK-PACK 395.00
"188
HAND ASEPSIS•AVAGARD •Chlorhexidine/Alcohol
surgical hand disinfectant •Equivalent to a traditional
surgical scrub •Let hands dry before
donning gloves"189
ORAL CAVITY ASEPSIS! Chlorhexidine 0.12% Rinse
prior to draping
"190
AIRWAY PROTECTION IS ESSENTIAL
AIRWAY PROTECTION
•Bite Block and Throat Pack
•Isolite
"191
BASIC SURGICAL TRAY SETUP FOR IMPLANTS•BITE BLOCK / MOUTH PROP •4 X 4 AND 2 X 2 GAUZE •LOCAL ANESTHETIC/ SYRINGE/ NEEDLE •MINNESOTA RETRACTOR •WIEDER RETRACTOR •SURGICAL SUCTION TIP •#15 SCALPEL BLADE •PERIOSTEAL ELEVATOR •MOSQUITO HEMOSTAT •STRAIGHT CURETTE •ADSON TISSUE FORCEPS •TISSUE SCISSORS •NEEDLE HOLDER •SUTURE SCISSORS •STERILE SALINE FOR IRRIGATION •STERILE CONTAINER FOR MIXING BONE GRAFT
"192
!Jay B. Reznick, D.M.D.,M.D. Essentials of Implantology and Guided Implant Surgery
Basic Surgical Tray Setup What to Buy
Instruments •! Silicone Bite Blocks (S-M-L) or Molt Mouth Prop •! 4 x 4 and 2 x 2 Gauze •! Univ of Minnesota Retractor •! 5” Wieder Retractor •! 3 mm Surgical aspirator (Stainless Steel) •! Bard Parker #3 scalpel handle •! Molt #9 Periosteal Elevator •! 5” Halstead curved Mosquito Forceps •! Molt #24C Straight Surgical Curette •! 5” Adson/Brown 1x2 toothed Tissue Forceps •! 6” Metzenbaum Curved Tissue Scissors •! 6” Crile-Wood Needle Holder •! 6” Kelly Scissors •! Sterile container for mixing bone graft (Stainless Steel) •! Local Anesthetic/ Syringe/ Needle •! #15 Scalpel Blades •! Sterile Saline for Irrigation
Sterile drapes, disposables, etc. •! Irrigation tubing •! IV Bags- 0.9% normal saline •! Irrigation saline •! Handpiece sleeves •! Sterile surgical gloves •! Light handle/ equipment button covers •! Surgical gowns and drapes •! Sterile towels
Where to Buy It •! Karl Schumacher Instruments
o! www.karlschumacher.com 800-523-2427 •! Salvin Dental Specialties
o! www.salvin.com 800-535-6566 •! Ace Surgical Supply
o! www.acesurgical.com 800-441-3100 ! "193
"194
INSTRUMENTS OF THE BETTER GRADE
737 E. Elizabeth Ave.Linden, NJ 07036(800) 523-2427
!
https://www.karlschumacher.com/Kits/Sets
"195
Reznick Basic Instrument Kit
#REZNICK-BASIC-KIT
Save 123.30 MEETING SPECIAL 895.00
Everything For Your Implant Practice But The Implants®
http://www.salvin.com/Reznick-Basic-Instrument-Kit-pluREZNICK-BASIC-KIT.html
"196
02-15-2017
Everything For Your Implant Practice But The Implants®
Reznick Sterile Kit
#REZNICK-PACK 395.00
http://www.salvin.com/Reznick-Sterile-Kit-pluREZNICK-PACK.html
IMPLANT PACKAGING
"197
IMPLANT PACKAGING
"198
DRILL PACKAGING
"199
TORQUE WRENCH EV Driver Handle, Surgical
Driver Handles, Prosthetic
Implant Depth Gauge EV
"200
ESSENTIALS OF IMPLANTOLOGY AND CBCT-GUIDED IMPLANT SURGERY
EV KIT IMPORTANT TIPS AND TRICKS! Clean drills with brush to get all debris out of flutes, then clean in ultrasonic ! Thoroughly dry all drills and components after washing, before autoclaving
- Washtray EV: SKU 31071000
! Autoclave EV Guided kit by itself - OK to leave implant drivers, torque wrench, depth gauge and stabilization abutments in kit
! Autoclave drills grouped by length, and implant color code
! Repeat autoclaving of drills will dull them, even if they have not been used! - $4800 - 6000 per full set
"201
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
LOCAL ANESTHESIA FOR DENTAL IMPLANT SURGERY
! Innervation of teeth
! Innervation of edentulous site
"202
DRILLING FOR SUCCESS•IT IS CRITICAL THAT THE BONE BE RESPECTED WHEN PREPARING THE IMPLANT OSTEOTOMY SITES. THIS MEANS: •Light pressure on the drill •Slowest drilling speed for the job •Drill speed decreases as drill diameter increases
"203
•HIGHER DRILL SPEED IS MORE EFFICIENT AND ACTUALLY CAUSES LESS HEAT GENERATION. •INCREASING SPEED AND LOAD TOGETHER DOES NOT INCREASE HEAT GENERATION.•SHARAWY M, MISCH CE, ET AL. HEAT GENERATION DURING IMPLANT DRILLING: THE SIGNIFICANCE OF MOTOR SPEED. JOMS 60 (10), 1160-1169, 2002. •BRISMAN DL. THE EFFECT OF SPEED, PRESSURE, AND TIME ON BONE TEMPERATURE DURING THE DRILLING OF IMPLANT SITES. INT J OMF IMPLANTS 11(1), 35 - 37, 1996. •ABOUZGIA NB, SYMINGTON JM. EFFECT OF DRILL SPEED ON BONE TEMPERATURE. INT J ORAL MAXILLOFAC SURG 1996; 25:394-399.
"204
INTERMITTENT VERSUS CONTINUOUS DRILLING•CONTINUOUS DRILLING RESULTS IN HIGHER TEMPERATURES IN BONE DUE TO: • CLOGGING EFFECT OF BONE DEBRIS • INABILITY OF IRRIGATION TO REACH SITE
•DECREASES CUTTING EFFICIENCY AND INCREASES TIME REQUIRED
" WATCHER R, STOLL P. INCREASE IN TEMPERATURE DURING OSTEOTOMY. IN VITRO AND IN VIVO INVESTIGATIONS. INT J ORAL MAXILLOFAC SURG 1991; 20: 245-249.
"205
IMPLANT DRILLING SPEEDSTISSUE PUNCH: OSTEOTOMIES:
THREAD TAPPING: IMPLANT DELIVERY:
COVER SCREW/ABUTMENT:
800 rpm 1200 - 1500 rpm 15 - 50 rpm/ 45 Ncm 15 - 50 rpm/ 35 - 45 Ncm 10 - 15 rpm/ 10 -20 Ncm
"206
BONY HEAT NECROSIS#DOCUMENTED AT TEMPERATURES 44!C TO 47!C FOR 1 MINUTE #DUE TO DENATURATION OF ALKALINE PHOSPHATASE
" Eriksson RA, Albrektsson T. Temperature threshold levels for heat-induced bone tissue injury. A vital microscopic study in rabbit. J Prosthet Dent 1983;50:101–107.
" Eriksson RA, Albrektsson T. The effect of heat on bone regeneration: An experimental study in rabbit using the bone growth chamber. J Oral Maxillofac Surg 1984;42:705–711.
"207
DRILL SHARPNESS
•Matthews LS, Hirsch C. Temperatures measured in human cortical bone when drilling. J Bone Joint Surg 1972;54:297–308. •Yacker M, Klein M. The effect of irrigation on osteotomy depth and bur diameter. Int J Oral Maxillofac Implants 1996;11:634–638. • Andrianne Y, Wagenknecht M, Donkerwolcke M, Zurbuchen C, Burny F. External fixation pin: An in vitro general investigation. Orthopedics 1987;10:1507–1516. •Sutter F, Krekeler G, Schwammerger AE, Sutter FJ. Atraumatic surgical technique and implant bed
A sharp drill creates less heat!
"208
GUIDED IMPLANT SURGERYCLINICAL QUESTION: IS MORE HEAT GENERATED DURING GUIDED DENTAL IMPLANT OSTEOTOMY PREPARATIONS AS COMPARED TO NON-GUIDED?
CLINICAL BOTTOM LINE: MORE HEAT IS PRODUCED WITH GUIDED DENTAL IMPLANT SURGERY. THIS IS SUPPORTED BY THREE IN VITRO STUDIES IN WHICH A STATISTICALLY SIGNIFICANT INCREASE OF TEMPERATURE WAS REPORTED WHEN UTILIZING SURGICAL GUIDES AS COMPARED TO CONVENTIONAL DRILLING WITHOUT A GUIDE.
"8&9%:;<3&9%=>?%$3%;#.%@<3%6%A2;#%B;CD##&';0%@*1#;<39.%E-FG%6;<5H$+IEJKFL,/F5M%%"BDN#D&2;3D%B?%$3%;#.%@<3%6%A2;#%B;CD##&';0%@*1#;<39.%E-FO%P&Q5R$0IEMKSL,FGSG5J%"BD9D2%TH?%$3%;#.%6%A2;#%B;CD##&';0%:"2N.%E--J%R$0ISUKFEL,ESSO5M
"209
BOTTOM LINE…•ALTHOUGH SIGNIFICANT, THE MAXIMUM TEMPERATURES DID NOT REACH CRITICAL LEVELS FOR BONE NECROSIS. •CLINICAL RESEARCH NEEDS TO BE CONDUCTED TO DETERMINE WHEN TEMPERATURE RISE USING SURGICAL GUIDES IN-VIVO IS CLINICALLY RELEVANT.
"210
SALINE VS. WATER FOR IRRIGATION•STERILE ISOTONIC (0.9%) SALINE IS THE RECOMMENDED IRRIGANT. •THEORETICALLY, IRRIGATION WITH WATER CREATES AN OSMOTIC GRADIENT WHICH CAUSES FLUID MOVEMENT IN TO THE OSTEOCYTES, RESULTING IN CELL BALLOONING AND RUPTURE.
"211
SALINE VS. WATER FOR IRRIGATION•HOWEVER... •DOES IT REALLY MAKE A DIFFERENCE IN CLINICAL PRACTICE? •PROBABLY NOT.
"212
DOES USING CHILLED SALINE FOR IRRIGATION REDUCE HEAT GENERATION VERSUS ROOM TEMPERATURE SALINE?
SENER BC ET AL. EFFECTS OF IRRIGATION TEMPERATURE IN HEAT CONTROL IN VITRO AT DIFFERENT DRILLING DEPTHS. CLINICAL ORAL IMPLANTS RESEARCH 20 (3) MARCH 2009, 294-298 •3, 7, 12 MM DEPTHS; SALINE AT 25!C AND 10!C •MORE HEAT GENERATED SUPERFICIALLY VERSUS BOTTOM OF OSTEOTOMY •EXTERNAL IRRIGATION AT ROOM TEMPERATURE PROVIDES SUFFICIENT COOLING FOR DRILLING •CHILLED SALINE MAY BE MORE EFFECTIVE FOR IRRIGATION OF THE OSTEOTOMY AFTER EACH DRILL
"213
IMPLANT DRILL CONTROLLER
•MAXIMUM SPEED= 1500 RPM • COPIOUS IRRIGATION
"214
IMPLANT MOTOR FOOT CONTROL4 PEDALS
Irrigation Pump- On/Off
Program
Forward/Reverse
“Gas Pedal”
"215
IMPLANT DRILL CONTROLLER•TISSUE PUNCH- 800 RPM •DRILLING- 1500 RPM •IMPLANT PLACEMENT- 50
RPM (35 NCM) •COVER SCREW/ HEALING
ABUTMENT - 10 NCM •COPIOUS IRRIGATION
"216
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PREPARING THE OSTEOTOMY AND PLACING THE IMPLANT FIXTURE
DRILL DIRECTION NEEDS TO BE KEPT TRUE• VERY CRITICAL ON PILOT DRILL (FIRST DRILL) • DRILL TRAJECTORY HAS A TENDENCY TO SHIFT AS
IT GETS DEEPER DUE TO FLEXION AT THE WRIST • YOU MUST KEEP YOUR WRIST STIFF AND KEEP
DRILL GOING STRAIGHT. • ON EACH SUCCESSIVE OSTEOTOMY- LET THE DRILL
FIND ITS WAY"218
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
INTRA-OPERATIVE RADIOGRAPHS! Freehand drilling
! To verify osteotomy position and angulation
"219
PRIMARY STABILITY - MECHANICAL•Primary stability starts to
decrease 24 hours after implant placement
•Due to bone bone remodeling around implant
•Implant is least stable about 3-4 weeks after insertion
"220
PRIMARY STABILITY•Implant stability increases
by about 8 weeks - secondary stability
•Due to biological integration (osseointegration)
"221
IMPLANT INITIAL PRIMARY STABILITY•GENERALLY MEASURED BY “INSERTION TORQUE VALUE” - ITV •RESONANCE FREQUENCY ANALYSIS (RFA)
"222
OSSTELL- IMPLANT STABILITY QUOTIENT
"223
ISQ•MEASURES BENDING LOAD •AFFECTED BY !IMPLANT STIFFNESS !INTERFACE WITH SURROUNDING BONE !TRANSDUCER DESIGN !IMPLANT LENGTH ABOVE BONE
"224
Patil R and Bharaswaj D. Is primary stability a predictable parameter for loading implant? J Internat Clin Dental Res Org 8(1): 84-88, 2016.
ISQ VALUES• ISQ <50 has higher non-integration rate • Will change after implant placement # ISQs <60 tend to improve during osseointegration # ISQ 60-69 tends to decrease during 1st 8 weeks, then returned to
initial ISQ values # ISQ >69 decreased stability 1st 4 weeks, then stabilized
"225Simunek A, et al. Development of implant stability during early healing of immediately loaded implants. Int J Orly Maxillofac Impl 27(3): 619-628, 2012
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
INSERTION TORQUE VALUE (ITV)!Mechanical friction between implant and bone !ITV measures resistance to rotation ! Resisting torque depends on - Surface area of implant contacting bone - Implant length and diameter - Critical pressure on the bone - Coefficient of friction
!Static value at implant insertion"226
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
INSERTION TORQUE VALUE (ITV) - IS HIGHER BETTER?! Implants inserted with a high ITV show more bone remodeling and soft tissue recession
that those inserted with “regular torque” - “Regular torque” = <50 N cm - High torque= $ 50 N cm
! ITV < 20 N cm had higher risk of non-integration
"227
Barone A. The clinical effects of insertion torque for implants placed in healed ridges: a two-year randomized controlled clinical trial. J Oral Science & Rehab 2(4):62-73, 2016
!Higher ITVs led to microfracture of (cortical) bone ⇒ net resorption of bone ⇒delayed healing ⟹ reduced bone-implant contact !Higher ITVs may delay secondary stability ⟹ higher risk of non-integration
Norton MR. Primary stability versus viable constraint- a need to redefine. Int J Oral Maxillofac Implants 28(1): 19-21, 2013
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
HIGHER ITV (>50 NCM)
!Thought to increase the risk of non-integration due to pressure necrosis of both cortical and medullary bone.
"228
ITV vs ISQ• AKÇA K ET AL. TORQUE-FITTING AND RESONANCE FREQUENCY ANALYSES OF IMPLANTS IN
CONVENTIONAL SOCKETS VERSUS CONTROLLED BONE DEFECTS IN VITRO. INT J ORAL MAXILLOFAC SURG 2010 39(2): 169-73, 2010. !Primary implant stability assessment by “Torque-fitting vs. RFA compared !No relationship was observed between torque-fitting and RFA.
• MONJE A ET AL. SENSITIVITY OF RESONANCE FREQUENCY ANALYSIS FOR DETECTING EARLY IMPLANT FAILURE: A CASE-CONTROL STUDY, INT J ORAL MAXILLOFAC IMPLANTS 29(2): 456-61, 2014 !3786 implants (June 2007 - January 2013) !20 failures- ISQ at placement and at 4 months !ISQ values are not reliable in predicting early implant failure
"229
Levin B P. The Correlation Between Immediate Implant Insertion Torque And Implant Stability Quotient. Int J Periodontics Restorative Dent 2016 Nov/Dec;36(6):833-840.
•The purpose of this retrospective study was to investigate whether a correlation exists between immediate implant insertion torque value (ITV) and implant stability quotient (ISQ) in nonmolar sites.
•A total of 59 implants in 52 patients were placed into extraction sockets. ITV was recorded at surgery, and ISQ was recorded at surgery and at followup. Implants with higher ITV and/or ISQ were evaluated at 6 to 8 weeks.
•An additional 4 to 6 weeks was permitted for implants with lower initial stability values.
"230
Levin B P. The Correlation Between Immediate Implant Insertion Torque And Implant Stability Quotient. Int J Periodontics Restorative Dent 2016 Nov/Dec;36(6):833-840.
•All 59 implants integrated and were definitively restored •A nonsignificant correlation coefficient of 0.06 could be found between the measurements at either time point. •The data suggests that there is no linear correlation between ITV and ISQ in the measured population. •The findings of this study question the requirement of excessively high ITV and ISQ for immediate temporization and as prerequisites for successful osseointegration.
"231
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
PRIMARY STABILITY> 30 Ncm ⟹ OK to Provisionalize 20 - 30 Ncm ⟹ Healing Abutment
%20 Ncm ⟹ Cover Screw/ Bury"232
POOR PRIMARY STABILITY•MAY BE DUE TO DECREASED BONE DENSITY •MAY BE DUE TO OVER-PREPARATION OF OSTEOTOMY •IF “VISIBLY MOBILE”- REMOVE IMPLANT AND GRAFT •IF “SOMEWHAT STABLE” (%20 NCM)- BURY FIXTURE
"233
POOR PRIMARY STABILITY - “SPINNER”
!
"234
"235
CURRENT CONCEPTS# Implants with lower ITV (<20) and ISQ (<60) values
that have been immediately provisionalized have been shown to osseointegrate
# High ITV and ISQ values are thought to decrease osseointegration
# AIM FOR ITV IN 20 - 35 Ncm RANGE
"236
HIGH (>35 Ncm) INSERTION TORQUE•REVERSE OUT IMPLANT •PREPARE SITE WITH ‘X’ DRILL •REPLACE IMPLANT
"237
INSTRUMENTS NEEDED – "SURGICAL TRAY EV
OVERLAY 3 IS RECOMMENDED FOR OSSEOSPEED PROFILE EV
"238
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ESSENTIALS OF IMPLANTOLOGY - LEVEL I
TRAY CONCEPT"- ONE TRAY FOR ALL OSSEOSPEED™ EV IMPLANTS
! Organized to support the user
! Color coded and simple layout
! Overlay snapped onto the tray base
! No rubber grommets
Overlay
Lid
Tray base
Base shield
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ESSENTIALS OF IMPLANTOLOGY - LEVEL I
OVERLAY 1
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ESSENTIALS OF IMPLANTOLOGY - LEVEL I
OVERLAY 2
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ESSENTIALS OF IMPLANTOLOGY - LEVEL I
OVERLAY 3
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Drilling protocol
Implant Driver EV
Optional drilling
Drill Extension EV Spare Implant Depth Gauge EV Hex Screwdriver EV Spare#Direction Indicator EV Torque Wrench EV
Space for Guide Drill
Drill with markings
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
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ESSENTIALS OF IMPLANTOLOGY - LEVEL I
DRILLING PROTOCOL "- OSSEOSPEED™ EV - CONICAL
2.5#mm
3.1#mm
2.5#mm
3.1#mm
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ESSENTIALS OF IMPLANTOLOGY - LEVEL I
GUIDE DRILL EV / PRECISION DRILL EV
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ESSENTIALS OF IMPLANTOLOGY - LEVEL I
DRILL LOGICS
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ESSENTIALS OF IMPLANTOLOGY - LEVEL I
BONE CLASSIFICATION
! One drilling protocol for preparation of the spongious bone
• Two options for preparation of the cortical bone
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ESSENTIALS OF IMPLANTOLOGY - LEVEL I
DRILLS
! Excellent cutting properties
! Twist drills and step drills
! Sterile packaging
! Multiple-use with option for single-use
! Color-coded and marked with diameters and drill letter/number
! Additional tip depth is maximum 1.0 mm
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ESSENTIALS OF IMPLANTOLOGY - LEVEL I
DRILL LOGICS
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ESSENTIALS OF IMPLANTOLOGY - LEVEL I
DRILL LOGICS"- OPTIONAL OSTEOTOMY PREPARATION
V-Twist Drill – optional extra apical preparation – Length: 6–17 mm
OSTEOTOMY PREPARATION OPTIONS
– 0.0/ 0.3
– 0.5
– 0.3
– 0.0
– 0.15
– 0.3
V DRILL - WIDENS THE APICAL PORTION OF THE OSTEOTOMY X DRILL - FOR DENSER BONE. UNDER-PREPARES THE BODY PORTION AND WIDENS APICAL PORTION
"251
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ESSENTIALS OF IMPLANTOLOGY - LEVEL I
DRILLING PROTOCOL "- OSSEOSPEED™ EV STRAIGHT
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ESSENTIALS OF IMPLANTOLOGY - LEVEL I
DRILLING PROTOCOL "- OSSEOSPEED™ EV STRAIGHT
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ESSENTIALS OF IMPLANTOLOGY - LEVEL I
DRILLING PROTOCOL "- OSSEOSPEED™ EV - CONICAL
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ESSENTIALS OF IMPLANTOLOGY - LEVEL I
DRILLING PROTOCOL "- OSSEOSPEED™ EV - CONICAL
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ESSENTIALS OF IMPLANTOLOGY - LEVEL I
EXPANDED DRILLING PROTOCOL"- OSSEOSPEED™ EV STRAIGHT AND CONICAL
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ESSENTIALS OF IMPLANTOLOGY - LEVEL I
FLEXIBLE DRILLING PROTOCOL "- PROVIDING THE PREFERRED PRIMARY STABILITY
! The stepped osteotomy design ensures proper preparation of the marginal bone for implant placement, while achieving the preferred level of primary stability
4.0 mm
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ESSENTIALS OF IMPLANTOLOGY - LEVEL I
DIRECTION INDICATOR EV! Narrow end is used after drill
! Wider end is used after drill
! A laser marking indicates the 6 mm depth
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ESSENTIALS OF IMPLANTOLOGY - LEVEL I
IMPLANT DEPTH GAUGE EV
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ESSENTIALS OF IMPLANTOLOGY - LEVEL I
IMPLANT DRIVER EV
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ESSENTIALS OF IMPLANTOLOGY - LEVEL I
TORQUE WRENCH EV ! Torque Wrench EV
! Driver Handle, Surgical
! Driver Handles, Prosthetic
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ESSENTIALS OF IMPLANTOLOGY - LEVEL I
IMPLANT PACKAGING
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ESSENTIALS OF IMPLANTOLOGY - LEVEL I
IMPLANT PACKAGING
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ESSENTIALS OF IMPLANTOLOGY - LEVEL I
IMPLANT PICK-UP
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ESSENTIALS OF IMPLANTOLOGY - LEVEL I
DRILL PACKAGING
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ESSENTIALS OF IMPLANTOLOGY - LEVEL I
"DRILLING"
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ESSENTIALS OF IMPLANTOLOGY - LEVEL I
IMPLANT INSTALLATION ""
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
WHAT IF THE IMPLANT FALLS OFF THE DRIVER?
! How do you pick it up and replace it? ! Schumacher- titanium implant holding
forceps #304 (IHF0304)
"268
HEALING OPTIONSONE-STAGE SURGICAL PROTOCOL
- HEALDESIGN EV, ROUND OR TRIANGULAR - HEALING UNI EV
TWO-STAGE SURGICAL PROTOCOL
- COVER SCREW EV, ONE HEIGHT
"269
ESSENTIALS OF IMPLANTOLOGY AND CBCT-GUIDED IMPLANT SURGERY
EV HEALING ABUTMENTS
"270
COVER SCREW VS. HEALING ABUTMENTHOW DO YOU DECIDE?
"271
COVER SCREW• SUBOPTIMAL INITIAL
STABILITY (<20 Ncm) • GRAFTING AROUND
IMPLANT • FLIPPER/ STAYPLATE
RESTING ON RIDGE"272
HEALING ABUTMENT• GOOD INITIAL STABILITY
(>20 Ncm) • TEMPORARY PROSTHESIS
CAN BE SEATED • MINIMAL OR NO
GRAFTING AROUND FIXTURE
"273
COVER SCREW VS. HEALING ABUTMENTSUBCRESTAL IMPLANT PLACEMENT • WHAT IF COVER SCREW OR HEALING
ABUTMENT WON’T SEAT COMPLETELY?
"274
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
POST-OP RADIOGRAPHS! Periapical is usually adequate
! Verify complete seating of cover screw/ healing abutment
! Panoramic in certain situations
"275
IF COVER SCREW/ HEALING ABUTMENT WON’T SEAT FULLY
•BONE IS IN THE WAY! •IMPLANT PLACED TOO DEEPLY •BONE PROFILING NECESSARY
(IF IMPLANT DEPTH GOOD)
"276
EV BONE REAMER KIT
"277
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ESSENTIALS OF IMPLANTOLOGY - LEVEL I
POST-OP INSTRUCTIONS
! Ice ! Soft Diet ! Rest ! Analgesia • 1000mg APAP + 400 mg Ibuprofen • Tramadol 50 mg
POST-IMPLANT SURGERY INSTRUCTIONS
"279
MY POST-OP APPOINTMENT ROUTINE•2 WEEKS - remove sutures •4 WEEKS LATER (6 WEEKS) •8 WEEKS LATER (14 WEEKS)- evaluate for
restoration
"280
IMPLANT INTEGRATION TIME•IMMEDIATE LOAD •8 WEEKS #4 MONTHS
"281
2ND STAGE - UNCOVERING THE FIXTURE•PRESERVE THE KERATINIZED MUCOSA •EXPOSE THE IMPLANT FIXTURE: • PLACE HEALING ABUTMENT • PLACE FINAL ABUTMENT • TAKE FIXTURE-LEVEL IMPRESSION
•SUTURE TISSUE BACK IN PLACE AROUND FIXTURE
"282
2ND STAGE SURGERY
"283
"284
2 WEEKS POST-OP
"285
"286
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
“ANY SURGEON WHO CLAIMS HE NEVER HAS COMPLICATIONS EITHER DOESN’T DO MUCH SURGERY, OR IS A DAMN LIAR!”
"287
COMMON COMPLICATIONS
DAMAGE TO ADJACENT TEETH
"288
DAMAGE TO ADJACENT TEETH•IF MINOR - WATCH •ENDODONTIC TREATMENT •IMPLANT REMOVAL
"289
DAMAGE TO ADJACENT TEETH
"290
BLEEDING DURING SITE PREPARATION
"291
"292
"293
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
“ALL BLEEDING EVENTUALLY STOPS!”
"294ESSENTIALS OF IMPLANTOLOGY AND CBCT-GUIDED IMPLANT SURGERY
SINUSITIS•AUGMENTIN 875MG BID X 14 DAYS •OTC ANTIHISTAMINES- CLARITIN, ALLEGRA •OTC NASAL STEROIDS- FLONASE, NASACORT
"295
SINUSITIS•IF ALLERGIC TO AUGMENTIN (PCN) - Cipro (ciprofloxacin) 500 mg BID - Cleocin (clindamycin) 300 mg QID - Biaxin (clarithromycin) 500 mg BID
"296
SINUSITIS• IF SINUSITIS FAILS TO RESOLVE:
# REMOVE IMPLANT # DEBRIDE GRAFT (CALWELL-LUC)
• SURGICAL EVALUATION (ENT OR OMFS) IF PERSISTENT
"297
PREVENTING IAN INJURY2MM SAFETY MARGIN
"298
NERVE INJURY•IAN INJURY MOST COMMON •Drilling injury
-DRILL EXTENDS 0.1 - 1.0 MM BEYOND FIXTURE DEPTH
•Fixture injury •PRESSURE ON IAN •IMPINGEMENT ON IAN
"299
SEDDON CLASSIFICATION#NEUROPRAXIA •Blunt trauma or
stretching •Minor deficit •No loss of continuity
"300
SEDDON CLASSIFICATION#AXONOTMESIS •Nerve damaged
but not severed •Partial deficit
"301
SEDDON CLASSIFICATION#NEUROTMESIS •Nerve is severed •Axonal degeneration •Neuroma formation •May be painful - dysesthesia •Poor prognosis for resolution
"302
NERVE INJURY PROTOCOL•DOCUMENT •DOCUMENT •DOCUMENT •FOLLOW CLINICAL PROGRESS •IF UNSURE, REFER
SOUTHERN CALIFORNIA CENTER FORORAL AND FACIAL SURGERY
PRELIMINARY NEUROLOGIC EXAM
Patient Name: _____________________________________ File #: ___________________ Date: _________________
Subj
Obj
Clinical Findings:Temperature (ice) + –Pain (pin prick- measure & diagram) + –
Pressure (pin prick, pinch reflex) + –Touch (brush) + –DirectionTwo Point Discrimination & Localization + – (normal = _______ mm) (test = ______ mm)Taste Sweet + – Salt + – Sour + – Bitter + –
Descriptive Findings:
Radiographs:
Comments:
Date of Surgery:Chief Complaint:
Subjective Symptoms:
Pt. given Nerve Injury Information sheet
Next F/U Visit:Consults:
"303
NERVE INJURY PROTOCOL!NEUROPRAXIA •Remove implant •Corticosteroids/ NSAIDs •May resolve in days to
weeks
!AXONOTMESIS •Remove implant •Corticosteroids/ NSAIDs •Sensation returns in 2 - 6
months (0.1mm/d)
"304
NERVE INJURY PROTOCOL!NEUROTMESIS •Complete anesthesia >3 months •Consider surgery for continued anesthesia or dysesthesia
Dysesthesia:Neurontin (gabapentin)900-1200 mg TID
"305
WITHOUT CT GUIDANCE•64 YEAR OLD WOMAN •MULTIPLE IMPLANTS PLACED •RIGHT LOWER LIP NUMB, PAINFUL (BURNING) •PERIAPICAL: #30 IMPLANT “CLOSE” TO MANDIBULAR NERVE
"306
CT SCAN•IMPLANT FIXTURE WAS REMOVED •GABAPENTIN 300MG TID •PAIN IMPROVED OVER 6 MONTHS •GABAPENTIN TAPERED OFF •NERVE SENSATION IMPROVED 80%
"307
"308
BioMed Central
!"#$%&%'(%)!"#$%&'()*%+&',-&.,+&/0-#-0,'&"(+",1%12
Head & Face Medicine
Open AccessResearchEfficacy of low level laser therapy on neurosensory recovery after injury to the inferior alveolar nerveTuncer Ozen†1, Kaan Orhan*2, Ilker Gorur†3 and Adnan Ozturk†3
Address: 1Gülhane Military Medical Academy, Department of Oral Diagnosis and Radiology, 06018, Etlik, Ankara, Turkey, 2Ankara University, Faculty of Dentistry Department of Oral Diagnosis and Radiology, 06500, Besevler, Ankara, Turkey and 3Ankara University, Faculty of Dentistry Department of Oral and Maxillofacial Surgery, 06500, Besevler, Ankara, Turkey
Email: Tuncer Ozen - [email protected]; Kaan Orhan* - [email protected]; Ilker Gorur - [email protected]; Adnan Ozturk - [email protected]
* Corresponding author †Equal contributors
AbstractBackground: The most severe complication after the removal of mandibular third molars is injuryto the inferior alveolar nerve or the lingual nerve. These complications are rather uncommon (0.4%to 8.4%) and most of them are transient. However, some of them persist for longer than 6 months,which can leave various degrees of long-term permanent disability. While several methods such aspharmacologic therapy, microneurosurgery, autogenous and alloplastic grafting can be used for thetreatment of long-standing sensory aberrations in the inferior alveolar nerve, there are few reportsregarding low level laser treatment. This paper reports the effects of low level laser therapy in 4patients with longstanding sensory nerve impairment following mandibular third molar surgery.
Methods: Four female patients had complaints of paresthesia and dysesthesia of the lip, chin andgingiva, and buccal regions. Each patient had undergone mandibular third molar surgery at least 1year before. All patients were treated with low level laser therapy. Clinical neurosensory tests (thebrush stroke directional discrimination test, 2-point discrimination test, and a subjectiveassessment of neurosensory function using a visual analog scale) were used before and aftertreatment, and the responses were plotted over time.
Results: When the neurosensory assessment scores after treatment with LLL therapy werecompared with the baseline values prior to treatment, there was a significant acceleration in thetime course, as well as in the magnitude, of neurosensory return. The VAS analysis revealedprogressive improvement over time.
Conclusion: Low level laser therapy seemed to be conducive to the reduction of long-standingsensory nerve impairment following third molar surgery. Further studies are worthwhile regardingthe clinical application of this treatment modality.
BackgroundThe close anatomic relationship between the inferior alve-olar nerve (IAN) and the roots of an impacted mandibularthird molar tooth is well known. Therefore, the possibility
of injury to the IAN resulting in paresthesia in the courseof the surgical removal of the impacted mandibular thirdmolars has been widely demonstrated [1-5]. The inci-dence of nerve damage after the removal of mandibular
Published: 15 February 2006
Head & Face Medicine 2006, 2:3 doi:10.1186/1746-160X-2-3
Received: 06 November 2005Accepted: 15 February 2006
This article is available from: http://www.head-face-med.com/content/2/1/3
© 2006 Ozen et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
BROKEN ABUTMENT SCREW
"309
ASTRA TECH SCREW REMOVAL INSTRUMENTS
"310
ASTRA TECH SCREW REMOVAL INSTRUMENTS
"311
BROKEN ABUTMENT SCREW•SALVIN IMPLANT RESCUE KIT
"312
"313
OTHER OPTIONS•ULTRASONIC - vibrate and loosen screw - back out with tip •COTTON APPLICATOR - break stick and engage screw - rotate counter-clockwise
"314
BROKEN IMPLANT
"315
FIXTURE REMOVAL•SALVIN IMPLANT RESCUE KIT
"316
"317
IMPLANT REMOVAL TREPHINE
"318
ASTRA TECH EV IMPLANT REMOVAL
"319
"320
"321
ESSENTIALS OF IMPLANTOLOGY AND CBCT-GUIDED IMPLANT SURGERY - LEVEL I
CLINICAL FINDINGS WITH HEALTHY DENTAL IMPLANTS
! Firm pink peri-implant mucosa ! Shallow probing depths (! 3 mm) ! Absence of bleeding on probing ! Absence of purulence or suppuration ! Non-responsive to percussion ! High-pitched resonance with percussion ! Maintenance of bone level to 1st thread of
fixture"322
Vered Y, et al. Teeth and implant surroundings: clinical health indices and microbiologic parameters. Quinessence Int 42(4): 339-344, 2011
PERI-IMPLANT MUCOSITIS AND PERI-IMPLANTITIS•DENTAL IMPLANTS ARE NOT SUSCEPTIBLE TO
CARIES •BUT THEY ARE SUSCEPTIBLE TO SOFT TISSUE
INFLAMMATORY PROBLEMS, JUST LIKE NATURAL DENTITION
•CAN RESULT IN LOSS OF IMPLANTS"323
PERI-IMPLANT MUCOSITIS•32 - 80% INCIDENCE •INFLAMMATION DURING HEALING •BIOFILM HARBORING BACTERIA (GRAM -) •REVERSIBLE INFLAMMATORY CHANGES •NO BONE LOSS
"324
Ziltman NU, Berglund T. Definition and prevalence of peri-implant disease. J Clin Periodontol 35(8):286-291, 2008
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
RISK FACTORS FOR PERI-IMPLANT MUCOSITIS AND PERI-IMPLANTITIS! Previous periodontal disease ! Poor plaque control/ inability to clean ! Smoking ! Genetic factors ! Diabetes ! Occlusal overload
! Residual cement
AAP Task Force on Peri-Implantitis. Peri-Implant Mucositis and Peri-Implantitis: A current Understanding of Their Diagnoses and Clinical Implications. J Periodontol 84(4): 436-443, 2013.
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
MANAGEMENT•Avoid manipulating implant fixture for the first 6 weeks of integration
#Light debridement
#Chlorhexidine irrigation/ rinse
•Infected- antibiotics #amoxicillin
#cephalosporin
#clindamycin"326
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
MANAGEMENT•Elimination of biofilm from the implant surface is primary goal #Irrigation device
#Chlorhexidine irrigation/ rinse
•Infected- antibiotics #amoxicillin
#cephalosporin
#clindamycin
ESSENTIALS OF IMPLANTOLOGY AND CBCT-GUIDED IMPLANT SURGERY - LEVEL I
SODIUM HYPOCHLORITE IRRIGATION! Oral rinse with 0.05% sodium hypochlorite resulted in significant reductions in
supragingival biofilm accumulation and gingival inflammation - De Nardo R, et al. Effects of 0.05% sodium hypochlorite oral rinse on supragingival biofilm and gingival
inflammation. Int Dent J 62(4): 208-212, 2012
! Twice-weekly oral rinsing with 0.25% sodium hypochlorite produced a significant reduction in bleeding on probing, even in deep unscaled pockets - Gonzales S, et al. Gingival bleeding on probing: a relationship to change in periodontal pocket depth
and effect of sodium hypochlorite oral rinse. J Periodontal Res 50(3): 387-402, 2015
! Sodium hypochlorite, hydrogen peroxide, chlorhexidine and Listerine showed a significant bactericidal effect against adhering bacteria - Gosau M, et al. Effect of six different peri-implantitis disinfection methods on in vivo human oral biofilm.
Clin Oral Impl Res 21(8): 866-872, 2010"328
PERI-IMPLANTITIS•10 - 40% INCIDENCE •INFLAMMATORY PROCESS •BIOFILM HARBORING PATHOLOGIC BACTERIA !TITANIUM AND ZIRCONIUM ABUTMENTS
SIMILARLY COLONIZED •IMPLANT IN FUNCTION •BONE LOSS
"329
Rosen P, et al. Peri-implant mucositis abd peri-implantitis: a current understanding of their diagnoses and clinical implications. J Periodontol 84(4): 436-4443, 2013
PERI-IMPLANTITIS•MOST COMMONLY ASSOCIATED WITH
IMPLANT-SUPPORTED OVERDENTURES •INCIDENCE 11-32% (FIXED 7-20%) • ARDEKIAN L, DODSON TB, COMPLICATIONS ASSOCIATED WITH THE PLACEMENT
OF DENTAL IMPLANTS; ORAL MAXILLOFACIAL CLINICS N AM15 (2003) 243-249
"330
A MULTIFACTORIAL ANALYSIS TO IDENTIFY PREDICTORS OF IMPLANT FAILURE AND PERI-IMPLANT BONE LOSS
•TO IDENTIFY PREDICTORS OF IMPLANT FAILURE AND PERI-IMPLANT BONE LOSS
! RETROSPECTIVE COHORT, 376 PATIENTS WITH 1320 OSSEOSPEED IMPLANTS
! AT LEAST 2 YEARS FOLLOW-UP (24-65 MONTHS) ! STATISTICAL ANALYSES, AT A LEVEL OF SIGNIFICANCE OF 0.05 • - MULTIVARIATE ANALYSIS (COX PROPORTIONAL HAZARDS REGRESSION)
Aim
Vervaeke S, Collaert B, Cosyn J, Deschepper E, De Bruyn H.
Clin Implant Dent Rel Res 2013;E-pub Sep 4, doi:10.1111/cid.12149
Materials
&
Methods
"331
A MULTIFACTORIAL ANALYSIS TO IDENTIFY PREDICTORS OF IMPLANT FAILURE AND PERI-IMPLANT BONE LOSS
SURVIVAL BONE LOSS
TREATMENT PROTOCOL NS NS •SMOKING STATUS P =0.001 P <0.001 • IMPLANT DESIGN NS NS •RECONSTRUCTION NS NS •TREATED JAW NS P <0.001 •OPPOSING JAW STATUS NS NS •RECALL COMPLIANCE P = 0.010 NS
Multivariate analysis
Results $ Cumulative implant survival 96.8% on patient level
$ Mean bone loss 0.36 mm (SD #0.68)
"332
Results: Risk factors for bone loss were: - Being a smoker - Having an implant in the maxilla
Risk factors for implant failure were: - Being a smoker - High recall compliance (patients who experienced an implant failure of one of their implants were more prone to check their oral status than patients not having experienced any failures)
$ Implant related factors did not affect marginal bone loss or implant survival $ Being a smoker was associated with implant failures and bone loss $ Implant in the maxilla was associated with more bone loss
Conclusion:
A MULTIFACTORIAL ANALYSIS TO IDENTIFY PREDICTORS OF IMPLANT FAILURE AND PERI-IMPLANT BONE LOSS
"333
PERI-IMPLANTITIS•MINOR •Scale with titanium
curette •Intrasulcular antibiotics •Home irrigator/ HClO
"334
CEMENT SEPSIS•NEEDS TO BE DEBRIDED; MANAGED LIKE PERI-IMPLANTITIS •BEST TO AVOID- KEEP MARGINS % 1MM SUBGINGIVAL
"335
EXPOSED FIXTURE- Expect further
exposure as inflammation reduces
- Pocket depth improves - May be maintainable
for long term
"336
MODERATE IMPLANTITIS•Mild radiographic bone loss/
pocketing •Increased probing depths •Bleeding on probing •Gingival erythema •Purulent drainage •Gram - anaerobes •No mobility
!337
PERI-IMPLANTITIS•Surgical debridement •Citrate, CHX •Bone graft •Infuse (rBMP) •Barrier membrane -
PerioDerm •Primary closure
"338
NEWER TECHNOLOGIES TO TREAT PERI-IMPLANT DISEASE•ER,CR:YSGG LASER - Removes biofilm and Ti Oxide - Removes granulation tissue - Sterilizes sulcus/pocket - May promote bony regrowth
"339
NEWER TECHNOLOGIES TO TREAT PERI-IMPLANT DISEASE•ER,CR:YSGG LASER - Removes biofilm and Ti Oxide - Removes granulation tissue - Sterilizes sulcus/pocket - May promote bony regrowth •GLYCINE POLISHING - Peri-implant mucositis - Adjuunct to laser
"340
ULTRASONIC IMPLANT DEBRIDEMENTNo peer-reviewed articles showing lack of damage to implant surface
"341
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
CAN AN IMPLANT HAVE A PERIAPICAL LESION?
! Inactive - probable apical scar from osteotomy longer than implant
! Infected - Implant placed in proximity to focus of infection
- Contaminated implant was placed
- Bony necrosis due to overheating
"342Reiser GM, Nevins M. The implant periodical lesion: etiology, prevention, and treatment. Compend Contin Educ Dent 16(8): 768-772, 1995
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
IMPLANT PERIAPICAL LESION
! If infected, requires surgical intervention - If not mobile: apical resection and debridement
- If mobile: removal and grafting
"343
Penarrocha-Diago M, et al. Implant periodical lesion: diagnosis and treatment. Oral Med Oral Path Oral Surg 17(6): 1023-1027, 2012
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
IMPLANT PERIAPICAL LESION
"344
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
IMPLANT PERIAPICAL LESION
"345
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
IMPLANT PERIAPICAL LESION
"346
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
IMPLANT PERIAPICAL LESION
"347
ESSENTIALS OF IMPLANTOLOGY AND CBCT-GUIDED IMPLANT SURGERY - LEVEL I
FAILING IMPLANT•Refractory to treatment •Continues to get worse "Bone loss progresses "Continued suppuration "Continued pain "Mobility
!348
IMPLANT FAILURE
"349
PROTOCOL•CHLORHEXIDINE RINSE- BID •AMOXICILLIN 875MG BID •START 2 DAYS PRIOR •CONTINUE 5 DAYS POST-OP
"350
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
RISK FACTORS FOR IMPLANT FAILURE! Smoking negatively affects healing and the outcome of implant treatment. - Chrcanovic BR, Albrektsson T, Wennerberg A. Smoking and dental implants:
a systematic review and meta-analysis. J Dent 43(5): 487-498, 2015.
! Smoking and antidepressant use were statistically significant predictors of implant failure
- Chrcanovic BR, et al. Factors influencing early dental implant failures. J Dent Res 95(9): 995-1002, 2016
"351
ESSENTIALS OF IMPLANTOLOGY AND CBCT-GUIDED IMPLANT SURGERY - LEVEL I
SALVAGE OF AN AILING IMPLANT! The fixed dental prosthesis supported by the implant does not require
replacement unless the implant is removed ! Esthetics is not a factor ! Adequate access for peri-implantitis treatment is available ! The implant is causing an esthetic problem that can be predictably treated by
surgical and/or prosthetic means (excludes poor implant placement) ! Removal cannot be done by reverse torquing the fixture (would require trephine
or drill) ! The patient has psychological or emotional attachment to the implant ! Financial considerations are an issue
"352
Tarnow DP, Chu SJ, Fletcher PD. Clinical decision: Determining when to save or remove an ailing implant. CDE World April 2016
ESSENTIALS OF IMPLANTOLOGY AND CBCT-GUIDED IMPLANT SURGERY - LEVEL I
! The fixed dental prosthesis supported by the ailing implant requires replacement
! The implant is causing an esthetic problem that cannot be predictably treated by surgical or prosthetic means (includes poor implant placement)
! There is existing attachment loss in combination with poor position ! The implant can be reverse torqued out with out damaging the surrounding
periodontium and adjacent teeth ! Prosthetic components are no longer manufactured for the specific existing
implant system
"353
Tarnow DP, Chu SJ, Fletcher PD. Clinical decision: Determining when to save or remove an ailing implant. CDE World April 2016
REMOVAL OF AN AILING IMPLANT
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
RITZER J., ET AL. NATURE COMMUNICATIONS 8:264, AUG 15, 2017
! Standard testing: matrix metaloproteins (MMP-8) in sulcular fluid in peri-implant pockets
! Developed a chewing gum test for peri-implantitis - Attached bitter peptide denatonium fragment
to chewing gum - MMP-8 cleaves off denatonium, resulting in a
bitter taste - Intensity of bitterness related to level of MMP-8
! Good correlation between home chewing gum test and chair side sulcular fluid assay
"354
ARTICLE
Diagnosing peri-implant disease using the tongueas a 24/7 detectorJ. Ritzer1, T. Lühmann1, C. Rode2, M. Pein-Hackelbusch3, I. Immohr3, U. Schedler4, T. Thiele4, S. Stübinger5,
B.v. Rechenberg5, J. Waser-Althaus6, F. Schlottig6, M. Merli7, H. Dawe7, M. Karpíšek8, R. Wyrwa2,
M. Schnabelrauch2 & L. Meinel1
Our ability of screening broad communities for clinically asymptomatic diseases critically
drives population health. Sensory chewing gums are presented targeting the tongue as 24/7
detector allowing diagnosis by “anyone, anywhere, anytime”. The chewing gum contains
peptide sensors consisting of a protease cleavable linker in between a bitter substance and a
microparticle. Matrix metalloproteinases in the oral cavity, as upregulated in peri-implant
disease, specifically target the protease cleavable linker while chewing the gum, thereby
generating bitterness for detection by the tongue. The peptide sensors prove significant
success in discriminating saliva collected from patients with peri-implant disease versus
clinically asymptomatic volunteers. Superior outcome is demonstrated over commercially
available protease-based tests in saliva. “Anyone, anywhere, anytime” diagnostics are within
reach for oral inflammation. Expanding this platform technology to other diseases in the
future features this diagnostic as a massive screening tool potentially maximizing impact on
population health.
DOI: 10.1038/s41467-017-00340-x OPEN
1 Institute for Pharmacy and Food Chemistry, Universität Würzburg, Am Hubland, 97074 Würzburg, Germany. 2 Biomaterials Department, Innovent e.V.,Prüssingstraße 27B, 07745 Jena, Germany. 3 Institute for Pharmaceutics, Universität Düsseldorf, Universitätsstraße 1, 40225 Düsseldorf, Germany. 4 PolyAnGmbH, Rudolf-Baschant-Straße 2, 13086 Berlin, Germany. 5Musculoskeletal Research Unit, Center for Applied Biotechnology and Molecular Medicine,Universität Zürich, Winterthurerstrasse 270, 8057 Zurich, Switzerland. 6 Thommen Medical AG, Neckarsulmstrasse 28, 2540 Grenchen, Switzerland.7 Indent—International Dental Research and Education srl, Via Settembrini 17/o, 47923 Rimini, Italy. 8 BioVendor—Laboratorni medicina AS and Departmentof Human Pharmacology and Toxicology, University of Veterinary and Pharmaceutical Sciences, Palackého 1-3, 61242 Brno, Czech Republic. J. Ritzer andT. Lühmann contributed equally to the work. Correspondence and requests for materials should be addressed to L.M. (email: [email protected])
NATURE COMMUNICATIONS |8: �264� |DOI: 10.1038/s41467-017-00340-x |www.nature.com/naturecommunications 1
Biomaterials Dept., Univ. of Würzburg, Germany
JBR
HANDS-ON EXERCISE
Overlay 3
Drilling protocol "- OsseoSpeed™ EV - conical
"Drilling""
"Implant installation ""
DRILL DIRECTION NEEDS TO BE KEPT TRUE• VERY CRITICAL ON PILOT DRILL (FIRST DRILL) • DRILL TRAJECTORY HAS A TENDENCY TO SHIFT AS
IT GETS DEEPER DUE TO FLEXION AT THE WRIST • YOU MUST KEEP YOUR WRIST STIFF AND KEEP
DRILL GOING STRAIGHT. • ON EACH SUCCESSIVE OSTEOTOMY- LET THE DRILL
FIND ITS WAY"360
Implant design "- OsseoSpeed™ EV
Green
1.8#mm
2.5#mm
3.1#mm
3.7#mm
4.3#mm
2.5 #mm
3.1#mm
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
•Adequate ridge width at crest with adjacent convergent roots #Congenitally missing tooth
•Sinus lift with 6-8 mm of bone
"362
INDICATIONS FOR EV CONICAL IMPLANTS
ESSENTIALS OF IMPLANTOLOGY AND CBCT-GUIDED IMPLANT SURGERY
OSSEOSPEED™ EV CONICAL - CLINICAL INDICATIONS
!Limited space between roots - maxillary anterior !Posterior maxilla - ridge height & 6 mm
"363
JBR
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
DRILLING PROTOCOL "- OSSEOSPEED™ EV - CONICAL
2.5#mm
3.1#mm
2.5#mm
3.1#mm
Drilling protocol "- OsseoSpeed™ EV - conical
Drilling protocol "- OsseoSpeed™ EV - conical
Expanded drilling protocol"- OsseoSpeed™ EV straight and conical
OSSEOSPEED™ PROFILE EVA UNIQUELY SHAPED, PATENTED IMPLANT, SPECIFICALLY DESIGNED FOR SLOPED RIDGE SITUATIONS THAT PRESERVE THE MARGINAL BONE AND SUPPORTS THE SOFT TISSUE ALL AROUND THE IMPLANT.
360° bone preservation in sloped ridges
"368
2.5 #mm
3.1#mm
IMPLANT DESIGN AND ASSORTMENT"- OSSEOSPEED™ PROFILE EV
3.1#mm 3.7#
mm "369
OVERVIEWSLOPED RIDGES ARE A COMMON CLINICAL SITUATION OSSEOSPEED™ PROFILE EV IS DESIGNED FOR SLOPED RIDGE SITUATIONS THAT PRESERVES THE MARGINAL BONE AND SUPPORTS THE SOFT TISSUE ALL AROUND THE IMPLANT
EFFICIENT USE OF AVAILABLE BONE REDUCED NEED FOR AUGMENTATION SOFT TISSUE ESTHETICS
"370
Noelken R., Donati M., Fiorellini J., Gellrich N.C., Parker W., Wada K., and Berglundh T. Clin Oral Implants Res 2012;E-pub Dec 5, doi:10.1111/clr.12079
0 WEEK OSSEOSPEED™ PROFILE IMPLANT PLACEMENT AND HEALING ABUTMENT 4.0/5.0 CONNECTION
16 WEEKS RE-ENTRY AND CLINICAL MEASUREMENTS 21 WEEKS FINAL ABUTMENT AND CROWN INSTALLATION (LOADING) 1 YEAR LAST FOLLOW-UP
• 2.2 MM PROBING POCKET DEPTH AT THE 21-WEEK FOLLOW-UP • 2.5 MM PROBING POCKET DEPTH AT THE 1-YEAR FOLLOW-UP • SMALL CHANGES IN CLINICAL ATTACHMENT LEVELS BETWEEN 21-
WEEK AND 1-YEAR FOLLOW-UP (-0.1 TO +0,1 MM)
:(VRW%(
AXY!X@YZ(
!Y:V>(:,
:AH(%(@::VY
SOFT AND HARD TISSUE ALTERATIONS AROUND IMPLANTS PLACED IN AN ALVEOLAR RIDGE WITH A SLOPED CONFIGURATION
"371
SOFT AND HARD TISSUE ALTERATIONS AROUND IMPLANTS PLACED IN AN ALVEOLAR RIDGE WITH A SLOPED CONFIGURATION
NO IMPLANT FAILURES STABLE MARGINAL BONE LEVELS
- BUCCAL BONE ALTERATIONS (16 W): - 0.3 MM - LINGUAL BONE ALTERATIONS (16 W): - 0.02 MM - PROXIMAL BONE ALTERATION (1 YEAR): - 0.54 MM
• STABLE HARD AND SOFT TISSUES • PRESERVED DIFFERENCES BETWEEN BUCCAL AND LINGUAL
BONE LEVELS
RESULTS:
HARD TISSUE
CONCLUSIONS
Noelken R., Donati M., Fiorellini J., Gellrich N.C., Parker W., Wada K., and Berglundh T. Clin Oral Implants Res 2012;E-pub Dec 5, doi:10.1111/clr.12079
"372
SURVIVAL AND TISSUE MAINTENANCE OF AN IMPLANT WITH A SLOPED CONFIGURED SHOULDER IN THE POSTERIOR MANDIBLE-A PROSPECTIVE MULTI CENTER STUDY24 CENTERS/ 184 PATIENTS/ 238 PROFILE OS TX IMPLANTS ASSESSMENT TIMES
•BEFORE PLACEMENT •AFTER PLACEMENT •PROSTHETIC DELIVERY •6, 12, 24 MONTHS AFTER PLACEMENT
Schiegnitz E at al. Clin Oral Implants Res 2016 May
"373
• AVG 2.4 (#0.4) YEARS - 99.2% SURVIVAL • INCREASED PERI-IMPLANT KERATINIZED MUCOSA • GREATEST DIFFERENCE IN %2MM KG AT POST-OP • MEAN INTER PROXIMAL BONE LOSS 0.30#0.6MM • SLOPED SHOULDER CONFIGURATION SUPPORTS
REGAIN OF KG
SURVIVAL AND TISSUE MAINTENANCE OF AN IMPLANT WITH A SLOPED CONFIGURED SHOULDER IN THE POSTERIOR MANDIBLE-A PROSPECTIVE MULTI CENTER STUDY
Schiegnitz E at al. Clin Oral Implants Res 2016 May
"374
IMPLANT SLOPE HEIGHT
"375
OPTIMAL POSITIONINGFOR OPTIMAL UTILIZATION OF THE FEATURES OF OSSEOSPEED PROFILE EV, THE POSITIONING OF THE IMPLANT IS CRUCIAL THE OBJECTIVES ARE TO: • PLACE THE IMPLANT LEVEL WITH THE
BUCCAL MARGINAL BONE LEVEL • SUPPORT THE MARGINAL BONE ALL THE
WAY AROUND THE IMPLANT
Note: One turn is equivalent to a 0.6 mm change in vertical position "376
INSTRUMENTS NEEDED – "IMPLANT DRIVER PROFILE EV• Seats in only one position in the
implant
• Dimple and one flat side to facilitate correct positioning
"377
Implant-abutment interface connection
Index free Index-free abutments will be seated in any rotational position.
One-position-only All ATLANTIS abutments and indexed components for OsseoSpeed Profile EV will fit in one position only.
OsseoSpeed™ Profile EV
Components specifically designed for OsseoSpeed Profile EV are not interchangeable with OsseoSpeed EV for ensured accuracy
Cover Screw Profile EV
The cover screw has a self-guiding feature • Designed to engage and
seat in one-position-only • Two-piece
Note: When removing a two-piece component, keep the sleeve and screw assembled.
Instruments needed – "Implant Driver Profile EV
• Seats in only one position in the implant
• Dimple and one flat side to facilitate correct positioning
Instruments needed – "Surgical Tray EV
Overlay 3 is recommended for OsseoSpeed Profile EV
SIMPLANT® with "ASTRA TECH Implant System™ EV
Guided Surgery with OsseoSpeed™ Profile EV
Instruments needed: • Implant Driver Profile EV • Proline Overlay
Osteotomy preparation
4.0 mm
Spongious bone preparation
Cortical bone preparation
Optional osteotomy preparation
Drilling protocol, straight Optional
preparationSpongious bone
preparationCortical bone preparation
Drilling protocol, conicalOptional
preparationSpongious bone
preparationCortical bone preparation
Drilling protocol
"Special considerations OsseoSpeed™ Profile EV
Implant slope height
Measuring – considerations
• Verify drilling depth after cortical drill • Place the Implant Depth Gauge against the
buccal and palatal walls of the osteotomy to verify the drilling depth
13 mm11.6 mm
OsseoSpeed Profile EV 4.2 PS,13 mm
• For OsseoSpeed Profile EV 4.2 PS, 13 mm implant, the buccal depth should be at least 11.6 mm
• If the osteotomy is too shallow, additional drilling is required
• If the depth is more than 11.6 mm make sure to stop the implant installation at, or slightly apical to the buccal margin
Measuring – considerations, cont.
1.4 mm
11.6 mm13 mm
OsseoSpeed Profile EV 4.2 PS,13 mm
Optimal positioning• For optimal utilization of the features of
OsseoSpeed Profile EV, the positioning of the implant is crucial
• The objectives are to: – place the implant level with the buccal marginal
bone level – support the marginal bone all the way around the
implant
Note: One turn is equivalent to a 0.6 mm change in vertical position
WHY DO WE PLACE IMPLANTS?TO REPLACE
MISSING TEETH!
"393
“PROSTHETICALLY-DRIVEN”•START WITH THE IDEAL
PROSTHETIC RESTORATION
•WORK BACKWARDS FROM THERE
Enamel
Dentin
Pulp
Gingiva
Periodontal Ligament
Custom Crown
Abutment
Implant Fixture
Alveolar Bone
"394
CBCT-GUIDED IMPLANT SURGERY• USES A CUSTOM SURGICAL GUIDE FOR
IMPLANT PLACEMENT. • MASTER SLEEVE CONTROLS IMPLANT
LOCATION, ANGULATION AND DEPTH. • SLEEVE-IN-SLEEVE SYSTEM CONTROLS
EACH OSEOTOMY DRILL. • MASTER SLEEVE POSITION DETERMINED
BY COMPUTER-DESIGNED TREATMENT PLAN
"395
IMPLANT PLANNING - GALILEOS IMPLANT
"396
KEY TO SUCCESS•GUIDED IMPLANT SURGERY IS NO DIFFERENT THAN ANY OTHER
RESTORATIVE PROCEDURE IN DENTISTRY. •GUIDED IMPLANT SURGERY ONLY WORKS IF THERE IS ATTENTION
TO DETAIL AT EVERY STEP. •THE WAX-UP SHOULD ACCURATELY REPRESENT THE DESIRED
FINAL PROSTHESIS. •THE POSITION OF THE RADIOGRAPHIC TEMPLATE AND THE
SURGICAL GUIDE MUST BE IDENTICAL OR IMPLANT PLACEMENT WILL BE INACCURATE.
"397
GALILEOS CLASSIC GUIDE WORKFLOW•THIS IS THE ONE THAT YOU NEED TO KNOW FIRST! •SCANNING TEMPLATE •RADIOPAQUE PONTIC
"398
GALILEOS WORKFLOW
•“CLASSIC” GUIDE VS. OPTIGUIDE
"399
WHAT IS THE DIFFERENCE?
"400
CLASSIC GUIDE OPTIGUIDE
When to UseDon’t have CEREC
Scatter Complex case
Have CEREC Few restorations
Simple case
What you needSICAT Scanning template
Wax-up Vacuform shell or FutarScan
CEREC optical scan CEREC proposal
Send to SICAT On CD Upload
STUDY MODEL
"401
DUPLICATE MODEL/ WAX-UP
"402
CREATE VACUFORM SHELL
"403
“CLASSIC” WORKFLOW- SCANNING WITH A TEMPLATE
Thermoformed Stent"404
SCAN PATIENT WITH TEMPLATE
"405
PLAN WITH ASTRA EV/ VIDEO
"406
"407
"408
"409
!
"410
"411
WITHOUT VACUFORM SHELL
"412
GALILEOS ADVANCED USERS’ TRAINING 2017
“DIRECT SCAN TEMPLATE”- FUTAR SCAN Classic Guide
DIRECT SCAN TEMPLATE- FUTAR SCAN
Futar® Scan – State-of-the-art material for optical data recording.Futar® Scan guarantees ideal results during recording via optics or laser in CAD/CAM systems.
Best scan results for optical and laser systems (naturally without powdering)Extra hard A-silicone (Shore-D 35 hardness) with excellent flexural stabilityExtra-fast setting characteristics: Total working time 15 seconds, setting time 45 secondsCan be cut very well with a scalpelLow material consumption due to extrusion through short mixing tipCan also be used as a syringeable material for “ conventional” bite registration, in terminal occlusion, or for all other laboratory applications that require an extra hard silicone
Futar® Scan - State-of-the-art bite registration material for optical data recordingIdeal for use in CAD/CAM systems
When using modern CAD/CAM systems in the dental office or laboratory, perfectly accurateimage replication is of utmost importance. That is exactly where Futar® Scan comes into play,as it has been optimised for data recording via optics and laser respectively. Futar® Scanstands out due to its high-quality scan results, naturally without actually having to usepowder! The excellent optical properties (best dynamic results!) guarantee high recordingquality and optimal image replication. Convince yourself about the advantages of Futar® Scan, the scanable bite registration material on vinyl polysiloxane basis, in a cartridge.
Product propertiesProduct Shore hardness Total Intra-oral Final set
working time setting time
Futar® Scan Shore D 35 15 sec. 45 sec. 1 min.
Futar® Scan, Order. No. 119712 x 50 ml + 12 mixing tips
0203
72_4
007
APPROVED BITE REGISTRATION MATERIALS• Futar Scan (Kettenbach) *• Futar D (Kettenbach)• Flexitime bite (Heraeus)• Metalbite (R-Dental)• Virtual CADbite (Ivoclar)
DIRECT SCAN TEMPLATE (CGI)
GALILEOS ADVANCED USERS’ TRAINING 2017
SURGICAL GUIDE WORKFLOWHow to produce a direct scan stent
#Drill 4 holes (Ø4mm) at indicated positions
#Apply Futar Scan bite registration material
#Register the bite plate in the patients mouth
# It is still necessary to send a stone model along with the stent!
RECOMMENDED STONE FOR STUDY MODEL
SCANNABLE STONE
GALILEOS SCAN
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
"422
CEREC-GALILEOS INTEGRATED WORKFLOW
• OPTIGUIDE FROM SICAT • CEREC DATA IS IMPORTED IN TO
GALILEOS • .SSI FILE
"423
OPTIGUIDE WORKFLOW- SICAT MILLED GUIDE• P&%+D3$%1#;3$%2$["D2$8%• V9$9%\Y!Y\%]12&1&9;#^%;9%
8DND3;#%_;C5"1%• G%&2%H$_$2%@*1#;<3%HDC3"2$9%• 7D#;3$2;#%:3;+D#D`;3D&<%• BD<D*;#%B$3;#
"424
CEREC-GALILEOS INTEGRATION
.SSI FILE CAN GO ON A MEMORY STICK
"425
"426
"427
"428
CRAIG BOONE PLANNING VIDEO
"429
"430
POSTOP
"431
!
ASTRA TECH SYSTEM EV PROTOCOL
"432
ASTRA TECH SYSTEM EV GUIDED TRAY
"433
AN RCT COMPARING GUIDED IMPLANT SURGERY (BONE OR MUCOSA SUPPORTED) WITH MENTAL NAVIGATION OR THE USE OF A PILOT-DRILL TEMPLATE
•59 PATIENTS WERE RANDOMIZED INTO 6 GROUPS AS FOLLOWS: $ GUIDING SYSTEMS 1) UNIVERSAL BONE, 2) UNIVERSAL MUCOSA, 3) FACILITATE BONE, 4) FACILITATE MUCOSA
CONTROLS 5) TEMPLATE PILOT DRILL 6) MENTAL NAVIGATION
•PLANNING IN SIMPLANT SOFTWARE USING IMPORTED CT SCANS •FABRICATION OF ALL STEREOLITHOGRAPHIC GUIDES WAS DONE BY DENTSPLY
IMPLANTS •314 OSSEOSPEED IMPLANTS WERE PLACED (4 - 6 IMPLANTS IN MANDIBLE OR MAXILLA)
•PRE AND POSTOPERATIVE SCANS WERE COMPARED IN MIMICS SOFTWARE (MATERIALISE)
•OUTCOME VARIABLES (DEVIATION): A) ENTRY POINT, B) ANGULAR DEVIATION, C) APEX POINT
Purpose
Vercruyssen M, Cox C, Coucke W, Naert I, Jacobs R and Quirynen M. J Clin Periodontol 2014;E-pub Jan 28, doi:10.1111/jcpe.12231
Materials
&
Methods
To evaluate the accuracy of stereolithographic surgical drill guides
"434
Results Entry point Angular Apex point
Guiding systems#(average of Universal and Facilitate) 1.4 mm 3.0% 1.6 mm
Mental navigation 2.7 mm 9.9% 2.9 mmTemplate pilot drill 3.0 mm 8.4% 3.4 mm
Guided surgery has an added value and shows smaller deviations compared to mental navigation or using a template for guide drills
Conclusion
- Larger deviation in lower jaw and in poor quality bone
- No influence of type of support, i.e. bone vs. mucosa or Universal vs. Facilitate
Deviation:
AN RCT COMPARING GUIDED IMPLANT SURGERY (BONE OR MUCOSA SUPPORTED) WITH MENTAL NAVIGATION OR THE USE OF A PILOT-DRILL TEMPLATE
"435
THE ACCURACY OF IMPLANT PLACEMENT BY EXPERIENCED SURGEONS: GUIDED VS FREEHAND APPROACH IN A SIMULATED PLASTIC MODEL
% Evaluate the difference in accuracy between freehand and guided implant placement
% Performed by experienced surgeons
X$2*$"#$<%6.%@<3%6%A2;#%B;CD##&';0%@*1#;<39.%E-FS%A03%FG.%8&D,%F-.FFS-Uab&*D./-S/
• 80 implants - anterior of maxillary models • 10 experienced surgeons • 4 single implant cases- partially / fully-edentulous • 4 freehand placement • 4 with SIMPLANT surgical guide • Compared CBCT based plan vs. actual placement • Measured: vertical, lateral, angular deviations
!"#$%&'
()*'#+),&-)./-
('*0%/&
"436
THE ACCURACY OF IMPLANT PLACEMENT BY EXPERIENCED SURGEONS: GUIDED VS FREEHAND APPROACH IN A SIMULATED PLASTIC MODELX$2*$"#$<%6.%@<3%6%A2;#%B;CD##&';0%@*1#;<39.%E-FS%A03%FG.%8&D,%F-.FFS-Uab&*D./-S/
!"#$%$&'"()%(*&)#+%'&%+%,&%-.%(#%,/%$&'"()%0,'&'#),#1#/2,34*&5#)5%(&.(%$#/326#4#3*&2,$&2//"(2/*&352,&1(%%52,$&.42/%7%,3
1'&",*&
2%.3,"&+%.
Angular Deviation Lateral Deviation - Crest
Lateral Deviation - Apex
Depth
Freehand 7.63! 1.27 mm 1.28 mm 0.78 mm
Guided 2.19! 0.42 mm 0.52 mm 0.54 mm
"437
DREISEIDLER T ET AL. ACCURACY OF A NEWLY DEVELOPED INTEGRATED SYSTEM FOR DENTAL IMPLANT PLANNING
• EVALUATED ACCURACY OF SICAT SURGICAL GUIDES • 10 PARTIALLY-EDENTULOUS MODELS • 54 IMPLANTS PLACED • 2MM PILOT SLEEVES VERSUS NOBELGUIDE • PLANNED VERSUS PLACED IMPLANT POSITIONS COMPARED • MEAN ANGULATION VARIANCE: 1.18 DEGREES • MEAN APICAL POSITION VARIANCE: <500 MICRONS
Clin Oral Implants Res 20(9) : 1191-9, 2009
"438
ESSENTIALS OF IMPLANTOLOGY AND CBCT-GUIDED IMPLANT SURGERY
"439
ESSENTIALS OF IMPLANTOLOGY AND CBCT-GUIDED IMPLANT SURGERY
PATIENT CARD
Item number 32670687-US-1705Comes in packs of 25
"440
SURGICAL COMPONENTS AND PROCEDURES! “STANDARD” EV SURGICAL KIT ! EV GUIDED SURGICAL KIT
"441
GUIDED SURGERY COMPONENTS AND INSTRUMENTS
GALILEOS computer guided implant treatment"
with the ASTRA TECH Implant System™ EV
"442
GUIDED SURGERY WITH ASTRA TECH IMPLANT SYSTEM™ EV
"443
GUIDED SURGERY WITH OSSEOSPEED™ PROFILE EVINSTRUMENTS NEEDED:
IMPLANT DRIVER PROFILE EV PROLINE OVERLAY
"444
GUIDED SURGERY COMPONENTS"– HIGHLIGHTS
User-friendly tray
Customized ordering system
Versatile implant designs
Components designed to support a complete digital workflow
Simplicity
& Flexibility
An easy and straightforward drilling procedure
Interchangeable overlays
"445
TUBE CONFIGURATION
Closed tubes where mouth opening capacity is not an issue
Open tubes when mouth opening capacity "is limited
The two most common implant sizes in same tube:
(WD) Wide Diameter:
(ND) Narrow Diameter:
"446
IMPLANT SIZE / TOOTH POSITIONTHE ILLUSTRATION INDICATES THE RECOMMENDED IMPLANT SIZES IN RELATION TO THE NATURAL DENTITION 3.0MM AND 5.4MM IMPLANTS ARE NON-GUIDED
"447
SIMPLANT® SAFE GUIDE "– WITH LATERAL ACCESS
Simplicity
*Unique for ASTRA TECH Implant System EV, ANKYLOS and XIVE implant systems
SIMPLANT® SAFE Guide with lateral access for improved accessibility
Flexibility
"448
SLEEVE-ON-DRILL™ CONCEPTPRECISE AND SAFE SHORTEST POSSIBLE DRILL USED EASY HANDLING NO “THIRD” HAND NECESSARY
"449
THE SLEEVE-ON-DRILL™CONCEPT
Simplicity
Sleeve-on-drill instruments for simple and precise drill guidance.
*Unique for ASTRA TECH Implant System EV, ANKYLOS and XIVE implant systems
Simple
&
Precise
Precision
& Ease of use
"450
SUPPORTED IMPLANTS AND CONNECTIONS3.0 AND 5.4 DIAMETER IMPLANTS ARE NOT FULLY SUPPORTED WITH ALL DRILLING STEPS.
"451
JBR
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
DRILL LOGICS
JBR
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
DRILL LOGICS- STANDARD VS. GUIDED DRILLS
SURGICAL TREATMENT AND DRILL LOGICS
"454
V-Twist Drill – optional extra apical preparation – Length: 6–17 mm
- OPTIONAL OSTEOTOMY PREPARATION
TRAY CONCEPT"– ONE TRAY FOR ALL OSSEOSPEED™ EV IMPLANTS
ORGANIZED TO SUPPORT THE USER COLOR CODED AND SIMPLE LAYOUT OVERLAY SNAPPED ONTO THE "TRAY BASE GROMMET-FREE TRAY DESIGN
Lid
Overlay
Tray base
Base shield
"455
PROLINE OVERLAY
"456
PROLINE OVERLAY
"457
"458
"459
"460
"461
ESSENTIALS OF IMPLANTOLOGY AND CBCT-GUIDED IMPLANT SURGERY
SMALL TRAY EV STORAGE! SKU 25984
"462
"463
"464
SYSTEM LOGICImplant Length
Tube diameter Drill diameterDrill diameter
TypeDrill Type
"465
SOFT TISSUE PREPARATION – PUNCH
THE PUNCH, MARKED WITH A P IS USED TO MAKE A MINIMALLY INVASIVE CIRCULAR INCISION IN THE SOFT TISSUE. IT IS A SINGLE-USE PUNCH DIRECTLY GUIDED IN THE TUBE OF THE GUIDE.
LASER MARKING CORRESPONDS TO THE IMPLANT LENGTH AND DIAMETER COLOR: CORRESPONDS TO THE IMPLANT DIAMETER SINGLE USE ONLY OPTIONAL USE
"466
DYNAMIC TUBE POSITION "– SPONGIOUS BONE PREPARATION
"467
CORTICAL BONE PREPARATION – INITIAL DRILL
THE INITIAL DRILL IS USED TO REMOVE THE SOFT AND HARD TISSUE AND TO PREPARE THE SHAPE OF THE BONE FOR THE FIRST FULL LENGTH DRILL. THE INITIAL DRILL IS MARKED WITH AN I AND IS DIRECTLY GUIDED IN THE TUBE OF THE GUIDE.
LASER MARKING CORRESPONDS TO THE IMPLANT LENGTH AND DIAMETER
COLOR: CORRESPONDS TO THE IMPLANT DIAMETER DELIVERED STERILE AND FOR MULTIPLE USE, APPROXIMATELY TEN CASES
"468
BONE CLASSIFICATION
ONE DRILLING PROTOCOL FOR PREPARATION OF THE SPONGIOUS BONE
Two options for preparation of "the cortical bone
"469
DEPTH CONTROL PRINCIPLESDRILLS FOR SPONGIOUS BONE PREPARATION •PHYSICAL DEPTH STOP
DRILLS FOR CORTICAL BONE PREPARATION • DEPTH LASER MARKS
"470
DRILLING PROTOCOL "– OSSEOSPEED™ EV STRAIGHT
"471
DRILLING PROTOCOL "– OSSEOSPEED™ EV CONICAL
"472
SPONGIOUS BONE PREPARATIONPHYSICAL DEPTH STOP SLEEVE-ON-DRILL CONCEPT LASER MARKING: DRILL DIAMETER AND NUMBER, IMPLANT LENGTH AND DIAMETER DRILL LENGTHS AVAILABLE ACCORDING TO THE IMPLANT LENGTH: 6–8 MM, 9–11 MM, 13–15 MM DRILL: DELIVERED STERILE AND FOR MULTIPLE USE, APPROXIMATELY TEN CASES SLEEVE: STERILE AND SINGLE USE ONLY DELIVERED TOGETHER WITH GUIDES
"473
CORTICAL BONE PREPARATION - STRAIGHT IMPLANTS
DIRECTLY GUIDED – NO SLEEVE NEEDED COLOR: CORRESPONDS TO IMPLANT SIZE MARKINGS: DIAMETER AND DRILL LETTER
A – THIN CORTICAL BONE < 2 MM B – THICK CORTICAL BONE $ 2 MM
TWO DRILLS AVAILABLE BASED ON IMPLANT LENGTH: "9-13 MM AND 8-11-15 MM DELIVERED STERILE AND FOR MULTIPLE USE, APPROXIMATELY 10 CASES
NOTE: THERE IS A SEPARATE DEPTH#MARKING FOR THE 6 MM IMPLANT.
– 0.0
– 0.5
– 0.3
– 0.5
"474
CORTICAL BONE PREPARATION - CONICAL IMPLANTS
DIRECTLY GUIDED – NO SLEEVE NEEDED COLOR: CORRESPONDS TO IMPLANT DIAMETER LASER MARKING: DRILL LETTER, IMPLANT DIAMETER AND LENGTH TWO DRILLS AVAILABLE BASED ON IMPLANT LENGTH: "9-13 MM AND 8-11-15 MM DELIVERED STERILE AND FOR MULTIPLE USE, APPROXIMATELY 10 CASES
"475
DYNAMIC TUBE POSITION "– CORTICAL DRILLS
"476
OSTEOTOMY PREPARATION OPTIONS
– 0.0/ 0.3
– 0.5
– 0.3
– 0.0
– 0.15
– 0.3
V DRILL - WIDENS THE APICAL PORTION OF THE OSTEOTOMY X DRILL - FOR DENSER BONE. UNDER-PREPARES THE BODY PORTION AND WIDENS APICAL PORTION
"477
JBR
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
IMPLANT DRIVER EV
IMPLANT DRIVER EV-GSCOLOR: CORRESPONDS TO IMPLANT GROOVES INDICATE THE IMPLANT DEPTH IN RELATION TO THE TUBE IN THE GUIDE SIX NOTCHES FOR ALIGNING TO THE SINGLE NOTCH OF THE TUBE IN THE GUIDE FOR POST-SURGICAL MANUFACTURED ABUTMENTS DO NOT EXCEED 45 NCM TORQUE - REVERSE IMPLANT AND WIDEN OSTEOTOMY
"479
"480
Driver position for
post-surgery manufactured abutments
"481
PROFILE EV - WHAT’S DIFFERENT• Implant-abutment interface
– Unique and different from OsseoSpeed EV
• Special Instruments needed – Implant Driver Profile EV
"482
IMPLANT-ABUTMENT INTERFACE CONNECTION
Index free
Index-free abutments will be seated in any rotational position.
One-position-only
All ATLANTIS abutments and indexed components for OsseoSpeed Profile EV will fit in one position only.
OsseoSpeed™ Profile EV
Components specifically designed for OsseoSpeed Profile EV are not interchangeable with OsseoSpeed EV for ensured accuracy
"483
COVER SCREW PROFILE EV THE COVER SCREW HAS A SELF-GUIDING FEATURE •DESIGNED TO ENGAGE AND SEAT IN ONE-POSITION-ONLY •TWO-PIECE NOTE: WHEN REMOVING A TWO-PIECE COMPONENT, KEEP THE SLEEVE AND SCREW ASSEMBLED.
"484
ASSORTMENT OVERVIEW
Index-free abutmentsOsseoSpeed Profile EV #implants One-position-only
ATLANTIS ISUS implant #suprastructures
SIMPLANT computer guided #implant treatment
Intra-oral and lab-based scanning
"485
THE STABILIZATION ABUTMENT SECURES THE SIMPLANT SAFE GUIDE AGAINST LATERAL AND HORIZONTAL DISPLACEMENT AND TWISTING WHEN MULTIPLE IMPLANT SITES ARE PREPARED. • COLOR: CORRESPONDS TO IMPLANT • TWO LENGTHS AVAILABLE: 6-9-13 MM "
AND 8-11-15 MM
• HANDLE AND SCREWDRIVER INTERFACE • PHYSICAL DEPTH STOP – NO MOVEMENT OF "
THE TEMPLATE IN ANY DIRECTION
EV-STABILIZATION ABUTMENT
"486
Astra Tech Implant System EV 5.4 Diameter
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
Ø 5.4 MM IMPLANTA 5.4 MM IMPLANT DIAMETER OPTION FOR TREATMENT OF THE MOLAR REGION
6 mm 8 mm 9 mm 11mm 13 mm 15 mm"488
IMPLANT SIZE / TOOTH POSITIONTHE ILLUSTRATION INDICATES THE RECOMMENDED IMPLANT SIZES IN RELATION TO THE NATURAL DENTITION 3.0MM AND 5.4MM IMPLANTS ARE NON-GUIDED
"489
ASTRA TECH IMPLANT SYSTEM EVHANDS-ON 4.2 X 11 EV-S FIXTURES
"490
DRILLING PROTOCOL "– OSSEOSPEED™ EV STRAIGHT
"491
CORTICAL BONE PREPARATION - STRAIGHT IMPLANTS
DIRECTLY GUIDED – NO SLEEVE NEEDED COLOR: CORRESPONDS TO IMPLANT SIZE MARKINGS: DIAMETER AND DRILL LETTER
A – THIN CORTICAL BONE < 2 MM B – THICK CORTICAL BONE $ 2 MM
TWO DRILLS AVAILABLE BASED ON IMPLANT LENGTH: "9-13 MM AND 8-11-15 MM DELIVERED STERILE AND FOR MULTIPLE USE, APPROXIMATELY 10 CASES
NOTE: THERE IS A SEPARATE DEPTH#MARKING FOR THE 6 MM IMPLANT.
– 0.0
– 0.5
– 0.3
– 0.5
"492
OSTEOTOMY PREPARATION OPTIONS
– 0.0/ 0.3
– 0.5
– 0.3
– 0.0
– 0.15
– 0.3
V DRILL - WIDENS THE APICAL PORTION OF THE OSTEOTOMY X DRILL - FOR DENSER BONE. UNDER-PREPARES THE BODY PORTION AND WIDENS APICAL PORTION
"493
ESSENTIALS OF IMPLANTOLOGY AND CBCT-GUIDED IMPLANT SURGERY
OSSEOSPEED™ EV CONICAL - CLINICAL INDICATIONS
!Limited space between roots - maxillary anterior !Posterior maxilla - ridge height & 6 mm
"494
DRILLING PROTOCOL "– OSSEOSPEED™ EV CONICAL
"495
CORTICAL BONE PREPARATION - CONICAL IMPLANTS
DIRECTLY GUIDED – NO SLEEVE NEEDED COLOR: CORRESPONDS TO IMPLANT DIAMETER LASER MARKING: DRILL LETTER, IMPLANT DIAMETER AND LENGTH TWO DRILLS AVAILABLE BASED ON IMPLANT LENGTH: "9-13 MM AND 8-11-15 MM DELIVERED STERILE AND FOR MULTIPLE USE, APPROXIMATELY 10 CASES
"496
"497
GUIDED IMPLANT SURGERY
PROBLEM SOLVING
"498
WHAT IF THE SURGICAL GUIDE DOESN’T FIT?
IF THE SPACE IS THAT TIGHT, THE EMERGENCE PROFILE IF PROBABLY LESS THAN IDEAL, SO!
•TRIM THE GUIDE •TRIM THE ADJACENT TEETH
"499
"500
WHAT IF THE PATIENT HAS LIMITED OPENING?
STRATEGIES • SLEEVE ON DRILL- MOVE DOWN • DRILL SHORT, THEN LENGTHEN • DRILL FREEHAND WITH STANDARD KIT
"501
"502
ANOTHER CLINICAL PEARL
Go with the longer implant"503
WHAT IF… THE GUIDE SHOULD BREAK?
DON’T PANIC!
"504
WHAT IF… THE GUIDE SHOULD BREAK?• THIS IS WHY YOU NEED TO KNOW THE
FUNDAMENTALS BEFORE YOU DO GUIDED SURGERY • THIS IS WHY I HIGHLY RECOMMEND HAVING A
STANDARD IMPLANT SURGERY KIT (I.E.: HAVE IT) • WHAT TO KNOW TO COMPLETE THE CASE
SUCCESSFULLY "505
DRILL DIRECTION NEEDS TO BE KEPT TRUE• VERY CRITICAL ON PILOT DRILL (FIRST DRILL) • DRILL TRAJECTORY HAS A TENDENCY TO SHIFT AS
IT GETS DEEPER DUE TO FLEXION AT THE WRIST • YOU MUST KEEP YOUR WRIST STIFF AND KEEP
DRILL GOING STRAIGHT. • ON EACH SUCCESSIVE OSTEOTOMY- LET THE DRILL
FIND ITS WAY "506
JBR
IMPLANT MAINTENANCEPROTOCOLS TO IMPROVE SUCCESS AND MINIMIZE PERI-IMPLANT DISEASE
THIS IS A LONG-TERM COMMITMENT•“IMPLANTS ARE LIKE A CAR” - Not a one-time event/expense - Long-Term implant success requires “Regular
routine maintenance” •PATIENT MUST BE COMMITTED TO SUCCESS •PARTNERSHIP
"508
"509
JBR
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
SUCCESS STRATEGY! Biofilm reduction
! Daily maintenance by patient
! Water flosser (Water-Pik) daily
! Dilute sodium hypochlorite solution - 7 drops per tank
! 6 month recall- Implant protocol
! Glycine air abrasion
! Piezoscaler (Ti tips)
! Er,Cr:YSSG laser (2780 nm)
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
STANDARD 6 MONTH RECALL
"Remove the titanium oxide layer and biofilm ! Hand scaling- titanium curette ! Piezotome(?) - Titanium tip
! Air abrasion - Glycine powder
ESSENTIALS OF IMPLANTOLOGY - LEVEL I
EARLY BONE LOSS
!Er,Cr:YSGG laser !REPAIR Protocol
PITFALLS- PROCEDURAL! “I THINK I CAN DO IT” ! “IT LOOKS EASY” !NOT HAVING THE CORRECT INSTRUMENTS !NOT LAYING A FLAP/ BIG ENOUGH FLAP !NOT PLANNING/ BEING PREPARED !NOT REFERRING THE PATIENT TO THE OS TO BEGIN WITH! !OFFER PATIENT OPTIONS: GP OR OS
"513
PITFALLS- MEDICOLEGAL•INADEQUATE INFORMED CONSENT •INADEQUATE RADIOGRAPHS •POOR RECORDS •FAILURE TO CALL FOR HELP/ REFER TO SPECIALIST •FAILURE TO INFORM PATIENT OF COMPLICATION •IGNORING A PATIENT’S COMPLAINT OF A COMPLICATION •FAILURE TO GIVE PATIENT OPTION OF SEEING A SPECIALIST
"514
BEGINNING IMPLANT SURGERY
Where do I start??
"515
WHAT WE STRONGLY RECOMMEND…• Implant surgery is a journey, not a race • Start off +%(* basic and '4084* advance from there • Your first 20 cases should be: #Flapless, 1st Premolar to 1st Molar sites • Then, you can move on to: #2nd molar sites, anterior Esthetic Zone, open flap/
limited bone augmentation"516
HAVE A MENTOR• DEVELOP A SYMBIOTIC RELATIONSHIP WITH A LOCAL
ORAL AND MAXILLOFACIAL SURGEON AND/OR PERIODONTIST
• YOU NEED HIM/HER • HE/SHE NEEDS YOU! • IT HELPS YOU DELIVER THE BEST CARE TO YOUR PATIENTS
"517
HOW TO DEVELOP THAT RELATIONSHIP • “I want to start doing straightforward implant cases.” • “I appreciate the relationship we have.” • “I want to make sure that I always do what is best for
my patients.” • “Could I watch you do some simple implant cases?” • “Could you watch me do some simple implant cases?”
"518
HOW TO DEVELOP THAT RELATIONSHIP •“I want to only do cases that I am comfortable with.” •“Learning to do straightforward implants will improve my understanding of what is possible with implants.” • “I will be referring bigger cases to you that I would
have previously recommended for a bridge or partial.” •“Thank you” gift?
"519
COMPLEX CASES- WORKING WITH A SURGICAL SPECIALIST“We discuss! ! and develop the best treatment options for the patient”
Dr. Lee Ann Brady
“If I do both the surgery and the restoration! ! that discussion never occurs”
"520
THANK YOU!
!521