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CBCT-GUIDED DENTAL IMPLANT SURGERY: ADVANCED TOPICS
JAY B. REZNICK, D.M.D., M.D. DIPLOMATE, AMERICAN BOARD OF ORAL & MAXILLOFACIAL SURGERY TARZANA, CALIFORNIA
CBCT-CAD/CAM INTEGRATED WORK FLOW
Using Digital Technology To Improve Patient Care
CRAIG BOONE PLANNING VIDEO
POSTOP
Placement 4 Month Postop
USING CAD/CAM TECHNOLOGY TO DESIGN AND CREATE IMPLANT-SUPPORTED PROSTHESES IN THE SURGICAL PRACTICE
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WHAT HAPPENED TO MY PLAN?•AS A SURGICAL SPECIALIST, MY REFERRING DENTISTS
SPAN THE SPECTRUM OF IMPLANT RESTORATIVE ABILITY.
- Some are practically prosthodontists - Some would love for me to do everything • I LIKE TO DO IMMEDIATE IMPLANTS/ PROVISIONAL
RESTORATION WHEN INDICATED
FOR THOSE CASES…• THE LOCAL LAB TAKES UP TO A WEEK TO
PRODUCE A CUSTOM ABUTMENT AND PROVISIONAL
• THE LAB BILL RANGES $ 300 - 500 • SOMETIMES, THEY SCREWED UP
OPPORTUNITIES•Having both GALILEOS and CEREC in the surgical specialty practice allows us to provide our patients not only with precise, efficient, and accurate implant planning and placement •It also gives us the opportunity to place a provisional restoration at the time of surgery or at second stage
CEREC PROVISIONAL OPTIONS•PROVISIONAL CAN BE MADE AHEAD
OF TIME •AT THE TIME OF IMPLANT PLACEMENT •AT SECOND STAGE SURGERY
TIBASE OR SCAN POST / SCAN BODY
CEREC TIBASE/ SCAN BODY COMPATIBILITY•ASTRA TECH OSSEOSPEED TX •ASTRA TECH SYSTEM EV (EXPECTED Q1 2017) •ASTRA TECH XIVE •BIOMET 3I: CERTAIN, EXT. HEX •NOBEL BIOCARE: REPLACE, ACTIVE, BRANEMARK •STRAUMANN: BONE LEVEL, TISSUE LEVEL •ZIMMER: TAPERED SCREW-VENT (BIOHORIZONS)
TIBASE: COST: $88 PER KIT SCAN POST: $50 EACH / SCAN BODY: $1
PROVISIONAL DESIGNS•SCREW-RETAINED: 1 PIECE • TelioCAD • CEMENT RETAINED: ABUTMENT + CROWN • e.max / TelioCAD • Requires oven
Telio CAD•HIGHLY CROSS-LINKED PMMA •DIRECTLY CEMENTED ONTO TIBASE •SCREW-RETAINED PROVISIONAL •CUSTOM HEALING ABUTMENT •LOW-TRANSLUCENCY/ A16 •SHADES: BL3, A1, A2, A3, 5, B1 •$50 PER BLOCK •TIBASE: $88 ($138)
e.max CAD•LITHIUM DISILICATE BLOCKS (LS2) •ABUTMENT BLOCK - BONDED TO TIBASE (HYBRID) - $70 •CROWN BLOCK - CEMENTED TO ABUTMENT - $32 •TIBASE: $88 ($190) •NEED OVEN
CEREC PROVISIONAL: PRE-MADE•MORE EFFICIENT USE OF SURGICAL TIME •SURGICAL GUIDE IS USED TO RETROFIT IMPLANT REPLICA (ANALOG) INTO STUDY MODEL •TIBASE/ SCAN POST FITTED INTO IMPLANT ANALOG •CEREC OPTICAL SCAN ACQUIRED (SCAN BODY) •DESIGN AND MILLING OF PROVISIONAL PRE-SURGERY •PROVISIONAL PLACED AT SURGERY
PRE-MADE PROVISIONAL •MAKING MASTER MODEL • Guided surgical stent • Stone model • Implant analog (replica) • Guided analog mount: Astra, Nobel, 3i • Implant mount/ sticky wax
IMPLANT ANALOG SET IN MODEL - NOBEL
IMPLANT ANALOG SET IN MODEL - 3I
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IMPLANT ANALOG SET IN MODEL - ASTRA TECH OS TX
IMPLANT ANALOG SET IN MODEL - ASTRA TECH OS TX
USING IMPLANT HOLDER/ STICKY WAX
PRE-OP SCAN- #8 IMMEDIATE IMPLANT
IMPLANT ANALOG SET IN MODEL•USING GUIDED IMPLANT MOUNT
WORKFLOW•TIBASE •SCAN BODY
RESTORATION DESIGN
MILLING
FINISHING
CEREC PROVISIONAL: AT SURGERY •IMPLANT IS PLACED USING SURGICAL GUIDE/ GUIDED SURGERY KIT •SIMPLER WORK FLOW- NO LAB/MODELS NEEDED •100% DIGITAL WORKFLOW •SCAN POST IS SEATED INTO FIXTURE •SCAN BODY PLACED •CEREC SCAN ACQUIRED •PROVISIONAL PLANNED AND MILLED WHILE PATIENT WAITS •PROVISIONAL DELIVERED
WORKFLOW! SCAN POST/ SCAN BODY
FRACTURE TOOTH # 13
TOOTH EXTRACTED, IMMEDIATE IMPLANT PLACED
BONE GRAFT INTO GAP
SCAN POST PLACED•SCAN BODY PLACED •PROVISIONAL DESIGNED IN CEREC •OUT OF OCCLUSION
PROVISIONAL MILLED IN TELIOCAD
PROVISIONAL BONDED TO TIBASE
PROVISIONAL DELIVEREDSCREW ACCESS SEALED WITH TEFLON TAPE/ LIGHT-CURED COMPOSITE
CEREC PROVISIONAL: AT 2ND STAGE •PROVISIONAL RESTORATION • Screw-Retained • Cement-Retained (2 piece) • PROVISIONAL RESTORATION/ FINAL
ABUTMENT • Cement-Retained
SIRONA CAD/CAM MATERIALS
!"#$%!&'()*
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CEREC PROVISIONAL: AT 2ND STAGE •IMPLANT COVER SCREW OR HEALING ABUTMENT REMOVED •SCAN POST IS SEATED INTO FIXTURE •SCAN BODY PLACED •CEREC SCAN ACQUIRED •PROVISIONAL PLANNED AND MILLED •PROVISIONAL DELIVERED
CUSTOM ABUTMENT/ PROVISIONAL AT SECOND STAGE
Using Astra Tech TempDesign EV to create a custom healing abutment
3 MONTH POSTOP
CEREC CUSTOM HEALING ABUTMENTS
CEREC CUSTOM HEALING ABUTMENT
CUSTOM HEALING ABUTMENT
Avoiding, Evaluating, and Managing Implant Complications
ESSENTIALS OF IMPLANTOLOGY AND CBCT-GUIDED IMPLANT SURGERY
OVERHEARD…
“If you are a dentist, and can drill a hole, then you can do implants.” - Anonymous, DDS
Joe Dentist
ESSENTIALS OF IMPLANTOLOGY AND CBCT-GUIDED IMPLANT SURGERY
“IMPLANTS ARE EASY!” “EVERYONE SHOULD BE PLACING THEM!”
DR. REZNICK…
WHAT DID I DO WRONG?
UNDERSTANDINGTHE TECHNICIAN UNDERSTANDS “THE HOW”
THE DOCTOR ALSO UNDERSTANDS! “THE WHY ! THE WHY NOT!
AND THE WHAT IF!”
IT’S NOT ENOUGH JUST TO RECOGNIZE A PROBLEM…
You have to know what to do about it!
DON’T FORGET THIS…
IMPLANT SURGERY IS!
SURGERY
DOCTOR, ARE DENTAL IMPLANTS PERMANENT?
“Implants are as permanent as your permanent teeth”
23-,
WHY DO IMPLANTS COMPLICATIONS OCCUR?•POOR TREATMENT PLANNING •PATIENT FACTORS !Medical issues !Medications !Smoking !Parafunction
•INCOMPLETE INFORMATION !Clinical exam
!Radiographic exam
PRE-SURGICAL CONSIDERATIONS•GET A THOROUGH MEDICAL HISTORY •GET A COMPLETE LIST OF MEDICATIONS •PRIOR SURGERY •ALLERGIES
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:
WHY DO IMPLANTS COMPLICATIONS OCCUR?•POOR TREATMENT PLANNING •PATIENT FACTORS !Medical issues !Medications !Smoking !Parafunction
•INCOMPLETE INFORMATION !Clinical exam !Radiographic exam
WHY DO IMPLANTS COMPLICATIONS OCCUR?
• IMPROPER SURGICAL TECHNIQUE • INADEQUATE PERI-OPERATIVE
CARE •BAD LUCK
WHEN DO IMPLANT COMPLICATIONS OCCUR?
•PLACEMENT •INTEGRATION •FUNCTION
PLACEMENT
•INSUFFICIENT BONE VOLUME •Cortical plate violation •Sinus violation •INADEQUATE KERATINIZED GINGIVA
Incomplete clinical/ radiographic evaluation
PLACEMENT
•INADEQUATE SPACING •Implant-Implant •Implant-Tooth •OFF ANGLE/ POSITION
Improper planning/ surgical technique
INSUFFICIENT BONE VOLUME•INADEQUATE BONE DEPTH
INSUFFICIENT BONE VOLUME•INADEQUATE BONE HEIGHT •INADEQUATE BONE WIDTH
4 -0.4 mm 5 0 mm
2mm - Buccal (facial) and Lingual (palatal)
INSUFFICIENT BONE VOLUME•INADEQUATE BONE HEIGHT •INADEQUATE BONE WIDTH •BOTH
IMMEDIATE IMPLANT PLACEMENT
IMPLANT IS PLACED AT TIME OF TOOTH EXTRACTION
ADVANTAGES OF IMMEDIATE PLACEMENT
•SAVES >3 MO OF TREATMENT TIME •ALLOWS FOR IMMEDIATE PROVISIONALIZATION •AVOIDS NEED FOR FLIPPER/ SPACE MAINTAINER •PSYCHOLOGICALLY BETTER
DISADVANTAGES OF IMMEDIATE PLACEMENT
•IMPLANT POSITION MAY BE DICTATED BY EXTRACTION SOCKET AND EXISTING ANATOMY •POORER INITIAL STABILIZATION •HIGHER FAILURE RATE? •MAY REQUIRE GRAFTING •MORE TECHNIQUE SENSITIVE •MORE PATIENT-SENSITIVE
WITHOUT GUIDED SURGERY
WITHOUT GUIDED SURGERY
PREVENTION• CBCT 3D
IMAGING • GUIDED
SURGERY
PREVENTIONFULLY GUIDED SURGERY
IMMEDIATE PROVISIONALIZATION OF DENTAL IMPLANTS PLACED IN HEALED ALVEOLAR RIDGES AND EXTRACTION SOCKETS: A 5-YEAR PROSPECTIVE EVALUATIONCooper LF, Reside GJ, Raes F, Garriga JS, Tarrida LG, Wiltfang J, Kern M and De Bruyn H. Int J Oral Maxillofac Implants 29(3): 709-717, 2014.
" 113 patients in need of anterior single implant rehabilitation were included
"55 implants were placed in fresh extraction sockets
"58 implants were placed in healed ridges
"A provisional crown was delivered at the day of implant insertion
"A permanent crown was cemented after 3 months
"Peri-implant bone response i.e. marginal bone level/change, was recorded at implant placement and yearly thereafter
"Peri-implant mucosal response i.e. papilla index and gingival zenith scores, were recorded yearly
Aim
Materials
&
Methods
To evaluate the 5-year clinical outcome of immediately loaded OsseoSpeed™ implants placed in extraction sockets or in healed ridges
Results
Bone &
Mucosa
Peri-implant tissues were healthy around immediately loaded OsseoSpeed implants placed in both fresh extraction sockets and in healed ridgesConclusion
" 94 patients (out of 113) attended the 5-year follow-up visit "45 patients in the extraction socket group, and 49 patients in the healed ridge group " 4 implants failed, all during the first year "3 implants in the extraction socket group and 1 in the healed ridge group
" Bone levels did not differ between the groups after 5 years " A mean gain was seen; 2.06 mm in the extraction socket group and 0.1 mm in the healed
ridge group " Papilla index increased over time and did not differ between the groups
" Mucosal zenith scores were stable over time and were similar in both groups
IMMEDIATE PROVISIONALIZATION OF DENTAL IMPLANTS PLACED IN HEALED ALVEOLAR RIDGES AND EXTRACTION SOCKETS: A 5-YEAR PROSPECTIVE EVALUATION
IMMEDIATE PROVISIONALIZATIONMINIMAL INSERTION TORQUE SHOULD BE
30-35N/CM2
Gazelles J, WismeijerD: Early and immediately restored and loaded dental implants for single tooth and partial arch applications. The
International Journal of Oral and Maxillofacial Implants. Vol. 19 Supplement, 2004, page 99.
OSSTELL- IMPLANT STABILITY QUOTIENT
HTTP://WWW.OSSTELL.COM/SCIENTIFIC-DATABASE/
INSERTION TORQUE VALUEAKÇA 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
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.
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.
SINUS FLOOR VIOLATION
SINUS FLOOR VIOLATION
THIS IS A PROBLEM…
MAXILLARY BONE REQUIREMENT•NEED AT LEAST 5MM OF SOLID BONE AT FLOOR OF SINUS TO STABILIZE FIXTURE •SINUS LIFT FIRST
“Since I have a CBCT-based surgical guide, does that mean that I can place the implant without a flap (tissue punch)?”
QUESTION
IF YOU HAVE ENOUGH…•BONE •ATTACHED GINGIVA
INADEQUATE KERATINIZED GINGIVA (KG)
INADEQUATE KERATINIZED GINGIVA (KG)•CONNECTIVE TISSUE (1MM) + JUNCTIONAL EPITHELIUM (0.5 - 1.5MM) + SULCUS DEPTH= BIOLOGIC WIDTH •NEED AT LEAST 2MM OF KG AROUND IMPLANT
PRESERVING KERATINIZED GINGIVA•TISSUE PUNCH: VERIFY ADEQUATE KG ! IF NOT: FLAP! • Design flap to preserve
KG
SPACING/ POSITION ISSUES•IDEALLY- •Parallel to adjacent teeth •Equally spaced between adjacent teeth •Aligned with occlusal tables of adjacent teeth
IMPLANT SPACING GUIDELINES
SOFT TISSUE BIOTYPESTHICK !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
SOFT TISSUE BIOTYPESTHICK •MINIMAL RIDGE ATROPHY •BONE/GINGIVAL CONTOURS MORE PREDICTABLE
THIN •APICAL/LINGUAL RIDGE RESORBTION •BONE/GINGIVAL HEALING LESS PREDICTABLE
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
PLACEMENT•NERVE (IAN) INJURY •BLEEDING •OVERHEATING INJURY •DAMAGE TO ADJACENT TEETH •INADEQUATE PRIMARY STABILITY •DEBRIS IN OSTEOTOMY SITE
PREVENTING IAN INJURY! 2MM SAFETY
MARGIN
TOO LATE
NERVE INJURY•NERVE (IAN) INJURY •Drilling injury • DRILL EXTENDS 0.1 - 0.5MM BEYOND FIXTURE DEPTH •Fixture injury •PRESSURE ON IAN •IMPINGEMENT ON IAN
SEDDON CLASSIFICATION!NEUROPRAXIA •Blunt trauma or stretching •Minor deficit •No loss of continuity
SEDDON CLASSIFICATION!AXONOTMESIS •Nerve damaged but not severed •Partial deficit
SEDDON CLASSIFICATION!NEUROTMESIS •Nerve is severed •Axonal degeneration •Neuroma formation •May be painful - dysesthesia •Poor prognosis for resolution
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:
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)
NERVE INJURY PROTOCOL!NEUROTMESIS •Complete anesthesia >3 months •Consider surgery for continued anesthesia or dysesthesia
Dysesthesia:Neuronitin (gabapentin)900-1200 mg TID
WITHOUT CT GUIDANCE•64 YEAR OLD WOMAN •MULTIPLE IMPLANTS PLACED •RIGHT LOWER LIP NUMB, PAINFUL (BURNING) •PERIAPICAL: #30 IMPLANT “CLOSE” TO MANDIBULAR NERVE
CT SCAN•IMPLANT FIXTURE WAS REMOVED •GABAPENTIN 300MG TID •PAIN IMPROVED OVER 6 MONTHS •GABAPENTIN TAPERED OFF •NERVE SENSATION IMPROVED 80%
BEWARE THE ANTERIOR LOOP!
BLEEDING•CAN COME FROM INSIDE BONE •CAN COME FROM OUTSIDE BONE
BLEEDING FROM BONE•PLACE IMPLANT •BONE WAX
SOFT TISSUE BLEEDING
FOM BLEED DECISION TREE
HEMOSTATIC SPONGES•GEL FOAM •SURGICAL
“ALL BLEEDING EVENTUALLY STOPS”
JUST REMEMBER!
DRILLING FOR SUCCESSIT 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
•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.
INTERMITTENT VERSUS CONTINUOUS DRILLINGCONTINUOUS 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.
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
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.
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 preparation. Quintessence Int 1992;23:811–816
A sharp drill creates less heat!
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.
SALINE VS. WATER FOR IRRIGATION
HOWEVER... DOES IT REALLY MAKE A DIFFERENCE IN CLINICAL PRACTICE? PROBABLY NOT.
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
DAMAGE TO ADJACENT TEETH
DAMAGE TO ADJACENT TEETH•IF MINOR - WATCH •ENDODONTIC TREATMENT •IMPLANT REMOVAL
POOR PRIMARY STABILITY•MAY BE DUE TO DECREASED BONE DENSITY •MAY BE DUE TO UNRECOGNIZED RIDGE WIDTH DEFICIENCY •IF “VERY MOBILE”- REMOVE IMPLANT AND GRAFT •IF “SOMEWHAT STABLE” (20 NCM)- BURY FIXTURE
INTEGRATION•INFLAMMATION DURING HEALING •INFECTION DURING HEALING •SINUSITIS
MANAGEMENT•AVOID MANIPULATING IMPLANT FIXTURE FOR THE FIRST 6 WEEKS OF INTEGRATION •Light debridement •Chlorhexidine irrigation/ rinse •INFECTED- ANTIBIOTICS •amoxicillin •cephalosporin •clindamycin
SINUSITIS•AUGMENTIN 875MG BID X 14 DAYS •OTC ANTIHISTAMINES- CLARITIN, ALLEGRA •OTC NASAL STEROIDS- FLONASE, NASACORT
INTEGRATION•LATE •Bone loss •Gingival recession •Exposure •Mobility
INTEGRATION
4 MONTH POST-OP IMAGE
MALPOSITION
TOOTH MOVEMENT•USE A SPACE MAINTAINER •ESSIX BRIDGE •BONDED BRIDGE •STAYPLATE/ FLIPPER
FUNCTION•PERI-IMPLANTITIS •BONE LOSS: AILING VS. FAILING •LOOSE ABUTMENT SCREW •BROKEN ABUTMENT SCREW •IMPLANT FRACTURE •CEMENT SEPSIS
PERI-IMPLANTITIS•MINOR •Scale with titanium curette •Intrasulcular antibiotics •Home irrigator/ HClO
EXPOSED FIXTURE•IF NO RADIOGRAPHIC POCKETING: •Peri-Implantitis protocol •Expect further exposure as inflammation reduces •Pocket depth improves •May be maintainable for long term
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
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)
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
PERI-IMPLANTITIS•SURGICAL DEBRIDEMENT •CITRATE, CHX •BONE GRAFT •INFUSE (RBMP) •BARRIER MEMBRANE •PRIMARY CLOSURE
CEMENT SEPSIS•NEEDS TO BE DEBRIDED; MANAGED LIKE PERI-IMPLANTITIS •BEST TO AVOID- KEEP MARGINS " 1MM SUBGINGIVAL
FAILING IMPLANT•SIMILAR TO AILING, BUT, REFRACTORY TO TREATMENT •CONTINUES TO GET WORSE
IMPLANT FAILURE
PROTOCOL•CHLORHEXIDINE RINSE- BID •AMOXICILLIN 875MG BID •Start 2 days prior •Continue 5 days post-op
BROKEN ABUTMENT SCREW
BROKEN ABUTMENT SCREW•SALVIN IMPLANT RESCUE KIT
BROKEN IMPLANT
FIXTURE REMOVAL•SALVIN IMPLANT RESCUE KIT
IMPLANT REMOVAL TREPHINE
FAILED MAXILLARY IMPLANT•HEALTHY 36 YEAR OLD WOMAN •FAILED #14 IMPLANT •PAIN, SWELLING, DRAINAGE •ORAL-ASTRAL COMMUNICATION
PRE-OP PREPARATION•AUGMENTIN 875 MG BID - #18 •CHX 0.12% BID - 16OZ •STARTED 2D BEFORE
POST-IMPLANT SURGERY INSTRUCTIONS
CLOSING THOUGHTS…•ONCE AN ISSUE IS RECOGNIZED- MANAGE IMMEDIATELY. •IMPLANT PROBLEMS WILL NOT GET BETTER ON THEIR OWN. •IF YOU ARE NOT COMFORTABLE MANAGING THE MOST COMMON COMPLICATIONS, DON’T ATTEMPT THE PROCEDURE. •GET THE EDUCATION YOU NEED TO GET COMFORTABLE!
“WHEN THINGS DON’T SEEM RIGHT…
…there’s a good chance that something’s wrong!”
JBR 1990
CBCT AND CAD/CAM INTEGRATION
Beyond Implants
VIDEO OF FACE SCANNER•MADELINE
SICAT OPTIMOTION AND OPTISLEEP
3D DIGITAL DENTISTRY AND SURGERY
IMAGINE THE POSSIBILITIES...“IF YOU WANT TO SEE WHAT YOUR FUTURE WILL LOOK LIKE! DON’T CHANGE ANYTHING. YOU WILL BE LIVING YOUR FUTURE TODAY.”
THANK YOU!
