LEVEL I - April 2018 Handout...18. Technical troubleshooting 19. Implant maintenance protocols 20. Hands-on with the Astra Tech EV (freehand) kit 21. Introduction to Astra Tech EV

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


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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“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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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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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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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


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)


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.


IV BISPHOSPHONATES

!Aredia (pamidronate) - 2001

!Zometa (zolendronic acid) - 2002

!Decrease pain and hypercalcemia in metastatic bone disease.

!Very potent. Zometa > Aredia

!Administered monthly


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


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



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”



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


RISK OF BRONJ DEPENDS ON:

!IV vs oral drug

!Dosage

!Duration of drug exposure

!Time since last used

!History of “trauma”


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%


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


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


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


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


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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)


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RIDGE PRESERVATION TECHNIQUE

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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??

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SYMBIOS™ REGENERATIVE PRODUCTS

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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

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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


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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


"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


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


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


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


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


"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


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


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


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


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


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


http://www.salvin.com/Reznick-Basic-Instrument-Kit-pluREZNICK-BASIC-KIT.html

"196

02-15-2017


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


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


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

JBR

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


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


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


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


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


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

JBR


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

JBR


OVERLAY 1

JBR


OVERLAY 2

JBR


OVERLAY 3

JBR

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


JBR


DRILLING PROTOCOL "- OSSEOSPEED™ EV - CONICAL

2.5#mm

3.1#mm

2.5#mm

3.1#mm

JBR


GUIDE DRILL EV / PRECISION DRILL EV

JBR


DRILL LOGICS

JBR


BONE CLASSIFICATION

! One drilling protocol for preparation of the spongious bone

• Two options for preparation of the cortical bone

JBR


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

JBR


DRILL LOGICS

JBR


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

JBR


DRILLING PROTOCOL "- OSSEOSPEED™ EV STRAIGHT

JBR


DRILLING PROTOCOL "- OSSEOSPEED™ EV STRAIGHT

JBR



JBR



JBR


EXPANDED DRILLING PROTOCOL"- OSSEOSPEED™ EV STRAIGHT AND CONICAL

JBR


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

JBR


DIRECTION INDICATOR EV! Narrow end is used after drill

! Wider end is used after drill

! A laser marking indicates the 6 mm depth

JBR


IMPLANT DEPTH GAUGE EV

JBR


IMPLANT DRIVER EV

JBR


TORQUE WRENCH EV ! Torque Wrench EV

! Driver Handle, Surgical

! Driver Handles, Prosthetic

JBR


IMPLANT PACKAGING

JBR


IMPLANT PACKAGING

JBR


IMPLANT PICK-UP

JBR


DRILL PACKAGING

JBR


"DRILLING"

JBR


IMPLANT INSTALLATION ""


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


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


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

JBR


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


“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


“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


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


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.


MANAGEMENT•Avoid manipulating implant fixture for the first 6 weeks of integration

#Light debridement

#Chlorhexidine irrigation/ rinse

•Infected- antibiotics #amoxicillin

#cephalosporin

#clindamycin"326


MANAGEMENT•Elimination of biofilm from the implant surface is primary goal #Irrigation device

#Chlorhexidine irrigation/ rinse

•Infected- antibiotics #amoxicillin

#cephalosporin

#clindamycin


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


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:


"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


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


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



"344



"345



"346



"347


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


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


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


! 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


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 ""




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


•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


OSSEOSPEED™ EV CONICAL - CLINICAL INDICATIONS

!Limited space between roots - maxillary anterior !Posterior maxilla - ridge height & 6 mm

"363

JBR



2.5#mm

3.1#mm

2.5#mm

3.1#mm



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


"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


"439


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


"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


DRILL LOGICS

JBR


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


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


– 0.0/ 0.3

– 0.5

– 0.3

– 0.0

– 0.15

– 0.3


"477

JBR


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


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


"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


– 0.0/ 0.3

– 0.5

– 0.3

– 0.0

– 0.15

– 0.3


"493


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




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


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)


STANDARD 6 MONTH RECALL

"Remove the titanium oxide layer and biofilm ! Hand scaling- titanium curette ! Piezotome(?) - Titanium tip

! Air abrasion - Glycine powder


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

Documents

LEVEL I - April 2018 Handout...18. Technical troubleshooting 19. Implant maintenance protocols 20. Hands-on with the Astra Tech EV (freehand) kit 21. Introduction to Astra Tech EV