You can think about doing a vestibuloplasty. Those aren’t very predictable, and they’re hard to do and very hard on patients. So, pre-operative planning. If we had don’t pre-operative planning on this before, we would have gotten tissue around this implant on the buckle aspects.
Collapse after extraction. You will lose a lot of soft tissue and bone tissue. This guy was in two days ago, and we have a lot of buckle bone and lingual bone lost. We’re going to expect a ton of soft tissue collapse. You’ve got an oral complication, some infection. We can pull this tooth, and we can graft. We’re going to have to extract and notify the patient that we’re going to pull this tooth, we’re going to bone graft, we’re going to lose a lot of soft tissue and bony structure. So, next time we go, we’re going to have to either do a vertical ridge augmentation, maybe even an internal sinus slip soft tissue to augment this area, to grow this area back. This is a very compromised site.
Hard tissue deficiencies in the maxillary interior, height and width ratios. This patient had these teeth pulled when she was 16. She’s 35 years old now. She has severe, as you can see, horizontal ridge loss. She has [27:48] lower anterior teeth. I would not recommend just getting her in and starting to put implants on the anterior maxillary area. The treatment planning for this patient would be to intrude the incisors, bulk out the maxillary interior ridge areas for height and width. You might even need to come up on the high tool of it, remove some bones, but this is a very difficult patient to restore. As you can see, the crest of her soft tissue is roughly 3 millimeters to 4 millimeters away from the edge of the mandibular anteriors.
Maxillary posterior region sinus involvement in this lady right here. She wanted two implants replacing these two teeth. We thought about placing an implant here in site 15, however, she doesn’t have an opposing tooth because she wanted two implants. So, the ability to pre-operatively plan internal or lateral augmentation graft, when to do an internal sinus and when to do a lateral internal sinus slip depending on the bone quality and quantity in this area.
Mandibular anterior hard tissue deficiency. You’re not going to be able to put an implant on this tissue on the same day. You’re going to augment this site with either a chin graft, a ramus graft, or a particular allograft. Suture the site really nicely. Let it heal and go back in here in a future date and place an implant.
Mandibular posterior area hard tissue deficiency. We didn’t have a CT scan for this patient, and that’s something really nice to have nowadays is the ability to have the technology. So, when we did this case in the residency program, we just flapped back, and we saw this super fine ridge, not a lot of bone, poor area to put an implant in. What we just had to do was to graft the site with a particular graft material and come back in. This is after 12 weeks. We’ve got tons of bone from the lateral ridge augmentation of the near graft.
Occlusion is something that we had talked about, and Dr. Mike McCracken who teaches that and goes in depth with this and how to restore somebody’s vertical dimension of occlusion, whether it’s implant-supported bar over dentures, implant retained dentures, implant screw down hybrids, or fixed dentition. If somebody has a closed vertical dimension of occlusion, we get them in. We just take a Panorex and realize she’s edentulous on the lower right mandibular, and we just want to put in implants. Well, that’s going to be a restorative nightmare to put in two implants up here. This is in the restorative phase. When are we going to make this a screw down prosthesis and when we’re going to make this a [30:49] prosthesis. Altered passive eruption. This is the same lady before. There’s no way we’re going to be able to sneak in some implants around here without intruding these lower anterior teeth to the ortho.
People that have parafunctional habits. This is a classic case of a guy in his mid-forties, and he just grinds through his teeth all day, every day. Occlusion is a big concern. You’re not going to be able to place an implant in site number 8 and get a nice tooth form and function. You’re going to have to do a full mouth rehab, open up this bite, crown the upper and lower anterior teeth, place an implant there, and try to scalp the tissues, and hopefully come out with a nice aesthetic outcome.
Joint instability. Patients that cannot keep their mouth open for a very long period of time, patients that have a very limited mouth opening, patients that suffer from TMJ, these are also concerns and complications that can arise during the implant surgery. So, you should also pre-operative plan for these cases.
Aesthetics. People’s smile line. This guys is not highly aesthetically demanding when I asked him to smile as big as he could. He has hyper lip ability, and this is not really aesthetically pleasing for me, but for him, it really didn’t matter. Pre-op planning, if we’re going to place implants on somebody, do they have a high smile line, do they have a normal smile, or do they have a low smile line? Treatment plan accordingly.
Long white teeth versus pink porcelain. If you’re going to do a full upper, full lower on somebody, are you going to shorten their teeth with pink porcelain, or are you going to create some long teeth and not use pink porcelain?
Flange, of course, are needed to support the lips of a person if somebody doesn’t have lip support. If you take that from them, you bring them from a complete denture to a full fixed, those people are going to have some issues. They’re either going to stick with implant-supported denture and just let them know their ability for aesthetic concerns with those patients, and we’ll talk how to treatment plan those patients and what to do beforehand.
Now, with the advents of cone beam CT technology, it has been tremendous, helping me out in my practice. I feel like it helps me, and the cases seem to go a lot quicker. I know the bone morphology. Without cone beam technology, if we want to place and implant here in this area and we look on the CT scan and it didn’t have a mandibular posterior lingual area, they have a severe curvature, which would inhibit this area to get an implant. So, we need to talk about other options for this area or even not placing an implant.
Pathology in an area. Get a nice radiograph. Patient came in with lots of pain on this tooth. She was referred to our practice for extraction and implant placement. I noticed something back here. So, we had to take a CT scan to figure out what’s going on, and we got a nice Panorex to show you guys from that.
There’s this huge pathology, and she had this develop in the past two years. We looked at a previous Panorex, and she never had this. You could also see it extending into the inferior alveolar nerve canal. This referred out to a local oral surgeon, and he removed the cyst. It came back as benign or odontogenic keratocyst, but knowing this ahead of time, if we just take a PA and we don’t know what’s going on back here, we can get in a lot of trouble.
Being close to a nerve in an area. This is a primary example of somebody who wants mandibular posterior implants, and these are two 10.5 millimeter implants. We’re not going to be able to place these implants in without either shortening the implants or moving to a vertical ridge augmentation, but it’s too close to the nerve. Cone beam technology gives us that.
Vascularity is also an issue. You don’t want to sever and artery and have some bleeding issues. So, this is a CT scan of a mandibular anterior lingual artery and also an incisal artery coming in the incisal canal. You definitely don’t want to hit those during surgery. Guided surgery has been a nice for dentists.
Lab fabricated. Some of this is what I used to do in my own practice. I used to make my own stents, developed the crown-to-implant ratio, marked my middle, use a pilot drill, and flap back the tissue and get a nice outcome. However, this surgery is only done on models. So, we don’t really always know the morphology of the bone underneath so it’s not really recommended.
Originally, Cerec by Sirona, the scanning software where you can scan the adjacent teeth and mill out an acrylic surgical guide. It’s really nice, and the technology has improved from whenever I did this. This was done a while back, and we can get a nice implant immediately. Again, it doesn’t account for the bones and the roots of the adjacent teeth. Now, they’ve come out with a nicer system. They’ve teamed up with GALILGEOS, and they’re outcomes are a lot nicer than this one.
CBCT aided guided surgeries. This is a case that we did. This is a laser-centered surgical guide done for the maxillary anterior region. The surgery was done flapless. It was a quick surgery. She was in and out, just a great tool to use for a hard and difficult case.
Medication protocol. A lot of people talk about pre-op antibiotics, and just recently, last week, the Journal of Clinical Oral Implant Research came out with a study with a multicenter randomized controlled clinical trial. Dr. Chen Pan stated in his conclusions, “For a single implant placement prophylaxis, systemic antibiotics before or after single implant surgery does not necessarily improve the outcome or prevalence of post-operative complications.” So, we need to dive in more to literature and talk about the antibiotic therapy in conjunction with implants.
Post-operative pain medications. What do we recommend and not recommend, understanding that Motrin®, ibuprofen, does inhibit a prostaglandin. So, you can get post-operative swelling after therapy. People always come into our office and say, “I want an implant done.” The day of the procedure, they come into our office, and we’re going to sedate them. That morning, they didn’t take their blood pressure medication. They didn’t take their routine medications. We need to tell patients all the time to continue all prescribed regular medications, and after we do the procedure to continue taking their medications as prescribed.
This is just a brief summary, like I said, of what we’re going to talk about at Rocky Mountain Dental Institute. If you go on the website, rockymountaindentalinsitute.com, and if you go under Courses, you’ll see a list of courses of what’s being offered. There’s eight different courses anywhere from prosthetic reconstruction to bone grafting to complications, and marketing. So, for the course, you can click on Implant Complications on the drop down tab.
You can read a little bit about the course overview, the course outline, a little bit about myself. On the Start Here tab, you can see the different dates. I want to make a note so that everybody who’s on this, the date that’s actually listed right here is incorrect. It’s actually the week before, March 14th. Then, you just go ahead and click on Register Now to register for a course. If you haven’t been to a course yet, you can create your own account, fill out the user registration information and hopefully we get to see you guys in March for the next course.
I’d like to open it up for other questions if you guys have anything.
Dr. Lavine:
Oh, yeah. They’ve got lots of questions. So, your course is March 14th, and it’ basically all on implant complications, correct? Is it a live course, or is it more of a didactic course?