Dr. Domingue:
Okay. That’s a great question. At the course, it’s going to be lots of lecturing on what we just talked about but absolutely in more details. We’re also going to talk about complications during the surgery. We’re going to talk about complications after the surgery and restorative complications like we talked about earlier, but we’re also going to do live surgeries. It’s a Thursday, Friday, Saturday course, and we’re going to give a live surgery each day. So, it’s going to be over the surgery, participation-involved surgeries.
We are also going to have a live hands-on course in the post-operative complications and restorative complications. We’re going to talk about implants whenever they fracture, how to remove the implants from the bone. We’re going to have some stuff on drills. We’re going to use ex-plants, the ability to remove an osseointegrated implant if it’s at a bad angle. We’re going to have some live hands-on participation as well.
Dr. Lavine:
Okay. Are you ready for the questions?
Dr. Domingue:
Let them roll.
Dr. Lavine:
Okay. We’ve got some great questions here. So, here’s the first question: I have a patient who has a draining fistula from the neck of a healing implant. At the covering, there was granulation at the neck of the implant, and approximately 1 to 2 millimeters of the implant exposed on the buckle. How should I deal with this?
Dr. Domingue:
So, it was draining from the neck after an implant placement? First of all, take a CT scan to figure out what’s going on. If the implant is that infected, you might need to take the implant out to avoid any other complications. Get the patient numb, remove the implant, degranulate the site, try to put some gentamicin or some type of antibiotic in the area, maybe some calcium sulfate or betadine hydrate. Suture the tissues. Get them on some strong systemic antibiotics like clindamycin 300 milligrams. Get them back in seven days. Check the wound healing. That seems to be like a very, very bad infection. I wouldn’t mess around with that, but you need to get the patient on the obvious recall to make sure the infection’s going away. If drain is coming out, you don’t want that to get to any of the submandibular or sublingual spaces and spread.
Dr. Lavine:
Okay. Next question. If a patient has two implants side by side in the mandibular molar areas, what’s the current thought on whether the implants should be splinted or restored separately?
Dr. Domingue:
That’s funny. This is a very common question that a lot of people are asking nowadays, splint versus not splinting implants in posterior crowns. This is a multifactorial answer. It’s not a “always splint” “don’t always splint”. There’s a lot that has to do with it. If you’re going to be putting two 6 millimeter implants on the posterior mandible, and you’re going to be restoring with implant crowns that are 10 millimeters in width and 8 millimeters in height, it’s probably advised to splint those teeth, especially if they’re opposing the actual dentition.
If the patient is an 80 year old female and she’s getting two implants side by side and they’re 10 millimters in length and she’s opposing a natural denture, she doesn’t have problems, it’s not necessary to splint in that instant. She’s not going to have impaired functionality. She’s probably not a bruxor. She probably doesn’t chew steak every single night.
The reason why we splint implants or increase the strength of the implants is if one implant is split into the next implant, if the value of each implant is 2, it’s not going to be 4. It’s going to be a multiplication of that implant. Do you follow me? So, it does increase the strength of an implant if you do splint, but it’s not always indicated to splint. However, I do splint many times when I see patients, and some patients don’t want their implant crowns to be splinted because they want to floss through them
Dr. Lavine:
Okay, what about splinting through natural teeth? Let’s say, for example, someone’s got implants on 8 and 9, and you’ve got to restore 7 and 10. Are you thinking of maybe making them bridges or something like that. Is that contraindicated?
Dr. Domingue:
The patient’s missing teeth 8 and 9?
Dr. Lavine:
Let’s say there’s implants already on 8 and 9, and maybe the dentist wants to splint or do a bridge. What’s the current thinking as far as splinting an implant restoration to a natural tooth?
Dr. Domingue:
That’s a great question, and for a long time, we’ve talked about not splinting. We used to, back in the day 20 years ago, always splint implants to natural teeth. Then, we saw a lot of failures, but with this failures what we saw was there was a 16% failure rate with whenever you splinted a natural tooth to an implant. The thought was that were was a periodontal ligament around the natural tooth, and in the implant, there’s no periodontal ligament. So, it has to be that the failure rate is associated with the periodontal ligament not being in the implant.
Well, that’s not necessarily true, and the research shows that there’s a low incidence of failure rate associated with splinting implants and natural teeth. The only failure rate is whenever you splint implants to natural teeth with a non-permanent cement or if you use interlocks, locking mechanisms.
You can splint implants to natural teeth. However, the issue becomes, why would you do that? What you’re doing is if you going to crown and make a bridge from an implant to a natural tooth, the reason why bridges fail is because of recurrent decay or the tooth becomes abscessed and needs root canal. You’re going to compromise the bridge integrity of the tooth.
So, yes, you can, but it’s not really advised to do that method, and if you are going to do it, use permanent cement. Cement it all the way without using interlocking mechanisms.
Dr. Lavine:
Okay. Have you ever heard of a patient being allergic to an implant? Is there such a thing as someone having an allergy to an implant?
Dr. Domingue:
It’s been stated that patients can be titanium-allergic. However, the incidence is extremely low, and there has been no recorded data of a patient being allergic to titanium. So, there was this big kick on doing a full zirconia implant, but, right now, the success rate, if you read the literature, is anywhere from 60% to 65% for zirconium. We do know that zirconium, in liquid, fractures.
So, that is a complication that’s listed, but, again, there has never been a literature that suggests that they’ve had an allergic reaction directly to the metal. Now, some people have had implants placed and then get migraines or they’ll have some temporary pain. I’ll hear stories of, “My sister had her implants, and they gave her problems. She had to take them out.” Well, that’s not really true allergy. I’m not too sure that’s a true allergy is what I’m saying. I don’t know if that patient was relating it to her implants or actually had a metal allergic reaction.
Did that make sense?
Dr. Lavine:
Yeah, I think that answered the question. We’ve got lots of great questions coming in here. How would you treat a retrograde implantitis?
Dr. Domingue:
A retrograde implantitis, like a periimplantitis coming to an apical completion? I’m guessing that’s what the question is being asked. Can you clear that up Lorne?
Dr. Lavine:
Yeah. I’ll see if they want to add anything to that.
Dr. Domingue:
I’m guess that’s what they’re talking about, paripathology associated with implant dentistry. Some people do apicalectomies on implant. I’ve heard about them. I’ve read about them. I’ve never had to do it before. Most bacteria with implantitis is always associated with coronal lesion of the implant and have a down growth of bone on the implant. I think I answered the question property if that was right.
Dr. Lavine:
Okay. If you have a broken implant, what bur do you normally recommend for removing that implant?
Dr. Domingue:
There’s two different methods. You can either use a trephine bur. If the core diameter of the implant is a 3.8, you might want to use a 4.0 trephine bur and hopefully restore the area with a 4.2 or 4.6 millimeter implant. So, trephine bur is one option.
There’s also a kit that you can buy called the Ex Plant, where it actually locks into the implant, and you can reverse torque. It’s pretty difficult, but you can reverse torque and implant out. There’s some pressure associated with the Ex Plant technique. I’ll show slides and talk amore about that later on.
Another technique that I was thinking of using before that I haven’t done myself is using a Lindeman bur, which is a side-cutting dental drill with copious irrigation on a surgical high speed drill, is another way to remove an implant that is either fractured or is osseointegrated at a bad area.
Lastly, if you want to be as least traumatic as possible, you can always use a [50:01] surgery to remove an implant and be less detrimental to the bone. It just takes a lot longer.
Dr. Lavine:
Okay. You were talking about smokers before. Are you, then, with the smoker, placing the implant subgingivally, never leaving it exposed?
Dr. Domingue:
Absolutely. Absolutely. Absolutely. Always place the implant subgingival and try to obtain primary closure, letting it heal for as long as you possibly can anywhere from four to six months just to be as careful as possible, letting the wound heal. There is a risk of poor circulation with those individuals so you have to give it a little longer time period before you go and try to restore the implant. So, yes, I do.
Dr. Lavine:
What about you go ahead and take a tooth out at the time of extraction and notice that there’s a periapical infection. Would that be a contraindication to xenografting, or do you do it on a case by case basis?
Dr. Domingue:
Okay. There’s literature that says whenever we see a periapical pathology, we should degranulate the area, get nice bone, clean bone healing, irrigate the site with sterile saline. Clean it all out. Irrigate it all out. Then, start decorticating the area to get better wound repair and just the site with other bone grafting material. There’s other literature to suggest to never graft the site because you’re going to worry about infection recurring in the area.
Now, in that particular site whenever anyone has a periapical pathology, in our practice, we will remove the infected tissue, completely clean the area, degranulate the area as much as possible, get nice healing points, decorticate the bone, get some nice injury in the area, get some nice vascularity. We’ll also use gentamicin antibiotic and graft the same day with a grafting material to build back the bone. If the site is deficient.
If you have less than two centimeters of buckle plate, it’s not necessarily needed in that instance. You don’t necessarily need to bone graft the area, however, typically, when people have that much infection, they’re going to have a lot of bone loss. I would always.
It’s harder to come back to that site and bone graft after the area is completely healed. You’re going to have to do a veneer graft or a hard ridge augmentation and maybe a vertical augmentation, which is extremely difficult, using 10 screws or different other things. So, yes, I always try to graft the same day, making sure that all the inspection is completely gotten rid of and making sure the infection is just localized in the bone tissue.
If the infection extrudes into the soft tissue and becomes a soft tissue infection in conjunction with the dental alveolar infection, it’s not necessarily a great area. If it’s a canine space infection, you’re going to pull the tooth. That’s actually the worse area to graft the same day. It’s also the area you want to graft the same day because there’s going to be so much bone loss, but you’re graft material will get infected. You really need to make sure all that gets out first and get them a very strong systemic antibiotic.