Dr. Domingue:
That’s what it is in literature. Literature says if you have anything 5 millimeters or more, consider doing an internal sinus lift. The reason why that is is because if it’s anything more than 5 millimeters, you’re going to be making a very large, very full thickness elevation flap. If you’re going to try to do a lateral technique sinus lift, it’s going to be really huge, and there’s going to be a lot of edema.
So, the technique to do would be to do a crestal approach if it’s more than 5 millimeters. If it’s 5 millimeters or less, you’re going to need a lot more room and also a lot more bone growth. So, a lateral technique would be the one recommended. Look, we do teach a technique on internal sinus lift that the founder of RMDI, Dr. Moody, invented. It’s a great technique to get vertical ridge augmentation in patients that have 5 millimeters to 10 millimeters of bone, and you want to get an extra 3, 4 millimeters.
Dr. Lavine:
It’s like the lift graft, the Moody Kit.
Dr. Domingue:
Yeah. You heard about it? It’s actually a great kit. I’ve had great success with it. It’s pretty impressive, and when I started doing that in my practice, I just saw improvements in the success rates. I just started doing it in my practice. I’m like, “Oh my gosh. This is just too easy.” It makes lift grafts a whole lot easier, and he has a whole kit.
Dr. Lavine:
Yeah. So, you showed that case where there was a cyst that was removed. Can you place an implant in the future there? If so, what’s the time frame to attempt to put an implant into an area like that?
Dr. Domingue:
I’m guessing it was that patient that was had the [01:08:28] on.
Dr. Lavine:
You showed on where it looked like there was a huge cyst distal to number 18.
Dr. Domingue:
Oh, the patient with the pathology, right?
Dr. Lavine:
I think so.
Dr. Domingue:
Yeah, yeah. For her, she was seen by the local surgeon. He removed the whole cyst out, closed back the area. She is now going to be on her regular recall. The recall and the recommended recall for the odontogenic keratocyst is initially once a month for first six months and then follow up once a year for the next five years. Then, after five years, once every five years, and she’ll continue coming to the office every six months for a routine hygiene.
Now, for her, in particular, we haven’t addressed it yet, but we’re going to assume obviously a re-appointment. We’re just letting her heal a little more, but whenever she comes back into our office, we will talk about if her tissues have healed well enough in that area, it’s not contraindicated to place an implant local to an area that had odontogenic keratocyst.
That tooth is still giving her issues. We’re not sure if it’s a fracture molar. We just know she’s had continuous pain and has been treated several times. So, we’re going to look at removing that tooth in the near future and putting in an implant.
Dr. Lavine:
Okay. A couple of questions here related to antibiotics. I’m not sure if I totally understand this one: What’s the gentamicin amount used? Do you place antibiotic in with the allograft material? Another question is if tetracycline is not available anymore, what do you use instead?
Dr. Domingue:
Okay. To address the tetracycline, doxycycline. Use doxycycline if you don’t have tetracycline available to you. To address the gentamicin, I don’t remember the doses off the top of my head. I’ll have to look it up for whoever asked that question. Please send me an e-mail, and I’ll e-mail you back the response after the phone call.
Dr. Lavine:
Okay. How do you know that you actually have a stable implant? Are you doing some resonance frequency? Are you just tapping it? How do you know that it’s ready to be restored?
Dr. Domingue:
I don’t have the Osstell unit that measures if it’s integrated and to what degree. I don’t have that. We never had that when Dr. Branemark was placing implants. So, usually what I do is at 3 months, 4 months, we’ll take a periapical radiograph, make sure everything looks fine, the bone has collectibly gotten better, there’s no radiofrequencies around there, everything looks perfectly fine. Intraorally, the soft tissue looks perfect.
We’ll first work out the healing abutment, place on a standard abutment, take our impression, and I’ve never had an issue with losing an implant. When you go to reverse torque, the healing abutment, if the patient yells, “Ouch,” when you do that, that’s a clear indication that the implant is not osseointegrated. You’re going to have some granulation tissue around the implant, and it’s not healed yet. So, either advised to remove the implant if it’s that bad or continue and let the patient heal for another four to eight weeks.
Dr. Lavine:
Okay. What about, let’s say you’re placing the implant, and the bone cracks as you’re screwing it down. What would be the typical course of action? Would you take it out and regraft the membrane at that time?
Dr. Domingue:
Great question. I’m really excited because we talk about this. So, this is one of those operative complications. You’re creating this perfect osseotomy. The bone looks amazing. You’ve got great healing, great flaps, and then you’re going to put the implant in. You’re not just paying attention, either you get cocky or you’re focused on something else. All of a sudden, you’re buckle bone just fractures. What do you do?
You spent all this time making the perfect surgery. We’ll show cases of where I’ve had complete bone fracture. Then, we’ve grafted it the day, and it healed perfectly. I’ll also show cases where we’ve grafted the same day we had buckle bone fracture, and there’s an aesthetic risk associated with it.
Then, we’ll actually show cases where this is a clear indication to remove the implant, graft the site, suture the tissue, let the area heal, and then, come back again another time because this is going to be an aesthetic nightmare. It’s also going to be a spinner implant, and it’s just a poor area for wound healing. It’s just a poor area for implant, and you need to abort it, graft, and come back at a later time.
So, that happens often. It even happens when you’re doing your osseotomy. You create the perfect osseotomy, and then, all of a sudden, you blow out the bubble because you weren’t paying attention. We’ll cover how to treat that with membranes, bone grafting, and ridge augmentation, site preservation to either get primary closure and place your implants the same day or just get primary closure with a bone graft.
Dr. Lavine:
What do you do with those spinners? You’ve got that spinner. Do you bury it in weight, assuming that you can’t put a larger diameter implant in there?
Dr. Domingue:
That’s the first thing I would say. I didn’t show a case today, but I’ve had a case where I put a 4.6 millimeter implant, and it was a spinner. What a disappointment because I did a beautiful internal sinus lift. Then, I come out with a spinner. Well, I moved over to a larger diameter implant, and it was able to suffice. If you can’t, what do you do?
If you can go with a longer implant, that’s advised. If you have a 10.5 millimeter implant, why not drill the osseotomy a little bit deeper then put a longer implant? If you still can’t get away and you still have a spinner, do you take it out and graft it? If it’s an anterior site, that’s a good question. You’re going to have to weigh the risk associated with the patient coming in. There’s going to be an infection there. You’re going to remove the implant and graft again. That’s going to cost you tons of time and tons of money, and you’re never going to make enough money off that case. That’s something we’ll talk about, too.
Bone graft is expensive. Membranes are very expensive, and what are we charging to preserve a socket? What are we charging to implant and bone graft and soft tissue graft whenever we do these procedures? Commonly, dentists will work a patient up for a single unit implant and say, “Look. We’re going to charge for the implant abutment crown. Let’s do it,” and they’re not really focusing on the big picture. The big picture is when you get in there, it’s like, “Oh my gosh. There’s absolutely no bone. I’m going to have to bone graft this area. There goes $150 of bone graft that I have to eat. I’m going to put a membrane on that area. There goes another $100.”
So, instead of pre-operatively charging the patient and realizing that ahead of time, we just ate up $300 worth of material, which could have potentially posed a lot better off with the patient. Then, say you do put a spinner in, there you go losing the implant. Now, you have to re bone graft that area, wait for it to heal again, and put them in the provisional. That’s tons of your time. Talk about losing money out the door. That’s tons of your time and effort that just gets completely lost.
So, the economics behind dental implants is something that we’re definitely going to be addressing and how that’s related to complications related to the implant industry.
So, for the spinners, weight the risks. If you want to risk putting an implant in, that’s your choice. I’ve done it both ways. I’ve placed a spinner in, and I’ve had success. I’ve placed spinners in and have not had success, and it’s just something that if you’re willing to risk the complications associated with spinners not working out. If you’re not, take it out and graft the area.
Dr. Lavine:
Okay. We did have a question about whether this session’s being recorded. The answer is yes. All of you are going to be a sent a link, probably by tomorrow, that you can download and watch the entire recorded webinar at your convenience. So, don’t worry about that.
A few more questions here, and then, we’re probably going to wrap it up. Do you use internal or external implants? I guess they’re asking about the hex.
Dr. Domingue:
I used internal hexed implants. If I ever would use an external hexed implant, do you guys remember that case that we showed earlier where it was a full arch, six implants on the lower where I increased the band of attached tissue? On that case, the prosthetics was very difficult, and again, we’ll talk about this in historic complications. It was very difficult with internal hex, and the way we did it was we had to use non-hex abutments to restore that case. In that case, it would have been really nice to have some external hexed implants to restore that case, which would have made my life so much easier. Typically, internal hexed implants as well. I used platform switched laser lock implants.