Dr. Lavine:
Okay. So, you have mentioned the need to degranulate these immediate sites. Have you ever used or read a literature about using a laser for that, a hard soft tissue laser, or is there a risk of damaging the bone if you did that?
Dr. Domingue:
I’m guessing you’re talking about a diode laser. A diode laser does remove soft tissue. It just takes forever. Mechanical removal of granulated tissue is so much more effective and so much quicker. I wouldn’t consider using a diode laser for those instances.
Dr. Lavine:
Okay. At least we’ve got some great questions here. I hope you’re not in a rush.
Dr. Domingue:
No, not at all. Please ask away.
Dr. Lavine:
You used that case where you were using the alloderm. It looked like it was partially exposed. Are you typically trying to get primary closure?
Dr. Domingue:
Primary closure, all the time. What I didn’t show was post-operative from that so that’s a great question. Whenever I do graft soft tissue around teeth or implants around the buckle aspect, 100% closure, 100% of the time. Whoever asked that question was a great question.
In that case, I didn’t have it. So, that piece of alloderm never got revascularized, and that piece of alloderm did wind up coming off. What I wish I could show you guys is what it looks like now. It looks tremendous, but there still remains a soft tissue deficiency in that site. It’s a lot better than what we started. It’s tremendous. If we had to put it on a percentage scale, it’s about 95% success rate with the 5% soft tissue where I did have some exposure. So, yes, ideally, I would have preferred to get 100% on those areas.
Now, I having said, if we’re going to extract the tooth and graft a socket, if there’s a very thin band of connective tissue, nobody teaches this better than Louis Cummings. He says, “You can leave that site of alloderm exposed on, and you will get revascularization of that area.” There’s tons of literature to support that, and there’s tons of examples to support that. If you’re coming to the meeting, we’ll go in depth and dig into that on why that works so well and why it doesn’t dig into the roots and the cervical region of natural teeth and implants.
Dr. Lavine:
Just to clarify, the alloderm you’re using, you’re typically using the GBR, the stuff from BioHorizons, not root covered alloderm?
Dr. Domingue:
I use the thickest one. GBR is a thinner one, I believe, 1 millimeter in thickness. I use the root coverage one which is 1.5 to 2 millimeters in thickness. I’m going to try to get as thick a tissue as I can.
Dr. Lavine:
That makes sense. What about when you need to graft and use a membrane, is there a specific bone graft material and membrane that you have found effective in your practice?
Dr. Domingue:
That’s a great question. There’s a lot of different companies that make a lot of different materials for bone grafting and for membranes, and really, it boils down to a couple of different things. I’m not typically going to promote one company because there are a lot of companies out there. [57:00] just happens to be one bone grafting material that I use, and it’s a mixture of corticocancellous bone material. The important part is the mixture of cortical and a mixture of cancellous. That’s proprietary, the percentage of what it’s composed of, but what you basically want to have is both cells. You want to have cells that are cancellous that will degrades quickly so the host can lay down it’s natural bone, and you want cortical bone that’s going to last a little bit longer for soft tissue scaffolding.
As far membranes, you want a membrane that’s not going to resorb in 7 to 10 days. You want a membrane that’s going to stick around for at least 12 weeks at most. You just want to prevent soft tissue invagination of your grafting site, and I use frequently use another product called MemLock®. That does a great job of decreasing the risk of soft tissue invagination around an area, and MemLock® does a good job. It’s nice and flexible. It’s has nice and easy handle properties. It’s nice and easy to suture in. So, that’s just one other product that I use.
Dr. Lavine:
Okay. What about INFUSE®? Did you ever use that for a bone graft material?
Dr. Domingue:
We have. Yes. We actually have done that are Rocky Mountain Dental Institute. Last course was bone grafting. What we did was socket preservation with INFUSE®, and we also did a bilateral maxillary lift with bone graft material with INFUSE®. Now, INFUSE® is an incredible product. It’s got great potential to grow bone. You just need to know how to use it and when to use it. It’s only FDA approved for socket preservation and for sinuses. It’s not FDA approved for other sites, but it is an absolutely great product. We lecture on it extensively.
Dr. Lavine:
Okay. I’m trying to get through as many questions as we can. We have a few questions here about occlusion as far as the restoration. Are you normally putting them in light contact, no contact? What about canines specifically? Are you trying to avoid canines with implant restorations? Is there a general rule of thumb that you’re typically suggesting.
Dr. Domingue:
Mike McCracken, next month in February, is going to go over this in detail, but I’ll go through it briefly for those that can’t attend. Yes, I recommend groove function occlusion always. Canine guidance is mandatory, whether it’s an implant or not. You just have to avoid. What a lot of people do is they get this beautiful implant placement, and they make this perfect all-ceramic crown, all-ceramic abutment. Then, when they cement it in the patient’s mouth, they just grind down the occlusion so that anytime the patient even bites, even if they clinch all the way, it’s not even touching in the mouth.
That’s not recommended. That could be a $3000, $4000 tooth. That needs to be an occlusion. You just can’t have it in poor contact and protrusive contact and working contact for lateral excursions. That’s a big topic in occlusions for implant therapy, but all my implants are in occlusion. It’s not the first tooth that touches, never, but it’s also not the last tooth that touches. It’s in groove function.
Dr. Lavine:
Okay. What about your suture material? Are you using sorbable, non-sorbable, vicryl? Is there a specific one that you like using?
Dr. Domingue:
I use PGA, which is vicryl, and I use [01:01:25], which is polyglycolic acid, and it is resorbable. For difficult cases, we use polytetrafluoride, which is a non-resorbable material.
Dr. Lavine:
Okay. You talked about when you have someone in the chair. You typically recommend they take their medications. What if they were on something like ibuprofen or blood thinners? Do you still recommend that they take those the day of the surgery, or are you adjusting for that?
Dr. Domingue:
Right. You are adjusting for that if you can if the physician says. I’ve requested to get the patient off Plavixx® or Coumadin®, and the doctor says, “Absolutely not. I will not let you take them off.” So, if that’s the case and you still have to do the surgery and they need to take their medications, that’s a risk that I assume now. Am I still going to remove this tooth and place an implant? That’s something that is a pre-operative complication. There’s going to be a lot of bleeding if their INR is really high.
If the patient is taking ibuprofen on a regular basis and they take it the day before the surgery, I’m going to expect some post-operative edema, and I will explain it to the patient. If that’s a recommendation from the medical physician, I’m not going to touch that. I prefer that they stay with their recommended dosage.
Dr. Lavine:
Okay. Most of my failed implants are immediate implants for the upper anterior teeth, specifically endoteeth. After placing implants and restoring implants, a few weeks later, I see swelling. Gingival bubbles appear on the buckle tissue. The implant’s already integrated. How do you treat this infected implant case, especially if there’s already restoration on it?
Dr. Domingue:
Well, I would find out the source of the infection. A lot of time what we’ll see, and we’ll talk about this in restorative complications, is one of the biggest things we see now is cement is a killer for implants. People are loading too much permanent cement on the implant crowns, cementing the implant. It extrudes out into the sulcus, and you will see, immediately after, some soft tissue swelling. You’ll start seeing some facial involvement.
You need to make a nice flat, curette the cement out. Clean the area, tetracycline bath, and try to regraft the area immediately the same day, and try to get primary closure around your restoration. You don’t have to take the restoration out of the occlusion, but it’s always advised to immediately get back in there and clean that area because you can lose that implant if the infection continues.
If the implant’s integrated, that’s quite unusual when the implant’s integrated and everything’s integrated. Then, once you put on the crown, you’re going to have some issues. So, my first thought would either be occlusion, check the occlusion, or cement extruding out in the sulcus. So, I’d start out with looking at those two regions.
You’re more than welcome. My e-mail’s on the website. Anybody that’s on this call, you’re more than welcome to e-mail me questions, and e-mail me photos or x-rays of cases and ask for my opinion. I don’t mind helping people out, and you’re more than welcome to call me if you have any other questions, too.
Dr. Lavine:
Okay. In your course, do you cover incision line opening during those three days?
Dr. Domingue:
That’s absolutely a post-operative complication, and we do see that at times. Either it’s due to sutures, poor suturing technique or it’s due to lack of releasing the tissue enough to get primary closure or it’s patients chewing food in that area or trauma to that area that will tear a suture. Absolutely, we cover that in detail, and the biggest thing is whenever you come across a complication, how to treat it, medicine-wise, how to educate patients, and what protocols should be set in place, for example, incision line opening. What are you supposed to do? Do you resuture that area immediately that same day, harming the tissue again and delaying working? What do you do?
That’s something that we will cover. Do you change the suture material that you’re using? Do you start using non-resorbable? Was it because the tissue was too thin? All these, we’ll definitely do in great detail, but yes, we will cover that.
Dr. Lavine:
Okay. Is it still recommended to have five millimeters of bone, coronal to apical, if one plans an indirect sinus lift versus a direct sinus lift?