<\/p>\n
Dr. Lavine:<\/p>\n
Okay.\u00a0 So, you have mentioned the need to degranulate these immediate sites.\u00a0 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?<\/p>\n
<\/p>\n
Dr. Domingue:<\/p>\n
I\u2019m guessing you\u2019re talking about a diode laser.\u00a0 A diode laser does remove soft tissue.\u00a0 It just takes forever.\u00a0 Mechanical removal of granulated tissue is so much more effective and so much quicker.\u00a0 I wouldn\u2019t consider using a diode laser for those instances.<\/p>\n
<\/p>\n
Dr. Lavine:<\/p>\n
Okay.\u00a0 At least we\u2019ve got some great questions here.\u00a0 I hope you\u2019re not in a rush.<\/p>\n
<\/p>\n
Dr. Domingue:<\/p>\n
No, not at all.\u00a0 Please ask away.<\/p>\n
<\/p>\n
Dr. Lavine:<\/p>\n
You used that case where you were using the alloderm.\u00a0 It looked like it was partially exposed. \u00a0Are you typically trying to get primary closure?<\/p>\n
<\/p>\n
Dr. Domingue:<\/p>\n
Primary closure, all the time.\u00a0 What I didn\u2019t show was post-operative from that so that\u2019s a great question.\u00a0 Whenever I do graft soft tissue around teeth or implants around the buckle aspect, 100% closure, 100% of the time.\u00a0 Whoever asked that question was a great question.<\/p>\n
In that case, I didn\u2019t have it.\u00a0 So, that piece of alloderm never got revascularized, and that piece of alloderm did wind up coming off.\u00a0 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.\u00a0 It\u2019s a lot better than what we started.\u00a0 It\u2019s tremendous.\u00a0 If we had to put it on a percentage scale, it\u2019s about 95% success rate with the 5% soft tissue where I did have some exposure.\u00a0 So, yes, ideally, I would have preferred to get 100% on those areas.<\/p>\n
Now, I having said, if we\u2019re going to extract the tooth and graft a socket, if there\u2019s a very thin band of connective tissue, nobody teaches this better than Louis Cummings.\u00a0 He says, \u201cYou can leave that site of alloderm exposed on, and you will get revascularization of that area.\u201d\u00a0 There\u2019s tons of literature to support that, and there\u2019s tons of examples to support that.\u00a0 If you\u2019re coming to the meeting, we\u2019ll go in depth and dig into that on why that works so well and why it doesn\u2019t dig into the roots and the cervical region of natural teeth and implants.<\/p>\n
<\/p>\n
Dr. Lavine:<\/p>\n
Just to clarify, the alloderm you\u2019re using, you\u2019re typically using the GBR, the stuff from BioHorizons, not root covered alloderm?<\/p>\n
<\/p>\n
Dr. Domingue:<\/p>\n
I use the thickest one.\u00a0 GBR is a thinner one, I believe, 1 millimeter in thickness.\u00a0 I use the root coverage one which is 1.5 to 2 millimeters in thickness.\u00a0 I\u2019m going to try to get as thick a tissue as I can.<\/p>\n
<\/p>\n
Dr. Lavine:<\/p>\n
That makes sense.\u00a0 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?<\/p>\n
<\/p>\n
Dr. Domingue:<\/p>\n
That\u2019s a great question.\u00a0 There\u2019s 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.\u00a0 I\u2019m not typically going to promote one company because there are a lot of companies out there.\u00a0 [57:00] just happens to be one bone grafting material that I use, and it\u2019s a mixture of corticocancellous bone material.\u00a0 The important part is the mixture of cortical and a mixture of cancellous. \u00a0That\u2019s proprietary, the percentage of what it\u2019s composed of, but what you basically want to have is both cells.\u00a0 You want to have cells that are cancellous that will degrades quickly so the host can lay down it\u2019s natural bone, and you want cortical bone that\u2019s going to last a little bit longer for soft tissue scaffolding.<\/p>\n
As far membranes, you want a membrane that\u2019s not going to resorb in 7 to 10 days.\u00a0 You want a membrane that\u2019s going to stick around for at least 12 weeks at most.\u00a0 You just want to prevent soft tissue invagination of your grafting site, and I use frequently use another product called MemLock\u00ae.\u00a0 That does a great job of decreasing the risk of soft tissue invagination around an area, and MemLock\u00ae does a good job.\u00a0 It\u2019s nice and flexible.\u00a0 It\u2019s has nice and easy handle properties.\u00a0 It\u2019s nice and easy to suture in.\u00a0 So, that\u2019s just one other product that I use.<\/p>\n
<\/p>\n
Dr. Lavine:<\/p>\n
Okay.\u00a0 What about INFUSE\u00ae?\u00a0 Did you ever use that for a bone graft material?<\/p>\n
<\/p>\n
Dr. Domingue:<\/p>\n
We have.\u00a0 Yes.\u00a0 We actually have done that are Rocky Mountain Dental Institute.\u00a0 Last course was bone grafting.\u00a0 What we did was socket preservation with INFUSE\u00ae, and we also did a bilateral maxillary lift with bone graft material with INFUSE\u00ae.\u00a0 Now, INFUSE\u00ae is an incredible product.\u00a0 It\u2019s got great potential to grow bone.\u00a0 You just need to know how to use it and when to use it. It\u2019s only FDA approved for socket preservation and for sinuses.\u00a0 It\u2019s not FDA approved for other sites, but it is an absolutely great product.\u00a0 We lecture on it extensively.<\/p>\n
<\/p>\n
Dr. Lavine:<\/p>\n
Okay.\u00a0 I\u2019m trying to get through as many questions as we can.\u00a0 We have a few questions here about occlusion as far as the restoration.\u00a0 Are you normally putting them in light contact, no contact? What about canines specifically?\u00a0 Are you trying to avoid canines with implant restorations?\u00a0 Is there a general rule of thumb that you\u2019re typically suggesting.<\/p>\n
<\/p>\n
Dr. Domingue:<\/p>\n
Mike McCracken, next month in February, is going to go over this in detail, but I\u2019ll go through it briefly for those that can\u2019t attend.\u00a0 Yes, I recommend groove function occlusion always.\u00a0 Canine guidance is mandatory, whether it\u2019s an implant or not.\u00a0 You just have to avoid.\u00a0 What a lot of people do is they get this beautiful implant placement, and they make this perfect all-ceramic crown, all-ceramic abutment.\u00a0 Then, when they cement it in the patient\u2019s mouth, they just grind down the occlusion so that anytime the patient even bites, even if they clinch all the way, it\u2019s not even touching in the mouth.<\/p>\n
That\u2019s not recommended. That could be a $3000, $4000 tooth.\u00a0 That needs to be an occlusion.\u00a0 You just can\u2019t have it in poor contact and protrusive contact and working contact for lateral excursions.\u00a0 That\u2019s a big topic in occlusions for implant therapy, but all my implants are in occlusion. It\u2019s not the first tooth that touches, never, but it\u2019s also not the last tooth that touches.\u00a0 It\u2019s\u00a0 in groove function.<\/p>\n
<\/p>\n
Dr. Lavine:<\/p>\n
Okay.\u00a0 What about your suture material?\u00a0 Are you using sorbable, non-sorbable, vicryl?\u00a0 Is there a specific one that you like using?<\/p>\n
<\/p>\n
Dr. Domingue:<\/p>\n
I use PGA, which is vicryl, and I use [01:01:25], which is polyglycolic acid, and it is resorbable.\u00a0 For difficult cases, we use polytetrafluoride, which is a non-resorbable material.<\/p>\n
<\/p>\n
Dr. Lavine:<\/p>\n
Okay.\u00a0 You talked about when you have someone in the chair.\u00a0 You typically recommend they take their medications.\u00a0 What if they were on something like ibuprofen or blood thinners?\u00a0 Do you still recommend that they take those the day of the surgery, or are you adjusting for that?<\/p>\n
<\/p>\n
Dr. Domingue:<\/p>\n
Right.\u00a0 You are adjusting for that if you can if the physician says.\u00a0 I\u2019ve requested to get the patient off Plavixx\u00ae or Coumadin\u00ae, and the doctor says, \u201cAbsolutely not. I will not let you take them off.\u201d\u00a0 So, if that\u2019s the case and you still have to do the surgery and they need to take their medications, that\u2019s a risk that I assume now.\u00a0 Am I still going to remove this tooth and place an implant? That\u2019s something that is a pre-operative complication.\u00a0 There\u2019s going to be a lot of bleeding if their INR is really high.<\/p>\n
If the patient is taking ibuprofen on a regular basis and they take it the day before the surgery, I\u2019m going to expect some post-operative edema, and I will explain it to the patient. If that\u2019s a recommendation from the medical physician, I\u2019m not going to touch that.\u00a0 I prefer that they stay with their recommended dosage.<\/p>\n
<\/p>\n
Dr. Lavine:<\/p>\n
Okay.\u00a0 Most of my failed implants are immediate implants for the upper anterior teeth, specifically endoteeth.\u00a0 After placing implants and restoring implants, a few weeks later, I see swelling. Gingival bubbles appear on the buckle tissue.\u00a0 The implant\u2019s already integrated.\u00a0 How do you treat this infected implant case, especially if there\u2019s already restoration on it?\u00a0 <\/i><\/p>\n
<\/p>\n
Dr. Domingue:<\/p>\n
Well, I would find out the source of the infection.\u00a0 A lot of time what we\u2019ll see, and we\u2019ll talk about this in restorative complications, is one of the biggest things we see now is cement is a killer for implants.\u00a0 People are loading too much permanent cement on the implant crowns, cementing the implant.\u00a0 It extrudes out into the sulcus, and you will see, immediately after, some soft tissue swelling.\u00a0 You\u2019ll start seeing some facial involvement.<\/p>\n
You need to make a nice flat, curette the cement out. \u00a0Clean the area, tetracycline bath, and try to regraft the area immediately the same day, and try to get primary closure around your restoration.\u00a0 You don\u2019t have to take the restoration out of the occlusion, but it\u2019s always advised to immediately get back in there and clean that area because you can lose that implant if the infection continues.<\/p>\n
If the implant\u2019s integrated, that\u2019s quite unusual when the implant\u2019s integrated and everything\u2019s integrated.\u00a0 Then, once you put on the crown, you\u2019re going to have some issues.\u00a0 So, my first thought would either be occlusion, check the occlusion, or cement extruding out in the sulcus.\u00a0 So, I\u2019d start out with looking at those two regions.<\/p>\n
You\u2019re more than welcome.\u00a0 My e-mail\u2019s on the website.\u00a0 Anybody that\u2019s on this call, you\u2019re more than welcome to e-mail me questions, and e-mail me photos or x-rays of cases and ask for my opinion.\u00a0 I don\u2019t mind helping people out, and you\u2019re more than welcome to call me if you have any other questions, too.<\/p>\n
<\/p>\n
Dr. Lavine:<\/p>\n
Okay.\u00a0 In your course, do you cover incision line opening during those three days?<\/p>\n
<\/p>\n
Dr. Domingue:<\/p>\n
That\u2019s absolutely a post-operative complication, and we do see that at times.\u00a0 Either it\u2019s due to sutures, poor suturing technique or it\u2019s due to lack of releasing the tissue enough to get primary closure or it\u2019s patients chewing food in that area or trauma to that area that will tear a suture.\u00a0 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.\u00a0 What are you supposed to do?\u00a0 Do you resuture that area immediately that same day, harming the tissue again and delaying working?\u00a0 What do you do?<\/p>\n
That\u2019s something that we will cover.\u00a0 Do you change the suture material that you\u2019re using?\u00a0 Do you start using non-resorbable?\u00a0 Was it because the tissue was too thin?\u00a0 All these, we\u2019ll definitely do in great detail, but yes, we will cover that.<\/p>\n
<\/p>\n
Dr. Lavine:<\/p>\n
Okay.\u00a0 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?<\/p>\n","protected":false},"excerpt":{"rendered":"
Dr. Lavine: Okay.\u00a0 So, you have mentioned the need to degranulate these immediate sites.\u00a0 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\u2019m guessing you\u2019re talking about […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[],"class_list":["post-198","post","type-post","status-publish","format-standard","hentry","category-detox-foot-patches"],"_links":{"self":[{"href":"http:\/\/footpatches.com\/detox\/wp-json\/wp\/v2\/posts\/198","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/footpatches.com\/detox\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"http:\/\/footpatches.com\/detox\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"http:\/\/footpatches.com\/detox\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/footpatches.com\/detox\/wp-json\/wp\/v2\/comments?post=198"}],"version-history":[{"count":2,"href":"http:\/\/footpatches.com\/detox\/wp-json\/wp\/v2\/posts\/198\/revisions"}],"predecessor-version":[{"id":237,"href":"http:\/\/footpatches.com\/detox\/wp-json\/wp\/v2\/posts\/198\/revisions\/237"}],"wp:attachment":[{"href":"http:\/\/footpatches.com\/detox\/wp-json\/wp\/v2\/media?parent=198"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/footpatches.com\/detox\/wp-json\/wp\/v2\/categories?post=198"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/footpatches.com\/detox\/wp-json\/wp\/v2\/tags?post=198"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}