20210701 Bone & Sinus Augmentation Trends and Techniques

20210701 Bone & Sinus Augmentation Trends and Techniques

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[Music] welcome everybody and uh it is indeed a pleasure for me to participate in this 2021 neo biotech webinar event the topic of my discussion today will be specific to bone and sinus augmentation trends and techniques and as you know i am from atlanta georgia here in the u.s i work with a team of specialists that have been practicing together for the past 30 plus years in a multi-disciplinary practice with an in-house laboratory so the opportunity for us to work side by side has been really effective and allows us to do the type of dentistry that we can be proud of but also also to teach and be able to share the the type of material that we collect and the type of cases that we perform with a group of specialists in one location so i'm going to attempt to share that with you today what you see on the right screen is a the most recent iteration of team atlanta with several new young specialists in oral surgery periodontics and prosthetics also many of you may know that we are also participate and have been part of the number one online dental education website www.dentalxp.com which is now in its 13th year and certainly welcome many of you the to take a look at this website to share in this community with over 220 000 dentists worldwide one of the aspects of this website is to take small blips of content and techniques and new materials that are available in aesthetic restorative and implant dentistry and provide that material to the members and the community through these short 15 to 15 minute to one hour presentations that go into and delve into very specific aspects of implant surgery prosthetic and aesthetic dentistry so i certainly hope you'll take the opportunity again of joining us on the website current implant concepts and technologies really is a great marriage of what we are as clinicians from the educational aspect the biological aspect and wound healing aspect of dentistry but also on the other hand it's a marriage with new concepts and technologies that become available and certainly for me and my uh my relationship with neo biotech over the last decade and a half has been the introduction of really tremendous new technologies that has enhanced my implant practice namely the sinus lift kits that have been made available that you'll see shortly the any check devices the implant devices and certainly the implant removal tools that have been made available amongst many others but we as dentists are focusing predominantly on the aspects of really taking this and being able to utilize it on a daily basis on the full arch patients that are dental handicaps patients with either trauma disease or genetic deficiencies and this young man that you see here is suffering from ectodermal dysplasia a genetic congenital deformity where many of his permanent teeth have not formed so what we want to do first is have a thorough diagnosis so we want to evaluate the case we want to see the mobility of the teeth we want to see the occlusion we want to make sure that we make an assessment from an orthodontic and facial standpoint and we take lateral supplemetric films cone beam cts panoramic films assessing all aspects of this congenital disorder and as you can clearly see here we have a patient with a class iii skeletal malocclusion midface deficiency and we want to be able to identify certain aspects from the facial standpoint from the lateral cephalometric standpoint and you can see here a very classic uh orthodontic measurement of facial position this is the sna line and you can see that we have a um over rotated mandible and a deficient maxilla as part of this congenital deformity planning of the case will also take into account just the ability for us to locate the areas that will acquire grafting mainly the posterior maxilla and the mandibular anterior region as well as the numbers of permanent teeth that are missing and the ones that will be left behind diagnostic study models of course today we have to consider the fact that even with digital technology we still 3d print models we mount models and even though more and more of this is being done digitally analog is certainly still available to many clinicians and whether it's digital or analog a diagnostic wax up at a proposed vertical dimension is critical digital dentistry certainly here our office now currently is fully digital taking advantage of this so what we want to do is basically a simplified form take a pre-op model digitally design where the teeth are going to be in three dimensions perform the wax up digitally or if you like through analog means and then create a mock-up and that mock-up will then be inserted into the mouth for the patient to have an evaluation process and very often these uh these mock-ups are spot bonded so the patient can live with them for a few days as a test drive of their future uh restoration much of this concept was created initially in atlanta with christian coachmen when he was part of our team for several years and now is part of a separate organization dsd and dsd laboratories run by christian coachman and he certainly deserves all the credit uh it was a wonderful opportunity for us to be creative and innovative with christian during his time with team atlanta the wax up as a proposed treatment plan is going to establish the width of the maxilla a opening of the vertical dimension to counter rotate the mandible and to achieve better facial aesthetics and lower lip support once the patient accepts the the mock-up and the treatment plan assessment based upon the digital wax up we are then going to go in and do this digitally guided you can see a fully guided solution here we're going to do sinus augmentation lateral access here is being performed and at the same time using the retained permanent dentition to support the surgical guide during the placement of implants now accessing the lateral sinus today for me is quite simply a much easier more efficient and more predictable procedure because of the utilization of the neo biotech sca and scl kits being able to access the sinus with these neurosurgical burrs being able to do them quickly and being able to do that without tearing of the schniderian member the augmentation of the floor of the sinus obviously when we look at this from a biological standpoint and looking at it from a scientific research standpoint we know that we have three choices we can utilize nothing at all simply allow for a blood clot to stabilize and wait for bone formation to occur um using the implant as a tent pole for the schniterian membrane to maintain the space but most often many of us are using bioactive materials prf prgf maybe cgf uh bmp2s many different types of growth factors that are now available both autologous and recombinant in nature well and they form a particular bone and many people using different types of particular bone or a mixture of particulate bone and a bioactive substance for me i typically like to use a mixture of two and three i find that i get better bone formation faster bone formation and i'm able to load my restorations more quickly so if we take a look at the the type of cases that we're doing today here's a small video all of these videos i'm going to share with you are on dental xp with voice over but accessing the sinus through a full thickness flap vertical incision and then being able to access the sinus through the sla burrs and sle kit from neobiotech this is the drill going at roughly 1500 rpm and you can see in a live video unedited that my access into the sinus takes most often less than a minute uh with these burrs and the burrs basically pushed bone dust in front of or bone powder in front of the drill protecting the schneiderian membrane so you have the ability of drilling through bone and then not having any issues as it has a stopper and does not tear through this nitrile membrane you'll also notice small blood vessels running through the outside portion of the sniderian membrane this lateral maxillary blood vessel is very often can be cut with typical drills here using the sla drills and using piezo devices as you've just seen allows us to avoid that complication and hitting the blood vessel we're now going to use hand instrumentation a lot of times these are where we do tear the sinuses during instrumentation and i'll often utilize another technology such as balloon elevation so where we lift this the remaining parts of the schneider membrane with a balloon filled with saline and we push this balloon in to gain complete lift of the schneider membrane without having uh to utilize instruments all the way around so this is a very slow methodical opening and lifting of the schneider membrane all the way to the medial wall and posterior walls of the sinus access so we fill the balloon up and then we remove the saline from the balloon and you'll see here the bellows effect of the schneider membrane as the patient is breathing in and out the sinus will reflect back and forth only at this time will we utilize the bioactive materials here we're going to use mixture as i said before i like to first use fibrin to protect the snideria membrane and its sticky nature will allow it to stick to the surrounding bony walls and i will introduce sticky bone a mixture of the gf here and the particulated um bone graft material so this is sort of a standard for me today and i think it is uh again it's facilitated by technology and this trend of quick access safe access without tearing of the membrane of the steiderian membrane and then making sure that we place a collagen membrane to prevent soft tissue invasion of the lateral axis so we just stabilize this with a few screws this is a cross-linked collagen barrier placed before closure and we can then place some more fibrin and then close as you see here so here we're doing everything all in one visit we're trying to minimize the amount of surgery through these trends and technologies flap access lateral access the snideria membrane placement of the implants fully guided and really small access not a large access for the window utilizing the sla drills so here's the maxilla day of surgery we're doing this in posterior areas on the left and right sides and phase one is now completed early healing you'll see this is very typical when you're accessing the sinus in this manner we can do this all as a one-stage procedure with healing abutments being placed and then we can move our attention to the mandible again you can see how in these ectodermal cases the deciduous teeth are absorbing at a significant rate they become very mobile and now we can use the remaining permanent teeth to support the fully guided option in the mandible and the implants are placed incisionlessly here but we still left with a bony defect in the anterior mandible and we're going to treat this with autologous bone so the flap is raised the same day you can access the uh the ramus buckle shelf as you see clearly here in this in this image this is a very good harvest site it's a fairly low morbidity unlike the chin area and we can perform these procedures utilizing a piezoelectric device to cut very thin cuts in the bone very safely does not cut soft tissue does not cut blood vessels and we can make very fine cuts in the bone so that we can then use chisels and out fracture the bone in this manner so here's a quick again quick video of us utilizing this technique it's uh can be utilized in a fairly effective small incision here just from the distal the bicuspid second bicuspid all the way to the retromolar space the cuts can be made very quickly using this piezoelectric device based on the cone beam ct and then we can chisel out the bone as you see here once the bone is taken a gel phone a hemostatic dressing is placed into the donor site and very simple nylon sutures are then separated and placed in position we can also use the uh neo-biotech acm drills which i believe one of my favorite drills for bone harvest so that we can harvest in two manners autologous bone is still very very important we have vital cells and here you can see in real time very quickly being able to harvest bone safely in this auto chip maker and um although there's been many others that have tried to duplicate this particular technology i still believe that the neo biotech the original device created by dr hill to me is still the best one i've ever utilized for this particular indication we can then mix this bone with an autologous blood-borne bioactive material here this is prf and we're going to create sticky bone made out of autonomous bone we can also harvest cortical bone chips from the ramus buccal shelf and you can see here the difference in the color of the bone this is more cortical where there's the previous harvest was more cancellous bone so a mixture of 50 50 here getting a half a gram each time so now we have a one gram mixture of cortical cancellous autologous bone mixed with the patient's own blood-borne bioactive material so fully autologous bone can be managed in this fashion sticky bone being made in this way so the acm drill for me is uh absolutely a necessity today's uh implant surgeon i would be uh more to me more often than not i'm using the six seven and eight millimeter diameter acm drills i i prefer wider diameter so i can harvest in just a few few times and what's nice about these drills is they they can be used in multiple sites in multiple spaces and they last maybe four or five times before you have to start changing them and getting a new one if you're going to be using them too much they start to be used too often at high speed which they shouldn't be so if you're going to be using the acm drills remember again the plastic sleeve cannot be placed in a sterilization unit it has to be cold steriled and the metal can be placed in autoclave also remember that you're going to be using these drills at low rpm it's very important that if you're going to be using them as you saw in the video that you're using them at low rpm typically i'm i use them between 150 and 250 rpm um and not anything above that if you get too high on your rpm you're going to end up killing a lot of the vital cells and the the graft will not be as biologically sound we then secure the bone blocks in the anterior mandible in the same patient and now in phase one and phase two we've utilized different technologies sinus lifts utilizing acm drills bone harvest with piezo and using acm drills in the mandible for a fully autologous graft in these areas and then of course digitally fully guided implant placement now we can go back to the laboratory based upon the digital smile design mock-up we are now going to transition this patient from the temporary restoration to the final restoration using a combination of remaining permanent teeth with veneers and crowns and we're going to be utilizing the implants that were placed at phase one if we take a look at this from a facial standpoint the pre-treatment with the bite opening on the left side so we can get better lower facial height and change the lip support and the profile of the face in the middle slide you see the implants at the original vdo you can see how we have a concavity of the face and then when we open the video on the right you can see a completely different soft tissue profile a very nice straight cupid's bow straight cephalometric lip supports beautiful here and a very straight profile not concave as you see in the middle screen and here the patient after final restoration has been placed a fully functional and aesthetic restoration utilizing the all the aspects of modern uh biology and technology in implant dentistry the actual phase treatment plan that took place you'll see on the left screen before uh during the implant the bone augmentation and the implants then placed in the bone graft on the right screen and now you see the pre-op on the left screen this is the original panoramic film and then the actual treatment plan with all the implants placed in all the bone graft sites and you can see again here the before on the left the provisional restoration based on the digital mock-up in the middle and then the final restoration now two years post-op on the right screen this patient is now 10 years after treatment still holding up very well with his grafting severe periodontal disease causes significant three-dimensional defects both horizontal and vertical nature some of the most challenging types of cases that we treat because by the time the disease has caused the mobility of the teeth we've lost vertical and horizontal bone around the alveolar process so the question always becomes should we be minimally invasive and my my answer to that is whenever possible you should always attempt to be minimally invasive but you should be maximally predictable so if minimally invasive does not make you maximally predictable then i often avoid the minimally invasive process so in a case like this where the periodontal disease teeth were removed because of mobility and bone loss you can see that we have substantial lingual bone loss which is maybe even more challenging in the mandible because of its location to the genioglossus attachments and the anatomy in the floor of the mouth but we also have vertical bone loss and interproximal bone laws uh that we see here in this case so what we're going to do here is we're going to once again because of the technology available being able to access the ramus buckle shelf that doesn't mean the retromolar space or the ascending ramus but just the ramus buccal shelf on many patients is a very common source of efficient and predictable bone harvest of at least on average three millimeters of cortical bone from this space with a low morbidity today we can take these plates these these blocks and we can cut them with a disc and create bone plates unlike the last case which was done a decade ago where i'd use the entire block of bone as a traditional block graft today we're taking this bone and we're splitting it into two plates rather than as one block and then what we can do is use a bone scraper to scrape these plates into very thin plates making them predominantly about millimeter or even slightly less than a millimeter in thickness and harvesting all that bone autogenously in those bone scrapers for the for the bone graft in between the plates we're going to use a bone clamp to stabilize one of these plates on the lingual and one of these plates on the buckle and then we will go into place small diameter 0.9 millimeter meizinger screws from the buckle to the lingual to stabilize the the plates on both sides so here's where we started in the pre-op this is the day of surgery recreating legitimately the lingual plate and the buccal plate utilizing autologous bone plates of approximately a millimeter in thickness using the autogenous bone harvested from the autogenous bone scrapers and mixing that with a bloodborne bioactive material ptfe sutures for tension preclosure and then what i call necessary invasiveness if we're trying to rebuild an alveolar ridge that has been damaged from trauma or disease to me this is probably the best form of three-dimensional bone augmentation a utilization of plates an autogenous bone with growth factors at three months you can see that the plates have remained we have good healing of the soft tissues and a maintained closed healing environment i can't say enough about how critical flap management the ability to release flaps the ability to close flaps and maintain a closed healing environment is because once we have wound dehiscence or opening of the suture line these cases can become quite a complication for management and we can lose most if not all of the intended result we can now plan our implants uh being placed into the grafted area at about five months we then go ahead and now we can be minimally invasive we can do this guided and since we placed our fixation screws in the area where we weren't placing implants we can leave those fixation screws in minimizing our flap dissection and placing our implants now another technology that i think is outstanding is the implant stability test or ist any check system what i like about it is it's easy to use we don't need special pegs and especially in grafted sites it's very important that before the restorative phase that we feel comfortable in assessing the stability of the implant we don't want to be too early in restoring these implants before they're completely osteointegrated so the any check is a device that can be used on any implant healing abutment impression coping analog whatever connects to the implant rigidly it can give us a measurement that assesses the stability of the implant and it is very very similar to other measurements that have been uh talked about in the past such as isq so here are the implants placed into the grafted site you can see the mizinger screws have been left behind and there's no reason to remove them since they're not in the path of the implants now if you're looking at the reliability of verification of this new technology with any check a recent publication just a few months ago in the international journal of oral macro facial implants has professed this as the conclusion at their in their conclusion that within the limits of this in vitro study implant stability was measured by a dampening capacity assessment and was suitable for the investigation and the extent of implant micromotions i think that this has been very effective for us in our practice we have two of them and we utilize it routinely the day of surgery after healing and then after temporization before final impression is taken we assess those measurements and are able to see the improvement of stability very often from first day all the way to the final restoration so here's a case that we treated with zygomatic implants and before we load such a case we want to make sure that these implants are stable so here in our office we're using an optorgate to reflect the lips and we're going to take the measurements on the multi-units without having to remove them which is very nice and it speeds up our ability to assess the stability and here's my partner marco todras dr a prosthodontist using the any check on this patient to assess the stability of the zygomatic implants so here he's checking he's got a seven uh an 87 on one of them this is 87 again on the posterior this is a quad zygoma case and it's very important to get the right angle when using the eddy check device if you don't have a good angle an acute angle it will tell you that there's an error and you just have to reposition so here's 78 on one of them 87 and 78 on the last one so those readings are very similar to the standard isq readings that you've seen before and there is a chart that you will that you can get from neobiotech that will tell you how to compare ist numbers to isq numbers because it's also based on the height of your prosthetic connection whether it's a healing abutment impression coping or if it is a multi-unit abutment as you just saw so how do you measure stability in the past we've been given hostile mentor perio test and now any check the advantage of any check for me is significant there's no need to remove the healing abutments especially in these multi-unit full arch cases that can be that can take a long time and every time you remove and attach a prosthetic component we all know that it tears the junction epithelium and it could cause at least some minor bone resorption around the top of the implants there's no need to connect the smart peg there's no additional cost for having smart pegs especially if you have a number of different implant systems that you're using you can contact to the healing abutment you can also take a stability testing of a tooth a lot of times we like to see how our teeth are doing if we're splinting them we're not going to splint them we want to assess stability not only of implants so this is a great device for assessing the stability of teeth there's a strong correlation with itv values and i believe as i've said before they're very predictable so when we're looking at modern techniques at bone augmentation as you've just seen modern techniques with sinus augmentation i think that for me i have moved away from using blocks which i've used probably for my first 15 or 20 years in practice and over the last decade or so i've been using the query technique autologous plates as i just showed you splitting the block scraping the bone from the blocks and using them almost like membranes in a box technique some people use an additional plate over the top i prefer to utilize a a collagen barrier non-cross-linked over-the-top just to get closure in between plates you can also utilize gbr techniques uh sausage techniques whatever you want to utilize that's also a technique that can be used for significant deficiencies i'd like to mix in large three-dimensional defects some autogenous chips so i would still use acm drills to mix with whatever bone graft substitute you were going to be using with it it's always good to get some autogenous bone uh in a three-dimensional defect even if you're using xenograft allograft or synthetic bone particles ridge splitting still a technique that is very viable uh being able to use interpositional grafting rather than utilizing uh extra alveolar grafting or online grafting if you look at rich splitting i kind of see it as a pedicle plate technique because you're kind of just separating the plates from each other and then grafting between the plates very similar to what we do with autogenous plate techniques we also using thai mesh and very important to get the right kind of thai mesh what you're seeing here is the utilization of thai mesh from the neo biotech gbr kits with small pore sizes for blood and and the growth factors and cells to be able to access the graft material and then of course we can use allograft blocks but for me allograft blocks are my least common technique to use although more recently there has been the advent of mixing these blocks infusing them with growth factors and doing this all through 3d printing so that may be something in the future as you see here on a stereolithographic model um a bone block allograftic block that was which was 3d printed from a plan that we had made and infused with bmp2 often people are confused about the timing of healing and regenerative dentistry and i i want to make some things perfectly clear the most efficient and fastest way to grow bone for me and i think in the literature would be autogenous blocks and plates typically we're waiting a period of about four months because this bone is very active and resolves and replaces very quickly gbr guided bone regeneration typically six months maybe even longer in a very severe uh type three three-dimensional defect ridge splitting and expansion i typically wait six to eight months and if i'm using bmp2 and time mesh or allergenic blocks with bmp2 i'm typically waiting the longest because this bone needs more time to turn over the bone is softer with the low houndsfield units in the beginning it's not fully calcified early on i like to wait about eight to ten months in in this in these types of situations so there's a very big difference between survival osteo integration and aesthetics so survival for us is the ability for the implants and the case to survive osseointegration being a biological term and then of course aesthetics has to incorporate the soft tissue and the um the design of the restoration the contour of the restoration and the emergence profile of the abundance so we're going to look at that in terms of some of the failing dentistry we sometimes are faced to deal with a patient with a failing implant in the posterior maxilla a previous sinus graft that had failed and we have a fracture of a press-fit implant and a very narrow posterior maxilla which is a very common finding we often have a narrowing of the ridge at the same time that we have pneumatization of the sinus so by the time we remove the implant and looking at this on the ct scan before removal you'll see that we already knew we had a very large pneumatized sinus with minimal remaining crystal bone to support an implant and here's the implant that this fracture needs to be replaced and we're going to be placing an implant in what appears to be mostly air in the sinus so we have to obviously have a very very profound bone augmentation in the sinus and at the same time we also have a narrow ridge so we have to do a combination of gbr and sinus augmentation with the press fit implants some of the counter torque removal kits don't work very effectively so we typically are forced to use trefying removal which causes an even greater defect and we want to avoid complications so we don't want to tear the sinus membrane whether it's crestal technique or lateral technique in the sinus you don't want to tear this nigerian membrane large tears and pushing a bone through those tears are what causes significant and severe complications so if we're going to go ahead and proceed in these cases very often what i like to do is if i can access the sinus through a crestal approach i obviously prefer to do so and one of the ways to do that after we raise our flap in a patient like this is the ability to do this with the sca kit the sinus crystal approach kit from neobiotech so you have a very nice system of neurosurgical burrs that turn at high speed and you'll see this after i clean off i want to make sure you can see here i want to remove any soft tissue that's remaining and now i'm going to go in with the neo biotech crestal sinus approach kit what you're seeing here is on my hand piece is a depth stop i know that my sinus begins at about three millimeters so right now i don't want to tear the sinus so i want to put a stopper that doesn't let my drill access the sinus immediately so i want to go about a millimeter before the sinus floor and then to the sinus floor and then only then all the way through so we're going to go in with the crystal approach and we're going to keep checking as we approach it we're going to go to the next depth and we're going to go with the diamond drill and we just walk it up many times i'll use the two then the three then the four millimeter stops so i never penetrate very very rapidly into the sinus and these drills again push bone powder bone dust in front of them to protect this nigerian membrane so even if you feel a small give you're more than likely not going to tear this nigerian membrane which is very critical as through a crestal approach is almost impossible to for us to repair it so we're walking the drills up using this technique and then once i get to the final drill this is now at four millimeters i'm going in and i can feel a give and when i feel the give only then will i go and i access the sinus so here you can see the sinus from the crestal approach after the last drill i'm just checking the depth or we can always go if you wanted and use the lateral approach kit so you have two options with this technology a lateral approach or crestal approach we access the sinus we're going to use a collagen barrier inside the sinus mixed with prf and then here we're going to use bmp2 we're going to use collagen sponges and bmp2 mixed together and you can see here inside the sinus is a clear septum that we needed to avoid so it's very important if you're going to access the sinus so we're going to use this technology to grow bone in the sinus and in the defect that you've just seen on the extracted implant this was shown in a study by dennis tarnow stephen wallace out of nyu about eight or nine years ago maxwell sinus augmentation utilizing recombinant bone morphogenic protein 2.

so we're going to mix this color acellular collagen sponge with bmp2 plus we're going to use 50 50 mix of particulated bone cortical and cancellous mixture we're going to tack the membrane here and build out the narrow ridge of the alveolus and then we're going to coronally advance our flap at eight months at re-entry notice the difference between the before and the after the only thing left behind are the pins that stabilize our long-term cross-linked collagen barrier collagen is no longer there it is resorbed but you can see the lateral window is now full of bone and the implant removal site is now also completely full of bone so i wait longer with bmp2 but i get profound bone regeneration as well so it is a very useful tool in regenerative protocol i can now place my four implants into augmented bone where the sinus was and then we place additional low turnover bone product and a little bit of acellular dermal material to thicken the tissue before our closure so again taking every opportunity to grow bone or to alter the tissue thickness either at the time of grafting the time of implant placement and then very importantly uncovering the case because when we do coronary advancement of the flap we alter the mucogenital junction we distort it so now the muco gingival junction is all the way at the crest of the ridge so we don't want to make a simple crustal incision or we would remove all of the keratinized gingiva we don't want to use a tissue punch in this indication or we will remove the keratinized gingiva so the same way that we use the coronal advanced flap we now want to use an apically repositioned flap to move the keratinized tissue and re-establish the mucous gingival junction so here we open the flap we see clearly that we have great robust healing around our implant sites now we want to make sure not only did we build out the ridge buccolingually not only did we take care of the extraction of the implant site and the the sinus augmentation we also now want to take care of the tissue so the tissue is very important everybody always hears us talk about the tissue is the issue so we're going to now apically reposition the caronized gingiva on the vertical incision and now we have another problem if we move the tissue from the palate to the buccal we're going to be left with three areas that are completely exposed into proximally between our healing abundance and what we're going to use here are three rotated palatal pedicle grafts this is a palachi grass patrick bellachi first wrote about this over 20 years ago we're going to rotate these pedicles in between the implant sites to protect that bone and they're just small rotational full thickness palatal pedicle grafts we can use this in a very very easy technique to utilize to place tissue in between the implants and we're now going to use a linear split thickness palatal release to bring the tissue up on the palatal aspect of the healing abutments and then we suture and leave that split thickness area to granulate in this is now six weeks at impression taking you can now see 360 degrees of healthy pink vibrant keratinized tissue around the implants that were all placed in a deficient three-dimensionally deficient ridge now the lab has an opportunity to assist us in tissue molding sculpting the tissue with emergence profile we talked about survivability we talked about predictability osteointegration and aesthetics this case shows it all because our ability to place the implants directly down the long axis based upon our bone regeneration tissue is available now to be molded and shaped and we can even end up with a scallop and interproximal tissue fill very healthy four unit restoration in a previously deficient posterior maxilla with excellent soft tissue quality and quantity this is now several years later you can see very very good post-op healing and implant to bone contact minimally invasive techniques are also available and internal crestal approaches to me are a big part of my practice today and i'm going to talk about that now because it can make these kinds of cases very very simple so here's a patient with fractured molar with the roots still remaining we don't have to wait to be able to do these cases now we can do them quite efficiently we're going to extract the root tips and root fragments utilizing luxaiders periatones whatever you'd like very important to get some diamond tip extractors as you see here to grab these root tips very effectively um that's probably uh one of the best instruments that i've come across and that way we now have a very nice site to work with and now rather than wait to do the sinus augmentation later we do it the day of extraction and we do that using the s reamer this is from the uh s um a cs sca kit the uh sinus crestal approach kit again neobiotechnic technology from dr heo and you can see what it does with the stopper it prevents you from puncturing this nigerian membrane as you enter the floor of the sinus so if you're looking at it here as that drill is going towards the schneider membrane it pushes the bone dust in front of the drill protect into sniderian membrane from puncture so a very very important technique we're going to go ahead in this case we're going to use the uh the is kit from neo biotech i know this is version one i know this probably uh this is an older version of the kit and certainly i'm sure there are newer ones available today and we're gonna go and place our implant at the same time as we do our sinus augmentation so here we're using the neo-cmi implant the is-2 active one of the things i love about it if you see the picture on the right i'm taking it out of the kit and i'm applying the uh prf the uh bloodborne bioactive material and you can see that the the implant is very hydrophilic it's friendly to liquid so it grabs on to the blood clot it grabs onto blood it grabs on to the bioactive materials and we now can place the implant and a healing abutment because we also get extremely good torque insertion with these implant threads healing abutment is tapered but not immediately so it comes up and then comes out which is better doesn't bind down to bone around the uh the implant sites and especially today as more people are placing implants subcrestly it's very important that your healing abutments are shaped in this manner the cmi fixation if you look at the implant itself you can understand why it has excellent uh implant stability at the time of placement we add bone density in the cmi fixation the threads are all different we have a rounded top so it doesn't puncture the sidereal membrane but then we have very aggressive drills and then over to the top we have crystal fixation threads middle fixation and then the inferior fixation more cutting at the apex the middle is for fixation and the crestal does not put the same amount of pressure on that crustal bone so we don't have bone resorption or die back so really an excellent technology here for this implant design and certainly think that it works quite well d2 d4 and d2 bone i can now grab my sticky bone matrix place it around the healing abutment and once again the implant design is really made for self-compaction so you get very good stability without compression of that crystal bone which is very important it's tapered it's narrow but has a strong apex and as i mentioned before good threads and it tapers to a rounded apex so here's the pre-op and the post-op utilizing the bone graft into the sinus access through the crest and another again i keep looking at technologies but another technology that has been so important for me is treatment of peri-implantitis a patient with an implant and central incisor doesn't want to lose the implant doesn't want to go through a myriad of different procedures to re-graft this area so what we do is we take off the restoration we place on this this brush titanium brush for periamplantitis that forms around the top of this attachment to the implant and cleans the implant threads from any soft granulationist material so the r brush from neobiotech very very useful technology for the treatment of peri-implantitis i always suggest if there's a crown on or healing abutment remove the crown remove the healing abutment go back down to the implant level you will screw on this adapter that protects the head of the implant and then the r brush fits directly over that in an implant motor at very low rpm you're not doing this at high rpm and it removes any of the debris around the implant that has been infected now after you do this i would still suggest that you treat the implant with tetracycline for three minutes irrigate with sterile water and then also utilize an ndiac laser for detoxification and that's just 80 joules of laser energy at about five millimeter distance and that should detoxify the implant prepared for bone augmentation so here's the tetracycline placed on the implant after the r brush has been utilized we're going to now utilize a neo biotech titanium mesh system which is very very uh again very creative very innovative by dr hill where we can screw the titanium mesh and fixate it not with screws or pins but by securing it to the implant itself so now we can screw the mesh onto the implant through a cover screw or through the utilization of spacers and this is not just for the neo-biotech system it can be utilized for other systems as well so the cti mesh being used you can see it here we have spacers and then on top of the spacer we have a screw that goes into the spacer and stabilizes the mesh and we place our bone graft underneath it the advantages are significant we don't need pins or screws it's time savings less exposure problems and very easily removed so here i'm placing my bone graft underneath the mesh flipping the mesh down now some people like to have the mesh at the bottom completely seated so if you wanted to you could place a pin or screw at the bottom uh i do this sometimes in these cases and then i place fibrin and sticky bone in combination here's a plasma rich in growth factors or prgf which was created by dr eduardo anito and i close with ptfe sutures the middle x-ray is the day of surgery the right x-ray is several months later and you can start to see cortical bone filling in the area under the mesh and here when we remove the mesh at approximately six months look at how robust the bone augmentation has been this technology it really works there's nothing more to say about what you're looking at in this in this image is profound bone augmentation about around the previously infected implant site and that's all that was necessary to do it here's the pre-op on the left and the post-op on the right pre-op and again from the occlusal view and you can see significantly about four or five millimeters of buccal bone and a almost root prominence over the implant site now that's available so when we're starting to look at cases again i like to always preface it by saying it depends on the complexities and the persons and the individuals that working on it when we have these types of class two problems type two defects don't try to get away with it with narrow implants or mini implants deal with the defect with augmentation build the bone build the tissue and then place your implants there are restorative implications of non-regenerative approaches and this is a non-regenerative approach and this is a young patient in her 20s look at the deficiency in the ridge even after implant placement with mini implants to me this a failure one implant has fractured the other one is inflamed the patient doesn't like the aesthetics again in her 20s so we're going to remove these mini implants and we're left with the defect and here the problem with these mini implants is we need to use trefying drills to remove them so fractured mini implants are removed very often if i don't have a mini implant one of the best removal tools on the market is the neo biotech removal tool removal it has a system for implant removal this is the neo biotech removal system uh there are many others it's very effective it has a screw that goes into the implant and then it has the gold cylinder that goes over the removal screw and then we torque it out at very high torque over 200 plus newton centimeters so this neo-biotech fixture removal kit very effective and you can see here on the right screen here's the kit in the middle screen and on the far right you can see how that looks when the implant is removed so when you've had some bone loss the implant is no longer salvageable or has been slated with a prognosis failed and you want to remove it from the remaining bone you put in the removal screw and depends on the diameter of the implant system you're using it is universal the system can be used for any implant system and it comes in different sizes for narrow standard and wide diameter we talk down a removable screw as you saw there and then we counter torque the removal screw goes in at 35 to 50 newton centimeters and then the removal tool is then placed on the ratchet and the ratchet removes the implants at roughly 250 newton centimeters and the implant will actually de-integrate you can go up to 300 if it doesn't work you can even go up to 350. and then the implant is removed so again a very novel technology and tool for the implant practice now i can go ahead once again do what i talked about before remus shell bone harvest the placement of the bone grafts in position here i'm not using plates this was an older case utilizing blocks two-point fixation using the 50-50 mixture of autogenous bone with growth factors and acm drills always part of harvest the fibrin over the top of the bone grafts and then primary closure during the healing phase very very important process it must be maintained throughout the healing phase but i wait typically with autogenous bone blocks or plates four months and then when we come back you can see this robust healing excellent bone very minimal bone resorption and we can place our implants into position always trying to augment the soft tissue so at the time of implant placement i'm going to add acellular dermal tissue to thicken the tissue so that we have more tissue for the restorative phase and for tissue sculpting with the restoration implants in place for three months we open it up we place our custom abutments look at the tissue volume the ridge concavity is now our convexity and then when the patient smiles look at the papilla formation right at the same height as the central incisor papillas and a very happy patient with beautiful permanent predictable and long-term restoration so i would like to take the opportunity to thank neo-biotech for inviting me today to speak with you i hope that it has been informative i hope that i've shared some of my new concepts related to sinus and bone augmentation related to implants i also hope that you've had an opportunity to see some of the very creative uh tools technologies that have come out of neo biotech that have assisted me in my dental practice for the last decade i'd like to thank dr heo because he really is the inventor of almost all of these products that you've seen and i'm still a user of those products they're outstanding and i look forward to some of the q a during the the question and answer period thank you very very much for your attention you

2021-07-26 09:47

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