Tag Archive for 'SurgicalTechnique'

Simple and Economical yet guided…

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Couple of decades ago there was the osseointegration revolution.  Then there was the bone grafting one.  The last decade has been all about two topics:  Soft tissue management in the esthetic zone and Guided implant placement. Guides are pretty common place today but not ubiquitous, although they should be.  Of course implants can be and are placed without guides.  But if given a chance everyone would like to have a guide for ease of placement and greater accuracy.  Then why don’t they?  Mainly due to the additional cost and the complexity of working up the case using software.  Well instead of having simplant or other CAD/CAM type guides made.  Here is a guided case done with a local lab.  The guide was made to the size of the final drill (nobel 4.5mm in this case).  The telescoping pieces slide in and out to make the drill hole 2mm and 3.5mm in diameters for the intermediate drills.  The precision placement allowed me to place this implant and immediately load it with a screw retained temporary crown for ideal soft tissue contours.  The cost of the guide – $100.  The two telescoping pieces are autoclavable and reusable for multiple cases.  No need for the guided kits from nobel or straumann, etc.  You can just use your normal surgical kit.

 

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Simplicity is the ultimate sophistication…

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Sometimes I wonder why I couldn’t have thought of this myself!  I have used multiple lasers in the past and currently use the Deka laser.  One of the main purposes is to expose implants.  I was recently given the Ceratip from Komet.  Billed as “the poor man’s laser”,  it is a zirconia coated burr which works fabulously for exposing implants.  It works on

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mechanical thermal principals.  Simply place it in your handpiece (turn the water off) and vaporize soft tissue to expose the implant.  I never believed it but after using it I highly recommend it.  It doesn’t replace the laser but gives 95% of the effect for exposing implants. And this is at a total cost of $50.  The laser cost $40K.  Also many times I may be in a operatory where my laser is not present and this burr will do the job!  You won’t believe it until you try it.  Let me know your experience?

 

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Basics of Socket Grafting Part I

A four walled bony defect has excellent healing potential when grafted.  However, if left on it’s own has an equally good chance of resulting in a atrophied site which may require more complex and costly grafting.  Today the best means of ridge preservation is by immediate implant placement.  The second best is socket grafting. The most common question I am asked by my restorative colleagues is what I use for socket grafting and what is my technique.  I think it is a great question if someone is preforming extractions in their general practice.  When I started practice 10 years ago I had to take a leap of faith into socket grafting as it was an emerging procedure and technique.  Today we have volumes of literature supporting it’s success.

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I personally believe it should be considered negligent not to offer this benefit to a patient in 2010 as part of an informed consent.  Bone is a very difficult tissue to regenerate.  It’s preservation after tooth loss is beneficial not only as a foundation for future implant placement but also to preserve the youth of the facial form.  The sunken appearance of denture wearers is partially attributed to bone loss from extractions.  Below I give a summary of my technique with no academic support or detailed rationale for the technique.  I hope to do so in future entries.   My own preference is a 50:50 mix of cerasorb and puros packed moderately covered with a regentex membrane and silk sutures.  In one week I remove the sutures; in two weeks I peel off he membrane.  There is a three month healing time prior to flapless implant placement.  Local infiltration is critical for hemostasis or else your graft will float away.  The membrane is neatly tucked under the gingival margins or it will fall off within a few days.

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The magical luxators…

I have spoken with many clinicians who don’t use either of these tools and it always shocks me! Today with implants well on their way to being the gold standard for tooth replacement and immediate implants enjoying functional and esthetic success in the 90 percent range it is even more critical to extract teeth atraumatically. The choice of tools are then either luxators, proximators, a periotome, or a powertome. I have used all of these and the one that now sits on every one of my extraction trays is the luxator. What makes it stand out is the large handle that allows forces to be transmitted with ease. This just can’t be achieved with the proximator or periotome without using a mallet. Untitled1.jpgThe powertome on the other hand creates too much noise for my liking. The luxators have very fine but yet durable tips that fit right into the PDL space. I take it all around the tooth going deeper each time until the tooth is loose. It is the quickest and easiest way to get that tooth out! (Atraumatically that is…) I even use it for wisdom teeth. Eventhough they are not elevators, and the manufacturer makes sure you are aware of that… it is hard to resist. This has led to multiple orders of the instruments as the tips will fracture or shred. So remember just apical forces and minimal torquing forces. Buy the plastic handled ones over the metal version and a pack of three maybe just as good to start. The real set comes as a pack of seven and has a greater variety of tips and angles. I find that I end up using three to four anyway most of the time. If you have picked up a drill to remove maxiallary teeth in the past five years then this bud is for you!

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