Lecture 2 01222024.txt

All right. So in order to, you know, think conceptually about how to treatment plan a dental implants, you want to think of it in in multiple ways, right? It’s not like, oh, here’s a space, I’m just going to place that dental implant. While ideally that would work, it isn’t necessarily always the ca...

All right. So in order to, you know, think conceptually about how to treatment plan a dental implants, you want to think of it in in multiple ways, right? It’s not like, oh, here’s a space, I’m just going to place that dental implant. While ideally that would work, it isn’t necessarily always the case, right? And you have to have sort of this very multifactorial type thinking. You have to think of it in terms of, yes, there’s a patient attached to that space. So there is some medical, some dental history that I have to take into consideration. There is what you can see, which is your clinical exam and what you can’t see, which is your radiographic exam. Because just because it looks like you have a space doesn’t mean that you have enough bone, or there aren’t any anatomical structures that may be in your way that may prevent you from having the surgery, right? So you have to think of things in a three dimensional manner. So if we we’re first going to talk about medical and dental history I think. As all of you, some of you who have joined us from As and for those of you who are in Dmed when you guys all come into clinic next year, and I’m sure all of you have already seen at least a primary care physician, it is extremely, extremely important that the doctor you are seeing knows everything about you, right? And us as patients, we get frustrated if we go in and our doctor doesn’t know exactly what’s wrong with us and they they have to review their history while we’re while we’re sitting there and they’re trying to be like, oh, you’re allergic to this way, then I can’t give you that. Right. So understanding the patient’s medical history is extremely important. So I emphasize this before you even get into clinic, because I see this a lot. When you guys get into clinic, make sure you review the patient’s medical history before they arrive, not when they’re in the chair and you’re chit chatting with Mrs. Smith or, you know, whatever it may be, you really have to take the time and study your patient’s medical history, because not only will it affect treatment outcomes and medications, it may even affect your treatment planning altogether. Right? Because if they’re more susceptible to bone loss, if they’re more susceptible to infections, if they have a poor oral hygiene and their dental history, that may affect your treatment planning as well. All right. Obviously thorough. If if you’re taking the medical history, you have to be very, very thorough. You’re not just asking them, hey, how are you feeling? Okay. Taking any medications? No. And you just move on. You have to ask questions. You have to. Were there any prior hospitalizations or have any allergies? Are there any diseases? Are there any familial. Right. So it’s just to find out if there’s any genetic component, finding out what kind of medications they’re taking. Are they taking NSAIDs? Are they taking NSAIDs regularly or is the only one there’s pain. Can it cause abnormal bleeding? Yeah. Can interfere when we’re doing an implant surgery. Yes it can IV bisphosphonates. Right. That’s usually a contraindication for dental implants. Um and corticosteroid therapy. It will suppress your immune response. It’s going to impair your wound healing and compromise the amount of adrenal response to stresses. So understanding some of these, you know, and you know, a patient who’s a controlled diabetic or a patient who, uh, has high blood pressure but is under control is very different than patient who’s on IV bisphosphonates. But understanding and knowing that history is extremely important. All right. You want to make sure that you’re taking into consideration any conditions that could pose a risk for any adverse effects, right? If they’re pregnant. Implants are typically an elective procedure. So then I will tell the patient, you know what? Let’s avoid this. If possible, let’s postpone this procedure until it’s time until after they’ve had the baby. And then maybe we can do it then, right? Um, want to make sure that if there is any question that we don’t know the answer to. Always, always seek medical clearance from their treating physician. Right, whether that’s their primary care, if they had, you know, hip replacement or knee replacement or shoulder replacement or some ortho surgery, heart surgery, whatever surgery that they may have had. And you’re not sure whether it’s okay to do this procedure? Do they need a prophylactic antibiotic? So on and so forth. The best way for you to make sure that you’re doing right by your patient is consulting their physician. Right. You we have these forms back in the clinic. You fill out the form, fax it over to the doctor. The doctor says, yep, nope. They need to take, you know, an antibiotic an hour before the procedure, an hour after the procedure. They don’t need to be on prophylactic antibiotics anymore. So on and so forth. This type of information, you want to make sure that you clarify it with the treating physician prior to you, um, performing any surgeries on the patient, you want to make sure that you not only look at the soft tissue, but also the heart tissue. Right? Soft tissue is the obvious stuff. There’s like implants, there’s Candida, there’s, you know, uh, all the things that our eyes can catch. Radiographic. Though there may be a lot more hiding. Okay. There’s very obvious and absolute contraindications like chemotherapy, uncontrolled diabetes and osteoporosis. Right. If you’re doing anything that involves bone, osteoporosis and chemotherapy kind of go hand in hand. Uncontrolled diabetes. The problem is you have very impaired wound healing. And. Research tells us that with uncontrolled diabetes, you have a much higher failure rate than you do with patients who have controlled diabetes. Another thing you want to take into consideration in with medical history is habits, right? Habits and behavioral considerations. Right. Is this patient a smoker? Does this patient use tobacco. Okay. Again we know from the research that it does affect implant success. So if you know the patient comes in, a patient comes to see you and says, hey, you know, I hear that the implants have about a 95% success rate. Um, you know, well, you’re a smoker, so that drops significantly, right? Because the patients here read something online and they don’t take into consideration their own case or situation. And as we know from from the literature, and I’m sure Doctor Fleisher is going to talk to you about this in this course and in another course about the effect of smoking. Right, on implant success, power, functional habits. Right. Again, if the patient’s a grinder or if the patient is, um, you know, is a bruiser. Okay. So how does that affect we? If you remember we talked last week about implants versus natural dentition. Natural dentition have periodontal ligament implants don’t right. Teeth have this protective function right. Where if you’re have these unwanted forces your jaw is going to open. It’s going to try to protect. The teeth are going to move away from each other. Implants don’t have that right. So if you keep putting these unwanted forces on the implant, something’s going to give. The crown is going to fail. The screw may fail. But you may get bone loss right? Depending on the type of force, the amount of force, the location of the force. It could be detrimental to the implant. Okay. Substance abuse again, a lot of it has to do with. What type of substance, how long, how often. Right. Patient compliance is a very, very big one with this one. Right. Um, and making sure that the patient can. Properly clean, follow up, all that kind of stuff, but also make sure that they’re not impaired to the point where they have impaired organ function. All right. All right. How about dental history? So oral hygiene plays a huge, huge role when it is we talk about dental implants. Doctor Fleischer and I when we meet with you guys individually, when it’s time for you to place your implant. One of the first things we talk about all the time is what’s the dental history? Right. And we try to find out how what’s the recall schedule? Is it a three months? This is six month. We’re not doing this just to do it. We’re doing it to find out. Is this patient a compliant patient? Does this patient have new lesions that are discovered within the past three six months. And what does that tell us? Right. Because I’ve had patients who’ve said I just want to get implants because then I don’t have to brush anymore. Well, that’s the wrong mindset. I know you’re maybe you’re laughing or smiling, but I swear to God, some patients think that way. Right. So how is it that we think in that context that by asking these questions and by observing this with our patients, can we actually come up with a proper treatment plan? Right. So you understand how this will affect our treatment plan if the patient is cleaning properly, don’t have new lesions within the past 3 to 6 months, what’s their periodontal condition. Right. Because if they have deep pockets and they have calculus everywhere, are they a good candidate for a dental implant? Right. You want to see what kind of restorative work they do. If they had an old full mouth series of X-rays. Um, if they don’t, then you’re taking a new one. That’s fine. But it’s sometimes hard for you, especially if the patient is a new patient for you. And you don’t see all of the work that has been done there. You want to make sure that you take note of it and see the quality of it. Right? Just because they have the filling or just because they have a crown, doesn’t mean it’s a good feeling or a good crown, or a good root canal and so on and so forth. Right. Especially if it’s an adjacent tooth to where you’re going to have the site of the surgery. Were they compliant? Did they follow up with the with their previous dentist or if you were them? Uh. Right and say, yes, you’re going to do your recalls every 3 to 6 months. You’re going to get your cleanings. You’re going to have to do this filling, that, filling, all that kind of stuff. Were they compliant with it? Because that’s going to tell you whether you have a good prognosis or a good outcome for the implant that you’re planning on placing. Do they have any previous experience with surgery and prosthetics in their mouth? Right. And the reason why this is important is you’re trying to gauge expectations, right. Oh, we as patients were very unrealistic. Right. You know, we we. God forbid someone gets into an accident or something and has to have surgery and be like, I can’t run like I used to. I’m really angry, doctor. Like. Like, yeah, you had an accident. Like miracles won’t happen, right? And so the prosthetic tooth that we’re placing in to replace your natural tooth is not going to be exactly the same. So setting expectations is extremely important for the patient, right. And their attitude and motivation towards influence as you saw from last lecture. Doctor Fleisher showed you those videos, whether it’s a one stage or sometimes if it’s a two stage, it’s could take up to 6 to 8 months, right, for the whole process. If you have a patient who isn’t motivated, this is taking too long. This is frustrating. And they start messing around in that surgical site or not listening to your orders because they think it’s taking too long. That’s going to impair your outcome. All right. So you have to make sure that you are having these conversations with the patients as your treatment planning, because it will give you an insight to what kind of outcome you might have. All right. So that’s a very brief overview of medical and dental history. All right so now let’s talk about radiographs. So when we’re talking about radiographic analysis there’s these two different modalities right. For taking or for for looking at radiographs either a 2D or a 3D. Your 2D which is your typical like like what you see here which is a pano or a lateral. Right. So you’re only looking at it in two dimensions or a PA or an FM, right. That’s also I don’t have a picture for that. But but that’s a 2D versus 3D where you’re actually seeing through the whole slice of it, right where you’re looking here at, you’re looking here at a CT scan in this or you’re looking at an MRI. We typically don’t do MRIs in um for dental unless there’s like, you know, some really large soft tissue lesion. And we want to see the extent of it. Um, for the most part, it’s always going to be a CT scan when we’re looking at dental implants. All right. The idea behind taking a radiographic, uh, analysis for an implant case is to rule out the presence of disease at the proposed surgery site, right. So again, if I’m looking at it, just soft tissue and I’d be like, huh, looks fine. But then you take an X-ray and you notice that there’s a cyst there. You won’t know that unless you have taken the X-ray. Right. Another thing is to rule out caries, bone loss, peri apical lesions, calculus. There’s all of these things that our naked eye cannot see. And you need an x ray to see this. Right. And it’s that much more important when we’re looking at it at a surgical site. You also want to determine the bone quantity. How much bone do I have? Right. We talked a couple of weeks ago about all these implant different sizes. Right. Talked about different diameters, different lengths. How do I know what size the implant site can accommodate? Right. If I take an x ray, I can measure that on the x ray. I’d be like, ah, I have 4 or 5mm of bone in width. I have 10 to 13 in length I this space can accommodate this size implant. All right. How dense the bone is. And again this is I wouldn’t call it controversial statement but it really depends on the kind of excuse me, the kind of, uh. Uh, CT scan. You’re taking the brand of the CT scan you’re using. Um, and the software you’re using can sometimes help you determine the bone density. But if you’re looking at it strictly from a, um. Scientific sort of doctor way of looking at it. You can say, oh, there’s a lot more. You know, bone marrow spaces cancel this bone versus compact bone here. This bone is going to be softer just based off of you looking at the bone. Right. And not calculating a density percentage but looking at and B like there’s a lot more marrow spaces here than there is here. This looks like it’s much more compact bone. That’s much more cancer, this bone. So you know that you’re going to have much more resistance spacing the implant and a compact bone versus cancel this bone. Right. Um, this is extremely important, right. To evaluate the relationship of critical structures to the prospective implant sites. So. You’re placing an implant in the mandible. Right. What do you have down here? Your ion. Right. Inferior. Inferior alveolar nerve. Last thing you want to do is place an implant and hit that nerve. Because then you’re just going to numb that half of the patient’s face right there lip. Everything gets numb. And. Depending on how deep you go, it could be reversible. But sometimes a lot of times it’s actually a reversible, right. Let’s say you’re going in the maxilla. You you have your maxillary sinus, right? All the way from about your first or second premolar all the way back to the tuberosity. Right. Last thing you want to do is perforate that implant with the sinus and give a patient basically, unless you handle it well, chronic sinusitis for the rest of their life. Right? So how do I know where to avoid? How to avoid? Should I ambulate my implant? Do I have enough? Bone is the perfect way of doing it right? If I take an x ray, it’ll show me, because I know that the difference between a radio opaque space and a radio lucent space, right? If there’s a if there’s a space that’s darker on the x ray, I know that that’s an airspace. I want to avoid that because that’s a sinus. If it’s a if it’s a lighter, it’s like a white, then that is bone that I can place the implanted. That’s a very primitive way of looking at it. But that’s an easy way to distinguish and think about it. Right. So it helps you understand because in certain patients if they don’t have enough bone right. Bonus healthy patient is healthy, but they don’t have enough bone. And the sinuses right there, then they’re not a good candidate for an implant. Although clinically they look like a perfect candidate and medical and dental history is great. But guess what? They don’t have enough bone. We’re not going to force that dental implant if we can’t place it, because if they don’t have enough bone now, are there ways to graft bone? Sure. Right. But that’s a separate conversation. But just on its face, you have to think of it in that context. That’s why we’re looking at these three different things medical, dental history, radiographic analysis and clinical examination. Because. Yes. The patient may be good in two of the three, but without that third one, it won’t work. All right. Determine the optimum position for the implant placement relative to the occlusal load. We’re going to talk a lot more about this, um, in not this next lab session, but the lab session afterwards. Um, with the software that we’re planning dental implants with today. You actually planned the dental implant? Not based off of where their bone is, but where your final restoration is going to be. Remember how we talked last lecture about the types of forces we like to compact? Forces we don’t like shear forces. We don’t like tensile forces on implants. So how do I plan my implant so that the forces are down the long axis of the implant. The software that we’re using and all of you are going to use in the SLC. This next session, we’re going to use that software, but we’re not going to plan an implant the week after. You all are going to get to do this, where you’re going to get to plan the implant based off of a restoration, and then you get to decide where the forces are going to come. So you can now plan that implant, right, to withstand the forces along the long axis of that restoration. All right. So how about a clinical exam? This stuff is pretty straightforward, right? So things you want to take into consideration. Pre implant consideration. What is the patient’s existing occlusion. What’s the occlusal plane look like. What are the orientation. Why is that important. Right. You guys already took occlusion with Doctor Moreau? Yes. Okay, so does it matter if the patient is canine guidance or group function? It does. Right. And if I’m restoring an implant, I’m restoring a canine implant. Do I want to put all the forces on that canine implant? No. Right. So understanding the patient’s existing occlusion is extremely important. So I don’t put those forces that are unwanted. The occlusal plane. Do I have a flat occlusal plane? Do I have a very steep curve of spee. Right. If I’m restoring that third molar and I have a very steep curve, what happens there when I go into lateral expressive movements? Am I causing an interference? Right. What are the orientation? The orientation really has to do more with? Um. Maybe I’ll get into that a little bit later, but maybe more not just buckle lingual right when we’re talking like curve of Wilson, but also orientation of the teeth, adjacent teeth to the space, how the teeth are oriented and whether that is going to cause, you know, esthetic issues as well as functional issues, because now I’m going to have to put a smaller tooth and I’m going to have these big black triangles between the adjacent teeth. And we’ll talk about that a little bit later into arch and into proximal space. So inter arch right. Remember we talked about this last time. Here’s a quick refresher. Your implant goes into the bone, right? So technically the space is from the soft tissue that’s on top of the implant to the occlusal of the opposing tooth. How much space do I have? Do I have enough space? Do you remember how in that one slide I showed you, we have two types of crowns. Screw retained. Cement retained. I’m hearing a little bit of hands, I see a little bit of head knots. So there were two different types of restorations, right? And I said, what’s going to determine what kind of restoration is a lot of things. One of them is space. In certain scenarios. If I have limited amount of space, I cannot do a cement retained restoration. Remember I talked about resistance and retention form, right? The abutment looks like a prep tooth, blah blah blah. Right. So and you’re going to hear a lot more about this, right. But understand that inter proximal space and inter occlusal space determine a lot of times what kind of restoration you’re going to do. All right. So that’s at least from that space. Another concept you have to think about is the jaw. Right. Where is this implant location going to be? Is it going to be in the posterior. Is going to be in the anterior. Do I have more space back or in the front? The jaw is a class three lever. Right. The further back, the less space, the further front you have more space, right? So if I’m placing an implant on number 30 or 31, I’m already have a limited amount of space. Versus if I’m doing it in the interior. I mean, try to fit your three fingers. You can probably fit them here. You can’t fit them back there. Right. So you’re already at a disadvantage when you’re trying to think of in terms of space. So keep that in mind as well and how that is going to affect. Are you going to be able to? Do you even have enough room for an implant? Right. Because we’re all different and we all can open our mouth different. We have limited range of motion, so on and so forth. Inter proximal space goes kind of hand in hand with what I was talking about tooth orientation. Right. How close the adjacent teeth are to one another. And that’s just from a clinical exam. Remember we just said radius. Graphically the teeth can look perfectly fine in a clinical exam. But then when you take the x rays the roots are coming in this way. What does that do for my implant? I can’t place an implant there. Right. So do you see how all of these factors kind of go hand in hand? You can’t just take one and not look at the other. All right. Existing vertical dimension of occlusion. You’ve heard that term probably from Doctor Chanel already? Yes. Yes yes one. Yes Video I know Remo is exciting. This is coming from a post on this, by the way. Um. Yes. Why does video matter? Video matters. Because again, if I were to change or if I’m going to have to modify the video, or if the patient doesn’t has a collapsed vertical or has an open vertical, isn’t that going to change and determine the height of your restoration? It will. Right. So if we’re planning eventually to change this patient’s vertical down the road, then maybe I’m not going to restore the implant until we do that. All right. The Archer relationship. Oh, sorry. The arch relationship. Right. Are they a skeletal one? Are they a skeletal class? Two? Are they a skeletal class three? Why does that matter? Exactly what I was just saying a slide ago, right? Patient’s range of motion and occlusal scheme. We know that patients who are class two and patients who are class three have a very limited range of motion in terms of opening and closing. Right. And we know that patients who are class three or edge to edge, sometimes even they don’t have canine guidance. And a lot of times they grind side to side. Right. And how is that going to affect my occlusal scheme for my restoration. Okay, so I have to take that into consideration. The TMJ status. Right. I’m sure Doctor Moreau talked to you guys a lot. You just want to make sure that the patient has healthy TMJ. You’re you’re evaluating all this as part of your clinical exam arch form. I’m going to show you this in a couple of slides. So I’ll skip that. And we’ll I’ll show you in detail what that is. But essentially what it is is you have different shapes for an arch. A lot of times you a lot of us think of it sort of as this ovoid, but it could be squarish, it could be triangular, right. Every patient’s a little bit different. And if we’re placing multiple implants, how does the arch shape matter. All right. And I’ll show you a pictures for that in a second. Missing teeth location a number again, it will matter if I’m restoring more than one implant, or if I’m doing more than one implant at the time. If I’m doing if I’m missing three teeth in a row, am I doing two implants and am I doing a three in a bridge? Am I doing three separate implants? Every patient is different. Every scenario is different. Right? So the location of where these missing teeth are and the number matters in terms of me coming up with a proper treatment plan for each specific case. Lip line at rest and during speech. So this is going to matter a lot more with anterior implants. And you’re going to get a lecture about that in about 3 or 4 weeks. Talking about why the lip line matters. Right. Do I have a high smile line? Do I have a small low smile line when I smile, do you see pink? Do you not see pink? Right. And this is going to matter. Do I need to do a soft tissue graph? Do I need not to do a soft tissue graft? Every patient is different. But if I’m not taking this into consideration as I’m planning and then I get a poor outcome according to the patient, then yes, the implant succeeded, but the restoration failed. Right? And that goes back to what I was talking about last week. Success versus survival. Yeah. The implant succeeded. Or did it? The implant survived, but it didn’t succeed because you have a negative outcome. All right. Soft tissue support. So again I, I may have showed you this last week. And if I didn’t you’ll see a case today where we actually I’ll show you a case a little bit later. Yes. Bowen. Uh, Bowen sets the tone, but the tissue is the issue, right? If you don’t have tissue. You’re not going to have an esthetic outcome. Right. So how do we make sure that we have proper soft tissue support? I’m not a periodontist. Doctor Fleischer will talk to you more about soft tissue, but do we have the proper amount of keratin tissue there? Do we not have keratinocytes? Tissue? Does it matter? Right and available. That goes without saying. All right. So occlusion right. We talked about sort of canine guidance versus GRU function. You see here in this image occlusal scheme going all over the place curve of Spee Wilson. All of this matters in terms of planning. Kind of the examples I gave you. Right. If I have a occlusal plane that’s going all over the place like this and I’m restoring an implant, I don’t know here. I’m going to get all kinds of unwanted forces on that. So before even planning to restore that implant, I have to tell the patient, hey, unless we fix the occlusion, that implant is going to fail no matter what we do. Right. And we have to learn how to tell patients no a lot of time, because a patient can walk in. And I’m sure you’ve seen the stories. I’m sure you’ve heard them too. And all of us can share stories where a patient walks in. They have missing teeth everywhere, and they just want veneers on eight and nine. And you’re like, well, you have a lot more to worry about than 8 to 9. But they don’t want to hear that. Right. So it’s important to be able to assess everything else prior to that one side of the surgery and specifically as dental students, one thing that we don’t do very well is we get very. Requirement or very procedure specific. Get blinders on and be like, oh, this patient needs an implant. And we’re just looking at that one site, ignoring everything else, right? I don’t want you to think in that context. I want you to see the full picture. That includes whether there was caries or not, whether it was periodontal disease or not, whether there’s proper occlusion. Another thing that you have to think about is whether this patient has posterior support. Does the patient have posterior support or if they only have, I don’t know from first premolar on and they don’t have anything in the back. And I’m restoring an implant in the anterior region. What’s going to happen? All the forces are in the front. All those horizontal. All those vertical and horizontal forces are now in the front. Because I don’t have any anything to hold them in the back. Right. That’s going to fail. So again, just keep in mind, yes, occlusion seems like something silly. It’s extremely important for all of your cases. Fixed or movable implants, whatever it may be it’s always going to come up. All right. Enter art space. Right. How much space? Does anyone read the turnout article yet? All right. So you read about the three and the one and a half, right. So we know that. But how much space inter arch can I have. Right. And again every article is different. You’re going to get different averages. Some people will say six. Some people will say seven millimeters right. Removable. Again it depends on what kind of removable is. It could be ten. It could be 12. It could be 13. Are you using micro IRAs are using locator abutments. These numbers are averages. They’re not absolutes. All right. Just keep that in mind. Um inter proximal distance. The minimum is six, right. Because you have three and then one and a half and one and a half. If you think about the removable and this is what I was talking about, the AP spread, um, I’ll show you in in a couple of slides. That AP spread is the arch space right. Or the arch form. So I’ll go over that in a second. So if you have increased space, what caused you having this increased space. Right. So obviously the easy one is you had bone loss. So since you had bone loss now you have inter much more inter art space. Right. Because the tissue is going to follow the bone. If you lose bone the tissue is going to go up with it. All right. So what that’s going to cause is now you’re going to have this crown to root ratio, or the implant crown to route ratio is going to be very off. Right. You’re going to have this very long crown and potentially a short implant. Right. Um, so how do we manage this? How do we manage this? Well, we can either graft right, that missing bone so that we get everything properly and even improve the patient’s hygiene. Because one thing you have to keep in mind, even if we were to place the implant with that, you know, reduced bone, and let’s say you can place an implant now you have this very big crown. Do you think now the contact point is essentially not going to be to the adjacent tooth. Now you have this tooth that’s extremely long. Do you think the patient is going to be able to clean that tooth all the way there. No. And yes, you’re going to get bone loss around the implant and affect the adjacent teeth as well. Right. So you have to think about it. Yes, you may have a successful outcome today, but if this is a patient of your practice and the patient’s going to be in your practice for the next 5 or 10 years, guess who’s going to fix that in 5 or 10 years? Is it going to be you? So to avoid having that problem. Well, doctor, you place the implant. I don’t understand why. Now, are you telling me it’s failing because I didn’t plan for it to. Right. So you want to avoid that? Um, what if you have decrease based? What can cause something for decrease base? Well. Teeth migrated right into the space so you can have a smaller inter proximal space because the adjacent teeth migrated into that space over eruption from the opposing tooth into the space. So now you have a much shorter space, um, abrasion attrition. Right. So you wore down the teeth and now you have a decreased vertical. So you have a smaller space. So how do we fix that. Well again. If you are going to alter the video. And I’m sure Doctor Murtaugh talked about this a lot, and I’m here to tell you again, you can’t alter the video on one side has to be done equally on both sides at the same time. Right. So you can increase the vertical if the patient has lost vertical, if the, uh, opposing tooth erupted into that space, depending on how much it did, you can enamel plasti that tooth to create some space. Right. The tooth migrated into that space. Maybe you can shave a little bit off of the proximal surface to accommodate, right? Maybe you need ortho, depending on how much space. How much of the space has been encroached into. Right will determine your approach. The effect of this right is obviously going to affect hygiene esthetics. Right. Because as I mentioned, if you have teeth that are coming in this way and your implant is going to go in straight, you have these big black spaces between the crown that’s going in straight and the teeth that came in this way. Right. So you have a poor esthetic outcome. And do you think the patient will be able to clean these spaces down here? Very difficult for the patient. And those pockets are what they are, their pockets. They’re going to allow for plaque food accumulation, all kinds of things. Right. So also as I just mentioned earlier in the lecture and I mentioned last week, if you have less amount of space, you have less resistance and retention form. Think of like a short prep. Then you don’t have a lot of room for your implant to stay on, right? So you have a limited restored repertoire. You don’t have all of the restorative options in your pocket to choose from. So now you have a limited type of restoration that you’re that you can only use, right? And in certain situations, let’s say if it’s in an interior or an esthetic situations and you don’t want to do a screw or retain crown. Right. So that’s why I’m saying you have to take all of this into consideration before you tell the patient, yeah, we’re going to go ahead and plan an implant. And then once you place it, you’re like, oh crap, now it’s time to restore it. But I have all of these things that I didn’t consider or think of. All right. The arch relationship. We talked about this. You may recognize this picture even. Um. Right. I’m not going to talk about that. This is what I was talking about. The arch form. Right? I promised you I wasn’t going to forget about it. So you have these different types of shapes, right? You either have ovoid tapered or square. Right. So there is something called the AP spread or the anterior posterior spread. Right. In your case in pre doc, it won’t matter. I’m telling you right now. I’ll explain it to you just so that you will hear this. I’m sorry about that part that’s missing. I’ll fix that. Um, it’s probably fixed in the PDF on blackboard, but if it’s not, I’ll let you guys know. But basically tapering is more in class two. What that what AP spread really matters for is if you’re doing, let’s say a full arch of implants. Right. So let’s say you have all of these teeth that are missing. And all these black dots represent where implants are. Right. So how the AP spread, which is. The distance from the center of the most anterior implant to the line joining the distal aspect of the two most distal implants or the most distal implant. So if I’m doing a full arch of implants right, I’m doing a patient’s missing all of their maxillary teeth. Right. Let’s say you’re going to place, I don’t know, 6 or 7 implants. And you’re going to do a fixed prosthesis on top of those 6 or 7 the distance. Right. From the center of the most anterior implant to the distal of the most distal implant. Right. That is what they call the AP spread. Why does this matter? It matters because you can see here this patient goes to the second premolar. Right. What if the patient has opposing natural molars? How much can I cantilever? You guys know what cantilever is? Yes. How much can I can to lever off of here? One tooth, two teeth. Three teeth. Let’s say this ended at the first premolar. Or the canine? How many teeth can I cantilever off of this? That AP spread is going to matter. Right. And a lot of times what determines this AP spread, besides how much bone I have left, is also the shape of. The arch. You can you can see that this distance is going to differ from here to here, how wide these implants are, right? Like I said, you’re never going to deal with this in pre doc. I’m just explain this this concept to you so that you’re you’re familiar with the term AP spread. And so that you just have some basic understanding. We can discuss it a lot more after the lecture and I’ll gladly do so. But this is just the concept of how the arch form and the AP spread may affect. Your implant placement choice of where you’re placing your implants to determine how much skin to leave you’re going to have, and won’t matter in product. You’re not going to get examined. You’re not going to get this on your exam. But I just want you to understand what AP spread actually means and why it’s important, right. Oh, we saw this. Sorry. All right. Missing teeth. Location. Remember, I talked about the the the job being a class three lever. Right. So less occlusal space. The further back you go and the higher chances for you getting more lateral interferences. Incisors is the opposite, right? You have a lot of space. You have less forces. So you’re going to have better esthetics. But it’s going to come back to the vertical versus horizontal forces. Right. You know how anterior teeth have these long roots that are tilted back, so they are better suited to accommodate horizontal forces versus vertical forces. Right. So that’s why I talked about if you have missing teeth in the back and you only have interior in the front, then you’re getting all these vertical forces in the front. Your teeth are not designed to accommodate those types of forces. Right. And nor the implant that you’re going to be placing will. So understanding just basic occlusion and all these occlusal principles is extremely important for us. To present the patient with a plan that will have a good prognosis. All right. Again. Number of teeth missing as I mentioned. Am I doing individual crowns? Am I splinting these crowns together? Um. And if they’re removable, right. Am I splinting? Uh, all these together? Like doing a fixed, like I showed you in that previous slide where I’m joining all the teeth together? Or am I doing a denture that clicks in and out? Right. So depending on how many implants I’m placing, the location of those implants, that’s going to determine that as well. Lip line. So again the resting lip line are variable. And there is a lot of data to talk about this. Uh, and it matters. Female to male, female actually have two and a half times more than a male. Hi. Smile line than average smile line. All right. Um. And. Think of it in context of a if you just think of in context of age, when gravity takes over, muscle tone is in your face falls down. Right? So that’s why when you see older folks on TV, right, you see more of their lower teeth than you do their anterior teeth. When they talk, right? Because they lost that muscle tone is in their face. Right. So that’s something to keep in mind. Okay. It’s very, very important to think about this in a team approach, right? In your case, a lot of times at least the way Doctor Fleisher interview this, you are the team, right? Because you are seeing the patient. You’re doing the clinical exam. You’re evaluating the radiograph. You’re placing the implant and you’re restoring it. It may not be like that. You may choose in private practice and be like, I don’t want to place implants. I’m going to send these all out to a periodontist, oral surgeon, whatever. And I’m just going to restore them. Right. But it is a team because you have to make sure to address the soft tissue. What kind of surgical sequence? Right. Whether this is a conversation you’re having with the patient, is this an immediate implant restoration? Is this going to be, um, a two stage, a one stage? Does it matter for the patient if it’s in the anterior region and they have a wedding coming up, what are you going to do if you don’t have this sort of team approach with you? And whether you’re doing it with a surgeon or by yourself, you won’t be able to come up and figure out a proper sequence for this patient. The angulation I think we talked about this last week a little bit this week, depending on the angle of the implant and where it’s going to go in, right? Whether it’s Buckley tilted lingual, medial or distal or whatever, that’s going to affect your final prosthesis and the design of your final prosthesis and the material you’re going to use for final prosthesis. Right. Because if it’s too thin, then that really nice esthetic porcelain I can’t use anymore because it’s the more just general concept. You’re going to hear from Doctor Suzuki next year. And just in general, anything that’s pretty is typically weak, right? The the the more beautiful the ceramic, the more esthetic, the weaker it is. It goes hand in hand, right? Has more matrix, more light passes through. It’s weaker. Right. So if I have this compromise restoration and I’m going to have a very thin part of ceramic, well that’s going to fracture. So now maybe I have to use a much more dense type of ceramic like a zirconia. But that won’t be as esthetic, right? So everything has an implication. Did does this patient need augmentation? You’re going to hear from Doctor Fleischer talk about this a lot. Do I need augmentation before the surgery? During the surgery. After the surgery. How do I determine that? Right. And again, if you’re working in a team, these conversations have to have have to happen before the surgery. Not oops. Hey patient’s in the chair. We’re going to do XYZ right? And how long is the healing time. Right. Patient expectation. You heard from Doctor Fleisher talk to you about the SLA, SL active different types of the implants. Uh, the coding. Does that affect healing time. All right. I’m going to show you a case where treatment planning gone wrong and how we kind of addressed it. And we’re going to take a quick break. And then Doctor Fleisher is going to come up. All right. So this was a patient of mine, uh, back in 2014, and he had missing seven through ten. And he had already had implants placed in the positions of seven and ten. So he was coming to me just to restore those implants. And when I first saw him, he said he just wanted to restore his implants. And. This was just the initial impression. What do you guys see in this image? SPEAKER 1 They. SPEAKER 0 The angulation of those is pretty severe, right? That’s like someone was like, here, place them. Right. Um, so besides the implant, what else do you see? What else? Keratinocytes. Tissue. What else? Hygiene. What else? SPEAKER 2 Domination, huh? SPEAKER 3 The action of the. SPEAKER 0 Invasion of the space. Right. So a lot of what we talked about. Right. So do you see now how this occlusal plane is flat? And then it comes up and then it goes back down. Right. So how is that going to affect my occlusion? A lot, right? And now I’m either going to have to have these way more buckle shorter so that when the patient goes into exclusive, it’s not just loading these implants. Right. What happened to the canines? See the recession on the canines. So do you see how you’re already at a disadvantage? Patients just coming to you, and you’re just restoring the implants. You didn’t place them. You didn’t plan them. Do you see why working in a team approach is extremely important to avoid all of this from happening. All right. So replace the impression coatings took radiographs. Right. And you can see just on the radiographs we have, you know, some decent amount of bone loss here. Right on these threads over here. A little bit here. All right. Nevertheless, we made the impression and this is what the cast looks like right now, if I’m trying to restore this and I’m looking at it just from a restorative lens. If I’m just looking at it. If you were to think of those as two prep teeth, how would you fit crowns on top of them? Right. You’d have to angle your prep so much down this way right now in order to do that. How much to structure where you have left? Almost nothing. Right? So those would be very weak. Another alternative is to do what the screws from the facial. Right. So you have these big screw holes and you can screw it in this way. But also those screws and the crowns are sitting on what they still has to be some type of abutment. Right. And those abutments are going to be basically paper thin because they’re going to have to come down almost at a 90 degree angle. Right. So restorative Lee, this is a nightmare challenge. Right. So what are our alternatives. Hmm. Hybrid prosthesis. On what though? How are you like? Are you going to use abutments? Okay. You said you. You said removable. So just bury the implants. SPEAKER 4 I read about. SPEAKER 0 Okay. Angular. How? What kind of angle? 90 degrees. UCLA abutment all the way, and you’re going to do a 90 degrees. Do you think that’s going to last? All right. So for those who said removable, you’re pretty close, right? You in order to restore these implants, it is going to be a severe compromise. So the decision was that we’re going to take these implants out. So when we took these implants out, we wanted to take them out and place two implants properly. But what we noticed is that the whole apical portion of the implant will not have any bone because of how flat these implants were placed. So the decision was made by the surgeon at the time to raise the floor of the nasal cavity by five millimeters, which they did right, to build a bone up this way. And we waited about, I can’t remember if it was 3 to 6, six months. Right. And then implants were placed properly in the right position. And then we waited three months, I want to say, or four months post-op. And here are the new year. The new models look a lot different than the ones we saw earlier, right? Now, the good thing is we had a very patient patient, right. Who, you know, wasn’t angry. He just wanted these implants restored. So was willing to go through all of this. That’s not going to be the case with a lot of patients. Right. So we just wanted to get a feel for how it’s going to look. So we made a provisional um, this is one way of doing them. Um, I make it in acrylic and then I use external staining. And I just wanted to see what it will look like. Now, if you notice from this top picture, what’s nice is that the patient has a little smile line. So I’m not too worried about the pink, right? I’m more worried about the white and you can notice it is shorter. Right. But we’re going to try to fake it. We do some staining. Open up the embraces. Right. And from afar it doesn’t look too bad. But to our eyes it doesn’t look too great because we don’t like this, right? So we tried the provisional on for a while and this is the compromise we came up for with the final right. And we ended up doing a porcelain infused zirconia restoration with this patient. You’ll see how much recession we got here. And here you can see we have a little bit of a black triangle here and here, but this is probably the best outcome we can get in a compromise situation like this. Given that the patient has already been through a lot right now. Again, good for us that the patient has a low smile line and is extremely easy going right and from afar it doesn’t look too bad, but that gives you an idea of why treatment planning is so critical, and working in a team is extremely important. To have these conversations. We are going to take a six minute break and nine at the doctor. Fleisher starting. All right. SPEAKER 3 Right now. SPEAKER 5 All right. Good morning everyone. So again, my apologies for last week was unavoidable. Both both of us were out and it was, uh, it was impossible to. To hold the class the SLC session, but you’re not going to lose any of that time. We will we will make it up. All right. I you know, I was listening to Doctor Noah talking this morning, and I was saying to myself that I’m quite sure that for many of you. Some or much of this isn’t making total sense that there’s information that’s being handed out to you, but you don’t really understand, uh, the full context of it, and that’s understandable. All I can tell you is you have to trust the process right now that as time goes by, this will start to make sense. It will start to come together that you hear this information in little bits and pieces, a little bit here and a little bit here. But neither of these two points make sense together yet. But they will. All right. So just hang in there. All right. I’m just going to review about single and single stage and two stage bone level and tissue level. I’m going to talk a little bit about platform switching, which is the one of the articles that you’re reading on by. Uh, Lazzara. And then considerations for the placement of digital of a placement of an implant. The digital workflow and treatment planning. Post extraction options. All right. So a bone level or tissue level describes where the top of the implant, the head of the implant, is in relation to the crest of bone. One stage refers to the implant being placed and the healing of button being placed and exposed to the oral environment, and the two stage refers to the implant is initially submerged under the tissue. So there are two somewhat related issues, but not totally related. All right. You can have a bone level implant that is either one stage or two stage. Right. And you can have a tissue level. You can even have a tissue level that is two stage. But it’s rare because it’s much more difficult. But the bone level versus the tissue level implant refers to where the top of the implant is. Think about it like you’re screwing a screw into wood. Right? And you have the top of that screw head. And you’re going to determine where you stop that screw head, what you’re turning it as, it’s entering a bone. Part of that screw is entering the bone. And you can either stop it where the head of the screw is level with the wood. Right. And in that case that that is a bone level implant where the, the implant screw is turned until the top is level with the, with the bone. Or you can stop it earlier, right where part of that screw sticking out of wood or part of that screw is sticking out of bone, right. And that is a tissue level implant. And the one stage versus this. And so this is a bone level implant here. And this is a tissue level implant here. Usually the tissue level implant will have a different surface configuration. At the at the tissue level above the level of bone. We talked about the roughened surface and the advantages of a roughened surface. So in bone it’s all going to be roughened surface. But for a tissue level implant above that is going to be a different type of surface. It won’t be a roughened surface. Okay. The two stage versus the one stage is telling is talking to us about whether or not we’re going to see the implant configuration at the time of the conclusion of the surgery, or whether it’s going to be completely covered over by soft tissue. Why would we cover it over with soft tissue? Completely? Because we want to allow maximum healing to take place for whatever reason. Right now, Brian and Mark originally did everything as a two stage. When he placed the implant, he put a cover screw and he put the soft tissue back over it. All right. So many of us had a bias. That two stage was better. The two stage was the way it was supposed to be done. But even at the same time that Brandon Mok was doing his surgeries, there were others that were doing surgeries and they were doing it as a one stage. If you had this tissue level implant, the the implant would rise up to this level. It would be very difficult to cover the soft tissue over it. And so the intent was to not cover the soft tissue over it, but to allow the healing of the soft tissue around the implant and the healing abutment to take place. Doctor Noah this morning mentioned about doing some sort of grafting procedures. If you’re going to do some sort of extensive grafting procedure at the time that you place the implant, then the likelihood is you’re going to want to cover the soft tissue over it, because otherwise the graft is not going to work very well. And so you’re almost always doing a two stage procedure if you’re doing some sort of grafting in conjunction with the placement of the implant. And that may include sinus lifts as well as ridge augmentation. Types of procedures. So bone level versus tissue level is describing where the head of the implant is in relation to the crest of bone. One stage versus two stage is talking about whether or not the implant is being submerged under soft tissue or not. Does that make sense to everybody? Clear. Okay. So just a little bit more about the one stage versus the two stage. When you are doing a two stage, you’re going to use what we call a closure screw. A closure screw is flat to the top of the implant. Right. We need something to fill in this hole while it’s healing. A healing abutment will have a construction that has material that is coronal to the implant head itself, and so it will traverse through the soft tissue. And so that’s what’s going to allow this to be a one stage type of procedure. So once more, bone level implant has the flexibility of doing either being a one stage or a two stage, depending on what type of, uh, screw you put into the implant itself, the healing cap, or the closure screw versus the healing abutment. So this is the original Branham implant where the. Head of the implant is here. This is the restorative component that the that you would attach the abutment to. And so when this when this implant screws driven into bone it was stopped at this level. Now we have different types of configurations of implants. This is a roughened surface with what we call a collar of machined surface. It’s about uh it’s less than one millimeter. It’s 0.75mm in height. This is still considered a bone level implant, but there is a little bit of a collar that is sticking up above the crest of bone. And we’ll talk about why this has been developed and what the consideration is for it. A couple of years ago, a newer design by Nobel Bio Care came out, and this is the Tai Ultra Select. This is also part of the implant itself. This gold portion or bronze portion is above the crest of bone. And it is analogous to this collar. It’s a little longer right in nature. Okay. It’s a different material. It’s been treated a little bit differently. And so there are some advantages. So we have a phenomenon. That, uh, that we started noticing with the brand Mark implant. So the brand mark implant was just a two stage procedure, right? It was placed, it was buried, soft tissue was covered over it. It was allowed to heal for between 3 and 6 months. Right. And. We noticed something called cupping taking place, the loss of bone around the coronal aspect of a dental implant. And this was very, um. A very normal thing to see, right? This was not an unusual finding, but what was interesting was that even though the brand mark implant could be buried for six months or even longer, this cupping only took place after the abutment was attached. So when you place this brand mark implant to this level of bone, and you put a closure, screw over this and you buried it and you covered it with soft tissue, and you let it sit there for three months or six months, or if the patient disappeared for a while and it was left there covered for a year or two years, and you came back and you uncovered it. There was absolutely no bone loss that took place in the vast majority of implants. Right? Once in a while you had a failure or something like that. But when you now converted this over, and now you put an abutment onto the implant on the brand mark implant. And now it was communicating, right. There was a communication with the oral cavity. You developed what was called cupping, which was about 1 to 2mm of bone loss around the dental implant. This is what it looked like and this was a very common occurrence. You see this all the time. So what’s going on here? Why do you have no bone loss when the implant is placed and a healing cap, a healing, a closure, screws placed over it, and the soft tissue is allowed to cover over it. And you have no bone loss that takes place. But when you put the abutment on. Within a couple of months. You see both radiographic and clinical evidence of bone loss of about 1 to 2mm around the dental implant. So what do you think is happening? SPEAKER 3 Bless you. SPEAKER 2 Thank you. SPEAKER 5 Bacteria. In what way are you? Do we have bacteria? Okay. So it’s closed off to the oral cavity. So there is no bacteria. Right. But what is important. About the bacteria. So let me add a little bit more information for you. I showed you the other type of implant, that tissue level implant. That tissue level implant was exposed to the oral environment from the day that the implant was placed. Right. It did not experience. It does not experience cupping. It does not experience that 1 to 2mm of bone loss around it. So there is bacteria. In the environment. But what is the difference between the tissue level and the bone level implant that would that you would theorize would cause this bone loss, this cupping to take place. They say that again to the. So in neither case is the implant. Placed into function yet, right is just an abutment that’s placed there. SPEAKER 6 By invading the. SPEAKER 5 Well, you could you can argue. I’m trying to understand. So in one case, you’re uncovering the implant and exposing it to the oral environment. But in the other case at the time of the surgery, it’s all exposed. And it’s and it’s exposed to the oral environment during the initial healing. So you have you would think, or at least I would think sort of a similar scenario there that wouldn’t seem likely to be the explanation. SPEAKER 3 Yeah. Say that again. SPEAKER 5 While the portion of the bone. SPEAKER 7 Exposing the bone to the urine. SPEAKER 5 But we’re exposing the bone to the environment in both cases, right in the tissue level and in the bone level. So what might be the difference? Towards the back in the blue blue shirt. SPEAKER 3 And the connection. SPEAKER 5 Say that again. SPEAKER 3 They are. SPEAKER 5 So the proximity of the connection between the abutment and the implant itself and the bone and that that is. And you’re going to read an article if you haven’t. I don’t know if you read the article already, but the the Herman article that you have to read about, we’ll explain this to you in great detail. So it is where the abutment implant interface is relative to the level of bone. Right if the abutment implant interface and it has to do with bacteria, we think. Right. But the abutment implant interface, when it’s at the level of bone, seems to create this environment that allows for the cupping, the bone loss to take place in the tissue level implant. The abutment implant interface is millimeters coronal to the bone level. And so it doesn’t seem to matter if there’s any bacteria that’s building up in that abutment implant interface or whatever it is about that abutment implant interface, but it doesn’t allow for any bone loss to take place. So a real significant difference. And I’ll tell you something. So this has broad implications. So when you’re reading articles as you will in the future when you’re reading articles about bone loss that takes place around dental implants, many of the articles, many of the studies that were done. And even. Well, probably don’t continue to this day because we don’t have the phenomenon of company taking place anymore. But while this cupping phenomenon was taking place, some of the articles would not count the first two millimeters of bone loss in the study. In a study about bone loss around dental implants. Right. Because they said, well, it’s a natural phenomenon, quote unquote, happens all the time. So we’re not going to count. So even though there may be a millimeter or two millimeters of bone loss, the articles are considering that zero bone loss. Which sounds kind of crazy, but that’s what they did. So you have to read these articles really closely, right? So. Concept of biologic with we have the level of bone. This is a tooth. We have connective tissue that inserts into the symptom of the tooth always above bone. With a dental implant you do not have this phenomenon. You have connective tissue coronal to the bone. But obviously it’s not inserting into the implant. And then you have the epithelium as well. All right. So very significant differences in terms of the ability of the body to prevent bacteria from getting down into that space right where the bone and the implant interface together. It’s not quite the same type of a scenario. So this. Is showing you same diameter. Of implants, but the healing cap is not as wide a diameter as this one is. So in this one, the diameter of the healing cap is coincident with the diameter of the of the implant, and in this case, the diameter of the healing cap is a smaller diameter than the diameter of the implant itself, and this was a bone level implant. Right. Two bone level implants that were placed right next to each other in the same patient’s mouth. You had the same environment that was taking place, and what was found was that, and this was just a single case. And what was found was there was no cupping that took place here, but there was cupping that took place on this implant. Now, this was, uh, a periodontist. This is Rich Lazzara, who identified this phenomenon first, which Lazzara is a graduate of Boston University Perio program, and he came out at a point in time. He was a, uh, an entrepreneur, uh, really terrific. And at the time, the brand mark implant was the dominant implant that was that was available. And the company had very limited types of abutments for dentists. And I mentioned to you, Brian and Mark was not a dentist. He didn’t really understand in great depth about what was needed to make an esthetic result for a dental implant. He was more concerned with the function with dental cripples. Right. But Lazzara and lots of other dentists were realizing that, hey, these implants are working great, but they don’t look so good. And he developed a he developed a UCL, UCLA abutment. Right. And he used to sell these at meetings out of his pocket, right. While he’d go to a dental meeting and go to a meeting and call some people over and he’d say, hey, look at this. This is a better type of abutment than what brand Mark is selling. And he turned that into a multibillion dollar company. It’s three that has been sold since then. It made implants as well. It’s, uh, was a phenomenal success. And I tell you this one, because of the, you know, the the human interest story associated with it. But I also tell you it because even though he is at this time when he figured this out, right, he’s the owner of a multibillion dollar company that has all sorts of components for implants. Do you know why he put the two different diameter healing caps on these implants. SPEAKER 3 He. SPEAKER 5 Didn’t have in his inventory at that moment? Right. Two healing caps that were the proper diameter. It was purely by accident, right? It was happenstance. He like he was looking through his inventory and he found one that was a little smaller diameter. He said, well, it’s not going to cause a problem. I’m just going to put that one on. But he was smart enough to recognize when he took the radiograph later on that, hey, what’s going on here? What is the difference? And this was the birth of the concept of platform switching. Right. Which is one of the articles that you are reading. So what? The theory that arose out of this was that platform switching is a method to preserve alveolar bone levels around bone level dental implants. Concept refers to placing a screwed or friction fit restorative abutment of a narrower diameter on the implant of a wider diameter, rather than placing the abutments of similar diameters. Right. So why would that matter? Why would that make a difference? So we have. We have the edge of the dental implant and we have the abutment implant interface. Remember I was mentioning that and remember we were just saying we all agreed that the tissue level implant, the reason why you didn’t have the cupping tape taking place, is because the abutment implant interface was a certain distance away from the bone implant interface, and that was in a vertical dimension. Right. But this accomplishes the same thing in a horizontal direction. Now. Maybe it’ll work. Maybe it won’t work. Turns out it does work. Right. But it’s so it’s literally where that implant abutment interface is relative to the implant bone interface. And if there is a distance between them that will allow for healing to take place and not the destruction of bone in that area. Right. So. So in some respects this may be the same concept of biologic width in a horizontal direction that we’re used to talking about in a vertical dimension. Right. So what has happened is that many implant companies are now incorporating into their design of a bone level implant. This concept of platform switching in 1 in 1 fashion or another, it could be a straight horizontal. It could be that little collar that I talked about. I showed you a little while ago. There was a collar around this bone level implant that stuck out above the bone, that also created that distance between the implant and the bone interface and the implant abutment interface. And then there are some that have a combination of the two. Right. That there is a there’s a physical distance. And there is also a movement more internally right for the abutment. So lots of different ways to to accomplish this. Yes. SPEAKER 2 You’re seeing this color collar that goes above the bone is now this horizontal biologic with. SPEAKER 5 Well, if there’s a collar. If there’s a collar, then that is a vertical, right? Yes. So it’s either vertical or horizontal or a combination of the two where it’s on an angle right where you’re, you’re moving it internally on the angle, but you’re also moving it vertically because there’s a little bit of a collar associated with it. SPEAKER 2 This corner is also covered by soft tissue. SPEAKER 5 Soft tissue not bone. That’s right. Yeah. SPEAKER 8 Biological rights for. SPEAKER 5 So. So biologic width is a concept that is ingrained in periodontitis associated with a tooth. Right. That is what we call biologic width. And when you invade biologic with you you’re probably learning about that a little bit with Doctor Panay. Has she talked to you about that yet? SPEAKER 3 Okay. SPEAKER 5 But for natural teeth, the concept is biologic width associated with natural teeth, and that you have to have a certain distance between the restorative margin and the and the crest of bone in order for there not to be bone loss. So in the same fashion, there appears to have to be a distance between the implant abutment interface and the crest of bone in order for there not to be cupping or bone loss. So in that regard, it’s similar to the concept of biologic width. It’s not exactly the same. The numbers aren’t the same, but conceptually there’s a similarity between them. Connective tissue. There’s going to be soft tissue right. It’s going to be connective tissue. That’s right okay. Yeah. SPEAKER 4 It doesn’t work if it plays a wider diameter. SPEAKER 3 I don’t. SPEAKER 5 If you place a wider diameter healing abutment on a on a narrower diameter implant, you’ll have cupping taking place. It’s only when the healing abutment is of a narrower diameter than the implant itself. Right. So this is showing you this polished collar. And this polished collar is going to be above the crest of bone. And so the implant abutment interface is going to be coronal to the implant bone interface. So you’re going to have that going on. So the question becomes if you’re understanding this, so do you need platform switching on a tissue level implant. You do not. Right. You need the platform switching on a bone level implant, but you do not need a platform switch on a on a tissue level implant, because the abutment implant interface is already a distance away from the implant bone interface. All right, so I showed you this already that when you’re placing a dental implant. That if you on a 13 millimeter long implant, if you are nine degrees off from your intended location, right, if it’s nine degrees off, your apical extent is going to be two millimeters further away from your intended apical location. And in in in a case like this, it doesn’t really make that much difference. You may have to use an angled abutment here, but it’s the case is going to be successful. Right. But in cases like this right. You just made a disaster out of this case. Did I explain this to you the last time I told you that this was dental student, right. So real big disaster. Okay. So. So if you look at this, this implant is outside the housing of the bone. Right here is the bone. Here’s the cortical plate of the bone. You can imagine. So it’s osteo integrated on probably less than 50% of the implant itself. It is stable. Right. But there’s absolutely no bone there. Now you can say well maybe there was bone there before and something happened and there was bone loss that took place. But when you see the cortical plate of bone like this, you know that the surgeon missed it. They they didn’t put it into the bone. Right. They kind of went right along the bone. Here mean you don’t have much space between this root and this implant. You might have gotten away with it this time, but you’re awfully close. And I can’t imagine that anybody who is placing this implant is intending to be that close to the route. Of the of the neighboring tooth. So how do you prevent this? Right. So it’s this utilization of the of the technologies that exist today where we take information, we take an intraoral scan of the patient’s mouth, and we take a CT scan and we merge this information together. Right. So here is a CT scan. Here is an optical scan. And we’re going to put both of these together in the same program. And this is what you’re seeing here now. Now you’re seeing a CT scan and you’re seeing the optical scan overlaying it. Right. And because we’ve been able to bring that information together, we can now plan the placement of a dental implant much more accurately. And more important than being able to plan it is being able to take that information and create a stent that we then bring to the patient’s mouth that will put the implant exactly where we planned it. And this is what we’re teaching you this year how to do step by step. SPEAKER 3 Okay. SPEAKER 5 So first year I taught this course. A couple of years back, I talked about the single most important factor considering the placement of a dental implant. Then I said, well, one is not enough. There are at least two things that are really, really important. And now I’m up to three. What are the three most important factors when considering placing a dental implant? Okay. So obviously, as Doctor Noah mentioned earlier, a medical history is critically important, right? Because it will derail any possibility of placing a dental implant under certain circumstances. So you must understand the medical history. You have to know if there’s enough bone to place the implant, and you have to know if there’s enough space to restore the implant. You need to have all three of these things in order to have a successful case. So when we’re talking about enough bone, we’re talking about the the inter tooth distance, we’re talking about the buckle lingual dimension of bone, and we’re talking about the depth of bone when we’re asking whether or not we have enough bone to place in enough space to place a dental implant. So it’s really important to understand that there has to be enough space here, because otherwise the diameter of the implant itself will just be too large for the for the space. Clearly not in a case like this buccal lingual dimension we need to know and the depth we need to know as well. And how do you figure that out? So when you’re looking. And just imagine that this is a cast, right? When you’re looking at this cast and you’re looking at the edentulous area here. Many people, myself included, would reach the conclusion that there is an insufficient amount of bone in a buccal lingual dimension here to be able to place a dental implant. That’s just the way it looks, right? And I can show you cases that the exact opposite in that soft tissue, looking at the surface of that cast or looking in the patient’s mouth, will lead you to conclude that there’s plenty of of bone there to be able to place a dental implant. But as they say, looks can be deceiving. Right. And you, you need to be able to see whether or not there is sufficient bone here in a buckle lingual dimension, not by looking at a cast, but by evaluating a CT scan. So some people in the past have advocated by by taking measurements on a cast. This is a completely incorrect way to measure. You cannot definitively tell whether or not there is sufficient bone present without a CT scan. It’s just not possible. So this is this case, right? In which when we’re looking at it, it doesn’t appear that there’s a sufficient amount of bone here. But when we actually look at the CT scan, we find that there is sufficient bone, because in the very most coronal aspect there is not a sufficient amount of bone. But if you just go two millimeters apical to that, there is a sufficient amount of buccal lingual dimension of bone that is present that you cannot see by looking in the mouth, you cannot see by taking a par. Right and you cannot guess about it. You need that CT scan where you get that cross sectional perspective and you’re able to see it. Now, we also talked about the spacing between the implants. And this is the Tano article that that talks about it. All right. And we’re talking about a millimeter and a half between a natural tooth and a dental implant in three millimeters between two dental implants. I’m going to caution you now, and I’m going to say to you to read very carefully to understand what Tano is talking about, and understand the limitations of the article, that Tano is talking about the circumstances in which he he discusses it, because this is not necessarily true all the time. All right. I’m going to leave it at that for the moment. I’m going to let you discover that as we go through. And then you have to have enough space in an apical incisal direction to be able to restore the case. So all of these things you need to look at before you ever start placing the dental implants, so that you know what the outcome is going to be. And as Doctor Noah mentioned, the density of bone is also important. You can get some, um, some sense of how dense the bone is by looking at the CT scan. And they have a they have aspects of the, of the program itself, which will give you some indication of what the density is on it. D1 is the most dense cortical bone and D4 is the least dense. And when you’re dealing with very soft bone, that’s medullary bone that doesn’t have a lot of cancer or cortical bone. Sometimes it’s really difficult to get a lot of bone implant contact. And that has an impact on the ability of the implant to be stable long term and to be osteo integrated to a sufficient extent to be able to withstand the forces that you’re going to place on it. Usually this type of bone, three and four are taking place in the maxillary posterior region, which is, you know, according to Doctor Noah, the area where that lever is placing a tremendous amount of force. So you need to understand this, and you need to take that into account when you’re planning a case as well. So keratinocytes tissue, you know, so these implants are surviving but are they successful and are they having problems associated with them. And they oftentimes do. There’s lots of inflammation. There’s lots of there may be some pus that’s present in the area. And you know, when you’re doing the procedure how do you preserve the carotenoids tissue. And at the time of the extraction, do you take into account that you may need more carotenoids, tissue. You need to be thinking and planning ahead. When you’re thinking about placing the dental implant and when you’re making that first incision, does it matter? Do you always do it mid crest. Early. Right. Because if you’re trying to preserve carbonized tissues, sometimes the proper place to make that initial incision is not mid crest. Maybe it’s a little bit further over to the to the lingual right. And there are ways to increase the amount of keratin tissue. And is it worth it to do these types of procedures. Is this is this going to result in a better outcome? Is it going to result in a better success rate? And is the time to do this before you place the dental implants or while you’re placing the dental implants? Lots of different questions, right? There aren’t necessarily clear cut answers to all of these questions, but you need to think about it. And on a case by case basis, make a decision about it. So this is a this is what we all used in in the 1980s. Branham implant came to this country in 1986. And in the 1980s and into the 19, into the early 1990s, we routinely use the Panamax radiograph to determine if there was enough bone to be able to place an implant because it was the best that we had. We didn’t have anything better than that, but we also had to take into account that there could be up to a 20 to 25% distortion, depending on the location, the aspect of the implant. What’s interesting is that all of these implants are the same exact diameter, and yet they appear completely different on this film. And that’s because of the distortion that took place when we used to plan dental implants off of a panel x we had. It was called an acetate. It’s this plastic, you know, see through. Um, it was the same dimension as a piece of paper, and it had an implant on the on the acetate, and it would be blown up 20 to 25% larger than the actual size of the implant, and you would place it over your. Over your panics to see whether or not it looked like there was enough space there to place the implant, and that was the best we were able to do. At that. SPEAKER 3 Time. SPEAKER 5 We also took PA. Radiographs. And I’m going to tell you this is this is a case that I had. This was a patient that came into my office and we already had a Cat scan. Right. But the first thing that the patient wanted to know was whether or not this tooth could be saved. And in order to know that I had to take a PA. And so I took a PA, and I made the determination that this tooth could not be saved. There wasn’t enough solid tooth structure left to be able to restore this tooth with the crown lengthening, and then have enough support for it to support a crown. And so but I was also looking at this and we’ll talk about it a little later. We’ll talk about whether or not an implant is placed at the time of the extraction, or whether it’s delayed in some fashion after an extraction. And under the right circumstances, you can place a dental implant at the time of the extraction. And one of the criteria is whether or not the most important criteria is whether or not you have sufficient bone to place that implant so that it is stable. Right. So I’m looking at this case and I’m saying, well, actually this is a pretty short route. I’ve got a lot of bone here apical to it. I’m pretty sure that the inferior alveolar canal is going to be apical to these roots, to the apex of these roots. And so I probably have plenty of bone to be able to place an implant that’s going to be about this long and grab apical bone to, to make it stable. And because it was a premolar, it wasn’t a very large diameter tooth. And I said, this is this is pretty much a perfect case for for an immediate implant. This is going to be really great, straightforward. And I made the mistake of telling that to the patient and saying, no, I did leave myself and out. I said, we have to take a CT scan just to verify everything. But in my experience, looking at this, this looks pretty much straightforward. It looks like it’s going to be great. We’ll be able to place an immediate implant. Let’s go outside. Let’s go take the CT scan. In fact, you don’t even have to wait around. If something comes up, I’ll call you. Right. This is the CT scan of this case. So what do you see? Uh oh. Right. So like, I saw this for like a half a second in my office, and I, like, I ran out of my the back office hoping he was still there so I wouldn’t have to call him up, you know, an hour later. And I said to him, you know, don’t leave yet. I’m reading the the CT scan, and I think it’s a little different than what I initially thought that PA gave me. No indication whatsoever. And I will tell you that the soft tissue profile in that case gave me no indication whatsoever that there was all this bone lacking on the on the facial aspect. None. But very easily. You can see it on the CT scan, right? There is just no bone here. So what’s going to happen when I take this tooth out and I’m looking to place an implant? I’m not going to say that it precludes me from placing an implant immediately, but it’s much more complicated than what I initially thought. It would require a significant amount of bone grafting to take place. The success rate is going to go down. It’s not the same scenario that I initially thought, and I can’t get that information with anything other than a CT scan, right? Okay, so after we get the CT scan, after we get the optical impression, we want to put these things together, right. First we’re going to create a virtual crown. For this area because we’re going to import that information into the CT as well, because that’s going to help us know exactly where we should be placing the implant. All right. So we’re going to export this file and we are going to export it to our CT scan. But before we do that we’re going to use the CT scan. We’re going to map the nerve. We’re placing a man implant in the mandible. And then this is working within the the CT program, which is called Sodexo’s and Galileo’s Sodexo’s. And you’re going to be doing this. And on the left here is the optical scan that has been imported into Sodexo’s. And on the right here is the CT scan itself. And you are going to help the computer take this and superimpose it on top of that. You’re going to do that by identifying some spots. The equivalent spots on the CT scan and on the optical scan will go over all of this in the in the next lab on Thursday. And once that data is merged properly, then you have this CT scan with the optical scan that’s sitting on top of it. And most importantly, you have that virtual crown that you created in the serac, right. That is now in here. Right. And here is this outline of it. And you can see it and you can see it here in the blue. Right. Why is that so important to us? What is that? Why did we take the time to create a virtual crown? What is that doing for us? So I need I see some people looking down and they’re not paying attention to what’s going on here. And this is this is critical for you to understand this course. Right. Why did we take a virtual crown in Serac and import it into Sodexo’s in the CT scan? Yes. SPEAKER 3 Please go back. For? SPEAKER 5 More. SPEAKER 3 I. Or now you. SPEAKER 5 Of the of the CT scan and the implant itself. SPEAKER 3 Okay. SPEAKER 5 Well, I think it’s. SPEAKER 3 I. SPEAKER 5 You’re talking about this? SPEAKER 3 No, I think it’s the one where the tooth is still in place. And the whole point is. Oh, that. SPEAKER 5 The clinical case? That? This one? No. Still not. Okay, but the question is. So this one doesn’t contain a virtual crown. Right. But what is the importance of the virtual crown? Why are we concerned about that? SPEAKER 3 Yeah. SPEAKER 4 About, uh. SPEAKER 3 We will go in the space. SPEAKER 5 So if you don’t have the virtual crown and I think this is what you’re saying, if you don’t have the virtual crown in the CT scan, how do you know how to orient the location of the implant? What are you using? Because the only thing that you have, if you don’t have that virtual crown imported, is the bone. Right. So you’re going to place the implant where the bone is. But does that necessarily mean that the implant is where the restoration is going to be? No. So if you create the virtual crown in Serac and then import it into the the Nexus program, now you have an A crown in place so that when you’re planning this case, you can look not only at the bone, but you can also look and see where the crown is going to be and whether or not you’re lined up underneath the crown. And let me tell you something. For a long time when we didn’t have that available to us. Right. And I placed the dental implant, I placed it where the bone was right, and the restorative dentist didn’t care where the bone was. The restorative dentist cared where that implant was relative to where the restoration was going to be. Right. And I didn’t care where the restoration was going to be. I only cared about where the bone was because I wanted my implant to I.C.U. integrate, and we both wanted an implant that was going to ask you integrate and be useful for the restoration. But we were both looking at it from different perspectives and focusing our attention in different places. And once we were able to merge this information together, we both could look at all the information at the same time. And that made all the difference in the world. Okay. So this is this is when the information is merged together. Right. And then you can then you can play and you’ll do this in the lab. You’re going to pick the particular type of implant you want the diameter of the implant the length of the implant. And you don’t have to worry if you make a mistake because you can change it almost instantly because this is all on a computer screen, right? The time to worry about it is when it’s in the patient’s mouth. But now we have the flexibility to play with it back and forth. And here’s this implant, and we’re going to decide whether it’s in the proper location. And we’re going to decide whether it’s in the proper location relative to the crown. I don’t know, in the back of the room if you can see this or not, but there’s the outline of the crown that’s here and also in the buccal view, the outline of the crown here. So this implant can be lined up exactly through the center of that crown. Right. And if it can’t be because there’s not enough bone, then we know it beforehand. And then we decide whether or not we want to add bone or whether we’re going to use an angled abutment, or whether an implant is not the appropriate choice of treatment for this patient. Right. So all of those things can be found out. Not only that, but we also see where the inferior alveolar nerve is. And we see what the dimension of the buccal lingual plate is at all levels. So we know what we’re dealing with. We know exactly what we’re dealing with before we ever start. And so this is what we plan and that’s what we can actually achieve. So. And the way that we do that is by exporting all of that information after we have planned it completely, and then putting it back into Serac and creating a surgical guide. Right. And then we place the surgical guide in the patient’s mouth, and then we place the implant exactly where we had anticipated it to be. So it’s really it’s a phenomenal process. And then once the implant is healed, then we’re going to place that restoration as we anticipate it to be. Right. Still using digital technology. And you will be going through every single one of these steps to get to this final restoration, on this, on a case. You will do it first in the ssLC and then starting this summer, you’ll start placing it in patients mouths as well. So when do you place an implant? What are the options associated with it? First of all, what time is it? SPEAKER 3 951. SPEAKER 5 951 we’re supposed to end at 950, right? Okay, so this is a good time to end. All right. So have a good day. We’ll see you on Thursday. All right. Have a good day. UNKNOWN You know. QR code. SPEAKER 9 Mike. Check. One, two. Mike. Check. One, two. Mike, check. One, two.

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