Lecture 5 02262024.txt

SPEAKER 0 Good afternoon everyone. So. After you’ve placed your implant. You’re going to have to make a decision as to when it’s appropriate to restore it. So how do you go about doing that? SPEAKER 1 Wait. SPEAKER 0 So you wait for a healing. So how do you know when healing has taken place? We chec...

SPEAKER 0 Good afternoon everyone. So. After you’ve placed your implant. You’re going to have to make a decision as to when it’s appropriate to restore it. So how do you go about doing that? SPEAKER 1 Wait. SPEAKER 0 So you wait for a healing. So how do you know when healing has taken place? We check for the primary stability. What does that mean? But. Okay. So the implant is not moving. And how do we check for that? Wait, wait. We put a three. There is a device. All right. We’re going to talk about it a device. All right. But so the the biggest point of this is that. That we don’t just necessarily go by a time by the, by the calendar, right? A lot of people do and a lot of people have done it over time. They just say, listen, we know it takes X amount of time for implants to heal, and that’s how long we’ll wait. Right. And some people say it takes eight weeks to do it. Some people say it takes six months to do it right. It depends on what year it is and it depends on what you’re thinking is about it. But let’s understand. Let’s review for a second some of the from some of the information associated with an implant and osteo integration. So primary stability. Refers to the initial stability of the implant when it is placed. You must have primary stability when you place an implant, which means that you can’t have any visible mobility associated with the implant at the moment that it’s placed. If you do, you might as well take the implant out because it is doomed to failure. Right? It will not as you integrate if there is initial movement associated with it. But primary stability is not the same thing as the stability that you’re looking for at the point in time when you’re deciding whether or not an implant is ready to be restored. Right. Because that is that involves a secondary stability, and that is new bone growth that is taking place, which is ICU integration or biologic stability. This graph represents the different types of stability that you have, right? So you have when you place an implant initially at time zero you have primary stability. You have 100% primary stability. It is a mechanical stability. It is no different than the stability that you get when you take a screw and you put it in wood. That is a mechanical stability. There is no growth of wood into the into the screw or against the screw. But that screw is totally stable at that moment. And so is that implant. The difference between a screw in wood and an implant in bone? Is that what will happen during the initial healing phase is that the bone that is holding that mechanical stability will necrosis. It will be lost. And so you lose that initial primary stability to some degree. Some of those bone cells are lost. Right. And that’s why you see this curve. With a decrease in this mechanical or primary stability. But at the same time that this is going on. This secondary stability is starting to take hold. Right and the secondary stability. This biologic stability is one in which new bone cells are growing into the area. If you place the implant correctly. Then new bone cells will grow. If you haven’t overheated the area and killed off all the osteoblasts right, then you will get new bone growth taking place over a period of time. And so what happens is. So initially the implant is held into place because of the mechanical stability. Over the first week or two. You start to lose that that mechanical stability. During that first couple of weeks, you have an increase in the biologic or secondary stability taking place. And at some point in time, that implant is going to be stable enough. So that you can restore it. The question is, when is that? So companies are working feverishly to separate themselves from each other, right? Why should I buy one implant versus another? And so, of course, one aspect of the the sales pitch to everyone is the, the the ease of restoration, the ease and flexibility of restoration of an implant. But of course, that doesn’t matter if the implant doesn’t become osteo integrated or if it’s difficult to become osteo integrated, or if it takes a very, very long time to become osteo integrated. So the other aspect that the implant companies work on is trying to improve. The level of success of, of stability of an implant and also the speed at which you can get there. Right. So Stralman is one of the leading companies involved in this. And for many years they had what they called the SLA, which is a a sandblasted lodge grit, acid etched surface. This is how they make the roughened surface. And it was introduced in 1998. And it’s been very, um, very successful. Many peer reviewed clinical and preclinical studies have confirmed its strong long term performance and reliability, making one of the most documented surfaces in dental implants. According to an independent study, the odds ratio of developing Perry implant Titus was more than three times higher in patients treated with a different type of implant system than compared to Stralman. And we’ll talk about Perry implant Titus in a moment. But that’s one of the aspects associated with that surface, is whether or not it’s going to start developing bone loss around it. But then they came out with a newer. Implant coating and treatment of their surface, which is SLA active, and it’s a chemically modified titanium surface. It’s been developed using the well documented topography of the SLA, but it’s chemically modified on the surface, characterized by a hydroxyl and hydrogenated titanium oxide film, and it’s carried out under night nitrogen conditions maintained by storage in an isotonic saline. So they claim, and they have documentation that backs this up, that this further treatment of this surface to make it an SLA active instead of SLA, makes it even more biocompatible and speeds up the healing process even more. On a technical note, when you’re placing this implant right, so it comes to you in a sealed vial, like all implants are, they’re sterile, but this one is filled with nitrogen. And when you open it. You have about ten minutes, which is plenty of time. You don’t have to rush, but between the time that you open it and it’s inserted into the osteotomy is about ten minutes before that surface loses its special conditioning, right? It’s exposed to the air and it will become oxidized. And so you have a limited amount of time to work with it. The Strom is not the only company. There are other companies that are also working on all these different modifications of the implant surface to make it more biocompatible and to make it work better, and Nobel bio care. Also, they have the zeal and the the Thai ultra, which also has been an altered surface differently than the than the Stralman, but also showing stability. Now I’m going to go back to strawman for a second. This is the SLA, this Doc Green, and this is the SLA act of this lime green color. Right? They both get to the same place. They both get to the same level of stability. It’s not like the SLA active is superior to the SLA in terms of final result. Right. But this is the healing in weeks. Right. And what takes the SLA over eight weeks to get to the SLA active gets to in about 3 to 4 weeks. Right. It’s here. Versus there. So what they tell you is that with the SLA active, you can restore this dental implant that you’ve placed after about 3 to 4 weeks. Because you will have that secondary stability that is in place holding that implant in place. ICU integrated. And with the SLA. They used to tell you it took about eight weeks, about two months to do that. Right. So these are real differences potentially. For different types of systems. So what is actually happening during the ACA integration process. So when you place that. That implant into the osteotomy. During the first day, it is surrounded by blood and coagulation. By day four, the coagulant is replaced by fibroblasts and inflammatory cells, and at one week there’s this provisional matrix that has been formed, and you’re starting to see some evidence of bone formation, right? As early as one week. During the second week, we have an intensification of the formation of new bone by four weeks. Newly formed mineralized tissue extends from the cut bone to the chamber. And we have some introduction of, uh, woven bone, often combined with parallel fiber and lamellar bone, and six, eight and 12 weeks. Most of the implant chambers are filled with bone at by six weeks, but continues on past that. Right. And that’s what the that’s not what the SLA active. That’s what the standard type of implants roughened surfaces that we’re talking about. So whatever the chart says and whatever the theory tells us, we still have a patient sitting in the chair that we have to make a clinical decision as to whether or not this patient heals a little bit faster than than the average patient, or heals a little bit slower than the average patient. And reviewing their medical history gives you no indication, or usually no indication as to whether or not they’re faster, healer or not. Patient comes in and they’re diabetic. You can take a guess that it’s probably going to be a slower healing process, but absent some obvious reason for delayed healing, you don’t know what one person’s healing potential is versus the other. And so we have to do some sort. Of a test, right? Some sort of objective test which will indicate to us whether or not this implant is ready. To be restored. And historically, we have three different ways to do it. We can do a percussion test. Which is exactly what it sounds like where you’re tapping on the implant itself. There is a talk test where some people will take a torque wrench and place it back on the implant and try to spin it up to the. To a certain level of Newton centimeters, a certain amount of torque on it, and some people will try to do it in reverse, the reverse torque test. And then there’s also something called a resonance frequency analysis RFA. We’re going to talk about all three. All right. So you have to listen carefully. Right. So for many years when you know I see you integration, the Branham type of implant came to the United States in 1986. And I’d say for probably about at least ten years, at least through the mid 1990s, and maybe even beyond that, and sometimes even today, there are days when I still do this test on a patient, but you will tap on the implant. And if you hear this. You are really happy. Okay. Because that to us indicates that these implants have also integrated. Why? Because the tapping sound on the implant is transmitted through the bone. And so you hear that kind of sound. If the implant. The thinking on this is that if the implant has not fully integrated and there is soft tissue interspersed between the implant and the bone, when you tap on it, you will not get that high pitched sound. You will get a dollar type of a of a thud sound associated with it. Right. So for many years this was the test that we did not the greatest of tests, not 100% reliable, but surprisingly not a bad test. It wasn’t like we ended up being fooled a lot of times, right? Definitely if you got the dull sound associated with it, pretty much you were sure that the implant was not osteo integrated. The problem was sometimes you got that higher pitched sound and you still had problems with the RCA integration. Right. But but we always did this. And as I said, we’ll we’ll do it to even today, mostly out of habit. And because we get some sort of a vicarious thrill by tapping on that implant and hearing that sound and saying, okay, things are things are in good shape. The reverse torque test. So this was the second kind of test that came along, right? You had to put. The carrier back on the implant after the implant had healed. You put the, uh, the torque wrench on, and then you assert you you pushed with a certain amount of force in a rotational manner on the implant itself. Right. And the problem with this was that some people would argue that occasionally you had an implant that was actually also integrated, that you that lost osteo integration because you, you put too much force on it. The type of force that you are applying on this implant is not really the type of force that this implant is going to encounter in the mouth, doesn’t encounter rotational forces around the implant, right? It’s vertical and lateral that it’s that it’s encountering. And so what is the ability to withstand the rotational force have to do with its ability to withstand lateral and vertical forces. So the argument is that if it’s also integrated, it can withstand both. And if it’s not integrated then ultimately it’s not going to withstand either. Right. So we did this this test. But you know variabilities between the torque wrenches variability between how much force is actually applied. So a number of different variables associated with it, but another fairly reliable way. And then we came along with a company, Austell, which developed this resonance frequency analysis. And it uses the principle of a tuning fork. The stiffer the interface between the bone and the implant, the higher the frequency. So it’s measuring a frequency, right, uh, from the implant itself. And it’s transmitted through the implant to the bone, through what we call a smart peg. So this is placed into the implant itself, and you have to purchase one specifically for the type and size of the implant that you’re, that you’re using. And they’re not that cheap, but it’s it’s available. And then you place a device next to it which emits this resonance frequency, and then it picks up the information as to what the what the frequency is. And it has developed over time a a very complex implant stability quotient. It is nonlinear correlation to micro-mobility. And then the scale is 1 to 100. And so these magnetic pulses vibrate the smart peg attached to the implant. And that’s the little device next to the smart peg. The vibration frequency of the smart peg is measured. The more stable the implant, the higher the frequency. By measuring on two different occasions, you can verify. Not only the initial mechanical stability, but also determine the degree of osteo integration. So ideally, what the company is recommending is that you you get an ISK at the time of implant placement. So you have that initial reading, and then you get an ISK at the point where you want to restore the tooth. So it gives you not only objective information but comparative information as well. A lot of people will only use it at the time that they’re ready to restore it, and we’ll use the guidelines that the company puts out as to what is a osteo integrated implant. So RFA measures resistance to lateral movement. Torque measures resistance to shear forces. Right. So obviously this is this is the type of force that an implant is going to encounter in in the mouth. So the insertion torque measures the rotational friction together with the force required to cut the bone. The diameter of the implant will influence the torque. This is an argument against using that torque device to measure the the stability. Peak torque can give high values due to the collar effect when the implant collar is seated in cortical bone. So you may have a situation where the cortical bone is relatively small right. And it’s mostly medullary bone. But the cortical bone is of sufficient depth so that it will cause the implant to be stable, right, and have osteo integration in its most coronal aspect, whereas the apical portion from the midpoint all the way down, and even even more than that, sometimes while you have some degree of osteo integration, you don’t have a heck of a lot of bone. Actually integrating on the surface of the implant. So if you do this rotational torque test, you won’t get any movement, because the most coronal aspect of that cortical bone is causing that resistance. Not to mention the fact if you have a wide diameter, there’s more resistance as well than a smaller diameter. So you have a lot of different geometric things that are taking place which will cause the, the resistance to the, to the torque rotation. Right. So but if you develop some bone loss around an implant, as we know sometimes can happen and you know, it’s the top three millimeters that has that cortical bone, which is for the most part holding the stability of that implant in place. Right. And then you lose two millimeters of it. Now suddenly you’ve taken an implant really is being held in place by only a millimeter of cortical bone in a situation like that. So even though that initial torque test told you that the implant was stable, it didn’t tell you anything about the full amount of ICU integration and the amount of mineralized bone around it, whereas the RFA is going to give you better information about it, right? So this is showing you the esque. And it’s showing you from 0 to 100. And I mentioned to you that it is non-linear. It is not a straight line. Right. And so it doesn’t mean that as the esque value changes, right, that the that there’s a exactly the same amount of as you integration that you’re, that you’re registering. And what you’re finding is that between 60 and 70 esque, you have approximately a 50% decrease. In the level of ICAO integration and stability. Right. So again looking at this right we’re trying to figure out you know how stable is stable. SPEAKER 2 Right. SPEAKER 0 And this is showing you what they have derived from tens of thousands of cases that they have, that they have tested with the Esrc, and they continue to gather this information. And so what you’re really looking for is in is Q of around 70, right? That’s that’s a number which you should you can be relatively comfortable with saying that that implant is osteo integrated and stable and able to receive a crown. You can go a little lower than that. Right. And if the implants are splinted together, if you’re using more than a single implant, then you can you can take that into account and sometimes use an risk that is lower than if it were for a single implant. Okay. So this is something that we have available to us in the clinic that we use. We don’t use it on every single case. We don’t use it on every single patient. But we do use it. And I’m to be honest with you, really, the cost is what prevents us from using it on every single patient. Otherwise we wouldn’t have any hesitancy. It’s a good device. It works well. It’s objective in its approach, and it’s reliable in the way it assesses it. Right? Yes, sir. How much is the machine itself, so that the cost of the machine is what’s not is not what is, uh, causing us hesitation because we already have the machine. I don’t remember exactly how much it is. It’s, you know, probably like $800 or something. I could be off, but it’s the smart pegs, the individual smart pegs that you have to purchase, that each one is a cost. That is. Um, and again, I don’t know that it’s not astronomical. And in private practice, when you’re charging your patient a significant amount of money for your for your implant, it’s not a big deal. But here we’re, we’re charging a patient. What is it like $1,200 for the entire, you know, the implant, the sinus lift, the ridge augmentation and the crown, you know, uh, using something that’s going to cost you another $40 or something is is something that starts to become, you know, a little prohibitive, especially when you’re talking about large numbers. SPEAKER 2 Right? Yeah. We. Yeah. SPEAKER 0 It’s not necessarily going to go to 100. It’s not a question of it will always get to a hundred. That is the amount of bone implant interface. If you look histologically you will see that in osteo integrated implant that doesn’t have 100% bone covering 100% of the implant surface. And so whenever that stops, that’s the highest risk that you’re going to get. And there are scenarios in which you will never achieve a satisfactory esque even after complete healing has taken place. And you know, the scenario that I talked to you about with the cortical bone. Is one way, you’re not going to get a very high ISK. And if you think that it’s, uh, make believe, I can tell you that I had a patient, I actually had a patient who was a, uh, an orthopedic surgeon. And I tell you that because it was really interesting, because, uh, he was he had an implant. We had a place it in the second molar position. And this was early on. We had CT scans, I believe, at that point, but we didn’t get a whole lot of information from the CT scans. And I drilled the osteotomy and I went through the cortical bone, which was very dense and was difficult to penetrate through. But as soon as I got through the cortical bone, which was about three three millimeters or so, I dropped into what I can only describe as just an empty hole, right? In fact, I got really nervous because the the drill just like dropped. So on pressing because it’s taking a lot of force. And the next thing I know I’m down, you know, like eight millimeters or so before I can stop myself. And I’m a little concerned that maybe I caused some damage to the to the mandibular canal. I’m not sure at that exact moment. I’m just I’m I just know I shouldn’t have dropped like, like that. Right. And of course, as it turns out, I didn’t. But now I’m looking around. Now I take a probe, right. And I’m sticking it in the osteotomy. And it’s only a two millimeter osteotomy at this point. I’m sticking it in there. And really, it’s empty. There’s nothing there. There’s like cobwebs in there or something. And that’s it. There’s no bone past the cortical component of it. And I’ve never encountered anything like that in all the years that I was practicing. And I was sitting there and I was thinking about it, and I was like, you know, I don’t even. I don’t know if I can put a bone graft in here because I don’t know what the bone graft. I don’t know where the limit of this bone graft is going to be. Am I filling up the entire mandible before I get some density? You know, some packing of the of the bone in a place like this? I don’t know if the inferior alveolar canal is actually covered in bone, or if it’s sitting there exposed. And if by placing a bone graft material, I’m going to stop putting pressure on the inferior alveolar canal. So I explained this to the patient, and I told him that actually I think we should stop the procedure. I don’t think we should place an implant because long term I think it’ll be fine. It’ll be fine for a couple of years and I’ll, you know, I’ll my hands will be clean. I go, but you’re going to be stuck with a problem because if you lose any bone in this area, that implant is then going to fail right away. And there’s nothing that I can do to prevent that. Yeah. Three. So sometimes some CT scans or most CT scans today can give you some estimation of the density of bone. And they do that by looking at the amount of radial opaqueness in the area. And they will actually compute it and give you some information. So it’s not 100% reliable, but it will give you some indication of it. Right. But that’s taken time that has that has occurred over time. Time that I did this with him. We didn’t have that. SPEAKER 2 Call. SPEAKER 3 To do the test for the idea that the one we placed for that one was going to restore. SPEAKER 0 Right? Anyone’s free to do it. It’s not like someone should or shouldn’t or can’t do it. And it’s a good question. What I would say to you is that most dentists that send the implant to a to a surgeon to place it are relying on the surgeon to say when it’s ready to be restored and they will take them. They will take their advice that it is now ready to be restored. But just like anything else, I will tell you that if things go sour, the person who’s restoring that case, it’s no longer a reasonable argument in a court of law that I relied on the surgeon to tell me when to restore it. All right. So if if the surgeon is not doing the risk, then maybe you should be doing the Esrc or should be working with a surgeon who doesn’t. The Esrc have a discussion with the surgeon and say, hey, I want more than a percussion test to know that this thing is ready to go. Yeah. SPEAKER 1 That. Healthy conditions. Healthy is the excuse. SPEAKER 0 So we’re going to talk about that. It’s a really good question. So two things. One is that once you put the crown on, so you have to put this smart peg on in order to be able to measure the scale in order. Once you have a crown on there, you’re going to you have to take the crown off to be able to get the smart peg back on it, which is possible under certain circumstances. Right? If it’s a screw retained implant crown, then you can certainly do it. But it’s not something that I know of people doing on any kind of a routine basis. So I don’t even know if there’s any literature that shows any period of time going by where the ISK stayed stable or, or if it dropped off over time. However, there are I mentioned, I alluded to it a little while ago, and we’ll talk a little bit more about it in a minute or two. And that is about, um, pari implant tightness in which bone loss is taking place around a dental implant. So to me, it’s obvious that the ISK is going to go down when the when the implant starts suffering from peri implant. Titus. So under that circumstance, it definitely will change, even though I’m not sure, I don’t know how many people have measured it from there. Okay, so restorative options and the consequences of the restorative options you choose. So. Common cause of denture related problems is the alveolar ridge resorption, right? This is a patient who comes in looking like this. You take a pano or you take a CT scan and it looks like this. And it’s it’s too late, right? It’s pretty much too late unless you’re unless this patient is willing to go under major surgery, possibly having rib, having some of their ribs taken out and replaced into the mandible, you know, like real serious major surgery. Uh, implants are not a likely solution for this patient, and there is no real likely solution for this patient. This patient is going to live the rest of their life like this, with dentures that don’t fit and no alternative to them. And the question becomes, why not a dental implant, right? Because that patient that we just saw that had a ridge that looked like this at some point had a ridge that looked like this. And over the years, all too often, a dentist looks at a patient and sees a ridge like this and says, I can make you a denture, no problem. You’re going to you’re going to love it. It’s going to look better than your natural teeth. It’s going to fit better. It’s going to be retentive. You’re going to be able to eat again. You’re going to be able to smile again, and it’s not going to be a problem. And the patient may say to you, well, what about those implant things? You don’t need implants. I’m going to make you a denture that’s going to fit great. And they will for now, until you start to get the resorption that takes place, which inevitably will take place, it’s 100% guaranteed. If the patient lives long enough, they’re going to end up with a ridge that’s resolved. So the question is why not place a dental implant here? Right. Because now you have a lot of bone. You have it’s easy to place the implants in there and you’ll get two advantages. The first one being that the denture itself will be more stable regardless of how much retention you can get from the surface tissue. You will get a more stable denture with implants, right? 100%. And on top of that, you will prevent the resorted pattern from taking place. Right now, if you only put two in the anterior, you’re still going to get resorption in the posterior. If you put four in, then you’re going to prevent the the result of pattern. All along I wrote an editorial. 2000. I’m not sure. I think it was 2003, something like that. And it was about that question. It was it was the question, you know, understand when I wrote this editorial that most dentists that were practicing went to dental school before implants were taught on a regular basis. So pre doctoral students didn’t, didn’t get lectures on dental implants. I didn’t get a lecture on dental implants when I was a pre doctoral student in the 1980s. And so even by the year 2000 and they they still hadn’t gotten that much information and the information that they had gotten. I make an analogy. It’s like a native language versus a versus learning a second language. So for me and everybody else that went to dental school, that didn’t have that experience and didn’t integrate the thinking of placing dental implants from the start, it’s kind of like an add on, right? It’s like, well, we go through a normal thought process of what we’re going to do to fix up this patient, and then we’re like, oh yeah, what about that implant? Can I get an implant here? And really, what you should all be looking at now and the way it’s supposed to be is that you should always be asking the question. You have either an edentulous area or an area that’s going to become edentulous. And the first question you should be asking yourself is why not a dental implant? Now, don’t think I’m suggesting that an implant is the right answer every time. It’s not. But a lot of times it is. And it should be your first go to question because depending on the medical history, depending on the amount of bone, depending on what the other teeth are like. It may very well be the option of choice, and that’s where you should be starting. And you should be eliminating the question of whether or not it’s appropriate to place an implant in that edentulous area, or soon to be in this area before you move on to the others. Right. And then you work your way down. This is a real patient that comes into the office. How are you going to treat this patient? What are you going to do for them? Anybody. A partial. We’re going to put the clasps. You’re going to put the class here. And let me ask something. Even if you put the class PR m1 here, how stable is that? Is that going to be? Not very stable. So what other options do we have? Okay. So we have implants. How many? Two three. Okay. What other what other options do we have? An over denture. So we’re extracting most of the teeth. Who said over denture. So you’re taking out. What are you leaving behind? What are you keeping? Oh, so it’s going to be an implant supported over denture not natural tooth. So you’re extracting all the remaining teeth. Well, that’s an over denture, right? So not an overt answer. Okay. All right. Forget the over denture. All right, so we have a partial denture that is supported by implants. We have a partial denture that is not supported by implants. And what other and what other options do we have? We thought we had an over denture as an option, but then they took it off the table. So what else? What is that? Fixed? Fixed to where? Fixed implants. So implants and fixed. Okay, so let me tell you, this patient came to me for a second opinion. And the opinion that they were given by their dentist was to extract all their remaining teeth. SPEAKER 2 All right. SPEAKER 0 It’s not it’s actually not really funny because this patient was like in her 50s and and it was recommended. They said there’s no denture I can make you that is going to be stable. And these teeth are just going to be a problem for you. So take it out and I can make you a denture that’s going to fit really well. And that was their recommendation. And patient decided to get another opinion because they didn’t like that that recommendation. All right. So this patient didn’t have a lot of money. Right. All I did was place two implants. That’s it. Just two simple implants that didn’t take very long. And the restorative on this were just these ball attachments, right? You can argue you can use different kind of attachments. You can use a zest and whatever I don’t care doesn’t. I’m I’m a surgeon. I don’t care what kind of attachments you use. But they all work to some degree. But this is a very simple bowl attachment. Right. With two. Just two. And I didn’t take out a single tooth. Right. This was the denture. That was made, it actually had less palatal coverage than what the standard type of denture. Less hardware associated with it had the two attachments for the, uh, for the implants that were in it. This is the patient. I am not suggesting that this is, you know, the greatest esthetic result in the entire world, but it’s not bad. Right. And, you know, depending on the, on the restorative dentist that maybe it could have been a little bit better, maybe the tooth position could have been a little bit better. But hey, this thing worked. This thing worked for years for this patient. Patient came back. I didn’t see this patient for about 7 or 8 years. One of the ball attachments broke off, right? She put the denture in the wrong way and it snapped off the bowl attachment, which is entirely possible that it wasn’t so much that she put it in the wrong way, but it must. The metal fatigue on the bowl attachment may have been at a point where it just snapped off. She said it was because she put it in wrong. I don’t know, doesn’t really matter. It didn’t take me long to get the the the rest of the bowl attachment out and replace it with a new one to the whole thing. Took like five minutes. Not a very big deal. And she was back on her way and she was out and and before implants came along. The full extraction may be using an over denture with a natural tooth, maybe the canine keeping that, doing an endo on it and keeping it as a as a post as underneath the the denture. Would have been about the only option for this patient, because the partial denture wasn’t going to fit and it wasn’t going to be stable for the patient. So you took what was an unmanageable situation, and you made it into a really straightforward, fairly easy, cost effective way to treat this patient. You can argue that you should only have two in the anterior. You can argue that you should have three in the anterior. You can argue that you can have four in the anterior. Each one comes with its own advantages and disadvantages, right? If you only have two, you have more of a tendency of an anterior posterior rocking of the denture off of those two, those two implants, if you have three or more, you reduce that ability for the posterior to rise up. Obviously, if you get the case early enough, you can actually move those implants further apart and get it, get it completely off the soft tissue. But either way that you do it. It’s pretty straightforward. And it works really well. And here are these bowl attachments again that we used. And here’s the underside of the denture. Right, and the patient is as happy as can be, has a denture that that is more stable, more functional for them than anything that you can do any of the. What’s the adhesives that they have to fix it end right. Fix it. It can never match the the stability of a of a ball attachment. Dental implant. All right. So now we’re talking about problems that exist and why they exist. So we have this. We have this phenomenon known as Perry implant Titus. It is generally described in the literature that dental implants have a 94 to 97% success rate. That’s just kind of the general numbers that we throw out all the time. But we also have Perry implant mucositis and Perry implant Titus. These are two. Diseases that affect dental implants, right? Oftentimes you hear dentists describe to their patients that if we take these teeth out, we take these remaining teeth out. You’re going to have these implants that are going to last forever. They never get decay. They never have a problem. And it’s going to be money that’s well spent, because you’re going to be happy for the rest of your life. Well, the one thing that they say that is true, that you can’t argue with, is that you will not get dental decay, that we know if you’ve taken all the teeth out, replace them with implants. You’re not getting dental decay, but it doesn’t mean that you’re not getting disease. And while you won’t get periodontal disease, you will get Perry implant disease. And you have Perry implant mucositis and peri implant Titus. So what exactly are these things? What’s the frequency that these things occur and how do you detect it? These are all important things for you to understand when you’re treating patients. So Perry implant mucositis is a reversible inflammatory process in the soft tissue around a functioning implant. And sort of sounds like gingivitis, right. Because it sort of is like gingivitis. Perry implant Titus is an inflammatory process affecting the tissue surrounding a functioning implant, which leads to the resorption of the Perry implant bone, which is sort of like periodontitis. Right? So peri implant mucositis, superficial inflammation of the soft tissue around a dental implant without associated bone loss. And Perry implant Titus is inflammation of the soft and hard tissues around a dental implant, which leads to bone loss around the implant. SPEAKER 2 Right. SPEAKER 0 So here’s the here’s one of the important questions is what is the prevalence rate. Of Perry and Plant. Titus and Perry. Mucositis. Today that that’s a really important question, right. So recent reports revealed that Perry implant mucositis was present in about almost 50% of implants, followed from 9 to 14 years after placement. Because Perry implant mucositis is reversible with early intervention, it is quite possible that this is. This prevalence could be underreported. So there could have been an area that suffered from Perry mucositis at some point, then got treated and then it reversed itself. Research concerning Perry implant Titus reported distinct differences in incident and prevalence from numerous authors, with studies ranging and get this from 6%. Over a 9 to 14 year period to as high as 36%, with a mean of 8.4 years after loading. How can you get different studies that are looking at the same issue? Bone loss around a dental implant as reporting something as varied as 6% or 36%. So it’s it’s six out of 100 or it’s one out of three. Right? That’s pretty crazy. The differential. So what is going on here? How do you account for this incredibly wide discrepancy? Any ideas? SPEAKER 1 Yeah. No. SPEAKER 0 It’s true. The diagnosis is not straightforward. Well, what do you mean by that? You mean they have a different threshold? SPEAKER 1 Yeah. SPEAKER 2 Well, when. SPEAKER 0 You say thresholds, what do you mean? So so the the definition right is leads to the resorption of implant bone. But what I hear you suggesting is that not everybody looks at it and says, if there’s any bone loss that I automatically counted as Perry implant Titus, that maybe I have to have a certain threshold of bone loss. And that’s exactly right. Right. Because let’s think about this for a minute. Right. And let’s look at all of these different aspects of it. And let’s look at, um, let’s think for a moment about the original brain implant. SPEAKER 2 Right. SPEAKER 0 Not that long ago. It’s a couple of weeks back that I talked to you about this. And what did I say to you about the original brand of Mac? Implant and bone loss. SPEAKER 1 When? SPEAKER 2 When? SPEAKER 1 After the. When you do discover. SPEAKER 0 When you uncover the implant and you place the abutment, you’re listening very carefully. That’s excellent. Very good. Yes. So every brand of mark implant suffers from 1 to 2mm of bone loss. We call it cupping. Right. So depending on how the study defined Perry implant. Titus. Then every single brand of morgue implant was suffering from Perry implant Titus as soon as an abutment was. You know, as soon as it was on long enough to have the bone loss taking place, which was a couple of months later. Right and other studies that you read, but you got to read it to understand it. They’ll say first, two millimeters of bone loss don’t count towards implant anything more than two millimeters of bone loss. Not because we can’t measure it accurately, but because everybody’s implant loses two millimeters of bone. Then it settles down. So we’re not going to count those first two millimeters. That’s why you have this crazy disparity. Between authors, or at least one of the reasons. The other is the type of implants that they’re looking at. Right? Because you also read an article by Herman. That’s what that say about bone loss. And around the dental implant didn’t have to happen, right? Depending on the exact design of the implant. And so for those you’re not getting any bone loss, and if you’re getting any bone loss as far as they’re concerned, the alarm should go off. There’s a real problem that exists there. All right. So how do you prevent Perry implant Titus? Well, we’re not really sure exactly what causes Perrie implants. There’s a lot of arguing and disagreement about it, right? Uh, we do think that, at least in some cases, and some people will say it’s in most, if not all cases, that oral hygiene and bacterial buildup plays a role. Now again, the people who are most involved with the Branham style implant Albertson and coworkers like Albertson. When they talk about those first two millimeters of bone loss, they do not think it’s a bacterial infection that is causing those first two millimeters of bone loss. They think it’s a natural reaction to the implant for those first two millimeters. All right. But a lot of the bone loss that takes place is, we suspect, related to bacteria. Why do we suspect it? Because that’s the only thing we know right now. Right. So we look at it and we figure, you know. Teeth are affected by the bacteria, so the implants probably are too. And at least some aspect of it is probably true. We have special types of scalers that we use. Around a dental implant, you do not use a standard scaler because it will damage either the abutment or the implant surface itself. We use either plastic or titanium tipped scalers, and we have them in the clinics available for for you to use. Here’s a little tip. You may not remember this, but by the time you get to the clinic, if you go to the window and they look at you like you’re crazy because you just ask for a titanium tipped scaler to be used for for a dental implant. And they say we don’t have those, right? It’s not that we don’t have them, it’s just that that person doesn’t realize what it is that you’re asking for. So either ask the faculty to help you out or talk to me because we have them. All right? Don’t listen to people who tell you that we don’t have. We do. All right. And the titanium tips are way better than the plastic ones, because the plastic ones, um, because of the nature of plastic, there’s a certain thickness and heaviness associated with it, and it’s a bulkiness and it’s difficult to clean, whereas the titanium tip ones are really a pleasure. They’re they’re very thin. They work. They work really well. Right hand instruments versus ultrasonics. When you’re cleaning a patient, when you’re doing a recall on a patient that has a dental implant. So for many years, I gave, uh, a lecture at a hands on at Yankee Dental. And I did this with one of my colleagues, uh, who used to work here at the school. And we did it for, like, I don’t know, 20 years or something like that. And while we agreed on most things, one thing that we disagreed on was this he had no qualms about using ultrasonics on a dental implant. Right. He there. The companies make special tips on the ultrasonics to be used around a dental implant. And I always was very hesitant. And I would say I don’t really have any documentation that supports me that makes me say that I don’t like using it, but I just don’t feel right about it until this came out. Right. So here was a study that showed that some titanium particles came loose from the dental implant while you were using ultrasonics. Now, does it actually cause a problem? Who knows? Right. But just when you’re thinking about this. You know, you don’t want titanium particles coming off the implant while you’re while you’re cleaning, if at all possible. So you would try to avoid it there. Look, it doesn’t mean that I would never pick up an ultrasonic if I. If the patient had, like, tons of calculus caked on around the tooth. I’m going to pick up the ultrasonic and judiciously use it to knock off some of that calculus that’s there. But am I going to use the ultrasonic routinely around the 360 degrees around the implant? I’m not. Not just because of this study, but just it, you know, you you’re applying forces on an implant, and I’m just I’m not sure why I want to take that chance. I’m babying the implant. So if your patient is unfortunate, whether they are one of the 6% or one of the 36%, depending on how you’re counting it. If they are unfortunate enough to have Perry implant Titus, how do you treat it? So you have to see this is the current thinking on it. You have to detoxify the implant surface, right. And you can do that in a number of different ways. So an implant or plasti is when you take a bar a high speed bar and now you have bone loss. And that means that some of the roughened surfaces now exposed and possibly some of the threads. And so you’re going to take a high speed bar and you are going to remove the threads that are exposed, and you are going to remove the roughened surface that is exposed. And you’re going to try and make it smooth. And the process, you’re going to be using a lot of water. And the reason why you’re using a lot of water is because you are generating a lot of heat. Not to mention a lot of titanium particles that are flying around. Right. None of which is good. For the patient, but people do it and people are, to some degree or another are successful in doing it. SPEAKER 2 Mhm. SPEAKER 0 There’s also a ah powder abrasion that you can use. There are ultrasonics that you can use to clean off their metal shirts that you can use. There are nonmetal curates that you can use this citric acid that you can use this chlorhexidine that you can use, there’s EDTA that you can use. There is hydrogen peroxide that you can use saline tetracycline lasers and a titanium brush. All of these things are in the literature. Every single one of them are in the literature and every single one of them. You can find literature that supports a successful outcome of treating Perry implant Titus even. Where is it? Even with saline? Right. So it all works to some extent. None of it works 100%. So. So what do you do? Because the the outcomes are equivocal. When you read it, there is no way to know which one is better, which one’s worse. People use combinations. Some people throw everything at it, some people only do one thing at it. And you have this. You have this very varied result, right? People will show you that the laser does this. People will show you that, you know, if you open it up and squirt saline, sterile saline, it’ll it’ll do it too. I’m going to show you one. I’m going to show you this titanium brush. And I’m going to show it to you because I like it. That’s why I’m showing it to you. So detoxifying the the implant with the titanium brush. This is about just cleaning off the the implant. Whether you place a bone graft afterwards that’s a that’s a separate story. You can’t place a bone graft. You can’t do anything to treat this defect until you take off the toxins and the poisons on the implant surface itself. So you’re making a vertical incision here, and you’re reflecting a full thickness flap to gain full access into the into the area. And you’re making it a circular incision which you will learn more about next year. And then you’re retracting all of that tissue and you’re removing the granulation tissue as best as you can. But I will tell you that the granulation tissue around an implant, especially a roughened surface implant, is really difficult to remove. So this titanium brush on the tip of a high speed handpiece, or actually a low speed handpiece, uh, does a pretty good job of removing all this stuff, right? Cleans it out really, really well. So once it’s all cleaned out. Right now, you can go and you can use. You want to use saline. You want to use tetracycline. You want to use EDTA. Whatever you want to use, you can use you want to place a bone graft, use it. But to me. Just when I’m looking at that, to me, I see a pretty clean surface, right? I know what I’m using. I know it’s not causing damage, and I’d rather do this and take a high speed and try to take off all of those, all of all of those threads. To me, that’s that’s not a good thing right now. They decorate the buckle plate, in this case the using minocycline to also clean off the the implant itself and kill off any bacteria that might be remaining. So. And the decoration that takes place is so that the bone graft, the marrow sites is going to allow for additional bone to grow in that area. It is not proven that it works, but a lot of us utilize that. And then we place the bone graft and place a membrane over it, and then we’ll suture it back up and we’ll allow it to heal over a period of time. So different types of membranes that you place different. And again, don’t get me wrong about this, I am not here telling you that this is the way to treat it, because this is what works. I can show you anything that works to some extent. We do not have a clear handle on this as to what to do and to how to treat it successfully, and we get varying degrees of success with just about any kind of treatment. But this is one treatment that I like because to me it makes it makes sense. So before you can treat it, you have to detect it. So how are you going to figure out whether or not your implant. Has Perry implant Titus. Yes. SPEAKER 1 In an office space like Vulcan. SPEAKER 2 What? SPEAKER 1 What type of bacteria have there is today? UNKNOWN The. That is because of. SPEAKER 0 Yeah. So two, two parts. One the most important is that we presume that it’s caused by the bacteria. The second thing is that, sure, there is an anaerobic component to it. Now remember, unlike around a natural tooth right. We do not have connective tissue inserting into an implant. So they are the connective tissue. Fibers are parallel to the implant and kind of form like a cuff over the bone, but are not as protective as connective tissue inserting into the tooth itself. So how far the bacteria gets down into that area? You know, that may be part of the contributing factor. Maybe the maybe bacteria is able to travel greater distances closer to the bone around the dental implant under certain circumstances than in others. Right. But it’s definitely anaerobic because it’s definitely almost always significantly. Uh, sub gingival there’s a there’s a substantial pocket of some sort. SPEAKER 1 So maybe that’s why. Not all the treatment that you showed has a significant improvement because you are changing. An anaerobic to an evolving environment. So. By opening this web and. So that’s why maybe all the treatments. SPEAKER 0 Kind of kind of work to some to some extent. Yeah, it’s it’s possible. But many of them also show new bone formation. So not only are we stopping the process by doing, we’re definitely opening it up for that reason. That is our rationale. We are opening this up to clean it out, to get rid of the whatever bacteria or whatever kind of organism it is that could be causing this. But as to whether or not we’re able to get new bone growth around it, that’s a different matter. You know, that only is partially answered by whether or not there’s a certain type of bacteria in the area. But there are other problems too. SPEAKER 2 Okay. SPEAKER 0 So how do we detect a failing implant? How are you going to detect a failing implant? SPEAKER 2 Yeah. SPEAKER 4 So. SPEAKER 0 Am I saying if it gets loose? So if the implant gets loose, it’s over. Right. We don’t have to worry about anything. We’re taking it out. Right? Because there’s no treatment for it other than the removal of it. So as long as it’s actually the implant that’s loose, right? X-ray. So we’re going to take an x ray. SPEAKER 1 Next. SPEAKER 0 Exudate. Sorry somebody else had said x ray I think. But um but okay. Whether or not there’s pus coming out is pus. Do you have to have pus to have periodontitis? Not necessarily. All right. So how are we identifying if we have this bone loss around the dental implant. Exudate may or may not help us a radiograph may or may not help us. Right. Let’s look at this case. Are these implants failing right. Can you use radiographs or radiographs. Reliable. So if I told you that there is oh here’s what it looks like clinically there’s no pus coming out of this when you press it. Right. Tissue doesn’t look that inflamed. You know I’ll give you that. There’s a redness to it. But I think it’s more the photograph than anything else that’s causing it. And as far as the radiograph is concerned, the radiograph you saw and it wasn’t showing you that much bone loss if anything at all. So I hear people saying that you need to probe because for those of you who think that a radiograph is sufficient, and let me tell you, there’s for many years there was an argument about whether or not you should probe around a dental implant. In fact, the argument still takes place today because as I described earlier, right, there is no connective tissue inserting into the implant. So the argument against probing is that you will create what seems like a very small hole right between the implant and the connective tissue. But to bacteria is like this major highway thoroughfare, right? That leads right down to the bone. And so by you putting your probe down into that area, you are potentially allowing bacteria to get down into that area. So what do you think? Does that make sense? Is that a legitimate argument? SPEAKER 2 Is it? SPEAKER 0 You don’t think so? Why not? In. Where? In Europe. SPEAKER 1 To treat 31. You know better. SPEAKER 2 Yeah. SPEAKER 1 I don’t know. I don’t think. SPEAKER 0 Not so much. So. So they’re not afraid. Okay, but the question is right. Are you able to detect if there’s bone loss? Because that’s, by definition what Perry implant Titus is. Do I need a bacteriological sample to tell me whether or not there’s bone loss? And in fact, does a bacteriological sample tell me for sure that there is or there isn’t bone loss? So I’m just asking right now, how do we determine if there’s bone loss. And so one group of people will say radiographs, one group of people will say probing. And some group will say don’t ever probe because it can cause a problem. Okay, well, let’s take a look at this. All right. That’s the clinical picture. And you can imagine why the radiograph doesn’t show any evidence of bone loss. Right. And yet you have a tremendous amount of bone loss associated with this. With this implant a radiograph 100% will not tell you whether or not you have bone loss around the tooth. Right. It can’t because it can’t tell you what’s going on on the buckle and what’s going on on the palate of the lingual. Right. So there is absolutely no way that you can verifiably say that a radiograph, a standard PA, is going to tell me whether or not I have bone loss around that implant. It won’t work. Now, if you take a CT scan, maybe even those are kind of hard to tell. Yeah. SPEAKER 1 I was wondering. When they have more. SPEAKER 0 Yeah. Great question. Some people do, some people don’t. It’s very variable. Some people will come in and right away. No something is going on. You know I don’t think all Perry implant Titus are the same. Some people come in with an infection as we know it. Pus coming out of the area. Things like that that are going on. And other people have this bone loss. But this doesn’t seem like there’s all that much going on. This case is one of them. You know, the patient has no awareness that anything is going on. There’s no mobility associated with this implant. It’s functioning. It’s not causing any problems. And yet he’s got a very significant problem. He’s about to lose the implant. SPEAKER 5 Hang. Hang on, hang on. SPEAKER 1 So regarding this case, I’m curious what led you. What critical senses or signs led you to this lab? SPEAKER 0 So this was probing. Yeah, because I don’t subscribe to the. To those that say don’t probe around and implant because I don’t have any other tool that I can. I can’t take a seat. Even if a CT scan can tell me whether or not there’s bone loss. I can’t take a CT scan every six months around a patient. I can’t take it every year around a patient. So how often am I going to check whether or not there’s bone loss, but a probe I can check every single time. SPEAKER 1 You’re going to lose it anyway, right? Right. SPEAKER 0 That’s how that’s that’s how I feel about it. SPEAKER 1 Yeah, but I think this. What guarantees me that is. Please. Was not there seeing. SPEAKER 2 Mhm. SPEAKER 0 Well so this was not an implant placed by me, but if it wasn’t implant in place by me then I would have known that there was bone covering this. Now is it possible that someone placed this implant with with no buccal bone on it? It’s possible, but I’ll tell you, when you look at the neighboring bone, this doesn’t really look like it’s outside the bony housing. Sometimes you see it. It’s clearly outside the bony housing. And even if you had bone to start, probably during the initial healing, you lost all the bone. But this one? I don’t think so. And but but you’re right. You don’t know for sure because you don’t know what somebody else did. SPEAKER 1 This is a consequence of the buckle insertion. SPEAKER 0 It’s entirely. It is. It is possible. And that’s why it’s so important to know the history of that of that case. All right. But regardless whether this particular case. Is a case of bone loss that took place, or whether it was like this from the start. There are lots of cases like this, and some of them for sure didn’t start out that way because some of them are my patients, and I know for sure they didn’t start out that way, and they developed the bone loss over time. So interestingly enough, so the people that don’t probe have a lower incidence of Perry implant Titus in their. In their practices. It’s a selling point. Hey that’s don’t look and you’ll never see it. So, um, you know what? They’re there are people that have taught this course, not this course, but similar courses like this in years gone by, big arguments that took place because they were insisting that you do not probe around a dental implant. And, you know, we went to war because it was like, it’s bad. It’s bad information. I don’t want that information out there. Okay. So there’s lots of different probing. There’s lots of different causes for bone loss. And not all of them are for the same reason. And you have to look at each individual case to make a determination about it. Now we have cement retained versus screw retained. And does it play a role in Perry implant Titus. Yeah. SPEAKER 1 Um so when you read into what will be like there. SPEAKER 0 Huh? Great question. So. All depends, right? It depends on where the implant was placed relative to the crest of bone of the adjacent teeth. Depends on how much soft tissue is there. So just like the person that was saying that unless you know what was going on when you first place the implant, whether or not there was bone there to begin with. You also don’t know what the probing depth was initially. Right? Because some people bury implants deeper in the anterior region, they place implants deeper for esthetic reasons. And so the probing depths will be deeper from day one. And it doesn’t necessarily mean that there’s bone loss. So it’s not the number that you that you have to look at. It’s relative to where the, the top of the implant is that you need to assess. And sometimes that’s not easy to do. Yeah. SPEAKER 1 Strict protocols so you can assess. SPEAKER 0 Well, so you’re not going to play. So I think I get what you’re saying, but you’re not actually probing on the day that you’re placing the implant. You’re probing soon after the healing has taken place. Right? Maybe like a couple of weeks after the restoration goes on or something like that. It should be. You should have baseline information about it. Absolutely. 100%. All right. So the history of screw retained and why we moved to cement. Right. The dreaded loose abutment screw accounting for up to 33% of post implant prosthetic issues. The incidence of screw loosening with single implant crowns has been reported as high as almost 60% within 15 years of placements. Remember the original brand of Mark implant, which had that hex design right, which was only 7/10 of a millimeter? That entire implant crown was retained on top of that implant because of a screw that went through the middle of the crown into the implant. And when you had a lateral force on that crown, it was that screw in the middle of the crown that was taking all the force. And it was bending and it was bending back and forth, and they would break all the time and they’d come loose. And it was lots of different problems. Right. This is 7/10 of a millimeter that you’re that you’re sitting on top of an implant with a crown, your prosthetics, what you’re learning in process. When you make a crown prep right. You do not make a crown prep. That’s 7/10 of a millimeter high, right? You don’t cut it all down because there’s no retention and there’s no resistance. So this doesn’t make sense. And so for a long time we had all of these problems that were going on. Right. Because here’s the screw that goes through the the crown and the abutment into the implant itself. And this is an internal hex. So it’s different. It is taking some of the forces some of the lateral forces. But the original brand mark, which was an external hex, the screw took all of the forces. Right. So that was a major problem. So the system is going to break down somewhere. And you’re either going to get an implant fracture that takes place. You’re going to get a screw fracture. And that’s the screw is stuck inside of here. And this is a disaster. The implant is well integrated and the screw is stuck inside in the middle and you can’t get it out. And or you have bone loss. So one of these things is going to happen when you overload the system. Right. Or you can have the screw loosening itself. So cement retain versus screw retain which is better. Right. And the answer has changed over time. And does it play a role in Pereon playing Titus. Well let me show you a case. So this is a patient that came in. This is a patient that was not a patient of mine, I did not it was a patient of the practice. So the implant was placed. And I can tell you that when the implant was placed radiographs all look good. And I know the people that are the other people in the practice that are doing the implants and the notes are meticulous. And if there was an issue, if there was no bone on the buckle aspect, it would have been noted. In fact, we would have placed a bone graft of some sort. There was no notation of it. Patient came in, gave me a history that the crown. On this implant was loose and that, uh, this was the second or third crown that had been placed, and it was a prostate. Honest patient made sure that I knew it was a dentist that was placing this. So I examined this. Right. And so first thing I’m doing is I’m testing to see mobility. UNKNOWN So you want more. SPEAKER 0 So you should be able to see that there’s movement of the crown that’s taking place. But the question is, is that the crown that’s moving or is it the implant that’s moving? And how am I going to address this case? What am I going to do? So let’s take an x ray and let’s see what it looks like. And this is what it looks like. So now what am I going to do. Or I should say, what are you going to do? Probe it. Okay, so I’m probing it. And I’m definitely getting some increased probing both into proximally and on the buckle aspect. And when I say some increased probing. First of all, it’s uncomfortable for the patient when I’m probing and probing probably about six millimeters on the facial aspect. SPEAKER 1 What I learned today I will select the flat and sanitized. SPEAKER 0 And so you think it’s an implant problem. Like this. Well, because here’s the problem. If this is if the screw is loose, right? Or this is cement retained. If somehow, even though the crown is cemented onto the abutment, the abutment is screwed in to the implant. So if the abutment is loose, right. And I raise a flap, what are the potential implications? What are the potential complications associated with that? Well, one. One person. SPEAKER 2 Yeah. SPEAKER 1 The. SPEAKER 0 Okay. What’s the. What’s the odds that I’m going to contaminate the area if I lift a flap? You know, in a healthy area. Uh, resorption of what? Okay, so maybe I’ll get some resorption. Maybe I’ll have a problem. But what’s the likelihood of a problem? What’s the likelihood of resorption? If I lift the flap in a healthy area. Any idea? Probably not that high. So while it’s a concern, it’s not a big concern. But what’s the big concern? Well. So if it’s the screw, right? We lift the flap when we see there’s no problem with the implant. Right. And it turns out that the screw is loose. Now, what are the possible implications for me having lifted that flap? So first thing is the cost. Now I can mitigate that problem by telling the patient in advance. Listen, I don’t know for sure I’m going to lift it up. It may not be the implant. It could be the crown, but you’re going to have to pay for it either way. You know, it’s your tough luck because I got to spend time on it and the patient agrees. Then there shouldn’t be a big argument about it. What else? SPEAKER 1 Consideration goes to. They do a battery of tests. SPEAKER 2 Well. SPEAKER 0 What other? Oh, you mean as far as paying for it? Yeah. I’m saying the chances are the patient’s not going to be arguing that much about it. So what’s the bigger? What’s the bigger umbrella that we put that under? Is one esthetics, right? I am taking a scalpel. To this area, and the one thing I know for sure is I am not going to improve the esthetics by doing that. And I run the risk, especially since I already see there’s some bone loss here, right? I’m running the risk that this thing esthetically is not going to look as good as when I started. Now again, I could talk to the patient about it. But you know, patients are funny like that and you could tell them, but then when they see it and they’re not happy about it, suddenly it becomes a different issue. Right. It’s one thing about knowing I have to pay for it and everything worked out fine, whatever. But this is like, ah, you know, you told me it wasn’t going to look good, but you didn’t tell me it was going to look this bad. SPEAKER 2 Right? SPEAKER 0 So this is a real problem. So. So what do I do? Do I lift a flap? No. Now we’re running away from the flap. So what are we doing? Because if we’re sending it back to the restorative dentist. Right. And we’re telling the dentist, you know what? Take that crown off. Cut that crown off. Take it off. And if we cut that crown off, and it turns out that it’s the implant that’s loose right now. It’s ICU integrated, but we’re going to cut the crown off, right? We do that all the time. Yes. And it runs a statistical risk that we can run into a problem. But chances are not. But what do you what do you think the restorative dentist is going to think? They’re going to be happy with me, that I sent them back a case that the implant had failed, and I told them to take the crown off first, and they just put aside half hour or hour. Are they charging the patient for this? Are they going through the same discussion with the patient? I’m going to take this crown off, but I don’t know. It could be a different problem. And patient’s not going to be happy. The dentist isn’t going to be happy. So this is a real quandary right. You’ve got to you run a risk. And it’s not an easy answer. In looking all of this over, I reached the conclusion that the chances were greater than it was the implant that was failing, as opposed to the the crown that was loose, but it was a calculated. Yes, on my part. And I explained it to the patient and I and I told them what was going on. So I’m raising the flap. Right. And can you see that? SPEAKER 2 Yeah. SPEAKER 0 What is. SPEAKER 2 That? SPEAKER 0 What is it? Cement. Because it says cement on the implant. All right. Now we know we can all read. All right, so, yes, there’s cement on this implant, which is not good, right? And at about this point in time, I told my assistant, I said, stop suctioning. I said, just use two by twos and get the camera ready, because I think this may be something for class. I’m not sure, but I think so. Yeah. What the heck? What is going on here? So here’s the good news. The good news is, I guessed right. Right. The the crown is on that implant. Right. It’s not loose. But what is going on here? How did that cement get two thirds of the way down that implant? SPEAKER 1 That kind of. My impression. SPEAKER 0 Well, I can go inside the flap, but how does it destroy the bone and get on the implant itself? Because the implant was completely covered in bone. It wasn’t. Well, it wasn’t integrated, but it had mechanical stability. There’s no space there. This was not an immediate implant. Right. So how do you think this got down there? When no Bone was definitely there in the first place. Right. Because this implant was placed in our office. SPEAKER 1 I thought it was cool at the time. SPEAKER 0 Okay, so you’re so first of all, you’re guessing just like I’m guessing, right? Well, you’re not you’re just guessing and you’re making some assumptions along the way. And so am I, because I don’t have the answer either. I don’t know what happened here, but if you remember and it’s along the lines of what you’re saying, if you remember, I mentioned to you that this was like the third crown that this patient had. Right? And the patient explained that the crowns didn’t fit. Right. So I am hypothesizing along the same line as you that at some point the occlusion was so bad that it caused a lot of bone loss around here. And at some point after that, when they replaced the crown, they used excess cement and it made its way all the way down in the area in which there is no connective tissue attachment. I don’t know if it’s true. Right. I’ll never know if it’s true. The one thing I know that’s true is that the the implant failed and had to be removed. Let me ask you something. If you’re me. What are you telling the patient? Implant failed is that it is at the beginning, in the middle, and the end of the story. Is that all your thinking? What else are you thinking? SPEAKER 2 And. SPEAKER 1 Pound. But this is what I found. I will contact you. Restorative tennis and found out. SPEAKER 0 It’s just. And do you think that that is totally fair to your patient? Do you think that that patient should have that dentist place another crown if we put another implant into this patient? So do you think that we should be telling the patient that. What do you think? We have an obligation to tell the patient that we do. So we’re going to say to the patient, don’t. And by the way, don’t go back to this dentist. SPEAKER 1 And I do I don’t like to talk about anything. SPEAKER 0 You would like to talk to the dentist. What are you going to say to them? SPEAKER 1 Hey, I found. SPEAKER 0 I found tons of cement. Don’t use so much cement when you’re when you’re placing a crown. So it’s a real dilemma, right? Because we have the patient’s interest. We have the dentists interest, the referring dentists interest. And we have my interest. It’s in my economic interest not to disrupt the relationship with the general dentist. But I’m not sure it’s in the best interest of this patient to go back to that dentist. Right. So sometimes we face these problems along with the technical problems of actually treating our patients. We have all these other issues that arise as well. And guaranteed you’re going to be facing these kind of problems. SPEAKER 1 What did you do. What did you do. I’m curious. SPEAKER 0 I actually told the patient not to go back to that dentist. Okay. And and I actually didn’t want to see any more patients from that dentist because I didn’t want to have to deal with this stuff. This was this was a gross mistreatment of the patient. Yeah. SPEAKER 4 What do you say to the patient when they ask you why? Oh, no. SPEAKER 0 I told them, I said there was all this cement. And I explained to them, I can’t think of a single reason why there would be all this cement on here, except that the dentist didn’t take care when they cemented it. Okay, there could be another explanation, but I can’t come up with one. I can’t think of any other reason. SPEAKER 3 Okay. Not as bad as this, but how can you see? Similar to. SPEAKER 0 You mean dentist era? Is that what you’re talking about? Or a Perry implant? Titus. Huh? So great question. We’re going to end with this question. How often do you see cement as a problem. And I’m going to show you other cases. Unfortunately we see a lot of cases like this. And it’s to the point. So the pendulum swung from screw retained to cement. And now it’s swinging back again to screw retain. And the reason is not this dramatic, but problems like this that are causing clear inflammation and clear problems. All right guys we’re all set for today. Have a good day. SPEAKER 1 Sure. So I was under the impression. SPEAKER 2 The reason. SPEAKER 6 Healthy teeth to prevent bone loss is because the PDL. Pressing forward to a point. SPEAKER 0 Around say that again. SPEAKER 6 So the PDL kind of holds on. SPEAKER 0 No attendance today, but maybe next time. SPEAKER 7 Yeah, I know that I’ll have to miss class next week. SPEAKER 0 Okay. SPEAKER 2 Thank you. Okay. You’re welcome. SPEAKER 6 So the PDL pulls on the bone. You press on a tooth. And it was my understanding that that’s the thing that prevents falls. SPEAKER 5 Uh, so it keeps. SPEAKER 0 It’s not the thing. Well, to some extent, we say that that’s a reason why an individual’s area will lose bone, but a dented area will not return because you have this constant apposition and deposition of bone that’s taking place. And so, yes, to some extent. But if that were the argument. SPEAKER 2 I’m sorry. Thank you. Oh. You’re welcome. SPEAKER 0 Um, but if that were the argument, then we would never suffer from periodontitis, right? So it can’t be the answer. SPEAKER 6 My real question is how come you know if you have a denture and the pressure leads to bone loss?