DOCTORS PAGE 7

- THE 3 MOST IMPORTANT BASIC CONCEPTS TO REMEMBER - WHY EXTREME PRECISION IS MANDATORY TO BE SUCCESSFUL

BASIC CONCEPTS

BASIC CONCEPT #1

PROCEED AND VERIFY

FOR MY MONEY, THIS IS THE MOST IMPORTANT CONCEPT TO REMEMBER. IN GENERAL DENTISTRY, WE DO THIS ALL THE TIME BUT ON A MORE SUBCONSCIOUS LEVEL. IF WE MISS SOMETHING BECAUSE WE DIDN'T VERIFY OUR PROGRESS, IT IS USUALLY JUST A MATTER OF REDOING A FILLING, OR A CROWN. WHEN PLACING ONE PIECE IMMEDIATE LOAD IMPLANTS IF YOU DON'T VERIFY THE SUCCESS OF EACH STEP, THE CONSEQUENCES CAN BE DIFFICULT FINANCIALLY AND EMOTIONALLY FOR THE PATIENT AND THE DOCTOR.

PROCEED AND VERIFY EACH STEP. AND YOU WILL BE FINE MOST OF THE TIME.

BASIC CONCEPT #2

DO IT YOURSELF

THE MORE YOU DO YOURSELF:

1. THE MORE INTIMATE KNOWLEDGE YOU WILL HAVE OF THE IMPLANT SITE, THE MORE SUCCESSFUL YOU WILL BE.

2. THE MORE YOU KNOW, THE EASIER IT WILL BE TO MAKE AN ACCURATE SURGICAL STENT. THE MORE SUCCESSFUL YOU WILL BE.

3. PRACTICING DIFFICULT CASES IN THE LAB FIRST WILL ALLOW YOU TO VERIFY YOUR PLAN AND PROCEED ON THE DAY OF SURGERY WITH CONFIDENCE. CONFIDENT HANDS ARE MORE SUCCESSFUL HANDS. "FREE HANDING" DIFFICULT FLAPLESS CASES WITH A HESITANT AND SHAKING HAND CAN BE DOWNRIGHT TERRIFYING!

DO THE TIME AND YOU WILL BE FINE! DO IT YOURSELF.

BASIC CONCEPT #3

SUCCESSFUL CASES START AT THE BEGINNING

I KNOW, I KNOW, THIS IS WHERE EVERYBODY SMIRKS AND THINKS, "GEE, DOC, YOU SURE HAVE A FIRM GRASP OF THE OBVIOUS". WELL, JUST FOR THE HECK OF IT, LET US BREAK IT DOWN.

1. CASE SELECTION - ONE PIECE NARROW DIAMETER IMPLANTS BY DEFINITION ARE USEFUL FOR PATIENTS WITH DIMINISHED BONE VOLUME. ACCEPTING AND SUCCEEDING WITH PROGRESSIVELY DIFFICULT CASES CAN BE EXCITING AND NERVE RACKING AT THE SAME TIME. MY PROPRIETARY TECHNIQUES WILL HELP YOU BUILD YOUR IMPLANT PRACTICE WITH PROVEN PROCEDURES. IT IS IMPORTANT TO BE HONEST WITH YOURSELF ABOUT YOUR CURRENT TALENT LEVEL AND PICK YOUR CASES ACCORDINGLY. ESPECIALLY EARLY IN YOUR JOURNEY.

2. IMPRESSIONS - IMPRESSION TECHNIQUES MUST BE AS PERFECT AS POSSIBLE. USE A-SPRAY TO REDUCE SURFACE TENSION OF THE PATIENT'S DENTITION AND USE THE BEST MATERIALS YOU HAVE TO ENSURE BLEMISH FREE MODELS. EXTEND YOUR BORDERS IF YOU USE STOCK TRAYS AND CAPTURE AS MUCH RIDGE AS YOU CAN.

3. XRAYS vs. 3D ORAL CT MACHINES - TAKE PA'S FROM DIFFERENT ANGLES - OCCLUSAL FILMS ANGLED PROPERLY OFFER MANY CLUES. IT IS EASY TO GET CAUGHT UP WITH COMPUTER TECHNOLOGY AND ALL THE NEWEST TOYS. THERE ARE BRAGGING RIGHTS INVOLVED IN THEIR ACQUISITION AND DENTAL EQUIPMENT MANUFACTURERS USE THIS TO THEIR ADVANTAGE. JUST REMEMBER, OLDER TECHNOLOGY, WHEN USED TO ITS FULLEST CAPACITY, OFFERS MUCH UTILITY. USE WHAT YOU HAVE FIRST AND YOU WILL BE SURPRISED HOW MANY CASES WORK OUT JUST FINE. OR MAKE THE BEST STENT YOU CAN AND HAVE YOUR PATIENT TAKE IT FOR A C.T.SCAN IN THE MOUTH FOR VERIFICATION.

THE SUCCESSFUL COMPLETION OF A CASE IS AS DEPENDENT ON THESE THREE INITIAL STEPS AS IT IS ON STENT FABRICATION AND THE IMPLANT SURGERY TECHNIQUE PROCEDURES THAT FOLLOW. THE SUCCESS OF EACH STEP IS DEPENDENT ON THE SUCCESSFUL COMPLETION OF THE PREVIOUS ONE.

EXTREME PRECISION - THE NITTY GRITTY OF PLACEMENT

YOU CAN NEVER BE TOO CAREFUL WHEN TURNING ONE-PIECE IMPLANTS INTO POSITION WITHOUT LAYING A FLAP. A FEW SCENARIOS REQUIRE THE ULTIMATE LEVEL OF SURGICAL PRECISION WHEN PLACING ONE-PIECE IMPLANTS. EXPERIENCED DENTAL SURGEONS WHO HAVE PLACED MANY ONE-PIECE IMPLANTS WITH FLAPLESS PROTOCOL WILL AGREE THAT THE FOLLOWING SCENARIOS OCCUR OVER AND OVER AGAIN AND MAY RESULT IN AN ABORTED SURGERY OR FAILED PROSTHETIC PROCEDURE. NEVER GOOD FOR THE PATIENT. NEVER GOOD FOR THE SURGEON.

1. DEFEATING THE KNIFE EDGE WITH A FLAPLESS PROCEDURE. MANY OF US HAVE GONE TO MINI IMPLANT "HANDS ON" PATIENT SURGERY SEMINARS ONLY TO SEE AN EXPERIENCED PRACTITIONER STRUGGLE WITH A "FOUR ON THE FLOOR" NARROW DIAMETER IMPLANT PLACEMENT DUE TO A SEVERE KNIFE EDGE IN THE ANTERIOR MANDIBLE. SIX OR MORE PILOT HOLE ATTEMPTS MAY BE REQUIRED TO ULTIMATELY END UP WITH FOUR IMPLANTS IN POSITION. AND ARE THESE FOUR IMPLANTS PARALLEL? PROBABLY NOT. OCCASIONALY, A PILOT DRILL WILL FEEL LIKE IT IS IN BONE BUT IT IS ACTUALLY CUTTING A PATH BETWEEN THE BONE AND PERIOSTEUM. OF COURSE, IMPLANTS PLACED IN THESE PILOT HOLES NEVER INTEGRATE WELL... :) FOLLOWING A "PROCEED AND VERIFY " PROTOCOL AND USING MY BONE SUPPORTED SURGICAL STENT SYSTEM WILL GREATLY MINIMIZE, IF NOT ELIMINATE, THESE PROBLEMS.

2. MANAGING THE PLACEMENT OF MULTIPLE ONE-PIECE IMPLANTS (4-10 IN ONE ARCH) IN NEAR PERFECT PARALLELISM. "FOUR ON THE FLOOR", "SIX ON THE CEILING" OR A TEN PIECE "ROUNDHOUSE". WHATEVER YOU CALL IT. THE POINT IS THE MORE IMPLANTS THAT ARE REQUIRED FOR YOUR OVERLAY OR HYBRID DENTURE CASE, THE MORE IMPORTANT PARALLELISM IS FOR EFFICIENT PROSTHETIC PROCEDURES. DOCTORS EXPERIENCED IN OVERLAY IMPLANT RETAINED DENTURES KNOW THAT YOU CAN SPEND AN HOUR OR YOU CAN SPEND AN ENTIRE AFTERNOON RETROFITTING THE DENTURE DEPENDING ON THE PARALLELISM OF YOUR IMPLANTS. GOOD CASE WORKUP TECHNIQUE AND A SECURE, EFFECTIVE STENT SYSTEM WILL SAVE YOU TIME AND FRUSTRATION. TIME IS MONEY. TICK TOCK.

3. A. PLACING A MINI IMPLANT BETWEEN TWO ADJACENT ROOTS THAT APPEAR TO BE 3 TO 5 mm APART.

B. PLACING A LONG MINI BETWEEN THE DISTAL SURFACE OF A MAXILLARY ROOT AND THE ANTERIOR SURFACE OF THE MAXILLARY SINUS.

C. PLACING AN IMPLANT INTO THE MAXILLARY TUBEROSITY (YES, IT CAN BE DONE WITH HIGH PREDICTABILITY - MORE ABOUT THIS TECHNIQUE IN THE NEXT SECTION).

D. PLACING THE APEX OF AN IMPLANT UNDERNEATH THE SEPTUM OF THE MAXILLARY SINUS TO GAIN AN ADDITIONAL 1 TO 3 mm OF BONE.

MAKING A DIAGNOSTIC STENT ALLOWS US TO TAKE MULTIPLE PA's FROM SLIGHTLY DIFFERENT HORIZONTAL ANGLES AND IDENTIFY THE BEST PILOT-HOLE ANGLE FOR SUCCESS IN THE ABOVE IMPLANT PLACEMENT SCENARIOS.

4. CEMENTING A PREFABRICATED CROWN OR BRIDGE ON THE SAME DAY AS IMPLANT SURGERY. BOLD AND TALENTED DENTISTS WHO PERFORM THIS PROCEDURE UNDERSTAND THE RISKS, BUT ALSO THE INCREDIBLE BENEFITS OF IMMEDIATE PLACEMENTS. ENJOYING THE BIG SMILES AND JOY IN THE PATIENT'S EYES WHEN WE PULL IT OFF IS WELL WORTH THE INHERENT RISKS. OF COURSE IF WE DON'T GET THE IMPLANTS PLACED IN THE JAW IN THE EXACT SAME POSITION (+/- A FEW MICRONS) AS THE IMPLANT ANALOGUES WERE POSITIONED IN THE WORKING LAB MODELS; WELL THAT'S WHEN ALL HECK BREAKS LOOSE. AT THE WORST OF IT, WE ARE ABORTING THE PROSTHETICS, TAKE NEW IMPRESSIONS AND EATING THE ORIGINAL PROSTHETIC LAB FEE. IF YOU ARE ABLE TO PLACE, IMPRESSION AND FABRICATE A CAD/CAM CROWN IN ONE DAY YOU ARE WELL AHEAD OF THE CURVE. BUT DOING SO STILL DEMANDS PERFECT PLACEMENT OF YOUR ONE-PIECE IMPLANT BEFORE THE REST CAN HAPPEN SUCCESSFULLY.

AS WITH FIXED PROSTHETICS ON NATURAL TEETH, MINOR ADJUSTING IN THE CEMENT CAVITY AND CROWN MARGINS IS A COMMOM OCCURRENCE. WE CAN FEEL A BIT MORE COMFORTABLE WITH IMPLANT CROWNS AS SLIGHTLY OPEN MARGINS THAT RESULT FROM GRINDING SO THAT THE MISALIGNED IMPLANT ABUTMENT CAN GET IN THE CEMENT CAVITY, WILL NOT RESULT IN DECAY UNDER THE CROWN, QUICKLY JEOPARDIZING THE RESTORATION AS IN NATURAL TEETH. OF COURSE OPEN MARGINS MAY ALLOW DENTAL CEMENT TO INFILTRATE THE GINGIVAL SPACES PROMOTING PAIN AND PERI-IMPLANT CONSEQUENCES.

IF WE CONTINUE TO OPEN THE CEMENT CAVITY FURTHER, POSITIONING OF THE CROWN PROPERLY DURING THE CEMENTATION BECOMES MUCH MORE DIFFICULT, THE MORE SPACE THAT EXISTS BETWEEN INTERNAL CROWN SURFACE AND IMPLANT ABUTMENT SURFACE, THE MORE PROBLEMS WE SEE WITH PREMATURE LOOSENING OF THE PROSTHETICS.

IF YOU ARE CEMENTING PREFABRICATED PROVISIONAL CROWNS, PROPER IMPLANT POSITION IS STILL IMPORTANT AS IT DECREASES CHAIR TIME FOR YOUR PATIENT AND MAKES IT EASIER FOR THE LAB TO FABRICATE A COSMETICALLY PLEASING FINAL CROWN. A PROPERLY POSITIONED PROVISIONAL GIVES YOU A NICER LOOKING GINGIVAL PROFILE AFTER HEALING.

SO WHAT ARE THE ANSWERS? BE AS PRECISE AS YOU POSSIBLY CAN, WHEN PLACING ONE PIECE IMPLANTS. IT DOESN'T MATTER IF THEY ARE NARROW, MEDIUM OR WIDE.

IT IS THIS WRITER'S OPINION THE BEST WAY TO ACHIEVE THESE GOALS IS WITH A BONE SUPPORTED SURGICAL STENT.

5 - PLACING MULTIPLE NARROW DIAMETER IMPLANTS IN THE MOLAR REGIONS IN A STAGGERED ARRANGEMENT (EACH SLIGHTLY TO THE RIGHT OR LEFT OF MID-LINE) FOR SECURE, LONG TERM CEMENTATION OF A FIXED BRIDGE. NARROW DIAMETER IMPLANTS SHOULD NOT BE PLACED IN A STRAIGHT LINE WHEN TWO OR MORE ARE USED TO SUPPORT A MOLAR OR MULTIPLE MOLARS. THINK ABOUT IT. PUT FOUR LEGS OF A TABLE IN THE CENTER LINE OF THE TABLE AND SEE HOW LONG IT STAYS UPRIGHT. PUT THE LEGS (IMPLANTS) NEARER THE EDGES AND YOU HAVE A SOLID BASE AND THE BRIDGE WON'T ROCK AND EVENTUALLY FAIL. A LOOSE NARROW DIAMETER IMPLANT BRIDGE CAN BE A NIGHTMARE. MANY BAD THINGS CAN HAPPEN WHEN YOU TRY TO CUT ONE OFF. MAKE SURE YOU HAVE YOUR TREPINE DRILLS HANDY. A SECOND PROBLEM (JUST AS IMPORTANT AS THE FIRST) WITH PLACING MINIS IN A STRAIGHT LINE IN THE CENTER OF THE RIDGE IS THAT THE TOPS OF THE ABUTMENTS END UP BELOW THE PALATEL CUSP OF THE MAXILLARY CROWNS. THIS DRASTICALLY REDUCES THE OCCLUSAL CLEARANCE AVAILABLE FOR PORCELAIN. PLACING MINI IMPLANTS 1 OR 2 mm LEFT OR RIGHT OF CENTER PUTS THEM UNDER THE CENTRAL FOSSA AND TO THE PALATEL OF THE CROWNS GIVING YOU MORE ROOM FOR ADEQUATE THICKNESS OF YOUR PROSTHETICS. PATIENTS THINK BETTER OF YOU AND YOUR SKILLS WHEN CROWNS AND BRIDGES "SLIP" ON THE ABUTMENTS WITH A MINIMUM FOR FUSS. PATIENTS WONDER IF YOU REALLY KNOW WHAT YOU ARE DOING WHEN YOU HAVE TO SPEND 60 MINUTES GRINDING ABUTMENTS AND OPPOSING DENTITION TO "MAKE IT FIT". IF THEY HAVE PAIN OR RETENTION PROBLEMS LATER OR THE CASE OUTRIGHT FAILS, THEY WILL REMEMBER YOUR STRUGGLES AND GUESS WHO THEY WILL BLAME.

IT HAS BEEN MY 30 YEAR EXPERIENCE THAT ABOUT HALF OF THE CONSULTATIONS OF PATIENTS REQUESTING LOWER MOLAR IMPLANT REPLACEMENTS PRESENT WITH NARROW RIDGES AND SUPER-ERUPTED MAXILLARY MOLARS SEVERELY LIMITING VERTICAL DIMENSION. THESE PATIENTS REQUIRE MINI IMPLANTS PLACED IN A STAGGERED ARRANGEMENT - VERY DIFFICULT TO PERFORM FREE HAND - A GOOD STENT . . . MY STENT, IS A VALUABLE TOOL FOR SUCCESS.

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