Lateral Ridge Augmentation/Implant PLacement. KNOW YOUR MATERIALS

Here is a case I just did this morning. People always ask me..
What type of Bone do you use?
What type of Implant do you place?
Whayt type of Membrane?
What Sutures.
Dentists on the lecture circuit say ONE ANSWER. It is totally incorrect. You need to know why you are using the materials and what you want to achieve. That being said Here is a case where we use different materials and they were all thought out. HEre we go.

Patient presents missing #5. Here is his Intraoral presentation. For those of you that say you don't need a CBCT. Here you go!

Intraorally looks like he has TONS of bone. Slight dehiscence. Here is his CBCT





The Whole Buccal and Palatal plate is practically missing. So what are my options

1) The August Method: FPD
2) Block bone graft wait 6 months, implant 3-4 months,
3) Simultaneous Implant and Lateral ridge augmentation


So we chose option 3. So we have to achieve certain criteria to make it successful
1)CHoose an implant that is tapered and has aggressive threads so that it can be stabilized in minimal bone. and an implant that is recession occurs can theoretically stabilize the soft tissue.
CHoice: Biohorizons Laser Lok 3.8X12mm
2) CHose a bone graft that will retain space and shape and will resist the pressure from the cheek and flap.
Choice: Dynagraft-D Putty

3) Chose a membrane that will resist pressure and maintain space. Chose a membrane that will not need primary closure in case the flap cannot be approximate
Choice: Cytoplast Titanium Reinforced Buccal Membrane
4) If defect is large have a Prosthetic PLanning Kit available to determine if angle and position of implant will work.
Choice: MIS PROSTHETIC PLANNING KIT
5) chose a Suture that is non resorb able so you can control the healing. Chose a suture that has a very low tissue reaction to prevent scarring and infection
Choice: 5-0 Nylon

With all my materials and procedure thought out prior to surgery off we are to the races and no surprises are there.

Palatal crestal incision with vertical releasing. When doing vertical releasing angle the blade so that reproximation is not butt end but rather slides over and scarring is minimized. Notice Defect.







Notice above the palatal plate is also thin




Notice the abutment its 15 degrees. and fits perfectly. IMportant to try in because if hex is not positioned correctly you won't be able to use a prefab abutment.



Looks buccal placed as it is. BUt palatal bone non existent. Will use Zirkonia abutment and emax crown to restore. Tissue very thick so should be ok.

Bone Graft Placed.Very Clean Very thick



Titanium Reinforced Membrane.


Prosthetic PLanning Kit



Sutures 5-0 Nylon








Notice Bulkiness of the ridge.



Enjoy. As usual COmments Welcomed!

Single Implant Trap Door Incision

So patient walks in with PAP on #7. What do you do? Assuming tooth non restorable or patient declines endo and Implant is treatment of choice. Options: 1) a-Extract tooth wait two weeks b-Full flap and GBR with titanium reinforced 4-6 months         c- Place implant 3-6 months d- Restore implant Timeline: 1-1.5 years Result? Esthetic? maybe 2) a-Extract the tooth,full flap, implant and bone placement 3 months      b- restore tooth Timeline 3-6 months Pain for patient: ???? Postion of papilla:???? Position of alveolar crest???? I am sure there are lots of options but here is how I routinely do these cases. Completed in 6-10 weeks depending on Ostell Reading. This case was completed in 8 weeks. Materials: Implant: Blue Sky Bio Trilobe 4.3 Membrane: Pericardium Suture: 5-0 Nylon Bone: CErasorb M Dental (PH EXCELLENT FOR Infected sites) Abutment: Zirkonia with titanium base Implant Direct Crown: Emax Laboratory: Lifelike Dental Studio (did a kick ass job) CBCT: Kodak 9500 Full Field of View So I wanted to keep the position of the papilla the same and I wanted to place the implant that day. I also didn't want the patient to be in any pain. Here is how he started: You can't see it in this photo but he had a draining fistula Here you can see it Below is the CBCT. Notice how there is a bridge of  bone at the alveolar crest but none at the apex. So we decided to use this type of incision design Tooth is extracted Atraumatically. Socket is curetter. Alveolar Crest Bridge is confirmed  Implant is palatally placed Trap Door is done Bone graft is placed pericardium membrane Sutures Notice how papilla is still intact Healing abutment is placed (comes free with the implant) Ostell is used at 8 weeks to check stability of implant. Reading of 74 is achieved and we are off to the races Shade Communication with the lab ANd Final Comments are Welcome.

Diastema Closure Steps to Success

Patients present for Diastema Closures all the time in our practice. This is one of the most challenging cases to be done correctly in dentist office. Lumineers is hot due to their direct marketing. The case below would have been a disaster if a dentist wuld have allowed the patient to dictate the treatment. Although patients have demands we are the professionals and must guide them to what is possible or not. Here are the steps we go through.

1) Discuss patient's expectations
2) Discuss Shade Change
3) Discuss Monetary Restrictions
4) Discuss Orthodontics
Step 1: Intraoral Photos
Not only are they important for you and your lab technician to see the case, but more importantly for the patient. This allows them to now OWN their problem and see where they are. This usually leads to more case closing.

Smile and Profile

Notice the deviation of her chin that is masked by her diastema

Intraoral Photos

Now that we have our case we see the challenges.

1)Diastema is large so doing two veneers is out of the question

Options 4-8-10. We never do 6 . That is a whole other discussion

2)Lack of papilla so long contact will be present. Papilla is not present because no bone peak is present. 

Tissue is the Issue but Bone sets the TONE

3)Flared Incisors and and edge to edge. This shows is that NO prep is not possible. Minimal Prep Maybe

We then go ahead take good diagnostic impressions, Bite registration and Kois facial Analyzer Registration to make sure that final waxup is straight.

Here are the models and Waxup.

Duplicate of Waxup

Recommended preparation to make teeth proportional. Moving everything MeDially

Diagnostic Waxup

Preparation Guide. In this technique a Clear Stent is placed. Teeth are prepped through the Windows. The Waxup is then transferred to the mouth and a 0.3mm reduction bur is used. This prevent haphazard preparation and allows Minimally Invasive Dentistry to be performed

Day of Prepartion. All the Work is transfered to the patients mouth.

Adequate preparation done. Prep polished and Polyether Impression taken.

Trial Smile done.

We don't like to make the temporaries So SPECTACULAR as patients then get too comfortable and do NOT return

Temporaries after Diode Laser Recontouring of gingiva

Notice Change in shade

Now is when we hit a speed bump. this is what the case came back looking like. In Diastema Cases make sure that your lab understands that no papilla is presents and to close the gingival embrasue completely.

After ditching the dies they lost sight of the embrasure so finished it to normal size. We resent to reaply porcelain.

Day Of insertion

2 week post op

2 week post op

 

All in all with 4 veneers we were able to get away with closing the diastema and not making her teeth look bulky. 

Enjoy! As always comments are welcomed.