ellone welcome to episode 153 of chairside live we have an amazing show for you today
with an interesting case of the week but first dr. buy how you doing I'm doing great the week
is going really well tomorrow is October 1st do you have your Halloween costume planned no
I have my mortgage payment plan okay yeah that makes sense that's probably a better option at
this point but I want to do a Flintstone theme I'll have to be Fred and Wilma and then have our
daughter for my husband and I'd be Fred and Wilma and our daughter be pebbles but enough about that
what's what's in the case of the week oh it's gonna be a really exciting case of the week so
we usually get patients that come in and they have a failing tooth and they say you know I want you
to take the tooth out and I want an implant and the traditional way of doing that is you take
the tooth out you bone grafts you wait about four months let me bring the patient back then you go
through another set of surgery with advancements in implant materials basically and the design of
the implants we can actually place the implants immediately sometimes given that the patient has
certain requirements to receive that implant so for the case of the week that's what we're going
to be talking about is extraction and immediate implant placement so why don't we go ahead and
take a look at the case of okay so let's go ahead and take a look at this week's case of the week
and I want to talk about immediate implant placement and in particular immediate implant
placement with the Hahn implant and the reason for that is dr. Jack Kahn is one of my mentors
and one of our grand poobahs in implant dentistry he has designed this implant and a thread pattern
to provide us with immediate placement stability when we place the implant so that's going to be
one of our requirements for the immediate implant or emergency implant placement so let's go ahead
and take a look at the case of the week for this week I actually have two cases that I want to
share with you and they are both similar scenarios where the patient comes in with a failing tooth
and these scenarios they're both anterior teeth for the first case it's tooth number seven and
as you can see here the patient has had a lot of work done on this tooth that there's a short route
the patient has undergone root canal therapy and a crown so the crown has lasted a while but now
we're starting to get a little bit of recurrent decay underneath the existing restoration so it
was time for us to actually remove this tooth so what I want to present to you is essentially the
protocol for placing an immediate implant and when to do it and what not to do it so in this
situation I'll go ahead and remove the tooth as a traumatically as possible the first requirement
for me is whether I was able to extract the tooth a traumatically or not and whether I need to place
any bone graft and just wait and bring the patient back or can I go ahead and place the implant now
in this situation what I did was I wanted to open a flap because when I extracted the tooth I took
my periodontal probe and I probed the buccal wall and buccal shelf and I realized that there was a
little bit of a defect there so the reason why we opened a flap is to visualize the bone and I
really wanted to do a pepillo sparing flap where I don't go all the way to the adjacent teeth and
I give the papilla a chance to remain where they are and I won't have the recession after the flap
and the second requirement for me when I'm placing an immediate implant is whether I can get primary
stability with my implant so in order to do that I go ahead and drill into the palatal of wall and
I want to make sure that I have what we call a purchase point where we can go ahead and create
our osteotomy and essentially create an area where the implants can be received by the bone and there
will be enough bone to be able to hold on to the implant so in this situation my osteotomy is
completed and I'll go ahead and place the implant and here you can see that the implant is in place
and you have some of the threads showing the bone level Muzio distally and approximately is going
to be held up by the adjacent teeth so I'm not worried about that I'm utilizing some bio Oz bone
graft material xenograft I'll go ahead and place the bio Oz in the buccal area and also covering
the implant itself obviously it's not going to bond to the to the to the top of the implant the
Polish titanium healing abutment and there's a situation right before i suture the grafted
site and what I'm utilizing here is essentially it's horizontal suture however it's a little bit
modified and it helps pull the tissue more coronal II and I try to create a primary closure as much
as possible and scenario I placed one horizontal mattress suture and interrupted sutures down the
size of the incision where I had my vertical releasing areas and then obviously we want to
send the patient home but we want the patient to have tooth there and the patient wants to have
the tooth there so we went ahead and fabricated a removable interim restoration this is a interim
partial and you don't want the the tissue surface to be in touch with your partial so what I usually
do is I'll go ahead and check the intaglio surface and I'll make the adjustments so now the patient
goes through a period of healing usually about 3 to 4 months before I uncover the implant and
place the healing a button the healing abutment is usually in place for several weeks before I can
go ahead and fabricate a temporary and start the process of tissue contouring before we fabricate
the final restoration so the second case is very similar to the first case except the patient came
in with tooth number eight obviously a lateral periodontal lesion in this situation and again
it's a challenge because you have to ask yourself can I extract this tooth a traumatically in this
situation can I extract and remove the lateral periodontal cyst and have an area where I can
go ahead and place the implants so again very gently working around the tooth I'll go ahead
and try to get a little bit of mobility with my perio domes and then I'll take my time with my
forceps and I'll make sure to extract the tooth as a traumatically as possible in this situation just
like the last the crown is removed and now I have a little bit more access to the tooth and I'll go
ahead and extract the tooth so once the tooth is extracted I'll do the same thing as I did
for the last case where I'll take my periodontal probe and I'll make sure that I have an intact
buccal plate if I don't I'll open a flap so I can visualize it and I'll be able to graft it
if I do half my buccal shelf I'll go ahead and proceed to the next step which is to create that
purchase point on the palatal so here you see the tooth is extracted a dramatically and I'll
go ahead and clean out the area and remove the cyst and keira at the socket as much as possible
to have a nice clean socket to be able to place the implant and as you can see here we were able
to remove the the lateral periodontal cyst and here you see that I'm probing the buccal shelf
and I have about three millimeters apical to my mica gingival junction to play around with and
place the implant so again same thing I'm gonna utilize the the paddle palatal shelf in order to
create that primary stability for my implant and I'll go ahead and proceed with the steps to create
the osteotomy forward implant now the question is if I create the osteotomy and I want to go
ahead and place the implant what if I don't have primary stability do I still place the implant
for me I feel more comfortable if I cannot create primary stability to just graph the area and come
back at a future date so that is determined at the time of implant placement as I'm doing here
I'll go ahead and place the implant and I'll double-check my primary stability and make sure
that I maintain that before placing bone graft and in suturing so in this situation I'll go ahead and
get to the correct depth and I'll check my primary stability I have about 25 Newton centimeters so
it's a really borderline I'm definitely not going to load this implant but in theory I can go ahead
and grafts around it and wait and let the implant Accio integrate and come back later and create the
temporary for the patient so here's an x-ray of the implant in place and there are certain
requirements that I look for in terms of how much stability I have and how much how much primary
stability I have at the apical end of the of the implant when I'm placing it in this situation
I'm using a allograft it's called Regenerist by Biomet and once the allograft is in place I'll
go ahead and place the suture and deliver the the temporary for the patient so again I'll go
ahead and create my horizontal mattress but it is a modified horizontal mattress in order to create
a better seal and as close to a primary closure as possible obviously this is an extraction socket so
at the center of the ridge you're not going to create that primary closure but the closer you
can get to it the better obviously for the healing and then once I have my suture in
place I'll go ahead and place the interim partial for the patient and again checking the intaglio
surface so that it is not touching the grafted area so that's our case of the week and I hope
you enjoyed it thank you for that doctor bye Thank You Megan so we were reducing the chair sight time
and the clinical time basically was being able to place immediate implants and hopefully restoring
in a four month period rather than an eight month period really is now let's go to a segment we call
you are ma'am this week's viewer mail comes to us from dr. David's bill Kia and he had just watched
episode 152 of chairside live and said that the video Schuldt old pfm crowns being cut off and he
noticed that number seven had amalgam visible he says when the impression was taken however
the amalgam either was removed or covered what actually was done here my concern is that with
the translucency of Brookes er interior there would be show through if this is not addressed
I still prefer metal posts over fiber posts and sometimes the metal will be visible and will ruin
an otherwise nice Brooke sir interior crown well that's a great point and looking at the video
you can definitely see that there is some metal showing on tooth number seven and making what you
can actually do is you can use a metal picker to get rid of that bright metal color so that
the Brooks our anterior doesn't show through the stump shade basically the other thing you could
do is you can still utilize a metal post but do the build up with a resin okay and that way you
have the benefit of the strength of the post and aesthetics is a resin and it's not going to show
through in your final restoration and what was done on the particular case of last week's episode
I believe that dr. Mears on had utilized opaque err okay that tooth yeah alright so yeah that was
a great question thank you so much dr. spookier for writing in and now let's go to the news the
news okay a Hong Kong woman got a crunchy surprise in her takeout sushi when she bit into a piece
of sushi she felt something hard spit it out and much to her disgust found a three-unit bridge she
took some pictures and contacted the restaurant the store manager assures them that none of its
staff wears false teeth and that all employees are made to wear masks during food processing the
restaurant chain called sushi Express is now under investigation by health inspectors by Hong Kong's
food in environment hygiene Department and this is exactly why patients should get implants right see
I mean just totally rallying for the cause here have you ever been into any sort of food and found
you know what I was thinking about this when I was a little kid I went to San Francisco and I had
some clam chowder and I've been into a clam shell but English is my third language so back then I
was new to the whole English thing yeah so I told the waitress I said you know I just bit into a
piece of clam uh-huh and she got offended like what are you saying we don't have clams in our
clam chowder right so yeah that was my relation to this story was yeah yeah you know and we've seen
many stories like this in the chairside live where you know they bite into something and there's a
tooth or there's a finger or whatever just random stuff that you know sometimes they find out that
the person actually placed it in there but in the in your case I would it's safe to assume that that
was just an accidental showpiece left in your soup but probably an accident probably yeah all
right well thank you so much for that case of the week and for your comments on the news thank you
for watching and please come back next week for another great episode of chairside live see you
next week Hey what so you're going directly to this camera after if you get a weird text just
don't judge me okay got it you should make it so your text messages come up as just sort eyes it
yeah yeah yeah what yes I'm at work where else would I be please keep the viewer mail coming
in we love to hear from you and we love to give you clinical tips in the view just talking just
just taking it sticking my tongue out for her right here just seeing what I can do you guys
done with me do you have your Halloween costume planned no I have my mortgage payment planned