today's presentation is going to be an interesting one it's called my first implant and you're going
to get a chance to watch me surgically place my first implant I've restored many implants over the
years but I've never surgically placed an implant you know I've heard Gordon Christensen one of my
mentors say many times over the last 10 years that GP should be placing implants from 6 to 11 and 22
to 27 and even though I've heard him say this and I've taken numerous implant courses to be able to
place the implants I never did surgically place an implant why not I was scared maybe the same reason
you've never placed one why you know I was afraid to put one into somebody's maxillary sinus I was
afraid to put one into somebody's mandibular nerve why would I want to get involved with that and let
me share with you an x-ray that pretty much sums up why I was afraid to place implants for the last
10 years and this is the x-ray that kept me from doing implants for at least the last ten years
from surgically placing an implant on my own and here you see two implants and they look pretty
nice and nothing wrong crowns look splitting together a good bony support around the implants
oh and as we scan to the mesial you see some bone loss on the distal of the first of those three
implants and as we continue to sweep over the mesial ouch there's the problem look at that we've
got an implant screwed right into a tooth that is not osseointegration that is a donto integration
and that's exactly the kind of thing that I was afraid of whether it was a sinus whether
it was a nerve whether it was a tooth I mean I was literally just afraid to drill a hole into a bone
and then put a titanium screw in there and you know I don't know who the dentist was who placed
this and don't know if it was the specialist or a GP but you can see when you look at that tooth
that the implant is screwed into how the root you know really tilts really leans to the distal and
how you could look at that if you couldn't see the x-ray and think that you were placing the implant
parallel to the long axis of that tooth in front of it because you look at the crown of the tooth
and it appears to be you know straight up and down in the mouth yet the root is fairly long has
a lot of cuspid roots are and it tilts actually a little inclination towards the distal and the
implant went right into it now but you're gonna see with the three-dimensional scan as opposed
to a one-dimensional panorex or a one-dimensional PA with the three-dimensional comb beam scan once
it's put into the software not only do you know the height of the bone but you know the width of
the bone and you have an idea about the density of the bone you can see where teeth are located and
other anatomic structures and then you can place an implant virtually into that bone and see how
much room you have between the implant and the mandibular nerve for example or maxillary sinus
you can see whether or not you might have to do some grafting and as you'll see after that in the
surgery it really is straightforward and you've pretty much used technology to get rid of all the
variables and then you construct the surgical guide so that the surgery can take place very
easily very rapidly and predictably as well so here is what that case looks like clinically you
can see we've got tooth number 19 missing where we're gonna place the implant so we're gonna go
ahead and get a shade on this I've used the Vita ez shade and it told me that the adjacent tooth
was an a4 and so we're putting the a4 shade tab into place and we're gonna take a photograph of
this and sent it to the technician because really what it's telling me is that a 4 is the closest
shade not that it's an absolute perfect match and now it's time to anesthetize the area and so I'm
placing some of the pfg gel in the back I'm gonna go ahead and give a lower block here just because
it's my first implant if it was farther down the road I might feel comfortable enough to just give
some local anesthesia in the area but I want to give a block and you can see I'm using the
STA device here and if you've watched any of our clinical presentations you know I'm a huge fan of
this device but usually I'm using it to do single tooth anesthesia on a lower molar for example so I
don't have to give a block but I love using it to give blocks as well because I can put a second car
peel in without removing the needle you change the car peel back of the unit itself so once you're
down to the hub or the full length of the 27 gauge long needle in this case you give the first car
peel change put a second one in and give a second car peel of anesthetic without removing the needle
so it just seems like one shot to the patient and that's a pretty patient friendly way to give a
lower block if you have to give one first step here we've got the surgical guide in place I'm
holding it down with my index finger this is the start drill and you can see the picture of the
start drill the part that's blue is responsible for the tissue punch so we're not gonna lay a flap
here dr. Bach horse during the digital treatment plan knew that I didn't want to lay a flap if I
didn't have to and he felt this case would be fine without it so a tissue punch and the tip that just
lit up on that start drill it's gonna countersink into the bone so the only part of that drill
that's going into the bone is that little tip and not the rest of the the width of this start drill
that's going to be our tissue punch that makes room for the rest of the drills once the tissue
punch has been advanced to its full depth it's time to go with the first drill this is a two
millimeter drill and you can see the insert that we have that's in my right hand that fits inside
of the surgical guide and it's perfectly fit for the 2 millimeter drill obviously the hole
in the stent itself is bigger than that so with this insert it makes sure that there's only one
direction that this drill can go into the next drill is the 8 millimeter narrow a platform drill
and again you can see I've got another insert in the surgical guide that I'm holding in place as we
push our way down with the 8 millimeter drill and you can see not meeting a lot of resistance you
can see the vertical stop I'm pushing down on the handpiece there and the drill simply will not go
any deeper than allowed by the surgical guide so this allows me to make this osteotomy with a high
degree of confidence that I'm nowhere near the nerve based on our digital treatment plan as I
work through the series of drills here I can take them all to their full depth with confidence that
I'm not doing any damage in that the osteotomy that's being created is in the correct anatomical
location so again you can see pushing the surgical stent down just to make sure that it's down all
the way and you can see the adjacent tooth the molars showing through there and that it is in
fact down all the way and then I hold it down in place and going in with the 13 millimeter regular
platform drill and again taking that to its full depth until the burr simply will not go down any
farther apical e and then we remove the handpiece and move on to the next drill and this is pretty
much real-time you can see it's only taking you know 10 12 15 seconds maybe for these drills to
go down to their full depth and again I have all the confidence in the world that it's going in
the right direction in the right place because of the surgical guide and now it's time to place the
implant so we don't need any guides on the inside of the surgical guide itself because this is for
the final size drill and the implant itself and if I just tilt the handpiece here a little bit there
it is you can see the implant spinning and how slowly that's going in so the speeds been turned
down on the handpiece and slowly just letting the implant thread its way into the osteotomy
and we're gonna stop a couple turns from it being completely seated and we're gonna use a torque
wrench a hand wrench to seat the implant the final couple turns instead of doing it by the handpiece
and you can see the mount that's still present on the implant itself that of course was attaching it
to the handpiece and to the torque wrench itself so I'm gonna do a couple turns here by hand the
last few turns as I can see the implant going down the rest of the way and as I as the torque wrench
starts to feel some resistance I'll go ahead and take the torque wrench part of the torque wrench
and as you can see while I'm pushing here and that is the sign that we do have the implant down all
the way once the torque wrench has been tapped out at that measurement and now we're gonna go
in with a hand wrench and unscrew the mount that is on top of the implant and just back that out
again using two hands just for a little better control as we take the mount off of here and
as soon as the mount comes off we will be able to take out the surgical guide and see how our
implant looks so here's our first peak with the implant in place and the surgical guide out and
we're gonna go ahead and place the healing screw on top of this and as my assistant does a little
suction she's also going to come in with pareo probe and just make sure that the tissue stays
clear we don't want to pinch any tissue between the screw and the implant itself and so she's just
using that to make sure that doesn't happen we take a post-operative radiograph and you can see
that the implant looks like it's right where it should be in fact if we compare this to the image
from the digital treatment plan now the one on the right obviously has the healing screw on top of it
the one on the left is just the implant itself but you can see that it ended up where it was
supposed to end up right between those two teeth at the proper mesial distal angulation and that's
the beauty of the surgical guide if I would have had to do this freehand for my first implant that
would have been sweat rolling down my forehead to the entire time as I was worried about whether
or not this was going in in the right spot at the right angle ation so here's the second appointment
and you can see that the healing screw is still in place little tissue over the mesial portion of it
and we can just take out a diode laser and remove a little bit of that tissue make sure that it's
going to be clear from when we go to place our abutment into place and we're gonna use the hand
wrench to go ahead and unscrew the healing cap and take a look around and see if everything looks
as it's supposed to look again using two hands just to help stabilize this and make sure that
we don't lose or leave any of the parts behind or lose grasp of the screw or anything like that so
once we take that out we're gonna go in and do a quick chlorhexidine rinse just as an antibacterial
measure and just kind of it clean out any debris that may be around there shouldn't be anything in
there but just going in and making sure we can get it clean there's the implant abutment itself being
held in by my assistant while I start the screw by hand just a couple turns to get it in and then we
can put it in the rest of the way with the torque wrench you can see the flat surface on the implant
abutment facing towards me on the buccal and that just kind of sucks down into places we put it in
there and then make the next turns with the torque wrench and then as it starts to tighten up again
you can see I'm leaning on the torque wrench arm of the torque wrench and once we have the abutment
torque down all the way on the implant we're gonna place a little cotton pellet very small one just
on on the head of the screw to keep that nice and clean and then we're putting some temp it
LC on top of that so this is just a temporary a light cured temporary material from Centrex you
know kind of like other ones that you might use for say inlays onlays things like that we just
want to be able to cover up this access hole and and cure it into place just to make sure we have
a good seal here before we try before we cement the crown on and here we are just curing this and
then we'll go ahead and try the crown and make sure that the contacts are good and that the
occlusion is light if any occlusion you know we want to have it on the light side make sure that
the margins look good on this you know again as I drop this into place it pretty much fits as well
as any crown that I've put in before which is neat to me because you know this was not a typical
crown where we had a impression of a preparation this was basically done you know digitally with
the implant abutment being fabricating the crown being fabricated all at the same time
out of the mouth we've got some nice spots on the adjacent teeth and very light occlusion on on the
crown maybe just a spot there so we're ready to go and we're just gonna put a thin layer of
relay excluding cement our typical crown of Bridge cement you know around the gingival third you know
keep in mind that unlike a regular crown where you have maybe three or four coats of die space or
even two coats of die spacer on the prep itself on the model we don't have that here and so there's
not as much room for cement you don't need as much cement basically just coating the gingival third
of it basically they have such good mechanical retention here we are cleaning off the excess
cement this is really important it's important on all teeth but on an implant crown you've
got to get all that cement off you can't have a low-grade infection or around the implant that's
a great way to lose the implant so even though you should take real good care of cleaning up
cement around any crown it's especially critical around an implant crown and you can see the crown
blends in pretty darn nicely it's a great result for this patient especially if you stop and think
as you look at these before-and-afters you know 20 years ago when I get a dental school the only
solution here was well there was a couple none of them really good there was a partial denture
maybe at Nesbitt you know just a tiny one on that side there was do nothing I guess was
an option the most common one would have been a three-unit bridge and both of those teeth would
have been prepped next to it for full crowns to put a fixed bridge in and the placement of an
implant like this with a single unit crown on it has a very elegant solution to this problem so I
think you can see by using the high technology available in dentistry today and so including
the surgical guide how easy it was for me to get a great result for me and the patient on my first
implant how difficult did that look in reality that was not all that difficult to surgically
place my first implant in fact I'd say the average crown preparation is more difficult than what you
just saw right there of course that's because of all the high-tech solutions that we have in
dentistry today that allowed us to have a surgical guide that was precise enough so the drills and
the implant ended up in the right position if like me you've been afraid for the last 10 or
15 years to surgically place an implant take another look at it with this digital treatment
planning you may find out that you're more ready than you think on behalf of all of us here at the
laboratory I want to thank you for your time and your continued commitment to quality dentistry
you