A2 Flashcards
——- stent for CBCTs (——- mixed with acrylic 1:3 mix with liquid).
Barium sulfate
Get lateral excursion photos, if you take out the ——, it will lead to malocclusion elsewhere. ***This can happen with any small filling, be particularly weary of this on 2nd molars (first contact is here).
guidance form
Always get —- PTFE – the reason for this is that it is stretchy and thick enough to work. 5.0, 6.0, 7.0 do not stretch (change needle size of PTFE instead). Maybe 4.0 at largest. By the time you go to tighten and cut, it will be ——. Vicryl or nylon are 5-7.0.
3.0
thinner than it originally was
Most CBCT errors are in the — microm range
200-500
High resolution protocols do not lead to —–
3D models with higher accuracy.
If above mandibular canal, it has potential for —- origin. In canal is either ——- or ——-.
odontogenic
bloodborne (metastasis) or neuro
——- lesions are tough to differentiate and diagnose, especially in initial status of remodeling with radiolucency. This is tough to distinguish this from other apical lesions. Goes from radiolucent to mixed to radiopaque.
Fibrocementoosseous
Hounsfield value – ——-Air = -1000, bone 60-3000, water 0.
msCT radiodensity measurements.
——– assessment could easily help determine if a patient suffers from osteopenia or osteoporosis.
Mandibular canal width
Mandibular width should be 3mm or more to be categorized as healthy (cortex width)
Mandibular width should be —- or more to be categorized as healthy (cortex width)
3mm
A lesion that is not touching a junctional area between cortical and trabecular bone is——
more or less invisible. These are difficult to see.
Resiliance (movement) of tooth: Vertical (premolar with good perio) —–, horizontal = ——
50 micro
250 microm.
Implant mobility: Vertical —–, —— horizontally. This has a certain flexibility but it is much lower than a tooth.
2 micron
50 micron
Mixed implant-tooth FPDs are a compromise. Their prognosis isn’t great. Force is distributed to both tooth and implant. Implant takes up initial load. — lower 10 year survival rate.
10%
W distal cantilever, pressure zone on —-, tension on —– of —– abutment implant.
distal
mesial
middle
Implant sites Type 1: Advantage is ——
Type 2: Matured tissue, but you decrease —— and have not completely filled the ext site.
Type3, 4: —– more or less, but you lose bone contour.
sufficient bone contour, minimal soft tissue.
bone contour
Healed ridge
Only pre surgical antibiotics: 1.87% annual failure rate. 7 day post op antibiotics significantly —-
reduced annual fail rate.
Buccal positioning on soft tissue (relative to buccal surface of adjacent teeth)——
Lingual positioning on soft tissue: ——
- 8 mm mean
0. 6mm mean recession.
For transmucosal healing, you need some amount of ——-
soft tissue excess.
Inevitably, you will lose soft tissue and bone. Even with over 100-120% coverage of defect with tissue graft, you get down to around ——-
60% coverage at 6 months out.
Tunnel technique is extremely helpful to add ——. Maintain papilla, elevate flap on ——-. Then you tunnel from lateral teeth, while still maintaining —–.
Then a buccal incision is formed in —–, then you get a connective tissue graft, and string the connective tissue graft through the incision, up to the —- of the implant.
gingival body
buccal
papilla
vestibule
sulcus
Mean facial recession from —— is expected in immediate implants. This tends to mask the real trend. Max recession from —– has been recorded.
0.5-1.5 mm
3-6 mm
Mean gingival thickness for premolar to premolar is about —— Thick tissue is —–, thin tissue is —–. These need to be considered.
- 1mm.
- 5mm
- 8mm
Majority of recession between—–, however thick tissue did not get worse than —-. Large recession is almost always thin.
0.5-1mm
2mm
At transmucosal implants, improvements of soft tissue deficiencies are —— to perform compared to submerged healing procedures.
more difficult
For immediate, you need at least —- alveolar bone apical to tooth (between sinus), if not, you need a delayed approach with partial bone healing (3-4 months).
3mm
Implants placed in sites of perio removed teeth, are—–times more likely to fail than implants placed in other sites.
2.3
Studies found that —- weeks of waiting after perio ext is not enough to make the survival rate on par with a healthy periodontium.
6-8
By placing bone substitute between implant outer surface and buccal plate, we will lose —– of bone. Thus, if you want to maintain 100%, you need to place bone substitute outside (on buccal of buccal plate) of site.
50%
If infection, wait — weeks for placement.
6
How to check tissue biotype
Lift probe in sulcus facially – if you can see the probe thorugh tissue, it is thin biotype. Problem with thin biotype is facial gingival tissue stability.
Facial mucosa thickness: 0.7-1.5mm,—–and less thin, 1.1 to — is thick.
- 1
1. 5
Visual and direct measurement are both variable and non-definitive. As such, you need to approach every case as if——-
it had thin tissue.
Subepithelial connective tissue graft performed at time of placement – improves gingival thickness by almost ——. After 1 year the tissue became thicker. Even without tissue graft, the tissue gets thicker. Most implants are placed palatally, and this is why it is thought that this occurs. You need to be palatal to original position to achieve this.
1+mm
In order to fully shield from discoloration, almost every material required —- of gingiva. —- could hide zirconia only, —- had discoloration from every group. Thus, if you want to hide something, you may want to consider a connective tissue graft.
3mm
2mm
1.5mm
Normal crest is —- from FGM to bone, high crest is less than 3mm, low crest is more than 3mm.
3mm
In order to have gingiva, you need ——-. Facial gingiva has an —– to underlying bone, and this is also —–. Once you get over —– in facial gingiva, it has risk of recession and is unstable.
underlying bone to support it
adhesive relationship
3mm
3mm
Long story short, place the implant —– below ideal facial-gingival margin. Any deeper, and you have the risk of facial bone loss and thus gingival recession.
3-4mm
Place no more than —– deeper than FGM
3-4mm
Anterior bone: Class 1: ------- Class II: ------- Class III: -------- Clas IV: --------
buccal tilt, root in contact with buccal plate
Middle of plates
Touching palatal plate
Root wider than dimension of base of bone. Class 1 is best for immediate, class III then next best ideal. Most patients are class I.
Taper group in implants has less —– than parallel implant group when immediate placement is involved. That said, bone loss is good around parallels. Immediate implants are usually a good situation for a——
spinning issues
tapered implant.
Gap size, instead should be a guide to make sure that you do not place an implant in an area that will lead to exposure. If you don’t have enough of a gap, you are destabilizing the implant as you didn’t compensate for ———. So, how much does the ridge remodel?
average amount of facial remodeling
With graft (6months): —–. Without graft (6 months): —–
- 5mm bone loss
2. 6-4.6mm bone loss
If you look at buccal bone thickness along length of implant: buccal bone for teeth in esthetic zone is 1mm or less, thus you need a graft, as —— loss is expected. You will lose the buccal bone. So what size of gap should you leave?
1.5mm
*Gap size of —– at least in order to maintain the original width of the buccal plate
1.5mm
Equation for anteriors:
Facial bone+Implant diameter+Gap –facial loss with graft (1.2-1.5mm) = width of ridge.
Measure —- on CBCT buccal to existing tooth to make sure that you have space.
3mm
Another way: Resonance frequency analysis:
Pretty much put a tuning fork to an implant and see how it resonates. Magnetic pulses vibrate the smarteg… rewatch this section
Critical distance an implant can move is —– microns. This is more or less the PDL width of a strong tooth.
50-150
Torque measures resistance to —- forces.
shear
Immediate loading has its advantages as well. You find more —– production earlier when immediate loading occurs. Well controlled immediate loading can enhance osseointegration. This was verified in animal and (limited) human studies (10% greater).
osteoid
—– has been shown to positively effect healing
Micromotion
**If you have to graft, do not —-
load that implant**
Unique situation with implants: You can have —— tissue. The attachment for this is usually on —– bone.
keratinized unattached
peri-implant
If you soft tissue graft, you need contact to —-, otherwise it won’t be attached
bone
Bone sound for posterior extensions (make sure that you don’t have too much soft tissue height). Thinning out to less than—–can lead to bone loss.
2mm
Bundle bone varies in thickness, however it is thin. Usually —– thick.
0.4-0.5mm
3 months after ext: Buccal-lingual dimension lost —-% of ridge.
30%
12 month after ext: lost —-% of ridge buccal-lingually.
50
In height:
12 months after ext: —- loss in buccal portion of alveolar ridge relative to lingual portion.
1.2mm
Benefit of splinting is prosthetic – when you splint, the connector is in the frame, hence lower risk of —–
porcelain fracture.
Detaching mylohyoid leads to opening to —– and makes it prone to infection. Some techniques request going down to —– or beyond – this is risky.
mediastinum
mylohyoid
Amox 2g —-
Clinda 600mg ——
1hr before, 1 hr after
A1c – 3 month average. Normal blood glucose 80-120, Doc’s line in the sand is —-.
250
A1c – 3 month average. Normal blood glucose 80-120, Doc’s line in the sand is —-.
250
If an implant survives a —–, that implant will behave the same in a diabetic vs healthy pt.
year
IV bisphosphonates – —-% MRONJ risk. Bisphosphonates stay in the body for —- years.
10%
8-10
Coumadin best monitored by —- – extrinsic pathway = use PT. intrinsic = —- (pet and pitt)
PT
PTT
Design flap to give you —– from bony anatomical structures *foramen, canine eminence, etc). Normally incise right down crest, if you have less gingiva, consider a more lingual cut.
6+mm
Eval 9, 10, 11 CN with——-
“say ah”.
Attached gingiva is important to shield bone from bacteria. How much hard keratinized tissue is really needed around an implant? ——–. If you don’t have ——, consider a graft, or a 2 stage procedure. If you want to do single stage (healing abutment), get at least —– of torque. Benefit is that this is one surgery. Give —– above gingival crest for healing abutment in order to maintain hygiene.
2mm
25 nm
1-2mm
Lindeman bur: —–
Side cutting bur
Resorbable membranes should have —–. Also, no —- with resorbable membranes that are exposed.
primary closure
peridex
Transmucosal collar beneficial if you have a —–. Micromovement occurs at abutment/implant interface. If your implant rocks, you introduce bacteria, and that interface is key. If you move the interface away from bone, you reduce bone loss.
bony defect
Exposure of cover screw: If you do 2 stage and a week or two later the screw is exposed, this is fine. This is just the warning sign that the patient needs to really keep this clean. These cases are the ones that —-. You have to choose at this point to either totally open it or close it. Do not leave this in between.
lose bone
Peridex can help with —–. Generally, there is no specific rule on how much tissue will move in. After —- days do not touch the implant. If you get uncover 2 days in, go in and free up or close before day —. PTFE are the next gen of —- sutures. These can stay intraorally for a very long time. —- sutures are very smooth and easy to work with, but whenever you use a ——- suture, you need to leave longer threads. If you do not, you have less thread to resist tissue inflammation and untying.
gingival closure
3 days
3
gortex
Cytoplast/cytosurge
Peridex can help with —–. Generally, there is no specific rule on how much tissue will move in. After —- days do not touch the implant. If you get uncover 2 days in, go in and free up or close before day —. PTFE are the next gen of —- sutures. These can stay intraorally for a very long time. —- sutures are very smooth and easy to work with, but whenever you use a ——- suture, you need to leave longer threads. If you do not, you have less thread to resist tissue inflammation and untying.
gingival closure
3 days
3
gortex
Cytoplast/cytosurge
Allograft – —- months of healing.
4-5
PTFE membranes – dimple faces the ——.
soft tissue
Cortical bone is nice as it —– – do 50% 50% cortical cancellous.
maintains volume
Bond bone – —— – fast setting, goes away in —- months. Other products with HA last—–
osteoconductive
4-5
7-8.
Consider length that graft material stays around, if you are grafting a socket, you want that bone to disappear by—-months/be replaced by new bone. Other way around for other procedures. For graft and membrane, consider charging in the ballpark of 700? BIC = bone implant contact. Usually lift tissue—–or so into vestibule (for case on #2 soft tissue coverage).
4-5
5mm
Temp bond is nice because it is —- and easy to clean and —–.
water soluble
radiopaque
Temporary abutment in —- holds bone and forms gingiva. Deep class II is a contraindication for ——.
immediates
Best spot for FGG harvest is from——–to avoid anatomical sites. Make this —– palatally to gingival margin.
1st premolar back to molar
3-4mm
Sling: .
Come in on mesial, over palatal tissue, thorugh palatal tissue, back through distal, tie off in facial
Anterior pedicle graft – counting on
anterior vasculature off of incisive foramen to help.
Suture for pedicle:
Go up in vestibule, go through tissue on distal, back in on mesial of tissue, tunnel back between bone and socket out to buccal vestibule to again create a sling.
Mean loss on buccal aspect is —- of loss, lingual aspect is —– (average from central back to molars). This is the same for both maxilla and mandible.
- 5mm
1. 7mm
Lingual walls are frequently wider than the —-, modeling occurs at the same rate on buccal and lingual, and thus this inherent starting thickness accounts for the difference.
buccal wall
Buccal bone wall: reduction after 4 months is —-
Lingual bone wall: reduction after 4 months is —–
- 9mm
0. 8mm.
Buccal contour reduction of —- after ext. This leads to —– of vertical loss, and the major reduction will occur before — months. After 2-3 years, reduction of contour is —–
50%
2-4.5mm
4
40-60%.
Buccal resorption was —- lingual was —- after —– months.
56%,
30%
4 months
We can reduce resorption to —- with grafting.
15-20%
After immediate implant placement and flap elevation a mean buccal bone resorption of —- must be anticipated.
56%
Soft tissue preservation: —weeks after ext. We can either do a soft tissue graft, or combine soft tissue grafting with a bone substitute.
6-8
Connective tissue grafts over fresh extraction sites are mainly dependent on ——, but the bone underneath is —–. We need to be sure that the suturing of such a graft allows for ——.
underlying tissue vascularization
not important
vascularization
What if a graft becomes necrotic? Not having sufficient —- can ruin a punch graft – it needs 360 degrees of intact tissue contact to work.
Grafts should be covered —-, —— exposed. If you do not do this, it can lead to necrosis.
papilla
70%, 30%
Soft tissue management:
Before ext: —–
With extraction: ——-
After extraction (if infection present): —–
Ortho extrusion
punch technique, connective tissue graft
connective tissue graft
Ortho extrusion: By slowly extracting teeth ——, then retaining teeth for —– months (composite or wire splint).
(6-8 weeks)
4-6 months
Flap elevation causes a change of volume of —–mm. Graft material with punch technique improved results regardless of flap or not.
0.4-0.6
Graft material only has a benefit when the —— disappears.
multinuclear cells (inflammatory reaction)
Graft materials – namely a collagen plug – can reduce bone loss by —-
50%.
In order: bone graft w/punch, then bone graft w/collagen matrix, then TCP without soft tissue closure, then spontaneous healing in terms of favorability.
Flapless socket techniques only for defects missing less than —% of buccal plate.
50
Implant-tooth relationship results in a vertical soft tissue height loss of —- (—- for implant-implant). With an adjacent tooth, it is reasonable to have —- distance (this is to be expected, and will work aesthetically).
.5-1.5
1.5
4-4.5mm
How to predict ahead of time if there will be recession: Interproximal recession predictors:
missing contact point (you need an adjacent restoration). Second highest is surgery on edentulous area in order to place implant (including ridge recontouring), if the bone crest to the contact point distance is too high, if the pre-operative adjacent tooth bone level is already periodontally involved, interproximal recession can be affected. That said, implant-to-tooth distance has little affect.
Regarding vertical placement of an implant (subcrestal vs supracrestal) and bone loss: if you place the implant into the middle of the socket, you need to be placed —- subcrestal to end up at a flush implant. If you place —- from buccal plate, you need to be —- subcrestal to eventually reach a flush implant after modeling. If you place —- from the buccal plate, you can place it at the —- and be fine. This is due to the stability of the lingual plate.
2mm
2mm
1mm
4mm
crest
Vestibular incision subperiossteal tunnel access (VISTA).
This is an access to the area that allows approach to facial without making an incision through papilla – like a semilunar flap for approaching the periapical pathology and graft placement.
If replacing two centrals, you need to consider the —– and the subsequent additional recession of—- on average.
increased distance between two implants
1mm
You can only predict —- papilla height for adjacent implants, thus you need to accommodate with a longer contact.
3.5mm
Rate of ortho extrusion: — or less per month, then —-month holding period.
1mm
4-6
Short implants need to be —– consider splinting (not thoroughly documented yet), consider reducing occlusal table, especially if crown height is elongated.
1 crown per root/implant,
Be careful with placing mandibular overdenture implants too far —– – this can lead to —–
posterior
too much rocking. Consider in canine-lateral incisor region.
Absolute implant contraindications:
Recent MI or cerebrovascular accident.
Recent valve prosthetic placement or transplant
INR greater than 3-3.5, platelets under 50000/mm^3
Significant immunosuppression (white count under 1500 cells/mm^3, absolute neutrophil count under 1000 cells/mm^3)
Active cancer therapy
IV bisphosphonates
Psychiatric disorders
Absolute implant contraindications:
Recent MI or cerebrovascular accident.
Recent valve prosthetic placement or transplant
INR greater than 3-3.5, platelets under 50000/mm^3
Significant immunosuppression (white count under 1500 cells/mm^3, absolute neutrophil count under 1000 cells/mm^3)
Active cancer therapy
IV bisphosphonates
Psychiatric disorders
Bisphosphonate destruction:
Frozen type:
: abundant bone necrosis, empty haversian systems without cellular beta component
Bisphosphonate destruction:
Osteolytic type:
extensive osteolysis with/without sequestrum formation
Bisphosphonate destruction:
En block type:
en block sequestration with an implant (considerable BIC may be maintained).
Consider the possibility for late onset micro/macro vascular complications with —- pts
DM pts.
Bleeding disorders: —-.
refer. If you do this, use antifibrinolytic agents before and after for up to 7 days. Bone grafts, lifts are contraindicated. Use sutures with local measures added. Antibiotics are fine
Bleeding disorders: —-.
refer. If you do this, use antifibrinolytic agents before and after for up to 7 days. Bone grafts, lifts are contraindicated. Use sutures with local measures added. Antibiotics are fine
Ectodermal dysplasia:
Increased failure rate, especially in maxilla present.
Ectodermal bullosa:
main complication is bleeding ulcers and blisters, possible problems from microstomia. Just drill with less irrigation, place aspirator in contact with bone, not tissue.
Immunocompromised pts:
Cyclosporin impairs implant bone healing. Transplants are fine. Overall, this is case based, and there isn’t enough research.
Sjogren:
Can link a saliva electrostimulation device on a dental implant, still in research. No problems with implant, just be aware of the severity and manage it.
Osteoporotic pts with mental foramen wider than —- will have normal bone mineral density. Just evaluate bone density of these patients before proceeding.
MCW, PMI and KI are good tools to check for reduced bone mineral density.
4mm
If you are unable to place an aesthetic implant properly the first time and need to remove and heal, use a —- over the sx site in order to heal smoothly.
FGG
When grafting, consider using a —-, as it forces you to be sure that you used the right flap design. A small —- will only truly work with a passive tension, otherwise it will break.
thinner suture material
suture
Two piece ceramics problems: The abutment is usually —-, and this margin is extremely close to bone. Titanium inserts or screws have also been used, but there is absolutely no evidence on their use.
bonded or cemented
All ceramic crowns do not survive on —–. You would need a —- coping to have it survive. That said, chipping and roughening had a high rate of occurrence.
zirconia implants
zirconia
For zirconia implant insertion, —- is max torque, —- max speed (it doesn’t conduct heat, so you have to go far slower on insertion. Recommendation for osseointegration is — months for zirconia.
35 nm
15 rpm
3-6
When using benzos, go for something with faster —-.
metabilization
Optimal pore size that would occlude cells but allow passage of nutrients is —-micron.
0.45
Trim all membranes to have a — margin with regards to neighboring tooth roots.
1mm
Bone grows about — per month (remodeling rate on average). This is good to bring up when you talk about augmentation. This is good to tell people if they are iffy on time periods.
1mm
HA and tcp (tricalcium phosphate)– —–
TCP is replaced by bone, but HA stays. This is a consideration for bone substitute materials.
Consider speed of degradation – you need to have space for bone material to move. Opposite problem if too fast, where you won’t be able to have bone move in. TCP (bi-phasic) is more or less plaster of Paris). This is usually gone in — weeks and replaced with net of blood vessels.
2
Ion release from various graft materials plays a roll on osteoblasts – — in particular from bovine bone is beneficial.
silica
—% of ridge mineral density can be resorbed before any radiographic changes.
70%
Consider that resorbed ridges will have a lower chance of having —–.
attached gingiva
Problem with vertical bone graft is the amount of —- for nutrient maintenance. The longer the distance, the harder the graft.
vascular ingrowth
Sharp edges of bone graft can induce —-
pressure necrosis.
Interpositional graft: cut —–, raise it and screw it in place (with a gap in the middle), fill with bone substitute. Leave it for —- months. Benefit of this technique is that the —- stays on top of the ridge.
alveolar ridge
4 months
gingiva
Interpositional graft: cut —–, raise it and screw it in place (with a gap in the middle), fill with bone substitute. Leave it for —- months. Benefit of this technique is that the —- stays on top of the ridge.
alveolar ridge
4 months
gingiva
¼: Facial wall of the ridge is resorbed not more than half of the prospective implant height. Dehiscence defect, treat at same time of placement in a lot of cases. —–
GBR w/particulate graft, or if aesthetic, block graft.
½: Facial wall is resorbed more than half of the prospective implant height. Usually ——-
staged implant approach. GBR w/block graft. Alternatively, this is when you can do ridge splitting with simultaneous implants.
¾: ½ plus the lingual wall is resorbed. This is —-
staged placement, start with GBR and shell block, alternative is swinging interpositional graft.
4/4: ½ plus over half lingual wall resorption.
Staged implant placement, interpositional graft, or consider iliac onlay block graft, or in esthetic areas distraction osteogenesis can be done.
Problem with interpositional graft, need room between —-, otherwise it won’t work in mandible.
—– can be used to hold bone prior to final implant placement.
IAN canal and bone
Provisional implants (minis)
More —- you go in sinus, higher the rate of membrane perf.
mesial
—- sx can alter anatomy (used to treat sinusitis by performing buccal performation to remove all sinus membrane, then creating a new ostium to drain sinus toward nasal fossa). Much higher risk at this area.
Caldwell lucq
If patient was treated with polypectomy to solve for polyposis in nose. Often ENT will remove —- of sinus, and not having this can lead to issues with graft stabilization.
medial wall
Pathology: Inverted papilloma is a contraindication to DSE – this is a benign tumor that must be resected. Problem is that there is a risk of cancer degeneration in —- following sx. This is a hard contraindication.
4 years
Importance for custom healing abutments in posterior: you can make sure that your tissue emergence profile is wide – beauty of this is that you can —- and eliminate food traps that inevitably result from a poor emergence profile. Further, if you have the lab create a custom healing abutment, you don’t need to give them a final impression. Can send an implant impression with a scan body (it is effectively the impression coping but scanable). Labs will often send a temp for an immediate with proper occlusion – you will need to take it out of lateral and protrusive contacts.
drop contacts
If young, consider placing CEJ at —– (from bone to CEJ) instead of —–, in anticipation of bone loss.
4mm
3mm
—– can be linked with periodontitis.
Hyperlipedemia
Never have separate crowns with —– – when in doubt, have bridged FPDs.
porcelain
Engram –
habit that the body does that the patient is unaware of (imagine biting consistently away from CO). If the patient exhibits an engram, you MUST ID it. If your restoration is in the way of the engram, it could fail.
Alloderm
acellular dermal matrix (allograft – donor skin stripped of cells). No need to tissue match, it just serves as a scaffold.
Alloderm – 2 things to be aware of with these – try not to
leave it exposed, it degrades much quicker and looks terrible and smells terrible. It is unpleasant if exposed. Also, because it is dermal tissue, not connective tissue, it mimics tissue it is placed underneath. If you have a problem with keratinized tissue, you will have thick mucogingival tissue, not keratinized. To learn more about alloderm – look up Dr. Pat Allen – Dr. Wong and Folleck recommend this course.
See rotated mand canines – this may lead to ———–
a very thin incisal edge for the implant, or a rounded wear facet in what should be square teeth.
You can have too much keratinized tissue – this may necessitate a —– at the edentulous site. Also, don’t neglect looking at adjacent tissue around teeth – in this case the tissue around adjacent teeth was deficient but the edentulous site was adequate.
gingivectomy
Sx – pt who has a few drinks over the weekend – it’ll
impact bleeding on Monday. Make sure that they don’t drink (only tell this to non-alcoholics) leading up to sx.
if you do sedation, drinking and marijuana can impact —–.
benzos
Tenting screws: Dr. Foleck prefers not to do it, Dr. Wong would be ok with it. The decision between tenting screw and block graft would be down to the amount of bone that is needed. If you need —- of bone, this is a particulate, tent screw procedure. If it is —-, do a block graft – it is more predictable. Ultimately, a block is going to be more stable. Membrane choice is key as well. You will have a thin band of keratinized tissue, so consider need for tissue graft and consider PTFE membrane.
2-3mm
5+mm
Sandwich technique with piezo –
put a plate of bone in the trough, let heal, and go from there. You can make the incision with a circular saw, piezo, drill. You can make the incisions crestally and vertically, close them up and let them heal for 6 weeks, and you can then expand. This way, the periosteum is still holding it in place, so that if it breaks you are not SOL. NOTE: This is much easier to do on the maxilla, mandible is really hard. It can be done, but do the maxilla first. `
If you have no loss of VDO in AI patients, they will likely have —– to compensate for lost tooth structure.
supraeruption
Dentinogenesis imperfect can have —— – AI doesn’t tend to have problems with ——. Diseases affecting dentin can reflect —— defects.
bone density issues
bone density
bone mineralization
With big cases, 2 years on —- month recall, discussion will be had about whether or not you should taper off.
3 month
In teeth, lateral force is bourne by the —- of the tooth, whereas for implants it is in the —-.
apical third
crestal bone
If you have all anterior implant supported restorations (or full FP1-2), consider going into —–. Always have 2 teeth in contact during ——- to disperse force. Do not have balancing contacts in such cases. Still avoid —– contacts.
group function
canine guidance (canine, premolar or lateral)
protrusive
Abutments that are not fully seated can shift —- over time during function.
clockwise
Teeth can move — micron during occlusion.
50
Moderate peri-implantitis
(PPD over 4mm, less than 2mm bone loss): debride, disinfect, they recommend systemic antibiotics.
Advanced peri-implantitis
(over 4mm pockets, over 2mm bone loss): surgical access, debridement, disinfection, systemic antibiotics.
—— may be adequate to clean rough implant surfaces. Air powder citric acid, gauze soaked with either citric acid or chlorhexidine may help as well. Ultimately, research is still ongoing here, no difference in the aforementioned techniques noted. No confirmation for improvement with laser decontamination.
Cotton pellets with saline
When grafting a defect, trim the membrane —– beyond defect. Also, when they are wet, it is difficult to trim them. Do this ahead of time before getting the membrane wet.
Order of membrane use:
2mm
Clean, place membrane, then pack in filler material, get tension free closure, suture.
Often, there is a — area between bone level and the base of the pocket with implants.
1mm
Ceramic crowns on titanium abutments had high fracture rates. Ceramic on ceramic was more or less equal to —- on metal abutments.
PFM
Cemented reconstructions have a slightly higher —- rate. This is amplified based on the span that is covered.
chipping
Critical soft tissue thickness for aesthetics found in study to be roughly
2mm.
Can also use —- tape along base of margin.
PTFE
Cementing technique: duplicate abutment: you duplicate the abutment, place the crown with cement on the duplicate, remove, clean excess, and cement. Problem is that you may not have enough cement now.
Cementing techniques: Venting:
Have a hole in a more occlusal position – this helps alleviate cement around the margins.
Cementing techniques: Venting:
Have a hole in a more occlusal position – this helps alleviate cement around the margins.
Biggest danger is overloading the implant – consider using a softer crown so that it is the weak link. —— on titanium (not yet tested on ceramic implants) can have this effect.
Lithium disilicate crowns
Implant Uncoverage in Esthetic Areas:
No defects: —–
Moderate defects: —–
Large defects: ——
Punch technique
modified roll flap
punch technique with CT graft.
When performing CT graft, completely —– to make sure that the keratinized tissue will be attached.
clean the bone
If you overcontour the temp crown, you can see more —-. You can purposefully do this as well, but it is risky.
recession
There is a tendency for metal based abutments to see more —- than ceramic abutments.
recession
Ortho extrusion can improve bone by —%, tissue by —% (based on distance/how much you extrude it).
70
60
Usually leave the implant supported transitional restoration for — months prior to the final impression.
3
If you torque out, consider backing out a bit and starting again. This allows for the —-
cutting threads to be cleaned and you may get to depth.
How much pressure can be applied by implant crown? — minutes of blanching really doesn’t harm soft tissues. Any more can cause problems.
5-10
If keratinized tissue is not abundant, consider —- when edentulating an arch.
saving papilla
Areas to be weary about with excessive bleeding: —– (lingual arteries insert here). There have been cases where these arteries have been transected during implant procedures. The problem is that the artery can pull back under the tongue, cause a bleed, expand the tongue, block the airway. Overall, just avoid this area. If you have to place an implant in this area, you must do a sx guide. In maxilla, incisive foramen is usually self contained and fine with flap coverage and compression. On occasion, the GP foramen and GP artery can lead to problems with bleeding. If you transect this artery around the 2nd 3rd molar area. If this occurs, —–
Mandibular midline
close flap, apply pressure for 5 minutes. If this doesn’t do it, lift flap up and do a Q: STICK TIE WITH A SUTURE
If implant penetrates the nasal floor (Usually occurs with max central implants). At radiograph, you can see this, palpate —. Back out/down implant, place bone graft or shorter implant. Consider — for 8 days in these events.
nares
amoxicillin
Accidental sinus perf:
Back implant out, concerns for antral-oral fistula. TO prevent this, clean area, use collagen membrane at the floor, place bone graft material, get primary soft tissue closure. It is usually appropriate for antibiotics to be used.
When making a radiographic splint, consider using a — tooth in a splint during CBCT, with a hole for the implant through the ideal place. You will see if it is feasible based on bone.
barium
Self cutting threads can lead to —- due to the increase in pressure upon placement. That said, this was in an animal model. Humans heal half as fast.
bone resorption
Be weary of coatings –
prior HA coatings would erode, which would lead to fibrous growth and loss of osseointegration.
Chronic peri-implantitis: can regraft if pathogen is limited to being —– – if it is found on ——-, no graft.
present on implant
both bone and implant, or just bone
Blood thinners and excessive bleeding can lead to —–. Treatment can be —– w/sx.
clotting outside of the graft and later infection
levoflaxin or moxiflaxin
If you remove an implant due to infection in the maxillary sinus, you will likely not be able to
regraft and replace the implant.
Another local factor is polyposis: ——— In this situation, ENT will decide on best therapy (—– usually), then functional endoscopic sx in which all inflammatory tissue will be removed in order to establish a clean sinus. Sometimes the situation is still present, but you can move forward with the green light from the ENT.
inflammatory disease of sinus and inflammation closes ostium
steroids
If you destroy the — layer of the membrane, you have —– the sinus membrane. This has to be treated like a —–.
periosteal
delaminated
perforation
When in doubt, just close the membrane and come back — months later.
4
Tattone technique:
membrane goes in and partially covers medial wall of sinus. Doing this closes the sinus in this area. Then you pin the membrane internally and externally.
Small perfs (<7-8mm):
First if you have a perf, —– to be able to see the full defect. Then ——. By ——-, you lower tension. Due to elasticity of the membrane, you inherently will ——. Only way to seal the sinus membrane is to seal with a collagen membrane. Membranes have 2 parts: —–. External portion allows for —– and making sure that the membrane doesn’t collapse.
enlarge the window
detach membrane in the opposite direction of the defect
detaching membrane in the opposite direction
reduce the size of the perf
external stabilizing membrane and internal acting membrane
holding the bone in the right place
Small perfs (<7-8mm):
First if you have a perf, —– to be able to see the full defect. Then ——. By ——-, you lower tension. Due to elasticity of the membrane, you inherently will ——. Only way to seal the sinus membrane is to seal with a collagen membrane. Membranes have 2 parts: —–. External portion allows for —– and making sure that the membrane doesn’t collapse.
enlarge the window
detach membrane in the opposite direction of the defect
detaching membrane in the opposite direction
reduce the size of the perf
external stabilizing membrane and internal acting membrane
holding the bone in the right place
Only way to detect perf is —-
to see them
– vasalva test is not proof that there is no perf.
How to treat artery damage:
Compression with tranexamic acid: can halt bleeding, but problem with post-op bleeding.
Electro-coagulation
Bone wax: problem with infection.
Pinch artery with clamp, after a few minutes the bleeding will stop. Then you can complete membrane dissection.
Maxillary artery is only detected in around –% of cases. Average height from bone crest is —-. Bleeding due to max artery issues occurs in — of cases.
50%
17mm
20%
If bone is more than—– and you still need to do a lift, you can place the implant simultaneously with the sinus lift.
5mm
Drain releasing incision, then suture. After 2 weeks, no
flying, SCUBA, playing instruments, free sneezing, no nose blowing.
Split thickness at —- in —- area for sinus lift in order to avoid —- nerve damage. Use tacks to hold in overlying collagen membrane after placing graft, or insert it into the sinus.
vestibule depth
canine
infraorbital
Dolichocephalic –
edentulism is longer than brachycephalic, buccal plate is thinner than brachycephalic and zygoma is flat while brachycephalic pts have bulkier zygomas. Thus, brachycephalic pts are harder to work on.
Vitamin D deficiency patients are good candidates for —–, but you need to be weary of this for grafting purposes.
prosthetic dentures
Concha bullosa (bulbous middle turbinate),
undeveloped sinus, deviation of nasal septum can all displace the ostium.
If ext tooth without patent —, you can have drainage through ext site due to inability to drain elsewhere.
ostium
Only diagnosis factor for TMJ is ——. ——– is not diagnostic and extremely variable (joint loading test***** can also be done). This is based on pt’s size – 3 of their fingers should be around maximum opening. To make this less awkward, measure with a tool and compare it against their 3 fingers. If patient can open this way, this will not hinder tx. Measure this at every hygiene appointment. Limited opening is the only sign of disorder.
maximum opening
Crepitis, clicking, popping, etc
You want a good impression of the —- in order to have the potential to harvest connective tissue if need be.
tuberosity
—% width, – inch height loss after 1 year
25
¼
- Natural teeth can perceive a difference of — microns
- Complete dentures can only perceive a difference of —- microns
- Implant teeth can determine a —- micron change
20
100
50
— are best for single or short spans, —- are better for long spans.
FP2
FP3
If you are under —-, you cannot use a bar. If you do not have —- (literature is —- for bar overdenture).
10mm
15mm
12mm
Don’t angle locater abutments over — degrees.
15
Technically RP4 - coeness abutment (done through dent supply). Abutment that screws into the implant and adjusts for around — degrees. Very retentive, if labs don’t activate it properly, they slide in and out. Great for minimal implants.
40
**Overdenture attachment issues occur in —% of patients.
30
Smokers have —% higher risk of failure
11
Compression to — forces leading —–.
shear
to rotation
—- is the worst force to put on bone. Tensile is —% weakness in bone, compression is —–%. Shear also destroys ——.
Shear
30
10-15
porcelein
Mobility over —-micron leads to fibrous encapsulation
100
Mobility over —-micron leads to fibrous encapsulation
100
Parafunctioning patients - you should —- the implant
bury during healing
Also consider placing the implant —– in the event of a complete denture, as this will allow for ——
slightly subcrestal
the bone to protect the implant as it heals. You cannot control the pressure that a denture places on a healing implant.
Natural teeth biting force:
Incisor region: —- psi
• Canine region: —- psi
Molar region: —– psi
35-50
47-100
127-250
Bone is strongest in —-, 30% weaker in —–, and 65% weaker in —
compression
tension
shear
Tension
Two opposing pulling forces
Shear
Two forces perpendicular to axis (causes rotation)
Wolff’s Law
Every change in form and function of bone or of its function alone is followed by certain definite changes in the internal architecture, and equally definite alteration in its external conformation
Indirect sinus lift can gain
3mm beyond floor of sinus (5mm from where you start).
3 implants instead of 2 can decrease moment torque by — and bone reaction forces by —- depending on position and size
1⁄2
2/3,
Every — increase in width gives 10-15% increase in surface area
– As greatest stresses are at the crest, —- is more significant than —–
0.5mm
width
length
Need —-mm of space for cemented crown.
Tissue is usually—-mm, then you want —-mm space for the crown.
7mm
2-3
4-5
Bar OD: Tissue to bone
3mm
Bar OD: Tissue to bar
1mm
Bar OD: Bar + Hadar clip
3mm
Bar OD: Bar + O ring
5mm
Bar OD: Teeth
8mm
Bar OD: Teeth
8mm
If you make an FP3, 7mm is not enough (that is for FP1/2 PFM). You instead need at least —-.
12mm
Grade V Titanium
Ti-6Al-4V
Often deliberately —– to allow for keratinized tissue to fill in.
loosely suture
Look at silverman Anatomy Slide 6
Draw it out
Look at silverman Anatomy Slide 7
Draw it out
Look at silverman Anatomy Slide 8
Draw it out
Look at silverman Anatomy Slide 10
Draw it out
Look at silverman Anatomy Slide 12
Draw it out
Look at silverman Anatomy Slide 16
Draw it out
Look at silverman Anatomy Slide 11
Draw it out
Look at silverman Anatomy Slide 13
Draw it out
SSRI effect on implants
It affects bone healing - improves seratonin, which doesn’t help bone healing. As this affects bone remodeling, you will see late failures.
Let these pts heal for. 6 months covered, then progressively load, then consider splinting.
Effect of Statins
Increase BMP2 release, increase bone density, decrease osteoclast differentiation.
Antacids effect:
ALuminum antacids (maalox, mylanta) - these bind phosphates in gut and inhibit absorption, which interferes with bone metabolism.
PPI effect:
Elevates gastric pH by blocking PP. Interferes with calcium absorption, prolonged use decreases bone density. **H2 blockers don’t have this effect.
If taking bisphosphonates for under 4 years, risk is
1%
If taking bisphosphonates less than 4 years but with —– may consider stopping for 2 months and 3 after
glucocorticosteriod
• If taking bisphosphonates for over 4 years may consider stopping for —-
2 months and 3 after
Just don’t do this.
CTX – Serum C-telopeptide good to monitor pts with —-. The test measures ——-
osteoporosis
the amount of bone turnover products circulating in the bloodstream by detecting the C- terminal telopeptide of type I collagen
CTX
— pg/ml and above minimal risk
—- pg/ml – —- pg/ml moderate risk
Less than —- pg/ml high risk
150
100, 150
100
Maxilla flap design - be weary of the following structures
Infraorbital foramen, incisal canal, sinus, piriform rim, PSA.
Incise over —– not ——
bone, pathology
Incision should be —–mm away from bony defect
6-8mm
Make sure that retracters are on —- not —-
bone not tissue -it can lead to tearing and swelling of the flap
Osteoconduction:
the process in which synthetic and inorganic material provides a bioinert scaffolding that conducts and is compatible with bone growth.
In general alloplastic graft materials are osteoconductive.
Osteoinductive:
Induces differentiation of stem cells into osteogenic cells. These compounds induce bone formation. Releases BMP.
Osteogenesis:
occurs when living osteoblasts are part of the bone graft as in autogenous bone transplantation. Patients own bone.
Bone graft options:
Non-vascularized Vascularized Cancellous CorIcal CorIcocancellous, has properIes of both types
Min vs Demin are options to the previous:
“ Mineralized freeze-dried bone allograft (FDBA)
“ Demineralized freeze-dried bone allograft (DFDBA)
Store autograft very briefly in
Sterile saline
lactated ringers soluIon
New bone can form as early as 4 weeks
and relies heavily on —–.
angiogenesis
Bone growth with autogenous grafts- phases Phase I ----- Phase II ------ Phase III ------ Phase IV ------
! Osteogenesis
! Bone regeneraIon by
surviving cells (osteoid)
! 4 weeks
! OsteoinducIon
! BMP release
! 2wksto6months,peakat6 wks
! OsteoconducIon
! Inorganic matrix replaced by creeping subsItuIon
! CorIcal plate acts as a barrier membrane
FDBA - Mineralized
! Used in sinus bone and socket graLing procedures.
Processing of Freeze dried bone
! CorIcal & trabecular bone is harvested in a sterile fashion from a disease free donor
! Washed in disIlled water & ground to a parIcle size of 500 micron to 5 mm
! Immersed in 100 % ethanol to remove fat
! Frozen in nitrogen
! Freeze dried & ground to smaller parIcle size of 250 to 1500 micron
Bone sterilization: IrradiaIon
Doses greater than —- are destrucIve to BMPs
Ethylene oxide sterilizaIon
5 hr sterilizaIon at 29 degree celsius to maintain —- properIes
2.5 Mrad
osteoinducIve
Demineralized freeze-dried bone allogra@(DFDBA)
! Created by
removing the ca and po4 salts to take beVer advantage of BMP for its osteosImulatory properIes.
! Freeze drying destroys all cells and the graL is rendered non viable.
“ It has the advantages of: -
Decreasing anIgenicity - FacilitaIng long term storage
Collagen
! Most common source is —–
! It can bond and acIvate —- to form a —– within the extracIon site.
! It may also act as a scaffold for —–
bovine collagen from the Achilles tendons in the leg.
platelets, platelet plug
migraIng cells of the epithelium
Alloplast gra@s CALCIUM SULPHATE -----: POP (Calcium sulphate) is biocompaIble and porous, thereby allowing ------- !
Plaster of Paris
fluid exchange, which prevents flap necrosis.
POP resorbs completely in – days
This material can be carved into the desired shape
30
DFDB is when we take out —- – what is leL is —
Ca and Ph
collagen
Best parIcle size is —– microns larger too long or not resorb all the way
200 – 1000
CorIcal bone graLs revascularize slowly gives graLs —
support
Cancellous bone provides more
open spaces for faster revascularizaIon, but it lacks mechanical strength, parIcularly when used for non weight bearing areas
Need (grafting):
1. Absence of infecIon
! Rapid soluIon mediated resorpIon in condiIons of low PH
Causes of gra@ material infec=on
! Endogenous bacteria
! Lack of asepIc surgical technique
! Failure of primary soft Issue closure
! Lack of blood supply in early stages of grafting
! Full thickness facial flap is elevated off the facial bone for —- above the height of vesIbule
5 mm
! Horizontal scoring of the periosteum parallel to primary incision each can lead to —- gain
! One incision 1 to 2 mm deep is made through the periosteum parallel to the crestal incision and 3 to 5 mm above the vesIbular height of periosteum
1 mm
Submucosal space technique
! Blunt dissecIon is done using soft Issue scissors or mesquito hemostat to create a tunnel apical to the vesIbule & above the unreflected periosteum
! Facial flap should be able to pass the lingual flap margin by more than 5 mm
Submucosal space technique
Disadvantages
- Loss of vesIbular depth
* Lack of keraInized Issue on facial region of graLed site • Swelling
The classificaIon of bone defects after extracIons: (Lindhe)
Type I –
Here minimal soft Issue and bone loss
The classificaIon of bone defects after extracIons: (Lindhe)
Type II –
Good soL Issue coverage and bone loss
The classificaIon of bone defects after extracIons: (Lindhe)
Type III –
Bone loss and soL Issue loss
The classificaIon of bone defects after extracIons: (Lindhe)
Type IV –
More extensive horizontal bone loss
The classificaIon of bone defects after extracIons: (Lindhe)
Type V –
More extensive verIcal and horizontal bone loss
! Type I, II, and III –
Extraction sockets defects typically at time of extractions
! Type IV and V –
Extraction sockets defects typically after healing of extraction sites
Managing class IV horizontal defects:
Tent screws in place, place bone grafting materials. Also consider tacking membrane.
Can also block graft with autogenous or allogeneic (bone screws work better with block grafts than tacks).
Managing class V defects
RAP, tack in graft, consider sausage technique, pray. Get either soft tissue closure or PTFE membrane.
RAP
Response to noxious stimuli by which tissue forms faster than the normal regional regeneration rate.
Healing is 2-10 times faster. This begins within a few days of sx, peaks at 1-2 months, continues for 6-24 months.
Dr. Silverman’s Graft Recommendations:
Five Wall defects
Allogeneic
Dr. Silverman’s Graft Recommendations:
Four Wall defects
Allogeneic
Dr. Silverman’s Graft Recommendations:
Three wall defects
Allogeneic bone block around margins or allogeneic putty
Dr. Silverman’s Graft Recommendations:
Two wall defects
Particulate autogenous bone graft with a barrier membrane secured with pins or screws.
Dr. Silverman’s Graft Recommendations:
One wall defect
referred to as knife edge defects and require a two stage treatment with bone graLing techniques
GBR is for
localized bone defect regeneration. This refers to promotion of bone formation.
GBR is great for
dehiscence defects.
! Residual intraosseous defects- incomplete healing of the alveolus leading to exposure of threads
! FenestraIon defects- anterior maxilla
! ExtracIon socket defects
Principle of GBR is we want to place a graft, keep its space so we can get bone formation and use barrier membranes over the defect to promote and allow the ingrowth of —– cells and prevenIng migration of undesired cells from the overlying soft Issues into the wound.
osteogenic
What provides space management for GBR:
Barrier membrane
Graft Material beneath the membrane
tent screws
Ti reinforced membranes
Expanded PTFE is characterized as a —–
polymer with high stability in biologic systems…
Expanded PTFE ! They are available in various sizes and shapes to custom fit around teeth and osseous defects.2
! Adv. -
Ability to maintain separaIon of Issues, when remove can help increase formaIon of aVached gingiva
! Disadvantage - Needs to be removed in one month and area must have good hygiene
Expanded PTFE
! Disadvantage -
Needs to be removed in one month and area must have good hygiene
BMPs are
differentiation factors that are part of the transforming growth factor super family.
Two of these proteins, ——( or osteogenic protein-1), have been cloned, studied extensively, and show promise for intraoral applicaIons
Human studies demonstrated product safety with —– in ridge preservaIon and sinus augmentaIon applicaIons
BMP-2 and -7
BMP-2
Pt inhales something
PA and lateral chest radiograph
Flat plate of the abdomen
*If in lungs, bronchoscopy.
Spade elevator is great for
Mand 3rds
Pinch —- to extract upper teeth - you want to make sure that you are moving the tooth, not the maxilla. If the maxilla moves, you are using too much force.
alveolus
If excessive bleeding:
Use back of spoon to burnish bone, avitene, gelfoam, bone wax on end of gelfoam, place implant and go with it.
Elian
• Type I –
Labial bone plate and associated soft tissues are completely intact
Elian
• Type II –
Soft tissue is present, but a dehiscence osseous defect exists that is indicative of the parallel or complete absence of the labial bone plate
Elian:
• Type III –
The facial soft tissue and the buccal plate of bone are both markedly reduced after tooth extraction. Usually can present with gingival recession and bone loss prior to extraction.
When treating type III sockets: Usually these sockets are difficult to treat as typically Need
soft tissue augmentation with additional graft of connective tissue and bone, in a staged approach to rebuild the lost -ssue.
Socket preservation:
Periosteum should not be reflected if —— is ideal as it helps bone remodeling or repair
bone volume
—— drape around the tooth is also affected by reflection of periosteum
Soft tissue
Resorbable membranes for socket preservation
Use when can get ——-
Use when have adequate —— and no chance of losing any
complete primary closure or if reconstructing buccal dehiscence
attached gingiva
Class II socket protocol:
Choose to either raise a flap or don’t.
-if you raise a flap, adapt membrane around and beyond defect.
Fix membrane in place
Get primary closure
If you don’t raise a flap, membrane is cut in a cone shape and placed inside the socket.
Complications: Early
Any complicaTon that occurs before place implant
Complications: Late
Any complication that occurs after implant placed Not part of this course
Early complications present with the following:
- Hemorrhage
- infection
- Incision line Breakdown or Exposure of Cover Screw • Delayed localized infection with membrane
- Inadequate socket grafting how treat
To avoid post-op infection, place on —–
preop antibiotics and give rx for 5 day antibiotics
To avoid post-op infection, thoroughly —— site prior to placing graft material.
rinse
Treat infection with
Amox500mg TID x7days, I+D if needed, do your best to keep graft.
Treat incision line breakdown or flap dehiscence
Control infection with antibiotics, chlorhexidine if possible. Allow site to granulate. Some advocate to resuture, doc doesn’t personally recommend this.
incision line breakdown or flap dehiscence prevention:
Adequate tension free closure
Adequate flap design with loss of blood supply
Sterile technique so no contamination of graft material.
Graft failure from infection of membrane
Starting to get infected - rinse with peridex, need to have membrane there for about a month (4 weeks). Make sure that they brush the 4 corners of the site. If the patient reports that things aren’t feeling 100%, this is probably the situation.
Some people treat sockets to be grafted with cotton pellets soaked in —– or —- (50mg/ml) Followed by additional irrigation.
60% citric acid
tetracycline
With ridge split, starting out, you can maybe take a 4-5mm ridge and open it by —-.
a mm
Amnion chorion membrane - for
tissue deficiency to get primary closure.
For Sausage graft
half xeno, half autogenous
Valsartan: used in pts with —–. Recalled due to impurities (some mixed with other meds).
left ventricular failure
When you have keratinized tissue on each side, do not
close by primary closure. Instead, suture in a membrane, it will always close up with more keratinized tissue.
Elastic memory is
High for –,
“ Lower for —-,
“ minimum for —-
nylon
silk
Gore tex
Knot tensile strength is
the force which the
suture strand can withstand before it breaks when knotted.
The tensile strength of the —— determines the size and tensile strength of suture.
tissue to be mended
! The accepted rule is that the tensile strength of the suture should never exceed the tensile strength of the tissue.
Absorption time or half life, which is defined as the
time required for the tensile strength of a material to be reduced to half its original value.
Dissolution time is
the time that elapses before a thread is completely dissolved
The speed of absorption of a suture is roughly proportional to the
vascularity of the surrounding Kssues.
Suture Hydrolyzation results in a —– of tissue reaction following implantation
lesser degree
Plain surgical gut properties:
! Rapidly absorbed.
! Tensile strength is maintained for only 7 to 10 days and absorption is complete
within 70 days.
! Can also be specially heat-treated to accelerate tensile strength loss and absorption.
! Used primarily for epidermal suturing where sutures are required for only 5 to 7 days.
Chromic gut – is plain gut that has been tanned with a solution of chromium salts prior to being spun, ground and polished. Chromium salts act as a —– and increase the tensile strength of the material and its resistance to absorption by the body. Usually monofilament.
cross-linking agent
! Chromic gut sutures minimize —–, causing less reaction than plain surgical gut during the early stages of wound healing.
tissue irritation
Chromic gut: Tensile strength may be retained for —–, with some measurable strength remaining for up to 21 days.
10 to 14 days
Advantages of chromic gut over plain gut:
- Slightly increased strength
- Prolonged rate of absorption
- Lesser stimulation of tissue reaction
POLYGLACTIN 910
! They come under trade name “Vicryl”
! Synthetic absorbable sterile surgical suture composed of a copolymer made
from 90% glycolide and 10% L-lacBde. ! —— absorbable suture
Strongest
Silk properties
# Most popular suture material for intraoral use. It is poly filament # braided which gives it excellent handling characterisBcs # produces a moderate Bssue response # does not irritate adjacent mucous membrane # Inexpensive
Silk
• Advantages:
– Inexpensive
– Easy to handle and Be
Silk • Disadvantages:
– It must be removed – It is multifilament
Nylon # ----- forms # Because of its -----, the ------- and a tendency to tear through ----- tissue, nylon is not frequently used intraorally.
Braided or monofilament
stiffness, large knot required, non-keratinized
Nylon positives:
superior tensile strength # minimal capillary acKon within the wound # induces less inflammatory reacKon.
Prolene”
! It is syntheKc, monofilament and non-absorbable.
! Composed of an isotacBc crystalline stereoisomer of polypropylene. ! It exhibits good tensile strength, minimal and transient Kssue reacKon. ! It is used in all types of sol Kssue approximaKon.
! It shows excellent handling characterisKcs.
Advantage of prolene
! When swelling occurs , prolene will
stretch to accommodate the wound, thus there will be little cutting through the tissue.
! When swelling recedes , the suture will remain loose & keep the edges properly approximated
E-PTFE
It is the most recent material to be used as suture material.
! It is monofilament strand obtained by polymerizaKon of Tetrafluroethylene
& is expanded mechanically to increase its flexibility.
• It is easy to handle , sterilize, Ke knot & has good tensile strength.
• It can be used for closure of flaps where the same material used as barrier
membrane.
Ideal suture needle:
! High quality stainless steel.
! Smallest diameter possible.
! Stable in grasp of the needle holder.
! Sharp enough to penetrate Kssue with minimal resistance. ! Sterile and corrosion resistant .
Suture shapes
The common shapes: • ROUND
– Less traumaKc than the other two, requires more force
• REVERSE CUTTING:
– The sharp TIP is DOWNWARD.
– More safe when working in delicate Kssue. • Cumng
– Sharp TIP is UPWARD.
– Extra sharp Kp in is more likely to tear the Kssue.
• 4- Pass from the —- to the — tissue
thinner
thicker
• 5- The suture should never be closed under tension (no
—–)
blanch
Simple Continuous Suture
• Indications:
Bone graft, removal of mandibular tori, tuberosity reduction and where esthetics are not important
• Used to suture a wide area
Simple Continuous Suture
• It should not be used in areas of
existing tension
LOCKING CONTINUOUS SUTURE
• 2 Advantages over simple continuous technique :
# suture will —— to the incision
# locking feature prevents —– of the suture as wound closure progresses.
align itself perpendicularly
continuous tightening
Mattress indications
Indications: large distances between tissues, bone grafts and implants, and closure of extraction socket. When a very strong suture is necessary.
Mattress
Advantages:
• Good for hemostasis, less
prominent scarring.
Mattress
Disadvantages:
• Leave a gap between flaps and it is difficult to remove.
Vertical mattress indications
Indications: where the wound edges tend to evert
• Used also where greater control of the papilla is necessary
Vertical mattress advantages
Advantages:
• greater closure strength and better distribution of wound tension
Vertical mattress
Disadvantages:
• Scar formation and the formation of edge necrosis.
Figure 8
Advantages:
• Rapid closure
Figure 8
Disadvantages:
• Due to its orientation, it is difficult to remove and it leaves a significant amount of suture threads inside the socket.
Figure of 8 sutures
• Indication: extraction socket closure, adaptation of gingival papilla around the tooth, and bone graft placement in socket
Late implant healing- —- months (complete bone
•
healing
> 6
Early implant placement broken into two categories
4-8 weeks (soft tissue healing)
12-16 weeks (partial bone healing)
Indication for early placement with soft tissue healing:
thin or damaged facial bone wall, sufficient apical bone volume for primary stability.
Early placement with soft tissue healing (or partial bony healign) sx approach
Full open flap, contour augmentation with GBR
Early placement with partial bony healing indications:
Lg periapical lesion which contraindicates sooner placement.
3mm for soft tissue, 5mm for the abutment and 2mm
for occlusal restoration (porcelain or metal)
2mm of sulcular and hemidesmosomal tissue. Sulcular tissue has no attachment, but the hemidesmome attachment does occur to the abutment.
1mm of supracrestal connective tissue (circumferential
•
and parallel)
The abutment should be —- supracrestal
2mm
—mm of abutment height minimum for cemented crown
4mm
Why do we lose buccal plate on CBCT?
Averaging of different densities within one voxel Leads to loss of information
Interforaminal Arteries
- Airway obstruction
- Prevalence (unknown)
- Median canal (49%)
- Diameter: 0.18 – 1.8 mm
- Blood flow: 0.7 – 3.7 ml/min
ON CT, higher kVp leads to
higher contrast
3 things to check on DICOM file before saving it
Patient information
Acquisition date
Date of birth
Lesions —- to the mandibular canal are not of odontogenic origin
inferior
Blastic lesion =
radiopaque lesion
Lytic lesion =
radiolucent lesion
Slower growing benign tumors or cysts
- Resorb tooth
- Displace teeth in a bodily fashion
- Loosening of teeth is rare
Rapid growing malignant lesions
- Destroy supportive alveolar bone
* Teeth floating in air appearance
Inflammatory lesions
• Teeth floating in air appearance
Perio disease
Osteogenic benign
Osteoma
Osteoblastoma
Osteogenic malignant
Osteosarcoma
Chondrogenic benign
Chondroblastoma
Osteochondroma
Chondrogenic malignant
Chondrosarcoma
Chondrogenic malignant
Chondrosarcoma
Fibrogenic benign
Fibrous dysplasia
Fibrogenic malignant
Fibrosarcoma
Vascular hematopoietic benign
Hemangioma
Vascular hematopoietic malignant
Hemangioendothelioma
Plasmacytoma
Lymphoma
Narrow maxillary sinus
– Anterolateral – medial wall – Angle < 300
Branches of Maxillary artery in sinus
– Infraorbital artery
– Post. Sup. Alveolar Artery
(PSAA)
Intra‐osseous artery
PSAA artery
+ Infraorbital artery
Intra-osseous artery
- > —-mm ↑ hemorrhage
- ≥ —–mm profuse hemorrhage
- 2nd common complication – Profuse hemorrhage
• Dimensions of canal > —-
• 25‐30% of canals are
—–
.5
3mm
2mm
indistinct
Schneiderian Membrane
• Continuous with —- epithelium
• Thinner & less vascularized than —–
• Immunologic barrier less than —–
nasal respiratory
nasal epithelium
nasal membrane
Healthy sch membrane up to —-mm in width
3
Ostiomeatal Complex
• Connects
– Anterior ethmoid air cells – Frontal sinus
– Maxillary sinus
– Sphenoid sinus
– Nasal cavity
• Most frequent sinus conditions
– MRC
– Seasonal allergies
– Acute rhinosinusitis – Chronic rhinosinusitis – Odontogenic sinusitis
Acute rhinosinusitis Chronic rhinosinusitis
• Inflammatory condition – Common • Beaumont et al: 40%; Manji et al: 45.1% • CDC 2017 – Adult sinusitis: 26.9 million (11%) • Time based • Similar signs & symptoms
Acute rhinosinusitis • < --- weeks (arbitrary) • +/‐ initial improvement • Inflammatory • Etiology: -----
4
Viral / Bacterial (non‐odontogenic)
Chronic rhinosinusitis • > ---- weeks • Chronic infection / inflammation • +/‐ prolonged /refractory acute sinusitis • Relapse ----- • Etiology: -----
12 weeks
acute sinusitis
bacterial, fungal
Acute rhinosinusitis Chronic rhinosinusitis • Management:
– Referral to ——
• Surgical (sinus lift) management:
– Resolution of disease prior to surgery
primary care physician or otolaryngologist
Concha Bullosa
Pnuematization of the middle nasal turbinates
Concha Bullosa
Pnuematization of the middle nasal turbinates
Joint Space
Can only be measured when patient is in —-
- Position of condyle in —–
- Joint space dimensions
- Bone to bone contact
maximum intercuspal position
glenoid fossa
