A4 Flashcards
Type I, II, III canals – all based on
where the nerve tracks mesially (most common tracks along lingual cortical plate).
Cadaver study – anterior loop on CBCT was off by up to —–. Also be weary that —— nerve can loop from IAN.
1.8mm
median incisive
Lateral approach to sinus lift – one stage vs two stage. Two stage is—– of sinus, one stage is —–m (implant placement on lift).
1-2mm
4-5mm
—– on sinus lift to see where the vasculature is and where to place lateral window. 3D guides are also helpful. For crestal approach, you really don’t know whether or not you have a perforation.
Transillumination
If you look at marrow space in a grafted site, it increases over time (47% at 6 months to 70%+ at 20 years). Bone graft goes down from 36% to 5% over 20 years. Issue is that new bone plateaus at—– out. This indicates that most bone formation occurs very early. This is also why the move to 4 months placement waiting time is used rather than 6 months.
1 year
Osteocyte index (——) is higher for —- bone than —– bone.
number of osteocyte to square mm)
regenerated
native
Thus, this bone you get in grafts is more likely to be able to heal.
Do you have protocols for the amount of graft material that you add to sinus: use —-s biooss but use large granulometry (granules from —-mm). Reason: paper comparing large granulometry to small granulometry. It found that better bone formation was found with large granulometry. Advantage is that you can save 1 vial of biooss.
2 gm
1-2
DFDBA: First has to become —- to turn into bone. —- bone can skip this step, but you still want to combine with xeno in sinus. Bare in mind that bio-oss has a tremendous advantage in sinus grafting literature (far more studies).
mineralized
Mineralized
Research indicates that autogenous, allograft, prf can be used in sinus, but it should be combined with —– at bare minimum.
xenograft
—- bone had highest amount of new bone and lowest amount of loss of material compared to other grafting materials. That said, —— in, no difference was found between various grafting materials.
Autogenous
6 months
PRF studies: helped DFDBA (bare in mind that the research is limited and subject to change) and accelerated maturation, but PRF combined with xeno had no significant affect in outcome. PRF fibrin membranes are great for covering sinus membrane or osteotomy window. That said, you can absolutely see the bias, as they are trying to show a certain outcome for this material. With better established PICO questions and design, we see a different result. Bovine autogenous bone compared with just PRF (split face animal model study). New bone formation without PRF at 3 and 6 months, new bone only at 6 months in group with PRF. That said, healing has also been seen to be slightly delayed with PRF.
PRF should also be used cautiously in max sinus as the sole material.
—- and —- combo can turn into bone at the same ratio, and is thus preferable in the sinus
xeno (bioss), mineralized allo.
Consider also placing some bone scrapings (auto) in.
Or: where would you use autogenous bone to graft sinus?
When you think you need it the most – when they have severe atrophies, and thus don’t have much vasculature from surrounding bone.
Crestal sinus floor augmentation using hydraulic pressure and vibrations – machine that measures resistance from membrane as it pumps water through osteotomy into sinus for crestal approach. —- perf rate was detected here, 90% survival.
10%
Crestal sinus floor augmentation using hydraulic pressure and vibrations – machine that measures resistance from membrane as it pumps water through osteotomy into sinus for crestal approach. —- perf rate was detected here, 90% survival.
10%
Nonresorbable membrane with titanium strips contained — bone
autogenous
Occasionally you have patient with defect that still has bone on buccal. Here, we can use
resorbable membrane. CT graft, autogenous bone, resorbable membrane placed. Then you can place the implant.
Another thing to consider – as you manipulate flaps, you may collapse vestibule. Consider —– to help with this problem.
CT graft
Another thing to consider – as you manipulate flaps, you may collapse vestibule. Consider —– to help with this problem.
CT graft
What is the blood supply when you did vert augmentation with block graft? Decorticate recipient site, and maintain integrity of ——. In order of frequency of what procedures you do the most: Ti mesh and traditional GBR, last is onlay block grafts. They only really do this in sinus/block graft layering.
mucoperiosteum. In order to get primary closure, make sure that you do your releasing incision away from graft – hence large size of flap
Autogenous bone heals faster –
3-4 months. Everytime you use a combo of xeno, give it more time for healing.
How long do you leave cytoplast membrane in place?
If membrane and tissues are intact after vert augmentation, leave cytoplast membrane. There may be a moment where you have some type of tissue rejection of the membrane – if this occurs, remove it. Otherwise, leave it in for as long as possible. If exposed, remove earlier.
Place CT graft on top of cytoplast? Vascularity comes from
periosteum (hence why you should not make releasing incisions to high.
What is the risk of severing PSA artery and nerve when doing these high releasing incisions?
It can happen unfortunately. Arterial bleeding is manageable, nerve damage is tough. Blunt dissection is tremendously important to minimize damage and risk.
—- – two kinds of bone that we deal with.
Alveolar bone, basal bone
Inflammatory response: Coagulum formation leads to —–, which leads to —- formation. —– bone and bone marrow then forms after this has been remodeled. Ultimately, —- bone compaction indicates that healing is almost complete. This is when you can consider placing an implant. Two words often get confused. Modeling and remodeling. Modeling is change in shape and architecture. Remodeling is change within tissue without anatomical change.
fibroplasia
woven bone
Lamellar
lamellar
Powertome vs periotome –
powertome can be better than periotome in minimizing trauma during ext. This impacts PDL space in a more gradual fashion. The “screw” instrument can also help by atraumatically extracting teeth.
Powertome vs periotome –
powertome can be better than periotome in minimizing trauma during ext. This impacts PDL space in a more gradual fashion. The “screw” instrument can also help by atraumatically extracting teeth.
Recommend using —- to graft the gap in anterior immediates.
xenograft
Avatine =
anticoagulant that can be used during CT graft to halt bleeding.
Suture for CT graft on immediates:
Suture up through socket in buccal tunnel. Put suture through CT graft, then go toward vestibule in buccal tunnel on opposite surface (mesial or distal). Then pull CT graft down into buccal tunnel. Then suture.
Recommends —– the provisional crown for immediates.
hand-torquing
Vista approach: Or vertical incision to great a tunnel on facial portion of alveolus. Then you can go through the vista tunnel to remove bone and get out any remaining root tip. Don’t need —- when you graft this vista gap.
membrane
Based on what literature says: Main benefit of immediate implant placement is the
maintenance of the interproximal tissue. This has been well documented. Facial-gingival margin can be affected by other factors, which is why it is not fair to manage it with an immediate – this logic will not hold.
When you have a high or low crest, where to place implants?
The problem isn’t so much the low crest, but the high crest (more likely to be related to thin biotypees). In these cases, you are more likely to need to place this further subcrestal.
Place CT graft before placing provisional crown. Benefit of CT graft over other biomaterials is that you
can leave part of CT exposed.
As an old rule, — implant diameters is the maximum horizontal cantilever. Therefore extensions could be —- mm depending on the implant diameter. Generally speaking, overload is not likely. This rule is really beneficial with cantilevered crowns.
2
6-10
Cuspal inclination: Cuspal morphology contributes to natural appearance. For every 10 degree increase in cusp inclination, there is approx.. —- increase in torque.
30%
Further, for every 10 degree increase in implant inclination, there is about a—–increase in torque. *All-on-4 is different, as you splint them. Splinting implants helps reduce this and this paper (Weinberg, 1995) is relevant for single crowns.
5%
Horizontal implant offset – for every 1 mm offset there is about —- increase in torque how far this implant is off to the side from true center. This is extremely common in molars due to immediate placement.
15%
Apical implant offset: (Crown-implant ratio) For every 1mm increase in vertical implant offset there is about — increase in torque due to vertical cantilever. The balance here is that we have a tendency to place implants more subcrestal – see high bone line from earlier example. Don’t violate this principle to avoid a bone graft. Even if the implant doesn’t fail here, you will likely have screw loosening.
5%
Anteriorly, 2 implants can be used to support a — unit anterior prosthetic. 2 implants can also support —- units, depending on crown-root ratio, arch ratio, etc. The opposite is true in unstable occlusal situations. Ultimately, it depends. Arch curvature (offsetting implants) can be helpful – this comes back to renger papers – by placing them in an offset manner, you improve mechanical properties with splinted restorations. The problem is aesthetics. That said, an offset implant in a 3 unit FPD (all implant supported) will reduce bending by about —-
4, 5 or 6
2/3rds.
Implant spacing: — mm is the minimum space needed for implant placement (instrumentation and implant itself). This is a general guideline, some systems try to push this envelope.
6-7
—–mm is average MD dimension of premolars. — implants are the minimum diameter that should be used to replace posterior teeth (3mm only used anterior).
7 to 7.5
4mm
2mm bone ideal between implant and adj. teeth, but this is not likely to be present with premolars. —-m is average width of molars M-D.
10-11mm
It is possible to place implant in tight spaces, but your —— is honestly going t be the limiting factor. Also, if you get too close, you can devitalize the adjacent teeth.
papilla
On average you can only expect — of tissue height between implants. Generally,this gives us the guideline that you want to be 3mm apical to CEJ for ideal emergence profile.
3mm
When facial bone is available in edentulous ridges, maintain at least — of facial bone —- this does not take into account immediate extraction sites.
1mm
Once you get over — of distance from proximal contact to bone, you drastically lose papilla.
5mm
Implants and teeth are not parallel: use — tray
Open
Implant and teeth are parallel: —– tray.
Closed
Abutment level impression: for —-
custom or prefab abutment, cemented crown.
Only use abutment level impressions if a crown came off, wasn’t retrieved and the pt wants a quick fix.
Splinting implants together for an impression is awesome for when you have implants that are —-
way off-axis from each other that need to be compensated for with custom abutments.
For individual custom abutments, what impression post do you want? You want — impression copings – otherwise if a custom abutment is compensating for an angulation issue and it rotates a bit, that could throw off the angle correction.
engaging
Cementation can compensate for
misfits, no visible screw access for aesthetics, they can be more durable due to not needing the access. However, screws allow for retrieval. In the real world, many don’t want this option. Removing cemented implant FPDs is tough.
Cement retained crowns and FPDs tend to have less complications, however use for single crowns and short span bridges (Charr and Strub, 2011 review). Use ZOE provisional cement unless retention is severely compromised. When this happens, use —- cement.
ZOE
Finally, occlusal adjustments: Perception of occlusal contact – threshold for natural teeth is — for incisors, —- for molars. Greatest perception present on —–
1gm
5-10 gm
incisors, and decreases posteriorly.
It takes higher forces to activate a patient’s perception when they have implants than when they have natural teeth. Implant perception is likely to occur due to —–. This triggers —-. Thus, there is variable implant perception – some have —, some have —-. It ultimately depends, some studies show improved perception in anterior, but not solid enough of evidence. Ultimately, we need to be careful with our adjustments. Delivery of these restorations are different.
bone deformation and activation of mechanoreceptors in response to this
periosteum
3gm
190gm
STL is a —–
stereolithography file.
You design custom abutmetns to match
bone
You design custom abutmetns to match
bone
When you can consider immediate load FP3:
Atrophic arches, implants with 35ncm, concave provisional, close monitor of hygiene. You should consider minor soft tissue reflection, not going without any reflection (you can preserve more keratinized tissue, which is often not in excess for these patients). Another thing to consider is just using a pilot drill sx guide, you don’t need it to be fully guided. There is wiggle room. Also, consider preprocessed acrylic monoblock for digital dentures. These blocks give more strength to the provisional prosthesis – the main complication of a provisional full arch prosthesis is fracture.
the main complication of a provisional full arch prosthesis is
fracture
Class I:
no arch defect, 8-11mm restorative space (you can do this flapless, or with a minimal flap) – true FP1-2 prosthesis.
Class II full arch:
Vertical defect present: You can use zirc, metal ceramic, or metal acrylic restorations. This is when you need to start looking at smile lines. Ultimately, this tissue needs to be replaced, otherwise we are looking into excessive FP-2s.
Class III:
Horizontal defects. This is when hygiene gets difficult. This is firmly FP-3 territory. Ultimately, these defects get tough to build in lip support with prosthetic.
Class IV:
Heavily compromised. We often convert patients to this general location when doing conversions.
To minimize porecelein problems:
— veneering only, occlusal/incisal —-. Zirc specific porcelain if using zirc. Lab will do a slow cooling rate.
Facial
monolithic
Max implant count: 4-6 – 6 for —– pts. Consider positioning max implants at 13, 10, 7, 4
brachiocephalic
Short implants (Dr. Foleck is only comfortable down to —— wide) can be used in cases of severe bone loss.
6mm long, 5-8mm
Sinus graft? Place —- bone per sinus. Also, always put —– membrane as a liner in sinus. When in doubt, assume you have a tear in the membrane.
5cc
PRF/collagen
Dr. Foleck and Wong do not prefer —- for grafting the gap – consider —–.
xenograft
allograft
You will often see periodontists use Astra, as they are catered to the anterior. They propose burying the implant subcrestally —-.
2mm
If grafting to provide lip support, use
HA or xeno – something that sticks around for a long time.
For occlusion of full arches:
anterior guidance (canine, incisal, all) – anterior guidance is great for separation of posterior teeth in excursive movements. Otherwise, use shallow cusps.
If you are doing an upper denture opposing lower FP3, do
bilateral balance – the purpose of that occlusion is to keep the max denture in. Occlusion serves function in dentures for retention.
Coreg:
non-selective beta blocker, epinephrine can lead to plummeting BP.
Norvast:
issue with gingival hyperplasia – it may make it harder to heal.
Something to consider – 2nd molar crowns often lead to —–
cheek biting. If you do this, you need to make sure that you have a significant buccal overjet on molar-molar.
Methotrexate:
can affect bone remodeling and healing of gingiva – this attacks quickly dividing cells and affects healing. Ultimately, you can have MRONJ, and there tends to be a higher failure rate with implants.
Entivia –
lowers immune response. Also limits pain meds due to liver issues – opioids are less of an option when you would normally want to go here due to ibuprofen issues.
Entivia –
lowers immune response. Also limits pain meds due to liver issues – opioids are less of an option when you would normally want to go here due to ibuprofen issues.
Bonequantityis measured by:
1) Width (B-L) 2) Height
3) Length (M-D) 4) Angulation
Division A bone:
- > 5mm width
- > 10-13mmheight
- > 7mmlength
- < 30 deg angulation
- C/I ratio < 1
Division B bone:
2.5-5mm width • >10-13mmheight • >12mmlength • < 20 deg angulation • C/I ratio < 1
Division C bone:
• Unfavourablein – Width (C-w) – Height (C-h) – Length – Angulation (C-a) ≥ 30° – C/I ratio ≥ 1
Division D bone:
Severe atrophy
• Basal bone loss
• Flat maxilla
• Pencilthinmandible
Greatest blood supply is —- – we instead must rely on adjacent periosteum and bone. Implants are at a deficit of blood. If you compromise blood from periosteum or bone, you will have an inflated problem because we are increasing the loss of blood supply. This is the biggest difference.
PDL
Second biggest difference: Fiber attachment to implant. Implant gingival fibers tend to run —– to implant – also why the pockets of implants are weaker.
parallel
Parameters of outcomes:
Hard tissue volume and topography,
Soft tissue volume and color
Soft tissue around final restoration,
Pink and white aesthetics in cross sections of tissue (a more in depth analysis of tissue color)
Submergence profile –
implant shoulder meets abutment to crown – this has everything to do with how the bone and tissue respond. If you alter this in different ways, you get different responses.
Ideally, you want a —– implant abutment for tissue health.
concave
i(A+B+C) = T
Abutment = A Bone = B Crown = C I = Implant T = Tissue
Ideal tissue management – in sagittal cross section,
place 3.5mm below CEJ of proposed restoration, 2mm palatal to buccal ridge. 3 vs 3.5mm – irrelevant honestly.
Collagen fibers are —- in gingiva – this allows us to manipulate this aspect of the flap to get extension to cover grafted area. Some blood vessels and mucous glands present in tissue – sometimes you sever these blood vessels and you get excess bleeding (nothing to worry about).
loosely arranged
Best way to determine mucogingival junction – take alveolar mucosa,
push it toward where you think the junction is. It will bunch up at the mucogingival junction.
