Implantology Breakthroughs for the GP

Part 3 - Efficient Implants with Crown and Bridge

Instructors:

Brady Frank, DDS

Brady Frank, DDS

Over the last ten years, Brady Frank has owned and managed multiple practices. Dr. Frank is a sought after speaker and Continuing Education trainer, and has addressed thousands of dentists at popular seminars throughout the country including Excellence in Dentistry, Phasing-Out Seminars (over 20 presentations delivered), and Schein/Camlog Seminars.

Implant in Site #18 and #20 with a Bridge #21-23

All right, our next case we’re going to be doing is implant site no. 18, no. 20. We’re actually going to be doing a bridge no. 21-23. As you can see down here we got a buccal bone defect where no. 22 was from a long term infected tooth down there. But we got plenty of bone site no. 20. I’m just going to go palpate the bone. We got good bone in the buccal. Our lingual bone is right here so we got plenty of room. We could do a 4.7 but we’ll do a 3.7. No need to stress it. No need to work the edge. We’ll do a 3.7 there. And then the back we got plenty of bone site no. 18. We look at the lingual lot of bone, buccal plenty of bone. So we’ll go with the 4.7 but something a little shorter an 8mm. That will allow us to stick to what I called the 6mm rule which is always staying 6mm from the mandibular nerve. If you’re always staying 6mm away if you do error and go 2-3 more millimeter then you’re still fine. You got a 3mm buffer zone. So that’s why that we’re going to use 8mm implant for no. 18. So whenever we’re doing crown and bridge and implants together always important to do your tooth preparation before you place the implants. Therefore you don’t get any of the tooth debris into the implant site so around that. So we’ll go ahead and prep that bridge first which we’re doing in the anterior here. Our other option was to extract no. 21 and cantilever to 20 and 21 implants, a 22 pontic. But a bridge in this case is perfectly fine and that’s what we elected to go with. So let’s get started. Just let me know if you feel anything okay. Do you feel anything? Good. So we’ve got a little buccal defect. The mucogingival junction as you can see has moved in about 2mm. We’re going to be placing a 3.7 implant. So we’re going to just kind of smooth that keratinized tissue just to the buccal slightly here. So we’ll do that. There we go. Just a little flap of that keratinized tissue. There we go. And on no. 18 same situation. There we go. Good. That’s good. Doing okay? Good. So we’ve done two mini envelop incisions on site no. 18 and 20. We’re going to go ahead and do our initial pilot hole with a high speed actually. So why don’t we go ahead and do that. So one thing we’re going to line up our drill with the adjacent teeth. Make sure we got the parallelism we’d like. There we go then right back here. Then once again verify the buccal lingual bone aspect using the high speed. There we go. We got our two pilot holes taking care of with the high speed. We’re going to be doing 3.7mm x 10mm implant on site no. 20 and a 4.7 x 10 for no. 18. There we go. So we’re going to estimate about 3mm of tissue which means we’ll go down a total of 13mm drill length for the site no 20. Site no. 18 we’re using 8mm implant. So we’re going to go down about to 10 or 11 maybe 11.5 in depth to accommodate some soft tissue. So we’ll do that on no. 18. Always guide it with the tooth in front or adjacent. There we go. Good. So now we simply go to our second drill in the series which is generally a 2.8. So we’ll go down the 13 with the 2.8. Watch your depth. There we go and the same thing with the distal. Good. Moving right along our third drill which is a 3.4mm diameter. What we’re going to do is we’re not going to use the final for no. 20 the entire length. We’re just going to go about a third the way in. Just do that initial cortical plate right there. Then we’re going to go ahead and place our implant, our 3.7mm x 10mm implant for that site no. 20. So we just take him out of his carrier and we go some plastic thing that we can hold onto. We’ll go ahead and seat that in there. I use an oscillating motion to get them going and then simply go till you have some tension and then take the plastic carrier off like that. And then we’re going to torque it the rest of the way with our torque wrench. I bet you feel like a car right now, don’t you. Kelly let’s use a 2.5 if you’d be so kind and we’ll do it the rest of the way. Sure that sounds good. So this basically just extends it so that the torque can go around the tops of the adjacent teeth. So we’re going to watch our buccal margin. We’re just at the gumline so we’ll go a little bit further down make them just subgingival. It looks pretty good down there. So we’re about 35-40 torque on that guy. So the reason I took a break and stop drilling on the back one is the final drill that you’re going to be using that site you should immediately keep that site as free from saliva as you can or any other stuff and immediate place that implant. Now we’ll go ahead and finish out drilling the 4.7 x 8 for that distal. Do you want the 10 or the 8? 4.7 x 8. So we’re drilling down about 11.5 on that distal. So that was a 3.4. Now we’re going to do a 3.8 which is our next up in the sequence. And the final drill is a 4.4. If the bone is real soft I generally don’t go to the final drill. That allows us to torque it tighter. In this case, he has a really good solid cortical plate. So we’re just going to go through that cortical plate with our 4.4 which is the final drill for the 4.7. There we go. Now we’ll go ahead and place our 4.7 x 8. And this particular implant company we’re using today has a dual sterilized package and it is OsteoCore that we’re using today which is very similar to a lot f the internal hex company like Zimmer or Implant Direct. So take out its carrier implant. Just be careful with him. We have very little bleeding there. So we’re going to torque that implant into place. So it’s getting tight with the plastic carrier. Once it gets pretty tight. You’re able to pop it off. And we will go in with your hand tightener. Just a little pressure here. We’re watching the buccal margin. We’re about 40 maybe 50 Newton right here. Really solid bone. So what we’re going to do is we’re going to take a look where we’re at. It looks like our position is nice. We angle the abutment as you can see a little bit to the buccal, toward the buccal. That’s because sometimes a lingual root concavity. We have plenty of buccal bone. So when you can, go to the area with the most forgiveness. So we did that so you can see it’s canted a little bit to the buccal. We’re just subgingival on the lingual. We’re right out the gumline on the buccal way far back like that. I don’t mind it right at the gumline. So we look very good right there. Of the instrument that you use when you initially take the transfer off use the longer hex that gets all the way down there and can unscrew that top part. So just put them on the finger tightener here. Unscrew those abutments. And what we’re going to do is section the lab transfer off of those. We’re going to customize those abutments today and take that impression directly. If we weren’t training today, what Kelly would generally do is I might be in the room doing hygiene and Kelly would actually section these abutments which is legal under board rules in most states. So we’ll do it together right now. Once again, we’re going to section the top part of this off. So easy as that. It took me 10-15 seconds. Now we got a customizable abutment that came packaged directly with the implant. Once again, why’s the transfer on here. If we wanted to we could have taken a closed tray impression then taken this off after the impression, stuck them right in the impression. This is a direct approach. When you can do the direct approach more user friendly, easier on the lab, less room for error and a lot of folks have switched over to doing it this way. Okay. Now we got our 3.7 for the anterior implant. We got a 4.7 for the posterior. I’m just going to clean out any little metal spurs on the holes there. And let’s get a shot right here what it should look like. So we’re using minimally invasive techniques today. As you can see back here there is actually more of a gum bruise where the shots were than the implants as you can see kind of darker, so really minimally invasive. You can see the nice keratinized tissue on both the buccal and lingual aspects of these implants. So we’re going to have really nice tissue result when the final prosthetic come in place. And so we’ll slide this on top. And in fact I’m going to have Kelly do that. Her fingers are very skinny, nimble and she’s been doing lab stuff for 28 years. Her dad started a lab. So she’s really good with her fingers so by all means if you can have your assistant do a lot of this work do that. So Kelly is inserting the abutments on the implants now. And what we’re going to do is we’re going to cement these crowns on this next appointment. We’ll probably wait about six weeks to cement the crowns and that bridge. But after she puts the abutments into place, we’re going to actually torque the prosthetic abutments down to 35 Newton. So we’re not going to take this off again. They’re going to be back there. So when you do prep these abutments just make sure you get any sharp edges off cause that can irritate the tongue. One quick trick is to give the patient a bunch of orthodontic wax. Therefore, if those abutments are tender to the tongue cause they’re not used to having a tooth in that area they can pack it full of wax and we’re in good shape. Often times when putting the abutments back into place there’s tissue impingement. So what you want to be real careful of initially is making a long enough mini envelop incision and reflecting enough tissue. You see how the keratinized tissues form a nice cuff around that implant, that’s exactly what we’re looking for. If you don’t make enough of an incision from mesial to distal that cuff won’t displace like that. So we’re going to tighten these abutments on here and then we’re going to double check that with a 35 Newton breakaway torque. So we’ve done this and we’ll double check the torque with a 35 Newton breakaway torque. There we go. That broke it 35 for the distal abutment. And we will do the same on the mesial. Reengage it. All right. So we’re about 30 right there which should be sufficient. The implant started moving. So we stop at 30. So we got our preps back here. These are both single unit and then we have a bridge right here. We are going to go ahead and correct any angulation with the bulk reduction. So, on this distal abutment I kind of correct that buccal angulation by taking off some of the lingual of the abutment. And we’re going to smooth any rough corner, round those off, make it easier for the lab. Labs can sometimes break off any sharp corner filling around those. Good. That’s a good general shape for the abutments. So we’re just going trough just slightly around this and place Expasyl and we’ll be ready for our impression. Okay. Ready for impression. And what we’re going to do is place some wax in the holes of the top of this after we place our Expasyl retraction. So you can see we have very little bleeding there. Expasyl retraction in place. Go ahead and place the wax on the holes of the top of the abutments. Go ahead and open. Last check. We’re going to take a look at his bite. Go ahead and bite down. We’ve got a good class one bite on this side but of course on this side we’ve got a crossbite as witness by our friend no. 19 here. Yup, just hold biting. Just like that. We’ve got good clearance on both our implant. We’ve got good clearance on our crown and bridge here. I may just take off a little more of the buccal of our friend here and try and correct that crossbite slightly. This will be in for aesthetic in. Go ahead and open and close down again. So this case is a great example of being able to complete crown and bridge procedures seamless with implants in the same appointment and maintaining a similar seat date for everything. So even though we can seat this bridge in three weeks we’re going to wait a good two months to seat the final implant work. So we’ll just wait the full two months to seat everything. We were going to temporize the bridge but as far as the implant goes we’re not going to put temporary crowns on top of those. And so we’ll leave those abutments in place and we should be in really good shape. All right, Kelly I think we’re good to go. And I’m going to prep this just a little more on the buccal. And then make sure there are no metal pieces around where those implants are. They will integrate with the gums and can cause something like an amalgam tattoo. It looks like we’re very clean there. So we’re okay. So we’re going to take a full lower arc impression here and take a Blue Mousse right after that. Standard impression technique. We’ll be taking impressions for both of the implant and the bridge. Excellent we’re using fast set today. Go one bite down if you would. All the way down. Yup, perfect bite hole just like that. Hold just like that. And Kelly would be finishing up by taking upper impression. Actually, I should say we will be finishing up by taking an upper impression and we got the Blue Mousse and we’ll just pick a shade. I think A2 will be our shade today. So it’s a great example of crown and bridge mix with implants but also taking final prosthetics for the implants at the same time as placement. All right, so we finished up this case where we placed a couple of implants, took the impressions for those implants, and also did a three unit bridge at the same time kind of demonstrating how efficient implants can also tie right into crown and bridge dentistry that you’re doing. Here’s the final [panel] with the implants. We place 4.7 x 8 on the lower left, no. 18. Our nerves right here. So we follow the 6mm rule roughly. I’d say that’s about 4-4.5mm. If this is 8, now we’re close to about 6. We still want to give the mental foramen its proper distance. So we’re about 4-4.5mm from the mental foramen. We could go with a longer implant but why go with longer implant 10mm is perfectly fine. Great success. And we’re only using it to support one tooth. So that case is completed. We actually did the final impression today as well. And so we’re going to be restoring this entire quadrant and then some in that particular procedure.