October 13, 2025 • 33 mins
A comprehensive overview of implant dentistry, detailing the surgical principles and biological foundations of osseointegration. They describe the necessity of interdisciplinary collaboration between surgeons and restorative dentists, emphasizing a prosthodontically driven approach to treatment planning using tools like CBCT scans and guided surgery. Much attention is given to the evolution of implant surfaces to enhance bone integration, including discussions on surface modifications and the effect of micromovement on healing. Furthermore, the text thoroughly examines hard and soft tissue augmentation techniques, such as sinus lifts and bone grafting, alongside critical considerations for managing patients with complex medical histories or in the highly demanding esthetic zone.
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Transcript
Episode Transcript
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Speaker 1 (00:00):
Welcome back to the deep dive. We're here to take
dense professional reading and make it sharp, make it usable
knowledge for you exactly. And today we're doing a deep
surgical cut. We're essentially giving you a short cut, the
fast track to understanding the core surgical principles from volume
two of a really key text in implant dentistry. So
whether you're a dental student you know, facing exams, or
(00:22):
maybe a younger professional wanting clarity on some of these
more advanced concepts, this is really your essential surgical guide.
Speaker 2 (00:29):
And it's so critical because look, implant dentistry today is
prosthetically driven. I mean, the final tooth dictates everything, but
the actual execution, especially in complex cases, demands really high
level surgical skill. It's not just a one person show.
It absolutely requires a mandatory interdisciplinary teamwork.
Speaker 1 (00:49):
So the restorative dentists and the surgeon have to be locked.
Speaker 2 (00:52):
In, absolutely connected at every single stage.
Speaker 1 (00:54):
Okay, so let's map this out for you listening. We're
going to start small, like really microscopic, the incredible science
of how bone actually fuses two titanium ostio integration exactly.
They'll jump into patient risk management, always high stakes there.
Then digital planning, advanced stuff like hard tissue reconstruction, and
(01:14):
will wrap up with loading protocols and the long game
maintenance and dealing with complications. Sounds like a plan, So
let's kick off with that interdisciplinary mandate. It sounds a
bit like jargon. But what does that collaboration actually look
like now compared to say, twenty years ago.
Speaker 2 (01:32):
Well, today, it's all about digital integration. Really. We have
to seamlessly exchange diagnostic information. We use cadcam software, we
have live internet meeting. Sometimes the restorative dentist designs the
final outcome the tooth first, and the surgeon's job is
to place that implant precisely where that virtual tooth needs
the support. Okay, and just a quick point, if a
(01:55):
restorative dentist decides to place the implant themselves, they absolutely
carry the same surgical responsibility as a specialist surgeon. No
difference in accountability.
Speaker 1 (02:03):
Got it? And the science behind it all ossiointegration. It's
just such a cool origin story, isn't it. Bron Mark's
accidental discovery.
Speaker 2 (02:10):
Oh it's classic, Yeah, finding that bone had grown so
tightly onto his titanium optical chamber in the rabbit femur
that he just couldn't get it out.
Speaker 1 (02:18):
Amazing.
Speaker 2 (02:19):
That accident basically launched the whole field so osteointegration. Formally,
it's the process where new bone deposits directly onto the
implant surface.
Speaker 1 (02:28):
How long does that usually take?
Speaker 2 (02:29):
Well, it varies. It can be anywhere from about two
weeks up to maybe four months. It really depends heavily
on the implant surface itself, how ostuconductive, how biologically active
it is.
Speaker 1 (02:41):
Okay, in this is where the physics comes in, right,
the critical micro movement threshold. We hear that term all
the time. But why is that one hundred two hundred
and fifty micrometer limit so so absolute?
Speaker 2 (02:51):
Because if you go beyond that threshold, the whole healing
process just breaks down. If that implant moves more than
say one hundred, one hundred and fifty micrometers, and that's
less than the width of a human hair, wow, that
tiny bit of excess movement disrupts the fibrine clot that's
essential for healing. It stops osteoblasts from differentiating properly, so
instead of bone forming on the implant, you get fibrous tissue,
(03:13):
a connective tissue interface, which is basically a failure. It
can't support a load. And that principle, that's the absolute
core concept behind whether immediate loading will work or not.
Speaker 1 (03:22):
Makes sense. Okay, So moving up from the bone, let's
talk about the soft tissues right around the implant, the
pery implant biologic width.
Speaker 2 (03:31):
Right, So, the biologic width around an implant's made up
of the junctional epithelium and the connective tissue just above
the bone crust. That the supercressible connective tissue. On average,
it's about three millimeters total, which is actually a little
bit bigger than around natural teeth interestingly.
Speaker 1 (03:47):
Huh And what about the type of gum tissue? Does
that matter?
Speaker 2 (03:50):
Oh? Hugely. What's really critical is having keratonized gingieva, that
tougher pink tissue. We really prefer that for long term
health because it attaches much more firmly to the underlying
periostim compared to say, looser alveol mucosa, and that helps
with it makes it much more resilient to brushing, to hygiene,
and it significantly reduces the risk of inflammation down the line.
(04:12):
Better sealed, better health.
Speaker 1 (04:13):
Okay, that clarifies the foundations. Now let's get into how
the implants themselves have evolved. The original machine titanium worked,
but modern surfaces are like hyper engineered right.
Speaker 2 (04:25):
Absolutely, The goal from day one, since bron Mark's originals,
has been to boost osteoconductivity, make bone grow faster and
stronger onto the implant.
Speaker 1 (04:35):
So how much of a difference did those first generation
rougher surfaces actually make compared to the old smooth machined
ones in terms of bone quality.
Speaker 2 (04:44):
It was a massive difference, a seismic shift.
Speaker 1 (04:46):
Really.
Speaker 2 (04:46):
If you looked at the bone right next to those
original nineteen eighties machined implants, its hardness was only about
the same as softer, spongy trabecular.
Speaker 1 (04:55):
Bone, okay, And then when they introduced moderately rough surfaces
like maybe a double acid etched one.
Speaker 2 (05:00):
Suddenly the bone forming around that implant was significantly harder,
much denser. It reached the quality of cortical bone, the
really hard outer layer of bone.
Speaker 1 (05:08):
Wow, how does that work? What's the mechanism?
Speaker 2 (05:10):
Well, the micro roughness, the texture itself. It actually speeds
up the expression of specific genes involved in collagen cross linking,
particularly one called P four H prole four hydroxylase. Okay,
and that just drives faster, stronger, mineralization, denser, bone quicker.
Speaker 1 (05:27):
But it wasn't all smooth sailing with surface modifications, was it.
I remember hearing about problems with early coatings like HA
hydroxy appetite.
Speaker 2 (05:36):
Yeah, the early plasma sprayed HA and calcium phosphate coatings.
They had pretty high failure rates. There were a couple
of reasons what went wrong. Well, the plasma sprain process
itself was often imprecise. It could inadvertently convert this stable
HA into tri calcium phosphate or TCP, which resorbs way
too quickly.
Speaker 1 (05:54):
Ah.
Speaker 2 (05:55):
And crucially, the bond between that coating and the titanium
underneath was purely machaire. It wasn't chemically integrated.
Speaker 1 (06:01):
So if bacteria got it exactly.
Speaker 2 (06:04):
If that coded surface got exposed to the oral environment
to bacteria, it could basically peel off delaminate and that
caused a really aggressive chronic inflammatory reaction. The implant was usually.
Speaker 1 (06:14):
Lost, right, So that brings us to the cutting edge. Now, Yeah,
hybrid topographies combining micro roughness with nano features. What is
adding that nano level structure achieve.
Speaker 2 (06:23):
It really gives you the best of both worlds. See,
micro roughness is fantastic for encouraging cells to differentiate into
bone cells, but it can actually slow down how fast
the cells proliferate, how quickly they multiply initially. Ok So,
modern surfaces often use techniques like titanium naninodular self assembly.
They create these tiny structures maybe around three hundred nanometers
(06:45):
layered onto the micro rough surface benefit. This hybrid approach
significantly boosts both proliferation and differentiation. You get more cells
and they turn into bone cells faster and better. The
result is dramatically stronger and faster into compared to just
micro roughness alone.
Speaker 1 (07:02):
Okay, that's fascinating. Now something that sounds almost like science
fiction UV light treatment, photo functionalization. This isn't about the
shape of the surface. It's about it's chemistry.
Speaker 2 (07:13):
Exactly, and it's incredibly important, maybe even essential. Now here's
the thing. All titanium surfaces, even brand new ones, start
to age the moment they're exposed to air. They get
contaminated by hydrocarbons from the atmosphere floating around, and this
contamination makes the surface chemically hydrophobic. Water heating and gives
it a negative.
Speaker 1 (07:32):
Charge, and UV light fixes that.
Speaker 2 (07:34):
It reverses it completely. Treating the implant surface with specific
UV light just before placement cleans off those hydrocarbons. It
restores super hydroflicity, the surface becomes extremely water loving, and
it flips the surface charge to electropositive.
Speaker 1 (07:50):
Okay, but what's the real world payoff for the surgeon
and the patient.
Speaker 2 (07:54):
It's huge. This chemical rejuvenation boosts the integration strength so dramatic.
It's like taking an aged implant that would normally heal slowly,
maybe with gaps needing to fill in what we call
gap healing, and making it perform like a pristine, brand
new surface that achieves contact healing where bone forms directly
against it, almost immediately, so.
Speaker 1 (08:15):
You could potentially use shorter implants or place them in
less than ideal bone.
Speaker 2 (08:19):
Precisely, it gives the clinician much more confidence in challenging situations,
potentially improving outcomes and sites with poor bone quality or
where implant length is restricted. It's a major enhancement.
Speaker 1 (08:30):
All right, Let's pivot now from the implant surface to
the patient themselves. We have to talk about medical history
and risk management. Our patient population is getting older.
Speaker 2 (08:39):
Right, absolutely, Managing geriatric patients, say sixty five and older
is becoming much more common and it brings its own
set of challenges. By twenty thirty, about a fifth of
the US population will be in that age group.
Speaker 1 (08:52):
And what are the key concerns with older patients?
Speaker 2 (08:55):
We have to be really vigilant about multiple existing health conditions, comorbidities,
and critically nutritional status. You'd be surprised. Up to thirty
seven percent, nearly forty percent of elderly patients and institutions
have significant nutritional deficiencies and that impacts healing severely. It
impairs the body's ability to heal properly after surgery.
Speaker 1 (09:16):
Okay. One common scenario the patient on blood thinners anticoagulants
like Warfare or cumdin. What's the standard approach? Now? Do
we ask them to stop?
Speaker 2 (09:25):
Generally? No, The current thinking, backed by most studies, is
that you should not routinely stop the antigragulant.
Speaker 1 (09:31):
Really, why not?
Speaker 2 (09:32):
Because the risk of a serious event like a stroke
or a blood clot if they stop the medication is
usually far far higher than the risk of problematic bleeding
during typical implant surgery, which you can manage locally exactly.
Bleeding during the procedure is almost always controllable with local measures. But,
and this is crucial, you absolutely must get clearance from
their physician first, and generally, if they're INR level, which
(09:56):
measures clotting time is three or less, invasive surgery is
ca considered safe.
Speaker 1 (10:01):
Okay, good to know. What about patients with specific heart
conditions who definitely needs antibiotic premedication before surgery?
Speaker 2 (10:09):
Right? Prophylactic antibiotics are mandatory for patients with prosthetic heart
valves or if they've had prosthetic material used to repair
a heart valve. This is to prevent a dangerous heart
infection called infective endocardinis.
Speaker 1 (10:22):
And the go to antibiotic is Amoxicillin is preferred.
Speaker 2 (10:25):
If they're allergic, then alternatives like clindamycin or cephalic cent
are used.
Speaker 1 (10:29):
Speaking of allergies, if someone is allergic to penicillin, what
are the risks with those alternatives like clindamycin.
Speaker 2 (10:35):
Well, clindamycin and some broad spectrum cephalosporins. They carry a
known increased risk of causing a severe intestinal infection called
Claustritium difficile or seed.
Speaker 1 (10:45):
Yeah, nasty stuff.
Speaker 2 (10:46):
Very so you need to monitor the patient carefully. If
they develop severe diarrhea, the antibotic needs to be stopped immediately.
Speaker 1 (10:53):
Okay, what about diabetes? When does that become a major
hurdle for implants.
Speaker 2 (10:57):
It's really about control. Poorly control diabetes is a definite
red flag. If a patient's HbA one C is over
six point four percent or their fasting blood sugar is
consistently above one hundred and twenty five milligedl, their healing
is likely to be delayed and other risks increased risk
of infections things like chronic east infections, candidiasis, even rare
(11:18):
fungal infections like mecromycosis, plus poorly controlled diabetes damage as
small blood vessels throughout the body, which further compromises healing.
Speaker 1 (11:26):
Okay, now for the big one in terms of bone health,
bisphosphonates and the risk of MRONJ medication related osteotochorosis at
the chow. What's the actual risk level for a typical
patient taking these drugs orally for osteoporosis.
Speaker 2 (11:40):
The risk is generally quite low. For oral bysphostinates used
for osteoporosis, it's estimated around zero point one percent. That
low initially, yes, but it does seem to double maybe
two point two percent after they've been taken the drug
for four years or more.
Speaker 1 (11:54):
And for IV bisphosphinates used in cancer.
Speaker 2 (11:57):
Treatment, ah, that's a completely different story. The risk with
ivy bysphosphonates, often used for cancer related hypercalcemia, is much
much higher. We're talking one to ten percent, maybe even
more depending on the drug and duration. Zoladrenate seems to
be involved in the vast majority over eighty percent of
reported MR and NJ cases.
Speaker 1 (12:16):
So for the low risk oral BP patient needing an implant,
is it contraindicated?
Speaker 2 (12:20):
Generally no. For patients on low dose oral bysphosphonates, studies
suggest that implant placement is not contraindicated. The drugs don't
seem to prevent ossio integration itself. The MRO and J
risk exists, but it's low.
Speaker 1 (12:33):
What about the idea of a drug holiday stopping the
bisphoscinate temporarily around the surgery.
Speaker 2 (12:38):
That's still debated. The American Association of Oral and Maxillofacial
Surgeons AAOMS has suggested considering a two month break before
and after surgery for patients who've been on oral BPS
for more than three or four years, but the FDA
itself is noted there's no substantial data to really support
if a drug holiday helps or for how long it
(12:59):
should be. A big part of the problem is that
bisphosphonates stick around in the bone for a very long time.
Speaker 1 (13:04):
So stopping for two months might not do much.
Speaker 2 (13:07):
It's unclear if it significantly reduces the drug concentration in
the bone. Danosumab, which is prolia, is different. It's not abysphosphonate,
it's an antibody. Its effects wear off much faster within
several months of stopping because it doesn't bind into the
bone matrix itself.
Speaker 1 (13:23):
Okay, One last medical check yep. The sinuses if we're
working in the upper back jaw.
Speaker 2 (13:28):
Absolutely critical. Before any kind of sinus augmentation, you need imaging,
usually a CBCT scan cone BEAMCT. It's mandatory to check
the sinus health and anatomy. You need to confirm its
draining properly and look for things like polyps, a deviated septum,
blocking drainage, or stenosis of the opening the costume. If
you see any of those issues, the patient needs to
see an ent specialist. An udorlary knowlogist before you touch
(13:51):
anything surgically.
Speaker 1 (13:52):
Makes sense. Get the plumbing checked first, exactly. All right,
let's move into the planning phase and the surgery itself.
Planning is everything you mentioned CBCT scan. How do we
use that three D info with the prosthetic plan.
Speaker 2 (14:04):
So the CBCT gives us the detailed three D anatomy
of the bone and nearby structures like nerves and the sinus.
That's the DICOM data Hiko Digital Imaging and Communications in medicine.
It's just the standard format for medical images. We then
digitally merge that anatomical data with a stan of the
planned final restoration, maybe from a scan, diagnostic wax up
(14:26):
or a digital design.
Speaker 1 (14:27):
So you see the final tooth superimposed.
Speaker 2 (14:29):
On the bone precisely. This lets us plan the ideal
implant position relative to both the available bone and the
final tooth position. But that prosthetic plan imposes a key
restriction vertical space. For a fixed screw retain or cemented crown.
You need enough height, generally a minimum of fifteen to
eighteen millimeters from the top of the implant platform up
(14:50):
to the chewing surface of the opposing tooth.
Speaker 1 (14:52):
Fifteen to eighteen millimeters. What if you don't have.
Speaker 2 (14:54):
That much room, then you need to create it. Often
this means planning for an alva eectomy, reducing the height
of the bone rage either before or at the time
of implant placement.
Speaker 1 (15:03):
Okay, now the actual surgery. Bron Mark's core principles still hold. Yeah,
minimize trauma, be precise, get good initial stability.
Speaker 2 (15:12):
Absolutely, those are timeless, and implant choice plays a role
here too, especially regarding stability and bone quality.
Speaker 1 (15:19):
Oh So, tapered versus great walled implants.
Speaker 2 (15:22):
Right in softer bone like you often find the posterior
maxilla type three or five ey bone, we generally prefer
tapered self tapping implants. Why tapered because the tapered shape
helps to gently compress the surrounding spongy bone as it's inserted.
This significantly boosts that initial mechanical grip, the primary.
Speaker 1 (15:39):
Stability and in very dense bone.
Speaker 2 (15:41):
In really dense Type I or two bone like the
anterior mandible, a tapered implant might generate too much stress,
So there we often prefer a straight walled implant, and
we might use surgical tax beforehand to prepare the threads precisely,
reducing insertion stress and the risk of overheating or even.
Speaker 1 (16:00):
Got it, let's talk flaps. Managing the soft tissue in
the lower jaw, the mandible where carotenized tissue could be limited.
How do you design the incision?
Speaker 2 (16:10):
The standard approach is a mid crestal incision. You carefully
place it right down the middle of the existing band
of carotenized tissue.
Speaker 1 (16:17):
If there is one, why split it.
Speaker 2 (16:18):
The goal is to divide that valuable tough tissue so
you have an adequate zone on both the cheek side
book hall and the tongue side lingual of the implant
after healing. This is really important for long term hygiene
and health around the implant.
Speaker 1 (16:31):
Any precautions on the tongue.
Speaker 2 (16:32):
Side, yes, absolutely. When you raise that lingual flap, you
have to be very careful with how far down you
dissect towards the floor of the mouth to avoid injuring
the lingual nerve. Keep the dissection minimal epicitly.
Speaker 1 (16:43):
Okay, Now, let's say we're working up front in the maxilla,
the esthetic zone. We want those nice gum contours the
papilla between the teeth. What's a flap strategy there.
Speaker 2 (16:53):
Often the best approach is to make the incisions slightly
towards the palate a paalatally positioned.
Speaker 1 (16:59):
And why towards the palette.
Speaker 2 (17:01):
Because the palatal tissue is usually thicker and has more
carrot andized tissue. By placing the incision there, you can
effectively borrow that thicker tissue from the pallett and move
it where you can then carefully advance it towards the
cheek side the buckle, and you sort of tuck and
roll it to build up volume, especially in those intra
proximal areas between the implants. This helps create those fuller,
(17:25):
more natural looking papillo contours, which is critical for esthetics
and even for speech clever.
Speaker 1 (17:30):
All right, let's wrap this section with computer guided surgery
and offers amazing precision. When we talk about a fully
guided approach, what exactly is being controlled by the surgical
guide or template.
Speaker 2 (17:41):
So a fully guided template controls pretty much everything the
exact entry point, position, the angle angulation, the width of
the drill diameter, and the final depth of the implant placement.
It's highly precise.
Speaker 1 (17:55):
Sounds great, but are there downsides or limitations?
Speaker 2 (17:58):
The main limitation is space. You need quite a bit
of room between the upper and lower jaws for the
drills and the guide itself. We're talking maybe up to
thirty eight millimeters of clearance in the front of the mouth,
maybe twenty five millimeters in the back.
Speaker 1 (18:11):
So are there situations where a surgeon might deliberately choose
not to use a fully guided approach even if they.
Speaker 2 (18:17):
Could, Yes, definitely. Two main scenarios come to mind. First,
if the patient's jaw ridge is extremely resorbed and compromised
what we classify as kwood and howl class V or six,
the bone might be so thin or uneven that you
just can't get the surgical guide to sit stably and accurately.
Speaker 1 (18:33):
Makes sense, Yeah, the guide needs a solid foundation exactly.
Speaker 2 (18:37):
And Second, sometimes, particularly in the esthetic zone, the surgeon
might want the flexibility to make microadjustments to the implant's
vertical depth during the surgery. They might want to see
the actual bone crest level visually and fine tune the
depth based on that direct feedback.
Speaker 1 (18:53):
So they might offer freehand or maybe a partially guided
approach instead, correct.
Speaker 2 (18:57):
To retain that final bit of interra oper of control
over the epicocronal positioning.
Speaker 1 (19:03):
Okay, that covers the basics in planning. Now let's get
into the more advanced stuff reconstruction. When bone is missing,
guided bone regeneration or GBR is common. What are the
absolute keys to making GBR work?
Speaker 2 (19:17):
Three main things. You need space maintenance, something to hold
the shape for the new bone. You need grapht immobilization.
The graphic material can't be moving around, and critically, you
need tension free soft tissue closure over the top. The
gum has to close passively without being stretched type.
Speaker 1 (19:31):
Let's talk about the graph material itself, the granules you
mentioned size matters. What's the science say about the ideal
particle size for bone graphs.
Speaker 2 (19:38):
Yeah, it's actually quite specific. Research points to an ideal
window for the granule size generally between about five hundred
and seven hundred and fifty microns.
Speaker 1 (19:47):
That's half a millimeter to three quarters of a millimeter,
pretty small range. What happens if you use particles outside
that sweet spot too small or too big?
Speaker 2 (19:55):
Well, if the granules are too small, say less than
four hundred microns, they ten to resorb too quickly. They
basically dissolve before the new bone has a chance to
properly form and mature within the space.
Speaker 1 (20:08):
Okay, so the scaffold disappears too fast, right.
Speaker 2 (20:10):
And conversely, if the granules are too large, maybe over
a thousand microns or one millimeter, they often don't resorb
properly at all. They can remain as inert non vital
particles embedded in the site, which can actually hinder the
quality of the final bone formation and potentially interfere with
implant integration later on.
Speaker 1 (20:29):
So size dictates the resorption rate, which needs to match
the bone.
Speaker 2 (20:32):
Growth rate exactly. You want the graph to stick around
long enough to guide the new bone, but then gradually
get replaced by the patient's own healthy bone.
Speaker 1 (20:40):
Okay, let's move up to the sinus, the lateral window
sinus augmentation. When you make that window in the side
wall of the maxxilla, what's the main blood vessel you
need to watch out for.
Speaker 2 (20:51):
The big one to be aware of is the alveolar
antral artery. It runs within that lateral bony wall.
Speaker 1 (20:56):
And surgically, how do you minimize risk when making the window.
Speaker 2 (21:00):
A key surgical principle is to keep the bottom edge
the inferior border of your bony window at least five
millimeters above the actual floor.
Speaker 1 (21:09):
Of the sinus why five millimeters?
Speaker 2 (21:10):
This helps ensure you maintain a solid bony base like
a three walled box. It provides better containment for the
bone graph material and helps stabilize it.
Speaker 1 (21:19):
Interesting now we're also hearing more about graphless sinus lifts.
How is it possible to get bone formation way up
in that elevated space without putting any graph material in?
Speaker 2 (21:28):
It sounds counterintuitive, right, but it relies on the biological
potential of the sinus membrane itself, the schnadarian membrane.
Speaker 1 (21:35):
It has bone forming cells.
Speaker 2 (21:37):
It contains osteoprogenitor cells, yes, stem cells essentially. So when
you carefully lift the membrane creating that space and place
a highly bioactive implant surface like those modern anidized or
chemically treated surfaces we talked about, the elevated membrane acts
like a tent. Okay, the blood clot that fills the
space undernath becomes scaffold, and the cells from the mem
(22:00):
and potentially migrating from the surrounding bone can differentiate and
form new bone directly onto that implant surface. It's basically
guided tissue regeneration principles using the membrane as the barrier.
Speaker 1 (22:13):
Does it work as well as grafting?
Speaker 2 (22:15):
Studies show good success, especially if there's still a few
millimeters of existing bone height below the sinus to provide
initial implant stability. It might not create the same volume
of bone as a large graft, but it can be
sufficient for implant integration.
Speaker 1 (22:28):
Okay, vertical defects though. Building bone height, that's still the
toughest challenge, isn't it?
Speaker 2 (22:32):
Oh? Absolutely, Vertical augmentation is significantly less predictable than horizontal.
If you need a really substantial gain in height, say
more than four or five millimeters, what's the go to distraction?
Osteogenesis is probably the most reliable method for large vertical gains.
Speaker 1 (22:47):
How does that work? Again?
Speaker 2 (22:48):
You make controlled bone cuts attached mechanical device, and then
very slowly, day by day, you turn a screw to
gradually separate the bone segments. New bone forms in the
gap you create benefit. A huge advantage is that it
also stretches and brings the overlying soft tissue up coronally
along with the bone segment, so you gain bone height
(23:09):
and you improve the gum line position. The mucogingi ole junction,
which is often compromised in these cases.
Speaker 1 (23:15):
What about GBR for vertical.
Speaker 2 (23:17):
GBR can work for smaller vertical gains, maybe up to
three or four millimeters if you use techniques like tinting
screws to hold the membrane up and maintain that vertical space,
but it's definitely more technique sensitive than horizontal GBR.
Speaker 1 (23:30):
Okay. Finally, in this advanced section, let's touch on solutions
for severely resorbed jaws, Tilted implants, and zygomatic implants.
Speaker 2 (23:39):
Right. These are workhorses when conventional implant placement isn't possible
due to lack of bone. Tilted implants famously used in
concepts like all on four.
Speaker 1 (23:47):
What's the strategy there?
Speaker 2 (23:49):
The idea is to angle the posterior implants, often tilting
them forward to engage better quality bone that's usually still
present in the anterior regions like the front wall of
the sinus in the maxilla or anterior to the mental
nerve in.
Speaker 1 (24:03):
The mandible, and the benefit of tilting.
Speaker 2 (24:05):
It allows you to achieve a wider antioposterior spread the
distance between the most forward and most backward implants. This
provides better biomechanical support for the prosthesis and crucially lets
you minimize or even eliminate cantilevers off the back, which
reduces stress.
Speaker 1 (24:23):
And they often allow for immediate loading.
Speaker 2 (24:24):
Yes, because you're typically engaging denser bone and achieving good stabidity.
Tilted implant protocols very often allow for immediate placement of
a provisional bridge. Clinical success rates are excellent.
Speaker 1 (24:36):
And then there as zygomatic implants for really extreme cases.
Speaker 2 (24:40):
Exactly, Zygomatic implants are indicated when there's severe maxillary atrophy,
maybe after tumor resection, or in certain congenital defect cases
like cleft pallets where there's just no usable bone in
the upper jaw itself.
Speaker 1 (24:53):
So what do they anchor?
Speaker 2 (24:54):
They bypass the maxilla altogether and anchor into the dense
zygomatic bone, the cheekbone. Specialized very long implants, sometimes up
to fifty or fifty two point five millimeters long wow,
and they're usually placed at a sharp angle, often around
forty five degrees to engage that zygoma. They require specialized
training and surgical skill.
Speaker 1 (25:15):
Okay, incredible options for tough situations. Let's move towards the
finish line, now loading the implants and long term care.
Immediate loading sounds great, but what are the hard requirements?
What metrics must be met?
Speaker 2 (25:26):
It comes down to primary stability. It's non negotiable. You
need a high initial grip. The most common benchmarks are
a minimum insertion torque of thirty five Newton centimeters and
CMA or an ISQ reading. That's implant stability quotient measured
with resonance frequency analysis of sixty or higher. And if
you achieve that, then immediate loading is generally considered safe
(25:47):
provided the provisional restoration is designed correctly, meaning careful biomechanics.
For a full arch, absolutely no cantilever extending off the
back in the maxilla. In the mandible, you might allow
a very short candileate, typically limited to half the measured
ap spread between the implants and the bite. The occlusion
must be meticulously controlled, usually only light contact in the
(26:09):
center in a back teeth, no guidance contacts during chewing movements.
Speaker 1 (26:13):
Initially, who should definitely not get immediate loading? Who needs
to weight?
Speaker 2 (26:17):
Two main groups. First, patients with what we call a
thin scalloped gingible biotype. They have very delicate, thin gum
tissue that's prone to recession. A media loading in these
cases carries a high risk of tissue loss and esthetic problems.
Speaker 1 (26:31):
Okay, and the second group.
Speaker 2 (26:33):
Any site where you've had to do simultaneous major bone grafting,
the graph needs time to mature and integrate without being
subjected to the stresses of immediate function. Let the biology work.
Speaker 1 (26:42):
First, right, So once the final restoration is in place,
what's the standard maintenance protocol? How often should patients be
seen and what are we looking for?
Speaker 2 (26:50):
Maintenance is absolutely key for long term success. The standard
protocol usually involve annual checkups.
Speaker 1 (26:57):
What happens at the annual check.
Speaker 2 (26:58):
It should include standardized radiographs, usually periopical X rays focused
on the implants or maybe a panoramic X ray specifically
to monitor the bone levels around the implants.
Speaker 1 (27:08):
Year after year, and clinically.
Speaker 2 (27:10):
Clinically, you assess for any mobility, which should be zero.
You perform periodontal probing carefully around the implant, measuring pocket depths,
and you evaluate the health and width of the carotenized tissue,
basically looking for any signs of inflammation or disease, and that.
Speaker 1 (27:25):
Disease around implants perimplantitis, what causes it?
Speaker 2 (27:28):
Well, peri implant mucasitis is just inflammation and the soft
tissues like gingevitis. Periumplantitis involves that inflammation plus progressive bone
loss around the implant, and interestingly, the bacteria implicated imperiumplantitis
are often very similar to those found in chronic period
on titis around natural teeth, bugs like pro Pheromonis, Gingevollis,
Pravatella intermedia.
Speaker 1 (27:49):
So, if you diagnose active peri implantitis with bone loss
and you need to do surgery to try and regenerate
the bone, you first have to clean the contaminated implant surface, right.
Speaker 2 (28:00):
Absolutely, decontamination is critical before attempting any regenerative procedure. There's
a well known protocol described by Frome and colleagues.
Speaker 1 (28:09):
Can you walk us through that cleaning process?
Speaker 2 (28:11):
Sure, it's quite thorough, involving multiple steps. First, you mechanically
debride the exposed implant surface, usually with titanium or plastic
curets to avoid scratching the implant.
Speaker 1 (28:23):
Ok.
Speaker 2 (28:23):
Then you often use an air brace of device like
a prophy jet with fine sodium bicarbonate powder for about sixty.
Speaker 1 (28:29):
Seconds like sand blasting it clean this.
Speaker 2 (28:31):
Sort of but much gentwerre. Then you irrigate thoroughly with
sterile saline. After that, some protocols involve rubbing a slurry
of tetracyclin and antibiotic onto the surface for its antimicrobial effect,
and then then, believe it or not, a second round
of the air brace of treatment, and finally a rinse
or application of chlormaxidine antiseptic just before you place your
(28:52):
bone graft or membrane. It's a multi pronged attack on
the biofilm.
Speaker 1 (28:56):
Wow, that's intensive. Let's highlight a couple of common complications.
Residual cement left behind after cementing a crown. Why is
that such a big problem around implants? Maybe even more
than teeth.
Speaker 2 (29:08):
It's a huge issue and yes, arguably more destructive around implants.
The reason lies in the fundamental difference in the soft
tissue attachment. So natural teeth have sharpies fibers, these connective
tissue fibers that embed directly into the cementum of the
root and into the bone, creating a really robust physical barrier.
Implants don't have sharpiees fibers. The just have They have
(29:30):
a weaker junctional epithelial attachment and then loosely arranged circumferential
connective tissue fibers that run parallel to the implant surface.
There's no perpendicular.
Speaker 1 (29:40):
Insertion, so inflammation can spread more easily.
Speaker 2 (29:43):
Exactly if a piece of cement gets trapped under the gum,
the resulting inflammation isn't contained by those strong fibers, it
can easily spread down and around the entire implant platform,
leading to rapid bone loss. That's why keeping crown margins
easily accessible for cleanup. Ideally super and jibvel above the
gum line in the back of the mouth is really
strongly advised for cemented restorations and quickly two other critical
(30:07):
complications to prevent nerve injury and mandibular fracture for the
inferior alveolar nerve in the lower jaw. How can we
minimize risk during drilling Besides careful planning with CBCT, some
surgeons actually prefer not to give a full mandibular nerve
block anesthetic. They'll use local infiltration instead.
Speaker 1 (30:25):
Why would they do.
Speaker 2 (30:25):
That, It's a deliberate choice to keep the nerve partially responsive.
The idea is that if the drill gets too close,
the patient might feel some sensation, maybe heat, or vibration
which acts as an early warning signal to the surgeon
before actual damage occurs.
Speaker 1 (30:39):
Interesting tactic. And if numbness does happen.
Speaker 2 (30:41):
And lasts, if anesthesia or altered sensation dysysthesia persists beyond
about sixteen weeks, it's unlikely to resolve on its own.
Referral to a microsurgeon specialized in nerve repair should be
seriously considered at that point.
Speaker 1 (30:54):
And mandibular fracture sounds terrifying.
Speaker 2 (30:58):
It is, but thankfully it's very rare. It tends to
occur almost exclusively in patients with severely resorbed, very.
Speaker 1 (31:04):
Thin mandibles, and what triggers.
Speaker 2 (31:06):
It Often it's associated with using wide diameter, aggressively tapered,
self tapping implants placed with excessive force in that already
compromised bone. The stress just overcomes the bone strength.
Speaker 1 (31:18):
So the takeaway is gentle surgery and maybe different implant
choices in those.
Speaker 2 (31:22):
Cases, precisely careful, precise drilling, maybe using straight walled implants
with tapping in dense areas of a thin mandible and
absolutely avoiding excessive insertion torque.
Speaker 1 (31:32):
Got it? Wow? Okay, we have really covered a huge
amount of ground today we certainly have. I mean, we
started right down at the nanoscale talking about UV light
and three hundred nanimeters bumps on titanium.
Speaker 2 (31:42):
Yeah, the surface science, and we scaled.
Speaker 1 (31:45):
All the way up to managing complex systemic risks like
blood thinners and bysphosphonates, and then tackled major reconstructions with
distraction and zygomatic implants.
Speaker 2 (31:58):
Success isn't just about screwing something in. It's built on rigorous,
prosthetically driven planning, meticulous surgical execution, and understanding this constantly
evolving material science.
Speaker 1 (32:10):
But those core principles remain yeah, right, stability, biology, precision.
Speaker 2 (32:14):
They are absolutely the bedrock. Those don't change.
Speaker 1 (32:17):
Okay, So to help you listening cement some of this,
here's a final thought, a mini case study pulling directly
from our risk management discussion.
Speaker 2 (32:23):
All right, imagine this patient They've been taking an oral bisphosphinate, say,
for osteoporosis for five years now. They need a single
implant placed in their lower back jaw, the posterior mandible
and let's say the bone quality there is pretty good
type I R two. What's the primary risk factor the
implant team needs to discuss and manage regarding that medication
history and what's the current, perhaps slightly controversial thinking about
(32:47):
how to handle their bisphosphinite medication around the time of surgery.
Speaker 1 (32:51):
Goodwin, So think about that MRONJ risk low but definitely
increased after five years. Consider the debate around them drug holiday,
whether it helps and for how long, And of course
the absolute necessity of talking to the patient's physician.
Speaker 2 (33:06):
Exactly puts it all together perfect well.
Speaker 1 (33:08):
Thanks for joining us on this deep dive into surgical
implant principles. We hope it provides a valuable shortcut for you.
We'll catch you next time on the deep Dive
Welcome back to the deep dive. We're here to take
dense professional reading and make it sharp, make it usable
knowledge for you exactly. And today we're doing a deep
surgical cut. We're essentially giving you a short cut, the
fast track to understanding the core surgical principles from volume
two of a really key text in implant dentistry. So
whether you're a dental student you know, facing exams, or
(00:22):
maybe a younger professional wanting clarity on some of these
more advanced concepts, this is really your essential surgical guide.
Speaker 2 (00:29):
And it's so critical because look, implant dentistry today is
prosthetically driven. I mean, the final tooth dictates everything, but
the actual execution, especially in complex cases, demands really high
level surgical skill. It's not just a one person show.
It absolutely requires a mandatory interdisciplinary teamwork.
Speaker 1 (00:49):
So the restorative dentists and the surgeon have to be locked.
Speaker 2 (00:52):
In, absolutely connected at every single stage.
Speaker 1 (00:54):
Okay, so let's map this out for you listening. We're
going to start small, like really microscopic, the incredible science
of how bone actually fuses two titanium ostio integration exactly.
They'll jump into patient risk management, always high stakes there.
Then digital planning, advanced stuff like hard tissue reconstruction, and
(01:14):
will wrap up with loading protocols and the long game
maintenance and dealing with complications. Sounds like a plan, So
let's kick off with that interdisciplinary mandate. It sounds a
bit like jargon. But what does that collaboration actually look
like now compared to say, twenty years ago.
Speaker 2 (01:32):
Well, today, it's all about digital integration. Really. We have
to seamlessly exchange diagnostic information. We use cadcam software, we
have live internet meeting. Sometimes the restorative dentist designs the
final outcome the tooth first, and the surgeon's job is
to place that implant precisely where that virtual tooth needs
the support. Okay, and just a quick point, if a
(01:55):
restorative dentist decides to place the implant themselves, they absolutely
carry the same surgical responsibility as a specialist surgeon. No
difference in accountability.
Speaker 1 (02:03):
Got it? And the science behind it all ossiointegration. It's
just such a cool origin story, isn't it. Bron Mark's
accidental discovery.
Speaker 2 (02:10):
Oh it's classic, Yeah, finding that bone had grown so
tightly onto his titanium optical chamber in the rabbit femur
that he just couldn't get it out.
Speaker 1 (02:18):
Amazing.
Speaker 2 (02:19):
That accident basically launched the whole field so osteointegration. Formally,
it's the process where new bone deposits directly onto the
implant surface.
Speaker 1 (02:28):
How long does that usually take?
Speaker 2 (02:29):
Well, it varies. It can be anywhere from about two
weeks up to maybe four months. It really depends heavily
on the implant surface itself, how ostuconductive, how biologically active
it is.
Speaker 1 (02:41):
Okay, in this is where the physics comes in, right,
the critical micro movement threshold. We hear that term all
the time. But why is that one hundred two hundred
and fifty micrometer limit so so absolute?
Speaker 2 (02:51):
Because if you go beyond that threshold, the whole healing
process just breaks down. If that implant moves more than
say one hundred, one hundred and fifty micrometers, and that's
less than the width of a human hair, wow, that
tiny bit of excess movement disrupts the fibrine clot that's
essential for healing. It stops osteoblasts from differentiating properly, so
instead of bone forming on the implant, you get fibrous tissue,
(03:13):
a connective tissue interface, which is basically a failure. It
can't support a load. And that principle, that's the absolute
core concept behind whether immediate loading will work or not.
Speaker 1 (03:22):
Makes sense. Okay, So moving up from the bone, let's
talk about the soft tissues right around the implant, the
pery implant biologic width.
Speaker 2 (03:31):
Right, So, the biologic width around an implant's made up
of the junctional epithelium and the connective tissue just above
the bone crust. That the supercressible connective tissue. On average,
it's about three millimeters total, which is actually a little
bit bigger than around natural teeth interestingly.
Speaker 1 (03:47):
Huh And what about the type of gum tissue? Does
that matter?
Speaker 2 (03:50):
Oh? Hugely. What's really critical is having keratonized gingieva, that
tougher pink tissue. We really prefer that for long term
health because it attaches much more firmly to the underlying
periostim compared to say, looser alveol mucosa, and that helps
with it makes it much more resilient to brushing, to hygiene,
and it significantly reduces the risk of inflammation down the line.
(04:12):
Better sealed, better health.
Speaker 1 (04:13):
Okay, that clarifies the foundations. Now let's get into how
the implants themselves have evolved. The original machine titanium worked,
but modern surfaces are like hyper engineered right.
Speaker 2 (04:25):
Absolutely, The goal from day one, since bron Mark's originals,
has been to boost osteoconductivity, make bone grow faster and
stronger onto the implant.
Speaker 1 (04:35):
So how much of a difference did those first generation
rougher surfaces actually make compared to the old smooth machined
ones in terms of bone quality.
Speaker 2 (04:44):
It was a massive difference, a seismic shift.
Speaker 1 (04:46):
Really.
Speaker 2 (04:46):
If you looked at the bone right next to those
original nineteen eighties machined implants, its hardness was only about
the same as softer, spongy trabecular.
Speaker 1 (04:55):
Bone, okay, And then when they introduced moderately rough surfaces
like maybe a double acid etched one.
Speaker 2 (05:00):
Suddenly the bone forming around that implant was significantly harder,
much denser. It reached the quality of cortical bone, the
really hard outer layer of bone.
Speaker 1 (05:08):
Wow, how does that work? What's the mechanism?
Speaker 2 (05:10):
Well, the micro roughness, the texture itself. It actually speeds
up the expression of specific genes involved in collagen cross linking,
particularly one called P four H prole four hydroxylase. Okay,
and that just drives faster, stronger, mineralization, denser, bone quicker.
Speaker 1 (05:27):
But it wasn't all smooth sailing with surface modifications, was it.
I remember hearing about problems with early coatings like HA
hydroxy appetite.
Speaker 2 (05:36):
Yeah, the early plasma sprayed HA and calcium phosphate coatings.
They had pretty high failure rates. There were a couple
of reasons what went wrong. Well, the plasma sprain process
itself was often imprecise. It could inadvertently convert this stable
HA into tri calcium phosphate or TCP, which resorbs way
too quickly.
Speaker 1 (05:54):
Ah.
Speaker 2 (05:55):
And crucially, the bond between that coating and the titanium
underneath was purely machaire. It wasn't chemically integrated.
Speaker 1 (06:01):
So if bacteria got it exactly.
Speaker 2 (06:04):
If that coded surface got exposed to the oral environment
to bacteria, it could basically peel off delaminate and that
caused a really aggressive chronic inflammatory reaction. The implant was usually.
Speaker 1 (06:14):
Lost, right, So that brings us to the cutting edge. Now, Yeah,
hybrid topographies combining micro roughness with nano features. What is
adding that nano level structure achieve.
Speaker 2 (06:23):
It really gives you the best of both worlds. See,
micro roughness is fantastic for encouraging cells to differentiate into
bone cells, but it can actually slow down how fast
the cells proliferate, how quickly they multiply initially. Ok So,
modern surfaces often use techniques like titanium naninodular self assembly.
They create these tiny structures maybe around three hundred nanometers
(06:45):
layered onto the micro rough surface benefit. This hybrid approach
significantly boosts both proliferation and differentiation. You get more cells
and they turn into bone cells faster and better. The
result is dramatically stronger and faster into compared to just
micro roughness alone.
Speaker 1 (07:02):
Okay, that's fascinating. Now something that sounds almost like science
fiction UV light treatment, photo functionalization. This isn't about the
shape of the surface. It's about it's chemistry.
Speaker 2 (07:13):
Exactly, and it's incredibly important, maybe even essential. Now here's
the thing. All titanium surfaces, even brand new ones, start
to age the moment they're exposed to air. They get
contaminated by hydrocarbons from the atmosphere floating around, and this
contamination makes the surface chemically hydrophobic. Water heating and gives
it a negative.
Speaker 1 (07:32):
Charge, and UV light fixes that.
Speaker 2 (07:34):
It reverses it completely. Treating the implant surface with specific
UV light just before placement cleans off those hydrocarbons. It
restores super hydroflicity, the surface becomes extremely water loving, and
it flips the surface charge to electropositive.
Speaker 1 (07:50):
Okay, but what's the real world payoff for the surgeon
and the patient.
Speaker 2 (07:54):
It's huge. This chemical rejuvenation boosts the integration strength so dramatic.
It's like taking an aged implant that would normally heal slowly,
maybe with gaps needing to fill in what we call
gap healing, and making it perform like a pristine, brand
new surface that achieves contact healing where bone forms directly
against it, almost immediately, so.
Speaker 1 (08:15):
You could potentially use shorter implants or place them in
less than ideal bone.
Speaker 2 (08:19):
Precisely, it gives the clinician much more confidence in challenging situations,
potentially improving outcomes and sites with poor bone quality or
where implant length is restricted. It's a major enhancement.
Speaker 1 (08:30):
All right, Let's pivot now from the implant surface to
the patient themselves. We have to talk about medical history
and risk management. Our patient population is getting older.
Speaker 2 (08:39):
Right, absolutely, Managing geriatric patients, say sixty five and older
is becoming much more common and it brings its own
set of challenges. By twenty thirty, about a fifth of
the US population will be in that age group.
Speaker 1 (08:52):
And what are the key concerns with older patients?
Speaker 2 (08:55):
We have to be really vigilant about multiple existing health conditions, comorbidities,
and critically nutritional status. You'd be surprised. Up to thirty
seven percent, nearly forty percent of elderly patients and institutions
have significant nutritional deficiencies and that impacts healing severely. It
impairs the body's ability to heal properly after surgery.
Speaker 1 (09:16):
Okay. One common scenario the patient on blood thinners anticoagulants
like Warfare or cumdin. What's the standard approach? Now? Do
we ask them to stop?
Speaker 2 (09:25):
Generally? No, The current thinking, backed by most studies, is
that you should not routinely stop the antigragulant.
Speaker 1 (09:31):
Really, why not?
Speaker 2 (09:32):
Because the risk of a serious event like a stroke
or a blood clot if they stop the medication is
usually far far higher than the risk of problematic bleeding
during typical implant surgery, which you can manage locally exactly.
Bleeding during the procedure is almost always controllable with local measures. But,
and this is crucial, you absolutely must get clearance from
their physician first, and generally, if they're INR level, which
(09:56):
measures clotting time is three or less, invasive surgery is
ca considered safe.
Speaker 1 (10:01):
Okay, good to know. What about patients with specific heart
conditions who definitely needs antibiotic premedication before surgery?
Speaker 2 (10:09):
Right? Prophylactic antibiotics are mandatory for patients with prosthetic heart
valves or if they've had prosthetic material used to repair
a heart valve. This is to prevent a dangerous heart
infection called infective endocardinis.
Speaker 1 (10:22):
And the go to antibiotic is Amoxicillin is preferred.
Speaker 2 (10:25):
If they're allergic, then alternatives like clindamycin or cephalic cent
are used.
Speaker 1 (10:29):
Speaking of allergies, if someone is allergic to penicillin, what
are the risks with those alternatives like clindamycin.
Speaker 2 (10:35):
Well, clindamycin and some broad spectrum cephalosporins. They carry a
known increased risk of causing a severe intestinal infection called
Claustritium difficile or seed.
Speaker 1 (10:45):
Yeah, nasty stuff.
Speaker 2 (10:46):
Very so you need to monitor the patient carefully. If
they develop severe diarrhea, the antibotic needs to be stopped immediately.
Speaker 1 (10:53):
Okay, what about diabetes? When does that become a major
hurdle for implants.
Speaker 2 (10:57):
It's really about control. Poorly control diabetes is a definite
red flag. If a patient's HbA one C is over
six point four percent or their fasting blood sugar is
consistently above one hundred and twenty five milligedl, their healing
is likely to be delayed and other risks increased risk
of infections things like chronic east infections, candidiasis, even rare
(11:18):
fungal infections like mecromycosis, plus poorly controlled diabetes damage as
small blood vessels throughout the body, which further compromises healing.
Speaker 1 (11:26):
Okay, now for the big one in terms of bone health,
bisphosphonates and the risk of MRONJ medication related osteotochorosis at
the chow. What's the actual risk level for a typical
patient taking these drugs orally for osteoporosis.
Speaker 2 (11:40):
The risk is generally quite low. For oral bysphostinates used
for osteoporosis, it's estimated around zero point one percent. That
low initially, yes, but it does seem to double maybe
two point two percent after they've been taken the drug
for four years or more.
Speaker 1 (11:54):
And for IV bisphosphinates used in cancer.
Speaker 2 (11:57):
Treatment, ah, that's a completely different story. The risk with
ivy bysphosphonates, often used for cancer related hypercalcemia, is much
much higher. We're talking one to ten percent, maybe even
more depending on the drug and duration. Zoladrenate seems to
be involved in the vast majority over eighty percent of
reported MR and NJ cases.
Speaker 1 (12:16):
So for the low risk oral BP patient needing an implant,
is it contraindicated?
Speaker 2 (12:20):
Generally no. For patients on low dose oral bysphosphonates, studies
suggest that implant placement is not contraindicated. The drugs don't
seem to prevent ossio integration itself. The MRO and J
risk exists, but it's low.
Speaker 1 (12:33):
What about the idea of a drug holiday stopping the
bisphoscinate temporarily around the surgery.
Speaker 2 (12:38):
That's still debated. The American Association of Oral and Maxillofacial
Surgeons AAOMS has suggested considering a two month break before
and after surgery for patients who've been on oral BPS
for more than three or four years, but the FDA
itself is noted there's no substantial data to really support
if a drug holiday helps or for how long it
(12:59):
should be. A big part of the problem is that
bisphosphonates stick around in the bone for a very long time.
Speaker 1 (13:04):
So stopping for two months might not do much.
Speaker 2 (13:07):
It's unclear if it significantly reduces the drug concentration in
the bone. Danosumab, which is prolia, is different. It's not abysphosphonate,
it's an antibody. Its effects wear off much faster within
several months of stopping because it doesn't bind into the
bone matrix itself.
Speaker 1 (13:23):
Okay, One last medical check yep. The sinuses if we're
working in the upper back jaw.
Speaker 2 (13:28):
Absolutely critical. Before any kind of sinus augmentation, you need imaging,
usually a CBCT scan cone BEAMCT. It's mandatory to check
the sinus health and anatomy. You need to confirm its
draining properly and look for things like polyps, a deviated septum,
blocking drainage, or stenosis of the opening the costume. If
you see any of those issues, the patient needs to
see an ent specialist. An udorlary knowlogist before you touch
(13:51):
anything surgically.
Speaker 1 (13:52):
Makes sense. Get the plumbing checked first, exactly. All right,
let's move into the planning phase and the surgery itself.
Planning is everything you mentioned CBCT scan. How do we
use that three D info with the prosthetic plan.
Speaker 2 (14:04):
So the CBCT gives us the detailed three D anatomy
of the bone and nearby structures like nerves and the sinus.
That's the DICOM data Hiko Digital Imaging and Communications in medicine.
It's just the standard format for medical images. We then
digitally merge that anatomical data with a stan of the
planned final restoration, maybe from a scan, diagnostic wax up
(14:26):
or a digital design.
Speaker 1 (14:27):
So you see the final tooth superimposed.
Speaker 2 (14:29):
On the bone precisely. This lets us plan the ideal
implant position relative to both the available bone and the
final tooth position. But that prosthetic plan imposes a key
restriction vertical space. For a fixed screw retain or cemented crown.
You need enough height, generally a minimum of fifteen to
eighteen millimeters from the top of the implant platform up
(14:50):
to the chewing surface of the opposing tooth.
Speaker 1 (14:52):
Fifteen to eighteen millimeters. What if you don't have.
Speaker 2 (14:54):
That much room, then you need to create it. Often
this means planning for an alva eectomy, reducing the height
of the bone rage either before or at the time
of implant placement.
Speaker 1 (15:03):
Okay, now the actual surgery. Bron Mark's core principles still hold. Yeah,
minimize trauma, be precise, get good initial stability.
Speaker 2 (15:12):
Absolutely, those are timeless, and implant choice plays a role
here too, especially regarding stability and bone quality.
Speaker 1 (15:19):
Oh So, tapered versus great walled implants.
Speaker 2 (15:22):
Right in softer bone like you often find the posterior
maxilla type three or five ey bone, we generally prefer
tapered self tapping implants. Why tapered because the tapered shape
helps to gently compress the surrounding spongy bone as it's inserted.
This significantly boosts that initial mechanical grip, the primary.
Speaker 1 (15:39):
Stability and in very dense bone.
Speaker 2 (15:41):
In really dense Type I or two bone like the
anterior mandible, a tapered implant might generate too much stress,
So there we often prefer a straight walled implant, and
we might use surgical tax beforehand to prepare the threads precisely,
reducing insertion stress and the risk of overheating or even.
Speaker 1 (16:00):
Got it, let's talk flaps. Managing the soft tissue in
the lower jaw, the mandible where carotenized tissue could be limited.
How do you design the incision?
Speaker 2 (16:10):
The standard approach is a mid crestal incision. You carefully
place it right down the middle of the existing band
of carotenized tissue.
Speaker 1 (16:17):
If there is one, why split it.
Speaker 2 (16:18):
The goal is to divide that valuable tough tissue so
you have an adequate zone on both the cheek side
book hall and the tongue side lingual of the implant
after healing. This is really important for long term hygiene
and health around the implant.
Speaker 1 (16:31):
Any precautions on the tongue.
Speaker 2 (16:32):
Side, yes, absolutely. When you raise that lingual flap, you
have to be very careful with how far down you
dissect towards the floor of the mouth to avoid injuring
the lingual nerve. Keep the dissection minimal epicitly.
Speaker 1 (16:43):
Okay, Now, let's say we're working up front in the maxilla,
the esthetic zone. We want those nice gum contours the
papilla between the teeth. What's a flap strategy there.
Speaker 2 (16:53):
Often the best approach is to make the incisions slightly
towards the palate a paalatally positioned.
Speaker 1 (16:59):
And why towards the palette.
Speaker 2 (17:01):
Because the palatal tissue is usually thicker and has more
carrot andized tissue. By placing the incision there, you can
effectively borrow that thicker tissue from the pallett and move
it where you can then carefully advance it towards the
cheek side the buckle, and you sort of tuck and
roll it to build up volume, especially in those intra
proximal areas between the implants. This helps create those fuller,
(17:25):
more natural looking papillo contours, which is critical for esthetics
and even for speech clever.
Speaker 1 (17:30):
All right, let's wrap this section with computer guided surgery
and offers amazing precision. When we talk about a fully
guided approach, what exactly is being controlled by the surgical
guide or template.
Speaker 2 (17:41):
So a fully guided template controls pretty much everything the
exact entry point, position, the angle angulation, the width of
the drill diameter, and the final depth of the implant placement.
It's highly precise.
Speaker 1 (17:55):
Sounds great, but are there downsides or limitations?
Speaker 2 (17:58):
The main limitation is space. You need quite a bit
of room between the upper and lower jaws for the
drills and the guide itself. We're talking maybe up to
thirty eight millimeters of clearance in the front of the mouth,
maybe twenty five millimeters in the back.
Speaker 1 (18:11):
So are there situations where a surgeon might deliberately choose
not to use a fully guided approach even if they.
Speaker 2 (18:17):
Could, Yes, definitely. Two main scenarios come to mind. First,
if the patient's jaw ridge is extremely resorbed and compromised
what we classify as kwood and howl class V or six,
the bone might be so thin or uneven that you
just can't get the surgical guide to sit stably and accurately.
Speaker 1 (18:33):
Makes sense, Yeah, the guide needs a solid foundation exactly.
Speaker 2 (18:37):
And Second, sometimes, particularly in the esthetic zone, the surgeon
might want the flexibility to make microadjustments to the implant's
vertical depth during the surgery. They might want to see
the actual bone crest level visually and fine tune the
depth based on that direct feedback.
Speaker 1 (18:53):
So they might offer freehand or maybe a partially guided
approach instead, correct.
Speaker 2 (18:57):
To retain that final bit of interra oper of control
over the epicocronal positioning.
Speaker 1 (19:03):
Okay, that covers the basics in planning. Now let's get
into the more advanced stuff reconstruction. When bone is missing,
guided bone regeneration or GBR is common. What are the
absolute keys to making GBR work?
Speaker 2 (19:17):
Three main things. You need space maintenance, something to hold
the shape for the new bone. You need grapht immobilization.
The graphic material can't be moving around, and critically, you
need tension free soft tissue closure over the top. The
gum has to close passively without being stretched type.
Speaker 1 (19:31):
Let's talk about the graph material itself, the granules you
mentioned size matters. What's the science say about the ideal
particle size for bone graphs.
Speaker 2 (19:38):
Yeah, it's actually quite specific. Research points to an ideal
window for the granule size generally between about five hundred
and seven hundred and fifty microns.
Speaker 1 (19:47):
That's half a millimeter to three quarters of a millimeter,
pretty small range. What happens if you use particles outside
that sweet spot too small or too big?
Speaker 2 (19:55):
Well, if the granules are too small, say less than
four hundred microns, they ten to resorb too quickly. They
basically dissolve before the new bone has a chance to
properly form and mature within the space.
Speaker 1 (20:08):
Okay, so the scaffold disappears too fast, right.
Speaker 2 (20:10):
And conversely, if the granules are too large, maybe over
a thousand microns or one millimeter, they often don't resorb
properly at all. They can remain as inert non vital
particles embedded in the site, which can actually hinder the
quality of the final bone formation and potentially interfere with
implant integration later on.
Speaker 1 (20:29):
So size dictates the resorption rate, which needs to match
the bone.
Speaker 2 (20:32):
Growth rate exactly. You want the graph to stick around
long enough to guide the new bone, but then gradually
get replaced by the patient's own healthy bone.
Speaker 1 (20:40):
Okay, let's move up to the sinus, the lateral window
sinus augmentation. When you make that window in the side
wall of the maxxilla, what's the main blood vessel you
need to watch out for.
Speaker 2 (20:51):
The big one to be aware of is the alveolar
antral artery. It runs within that lateral bony wall.
Speaker 1 (20:56):
And surgically, how do you minimize risk when making the window.
Speaker 2 (21:00):
A key surgical principle is to keep the bottom edge
the inferior border of your bony window at least five
millimeters above the actual floor.
Speaker 1 (21:09):
Of the sinus why five millimeters?
Speaker 2 (21:10):
This helps ensure you maintain a solid bony base like
a three walled box. It provides better containment for the
bone graph material and helps stabilize it.
Speaker 1 (21:19):
Interesting now we're also hearing more about graphless sinus lifts.
How is it possible to get bone formation way up
in that elevated space without putting any graph material in?
Speaker 2 (21:28):
It sounds counterintuitive, right, but it relies on the biological
potential of the sinus membrane itself, the schnadarian membrane.
Speaker 1 (21:35):
It has bone forming cells.
Speaker 2 (21:37):
It contains osteoprogenitor cells, yes, stem cells essentially. So when
you carefully lift the membrane creating that space and place
a highly bioactive implant surface like those modern anidized or
chemically treated surfaces we talked about, the elevated membrane acts
like a tent. Okay, the blood clot that fills the
space undernath becomes scaffold, and the cells from the mem
(22:00):
and potentially migrating from the surrounding bone can differentiate and
form new bone directly onto that implant surface. It's basically
guided tissue regeneration principles using the membrane as the barrier.
Speaker 1 (22:13):
Does it work as well as grafting?
Speaker 2 (22:15):
Studies show good success, especially if there's still a few
millimeters of existing bone height below the sinus to provide
initial implant stability. It might not create the same volume
of bone as a large graft, but it can be
sufficient for implant integration.
Speaker 1 (22:28):
Okay, vertical defects though. Building bone height, that's still the
toughest challenge, isn't it?
Speaker 2 (22:32):
Oh? Absolutely, Vertical augmentation is significantly less predictable than horizontal.
If you need a really substantial gain in height, say
more than four or five millimeters, what's the go to distraction?
Osteogenesis is probably the most reliable method for large vertical gains.
Speaker 1 (22:47):
How does that work? Again?
Speaker 2 (22:48):
You make controlled bone cuts attached mechanical device, and then
very slowly, day by day, you turn a screw to
gradually separate the bone segments. New bone forms in the
gap you create benefit. A huge advantage is that it
also stretches and brings the overlying soft tissue up coronally
along with the bone segment, so you gain bone height
(23:09):
and you improve the gum line position. The mucogingi ole junction,
which is often compromised in these cases.
Speaker 1 (23:15):
What about GBR for vertical.
Speaker 2 (23:17):
GBR can work for smaller vertical gains, maybe up to
three or four millimeters if you use techniques like tinting
screws to hold the membrane up and maintain that vertical space,
but it's definitely more technique sensitive than horizontal GBR.
Speaker 1 (23:30):
Okay. Finally, in this advanced section, let's touch on solutions
for severely resorbed jaws, Tilted implants, and zygomatic implants.
Speaker 2 (23:39):
Right. These are workhorses when conventional implant placement isn't possible
due to lack of bone. Tilted implants famously used in
concepts like all on four.
Speaker 1 (23:47):
What's the strategy there?
Speaker 2 (23:49):
The idea is to angle the posterior implants, often tilting
them forward to engage better quality bone that's usually still
present in the anterior regions like the front wall of
the sinus in the maxilla or anterior to the mental
nerve in.
Speaker 1 (24:03):
The mandible, and the benefit of tilting.
Speaker 2 (24:05):
It allows you to achieve a wider antioposterior spread the
distance between the most forward and most backward implants. This
provides better biomechanical support for the prosthesis and crucially lets
you minimize or even eliminate cantilevers off the back, which
reduces stress.
Speaker 1 (24:23):
And they often allow for immediate loading.
Speaker 2 (24:24):
Yes, because you're typically engaging denser bone and achieving good stabidity.
Tilted implant protocols very often allow for immediate placement of
a provisional bridge. Clinical success rates are excellent.
Speaker 1 (24:36):
And then there as zygomatic implants for really extreme cases.
Speaker 2 (24:40):
Exactly, Zygomatic implants are indicated when there's severe maxillary atrophy,
maybe after tumor resection, or in certain congenital defect cases
like cleft pallets where there's just no usable bone in
the upper jaw itself.
Speaker 1 (24:53):
So what do they anchor?
Speaker 2 (24:54):
They bypass the maxilla altogether and anchor into the dense
zygomatic bone, the cheekbone. Specialized very long implants, sometimes up
to fifty or fifty two point five millimeters long wow,
and they're usually placed at a sharp angle, often around
forty five degrees to engage that zygoma. They require specialized
training and surgical skill.
Speaker 1 (25:15):
Okay, incredible options for tough situations. Let's move towards the
finish line, now loading the implants and long term care.
Immediate loading sounds great, but what are the hard requirements?
What metrics must be met?
Speaker 2 (25:26):
It comes down to primary stability. It's non negotiable. You
need a high initial grip. The most common benchmarks are
a minimum insertion torque of thirty five Newton centimeters and
CMA or an ISQ reading. That's implant stability quotient measured
with resonance frequency analysis of sixty or higher. And if
you achieve that, then immediate loading is generally considered safe
(25:47):
provided the provisional restoration is designed correctly, meaning careful biomechanics.
For a full arch, absolutely no cantilever extending off the
back in the maxilla. In the mandible, you might allow
a very short candileate, typically limited to half the measured
ap spread between the implants and the bite. The occlusion
must be meticulously controlled, usually only light contact in the
(26:09):
center in a back teeth, no guidance contacts during chewing movements.
Speaker 1 (26:13):
Initially, who should definitely not get immediate loading? Who needs
to weight?
Speaker 2 (26:17):
Two main groups. First, patients with what we call a
thin scalloped gingible biotype. They have very delicate, thin gum
tissue that's prone to recession. A media loading in these
cases carries a high risk of tissue loss and esthetic problems.
Speaker 1 (26:31):
Okay, and the second group.
Speaker 2 (26:33):
Any site where you've had to do simultaneous major bone grafting,
the graph needs time to mature and integrate without being
subjected to the stresses of immediate function. Let the biology work.
Speaker 1 (26:42):
First, right, So once the final restoration is in place,
what's the standard maintenance protocol? How often should patients be
seen and what are we looking for?
Speaker 2 (26:50):
Maintenance is absolutely key for long term success. The standard
protocol usually involve annual checkups.
Speaker 1 (26:57):
What happens at the annual check.
Speaker 2 (26:58):
It should include standardized radiographs, usually periopical X rays focused
on the implants or maybe a panoramic X ray specifically
to monitor the bone levels around the implants.
Speaker 1 (27:08):
Year after year, and clinically.
Speaker 2 (27:10):
Clinically, you assess for any mobility, which should be zero.
You perform periodontal probing carefully around the implant, measuring pocket depths,
and you evaluate the health and width of the carotenized tissue,
basically looking for any signs of inflammation or disease, and that.
Speaker 1 (27:25):
Disease around implants perimplantitis, what causes it?
Speaker 2 (27:28):
Well, peri implant mucasitis is just inflammation and the soft
tissues like gingevitis. Periumplantitis involves that inflammation plus progressive bone
loss around the implant, and interestingly, the bacteria implicated imperiumplantitis
are often very similar to those found in chronic period
on titis around natural teeth, bugs like pro Pheromonis, Gingevollis,
Pravatella intermedia.
Speaker 1 (27:49):
So, if you diagnose active peri implantitis with bone loss
and you need to do surgery to try and regenerate
the bone, you first have to clean the contaminated implant surface, right.
Speaker 2 (28:00):
Absolutely, decontamination is critical before attempting any regenerative procedure. There's
a well known protocol described by Frome and colleagues.
Speaker 1 (28:09):
Can you walk us through that cleaning process?
Speaker 2 (28:11):
Sure, it's quite thorough, involving multiple steps. First, you mechanically
debride the exposed implant surface, usually with titanium or plastic
curets to avoid scratching the implant.
Speaker 1 (28:23):
Ok.
Speaker 2 (28:23):
Then you often use an air brace of device like
a prophy jet with fine sodium bicarbonate powder for about sixty.
Speaker 1 (28:29):
Seconds like sand blasting it clean this.
Speaker 2 (28:31):
Sort of but much gentwerre. Then you irrigate thoroughly with
sterile saline. After that, some protocols involve rubbing a slurry
of tetracyclin and antibiotic onto the surface for its antimicrobial effect,
and then then, believe it or not, a second round
of the air brace of treatment, and finally a rinse
or application of chlormaxidine antiseptic just before you place your
(28:52):
bone graft or membrane. It's a multi pronged attack on
the biofilm.
Speaker 1 (28:56):
Wow, that's intensive. Let's highlight a couple of common complications.
Residual cement left behind after cementing a crown. Why is
that such a big problem around implants? Maybe even more
than teeth.
Speaker 2 (29:08):
It's a huge issue and yes, arguably more destructive around implants.
The reason lies in the fundamental difference in the soft
tissue attachment. So natural teeth have sharpies fibers, these connective
tissue fibers that embed directly into the cementum of the
root and into the bone, creating a really robust physical barrier.
Implants don't have sharpiees fibers. The just have They have
(29:30):
a weaker junctional epithelial attachment and then loosely arranged circumferential
connective tissue fibers that run parallel to the implant surface.
There's no perpendicular.
Speaker 1 (29:40):
Insertion, so inflammation can spread more easily.
Speaker 2 (29:43):
Exactly if a piece of cement gets trapped under the gum,
the resulting inflammation isn't contained by those strong fibers, it
can easily spread down and around the entire implant platform,
leading to rapid bone loss. That's why keeping crown margins
easily accessible for cleanup. Ideally super and jibvel above the
gum line in the back of the mouth is really
strongly advised for cemented restorations and quickly two other critical
(30:07):
complications to prevent nerve injury and mandibular fracture for the
inferior alveolar nerve in the lower jaw. How can we
minimize risk during drilling Besides careful planning with CBCT, some
surgeons actually prefer not to give a full mandibular nerve
block anesthetic. They'll use local infiltration instead.
Speaker 1 (30:25):
Why would they do.
Speaker 2 (30:25):
That, It's a deliberate choice to keep the nerve partially responsive.
The idea is that if the drill gets too close,
the patient might feel some sensation, maybe heat, or vibration
which acts as an early warning signal to the surgeon
before actual damage occurs.
Speaker 1 (30:39):
Interesting tactic. And if numbness does happen.
Speaker 2 (30:41):
And lasts, if anesthesia or altered sensation dysysthesia persists beyond
about sixteen weeks, it's unlikely to resolve on its own.
Referral to a microsurgeon specialized in nerve repair should be
seriously considered at that point.
Speaker 1 (30:54):
And mandibular fracture sounds terrifying.
Speaker 2 (30:58):
It is, but thankfully it's very rare. It tends to
occur almost exclusively in patients with severely resorbed, very.
Speaker 1 (31:04):
Thin mandibles, and what triggers.
Speaker 2 (31:06):
It Often it's associated with using wide diameter, aggressively tapered,
self tapping implants placed with excessive force in that already
compromised bone. The stress just overcomes the bone strength.
Speaker 1 (31:18):
So the takeaway is gentle surgery and maybe different implant
choices in those.
Speaker 2 (31:22):
Cases, precisely careful, precise drilling, maybe using straight walled implants
with tapping in dense areas of a thin mandible and
absolutely avoiding excessive insertion torque.
Speaker 1 (31:32):
Got it? Wow? Okay, we have really covered a huge
amount of ground today we certainly have. I mean, we
started right down at the nanoscale talking about UV light
and three hundred nanimeters bumps on titanium.
Speaker 2 (31:42):
Yeah, the surface science, and we scaled.
Speaker 1 (31:45):
All the way up to managing complex systemic risks like
blood thinners and bysphosphonates, and then tackled major reconstructions with
distraction and zygomatic implants.
Speaker 2 (31:58):
Success isn't just about screwing something in. It's built on rigorous,
prosthetically driven planning, meticulous surgical execution, and understanding this constantly
evolving material science.
Speaker 1 (32:10):
But those core principles remain yeah, right, stability, biology, precision.
Speaker 2 (32:14):
They are absolutely the bedrock. Those don't change.
Speaker 1 (32:17):
Okay, So to help you listening cement some of this,
here's a final thought, a mini case study pulling directly
from our risk management discussion.
Speaker 2 (32:23):
All right, imagine this patient They've been taking an oral bisphosphinate, say,
for osteoporosis for five years now. They need a single
implant placed in their lower back jaw, the posterior mandible
and let's say the bone quality there is pretty good
type I R two. What's the primary risk factor the
implant team needs to discuss and manage regarding that medication
history and what's the current, perhaps slightly controversial thinking about
(32:47):
how to handle their bisphosphinite medication around the time of surgery.
Speaker 1 (32:51):
Goodwin, So think about that MRONJ risk low but definitely
increased after five years. Consider the debate around them drug holiday,
whether it helps and for how long, And of course
the absolute necessity of talking to the patient's physician.
Speaker 2 (33:06):
Exactly puts it all together perfect well.
Speaker 1 (33:08):
Thanks for joining us on this deep dive into surgical
implant principles. We hope it provides a valuable shortcut for you.
We'll catch you next time on the deep Dive
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