Running Time: 13 min Language:
This high-quality clinical video demonstrates the implant placement 12 months after a horizontal ridge augmentation procedure and the treatment results in a 50-year old healthy female treated for a thin, knife edge ridge in the mandibular posterior zone using a resorbable membrane and particulated autogenous bone with xenograft and rhPDGF (GEM-21). This video demonstrates in detail the surgical steps with microsurgical techniques to evaluate a staged horizontal ridge augmentation and the placement of 3 implants. The following details are discussed and demonstrated in this video: the diagnostics and treatment planing, the flapdesgn and -elevation, the bone regeneration result evaluation, three implant placements, the periosteal flap release and coronal repositioning and the primary closure with PTFE sutures. As a follow-up the panoramic radiograph are shown of the 2-week outcome. The patient is presented from initial start of treatment to the follow-up appointments during healing and narrated throughout by Dr Sascha Jovanovic. A part 1 of this video was released under CV-45 will demonstrate the first step of the treatment and the placement of the Bone Graft mixtur.
Release Date: November 09, 2012Subtitle:
The patient was recalled for normal follow up treatment, and due to personal reasons, it took the patient 12 months prior to the next step for implant placement. At this time, at 12 months, which normally would be somewhere between 6 to 8 months in a normal followup patient, a CT scan was taken and a panoramic x-ray. The panoramic x-ray demonstrates good amount of bone, specifically in the posterior left area. And now we requested a CT scan to evaluate the horizontal width. From the CT scan, we can see a beautiful amount of formation of horizontal bone at the crest. This quality is dense. It’s vascularized. And it demonstrates the difference in the narrow ridge, which the patient had initially, to now wide ridge. And it actually ranges, from in this particular patient, anywhere from 6 millimeters width to 8 millimeters width. And if we compare that to the previous CT scan prior to the bone augmentation, it ranged somewhere from between 2 to 4 millimeters. So we’ve gained in this patient anywhere from about 4 to 6 millimeters of horizontal width. We’re very confident to recommend this patient to receive three implants as the treatment plan called, and to be quite confident that the quality of bone will be excellent. The clinical procedure of the implant placement starts with a flap design which will be crestal, splitting the keratinized tissue equally to the buccal and to the lingual, full thickness down to bone, connecting the crestal incision to the sulcus of the mesial tooth, the canine, and then extentuating it all the way to distal so a good full thickness flap elevation can be achieved. A sulcal incision is moved towards the canine mesially. And then a [INAUDIBLE] chisel elevator is used to go full thickness and do a full thickness flap elevation towards the buccal, as well as towards the lingual. At this moment, a vertical short incision is made on the mesial line angle of the canine to give an easier elevation of the flap and to allow better visualization and evaluation of the newly formed bone. At this moment, an occlusive view demonstrates a beautiful horizontal gain of bone, which took the narrow knife edge ridge to now a ridge which is at least 6 millimeters wide, sufficient to place a regular platform implant. A beautiful view here of that augmentation achieved with the combination of autogenous, xenograft, and PDGF. A surgical guide stent is placed on the teeth, and then a precision drill is used to perforate the crestal the bone exactly where the three teeth have been planned to be used for the restoration. After the precision drill has been used, the surgical stand is removed, and the drill is used to accentuate the osteotomies to a depth of approximately 8 to 10 millimeters. Any kind of lose, fibrous tissue is removed, so that the osteotomies truly are in full, mineralized bone, important after bony regeneration so that the imposition of the drills and of the implants is really in mineralized bone. Here just from the drilling sequence, very well visible is that the quality of bone is dense and vascularization of the bone is optimal. Quite nice here on the facial view, the visual of the Bio-Oss incorporated in the newly formed native bone, the newly formed regenerated bone. The next to drill sequence follows the twist drills off in a straight Nobel speedy implant, which is going to be used here in this newly regenerated ridge. The length of the implant is long enough. We’re going to 13 millimeter, as this patient from the personal history had a car accident many years ago, and at that time a lost the innervation of the inferior alveolar nerve and had complete anaesthesia in this area. So we were able to take advantage of long implants and not having to worry really about the inferior alveolar nerve. So we were lucky in this case. The three implants here placed in the proper mesial distal position, also proper buccal lingual position, and of course care taken to maintain proper bone surrounding the implants and maintaining good integrity of this bone. Again, the drill is increased in sequence following the normal protocol for the Nobel speedy implant up to a length of 13 millimeter. Copious irrigation used with an up and down motion to prevent any overheating of this particular site. Here we’re going down, an occlusive view of the positioning, and then the approximate towards the surgical stent to know that we’re in the right position. Here, a visual of the occlusal, noticing great bone quality on the buccal and lingual. Implants started to be placed, the surface wettened with some sterile water, and then slow speed using 20 Newtons that the implant is positioned into its osteotomy. An incremental increase of torque is being utilized to limit the amount of pressure on the bone. So we go from 20 Newtons, then reversal, then increase to 30. And the implants will be placed with the neck of the implant at bone level. At this moment, no screw tip was used, just the normal twist drills, and the insertion of the implants here. The incremental increase of the torque with the bone level placed implant in this position. Maximum torque, which was placed here, was 45 Newtons. Second implant will be positioned here in the same way. You can see the Nobel speedy, with the tri-lobe connection, slow insertion, with an incremental increase of the torque in this particular case. Again, the maximum torque, which we are trying to achieve here, is 45 Newtons, till the implant is placed at the level of bone or slightly below. The third implant is interesting, because the density of the bone increases towards the posterior. At this moment, we’re increasing the torque on this implant to the maximum of 40 Newtons. But the implant was still too much torqued into the site. So at this moment, I chose to change the protocol and increase the twist drill to a larger twist drill to increase the osteotomy, again up to 13 millimeters, and then checked for any kind of perforations, especially towards the lingual, which was not apparent. And then I used the screw tap to prepare the osteotomy passively, so it could fit the implants. So this is a protocol which I used in this particular case because the density of the bone was so high that I could not place the implant without over-torquing the potential bone site and potentially micro fracturing the bone site. So now using a larger twist drill and a screw tap, and then preparing the site very passively to receive the implant. Now the second attempt to place the implant, as you can see. In the meantime, the implant was placed on the operating table in a titanium sleeve. And now you can see it moves quite nicely and guides swiftly into position. The second and third implant are slightly above the bone. So here comes the manual torque wrench, which is moving the implant at bone level, or slightly below bone level in this middle implant. And the same will be done at the third implant, again making sure that the torque is not more than 45 Newtons in this particular implant site. The three implants placed, all at bone level, well surrounded by healthy, regenerated bone, which was regenerated 12 months ago with the combination of one to one ratio of autogenous and xenograft. Three cover screws are placed for the purpose of getting a submerged healing. And the main goal in this particular case was to submerge this was, as the patient had minimal keratinized tissue, to be able to do a submerged healing, which will allow us after an appropriate osseointegration period of three to four months to do a mucogingival procedure to increase the keratinized gingiva. Certainly, we could have done here a stage procedure, based on the stability of the implants, but it would not have given us an opportunity to correct the thin keratinized tissue, and therefore would then, later on, have necessitated the use of a free [? gingiagraft ?] with a harvest from the palate, which would be a double trauma to the patient. So like this, we’re closing this with horizontal mattress sutures, using a mono-filament PTFE sutures. This is a Gore suture, and alternating horizontal mattress, and interrupted sutures. This allows us for a very beautiful ceiling and also maintaining, of course, as much as possible of the keratinized tissue as was available. The prognosis on this particular case will be excellent. Because the three implants are surrounded by great bone. The regeneration process was very successful. And we have great stability. We have good soft tissue. So now at this moment, we’re waiting for the healing of the bone and the soft tissues. Occlusive view giving us the full view of the closure and the limited amount of keratinized tissue. The follow up x-ray which was taken was a panoramic radiograph to demonstrate the position of the three implants. And as you can see, the three implants are well distributed, well paralleled to the canine, safety zone towards the canine, and a safety zone of horizontal bone between the implants. And the only thing as a comment that’s here that as you can see the implants are somewhat long in the second pre-molar and molar area. And that’s only possible in this particular patient as the patient had already complete anaesthesia for over 20 years due to the traumatic car accident she had at this time. So we were basically lucky to be able to place these long implants for her, which will allow us to give her then really a very stable restoration once the implants have gone through osseointegration. Prognosis is excellent. Follow-up healing will be now an osseointegration period of plus or minus three to four months. And then we’ll be ready to do an uncovering procedure with a mucogingival procedure to increase the band of keratinized tissue before the start of the restorative phase. For more education programs, visit the guide institute at www.VIDEdental.com