BASIC Level 1 Practitioner Certification€¦ · Because a good candidate includes a psychological...

BASIC Level 1 Practitioner Certification

1 – 1 2000 - 2003. Basic Dental Implants. All rights reserved. (888)888-1468 www.basicdentalimplants.com. V2.0

Notes:Chapter 1 – Pick the Patient

Correctly picking the patient, case selection, is one of the most important factors in implant treatment success. In fact, it ranks right along with correctly placing the implant! Wait just a minute…Case selection is as important as the placement procedure? Yes! We as doctors at BASIC want to impress upon you as doctors in practice that we need to be cautious and as fully aware as possible of the patients and situations that should preclude us from placing an implant. The demands on us are great enough. We don’t need problems that could and should have been foreseen. For this reason, this Omni-TightTM Certification Manual will state the cautions for implant placement first. Be informed and aware and then enjoy using the real neat stuff and enjoy providing a fine service for years to appropriate patients. As dentists, we treat patients with dental needs and desires. This is our professional duty and we do it well. However, we are also quite aware of our own and our patients’ human limitations. Therefore, a good understanding of diagnostic procedures, both initial and secondary indications, and patient communication skills, is extremely important for a successful treatment outcome before we ever pick up the anesthetic syringe. This is not a daunting task and repetition, along with your implant history and questionnaire for the patient, aids greatly our awareness of possible complicating conditions. Minimize procedural risk. Correctly picking the patient optimizes the Omni-TightTM

implant system so all of the built-in features are fully used and maximized. Maximize the likelihood of a successful osseointegration. Because a good candidate

includes a psychological and dental lifestyle screen, this minimizes the chance of infection, and other hygiene problems that can compromise osseointegration.

Provide caring service. Placing an implant for a patient that is not likely to properly care for the implant or who simply can not afford the procedure is not helpful to anyone.



Notes: What are the major actions of this activity? 1. Pick the Patient

Major Action: Overview: Tools, Equipment Materials, Etc.

a. Approach the patient

See if he/she is interested in a prosthetic service to replace a missing or non-restorable tooth

b. Conduct an initial clinical evaluation

I. Attain an excellent 1 to 1 ratio P.A. radiograph

II. Palpate proposed site for any abnormal anatomy (severe undercuts, etc.)

II. Evaluate crestal ridge width – underlying bone must be at least 6 mm wide

Radiographic or digital system with 1 to 1 capabilities

c. Review the patients history

Review the patients current medical, dental, and patient psychological history

Medical History and Dental History Evaluation forms

d. Discuss options and findings with patient

Inform before you perform

e. Conduct and evaluate a panograph or cephalometric radiograph

Take Pano or Ceph (for overdenture service) and evaluate for adjacency to vital structures and anatomy

Panoramic System or Ceph. System

f. Using ridge diagram, bone map the proposed site

Implement bone mapping procedure Anesthetic, sharpened SS perio-probe, or bent anesthetic needle, endo stop. Cast and bone map

g. Take excellent impression

Take excellent anatomical impression of proposed implant site for quadrant or full arch cast

Impression Tray and Material

h. Make Model TomographTM

Determines useable bone volume from B/L aspect

Cast, Bone Soundings, Calipers

i. Approach the patient to make a final determination

Advise patient of fee and receive permission to construct a Model-TomographicTM of the proposed site

j. Provide the patient the written information

Dispense informational booklet with medical history form and informed consent form

Patient info packet Consent form

k. Schedule Appointment

Schedule Appointment time for procedure Appointment schedule



Notes:How do I do this? a. Approach the patient (initial) At this point, you have pre-qualified the patient as having a high potential for a single tooth implant option. Now, it is time to discuss the option with the patient. Most patients have five options. Explain the five treatment options. Each option has advantages and disadvantages.

Quickly go through each with the patient. Type Description: Advantage: Disadvantage:

1 – Nothing No cost Long term hygiene and oral health consequences, migration of surrounding and opposing teeth

2 – Three unit fixed bridge 6 to 10 yrs

Reduce two teeth to replace one

Two-week replacement time, known procedure

Reduce two teeth, long term hygiene and oral health consequences

3 – Removable partial denture (Nesbitt)

Clasp retained to adjacent teeth

Inexpensive Removable, decay potential, overall oral safety i.e. swallow or aspiration debonds

4 – Maryland bridge

Partially reduce two teeth

Less tooth reduction Shorter life, Debounds, long term hygiene and oral health consequences

5 – Omni-tight Single tooth implant

Titanium root and attached crown

No tooth reduction, longer lasting, highly esthetic result

Time for osseointegration

Explain your recommended solutions (If appropriate for the patient). After

discussing the advantages and disadvantages of the five (5) possible options, help the patient reach a decision on the best option for him or her. If the patient qualifies for the implant and is comfortable with the procedure and cost, the vast majority will find the single tooth implant as the best option! If the Omni-tight system appears to be a viable solution at this point, explain the Omni-tight system in greater detail.



Notes:Suggested Dialogue – Use before conducting the radiographs EXPLAIN: “Based on what we know at this point, I would recommend the Omni-Tight™ single tooth replacement implant system for you because it is reliable and it works when certain conditions are met. Let me explain a little about this solution.” EXPLAIN: “The system works like this …. (Use the laminated pictures if available). After the missing tooth area is numb, a small hole is placed into the gum and underlying bone. The implant, that you can think of as a root of titanium, is gently screwed into place within the channel and allowed to bond or heal to the surrounding bone for three or four months. We have known for a long time that bone will grow to titanium under suitable conditions over 97% of the time and become stable. Due in large part to the high-tech design of this system’s titanium root and unique channel preparation instruments; we achieve an immediate physical fit of the root to the bone surface enabling us to often take a crown impression at this same appointment. Then with excellent oral hygiene on your part and good healing of the bone, we can have your new tooth in place, attached to your own bone in just four months without having to cut down your adjacent teeth. This is preventive dentistry of the highest form!” EXPLAIN: “In order to further evaluate whether this solution would fit your needs, we will need to conduct a couple of evaluations. There are four (4) we will conduct. If any of these indicates that you would not be a good candidate for this procedure, we will consider other options. If each comes back positive, we then conduct a fifth evaluation which also prepares two items we use during the procedure.” ASK: “Should we move forward with the evaluations?” Conduct P.A. and Pano. Radiographs Suggested Dialogue – Use after the conducting the radiographs If by clinical exam and dental radiograph, your patient appears to be appropriate for an implant, the following dialog might be used and tailored to the situation. EXPLAIN: “You know ____________there are several options available to us to replace your missing tooth and we will discuss each separately, but I think you might like to know, that we can offer a dental implant placed here in our office using just local anesthetic. A new simplified system allows us to do this without painful surgery and often without sutures. This means we could provide a tooth for you without having to cut down your natural teeth on either side of the space in order to place a conventional fixed bridge. We may be able to provide this option for you for very little more money than the standard gold bridge with porcelain on it. ASK: “Is this something you might be interested in learning more about?”



Notes:If positive, discuss briefly the other options, provide the patient with an information packet, (e.g., history with informal consent form, etc.), conduct the bone mapping and reappoint for a consult. You must also have an excellent P.A. film of the proposed site with adjacent teeth fully visible as well as a panograph for major structure determination. You will then do a diagnostic work up to be sure physical criteria are met, and at the time of consult go over the patient’s history, answer any questions from the packet and outline risks, healing time and end positively with a reasonable fee and encouragement. EXPLAIN: Your new tooth will feel more natural because it is not welded to adjacent teeth Better looking because there are no adjacent crowns needed It’s non-destructive to adjacent teeth Longer lasting because there is no decay potential around the crown, but you must still

exercise excellent oral hygiene It’s really additive, protective dentistry rather than subtractive, destructive dentistry to

replace a missing tooth Achieve the patient’s consent to conduct the investigation. Once the patient agrees to

have the procedure, provide the consent form. Ideally, the patient will read the form and ask questions during the same visit.

Option 1: Patient Agrees to move forward with the evaluations - Move to the next action. The patient signs the consent form and completes the current medical history. Option 2: Patient wants more information - Sometimes, patients with a “systematic” decision-making style may ask for more information before agreeing to the procedure. It is completely appropriate to provide additional information and schedule a follow-up call or visit to make a decision. ASK: “What specific concern do you have about the procedure?” Concern: Suggested response: Cost About the same as a three crown bridge Possible pain “There are no nerve endings in the bone; you may sense vibrations at times.” Safety “This product and procedure are highly effective with only 1 in 25 implants failing. If

failure happens, we can still make a three unit bridge” With ongoing maintenance

“The implant should last years, and is easily maintained with normal flossing and brushing”

Effectiveness “The procedure is very effective. The crown is not welded to adjacent teeth. There is both a natural appearance and feel.”

Option 3: Patient declines to move forward with the evaluations - Some patient’s may be concerned and may need a little helpful nudging. Although you did not go into dentistry to “be a salesmen” if you feel the single tooth implant is the best option, it is certainly the ethical path to try and provide the appropriate level of influence. Ask questions. There are a couple of very straightforward questions you can ask to

discover why the patient is reluctant to agree to the procedure. See Option 2.

Remember:

Patients are looking for your informed

leadership!



Notes:b. Conduct an initial clinical diagnostic evaluation Identify likely candidates. We understand the benefits of dental arch integrity. When in

our clinical exams we observe a missing tooth (teeth) space, it is a reasonable first step to evaluate how best to remedy the deficiency if the patient is so inclined. No treatment is also offered. The patient must be offered those options that we in our professional judgment deem applicable. These options might include a RPD, NRPD or variations or an implant. The implant might be the treatment of choice if there exists adequate bone, sound adjacent teeth (that you believe should not be cut down), sufficient vertical room, and a patient amenable for various reasons.

Consider cautions. Now that we have examined some important medical, dental and

psychological cautions and understand that this area is extremely important, it is time to begin to look at case/patient selection as it relates to the implant placement possibility.

How is an “Acceptable Bone” Site Determined?

Implant diameter will be determined most often from the B/L aspect but in certain situations will be determined from the M/D aspect when adjacent roots and/or crowns are close together.

Medically? Dentally? Psychologically?

By patient records

B/L Volume? By Bone Mapping and the

Model Tomographicsm

Determines: 1) Usable Bone Volume – B/L 2) Implant Body Direction – B/L 3) Implant Body Diameter – B/L*

M/D Volume? By P.A. Film Overlay Determines: 1) Usable Bone Volume – M/D 2) Implant Body Direction – M/D 3) Implant Body Diameter – M/D* 4) Implant Body Length – V

Bone Density? By Excellent Radiograph Determines: 1) Bone density (D1, D2, D3, D4)

Vital Site Structures? By PANO Film Determines: 1) Vital structure adjacent to implant site



Notes:What are the Case Selection Needs from a Bone Volume Aspect? Determining if a patient is a good candidate for this procedure involves five (5) separate albeit integrated evaluations. 1. Patient records (Current), Med. Hx, Dental Hx, Psychological 2. Pano Film 3. An Excellent P.A. Radiograph or 1 to 1 digital picture 4. Accurate Site Cast 5a. Bone mappings of the site 5b. Model Tomographic Note: Because the accuracy of the five (5) patient records will later determine the parameters of the three dimensional (3-D) surgical guide stent, they must be very accurate. Each is critical in this process. Please read the following directions carefully and have your staff do likewise and then be very observant to assure an excellent outcome. When viewed together, the five (5) evaluations will clearly indicate whether the patient is a good candidate for the Omni-tight single tooth procedure. However, at this point in the process, 5b is not completed. Why? 5b requires additional expense and time, and is only conducted if the other four indicate a high probability for positive selection. Model Tomographic is conducted after the previous evaluations are positive AND the patient agrees to move forward with the procedure. It is unlikely that the Model Tomographic will reveal additional information that excludes the candidate. This happens in about 1 out of 25 candidates. 1. Pano. Film – Hints

• The pano. must be clear enough to easily see and delineate the major nerve channel, mental foramen, and anterior extent of the nerve canal on the view box.

• Determine what magnification percent is achieved with the machine you are using. Machines vary greatly from nearly 1 to 1 to as much as 25% or more enlargements.

• Learn to trace the alveolar nerve canal, especially the superior fold back aspect and its relation to the apex of adjacent roots and mental foraman. This learned ability helps greatly your evaluation of the P.A. film and all that it shows.

2. Excellent P.A. Film – Hints

This heading says it all. The film must pass scrutiny from every correct aspect:

• One to one ratio (very important) • No elongation or foreshortening of adjacent teeth • Site adjacent teeth and root tips clearly visible • Soft tissue thickness above cortical bone visible on view box or hot light • No occlusal anatomy of adjacent teeth visible



Notes:3. Create a quadrant or full arch dental stone cast – Hints When constructing a model tomographic, the more ridge anatomy present, the more accurate the directional stent. For example, the laboratory can’t do a good job of stent fabrication when they receive an impression or cast with a ridge only ¼” high and bordered by the tongue and collapsed cheek. In other words, the excellent alginate impression should completely capture all of the ridge height possible with no interference from the cheek or tongue. This is easily accomplished by injecting alginate into the vistibular areas adjacent to the proposed site using a 60 ml monoject syringe. Don’t forget the lingual vistibule. This injection is done before placing the alginate filled three-way or sectional tray. Full closure and a static tongue reminder to the patient will insure a great impression if the 3-way tray is used. The cast should be poured with at least a ¾” base and medium density stone should be used. Buff lab. stone works well. 4. Take Five (5) bone mappings of site – Hints We need to know the bone volume and its shape beneath the site ridge soft tissue. We can either have an $800.00 CAT Scan made of the site or construct a Model-Tomographic™ using five (5) bone sounding of the ridge bone and about $2.00 in materials.

• Using the ridge diagrams, a 90-degree bent anesthetic syringe needle, and an endo. stop, map the underlying ridge bone anatomy with at least five measurements

• Be certain that the needle is pushed into the anesthetized ridge site tissue fully until the bone is truly felt and stops the advancement of the needle

• The pierced soft tissue will push the endo. stop disc along the bent portion of needle until the bone is met

• The needle is then withdrawn and the distance from its apex to the endo. stop is the gingival thickness in mm

• This can be easily measured on an endo. ruler and this number in mm denoted on the ridge diagram in the correct orientation: i.e. B/L,B/P mandibular, maxillary

• Keep the needle parallel with the horizontal plane • Infiltrate with local anesthetic or a lidocain patch

5. Patient Records As presented in the section on the “indications and cautions of this procedure” the patient’s records, medical history, current treatment, current prescriptions, dental history, current dental treatment, dental goals, and psychological (motivation, desires and expectations versus reality) conditions should all be considered when identifying the appropriate candidate. When first starting out, it is clearly advisable to be cautious, and when in doubt about the viability of the patient’s situation, err on the side of caution. Long time patients of record may be best.



Notes:Note: The following actions c through f can be conducted in any order c. Review the patient’s medical, dental and psychological history Evaluate the medical history. Systemic, healing and bone regeneration problems are

certainly severe cautions for implant osseointegration and long-term retention. Bone deficiency disease of all types is an extreme negative. These include Diabetic concerns even if the patient is “controlled,” immune deficiency disease, patients under Ca treatment; as well as cardio vascular disease. One should be very careful and consult with informed professionals and keep them in the loop.

Evaluate the Dental history. Is this patient a problem patient when it comes to treatment

outcomes? Do their desired far outweigh treatment results? Are they constant complainers? Are they ready to litigate at the drop of a hat? Do they take oral hygiene seriously? Are their bills paid on time or a constant problem? In other words, only place implants for motivated patients that have high regard for the practice and you the practitioner.

Review the psychological evaluation. We cannot obviously know the hearts and minds

of our patients completely but a general sense about our patients of record or referral patients with a good recommendation is important. Out staff will often be a good resource. Being always upfront with our presentation of options and realistic with the probable outcomes is truly wise. Be sure the patient is fully aware of potential problems and understanding of the matters that cannot be easily remedied such as thin tissue, gingival retraction about adjacent teeth that will more than likely result in some triangular “black holes.” Let them know beforehand so that there are no surprises. As the dental school saying goes, “Always inform before you perform – especially as to possible outcomes. Send perfection oriented people elsewhere.

d. Discuss options and findings with patient Meet with the patient to discuss records and your determination as to whether or not the patient is a viable candidate for an implant. At this point, you should also make the determination as to whether or not you will be doing the placement. You will encounter patients that are good candidates for implant placement that you feel comfortable working for. You will also find patients that are good candidates that you would feel more comfortable referring to a specialist.



Notes:e. Evaluate the implant site using an Excellent Radiograph e.1 Take a current, excellent radiograph. If the initial clinical diagnosis is positive, then take a current and an excellent P.A. radiograph of the proposed implant site. e.2 Check site using the clear PA Film Implant Overlay. The Omni-Tight™ P.A. Overlay is a critical tool in evaluating the implant site and selecting the best possible implant. It determines the M/D and depth information of the proposed implant site while the Model-Tomographic is very important in B/L or B/P information determination of the proposed implant site. Together, the two enable the fabrication of the drill guide stent. Use the Omni-Tight™ clear overlay, to quickly check for implant limiting structures. When the plastic overlay is placed on top of an excellent P.A. dental film of the proposed implant site and placed on a view box, we are able to determine with excellent accuracy: The most correct implant size (both initial diameter and length) via the silhouettes The best position for the implant in the site relative to surrounding structure The most correct height for the pilot drill guide cylinder via the overlay formula All of the sizes offered are represented in silhouette form on these transparencies both in

length and width on a single overlay. The BASIC companies’ overlay is also used in conjunction with our Model-Tomographic aid.

A low maxillary sinus floor A large and high mandibular nerve canal Mental nerve orifice Implant room between crowns and roots Adjacent root angulation Bone density Crestal bone presence or absence Crestal soft tissue thickness Note: This implant diameter size determination will be for the M/D aspect only and may change when we determine the B/L width of the ridge bone. Think 3-D! The Panoramic radiograph is very important to locate vital structures to stay away from with the implant. Interpolation is used since the magnification of the Pano may very from 1 to 1 up to 25% or more. Thus, the Omni tight PA Overlay is only rarely used. The percent enlargement can easily be determined arithmetically by the measuring of a P.A.'s 1 to 1 root versus measuring the same root on the panoramic radiograph and calculating the enlargement. For the same root - Example: A) 20 mm (1 to 1) root versus B) 25 mm panoramic root

Or

B-A A

25 –20 20 = 0.25 or 25% enlargement



Notes:e.3 Consider implant adjacency - Consideration must be given to a 1.5 to 2 mm margin of safety of bone between the apical end of the implant and the adjacent vital structures such as the floor of the maxillary sinus and the mandibular nerve canal and mental foramen. Also there should be a 1.5 mm or greater margin of safety of bone between the implant body and the buccal and lingual cortical bone plates. There should be at least 1.5 mm of bone between the implant body and adjacent roots. e.4 Consider bone quality – Although this is a rather subjective determination short of biopsy, a fairly accurate assessment of the type of bone can be made from the P.A. film according to trabecular pattern, density of the lacunar walls and general opacity. There are four bone density classifications:

D1 – (Most Dense), D2 – (Good Density), D3 – (Fair Density), D4 – (Least Density)

Excellent P.A., Panograph, Lateral Cephalometric. (for overdenture use)



Notes:

Overlay Features: 1. Determines the recommended bone height with reference to the placed implant. The crest of the bone should rest somewhere within the trumpet flare of the implant neck for a “corking “effect to ward off soft tissue invasion and to aid in stabilization during osseointegration. 2. Determines the gingival height or thickness above the bone crest in mm increments 3. Determines the right implant size. The implant silhouettes on the overlay match all the current implant sizes available both in diameter and length. The numbers beneath each silhouette denote the top diameter (e.g. 3.5 mm) by length (e.g. 11 mm). 4. Determines the “constant.” The constant numbers are derived from subtracting the length of the implant silhouette below the recommended bone height line from the pilot drill length from cutting tip to collar stop. Example: Pilot Drill So then: 21 mm – 10 mm (that amount of the 11 mm implant actually in bone in the ideal situation) = 11 the Constant number below the 3.5 X 11 implant silhouette. 5. Determines the Pilot Drill Guide Height Formula. The constant number for the silhouette implant chosen minus the gingival thickness equals the pilot drill guide cylinder height. The gingival thickness can most often be seen on an excellent P.A. film, so its thickness can be measured beneath the overlay via the 1 mm increment gingival height interrupted lines. The ridge top bone sounding measurement should confirm this tissue thickness number.

21 mm

1

2

3

4

5



Notes:Example: An Overlay on an Implant Site It can be seen then that the Omni-Tight™ overlay is very important and extremely useful for the M/D aspect of the site. Observe angulations of implant silhouette due to: adjacent crowns and roots.

Radiographic Marker Ball This 5mm marker ball is utilized in those instances when the exact magnification percentage of a radiograph is unknown. This is often the case in older panographs both film and digital and in digital P.A.’s. Radiographic film P.A.’s are very nearly 1 to 1 when taken correctly, perpendicular to long axis of the proposed site. Therefore the BASIC P.A. Film Implant Overlay may be used accurately on these films only. Methods in Marker Ball Use:

1. The 5mm ball is stabilized in the proposed site upon the cast (super glue or sticky wax). A vacuform “suck down” stent is then fabricated trapping the ball within the stent. The stent should be trimmed so that it can be placed and removed easily in the patients mouth and yet be stable and secure. Once placed in the patient’s mouth, a radiograph is taken.

2. The 5mm ball is incorporated into an amount of soft wax (orthodontic or beeswax) and placed directly into the proposed implant site in the mouth and stabilized to the adjacent crowns by virtue of the tackiness of the wax. Patient is fully instructed in its care. The radiograph is taken and the wax removed.

Either method works well. The stent is of course safer and is to be utilized for those patients that are suspect in the care of the wax procedure. The marker ball then shows up in whatever magnification is present but this is not important because the doctor knows in reality the marker is 5mm. The caliper is then set to the radiographic diameter and the magnified bone is measured in these caliper increments.



Notes: e.5 Determine the anatomy, angulation, and volume of the mandibular bone.

Implant Size Choice vs. Available Mandibular Bone

Note the cutback (Submandibular gland fossa)

Note the thinness



Notes:e.6 Determine the anatomy, angulation, and volume of the maxillary bone.

Implant Size Choice vs. Available Maxillary Bone



Notes:f. Using ridge diagram, bone map the proposed site At this point, the patient appears to be a good candidate for an implant based upon history, and the PA radiograph. However, we still don’t know enough about the shape of the bone, especially the crestal ridge, to be certain the implant is a good choice. To determine this, we conduct an initial, limited bone mapping procedure. This preliminary mapping answers two critical questions: Is there a knife-edge ridge bone configuration set? Is there physically enough bone present to reasonably encapsulate the implant body top

1/3? f.1 Make the mapping gauge (option). Bone mappings are easily made by measuring the patient’s soft tissue thickness about the proposed implant site ridge. This is accomplished by using: or:

• An anesthetic syringe • BASIC mapping instrument

• A 27 gauge needle • BASIC Mapping needle

• A choice of local anesthetic • Special topical spray

• A small rubber disc called an endodontic stop • Endodontic stops

The anesthetic needle is bent at a 90º angle one half inch from its apex using a three pronged pliers. The disc is pierced through its center and pushed 1 mm back from the apex of the needle tip. Basic now has a bone mapping instrument available using the finest ultra thin needles for a near painless procedure! f.2 Take the bone mappings. Five or more bone mapping are now taken at the spots on the proposed ridge site that are indicated on the Model Tomographic adhesive label and noted in mm on the spaces provided being sure to note the Buccal aspect and the lingual or palatal aspect. Take mappings through tin foil or make on cast where measurements were taken on ridge site.



Notes:f.3 Anesthetize the area. A drop of anesthetic is injected into the soft tissue spot. Or, if using the topical spray, a narrow strip of gauze is sprayed lightly and placed onto the ridge site for 2 minutes f.4 Make the first sounding The needle tip is then slowly progressed into the soft tissue pushing the rubber disc along the needle until cortical bone is encountered.

f.5 Check the sounding The needle is then retracted and a measurement is made from the needle tip to the rubber disc. This is the exact thickness of the soft tissue covering the bone.

f.6 Examine the measurement The measurements are taken using an endodontic gauge or Boley gauge.

f.7 Record the sounding and repeat The procedure is repeated for each of the four or more remaining ridge spots and the measurements noted on the adhesive label for record purposes.

Perio. Probe alternative

Anesthetic Syringe Alternative



Notes:g. Take an Excellent Impression This impression will be the basis for further evaluation and the manufacture of the surgical stent so the quality of this impression must be excellent. Use either 3-way tray or closed tray with opposing impression and bite relation. As was outlined on EA 1 – 8, the taking of an impression is critical. Your staff must be shown the correct procedure in all aspects so that the entire site anatomy is available in the impression. Use of the large syringe is important and adequate material utilized. I still like alginate, fast set, of excellent quality if I am going to pour the impression. The material is your choice however just be sure the impression is outstanding. Spray with debubbleizer prior to the pour up and have a nice base amount. Use buff laboratory stone of good quality but not die stone – much too hard to section.



Notes: h. Make Model-TomographicTM (In office or by certified laboratory) At this point in the process, the practitioner has conducted a four part evaluation of the patient; the patient has consented to move forward and is aware of the fee. What is the Model-Tomographic TM, PP The Model-TomographicTM is a unique and proprietary implant site diagnostic and practical aid that is integral to the Omni-Tight placement protocol. This aid gives us the critical visible information about the transverse aspect of the proposed implant site. The aid allows us to accurately evaluate the useable bone volume of the site from a width (B/L) as well as a directional (shape) standpoint. The Model-Tomographic TM, PP and surgical guide stent came about because we at Bio Anatomical Systems wanted a physical means to aid the dentist in placing the implant body in the most exact position within the site bone. This meant that both the pilot and osteotomy drills had to be directed accurately and three dimensionally. It’s one matter to know your drilling direction from, let’s say a CAT scan, but it’s entirely different to translate that information to the brain and then to motor skills to duplicate that visual information, not to mention the different planes involved that must be addressed simultaneously. We believe that using a placement drilling guide stent that incorporates 3-D information into its construction makes a great deal of sense, especially for the busy general practitioner. Armed with the information from the P.A. Overlay and completed Model-Tomographic, we developed a double cylinder Delrin guide complex and a protocol for an in office or dental laboratory constructed drill guide stent. This placement guide not only informs us of the start point (as all other guides do also), but physically directs the pilot drill for direction as well as length (depth) of channel, and physically directs the osteotomy drill in the same manner. In other words, it guides us to three dimensionally place the implant in that position within the ridge site that the informational data states is the most appropriate. It does away with the need to “free hand” drill into a surgically flapped site with the subsequent loss of vital vascularity to the cortical bone and enables a “cookie cutter” hole approach, which greatly increases safety, reduces risk and postoperative pain, and enhances the potential for an excellent treatment outcome.



Notes: How do I Fabricate the Model-TomographicTM? 1. Gather the required materials The preliminary needs and materials necessary in the construction of the Model-TomographicTM are as follows: An excellent periapical (P.A.) dental x-ray radiograph of the proposed implant site and

adjacent teeth A Panograph radiograph An excellent full arch or quadrant three way impression of the proposed site, capturing all

of the pertinent adjacent anatomy and tooth crowns Five (5) or more bone mappings (to determine the overlaying tissue thickness) of the

ridge of the implant placement site Materials needed: Impression material of choice and a three-way sectional or full arch tray Anesthetic syringe, needle and anesthetic of choice Endodontic stop (a small disc of rubber) BASIC Implant P.A. Overlay Dental plaster, bowl, spatula, vibrator Die pins Plaster cutting hand saw or disc Endodontic measuring gauge or Boley gauge Red and black permanent marking pens of ultra small tip type Swiss style needle file (small) of triangular shape 1.8mm diameter twist drill (BASIC Pilot Drill) – cast type not surgical Chromed guide pin



Notes:2. Pour the Impression Take a three-way or sectional alginate impression. Take an excellent impression of the proposed implant site including the adjacent teeth using a dimensionally stable dental stone, not die stone. The impression should be poured up in soft, quick-set dental stone for the construction of the Model-TomographicTM. The pour should be trimmed and made ready for a die pinned and base procedure. Closed tray option

2.1 Alginate impression Use the 60 ml monoject syringe to take a full anatomical impression.

2.2 Ensure the accuracy of the impression This shows a good anatomical capture. This is critical for the positive outcome of this cast!

2.3 Make the cast This shows the poured cast in yellow dental stone, not die stone. Crown and root direction (from the PA and Panograph film) denoted on the cast and proposed implant direction and starting point also denoted.



Notes:3. Prepare the cast Trim the cured plaster cast, pin the underside at each side of the edentulous proposed site and pour up a plaster pin holding base. Don’t trap the model; stop at the base of the cast. 3.1 Review the radiograph film This mandibular film shows the:

• Occlusal plane • Cortical bone • Adjacent tooth root angulations

3.2 Determine the M/D direction From the excellent P.A. film determine the best M/D direction of the proposed implant by virtue of the root angulations of the adjacent tooth or teeth. This determination is made from the lateral standpoint using the P.A. Implant Overlay. Keep the implant silhouette as vertical as possible.

3.3 Mark the cast Draw the root angulations of the adjacent tooth or teeth on the plaster cast from information derived from the P.A. film, PANO and cast anatomy. 3.4 Draw the best angulations line Now for the proposed implant body using the previously drawn adjacent lines and P.A. film as your guide. This then will be the first guide plane determination, i.e. the lateral M/D determination of the 3-D direction. Keep this direction as vertical as adjacent roots and crowns will allow.

Note: This is important because we do not wish to intersect adjacent roots, vital structures, abscesses, cysts or foreign bodies with the proposed implant, but wish to keep biting forces as axial (vertical) as possible. Axial occlusal forces are good. Non-axial occlusal forces are poor.



Notes:4. Make the tomo cut Place a 1 mm red dot on the top of the proposed implant site at the point you think the implant needs to be from a functional and esthetic standpoint. This position may or may not change as per the Model-TomographicTM. 4.1 Make the narrow cut Using a fine blade plaster saw or disc, cut the proposed site plaster through and through transversely (cross sectionally) about 1 mm in front or in back of the 1 mm red dot already made at the site ridge top. This dot was placed on what would be a line connecting the central grooves of the adjacent teeth if present.

4.2 Cut through The saw cut should parallel the directional line you made between the adjacent root directional lines.

4.3 Complete the cut Cut the plaster model just to the die pin base plaster. Expose and tap the die pin ends beneath this base and remove the now separated site cast. Choose for the graphic site the side upon which the red dot rests.



Notes:5. Make the Model-TomographicTM

Use the Bone Mapping Measurements to mark the model. 5.1 Mark the perimeter Dot the cut surface chosen of the transversely sliced ridge model at five or more designated points of measurement. This is easily done using a small mm designated ruler, measuring from the outer most portion of the model inward towards the cast center.

5.2 Make an outline Next connect the dots using an ultra fine tip black pen thereby outlining the interior edge of the soft tissue covering of the bone. (Please Note: The picture above shows two extra measurements dots).

5.3 Color it in Color in the perimeter with a red pen, which represents the soft tissue covering. What you now see in graphic form is an accurate, life size cross sectional picture of the proposed implant site showing with stark contrast, the extent of the soft tissue present and the extent and shape of the hard tissue (bone) present!

5.4 Check the silhouette This outlines the actual bone volume and shape of the bone as seen from a transverse (Buccal-Lingual) perspective. This enables us to determine the best width and direction of the implant body. Determine the best implant size using the P.A. Overlay and by physically laying each silhouette size atop the available bone on the model and choosing the best diameter (width) implant (silhouette) and position (direction) in the bone volume. As you can see, the accuracy of this model is unprecedented. The impression is highly accurate when done with stable material, and the bone mappings are accurate since they are taken from the patient’s actual site. This creates accuracy unmatched even by computer aided Tomograms and at one-tenth the cost.



Notes:6. Mark the implant direction 6.1 Orient the silhouette Place the best-sized silhouette upon the cast bone volume available in the best possible attitude (direction) for stability, bone healing potential, function, and prosthetic esthetic orientation.

6.2 Draw in the long-axis Now with an ultra-fine tip black pen mark the center top of the implant silhouette and the center apex of the positioned silhouette through the tiny holes provided in each implant silhouette. Connect the two dots, after removing the transparency, with a dark pen and straight edge.

This line is now the best directional guide for the implant to take via the drilled bone channel, from Buccal-lingual or Buccal-palatal (transverse) aspect.

NOTE: If the proposed site bone volume is found to be appropriate from the Buccal-Lingual aspect, then the Model-Tomographic’sTM use continues and is used to construct the three dimensional pilot drill and osteotomy drill guide stent. If the proposed site bone volume is found to be too minimal from the Buccal-Lingual aspect for implant placement then the following steps are taken:

1. Patient informed that the site is not appropriate as is. 2. They could be referred for bone regeneration procedure (oral surgeon or

periodontist) to increase available bone. 3. Revisit options previously outlined.



Notes:If the B/L bone volume is acceptable: 7. Make the cast B/L pilot drill channel 7.1 File the groove Using the triangular file or a saw blade and following the long-axis line exactly, file a groove atop this line for its full length into the dental plaster. This line may or may not intersect the initial dot that was made on the top of the ridge. Intersecting it would be the best, but the pictured bone volume present and diameter of implant chosen takes precedence over this initial mark.

7.2 Round out the groove The filed groove is now rounded out along its entire length using a model pilot drill. The depth should be just enough to accept the chromed cylinder guide pin when the two parts of the model are reseated in the die pin base.

7.3 Check the pin Insert the chromed guide pin into the newly prepared channel. This pin, as it extends above the Model-TomographicTM, now shows exactly the three -dimensional direction that we have determined would best place the implant for healing and final crown positional reasons.

7.4 Check the pin, again The cast is again separated to make sure the chromed guide pin is indeed in the slot created for it.



Notes:8. Evaluate the Model-TomographicTM

Consider the Mesial/Distal (M/D) – The excellent P.A. radiograph gives us information

about the available mesial-distal site bone present with respect to our choice of implant. Namely:

Possible width of the implant with respect to adjacent crowns and roots Possible length of the implant (vertical bone height available) with respect to vital

structures: mandibular, nerve canal, mental nerve, sinus floor Best M/D implant body direction with respect to adjacent roots and/or sinus floor

anatomy. Remember to keep the implant silhouette as vertical as possible yet consistent with directional parameters

Consider the Buccal/Lingual (B/L) – We are now able to get accurate information

about the B/L bone volume of a ridge site by using a Boley gauge, bone mappings (tissue thickness measuring probes) and the Model-TomographicPP, TM.

Consider structure adjacency – As we have already stated (and will continue to do)

vital structure position is extremely important when considering implant diameter (3.5, 4.0, or 4.5 mm) and length (11, 13, 15 mm) for the bone site. The Omni-Tight™ overlay is very useful in this regard. The overlay enables us to see not only what size and length of implant to utilize, but where to place the chosen implant with respect to not only vital structure but also:

• Crestal soft tissue thickness • Crestal cortical bone placement within the “trumpet” area yet below the polished

tissue surface of the implant (ideally located after implantation) • Adjacent roots with their direction determined and 1.5 mm margin of safety of

bone should be between the implant body and adjacent roots • Periodontal and/or periapical rarefactions. These must have been treated and well

under control and healing before starting adjacent implant placement • Retained roots or artifacts • Other pathology or degenerative processes



Notes: i. Approach the patient to make a final determination When examining the proposed implant site, look for: Sufficient horizontal (both B/L and M/D) and vertical residual bone (unless splitting or

augmenting) at the placement site to adequately accommodate the implant body. Are the opposing and adjacent teeth repairable or in good condition, or is a NRPD a

better choice? Is the implant site in the anterior or posterior areas of mouth and in the maxilla or

mandible? Bone type and quantity vary greatly from area to area. Is there super eruption of the opposing teeth into the implant site, occlusal problems,

orthodontic considerations, TMD complaints? Will RPD design, either in the present state or in a future appliance come into play? Will the implant be free standing, splinted to another implant or be attached to another

tooth? I discourage this last option because of lack of ligament structure around an osseointegrated implant body.

By completing the previous evaluations, each within the specified parameters, the patient has been determined to be an excellent candidate for the Omni-tight system. Suggested Dialogue – “We should move to next step” EXPLAIN: “After reviewing the results of our evaluations, it is my opinion that the Omni-tight system would be an excellent solution for your missing tooth. ASK: “Do you agree that we should move forward?” Option 1: Patient agrees – Continue with the next action Once the patient agrees to have the procedure, provide the patient consent form in the patient portfolio. Or, ask the patient to read the information in the lobby and discuss it when the patient is ready during the same visit. Option 2: Patient is unsure – Discuss any questions or concerns the patient may have. ASK: “What is your specific concern about the procedure that I can help you address?” Concern: Suggested response: Cost It is about the same as three-unit bridge.” Possible pain “There are no nerve endings in the bone, you will only sense

vibration.” Safety “This product and procedure are highly effective with only 1 in 25

implants failing. If that is the case, we can still make a three unit bridge With ongoing maintenance

“The implant should last years, and is easily maintained with normal flossing and brushing.”

Effectiveness “Statistically, one out of twenty-five implants fail, but I believe you are an excellent candidate for this procedure. The implant has the added benefit of not altering any other teeth so all of your other options remain open if there is any problem.

Option 3: Patient wants a different solution - Discuss the agreed to treatment option.



Notes: j. Provide the patient the written information Either as part of the decision-making process or once the patient has signed the consent form, provide the patient with the “Patient Handout.” Note: Additional copies of these handouts and videos are available through Basic Dental Implants. k. Schedule the procedure Depending on the patient’s condition up to this point, there may be four (4) possibilities. Option 1: Schedule an extraction on an existing tooth Option 2: Schedule a bone augmentation (regeneration) Option 3: Schedule the implant procedure Option 4: Schedule a re-evaluation



Notes:What would an expert do? Do a thorough evaluation. Evaluate all potential implant sites for soft and hard tissue

regeneration thereby allowing nearly all sites laterally appropriate. It is very difficult to regenerate bone vertically more than 2 mm unless a distractive osteogenesis treatment is used.

Overly clarify patient expectations. Be certain that the patient’s desires and

expectations are fully discussed before treatment. Some patients are unrealistic and demand visual perfection in the result.

Keep it current. Stay current with the patient’s medical history and consult with the

patient’s physician for any and all medical concerns. Refer it. Refer out any cases that are not within your comfort zone or your patients. What are some cautions or problems? Overdentures. A word about mandibular o-ring/ball attachment support. This procedure

is of great help to the patient who has lived with a loose fitting mandibular denture, but be extra careful and get good mentoring advice: • An anterior flap procedure is a must because the bone may have a knife like ridge

and must be flattened to accept the implant body. • An A/P (cephalometric) film is necessary to evaluate the actual remaining

mandibular anterior bone anatomy and volume for directional purposes. • Very careful pilot and osteotomy drilling will have to be done free-hand because

of the instability of a guide stent due to lack of adjacent crown support. • Be extremely careful not to perforate the lingual cortical bone due to potential of

vascular penetration and its extreme complications. • Bottom line: Get good advice, watch several actual procedures, be certain of the

anatomy with a full flap observation, and utilize excellent films and have a mentor present for your first placement procedure.

The site location. Many practitioners won’t go distal of 1st molas in the mandible or

maxilla due to lingual perforation potential in the mandible and extremely poor bone density in the maxilla resulting in an unstable implant

Over recommending. Always inform and be truthful about the procedure and potential

results. Do not talk a patient into having an implant placed if he or she is not supportive of the idea after an initial discussion.



Notes:Case Study: Are they a good candidate?

Directions: Individually, read the situation. When done, answer each question as a table group. Please be prepared to share your responses with the larger group. Situation 1: A middle aged female patient of record presents with an understanding that you now place appropriate implants and wishes to have a missing upper right cuspid replaced without grinding down the adjacent teeth in the process. She has recently been tested for osteoporosis and has been placed on medication for the condition. What would you do? Situation 2: Mrs. Astis presents by referral from a new patient because she has been advised that you do “fantastic anterior teeth.” She shows gingival recession about her remaining anterior and the darn Maryland bridge keeps debonding.” She just wants a beautiful anterior and is willing to pay for it What would you do? Situation 3: Bill Roth presents with tooth #30 missing. He has worn a Nesbitt partial for 20 years and it just doesn’t fit anymore. He understands that in some cases, you can place a titanium root and cement a crown on top and he can function again. He doesn’t much care how he looks just so he can eat again and is comfortable. His ridge height is okay but the width is insufficient by 3 mm What would you do?

BASIC Level 1 Practitioner Certification€¦ · Because a good candidate includes a psychological...

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