The importance of proper surgical training
This is a case that I have been meaning to post for a while. It really shows the importance of proper surgical training to make sure that you have a good feel for what drilling in to bone feels like and also when something just doesn't feel correct.
The patient in this case is an elderly gentleman that was edentulous posterior to the bidcuspids. Due to a nerve injury suffered during military service he is incapable of having anything past the bicuspid area. He had two existing bridges. One of which was the area of concern. There was recurrent caries under both abutments 5 and 8 respectively.
The plan was to remove 5 and 8 with concurrent placement of implants in the area of 5,6 and 8.
As you can see there is not a lot of wiggle room for #6 implant. I got a guide done by codiagnositcs. The reason I used them was I had already gotten the CT scan and didn't have the bite plate at the time. I didn't want to rescan the patient so with this method I was able to get a guide fabricated without having to rescan. The stone model was digitized and used to fabricate the guide. I also wanted to try out other options that are available to use. So I extracted the teeth a traumatically. Now as can be seen on the CT cross section of #8 there was not a lot of buccal bone. After extraction and inspection of the extraction sites is when things didn't feel right. I had planned on flapping to help build up the area of 6 but upon inspection of 8 the buccal wall felt "weak".
So I flapped it and with just the action of gentle reflection of the facial tissue the buccal plate at the coronal aspect peeled away with the tissue.
So now I am definitely having to graft. I verified the fit of the guide.
I then went ahead and started the osteotomies for the three locations. The two in the extraction sites went very smooth. The one for #6 didn't feel right when I drilled into the area. So I removed the guide and looked at where the osteotomy was. Low and behold it was lingual to the designed location.
What appeared to have happened is with no distal support for the guide the drill deflected off the hard ridge and gained purchase lingual into the palatal bone. This is where having a good grasp of surgery helped. The feel of the drilling into the bone did not feel right given the density of the ridge and then of course when probing the site it really didn't feel right. If this case had been done flapless it would have been very likely to place the implant and get good stability, however the implant would have only had the apical third completely in bone the coronal two thirds would only have had bone on the facial, mesial and distal. Just enough to integrate but not enough for long term success. I tried to free hand the osteotomy but with the damage to the lingual aspect all I got was a nice through and through defect to repair.
I went ahead and punched a few holes in the buccal plate to allow for medullary bleeding. I then placed the implants in the extraction sites.
So now the reconstruction of the facial area needed to happen. First we mix some a-PRF with cortical cancellous bone and Bioss. 
Then our membranes are placed. This is the sandwich technique that Farhad talks about.
Then we suture it closed and allow it to heal. I buried the implants to after it healed we had to uncover and let the healing abutments settle in. Here is the site after healing. Note the thickness of the buccal area after grafting.
Now we just need to temporize while the lateral wall grafting continues to settle in and stabilize. I want to give it a good 6 months before going back in to place the implant in the site of #6. So once the sites are uncovered we reline a shell temporary and recontour it to give good tissue and papillae support.
Now we wait. Once the bone has healed I will get a new scan and fabricate a guide to place the implant in the location of #6. With good stability we will reline the temp at the day of surgery. Then the restoration will happen.
The big take away from this is while guided surgery is definitely a huge benefit for us and our patients we as surgeons still need to have good surgical knowledge to be able to evaluate what is happening during surgery to make sure it is going as planned. And if not how to handle the complications that can arise.
Darin, Great Job!
I would work on soft tissue especially at premolar area with frenectomy. W
What do you think if you use "Socket Shield" technique? Gregory
On 2/10/2016 at 12:36 pm, Gregory Mark said...Darin, Great Job!
I would work on soft tissue especially at premolar area with frenectomy. W
What do you think if you use "Socket Shield" technique? Gregory
Spot on Gregory. I am already starting to see the frenum pull at the gingva. I plan on doing the frenuctomy in the near future.
As for the scoket shield. I have never done one but this wall was so fragile I would be afraid of it still being fractured like it was with the manipulation of the root pieces coming out. I can tell you I placed next to no pressure on the tooth to remove. It was barely held in place. I am not sure the wall wasn't fractured before I got in there.
Thanks for sharing that case. You are absolutely right, fully guided doesn't mean fully guaranteed.
I check every osteotomy with a guide pin or osteotome after the pilot drill to confirm correct angulation and depth.
I have had very few problems, but it only takes one...
https://www.facebook.com/gregory.mark.180/media_set?set=a.1174047749280517.1073741860.100000259103586&type=3
This is my case.
May be deepen the vestibule with soft tissue graft. Gregory
Also how was the process with the lab for the surgical guide?
For the future implant in #6 positiion will you fabricate a new guide with Sicat?
Nice Darin...and great example of why you need to be cautious with a free-end guide. Excellent documentation and explanation...
On 2/10/2016 at 1:38 pm, John Pasicznyk said...Also how was the process with the lab for the surgical guide?
For the future implant in #6 positiion will you fabricate a new guide with Sicat?
The process was fine. It was a little strange not placing the implants in the CT but I sent them what I had and they got it really close. We did a phone conversation with a shared screen to tx plan.
The next guide I will do with sicat. Or if I can get stability CERECguide 2. I'm not sure if that one will be stable enough however.
On 2/10/2016 at 1:45 pm, Darin O'Bryan (Faculty) said...On 2/10/2016 at 1:38 pm, John Pasicznyk said...Also how was the process with the lab for the surgical guide?
For the future implant in #6 positiion will you fabricate a new guide with Sicat?
The process was fine. It was a little strange not placing the implants in the CT but I sent them what I had and they got it really close. We did a phone conversation with a shared screen to tx plan.
The next guide I will do with sicat. Or if I can get stability CERECguide 2. I'm not sure if that one will be stable enough however.
What if you section that provisional and scan/mill a CG2 that's supported by the existing implants? Then have a backup provisional already milled for after surgery.
A perfect example of why the "Circle of Trust" isn't to be blindly trusted. Experienced surgeons such as yourself can manage these cases, and I do think it's important for well meaning people without comprehensive surgical implant training to pursue it if they want to integrate implant surgeries into their office. I see many failed guided and non guided implant cases in my office that were performed by weekend warrior implant surgeons who simply don't know that they don't know, and when a case goes poorly they continue to not know why that is and how to manage it. Well documented, well presented, well managed, and a great example for the community!
Jeremy
On 2/10/2016 at 2:30 pm, Jeremy Bewley said... A perfect example of why the "Circle of Trust" isn't to be blindly trusted. Experienced surgeons such as yourself can manage these cases, and I do think it's important for well meaning people without comprehensive surgical implant training to pursue it if they want to integrate implant surgeries into their office. I see many failed guided and non guided implant cases in my office that were performed by weekend warrior implant surgeons who simply don't know that they don't know, and when a case goes poorly they continue to not know why that is and how to manage it. Well documented, well presented, well managed, and a great example for the community! Jeremy
Jeremy,
As of now I am one of those weekend warrior implant surgeons. I finished Dr. Garg's implant course and his live patient in July of 15. I am reading and researching as much as I possibly can, but other than jumping in and developing my skills what would be your recommendations be for learning more advanced techniques on grafting and implant placement. As of now my l have very little experience in these areas. I have limited my procedures to very simple socket preservations and implant placements. Would you have any recommendations on any CE that I could learn more on grafting , membranes, and more advanced implant placement. I am wanting to provide the best possible care for my patients and would appreciate any suggestions you might have.
On 2/10/2016 at 3:56 pm, Robert Hunter said...On 2/10/2016 at 2:30 pm, Jeremy Bewley said... A perfect example of why the "Circle of Trust" isn't to be blindly trusted. Experienced surgeons such as yourself can manage these cases, and I do think it's important for well meaning people without comprehensive surgical implant training to pursue it if they want to integrate implant surgeries into their office. I see many failed guided and non guided implant cases in my office that were performed by weekend warrior implant surgeons who simply don't know that they don't know, and when a case goes poorly they continue to not know why that is and how to manage it. Well documented, well presented, well managed, and a great example for the community! JeremyJeremy,As of now I am one of those weekend warrior implant surgeons. I finished Dr. Garg's implant course and his live patient in July of 15. I am reading and researching as much as I possibly can, but other than jumping in and developing my skills what would be your recommendations be for learning more advanced techniques on grafting and implant placement. As of now my l have very little experience in these areas. I have limited my procedures to very simple socket preservations and implant placements. Would you have any recommendations on any CE that I could learn more on grafting , membranes, and more advanced implant placement. I am wanting to provide the best possible care for my patients and would appreciate any suggestions you might have.
Robert
What Jeremy is talking about is the doctor that goes to a single weekend course, usually put on by an implant manufacturer, and then starts placing implants with abandon. Taking a multi weekend continuum like Garg's course will definitely get you started on the right path. He has a master course that also covers advanced grafting techniques. Pikos also has a great series of course for grafting around implants. Either of those would be good.
On 2/10/2016 at 3:53 pm, Jeremy Heldt said...Awesome case, thanks for sharing. What PRF machine do you recommend?
This is the one that I am using.
http://www.a-prf.com/en/
On 2/10/2016 at 4:38 pm, Darin O'Bryan (Faculty) said...On 2/10/2016 at 3:56 pm, Robert Hunter said...On 2/10/2016 at 2:30 pm, Jeremy Bewley said... A perfect example of why the "Circle of Trust" isn't to be blindly trusted. Experienced surgeons such as yourself can manage these cases, and I do think it's important for well meaning people without comprehensive surgical implant training to pursue it if they want to integrate implant surgeries into their office. I see many failed guided and non guided implant cases in my office that were performed by weekend warrior implant surgeons who simply don't know that they don't know, and when a case goes poorly they continue to not know why that is and how to manage it. Well documented, well presented, well managed, and a great example for the community! JeremyJeremy,As of now I am one of those weekend warrior implant surgeons. I finished Dr. Garg's implant course and his live patient in July of 15. I am reading and researching as much as I possibly can, but other than jumping in and developing my skills what would be your recommendations be for learning more advanced techniques on grafting and implant placement. As of now my l have very little experience in these areas. I have limited my procedures to very simple socket preservations and implant placements. Would you have any recommendations on any CE that I could learn more on grafting , membranes, and more advanced implant placement. I am wanting to provide the best possible care for my patients and would appreciate any suggestions you might have.
Robert
What Jeremy is talking about is the doctor that goes to a single weekend course, usually put on by an implant manufacturer, and then starts placing implants with abandon. Taking a multi weekend continuum like Garg's course will definitely get you started on the right path. He has a master course that also covers advanced grafting techniques. Pikos also has a great series of course for grafting around implants. Either of those would be good.
Darin has the correct interpretation of my comments. Craig Misch usually does an Advanced Bone Grafting course once a year (November, I think) that covers all the the advancements in research throughout the previous 12 months. There's a pretty deep scientific presentation and clinical cases are presented. That course is usually 90% or more specialists. I met Pikos there. Highly recommend this course.
If you're still not feeling confident that you're able to provide the best treatment for your patients, I'd recommend finding a surgical mentor in your area who doesn't mind letting you observe and assist on procedures, and maybe even occasionally stand over your shoulder while you perform the procedures. These are important relationships to have, because we all have our own insights in how to approach a case and hearing what others have to say about a certain clinical situation can help you achieve better perspective and planning for your patients.
I also use the a-PRF system, with good results.
Jeremy
Darin,
You always show some great teaching cases.
What is the restorative plan on this. I am very cautious about unilateral fixed implant cases like this. Kind of scare me with function.
Michael
I will have a 4 unit FPD on the 3 implants. Proper control of occlusion is key in this case. I'm mapping out the occlusion in the temps to make sure his functional habits are not going to be a problem.
Darin. That is a great case to showcase your skills in planning and treatment. You show the necessary advanced skills that weekend warriors need to learn and gain confidence in to plan and treat patients lime this. Its cases lime this that make me push my envelope.
Thanks for showing cases that are real! Not all cases are straight forward.
JZ
insanely sweet my brother. great work and great documentation for all of us to learn from. fantastic!!
Hey guys, regarding the socket shield technique, Dr. Howie Gluckman from South Africa, developed a better protocol for socket shield. It may be posted on the Dental XP website. In a nutshell, don't go through the tooth with your implant drills as the original protocol called for, there is too much chatter. If the buccal shield is mobile at all, the technique doesn't work. Instead, take a surgical bur and split the tooth mesial-distal and carefully remove the palatal aspect without disturbing the buccal. Leave the socket sheild 1mm above the crest of the bone. Once the implant is placed graft the gap.
Darin,
First off as others have pointed out you handled this case beautifully.
I have the Co-Diagnostix software in addition to the DWOS (Dental Wings) software and we have been using Co-Diagnostix for several years now. I really like their software and workflow, especially the "Synergy" workflow with DWOS and we are starting to do some cool things with that workflow for fully edentulous cases. However, a word of caution:
In trying out many different guided surgery softwares/systems I still think the CEREC-Galileos workflow is the most precise one...AND my personal impression is that the merging algorithms in the CEREC-Galileos workflow are still more accurate than the other systems. This means that if you can't get an accurate merge in Galileos then it is not possible to get an accurate merge in any of the other softwares either (without the adjunctive use of other radiographic appliances).
While it is a distinct possibility that your osteotomy in site #6 was off due to the free-end guide situation, I think there is also a good chance that your osteotomy was off due to an inaccurate merge of the optical impression in Co-Diagnostix (or if you didn't use an optical impression merge then the fabrication of the guide based off the CBCT scan data).
I just don't want people to think that if they can't get an accurate merge in Galaxis then they can use other softwares without another intervening radiographic appliance step.
Farhad
Farhad
I agree that the sirona/sicat stitching and workflow is the best no question about it. The only reason I seriously think is was deflection is the other two implants went in perfect, but the bone was much easier to drill into. but
Now what I should have done was use the stabilization pins that are in the guided kit. That would have taken the possibility of guide stability out of the equation. But unfortunately I didn't realize there was a problem until the damage was done.
I would agree and not.
It is easier with CEREC and Sirona integration. But we have to keep in mind other factors: Like patient moved during scan. So it is not all about the system.
I also would rely on experience of practitioner. Gregory
