Pasqual Oral & Maxillofacial Surgery

Hyperbaric Oxygen in Wound Healing

Although not a new concept or treatment modality as this was the subject of scientific articles dating back to the mid 1980’s. Robert Marx even had a specific study article on Osteoradionecrosis published in the Journal of the American Dental Association in 1985. Since then there have been many studies and publications regarding the effectiveness of HBO in improved would healing. Most importantly, in recent years many communities have established centers for wound healing and hyperbaric medicine.

The indications for hyperbaric oxygen include:

  • Diabetic wounds of lower extremity
  • Gas gangrene of tissues
  • Compromised skin grafts and flaps
  • Carbon monoxide poisoning
  • Delayed radiation injury
  • Decompression sickness
  • Necrotizing soft tissue infections
  • Air or gas embolism
  • Osteomyelitis (Refractory)
  • Select problem wounds
  • Crush injury, compartment syndrome and other acute traumatic ischemia

The principals of hyperbaric oxygen treatment are to increase the dissolved oxygen content in blood plasma and the diffusion distance for oxygen into tissues.

The physiologic benefits are:

  • Correction of tissue hypoxia in partially ischemic, infected or irradiated tissue.
  • Stimulation and support of fibroblast replication, collagen synthesis and angiogenesis.
  • Reduction of local tissue edema by alteration in blood flow with greater diffusion of oxygen into tissue.
  • Enhancement of leukocyte killing of microorganisms, improved antibiotic function and direct toxic effects on anaerobic organisms.

When combined with appropriate conventional wound care such as surgical debridement, antibiotics, edema control and pressure relief, many previously non healing wounds can be successfully managed. In our area of involvement, HBO has been shown to provide significant benefit in treating established and preventing new osteoradionecrosis of the jaws in patients at risk.

Patients with established osteoradionecrosis or who have had previous head and neck radiation treatment and who are scheduled for elective dental extractions or oral maxillofacial surgical procedures, should be referred for evaluation for HBO treatment. Of note is that to date HBO therapy has not been shown to be effective in treating jaw osteonecrosis caused by pre oral and maxillofacial surgery bisphosphorate chemotherapy agents specifically Zometa and Aredia.

The Palm Beach Center for Oral Surgery and Dental Implants providing
quality care to Delray Beach, Boca Raton, Boynton Beach, and  Palm Beach
County.  561.900.9080 www.PasqualOMS.com

 

The Palm Beach Center for Oral Surgery and Dental Implants providing
quality care to Delray Beach, Boca Raton, Boynton Beach, and Palm Beach County.

561.900.9080 | www.PasqualOMS.com

Treatment Planning Dental Implants for the Fully Edentulous Patient

The fully edentulous patient represents a group of individuals who may be missing teeth, teeth and gums, or, teeth, gums and bone.

Composite Defect:

A denture is a prosthesis which can replace teeth, gums and / or bone. The tooth part is obvious. It is the “white” portion of the denture. The gum and bone are replaced by the “pink” portion of the denture. The more resorbed the maxilla or the mandible, the thicker the pink portion of the prosthesis. In treatment planning the fully edentulous patient, it is essential to identify and quantify the soft and hard tissue defects. Several different prosthetic designs are available for treatment of this group of patients. The types of prosthesis available to treat the composite defects are: the overdenture, PFM Bridge, and the Hybrid Bridge.

Prosthetic Options:

Prosthesis available to reconstruct the composite defects have specific biomechanical properties. It is essential to understand the biomechanics of the prosthesis before treatment planning. I will define the IRTS and the IRIS designs.

IRTS ( Removable Prosthesis):

IRTS is the acronym for the Implant Retained, Tissue Supported prosthesis. This prosthesis is essentially a denture. The IRTS is also known as the overdenture. When the patient occludes, the prosthesis is supported by the gingiva and the bony structures, such as the alveolus, palate, and the buccal shelf. The implants should be only involved in retention. When the denture is lifted off the alveolus, the implant’s retentive components play their role.

The most common retentive components of an over-denture is the gold or plastic clip. The implants are connected to each other by a bar, The clip should be fabricated with a spacer in place so that there is no contact of the clip with the bar at rest or centric occlusion. The clips engage the bar and are in “function” as the denture is pulled away from the alveolar ridge. The placement of the clip is critical so that it only contacts the bar as the denture is lifted sway from the alveolar ridge. During all other loading of the denture, the denture should only contact and be supported by the soft and hard tissues. To accomplish this goal, a single clip is placed parallel to the hinge axis. Therefore, the prosthesis rotates around the bar with no loading of the implants. Disadvantage of this type of prosthesis is one of continuous resorption of the alveolus as minimal internal loading is introduced within the edentulous ridge. This presents an ongoing clinical evaluation and relining of the denture base.

IRIS (Fixed Prosthesis):

The IRIS prosthesis is usually a fixed prosthesis. The gold screws retain the prosthesis to the abutments. During centric occlusion, only the implants are supporting the bridge, as there is no soft or hard tissue contacts between the base of the prosthesis and the edentulous ridge. The loading of the implants introduces internal forces to the edentulous ridge and results in maintenance of the residual alveolus similar to the dentate patient.

This type of prosthesis provides the most stable functional appliance with minimal long-term maintenance.

How many implants to place?

The number of implants for either type of prosthesis depends on the ridge being reconstructed.

The Fully Edentulous Mandible:

The anterior mandible represents type I bone. For the IRTS prosthesis, 2 implants are placed in positions 22 and 27. For the IRIS prosthesis, 5 implants are placed between the mental foramanae.

The Fully Edentulous Maxilla:

The anterior maxilla is type III bone. For the IRTS prosthesis, 4 implants are placed in positions 6, 7, 10 and 11. For the IRIS prosthesis, 6 implants are distributed between the first bicuspids. The limiting factor in this arch is the anterior extension of the maxillary sinus.

The Palm Beach Center for Oral Surgery and Dental Implants providing
quality care to Delray Beach, Boca Raton, Boynton Beach, and  Palm Beach
County.  561.900.9080 www.PasqualOMS.com

 

The Palm Beach Center for Oral Surgery and Dental Implants providing
quality care to Delray Beach, Boca Raton, Boynton Beach, and Palm Beach County.

561.900.9080 | www.PasqualOMS.com

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Anesthetic Considerations in Oral Infections

One of the most difficult situations for both the practitioner and the patient is when adequate paincontrol cannot be accomplished during a procedure. This may be very challenging, especially when the patient is experiencing an infection. In these cases, the patient may present with pain alone or in conjunction with swelling. It is important to understand the pharmacology of the local anesthetics and the physiology of the infection in order to optimize the patient care.

Local anesthetics present in two chemical states, a weak base or a unionized form that penetrates tissue and an impermeable cationic state that does not penetrate tissue very well. When the local anesthetic is administered into an infected environment with a low ph, there will be a greater concentration of the cationic form. (1) The clinical effect will result in delayed onset and decrease intensity of the local anesthetic. Another theory proposed is that in an infected area there is degenerative and inflammatory changes found in the nerve structures. (2) These findings support the need for administration of nerve blocks, as opposed to local infiltration. This will allow the local anesthetic to be administered away from the infected site.

When administering the local anesthetic as a block in an infected environment, it is imperative to change the needle. Using the same needle will cause seeding of the tissue into deeper tissue planes. Never inject directly into tissue that is underpressure from the abscess. You must first establish some form of drainage prior to local infiltration. This will be much more comfortable to the patient and you will not tract the infection into deeper tissue planes.

The local anesthetic that has the closest Pka to the tissue Ph will demonstrate the quickest onset time. Mepivacaine falls into this category and is a great anesthetic to use in an infected patient when lidocaine is not doing the job. (3) Mepivicane is best administered in the plain form, without the vasoconstrictor in order to help overcome the acidity created by the infection.

Using a larger amount of the local anesthetic (but not exceeding the maximum recommended dose) will allow a greater concentration of the unionized form to penetrate the tissue. Other techniques for increasing volume of local anesthetic to the infected site include periodontal ligament injection and interseptal injection technique.

Most important of all, you must have patience and allow adequate time for the local anesthetic to take effect. This may take up to 10-15 minutes. During this time, it may be helpful to place the patient in an upright position.

Treating the infected patient has many challenges and satisfactory results may not always be achieved, despite the aforementioned techniques. At this point, there are two final options available. One is to place the patient on antibiotics and have them return another day or you can refer them for treatment under general anesthesia. Communication plays a major role in these situations, and the patient must be prepared for all possible outcomes.

  1. Hersh EV, Condouris GA: Local anesthetics: A review of their pharmacology and clinical use. Compend Contin Educ Dent 1987,8:374-382
  2. Brown RD: The future of local anesthesia in acute inflammation: Some recent concepts. Br Dent J 151:47, 1981
  3. Jastak JT, Yyagieva JA Donaldson D: Local anesthesia of the oral cavity. Philadelphia WB Saundes 1995

The Palm Beach Center for Oral Surgery and Dental Implants providing quality care to Delray Beach, Boca Raton, Boynton Beach, and  Palm Beach County.  561.900.9080 www.PasqualOMS.com

The Palm Beach Center for Oral Surgery and Dental Implants providing
quality care to Delray Beach, Boca Raton, Boynton Beach, and Palm Beach County.

561.900.9080 | www.PasqualOMS.com

Antibiotics and Kidney Disease

Surgical patients with renal disease offer special challenges to the treating doctor.  Antibiotic coverage during the perioperative period if merited should be carefully chosen.  These general guidelines listed  are no substitute for a nephrology consultation prior to surgery.  The renal specialist plays an important role in medication choice and dosage.

SAFE ANTIBIOTICS
Clindamycin: No dose change
Azithromycin: No dose change
Doxycycline: No dose change
Metronidazole: Normal dose for Mild/Mod. disease
Vancomycin Pulvules

ANTIBIOTICS WITH ALERTS
Pen VK: Prolong interval
Amoxicillin: Prolong interval
Augmentin: Decrease dose
Ampicillin: Decrease dose
Dicloxacillin: Decrease dose
Keflex: Prolong interval
Duricef: Prolong interval
Clarithromycin: Avoid
Metronidazole: Prolong interval for severe disease
IV Vancomycin: Avoid
1)Pen VK: INTERVAL PROLONGED; DOSE UNCHANGED

a)Serum Creatinine < 2.0 mg/dL or the CrCl is > 50 mL/minute:
Pen VK is dosed normally at 250-500 mg PO q6h
b)S. Creatinine 2.0 mg/dL to Predialysis or CrCl 10-50 mL/minute:
Pen VK is dosed at 250-500 mg q8-12h
c)Patient on Dialysis:
Pen VK is dosed at 250-500 q12-16h

2)Amoxicillin: DOSE UNCHANGED; INTERVAL PROLONGED

a)Serum Creatinine below 3.3 mg/dL or Cr Cl >30 ml/minute:
Dispense the normal dose of Amoxicillin: 250-500 mg PO q8h
b)Serum Creatinine above 3.3 mg/dL to Predialysis or Cr Cl 10-30 ml/minute:
Prolong the interval and dispense: 250-500 mg PO q12h
Avoid using the 875 mg tablet
c)Cr Cl <10 ml/minute or the Dialysis Patient:
Prolong the interval and dispense: 250-500 mg PO q24h
The dose must be administered after dialysis completion

3)Augmentin:
Decrease the total dosage by 50% in the renal compromised patient

4)Azithromycin:
Use full dose of Azithromycin in the Renal compromised patient
Kidney disease: No dose change is needed with Kidney disease or Renal failure
Used with 50% total dose reduction in patient with both Kidney & Liver disease

5)Metronidazole (Flagyl):
Dose adjustment is required only in the presence of renal failure/dialysis
Metronidazole should be dosed at 500 mg PO q12h instead of q8h after the dialysis

6)Tetracycline HCL:
a. Serum Creatinine between 1.25-2.0 mg/dL or CrCl 50-80 mL/minute:
Dose Tetracycline HCL q8-12h
b. Serum Creatinine between 2.0 mg/dL to Pre-dialysis or CrCl 10-50 mL/minute:
Dose Tetracycline HCL q12-24h
c. In the presence of Dialysis or CrCl <10 mL/minute:
Dose Tetracycline HCL q24h

7)Doxycycline:
No dose change needed with kidney/live/kidney & liver disease

The Palm Beach Center for Oral Surgery and Dental Implants providing quality care to Delray Beach, Boca Raton, Boynton Beach, and  Palm Beach County.  561.900.9080 www.PasqualOMS.com

The Palm Beach Center for Oral Surgery and Dental Implants providing
quality care to Delray Beach, Boca Raton, Boynton Beach, and Palm Beach County.

561.900.9080 | www.PasqualOMS.com

Antibiotic Decision Making

The Players:

PenVK:

Effective against most oral organisms including anaerobes, has a low toxicity. and low cost. A loading dose of 1,000mg followed by 500mg every six hours for 7 days (cost $17). Significant portion of population (10%) has some history of allergic reaction.

Amoxicillian”

An analogue of penicillin that is rapidly absorbed and has a longer half-life. Has a higher and more sustained serum level and a slightly larger spectrum. Associated with occasional diarrhea. Usual dose is 1,000mg loading dose followed by 500mg every 8 hours for 7 days (cost $17).

Augmentin:

A combination of amoxicillin with clavulanate (inhibitor of enzyme produced by bacteria to inactivate penicillin). Slightly more effective. The usual dosage is 1,000mg loading followed by 500mg every 8 hours for 7 days (cost $87).

Clindamycin:

Effective against gram-positive aerobic microorganisms and anaerobes. Good choice if a patient is allergic to penicillin. Usual dose is 600mg loading dose followed by 300mg every 6 hours for 7 days (cost $107). Warning of colitis. Rarely seen in short term but inform patient of symptoms.

Cephlosporins:

Don’t offer much more than Penicillin. Possibility of cross allergicity with penicillin. If penicillin allergic history is not severe can use with caution. Usual dose is 1,000mg loading dose followed by 500mg every 6 hours for 7 days (cost $30).

Flagyl (Metronidazole):

Used in combination with penicillin or clindamycin. It is effective against anaerobes and used when that is expected to be a significant factor, but lacks activity against aerobes. Usual dose is 1,000mg loading dose followed by 500mg every 6 hours for 7 days (cost $32). Patients should not drink alcohol when taking this medicine. Can increase INR for patients on warfarin.

Z-Max (Azithromycin):

Doesn’t work as well as others. Popular because of long 1/2 life and easy to give once a day. Oral dosage 500mg loading dose followed by 250mg every 12 hours for 6 days (cost $90)

Erythromycin:

Not effective against anaerobic bacteria, has a poor spectrum, significant GI upset and not used much any more for oral infections.

The Plan:

When treating an infection I consider its history, clinical findings, and the patient’s health. Then I ask myself “at the rate it is progressing what will it look like in 2 or 3 days”, and I then treat that infection. Look for the etiology and remove the cause. The antibiotics may take 48 to 72 hours to get an effective response. Therefore it may be counterproductive to switch antibiotics just because it is not getting better after a day or two. Look to I & D if possible.

Penicillin, Amoxicillin or Clindamycin are still the drugs of choice for oral infections along with removing the etiological cause.

The Palm Beach Center for Oral Surgery and Dental Implants providing quality care to Delray Beach, Boca Raton, Boynton Beach, and  Palm Beach County.  561.900.9080 www.PasqualOMS.com

The Palm Beach Center for Oral Surgery and Dental Implants providing
quality care to Delray Beach, Boca Raton, Boynton Beach, and Palm Beach County.

561.900.9080 | www.PasqualOMS.com

Bone Screws and Plates for Orthodontic Anchorage

The extent to which teeth can be moved with orthodontics is dependent on the available anchorage. When the necessary forces required to move teeth in a particular direction cannot be applied with traditional anchorage techniques (appliances on other teeth), orthodontic practitioners have relied on extraoral anchorage and/or orthognathic surgery to achieve desired results. Unfortunately, headgear use is lengthy, compliance dependent and inappropriate for many patients; orthognathic surgery is expensive and seldomly covered by insurance carriers. For these reasons, there has been an ongoing search for new anchorage techniques.

With the advent of osseointegrated dental implants, dental researchers found that orthodontic forces could be applied to an osseointegrated root form dental implant without implant movement or damage to the implant’s structural integrity. Dental implants, for these reasons, can be ideal orthodontic anchorage sources. If a patient is “fortunate” enough to need dental implants, orthodontics, and the implants will be in an appropriate location to serve as orthodontic anchors, amazing tooth movement can be possible. If the patient does not need tooth replacement, root form implants can often be placed in the retromolar areas or palatal areas to serve as anchorage devices. Following the completion of orthodontic treatment, the implants are then removed, or when possible, the implants are “put to sleep” by allowing soft tissue to cover them. One shortcoming of this technique is that the implant surgery can be extensive and cost prohibitive.

Recently, much research has been directed toward the possibility of using titanium alloy plates and screws, like those used in facial fracture repair, for orthodontic anchorage. Numerous prospective studies have proven that these screws and plates can predictably withstand typical orthodontic forces and that they can be placed with minimally invasive surgical procedures. Typically, screws or plates are placed bilaterally between or apical to tooth roots in appropriate locations for the orthodontic practitioner to use as orthodontic anchorage. These surgical procedures can often be completed with local anesthesia or IV sedation and local anesthesia. This topic is currently popular at orthodontic and oral and maxillofacial surgery continuing education meetings. I have attended several such meetings and the results shown are very impressive. In some cases, results previously thought to be impossible without orthognathic surgery are being
accomplished. Reported complications have been minimal. The success of this research has prompted several companies to market ADA and FDA approved plate and screw kits specifically for these procedures.

I recently placed orthodontic anchorage plates on a patient for the purpose of retracting her maxillary teeth to eliminate overjet. After applying orthodontic forces for only a few months, her orthodontist reports her progress to be very good. This patient had previously been in conventional orthodontic treatment for 2-3 years without success.

Based on results I have seen from the research and my personal experience with this technology, I firmly believe that skeletal anchorage with bone plates and screws will become a standard of care for treating many difficult orthodontic cases. It will definitely become an affordable alternative to orthognathic surgery for correction of some malocclusions.

The Palm Beach Center for Oral Surgery and Dental Implants providing quality care to Delray Beach, Boca Raton, Boynton Beach, and  Palm Beach County.  561.900.9080 www.PasqualOMS.com

 

The Palm Beach Center for Oral Surgery and Dental Implants providing
quality care to Delray Beach, Boca Raton, Boynton Beach, and Palm Beach County.

561.900.9080 | www.PasqualOMS.com

Smoking – Why Does It Reduce Implant Success?

It is generally well recognized that the skin of smokers appears prematurely aged when compared to nonsmokers. We all recognize higher rates of periodontal disease and lower rates of implant success in smokers. Oral bone and soft tissue grafts in smokers fail at alarming rates.

What is the commonality in these adverse effects of smoking? The reality is that one of the chemical effects of nicotine and other substances in cigarette smoke is vasoconstriction. Nicotine causes vessels, particularly capillaries, to constrict for varying amount of time after each cigarette is smoked. The more frequently one smokes, the less time the capillaries have to recover and in a short period of time, capillaries atrophy and disappear. Thus, the smoker has a reduced blood and oxygen supply throughout all areas of the body when compared to the nonsmoker. With reduced blood supply, they are less able to repair the normal everyday damage sustained from the environment and the activities of daily living. For example, normal trauma to teeth that is generally subclinical and easily repaired at the microcellular level in the smoker is not repaired to the same degree due to a decreased blood supply to the area.

The skin of smokers exposed to sunlight and other oxidative stress is less able to reverse and repair these challenges and, therefore, ages at an accelerated rate when compared to a nonsmoker of similar age and background.

Bone and soft tissue grafts, which in essence are transfers of tissue to a recipient bed in the mouth, are at tremendous risk of failure in the smoker due to a decreased vascular bed to nourish these grafts. If they do not become incorporated, they simply become infected or atrophy.

Finally, dental implants, which depend on bone ingrowth at the microscopic level in order to integrate, fail at higher rates in smokers due to compromised blood supply which then compromises the bone’s ability to grow densely into the implant surface.

Ironically, if smokers can cease smoking for three months prior to these procedures, the majority of the capillary density is reformed and bone, soft tissue and implant success rates rival those of people who have never smoked.

As dental professionals, we have the opportunity to advise our patients as to the specific risks of smoking as it relates to their oral health. By explaining to patients how smoking affects our ability to heal and accelerates our aging, especially as it relates to the oral cavity, we, as dental professionals, can improve not only our patients’ dental implant success rates, but also their overall health.

Doing so may not only add years to their lives, but also add life to their years!

The Palm Beach Center for Oral Surgery and Dental Implants providing quality care to Delray Beach, Boca Raton, Boynton Beach, and  Palm Beach County.  561.900.9080 www.PasqualOMS.com

The Palm Beach Center for Oral Surgery and Dental Implants providing
quality care to Delray Beach, Boca Raton, Boynton Beach, and Palm Beach County.

561.900.9080 | www.PasqualOMS.com

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Dental Implants or Bridge Work- Making the Best Choice

When you need to replace a missing tooth, there are two general alternatives to consider: You can choose traditional bridgework, or select the newer option of dental implants. Both offer a solution that’s reliable, functional, and esthetically pleasing. However, there are a few important differences between the two systems.

A fixed bridge is a dental restoration that’s held in place by attachment to the adjacent natural teeth, which are referred to as abutments. The tooth-replacement section — called a “pontic” (after the French word for bridge) — spans the gap. Pontics require attachment to the abutments by either a metal frame, or today, a space age porcelain, to bridge the space from abutment to abutment. The system works well, but there’s a catch: Even a single-tooth replacement requires a three-unit bridge — and healthy adjacent teeth must be “prepared” by removing their enamel, which increases the risk for root canals.

By contrast, a dental implant can be a single-tooth replacement system, with no effect on healthy adjacent teeth. It involves placing a titanium metal implant directly into the living bone of the jaw, in a minor surgical procedure. After a short time, the bone and the implant fuse, and a crown restoration is placed on top to complete the prosthetic tooth system. Dental implants don’t decay, and they’re less likely to lead to gum disease than a natural tooth bridge. They also last longer, potentially offering far greater value.

The Palm Beach Center for Oral Surgery and Dental Implants providing quality care to Delray Beach, Boca Raton, Boynton Beach, and  Palm Beach County.  561.900.9080 www.PasqualOMS.com

The Palm Beach Center for Oral Surgery and Dental Implants providing
quality care to Delray Beach, Boca Raton, Boynton Beach, and Palm Beach County.

561.900.9080 | www.PasqualOMS.com

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The Importance of Ovate Temporaries In Achieving Aesthetic Implant Restorations

One of the most difficult tasks in implant dentistry is obtaining esthetically pleasing soft tissue around implant retained crowns. Though many factors are involved in reaching this goal, few are more important than proper temporization of an extraction site.

Though more implants are being placed immediately following tooth extraction, allowing an extraction site to heal for 3-4 months with delayed implant placement still offers the most predictable result. In most cases where implant placement will be delayed, the patient requires a temporary prosthesis for esthetics. These appliances, when properly designed, can preserve and even improve the contours of the soft tissue where the permanent implant prosthesis will be placed. This applies to all temporary types -removable partial dentures, bonded natural crowns or denture teeth, and fixed partial dentures. The critical design feature is that the prosthetic teeth have convex apical contours allowing the soft tissue to “grow” around it. With a fixed partial denture, such a design would be called an ovate pontic.

Unfortunately, most dental labs typically make removable partial dentures with “saddle” type denture teeth. This occurs for two primary reasons – denture teeth are manufactured with a flat or concave apical contour, and gingival colored resin is usually placed around denture teeth to replace the gingival papillae. These traditional partial designs can obliterate the existing papillae and create a flat or convex edentulous ridge.

A properly designed temporary prosthesis will not impinge on the existing papillae, will allow room for soft tissue proliferation in embrasure spaces, and will be highly polished to resist food and bacteria accumulation. As the extraction site heals, material can be removed or added to the prosthesis to guide the soft tissue to the desired form.

When temporized properly, the healed extraction sites have the papillae preserved at the time of implant placement and the temporary prosthesis can continue to be utilized after minimal adjustment. This is far better than trying to reconstruct the papillae after the implant restoration is completed.

The next time you treatment plan an implant restoration, particularly one in the esthetic zone, request that your lab technician make a temporary prosthesis with ovate prosthetic teeth. By doing so, the soft tissue esthetics of your implant restorations will likely be improved.

The Palm Beach Center for Oral Surgery and Dental Implants providing quality care to Delray Beach, Boca Raton, Boynton Beach, and  Palm Beach County.  561.900.9080 www.PasqualOMS.com

 

The Palm Beach Center for Oral Surgery and Dental Implants providing
quality care to Delray Beach, Boca Raton, Boynton Beach, and Palm Beach County.

561.900.9080 | www.PasqualOMS.com

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Dental Implants: Surgical & Prosthetic Perspective

If an implant is not placed in the right position or with the correct angulations, then the prosthesis will be compromised. Although this may seem like an obvious statement, it brings to light that an implant must be guided by the position of the final prosthesis. Any other method leaves room for complications and the probability of poor results.

When treatment planning an implant case, we need to work our way back from the prosthesis to the implant. A wax up of the final prosthesis needs to be done. This will give us a guide for whether enough bone is present or if we have enough prosthetic space available. The bone volume can be determined based on the final position of the prosthesis. This means that if there is not adequate bone in the area, a bone graft must be planned to support the positioning of the implant with the correct orientation. Furthermore, we will also be able to demonstrate whether there is an adequate amount of prosthetic space to the opposing teeth.

Ideal vertical space required from ridge to the opposing tooth is 7 mm and the minimum space required is 4mm (this may result in a screw-retained prosthesis) the minimum bone width required is 7mm for a regular platform implant. This must be planned in such a way that the implant is centered on the posterior teeth and slightly palatal to the incisal edge on the anterior teeth for cement retained prosthesis and in the cingulum for a screw-retained prosthesis. All this information can be visualized comparing the waxed up models to the edentulous models.

The surgical guide will be fabricated based on the wax up that demonstrates the final position of the prosthesis. Therefore, as you can see the implant treatment is dictated by the final position of the teeth, in relation to one another. I recommend obtaining study models for any possible implant patient prior to the extraction(s), since this will be valuable information that can be used at the time of implant therapy. The days are long gone when treatment plans were based on placing an implant wherever the bone is. If the final outcome is not fully functional, maintainable and esthetically pleasing; regardless of the successful integration of the implant, the case is compromised and is considered a failure. In conclusion, the importance of the restorative dentist is vital and the surgeon must have a greater appreciation and knowledge for the prosthetic planning of these cases in order to make them successful. A collaborative team approach is paramount.

The Palm Beach Center for Oral Surgery and Dental Implants providing quality care to Delray Beach, Boca Raton, Boynton Beach, and  Palm Beach County.  561.900.9080 www.PasqualOMS.com

 

The Palm Beach Center for Oral Surgery and Dental Implants providing
quality care to Delray Beach, Boca Raton, Boynton Beach, and Palm Beach County.

561.900.9080 | www.PasqualOMS.com

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