so a little bit about me well here's our you know opening page uh you're hoping to get through extractions grafting uh proper implant placement which uh encompasses a lot of different things as far as uh pre-operatively the planning part um during the surgery as far as implant Choice uh platform Choice um provisionalization at the time of implant placement so we'll we'll hit on a lot of those topics um and then if I need to explain more then please ask uh but for me uh I graduated in 2002 from case um I was actually taking uh courses down at Midwest implant Institute during dental school I'd go down and assist for Dr Duke Keller uh during my time in school I'd go down there every Tuesday and uh that was great because I got you know to see everything that he was doing and then once I graduated I took his externship program um and then after that I did a maxi course as well um I since have uh passed my board exams uh for the American Board of oral implantology and the American Academy of plant dentistry and that allows me um to say that I'm a specialist in implants now and and I've limited my practice to implants only um and related surgeries and grafting so that's been going well and at that time I started to develop uh Cleveland implant Institute which is similar to uh implant rock stars but uh just on a much smaller scale um so when I was approached by Sarah and the other doctors were looking to make this a lot more comprehensive and so hopefully we can get you guys a lot more information a lot more courses it'll be more convenient for you and we can take this up a notch because we'll do some full Arch courses if you want to learn photogrammetry or just how to do all on X kind of cases or even if you don't want to do the surgeries we can definitely help you with restoring those cases um and then we'll do complications or even contemplating doing some uh kind of uh coding courses to where we can go through a case and maybe talk about the codes that we would use to make sure you're getting reimbursed as best you can for your insurances or the patient's getting as much insurance money from it and uh I kind of see for me in the PPO plans that we've been a part of it's fairly PPO proof as long as you're not in a PPO that's you know making you write off over 50 percent of your fees but if you're only writing off 15 20 25 from a PPO plan implants can definitely get you back up to your full fees uh and it's just a matter of noting knowing the codes and knowing what you're doing with each case and making sure you're you're charging out for those so we're looking at doing that as well as many other science grafting block graphs and things that that you guys might be interested in uh on this page though is my email so that's my personal email um my my website and my cell phone number um or you could send me messages on Whatsapp um I would encourage you to do it through the group uh page though just so we can share with everybody because I'm sure a lot of you have the same questions so um so just save that and and you can contact me if you have any any issues um thanks to buy Horizons none of us are being paid by buy Horizon so there's no conflict of interest there but they're allowing us to uh provide CE for you and so it's nice that we can partner up with them and help everybody I had mentioned an American Academy and plant Dentistry before I'd highly recommend joining their the organization they have an excellent Journal that you'll get every uh quarter and then they also have um excellent meetings uh where you'll meet a lot of people like Jay and myself they're willing to share knowledge willing to help you out um and I've been a member of that for over 20 years um you may have heard me mention the board exam when uh when Robert did mentioned he had taken the the boards I'm actually the chair of the uh Admissions and credentialing committee for the aid so I'm the one that runs the exams for the board exams uh and uh yeah if you need help trying to get your credentials definitely reach out to me I can help you there foreign let's get down to some implant stuff uh or for me kind of semi Venn diagram is how I look at it right if you want to get good at Surgical and restorative to have a successful implant practice that's where we're going to focus on is is that Surgical and restorative part of it but there's a big portion that's going to be patient management and we'll subsequently talk about some of those and other other lectures and and as I mentioned we can get into some of the financial uh parts of it too um at other lectures um I like to show this photo because this gentleman came into my office another surgeon had placed the implant at number seven healed fine it was an immediate you know it's it's a good implant but to me it misses the whole picture right there's not a whole lot of planning done for this patient in multiple ways and here I they miss all five all four of these outer circles in doing this because to me surgically it could have been done better because you could have developed some papilla while I was healing so it makes it much easier for the restorative doctor planning wise it didn't take into account that six and eight are both bombed out and need to be extracted so the treatment plan the most ideal place for putting an implant wouldn't have been tooth number seven it might have been eight or six financially the patient came in and was complaining because when he got this implant done he thought he had paid for the whole thing he thought it included the crown so now coming to me he's a little Tech that now he has to get a crown done with me and and do extra charges and then when he comes to see me I'm telling him Emma right now I need to make a temporary crown so that I could develop a pillow to make this look halfway decent and then I'm also telling him these other teeth are bummed out and what are we going to do about that um so this guy wasn't very happy but it was all because of the pre-planning the discussion with the patient prior to it and so if we can get all of you thinking way down the line of what needs to be done rather than focusing on one tooth I think you're all going to be much better more successful with your practices and uh have happier patients another case that that came to our office done by other certain locally issue with this is you could see in that middle photo that in that middle CT slices of the left implant so it's outside the ridge it was done immediately but this was showing gray through the tissue unfortunately the the right implant the number I believe it was nine tooth position that implant was too shallow this lady had a really deep bite because she was missing posterior teeth she couldn't wear a flipper because there was just no room and so now there's no prosthetic space for the right implant there's no uh bone on the buccal of the left implant and now we're it's only this lady she should go back to the surgeon and yeah maybe have something replaced um or at least talk to them so she did she went back got uh the number seven implant uh moved and replaced but uh you know unfortunately there wasn't a whole lot of prosthetic consideration prior to starting this and so it just led to a lot of you know unhappy patients and uh extra work another case I like to show where this one the person just didn't the the surgeon didn't want to do a sinus pump and in my opinion used an implant that was larger than it needed to be um so that just created issues for me trying to restore this when it came in uh to where I had to cut away that open and depression tray coping uh just to be able to get that squeezed in there so there wasn't room to even use the encode abutment there because it was hitting against the tooth couldn't get a good impression of it and I couldn't use a closed try impression uh above it because it would have ripped so just extra costs that would were incurred by me because now I have to do a custom abutment and still instead of a screw attain crown and again just because of the lack of planning or thought from the surgeon and so if all of you are going to be doing your own implants now that's great now you can like I did you'll unfortunately see some of the errors that you make and how it affects you down the road but if all you are is the surgeon you you unfortunately don't usually hear about the complications that arise um and so then you're not learning from those those mistakes uh so great for all of you being here and uh we'll get you all coached up another implant that came in uh this implant was an immediate for number uh 14 excuse me and uh all they did was place the implant in the palatal root so when the patient came in he was complaining that the implant the crown was moving and I was going into the operatory thinking I was going to find a failed implant but actually the implant was integrated and healthy it was just such a big cantilever towards the buckle that it was just rocking on their uh Boeing the abutment and everything every time he chewed on it um so again just poor planning obviously it integrated and in some terms would be successful but prosthetically this wasn't so so I showed that in contrast to just showing a couple photos of some of my cases to where I can take on the left these pre-op uh starting photos to where there's a broken tooth or a failing tooth and if you compare the two the papillas the same right so how easy is this to restore and it's actually easy to to place the implants this way and we can show you how to to do this in very simple ways and predictable ways so you can start to provide you know aesthetic healthy uh implant implants and and crowns now in my mindset I I initially saw a lot of crown and papilla development in the anterior but I kind of thought well why doesn't anybody do this for the posterior you don't see this done or or lectured about or or published or posteriority um but I I do this for all teams so for me I'm developing papilla no matter where it is it's healthier less food traps looks nicer just all around a better service for the patient so you can see here I could just take molars and still keep that papilla rather than letting it just turn into a flat area that that's a food trap so we can go over that and we'll show you how to do that and then once you start doing one tooth then why don't you do multiple teams so here all I did was take out this ladies periodontally involved teeth I placed three implants and I put a temporary bridge on it done when she comes back four months later this is what we had I didn't have to do anything crazy on the back end now when I send this back to my referring doctor how nice would this be to restore rather than a flipper over the top with cust with stocky round healing abutments on there and no papilla right the patient wants their teeth now they've been waiting four months with a flipper and now all of a sudden they come to you as the restoring doctor and they're going to want to get that bridge done ASAP and they're not going to want to wait six more weeks or more for you to develop a pillow and create Elevate pontics and numb them up and do a lot so if you do a lot of this at the time of the surgery it's simple then to restore these without having to numb them up and you know take more of your time in the patient's time and then I thought well let me throw some photos in because a lot of times people are showing their lectures their best cases right the ones that they've documented and uh maybe that's not what they do on a daily basis so I just thought I would take some photos of cases coming in over the course of a few days at my office to show that this isn't me you know kind of talking from a soapbox but this is my everyday all-day kind of thing um so here's just some photos of me developing Capilla here for a premolar the one prior an anterior tooth um so I'm doing this for everything molars uh you know other molars you can see that it's just something that I do with all of my cases I I develop custom healing abundance and all of my my implants and today we'll talk about how I do those um and you could see if it's something you want to do but I I wholeheartedly believe this is a big part of my success for the patients and and their emergence profiles so we've got Bridges uh more papilla I see in this case too the one I showed earlier you can see how um in that biotype would be and if we just put a flipper over the top of that right what would be left um to uh to use for making up a pill later on uh one second I'm gonna see if are you able to see my cursor right now yes we can okay let me uh I was gonna see if I could change it so it looks more if you can see it better Dr fiorina are a lot of these cases um uh immediate is it a mix of immediate and delayed placement is it a it's both right so I do this with I do this with all of them so it's easier with immediate because you have papilla already but I do it with non-immediates as well because it takes a while to develop a pillow sometimes it's not six weeks it could be months so why don't you let them heal in their custom either brown or Custom Custom healing abutment and let them develop a pilla while you're waiting for the implant to heal anyways does it require just one uh pre-operative Records appointment most of the time I hand make them at the time of surgery so no I don't do any prerequis I could have someone call them in five minutes before and do all this the same time awesome I'm I'm the first to admit that I'm pretty poor on my pre-planning I I'm so used to same-day Dentistry that we get people coming in with broken teeth that I'm just doing a lot of immediates here and there um you know squeezing them in especially for anteriorities because people obviously want something back in right away um that all of my techniques are cheap and and uh pretty simple and and with minimal planning prior to it so I I can be guilty of right not waxing everything up um but I've Gotten Good at it and then one thing I think that keeps me out of trouble is because I make a lot of media provisionals I can see if it's restorable at the time that I place the implant so if I go to put a temporary crown or bridge on one of my implants and I'm way out the Buckle I still can take out the implant and replace it now fortunately I've you know over the years I've been placing implants for what 20 plus years now um I I don't have that but if I did if I did make an issue have a problem then I can correct it most of the time I I'm maybe changing the position of the implant depending on the depth so that's really helpful too as far as how you're going to create that emergence profile so that helps yes um so yeah good question more right more single teeth molars full arches so here's one where uh nowadays I have photogrammetry and if you're not familiar with that that's a scanner that could take the implant positions at the time of uh inside the place and of course I mean it's supposed to be a beginning first niche um and so I can um I can make uh my provisionals with a 3D printer nowadays but before I had the 3D printer I would would make these Temporaries by hand and so in this case this lady had all of her teeth and so what I did is I I just took uh an alginate um the day of surgery I can add composite or wax to just wax it up and then um I make a suck down and so this lady had second molars and I just was able to lock the the suck down onto the molars and then I used the the clear Matrix to make my temporary and then I'll have the uh the temporary abutments coming through the the suck down and then I could pick up all of them at one time so now I've got a provisional that will last them uh the four or five months while they're healing and then I can make all my contacts uh from there so again easy cheap minimal pre-operative work needs to be done there if you wanted to spend a little bit more time or send the lab to have it mocked up I would do that at times if someone came in with really gnarly teeth that would just need a little bit more work but uh again very very simple so it looks a little gnarly here but here's our Bridge all screwdained straight no angled screw channels um and uh then we've got a passive fit so it looks a lot better in place than looking at the ovate pontics but um you can't beat fp1 Bridges and fp1 means there's no ping how easy is this for this patient to clean rather than a bridge that has all the bulk to it and they're having to use water picks to get underneath it this is a lot healthier and we're not cutting away all the bone like you might see with clear choice or some of the other programs and then I don't go over it too much today but we can in future lectures but uh I do a lot of immediate placement for for Implant excuse me for denture retention so you can see on the left leg comes with hopeless teeth I can place these implants uh same day and clip The Denture in now this is a three month check afterwards but in in just two weeks you'll see something very similar and they're able to to retain their Dentures so much nicer throughout the healing process rather than having that float around and you have a lot more headaches with them thank you would a meet with many those are mini implants I don't use minis they look like minis but I stay away from many implants just because they they tend to wear down very quickly uh this is a one piece implant so I offer one piece of implants as a cheaper alternative to the two-piece uh so that I could place four of these for less than someone would pay for two with locators um so it's just giving people options now the downside to this is it does lock them into a denture if they wanted to go fixed then I would need to take these out or bury these and place other implants so it does require talking to them seeing where they're at if the person's been using a denture for decades and just wants some better retention then this is a great way to go with a cheaper option and one p you know one piece implants you know loading them immediately which you load to immediately or does it need to be four for an immediate uh it could be two uh now it's only in the mandible that this works right because it doesn't work in the max traveler because of the angulation and the softer bone uh so it as long as you had some good solid bone to work with I don't think that using two would be bad but because I'm doing it at a much lower rate the four is awesome as far as retention because we're eliminating any cantilevers we're getting some more spread on those implants to where these people aren't coming back like you see with two locators and and they're still not happy with the retention so it just saves me a lot of headache of having these people come in all the time with needing their gaskets uh the inserts the nylon inserts replaced um with O-rings that are on the these ball attachments not that it's a good thing but they don't come back for years um until they need them replaced so it's nice for me not to have to see them all the time what's the brand of implant there that one piece implant uh this one in particular is uh is Tatum surgical uh but there are other brands out there that that will do the same thing um lately I've been using the two-piece um and I can do so if the patient's not certain that they want to uh if they're showing that they might want to do a full Arch Bridge but it's just the cost that's prohibiting them that I probably wouldn't use the one piece but I can still do the same thing with a two-piece and and just place it so that I uh I'll just buy I keep a three millimeter cuff height locators or ball attachments on hand and then I can uh just add those that make it essentially like a one piece but give myself the leeway to change it out later on now this is an older case where I was still doing some cement retained uh Bridges but this this gentleman had these implants and abutments made custom abutments and the the bridge on top and then kind of the old school way of doing it where before we started angling implants and do xagomatics and pterygoids we used to graph sinuses so this lady uh was a part of our my earlier courses um to where we grafted her sinuses on each side uh and then in subsequent courses once the sinuses healed we placed implants for her and then we also did a incisive foramen implant which is that implant in the middle and then with my photogrammetry we uh we printed her out a bridge to where so she got all this done for free so it was a nice service for her but she was great patient for all the doctors coming in and then nowadays or something like that this this young girl we did two zygomatic implants and some angled implants in the anterior to get her restored and uh the you know right away you can see how much of a difference this makes in her facial support and uh you know it's a lot of fun to help her out any questions so far all right um so continuing with the the surgeries the major could thing you need to be good at the most important part is being good at extractions so if you're not comfortable doing them you need to get comfortable and you need to get good at taking them out without taking out bone so if you're laying flaps and cutting away interceptal bone cutting away inner proximal bone um you're never going to be able to do immediates at least not do them successfully and predictably you're going to cause a lot more bone loss for yourself than when you go to get back into these uh Place implants I I personally try to give my patients a treatment plan from start to finish so that they know what's coming it's kind of hard to give them one uh one plan to just take out the tooth and graft it and then make them wait to give them a treatment plan for the implant um right they're not going to accept treatment because there's too much unknown so I try to give them all the three steps if there's an extraction graph implant second phase third phase the crown I try to do that all prior now if I'm not good at extracting and I break off Buckle plates I I still plan to honor that treatment plan I gave them to start so now I'm going to incur a lot more grafting costs membrane costs time and chair to get this all fixed um and so it becomes much more difficult and it all just starts with the extraction so um we'll review some of my protocols for extracting teeth tonight hopefully we can work on some of those in the course this weekend or substant courses on how to how to do extractions so in dental school you kind of get an elevator you might get a forceps and you'll see the handpiece on the table but they never let you use it right so then you're never good at taking out teeth in dental school because they don't teach you how to do it properly and they do it intentionally in my opinion so that you don't want to take teeth and you end up referring them out um and that's what I started with when I got out of practice um but or I got out of dental school but these alone aren't going to cut it either it wasn't until I started incorporating period tones and uh elongated surgical Burrs that I was really able to take out teeth atraumatically without cutting away bones without laying big flaps so now my patients are less sore afterwards and I'm maintaining bone so I'd highly recommend getting some periodomes they're just a little much thinner than a regular elevator so you can get in between the the periodontal ligament and kind of get those roots out I like the ones with the serrated ends to them so that it gives you a little bit more grip when you're trying to get in there and then they have even thinner ones that you see here uh that are just able to squeeze it down between create a little bit of space to start between the root and then you could slide the larger periodome in there to get the rest of it out you'll also want to have multiple curettes and serrated curettes so on the bottom you can see the serrated curette when you have cysts down in the socket you really need to get those out even if you're not planning to do an implant you need to spend time curating it out because the patient may come back with just a chronic infection in there if you're not really depriding that area so the serrations are nice for getting the cyst out the big chunk of it out and then you can go back in with the smooth ones to uh to really get all the little little bone excuse me tissue tags out of there and then get the bone nice and smooth and get down to healthy bone uh so with extractions you need to get good at sectioning I would say that's probably one of the hardest things to get good at so you're not off angle and drilling right into a root and just creating yourself more more problems so on two rooted teeth obviously because some for number 19 just gonna section through the uh mesial and distal roots and then it's like taking out a premolar it's much easier to get those roots out and then I don't have to lay a flap and I can place an implant into this interceptal bone here um which is you know that's pretty nice bone to work with for single rooted teeth uh I still section so this gentleman I remember had Rock Solid bone rocks are with big excess doses um nothing was budging so even though it was a little bit of tooth remaining above the the gum line I I couldn't even get any wiggle started so rather than lay a flap because I wanted to place an implant and I didn't want to take away bone either I'm going to section that tooth and if it's a single rooted premolar I'm going to section it from Buckle the lingual the reason being is if I section it easily excuse me dissection at mesial the distal then when I start to push and split that root I'm going to be pushing on the Buckle plate so I'd rather section it this way so that when I do crack it I'm just pushing on the interceptal bone inner proximal bone and uh and then I can get out half of it like you see here and then now I have space to sit to put my little peritones in there and rock out the other half um so that's here's a video showing that extraction the other thing I do which isn't quite popular I guess as I I drilled dry the reason why I do that is I could see um I'm staying on tooth so I'm not worried about heating anything up at this point um and I think it could be a lot more exact in my my cutting um so I'm able to get the tooth to be pretty thin I'm typically not trying to go all the way through the root I'm just trying to get it down to something that's paper thin and so now I could see right looking in my mirror you can see that I'm getting towards the Apex and I'm not in bone it's kind of nice when you have um got a percher there too that helps you to guide you to the Apex so now I put in my periodome in there to just kind of crack off half of that remaining root so I usually just try both sides but everyone seems to be the looser of the two I'll take that out first and then like I said that creates more space now so I'll be able to see down in there better and then have more room to shimmy out the other the other half you'll also want to have uh Fraser suctions like you see in the video there just real small root tip sections very nice for getting down in there they have lumens I think of two to three millimeters in size so now your assistant can get down into the socket suction it out so you can see better so as you can see in my mirror I can see down into that socket section it out and then uh you know keep sectioning down deeper also watch my finger on the buckle I always hold it there to make sure I'm not cracking anything right if you feel it start to crack then you know you can start stop real quick your fingertips are very a very good tactile sense so just keep that on there uh make sure that you're not breaking through the plate so now I just have the little root tip left uh which is loose it's just a matter of finding the right instrument to get it out it's wobbling around in there it just wedged a little bit all right there it is so again no no cutting a bone cutting a tissue patient's gonna have less pain and now I can place my implant now this goes back to the anteriority that I was showing you uh we've got the the broken Post in there so we're gonna get that out uh again with this we're going to section right there uh from Buckle lingual following the gutter perch is nice as I mentioned uh so now we can get in crack out the rest of it and have a clean socket here and then put my peritones on the mesial portion to get out the rest of that tooth root here's one where sectioning is very important you can see the sinus floor is nearly at the surface and with these curved Roots if I were to try to just take this out in one piece it would be very difficult with the broken tooth as you see there but if we were able to take it out we'd likely rip this open and have a sinus communication once we I've got a video of this once we take out this Distillery you could see the grayness of the schneiderian membrane there um now if you were to have a communication just even to puncture through the membrane in the distraction like this because it's so close to this the surface you likely would have a communication that you'd have to repair later on so for me it's a lot nicer just for avoid getting Communications to begin with uh and and sectioning well is is a big part of that what are the basic principles of repairing a sinus perforation because I have no clue I would say refer if you do get one at first but most of the time they heal on their own so that's why keeping as much bone as possible is crucial because in a case like this if you still had the interceptal bone uh between all the that was between the roots and all he did was have a socket but you perforated at the tip of the the one root I wouldn't even bother doing much other than putting a collar plug in there and just getting them back to make sure that it heals but if you rip out the intercept the bone and the buccal plate and you have a hole in the sinus that probably is going to lead to a communication and that will need repair and there's multiple ways of repairing it whether it's getting a buckle fat pad or doing a pedicle flap or doing some other membrane use uh and I can explain those better with some of my sinus lectures because I have uh photographs showing that but um that that's kind of some of the ways to do it I would say if you get one asked me I guess so we could talk about it but let's try to avoid him to begin with but you can see here I section that uh so usually the sectioning is kind of like in a y shape or a t-shape uh we sectioned out the power route and then got the museum just the roots separated and you can see how easy that comes out now that it's separated and it's got a you know a decent hook on it now it does take time to get good at this I I know I took me hour or two sometimes on these extractions when I was just starting but I'm stubborn and I would just keep struggling unfortunately the patients put up with me but I've gotten a lot faster and better at these to where I you know most extractions don't take me more than five ten minutes even the difficult ones and I even do this with full bony horizontally impacted third molars right I don't typically cut any bone away for taking those up as long as there's a the the roof is missing on on those extractions then I can get them out so we got our palatal what do you mean by the roof is missing well obviously to do an extraction you have to have some access to the tooth so if it's horizontally impacted third molar as long as the crown got it the crown is exposed on the crest I could take out the whole tooth I don't have to cut away bone around the root or anything so at most I might drill a little bit of bone directly over the top of the crown but I don't do it on the Buckle or the lingual or mesial distal areas so once this is removed you can kind of see the grayness down there so be a little careful curating if you do poke it a hole in the membrane I wouldn't worry about that again if you have that intercept the bone and intact then poking a hole in the membrane isn't isn't a big deal but see that greatness down in there that's the membrane there's no bone there so we could create a nice big hole there but with that intercept the bone now my socket graft is going to hold a lot more weight if I had ripped that all out my soccer craft is not going to do anything so now so the difference would be because I kept that interceptable bone when I graphed it I can do an implant in a few months with a sinus bump if I rip that all out I'd be doing a lateral window sinus lift and still waiting to place my implant and again if I had quoted her costs I'm doing a heck of a lot more work and spending a lot more money in on the grafting materials with that lateral window rather than a sinus bump okay so this easy extraction here but the difficult part here is getting all that granulation tissue out so let's watch just with the the curettes you need to be very diligent and it's going to take you time the extraction here took me less than a minute but it's going to take me six minutes or so just to get all that out and I usually keep the needle holders or I will keep bronzers nearby just to uh pick all those little tags off because it sometimes you scrape scrape scrape you can't get them out so it's nice to rip them off what are your thoughts on alvioplasty or not I'll be plastic but like Burrs that are made to clean out that tissue uh uh those are fine um I I don't use them I because I just been doing this before those were ever available I I probably should try one I just haven't tried them before so they're fine to use but I I so I can't speak to them specifically but no major cons jump to your head immediately I mean no major what I'm sorry Collins like pros and cons no no I don't think so I mean the only thing I would think of is if if you were sitting there too long so say this socket wasn't bleeding and you're sitting over at the Burr kind of burnishing the bone I think you'd be killing the bone right right sometimes you get in these sockets and there's no bleeding whatsoever I think that would be a maybe a contraindication to using one of those I've been using them but I've been cutting wet so I'm just making a huge mess so yeah right so that would be fine but even then it's because there's not a lot of bleeding it's just not and I still I still cure it at the end but I just wanted to make sure there wasn't some agreed upon thing of oh yeah those are terrible you shouldn't be using those no no you check that a lot of people use them so yeah I keep using them so again you can just see me taking my time being very diligent to get all that up okay um so now that we've got our tooth extracted and cleaned out we need to talk about wound healing and how that affects us and why we tell patients right you're not supposed to suck through a straw you can't swish your mouth out with water and that's because of the the normal healing during the inflammatory stage we're waiting for clot formation and the platelets don't start to aggregate for a few days well they start immediately but they don't start forming thrombin and turning into fiber and uh for a few days now there's things we can do to accelerate that and that's where using prf comes in or even PRP if you want to but prf is the primary one people are using nowadays uh so then you're putting more platelets into the socket getting that fibrin clot to form quicker which is then preventing dry sockets and so I use prf and all of my thermolar extractions for the man to for the lower thirds and uh really have no issues with people coming back with dry socket so it's nice to be able to eliminate that and have fewer post-op checks but it's also nice to use it for some of my bigger grafting cases or use Liquid prf and add it to my sinus grafts because there's leukocytes in there which then will help to fight against bacteria that might invade your graft and cause infection um so that's the first phase of it and then you've got the granulation tissue formation that's up to a week that's starting to form the collagen that's if you come back and see a patient about a week later sock it seems like it's caved in a little bit and the tissue is just kind of rounded Over the Hole now if you imagine too you've got the walls of the sun of the socket and the the blood vessels grow a millimeter uh most likely a half a millimeter a day from the walls so that's why also if you're missing a wall on your socket that's an area that's not going to heal as well and collapse more because you don't have blood supply coming from that area it has to come from the other three four walls whatever's remaining and um towards that Buckle to replace it um you also then have the osteoclasts for starting to resorb the dead bone now this is where the issues with bisphosphate medications come into play right the last two class are coming into the socket to break down the bone then the Boston blasts are following those up to try to rebuild that back up with bisphosphonate medications there's no osteoclastic activity so now that necrotic bone isn't being turned over and then when there's dead bone the bone will sloth you'll have exposed bone and sequestration um so what's those viscinate drugs uh and I know Jay talked a little bit about it yesterday um and then there's uh you're starting to get the the woven bone after that right so if you were to go back into these a lot of times it's uh kind of like granulation tissue at this point or starts to get a little bit more formed um but it's going to take months for those osteoblasts to turn into live uh bone cells but at that point the tissue is pretty well healed over the top and then you're just waiting for everything to heal down uh in the socket and then it's going to take at least three months or so for all that unmineralized bone to turn into uh fully calcified bone and the main thing to look at an x-ray you'll know that a socket is fully healed if you don't see any lamina dura remaining so if you can look in and not see the outline of the soccer remaining it's fully healed but that could take year more than a year for that to even turn over and then over time it remodels the rate drowns off and things start to uh to shrink away so what can affect our bone healing uh poor blood supply so smokers are a big big one right have you ever taken out a tooth on a smoker you'll notice that a lot of times there's less bleeding so for me if I notice that I take my serrated curette or I even take a 15 or 12 blade and I get in there and start to just score the bone I want to get that bleeding before I'm done I don't want to just put a gauze in their mouth and leave and then they come back soon one being a smoker they're more likely a dry socket but if there's no clot in there to begin with there's no way that it's ever going to heal because that pathway we just talked about doesn't start there's no platelets coming in so there's going to be no osteoclasts no osteoblasts no no fibrin formation um so they're just gonna have to wait to heal by secondary intention once all that bone slips off um you got to keep uh write any motion off of it that's why putting flippers and other thing partials over the top of our extractions or graphs is a big No-No um you want to avoid flippers at all costs um patient Health obviously is an issue if they're diabetic if they're diabetes is uncontrolled if they're elderly they're going to heal slower uh to talk about the soft tissue granulation tissue issues right you want to clean those out um right now in order to understand how we graph sockets we need to categorize all of our sockets and our defects so we know in general what you're going to need so the easiest thing to graft is a five wall defect and that's primarily something you're going to find in the mandible if you take out a tooth because there's a nice big thick Buckle plate and if all the other walls are intact then you're in great shape and pretty much anything's going to work in a five wall defect our second one is going to be the thin five ball defect and the reason why I separate that is when you take out this tooth or any other tooth similar to this that bucket plate isn't going to be there for long um so that it's a little bit different you're going to treat it differently the four wall defect is like that one I was showing with the granulation tissue you're going to want to curate that out and get it all nice and clean but now we're probably gonna have to talk about using membranes and maybe different bone grafts to be able to uh to get this to heal successfully all right and then you've got your two or three wall defects uh in this case this patient is missing the buccal and palatable walls here you can see uh but fortunately they still have the inner proximal bone and so that's going to allow us to be able to graph this more predictably if this bone wasn't there then we definitely would have a much worse healing and uh probably a very difficult time getting it implant into that site and then our one wall defects are typically going to need block grafting or some kind of titanium mesh something that's going to be a lot more involved uh require bigger flaps and a lot more healing time um all right so this brings us to soccer preservation and the difference between repair and regeneration so in repair if we have a hole but we do nothing it's obviously going to collapse and how much it collapse depends on how many walls that we're dealing with so in the five law defect kind of like what this pothole is this sinkhole this might fill up with you know you could with dirt and eventually be maybe just a little bump in the road but it would be better to regenerate it with some bone graft because if you don't in this case uh you're going to get up to 50 bone loss in the first well months of a buckle plate and an anterior area that's going to be crucial to having success you're either going to have a loss of your papilla the might not be able to place the implant or you're going to need to do some block crafts first or some other kind of grafting to be able to get these in so it's going to be important to graph these at the day that you take the tooth out so you can particularly get an implant in down the road versus regeneration where we're putting in uh membranes and Bone grafts and so here you're going to need a membrane right you're going to need some kind of retention wall that you would need to repair this road and that's what the membrane is going to be it's going to help to hold one two three sides of this graft so that the graft is going to stay in position because if you remember that's one of the five main uh things to for success and then uh you can then leave that in if you use non-resorvable or a resorbable membrane so here's those five principles again you want to have asepsis basically just keeping a clean field don't want to do this in the within active infection you want to get soft tissue coverage if you can because that's going to provide blood supply which is another main principle it's going to exclude bacteria right so that's going to keep that asepsis and then the space maintenance and graphene mobilization is kind of in relation to Temporaries over the top or maybe a patient has some oral habits of chewing on a pen or tongue thrust habits that are going to uh hinder our ability to heal so back to the five wall defect most things are going to work out well here you could do no grafting you could place a graft you could use prf as you see in these pictures they're all going to do do fine if the patient does show an interest in in getting an implant I would highly recommend grafting though do a good graft place a bone graft maybe put a collagen membrane or a non-resolvable membrane over the top and the reason being is you could have an undercut That You Don't See on an X-ray until you get a CT and so if you are looking at this x-ray from a panorex or a PA it would look like you had 15 20 millimeters of bone there but because of his undercut you only have eight and now if you didn't graph this socket when you took out this tooth now you only have six so it's important to keep that in mind and and why I encourage anybody if the patient does show interest in doing an implant to craft it regardless if you think it'll heal okay now that brings into question to all the types of bone grafts so they could be pretty confusing trying to think of all the terminology what's an allograft a xenograft alloplast and we'll kind of simplify that for you tonight but uh excuse me I want to give you a background on on what those all are just so you have an idea of of why we choose why I'm going to tell you what we we typically use rather than just tell you and you don't have the the mindset for at least thinking outside the box down the road when you might be doing bigger bone grafts and and maybe not using just one type uh so an autographed uh autogenous graft is the host bone right easy you can scrape that from from the Jaw you could take block grass from the chin or the ramus um and those all work very well allograft is from cadaver same species different host and that's primarily what you're seeing out there all those Tomato Eyes and freeze-dried bones uh cortical and cancellous Bones there's a lot of different different options there xenograft is different species so in our usage usually that's going to be a cow or or Pig bone uh and then the alloplasts are the synthetics which are Ceramics or tricalcium phosphate or other things that are are made synthetically now the properties of the bone are important as well osteogenic means that there's live cells in the bone that are viable and able to create bone themselves and you're only going to find that in autographed in an octogenous bone nowadays now there are some uh different things coming out new bone grafts that may change that ability but for now the only thing we have available is taking out touch this bone now you have to think though you it all depends on how you prepare and obtain that bone graft so you can get an autogenous graph say chin or scrapings from from the Jaw but if you put it in a cup and let it sit there for a half hour an hour before you use it it's not very viable anymore uh so those need to be harvested soon be right before you need it so that you can keep the those cells viable and then when you do put them into the graft that they're near a blood supply because the other thing can happen is you could take all the bone graft put it into a big huge defect say even a sinus graft and then now it's a centimeter away from the membrane it's going to take a week or more 10 days for the blood supply to get to that graft so by that time the cells are no longer viable so that's why you might see in some lectures and articles people are doing layering of it where they might put the autogenous bone next to the membrane or next to the the bone the live bone and then putting another layer outside of that of of uh allograft uh so that there aren't uh to uh obtain so much bone graft from the patient that just makes it a lot easier and then there's Osteo inductive which just means there's progenitor cells in the graft itself and so that's why allografts are are nice to use because they have bone morphogenic proteins in them and so those are able to uh basically call for other cells to induce them to grow bone so they themselves don't grow the bone but they're able to pull cells from the neighboring tissue uh to then grow the bone in that area uh uh and so that's important and then there's Osteo conducted and also conductor just makes a scaffold for the bone to grow in that area so it's excluding tissue and it's allowing the blood vessels to grow in and just creating space so that the bone can grow in that area and and all the the bone grafts pretty much do that as long as they're calcified bone grafts the alloplastinographs allografts and autogenous Bone they're all going to be caught doing some kind of Osteo conduction and then there's different preparations uh so I mentioned the demineralized or the mineralized the reason why we demineralize freeze-dried bone is by taking the calcium out of the bone it opens up the bomorphic genoproteins so primarily seeing that t that the mineralized bone used in in periodontal surgeries but you'll see it in a mix so sometimes you'll see a demineralized and a mineralized combined into one so you're kind of getting a nice uh half of it of providing more bone morphogenic proteins and the other half that's mineralized providing more of a scaffold and is still maintaining that Osteo conduction all right and then there's cortical and cancellous and you might see a 50 50 mix so cortical is going to last longer because there's less of the Persian cat canals there and so it's less porous it's going to take longer for the body to grow that down so you might use a cortical particulate in something that you need just keep there for a long time you could use cancels only in an area that might be a five well defect and you want to turn it over faster and get an implant in sooner now for your use and most of my use typically we're using that 50 50 mix of demineralized and mineralized so if you want to take home kind of message that 50 50 mix is primarily what you're going to use and work well and immediate implants and socket crafts and in a lot of your primary bone grafts your sinus bumps your side leg even lateral window sinus grabs once you start doing more cases and maybe get more involved that's where you might start using a xenograft or just pure cortical bone or so for my use I have all of these available and I'm kind of like a little chef during the surgery I just get out my bottles and kind of mix and match what I think is the best for this case but again most of the time you're going to use that cortical cancels blend that's going to be great for for 95 percent of your cases so Dr Sarah by Horizons has their minerals uh and I actually learned uh just last year actually that um excuse me by Horizons is one of the two uh bone banks that uses uh cadavers that have been um rigorously tested for their osteoinduction abilities there's a lot of uh bone Banks out there that just kind of don't vet their their cadavers and a lot of the quality of the bone coming from them is is subpar um so by Horizons as a good bone graft with a lot of good osteaductive properties and then you have different particle sizes I would suggest probably getting the 250 to a 1000 microns or that's you know a quarter of them a millimeter to a millimeter in size the one to two millimeter size uh can be used I like using that maybe in sinus grass because the bigger particle is a little bit easier to press in there um when they're smaller particles if they get wet or bloody then they seem to get a little mushy and a little harder to put in but in general get the uh millimeter and smaller would be your go-to and in most of your cases and then for the sizes of the graphs uh you can get sometimes a quarter CC half CC one to two cc's uh most of your graphs are going to be in the quarter to half CC size if you're doing soccer crafting the half cc is going to be your size for most of your molars and the quarter size will be for most of your premolar sockets now if you've got some big defects around them obviously you're going to need a little bit more but in general that's a good kind of thing to go off of and then consistencies you get your particulate which is mostly what I use black graphs or I'll use for larger defects to create bone horizontal and vertical and then your putties and that's all just personal preference if you want something that you can kind of shape with your fingers push down into a socket then the potty putties can be a good way for that question how's everybody doing I'm talking for a while okay we've got our blood products um PRP isn't being used all as much the reason being is Once you pull those platelets out the uh the platelets only are active for one to seven days because you're act adding the the bone by enthrop into it and it makes it it wear off quicker or even if you just don't use the bovine throttle and leave it in the liquid form uh it's going to lose its osteointductive properties uh much much quicker so nowadays uh well sorry let me there's the uh prgf2 which was an older way of even concentrating that those platelets down even more but again it's a short-term benefit because you're adding the bone fine thrombin towards only one to two days so most people aren't using these much anymore they're using prf whether it's the solid form like you're seeing in the picture or a liquid form uh and that all depends on the uh the tube that you use to centrifuge the blood down so with these it's nice that's what I use for my thermolar cycle I just take one of these little goobers put it down in the socket and the fibrin is what protects those platelets and that's why it's kind of an extended release as the body starts to break down the thrombin and then those platelets get exposed and then you're getting a prolonged effect from those platelets uh but it's also nice because you have enough exposed that you're going to get blood clotting a lot faster uh they're going to be leaving your office and they're already done bleeding really no you know residual redness in their saliva and then uh much less issues with uh dry socket so now with our five ball defects as I talked we can use just about anything um but we'll skip to the five wall and the four wall defects so I combine these just because that four five wall defect again we talked at the uh that Buckle plate is going to be gone pretty quickly after the extraction so if we're doing these now we have to use a membrane and so what membranes are available there's collagen membranes so those are very nice because they resorb on their own very biocompatible and if you choose the right type you want one that lasts three plus months you can put it under your flaps it will exclude the tissue and bacteria it will help the bone to form underneath and it'll stay long enough until that bone turns over but you do need to get in most cases you need to get primary closure over the top of these because if if excuse me uh if acidic Foods or coffee uh hit these membranes they're going to break down prematurely and you're going to get a lot of uh The graft exposed but these do well work well for covering over buccal defects and Lasting to keep your traps intact so as far as reservable membranes there's a collagen memories that I showed you or there's the allografts now the collagen membranes if you only go to like a tall plug or call a tape those aren't meant they're not cross-linked and so they don't last more than a few days so I wouldn't use these for covering over a membrane unless maybe it's a excuse me covering over a graph unless it's just a small little premolars or you know incisor to where that tissue is going to heal over pretty quickly uh and then you've got your uh alloderm uh which is a dermal allograft so it's actually connective tissue that you're going to be putting in there the benefit to using these products is now you're thickening the the biotype the tissue biotype in that area the downside to them is that because they're thicker sometimes it's hard to get primary closure over the top of it and if you don't get primary closure and there's some exposure of these grafts they can get a little icky a little stinky which isn't a problem though eventually granulate over the top but it just is a you know the patients are going to notice that they're kind of stinky uh you do need to rehydrate these for 15-20 minutes so you do need to take them out and put them in some saline or prf uh to get them uh softened up pericardium is one of my favorites to use when I'm grafting uh the reason being is it's very thin but it's tenacious so it's just the lining around the heart um it's a really thick uh kind of sinewy material and because it's uh thin it's you can go over the top of a graft and not add thickness to trying to get primary closure but it does last for a few months and so that helps um to get that graft to heal in properly and then a lot of people like to use the amning chlorine membrane which is just uh you know from placental tissue and uh I I'm not as big a fan a little harder to use in my hands but again if you like using those those are very useful as well and then the non-resortable membranes your two main ones nowadays are you going to be your PTFE your polytic fluoroethylene membranes so that's the cytoplasmen Rings and your titanium mesh so I use a lot of the the PTFE membranes and I particularly like the singles like you see down here in the the bottom middle area um so for my socket graphs I like to use those because now I don't have to lay a flap with my extractions I just make at least I don't have to make a releasing incisions all I have to do is make a little envelope flap a little tunnel around the buccal lingual of the socket and Tuck the sand and I've got a video to show you of how I do that um and then now instead of having to create your primary closure I can leave that open and now I can get all this keratinized tissue to heal in rather than pulling the keratinized tissue and I'm left with a lot of non-keratin eyes on the the crest of the uh is the keratinized tissue growing over your PTFE it grows underneath he's in say the socket is around here if you can see my cursor that will all grow in underneath it so when you tweeze it out usually leave it in for three to four weeks when you tweeze it out that'll be care nice tissue underneath it and again I'll show you a video and photos of it soon so you'll see what I mean uh they also come with titanium meshes you can see kind of woven into the center of these so if you need more stability um because there's more bone missing then these are nice to use these little wings are primarily meant for putting on the Buckle of of a defect attacking these areas down so it doesn't move and then putting this over the the crest of the ridge to Flap over towards the lingual or the power this is meant for an anterior tooth again this would be on the Buckle and this would fit between the teeth this would be if you just want to maybe a premolar or you could be using the interior but primary premolar is probably where you could fit this between the teeth and you want this on the Buckle and pal a little or Buckle label Dr fiorita I'm confused about the keratinized tissue growing underneath the membrane because I thought the purpose of the membrane was to separate your graft material so that the soft tissue that grows doesn't indoginate into your graft material that's correct but because there's no blood supply it can't grow inside uh it can't grow on the outside so in this case they it grows just underneath so it does protect the graft but it it allows because these are permeable they have enough thick enough uh the holes are large enough that allows blood vessels to get through but no bacteria so it does look I've never had it explained to me like that and now it makes sense why so many people use PTFE because I was like why would I ever do that because I'm gonna have to it's going to be exposed so there's risk of all that risk of them popping it out I have to wait three to four weeks to take it out so I've always used collagen membranes because I'm like why would I want to have to go back in there and take something out but now that you're explaining well keratoconized tissue is going to grow underneath it and now you don't have to suture and pull tight all your tissue that makes a lot of sense I never really that never lit up in my brain as a property of PTFE well and good I'm glad it makes sense and for me the patients today have so much more pain and it's a lot harder to get primary closure if you've got adjacent teeth and you're trying you have a short vestibule right that's it's nearly impossible without hacking the heck out of the tissue to get primary closure on that So the patient's gonna have a lot of swelling a lot of bruising a lot of pain doing that for me it's so much quicker and less painful for the patient for me to just tuck this underneath yes you do need to see them again but it's a quick two minute visit for me to stick an Explorer in there squeeze it out and you've got great keratinized tissue so now you've increased your band of careless tissue which is excellent for Implant success rather than change that whole vestibule and muck it all up uh again I'll I'll show you the videos of how you do it and if it doesn't quite make sense that anybody it'll it'll make more sense uh membranes continue now we've got the titanium mesh which are a little bit easier nowadays we used to have to uh Bend and cut these sheets of of titanium mesh very difficult to do to get them to fit in there properly and then if it was too sharp in some areas the the tissue would burn it would burn through the tissue now if you expose mesh that's going to get into the particulate on the inside and then you lose the whole graft nowadays with CT machines and and 3D design you can print these up and have them ready to go and all you do is put it in so much simpler but still Technic sensitive to where if you have any dehiscence through the tissue you're going to have some issues with your your graft all right so let me show you my socket craft so this is again going back to that same patient with the buccal defect and we took all the granulation tissue out so I take a multi-rex like you're seeing here and all I do is slide it in on the between the bone and the tissue and and create a little envelope so I'm kind of just prying that away going down maybe a 10 millimeters or so just to so that when I go to tuck my membrane in there's something to tuck it into you don't want to make it too shallow so that it's all bunching up so here I'm just trying to release that papilla I could have cut it but I was lazy to get the the blade so I just kind of fried It Off um and in this instance I'm not going to use a any reinforcement on my membrane because the dehiscence through the uh the buccal plate was fairly thin and so there was enough wing of bone on the mesial distal aspect that I I didn't need to do that and just to go back to that one part there um so that part you saw just before I like to tuck my membrane in before I put the Graft in because that's one of the harder parts of doing this procedure is getting that membrane to go in so on the lower I typically put the membrane on the lingual first because it seems to stay in there fairly well without having to hold it if you put a try putting it on the Buckle first it tends to slide out and think and fall out before you can get your Grafton what I want to do is have that membrane in place so once I get my Graft in I'm not trying to fuss around get this in place and then all my graft is washing away so as soon as I get this in I just fold it over tuck it under the Buckle put my sutures in good to go um so let me finish this video so now my assistant is is handing me on the periostic elevator all the grass I get it all in and then I just take my molt curette and and start to tuck it in there I mean you've got the forcep the pickups first but then I get it somewhere close and then usually what I do is I take the curette and pinch it against the bone to help slide it down so now it's slid down in there and then I'll put a crisscross suture over the top and then we're done so I like to use uh chromic gut I'm not using it there but this was an older video when I was using some difference so chromic gut is nice to use here because it'll fall out in five to seven days and then uh it'll be gone by the time you see them for their three to four week check you want to leave it in for about three to four weeks because you take it out too soon that tissue hasn't had a chance to grow in underneath and cover Over The graft you leave it in too long the membrane will start to irritate the tissue and it creates a little pouch where you might get some exudate coming out of there so three to four Windows is a pretty good three to four week window is a good good you know starting point um okay so you can see immediately two week when I used to take out sutures that's what it would look like I stopped doing it because in 20 years of doing it this way I never had a problem so I said why am I seeing him in two weeks and so I now all I do is jump all the way to the four week if you're getting new into this then you may want to check them in two weeks just to uh follow up until you know you're more successful and these membranes are staying in place uh one thing to mention if you might have noticed the membrane I'm using here is smooth they don't make them that way anymore the reason they put the dimples on them is just for more surface area so they don't slide out as easy so typically the dimples go out against the tissue so that the tissue will kind of fit into those dimples and hold it down better and then Robert going back to your question this is what it looks like when you take it out right so all that is gained keratinized tissue so rather than try to pull this up to the middle and now you've got maybe a thin band a carrot nice tissue left now I've tripled my carotidized tissue and so when I make an incision to put my implant I can gain more keratinized tissue because if I put my implant here and then leave the caranized tissue out here I'll gain another few more millimeters of keratinized tissue without ever having to take a free gingival graft or some gingival graph from another area I can just keep double tripling my my connective tissue every time I go back in yeah that's great ptff PTFE membrane was never explained to me in that way of how that's a benefit so that's really cool yeah and I like it for me again other ones work you'll hear from the other doctors from Jay and Mike that uh they they do it a little different than me but that's my reasoning behind it so um if you want to try it we can we can go over that I know uh the ptfe's are you know buyer rise and sells those so they can uh get those to you um so let's uh here's a video on on a soccer craft uh let me go through for the second time here just the extraction here's me sectioning this single tooth so actually this was a two root or two so if it's too rooted you're going to section mesial distally uh so they can get out the Buckle and then the palette will uh and then you're watching me uh he granulated everything so now I'm making the little envelope flap like I mentioned so it's just as simple as just sliding it underneath going down deep enough to get the uh the pouch stop sliding it in as I mentioned on the maxilla I like to place it on the uh Buckle first because it's too hard to hold it in the paddle so that's where it changes the mandible I like the lingual better the maxilla like the Buckle better to start you can see I'm not getting it perfectly in there it's bunching up a little bit but once I get in it further then I can uh smooth it out now in this case it's gonna ride up the T so you're gonna need to trim it a little bit if it's riding up the teeth you're going to get bacteria so you want to notice that I figured I'd need to trim it more so I took it out uh we'll make it more of a figure eight shape so that I can slide it in the the pouch better and then also get it between the teeth without riding up and rather than cutting usually I'll just put it on the table because this Cuts so easily with just a 15 blade uh some reason I use scissors here so now I put it back in it's going to be easier to put in and then we'll place our graft and now the grass in so I can just fold it over and then use that molec here at to tuck it in so you're trying to get at least five millimeters or more of overlap between the membrane and the tissue if you have less than that that's when it might start to slide out during the healing put our suture in and then you don't need to anesthetize the patient to take these membranes out uh even your patients that are babies they're fine so here's the four week check right it'll be a little brown because they might have been using Paradox there's a little bit of plaque on it but not to worry just take your uh your your Explorer poke it through tug on it so this case I over filled the graft a little bit so it's going to be a little bit graphed on the on the surface so just take and explore and just kind of scrape that off you only need to put the graph to the level of the bone if you put more then you're just wasting it like I did here so just scrape that off and you'll have your tissue underneath all right we can look at another one here so this is the molar sectioning it taking out a little root section of mesial distal Dr furio when you're sectioning molars do you before you start sectioning do you do any like elevation like trying to elevate a little bit or do you just go straight to the sectioning uh I'll try to elevate a little to see if I get a little wiggle but especially on third first molars where they're so flared there's no way to really get it out without breaking plates or getting boned to come with it right so it doesn't make sense to uh to try to take it out in one piece if they're more conical that's a different story then I'll start elevating and see if I can get cow horns or or something to take it out in one piece but typically the first molar is going to be more flared Roots uh so in my opinion I just I typically just pull out the the handpiece and start sectioning to begin with because then it's much easier to start pushing Roots against roots and take them out of single rooted teeth rather than the multi-rooted so that's all preference yeah sometimes I will if I think I can get a little wiggle on it but if I look at an x-ray and it looks like it's not gonna budge I just start sectioning I left dental school never Having learned how to put a burr on a tooth so when I started learning it on my own uh I would go straight to sectioning because that's what I had learned and then that's why I asked because now I try to elevate a little bit and I feel like it's helped yeah it does no I there's no problem in doing that and and I I do it both ways so I'm not saying one is wrong and one is right I I switch it and that's why I asked those questions because there's been so many times in my surgical training where someone's been like oh never do that or oh always do that and I had no clue so I would say in dentistry there's never a never and you should never do something right there's always an indication for doing something um so yeah keep both in mind right if you get in there in the two solid decayed it and you know it's gonna break off or sometimes I'm working next to a tooth that I don't want to uh Elevate against then I'm sectioning right away right you've got these scary looking crowns next to the ones you're taking off I don't want to pop them off and then run into the issue of trying to explain to the patient when it came off and trying to repair it for free so I just start sectioning and try to avoid ever pushing off and elevating off an adjacent tooth that that might just fracture on me we're getting all the granulation tissue out making our Buckle flap here I have to use a 15 blade just to get off some of the tissue tags before that was zooming past it but I did a little bit of that sometimes the cysts are all connected to the the Buckle and pedal tissue for making our little envelope flash you can see I'm just getting down between that placing it on the Buckle checking to see if it folds over now if it folds over fairly well maybe riding up the tooth you can still just leave it and then just trim it in the mouth which I like to do just with the 15 blade you can kind of cut it back if it's too hard to get it in there then you need to take it out and shape it like it did on the last case so here you can see I flipped it over and then you just take a 15 blade and it cuts very very easily just hold all the doubt with something pickups or whatever then we put our stitch in and then two weeks later then the four weeks when you remove it patient's tongue is getting curious so just a few little particles there but excellent healing and that'll all healed down nicely okay so going back to this case where I had the buckle dehiscence three months you can see we had excellent healing right so that Buckle plate is is healing back in and so rather than having a defect on the Buckle which if I didn't do any grafting or did it poorly would have been way in so now I'd have to look at either placing an implant more apically and doing aviaplasty to even it out but since there's adjacent teeth we don't want to be that far apical so do we place our implant up here but then if drugs exposed that is a lot less predictable to try to grow bone on the buccal of the implant so when we place our implant now we can have it nice here that's because this grafted bone doesn't show as much but we've got the bone all the way up to here uh on the implant there and so we can go from that big defect to our implant crown with nice you know gingival architecture nice carrot nice tissue a nice Crown form right so it's got some emergence profile to it much better than than could be expected and you're saying that now on the same day you place you would make a custom healing abutment so that you're developing the emergence profile the whole time correct so here I used a concert healer I used a one that was pre-shaped but nowadays I I would even make my own to to make this a little bit more of a you know wider on the mesial distal aspects and is there some type of like product that's like a healing abutment but you can like stack composite on it to make it the shape you want or something so I'll show that later I just use the peak abundance that I get with the implants and so they're little plastic ones and I just add flowable to those and just shave it down so that it's really low and has no occlusion on it correct yeah so what's nice is I could do one of two things I could keep building it up and make it a screw retain crown if I don't have stability or the desire to do that then I could just make it the shape of what a crown would be and then cut it down flash flush with the the gingivine so I tell the patient it's kind of like a manhole cover right it's nice and flat but it's seals off the hole and so now and you're doing that with Peak abutments and the peak abutments come with the implant you're not having to order a bunch of peak abutments uh a lot of times you can order uh some kind of side uh thing with your implants if you you know I just found Peak abutments but to be expensive but I bet if you buy enough of them like you do it's not that bad right I mean Sarah could maybe talk to what the ordering parts are but with with me when I order mine I usually just get a lot of uh Peak abutments with with my orders Sarah are you there we'll ask her some other time we'll ask her this weekend all right perfect um here I was just muted so I I just wasn't sure uh can you speak to that I don't know what the the typical protocol is I know because it's like your implant will come with healing abutments like they'll throw that in but I don't think they would throw in Peak abutments so that seems like it can make it a little more pricey but like I said it makes total sense when you're buying the amount that you're buying and also it just makes sense if you want to do a good job you get it so that you can make the custom apartment it makes sense either way we just got up with a good rep that's all Doc you know I I offer either a healing abutment or a peak abutment for free yeah I've never heard that deal before that's awesome right yeah I see Rob that's what I was saying so right how many how many healing above us do you need or how many uh well see I don't like the round one so I never use them or how many impression posts do you need you don't need one for every implant so rather than get all of those substitute some of them for Peak above it so when you need them you have them but again like Sarah said they're they're they come with your implant that you bought so now you could just use those so rather than me and I also equate it to that like early anxiety of when you first get into this just like Dr Marshall was talking about last night like you go and take these courses you spend all this money then you got to buy all the stuff and you just have that anxiety which a lot of it isn't founded but it's just that's kind of The Beginner's anxiety of oh crap should I spend money this that the other thing so super helpful to hear that from Sarah that those kind of deals can be made right and those are things you don't know about it and I didn't know when I first started I didn't know for probably six or seven years that if you have an implant failure the company will replace it for you for free right so I had eaten all the costs of my failures early on not realizing that that was possible um so if you guys don't know that that's that's feasible too all you do is fill out a form and um save your implant and the uh the the order the product number and all that and and you can send them in and get it replaced um so there's little things that uh you know do help with your ordering and and just uh saving you money uh and that's that's the other reason I bring it up it's like when you're a practice owner in kind of the middle of nowhere like I am and you don't really have a rep close by it's harder to develop those good relationships with reps so it can always somewhat feel predatory even if it isn't it just feels like it like oh am I getting the same deal as somebody who lives close to them or not that kind of stuff so super helpful to get that information in Doc it's it's like on an average day I'm driving an hour to an hour and a half to each office hour hour and a half back and it's not uncommon for me to drive two hours One Direction to an office so I'm only Northeast Ohio and so all of you are like um close to me if that makes sense just because we get used to driving like that so we'll get you taken care of no worries all right so we got our two to three wall defect right we're taking out the tooth fractured tooth you can see in this picture there's no palatal wall no Buckle wall so now I'm going to use the reinforced membrane just to give us a little more stability uh it's like tack it into the the Buckle put my Graft in uh flip that over and because it was riding up the tubes I trimmed that down you don't see it but I trimmed it down put my suture in two weeks four week removal for a month and so you can see we're able to maintain that wall of bone and so rather than have a huge defect now we've got a nice Ridge to place it implant into one wall defects gonna need uh block graphs uh just to show quickly uh I like to do remote incisions um excuse me if you remember our one of our main keys to uh implant success or excuse me grafting success is is blood supply and tissue coverage so if we could do a remote incision if all I do is make an incision in the midline here I can tunnel all the way to tooth number five four here and to tooth number 11 here and do my block grass so I create a little pouch all the way through I go all the way to the palette to release it more I make my bleeding points to make sure that there's blood supply to my block grafts same here I can place my block craft in put my screws in put my block craft on the other side with my screws uh put the particulate around it to kind of mortar around those sharp edges of the The graft uh put my membrane over the top of my suture so now I can go from you know a thin Ridge and just in three weeks time rather than having this open up and expose my grass this is the only incision that I need to worry about and even if it did open up it's not directly over the top of my my blocks so I might lose a little bit in the midline but I would lose much but here you can see this lady's doing much better than if I had made some huge flaps with the releasing incisions uh the key here is we've cut this back so it wasn't hitting and she was good enough to even not wear it most of the time uh so in five months she comes back we've got the healed ridges you can see the black graphs are all bleeding so we've got good bone so we went from an implant needed to be here to gaining five millimeters of width on that graft and being able to put an implant in with a good Buckle plate placing our implants and then putting provisional bridge on it same day and uh you know giving her something that's fixed and then I can also do vertical grafting with these same techniques so this this lady came in she had been an ortho for seven years they couldn't get this impacted canine down any further she has this slanted cant and a high smile line unfortunately uh so doing any kind of pink porcelain or having long crowns wasn't going to be uh you know acceptable so nine was failing as well so we were going to take this out this is just a bonded pontic so this is all going to be gone so it says we extract it unfortunately that's what we're left with even worse a defect here um now from my pre-planning I kind of knew these were a little bit uh there was a little bit of alter passive eruption here so I had told her that we made you to do some Crown Lane thing on these to help me match up these digital links because I knew there would be some defects here so you want to preemptively tell the patients some of these things before you start so that if there is our issues down the road it's not an excuse you've already kind of explained the reason for doing these and you can do them pretty quickly so you can see just from extracting those two teeth we already had some recessions showing the rest of the enamel on this Central but if I need to I can kind of lengthen these to try to even it out so after extraction and grafting we're going to let this tissue heal for a long time to make sure it's mature if you look at our CT prior to starting there's a lot of bone there for me to place an implant but it's so far away from where the tooth needed to be and this is my mock-up on the CT of where the tooth needed to be that it would be some pink there so we needed to gain some horizontal and vertical growth on this Ridge so my technique is to still do remote incisions but what I did is I kind of flapped the palette I know it looks kind of gruesome but actually the patient has less soreness doing this than if I were to try to release all of this tissue so what I do is I I take a partial thickness flap on the pallet make a full thickness flap on the ridge and be able to bring all that tissue to the Buckle so now I can directly see the defect I could place my three block graphs in this area and then day of you can look I get the keratinized tissue back to where it used to be if you've ever seen someone make an incision along the crest and try to pull all this down with releasing decisions a lot of times the non-karadanized tissue ends up being on the Ridge and so then that creates some issues later on we're trying to get that keratinized tissue back to where it has to be but because I'm able to get this back to where it was before now there's an open wound that needs to heal by secondary tension on the palate but this is backed by the molars so it's not even close to where my graft is going to be so that's nice that I can just leave that open let that granulate in um and then protect my my gr my bone crap so you can see in two weeks time that looks excellent for two weeks so there's very little inflammation no bone exposure you can see my screw here the pallet is just granulating a little bit and again not affecting our our bone graft after four weeks you'd see the pallets healed in everything looks really awesome um and then six months time to let that fully heal nice pink tissue and you can see the thickness of our bone here so we went from uh you know the ridge used to be here and we gained basically five millimeters on the crest five millimeters on the buckle what I also did is I obliterated the nasal Palatine canals and grafted that so that's what you're seeing here because that was in the way of my uh number eight excuse me number nine implant um and then you can see it flapped and how much bone we've gained so we'll place a couple implants play some provisional day of start developing pillow and uh probably can go from something like this to to that all right um I'm not sure how much Jay talked about it but just quickly I I like to give cephalexin is my go-to pre-medication prior um to surgery just because there's fewer allergies to it but you can give amoxicillin you're going to give the two grams prior to starting and then I'm always giving Ibuprofen before we start in dexamethasone uh and uh so we'll give eight milligrams prior to surgery of the dexamethasone to keep the inflammation down as long as they're not diabetic or have any issues with with steroids same with that are you giving that cephalexin in the office like are you buying a bunch and giving it to them there are you having them pick it up beforehand I give it to them at the office so nice we schedule our my patients on a next schedule so my patients my next patient I've been working on a surgery here my next patient is already in the room available so my assistants are giving it to them probably a half hour 40 minutes before I actually start doing any surgery anyways so they come in we go through all the medications that are needed the day before or you know a few days before so they have a list of okay when Mr Jones comes in he's getting XYZ medications they have them already kind of prepared in little pouches and then they just give the patient the medication so it's all done and ready for me to go from one surgery to the next and they're already ready to go all right so let's talk a little bit about implants I know Jay talked about design but I just want to talk about in relation to doing immediates and some other things uh so the by Horizons here you've got your your body your Apex and your Crest your platform area um and the different thread designs uh so for me when I'm thinking about placing an implant I want to have something that that cuts into bone well so that's why on the left you'll see more of a b thread and that gets the implant started a lot of implants nowadays you see that b thread at the apex of the implant because that's going to be more aggressive it's going to start to dig into the bone and get in there and start tapping it but then towards the platform as you get closer and closer you're going to see more of a a buttress thread right so this is going to be fatter the the middle of the implant is going to be closer to the edge of the the fins because now you're compressing that bone and getting more primary stability so it wedges in there so what's nice is these tapered implants start aggressive and then they get thicker and thicker to wedge that in for you which is important for immediate implants so this little video here kind of shows that so as it starts to go in it's digging into the bone and then as it gets to the Apex or the platform or this middle portion of the implant starts to get wider and you can see how it just starts to compress the bone and get more bone to implant contact if you already said this I apologize for asking the question again but if these have these advantages of being able to be used for immediates and then just these advantages you're showing here why not use this type of implant for every implant regardless of a mediate or not I do uh because then it's less inventory and I would suggest you guys probably should too because this is good for soft bone types this isn't as good for hard bone types right so you're gonna have a harder time placing an implant like this if the Bone's really hard but all you do is just prep it more and it's not that often that we have bone that solid that you're gonna have to prep it more and even if it is solid that's what you have osteotomy Brews for correct right so you could just uh you drill a little bit more I had a case like that today I had to keep drilling more and more because I couldn't get the implant a to the Apex um because it just kept getting too tight in there I didn't want to strip the hex so I kept taking it out and had to drill a little bit more even past what the actual drill was um I kind of had to you know push sideways a little bit to to make it a little bit more oval um so in my opinion getting one implant type is a lot easier because then you have less inventory and it's going to cover you for 95 of the percent of the implants you do I do keep some other types just in case but um I don't stock a lot of those I do stock a lot of the tapered Pro and the tapered plus implants um are the ones I mostly mostly have in stock and the just in case moments are just for hard bone what are there any other just in case actually no I don't keep any for hard bone because I can just prep that more what I do keep just in case implants for are extra long implants that I might need for some of my full Arch all on X cases zygomatics and pterygoids and per nasal parasitus kind of implants or uh Ultra short implants to where um right I have minimal bone I'm trying to avoid a nerve uh kind of things I like to be prepared for anything I get into so I could pick an implant for the specific case rather than try to make my surgery fit the implant that I have on hand I mean that can work and as long as you have a few available that'll be fine and I'm not saying you all have to go out and buy every implant but as you start to do more and more of them it's just easier to have what you need on hand um so in a few years when you guys are placing hundreds at a time then then you'll buy and have more but uh you know right now just to have you know the normal sizes available and uh you can plan most of them on a CT and have those ready to go so here it kind of just shows the V thread where it's a little more aggressive versus the butcher's thread now you're going to pick platform level or or bone level uh typically and this all relates to uh um emergence profiles so when you have a bone level implant like these on the left you're limiting yourself to developing an emergency profile because now you can't start from the bone level and work your way out to create contacts and create a pillow and tissue shape with the bone level implants you could do that now the downside to the Bone level is now you've got a a margin between the abutment and the implant that could cause bone loss so these are better for maintaining marginal bone but you have more in my opinion more prosthetic complications and trying to restore these because now you're putting a crown on an implant that's already at the tissue level and if this is for a molar which is the only area you can use these is in the posterior you're going to have open embrasures where you have food traps and all the patients getting Decay on the adjacent tooth they're having annoying food traps that they have to clean out all the time so that that's more of a prosthetic failure um you can't put these in the anterior because if you ever get any recession you're going to show metal so I would say if you're going to buy an implant you're going to buy a bone level implant with a tapered implant apparently please and they all come with different platforms you typically want to get one with more of a platform switch to it um but these are all good implants there and this shows that with platform switching uh nodeja this article uh that you're gonna have less marginal bone loss and that's kind of like a uh the biological width concept right when you're making a crown you want to keep that margin at least three millimeters away from the bone level because that gives you room for the connective tissue your junctional epithelium and the sulcus if you start to impinge on that with your crown margin the bone shrinks right you're gonna have bone loss tissue impingement and inflammation same with an implant you want to keep the margin between the implant and the abutment at least three millimeters away or as far away as you can from the bone level and the way you do that is add a bevel onto these implants so now when you uh like this now this margin is an extra millimeter away from the bone level and so that's going to be more advantageous now there can be in my opinion a little bit overdoing of a platform switch you'll see some implants that have one implant platform for their whole line of implants from the three five implant all the way to a six millimeter implant again these are going to be less likely to get bone loss but they're going to be more likely to have implant fracture excuse me uh well implant fracture more likely abutment fracture because when you have a molar on a 3-5 platform or 30 platform and a screw through it it's very thin titanium and you're going to see those fracture a lot more because it's not as supported enough in the molar area um so if you look at studies and I'm not sure if I have it here I don't have it here but I have articles I could show you that there is more issues with with these smaller platforms another key page uh to follow is is keeping these uh Jay showed this last night but we'll elaborate a little bit more uh keeping a millimeter away from the Buckle lingual plates keeping a millimeter half away from adjacent roots and that's just to keep blood supply so that you can maintain those that bone and then ideally the bigger point I wanted to make here for us going forward for emergence profiles is you want that platform to be three millimeters of below the desired free gingival margin so what that means is where do you want your gingival level to be for your implant crown so once you figure out where that needs to be your implant needs to be the platform of the implant needs to be about three millimeters below that and I would say you probably want to err on the side of being three to four millimeters below that so that then you've got the room to develop your emergence profile develop the shape of the tooth without being too deep and creating pocketing around your implant because once Pockets around the implants get to be five millimeters plus they've become more they get more separation more irritation to them so again showing that millimeter and a half between teeth and if you start to impinge on it like this implant did you're just going to have a nightmare of issues losing bone around the tooth now that doesn't mean I say a millimeter and a half that's that's where you start to drill now you have to consider what tooth am I replacing so in this case you're looking at a molar that we need to replace number 30 so a millimeter has the minimum but we're looking at typically a 10 and a half to 11 millimeter tooth for a normal molar so in order to do that we're going to go five and a half millimeters or so problem the contact area of the anterior tooth and that's where osteotomy needs to start so the one and a half millimeters are typically not going to run into issues with that unless you're talking about anterior teeth uh the lower anterior or maybe there's crowding around some teeth so now we place our hypothetical implant and now you've got great spacing where it needs to be and uh you can plant from there now what width do you typically pick uh so for implants right we want a platform to be three to four millimeters below the the desired free gingival margin which is kind of the cej of the tooth right that's typically where the gingival margin is so if you go Lop off a tooth at three to four millimeters below that most teeth are going to be about three and a half to four millimeters wide so essentially from Primo that are premolar you're going to be choosing three and a half to four millimeter implants it's only the molars that are larger and those typically are about seven millimeters but for us it's hard to find 10 plus millimeter ridges so usually we're going to be placing five to six millimeter implants for molars so as long as the width of the ridge is great enough to hold one of these implants right so if a six milligram plant you need at least a nine millimeter Ridge uh and that's minimum I would say more so you'd want a 10 millimeter Ridge at least two millimeters on each side would be a safe Zone and then same for the maxilla for premolar to premolar you're going to be picking uh three and a half to four milliliter implants now in the Central Area yes you could probably put a five but I would shy away from putting a five plus millimeter implant in there because a lot of times you're getting some Buckle die back and you're not going to be able to get that in so usually the ridge isn't going to be nine plus millimeters in the central area so again I would choose those three five to four video four two size implants and what's our angulation need to be uh primarily we're going to shoot for A's and B's for me I want my incisal Edge to be my kind of guy so I look at the adjacent teeth or I look at my mock-up and I'm trying to get that screw channel to exit somewhere in the incisal edge they used to try to teach us to place them so we can get them in the singulum area but that creates some issues to where potentially you're thinning out the vocal plate you're also creating cantilevers towards the Buckle at times uh this could be difficult to have enough thickness of zirconia and Thai base to have this be strong enough without this potentially fracturing um so for prosthetic reasons I think C isn't as ideal as a and b D is a No-No in all aspects your crown is going to be horrible your placement's going to be horrible so D you definitely need to to avoid because when you do that you're thinning out the Buckle plate you're going to get threads exposed and uh you know horrible Aesthetics so implantic deletion with this immediate right we're going to be placing this more towards the palate so we can keep away from that vocal plate we're going to graft around the anything left in the socket and then in four months you can have this nice emergence profile again with this you can see we grafted the buckle have a nice vocal plate now uh now this on Pas always looks closer but my implant is palatable to this root right teeth roots are always sticking out the Buckle this is more towards the palate like you see here so the root of this tooth is way out here this is way back here so they're even though on a PA it's going to look close they're they're definitely far enough away and you can see after three years we still are maintaining all that bone same here and then again for molars we're going to place it in the interceptal bone we're able to wedge that in between the the that bone and the Buckle plate again keeping away uh way away from the Buckle plate so we're not impinging on it and then we can get a nice screw tank ground I am not a fan of stock up healing abutments uh you can use them I just feel you're going to get crowns that look more like lollipops and so if you want to avoid that you need to buy contoured healers ones that are pre-formed the reason I got away from using some of these is just they're more expensive uh and just not as ideal as something that I can make by hand it says these are one time use then you need to throw them away and just adding all this extra expense so if I can use those Peak abubas like we talked and just add some flowable to them then I can just make them quickly in my hand within less than five minutes and have something that that'll be more ideal for the patient so the way I do it is I add flowable around the peak abutment before I put it into the mouth and so then I screw it down onto the implant then I take flowable and I'm not talking about sure fill or something that's very uh runny you want something a little more viscous so that when you put it in around the sulcus it's going to uh hold still a little bit longer and then I can just cure it so all I'm trying to do is just keep it right at the surface and cure it uh quickly and then when I take it out there's going to be bubbles on the inside but then in my hand I can start to form the emergence profile and so here you can see where the important parts are so when I put that Global in I'm trying to establish What's called the critical Contour that's what's going to support those papilla the subcritical Contour is anything between the platform and your critical contour and that typically needs to be concave and so when I take that out of the mouth I can do that by hand because it doesn't matter what's underneath I can take my flowable add it to the inside then take a finishing burn and just polish that up and make it kind of cave the way I want it to be and then just smooth this area down that what I formed in the mouth so that that continues to support the uh the tissue and the shape of those is going to vary by how you position your implant uh so this kind of shows whether it's in the middle apically or coronally or deeper it's going to change how this shape is right so this is more towards the crust it's going to be a little bit more concave versus something that's deeper it's going to be a little straighter and this just shows whether it's more lingual middle or buckle and how that's going to change the shape of the the crown and hear uh again showing more of the uh Presto or or incisal or more apically positioned and then what this is showing is you can change your your gingival Heights so say the person comes in with Heights that are uneven just by taking this critical contour and moving it up and moving it here a couple millimeters more apically to even it out to number nine you just put that in place and you can reshape that tissue up and then vice versa if you place maybe a little if you need to gain some height that make your critical Contour down lower and you can try to grow tissue down around that all right sweet but you can see with this one that I made where it's closer to the surface and closer to the the lingual plate it's going to be more straight versus on the Buckle we've got a lot more concave to be able to support that buccal tissue without impinging on it so now I've got all this space uh in the mouth The graft and the grow bone in there um maintain that book complete so you can see how nice these are they're low level they'd be less likely to get banged up in this case because he had adjacent crowns I just put an Essex in here while I was healing um I could have put an immediate provisional on it if I felt safe uh with the isq and stability implant or if there's a natural tooth here I will bond the tooth in there just to hold that in and so after four months after the inflammation goes down a little bit you can see how we lost maybe a millimeter of of height there but that just evens it out with the adjacent tooth and here's just showing a premolar doing the same thing I mean how nice is this to restore right beautiful Contours easy to make a nice crown on that let me just show you the video of just adding what I do I add the flowable to the uh deposit excuse the composite to the peak above it I do outside the mouth to keep the blood off of it and then when I get it to the mouth I can quickly just get the flowable in there keeping it rated surface building it up during it a little bit building some more just so it doesn't Slough all the way down into the the socket so I do it pretty quick this also doubles as a membrane right so I don't have to spend money on a PTFE membrane here or a collagen membrane because this is excluding all the tissue from and getting down into that socket it keeps all the food out keeps my bone graft in uh so it's providing a lot of benefit there so you can see all the bubbles there I'm just taking the flowable adding it in tear it in then take my finishing Burr shape it up and then drag it in here we're going to use a [Music] I did put a prf membrane in there you can use those if you'd like I don't do that as much anymore in this situation and then all I do at the end is cut it down so in situations like these I don't use sutures I have the patient start brushing it the next day so I don't have to use paradex and have to hear them complain about that um so many benefits to using these cut these uh custom healing abundance foreign multiple t right so it's nice to have these nice emergence profiles open pontics and then post operative for me I'm going to get them back 10 to 14 days take out sutures if they're there or at least just check the healing uh usually like to palpate the Buckle and just see if there's any exudate or any issues most of the reason I get them in is just to encourage them for better oral hygiene a lot of times they're not even touching this area they're too scared to touch it so I give them uh more confidence to start to brush those those abutments and keep them clean so if you bring them in for that 10 to 14 days and there is exudate when you palpate the buckle you're taking the implant out no most of the time it's just because there's they haven't been brushing it well enough and it's just a little bit of of separation kind of because there's a little bit of a pocket there because of the socket is still there and everything's still tacking down um so it all depends it depends on am I getting that separation because I'm pushing the Buckle plate and I'm able to get something from apical all the way up and there's a lot of inflammation usually I can have a lot of granulation tissue forming around the healing above it uh I mean I don't I normally don't get any separation but sometimes you will and it doesn't concern me much if if I can rinse around the abutment and then I press again and there's no exiting right it might just been just a a drop of of something that just kind of collected in there and it's usually because they're not brushingable enough so then when I have them start to brush it if you're at all concerned with it I get them back two weeks later so if I get them in and there's a lot of inflammation war and I think there should be or if they're having any symptoms or if they're having maybe some separation there I coach them on the brushing get them back in two weeks and reevaluate typically at that point everything looks great and then you're you're good to go all right let's go over a little bit of suturing uh this is more important than you might think it needs to than it is and I would guarantee most people don't do it properly uh people don't tie their knots correctly um and so that's why they come loose so the main objectives to suturing is uh to hold the tissue there keep the blood supply keep the bacteria out to provide comfort for the patient um and and then It ultimately promotes better healing uh but if we look at how we tie our shoes now normally I do this live and I can kind of show you uh what I'm talking about I've got a little model that I use but if you're someone that ties your shoes and you're not laces are typically side perpendicular perpendicular to your your your other laces that's a square knot but if you tie them and they seem to rotate and get more parallel here you're crap you're creating a granny knot and those come out and I would guarantee a lot of people who are doing grinding us inside the mouth because they're not tying their their sutures properly so it's a lot easier to do some of the throws and I'll show you on a video uh with your suture and create granny knots but if you want those sutures to stay closed and to keep the tissue closed over your bigger grass without opening up you need to to pay attention to how to and suture properly um so the square knot is just throwing one forward and pulling it tight and then going backwards that's one square knot uh but let me show you what I'm talking about with the incorrect verse correct right most of us will go forward twice but because it's easier to keep the loose end towards the Buckle because that's where we're working we always pull that loose end towards the buckle and so you can see if we were tying our shoes we would never do that you never take one lace and keep it on the same side because it would never not and that's what's happening here but this is what a lot of people do so you can see I pulled really hard and then it snapped out of the needle holders and how it just came undone so then when the patient's tongues playing with it or me just tugging out here and there you can see how it's just coming loose and that's just one square knot now normally we do two so now you'll go backwards again but the same idea is that this is going to unravel and this is silk suture which we don't use anymore but it's known for being very good for making knots with and you can see how this isn't making a very good note all right so versus uh a correct square knot you always want to take that loose end and go to the opposite side so now all I do is go the opposite way and you see how it lays flat so you're just doing it snug you don't need to pull tight because you don't want to blanch the tissue so now I can pull on it both ways and that's even just doing one throw is staying much nicer than than the the granny knot the slip knot so now we go too backwards to create the square knot but now we're taking that loose end and going to the opposite side again so now that's a true square knot now even with just doing one square knot we've got something that I can tug all over the place and that is not coming undone and then just to play it safe we'll do one more throw and create two square knots back to back which then makes them less likely to slip at all and you can see I can tug on as hard as I can and it doesn't tighten around the uh the tissue so in most cases we're going to use the simple interrupted suture right that's where you go through the Buckle and the lingual tissue and just tie it over the top so that's very good for around implants you do one on the mesial one on the distal easy easy to do a vertical mattress suture can be useful when you're doing sinus grafts for me when you're trying to attack uh papilla back down all that is it's like an interrupted suture so you go from Buckle to palette or Buckle lingual but instead of tying it over the top now you go back through the lingual back through the Buckle again and so now this will help to tack down that flap a little bit better without tearing when you only go through once this will tend to pull through the tissue more and tear the tissue so see these sutures used a lot in periodontal procedures and I could tissue grafts and things where you need to tack down that papilla here's a kind of a view from the side where you went from the Buckle usually starting apically go through the Buckle through the pallet and go a little bit more coronally or towards the Ridge and go through again and you tie it over here and then a horizontal mattress suture is the same thing just laying it on its side so you're going to go from either mesial distal on the buckle to the palette through the pallet to the Buckle and then tie it off here you always want to start on the Buckle because rather you don't want to tie on the lingual because then the patient's tongue will play with that suture a lot more and they're going to complain the nice thing about this is then it helps to hold down that all of that buccal tissue again less likely to tear and it just helps to hold that around the implant or hold these uh loose ends together better and then the crisscross suture is what you want to use over the top of those PTFE membranes or anything you want to tack down in the middle that's what I use here it's kind of like the horizontal mattress suture that we just showed except for you're just going to crisscross between sides let me show you that so I like to go inside on the Buckle or lingual that doesn't matter too much and then outside to inside on the same side on the bezilla distal here and then now you're going to crisscross the other side and go from inside outside and then outside the inside and so I like doing it this way because now I've got these two straps of suture holding my membrane down so they're tacking that membrane flat against the bone and so it's less likely to slide out you don't want to put the suture through the membrane though because if you poke holes in the membrane that's area that that bacteria can get into so you want to avoid holes in the membrane but it's nice to have this draped over the outside to uh to hold it down is there any way for you to replay that video so we can see the insertion points again uh just for a sake of time I could we can either send it to or be on the the video or okay I could send it to you so I'm more I'm happy to share it I just I I have we're running low on time that's all uh and then as far as continuous searching sutures uh continuous locking suture is very helpful for doing large extractions right if you're doing an immediate denture um to where you're tying you're not here initially and then you're just locking it in every time you go through so as you go through from Buffalo lingual you're pulling this needle through the loop and then it locks it in there if you need more explanation Robert or anybody I can show you live I think we're going to spend time doing this on Friday so it'd be much easier for me to show you in person than to show you the video but you're welcome to have the video anyways let me just show you this real quick so again you've tied and interrupted but you only cut the short end here now you're pulling it through but rather than pulling it all the way out you go through the loop so now that it starts to lock that in so the benefit to doing this is if this ever gets cut while the patient's at home the whole thing doesn't come undone this is tacked down so then the cup part will just stay kind of where it is and then the rest of it will will stay intact long enough for the tissue to heal and then suture types uh I would recommend not using silk suture suture is is wicking which means when it's sitting there it's sucking bacteria and because it's got a hole through the tissue now you create a wick that takes bacteria below the gum line and so it's very irritating to the tissue your patient's going to come back with the flame uh gingiva around your implant around your graft and you don't want that uh nylon is good other than it's stiff so nylon is just a fishing wire fishing line excuse me and so when you cut it it the patients are going to complain that it pokes their tongue and they're cheap so I usually avoid the nylon it is very biocompatible you're going to see nice tissue healing around it you're just going to hear a lot of complaints so I think if you're going to go in a non-resorvable suture you're going to want to go with the PTFE uh it's softer it's easier to suture it's very biocompatible doesn't create inflammation so for me non-resorvable I go with PTFE and the resorbable type uh playing gun is good it just resorbs away pretty quickly so for me I typically go with chromic gut as my go-to uh it'll last for about a week and then it falls out which is plenty of time for the tissue to adapt and hold up if I want something to last maybe about four weeks I do have some bike roll which is the poly glycolic acid suture that does work well um but it takes much longer to fall out a little bit more irritating to the tissue as well so it's you're gonna have a little bit more inflammation that say the PTFE would and then most of the time I'm using 40 either three to five o suture Sipes in general or most of it is 4-0 for me but that's more of a preference anything three to two or or larger is just really thick um and you get past the 5.0 it's so thin that it can tear the tissue a little bit so the smaller types you're going to use with more micro surgery with periodontal treatments for us with implants I think four row if you're going to have one available would be useful for most if not all of your procedures and then the swage is the the needle and the Arc of that um most of us are I think a lot of people use the 3 8. if you try to use the half circle or the five eighths it gets it gets more difficult to try to get from Buckle to lingual without it just wanting to come right back at you so with this you could start on the Buckle and still get the lingual tissue all in one swoop um so 3 8 is 3 8 is pretty popular and you also want a reverse cutting needle which means that the sharp edge of the needle is uh on the bottom so if you're trying to put a needle uh through the tissue and the sharp is on the the top it tends to tear the the flap right you're going to tear through the flap before you can you can get all the way through as you're bringing this all the way around