A4 Flashcards
(240 cards)
1
Q
Type I, II, III canals – all based on
A
where the nerve tracks mesially (most common tracks along lingual cortical plate).
2
Q
Cadaver study – anterior loop on CBCT was off by up to —–. Also be weary that —— nerve can loop from IAN.
A
1.8mm
median incisive
3
Q
Lateral approach to sinus lift – one stage vs two stage. Two stage is—– of sinus, one stage is —–m (implant placement on lift).
A
1-2mm
4-5mm
4
Q
—– on sinus lift to see where the vasculature is and where to place lateral window. 3D guides are also helpful. For crestal approach, you really don’t know whether or not you have a perforation.
A
Transillumination
5
Q
If you look at marrow space in a grafted site, it increases over time (47% at 6 months to 70%+ at 20 years). Bone graft goes down from 36% to 5% over 20 years. Issue is that new bone plateaus at—– out. This indicates that most bone formation occurs very early. This is also why the move to 4 months placement waiting time is used rather than 6 months.
A
1 year
6
Q
Osteocyte index (——) is higher for —- bone than —– bone.
A
number of osteocyte to square mm)
regenerated
native
Thus, this bone you get in grafts is more likely to be able to heal.
7
Q
Do you have protocols for the amount of graft material that you add to sinus: use —-s biooss but use large granulometry (granules from —-mm). Reason: paper comparing large granulometry to small granulometry. It found that better bone formation was found with large granulometry. Advantage is that you can save 1 vial of biooss.
A
2 gm
1-2
8
Q
DFDBA: First has to become —- to turn into bone. —- bone can skip this step, but you still want to combine with xeno in sinus. Bare in mind that bio-oss has a tremendous advantage in sinus grafting literature (far more studies).
A
mineralized
Mineralized
9
Q
Research indicates that autogenous, allograft, prf can be used in sinus, but it should be combined with —– at bare minimum.
A
xenograft
10
Q
—- bone had highest amount of new bone and lowest amount of loss of material compared to other grafting materials. That said, —— in, no difference was found between various grafting materials.
A
Autogenous
6 months
11
Q
PRF studies: helped DFDBA (bare in mind that the research is limited and subject to change) and accelerated maturation, but PRF combined with xeno had no significant affect in outcome. PRF fibrin membranes are great for covering sinus membrane or osteotomy window. That said, you can absolutely see the bias, as they are trying to show a certain outcome for this material. With better established PICO questions and design, we see a different result. Bovine autogenous bone compared with just PRF (split face animal model study). New bone formation without PRF at 3 and 6 months, new bone only at 6 months in group with PRF. That said, healing has also been seen to be slightly delayed with PRF.
A
PRF should also be used cautiously in max sinus as the sole material.
12
Q
—- and —- combo can turn into bone at the same ratio, and is thus preferable in the sinus
A
xeno (bioss), mineralized allo.
Consider also placing some bone scrapings (auto) in.
13
Q
Or: where would you use autogenous bone to graft sinus?
A
When you think you need it the most – when they have severe atrophies, and thus don’t have much vasculature from surrounding bone.
14
Q
Crestal sinus floor augmentation using hydraulic pressure and vibrations – machine that measures resistance from membrane as it pumps water through osteotomy into sinus for crestal approach. —- perf rate was detected here, 90% survival.
A
10%
15
Q
Crestal sinus floor augmentation using hydraulic pressure and vibrations – machine that measures resistance from membrane as it pumps water through osteotomy into sinus for crestal approach. —- perf rate was detected here, 90% survival.
A
10%
16
Q
Nonresorbable membrane with titanium strips contained — bone
A
autogenous
17
Q
Occasionally you have patient with defect that still has bone on buccal. Here, we can use
A
resorbable membrane. CT graft, autogenous bone, resorbable membrane placed. Then you can place the implant.
18
Q
Another thing to consider – as you manipulate flaps, you may collapse vestibule. Consider —– to help with this problem.
A
CT graft
19
Q
Another thing to consider – as you manipulate flaps, you may collapse vestibule. Consider —– to help with this problem.
A
CT graft
20
Q
What is the blood supply when you did vert augmentation with block graft? Decorticate recipient site, and maintain integrity of ——. In order of frequency of what procedures you do the most: Ti mesh and traditional GBR, last is onlay block grafts. They only really do this in sinus/block graft layering.
A
mucoperiosteum. In order to get primary closure, make sure that you do your releasing incision away from graft – hence large size of flap
21
Q
Autogenous bone heals faster –
A
3-4 months. Everytime you use a combo of xeno, give it more time for healing.
22
Q
How long do you leave cytoplast membrane in place?
A
If membrane and tissues are intact after vert augmentation, leave cytoplast membrane. There may be a moment where you have some type of tissue rejection of the membrane – if this occurs, remove it. Otherwise, leave it in for as long as possible. If exposed, remove earlier.
23
Q
Place CT graft on top of cytoplast? Vascularity comes from
A
periosteum (hence why you should not make releasing incisions to high.
24
Q
What is the risk of severing PSA artery and nerve when doing these high releasing incisions?
A
It can happen unfortunately. Arterial bleeding is manageable, nerve damage is tough. Blunt dissection is tremendously important to minimize damage and risk.
25
---- – two kinds of bone that we deal with.
Alveolar bone, basal bone
26
Inflammatory response: Coagulum formation leads to -----, which leads to ---- formation. ----- bone and bone marrow then forms after this has been remodeled. Ultimately, ---- bone compaction indicates that healing is almost complete. This is when you can consider placing an implant. Two words often get confused. Modeling and remodeling. Modeling is change in shape and architecture. Remodeling is change within tissue without anatomical change.
fibroplasia
woven bone
Lamellar
lamellar
27
Powertome vs periotome –
powertome can be better than periotome in minimizing trauma during ext. This impacts PDL space in a more gradual fashion. The “screw” instrument can also help by atraumatically extracting teeth.
28
Powertome vs periotome –
powertome can be better than periotome in minimizing trauma during ext. This impacts PDL space in a more gradual fashion. The “screw” instrument can also help by atraumatically extracting teeth.
29
Recommend using ---- to graft the gap in anterior immediates.
xenograft
30
Avatine =
anticoagulant that can be used during CT graft to halt bleeding.
31
Suture for CT graft on immediates:
Suture up through socket in buccal tunnel. Put suture through CT graft, then go toward vestibule in buccal tunnel on opposite surface (mesial or distal). Then pull CT graft down into buccal tunnel. Then suture.
32
Recommends ----- the provisional crown for immediates.
hand-torquing
33
Vista approach: Or vertical incision to great a tunnel on facial portion of alveolus. Then you can go through the vista tunnel to remove bone and get out any remaining root tip. Don’t need ---- when you graft this vista gap.
membrane
34
Based on what literature says: Main benefit of immediate implant placement is the
maintenance of the interproximal tissue. This has been well documented. Facial-gingival margin can be affected by other factors, which is why it is not fair to manage it with an immediate – this logic will not hold.
35
When you have a high or low crest, where to place implants?
The problem isn’t so much the low crest, but the high crest (more likely to be related to thin biotypees). In these cases, you are more likely to need to place this further subcrestal.
36
Place CT graft before placing provisional crown. Benefit of CT graft over other biomaterials is that you
can leave part of CT exposed.
37
As an old rule, --- implant diameters is the maximum horizontal cantilever. Therefore extensions could be ---- mm depending on the implant diameter. Generally speaking, overload is not likely. This rule is really beneficial with cantilevered crowns.
2
6-10
38
Cuspal inclination: Cuspal morphology contributes to natural appearance. For every 10 degree increase in cusp inclination, there is approx.. ---- increase in torque.
30%
39
Further, for every 10 degree increase in implant inclination, there is about a-----increase in torque. *All-on-4 is different, as you splint them. Splinting implants helps reduce this and this paper (Weinberg, 1995) is relevant for single crowns.
5%
40
Horizontal implant offset – for every 1 mm offset there is about ---- increase in torque *how far this implant is off to the side from true center*. This is extremely common in molars due to immediate placement.
15%
41
Apical implant offset: (Crown-implant ratio) For every 1mm increase in vertical implant offset there is about --- increase in torque due to vertical cantilever. The balance here is that we have a tendency to place implants more subcrestal – see high bone line from earlier example. Don’t violate this principle to avoid a bone graft. Even if the implant doesn’t fail here, you will likely have screw loosening.
5%
42
Anteriorly, 2 implants can be used to support a --- unit anterior prosthetic. 2 implants can also support ---- units, depending on crown-root ratio, arch ratio, etc. The opposite is true in unstable occlusal situations. Ultimately, it depends. Arch curvature (offsetting implants) can be helpful – this comes back to renger papers – by placing them in an offset manner, you improve mechanical properties with splinted restorations. The problem is aesthetics. That said, an offset implant in a 3 unit FPD (all implant supported) will reduce bending by about ----
4, 5 or 6
2/3rds.
43
Implant spacing: --- mm is the minimum space needed for implant placement (instrumentation and implant itself). This is a general guideline, some systems try to push this envelope.
6-7
44
-----mm is average MD dimension of premolars. --- implants are the minimum diameter that should be used to replace posterior teeth (3mm only used anterior).
7 to 7.5
4mm
45
2mm bone ideal between implant and adj. teeth, but this is not likely to be present with premolars. ----m is average width of molars M-D.
10-11mm
46
It is possible to place implant in tight spaces, but your ------ is honestly going t be the limiting factor. Also, if you get too close, you can devitalize the adjacent teeth.
papilla
47
On average you can only expect --- of tissue height between implants. Generally,this gives us the guideline that you want to be 3mm apical to CEJ for ideal emergence profile.
3mm
48
When facial bone is available in edentulous ridges, maintain at least --- of facial bone ---- this does not take into account immediate extraction sites.
1mm
49
Once you get over --- of distance from proximal contact to bone, you drastically lose papilla.
5mm
50
Implants and teeth are not parallel: use --- tray
Open
51
Implant and teeth are parallel: ----- tray.
Closed
52
Abutment level impression: for ----
custom or prefab abutment, cemented crown.
Only use abutment level impressions if a crown came off, wasn’t retrieved and the pt wants a quick fix.
53
Splinting implants together for an impression is awesome for when you have implants that are ----
way off-axis from each other that need to be compensated for with custom abutments.
54
For individual custom abutments, what impression post do you want? You want --- impression copings – otherwise if a custom abutment is compensating for an angulation issue and it rotates a bit, that could throw off the angle correction.
engaging
55
Cementation can compensate for
misfits, no visible screw access for aesthetics, they can be more durable due to not needing the access. However, screws allow for retrieval. In the real world, many don’t want this option. Removing cemented implant FPDs is tough.
56
Cement retained crowns and FPDs tend to have less complications, however use for single crowns and short span bridges (Charr and Strub, 2011 review). Use ZOE provisional cement unless retention is severely compromised. When this happens, use ---- cement.
ZOE
57
Finally, occlusal adjustments: Perception of occlusal contact – threshold for natural teeth is --- for incisors, ---- for molars. Greatest perception present on -----
1gm
5-10 gm
incisors, and decreases posteriorly.
58
It takes higher forces to activate a patient’s perception when they have implants than when they have natural teeth. Implant perception is likely to occur due to -----. This triggers ----. Thus, there is variable implant perception – some have ---, some have ----. It ultimately depends, some studies show improved perception in anterior, but not solid enough of evidence. Ultimately, we need to be careful with our adjustments. Delivery of these restorations are different.
bone deformation and activation of mechanoreceptors in response to this
periosteum
3gm
190gm
59
STL is a -----
stereolithography file.
60
You design custom abutmetns to match
bone
61
You design custom abutmetns to match
bone
62
When you can consider immediate load FP3:
Atrophic arches, implants with 35ncm, concave provisional, close monitor of hygiene. You should consider minor soft tissue reflection, not going without any reflection (you can preserve more keratinized tissue, which is often not in excess for these patients). Another thing to consider is just using a pilot drill sx guide, you don’t need it to be fully guided. There is wiggle room. Also, consider preprocessed acrylic monoblock for digital dentures. These blocks give more strength to the provisional prosthesis – the main complication of a provisional full arch prosthesis is fracture.
63
the main complication of a provisional full arch prosthesis is
fracture
64
Class I:
no arch defect, 8-11mm restorative space (you can do this flapless, or with a minimal flap) – true FP1-2 prosthesis.
65
Class II full arch:
Vertical defect present: You can use zirc, metal ceramic, or metal acrylic restorations. This is when you need to start looking at smile lines. Ultimately, this tissue needs to be replaced, otherwise we are looking into excessive FP-2s.
66
Class III:
Horizontal defects. This is when hygiene gets difficult. This is firmly FP-3 territory. Ultimately, these defects get tough to build in lip support with prosthetic.
67
Class IV:
Heavily compromised. We often convert patients to this general location when doing conversions.
68
To minimize porecelein problems:
--- veneering only, occlusal/incisal ----. Zirc specific porcelain if using zirc. Lab will do a slow cooling rate.
Facial
monolithic
69
Max implant count: 4-6 – 6 for ----- pts. Consider positioning max implants at 13, 10, 7, 4
brachiocephalic
70
Short implants (Dr. Foleck is only comfortable down to ------ wide) can be used in cases of severe bone loss.
6mm long, 5-8mm
71
Sinus graft? Place ---- bone per sinus. Also, always put ----- membrane as a liner in sinus. When in doubt, assume you have a tear in the membrane.
5cc
PRF/collagen
72
Dr. Foleck and Wong do not prefer ---- for grafting the gap – consider -----.
xenograft
allograft
73
You will often see periodontists use Astra, as they are catered to the anterior. They propose burying the implant subcrestally ----.
2mm
74
If grafting to provide lip support, use
HA or xeno – something that sticks around for a long time.
75
For occlusion of full arches:
anterior guidance (canine, incisal, all) – anterior guidance is great for separation of posterior teeth in excursive movements. Otherwise, use shallow cusps.
76
If you are doing an upper denture opposing lower FP3, do
bilateral balance – the purpose of that occlusion is to keep the max denture in. Occlusion serves function in dentures for retention.
77
Coreg:
non-selective beta blocker, epinephrine can lead to plummeting BP.
78
Norvast:
issue with gingival hyperplasia – it may make it harder to heal.
79
Something to consider – 2nd molar crowns often lead to -----
cheek biting. If you do this, you need to make sure that you have a significant buccal overjet on molar-molar.
80
Methotrexate:
can affect bone remodeling and healing of gingiva – this attacks quickly dividing cells and affects healing. Ultimately, you can have MRONJ, and there tends to be a higher failure rate with implants.
81
Entivia –
lowers immune response. Also limits pain meds due to liver issues – opioids are less of an option when you would normally want to go here due to ibuprofen issues.
82
Entivia –
lowers immune response. Also limits pain meds due to liver issues – opioids are less of an option when you would normally want to go here due to ibuprofen issues.
83
Bonequantityis measured by:
1) Width (B-L) 2) Height
| 3) Length (M-D) 4) Angulation
84
Division A bone:
* > 5mm width
* >10-13mmheight
* >7mmlength
* < 30 deg angulation
* C/I ratio < 1
85
Division B bone:
```
2.5-5mm width
• >10-13mmheight
• >12mmlength
• < 20 deg angulation
• C/I ratio < 1
```
86
Division C bone:
```
• Unfavourablein – Width (C-w)
– Height (C-h)
– Length
– Angulation (C-a)
≥ 30°
– C/I ratio ≥ 1
```
87
Division D bone:
Severe atrophy
• Basal bone loss
• Flat maxilla
• Pencilthinmandible
88
Greatest blood supply is ---- – we instead must rely on adjacent periosteum and bone. Implants are at a deficit of blood. If you compromise blood from periosteum or bone, you will have an inflated problem because we are increasing the loss of blood supply. This is the biggest difference.
PDL
89
Second biggest difference: Fiber attachment to implant. Implant gingival fibers tend to run ----- to implant – also why the pockets of implants are weaker.
parallel
90
Parameters of outcomes:
Hard tissue volume and topography,
Soft tissue volume and color
Soft tissue around final restoration,
Pink and white aesthetics in cross sections of tissue (a more in depth analysis of tissue color)
91
Submergence profile –
implant shoulder meets abutment to crown – this has everything to do with how the bone and tissue respond. If you alter this in different ways, you get different responses.
92
Ideally, you want a ----- implant abutment for tissue health.
concave
93
i(A+B+C) = T
```
Abutment = A
Bone = B
Crown = C
I = Implant
T = Tissue
```
94
Ideal tissue management – in sagittal cross section,
place 3.5mm below CEJ of proposed restoration, 2mm palatal to buccal ridge. 3 vs 3.5mm – irrelevant honestly.
95
Collagen fibers are ---- in gingiva – this allows us to manipulate this aspect of the flap to get extension to cover grafted area. Some blood vessels and mucous glands present in tissue – sometimes you sever these blood vessels and you get excess bleeding (nothing to worry about).
loosely arranged
96
Best way to determine mucogingival junction – take alveolar mucosa,
push it toward where you think the junction is. It will bunch up at the mucogingival junction.
97
Attached gingiva is inadequate once you have less than ---- of attached gingiva (with thickness).
1 mm
98
With implants – connective tissue always attaches to ----, hence why it runs perpendicular to the implant.
bone
99
Proper vascular supply and ---- are needed for proper bone healing – low ----- (COPD, Smokers, Diabetics) leads to primary stem cells differentiating into ----, which leads to higher chance of -----. Also, if bone is overheated or crushed in sx, it can lead to necrosis, nonmineralized scar tissue which also decreases chance of success (irrigate properly).
oxygen tension, oxygen tension
fibroblasts
fibrous encapsulation
100
Active implant
Cutting - more aggressive, consider for softer bone
101
Passive implant
Non-cutting, less aggressive, consider for denser bone.
102
Aside from bone and healing, ----- is affected by implant macrodesign, ----- is affected by implant microdesign. If an implant is wobbling, primary stability is awful and you should remove it. If it is spinning, you can cover it and it should be fine.
primary stability
secondary stability
103
Stability is at its lowest at ---- roughly. The problem is when the low point is earlier. This dip can be around 50% of final stability.
4 weeks
104
Keratinized tissue is absolutely needed around implants - you can get away with having no tissue if they come in monthly, but that’s not happening. Minimum ---- keratinized tissue around implants.
2mm
105
Bare in mind cultural background when considering xenograft. There is a lot of superstition about death in east Asian cultures. There are patients from these cultures that may not want ----.
allografts
106
There has never been transmission in currently accepted bone graft techniques. During the 80s, fresh-frozen bone grafts were used where viral transfer could occur. This will not occur today due to combined screening and processing.
They have even spiked bone with HIV, sent it through sterilizing process, tested it to find absolutely no trace of virus. Don’t beat around the bush with this topic.
107
Ultimate test for osteoinductive or not:
Can it create bone in a place where you do not normally have bone? If not, it is osteoconductive.
108
Without -----, the bone will definitively lose the race to tissue.
osteoconduction
109
Without -----, the bone will definitively lose the race to tissue.
osteoconduction
110
Without -----, the bone will definitively lose the race to tissue.
osteoconduction
111
You will lose 75% of bone if no grafting is done, ---% if grafting is done.
25
112
ABBM = ---. CS = ----- = alloplast
xenograft
calcium sulfate
113
Beta TCP =
beta tricalcium phosphate = alloplast.
114
What about ptfe (non-expanded) aka teflon? Medical grade Teflon. For GTR remove at ----. When creating new bone in an area, leave there as long as possible. If you get tissue breakdown, it is usually due to poor shaping, sculpting, management of stability. This absolutely 100% needs to be secured and stable. Istvan Urban course emphasizes membrane management.
3 weeks
115
Amnion chorion:
placental materials given willingly by mothers who had a natural childbirth. Medical companies process it for use as a membrane. Dr. Karateew: Feels it is good for grafting a socket. It doesn’t last long, but releases a lot of positive biologically active markers, materials, proteins, and promotes recruitment of osteoprogenitor cells as well as promoting epithelial overgrowth. You get a rapid healing of the area. This speed is inherently where the value is. There are also products that allow you to inject amnion chorion materials into bone graft to give you similar osteoinductive effects. Amniospark is the name (salvin).
116
If you use just alloplast, you will inevitably get
large hollow spaces in the bone. Be weary of studies with alloplast that use expensive barriers.
117
Note: If you graft an implant at time of placement, you are --- more likely to have peri-implantitis at some point in the future. Canulo et al. 2016. Look into this paper to really figure out your opnion on it. It seems to be skewed by immediates.
5x
118
V incisions should only be reflected by ---.
5mm
119
Try not to use vicryl, silk, chromic for ---.
GBR
120
Using ----- sutures are preferred by Dr. Karateew.
prolene, ptfe
121
Another benefit of RAP: You get
interlocking of bone graft and bone. **Do not use most high speed round burs – weld between shank and head tends to break. These are sx steel and you don’t want to leave this.
122
Xeno has delayed healing in extraction sites – ----- delay. ---- on is when it starts to really integrate, however ---- years out you still get residual material. This presenter likes to use it in combination with allograft or autograft. It keeps the shape of the ridge because it’s slow.
2 week
3months
10
123
For Teflon sutures, go
one size up – if you normally use 4.0, use 3.0. When you tighten, it stretches and the diameter collapses down a size. Also, do a couple extra throws, as Teflon is slippery.
124
Doc’s views on block graft:
falling out of favor. Benefit of autograft sites: try to get bone from the same sextant you are placing.
125
Generally, ----- is the most successful for a block graft.
anterior maxilla
126
Be weary of symphysis graft – you need ---- buffer from donor site to apices of teeth.
5mm
127
Allograft works just as well in anterior max as autograft. Most allograft block graft failures is in the posterior mandible – possibly due to -----
muscle pressure.
128
Keep vertical incisions far away from -----
graft area.
129
Sausage tech:
It was created by Dr. Istvan Urban, discussed by Dr. Jaime Lozada. Basically particulate graft with 50% autogenous and 50% BioOss and using BioGide membrane. Scrape the posterior mandible to get the autogenous. Tack the BioGide membrane and "stuff" it with the bone graft mixture until it's stuffed full and solid like a "sausage". 9 month healing period.
130
Enamel matrix derivative: works about as well as ----. Combined with other materials, you often have a better outcome. So, we are now looking into GBR uses for this.
GTR
131
PRP: needs bovine thrombin or CaCl2. Often, PRF sees release of growth factors for -----.
Dr. Karateew: Preference for PRF over Ti mesh for ease of healing.
7-10 days
132
BMP: Work best in -----. Problem is that these two kinds of grafts work well without BMP, so what is the point? BMP costs about 1000 an application. There are also complications arising in orthopedic and dental literatures – bone goes away within a few years promptly. Another concern: BMP causes a quick flood of osteoprogenitor and stem cells to the area, which causes a ton of swelling.
sockets, sinus
133
Stem cells:
reduce need for autografts – consider as an option for immunocompromised pts for whom autografts are contraindicated due to morbidity.
134
What happens if you don’t graft a recession site? Answer is that we graft to
prevent further recession, mucogingival defects, sensitivity, and to correct aesthetic deficits. The tooth is fine, it won’t fall out because of this (except for intensely extreme cases).
135
Miller classification: Class 1:
FGM recession above mucogingival junction – no interdental bone loss or papilla loss. We can expect 100% root coverage.
136
Class II:
FGM recession extends to or beyond mucogingival junction but still has interprox height of bone and papilla. You can expect 100% root coverage.
137
Class III:
Extends to or beyond mucogingival junction, with loss of interdental bone or soft tissue. You will not get 100% root coverage, but you will get coverage up to interproximal bone.
138
Miller class IV:
Big loss of interprox bone, you will not get root coverage. You will manage this entirely differently. Class IV is when you start thinking of other procedures aside from CT or FGG.
139
Subepithelial CT graft: Consider applying ---- to teeth to roughen up the surface prior to CT graft – however new evidence is seemingly going against this grain. SECT graft. Traditionally, this does not have epithelium on the surface. You are taking a wedge out of the palate and dissecting off the epithelium. You can either use this graft as an in lay or onlay – epithelium will grow over an onlay SECT.
Citric acid
140
SECT: Onlay graft over area of gray from implant can relieve color issues – 2mm thickness is really needed. SECT is often preferred in ----
aesthetic areas.
141
Root conditioning:
Debated, can use EDTA, citric acid, tetracycline (burnishing capsules). Changes exposed tooth structure to get rid of remnants of cementum, dentin, sharpey’s fibers, it also demineralizes root surface to allow for attachment. Again, evidence indicates that this can helps, and it is not necessary. It is split.
142
Something to know: CT grafts will determine
color of overlying tissue. If you are in the aesthetic area, you want to try to get complete coverage so that the overlying epithelium has the original color. You may still have what appears to be a keratinized deficiency, even though you have plenty of CT.
143
Interpositional connective tissue grafting VIP-CT:
Great for area where you need to bulk up tissue at implant – this is a pedicle graft. Also helps with color match since you slide this pedicle under the buccal tissue.
144
Coronally advanced flap:
split thickness flap w/2 vert incisions.
145
Semilunar CAF:
Incision apically, tunnel, suture through interproximal. Critique is that you can have rebound back down.
146
Opposite of coronally advanced flap: Apically repositioned flap:
we do this because in our pre-implant bone sx, we have to cover it with a flap for blood supply. Because of this, we have a great change in mucogingival junction (often, the junction and tissue doesn’t match and we need to relocate it up). So, make a palatally leaning incision with two vertical releasing incisions and lift all tissue up and away, exposing implant. Put healing abutment on it, and suture it in place on buccal aspect. This way, you relocate the zone of keratinized tissue. Now you’ve created this keratinized tissue on buccal aspect. This is effective and honestly very simple.
147
For brushing after perio sx, brush within ---- of the area, and if they want to brush in that area, wait ---- and then be extremely gentle. TEPE has very good post sx brushes that are dead soft. Other soft brushes are never quite soft enough.
2 teeth
5 days
148
Acellular dermal matrix – from donor human skin. In processing, epidermis and many cells are removed. They won’t tell you what they do to process it. This can only be used -----, it cannot be used as a FGG. Increased bleeding, pain, swelling can occur. Dr. Karateew has personally experienced significant failures with this. This is beneficial for pts with inadequate volume of tissue at common donor sites. CT graft is the most uncomfortable procedure in dentistry. Put it as bluntly has humanly possible. It hurts like hell, and is inexpensive and is your own tissue. ADG – accellular dermal grafts – are only considered in lieu of SECT grafts.
underneath a flap
149
Look at VISTA technique. Don’t tunnel without a good tunneling kit – this is extremely technique sensitive. There are limitations with intrasulcular tunneling – ti is difficult to stuff tissue without tearing. This issue of tearing led to the VISTA technique. Incision is made through apical horizontal incision, and you elevate tissue while maintaining papilla. Beauty of VISTA: less possibility of trauma, lower scarring visibility, can also coronally advance. VISTA works better with ----. This is when we start to get as good as autograft (depending on the paper you read).
ADG
150
Laterally positioned flaps are often used in -----
mandibular anterior.
151
FGG: Consider placing ---- on wound, suture it in, then use essix or Hawley for 2 weeks. Again, these wounds suck. Some use periacryl (medical grade crazy glue) to hold in this tape, Dr. Karateew doesn’t like it because he feels like he always gets glue under the membrane. This glue is bacteriocidal.
collatape
152
When doing FGG – do ----- deep in underlying CT to pin the graft to the tissue to ensure stability. Just don’t bury knot down in wound, have it go overtop graft or preferably tooth.
horizontal mattress
153
GBR = Guided Bone Regeneration
bone only, GTR is bone, tissue, periodontium.
154
d-PTFE vs ePTFE
e is expanded, d is dense. E is thus more porous.
155
Continued caution should be used for considering the therapeutic use of r----- for reconstruction of bone defects in oral cancer patient
hBMP-2
156
Amniotic membrane has gained importance specifically because of various factors
Amnion Layer
It reduces scarring and inflammation Enhances wound healing
Serves as a scaffold for proliferation and differentiation of cells owing to its antimicrobial properties
Its extracellular matrix and the growth factors contained within it make it an excellent biomaterial to act as a native scaffold for tissue engineering
It can be easily procured, processed, and transported
157
Absolute minimum space required for OD is ----- from crest of ridge to occlusal plane.
12mm
158
Classification for vertical restorative space: Class I: ---- or greater, class II: ----, Class III: -----, Class IV: less than ----.
15mm
12-14 mm
9-11mm
9mm
159
You need at least ------ acrylic above OD attachment.
2mm acrylic
160
Dr. Peabody prefers ---- height healing abutments when doing ODs.
5mm
161
With locators: they do have an extended range system to allow for off-angulation compensation. Ultimately, the range increases when you remove -----
the internal dimple.
162
As a general rule, if you fix rotational movement, you get
shear/fracture and thus you need to manage to this.
163
For max OD – minimum 4 implants, prefer palatal coverage to improve success. If failures in the past with implants, do 6 implants. Implants should be --- or longer, ---- implants had a 2-3x higher failure rate. Angled vs axial implants didn’t really matter.
12mm
7-10mm
164
Hinging 2 implant bar is not great on maxilla. Bars with cantilevers in max ODs will increase load on terminal implants by more than ---. Bars however provide more retention than single implants (probably due to bone quality in maxilla), and magnets suck.
3x
165
Max ODs require the most maintenance, and the most problems are seen in ----
year 1.
166
Incidence of hyperplasia adjacent to bar (tissue hyperplasia from not taking out dentures) was at ---% at 7years.
64
167
--- higher prosthetic fracture incidence without metal framework in max OD.
3x
168
Lack of extension base for tissue increases stress on ---
terminal implant
169
---% of max ODs require a reline within first year, ---% in under 3 years.
24
40
170
Most important of all, patients that are satisfied with their max CD find no
significant improvement when restored with implants.
171
Occlusal rests in ODs: can help improve by
putting preferable fulcrum points – Naert 1998. Problem was that pts did not want to take out denture at night.
172
Remember than making an OD increases biting efficiency by 50%, hence the need for
support for the acrylic.
173
Wolff’s law of transformation:
bone will adapt to the load under which it’s placed. By placing implants, you cause body to continually remodel around implants.
174
For ODs – at least have ---- recall. You can catch things before they become a big problem.
6-month
175
When you do more implants, you need to have
higher precision – FP3s have lower precision required than FP1 or 2.
176
When doing all-on-x, this doc recommends placing ----- first. Reason for this – if you place the posterior, you know that the apices will not interfere with anterior implants. Typically, you put in angled implants first and then you can measure/image where the apices would be and ensure that you stay mesial to that for the anterior implants. This prevents headaches from colliding implants.
posterior implants
177
If traditional hybrid (acrylic on Ti) avoid anything that can’t be
mashed with a plastic fork – the acrylic tends to not handle the forces well. If they want to move to a stronger restoration (zirconia), then we can stabilize things.
178
If you see a lot of calculus build up, you get an idea of
pt’s hygiene and how much tissue has receded. This is when you have a really blunt conversation. If you see a ton of buildup in the provisional phase, consider 3-month hygiene intervals.
179
If pt wants to use a waterpik – use
50:50 mix of water to hydrogen peroxide (don’t swallow).
180
How often to change screws? No evidence unfortunately. Recommends changing screws once a year. Once you torque a screw, you create an --- deformation. Too many times, you can get a ---- deformation (won’t bounce back) and it can fracture. So how many times can you torque and untorque? We don’t know. A broken screw is a massive, massive, massive, massive PITA.
elastic
plastic
181
Occlusal guards: Do a
soft night guard that can be made on a vacuformer and cut – make sure it fits snuggly on prosthesis. Wrap around the last tooth.
182
Telio –
used for inlay/onlay provisional restoration. Great for access opening (with Teflon underneath). Fermit can be used for the same reason, and can be used for inlays/onlays. Ultimately, you want your assistants to be able to remove this without needing you to be there to drill it out.
183
Implant failure =
bone failure. Use bone failure as a term, so that patient’s understand that it is the bone, not the implant.
184
Severe back pain:
when these pts go through this sx, they now have back pain but are numb and need medicine. It is ultimately a PITA when you are trying to get the case provisionalized.
185
Partially stabilized zirconia: ---
Fully stabilized zirconia: -----
Monoclinic = monoclinic.
yytria or other oxides to stabilize in tetragonal.
cubic phase primarily.
186
Transformation toughening: =
the formal term for tetragonal property.
187
The more ---- phase in Zr – the weaker and more brittle. Larger grains indicate that there are more --- phase. More ---- phase = improved aesthetics.
cubic
cubic
cubic
188
Problem with Zr:
Low temp degradation: Aging at low temps that involves spontaneous T→M transformation. Overtime, Zr will have a rougher surface and be uglier than it once was.
189
3Y-TZP gen 1 zirconia:
mainly used for full arch frameworks, frameworks for FPDs, as it is the ugliest but by far the best for mechanical properties. 3 mol% yttria 0.25wt % alumina
190
Gen 2 zirconia:
3Y-TZP, 3mol%yttria, 0.05 wt% alumina: Lower strength, lower aluminum, higher low temp degradation, but better easthetics. Kind of a compromise
191
Gen 3 zirconia:
5Y-TZP, 5mol%yttria, 50% cubic particles: lower strength, no LDT***, no transformation toughening due to cubic involvement. Use for single units or 3 unit FPDs at most.
192
Zirconia: Very kind to opposing arch in terms of ----.
abrasion
193
Coefficient of thermal expansion: CTE: Metal ceramics bind via ---. The problem is that coefficient of thermal expansion must match ----
oxide layer
zirconia to a T, otherwise it will not bond well to the underlying material – especially metal. You can have a crown be far more vulnerable to chipping. Certain ceramics are specially designed to be used with zirconia to manage to the lack of bonding.
194
Full Zr abutment problem:
you can wear titanium connection in implant. These can lead to TiO2 and Zr getting into tissue, creating a “tattoo” akin to amalgam.
195
Abutments: Zr fracture is the most common problem, do not angulate over --- deg.
20
196
For Zr abutments, no difference between custom and prefab in terms of ---year outcome.
1-12
197
Zr layered with porcelain: comparable survival rate to metal. Issue is that ---- is higher, but not too much. If ----, we have no difference on implant supported or natural tooth supported Zr crowns. Polished Zr produce less wear than feldspathic porcelain on opposing dentition.
hcipping
monolithic
198
You can always do a --- while leaving the ---- in Zr for strength.
facial cutback
incisal edge
199
0.6% sensitivity to Titanium----- test (memory lymphocytic immunostimulant assay).
Melisa
200
Zr one piece work really well, two piece have higher failure rates at ----- and are not recommended. We need to figure out the internal connection and the complications of such.
13.7%
201
Polished surface on monolithic Zr: What happens when occlusion needs to be adjusted? We have polishing burs, but you still ----. This is thankfully not too damaging for opposing crowns. There are reports in literature that removing glaze on gingival half of zirconia abutments – apparently we have literature to show that this helps.
remove the glaze
202
Zr crown adjustments: ---- bur. If you get below ---mm, you are gonna have a bad time.
red diamond
0.7
203
Sleeves in Zr framework can become ----.
debonded
204
Sleeves in Zr framework can become ----.
debonded
205
Ti corrosion can be electrical, chemical, mechanical. Overall, this has an effect on peri-implant soft and hard tissue health with long term survival. ---- can lead to Ti corrosion.
Heavy acids HF
206
How to modify Ti surface and color:
Thermal, chemical, anodic oxidation or Ti-Nitrate coatings.
207
Thermal oxidation:
poor color uniformity.
208
TiN coating:
can induce allergic rxns, but colors it gold.
209
Anodic oxidation:
forms various colors on titanium surfaces. Improves corrosion resistance due to thickness of new oxide layer. The colored appearance is mainly due to light interference on oxide layers – this is the best way to color it. Normally pink or yellow in color.
210
Elastic deformation from torqued screw leads to tensile force called ----. This is the axial force generated between the abutment screw and the inner part of the implant. ---% of torque is converted to preload (----% lost to friction between interface). Loss of preload observed over----- minutes. This is called the ----. Thus, we know that we need to torque the abutment a few times.
preload
10
90
2—3
settling effect
211
When preload exceeds the yield limit of the abutments screw material, you get plastic deformation. Ideally preload is usually ----% of the yield strength of the material.
60-80
212
Suggestions: revisit retightening screw every 10 minutes after initial tightening. Retightening can reduce torque loss by ----%. After 10 cyclings of screw loosening you need to replace the screw. To heck with this standard.
17-19
213
Why use external connection?
Limited height and diameter of the contact parts of the joint, but it is not stable. It is vulnerable to micro-motion. External forces here are transmitted directly to abutment screw, causing stress concentration.
214
Consider the diameter: torque loss was greater for
lower diameter implants.
215
Implant-abutment connection is most stable when the degree of rotational freedom is less than ------ Significant torque loss occurs when the degree is greater than --- degrees. In a single unit crown, this problem ----. You can get away with this if you have more implants splinted.
2 degrees.
5
amplifies
216
Non-passive connections can cause
internal damage to implants.
217
Zr abutments: inferior to Ti in terms of
precision and degree of rotational freedom, torque loss, more prone to implant-abutment connection instability, debris found between abutment, implant and screw and can lead to further torque loss.
218
Screws:
Ti alloy (grade 3 titanium). In the past, branemark implants used gold screws, gold abutments. While softer, they still work.
219
Dynamic abutments:
Valuable as they allow use to modify a screw position with 25-30 deg draw.
220
Titanium frameworks tend to fit better than
zirconia, but it is not clinically significant.
221
L-shape framework design: will support much better – the titanium frameworks must be ----. Vertical and horizontal component of framework – these frameworks have vertical and horizontal walls – in essence, an L-shape framework maintains titanium surface against tissue. A full wrap around framework will have only acrylic exposed. These are great if you have functional concerns (small AP spread, this is great).
4mmx4mm
222
Scan bodies are often made of either
PEEK or Ti.
223
Screws must be surrounded by --- of zirconia.
2mm
224
Zr fracture: --- reported in literature. The problem is that we don’t have a ----
14%
5 pontic standard (5 pontics between implants). In essence, don’t do this.
225
Ultimately, for different situations, different materials will be indicated. Polymer prosthetics are ----. Just let the pt know. Evaluate their bite and accommodate based on the strengths/weaknesses.
long term temps
226
Ideally, use a ---- for confirmation jig – she recommends using ----, as any issues will lead to ----
brittle material
stone
fracture if you try to force it.
227
For zirconia connector: width of connector needs to be about ---% in interproximal areas (weakest areas).
60
228
Radius of embrasure:
larger radius increases the load bearing capacity of the restoration – smaller radius acts a stress conscentrator – in essence, a cross section of the framework should be U shaped, not V shaped.
229
Don’t touch --- of zirconia framework, because you don’t want to create sharp angles. Consider filling in palatal embrasures in full to help with stability.
embrasures
230
Implant level framework – what it sounds like – --- fits tend to give you a more forgiving fit to allow for this to work.
triangle
231
For titanium and Zr cementing: use -----
resin cement (panevia and relyx dual cure cement). Luting gap should be 30-60micron – the smaller the better. Surface roughness is important as well – air abrading titanium surface with 50 micron aluminum oxide particles.
232
Metal primer –
MDP creates a chemical bond between titanium and zr.
233
Nobel tri-lobe is the triangle fit. These are easier to
determine a passive fit. The longer the titanium sleeves, the better.
234
Something to note: glaze on Zr tends to be lost within --- years, so don’t hang your hat on glaze alone for aesthetics.
4-5
235
Additive technique – ---- stains Zr – ---- can be mixed with Zr powder at block manufacturing, the block is sintered, flexural strength decreases as color content increases. Flexural strength decreases as well.
acid base
metal oxide
236
Painting with a water based liquid –
color added by brush or dipping prior to sinterizing, then glazed and stained.
237
Tooth size defect: Restorative space-----. How to manage tissue, implant position? These are very unforgiving and difficult to get right. Ideally, do this with thicker biotype pts.
10-12mm
238
Space requirements/indications for each type of defect: metal ceramic – ---, Zirc ----, ----+ metal and PMMA.
8-12mm
10-14
15
239
Allow 4-6 months for tissue shrinkage for
Zr or Ti-PMMA prosthetics after sx. If FP-1 you can be a bit more aggressive with this for ovate pontic formation.
240
CAD Design: Do full contour Zr incisal and occlusal
Digital cut back for facial porcelain: ----mm
Consider Zr aqueous stain for strength
Lateral guidance: gentle canine guidance with built-in group function
Opposing arch: natural, acrylic/polymer, Zr is kind to both of these. Also, 100% do an occlusal guard.
Consider botox in elevator muscles if someone is incredibly strong in this regard.
0.7-0.8
