TRANSCRIPT:

All right, so the first thing that I'm going to do is get the patient numb. After using topical, I use a short small gauge needle with septocaine with EPI and I start at the vestibule, giving a little bit at the vestibule. I start inching my way towards the crest of the ridge because they feel it the least around the vestibule, and by inching towards the crest of the ridge, that area becomes a little bit more numb each time. I only give a little bit at a time, using local infiltration; I'm not doing any blocks unless I'm pulling teeth.

I use local infiltrations everywhere that I'm going to be placing the implant or possibly raising a flap. It's a bit tricky right on the crest of the ridge because that tissue is tightly attached to the bone, making it sometimes difficult to inject the anesthetic. You might notice my hands shaking and the needle shaking due to the force needed to get the anesthetic in there. The tissue starts to blanch nicely, having a pale yellow color, indicating proper numbness for the implant procedure.

I ensure to get the lingual aspect as well, so it doesn't hurt them when I flap it. Now, I'm taking a 15 blade and starting to make a flap, going from the midpoint of the molar to the midpoint of the premolar. I decided on a flap because the tissue punch I had was a bit fat and wouldn't fit in the areas. Flapping for the first 50 cases is recommended for proper bone visualization.

After making intrasulcular incisions, I use a periosteal elevator to cut away extra connective tissue, allowing proper flap elevation. The flat end of the elevator is used towards the bone, and sometimes I flip it to cut tissue. I use the pointy end to snip away connective tissue hindering flap elevation.

After cutting away tissue and visualizing the bone boundaries, I use a Minnesota to hold the buccal margin and repeat the process on the lingual side. Suction is crucial for proper visualization. Then, I use a Lance pilot drill to make a starting point for the osteotomy drill. Running it at 900 RPM with ample irrigation, I drill to the desired depth.

Now, I'm ready for the 2.2 mm pilot drill, making the osteotomy slightly deeper and wider. I take it to the first marking, approximately 8 mm, to accommodate the paralleling pin for angulation and orientation checks before taking an X-ray. After reaching the desired depth, I place a paralleling pin and take a periapical X-ray.

Taking an X-ray after using the 2 mm pilot drill is crucial for proper implant placement, avoiding complications such as being too close to adjacent teeth.

Maybe one of the roots was curved in a funny way or maybe you can honestly, maybe I was just looking at it and I'm looking at it upside down and sideways and I don't have the right orientation and so I place my implant kind of tilted to one tooth. So it's really hard to be very careful when you're drilling, but I think it's equally as important to take one of these x-rays. Especially when you're learning for your first 50 cases. Definitely, always. Always always take one of these. Intraoperative radiographs. So hear what I'm looking for is the distance right mesial distally, I want to see that my implant is positioned in the middle of the two tooth you know, it doesn’t have to be exactly in the middle. Like, for example, this one's just a lil bit more distal, but I'm still really happy with this position. It's parallel to the, to the two adjacent teeth. And also I want to see my depth. So here are the important Landmark for depth is the maxillary sinus. So, if you look up towards a sinus, you can see the floor of the sinus. So you can see that white line indicating the floor of the sinus and you can see that my parallel pin just like, just barely peeks right above that. So as I mentioned, when I was drilling, when I drilled 8, mm, I just barely broke the floor of the sinus and you'll know you broke it because the bone will get really, really dense, right at the floor of the sinus. And then you want to be really careful. Because, because in just an instant just like that it'll it'll give and then your drill will go deeper and so you want to make sure you don't go too deep. But but in any case, that's what I do for these types of cases. So I can engage the floor of the sinus as well, and I get some really good in my stability. But you see that my parallel pain is just barely into the floor of the sinus and it's parallel to the two adjacent teeth. It's placed me mesial-distally it’s at the midpoint. So I think this is right on the money and I'm happy and I'm, and I'm okay with going forward and finishing, finishing the case. If you do have doubts at this pointm if your implant is at a weird angle at this point, that's okay. Because you can still change your angle because you've only used small drill so far, you can definitely change your angle. So start over again start over with your your Lance pilot drill or there's even apologize called the Lindemann pilot drill. That's got some some serrated edges to it so you can change your Angulation. Definitely if you're not happy with the angle at this point you got to change it and now you can't keep Drilling and hope that it'll work out in the end. All right, so now I'm going to go ahead and take my paralleling pin back out. And what I'm going to do now I mentioned that I feel like I barely broke through the floor of the sinus, but my implant didn't have that. Give that I was talking. I’m sorry my drill didn't have that give that I was talking about Remember I said that the drill just gives away and kind of goes deeper. So I'm actually going to make sure. Now with that same drill that same 2.2 twist drill, I'm going to make sure that I break that floor. So I'm going to go back and forth up and down, you see that it's bottoming out there right at the 8mm it's, that’s where the hard bone is. You see them, even though I'm going up and down the implant drill is not moving, its not budging in just a second you're going see it give, you're going to see it. Give. You are going to see it just break through and that's when you know that you're through the floor of the sinus. If you don't do this here watch, there you go. Now, I'm through the floor of the sinus. If you don't do that, then you're then when you go ahead and use all the rest of your drills and you don't go through that floor. Then if you want to Place your implant a little bit deeper. If like, for example, you are up above the crest like a half a millimeter, you want to place your implant deeper, it's not going to It might not push past the floor of the sinus. The floor might be like its barrier and the last thing you want is a spinner, a spinning implant to ruin all your Threads. Anyway now you see that I'm just sequentially increasing the size of my drills. Hear you see, I'm using Zimmer kit, it's got a little color. Coded implant drills. And I’m just sequentially. Increasing my drill size. I generally start off at 900 RPM with my first drill, and I work my way down to 350 RPM. I follow that protocol, just so that I don't over heat the bone. So, I start off a little faster and then I go down to a slower RPM. The only time that I, you know, that I use a higher speed is when I'm I'm working on the anterior, mandible, and that bone is like cement that bone. You're like, you're going to be pushing down on that bone. So hard and it's not going to be budging. So that's that's where I run my drills higher. So, my first drills for the anterior mandible are running at, like 1500 RPM Anyway, you want to make sure that you're irrigating a lot. Here you go out here I’m irrigating before my dental implant placement and so you don't want to irrigate outside. It doesn't matter so much. You want to stick it in there and irrigate inside, here because I broke the floor of the sinus. I don't want to stick it in there. And and then squirt, it really hard. Otherwise you're going to feel that water gushing up. All that saline gushing up into their sinuses so just gentle irrigation just to get all the debris out. Now, I'm going in with my implant, I actually use a little, a little hand Mount, I put on a little hand wrench, and I just, I just hand torque it in. I like that, because I feel a lot of control being able to, to direct the implant and really slowly get it in there. And so usually my rotations with this hand driver are like maybe like a hundred and sixty degrees or something they are usually a lot bigger than this but for the sake of not getting in in the way of the camera, I'm just doing this little baby rotations. What I'm shooting for is I want this implant to be submerged below the margin of the bone, that's why the flap is so nice. That’s why I really recommend flapping because you get a sense of of how deep you want to place your implants. I'm just slowly getting to the point where I'm getting the implant below the margin of the bone. Sometimes you can't clearly visualize that when you have it on a on a implant transfer like that so sometimes you got to you got to take the transfer off and then insert the implant the rest of the way.

These implants transfers at least the ones that I use the Zimmer ones, they they tend to get a little stuck. If your implant has some pretty good stability they get stuck in. So you there's a little trick to taking them off. I'll show you right now. But now you see my implant is fully submerged. You can't see any of the metal of the implant anymore.

So I'm going to go in and unscrew the implant Mount that little green transfer. I’m unscrewing that. And like I was mentioning this little thing gets stuck. So all you got to do, it is super easy to get it off. You just got to take your, your little hand wrench and turn it upside down, or just run it on reverse. And then just like just barely just barely unscrew it. Just a little a little tiny rotation, it'll come right off. You’ll see it in a second. So I’m putting my hand driver on right now, boom and then it comes right off. Nice. When I first started using this I didn't know how to get. How the heck they get these things off cuz I felt stuck but it's it's Peace of cake, anyway. You see the implant there. It's submerged. It's like a millimeter or like half a millimeter below bone level. So that looks beautiful. I'm really happy with that.

And so now you can go ahead and Sometimes I use this perio probe. I use a perio probe just to measure how far below the bone. I am. It's just kind of like, I use that to feel the, the margins of the or the margins of that platform and the margins of the Bone. Now you can go ahead and put your healing abutment or cover screw there's really no wrong way to do it. Healing abutment will make it easier for you at the time of of Impressions, you don't got to do a, you don't got to do an implant uncovery. But there’s nothing wrong with Using a cover screw. Actually. So actually there is a wrong way to do it. I remember I was assisting on a surgery and it was at a number three site. Also and it look pretty similar to this one. Maybe with a little less bone but the guy was screwing on a healing Abutment. And then it just keep rotating, kept rotating kept going and it just kept spinning and then before you know it, the healing abutment disappeared and all you saw was the osteotomy so be careful with these sites. Don't trust the bone, don't trust the bone density. If it keeps spinning on you, check on it, make sure that you're not actually spinning the implant and it ends up in the sinus. So when I was, when I was assisting on this, it actually ended up in the sinus and so definitely not something that you that you want ever. So just be careful when you're screwing these things in. This is a little example that I pulled up of something that you don't want. This is not my case and this is not that case I was talking about either. But anyway, just wanted to illustrate. You don't want to make that that patients head a maraca.

To our case. After you put the cover screw on or the healing abutment on you can go ahead and suture up here I use polypropylene but there's nothing wrong with using catgut or PTFE after you get them cleaned up. You want to take a post op x-ray. So this is this is the image of our post op PA. It's looking pretty good. I'm happy with that pretty much followed along the same lines of the of the X-ray that we took after the after you take a pilot drill, maybe we we took the X-ray at a slightly different angulation but I'm really happy with that with where that implant is. I'm happy with where the margin is in relation to the surrounding bone. And I'm also happy with how it is with relation to the maxillary sinus. You can see that the implant goes slightly into the sinus, maybe like a millimeter or like half a millimeter or something. Not Very much. This is an example of what I consider a good result. Something I guess that now that I'm looking at it a little bit little bit more. The bone looks a little bit less dense on the distal edge of that Implant, it might just be the angulation. Also, but really, I'm not, I'm not concerned about it. It did not look like it was at that angle in the in the mouth. I'm still happy with that. But in any case, I'll be taking another PA when it's time to take impressions.

Lesson Summary

The text discusses a dental procedure involving the placement of a dental implant. The process is described in detail, starting with the use of local anesthesia and raising a flap to visualize the bone. The dentist then creates an osteotomy using drills of increasing size, taking X-rays throughout to ensure correct placement and avoid complications. Irrigation and control of drill speed are emphasized.

The implant is placed using a hand wrench and must be submerged below the bone margin. The use of a healing abutment or cover screw is mentioned, with caution advised when screwing them in to prevent complications. The site is sutured, and a post-operative X-ray is recommended to evaluate the implant's position.

The dentist is satisfied with the procedure but plans to take another X-ray during the impression stage. The process of numbing the patient is also explained, involving the use of local infiltration and starting from the vestibule towards the ridge. Difficulty may be encountered when injecting anesthetic into the tissue. Connective tissue is cut away using a periosteal elevator and radiographs are taken to ensure correct implant position before progressively using larger drills and irrigating the area. The final step is hand-torquing the implant into place.