TRANSCRIPT:

Now, I'd like to show you a case in which number 18 was extracted, and a socket graft was performed. So you can see at the number 18 site, there's a little bit of a shadow. This is a post-op x-ray from the extraction. This is four months after the extraction. Now the patient is ready to get an implant placed at that site. So here you see a little trio scan of the area. I just wanted to share this scan with you because it gives you a good appreciation of what the site kind of looks like. It's a pretty fat platform.

Alright, so let's check out the surgery here. So the first thing I'm going to do is I'm going to feel the ridge with my fingers. I want to do this just to get a good sense of where the bone is and when I feel like I know where the thickness of the bone is, I want to go in with a perio probe, and I'm going to mark the midpoint. So, I'm just going to go up and down like a lot of times. You see me here stabbing it quite a bit because if you only do it once sometimes it actually doesn't really bleed and then you're having a hard time seeing where your midpoint was.

So, now that I marked it, I'm going to go back and I'm going to do a little tissue punch there. Actually not a little tissue punch, I'm going to do a fat tissue punch. Usually, I'm using like 4mm or 6mm tissue punch or a molar site I prefer to do a 6mm tissue punch, just so that way I can see later if I actually, umm that way I can see my platform of the implant in comparison to the bone. So here you see, I punched it and you can see the outline of my tissue punch.

After I punch it, I'm going to go in with a little curette and I'm just going to use it like a lever and flick that off. Takes a little maneuvering, but it comes off. Another thing that I could have done in this case is...umm, right now, I'm actually punching away the keratinized tissue. You see, there's not too much keratinized tissue on the buccal aspect. So, flapping this case would have preserved some of the buccal keratinized tissue, or what you can also do is just put a cover screw at the end of this procedure. So that way the gums just heal back over.

Anyways, the tissue is removed and now I'm going in with a round pilot drill. So I got a round pilot drill and notice I have the extender on there because I'm having a hard time reaching that site because of that anterior tooth. After I've marked my midpoint and I'm happy with where that's at, I use my 2mm twist drill. And I want to make sure that I'm perfectly parallel in all directions. So I usually ask my assistant to make sure to watch from their point of view also. I'm going to take this up and down, just making sure that I'm parallel and I'm following the path I want to follow.

And I'm just going up and down. Some of the bone starts to feel a little bit hard as I approach the bottom of this prep, and I'm kind of wondering why it's so hard. So I'm just going up and down, putting a little bit of pressure. Sometimes in these mandibular, posterior mandibular, and sometimes anterior mandibular, the bone is quite hard, white hard, and you've got to put a good amount of pressure on it, and you have to use the implant motor at a higher RPM. Sometimes I bump it up to even like 1200 or 1500.

And remember I'm prepping this for an 8mm implant. I'm prepping this a little bit deeper though so, even though we're placing an 8mm, I'm actually prepping to like 10 mm, maybe even a little bit more, but I am going to put an eight-millimeter implant in later. So now I'm going with a pair of pro but I'm just feeling all those walls because you saw those grafts in the true in that site. You saw that you can still kind of see the outline of the extraction site. So I want to make sure that those are bony walls. Really, are bony walls.

Sure that the bone graft is pretty stable. So that's what I was doing my. Broke. And now I'm going to go ahead and continue with my sequential drilling. I was actually measuring the depth also that. That's a good instrument to use to measure your implant up. Some implant manufacturers also make a little depth gauge, which is a pretty cool little tool as well. I'm continuing with the implant drill sequence. Nothing really fancy going on here. I'm just going down the line.

All right. So now I'm going to the next size drill. So notice that this one goes deeper. So, notice that, what you're using, if you're using, if you're doing what you're using as your reference is basically the gums, so you're estimating the gum depth. So if your gum depth is like three, mmmm, you're basically using that as a depth marking to compare to your drill. So if on a drill you're drilling 2/8, mm basically. If you want two millimeters in your bone and you have three millimeters of gums, you're asking to be prepping to 11 mm at the gum level so it's a little distinction but it's really important to follow that.

So, remember, as I'm progressing to the rest of the drills as been pouring down the line of the drills, I am reducing my speed, so I may have started with 1,200 RPM.

Mandibular bone. Sometimes, it's real hard, but as I progressed, I'm going to be lowering the RPM. It would be nice if I can use my last drill. I got 500 RPM, sometimes have been, Diggler bone, it's just not possible because it's too hard, but I like to continually decrease it.

So just I'm just going up the next size in implant drills. Like I said, really nothing fancy about it. It's important that I am forgettable; what I like to do is use almost pretty much every drill. Some implant systems allow you to skip some drills. We went to the next size. I like to just use all of them so that way I follow the same path. There's no question about the implant angulation or anything like that. I like using every single drill.

I'm going to take a second ago; you saw me use my Broke again. I'm just once again checking all my walls, making sure there's bone around the entire circumference of my preparation.

Now I'm using my manual little hand Ranch to put this implant in, and I can only take it so far because that tooth mesial to it is bumping up against them too manually. So I'm going to put my Extender on now.

I put my little Extender on, and I'm going to continue here. And noticed that that purple thing at the base of the implant transfer this little line, kind of like the margin of the abutment almost like a margin going to be submerged in that to where the margin is basically, at the gum line because usually that margin is at the premature approximates, a gingival stickies.

I'm going to sink a little bit further. That margin, if I place it to where it's at my gum level, that's usually a pretty good indicator that my implant is at board level and a guesstimate though. It's not any hard and fast rule; you're not going to always be 100%.

So after I take off this transfer, I'm going to check again so many years of a mirror to check with my probe and make sure that there's definitely bone everywhere. Sometimes with these mandibular molars, there's a little defect on the Buckle aspect because of the way that the anatomy is because of the way that the mandibular bone is slope. So what I like to do is think my implants a little bit deeper or if there really is a defect, you can sink your implant a little bit such that the lower-margin so that your single Merchants little higher than the buck.

That's my point right there, a place to eat in plant. You can see that I prep a little deeper than that. You can actually see the outline of my prep going to be on the apex of the implants. I could have placed a stent implant and it looks like it might be a good idea to do a 10 mm plant but I think I get the margin of where the implant meets the bone and it looks like a pretty good spot. It's just below the margins of the mesial and distal areas of that little bit higher.

All right, and now let's take a look but I put a healing abutment on. And I think it's going to turn out okay.

As I mentioned earlier, one way to improve this case, I think would be to have any place to cover screw on this afterward. So that way the tissue can granulate in the issue would have formed over that, and then I would have to expose the implant later, and that would have helped preserve some of that keratinized.

So, those two things I think would have made this case better. Again, this case went fine, but anything that you can do to kind of improve cases incrementally is this going to help you.

Lesson Summary

This is a summary of a dental surgery case in which a socket graft was performed and an implant was placed at the number 18 site.

The surgeon started by marking the midpoint of the bone using a perio probe and punching the tissue to remove the keratinized tissue.

To prepare the site for the implant, the surgeon used a round pilot drill and sequentially drilled, using different drill sizes and adjusting the speed as necessary.

Checking the bone walls and ensuring stability, a bone graft was used before placing the implant.

The surgeon explained their technique for measuring the depth and angulation of the implant.

The implant was placed using a manual hand wrench, and a healing abutment was placed at the end.

The surgeon suggests that flapping the case and using a cover screw instead of a healing abutment would have improved the outcome in future cases.