Immediate dentoalveolar restoration technique IDRT
He starts without preliminaries his perfectly pictured presentation:
The problem: how to restore compromized sockets, with no buccal bone, without loosing the gingival hight.
The idea: replace all-in-one (step) hard & soft tissue: the bone of the tuberosity is mimikring the alveolar bone, is osteoconductive, at no add. cost;
- Immediate loading with is possible if 30Ncm is obtainable.
- flapless (except triple grafting)
- infected sites: admin. antibiotics 7 days post op/5 days in advance when fistula is present and go 4 it
clinical evaluation
- buccal root volume
- changes in level of ginigval margin
- abszess location
- periodontal probing, median mesial distal
- history of endodontic surgery
Radiologic Diagnosis
recommends soft tissue enhanced CBCT scan (= simply use a lip retractor while taking the scan)
Classifications:
–>Intact socket: bone substitute is enough
no bone buccally: compromized socket:
- 1/3 missing
- 2/3 missing
- 3/3 missing
- add. missing over apex add loss (!)
- add. approx loss add (!) —> cancellous bone substitute only
- palat. loss
reconstruction both in same surgery possible: triple graft
>> cancellous cortical bone and connective tissue graft for defects with recessions and bony defect
Donor site (tuberosity)
– reception site must be congruent then no fixation ist nessessary
– high vitality means quick revascularization
– mechanical resistance 3 months
Receptor site
Immediate Restoration: no interferences at all
Dimension of the alveolar defect must be measured (soft tissue dimensions) to select the implant diameter. 3mm Distance to buccal bone is demanded
Diameter selection
Splint: on cast-model; removement of tooth to be extracted: make splint, bur hole through and select diameter
soft tissue distance: gap should be 3mm between imp and soft tussue
<7 mm NP
=7mm RP
>7mm WP
Extract tooth: good careful curretage (serrated curettes)
Implantation: 1st bur angulated seeking pal wall, 2nd correct to right angulation
– depth position 3mm below Gingiva level (similar to neighbouring tooth)
– if recession less deep (eg. 1.5mm loss, set to 1.5mm depth)
Fabrication of Temporary crown;
pre surgery prepare the veneer on the cast
then connect after implantation to the temporary abutment und create the concave emergence profile (see pix below)
Bone substitution
- – mapping bone defect (triangel shape, rectangular, depth, width…)
- – harvesting graft and particles: get with indexed chisel, which is 2mm wider then the graft to be harvested.
- – inserting graft above shoulder of implant (overlooking implant shoulder)
- – crushing remaining particels and grafting/compaction into the socket, avoiding empty spaces (marked instruments/compactor)
( no overbuilding) - – no grafting, the CC graft allone has the potential of remodelling the tissue
- Insert provisional crown (screwed) week contact to adjacent teeth, infraocclusally
- Oral hygiene with floss 1 w post op., soft brush two months /compromized cases: recessions , Q-tip only, for two months
Patient advisory NOT to bite
Problems:
no stability over 30Ncm: Replica of temporary crown and cut it epigingivally as temporary coverscrew
donor site compromized: third molar, low mouth operning etc. : measure the thickness over root, and slice a piece of bone of it.
Evidence
at least 58 month back – no recession during the evaluation period
periodonic & restorative dentistry 2015 ROSA JCM, 300 cases.
Experience >10 years
rad. diagnosis: CBCT pre and post op, 6 months 1 y later
Complications: 6 out of 300
sequester, take it out if no infection and put tissue graft inside and wait…
www.rosaodontologia.com.br