Dr. Tae Kwon performs a sinus augmentation required during the treatment of his patient Scott during an extraction and restoration of 2 molar teeth with implants.

Surgical Cases 13 Video

Hello everyone this is Tae Kwon from Keene New Hampshire and this is your Ripe Global Fellowship and Implantology case review.

Today I would like to share a case of Scott. Scott presented to my office needing extraction of two molars on the maxillary left quadrant and before the extraction we already discussed about options to replace these missing teeth with Scott and restore it provider decided to proceed with implant therapy on first molars site. Before we start the extraction, I already informed them that the sinus is very close to the future implant site you can clearly see from periodical radiograph the sinus is currently placed or neumotized. So our plan was to extract these two teeth and then let the site heal for six months and reassess the position of the implant, of position of the sinus and place the implant with a sinus augmentation.

So this is very important to discuss this potential need for sinus left or head so that you don’t alarm the patient or surprise the patient later in the treatment plan or later in the treatment. Furthermore, it did really not need a socket grafting because he had wide buccal and lingual width and in case let’s say somehow the bone really resorb to the point where we need to graft the bone horizontally. Most likely I can probably combine them when he needs sinus augmentation anyway, so instead of doing two separate surgery where I do socket grafting, and the later I do the where I do socket grafting and then later I do the implant placement with a sinus augmentation, which is another part of bone graft, I told them maybe if you need ever need a bone graft horizontally then we can combine that when you’re doing the implant along with a sinus augmentation.

So teeth were extracted and then you can clearly see there not much bone that is available before the tip of the crest hit the sinus and this is how the site look after six months of healing you can clearly see the floor of the sinus migrated more coronally and remaining bone is extremely thin or maybe two to three millimeter. Generally if the remaining bone is less than five millimeter on the PA then this is when I normally use lateral sinus augmentation approach as opposed to crustal/internal sinus lift. So this is how he looked preoperatively and then you can clearly see that he has nice width of buccal lingual bone and first I made an incision always I would like to use the vertical incision on the medial aspect of potential prospective Windows location so that I can create nice access and then I used a high speed rombar diamond rombar just clearly and slowly outscoring the window and the size of the window can be big or small. I always like to make the size of the window smaller, which kind of gave me a little bit difficult access but I have instruments that allow me to go into the sinus through the small window because the shank of the instruments are long.

Once they outline the sinus, this is when I tap this remaining bony island that is surrounded by the outline and then I tap this bone with a mirror handle and then break into the sinus like so, and after that I gently move the sinus floor using series of instruments up, up, up and after I elevate enough the implant is placed and then I can when I’m placing the implant I can visualize the sinus making sure the implant does not go into the sinus and after that, I complete the packing the bone graft in terms of the bone graft I pack the palatal side of implant site first place the implant and then finish the buccal site later, because otherwise if you put the implant in how are you going to pick the bone on the palatal side when you have an implant on the way right. So again, I grabbed the palatal site first place the implant and then buckled sight and sinuses has been filled.

In this particular case, I’m going to- I have used mostly human bone graft with a little bit of Zeno graft mixed and window has been covered with the collagen membrane which is not shown here, because the study indicated that when you actually put a membrane over the lateral sinus augmentation window, then you actually ended up getting more vital bone formation and then after that I close the site with in this case 3-0 and 4-0 chromic suture and this is how skull leaves the office and knowing that there were a significant amount of sinus augmentation, I did not want to have any disturbance around the implant during the healing, so I decided to submerge the implant. Six months later, I expose this implant for a second stage surgery and this is why because I encode the healing abutment, which is also a scan body, I placed that and then restoration has been completed by the restorative dentist, then you can clearly see there is good radiographic Bond-vile with evidence of sinus floor elevation on the peri apical radiograph.

So if you like to learn how to do this sinus augmentation laterally or internally, please join me at Ripe Global Fellowship in Implantology is one of the module they were going to spend time A: to understand when to use what approach and Two: how to avoid complication when you’re doing sinus augmentation, such as when you get a membrane perforation or if there’s not much primary sturdily with an implant.

We’re going to go over all of these with you during the fellowship Implantology so please join me and otherwise I’ll see you next time for your next case review.

Dr. Tae Kwon walks us through the case of Claudia where he details the approaches he takes in socket grafting which is a type of implant procedure

Periodontics | Case Studies - Socket Preservation - with Dr Tae Kwon

Hello everyone this is Tae Kwon from Keene New Hampshire and this is your Ripe Global weekly case review.

Fellowship in modern Implantology.

Today I would like to share a case of Claudia. She presented to my office for evaluation on number 30, she was having a lot of pin around this area – and when you look at the video graphs you can clearly see that there is a periapical lesion on number 30 distal root, and also there’s a large post on the distal root and there’s a broken file on the mesial root, and although number 31 also has possible peri-epical lesions which was under Endodontist care, number 30 deemed to have questionable to help the periodontal prognosis. Thus we decided to extract number 30 and plan for socket grafting and implant placement in the future.

On the buckle aspect if you remember the photo, from before you can actually see there is some recession on the buckle aspect most likely suggesting that there is some buckle dehiscence on the crystal aspect and to preserve the volume of the bone, we decided to perform socket graphing at the time of extraction.

Extraction was done in a very a-traumatic manner, we sectioned the medial and distal root and this is how the socket looks likes, and you can clearly see as we anticipated there was crystal buckle dehiscence about 3, 4 millimeters and you can clearly see the level of the crystal bone at the mid buckle aspect is much lower than the proximal aspect. Now a lot of times, one way to do bone grafts is to take the tooth out and then to put some bone graft in without elevating the flaps, and then put a membrane and tuck it under the flap and then suture it. That is one way to do it and I am sure that it works as predictable as what a lot of people expect, but sometimes I like to close these sockets completely so that the membrane and bone grafts do not get disturbed or contaminated during the healing – because from certain literature, it is found that whenever the membrane gets exposed you actually get less quality bone or less volume of the bone, but there are also literature suggesting that when you actually do the flapless technique and then let the membrane expose you’ll get the same bone so this is one of the areas that you can approach in both ways but I just want to show you this case where I – how I approached this to get the primary closer. So the bone graft has been placed in this case I used the freeze dried bone yellow graft which were hydrated with platelet drive gross factor to maximize the regenerative potential and I put a cross-linked collagen membrane which is more rigid in general, and also is less prone to degradation when it gets exposed and after that, I release the buckling lingual flap with the elevator without any vertical incision I just go in with my – used elevator or periodteum elevator and I stretch the tissue from the buckle, and stretch the tissue on the lingual and this is all blunt dissection – and what I want to empathizes here is I actually released a lingual aspect and when you are doing that, obviously you want to do it very bluntly because there are some important structures on the lingual aspect and then what you are trying to do is actually you are purposely tearing the attachment of myelohyoid muscle and when you do that you will actually notice that your lingual flap will be so much more released to the point where you can achieve primary closure tension free.

Once I snuck it in , this membrane I will actually put the series of the suture – in layers, one being horizontal Matrix suture starting from the buckle aspect go over the membrane and then come out through the lingual and come back from lingual to buckle, and tie the knot on the buckle and when you do that the flap is going to be currently advanced and after that I use continuous sutures, on the crest with a little bit of twisted interlock so that I can bring the flaps together and then sometimes if necessary I may actually augment this crystal aspect with single interrupted sutures, so this is how it looks.

In this case I didn’t need single interrupted sutures at the end – pretty much I was able to get the primary closer by putting a horizontal matric suture form the buckle aspect and then crystal continuous interlock suture, suing 4.0 vicro and you can clearly see that primary closer has been achieved and the side can now help without any disturbance, worrying about opening up the flap and even though lets say it opens up from the tension it will take much less time to close – compared to when you leave this membrane exposed from the beginning on purpose.

I don’t always do this way, but in certain cases where I think for getting the primary closure is more important especially when buckle bone is missing or there is some large infection I like to close the socket like that.

One may argue that well, when you actually advance the flap to get the primary closer, you’re going to alter muco gingival junction and you may lose keratinized tissue – I think that is a good argument, but sometimes in my hand, as a periodontist – soft tissue surgery is much more predictable than bone graft surety so I rather want to mess up the soft tissue to get better bone because I know how to correct he soft tissue later completely so one way to solve this is when you are doing the incision when I’m doing the implant I can always make the incision lingual zed and then push this muco gingival junction back to where it should be and if that’s not enough I can always augment this area with free gingival graft of any other gingival graft technique. So I hope you learned how I do every day basic socket grafting when I decide to get the primary closer and this is how I do it, and if you want to learn a little bit more about how I suture how I manage the flap, when do I want to get the primary closer when do I want to leave this membrane exposed – and then let the tissue heal if you want to learn these feel free to join me at Ripe Global for fellowship in Implantology. Otherwise I will see you for your next case!

Dr. Tae Kwon dissects the details on his weekly case study review of his patient Juliet; an 18 year old and her case of gingival recession that was managed with gingival grafting

Revitalising a Recessed Incisor with Gingival Graft Therapy - with Dr. Tae Kwon

Hello everyone, this is Tae Kwon from Keene New Hampshire and this is your Ripe Global Implantology case review.

Fellowship in Modern Implantology

Today I would like to share case of Juliet that I treated a while ago. She was 18 years old at that time, and then she was referred to my clinic for evaluation of gingival recession on mandibular right central incisor – as you can see from the clinical photo there was significant gingival recession about 5 or 6 millimeters, completely missing keratinized gingiva at this point. High franamal attachment, gingival inflammation as evident by marginal gingival redness.

Furthermore around the areas of gingival redness you can clearly see there are moderate deposits of dental plaque which make this recession worse but also inflation worse and this is very common on patients who have gingival recession because a lot of time these patients were told that they should not brush too hard around these areas with gingival recessions but unfortunately when you explain to the patient you cannot brush too hard, patient will actually stop brushing on this area, so when you evaluate this area compared to others you can clearly see there are more gingival inflammation and 2: a lot of times patients think they are brushing around the gingival line, however because of the gingival recession – the brush is actual not touching the gingival margin which clearly cause more plague accumulation – obviously the reason why I ‘m showing you this case is that I would like to show you what soft tissue graft can do to resolve this situation which is a critical component to achieve successful implant therapy. Obviously we are not doing implant here but I just want to show you what soft tissue can achieve in terms of the intervention.

Now, whenever you have a case like this – the first thing you have to do is to reduce the inflammation before you do any type of treatment, the way I treat- the way I communicate this to patients is that okay you are going to make your gum much healthier so that I can operate on this area with gingival grafts and basically what I tell patients to do is just simply retract her lid and then put the brush over the area that has gingival recession and then brush until there’s no plaque and I explained to the patient there will be a little bit of bleeding at the beginning but don’t worry just go ahead and do it and then you will notice that bleeding will be less and less as the tissue heals.

Let’s see how it looks after 2 weeks, this is how it looks after 2 weeks – you can clearly see there is less gingival inflammation and redness has substantially got reduced. This is where I am going to do the gingival graft, because the environment is much cleaner and tissue healing will be a lot better – first I will use the scaler and then clean out this root surface that is exposed, and then I will make an incision to prepare the recipient bed, and then after then I will actually put the graft on that area – where does the graft come from? The graft is going to come from the palette and you can actually see that my- where I take the graft is closer to the gingival margin of the premolar. The reason is I would like to actually the marginal gingiva and put it over this tooth, just trying to mimic as close as possible – by having the graft with a marginal gingiva which will go into the marginal gingiva area of the tooth that is going to receive the graft.

This is how I suture my graft, there are 4 sutures in this case I use five-o monocle sutures and then you can also see that I clearly released the frenum as well which was the contributing factor for gingival recessions, connected tissue graft was not my choice in this case, because A: I would like to believe the frenum, B: I would like to create some keratinized tissue – and 3: I wanted to extend a little bit of vestibule too. So we decided to go with the fridge and demography.

One of the things that is extremely important that you don’t see in this case is that the recipient bed and the graft are all beveled they are not but joining they are beveled, so that when there’s a healing with a contraction of the wound – there is a less amount of the scarring that’s going to happen – so always remember bevel the incision and after that I put well because of a co-pack which is the surgical dressing to protect the graft, and then also I put another role pack on the palate where I took the tissue from , there was no suture used on the donor site, I just simply put the col pack on and then just let this heal – ad this is how we looked after eight months following the graph you can clearly see that A: significant root coverage has been achieved, B: there is complete resolution of gingival inflammation now because patient is much more comfortable brushing on this area – 3: the Frenum has been attached – detached from the previous location, for the vestibule has to extend this significantly on this area – 5 you can see the tissue is a lot thicker.

If you can do gingival graft and be competent in doing gingival grafts on natural teeth you can certainly extend the same principle of soft tissue management for your dental implant and this is what we are going to teach you during the fellowship in motor Implantology. If you want to know a little bit more about it and then if you want to be part of the fellowship – please reach out to us, reach to us at rightglobal.com, otherwise I will see you for your next case review and have a good day!

Dr. Tae Kwon explains the details of the case of Cheryl – an intricate case study of gingival recession and discusses the methodologies taken to address this patient’s condition with gingival grafting

What would a Periodontist do? with Dr Tae Kwon - Case 10

Hello everyone, this is Tae Kwon from Keene New Hampshire and this is your Ripe Global Implantology case review.

Fellowship in modern Implantology:

I would like to share a case of Cheryl today with you, Cheryl was referred to my practice several years ago for evaluation of gingival recession or I should say peri-imply mucosal recession, around max 3 canine, and you can clearly see there is muco gingival deformity with no attached tissue, and threats of the implant is exposed, clinically – and you can also see plaques around them. A lot of time when you see these implants, with buckle threads exposer or peri-imply ulcer, a lot of times that means implant fixture was placed too buckle and when implant is placed too Buckley it does not leave enough buckle plate, or even it leaves thin buckle plate which is going to resolve eventually and case peri-imply recession. From the scientific study it is recommended to have at least 2 millimeter bone buckle to the fixture in maxillary arch, now I a case like this, where the interproximal bone is intact – I always like to treat this case as not with a bone graft, but with gingival graft first – the reason is, growing the ovular bone, or growing the bone, outside of the normal ovular housing, especially when you are already having implant fixtures – it is extremely unpredictable in my hands, and I do think this is related to a – vascularity of the implant threads, obviously which are metal, but also the metal threads are also contaminated so when you put bone graft in, which is already dead in nature because when you sue the bone graft there – usually dead bone, you cannot really grow something dead around something dead – it is dead! So I always like to correct this with soft tissue in my humble opinion which is much more predictable, so the way I approached this case, is first I prepare the recipient bed, like I am doing with free gingival graft surgery, and after I remove the epithelium around the implant I kind of gently clean around the implant threads with saline and scalar, and then after that I take free gingival graft from the palatal donor site and then place it over the area and stabilize the graft with stitches and you can also see there is what I call as a compression suture, which adapt the graft against the implant tightly so that there is no dead space, and the graft is actually coming from the palette but you can actually see there is something different from regular free gingival graft. In regular free gingival graft, you will harvest a tissue away form the gingival margin, but in a case like this – I would like to take some tissues, that is around the palatal marginal gingiva because that the tissue that somehow survives around natural teeth even though they’re not attached to the teeth so I want to actually sue that almost that marginal gingiva, and then transplant it over the exposed thread to see if that marginal gingiva can survive without too much vascularity. So this is 4 weeks after – and you can clearly see that the full coverage of the implant threads were exposed, were achieved, and let’s look at how thing are healing this is 4 week follow up on the palatal donor side, you can actually see the tissue healing is looking really good, and this is 3 months so you can clearly see the tissue is continually maturing and this is 3 months follow up and at this point, the underlying connective tissue graft healing, the underlying connected tissue healing is completed so I was able to put the probe in safety and you can clearly see the probing depth is about 3, 3 millimeter or so, this was really nice result test being achieved this is 3 months on the donor site, and I saw her for 36 months and you can clearly see nice results has been maintained and probing that has been maintained very normal thus we did not need any additional procedure. Yes, one may argue that we might be able to do some bone grafting to see if we can add some particular bone particulate bone, on the buckle threads of the implant – but when there is no parental pocketing and the peri-imply plan mucosa appeared healthy there’s no reason to intervene with more surgery so the principle of regular or conventional periodontal surgery including gingival graft can be applied when you’re dealing with implants or implants that are alien and this is why in our fellowship in modern Implantology, we heavily focused on management of the soft tissue around dental implants. If you want to learn more about it, and you want to do gingival graph around periodontist around natural teeth and implants, please join me at fellowship in modern Implantology. Thank you very much! I will see you later!

Dealing with an un-restorable mandibular molar requires intricate attention and careful extraction. Dr. Tae Kwon talks about the procedural methods and techniques that he used to help in the case of his patient Shelley

What would a Periodontist do? with Dr Tae Kwon - Case 9

Hello everyone, this is Tae Kwon from Keene New Hampshire and this is your Ripe Global Implantology case review.

Fellowship in modern Implantology:

I would like to share a case of Shelley with you today. Shelley was referred to my office due to un-restorable mandibular right first molar, as you can see tooth was fractured at the gingival line and it was deemed un-restorable. And this is the radiographic view before the extraction and as you can see in this case, the root mesial and distal root appear to be, relatively well diverging, leaving a lot of septal bone that is available to secure the implant, and a lot of time when I do first molar immediate implant, especially if this tooth is the very last or distal tooth in the arch I would like to keep the occlusal table of the first molar implant to be about 8 to 9 mm instead of 12 millimeter, the reason is I don’t want to keep the occlusal table as small as possible so that there is not too much occlusal trauma on this implant, by being the most distal tooth. So a lot of time when that the case – the best place to place the implant in first molar case – is between the septum and the mesial socket or maybe in the mesial socket, they will give you about 8 to 9 mm occlusal table, by being 4 or 5 mm away from the distal marginal ridge of the second premolar – so after the tooth was taken out a dramatically, without eliminating too much bone, or grinding too much bone away. Initial osteotomy was performed and guide pin was placed, and you can clearly see from the distal marginal ridge of the second premolar to the center of the pin is about if you look at it between 4 and a 4.5 millimeter, then this will give me at the end – 9 – 8 to 9 millimeter occlusal table for the particular implant, so after I finish the osteotomy implant was placed and you can see it is kind of between the mesial socket, and the center of the septum. After the implant is placed in a prosthetically driven position – bone graft was placed and healing abutment was chose and then the flaps were approximated together using stitches, and this is periapical radiographs right after the extraction you can clearly see there is a good septal bone, that I can engage the distal part of my implant that is going to go close to the mesial socket, and this is with the initial guide pin, after initial osteotomy and this is after I place the implant the size of the implant is 4.8 mm by 10 mm and after that I place the healing abutment and then graft the remaining socket, with FDBA, cross linked collagen membrane and biologic modifier in this case was platelet-derived growth factor which were used to hydrate the FDBA. So a lot of time, immediate implant concept can be applied not only to the anterior zone, but you can also doing that do that on the posterior molar especially when mesial and distal root or in the upper three roots are diverging, that means there’s a more septum available that you can secure the implant to get nice primary stability.

Another thing that is really important in this case is when you are thinking about doing immediate implant; you want to make sure that you do not traumatize hard and soft tissue during the extraction the extraction has to be done in a very a-traumatic way to preserve soft and hard tissue architecture.

If you would like to learn how to do an a-traumatic extraction, and immediate implants, like so – in combination with predictable bone grafts, please join me at Fellowship in Modern Implantology

Dr. Tae Kwon examines the case of Joni that involves the repercussions on an unsuccessful endodontic treatment. Watch as he walks through the intricate process of assisting this patient’s recovery

What would a Periodontist do? with Dr Tae Kwon - Case 8

Hello everyone, this is Tae Kwon from Keene New Hampshire and this is your Ripe Global Implantology case review.

Fellowship in modern Implantology:

I would like to review a case of Joni today. She presented to my office, with failing endodontic treatment on maxillary left central incisor and lateral incisor which are part of four unit bridge, from maxillary right lateral incisor to maxillary left lateral incisor. As you can see the maxillary right lateral incisor is a cantilever restoration and she had trauma in the past, which ultimately led to failure of the endodontic therapy. When you look at periapical radiographs you can clearly see there is a large periapical lesion, on left lateral incisors, and you do not really see too much going on, any lesion on the right central incisor. Although initially the patient was recommended, for implant therapy to replace the left incisors only, with 2 implants, when I look at Joni’s case I was thinking wait a minute with the same number of implant which are 2, we could place one on the right incisor, lateral incisor area and the left incisor area and then make it into 4 unit bridge, instead of doing a patchwork so this is where a comprehensive treatment plan is extremely important, as opposed to doing a patchwork. Sometimes when you do a patchwork it might be a little bit easier but at the end, it can lead to overtreatment but also the patient becomes a victim of the patchwork, so this is where looking at a case more comprehensively and then provide a treatment that is going to last much longer, becomes critical of your success – so we proceed with extraction we remove tooth number central incisor and left lateral incisor a-traumatically you can clearly see extraction was done, with a very minimal trauma to the bone. However if you remember from radiograph there was a large periapical lesion so how do I remove the periapical lesion? I don’t trust myself using a curette into these sockets, hoping to clear all this infection what I do is I elevated a large flap, so that I can visualize the defect completely and then you can clearly see on this areas – there is a large periapical lesion. Could we remove these lesions without elevating the flap?

Probably not – another way to do it is you can extract these teeth and then let them heal first and then go back to the bone graft which I don’t like because then you ended up going another surgical procedure.

After I clear the periapical lesions, onto this alveolar bone defect I grafted with freeze dried bone allograft – these bones were hydrated with platelet dried growth factor to maximize potential of periodontal and guided bone regeneration and then after that, I place cross-linked collagen membrane which are completely tacked using periosteal sutures, and after that I coronally advanced the flap to achieve primary closure over the defect. Now I have to wait for this osseous healing for about minimum 6 to 8 months, so at 8 month follow up this is how Joni presented. You can see the soft tissue healing looks really nice; you can appreciate convexity on the maxillary incisor area.

This is the occlusal view, and now in going to make an invasion – and you can clearly see wonderful outcome, of new regeneration was noted on the area – and based on the surgical guide I placed 2 implants on the lateral incisor areas, and this is the occlusal view – don’t forget as I previously mentioned you always want to leave at least 2 millimeter of bone buckle to the fixture, all right? So the implant need to go as palatal as you can, cause when you have less than 2 millimeter of buckle bone, buckled to the fixture than the implants are going to experience, the risk of recession and after placing the implants, this is how we look on other view without the mount fixture and primary closure was achieve over the implants – and implants will be further the submerged for Osseous healing and roughly 3,4 months later – we are going to expose these implants with possible connective tissue grafts and then patient will be cleared, for either temporary restoration, if patient wants to develop some soft tissue aesthetics, or final restoration directly – so the key for this case is to understand, when you want to separate, doing minimally invasive extraction and bone graft, from elevating a large bone large flap – to another thing that I want to review on this case is that how long we have waited. I waited almost 6 to 8 months because of large augmentation procedure, 3: a predictable bone augmentation can be achieved. A: if you give enough time but 2: if the right material is used in a right way, especially how I fix the membrane completely so that the membrane and bone graft are completely immobilized, and then 2: I use the right growth factor to induce better outcome of regeneration. 3: I achieve tension-free primary closure, margin sure that the bone graft and membrane that I place are not going to be exposed or minimally exposed during the healing process. If you achieve that placement if the implant, and that surgical day will be the easiest day that you’re going to have for the patient because solid foundation has been already established.

If you want to learn a little bit more about how to do the bone graft better predictably, then I will be more than happy to share that in Ripe Global Fellowship in Modern Implantology. I look forward to seeing you again and I’ll see you for your next case review!

Dr. Tae Kwon shares with us the details of his patient Margaret who required an implant replacement

What Would a Periodontist Do? With Dr. Tae Kwon - Case 7

Hello everyone, this is Tae Kwon from Keene New Hampshire, and this is your Ripe Global Implantology case review.

I would like to share case of Margaret; she was referred by general practitioner regarding needing implant on maxillary right central incisor edentulous area. Patient presented to general practitioner with large periodical lesion with failing endo on this area and general dentists extracted the tooth, removed the periapical lesion and placed a bone graft and patient ended up in my chair for implant placement. Now, when you look at the profile of her case, you can see there are some vertical rich resorbption as evident by gingival recession on the adjacent teeth specially on the lateral incisor, and when you look at it occlusally, you can clearly see that there is a buckle concavity This is not surprising, because on the literature when you do extraction and socket grafting, believe it or not, you still lose about 15% of alveolus width.

Your bone graft uses about 40% of the alveolar width, so it’s not surprising to see some bulk of concavity on this area. Now, is the site ready for dental implant? The graft has been done more than six months ago, and the question is, what kind of bone do we have in this area? Conventionally we’ll rely on CT scan or Peri apical radiograph to determine the quality of the bone. However, the reason why I want to share this case today is because you cannot rely on radiograph all the time. The reason is what is the material that we use as bone graft is usually mineralized bone powder. So if you put those mineralized structures into the socket, and then you take x ray is going to appear like his bone because you technically put some bone in but it doesn’t really tell you how well these bone grafts are Osseo-integrated into the socket. So a lot of times that decision has to be remade when you app open up the flap, like so. So when I elevate the flap, you may wonder that’s really nice bone, but when you look a little bit closely, you can see that there is a little gray bluish area, and a lot of time this is the residual granulation tissue or fibrous encapsulated graft particle that are not Osseo-integrated into the existing bone. I use the mini curettes is called Hirschfield file, and I use the minute curette to trace this granulation tissue and then remove completely.

When you do that, you can clearly see that there is significant hole in the alveolus where the socket used to be, and the depth of this just to give you an idea was about 8 to 10 millimeter which is the full depth of the socket. Do we place bone graft here? Absolutely not because there is a defect on alveolus, and as you already had a history of not taking full bone graft, I want to graph this site again have a nice base and repaired this Capaco concavity and converted into buccal convexity. So graft has been placed and then now I’m going to fold this membrane over and stabilize it using periosteal sutures. So these periosteal sutures start from the palatal aspect, go over the membrane Buckley, grab the periodteum and then come back to the palatal and then we make the knot and then you can see there to periosteal suture that is compressing the membrane and bone graft against the recipient area.

Then this mucosal flap here will be currently advanced to achieve the primary closure like so, and like so. Achieving the primary closure is extremely important, especially when you do large bone augmentation. The reason is, the more close the flap is there’s a less chance for bacteria to get into this membrane and bone graft material. Most likely the reason why this Margaret’s case initially had granulation tissue to begin with is probably because of a maybe some of the granulation tissue was not completely removed during the extraction. A lot of time when a patient present with a large period collision, I recommend raising a flap completely so that you can expose the defect and clean out everything. 2: it could be when graft was done membrane and bone graft has been purposely exposed or left exposed, and these bone graft a membrane could have been contaminated during the healing which may have caused the granulation tissue formation.

Another tip that I want to share here is you can clearly see my incision crustal incision is on the palatal not mid crustal. The reason is, even though I achieved the primary closure in this case, there is a chance that this flap may open up. If I place this incision mid crustal when it opens up, guess what happened? I expose a lot of bone graft especially on the buccal aspect where I need bone graft. By placing this incision palatably away from I need to grow bone which is mainly buccal. Even if the flap opens up changing from healing by primary intention to secondary intention, there is a less chance for bone graft on the buckle to be contaminated during the healing process.

So when you’re making the incision, you always have to remember A how you’re going to close it but B also potential complication that can rise. Lastly, when I do this kind of bone grafting large augmentation case, I always tell patient on our head that there will be significant swelling on the face bruising sometime and significant pain. So you always want to let patient know ahead so that they are well prepared. I hope you learned something from this case, and I will see you for your next case review very soon. Take care

It’s not always about how great your skill set is, but rather how good you are a knowing when and where to apply them! Dr. Tae Kwon examines the intricate case of Roberta

What would a Periodontist do? with Dr. Tae Kwon - Case 6

Hello everyone, this is Tae Kwon from Keene New Hampshire, and this is your Ripe Global Implantology case review.

Today, I would like to share my patient Roberta, who presented to my office due to tooth number 9, or tooth number 2-1 depending on where you live, and the maxillary left central incisor was deemed un-savable. It’s because of the endo lesion that developed, potentially due to fracture, and she already had, as you can see from the apical, metal shadow, she actually had apical surgery in the past and which was repaired, and unfortunately, as you can see from the buckle swelling, there was some fistula forming and the area was kept draining over time tooth did have mobility of grade two plus, and I know this will be a really straightforward extraction.

A lot of time, you were probably told by other people, or maybe Facebook or other implant training program. They say oh, these are the very easy cases, just take the tooth out, use the granulation tissue removal curettes, clean it out, and then put some bone graft material and then put a collagen plug or membrane and then put some x sutures and close the day. If you do that, in this case, it’s a big mistake. You have to know which case is suitable for a-traumatically treated, a-traumatic minimally invasive extraction and bone graft like without a flat, versus you have to know when you have to use conventional flap principle to open this area completely to ensure that you remove all the infected lesions. So the case is where there’s an endo lesion, or has a significant mobility, ironically, I know there are more infection and because of that I actually scheduled extra time for these patients, and you’ll see why.

Look at the CT scan here, you can clearly see that there is a complete missing of buccal plate and the radiolucency, the size of the radiolucency is much bigger than the tooth, which means there are a lot of infection and granulation tissue around this tooth. Look at the sagittal view where the buccal plate is completely missing, and again, this is not the case that you can just do extraction and bone graft without raising flap and then leave this area open. You have to do conventional flapping with conventional guided bone regeneration. So tooth was extracted a-traumatically using perio tone and 150 Forceps with just a rotational force and tooth came out a-traumatically. After that when I always the flap, you can clearly see there’s a large bony concavity or bone cavity. If you think you could remove all these granulation tissue without raising a flap, you’re making a big mistake. If you theoretically did this without a flap and then remove some bone or remove some granulation tissue and then do a-traumatic bone grafting, your implant will fail so much prematurely then conventional bone grafting case because the reason is you will leave some granulation tissue behind which will negatively affect the outcome of your bone graft which means poor foundation for your implant.

So after I completely remove the granulation tissue, I put bone graft which were hydrated with platelet derived growth factor and you can clearly see in these kinds of cases you have to not just do socket grafting but you have to graft beyond the socket. Why not, because you have an access to add more bone and as you know, people lose bone in maxilla from buckle towards palate over time.

So I want to make sure that I give you enough hard tissue for this potential implant site. After that I use cross-linked re-absorbable collagen membrane which is completely packed using a periosteal suture technique and the membrane is completely immobilized and this membrane will be there for about six months. Now I want to close this area completely by achieving primary closure and I advanced the flap coronally. We like so, you can clearly see that primary closure was obtained, and in cases like this achieving the primary closure is the key. When you have this much larger augmentation if you leave this membrane or bone graft exposed more chance for contamination by saliva plaque, bacteria and food debris and this is the frontal view. One may say hey, you just out altered the mucogingival junction. Yes, I did. However, I read I want to get good bone and mess up the mucogingival junction because as a periodontist, experienced surgeon, I can always recollect this predictably using the principles of soft tissue grafting.

Whenever you get a case like this and then you suspect there’s a big cyst or Peri apical Legion, I always like to send these to pathology review, so that I do ensure the patient that there was no malignancy. So this turned out as we expected as Peri apical granuloma. So, I hope you learned something from this case.

Sometimes you can be the greatest surgeon or you can have the best hand but if you don’t know how to approach certain cases, then your skill is useless. At Ripe Global Fellowship in Modern Implantology we will teach you how to make these decisions where you want to do a traumatic flatness, extraction and bone graft where you leave the membrane and bone exposed bone graft expose versus where you have to open up a flap and do more conventional guided bone regeneration.

Please join us at Ripe Global Fellowship in Implantology if you’d like to learn more, and do the procedure like a periodontist.

Dr. Tae Kwon introduces us to the case of Laurie who he helped recover from a fractured maxillary right central incisor

What would a Periodontist do? with Dr. Tae Kwon - Case 5

Hello everyone, this is Tae Kwon from Keene New Hampshire and this is your Ripe Global Implantology case review.

I would like to present a patient of mine named Laurie and Laurie presented to the office due to a fracture around the post on tooth number eight, which is the maxillary right central incisor. When you look at our case, you can clearly see there’s some gingival erythema on the mesial buccal aspect of the incisor, which indicates the micro leakage between the post space and the crown. As a result, the tooth was deemed on restorable and from general dentist, the patient actually was referred to my practice for implant therapy.

Well, when you look at Lori’s case, there are many different ways that you can go. Preferably, I always like to get primary closer when I do the extraction and bone graft, which means I do the bone graft and I close the site completely with soft tissue, but in certain cases, that’s not the best way to do it especially if patient is really nervous, and you want to keep the surgical site as less invasive as possible and also when you relatively have intact buccal plate or the four wall socket, then sometimes I may actually do some procedures so that I can do it without achieving primary closure, which often makes the procedure less invasive.

I want to show you how I do that in her case, so first thing first we want to make sure the tooth is extracted a-traumatically. So without elevating any flap, I use a Perio tone because it is one of the small instruments that is designed to be fit into the periodontal ligament space, I go in with Perio tone, and then go around the to 360 degree and I do not use any elevator in this case, because a lot of time, when you use an elevator in the maxillary anterior zone, you will tear the papilla and we don’t want to do that. I mean her case was not a super aesthetic case, but every single case I treat them as super aesthetic case. Why not achieve better aesthetic, right?

So I recommend not to use any elevator when you actually do the extraction on the maxillary aesthetic zone. After I use the Perio tone to sever the periodontal ligament, and also micro Lochside this tooth with a period of time I going with 150 or 151, forceps and then I just used the rotational force as opposed to luxated Buckle lingually – just rotate and then I put my finger on the buccal plate as I’m doing it and I rotate it and take the tooth out and you can clearly see the popular has been in tech. Now after that I have to create a space to talk my bone graft and a membrane. Especially if you can imagine I want to talk the membrane between buccal plate and the soft tissue or the gingival tissue that is surrounding it and to do that I use why because a little bit of urban knife is a knife that I use it for a lot of time for tunneling the soft tissue, and I pretty much go in and then create a little pouch between the gum tissue and the buccal plate and the buccal plate had a little bit of fenestration in the middle, and I’m already aware of that, as I’m cleaning this socket.

After I do that, I tuck this membrane between the buccal plate and the soft tissue and I start putting the bone graft in, this bone graft has been already pretreated with growth factor which is platelet derived growth factor which makes the environment much more favorable for regeneration, and this is how it looks when you look at from the occlusal so you can see I fold it the membrane away, and then I put my finger on the buckle and then I push the bone graft as much as I can. If you imagine there was a fenestration, right, so I want to make sure that when I’m placing the bone in the bone is actually pushing against this fenestration, then I know that I filled all the way in because a lot of time, clinicians actually do not place too much force when they are putting the bone graft in which leaves a void and you don’t want to do that. So when you’re doing the bone grafting, making sure you use the condenser: a lot of time I use the amalgam condenser and then push it really well so that you were really, really condensing the bone graft without creating any dead space, and after that, because I actually tunneled or create a little pocket between the buccal soft tissue and buccal plate, I can even move this tissue slightly coronally with sutures. So, you can actually see the size of the wound that is exposed or the membrane that is exposed is smaller than the size of the socket, which reduce the amount of healing by secondary intention, which means there will be less chance for this membrane to be contaminated by saliva and food. It will take less time for the soft tissue to completely close. And this is how it looks from the frontal view, you can see that this has been done really nicely. In this case, I use Fibre monochrome suture which dissolves usually in the mouth for about four to six weeks, because I want to make sure during that healing time, this Sutures do not prematurely reserve to the point where the flap start opening up more.

This is a little trick that I want to share, also, at the end of the extraction; I always measure and take a photo with my periodontal probe. The reason for that is eventually I want to put an implant here, and then it gives me some idea about what is the length of the socket, which will help me decide what will be the length of the implant to obviously, with a CT scan, we don’t have to do that often, but always having the idea about what it was the length of the tooth before the extraction always helped me to plan the size of the implant. So this was a very interesting case, because I apply the principle of a traumatic extraction, which is the fundamental step to preserve the heart tissue, and then the way I prepare the recipient site for the bone graft, and the way I minimize the amount of secondary healing by intention, by healing by secondary intention was to apply my connective tissue graft skill, which is tunneling. I tunnel the buccal side to create a space to place the membrane. So I use the principle of the soft tissue, and then obviously, I use the heart tissue, which is the socket grafting. So this is a combination of using not only the Implantology concept, but pre-Implantology concept, which is the a-traumatic extraction, soft tissue and hard tissue management, and obviously, the suturing too.

This is how the implant education should be tailored. If you’re thinking about taking an implant course and just focus on placing the screw into a model or patient’s head, maybe that’s not enough. You have to know how to manage the other things – if you want to learn that, please join us Ripe Global Fellowship in Modern Implantology then I’ll see you for the next case review. Take care and bye now.

Dr. Tae Kwon walks us through the case of Noah who suffered gingival recession after a previous implant

What would a Periodontist do? With Dr Tae Kwon - Case 4

Hello everyone, this is Tae Kwon from Keene New Hampshire and this is your Ripe Global Implantology case review.

I would like to share this case, Noah, who happened to camp- who happened to come to my office a few days ago, and we already placed the implant on maxillary left central incisor area and this is how he presented. An implant is almost ready to be restored and when you look in his case, he already had an implant on the contralateral side, and you can clearly see that there is a free gingival graft that was augmented. The reason for that was that when this implant was done 10 years ago, over time, he actually developed gingival recession, which caused showing off the metal abutment. This happens a lot when the soft tissue that is surrounding the implant, and also the bone is extremely thin and when that happens, and you have a metal exposure, the only way that you can predictably treat this is using free gingival graft that goes on the top of the existing mucosa. When you do that, although we’ve worked really nicely in his case where the metal exposure was completely closed. Aesthetically, you can see this is not the best scenario because you can almost see I call it a tire patch of the gingiva around this implant. So when they are restoring the implant on the other side now, which is the maxillary right left central incisor, can you do a little bit differently to thicken the soft tissue so that we can prevent recession but also we can avoid doing this on aesthetic free gingival graft later, later in his life – and this is when the minimally invasive connective tissue graft technique come into play and I’ll show you how to do that.

First I remove the healing abutment and you can see the emergence of the soft tissue, and once I do this, I use what because of Urban knife, which is a sharp instrument, but it’s not as sharp as 15 or other blades and I go in and create this pocket of the gum within the emergence and after that I harvest connective tissue graft from the palate and to this pocket that I just created, I can insert this graft like so and once the graft is inserted into this buckle emergence pocket, how do I finish this? You don’t need any stitches, all you need is just putting a healing abutment back and you have a completely sealed surgical site and look at the post-operative, immediate post-operative emergence, you can see the buckle area now is more convex as opposed to concave and because the tissue actually went inside layer aesthetically is not going to be as non-aesthetic as the free gingival grab which was on the other side and this is how he finished or how he left my office. You can clearly see there’s almost bulging of the buccal tissue, but aesthetically, it looks totally acceptable because there is no graft showing on the outer layer and this is how I look on the donor site where I made an incision on the palate, and then went to the inside layer of the palatal epithelium and then took the connective tissue graft.

So this is a short case that I wanted to share with you and this is extremely important again, because the thicker soft tissue means more blood supply for the underlying buccal bone, which normally thin around the implant in the aesthetic zone anatomically, so by giving this extra thickness we can prevent the resorbption of the bone which can prevent the resorbption or recession of the gingiva that is surrounding the implant.

If you want to learn this technique, little bit more in detail and you want to try maybe in your cases, I strongly recommend you’re joining Ripe Global Modern Implantology program where not only we’re going to teach you how to do the implant, but how to build soft and hard tissue which is the indispensable components to acts to achieve successful outcome of implant therapy. Thank you very much and I’ll see you for your next case review.

Dr. Tae Kwon discuss the case of Paul who is looking to fix his missing maxillary right and lateral incisors

What would a Periodontist do? With Dr. Tae Kwon - Case 3

Hello, this is Tae Kwon with today’s Ripe Global Implantology case review.

And today’s case is my friend named Paul. He is the husband of one of my staff member, and he has been missing his maxillary right and lateral incisors for many, many years. He is in his mid 50s and he had this flipper/partial denture that was holding the space on number 7 and 10 which is the lateral incisor and he has been missing them congenitally. Now, you will actually encounter these patients who are mid-50, all of sudden wanting to replace these teeth in fixed manner, and a lot of time this is financially driven. So he has two kids who just finished college, so he said, “Now I’m ready to invest on my own mouth and I would like to have the implant” so he was very excited about having an option of dental implant.

Now, when you look at his teeth on lateral incisor that he’s missing you can clearly see that the soft tissue and hard tissue even though you cannot really see the hard tissue soft tissue contour looks really good. The reason is I already grafted this site about six months ago, he had large concavity on the buccal aspect of these edentulous area and the guided bone regeneration was done successfully, and then now he’s ready to proceed with Implantology implant therapy.

Now, one thing that I that is very interesting that I quoted on the previous Implantology case review is that depending on the bio type of the patient, i.e.: the thickness of the gum tissue, sometimes making the interest ocular incision may risk causing gingival recession on the adjacent teeth from which the flaps were raised. In his case, you can clearly see that the thickness of his flap is extremely thick, and he is so called thick biotype patient. So even though I did previously bone grafting surgery with regular intra-circular incision and some vertical incision on the lateral aspect of lateral incisor area, you can clearly see there’s no recession. So in this case, I am very comfortable proceeding with intra-circular incision from canine to the contra-oral canine and opening up the gingiva because he’s thick gingival bio phenotype I’m not worried about causing any post-operative veins gingival recessions. Now, after we elevate the flap excellent bone has been noted and the right lateral incisor area received dental implant successfully and again I always like to be on a pallet or position when you put a periodontal probe from the buccal surface of central incisor to the buccal surface of the canine the implant should be parallel to that line ideally coming from incisal edge or slightly palatal to the incisal edge and you can clearly see I left a lot of buckle bone buckle to the implant, you always want to have at least two millimeter of thickness in this area buckled to the implant making sure you do not cause any post-operative gingival recession from the implant.

So, from the scientific study what we have noticed was that when implant is less than two millimeter of buccal bone, buckle to implant then the chance of causing gingival recession around the implant in long term has significantly increased, so always remember you want to have two millimeter of the buccal plate buckle to the implant and the contralateral side to the left sides in implant has been also successfully placed. Same thing you want to make sure you have enough buccal thickness of the bone and after that I chose the healing abutments and then close the area. You can actually see that I purposely placed the healing abutment that is slightly less or shallow from the thickness of the gingiva and this is because of the two reasons one, I want to make sure his existing flipper fits, because if I put something that is taller, that’s not going to fit, but that’s not my main reason. The second reason why I did that is I purposely chose the height that is a little bit shallower, so that gingiva can actually kind of hog around the healing abutment, and in what I’m asked, what I’m expecting, or what I’m hoping that is going to happen is that I actually want gingiva to close over the healing abutment as much as he can. The reason is, by doing that, I can actually gain some height of the soft tissue and secondly, I placed the healing abutment that has a narrow diameter, instead of placing wide diameter.

Right after the surgery, I would like to put the narrow diameter for the aesthetic area, because I want the tissue to grow as much as it can because I want to increase some thickness of the tissue. If I put a wider healing mode from the beginning, then I actually lose this opportunity for tissue to grow and gain some thickness of the volume of the tissue. Eventually, I’m going to see consequently change this narrow healing abutment to something wider, so that I can build up nice emergence but again, want to build a tissue first and then start widening. Technically, we could immediately load these cases when the primary stability is greater than 35. In his case we did but his occlusion was extremely heavy and I didn’t want to risk the possibility of having early implant failure by doing immediate temporization, and these are the post-operative X ray you can see nicely placed number 7, which is the right lateral incisor area was a little bit tight medial distally and sometimes clinicians whenever that space is tighter, they want to use guided surgery because they say they want to be more accurate. I want to challenge that dogma, it is actually the opposite. When the tighter the space, you want to make sure you stay away from the guided surgery because you cannot rely on the guided surgery because guided surgery has inheritant deviation of the osteotomy. So if you purposely just use the guide and then 100% faced on it and then drill it a lot of time you will notice that in a tight space, you may be actually encroaching the next teeth root or the angulation in vivo might be really different from what you plan from the guided surgery.

So the tighter the space, you have to develop a skill that you believe in your hands and your eye coordination making sure you can park the same plan really nicely. So this is my implant case review of the day. I hope you enjoy and then I’ll see you next time for your next one.

Dr. Tae Kwon uses comparative analysis of his patients Rachel and Laurie in enlightening how thinking outside the box can help a patient overcome their oral health issues. Watch to learn more!

What would a Periodontist do? With Dr. Tae Kwon - Case 2

Hello everyone, this is Tae Kwon from Keene New Hampshire.

Hello, everyone, I just want to share a case that I treated yesterday and this is a gum graft case and Rachel was referred to me due to high frenum attachment and gingival recession onto mandibular central incisors tooth number 24, 25, and depending on where you are, this is tooth number four, one and three one. You can clearly see that she has very minimal attached gingiva and thin gingiva and high frenum attachment, and she indicated that her recessions on to summer 24 and 25 are getting worse. However, we have a couple of challenges here. Normally, we will do free gingival graft or regular connective tissue graft: free gingival graft, meaning that we remove the outer surface of the epithelium and then place a gingival graft including epithelium that was harvest from the palate. When you do that, although it will give us nice attached gingiva and keratinized tissue, and we can also address the frenum attachment, aesthetically, usually it presents like a tire patch and secondly, freeze into a graph is really not the best procedure to gain or resolve gingival recessions.

Then what is the alternative? We will do connective tissue grafting. Connective tissue grafting meaning that we either open up a flap and then take connective tissue from the inside layer of the palate and then put it over these roots and then coronally advance the existing flap up to gain the root coverage. Aesthetically will really look nice because we can reduce the recession, but it has a problem of shallowing the vestibule because it’s already you can see because of the high frame of attachment, the vestibule is already shallow. So by pulling the gum up, you’re actually making the vestibule even shallower, and also compared to free gingival graft it will not give you as much as keratinized tissue. It may give you thickness of the tissue but not necessarily keratinized tissue. So I was thinking about this case, and then I always like to think outside of the box and I asked myself Is there any way that I can do the procedure with in- with combining the strength of both techniques, and this is how I solved.

First I took connective tissue graft from the palate, and on the recipient area, like I’m doing connective tissue grafting, I actually created a tunnel on tooth number 24 and 25, 4-1 and 3-1, and you can clearly see that I left epithelium on connective tissue graft on purpose, and now instead of cutting the gum open, I’m going to introduce this connective tissue graft with epithelium into the tunnel like so. So you can see I’m inserting this connective tissue graft from the right central incisor sulcus that I tunneled, and then by putting it in, I can slide it through and then I can put a shot within the tunnel like so and then you can clearly see that I stuffed the connective tissue graft really nicely. That’s why the recipient area looks thicker, but at the same time, you can clearly see that I left epithelium from the connective tissue graft exposed on this area and I tuck the lip making sure there’s no movement and I just finished a case by putting surgical dressing so there is no suture on the recipient side which also like patients likes a lot. By doing it, I can thickened the gingiva like connective tissue graft. I can reduce the recession, like connective tissue graft, but I will also gain keratinized tissue like free gingival graft because this exposed epithelium will be keratinized tissue.

Lastly, I do not shallow the vestibule because I’m not currently advancing the existing flap like we do with connective tissue graft, and this is how my patient Rachel left and she was extremely happy. You may wonder hey, I mean does it really work in long term you just you’re just showing me that case of the day. Well, that’s the whole purpose of this RG five, but I want to show you another case named Laurie, who had a very similar situation but I had eight months follow up. Laurie presented to me due to gingival recessions on mandibular incisors, lateral and central incisor from 3-2 to 4-2 or 23 to 26 and like I explained to you I harvested connective tissue with nice thick epithelium, and I tunneled the recipient area, and then insert this connective tissue graft with the epithelium to the tunnel. Don’t forget, I never cut this area open. It was all tunneled, minimally invasive way, and then I positioned it on the connective tissue graft with epithelium at the right level, and then I left epithelium portion on purpose exposed – and let’s see what happened.

This is eight months later, you can clearly see I totally converted the phenotype of the patient from thin bio type to thick bio type and two: look at the gain in keratinized tissue, then three: I did not alter the vestibular depth, so she’s still has normal vestibule, and four: gingival recession has significantly reduced. So I hope you’ll learn something from this case of the day and sometimes thinking outside of the box will make you a be more creative and innovative and then you can come up with your own techniques.

So I’ll see you next time!

Dr. Tae Kwon narrates the case of Caitlin – a patient with an restorable maxillary right central incisor. Listen to his detailed explanation of how he helped this patient overcome her situation

What Would a Periodontist Do?

Hello everyone, this is Tae Kwon from Keene New Hampshire.

I’m going to share a case that I just treated yesterday and the patient name is Caitlin and Caitlin unfortunately lost maxillary right central incisor due to resorbption making the tooth un-restorable, and nine month ago I did extraction and large bone augmentation on this area and the site appeared to be ready for dental implant, and this is how it looks preoperatively before I start making incision. When I look at this case, where the soft tissue around the adjacent teeth maxillary left central incisor and maxillary right lateral incisor, the soft tissue healing looks excellent. Now the one thing that I don’t want to do is with an incision, I can cause gingival recession around these adjacent teeth. What I mean by that is normally, most of the clinician will actually go and make intra-circular incision around the central incisor
to the crystal incision, and then the intra-circular incision around this lateral incisor, and then when you elevate the full thickness flap, and you place the implant in place and this flaps back you’re actually risking potential recession around these adjacent teeth, specially interproximal area. Luckily, in Caitlin’s case, the soft tissue seems to be pretty thick, so there’s a less chance of gingival recession, but I don’t want to take any chance with her case, causing any gingival recession.

So before I start the treatment, I have to think about how I’m going to make an incision. Two: one thing that I want to see is how much bone is available and this is done by obtaining a CT scan, so the CT scan allows me to trim and plan the right size of the implant and right length of the implant preoperatively and simulated first, and based on the shape of the bone and alveolar structure and underlying anatomical landmark, I can I have decided to place 3.3 by 10mm 12millimeter implant in this location. Now, when you look at this sagittal view closely, you can actually see there is a little bit of concavity on this area. I want to make sure that when I’m placing the implant I do not- I do not cause fenestration around this area with my drill. So how do I make an incision design to, A: minimize gingival recession on the adjacent teeth, but B: to give me enough access so that I can visualize this apical area?

This is how my incision look like, so you can clearly see I dropped two vertical incision and crystal incision and then the vertical incisions are away from the adjacent teeth, leaving at least two to three millimeter of gingiva there and this is why because of papillary preservation incision and by dropping two verticals, I can clearly see the apical portion of the alveolus by reflecting in a flap. Now I’m going to place the implant and implant has been placed very successfully. Primary stability was about 20 Newton centimeters.

So I’m going to submerge this implant for further osseous sealing. Now when you look a little bit closely, there’s a slight green fracture on the buccal plate. What do I do? I want to protect the buccal plate because from the scientific study, if implant has more than two millimeters of buccal plate thickness, then there is a minimal risk or reduce risk of causing gingival recession around dental implant. Knowing that this is a highly aesthetic area, I want to make sure I minimize that. So after I placed the implant in a prosthetic lead driven position, I added some Zeno graft to thicken the buccal plate in this area, and then after that, I simply close the flap back and this is how the case has been- was finished. I use some chromic sutures on the vertical incision and then I use monochrome sutures on the crystal aspect and she had a flipper and then I wanted to make sure the flipper fits back there and I come from the sitting and this is the radiographs so preoperative radio graph and intra operatory radiograph with a guide pin and three placement of the dental implant with a cover screw and implant is further submerged.

Then we’re going to wait about three months for RCS healing before we do the second stage surgery to expose this implant- so I hope you enjoy my short case synopsis of Caitlin, take care!