- 5 REASONS WHY YOU SHOULD ALWAYS MAKE YOUR OWN STENT - 5 THINGS TO DO B4 PLACING YOUR FIRST IMPLANT

WHAT ARE THE FUNDAMENTALS OF AN IDEAL DENTAL IMPLANT SURGIAL STENT?

1. THE STENT SHOULD BE EASY TO MAKE.
2. THE STENT'S DESIGN SHOULD ALLOW FOR QUICK FABRICATION.
3. THE STENT SHOULD REQUIRE A MINIMUM NUMBER OF PARTS.
4. THE STENT SHOULD BE INEXPENSIVE TO MAKE. YOU SHOULD NOT HAVE TO SPEND $400-$800 TO PROVIDE A PRECISION SURGICAL STENT FOR YOUR PATIENT.
5. ITS BASIC DESIGN SHOULD BE USEFUL FOR MULTIPLE TYPES OF APPLICATIONS AND INDIVIDUAL CASE REQUIREMENTS; SINGLE, MULTIPLE AND FULL ARCHES.
6. THE STENT'S DESIGN SHOULD ALLOW THAT STERILE IRRIGATION IS PROVIDED DIRECTLY ON THE DRILL/BONE INTERFACE DURING DRILLING.
7. AS ALL DENTAL IMPLANT SURGERIES ARE UNIQUE AND DIFFERENT FROM EACH OTHER, THE IMPLANT SURGICAL STENT MUST BE EASILY CUSTOMIZED TO SATISFY EACH CASE'S REQUIREMENTS WHILE MAINTAINING ALL OTHER UNIQUE FEATURES OF A BONE ENGAGING DENTAL IMPLANT SURGICAL STENT.
8. IT SHOULD BE AS SMALL, YET AS SECURE AS POSSIBLE, LEAVING ROOM FOR REQUIRED INSTRUMENTATION AND FINGERS OF FOUR HANDED IMPLANT DENTISTRY AND ALLOW FOR MAXIMUM VISUALIZATION OF THE SURGICAL SITE.
9. THE PILOT DRILL GUIDE SLEEVE MUST PROVIDE MAXIMUM GUIDANCE OF PILOT DRILL BY ENDING AT OR WITHIN THE SURFACE OF THE JAW BONE.
10. THE STENT SHOULD BE SECURED OR FIXED BOTH AT THE TOP AND BOTTOM TO PREVENT ROTATION DURING PILOT HOLE DRILLING. THE TOP BEING A BASEPLATE MATRIX THAT CONTACTS THE OCCLUSAL SURFACES OF THE ADJACENT TEETH (WHEN ADJACENT TEETH ARE PRESENT). THE BOTTOM BEING THE LOWER EDGE OF THE PILOT DRILL GUIDE SLEEVE AS IT ACTIVELY CONTACTS THE SURFACE OF THE PATIENT'S JAW BONE.
11. THE STENT'S DESIGN AND SMALL SIZE SHOULD ALLOW FOR ITS USE EVEN IN THE MANDIBULAR SECOND SECOND MOLAR AND MAXILLARY TUBEROSITY REGIONS.
12. THERE SHOULD BE NO LOOSE PARTS THAT MAY LEAD TO A PATIENT'S INHALING OR SWALLOWING CAUSING CHOKING, COUGHING OR GAGING RESPONSES.
13. LARGE SURGICAL STENTS (EXAMPLES WOULD INCLUDE EDENTULOUS ARCHES BEING PREPARED FOR MULTIPLE IMPLANT PLACEMENTS) SHOULD BE ANCHORED TO THE RIDGE SECURELY WITHOUT THE ADDITIONAL PHYSICAL TRAUMA OF MULTIPLE HORIZONTAL FIXATION SCREWS.
14. THE STENT'S SIMPLE DESIGN AND MATERIALS USED SHOULD ALLOW FOR EASY CLEANING AND COMPLETE STERILIZATION EVEN WITH STEAM AUTOCLAVING.
15. THE SIMPLE DESIGN SHOULD MAKE IT EASY TO TRANSFER FROM WORKING STONE MODELS TO THE PATIENT'S IMPLANT SITE WITH NO OR MINIMAL ADJUSTMENTS.
16. THE DESIGN MUST PROVIDE THE OPPORTUNITY TO UTILIZE "PROCEED AND VERIFY" PROTOCOL EVEN WHEN THE SITE IS DIFFICULT TO VISUALIZE DURING BLEEDING OR WHEN THE PATIENTS' CHEEK OR TONGUE COVER THE SURGICAL SITE.
17. THE STENT'S DESIGN WILL NOT ALLOW ANY MOVEMENT OF THE PILOT DRILL GUIDE SLEEVE IN ANY DIRECTION BEFORE AND DURING PILOT HOLE DRILLING.
18. THE SAME PROCESS USED FOR PILOT DRILL GUIDANCE SHOULD BE ABLE TO BE ADOPTED FOR THE IMPLANT PLACEMENT GUIDANCE, ESPECIALLY WHEN PLACING A "SELF-TAPPING" MINI IMPLANT.

5 REASONS TO MAKE YOUR OWN STENT WHEN PERFORMING FLAPLESS PROCEDURES

1. MAKING ONE'S OWN STENT MOTIVATES US TO PAY ATTENTION TO DETAIL AND BE AS ACCURATE AS POSSIBLE. THIS RESULTS IN AN INTIMATE KNOWLEDGE OF THE IMPLANT SITE.

AS YOU WILL SEE IN LATER SECTIONS, MAKING YOUR OWN STENT ON A SURGICAL MODEL WILL PROVIDE THE HIGHEST LEVEL OF CONFIDENCE GOING INTO AND DURING THE SURGICAL PROCEDURE.

NEVER UNDERESTIMATE THE VALUE OF A HIGH CONFIDENCE LEVEL WHEN PERFORMING FLAPLESS PROCEDURES!!

2. MAKING YOUR OWN STENT AND SURGICAL MODEL ALLOWS YOU TO PRACTICE THE SURGERY AND CONFIRM THE STENTS ACCURACY.

AFTER YOU PRACTICE ON THE SURGICAL MODEL YOU MAY CONFIRM YOUR LENGTHS AND ANGLES AND RE-EVALUATE YOUR IMPLANTS SIZE SELECTION, ENSURING THAT YOU ARE USING THE CORRECT IMPLANT i.e., THE LARGEST SIZE POSSIBLE FOR THE IMPLANT SITE.

3. BEFORE YOU THINK THIS IS TOO MUCH LAB WORK, REMEMBER YOU CAN DRESS UP SOME OF THESE SURGICAL CASE MODELS AND USE THEM FOR PATIENT EDUCATION.

GOOD LOOKING MODELS WITH SAMPLE PROSTHETICS, CROWNS, BRIDGES, OVERLAY PARTIALS, FULL DENTURES AND HYBRID DENTURES OF ACTUAL CASES YOU'VE DONE, WILL SELL YOUR NEW IMPLANT CONSULTATION PATIENT ON YOUR EXPERIENCE, EXPERTISE AND ABILITY TO FULFILL AND SATISFY HIS/HER EXPECTATIONS. HAVING CLEAR, ACRYLIC, "STORE BOUGHT" DISPLAY MODELS YOU FIND AT ALL THE IMPLANT CONVENTIONS ARE FINE, BUT THEY DO NOT PROVE TO THE NEW PATIENT THAT YOU CAN ACTUALLY PERFORM THE PROCEDURE FOR THEM. PRODUCING GOOD LOOKING MODELS OF YOUR CASES WITH REPLICAS OF THE PROSTHESIS YOU MADE, INSPIRES THE PATIENT'S CONFIDENCE THAT YOU CAN DO THE SAME FOR THEM!

SOMETIMES THE CASES I'VE DONE AND PRESENT THIS WAY, IMMEDIATELY MOTIVATE THE PATIENT TO ACTION. OCCASIONALLY, I DON'T HAVE TO SAY AN ADDITIONAL WORD EXCEPT, 'PLEASE SEE MY RECEPTIONIS FOR YOUR NEXT APPOINTMENT".

4. MAKING A STENT FORCES US TO EVALUATE THE UNIQUE VARIABLES OF EACH CASE AND HELPS US TO AVOID THE UNFORTUNATE REMARK, "D_ _ _, I DIDN'T SEE THAT ONE COMING"!

IN THE PAST, I'VE HAD LONG STRINGS OF SUCCESSFUL CASES AND THE TENDENCY THEN, IS TO BECOME OVER CONFIDENT AND CUT CORNERS ON "NEW CASE" WORK-UPS. WHEN THE DAY COMES THAT YOU START TELLING YOURSELF HOW EASY IMPLANTS ARE, THE NEXT DAY IS THE DAY TROUBLE FINDS YOU.

MAKING A STENT FORCES US TO EVALUATE EACH CASE ON ITS OWN MERITS IN DETAIL, ALLOWING US TO CONTINUE OUR STRING OF SUCCESSFUL CASES. DO THE TIME AND YOU'LL BE FINE!!

NUMBER 5 IS ENTITLED "NEVER LET THEM SEE YOU SWEAT"! PLACING MULTIPLE IMPLANTS WITHOUT A FLAP CAN BE A DAUNTING TASK EMOTIONALLY. UNABLE TO SEE THE BONE, FOSSAE, KNIFE EDGES, NERVES AND OTHER IRREGULARITIES OCCASIONALLY RESULT IN OUR HESITATION IN MAKING THE PILOT HOLE, ONE SLIP-UP, ONE SPINNER, AN IMPLANT OFF LINE AND OUR HESITATION TURNS TO FRUSTRATION THEN WE START SCAMBLING TO SAVE OUR CASE. "LET'S TRY A LARGER IMPLANT" WE CALL TO OUR ASSISTANT! MEANWHILE, OUR PATIENT SEES OUR FRUSTRATION BEADING UP ON OUR FOREHEAD AND THEIR CONFIDENCE LEVEL PLUMMETS. EVEN IF THE CASE WORKS OUT FINE, YOU WILL ALWAYS WONDER IF THAT PATIENT WILL RETURN FOR MORE TREATMENT OR REFER THEIR FRIENDS. STAY COOL - MAKE A STENT YOU CAN RELY ON.

IN LATER SECTIONS, I'LL SHOW YOU HOW TO MAKE A STENT IN 15 MINUTES.

MAKING A STENT FOR OVERLAY DENTURE CASES RESULTS IN MORE PARALLEL IMPLANT ABUTMENTS. THIS DRASTICALLY REDUCES THE TIME REQUIRED FOR PROSTHETIC RELINING WITH RETAINERS.

FIVE THINGS TO DO BEFORE YOU PLACE YOUR FIRST IMPLANT

1. SET YOUR GOALS. YOU CAN'T GET THERE IF YOU DON'T KNOW WHERE YOU ARE GOING. MY SUGGESTION HERE IS, IF YOU WANT TO JUMP IN, JUMP IN ALL THE WAY. YOU REALLY HAVE TO DO IMPLANTS TO GET GOOD AT IMPLANTS. FIVE OR SIX IMPLANTS A YEAR IS PROBABLY NOT A PRODUCTIVE GOAL TO AIM FOR.

2. IDENTIFY CASES IN YOU PRACTICE THAT WILL GIVE YOURSELF THE BEST CHANCE FOR SUCCESS. YOUNG, HEALTHY PATIENTS WITH WIDE, DEEP RIDGES AT THE IMPLANT SITE. TAKE AN IMPRESSION, POUR UP A MODEL IN PLASTER AND TAKE IT WITH YOU TO YOUR "INTRO TO IMPLANTS" COURSE. YOU CAN USE IT DURING YOUR HANDS ON PORTION OF THE SEMINAR. MANY COURSES HAVE YOU DRILLING INTO WOOD BLOCKS TO UNDERSTAND BONE DENSITY ISSUES. USING A PATIENT MODEL HELPS YOU TO UNDERSTAND ANGULATION AND DEPTH ISSUES.

3. PERFORM YOUR OWN SURGICAL EXTRACTIONS. IF YOU DON'T ALREADY START NOW! READ YOUR ORAL SURGERY TEXT BOOKS AND TAKE A COURSE IN BASIC SURGERY SKILLS. DO WHATEVER YOU HAVE TO DO TO BECOME COMFORTABLE SECTIONING AND EXTRACTING MOLAR ROOTS, LAYING SMALL FLAPS, CURETTING AND DRILLING OUT INFECTIONS, (GRANULATION TISSUE/RESIDUAL CYSTIC TISSUE) AND SURTURING. THE MORE OF THIS YOU DO NOW, THE EASIER IT WILL BE TO HANDLE DIFFICULT IMPLANT CASES LATER.

4. LEARN TO GRAFT, POST EXTRACTION, NOW! TAKE A GRAFTING COURSE FIRST, BUY SOME PARTICULATE, SELECT A HEALTHY NON-SMOKER, THEN GRAFT AFTER YOU EXTRACT A TOOTH AND SUTURE DOWN A BARRIER MEMBRANE. PICK A CASE THAT HAS NO IDENTIFIABLE INFECTION PERIAPICALLY OR PERIODONTALLY, WITH SOLID BUCCAL AND LINGUAL WALLS AND PREFERABLY A PATIENT WHO HAS EXPRESSED AN INTEREST IN HAVING AN IMPLANT PLACED LATER. IT IS EASIER TO GRAFT A LOWER TOOTH THAN AN UPPER TOOTH. MEDICATE WITH APPROPRIATE ANTIBIOTICS WHENEVER YOU GRAFT. WE START TWO DAYS BEFORE SURGERY AND SEVEN DAYS AFTER SURGERY. 10 DAY TOTAL.

5. BUY A SKULL!!! NO, SERIOUSLY, THEY ARE VERY HANDY TO HAVE AROUND. I USE MINE ALL THE TIME TO CHECK ANATOMTY, FOR PATIENT EDUCATION AND JUST TO FREAK PEOPLE OUT AT HALLOWEEN!! PICK A SKULL WITH NUMEROUS MISSING TEETH AND SOME ATROPHIED RIDGES. YOU ARE ABLE TO GET THEM ONLINE AND NO I'M NOT MAKING THIS UP...AT SKULLSUNLIMITED.COM. THEY ARE BETWEEN $1100 AND $1700. I DIDN'T BUY MINE FROM THERE, SO AS WITH ANYTHING YOU BUY ONLINE IT IS "BUYER BEWARE". I AM SURE YOU CAN GOOGLE SEARCH FOR OTHER SOURCES AS WELL.

MAKING A CASE FOR VERY NARROW DIAMETER PILOT DRILLS FOR MINI AND NARROW DIAMETER IMPLANT SYSTEMS

ALTHOUGH THIS DISCUSSION IS MOST RELEVENT FOR NARROW ONE-PIECE IMPLANTS, ITS RELEVANCE MUST NOT BE LOST FOR WIDER (>3MM) IMPLANTS AS WELL.

DENSITY ISSUES:

IT IS KNOWN THAT MOST SELF-TAPPING MINI IMPLANT SYSTEMS UTILIZE PILOT DRILLS BETWEEN 1.1mm AND 1.4mm IN DIAMETER AND MANY OTHER ONE-PIECE IMPLANT SYSTEMS THAT ARE NOT SELF-TAPPING UTILIZE PILOT DRILLS BETWEEN 1.5mm AND 2.0mm DIAMETER.

IT IS ALSO KNOWN THAT A SUCCESSFUL ONE-PIECE IMPLANT CASE, ESPECIALLY WHEN IMMEDIATE LOAD PROTOCOLS ARE OBSERVED, PRIMARILY DEPEND ON THE EXISTENCE OF ADEQUATE DENSE BONE AT THE IMPLANT SITE. IT FOLLOWS THEN, THAT WHEN DRILLING IN SOFTER BONE THE LARGER THE PILOT DRILLS ARE, THE MORE LIKELY WE ARE REMOVING THE VERY BONE THAT IS NECESSARY FOR INITIAL STABILIZATION AND INTEGRATION OF THE IMPLANT.

I HAVE LISTENED TO LECTURERS SAY, "IF THE IMPLANT KIT'S PILOT DRILL IS USED AND REMOVED AND SIGNIFICANT BLEEDING OCCURS IMMEDIATELY OUT OF THE HOLE, YOU SHOULD ABORT THE OPERATION AND SEND THE PATIENT HOME". INDEED, GORDON CHRISTENSEN RELATED THIS WARNING TO US AT HIS MINI IMPLANT SYMPOSIUM IN MAUI, OCTOBER 2009. IT IS MY FEELING THAT ABORTING AN OPERATION SHOULD BE AVOIDED IF AT ALL POSSIBLE. IT IS TIME CONSUMING AND COSTLY TO SELL AND WORK-UP AN IMPLANT CASE AND PATIENTS DO RESENT BEING SENT HOME WITHOUT AN IMPLANT RETAINED TOOTH OR DENTURE.

MORE ABOUT HOW TO AVOID THESE NEGATIVE EVENTS IN OUR NEXT SECTION.

ANGULATION CONCERNS:

MANY IMPLANT SITES HAVE CONSTRICTED AREAS OF BONE THAT WE MUST NAVIGATE THROUGH TO SUCCEED.

1. CONGENITALLY MISSING MAXILLARY LATERALS OFTEN HAVE ONLY 3mm - 5mm OF BONE BETWEEN ADJACENT ROOT SURFACES.

2. MISSING MAXILLARY 2ND PREMOLARS OFTEN PRESENT WITH ONLY A FEW mm's OF BONE BETWEEN THE ROOT OF THE 1ST PREMOLAR AND THE ANTERIOR SURACE OF THE MAXILLARY SINUS.

3. THE ANTERIOR MANDIBLE HAS LINGUAL AND LABIAL FOSSA TO NAVIGATE BETWEEN.

THESE AND OTHER CHALLENGING AREAS ARE EASIER TO MANAGE WHEN A NARROW DIAMETER PILOT DRILL IS USED FIRST.

PARALLELING ISSUES:

GET THEM PARALLEL THE FIRST TIME!

SECOND CHANCES ARE HARD TO COME BY WHEN PLACING IMPLANTS ESPECIALLY WHEN PLACING MULTIPLE ONE-PIECE IMPLANTS. FOR ROUND HOUSE OR DENTURE CASES IF YOU PLACE FOUR PERFECTLY AND JUST ONE IS OUT OF LINE YOU CAN'T JUST PULL IT OUT AND REDO IT WITHOUT CONSEQUENCES AND RISKS TO THE ENTIRE CASE.

IF YOU REMOVE THE IMPLANT AND ATTEMPT TO REALIGN IT WITH A NEW OR LARGER PILOT HOLE, THE IMPLANT MAY LOSE INITIAL STABILITY AND PROBABLY NOT INTEGRATE.

IF YOU REMOVE IT, ENLARGE THE PILOT HOLE AND GO WITH A LARGER DIAMETER IMPLANT, YOU CAN OFTEN SAVE THE CASE BUT IT IS NOT ALWAYS POSSIBLE AS THE RIDGE MAY NOT BE WIDE ENOUGH OR YOU MAY COMPROMISE BLOOD SUPPLY IF THE NEW LARGER IMPLANT IS TOO CLOSE TO ITS NEIGHBORS.

OF COURSE, WHEN THE CASE DOESN'T GO ACCORDING TO PLAN, PATIENT CONFIDENCE IS COMPOMISED AS WELL.

USE NARROW DIAMETER PILOT DRILLS AND GIVE YOURSELF MORE ROOM FOR ERROR WHEN ANGULATION PROBLEMS REQUIRE CORRECTION. USE A GOOD SURGICAL STENT AND INCREASE YOUR CHANCES FOR SUCCESS.