Case done by Dr. Joseph Mongalo and myself. Patient is a 38 year old hispanic female suffering early loss of dentition.

Chief complaint: “I hate to wear a partial, It makes me feel like an old lady”

Patient desires a solution that is both fixed and aesthetic.

Intraoral clinical presentation

Pre-op radiographs.

Large cases need to be treatment planned using CT-scan images

Clinical evaluation: Adequate ridge width, healthy gingival tissue.

This condition is not uncommon in patients under 40 years of age.

Initial model evaluation, marking of 7mm rules.

Normal class I profile.

Model base surgical guide will be fabricated.

Inexpensive transparent acrylic guide fabricated to reduce costs.

Placement of 7 Conus implants.

Implants torque at 45 Newtons.

Temporary screw retained cylinder.

One implant had fenestration, was grafted and buried.

Anterior immediate temporary made out of acrylic wit resin teeth.

Posterior immediate temp.

Ideal lingual implant positioning.

Scalloped gingival recreated on the temporary bridge.

Vertical dimension and centric relation restored.

Having patient walk out with a fixed bridge has a great positive impact on their lives.

Post-op radiograph.

4 months post-op, note excellent tissue.

Canine was left to maintain vertical dimension.

Autramatic extraction.

Bone graft: socket preservation.

2 weeks post-extraction, 7th implant exposed.

Excellent tissue.

Multi-unit abutments placed for screw retained bridge.

Lingual implant positioning.

Final abutment impression.

2 master casts to verify passive fit.

Prettau Zirconium bridge, absolutely beautiful material.

Prettau has pressed zirconia structure.

Lingual implant positioning is crucial in clinical success.

Patient desired white teeth on the top.

Final aesthetic outcome.

Access holes sealed with fermit.

Beautiful aesthetic profile.

Passive aperture exposing centrals in necessary for aesthetic outcome.

Satisfied patient.

Introduction:
Oral implantology is an ever-evolving science seeking solutions to clinical challenges. A common challenge is treating atrophic maxillary ridge with deficiency in vertical height. In 1974 Dr Hilt Tatum performed the first sinus lift in the world, this lateral window approach has proven to be effective technique but is invasive in nature and requires great surgical experience.

The pursuit of less invasive methods led to the introduction in 1994 to a new technique using a crestal approach by Summer where osteotomes were used to “push” the floor of the sinus. In the past 20 years many variations of Summer’s technique have proven to be effective in sinus elevation.

This is the 1st of a series of four clinical presentations where we will explore the following approaches:
A. Hammerless intra-crestal
B. Hydraulic intra-crestal
C. Conventional lateral window
D. Lateral “punch” window

Hammerless intra-crestal lifts are those performed through the alveolar crest in a vertical direction as opposed to lateral windows. The inclusion criteria for crestal lift are: sinuses free of infection process, minimum of 3.5mm residual alveolar bone height from alveolar crest to the floor of the sinus and minimum alveolar width of 7mm.

Clinical case: X-ray reveals pneumatized sinus with 3.7mm of residual bone, full mucoperiosteal flap shows adequate bone width greater than 7mm (fig 1-2).

The hammerless kit used consists of 3 safe sinus drills, stoppers ranging from 2mm to 12mm, bone condenser, bone carrier and sinus probe (Blue Sky Bio, USA), the technique is to take a digital periapical and measure the height of bone and drill 1mm short of the floor of the sinus floor using 50 RPM and drill stoppers. Increase the length by changing stoppers until the floor has been pushed (fig 3-5).

There are 3 possible ways to verify that the floor has been pushed and that you are in contact with the sinus membrane:
1…Patient will feel slight pain at the moment the floor is broken because innervations to the maxillary antrum comes from V1 (ophthalmic branch of the trigeminal)
2…Doctor will feel a “drop” when the floor is pushed
3…Using a round sinus probe the clinician will feel “soft-squishy” material and not hard bone.

Once it is confirmed that the floor is pushed or broken, start adding bone with an amalgam carrier until the site is filled. Condense this bone with light apical pressure and repeat this procedure 3-5 times until you are able to observe a well-defined “bone dome” (fig 6-7).

Select an implant that is self-treating, 1mm wider than your final drill to compress the walls and double the length of the stopper that broke the floor. In this case the last stopper was at 5mm so we selected a 4.5 * 10mm fixture (fig 8-10).
Conclusion:
Following these steps the hammerless intra-crestal lift becomes a safe and predictable surgical procedure that your patients will benefit from and that general dentists can master in short amount of time.

To learn this are other “cool” surgical techniques, come and join us in at the west coast of Mexico at Live Implant Training where you will perform this surgeries under direct supervision of board certified oral and maxillofacial surgeons. For more information contact Dr Mongalo at Liveimplants.com or 786-249-4510.

Questions? Feel free to ask us for more information
Online Course Information | Inquiry Form

Our team is motivated to help any doctor interested in our dental implants on patient courses. That’s why our website is full of detailed information for you to make an informed choice on what dental Implant course to choose.

You can see our qualifications, our experience, and read real dentist reviews and testimonies of our live implant course.

It is also necessary to show our physicians and other non-academic aspects of our course of implants in patients, aspects such as our venue in Guadalajara.

In this article we will show you different aspects that will make it easier and enjoyable trip to Guadalajara.

Data and information from: Wikipedia

Video from Expedia

First, where is Guadalajara?

Guadalajara is the capital and largest city of the Mexican state of Jalisco, and the seat of the municipality of Guadalajara. The city is in the central region of Jalisco in the Western-Pacific area of Mexico. With a population of 1,495,189, it is Mexico’s fourth most populous municipality.

Mexico’s second largest city provides a compact historical center with colorful traditions including mariachi and artisan glass-blowing. It is the birthplace of  tequila and its vibrant neighborhoods offer visitors upscale suburbs, amazing folk-art shopping and a great and varied cuisine from street-side tacos to fine dining original colonial mansions.

Here is some distances and air travel time from our Live Implant Training Institute in Guadalajara, Mexico.

Approximate travel time from New York, New York to Guadalajara, Mexico is: 4 hrs, 38 mins
Approximate travel time from Ottawa, Canada to Guadalajara, Mexico is: 4 hrs, 51 mins
Approximate travel time from Guadalajara, Mexico to Houston, Texas is: 1 hrs, 56 mins
Approximate travel time from Los Angeles, California to Guadalajara, Mexico is: 2 hrs, 45 mins
Approximate travel time from Guadalajara, Mexico to Chicago, Illinois is: 3 hrs, 36 mins

Is Guadalajara a safe place?

Yes – Guadalajara is no more of a risk to your safety than any other major city in the world and you are likely to enjoy a safe trip.

Guadalajara is a large city and there are no major downsides to visiting, any more than any other city. Use common sense, do take care of your valuables, as you would anywhere else. 

Do I need to speak Spanish?

No. In our “Live Implant Training Institute Guadalajara” we have English-speaking staff, so you will have no problems being understood. Though Spanish is the main language on Guadalajara, you will find that English is spoken by many people throughout the city.

How is Guadalajara’s Weather?

Guadalajara’s weather is warm all year round although there are marked seasonal differences in rainfall. The wettest time of the year tends to be summer, with peak rainfall falling in July. During the rainy season afternoon storms are very common, but during the rest of the year the climate is arid. 

What we recommend to do in Guadalajara?

You can tour Guadalajara during every night.  You will find thousands of things to discover and enjoy the varied delights of this laid-back city.

Tourism is one of the cities major industry, the variety of classical architectural styles in the center housing a large number of museums, theaters, galleries, libraries, concert halls and auditoriums. The city was named American Capital of Culture in 2005, and the fascinating cultural aspects alone ensure this historic but modern city is more than worthy of a visit.

Guadalajara is the home of Tequila: Explore the region aboard the “Tequila Express” train.  This train departs from downtown Guadalajara and includes a tour of the “Herradura distillery” with lunch at a Mexican hacienda. 

Guadalajara is the birthplace of mariachi: The “Plaza de los Mariachis” is the perfect place to have fun, relax, have a drink and listen to the mariachis play.

Cuisine here is good and varied with friendly restaurants and eateries to suit every budget and palate.  From street-side tacos, to fine dining restaurants in classical mansions for colonial times.

Charro is a colorful mexican cowboy, and “Charreria” is a officially sport in Mexico, The best displays of “charreria” are at the Mexican “National Charro Championship” at the “International Mariachi and Charreria Festival” each September, and includes colorful parades and concerts in downtown district. 

And of course, Guadalajara is not just an traditional city, there are plenty of 21st century activities, including shopping, modern high-end malls, such as Plaza del Sol and Plaza Milennium, and Casa de Las Artesanias de Jalisco and Tlaquepaque.

Dental Implants Facts and Figures

Facts and Figures on Dental Implants

• More than 35 million Americans are missing all their teeth in one or both jaws according to prosthodontists
• 15 million people in the U.S. have crown and bridge replacements for missing teeth
• 3 million have implants and that number is growing by 500,000 a year
• 10 percent of all US dentists place implants but that is increasing
• The estimated US and European market for dental implants is expected to reach $4.2 billion by 2022
• The success rate of dental implants has been reported in scientific literature as 98 percent
• Implants performed by US dentists………………………..5,505,720 (2006)
• Implants performed by US general dentists……………….3,103,930 (2006)
• The global prosthetic supplies market is projected to reach $4 billion by 2018.
• The dental implant and prosthetic market in the U.S is projected to reach $6.4 billion by 2018.

Article from: www.aaid.com?utm_source=rss&utm_medium=rss

Dr. Paolo Malo from Portugal is the researcher and creator of one of the most popular surgical and prosthetic technique, we are talking about the “all-on-4”. This technique has been proven scientifically over the past two decade, hundreds of scientific articles have validated its results. The value in it comes from been able to place implants in atrophic mandibular and maxillary arches without the need for bone augmentation procedures such as lateral windows and block grafts.

A draw back to this technique is that the prosthesis usually results possessing 10 units since cantilevering must be avoided. To solve this situation and be able to add 1st and 2nd molars we suggest to place two short implants in the posterior region either in the retro molar or the tuberorisity. The following
Case shows how we can modify this technique from a surgical perspective Respecting all principles established by Dr Paolo Malo yet added a component that allows us to have a prosthesis with 12-14 units without cantilevering.

A 61 year old healthy Latin female presents to our clinic with a broken molar that supports a removable partial and 6 anterior units with moderate-advanced periodontitis and periapical pathology (fig 1)

3D images from a Ct-scan (Carestream, USA) were used to plan the case using a “Modified all-on-4”.
A traditional “all-on-4” will be performed in the intraforamina region and two short will be placed on the 2nd molar site (fig 2).

Digital panoramic view of pre-op case. An “all-on-4” is indicated since the resorption of the alveolar ridge has approached the Inferior Alveolar Nerve and is not possible to place implants in the posterior region without resorting to block grafts (fig 3).

Autramatic extraction is performed, note bucco-lingual resorption of the posterior areas (fig 4).

Full muco-periosteal flap is raised from molar to molar. Bony topography is irregular and not suitable for implant placement without full arch regularization (fig 5).

The alveoloplasty is achieved with a large bone cutter bur (Meisinger, USA) at 35,000 RPM utilizing a straight hand piece and copious irrigation (fig 6).

Care is taken to create a flat occlusal alveolar table and avoid creating a chamfered ridge (fig 7).

The alveoloplasty will allow the prosthesis to sit on a stable occlosal table, creates prosthetic room for abutments and simplifies the surgery (fig 8).

A bone caliper (Salvin, USA) is used to verified that we have achieved an occlusal table of 7mm which will allow us to place RP implants. Note the exposed mental foramen (fig 9).

The initial bone perforation is achieved with a starter drill or lance following the angled line drawn on the bone (fig 10).

Guide pins are in place , this allows for visualization and final correction of angulations and spacing. Remember that 80% of the work is done with the lance and the pilot drill, this is similar to non-surgical endodontic where most of the work is accomplished with 6-10 files (fig 11).

Bone D2, Dr. Misch’s osseous classification, calls for site under-preparation. We select a 3.75 self tapping implant (Noris Implant System, Israel) and our last drill is 3.1mm (fig 12).

All implants are placed flush with the alveolar ridge, we have achieved perfect bio-mechanical distribution utilizing the “Modified all-on-4” surgical technique (fig 13).

Pre-operative panorex shows the severe atrophic ridge resorption (fig 14).

3D image shows the pre-surgical “modified all-on-4” planification (fig 15).

Post-operative panorex reveals a “all-on-4” plus two short implants anterior to the 3rd molars. This technique calls for thinking out of the box and understanding that Dr. Mongalo’s phrase is true in almost all cases “ No bone, no problem” (fig 16).

Live Implant training institute

The case of the month was performed by an attending USA licensed dentist under direct supervision of Dr. Mongalo while attending a 7 day surgical externship at LIT.

For more information on these courses contact us at www.liveimplants.com?utm_source=rss&utm_medium=rss Or call 786-249-4510

• It’s impossible to argue with the clinical efficacy of Dr. Paolo Malo’s “all-on-4”. He has truly had an enormous effect on implant dentistry, many other clinicians have modified His technique according to clinical situations.

• The following case demonstrates two surgical modifications since we plan to reconstruct the maxillary arch with 14 units and want to avoid using cantilevering.

• This is achieved by elevation the maxillary sinuses in the 1st molar site using intra-crestal lift technique since we have more than 4mm of residual bone and also by placing implants in the Pterygo maxillary region which are commonly referred to as Pterygoids.

• 47 year old healthy female presents to LIT Institute with failing maxillary fixed bridges cemented 20 years ago.

• Clinical view shows that the existent prosthesis was well designed fabricated following Antle’s law

• Digital panoramic view reveals broken abutments

• Upon removal of the 8 unit segment, we observe complete destruction of the natural abutments. At this conjecture is clear that we must remove all maxillary teeth and place sufficient implants to support a 14 unit fixed prosthesis

• Using a CBCT (Carestream 8100, USA) we are able to obtain 2D images that are converted into a 3D working model via conversion of advanced algorithms.

• In this frontal 3D image we are able to confirm what we observed clinically, the poor condition of natural abutments and need for full arch extractions.

• Lateral left 3D image reveals periapical pathology on several teeth as well as site were implants can be placed in the anterior and posterior region.

• 3D plan will consist of:
  A… “all-on-4”
  B… implants in the pterygo maxillary region
  C…and implants in the 1st molar region by means of intracrestal sinus lifts.

• Full muco-periosteal flap from 2nd molar to 2nd molar, autraumatic surgical extractions is achieved and care to preserve the thin buccal bone.

• A large bone acrylic bur is used at 35,000 RPM under copious irrigation to plasty the entire ridge and achieve a flat working platform which is essential for placement of RP implants and also creates height for prosthetic components.

• Maxillary sinus is identified and outlined with a sterile #2 pencil.

• A bone caliper is used to draw a line that will be parallel to the anterior-ascending part of antrum.

• This line will guide the placement of the most posterior implant as indicated by Dr. Paolo Malo.

• The sinus is outlined posteriorly and a second line is drawn to indicate the placement of a Pterygoid implant.

• Orientation of Pterygoids: start at site of ML of the 2nd molar, at 30=45* drilling through the tuberosity and engaging the Lateral Pterygoid plate. This is strictly reserved for advanced doctors that have placed 300+ fixtures.

• 3D rendering of “all-on-4”, placement in 1st molar via crestal lift and Pterygoid implants.

• Six guides pins confirm that the orientation and spacing for the “all-on-4” and for the Pterygoid fixtures are correct.

• X-ray verification demonstrate how we have avoided to perforate the maxillary sinuses in an anterior and posterior relation.

• Pterygoid implants are inserted manually. This site is always D3-D4 and as such allows for under-preparation of the site by 1-2 drills.

• Implant anterior to the maxillary sinus (TUFF series by Noris Medical System, Israel). This self-tapping, aggressive thread design is selected due to its bio-mechanical characteristics.

• Initiation of intra-crestal sinus elevation: start with stopper 1mm less than the height of the sinus from the ridge.

• Use sinus probe with stopper. Look for one of 3 signs to confirm reaching the sinus membrane.
  A…Tactile sense will feel smooth, rubbery or spongy
  B…while drilling you might feel a drop
  C…patient might feel pain

• Once you have confirmed reaching the sinus membrane, begin adding bone particles until site is filled to the crest, proceed to condense site using the instrument and stopper, repeat this step 3-5 times.

• What appeared to be an atrophic ridge resulted in a modified “all-on-4” with 4 additional posterior fixtures.

• Lets compare our 3D planning with actual free-handed surgery.

• Post-op ct-scan demonstrating the clinical advantages from planning a case using 3D models.

• The “all-on-4” would had yield a 10 unit prosthesis to occlude with 2nd pre-molars, the addition of Pterygoids allows for incorporating 4 extra molars with

• Post-op scan of final surgery, note how every mm of available residual bone has been utilized.

• While this might appear to be a “restorative nightmare” due to crazy angulations, is not !
  Noris Medical System has 0*, !7*, 30*, 45* and 60 * multi-unit abutments that will allow a screw retained prosthesis with less than 10* divergency.

• Soft tissue management cannot be overlooked, mastering suturing techniques is paramount in the healing process.