implant concepts
 Implants - surgical procedure driven by prosthetics
 Bone is the first requirement (sets the tone)*
 Surgeons focus - 3-D bone to imp relationship
 Soft tissue depends on bone (is the issue)*
 Missing bone is the limiting factor for esthetics
 Imp-tooth & imp-imp distance is critical
 Lacks of esthetics is unacceptable
Esthetic Hierarchy
 Restoration
 Soft Tissue Form
 Implant Placement
 Site Development
Why An Implant?
 Segment the case
 Decrease future costs
 Increase strength of the restoration
 Preserve bone
 Patient able to floss
 Cosmetics
 Psychological health
Implant Success is Dependent Upon
 Implant stability
 Good restorative position
Implant Stability Dependent Upon
 Bone quantity
 Bone quality
Good Restorative Position is Dependent Upon
 Bone quantity and quality
 Adequate gingiva – esthetics
 Ideal 3-D implant placement
 Timing of implant placement

Implant Advantages
 Maintenance of bone
 Improved stability of prosthesis
 Improved proprioception
 Increased support
 Direct occlusal loads
 No caries or endo
 Improved psychological health
Consequences of Bone Loss
 Denture retention difficult
 Reverse smile line
 Minimal display of maxillary teeth
 Upper lip does not follow mx incisal edge
 Hypererupted mand anterior teeth “combination sx”
 Resorbed max ridge
Loss of teeth
 Decreased V.D.
 Increased nasal-labial fold
 Prominent chin
 Pointed nose
 Witch‘s profile
Which Graft
 Nothing
 Bone Graft? o Autograft, allograft, xenograft, synthograft, combograft
 Membrane? o Non-resorbable, Resorbable – bovine, porcine, human, synth
 Growth factors o PRGF, PRP, Emdogain, rhPDGF-BB (Gem 21),rhBMP-2(Infuse)
 Soft tissue graft? o Autograft, Allograft, Xenograft
 All or some combination of the above
Extraction Facts
 General DDS extract 23 million teeth/year
 First year – 25% loss of bony width
 First year – multiple extractions 4 mm loss of vertical
 Years 2 to 3 – 40% bone loss

Tooth Extraction Sequellae
 Resorpton and remodeling
 Insufficient bone for implant placement
 Increased crown to root ratio
 Gingival loss
 Recession at adjacent teeth
 Lifelong bone resorption
Tooth Extraction -classification
Simple – no flap elevation (and GFs?)
 nothing
 fdbg & collacote
Complex – flap elevation (and GFs?)
 fdbg & membrane
– resorbable or non-resorbable
 fdbg & membrane & soft tissue graft
– autogenous or allograft (alloderm TM)
 fdbg & soft tissue graft
Tooth Extraction - Simple Grafting Technique
 Remove tooth atraumatically o Sulcular incision o Minimal elevation o Ogram system o Consider Piezosurgery
 Good degranulation – use neumeyer burs (Brassler)
 Copious irrigation – saline and CHX
 Hydrate FDBG with water and Growth Factor and fill defect
 Place collacote plug
 Suture with 4-0 gut, rapide or gortex
Post-extraction changes
 Tooth removal spurs external bone resorption o Horizontal 3 - 6 mm o Vertical 1 - 2 mm
 Must minimize loss o Via grafting extraction site o Termed “socket preservation” or “ridge preservation” o Atraumatic extraction techniques
The Excessive Loss of Branemark Fixtures in Type IV Bone: A 5 Year Analysis
1054 implants placed in 246 jaws
952 fixtures in Type I, II, III bone
Implant failure rate 3% (29/952)
102 fixtures Type IV bone
Implant failure rate 35% (36/102) in Type IV bone Jaffin and Berman 1991

Tooth Extraction - Ogram Technique
 Understand dental anatomy
 Section all multi-rooted teeth
 Two axis bioengineering principles
 Fulcrum at the level of bone – don’t position forceps apically
 Micro motion relative to anatomy
 Teeth removed quickly
 Bone is preserved
Why a membrane?
Resorbable
 Collagen o Bovine
 Achilles tendon
 Pericardium o Porcine o Human
 Pericardium
 Acelleular dermis
 Fascia Lata
 PLA/PGA
 PRGF
Non-resorbable
 Expanded PTFE
 (e-PTFE Gortex) o Plain o Titanium re-enforced
 Non-expanded PTFE o (n-PTFE Teflon)
What is an ideal membrane?
 Space making
 Allow nutrients to pass
 Does not allow soft tissue cells to pass
 Bio-compatible
 Does not become easily infected
 Maintains its barrier function for 6 months
 Resorbs after 6 months
 Does not have to be removed
no second surgery
Incision Design
 Sulcular circumferential incision
 To adjacent palatal line angles
 Extend 1 tooth distally
 Vertical radicular bone
 Perpendicular to bone

 At right angle to mesial tooth
 Full thickness reflection past MGJ
 Explore the buccal plate
Membrane Preparation
 Soak in sterile saline or
 patient’s blood for 3 - 5 min
 Trim (template provided)
 Use only curved scissors
 Do not tack
Membrane and Graft Placement
 Hydrate graft & membrane
 Pack loosely into site
 Place membrane
 Cover the defect
 Shy of adjacent teeth
 Obtain passive primary closure
 Periosteal release may be needed
Membrane Surgical Considerations
 Flap preparation
 Site preparation
 Space beneath the membrane
 Lie passively over defect
 No sharp edges
 Adapt margins of membrane to bone
 Cover the defect by 2 mm
 Avoid the teeth by 1.5 mm
 Stability of the membrane
 Obtain primary closure
Closure
 Replace flap
 Maintain anatomy
 Tack vertical with gore
 Close vertical (5-0) gut
 Pack collacote plug or CTG
 Close socket with gore
 No pressure on wound

Incision Design
 Full thickness flap
 Expose buccal plate
 7 threads exposed
 Verticals 1 tooth lat
 Interradicular incisions
 Connect with sulcus
 Ideal position – 3 D
Autogenous Bone - Harvesting Options
 Locally o Rounger, trephine, safescraper
 Osteotomy site o Bur slow speed, spoon
 Chin or Ramus o Piezosurgery, bur, chisel, trephine
Second Stage Surgery
 Palatal surgical flap
 Increase tissue thickness
 Increase keratinized tissue
 Provide proper abutment seating
 Facilitate oral hygiene
 Provide proper ridge contour
Growth Factors
 Autologous o PRGF – Plasma Rich Growth Factors o PRP – Platlet Rich Plasma
 Xenologous (Pig) o Enamel Matrix Proteins (amelogenins) - Emdogain
 Synthetic o rhPDGF-BB – Gem 21 o rhBMP-2 - Infuse

Site Development hard tissue soft tissue
Site Development - hard tissue options
 Orthodonics
 Membranes & bone grafting o non-resorbable (titanium reinforced) o resorbable
 Block grafts
 Sinus grafts
Site Development - soft tissue options
 Connective tissue grafting o 1 st stage surgery o Post 1 st stage surgery o 2 nd stage surgery o Post 2 nd stage surgery
 Alloderm
 Flap management second stage surgery
 Guided gingival growth
Orthodontics
 Tooth movement moves bone
 Vertical defects can be reduced
 Bone can be leveled
 Potential implant sites created

Radiographic evaluation of marginal bone loss at tooth surfaces facing single
Branemark implants
Decreased horizontal distance between implant and tooth correlated to increased bone loss
Gingival recession around implants 1-year longitudinal prospective study
 63 implants in 11 patients
 evaluated at baseline, 1 week, 1 month, 3 months, 6 months, 9 months, and 1 year
 majority of the recession occurred within the first 3 months
 80% of all sites exhibited recession on the buccal
 wait 3 months for tissue to stabilize before crown
What is Osseoguard ?
 Type I Bovine Collagen
 Bovine Achilles Tendon
 U.S.D.A Certified
 Australian Bovine Source
 Manufactured in U.S. by Collagen Matrix Inc

Implant Surgical Placement - When?
 Post extraction
delayed
 Two months post extraction
– immediate delayed
 At the time of extraction
immediate
Site Development Implant Placement Provisionalization
Without Implant Placement
 Six months post exo
 Two months post exo
 At the time of exo
With Implant Placement
• Six months post exo
• implant, heal, expose, heal, temp
• implant, heal, expose, temp
• implant and temp – immed temp
• Two months post exo
• implant, heal, expose, heal, temp
• implant, heal, expose, temp
• implant and temp – immed temp
• At the time of exo
• implant, heal, expose, heal, temp
• implant, heal, expose, temp
• implant and temp – immed temp

Implant Placement Two months post extraction - disadvantages
• No immed gratification
• May still need CTG
• Bone resorption
• Bone grafting needed
• May lose papillae
Implant Placement Two months post extraction - benefits
• Soft tissue has healed
• No need for CTG
• No anatomic distortion
• Infection has healed
• Less surgery needed
• Less technique sensitive?
• Some bony healing
Immediate Implant - benefits
• One surgical visit
• Patient committed to imp
• Shorter treatment time
• Papillae preservation
Immediate Implant - disadvantages
• Must deal with infection
• Site larger than implant
• Bone graft needed
• Gingival closure difficult
• Membrane exposure
• Provisionalization
• Technique sensitive
• Rececession

Immediate Occlusal Loading (IOL)
Provisional or final restoration is in function with contact in centric occlusion, lateral working and balancing movements.
Requires multiple implants rigidly splinted by a fixed prosthesis.
Five-year prospective study of immediate/early loading of fixed prostheses in completely edentulous jaws with a bone quality-based implant system
• Immediate load cases followed average 2.6 years
• Average bone loss first year < 0.7 mm
• No implant failures occurred
• Bone loss similar to a two staged approach
Immediate Non-Occlusal Loading
Provisional restoration is not in function, has no contact in centric or non-centric occlusion.
Can be accomplished with single tooth or multiple restorations.
Immediate Non-Occlusal Loading - Advantages
• Fewer appointments
• Stimulate bone formation
• Preserve esthetics
• Form a “niche” practice
Immediate Temporization
• Primary stability a must
• Dense cortical bone preferred
• Instability > micromovement
• Instability > fibrous ecapsulation
• Within 48 hours of implant surgery

PreFormance™ Posts And Cylinders
• For screw retained or cemented restorations
• Packaged with hexed titanium alloy screw
• Knurled surface for mechanical retention
• Titanium alloy interface
• Non-Hexed available
Five-year prospective study of immediate/early loading of fixed prostheses in completely edentulous jaws with a bone quality-based implant system
• Immediate load cases followed average 2.6 years
• Average bone loss first year < 0.7 mm
• No implant failures occurred
• Bone loss similar to a two staged approach
“25 percent of people without teeth reported that they avoided close relationships because of fear of rejection when their toothlessness was discovered.”
Process for Creating CAM StructSURE ™ Bars
• Make impression and pour cast
• Fabricate occlusion rim & verification index
• Set denture teeth and wax for try-in
• Scan analogs and wax try-in
• Design bar in CAD
• Mill bar from CAD design (CAM)
• Polish bar and add attachments
• Tooth/bar try-in
• Process denture with attachments in acrylic
Immediate occlusal loading of Osseotite implants in the lower edentulous jaw. A multicenter prospective study
• 325 Osseotite implants inserted & loaded
• Temp prosthesis delivered within 4 hours
• Final delivered in 6 months
• Implant Success: 99.4% 12-60 months post insert
• Crestal bone loss similar to that reported for standard delayed loading protocols.

1047 Old Post Road Fairfield, CT 06824
Voice (203) 254-2006 mike@sonickdmd.com
Dr. Michael Sonick is a full time practicing periodontist and implant surgeon in Fairfield,
Connecticut. He is on the Editorial Board of Compendium of Continuing Dental
Education, Functional Esthetics and Restorative Dentistry, Inside Dentistry, Journal of
Implant and Advanced Clinical Dentistry, Journal of Implant and Reconstructive
Dentistry, and Dental XP. He currently is a Guest Lecturer at New York University School of Dentistry in their international dental program was previously a Clinical Assistant
Professor in the Department of Surgery at Yale University School of Medicine and
University School of Dental Medicine.
He is a frequent lecturer throughout the United States and abroad. His diverse lecture topics include cosmetic periodontics, dental esthetics, periodontal surgical technique, diagnosis and treatment planning, dental implant surgery, advanced hard and soft tissue grafting, sinus grafting, and practice management.
Dr. Sonick is the founder and director of the Fairfield County Dental Club, an advanced continuing education organization with over 100 active members. Dr. Sonick is also the founder and director of Sonick Seminars, LLC, a multidisciplinary teaching institute located in his clinical office and teaching center. Courses are given on all surgical aspects of periodontics and implant dentistry. Unique to this program is the three part continuum: dentists get to observe live surgery, participate during the Hand’s on portion and attend lectures. Courses are limited to 20 participants to maintain the intimacy of the group and to facilitate a great educational experience. Interested participants wishing to participate can contact Carole Brown at 203 254-2006 or visit us
on our website, www.sonickdmd.com.
Dr. Sonick is a frequent contributor to dental literature having published articles on periodontal surgical technique, esthetics, dental implants, bone grafting, gingival grafting, and radiographic protocol for predictable implant placement. Dr. Sonick is the recipient of an Honorary Membership in the Indian Society of Periodontists,
Fellowship in the American College of Dentists, Fellowship in the Pierre Fauchard Society and a member of Who's Who in Dentistry. The General Dental Practice Residents at
Yale New Haven Hospital have awarded Dr. Michael Sonick the honor of “Teacher of the Year.”
Dr. Sonick completed his undergraduate college education at Colgate University in
1975. He received his DMD from University of Connecticut School of Dental Medicine in
1979. He completed his residency in periodontics at Emory University in Atlanta in 1983.
He received implant training at the Branemark Clinic at the University of Gotenborg in
Sweden in 1986 and at Harvard.