@@Stanleyinstitute consider the lowest part which is the buccal that is the bone level or always take buccal wall even if it is higher than lingual wall as a bone level
Also what was bothering me when I was reading about different implants and bone level - what of your bone around an implant recedes a little over time, which may happen even with your own teeth. So it will not technically be at the bone level and then what, should it be considered an implant failure? I would expect many people have that happened to them over time (some bone recession) but their implants still continue to function. Also, is it true that bone grafts are more prone to receding than one's natural bone and are better be avoided if at all possible to place an implant without grafting?
It has been my clinical experience (my observations) that if the implant is placed in the proper position for mechanical and biological considerations then it will not experience bone loss over time. I have not seen any literature supporting that grafted bone recedes more than natural bone. However, when placing an implant I would take natural bone over grafted bone all day long. That is not to say we don't need bone grafting for certain cases. Hope this helps and thanks for watching.
I am a beginner but have noticed this after my first few cases. My guess is that it's one of those "problems" that does not cause too much troubles ultimately hence clinicians just disregard it.
Certainly, Dr.! I raise this point more to address the problems with research around "placement depth" rather than direct clinical applications. Research papers typically use this sort of terminology, which is ultimately useless to us as clinicians because it's not an accurate description of where implants are placed. My hope is that we'll eventually get research that uses 3D data or better depictions to accurately measure implant success vs. placement depth and location without using inaccurate terms like "bone level!"
No kidding. So what's your solution? sloped implants exist if your so inclined. But in reality, bone level is a valid concept. Firstly, often we'll flatten bone or profile bone. But more fundamentally, the concept of 'bone level' is what you aim for and try to mitigate against what's preventing you from achieving ideal level.
Thanks for watching, Doc! Unfortunately, sloped implants only account for one dimension of change, while most single implant sites are saddle points. Since this is the case, we should select an implant that has crestal features with dual affinity for both osteoblast and fibroblast attachment. This allows us to place the implant in the optimal location for the prosthetic solution, which typically places some of the crestal portion of the implant in bone and some in soft tissue. You're totally correct that we attempt to level bone in an All-on-X case, but in most cases, bone is rarely anywhere close to level or even planar. We simply must select an implant designed with an affinity for both soft tissue and bone!
As someone who does this for a living this is an oversimplified opinion that makes little sense on the research world. Advocating for ct scans or cbct when you know you can't really see around the implant due to scattering is dubious. I did like the pringle example but I don't see it all the time maybe half the patients. As you well know you do need to prepare the bone for implant placement
As someone who “does this for a living” who claims this to be an over simplification you are now my spokesperson! Thank you for such a wonderful compliment. My slogan is Implants Made Simple! Despite the fact I made it simple there seems to be a bit of misunderstanding in your comments. I advocate for CBCT and optical scans prior to surgery such that an ideal 3d prosthetic driven implant location can be defined (not after placement). I will post a picture soon of a typical human alveolus that will help to clarify the true nature of bone and why there isn’t any level of bone. The implications of this simple observation can not be over stated regarding the literature. If, as I have stated, there is no level bone then how have the reports on bone loss been measured? The implication is ALL 2d research regarding crestal bone loss is flawed!
@@Stanleyinstitute thank you for the appointment 😄 I wont ask for a retainer 😁and thank you for the time for the reply "The implication is ALL 2d research regarding crestal bone loss is flawed!" yes I agree I didn't misunderstood you. Evaluating long term implants in the bone, as you know, is not easy. Scattering around the implant happens with CBCT and that prevents us to see exctly where we need: the buccal plate. In this situation not even ISQ analysis help that's way most research is trying to find something better than the state of the art: Standardized Intraoral Radiographs.
That's indeed hilarious. All of it, including the Ironman part. Great explanation. I'm not a medical professional, but I have an implant in the anterior. I've done a CT scan recently and learned that it's front ridge or margin is not entirely in the bone buccally. I was a bit worried about it even though it doesn't give me any problems and my dentist didn't point out there was a problem.
Many times these implants that are slightly off in position can last I very long time. If you are not having any issues then that is a great sign. Just keep up with your regular dental visits in case things change. Best of luck!
Thats a very good info, can you tell me what's your stand point in these type of cases. Like whether to level the bone or to place graft to make it uniform or to place as it is and let the crest module exposed. Thank you
Great question! Our plan always starts with the ideal replacement tooth. From there, we place the implant virtually, marking sure to adhere to all our placement rules. This is the step where we'll determine whether we need to graft. We observe whether our implant position is surrounded by sufficient bone. If it is, we proceed with placement and allow the bone to model or remodel. If there isn’t sufficient bone, we graft the site. In either case, we simply place the implants at the depth our 3D virtual plan determines they need to go!
How about the upper jaw bone ? Especially on the side, it is really true that if you extract tooth from the upper jaw and dont add bone graft the sinus pocket will fall down filling the socket
The literature is clear that without a bone graft the site will heal with less bone. So a graft is helpful if you want an implant in the future. Just don’t wait too long or the bone will eventually start to melt away.
Doc. Your implant explanations are super informative. Bringing it to the people is an admirable quality. Many many people cannot afford implants because of uniformity in price quotes among dentists. A price of $1500 for post installation and another $1500 for cap installation seems unreasonable. How much of the cost is labor and how much of the cost is material. Nevertheless, your explanation of implants would make me feel confidant in choosing you as my dentist. That is until the time when AI robots offer dental implant services. Thanks again for the video.
You may want to consider going abroad for treatment. For example, in the former USSR there are many very good surgeons and prices are probably at least twice as low. If you are in the US, then it may be a bit too far, but maybe some places in South America would be a good fit logistics wise.
@@inquisitivenessandcontempl9918 Thank you for reply. What is your cost for post & cap. The average salary for a dental technician in California is $70-$80 thousand dollars. There is the reason for high cost of implants. The people cannot afford those salaries. Inflation will spiral out of control. As it is many middle and lower class citizens are foregoing dental services. Your a very good teacher, but we must bring inflation under control or all of us will be living on a diet of Pringles and Coca- Cola. Once again thank you for your help . Be well.
Hey Robert, thank you for such kind words. I truly do this for folks just like you. The good news about implant solutions is the price is being driven down rapidly from a competitive market. As far as going abroad I caution folks on that tactic. The main reason is if you have a complication you would need to return to say Italy, which might be fine for you, but could be an unexpected cost for others.
So according to ur theory there also is no Supra or sub crestal placement too , which also implicates that the implant is always exposed a little no matter where u place it unless u place it so deep or u level the bone , but yet a lot of implants succeed , and this also implies that what Zuchelli said about covering the implant with just a connective tissues graft is enough ( maybe 2-3 mm )
You're absolutely correct that there is no absolute placement level of implants-whether that's at "bone level," "supra," or "sub" crestal. As I mention in this video, bone isn't level, so a single implant can have sections that are at, above, or below the adjacent bone. This doesn't imply that an implant always has sections that are exposed-all areas of the top of an implant can be below the bone adjacent to those areas. However, the distance from each point on the top of an implant to the bone directly above it would differ, even if only slightly and even if you level the bone (as leveled bone is still imperfect). This makes designations like "below the level of the bone" inaccurate and useless for scientific study. And you're right-as I mention, a lot of implants do succeed (and many succeed DESPITE poor design and poor placement). I think we can agree that we'd prefer to engineer good implant solutions so that ALL of our implants succeed, not just a lot of them, right? :)
You are right , maybe we should go back to tissue level implants where a part of the implant is placed above the bone , I have seen so many topics about the importance of bone but what really protects the implant is thick soft tissue 2-3 mm above the coronal part of it , but even then you have to rely on patient hygiene to keep everything in place.
@@hasansaleh6232 If only patient hygiene didn't play a role in the recovery process! I can't tell you how many times I've seen patients permanently lose implant sites because the smoked during recovery or made other poor decisions. All we can do is ensure we've followed all 21 keys to implant success and advise the patient on what's needed of them!
Very interesting! I'd never seen someone challenge the concept of "bone level," but this makes total sense.
Agreed! I love this stuff and "bone level" has never made sense to me.
@@Stanleyinstitute consider the lowest part which is the buccal that is the bone level
or always take buccal wall even if it is higher than lingual wall as a bone level
Also what was bothering me when I was reading about different implants and bone level - what of your bone around an implant recedes a little over time, which may happen even with your own teeth. So it will not technically be at the bone level and then what, should it be considered an implant failure? I would expect many people have that happened to them over time (some bone recession) but their implants still continue to function. Also, is it true that bone grafts are more prone to receding than one's natural bone and are better be avoided if at all possible to place an implant without grafting?
It has been my clinical experience (my observations) that if the implant is placed in the proper position for mechanical and biological considerations then it will not experience bone loss over time. I have not seen any literature supporting that grafted bone recedes more than natural bone. However, when placing an implant I would take natural bone over grafted bone all day long. That is not to say we don't need bone grafting for certain cases. Hope this helps and thanks for watching.
I am a beginner but have noticed this after my first few cases.
My guess is that it's one of those "problems" that does not cause too much troubles ultimately hence clinicians just disregard it.
Certainly, Dr.! I raise this point more to address the problems with research around "placement depth" rather than direct clinical applications. Research papers typically use this sort of terminology, which is ultimately useless to us as clinicians because it's not an accurate description of where implants are placed.
My hope is that we'll eventually get research that uses 3D data or better depictions to accurately measure implant success vs. placement depth and location without using inaccurate terms like "bone level!"
Try profiling the bone.
No kidding. So what's your solution? sloped implants exist if your so inclined.
But in reality, bone level is a valid concept. Firstly, often we'll flatten bone or profile bone. But more fundamentally, the concept of 'bone level' is what you aim for and try to mitigate against what's preventing you from achieving ideal level.
Thanks for watching, Doc!
Unfortunately, sloped implants only account for one dimension of change, while most single implant sites are saddle points.
Since this is the case, we should select an implant that has crestal features with dual affinity for both osteoblast and fibroblast attachment. This allows us to place the implant in the optimal location for the prosthetic solution, which typically places some of the crestal portion of the implant in bone and some in soft tissue.
You're totally correct that we attempt to level bone in an All-on-X case, but in most cases, bone is rarely anywhere close to level or even planar. We simply must select an implant designed with an affinity for both soft tissue and bone!
As someone who does this for a living this is an oversimplified opinion that makes little sense on the research world. Advocating for ct scans or cbct when you know you can't really see around the implant due to scattering is dubious. I did like the pringle example but I don't see it all the time maybe half the patients. As you well know you do need to prepare the bone for implant placement
As someone who “does this for a living” who claims this to be an over simplification you are now my spokesperson! Thank you for such a wonderful compliment. My slogan is Implants Made Simple!
Despite the fact I made it simple there seems to be a bit of misunderstanding in your comments. I advocate for CBCT and optical scans prior to surgery such that an ideal 3d prosthetic driven implant location can be defined (not after placement). I will post a picture soon of a typical human alveolus that will help to clarify the true nature of bone and why there isn’t any level of bone. The implications of this simple observation can not be over stated regarding the literature. If, as I have stated, there is no level bone then how have the reports on bone loss been measured? The implication is ALL 2d research regarding crestal bone loss is flawed!
@@Stanleyinstitute thank you for the appointment 😄 I wont ask for a retainer 😁and thank you for the time for the reply
"The implication is ALL 2d research regarding crestal bone loss is flawed!" yes I agree
I didn't misunderstood you. Evaluating long term implants in the bone, as you know, is not easy. Scattering around the implant happens with CBCT and that prevents us to see exctly where we need: the buccal plate. In this situation not even ISQ analysis help that's way most research is trying to find something better than the state of the art: Standardized Intraoral Radiographs.
Eat that Pringle!!!
Too funny.
@@Stanleyinstitute ua-cam.com/video/pR6z-gm5_cY/v-deo.html
we dont use modern technology because its very expensive. we are not earning $. everyone would be happy top tech stuff :)
Keep at it, doc! Guides are getting cheaper and more accessible every year!
That's indeed hilarious. All of it, including the Ironman part. Great explanation. I'm not a medical professional, but I have an implant in the anterior. I've done a CT scan recently and learned that it's front ridge or margin is not entirely in the bone buccally. I was a bit worried about it even though it doesn't give me any problems and my dentist didn't point out there was a problem.
Many times these implants that are slightly off in position can last I very long time. If you are not having any issues then that is a great sign. Just keep up with your regular dental visits in case things change. Best of luck!
Hence the concept of variable surface roughness implants that can be placed 'bone-level' or tissue-level and can accommodate ellipsoidal bony anatomy.
Now we are talking!
@@Stanleyinstitute hey man, good to ‘see’ you again. It was nice meeting you at the IV Sedation course last year!
Yes, that’s why I do some bone reduction to flat even in a single implant placement
Are you doing this with a bone profiler set?
@@Stanleyinstitute yes I do
👏
Thank you
You just killed it Doc! You made it so simple thanks a lot!
Thank you. That is my goal! Implants Made Simple!
Thats a very good info, can you tell me what's your stand point in these type of cases. Like whether to level the bone or to place graft to make it uniform or to place as it is and let the crest module exposed. Thank you
Great question! Our plan always starts with the ideal replacement tooth. From there, we place the implant virtually, marking sure to adhere to all our placement rules. This is the step where we'll determine whether we need to graft. We observe whether our implant position is surrounded by sufficient bone. If it is, we proceed with placement and allow the bone to model or remodel. If there isn’t sufficient bone, we graft the site. In either case, we simply place the implants at the depth our 3D virtual plan determines they need to go!
Bone level refers directly to the bone that is in contact with implant neck . Not 3mm and not 3km further.
But if the bone is not level then some of the implant is below bone, some is above and some is “at” the bone level.
Great concept to understand. Thanks for this video Smile Engineer!
Glad you enjoyed it! Thanks for your kind words.
How about the upper jaw bone ? Especially on the side, it is really true that if you extract tooth from the upper jaw and dont add bone graft the sinus pocket will fall down filling the socket
The literature is clear that without a bone graft the site will heal with less bone. So a graft is helpful if you want an implant in the future. Just don’t wait too long or the bone will eventually start to melt away.
Not a dentist. How invasive is a bone graft? It was mentioned to me I could have a sinus bump rather than a lift? What’s your take on that?
Doc. Your implant explanations are super informative. Bringing it to the people is an admirable quality. Many many people cannot afford implants because of uniformity in price quotes among dentists. A price of $1500 for post installation and another $1500 for cap installation seems unreasonable. How much of the cost is labor and how much of the cost is material. Nevertheless, your explanation of implants would make me feel confidant in choosing you as my dentist. That is until the time when AI robots offer dental implant services. Thanks again for the video.
You may want to consider going abroad for treatment. For example, in the former USSR there are many very good surgeons and prices are probably at least twice as low. If you are in the US, then it may be a bit too far, but maybe some places in South America would be a good fit logistics wise.
@@inquisitivenessandcontempl9918 Thank you for reply. What is your cost for post & cap. The average salary for a dental technician in California is $70-$80 thousand dollars. There is the reason for high cost of implants. The people cannot afford those salaries. Inflation will spiral out of control. As it is many middle and lower class citizens are foregoing dental services. Your a very good teacher, but we must bring inflation under control or all of us will be living on a diet of Pringles and Coca- Cola. Once again thank you for your help . Be well.
Hey Robert, thank you for such kind words. I truly do this for folks just like you. The good news about implant solutions is the price is being driven down rapidly from a competitive market. As far as going abroad I caution folks on that tactic. The main reason is if you have a complication you would need to return to say Italy, which might be fine for you, but could be an unexpected cost for others.
So according to ur theory there also is no Supra or sub crestal placement too , which also implicates that the implant is always exposed a little no matter where u place it unless u place it so deep or u level the bone , but yet a lot of implants succeed , and this also implies that what Zuchelli said about covering the implant with just a connective tissues graft is enough ( maybe 2-3 mm )
You're absolutely correct that there is no absolute placement level of implants-whether that's at "bone level," "supra," or "sub" crestal. As I mention in this video, bone isn't level, so a single implant can have sections that are at, above, or below the adjacent bone.
This doesn't imply that an implant always has sections that are exposed-all areas of the top of an implant can be below the bone adjacent to those areas. However, the distance from each point on the top of an implant to the bone directly above it would differ, even if only slightly and even if you level the bone (as leveled bone is still imperfect). This makes designations like "below the level of the bone" inaccurate and useless for scientific study.
And you're right-as I mention, a lot of implants do succeed (and many succeed DESPITE poor design and poor placement). I think we can agree that we'd prefer to engineer good implant solutions so that ALL of our implants succeed, not just a lot of them, right? :)
You are right , maybe we should go back to tissue level implants where a part of the implant is placed above the bone , I have seen so many topics about the importance of bone but what really protects the implant is thick soft tissue 2-3 mm above the coronal part of it , but even then you have to rely on patient hygiene to keep everything in place.
@@hasansaleh6232 If only patient hygiene didn't play a role in the recovery process! I can't tell you how many times I've seen patients permanently lose implant sites because the smoked during recovery or made other poor decisions.
All we can do is ensure we've followed all 21 keys to implant success and advise the patient on what's needed of them!
Another great vid doc 👍🏽
Much appreciated
I love this Dr
THanks, Dr!