Silicon Valley Surgical Arts, Inc. & San Francisco

Guided implant surgery saves bone – leading to better outcomes

Dr Massoomi JOMS paper 9-1-2015

In the most recent edition of the JAOMS, a group of researchers look at the difference between the amount of bone that is removed during implant placement, in guided cases versus non-guided (traditional) cases.  Findings:  The use of fully guided implant surgery decreases the volume of bone that is removed during the drilling process, which leads to better primary stability of the implant…leading to a higehr chance of implants osseointegrating.

This is the reason why we encourage CBCT guided surgery for implant placement.  Better outcomes for the patient.

Citation: J oral Maxillofacial surg 73:1723-1732, 2015


Flapless surgery using “Green CT”? what?!

How do we accomplish surgery without making an incision…better known as “flap-less”surgery….?  3D Guided technology.

IMG_1898 IMG_1901


Our goal is to provide the best of care with the least amount pain and discomfort to the patient.  Research shows that the smaller the incision, the less the discomfort after the surgery.  At times we are able to accomplish some surgeries with no incisions at all…leading to the healing period that is reduced by at least 45% or more.

However, the only way to accomplish this feat: 3D guided technology.  Using the latest CBCT 3D imaging we are able to visualize the position and the quality (density) of the bone prior to making incisions.  (Most importantly we use only “Green CT” technology in our practices in San Francisco and Cupertino, for truly “low-dose” imaging, minimizing unnecessary radiation exposure to patients…curious? )

Photo Jun 19, 07 10 10  Photo Jun 19, 07 10 42

This allows us to virtually perform the surgery in an imaging software, prior to even seeing the patient for surgery.

Dr Massoomi CT guided implant placement

Then the same software program 3D prints a “surgical guide” that directs the surgical drill and dental implant to the same exact location as noted in the software program.

2012-12-20 08.36.47     2012-12-20 08.37.59

Our research shows that with the use of this technology we are  less 0.5mm off the predicted plan in the software program….hence, we do not even need to make any incisions to perform the surgery = “Flap-less”

Dr Massoomi Superimposition

The next time you see your dentist or surgeon for a dental implant, ask them: “do you utilize a surgical guide?”,  “Do you do flapless surgery?,  “Do you have a Cone Beam CT?”

I promise, You will have less discomfort after surgery…



Torque wrench anyone?

Dr Massoomi Dental Torque Wrench

I get this question a lot?   Whats a torque wrench?

At the time of surgery, the clinical stability of an implant is tested and assessed based on insertional torque measurements….this is the amount of force that is taking to place the implant into the jawbone.  We measure this with all implants, at the time of placement with a torque-wrench, (as seen above) and right before the dentist restores or “loads” the implant with a crown.  The purpose for doing this is to make sure that the bone cells have engaged or adhered or “osseointegrated” the implant.  Torque numbers between 30-40Nm at the time of placement are typically a number we shoot for.  This is usually indicative that sufficient stability of the implant  has been achieved, increasing the likelihood of the implant osseointegrating.  On a microscopic level, the is really measure the amount of space, or gap or lack there of, between the implant surface and the hold that is drilled into the bone.  The “tighter” the fit, the higher the torque number.  However on the flip side…..

For years there was some thought that high torque numbers (over 45Nm) at the time of placement of dental implants could actually be detrimental and lead to implant failure and none-osseointegration!  This was thought to be due to “marginal bone resorption” around the implant.  Although this concept was widely accepted in the literature years ago there is new research that showing that actually high torque numbers at the time of placement show a higher clinical success rates.

In the most recent edition of the JOMI journal (International Journal of Oral & Maxillofacial Implants), they perform a meta-analysis of 154 articles (11 from Ovid, 112 from PubMed, and 31 from EBSCO) to evaluate correlations between marginal bone resorption and high insertion torque value (> 50 Ncm) of dental implants.

Conclusion:  No need to worry about high insertion torque and marginal bone loss.   This study revealed there was no statistically significant differences between high insertion torque of >50Nm and conventional insertion torque in terms of effects on marginal bone resorption.

Int J Oral Maxillofac Implants 2015;30:767–772. doi: 10.11607/jomi.3884

Notes from Drs. Marx and Peleg’s (University of Miami) talk on Implants and bone grafting

Dr. Marx's talk on ridge augmentation prior to dental implant placement

Some of my students have asked me to post the notes form this talk…so here it is.  Hope this helps.

Dr. M. Peleg:

  • Always do soft tissue grafting in addition to bone augmentation
  • When you lose bone, you lose soft-tissue & when you lose soft-tissue, you lose bone.
  • As we age, we lose teeth, we end up with a pseudo-class III malocclusion, where the lower jaw is forward of the upper jaw.
  • Tension free primary closure is critical, underscore the periosteum!
  • Implant that is not surrounded by attached gingiva is compromised, even 2mm is better than nothing.
  • Subperiosteal dissection first, then graft. If done in reverse, it will bleed and dilute the bone graft due to hematoma. If you dissect first, it will spontaneously stop bleeding before the bone graft. If the bleeding does not stop in 10 minutes, then there is vessel that needs to be ligated. Metzenbaum scissors (rounded tips), dissect up.
  • Bone grafting: mineralized bone, cancellous bone, particle size 250-500mM preferred.
  • Membrane (Dura mater, freeze dried) resorbs slowly 7-8 months so it does not collapse into the grafted site. “Bioguide” from Zimmer great for perio, “Biomet extend” lasts longer. No need to stabilize the membrane.
  • Ideally, no pressure on the grafted site for 10-14 days. Then okay to wear an Essix retainer.
  • Any membranes has to cover the entire ridge.
  • Dental implants have to be stable at the time of placement. Otherwise it should be taken out….it will not osteointegrate.
  • Splitting the ridge technique– Need at least 3mm width. Need to keep the periosteum on the bone for blood supply – hence a supraperiosteal dissect for primary closure. Works great in the maxilla only, unpredictable in the mandible.  If the segment completely becomes free, stabilize it with a 24G wire between the implants. Extend as high as 10mm. Or cover with collagen membrane (salvin for 32 wks resorption)
  • Block grafts in esthetic zones are beneficial. Tension free closure, perfectly adapt the block, rigid fix, barrier membrane. He likes to use ramus.
  • If no cancellous bone from the medullary space –> no osteoblast!
  • With a block graft in the esthetic zone, you get better soft tissue support
  • For a prepped tooth and implant, using papilla sparing incisions, leaving a 2mm soft tissue collar. Always include the papilla in the incision if possible.
  • He uses cortico-cancellous allogenic blocks. Not cortical or cancellous bone only. Need both. Cortical bone helps with fixation, long screws that penetrate the palate, 2mm screws
  • Cover the mesh with collagen membrane to prevent soft-tissue ingrowth.
  • Leave mesh in 4-6 months.
  • Soft tissue grafting – 3 simple techniques
    • Tissue roll over – on the maxilla just borrow from the palate and move buccal. Midline releasing incision for better access. Fill the gap between placed implants and healing abutments with membrane. Long healing abutments to have the soft tissue around it.
    • Palatal grafting – for growing attached gingiva in the mandible. Or alloderm. 1mm thickness tissue is minimum. For connective tissue graft – be ware of GP artery. Cover the palate with stent to prevent complications, stays in for 48 hours, then okay to take on and off, but need to wear for a total of 5-7 days.
    • Connective Tissue Graft

Dr. R. Marx

  • Tibia bone harvest
    • Possible as an in office procedure preferably under IV sedation but can be done with local anesthesia.
    • Lateral approach is best, Gerdy’s tubercle, no muscle or vein or anything is near it. It’s close to the surface (only about 5mm from skin to bone). Ilio-tibial tract.
    • Can harvest up to average of 30cc of bone, (for sinus lift only need 7cc for only!
    • Put a pillow below the knee, to flex it in a passive fashion.
    • If right handed, go after the left knee, better angle of entry. And vice versa.
    • Do not use power tools to harvest the bone. Only use hand instruments. Otherwise you will go into the knee joint.
    • Full sterile prep and drape technique.
    • Local anesthesia: 1 carpule infiltrate subcutaneous and another carpule down to bone.
    • Incision is about 1 inch long
    • 1 cm window or opening into the cortex, then curette the bone out with spoon excavators (#4 Molt Curette)
    • Hemostatic agent: Avetin (powered bovine collagen), to prevent hematoma, at the osteotomy prior to layered closure.
    • Closure with ethicon sutures
    • Preop meds: Unasyn or doxycycline for IV meds. 12mg of decadron (good for surgical edema, supports bone growth) better than Medrol dose pak and solumedrol.
      Postop antibiotics: PCN VK or Augmentin or clindamycin
    • No running or sports for 6 wks. No need for crutches. Ice for 48hrs is enough. Elevate the leg
    • There is going to be a scar. Leg will swell below the knee and bruise.
    • Potential complications: fractures, knee joint issues, hematomas, wound dehiscence, scar, ecchymosis
  • Osteogenic bone grafting
    • Can use Allogenic corticocancellous bone, thin the cortex, soak in PRP, PRGF or even blood.
    • Round off any corner on the bone blocks
    • Lag technique for screw placement
    • PRP: accelerates normal soft-tissue and bone healing: VEGF, TGFb, EGF, PRGF…
    • 1cc of PRP has 250000-400000 of stem cells!
    • Natural blood clot has fibrin and other factors that help to heal the extraction sites.
    • Need at least 1 million / microliter of platelets after the PRP is concentrated, less is of no benefit.
    • After chronic periodontitis and loss of all the teeth, the periosteum has very little progenitor cells! Hence need to have osteoinduction.
    • BMP is now cleared for sinus lift and socket grafting
    • Product corruption is different than off label use of FDA approved drugs.
    • KLS resorbable mesh, instead of Titanium mesh. It lasts 3 months before its resorbed.
    • The BMP sponge from Medtronic’s is just a carrier and not a scaffold.
    • BMP will have lots of swelling, can use intraop decadron to reduce swelling.
    • To replace one tooth = you need 0.5mg of BMP
    • To fix continuity defect = you need 1mg/cm
    • The smallest BMP kit is 1.05mg.
    • Titanium Mesh exposure within 2 wks will lead to loss of some of the bone graft material and or infection. If over 2 wks, no issues, just keep on Peridex.
    • Come back in 6 month for implant placement.
    • The cleft lip and palate patients require a bit more BMP: 1mg /replaced tooth.
    • You can make a vestibular incision, instead of a crestal to prevent tissue dehiscence or mesh exposure.
    • If radiation post cancer – should not use BMP

Stem cells for sinus lifts?

In the most recent CDA article (Jan 2015) they mentioned a study in Translational medicine (Nov 2014), there is mention of stem cells being used to regenerate new bone in patient’s jaw bone to place dental implants. 

We have been using stem cells in my practice for the past 2 years to improve the quantity and quality of bone for implant placement.  This method is reserved for the more complex facial bone defects and is not used on a routine basis.  Patients that typically undergo stem cell augmentation are doing so in preparation for dental implant placement.  We have noted a greater amount of bone production and a higher quality (density) of bone during the implant placements.

This method is especially useful for patients with pneumatized (large) maxillary sinuses, that lack bone in the posterior of the upper jaw, requiring “sinus lifts”.  Below is patient that presented to me in 2012 for total rehab of her failing dentition.  She desired a fixed solution to her missing upper teeth and did not want a denture.  On her initial panorex, it is clear that she has large sinuses, without adequate bone to place any implants in the posterior of her upper jaw.  Hence she underwent stem cell grafting of her maxillary sinuses.  Please note the increase in bony height at the bottom of her maxillary sinuses.

Dental implants in patients taking Fosamax and similar meds (bisphosphonates)

Dr. Robert Marx recently had a great article in the JIRD on bisphosphonates and how it relates to implants.

As some may know, Post-menopausal women make up a significant portion of our patient population seeking dental implants, to replace removable partial or full dentures.   This population is also typically on medications, such as bisphosphonates, to treat or prevent osteoporosis.

Oral bisphosphonate medications inhibit osteoclastic activity, meaning they prevent the function of osteoclast cells that typically destroy bone.  Interestingly, osteoclasts play a critical role in deposition of bone by another cell, called: osteoblast.  Without the inter-play of these two types of bone cells, a patients bone physiology is altered…for the better to worst.  Thus patients who are taking such drugs may be at risk for developing “bisphosphonate-induced osteonecrosis of the Jaw (BIONJ) following dental extractions and/or placement of dental implants.  For that reason, some have suggested that osteoporotic women receiving bisphosphonate therapy may not be good implant candidates.  This is where it gets complicated….not all bisphosphonate medication have the same profile, meaning just taking oral bisphosphonates does not preclude you from getting an implant.  It depends on which bisphosphonate (oral vs. IV form), the duration and the amount of the medication that is ingested prior to surgery.

Among the 3 most commonly prescribed oral bisphosphonates- Actonel, Boniva and Fosamax…Fosamax is the only one of major concerns.  Fosamax is typically given at twice the dose of the other two medications and has been associated with a greater incidence of BIONJ.  Among Dr. Marx’s patients, Fosamax accounted for 97% of such cases.  Hence, patients who are taking either Actonel or Boniva can be treated essentially like any other patient receiving an implant.

For those taking Fosamax, the length of treatment should be considered: How long has the patient been on Fosamax?  Those who have taken it for 2 years or less appear to have normal bone healing when it comes to implants.  If taken for more than 2 years, the risk of BIONJ appears to increase with time.  Since Fosamax affects mature osteoclasts, as well as immature or young osteoclasts in the bone marrow, it usually takes 2 or more years of Fosamax to reduce the mature osteoclasts enough to affect osseointegration of implants.  Remember, osteoblast are needed for the implant to osteointegrate.  Below is the actual article:

Bisphos in implant pts, Marx

No association found between high sugar levels and implants!

No assoc between DM and implants.

In a the most recent volume of the Journal of California Dental Assoc. (CDA) they cites an article in the JADA, where 117 patients with diabetes were followed for one year via HbA1c levels, to determine the success rates of implants.  No difference in implant survival was noted in the diabetic patients versus non-diabetic patients after one year.  The baseline levels of HbA1c were as high as 11.1 – 13.3%.   Implant survival rates for 110 of 117 patients (7 patients lost to follow up) who were followed for one year after loading were 99.0 percent for patients without diabetes, 98.9% for well-controlled diabetes (n = 44) and 100% for those with poorly controlled diabetes (n = 19).

Although this finding is reassuring for diabetic patients, a larger study and further long-term investigation and evaluation is needed.  Excellent blood glucose control is still recommended in all patients, even implant patients.  The close the HbA1c to 7.5% the better the indication of control.

Below is the citation: JADA Dec 2014, Vol 1445, No 12, pp 1218-1226.

No assoc between DM and implants_Page_1


Chewing or “smokeless” tobacco Facts…

Many patients that are interested in implant are not aware of the detrimental effects on smoking on dental implant.  Some may even opt for chewing tobacco instead, but smokeless tobacco is just as bad, if not worst

It may be smokeless, but it’s still tobacco

Smokeless tobacco

Using tobacco can harm your health, including your teeth and gums, in a number of ways: from tooth discoloration and gum disease to throat, lung and oral cancer and, ultimately, death.

What is “smokeless” tobacco?

Smokeless tobacco comes in different forms and is called by different names, including “spit tobacco,” “chewing tobacco,” “dip” or “snuff.”

One of the newest forms of smokeless tobacco that is gaining popularity in America is called snus (rhymes with “goose”). It’s a Swedish type of smokeless tobacco that comes in teabag-like pouches that a user sticks between the upper lip and gum for up to 30 minutes and discards without spitting. This form of smokeless tobacco has become more popular because it’s not as messy as chewing tobacco, dipping tobacco and moist snuff, which often cause excess saliva during use. It does, however, still contain the active ingredients of chewing tobacco.

Smokeless tobacco and oral health

Just because chewing tobacco and other forms of smokeless tobacco aren’t smoked as cigarettes does not mean they are harmless, especially when it comes to oral health. Smokeless tobacco users can experience:

  • Bad breath
  • Teeth discoloration
  • Decreased sense of smell and taste
  • Greater risk of developing cavities

Like cigarettes, smokeless tobacco can lead to higher incidences of oral cancer. A few of the other known health dangers of smokeless tobacco include:

  • Smokeless tobacco products, just like cigarettes, contain at least 28 cancer-causing chemicals.
  • Smokeless tobacco is known to cause cancers of the mouth, lip, tongue and pancreas.
  • Users also may be at risk for cancer of the voice box, esophagus, colon and bladder, because they swallow some of the toxins in the juice created by using smokeless tobacco.
  • Smokeless tobacco can irritate your gums, causing gum (periodontal) disease.
  • Sugar is often added to enhance the flavor of smokeless tobacco, increasing the risk for tooth decay.
  • Smokeless tobacco typically contains sand and grit, which can wear down teeth, causing tooth sensitivity and erosion.

Warning signs

The most common sign of possible cancer in smokeless tobacco users is leukoplakia, a white, scaly patch or lesion inside the mouth or lips, common among many smokeless tobacco users. Red sores are also a warning sign of cancer. Often, signs of precancerous lesions are undetectable. Dentists can diagnose and treat such cases before the condition develops into oral cancer. If a white or red sore appears and doesn’t heal, see your dentist immediately.

What you can do

The best thing you can do for your oral health is to stop using smokeless tobacco. Your dentist can help you kick your smokeless tobacco habit.

If you are a user of smokeless tobacco, you should understand that tobacco dependence is a nicotine addiction disorder. There are four aspects to nicotine addiction: physical, sensory, psychological and behavioral. All aspects of nicotine addiction need to be addressed in order to break the habit. This can mean that tobacco users may need to try several times before they are able to successfully kick the habit.

Your dentist may prescribe any of a variety of nicotine replacement therapies, such as a transdermal nicotine patch or nicotine gum. Nicotine patches are worn for 24 hours over several weeks, supplying a steady flow of nicotine. Over the course of treatment the amount of nicotine in the patch decreases. Nicotine gum is slowly chewed every one to two hours. Each piece should be discarded after 20 to 30 minutes.

Smokeless tobacco users may need to see their dentist more often to make sure a problem doesn’t develop. Studies have found that 60 to 78 percent of daily users of spit tobacco have oral lesions. A dentist can detect these lesions with an oral examination and will be able to determine a course of treatment.

Dental implants outcomes in General Dental practices


Happy new year every one!

You may asked, is this IV fluids for treatment of dehydration after a little too much NYE celebration?  Or is this a sedated patient undergoing surgery?  Read on…

In a recent retrospective study published in the Journal of the American Dental Association (JADA) (2014;145(7):704-713) results suggest that dental implant survival and success rates in general dental practices may be lower that those placed by a specialist or academic practices.  This study was conducted by the PEARL network – a group of practitioners engaged in Applied Research and Learning.  Close to 920 implants and patients from 87 practices were followed for close to 4 years.  Of the 920 implants only 7% failed.  Below is a chart of the analysis of the risk factors:

Outcomes of the implants in GP practices results


The failures were mostly attributed to: 1. preexisting inflammation (at the site of the implant placement due to previously infected tooth), and 2. low quality type IV bone (due to a lack of bone grafting at the time of the extraction of the tooth).   How does this apply to our practice?

1. Pre-existing inflammation – This is the reason why prior to placement of dental implants, we provide PRE-OP IV antibiotics – through the same IV access that we provide the sedation.  Most patients assume that IV sedation is only provided for patient comfort, but they don’t realize that more importantly we provide other medications to reduce the risk of complications after surgery; i.e. antibiotics, anti-nausea, anti-swelling and even long-term pain medication.  Its the combination of all these IV medications prior to surgery that allow for a speedy post-operative recovery, with the least amount of complication – such as implant failures.

2. Low quality bone at the time of placement – This is why the research supports bone grafting any extraction site, especially if the ultimate goal is to replace the extracted tooth with an implant later.  Recently, a patient presented to my office in for an implant consult, 2 weeks after undergoing an extraction without bone grafting.  She was falsely under the impression that she could now magically have the dental implant placed in the same extraction site.  Unfortunately, because she was not bone grafted, she lacked quality bone.  Hence we could not place the dental implant.  We are now waiting at least another 4-6 months for the extraction site to naturally heal and to undergo osteogenesis before we can attempt the implant.  Initially if she had undergone the bone grafting at the same time as the extraction, then that time would be possibly cut in half.  Furthermore, she could have even been a candidate for an “immediate dental implant placement” – where the implant is placed on the same day as the extraction.

This is an example of evidence-based practice.  Only performing surgeries based on sound, proven science.

Take home message: Bone graft any extraction site when considering dental implants AND provide preoperative IV antibiotics for dental implants.