My alveolar reduction consists of two principle steps:
First, removal of bulk bone with a double action rongeur – which I affectionately call the “Monster Rongeur”.
And second, removal of any additional bone, smoothing, and leveling of the bone shelf with a “barrel bur”.
For the second step, I prefer the barrel bur (highlighted with the star above) for two very important reasons.
1. The barrel bur has a completely flat edge.
In my hands, this is preferable to the more popular and more frequently seen “tree shaped” reduction burs.
For my surgeries, I attempt to get as flat and level a bone shelf as possible. This is difficult to do with the tree shaped, round, or acorn shaped burs that are often seen in full-arch surgery.
By their very nature, the tree shaped, round, or acorn shaped burs are not “flat”. They all have some rounded or angled shape to their body and will therefore remove bone in an angled or arced fashion. While you can avoid creating this angled or “scooped” out reduction, it requires you to cut with a much smaller portion of the bur (avoiding either end and cutting only in the middle) – thereby greatly reducing your surface area and efficiency.
The true barrel bur on the other hand, has a large, “flat” cutting surface providing increased surface area and efficiency – while maintaining and creating a smooth, flat bone shelf.
2. Because the barrel bur has a uniform, flat, working surface – it also has a uniform “depth” when sunk into the alveolus during reduction.
I know that the barrel bur I use has a measured depth of 7 mm (simply measure the body, or depth, of the barrel bur with a periodontal probe). This is helpful in cases where more aggressive reduction is still required after using the rongeurs, or in cases where the rongeurs are unable to be used.
In this way, I know that if I sink the barrel bur to depth – I have now reduced to a level 7 mm below the current alveolar crest.
This does not always correspond exactly to the necessary reduction, but is simply another check point and visual confirmation of the reduction being carried out.
This 7 mm measurement is accurate only because the bur is uniform and flat along its entire body. If we measure a tree shaped or acorn shaped bur we will get different measurements (and therefore different depths) depending on where along the body we measure the bur.
It might just be time to dust off that old barrel bur you forgot you had…
“It’s the little details that are vital. Little things make big things happen.”
John Wooden
Q & A with Dr. K
“I am finding a consistent loss of keratinized tissue on my lower left posterior implant (I’m right handed btw). Any thoughts as to why this might be happening? I feel I am needing consistent free gingival grafts on the buccal aspect.” |
|
Hmmm… That’s interesting. Without watching you or seeing the patient clinically, it’s tough to know exactly what’s going on. That being said, the obvious thought (which I’m sure you’ve addressed) is that you’re removing too much keratinized tissue with your incision. The keratinized tissue shouldn’t really “disappear” during the healing process. Therefore, my initial thought is that you are inadvertently removing too much KG during the incision. The easiest way to avoid this, in my opinion, is to remove the teeth first so that you have better access to make a more strategic incision. I would be extra cognizant in this area to leave as much keratinized tissue as possible. Second, are you trying to do any bone grafting around this site at the time of implant placement? You may be unnecessarily grafting and creating a tissue reactivity or recession due to secondary inflammation at the graft site. I would advise avoiding grafting unless truly clinically indicated – at least temporarily to see if this alleviates the issue. Third, while I would try to avoid bone grafting, I would suggest application of a flattened PRF clot over the buccal aspect of this implant to “plump” the soft tissue out in this region and enhance soft tissue healing in the area that seems to be prone to the defect you’ve described. Finally, the last thing I would say is do not feel the need to too quickly jump to doing other procedures like free gingival grafting or connective tissue grafting. *I’m assuming based on your question that you are indicating you have limited KG but NOT implant thread exposure. If it is simply a lack of keratinized tissue, I would monitor the patient. Very often in AOX patients, a lack of KG does not automatically mean the patient will become symptomatic or even have any issues with that implant at all. As long as their hygiene is adequate, they may very well be just fine. Now, this is a different story if your implant has actual thread exposure or recession. Hope that helps! Matt |