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Chandur Wadhwani (FOR.org) - Healing abutment to final restoration - Duration: 38:32.
bSo I'm gonna explore with your some of
the science that I've been working on
over the last seven or eight years as it
relates to me a restorative
prosthodontist working with implants.
So here's the question I would like to pose
to you.
Where do we common commonly see bone
changes or bone loss around implants or what site?
And if you could help me here
to get an understanding of what you
believe. If you could text to the number
and tell me where you consider is the
optimum... or not the optimum. Where is the site we most commonly
find bone changes when we make radiograph.
Do we find it commonly at the apex of the implant?
For example something similar to a
periapical lesion on a tooth.
Do we find it at the crestal bone area that's commonly being lost.
Do we find it at midway down the implant? Or do we find
that bone around adjacent teeth is being lost
Where do you think is the most frequent
site we lose bone? Because this is
something that I've been thinking about
over the last few years I've been
developing my concept, as to why is we
have problems with certain types of
restoration. So nearly everybody in this
room believes that bone is being lost
predominantly around the marginal site
of the implant or the crestal bone;
which is what I believe.
Now we do know that bone changes do
occur at the apex, but we also know that
this is very rare and very infrequent.
It really only occurs when an
implant is placed in a site that had a
previous endodontic lesion or scar
tissue or is adjacent to a tooth that
has also got an endodontic issues.
So our premise that bone loss develops at the
margins of of the implant is something
that we're all seeing. So I'm going to
explore with you why I believe this
occurs. Why is it
we're losing bone specifically at the
crestal sites, rather than in other areas.
So we're finding bone loss at margins, we
see evidence such as this in clinical
photographs in and in radiography when
we're looking at where implants are
failing us. Where the bone is actually
resorbing. So why should that be?
I've found is very perplexing because
when I think about what I do is a
restorative dentist I know there's
certain things that will affect the
long-term stability within the bone of
the implant and I want to minimize those.
What I've also realized is that the
first line of defense for the bone is
the soft tissues. You have to somehow
damaged irritate or negatively influence
the soft tissues, then the bone loss
appears to be secondarily to the
information and the effect with the soft
tissues changing their position.
This is made me think very very
differently. So I started looking at how
soft tissues attached around implants.
I started looking at this fragile
connection that hemidesmosonal
between the implant surface or the
abutment surface and the actual
soft-tissue at this connection.
What is it? How does it develop and how
can we affect it. Now we know from
data that's being taken from a study
done in Brazil, which we would never be
able to do here. In this particular study,
published last year, they placed 16 implants
in eight live human being.
Then after four months they harvested
the implant even though they were
completely healthy. Then they looked at
the bone and the soft tissues around
them. They found that there is a mark
of biological width, if you like,
an attachment site that has a definite
dimension around implants. In the same
way we have a biological width around
teeth. Now we understand what happens
with the biological width around teeth
that we can invade it.
We also know that if this biological
width is affected around implants, the
soft tissues don't like it. They do what
they're supposed to do, they collapse.
What's the core of the body, they're
doing exactly what they're supposed to do,
what nature design them to do.
In order to collapse towards the core of
the body they have to resorp bone in
order to make space for them.
So I started to believe that our
understanding about implants is slightly
skewed. We always talk about the bone,
because that's the only thing we can see
on a radiograph. But maybe we should be
talking about the way the soft tissue
complex, actually protect the bone.
Because it is the first line of
mechanical protection. So how can we
damage this. Let's look at this
particular case that came out from the
University of Washington where a
prosthodontist is trying to cement a
restoration and he's trying to safeguard
cement from getting down around the
tissues. So he packs retraction cord, but
what he doesn't realize is the
retraction cord is going
to cause him a problem. Because not only
does he leave some of the cord behind,
what goes beyond the cord is really
important. Because the cement has been
given a space to flow. The reason it was
given a space to flow, was because that
fragile connective tissue and epithelial
attachment was blunt dissected away.
We know some data from Van de Velden
that the average force we use when we
push cord around any soft tissue site is
1 newton per millimeter. That's the
average for the pressure. We also know
that you will tear tissue, not between
the titanium and the soft tissue, or the
zirconia and soft tissues, but
into epithelial cells will be displaced.
You'll tear it within the tissues.
That occurs when you use approximately
one eightsh of the force that we commonly used to
pack cord around the soft tissue site.
So this is one of the ways we can
mechanically abuse the soft tissue and
get a response in the bone if it's left
long enough. My topic over the last
eight years has been cement. People
that asked me if it is that the chemistry of
the cement. Is it the pressure of the
cement destroying the hemidesmosomal attachment
what is it about cements that caused the
problem. The problem is
it can be physical. We can disrupt it
by the loading of the crown, seating the
crown down. As that cement squeezes out
it can disrupt the hemidesmosomal
attachment. It could be an allergic
response to the materials that we've
been using. Iit could be because bacteria
are allowed to grow around that site
causing inflammation of the tissue.
The tissue resorts towards the core.
The bone underneath it goes. It could be
foreign-body reaction. Or it could be
that we've irritated or change the
chemistry of the titanium by results due
to corrosion. So the soft tissues, to me,
have become the most important aspect.
And if you think about, we now know if
you exchange an implant abutment
multiple times, you take it on and off
take it on and off, taking on and off.
What happens? Bone resorption, why would that be?
Because we irritated and inflamed the
soft tissues. They get so inflamed again
they move towards the core of the body.
I believe the most of the results
that we're getting after surgery, after
an implant has been allowed to integrate,
is because we are damaging and insulting
the soft tissue. So let's talk a little
bit about my favorite topic: cement
extrusion. Why is it problematic?
It's problematic because we don't understand it.
We don't understand the cementation
process is actually a system. When you
have your abutment and you see your
crown on it with a fluid, like cement.
This is actually a system, it's like a
piston being driven into a chamber.
The studies that we've been doing in
conjunction with industry and the
university of Washington and Texas, have
taught us where you place the cement.
Simply where you put the cement will
have a critical effect on how it flows
and how it displaces air and how it will
affect the soft tissues. So placing it
higher up is much more beneficial. Sorry
placing it near the coronal aspect
by the margin is much more beneficial
than placing it near the occlusal. The
studies have shown that time and time
again using million-dollar computers
being run simultaneously four months.
We also know from this same processes
we can actually find out
what speed the cement is ejected at
depending on the form of the abutment,
where we place it. Is it going to tear a
hemidesmosomal attachment. All the
things that I do every day, I've now
realized that I'm more of the biologists
then I am a prosthodontist, because if
the biology of the soft tissues is it
maintained in health
I cause destruction. Mechanical
trauma tissues is not as infrequently
as you think. We've all seen it, when you
look at things like this, you know the
cement gets down there because you see
it being pushed past the hemidesmosomal
attachment. You see being pushed
within the tissues. Whenever you take any
kind of abutment off the tissues you
noticed bleeding. Because you've torn the
cells. They're sticking partly to the
abutment and they tear. Blood comes out
in spots. Now when blood comes out, the
blood red blood cell has a dimension of
628 microns. It's not very big, but
unfortunately some of the cement
manufacturers are actually producing
cement that are thinner than a red blood
cell is. So we can push these cements
directly into the tissues, if we don't
control our processes. Material
within the tissue occurs in dentistry.
This is foreign body giant cell reaction
that develops around implant sites. We
rarely see it in periodontal disease, but
we see it around implants, because the
tissues are getting so angry and
inflamed, they don't like it. What do you
think the bone responses is like
underneath any one of these? What can the
bone do. Nothing but resorb. So Naomi Ramer,
pathologist from New York, has
been taking the tissues and she's been
looking them at them under scanning
electron microscope and doing
histological studies on them. We find
routinely cement in the tissues. We've
gone one step further at the University
of Texas. We took soft-tissue from 34
failed implants. We looked at it under a
scanning electron microscope.
We found that in 19 cases, 19 out of 34,
not only could we find cement within the
tissues, because we were using some
elemental diffraction. We can actually
tell you what the cement was. Things like
this, that you see up there. These are
globules of cement that have got within
the tissues. Now dentistry is familiar
with things going into tissues, because
we frequency amalgam tattoos. We've all
seen those. The amalgams getting into the
tissues. There's a site, which is
written up here, that shows you that is
also alginate gets into the tissues.
Cavet gets into the tissues. Cotton ball
gets into the tissues. And even titanium
particles get into the tissues.
This tells us the tissues are fragile.
They are particularly fragile around
implant sites and we have to respect
them. If we don't, the bone
doesn't understand what's going on and
it simply resorbs as a secondary effect.
So how does titanium get into the tissues?
Let me show you one example of how
titanium gets in. This comes from one of
my really good friends Roger Lawton, who
practices about 40 miles from me. He
described this case, where there is a
titanium tatoo. Because the implant
components were in sufficiently strong
to maintain the force placed on them,
this broke and after a few months, the
titanium from the implant was wearing
and it was washing into the tissues.
But that's not the only place that titanium
can come from physical manipulation.
Believe it or not, we can chemically
manipulate it.
I always thought the titanium was
supposed to be a very robust material.
But then I realized doing my cement
studies, it's actually very susceptible
to certain elements that we routinely
using dentistry. I find this out by
looking at cement. Durelon, which 17%
of the US dental schools, claim to use for their final
restorative material on implants.
Now most of us use titanium implants. When I was
going to do a study I wanted to do a
radiographic, an x-ray study on this
material to see how dense it was. But I
did something that very few people do.
I read the instructions. And it says in
the instructions don't use it for
titanium. So when we contacted the
manufacturer and we said what's the
problem with titanium and using your
materials. They say it corrodes,
it activates a corrosive process
So we decided that
we're actually going to do a study, which
we just we just published in the Journal
of Prosthetic Dentistry. We take these
cement. What we do this is a study
that was sponsored by Nobel Biocare, we
take two types of machined titanium
aluminum vanadium alloys; it's either
turned or it's machined/milled and what
we do is we stick these components
together. We leave them in a moist
environment for one week. Then we pull
them apart and we examine them
underneath scanning electron microscopy.
The picture on your right shows black
holes in it. That's corrosion
that's very similar to the corrosion you
see in the amalgams that go black. It's a
self-perpetuating electrochemical
reaction that goes on indefinitely
unless you cut it out. Now the
interesting thing about this is you can
actually use the corrosion to your
advantage. We've just published the
material on that. What we do is we
actually actively corrode certain parts
of titanium by using this corrosive
aspects. The chemical that we use is
fluoride, something that ubiquitous in
restorative dentistry to save teeth.
This is why Durelon causes corrosion
on titanium, because Durelon is a
polyacrylic acid with zinc oxide. But
what they did was SP added stannous
floride. By the adding of
stannous fluoride in an acid environment a
chemical reaction occurs. You get HF -
hydrofluoric acid. Now the hydrofluoric
acid when it reacts with titanium
releases hydrogen. I''m going to show
you that. I''m going to show you the
effect of hydrofluoric acid
on titanium. One of the effects is you
can roughen titanium. So I no longer
have to go to my lab with a piece of
titanium abutment and ask them to etch it.
I can do that in my office. And I
can do that within 10 seconds by simply
adding some hydrofluoric acid. So watch
this. This is me with an abutment and
I'm going to etch within 10 seconds
I'm going to use force Lich now I
usually protect the tissue touching
components but watch how quickly this
react
this is titanium that material is
supposed to be robust that doesn't
corrode you see it bubbling like a
volcano that's hydrogen being liberated
this is how quickly is fire button then
I watched them off in deionized water
and I have a beautifully roughened
titanium surface that gives me
micromechanical retention for my cement
so this is what we've just published in
the journal prosthetic dentistry to show
people what we do because everything i
do i published because i'm out there I
want people to tell me i want the
reviewers to say you're not correct
there's a problem that we etch titanium
like this with hydrofluoric acid very
clean very quick very efficient we've
just finished a study at the University
of Washington that shows etchings
titanium like this gives you the same
micromechanical return retention of your
cement as does air abrasion sandblasting
but there's a problem because we use
Hyper thought we use fluoride to save
fish so we are beginning to get a little
bit of a dilemma because when I have a
mixed dentition like this morning the
two slides I couldn't show you because I
ran overtime Milkha was what's the
problem with trying to keep teasing
implants in the same mouth in somebody
who's taking medications that are going
to induce the dry mouth Ingram where I'm
going to use camera where I'm going to
use carries assessment and management by
risk assessment and I'm going to throw
fluorides that if I use the wrong
fluoride i will damage the implants and
this is particularly true it's
especially true when the titanium that
is used by the implant companies is not
commercially pure so when you start
adding things to titanium it become more
and more corrosive related to
hydrofluoric acid so if you put aluminum
and Van Diemen your implant system it's
more corrosive and commercially tight
commercially pure titanium if you put
the co nghia into your implant system
you get a wonderfully strong implant
that is far more corrosive the normal
implants that are commercially pure and
i'm going to show you what happened
so titanium is a noble metal is an order
of noble metals that exists is it
existing chemistry so the most noble of
all the metal this platinum then we have
gold then we have feel that but they
look at commercially pure titanium and
you'll see towards the right of it are
the alleys so in particular cases where
you have a patient that is going to be
Kerry's prone and you want to do your
damnedest to save those teeth you have
to be particularly aware of how you're
going to save them and you're going to
have to start thinking about the product
you're going to use here are two
implants the one on your left is
commercially pure titanium the one on
the right is an alloy look at the
difference which do you think made
potentially give you a lot more problems
in the mouth when hydrofluoric acid is
involved now hydrochloric acid doesn't
just come from that you forcefully match
i gave you or I showed you the
hydrofluoric acid comes from bacteria
bacteria can induce corrosion we've done
an experiment of the university of texas
where we've induced corrosion on
titanium by changing the microbial flora
it also comes from agents like peroxide
patients coming to me to have their tea
speech before they have their implants
restored I have to be very careful with
the Carbonite peroxide because that is
another corrosive agent and so if some
of the acidic phosphorylated of acidic
saw spirit of fluorides that we used on
children so you have to be very aware
that there are some patients you're
going to increase the septum
susceptibility to corrosion and if you
do
titanium will come out of the system so
there is a problem and this is a study
we gained at the University of Texas we
took failed implants for failed in class
and compare them to a brand new implant
and we looked at them understanding
electron microscope this is a brand new
implant have a look at the surface
detail on it
compare it to the failed implants where
we're seeing pitting corrosion and
pitting corrosion may not have a really
extreme effect on the implant site but
it could tip the fresh home
if a patient has a threshold or is near
thresholds are getting soft tissue
disease the reactive oxidative species
that results in corrosive agent can tip
it over the edge so corrosion is
something that you have to think about
especially with alloyed components
titanium is not titanium is not tithing
and please be aware of that and another
problem with soft tissues allergies
now we know some cement induce allergies
but did you know that some of the
materials you might use have been
documented to cause allergies as well
for example apartment that are made of
titanium nitride this was documented in
the journal of prosthetic dentistry
titanium nitride is a very nice
aesthetic material it warms our crowns
but the soft tissues and some patients
don't like it
my next question would you tell me
whether or not you can recycle healing
abutment so if you have a patient and
you finished with the healing abutment
you restore the implied how about
cleaning it sterilizing it and reusing
it do you do that
what do you think would you like to see
if you could answer these questions by
texting me and see what what you do in
your clinic
what are your surgeon
so we're beginning to get a spread some
people don't know and it's roughly even
between yes or no
so here's the dialer for you what do you
do with your hitting buttons do you
reuse them because in the literature the
literature suggests that you can reuse
them literature says when you get the
healing abutment clean it so in your
autoclave when it comes back you can
reuse it because it's tear off let me
show you some of my latest research I
understand now that the soft tissues are
paramount to the health of the bone if
the soft tissues aren't healthy the bone
cannot be healthy so where do the soft
tissues initially start to heal they
start to heal against our healing
abutment like this and when we finished
with them
can we use them because what is
important to me for my patients is that
the first time the cells grow they touch
something that allows them to spread out
here and proliferate we know that
titanium oxide is the best material
irrespective of whether you think peak
is dead or the Korea the studies have
shown that titanium oxide is the most
superior materials because it's got a
very high surface energy so epithelial
cells really like it we also know that
unlike the Kolia so the kona has to be a
little bit rough as Marcus splats
reported this morning
titanium should be machine so should be
machine it should have a high surface
energy and it should be titanium so
people like this
published report 2012 things you can
sterilize these healing abutment think
about reusing them save some money for
yourselves in your patients so I got
contacted by my oral surgeon when I work
with very closely Superguy brilliant guy
he calls me about 10 months ago he says
would you do me a favor you're restoring
an implant today when you finished with
the healing about meant could you
sterilize it send it back to me and I
said short because I've been doing that
for years
I mean driving home and I'm thinking
what's the validity of sterilization of
a healing abutment so I look at this
article and I go with it it's there are
it's great but then I look at it closely
does anybody think that healing abutment
is clean compared to a new one so we
just found a study that we submitted for
publication
we took a hundred used and clean ceiling
apartments from eight different offices
in the US and canada and what we did
with them is we asked the offices how to
clean them and they say well we wipe
them and some of them wipe them with
alcohol
some of them like them with disinfectant
cloth then they put them in an
ultrasonic bath and then they sterilize
them in an autoclave and so we have
healing abutment from these different
companies and what we're going to do is
we're going to do something special with
them
we're going to look at them and
photograph them in all directions to see
if there's anything that we can see that
we know that the naked eye is not really
very useful at finding things
so what we're going to do after we
photograph them is within a place them
in a forensic stain the type of stain
the police would use when they're
looking for proteins and polypeptides in
this particular case its course locks in
be we're going to put them in a bag and
we cannot ultrasonically pay them into
solution thereafter for 20 minutes then
we're going to take them out the bag
we're going to wash them underwater and
then we're going to let them air dry and
then we're going to see what we can see
I'll show you what we can see
so fluxing be is also unknown stain the
bacteria for proteins and polypeptides
that's what we found
what this lock-in be does it gets
absorbed by proteins and polypeptides
which then expand and it shows up
orange-red do any of you think those are
clean and the epithelium would really
like to stick to them as the patient
heels
what do you think because i don't think
they are so my oral surgeon is never
going to get any healing abutment back
from me because I want my patients
a feeling and connective tissue
soft-tissue attachment to be optimum
from day one
now people say to me what's the clinical
relevance for this we will never find
out in the u.s. because i don't believe
there's any study that would allow us to
do this on patient if we know that we're
putting dirty healing abutment back
inside them
yes they are sterile they have no
microbes on them but they are not clean
epithelium will not attach it will not
spread it will not optimize its health
we found out of 9999 out of that 100
hearing but abutment had contamination
of them somewhere 99 we found it in
cracks and groove some healing abutment
have actual grooves in them if you use
those you're going to get material
inside there that is going to be a
contaminant we found it in the engaging
part of the screw why would we not find
in there because that's where food passu
we found that there was protein all the
way down there and we nearly always
found it on the screws rate nearly
always because the blood gets down there
in other products and what we did find
out about the one handing about moment
that was clean that it is probably never
been used in the oral environment now if
you want to do this in your own office
piloxing be is disclosing solution if
you don't believe what I'm saying to you
when you go back to your office get some
disclosing solution this one I don't
know if all brands are the same put your
healing abutment in this disclosing
solution for 20 minutes
agitate them take them out give them a
quick rinse let them dry and see what's
happening to them because you will be
changing the surface that is the most
important from day one for that
influence so that left me for the
dilemma because my oldest urgent dodge
is never going to get those healing
buttons back again the development that
I now personally have is what do i do
when i make an impression I've taken the
hearing about mine out my patient I lead
on the side i make my impression am I
going to put that dirty
the apartment back in the patient's well
now i have a dilemma or do I have to go
and buy a new healing abutment and
charged my patient another fifty dollars
or whatever
what should I be doing as a clinician
and I thought long and hard about this
should I throw the healing about my way
or can i reuse it
my opinion is that i can reuse it if I
clean it reasonably well because the
tissues are now mature I'm not
anticipating healing from day one
because they've already here they have
college and inside of them and I know
that they can now maintain their own
position and I also know that when i
unscrew the healing about man I've torn
some of it and there's a load of plants
around the sulcus anyway so this is what
I've decided that I would do I would
clean my apartment while I'm making the
impression so I would have the apartment
to my assistant while i'm placing the
impression coping in the first thing
that she will do is to clean that
apartment very very solidly with an
alcohol wife now I know some people say
that they're still live epithelial cells
attached to that that might be true in
sports because if you remember when you
take a healing about it off it believes
in isolated sites it doesn't bleed
uniformly so it means that there's not
your not caring at uniform you're
tearing it from spot attachments only
and it's true there will be live a
fulfilling yourselves on that
environment but when you go to try to
get back in because of the way of screw
works you will never get it back into
the same orientation and when you took
it out so the bleeding spot is now most
likely going to be opposite from plank
or some contamination so I think those
epithelial cells die anyway so what I'm
going to do is wipe it
I'm going to make my impression and then
i'm going to do citric acid which is the
cleaner that most people agree today is
useful for peri-implantitis riparian
flatteries to clean a titanium surface
because it removes most of the biofilm
so i'm going to use food-grade citric
acids this is a food you can buy this in
a food store believe it or not and i'm
going to make a forty percent solution
up by using two brands of the material
three mils of water and then i'm going
to put in an ultrasonic far for about 10
minutes and then I'm going to wash it
with deionized water and that makes me
feel comfortable
the only sad thing about the protocol I
just told you about
it's what I feel it hasn't been
scientifically tested but i think that
people will scientifically test in the
future but I have to do something I can
tell my oral surgeon know you're not
going to do this if I don't do something
differently myself so that's the soft
tissue i believe that the soft tissues
are the problem not the bone the bone is
important in the planning stage the bone
is important in the execution of the
surgical stage the bone is important for
stabilization both initial and long-term
once the implant field but after about
four months if everything is going well
I believe the soft tissues are the
vulnerable site that causes destruction
so I'm going to ask you some questions
about some x-rays because I realized
that we have the group of dentists are
very very poor at reading radiographs
something we do all the time so let me
ask you this question
have any of you seen this on the front
of these themes journals that we get
it's a flyer that you tear off in order
to get into your journals i see this
routinely on many of my journals and I
started looking at it very closely and i
and i truly don't mind if you if you
like this company and you want to place
your prosthetics in with a hammer
fine i don't mind them advertising
because if you advertise on the front
cover of one of my journals we get
better pictures we get more paper at the
qualities that i have no problem but
what I had a problem with was the
content on the top right hand corner it
says bone gained over time and so I
thought I'd look at this
so what do you think look at the
difference between 2006 and 2010 the
bone changes and here's another 1 2003
nine years later that
it's really quite impressive at first
gloves right and here's another one
this was from nobel biocare this was a
very interesting study i met the
officers that publish this study and the
story goes like this i met the primary
officer in a bar in New York and I said
to him I went up to him and I said
you've never met me before
my name starts with money i'd like to
buy you a drink and he looks at me and
if they actually I'd like to buy you two
drinks because i don't like your study
that got his attention so he says buy me
drinks so I open my computer and I shown
this picture i say you're trying to make
a point here that this implants cord is
allows bone to grow at these particular
sites and he says
yep and I say then I have a problem
because by the same radiograph you also
cause I split in the bone here and he
looks at me and I say that's not a spit
in the bone that's the mid powerful suit
shot of the maxilla it was always there
why don't I see in the first x rays I
see a little bit on the second xtreme by
the third x rays very prominent the
reason i don't see it is because you
change the angle of the x-ray so I get
no comparative measures from these three
radiographs they show me nothing I see
him
just imagine you had put this implant
two millimeters over towards the midline
in the first year you would have been
telling everybody this implant is
horrible because you've lost two
millimeters the bone by the second year
you'll be telling everybody take this
implant off the market because look at
the bone loss around it and he stopped
and he thought when he bought me a drink
so let's go back to this one what do you
think now because I contacted the author
that published this very nice guy and I
called him up and I see renia you
publish this and he says yes and I say
did you change the restoration to your
left and he says no I say radio you are
an amazing dentist you are the only day
since I've ever met in my life who can
actually grow attachment on adjacent
tooth by placing an implant is fabulous
and when you know you're the only person
I've ever met in my life who can make a
stainless steel pin disappear and radio
if I truly believe your implants can do
this I'm gonna buy shares of them and
I'm going to tell my family to buy
shares now because this is the only
implant system I've ever met in the
world that grows gold look at the size
of those two goals components on the
Crown's we have to become much more
astute at reading x-rays the trick is
never look at the influence ignore the
implant look at everything else around
it and if you truly did believe that
these pictures the 2012 groove on how
did you get grown too attached all the
way out titanium and then on to
partially how do you do that I can't do
that we have to start looking carefully
so now if you look at the thing that
comes on the journal you see they
propped the picture they crop the
picture so you don't get any indication
what's happening around it if you see a
prompt radiograph ask them to show you
the whole radiograph so it hasn't
finished hasn't changed position the
reason is changing position is because
when we standardize radiograph we do it
very poorly least two radiographs of
this implant site effectively could be
considered to be standardized as I use
the same materials same ring jolla hold
the same x-ray i'm going to use the same
x-ray unit they're not standardized and
if you don't believe me have a look at
this this is what I published on where I
made a healing abutment propped up by a
hundred microns against one of the
implant anilos that they had and I took
radiographs that measure different
angles so here we go this is orthogonal
the radiographs the 90 degrees on to the
long axis of the inside you see the gap
the gap exists you know that that
component doesn't fit i'm going to make
it fit now by changing the x-ray angle
oh it's this and I'm going to grow some
bone by changing the radiographic angle
as well now if any of you
leave the I grew plastic bone I've got
some implants I'd love to sell you so we
have to be much more careful with the
way that we read radiograph and that's
not only from other people
that's your a graph that's you when you
make a radiograph sequentially from one
time to the next time
learn to standardize them otherwise you
get no information about a
three-dimensional object that's being
projected in the two-dimensional plate
play so i think with that I'm early so i
will say thank you very much
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Mary Had A Little Lamb | Nursery Rhymes | YouTube Nursery Rhymes from | By ORIGAMI FOR KIDS TV - Duration: 2:28.
Mary Had A Little Lamb | Nursery Rhymes | YouTube Nursery Rhymes from | By ORIGAMI FOR KIDS TV "Mary Had A Little Lamb" nursery rhyme! This song expresses the love and affection between Mary and her cute friend, the Little Lamb. "Mary Had A Little Lamb" Lyrics: Mary had a little lamb, Little lamb, little lamb, Mary had a little lamb, Its fleece was white as snow. Everywhere that Mary went, Mary went, Mary went, Everywhere that Mary went The lamb was sure to go. It followed her to school one day School one day, school one day It followed her to school one day Which was against the rules. It made the children laugh and play, Laugh and play, laugh and play, It made the children laugh and play To see the lamb at school. And so the teacher turned it out, Turned it out, turned it out, And so the teacher turned it out, But still it lingered near. "Why does the lamb love Mary so?" Love Mary so? Love Mary so? "Why does the lamb love Mary so?" The eager children cry. "Why, Mary loves the lamb, you know." the lamb, you know, the lamb, you know "Why, Mary loves the lamb, you know." The teacher did reply. Mary had a little lamb, Little lamb, little lamb, Mary had a little lamb, Its fleece was white as snow.
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These Boots Were Made for Stalking - Duration: 42:43.
For more infomation >> These Boots Were Made for Stalking - Duration: 42:43. -------------------------------------------
Colours song for kids and toddlers in english: primary, second, mix colours - music video - Duration: 2:03.
Colours song for kids and toddlers in english: primary, second, mix colours - music video
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5 Surprising Home Remedies for Skin Sagging - How to get Rid of Sagging Skin - Duration: 3:36.
5 Surprising Home Remedies for Skin Sagging - How to get Rid of Sagging Skin
As we age, our skin begins to show signs of aging.
It begins to lose its natural
elasticity, which leads to sagging.
Flaccidity of the skin is a natural process and
is irreversible, but it can be reduced and delayed.
Often, people opt for cosmetic
surgeries that are very costly and have side effects.
Fortunately, there are some home remedies to tighten the skin.
They are simple and
easy and also work effectively to reduce wrinkles and fine lines.
Before we delve
into the various home remedies, let us understand the reasons your skin is loose and
loose.
Lemons
Collagen is naturally produced in your body (and can be injected artificially by a
plastic surgeon) to help your skin firm and regain some of its elasticity.
To
increase your collagen levels naturally, your body needs to take in plenty of vitamin
C, which is exactly what lemons offer.
This method will also help you keep wrinkles
away, which is a good added bonus.
To use the lemon on the skin, squeeze some juice from the fruit itself.
Rub in
problem areas and let stand for about 10 minutes.
You will have to do this up to
three times a day to see the maximum results.
If desired, you can also mix water with
lemon juice and let it dry on problem areas.
Strawberries:
Strawberries work as astringents on the skin, and they are 100% natural.
They provide
your skin with abundant minerals too.
Any fruit with these properties helps to harden
the skin.
So, go ahead and enjoy a refreshing facial mask made from freshly ground
strawberries.
Cucumbers
Cucumbers are used all the time in spas.
When you get a facial, your beautician will
usually give you two patches in the form of cucumber slices.
This ancient method has
been successful for many because of the moisturizing properties found in each slice
of cucumber, which squeezes the skin and removes dark circles around the eyes.
There is another trick in addition to putting slices of cucumber in your eyes which
is even more effective.
Put a cucumber in a blender to produce more juice.
Rub this
juice in any area where your skin is falling, and let it sit there until it is dry.
Rinse the cucumber with water, repeating this process once a day.
Egg white:
Again, we have a stinky recipe to treat your sagging skin, but it sure works.
Try it
to believe it!
Beat an egg white with a few drops of lemon until light and frothy.
Apply this facial mask and leave it on for 15 minutes and wash it.
This is an instant
skin tightening mask that is also very affordable.
Honey
Honey is also a great antioxidant that helps moisturize the skin, and can take years
off your face.
Also, it has a great smell (but be careful not to attract any bear).
The use of honey on your skin will leave you looking much younger in no time.
Giving
it a natural glow will make you appear as if you just left the beach.
You do not have
to foam on honey, either, to get the full effect.
You only need two teaspoons of honey to start, adding a couple of dabs of olive oil
and freshly squeezed lemon juice.
Stir all these together in a small bowl until you
have a good serum, then rub in the skin and let it dry.
Once it dries, rinse the
viscosity with water, but make sure it is hot.
For fast results, use this method up
to twice a day.
If You Like this Video Please Appreciate Us by Like, Thumbs Up and Share This Video
With You Friends & Family.
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Dive Conditions Report For Caloundra 26 April 2017 Sunshine Coast Queensland Australia #ScubaDive - Duration: 3:09.
Hey people of the interwebs it is Q
bringing you your dive conditions
midweek report. At the Caloundra coast
guard jetty we're on an outbound tide and
The Pumicestone passage waters are
looking surprisingly clean. So that's an
encouraging sign and if you were
thinking about a drift dive in The
Passage, as long as it gets cleaner by
the time Saturday and Sunday rolls
around, the tides are going to be in your
favor as well. The wind is currently
moderate from the North and we can tell
that by the sea state here, as we
overlook Kings Beach. Very flat, calm
surface conditions and the good news is
that I can actually see some colors
coming back into the water that are
meant to be there. Some slight blues and
some slight greens. By the time the
weekend gets here the wind will swing
around and become moderate from the
South. Taking a closer look at the water
on Kings Beach boat ramp we've got some
very expectant surfers here, although I'm
not sure whether they're going to catch
any big waves. Looking at the surface it's
quite calm and flat and slowly but
surely the visibility is returning back
to the water. These gray overcast skies
that we're looking at, at the moment, are
going to change. For the rest of the week
we're expecting it to be sunny with some
clouds coming back by Sunday. Now at
Shelly Beach, while the water is not that
coffee brown color anymore, it is still
very opaque. There's zero visibility in
here at the moment and of course getting
a fair bit of exposure to that northern
wind means the waves are slightly bigger
here too.
I still don't think there's any chance
of this clearing up in time for a
scuba-dive at the weekend, the visibility
just won't be there. As I take a
bird's-eye view down onto The Keyhole
site and just beyond that, I can still
see remnants of the very dirty water
that we've had, but the good news is it's
changing color in places, which means
the visibility is slowly but surely
coming back. Although there is no chance
that The Keyhole dive site will be
available for a shore dive this weekend.
Moffatt Beach is of course the most
exposed to the current Northerly wind
direction and that shows with the waves
here being a lot bigger than other dive
sites along the Caloundra coast at the
moment. Your tide times for this weekend,
Saturday we have a high at 10:05 am
and a low at 4:08 pm. Sunday we have a
high at 10:58 am and a low at 4:57 pm.
And the swell for Saturday and
Sunday is expected to be around about
the 1.5 meter mark.
So in summary although the signs are
looking good that things are starting to
clean up, I still don't think there's any
possibility of a shore based scuba dive
off the Calandra coastline anytime soon
and certainly not this weekend.
If you found this dive conditions midweek
report with Q helpful, don't forget to
leave a thumbs up down below, it
helps me out immensely and of course
subscribe to the YouTube channel to see
future videos,
Thanks for watching and take it easy.
-------------------------------------------
Lego Haul For April 2017 - Part 2 of ? - Duration: 4:10.
Hey everyone!
JAYSTEPHER with my second Lego haul for April 2017.
Let's see what's inside the bubble mailer.
We didn't need scissors to open up this package.
Let's see if I can feel the receipts.
I don't see any in there.
Oh I do.
Okay.
Oh yeah!
Let's see what kind of awesome parts I got.
Well hold on.
They got another receipt stuffed in the bag.
Really?
Lego doesn't like me doing hauls I guess.
So look at all the bricks.
I got mainly bricks this time.
I was trying to clear an order.
So I decided to just stock up on bricks,
and these were extra cheap too!
So I end up getting a bunch of black 1 by 10s,
and some 1 by 16s,
got some greens,
brown,
some gems.
All sorts of stuff.
I even got some corner bricks.
You all who follow me on Instagram,
you probably have remembered I broke a few of these.
So I decided to replace them.
So let's see if everything is in the order.
I just tallied up the order.
Everything is present.
I have 20 of the 1 by 10 black bricks,
20 of the 1 by 8 brown bricks,
20 of the 1 by 6 bright green bricks,
10 of the 1 by 16 black bricks,
five 1 by 8 plates,
five 2 by 4 flat tiles,
five 1 by 2 by 2 corner bricks,
and several gems
or crystals
or diamonds.
It depends on what their names are.
So that's it.
I have some plans for these parts,
but I'm probably going to need to get a lot more brick in that color.
Now there is something I like to discuss real quick
and that is bullyism.
It's getting to be an ongoing problem
especially within the Lego community,
and I'm getting tired of it.
So none of that on my channel.
I'm probably one of the very few
Lego YouTubers that is not afraid to use that block button.
So be very careful.
Constructive criticism is welcomed.
But using some very colorful language,
that's just not acceptable.
It's just not right.
You don't need to do that on YouTube.
So if you have something that's not nice to say,
just kind of keep it to yourself.
You know don't go on YouTube
and just dazzle everyone with the colorful language.
I won't tolerate it.
Like I've said, I'm not afraid to use the block button.
That's it!
There's the haul.
I think this is the last haul for April.
Thank you for watching!
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Learn Wild Animals Cartoons For Children 3D Dinosaurs Gorilla Tiger Lion T-Rex Elephant Horse - Duration: 1:02:14.
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Shark Movies Full Movie English Dianosures Shark Attack Epic Battle 3D Baby Shark Song For Children - Duration: 1:00:33.
Shark Movies Full Movie English Dianosures Shark Attack Epic Battle 3D Baby Shark Song For Children
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Colors for Children to Learn with Cocktail Heads Peppa Pig Sam Fireman Doreamon - Finger Family Song - Duration: 2:01.
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Is the Customer Always Right? 5 Top Rules For House Cleaners (2017) - Duration: 7:00.
Hey there.
I'm Angela Brown, and this is Ask a House Cleaner.
This is a show where you get to ask a housecleaning question,
and I get to help you find an answer.
This question comes from a woman who was watching her house cleaner on a home security camera
and the girl sat down and was visiting on the phone for an hour and a half, while she
was being paid by the hour.
And the homeowner wanted to know: "What are the rules and regulations behind that?
If someone is charging me by the hour, don't I have the right as the person paying the
money to demand that they work during that time?"
Well, that is an honest and a very fair question.
And the answer is yes you do.
If you're the one that's paying the money, then yes, it is in your power and it is your
right to declare your own rules.
Now, every homeowner is going to have a different set of rules, and every housecleaner is going
to have a different set of rules.
So, when you hire a house cleaner to come to your house, or a maid, or a housekeeper,
or whatever the term is that you use.
You need to be very specific about the rules that you create.
One of the rules that I would recommend upfront, and they're probably five or six rules that
are really important that you clarify upfront.
These are things that are important to you.
One of them is no talking on the telephone while you're on the clock.
"I understand that you run a business.
And so, if you're running a business and you're working in my home, you either need to turn
off the phone while you're at my house, or you need to have the little setting that sends
the quick message that says "sorry I can't talk right now."
So, you can respond really quickly and then after you get off the job and you're back
in your car, you can return the phone calls to your regular customers."
But if you're my customer and you're at my house and I'm paying you right now for a service,
I expect a full 100% of your attention.
I think that's fair what do you say?"
I think that's fair.
The next rule that I would suggest is no eating on the job.
There are numerous reports that I have heard where a house cleaner will come and they may
work for an hour and then they stop and take a half hour lunch break.
Okay, they're at your house cleaning.
Right?
They're at your house cleaning and while they're cleaning your house,
they should be working.
That's just common sense.
So, I would make a rule that when a housecleaner comes to your house that they not talk on
the telephone while they're there, and that they not eat while they're on the job.
The next thing I would recommend and strongly suggest is that you have a rule of no smoking.
There are lots of house cleaners who smoke.
And what you don't need in the middle of a two-hour cleaning that you're paying for or
a four-hour cleaning that you're paying for, is two or three 15 minutes smoking breaks.
Where a housecleaner leaves the job, and goes outside and takes a smoking break.
What is that?
"Smoke before you arrive or smoke when you leave.
But don't smoke when you're at my house cleaning."
Right?
I think that's a fair rule that you as a homeowner have the right to make.
And so I would have at least those three.
The other one that I might recommend (and this sounds very peculiar and you're going
to ask why I even bring it up) but this happens so many times, is no leaving while you're
on the job.
No leaving while you're on the job.
Do you know how many house cleaners check into a customer's house?
They type in the alarm code, and they start cleaning.
"Oh, I think I forgot something I'll run to the store and go pick it up."
And they leave.
Don't lock up the house because they don't want to trigger the alarm
that they're not there.
They just leave and they're gone for an hour or two hours.
"While I'm at the store I'll just do my regular grocery shopping and then I'll come back."
Then they come back to the house and lo and behold, "Well, my time is up."
So, they tidy up a few things and then run a few vacuum lines over the front of the carpet
and then they leave.
So it looks like they've been there.
Your alarm security code says that they've been there but they've been gone half the
time there was supposed to be there.
So, my other rule is I would recommend, that you recommend them not leaving while they're
on the job.
That's just sort of common sense.
Another rule I might suggest is that if your housecleaner has a friend that's in from out
of town unless that friend is actually bonded and insured with the company that your housecleaner
works for, they should not be able to bring their friends over.
No friends, no family members that are not specifically bonded and insured from the company
that you work for.
The reason for that is this.
Even with the best of intentions, a person that you bring along with you to help clean
a house that's not insured and not bonded, they can use the wrong chemicals on an appliance
that you have.
Or on the top of your desk, or the top of your fancy china cabinet or whatever and they
could ruin it.
And because they're not insured by that cleaning company it's going to be on you to pay that.
Or also if that person steals something from your house and that house cleaner is not,
they are not bonded through that housecleaner, that's not going to be covered.
Right?
Now, this person might trust their friend.
But you don't know their friend.
For example, my Mom came to town one time.
And I love my Mom.
She's the greatest housecleaner in the world… (well maybe besides me. ha ha)
Anyway, she came to town and she says "Oh, you've got houses to clean today.
Why don't I come help you?" and I said "Mom, I would love to have you
come help me clean the house.
And there's nobody that's probably more qualified to clean houses than you.
But unfortunately, you're not insured or bonded with my company so you're going to have
to stay home and watch TV or read a book while I go clean some houses because I can't take
you with me."
And she's like "I'm really good.
I am trustworthy."
"I trust you, Mom.
I know you're qualified to do it.
I know you've been trained properly.
My clients don't know that.
They don't know you and they don't they don't know that."
And so, I had to leave my Mom at home.
(She loved the day off, I mean don't get me wrong.)
But you can't bring people with you that are not licensed and bonded through your company.
So if you're a homeowner and you're looking to hire a house cleaner
I would make those rules.
I would say no telephone while you're on the job.
No eating while you're on the job.
No smoking breaks while you're on the job.
And no bringing people with you that are not licensed and bonded with your company.
Or insured and bonded with your company.
So, those would be my rules.
And that's it for today.
If you found it helpful please pass it along to somebody who may benefit from it.
And until I see you again, leave the world a cleaner place than when you found it.
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Color Horse Rhymes For Children 3D Horse Cow Fight Horse Videos Cow Cartoon Horse Riding Accident - Duration: 49:04.
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Dragon Attack 3D Animal Cartoon Video For Children Lion Dinosaur Dragon Cartoon Full Movie For Kids - Duration: 1:00:33.
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Spokane family knows first hand high demand for behavioral health services - Duration: 3:10.
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