When a patient presents to your dental practice with nonrestorable teeth requiring full mouth extractions, the biggest concern is whether or not implants can be placed at the same surgical visit and if so will they be able to walk out with fixed teeth. Having an implant within your practice that allows you to load or progressively load, so that these patient’s demands are met, allows you to position your practice to a whole new level. Of course, certain parameters must be met in order to facilitate this type of treatment. This includes, but is not limited to the quality and quantity of bone, the presence of infection, the patient’s health and the skills of the dental provider. Additionally, the selection of the most appropriate materials for the most ideal situation must be met.
A patient presented to my practice for a consultation wanting to restore her lower dentition. She complained of generalized discomfort in these teeth due to the gross caries and periodontal disease that was readily apparent (Figure 1). The upper arch was already edentulous and restored with a denture.
Figure 1; Preoperative view of lower dentition
Figure 2; CS 8100 3D
Figure 3; Virtual Treatment Plan
Figure 4; Surgical Guide
Figure 5; Guided Kit
Figure 6; Engage dental implant
Figure 7; Temporary Abutments
Figure 8; Lower Immediate Provisional Restoration
A CBCT scan using the CS 8100 3D (Carestream Dental) (Figure 2) was taken to accurately treatment plan this case to make certain that no complications would arise from doing all the procedures (extract, graft and implant placement) within one visit. Since her entire lower dentition had caries as well as periodontal disease, the treatment would require extracting all the remaining teeth.
To further develop a treatment plan, diagnostic models were forwarded to the dental lab and mounted on the articulator for further analysis in order to meet the patient’s esthetic and functional needs. Additionally, a 3D virtual treatment plan was created with the assistance of 3DDX (Figure 3). The patient desired having fixed restorations supported by dental implants in the lower arch that would oppose a new complete denture
The implants utilized in this case were OCO Biomedical’s Engage dental implants. These implants are known for their unchallenged high implant stability at placement which is a critical success factor in these immediate load cases. With the combination of their patented Bull Nose Auger™ tip and Mini Cortic-O Thread™, the Engage™ implant system offers practitioners a bone level implant with high initial stability for selective loading options.
The Engage™ implant is self-tapping for an enhanced mechanical lock in the bone. The Bull Nose Auger™ tip will not proceed any deeper than the initial pilot drill preparation locking into the base of the osteotomy. Engage™ implants have a proprietary surface treatment designed to increase the surface area of the implant for optimal bone in-growth and stability. Other dental implant systems in the market with high initial stability may include but are not limited to; Hahn (Glidewell Direct), Nobel Active (Nobel Biocare), Seven (MIS), I5 (AB Dental USA), Conus 12 (Blue Sky Bio) and Any Ridge (Megagen).
Once the teeth were extracted, the tissue was reflected in order to get the surgical guide seated and fixed with their respectful retention pins. Using this universal surgical guide (Figure 4) provided by 3D Diagnostix, the sites for the implants was initiated with a designated 1.8mm pilot drill from the OCO Biomedical Guided Kit utilizing the Mont Blanc surgical handpiece and Aseptico surgical motor at a speed of 1200rpm with copious amounts of sterile saline. Sequential osteotomy formers from the OCO Biomedical Guided Kit were then used to shape the final osteotomies (Figure 5). Once the osteotomies were complete, an implant driver was used to place the dental implants until increased torque was necessary (Figure 6). The ratchet wrench was then connected to the adapter and the implants torqued to final depths reaching a torque level of about 40-50Ncm.
A baseline ISQ reading was taken of these implants utilizing the Osstell ISQ unit. Since the initial readings were all above 70 and the quality of bone after leveling was good, temporary abutments (OCO Biomedical) were tightened into the Engage (OCO Biomedical) dental implants and prepped with copious amounts of water for immediate provisionalization.
Any residual areas around the implants or in the sockets were grafted with a cortical mineralized and demineralized bone grafting material (OCO Biomedical) to optimize the area for regeneration. Primary closure was achieved by suturing the tissue with resorbable sutures (Figure 7).
The prefabricated immediate provisional restoration was tried in to insure a passive fit over the temporary abutments. Once confirmed, rubber dam material was placed to avoid the restoration from locking on during the relining procedure with white Triad (Dentsply). After the material polymerized, the immediate provisional restoration was removed and any access material removed with the Torque Plus (Aseptico) lab handpiece and acrylic bur (Komet). Once trimmed and polished, the provisional restoration was seated with Temp Bond Clear (Kerr).
Seven days post-operatively the patient returned with very little discomfort, swelling, or bruising. She was very pleased with her new upper denture and lower fixed provisional restoration (Figure 8). Now that the patient was no longer anesthetized, the occlusion was checked again to confirm there were no interferences in lateral and protrusive movements. The next step in her treatment would consist of impressions for the definitive lower restorations approximately 4-5 months post-operatively.
Having the ability to take a patient from start to finish in a fewer amount of appointments within your practice allows you to position yourself as a provider that can fulfill your patient’s surgical and restorative needs. With the proper training and appropriate materials, a dental provider may provide extraction, grafting and implant placement within one appointment at one location. Not only does this allow you to reduce the amount of visits for the patient, but this type of service also helps maintain the cost to the patient since they are not seeing multiple dental providers. Most importantly, this enables the dental provider full control of the surgical and prosthetic outcome. Depending on the patient’s desires, the clinical conditions of the oral environment present and the skills of the provider, a dentist may choose to extract teeth, level bone, and graft with guided dental implant placement within his/her dental practice.
Dr. Nazarian maintains a private practice in Troy, Michigan with an emphasis on comprehensive and restorative care. He is a Diplomate in the International Congress of Oral Implantologists (ICOI). His articles have been published in many of today’s popular dental publications. Dr. Nazarian is the director of the Reconstructive Dentistry Institute. He has conducted lectures and hands-on workshops on aesthetic materials and dental implants throughout the United States, Europe, New Zealand and Australia. He can be reached at 248-457-0500 or at the Web site www. aranazariandds.com
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– Mortimer J. Adler