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  • 1. C A S E P R E S E N T A T I O N Non Submerged Implant Surgery for the General Practitioner Bruce Bohunicky, DDSABSTRACT Perhaps this is part of the reason that over five million bridges were placed in the USA last year. Today, far too often, a patient with a missing or non-restorable tooth elects to have a fixed bridge. To opt for an implant, they would be choosing a Seven year survival rates of multi-doctor treatment that involves more time, cost and pain. This discus- bridges were found to be notably less than for single tooth im- sion will describe an implant technology and surgical protocol that will plants.3 Bridge survival rates enable a general dentist to perform conservative implant surgery and pros- begin to decline sharply after 10 years.4,5 The consequences of thetics in a quality and cost-effective manner. these failures, though serious and often overlooked, range fromI t is important for general den- The vast majority of dentists are caries and pulp disease, to peri- tists to become efficient at a recommending implants for partial odontal breakdown and abutment treatment that is now the stan- edentulism and denture stabiliza- tooth loss. An implant’s high sur-dard of care in single tooth replace- tion. However, very few of these vival rate, combined with a lowment. Many general practitioners dentists surgically place implants.2 occurrence of prosthetic and adja-perform surgery in some form, Thus, unlike all other areas of den- cent tooth complications, indicatessuch as surgical extractions, peri- tistry, implantology remains large- a tooth preserving effect and cost-odontal and endodontic surgery. ly a multi-discipline treatment. benefit over the long term.6 BoneGiven adequate training, general General dentists in Europe and preservation is also a benefit thatpractitioners can perform all as- Asia have been successfully per- no other treatment can match.pects of implantology with un- forming all aspects of implant den-compromised success rates.1 Ad- tistry for quite some time now. In While we explain to our patientsvances in surgical techniques and North America the coordinated that implants are the best treat-prosthetic components are making approach to surgery and prosthet- ment, to them it still means higherimplants more cost-effective to ics makes implant treatment fees, more appointments, less insur-both the patient and dentist. expensive and time consuming. ance benefits, and seeing a special- August 2005 oralhealth 59
  • 2. C A S E P R E S E N T A T I O NFIGURE 1—Tissue thickness. FIGURE 2—P.A. overlay. FIGURE 3—Model.FIGURE 4—Model of bone and soft tissue. FIGURE 5—Pilot channel. FIGURE 6—Buccal-lingual view.FIGURE 7—Mesial-distal angle. FIGURE 8—Triad addition. FIGURE 9—Stent and pilot drill.ist who may advise bone grafting. patient to bone augmentation, bone soundings of the surgicalThe reality is that for many den- especially when aesthetic dem- site. These measurements of softtists, a fixed bridge is more prof- ands are minimal. A streamlined, tissue thickness are acquired byitable than an implant in compara- common sense approach to im- using an anaesthetic syringe andble situations. Here lies the injus- plantology will make it advanta- endo file stopper, acting as a depthtice, that is, higher compensation geous for the patient and doctor to gauge. Soundings are made at thefor an inferior treatment. choose the healthiest treatment. ridge crest and 2-3 locations on each buccal and lingual aspect, 90 In general practice, the majority SURGICAL TECHNIQUE degrees to the surface, depositingof implant cases we see are non- Case selection is paramount to anaesthetic ahead of the needlecomplicated. Today’s root-form successful treatment. This is ac- tip and stopping at bone. Soft tis-implant fixtures are extremely complished by recognizing cases sue thickness is measured andversatile and require less than with favourable bone. Diagnostic recorded on the form (Fig. 1).ideal bony architecture. We can information required for this sur- These records are sent to a certi-improve the bone health of even gical protocol include the follow- fied lab for construction of amoderately resorbed edentulous ing: study models, radiographs “Model Tomographic” p.p., t.m. byareas without subjecting the (p.a., and panoramic), and 5-7 B.A.S.I.C. Dental Implants. The60 oralhealth August 2005
  • 3. C A S E P R E S E N T A T I O NFIGURE 10—Guide sleeve. FIGURE 11—Pre-op. FIGURE 12—Pilot hole verification.FIGURE 13—Soft tissue trephine. FIGURE 14—Trephine cutting. FIGURE 15—Soft tissue incision.doctor will also utilize a “ periapi- encompass the middle of the bone an index pin, which occupies thecal x-ray overlay”, (or template) (Fig. 5). A Periapical Implant pilot channel that has been creat-for implant size selection. This is Overlay is held up to the model ed to reflect the ideal mesial-distalan actual size silhouette of the dif- (Fig. 6). A buccal-lingual view of and buccal-lingual direction. Triadferent implants available (Fig. 2). the implant in bone is very helpful acrylic is formed around the guideIt acts as a convenient diagnostic in avoiding difficult cases. When sleeve (Fig. 8). The height of theaid for initial case planning to the doctor receives the model sleeve is adjusted to control theassess available bone mesial-dis- tomographic from the lab, accept- pre-determined cutting depth astally, and vertically with respect to able bone is easily determined by calculated from the pilot drillmandibular canal or maxillary viewing the implant position in all length, implant length and posi-sinus. While at the lab, the techni- three dimensions (Figs. 2 & 6). tion with respect to the soft tissuecian makes a cross-sectional cut crest. The pilot drill has a collaron the model, slightly distal to the The Model Tomographic deter- stop which allows the stent to pre-surgical site and parallel to the mines the best position and direc- cisely control cutting depth accord-mesial-distal root angulation of tion of the implant body for heal- ing to the height of the guidethe neighbouring teeth (Fig. 3). ing, bone support and crown posi- sleeve (Fig. 9). Actually, the guideModel tomographic measure- tion. However, equally important sleeve is a double cylinder featur-ments are transferred onto the is that it is also the basis for con- ing a narrow inner sleeve for themodel to map out the bone and struction of the “3-D Pilot/Osteot- pilot drill that is removed to createsoft tissue (Fig. 4). A pilot channel omy Drill Guide Stent “pp. t.m. by a wider diameter outer sleeve foris then made at the best buccal- B.A.S.I.C. Dental Implants. Figure the larger osteotomy burrs (Fig.lingual direction that would 7 shows a guide sleeve placed on 10). Through the use of the Model August 2005 oralhealth 63
  • 4. C A S E P R E S E N T A T I O NFIGURE 16—Soft tissue prep. FIGURE 17—Osteotomy drill. FIGURE 18—Implant driven in.FIGURE 19—Implant at proper depth. FIGURE 20—Healing cap and tissue former. FIGURE 21—Pre-cement try-in.FIGURE 22—Final crown two months after FIGURE 23—Fifteen months after surgery. FIGURE 24—Fifteen months final.cementation.Tomographic and 3-D Pilot/Oste- and predictably. another x-ray. Figures 13 to 16otomy Drill Guide Stent, implants depict the circular incision madeare placed accurately and three- Figure 11 shows the pre-op site with a trephine-like soft tissue-dimensionally by addressing three for a missing upper left central cutting tool. The fact that we haveplanes simultaneously, that is buc- incisor. A 1.8mm diameter stent- established the presence of fav-cal-lingual, mesial-distal and ver- assisted pilot hole is made at 2⁄3 – 3⁄4 ourable bone and that it can betical. The diagnostic procedures of the pre-determined depth. Pilot precisely accessed, makes flappingperformed thus far demand a min- hole position is then verified by unnecessary. This means we canimum of time, effort and expense placing a guide pin into the prep expect a quick, minimally invasivebut yield valuable information and and x-raying it (Fig. 12) The pilot procedure with much less bleed-a precision drill guide. Implant hole can then be safely taken to ing, trauma and post-op pain,surgery may now proceed safely ideal depth and verified with while enabling rapid healing and64 oralhealth August 2005
  • 5. C A S E P R E S E N T A T I O Nmore predictable soft tissue posi- tremely reliable for post and crown selection this is certainly withintion as vascularity is preserved. cementation with this system. the realm of capabilities of a gener- Figure 22 shows the restoration al practitioner, providing they have The bone is then enlarged with two months after final cementa- proper training and technique.a series of side cutting osteotomy tion. Figures 23 & 24 are a radio- Advances in bone regenerationdrills (Fig. 17). Bone preparation graph and photo at fifteen months technology, combined with ancan all be done through the guide after surgery. increased awareness and enthusi-stent, which adapts for the larger asm of front-line general dentists,diameter cutting tools. All rotary In cases where bone volume is should provide oral surgeons andtools are used with a slow speed questionable, it may be necessary periodontists more opportunities incontra-angle with reduction to flap the tissue or augment the implantology. Our profession issheath or rotary endo handpiece. bone. Oral surgeons, and peri- obligated to promote a more effi-A 4.5 mm wide x 15mm length odontists should be considered in cient means of delivery, allowing aOmni-Tight fixture by B.A.S.I.C. these situations. However, the greater number of patients accessDental Implants is placed 1-2mm majority of cases encountered in to this benefit. OHbelow the labial soft tissue crest, general practice should qualify(Figs. 18 & 19) much like deter- for non-flapped, non-submergedmining the position of a labial surgery. In summary, this single Dr. Bohunicky was born and raisedmargin for crown & bridge. Since tooth implant treatment was com- in Winnipeg, graduating from thethe implant is solidly fixed in the pleted in essentially two working University of Manitoba Faculty ofbone and the surgical field is appointments with a post-op in Dentistry in 1984. While presentlyclean and dry, a final involved with full time generalimpression can be taken practice, he has been placingimmediately after place- Our profession is and restoring implantsment. A transfer device is through the use of a minimallyeasily pushed all the way obligated to promote a more invasive non-flap, non-sub-into the implant and ispicked up with an ordinary efficient means of delivery, merged technique since 1996. He is one of the pioneer users ofpolyvinyl-siloxane impres- allowing a greater number of the B.A.S.I.C. Dental Implantsion. A low profile healing System, and is activelycap is coupled with a white patients access to this benefit. involved in teaching this tech-delrin tissue former, used nology to other dentists.for widening the soft tissueemergence profile (Fig. 20). This between. The cost of the implant, Oral Health welcomes this originalcan be trimmed even lower to fit together with all components and article.under a removable interim den- lab expense was slightly higherture. than a 3-unit bridge lab bill. REFERENCES 1. Henry, Rosenberg, Bills, Chan, Cohen, Halliday, However, the chair-time is consid- Kozeniauskas. Osseointegrated implants for single Research-based evidence in a erably less for this treatment tooth replacement in general practice: A 1 year report form a multicentre prospective study. Australian Dentalone-stage, non-submerged implant than for similar bridge cases. Journal 1995; 40(3): 173.placement is resoundingly clear. 2. Gail Weisman. Implants Take Hold Dental Products Report. Feb 2000. Pages 17-22.There is no difference in osseointe- CONCLUSION 3. Lindh T, Gunne J, Tillberg A, Molin M. A meta-analysisgration, soft tissue health, or sur- One of our main responsibilities to of implants in partial edentulism. Clinical Oral Implantsvival rates when compared to a patients is the preservation of 4. Research 1998: 9;rates of restorations for single tooth Priest G.F. Failure 80-90.traditional two-stage, submerged teeth and associated oral struc- replacement. Int.J. Prosthodont 1996;9;38-45.technique.7-9 The patient returns tures. Using natural teeth as abut- 5. Mazurat R.D. Longevity of partial, complete and fixed prostheses. A literature review. J CAN. Dent. Assoc.for a brief appointment in two ments by amputating enamel and 1992;58: 500-503.months to check for progressive increasing occlusal forces, un- 6. Priest G. Single Tooth Implants and Their role in Preserving Remaining Teeth: A 10-year Survivalosseointegration, after which pros- doubtedly shortens the lifespan of Study. Journal of Oral and Maxillofacial Implantsthetic fabrication begins. Post and these teeth while allowing contin- 1999; 14:181-188.crown cementation is done very ued loss of alveolar bone. General 7. of Branemark Fixtures using a single step operating Bernard, Belser, Martinet, Borgis. Osseointegrationsimply, usually without anaesthet- dentists whose involvement with technique. Clinical Oral Implants Research 1995:ic, as if restoring an endodontically implants is limited to prosthetic 8. 6,122-129. Henry, Rosenberg. Single-stage Surgery for Rehabili-treated root with a cast post/core restoration would receive tremen- tation of the Edentulous Mandible. Practical Perion- dontics and Aesthetic Dentistry 1994; 6: 15-22.and crown. Prior to cementation, a dous satisfaction and considerably 9. Buser D. Mericske-Stren R, Dula K, Lang NP. Clinicalperiapical radiograph is taken to higher profits by implementing a Experience with one-stage, non-submerged dentalcheck the marginal fit (Fig. 21). conservative, one- stage, non-flap implants. Advances in Dental Research 1999: 13:153-161.Resin cements have proven ex- implant surgery. With careful case @ARTICLECATEGORY:590;66 oralhealth August 2005