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Contents... 1 Implant research update.................................................................. 4
Implant research update....................................................................... 4
References............................................................................................... 7
Recommended Further Reading.......................................................... 7
2 Taking a simpler implant option - Zaki Kanaan................... 8
History and Presenting Complaint......................................................... 8
Treatment plan by another dental centre........................................... 10
My proposed treatment plan................................................................ 10
Surgical phase......................................................................................... 10
Restorative phase.................................................................................... 12
Acknowledgement................................................................................. 14 Disclosure.................................................................................................. 14
3 Digital technology and implant dentistry................................ 16
Stent fabrication for CBCT scanning..................................................... 16
Interpretation of the Scan...................................................................... 18
Utilisation of the radiopaque guide at surgical placement............... 18
Digital impressions.................................................................................... 19
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Chapter 1
Cleaning instruments
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With so much interest in dental implants around the world there is an enormous amount of research being reported into a wide range of topics. Here, Stephen Hancocks describes some of the most recent studies scanned from the literature and looks particularly at current thinking on bisphosphonates and implants. There has been considerable debate about the use of the class of drugs called bisphosphonates (BP) for some years now especially in relation to their propensity to mediate BP-related osteonecrosis of the jaws (BRONJ). The drugs are prescribed to help treat conditions in which there are disturbances of bone growth such as osteoporosis, osteitis deformans (Paget’s disease), bone metastasis from cancers and other conditions involving fragile, breakable bone. They work by inhibiting the digestion of bone by causing osteoclasts to undergo cell death, thereby slowing bone loss and undermining the usual homeostatic body balance of osteoblast and osteoclast activity which keeps bone in constant turnover. This has an obvious relevance to implant treatment which relies on continuing healthy bone metabolism and growth for implants to undergo successful osseointegration. Risk factors for developing osteonecrosis of the jaw that should be considered are: potency of bisphosphonate (this is highest for the drug zoledronate), route of administration – oral or intravenous, cumulative dose, duration and type of malignant disease, concomitant treatment, smoking and history of dental disease. NICE recommends that all patients should have a dental check-up (and any necessary remedial work should be performed) before bisphosphonate treatment, or as soon as possible after starting treatment. Patients should also maintain good oral hygiene, receive routine dental check-ups, and report any oral symptoms such as dental mobility, pain, or swelling, non-healing sores or discharge during treatment. Because of this, there has been disagreement as to whether it is safe to place implants in patients under BP therapy owing to the risk of developing BRONJ. For example The American Association of Oral and Maxillofacial Surgeons recommends that dental implants should be avoided in oncologic patients treated with intravenous BPs. Conversely, for patients receiving oral BPs, dental implant placement is not explicitly contraindicated even if a cautious approach is suggested.
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One recent study1 aimed to assess the risk level as related to adverse events such as implant failure and BRONJ in a large cohort of osteoporotic patients who had implant placement and concomitant application of plasma rich growth factor (PGRF)-Endoret. The clinical charts of 235 middle-aged women under oral BP therapy for osteoporosis, who underwent placement of 1,267 dental implants, were reviewed. In order to attempt to improve osseointegration the implants were always placed in association with the growth factor. Over the 10 year follow-up period 16 implants were lost in 16 patients giving a survival rate of 98.7% and 93.2% on an implant basis and patient basis, respectively. No cases of BRONJ were reported and the authors concluded that their results supported the current literature that the risk for developing BRONJ associated to dental implant surgery remains low for patients receiving oral BPs. Meanwhile in another comparative, prospective study2, 24 female patients, aged >54 years, were chosen, all with partially edentulous mandibles. Group A consisted of 12 patients with osteoporosis taking the BP zoledronic acid receiving a onceyearly intravenous infusion (5 mg). Control group B consisted of 12 similar patients without osteoporosis but not taking drugs. In both groups, the remaining teeth were extracted before 120 implants, 3.7-mm wide and 16-mm long, were immediately placed in the interforaminal region of the mandibles. The 1-year implant survival rate was 100%. No apparent necrotic bone was observed among the patients receiving BP after implant surgery. Once again this encouraged the authors to conclude that immediate implant osseointegration can be successful in patients with osteoporosis using bisphosphonates, suggesting the safety of implantology as a treatment modality. One of the often quoted facts about modern medicine and dentistry is that the ageing population experiences complex medical histories and is often subject to poly-pharmacy. So, given the potential risk of BRONJ, how much of a benefit are dental implants to those patients taking BP? Research in the USA3 compared the quality of life (QoL) in partially edentulous osteoporotic women who had missing teeth restored with dental implant retained restorations with those who did not and also reported the rate of osteonecrosis in the sample. The 237 participants completed a 23-question document enquiring across psychosocial domains of well-being including occupational, health, emotional, and sexual domains which together contributed to an overall score. The subset of participants having dental implant supported prosthesis (64) was compared to the subset having nonimplant supported fixed restorations (47), the subset having non-implant supported removable restorations (60), and the subset having no restoration of missing teeth (66). Results showed a significant difference in all QoL domains between the four
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subsets. While 134 participants reported oral bisphosphonate and 51 reported intravenous bisphosphonate use, no signs of BRONJ were identified. The findings show implant retained oral rehabilitation has a statistically significant positive impact over nonimplant and traditional fixed restorations, removable restorations, and no restoration of missing teeth for these participants. Overall, while continuing and further research is needed, the message seems to be that with awareness of all parties concerned and with due care and consultation the placement of dental implants in patients undergoing BP therapy, especially oral therapy is safe and of benefit. References 1.
Mozzati M et al. Failure risk estimates after dental implants placement
associated with plasma rich in growth factor-Endoret in osteoporotic women
under bisphosphonate therapy. J Craniofacial Surg 2015; 26: 749-755.
2.
Siebert T et al. Immediate implant placement in a patient with osteoporosis
undergoing bisphosphonate therapy: 1-year preliminary prospective study. J
Oral Implantol 2015; 41 Spec No: 360-365.
3.
DeBaz C et al. Dental implant supported restorations improve quality of life in
osteoporotic women. Int J Dentistry 2015; 45: 1923.
Recommended further reading Guidance for dentists in primary care is included in Oral Health Management of Patients Prescribed Bisphosphonates: Dental Clinical Guidance, Scottish Dental Clinical Effectiveness Programme, April 2011 (available at www.sdcep.org.uk)
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Chapter 2
Taking a simpler implant option - Zaki Kanaan
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When planning for implants it is wise to opt for the simpler option. The following case highlights the point that proceeding with a more complex option may have lead to a poor final result, as well as an unpredictable long term prognosis and outcome for a young patient. History and presenting complaint This young gentleman presented with his mother for a second opinion as she was concerned about a treatment plan recommended elsewhere. A student on his gap year, he had lost his upper right lateral incisor 10 months earlier through a skiing accident. A provisional acrylic crown was bonded to adjacent teeth as an emergency measure and the central incisors were splinted at this visit (Figure 1). The upper centrals were also traumatised during the accident, with periapical radiographs exhibiting signs of horizontal fracture lines at various levels (Figure 2). The upper right lateral and central had been root treated shortly after the accident and all teeth had been symptomless since.
Figure 1 The upper right lateral incisor at initial presentation
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Figure 2 Periapical radiographs exhibiting signs of horizontal fracture lines
Treatment plan by another dental centre The initial suggested treatment plan included the extraction of the upper right lateral and central incisors and the upper left central incisor, with the provision of an immediate partial acrylic denture. This would have been followed by the placement of an implant-supported bridge with implants in the upper right lateral incisor and upper left central incisor positions. Although this was a viable option, it would have lead to the extraction of three important teeth in the smile zone. My proposed treatment plan In view of the fact that the traumatised centrals had been asymptomatic, with no apical changes since the accident, I suggested leaving them alone with no treatment initially. I recommended the extraction of the upper right lateral incisor, with the immediate placement of an implant. A provisional tooth would have also been provided. A final abutment and porcelain crown would then be fitted after the healing phase. It was important to inform the patient that further treatment may well be required on the central incisors. This treatment plan was accepted. Surgical phase A 30 second chlorhexidine pre-surgical rinse was carried out prior to administration of local infiltration anaesthesia. A flapless surgical technique was utilised by using a size 15c micro-blade into the dento-gingival sulcus around the upper right lateral
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incisor root. The root was then gently and atraumatically elevated using periotomes, taking care not to stress or damage the fragile buccal plate. The resulting socket was inspected, especially for the integrity of the buccal plate. A good instrument to do this with is the AstraTech™ measurement gauge. It has a blunt, hemispherical end, which gives good tactile feedback and can also be used to measure the length of the socket as well as to give visual feedback on the direction of the imminent osteotomy site preparation. Socket curettage was carried out to ensure it was free from any granulation tissue. The buccal plate, although thin proved to be intact and ended approximately 3mm below the labial gingival level. The initial pilot drill used was positioned with a slight palatal inclination and position to the previous root apex, to avoid perforating labially. The site was prepared using a standard sequence and saline, with special attention to avoid the thin buccal plate of bone during preparation. A 3.5 x 16mm NobelReplace Tapered Groovy implant was torqued into position with an initial stability of 20Ncm and ensuring that a tri-channel internal lobe was positioned mid-buccally. The initial stability of 20Ncm is not enough to immediately restore an implant. If immediate loading had been planned there would have needed to be a contingency plan if good primary stability of the implant had not been achieved. The implant head was placed 3mm apical from the anticipated final labial gingival margin (adjacent dentogingival levels can also be used as a guide if needed). There was a 2.5mm space between the buccal plate and the implant. A narrow healing abutment was placed and the void was filled with a mixture of BioOss™ (Geistlich) and autogenous bone harvested with an Astra™ Bone Trap. It is my usual protocol to fill voids that are approximately 1.5mm or more. No sutures were needed. A Maryland acrylic provisional bridge was bonded in place with a wing on the adjacent canine. The pontic was adjusted and polished to fit around the healing abutment. Note the good marginal adaptation and minimal bleeding (Figure 3).
Figure 3 The implant placed with a Maryland acrylic provisional bridge
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Restorative phase Twelve weeks later, open tray impressions were taken and custom shade matching was carried out. It is important to take a photo of the contralateral tooth for comparison (Figure 4) and a discussion with the patient about whether to copy this tooth needs to be communicated with the lab, especially if there are any unusual characteristics. In this case the upper left lateral had a mesio-buccal rotation and the patient wanted a slight element of rotation with his new tooth. Due to the depth of the implant head it was decided best to use a goldadapt abutment. This was covered with a layer of opaque porcelain to help mask any possible metal shine through. This was torqued down to 25Ncm and the access filled with GP and Systemp provisional composite. It was also decided to make a Lava crown with an opaque core (3M, Espe). The Lava crown was tried in and approved by the patient for shade and form before being cemented with temporary cement.
Figure 4 Photograph of contralateral tooth for comparison in constructing crown
It is always advisable in aesthetic situations such as this to condition the tissues by providing a prototype restoration. In situations where tissue conditioning has not been carried out the final crown will most likely have a different emergence profile to the healing abutment. In these cases the final crown needs to be tried in and seated with constant force to overcome the pressure from the circumferential tissues. A three month review and one year follow up were carried out (Figures 5 and 6). The centrals were still symptom free with no radiographic changes at both appointments. Bone levels were also as they were at baseline.
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Figure 5 The completed case at one year review close-up
Figure 6 The completed case at one year review full mouth view
Conclusion Implant treatment involves many variables and as clinicians we must consider all these parameters to provide the best outcomes for our patients. If we aim to keep treatment as simple as possible, then the success of the final case will be greatly increased. Careful consideration needs to be given to the proximity of the implant surface to the labial bone, as well as the position of the implant head to adjacent teeth, as there is a horizontal, as well as vertical component to the biologic width (sometimes now termed the biologic doughnut).
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No matter how talented your ceramist, if the final restoration is not framed by the surrounding tissues in the correct way, the outcome may be compromised. A key aesthetic concern in implants is to maintain the gingival architecture and harmony, especially the interdental papillae. With our current level of knowledge and understanding of implants as well as having the services of the most talented master ceramists, we have no excuse not to deliver the very best for our patients. Acknowledgement I would like to thank Atsu Kakinuma at Dental Excellence, for his invaluable contribution for the technical aspects and ceramic work in this case. Disclosure The author has no financial or personal relationships, directly or indirectly, with any companies or products mentioned in this article, that could have influenced this work inappropriately.
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Chapter 3 Digital technology & implant dentistry- Aws Alani
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Digital technology has modified and improved the delivery of clinical dentistry particularly in the past decade or so. From digital photography to the utilisation of cone beam computed tomography (CBCT) - also referred to as C-arm CT, cone beam volume CT, or flat panel CT - to guide implant placement, these developments have improved patients understanding of the planning and experience during the procedures. Improvements in visualisation of the prospective surgical site have been one of the main areas of treatment enhancement. The ability to see vital structures and adjacent teeth when planning implant placement decreases complications and increases the scope of achieving an acceptable prosthetic result. Stent fabrication for CBCT scanning Accurate records are a prerequisite for provision of a radiographic stent for implant placement. Depending on the number and position of the edentate spaces requiring replacement facebow records and mounted study casts maybe required. Where edentate spaces are associated with anterior guidance or there is a planned increase in occlusal vertical dimension then there is a definitive need for full records. In contrast in a patient who has a solitary edentate space with a stable occlusal relationship then stent fabrication can be provided without further records. Where stents need to be fabricated for implants in the aesthetic zone a wax-up and intraoral mock up prior to stent construction would be wise. Once records are taken, the construction of a stent requires close liaison with the laboratory technician as to what is required. If the prosthetic replacement required seems straightforward the technician can wax up the crown into the site, duplicate the model and then provide a vacuum formed splint which needs to be filled with a radiopaque material. The material of choice is barium sulphate which can be incorporated into acrylic and then placed into the edentate area. To provide the practitioner with appreciation of the bone volume within the site and the proposed prosthetic unit the technician or the dentist can drill a hole through the occlusal portion of the guide, the void from which can be seen on the subsequent scan. This can provide an idea for the clinician on the scope for a screw retained restoration. Once fabricated the dentist may consider the need for a try-in appointment to ensure seating of the guide and stability intra-orally for the duration of the imaging. 16
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Interpretation of the Scan Once the scan is completed analysis can be achieved through the use of bespoke implant planning software or generic CBCT imaging programs. The CBCT scan can be visualised through a number of different planes. Axial, vertical, horizontal and transverse views provide information on the bone envelope that would not be available with traditional 2-dimensional imaging. From both axial and transverse views the assessment of the long axis of the implant and the available bone for implantation can be achieved. Indeed, where the bone envelope available is adequate but at an angle remote from the long axis of the prosthetic tooth an abutment retained restoration would have to be considered. Where there is a minor lack of bone, more likely on the buccal aspect, the need for bone grafting with particulate matter can be planned for. In cases where a severe lack of bone is present in the horizontal direction then block grafting would need to be considered.
Once the bone envelope is assessed planning for the size and shape of the implant can begin. Choice considerations need to include accommodation of at least 1.5mm space between the implant and the adjacent tooth root whilst also providing adequate depth of the implant fixture head. If the implant is placed at too shallow a depth, a consideration where too long an implant is placed, then an abrupt emergence can result in suboptimal aesthetics. Utilisation of the radiopaque guide at surgical placement At the time of surgery the scan needs to be accessible and be able to be referred to during surgery. Placement of the stent can now provide a surgical guide triangulating information between the patient, the scan and the associated laboratory work.
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Digital impressions The emerging field in digital dentistry is impression taking without the need for a ‘wet’ impression. Other positive aspects include the ability to retake impressions almost instantly, the ability to record soft tissue as well as hard tissues, the recording of the shade, the recording of the occlusal relationship and the ability to digitally design every aspect of the restoration. Aesthetic characterisation of the restoration may seem to be the most pertinent aspect of this process. The detail of the functional aspect of the restoration can also be designed. Contact areas, cuspal inclines and the emergence of the implant restoration can be planned. Once the impression is taken it can be saved and utilised again in the future if required for record or for refurbishment of the restoration without the need to physically store models or casts. Due to the relatively new nature of these new technologies problems are only likely to become apparent with time but it seems as though the current generation of scanning workflows have ironed out previous problems. Overall, the emergence of new technologies and the refinements and developments of existing systems is helping to improve efficiency of implant procedures as well as patient experience and of course ultimately patient care and satisfaction.
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