My First Implant: My First ‘Emergency’ Implant

with Stuart E. Coe, DDS

chairside@glidewelldental.com

Dr. Stuart Coe began offering implant surgery at his Roswell, Georgia, practice to make treatment available to more of his patients. In this interview, he describes how the unique features of the Hahn™ Tapered Implant System helped him confidently perform his first “emergency” implant case — immediate implant placement and provisionalization at the time of extraction.

CHAIRSIDE® MAGAZINE: Can you begin by telling us about yourself and how you got started in dentistry?

DR. STUART COE: I’ve been practicing dentistry for 35 years. My interest in dentistry began way back in seventh grade when I wrote a paper about wanting to be a dentist when I grew up. I knew back then the direction I wanted to go, and I have never looked back. I am very blessed to wake up every morning and feel enthusiastic about going to work and treating my patients.

CM: How much exposure to implantology did you receive in dental school?

SC: Implants were not being taught in dental school when I was a student. Implants had not gone mainstream yet. We were aware of the concept of implants, but no practical instruction was offered. Very early in my practice I did get involved with restoring implants, but I have only been placing implants for about four years now. I wish the simple implant systems of today, such as the Hahn™ Tapered Implant System (Glidewell Direct; Irvine, Calif.), were available 20 years ago, as it would have been nice to get started earlier in my career.

Dr. Stuart Coe serves many longtime patients who trust him to deliver a broad range of treatment options. Offering implant placement has made treatment possible for more patients in his practice.

CM: What got you started placing implants?

SC: I have been very comfortable performing my own surgeries for a long time: extractions, socket augmentation and flap surgery. So the learning curve for implants really just involved how to place them. Many of my patients have been coming to me for a very long time, so they automatically had a great amount of trust in me. Implants were a treatment option they were asking for, and I wanted to provide it so they could receive care from someone they knew and trusted. My patients also love the fact that they can get the implant and the restoration completed at one office.

CM: What kind of education did you invest in, and what courses did you take?

SC: I took a relatively simple but effective hands-on course from the American Academy of Facial Esthetics. The course actually featured quite a few of Dr. Timothy Kosinski’s videos. I know he teaches for Glidewell Clinical Education and has done numerous informative articles on implantology for Chairside magazine, so it was great to learn from him. The Hahn implant system was used throughout the course, too.

CM: Is that how you got started with Hahn implants?

SC: Yes, and I’ve been familiar with the Hahn implant ever since the Misch International Implant Institute made it their official implant system. After taking the course and seeing the system in action, I started doing my own research on the implants and comparing them to the other products on the market. But knowing that the Misch Institute uses Hahn really made the choice a slam dunk for me.

The Hahn™ Tapered Implant System’s user-friendly surgical protocol has helped Dr. Coe expand the implant services offered by his practice to include a wider range of indications, including extraction with immediate implant placement.

CM: We understand that you recently performed your first emergency implant case. Can you share your experience with us?

SC: She’d been my patient for 20 years, so we knew each other really well. She presented with a fractured cuspid. The existing crown had broken off at the gumline. We discussed doing crown lengthening, post and core, and a crown. But from my experience, the long-term survival of a post and core and a crown on a cuspid tooth is limited. After explaining the pros and cons of both options, she opted to do an extraction with immediate implant placement and loading, which was my first time doing that. Because this was in the anterior region, my concern was to make sure the interdental papillae were preserved for esthetic purposes.

CM: And how did the case go?

SC: The extraction went perfectly. We were able to preserve the buccal bone really well, so I felt comfortable going with immediate placement. Using digital radiographs, I determined that I needed to use a 3.5 mm x 13 mm Hahn implant. After placement of the implant, we got excellent initial stability, which is a testament to the aggressive thread design of the Hahn implant. It really just grabs onto the bone, and I was able to torque it down to 50 Ncm. I did place some cortical/ cancellous allograft to fill in any voids around the implant.

Figure 1: The patient presented with a fractured existing crown on #11.

Figure 2: After taking digital radiographs, it was determined that extraction followed by immediate placement of a Hahn Tapered Implant would be the best treatment.

CM: Why did you choose to immediately load the implant with a provisional crown?

SC: The Hahn implant established high primary stability, so I felt comfortable immediately loading it. I could have used a healing abutment, but because this was in the anterior region of the mouth I thought we should just go with a nice temporary that would mimic the final restoration and preserve the papillae. Plus, as a general practitioner, I am well trained in fabricating high-quality, esthetic provisionals because we do it all the time. This meant that I could provide her with a beautiful temporary restoration.

Figure 3a

Figure 3b

Figures 3a–3c: The tooth was extracted, the site was prepared following a simplified drilling sequence, and the implant was placed, establishing the high primary stability needed for immediate loading.

CM: How did you provisionalize the patient?

SC: I fabricated a vacuum-formed stent over the original model, and then screwed a Hahn Temporary Abutment into the implant. I cut the abutment down to the correct size in the lab and replaced it on the fixture. I cut a hole in the stent so the abutment screw pin would extend beyond the stent. I then filled Integrity® Temporary Crown and Bridge Material (Dentsply Sirona Inc.; York, Pa.) in the incisal ¾ of the cuspid tooth in the stent, adding enough material to engage the abutment.

Once the material set, I unscrewed the abutment and pulled it out of the stent.

I then used Flow-It™ ALC™ Flowable Dental Composite (Pentron Clinical Technologies LLC; Wallingford, Conn.) to fill in the rest of the voids. Then I incrementally added more composite to create the gingival marginal area and the appropriate emergence profile. The final result was a nicely contoured provisional that did indeed look very much like the final restoration. I also adjusted the occlusion so that the patient’s bite was not colliding in the case of any excursive movements.

Figure 4a

Figures 4a, 4b: The goal of provisionalization was to preserve the interdent papillae. A vacuum-formed stent was fabricated chairside, and a screw-retained temporary restoration was crafted using composite material.

CM: How was the healing process?

SC: Well, first of all, after the patient left she had very little postoperative pain. She took one prescription pain pill the first evening, and then just ibuprofen after that. We left the beautiful provisional in for about four months while everything healed and integrated. When the patient returned for the final impression, the implant had indeed established excellent integration. I was extremely pleased with the results, and it was solid as a rock. There was no doubt about that. But what I really loved was the appearance of the tissue. The papillae were well developed and ideal in form. All of this made for a perfect final impression to send to Glidewell.

CM: How did the patient like the final result?

SC: She was ecstatic about it. Everything looked perfect. Glidewell made a beautiful screw-retained restoration that was seated with very few adjustments.

Figure 5a

Figures 5a, 5b: The patient’s healing progression was predictable. Figure 5a is day of surgery and Figure 5b is at four months.

Figure 6a

Figures 6a, 6b: The gingival architecture was well preserved, and the patient was very pleased with the final screw-retained crown fabricated by Glidewell.

CM: How has your experience been using the Hahn Surgical Kit?

SC: It is very orderly and simple. The way they color-code the drills is brilliant. For doctors who are just starting out with implants, you don’t want to be thinking too much about what drill comes next and what sequence to follow. The surgical kit makes it all very straightforward. You really can’t make too many mistakes with the Hahn system. Its simplicity is definitely one of the many strengths of the system.

CM: For general dentists interested in placing implants, how would you recommend getting started?

SC: If the dentist is not presently doing any oral surgery in his or her practice, my first suggestion is to begin doing some surgeries such as simple extractions, laying gingival flaps, and bone augmentation procedures to re-familiarize oneself with basic surgery techniques, just as I did. It is quite a jump to go from doing no oral surgery at all to placing implants. Taking an implant course is essential too, of course. There are a lot of great courses out there, from the Misch Institute to the programs offered through Glidewell Clinical Education, so I recommend that all dentists consider taking that first step. That in turn can lead you down a path that makes a huge difference in the lives of your patients.