Show your work: Same-Day Service by Ara Nazarian, DDS, DICOI

A note from the editor
Last October we introduced a new department called "Show Your Work" that gives Townies another opportunity to do just that. Here, you'll find straightforward case studies that your fellow dentists take pride in.

Maybe they feel like they've finally mastered a new technique they've been working on. Perhaps they rose to the challenge of a particularly tough patient case. Or it could be that they just want bragging rights for something that, in their eyes, approaches perfection.

If you've got a case you think might be a great fit, shoot me an email: sam@farranmedia.com. Be sure to include a sentence that sums up why this case is so special to you, to help us review and select the best contenders for publication.

One last clarification: This opportunity is available to registered Townies only! So be sure to update your member information at Dentaltown.com before giving us a shout.

Thank you!

Sam Mittelsteadt

Introduction
Today we see more patients presenting with teeth that have failed because of fracture, recurrent caries, endodontic treatment or periodontal problems. In the past, the common treatment would be extraction, followed by the preparation of the adjacent teeth for a three-unit bridge or a recommended partial. However, with implant therapy gaining popularity among patients and providers, the requests for implant treatment have increased. In my opinion, tooth replacement with dental implants should be the standard of care, and every dental provider needs to know how to replace missing teeth at some level. Here, we'll demonstrate placing dental implants in the lower posterior regions within one appointment, using a simple yet effective implant system created for general dental practices.

Case report
A 64-year-old patient presented for replacement of missing #20, 21, 28 and 29 (Fig. 1). The patient's medical history was noncontributory; the teeth had been extracted more than 15 years earlier because of decay and fracture.

A clinical examination identified the remaining ridge, the amount of keratinized tissue in the area and the clearance with the opposing dentition. Using the necessary radiographs along with the clinical examination, it was determined that the edentulous areas of those teeth still had sufficient bone for dental implant placement. Different options to replace the missing teeth, as well as the risks and benefits, were discussed with the patient, who ultimately decided to have implants inserted to replace the missing teeth in the posterior mandibular areas.

Because the patient had driven more than an hour to come in for the consultation, we mentioned that we had an opening later in the day to place the implants, so he wouldn't have to return again the following week for implant placement. Delighted, he decided to have all four dental implants placed and opted to use a third-party payment option through Lending Club.

The work begins
The work areas were anesthetized using 1.8 milliliters of 4% Septocaine (Septodent) with 1:100,000 epinephrine. The sites for the implants were then begun with a #169L surgical bur (Axis) in a high-speed handpiece through the soft tissue, extending approximately 1 millimeter into bone. The locations were centered facial/lingually as well as mesial/distally. Because the teeth being replaced were premolars and there was sufficient bone width and height, 4mm-by-12mm TSI threaded implants from OCO Biomedical were selected for the #21 and #28 areas; 4mm-by-10mm TSIs were selected for #20 and #29.

A 1.8mm pilot drill initiated the osteotomies in all four areas using the AEU7000 (Aseptico) surgical motor and corresponding surgical handpiece. Paralleling pins were placed in the sites of the osteotomies and an X-ray was taken to check the angulations of the pins. Using a rotary tissue punch provided in the surgical kit, a 4mm outline was created over the initial osteotomies, and the tissue plugs were removed with a curette.

The final drill in the OCO Biomedical surgical drill is side cutting only and used to form the final osteotomy, because the depth was set by the pilot drill. (Intermediate drills are not required in this system, which makes the drilling sequence easy to implement.)

Once the osteotomies were completed, the threaded implants were placed into the sites using an implant finger driver until increased torque was necessary. The ratchet wrench was connected to the adapter (Fig. 2), and the implants torqued to final depth reaching a torque level of 65 newton centimeters (Ncm). Healing caps, included with the implants, were hand-tightened (Fig. 3). A postoperative radiograph was made of the implants and healing caps to ensure complete seating. The implants were evaluated clinically after one week; the patient stated he had no postoperative discomfort or swelling.

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  Figure 1

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  Figure 2

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  Figure 3

The next appointment
When the patient returned 6–8 weeks later, the healing caps were removed (Fig. 4) and the implants were tested with the Osstell unit (Fig. 5), using resonance frequency analysis to ensure osseointegration. Because the dental implants had a very good ISQ value, solid stock abutments 4mm high were tightened into the implants (Fig. 6), then retightened with a torque wrench to the manufacturer's specifications for proper seating.

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  Figure 4

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  Figure 5

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  Figure 6

The implant/abutment complex of each implant was captured using tissue retraction impression pickups (TRIPs)—white nylon baskets from OCO Biomedical that snap on the implant/abutment complex to accurately capture an impression with polyvinylsiloxane material. It was important to make sure the TRIPs displaced the gingiva and snapped over the collars of the implants to ensure proper seating. Using a full arch thermoplastic custom tray (Goodfit), an impression was taken using a heavy and light-bodied polyvinyl siloxane impression material. Once the impression material was set it was removed from the mouth, picking up the TRIPs, and a 4mm marginal collar was snapped into the impression and sent to the lab for pour-up. From this pour-up, the marginal collar would reproduce the margin of the implants and the pour-up would replicate the abutments (Fig. 7).

When the patient returned for the seating appointment, the PFM splinted crowns

(Fig. 8) were placed on the abutments with their margins on the implants. An X-ray was taken to verify an accurate fit. Because there were no open margins and the contacts and occlusion were good, the crown restorations were seated using Nexus RMGI (Kerr) cement. Once the cement reached its gel stage, it was quickly cleaned off, with any excess quickly and easily removed (Fig. 9).

The patient was pleased with the end result and surprised at how atraumatic the whole dental implant procedure was, compared with previous visits to the dentist. In fact, he referred his wife and sister to the practice for a similar type of treatment.

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  Figure 7

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  Figure 8

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  Figure 9

Conclusion
Today's patients like to get all their services under one roof, in a shorter number of visits, so it's essential to have the proper training and equipment to be able to deliver efficient, effective dental implant treatment. Every dental provider should be able to implement this type of implant treatment within their practices with the appropriate training. General dentists interested in offering implant treatment should pursue postgraduate implant training if they want to meet the demands of today's society.