Show Your Work: All in a Day’s Work by Dr. Ara Nazarian

Last October we introduced a new department called "Show Your Work" that gives Townies an 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 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

editor, Dentaltown

When a patient comes to your dental practice with nonrestorable teeth requiring full-mouth extractions, the biggest concern is whether 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 a patient's demands are met, allows you to bring your practice to a whole new level. Of course, certain parameters must be met 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, being able to objectively test the implants' stability at the time of placement is essential for this treatment.

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 apparent gross caries and periodontal disease (Fig. 1). The upper arch was already edentulous and restored with a denture.

Planning
A CBCT scan, using the CS 8100 3D (Carestream Dental) (Fig. 2, page 38), was taken to accurately treatment-plan this case and 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 model impressions were taken using Silginat (Kettenbach). They were then poured up and forwarded to the dental lab. The models were mounted on an articulator (Stratos 100, Ivoclar Vivadent) for further analysis to meet the patient's aesthetic and functional needs. Additionally, a 3-D virtual treatment plan was created with 3D Diagnostix (Fig. 3). The patient wanted fixed restorations supported by dental implants in the lower arch that would oppose a new complete denture.

Financing options using a third-party payment option (Lending Club) were discussed with the patient, which was an important part of facilitating acceptance of her care. This payment option made the cost of treatment more feasible.

OCO Biomedical's Engage dental implants were used in this case. These implants are known for their high implant stability at placement, which is a critical success factor in these immediate load cases. The system's patented Bull Nose Auger tip and Mini Cortic-O Thread provide 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 go any deeper than the initial pilot drill preparation and lock into the base of the osteotomy. The implants have a proprietary surface treatment designed to increase the implant's surface area for ideal bone in-growth and stability.

Once the teeth were extracted using the Physics Forceps (Golden Dent), the tissue was reflected to get the surgical guide seated and fixed with its respectful retention pins. Using this universal surgical guide (Fig. 4) provided by 3D Diagnostix, the sites for the implants were initiated with a designated 1.8mm pilot drill from the OCO Biomedical guided surgery kit utilizing the Mont Blanc surgical handpiece. In addition, an Aseptico surgical motor was used at a speed of 1200rpm with copious amounts of sterile saline. The kit's sequential osteotomy formers were then used to shape the final osteotomies (Fig. 5). Once the osteotomies were complete, an implant driver was used to place the dental implants until increased torque was necessary (Fig. 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 implant stability quotient (ISQ) reading of the implants was taken with an Osstell IDx unit (Fig. 7). The Osstell IDx is a fast, noninvasive and easy-to-use system that determines implant stability and accesses the process of osseointegration without jeopardizing the healing process. It provides the necessary information to make well-founded decisions.

With more than 870 scientific references, we now know that high stability is greater than 70 ISQ, between 60–69 is medium stability and less than 60 ISQ is considered low stability. Since the readings on each of the eight placed dental implants were above 70 and the quality of bone after leveling was good, temporary abutments (OCO Biomedical) were tightened into the dental implants (Fig. 8) 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 (Fig. 9).

The prefabricated immediate provisional restoration was tried in to ensure a passive fit over the temporary abutments. Once confirmed, rubber dam material was placed to prevent 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 excess material was removed with the Torque Plus (Aseptico) lab handpiece and an acrylic bur (Komet). Once trimmed and polished, the provisional restoration was seated with Temp Bond Clear (Kerr).

The patient returned seven days post-op for suture removal with very little discomfort, swelling or bruising. She was very pleased with her new upper denture and lower fixed provisional restoration (Fig. 10). Now that the patient was no longer anesthetized, the occlusion was checked again to confirm there were no interferences in lateral and protrusive movements.

Approximately four to five months post-operatively, the dental implants were further tested for osseointegration with the IDx by removing the temporary abutments, placing an Osstell SmartPeg and capturing the ISQ. Once confirmed, impressions could be captured with either polyvinylsiloxane material or digital impressions.

Conclusion
Having the ability to take a patient from start to finish in fewer appointments and the ability to accurately assess implant stability within your practice allows you to ideally fulfill your patient's surgical and restorative needs when it comes to dental implant treatment. With the proper training and appropriate materials, a dental provider may provide extraction, grafting, implant placement and fixed provisional restorations within one appointment.

Show your work in Dentaltown!
If you've got a case you think might be a great study for Show Your work, email Editor Sam Mittelsteadt: sam@dentaltown.com. Be sure to include a sentence that sums up why the case is so special to you, to help us review and select the best contenders for publication.