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Single Tooth Implant Case by Tarun Agarwal, DDS

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Implantology is one of the fastest growing segments of dentistry. There are tremendous numbers of patients who are looking for and could benefit from implant treatment. General dentists are poised to benefit by being able to do both the surgical and restorative phases of treatment. As it stands, roughly 20 percent of general dentists are placing implants - and there's no reason it shouldn't be 80 percent.

Patients are looking for a single source of dental treatment. Think about it: If you needed to get your car repaired, would you want go to one place that fixes your brakes, another that fixes your muffler and another to do an oil change? Or would you like to find a place that can do all three of those things well? The answer is pretty obvious. Your patients are no different. They would like to go to a dental office that can combine all aspects of treatment and do it all very nicely using the latest technologies. As a dentist, wouldn't you like to have the production and the control that placing your own implant allows?

What's Holding You Back?

What keeps most dentists from placing implants isn't a lack of education - that's the easy part. We can all take classes. We can all understand how to do it. Typically there are two things keeping dentists from placing implants - fear and intimidation. There is a fear of the procedure itself - hitting a nerve, getting a less than ideal result, etc. We are very comfortable doing fillings and root canals, but when it comes to placing an implant fixture into a bone, suddenly we become very uncomfortable. Additionally, there is the intimidation of stepping on the toes of specialists. This is understandable, but at the end of the day we have to be true to our practice and provide the best care for our patients.

To combat the fear in my practice, we utilize 3D cone beam computed tomography (CBCT) technology. By having an inoffice cone beam scanner, we are able to use Superman-style Xray vision and see exactly how much bone the patient has, exactly what size implant we can place, and exactly how to stay away from vital structures. We can take this virtual planning a step further and have a surgical guide fabricated, which will then allow us to very accurately, predictably and safely place that implant exactly where we planned. We call this a crown-down approach to implantology – where the restorative outcome dictates implant placement.

What most general dentists fail to truly understand is CBCT allows you to pick and choose which cases are right for you! There is no rule that says you have to be able to place every implant that walks into your office. Additionally, CBCT is not just for the dentist - it's also for the patient. It's the absolute best patient education tool, builds patient confidence and increases case acceptance. Remember, seeing is believing!

An Implant Case Every Clinician Should Be Doing

Let's take a look at a case that represents an extremely common patient in every general dentist's office. Linda came into my office originally with a pain on the lower left. Clinically and on the radiograph, we saw there was a fracture that extended all the way down the tooth, making it non-restorable (Fig. 1).

We both knew the tooth had to come out and there were several treatment options. First, we could have taken the tooth out and left an empty space, which is the least desirable option. Option number two would be to take the tooth out and give her a removable appliance, which for a single tooth on a young lady, is probably not a realistic option (and wasn't in this case). Option number three would be to do a fixed bridge, which 10- 15 years ago would have probably been the ideal option. But the ideal option in today's world was option number four: replace it with a single implant.

For implants, there are two treatment paths. We could do immediate placement, which is where we place the implant at the time or very soon after we take the tooth out. Or we can do traditional placement - take the tooth out, allow the site to fully heal, and then place the implant. My personal preference is immediate placement when appropriate. In this case, due to patient uncertainty, we decided to take the tooth out along with socket preservation to alleviate pain, and then revisit a few months later to place the implant.

Fast-forward four months, the patient came back in for an evaluation and the site has healed very nicely (Fig. 2 and 3), and we are ready to move forward with the implant procedure. In my opinion, this should always start with a CBCT and impressions for proper planning. In my office we utilize Sirona Galileos CBCT imaging and Sirona CEREC Omnicam for digital impressions.

The CEREC digital impression is going to serve two purposes. It's going to allow us to do a virtual wax-up of the missing area (Fig. 4), and it's going to be used to fabricate a precisely fitting surgical guide. The CEREC data is then integrated with the Galileos CBCT 3D scan to virtual implant planning (Fig. 5). The result is a perfect implant placement plan that is based on supporting the final restoration (Fig. 6). Everything is brought full circle and a digital surgical guide (Fig. 7) is ordered from the combination.

The result is a perfect plan that takes into account the bone availability, avoids vital structures, properly and hygienically supports the final restoration, and produces a surgical guide to execute the placement in a safe, predictable, efficient and minimally invasive procedure. All this in a single patient visit!

The patient's second visit is for implant placement utilizing the Nobel Guided Implant protocol. First, the surgical guide is verified for full seating and stability (Fig. 8). The beauty of fully guided implant surgery is both the osteotomy (Fig. 9) and the actual implant placement (Fig. 10) is controlled for depth and angulation. This ensures a final implant placement (Fig. 11) that is virtually identical to your implant plan. And more importantly, in cases where grafting is not necessary and the presence of adequate keratinized tissue, the implant placement can be done without raising a flap or even needing sutures (Fig. 12).

The underlying benefit of all this planning and guided surgery is the ease of restoration. If we have ideal placement then we make impressions easier, fabrication easier, delivery easier, and, of course, the lab bill easier on the bottom line.

Conclusion

We've all had troubles with the economy in the last four or five years and surviving and thriving in our practices isn't going to be based on finding more and more new patients, it's going to be by providing more procedures to our existing patient bases. How many times have you heard a patient say "Doc, can't you do that for me?" Stop saying no!

Our goal shouldn't be to provide procedures just for production. It should be to provide the procedure in a manner without compromise and to the level of or above a specialist. And technology can allow you to do that - to properly plan, to choose which cases are right for you, and to execute the plan. These technologies make tremendous sense for our patients, for our practice - and they make dentistry fun!

I encourage general dentists to take a closer look at cone beam technology and the benefits it can have, and to have an open mind of what it can do for your practice, for your personal satisfaction, and most importantly the patient outcomes.

Author's Bio
Dr. Tarun Agarwal maintains a full-time practice emphasizing 3D implant and restorative dentistry in Raleigh, North Carolina. He completed extensive continuing education with dental leaders Dr. Ross Nash, Las Vegas Institute, Dr. Frank Spear, and, most importantly, the school of hard knocks.

Dr. Agarwal currently provides hands-on workshops for general dentists wishing to master 3D implant dentistry.
To contact him or get more information, visit www.3d-dentists.com.
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