Keep it Simple Stupid by Dr. Zaki Kanaan

Dr Zaki Kanaan argues the case that when it comes to implants, treatment should be kept as simple as possible.

Albert Einstein said “Make everything as simple as possible but no simpler”.

The old adage goes that if 10 dentists were to treatment plan a case you will get as many varying opinions. There is nothing wrong with this for simple general restorative cases, but 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 mum for a second opinion, after being recommended by a hygienist. She was concerned about, what she felt was a drastic treatment plan that was recommended to her son by another respected dental centre.

Her son, a student on his gap year, 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 centrals were splinted at this visit (Figure 1,2,3,4). The upper centrals were also traumatised during the accident, with periapical radiographs exhibiting signs of horizontal fracture lines at various levels (Figure 5). The upper right lateral and central had also been root treated shortly after the accident and all teeth have been symptomless since.

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 is a viable option, it would have lead to the extraction of 3 important teeth in the smile zone of this young gentleman. This treatment plan had been accepted by the young gentleman and his parents but fortunately, due to a waiting list for the implant phase of treatment, this treatment plan had still not been carried out.

My Proposed Treatment Plan
In view of the fact that the traumatised centrals have been asymptomatic, with no apical changes since the accident, I suggested leaving the centrals alone with no treatment initially. I recommended the extraction of the upper right lateral incisor, with the immediate placement of an implant.^{1, 2} A provisional tooth would have also been provided. A final abutment and porcelain crown would then be fitted after the healing phase. It is important to inform the patient that further treatment may well be required on the central incisors. Staging treatment in this way will minimise the risk of losing soft tissue architecture. This treatment plan was accepted.

Surgical Phase
The patient attended for treatment and carried out a 30 second Chlorhexidine pre-surgical rinse 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 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 nice 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. It can also be used to give visual feedback on the direction of the imminent osteotomy site preparation. Socket curettage was carried out to ensure it is 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.³ 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 is positioned mid-buccally.

The initial stability of 20Ncm is not enough to immediately restore an implant. If immediate loading has been planned, you should always have a contingency plan if good primary stability of the implant is not 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 metallo-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 6).

Restorative Phase
12 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 7) 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 as much as possible. 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 implant cement. Great care was taken to ensure no excess cement was left behind.

It is often the case that the embrasure between a canine and a new crown is increased, as it was here (Figure9).

This can easily be remedied by bonding some composite to the mesial of the canine, as was done in this case, which reduces the embrasure giving a more aesthetic result, which was to the patient’s satisfaction (Figure 10).

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.

As this is done blanching will be evident (Figure 8). It is important to wait for the blanched tissues to return to their normal colour before final cementation. Failure to do this may result in ischaemia of the surrounding tissues, pain and may even lead to an element of necrosis, if the patient is allowed to leave in this way.

Occlusion was checked with articulating paper in centric relation, as well as in excursive movements until shimstock foil glided through with light contacts. A post-restorative baseline radiograph was taken showing good bone levels.

A 3 month review and 1 year follow up were carried out (figure 11, 12, 13). The centrals were still symptom free with no radiographic changes at both appointments. Bone levels were also as they were at baseline.

Follow Up
I wrote this case in 2007. I would do things differently now and in most cases of immediate implants I would often add a free gingival graft or deepithelialised connective tissue graft, to further augment the soft tissues around the implant. This case highlights that through careful case selection and adherence to certain principles, immediate implants can exhibit successful long-term outcomes.

Follow up was done almost annually. With no reported problems at all. Gingival levels around the implants were maintained well, apart from the patient attending at the 8-9 year mark with a small sinus above the implant. As shown in Figure 14. On questioning the patient reported that he had recently seen a local dentist to recement the implant crown as it had decemented. Luckily the patient attended as soon as the sinus came up and the so did not manifest itself as full blown cementitis, which could lead to destruction of the soft tissue and bone loss.

The excess cement was visible through the sinus and was removed though the sinus as shown in Figure 15. The crown was removed and the area debrided with conventional ultrasonics. The crown was recemented with a temporary implant cement paying particular attention to remove any excess cement. On review the sinus can be seen to be healing well and a decision as to whether any further soft tissue augmentation was needed in due course. We can clearly see however despite this small set back, that the maintenance of peri-implant gingival levels and stippling were maintained as they were shortly after delivery of the crown 9 years earlier. Figure 16. 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 width5 (sometimes now termed the biologic doughnut).

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.⁴ The immediate implant protocol, in combination with a flapless, single stage technique, seems effective at maintaining the gingival architecture and when combined with a good ceramist, gives the clinician every chance of replicating nature.

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.

Zaki runs the London Implant Academy with 2 colleagues, a 1 year practical implant course and is Director of K2 Dental Seminars, where he has trained hundreds of dentists, hygienists and therapists in the art and science of teeth whitening techniques.

He works at several prestigious dental clinics in central London and also runs K2 Dental, a private practice in the heart of London’s Fulham Palace with his wife Dominique, also a dentist.

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  Figure 1
  1:2 Anterior Retracted View at Presentation

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  Figure 2
  1:2 Right Retracted View at Presentation

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  Figure 3
  1:1 Right Retracted View at Presentation

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  Figure 4
  1:1 Right Retracted View Immediately Pre-op

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  Figure 5
  Periapical Radiograph at Presentation

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  Figure 6
  1:1 Right Retracted View With immediately placed implant and provisional Maryland Bridge in place. Note Minimal bleeding and bruising to surrounding tissues

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  Figure 7
  Left Retracted View Communication with the lab should include a photo of the contralateral tooth

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  Figure 8
  1:2 Anterior Retracted View Note blanching of tissues during trial insertion

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  Figure 9
  Right Retracted View During trial insertion of Lava crown prior to bonding mesial composite to 13 to reduce embrasure

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  Figure 10
  Left Retracted View Communication with the lab should include a photo of the contralateral tooth

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  Figure 11
  1:2 Anterior Retracted View Note blanching of tissues during trial insertion

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  Figure 12
  1:1 Right Retracted View at 1 year

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  Figure 13
  Right 1:1 Retracted View at 1 year Note good papillary infill and stippling of gingival tissues above implant crown.

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  Figure 14

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  Figure 15

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  Figure 16
  9 year post op and after cement removal showing resolution of the sinus but maintenance of stippling and gingival peri-implant levels.

References
1. Garber DA, Salama MA, Salama H (2001). Immediate total tooth replacement. Compend Contin Educ Dent 22(3): 210-6, 218 Gelb DA (1993). Immediate Implant Surgery: three year retrospective
2. evaluation of 50 consecutive cases. Int J Oral Maxillofac Implants 8(4) : 388-399
3. Schwartz-Arad D, Chaushu G (1997). The ways and wherefores of immediate placement of implants into fresh extraction sites: a literature review. J Periodontol Oct;68(10):915-923
4. Schroeder HE & Listgarten MA (1997). The gingival tissues: the architecture of periodontal protection. Periodontology 2000 13: 91-120
5. Hermann JS, Buser D, Schenk RK, Higginbottom FL, Cochran DL (2000). Biologic width around titanium implants. A physiologically formed and stable dimension over time. Clin Oral Implants Res . Feb;11(1):1-11

Zaki Kanaan BDS, MSc (Implant Dentistry), DipDSed, LFHom Zaki is a highly experienced and respected implant and cosmetic dentist and is well known in the dental community. He is the past President of the British Academy of Cosmetic Dentistry and currently sits on the Board of Directors for The Association of Dental Implantology UK. He features prominently on the lecture circuit lecturing on all aspects of cosmetic dentistry with a special interest in dental implants, where he has achieved a Masters Degree from Guy’s Hospital in 2001. He also has a Diploma in Sedation, a Diploma in Hypnosis and is a Licenciate of the Faculty of Homeopathy.

Through his expertise in all aspects of tooth whitening, he has been a Key Opinion Leader for Philips Oral Healthcare for several years. After being voted 2nd in Private Dentistry’s poll of the top 20 Elite Dentists in the UK in 2011 and 2012, it was 3rd and 4th time lucky when he topped the poll in 2013 and 2014. He was also judged by his peers as ‘UK Dentist of the Year’ at the Dental Awards in 2012 and was more recently awarded the prize for Outstanding Contribution to Private Dentistry at The Private Dentistry Awards in London in 2015. He is a Past President of The London Dental Fellowship and sits on the editorial board for The International Journal of Cosmetic Dentistry and DentalTown UK. He has also appeared on Channel 4’s Embarrassing Bodies programme carrying out complex implant treatments.