Thinking Implants by Guy Laffan

I’ve always found Implantology fascinating. Brånemarks’ discovery of titanium’s unique biocompatibility and ability to integrate with bone was as much of a game changer to dentistry as the discovery of bonding (at least in my opinion).

The day is fast approaching where dentures will be a thing of the past, primarily due to the generalised increase in oral hygiene and reduced tooth loss, and it’s reassuring to know that should I ever lose a tooth (touches wood), a restored dental implant will be the option of choice.

Much like a filling, when you commit to placing an implant, it’s yours for life. The technical and surgical demands are exceptionally high – as is the cost to the patient and so this why thorough training, planning and execution are so incredibly important.

I’ve been placing implants for seven years and despite reading every book and journal out there I still feel like I’m still second guessing at the best of times.  I’ve almost finished my masters and it still feels like I have a thousand unanswered questions. Like with everything it’s a never-ending journey and as long as you’re prepared to put the effort in you will soon reap the rewards.  Still to this day I am constantly critical of all my work but this allows me to reflect, learn and grow on a daily basis.

When I started my journey I longed for someone to simply explain a logical sequence of what to do, with the odd pearl of wisdom thrown in.  Alas, this version of events wasn’t available, so I committed myself entirely and endeavored to learn as much as I could.

We’re fortunate to have so many invaluable resources at our disposal - Text books such as that from the late and great Carl Misch, a plethora of journals, online forums such as www.dentaltown.com and even social media. There are some superb organisations to join too.

The ADI for instance is a registered charity – a non-commercially sponsored organisation that sets out to support everyone with an interest in dental implants.

They have regular local study groups and bigger events annually. Next year’s congress is in London on March 2nd so why not come along and dip your toe in the water?

When simply mentioning all of the above, I can’t help but feel a deep sense of gratitude to the pioneers before me who have ultimately made my learning experience comparably straightforward.

Before you immerse yourself into the world of dental implants you must appreciate the sheer complexity of this multidisciplinary treatment. You don’t need to be a specialist in any field but you need an appreciation of their symbiotic relationship if you are going to start placing.

It’s good to know a basic workflow so I thought I’d explain mine briefly. Please remember that 10 dentists would have 10 different opinions – so don’t take it as literal – use it to start planning your own system.

New patient assessment
Get to know the patient and their goals. Understand the reasons why the patient lost the tooth originally. Collect a detailed MH – things to watch out for, as with any surgery, are warfarin, bisphosphonates, diabetes, smokers and any immunity issues. Enquire about RDH and RSH to help build a background on the patient and their suitability for implants. Conduct a full E/O and I/O exam then collect impressions & photos.

CBCT scans are invaluable when planning and patient education. Learn to report on these yourself or even source someone who will. Locate all the vital structures and assess the osteotomy site fully. Look at the bone volume and for any abnormalities. Report the whole scan and don’t be narrow sighted. Chance findings do happen so be vigilant.

Review the patient after a cooling off period and discuss the treatment, quote and consent in detail. Use the CBCT scan to help explain things - informed consent is just as important as written.

The surgery
After complete wipe down, make sure everything is sterile and laid out where you want it. It’s better to have too much out and not need it, so I’d even suggest implants of all sizes because things can change unexpectedly. Ultimately if you fail to prepare, you prepare to fail.

Before surgery, reassure your patient and put them at ease. Make sure they take pre operative antibiotics and anti-inflammatory medication. You and your assistant will be fully scrubbed and the patient fully draped. The patient should rinse with chlorhexidine and use it to sterilise the peri-oral tissues.

Ensure adequate anaesthesia before surgery – it gets tricky to infiltrate when a flap is raised. Think through your flap design and be confident with your incisions. Obey the basic principles and respect the tissues. Do some research around soft tissue surgery and you’ll pick up some great tips.

Once the flap is raised inspect and neaten your osteotomy site – removing any sharp edges with a round bur and proceed to mark your starter point. It’s a real art maintaining the same drill trajectory so be confident and precise. Use the markers throughout and take an initial PA after your first drill – you can still make corrections at this stage if needed.

Using 1200 rpm (this varies) and copious cold saline irrigation follow the drill sequence until you reach the desired width and depth. In less dense bone you can use a lower rpm and vice versa. But respect the bone.

Inspect your osteotomy walls with a blunt instrument and all being well you’re ready to place. It’s about now you’ll be thinking about graft materials. They can be fiddly so find a good course. Soft tissue grafting is a whole new kettle of fish so maybe put it in the diary for the future, as you’ll need to get good at it.

Taking an implant out of its packaging is nerve racking at first. You’ll see what I mean when you do it. Just make sure you engage the driver fully before moving and in one clean movement straight into the osteotomy. Start it off by hand then finish with the torque wrench to 35ncm (this varies with manufacturers). We’re looking for good ‘primary stability’ - a self-explanatory term. Take a post op radiograph and hand-tighten the healing abutment. Implants are usually buried when a large volume of particulate is used, or block graft performed. 2-stage surgery is a nice way to develop the gingival tissues for emergence profile – a technique worth learning.

Suture with whatever material and technique works best for you. Don’t be afraid to take bigger bites if it helps close the wound and ideally they should be tight enough to just approximate the wound edges. If they are too tight they’ll just tear through with the post op inflammation and restrict blood flow.

Make a personalised set of post op instructions covering all the key areas and give strict advice to leave dentures out initially. I put my mobile number on mine in case of emergencies.

Make thorough notes. Include the Lot and batch of the implants used and record even the slightest details – trust me it will help you sleep at night. Also make sure you write up and grade your radiographs. Keep a logbook of all your cases - record patient name, date and procedure then stick an implant sticker next to it. Put another sticker on the consent for continuity.

Remove the sutures after 2 weeks and plan the pick up impressions 6 weeks later. If you’ve done extensive hard tissue grafting its often wise to leave it for at least 3 months.

Never forget that implants can fail early on. Nothing quite prepares you for your first ‘spinner’ – often detected when you first unscrew the healing abutment. Mention it in your consent and should it happen just explain, reflect and move on. It’s good to document your failures for audit purposes.

Impressions
The technique is similar to a post crown. Simply put: Healing abutment off; screw in pick up post; cut hole into tray to accommodate post; take impression; clear extruded material from hole to locate post; wait for set; unscrew post; remove. Spend time taking the shade.

Screw Vs Cement retained is a big topic of discussion, both having pros and cons. Retrievability is a very desirable thing but the screw hole can weaken the porcelain.

Excess cement can however cause peri-implantitis and unexpected debond. Ultimately both have their place and the decision is case selective.

Crown fit
The lab will have sent a transfer jig made from Duralay to help you seat the abutment. Tighten with the torque wrench as per the manufacturers guidelines (usually 25ncm) then fit the crown.

Stress the need for follow-up appointments and give rigorous OHI focused on implant care. Take a PA at 1, 3 and 5 years to monitor.

I’m sure you can appreciate that there’s a lot more to it than that. I just hope it’s given you some insight and even clarity about dental implants. I’ll be learning for some years yet and I hope that like me, you never lose the hunger for knowledge.

In the words of Benjamin Franklin:
“An investment in knowledge pays the best interest”.

Remember the journey is long... and it’s a marathon, not a sprint.

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  Pre op

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  Post op

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  One year fit

Guy Laffan graduated from Bristol in 2010 and now works in the family practice, Laffan Dental Care, one of the oldest in south Wales. He is currently writing his dissertation for his Masters in Dental Implantology at Cardiff University, whilst also studying for a diploma in Oral Surgery in Bristol. He is one of the highest providers of Invisalign in south Wales and has been advancing himself in the field of fixed orthodontics for the past three years. He also is a member of the Gwent local dental committee.