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Innovative Techniques in Implantology by Dr. Edward R. Kusek

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Categories: Laser Dentistry;
Innovative Techniques in Implantology 

A case study involving advanced bone grafting and laser therapy for optimal outcomes

by Dr. Edward R. Kusek

Introduction
This case involved a 35-year-old female who lost tooth #9 because of an accident when she was 10 years old. She wore a provisional appliance and was ready for a permanent solution without destroying more dentition. The patient was motivated as she was getting married in a year. At presentation, the patient had a thick biotype: hard and soft tissues were within normal limits, no popping or clicking of the temporomandibular joint and no pain from the muscles of mastication. Maximum opening was 40 mm. A CBCT was taken to determine if there was adequate bone in the site #9 in terms of width, height and depth. On evaluation, it was found that the height was adequate, but the site lacked width (approximately 2 mm) (Fig. 1). Thus, implant placement would be compromised.
Innovative Techniques in Implantology
Fig. 1: CBCT

The use of osseodensification drills was contraindicated, as the implant site could still work more to the facial aspect than toward the palatal site. Bone spreading is a possibility, but for this clinician, not a viable approach. Block grafting from an irradiated vertebral block was chosen instead of an autogenous block graft, which eliminates a second site of surgery.1 The CBCT was sent to a maxillofacial radiologist to evaluate the radiograph to determine if there was any pathology that this author did not diagnose.

Records taken for the patient included a full CBCT (Fig. 1), photographs of the oral cavity (Figs. 2–3), a scan of the maxilla and mandible with bite registration, shade matching with a Vita shade guide of A-1, Oral DNA bacterial testing (to determine if the patient was susceptible to periodontal disease), and the fabrication of an Essex appliance (to take forces away from the block graft during the healing stage and from the implant placement).2
Innovative Techniques in Implantology
Fig.2: Pre-op photo.
Innovative Techniques in Implantology
Fig.3: Pre-op photo.

The maxillofacial radiology report showed the following: moderate to severe mucosal thickening in the maxillary sinuses, nasal cavities showed no abnormalities, no airway abnormalities, both temporomandibular joints were well visualized and no abnormalities were detected. The site of #9 showed completely healed bone with no radiographically remarkable dental or osseous pathology detected. The report also suggested an ENT assessment for the moderate to chronic sinusitis and indicated no contraindication for the lateral ridge augmentation needed to create more bone volume for implant placement.


Treatment plan
  • Vertebral block graft (VBG) (Rocky Mountain Tissue Bank) in the site of #9, using an Erbium laser 2780 nm (Biolase) to decorticate the bone, trim the block to the site and fixate the block with bone screws. Place shavings from the cortical block around the periphery of the block, cover with pericardium and then PRF. This procedure is to be done under IV sedation.
  • Treat the site with high-intensity level therapy (Deka Nd: YAG 1064 nm) to stimulate bone growth.3 The settings will be applied in three visits, with the intensity of laser therapy adjusted per the protocol set by Alessandro Bizzarri.
    • First treatment: 60 mJ, 250 μs, 30 Hz, 2.4 W for 20 seconds.
    • Second treatment: 80 mJ, 250 μs, 30 Hz, 2.4 W for 20 seconds.
    • Third treatment: 100 mJ, 250 μs, 20 Hz, 2.0 W for 20 seconds.
  • Remove 3.0 PTFE sutures in 10–14 days, depending on healing.
  • Take a CBCT at 2.5 months to determine if the graft is healing.
  • Perform implant surgery at the 3+ month interval under IV sedation with PRF.
  • Uncover the implant using a 10600 nm CO2 laser, place the scan body and take a radiograph to confirm the scan body is seated at the base of the implant. Scan the full arch for a custom gold-colored Atlantis abutment.
  • Seat the abutment, tighten to 35 N ×2, and cement the crown, making necessary adjustments.
  • Perform a post-op bite and tissue check.
  • Schedule maintenance.

Treatment considerations
  • A salivary diagnostic test (Oral DNA Labs) to determine if the patient has bacteria that can contribute to periodontal and/or systemic issues.
  • High-intensity laser therapy (HILT) treatments to decrease inflammation, increase bone formation and accelerate healing time.
  • Use of an erbium laser (Biolase) to create decortication and a regional acceleratory phenomenon (RAP)4, which can increase bone-to-implant contact.
  • Use of a CO2 laser (Deka) to flap the tissue during the initial surgery for placing the block graft, during the placement of the implant and finally during uncovering.
  • Use of aqueous ozone5 (Biosure) to disinfect the osteotomy site at the uncovering of the scan body and healing abutment.

Case report: block grafting
The patient was treated surgically to place a vertebral block graft from Rocky Mountain Tissue Bank to increase width and enable implant placement in the correct position for optimum aesthetics in site #9. IV access was completed in the patient’s right antecubital fossa, where blood was drawn to obtain sufficient samples for centrifugation to create PRF, which would aid in healing by using the patient’s own bone morphogenic proteins.6

Drugs administered:
  • 20 mcg of dexmedetomidine
  • 5 mg of midazolam
  • 50 mcg of fentanyl
  • 8 mg of dexamethasone sodium phosphate
  • 40 mg of depo-solumedrol (IM)
  • 1 g of cephalosporin in total upon completion of the sedation
Flap reflection was performed from the #11 mesial area to the mesial of #7 using a 10600 nm CO2 laser (Deka) with a 0.5 mm spot size, no water, for about 30 seconds, with no vertical releasing incision and an entirely sulcular incision. Elevation was performed to expose the defect. An erbium laser (Biolase) (Fig. 4) was used to prepare the graft site and decorticate it for placement of the VBG (5 × 10 mm). The VBG was trimmed with a high-speed surgical handpiece and Rongeurs forceps. The block was then soaked in plasma from the PRF for one minute and fixated with two bone screws (Fig. 5). Shavings from the trimming of the VBG were placed around the corners of the graft. Pericardium (15–20 mm) was placed over this, and a PRF membrane (Fig. 6) was placed over the pericardium.
Innovative Techniques in Implantology
Fig.4: Erbium laser and site preparation.
Innovative Techniques in Implantology
Fig.5: Bone screws placed.
Innovative Techniques in Implantology
Fig.6: Pericardium and PRF placed.


The site was closed with 3.0 PTFE sutures. The tissue was de-epithelialized with an erbium laser (5.0 W, 40/0). The site was then stimulated using HILT (100 mJ, 20 Hz, 250 μs) for one minute, along with stimulation of four lymph nodes in the head and neck region (right and left submandibular and right and left subclavicular lymph nodes).


Post-op instructions
  • Use saltwater rinses twice daily.
  • Take a combination of NSAIDs (2× 200 mg) with acetaminophen (2 × 500 mg) every six hours for four days.
  • Take Keflex 500 mg, 15 tablets, three times daily until finished.
The patient was seen two more times for HILT (100 mJ, 20 Hz, 250 μs for one minute) and for suture removal at two weeks using the same settings. The patient experienced some swelling and minor discomfort during the first four days.


Post-op check
At the three-month healing check, a new CBCT (Fig. 7) was taken to evaluate bone growth and plan for implant placement. The width had expanded to more than 6 mm, which was adequate to place a 3.75 × 13 mm Ditron implant. Tissue health appeared excellent, and the patient was scheduled for implant placement in one month.
Innovative Techniques in Implantology
Fig. 7: New CBCT.

Implant surgery
IV access was again established in the right antecubital fossa (RAF). Blood was drawn to obtain sufficient samples for PRF, and the following drugs were administered:
  • 20 mcg of dexmedetomidine
  • 5 mg of midazolam
  • 50 mcg of fentanyl
  • 8 mg of dexamethasone sodium phosphate
  • 40 mg of depo-solumedrol (IM)
  • 1 g of cephalosporin upon completion of sedation
Flap reflection was performed using a 10600 nm CO2 laser from the mesial of #8 to the mesial of #10, with a sulcular incision from the mesial of #7 to the distal of #10 and no vertical releasing incisions.

Upon reflection, bone screws fixated during the first surgery were not visibly apparent. After scraping the bone and using a surgical handpiece, the bone screws were revealed, showing more than 2 mm of bone growth over them.

The appropriate drill sequence was used to prepare a 3.3 mm-wide osteotomy. The osteotomy site was decorticated with an erbium laser (Fig. 8) to improve implant-to-bone contact and disinfected with aqueous ozone (30 cc, Biosure) (Fig. 9).
Innovative Techniques in Implantology
Fig.8: Erbium laser used to decorticate.
Innovative Techniques in Implantology
Fig.9: Aqueous ozone.


I seated the 3.75 × 13 mm implant at the facial of the bony crest. PRF membranes were placed over the implant, and the site was closed with 3.0 PTFE sutures. The site was again treated with an erbium laser to de-epithelialize (Fig. 10) as described earlier and then rinsed with 10 cc of aqueous ozone. The site was stimulated with HILT (60 mJ, 30 Hz, 250 μs) for 20 seconds on the four lymph nodes as previously described and then on the facial and lingual aspects of the surgical site. Post-op instructions were the same as discussed earlier.
Innovative Techniques in Implantology
Fig. 10: Deepithialized with erbium laser.

Uncovering implant and scanning case
After three months of healing, the patient was scheduled for implant exposure. Topical anesthetic was applied, followed by administration of 0.5 cc of 20 mg lidocaine with 10 mcg of epinephrine and 2.0 cc of 40 mg Septocaine with 5 mcg of epinephrine. A 10600 nm CO2 laser was used to make a vertical incision palatal to push attached tissue to the facial, followed by a horizontal cut to leave attached tissue on the adjacent teeth, creating an “H” appearance.

A TruAbutment scan body was placed, and a radiograph was taken to confirm proper seating of the scan body on the implant. A full-arch scan of both the maxilla and mandible, including the bite, was completed using the Trios 4 scanner.

The case was then emailed to the lab (Caldent) for the fabrication of a gold-colored Atlantis abutment with a facial margin 1 mm from the base of the implant body. A healing abutment was placed after being soaked in aqueous ozone and the exposed gingiva around the implant site was flushed.

After three weeks, the abutment was soaked in aqueous ozone and seated with 35 N of force, torqued into place twice. The access was sealed with First Plug, and a photo was taken of the access site (Fig. 11). Contacts were checked, and the case was cemented using eCement (Bisco). Excess cement was removed, and a radiograph was taken to confirm all cement was cleared. The bite was checked, adjusted, and polished (Fig. 12).

A follow-up occurred two weeks later to ensure the bite was correct and tissue health was good.

Innovative Techniques in Implantology
Fig. 11: Atlantis abutment placed with first plug in the access.
Innovative Techniques in Implantology
Fig. 12: Final crown.


Conclusion
This case demonstrates several steps taken to achieve optimal results. Using high-intensity laser therapy (HILT) increased bone volume more than this author has previously observed when performing block grafting. Studies have shown that HILT can enhance bone and cartilage formation. Aqueous ozone can disinfect bacteria and viruses within 15 seconds.

It is crucial to evaluate the outcome and then work backward to determine the necessary steps to accomplish treatment. A true implantologist must possess knowledge in oral surgery, prosthodontics and periodontics and be able to evaluate health histories that may compromise patient treatment.

References
1. Resnick D. The new gold standard for intra-oral grafting to augment ridges: Allograft bone blocks that are vertebral in origin and irradiated. AAID Annual Meeting. Nov 16, 2024.
2. Khorsandi D, Fahimipour A, Abasian P, Saber SS, Seyedi M, Ghanavati S, Ahmad A, DeStephanis AA, Taghavinezhaddilami F, Leonova A, Mohammadimejad R, Shabani M, Mazzolai B, Mattoli V, Tay FR, Makvandi P. 3D and 4D printing in dentistry and maxillofacial surgery: printing techniques, materials, and applications. Acta Biomater. 2021 Mar 1;122-49.
3. Pineda S, Pollack A, Stevenson S, Goldberg V, Caplan A. A semiquantitative scale for histologic grading of articular cartilage repair. Acta Anal (Basal). 1992; 143:335-40.
4. Kusek ER. Immediate implant placement into infected sites: bacterial studies of the hydroacoustic effects of the YSGG laser. J Oral Implantol. 2011 Mar; 37:205-211.
5. Premjit Y, Sruthi NV, Pandiselvam R, Kothakota A. Aqueous ozone: Chemistry, physicochemical properties, microbial inactivation, factors influencing antimicrobial effectiveness, and application in food. Compr Rev Sci Food Saf. 2022 Mar;2(2):1054-1085.
6. Aizawa H, Tsjiino T, Watanabe T, Iisobe K, Kitamura Y, Sato A, Yamaguchi S, Okudera H, Oduda K. Quantitative near-infrared imaging of platelet-rich fibrin (PRF) matrices: Comparative analysis of Bio-PRF, leukocyte-rich PRF, advanced PRF, and concentrated growth factors. Int J Mol Sci. 2020 Jun 22;21(12):4426.

Author Bio
Ed Kusek Dr. Edward R. Kusek is a diplomate of the American Board of Oral Implantology, the immediate past president of the American Academy of Implant Dentistry, a past president of the Academy of Laser Dentistry, and an adjunct professor at the University of Nebraska Medical Center College of Dentistry and the University of South Dakota Dental Hygiene School. He holds masterships in the Academy of General Dentistry and the Academy of Laser Dentistry and is a member of Dentaltown’s editorial advisory board.


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