INTRODUCTION
A next-level dental practice is one that confidently offers solutions for complex dental problems and one that provides advanced treatment options to improve the quality of life for its patients. These treatments usually involve bone augmentation procedures, implants, implant-assisted removable prosthetics, and implant-supported fixed restorations. I practice aesthetic and reconstructive implantology, which defines and differentiates the type of dentistry that is possible in the 21st-century dental practice: treating people, not teeth.
This article will feature my experience with the Astra Tech Implant System EV (Dentsply Sirona Implants). I will present a compilation of indications and clinical documentations that show how this implant system was used to predictably replace single or multiple missing teeth, as well as its use in All-on-4 applications.
A Unique and Innovative Implant
I have enjoyed great success since implementing the use of the Astra Tech Implant System EV. It has helped me to reduce treatment times and streamline the restorative process in my practice. The foundation for the Astra Tech EV Implant System is the BioManagement Complex (Denstply Sirona) that works to improve long-term stability and to preserve both hard and soft tissues.1,2 Its drilling protocols are very specific, providing detailed control of the installation of implant fixtures, and it has the capability to work effectively in all types of bone qualities. Primary stability can be achieved by inserting the fixture to full depth, with great precision.
A common clinical problem that occurs after tooth loss is bone atrophy and buccal resorption, resulting in a sloped ridge. This bony architecture makes tooth replacement using an implant more challenging. If we utilize an implant with a flat platform, then we are forced to either sink the platform sub-crestally or do bone augmentation procedures to create a flat ridge. The Astra Tech Profile EV implant (Dentsply Sirona Implants) was developed and designed to overcome this problem and to improve our implantology protocols. Furthermore, I no longer consider the implant for the sloped ridge as a niche implant solution but part of my overall implant repertoire.
I was eager to work with this innovatively designed implant when the perfect ridge presented itself for its use. It was designed to follow the geometry of the alveolar ridge and maximize the existing anatomy of alveolar bone, bearing in mind the reduced ridge volume by contouring one side of the fixture to follow the slope of the ridge. These ridges are prevalent in healed post extraction sites, so having the option of this fixture can reduce the need for ridge augmentation, reduce surgical chair time, and result in the placement of an efficient bone- and tissue-supporting implant that preserves the natural contours of the existing bone.3,4
CASE REPORTS
Case 1: My First Case with the Profile EV Implant
In this case, the patient was diagnosed and treatment planned for 2 implants and a 3-unit bridge using Galileos 3D (Dentsply Sirona) imaging and implant planning software.
The patient presented with a failing lower right quadrant of teeth; teeth Nos. 29 and 31 were deemed hopeless, tooth No. 30 was missing, and No. 31 was not planned to be replaced in this phase of treatment. The plan called for the placement of 2 Astra Tech EV implants to support a 3-unit fixed bridge. The space between the second premolar and first molar was wide enough to accommodate a third premolar, hence the restoration would be a 3-unit bridge. The Astra Tech Profile EV implant was virtually placed in the No. 30 site and appeared to offer an ideal option. The planning software allows the clinician to review any implant in 360º, and, by using this tool, it was determined that the anatomy in this case was perfect for the use of the Astra Tech Profile EV implant.
Profile EV implants pair well with the Simplant SAFE Guide tooth-borne guide (Dentsply Sirona Implants), so I elected to take advantage of this treatment option. The DICOM data was exported into the Simplant software to complete a definitive virtual plan and create the Simplant tooth-supported surgical guide. After a review of the digital data, a 4.2- × 11-mm Astra Tech EV implant was virtually positioned in the tooth No. 29 site, and a 4.8- × 11-mm Astra Tech Profile EV implant was positioned for the tooth No. 30 site. I contemplated an immediate placement post-extraction for tooth No. 29, but the actual treatment would depend upon the buccal plate condition after removing this tooth (Figures 1 to 3).
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The patient was anesthetized with an inferior alveolar block, and a full-thickness flap was done to expose the underlying alveolar bone and the residual roots at teeth Nos. 29 and 31. The osteotomy for the tooth No. 30 site was completed, and the Profile implant was installed using the Simplant surgical guide.5 It was torqued to 45 Ncm and positioned precisely as had been previously planned with the virtual fixture. The extraction site for tooth No. 29 was insufficient to place an immediate implant, so I proceeded to section and extract the tooth No. 31 roots and graft both sites with a mineralized cortico-cancellous bone allograft. The implant received a cover screw and was 2-staged while the grafts were covered with a resorbable collagen membrane. Primary flap closure was achieved, and the patient was dismissed and placed on postoperative medications (Amoxicillin 500 mg, 1-tid; Medrol 4 mg dose pack, taken as directed; and 800 mg Motrin, taken as needed once every 8 hours) (Figures 4 and 5).
The area healed uneventfully, and a new CBCT scan was done at 4 months post-op to evaluate the prospective tooth No. 29 implant site. The tooth No. 29 site healed with a slope and was now treatment planned to receive another Profile EV fixture. This scan allowed the assessment of the Profile implant previously placed in the tooth No. 30 site. The result is shown in the cross-sectional image presented (Figure 6). This implant has maintained both the bone and soft tissue. A full-thickness flap performed during the second implant surgery revealed that No. 29 did, indeed, warrant placement of a 4.2- × 11-mm Astra Tech Profile EV implant to support the sloped buccal ridge. The second Profile EV fixture was installed without issue and was one-staged.
As a clinician, this case gave me the confidence to trust the usefulness of this unique and innovatively designed implant. Note the width, color, and stability of the keratinized mucosa at the ready-to-restore stage (Figure 7). The methodology I use to assess integration is resonance frequency analysis (RFA), along with radiographic and clinical parameters. The implant stability quotient (ISQ) is the value recorded via an Osstell RFA. ISQ has a nonlinear correlation to micromobility, measuring the stiffness of the bone-to-implant contact on a scale of 1 to 100. A value greater than 70 indicates high stability, demonstrating good bone-to-implant contact. The mechanical stability attained during installation will be replaced by biological stability over time when successful osseointegration occurs. RFA through the Osstell system is an objective, noninvasive, and reproducible method for measuring implant stability and can aid the clinician in determining if an implant is ready to be loaded.6,7
Prior to taking impressions, ISQ values were recorded for both implants. The tooth No. 30 implant recorded values of 81/8; the tooth No. 29 implant values were at 80/80. These values were taken in a buccal-lingual and then a mesial-distal direction so that the contact to bone was appraised in various locations of each implant. High initial values at placement generally do not rise much as biological stability grows; however, if the initial value is low (60 or lower), we would expect that value to rise when successful integration has occurred. Images presented document the digital impression for Atlantis abutments and the subsequent restorative phase of treatment. I utilized a digital workflow to restore the 2 Astra Tech Profile EV implants with Atlantis (Dentsply Sirona Implants) custom abutments and an IPS e.max (Ivoclar Vivadent) 3-unit fixed bridge. The digitally designed custom abutments offer the lab and clinician full control of the emergence width, the amount of tissue displacement, and soft-tissue contours and support for the definitive restorations (Figures 8 to 11).
I have planned and placed multiple units since I completed this first case, and the results have all been favorable, with the soft tissue being supported, bone being maintained, crestal remodeling being avoided, and the need for bone augmentation being reduced.
Case 2: Replacing Two Lower Left Molars Using Profile EV Implants
A full-mouth rehabilitation case was nearing completion and required implants to replace the patient’s remaining missing lower left first and second molars. This case involved the use of multiple dental disciplines to return this patient to a fully fixed, aesthetic, and functional dentition. A cone beam scan revealed a resorbed ridge in the lower left molar region. These teeth had been removed a few years prior to the patient presenting for treatment at my office. The clinical decision was made to use the Astra Tech Profile EV implant, as my technique and confidence had grown to the point where I could predictably and successfully place and restore these fixtures without complications. I designed and fabricated a Simplant SAFE Guide to facilitate and control the implant surgery (Figures 12 and 13).
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The Profile EV implants were planned in the Simplant software, bearing in mind the available bone, residual sloped ridge, lingual bone anatomy, inferior alveolar nerve, and opposing occlusion. I was confident that these fixtures could support 2 restorations and maintain the existing hard and soft tissue. (Remember that the design of these fixtures was developed specifically for this type of anatomy.) The digital workflow allowed for a streamlined, efficient, and uneventful implant surgery. I handled this surgery using a flapless, guided approach. Post-op cross-sectional views validated how the virtual and actual Profile EV implants were embedded in the existing bone anatomy (Figures 14 to 19). As determined by Osstell resonance frequency analysis, both fixtures recorded high ISQ values at placement. The No. 19 fixture values were at 85/85; and the No. 18 fixture was at 81/81. No issues were reported post-op, and they were nearly ready to be restored. The unique implant geometry provided multiple benefits—specifically, negating the need for bone grafting.
Case 3: Expanding Indications for the Profile EV Implant
I would like to share 2 more examples of successful placements in a patient who was medically compromised and desired a fixed full-arch prosthesis. Limited bone volume existed posterior to the mental foramina, and extensive bone grafting was not a good option. The Profile EV implants maximized the existing bone and rescued the posterior sites after both previous implants failed. The treatment was uneventful, and we gained additional A-P spread that will distribute the forces of mastication over a greater span and reduce the cantilevered extensions for a fixed prosthesis. Out of an abundance of caution, I did not immediately load this case, and we are waiting an appropriate amount of time for integration. The patient was medically compromised with diabetes; however, the graft that followed implant removal healed sufficiently to receive the specially designed geometry of the Profile EV implant. The surgery was completed via a flapless, guided approach. The No. 21 implant recorded Osstell ISQ values of BL80/MD79, and the No. 29 implant values were at 70/86 at the time of installation. The use of a flapless and guided surgical approach provided numerous benefits for this patient. This approach preserved the circulation of the soft-tissue architecture, reduced surgical time, lessened the amount of instrumentation, improved patient comfort, and allowed faster healing (Figures 20 to 29). The restorative phase of this case will be documented and presented in a future article. It will feature advanced treatment options comparing the innovative and streamlined SmartFix concept with the previous methods of the All-on-4 protocols.
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CLOSING COMMENTS
I have utilized this fixture in cases with previous implant failures and to manage medically compromised patients through a flapless, guided approach. The result has been the reduction of the post-op sequelae often associated with conventional flapped surgery. Reducing the need for bone augmentation in these instances has resulted in positive implant experiences and uneventful post-op healing. Because of these and other clinical experiences, I do not hesitate to use the Astra Tech Profile EV fixture as a solution for the sloped ridge. This implant has added value to my All-on-4 surgical protocols and to the subsequent prosthetic conversion during a “teeth-in-a-day” treatment. The confirmation of successful implant installations and subsequent integration with radiographic validation, clinical assessment, hard- and soft-tissue maintenance, and corroboration with RFA validates the use of this implant.
This unique and innovative implant has given clinicians a better way to accomplish the goal of replacing missing teeth, while working smarter, not harder. In my opinion, the Astra Tech EV Profile Implant System should be part of everyone’s clinical decision-making process when challenged with these situations.
References
- Palmer RM, Palmer PJ, Smith BJ. A 5-year prospective study of Astra single tooth implants. Clin Oral Implants Res. 2000;11:179-182.
- Stanford CM, Barwacz C, Raes S, et al. Multicenter clinical randomized controlled trial evaluation of an implant system designed for enhanced primary stability. Int J Oral Maxillofac Implants. 2016;31:906-915.
- Dentsply Sirona Implants customer survey conducted in Austria, Germany, North America and Switzerland. Data on file.
- Noelken R, Donati M, Fiorellini J, et al. Soft and hard tissue alterations around implants placed in an alveolar ridge with a sloped configuration. Clin Oral Implants Res. 2014;25:3-9.
- Dentsply Sirona Implants. Astra Tech Implant System EV computer-guided implant treatment [manual and product catalog].
- Jaramillo R, Santos R, Lázaro P, et al. Comparative analysis of 2 resonance frequency measurement devices: Osstell Mentor and Osstell ISQ. Implant Dent. 2014;23:351-356.
- Díaz-Sánchez RM, Delgado-Muñoz JM, Hita-Iglesias P, et al. Improvement in the initial implant stability quotient through use of a modified surgical technique. J Oral Implantol. 2017;43:186-193.
Dr. Ramirez earned his DDS degree from the New York University College of Dentistry. He is a Master of the AGD and a Diplomate of the International Congress of Oral Implantology. He maintains a private practice in Brooklyn, NY, focusing on cosmetic smile design and implantology. He utilizes 3-D CBCT imaging and CEREC CAD/CAM technologies to promote a fully integrated digital dental practice to improve the quality of life for his patients. He can be reached at (718) 748-3003 or via email at info@dranthonyramirez.com.
Disclosure: Dr. Ramirez reports no disclosures.
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