Flapless Implant Surgery With Aesthetic Temporaries

INTRODUCTION
During the past 10 years, dental implant therapy has progressed considerably. For the replacement of teeth, single-tooth implants have become the standard of care in dentistry. Development and advances to the restorative armamentarium have significantly improved the clinician’s ability to deliver predictable and reliable treatment. Dental implants placed by raising a surgical mucoperiosteal flap can cause a number of complications of concern such as tissue recession, crestal bone loss, and scarring.
The current trend is to develop techniques that can provide function, aesthetics, and comfort with a minimally invasive surgical approach. Achieving those goals is possible with a technique of flapless implant surgery using a tissue punch technique with reformation of computed tomography (CT) to 3-dimensional (3-D) computer model and finally fabrication of a SurgiGuide using a stereolithographic model.¹
However, the healing period remains a clinical obstacle towards restoring function and aesthetics for both the clinician and the patient. Within this period, many patients experience apprehension towards losing their social image or daily function, which might develop into resistance to implant therapy for others. Clinicians should provide a provisional restoration to their patients that is stable, stress-free, functional, and aesthetic during this critical period. The reality is that aesthetics remains very subjective, thus it is imperative to routinely use a diagnostic wax-up and well-designed provisional for a superior and more predictable restorative outcome.
This article describes techniques used for presurgical protocol, surgical flapless implant surgery, reducing operative time, accelerating postsurgical healing, increasing patient comfort, prosthetic temporization, and final prosthesis.

CASE REPORT
Diagnosis and Treatment Planning
A 67-year-old male presented to our office for an emergency appointment for the evaluation of a toothache that had lasted for more than one week. Tooth No. 13, which presented with an existing MOD amalgam, was sensitive to both percussion and pressure.
On further observation, a pocket of 7.0 mm was found in the mid-lingual area. The lingual portion of the tooth was mobile. After administering local anesthetic, further examination revealed a fracture that extended sublingually, making the tooth nonsavable.
The patient’s dental history presented with numerous amalgam and composite restorations, crowns, and root canals. This would be the first tooth lost in aesthetic area of the patient’s mouth. There was no soreness in the muscles of mastication or any history of tempromandbular disease problems.
The patient was in good medical condition and was taking Isopril (for high blood pressure) and aspirin on his physician’s recommendation.
The recommendation was to extract the tooth and graft the socket with irradiated cancellous bone, plasma rich growth factors,² and a membrane to hold the graft material in place. After being informed about the pros and cons of every option, the patient accepted this treatment and opted to extract his tooth and graft the socket.

Atraumatic Extraction and Consultation for an Implant-Supported Crown
The patient rinsed with Peridex (Omni Preventative Care Products, a 3M ESPE company) for 30 seconds. Then, 3.0 cc of 20 mg of lidocaine with 10 mcg of epinephrine was administered. Periotomes were used to loosen the ligament around the tooth, followed by the use of Proximators (Karl Schumacher) to deliver the tooth as atraumatically as possible. Next, the socket was curetted with surgical curette, followed by the use of YSGG laser to detoxify^3,4 the socket and decorticate to start the regional acceleratory phenomenon (RAP).⁵ After graft material was placed (Irradiated Cancellous Bone [Rocky Mountain Tissue Bank]), and plasma rich growth factor (blood product from the patient’s own blood)) a Biomend Extend membrane (Zimmer Dental) was placed to prevent tissue invagination into the socket. Closure was aided using placement 4.0 vicryl sutures (Ethicon [Johnson & Johnson]). The Waterlase MD (BIOLASE Technology) was used in the hard-tissue mode to de-epithilialize the tissue to start tissue healing phase response (rebound effect).⁶
Over the next few weeks, the patient healed uneventfully. He was scheduled for a consultation to go over the time and sequence of treatment, costs involved, and the possible options available. After consultation, the patient approved of an implant-supported crown to restore tooth No. 13.

Implant-Supported Crown: Clinical and Laboratory Procedures

Figure 1. Placing Aquasil putty (DENTSPLY Caulk) into nonretentive tray (no adhesive used).	Figure 2. Placing the light-bodied vinylpolysiloxane impression material (Aquasil Ultra [DENTSPLY Caulk]).
Figure 3. Seating tray into model.	Figure 4. Marking external position to aid in seating.

The dental records that were obtained after his approval to proceed included: a periapical x-ray of tooth No. 13, a Panorex and cone beam CT radiograph, and maxillary and mandibular alginate impressions for the creation of a SurgiGuide (Materialise). The maxillary model was sent to the dental laboratory for the aesthetic and functional (occlusion placed in limited lateral contact) wax-up of tooth No. 13.
The model was used to fabricate a putty stint for the fabrication of an aesthetic temporary crown (Figures 1 to 4). The model was lightly lubricated with Coe Sep (GC America). Then a light-bodied vinyl polysiloxane impression material (Aquasil Ultra [DENTSPLY Caulk]) was syringed over the area adjacent to tooth No. 13, and a (nonretentive) tray partially filled with Aquasil putty impression material was seated. After the impression materials had set, the putty stint was removed from the tray and trimmed. Then, the outside of the impression next to the cuspid was marked with a permanent marker (for positive landmark to seat the tray in the mouth).
The information gained from the reformation of the 3-D computer model was treatment planned for the exact position of the implant so the case could use a tissue punch technique for the implant placement. Upon completion of this procedure, it is possible to attain a SurgiGuide that is tooth borne to allow this clinician to do the osteotomy through the tissue-punched opening.⁷ This allows a noninvasive surgical approach, less postoperative discomfort, and better aesthetics.⁸

Surgical Phase of Implant Placement

Figure 5. Seating implant with TempBase (DENTSPLY Tulsa Specialties).	Figure 6. Placing C&B Metabond (Parkell) on TempBase.
Figure 7. Placing the bisacryl composite provisional material (Luxatemp [DMG America]) into the prefabriacted putty stint.	Figure 8. Seating the putty stint. (Note external marker to the cuspid to aid in seating.)
Figure 9. Temporary fabricated.	Figure 10. Trimming excess provisional material.
Figure 11. Trimming with a 12-bladed finishing bur No. 7901 (SS White).	Figure 12. Use of a metal finishing strip (GC America) to trim contacts.
Figure 13. Checking contact.	Figure 14. De-epithilializing tissue with the YSGG laser (1.0 W. 20 Hz 0/14 setting) (Biolase Technology).

The surgical phase of implant placement started with an oral rinse of Peridex for 30 seconds. Then the patient was sedated parenterally with Versed, Nubain, and Benadryl. Local anesthetic (20 mg of lidocaine with 10 mcg of epinephrine, followed by 5 mg of Marcaine with 5 mcg of epinephrine) was administered. The SurgiGuide was used for placement of the tissue punch; then, the appropriate SurgiGuide and the corresponding drills were used to create the osteotomies.
After completion of the osteotomies, the technique with the YSGG laser to detoxify and decorticate the site to start the RAP was used. Following detoxification, a 4.5 x 13 mm XiVE implant (DENTSPLY Tulsa Dental Specialties) was seated at the cervical crest. The implant was able to withstand 35 Ncm of reverse torque (standard criteria for immediate load).⁹ The implant has a TempBase that can be used as a temporary post (Figure 5). The fabrication of a temporary aesthetic crown is aided in the use of C&B Metabond (Parkell) bonding agent to the metal of the temporary post (Figure 6). This has 2 uses: it is used as an opaquer to mask the color of the metal, and to bond the metal to the bisacryl composite material (Luxatemp [DMG America]). A bisacryl composite provisional material is chosen because of the following characteristics: good marginal fit, low exothermic reaction, good abrasion resistance, good transverse strength, and low shrinkage.¹⁰ The ease of handling the preloaded cartridges (Figure 7) makes it easy to dispense in a timely fashion. Figure 8 shows the putty stint fully seated with firm finger pressure for the 2-minute setting time. For any voids that may occur, bisacryl composite materials can be easily repaired with either a flowable or compactable type of composite. Then, the temporary can easily be trimmed in a few minutes. (The author likes to under contour the restoration gingivally to allow the tissue to rebound to optimal tissue height.)
The temporary was trimmed (Figures 9 to 11) with a 12-bladed finishing bur No. 7901 (SS White). Then, the contacts were polished (Figure 12) with the use of medium grit metal strips (GC America), flossed (Figure 13) to verify they were free of debris, and checked for proper contact with the adjacent teeth. The area was rinsed to remove all composite debris away from the site. Finally, the tissue was de-epithialized (Figure 14) with the YSGG laser (1.0 W. 20 Hz 0/14 setting [BIOLASE Technology]). This irritates the tissue to increase vascularization to the area, which in turn actually allows the tissue to rebound. PeriAcryl (GluStich Delta) cement was used to seal the tissue, thus eliminating suturing and acting as a seal until the epithelium heals in 3 days (Figure 15).

Figure 15. Placing PeriAcryl (GluStich Delta) cement.	Figure 16. Occlusion adjusted.
Figure 17. Face-bow (Panadent) taken.	Figure 18. Temporary: 4 days postoperatively.

Figure 19. Final crown (Captek [Precious Chemicals]) after 3 months.

The occlusion was adjusted (Figure 16). Then, the restoration was polished with a PDQ composite polishing bur, and the external surfaces were sealed with OptiGuard (Kerr) to maintain polish. Before removing the IV, the patient was given dexamethasone and cefazolan. Finally a face-bow (Panadent) was acquired (Figure 17).
Postoperative instructions were given: the patient was asked to stay away from direct function and not chew gum for 3 months. Four days postoperatively (Figure 18), the patient rated the pain as a zero on a scale of zero to 10 (zero meaning “no pain,” and 10 meaning “ the most pain ever experienced”).
The case healed uneventfully for 3 months. Finally, the case was completed with the seating of the custom post and a Captek crown (Precious Chemicals) (Figure 19). Since the temporary was bonded to the metal, the temporary needed to be sectioned off the abutment with the use of a composite flame-shaped finishing bur. The pieces were removed by the use of a crown remover (Brasseler USA).

CLOSING COMMENTS
The case described in this article was accomplished in an hour and a half. (The surgical time was 60 minutes, 2 post-op times were 10 minutes, and seating time of the post and crown was 20 minutes.) This included IV sedation, placement of the implant, impression of the final restoration, temporary post and crown fabrication, occlusal adjustments, face-bow registration, and giving the patient postoperative instructions. This author has used this same technique for the fabrication of large anterior implant supported bridges.
The cost of implant dentistry is expensive, the concept of surgery is stressful, and the trust your patient bestows upon you is great. But when the patient comes back for postoperative check and thanks every one of your staff for the painless and very pleasing result, the only word that comes to mind is priceless!

Acknowledgment
The author would like to thank the dental technician team at YES Dental Laboratory, Tarrytown, NY.

References

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Dr. Kusek is a 1984 graduate of the University of Nebraska School of Dentistry. He has been a general dentist for more than 25 years in Sioux Falls, SD. He is a Diplomate of the American Board of Oral Implantology/Implant Dentistry and the International Congress of Oral Implantologists, a Fellow of the American Academy of Implant Dentistry, and has earned Mastership in the World Clinical Laser Institute and the Academy of General Dentistry. He is adjunct professor at the University of South Dakota and lectures nationally on YSGG lasers. He can be reached at (605) 371-3443 or implantdental@midconetwork.com.

Disclosure: Dr. Kusek reports no conflicts of interest.