INTRODUCTION
Dental implants have become a mainstream treatment modality for our patients. Many individuals with dental problems first investigate possible solutions by searching on the Internet. Searches often include “tooth aches,” “missing teeth,” “hate my partial,” “hate my denture,” “want permanent teeth,” “ugly teeth,” and “help my mouth!” The typical result of these searches is “dental implants.” As our practical and continuing education (CE) opportunities have increased, the general dentist is now able to diagnose and treat edentulous situations with confidence.
Dental implants are no longer considered to be experimental, and the long-term prognosis is excellent when the process is planned and completed properly. Of course, options are discussed with our patients, including conventional removable and fixed appliances. Permanent dental implant restorations are advertised extensively in the media, so the public has become astute to the possibilities of dental implant reconstruction. Certainly, the protocols for dental surgical implant placement can be taught. The newest technological advancements make these procedures predictable. Visualizing the case finished prior to any surgical intervention is accomplished with CBCT analysis and experience.1 Diagnostic software allows us to idealize implant and tooth positions, emergence profiles, and maximized function.
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| Figure 1. CBCT diagnosis from 3DDX (coDiagnostiX software) allows the practitioner to virtually place dental implants in ideal positions, allowing for proper emergence profile in the central groove and cingulum areas of the teeth in the prosthesis. | Figure 2. The height and width of the usable bone was calculated to ensure acceptance of the diameter and length of the chosen implant. |
Our job as dentists is not to sell procedures to our patients but rather to educate and instruct them on the benefits and risks of various treatment modalities. Removing teeth, especially in the aesthetic smile zone, is emotional to the patient. An edentulous anterior space can negatively affect the psyche. Even as patients understand the demise of their natural dentition, losing these teeth can be traumatic. Our positive reinforcement of what dentistry can provide helps convince these patients that the treatment is a need that will improve the quality of their life. Looking and feeling younger and being able to chew properly is priceless.
As the general dentist is often the first professional consulted for such issues, being confident and competent to provide implant dentistry is important. The referral process is still applicable and important, but with proper training on our advanced technology, the modality is certainly within the realm of the GP. CE is the key to the dentist being able to provide this innovative treatment. Understanding vital anatomy and physiologic restraints in both the hard and soft tissues is critical to proper implant placement. Taking a tooth down/up approach provides the matrix for proper fixture positioning, which is the foundation to emergence profile and smile design.2
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| Figure 3. A precise surgical guide was fabricated by 3DDX using coDiagnostiX software. | Figure 4. Preoperative view of the edentulous space. |
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| Figure 5. The amount of vertical dimension of occlusion (VDO) was evaluated to accept the final implant-retained prosthesis. | Figure 6. The nonrestorable, periodontally involved maxillary bicuspid tooth was atraumatically removed by using the forceps with an atraumatic technique to maintain the facial plate of bone, allowing for immediate implant placement into the socket site. |
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| Figure 7. The edentulous ridge’s attached gingiva was aggressively reflected to visualize the available hard-tissue contour. This allowed for a complete seating of the surgical guide. | Figure 8. The surgical guide was seated directly onto the available bone with no interference from the reflected tissue. A complete seat was mandatory for use of a bone-level surgical guide for implant placement. |
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| Figure 9. Guided surgical burs were used to create the final osteotomy to accept the implants. Starting with a smaller-diameter bur, the osteotomy width was progressively increased to the predetermined size. | Figure 10. The 6 Hahn Tapered Implants Systems (Glidewell Laboratories) were then precisely positioned using the surgical guide. |
We are aware that, physiologically, bone loss continues following the removal of teeth. Removable appliances may need to be realigned or replaced over time because of changes in the hard tissue, not because the plastic distorts it. With this resorption of bone comes a collapse of facial structures and lip support. Our modern implants are used for single-tooth replacements all the way up to full-arch reconstructions.3,4 It seems that permanent tooth placement is the gold standard to the public. Realistically, if we had an option, each of us would select a fixed result. There are essential plans to maximize implant position to ensure aesthetics, form, and function. With these fixed appliances, there is elimination of any palatal coverage in the maxilla and minimization of the ridge coverage in the mandible.5 Home care with these implant-supported prostheses becomes critical. Reinforcing hygiene with tools such as floss, super floss, a Waterpik, or irrigators is paramount to a healthy, long-term result. Our patients must take some responsibility for continuous care and monitoring.
CASE REPORT
In this case, monolithic zirconia (BruxZir Solid Zirconia [Glidewell Laboratories]) fixed bridgework was discussed with our patient. The long-term positive prognosis of such a reconstruction requires that the supporting implants be strategically placed. There are 2 essential criteria to be considered for success with implant placement: (1) overall health and the absence of uncontrolled medical healing problems, and (2) quality and quantity of the available hard tissue. The use of our modern CBCT analysis is an excellent tool that allows the dentist to virtually design and place the implants prior to any surgical intervention. Using the proper software, the final prosthesis can also be designed. In this case, the PaX-i3D Green CT (Vatech America) was used to evaluate the bone structure in 3-D. Virtually placing the implants in ideal positions in the available bone allows for the evaluation of a maximized emergence profile in the central groove and cingulum area of the teeth in the final prosthesis (Figure 1). The height and width of usable bone was calculated to ensure acceptance of the diameter and length of the chosen implant (Figure 2).
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| Figure 11. A postoperative panoramic radiograph was taken to demonstrate the implant positions. | Figure 12. A post-op CBCT evaluation indicated nice positioning of our implants in the available bone. |
DICOM files from the diagnostic CBCT scanner (Vatech America) were uploaded to 3DDX (coDiagnostiX) to begin the planning phase of this restoration. Study casts were sent to 3DDX for digitizing via laser scanning and virtual planning and creation of the digital wax-up. These 2 files were then merged to create an opportunity to create a precise surgical guide (Figure 3), which is fabricated specifically for the type of implant chosen (Hahn Tapered Implant System [Glidewell Laboratories]) so that the implant body can be threaded through the guide to the predetermined angulation and depth.
Figure 4 illustrates the preoperative view of the edentulous space. There were no anatomic contraindications noted. The surgical guide was designed to be tooth-supported and stable. Stability is critical to the success of any guided surgical procedure. Any discrepancy can result in improper implant positioning. The precision of merging the hard model and CBCT DICOM files cannot be underestimated. An evaluation was also done to ensure there was enough vertical dimension of occlusion: There needs to be enough clearance for the final prepared abutments and implant-retained bridge to be fabricated (Figure 5). It was determined that the non-restorable, periodontally involved maxillary bicuspid would be extracted, and this tooth was added to the final bridgework. A pair of forceps was used to carefully and atraumatically remove the tooth, thus maintaining the facial plate of bone. A socket that was acceptable for an immediate implant placement was then created (Figure 6).
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| Figure 13. Following integration of the implants, open-tray impression copings were inserted into each implant. Note the significant band of attached gingiva. | Figure 14. The final VPS impression was very accurate (Panasil Putty soft and Panasil initial contact regular [Kettenbach LP]). |
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| Figure 15. The dental laboratory team (Glidewell Laboratories) fabricated custom titanium abutments with margins at the gingival crest, or ever so slightly subgingivally. | Figure 16. A PMMA transitional smilecomposer was fabricated to help the patient and clinician evaluate the occlusion and smile design. |
Once the guide was received, the surgical process began with reflection of the attached gingiva. The hard-tissue contours were thus visualized clinically (Figure 7). Figure 8 shows how the surgical guide was seated directly onto the available bone with no interference from the reflected tissue. A complete seat is mandatory for the use of a bone-level surgical guide for implant placement. Guided surgical burs were used to create the final osteotomy to accept the implants. We started with a smaller-diameter bur and increased the osteotomy width to the predetermined depth (Figure 9). The 6 Hahn Tapered Implant Systems were then precisely positioned using the surgical guide (Figure 10). The postoperative panoramic radiograph and CBCT scan in Figures 11 and 12 show the accurately positioned implants in the available bone. Following integration of the implants, open-tray impression copings were inserted into each implant. Note the significant band of attached gingiva (Figure 13). An accurate vinyl polysiloxane final impression (Panasil Heavy body putty and monophase Medium [Kettenbach LP]) was taken (Figure 14). With this impression, the dental laboratory team (Glidewell Laboratories) was able to fabricate a master cast and mill custom titanium abutments with margins at the gingival crest, or ever so slightly subgingivally (Figure 15). To help the patient and practitioner evaluate the aesthetics and occlusion, a PMMA transitional smilecomposer was fabricated prior to milling of the final BruxZir prosthesis (Figure 16). After proper aesthetics were confirmed, the final BruxZir zirconia implant-retained prosthesis was created.6 Gingival shading allowed for more “normal” contoured teeth (Figure 17). The occlusal view of the arch with the custom-milled titanium abutments verifies the implant positions (Figure 18); Figures 19 and 20 illustrate the final implant-retained prosthesis in position following cementation with an implant transitional cement (Improv Temporary Implant Cement [Salvin Dental Specialties]) and the final smile design, which restored both aesthetics and function for our patient.
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| Figure 17. After acceptance of the aesthetics, the final zirconia (BruxZir Solid Zirconia [Glidewell Laboratories]) implant-retained prosthesis was created and delivered to the dental office. Gingival shading allows for more “normal” contoured teeth. | Figure 18. Occlusal view of the custom titanium abutments. |
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| Figure 19. The implant-retained prosthesis was retained using a transitional cement (Improv Temporary Implant Cement [Salvin Dental Specialties]). | Figure 20. The final smile design restored the patient’s aesthetics and function. |
CLOSING COMMENTS
Investment in technology makes the GP more efficient and proficient. As visualizing a case finished prior to any surgical intervention was once seen as an art that came with experience, CBCT analysis and digital planning allows the GP to predictably plan and implement implant surgical procedures in the practice. Competency in giving quality and predictable patient care is the result of continuous learning. Proficiency is the result of knowing our limits and practice. Conventional dental techniques continue to be an option to our patients; however, as implant dentistry continues to become more mainstream and as our patients begin to educate themselves on the long-term benefits of this treatment, it behooves the GP to get involved.
References
- Benavides E, Rios HF, Ganz SD. Use of cone beam computed tomography in implant dentistry. The International Congress of Oral Implantologists consensus report. Implant Dent. 2012;21:78-86.
- Scherer MD. Presurgical implant site assessment and restoratively driven digital planning. Dent Clin North Am. 2014;58:561-595.
- Carames J, Tovar Suinaga L, Yu YC, et al. Clinical advantages and limitations of monolithic zirconia restorations full arch implant supported reconstruction: case series. Int J Dent. 2015;2015:392496.
- Preciado A, Del Río J, Lynch CD, et al. Impact of various screwed implant prostheses on oral health-related quality of life as measured with the QoLIP-10 and OHIP-14 scales: a cross-sectional study. J Dent. 2013;41:1196-1207.
- Pozzi A, Holst S, Fabbri G, et al. Clinical reliability of CAD/CAM cross-arch zirconia bridges on immediately loaded implants placed with computer-assisted/template-guided surgery: a retrospective study with a follow-up between 3 and 5 years. Clin Implant Dent Relat Res. 2015;17(suppl 1):e86-e96.
- Agustín-Panadero R, Román-Rodríguez JL, Ferreiroa A, et al. Zirconia in fixed prosthesis. A literature review. J Clin Exp Dent. 2014;6:e66-e73.
Dr. Kosinski is an affiliated adjunct clinical professor at the University of Detroit Mercy School of Dentistry (Detroit Mercy Dental) and is the associate editor of the AGD journals. He is a past president of the Michigan Academy of General Dentistry. Dr. Kosinski received his DDS degree from Detroit Mercy Dental and his mastership in biochemistry from the Wayne State University School of Medicine. He is a Diplomate of the American Board of Oral Implantology/Implant Dentistry, the International Congress of Oral Implantologists, and the American Society of Osseointegration. He is a Fellow of the American Academy of Implant Dentistry and received his mastership in the AGD. He can be reached at drkosin@aol.com or via the website smilecreator.net.
Disclosure: Dr. Kosinski reports no disclosures.
Dr. Tilley is a graduate of the University of Alabama School of Dentistry. She is a native of Pensacola, Fla, and has been practicing dentistry in her hometown since 1998. Dr. Tilley keeps up with the latest in dentistry by attending continuing education seminars on topics such as oral surgery, implants, veneers, periodontal disease, cosmetic procedures, and much more. She has also done extensive training at the Las Vegas Institute and the Engel Institute with Drs. Kosinski and Todd Engel. She is a member of the AGD, ADA, Florida Dental Association, Alabama Dental Association, Academy of Laser Dentistry, and the Academy of American Facial Esthetics. She can be reached at stephflynntilley@cox.net.
Disclosure: Dr. Tilley reports no disclosures.
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