Written by Edward R. Kusek, DDS Friday, 31 August 2007 19:00
The 2 case reports described in this 2-part article utilize computed tomography (CT) technology to achieve exact implant placement in combination with the use of a YSGG laser to accomplish faster healing, less tissue shrinkage, and increased bone-to-implant contact. This allows the dentist/lab technician to develop a custom post and crown to deliver treatment with greater aesthetics, quicker case completion, and, most importantly, reduced postoperative discomfort for the patient. Part 1 of this article (April 2007) presented an immediate load case. This article presents a 2-stage approach.
A 17-year-old male presented with the request to restore areas Nos. 7 and 10 with dental implants. The patient was congenitally missing these teeth. After completion of orthodontics, he had sought a clinician who could complete his case. He had no dental history other than orthodontics; there were no restorations or decay present upon examination. No medical history of any significance was noted. The soft-tissue exam was normal, with no pocketing of 3 mm or more. There was no pain of the muscles of mastication and no history of TMD problems. A clinical exam revealed 6 mm of space between the central incisors and cuspids. Dental records taken included a Panorex and periapical x-ray. A CT scan was requested to determine if the 6 mm of space maintained itself from the coronal to apical portions of both areas. After being informed about the pros and cons of every option, the patient and parents opted for block grafts followed by implant-supported crowns.
Figure 1. Immediate implants would probably not be possible for this patient.
It was determined from the CT scan that it would be possible to place implants into the space, but a block graft would be needed first. This graft would allow exact placement of the implant for the highest level of aesthetics. Bilateral block grafts were completed (as described by Kusek) using a YSGG laser (Biolase Technology) for faster healing and less discomfort.1 After the block graft healed, a new CT scan was completed and reformatted for use with SimPlant software (Materialise) to plan the case in 3-D on the computer. Implant positions were treatment planned, and a SurgiGuide (Materialise) was requested to enable exact positioning of the implants. It was determined that a Nobel Biocare Select Groovy 3.5x13-mm would be the implant of choice. The surgery was scheduled 4 months from the block graft procedure.2 Hounsfield values for the bone surrounding the implants were approximately 700. Thus, the patient was informed that immediate implants would probably not be a possibility (Figure 1).
Figures 2 and 3. Removal of fixation screws from block graft using the YSGG laser.
The patient performed an oral rinse of Peridex (OMNI Preventive Care, a 3M ESPE Company) for 30 seconds. Then, the patient was sedated parenterally with Versed, Nubain, and Benadryl. A local anesthetic of 20 mg of lidocaine with 10 µg of epinephrine followed by 5 mg of marcaine with 5 µg of epinephrine was administered. Removal of fixation screws from the block graft was accomplished by a small incision made with the YSGG laser using 1.25 W 30 Hz 7/12 settings (Figures 2 and 3). The SurgiGuide was used for placement of the tissue punch, then the appropriate Surgi-Guide and the corresponding drills were used to create the osteotomies.
Figure 4. The YSGG laser is used to detoxify the site and start the RAP phenomenon.
Figure 5. Following detoxification, implants were seated 3 mm below the gingival crest.
Figure 6. Impressions were taken, but the implants were not loaded. Figure 7. After tissue welding with the YSGG laser, cyanoacrylate cement is used as an oral bandage.
Figure 7. After tissue welding with the YSGG laser, cyanoacrylate cement is used as an oral bandage.
Figure 8. A face-bow record is taken, and bite registration is completed.
After completion of the osteotomies, the technique with the YSGG laser to detoxify the site and start the regional acceleratory phenomenon (RAP), as described in Part 1, was used (Figure 4). Following detoxification, implants were seated 3 mm below the gingival crest (Figure 5). Impressions were also taken as described in Part 1, but this time the implants were not loaded because they could not withstand 35 Ncm of reverse torque (Figure 6). Healing caps were placed, and the tissue removed by the tissue punches was tissue-welded back into position with the YSGG laser. This was followed by cyanoacrylate cement used as an oral bandage (no sutures; Figure 7). Before removing the IV, the patient was given dexameth-asone and cefazolin. Biostimulation was performed at 1.5 W 30/30 for 30 seconds (this dosage was applied 2 more times in a 2-week period). A face-bow was done using the Panadent system, and bite registration was completed (Figure 8).
Figures 9a and 9b. Tissue health 2 weeks after implant placement.
Figures 10 and 11. Implant uncovering is accomplished with the YSGG laser.
Figure 12. Radiograph verifies that the post is seated flush with the implant body.
Figure 13. Final aesthetics of the case.
Three days postoperatively, the patient rated the implant placement procedure at 0.5 on a scale of 0 to 10, with zero meaning ìno painî and 10 meaning ìthe most pain ever experienced.î Again, using the YSGG laser and biostimulation makes it possible to achieve these results. Note the tissue health 2 weeks after placement of the implants (Figures 9a and 9b). The case was sent for completion after the surgical phase (lab partner: Americus Dental Laboratory) and was ready to seat in 3 months.
Uncovering was accomplished with the use of a YSGG laser using 1.25 W 20 Hz 5/12 settings (Figures 10 and 11). Note the oval-shaped window cut on the palatal side of the healing cap. Then, the laser tip was taken subgingivally in a split thickness approach. This provides extra tissue facially when the posts and crowns expand the tissue. If any extra tissue remains, then it can be easily trimmed with the YSGG laser. Anesthetic was used in an infiltration around the attached tissue only. X-rays were used to verify that the post was seated flush with the implant body (Figure 12). The crowns were tried in, and the contacts and occlusion were adjusted. The aesthetics were acceptable to the patient, so the case was seated using IMPROV cement (Alvelogro; Figure 13).
High-tech implant dentistry means offering the patient a quicker restoration from start to finish. This is accomplished by the use of 3-D CT technology, the YSGG laser, biostimulation, and having a dental laboratory as a true partner. Changing the density of bone surrounding the implant is paradigmatic in concept. Decreasing the amount of postoperative pain can be likened to removing the word ìsurgery,î which can be a deterrent to case acceptance. Finishing treatment quickly allows patients to go back to their normal activities without repeated explanations to friends and colleagues. Using the laser with implants has raised the bar in implant dentistry. This is a positive change, as we as clinicians continue to strive for better treatment modalities for our patients.
- Kusek ER. Use of the YSGG laser in dental implant surgery: scientific rationale and case reports. Dent Today. Oct 2006;25:98-103.
- Pikos MA. Alveolar ridge augmentation using mandibular block grafts: clinical update. Alpha Omegan. 2000;93:14-21.
Disclosure: The author has no financial interest in Biolase or funding from the manufacturer for research studies.
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