Written by Kenneth L. Hilsen, DDS, and John Kallis, DMD Monday, 01 January 2007 00:00
The prosthodontist, along with the oral and maxillofacial surgeon, are always looking for better ways to provide permanent teeth with the least amount of discomfort and inconvenience for their patients. In the case presented in this article, with both specialists at the same location the patient was given anesthesia and the clinicians rotated their services as needed to accomplish their plan. The diagnosis and extensive treatment planning were done in advance so as to have temporary teeth ready for the day of surgery. The surgeon removed the teeth and placed the implants, and the prosthodontist then loaded the implants with temporary teeth. The patient experienced no discomfort during the procedure and left the appointment with fixed teeth, able to eat and resume normal activity.
Over the years, techniques have changed and developed as the field of implantology has progressed. The original protocol for implant placement involved an edentulous ridge, which was stable for several months.1,2 Implants were inserted into the bone through a full thickness flap. The flap was then sutured closed and not disturbed for approximately 6 months. The patient was instructed not to wear any dentures for a period of one week, and thereafter as little as possible. It was extremely important not to sleep with the dentures, as micromotion of the implants under the dentures could lead to implant failure. Therefore, the patient was inconvenienced for an extended period.
When the osseointegration period was over, a second-stage surgery was performed to expose the implants by removing the overlying tissue and placing a transmucosal element. At this point temporary teeth could be placed and the reconstruction begun.
This 2-stage surgery technique was improved upon with a single-stage technique, whereby the transmucosal element is placed the same day as implant placement, or differently designed implants are used that remain supragingival. The one-stage technique has the great advantage of requiring only one surgery, and it eliminates the need for a second surgery to expose the implant. (Many patients report that considerable pain is associated with the second surgery.) This technique also results in saving time, as the soft tissue heals during osseointegration.3 In addition, phobic patients appreciate less time in the chair. However, the technique provided for extended osseointegration time before loading, therefore no teeth were placed on the implants until after the 6-month healing period in both cases.
The placement of special surfaces on implants was found to promote osseointegration. These surfaces include osseotite, titanium plasma sprayed (TPS),4 sandblasted large-grit acid-etched (SLA), Nobel Biocare’s TiUnite, and others. Researchers such as Lazzara,5 Buser,6 and Cochran7 showed that the osseointegration period could be reduced to 3 months, to 2 months, and now to about 6 weeks.
The next advance was to place teeth on implants on the same day they were surgically implanted into edentulous areas in the mouth. This is called immediate loading. The author (Hilsen) was involved in some of the earliest research trials in this technique. The success of this procedure was confirmed by Jaffin,8 Schnitman,9 Henry,10 Chiapasco,11 Randow,12 and Tarnow13 in various clinical trials.
The next advance was to extract teeth and place implants into the extraction site(s) the same day. This is called immediate placement. However, teeth were not placed on those implants the same day.14
The latest advance is to provide immediate placement (extract teeth and place implants the same day) and also immediately load the implants by placing temporary teeth onto those implants the same day. This is what we have been working on for years. This procedure requires the practitioner to be selective in picking appropriate patients. The bone must be adequate in height and width to accept the implants. There must be enough bone past the socket sites to achieve rigid fixation of the implants. In addition, all residual infection, if any, must be eliminated prior to implant placement.
Immediate placement and immediate loading can be used in any situation if the above conditions are present. This includes single-tooth as well as multiple-tooth situations, maxillary or mandibular, aesthetic or nonaesthetic areas, and other variable situations. The occlusion should be bilateral with cuspid or anterior disclusion in full-arch cases, and not in occlusion if unilateral. Most recently, we have been successful with a procedure that can provide permanent implants and finished teeth in one day of clinical work.15 Not only has the time expended by the participating dentists been compressed, but the time the patient has to endure any discomfort or inconvenience is lessened. Our patients report only minor discomfort, which may be the result of a positive attitude that develops because they can smile immediately with good-looking teeth! The patient experiences little discomfort overall and is able to leave the procedure and resume eating and normal life activities the same day.
The patient, a 55-year-old male, first came to the practice on November 29, 2005. He presented with complete periodontal breakdown; he had 25 loose teeth, and 7 were missing. The overall prognosis was deemed hopeless or questionable for all of his teeth. In the past, extensive periodontal treatment would have been instituted with every effort expended to save even a few teeth to help hold replacement dentures, which would have been removable. The patient’s chief complaint was pain in several areas, loose teeth, difficulty chewing, and poor appearance. He refused any removable prosthesis and demanded aesthetic fixed bridgework.
Figure 1. Preoperative photograph.
Figure 2. Preoperative panoramic radiograph.
The initial work-up involved a complete dental and medical history, a complete examination, preoperative photographs (Figure 1), panoramic radiographs (Figure 2), full-mouth series radiographs, and diagnostic study casts.
After discussing the patient’s goals, it was decided that the latest technology of dental implants should be used for the upper and lower jaws at the same time. The patient’s teeth would be removed by the oral surgeon, and a full complement of implants would be immediately placed with temporary teeth immediately loaded. The surgery would be performed with sedation to maximize the patient’s comfort.
Examination of the radiographs revealed that adequate bone was present to support the implants. Alginate impressions and bite registrations were acquired so that a diagnostic wax-up could be produced. From this a full set of upper and lower provisional acrylic temporaries were fabricated. These temporaries resemble a full-arch temporary constructed for crown and bridge procedures with all teeth being abutments.
The dentists and patient discussed post-treatment guidelines and possible post-treatment challenges. Also discussed were the possibility of implants failing as well as all possible side effects. Informed consent was obtained after the patient understood everything. It was suggested that a third molar that was located completely in the bone be removed, as it could pose a problem in the future. Since the patient was already undergoing surgery, having the wisdom tooth removed would not cause any additional complication.
Post-treatment guidelines that were discussed mostly related to eating. The patient was to maintain a liquid diet for one week, including food choices such as soup or yogurt. During the second week he would be allowed soft scrambled eggs, mashed potatoes, or similar foods. By the fourth week he could resume a normal diet with any food that could be cut with a fork. Challenges could be swelling, infection, discomfort, rejection, and bruising. The patient was instructed that he would need to be seen at one week postoperatively, at 4 weeks postoperatively, and again at 8 weeks postoperatively. As noted below, the patient experienced very little of the possible challenges.
Figures 3a and 3b. Solid abutments.
Figure 4. Premade, processed acrylic temporaries.
Figures 5a and 5b. Plastic temporary cylinders.
Figure 6. Temporaries finished and inserted.
Figures 7a and 7b. Open tray preparation.
Figures 8a and 8b. Final impressions.
Figure 9. Final denture teeth setup.
Figure 10. Denture teeth try-in.
Figure 11. Custom abutments in the mouth.
Figure 12. Finished gold framework.
Figure 13. Finished restorations.
On December 27, 2005, the patient received both intravenous (IV) sedation and local anesthesia. The oral surgeon extracted all remaining teeth. In 2 hours, a total of 16 Straumann ITI implants, 8 in the maxilla and 8 in the mandible, were inserted. Fourteen were 4.1x12 mm and two were 4.8x 12 mm, and all were synocta design. No bone grafting was necessary, as the bone was in good condition with no dihiscences or fenestrations present. Standard, straight, solid abutments were placed in all implants, and parallelism was checked (Figures 3a and 3b). The prosthodontist adjusted any discrepancies using diamond drills and high speed. Temporary teeth were placed on the implants using the premade, processed acrylic temporaries (Figures 4). A plastic temporary cylinder was placed on each implant abutment prior to relining the temporaries (Figures 5a and 5b). After setting, additional cold-cure acrylic was placed to the margins of each plastic cylinder to establish proper contour. The final temporary bridges provided the correct shape to promote healing of the tissue and result in a final gingival architecture that would be both functional and aesthetic. Any cantilevered teeth were removed at this time, as these are contraindicated during osseointegration. The teeth were cemented to the abutments with IRM (Intermediate Restorative Material [DENTSPLY Caulk]), which is strong enough to prevent dislodging (Figure 6).
In this case 2 months were allowed for the implants to integrate with the bone. However, using this immediate placement and immediate loading procedure the patient was able to go about his normal life with a beautiful set of temporary teeth immediately. Once the healing and osseointegration were determined complete, the author (Hilsen) and his team proceeded with the final restoration. An open tray technique (Figures 7a and 7b) and open tray impression copings were used to obtain final Impregum (3M ESPE) impressions (Figures 8a and 8b). Occlusion rims were fabricated on the models, and these were used to establish vertical dimension and centric relation as would be done for complete dentures. A final setup of denture teeth was tried-in (Figures 9), and the aesthetics, phonetics, and relationships were checked before the implant-supported metal frameworks were constructed. When the setup is finalized and approved (Figure 10), the laboratory can use standard abutments, or wax-up and cast custom abutments (Figure 11), and a framework (Figure 12) that will properly support the porcelain that will be placed over it. This framework was made in sections so that final soldering could be completed using registrations obtained in the mouth.
The laboratory also fabricated a new set of upper and lower processed acrylic temporaries, which would now fit over the new abutments and follow the setup of the denture teeth. In this manner the final positions of the teeth can be checked for aesthetics, phonetics, and function as the final prosthesis is fabricated. This greatly reduces or eliminates any changes or modifications of the final teeth. The abutments were seated and torqued to 35 Ncm. A final bite registration was obtained using Blu-Mousse (Parkell). New Impregum final impressions were obtained, which picked up the frameworks to create final master models.
The finished teeth (Figure 13) were inserted 6 months after implantation with a temporary cement (Temp-Bond [Kerr]). There was more than enough retention inherent in the restoration to allow for the final teeth to be left in 2 upper sections and 2 lower sections, and for the continued use of the temporary cement on a long-term basis. This ensures that the restoration can always be removed in the future, if necessary, for any repairs or adjustments.
The patient was able to leave the dentist’s office without pain and did not need to take pain medication that evening, although many patients require this. There was also no swelling or discomfort, and the patient was able to function in his daily routine. Perhaps most importantly, the patient had a full set of teeth…a full, confident smile. The patient was delighted with his outcome (see Before and After photos). He can speak, chew, and smile with a totally healthy and restored mouth. There is approximately a 95% chance15 that the implants, which took one day to provide, will last an entire lifetime.
Based on this experience we can assume that this procedure will become more prevalent in dental offices. This is truly offering a spectacular service to patients. The loss of teeth no longer means months or years of extensive treatment or being doomed to wear removable dentures. This is particularly relevant for the aging baby boomers who are now facing this dilemma. A new technique being developed today involves “guided implant surgery,” which will further reduce the time and increase the accuracy of implant placement, allowing the immediate insertion of finished, permanent teeth and eliminating the need for temporary teeth altogether.
1. Branemark P-I, Zarb GA, Albrektsson T. Tissue-Integrated Prostheses: Osseointegration in Clinical Dentistry. Chicago, Ill: Quintessence Publishing; 1985:199-209.
2. Albrektsson T, Zarb GA. The Branemark Osseointegrated Implant. Chicago, Ill: Quintessence Publishing; 1989:165-195.
3. Buser D, Weber HP, Bragger U, et al. Tissue integration of one-stage ITI implants: 3-year results of a longitudinal study with Hollow-Cylinder and Hollow-Screw implants. Int J Oral Maxillofac Implants. 1991;6:405-412.
4. Babbush CA. Titanium plasma spray screw implant system for reconstruction of the edentulous mandible. Dent Clin North Am. 1986;30:117-131.
5. Lazzara RJ, Testori T, Trisi P, et al. A human histologic analysis of osseotite and machined surfaces using implants with 2 opposing surfaces. Int J Periodontics Restorative Dent. 1999;19:117-129.
6. Buser D, Nydegger T, Hirt HP, et al. Removal torque values of titanium implants in the maxilla of miniature pigs. Int J Oral Maxillofac Implants. 1998;13:611-619.
7. Cochran DL, Nummikoski PV, Higginbottom FL, et al. Evaluation of an endosseous titanium implant with a sandblasted and acid-etched surface in the canine mandible: radiographic results. Clin Oral Implants Res. 1996;7:240-252.
8. Jaffin RA, Kumar A, Berman CL. Immediate loading of implants in partially and fully edentulous jaws: a series of 27 case reports. J Periodontol. 2000;71:833-838.
9. Schnitman PA, Wohrle PS, Rubenstein JE, et al. Ten-year results for Branemark implants immediately loaded with fixed prostheses at implant placement. Int J Oral Maxillofac Implants. 1997;12:495-503.
10. Henry PJ, Tan AE, Leavy J, et al. Tissue regeneration in bony defects adjacent to immediately loaded titanium implants placed into extraction sockets: a study in dogs. Int J Oral Maxillofac Implants. 1997;12:758-766.
11. Chiapasco M, Gatti C, Rossi E, et al. Implant-retained mandibular overdentures with immediate loading. A retrospective multicenter study on 226 consecutive cases. Clin Oral Implants Res. 1997;8:48-57.
12. Randow K, Ericsson I, Nilner K, et al. Immediate functional loading of Branemark dental implants. An 18-month clinical follow-up study. Clin Oral Implants Res. 1999;10:8-15.
13. Tarnow DP, Emtiaz S, Classi A. Immediate loading of threaded implants at stage 1 surgery in edentulous arches: ten consecutive case reports with 1- to 5-year data. Int J Oral Maxillofac Implants. 1997;12:319-324.
14. Becker W, Becker BE, Israelson H, et al. One-step surgical placement of Branemark implants: a prospective multicenter clinical study. Int J Oral Maxillofac Implants. 1997;12:454-462.
15. Jaffin RA, Kumar A, Berman CL. Immediate loading of dental implants in the completely edentulous maxilla: a clinical report. Int J Oral Maxillofac Implants. 2004;19:721-730.
Dr. Kallis received his DMD degree from Farleigh Dickinson University School of Dentistry, and completed his dental residency at Columbia Presbyterian Medical Center. He subsequently completed a 4-year oral and maxillofacial surgery residency at the East Orange Veterans Administration Medical Center, which also included a 1-year general surgery residency at the University of Medicine and Dentistry of New Jersey. Dr. Kallis is a faculty member of the Hospital Dental Service at Columbia Presbyterian Hospital in the Department of Oral and Maxillofacial Surgery. He also serves as assistant clinical professor at Columbia University School of Dental and Oral Surgery, and is co-director of the implant division of Oral and Maxillofacial Surgery at Columbia University. He can be reached at (201) 585-8282.
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