MICROEVOLUTION OF IMPLANT DENTISTRY
The world of dental implants has seen many changes since Dr. Brånemark placed the first implant in 1965. Historically in the United States, implantology was mainly considered to be territory of the specialists. In the early 2000s, mini implants gained a great deal of popularity among general practitioners (GPs) due to the minimally invasive nature of the surgery and, furthermore, with the ability to integrate these procedures into the practice in a very streamlined manner. It is this movement that has provided the basis for the most recent minimally invasive technologies in implant dentistry. This is wonderful news for patients in need of implant services because we are now able to provide a wide range of implant services in the GP practice in an efficient and minimally invasive manner. During the last decade, specialists have embraced general practitioners placing routine implants in their family practices. Now that specialists assume/expect that the GPs place 80% of the implant cases, it only makes sense that all GPs offer minimally invasive implants to their patients.
|Figures 1a and 1b. The 3-in-1 Implant Procedure performed on site No. 30 using the high-speed handpiece approach.|
Minimally Invasive Implant Procedure Integration
It is important to define the term minimally invasive as it relates to implant dentistry in the GP practice because many GPs are not using up-to-date implant techniques. By following a few principles, the GP should have very little need for bone grafting or membrane procedures. The key to efficient implant placement for the GP is to triage the implant cases that can be done within the scope of the family practice and to refer the cases out to specialists that cannot be efficiently and minimally invasively performed in-house. As Lasik surgery has revolutionized ophthalmology, and laparoscopic surgery transformed orthopedic surgery, so have the techniques used for the 3 procedures to be discussed below reinvented implant dentistry for the GP.
FULLY UTILIZING AVAILABLE BONE (REDUCTION IN GRAFTING)
The Availability Principle focuses on the available bone present to accommodate an implant to fit those specific dimensions. This may mean a very narrow, long implant for some sites with a great deal of bone height and little width. Conversely, it may mean a very short, wide implant for sites with ample width and deficient height. The international implant community has now proven long-term success rates with short implants (6 to 8 mm long) as well as longer and narrower implants. This allows us to choose or size an implant contingent on the available bone present rather than manipulate vital structures and bone tissue to fit what we used to believe was the “ideal” size implant. So, rather than doing an open or closed sinus augmentation, we are able to choose a length and width of implant that can accommodate an area of what we traditionally called deficient bone. Since the mid-1980s, the implant field has demonstrated that even 6.0-mm length implants have the same, very high success rate. A recent study by multiple oral surgeons concluded that short implants (8.0 mm or less) had the same statistical long- and short-term success rates.1
By following the Availability Principle, the average GP may open the doors to a wide variety of implant cases on a monthly basis. The following is a brief overview of the 3 procedures that can transform your practice, if you choose to learn more about them.
The 3-in-1 Implant Procedure
The first procedure that I would like to review is called the 3-in-1 Implant Procedure (Figure 1). Many GPs call this the “5-minute implant, abutment, and crown” procedure. This procedure allows a patient to reduce his or her time in the dental chair to receive an implant, abutment, and crown, by up to 3 appointments. It is a huge benefit to your patients because there is less time investment in the dental office, and there is typically much less discomfort associated with the procedure. The reduction in discomfort is largely related to the usage of one of the top 5 minimally invasive, no-suture, soft-tissue accesses. Remember, bone is not innervated; nerves may travel through the bone but do not directly innervate. Any discomfort related to an implant procedure postsurgically is caused by soft tissue. When we provide for a less invasive surgery, we reduce soft-tissue involvement and any resulting pain. The 3-in-1 Implant Procedure is applicable for almost any edentulous area in the mouth that is suitable. Many believe that this is highly related to the fact that the periosteal membrane is left intact, allowing for more blood flow to the bone during the implant integration phase. A flap disturbs periosteal blood flow and allows a greater opportunity for micro-organisms to enter the site. A recent study notes the same high success rate with flapless compared to flap procedures with a more favorable crestal bone response with flapless.2
The most popular of the 5 minimally invasive soft-tissue accesses is the high-speed handpiece approach. The initial soft-tissue access, and the first 2.0 to 5.0 mm of the pilot hole in bone are created using a circular motion with the high-speed handpiece and a special bur designed for this purpose. A very exacting initial hole is created in this procedure because one of the most accurate tools in the GP’s hands is the high-speed handpiece. The final osteotomy is created with the normal implant handpiece and MultiDrill, and then the implant is placed. Immediately after implant placement, an OsteoReady Customizable abutment is torqued to 32 Ncm. This abutment is unique in that it has 20% more titanium than many abutments and can be prepared directly in the mouth just like a standard crown preparation. This technique saves 2 appointments and reduces the costs and complexity for both the clinician and patient. From a clinical standpoint, the risk of peri-implantitis from cement retention is virtually eliminated due to the perioseal or attachment that develops around the abutment prior to seating the final crown.
To more fully understand the 3-in-1 Implant Procedure, please visit tinyurl.com/jwmcxbz to view a video on this technique.
|Figures 2 to 4. Unrestorable tooth No. 13 extracted and a No-Drill implant placed using the OsteoConverter.|
The No-Drill Implant Procedure
Of all of the advances made in implant dentistry within the last 10 years, the OsteoReady No-Drill Implant Procedure, using an OsteoConverter, has had a notable impact on the general practitioner’s productivity and patient satisfaction (Table 1) (Figures 2 to 4).
Immediately after extracting a tooth, an OsteoConverter is inserted with a spiraling motion into the socket, which achieves the following 2 important tasks: first, the periodontal ligament is scored in roughly 2.0-mm increments allowing blood flow and bone forming cells to enter the site to aid in osseointegration; second, the unique curvature of the root is “converted” to more of a cylindrical shape that allows for an implant-worthy osteotomy. The OsteoConverter is a hybrid of a bone condenser and osteotome but is also serves as the permanent implant once inserted.
It is the author’s finding that the majority of GPs who learn this procedure are able to immediately incorporate it successfully into their busy practices. Undoubtedly, the extraction takes more time to complete than the implant procedure. In many practices, about 50% of extractions have transformed to extraction and implant cases using the No-Drill Implant Procedure.
|Figure 5. Teeth Nos. 12 and 13 implant, abutment, and crown completed using the 1-Drill and the 3-in-1 Implant Procedures.|
Studies support the success of immediate placement flapless procedures which result in little to no crestal bone loss and show high success rates. In a study titled, “Flapless Single-Tooth Immediate Implant Placement,” researchers found a favorable implant success rate related to the flapless immediate implant placement protocol.3
The 1-Drill Implant Procedure
The third and final procedure that can help GPs with placing implants more efficiently is the OsteoReady 1-Drill Implant Procedure (Table 2) (Figure 5). Quite simply, instead of the clinician going through a series of 4 or 5 drills to complete one osteotomy, one drill is used to complete the final osteotomy. The drill designed specifically for this technique is called the MultiDrill; it has the widths of 4 to 5 drills built into it. This procedure has the potential to impact implantology in the GP’s practice much like the many recent advances in endodontics have done.
Implants placed with this procedure take less time to complete than the typical occlusal composite resin restoration, allowing the clinician the opportunity to reduce the surgical fees for patients in need of implants.
Two of the most exciting subcategories within the 1-Drill Procedure include the OsteoHybrid Implant Procedure and the OsteoLift Implant Procedure. The OsteoHybrid Implant Procedure acts as the bridge between using mini and conventional implants. If you often ask yourself, “How do I place a conventional implant in a narrow ridge?” then the OsteoHybrid Implant Procedure opens wide the doors to many cases that used to be infeasible to properly complete without complex and invasive ridge-splitting surgery or block grafting. This implant allows for just one drill, and acts as a bone expander to widen the ridge to accommodate the implant, making a hybrid implant particularly well-suited for successful osseointegration in a narrow ridge. A study titled, “Less invasive surgical procedures using narrow-diameter implants,” supports the success of using narrow implants—such as the implants that are used for the OsteoHybrid Implant Procedure. Researchers in this study found that narrow implants had very favorable survival and success rates4 (Table 3) (Figure 6).
|Figure 6. The OsteoHybrid Implant Procedure.||Figure 7. The OsteoLift Implant Procedure.|
If you’ve ever felt concerned about placing a conventional implant in the maxilla with a limited bone height or have been worried about the hazard of sinus damage, then the OsteoLift Implant Procedure will benefit your practice and your patients. As mentioned previously, short wide implants (6.0 to 8.0 mm) placed near the sinus without any sutures, grafting or membranes have been demonstrated in multiple studies during the last decade to be just as successful as longer implants (10.0 to 13.0 mm). In a study titled “Short Implants: A Systematic Review,” researchers5 found that the survival rate of short implant increased from 80% to 90% gradually, with recent articles showing 100% (Table 4) (Figure 7).
If you currently place implants in your practice, I hope that you consider adding these influential procedures into your daily mix. Just an example to show how easy it can be to incorporate these procedures in your practice—a GP who recently attended one of the OsteoReady courses went from placing 15 implants a month to 30 after reading a recent article I had written. He then attended the 2-day mini-residency with the hopes of going up to 75 implants a month while still maintaining the same volume of bread-and-butter dentistry in his practice. He is on track to exceed his goal by incorporating the 3 procedures that were discussed herein. In my own practice, I have found that one of the greatest benefits from the efficiencies related to these 3 procedures is the ability to provide lifetime implant services at very reasonable fees to my patients.
If you do not currently place implants, or only place mini (small-diameter) implants or fewer than 40 conventional implants per month, I would encourage you to dig deeper into the procedures discussed in this article. When performed properly, these techniques will help you provide more streamlined, simplified, and comfortable implant services for your patients.
- Grant BT, Pancko FX, Kraut RA. Outcomes of placing short dental implants in the posterior mandible: a retrospective study of 124 cases. J Oral Maxillofac Surg. 2009;67:713-717.
- Bashutski JD, Wang HL, Rudek I, et al. Effect of flapless surgery on single-tooth implants in the esthetic zone: a randomized clinical trial. J Periodontol. 2013;84(12):1747-1754. [Epub January 24, 2013.]
- de Carvalho BC, de Carvalho EM, Consani RL. Flapless single-tooth immediate implant placement. Int J Oral Maxillofac Implants. 2013;28(3):783-789.
- Lambert F, Lecloux G, Grenade C, et al. Less invasive surgical procedures using narrow diameter implants: a prospective study in 20 consecutive patients. J Oral Implantol. April 25, 2014. [Epub ahead of print]
- Karthikeyan I, Desai SR, Singh R. Short implants: A systemic review. J Indian Soc Periodontol. 2012;16(3):302-312.
Disclosure: Dr. Frank is founder of OsteoReady, LLC.