October 1, 2006
by Milan Somborac DDS
Implant treatment has high documented success rates. In a number of common forms of partial edentulism and in all total mandibular edentulism, implant treatment has become the first choice standard of care. General dentists are exploring the possibility of providing complete implant services (surgery as well as the prosthetics) to their patients. Since very little implant treatment is taught in the predoctoral curricula of the world’s dental schools, most dentists receive their implant training in continuing education courses provided by dental schools and implant manufacturers. The ideal training program involves the treatment of live patients and encourages graduates to maintain ongoing contact with mentors and teachers. The ideal implant system for general practice use has all the features needed for long-term success, which were uncovered in meticulous, long-term prospective studies but without the large number of components historically used in these studies. The ideal first surgical case for the beginning dentist is a bicuspid replacement with adequate bone shape and quality in a non-esthetic area. The examples shown in this paper suggest the inclusion criteria for general practitioners in the emerging phase of their implant career as well as what to refer to the specialist or experienced general dentist colleagues.
Canadian demographic trends indicate that the need for implant treatment will experience a double digit annual increase over the foreseeable future.1 To-date, implant treatment has largely been an area of specialist activity, especially in its surgical aspect.2 Surgical specialists will not be able to meet the projected need and general practitioners will have to become increasingly involved.3 In orthodontics, endodontics, periodontics and non-implant surgery today, specialists look after challenging cases while general practitioners look after routine cases in these areas often providing 75% of all treatment. Implantology is at the beginning of a similar distribution of responsibilities. The progressive general practice will include complete implant treatment.
Dentists contemplating the inclusion of implant surgery and prosthetics in their mix of services need to choose an appropriate training program which uses an appropriate implant system. They will need to develop diagnostic and treatment planning skills to separate the cases they should treat from the ones they should refer.
With exceptions, the maxillary and mandibular bicuspids tend to offer good opportunities for the dentist beginning surgery after the completion of a hands-on program.
The maxillary and the mandibular first and second bicuspid each have their own unique characteristics which need to be taken into account in implant treatment.
The features which need to be considered can be further divided into delayed and immediate placement. Frequently, missing bicuspids can be restored with immediate implant treatment. (Implant placement into extraction sockets.) See Figures 1-24.
CHALLENGING BICUSPID CASES
The following cases have inadequate bone shape according to the Lekholm and Zarb classification.4 Dentists beginning their implant surgeries need to be cautious. They should consult with a specialist or experienced general dentist.
1. Immediate placement in a maxillary first bicuspid site (Fig. 25)
The two roots of the first maxillary bicuspid often diverge. Placing an implant in the buccal root socket can leave an inadequate layer of bone buccal to the implant. Placing an implant in the palatal root often results in steep angulation creating restorative challenges. Ideally, the implant needs to be placed into the inter-radicular septum and the buccal and palatal root socket voids need to be grafted. This sort of case is a surgical challenge and needs specialist or experienced generalist input (Figs. 26 & 27).
2. Delayed placement in a maxillary bicuspid site with advanced bone resorption and a low sinus floor (Fig. 28).
It is common for a maxillary bicuspid site which has been edentulous for long to be narrow as well as to have a pneumatized sinus. Both the bone width and depth are inadequate. This is another example of a surgical challenge which needs specialist or experienced generalist input (Figs. 29 & 30).
3. Delayed placement in a mandibular bicuspid site with advanced bone resorption (Figs. 31 & 32).
A narrow mandibular bicuspid area ridge needs horizontal augmentation before implant placement. The technique requires staged ridge splitting6 and is another example needing specialist or experienced generalist input (Fig. 33).
SURGICAL CASE SELECTION CRITERIA FOR BEGINNING IMPLANT SURGERY
The standard medical history and health questionnaire used in the typical practice need to be completed for each potential implant patient. In addition, an implant treatment informed consent form should be completed. The example below, or a variation of it, serves the purpose (See Chart 1).
And finally, Chart 2 can complete the selection process.
With the appropriate training and guidance, the general practitioner can undertake uncomplicated implant surgery and prosthetics. Accurate diagnosis and treatment planning are critical for appropriate case selection. With good documentation before, during and after treatment, replacing a missing bicuspid is a good place to start.
Dr. Somborac is a shareholder in Tenax Implant Inc., and is the co-inventor of the Tenax Dental Implant System. Dr. Somborac maintains a general dental practice which includes both the surgical and prosthetic phases of implant treatment.
Tenax Dental Implant System implants were used in all cases illustrated in this article. Using Tenax implants over the past six years, he and other mentors have launched the implant careers of more than 500 colleagues in Canada and abroad.
Oral Health welcomes this original article.
1. Tosto M. Dental Implants in Canada: A Growing Opportunity, Oral Health, August 2006.
2. Clinical Research Associates Newsletter, Vol. 29, Issue 8.
3. Somborac M. How to Integrate Implant Dentistry in General Practice, Oral Health, February 2003
4. Lekholm, U., and Zarb, G.A. Tissue-lntegrated Prostheses, Quintessence Publishing Co., Inc., 1985
5. Summers R.B. Sinus floor elevation with osteotomes J Esthet Dent. 1998;10(3):164-71.
6. Enislidis G., Wittwer G. and Ewers R. Preliminary report on a staged ridge splitting technique for implant placement in the mandible: a technical note R Int J Oral Maxillofac Implants. 2006 May-Jun;21(3):445-9
Implant Treatment Informed Consent Form
I agree to have implant treatment to improve my dental health. I understand the alternative conventional dental treatment options and I am aware of the consequences of receiving no treatment.
The reason why I am having implant surgery is to provide the equivalent of tooth root(s) where I am missing teeth so that artificial teeth can be attached to them either in a removable or in a permanent way.
I understand that the implant surgery and prosthetics will be done in the established way and that the risks in the front of the mouth consist of the usual ones associated with the use of freezing and simple gum surgery including, but not limited to, drug reaction, pain, swelling, bruising, infection and bleeding.
Additional complications have been reported for implant surgery in the back of the mouth; they consist of possible permanent numbness of the lower lip on the treated side in the lower jaw, and the creation of a hole between the sinus and the mouth on the treated side in the upper jaw. Both of these complications would require further surgery for correction.
I know that it is possible that one or more of the implants may not fuse to my jaw as i
ntended or that a localized infection may develop and the involved implant(s) will need to be removed, again using simple surgery. If I decide to have a fused implant removed because I don’t like the results, then the surgery will be more extensive and require that the adjacent jaw bone be removed as well.
I know that smoking lowers the chances of implant success in direct proportion to the amount smoked. A 95% success rate in the lower jaw and an 88% success rate in the upper jaw is normal.
I agree to make every effort to return for follow-up visits three months, six months, one year, eighteen months and two years after the surgery and to have the needed x-rays taken as well as any cleaning and adjustment procedures needed to keep my mouth healthy at the usual and customary fees, but I am aware that this is entirely voluntary on my part.
I know that the usual methods of minimizing radiation will be used and that all x-rays, photographs and clinical data might be used in scientific papers and presentations and that confidentiality will be respected.
I have had an opportunity to ask questions and I have been advised of the fees.
Time: ________________Date: ______________________
Signed: ______________Signed: _____________________
Patient / Dentist
|1. Patient is older than 18.||__||__|
|2. Patient will comply with treatment and monitoring schedule.||__||__|
|3. Crestal bone width 2 mm greater than the implant diameter is present or can be surgically created.||__||__|
|4. There is at least 2 mm of bone coronal to vital structures. (Mandibular canal, mental foramen, sinuses, nasal floor) after the removal of a knife ridge should it be present.||__||__|
|5. Patient has no parafunctional habits.||__||__|
|6. There is no uncontrolled periodontal disease present.||__||__|
|7. The patient is a non-smoker.||__||__|
|8. The patient is a moderate drinker.||__||__|
|9. The patient has understood and signed the informed consent form.||__||__|