August 1, 2007
by Milan Somborac, DDS
For implant treatment to reach more dentally dysfunctional patients, treatment costs need to be lowered. An effective way to do so is to reduce the number of treatment steps. One-piece, one-surgery implants were used (Tenax Dental Implant System) to treat 10 consecutively selected patients in varying single missing tooth applications. Patients were chosen for having adequate bone shape and quality to achieve good primary implant stabilization. At the first appointment 15 implants were placed either immediately or in a delayed technique. Prosthetic treatment was initiated with impressions, bite registration and temporization.
At the second and final appointment 21 units of crown and bridge work were cemented, occlusions adjusted and patients dismissed. During a period ranging from six to 66 months, the survival of all implants has been 100%.
Nearly 100 years ago the U.S. Patent and Trademark Office issued its first root form implant patent to an Edwin J. Greenfield of Wichita, Kansas.1 Clearly, designs of modern implants are variations on the original with the important exception of having a science-based foundation. That science began developing over 30 years ago by Brnemark2 and co-workers studying a two-surgery approach to implant treatment. At about the same time, Schroeder3 and co-workers were investigating the simpler, one-surgery approach (Fig. 1).
Implant treatment has revolutionized dentistry. However, nearly a decade ago Lewis wrote, “Even implant-supported prostheses that are clinically effective have yet to be proven societally effective because they are inaccessible economically to some who need them.”4 Recently, the editor of the Journal of Oral and Maxillofacial Implants expressed the opinion that conservative prosthodontics survives only “because the financial means of patients in need of tooth replacement are limited.”5 That is, little progress has been made in lowering treatment costs to patients. For implant treatment to reach more of the dentally dysfunctional patients, these costs need to be lowered. An effective way to do so without reducing clinicians’ incomes is to reduce the number of treatment steps.
MATERIALS AND METHODS
One-piece, one-surgery implants with cemented abutments were used (Tenax Dental Implant System of Collingwood, ON). This system was chosen because its platform is at the gingival level and abutment and crown cementation is identical to the familiar post-and-core cementation in a natural tooth. Patients were chosen for having adequate bone shape and quality to achieve good primary implant stabilization. Ten patients were treated consecutively in varying applications. At the first appointment 15 implants were placed either immediately or in a delayed technique. Prosthetic treatment was initiated with impressions, bite registration and temporization.
At the second and final appointment 21 units of crown and bridgework were cemented, occlusions adjusted and patients dismissed.
FIRST TREATMENT APPOINTMENT
For all patients, active, diffuse infection and generalized inflammation were first minimized with a program of scaling, root planing, curettage and antibiotic coverage.
All patients were given a loading dose of 2g of amoxicillin (APO-AMOXI, Apotex Corp.) one-hour pre-operatively.
All patients rinsed with an essential oil rinse (Cool Mint Listerine Antiseptic Mouthwash, Johnson & Johnson Inc.) for three minutes, pre-operatively.
Peri-oral tissues were swabbed with a 0.05% Chlorhexidine Gluconate (BAXEDIN, Omega Laboratories Ltd.) solution.
Triazolam (APO-TRIAZO, Apotex Corp.) p.o. was used to provide sedation when deemed necessary.
Following the manufacturer’s protocol, a corticosteroid regimen was used to control intra and post surgical inflammation and pain.
Block or infiltration anaesthesia was administered as needed using 5% Ultracaine 1:100,000, HANSAmed Ltd.)
Minimal flap or flapless surgery was used throughout (Figs. 3 & 5).
All visible and palpable granulation tissue was curetted out (Fig. 4).
Osteotomy sites were prepared in accordance with the manufacturer’s instructions using high volume suction to aspirate the normal saline irrigating solution.
An osseous coagulum trap, attached to low volume suction was used to gather the bone chips produced in the drilling process. These were mixed with a bioactive glass (PerioGlas, NovaBone Products, LLC) to increase graft volume.
The autogenous bone/bioactive glass mix was then packed lightly into all voids (Fig. 7).
The mucosa was coapted around all implants using .000 or .0000 chromic gut sutures (Fig. 10).
Prosthetic treatment was initiated by placing a manufacturer’s transfer coping into each implant (Fig. 10).
Impressions were taken (Fig. 11) and bite registrations were completed.
Impressions and bite registrations were sent to a commercial lab with the appropriate laboratory prescription.
The patients were dismissed.
Within a week or less, each patient’s progress was monitored in a post-surgery follow-up appointment.
SECOND TREATMENT APPOINTMENT
After the prosthetic loading interval recommended by the manufacturer, each patient was scheduled for prosthesis cementation and occlusal adjustment.
Cementation is at the gingival level allowing visual inspection for seating accuracy (Figs. 15 & 16).
A post-operative PA was taken for each patient (Fig.17).
All patients are being monitored on an on-going basis using clinical examination of the peri-implant soft tissues, radiography, mobility testing and gentle peri-implant probing.
During a period ranging from 6 to 66 months, the survival of all 15 implants has been 100%.
In order for implant treatment to reach a wider audience and include more patients who can benefit from it, treatment costs to patients need to be lowered.
Further, these costs need to be lowered in a manner that will not reduce the clinician’s customary hourly billing rates for surgery and prosthetics. Since implant component costs are quite small relative to overall treatment costs, reducing component pricing would be of marginal value. A reduction in the number of appointments, however, can reduce valuable chairside time. It could prove to be a safe and effective way to make implant treatment economically accessible to a greater number of potential patients.
Complete two-appointment implant treatment appears to be practical and should be investigated prospectively in a statistically valid patient population size.
Dr. Milan Somborac is the Chief Instructor of the Collingwood Institute of Implant Research based in Collingwood Ontario.
Dr. Somborac is a minor shareholder in Tenax Implant Inc.
1.United States Patent Office, Patent Number 943,113.
2.Adell R, et al: Marginal tissue reactions at osseointegrated titanium fixtures. Swed Dent J Suppl. 1985;28:175-81.
3.Schroeder A, van der Zypen E, Stich H, Sutter F. The reactions of bone, connective tissue, and epithelium to endosteal implants with titanium sprayed surfaces. J Maxillofac Surg. 1981 Feb;9 (1):15-25.
4.Lewis DW. Optimized therapy for the edentulous predicament: Cost effectiveness considerations. J Prosthet Dent. 1998 Jan;79(1):93-9.
5.Watzek,G. Editorial, IJOMI, Vol. 21, No. 6, 2006.