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Seven Simple Steps to Implant Success

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by Paresh B. Patel, DDS

Implant therapy is an accessible mode of treatment that can be executed with a high degree of predictability by following some simple steps and techniques. According to estimates, 80 to 90 percent of all implant restorations are single-unit cases involving patients with good general health and adequate bone in the area of implantation.1 This provides ample opportunities for general dentists — after receiving the proper training — to begin placing implants.

A common source of straightforward, single-unit implant cases are patients who present with a tooth that has fractured or otherwise failed after receiving endodontic treatment (Fig. 1). In many of these cases, the prognosis for further conventional treatment is unfavorable, and the tooth must instead be extracted. To take advantage of the superior long-term prognosis offered by implant therapy, the practitioner need only preserve the ridge, allow the site to heal, place the implant, and deliver the crown. These make excellent cases for clinicians new to implant placement.

A common source of straightforward, single-unit implant cases are patients who present with a tooth that has fractured or otherwise failed after receiving endodontic treatment.

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Figure 1: Preoperative X-ray of root-canal-treated premolar (middle-right), the coronal portion of which had fractured from the root. The tooth was not indicated for further endodontic treatment, and the patient opted for tooth replacement via implant therapy.

The treatment protocol to place and restore an implant in these situations is quite approachable and can be broken down into seven simple steps.

Step 1: Extract the Tooth

The tooth should be removed atraumatically, taking care to preserve as much of the buccal plate and surrounding bone as possible (Fig. 2). After using a very fine diamond bur to trace around the root, periotomes can be situated between the root and the bone to aid atraumatic removal. Following careful removal of the tooth, the condition of the extraction site should be assessed by exploring the socket with an endodontic or periodontal probe, looking for any bony defects. So long as the buccal plate and other bone surrounding the socket is intact, practitioners new to the surgical side of treatment should feel comfortable moving forward with implant placement.

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Figure 2: Coronal portion of the patient’s untreatable premolar following extraction.

Step 2: Graft the Socket

To simplify the eventual placement of the implant, it’s important to preserve the bone of the extraction site by grafting the socket. First, any granulation material should be carefully removed from the socket with a surgical curette. The site should then be irrigated and the walls scraped with a Crane-Kaplan CK-6 scaler to initiate some bleeding. At this point, the socket is filled up to the crest of bone with grafting material, either synthetic or allograft (Fig. 3). The site can then be closed with a simple X-suture.

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Figure 3: Demineralized freeze-dried bone allograft material was used to graft the socket site.

Step 3: Allow the Grafted Extraction Site to Heal

Following the ridge preservation procedure, the grafting material helps maintain the bone volume that is essential to a simple, predictable implant placement procedure and an esthetic, functional outcome.2 It takes approximately four months for the extraction site to heal and the graft to mature. During this time, the graft serves as an extracellular scaffold that allows the patient’s native bone cells to replace the grafting material with live bone, creating an ideal site for implant placement.

Step 4: Place the Implant via Flapless Surgery

After the socket site has healed, the patient returns for placement of the implant (Figs. 4a, 4b). By following the previous steps, the buccal plate should be intact and the site will have adequate ridge height and width. The site can be evaluated intraorally and radiographically to verify sufficient bone volume for implantation (Fig. 5). Once the patient has been anesthetized for implant surgery, the facial-lingual and occlusal bone can be further confirmed using a periodontal probe (Fig. 6). At this point, the diameter of the implant to be placed can be determined according to the mesial-distal and buccal-lingual dimensions of the edentulous space (Fig. 7).

Flapless implant placement is an excellent option for many of these cases because it is minimally invasive, reduces disruption to the blood supply, and facilitates a smooth healing process. To begin the flapless surgical procedure, a tissue punch is used to create an opening for the osteotomy in the appropriate location, noting that the implant should be situated 1.5 mm from the adjacent teeth while taking care to ensure there is 1.5–2.0 mm of bone on the facial aspect.

The osteotomy is created following the manufacturer-recommended sequence of surgical drills for the diameter and length of implant being placed (Fig. 8). Radiographs should be taken periodically during the procedure with a surgical drill or parallel pin in place in order to confirm proper angulation and positioning (Figs. 9a–9c). Once the surgical procedure is completed with the final shaping drill, the implant is placed.

It is advantageous to use an implant with a pronounced thread design like the Hahn™ Tapered Implant System, which helps the clinician maintain directional control during placement and establish high primary stability. Selecting a system with a tapered implant design is also beneficial, as the tooth-root-like shape is easier to situate within the available bone. These attributes simplify the task of implant placement, which is of particular value for implant practitioners who are just getting started.

Selecting a system with a tapered implant design is … beneficial, as the tooth-root-like shape is easier to situate within the available bone.

The implant is first threaded into the osteotomy site using a handpiece driver (Fig. 10). Final placement should be achieved using a torque wrench so the stability of the implant can be determined (Fig. 11). As a rule of thumb, 35 Ncm indicates good primary stability, though implant manufacturer recommendations should be followed.

Step 5: Deliver Healing Abutment

If adequate primary stability has been achieved — and this will typically be the case when the steps above have been followed — a healing abutment, rather than a cover screw, can be delivered at the time of implant placement (Figs. 12a, 12b). In doing so, it’s important to ensure that the healing abutment is out of occlusion in centric and all excursions. This will avoid any forces being applied to the implant during the healing phase.

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Figures 12a, 12b: Having achieved excellent primary stability, a 3-mm-tall Hahn Tapered Implant Healing Abutment was placed. Note the contoured shape of the healing abutment, which helps mold the soft tissue for an esthetic emergence profile.

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Figures 12a, 12b: Having achieved excellent primary stability, a 3-mm-tall Hahn Tapered Implant Healing Abutment was placed. Note the contoured shape of the healing abutment, which helps mold the soft tissue for an esthetic emergence profile.

Delivering, for example, a 3-mm-tall healing abutment, is advantageous as it helps contour the soft tissue to form a healthy, esthetic transmucosal emergence as the implant integrates. Placing a healing abutment also benefits the patient by avoiding the need for a second surgical procedure to uncover the cover screw.

Step 6: Take Final Impression

Approximately three months after implant placement, the patient returns for the final impression, and the healing abutment is removed. This will reveal a healthy and esthetic soft-tissue collar around the implant site, which has been guided by the healing abutment since implant placement (Fig. 13). An impression coping is then connected to the implant (Fig. 14). A closed-tray impression can be taken using a vinyl polysiloxane material, such as Capture® (Glidewell Direct; Irvine, Calif.), and sent to the lab for fabrication of the final restoration.

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Figure 13: At the final impression appointment, removal of the 3-mm-tall healing abutment exhibited a healthy, nicely formed sulcus.

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Figure 14: A Hahn Tapered Implant Impression Coping was seated with ease, as its cervical area is contoured to match that of the healing abutment.

Step 7: Deliver Screw-Retained Crown

The dental lab fabricates the definitive restoration based on the final impression. Screw-retained crowns are esthetic, predictable, easy to deliver and an excellent choice for single tooth implant cases. A crown that attaches directly to the implant also avoids the task of cementing the restoration over an abutment and provides ease in retrievability. CAD/CAM-produced restorations like BruxZir® screw-retained crowns excel in achieving a precise fit and natural emergence profile, as the shape, contours and margins are digitally designed with precision to align perfectly with the soft tissue (Figs. 15a–15c).

CAD/CAM-produced restorations … excel in achieving a precise fit and natural emergence profile.

After removing the healing abutment, the screw-retained crown is seated in the implant (Fig. 16). Complete seating of the crown should be confirmed radiographically (Fig. 17). The prosthetic screw is then tightened into place using a torque wrench. Teflon tape is inserted into the access channel to cover the screw, and the opening of the crown is sealed using composite (Fig. 18). With final delivery of the monolithic zirconia implant crown complete, an excellent long-term prognosis can be expected for this durable, esthetic implant restoration (Figs. 19a, 19b).

Conclusion

Single-unit extraction cases in the posterior are ideal for building confidence, developing surgical and restorative skills, and creating predictable, reproducible results placing implants. With so many of these patients presenting for treatment, the well-trained general dentist has every reason to provide implant treatment to them directly, expanding the services and quality of care offered by the practice. Most importantly, the patient receives a better long-term solution to the problem of a missing tooth. Indeed, the results achieved are transformational to both the implant patient and the doctor.

With so many of these patients presenting for treatment, the well-trained general dentist has every reason to provide implant treatment to them directly.

References

  1. Christensen GJ. Observations on current controversies in dentistry. Dentistry Today. 2015;34(11):100, 102, 104-5.
  2. Cardaropoli D, Tamagnone L, Roffredo A, Gaveglio L. Evaluation of dental implants placed in preserved and nonpreserved postextraction ridges: a 12-month postloading study. Int J Periodontics Restorative Dent. 2015 Sep-Oct;35(5):677-85.
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