Ensuring primary stability and optimising aesthetics
Featured Products Promotional FeaturesPosted by: Dental Design 22nd November 2022
Dr Kunal Shah, principal of LeoDental in London, recently treated a patient who had aesthetic concerns about a gap in her smile. Dr Shah placed a dental implant and shares his case below:
Patient background
A female in her early 30s was seeking a solution to replace a missing tooth in the UR4 region. She needed several additional restorations, but the UR4 was the most pressing concern.
Assessment
A full assessment was conducted. The patient had a clear medical history and was periodontally stable. The tooth that was extracted several months ago in the UR4 region was in the smile line, meaning there were aesthetic concerns with the gap visible. She was not wearing any temporary solution on presentation.
The patient’s oral hygiene was adequate, but a dental hygienist appointment was recommended prior to surgical or restorative treatment. She returned to the clinic for a radiograph and CBCT scan. The images demonstrated good bone width and height, with a clear upper right maxillary sinus. The patient presented as an ideal candidate for implant treatment.
I discussed all treatment options: no treatment, denture, bridge and dental implant. The patient opted for a dental implant; she had one placed previously and so was aware of the process, although everything was explained again. I developed a suitable treatment plan and discussed it with the patient, answered her questions and disclosed the treatment timeframe, the costs and potential risks. The patient gave her fully-informed consent and was then booked in for the procedure.
Procedure
The patient was prepped for surgery. Prior to the procedure, I had already planned which dental implant would be used and where it would be placed, following prosthetic-driven implant planning (PDIP) principles. During the surgery, a flap was opened and the bone was assessed with good visualisation. I used a NobelReplace®Conical Connection (CC) Partially Machined Collar (PMC) 3.5mm x 11.5mm dental implant, as it provides high initial stability when compared to a parallel implant in this type of case. Firstly, we went through the standard drill sequence, then checked the implant angulation with a direction indicator to ensure we had the correct angulation from a buccal-lingual and mesial-distal perspectives, and occlusally in terms of where the crown will be positioned.
Once satisfied with our direction indicator, the dental implant was then placed. In order to confirm stability, we used the Osstell Beacon with SmartPegs from W&H. It is essential to ensure sufficient moisture control and the correct SmartPegs for the implant used to provide an accurate reading. We then used the Osstell Beacon to check both stability readings (buccal-lingual and mesial-distal) and they were above 70 on both readings, which is shown with a green light on the Osstell Beacon, indicating high primary stability. This system is ideal for determining stability and the degree of osseointegration, without compromising the healing process. Finally, we placed a cover screw and sutured the flap.
The next step of treatment was to complete the restorations for the UR3 and UR5 regions, which had been planned prior to this procedure.
The next steps
In three months, the patient will return to the clinic and I will assess how the site has healed before preparing for restoration. A radiograph will be conducted to evaluate whether osseointegration was successful, and I will take a secondary reading with the Osstell Beacon to confirm implant stability ahead of fitting a crown.
Dental implants can greatly enhance the quality of a patient’s life, by improving aesthetics and/or function. With regards to this case, there were two important aspects to recognise. Firstly, it’s essential to understand the bone anatomy, because the jaw bone is concave towards the apex. Ensuring that you plan this treatment pathway correctly is key. Also, the angulation is important, hence why we used a direction indicator. Secondly, confirming primary stability is vital for all implant placements. The reason we took a reading with the Osstell Beacon is for confirmation that we had achieved good primary stability. It is also something we can look back on when restoring the dental implant, to check on the process of osseointegration.
Fig 1. CBCT Scan 3D Render showing UR4 region
Fig 2. Sectional OPG derived from CBCT Scan showing UR4 region and Upper Right Maxillary Sinus Region
Fig 3. Sectional Slice showing UR4 region and Upper Right Maxillary Sinus Region
Fig 4. IO image showing UR4 edentulous region Palatal View
Fig 5. IO image showing UR4 edentulous region Occlusal View
Fig 6. IO image showing incision and Flap Elevation
Fig 7. IO image showing Osteotomy Prep for UR4 following Final Drill
Fig 8. IO image showing UR4 Osteotomy prep with a Direction Indicator Buccal View
Fig 9. IO image showing UR4 Osteotomy prep with a Direction Indicator Palatal View
Fig 10. IO image showing SmartPeg for NP 3.5×11.5mm Replace CC PMC Implant Seated Buccal View
Fig 11. IO image showing SmartPeg for NP 3.5×11.5mm Replace CC PMC Implant Seated Occlusal View
Fig 12. IO image showing SmartPeg and Ostell Beacon for NP 3.5×11.5mm Replace CC PMC Implant Seated and measuring Torque Strength
Fig 13. IO image showing RP 3.5×11.5mm Replace CC PMC Implant Seated with Cover Screw Occlusal View
Fig 14. IO image showing UR4 sutures
To find out more visit www.wh.com/en_uk, call 01727 874990 or email
