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27Dental Tribune Middle East & Africa Edition | November-December 2014 implant tribune Fig 1. Dr. Costa and Dr. Petros in line with Prof. Branemark’s philosophy of “Lesser Surgery to Treat More Patients”. Fig 6. Silicone key of a diagnos- tic wax up. Fig 11. The single implant with a Zirconia screw retained crown. Fig 7. The silicone key can di- rect the implant surgeon. Fig 12. Palpation of the extrac- tion socket walls with a peri- odontal probe. Fig 9. Good peri-implant tissues with “One Abutment One Time” approach. Fig 14. All-On-4 Fig 10. Healing caps placed on abutments. Fig 15. All On-6 Fig 8. Bite registration is start- ed prior to extraction of all the teeth and is completed with ad- dition of bite registration mate- rial onto the remaining healing caps. Fig 13. In healed sites where possible the “punch” technique is used. Fig 2. Angled implants placed into available bone anterior and posterior to the maxillary sinus. Fig 3. Immediate molar replace- ment implants. Fig 4. 45Ncm Primary Stabil- ity measured during implant placement. Fig 5. Silicone key of the facial surfaces of the existing teeth. > Page 28 SameDay Dental Implants® & Teeth A Surgical & Prostho Protocol By Costa Nikolopoulos Oral & Maxillofacial Surgeon (S.A.) & Petros Yuvanoglu Specialist Prosthodontist (U.S.A.) T he original Branemark protocol advocated the use of a two stage surgi- cal approach where the turned (smooth) implants were buried for several months under the mucosa. With the advent of sur- face enhanced and tapered im- plants the protocol later evolved into a one stage approach. Several clinicians then proceed- ed to immediately load these one stage implants with good success provided good primary stability (more than 45Ncm) was achieved at time of implant placement and provided micro- movements could be limited to 100μm. Ample reports have been published on immediate loading of dental implants show- ing an initial unloaded period of 3 – 6 months is not necessary. From a patient’s point of view the reduction of treatment time between implant placement & installation of a functional pros- thesis leads to increased patient satisfaction & treatment accept- ance. This gain in time for the patient implies an economical benefit especially for profes- sionally and/or socially active patients. High treatment acceptance and patient satisfaction are the most important advantages of imme- diate loading and immediate function. Surgical Protocol The surgical protocol of imme- diate loading of dental implants with same day teeth is based on the following: Avoid Bone Grafts This is in line with Prof. P.I. Branemarks philosophy of “Lesser Surgery to Treat More Patients” (Fig 1). With increased costs and patient morbidity due to bone grafting, an increased patient resistance to implant treatment has been noted. An alternative method of treating implant patients who have suboptimal bone volume without bone grafting is made possible by using: 1) Angled implants in a titled manner placed into available bone anterior and posterior to the maxillary sinus (Fig 2). 2) Wider and appropriately shaped implants placed into im- mediate extraction molar sock- ets thereby avoiding socket or sinus grafting (Fig 3). High Primary Stability An important factor for immedi- ate loading success is high pri- mary implant stability (greater than 45Ncm) which can be achieved by using a surface en- hanced tapered implant design to enhance lateral compression of bone. By underprepping, high inser- tion torque and primary stability can be achieved even in cases of decreased bone density such as is often the case in maxillary alveolar bone and as well as in osteoporotic patients. Primary stability can easily be measured during implant placement with a torque wrench (Fig 4). If 45Ncm insertion torque is not achieved, the implant should be removed and without further bone preparation a 1mm wider implant is placed. This usually results in adequate primary stability of 45Ncm for immediate loading. If 45Ncm insertion torque is still not achieved then again the implant can be removed and replaced with an even wider diameter implant if the available bone width permits. This usually re- sults in adequately high inser- tion torque and primary stability greater than 45Ncm. If despite this, adequate primary stability is not achieved then immediate loading is not recommended. Prostho Driven Implant Place- ment By using a silicone key of the facial surfaces of the existing teeth (Fig 5) or a silicone key of a diagnostic wax up (Fig 6), it is possible to place the implant in the correct position and angle so that the screw access hole can exit in the correct place to allow for screw retention. In order not to loose significant orientation, extractions are not performed all at once prior to implant placement but are rath- er performed one at a time fol- lowed by implant placement so that the silicone key can direct the implant surgeon (Fig 7). It is very often necessary to use an implant with a built in angle of 12o , 24o or even 36o so that the case can be screw retained. Screw retention is an absolute requirement for biological rea- sons (to avoid risk of inflamma- tion due to excess cement) as well as the ease of handling of immediate loading in a surgical environment. Bite registration is started prior to extraction of all the teeth in the full mouth/arch case so as not to loose the centric relation and vertical dimension (Fig 8). The remaining extractions are then performed, further im- plants are placed and the bite registration is completed with addition of bite registration ma- terial onto the remaining heal- ing caps. One Abutment One Time After bone milling to remove any interfering bone, in multi- ple implant cases transmucosal multi-unit abutments are placed on the implants and torqued to 45Ncm at the time of surgery. These abutments are placed and torqued onto a “clean” implant platform with no interfering bone or soft tissue and are never removed again. Scientific research shows less bone loss, better bone levels and peri-implant soft tissues when the transmucosal abutments are placed at time of surgery and never removed (Fig 9). Healing caps are then placed on the multi-unit abutments (Fig 10). After abutment placement, at the same surgical appoint- ment, the impression is taken at abutment level and provisional acrylic screw retained fixed teeth are placed in the same day as the implant surgery. In single implant cases the heal- ing abutment is placed directly at implant level. An implant impression is taken and six hours later a full ceramic/zir- conia screw retained crown is then connected and torqued to 45Ncm directly on to the implant without an intermediate/trans- mucosal abutment (Fig.11). No multi-unit abutment is in- dicated or placed in the single implant case as the multiunit abutment has no anti-rotation feature. Flapless/Minimal Flap Surgery In extraction cases no muco- periosteal flap is reflected. The integrity of the extraction socket walls is inspected and assessed with a 15mm or 20mm peri- odontal probe placed into the extraction socket. Palpation of the extraction socket walls is performed with the probe (Fig 12) and this is complemented by good vision with magnifying loops and light illumination. In healed sites where possible the “punch” technique is used (Fig 13). Alternatively minimal flaps are raised where indicated. This flapless/punch technique/ minimal flap approach results in minimal or no soft tissue chang- es thereby allowing the restora- tive dentist/prosthodontist to proceed with the provisional acrylic screw retained teeth in the same day and permanent ceramic screw retained teeth in 1 week in the case of multiple implants. In the case of the sin- gle implant the permanent full Zirconia screw retained tooth can be delivered in 6 hours on the same day. Number of Implants In edentulous cases 4 to 6 im- plants (figs 14 & 15) are placed per arch depending on: 1) Bone volume & quality 2) Implant length & diameter 3) Implant distribution (A-P spread) 4) Patient’s age 5) Patient’s finances (cost to ben- efit ratio) Prosthodontic Protocol The Prosthodontic protocol of SameDay Dental Implants & Teeth is focused and designed around the patient’s needs. It’s fast, efficient and doesn’t com- promise quality. The patients are never left without teeth for more than six hours. As a result treatment acceptance is high. All implants with good primary stability (>45Ncm) are immedi- ately loaded with screw-retained teeth. For single implant cases, the final all ceramic screw re- tained tooth is fabricated and delivered to the patient within six hours. For multiple implants cases, temporary screw retained acrylic teeth are fabricated with- in six hours and the permanent screw retained all ceramic or metal ceramic teeth are deliv- ered one week later. Timing of Immediate Loading Dental implants either should be loaded the earliest possible (never exceed ten days after surgery) or alternatively two months after placement. This is because the so-called initial “primary stability” (mechanical stability) that an implant has, starts to drop gradually and the implant become more prone to failure if forces are applied. For- tunately, simultaneously a “sec- ondary stability” (Osseointegra- tion) starts to build up. The sum of the two “stabilities” which is demonstrated on the stabil- ity graph (Fig. 16), gives us the “total stability”. As a golden rule implants ideally should never be disturbed during the “stability dip” period. Preoperative Preparation In order to achieve this proto- col, preoperative screening and detailed surgical and prostho-