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ePaper created 2016-04-13, 10:04:12 | version 1.38.0
Feline dental implants: New paradigm shift in maxillary.... Continued from page 04 General anesthesia was induced by mask with Sevoflurane (vaporizer #7, O2 @ 4L per minute; VetOne). Oral tracheal intubation was completed and anesthesia was maintained at vaporizer setting #3, O2 1L/minute following Feline Anesthetic Protocol (FAP). A complete oral exam and digital PA radiographs were obtained. A luxation of tooth #104 and some mobility was noted. Additionally, a widening of the periodontal ligament space with a vertical fracture of the incisive bone at the diastema of teeth #s 103/104 was observed (Fig. 1). A sulcular full thickness MP flap was elevated to evaluate the alveolar process of the maxillary bone. The canine tooth (#104) was atraumatically extracted to avoid any further damage to the alveolar socket and surrounding bone. Socket debridement was performed and copious levage was complete with 0.9 percent NaCl (VetOne). The site was prepared to accept a 5.0 x10 mm Engage implant (OCO Biomedical, Albuquerque, N.M.), which was subsequently placed into the osteotomy and positioned subcrestally with a final insertion torque of 45 Ncm. The crestal gap between the implant and socket was filled with Fusion Bone Putty (Veterinary Transplant Services (VTS), Kent, Wa.) to assist in socket regeneration and to minimize bone resorption.[3,4,5] A cover screw was placed and the flap repositioned to achieve primary closure with 5-0 resorbable monofilament sutures (Securos Surgical, Fiskdale, Mass.) (Fig. 2). Recovery was uneventful and the patient was discharged with post- surgical instructions the same day. Clavimox (62.5 mg/ml @ 1ml bid) (Zoetis, Florham Park, N.J.), a broad- s p e c t r u m a n t i b i o t i c , a n d Buprenorphine (0.1 ml bid orally for 3-5 days) (Reckitt Benckiser Healthcare, Parsippany, N.J.), an opioid pain reliever, were dispensed to the owner. Uncovering and restoration phase At six months post-insertion, the patient was re-evaluated for soft-tissue healing and osseointegration. FAP was again utilized as in the surgical phase. Dental radiographs were evaluated and implant stability and integration were determined to be adequate. A tissue punch was used to expose the implant head, preserving adequate attached gingiva on the buccal. The cover screw was removed and closed tray implant impression abutment was placed (OCO Biomedical) and a radiograph taken to verify proper mating of the impression head to the implant (Figs. 3a, 3b). Impressions were fabricated with a fast set VPS hand mix putty and a fast set light body VPS impression material (Benco Dental Supply, Tucson, Ariz.). A transmucosal healing abutment (OCO Biomedical) was placed to insure proper emergence profile to support the future prosthetic components[6, 7] (Fig. 3c). The impression was sent to the dental lab (Doks Dental, Tucson, Ariz.), and a soft-tissue stone model was fabricated with analogs embedded within. The planned prosthetic was waxed up for a palladium implant restoration, which would be luted into the implant (Fig. 4). At one-month post impressions, the patient returned for delivery of the implant restoration. FAP was again utilized and the prostheses was tried in and then was cemented into the integrated implant utilizing a self- adhesive resin cement (BisCem, Bisco Inc., Schaumburg, Ill.) (Fig. 5). The 26-month follow-up demonstrated excellent emergence profile and implant stability with no evidence of periimplantitis or soft-tissue inflammation surrounding the implant restoration (Figs. 6, 7). Case report 2 A14.3-year-old male neutered DLH cat weighing 16.2 pounds presented for an oral examination. Generalized calculus and gingivitis was noted, as well as multiple Feline Oral Resorptive Lesions (FORL) and a complicated crown fracture of the right maxillary canine (#104). Initial treatment options were discussed with the owner, which included scaling and root planing to treat the generalized periodontal condition and selective extractions determined by the initial probing and dental radiographs. The fractured canine treatment would be discussed after a complete oral examination and radiographs were completed under a general anesthesia. The right maxillary canine (#104) fracture appeared to have been present for a long period with some definite buccal bone changes related to the fracture. Surgical phase Patient was pre-medicated with Atropine Sulphate (1/120 grain; .2 ml subcutaneously) (VetOne) and Acepromazine (10 mg/ml; .05 ml subqutaneously) (VetOne). General anesthesia was induced by mask with Sevoflurane (Vaporizer #7 / O2 at 4L/minute) (VetOne). Oral tracheal intubation was completed and anesthesia was maintained at vaporizer setting #3 / O2 at 1L/minute following Feline Anesthetic Protocol (FAP). A complete oral exam and dental radiographs were obtained. Multiple FORL were noted and charted. FORL are common in cats and are similar to cervical external resportive lesions in humans. These teeth typically have a poor prognosis and require extraction to treat them. Selective surgical extractions were successfully completed while tension-free tissue flaps were placed at the extraction sites to achieve primary closure. The right maxillary canine (#104) had sustained a prior traumatic fracture with pulp exposure. Definite buccal enlargement consistent with alveolar inflammation (osteitis) was present. Radiographs confirmed the diagnosis with secondary root changes evident (Fig. 8). Endodontic treatment would have been an option; however, the root morphology and sclerotic canal would be problematic. As in Case 1, the owner elected to extract the tooth and place an immediate endosseous implant, if possible, and wait four-to-six months before a final restoration could be placed. In many cases, the author is placing immediate implants with the future option of restoration utilizing digital treatment planning. Using these advanced computer-aided techniques (extra-oral scanning and CAD/CAM design and milling), final results have proven to be exceptional compared to the traditional methods of VPS impression taking and wax-cast restorations. A coronectomy was made on the right maxillary canine (#104) for easy access of the tooth root. It is imperative to remove the remaining root while maintaining the buccal eminence. A mini envelope flap was utilized to maintain a good blood supply to the crestal bone. A fine diamond burr (#FG 703) (Benco Dental) in a high- speed water cooled drill was used to detach the periodontal ligament, making luxating and extraction a simpler process with less risk of alveolar fracture (Fig. 9a). Examination of the socket was performed and removal of any inflammatory granulation tissue was accomplished with a curette and fissure burr. Socket measurements (probing and radiograph) were obtained and the site was prepared to accept a 5.0 x10 mm Engage implant (OCO Biomedical), which was inserted subcrestally with a final insertion torque of 50 Ncm (Figs. 9b, 9c). The crestal gaps between the implant and osteotomy were augmented with feline periomix, a DFDBA product (Veterinary Transplant Service, Kent, Wa.), which was rehydrated with 2 percent Xylocaine with 1:50.000 epinephrine (Dentsply, York, Pa.). Flap apposition was made to achieve primary closure with a combination of simple interrupted and cruciate suture patterns. Suture material was 5-0 Securocryl with a reverse cutting P3 needle (Securos Surgical, Fiskdale, Mass.) (Fig. 9d). Recovery was uneventful, and the patient was discharged with Continued on page 14 Fig. 12: Closed tray impression head placed onto implant to take impression (bottom left) and healing abutment in place (top right). Fig. 13: Virtual cast with analog created using digital scanning of the soft-tissue model ready for virtual design of the restoration. Fig. 14: Completed CAD/CAM metal abutment and zirconia crown (top) and the abutment on the soft-tissue model (bottom left) and with crown inserted over the abutment (bottom right). Fig. 15: Radiographs at abutment placement. Fig. 16: Completed restoration seven months post-insertion demonstrating a lack of soft-tissue inflammation. Fig. 17: Completed restoration 10 months post-insertion demonstrating a lack of soft-tissue inflammation. CLINICAL PRACTICE12 DENTAL TRIBUNE Pakistan Edition March 2016