D4 ◊Page D3 IMPLANT TRIBUNE Dental Tribune Middle East & Africa Edition | 1/2019 Figs. 39: Final cosmetic check-up showing correct lip support with the new extremely reduced false gingiva. Fig. 40: Radiographic check-up after seven years. were compressed between two com- presses to evacuate the serum and to form the membranes which were then applied to the surgical site and in the mandibular harvesting sites (Figs. 8 & 9). Pre-implant prosthetic study After four months, according to ra- diographic examination, the tissue had healed and the bone mass ap- peared stable (Fig. 10). New impres- sions were taken to prepare for the next step in treatment: the implant drilling guide. After four months of healing, the increased vestibular bone volume allowed positioning the teeth at the crestal bone and re- duction of the false gingiva using additional wax (Fig. 11). A key of the added wax was taken and fabricated in clear casting resin. The implant positions were decided on and fi- nalised by drilling placement holes, determining the exact position of the implants (Fig. 12). The correct po- sitioning of implants in relation to the future prothesis is an important prerequisite for aesthetic and func- tional success. Implant placement Local anaesthesia was adminis- tered and the bone site reopened. The site showed correct integration of the grafts, a notable increase in cortical bone and excellent vascu- larity throughout the site (Fig. 13). The sterilised surgical drilling guide was tested and showed that drilling would in fact be at the centre of the reconstructed bone ridge (Fig. 14). After removal of the screws stabilis- ing the grafts, the guide was placed and drilling (using physiological sa- line solution) completed. Five Aadva (GC Tech.Europe) self-tapping Grade 5 titanium microstructure implants were inserted by slow drilling (Fig. 15). Aspiration with physiological saline solution was not used at this time so that the first contact with the ti- tanium oxide would be the patient’s blood, thus promoting the implants’ osseointegration. This specific im- plantation technique was validated by Brun et al.6 All of the implants were equipped with threaded cover screws and the surrounding tissue was sutured (Fig. 16). To minimise risks, the implants were left unloaded for four months, as im- mediate loading of a site such as this one could have proven to be prob- lematic. Implant loading and impressions After four months, the implants were loaded using an apically posi- tioned flap. The healing abutments were placed and the flap sutured around them (Fig. 17). Radiographic analysis and especially a percussion test showed the implants’ perfect osseointegration. After 15 days of gingival healing around the abut- ments, they were removed and the impression copings were placed and secured with a self-curing resin (Fig. 18). Impressions were taken and the healing screws were reinserted (Figs. 19 & 20). Validation prosthesis Rather than calling the appliance at this stage a “temporary prosthesis” or “provisional prosthesis”, it is more appropriate to call this temporar- ily placed prothesis, a “validation prosthesis of the implanto-occluso- prosthetic concept recommended to the patient”7. Over the course of several months, this prosthesis vali- dates –– the osseointegration of the implants; –– the aesthetic aspect, especially for the anterior teeth; –– phonation, which is also impor- tant for the maxillary anterior re- gion;8 –– the patient’s ability to correctly clean the prothesis; and occlusion and, in this case, the ability of the an- terior to guide the disclusion of the canine groups in protrusion. This prosthesis serves as a model for the final prosthesis. It is made with easily modifiable material like resin, but with a metal framework to guar- antee a certain level of rigidity. In the first step, a model of the framework, which temporarily included the ca- nine to increase stability, was cast in pattern resin (Fig. 21). The model was then scanned (Aadva, GC Tech.Eu- rope; two cameras, 2 MP, precision: 10 µm) before being transferred to a machining centre (GM 1000, GC Tech.Europe; Figs. 22–24). Once back from the machining, the titanium framework was tested on the work- ing model and its stability was veri- fied (Figs. 25 & 26). The cosmetic material (UNIFAST III resin; surface rendering: OPTIGLAZE colour, GC Tech.Europe) was then placed on the framework (Fig. 27). The bone graft permitted a maxi- mum reduction of the vestibular false gingiva. In the following step, the prosthe- sis was attached in the mouth with screws and the necessary occlusal verification was conducted, includ- ing maximum intercuspation, pro- trusion and lateral excursion. The natural canine on the right was also equipped with a verification tooth. It should be noted, that in lateral excursion on the left, with the an- tagonist being the original tooth equipped with its periodontal liga- ment receptors, the canine function was retained; however the group function, which is usually preferred, was neurophysiologically inept (Figs. 28 & 29). The patient’s smile showed that the incisors were now well balanced and in line with the face’s sagittal plane. Lip support appeared to be correct and, as often is the case, this would all be validated by the patient’s sur- rounding friends and family (Fig. 30). After three months, the validation prosthesis was removed in order to examine the areas where mucosa had been compressed and dental hy- giene difficult. These areas were cor- rected and the validation prosthesis reinstalled (Fig. 31). Final prosthesis After six months, all of the param- eters were validated. The final prosthesis was then fabri- cated as an exact copy of the valida- tion prosthesis, but in a more dura- ble material: zirconia for the framework and ce- ramic for the aesthetic material. As with the titanium validation pros- thesis, the framework and the coping for the right canine were scanned and transmitted to the machining centre. They were then tested on the working model (Figs. 32 & 33). After fitting of the zirconia framework, the ceramic was cast using the exact parameters validated by the resin prosthesis (MB Dentaltechnik, Figs. 34 & 35). In the following step, the final pros- thesis was installed and the correct occlusion verified: maximum in- tercuspation, protrusion and lateral excursion. The screw channels were filled with composite (Figs. 36 & 37). The final cosmetic check-up, validat- ed by the resin prosthesis, showed the lip support with the new ex- tremely reduced false gingiva to be correct (Figs. 38 & 39). This was achieved owing to the bone graft. Regular check-ups Retreatment was regularly moni- tored with patient check-ups (Fig. 40). All implant treatments, no mat- ter of what type, must be rigorously monitored in all treatment phases, but a retreatment requires even more diligence. A patient affected by the failure of a previous treatment will not accept even the smallest problem. To this end, the role of healing periods is thus essential to retreatment suc- cess. Editorial note: This article was original- ly published in implants international magazine of oral implantology, Issue 3/18. Dr Philippe Leclercq President of SIOPA (Society for Oral Implantology and Applied Prosthe- sis) Implantological practice 45, rue de Courcelles 75 008 Paris, France ph.leclercq@siopa.fr Implants – Immediate loading with NO patient selection By Vivek Gupta, UK At EAO 2017, Dr Göran Urde present- ed a paper titled “Evolution of surgi- cal protocols in implant dentistry” as part of the scientific programme. Dr Göran Urde, is the Program Lead for Tipton Training’s PG Certificate in Dental Implantology and is the Director of the Futurum Clinic at Malmö University’s Faculty of Odon- tology in Sweden. Extracts from his presentation are below. In the good old days, as he put it, im- plants were only placed by special- ists in oral surgery and prosthetics. One had to be thoroughly trained to even purchase implants. Compa- nies kept records of the clinician’s success rates and if someone had a higher than normal failure rate, they showed up at their door! This obvi- ously has changed now as technol- ogy and consequently education of dental implants has evolved. Over the years he has been involved in developing concepts like “Tooth Now” or Immediate Loading, ac- cording to which a tooth is extracted and immediately replaced with an implant and loaded with the final abutment and a temporary crown, with extremely high success rates for both implant survival and aesthetic outcome. He appreciates the bene- fits of immediate loading, but, warns that patient selection is very impor- tant and often not appreciated. Consider this, patients for decades have not taken care of their natural dentition are now being treated in accordance with concepts like im- mediate loading. Within an hour, any remaining decayed teeth are removed and replaced with implant- supported crowns and bridges in the belief that the patients will start tak- ing care of their new teeth. Unfortu- nately, this is not realistic! In his opinion, this is a ticking time bomb. It is just a matter of time be- fore patients will come back with problems like peri-implantitis and failing implants. Who is going to sort that out? Think litigation! That is why training courses are so im- portant. Placing implants is a great skill and income generator, however, there is no substitute to Patient Se- lection and Treatment Planning. Prof Urde with his students during the surgery (Photograph: Dental Tribune MEA)