Implants

LONDON KISS: Keep It THE GRAND CONNAUGHT ROOMS - 1 APRIL 2017 61-65 GREAT QUEEN ST, LONDON WC2B 5DA Simple Stupid Dr Zaki Kanaan argues the case that when it comes to implants, Dr Tif Qureshi Dr Ian Buckle Dr Richard Porter Dr Jorge Perez Dr Emma McGlashan Professor Ross Hobson treatment should be kept as simple as possible. Figure 1 1:2 Anterior Retracted View At Presentation

Albert Einstein said “Make everything as simple Treatment Plan by Another as possible but no simpler”. Dental Centre Dr Zaki Kanaan Dr Louis Mackenzie Dr Anoop Maini Dr Rhona Eskander Dr James Russell Dr Fazeela Khan-Osborne The old adage goes that if 10 dentists were The initial suggested treatment plan included to treatment plan a case you will get as many the extraction of the upper right lateral and central varying opinions. There is nothing wrong with incisors and the upper left central incisor, with the this for simple general restorative cases, but when provision of an immediate partial acrylic denture. DO YOU WANT TO IMPROVE THE planning for implants, it is wise to opt for the This would have been followed by the placement simpler option. The following case highlights of an implant supported bridge with implants in the point that proceeding with a more complex the upper right lateral incisor and upper left central YOU DO EVERY DAY? option may have lead to a poor final result, as incisor positions. Although this is a viable option, Figure 2 well as an unpredictable long term prognosis it would have lead to the extraction of 3 important 1:2 Right Retracted View at Presentation and outcome for a young patient. teeth in the smile zone of this young gentleman. This one-day conference brings together some of the leading speakers in the UK to provide the foundation for This treatment plan had been accepted by the young learning and education that will help you take the next step in learning about how you can start providing ethical History and Presenting Complaint gentleman and his parents but fortunately, due to high quality private dentistry to your patients. This young gentleman presented with his mum a waiting list for the implant phase of treatment, for a second opinion, after being recommended this treatment plan had still not been carried out. by a hygienist. She was concerned about, what MANAGEMENT OF LESIONS FACE OF THE FUTURE she felt was a drastic treatment plan that was My Proposed Treatment Plan recommended to her son by another respected In view of the fact that the traumatised centrals dental centre. have been asymptomatic, with no apical changes CLEARSMILE BRACE TREATMENT ADVANCES IN CLEARSMILE ALIGNERS Her son, a student on his gap year, had since the accident, I suggested leaving the centrals lost his upper right lateral incisor 10 months alone with no treatment initially. I recommended BEYOND AAO RESTORATIVE DENTISTRY PLANNING earlier through a skiing accident. A provisional the extraction of the upper right lateral incisor, acrylic crown was bonded to adjacent teeth as with the immediate placement of an implant.1, 2 Figure 3 an emergency measure and the centrals were A provisional tooth would have also been provided. 1:1 Right Retracted View at Presentation FUTURE AESTHETIC CONNECTIONS DATES AND LOCATIONS COMING SOON! splinted at this visit (Figure 1,2,3,4). The upper A final abutment and porcelain crown would then centrals were also traumatised during the accident, be fitted after the healing phase. It is important with periapical radiographs exhibiting signs of to inform the patient that further treatment may horizontal fracture lines at various levels (Figure well be required on the central incisors. Staging To book your place visit www.aestheticconnections.com 5). The upper right lateral and central had also treatment in this way will minimise the risk of Please note: Speakers may vary dependant on event location - call 0208 916 2024 for speaker details been root treated shortly after the accident and losing soft tissue architecture. This treatment plan all teeth have been symptomless since. was accepted.

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Dr Zaki Kanaan argues the case that when it comes to implants, treatment should be kept as simple as possible.

Surgical Phase A Maryland metallo-acrylic provisional The patient attended for treatment and carried bridge was bonded in place with a wing on the out a 30 second pre-surgical rinse adjacent canine. The pontic was adjusted and prior to administration of local infiltration polished to fit around the healing abutment. anaesthesia. A flapless surgical technique was Note the good marginal adaptation and minimal utilised by using a size 15c micro-blade into the bleeding (Figure 6). dento- around the upper right lateral incisor root. The root was then gently and Restorative Phase atraumatically elevated using periotomes, taking 12 weeks later, open tray impressions were care not to stress or damage the fragile buccal plate. taken and custom shade matching was carried Figure 4 The resulting socket was inspected, especially for out. It is important to take a photo of the 1:1 Right Retracted View Immediately Pre-op the integrity of the buccal plate. A nice instrument contralateral tooth for comparison (Figure 7) to do this with is the AstraTech™ measurement and a discussion with the patient about whether gauge. It has a blunt, hemispherical end, which to copy this tooth needs to be communicated gives good tactile feedback and can also be used with the lab, especially if there are any unusual to measure the length of the socket. It can also be characteristics. In this case the upper left lateral used to give visual feedback on the direction of had a mesio-buccal rotation and the patient the imminent osteotomy site preparation. Socket wanted a slight element of rotation with his new curettage was carried out to ensure it is free from tooth. Due to the depth of the implant head it any granulation tissue. The buccal plate, although was decided best to use a goldadapt abutment. thin proved to be intact and ended approximately This was covered with a layer of opaque porcelain 3mm below the labial gingival level. to help mask any possible metal shine through The initial pilot drill used was positioned with as much as possible. This was torqued down Figure 5 a slight palatal inclination and position to the to 25Ncm and the access filled with GP and Periapical Radiograph at Presentation previous root apex, to avoid perforating labially.3 Systemp provisional composite. It was also The site was prepared using a standard sequence decided to make a Lava crown with an opaque and saline, with special attention to avoid the thin core (3M, Espe). The Lava crown was tried in buccal plate of bone during preparation. A 3.5 x and approved by the patient for shade and form 16mm NobelReplace Tapered Groovy implant before being cemented with temporary implant was torqued into position with an initial stability cement. Great care was taken to ensure no excess of 20Ncm and ensuring that a tri-channel internal cement was left behind. lobe is positioned mid-buccally. It is often the case that the embrasure between The initial stability of 20Ncm is not enough a canine and a new crown is increased, as it was to immediately restore an implant. If immediate here (Figure9). loading has been planned, you should always have This can easily be remedied by bonding some Figure 6 a contingency plan if good primary stability of the composite to the mesial of the canine, as was 1:1 Right Retracted View implant is not achieved. done in this case, which reduces the embrasure With immediately placed implant and provisional The implant head was placed 3mm apical from giving a more aesthetic result, which was to the Maryland Bridge in place. Note Minimal bleeding the anticipated final labial (adjacent patient’s satisfaction (Figure 10). and bruising to surrounding tissues dentogingival levels can also be used as a guide It is always advisable in aesthetic situations if needed). There was a 2.5mm space between such as this, to condition the tissues by providing the buccal plate and the implant. A narrow a prototype restoration. In situations where tissue healing abutment was placed and the void was conditioning has not been carried out, the final filled with a mixture of BioOss™ (Geistlich) and crown will most likely have a different emergence autogenous bone harvested with an Astra™ Bone profile to the healing abutment. Trap. It is my usual protocol to fill voids that In these cases the final crown needs to be tried are approximately 1.5mm or more. No sutures in and seated with constant force to overcome were needed. the pressure from the circumferential tissues.

Figure 7 Left Retracted View Communication with the lab should include a photo of the contralateral tooth

50 MARCH 2017 // dentaltownuk.com Implants

Dr Zaki Kanaan argues the case that when it comes to implants, treatment should be kept as simple as possible.

As this is done blanching will be evident (Figure The excess cement was visible through the 8). It is important to wait for the blanched tissues sinus and was removed though the sinus as shown to return to their normal colour before final in Figure 15. The crown was removed and the cementation. Failure to do this may result in area debrided with conventional ultrasonics. ischaemia of the surrounding tissues, pain and The crown was recemented with a temporary may even lead to an element of necrosis, if the implant cement paying particular attention to patient is allowed to leave in this way. remove any excess cement. Occlusion was checked with articulating On review the sinus can be seen to be healing paper in centric relation, as well as in excursive well and a decision as to whether any further soft movements until shimstock foil glided through tissue augmentation was needed in due course. with light contacts. A post-restorative baseline We can clearly see however despite this small Figure 8 radiograph was taken showing good bone levels. set back, that the maintenance of peri-implant 1:2 Anterior Retracted View A 3 month review and 1 year follow up were gingival levels and stippling were maintained Note blanching of tissues during trial insertion carried out (figure 11, 12, 13). The centrals were as they were shortly after delivery of the crown still symptom free with no radiographic changes 9 years earlier. Figure 16. at both appointments. Bone levels were also as they were at baseline. Conclusion Implant treatment involves many variables Follow Up and as clinicians we must consider all these I wrote this case in 2007. I would do things parameters to provide the best outcomes for our differently now and in most cases of immediate patients. If we aim to keep treatment as simple implants I would often add a as possible, then the success of the final case or deepithelialised connective tissue graft, to will be greatly increased. Careful consideration further augment the soft tissues around the needs to be given to the proximity of the implant Figure 9 implant. This case highlights that through surface to the labial bone, as well as the position Right Retracted View careful case selection and adherence to certain of the implant head to adjacent teeth, as there During trial insertion of Lava crown prior to bonding principles, immediate implants can exhibit is a horizontal, as well as vertical component to mesial composite to 13 to reduce embrasure successful long-term outcomes. the biologic width5 (sometimes now termed the Follow up was done almost annually. With no biologic doughnut). reported problems at all. Gingival levels around No matter how talented your ceramist, if the the implants were maintained well, apart from final restoration is not framed by the surrounding the patient attending at the 8-9 year mark with a tissues in the correct way, the outcome may be small sinus above the implant. As shown in Figure compromised. A key aesthetic concern in implants 14. On questioning the patient reported that he is to maintain the gingival architecture and had recently seen a local dentist to recement the harmony, especially the interdental papillae.4 implant crown as it had decemented. Luckily the The immediate implant protocol, in combination patient attended as soon as the sinus came up with a flapless, single stage technique, seems and the so did not manifest itself as full blown effective at maintaining the gingival architecture cementitis, which could lead to destruction of and when combined with a good ceramist, gives Figure 10 the soft tissue and bone loss. the clinician every chance of replicating nature. Right Retracted View After composite bonding on 13 to lengthen contact area and reduce embrasure With our current level of knowledge and understanding of implants as well as having the services of the most talented master ceramists, we have no excuse not to deliver the very best for our patients.

Figure 11 Anterior 1:2 Retracted View at 1 year

dentaltownuk.com \\ MARCH 2017 51 Figure 12 1:1 Right Retracted View at 1 year Acknowledgement I would like to thank Atsu Kakinuma at Dental Excellence, for his invaluable contribution for the technical aspects and ceramic work in this case. Disclosure The author has no financial or personal relationships, directly or indirectly, with any companies or products mentioned in this article, that could have influenced this work inappropriately. Figure 13 Right 1:1 Retracted View at 1 year Note good papillary infill and stippling of gingival tissues above implant crown.

Zaki runs the London Implant Academy with 2 colleagues, a 1 year Figure 14 practical implant course and is Director of K2 Dental Seminars, where he has trained hundreds of dentists, hygienists and therapists in the art and science of teeth whitening techniques. He works at several prestigious dental clinics in central London and also runs K2 Dental, a private practice in the heart of London’s Fulham Palace with his wife Dominique, also a dentist.

Figure 15. References Garber DA, Salama MA, Salama H (2001). Immediate total tooth replacement. Compend Contin Educ Dent 22(3): 210-6, 218 Gelb DA (1993). Immediate Implant Surgery: three year retrospective evaluation of 50 consecutive cases. Int J Oral Maxillofac Implants 8(4) : 388-399 Schwartz-Arad D, Chaushu G (1997). The ways and wherefores of immediate placement of implants into fresh extraction sites: a literature review. J Periodontol Oct;68(10):915-923 Schroeder HE & Listgarten MA (1997). The gingival tissues: the architecture of periodontal protection. 2000 13: 91-120 Hermann JS, Buser D, Schenk RK, Higginbottom FL, Cochran DL (2000). Biologic width around titanium implants. A physiologically formed and stable dimension over time. Clin Oral Implants Res . Feb;11(1):1-11 About The Author Zaki Kanaan BDS, MSc (Implant Dentistry), DipDSed, LFHom Zaki is a highly experienced and respected implant and cosmetic dentist and is well known in the dental community. He is the Figure 16. past President of the British Academy of Cosmetic Dentistry and currently sits on the Board of Directors for The Association of 9 year post op and after cement removal showing Dental Implantology UK. He features prominently on the lecture circuit lecturing on all aspects of cosmetic dentistry with a resolution of the sinus but maintenance of special interest in dental implants, where he has achieved a Masters Degree from Guy’s Hospital in 2001. He also has a Diploma in Sedation, a Diploma in Hypnosis and is a Licenciate of the Faculty of Homeopathy. stippling and gingival peri-implant levels. Through his expertise in all aspects of tooth whitening, he has been a Key Opinion Leader for Philips Oral Healthcare for several years. After being voted 2nd in Private Dentistry’s poll of the top 20 Elite Dentists in the UK in 2011 and 2012, it was 3rd and 4th time lucky when he topped the poll in 2013 and 2014. He was also judged by his peers as ‘UK Dentist of the Year’ at the Dental Awards in 2012 and was more recently awarded the prize for Outstanding Contribution to Private Dentistry at The Private Dentistry Awards in London in 2015. He is a Past President of The London Dental Fellowship and sits on the editorial board for The International Journal of Cosmetic Dentistry and DentalTown UK. He has also appeared on Channel 4’s Embarrassing Bodies programme carrying out complex implant treatments.

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