Custom Emergence Profile Around Implants - JIACD · Dr. Samar M Jambi, Dr. Meisan A. Bukhari 2 ......

The Journal of Implant & Advanced Clinical Dentistry

Volume 9, No. 5 July 2017

Partial Enucleation of the Nasopalatine Canal for Implant Placement

Custom Emergence Profile Around Implants

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The Journal of Implant & Advanced Clinical DentistryVolume 9, No. 5 • July 2017

Table of Contents

6 An Innovative Approach for the Selection, Generation and Recording of a Custom Emergence Profile Around Implants Ioannis Vergoullis, Catherine Badell, George Papadopoulos

20 Partial Enucleation of the Nasopalatine Canal for Implant Placement: A Novel Procedure Dr. Samar M Jambi, Dr. Meisan A. Bukhari

2 • Vol. 9, No. 5 • July 2017

The Journal of Implant & Advanced Clinical Dentistry • 3


Table of Contents

26 Clinical and Radiographic Evaluation of Short Dental Implants in Posterior Atrophic Ridges with a Follow-up Period of 1 Year after Loading: A Controlled Clinical Trial Amr Zahran, Fouad Al Tayib, Amr Ali, Moemen Sheba

36 A New Standard Classification System for Dental Implant Drills and Role of Implant Drills in Successful Osseointegration Dr. Bhushan Kumar, Dr. Sunny Bhatia, Dr. Prabhdeep Kaur Sandhu, Dr. Sachin Mittal


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Tara Aghaloo, DDS, MDFaizan Alawi, DDSMichael Apa, DDSAlan M. Atlas, DMDCharles Babbush, DMD, MSThomas Balshi, DDSBarry Bartee, DDS, MDLorin Berland, DDSPeter Bertrand, DDSMichael Block, DMDChris Bonacci, DDS, MDHugo Bonilla, DDS, MSGary F. Bouloux, MD, DDSRonald Brown, DDS, MSBobby Butler, DDSNicholas Caplanis, DMD, MSDaniele Cardaropoli, DDSGiuseppe Cardaropoli DDS, PhDJohn Cavallaro, DDSJennifer Cha, DMD, MSLeon Chen, DMD, MSStepehn Chu, DMD, MSD David Clark, DDSCharles Cobb, DDS, PhDSpyridon Condos, DDSSally Cram, DDSTomell DeBose, DDSMassimo Del Fabbro, PhDDouglas Deporter, DDS, PhDAlex Ehrlich, DDS, MSNicolas Elian, DDSPaul Fugazzotto, DDSDavid Garber, DMDArun K. Garg, DMDRonald Goldstein, DDSDavid Guichet, DDSKenneth Hamlett, DDSIstvan Hargitai, DDS, MS

Michael Herndon, DDSRobert Horowitz, DDSMichael Huber, DDSRichard Hughes, DDSMiguel Angel Iglesia, DDSMian Iqbal, DMD, MSJames Jacobs, DMDZiad N. Jalbout, DDSJohn Johnson, DDS, MSSascha Jovanovic, DDS, MSJohn Kois, DMD, MSDJack T Krauser, DMDGregori Kurtzman, DDSBurton Langer, DMDAldo Leopardi, DDS, MSEdward Lowe, DMDMiles Madison, DDSLanka Mahesh, BDSCarlo Maiorana, MD, DDSJay Malmquist, DMDLouis Mandel, DDSMichael Martin, DDS, PhDZiv Mazor, DMDDale Miles, DDS, MSRobert Miller, DDSJohn Minichetti, DMDUwe Mohr, MDTDwight Moss, DMD, MSPeter K. Moy, DMDMel Mupparapu, DMDRoss Nash, DDSGregory Naylor, DDSMarcel Noujeim, DDS, MSSammy Noumbissi, DDS, MSCharles Orth, DDSAdriano Piattelli, MD, DDSMichael Pikos, DDSGeorge Priest, DMDGiulio Rasperini, DDS

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Vergoullis et al

Background: Currently the clinical dexterity required along with the time and cost involved has been a constant obstacle for the evolve-ment of the process of custom emergence profile development to a standard of care. This is the first report on the protocol of use of a novel system (VPI EPMS) that can assist the clinicians select, generate and record a custom emergence profile in a predictable way and a time and cost effective manner.

Methods: A 77 years old female patient pre-sented with a hopeless upper first premo-lar seeking for implant replacement therapy. The hopeless tooth was replaced with a den-tal implant utilizing the VPI EPMS system and its protocol of use. The guide tool of the sys-tem (EPI) was utilized to properly select the shape, dimensions and orientation of the

emergence profile to be generated and for guiding the proper implant positioning in rela-tion to the aforementioned selected infor-mation. The mold tool of the system (EPM) was utilized to fabricate the depicted by the EPI proper shape and size custom healing abutment and its duplicate impression post to be used for the generation and record-ing of the desired custom emergence profile.

Results: 1 year post treatment evalua-tion, the hard and soft tissues were clini-cally and radiographically within normal limits. Conclusions: The VPI EPMS and its proto-col of use provide an easy and predictable way to properly select, generate and record a cus-tom emergence profile around an implant and no adverse effects were noted with its use.

An Innovative Approach for the Selection, Generation and Recording of a Custom Emergence

Profile Around Implants

Ioannis Vergoullis, DDS, MS1 • Catherine Badell, DDS1

George Papadopoulos, CDT2

1. Vergoullis Dental Clinic, Rhodes, Greece. Visiting Assistant Professor, Periodontics, Louisiana State University, New Orleans, USA

2. Vergoullis Dental Clinic, Rhodes, Greece

Abstract

KEY WORDS: Emergence profile, dental implants, custom healing abutments, custom impression posts

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INTRODUCTIONOne of the major existing problems in the daily practice of implant dentistry remains the routine generation and recording of a natural emergence profile around an implant. The development of a natural emergence profile is a very important parameter as it relates not only to the esthetic but also to the functional result of treatment.1,2 In par-ticular a properly developed gingival emergence profile is necessary in order for a final crown to be designed and fabricated, comprising a proper contour and establishing adequate contact sur-faces with the adjacent dentition.3, 4 However the process of custom emergence profile generation and recording is a process that requires high clini-cal dexterity, it involves extra cost and increases working time.5, 6 All these factors prevent the process from becoming a standard practice.

Finally, today the clinicians do not have avail-

able a guide tool that can help them identify intra-orally, the proper shape, dimensions and orientation of the emergence profile that needs to be generated in an edentulous space, in an objective, fast and easy manner. This is a pro-cess currently done mostly after the implant has been placed and an impression has been taken. The lab technician then depicts and generates the emergence profile on the working cast before fabricating one or a series of temporary pros-thesis to be utilized in order to gradually sculpt the depicted emergence profile in the mouth.7

This paper describes for the first time the pro-tocol of use of a novel system (VPI EPMS) (VP Innovato Holdings Ltd, Cyprus) that comprises an emergence profile indicator (EPI) and an emer-gence profile mold (EPM) (Fig.1). The EPI is an intra-oral guide that can be used in order to select the proper shape, dimensions and orienta-

Figure 1a: VPI EPMS, EPI. Figure 1B: VPI EPMS, EPM.

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tion of the suitable emergence profile to be gen-erated and also to assist with implant position and orientation in relation to the aforementioned information. The EPM is used for the fabrica-tion of a custom healing abutment and its dupli-cate impression post, where their custom bodies are corresponded to the information depicted by the EPI. The functional parts of the system are coded in different groups (anterior, premo-lars, molars) and their shapes and sizes relate

to the known shapes and sizes of the root trunk of different groups of teeth as this information is available from the dental literature.8, 9, 10, 11, 12, 13

CASE PRESENTATIONA 77 year old female with a hopeless upper first premolar presented in our clinic for implant replacement therapy. The patient was non smoker, with a medical history of controlled hypertension, no active dental disease and no contra-indica-

Figure 2a: Pre-op clinical view. Figure 2b: Pre-op x-ray.

Figure 2c: Pre-op evaluation with cylindrical tab of EPI. Figure 2d: Pre-op evaluation with anatomical tab of EPI.

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tions present for implant therapy.14 The radio-graphic and clinical evaluation revealed that there was adequate hard and soft tissue to proceed with an immediate implant replacement therapy (Fig. 2a, 2b). The requirements of the Helsinki Declaration were observed, and the patient gave informed consent for all surgical procedures.

At the day of consultation, the edentulous space was evaluated with the EPI of the system. The edentulous site was first evaluated with the

use of the cylindrical tabs of the premolar group of the EPI. The selected tab was the small size cylindrical (#4.0) as this fitted best in the eden-tulous space in the mesiodistal dimensions, being in light contact with the proximal surfaces of the adjacent teeth (Fig. 2c). The anatomical tabs from the premolar group were subsequently utilized for the selection of the proper size and shape of the emergence profile to be generated, along with determination of the proper orientation of the lat-

Figure 3a: Custom healing abutment. Figure 3b: Custom healing abutment.

Figure 3c: Custom impression post. Figure 3d: Custom impression post.

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ter. The medium size-premolar anatomical tab (#5.1) was the one selected as most appropri-ate, as this resembled best the root trunk of the tooth to be replaced by the implant, expanding 1-2 mm within the borders of the future crown (Fig. 2d). Moreover, the T line imprinted on the top surface of the anatomical tab, served as a reference for the proper orientation of the emer-gence profile and depicted the proper orienta-tion of the prosthetic connection of the implant

to be placed. In other words, the flat surface of the hex of the prosthetic connection of the implant should be facing the same direction as per the T line on the tab. In this case, the proper orientation was determined to be facially (Fig. 2d). The coding of the selected cylindri-cal and anatomical tab along with the orienta-tion of the reference T-line and the implant type and platform size to be utilized were noted in the patient’s chart. The treatment plan of the

Figure 4: Custom healing abutment and impression post. Figure 5a: Osteotomy marking.

Figure 5b: Facial view post socket shield preparation. Figure 5c: Occlusal view post socket shield preparation.

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patient included the following information: a 3.5mm platform, internal hex implant will be placed and it will receive a medium size-pre-molar custom healing abutment (#5.1) with a 2mm titanium shoulder, facing facially. The #4.0 cylindrical tab will be utilized as surgical guide.

Custom Healing Abutment and Impression Post Fabrication ProcessA temporary titanium abutment with an internal

hex connection, 3.5mm platform and 2 mm pol-ished shoulder was installed into the #5.1 well of the mold according to the manufacturer guide-lines (Fig. 3a). Composite nano-hybrid material was then introduced into the open space avail-able in the well, until the space was completely filled and it was subsequently light cured for 40 seconds (Fig. 3b).15, 16, 17, 18, 19 The cus-tom healing abutment was then removed from the well and it was light cured for an additional

Figure 6a: Custom healing abutment. Figure 6b: Custom healing abutment.

Figure 6c: Custom impression post. Figure 6d: Custom impression post.

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Figure 7a: Clinical evaluation post-surgery.

Figure 7b: Radiographic evaluation post-surgery.Figure 7c: Developed emergence profile post-surgery.

20 seconds. Minor height adjustments were done and the composite surface was highly pol-ished using polishing brushes and paste. The #5.1 well of the mold was cleaned with a cotton tip soaked in alcohol and air dried. The described process was performed again for the fabrication of the duplicate impression post by utilizing an impression post core with the same type pros-thetic connection and same size prosthetic plat-form and shoulder (Fig. 3c, 3d). A custom shaped

healing abutment and duplicate impression post were fabricated and stored for later use (Fig. 4).

Day of SurgeryAt the day of surgery the fabricated #5.1 cus-tom healing abutment was thoroughly cleaned with the use of steam, followed by an ultrasonic bath with 95% alcohol solution for 5 minutes. It was then put in a sterile surgical cup filled with chlorhexidine solution 0.2% (Froiplak Plus, Froika,

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Figure 8a: Custom impression post. Figure 8b: Custom impression post installed to the implant.

Figure 8c: Impression. Figure 8d: Custom impression post installed into the impression.

Greece)for approximately 15 minutes.20, 21, 22, 23

Local anesthesia was administered (Ubistesin 4%, 3M ESPE, Germany ) and the #4.0 cylindri-cal tab attached on the handle of the guide was placed on the edentulous site. The central refer-ence line present on the top surface of the tab was aligned with the occlusal lines of the adjacent teeth. The initiation point of implant osteotomy was performed with the use of a 1.3 mm pilot drill (Salvin Dental, VA, USA) through the central open

bore of the tab (Fig. 5a). A full thickness flap was elevated. The palatal root was removed. The buc-cal root was sectioned mesiodistally. The palatal portion of the buccal root was removed while a facial shield of 1.5 mm thickness was left intact in place24 (Fig. 5b, 5c). The socket was thoroughly curetted and rinsed with a tetracycline solution (50mg/ml) and sterile saline solution. The osteot-omy was then identified and enlarged with subse-quent drills of larger diameter as per the implant

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Figure 8e: Working cast. Figure 8f: Final screw-retained prosthesis, occlusal view.

Figure 8g: Final screw-retained prosthesis, facial view. Figure 8h: Final prosthesis in the mouth, occlusal view.

Figure 8i: Final prosthesis in the mouth, facial view.

manufacturer recommended protocol for oste-otomy preparation. After each drill was used, a corresponding in size guide pin available in the system was inserted into the osteotomy and the selected #5.1 anatomical tab of the guide was installed on the top pillar of the pin. This allowed the consistent evaluation of the implant osteotomy position and angulation in relation to the desired emergence profile to be generated. After comple-tion of the osteotomy, the implant was placed

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Figure 9a: Final prosthesis in the mouth, occlusal view 1 year post surgery.

Figure 9b: Final prosthesis in the mouth, facial view 1 year post surgery.

Figure 9c: Peri-apical radiograph 1 year post surgery.

Figure 9d: Bite-wing radiograph 1 year post surgery.

keeping the flat surface of the implant prosthetic connection facing facially (Fig. 6a, 6b). The gap between implant body and surrounding structures was filled with allograft material (Oragraft, Freeze dried bone allograft, Cortico-cancellous, Lifenet, VA, USA) and the facial fenestration was treated with the same allograft material and covered with collagen membrane (T Barrier, B&B Dental, Italy).

Adequate primary stability of the implant was achieved (Insertion torque 40N/cm and ISQ 77). The #5.1 custom healing abutment was

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thoroughly rinsed with sterile saline and it was installed onto the implant with a 30 N/cm torque as per the manufacturers recommendation for final abutment torque. This technique has been shown to be beneficial for the hard tissue response in comparison to standard one piece healing abut-ments. This response is due to the fact that it mini-mizes micro-movement during the healing phase, but also because allows proper oral hygiene mea-sures.25 A final evaluation was made and the flaps were repositioned and sutured utilizing resorb-able sutures (Chromic Gut 4.0 – Salvin Dental, VA, USA) (Fig. 6c). The occlusal screw access bore was sealed with a bottom layer of sterile Tef-lon tape and a top layer of composite material as per standard practice of sealing the screw access bore of a temporary or a final implant crown (Fig. 6d). Postoperative instructions were given. The patient was given a prescription for Amoxicillin 500mg (GlaxoSmithKline, UK) every 8 hours for 5 days; Ibuprofen 600mg (Actavis Group, Greece) every 8 hours for 4 days and then as needed; and Chlorexidine rinse 0.12% (Froiplak 0.12%, Froika, Greece) twice a day for two weeks.

The healing process was evalu-ated at 2, 4, 8, 12 and 16 weeks post implant placement and it was uneventful.

Impression StageFive months post dental implant placement, clini-cal (ISQ 78 - Ostell) and radiographic evalua-tion revealed successful osseointegration of the implant with healthy looking surrounding soft tissue (Fig. 7). The area was rinsed with ster-ile saline. A small notch was made on the top surface of the composite area of the #5.1 dupli-cate impression post using a high speed hand piece and a round diamond bur (Fig. 8a). The

impression post was thoroughly cleaned with the same protocol as per the custom healing abut-ment previously described. The duplicate impres-sion post was installed onto the implant with the same orientation as the custom healing abutment had (Fig. 8b). Proper installation onto the implant was confirmed radiographically. An impres-sion was taken utilizing polyvislioxane material (Image PVS, Dental Line, Greece), using a stan-dard tray with the closed tray impression tech-nique26 (Fig. 8c). An impression of the opposing arch was also taken along with bite registration.

Laboratory The lab technician coupled an appropriate implant analog with the duplicate impression post and installed the later into the impression (Fig. 8d). The notch present on the compos-ite surface of the impression was replicated in the impression and it provided a reference for proper installation in only one functional posi-tion (Fig. 8a, 8c, 8d). Silicone material (gingival mask) was inserted around the exposed surface of the custom impression post. The gypsum was then poured to fabricate the working casts. The two casts were articulated using a semi-adjust-able articulator. The generated emergence pro-file appeared to be accurately recorded and provided the lab technician the foundation for the fabrication of a screw retained, natural in shape and size implant prosthesis with proper contour and contact surfaces 3 (Fig. 8e, 8f, 8g).

Prosthesis DeliveryAt the day of final prosthesis delivery, the cus-tom healing abutment was replaced by the final prosthesis. The proper fit of the prosthesis was evaluated clinically and radiographically. Occlu-

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sal adjustments were made. The contact surfaces were evaluated with the use of dental floss. The screw-retained prosthesis was torqued at 30N/cm as per the implant manufacturer recomman-dation. The screw access bore was blocked with a layer of sterile Teflon tape and a second layer of micro-hybrid composite material (Fig. 8h, 8i). Oral hygiene instructions were given to the patient. The patient was very happy and satis-fied with the esthetic outcome of the treatment.

The patient was re-evaluated at 12 months post implant placement. The hard and soft tis-sue was clinically stable and within normal lim-its (Fig. 9). At this appointment the patient confirmed that she was totally satisfied with the esthetic and functional result of the treatment.

DISCUSSIONThe development and recording of a natural, in shape and size, custom emergence profile is one of the fundamental elements for the estheti-cally and functionally successfull implant therapy.

Today the common practice is the develop-ment of a cylindrical in shape emergence profile as this is generated by the currently existing and widely used cylindrical in shape standard healing abutments, available by the different implant com-panies.27, 28 The cylindrical in shape emergence profile leads to the design and fabrication of a crown comprising a cylindrical sub-gingival por-tion. This then results in a ridge lap contour of the crown, with areas of undercuts and inadequate contact surfaces with the adjacent dentition. The contour of the prosthesis, with a mushroom like shape, creates several clinical problems, like food impaction, large open triangles with the adjacent teeth on the cervical portion, among others.29 Also in the aforementioned cases, when standard final

abutments are used to support cemented res-torations, the process of controlling and remov-ing the excess of cement during the cementation process becomes a very difficult task that often is ineffective. When left behind, the presence of cement subgingivally leads to the development of biological complications like cement sepsis around the implant.30, 31 Finally, there is evidence arising from animal research that shows that in cases of immediate implants in extraction sockets, the standard healing abutments provide inferior outcomes compared to anatomical in shape and wider in dimensions custom healing abutments with regards to soft and hard tissue response.32 Many clinicians have identified the aforemen-tioned problems and try to prosthetically sculpt the peri-implant tissue by using a series of tem-porary prostheses that they gradually adapt in shape and dimensions in order to change the existing cylindrical in shape emergence profile to one with a natural shape and dimensions.33,34,35,

36,37,38 Even when a natural emergence profile is achieved, another problem that the clinician might face is to accurately record the developed custom emergence profile during the impression stage. In order to accurately record it, a custom-ized impression post has to be developed with a subgingival portion that will be the exact duplicate of the subgingival portion of the final temporary prosthesis that was used to develop the custom emergence profile.39,40,41,42 This is a process that requires high dexterity, is laborious, takes time and becomes even more difficult in cases involving the impression of several implants in the same arch.43

All those factors have played a role on inter-fering with the process of custom emergence profile development and recording from becom-ing a standard protocol of care for both anterior

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and posterior cases. The superior results that this customization process withholds both estheti-cally and biologically have been well proven. The use of a system that could simplify the implemen-tation of this process in the daily practice will have a positive impact on the long term results of implant therapy. The VPI EPMS is a system that can facilitate the achievement of this goal since it simplifies the process making it accessible to all dentists practicing implant dentistry. The innova-tive tools in the VPI EPMS system, facilitate the process of proper implant positioning as well as the selection, establishment and recording of a natural in shape and dimensions emergence pro-file. We have been utilizing the system in our clinic for the last 3 years and no adverse effects asso-ciated with the system have been noted in 120 cases treated with the assistance of the system.

CONCLUSIONSThis is the first report of an innovative system that appears to be effective in assisting clini-cians to easily and predictably place a dental implant in the proper restorative position; and to select, develop and record the ideal custom emer-gence profile during implant therapy. More stud-ies involving a greater number of clinical cases and different clinicians are needed to prove the reproducibility of the results of the system. l

Correspondence:Ioannis Vergoullis, DDS, MS*31 Ammohostou street, 85100 Rhodes, GreeceTel: +30- 2241078843Email: [email protected]

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15. Endo T, Finger WJ, Kanehira M, Utterodt A, Komatsu M. Surface texture and roughness of polished nanofill and nanohybrid resin compos-ites. Dent Mater J. 2010 Mar;29(2):213-23.

16. Uçtali MB, Arisu HD, Omürlü H, Eligüzelolu E, Ozcan S, Ergun G. The effect of different finish-ing and polishing systems on the surface rough-ness ofdifferent composite restorative materials. J Contemp Dent Pract. 2007 Feb1;8(2):89-96.

17. Janus J, Fauxpoint G, Arntz Y, Pelletier H, Etienne O. Surface roughness and morphol-ogy of three nanocomposites after two differ-ent polishing treatments by a multitechnique approach. Dent Mater. 2010 May;26(5):416-25.

18. Ozel E, Korkmaz Y, Attar N, Karabulut E. Effect of one-step polishing systems on surface rough-ness of different flowable restorative materi-als. Dent Mater J. 2008 Nov;27(6):755-64.

19. Andriani W Jr, Suzuki M, Bonfante EA, Carvalho RM, Silva NR, Coelho PG. Mechanical testing of indirect composite materials directly applied on implantabut-ments. J Adhes Dent. 2010 Aug;12(4):311-7.

20. Sennhenn-Kirchner S, Weustermann S, Mergeryan H, Jacobs HG, Borg-von ZepelinM, Kirchner B. Preoperative sterilization and disinfection of drill guidetemplates. Clin Oral Investig. 2008 Jun;12(2):179-87.

21. Canullo L, Micarelli C, Lembo-Fazio L, Iannello G, Clementini M. Microscopical and microbio-logic characterization of customized titanium abutments after different cleaning procedures. Clin Oral Implants Res. 2014 Mar;25(3):328-36.

22. Moeintaghavi A, Arab H, Khajekaramodini M, Hosseini R, Danesteh H, Niknami H. In vitro antimicrobial comparison of chlorhexidine, persica mouthwash and miswak extract. J Con-temp Dent Pract. 2012 Mar 1;13(2):147-52.

23. Haragushiku GA, Back ED, Tomazinho PH, Baratto Filho F, Furuse AY. Influenceof antimi-crobial solutions in the decontamination and adhesion of glass-fiber posts to root canals. J Appl Oral Sci. 2015 Jul-Aug;23(4):436-41.

24. Bäumer D, Zuhr O, Rebele S, Schneider D, Schupbach P, Hürzeler M. The socket-shield technique: first histological, clinical, and volu-metrical observations after separation of the buccal tooth segment – a pilot study. Clin Implant Dent Relat Res. 2015 Feb;17(1):71-82.

25. Nader N, Aboulhosn M, Berberi A, Manal C, Younes R. Marginal Bone Remodeling around healing Abutment vs Final Abutment Place-ment at Second Stage ImplantSurgery: A 12-month Randomized Clinical Trial. J Con-temp Dent Pract. 2016 Jan 1;17(1):7-15.

26. Gallucci GO, Papaspyridakos P, Ashy LM, Kim GE, Brady NJ, Weber HP. Clinicalac-curacy outcomes of closed-tray and open-tray implant impression techniques for partially edentulous patients. Int J Prostho-dont. 2011 Sep-Oct;24(5):469-72.

27. Bernard JP, Belser UC, Martinet JP, Bor-gis SA. Osseointegration of Brånemark fixtures using a single-step operating tech-nique. A preliminary prospective one-year study in the edentulous mandible. Clin Oral Implants Res. 1995 Jun;6(2):122-9.

28. Collins JR, Berg RW, Rodríguez M, Rodríguez I, Coelho PG, Tovar N. Evaluation of human periimplant soft tissues around nonsubmerged machined standard and platform-switched abut-ments. Implant Dent. 2015 Feb;24(1):57-61.

29. Wang JH, Judge R, Bailey D. A 5-Year Ret-rospective Assay of Implant Treatments and Complications in Private Practice: The Restor-ative Complications of Single and Short-Span Implant-Supported Fixed Prostheses. Int J Prosthodont. 2016 Sep-Oct;29(5):435-44.

30. Piñeyro A, Ganeles J. Custom abutments alone will not eliminate the clinical effects of poor cementation techniques around dental implants. Compend Contin Educ Dent. 2014 Oct;35(9):678-80, 682-6.

31. Alani A, Bishop K. Peri-implantitis. Part 2: Prevention and maintenance of peri-implant health. Br Dent J. 2014 Sep;217(6):289-97.

32. López-López PJ, Mareque-Bueno J, Boquete-Castro A, Aguilar-Salvatierra Raya A, Martínez-González JM, Calvo-Guirado JL. The effects of healing abutments of different size and anatomic shape placed immediately in extrac-tion sockets on peri-implant hard and soft tissues. A pilot study in foxhound dogs. Clin Oral Implants Res. 2016 Jan;27(1):90-6.

33. Wittneben JG, Buser D, Belser UC, Bräg-ger U. Peri-implant soft tissue condition-ing with provisional restorations in the esthetic zone: the dynamic compression technique. Int J Periodontics Restorative Dent. 2013 Jul-Aug;33(4):447-55.

34. Al-Juboori MJ. Interdental Implant Papil-lae Grow up with Temporary Abutment-displaced at Monthly Intervals. J Contemp Dent Pract. 2015 May 1;16(5):422-6.

35. Schoenbaum TR. Abutment Emergence Profile and Its Effect on Peri-Implant Tis-sues. Compend Contin Educ Dent. 2015 Jul-Aug;36(7):474-9. Review.

36. Macintosh DC, Sutherland M. Method for developing an optimal emergence profile using heat-polymerized provisional restorations for single-toothimplant-supported restorations. J Prosthet Dent. 2004 Mar;91(3):289-92.

37. Parpaiola A, Sbricoli L, Guazzo R, Bressan E, Lops D. Managing theperi-implant mucosa: a clinically reliable method for optimizing soft tis-sue contours and emergence profile. J Esthet Restor Dent. 2013 Oct;25(5):317-23.

38. Hochwald DA. Surgical template impression during stage I surgery forfabrication of a provi-sional restoration to be placed at stage II sur-gery. J Prosthet Dent. 1991 Dec;66(6):796-8.

39. Shah K, Yilmaz B. A Technique to Trans-fer the Emergence Profile Contours of a Provisional Implant Crown to the Definitive Impression. Int J Oral Maxillofac Implants. 2016 Mar-Apr;31(2):e15-7.

40. Papadopoulos I, Pozidi G, Goussias H, Kourtis S. Transferring the emergence profile from the provisional to the final restoration. J Esthet Restor Dent. 2014 May-Jun;26(3):154-61.

41. Elian N, Tabourian G, Jalbout ZN, Classi A, Cho SC, Froum S, Tarnow DP. Accurate transfer of peri-implant soft tissue emergence profile from the provisional crown to the final prosthesis using an emergence profile cast. J Esthet Restor Dent. 2007;19(6):306-14; discussion 315.

42. Neale D, Chee WW. Development of implant soft tissue emergence profile: a technique. J Prosthet Dent. 1994 Apr;71(4):364-8.

43. Ntounis A, Pelekanos S. Custom cop-ings for accurate impressions of mul-tiple internal connection implants. Implant Dent. 2010 Oct;19(5):365-9.

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Jambi et al

One of the anatomical obstacles for den-tal implants placement in the upper ante-rior region of the oral cavity is the incisive

canal or the nasopalatine canal. Presence of the incisive canal jeopardizes the ideal position of the implants placement. As a result, enucleation of the canal content and placement of bone graft or substitute are necessary to improve the bone bed.

In order to prevent any change in sensation (even a temporarily one) and having bone aug-mentation at the same time, partial removal of the

canal’s contents and placement of allograft bone is presented in this case report. Re-entry sur-gery after 6 months of the surgical site showed an adequate bone. An implant was placed then a prosthetic restoration was placed. After 1 year of follow-up the implant was successful and no sensory disturbances were shown. This novel surgical approach that shows partial removal of neurovascular content of the incisive canal dur-ing bone augmentation procedure is successful for implant placement and function in the future.

Partial Enucleation of the Nasopalatine Canal for Implant Placement:

A Novel Procedure

Dr. Samar M Jambi1 • Dr. Meisan A. Bukhari2

1. The North Centre of Dental Specialities, Department of Dental Implantology and Periodontology, Jeddah, Saudi Arabia

2. The North Centre of Dental Specialities, Department of Prosthodontics, Jeddah , Saudi Arabia

Abstract

KEY WORDS: Dental implants, nasopalatine canal, enucleation

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INTRODUCTIONA lot of patients face the embarrassment and frustration of tooth loss either in the maxilla or in the mandible. In the maxilla, dentists are chal-lenging replacement of missing teeth in the maxilla in their daily practice. The incisive canal (the nasopalatine canal) is located between the two central incisors, slightly palatal. Its volume can prevent implant placement. The neurovas-cular content includes nasopalatine nerve and terminal branch of nasopalatine artery and also anastomoses with the greater palatine nerve and artery. This gives innervation and vascular-ization for the upper anterior region from the right canine to the left canine. The incisive canal ranges from 4 to 26 mm in length.1,2 Mraiwa et al. published their 3-dimensional analysis of the incisive canal in 2004 and found that It’s diameter range from 1.5 mm to 9.2 mm and The width of the bucco palatal bone anterior

to the canal range from 2.9 mm to 13.6 mm.3 Unfortunately, after extraction of the anterior

maxillary teeth, high resorption rate happens on the area. In addition, the presence of the incisive canal jeopardizes the ideal position of the implant placement. Non-osseointegration of the implant and impairment of sensation are common implant complications when it is in a direct contact with nervous tissue.4 As a result, enucleation of the canal content and then replaced by bone graft or substitute is necessary to improve the bone bed. It is crucial to evaluate the canal and its surrounding bone and anatomical landmarks precisely before implants placement to avoid complications.5

Neurological impairment of the soft tis-sue such as paresthesia (abnormal sensa-tion of the soft tissue such as tingling or pricking) or dysesthia (burning sensation) may exist after enucleation of the canal.2 The loss of sensation is the most concern when

Figure 1: Pre-surgical clinical appearance of missing right central incisor.

Figure 2: Presurgical CBCT scan for the missing area.

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dealing with the incisive canal enucleation. In 2009, Spin-Neto et al. placed an implant

inside the canal after its enucleation without using of any bone graft. No loss of sensation was found.6 Artzi et al. displaced the content posteriorly but not removed with using of cor-tico-cancellous bone block graft. Then imme-diate placement of an implant was placed. There were no sensory disturbances in the case he did and it was successful. The re-entry was after 9 months of the procedure.7

There was slight loss of sensation ini-tially then recovery happened in the patients of Penarrocha et al.8,9 For Rosenquist et al study, none of their cases had sensory distur-bances.10 Slight numbness of the two cases was reported by Verardi et al after one week of the surgery and existed for 4 weeks.11

Variations of bone grafts were used after enu-cleation of the incisive canal. Autogenous can-cellous bone was used in 4 canals in a study by Rosenquist et al. who used autogenous cancel-lous chips for chins. The results showed 100% implant survival at 12-15 months.10 Penarrocha et al concluded that placing implants in nasopala-tine canal may be considered a variable treatment

approach for severely atrophic maxilla rehabilita-tion. They .performed two studies and used the same type in addition to beta tricalcium phos-phate. He had successful reentry after 9 months in the earlier study of 7 implants placed into the incisive canals after enc. The latter study had follow up for 13 cases and 2 early failures of 2 cases were found and no failures for the rest

Figure 3: Canal enucleated.

Figure 4: Allograft bone was placed.

Figure 5: Membrane covering the surgical area.

Jambi et al


of the cases (mean follow up of 70 months). 8,9 Scher used DFDBA and Calcium sulphate after removal of soft tissue content of 2 incisive canals and he got 100% implant survival rate one of the 2 cases has follow up at 3 years.12 Verdi et al. placed collagen plug in 2 cases apically and can-cellous allograft particles in one case and bovine xenograft and autograft in the other case placed coronally.11 The most recent case was reported by Wassdorp who used block allograft after removal of the incisive canal contents. No sen-sory disturbances was reported by the patient after six months of the implant placement.13

Figure 6: Postoperative CBCT. Figure 7: Clinical appearance of the surgical site.

Figure 8: Implant placement.

Figure 9: X-ray of installed implant.

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CASE REPORTA 20 years old Saudi male came to the Dental Hospital of King Abdul-Aziz University in Jeddah to replace missing tooth #11 which was extracted after its fracture due to trauma. His medical his-tory was not significant. The patient has low lip line and has thick gingival biotype. He has a defi-cient bony ridge in the missing area (Figure 1). CBCT findings showed severe bone loss in the missing area in close proximity to the incisive canal (Figure 2). The surgical procedure was discussed with the patient including the possi-bility of canal enucleation and its complications.

After anesthetizing the area under local anesthesia with buccal and nasopalatine infil-tration (Lignospan special, Lidocain hydrochlo-ride 2% & 1:80,000 epinephrine). Full thickness flap was reflected with vertical releasing inci-sions. Enucleation of the coronal 2/3 of the inci-sive canal was performed with copious irrigation using debridement burs and curettes (Figure 3).

Puros® demineralized freeze-dried corti-cal bone allograft (DFDBA) was placed into the canal (Zimmer, Warsaw, IN) and on the buc-cal surface of the surgical area (Figure 4) then

both the buccal and the lingual surfaces were covered by BioMend®, a collagen membrane (Zimmer, Warsaw, IN ) to get guided bone regen-eration in the area (Figure 5). Multiple Simple interrupted sutures using VICRYL® (ETHICON, USA) were performed to close the flap after obtaining periosteal releasing incisions. Dur-ing healing time (6 months), patient was wearing an interim partial denture which was relived to be not in a direct contact with the surgical site.

After 6 months, CT scan and re-entry surgery showed an adequate bone (Figure 6 & 7). An implant was placed size 4.1*11.5 (Prima Con-nex, Keystone Dental Inc., Burlington, Massa-chusetts, USA) with cover screw (Figure 8). The buccal bone covering the implant was thin so Puros®(Zimmer, Warsaw, IN), demineralized freeze-dried cortical bone allograft (DFDBA) was placed over the buccal bone to gain thicker bone (Zimmer, Warsaw, IN). Then a collagen membrane BioMend® (Zimmer, Warsaw, IN) was placed.

The surgical site was allowed to heal for another 6 months before starting mak-ing the final prosthetic part. An impression was taken and a temporary crown was placed for 1 month then a final impression was taken for the final restoration (Figure 10). After 1 year of follow-up the implant was success-ful and no sensory disturbances were shown.

CONCLUSIONAccording to the previous findings regarding par-tial removal of neurovascular during bone aug-mentation procedure in the upper anterior region is successful for implant placement and function in the future. This procedure can be performed only in long nasopalatine and the canal should be longer than the implant that would be placed.

Figure 10: Final restoration of missing right central incisor.

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This is to avoid placing the implant in a soft tis-sue (the content of the canal). Otherwise implant will be in a direct contact with neurovascular tis-sue leading to loss of osseointegration and sen-sory changes will happen Panjnoush et al.1 l

Correspondence:Dr. Samar M. JambiThe North Centre of Dental Specialties Al-Amal StreetJeddah, Saudi ArabiaPhone: +966595141616Email: [email protected]

DisclosureThe authors report no conflicts of interest with anything mentioned in this article.

References1. Panjnoush M, Norouzi H, Kheirandish Y, Shamshiri AR, Mofidi N. Evaluation of

morphology and anatomical measurement of nasopalatine canal using cone beam computed tomography. J Dent 2016; 13 (4):287-294.

2. Misch CE, Strong JT, Bidez MW. Contemporary Implant Dentistry, 3rd ed. St. Louis, MO: Mosby; 2008: 200-229.

3. Mraiwa, N, Jacobs R, Van Cleynenbreugel J, Sanderink G, Schutyser F, Suetens P, van Steenberghe D, Quirynen M. The nasopalatine canal revisited using 2D and 3D CT imaging. Dentomaxil Radiol 2004; 33 (6): 396–402

4. Liang X, Jacobs R, Martens W, Hu Y, Adriaensens P, Quirynen M, Lambrichts I. Macro- and micro-anatomical, histological and computed tomography scan characterization of the nasopalatine canal. J Clin Periodontol 2009; 36 (7):598–603.

5. Loubele M, Guerrero ME, Jacobs R, Suetens P, van Steenberghe D. A comparison of jaw dimensional and quality assessments of bone characteristics with cone-beam CT, spiral tomography, and multi-slice spiral CT Int J Oral Maxillofac Implants 2007; 22(3):446–54.

6. Spin-Neto R1, Bedran TB, de Paula WN, de Freitas RM, de Oliveira Ramalho LT, Marcantonio E Jr. Incisive canal deflation for correct implant placement: case report Implant Dent 2009; 18(6):473-9.

7. Artzi Z, Nemcovsky CE, Bitlitum I, Segal P. Displacement of the incisive foramen in conjunction with implant placement in the anterior maxilla without jeopardizing vitality of nasopalatine nerve and vessels: a novel surgical approach. Clin Oral Implants Res 2000; 11(5):505–10.

8. Peñarrocha M, Carrillo C, Uribe R, García B. The nasopalatine canal as an anatomic buttress for implant placement in the severely atrophic maxilla: a pilot study. Int J Oral Maxillofac Implants 2009; 24(5):936–42.

9. Peñarrocha D, Candel E, Guirado JL, Canullo L, Peñarrocha M. Implants placed in the nasopalatine canal to rehabilitate severly atrophic maxillae:a retrospective study with long follow up. J oral implant 2014; 40 (6): 699-706.

10. Rosenquist JB, Nyström E. Occlusion of the incisal canal with bone chips. A procedure to facilitate insertion of implants in the anterior maxilla. Int J Oral Maxillofac Surg 1992; 21(4):210–1.

11. Scher EL. Use of the incisive canal as a recipient site for root form implants: preliminary clinical reports. Implant Dent 1994; 3(1):38–41.

12. Waasdorp J Enucleation of the incisive canal for implant placement: a comprehensive literature review and case report. J oral implant. 2016; 42 (2): 180-183.

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Jambi et al

Zahran et al

Objective: to evaluate clinically and radiographi-cally the performance of short dental implants in the posterior atrophic ridges (maxilla and mandible) with deficient vertical bone height as an alternative treat-ment modality to other more invasive procedures.

Methods: 30 patients, with residual bone height 7-9 mm in the mandibular or the maxillary poste-rior regions, were selected to receive 6.5 mm short dental implants (Maxi Z Flat-End, Osteo-Care™ Implant System, London, UK). Implants were loaded 4 months (T2) after placement and Patients were followed up 1 year after loading (T3). 32 implants were inserted, 15 implants in the posterior maxilla and 17 implants in the pos-terior mandible. Outcomes measured included: Implant stability measured by Periotest®M mean values (PTMVs), Implant failure rate, mar-ginal bone loss (MBL) and other complications.

Results: 30 patients were evaluated at 1 year after loading. The PTMVs were -1.23 ± 0.31 in maxilla, and 2 ± 0.23 in mandible. Marginal bone loss in the maxilla recorded -1.55 ± 0.29 mm and in the mandible -1.10 ± 0.12 mm after1 year of loading. The difference between the two groups showed no statistical significance (difference = -0.44 mm; 95% CI: -0.18 to 1.06; P = 0.1549). 2 implants failed in the maxilla with a failure rate of 13.3% while there were no failures in the man-dible. Statistical analysis showed no significant dif-ference between the studied groups (P=0.4828). Conclusion: Short dental implants seem to be an effective alternative treatment for atrophic ridges with a very high success rate in the mandible. They minimize the need for bone grafting procedures and increase the patients` acceptance, as well as, maximizing dental implant placement possibilities.

Clinical and Radiographic Evaluation of Short Dental Implants in Posterior Atrophic Ridges with a Follow-up

Period of 1 Year after Loading: A Controlled Clinical Trial

Amr Zahran, BDS, MDS, PhD1 • Fouad Al Tayib, BDS, MDS, PhD2 Amr Ali, BDS, MDS3 • Moemen Sheba,BDS4

1. Professor, Department of Periodontology, Faculty of Dentistry, Cairo University, Cairo, Egypt.

2 .PhD Candidate, Department of Periodontology, Faculty of Dentistry, Cairo University, Cairo, Egypt.

3. Assistant Lecturer, Department of Fixed Prosthodontics, Faculty of Dentistry, Cairo University, Cairo, Egypt.

4. Resident, Department of Removable Prosthodontics, Faculty of Dentistry, Cairo University, Cairo, Egypt.

Abstract

KEY WORDS: Dental implants, short implants, dental implant survival, atrophic ridges

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Zahran et al


INTRODUCTION Implant dentistry is becoming more popu-lar as a treatment modality especially with the emergence of newer and improved implan-tation technologies. Much of these improve-ments can be attributed to the relatively high success rates of implants in both partially and completely edentulous patients.1 In patients with long-standing edentulous arches, alveo-lar bone resorption (Both vertical and hori-zontal or combined defects) is frequently observed. The insertion of dental implants in patients with reduced alveolar bone height is challenging and may require additional invasive bone augmentation procedures.2

The use of short dental implants could ful-fill various indications where there is insufficient bone volume to avoid complicated bone aug-mentation or maxillary sinus floor elevation pro-cedures. Owing to the need for rehabilitation of such an increasing number of atrophic jaws, the 7mm standard implant was introduced in 1979. The survival rates of implants shorter than 10mm seem to be comparable to that of longer implants. The success rate of short implants is proposed to be higher in the mandible than the maxilla due to the nature of softer bone in the maxilla.3,4,5,6 The possibility of restoring the dentition without the need for significant surgi-cal augmentation has widened the scope for treatment options which, in turn, can lead to simplified implant rehabilitation procedures. These factors may increase patients` accep-tance, making the treatment option available to more people, further contributing towards improved oral function and general health.7

A broad number of cases series,8,9,10 and reviews,11,12 have reported favorable outcome

in terms of survival rate for short implants placed in posterior areas. Nevertheless, there are still controversies regarding the long-term consequences of peri-implant bone loss around short implants and its impact on the long-term implant success rate. As a conse-quence, the borderline scenario with 5–8mm of available bone still constitutes a challeng-ing therapeutic dilemma for clinicians.13 How-ever the development of implant design, surface structure and improved surgical tech-niques have given a reason to re-evaluate pre-vious results, and recent randomized clinical studies with 3 to 5 years follow-up indicated that short implants survival and success rates were similar to long implants and may support most prosthetic restorations adequately.14,15,16

Most recently, a number of systematic reviews evaluated the survival rate of short den-tal implants, overall concluding that the survival rates are similar to that of long implants.11,6,5,13,17 Nevertheless, limitations such as a slightly lower survival rate in soft bone or in the posterior max-illa were reported.5,18 Scientific evidence is scarce on short dental implants placed in the poste-rior maxilla. In addition, in most clinical studies short implants were splinted to longer ones.9,19

Sinus floor elevation procedures with long implants or complicated bone augmentation procedures have been reported to suffer many drawbacks in terms of complications faced and patients` acceptance, besides other consider-ations including cost, treatment time and morbidity associated with aforementioned procedures.18,19

The aim of the present study was to evaluate, clinically and radiographi-cally short dental implants placed in the posterior maxilla and mandible.

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SUBJECTS AND METHODSPatient SelectionPatients were selected, from the out-patient clinic of the Faculty of Oral and Dental Medicine (Cairo University), according to pre-set eligibility crite-ria. Any partially edentulous patient missing teeth in the premolar and molar area requiring one to three dental implants, aged 18 years old or older, and able to sign an informed consent form, was considered eligible for inclusion in this trial. Ver-tical bone heights at implant sites had to be at least 8 - 9 mm above the mandibular canals and 7 - 8 mm below the maxillary sinuses, with bone width of at least 6.0 mm as measured on cone beam computed tomography (CBCT) scans.

Exclusion criteria were as follows: (1) severe systemic diseases that might contraindicate surgi-cal intervention; (2) uncontrolled diabetes mellitus; (3) immune-compromised status; (4) coagulation

disorders; (5) radiotherapy; (6) chemotherapy; (7) alcohol or drug abuse; (8) pregnancy or lactation; (9) use of oral and/or intravenous amino-bisphos-phonates; (10) untreated active periodontal infec-tions; (11) active infection in the site of implant placement (13) heavy smokers and (12) bruxism.

The study protocol was reviewed by the Ethi-cal Committee for Human clinical trials at the Fac-ulty of Dentistry, Cairo University. The protocol of this study was also registered at the Pan African Clinical Trial Registry (PACTR) in 2015/07/11 and the registration no. is PACTR201610001197438.

Surgical ProceduresAll procedures were done under completely aseptic conditions. Patients were anesthetized at the surgical site by infiltration, using Artic-aine Hydrochloride 4% (Septocaine® 1.8 ml. Articaine Hydrochloride 4% and epinephrine

Figure 1: CBCT cross sectional view of immediate post placement (T1) of short implant in the mandible.

Figure 2: CBCT cross sectional view after 1 year of loading (T3) of short implant in the mandible.

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1:100000. Septodont, USA). Bone width was assessed using a bone caliper. Using a Bard Parker blade no.15, a palatal or lingual sub-crestal incision was created in the surgical site, extending the entire length of the edentulous area. Two oblique releasing incisions were then created on the buccal aspect. A full thickness flap was then elevated to expose the under-neath buccal alveolar bone. Under copious saline irrigation, the osteotomy was prepared by sequential drilling. The Maxi Z Flat-End implant 4.5 x 6.5mm (OsteoCare™ Implant System, Lon-don, UK) was inserted into the osteotomy using its peek carrier. Then the full seating of the implant was done using the 2.2mm hex-driver until implant platform was flush with the bone level and torqued to 30NCm to check the ini-tial stability. A periapical radiograph was taken to check the final implant position and to esti-

mate the initial bone level around the implant. The recipient site area was then sutured with 4-0 silk (Hu-Friedy, USA) interrupted sutures which were removed after 2 weeks.

Post-operative care: post-surgically patients were prescribed 875mg of Amoxicillin and 125mg of Clavulanic acid tablet (1gm Augmen-tin, Glaxosmith Kline, England) twice daily for 7 days, anti-inflammatory tablets (Brufen 200 mg, Abbott, India ltd.) twice per day for three days. A CBVT (Scanora 3D Soredex, Helsinki, Finland) scan was done within 24 hours post-surgically (T1) to assess marginal bone level (Fig.1, Fig.3)

Four months after implant placement (T2), re-entry using a tissue punch was done to fit a healing collar. A periapical radiograph was taken to check the proper fixation of the heal-ing collar. Seven to 10 days later, impressions were made using impression transfers and

Figure 3: CBCT cross sectional view of immediate post placement (T1) of short implant in the maxilla.

Figure 4: CBCT cross sectional view after 1 year of loading (T3) of short implant in the maxilla.

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30 • Vol. 9, No. 5 • July 2017

implant replicas and the final ceramo-metallic restorations were delivered and cemented after being checked for shade matching, marginal fitness and occlusion. Stability of implants in the two groups was tested using Periotest® M (Medizintechnik Gulden, Bensheim, Germany).

Outcome Measuresl Stability was tested using Periotest® M at the

loading stage (T2) and 1 year after loading (T3). Periotest® M values of (-8 to 0) were con-sidered the ideal values that denote successful osseointegration.

l The marginal bone loss (MBL) around the short implants was assessed using CBVT within the first 24 hours post-surgically (T1) and also after 1 year (T3) (Fig.2, Fig.4). The CBVT raw DICOM data set images CT was imported to the third party soft-ware for secondary reconstruction.

l Any biological or prosthetic complications were recorded.

l Implant failure: implant mobility and removal of stable implants dictated by progressive marginal bone loss or infection.

Statistical AnalysisThe statistical software used was IBM SPSS (IBM Corp., Armonk, NY, USA), and Excel (Microsoft, Redmond, WA, USA).The patient was the statistical unit of the analyses. A para-metric statistical approach was applied. Dif-ferences in the proportion of patients with implant failures and complications (dichoto-mous outcomes) between maxilla and man-dible were compared using the Fisher‘s exact test. The mean differences, standard deviation (SD), confidence intervals, val-

ues and results of the Students’ T-test for the changes by time in marginal bone level around implants of each group were used.

RESULTSDuring the 1 year follow-up period no drop-outs occurred. The main baseline patient and intervention characteristics are presented in (Table 1). There were no failures in the man-dible while there were two failures in max-illary implants (Table 2). The failure in the maxilla occurred in two patients, one fail-ure occurred in the preloading stage and the other occurred four months after load-ing (PTMV > 0). Post-operative swelling occurred in five cases, three in the maxilla and two in the mandible. The data of all patients was evaluated in the statistical analyses.

Implant stability was measured by Periotest M at preloading stage (T2) and 1 year after load-ing (T3). At the pre-loading stage the mean Periotest values were -1.99 ± 0.3 in the max-illa and -2.42 ± 0.26 in the mandible. At 1 year after loading the mean Periotest values were -1.23 ± 0.31 in the maxilla and -2 ± 0.23 in the mandible. Statistical analysis showed no sig-nificant differences (P ≥ 0.05) between the mandible and maxilla at T2 and T3 (Table 3).

The marginal bone loss around implants was measured at the mesial, distal, buccal and lin-gual aspects of all implants. The mean marginal bone loss 1 year after loading in the maxilla was -1.55 ± 0.29 mm while in the mandible it was -1.10 ± 0.12 mm, statistical analysis showed no significant difference (P ≥ 0.05) between the two groups. The results of Students’ T-test for the marginal bone loss around implants of each group were presented in (Table 4).

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DISCUSSION Restoration of the atrophic ridges presented a challenge in the past due to the limitation of implant placement especially in the posterior mandible and maxilla and the risk of approximat-ing vital structures. In the past, the only solution was performing bone augmentation procedures, which required extended treatment periods, extra expenses and surgical complications. An alterna-tive for restoration of such atrophic ridges is the use of short implants. Short implants were com-monly associated with lower survival rates due to the reduced bone-to implant contact. Moreover, the posterior region commonly shows moder-

ate to extensive bone resorption which results in increased crown height space and unfavorable crown-to-implant ratio. However, recently, the development of modified implant designs and sur-face treatments contributed for to the increased survival rates of short implants. Clinical literature has demonstrated no significant differences in the survival rate of short and standard implants.21,22

Care was taken to standardize the study con-ditions for all patients and to exclude conditions that might affect the success of short implants, such as smokers and medically compromised patients and patients exhibiting parafunctional habits - such exclusion was executed in line with

Table 1: Summary of the Main Results

Maxilla Mandible

Female 8 (53.34%) 10 (66.67%)

Mean age at recruitment 32.7 ± 0.97 33.67 ± 1.28

No. of patient 15 15

Total of implant inserted 15 17

Implant length and diameter 6.5 (4.5) 6.5 (4.5)

No. of implants placed with less 6 1 than 25 N/cm torque

No. of patients 15 13 receiving 1 implant

No. of patients 0 2 receiving 2 implants

Drop outs 0 0

Implant failure 2 0

Complication 3 2

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Table 2: Results of Fisher’s Exact Test. *:Significant at P ≤ 0.05.

Test Group Percentage Control Percentage P value

Implant failure 2 (15) 13.33% 0 (15) 0% 0.4828

Complications 3 (15) 20% 2 (15) 13.33% > 0.9999

the recommendations of previous studies.23,24,5 These criteria limited the number of patients recruited in the current study. The primary stability of the implant, which results from the initial inter-locking between alveolar bone and the body of the implant, affects the secondary stability of the implant because the latter results from subsequent contact osteogenesis and bone remodeling.25,26 Implant stability is a prerequisite for the long-term clinical success of osseointegrated implants.27

In this study, implant stability was assessed by means of Periotest®M, which is considered as a fast, safe and non-invasive method of measure-ment that is useful for long-term implant follow-up. This was in accordance with Wijaya et al.28 who concluded that the implant mobility checker (Periotest®) was reliable and a reproducible method for dental implant mobility assessment.

At the pre-loading stage (T2) and at 1 year after loading (T3), there was no statistical signifi-cance difference in mean Periotest®M values in both mandible and maxilla. The Periotest®M value of one short maxillary implant was (+3) after 1 year of loading (T3) and was considered as a failed implant while the other implant was lost at the pre-loading stage (T2). This was in accordance with Al Hashedi et al.29 where they considered the positive implants periotest values as questionable and requiring further clinical examination before

loading. Al-ghamdi et al.30 also reported that from the observed primary stability it can be concluded that short implants are able to achieve desired primary stability in areas with good bone quality.

The percentage of implant failure in maxilla was 13.3% while in mandible it was 0%. Many researchers,3132 considered bone quality as a sig-nificant risk factor for failures. Goodacre et al.33 reported that implants placed in poor bone qual-ity areas showed failures rates 16% higher than those placed into greater bone density areas. Another 5-year report of a prospective single-cohort study reported by Perelli and co-workers in 2012,34 reported that implant failure in 110 short implants placed in posterior atrophic maxilla after 5 years was 10% and at the end of the fol-low-up period the implant survival rate was 90%, and 93.1% with regard to prosthetic reconstruc-tion. On the other hand another study by Weng et al.35 reported a 25% failure rate when short implants were placed in the posterior maxilla, especially during the first 18 months of loading.

Crestal bone loss is another important parameter to guarantee long-term clinical ser-vice. The maintenance of a stable marginal bone level becomes more critical when short implants are used.36,37 In the present study the crestal bone loss around implants was measured at the mesial, distal, buccal and lingual aspects of all

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Table 3: Mean Periotest Values at T2 (Pre-loading) and T3 (1 Year After Loading).

Maxilla Mandible Mean Time Mean ± SD 95% CI Mean ± SD 95% CI Difference 95% CI P value

Pre-loading -1.99 ± 0.3 -2.14 to -2.42 ± 0.26 -2.56 to -0.44 ± 0.4 -1.26 to 0.2795 Stage (T2) -1.84 -2.29 0.38

1 Year After -1.23 ± 0.31 -1.39 to -2 ± 0.23 -2.12 to -0.77 ± 0.39 -1.56 to 0.0585 Loading (T3) -1.07 -1.88 0.03

Table 4: Marginal Bone Loss Around Implants 1 Year After Loading. *:Significant at P ≤ 0.05

Data Maxilla Mandible Mean Time Mean ± SD 95% CI Mean ± SD 95% CI Difference 95% CI P value

Insertion (T1) -1.55 ± 0.29 -1.7 to -1.10 ± 0.12 -1.16 to -0.44 ± 0.3 -0.18 to 0.1549 1 Year After -1.4 -1.04 1.06 Loading

Insertion (T1) -1.55 ± 0.29 -1.7 to -1.10 ± 0.12 -1.16 to -0.44 ± 0.3 -0.18 to 0.1549 1 Year After -1.4 -1.04 1.06 Loading (T3)

implants by using CBVT which was taken at baseline (T1: immediately after insertion) and 1 year after loading (T3). There was no statistical significant difference between the two groups for the marginal bone level changes around short implants from the baseline (T1) till after 1 year of loading (T3). After 1 year of loading the short implants placed in the maxilla showed a mean marginal bone loss of -1.55 ± 0.29 mm while the short implants placed in the mandible showed a mean marginal bone loss of -1.10 ± 0.12 mm.

Perelli el al.34 reported a minimal crestal bone resorption around short implants placed in the posterior atrophic mandible after 5 years follow-

up, he reported 1 mm marginal bone loss around 5 mm implants and 2 mm bone loss around 7 mm implants. In contrast with our study Ren-ouard and Nisand9 placed 96 short implants in the posterior atrophic maxilla. The mean marginal bone resorption after 2 years in function was 0.44 ± 0.52 mm. Recently Felice et al.38 evalu-ate the efficacy of short (5 or 6 mm-long) dental implants versus 10 mm or longer implants placed in crestally-lifted sinuses. They placed 16 short implants and 18 longer implants and they found that there was no significance difference in the mean crestal bone loss after 1 year follow up.

The use of short dental implants could be con-

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sidered as an alternative to avoid complicated bone augmentation procedures. The possibil-ity of restoring the dentition without the need for complicated surgical procedures has widened the scope for treatment options and increased patients` acceptance which contributes towards improved oral function and general health

CONCLUSIONS Within the limitations of the cur-rent study it was concluded that:

1. Short implants are considered a suc-

cessful treatment option for restoration of atrophic ridges with deficient vertical bone height in both the maxilla and the mandible.

2. Short implants placed in the atro-phic mandible showed higher success rate and less crestal bone resorption than those placed in the atrophic maxilla. l

Correspondence:Dr. Amr [email protected]

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DisclosureThe authors report no conflicts of inter-est with anything in this article.

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C., Cantero-Álvarez, M., Fernández-Cáliz, F. & Martínez-González, J. M. Meta-analysis on the survival of short implants. Med. Oral Patol. Oral Cir. Bucal 16, (2011).

2. Anitua, E., Piñas, L., Begoña, L. & Orive, G. Long-term retrospective evaluation of short implants in the posterior areas: clinical results after 10-12 years. J. Clin. Periodontol. 41, 404–411 (2014).

3. Anitua, E. & Orive, G. Short Implants in Maxillae and Mandibles: A Retrospec-tive Study With 1 to 8 Years of Follow-Up. J. Periodontol. 81, 819–826 (2010).

4. Pommer, B. et al. Impact of dental implant length on early failure rates: a meta-analysis of observational studies. J. Clin. Periodontol. 38, 856–863 (2011).

5. Telleman, G. et al. A systematic review of the prognosis of short (<10 mm) dental implants placed in the partially edentulous patient. J. Clin. Periodontol. 38, 667–676 (2011).

6. Annibali, S. et al. Short Dental Implants: A Sys-tematic Review. J. Dent. Res. 91, 25–32 (2012).

7. Gerritsen, A. E., Allen, P. F., Witter, D. J., Bronkhorst, E. M. & Creugers, N. H. Tooth loss and oral health-related quality of life: a systematic review and meta-analysis. Health Qual. Life Outcomes 8, 126 (2010).

8. Fugazzotto, P. A. et al. Success and Failure Rates of 9 mm or Shorter Implants in the Replacement of Missing Maxillary Molars When Restored with Individual Crowns: Preliminary Results 0 to 84 Months in Function. A Retrospective Study. J. Periodontol. 75, 327–332 (2004).

9. Renouard, F. & Nisand, D. Short implants in the severely resorbed maxilla: a 2-year ret-rospective clinical study. Clin. Implant Dent. Relat. Res. 7 Suppl 1, S104-10 (2005).

10. Grant, B.-T. N., Pancko, F. X. & Kraut, R. A. Outcomes of Placing Short Dental Implants in the Posterior Mandible: A Ret-rospective Study of 124 Cases. J. Oral Maxillofac. Surg. 67, 713–717 (2009).

11. Srinivasan, M. et al. Efficacy and predict-ability of short dental implants (. Int. J. Oral Maxillofac. Implants 27, 1429–37

12. Mohammed, S. short dental implants Short Dental Implants : Its Rationale for Use. 50–54 (2015). doi:10.13140/RG.2.1.5170.4163

13. Nisand, D., Picard, N. & Rocchietta, I. Short implants compared to implants in vertically augmented bone: a systematic review. Clin. Oral Implants Res. 26, 170–179 (2015).

14. Esposito, M., Pistilli, R., Barausse, C. & Felice, P. Three-year results from a randomised controlled trial comparing prostheses supported by 5-mm long implants or by longer implants in aug-mented bone in posterior atrophic edentulous jaws. Eur. J. Oral Implantol. 7, 383–95 (2014).

15. Felice, P., Cannizzaro, G., Barausse, C., Pis-tilli, R. & Esposito, M. Short implants versus longer implants in vertically augmented pos-terior mandibles: a randomised controlled trial with 5-year after loading follow-up. Eur. J. Oral Implantol. 7, 359–69 (2014).

16. Romeo, E., Storelli, S., Casano, G., Scan-ferla, M. & Botticelli, D. Six-mm versus 10-mm long implants in the rehabilita-tion of posterior edentulous jaws: a 5-year follow-up of a randomised controlled trial. Eur. J. Oral Implantol. 7, 371–81 (2014).

17. Fan, T., Li, Y., Deng, W.-W., Wu, T. & Zhang, W. Short Implants (5 to 8 mm) Versus Longer Implants (>8 mm) with Sinus Lifting in Atrophic Posterior Maxilla: A Meta-Analysis of RCTs. Clin. Implant Dent. Relat. Res. 19, 207–215 (2017).

18. Thoma, D. S., Zeltner, M., Hüsler, J., Hämmerle, C. H. F. & Jung, R. E. EAO Supplement Working Group 4 - EAO CC 2015 Short implants versus sinus lifting with longer implants to restore the posterior maxilla: a systematic review. Clin. Oral Implants Res. 26, 154–169 (2015).

19. Sahrmann, P. et al. Success of 6-mm Implants with Single-Tooth Restorations. J. Dent. Res. 95, 623–628 (2016).

20. Sahrmann, P. et al. Success of 6-mm Implants with Single-Tooth Restorations: A 3-year Ran-domized Controlled Clinical Trial. J. Dent. Res. (2016). doi:10.1177/0022034516633432

21. Gonalves, T. M. S. V. et al. Long-term short implants performance: Systematic review and meta - Analysisofthe essential assessment parameters. Braz. Dent. J. 26, 325–336 (2015).

22. das Neves, F. D., Fones, D., Bernardes, S. R., do Prado, C. J. & Fernandes Neto, A. J. Short Implants - An Analysis of Longitudinal Studies. Int. J. Oral Maxil-lofac. Implants 21, 86–93 (2006).

23. Misch, C. E. Short dental implants: a literature review and rationale for use. Dent. Today 24, 64–6, 68 (2005).

24. Romeo, E., Ghisolfi, M., Rozza, R., Chiapasco, M. & Lops, D. Short (8-mm) dental implants in the rehabilitation of partial and complete edentulism: a 3- to 14-year longitudinal study. Int. J. Prosthodont. 19, 586–92 (2005).

25. Berglundh, T., Abrahamsson, I., Lang, N. P. & Lindhe, J. De novo alveolar bone forma-tion adjacent to endosseous implants. Clin. Oral Implants Res. 14, 251–62 (2003).

26. Esposito, M., Grusovin, M. G., Maghaireh, H. & Worthington, H. V. in Cochrane Database of Systematic Reviews (ed. Esposito, M.) CD003878 (John Wiley & Sons, Ltd, 2013). doi:10.1002/14651858.CD003878.pub5

27. Dilek, O., Tezulas, E. & Dincel, M. Required minimum primary stability and torque values for immediate loading of mini dental implants: an experimental study in nonviable bovine femoral bone. Oral Surgery, Oral Med. Oral Pathol. Oral Radiol. Endodontology 105, e20–e27 (2008).

28. Wijaya, S. K., Oka, H., Saratani, K., Sumikawa, T. & Kawazoe, T. Development of implant move-ment checker for determining dental implant stability. Med. Eng. Phys. 26, 513–522 (2004).

29. Al-Hashedi, A., Taiyeb-Ali, T. & Yunus, N. Out-comes of placing short implants in the posterior mandible: a preliminary randomized controlled trial. Aust. Dent. J. 61, 208–218 (2016).

30. Alghamdi, A. Influence of Dimensions on the Primary Stability and Removal Torque of Short Dental Implants Influence of Dimensions on the Primary Stability and Removal Torque of Short Dental Implants. 1, 2005 (2015).

31. Gentile, M. A., Chuang, S.-K. & Dodson, T. B. Survival estimates and risk factors for failure with 6 x 5.7-mm implants. Int. J. Oral Maxillofac. Implants 20, 930–7

32. Morand, M. & Irinakis, T. The Challenge of Implant Therapy in the Posterior Maxilla: Provid-ing a Rationale for the Use of Short Implants. J. Oral Implantol. 33, 257–266 (2007).

33. Goodacre, C. J., Bernal, G., Rungcharas-saeng, K. & Kan, J. Y. . Clinical complica-tions with implants and implant prostheses. J. Prosthet. Dent. 90, 121–132 (2003).

34. Perelli, M., Abundo, R., Corrente, G. & Sac-cone, C. Short (5 and 7 mm long) porous implants in the posterior atrophic maxilla: a 5-year report of a prospective single-cohort study. Eur. J. Oral Implantol. 5, 265–72 (2012).

35. Weng, D. et al. A prospective multicenter clinical trial of 3i machined-surface implants: results after 6 years of follow-up. Int. J. Oral Maxillofac. Implants 18, 417–23

36. Salvi, G. E., Gallini, G. & Lang, N. P. Early loading (2 or 6 weeks) of sandblasted and acid-etched (SLA) ITI implants in the posterior mandible. A 1-year random-ized controlled clinical trial. Clin. Oral Implants Res. 15, 142–9 (2004).

37. Monje, A. et al. Are Short Dental Implants (<10 mm) Effective? A Meta-Analysis on Prospective Clinical Trials. J. Peri-odontol. 84, 895–904 (2013).

38. Felice, P. et al. Short implants as an alter-native to crestal sinus lift: A 1-year mul-ticentre randomised controlled trial. Eur. J. Oral Implantol. 8, 375–84 (2015).

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Kumar et al

Background: Implant drill use is common and clinicians are acutely aware of the implant drills for the system which they are using. It is demand of the time that we should formulate a clas-sification system to categories these drills for ease to remember and identification. Attempts have been made through this article to shed some light on various types of implant drills along with a simplified system of their classifica-tion. Another aspect included in this article is various factors influencing the drilling process and causing overheating in osteotomy site.

Methods: Searches performed in MEDLINE related to Dental Implant Drills and a system-atic review was carried out regarding various types of drills available and various variables during drilling process which affect the osseo-

integration process (Implant Success rate).Results: Reviewed literature revealed that there are four different criteria based on which implant drills are classified in this review. Even the drilling process seems very easy but little more aware-ness about small looking steps can drastically improve Implant success rate. This procedural information is concluded as “guidelines of drilling process” for the betterment of clinical practice.

Conclusions: Every clinician should be well aware about the instruments which they use in daily routine and a classification system helps in categorization and easy remembrance of these similar looking mechanical tools. This review arti-cle is presenting a classification system for the dental implant drills and also discussing the points where operator’s negligence is very common.

A New Standard Classification System for Dental Implant Drills and Role of Implant

Drills in Successful Osseointegration

Dr. Bhushan Kumar1 • Dr. Sunny Bhatia2 Dr. Prabhdeep Kaur Sandhu3 • Dr. Sachin Mittal4

1. Prosthodontics, Graded Specialist, Army Dental Corps, India.

2. Dental Officer, Army Dental Corps, India.

3. Orthodontics, Private Practitioner, Hisar (Haryana), India.

4. Oral and Maxillofacial Surgery, Private Practitioner, Hisar (Haryana), India.

Abstract

KEY WORDS: Dental implants, dental implant drills, review

36 • Vol. 9, No. 5 • July 2017

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INTRODUCTION:Dental implants have been used since mid-1960s, but in recent years their use has been increased drastically as evidence from studies and clinical experience have shown that they are safe, most conservative approach for resto-ration, convenient to place and their results not only restoring function but aesthetics too. This success rate is determined by various factors like operator knowledge & skill, case selection, surgical technique, bone graft/augmentation procedure, implant type/design/number/angu-lations, loading protocol and type of overly-ing prosthesis.1 However the focus of most of the studies/ research in literature is on design, surface modification, and loading conditions. It is unfortunate that the effect of surgical pro-cedures such as the drilling protocol has been sparsely explored, and clinicians basically fol-low the instructions given by the manufacturers. This article is bound to discuss role of Implant Drills in healing process (osseointegration) and a system of classifying dental implant drills is also incorporated for a better understanding.

A dental implant drill is a small-high speed drill used during dental implant proce-dure to create a hole and to prepare implant bed for the best fit at recipient site. These drills are run by a powered hand-piece/ dental engine designed with special controlling features meant for implant placement. They can be of different shapes and designs as per their func-tional requirement. Unfortunately, no standard classification system is available for them. A very simplified way to categorize them is as follows:

CLASSIFICATION SYSTEM FOR IMPLANT DRILLS:

Presently available implant drills can be classified on the following basis:

BASED UPON THE DRILL DESIGN [2,3]l Twisted Implant drills (further categorized into)l Triple twist drill with a relief anglel Triple twist drill without a relief anglel Double twist drills with a relief anglel Double Twist drill without a relief anglel Fluted drills

BASED UPON METHOD OF COOLING [4-10]l Drills with internal irrigationl Drills with External irrigation

BASED UPON DRILL USE [11,12]l Single use/disposable drillsl Multiple use drills

BASED UPON THE USAGE DURING OSTEOTOMY [13]l Mucosal punch drill [14]l Locator drilll Pilot drilll Conical or cylindrical drilll Countersink drill/profile drilll Tap drilll Trephine drill [5]

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ROLE OF DRILLS AND DRILLING PROCESS IN OSSEOINTEGRATION

Dental implant surgery involves drilling a hole in the bone, which is a friction process between the drill and bone resulting in heat generation.15,16 Majority of generated heat is absorbed by drill but bone also absorbs a significant amount of heat. In the absence of irrigation, bone temperatures may exceed 1000 C. It has been documented that bone cell changes may occur when bone is heated over the critical temperature i.e. 470 C16,17,18,19 (thresh-old temperature is 30.3o C for 5 seconds20 or 44-47o C for 1 min).7,15,18,20 The negative effect of heat on bone results in the denaturation of the enzymatic & membrane proteins, hyperemia, dehydration, desiccation, fibrosis, decreased osteoclastic & osteoblastic activity and necrosis, which may all contribute to cell death (osteone-crosis).21-26 This may result in a failure of bone to bond to the implant, leading to early failure.27, 28

FACTORS AFFECTING HEAT GENERATION3,29

After a detailed literature survey, the fac-tors that can affect a temperature rise during the drilling process can be listed as follows: l Drill sharpness l Drilling speed and pressurel Drilling timel Drilling statusl Drill design/ drill geometryl Drill material and wearing/coatingl Drill diameterl Drilling depthl Irrigation (coolant delivery) systems l Miscellaneous factors (type of the

recipient bone, age of the patient and experience & skill of clinician)

DRILL SHARPNESSThe condition of drill plays a major role in regu-lating the temperature of bone during drilling.30 A worn drill will thus have more heat produc-tion than a sharper drill.23 There are many fac-tors that reduce the sharpness of a drill like density of bone, multiple reuse of the drill, the debris released during the process, material con-struction & surface treatment of drill.10 Indica-tion for drill change are loss of shine at cutting edge and wear off along cutting blade (visual examination), clinical observation of when the drill fails to progress rapidly and after number of sites prepared as suggested by manufacturers.

DRILLING SPEED AND PRESSURE

There are variable results from different studies about the optimal speed for dental implant sur-gery. Earlier reports have supported the slow-speed as heat generation was assumed to be less compared with high-speed31-33 (recommended speeds were 600 rpm,34125-2000 rpm2) and this rise in temperature was noticed up to an approxi-mate speed of 10,000 rpm.34 At very high speeds (27,000 rpm to 97,000 rpm) temperature rise was very less and healing was faster compared to lower speeds.31,35.36 At this point of discussion, it is very important to understand that osteotomy procedures for implant bed preparation require a precise cutting because it should match exactly the specifications like implant diameter/length, thread shape/design for its primary stability which can’t be achieved with high speed beyond 2500 rpm. Slower rotational speeds require more drill-ing time, which produces more frictional heat so rpm (drilling speed) is not the only factor for rise of temperature, however duration/time of drilling

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is more important and is major determinant than speed. This duration of drilling can be reduced by incorporating factors like torque and pres-sure10,23,37-39 along with optimum speed. Eriksson has shown that using high torque and low rpm (1500-2000) are ideal to avoid temperature rise and to increase drilling accuracy.19 Role of pres-sure was studied by Brisman40 who compared the drilling at 1,200 rpm and 2,400 rpm under loads of 1.2 kg and 2.4 kg in dry bovine femo-ral bone and found that less heat was generated with 2,400 rpm (or 2500 rpm41) under 2.4 kg of force.40 However the pressure is a variable factor which differs from operator to operator42 and there is no standard way to optimize it but it is interest-ing to know that generally clinicians use a force of approximately 2 kg during implant drilling pro-cedure under normal clinical conditions.3,38,42 So this factor can be assumed optimal for all opera-tors; with its least effects on heat generation.

DRILLING TIMEThis factor can be discussed under two crite-ria, i.e. drilling time and the time required for the heated part to return to its normal temperature. This can be simplified as more drilling time will cause more rise in the bone temperature which will require more time for the heated part to return to its normal temperature hence more damage can be noticed in situ. Eriksson and Albrektsson dem-onstrated that the long-term effect of heating bone up to 47°C for 5 minutes resulted in dominant bone resorption (about 20%) after a period of 30 days.20 This was accompanied by an invasion of fat cells and little osteogenic activity, so less osseointegration at site.44,45 Best way to control this variable is to remove drill gradually in between every 5 seconds for at least 10 seconds to allow

the temperature of bone to return to baseline and use of copious irrigation (Intermittent Drilling).

DRILLING STATUSIncremental Vs Single step drilling: In one step drilling, the hole is being drilled in a single step using a single drilling tool whereas in incremen-tal or multi-step drilling the diameter is increased gradually starting from the minimum to the final diameter using a series of drilling tools. Eriks-son44 has described a single step technique while Branemark46 and others15,18-20,47,48 have rec-ommended an incremental enlargement of the osteotomy site. Branemark’s46 hypothesis on the incremental drilling sequence was that each drill bit gradually enlarges the osteotomy site, which would dissipate heat better than a one-stage drill sequence. In a later study, Eriksson also found that the incremental drilling is better at reduc-ing heat production compared to single drilling.18

Intermittent Vs Continuous drilling: Drill-ing into bone involves the use of irrigation, either internal or external, to reduce the heat gener-ated. Because of the intimate contact present at the bone-drill interface, the irrigation solution has to reduce the temperature throughout the whole length of the bony walls. This mechanism could not be achieved unless the bur or drill was inter-mittently removed to allow the escape of bone chips and access for the irrigation fluid.37 When-ever continuous drilling is performed, temperature will rise not only because of the inaccessibil-ity of coolant, but also because of the clogging effect of the bone debris on the cutting edge of the drill, which will decrease its cutting efficiency and consequently increase the time required for the bone bed preparation.10,18,47,49 In addi-tion, it is suggested the clinicians should inter-

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rupt the drilling procedure, while saline is applied to the bone. The interruption will dramatically decrease the bone temperature. Even while pro-ceeding to next size drill in the osteotomy before allowing the bone to return to baseline tempera-ture may eventually heat up the bone more than 10°C (47°C when baseline is body temperature).

This is most important in the dense bone types.

DRILL DESIGNThe drills usually follow the morphological and the topographic skeleton of the implant. In general, twist drills and taps are used to prepare sites for screw-shaped implants, whereas fluted drills are used to prepare sites for cylindrical implants.50 Cordioli and Majzoub compared twisted and fluted drills for heat generation and found fluted drills increase less temperature than twisted drills.18,51 But screw implants are used more than cylindrical and fluted drills can’t be used for screw implants as it will decrease primary stability so twisted drills are more in use. Twisted drills with relief angle at cutting sides52 and point angle at apex53 are more efficient and produce less heat than twisted drill without relief angle. Among flute geometry, the four flute drill has been considered to reduce frictional heat, although Kay et al rec-ommended that 3 is the maximum no of flutes that could withstand use without technical problems.50

DRILL MATERIAL AND ITS COATING

Most of available drills are made in stainless steel alloys however they are available with coatings also to increase cutting efficiency and to reduce wear rate (e.g. Stainless steel coated with tita-nium nitride). Recently oxide Zirconia based ceramic drills (80% Zirconia oxide and 20% alu-

mina oxide) have also been studied and found that they show more hardness with less wear com-pared to stainless steel so have better cutting efficiency and induce less heat but further studies under different conditions are still needed.40,54-56

DRILL DIAMETERLarger diameter drills produce less heat than smaller diameter, even the time required for the temperature to return to baseline is also less.2,10,51 Amount of bone removed by smaller diameter is less so needs more time for same osteotomy when compared with larger diameter. Therefore, time of drilling is more critical than the diameter of the drill. Correct orientation and depth of pilot drill is key to minimize temperature rise during complete osteotomy procedure.10

DRILLING DEPTHMore deep drilling increases temperature rises due to increase in cutting surface area along with less irrigation at the inaccessible apical extent of the drill and also because of the clog-ging effect of the bone cuttings.2,8,50 Such cases are highly indicated for intermittent drilling with adequate intervals and copious irrigation.

IRRIGATION SYSTEMSImplant systems have begun to use irrigation systems with coolants for heat dissipation dur-ing osteotomy for implant placement. There are two types of cooling system: internal and exter-nal. If one does not use any coolant, then the critical bone temperature is always exceeded so irrigation is a key factor in implant osteotomy.10 Kirschner and Meyer9 introduced internally cooled drills to dentistry, later Huhule57 con-cluded several advantages of internal irrigation

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over external like; it prevents clogging of the drill twists/flutes by bone chips thus increas-ing its efficacy regardless of the depth of the cavity and causes more heat dissipation.9,58-60 Haider et al. found external cooling better in superficial cutting whereas internal more effi-cient in deep drilling so he recommended that additional of external cooling alongwith internal system, particularly in compact bone, seemed most beneficial.8 The low temperature (4oC) irrigation solution is better than room tempera-ture solution.61,62 Normal saline or distilled water can be used as irrigation solution;51 however air-water coolant mixture should not be used as chances of air embolism formation are there.63,64

MISCELLANEOUS FACTORSThe temperature produced also depends on many factors like density and the texture of the bone, age of the patient etc. Bone usu-ally varies in density from person to person, bone to bone in the skeleton, and from site to site in the same bone. Compact or dense bone has less body fluid (blood, lymph, tissue fluid) for heat absorption and requires more drill-ing time as it poses more friction for cutting so all these factors result in more raise in local temperature.5,10,65 Similarly, drilling in heal-ing socket or extraction socket during imme-diate implant placement requires less cutting and less time so resulting in less heat produc-tion compared to healed socket.66-69 Even bony structures in older patients tend to become denser and more fragile; the medullary cav-ity space enlarges faster thus resulting in a net decrease of cortical thickness and mass and also healing capability is usually impaired.70-72

ALTERNATIVE METHODS TO DRILLING

Ridge split technique (Pneumatic chisel and osteotome),73-75 bone-condensing tech-nique,76 Er:YAG laser,77 piezoelectric surgery,77 peizotome;78 however ultrasonic implant site preparation is more time consuming and gen-erates higher bone temperatures than con-ventional drilling.79 These techniques are not common among clinicians due to lack of long term studies to support their reliability and superiority over conventional drill osteotomy.

CONCLUSIONEven after following all guidelines we can’t totally avoid rise in temperature in osteotomy site, we can only minimize it to below critical level. Accord-ing to a theory, a smaller devitalized zone next to implant surface would be beneficial in immedi-ate loading as implants are loaded before bone remodeling is complete and this devital zone will be replaced by healthy bone during remodel-ing process.84 If future implants have the ability of bone regeneration around their surface then there will be no or very less failures; till then suc-cess rate is relying on repair/healing process which is dictated by various guidelines for all determinant procedures used during implant placement, restoration and maintenance. l

Correspondence:Dr. Bhushan KumarE-mail: [email protected]

Kumar et al

42 • Vol. 9, No. 5 • July 2017

DisclosureThe authors report no conflicts of inter-est with anything in this article.

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