INTRODUCTION
One of the biggest challenges in dentistry today is the constant demand for instant results that society and patients desire. This is the most pressing in cases involving loss of teeth in the aesthetic zone either due to trauma or endodontic failure.
How many times have we seen an upper central incisor knocked out due to a sport injury?
How many times have we seen a #7 or #10 endodontically treated lateral incisor fractured at the gumline due to a lacking ferrule effect and a patient who clenches and grinds? Those laterals also have a high endodontic failure rate with recurrent abscesses.
What have we been doing to treat these cases? Three unit bridges, Maryland bridges, extraction bone grafts and flippers with a waiting game of 8-9 months until the graft integrates and the subsequent implant does so too.
Our patients loathe all of these treatments! They always ask: when am I going to get my smile back? Will I be able to eat with this flipper? Will it look the same as before?
The answers are not very satisfying to them. They want results now.
Obviously the best treatment available to us is to extract the tooth, graft the area, wait four months, place an implant, play the four month waiting game and THEN restore. The main downside to this treatment is the time that it takes. The loss of the emergence profile of the gingiva in the aesthetic zone can also be troublesome. I call this the gingival flattening effect. The absence of the root and the root’s support of the surrounding bone allows the gingiva to roll and flatten thus creating an unnatural gingival profile which some patients describe as their implant crown looking fake.
What if there is a way to extract the afflicted tooth, remove any pathology, do your osteotomy, and then place a root form implant that expands in the bone? Even better, what if this root form implant can be immediately loaded at the time of placement with a temporary crown, allowing the patient to use it that same day and normally eat their meal?
Today there is a way to restore that damaged tooth with an immediate load implant. Biodent’s Ultratooth is the only implant certified by the FDA for immediate load. It is to be placed after an extraction and then loaded immediately with an abutment and a crown.
CASE REPORT
A 29-year-old male came to my office with two chipped central incisors accompanied by moderate to severe pain. The patient reported falling down the stairs of a local restaurant and hitting his head on the ground.
X-Rays were taken and a CBCT Cone Beam Scan was performed. At first glance the teeth just looked chipped. Upon further clinical and radiological examination, it was discovered that the patient suffered two oblique fractures on teeth # 8 & 9 (figure 1). Because of the depth of the fracture lingually, it was decided that crown lengthening, endodontic treatment, and crowns would not be a good choice.
The patient was informed that he would need both of his centrals extracted and replaced with two Ultratooth implants. He was very worried about what he was going to have in place of his damaged central incisors. We explained to him that he would walk out of the office looking better than he came in. He would have two temporary crowns on top of two very solid implants that he could eat with as soon as the anesthetic wore off. He couldn't believe it. He told us that he was under the impression (from a Google search) that if he lost both teeth he would have to wear a flipper for eight to nine months. After explaining the details of the procedure, he gave consent and we moved forward.
As outlined in figure 2, the roots beyond the fracture areas were very healthy and strong.
It is imperative that, while placing any kind of implant in either of the jaw bones after an extraction, the extraction itself is done as cleanly as possible so that much of the socket is preserved. Excess bone removal and destruction is counterproductive for successful implant placement. To remove the remaining roots as cleanly as possible the Magnetic Mallet (figure 3) was used. This is a very effective device used to assist the dentist on performing a very clean extraction with very little collateral damage to adjacent bone. It is basically an extraction elevator attached to a magnetic device that when activated uses the mass of the mallet to drive the elevator between the root and the bone without breaking the bone. The result is an extremely “clean” extraction without adjacent bone damage (figure 4).
After the extractions, both osteotomies were performed. The indication for placement of the Ultratooth in this particular area is palatal to the socket and apical to the end of the socket. You don’t want to place the expanding implant in the socket, but instead you create an osteotomy behind the socket where there is 360 degree bone to place and expand the implant so the four pods engage in bone and provide the mechanical osseointegration that stabilizes the implant. The empty socket area is grafted to provide gingival support and emergence profile preservation.
Two Ultratooth 16mm regular implants (figure 5 ) were placed in the area (figure 6 ) and X-rays were taken to verify expansion and placement (figure 7).
Two Ultratooth small abutments were screwed by hand on top of both implants. These can be hand torqued because of the Morse taper incorporated in the system, so a torque wrench is unnecessary.
Temporary crowns were made and cemented with TempBond clear (Figure 8). The patient was recalled a week later for a post-op examination (figure 9). The gingiva around the temporaries was in such a good shape that a digital scan of the abutments was obtained and crowns were ordered that day. At this point the patient reported that he had a slight discomfort for three days after the extractions and that after three days everything felt “normal.” He reported that he was able to bite into a slice of pizza on day 5 after the surgery.
Two layered zirconia crowns were made and placed 21days after the extraction and placement (figure 10). Three weeks after the surgery, the emergence profile of both centrals looked very normal, which is very aesthetically pleasing. The patient was extremely satisfied and couldn’t believe that he finished his treatment in three weeks.
DISCUSSION
The Ultratooth Implant System is specifically designed to replace damaged teeth immediately after extraction in full function. It has received FDA Clearance for full immediate load since 1994 based on 3-year clinical data submission. During this clinical study, 286 implants were placed in 75 patients during a 40 month period, 81 were placed into fresh extractions sockets and immediately loaded, 162 were placed into healed sites and immediately loaded, and 30 were delayed loaded. The overall survival rate during the study was 96% in the maxilla and 94.8% in the mandible. The implants placed immediately after extractions showed a 98% success rate.
reference - Jo,Hobo,and hobo 2000 journal of Prosthetic Dentistry feb 2001
These implants are made of Titanium Alloy 6AI4V (figure 11) and have been tested for strength and durability under the most stringent test protocols -
The following are 5 characteristics that make these implants unique and suitable for immediate loading with full function:
1 - Immediate Full Functionality at time of placement
2 - Preservation of Original Emergence Profile due to the fact that there is no absence of a “root,” the implant replaces the root and the gingival tissue position does not fluctuate.
3 - Does not lose coronal bone due to its Eiffel Tower Design - It is wider apically than coronally. Due to surrounding bone compaction (figure 12) demonstrated by Photo Elastic Studies and confirmed by histological studies done at Indiana University.
4 - Increases surrounding bone density by compacting the bone around itself. The Ultratooth is a bone generating device (figure 13) - Termed Oscillating Effect by Indiana University.
5- 30% more surface area compared to its equal size traditional screw implant. (figure 14)
The Ultratooth implants placed in the aforementioned case succeeded because of the innovative design appropriate for placement right after extractions.
CONCLUSION
Today’s implant advancements in dentistry have made the tooth replacement paradigm with implants ubiquitous among general dentist’s practices. The next step in providing the latest and best to our patients is our ability to send them home fully functioning mechanically and aesthetically, even after a traumatic extraction. The Ultratooth system gives us the ability to do exactly that. Under normal conditions, the Ultratooth implant can be placed right into the modified socket after the tooth is extracted. As in the case presented, the patient can go home with a fully functional temporary crown.
Because when expanded, the diameter of the apical region of the implant becomes wider than the coronal, occlusal forces are transferred apically not coronally thus protecting the vulnerable coronal zone which we frequently see affected by peri-implantitis.
Every day our patients become learn more about the new trends in dentistry. They are anxious to get in and get out with the least amount of trouble. An immediate load implant can provide them with that sense of immediate completion of treatment.
Article by Dr. Jose Marcano
Dr. Jose Marcano is a graduate of the University of Pennsylvania School of Dental Medicine and has over 30 years of experience in the dental field. His philosophy in dentistry encourages persistent monitoring of innovative trends that emerge in the dental field. He believes that an open mind to these paradigm-shifting trends allows him to be in the forefront of the dental profession.
Dr. Marcano has taken numerous continuing education courses in the implant, laser, and cosmetic dentistry fields. His practice is fully reconstructive and cosmetically restorative. One of the most appealing aspects of his practice is his ability to replace unrestorable teeth using the Ultratooth Immediate Load Implant System on the same dental visit.
Dr. Marcano is a master certified trainer for Biodent and has certified hundreds of dentists in the use of the Ultratooth Implant System.
REFERENCES:
1 - Food and Drug Administration 510 (K) NUMBERS K981141 and K930071, Device Classification Name: Implant, Endosseous, Root Form.
2 - Freestanding and multiunit immediate loading of the expandable implant: An up-to-40-month prospective survival study Jo,Hobo,and hobo 2000 journal of Prosthetic Dentistry feb 2001.
3 - ARTECH TESTING, LLC. 14554 Lee Rd Chantilly, VA 20151
4 -INT 1 ORAL MAXILLOFAC IMPLANTS 2002;17: 353-362
5- Photoelastic analysis courtesy of Dr. Chansung Park, UCLA School of Dentistry.
2002;17: 353-362
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