The Profitable Implant Dentist: Procedural Efficiencies and Overhead Reduction Strategies – Part 1 of 4
By Dr. Calvin Bessonet and Dr. Robert Lucero
Innovations in implant design and technology have been so profound in recent years that a small group of my peers in private group practice began working directly with the implant engineers and manufacturers to uncover the most beneficial new products and procedures to stay ahead of the implant technology curve. What was uncovered has vastly changed all of our practices for the better. This 4 part series will outline and expose what was found in our research and include the clinical application within our practices.
Find out more about the Implant Mastery Webinar moderated by Dr. Brady Frank at https://www.ddsolive.com/ddso-live
Perhaps one of the most influential trends observed has been on the topic of bone condensation, densification and ridge expansion. At the Branemarkonian starting point, the protocol provided for an osteotomy that was nearly the same diameter as the fixture with a recommended torque on insertion of less than 30 Ncms. This protocol provided very little densification of the bone and relatively lower stability values. This protocol oftentimes produced what some clinicians call a “spinner” wherein the threading has stripped within the osteotomy. Over the last twenty years, recommended torque values have increased, stability has increased, bone densification has increased and both immediate and slightly delayed loading have become the standard. Clinicians use a variety of auxiliary tools to influence the bone from osteotomes to bone condensers to special drills functioning in reverse. The trend has been incorporating these attributes to the implant body itself creating greater efficiency and simplicity. This also creates an enhanced clinical effect when these auxiliary tools are used. Here is an illustration demonstrating this concept:
A recent article titled, The Effect of Simplifying Dental Implant Drilling Sequence on Osseointegration, in the International Journal of Biomaterials 1 comparing the traditional multiple drill sequence versus a simplified drilling protocol (pilot to final drill) found no difference related to success and osseointegration. The article concluded, “since a simplified surgical drilling procedure did not negatively affect the biological response of the implants placed in these sites and was comparable to the conventional drilling sequence, our initial hypothesis that no difference in implant osseointegration occurs by reducing the number of drills for bone site preparation relative to the conventional drilling sequence was accepted. The results of this study strongly suggest that the osteotomy preparation may be simplified and be less time consuming; however, constant irrigation will always be necessary to avoid the deleterious effect of temperature elevation in the bone…” This is great news for clinicians on the cutting edge of efficiency.
A combination of simplified drilling protocol and recent advances in implant fixture design have opened up numerous opportunities for clinicians. One such opportunity is for a clinician to use certain advanced engineered implants to be used with their existing surgical drilling kit. Because much of the work is performed by the implant itself (ofter only requiring drilling down 75% of the osteotomy site), these modern implant systems will accommodate utilization of a wide variety of drilling systems. This saves the clinician time and money as these osseocondensing, self-tapping and self-drilling types of implants can be integrated directly into the existing suite of implant systems without having to purchase yet another surgical implant drilling kit. This 100% compatibility feature allows clinicians to add advanced implant systems to their arsenal without the high cost and redundancy of adding a new surgical drilling kit.
A simplified drilling protocol (Figure 1)combined with self-drilling aspects in the implant body itself also allow for simplified and efficient treatment in the area of the sinus. Many cases that have sufficient bone inferior to the sinus can be successfully treated through bone condensation, Self-drilling and creation of bone density as illustrated. Both of the techniques illustrated are very popular in Europe due to their minimally-invasive attributes.
As a sneak preview to part 2 I would like to delve into the topic of atraumatic extraction and immediate implant placement. One of the best ways to practice economical and predictable implant dentistry is to utilize immediate placement at the time of extraction when appropriate. The patient is in the chair and motivated to complete treatment right now. I have found that with some patients if you extract the tooth and wait a few months to place the implant, they will sometimes get used to the empty space and procrastinate on having the tooth replaced. The repercussions of not replacing the tooth, such as bone loss, shifting, bite changes, occlusal overload of neighboring teeth, etc take time to manifest and are not always apparent to the patient for some time. Once these problems are noticed by the patient the treatment plan has often become more involved and expensive and sometimes out of reach financially. Large grafting procedures can also be intimidating to the patient and prevent them from following through with the procedure.
Another reason immediate placement is advantageous is that once the extraction is complete, the hole is usually already in the proper place for the implant. You may have to redirect your osteotomy slightly palatal or mesial/distal but the socket serves as an excellent guide for placement. In some cases, especially premolars, you can use an implant with aggressive threads to place without any osteotomy at all by engaging the mesial and distal walls to achieve primary stability. This greatly shortens the appointment time, lowers risk, and increases patient satisfaction.
There are some circumstances where immediate placement is not desirable. If the socket is too large to engage the mesial and distal walls and vital anatomical structures are located just apical to the socket, immediate placement is not recommended. Chronic infected sites also present a higher risk for immediate placement. If you can completely rid the socket of all soft tissue and the patient has the appropriate antibiotics on board it is possible. However, most of these cases are more predictably treated with early placement (waiting 4-6 weeks without grafting) or delayed placement (3-6 months with grafting).
When placing an immediate, you must maintain a gap of at least 2 mm between the implant and buccal wall to prevent resorption of the plate and thread exposure.
Once the implant is placed and the buccal plate is still intact, I recommend grafting the space between it and the implant. Two predictable and well studied materials used for this are MFDBA (mineralized freeze dried bone allograft) and ABBM (anorganic bovine bone material). You can then place a PRF membrane or collagen plug occlusal to the graft. If there is a fenestration or dehiscence in the plate, a barrier membrane should be placed to prevent soft tissue in growth. I have found that using a nonresorbable high-density PTFE membrane works great in these cases. Because they can be left exposed there is no need to obtain primary closure. You can place the membrane without reflecting a large flap by tunneling down the socket to create a pocket on the mesial, distal and apical bone. You then place the membrane into this space, add your bone graft, then finish with a criss cross mattress suture from the buccal to lingual tissue. The membrane is easily removed with cotton pliers at 4-6 weeks post op without anesthesia. By not advancing the tissue you preserve the vestibular depth and keratinized tissue, often eliminating the need for a tissue graft. This also saves time, expense, and the morbidity that comes with incising the tissue to release a flap. Stay tuned for part 2 where we will explore some of the most minimally-invasive techniques and instrumentation for atraumatic extractions and top implant designs for immediate implantation.
1 Gabriela Giro, Nick Tovar, Charles Marin, et al., “The Effect of Simplifying Dental Implant Drilling Sequence on Osseointegration: An Experimental Study in Dogs,” International Journal of Biomaterials, vol. 2013, Article ID 230310, 6 pages, 2013. https://doi.org/10.1155/2013/230310.
Calvin Bessonet, DDS
Dr. Calvin Bessonet is committed to lifelong learning in the dental field and has been recognized by other general dentists as a leader who exemplifies the importance of quality continuing dental education. He has been placing and restoring implants for over 15 years. In 2010, he completed an advanced hands on 400-hour implant and bone regeneration program with the esteemed Dr. Hilt Tatum, one of the pioneers in the field of implant dentistry and inventor of many of the advanced surgical techniques used today. Dr. Bessonet is a member of the American Dental Association, the American Academy of Implant Dentistry, the American Dental Society of Anesthesiology, and the International Congress of Oral Implantologists. He has also achieved Fellowship in the Academy of General Dentistry (FAGD) by completing 500 hours of various continuing education and passing an extensive comprehensive exam.
Robert Lucero, DDS
Dr. Bob Lucero did his undergraduate work at Brigham Young University and graduated with his dental degree at the University of Michigan. Dr. Lucero opened a practice in Draper, Utah in 1994 where he has been providing dental services to the south valley for over 2 decades. He began placing implants in 2004 and has received advanced training in periodontics, sinus lifts, placing bone grafts and lasers. Dr. Lucero loves the results and quality of life implants provide for his patients. He is a member of the American Academy of Implant Dentistry, Utah Dental Association, Utah Dental United, and the American Dental Association. His second love is teaching. He was an instructor for Discus Dental and trained dentists and endodontists across the nation in new techniques in the endodontic field for several years.