Immediate loading of implants?

[TSDentSurg]

Hi guys!

My name's Lexi, and I'm a D3/5 at Charles University First Faculty of Medicine's dental program.

I recently started my periodontics rotation, and they do a lot of implants and osseous surgery.

I've been following the debate over immediate functional loading of dental implants, and IMHO, I'd rather wait for osseointegration than risk failure. But, if the implant is to replace a site in the aesthetic zone, then I have a trilemma: risk failure by immediate loading, destroy two healthy teeth to place a bridge in lieu of placing an implant (and risk complications like decay of the abutments, gum damage, and resorbtion of the non-loaded bone), or leave the patient with an unsightly gap for a few months while the implant integrates.

Option 1: patient gets their smile back in 1 appointment if no bone graft is necessary, with a slight risk of having to do it all over again in the worst case.

Option 2: patient has to have 1 appointment as well, but has to have two healthy teeth ruined, and risks further damage to the area.

Option 3: patient requires two appointments, has to go a few months with a gap, but risk of implant failure is greatly reduced.

So, my question is: can an immediately-restored implant be splinted to adjacent natural teeth to redirect the load while it integrates?

I apologize if this was a stupid question.

PS: I plan to practice in California, where I'm originally from (please don't ask why I'm studying dentistry in Prague instead of there...as my username suggests, I am transsexual, and I had many, many problems in my life.at least I'm about to acheive my dream now!). After I graduate, I hope to get accepted into an IDP and then do a periodontics residency. Maybe I should practice in Minnesota to build up funds for the IDP and perio tuition. I'd need to find a dentist who'd supervise me and work for cheap for three years under a limited license, but then I'd have an unrestricted license at the end of it, which I should be able to transfer to California.

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[mid]

You can also place the implant then give the patient a flipper or Maryland bridge during osseointegration.


As for your degree, I think it will depend on the state, I know NY lets the MBBS folks pay a fee and submit transcripts then the state will give them a MD, maybe CA has something similar.

 

[TSDentSurg]

You can also place the implant then give the patient a flipper or Maryland bridge during osseointegration.


As for your degree, I think it will depend on the state, I know NY lets the MBBS folks pay a fee and submit transcripts then the state will give them a MD, maybe CA has something similar.

Lol, I just thought of that. And splinting the implant to the adjacent teeth during osseointegration would just combine the worst aspects of a fixed bridge and an immediately-loaded implant: rapid accumulate of plaque in the interdental papillae and possible implant failure.

 

[DentinBond]

Splinting a healing implant to adjacent teeth would be worse for it than not splinting it at all--

Natural teeth have periodontal ligaments and demonstrate movement under occlusal forces; implants, of course, have no ligament and a rigid connection to bone.

Splinting an implant to teeth will just torque it and shake it about even more than if it's lone-standing.

If an immediate temporary is made, naturally we keep it way out of occlusion. And either make it right away at surgery, or six weeks later. (Do not touch implants with any sort of operative manipulations in the time window from three days to six weeks post-op!!!!!) Then we cajole and beg and threaten the patient not to bite things directly on it.

And then, as for me, even though I'm not Catholic, I pray to Saint Appolonia...

 

[TSDentSurg]

Thanks for your advice!

Now, I have another question: when third molars are extracted, why do most OMFSs leave the socket open, instead of covering it with L-PRF? It wouldn't add that much cost, it'd accelerate healing of the site, and it'd protect the patient from alveolar osteitis and infection, since the socket is no longer exposed to the oral environment.

And why are complex RCTs still done in today's era of implantology? Is there any advantage to having a dead tooth over an implant? Is the only reason endodontics is still around because implants are still expensive? And the occasional bisphosphonate patient where implant surgery would cause a high risk for osteonecrosis.

 

[DentinBond]

Now, I have another question: when third molars are extracted, why do most OMFSs leave the socket open, instead of covering it with L-PRF? It wouldn't add that much cost, it'd accelerate healing of the site, and it'd protect the patient from alveolar osteitis and infection, since the socket is no longer exposed to the oral environment.

I don't know about third molars-- I'd rather be stuck in an elevator with both a random Kardashian and Senator Rick Santorum than mess about with those. I'll extract anything else, mind you, but back in my residency I decided there was a reason the ADA made oral surgery a specialty way way back before I was born.

From all my experience extracting other, saner types of teeth, however, I can confidently say this: placing something in the socket is a whole lot better than placing nothing. Specifically, bone graft materials.

Here are the benefits I've noted:
-Spectacular decrease in post-operative pain. 100% of the time, if I compare current cases that were grafted with similar cases (difficulty, site in the mouth, age and health of the patient, etc.) in the pre-graft era.
-Essentially no chance of dry socket.
-Buccal and vertical site contours are maintained, making for more predictable and esthetic implant or bridge placement. (No more horsey-pontics.) Or, putting it the other way 'round, bone grafts prevent collapse of the buccal plate.
-Decreased % of post-op infections, presumably due to the lack of a "hole" in which foreign objects can lodge.

I'm sure there are yet more beneficial effects of bone grafts. These are the most significant ones that I've noted though. And regarding infection-- we must always keep in mind the biological principles at work. Blood clots in sockets, and bone graft materials in sockets, are both dead things. There's no vitality until blood vessels invade, immune cells start breaking down the dead stuff (macrophages have always been my favorites), and vital tissue starts to form again, beginning the near-miraculous transformation into new bone. Until this all starts to happen, you have one of the world's most inviting Petri dishes in one of the world's most bacteria-infested locales. Essentially, blood agar in the human mouth. So we can prescribe chlorhexidine rinses and even increase the world's population of penicillin-resistant bugs by the use of prophylactic antibiotics if we like, but the statistics seem to indicate that post-op infections occur less often with bone grafted sockets than without.

And then there's my own personal obsession in dentistry to consider-- the buccal plate. Please, students, study to learn, not just pass the test, when it comes to all things buccalish. Humans have too-thin buccal plates of bone as compared to the palatal and lingual, and all kinds of things go wrong because of it. Recession under occlusal function or secondary to orthodontic and operative procedures; hidden fenestrations and dehisences; abfractions; total collapse after extractions; the list of woes goes on and on.

The essence of the problem, as my former Dean, periodontal researcher Jan Lindhe so capably explains, is that the buccal plate consists, for much of its length, of only bundle bone. There's no marrow; it has no blood supply of its own. The only blood supply comes from the periodontal ligament and the overlying gingiva. That's why Dennis Tarnow admonishes us in his lectures never to flap an extraction site if we plan an implant. "Don't flap!", he yells at his audience with a wry grin, knowing how great is our temptation, having been there many times himself. Rather, we leave the gingiva alone, extract and curette and place his charming little ice-cream-cone-shaped resorbable membrane and then pack in our bone graft.

And our implants come out beautiful, with full buccal contours and intact papillae.

So, bottom line? I bone graft as much as I can, meaning as much as patients will let me. And yes I admit, sometimes when cost is the one thing preventing it, I'll do a "mercy bone graft," at no charge, using a low-cost synthetic material-- where the question "What's in it for me?" has this answer: no post-op calls, and no emergency visits to pack dry socket paste on my day off when I should be out biking.

 

[jay47]

One word answer for the entire thing- solves all of your "problems" with implants

Essix

 

[DentinBond]

One word answer for the entire thing- solves all of your "problems" with implants

Essix

Well, though I had Invisalign treatment and loved it, Essix has some issues...

Patients tear and rip these things up, and they get stained terribly. Maybe it's because the choice at meals is either to eat with them in place, trapping food under the tray material, or taking them out and eating with a missing tooth in front of people.

I've only done a few because of this, but in my limited sample size, an Essix just looks beat up in a very short period of time. And it gets floppy.

 

[TSDentSurg]

I don't know about third molars-- I'd rather be stuck in an elevator with both a random Kardashian and Senator Rick Santorum than mess about with those. I'll extract anything else, mind you, but back in my residency I decided there was a reason the ADA made oral surgery a specialty way way back before I was born.

From all my experience extracting other, saner types of teeth, however, I can confidently say this: placing something in the socket is a whole lot better than placing nothing. Specifically, bone graft materials.

Here are the benefits I've noted:
-Spectacular decrease in post-operative pain. 100% of the time, if I compare current cases that were grafted with similar cases (difficulty, site in the mouth, age and health of the patient, etc.) in the pre-graft era.
-Essentially no chance of dry socket.
-Buccal and vertical site contours are maintained, making for more predictable and esthetic implant or bridge placement. (No more horsey-pontics.) Or, putting it the other way 'round, bone grafts prevent collapse of the buccal plate.
-Decreased % of post-op infections, presumably due to the lack of a "hole" in which foreign objects can lodge.

I'm sure there are yet more beneficial effects of bone grafts. These are the most significant ones that I've noted though. And regarding infection-- we must always keep in mind the biological principles at work. Blood clots in sockets, and bone graft materials in sockets, are both dead things. There's no vitality until blood vessels invade, immune cells start breaking down the dead stuff (macrophages have always been my favorites), and vital tissue starts to form again, beginning the near-miraculous transformation into new bone. Until this all starts to happen, you have one of the world's most inviting Petri dishes in one of the world's most bacteria-infested locales. Essentially, blood agar in the human mouth. So we can prescribe chlorhexidine rinses and even increase the world's population of penicillin-resistant bugs by the use of prophylactic antibiotics if we like, but the statistics seem to indicate that post-op infections occur less often with bone grafted sockets than without.

And then there's my own personal obsession in dentistry to consider-- the buccal plate. Please, students, study to learn, not just pass the test, when it comes to all things buccalish. Humans have too-thin buccal plates of bone as compared to the palatal and lingual, and all kinds of things go wrong because of it. Recession under occlusal function or secondary to orthodontic and operative procedures; hidden fenestrations and dehisences; abfractions; total collapse after extractions; the list of woes goes on and on.

The essence of the problem, as my former Dean, periodontal researcher Jan Lindhe so capably explains, is that the buccal plate consists, for much of its length, of only bundle bone. There's no marrow; it has no blood supply of its own. The only blood supply comes from the periodontal ligament and the overlying gingiva. That's why Dennis Tarnow admonishes us in his lectures never to flap an extraction site if we plan an implant. "Don't flap!", he yells at his audience with a wry grin, knowing how great is our temptation, having been there many times himself. Rather, we leave the gingiva alone, extract and curette and place his charming little ice-cream-cone-shaped resorbable membrane and then pack in our bone graft.

And our implants come out beautiful, with full buccal contours and intact papillae.

So, bottom line? I bone graft as much as I can, meaning as much as patients will let me. And yes I admit, sometimes when cost is the one thing preventing it, I'll do a "mercy bone graft," at no charge, using a low-cost synthetic material-- where the question "What's in it for me?" has this answer: no post-op calls, and no emergency visits to pack dry socket paste on my day off when I should be out biking.

So, based on what you're saying, when I perform an extraction, I should:

1. Draw blood to be spun down into L-PRF.
2. Make a tiny incision into the ramus and shave off some bone, and close it. (I'd rather not use alloplast, as it's expensive)
3. Roll the L-PRF around the bone shavings to make a little ice-cream cone. Take some excess L-PRF.
4. Stick the cone into the socket, and cover it with some of the excess L-PRF.
5. Prescribe a single Vicodin tablet to cover any post-op pain (I'd rather not use an NSAID, as the anti-inflammatory effects could interfere with the surgical site healing) and a week of Periogard rinses to reduce infection risk.
6. Follow-up by phone the night of surgery, and in-office a week later.

 

[DentinBond]

So, based on what you're saying, when I perform an extraction, I should:

Oh, for heaven's sakes, TSDentSurg, you'd better start applying Occam's Razor to dental practice or you'll be sunk.

Extract. Without flapping whenever possible, which is nearly always. Fill the socket with bone graft. If the buccal plate is more than 1/2 missing, apply a resorbable membrane that's shaped like an ice cream cone, a la Tarnow. Otherwise, just bone graft. Suture. Maybe Histacryl or collagen at the surface, if you like.

Simple.

Where did you get all this talk of centrifuges and ramus-cutting and L-PRF from my reply???

As for the graft materials themselves, I use synthetics these days. IngeniOs, OsteoGraf if just particulate; NovaBone if putty is desired. (It holds together better, but the filler agent slows bone formation, already slower with synthetics than with allograft or xenograft.) Research all the synthetics, allografts and xenografts out there, see what works in your hands, and make your own decisions on materials.

I used to use allograft, specifically Puros. But one always has to explain human source materials to patients, and some are uncomfortable with the idea. More than that, I had three catastrophic failures. Science-based as I try to practice, failures make clinical decisions real easy.

And xenografts never completely resorb. As Lindhe and others have said, cow bone is like thousands of little tiny dental implants, islets of foreign non-vital bone, surrounded by host bone, and your patient will likely take them to their grave. Somehow, complete turnover seems better, doesn't it?

But, dang, man, keep it simple. I never said anything about drawing blood and ramus-shaving. I have enough trouble with my face in the mornings.

*It's a throwaway journal, but the pics are succinct:
http://www.dentistrytoday.com/implants/3801-clinical-pearls-for-surgical-implant-dentistry-part-3

 

[Mackchops]

Oh, for heaven's sakes, TSDentSurg, you'd better start applying Occam's Razor to dental practice or you'll be sunk.[/URL]

😀 Classic

Loving the discussion of clinical cases on SDN for a change. Thanks for the input.

 

[DentinBond]

There's actually some clarification we should be talking about here when it comes to bone grafts.

Consider the following bone graft materials:
Synthetic.
Xenograft, highly processed to destroy pathogens.
Allograft, highly processed to destroy pathogens. (For example, the Puros "Tutoplast" process involves Oxidative Treatment, Solvent Dehydration, Low-dose Gamma Irradiation, Delipidization, Osmotic Treatment, and then they make the graft watch CSPAN-2 for 72 hours straight. Nothing can survive that.)
Autograft, directly harvested at surgery.

What do they all have in common? Well, to paraphrase a well-known medical officer, "They're dead, Jim."

Even directly harvested cortical and marrow bone die back in the clot in a tooth socket, or so the histology tells us. Then they revitalize when new vessels invade, etc. All these substances provide a scaffolding, but they don't act as viable living bone. Block grafts of significant size? Do they remain viable? I don't know. Does anyone here know? Sort of a moot point for me because I don't intend to do surgery of that magnitude. But it's an important bit of theoretical knowledge that I'll have to ask my surgeon referrals about.

But then, since all bone grafts in extraction sockets are non-vital at the start, are there sufficient advantages to autologous yet dead bone to make a second surgical site worth it? Or can we just turn to the bottle and relax? (In my own practice I'm getting robust and predictable results with synthetic.) Any thoughts? Any definitive double-blind studies?

 

[TSDentSurg]

There's actually some clarification we should be talking about here when it comes to bone grafts.

Consider the following bone graft materials:
Synthetic.
Xenograft, highly processed to destroy pathogens.
Allograft, highly processed to destroy pathogens. (For example, the Puros "Tutoplast" process involves Oxidative Treatment, Solvent Dehydration, Low-dose Gamma Irradiation, Delipidization, Osmotic Treatment, and then they make the graft watch CSPAN-2 for 72 hours straight. Nothing can survive that.)
Autograft, directly harvested at surgery.

What do they all have in common? Well, to paraphrase a well-known medical officer, "They're dead, Jim."

Even directly harvested cortical and marrow bone die back in the clot in a tooth socket, or so the histology tells us. Then they revitalize when new vessels invade, etc. All these substances provide a scaffolding, but they don't act as viable living bone. Block grafts of significant size? Do they remain viable? I don't know. Does anyone here know? Sort of a moot point for me because I don't intend to do surgery of that magnitude. But it's an important bit of theoretical knowledge that I'll have to ask my surgeon referrals about.

But then, since all bone grafts in extraction sockets are non-vital at the start, are there sufficient advantages to autologous yet dead bone to make a second surgical site worth it? Or can we just turn to the bottle and relax? (In my own practice I'm getting robust and predictable results with synthetic.) Any thoughts? Any definitive double-blind studies?

ROFL at "they make the graft watch CSPAN-2 for 72 hours straight. Nothing can survive that."

I'm still concerned about the expense of the alloplast. Wouldn't shaving a bit of ramus be cheaper?

But, if you're having good results with alloplastic grafts...I'll tell my patients they have two choices: using expensive alloplast, or adding time and risk to harvest an ramus autograft. Whichever they choose is fine.

 

[DentinBond]

I believe I updated a Word document of costs of the bone graft materials we use. If I did, I'll post them tomorrow. Our fees for bone grafts compensate for skill in using them and purchase cost, but are not really large expenses for the patient. It's up to them in the end, but most seem to go for it. And if an implant is the definite treatment plan, then if the buccal plate is damaged, we really must insist.

Also, I often take post-op radiographs some weeks later and find that most of the socket is radiopaque but the apices are radiolucent. Particles or paste; happens with both. The apices will fill in with bone, the histology gives them no choice, but it still seems bad form somehow. Anyone have a way of ensuring that the whole socket is filled?

 

[charlestweed]

My wife doesn't like to put any bone material into the extraction sockets and she just lets the extraction sockets heal on their own . She's done a lot of immediate implant placement after dental extractions. If it is a severe chronic dental infection, she usually waits for the extraction socket to heal for 3 months before placing an implant. Since she offers guarantee for every implant that she places (or money back), she doesn't immediately load the implant.

When doing graft, she only uses patient's own bone or own connective tissue.....no alloderm, no cadaver bone. That's how she was trained at her perio program. Just last month, she had to remove a failing allograft material from the extraction socket of her reffering GP. This GP got the bone graft done by a perio instructor at his school when he was a dental student there.

 

[DentinBond]

Here are the graft material costs for three synthetics:

OsteoGraf 4 pack $77 per dose

IngeniOs B-TCP 0.5cc $69; 1.0cc $98

Novabone Putty 0.5cc $115

Novabone Putty Cartridge 0.5cc $446 / 4 or $111 each

Not earth-shattering expensive; the patient fee can be very reasonable.
We use code 7953 when it's implants/extractions, not the perio code 4263-- that's for use in perio surgery per se.

*If an immediate implant is being placed, the bone can "jump" up to 3mm from the socket wall to the titanium in a socket/blood clot without bone graft material, according to Tarnow's research.

And it seems that perio programs are demonstrating vast variability in the techniques being taught, from ramus harvesting all the way to no bone graft material at all...

(Read Tarnow. Read Lindhe.)