Predictable Immediate Extraction and Provisional


Dr. Ron Zokol: Vancouver, BC - Febuary 2017

Brief:

The replacement of a single central incisor may be one of the most demanding implant treatments clinicians face. Still, clinicians have been able to achieve aesthetic results in these challenging cases through excellent treatment planning and meticulous surgical placement. The following case study highlights how Dr. Zokol was able to integrate Inliant® into his treatment plan providing an excellent result for the patient in one visit – utilizing the patient’s extracted tooth as the immediate provisional.

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Increasing the predictability of implant treatment is a primary goal of our company’s product. The combination of the clinician’s skills and Dynamic Surgical Guidance technology enhances patient outcomes. The aesthetic result was achieved with the assistance of the device’s real-time three-dimensional feedback. 

Frequently, this type of case requires multiple appointments. Static guides require a CT scan, subsequent planning session, and delay to fabricate the guide. Today, with the use of the Inliant system, this procedure becomes more predictable by providing the visualization of the 3D drill position over the patient’s CT data, in real-time during implant surgery – in one appointment. 

Using this technology, Dr. Zokol was able to achieve submillimetre accuracy while continuing to drill free hand, using his handpiece that looks and feels like his standard surgical handpiece. He was able to plan the osteotomy in the software and proceed to surgery without the frustration of waiting for a guide to be fabricated and without the bulk of a static guide. 

PATIENT: 

32 year old healthy male (Fig 1) with a full complement of healthy teeth, with the exception the maxillary right central incisor. This tooth

was diagnosed with non-restorable external resorption at the palatal alveolar crest and referred for extraction and implant-supported restoration.

The treatment plan for this case was completed prior to removal of the maxillary right central incisor.  The position of the Inliant Fiducial™ is identified as per the company’s instructions. The essential criteria for Fiducial placement includes:

  • adequate visibility of the laser engraved optical markers on the handpiece concurrently with the Patient Tracker, the Patient Tracker is inserted into the Fiducial at time of surgery; and
  • non-interference with orofacial structures and movement of the handpiece during the surgical procedure (Fig 2).

Once the Fiducial has been properly secured in place, a CBCT scan is taken and the DICOM files are opened in the Inliant software. The

Inliant treatment plan is completed and saved. 

The patient is returned to the operatory for surgery. The maxillary right central incisor is extracted atraumatically and the socket is properly debrided and prepared for the implant osteotomy. 

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The Inliant Patient Tracker is inserted into the Fiducial (Fig 3).  The osteotomy entry position and angulation are performed with the guidance of Inliant’s navigation software. The osteotomy is performed completely with reference to the software and confirmed visually in the mouth (Fig 4 to 6). The implant is delivered visually in the mouth and angulation is displayed with reference to the Inliant software throughout the insertion of the implant. 

The implant, now delivered, is torqued to the manufacturer’s specifications, the balance of the socket is grafted and preparations are made to fabricate an immediate provisional screw-retained restoration.

The provisional restoration is fabricated using the clinical crown of the extracted tooth bonded to a titanium provisional abutment utilizing flowable composite. The restoration is contoured, inserted to the implant, and torqued to 15NCm.  It is adjusted to ensure no contact in MIP (Maximum Intercuspal Position) or excursions (Fig 7 and 8)

A post-operative CBCT scan is taken to verify surgical accuracy (Fig 9). In most normal clinical situations, a single implant is often performed without templates or guidance systems. In cases complicated by the close proximity of adjacent teeth or vital structures, there is merit in utilizing protocols to ensure a high degree of clinical accuracy.

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Dr. Ron Zokol graduated in 1974 from the University of British Columbia’s Faculty of Dentistry where he continues as a sessional Lecturer to the Graduate Prosthodontic students and as a member of the Dean’s Board of Councillors. He is also a member of the External Advisory Board for the Department of Bioengineering at the University of Maine. He holds fellowships in the AAID, the American College of Dentists and the Canadian Academy of Restorative Dentistry and Prosthodontics. He is a Diplomate of the American Board of Oral Implantology and the International Congress of Oral Implantologists. He is a past president of the Vancouver and District Dental Society, past Chair of the General Examination Committee, and a past Chief of Examiners for the College of Dental Surgeons of BC. He was a surgical for the Misch Implant Institute for 10 years. He founded the Paci c Institute for Advanced Dental Education in 1996 and has lectured locally and internationally for more than 25 years in prosthodontics and surgery. He continues to practice at BC Perio in Vancouver with a team of Periodontists providing services in advanced surgical and prosthetic rehabilitation.

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