This case kicked
off the AAID’s
program that
helps U.S.
veterans who
need dental
implants
by Dr. Ed Kusek
Introduction
In 1982, the American Academy of Implant Dentistry (AAID)
created the AAID Foundation with the mission to further the science
of oral implantology through research and education and to support
delivery of implant care through charitable programs. And in April
2018, AAID began providing dental work at no charge to qualifying
honorably discharged veterans of the U.S. armed forces. This case
study is for the first patient who was treated through the program.
Medical history and examination
The 73-year-old patient had a recent history of Type 2 diabetes,
high blood pressure and a heart murmur, and had a stent placed
one year previously. Medications included metformin and glipizide
(for Type 2 diabetes), atorvastatin (for high cholesterol), aspirin,
lisinopril (an ACE inhibitor for high blood pressure), meloxicam (an
NSAID used to treat inflammatory rheumatic disease), fish oil (to
reduce inflammation) and clopidogrel (an antiplatelet medication).
A digital panoramic X-ray (Fig. 1) and CBCT were taken
to plan implant placement, while an OralDNA study helped
determine if the patient was predisposed to periodontal disease.
Then, impressions were taken for use in fabrication of a maxillary
provisional denture, bite registration and shade tab matching.
After these steps were completed, doctors went over the treatment
sequence with the patient and his wife.
Fig. 1
The patient did not smile often because he was self-conscious
about his teeth. Because he had been exposed to Agent Orange
during the Vietnam War, he had developed a few medical problems
that created dental issues including broken teeth and low salivary
fl ow, which in turn created root decay.
The patient had seen the same dentist for
38 years, with several restorative treatments
to fix problematic areas as needed (Fig. 2).
Nothing had been done comprehensively,
however, and as time went on, the patient
needed to have a definitive treatment plan.
His options included a full maxillary denture,
an implant-supported maxillary overdenture
or a maxillary hybrid implant prosthesis,
which the patient chose.
Fig. 2
Procedure
Blood was drawn in the left antecubital
fossa to fill four 3-cc vials, which were
centrifuged for 12 minutes at 2,700 rpm to
gain plasma-rich fibrin that would be used
as a membrane over the implant/graft sites.
The vena puncture was made in the right
dorsum of the hand. Vital baselines were
established. Medications included 5 mg of
Nubain, 10 mg of midazolam, 20 mcg of
dexmedetomidine, 1 g of cefazolin and 8 mg
of dexamethasone for the entire procedure.
The patient stayed in Level III sedation until
the procedure was completed.
Teeth #4, 5, 6, 9, 11, 15 and 18 were
extracted, and a flap reflection was created
in the area from #4 to #12 by using a
10,600-nanometer CO2 laser with 0.5 mm
spot size. Elevators were used to reflect tissue.
A surgical handpiece was used on the
alveolar crest to create a flat surface on which
to place implants. (Because #10 already
had an implant placed from a previous
treatment, new implants were planned only
for sites #5, 6, 7, 9 and 11.) Periotomes were
used around teeth to loosen ligaments and
Physics Forceps (Golden Dental) were used
to aid in elevation.
Implants were placed using Densah
drills (Versah, Fig. 3) with diameters of
2 millimeters, 2.3 mm, 2.5 mm, 3 mm and
3.5 mm, and started 4 at mm. Implants
(Zimmer TSVT, Zimmer Biomet Dental)
were all 4.1 mm diameter, while lengths
were either 10 mm (#5 and #7) or 13 mm
(#6, #9 and #11).
Fig. 3
Before seating the implants, an erbium
laser (Biolase) was used for about 40 seconds
(Fig. 4) to increase fibroblast formation
and detoxification.1 Then, Bio-Oss bone
(Geistlich Pharma AG) was placed in gap
spaces (Fig. 5) and soaked with plasma
from the PRF membranes,2 followed by the
membranes themselves (Fig. 6) being placed
over this and closed with 3.0 polytetrafluoroethylene
sutures. Finally, the laser was
used again (Fig. 7) to cover the entire site
and 1 centimeter beyond. This also aided
the increase of soft tissue healing.3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Photobiomodulation (Thor, Chesham)
was used—with 12 joules of energy at
sites of implant placement and 6 j at the
submandibular and subclavicular lymph
nodes—to increase natural endorphins for
pain management and decrease swelling
by stimulating lymph system in the head
and neck region.4 Then, the provisional
denture was delivered and the vena puncture
was removed.
Postoperative steps
At the first postoperative appointment,
one day after surgery, the patient reported
minimal discomfort, but we adjusted three
sore spots and placed a soft liner to allow
better retention of the provisional denture.
One week after surgery, the sutures
were removed and we again adjusted sore
spots in the maxillary provisional denture.
PBM was done again to surgical sites, using
6 j of energy to promote healing5 and 6 j to
aid the lymph nodes to prevent swelling.6
The patient was seen over a few more
visits to adjust sore spots in the provisional
appliance and to change soft liner to aid in
retention of it.
After three months, implants were
uncovered using a 10,600 nm CO2 laser
(Denta 2, Great Plains Technology), with the goal of keeping attached tissue of 2–3 mm
around the implants. I find that using
a superpulsed laser helps prevent tissue
shrinkage and needing to use sutures.7
Impression posts were seated (Fig. 8)
for implants and radiographs were taken to
verify the posts were seated to the base of
the implants. Impressions were taken with
Thermo Clone impression material (Ultradent);
the maxillary denture was duplicated
using a putty material of Thermo Clone and
high-viscosity impression material to aid the
lab (Root Laboratory) with aesthetics and
vertical dimension. Healing caps were placed
and the maxillary provisional appliance
was relined.
Fig. 8
Three weeks later, a verification jig was
created by the lab and seated; an open-tray
impression was then taken with Thermo
Clone to pick up the verification jig with
maxillary ridge. Healing caps were then
replaced and patient again left with his
removable maxillary provisional appliance.
In three more weeks, the patient was seen
to seat the multilevel abutments and seat
the polymethyl methacrylate (PMMA)
temporary that had been fabricated to
verify vertical, passive fit and correct
aesthetics. All were acceptable and the
patient approved to proceed for the final
restoration of a fixed zirconium hybrid.
Minor adjustments were made for occlusion
on the PMMA, which was sent back to the
lab for final fabrication.
After another three weeks, the final zirconium
fixed hybrid was seated (Figs. 9–12).
Minor occlusal adjustments were made,
screws were tightened to 10 newtons of force
and access holes were filled with Teflon tape
and flowable composite.
Two weeks later, the patient had a postoperative
occlusal and hygiene check. All
were very good, and the patient was pleased
with the results. He was given a HydroFloss.
Fig. 9
Fig. 10
Fig .11
Fig. 12
Discussion
This veteran’s service had led to numerous
medical and dental problems: He did not
smile, and had to restrict his diet to foods he
could chew without fear of breaking teeth.
I have not served in the armed services,
but feel a huge gratitude for all the veterans
who have defended our country to keep it free.
I’m proud to have made a small difference
in this patient’s dental health, and want to
thank Zimmer’s implant division for donating
implants and Root Laboratory for donating
services and materials to complete this case.
As I finish writing this article, it is
Memorial Day and I am reminded of all
veterans and those who have given their lives
for our freedom. To quote President John
F. Kennedy, “As we express our gratitude, we
must never forget the highest appreciation is
not to utter words, but to live by them.” To
help do my part, I’ve already begun treating
the AAID’s next Veterans Smile case.
Reference
1. Kusek ER. “Use of the YSGG Laser in Dental Implant
Surgery: Scientific Rationale and Case Report.” Dent
Today 2006;25(10):98,100, 102–103.
2. Schwartz F, et al. “Healing of Intrabony Peri-Implantitis
Defects Following Application of Nanocrystalline Hydroxyapatite
(Ostim) or a Bone-Derived Zenograft (Bio-Oss) in
Combination With Collagen Membrane: A Case Series.” J
Clin Periodonol. 2006.
3. Kusek ER. “Use of the YSGG Laser in Dental Implant
Surgery: Scientific Rationale and Case Reports.” Dent Today.
2006; 25:98–103.
4. Kusek ER. “Soft Tissue Management Following Implant
Placement.” Perio/Implant, product showcase A-B.
5. Wagner VP, Curra M, Webber LP, Nor C, Mattle U,
Meurer L, Magner MD. “Photobiomodulation Regulates
Cytokine Release and New Blood Vessel Formation During
Oral Wound Healing in Rats.” Lasers Med Sci. 2016
May;31(4):665–71.
6. Webb C, Dyson M. “The Effect of 880nm Low-Level Laser
Energy on Human Fibroblast Cell Numbers: A Possible Role
in Hypertrophic Wound Healing.” J Photochem Photobio B.
2003 Apr;70(1):39–44.
7. Hobbs ER, Bailin PL, Wheeland RG, Ratz JL. “Superpulsed
Laser: Minimizing Thermal Damage With Short Duration,
High Irradiance Pulses.” J Dermental Surg Oncol. 1987
Sept; 13(9): 955–64.
Dr. Ed Kusek is a diplomate
of the American Board of
Oral Implantology, a past
president of the Academy
of Laser Dentistry, a fellow
and president-elect of the
American Academy of Implant
Dentistry, and an adjunct professor at the University
of Nebraska Medical Center College of Dentistry
and the University of South Dakota dental hygiene
school. He has earned mastership in the Academy of
General Dentistry and Academy of Laser Dentistry.