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Giving Thanks by Giving Back by Dr. Ed Kusek

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Categories: Implant Dentistry;
Giving Thanks by Giving Back 

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.

 Implant dentistry case
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.

 Implant dentistry case
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).

 Implant dentistry case
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
Implant dentistry case
Fig. 4
Implant dentistry case
Fig. 5
Implant dentistry case
Fig. 6
Implant dentistry case
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.

 Implant dentistry case
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.
Implant dentistry case
Fig. 9
Implant dentistry case
Fig. 10
Implant dentistry case
Fig .11
Implant dentistry case
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.

Author Bio
Dr. Ed Kusek 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.

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