As a new dentist starting the implant journey, you are faced with a mind-boggling plethora of information from experts in the implant world. What really helps, is to have someone who is going through a similar process to share advice and compare notes with, on various topics such as – methodology, what system to use, what instruments to procure, what's the protocol to follow for placement and loading, how to go about finding a suitable mentor and so on. I find myself at this juncture, at the moment, and I invite you to take this journey along with me.
At King’s College where I completed my MClinDent in Prosthodontics, the placement of
implants was not a part of the prosthodontics curriculum. It was instead part of the periodontal
and Oral Surgery curriculum.
After an initial consultation with restorative consultants who makes a rough plan for the placement, the case is then passed onto us prosthodontic /restorative registrars. We take into consideration patient expectation, availability of bone and the restorative need of the whole mouth feasibility with wax-up and mock-up , we arrive at a suitable treatment plan.
Where implants are required the planning is restorative based, so the
final position of the restoration is planned according to function and esthetics and then we
work backwards to see if there is any need for any bone or gingival augmentation needed with grafts. Once the position, length and width of the implants are ascertained, it is passed on to our periodontal or oral surgery colleagues.
Once the placement of implants is satisfactory, they then pass it back to us for restoration
and completion. As it is not part of the curriculum at college, we were expected to place
implants for only three cases. However, I decided to be proactive and with the help of my
consultants, I was able to see eight patients and have placed fourteen implants, so far. The
implant systems that I have used are mainly: Astra (TX and EV) and the Nobel Biocare.
The experience so far has been amazing. However, up until now, it has all been guided and mentored to a large degree. Although there was a considerable amount of input from us registrars, the plan was mostly based on each consultant the case was allocated under and their preference or comfort level.
Unfortunately, we start with implant planning and restorations from our second year, (as most cases take about 1-2 years to complete) at a time when the knowledge base about implants is not sound, I feel that it’s only once you have completed the exams and the course, you get a good understanding of why we did the things we did. It all starts to make more sense, when we plan for a grilling viva session as to why we did what we did in terms of length/size/placement protocol /loading protocol/screw v/s cement - it's like a jigsaw puzzle and it puts a lot of things into perspective.
My intention is to keep a diary– a new implant dentist diary, so to speak, in which I record the details of how I proceed from one case to another in surgical implantology. I’d like to begin with a series of observations, wherein I observe different implant dentists in clinical practice. These practical observations will no doubt be highly beneficial, especially when you consider how textbook-oriented implantology practice in institutions has become. For instance, at the institutional level, practical considerations such as time and costs of things are not considered to be major factors. On the contrary, in a real-world clinical setup, these factors are integral to the success of the practice. I believe that we can learn valuable lessons through observation.
The first of my observations was at Wolds Dental Studio with Dr Sam Mohamed. I was truly stunned and amazed by the different techniques employed by him and I think that there is much to learn from his example. He has been placing implants since 1998– long before I even qualified as a dentist. Not only does he have a lot of experience, but he also runs a course on clinical practical implantology, where students are taught how to place implants. The course has got great feedback and is a collaborative effort between him and his colleague Mukesh Soni and Azhar Sheikh.
I had made prior arrangements to visit him at the surgery where he had planned an immediate implant placement of the upper right first premolar which had a periapical pathology. During the treatment, he used periotomes for a very atraumatic extraction, releasing the periodontium and extracting the teeth in a manner that ensures that there is no bone loss.
An interesting fact that I observed was that he used degranulation burs to remove the granulation tissue than a surgical excavator for enucleation. There was a buccal perforation at the bottom of the root where there was the periapical pathology. He used degranulation burs to clean out the area and then used a thick membrane which was initially shaped and then cut out and placed into the buccal cavity. The soft tissue was relieved off the periodontium and a pocket was created buccally that was wide enough so that the membrane could be inserted between the bone and the buccal mucosa, as a pocket to help filling it with porcine bone, as porcine chips were the bone graft material being used.
Once this was completed, the osteotomy for the implant was done and an 'Osstem' implant was placed. All the remaining defects in bone was filled with porcine chips.
I noted that Dr.Mohamed did not use any sutures because of the fact that it’s not possible to attain primary closure, since the mucosa wouldn’t stretch. So, in order to keep the porcine chips in place, he used a bit of flowable composite to shape it on top of the chips onto the implant, so that it remains in place until the area heals. All in all, it was an enlightening observation.
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Sam has been mentoring me with surgical implantology - I will be sharing all the new information I have picked up along with him.