Delivering implant stability with no compromise on soft tissue adaptation
Dr Duncan Park presents one of his first cases using the brand-new Tapered Pro Conical implant from BioHorizons Camlog, achieving both primary stability and an excellent emergence profile on a molar implant restoration.
The fundamental goal of implant treatment is to improve function of the dentition, but it is also important to deliver aesthetics. As a relatively new treatment modality, more comprehensive research is needed in the field regarding patient priorities. However, evidence so far demonstrates patient demand for both functional and aesthetic outcomes from dental treatment, especially with regards to implantology as a more expensive elective procedure.i
The clinician’s focus is often on achieving primary stability and facilitating osseointegration, with a conical connection implant shown to deliver high stability and successful clinical outcomes.ii It is just as essential to optimise soft tissue outcomes. This necessitates the development of a good emergence profile around the implant site, utilising the temporary restoration to encourage effective soft tissue adaptation.iii Consideration must be given to both hard and soft tissue management whether restoring a tooth or teeth in the anterior or posterior region of the mouth.
The following case presentation demonstrates the achievement of excellent hard and soft tissue outcomes using a new implant system with proven protocols.
Figure 1: Pre extraction radiograph
Figure 2: Healed extraction site at the LR6
Figure 3: Pre-operative LR6 region
Figure 4: Digital planning of implant placement
Figure 5: CT scan showing sightly narrow crestal bone
Case presentation
A 38-year-old male patient presented. He was medically fit and well, although he did admit to drinking approximately 13 units of alcohol a week. He was a regular patient of the practice and had a well-maintained mouth. He had been advised of a problem with the LR6, despite it not causing the patient any pain.
A comprehensive assessment was conducted, revealing the LR6 to be root filled. The tooth was fractured with limited residual tooth structure remaining. It was deemed unrestorable and therefore indicated for extraction.
Treatment options were discussed with the patient in detail, including no treatment, extraction of the LR6 alone, and extraction alongside restoration with either a bridge or an implant-retained crown. The patient expressed a preference for a fixed solution and was keen to proceed with an implant.
The clinician’s focus is often on achieving primary stability and facilitating osseointegration, with a conical connection implant shown to deliver high stability and successful clinical outcomes.
All of the benefits, limitations and potential risks were then explored, with particular attention given to the patient’s history of dental restoration. The impact of excellent oral hygiene was also emphasised and the patient made to understand all his responsibilities in managing the long-term success of implant treatment.
To remove the tooth as safely and atraumatically as possible, it would need to be sectioned first. This would be performed as the initial phase of treatment and the site would be left to heal. A delayed placement approach was chosen in this case, partly to allow adequate bone formation at the surgical site, and partly due to the patient’s lifestyle choices. Ideally, the implant would be placed around 12 weeks after the extraction. The literature shows a lower risk of early implant failure when employing a delayed placement technique.iv
Figure 6: Implant positioning checked
Figure 7: Radiographic check of implant position
Figure 8: Implant placed and torqued to X Ncm
Figure 9: Implant placed
Figure 10: Post implant placement and closure
Treatment commenced with the sectioning and removal of the LR6. The patient returned to the practice approximately five months later for implant placement – the delay was due to his limited time availability. Although this was longer than planned, in this situation, it didn’t result in any further bone loss, but did mean there was more healing in the socket at the time of placement.
A pre-operative CT scan was taken. This revealed a slightly narrow ridge measuring 8mm. The crestal ridge was about 4mm wide, while at 2mm subcrestal a width of 8mm was identified. This required the implant to be placed slightly subcrestally and deeper in comparison to the adjacent teeth in order to obtain primary stability and avoid the need for augmentation procedures.
Surgical treatment provision
On the day of surgery, the patient was given 3g of amoxicillin and a one-minute Corsodyl mouth rinse immediately pre-operatively. A flap was raised and a small alveoloplasty was performed to flatten and widen the ridge. The osteotomy was prepared to 10.5mm.
A radiograph was taken to confirm positioning of the implant. The drilling sequence followed the standard protocol set out by BioHorizons Camlog. A 4.6mm x 10.5mm Tapered Pro Conical implant was placed, achieving excellent primary stability at a torque of approximately 50Ncm. The implant choice was driven by the volume and width of bone available in this case, as well as the proximity of the implant to the ID nerve.
A 4.6mm x 10.5mm Tapered Pro Conical implant was placed, achieving excellent primary stability at a torque of approximately 50Ncm.
The design and material of the implant as a titanium alloy (Ti-6AL-4V ELI) means it affords the strength required to ensure implant stability even when used in a smaller diameter, should the case demand it. The new conical connection also optimises soft tissue healing and aesthetics by creating an excellent emergence profile. Torqued to 50Ncm, high primary stability was achieved as anticipated.
A healing abutment was placed and the flap was closed tension–free using PTFE sutures. The patient was given standard post-operative instructions, which included avoiding chewing on the LR6 and eating soft foods for a few weeks while the site healed.
Figure 11: Post implant placement radiograph
Figure 12: Radiograph taken post
Figure 13: Intraoral photograph at 12 weeks post-operative
Figure 14: Implant exposed at 12 weeks post-operative
Review
The patient returned to the practice two weeks later for removal of the sutures. Healing had been uneventful and everything was proceeding as expected. At 12-weeks post-operative, the healing abutment was removed and replaced with a wider alternative to further facilitate soft tissue stability and aesthetics, and an impression was taken for the final crown. It was noted that the soft tissue had adapted and matured very nicely around the healing abutment, with no bleeding around the emergence profile. A full contour zirconia crown bonded to titanium was fabricated and screw-retained in the mouth. The patient was delighted with the outcome.
Reflections
This treatment delivered a good clinical result for the patient. Upon reflection, the only aspect I would do differently is to use a wider healing abutment immediately post-surgery, though this did not seem to affect the result in this case.
The connection is based on the proven CONELOG design which has been available for over 13 years and is among the best available.
With regards to the system used, the Tapered Pro Conical implant was a good choice because it achieves excellent stability in a range of situations. It is comparable to the BioHorizons Camlog Tapered Pro implant both in terms of design, which affords primary stability, and of simplicity to place, but builds further on the design of the previous generation of products. The connection is based on the proven CONELOG design which has been available for over 13 years and is among the best available.ii The emergence profile lends itself to create a very nice curvature of the gingiva, improving the soft tissue adaptation for exceptional aesthetics and cleansability. In effect, it is the best of both companies – BioHorizons and Camlog.
To discuss how you can implement Tapered Pro Conical into your implant practice contact our team.
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*Article originally published in February issue of The Probe magazine.
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Article Author
Dr Duncan Park is the principal of Green Square Dental & Implant Centre in Yorkshire. Since qualifying in 2003, he has completed a certificate in dental implants, followed by a master’s degree in 2010. He now mentors on the implant master’s programme at ICE postgraduate dental institute and Hospital in Salford, Manchester.
