I once overheard a colleague saying to someone in angst “Don’t F#### the bone, feel the bone.” A recent discussion with a colleague following a mentored case brought these words rushing back to me. As I chuckled to myself, recalling the incident, I stopped for a moment to really understand what the statement was implying.
Being able to immediate load in full arch implant cases has many advantages including increasing patient acceptance to treatment, expediting the treatment time and simplifying the restorative process. A number of principles need to be met to allow delivery of a fixed set of teeth, on the same day. One principle is, implants placed in the jaw have to attain a minimum torque value on insertion. There are multiple factors and techniques to consider which allow you to achieve adequate torque values.
Below are some points to consider to help us achieve adequate torque values of our implants in full arch immediate load cases.
Knowing your implant dimensions and utilising an implant manufacturer and design which aids achieving high torque values.
Often in full arch implant treatment an alveoplasty (bone flattening/bone profiling) is required and this removes the cortical layer of bone on the crest therefore increasing the difficulty in achieving adequate torque values.
Using the lance/precision bur to determine the quality of the bone by piercing the bone without it running.
Under preparing the osteotomy and accounting for the quality of the bone. Developing the tactile feedback on assessing the quality of bone and analysing and adjusting accordingly by quick brain processing. This develops with experience however, you have to be conscious of doing this when drilling.
Be aware to follow the path of the osteotomy as you step up drill sizes, being careful not to assert lateral forces which will widen the osteotomy inadvertently. Run the drill before you place it into the osteotomy and avoid stopping the drill when it is in the osteotomy. Be careful when assessing the osteotomy with your explorer as not to damage the preparation.
Bicortical fixation of the dental implant.
Engaging the best quality areas of bone. In the maxilla this is located in the anterior maxilla. Your implant placements should be palatal as to hug the palatal cortex of bone, aim apices of implants palatally and when angling in an “all on 4” type arrangement the distal implant apices should be engaging the anatomical area described as the Y line of Ennis. In the mandible the best quality bone is located in the symphyseal region.
To be able to successfully deliver an immediate load full arch implant treatment requires us to develop the skills and be aware of the techniques to prepare an osteotomy. We must respect the bone.
As Guy McLellan says “Know your implant, know your drill and know your bone.”