State of the art
Dr. P. Tardieu*
The topic of implants immediately put in function is very hot today. It seems that there is a lack of information about immediately loaded implants. What is possible, and what is still a dream? In this article, a specific protocol for creating an Immediate Smile will be announced. First of all since at least 12 years we have been able to immediately load implants following a routine protocol: manual implant placement, impression, transfer of occlusion and fabrication of a temporary bridge (on abutment or implant level) to be delivered the same day or a day after following office and lab schedules. The use of computer technology in implantology has been a major advantage. Starting from a CT scan - during which the patient is wearing a scannographic template - implant planning in dedicated SimPlant software can be done. Based on the computer-made implant planning, a stereolithographic SurgiGuide can be built to transfer the
planning towards the surgery. The SurgiGuide together with a jaw model mounted in an articulator offer all information for the creation of a temporary prosthesis beforehand. This paper will especially focus on the way we currently perform these last steps to introduce the Immediate Smile procedure. In June 2003, 1660 SurgiGuides were fabricated by Materialise. Taking an average of 5 implants per case, about 8300 implants were placed using the SimPlant-SurgiGuide concept. Since commercialization of SurgiGuides in 1999, our office has been using more than 200 drill guides either on bone, mucosal or teeth support to place around 1000 implants. So, is there anything new today, are there major improvements and what are they? Let's see what the current state of the art is. Some components, e.g. the SAFE System, are at the stage of validation studies and will be soon commercialized.
SimPlant and SurgiGuides
A radiopaque scannographic template (ScannoGuideTM) is the keystone of the whole process since it allows the transfer of the predetermined prosthetic set-up to the actual implant planning as well as visibility of mucosa information in the images. A SimPlant project will be made containing as well 2D CT information as 3D edited volumes of bone, scan prosthesis, etc.
approved resin) containing medical grade stainless steel tubes. The position and direction of the cylinders correspond exactly to the position and direction of the planned implants.
The SAFE System can be incorporated in the SurgiGuide. This
new system allows as well the drill as the implant placement guidance through one SurgiGuide. SAFE is the acronym of Secure, Accurate, Functional and Ergonomic. It provides a perfect positioning, angulation and depth of the implants. Some other instruments such as a trephine to remove soft tissue or different kinds of taps can be used too.
One of the major issues in using SAFE-SurgiGuides is the exact
transfer of implant positions to the mouth. We have been using a variety of systems to do that. The mucosal SAFE-SurgiGuide in this case is directly stabilized using an occlusal template and secured by several osteosynthesis screws to prevent it from moving during surgery. With the SAFE System, implants are placed accurately as well in position, angulation as depth. After accurate implant placement, the procedure is not finished. We should never forget that “patients don't want implants, they want teeth”!
Several different teams propose a short time delivery of a prosthesis, by relining or adapting a previously made bridge or by very fast fabrication of the prosthesis. We have been doing that since a long time. Today, we are looking for immediate screw-retained prostheses with as limited lab modifications as possible. To reach this goal we need to have a good control over a certain number of points.
1. One needs to have a good control over immediate loading procedures. The surgeon and his team, including the lab technician, need a certain clinical experience to be comfortable with these procedures. There is a variety of ways to immediately load implants and it's not as simple as it seems at glance.
2. One should be able to transfer implant position and angulation from computer plan to the mouth with submillimetric accuracy. It has been proven, by measuring implant positions on before and after superposed CT scans, that since the introduction of SurgiGuides, improved with the SAFE System, we can work at
this range of precision today.
3. One should be able to control the
depth of implants, independent of the kind of surgical guide used: bone-, mucosa- or tooth-supported.
4. One should be able to fabricate a prosthesis at the lab prior to the surgery using a lab model including the transfer of implants analogues. Materialise can provide a stereolithographic model with reservations for implant-analogue placement. This model can be mounted on the articulator using the scannographic guide (ScannoGuideTM), to transfer the occlusion. We now have all the
required elements to be able to fabricate the immediate temporary prosthesis.
5. It should be possible to overcome some minor differences between implant plan and real implant position in the mouth. Research about components that allow a certain amount of deviation is performed by several teams nowadays. We should notice that the difference between implant positions is often very small as long as implants are driven in position by the guiding cylinders of the SAFE System.
Many Immediate Smile cases have been treated in our office since our first trials in 2002. We have been doing a wide variety of cases: full upper and lower cases, partial upper and lower cases. In our learning curve, not all cases went out perfectly at once, but we improved fast. The more implants we have the more difficult it is
to adapt all of them without any modification. The main problem consists of adapting a screwretained prosthesis on implants
that are not exactly in the plan position. By the right components, the Immediate Smile dream of our patients will become reality.
These results are very encouraging since we started from zero in 1999, improving fast, and bringing us to a higher level every month. Immediate Smile is the knife-edge knowledge in this field and brings several benefits to our patients and to the surgical team. Immediate Smile allows us to work securely because we can get submillimetric accuracy in implant placement. This procedure is very efficient because in one appointment not only the surgery is performed but also the bridgework is delivered.
Patients never forget this kind of experience! Pain is limited
to nearly nothing. Working through the mucosa avoids the use of flaps, sutures and keeps the supra-crestal vasculature intact to keep underlying bone intact. A recent longitudinal study of implant placed in our office since three years compared to a longitudinal study done from 1994 to 1996 shows that our immediately loaded implants ratio grew up from 10% to 70% today with the same
success ratio of 97,5%.
* DDS from University Paris VII, PG in Implantology from University of Nice Sophia Antipolis, Adjunct Associate Professor New York University.
The Palm Jumeirah, Al Dabas #303, Dubai, UAE
Tel.: +971 50 658 2616
Web site: www.philippetardieu.com
Dr. Philippe B. Tardieu
Dr. Philippe B. Tardieu has a Phd. in Dental Surgery of the University Paris VII and a PG in Implantology from the University of Nice Sophia Antipolis. He is Adjunct Associate Professor at the New York University, Division of Reconstructive Comprehensive Care. As a lecturer, he is in charge of a Post Graduate Implantology course at the University of Strasbourg (France).
Dr. Tardieu is founder and President of the Institut International d'Etudes Dentaires Avancees.
He is an international member of the American Academy of Periodontology, member of the Association Francaise d'Implantologie.
He is involved in the Committee of lecture of the Implant Dental Journal for correcting articles in the field of Implantology. In 1996 he wrote a book to present and explain dental implantology to patients and the second edition including Computer Guided Implantology is going to be issued in 2004.
He is an international lecturer and author and an experienced user of surgical guides.
Since 1999 he is involved in R&D in Materialise Company in which he also has a position at the Medical Advisor Board. He is the co-inventor with Dr. Vrielinck of the SAFE System and he is the inventor of the Immediate Smile procedure and components.
Dr. Tardieu is the Director of Accuracy Current Technologies LLC (ACT) which is established in Dubai (United Arab Emirates) to develop Computer Guided Implantology in the Middle East.
Dr. Tardieu currently practices in Grenoble, France.