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Review Article

Biodynamic Implantology. Full Arch: Extractions, Immediate Implant Placement, Immediate Implant Functional Loading, PRF, and Immediate

Aesthetic Screwed Fixed Prosthesis

Patricia Uribe Vargas1,2,3* 1Prosthodontics, Universidad San Martin, Bogota, Colombia 2Esthetic and Oral Rehabilitation, NYU, College of Dentistry NY, USA 3Implantologists, EIRO, Buenos Aires, Argentina

Citation: Patricia Uribe Vargas., et al. “Biodynamic Implantology. Full Arch: Extractions, Immediate Implant Placement, Immediate Implant Functional Loading, PRF, and Immediate Aesthetic Screwed Fixed Prosthesis”. EC Dental Science 17.9 (2018): 1616-1632.

*Corresponding Author: Patricia Uribe Vargas, The Beauty Smile®, Bogota, Colombia.

Received: July 09, 2018; Published: August 29, 2018

Abstract

No any specific implant system was used. Nevertheless, I have been careful to describe principles and protocols rather than spe-cific components. No matter what implant system is utilized, all readers of this article will derive useful information from it.

Keywords: Atraumatic Extraction; Immediate Loading; Immediate Placement; Implant; Full Arch; Implants; Biodynamic Implantology; PRF, Esthetics; Extraction of Teeth; Function; Platelet-Rich Fibrin; Regenerating Surgery

Once colleagues experienced it and learned to appreciate advantages and efficiency of biodynamic implantology, they never want to return to the old, lengthy ways of reaching their journey’s end. Switch from the lengthy healing protocols to immediate loading has demanded a veritable intellectual revolution, a cognitive rupture, a paradigm shift.

I groped my way along new trails, making cautious decisions, sometimes staggering, sometimes faltering, and finally succeeded in establishing a reliable protocol. I have collected the results of this effort and present them in this article to the largest possible professional audience to provide access to a helpful and effective technique that I named biodynamic Implantology where the patient becomes the principal beneficiary.

The cases I will present show successful outcome with a 2 year follow-up period. In these cases, harmony of hard (white) and soft (pink) tissue is preserved by biodynamic implantology protocol, which leads in time saving, due to this new protocol and bio materi-als used, a reduction in overall clinical time, decrease of hard and soft tissue resorption, increase of patients’ treatment acceptance, along with improvement of better function, aesthetic smile and psychological benefits were obtain.

Biodynamic implantology protocol, has been simplified by innovations in implant design, grafting materials and full arch immediate functional prosthesis, making this an excellent option for dentist that provide implant therapy for a terminal dentition, severe periodontal compromised, or edentulous patients.

The search for an esthetic result in a full arch implant treatment is a continues searching topic in the routine of dental professionals, but the found results are not totally aesthetically satisfactory, in almost all cases.

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Biodynamic Implantology. Full Arch: Extractions, Immediate Implant Placement, Immediate Implant Functional Loading, PRF, and Immediate Aesthetic Screwed Fixed Prosthesis


Patients who present terminal dentition commonly suffer discomfort, deficient dental function and low self-esteem as a result of their poor oral health condition. Biodynamic implantology is a treatment option that offers instant, life-changing benefits for these patients while setting the stage for a short-term treatment with a long-term success outcome. This protocol allows the patient to walk out of the office with dramatically improved form and function. This immediately enhances the patient’s quality of life and provides a significant “wow” factor to the patient as much as to the dental practice.

Implant placement on a full arch has enormous aesthetic challenges in implant dentistry because when all teeth are lost, it leads to bone resorption and collapse of gingival thickness and architecture, which leads to aesthetic compromise and inadequate bone for im-plant placement. And the only solution given to a patient is the popular overdenture or a hybrid prosthesis (white and pink materials), which, in my humble opinion, this is not esthetic. Following this trend, periodontally compromised patients have sought treatment with the primary purpose of improving smile esthetics, not only recovering all teeth. The challenge for dentists is along implant supported teeth, keep a healthy gum and papilla, and allow maximal preservation of peri-implant tissues on the full arch. The aim of this article is to present a protocol to deliver a functional occlusion, and a white aesthetic smile to a severe periodontal compromised patient in just few hours, conserving and reconstructing the natural pink maxilla tissues, avoiding the use of pink fake gum on the new reconstructed mouth [1].

As dentists, we have to learn, recognize and understand the intricacies of the biodynamic implantology protocol, the different pos-sibilities it offers and, above all, its limitations.

Figure 1: Biodynamic implantology Case.

Preface

In 1997, a term in the dental glossary was started used by dentists. Since then, immediate loading has become one of the hottest term as well as the most relevant topic in contemporary implant dentistry [2].

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In the 1970s and 1980s, immediate loading was used routinely in dentistry. However, dentists had to abandon the technique for fear of being discredited. Firsts immediate-loading protocols were used in the pre-Brånemark era [3] but today’s biodynamic implantology protocol has nothing in common with the technique practiced in earliest times.

Introduction In the last 30 years, concepts and treatment modalities in implantology have endured remarkable changes. At first, only protocols

involving two-stage surgery were recognized as providing reproducible and reliable results [4]. Later, a single-stage surgical procedure became acceptable [5]. Later still, the waiting periods for bone healing were shortened; instead of 3 to 8 months, no more than 6 to 8 weeks was deemed necessary [6,7]. The rediscovery of the immediate loading protocols, which for decades had been considered unten-able, is viewed as a veritable revolution [8].

Opinions vary about the maximal acceptable interval between implant placement and immediate, early or delay loading. Some re-searchers use the term immediate loading only when the provisional prosthesis is placed during the same session in which surgery is performed [9]. Others believe that, to qualify as an immediately loaded implant, the definitive prosthesis must be placed on the same day [9]. Still others accept a delay in loading within 48 [10] to 72 hours [11]. Regardless, these concepts remain empirical because no one of them is based on biologic or physiology reactions at the bone implant interface.

Many studies have documented results for an immediate loading treatment from hour cero to 72 hours. I have used an interval throughout this volume, without any way judging the validity any of these parameters. The interval presented in the clinical cases of this article goes from 36 to 48 hours.

Biomechanical differentiation of biodynamic implantology and immediate loading:

• Some authors give the concept of immediate loading when the coronal portion of the prosthesis is inserted, even if it is kept out of occlusion right after the implant is inserted [9-11]. Usually this immediate loading of a full arch, refer to complete prosthesis cover with pink materials that restore gum resorption, and papilla.

• The term of Biodynamic Implantology is always a treatment of a full arch, which includes: extractions, immediate implant place-ment, hard and soft tissue grafting, PRF and growth factors, to promote thick healthy soft and hard tissue, where the prosthesis is inserted between 36 and 48 hours, immediate occlusal and functional loading is applied, restoring the functionality of the patient and his/hers white and pink mouth esthetics immediately.

The difference is significant because of the esthetics, convalescing teeth, soft and hard tissue, and function in just one procedure. Therefore, a full mouth reconstruction is a predictable optimum outcome. With a future unique advantage over all other treatments: the patient has the possibility to recover his individual teeth and papilla.

Figure 2: Initial pictures.

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In all cases, the dentist embarks on the prosthetic treatment immediately after the surgery has been completed. This means that within 48 hours, a prosthesis will be exerting considerable pressure on the implants supporting it, in an interaction that is described as biodynamic implantology. To simplify it, throughout this article I refer to the two aspects as pink and white esthetics and occlusion. In this specific treatment of a recent edentulous mandible or maxilla, occlusal forces should be minimized by distributing them over a greater number of implants. I have taken an active role in establishing the foundation for the biodynamic implantology protocol and I am eager to tell others what I have learned, so the greatest possible number of dentist and patients can benefit from this technique. This implant procedure provides clear benefits to patients.

General rules for biodynamic implantology

The 3D implant positioning must consider the following three oral planes: mesiodistal, buccolingual or palatal, and coronoapical. These planes define the emergence site of the implant in the dental arch, the implant angulation and the access holes of screw retained implant prostheses. Implant positioning in the three arch planes must coincide with the biologic rules.

Figure 3: Intraoral Pictures.

Bite registration and vertical dimension record

Recording the jaw relations is a very important procedure in the creation of a full arch implant supported prosthesis. An error at this stage can result in a uncomfortable, or unwearable restoration, making difficult to restore a functional optimum bite, and may even have the potential to produce damage to elements of the stomatognathic system.

Patients who have their natural dentition has a space between the occlusal faces of the teeth of the opposing jaws This space is called the freeway space (FWS) or interocclusal distance, which is determined by a balance between the elevator and depressor muscles at-tached to the mandible, besides this FWS, surrounding soft tissue of the natural dentition has to be recorded too; bite registration requires records of upper and lower teeth and rims in its most retruded position and with the jaws separated by the established OVD [12].

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Polivinil-Siloxane Squash Bite

Accurate and reproducible occlusal relation is paramount to design a new full arch prosthesis that restore esthetics and mastication, this will determine a proper vertical dimension and occlusion registration, which is created from a silicone matrix of original dentition on maximum occlusion Adjustments can be made on teeth in order to look for an equilibration between CR-CO discrepancy or a change of VDO to a more comfortable position for the patient. Regular Vertical dimension should not be altered.

Figure 4: Record of OVD.

The squash bite involves placing a horse- shoe shaped roll of softened silicone between the upper and lower rims and having the pa-tient close the jaws together.

An important goal in the treatment of completely dentulous patient, whose teeth are going to be extracted is to reestablish the jaw relation in transversal and sagittal dimension without comprising verified facial height.

Atraumatic extractions and preservation of fresh sockets

The goal of any extraction is to cause least damage of the alveolar bone, in order to protect it for the future. The most important advan-tages in extraction surgery is given by piezo surgical machine, which allow extractions without affecting adjacent tissues, its extraction tip generates ultrasound which weaken the fibers of periodontal ligament easing the extraction without affecting the bone structure around the teeth. Atraumatic extractions ensure healing, which is in beneficial of the immediate implant placement and integrity of the soft tissue. With atraumatic extractions, tissues heal faster, without pain or inflammation, since the site has been protected during the procedure.

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Figure 5: Atraumatic extractions.

Distance between implants and contiguous structures

The theory of a minimal distance between two adjacent implants [13], derives from the principle of preservation of the biologic width in the mesiodistal plane. Minimal distances of 3.0 mm between two implants should be maintained. These values are based on the bone resorption that occurs during the first months of implant function in the vertical and horizontal directions. Both resorption patterns in-volve the surrounding bone to a distance of 1.0 to 1.5 mm [14,15].

Figure 6: Distance between adjacent implants.

When the distance between two implants is less than 3.0 mm, the height of the bone crest is entirely resorbed [16]. Therefore, the papilla no longer receives enough bond support. On the other hand, when the distance between two implants is bigger than 3.0 mm, the papilla is supported on the bone, so the crest is well preserved, assuring long term results for pink natural esthetics. And the possibility of restoring the patient in 60 days with single crowns is doable.

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Immediate implant placement in fresh sockets

The progressive involution of the crests and whole alveolar bone starts after teeth extractions, and it is usually accompanied by reduc-tion of quality and quantity of hard (bone) and soft (gingiva) tissue. It was demonstrated that major changes on the extraction site occur in the first 3 to 12 months, and a much as 50% of buccolingual width is lost too. Placing implants immediately after tooth extraction can eliminate the waiting period for socket healing and may reduce the bone resorption that normally occurs following the loss of a tooth [17].

To establish the foundation needed for a full arch screw-retained restoration and avoid a facial access hole of the screw, clinicians must position the immediate implant against the lingual or palatal wall on the fresh extraction socket.

The longevity of implant supported prosthetic of a full arch, depends on how the masticatory forces are transferred to the implants and to the surrounding bone. In immediate implants, anatomical conditions, teeth position, bone morphology and aesthetics usually dictate implant placement in less than ideal position. Parallelism is mandatory on biodynamic implantology, to allow an even draw of the pros-thesis without undue force on an individual implant or prematurely distorting. with parallel implants, the stress distribution follows the long axis, and the fringes concentration is adequate.

Although clinical success rate exceed 98%, bony defects that surround implants may affect their primary stability and make it difficult to achieve an ideal white prosthesis. It was shown that when the horizontal gap was < 2 mm, the defect had the capacity to naturally heal and generate new bone right after implant is inserted. However, if the gap between the implant and the socket wall is bigger than 1.5 mm, it can be occupied by soft tissue [15-18].

Use of platelet-rich fibrin, in fresh sockets

Several techniques and materials have been elaborated to expedite bone regeneration and to reduce its healing time. Platelet-rich fibrin (PRF) is an autogenous derived from the patient’s blood, which increases regeneration and accelerate the healing of the wound, due to the comprising growing factors.

Figure 7: PRF.

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Platelet-rich fibrin, as a fibrin biomaterial, which carries a large quantity of platelets and leukocyte cytokines [19]. Concentrated plate-lets contain many growth factors, including the PDGF, TGF-β, IGF, EGF, fibroblast growth factor, and bone morphogenic protein. These growth factors are autologous, nontoxic, and no immunogenic, which enhance and accelerate the normal bone and these growth factors play a main role in hemostasis and angiogenesis process, proliferation of osteoblasts and its differentiation, a simple and available tech-nology [20,21]. PRF allows a significant postoperative protection on the surgical site and seems to accelerate the integration, maturation, and remodeling, while enhancing bone graft density [22].

After immediate implant placement, I use platelet-rich fibrin, i-PRF (liquid) and A-PRF (clot) as well as PRF membrane to achieve guided bone regeneration. In order to enhance peri-implant bone healing and achieve an aesthetic final outcome through the full arch, the use of new generation of PRF on bone and collagenous grafting, to fill in residual peri-implant and buccal sites is mandatory. Barrier membranes may prevent connective tissue and epithelium from invading the gap between the implant and the bone walls [23]. Histomor-phometrical analyzes showed that PRF can be used alone or used in conjunction with autogenous bone graft, PRF accelerated the healing of the bone on biodynamic implantology protocol.

The fibrin acts like a scaffold and plays a major role in different stages of bone and soft tissue healing [1]. Platelet rich fibrin provide. Platelets play a crucial role in the periodonto regeneration as they are reservoirs of grow factors and cytokines which are the key factors of regeneration of soft tissue [24]. Tissue engineering with PRF is a predictably regenerating pathway, enhancing, or recovering damaged or missing soft tissues in biodynamic implantology cases.

Figure 8: Bone grafting.

Treatment variant: thick or thin periodontal biotype

The patient’s periodontal biotype is always important for the approach to and the outcome of final pink aesthetic treatment outcome. Thin and thick biotype of the patient are differently treated, the use of soft brushing tool [25,26]. It is used to extend the flap, disorganizing the collagen fibers of the fibrous periosteum. This technique reduces the stiffness of the flap allowing it to release farther. If this tissue can be stretched, more A-PRF membranes can be put in place and a better quality of queratinized tissue is generated.



Figure 9: Impression technique.

Emergency profile and impression technique

A suitable treatment protocol should include a deep evaluation of each parameters of the whole treatment: study of bone quantity and quality, soft tissue quality, surgical phase and, provisional and final prosthetics. Which are crucial for an aesthetic and functional result. The implant emergence profile concept guides the choice of: implant, and kind of provisional prosthesis.

The coronal bone remodeling around immediate implants and the use of GBR procedures show a healing pattern with new bone ap-position around the neck of all implants and, at the same time, soft tissue remodelation occurred. Therefore, new papilla is forming and final prosthesis can be made with single crowns [27].

Figure 10: Open tray impressions.

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A splinting impression technique in multiple implants with auto-polymerizing acrylic like resin is among the most routinely practiced splinting material for full arch implant impression technique [28]. Transferring the implant position from the mouth to the definitive cast is one of the most critical steps in implant final prosthodontics, but because dental implants are not osseointegrated yet, not passive fit of the provisional prosthesis is needed, but an accurate implant impression is crucial because discrepancies can induce to biologic and mechanical complications [29].

Stabilization of the pink tissue architecture immediately after teeth extractions and implant placements is required for a final esthetic outcome. In addition, it includes providing a custom seal over the surgical site to retain graft particles and PRF membranes.

In the biodynamic implantology procedure, the gingival emergence architecture is designed and shaped since day of implantation. So, the emergence profile can be as aesthetic as of the original teeth [30]. This protocol makes it so much easier for the laboratories to create a provisional and final restoration with a proper and emerge like the natural dentation emerging from the site [31].

Figure 11: Gum 48 hours of implant placements.

Suturing for optimal tissue management

Successful suturing is dependent on accurate cooptation of the flaps, an inadequate suturing will lead postoperative pain or discom-fort, flat skipping, exposed bone grafting, necrosis and delayed wound healing.

Two knots of an apical modified mattress suture are made in each side of the maxilla with monofilament suture, which display excellent handling properties, full absorption, with none, slight or minimal tissue reaction, and an unparalleled combination of easy gliding through tissue, excellent tensile strength, prolonged stretch retention, improved flexibility, elicit minima inflammatory response, these sutures are designed to improve healing process on the soft tissue due to its favorable characteristics. This monofilament suture completes full resorption between the 91st and 119th days of implantation, enough time to complete full osseointegration and soft healing period [32,33].

The most complex site is the alveolar crestal, so no pressure is applied. Eversion is produced with less risk of suture marks than the vertical mattress suture, and with less tissue distortion than the horizontal mattress suture. More wound is closed with four entry and exit points than with conventional vertical mattress suture, so closure is more efficient. first suture is made while impression copings are in pace, once impression is taken, healing abutments are screwed, and suture is completed.

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Functional immediate loading

With independence of the fabrication technique, immediate loading prosthesis may be cemented or screw-retained. Numerous tech-niques have been described to fabricate temporary immediate fixed full arch prostheses, without long lasting optimum results like: clini-cal adaptation of a previously fabricated denture/prosthesis which is delivered immediately after implant placement, which is relined on site [17,22], temporary relined with self-curing temporary made of BIS-acrylic material and temporary fixed prosthesis fabricated by a dental technician, that is delivered within the two weeks. These mentioned clinically adapted prostheses are fabricated often with no reinforced acrylic [34] which lead negative results of these prostheses, it’s a common clinical mistake in most of the full arch cases [35].

Figure 12: Lab splinted prostheses.

Initial implant stability is the key condition for the success of immediate loading [36]. Most studies establish a minimum implant insertion torque to perform full arch immediate loading, which varies from 10 to 90 Ncm [37]; if enough implants are placed, immediate loading can be performed even if not all the implants achieve an adequate stability.

Biodynamic implantology only succeeds if eight or more implants are splinted with a rigid metal frame, the design avoid long distal cantilevers. A thorough occlusal adjustment ensures uniform load distribution, the metal rigid reinforced prostheses is the key factor for success of a full arch immediately loaded prosthesis because it minimizes macro and micro movements during osseointegration.

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Occlusal

Figure 13: Functional loading.

Figure 14: Screw holes covered with teflon.

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Figure 15: Composite reconstruction of palatal an lingual screw holes.

Sequential Control

Immediately after loading, the occlusion is adjusted. All the patients were assessed for occlusal checkup after the surgical procedure. The same of loading a panoramic radiograph is taken to check the correct seating of the prostheses. The patients were recalled for clinical evaluation at 4, 8, 15, 30, 60 and 90 days after surgery, Occlusal stability and balanced contact points are checked in each control. More-over, always we recommend a soft diet during osseointegration period [38].

Figure 16: Implantology biodynamic lab and clinical.

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This patient presented for full mouth restoration. The radiographic examination revealed advanced periodontal disease requiring tooth extractions, and unsolvable dentition.

Figure 17: Soft tissue evolution.

Figure 18: X Rays Sequence.

Conclusion

Figure 19: Before and after pictures.

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Citation: Patricia Uribe Vargas., et al. “Biodynamic Implantology. Full Arch: Extractions, Immediate Implant Placement, Immediate Implant Functional Loading, PRF, and Immediate Aesthetic Screwed Fixed Prosthesis”. EC Dental Science 17.9 (2018).

Implants can be placed successfully in fresh extraction sockets, autologous bone graft material to fill the gap between implant and labial bone and buccal bone was used through. Biodynamic implantology protocol demonstrated acceptable clinical and radiographic, and aesthetics and functional outcome over a 2-year period in 8 patients, 12 arches, with 40 implants. This protocol is an efficient means of teeth replacement that reduces the number of surgical procedures and shortens the duration of the treatment. In full arch indications, this approach can deliver results that instantly transform esthetics, function, personal confidence and quality of life. Achieving a predictable, short-term treatment, and long-lasting results. The Biodynamic implantology protocol, has been simplified by innovations in implant design, grafting materials and full arch immediate functional prosthesis, making this an excellent option for dentist that provide implant therapy for a terminal dentition, severe periodontal compromised, or edentulous patients.

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