Prof. Dr. Eduardo Topete Arรกmbula
RETURN TO THE BEGINNING: In the past, the replacement of one molar with a single implant has been widely accepted as the recommended standard of practice. As an innovative and viable alternative to the current standard practice, this author has since 1994 successfully replaced lower molars with two implants and upper molars with three implants (ONE IMPLANT PER ROOT LOST). This technique of using multiple implants preserves the crown root ratio that molars naturally have. More importantly, multiple implants reduce and balance the occlusal forces. This reduction of occlusal forces greatly enhances implant-bone less stress surface contact areas in the posterior regions of the mouth where maximum stress on molars is encountered.
Scientific studies on the skulls of Cro-Magnon man have scientifically demonstrated the existence of molars with two and three roots for lower and upper molars, respectively. Over millions of years the evolutionary forces of nature created by design the exact configuration of our molars to support the stresses that must be endured for optimal mastication.
(Fig. No. 1) Acrylic Model showing the exact number of roots per tooth in humans
Evolutionary nature has designed organisms for millions of years. Evolutionary efficiency has culminated in creating the present bipodal and tripodal configuration of our molars. This functional design supports and accommodates for the greatly increased chewing forces and ensuing pressure exerted on molars and bicuspids as compared to the lesser demands put upon the canines and incisors.
In the past, difficulties have often been encountered in balancing the reduction of forces and surface contact areas in the posterior regions of the mouth. Studies have shown that the forces exerted in the posterior regions of the mouth measure to 300 % more, compared to the anterior regions of the mouth. The strength and density of the bone structure in the posterior area where the molars are located, however, is noticeably weaker, measuring between 50% and 200%. Additionally, in that area the bone has less height. Natural posterior teeth will normally have short roots despite the increased and continuous stress applied to these teeth(5). Due to these complex factors, we recommend our technique of increasing the surface area in contact with bone by placing two implants in each lost inferior molar. This procedure essentially recreates the more natural and original double root configuration intended by nature. Whenever there exists available bone of adequate width, this author advocates replacing lost roots with the same number of implants, placed in the same position and direction that nature created (within anatomic limitations). (8) Since 1994, this author has successfully used the following procedure: the three roots of a maxillary molar are replaced by three implants inserted in the same mesial, distal and palatal positions as the roots had.(12) Using this method, the contact surface with the bone is increased. A greater number of implants is crucial to increase the resistance of the bone to the greater occlusal forces normally applied to the molars.(5)
CLINICAL CASES REPORT:
In 1991, this implantologist performed, for the first time, a total oral rehabilitation with 27 crowns on 27 implants on a 51 years old male patient. Each crown was individually inserted, and they were neither physically nor chemically bonded to each other. (10)
(fig. No.2) Case of 27 crowns over 27 individual implants, 1991.
This authorâ€™s clinical goal was to follow the example set by nature, i.e. to copy the original human denture as closely as possible by setting individual crowns on implants. (9) A physiological prophylaxis of the alveolar bone structure was made, root by tooth, (ONE IMPLANT PER LOST TOOTH) through the radicular insertion of intraosseous implants. (7) Nature did not provide us with bridge prostheses, but instead provided individual pieces, each having evolved for a specific purpose. All the individual parts work together perfectly to achieve functionally optimal mastication.
The patient presented above was clinically evaluated daily for one week following the insertion of the implants and the provisional prosthesis. Similar clinical evaluation was continued following the collocation of the permanent crowns for the first year to observe the ongoing oseointegration process. Thereafter, the patient was checked in three-month intervals for three years after the procedure. This author did, however, observe resorption of bone surrounding the upper and lower molars, but especially on the former ones; contrarily, no resorption was observed around the front teeth. These clinical observations made in 1994 motivated this author to seek a solution which would more closely imitate the shape, direction, size, and number of roots evolutionary nature provided for us. The goal was to recreate as faithfully as possible a copy of the natural, masticatory apparatus with all its unique root structural configurations, whether unipodic, bipodic, or tripodic in nature. (12) The idea immediately arose to replace lost pieces and their individual roots with “ONE IMPLANT PER ROOT LOST” by using the same alveolus that nature had created for this purpose. This procedure continued to develop further, resulting ultimately into the collocation of implants without tissue reflection. This technique has been named by this author as “Implants without Surgery”, (without soft tissue reflection). This technique was presented for the first time at an international congress in 1997. (11) As a result of extensive professional experience since 1974, this author has pursued the recreation of the more natural alveoli for every one of the 40 roots that nature provided for our dentition. (Not considered were the third molars and the two separate roots of the first upper bicuspids nor the two fused roots of the second upper bicuspids).
(Fig. No. 3) Case of 40 Implants in one patient, 2001.
The case pictured above and completed in 2001 has been closely monitored by thorough check-ups that included X-rays every three months. No apparent resorption was observed in this 55 year old male patient. He continues to show no periodontal complications nor any complications associated with his implants. He was instructed regarding the importance of maintaining daily dental hygiene to include flushing and cleaning of the areas of contact between the implants, gum and crowns with pressurized water and vibrating point devices (Wather pick & Power Flosser) in order to avoid bacterial plaque buildup. It is well known, however, that this principle and ideal technique of one implant per root lost, cannot be implemented with all patients. In addition to the great care that patients have to observer in hygienic terms (as we all do), the patient must have the sufficient height and width on the maxillary or jawbone selected for the insertions. (4)
It is very important that any implantologist have experience to achieve a total oral rehabilitation with 28 individual crowns on 40 implants, (one implant per root lost) and â€œwithout surgeryâ€? (without soft tissue reflection). Such a case was presented by this author in the master course: Preceptorship in Dental Implantology 2002-2003 in the University of Texas, Health Science Center at San Antonio, USA.
(fig. No. 4) Author exposing his case in the University of Texas, USA, 2003.
Recently, this author replaced one by one, all the roots that conformed a human denture. Forty four implants were inserted (including upper bicuspids with 2 implants) in a 57 year old male patient. On March 11, 2005, the goal was achieved in recreating equality within the entire masticatory system with all roots.
Fig. 5: Case of 44 implants in one patient, 2005.
Fig. 6: One implant per root lost.
MATERIALS AND METHOD:
Upper molars are exposed to masticatory forces of approximately 44 kg or (100 Ibs). Due to this high level of stress, it is recommended to replace the lost roots with three implants rather than one or two short ones. The three implants will then act as a tripod and resist the forces and pressure generated on posterior upper regions of the mouth. The length used for mesial and distal implants is usually Top-Easy 8, 10 & 12 mm or, if possible, a larger implant. The palatal implant could be somewhat longer, since it is replacing the palatal root of an upper molar which is the longest one.
(Fig. No. 7) Three Implants in each upper molar (1st & 2nd)
Lower molars support chewing forces of approximately 31 kg. Therefore, this author recommends the replacement of each of the two roots with Top-Easy implants Two-Stage of 8, 10, 12 or 14mm, if the lower dental conduct is too low.(12)
(Fig. No. 8) Two Implants in each lower molar
Upper bicuspids support forces of 22 to 28 kg. The first one has two roots separated in the apex. These could be replaced with two Top-Easy implants of 3.26mm of diameter from Oraltop速. The second one with two fused roots ending in one at the apex could be replaced with two Top-Easy implants of 3.26mm of diameter from Oraltop速. These implants would give the bicuspids the balance that vestibular and palatal roots have.
(Fig. No. 9) Two Implants in a first bicuspid that recreate a more natural root configuration.
(Fig. 10) Two implants in a second upper bicuspid that recreate a more natural 2 root-fusion configuration.
Upper and lower incisors receive masticatory forces of about 15 and 16 kg. Since they have naturally only one root, a single implant of the same length of the extracted root is sufficient. When possible a larger implant may be used (within anatomic limitations).
(Fig. No. 11) Replacement of each lost teeth with implants of 4.10, 3.26 & 3.76mm of diameter and 16mm of length.
A retrospective clinical study of restorations made by placing individual crowns on implants has proven that a higher number of implants has resulted in a decrease in bone resorption. (1) Another very issue that needs to be considered is the fact that the diameter of clinical crowns is not the same for all pieces. There have been problems in the precision collocation of individual crowns on molar implants. O ensure greater precision of collocating individual crowns on molar implants, this author invented the Oraltop Implant Positioning Space Paralelometer System速 (O.I.P.S.P.S.)速 as useful as the (O.I.P.S.P.S.)速 has been in the past, we are now able to equal the diameter of the lost molars by using two or three implants without resorting to the use of voluminous and heavy implants that were unable to provide the necessary bi-or tripod support needed in posterior pieces.
(Fig. No. 12 O.I.P.S.P.S Oraltop Implant Positioning Space Paralelometer System TOP-EASY ONE & TWO STAGE IMPLANTS INMEDIATE-LOAD & FUNCTION
(Fig. No. 13) O.I.P.S.P.S. 速 Diagram for implants of 3.26, 3.76 & 4.10mm of diameter
(Fig. No. 14) O.I.P.S.P.S. Diagram for implants 3.10, 2.50 & 2.75mm diameter
If we are to realize the esthetic and functional demands encountered in our modern and fast paced world, a more efficient and immediate, unitary individual reposition of lost pieces is needed. This goal can best be achieved by using the collocation of implants without incisions and without soft tissue reflection. Such a technique offers an enormous advantage. Concomitantly, it is highly recommended to perform the least possible osteotomy on the basis of the principles of osteocompression. Utilizing osteocompression has been proven physiologically to result in a potentially massive increment in venous pressure that promotes ossification (Otter). Bone compression induces extracellular fluids to flow around the surface of cells charged with osteoblasts, which produces faster osseous regeneration (Salzstein and Erickson).
Histological studies carried out at Louisiana State University by Block and Meffert have demonstrated the principle of controlled functional osteocompression. Within three months, single-piece implants immediately exposed to loads showed more than twice the bone density on the implant interface than two-piece implants (implant plus post) without immediate load exposition. Currently, single-piece implants with built-in posts substantially improve the surgical-prosthetic protocol, since their insertion is faster regardless of whether the angle is 0,16 or 26 degrees, as is the case using Top-Easy One-Stage Implants from Oraltop速. Previously, complications have arisen with prosthetic parts, but the insertion of single-piece implants with osteocompression will undoubtedly improve the surgical as well as the prosthetic prognosis. The bone-compression technique especially improves bone quality at the implant site. Special instruments devised for this procedure assure that the Implants may be inserted into the posterior maxillary without elevation of the cavity, since the insertion of implants in the posterior maxillary quadrant is generally recognized to represent a challenge even to the most experienced implantologist. This region has very poor bone quality (D4). This deficit adversely affects the possibility of inserting sufficiently stable implants in this area. The techniques of osteocompression, of bone transplant and of subantral augmentation are recommended (Palti and Steigmann) in the presence of deficient alveolus crests. This author is currently using zigomatic implants as an alternative in a total absence of alveolus crests.
This author recommends the use of two or three implants in bone of posterior quadrants “one implant per root lost in molars” (Topete 2001) with an osseous quality of D4 to create a greater predictability. A grater positive predictability is achieved when pieces are substituted with “individual crowns over the implants” (Topete 1995) on lower and upper molars. Alternately, by using the technique of “implants without surgery” (Topete 1999) (without soft tissue reflection) developed by this author in 1997, in combination with the technique of osteocompression for the insertion of one-piece implants will potentially negate any need for additional appointments to attend to the possible complications of prosthetic components. The use of these cost-saving, effective, time-saving techniques will ultimately save the patient unnecessary anguish, fear, stress, or even the possibility of a future complicated and possibly traumatic surgery. This author can assure the possibility of replacing one by one all he 44 roots with implants that conform to a more natural and human denture. The techniques mentioned above also have the advantage of avoiding pain and inflammation both during and after the procedure, which allow for a more rapid healing and osteointegration process of the implants. Most importantly, these techniques provide reposition and immediate load (with provisional acrylic or polycarbonate crowns) of each lost piece in a fast, simple, effective, economic and esthetic manner.
DISCLOSURE: This author claim to have no financial interest in any company or producto mentioned in this article.
REFERENCES: 1. BENDER, M.F.: Individual Crowns in the Molar Region: a new method of treatment Int. <J. Dental Symposia>, 2: 65-68, 1994. 2. ENGLISH, C.E.: Beware the Premaxilla. < J. Tenn. Dent. Assoc. >, 72(3): 16-18, 1992. 3. LANEY, W.R.; JEMT, T.; ZARB, G. A., et al: Osseointegrated Implants for Single-tooth Replacement: Progress Reports from a Multicenter Prospective Study after 3 Years. <Int. J. Oral & Maxillofac. Impl. >, 1: 49-54, 1994. 4. MEIJER, H.J.; KUIPER, J.H.; STARMANS, F.J.; BOSMAN, F.: Stress Distribution Around Dental Implants; Influence of Superstructure, Length of Implants and Height of Mandible. <J. Prosthet Dent. >, 68(1): 96-102, 1992. 5. NIEDERMEIER, W., et al.: Physiological Reactions of the Denture Bearing Reactions of the Denture Bearing Mucosa Folowwing Mechanical stress. <Dtsch. Zahnarztl Z. >, 45(8): 443-448, 1990. 6. SCHUH, E.; SHUMIED, R.; VOGEL, G.: Anatomic Limits of Endosseous Dental Implantation. <Z. Stematol. >, 81(2): 81-90, 1994. 7. SHMITT, A.; ZARB, G. A.: The Longitudinal Clinical Effectiveness of Oseointegrated Dental Implants for single-tooth Replacement. <Int. Prosthodontic>, 6(2): 197-202, 1993. 8. TOPETE EDUARDO; Rehabilitaci贸n total con 27 coronas individuales colocadas sobre 27 Implantes oseointegrados en un paciente, <Revista Espa帽ola Odontoestomatologica de Implantes> 3,(3),107-110,1995. 9. TOPETE EDUARDO, Implants without surgery, without soft tissue reflection, <Internationaler Kongreb; Die Reduziert Invasive Implantologie> 58 (6) 11-12, 1999.
10. TOPETE EDUARDO: Alternatives to enhance implant bone surface area, <International Magazine for Oral Implantology>, 1(2), 22 - 23, 2001.
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ICOI Board of Directors: Dr. Kenneth W.M. Judy Dr. Ady Palti Dr. Eduardo Topete Dr. Carl E. Misch Dr. Marco Degidi Dr. Roland M. Meffert Dr. Blake Nicolucci Dr. Charles E. English Dr. Hajime Okudera Dr. Richard A. Kraut Dr. Gerad Scortecci Mr. R. Craig Jhonson Dr. Edwin L.C. Scher Dr. Peker Sandalli