An Idiot’s Guide to Restoring Single Implant Crowns Part 2 – PDP157

Jaz’s Introduction:
You should probably start there first because Dr. Devang Patel, our esteemed guest, he talks us through from the very beginning, like how do you assess the site that might be suitable for an implant and what to actually do if someone else’s placed implant is coming to you for the restoration.

And let me tell you, I learned so much. The episode is called an Idiot’s Guide. I’m the idiot, right? So I was learning so much as getting along. He taught us about internal hex, external hex, conical, or butt joints, all these things I was learning about implants. Then we talk about impressions and scanning.

And now we’re going to be talking about what happens when the lab work comes back from the lab and you’re going to assess it. You want to take a radiograph. You’re going to actually screw the screw retain crown in. But what are you checking for? Do you have to give local anesthetic, for example? How much talk do you need to give at that point?

How do you then restore the screw access hole? And what should be the follow up protocol going forward, as well as the all important troubleshooting? It’s really important when you learn a new skill, that you learn about the troubleshooting. So any of the common complications that you can get ahead of it.

Protrusive Dental Pearl
So just before we go and join Devang for that Part two, I’m going to give you the Protrusive Dental Pearl. It’s basically a summary of both these two episodes, so PDP156 and this episode, because I imagine as a learner, it can become quite overwhelming, especially if you’re commuting, chopping onions, and then to try and remember and think, you need like an aid memoir.

I know the premium notes are there. But this is like a step-by-step appointment by appointment summary, which I will make available. So if you’re a premium subscriber, you will find it in the app already, but if you’re not, and you’d like to get your hands on this appointment by appointment checklist, if you’d like based on everything that Devang is teaching, then all you have to do is go to protrusive.co.uk/idiot. That’s right. It’s protrusive.co.uk/idiot. And I’ll take you to the landing page so I can email you the PDF. Thank you to Devang for helping us make this so we can make this confusing topic tangible for you. Let’s now join Devang for the main episode and I’ll catch you in the outro.

Main Episode:
Welcome back again Devang. We covered last time about restoring implants and there was so much to it that we split it into a two-part episode. Just briefly remind us the three steps that we covered so far and what step four is today and the journey you’re going to take us on today.

[Devang]
Okay. So thank you very much Jaz for having me again. So it’s always delighted to come to your podcast. In step one, we discussed about how to do clinical assessment for the implant restorations. We discussed how to record impression, how to take a impression for implants. And we mainly discussed how to communicate with the laboratory, what to write in the lab docket, because if you are really taking digital impression for implant, it’s quite easy, very straightforward.

You just need to put the scan body in, scan it like you normally do. But it’s the communication with the lab and you need to be a little bit in control as to how labs are making the restoration. Are they using Ti bases, which is off-the-shelf abutment and then cementing crown on top, because that’s the cheapest way to do it.

So if your lab cost is really low, that’s how your lab is doing the crowns. And nothing wrong with it, but many time Ti bases are very very small and there is a risk of their crown decementing even though you have a screw retained crown. Because lab would make the crown in the lab, create a hole through the crown and cement it onto the abutment.

You can gain access to the screw really. So you need to be aware of that. And now in today’s episode, we’re going to discuss about step number four, which is Fitting of the Crown, step number five, which is Maintenance. And we’ll discuss some of the complications because when you start doing everything, everything’s going fine. That’s great. But really, you understand your depth of knowledge when something doesn’t go right, and you need to correct it.

[Jaz]
Great. Well, if you pick up from the point where you sent your scan body or impression to lab, you put the healing abutment back on. A few weeks later, you’ve done your lab communication, the patient comes back, and you’re now going to remove the healing abutment? Or what are the procedures, checking lab work? You take it whichever direction you want, sir.

[Devang]
Okay, so, first of all, when the lab work comes in, I would check, make sure that on the model, the crown looks fine, okay? So, make sure that you check it on the model, what you need to do is when the model comes back, most of the time it will come up with a gum attached to the, you have a fake gum on the model, it would be there.

I take the gum off and then put the crown in on the model. Check, make sure the crown seat’s okay. The other thing you need to do that is that you need to have, or you need to ask your lab to get you a new screw. You don’t want to use the same screw which lab used in this lab to tighten patient’s mouth because the screw have gone in and out multiple times and it’s not ideal.

So you want to use, maybe you can use the same screw to try in the crown and make sure everything’s fine before you use, but finally, right at the end, you want to use a fresh new screw to screw the crown in. So you’re going to check everything on the model, make sure the contacts are not tied.

[Jaz]
Devang, is this standard protocol or is this you being like extra careful? Is this like what is standardly taught and practiced?

[Devang]
This is how I was taught when I was taught, implant restoration at Eastman. That’s how I was taught. I know it’s not a standard protocol in the sense that I know most of the technician will not send you a new screw. You do need to request for it.

I have actually, I’ve just bought the screw from the company itself because it’s cheaper for me to buy it that way. So, I buy it on bulk, like 50 screws. They’re not very expensive. If you buy 25 BioHorizons screws, they are like 80 pounds, 85 pounds. So it’s not tremendously expensive. So I just buy it. I have it with me and the technician will send me the crown and I’ll change it myself. It’s a recommended protocol-

[Jaz]
Good point.

[Devang]
And that’s how I was taught, but I don’t think that’s a commonly used protocol, if that makes sense. But it won’t add too much to your lab costs.

[Jaz]
A nice little tip and a pearl for those implant dentists.

[Devang]
Now, once you assessed on the model that everything fits fine, now you’re going back to patient’s mouth. So patient come in, you are doing the same protocol like you do for normal cementation of the crown, right? So you’re going to check. Before you even put the crown in the mouth, you’re going to check shim stock holes. You’re going to check the occlusion before you put the implant crown in the mouth. So you’re going to really assess patient’s current occlusion, which we don’t want to change after we place the implant.

Once we assess that, we take the healing abutment out. Any time I put, or I take things out from the implant screw on screw, I would irrigate using chlorhexidine because you don’t want to really push any bacteria into the implant, into that channel, screw channel when you’re pushing the crown back in. So even like during the appointment, if I take the crown in and out, patients close their mouth, I would always irrigate with the chlorhexidine.

So my protocol is anything, every time I take the crown to patient’s mouth, I would irrigate before with chlorhexidine. Again, it’s a little bit OCD, but I know Khoury, I learned it from Khoury where he would put antibacterial sort of a gel or antibacterial sort of a paste in the screw channel just because he was worried that there could be infection leading or bacteria leading from the screw access channel to the implant causing bone loss.

So, again, what was the study behind it? Not much, there is not much evidence behind it. But we want to make sure that we don’t really push any bacteria in there. So then I’ll take the healing abutment out.

[Jaz]
That makes sense. Now, just a bit more, a step back, actually. How often would you be anesthetizing these patients? Would you have to ever give LA?

[Devang]
Oh, well, good question, actually. So when patients come in, I tell patient that around 60% of the patients, 70% of the patient can get away without any injection. Would you want me to give you injection or you want to see how things go? While I’m doing the treatment, fitting the crown in, if it’s painful, you can stop me and I can give you injection then.

Or I can give you injection from beforehand. Some of the patients, if they are really anxious, they’re like, no, just give me injection. So I’ll give them injection, which is fine. Some of the patients, they don’t like the numbness and they will be saying like, okay, we don’t want to. So I don’t. Generally, when I do the crown, I don’t really compress the gum too much.

So my instruction generally to the technician would be, I want a narrow emergence profile. So compression to the gum is not excessive, so I would generally, it’s okay for my patients, but yes, I do give patient an option that whether they want LA or not.

[Jaz]
Okay.

[Devang]
So once that’s done, so I would take the crown to patient’s mouth. And generally, when you put the crown in, it should slot in unless you’re using very old type implants or it’s a different implant, like the name of the implant, it’ll come to me, but where there is no connection, you literally, it’s a friction fit connection where there is no hex or anything like that.

But generally, most of the implant would have some sort of a hex where you would, you will feel the crown slotting in. When that happens, yeah, conical connection or it could be a butt joint connection, but either or any internal connection will have an internal hex in there. So the crown will feel going in unless your crown is really compressing the gum a lot, that time you might not feel the connection.

But generally, you will feel the connection, you will slot it in. And then start screwing the screw in. As soon as you feel the first resistance, you need to stop. And you need to check the contact point. Because what will happen is, if you’re taking a general, normal impressions, open tray or closed tray impression, you are, there is a small chance always that, during the process, the impression post moved a little bit, and the crown might not be in the really exact position.

So, if the contact point is a bit tight, Then you could just keep screwing it in and you will use a cross thread the screws and you ruin the screw threads. So you want to make sure you first resist and you check the contact points. If the contact points are fine then you carry on because it may be just compressing the gum and the gum is sort of giving that resistance if that makes sense. So you would keep doing it.

[Jaz]
It’s just normal checking with floss, right? Nothing more to it?

[Devang]
Yeah. No, just floss and you checking that floss goes in nicely. With implants I’m slightly more sensitive So if the floss goes in but with the bit more pressure, I don’t like that. So I want it with the gentle pressure floss should go in click click. So you should feel still here or feel the clicking but I want that to be lighter because with the screw-it-in crown you never know, the crown might be compressing a bit, little bit too much and it may not seat completely and you won’t know because floss will still go in because the crown’s nice and smooth.

Generally, technician make the crown with the small point contact rather than surface contact interproximately. So it’s easy to just go through that even though they are quite tight. So I would, I would do that and keep checking going back and forth, back and forth, back and forth until I know the crown’s completely seated, the screwdriver’s not turning more and contact points are fine.

Only then I would really check occlusion. Okay. So I’ll need to make sure the crown and this is the same thing with the normal crown fitting, right? So you want to make sure the interproximal is fine before you start checking the margin or occlusion, really. So I’ll come to that occlusion in a minute.

So I’ll check occlusion. Everything’s fine. Then I’ll take a radiograph to make sure that the crown’s seated properly on the implant. I’ll come back to the occlusion that with regards to occlusion, if you think that the occlusion is quite high, which you weren’t expecting, then you take a radiograph first, because it could be there is something not allowing the implant to seat properly, implant crown to seat properly in the implant, you take half an hour adjusting occlusion, and then you think, oh, the crown is not seated properly, and then you have to send it back anyway to the lab.

So make sure that if you think that it’s way off, then check the radiograph first, before you check the occlusion. Now, with regards to occlusion, we want our implant to be 30 micron off occlusion in the sense that you don’t when patient closing. You want 30 micron space between implant and opposing tooth, okay?

[Jaz]
Clearance.

[Devang]
Yeah, that’s because obviously we know that our PDL, the teeth have PDL ligament, and then, you know, when patient closes and grinds, they intrude the natural teeth, but the implants don’t intrude. So because of that, we want to give some sort of a cushion effect, some sort of a leeway when patient bite really hard, then all the teeth will intrude and then implant will be very small in contact, very tiny bit.

And one of the easiest way to measure that is to, I use articulating paper which is around 12 to 14 micron thick. So, I just double the articulating paper and then ask patient to close and check the occlusion that way. So, make sure that you have 30 micron clearance. Now, guidance is another thing you may need to really consider when it comes to occlusion, whether you’re going to use your implant for the guidance or not.

For a single tooth, I will never put guidance on my implant because you can get away with most of the things. So let’s say if your implant is upper right one, you have rest of the anterior teeth, do you use a protrusive guidance? If your implant is upper right three and you prefer, you can’t use canine guidance because it’s your implant.

Then you can use a group function. I’m not really too faffed about using group function. Obviously I like canine guidance because it’s easy, but if I have to use a group function, I would use group function. So I would avoid for single implants anyway, my guidance. Now, if you’re doing small bridges and if you cannot avoid guidance, then you need to spread it, spread it out.

As much as possible, because I’m doing a full arch implant now, I can’t really avoid guidance on full arch implant. So you need to spread your guidance as much as possible everywhere. So it’s very simple for single tooth.

[Jaz]
Now just a question on that, just making it really practical, just basic occlusion checking is, if you put in your article paper and you fold it, so let’s say you’ve got roughly 30 microns and the patient bites together and you want to see it pull through because it’s clearance, but do you then check again with the patient clenching really hard and then you don’t mind if it just contacts a bit? Is that right?

[Devang]
Yes, clenching hard, I want, I mean, if you really want to assess with the clenching hard, then you want to put shim stock in there. When they’re clenching hard, your shimstock may be just about to, just about whole, but you should be able to still pull through, but you may feel a little bit of resistance when they clench hard.

[Jaz]
Like a drag, like a shim drag basically.

[Devang]
Yeah, exactly. That’s what, but if it just pulls through and there’s a little bit, a small gap, I’m not terribly worried about that to be honest. I don’t want too much load on my implant.

[Jaz]
Here’s an interesting question for you then Devang. If you, let’s say you’re doing a lower first molar implant crown. Okay, and you want it out of the occlusion. Now, let’s say this patient is half a unit class two. Therefore, the opposing tooth would be like an upper molar as well. So, now you’re out of the bite, but over time, wouldn’t that upper molar just keep erupting, keep compensating, keep coming into the bite? Because it doesn’t have like half a cusp on the tooth behind or tooth in front. So how do you guys deal with that?

[Devang]
Yeah, that’s a really good question. And I don’t have the answer to it, to be honest. What happens is, which I’ll cover in maintenance is that when patient comes in every yearly, you would assess the occlusion. And what I’ve found in many time is that’s exactly what’s happened there.

Especially sevens. Sevens are buggers because you create a clearance, and you lose it like this. Like when patient come back, I can guarantee you that you lost that clearance, which you made in a year’s time. There are a few options you have, you’re either adjust the opposing tooth because you definitely, you don’t want your implant to be loaded.

Unfortunately, you will, there are lots of problems, lots of issues. I actually saw a patient this Thursday came in with a loose crown, screw retained crown, and that was because I fitted the crown and then I checked the occlusion. It was proud. And that crown’s been there in six years in his mouth.

So I know I’ve checked it last year and he wasn’t proud. So it just becomes, it was the first, almost first point of contact and it was last tooth in the arch. So recurrently, this is how I manage. I either adjust the implant crown. or adjust the opposing tooth. Generally, I adjust the implant crown. And that’s it. I leave it like that.

Now I’m starting to change my philosophy in the sense that I don’t think the material we are using for implant, I don’t think it’s the right material. I think we should be using more sort of a shock absorbing material, such as like a composite for implants, where we can get away with a little bit of occlusal load, where it absorbs the shock of that little bit of occlusal load.

Otherwise the same thing happens. Keep teeth keep moving. We know that teeth move all the time. That’s what I do, for now, but I don’t have any robust answer as to what to do. Then someone would say, okay, give them a mouth guard, give them Essix retainer, so teeth don’t move. Studies have shown that it’s not reliable. Teeth still move, like small movement, it still happens with the Essix Retainer on. But if you want to be a bit more-

[Jaz]
Yeah, because we’re dealing very minimal amount of microns.

[Devang]
Yeah, exactly. But you can give Essix Retainer just to make you feel a bit better. I’ve tried both ways and I’ve still seen teeth move. Because exactly, we’re looking at microns, we’re not looking at millimetres.

[Jaz]
Fine, so you’ve checked the occlusion thoroughly, static and dynamic, what next? Are you finally going to switch, get your screw, the one that you have, the one that you bought, independently?

[Devang]
Yes, so, what I tend to then do is, once everything’s fine, I’m happy. This crowns fitted. I’ve shown it to patient patients happy. At this time, I show them the screw access hole as well, that there is a hole in the crown. They usually don’t feel surprised because I would’ve shown them during my consultation that this would happen. Initially, I didn’t. And then patient’s like, what you going to gimme hole in my crown?

Like this is a new crown and you really get a crown with the hole in it. So I need to, I generally explain it to them on the consultation appointment that this is how I approach it. So I show them everything, explain that our hygiene patient’s happy. Then I would take the old screw out, swap it with the new screw.

And I would hand tighten it. And I would put a PTFE in there and then I would put a, some sort of a material like a clip or sort of temporary composite material in there, in the excess hole. Generally, so I put a PTFE until, let’s say, 3mm spaces left. So you don’t need, like, small PTFE and a big TFM sort of a material.

You want big PTFE and then small material. It just makes your life easy next time when patient comes in. So I would do that and then I will let patient go for a test ride. So that I’ll see patient for anything between 6 to 8 weeks after I’ve fitted the crown for a second, for a review. To make sure patient’s happy, I look at the gums, make sure everything’s happy, take the photos, because on the day, gum will be blanched, so, you don’t want to take photos on that day because it won’t look nice, so you want to wait till six weeks anyway, six to eight weeks, but mainly patient would give you an opinion. With a screw-retained crown, it’s really good, if patient comes back and like, I don’t like this, I don’t like that, you unscrew it. Put a healing about them back, send it back to lab for whatever amendments you want to make.

So it’s fine. However, I tell patient that as we know with porcelain, if you’re using UCLA type crowns, where the lead porcelain, they’ve used a PFM type porcelain. The longer it stays in patient’s mouth, refiring, when you want to change, it becomes a bit trickier because of the water content.

So the water goes into the crown, it gets moisture in there, and then when you put it in a furnace, there is a chance that everything just breaks apart. So I tell patients that if you don’t like anything, don’t wait till six weeks, just come sooner, okay? But generally, 99% patients like fine.

Everything’s happy. They’re happy. So when they come back in six to eight weeks time, then I would torque the implant. And torque range, it ranges from 20-35 N-cm. You need to check which implant company you’re using, and you need to use a torque setting to the recommended implant company. So Neodent, I know, I think they recommend 20, Straumann’s 35. BioHorizons 30. So it depends really what kind of torque range implant system you’re using. I’ll torque it.

[Jaz]
And does each implant system have its own torque wrench? Or does one torque wrench be applicable to all the systems?

[Devang]
No, but just to make your life difficult, each company will have their own torque wrench. However, each company will have a machine fit driver, which means it’s a latch grip driver. Now, if you have a torque your own torque wrench, you can put that let’s grip into your torque wrench and you can use one torque range for everything. But generally your restorative kit would have some sort of a torque wrench which company has provided.

So it’s not a big, big issue. When you are like me and you’re treating like multiple implants and everything, then it may be worth having a universal torque wrench kit where it comes with a handle. I don’t know if you remember, when we removed gutta percha for doing post and core preparation.

We used to have this handle and then you snap the drill into the handle rather than using the slow hand piece to remove the gutta percha you can use a handle and use the hand to remove the gutta percha. So you’re not really removing it too much. But at least at Eastman we used to taught it like that teach it. So you can use a majority gutta percha with the hand piece and the last bit you can use with the hand. But it’s basically a latch grip.

You can just put it in the handle and you can use it. You can torque it and then a new PTFE. If you, let’s say patient comes back and your crown’s loose, the screw is a little bit loose. Then you need to go back and check whether your contact points a bit tight or why this screw became loose. Generally, they don’t become loose that easily.

So you need to make sure that it doesn’t, if it has become loose, then I’ll retighten it. And review the patient again, in six to eight weeks time. I don’t want to become loose within eight weeks time, even if I’m hand tightening it. That means there is some other issue going on. So once it’s fine, I’ll torque it.

I’ll irrigate the channel, make sure there is nothing in there. Dry it. PTFE, new PTFE. Now, there are lots of material people have used. So not just PTFE, they’ve used antibacterial seal to seal the whole access hole. But I’ve seen studies and they recommend PTFE with composite on top. Works fine. Cotton wool actually doesn’t work very well.

So PTFE is much better than a cotton wool. So PTFE again. And then if you have, if your technician has done their job properly, what you would have is you will be able to see the screw, the metal channel extending right just above the occlusal surface. So just one millimeter shy, because you want metal to cover, support the whole porcelain, right?

But the problem is with the screw retainer, especially the mandibular, let’s say molar, it doesn’t look nice when you put the cement, the metal shines through. Okay. So patient will be like, it doesn’t look nice. So, what I tend to do is PTFE, 3mm gap, and I have a Opaquer. I use a similar Opaquer where technician would use for composite to hide the metal. So I would use Opaquer to bond to metal.

[Jaz]
Is this like a liquid form? Like a Tippex kind of thing?

[Devang]
Yeah, it’s a dental version. Do you know a pink opaquer from Cosmedent? That works fine.

[Jaz]
Yeah, I use the Ivoclar one, the direct opaque.

[Devang]
Yeah, same thing. Any opaquer. So I would use silane metal primer first to prime the metal. Dry it. I tend to use bond. There is no evidence behind it, but you can use a little bit bond. Cure it and then metal opaquer. Cure that and then composite and that will mask the hole. You don’t want to mask it very, very nicely because obviously you want to go back again. You might have to go back again at some point. So you want to see where the marginal hole is. So I would explain to patient always and patients generally are fine. They don’t, they’re not that fussy.

[Jaz]
Yeah. I’ll just ask a timely question then Devang, because you mentioned the fact that you want the retrievability. So you want to be able to go in again. How often, like for restoring the single implant crown let’s say a premolar molar and you see them at the six to eight week control and then this time you’re going to use a torque wrench whereas before when you fitted it you used the hand tightening but this is the first time you use a torque wrench you do your PTFE you do your Clip or Telio or whatever. How often through the lifespan of the next 20 years on average would it be required for someone to go back in and remove the clip, remove the PTFE and unscrew it? Obviously, there’s going to be various reasons this can happen, but is there an average in your experience so that you have to go back in?

[Devang]
Well, I would say less than five percent. So you don’t have to do too many times, like less than five percent of the patients would need me some inter- and generally there is a reason behind it. Either they chipped something, there is an inflammation or they have some sort of-

[Jaz]
Screw loosening.

[Devang]
Have done or something. Yeah, screw loosening. Screw loosening is more prevalent with the implant with the butt joint than the conical connection. So if you have a conical connection, screw loosening is much less unless the occlusion comes in a way.

So if occlusion changes, then there is a screw loosening. So these are the reasons. Generally, I would say posterior teeth, you get more through loosening the anterior teeth again because of the occlusion, but yeah, so not very often if patient comes in for a review, so that’s really, as you said, timely question.

So the next thing is really a Maintenance. When patient come in for maintenance appointment, right? So now you’ve seen patient, torqued it, filled it. Now I would tell patient that, okay, I’ll see you in a year’s time. So I’ll see patient in a one year time for a review. So when the patient come back for a review, in a year’s time, I would make sure that I’ve done the full assessment, I gain occlusion.

First thing I check because that’s the thing support probably would have changed. I would assess the pocketing. Now, there is a controversial thing where there are some people recommend to pocket probe around the implant. Some people don’t recommend probing around the implant. And there are two different camps.

I gently probe around the implant because without that you’re kind of blind. But I’m not going to worry too much if my probe goes down as far as there is no bleeding because you need to imagine that the implant is quite subcrestal. Crown and abutment almost will be four millimeter before it emerges out from the gum.

So three to four millimeter. So pocketing of three millimeter is not really a pocketing. You’re going towards the implant level really. So, plus it’s very difficult to probe because of the convexity of the crown. So you don’t know. So what all I’m checking is when I do probing, is there bleeding or not.

I’m checking that I’m taking a radiograph to assess the bone level to make sure everything’s fine. Checking occlusion, checking mobility of the crown. So make sure you check. literally grab the crown and just try and move it to make sure that it doesn’t move. So these are the main checks I do with regards to implant restoration. Now, if there is a bleeding and everything, we can then discuss next, but it’s very simple, few checks when patient comes back for a review. So it’s nothing really complicated.

[Jaz]
And at this point, how many years would you continue to see this patient for? For doing that protocol and for how long do you take PAs for? Is it every year for five years or any guidelines on that?

[Devang]
Yeah, so generally the protocol which I’ve read in old ADI website, I think it’s still valid, is that you need to do it for two consecutive years. And if you don’t see any changes in the bone, everything’s fine. Then you can do it every other year, every three years or something like that.

So you don’t need to take it every yearly radiograph. I give after two years. So I would do it for two years. After second year, everything seems fine. Then I give patient an option. I tell them that, okay, you have an option. You can either see me every two years or you can either see me still every yearly.

I personally prefer to see patient yearly. Like, nice guidelines about patient. Some of the patient. You can-do two-yearly checkup, right? If there is a very low risk of caries, just generally, generally. Yeah, I just don’t agree with that personally, because there’s so many things can change in two years.

People, lifestyles can change. Their habits can change. So, you don’t know what you see. In two years time, things can be completely different. So I prefer to see patient on a yearly basis. And I tell them that, look, you’re paying me whatever review, assessment appointment for like five minutes for me to have a look in your mouth.

But I would rather you do that. Then I have to work hard in your mouth because you cause some problem. But it’s entirely up to you. If you want me to see you, I would prefer to see you. But if you say, look Dev, I want to save money and let my general dentist assess my implant, then that’s fine.

So I give them an option after two years. First two years is kind of non negotiable. So I tell them and they’re generally happy with that. And then after two years, some patients would be like, look Dev, there’s nothing wrong with it. I don’t even know which tooth is implant. And also if the patient is our own patient, then I feel a bit more comfortable because all our associates understand how to assess implant. So I’m comfortable referring them back to their dentist. And I know that if there is any issue, the dentist will refer a patient back to me.

[Jaz]
Amazing. So that’s the maintenance capped up there. And then troubleshooting. I mean, one thing that I wanted to ask you by saved it for troubleshooting is a scenario whereby you’re placing the crown back from the lab and you’re getting maybe excessive blanching, or the soft tissue is just, it’s impeding the seating of your crown too much. At which point do you get out the laser or do you get out some sort of a gingival removal? Is that something that you want to cover?

[Devang]
Yeah. Okay. So it generally doesn’t happen. The reason being that if I feel that I want a bigger emergence profile, I would have put a bigger, wider healing abutment to already while when I do the second stage surgery for me to get the the structure of the gum ready for my final crown.

I sometimes do custom abutment if I feel that I want a better emergence profile. So I would have done all that before I fit the crown in. So it would have been done before. It used to happen when I started restoring implant where I would use your wrong healing abutment, like a very small one, because like if you use a big healing abutment during the second stage.

You need to know how to close the wound if because it’s difficult to close it before the big healing abutment. So I used to use a small healing abutment so I can close the area nicely. And then when it comes to doing fitting of the crown, crown would always be like really really stretching the gum. So no laser, nothing.

I would give patient obviously LA by this time patient would have been pain anyway. So you need to give patient LA, use a blade to just put into proximal incisions to sort of a crestal incisions, loosen the flap a little bit and put the crown in. So what will happen is the ground gum has become loosened.

You literally move the gum, crown goes in. If you feel that it’s opened up the flap, then just a couple of interdental stitches and then that’s it. If it’s not, then you don’t even many time need to use the stitch. It will have a small gap interproximately which will heal by secondary intention. Okay? Does that make sense?

[Jaz]
Okay, very good. What other complications do you want the general dentist to know about?

[Devang]
Okay, so there are 6 plus 1 because you discussed last time about the open contact points. So we’ll cover that. So let’s start with that. So, apart from high occlusion point, which you must check because you will see much more commonly than normal.

And this is when you would understand that occlusion is very dynamic. It keeps changing. So, this is when you realize because implant doesn’t move. And then if you know, you’ve made sure you got 30 micron clearance and patient comes back in a year’s time with a high occlusion on that tooth, you know that something’s changed.

That’s the main thing that’s the most commonly happens. So I would expect that on my review appointment. The other thing can happen is open contact points. Now there have been studies done and we know that the teeth have the tendency to move mesially. So there is a higher probability with the molars.

There is lower probability with the premolars and the higher with the molars because of the bite and everything that there will be mesial open contact point at some point in next 10 years. Okay. The studies done for five years and the probability was probably, I think it was 38% to 42% that there will be some sort of an open or light contact will develop.

However, the good thing is they could not find any correlation between open contact and peri implantitis. So, they didn’t find any correlation between open contact and any issue with the implant itself. So that’s a good thing, but obviously, nonetheless, that can happen. The other scenario can happen where there is a space distal to the implant.

So if I placed restored 6, there is open contact between 6 and 7. There is no clear cut answer to that. There is no study suggesting, oh, if this happens, you do this. What’s clear is that the occlusal splints doesn’t work. So if you give patient Essix Retainer, it does not work. But you by all means give them just for your security.

So what are the other options? Someone has suggested that if there is a space between 6 and 7, you could do occlusal adjustment so that 7 is not as high, not too much load on the 7, because the theory was that because of the occlusion, because of the closure backwards, causing the space in the front.

So you can, if you need to see if there’s a first point of contact on that seven and that’s causing the space. What I have done in past is I’ve done two things. One is if it’s a light contact, then I don’t do anything. Just leave it and monitor it. If it’s open contact, then I have done in past, taken the crown off and send it back to lab to add some material on there, which is a lot of faff. What I’ve done in past is this is a normal tooth on either side. Then I would add composite to the interproximal surface of the tooth. So to close the contact, basically you take the can off, add some composite to close really.

[Jaz]
That’s what I’ve done before actually. Like if there’s a DO composite and then you just make the DO wider.

[Devang]
But none of the study mentions that, you know. So then you’re thinking, am I doing the right thing? But that’s the logical thing to do, really. There is no clear-cut answer, if that makes sense. So does that answer your question?

[Jaz]
Fair enough. What are the other three?

[Devang]
So the number one scenario, which is not really a complication, but it’s a scenario where patients come to you, and patients, because they love you so much, they want you to restore their implant. So someone else has placed the implant or someone has already restored the tooth, but the tooth is fractured, porcelain is chipped or whatever.

And now patient wants you to restore that implant. What kind of information would you need? So first of all, when patient like that comes in, I might always, even though I can restore implants, might always go to suggestion for patient is to go back to the dentist who’s placed the implant. Not because I don’t want to take responsibility.

Especially whether it’s in UK because it will be cheaper for patient to get it replaced by the dentist who is referred. So now if I have done the crown if patient comes back to me within like less than 10 years time and needs a new crown because I’ve done it. I have all the instruments. I have all the healing abutment.

I have impression post. I won’t have to source it If that makes sense. So my life is easy. So I generally don’t charge patient much more than a normal crown fees. But if patients coming to me and with the implant, which I don’t restore generally, I would add probably four or 500 pounds more.

Because I need to source all the material. I need to call the rep. I need to get the impression post. I need to get the drivers.

[Jaz]
Devang, I think that’s totally fair. Like, it’s kind of like an inconvenience fee, right? Because you’re seeing someone. It’s like the patient may know you and love you, but it’s the tooth. The implant is still a stranger to you. So I think that’s completely justified. I think you had two more complications you wanted to cover. And I’m going to then go back to complication number one. I just want some more information about that. But let’s just finish off the two complications.

[Devang]
Okay. So, so this one actually, so I just took, close this conversation, this first one, the patient’s coming, you need to know few details before you can restore the implant, right? So you need to make sure that you know when the implant was done. What, when was it done? So if it’s like 15 years ago, you may have an old implant. You need to know, you need to do clinical assessment to see is it viable for patients to spend another 1500 pounds to restore the tooth with implant crown.

You need to take periapical radiograph. And I take a small CBCT to really check the implant, because I don’t want to charge patient 1500, load that implant and then realize the implant fails because there is no bone.

[Jaz]
Do you not get like lots of scatter from the implant? Is it possible to get this data?

[Devang]
Yes, you can remove scatter from implant sort of smart CBCT assessment softwares can remove, scatter enough for you to know roughly. Now, if there is a one millimeter bone buccally, you will not be able to see it, but generally you will get an idea, vertical height of the bone. You’ll get some idea of the bone.And then you need to make sure you know what type of implant it is. If unless you know what type of implant is it? You can’t restore it. And then, as I said, you need to consider the fees.

[Jaz]
Do you use that website Devang? What’s that implant dot com or whatever?

[Devang]
Yeah, I know it was helpful to me. Like there’s so many, so many implants in there. You get locked down.

[Jaz]
They all look the bloody same.

[Devang]
Same. Yeah, they all look the same. So what I do is I go by when was the implant done. If it’s pre-2005, then it is more likely possibly Nobel or Straumann, some sort of a older companies. And I ask around most of the time, someone from the group somewhere would know what implant it is.

[Jaz]
I think there must be some AI now that there must be some AI where you upload your radiograph and the AI will tell you which implant that is, rather than, I know that’s the whole point, the website, but then he still gives you some options, but now it just does all the work for you. It actually tells you, is this implant?

[Devang]
Yeah, that would be amazing. So the second most common complication you would come across when you are doing screw retain restoration is the screw hole comes out from the buccal aspect. Okay, so if the implant is not in the right position placed not in the right position and you want to make the screw retain crown, but the screw access hole is coming out buccally then if you’re restoring central incisor, you can’t really restore the incisor with the aesthetics. So then you need to do an angle correction.

So in angle correction is all it is, is basically a screw head and a special screwdriver where that screw driver can engage that screw head at a certain angle. So you can tighten, you know, usually to tighten the screw, you need to go 90 like straight to the angle of the screw head and then you tighten the screw.

Now, if you want to tighten the screw with the 25 degree angle. You need a special screw head and special screwdriver so you can avoid the angle. You can still tighten the screw because the fact that the screw needs to go into the implant doesn’t change. Implant doesn’t change where it is. So now you need to, you’re thinking about the excess of the screw hole and if you have a special screwdriver, then you can, and that’s all is angle correction basically.

So you’re not angle correcting implant, you’re angle correcting, not even a screw, you angle correcting your screwdriver so that your screwdriver can fit into the screw at 25 degree angle. Does that make sense?

[Jaz]
It makes sense to me but this is all so that we can still do it in screw retain and avoid the cement retained.

[Devang]
Cement retained, exactly. Now the other option is you can go straight to cement retain, avoid all that issue and cement retain crown. But now 25 degree screw channel angulation correction is very common nowadays and very predictably done, so I wouldn’t hesitate doing the angle correction. Now-

[Jaz]
And this is all, like, all the hard work here is pretty much done by the lab, right? You’re just writing on your prescription and they just send you it, so really-

[Devang]
You’re not even writing it.

[Jaz]
Your steps aren’t, yeah, okay, the lab will know, yeah.

[Devang]
Yeah, you’re just telling them, I want screw-retained crown, so the lab should call you saying that, look, the crown needs angle correction. Most of them, the problem is that the lab doesn’t call you. They will just use angle correction screw and send it back. And now you’re thinking, oh, my screwdriver doesn’t fit into the crown because you’re using normal screwdriver. Lab hasn’t told you that they’ve used an angled screw and you need an angled screwdriver. I had a dentist who fitted the crown.

What happens is the screwdriver, normal screwdriver, went into the screw and half turned the screw in. Now the dentist couldn’t turn it back off and couldn’t tighten it either. So the patient came with a dangling crown to see me. Just because I had this, so, lab communication is really important.

So lab must tell you what screw they’ve used so you can use appropriate screwdriver. But you’ll be surprised how many times labs don’t tell you, give you the information.

[Jaz]
And this is like all part of the kit, like, whichever implant system you use, you got like different degrees of angles of screwdrivers. Is that right? Is that how it works?

[Devang]
No. So again, no, it’s a separate kit. So you need to buy a separately that screwdriver depending on what screw channel. So the lab would have tell you that they’re all same, angle corrective screwdrivers, you can use one angle corrected screwdriver for everything. It’s not true in my book I’ve got several screwdrivers lined up and you can tell that they are different heads. So you need to know-

[Jaz]
Is there a 15 degree one different to a 20 degree one different to a 25 degree one?

[Devang]
Yes. But in similarly like if you have a 25 degree one, you can use it for 15 degree correction. Does that make sense? It’s not like that. So but Straumann has their own angle correction screwdriver, the Createch lab, which mills the thing in Spain, they have their own angle corrected driver, Bio Horizon they have their own, Nobel has their own.

So it’s a plethora of angle corrected screwdrivers. Now if you can’t angle correct because it’s more than 25 and you still want to do screw retain crown, then what I have done in past once is when patient came to see me where her bridge was de cementing. Someone else placed the implant, cemented implant bridge, de cementing.

So we wanted to make a screw retained bridge and the screw hole were coming out buccally. So we made a composite bridge. So metal framework with the composite on top with the buccal screw holes. I tightened the screws and did a buccal filling, buccal veneer on the thing. So masking the screw hole. Okay, so it’s a composite bridge. And that’s the compromise again. Where you cannot really even angle correct.

[Jaz]
Okay. And it is a composite bridge because you were able to then use your direct composite to fix it.

[Devang]
Yes. To fill the hole. So that’s the really, the main complication if you want to make a screwin crown would come across. Now the long term would be really generally two things. Screw loosening we already discussed. But when you, when patient comes with a screw loosening, you need to make sure you take the crown off. Don’t just tighten the screw because food and back, everything would have gone under the crown.

So take the crown off, clean it with the brush, disinfect it with the chlorhexidine, clean the area of the gum, everything in the implant, and then fix the crown back in again. Don’t just, like, screw the crown in. Okay, because you are then pushing all the bacteria back into the screw channel. So you need to disinfect, dismantle everything, clean it and put it back in.

[Jaz]
And then thoroughly check the occlusion again.

[Devang]
Yes, 100 percent. Yeah, 100 percent. And there will be some issue with occlusion unless there was issue with the contact points. And then obviously there is a bleeding. So if you feel that there is a bleeding around the crown. Give it a good clean using either titanium instrument or the plastic instrument, which I find plastic instrument a bit of rubbish. They don’t do anything. So you can’t use ultrasonic around implant because it just scratches the implant surface and the crown.

So you need to use titanium instrument or they are like a jet wash sort of a perio jet instruments around. So you can use that to clean around it to break the biofill, but it still doesn’t work. Give patient oral hygiene instruction If it still doesn’t work Then you take the crown out, scrooge and crown, put the healing abutment back in again and let that heal because sometime I would notice that patient hasn’t been good and they start, there is inflammation. And the cycle starts because there is an implant crown, patient can’t clean properly, patient can’t clean properly, there is inflammation.

So you need to break that cycle by just taking the crown off and giving the healing abutment. That leads to another important thing, that when you finish treatment, give patient everything back. Which means you give patient, most of the components, the implant companies are clever, they are 2-cross. So in the sense you can’t reuse it anyway.

So you can’t reuse healing abutment, you can’t reuse impression post. So I give everything back to patient. I can’t store everything everywhere anyway. So I give everything back to patient, including their provisionals, which I give if they needed one, which I give them back and get them signed that paperwork that they’ve got it.

So if I need to remove the crown back, I use the same provisional which I fitted before. So if I’ve given them denture, I fit the denture back in because they need some, if it’s an anterior tooth, they need some sort of a provisional, right? So they don’t have to pay again to make the new provisional.

[Jaz]
And at what point is this implant passport that I’ve heard about? Giving patients so they have this information carry around? Is this something that you do? Is it something that’s company specific? How does this work?

[Devang]
I don’t do implant passport. So I do like every company does it. But what I tend to do is I do this where at the end of in a discharge patient, when let’s say, the eight weeks appointment review appointment, I’ve talked everything at that discharge appointment, I give them a clinical log sheet.

So I have a log sheet with the stickers of the implant and components and everything. So it’s a A4 size paper with the table on it. And I scan that and give them that. And I give them the consent form saying that I’ve hand over all the lab work material and what I have given it to them.

Everything’s in there, patient sign it and take it. So that’s all with the patient. So patient knows, but most of the patient, they end up losing the information and calling the practice if it’s needed. But at least you’ve given them the information. So I think these are the really the main complications which you need to be aware of.

[Jaz]
Well, the only one I had a question about then is, again, about frequency of things, right? As someone who doesn’t routinely restore implants, I’d like to get an idea of how frequent it really helps when you give me a 5% of the time, 10% of the time. So this thing about constantly, dynamically checking the occlusion to make sure that things are no longer proud where they weren’t before because things are always changing.

How often do you think there will be some adjustments being made? For example, you see a patient annually for the next 20 years. Is it that every patient for every 20 years you’ll need to do a little tickle or certain percent of patients for certain years? Any guidelines on your experiences?

[Devang]
So my experience is that some patients are more prone to the others. So I have one patient every time I see. Occlusion is a little bit high every time I see, but majority of the time, let’s say you will have 70% of the patient, nothing would have changed. Let’s say in five years, maybe one time adjustment, maybe.

[Jaz]
Okay.

[Devang]

I haven’t been placing implant for 20 years, so I can’t really, I’ve been placing for 13 years. So I can tell you 13 years experience. So it’s probably five years, I would say yes, but there will be 20% to 30%, which is still a high number of cases where you will have to adjust it. Maybe every other year, if you, or every three years.

[Jaz]
That does help. It just highlights the importance of it and highlights the frequency of it. And I think in terms of a common complication, which if it goes undetected, can lead to more porcelain chipping, screw loosening, and maybe even overload and failure. Dev, you’ve covered a lot in these two episodes, as I always like to ask my guests, where can we learn more?I know you, you mentioned the book a few times, your occlusion, your FMR book was a huge success. Tell us about the implant book and where else we can learn from you.

[Devang]
So the implant, yes, I’ve just finished writing an implant book and this time the implant book is part of my full core course. So the way I’ve structured this is I have an online course implant book and a hands on course.

It’s a full circle where if someone comes into that, they will end up restoring implant by the time they leave and finish the course. So if they need more information, then I’m available on social media or they can contact me at info at drdevangpatel.com.

[Jaz]
Any website yet?

[Devang]
So I, yeah, I have a drdevangpatel.com website. So it’s www.drdevangpatel.com. That’s the website.

[Jaz]
I’ll put it in the show notes. So you can just click on it and the implant restorative course is on there?

[Devang]
Yes. So it’s coming soon of course. So it will be launched by end of August.

[Jaz]
If you guys don’t know Devang, like he’s such a brilliant educator. He gives all his delegates so much of himself and his energy. Like he, as you know, already, he gives all of his patients his mobile number, right? You said that, right? And I’m pretty sure you give all the dentists your mobile number as well. So you must be like the busiest guy ever which I know you are.

But you will always go out of your way to help a dentist. So if you’re always looking for people to learn from, Devang is very, very good person to, as a mentor in any realm, where there’s FMR implants. So, I appreciate everything you’ve done in terms of giving to the Protruserati, all this knowledge and for some of them who need handholding.

I was strongly encouraged to look at Devang and it’s a big topic. Where do I learn restoring implants from? So, I’m hoping they’ll be able to learn those things from you because you’re so good at supporting them. You see?

[Devang]
Yeah, I hope this two episode would help them as well, because as I said, my aim is to give everything and then some people would just say the episodes enough and that’s fine. I don’t generally hide anything. So, it’s not like you come to my course, I’ll give you more. It’s everyone should be, you get information in all sorts of formats.

[Jaz]
It’s like case specific, right?

[Devang]
Exactly.

[Jaz]
Case specific. And there’s so many nuances to every single individual case that can’t be covered in an episode. And that’s where if you’re taking this seriously, but you need a course or a mentor, that’s where you come into equation. So I’ll put all the links below. Dev, thanks so much once again for really wowing us. You did the whole FMR series many episodes ago, and now they’re storing implants. I don’t know how you find the time to write these books and do these things.It’s quite spectacular. So, kudos, my friend, but keep going, my friend, keep going, because what you’re doing, the energy you’re putting out to the world, it really helps all dentists.

[Devang]
Thanks for having me, Jaz. And thank you. I’ve learned a lot from the community itself as well. So thank you again for giving me the opportunity.

Jaz’s Outro:
Thank you. Well, there we have it, guys. Thank you so much for making it all the way to the end. Remember, you can download a guide or a summary and aid memoir of the previous two episodes by going to protrusive.co.uk/idiot. Now, if you’re someone who hasn’t reviewed the podcast before, would you consider reviewing it today?

I’d really appreciate that. So whether it’s on Spotify or Apple or wherever you get your podcast, consider leaving a review if you learn something with me and Dr. Devangkumar Patel. And again, thank you to Devang for being a brilliant guest, not only in this series, but also the Full Mouth Rehab in 11 appointments.

If you haven’t heard that series before in the podcast, do check that one out as well. If you’re part of Protrusive Premium, you can answer a few questions and get the CPD, like you’ve already listened to it. Just verify your learning, do the reflections, and you’ll get your CPD or CE certificate. And that of course you can access on the web on protrusive. app, that’s protrusive.app, or on your app, whatever you prefer. I’ll catch you guys in the next episode of Protrusive.