First two cases with NobelPearl™ completed in Ireland – Dr Wilson GrigolliFeatured Products Promotional Features
Posted by: The Probe 5th November 2018
Dr Wilson Grigolli was the first oral sugeon to perform treatment using the brand new NobelPearl™ceramic implants in Ireland. Here, he presents his first two cases.
A 46-year-old female patient presented with a missing upper left central incisor, for which she was using an acrylic partial denture (Figure 1). The extraction was performed four months previously in another practice, following failed root canal treatment.
Assessment and treatment planning
Our clinical assessment revealed reduced bone volume on the buccal aspect (Figure 2-3), minor gingival recession and healing tissue on the extraction site, which was asymptomatic.
Due to the significant aesthetic demands on this case, the NobelPearl ceramic implants were an ideal solution and so surgery was planned with RP 4.2mmx14mm implants. We also intended to include a xenograft to enlarge the buccal bone volume and improve soft tissue management for an enhanced smile line. The patient’s own acrylic partial denture would then be adjusted right after the procedure so it could be used as a provisional prosthesis during the healing period.
When the patient returned for the surgical appointment, Articaine 4% anesthetic was administered and a conventional local technique was performed.
A full thickness flap was raised (Figure 4). The design of the flap was respectful of the original margins of the natural gingival tissue, extending onto the adjacent teeth. All fibrotic healing tissue was then removed, allowing full access to the remaining bone structure.
Using the unique NobelPearl surgical kit (Figure 5) the recommended drill sequence was followed. The first mark was performed with a round bur, followed by a tapered twist drill with 2.3mm diameter, in order to set the depth of the preparation (Figure 6).
According to the clinical situation and supported by the OPG data, the chosen depth was 14.0mm with up to 1.0mm of the implant collar below the bone level, which was indicated by the soft tissue thickness and final rehabilitation goal. The drilling sequence was therefore continued with the tapered drill NP 14.0mm, over drilling by 1.0mm to accommodate the supra-bone placement (Figure 7), and sequentially the drill RP 14.0mm. The depth and angle were double checked using the Depth / Direction indicator WP (Figure 8).
The next step was to use the RP screw tap, which is essential in the placement of the NobelPearl implants (Figure 9). Figure 10 shows the bone structure after the use of the tap, demonstrating the threads marked on the bone surface, concluding the bone preparation stage. The implant packaging (Figure 11) was carefully opened by the second dental nurse and the implant was captured using the implant driver, already engaged on the handpiece (Figure 12).
The implant was positioned on the prepared site and the insertion torque on the drilling unit set to 40N. The ceramic implant insertion torque cannot exceed 45N in any circumstances.
The implant was placed and both the positioning and torque were manually confirmed with the wrench. The final position means that only 0.6mm of the implant collar was supra-bone, as planned (Figure 13).
In this case we chose to immediately place the healing abutment, 3.0mm height, made of PEEK (polyether ether ketone) and organic thermoplastic polymer, tightening it in place with 5N torque (Figure 14).
The next stage was to perform the bone graft on the buccal aspect. A creos xenograft from Nobel Biocare was carefully placed over the defect – small particles mixed with saline solution – covering all the implant threads (Figure 15). Any excess graft material was removed and the material reshaped. The flap was then replaced coronally to match the gingival margin and sutured into place using Vycril 3-0 (Figure 16).
The patient’s original partial acrylic denture was adjusted and replaced as a provisional prosthesis (Figure 17). Due to the grafting procedure, it was decided not to load the implant immediately, allowing two and a half to three months for healing. A final OPG was taken to confirm implant position (Figure 18). Post-operative instructions were given to the patient, and a review appointment was scheduled for a week later.
A 36-year-old female patient presented with a missing lower left first molar. The extraction was performed in another practice a few years ago and she was using no prosthetic device (Figure 19).
The clinical assessment revealed good width and length of bone in the area (Figure 20). There was also good quality gingival tissue, including an adequate margin of keratinized tissue.
In this particular case, the patient requested a metal-free solution and as it required a single implant, the NobelPearl ceramic implant was well indicated. Due to the crown surface area on the final rehabilitation, a wide diameter implant was indicated so the NobelPearl WP 5.5x10mm implant was selected.
The same basic surgical and technical protocol was followed as in the first case and a full thickness flap was raised (Figure 21). On the drilling sequence, the WP tapered drill – 5.5mm in diameter, 10.0mm long – was added to accommodate the larger implant diameter. The site was over drilled by 1.0mm (Figure 22) so that the implant collar could be accomodated and it was subsequently tapped (Figure 23). A PEEK healing abutment 5.5mmx3.0mm was placed (Figure 24), the flap was sutured closed (Figure 25) and a final radiograph taken (Figure 26).
The all ceramic system was artistically designed, being extremely precise, intuitive and easy to handle in surgery. Having been an oral surgeon for almost three decades, I am sure this technology will soon be widely used. The titanium implants have their place for sure, but in highly demanding cosmetic cases, or even for a metal-free, holistic approach, I think the ceramic implants will quickly grow in popularity. As any other surgical technique, experience is essential and planning fundamental.
For more information, contact Nobel Biocare on 0208 756 3300, or visit www.nobelbiocare.com/pearl
Wilson Grigolli – DMD, PhD.
Specialist in Oral Surgery – Dental Council of Ireland- 16DS17
Wilson has finished the Dental School at the Sao Paulo University, in Brazil, in 1989, and since then he is focus on Oral Surgery and Oral Implantology fields, holding also a significant experience as Adjunct Professor. With a large clinical experience, more than 27,000 oral implants placed, Wilson has been working in Brazil, Portugal, and Ireland; including directly with Professor Branemark.
Currently, he is the Head Implant Surgeon at the Ratoath Dental Centre, Dental House, Dundrum Dental Clinic and McMahon Dental in Ireland, and also responsible for several clinical courses in Lisbon, Portugal, being official lecturer of Nobel Biocare Portugal.
Wilson also holds Master and Doctoral degrees, and three specializations: Oral Implantology, Oral Surgery and Periodontology.
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