From 17 to 19 July 2014, Dr Jean-Louis Zadikian in Sarcelles, France, together with his team, treated edentulous patients free of charge for three days. 14 patients were selected beforehand and operated on in his clinic which is also home to the AFOPI Campus (Association Française des Omnipraticiens Pratiquant l’Implantologie). All patients were given a bridge fixed to implants in both the mandible and maxilla. The remaining damaged teeth were removed and immediately afterwards the implants were placed. Immediately after the surgery, the prosthetics laboratory made the new temporary teeth which were fitted in the patient the same day. The temporary remains in the mouth for 3-6 months before it is replaced by the final prosthesis.
A SYMPHONY OF TREATMENT WORKFLOW, PRODUCT DESIGN, MATERIAL AND SURFACE
The Straumann® Pro Arch solution is based on the treatment concept introduced by Paulo Malo (Malo et al., 2003b) and offers a safe, reliable and less complex treatment option for patients requiring full-arch treatments. Patients and clinicians benefit from the combination of the individualized prosthetics and the surgical advantages of the Straumann® SLActive® implant surface, as well as the unique material properties of Roxolid®. In combination with the Straumann® Bone Level Tapered Implant this solution offers the perfect symbiosis of treatment workflow, product design, material and surface: excellent primary stability even in compromised bone situations surface properties designed to maximize your treatment success and predictability.
The Straumann P2P (Peer-to-Peer) program started around 2 years ago and is currently expanding worldwide. Thanks to the Straumann Research Team and the local distributor in Poland, 15 surgeons with a high level of clinical expertise were identified, and they then participated in a clinical investigation to develop further the Pro Arch surgical technique. From the initial pilot cases to the calibration of the peers, the project culminated in an in-line case series in which 27 fully edentulous cases were fully rehabilitated and documented in 4 days (Hotchkiss et al., 2016).
Dr Zadikian‘s event attracted great attention in the French media and the television recordings went out at prime time. Not only because of the fast treatment procedure but also because “Un jour, un sourire” (“One day, one smile”) is a charitable project. None of the participating patients were in a financial position to pay for such treatment and they received everything free of charge. This was possible only because the teams – dentists, dental technicians and clinic staff – gave their time and the industry partners provided all the material free of charge. For this action, all implants and the corresponding components were provided by Straumann. For years, these patients struggled with their old prosthesis for various reasons, suffered pain and neglected their social life. The moment they were able to look in the mirror and approve of their new teeth compensated these people for all the stress during the surgery as they know that a new life has begun for them.
“Straumann has succeeded in reconciling biology and mechanics”
Dr Zadikian, could you tell us something about the AFOPI?
I’d be happy to. The AFOPI is the French society of dentists working in implantology and was founded in 2004; this year we celebrate the 10-year anniversary. The aim of the AFOPI is to develop implantology in France. For this purpose, private training courses at different levels and on various topics are offered and about 120 dentists take part in these every year. The strength of the AFOPI is the learning support which is based on the value of sharing.
The AFOPI Campus is a place where students are able to put into practice what they have learned. This offers them an invaluable opportunity to gain hands-on experience after training. The support also continues after the conclusion of the course. Ours is an “open” clinic where colleagues can come to fit their patients with implants. We also organize operations, like right now, so that our colleagues can practice implantology at a really high level. 94 % of practicing dentists who have registered for our courses insert implants.
One of the aims of this platform is that a patient who has lost his teeth will no longer leave after his extractions with a removable temporary restoration but will directly receive his temporary implant-loaded teeth the very same day. We develop and practice methods that involve specialized areas of extraction, implantation and immediate restoration.
You are set up here like a dentist’s office?
The AFOPI Campus is an eight hundred square meter technical platform consisting of ten operating rooms, a prosthetic laboratory and two scanners. We therefore have everything we need, in one place, to enable us to replace damaged teeth immediately. There is a dedicated conference room for courses and for viewing live transmissions of surgical operations.
Where do your patients come from?
We have patients from all over France because we provide solutions that meet their expectations. For instance, there are cases of patients whose teeth are all irreparably damaged. 10 years or so ago I would extract the teeth and use a removable prosthesis during the healing process, which is the conventional way. Then I would place the implants and we had to wait another six months before these could be restored with a fixed denture. But, since 2006, due to the discomfort of this method and the length of waiting time, I have been offering my patients quite a different protocol which involves extraction and implantation in one session, followed by immediately fitting temporaries, in just one day, either in the mandible or the maxilla, or both at once. We have developed a procedure that allows us to make great headway in this area. On the AFOPI Campus, in a parallel restoration of both the maxilla and mandible: we get the patient to come in at 10 o’clock in the morning and by 6 p.m., the teeth have been extracted and the implants placed. This service is offered by very few and that is why we have patients from all over France and some even from abroad, who would like to benefit from this.
Please tell us about “One day, one smile”.
Now, this is already the second edition. We organize this “One day, one smile”, because these procedures are our core competence – we perform these procedures all year round. We therefore offer selected patients this one day to find their smile again and naturally get back their chewing function. We named this action “Un jour, un sourire” in French. In our clinic we regularly see patients who do not have the means for these relatively expensive treatments. Because things are going very well for our team, we asked ourselves what we could do to pass on the happiness we experience with other patients to patients who cannot afford implant-borne restorations. We therefore decided to make three days available once a year when we would operate on as many patients as possible and fix their teeth for free.
As many patients as possible in three days – that sounds a bit like an assembly line…
That’s true: bimaxillary treatments in 14 patients in three days are a real challenge. However, I am not alone at the helm but we have succeeded in assembling 60 dentists from France and not least from abroad for this occasion. Since our campus maintains a partnership with Rio de Janeiro State University, two professors came from Rio and a professor from New York University was also there. So this is by no means “mass production” – everyone has his own patients. Moreover, an action like this is possible in this clinic because we have ten ORs and in this way we can treat 14 patients in three days.
There is personal care, as I have seen. You have someone who receives the patients and assists them with their concerns and questions.
Yes, that is important for us. We already carried out a detailed pre-implant study, drew up implant plans and recorded the data pertaining to each patient that we needed in order to make the new teeth and produce the multi-functional guide necessary to insert the implants, capture their positioning and transfer the data using a corrected model (method taught at the AFOPI Campus). We had therefore done a lot of work in advance. In addition, we were assisted by of one of the patients who was treated when we performed the first operation. This is a woman who has a beaming smile today and is now the operation’s godmother so to speak. She looked after all the patients, saw them before the surgery, chatted with them and reassured them. We tried to do everything so that these patients really experienced a VIP treatment just like paying patients and follow-up care is just the same. Their aftercare is no different because this treatment was free of charge.
A year and a half ago we performed the first surgery series and this was reported in all the media in France. It was on the television news on many TV channels, in the newspapers, and many patients called us afterwards and said: “Oh, we didn’t know about it and we missed it! Will it be repeated?”
What are the criteria for selecting the patients?
A year and a half ago we performed the first surgery series and this was reported by all the media in France. It was on the television news on many TV channels, in the newspapers and many patients called us afterwards and said: “Oh, we didn’t know about it and we missed it! Will it be repeated?” Finally, more than 90 people contacted us about this. And there was a lot of work with these 90 people as we examined each one of them in the clinic. We took X-rays and CT scans, did a preimplant examination and then chose 14 of these patients. We selected these 14 carefully. The clinical selection criterion was to identify the most severe cases – with regard to the patient and the surgical difficulty. We really did take “hopeless” cases – patients who, under the classical protocol, absolutely had to leave us with a denture even if this meant bone grafts for some of them. We will try to treat the candidates who were unsuccessful in another series of surgeries.
Apart from the immense technical resources that the AFOPI Campus offers, are there other factors that make such an action possible?
For this action to be possible, we needed industry partners to provide us with the material free of charge, as treatment even in a favorable case costs at least 25,000 Euro. These patients cannot afford such treatments. We therefore turned to our suppliers, and in particular to implant manufacturers like Straumann. I should like to take this opportunity to express my thanks to Straumann because without them we would never have had the necessary implants. Straumann not only supplies us with the implants free of charge – they also understood that in 14 patients 240 implants have to be placed in a short time. One can’t say two months in advance: “I would like this size, that diameter” – with rigid planning and without flexibility. We therefore received more implants than necessary from Straumann so that we had a stock that we could choose from at the last minute, e.g. whether to use a length of 14 mm rather than 12 mm. We had every freedom for tailored treatments and the implants were selected as the case required. That was essential for us.
So system flexibility is important for you?
Yes, and what I am particularly happy about is that volume augmentation, that is, bone grafts, would have been necessary for our selected patients if they were having conventional treatment, given the waiting time necessary with a removable prosthesis prior to inserting the implants. Furthermore, we avoided our patients undergoing more invasive treatment and for the thickest distal implants we were able to use Straumann® Narrow CrossFit®, that is, narrow implants. The special feature of these implants made of Roxolid® is their superior mechanical strength. Because of this, we are able to place these implants confidently in the posterior areas and for this reason we do not have to undertake volume augmentation. We have made real progress and are now able to perform more complex and at the same time less invasive procedures. With these innovative techniques we can reduce both the number of procedures and the healing time. This is why we used SLActive® because with them healing time is one month, meaning that they become operational more quickly so they are functional sooner. In this operation, we really used the best material that exists today to treat our patients.
In this operation, we really used the best material that can be imagined and treated our patients like VIPs.
How were you able to recruit your colleagues for this action?
60 dentists from all over France helped and I cannot thank them enough. I should like to comment that these were dentists who attended our courses so they are familiar with these techniques. Of the 120 dentists who come to courses on the AFOPI Campus every year and who are members of our association, it was not difficult to mobilize 60. We simply sent out a letter and stopped recruitment very quickly after the first 60 replies.
Could you imagine this action taking place elsewhere?
Yes, that would be my dream, to extend this surgical method “one day, one smile” developed at the AFOPI to other technical platforms. There are other implantologists practicing in and outside France who use these techniques. And I should be very happy if we could some day carry out this action in different centers and on an international level – so perhaps several platforms performing these surgeries the same day.
I should be very happy if we could some day carry out this action in different centers and on an international level.
Could you describe the procedure and the technique that you use?
The patient comes to the clinic, we do a CT to examine the bone volume and perform the entire pre-implant examination. At the same time, we take impressions, make study models and then a wax-up. The data is used to enhance the aesthetics. A key stage to attaining immediate aesthetic success as teeth will not be extracted until the day of the operation so there will be no trial prior to that. We have planned the project like an architect building a house. For this purpose I have developed a special multifunctional guide: we can use this, for example, to make the incision lines, optimize the soft tissue, determine the direction of drilling and also to capture the positioning of the implants.
The purpose of this stage is to provide the prosthetic laboratory with as many elements as possible so the new teeth can be made in one to one and a half hours per maxilla. What makes the prosthetic laboratory original is that a maxilla and a mandible are treated separately by two people at the same time. It is then that the occlusal balancing is done. During the procedure we have available to us, on the one hand the guide that contains the information on the new teeth, and on the other the information provided by the CT with its plan, which is actually never rigid. Then when it is time to operate, the information has to be compared and a hierarchy is established to reach the final decision as regards the best positioning and implanting axis. In other words, this approach also makes it easier for the clinician as it gives him more freedom, so it is now longer a one shot procedure.
What has been your experience with the new Straumann® Bone Level Tapered Implant – BLT for short?
I am very happy to be able to use this implant as it is a conical implant. Quite apart from the SLActive® surface, which is a real bonanza. In effect, in one month osseointegration is already very far advanced. Implant stability and osseointegration are a dream. Under-preparation, or rather a preparation adapted to each type of bone, is possible with a conically-shaped implant, and precisely what was lacking with cylindrical implants was this primary stability obtained in such cases. Amazing primary stability is achieved, which is an important requirement for immediate loading and particularly for single rehabilitations. Moreover, a special aspect of these treatments is the ability to create bone with the aid of fillers around the stabilized implant in order to prevent autogenous grafts and it is easier to stabilize a conically shaped implant. With the new Straumann® Bone Level Tapered Implant, Straumann has succeeded in reconciling biology and mechanics. This is extremely significant for our patients for whom immediate loading is important and indicated.
With this new Straumann® Bone Level Tapered Implant, Straumann has succeeded in reconciling biology and mechanics. This is extremely significant for our patients for whom immediate loading is important and indicated.
Some staff at Straumann regard the BLT more as a development than as a “revolution”. There are other tapered implants with a similar technical design, even if not with the SLActive® surface. How do you see it?
To call the BLT a “development”, that is a sign of Straumann’s modesty. I personally would rather talk about a real revolution. Why? Because mechanics must not simply be considered separately from biology. Combining these two disciplines is what makes it a revolution. For a dentist, the revolution consists of being able to have full confidence in both the biology and the mechanics. This new generation of implants is functional after one month and allows full utilization and stability despite minimal bone resources, enabling the execution of increasingly complex surgical procedures with less invasive steps. It is for these specific clinical challenges that Straumann has developed this new implant with its conical design, Roxolid® material and SLActive® surface.
Does the fact that immediate loading is possible with Roxolid® and osseointegration is further advanced with SLActive® therefore mean that you can place the final prosthesis sooner and prevent fractures of the temporary filler bridge?
Yes. Things actually go faster for the final prosthesis, even if the placement depends on the healing of the soft tissue and the maturing of the fillers whose purpose is to augment the volume in a horizontal direction. The problem during the waiting period is the consequences of the fracture of the resin bridge. Imagine that you have placed an angled implant at the level of tooth position 5 and another in front, in the position of the lateral teeth. The distance between the laterals and the last implant is relatively large. A patient who undergoes this type of treatment is generally careful for one month. After not being able to eat properly for a long time, he feels well again and that’s when the problems start. He begins to chew harder and each time there is a problem fracture in the temporary bridge, it is at the level of the distal side of the laterals. I therefore rely on a study I conducted between June 2006 and September 2012 on 1042 implants used in this type of situation and inserted immediately; this study provides much information about the mechanical facts. In practice, when the patient attends the same day we repair it immediately and the implant is not affected. However, if he only comes three or four days later, the osseointegration is not yet complete. The extended effect of the fractured parts causes the distal implant to be uprooted, and I think this is the hardest to replace quickly. And that, precisely, is the problem: in our clinic, we treat patients from far afield. I personally know as an implantologist that I can feel completely secure with the BLT implant even if the patient receives his final prosthesis after two, three, four or six months.
I feel perfectly confident with a BLT implant, even if the patient receives his final prosthesis two, three, four or five months later, because the SLActive® implant will have healed in one month.
That’s a good prospect. Have you also use the new angled abutments from Straumann?
Of course. The new Straumann® Screw-retained Abutment is really very simple to use and the platform switching of the Bone Level Implants is perfect. It simply has everything that can be expected of an abutment regardless of whether it is straight or angled. With straight abutments a lot can be corrected. The angle is 17° – we do not need any more. When the implant has a wide angle, this abutment is ideal. The prosthetic restoration must be as simple as possible and the surgery must be designed to make the prosthetics simple. The new products meet this criterion in full.
The prosthetic restoration must be as simple as possible and the surgery must be designed to make the prosthetics simple. The new products meet this criterion in full.
Dr Zadikian, thank you for all you have done here and we wish you every success for your next endeavors!