Aip Kane 2019-winter

Presented by Dr. Jesse Kane and Dr. Thomas Bloem

Winter 2019

Advances In Prosthodontics

TM

New Findings & Best Practices for Cosmetic & Restorative Dentistry

Implant Abutment / Screw Complications (Part 2 of 2)

INSIDE THIS ISSUE

Part 1 available at:

SPECIAL REPORT: What Is The Best Approach For These Complications?

AdvancedProsthodontist.com/Kane

Problems # 1 & 2: Loose Screw / Cement Retained Implant Crowns… (last time) Problem # 3: Stripped Abutment Screw…

Here’s how I approach complications with implant abutments and screws…

pages 2-3

Welcome to Part 2 of our abutment/screw complications special report. Last time we discussed how to salvage loose implant screws. This time we will dive a bit deeper to discuss stripped and broken screws.

Problem # 4: Broken Abutment Screw…

As I mentioned before, the incidence of loosening is approximately 15% over a period of 5 years. A more recent study by Kreisel estimated screw fracture at around 3.9% over 5 years [COIR 2007]. Though fracture is significantly less common, the ramifications can be dire. Complete removal of the remaining screw fragment is necessary for future use of the implant. If the fragment cannot be removed, the recommendation is to either bury the implant or explant and graft. Read on to learn about ways to avoid this!

COMPLEX CASES: Dr. Kane & Dr. Bloem’s Specialized Training, Prosthodontic Treatments, and Personal Message To Fellow Dental Practitioners... (see insert enclosed)

© Sams Media Group, LLC

pages 3-4

Remember, I am always only a phone call away if you ever need to talk something through with a colleague. Or, if you have a patient with a failing restoration that you’d like to have me assist as the Prosthodontist on the treatment team, please let me know.

Special report (part 2 of 2) continued on next page…

Do you want another opinion on a complex case? Or to meet and share ideas? Our prosthodontic specialty practice is built on the support of our fellow dental colleagues. That’s why we share our knowledge and experience about complex restorative cases, so you 
 know all the ways we can work together on advanced treatments to help your patients.
 If you’d like to meet to discuss a difficult procedure, or talk about how we can help each other, 
 please email or call us.

Drs. Kane & Bloem, Prosthodontists ! Specialists In Complex Care

!

734-274-0667 (cell) !

[email protected]

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SPECIAL REPORT: Implant Abutment / Screw Complications PART 2 — This publication

PART 1 — Last publication

by Jesse Kane
 DDS, MS


Problems addressed:

Problems addressed:

3 - Stripped Abutment Screw 4 - Broken Abutment Screw

1 - Loose Screw Retained Implant Crown 2 - Loose Cement Retained Implant Crown

Read below…

Read at: AdvancedProsthodontist.com/Kane

Prosthodontist

As a Prosthodontist, I work on challenging cases every day and coordinate treatment with general dentists and other specialists. A question that I frequently get is: “How do you approach complications with implant abutments and screws?” So I decided to create this special report as a 2-part series. I hope this is helpful, and if you have questions or would like to discuss 
 a specific case, please email at: [email protected] ———————————— Background notes — Refer back to Part 1 for recommendations on steam cleaners and implant drivers. My first recommendation for this second part is magnification, and at least 4x is preferred. 
 If you have a scope, use it! Next, you will want to have an abutment screw remover as a first line of attack (fig. 1). All of 
 the main implant companies sell these but I like the one from 
 fig. 1 fig. 2 fig. 3 Astra probably the most. Basically, it is a normal latch drill bit, 
 but instead of a hex at the end, it has sharp teeth meant to engage into stripped or fractured screws. Sometimes this is enough to tease it out. For more complicated situations, I recommended the “Fixture and Screw Removal Master” from Salvin (fig. 2). This kit has everything you need to remove an implant via reverse torque and a great system for safely reverse tapping implant screws and removing them without harming the implant. Many implant companies have their own version of this but since I work with multiple platforms, I find this one to be the most useful. The runner up is the “Abutment Screw Retrieval Kit” from Nobel Biocare (fig. 3). Clear instructions and labeling make it easier to use and for some reason the components never seem to break or wear down. ————————————

Problem #3 — Stripped Prosthetic Screw

Slotted

Screw after 5 years in function

Stripped screws can arise from (a) over-torqueing the screw, (b) excessive insertion/removal or (c) use of a 
 worn out or incorrect driver. 1) You know you have encountered a stripped screw when you feel your driver bit slip repeatedly when trying to remove the screw. Apply extra downward force with the driver and try different angles to see if you can engage any part of the screw. If that fails proceed to step 2.

Stripped

Chart showing common implant screws and torques:

2) Place 1-2 thicknesses of PTFE Tape on the end of your driver and to try remove the screw, again using increased downward force. If that fails proceed to step 3.

See reverse side of the enclosed letter or download 
 this resource at… AdvancedProsthodontist.com/ Kane

Continued on next page...

Do you have a patient with a failing restoration? Or another complex case? If you have a question about a case and want another opinion, give us a call. Or, if there’s a case that you want to work together on, please fill out and send in the enclosed referral form. We will take great care of your patient and keep you informed. Dental professionals refer to us
 because we perform complex cases every day. Drs. Kane & Bloem, Prosthodontists ! Specialists In Complex Care

!

734-274-0667 (cell) !

[email protected]

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SPECIAL REPORT: Implant Abutment / Screw Complications Continued from previous page — Problem #3 — Stripped Prosthetic Screw… 3) This step involves drilling a slot in the screw and removing it with a slotted driver. This was first described by Williamson [JPD 2001], he also described a nifty technique for making a slotted driver from a latch grip round bur. Use magnification to help ensure you don’t nick the implant. In a high speed with the water on, select a flat ended carbide bur with a diameter around 0.8mm. I use the FG 56 or a ¼ round bur, but the more common 330, 245 or 169 work too. Just stay away from the crosscut burs, these cut a little too aggressively. Next insert a slot driver to test to see if you feel resistance. If you do, place it into a torque wrench and remove. If you don’t, shape up your slot a little and try again. If this fails… you will have to treat this as a fractured screw and proceed to the next section. Note: Many implant companies sell slot drivers. If you bought the kit from A.Titan that I recommended in Part 1 of this special report (see AdvancedProsthodontist.com/Kane), then you already have one! My only concern with this driver is that it tends to deform after repeated use. Zimmer sells one that is a little more expensive but keeps its shape a little better. If you don’t have any slot drivers, you can make one out of a latch grip #1 round bur. Shave the head down using first a white heatless stone then a green stone. On to Problem # 4… ————————————

Problem #4 — Fractured Prosthetic Screw Fracture of a prosthetic screw usually occurs just below the head of the screw. The screw head is rarely in sight by the time you see the patient. The head is what provides the clamping force or “preload” to hold the restoration onto the implant platform. So, without the screw head the restoration will usually be detached as well and you will only have to overcome the friction between the screw threads to remove the fragment, i.e. no torqueing involved. First, take an x-ray as parallel to the implant as possible. Evaluate where the fragment is located in relation to the platform. It can be above, equal, or at varying depths below the platform. Clearly, the deeper the fragment, the more difficult the retrieval. Follow these steps in order to attempt to remove the fragment or if at any point you feel in over your head, feel no shame in referring, these can get quite complicated. 1) If the fragment is above the platform, attempt to twist it out using forceps or a hemostat with tiny beaks. Microsurgical “mosquito” forceps work well. If this isn’t possible, proceed to step 2. 2) Loosen the fragment with an explorer, file or ultrasonic instrument. Don’t forget the screw fragment tool I mentioned earlier! Moving in a counter-clockwise motion, try to turn or dislodge the fragment. Often times you can spin the fragment right out. If you’re looking in a mirror remember it’s backwards! This may seem obvious, but during my first screw retrieval I ended up driving the fragment deeper into the implant by spinning the wrong way. If this does not work, proceed to step 3.

Continued on next page...

Why other dental professionals work with a Certified Prosthodontist Certified Prosthodontists are specialists in implant, esthetic, and reconstructive dentistry. 1.

You have a patient requiring treatment outside your typical scope of practice.

2.

You have a patient with complex needs that may drain your time.

3.

You have a demanding patient who wants perfect esthetics.

4.

You have a question and want to discuss a case with a colleague to ease your mind.


Drs. Kane & Bloem, Prosthodontists ! Specialists In Complex Care

!

734-274-0667 (cell) !

[email protected]

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FROM THE PROSTHO FILES Continued from previous page — Problem #4 — Fractured Prosthetic Screw… 3) Even if the previous step did not retrieve the fragment entirely, it will have loosened it and released some of the friction between the fragment and the implant. Take a cotton tip applicator, loosen up the cotton by tearing 
 at it with an explorer until it is more “wispy”, then jam the cotton tip into the implant and turn counter-clockwise. You may need to cut a little around the sides of the cotton tip to reduce the diameter. Check to see if the fragment is turning at all. If you get it above the implant platform then return to step 1. If this doesn’t work, 
 it’s time for step 4. 4) This step is identical to step 3 in the previous section for stripped screws, except you are now drilling into a screw fragment instead of a screw head. The fragment is smaller, deeper and darker, so tread carefully. Read the previous section for the step by step. If this doesn’t work, it’s time to pull out your implant retrieval kit in step 5. 5) The final step involves engaging the fragment with a reverse threaded drill and then applying a reverse torque to back it out. This step utilizes the kits I mentioned earlier. The goal of these kits is to utilize drill stops and positioners to align and angulate the drill in the proper direction in order to protect the implant platform and internal threads. You will need to be sure you have the proper drill positioners for the implant at hand. Each kit has slightly different sequences and drilling speeds etc., so be sure to read the instructions and watch the videos that often come with the kit. Here is a schematic that describes the general idea. The proper drill positioner is secured to the implant platform. Many of these have a handle for easy stabilization. A drill is then passed through the positioner and run in reverse at around 1200 RPMs approximately 1mm into the fragment. Next another drill is screwed into the fragment and rotated counterclockwise either by hand or at around 50RPM to remove the fragment. This process does take some experience to get comfortable with it, but it is very efficient and relatively safe to the implant itself. Fractured Screw

Drill Positioner

Reverse Drilling

Remove Fragment

Note: Every time drilling is done near an open implant, metal fragments will be created and may lodge in the implant body. Be sure to irrigate thoroughly as soon as the screw is retrieved. That wraps up Part 2 of this series! To reference Part 1 where we addressed loose screw or cement retained implant crowns you can go to this website: AdvancedProsthodontist.com/Kane Quick tip — Whenever attempting a screw retrieval, be mindful of the implant platform and the internal implant threads. Damaging these areas can render the implant unusable. My advice is to warn the patient of this possibility because if you tell them before, it’s an explanation… if you tell them after, it’s an excuse. See common implant screws and torques on the reverse side of the enclosed letter. If you have any questions, you can always reach out by emailing [email protected] or call my cell phone at (734) 274-0667.

How can a Certified Prosthodontist assist you and your dental team? We specialize in the treatment of complex cases, usually involving several procedures over months 
 of care. The next time you see a challenging case, please feel free to call us and we can discuss treatment planning or help you with any part of the treatment. Our goal is to be a resource for your office by helping manage difficult and time-consuming procedures, restoring the function and esthetics that each patient desires, then referring them back to your office for their ongoing care. Drs. Kane & Bloem, Prosthodontists ! Specialists In Complex Care

!

734-274-0667 (cell) !

[email protected]

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