Dental Implant Rehabilitation: Treatment Planning and Techniques with Minis

OsseoNews is delighted to have the opportunity to talk with Dr. Samuel Shatkin, DDS, MD and owner of Samuel Shatkin FIRST, LLC a full-service dental laboratory that specializes in mini dental implant rehabilitation. The laboratory is located in Amherst, NY.

Background
Dr. Samuel Shatkin is a pioneer in many fields in medicine and dentistry, including organ transplant and open-heart surgery. Dr. Shatkin developed the first successful protocol for preserving organs during their transport and storage, prior to their transplantation, thus saving countless lives. He also developed the first successful protocol for preventing thoracic dehiscence following open-heart surgery, again saving countless lives. He is a graduate of the University of Buffalo Dental and Medical Schools and was trained in Oral Surgery, Plastic and Reconstructive Surgery, Maxillofacial Surgery and Head and Neck Cancer Surgery.

Using his training he developed the original Vertical Osteotomy of the Mandible for prognathic jaw reconstruction. He was the Plastic Surgeon at the Cleft Lip and Palate Clinic at Childrens Hospital, and the Chief of Head and Neck Surgery at Buffalo General Hospital and Past President of The American Society of Maxillofacial Surgeons. He served as Chairman of the New York State Society of Plastic and Maxillofacial Surgery. Dr. Shatkin also has become a leader in dental implants having placed many different implant types since the mid 1950’s and most recently has become a pioneer in mini dental implant treatment planning and reconstructive procedures.

He has been in private practice of Plastic and Maxillofacial Surgery in the Buffalo, NY area for nearly 50 years and works with his 2 sons Samuel Shatkin, Jr, MD a Plastic Surgeon and Todd E. Shatkin, DDS a Cosmetic and Implant dentist who has developed many of the procedures used today with mini dental implants.

Interview

OsseoNews: Dr. Shatkin, one of the most difficult aspects of implant rehabilitation is the treatment planning phase. We have seen this time and again over the years with our readers on Osseonews.

Dr. Shatkin: I agree completely with that statement. Treatment planning is absolutely critical. If your treatment plan is wrong, you may end up with a poorly done case or even be unable to complete the treatment in some cases. So you have to have a treatment plan that addresses the patient’s chief complaint but also is in accordance with the anatomy of and function of the jaws and our ability to produce an adequate restoration.

OsseoNews: At Samuel Shatkin FIRST laboratory when you receive the diagnostic information for planning or rehabilitating a case, you first evaluate the treatment plan.

Dr. Shatkin: In the past with many of the traditional conventional implant systems, most cases were treatment planned by the oral surgeon or periodontist who acted as the quarterback. With the INTRA-LOCK mini implant system, most general practitioners treatment plan, place the implants and restore the case. One critical function that I perform is to insure that the case is planned correctly. If I think there are problems, I contact the dentist and discuss the case. We want to maximize the chance of success right from the beginning using all our resources.

OsseoNews: After evaluating the treatment plan, what do you do next?

Dr. Shatkin: We determine the best positions for the implants in accordance with the treatment plan proposed by the dentist. We receive diagnostic casts, panoramic radiographs, cone beam volumetric CT scans, etc. If we need more diagnostic information, we request it from the dentist. We have standardized forms for collecting this kind of information.

We create a surgical guide stent that guides the placement of the implants to the desired depth and angulation. The dentist places the stent, drills the pilot holes, and places the mini implant into position. The guide stent guides the implants into the exact required position, angulation and depth. There is no guesswork or potential for getting this wrong. The guide stent gets you exactly where you want to go.

OsseoNews: So it’s just that simple. Place the guide stent, drill and then torque down the implants.

Dr. Shatkin: That is exactly right. We do all the planning and make it simple for you to place the implants. With our INTRA-LOCK mini implant system, it is all laid out. You start at the beginning and go right through the protocol. Not only is it simple, it is very fast and very safe. Our guide stent keeps you out of drilling into any areas where you should not be.

Let me also make clear that although our main thrust is for the INTRA-LOCK mini implant system, we treatment plan cases and prepare guide stents for all implant systems. We experience great success with all the implant systems we plan cases for. Let me put this another way, we do all the planning and preparation and all you do is drill, torque and insert the finished crown and/or bridge restorations.

OsseoNews: So most of your cases are completed at the time of implant placement? One visit and the crown, bridge or overdenture is delivered.

Dr. Shatkin: That is exactly right. Our overall plan is for the implants to be torqued down and for the case to be delivered. With the INTRA-LOCK system, this is our standard operating procedure. This is one of the reasons we decided to be an authorized reseller of the INTRA-LOCK system. In one visit, the dentist places the implant and inserts the definitive prosthesis. The patient walks in without teeth and walks out with teeth.

OsseoNews: How is the prosthesis fabricated? For example, how would you deal with a 3-unit bridge?

Dr. Shatkin: Our rule of thumb is ‘1 implant for each missing tooth’. In general that is how I plan these cases. For molars we use 2 and occasionally 3 mini implants. So we would create a stent that directs the placement of 3 implants. We would fabricate the permanent bridge on the diagnostic casts with the implants placed to their correct location, angulation and depth. So if the dentist follows our guidelines and uses the stent correctly, the implants end up exactly where they should be. All you do is then insert the bridge.

For our INTRA-LOCK implant system – which by the way is my preferred way of rehabilitating these cases – you insert the bridge on to the implants immediately after torquing down the implants. We recommend using a surgical high torque handpiece to insert the mini implants into the bone. This is done at a slow speed of about 35-45 RPM’s

OsseoNews: What is the mechanism for connecting the bridge to the implants?

Dr. Shatkin: The bridge has an area hollowed out in the metal framework that fits over the implant. There is just enough space for the implant to fit into this socket. We then use our proprietary resin cement for the insertion. The resin cement engages the undercut around the bottom of the ball head of the implant and when it sets, locks the bridge on firmly.

OsseoNews: So when you cement this bridge on to the implant, the implant is engaging the intaglio of the metal framework. This is not an acrylic to implant connection.

Dr. Shatkin: This is a metal-to-metal connection or a Ceramic to metal connection depending on the type of restoration the dentist chooses to have made. The resin cement – which is very strong, by the way – connects the metal implant head to the metal or porcelain framework of the bridge. We are not connecting the implant to an acrylic bridge. This is a metal or ceramic bridge just like you would use to restore natural teeth. These are PFMs, or Emax crown restorations.

OsseoNews: Is it necessary to place a rubber dam fragment over the implant to contain the flow of excess resin cement or to place some block-out material around the implant?
Dr. Shatkin: You can do this, but we have found that it really is not necessary. But you do what is most comfortable for you.

OsseoNews: What happens if the bridge does not fit?

Dr. Shatkin: This occasionally happens. The dentist makes a new final impression of the implants, inserts a temporary bridge and we fabricate a new permanent bridge. The dentist then removes the temporary bridge and inserts the new one. No charge. Our system works very well but when there is a problem, we just make a new restoration at no cost to the dentist.

OsseoNews: You have had great success in rehabilitating edentulous jaws.

Dr. Shatkin: For a typical maxillary roundhouse, we need 12 INTRA-LOCK implants. The dentist uses our guide stent to place 12 implants and then inserts the roundhouse. These work great. Simple to do and very successful. One visit and the patient walks out with the implants and the permanent bridge. We use 1 implant to replace each tooth up to the second premolar and then we cantilever off the first molars.

OsseoNews: What about implant retained overdentures?

Dr. Shatkin: For the typical edentulous maxilla, we need 6-8 INTRA-LOCK implants. For the typical edentulous mandible we need 4. We use O-rings for retention. This eliminates the need for complicated attachment systems. Later on if the patient wants to convert to a roundhouse this can be done easily with the addition of the appropriate number of implants.

OsseoNews: The INTRA-LOCK mini-implant system has three mini-implants – 2.0mm, 2.5mm and 3.0mm. Are these strong enough to support a bridge?

Dr. Shatkin: Absolutely. In the first place, these implants are all solid core structures. They do not have a hollow core like most conventional implant systems. I really would like to put to rest this serious misunderstanding of the physical and mechanical properties of the INTRA-LOCK system. These INTRA-LOCK MDL and MILO implants are extremely strong and independent tests have proven them to be significantly stronger then competing mini implant systems.

OsseoNews: You also have a system similar to the Nobel Biocare All-on-4.

Dr. Shatkin: Specifically for the edentulous maxilla where bone is lacking, we can use our 18mm implants to engage the pyriform sinus and nasal spine. We can then place a roundhouse over these implants.

OsseoNews: Dr. Shatkin can be reached at Samuel Shatkin FIRST, LLC laboratory for consultation assistance and ordering of INTRA-LOCK implants by calling 1-888-4SHATKIN (888-474-2854)

On behalf of OsseoNews, I would like to thank you for taking time out of your busy schedule to discuss your dental laboratory and the INTRA-LOCK mini-implant system with us.

Interview conducted by
Gary J. Kaplowitz, DDS, MA, M Ed, ABGD
Editor-in-Chief, www.Osseonews.com