Page 16 - NYSAGD GP Fall 2018

Finally a Standardized approach to an old procedure through a case report:

Implant dentistry, introduced in 1967 by Per-Ingvar Branemark, has captured the interest of all dentist. The procedure,
approach and success has improved over the last 50 years. First considered for older edentulous patients, has today
transformed to a highly accepted and a standard of treatment.

The Coronal Trans-Odontal Technique also known as the “CTO” technique has proven to be beneficial in proper implant
placement in all in Intra-oral sites. The use of CTO approach allows the dentist to place an implant without the use of CBCT or
a Surgical guide. This is a skill one must have if costly technology is not immediately available. Considering the time and cost
involved the surgical guide fabrication and patient care the CTO is a procedure which can implemented quickly, saving time
and eventually reducing cost.
It is obvious with the limitless advancement of digital technology in dentistry, the diagnosis, surgical navigation and overall
implant placement precision is far beyond what we have had in the past. It would be difficult to have a successful practice
without everything digital technology has to offer.

With over 160,000 dentist today in the USA and only about 0.3 percent are credentialed with diplomate status, it is important
to be properly trained it all aspects of implant dentistry. These credentials standardizes the fact that we can deliver the best
possible treatment for our patients. Having credentials is all together another topic but it is important to mention since it
promotes a high standard for all Dentist in general to achieve.

Attending meeting after meeting of various world recognized organizations, several facts exist. Digital dentistry taught today to
the seasoned dentist is nothing new to the newly graduated dentist.
Every single dentist today is trained using intraoral scanners and CBCT as part of their education. The incorporation of
technology in the education of every dentist is important since we are in a digital age. Unfortunately, the increased reliance on
this technology has also affected the dentist in the ability to use brain guided abilities and surgical confidence. As the director
of the Calderon Institute, I do find myself teaching the new dentist the true foundation of Implant dentistry by incorporating
actual hands-on training. This involves knowledge in
1- biology
2- anatomy
3- Pharmacology
3- soft tissue management
4- Implant surface chemistry
5- Implant surface geometry
6- basic anatomical requirements
7- Proper Hands-On training
8- Constant rapport with other colleagues.
Finally, a Standardized Approach to an Old Procedure:

A Case Report
Let’s start with he first example, simple placement of implant #9 after an extraction of a non-restorable tooth 24 hours post

Option #4 involves the same training as option 3 but with the added cost and knowledge of the use and implementation of a
trauma. With a full schedule, how does one treat such a patient the same day, without multiple visits?
By Mike E. Calderón, DDS, DABOI, DOCOI CBCT, intra-oral scanner, surgical plate fabrication either in-office or a 3rd party.

Implant dentistry, introduced in 1967 by technique only involves the use of multiple

Finally the treatment of choice, Option #5. This procedure is implemented the same day one hour after premedication. The
Per-Ingvar Branemark, has captured the periapical radiographs.
Option #4 involves the same training as option 3 but with the added cost and knowledge of the use and implementation of a
CTO technique involves only the use of multiple periapical radiographs.
interest of all dentists. The procedure, ap- CBCT, intra-oral scanner, surgical plate fabrication either in-office or a 3rd party.
1- Decoronation- which the removal of the clinical crown and scalloping the cervical aspect of the the remaining tooth to the
proach, and success has improved over the The CTO Technique

last 50 years. First considered for older 1. Decoronation (Figure 2), which is the re-
alveolar crest.

Finally the treatment of choice, Option #5. This procedure is implemented the same day one hour after premedication. The
edentulous patients, has today transformed moval of the clinical crown and scalloping

CTO technique involves only the use of multiple periapical radiographs.
into a highly accepted treatment and a stan- the cervical aspect of the remaining tooth

1- Decoronation- which the removal of the clinical crown and scalloping the cervical aspect of the the remaining tooth to the
dard of care. to the alveolar crest.
alveolar crest.
The Coronal Trans-Odontal Technique, Figure 1. Non-restorable #9.
also known as the “CTO” technique, has
proven to be beneficial in proper implant Your treatment options are,
Your treatment options are:

placement in all intraoral sites. The use of 1. Permanently cripple the patient by ex-
Option #4 involves the same training as option 3 but with the added cost and knowledge of the use and implementation of a
1- Permanently cripple the patient by extracting and fabricating a 3 unit bridge (1-1.5 hours)
the CTO technique allows the dentist to tracting #9 and fabricating a 3-unit bridge

place an implant without the use of CBCT (1-1.5 hours). CBCT, intra-oral scanner, surgical plate fabrication either in-office or a 3rd party.

2- Refer it out to another dentist who has been educated in implant dentistry (5 minutes)
or a surgical guide. This is a skill one must 2. Refer it out to another dentist who has
Finally the treatment of choice, Option #5. This procedure is implemented the same day one hour after premedication. The
have if costly technology is not immediate- been educated in implant dentistry (5 min-
CTO Decoronation
ly available. Considering the time and cost utes). CTO technique involves only the use of multiple periapical radiographs.
3- Extract, Graft and place a fixed or removable temporary (2-3 hours)

Figure 2. CTO decoronation.

involved, the CTO technique is a procedure 3. Extract, graft, and place a fixed or re- CTO Decoronation
1- Decoronation- which the removal of the clinical crown and scalloping the cervical aspect of the the remaining tooth to the
alveolar crest.
which can be implemented quickly, saving movable temporary (2-3 hours). 2. Ideal initiation of the osteotomy site with
If you have a CBCT, Scanner and 3D printer then

time and reducing cost. 4. If you have a CBCT, scanner and 3-D a #4 surgical round bur. During this proce-

2- Ideal initiation of the osteotomy site with a #4 surgical round bur. During this procedure you must ignore the presence of the

2- Ideal initiation of the osteotomy site with a #4 surgical round bur. During this procedure you must ignore the presence of the
printer, then you can extract, CBCT, scan dure you must ignore the presence of the
4- Extract, CBCT, Scan and fabricate a surgical guide (2-3 hours), then do step 3 (a total of 4-6 hours).
With the advancement of digital technolo- and fabricate a surgical guide (2-3 hours), root and approach the osteotomy as if there
root and approach the osteotomy as if there were an ideal ridge and an ideal location in all 3 dimensions. The retention of the

root and approach the osteotomy as if there were an ideal ridge and an ideal location in all 3 dimensions. The retention of the
gy in dentistry, the diagnosis, surgical nav- then do step 3 (for a total of 4-6 hours). were an ideal ridge and an ideal location in
root allows the osteotomy to be done with out the classic bouncing of the osteotomy drills in a extraction socket. This is done
root allows the osteotomy to be done with out the classic bouncing of the osteotomy drills in a extraction socket. This is done

5- Incorporation of the CTO Technique.
igation and overall implant placement pre- 5. Incorporation of the CTO technique. three dimensions. The retention of the root
in the usual manner and to one step drill before your planned final step drill.
in the usual manner and to one step drill before your planned final step drill.

cision is far beyond what we have had in allows the osteotomy to be done without the

the past. It would be difficult to have a suc- Option #1 is no longer considered the best classic bouncing of the osteotomy drills in

cessful practice without everything digital treatment option. In the past, damaging the extraction socket (Figure 3). This is done

technology has to offer. With over 160,000 two natural teeth to support a multiple unit in the usual manner and to one step drill be-

dentists today in the US with only about 0.3 bridge would be considered the treatment fore your planned final step drill (Figure 4).

percent credentialed with diplomate status, of choice. Today the patient is well aware
Option #1 is no longer considered the best treatment option. In the past damaging two natural teeth to support a multiple unit
CTO Decoronation
it is important to be properly trained in all of the implant treatment option and refuses
aspects of implant dentistry. These creden- the reduction of healthy, sound teeth. It is
bridge would be considered the treatment of choice. Today the patient is well aware of the implant a treatment option and
tials standardize the fact that we can deliver well known that a fixed 3-unit bridge tends

the best possible treatment for our patients. to last about 8-10 years with eventual com-
2- Ideal initiation of the osteotomy site with a #4 surgical round bur. During this procedure you must ignore the presence of the
refuses the reduction of healthy sound teeth. It well known that a fixed 3 unit bridge tends to last about 8-10 years with
root and approach the osteotomy as if there were an ideal ridge and an ideal location in all 3 dimensions. The retention of the
plications and necessary replacement.
Attending meeting after meeting of various root allows the osteotomy to be done with out the classic bouncing of the osteotomy drills in a extraction socket. This is done

world recognized organizations, several eventual complications and necessary replacement.
Option #2 is another choice, but with the
in the usual manner and to one step drill before your planned final step drill.
facts exist. Digital dentistry taught today increasing cost of technology, training and CTO with Guide Pin

to the seasoned dentist is nothing new to overall education, we want to increase our CTO Final

the recently graduated dentist. Every single production by increasing our skills. So, this Figure 3. CTO with guide pin. Step Drill

dental student today is trained using intra- is an option that is not financially favorable CTO with Guide Pin
Option #2 is another choice but with increasing cost of technology, training, and over all education, we want increase our

oral scanners and CBCT as part of their for the general dentist. 3- At this point the remaining root fragments are removed and the socket freed of any residual tissue. Observe what was once
CTO Final

education. Unfortunately, the increased production by increasing our skills. So, this is an option that is not financially favorable for the general dentist.
Step Drill
the apical location the the root and what will be the ideal location of the apical portion of the implant.
reliance on this technology has also affect- Option #3 involves minimal training in soft
ed the dentist’s ability to use brain-guided tissue management and biomaterials.
abilities and surgical confidence. 3- At this point the remaining root fragments are removed and the socket freed of any residual tissue. Observe what was once

Option #4 involves the same training as op- the apical location the the root and what will be the ideal location of the apical portion of the implant.

Option #3 involves minimal training in soft tissue management and bio materials.

Case Study tion #3, but with the added cost of a CBCT,
In this example, implant #9 is placed af- intraoral scanner, surgical plate fabrication
ter an extraction of a non-restorable tooth
either in office or by a third party.
(Figure 1) 24 hours after trauma. With a

full schedule, how does one treat such a Option #5 is the treatment of choice. This
CTO with Guide Pin
patient the same day and without multiple procedure is implemented the same day Figure 4. CTO final step drill.
CTO Final
visits? one hour after premedication. The CTO CTO Osteotomy
Step Drill

www.nysagd.org l Fall 2018 l GP 16 3- At this point the remaining root fragments are removed and the socket freed of any residual tissue. Observe what was once

the apical location the the root and what will be the ideal location of the apical portion of the implant.

CTO Osteotomy

CTO Osteotomy