European Journal of Dental Education ISSN 1396-5883
Dental implants placed by undergraduate students: clinical outcomes and patients’/students’ perceptions S. Vandeweghe1,2, S. Koole1, F. Younes1, P. De Coster3 and H. De Bruyn1,2 1 2 3
Department of Periodontology and Oral Implantology, Dental School, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium, € University, Malmo €, Sweden, Department of Prosthodontics, School of Dentistry, Faculty of Odontology, Malmo Department of Restorative Dentistry and Endodontology, Section of Fixed Prosthodontics, Dental School, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
Keywords assessment; dental implants; dental curriculum; patient satisfaction; undergraduate education. Correspondence Prof. Dr. Hugo De Bruyn Department of Periodontology and Oral Implantology Dental School Faculty of Medicine and Health Sciences Ghent University Hospital-P8, De Pintelaan 185, B-9000 Ghent, Belgium Tel: +32 9 3324017 Fax: +32 9 3321526 e-mail: [email protected] Accepted: 7 November 2013
Abstract Introduction: Implant dentistry in undergraduate education is predominantly theoretical or prosthetics oriented. Clinical experience with implant surgery could provide students a better understanding of alternatives for tooth replacements. This study describes an implant dentistry programme for undergraduate students, which included surgical placement of implants. The study presents the clinical outcomes of the programme, patients’ satisfaction and students’ attitudes/perceptions. It reflects on barriers and problems encountered during implementation and provides suggestions for other institutions. Materials and methods: Thirty-six students placed one implant each for a single tooth replacement after careful radiographic assessment and pre-surgical planning. One-stage surgery was performed under one-to-one supervision. Crowns were cemented on individual abutments 3–6 months later. Crestal bone loss was assessed radiographically immediately after surgery, at crown placement and after 1 year of loading. Questionnaires were used to investigate patients’ perspectives and students’ opinions towards the programme, as well as their perceived level of competence.
doi: 10.1111/eje.12077
Results: Thirty-six implants were placed in 27 patients; two (5.6%) failed prior to loading; mean bone loss from time of surgery to crown placement was 1.41 mm and remained unchanged thereafter, reflecting implant success. Overall, patients were satisfied and the majority would repeat the treatment by a student. The students thought it was a valuable experience, although they realised that additional education is necessary to perform implant surgery without supervision. Conclusion: Implant placement by undergraduate students resulted in acceptable clinical outcome parameters, patient satisfaction and positive student perceptions. These findings support the further development of clinical implant education in undergraduate dental curricula.
Introduction Due to advances in technology and research, both the indication and use of oral implants have increased continuously over the last decades. Dental implants as support for functional as well as aesthetical tooth replacements are increasingly used as alternatives to conventional restorative treatment options in fully or partially edentulous patients (1). Whilst implant treatment was initially rather restricted to universities and specialist centres, it now is part of everyday dental practice. As a result, 60
there is an increasing demand for postgraduate education and implant-related topics receive much attention in conferences. The implant industry has often been a source of training for general practitioners who wish to implement implant dentistry in their practice. However, expert consensus meetings and opinion leaders throughout the world have repeatedly pointed to the importance of an academic, evidence-based education (2–5) prior to engagement with the practice of implant dentistry. At the 2008 Prague Consensus Conference on implant dentistry organised by the Association for Dental Education in ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 60–69
Vandeweghe et al.
Europe, a consensus was reached describing a variety of domains and procedures within implant dentistry which the newly graduated dentist must be familiar with, have knowledge of or be competent at. This requires that implant dentistry should become part of the curriculum at an undergraduate level (1, 2, 6). To teach undergraduate dental students the use of implant therapy as a valuable treatment option, education should include basic aspects of healing and tissue integration, biomechanical and material principles and prosthetic and surgical skills and procedures (4, 7, 8). Whether this also includes acquiring competence in implant surgery as a goal remains a matter of debate and a staged educational level approach is agreed upon. This means that dentists should be competent to prosthetically restore straightforward cases, but only be familiar with implant surgery. By and large, the academic viewpoint states that a more complex treatment requires a higher educated clinician, often at the postgraduate or specialist level (9). Furthermore, the competence level to which the future dentist is educated and the practical implementation within the dental curriculum may also be dependent on the socio-economic situation and the treatment need within the local population (10). Hence, it might be unrealistic at present to expect a globalised standard of integration of implant dentistry into the undergraduate curriculum. Educational research has pointed to a steady increase in implant dentistry within dental curricula (11–13). Nevertheless, there is a great diversity amongst universities with regard to teaching methods used and curriculum time devoted to this purpose (14, 15). According to a survey in 2009 (12), 70% of the dental schools provided the undergraduates with clinical experience in implant prosthetics, although only 50% of the students were treating patients clinically. When it comes to implant surgery, only in 5% of the academic institutions did students perform implant surgery, mainly limited to single tooth replacements or mandibular overdenture treatments. It can be concluded therefore that theoretical education is adopted in most dental schools, but the opportunity for students to acquire clinical experience to restore dental implants is often limited, let alone the actual surgical placement of implants (12, 13). Barriers to including implant placement surgery in the undergraduate curriculum include limited time, lack of trained faculty staff, investment costs and patient recruitment (2, 12, 16). Nevertheless, educational programmes that provide some kind of (pre-)clinical experience have reported positive outcomes. Pre-patient care laboratory exercises were reported to have a positive influence on future plans to perform implant therapy (17). Participating in an elective course on treating selected edentulous and partial edentulous patients, including the participation in diagnosis, treatment planning, surgical placement and prosthodontics procedures, appeared to be strongly correlated with offering and restoring implants after graduation (18). When comparing students from a dental school with and without extensive implant education (laboratory and clinical experience to place and restore implants), graduates with clinical experience had twice as many implant restorations in their practice, placed more dental implants, referred more patients for specialised surgery and more often followed continuing education in implant dentistry (19). ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 60–69
Dental implants placed by undergraduate students
Based on reported positive influences of clinical experience in undergraduate implant education, a pilot project in implant surgery and prosthetic restoration was introduced in the dental curriculum of Ghent University, Belgium. This study describes the programme outline and investigates the impact of the programme’s clinical outcomes. Participating patients’ and students’ perspectives were also evaluated. The study was based on the following research questions: RQ1: Which are the clinical outcomes with regard to insertion torque, failed implants and bone loss in implants by undergraduate students? RQ2: What is the patients’ perspective with regard to students’ capabilities, as expressed 1 week post-operatively and also 1 year after treatment? RQ3: What is the students’ perspective with regard to the value of the programme in the undergraduate curriculum, the learning opportunities, the quality of supervision, the safety of the environment, and infrastructure, the teaching methods to prepare students for implant surgery, their selfefficacy to perform implant surgery and the self-perceived difficulty of treatment aspects?
Materials and methods Description of programme outline The programme is built on three components: theoretical education, pre-clinical laboratory education and clinical treatment. Each of the components will be briefly described. Table 1 provides a blueprint of the programme, integrated in the undergraduate dental curriculum at Ghent University. Theoretical education At the beginning of the final year of the dental curriculum (= year 5), 10.5 h of theoretical courses were organised to teach students the basics of oral implantology. These lectures further elaborated on previous lectures and clinical education provided from years 2 to 4. In those previous years, the principles of osseointegration, biocompatibility of titanium, soft and hard tissues around teeth compared with implants, patient selection criteria, disease prevention and maintenance were dealt with. During years 3 and 4, students treated implant patients in the recall clinic and assisted with implant surgery and prosthetics in the respective specialist departments. The theoretical course in year 5 covered multiple aspects related to anatomical limitations, radiographical and clinical diagnosis, indications, contraindications and patient selection. These also included implant materials and components of the system used in the clinic, pre-surgical treatment planning, surgical and restorative stages, prosthetic treatment options and procedures, biological and technical complications. The course was further supported with a literature summary in the form of abstracts aiming to equip students with an evidence-based background. At the end of the first semester, students were examined on the theoretical course by means of a written exam with openended questions. 61
Dental implants placed by undergraduate students
Vandeweghe et al.
TABLE 1. Integration of the implant programme in the undergraduate dental curriculum at Ghent University Year
Course Title
Teaching – hours
Topics
Assessment
2
Oral Infection II (Basic Periodontology)
Lecture – 3.75
Oral exam
3
Periodontal Therapy
Lecture – 3.75
Restorative Dentistry II
Lecture – 10.25
Dental Materials Removable Prosthetics
Lecture – 0.75 Lecture – 3.75
Clinical Training Assisting Sessions Clinical Training Assisting Sessions Head and Neck Surgery
Case dependent Case dependent Case dependent Case dependent Lecture – 10.5
Osseointegration; peri-implant soft and hard tissues (healthy and diseased); implant survival and risk factors; peri-implant mucositis (aetiology, diagnosis); oral hygiene measures Bone volume and bone quality; crestal bone remodelling; implant success; soft and hard tissue changes after tooth extraction; peri-implantitis (aetiology, diagnosis, treatment); maintenance Fixed implant prosthetics: indications and patient selection, clinical procedures, planning, complications, maintenance Biocompatibility of titanium Overdenture on connected and non-connected implants; attachments; technical procedures Recall treatments Diagnosis, surgery, prosthetics, complications Maintenance; overdenture on implants Assisting with consultations, surgery and prosthetics Literature abstracts; case selection; risk assessment; surgical protocols; prosthetic protocols; flap surgery; risk assessment; biological and technical complications; aesthetics and patient’s opinion Pre-clinical training: flap management, suturing, hands-on pre-clinical drilling, implant placement; prosthetic components and procedures Case planning; diagnosis and risk assessment; prosthetic treatments Assisting with consultations, surgery and prosthetics
4 5
Hands-on – 6
Clinical Training
Case dependent
Assisting Sessions
Case dependent
Pre-clinical education Before performing the actual surgery, all students participated in compulsory pre-clinical training. Exercises included different incisions, flap procedures and suture protocols on the jaw of a pig cadaver. During the second part, students had to drill and place an implant on a plastic phantom model, to gain familiarity with the equipment and competence in using the instrumentation and drilling protocols (Fig. 1a). Additionally, they performed implant socket preparation and the placement of a dummy implant in the cadaver bone (Fig. 1b). They became familiar with impression techniques and the different stages of the prosthetic procedure by practising with the models and demonstration tools. The protocols followed were according to the guidelines of the implant system (Nanotite Certain Tapered, BIOMET 3i, Palm Beach Gardens, FL, USA). There was no formal examination of the pre-clinical training, but students were closely supervised and remediated during the session. Clinical treatment Patients requesting a single tooth implant at the dental school of Ghent University Hospital were invited to participate in the 62
Oral exam
Written exam
Oral exam Oral exam
Observation-based permanent evaluation Portfolio assessment Observation-based permanent evaluation Portfolio assessment Written exam
No formal test
Observation-based permanent evaluation and presentation Portfolio assessment
project. All patients showing interest were first examined by an experienced clinician, to evaluate the patient’s general and oral health and to determine the feasibility of inclusion in the programme. Patient history, clinical pictures revealing jaw relation, a panoramic radiograph, a peri-apical radiograph of the region of interest and alginate impressions were taken for documentation purposes as well as to allow pre-surgical planning of each case. Inclusion criteria were lacking a single tooth, having adequate bone volume to install implants of at least 8.5 mm length and 3.25–5 mm width, no need for additional bone grafting and no unrealistic aesthetical demands which would preclude soft tissue grafting. If the patient qualified to be treated by a student and expressed no objection to treatment, the patient was sent to the department of medical radiology for threedimensional bone evaluation using CT or CBCT analysis. Patients were appointed to a student for further treatment, who received the patient’s stone models, clinical pictures and radiographs from the previous examination. Additionally, each patient was invited for a second clinical examination by the treating student. Students had to check for caries, periodontal problems and peri-apical infections. Based on the available and newly collected information, students made an overall treatment plan, which they uploaded together with all collected ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 60–69
Vandeweghe et al.
Dental implants placed by undergraduate students
A
B
Fig. 1. (A, B) During pre-clinical lab exercises, the students were instructed to practise flap procedures and to place a dummy implant in a pig cadaver. Also, they had to practise the drilling protocol on a plastic model.
information in an electronic portfolio on a secured online learning platform. The information was restricted to the respective student and the supervisor, and was discussed. After approval by the supervisor, students were allowed to initiate the actual treatment. An appointment for implant surgery was only booked when all dental infections were solved, and the patient was in good oral health and showed good oral hygiene habits. All students performed the surgery themselves but were closely assisted and supervised on a one-to-one basis by an experienced surgeon (Fig. 2). After administration of local anaesthesia, two sulcular incisions were made at the mesial and distal tooth and connected by a crestal incision. A full-thickness flap was elevated to allow access to the bone and determine the shape of the crest. Implants (NanoTite Certain Tapered, BIOMET 3i) were installed according to the guidelines of the manufacturer. A minimal machine-driven implant insertion torque of 35 Ncm was set as a threshold for one-stage surgery in that the healing abutment was screwed on the implant to allow for transmucosal healing. If necessary, the torque was increased to 50 Ncm to get the implant seated at the appropriate depth using the manual torque wrench. If implant stability was
Dental implants placed by undergraduate students: clinical outcomes and patients’/students’ perceptions S. Vandeweghe1,2, S. Koole1, F. Younes1, P. De Coster3 and H. De Bruyn1,2 1 2 3
Department of Periodontology and Oral Implantology, Dental School, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium, € University, Malmo €, Sweden, Department of Prosthodontics, School of Dentistry, Faculty of Odontology, Malmo Department of Restorative Dentistry and Endodontology, Section of Fixed Prosthodontics, Dental School, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
Keywords assessment; dental implants; dental curriculum; patient satisfaction; undergraduate education. Correspondence Prof. Dr. Hugo De Bruyn Department of Periodontology and Oral Implantology Dental School Faculty of Medicine and Health Sciences Ghent University Hospital-P8, De Pintelaan 185, B-9000 Ghent, Belgium Tel: +32 9 3324017 Fax: +32 9 3321526 e-mail: [email protected] Accepted: 7 November 2013
Abstract Introduction: Implant dentistry in undergraduate education is predominantly theoretical or prosthetics oriented. Clinical experience with implant surgery could provide students a better understanding of alternatives for tooth replacements. This study describes an implant dentistry programme for undergraduate students, which included surgical placement of implants. The study presents the clinical outcomes of the programme, patients’ satisfaction and students’ attitudes/perceptions. It reflects on barriers and problems encountered during implementation and provides suggestions for other institutions. Materials and methods: Thirty-six students placed one implant each for a single tooth replacement after careful radiographic assessment and pre-surgical planning. One-stage surgery was performed under one-to-one supervision. Crowns were cemented on individual abutments 3–6 months later. Crestal bone loss was assessed radiographically immediately after surgery, at crown placement and after 1 year of loading. Questionnaires were used to investigate patients’ perspectives and students’ opinions towards the programme, as well as their perceived level of competence.
doi: 10.1111/eje.12077
Results: Thirty-six implants were placed in 27 patients; two (5.6%) failed prior to loading; mean bone loss from time of surgery to crown placement was 1.41 mm and remained unchanged thereafter, reflecting implant success. Overall, patients were satisfied and the majority would repeat the treatment by a student. The students thought it was a valuable experience, although they realised that additional education is necessary to perform implant surgery without supervision. Conclusion: Implant placement by undergraduate students resulted in acceptable clinical outcome parameters, patient satisfaction and positive student perceptions. These findings support the further development of clinical implant education in undergraduate dental curricula.
Introduction Due to advances in technology and research, both the indication and use of oral implants have increased continuously over the last decades. Dental implants as support for functional as well as aesthetical tooth replacements are increasingly used as alternatives to conventional restorative treatment options in fully or partially edentulous patients (1). Whilst implant treatment was initially rather restricted to universities and specialist centres, it now is part of everyday dental practice. As a result, 60
there is an increasing demand for postgraduate education and implant-related topics receive much attention in conferences. The implant industry has often been a source of training for general practitioners who wish to implement implant dentistry in their practice. However, expert consensus meetings and opinion leaders throughout the world have repeatedly pointed to the importance of an academic, evidence-based education (2–5) prior to engagement with the practice of implant dentistry. At the 2008 Prague Consensus Conference on implant dentistry organised by the Association for Dental Education in ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 60–69
Vandeweghe et al.
Europe, a consensus was reached describing a variety of domains and procedures within implant dentistry which the newly graduated dentist must be familiar with, have knowledge of or be competent at. This requires that implant dentistry should become part of the curriculum at an undergraduate level (1, 2, 6). To teach undergraduate dental students the use of implant therapy as a valuable treatment option, education should include basic aspects of healing and tissue integration, biomechanical and material principles and prosthetic and surgical skills and procedures (4, 7, 8). Whether this also includes acquiring competence in implant surgery as a goal remains a matter of debate and a staged educational level approach is agreed upon. This means that dentists should be competent to prosthetically restore straightforward cases, but only be familiar with implant surgery. By and large, the academic viewpoint states that a more complex treatment requires a higher educated clinician, often at the postgraduate or specialist level (9). Furthermore, the competence level to which the future dentist is educated and the practical implementation within the dental curriculum may also be dependent on the socio-economic situation and the treatment need within the local population (10). Hence, it might be unrealistic at present to expect a globalised standard of integration of implant dentistry into the undergraduate curriculum. Educational research has pointed to a steady increase in implant dentistry within dental curricula (11–13). Nevertheless, there is a great diversity amongst universities with regard to teaching methods used and curriculum time devoted to this purpose (14, 15). According to a survey in 2009 (12), 70% of the dental schools provided the undergraduates with clinical experience in implant prosthetics, although only 50% of the students were treating patients clinically. When it comes to implant surgery, only in 5% of the academic institutions did students perform implant surgery, mainly limited to single tooth replacements or mandibular overdenture treatments. It can be concluded therefore that theoretical education is adopted in most dental schools, but the opportunity for students to acquire clinical experience to restore dental implants is often limited, let alone the actual surgical placement of implants (12, 13). Barriers to including implant placement surgery in the undergraduate curriculum include limited time, lack of trained faculty staff, investment costs and patient recruitment (2, 12, 16). Nevertheless, educational programmes that provide some kind of (pre-)clinical experience have reported positive outcomes. Pre-patient care laboratory exercises were reported to have a positive influence on future plans to perform implant therapy (17). Participating in an elective course on treating selected edentulous and partial edentulous patients, including the participation in diagnosis, treatment planning, surgical placement and prosthodontics procedures, appeared to be strongly correlated with offering and restoring implants after graduation (18). When comparing students from a dental school with and without extensive implant education (laboratory and clinical experience to place and restore implants), graduates with clinical experience had twice as many implant restorations in their practice, placed more dental implants, referred more patients for specialised surgery and more often followed continuing education in implant dentistry (19). ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 60–69
Dental implants placed by undergraduate students
Based on reported positive influences of clinical experience in undergraduate implant education, a pilot project in implant surgery and prosthetic restoration was introduced in the dental curriculum of Ghent University, Belgium. This study describes the programme outline and investigates the impact of the programme’s clinical outcomes. Participating patients’ and students’ perspectives were also evaluated. The study was based on the following research questions: RQ1: Which are the clinical outcomes with regard to insertion torque, failed implants and bone loss in implants by undergraduate students? RQ2: What is the patients’ perspective with regard to students’ capabilities, as expressed 1 week post-operatively and also 1 year after treatment? RQ3: What is the students’ perspective with regard to the value of the programme in the undergraduate curriculum, the learning opportunities, the quality of supervision, the safety of the environment, and infrastructure, the teaching methods to prepare students for implant surgery, their selfefficacy to perform implant surgery and the self-perceived difficulty of treatment aspects?
Materials and methods Description of programme outline The programme is built on three components: theoretical education, pre-clinical laboratory education and clinical treatment. Each of the components will be briefly described. Table 1 provides a blueprint of the programme, integrated in the undergraduate dental curriculum at Ghent University. Theoretical education At the beginning of the final year of the dental curriculum (= year 5), 10.5 h of theoretical courses were organised to teach students the basics of oral implantology. These lectures further elaborated on previous lectures and clinical education provided from years 2 to 4. In those previous years, the principles of osseointegration, biocompatibility of titanium, soft and hard tissues around teeth compared with implants, patient selection criteria, disease prevention and maintenance were dealt with. During years 3 and 4, students treated implant patients in the recall clinic and assisted with implant surgery and prosthetics in the respective specialist departments. The theoretical course in year 5 covered multiple aspects related to anatomical limitations, radiographical and clinical diagnosis, indications, contraindications and patient selection. These also included implant materials and components of the system used in the clinic, pre-surgical treatment planning, surgical and restorative stages, prosthetic treatment options and procedures, biological and technical complications. The course was further supported with a literature summary in the form of abstracts aiming to equip students with an evidence-based background. At the end of the first semester, students were examined on the theoretical course by means of a written exam with openended questions. 61
Dental implants placed by undergraduate students
Vandeweghe et al.
TABLE 1. Integration of the implant programme in the undergraduate dental curriculum at Ghent University Year
Course Title
Teaching – hours
Topics
Assessment
2
Oral Infection II (Basic Periodontology)
Lecture – 3.75
Oral exam
3
Periodontal Therapy
Lecture – 3.75
Restorative Dentistry II
Lecture – 10.25
Dental Materials Removable Prosthetics
Lecture – 0.75 Lecture – 3.75
Clinical Training Assisting Sessions Clinical Training Assisting Sessions Head and Neck Surgery
Case dependent Case dependent Case dependent Case dependent Lecture – 10.5
Osseointegration; peri-implant soft and hard tissues (healthy and diseased); implant survival and risk factors; peri-implant mucositis (aetiology, diagnosis); oral hygiene measures Bone volume and bone quality; crestal bone remodelling; implant success; soft and hard tissue changes after tooth extraction; peri-implantitis (aetiology, diagnosis, treatment); maintenance Fixed implant prosthetics: indications and patient selection, clinical procedures, planning, complications, maintenance Biocompatibility of titanium Overdenture on connected and non-connected implants; attachments; technical procedures Recall treatments Diagnosis, surgery, prosthetics, complications Maintenance; overdenture on implants Assisting with consultations, surgery and prosthetics Literature abstracts; case selection; risk assessment; surgical protocols; prosthetic protocols; flap surgery; risk assessment; biological and technical complications; aesthetics and patient’s opinion Pre-clinical training: flap management, suturing, hands-on pre-clinical drilling, implant placement; prosthetic components and procedures Case planning; diagnosis and risk assessment; prosthetic treatments Assisting with consultations, surgery and prosthetics
4 5
Hands-on – 6
Clinical Training
Case dependent
Assisting Sessions
Case dependent
Pre-clinical education Before performing the actual surgery, all students participated in compulsory pre-clinical training. Exercises included different incisions, flap procedures and suture protocols on the jaw of a pig cadaver. During the second part, students had to drill and place an implant on a plastic phantom model, to gain familiarity with the equipment and competence in using the instrumentation and drilling protocols (Fig. 1a). Additionally, they performed implant socket preparation and the placement of a dummy implant in the cadaver bone (Fig. 1b). They became familiar with impression techniques and the different stages of the prosthetic procedure by practising with the models and demonstration tools. The protocols followed were according to the guidelines of the implant system (Nanotite Certain Tapered, BIOMET 3i, Palm Beach Gardens, FL, USA). There was no formal examination of the pre-clinical training, but students were closely supervised and remediated during the session. Clinical treatment Patients requesting a single tooth implant at the dental school of Ghent University Hospital were invited to participate in the 62
Oral exam
Written exam
Oral exam Oral exam
Observation-based permanent evaluation Portfolio assessment Observation-based permanent evaluation Portfolio assessment Written exam
No formal test
Observation-based permanent evaluation and presentation Portfolio assessment
project. All patients showing interest were first examined by an experienced clinician, to evaluate the patient’s general and oral health and to determine the feasibility of inclusion in the programme. Patient history, clinical pictures revealing jaw relation, a panoramic radiograph, a peri-apical radiograph of the region of interest and alginate impressions were taken for documentation purposes as well as to allow pre-surgical planning of each case. Inclusion criteria were lacking a single tooth, having adequate bone volume to install implants of at least 8.5 mm length and 3.25–5 mm width, no need for additional bone grafting and no unrealistic aesthetical demands which would preclude soft tissue grafting. If the patient qualified to be treated by a student and expressed no objection to treatment, the patient was sent to the department of medical radiology for threedimensional bone evaluation using CT or CBCT analysis. Patients were appointed to a student for further treatment, who received the patient’s stone models, clinical pictures and radiographs from the previous examination. Additionally, each patient was invited for a second clinical examination by the treating student. Students had to check for caries, periodontal problems and peri-apical infections. Based on the available and newly collected information, students made an overall treatment plan, which they uploaded together with all collected ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 60–69
Vandeweghe et al.
Dental implants placed by undergraduate students
A
B
Fig. 1. (A, B) During pre-clinical lab exercises, the students were instructed to practise flap procedures and to place a dummy implant in a pig cadaver. Also, they had to practise the drilling protocol on a plastic model.
information in an electronic portfolio on a secured online learning platform. The information was restricted to the respective student and the supervisor, and was discussed. After approval by the supervisor, students were allowed to initiate the actual treatment. An appointment for implant surgery was only booked when all dental infections were solved, and the patient was in good oral health and showed good oral hygiene habits. All students performed the surgery themselves but were closely assisted and supervised on a one-to-one basis by an experienced surgeon (Fig. 2). After administration of local anaesthesia, two sulcular incisions were made at the mesial and distal tooth and connected by a crestal incision. A full-thickness flap was elevated to allow access to the bone and determine the shape of the crest. Implants (NanoTite Certain Tapered, BIOMET 3i) were installed according to the guidelines of the manufacturer. A minimal machine-driven implant insertion torque of 35 Ncm was set as a threshold for one-stage surgery in that the healing abutment was screwed on the implant to allow for transmucosal healing. If necessary, the torque was increased to 50 Ncm to get the implant seated at the appropriate depth using the manual torque wrench. If implant stability was
