Challenging cases in the practice of Dr. Damyan Enchev

Part 1

The vocation of being a dentist

Treatment options in dentistry are constantly increasing with the help of new technologies. While in the past it was often necessary to surgically remove diseased teeth, with the advancement of science nowadays it is possible to treat even the most complex cases and achieve the desired result for both the dentist and the patient. Thanks to dentists, dental technicians, and advancing technology, patients are gaining more and more confidence in smiling widely.

Dentists are specialists who, in any situation, must know which solution is best, because the patient has trusted them.
Many dentists face complex cases in their practice, which are challenges for them and they had to act in the fastest way.

What does the specialist share?

Let’s see how solving some of the difficult cases in the dental clinic goes, Simona from the Teacs team conducted an interview with Dr. Damian Enchev. He is a Co-Founder of ”ENVIZIA” Dental clinic since December 2013. His responsibilities are to successfully apply a multidisciplinary approach in gaining the patients trust and sending them off with a great smile.

Simona: Hello, Dr. Enchev,
Would you share with us the most complicated dental cases?

Dr. Enchev: “The most complicated cases in dental practice are those for which we are not prepared with equipment and skills. Whenever a doctor hesitates whether they will succeed or not, they are sure of their knowledge and skills to solve a given task, because every case is a task. At the very least, the doctor should call for advice and help from another colleague, and refer the case to a doctor with the necessary knowledge, skills, and equipment to resolve this case.

Every day, patients come to my clinic looking for help in all areas of dentistry, because Dr. Encheva and I, working in the city of Shumen, Bulgaria, cover every specialty in dentistry. Among other things, I am intensively involved in endodontic treatments, oral surgery, and implantology. Dr. Encheva deals with children’s dentistry and endodontics. We are constantly developing our knowledge and skills so that we can respond to new problems, keep up with technology and treat our patients better.

One of the most advanced technologies currently on the market, with which I have been working since 2016, is the dynamic navigation for oral surgery and implantology, which is called Navident. The system monitors in real-time the patient’s jaw and can guide the doctor where to make the box with an accuracy of about 0.1mm, planning the case in advance. And the execution is obtained one-to-one with our treatment plan – safe for the patient, at the same time because of the extreme precision with which the system works, we place the implants in the ideal places.”

While working with a Navident
While working with a Navident

Following is an interview in which Dr. Damyan Enchev shares how he dealt with one of the most challenging cases in his practice

Simona: What necessitates the extraction of six teeth, how to place implants in just one visit to the dentist, and which implant placement technology is preferable – “static surgical guide” or “dynamic navigation”, how does the case end?

Dr. Enchev: “I will share a case from last week (August 2022) in which a patient came to the clinic with six teeth left on her upper jaw. Half of which wore a metal-ceramic bridge structure. They had increased mobility, that is, impaired stability. They had to be taken out. After which several implants are placed to carry a new prosthetic structure on them.

Normally without navigation, skills, and equipment, a dentist would make a removable plaque prosthesis. This is the fastest and easiest solution that is the most budget-friendly and the easiest to maintain proper oral hygiene. You take your teeth off, brush them with toothpaste, then put them back on. This is not always the desired solution for the patients because it is associated with constant movements of these teeth. The inconvenience of removable plate prostheses is that they can move or fall during meetings or conversations. During eating, they are not so stable. We are not talking about aesthetics, aesthetics is a compromise. Just function is restored.

The next thing one would do is use a static surgical guide. It’s sort of like a template that an implantologist can use to drill the hole for the implant in the patient’s jaw. Static surgical guides have many disadvantages compared to modern dynamic navigation because they need time to be planned, produced, and reach the clinic. If we decide at the last minute to change the work plan, this cannot be done because the guide has already been created. The plan cannot be changed until a new static surgical guide is made.”

Simona: Do the steps have to be planned in advance, if something changes, can the already made guide be used for the specific case?

Dr. Enchev: „Yes, if something changes we need to send the dental laboratory our new work plan. Which I think is a lot more expensive these days than it used to be. After all, patients pay for our time, neither equipment nor dental materials are as valuable at this stage as the time we spend treating patients and theirs of course.
One of the most important things is “drilling the bone” and, cooling the cutter.

It is known that when drilling something if the cutter is not adequately cooled, the material can be damaged, as well as the cutter. The tip is that the drill has to go through the surgical guide that directs where to work the drill, the cooling is not adequate. The deeper the drill enters the bone through the surgical guide, the less it cools. This can harm the bone and then the future healing of the tissue around the implant and its life.”

Bone condition before surgery
Bone condition before surgery
Bone condition before surgery

Simona: How “bone drilling” is made with dynamic navigation?

Dr. Enchev: „After the patient takes a 3D photo or a photo of the bone (the jaw in volume), we can start working immediately.
A treatment plan can be made, but it is not mandatory. The plan is made extremely quickly in minutes and the work can begin, with the dynamic navigation guiding you and showing you exactly where to work.”

Digital case planning with Navident

Simona: How long does the entire extraction procedure and implant placement take?

Dr. Enchev: „The patient came with a photo. In about 10-15 minutes, a work plan was made, and anesthesia was applied. The system is calibrated within 5 minutes. Calibration is important for the system to understand where the patient is in space. After which the old teeth were extracted. The six teeth did not require much extraction time. Аfterwards, six implants were placed, in the ideal position according to the plan we had prepared.

Within one hour visit: The patient came in a treatment plan was agreed and extraction, implants and impression were made. As for now, the print we take is analog. Very soon I plan to purchase an intraoral scanner, which will shorten the way of tooth impression and its path to the laboratory quite a bit. Thanks to AMOSYS software, which we use now and having a digital impression, the laboratory can start working as soon as the impression is taken and sent.

Dynamic navigation has no incisions and no sutures because it allows us to work directly transgingivally through the venega, it is not necessary to do a “flap”, that is, to peel the gingiva or soft tissue to see when we work. The system shows us all this in real-time. Because of this, the healing stage is much, much faster and associated with far fewer adverse post-operative reactions and problems.”.

Before operative orthopantomography
After operative orthopantomography

Simona: Is tooth extraction and implant placement painful for the patient?

Dr. Enchev: „The patient feels absolutely nothing. He is under terminal anesthesia.
This is all in the upper jaw near anatomically dangerous areas, such as the maxillary sinuses. Thanks to the equipment and the skill of working with it, the implants were placed completely safely and in the correct position.”

Simona: How long does the recovery process take?

Dr. Enchev: „Soft tissues recover quite quickly, while bone recovers completely in up to several months. This usually takes up to 3-4 months. However, there is a difference from implants that are placed with delay ie. after 3-4 months, and those that are loaded immediately.

In my practice so far, I have noticed that implants that are loaded sooner are much stronger. Naturally, if they can be loaded, if there are the necessary conditions for that.”

Simona: What is the aftercare for implants?

Dr. Enchev: „As soon as patients invest time, effort and money in implantology, the advice is that hygiene should be obsessive. They must use all available means of oral hygiene: toothbrush, toothpaste, mouthwash, interdental brushes for under and around the structure, and special sutures for under bridges around implants. All oral hygiene maintenance materials should be used. Otherwise, they won’t be able to enjoy their new teeth for long.”

Simona: Is there a high risk group of patients?

Dr. Enchev: „Previously, implantology was refused to people with high blood pressure, as well as high blood sugar in diabetics. It is now known that when these factors are controlled, implants can be placed without negative effect on the health of the patient.”

Simona: You create smiles on people’s faces.

Dr. Enchev: „First and foremost is the restoration of chewing function. Last but not least is the high esthetics we create in the patient’s mouth. It plays a huge role in their self-esteem and their quality of life afterwards.”

In part 2 you will learn: How did a 6.5mm instrument break and block the root canal of a tooth? What decision did Dr. Damyan Enchev make and how did the endodontic treatment end?

You may also like:

  1. 02.09.2022, “TOP 5 WEIRD DENTAL CASES” https://amosys.eu/en/top-5-weirdest-dental-cases-in-the-world/
  2. August 11. 2022; “Innovations and challenges in dental technology” https://amosys.eu/en/innovations-and-challenges-in-dental-laboratory/
  3. June 27, 2022, “Intraoral scanners- how to protect the planet with every tooth impression taken” https://amosys.eu/en/intraoral-scanners-how-to-protect-the-planet-with-every-tooth-impression-taken-today/