Challenging cases in the practice of Dr. Damyan Enchev

Part 1

Born to be 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 decayed teeth, with the advancement of science nowadays it is possible to treat even the most challenging 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 their smiles. Many dentists encounter complex cases in their practice that are challenging for them, but they still need to act quickly. Because when the patient visits the dental practice, he relies on good care and an appropriate treatment and dentists are the specialists who must know which solution is best in any difficult situation.

What does the specialist share?

In order to visualize how the resolution of some of the challenging cases in the dental practice goes, Simona from the Teacs team conducted an interview with Dr. Damyan Enchev, Co-Founder of ”ENVIZIA” Dental clinic since December 2013.

Simona: “Dr. Enchev, first of all we want to thank you for taking the time to tell us a little more about the challenging cases you deal with!”

Dr. Enchev: “It’s a pleasure for me too. And yet, I would love to share “things from the kitchen”. I think it will help both patients and dentists to feel more relaxed during a dental visit, and colleagues themselves to gain experience and knowledge.”

Simona: Thank you! We can start with the topic ” Challenging cases”. Which cases do you find complex and difficult? Why are they challenging?

Challenging cases in dentistry

Dr. Enchev: “The most complicated cases in dental practice are those for which we are not prepared with equipment and skills. This is when the dentist hesitates whether he could overcome the challenge and is not sure of his knowledge and skills to solve a given task. In case of such doubts, at the very least, he should call for advice and help from another colleague, refer or forward the case to a specialist with the necessary knowledge, skills and equipment to help him.

In Shumen, Bulgaria, we work together with Dr. Encheva. Every day, patients come to our clinic seeking help from all areas of dentistry. This is because together we cover every specialty in dentistry. I am, among other things, intensively involved in endodontic treatments, oral surgery and implantology. Dr. Encheva deals with children’s dentistry and endodontics. We strive to constantly develop our knowledge and skills so that we can respond to new problems, keep up with technology and be able to treat our patients better.

Modern solutions

Simona: “Which of the modern technologies you work with do you think help you solve the most challenging cases?”

Dr. Enchev: “One of the most advanced technologies currently on the market that I have been working since 2016, is dynamic navigation for oral surgery and implantology, called Navident. The real-time system monitors the dentist’s handpiece and the patient’s jaw and can guide the dentist with an accuracy of about 0.1mm where to make the location and plan their case in advance. The execution is carried out one-to-one with our plan. It is safe for the patient and at the same time extremely precise because we place the implants in the ideal places for them. In this way, we handle challenging even better.

Working with Navident
Working Navident
A case from the practice of Dr. Damyan Enchev

Simona: Can you share a challenging case from your practice?

Dr. Enchev: “I will share a case from last week in which a patient came to the clinic with six teeth left on her upper jaw. Half of them carried a metal-ceramic bridge structure. They had increased mobility, i.e. impaired stability, which meant that they had to be removed and then replaced with several implants that would carry a new prosthetic structure on top of them.

In the absence of technology like Navident, skills and equipment, the normal thing a dentist would do is a removable plaque prosthesis. This is the fastest and easiest solution. It is the most budget-friendly option and it is subsequently the easiest to maintain proper oral hygiene. The patient would remove the teeth, wash them with a brush and paste, and then put them back in. It should be noted, however, that this is not always the solution desired by patients. The reason for this is that it involves constant movement of the prosthesis. The inconvenience of removable plate prostheses is that they can move or fall during meetings or conversations, for example. Also during dining they are not so stable. We are not talking about aesthetics, aesthetics is a compromise. In this case, the function is simply restored.

Bone condition before surgery

The next thing a colleague would do is to use a static surgical guide. This is a kind of template that the 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 delivered to the clinic. If we decide at the last minute to change the work plan, it turns out to be impossible because the guide has already been created. The plan cannot be changed until a new guide is made.”

Planning the steps

Simona: “Does this mean that all steps must be planned in advance? If something changes, can the already made guide be used for the specific case?’

Dr. Enchev: “Yes, but corrections will be necessary. In this case, we will have to resubmit our plan to the dental lab to have everything adjusted accordingly and sent back to us. But I think that today it all turns out to be very expensive. After all, patients pay for our time. Neither equipment nor dental materials are as valuable at this stage as the time we devote to treating patients. And their time, of course.

Bone condition before surgery
Bone condition before surgery
What do modern technologies give us?

Simona: “What do you think is one of the most important benefits of dynamic navigation?”

Dr. Enchev: “One of the most important procedures is “drilling the bone” and therefore cooling the drill. It is known that when drilling something, if the cutter is not adequately cooled, both the material and the cutter can be damaged. Because the drill must pass through the surgical guide, which directs where the drill should work, cooling is not adequate. The deeper the drill enters the bone through the surgical guide, the less it cools, which can harm the bone and then the future healing of the tissue around the implant and its life.

With dynamic navigation, these problems are solved. A 3D photo or photo of the bone (the jaw in volume) is taken, and we can start working immediately afterwards. A plan can be made, but is not required. However, it is done extremely quickly and the work can begin, with the dynamic navigation guiding the dentist and showing exactly where to work.

Thus, speaking of the specific case of last week, the task that was assigned to the clinic was very quickly and successfully completed with a single visit by the patient.”

Digital case planning with Navident
The process itself

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 we made a work plan and administered anesthesia. The system was calibrated within 5 minutes. Calibration is important for the system to understand where the patient is in space, as well as our handpiece and bur. Then we pulled out the old teeth. The six teeth did not require much extraction time. Immediately afterwards, six implants were placed – in the ideal position according to the plan we had made. After all, it all happened within a one-hour visit. The patient came in and a work plan followed, extraction of the old teeth, implants and an impression.

Simonа: “What kind of impressions do you use in your practice?”

Dr. Enchev: “For now, the impression we take is analog. Very soon we plan to purchase an intraoral scanner, by which the impression and its path to the laboratory will be shortened. Thanks to the AMOSYS software, which we already use, the laboratory can start working immediately after the digital impression is removed.

Before operative orthopantomography
After operative orthopantomography
On the patient’s side

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

Dr. Enchev: “The patient feels absolutely nothing. He is under anesthesia”

Simona: “How long does the recovery process take?”

Dr. Enchev: “When working with dynamic navigation, there are no incisions or stitches, because it allows us to work directly transgingival through the venega. It is not necessary to make a “lambo”, i.e. to peel back the gum or soft tissue so we can see when we work. All this is visible in the system in real time. Therefore, the healing stage is much much faster and associated with much less adverse post-operative reactions and problems.

The soft tissues recover quite quickly, while the bone recovers completely by 3-4 months. However, there is a difference between the recovery of implants. When the patient loads the implants immediately, the implants will be much stronger in the future. Of course, if there are the necessary conditions for this. Now the patient will have temporary teeth for 2-3 weeks, after which we will place the permanent ones, along with the dental laboratory we work with.”

Is there a risk group of patients?

Simona: “Is there a group of patients at risk?”

Dr. Enchev: “In the past, dentists refused implantology to some people. For example, with high blood pressure, as well as high blood sugar and diabetics. When we control these factors, we can place Implants without negatively affecting the patient’s health in general.

Aftercare for implants

Simona: “What is the aftercare for implants?”

Dr. Enchev: The advice is that hygiene should be obsessive. They must use all available oral hygiene products. This includes a brush, toothpaste, mouthwash, water shower, interdental brushes for under and around the structure. And also special sutures for subbridge structures around implants. Otherwise, they will not be able to enjoy the new jewel in their mouth. And yet the patient invests quite a bit of financial and time resources.”

Simona: “Do you think you’re putting smiles back 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?

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