Implant Practice US February-March 2016 Vol 9 No 1 Issue by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews February/March 2016 – Vol 9 No 1

Digital dentistry for private practice Dr. Dean C. Vafiadis

Optimizing lateral incisor function and esthetics with the Hahn™ Tapered Implant System Dr. Timothy Kosinski

Educator insight Drs. Pamela McClain and Rachel Shallhorn

Treating edentulous patients using the All-on-4® treatment concept Dr. Moss Osman

BETTER. SIMPLER. STRONGER.

PROMOTING EXCELLENCE IN IMPLANTOLOGY

Cash balance plans Tony Robbins and Tom Zgainer

Corporate profile The OCO Biomedical story

Please visit zestanchors.com/rtx, call us at 800.262.2310, or contact your implant manufacturer for more information.

PAYING SUBSCRIBERS EARN CONTINUING EDUCATION CREDITS PER YEAR!

BETTER. SIMPLER. STRONGER. Introducing the next generation of LOCATOR, the LOCATOR R-Tx™ Removable Attachment System– combining improved design, system simplicity, and DuraTec™ Coating toughness. DuraTec Titanium Carbon Nitride Coating is aesthetic, harder and more wear resistant.

Industry standard .050"/1.25mm* hex drive mechanism.

Dual retentive surfaces for engagement & narrower coronal geometry for easier seating of the overdenture.

50% increase in pivoting capability to 60° between implants.

Convenient all-in-one packaging.

Enhanced geometry to resist movement and anodized pink for improved aesthetics.

Experience the next generation LOCATOR R-Tx Removable Attachment System today! Please visit ZESTANCHORS.COM/RTX, call us at 800.262.2310, or contact your implant manufacturer for more information.

Available NOW for leading implant systems. *Excluding connections that utilize .048” hex drive mechanism. Please contact your implant company provider for more information. ©2016 ZEST Anchors LLC. All rights reserved. ZEST and LOCATOR are registered trademarks and DuraTec, LOCATOR R-Tx and R-Tx are trademarks of ZEST IP Holdings, LLC.

EDITORIAL ADVISORS Steve Barter BDS, MSurgDent RCS Anthony Bendkowski BDS, LDS RCS, MFGDP, DipDSed, DPDS, MsurgDent Philip Bennett BDS, LDS RCS, FICOI Stephen Byfield BDS, MFGDP, FICD Sanjay Chopra BDS Andrew Dawood BDS, MSc, MRD RCS Professor Nikolaos Donos DDS, MS, PhD Abid Faqir BDS, MFDS RCS, MSc (MedSci) Koray Feran BDS, MSC, LDS RCS, FDS RCS Philip Freiburger BDS, MFGDP (UK) Jeffrey Ganeles, DMD, FACD Mark Hamburger BDS, BChD Mark Haswell BDS, MSc Gareth Jenkins BDS, FDS RCS, MScD Stephen Jones BDS, MSc, MGDS RCS, MRD RCS Gregori M. Kurtzman, DDS Jonathan Lack DDS, CertPerio, FCDS Samuel Lee, DDS David Little DDS Andrew Moore BDS, Dip Imp Dent RCS Ara Nazarian DDS Ken Nicholson BDS, MSc Michael R. Norton BDS, FDS RCS(ed) Rob Oretti BDS, MGDS RCS Christopher Orr BDS, BSc Fazeela Khan-Osborne BDS, LDS RCS, BSc, MSc Jay B. Reznick DMD, MD Nigel Saynor BDS Malcolm Schaller BDS Ashok Sethi BDS, DGDP, MGDS RCS, DUI Harry Shiers BDS, MSc, MGDS, MFDS Harris Sidelsky BDS, LDS RCS, MSc Paul Tipton BDS, MSc, DGDP(UK) Clive Waterman BDS, MDc, DGDP (UK) Peter Young BDS, PhD Brian T. Young DDS, MS CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day BDS, VT Julian English BA (Hons), editorial director FMC Dr. Paul Langmaid CBE, BDS, ex chief dental officer to the Government for Wales Dr. Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-in-chief Private Dentistry Dr. Chris Potts BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin Dr. Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral implant surgeon

PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com MANAGING EDITOR | Mali Schantz-Feld Email: mali@medmarkaz.com | Tel: (727) 515-5118 ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkaz.com EDITORIAL ASSISTANT | Mandi Gross Email: mandi@medmarkaz.com NATIONAL ACCOUNT MANAGER | Adrienne Good Email: agood@medmarkaz.com CREATIVE DIRECTOR/PRODUCTION MANAGER | Amanda Culver Email: amanda@medmarkaz.com FRONT OFFICE MANAGER | Theresa Jones Email: tjones@medmarkaz.com

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Volume 9 Number 1

dentulous patients frequently complain about the lack of denture retention, stability, and support. In fact, 50% of denture wearers have problems with retention and stability. The lack of denture retention is mostly noted with the mandibular denture and is accompanied by poor function, speech, neuromuscular control, and continued bone resorption. Studies found that denture stability in both arches was determined to be the criteria that most significantly affected the patient’s quality of life. On the other hand, a stable mandibular denture was the most significant factor in determining patient satisfaction. Dr. Nadim Z. Baba Implant overdentures generally offer the advantages of improved comfort, support, retention, and stability. Retaining and supporting the mandibular denture by using endosseous implants yield improvements in comfort and stability, affording the patients not only effective oral rehabilitation but also greater self-confidence. In addition, treating complete denture wearers with implants to support their dentures improves their chewing efficiency, increases maximum bite force, and clearly improves satisfaction. A key diagnostic decision relates to the number of implants that will be used. This decision is determined by the patient’s expectations, complaints, desires, and financial commitment. The number of implants determines the degree of denture stability, the choices of attachments, and the design of the overdenture. An abundance of abutments have been introduced to retain implant-supported overdentures. Resilient attachments like the LOCATOR® that permit movement about all axes have been proven through the years to be efficient and reliable. The LOCATOR® has grown to be the market leader for implant-supported overdentures.

New abutment The success of the traditional LOCATOR® and Zest Anchors’ quest for innovation and excellence led to the introduction of an improved LOCATOR® abutment, the new LOCATOR® R-Tx Removable Attachment System. LOCATOR® R-Tx can correct divergence up to 30° per implant and 60° between implants without any need for pre-angled abutments. The abutment is coated with titanium carbon nitride (TiCN), which renders the abutment harder, with greater wear resistance and esthetics (pink in color). In addition, the TiCN coating reduces the roughness of the abutment by 64%, potentially minimizing plaque accumulation. The LOCATOR® R-Tx can be inserted onto the implant with a conventional .050” (1.25 mm) Hex driver and has been designed with dual retention on the external surface of the abutment with one set of retention inserts designed to resist edge deformation and provide easy denture insertion alignment. The retention inserts are available in four force levels: zero, low, medium, and high. The denture attachment housing has been anodized pink for improved esthetics under the overdenture where acrylic is thin. In addition, vertical grooves and anti-rotation (flat) features have been designed into the housing to enhance fixation. My clinical experience with LOCATOR® R-Tx shows that the abutment is superior to the traditional LOCATOR®. It allows for more divergence between implants, and the majority of the patients preferred it to the traditional LOCATOR®. This new abutment offers an excellent service both to the patients and their treating dentist. Kudos to Zest Anchors!

Nadim Z. Baba, DMD, MSD, FACP, received his dental degree from the University of Montreal in 1996. He completed a Certificate in Advanced Graduate Studies in Prosthodontics and a Master’s degree in Restorative Sciences in Prosthodontics from Boston University School of Dentistry in 1999. Dr. Baba currently serves as a Professor in the Department of Restorative Dentistry and the Director of the Hugh Love Center for Research and Education in Technology at Loma Linda University School of Dentistry. He is an active member of various professional organizations, a Diplomate of the American Board of Prosthodontics, and a Fellow of the American College of Prosthodontists and the Academy of Prosthodontics. Dr. Baba has received several honors and awards during his career, including the David J. Baraban Award from Boston University, the Claude R. Baker Faculty Award for Excellence in Teaching Predoctoral Fixed Prosthodontics in 2009 from the AAFP, and the California Dental Association’s Arthur A. Dugoni Faculty Award in 2010. He is also the Associate Editor for the Aesthetics/Prosthetics/Restorative section in the Journal of Dental Traumatology and a reviewer for the Journal of Prosthodontics and the Journal of Prosthetic Dentistry. He is the author of numerous publications, has recently published a book entitled Restoration of Endodontically Treated Teeth: Evidence-Based Diagnosis and Treatment Planning, and has lectured nationally and internationally. Disclosure: Dr. Baba is a paid lecturer for Zest Anchors.

Implant practice 1

INTRODUCTION

February/March 2016 - Volume 9 Number 1

New abutment benefits both patient and practitioner

TABLE OF CONTENTS

Financial focus Cash balance plans Tony Robbins and Tom Zgainer discuss an option to accelerate retirement savings and lower tax liability........................................10

Corporate profile The OCO Biomedical story

A celebration of four decades of innovations and accomplishments in implant dentistry

Case study Optimizing lateral incisor function and esthetics with the Hahnâ&#x201E;˘ Tapered Implant System Dr. Timothy Kosinski illustrates treatment of a patient affected by maxillary lateral incisor agenesis .......................................................16

Clinical Single anterior implant crown Dr. Eimear Oâ&#x20AC;&#x2122;Connell presents a single anterior implant crown case in a young patient................................22

Replacing a fractured single central incisor: a natural approach Dr. Attiq Rahman presents a UL1 implant case................................... 26

Educator profile

Case study

Drs. Pamela McClain and Rachel Shallhorn Striving for implant stability..............32

Placement and restoration of a posterior implant Dr. Alif Moosajee demonstrates the placement and restoration of a dental implant on the LR6 and offers hints and tips along the way

2 Implant practice

Volume 9 Number 1

OsseoSpeed™ Profile EV —A unique implant specifically designed for sloped ridges OsseoSpeed Profile EV is specially designed for efficient use of existing bone in sloped ridge situations. • Provides 360 degrees of bone preservation maintaining soft tissue esthetics • Can help to reduce the need for bone augmentation • Components designed to allow for accurate identification of the implant position throughout the treatment process OsseoSpeed Profile EV is an integral part of the new ASTRA TECH Implant System™ EV and is supported by the unique ASTRA TECH Implant System BioManagement Complex. For more information visit

www.jointheev.com

www.dentsplyimplants.com

Follow nature‘s contour

TABLE OF CONTENTS

Product profile Better. Simpler. Stronger.

Continuing education Digital dentistry for private practice

Dr. Dean C. Vafiadis reviews the significant contribution of digital dentistry to implant procedures for better diagnostic techniques and implementation

The next generation of LOCATOR® is here: introducing the LOCATOR R-Tx™ Removable Attachment System.......................................45

Industry news...............46 Practice management Discover the key to achieving 98% case acceptance .................................................48

Practice development Spreading the word Toks Oyegunle continues his series into part 4 with a look at the best media to use to get your message across........................................50

On the horizon The implant practice — it’s more than just implants Dr. Justin Moody discusses his implant system of choice..........................52

Continuing education

Practice management

Treating edentulous patients using the All-on-4 treatment concept

Transitioning employees after a practice purchase

Dr. Moss Osman demonstrates the treatment of a patient with worn and damaged teeth

Paul Edwards offers five effective post-

4 Implant practice

purchase policies.........................54

Volume 9 Number 1

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Buy (15) SDI implants * Get (5) FREE! Call 800-228-0477 to take advantage of this special offer.

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1-800-228-0477 Complete Implant Solutions

CORPORATE PROFILE

The OCO Biomedical story A celebration of four decades of innovations and accomplishments in implant dentistry

OCO Biomedical: a driving force in implant dentistry innovation and performance Celebrating its 40th Anniversary in 2016, OCO Biomedical, Inc., is a proven global leader in world-class dental technology, training, and instrumentation. Headquartered in Albuquerque, New Mexico, the company maintains the position as an industryrecognized leader in implantology. In addition to the company’s vast network of practitioners using OCO products in the United States, OCO Biomedical has a worldwide network of distributors located in Asia, Central and South America, Europe, and the Caribbean. All products are American made.

with an implant, as opposed to a free-end partial denture, was amazing. This experience made me eager to find new ways to incorporate implants into my practice and treat my patients more effectively and quickly. This philosophy stands today as OCO Biomedical’s unshakable platform.”

The development of the O-Ring Overdenture Attachment System According to Dalise, “In the late 1960s, in addition to blades, screws, pins, and endo stabilizers, I began to place subperiosteal implants. Up until that time, all of the abutments and attachment systems used

for attaching an overdenture to an implant were a dental technician’s work of art and practically impossible to reproduce when a new denture was required. Obvious to me, something better was needed.” He began to modify the crown and bridge-like abutments for retention with an O-Ring. He created and developed an O-Ring Overdenture Attachment System consisting of an abutment with a horizontal groove and housing to retain the ring in a PVC plastic or metal encapsulation. In the early 1970s, the prototypes of the System were very crude. In 1974, he found a machinist to accurately cut the Delrin abutments on a lathe. Dalise

The formative years Early on, Dr. David D. Dalise, OCO Biomedical founder, president, and implant innovator, was fascinated by all aspects of mechanics and mechanical engineering. His first exposure to dentistry occurred while serving in the U.S. Air Force. His intent was to become a pilot. By chance, through meeting and being inspired by military dental practitioners, the Chicago native changed his focus to dentistry. Vision became reality when he graduated from the University of Illinois College of Dentistry in 1965 and after that ran a private implant practice. Dalise says, “During my early years in general practice, I was profoundly influenced by the early implant pioneers like Lenny Linkow, Isaiah Lew, and Aaron Gershkoff. “Motivated by the exciting work that they were doing, I made the decision to incorporate dental implants into my general practice. I joined numerous professional organizations such as the AAID, ICOI, and the AGD to gain greater knowledge of ways to increase my skills, improve on known dental devices, and enhance techniques in order to make procedures more efficient.” Dalise continues, “My turning point came when I attended an ADA meeting and purchased a blade implant that intrigued me. My patient had missing lower molars, and I used the blade implant, novel at the time, as a treatment option to replace them. The joy and impact of replacing the missing teeth 6 Implant practice

“O” Company catalog Volume 9 Number 1

CORPORATE PROFILE

recalls, “I then used a vacuformer to shrink form the PVC plastic encapsulations of the rings on abutment-shaped pedestals. I later located an old metal shoelace hole manufacturing machine that converted into making metallic encapsulations for the O-Rings. We were now able to provide both the PVC and the metallic ring female retainers for the castable Delrin male abutments, which also served as a resilient lab transfer die.”

Formation of the O-Company Dalise began to produce and manufacture the O-Ring Attachment System and made his System available to the few laboratories that were constructing subperiosteal implants. He began working with Eric Bausch at Howmedica/Austenal, a Chicago-based laboratory, which pioneered subperiosteal implant design. At Howmedica’s suggestion, he patented the O-Ring Attachment System. A proven entrepreneur, Dalise incorporated his business and formed the O-Company in 1976.

The blade implant — root-form implants In the late 1970s and early 1980s, the O-Company began producing blade implants along with pioneering the carbon coating of blade and subperiosteal implants. In the early to mid-1980s, the Branemark threaded root-form implant was introduced in the U.S. According to Dalise, “Branemark spent $25 million to market the root-form implant, and it began gaining popularity. Their outreach to colleges, universities, and dental specialists convinced the dental community that all other types of implants were invalid.” Shortly thereafter, Calcitek introduced the HA-coated cylinder implant, and the O-Company, responding to this growing market trend, started producing the O-Ring Attachment System for all root-form systems that came to the market.

Root-form manufacturing and HAcoated surfacing Dalise explains, “Three companies licensed our patented O-Ring Overdenture Attachment System, but we also machined the System for all root-form implants that hit the market. This strategic move made our O-Ring Overdenture Attachment System the most widely used system in the world, then and still today.” After discovering that the System had been imitated, the decision was made to make an improved proprietary root-form product instead of litigation. Consequently, a Volume 9 Number 1

Micro-Ring Lab manual 1979

Micro-Ring ad 1978

Practitioners are given highly responsive and personalized service with open access to experienced technical representatives and to practicing implantologists for clinical advice.

modified root-form cylinder that was HA-coated was developed. The Company incorporated unique features in a design that included slots halfway up the implant to prevent rotational dislodgement. Rather than having a hole at the apex, a dimple was placed that would further stabilize the apex and eliminate a void after integration.

The transition to tissue level implant production In the early 1990s, the O-Company added a 2-mm machined collar to the top of the implant to protect the HA-coated

O-Butment surgical technique manual

surface from invagination of oral fluids and breakdown after slight bone resorption. A year later, an additional millimeter was added to the collar so that the implant was essentially a tissue level implant as opposed to a bone level implant. This modification facilitated an abutment that was easier to restore and also protected the crestal bone from the slight microleakage at the implant/abutment interface. Implant practice 7

CORPORATE PROFILE Implant design refinement Dalise states, “By the mid-1990s, it became apparent that the threaded versus cylinder implants were becoming more popular. To meet growing market demand, we refined our already successful threaded cylinder implant with a 32-thread-per-inch design. The slots on the side of the implant were left in place so that the implant could be placed by first tapping the bone or placed as a self-tapping implant. We also added an internal spline and then a taper to support an anti-rotational, timed abutment.”

The development of the awardwinning 3.0-mm mini implant By the year 2000, mini implants were becoming popular. Then Production Manager, Larry Vetter, suggested that the Company add a mini implant to the product line. States Dalise, “I felt that if we were to introduce a mini implant, it must be the best

and most reliable on the market. From my earlier experience with pin implants, the 1.8-mm and 2.5-mm diameter implants were too flimsy; so I reasoned that a 3.0-mm would be ideal. After beta testing several different tip designs, we developed an orthopedic-like bullnose auger tip and added a new embedded tapered platform at the top of the implant. The design, being unique and extremely stable, was patented with distinctive and key features to facilitate immediate loading. Designed with an O-Ball abutment or a crown and bridge abutment, the 3.0-mm one-piece implant could be used in various types of implant procedures such as overdentures, failed implant revision, and the replacement of individual teeth.” Dalise asserts, ”At that time, I was promoting direct placement rather than reflecting a flap. I knew that the embedded tapered platform would ensure that the coated portion of the body of the implant

would always be below the crestal cortical bone and add initial stability. After placing many of these implants and immediately loading both the O-Ball and crown and bridge version, the performance and success rate were remarkable. This initial stabilization is what we now call osseous fixation.” Dalise states, “Serendipitously, the O-Company designed an implant that is biomechanically active once placed. The design of the implant puts effective forces, mainly tension, on the bone once fully seated. This allows for early loading, and the resultant forces during function have the ability to alter the biologic stability and healing in a positive way.

OCO extends product line with additional one- and two-piece implants Due to the superior performance and proven effectiveness of the one-piece 3.0-mm diameter implant, the product line was expanded by producing a 3.25-mm, 4.0-mm, and 5.0-mm versions of the onepiece implant. This product became known as the ISI (Immediate Stabilizing Implant) line. In 2005, The O-Company had a name change to OCO Biomedical. By 2006, the two-piece versions, known as the TSI (TwoStage Implant) with a removable abutment were introduced. The ERI (Esthetic Region Implant) with a 1.0 -mm embedded tapered platform was also added. Market ready, the comprehensive methodology was introduced as “OCO Biomedical’s Complete Implant System,” a system patented and unchallenged for immediate or early loading.

OCO’s complete implant solutions approach changes implantology today With the exceptional record of progressive innovations associated with the company, the future looks even brighter and more promising. Over the last few years, there has been a concerted effort to continue to innovate and refine the existing system and product line to better address the needs of users through product development, education, and customer care.

Education and training are key components to OCO’s success

“O” Company PS Bar Technique manual 8 Implant practice

In late 2012, Charles Schlesinger, DDS, FICOI, became Director of Education and Clinical Affairs and eventually assumed the role of Chief Operating Officer. States Schlesinger, “My first objective was to overhaul the educational program at OCO. Along with the restructuring and implementation of a Volume 9 Number 1

CORPORATE PROFILE

OCO Biomedical’s current full line of implants

multilevel educational curriculum, I wanted to create a yearly symposium to bring together practitioners from around the world. In 2016, the third annual OCO Biomedical International Symposium will be held July 22-23 in Albuquerque, New Mexico. Today, the OCO Biomedical educational program, aligned with our educational partners, has trained thousands of doctors nationwide.”

The propriety and exclusive OCO Guided Surgery Kit and System and other product developments A significant challenge in this field is to recognize viable trends. With this in mind, and with the movement toward digital dentistry, the company developed its proprietary OCO Guided Surgical System, which has been successfully implemented into the majority of today’s CBCT and guide libraries. Over the last 3 years, the OCO product line has grown with the addition of the 7.0-mm Macro implant and enhancements Volume 9 Number 1

to the already successful Engage™ bone level line, including the introduction of the 7.0-mm and 8.0-mm diameter implants. Omni-Load abutments, which allow for multi-unit, screw-retained restorations, were also additions to the restorative lineup to address the growing use of screw-retained hybrid restorations in all-on-4TM and all-on-6 clinical applications. States Schlesinger, “Our commitment to innovative breakthrough solutions remains steadfast.”

Strategic partnerships Schlesinger affirms, “We continue to provide everything a practitioner will need to run a successful implant practice. To achieve that, we have formed strategic partnerships with Vatech USA, Dani Dental Laboratory, 3DDX, Progressive Dental, and educational partners to offer a comprehensive solution for the doctor who is committed to improving practice performance and patient care.”

Customer care is a priority at OCO Biomedical, Inc. Another area where OCO excels is the continued refinement of the company’s already unmatched customer care. Practitioners are given highly responsive and personalized service with open access to experienced technical representatives and to practicing implantologists for clinical advice.

Vision for the future — a legacy of leadership and innovation “As we look to the future, it is our goal to continue to address the needs of our doctors to allow them the ability to provide predictable and quality implant dentistry for their patients. The culture and implant ideology set in motion by David Dalise in 1976 will evolve and thrive. I am privileged and proud to carry on the torch for years to come,” declares Schlesinger. IP This information was provided by OCO Biomedical.

Implant practice 9

FINANCIAL FOCUS

Cash balance plans Tony Robbins and Tom Zgainer discuss an option to accelerate retirement savings and lower tax liability

ach year around this time, we can all see the inevitable not too far in the distance. Our tax liability — and how we manage it — is generally not as festive as the recently past holiday season. However, your retirement planning and the type of plan you establish can offer a reduction of tax liability and accelerated contributions to help produce additional income when you’ll need it most — at retirement after active work. There are two general types of pension plans — defined-benefit plans and definedcontribution plans. In general, defined-benefit plans provide a specific benefit at retirement for each eligible employee, while definedcontribution plans specify the amount of contributions to be made by the employer toward an employee’s retirement account. In a defined-contribution plan, the actual amount of retirement benefits provided to employees depends on the amount of their contributions, along with employer contributions such as Safe Harbor or profit-sharing contributions, as well as the gains or losses of the account over time. Many of our dentist clients take advantage of this combination by “maxing” out the total allowable contributions, currently $53,000 if under age 50 or $59,000 if over age 50, while giving a needed ratio of contributions to eligible staff as well. However, we often are asked, “What else can I do aside from after tax investing? What other types of retirement plans are available?” Enter the cash balance plan, a type of defined-benefit plan that when paired with a 401k/profit-sharing plan provides an opportunity to essentially squeeze 20 years of saving into 10, while at the same time significantly reducing your tax liability along the way. As the chart accompanying this article shows, the benefits of the cash balance plan really start to accelerate as the business owner gets beyond age 45-50. While employer matching and profitsharing contributions are discretionary, cash

Peak performance strategist Tony Robbins and Tom Zgainer, founder and CEO of America’s Best 401k, offer advice on growing retirement savings.

10 Implant practice

2016 Contribution Limits 401(k) PROFIT-SHARING AND CASH BALANCE PLANS Age

401(k) with Profit Sharing*

Cash Balance

Total

Tax Savings**

$59,000

$237,000+

$296,000+

$133,200

$59,000

$237,000

$296,000

$133,200

$59,000

$243,000

$302,000

$135,900

$59,000

$248,000

$307,000

$138,150

$59,000

$254,000

$313,000

$140,850 $135,000

Above 65

$59,000

$241,000

$300,000

$59,000

$228,000

$287,000

$129,150

$59,000

$216,000

$275,000

$123,750

$59,000

$205,000

$264,000

$118,800

$59,000

$194,000

$253,000

$113,850

$59,000

$184,000

$243,000

$109,350

$59,000

$175,000

$234,000

$105,300

$59,000

$165,000

$224,000

$100,800

$59,000

$157,000

$216,000

$97,200

$59,000

$149,000

$208,000

$93,600

$59,000

$141,000

$200,000

$90,000

$59,000

$133,000

$192,000

$86,400

$53,000

$126,000

$179,000

$80,550

$53,000

$120,000

$173,000

$77,850

$53,000

$114,000

$167,000

$75,150

$53,000

$108,000

$161,000

$72,450

$53,000

$102,000

$155,000

$69,750

$53,000

$97,000

$150,000

$67,500

$53,000

$92,000

$145,000

$65,250

$53,000

$87,000

$140,000

$63,000

$53,000

$82,000

$135,000

$60,750

$53,000

$78,000

$131,000

$58,950

$53,000

$74,000

$127,000

$57,150

$53,000

$70,000

$123,000

$55,350

$53,000

$66,000

$119,000

$53,550

$53,000

$63,000

$116,000

$52,200

35 Under 35

$53,000

$59,000

$53,000

Up to $56,000

*401(k): $18,000; $6,000 catch-up; $35,000 profit sharing

balance plans require more of a commitment to fund the plan by the employer. Most plans are set up with a 3-5 year funding period, so they work well in environments where the business owner will have predictable income over that time frame. Different from a 401k plan where participants generally choose their investment options, the assets of a cash balance plan are managed by the employer or an investment manager. In a typical cash balance plan, a participant’s account is credited each year with a “pay credit” (such as 5% of

$112,000 Up to $109,000

$50,400 Up to $49,050

** Assuming 45% tax, varies by state. Taxes are deferred

AMERICA’S BEST 401k

compensation from the employer) and an “interest credit” (either a fixed rate or a variable rate that is linked to an index such as the 1-year Treasury Bill rate). To determine if a cash balance plan is right for you, enlist an actuary who is an expert in retirement plan design to analyze your practice demographics with a current census of full-time employees. If this plan design can meet your individual and corporate objectives, you have a far greater pool of income available when the time comes to hang up the white coat. IP Volume 9 Number 1

Dr. Alif Moosajee demonstrates the placement and restoration of a dental implant on the LR6 and offers hints and tips along the way

patient presented to the clinician with a lost LR6, which she wanted restored. This case study details her dental implant treatment.

Presentation Patient complaint • The patient had lost the LR6, a failed root-filled and crowned tooth, 2 years previously; she had considered an implant in the past and felt that it was the right time to pursue this course of treatment. • The patient found herself chewing on the left-hand side to avoid the gap on the right. • The patient had no other dental concerns, and her expectations were realistic. • The patient was a dental nurse and had assisted on dental implant procedures, so was well aware of the treatment, risks, and benefits. Medical history • The patient had a well-restored mouth and no previous implants. • Dental attendance is good. • Her last treatment was removal of the LR6 2 years ago. • Her dental awareness was very good. • The patient was a nonsmoker. • The patient consumed three-to-four units of alcohol per week. • There was no other significant medical history to report.

Intraoral examination • All teeth present except for LR6. • Soft tissues — scalloped tongue and linea alba on the left and right buccal mucosa. • No caries present. • BPE was 000/020 (minimal supragingival calculus on the lower anterior teeth with no inflammation). • Tooth wear was age appropriate. • Patient was aware of clenching. The only signs were the scalloped tongue and linea alba on the left and right buccal mucosa. • Teeth were carefully examined for signs of occlusal disease; and there were no cracks or fractures, no fremitus, no bruxism-related wear, and no unexplained sensitivity or other signs of active bruxism. • Posterior occlusion was stable, and posterior support was sufficient. • The opposing tooth was very slightly overerupted (less than 1 mm). • The occlusal contact pattern in maximum intercuspation is a cusp/ fossa contact pattern. • In lateral excursions, the patient starts with group function, which proceeds to canine guidance.

Implant site assessment When considering the site for the implant in more detail, it was noted that there were no horizontal or vertical defects in the ridge. There was good horizontal and vertical space for placement of the implant. The opposing tooth had not extensively overerupted, and the teeth mesial and distal to the space had not drifted; hence, there was also adequate room for the restoration of the implant. There was, therefore, no need for any pre-prosthetic adjustments to the occlusion, to the arch form, or to the adjacent teeth.

Special tests Upper and lower alginates were taken along with a facebow so that mounted models could be made. A wax-up of the proposed crown was made upon the mounted cast and duplicated. An X-ray stent with radiopaque tooth and a drill guide was also fabricated. As with all good implant planning, the treatment was prosthetically driven, so making the final crown first in the form of a wax-up was the natural first step in properly planning this case. Bitewings and periapical radiographs of the LR6 area were taken and did not suggest any problematic anatomy. Proximity to the inferior dental (ID) canal was

Extraoral examination • Muscles of mastication — NAD. • Mouth opening — even opening to three fingers width. • TMJ — no deviations and no clicking or crepitu. Alif Moosajee, BDS, MFGDP(UK), MJDF (RCS eng), is the owner of the Leicester, United Kingdom-based dental practice Oakdale Dental, which provides implants and orthodontic treatment along with cosmetic and general dentistry. His passion for patient communication led to the idea of his newly launched book, The Smiling Dentist. Find out more at www.smilingdentist.co.uk.

Figure 1: Preoperative photo – full retracted smile Volume 9 Number 1

Implant practice 11

CASE STUDY

Placement and restoration of a posterior implant

CASE STUDY

Figure 2: Preoperative photo of LR6 area

carefully considered, and the decision was made to take a CBCT scan in order to ensure there were no anatomical issues. Potential concerns in this area are damage to the ID bundle or perforation into the lingual space if there is a surprisingly deep lingual concavity. It was clear that the case needed to be prosthetically driven, so as previously mentioned, a wax-up was made before the CBCT scan so that a radiopaque tooth could be placed in a stent, and the CT scan could be done with the radiopaque tooth in place. This allowed planning of implant placement in the perfect position within the bone in order for the crown to be placed optimally and ensuring that a screw-retained crown could be used. There is much to be said in the debate between screw-retained and cemented crowns. It is the author’s opinion that screwretained crowns are more easily retrievable, and although the number of failures with screw-retained and cemented crowns is similar, the evidence shows that the types of failures attributed in cemented crowns tend to be more serious. It is very easy to leave the cement deep down where the crown margins are (if a customized abutment is not used), and these can lead to the inability to clean and, ultimately, to peri-implant disease. This author feels that that screw-retained crowns sidestep this problem. Although they have a higher rate of technical complication (such as screw loosening), they are also relatively easily retrieved, and these complications can be managed relatively simply.

Figure 3: Preoperative photo of LR6 – occlusal view

Figure 4: Surgical stent in place

Figure 5: Radiographic stent

Figure 6: CBCT scan

Figure 7: Post incision – flap raised, exposing the full extent of the ridge

Surgical treatment Local anesthetic was administered (4.4ml lignocaine with adrenaline 1:80,000) as an ID block as well as infiltration around the area to give good anesthesia when raising the flap and preparing the osteotomy. An H-shaped incision was made in the middle of the ridge in the LR6 position (making sure there was adequate attached gingivae both buccal and lingual to the incision). The flap was reflected to ensure the entire width of the ridge could 12 Implant practice

Figure 8: Checking the osteotomy orientation and position

Figure 9: Socket tapped Volume 9 Number 1

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CASE STUDY be visualized so that we could place the implant optimally. The drill guide was placed and used to start the osteotomy in the correct position. The position of the implant for optimal crown placement is not always consistent with the middle of the ridge. Once upon a time, the implant would be placed in the best surgical site, and then the crown would just have to “fit.” This often resulted in compromised treatment. The drill guide pushes the clinician to think more about where the implant needs to go to ensure that the crown is in the correct place. Sometimes this means that the implant is not squarely on the ridge; and especially in the esthetic zone, this can mean that the ridge has to be augmented (either before the implant is placed or at the time of placement). Raising of the flap and adequate visualization allows the surgeon to make sure that the quality of the bone is good, and in this case, that the prosthetically-driven position of the

osteotomy was not so buccal or lingual that it might need augmentation afterwards. The sequence of drills was followed exactly as outlined by Straumann®, and checking was done between each successive drill to ensure that angulation and depth were correct. After drilling to a length of 8 mm, the bone was tapped as it was very dense, which you would expect in the posterior mandible. A Straumann bone level 8 mm RC (4.8 mm) implant was then placed, achieving primary stability with a very high insertion torque. With the implant in situ, a healing cap was placed and two simple interrupted sutures (5.0 Vicryl Rapide™ dissolving [Ethicon]) were placed mesially and distally. Good closure of the wound was obtained.

Post-surgical treatment Being that the patient is the dental nurse

at the clinician’s practice, she was seen again just 3 days after the procedure. She had experienced no swelling or bruising over the weekend, so both the patient and I were very happy with this result. The patient was seen again after 2 weeks for a review and removal of the sutures. It had been an uneventful 2 weeks. On examination, the patient’s oral hygiene was excellent.

Prosthetic treatment After 2 months, the healing cap was removed, an impression fixture was placed, and a closed tray putty wash impression was made. The lab used a Variobase™ (Straumann) abutment, and a Straumann original zirconia coping was milled using CAD/CAM. Feldspathic porcelain was added as a veneering ceramic. When the crown returned, it was checked on the articulator so assessment

Figure 10: Post-surgical periapical radiograph

Figure 11: Postoperative photo

Figure 12: Closed tray impression

Figure 13: Computer-aided design of the restoration (occlusal view)

Figure 14: Computer-aided design of the restoration (buccal view)

14 Implant practice

Figure 15: Restoration returned from the lab (buccal view on articulated model) Volume 9 Number 1

in lateral excursions, though shimstock could not be pulled when the patient was in contact with light force. Therefore, the occlusion was very subtly adjusted down until shimstock was pulled through on light contact but was held on heavy contact. This was done because the implant has no suspension as it has no periodontal ligament. (It is an ankylosis.) Therefore, when patients bite down hard or if they clench, the teeth will move apically very slightly but the implant cannot, and so it has to be protected slightly by managing the occlusion this way to act as a stress break.

Figure 16: Restoration returned from the lab (occlusal view on model)

Figure 17: Screw-retained restoration in place with access filled (occlusal view)

Figure 18: Screw-retained restoration in place (buccal view) Volume 9 Number 1

A postoperative periapical radiograph was taken, which showed that the implant crown was well seated and that there was no bone loss since the implant was placed. The patient is delighted with the result, and she says that it feels as though the tooth is her own. A review was carried out 2 weeks posttreatment, and she is keeping the area very clean. The occlusion is stable, and tissues have healed and adapted well.

Personal reflection Having completed the International Team for Implantology (ITI) FID yearlong course in dental implants, I was very keen to place my first implant. Theoretical learning is incredibly important, but it does not compare to practical experience. This is the time when you can test your knowledge and learn the little nuances that allow you to treat cases better. When I reflect on this case, I see many positives. I believe it was planned well and that the execution was generally good. I have become very comfortable with â&#x20AC;&#x153;hard tissue dentistry.â&#x20AC;? Crown and bridge provision and treatment of occlusally complex cases used to really worry me, but I am very comfortable with these cases now. However, I am well aware that my personal weakness lies in surgical dentistry. This was something that I knew had to be addressed if I wanted to have any chance of being able to do good surgical implant work, and this is why I enrolled on a certificate course in oral surgery at the same time as doing my implant training. As my first case, I think it was really important to have my mentor Dr. Bayan Al-Sarraj by my side. There were times when his guidance on this case was invaluable. By its very nature, the stakes are high when performing implant treatment, and failure can be punished harshly. Our patients deserve the best, so if guidance will allow us to provide this, then that can only be a good thing for all parties. IP

Figure 19: Final post restorative X-ray Implant practice 15

CASE STUDY

of the occlusion could be carried out before it was fitted. Contacts were checked as well. The crown was a screw-retained porcelainfused-to-zirconia on a Variobase abutment. On the day of the crown fit, the healing abutment was removed, and the crown was seated and then torqued to 35Ncm. The screw access hole was protected with polytetrafluoroethylene (PTFE), and then an occlusal composite was placed to restore the access hole. The fit was excellent, and the contacts were fine, though the occlusion did need some adjustments. There was point contact in centric, with no contact

CASE STUDY

Optimizing lateral incisor function and esthetics with the Hahn™ Tapered Implant System Dr. Timothy Kosinski illustrates treatment of a patient affected by maxillary lateral incisor agenesis

axillary lateral incisor agenesis (MLIA) is a condition in which at least one of the maxillary lateral incisors is missing in the primary or permanent dentition. One of the most common congenital anomalies, MLIA occurs in the smile zone and affects both dental esthetics and function. These problems can impact the self-esteem and social relationships of individuals with this condition.1,2 As innovations in dental implants and prosthetic materials have been made, esthetic restoration of dental function has become a straightforward, predictable process. With advanced designs and surface treatments, modern implants integrate exceptionally well, ensuring long-term stability and function. Implant dentistry is an excellent mode of treatment for improving the lives of patients with MLIA. Although tooth replacement at the maxillary lateral incisor site may present challenges due to limited anatomical space and its location in the esthetic zone, implant therapy has become one of the primary treatment options for addressing this anomaly.3 In addition to providing optimal, esthetic restorative results, this mode of treatment preserves the alveolar ridge. For patients with MLIA, implant therapy is a conservative approach that avoids damage to the morphological features of neighboring dentition.1 Provided the available space is sufficient for implant placement, treatment is relatively noninvasive because adjacent teeth do not need to be prepared for a bridge. In the event that there is not enough room to receive an implant, it

Timothy Kosinski, DDS, MAGD, graduated from the University of Detroit Mercy (UDM) School of Dentistry and received a Master of Science degree in biochemistry from Wayne State University School of Medicine. An adjunct clinical professor at UDM School of Dentistry, he serves on the editorial review board of numerous dental journals. Dr. Kosinski is a Diplomate of the ABOI/ID, ICOI, and American Society of Osseointegration, and a Fellow of the AAID, ACD, ICD, and ADI. He has a Mastership in the AGD and is immediate past president of the Michigan AGD, from which he received the Lifelong Learning and Service Recognition award in 2009 and 2014. Dr. Kosinski has published over 140 articles and contributed to textbooks on the surgical and prosthetic phases of implant dentistry.

16 Implant practice

is possible to create the necessary space through orthodontics.4 The following case summary demonstrates implant placement in a 20-year-old female who presented with an acid-etch bridge that was used to restore her congenitally missing maxillary right lateral incisor. Following orthodontic therapy that had straightened the patient’s smile, the existing bridge was placed and maintained the mesial-distal space nicely during the patient’s formative years. Although esthetic, the patient’s bridge was unstable and fell off periodically. Due to problems with long-term retention, the acid-etch bridge is not considered a viable permanent solution.5 The young college student was interested in single-tooth replacement and had discussed dental implant treatment with her general dentist. The Hahn™ Tapered Implant System (Glidewell Direct, Irvine, California) was utilized to restore the missing tooth. The implant system includes implants with narrower diameters, a feature that is beneficial for cases in which space is limited. Additionally, the tapered body of the implant is

ideal for use in anatomically constricted areas. The prominent thread design also allows the implant to be more easily positioned and controlled by the clinician during placement. Following integration of the implant, a cement-retained BruxZir® Anterior crown provided a strong, esthetic final result.

Case summary The patient presented with a cuspid and central incisor that were minimally prepared on the palatal aspect to support the wings of the acid-etch bridge (Figure 1).

Figure 1: The patient presented with an acid-etch bridge. The teeth adjacent to the edentulous site had been minimally prepared to permit retention Volume 9 Number 1

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CASE STUDY The acid-etch bridge was indeed nice and esthetic (Figure 2). However, the patient was mainly concerned about long-term function. There was no indication to prepare the adjacent teeth for a conventional 3-unit bridge. Although there were no medical contraindications to implant therapy, the amount of space between the adjacent natural teeth was minimal. As mentioned earlier, the lateral incisor site can present some difficulties when surgically placing dental implants. The facial-palatal width is often compromised, especially for cases in which the edentulous condition is congenital. A digital periapical radiograph of the edentulous site indicated, however, that there was enough space to surgically position and accept a dental implant (Figure 3). When placing an implant, the practitioner needs to be certain that the angulation, depth, and position of the implant are appropriate to allow for a natural emergence profile. For this case, scans were taken using the PaX-i3D Green imaging system (VATECH America Inc., Fort Lee, New Jersey) for CBCT image analysis. The sagittal view of the scan illustrates the amount of vertical and horizontal bone that was available (Figure 4). The amount and quality of bone was precisely determined with the imaging software. Virtual placement of the implant can also be

performed, helping the practitioner select the appropriate implant size and visualize how the implant should be positioned in the edentulous space. Because the patientâ&#x20AC;&#x2122;s anatomy did not present any complications, the implant was placed without the use of a surgical guide. After treatment planning, the acid-etch bridge was easily removed from the adjacent teeth (Figure 5). This revealed a defect on the facial contour of the edentulous space. Due to the lack of interseptal bone, no interdental papillae were present (Figures 6A-6B). A pilot drill was centered between the teeth adjacent to the edentulous site. The osteotomy was positioned approximately 3-mm palatal to the facial aspect of the adjacent dentition to allow for the best esthetics and enough facial room for a custom

Figure 2: Though the acid-etch bridge provided good esthetics, it would come loose, causing the patient to worry about its long-term function

abutment and implant-retained crown. The mesial-distal angulation of the drill was checked with a periapical radiograph. The diameter of the osteotomy was slightly smaller than that of the implant chosen for this case, and a depth of approximately 13 mm was established (Figure 7). A 3.0-mm-diameter Hahn Tapered Implant was chosen for this case. The diameter size and tapered body of the implant

Figure 3: Radiography indicated that there was sufficient bone volume for the placement of an implant

Figure 5: The acid-etch bridge was removed without complication

Figure 4: With CBCT technology, the quantity and quality of bone can be assessed digitally

Figures 6A-6B: No interdental papillae were present due to the patientâ&#x20AC;&#x2122;s congenital condition 18 Implant practice

Figure 7: The depth of the osteotomy was about 13 mm Volume 9 Number 1

(Figure 10). A postoperative CBCT scan was used to verify the position of the implant and proper maintenance of the facial bone. The patientâ&#x20AC;&#x2122;s acid-etch bridge was then cemented back onto the adjacent teeth (Figure 11). Four months following surgery, the patient returned to begin the restorative process (Figure 12). A tissue punch was utilized to access the healed implant site (Figures 13A-13B). Because of the relatively noninvasive nature of the tissue punch, the final impression was taken during the same visit. The cover screw was removed, and an impression coping was hand-tightened into the conical internal hex connection of the Hahn Tapered Implant (Figures 14A-14B). PanasilÂŽ vinyl polysiloxane material (Kettenbach, Huntington Beach, California) was used to create a final impression so the dental lab could fabricate the restoration (Figure 15).

Figure 9: A cover screw was hand-tightened into the implant

Figure 10: Despite the small space that was available, a 3.0-mm diameter tapered implant was placed with ease

Figure 12: Full osseointegration was achieved 4 months after implant placement

Figures 13A-13B: The implant was exposed with a tissue punch

Figures 14A-14B: After removing the cover screw, a transfer coping was attached to the implant Volume 9 Number 1

Figure 11: The acid-etch bridge that the patient had been using prior to implant treatment served as a temporary during the healing period

Figure 15: A final impression was taken with Panasil vinyl polysiloxane impression material Implant practice 19

CASE STUDY

Figure 8: The implant was threaded into the undersized osteotomy

was ideal for the limited space that was available. Additionally, the implant features prominent threads, which ease placement and allow the clinician to thread the implant into an undersized osteotomy (Figure 8). The ability to place an implant in a slightly smaller osteotomy can help ensure excellent primary stability.6 This is especially beneficial in cases where bone quality is not optimal. Because her acid-etch bridge would function as a transitional appliance during the period of healing and osseointegration, a cover screw was hand-tightened into the implant (Figure 9). As illustrated in the radiograph, the implant was nicely positioned

CASE STUDY Based on the final impression, the lab produced an Inclusive® Titanium Custom Abutment and an esthetic BruxZir® Anterior crown. In order to achieve symmetrical esthetics and occlusion when the patient is missing only one maxillary lateral incisor, the dimensions of the restoration should be primarily dictated by those of the contralateral tooth.3 Thus, the lab aimed to mimic the shape and contours of the contralateral incisor. Because the patient could return to the dental office only during school breaks, the patient again used the acid-etch bridge as a transitional prosthesis. At the final delivery appointment, the soft tissue was once more removed using a simple tissue punch (Figures 16A-16B). The custom implant abutment was then placed, and the prosthetic screw was tightened. Note that the margins of the abutment were just slightly subgingival, making removal of the cement easy and predictable (Figures 17A-17B). The final crown was cemented on the custom abutment. A final radiograph verified complete seating of the restoration (Figure 18). The patient was pleased to have a fixed restoration that exhibits high stability, strength, and esthetics (Figure 19).

Conclusion Implant treatment is an excellent method of restoring dental function and esthetics. Understanding the complexity of the patient’s condition is imperative to the long-term success of the case. Choosing not only the right dental implant, but also

considering the proper prosthetic components is important. In this case, implant treatment proved to be an outstanding treatment modality in a difficult situation, and the Hahn Tapered Implant allowed for surgical predictability and reliable osseointegration. IP

Figures 16A-16B: A tissue punch was utilized prior to placement of the Inclusive Titanium Custom Abutment

Figures 17A-17B: The custom titanium abutment was designed with margins that were slightly subgingival in order to simplify removal of excess cement

Figure 18: Radiography demonstrated complete seating of the final restoration REFERENCES 1. Pini NI, De Marchi LM, Pascotto RC. Congenitally missing maxillary lateral incisors: update on the functional and esthetic parameters of patients treated with implants or space closure and teeth recontouring. Open Dent J. 2014;8:289-294. 2. Willhite C, Bellerino M, Eubank J. Treatment of congenitally missing lateral incisors with resin-bonded fixed partial dentures. Quintessence Dent Technol. 2002:63-72. 3. Richardson G, Russell KA. Congenitally missing maxillary lateral incisors and orthodontic treatment considerations for the single-tooth implant. J Can Dent Assoc. 2001;67(1):25-28. 4. Nirola A, Bhardwaj SJ, Wangoo A, Chugh AS. Treating congenitally missing teeth with an interdisciplinary approach. J Indian Soc Periodontol. 2013;Nov;17(6):793-795. 5. El-Mowafy OM. Posterior acid-etch bridge—a modified retentive design. J Can Dent Assoc. 1996;Nov;62 (11):862-865. 6. Degidi M, Daprile G, Piattelli A. Influence of underpreparation on primary stability of implants inserted in poor quality bone sites: an in vitro study. J Oral Maxillofac Surg. 2015;Jun;73(6):1084-1988.

Figure 19: The final restoration exhibits lifelike translucency and contours that mimic those of the contralateral incisor 20 Implant practice

Article published with permission from Inclusive magazine.

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3034532_1.0 ECO #3034511

CLINICAL

Single anterior implant crown Dr. Eimear O’Connell presents a single anterior implant crown case in a young patient Initial complaint

Patient expectations

Examination

This young man attended the practice complaining that his adult tooth was missing on the upper left lateral site, and the deciduous tooth was starting to come loose. He wanted to find out more about what the options were for treatment.

The patient didn’t want to wear a denture as he is only 23, and he did not want to damage his adjacent teeth in any way. This immediately ruled out an adhesive bridge. I discussed using orthodontics to correct his occlusion as he has a Class III malocclusion. He did not want to wear a brace as he had just started at art college. The treatment may even have included an osteotomy, but would definitely have to involve having teeth extracted in the lower arch. The patient did not want to go through such extensive treatment and wanted a conformist approach accepting his malocclusion and replacing the baby tooth with an implant-retained crown in the space available once extraction was carried out.

At the first visit, he was examined, and extraoral and intraoral findings were clear. He has a Class III malocclusion, which will in part determine the outcome of the treatment. Study models and a periapical X-ray of the upper left bicuspid (ULB) were taken. His community periodontal index of treatment needs (CPITN) was 111/110. He has a thin, highly scalloped periodontium, and bone-sounding revealed adequate bone width.

Figure 1

Past dental history The patient has been a regular dental attender at a practice near his home in England and has good oral hygiene and no fillings.

Past medical history The patient is medically fit and well and is a nonsmoker.

Diagnosis His past dental history is uneventful, but he had never had any invasive dentistry, not even a local anesthetic, so we had to discuss what would be involved in the extraction of the deciduous tooth and subsequent surgical placement of the implant. There were difficulties with the over eruption of the lower left canine, and this was fully discussed and presented in the treatment plan. He also has a reverse overbite, and so room to lengthen and widen the new implantretained crown at UL2 was going to require modifying his existing teeth. This is clearly illustrated by Figures 3, 4, and 5. He has thin and highly scalloped

Figure 2: Periapical showing the ULB in situ

Eimear O’Connell qualified from Edinburgh University in 1992 and worked as an associate until 1995 when she left to set up her own practice. She has been working in Edinburgh ever since. Dr. O’Connell’s practice became fully private in 1997. She has worked with the same group of support staff for 10 years, and they have all completed advanced training in implant dentistry, radiography, and sedation. She sat her MFGDP in 2007 and her DipImpDent RCSEd in 2013. In November 2014, to celebrate 20 years in practice, Dr. O’Connell took her whole practice to New York for 5 days where they attended the Greater New York Dental Meeting and had a great time seeing the sights.

Figure 3 22 Implant practice

Volume 9 Number 1

CLINICAL

Figure 4

Figure 7: Photograph showing the pre-op wax-up

periodontal biotype. He has a high lip line during full smile. After the initial consultation, once all the necessary preoperative information was gathered over a 2-month period, and after a verbally agreed treatment plan was finalized, the patient was sent a full treatment plan and consent forms for implant placement. This included consents to permanently alter the incisal length of some of the anterior teeth, both upper and lower. The adjacent teeth, i.e., UL1 and UL3, needed some distal and mesial reduction, respectively, to allow placement of a sufficiently large tooth at the ULB site to give a more balanced result. We were slightly limited for space, as the patient did not want to move the teeth orthodontically. Careful measurements were required to ensure a sufficient mesial and distal clearance from the adjacent teeth roots of at least 1.5 mm and preferably 2 mm.

Definitive treatment A 3 mm Astra Techâ&#x201E;˘ implant was used as the replacement, as this allowed the interdental clearance to be adhered to. A clear surgical stent was used to guide the surgery. It is shown on the implant model in Figure 8. The deciduous tooth was removed atraumatically using periotomes and luxators on February 1, 2011. A temporary denture was Volume 9 Number 1

Figure 5

Figure 6

Figure 8

Figures 9 and 10: Cement-retained UL2 implant crown in situ

used as the provisional restoration and was fitted at this visit. The patient returned 5 weeks later for placement of the implant. As discussed earlier, a 3.0 OsseoSpeedâ&#x201E;˘ Astra Tech 13-mm implant (Dentsply Implants) was placed using an open surgical method, and the site was closed using 5x 5-0 MonocrylÂŽ (Ethicon) sutures. After 2 days, the sutures were removed. Healing was uneventful. The temporary denture was used until the healing abutment was placed on June 9, 2011. Two weeks later, an open tray 3.0 pickup impression was taken for the laboratory to make a customized abutment and cement-retained crown, which was fitted with a temporary bond on August 15, 2011. The tissue depth at the time of taking the impressions for the laboratory was recorded as 2 mm. A facebow

record and bite were recorded along with a new alginate impression of the newly adjusted lower teeth. The patient is studying design at the Edinburgh College of Art and wanted to include his models and a gold crown for part of his finalyear presentation. We subsequently made a cement-retained gold shell crown, which can be interchanged with the porcelain one should the patient desire it. Once he saw it in situ, he preferred the porcelain. The restoration has been bonded in with a temporary bond, so as to be retrievable in future if necessary. There was insufficient room for the new crown without incisal reduction of LL3 and LL2 and reshaping the distal aspect of the UL1 and mesial aspect on UL3. These minor adjustments were fully discussed with the patient before the commencement of treatment. Implant practice 23

CLINICAL

Figures 11-12: Working casts in Figure 11 are not sitting in the correct Class III bite that is shown in the final casts in Figure 12

Figure 13: Postoperative photo 2 years after implant therapy

Figure 14: Note the more balanced incisal lengths

Prognosis The prognosis for the patientâ&#x20AC;&#x2122;s dentition is very favorable as he is a highly dentally motivated individual. He has returned for regular checkups, and presently his implant can be classified as successful according to the criteria defined by Roos, et al., (1997). He is a nonsmoker and does not appear to clench or brux. He is planning to live in Edinburgh so will be able to return for regular reviews.

Figure 15: The postoperative X-ray taken March 8, 2011

Figure 16: The postoperative X-ray taken May 13, 2013

Reflection The patient was very happy with the results, and he has a good understanding of the maintenance required to keep his dentition healthy, including the implant. He is young, and therefore, the implant will have many years to survive if he lives to the average life expectancy age. It is in the esthetic zone, and so any problems will be very obvious. I paid particular attention to the occlusal issues in this case since the lower canine is in working contact with the implant on the labial surface. Since he has a reverse overbite, this will inevitably place more stress on the restoration over the years. I deliberately used a cement-retained restoration in the hope that any occlusal overload should make itself apparent by debond rather than potentially causing a screw fracture or implant fracture. Perhaps I would now place an immediate implant with some buccal grafting with xenograft/autograft to try to ensure longevity of the buccal plate. My increased experience of working in the esthetic zone has led me to adopt a 24 Implant practice

Figure 17: Photograph of the definitive restoration

more conservative surgical approach, especially when dealing with thin, scalloped periodontium. One can clearly see some dark shine through from the implant, and if this concerned the patient, either a customized zirconia abutment or some soft tissue grafting could be carried out to improve this situation. I try to use curvilinear and U-shaped peninsula flaps as recommended by Anthony Sclar to increase the thickness of the labial mucosa.

The photos and X-ray show a 2-year follow-up. The patient is maintaining healthy periodontium around the implant, so it will hopefully last for many more years. IP

REFERENCES 1. Roos J, Sennerby L, Lekholm U, Jemt T, GrĂśndahl K, Albrektsson T. A qualitative and quantitative method for evaluating implant success: a 5-year retrospective analysis of the BrĂĽnemark implant. Int J Oral Maxillofac Implants. 1997;12 (4): 504-514. 2. Sclar A. Soft tissue and Esthetic considerations in Implant therapy. Chicago, Illinois: Quintessence; 2003.

Volume 9 Number 1

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Surface

CLINICAL

Replacing a fractured single central incisor: a natural approach Dr. Attiq Rahman presents a UL1 implant case

ne of the most difficult challenges faced by dentists and technicians alike is the placement and restoration of an implant to replace a single central incisor tooth, especially in a medium- to high-smile line when the contralateral incisor exhibits complex internal characteristics. The dentist not only must place the implant in the ideal 3D position, but also must take into consideration possible future resorption of the ridge, recession of the peri-implant tissues, and also the final white esthetics of the definitive restoration. In some cases, achieving a perfect match of the white esthetics can prove to be exceptionally difficult. Frequently, the dentist must ask the patient to attend for multiple try-in appointments in the hope of getting incrementally closer to an acceptable esthetic result; however, it can feel like a case of taking one step forward and two steps back. Presented below is a case where a novel approach was adopted in order to achieve the best possible white esthetics.

Case presentation The patient was a 36-year-old male who was referred to the practice presenting with trauma to the UL1. There was an obvious subgingival fracture, and the patient had been advised by his GP that an implant would be required. He was a nonsmoker, nondrinker, with no relevant medical history. The oral hygiene was good, and the only other restoration was an electively placed cantilever bridge at UR3 (UR2). The UL1 was darker than UR1, Grade III mobile, and the incisal edge was positioned 1 mm lower than the UR1 seen in Figure 1. Note the highly complex pattern of striations, Dr. Attiq Rahman qualified from Glasgow Dental School in 1994 and is in full-time private practice in Glasgow, Scotland. His practice is limited to implant, restorative, and esthetic dentistry at Visage Clinic, Glasgow, where he is clinical director. Dr. Rahman lectures nationally and internationally on the subject of implant and esthetic dentistry.

26 Implant practice

Figure 1: First presentation

mild fluorosis, halos, translucencies, and opacities within the enamel of UL1. There was significant gingival inflammation around the UL1, and therefore, the gingival margin was clearly visible at full smile, whereas at the UR1 it was not (Figure 2). The periapical radiograph showed a horizontal fracture approximately 2 mm apical to the cementoenamel junction (CEJ) with 1-1.5 mm recession of the buccal plate (Figure 3). Treatment options presented to the patient were: • Extraction under local anesthetic (XLA) UL1 and a partial acrylic prosthesis • Root canal therapy on UL1 followed by extrusion of the remaining root and a post crown • Extraction under local anesthetic and an implant-retained crown Having fully discussed all the options, the patient elected to have the tooth extracted and an implant-retained restoration. It is vitally important when treatment planning anterior implant cases to carry out an esthetic risk assessment (ERA) to determine the correct placement protocol. The options for placement are: • Immediate: immediately following XLA • Early: 4–6 weeks post XLA and following soft tissue closure

Figure 2: Note gingival inflammation, incisal edge position, and complex enamel structure

Figure 3: PA showing horizontal fracture Volume 9 Number 1

CLINICAL

Figure 7: Removal of pulp and dentin color noted

Figure 5: Note medium to thick biotype and abundance of attached gingiva

Figure 6: Highly complex enamel

Figure 8: Enamel shell

Figure 9: Enamel shell

Figure 11: Before Bio-Oss

Figure 12: After Bio-Oss

Surgery

shell (Figures 8 and 9). The remaining root was atraumatically extracted, and a 4.3 mm x 13 mm tapered implant placed (Figures 10 and 11). The gap between the buccal plate and the implant was then filled with xenograft, (Bio-Oss® Geistlich Pharma North America Inc.) (Figure 12). An immediate temporary abutment was then placed and tightened with finger pressure only (Figure 13). The inner surface of the enamel shell was then etched with 37% orthophosphoric acid followed by Scotchbond™ Primer and then Scotchbond™

Figure 10: Implant placed

• Delayed: 3–6 months post XLA following full ridge healing A simplified ERA table is presented on Figure 4. In this case, the gingival biotype was thick, smile line was medium to high, oral hygiene was good, there was no recession, and there was seen to be 4–6 mm of attached gingiva throughout the upper anterior and premolar segments (Figure 5). The esthetic risk in this case was low to medium, and therefore, an immediate placement protocol was deemed appropriate. Given the extremely complex enamel patterns described earlier, the favorable position of the fracture in relation to the CEJ and in consultation with the patient, it was decided to try to use the patient’s natural UL1 as both the immediate temporary and eventually convert it to the final definitive restoration. Volume 9 Number 1

The patient was anesthetized with buccal and palatal infiltrations, and following standard aseptic surgical protocol, the fractured coronal portion of UL1 was easily removed and inspected (Figure 6). As the crown dehydrated, its complex structure became even more apparent. The crown was then given to the technician who, using a turbine and a diamond bur, removed the necrotic pulp and noted the color of the underlying dentin (Figure 7). This dentin was then also removed to leave a hollow enamel

Implant practice 27

CLINICAL

Figure 13: Immediate temporary abutment fitted

Figure 14: Etching of enamel shell interior

Figure 15: Adding flowable resin to interior of enamel shell

Figure 16: Approximately the shape around the immediate temporary abutment

Figure 17: Enamel shell tried over abutment

Figure 18: Enamel shell filled with Luxatemp and seated over abutment

Figure 19: Shell removed from abutment to show hexagonal shape

Figure 20: Shell mounted on duplicate abutment, ready for addition of resin

Figure 21: Addition of flowable resin to create submergence profile

Figure 22

Bonding Resin (3M ESPE) (Figure 14). Flowable Resin shade A2 was then placed in the shell and cured in increments to approximately the correct shape to fit the immediate temporary abutment (Figures 15 and 16). The shell was tried in over the abutment to ensure proper seating (Figure 17), following which the interior of the shell was filled with a bisacryl temporary crown material (Luxatemp速, DMG America) and seated until the material had fully set (Figure 18). The shell was then removed from the abutment in situ and mounted on a duplicate abutment, following which flowable resin was added to create an ideal junction between the abutment and the cementum (Figures 19-23). 28 Implant practice

Figure 23: Resin addition complete Volume 9 Number 1

CLINICAL

Figure 24: Abrasive discs used to shape and polish resin to cementum interface

Figure 25: Submergence profile complete

Figure 26: Removed from duplicate abutment, ready to seat

Figure 30: UL1 fully seated. Note improvement in value

Figure 27: Seating on abutment with no need for cement

Figure 31: Review at 2 weeks. Note stabilization of value

Figure 28: Palatal surface eased to eliminate contact in centric and protrusive excursions

Figure 29: PA showing full seating of UL1 crown on abutment

Figure 32: Note significant improvement in gingival health and color Volume 9 Number 1

Abrasive discs were then used to shape and polish the area until a seamless polished junction was achieved without overhangs or areas of deficiency (Figures 24-26). The crown was then seated with firm pressure onto the abutment and the occlusion checked (Figure 27). It was imperative to ensure that there was no contact in centric occlusion or in protrusive movements. The palatal surface was eased to ensure this (Figure 28), and a radiograph was then taken to check that the crown was fully seated (Figure 29). The removal of necrotic pulp and stained dentin together with dehydration resulted in an immediate improvement in value (Figure 30). The patient was advised that in the coming days, rehydration would lower this value once again, but given that the dentin color was now more favorable, the end result should be a good match for UR1. The patient attended for review at 2 weeks, and this was indeed found to be the case (Figure 31). There was also found to be a significant improvement in the health and color of the gingival tissues at UL1 (Figure 32), and it was Implant practice 29

CLINICAL

Figure 33: Enamel shell bonded to definitive IPS e.max hybrid abutment

Figure 34: Immediately after fit. Note dehydration causing value to be too high

Figure 36: Some loss of the mesial and distal papilla but much improved pink esthetics

Figure 35: Final review at 2 weeks

Figure 37: A very acceptable esthetic result

The patient is delighted with the overall esthetic result, and with the exception of his wife, no one in his family is aware that he ever lost his tooth. likely that the gingival margin would migrate apically as the tissues continued to heal. During the healing phase, orthodontic treatment of the mandibular arch was carried out to lingualize the lower anteriors. This was done in order to reduce the risk of heavy contacts on protrusive movements. The lingualization process was completed using a series of clear aligners since the patient could not tolerate an Inman Alignerâ&#x201E;˘. The process took nearly 12 months, during which time the enamel shell temporary performed faultlessly. At 12 months post-op, the patient was reviewed and bleaching trays fitted to allow him to bleach his teeth, including UL1. After 2 weeks, the UL1 was removed, and a fixture head impression was taken for the definitive abutment that would support the enamel shell. The technician then repeated the original hollowing out procedure until again only the 30 Implant practice

enamel shell remained. This was then bonded to a custom IPS e.max hybrid abutment (Ivoclar Vivadent) bonded to a titanium base (Figure 33). This was fitted, and again, the value appeared to be too high (Figure 34). The patient was reassured again that rehydration over the coming days and weeks would lower this value until it matched the UR1. The patient was reviewed at 2 weeks, and the value had indeed lowered to match the UR1, and the difference was almost indistinguishable (Figure 35). Pink esthetics were much improved with a healthy gingival cuff; however, there had been some loss of the mesial and distal papillae (Figures 36 and 37). This will need to be monitored in the coming years, and if necessary, connective tissue grafting can be planned. A final radiograph was exposed (Figure 38), which shows acceptable bone levels with no recession since placement approximately

Figure 38: Final radiograph

1 year previously. The patient is delighted with the overall esthetic result, and with the exception of his wife, no one in his family is aware that he ever lost his tooth. IP

Acknowledgment The author would like to thank the team at Visage Dental Lab for their very skilled handling of this case. Volume 9 Number 1

AUTHOR GUIDELINES Implant Practice US is a peer-reviewed, bimonthly publication containing articles by leading authors from around the world. Implant Practice US is designed to be read by specialists in Periodontics, Oral Surgery, and Prosthodontics.

Submitting articles Implant Practice US requires original, unpublished article submissions on implant topics, multidisciplinary dentistry, clinical cases, practice management, technology, clinical updates, literature reviews, and continuing education. Typically, clinical articles and case studies range between 1,500 and 3,000 words. Authors can include up to 15 illustrations. Manuscripts should be double-spaced, and all pages should be numbered. Implant Practice US reserves the right to edit articles for clarity and style as well as for the limitations of space available. Articles are classified as either clinical, continuing education, technology, or research reports. Clinical articles and continuing education articles typically include case presentations, technique reports, or literature reviews on a clinical topic. Research reports state the problem and the objective, describe the materials and methods (so they can be duplicated and their validity judged), report the results accurately and concisely, provide discussion of the findings, and offer conclusions that can be drawn from the research. Under a separate heading, research reports provide a statement of the research’s clinical implications and relevance to implant dentistry. Clinical and continuing education articles include an abstract of up to 250 words. Continuing education articles also include three to four educational aims and objectives, a short “expected outcomes” paragraph, and a 10-question, multiple-choice quiz with the correct answers indicated. Questions and answers should be in the order of appearance in the text, and verbatim. Product trade names cited in the text must be accompanied by a generic term and include the manufacturer, city, and country in parentheses. Additional items to include: • Include full name, academic degrees, and institutional affiliations and locations • If presented as part of a meeting, please state the name, date, and location of the meeting • Sources of support in the form of grants, equipment, products, or drugs must be disclosed • Full contact details for the corresponding author must be included • Short author bio • Author headshot Volume 9 Number 1

Pictures/images

Disclosure of financial interest

Illustrations should be clearly identified, numbered in sequential order, and accompanied by a caption. Digital images must be high resolution, 300 dpi minimum, and at least 90 mm wide. We can accept digital images in all image formats (preferring .tif or jpeg).

Authors must disclose any financial interest they (or family members) have in products mentioned in their articles. They must also disclose any developmental or research relationships with companies that manufacture products by signing a “Conflict of Interest Declaration” form after their article is accepted. Any commercial or financial interest will be acknowledged in the article.

Tables Ensure that each table is cited in the text. Number tables consecutively, and provide a brief title and caption (if appropriate) for each.

References References must appear in the text as numbered superscripts (not footnotes) and should be listed at the end of the article in their order of appearance in the text. The majority of references should be less than 10 years old. Provide inclusive page numbers, volume and issue numbers, date of publication, and all authors’ names. References should be submitted in American Medical Association style. For example: Journals: (Print) Greenwall L. Combining bleaching techniques. Aesthetic & Implant Dentistry. 2000;1(1):92-96. (Online) Author(s). Article title. Journal Name. Year; vol(issue#):inclusive pages. URL. Accessed [date].

Manuscript Review All clinical and continuing education manuscripts are peer reviewed and accepted, accepted with modification, or rejected at the discretion of the editorial review board. Authors are responsible for meeting review board requirements for final approval and publication of manuscripts.

Proofing Page proofs will be supplied to authors for corrections and/or final sign off. Changes should be limited to those that are essential for correctness and clarity. Articles should be submitted to: Mali Schantz-Feld, managing editor mali@medmarkaz.com

Reprints/Extra issues If reprints or additional issues are desired, they must be ordered from the publisher when the page proofs are reviewed by the authors. The publisher does not stock reprints; however, back issues can be purchased.

Or in the case of a Book: Greenwall L. Bleaching techniques in Restorative Dentistry: An Illustrated Guide. London: Martin Dunitz; 2001. Website: Author or name of organization if no author is listed. Title or name of the organization if no title is provided. Name of website. URL. Accessed Month Day, Year. Example of Date: Accessed June 12, 2011. Author’s name: (Single) Doe JF

(Multiple) Doe JF, Roe JP

Permissions Written permission must be obtained by the author for material that has been published in copyrighted material; this includes tables, figures, pictures, and quoted text that exceeds 150 words. Signed release forms are required for photographs of identifiable persons.

Checklist for article submissions: 3 A copy of the manuscript and figures, captions, including all pictures (low res) necessary for reviewers 3 Manuscript: double-spaced including separate references, figure legends, and tables 3 Abstract, educational objectives, expected outcomes paragraph 3 References: double-spaced, alphabetical, American Medical Association style 3 Tables: titled and cited in the text 3 Mandatory submission form, signed by all authors Please contact managing editor Mali SchantzFeld with any questions via email: Mali@medmarkaz.com

Implant practice 31

EDUCATOR INSIGHT

Drs. Pamela McClain and Rachel Shallhorn Striving for implant stability

Could you please each introduce yourself to our readers and tell us a little bit about your background? Dr. McClain: I’m a Periodontist and have been practicing for 28 years. I am a past President of the American Academy of Periodontology and a Diplomate of the American Board of Periodontology. We have been very fortunate to participate in clinical research in our practice, including several FDA trials. I’ve also had the opportunity to provide continuing education through lecturing at various venues in the United States and abroad. I’m thrilled that I’ve been able to practice with my father, Dr. Robert G. Schallhorn, for 20 years, and now with my niece, Rachel Schallhorn. Dr. Schallhorn: I’m a private practice Periodontist. I’ve been in private practice for about 6.5 years. I did my specialty training at the University of Texas, San Antonio. I’ve been involved in clinical research, published several articles related to periodontal disease, and also done some lecturing. I’m also a past President of the Rocky Mountain Society of Periodontists.

How do you use Osstell in your clinic? Dr. McClain: We use it to get a baseline measurement at the time of implant placement on all of our implant cases. Osstell helps us decide if the case is a good case for early loading, or whether we need to bury the implant. Most implants we do are single stage. Dr. Schallhorn: We use Osstell to determine when we’re ready to restore the implant. To me it’s an objective tool to really assess our implant stability. On most cases, we take a second reading around 3 months post-surgical. If I don’t feel the implant is ready at that time, I will recheck every 4 to 6 weeks after that.

What are the main benefits you see from using Osstell and ISQ values? Dr. McClain: It’s an objective tool to determine implant stability, and it’s a way we 32 Implant practice

to inform our colleagues about when the patient is ready for the restorative phase.

Before using Osstell, how did you assess implant stability? Dr. Schallhorn: It was subjective. You basically relied on torque value on placement and then tactile feel, which is not a very good measurement.

ISQ values increase the chance for success and help us guide the treatment of the patient.

can track stability over time. It’s an additional piece of information for the decision-making during surgery. The biggest advantage is to have an objective measurement tool in cases where the bone quality is less than optimal. ISQ values increase the chance for success and help us guide the treatment of the patient.

So in your experience, what kind of ISQ value are you targeting? Dr. Schallhorn: 70 or above. Dr. McClain: I agree. Depending on the implant size, a minimum measurement of 60 is necessary, but if the value is over 70, I feel much more confident about the implant stability.

Do you communicate around the ISQ value with the patients? Do you explain it to them? Dr. McClain: Yes, and we also communicate the value with the restorative dentist. We’ve been doing this for over 6 years and have found it to be a good objective tool

How much does a failure cost? Dr. Schallhorn: You need to consider the monetary cost, but also time, and how it impacts the patient’s confidence in you. I would say a failure is pretty costly in many respects.

What do you think will change in implant dentistry over the next 5 years? What trends are you seeing in the industry? Dr. Schallhorn: I see a trend moving toward shorter treatment times and quicker loading protocols. I would say, once a week people ask me about “teeth in a day.” So everyone wants it fast, and they want it now. If there’s a viable option for shortening treatment times, we would certainly consider it to get our patients their end results quicker. But we want to be pretty sure that it is going to work by good indicators of stability before we commit to a shorter protocol.

Who has inspired you the most in your career? How and why? Dr. McClain: My father, Dr. Robert Schallhorn, who was a pioneer in Periodontics with his innovative bone-grafting techniques and the research he did that really changed how we practice Periodontics today. He has been a wonderful mentor and teacher for me in my career. Dr. Schallhorn: I’d second that, but I would say Pam as well — not only as a Periodontist, but also as a person. IP This article was provided by Osstell.

Volume 9 Number 1

You have the know-how. Now get the know-when. Osstell helps you to objectively determine implant stability and to assess the progress of osseointegration, allowing you to reduce treatment times and to better manage patients with risk factors. “We are currently using Osstell when we place all implants to establish a baseline measurement of implant stability. At the time of placement if the ISQ is too low (depending on the location - anything below 45) we will remove the fixture, possibly graft and then wait another 3-6 months before trying to place another fixture. We try to take the measurement on the buccal/lingual, and mesial /distal aspects and record the highest and lowest values.

“[Osstell] gives us and the patient a more objective way to assess the implant stability”

We typically recheck the ISQ value at three months. If the ISQ has improved (or is stable if the number was high to begin with - over 65) we will release the patient for restorative treatment. It gives us and the patient a more objective way to assess the implant stability. If it’s not ready at that time we continue to recheck every 6 weeks until the ISQ has improved or indicates stability.

Since we began using this device in 2009, our decision making process has become more simple and objective. We will continue to use the Osstell values to help guide treatment decisions and as a communication tool with our referring dentists.” Pamela K. McClain, DDS & Rachel Schallhorn, DDS Diplomates, American Board of Periodontology

Why Do You Need Osstell in Your Implant Practice? Listen to the lectures from the Osstell Corporate Forum at AO 2016 Speakers: Drs. Pamela McClain, Rachel Schallhorn & William Martin

www.osstell.com/ao2016

CONTINUING EDUCATION

Digital dentistry for private practice Dr. Dean C. Vafiadis reviews the significant contribution of digital dentistry to implant procedures for better diagnostic techniques and implementation

ver the past 10 years, digital dentistry has made a significant contribution to our profession. It has allowed the clinician better diagnostic techniques and allowed us to view the head and neck area from a different vantage point.1,2 We have broadened our diagnostic capabilities from using cone beam CT scans of the bony architecture to milling restorations for placement in a one-visit protocol. But which systems are best for your practice? The real answers lie in the training of these high-tech software and milling machines. The good news is that all the manufacturers and laboratories have made an educational and financial commitment to help clinicians make the right decision.

Intraoral impressions with in-office milling The first question to ask for your specific clinical private practice is, What kind of digital platform do I want to have? Does your office have the space to house a milling machine, and do one-visit restorations fall into your specific patient demographic? If so, then your choices are the CEREC Omnicam system (Sirona Dental Systems, New York) the NEVO-E4D (Planmeca E4D, Richardson, Texas), and the Carestream CS 3500 system (Carestream Dental LLC, Atlanta, Georgia). These scanning and milling technologies

Educational aims and objectives

This article aims to discuss the various options and benefits regarding digital technologies available to dentists who provide implant procedures.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 39 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Realize the various benefits of intraoral impressions with and without in-office milling. • Identify various software programs available to facilitate implant placement. • Recognize the possible uses for CBCT imaging in the implant process. • Recognize how merging information in digital STL files and DICOM files can facilitate sharing data with the dental laboratory.

have made multiple upgrades that make scanning and milling possible within minutes and a total patient-specific restoration, even an anterior central veneer or crown, from scanning to insertion in under 90 minutes.3 The ceramic material by Ivoclar Vivadent® and 3M that is available has also been upgraded and provides very lifelike natural esthetics,

good enough for even anterior central incisors (Figures 1-3). This comes with a large financial investment from the clinician, but the financial plans that are available can make this decision a comfortable and affordable 6-year payout. The laboratory costs, materials, and supplies used with conventional impressions will be huge savings for the

Figure 1: IPS e.max® CAD-block high-translucent material (Ivoclar Vivadent, Amherst, New York) Dean C. Vafiadis, DDS, is a program director of the Full Mouth Rehabilitation CE course at NYU College of Dentistry (NYUCD). He has been on faculty at NYUCD since 1993. He currently practices in New York City, New York, where he is the president of the New York Smile Institute — a multi-specialty practice for esthetics, CAD/CAM, and implant dentistry. He currently uses CEREC®, TRIOS®, E4D, and 3M™ True Definition Scanners in his office. He has lectured around the world and has given over 300 all-day courses on esthetics, implants, and CAD/CAM technologies.

34 Implant practice

Figures 2 and 3: Right central incisor CAD/CAM one-visit treatment — fractured, prepared, scanned, designed, and milled within 90 minutes Volume 9 Number 1

Intraoral impressions without inoffice milling Due to the cost of scanning and in-office milling, some clinicians have decided that simply scanning will save them the cost of making a restoration and avoiding the goopy mess of regular PVS impression materials, which is what patients always complain about. Enter the intraoral scanners: 3Shape TRIOS® (3Shape Dental, Warren, New Jersey); 3M™ True Definition scanner (3M ESPE Dental, St. Paul, Minnesota); iTero® scanner (Align Technologies, San Jose, California). All these allow accurate impressions for any restoration, posterior, anterior, and full arch. Although there are other scanners available and more being manufactured in Europe and Asian markets, these have not yet made it into the U.S. market (Figures 4-5). A recent article was published that made a very detailed comparison with 10 different intraoral scanners but could not give a definitive answer as to which, if any, were better than another.4 The orthodontic community has readily adapted the iTero due its collaboration with Invisalign®. They can very abruptly take impressions and merge the files with the orthodontic software to create models and treatment plan for the orthodontic patient. But the others are soon to follow that digital orthodontic model. The accuracy of these new scanners

is unprecedented, and the integration with the laboratory component has never been easier. The 3Shape TRIOS scanner is one of the fastest scanners available. It is easily integrated into any dental office. In single-provider dentists, group practices, or dental clinics, it can quickly be used for any restoration. In addition, the staff can be trained to take the intraoral impressions for diagnostic models, final impressions, and full arch impressions. Can you imagine that you could take a full arch impression to restore a full arch of restorations, a digital occlusal record in MIP position, and a counter scan in under 4 minutes? This is the average setting time of most PVS impressions. Then within 7 working days, you can have copings or even final restorations made at the highest level of accuracy and ready for delivery. One of the main advances in digital dental technology has been made possible by using printed models or stereolithography (SLA), instead of stone casts. Figures 6A-6D are examples of a printed model. The printed models have been shown to accuracy levels of 30-50 microns, can be printed in less than 10 minutes, and with zero expansion, unlike dies and stone casts. This allows the technicians to really adapt the margins, interproximal contacts, and occlusal relationships on the computer monitor and deliver close to perfect restorations in any type of material, whether it be ceramo-metal,

Figures 4 and 5: 3Shape TRIOS scan of full lower arch of preparations and interocclusal record for all ceramic CAD/CAM crowns

Figures 6A-6D: 6A: TRIOS SLA model with 6 procelain veneers. 6B: Virtual LAVA COS scan then converted to SLA model. 6C: Digital TRIOS design of crown No. 4 and central No. 8. 6D: TRIOS SLA model with central incisor Volume 9 Number 1

Implant practice 35

CONTINUING EDUCATION

practice. In most offices and clinics, the savings will offset some of the cost of the payment. For example, a $120,000 investment over 6 years may average around $2,000 per month. But the lab costs saved may be around $1,000 per month, and the supplies and materials savings may be $300. In addition, the savings of time and the second appointment will pay for the initial financial investment over the course of the year. The one-visit in-office CAD/CAM financial model will definitely save the clinician the cost of labs, materials, provisionals, trays, and countless hours of saved appointments. When looking at the office’s financial profit and loss columns, the practice saves thousands of dollars over the course of the 5-year payout. In addition, this provides the patient with a one-visit dental experience.4 The good news is after the unit is paid off, the financial gains really manifest to the bottom line of the practice. Although the technology is constantly changing, the scanners are still useful and will probably need upgrades every 2-3 years. Asking for this and cost differentials of “trade-in” packages ahead of time is a good idea. Also, the quality of the dentistry improves due to better preparation, margination, and the reduction of remaking impressions or remaking crowns because of quality control of the clinician and more accurate occlusal reduction.

CONTINUING EDUCATION

Figures 7A-7B: 7A: Digital design of abutment on screen. 7B: LAVA COS SLA model with two implant crowns

Figures 8 and 9: Digital implant design using the CBCT scan and implant software — will be used to fabricate ideal digital surgical guide (Blue Sky Bio plan) (blueskybio.com, 3D software, Grayslake, Illinois)

lithium disilicate, zirconia/feldspathic, or even gold crowns for the purist. An example of the screen shots used by the 3Shape designer software is shown in Figures 7A-7B.

Implants and digital technology Want to place your own implants? Software programs such as Materialise (Materialise Plymouth, Michigan), Anatomage (Anatomage, San Jose, California) and SIMPLANT® (Dentsply, Waltham, Massachusetts), as well as many others, can diagnose the best possible placement angle, depth, width size, and type of implant that you desire. With the help of a CBCT scan and a trained laboratory technician, you can virtually look at the surgical plan and “print” a perfect surgical guide that actually fits within 4 business days. Placement of implants through flapless techniques better preserve the gingival tissues and allow the clinician ideal accuracy within a 100 micron tolerance for surgical placement. The digital workflow from surgical guides to final restoration can now be entirely done on the computer screen and verified instantly by a portable mobile device or tablet by the lab or clinician (Figures 8-11). 36 Implant practice

Figure 10: Surgical printed surgical guide for central incisor implant

After the implants are healed, it’s really simple to fabricate your ideal CAD/CAM patient-specific abutments with digital scanned healing abutments such as Encode® (BIOMET™ 3i, Palm Beach Gardens, Florida). These have been around since 2004 and have cornered the market on digitally design CAD/ CAM abutment fabrication.5,6 They are sitespecific and patient-specific. They create

Figure 11: Surgical guide used for implant No. 30

ideal contoured and anatomically shaped abutments to replace the root and gingival form of the tooth that has been lost without removing them to take a fixture-level impression (Figures 12-15). For those not using the Encode system from BIOMET, there is a vast choice of scan bodies for all the other implant systems. These are made for each specific implant and size for the specific manufacturer, Volume 9 Number 1

Another emerging technology is at the forefront with digital information. That is the merging of digital STL files and DICOM files. DICOM is a common file format, allowing utilization of the information between different platforms and manufacturers’ units. This allows the practitioner to have a specific scanner, for example, and the lab to have different software and still permit communication between the dentist and lab. This allows the laboratories to use open platform information and merge different software within one program (Figure 18). If it sounds like a “space-age concept,” well, it is. This has been available only within the past 3 years in the dental market but has been used

by the U.S. NASA space program for over 15 years. The manufacturers have realized the potential to capture all esthetic dentists as well as implant dentists, and to do that, they had to open their software platforms to allow labs to use them with any digital software design system. This allows the lab techs to merge files from various scanners and milling systems to idealize every patient treatment, from implant placement to digital guides, and provisional materials such as polymethyl methacrylate acrylic (PMMA). In addition, with the new digital design systems that are available, the clinician can take a digital impression and fabricate ideal smile design with a printed digital wax-up that is available with the 3Shape software. For example, think about a 10-unit bridge on teeth or implants. The clinician would like to evaluate the placement of abutments, so that interproximal space is available. Utilizing two individual software programs (3Shape and Materialise), the laboratory can merge the scan of the provisional, which is superimposed onto the implant abutments or prepared teeth. Utilizing the provisional, the technician and clinician can review the proposed position of the final porcelain and restorations on a personal device or smartphone and in minutes communicate whether

Figure 17: CAD/CAM implant crown designed with CEREC. IPS e.max block has centric access hole

Figure 18: Merging of three files — intraoral scan (gray), CBCT scan (yellow), and ideal implant placement with diagnostic tooth wax-up (blue and green) — to create ideal diagnostic view

Figures 14 and 15: Final CAD/CAM abutments placed and CAD/CAM IPS e.max crowns. Addition of ceramic material was added to contact between No. 28 and No. 29 after radiograph was made. Provisional cementation of individual crowns with Temrex (Temrex Corp. Freeport, New York). 3-year postoperative photo

such as BioHorizons®, Straumann®, Ritter™, and MegaGen implants. They have their own scan bodies for their implant line. However, because of the high demand from the laboratories, independent companies have fabricated their own scan bodies that are available for each implant system, such as Elos Medtech (elos.com) and Bio-Dent (biodent. com) (Figure 16). These can be scanned for any implant being used and create a custom CAD/CAM abutment for ideal design. Some scanners are allowing clinicians to mill their own abutments, but this requires specific technical abilities that many clinicians are not comfortable with. I believe this will be a market that will soon get increase popularity, again only to minimize cost and time (Figure 17).

Figure 16: Various types and shapes of scan bodies that are used specifically for each implant manufacturer (Ritter, Glidewell, and Elos scan bodies) Volume 9 Number 1

Merging of digital files

Implant practice 37

CONTINUING EDUCATION

Figures 12 and 13: 3M True Definition Scanner and 3Shape abutment design software with Bellatek Encode System, healing abutments (BIOMET 3i, Zimmer/BIOMET, Palm Beach Gardens, Florida)

CONTINUING EDUCATION

Figures 19 and 20: Merged files of CAD/CAM abutment design with provisional intraoral scan overplayed for viewing and quality control. This can be viewed on personal computer or smartphone. Final implant restorations completed utilizing this technique shows proper facial contour and lip support that was worked out in the provisional phase before porcelain was placed onto frame

to continue or fine-tune the proposal. So with one image, the clinician can see the preparations or abutments, evaluate the frame to be milled, and see the final restorative position, all at the same time, and looking at exact occlusal contacts to be designed (Figures 19-20). This has been a dream of many of us for years — finally, a program that lets us see everything in one view, accurately and clearly to all members of the restorative and surgical team. Diagnostically, this is an amazing breakthrough, especially for quality control. Using these programs, the labs can now design and fabricate restorations, surgical guides, partial and complete dentures, working smile designs, frames, and arches without depending on one certain scanner or software system. The dentists are free to make the best decision for their practices and not worry about their favorite labs purchasing software from the same company. This allows the laboratories to deliver excellent restorations regardless of the scanning system and platform that are provided. This gives a long awaited freedom to the clinician and maximizes efficiency for the labs. Of course, time for the patient and clinician is reduced as well as the cost of fabrication. Many people ask, Why this massive change in the dental world? This all began when the cost of gold and precious metals reached record highs, and the cost of making a dental restoration was becoming prohibitive. Add labor costs to this, which account for a large percent of lab costs, To keep costs down, CAD/CAM technology allows high precision while allowing the lab to keep fees down and still generate a profit for the lab. This began a wave of corporate decisions from every dental company to create a digital platform within their business model. A rampant change in the profession also followed that utilized high-strength ceramics 38 Implant practice

Digital technology reference sites • • • • • • • •

3M™ True Definition Scanner: www.solutions.3m.com 3Shape TRIOS® Scanner: www.3shapedental.com Align Technologies / iTero Scanner: www.itero.com BIOMET 3i™, Zimmer/Biomet Co. Bellatek Encode System: www.biomet3i.com Carestream CS 3500 scanner: www.carestreamdental.com Planmeca / E4D Technologies / NEVO scanner: www.e4d.com Sirona / CEREC Omnicam: www.sirona.com Materialise 3D Software: www.materialise.com

and materials that have allowed the low- as well as high-income practices to deliver excellent restorations for their patients. Like all things, change equals growth in different areas, and we have seen the collaboration of corporations, laboratories, and clinicians, where patients will finally benefit from this amazing and ever-changing technology. We must also give credit to the wonderful touchscreen phones and computers that have influenced all of our lives. It’s not difficult to realize that they would eventually infiltrate the medical and dental profession.

only paralleled with one’s imagination, and my prediction is that our young dental professionals will push the envelope even more to where “no one has gone before.” As always in technology, we are faced with the decision to be the first, follow a friend, or wait and see which is the best choice. It seems clear that regardless of the platform one chooses, it will no doubt impact the practice, the employees, and the overall patient experience. Digital dentistry is here, and it’s exciting. Sometimes you have to jump right in and swim! IP

What is the future? How much better can it be? Let’s think about what we do every day, and how we can make it better. Take, for instance, and extraction of a single tooth. This treatment is performed every day all around the world. What if we could scan the tooth and the root before extraction and have a duplicate root form of the exact shape and size ready at the time of surgery? In addition, what if it was made out of titanium and a high-grade surface texture with lateral side screws that could engage bone? How would the tissue response be to that surgical site? How would the loads be transferred with the exact anatomy of the root for that patient? Basically, every scenario of every procedure we do can be performed digitally. The ideas are

REFERENCES 1. Birnbaum NS, Aaronson HB, Stevens C, Cohen B. 3D digital scanners: a high-tech approach to more accurate dental impressions. Inside Dentistry. 2009;5(4):70-77. 2. Fasbinder D. Using digital technology to enhance restorative dentistry. Compend Contin Educ Dent. 2012;33(9):666-668, 670, 672. 3. Logozzo S, Franceschini G, Kilpelä A, Caponi M, Governi L, Blois L. A comparative analysis of intraoral 3D digital scanners for restorative dentistry. The Internet Journal of Medical Technology. 2008;5(1). Internet Scientific Publications. http://ispub.com/IJMT/5/1/10082. Accessed January 15, 2016. 4. Mitchem C. Why Digital Impressions? Dent Economics. 2012;102(1):32, 54, 88. 5. Vafiadis D, Goldstein G. Single visit fabrication of porcelain laminate veneer with CAD/CAM technology: a clinical report. J Prosth Dent. 2011;106(2):71-73. 6. Ramsey CD, Ritter RG. Utilization of digital technologies for fabrication of definitive implant-supported restorations. J Esthet Restor Dent. 2012;24(5):299-308. 7. Vafiadis, DC. Computer-generated abutments using a coded healing abutment: a two year preliminary report. Pract Proced Aesthet Dent. 2007;19(7):443-448.

Volume 9 Number 1

Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement 12/1/2012 to 11/30/2016 Provider ID# 325231

REF: IP V9.1 VAFIADIS REF: IP V9.1 OSMAN

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Digital dentistry for private practice VAFIADIS

Treating edentulous patients using the All-on-4® treatment concept OSMAN

These scanning and milling technologies have made multiple upgrades that make scanning and milling possible within minutes and a total patient-specific restoration, even an anterior central veneer or crown, from scanning to insertion in _______. a. under 90 minutes b. 3 hours c. 1 day d. 1 week

Although the technology is constantly changing, the scanners are still useful and will probably need upgrades ________. a. every year b. every 2-3 years c. every 5 years d. if the system must be restarted 8.

Due to the cost of scanning and in-office milling, some clinicians have decided that simply scanning will save them ________, which is what patients always complain about. a. from hearing dental office-related noises b. the cost of making a restoration c. avoiding the goopy mess of regular PVS impression materials d. both b and c

The printed models have been shown to accuracy levels of ____, can be printed in less than 10 minutes, and with zero expansion, unlike dies and stone casts. a. 5-10 microns b. 30-50 microns c. 60-70 microns d. 80 microns This allows the technicians to really adapt _______ on the computer monitor and deliver close to perfect restorations in any type of material, whether it be ceramo-metal, lithium disilicate, zirconia/feldspathic, or even gold crowns for the purist. a. the margins b. interproximal contacts c. occlusal relationships d. all of the above

Volume 9 Number 1

10.

With the help of _________, you can virtually look at the surgical plan and “print” a perfect surgical guide that actually fits within 4 business days. a. a CBCT scan b. a trained laboratory technician c. a 2D digital radiograph d. both a and b Placement of implants through flapless techniques better preserve the gingival tissues and allow the clinician ideal accuracy within a _______ tolerance for surgical placement. a. 50-micron b. 75-micron c. 100-micron d. 150-micron _____ is a common file format, allowing utilization of the information between different platforms and manufacturers’ units. a. STL b. DICOM c. HTML d. ENCODE This (when manufacturers open their software platforms to allow labs to use them with any digital software design system) allows the lab techs to merge files from various scanners and milling systems to idealize every patient treatment, from implant placement to digital guides, and __________. a. provisional materials such as polymethyl methacrylate acrylic (PMMA) b. scan bodies c. materials such as PVS impression materials d. non-provisional materials such as lithium disilicate To keep costs down, ____________ allow(s) high precision while allowing the lab to keep fees down and still generate a profit for the lab. a. Conventional casting techniques b. CAD/CAM technology c. PVS impression material d. wax-up bodies

This (All-on-4 treatment concept) involves placing two straight implants in the anterior region and two angulated implants in the posterior region — the distal implants are placed diagonally at an angle of ________. a. 10° to 15° b. 20° to 25° c. 30° to 45° d. 50° The patient wished to avoid advanced grafting techniques and didn’t want to be left without teeth at any stage of the treatment, so the All-on-4 treatment concept of implant therapy was chosen, based on the evidence of Malò and colleagues, which required ________. a. sinus augmentation b. sacrifice of remaining teeth c. alveolar bone reduction beyond the smile line d. both b and c

(During provisional bridge/denture construction) The wax rim was adjusted to ensure ________ to prescribe the buccal corridor width. a. correct incisor length b. lip support c. buccal contour in the posterior region d. all of the above

After primary impressions with stock trays, special trays and bite blocks were created to __________. a. register the occlusion b. assess the increase in vertical dimension c. assess the decrease in vertical dimension d. both a and b

After extraction of the teeth and roots, ___________ to obtain a wide bony bed around the implant shoulder. a. acrylic teeth were positioned at the vertical dimension b. alveolar bone was augmented

c. the sockets were debrided and vertically reduced d. the implants were placed at similar angles 6.

The five implants (NobelActive™, Nobel Biocare®) were inserted in the planned positions _______ after reduction of the alveolar ridge. a. 1 day b. 2 hours c. immediately d. later in the day

Due to its specific design, the NobelActive implant ________ the bone during insertion, achieving a high level of primary stability even in compromised bone situations. a. compresses b. releases c. sacrifices d. contours

All (of the implants) had insertion torque of ______, taken to be acceptable for immediate loading, and so immediate loading was possible. a. about 10Ncm b. above 35Ncm c. below 35Ncm d. about 25Ncm

After the implants and the multibase abutments were placed, the temporary acrylic dentures were placed to check ________. a. occlusion b. esthetics c. smile line d. all of the above

10.

Only soft food was advised during the healing phase of _______, and the dangers of load pressure were explained to the patient. a. 1 month b. 6 weeks c. 3 months d. 6 months

Implant practice 39

CE CREDITS

IMPLANT PRACTICE CE

CONTINUING EDUCATION

Treating edentulous patients using the All-on-4® treatment concept Dr. Moss Osman demonstrates the treatment of a patient with worn and damaged teeth

any edentulous patients suffer from having to wear a conventional complete denture and would much prefer to have a fixed implant-supported bridge instead (Strassburger, Kerschbaum, and Heydecke, 2006). One possible form of therapy is the All-on-4® treatment concept designed by Professor Paulo Maló, which enables restoration of edentulous jaws without augmentation procedures (Maló, et al., 2014). This involves placing two straight implants in the anterior region and two angulated implants in the posterior region — the distal implants are placed diagonally at an angle of 30° to 45°. Ultimately, this treatment modality requires fewer sites, so each implant can be placed in a more optimum position. This biomechanical approach has advantages over conventional rehabilitation of the edentulous arch where eight implants are placed with external sinus augmentation. Advantages of the All-on-4 treatment concept follow: 1. Minimal or no bone augmentation is required. 2. No sinus augmentation is required. 3. Only four implants are needed in the mandible or four to six implants in the maxilla. 4. It can be immediately restored with a provisional bridge. 5. Existing bone can be optimally used. 6. Vital anatomical structures can be avoided. Studies have shown excellent outcomes for both tilted and axial implants; indeed, this protocol facilitates use of longer implants, improves bone anchorage, and avoids bone grafting procedures (Malò, at al., 2014). A retrospective clinical study showed important results using two posterior tilted implants and two anterior non-tilted ones with the All-on-4 treatment concept. Many authors have reported reduced surgical invasion (compared to alternatives

Educational aims and objectives

This article aims to discuss the rationale for the All-on-4 treatment concept of providing implant-supported dentures and demonstrate a successful case study.

Expected outcomes

... This protocol facilitates use of longer implants, improves bone anchorage, and avoids bone grafting procedures.

such as sinus grafting surgery), shorter treatment time, lower cost, natural esthetic profiles, functional bite, and easier repairability.

Baseline situation A patient presented at the practice looking to explore the options available for replacing his broken-down dentition. The main concerns were the shape, color, and general position of his teeth. The teeth were uncomfortable, and because he could not eat properly, he had a limited choice of foods. In addition, he lacked confidence socially and felt he had the teeth of an “older man.” Although the medical history was clear, the tooth fracture and loss were related to general lack of attention. After verbal consent was obtained, an intraoral examination was performed as well as comprehensive periodontal and dental charting, including fullmouth periapical imaging and a panoramic radiograph.

Moss Osman, BDS, MSc, is the founder of Bridge Dental & Implant Clinic. He has more than 13 years of experience in implant dentistry, with a particular interest in implant treatment in the esthetic zone. A member of the ITI, ADI, and BSOS, Dr. Osman is also a certified Straumann® user and an accredited mentor.

40 Implant practice

In addition to addressing the needs and expectations of the patient, all alternative treatment options available were discussed, which included both fixed and removable options: 1. Full dentures 2. Overdenture 3. Eight implants with extensive bone and sinus grafting, implant placements with fixed porcelain bridges 4. All-on-4 treatment concept with immediate fixed provisional bridge placement. A dilemma often presents itself in these cases when extracting teeth that are potentially salvageable. It is very important for the patient to have full understanding of the treatment and consent. After exploring the advantages and disadvantages of all options, the patient decided upon an implant-based solution for both arches.The patient wished to avoid advanced grafting techniques and didn’t want to be left without teeth at any stage of the treatment, so the All-on-4 treatment concept of implant therapy was Volume 9 Number 1

CONTINUING EDUCATION

Before

Transitional stage

Definitive stage

Diagnosis, planning, and pretreatment

given to occlusion and esthetics during construction of the provisional bridge. Primary impressions were taken with alginate, including a facebow record for a transfer to the horizontal plane. The wax rim was adjusted to ensure correct incisor length, lip support, and buccal contour in the posterior region to prescribe the buccal corridor width. After primary impressions with stock trays, special trays and bite blocks were created to register the occlusion and

Figures 1A-1F: Before through final stage

chosen, based on the evidence of MalĂ˛ and colleagues, which required sacrifice of remaining teeth and alveolar bone reduction beyond the smile line (2014). Upper and lower full acrylic dentures were then constructed, which would allow for in-surgery conversion to a fixed provisional bridge or provisional dentures, should implant placement torques be unsuitable following the loss of remaining teeth beyond the smile line.

The three-dimensional image from CBCT was analyzed, revealing sufficient bone volume to place five implants in the upper arch and four implants in the lower arch.

Provisional bridge/denture construction This stage was completed by a clinical technician. Paramount consideration was

Figures 2A-2F: Preoperative photographs. 2A: Right view. 2B: Upper arch. 2C: Smile line. 2D: First occlusal contact in centric. 2E: Left view. 2F: Lower arch Volume 9 Number 1

Implant practice 41

CONTINUING EDUCATION

Figure 3: Post extraction

Figure 4: Sockets debrided and vertically reduced

Figure 5: Implants placed in upper arch

Figure 6: Implants placed at varying angles

assess the increase in vertical dimension. The working models were casted and articulated using the facebow. Then the teeth were removed from the working model and the amount of alveolar bone reduction anticipated. Thereafter, acrylic teeth were positioned at the new vertical dimension for the fixed prosthesis. Construction of the provisional bridge was performed by the clinical technician — this is very helpful as it removes a large component of guesswork from the esthetics. When all parameters of esthetics and occlusion were precise, the denture/bridge was processed ready for the implant stage.

Figure 7: Upper and lower implants placed

Figure 8: Upper implants in situ

Surgical procedure After extraction of the teeth and roots, the sockets were debrided and vertically reduced to obtain a wide bony bed around the implant shoulder. The five implants (NobelActive™, Nobel Biocare®) were inserted in the planned positions immediately after reduction of the alveolar ridge. Due to its specific design, the NobelActive implant “compresses” the bone during insertion, achieving a high level of primary stability even in compromised 42 Implant practice

Figure 9: Radiograph showing implant sites Volume 9 Number 1

10C

10E

10B

10D

10F

Figures 10A-10F: 10A: Temporary denture loaded immediately – left view.10B: Temporary denture retracted – left view. 10C: Temporary restorations – central view. 10D: Temporary denture retracted – central view. 10E: Temporary denture – right view. 10F: Temporary denture retracted – right view

bone situations. The existing jawbone was maximally utilized for anchoring the implants, which were inserted as planned. The implants placed, 4.3 mm x 13 mm, can be seen on the panoral radiograph with corresponding multi-unit abutments angulated by 0° to 35°. The required primary stability was achieved for all five implants in the upper arch and four implants in the lower arch. All had insertion torque of above 35Ncm, taken to be acceptable for immediate loading, and so immediate loading was possible.

Vicryl® (Ethicon, Inc.) sutures were removed. Also, parafunction activity was checked while provisional restoration was worn.

The dental technician had prepared the provisional resin dentures for both the upper and lower arch prior to surgery. After the implants and the multibase abutments were placed, the temporary acrylic dentures were placed to check occlusion, esthetics, and smile line. Implant positions were marked on the dentures, and access holes were created. Temporary cylinders were fitted, and a rubber

dam was placed to prevent the cold-cure acrylic from attaching to the suture. A quicksetting acrylic material was used to secure the cylinders within the provisional bridge. The provisional was then precisely adapted to the implant positions, and a 12-unit was immediately loaded on the provisional resin bridge for the upper and lower arch. During the healing phase, it was important for the patient not to exert too much force during function. Acrylic provisional bridges were created without metal substructures, meaning excessive pressure could cause the provisional to break. To help prevent this and aid success of the implants, night guards are usually provided. Only soft food was advised during the healing phase of 3 months, and the dangers of load pressure were explained to the patient. The patient was reviewed 2 days later with no pain, swelling, or side effects and was very pleased with the results. A follow-up visit was scheduled 2 weeks after surgery; the provisional bridge was checked and cleaned, and unresorbed

Figure 11: Preparation for upper impression

Figure 12: Preparation for lower impression

Figure 13: Impression

Immediate restoration

Volume 9 Number 1

Final restoration After 3 months of healing, construction of the final bridge was underway. The dental technician planned the final bridge on the basis of the provisional restoration. In general, we attempt to raise patients’ awareness of the appearance in the early provisional stages, when discussing the possible outcome. The titanium framework was precision-milled via NobelProcera® and injectable acrylic. About 4 months after surgery, the definitive bridge was placed. At the same time, the second acrylic bridge without milled bar was created as a provisional for emergency use.

Definitive work Using the impressions taken on the placement day, working models were created, and a silicone index of the provisional teeth was

Implant practice 43

CONTINUING EDUCATION

10A

CONTINUING EDUCATION

Figure 14: Final bridge fitted – left, smile view

Figure 15: Final bridge – central view

Figure 16: Final bridge – left view

Figure 17: Final bridge retracted – right view

Figure 18: Final bridge retracted – central view

Figure 19: Final bridge retracted – right view

used to fabricate bite blocks. In addition, we made a special tray using double thickness light-cured tray material to optimize the rigidity. By using the index of the implants into which we had placed the impression copings, we were able to put the access holes in exactly the correct position.

tooth color, and the patient decided on A1. Gingival shade tabs (Ivoclar Vivadent) were used to help communicate the pink acrylic required.

Impressions and initial bite The upper provisional was removed, and the multi-abutments were checked. Impression copings were placed and splinted with stainless steel metal and composites to prevent the impression post being distorted. An impression was then taken. The occlusal registration was performed and incisal length, vertical dimension, midline, and lip profile were assessed. In the impressions, abutment analogues were placed, and a plaster base was poured to create final working models.

Wax trial A wax try-in was constructed using a silicone index taken of the teeth. This stage was completed in the presence of the technician who also examined all the areas. Any alteration either requested by the patient or me was rectified by the technician. With the patient’s approval, we proceeded to the metal work. The framework was milled by CAD/CAM. The accuracy of fit was checked at all abutments, and the interarch relations were confirmed and recorded. At this stage, the shade prescription was determined — restoring both the upper and lower arch afforded freedom to choose the 44 Implant practice

Trial The occlusion was adjusted in order to obtain a mutually protected occlusal scheme, and then the esthetics were concentrated on. Key esthetic parameters such as incisal tip placement, midline, lower lip reflection, and buccal corridors were all fine.

Fit With both a lighter and wider smile, the display of tooth and gingival contour were harmonious. All esthetics and occlusal parameters were checked, and finally, the upper and lower bridges were torqued according to the manufacturer’s instruction. The patient is under review every 3 months at present to make sure oral hygiene is maintained.

Conclusion In traditional dental implant therapy, the time between implant placement and delivery of the definitive prosthesis can be long and uncomfortable for a patient wearing a conventional removable denture.

Figure 20: Postoperative facial view

The All-on-4 treatment concept uses tilted implants to immediately restore maxillary and mandibular implants with provisional restorations, thus shortening the patient’s return to function, reducing surgical invasion (sinus grafting surgery), shortening treatment time, lowering cost, and enhancing natural esthetic profiles and functional bite. The high cumulative implant and prostheses survival rates indicate that the All-on-4 treatment concept with immediate-function, combined with Nobel Biocare implant systems, is a viable treatment modality for completely edentulous mandibles.The case that suggests immediate loading associated with tilted implants prosthesis can be considered a viable treatment modality for the edentulous upper and lower arch. IP

REFERENCES 1. Strassburger C, Kerschbaum T, Heydecke G. Influence of implant and conventional prostheses on satisfaction and quality of life: A literature review. Part 2: Qualitative analysis and evaluation of the studies. Int J Prosthodont. 2006;19(4):339-348. 2. Maló P, de Araújo Nobre M, Lopes A, Ferro A, Gravito I. All-on-4® Treatment Concept for the Rehabilitation of the Completely Edentulous Mandible: A 7-Year Clinical and 5-Year Radiographic Retrospective Case Series with Risk Assessment for Implant Failure and Marginal Bone Level. Clin Implant Dent Relat Res. 2015;Oct;17 Suppl2:e531-541.

Volume 9 Number 1

The next generation of LOCATOR® is here: introducing the LOCATOR R-Tx™ Removable Attachment System

OCATOR R-Tx™, is a better, simpler, and stronger system that relies on the same restorative techniques as the awardwinning LOCATOR. At ZEST Anchors, we proudly claim a 40-year heritage of overdenture attachment innovation. Over the past decade and a half, the LOCATOR Attachment System has grown dramatically, evolving into the undisputed market leader for implant-retained, tissue-supported overdenture attachments and trusted by the industry, the clinician community, and patients alike. In keeping with our innovative spirit, ZEST has continued to refine and even reimagine LOCATOR. We started by listening to you, the influential specialists, clinicians, and manufacturers. Then our engineers put those ideas to the test and into real application. Welcome to LOCATOR R-Tx — evolutionary design with practical benefits.

New DuraTec™ coating

Efficient Abutment/Insert engagement

DuraTec™ Titanium Carbon Nitride Coating is esthetic, harder, and more wear resistant. DuraTec is composed of multiple layers of titanium nitride and titanium carbon nitride, achieving increased strength, wear resistance, and reduction in roughness.

The Nylon Retention Inserts now engage dual retentive surfaces on the exterior of the Abutment. No internal engagement prevents debris and plaque accumulation within the drive mechanism from impacting proper seating.

New drive mechanism

New retention insert design

Industry standard .050"/1.25mm* hex drive mechanism simplifies placement. Smaller center cavity reduces area for food and plaque accumulation.

Improved design resists edge deformation. Simplicity is also top of mind — the system utilizes only one set of Retention Inserts with straightforward retention values — Zero, Low, Medium, High.

Easier denture seating with pivoting technology Dual retentive enhancements to the Abutment and Nylon Retention Insert work in harmony with the redesigned Denture Attachment Housing to allow for a 50% increase in pivoting capability (60° between implants) and easier alignment and overdenture seating during insertion/removal for the patient.

Narrower coronal geometry The dual-engaging geometry of the Abutment offers a narrower leading edge and taper-like effect to allow the patient to more easily align and properly seat the overdenture.

Retention Insert

Convenient all-in-one packaging Custom designed all-in-one, doubleended vial separately holds Abutment and Processing Components, providing all the necessary components for the case with one part number.

Practical denture attachment Housing design Horizontal grooves and flats resist vertical and rotational movement, and a channel inside the top of the Housing enhances pivot range of motion. New pink anodization improves esthetics in areas of thin denture acrylic.

All-in-one packaging

Custom retention insert tool Dual-sided tool allows for easy insertion and removal of the LOCATOR R-Tx Retention Insert. Metal slot feature on the back of the tool allows the clinician to disengage a Retention Insert without the risk of tearing gloves. IP LOCATOR R-Tx Volume 9 Number 1

Cutaway view of Denture Attachment Housing showing inner channels

This information was provided by Zest Anchors.

Implant practice 45

PRODUCT PROFILE

Better. Simpler. Stronger.

INDUSTRY NEWS Salvin Dental Specialties announces the acquisition of Exactech’s Dental Biologics assets Salvin Dental Specialties, Inc., through its Salvin Regenerative subsidiary, announced that it has acquired substantially all of the assets of Exactech Inc.’s dental biologics business. Salvin Dental Specialties, Inc., a privately held company doing business in over 100 countries, develops, manufactures, and markets regenerative biomaterials and surgical instrumentation specifically for implant dentistry. According to Founder and CEO, Bob Salvin, Exactech has an exciting dental product line, and this acquisition will provide Salvin with greater product depth as well as additional manufacturing capabilities. Exactech, Inc. (Nasdaq: EXAC) is a publicly traded company that develops and produces bone and joint restoration products for hip, knee, shoulder, and spine. Exactech’s Dental Biologics Division supplies the dental market with dental biologic products including Optecure® and Oralife®. Optecure® Dental is an engineered bone graft for reconstruction and augmentation of deficient maxillary and mandibular alveolar ridges and dental intraosseous defects. Exactech’s Senior Vice President and General Manager of Spine and Biologics Bruce Thompson said, “We have made the strategic decision to focus more exclusively on our core orthopedic business, and our long-standing distribution relationship with Salvin gives us confidence that they will take good care of dental customers in their pursuit of improving patient care.” Financial terms were not disclosed. Deloitte Corporate Finance acted as an advisor to Salvin Dental. For more information, contact Salvin Dental Specialties, Inc., 3450 Latrobe Drive, Charlotte, NC 28211; Phone: 704-442-5400; Fax: 704-442-5424; email: orders@salvin.com; www.salvin.com.

OCO Biomedical launches “2016 Pan-Caribbean Introductory Implant Planning and Placement” course, April 1-2

LED Medical Diagnostics announces successful results for latest clinical research using VELscope® Tissue Fluorescence Technology

OCO Biomedical Inc. has announced the addition of the “2016 OCO Biomedical Pan-Caribbean Introductory Implant Planning and Placement” course to be held from 8 a.m. to 5 p.m. on Friday, April 1, and Saturday, April 2, at the DoubleTree by Hilton Hotel San Juan, 105 Avenida De Diego, San Juan, Puerto Rico. OCO reports that this course offers practitioners the hands-on opportunity to learn innovative implant skills to change the way that they provide implant care. The widely accepted OCO Biomedical System is centered around the patented Dual Stabilization™ implant, which makes immediate/early load treatment protocols a reality. Traditional implant therapy requires an extended healing phase. By contrast, the OCO System attains such a high degree of mechanical stability at placement, that the patient can be moved into the restorative phase either immediately or early in the overall treatment. This 14 CE unit, AGD-Pace accredited course is designed for either the general practitioner or the more experienced implantplacing dentist. Diagnosis, treatment planning, surgical protocol, restorative protocols, and socket preservation/bone grafting are covered in the instructive portion of the course. These concepts will be reinforced through the hands-on exercises over the two-day seminar. For more information, call OCO Biomedical at 1-800-2280477, or visit www.ocobiomedical.com.

LED Medical Diagnostics Inc. has announced that the results of a study, titled “Fluorescence VisualizationGuided Surgery for Early-Stage Oral Cancer,” have been published in the Journal of the American Medical Association – Otolaryngology – Head and Neck Surgery. The publication reports the findings of a retrospective, casecontrol observational study that was conducted on 246 patients from September 1, 2004, to August 31, 2009. The study showed a significant reduction in the rate of local recurrence of early-stage squamous cell carcinoma and high-grade precancerous lesions in patients where VELscope tissue fluorescence visualization was used to assist in determining the surgical margin for excision, compared to those patients where conventional methods were used. “This is really a revolutionary way for surgeons to visualize a diseased region,” stated Dr. Catherine Poh, principal investigator and Provincial Oral Medicine Leader for Oral Oncology at the BC Cancer Agency. “We are now working with head and neck surgeons across Canada to conduct a multi-center trial that will convince the world to change practice and improve the treatment of oral cancer.” The article can be viewed at http://goo.gl/Xp4Hao.

46 Implant practice

Volume 9 Number 1

Everything For Your Implant Practice But The Implants®

• AlloSculpt ® Demineralized Allograft Putty • A llosculpt-3D ® Demineralized Cortical Allograft Putty With Cortical Cancellous Chips • R esorbable Hydrogel Carrier Resists Irrigation To Keep Graft In Place • R apid Mixing With Either Autogenous Blood Or Included Buffer Solution

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PRACTICE MANAGEMENT

Discover the key to achieving 98% case acceptance

n a Q&A, Dr. Paul Fugazzotto, successful periodontal and implant specialist, visiting lecturer at many universities, and Director of the Institute for Comprehensive Implant Therapy, discusses how professional relationships can help bring your practice to a new level.

“If everyone is moving forward together, then success takes care of itself.”

Q: Your practice currently enjoys a 98% case acceptance rate. What do you attribute that extraordinary success to? A: Relationships — that’s how you build a strong, profitable practice. Before you can expect a patient to say “yes,” there needs to be a network of professionals laying the groundwork together. The tenets that make up any healthy working relationship are mutual respect, open communication, and trust. Trust is the foundation of a good relationship. For fellow practitioners, this means open communication during every stage of the treatment plan, including the discussion of who’s charging what. My referring doctors and I do this with our patients. The goal is to streamline everything for the patient — the diagnosis, the recommended therapies and a single fee for service. The result is greater patient understanding and increased acceptance of therapy.

Q: A single fee for the entire treatment plan? How do you make that happen? Even if you streamline the referral and scheduling, there are still two offices that need to invoice the patient. A: Our team relies upon the multipayment program from Lending Club Patient Solutions. The program helps strengthen practice relationships while allowing patients to consolidate costs for all the providers

— Henry Ford engaged in their treatment plan — dentist, lab, implant specialist, everyone regardless of location — into one convenient payment plan. The dentist presents one total treatment fee for service to the patient. It’s easier for the patient to understand, and you’re more likely to get a “yes” to the treatment plan. Under the multi-payment program, Lending Club Patient Solutions distributes funds to the various participating provider locations (minus the applicable practice fees), and the patient makes a single, low, fixed monthly payment through Extended Plans for the entire therapy. One team. One financing application. One total treatment fee for service. One repayment plan that fits the patient’s needs. Now, patients understand the therapies we’re recommending and how they must meet their needs and budget. Even the most complex procedure can be affordable if you empower patients with more responsible and convenient financing options. That’s why it’s important to include patient-friendly financing. It’s like the third leg of the relationship stool. By working together with a “one-stop” financing process, patients get the care they need, all of our practices streamline workflows, and accounts receivable disappear.

Dr. Paul Fugazzotto is a Boston University graduate; a visiting lecturer at Tufts University, Harvard University, and the University of Ancona in Ancona, Italy; and Director of the well-respected and highly successful Institute for Comprehensive Implant Therapy where training courses are taught to dentists from the United States and around the world on the most up-to-date techniques regarding dental implant placement and bone regeneration. Dr. Fugazzotto received his doctorate of dental surgery from New York University in 1979 and his Certificate of Advanced Graduate Study from Boston University in 1981. Dr. Fugazzotto and his partner, Dr. Anya Rost, have a combined 30-plus years of experience with bone regeneration (both around teeth and in preparation for implant placement) and dental implant therapy. They have published extensively on these subjects in scientific journals. Dr. Fugazzotto is a fellow of the International Team for Implantology (ITI). Fellowship in the ITI is by election only. He is a former National Director of the U.S. ITI Study Clubs and Editor-in-Chief of the journal, Implant Realities™. He has also authored three textbooks, including Implant and Regenerative Therapy in Dentistry: A Guide to Decision Making, and lectures extensively throughout the world on the topics of periodontal therapy, regrowing lost bone, esthetics, and implant therapy.

Q: Building a robust network takes commitment. How do you fit everything into your busy schedule? A: One way we connect is through continuing education. By offering our partnering doctors regular evening and full-day presentations, we have a great tool for getting the team on the same page. The topics range from restorative techniques to treatment planning to advanced therapies to business concepts. These meetings also provide an opportunity to discuss industry tools like the Lending Club Patient Solutions multi-payment program. The majority of the events are at no charge as a way to say thanks. We learn techniques together and can, in turn, improve patient care and all of our businesses.

Q: What about those referring practitioners who prefer to stay independent, to keep it all in-house and offer office financing? A: I’d say, put yourself in the patients’ shoes. They’re already worried about the procedure: “Will it hurt?” “How will it look?” “How much time will I lose from work?” If they also have to worry about how to pay for the treatment, you will have a harder time getting them to say “yes” to necessary care. By simplifying payment and offering a single fee for service, you remove more of the roadblocks. As for self-funding or in-office payment plans, we don’t do either. Naturally, we offer patients a 5% “courtesy discount” for immediate payment. But self-funding? No. I’m not a bank. Financing offered through Lending Club Patient Solutions changes my accounts receivable from 30 days to 3 days, and it eliminated the need for my staff to have the tough “your payment is overdue” conversation with patients. When there is a program like the multipayment program from Lending Club Patient Solutions, why consider self-funding?

Information Find out more about Lending Club Patient Solutions at www.lendingclub.com/ patientsolutions. IP

Disclosure: Dr. Paul Fugazzotto receives no compensation from Lending Club.

48 Implant practice

Volume 9 Number 1

Isn’t it time your patient ﬁnancing measured up to your patient care?

“Same-day treatment acceptance has gone up since incorporating Lending Club Patient Solutions into our treatment presentation.” —Christina C., Senior Treatment Coordinator, Georgia

“Their high-quality customer service is unbeatable, plus they cost less than any other patient-ﬁnancing providers—a win for our patients and our practice.” —Dee Dee R., Patient Concierge, Texas

Discover a new approach to patient ﬁnancing and see why we continue to get rave reviews. To learn how easy patient ﬁnancing can be: Call (844) 936-6673 or visit lendingclub.com/providers.

Formerly Springstone Patient Financing

PRACTICE DEVELOPMENT

Spreading the word Toks Oyegunle continues his series into part 4 with a look at the best media to use to get your message across

hat exactly does the word media mean to you? A simple dictionary definition seems like a good starting point: “The means of communication, as radio and television, newspapers, and magazines that reach or influence people widely.” Please note the use of the word influence in the definition — this is critical, as the primary purpose of marketing is to influence the market to buy your services. For the purpose of this article, I would like to propose a simple, broader definition of media that is particularly relevant to the profitable marketing of your dental practice. Consider this definition of media: any platform that enables you to effectively communicate your marketing message and positively influence your target market. Take a moment to reflect on this, and consider the many different platforms that you may use to communicate your marketing message and positively influence the market.

The preceding classification and media types are not meant to be comprehensive — that is beyond the scope of this article. The list is simply meant to draw your attention to the broad array of media choices available to use for the profitable marketing of your practice. The broad list of available media can quickly become overwhelming for many practice owners, leading to confusion in some cases and apathy in others. That is the wrong attitude to take with this; the fact is, you cannot possibly use all the media options available for a variety of reasons, including cost, suitability, and effectiveness among

others. The right attitude to take regarding media is to ask, What is the right media for you to use for the profitable marketing of your practice? Do not underestimate the importance of this question — understanding what media to use and why will provide you with invaluable information regarding where you should regularly advertise your practice. It is probably the most important question you can ask regarding your use of media. If you get the answers wrong, you will probably incur considerable advertising costs with relatively few results to show for them. I am sure some of you have already had this experience. On

Different types of media Within the context of the marketingdriven definition of media detailed earlier, it becomes obvious that media is pretty broad and covers many platforms, which may facilitate the ability to communicate your marketing message. Review this brief overview of some of the different types of available media below. How many of them do you currently use as part of your ongoing marketing efforts? Are there any you think you can use in future? • Print media: books, directories, newspapers, magazines, newsletters, letters, brochures, billboards, posters • Broadcast media: television, radio • Electronic media: Internet (website/email/social media/blogs, etc.), telephone

Toks Oyegunle is a leading business coach and an awardwinning entrepreneur. The Harvard Business School alumnus is the founder of Thriving Practices: profitable marketing solutions; experience-based, technology driven.

50 Implant practice

Volume 9 Number 1

Target market Based on this analysis, there is a need for you to fully understand and use the most efficient and effective media to communicate with your target market. To help you understand what media you should be using for profitable marketing, here are some questions that need to be answered.

2. What media do your perfect patients use? You must understand the media consumption habits of your perfect patients: what TV shows do they watch? What radio stations do they listen to? What newspapers and magazines do they read? Are they online regularly? What websites and blogs do they read? You can get this information in a number of ways — the easiest being to simply ask your perfect patients what newspapers/ magazines they would prefer to read while waiting in your reception area. If you have TV/ radio, you may ask them what channels they prefer. Another way is to request this information during your regular customer satisfaction surveys, assuming you already do this as part of your marketing system.

1. Who are your perfect patients? If you have been following this article series, you should now have a clear understanding of who your perfect patients are. Hopefully, you have a good understanding of the demographics and Your target market psychographics of the market you wish to attract. This is very important Work out who your target audience is: because it is this understanding that • What TV shows do they watch? will enable you to answer the next • What radio stations do they listen to? question. • What newspapers do they read? • What magazines do they subscribe to? • Are they online regularly? • What websites and blogs do they read?

The key point here is to understand how much choice you have and to be creative, effective, and profitable with your use of media ...

3. What media should you use? Armed with a comprehensive list of your perfect patients’ preferred media choices, you must decide on a subset that is ideal for you to use in your marketing to them. It’s important to understand the different media used by your perfect patients; however, the real marketing benefit will be realized when you are able to identify and invest in the best media to communicate with your target market. Some forms of media will be more suitable for you than others for different reasons. For example, your budget may be a limiting factor where the more expensive media is concerned. The attention span of Volume 9 Number 1

your target market may also be an issue with other media.

Tracking results What is the most appropriate and responsive media for you to use to communicate with your target market? Will this be an advertisement in the local paper, your website, or a direct mail letter sent to them at home? This will definitely depend on what type of service or product you are selling, and whom exactly you are selling it to, so how can you know what the best media is? To know this, you will need to actively test and track the results from advertising in different forms of media during your marketing campaigns. Over time, these results will develop into a pattern that will help you understand what the best media for marketing your practice is. One of the most understated forms of media, but one that is extremely powerful, is the tried and tested “word of mouth.” It can be used successfully on a regular basis if you have the right referral-generating systems in place. You may want to consider this media form as a core part of your marketing strategy and invest accordingly in getting referrals from all your existing and new patients. Another powerful media that is often overlooked is the simple newsletter; it is a form of media where you totally control the content and is one of the best patient retention strategies you may deploy for your practice.

Key platform You need to think of media as a platform that will help you get into the mind of your market. Many dentists are trying different types of media these days, with mixed results. One of my local dentists recently put a massive billboard at the entrance to a local train and bus station; I thought it was a great idea, as the dentist also added the fact that the practice was just a few minutes’ walk away. Unfortunately, they made the classic mistake of excluding any call to action, making it difficult to motivate the market to act immediately, and for them to track the effectiveness of the advertisement. Other dentists are using radio advertisements to reach out to the market. The key point here is to understand how much choice you have and to be creative, effective, and profitable with your use of media for the marketing of your dental practice. IP Implant practice 51

PRACTICE DEVELOPMENT

the other hand, if you get this right, you should soon see considerable growth in the sales of your services and products.

ON THE HORIZON

The implant practice — it’s more than just implants Dr. Justin Moody discusses his implant system of choice

ith the theme of this issue being implant systems, I got to thinking about what that really is. I could show you the surgical kit that I use and the implants that I place, but there really is more to that than just the mechanics of the dental implant. In my 19-year career, I have used several systems, but for the last 8 years, I have used BioHorizons® as my implant partner. There are literally hundreds of implant systems on the market today, and we can put in general terms that they all work from BioHorizons Tapered surgical kit BioHorizons Tapered PLUS with Laser-Lok® an integration and restorative standpoint. So why do I consistently choose BioHorizons? To add implants within your practice or to grow your existing implant practice to something much larger, you need a true partner, and I have found this in BioHorizons. When a dentist is first starting a practice, dental implant representatives are valuable resources for completing those first few cases successfully; they can help in understanding the surgical kit, and talk with The Dental Implant Center in Rapid City, South Dakota your office team on how to order and maintain just the right inventory without killing your overhead. But as time BioHorizons Tapered PLUS implant with a custom hybrid goes on, these reps are so featuring Laser-Lok technology 18-months post-prosthetic much more; they provide you and your team with information and promote my practice from within through education both in the office and outside the use of brochures, patient education, from classes, training seminars, and larger and marketing pieces such as the Teeth meetings such as their global symposiums. Xpress® magazine. All this is offered, along Your implant partner should also underwith dental implants and prosthetic options stand your market and how to grow this that are backed by science, confirmed with within your area. The marketing support long-term clinical success, and made in the I get from BioHorizons has helped me United States. IP Justin Moody, DDS, DICOI, DABOI, is a Diplomate of the American Board of Oral Implantology and of the International Congress of Oral Implantologists, Fellow and Associate Fellow of the American Academy of Implant Dentistry, and Adjunct Professor at the University of Nebraska Medical College. He is an international speaker and is in private practice at The Dental Implant Center in Rapid City, South Dakota. He can be reached at justin@justinmoodydds.com or at www.justinmoodydds.com. Disclosure: Dr. Moody is a paid speaker for BioHorizons.

TeethXpress® magazine 52 Implant practice

Volume 9 Number 1

introducing the new

snap coping

â&#x201E;˘

Clinical image courtesy of Dr. Neal Gittleman

accurate impressions in a snap The snap coping offers an accurate implant-level impression for single or multiple units with an easy to use closed tray, pick-up technique. The one-piece design easily snaps into the prosthetic platform by hand, without the need for additional instruments. The color-coded titanium ring is used to verify seating on a radiograph and matches the emergence of the corresponding healing abutment. The low profile 9.5mm coping height can be reduced further to 6.5mm by removing the top flange without compromising the accuracy of the impression.

For more information, contact BioHorizons Customer Care: 888.246.8338 or shop online at www.biohorizons.com

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PRACTICE MANAGEMENT

Transitioning employees after a practice purchase Paul Edwards offers five effective postpurchase policies

henever I hear that a dental professional is thinking about buying a practice or has just gone through with a purchase, the first question that springs to my mind is, Do you have a plan for transitioning the employees? Practice transitions are fascinating because they touch upon nearly every HR issue possible — from your underlying policies and onboarding employees, to managing complex ongoing HR issues, to (in many cases) letting one or more employees go by the time the transition is complete. After watching the post-purchase HR scenario play out time and time again and providing guidance and problem-solving for scores of dentists during the rough patches, I’d like to share the treasure trove

Paul Edwards is the CEO and Co-Founder of CEDR HR Solutions (www.cedrsolutions.com), which provides individually customized employee handbooks and HR solutions to dental offices of all sizes across the United States. He has over 25 years’ experience as a manager and owner and specializes in helping dental offices solve employee issues. Paul is a featured writer for The Profitable Dentist, Dental Economics, and other publications, and speaks at employment education seminars, conferences, and CE courses across the country. He can be reached at pauledwards@ cedrsolutions.com, or by calling 866-414-6056.

54 Implant practice

of recommendations I’ve stockpiled. Some are directly aimed at lowering your risks as an employer, and others will smooth out your management transition with your new team (which, by the way, also lowers your risks). This guidance applies whether you’ve just bought your first practice or have purchased a second or third. I’m also assuming that you’re trying to keep at least some of the practice’s existing staff, although I’m by no means suggesting that you keep them all. First, though, I want to point out that transitions in practice ownership are scary for employees; and fear, intimidation, and insecurity are not the way to begin, maintain, or grow your management relationship — especially when what you want in return is loyalty, positivity, and commitment to your goals. Employees are your lifeline to your patients. Keep that in mind throughout your transition, along with these tips.

1. Start with honesty. It’s critical to be honest with all employees involved in the transition because you need their honesty and good faith efforts in return. During this time of uncertainty, you’ll establish

control more easily if you don’t exacerbate their negative feelings. Employees will be worried — and rightly so — about whether they can expect to keep their jobs, whether their pay or benefits will change, and whether there are going to be unpleasant upheavals. They want to know what to expect from you, and what you expect from them. Address all of those issues. If some things have not been decided yet, such as whether PTO or benefits will be changing, let the employees know when they can expect a decision. Meet with each employee as soon as you can (if possible, before the deal is even done) to discuss the transition. Ask them what they do, if they are happy, and how they see the practice evolving. This is an opportunity to show you are a worthy leader, capable of compassion, and rewarding of those who commit to the practice’s success. A good approach is: “I want to be very clear about my expectations for each employee and will be evaluating each individual. I want employees who support our patients and my vision for our success. But it is not my intention to keep anyone in a position you don’t want to be in. I encourage you Volume 9 Number 1

PRACTICE MANAGEMENT to talk to me, and tell me your concerns, and you can expect the same from me.” Even if you are the World’s Best Boss and have the coffee cup to prove it, you will probably encounter resistance to your changes because human nature is great at resisting change. Sometimes we even resist positive change, just because it’s different! So while you want to show understanding, this is also the time to let employees know that you won’t be managing from a place of fear.

2. Know what you don’t know, and get help. You might be hoping not to upset the apple cart too far during your transition, especially if you’re buying a practice that’s apparently been running smoothly for years. But you’ll still want to put your own employee policies in place, not retain the potentially mine-filled preexisting employee manual. To do this, you’ll need expert help because chances are you didn’t spend dental school studying employment law or getting an advanced HR degree in your spare time. But why can’t you keep those preexisting policies, since they seemed to work fine? It’s just not safe, no matter how fervently the selling doctor may believe in them. Countless ever-shifting laws govern employers’ every action, and you’ll have no idea which policies have been recently updated and which ones are risky or outright dangerous now. Most employee handbooks are full of policy errors, missing protections, and illegal or unenforceable “red flag” areas that invite legal claims. Often, everything looks fine on the surface. You won’t find out there’s a problem until the day you get a very unpleasant letter … from an employee’s attorney. Instead, you want a policy manual that is professionally written and up-to-date, and you need expert guidance you can trust to safely resolve or minimize the risks in any issues you encounter. Have your new employee handbook ready early in the game! The most common mistake I see in practice transitions is not getting reliable expert support on employment issues.

Practice transitions are fascinating because they touch upon nearly every HR issue possible — from your underlying policies and onboarding employees, to managing complex ongoing HR issues, to (in many cases) letting one or more employees go by the time the transition is complete. to read it thoroughly. Let everyone know that you need his/her signed acknowledgment by the next day. Note that employees are signing an acknowledgement. They do not need to agree with each policy, but they do need to understand that you will hold them accountable if they choose to break the rules you’ve laid down. If your handbook is good enough, your employees are also acknowledging their responsibility to let you know when they experience a problem while working at your practice. Make sure the expectations you set are clear and aboveboard. This is the first day of the rest of your employment relationship.

4. Make affirmative decisions to hire or fire. Don’t passively inherit the entire team of the practice you’re purchasing — this is your chance to eliminate any obvious “bad apple” employees before they spoil the whole barrel (your new team and practice). Instead, make affirmative decisions to hire or fire. Keep in mind that you still need to be careful your actions won’t seem discriminatory. For the employees you’re hiring, let them know they are in their 90-day “gettingacquainted period,” during which you can both decide if the new employment situation is a good fit.

3. There’s a new sheriff in town.

5. Fixing small problems early prevents huge problems later.

Establishing a comprehensive set of policies isn’t enough — your real goal is to establish yourself as the “new sheriff in town,” and make sure the team has read and understood the law of the land. Meet with them, distribute your employee handbook, and allocate some time on the clock for them

Once your purchase goes through, the obligations of being an employer immediately fall upon you. Hopefully, you already developed some pre-sale impressions of the biggest challenges ahead. But post-sale, it’s up to you to identify, evaluate, and solve small transition problems rapidly so they

56 Implant practice

don’t grow into big employer nightmares. Check each employee’s files. Do they contain old paperwork or write-ups, or are they empty? If they are, just remember an empty file does not mean there’s never been a problem. It just means you’ve got no documentation from the previous owner about what type of employee this person has been up to now. Make everything official with all-new hiring paperwork, and don’t put this off. Use a hiring checklist to ensure you hit everything that is required (e.g., new I-9s, W4s, other state and federal requirements, noncontractual offer letters, job descriptions, and background or reference checks, to name only a few). Email me if you’d like a free hiring checklist that’s attorney-reviewed. As you move forward, and issues arise with your new staff — and they probably will, as you get used to each other — be proactive and diligent about letting employees know what changes you need to see. Document your requests, any corrective actions, and what did or did not occur, especially if you took over an empty file cabinet! If you have an employee or two whose pushback is excessive, or who is simply not adjusting in the way you need, evaluate your risk factors and then let them go as soon as you can safely do so. Every transition situation is unique, and I could fill books with the sum total of what you should do before, during, and afterward to streamline your experience and improve your experience with your new team. You’ll definitely want to consult with your favorite attorney or HR expert before you make final decisions about policies, grandfathered benefits, terminations, and situations unique to your sale. But if you begin with these five tips, you’ll have made a very good start. IP Volume 9 Number 1

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