clinical articles • management advice • practice profiles • technology reviews November/December 2013 – Vol 6 No 6
PROMOTING EXCELLENCE IN IMPLANTOLOGY
Corporate profile Planmeca
Collagen plug application in extraction sockets Drs. Jon B. Suzuki and Diana Bronstein
Pride Institute “Best of Class” special awards tribute
Corporate insight ZEST Anchors
Hard tissues Drs. William C. Martin, Emma Lewis, and Dean Morton
Practice profile Dr. Yong-Han Koo
The most innovative 3D technology available today… Ask For It By Name
See the inside back cover to learn more about why the ProMax oﬀers the ideal 3D imaging solution for your practice.
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WHEN THE OSTEOTOMY MUST BE NARROW -
SO MUST YOUR IMPLANT CHOICE Choose the LOCATOR® Overdenture Implant System 2.5mm Cuff Heights 4mm
included with each Implant
It’s a fact – denture patients commonly have narrow ridges and will require bone grafting before standard implants can be placed. Many of these patients will decline grafting due to the additional treatment time or cost. For these patients, the new narrow diameter LOCATOR Overdenture Implant (LODI) System may be the perfect fit. Make LODI your new go-to implant for overdenture patients with narrow ridges or limited finances and stop turning away patients who decline grafting. Your referrals will love that LODI features all the benefits of the LOCATOR Attachment system that they prefer, and that all of the restorative components are included. Discover the benefits that LODI can bring to your practice today by visiting www.zestanchors.com/LODI/31 or calling 855.868.LODI (5634).
©2013 ZEST Anchors LLC. All rights reserved. ZEST and LOCATOR are registered 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
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Volume 6 Number 6
Three reasons why cone beam imaging is good for your practice
one beam imaging is a relatively new technology, which has firmly established itself in clinical dentistry since its introduction into the U.S. dental marketplace in 2001. With cone beam imaging, the X-ray energy emitted from the device is divergent, forming a cone-shaped beam. During a cone beam scan, more than 500 images are obtained while the patient remains stationary, and the scanner rotates around the patient’s head. The resulting images, which are interpreted by computer software, are threedimensional, and it is the third dimension that allows for a world of difference in dental diagnosis and treatment planning. The three-dimensional images generated by a cone beam scan can be manipulated by sophisticated computer software for a wide variety of applications, including implant diagnosis and treatment planning, orthodontic diagnosis, detailed evaluation of the temporomandibular joints, examination of the patient’s airway, endodontic diagnosis, evaluation of impactions, and assessment of maxillary and mandibular pathology, along with numerous other diagnostic purposes. For both general practitioners and specialists, cone beam technology deserves serious consideration for incorporation into everyday practice. Reason No. 1: The standard in diagnosis and treatment planning has been raised. With the availability of the third dimension in diagnosis, it quickly becomes apparent that two-dimensional images present the clinician with severe limitations. Because of its superior ability to view anatomical structures in their precise location with remarkable detail, the bar has been raised significantly when it comes to dental diagnosis. For example, when evaluating an impacted third molar, a two-dimensional film superimposes all structures, and it is virtually impossible to distinguish exactly where any given tooth sits anatomically in relation to its surrounding structures. The third dimension made available by cone beam imaging allows the clinician to precisely plan a surgical approach that will avoid damage to surrounding structures and facilitate a safe surgical outcome. Reason No. 2: Implant treatment planning is driven by the prosthetic needs of the patient. Implant patients seek treatment because they are missing teeth, not because of a desire for implants. In asking for implants, a patient’s true desire is to replace teeth that are missing. Today in 2013, our patient expectations are high. They expect teeth that will look good, feel good, allow them to eat comfortably, and which will be relatively free of maintenance. This can only be accomplished when implant treatment is prosthetically driven. The third dimension provided by cone beam imaging allows for a true prosthetically driven implant placement.
Reason number 3: Significant savings in terms of cost and radiation exposure. Prior to the availability of cone beam imaging in dentistry, dentists often referred out their imaging needs to outpatient imaging centers or radiologists. These required the patient to travel to a facility outside of the practice, with the financial cost of these images being far greater than that of in-office cone beam images. The cost extends far beyond dollars – a CAT scan image delivers far greater radiation to the patient than a typical cone beam image. Technology available to dentists today, such as Planmeca’s ProMax® 3D technologies, allows for adjusting the size of the volume to suit the specific area that is being studied. Eugene Antenucci, DDS, is a general dentist who maintains a full-time private practice in Huntington, New York. His state-of-the-art dental facility is also home to a continuing dental education training center for dentists, as well as a commercial dental laboratory. His practice, Huntington Bay Dental, was distinguished as “Dental Practice of the Month” by Dental Economics in May 2003 and “Business of the Year” by the Huntington Chamber of Commerce for 2003. Dr. Antenucci is a 1983 graduate of New York University College of Dentistry. He was awarded his Fellowship in the Academy of General Dentistry in 1992, the American College of Dentists in 1999, and the International College of Dentists in 2005. Dr. Antenucci is a certified CEREC Basic and Advanced Training Instructor, and has conducted training seminars throughout the United States. He lectures internationally, conducting seminars in the clinical utilization of advanced technology in dentistry, as well as seminars in cosmetic dentistry, practice management, CEREC, and laser training. Dr. Antenucci serves on the Board of Benefactors of the Guide Dog Foundation and America’s Vet Dogs, and is also an active member of the National Italian American Foundation, serving as the New York Area Coordinator for the organization. Dental equipment manufacturer Planmeca USA has retained Dr. Antenucci as a spokesperson for its line of 3D imaging products and to advise the company on marketing, advertising, and continuing-education efforts.
Implant practice 1
November/December 2013 - Volume 6 Number 6
TABLE OF CONTENTS
Clinical Collagen plug application in
Dr. Yong-Han Koo: Honesty, integrity, and precision Dr. Koo strives to make a positive impact on his patients, colleagues, and staff.
Planmeca : innovative, upgradeable imaging technology 速
Planmeca, a leader in dental imaging, stays in the forefront of technology as dentistry evolves.
extraction sockets Drs. Jon B. Suzuki and Diana Bronstein explore the efficacy of a collagen plug-in........................... 14
Case study Stem cell block grafts Dr. Paul Petrungaro delves into allogenic stem cell block grafts to facilitate reconstruction of localized/ severe ridge defects and reconstruct proper alveolar contours prior to dental implant placement ............ 22 Ideal tissue management when immediate provisionalization is not appropriate Drs. Robert L. Holt and Bernard E. Keough illustrate a specific type of implant management .................. 26 Reflections on the Straumann速 Tissue Level (TL) implant Dr. Robert Margeas discusses a predictable and easy-to-use implant option ......................................... 28
ZEST Anchors Overdenture product innovations changing the lives of edentulous patients worldwide
2 Implant practice
Volume 6 Number 6
TABLE OF CONTENTS
Avoiding therapeutic failure
Pride Institute “Best of Class” special award tribute ................32
Integrated implant technology – GALILEOS CEREC Integration (GCI) by Sirona ...........................50
Continuing education Hard tissues Drs. William C. Martin, Emma Lewis, and Dean Morton examine adjacent implant restorations.......................42 The root of the matter Drs. Mike Lloyd Hughes and Graham Stuart Roy look at the placement of a first dental implant as part of an inhouse implant mentoring program .....................................................46
4 Implant practice
Practice management Materials matter Dr. Paul A. Fugazzotto offers advice on avoiding therapeutic failure that can affect the implant practice.......60
Product profile Osstell ISQ..................................54 ACE Surgical – infinity Dental Implant Systems.........................56 Dental technology gets a new look with Henry Schein’s augmented reality app....................................58
On the horizon 3D at 38,000 feet Dr. Justin Moody reflects on the benefits of cone beam 3D imaging .....................................................62
Materials & equipment .....................64
Volume 6 Number 6
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Dr. Yong-Han Koo Honesty, integrity, and precision What can you tell us about your background? I was born and raised in Seoul, South Korea, and moved to the U.S. when I was 16. My father was an architect, and I had always been fascinated with structures and the engineering involved. I was exposed to dentistry during my years in college at Washington University in St. Louis and decided that this was the field I wanted to pursue. Dentistry has the perfect combination that satisfies my curiosity in structural foundation and engineering, as well as the ability to make a positive impact on others’ lives. I proceeded to obtain my DDS from Columbia University College of Dental Medicine and my oral and maxillofacial surgery residency training from Yale-New Haven Hospital. After several years in an oral surgery group practice, I opened my solo practice in Wayland, Massachusetts.
Is your practice implants?
My practice is limited to oral and maxillofacial surgery with emphasis on 3D-guided implantology.
Why did you decide to focus on implantology? The dramatic impact that implants have on dental reconstruction and the individual’s quality of life is astounding. We now have options that we could not have imagined years ago. It is an exciting, ever-evolving field, and the importance of continuing education to stay abreast of current technology is crucial. I am passionate about being innovative and seeking inspiration from everyone I work with. I believe that continuing education should be utilized to improve the quality of life of not only the patients, but also the clinicians and all the staff involved. To bring this vision into reality, I launched my study club, the Academy of 3D Connection in Osseo-Integration. We had a successful, 2-day inaugural meeting this past May in Boston. The main purpose of the academy is for all of us to appreciate the value of precision in dental implantology utilizing 3D CBCT from the 6 Implant practice
O.R. suite at Wayland Oral Surgery
diagnosis and treatment planning phase to the final surgical and prosthetic execution phase. Through the academy, we also offer small-group, hands-on courses throughout the year. Since I am also involved in clinical studies through Harvard School of Dental Medicine, my goal is to create a bridge between academics and the community clinicians, to bring in research results, and actively apply them to everyday practice that the clinicians can relate to.
How long have you been practicing, and what systems do you use? I have been in practice since I finished my residency in 2007. I have used multiple systems over the years, and presently my preferences are Nobel Biocare® and Straumann®. I personally believe they have the best 3D-guided systems currently on the market.
What training undertaken?
I am board certified through the American Board of Oral and Maxillofacial Surgery. I regularly attend meetings with AAOMS, AO, and ITI, as well as numerous advanced courses both domestically and internationally. I also teach through my academy, and I am also clinical faculty for the implant
CE courses at Harvard School of Dental Medicine. Teaching and lecturing opens up avenues that I may not have been aware of, and I always feel that I gain so much more knowledge.
Who has inspired you? By far, my late father and father-in-law. My father owned his architectural/civil engineering firm, and my father-in-law was the head of a global Fortune 500 company. Although neither one was in the healthcare industry, I learned the importance of honesty, integrity, precision, and the fact that “people” are the biggest assets in a business. They both put tremendous emphasis on developing and supporting staff members, which I also aspire to do always. Patients come first, but our staff members must be happy and fulfilled in order to provide a great environment for the patients. I was also very fortunate to undergo my oral and maxillofacial surgery training under the tutelage of the incomparable Dr. John P. Kelly. I cannot forget my imaginary best friend, Steve Jobs, who reminded us that death renews the old, and our time on earth is truly limited. It is our job to find the Volume 6 Number 6
The staff at Wayland Oral Surgery
unique talent that God has instilled in each and every one of us and to utilize it for the greater good.
What is the most satisfying aspect of your practice? The feedback we receive from our patients. For instance, we received a letter from the mother of a 4-year-old-boy who told his classmates that he wants “to be like Dr. Koo” so he can help people; we were also told by a Stage IV cancer patient’s wife that we provided “much more than oral surgery” for her husband and her family. These are reminders that we are all part of each others’ lives and that we have a chance to inspire people through our profession.
Reception Area (above) Dr. Koo at the Academy of 3D Connection in OsseoIntegration meeting (below)
Sirona Galileos® Cone Beam CT scan with face scanner. Sirona/SiCAT has a great 3D-guided system and technical support team, which have allowed us to incorporate unparalleled precision into not only implant placement, but to the pre-prosthetic surgical stage as well. We also have the beta version of the NobelClinician™. I am also one of the key opinion leaders for Sirona, Nobel Biocare®, and Straumann®. These opportunities allow us to be on the cutting edge of new technology and to be constantly involved in its development.
What has been your biggest challenge? Time management!!
Professionally, what are you most proud of?
What would you have become if you had not become a dentist?
Connections and relationships we have built over the years with clinicians, staff, corporate partners, and patients. With synergy and collaboration, we can make a significant difference.
Professional golfer. Not that I am saying that I would have definitely made it, but I certainly would have tried my very best to become one!
What do you think is unique about your practice? We make a point to fully engage our patients, educate them on the technology available, and allow them to become active participants in their treatment planning process. This enables them to grasp realistic expectations of their treatment, whether good or bad, prior to committing to any procedures. Our practice was recently chosen as one of the five beta centers for the new
What is the future of implants and dentistry? True digital integration from start to finish.
What are your top tips for maintaining a successful practice? Honesty, integrity, and professionalism, in that order. I believe everything else will follow as long as we do not lose sight of these qualities. Also, to continue to inspire my staff to make a difference together as a team.
What advice would you give to budding implantologists? “You can’t treat what you can’t see.” Therefore, having the best diagnostic tools, as well as the ability to execute your plan accordingly with precision, is paramount. Always listen to your patients, and do not initiate treatment until they have a good understanding of the process involved. Assemble an outstanding team of professionals who are truly committed to excellence in patient care. Last but not least, as cliché as this sounds, treat all your patients as though they are your family members and present the most optimal plan.
What are your hobbies, and what do you do in your spare time? I love to travel with my family. I am an avid golfer and also enjoy skiing during the long winters in the Northeast. IP
Top Ten Favorites 1. 2. 3. 4. 5. 6. 7.
God Family and friends Patients and staff Golf Starbucks Traveling Reviewing and learning from past complications 8. Ketorolac 9. Galileos with face scanner 10. Kimchi and sushi
Volume 6 Number 6 Implant practice 7
Planmeca®: innovative, upgradeable imaging technology Company history Planmeca is the world’s largest privately held dental imaging company and one of the industry’s leading manufacturers of panoramic and cephalometric X-rays. Over the past four decades, it has expanded its sales network in more than 100 countries worldwide. Planmeca’s imaging units offer superior image quality, reduced radiation during routine procedures, easy upgradeabililty, and advanced, userfriendly imaging software. Planmeca has been a leader in digital imaging and advanced computer-integrated dental care concepts for years and remains in the forefront of technology as the field of dentistry evolves. Since the company’s establishment, Planmeca’s developers have worked closely with dentists and leading universities to anticipate future trends, using the data to design an advanced line of high-tech products. From the introduction of the first microprocessor-controlled chair, to the development of the ProMax™ line of imaging units with SCARA (Selectively Compliant Articulated Robotic Arm) technology, Planmeca has always led the way with new technology. The company’s goal is to supply dental professionals with the highest quality dental equipment that is uniquely designed for today’s modern, technologically advanced practice.
Patented SCARA technology What truly sets Planmeca apart from the competition is the company’s patented, exclusive SCARA technology. This robotic arm, which comes standard on all ProMax units, enables free geometry based on image formation and can produce any movement pattern required. The precise, free-flowing arm movements allow for a wide variety of imaging programs not possible with any other X-ray unit on the market; this allows the dental professional to take images based on diagnostic needs, not machine limitations.
Anatomically accurate extraoral bitewing program Planmeca’s ProMax Mid imaging units extraoral bitewing only with SCARA innovative program 8 Implant practice
S3, 3D, and 3D offer an exclusive program, possible technology. This consistently opens
interproximal contacts, eliminates patient positioning errors, and is more diagnostic than other intraoral modalities. ProMax extraoral bitewings are ideal for a number of patients, from the elderly and those requiring periodontal work to those with claustrophobia, sensitive gag reflexes, or those in pain. All of this comes in a true bitewing program that enhances clinical efficiency and takes less time and effort than a conventional intraoral bitewing.
Upgradeable innovation One of Planmeca’s greatest contributions to dental imaging is its innovative, upgradeable product platform — all based on exclusive, patented SCARA technology. Since it’s software-driven, SCARA technology enables limitless possibilities to upgrade existing equipment, allowing the new dentist on a smaller budget to grow while making only appropriate and necessary equipment investments. For example, Planmeca products can be upgraded from a 2D panoramic X-ray to a combination of pan/ceph capabilities, which can be further upgraded to accommodate 3D imaging needs. Whether it is the transformation of a film to a 3D unit, or the addition of a cephalometric arm, Planmeca offers solutions for every upgrade need. This single piece of technology makes the ProMax the most versatile all-in-one X-ray unit available on the market.
Reduced radiation procedures
All Planmeca products are designed around the ALARA radiation principle (As Low As Reasonably Achievable). Through specially designed programs, such as horizontal and vertical segmenting, autofocus, and pediatric pans, dental professionals are able to provide their patients with excellent care without compromising their safety. Horizontal and vertical segmenting options limit the exposure to diagnostic areas of interest. By selecting these options, patient dosage can be reduced by up to 93%, which is highly advantageous when follow-up images are needed. Autofocus automatically positions the focal layer using a low-dose scout image of the patient’s central incisors, and uses landmarks within the patient’s anatomy to calculate placement. The result is a
“The company’s goal is to supply dental professionals with the highest quality dental equipment that is uniquely designed for today’s modern, technologically advanced practice.”
fast, diagnostic pan every time, which drastically reduces retakes caused by false positioning. Pediatric programs further lower the dose by automatically selecting the narrow focal layer of young patients, adjusting the collimator, and reducing the area of exposure from the top and the sides. This reduces the dosage area while still providing full diagnostic information.
Digital Perfection™: standard
Building on the well-established all-in-one idea of integration, Planmeca introduced the Digital Perfection concept in 2011. Seamless integration of dental equipment and software creates efficient diagnostic tools, optimized workflow, and advanced infection control methods that result in a treatment environment where all equipment shares an open interface. The company works worldwide with all aspects of the dental industry, including dental schools, dentists, and dental team members, as well as dealers, and uses the latest technologies to create the best products for dental offices and patients alike. As a forerunner in digital imaging technology, Planmeca delivers complete dental solutions based on integrated hightech device and software options with exquisite design. IP For more information, visit www.planmecausa.com This information Planmeca.
Volume 6 Number 6
ZEST Anchors Overdenture product innovations changing the lives of edentulous patients worldwide
ocated in Southern California, ZEST Anchors is a global leader in the manufacturing and distribution of innovative technologies developed specifically for overdenture treatment. Its impressive 41-year history of producing innovative products for overdenture patients has been driven by the philosophy of placing patient satisfaction above all else. This philosophy led to the creation of the original ZEST Anchor Attachment developed in 1972 by Max Zuest at his dental laboratory in San Diego, California. Following in his footsteps was Max’s son Paul Zuest who had the same vision and passion for bettering the lives of patients worldwide. This vision led to the development of the industry’s first self-aligning attachment, combating the improper seating of overdentures. In 2001, Paul Zuest and Scott Mullaly, then Chief Operating Officer for ZEST Anchors, developed the patented LOCATOR® Attachment. A third generation attachment, LOCATOR, has achieved worldwide acceptance as the premier overdenture attachment in the dental industry and is currently interface compatible with more than 350 implant products, making it compatible with nearly all implant designs. ZEST Anchors is the only manufacturer of LOCATOR. ZEST sells the LOCATOR Attachment directly in the U.S., and it is distributed through OEM implant companies and distributor networks worldwide in more than 45 countries. These genuine LOCATOR Attachments are designed with the primary benefits of ease of insertion and removal, customizable levels of retention, low vertical profile, and exceptional durability. Its most critical design feature is its innovative ability to pivot, which cannot be replicated due to its patented technology. The pivoting technology increases LOCATOR’s resiliency and tolerance for the high mastication forces an attachment must withstand and allows it to compensate for the path of insertion even with up to 40 degrees of divergence between implants. During seating, while the LOCATOR male pivots inside the denture cap, the system’s self-aligning design centers the male on the attachment before
10 Implant practice
“We are now celebrating a year since the system commercially launched. It is clear that the LODI System surpasses what was available on the market previously, as well as our own sales projections… this is no temporary implant.” — Steve Schiess, ZEST Anchors CEO
engagement. These two actions in concert allow the LOCATOR to self-align into place, enabling patients to easily seat their overdenture without the need for accurate alignment and without causing damage to the attachment components. This selfaligning feature also increases the durability of the LOCATOR Attachment. Once seated, the male remains in static contact with the attachment while the denture cap, which is processed into the overdenture, has a full range of rotational movement over the male for a genuine resilient connection of the prosthesis without any loss of retention. The introduction and ultimately the success of LOCATOR have allowed millions of patients to realize the benefits of implant-retained overdentures. ZEST Anchors continually receives feedback
from clinicians about what a great product LOCATOR is, and how it has changed their patients’ lives. Being a leader in this product category, clinicians contact ZEST to provide input about new solutions needed for this niche group of patients. Collaborating with these clinicians allows the company to identify new key market opportunities within the overdenture category. Recent market research demonstrated that the implantretained overdenture demographic is projected to grow substantially throughout the next 20 years and indicated that narrow (less than 3 mm) diameter implants will play an increased role in retaining overdentures. Even today, this type of technology is being used to retain about a third of all implantretained overdentures. The LOCATOR Attachment, while made for nearly all Volume 6 Number 6
It’s amazing what a great image can do for your practice. The CS 9000 3D and CS 9300 Select are ready to work hard for your practice. These technologically advanced systems will finally give you clarity, flexibility and, most importantly, complete control of your image quality and dosimetry. It will also show your patients how dedicated you are to their dental health. • Optimize your image quality and dosimetry • Make accurate assessments, diagnoses and treatments • Experience seamless integration • One system for superior 3D exams, 2D panoramic scans and optional one-shot cephalometrics
To learn more about what a great image can do for your practice, visit carestreamdental.com/3DIP or call 800.944.6365 today.
© Carestream Health, Inc., 2013
9438 DE AD 0713
CORPORATE INSIGHT The surgical instrumentation The surgical instrumentation includes easily identifiable laser-etched depth markings and drill stops, as well as a simple procedure making osteotomy preparation intuitive and safe while offering the less invasive option of a flapless surgery or the option to create a flap.
implant systems, at the time, was not available for the narrow diameter implant segment. Recognizing this and the desire to continue developing innovative products specifically for overdenture patients led to ZEST Anchors’ latest product innovation, a next generation narrow diameter implant system — The LOCATOR Overdenture Implant (LODI) System. Utilizing years of collective knowledge in the dental implant market while focusing on all of the features that were lacking in current designs, such as o-ball mini implants, allowed for the creation of an enhanced narrow diameter implant system designed exclusively for overdenture patients. “With LODI, we were able to listen to, and benefit from, the valuable information of Key Opinion Leaders about other mini implant systems on the market,” says Steve Schiess, ZEST Anchors CEO. “What we found was that the mini implants on the market had little to no innovation throughout the last decade. This allowed us to design LODI, addressing the most sought after improvements. We are now celebrating a year since the system commercially launched. It is clear that the LODI System surpasses what was available on the market previously, as well as our own sales projections…this is no temporary implant.” The implant The implant is manufactured using the strongest titanium available and has a proven RBM surface. The implant body is tapered and includes self-tapping, cutting edges for easy insertion. The thread design on LODI is unique in the narrow diameter implant market; the threads are aggressive in pitch and gradually widen to the coronal thread terminus to provide increased primary stability. The LOCATOR Attachment The LOCATOR Attachment is detachable for simple replacement if tissue height changes or if wear occurs throughout time. It is also the same familiar design that clinicians have used for years, offering dramatically lower attachment height necessary for denture strength and patient comfort when the denture is removed. Since the LOCATOR Attachment for LODI is identical to that of a LOCATOR used for standard-sized implants, the LOCATOR Overdenture Implant can also be used alongside standard-sized implants on the same case.
12 Implant practice
The LOCATOR Overdenture Implant (LODI) System incorporates key features not found with other small diameter implant systems.
Answering the needs of patients All of these features combine to answer the market need for an implant system designed specifically for patients requiring a cost-effective, predictable, and long-term implant-retained overdenture option. The success of LOCATOR and now LODI has propelled a small business into a leading manufacturer and global distributor of dental solutions for the treatment of edentulous patients. In 2010, Paul Zuest retired from ZEST, passing the leadership role to Steve Schiess who maintains the position of CEO of ZEST Anchors. The company now has more than 120 employees with more than 70 years of experience on its leadership team, consisting of Steve Schiess CEO, Tait Robb replacing Scott Mullaly as COO, Matt Powell who is directing all marketing activities and Chris Gervais who directs engineering. The company was recently acquired by Avista Capital Partners, a leading private equity firm with vast expertise and an impressive track record in the healthcare space. Partnering with Avista Capital allows ZEST Anchors to continue to improve the lives of edentulous patients with the company’s existing product portfolio as well as expanding into exciting new products focused on overdenture treatment options. With this laser-sharp focus, clinicians can be assured that ZEST Anchors will continue to define the overdenture market by introducing new products designed to provide clinicians with new opportunities to increase practice revenues and fill the gaps in overdenture treatment available to patients today. For more information, please call 1-800-262-2310 or visit www.zestanchors. com. IP This information was provided by Zest Anchors.
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Soft tissue Autografts and Allografts
Dr. George Duello
Conservative Strategies for the esthetic Zone implant placement
Dr. Dwayne Karateew
Dr. Mitra Sadrameli
Dr. Dan Holtzclaw
Dr. Robert J. Miller
Avoiding Complications... the digital Workflow
understanding and Application of Amnion Chorion Allograft, A protein enriched Barrier, to reduce Surgery time, Minimize patient trauma, and enhance esthetic outcomes and predictability in regenerative procedures
Autologous growth Factors for 7 days plus a Bioactive implant System for Better esthetics
Collagen plug application in extraction sockets Drs. Jon B. Suzuki and Diana Bronstein explore the efficacy of a collagen plug-in Introduction Post-extraction healing is characterized by osseous resorption and significant contour changes in buccal-lingual and apico-coronal width of the residual alveolar ridge.1 Research suggests that an extraction socket augmentation carried out at the time of tooth removal is a reliable and predictable method to reduce significantly crestal bone resorption and atrophy, aid socket fill, and minimize loss of horizontal ridge height. Ultimately, it helps patient and practitioner to reduce or eliminate the need for further costly and traumatic ridge defect augmentation at the time of esthetic rehabilitation or implant placement.1 Clinicians today are aware that sufficient alveolar bone volume and favorable architecture of the alveolar ridge are essential to achieve ideal functional and esthetic prosthetic reconstruction. Ridge preservation procedures that are carried out immediately after extractions significantly reduce the threedimensional alveolar bone loss that inevitably follows tooth extraction alone..2 Patients undergoing this procedure benefit from a ridge form that allows for better esthetics, contour of fixed or removable prosthesis, and implant placement.1 This article will discuss the efficacy of a collagen plug-in, preserving alveolar ridge dimensions in immediate extraction sites and present the data from the literature that involves flapless ridge preservation procedures with the use of specially heattreated collagen plugs for occlusion of the extraction socket.3 Traditional methods of tooth extraction often result, at the least, in loss of the labial plate of the alveolar bone.
Jon B. Suzuki DDS, PhD, MBA, is a Professor at Temple University, Kornberg School of Dentistry, Graduate Periodontology and Oral Implantology Department, Philadelphia, Pennsylvania. Diana Bronstein DDS, MS, is a Professor at Nova Southeastern University, College of Dental Medicine, Department of Periodontology, Ft. Lauderdale, Florida.
14 Implant practice
Long-term ridge preservation
Medium-term or transitional ridge preservation
Short-term ridge preservation
• pontic site development or to improve the stability of removable appliances • non-resorbable materials are used for this indication and • not favorable for implant placement • slowly resorbable bone grafts used in ridge preservation allow for the preservation of the alveolar ridge for an extended period of time, enabling the placement of an osseointegrated implant in the site after the initial healing period, even in the presence of some unresorbed graft particles • indicated in cases where it is still undetermined whether the patient is going to restore the edentulism with an implant, or in cases where the patient has chosen to have an implant placed, but will be unable to return and place the implant for a substantial amount of time3
• objective is to maintain the post-extraction alveolar dimensions during the initial healing phase in order to allow for the placement of an implant in the shortest possible time period3
Modified from B.K. Bartee37
Atraumatic extraction focuses on gently severing the periodontal ligament using micro instrumentation, e.g., periotomes, intending to preserve alveolar crestal height in all three dimensions.1 Already before 1970, the first attempt for the reasonable studying and the prevention of the ridge resorption phenomenon had started.4 The submerged root concept was introduced as a ridge preservation technique.7,13 The trauma of the extraction brings a cascade of cellular events to fill the socket with bone. Grafting at the same time takes advantage of this phenomenon. Contemporary socket preservation techniques involve the placement of different biomaterials into the socket.5,8 Dr. B.K. Bartee proposed a classification of application techniques depending on the purpose of the ridge preservation. This classification is based on the resorbability pattern of the bone graft, and three categories were identified as follows.37 As far as primary wound closure is concerned, soft tissue coverage of the graft with or without membrane, sealing of the socket with a free gingival graft, or
a connective tissue graft, and placement of a collagen plug for socket occlusion have all been proposed.14,15,36,38 Barrier membranes as used for GBR have been employed, showing good results in ridge preservation.17,18,19 The need for primary soft tissue closure presents the main drawback associated with this technique.3 It requires significant coronal flap advancement causing coronal displacement of the mucogingival junction and of the keratinized gingiva toward the crest, and increases postoperative swelling and discomfort due to periosteal scoring and/or relieve incisions.20 Furthermore, if membrane exposure occurs, risk for infection of the graft increases, and the outcome of the preservation procedure becomes less predictable,21 even though one study by Nam and Park in 200911 showed that membrane exposure during the healing period did not affect the efficacy of ridge preservation procedures. In full-thickness buccal and palatal/ lingual mucoperiosteal flaps, which are raised to facilitate barrier membrane placement over sound alveolar bone, Volume 6 Number 6
the vascular innervation via the boneperiosteum continuity is disrupted, and a marginal bone resorption of approximately 1 mm should be anticipated.6 Based on this, for predictable postextraction ridge preservation, flapless techniques should be favored. Reflecting a flap may initiate further bone resorption due to disruption in the blood supply to the cortical bone under the periosteum. Further ridge atrophy would occur additional to the natural bundle bone resorption of the alveolar post-extraction healing socket.1 The “socket seal surgery” technique, a ridge preservation technique that does not require flap advancement, was introduced to counter these procedure-inherent drawbacks.22 This minimally invasive ridge preservation procedure involves bone and soft tissue grafting. The extraction socket is filled with bone graft, and then an autogenous soft tissue graft of adequate size is harvested from the palate and is placed over the bone graft in order to seal the socket.23 Even though the “socket seal surgery” technique was innovative in introducing a ridge preservation procedure that would not require advancement of mucoperiosteal flaps for primary wound closure, it still did not minimize the postoperative discomfort due to the graft harvesting at the donor site.3 Recent work by Araujo and Lindhe37 in a dog model showed using a subepithelial connective tissue graft taken by a window or envelope procedure from the palate may increase soft tissue coverage, but this did not result in increased bone fill.3
Then, the Bio-Col technique was introduced shortly afterwards, using the same principles as the “socket seal surgery,” but specifically using anorganic slow-resorbing bovine bone particulates as a socket graft and replacing the soft tissue graft with the use of a collagen plug to occlude the wound.24 This new technique reduced postoperative morbidity, as there was no need for flap elevation or graft harvesting.3 After the introduction of this concept, many modifications were proposed in the literature, differing either in the graft that was used (Alloplug technique, Nu-mem technique) or in the placement of the collagen plug (modified Bio-Col technique ).25-27 Because of the configuration of the extraction socket, the majority of bone graft may be lost if no protection is provided.1 Therefore, the use of collagen wounddressing material was suggested, not only to protect the graft material, but also to induce blood clot formation and stabilize the wound.8 A collagen dressing material is preferable due to its high biocompatibility and hemostatic ability that can enhance platelet aggregation, and thus, facilitate clot formation and wound stabilization.9 Collagen also has a high chemotactic function for fibroblasts. This might promote cell migration and accelerate primary wound coverage.10 Variations of the “socket-plug” technique have been also used for more than a decade to help minimize the amount of bone loss and ensure the esthetics of the future restoration.24 One contraindication to
the application of this technique is severe buccal plate dehiscence.3 In such cases, a barrier membrane should be employed in order to contain the graft and exclude the soft tissue from invading the buccal space.39 The cases presented will illustrate the basic steps used in this technique:3 • Atraumatic tooth extraction • Preservation of soft tissue architecture with the flapless technique • Placement of the appropriate biomaterials in the extraction site • Collagen plug stabilization
Case 1 Dr. Yueh Hsiao, Temple University Fractured No. 19 was extracted atraumatically, and ridge preservation with Foundation® Bone Filling Augmentation Material was performed for future implant placement. Figure 1 depicts preserved socket after careful extraction of tooth No.19 with intact buccal plate and interdental septum. Figures 2 and 3 depict J. Morita’s Foundation®.31 It is a bone-filling augmentation material indicated for use after extractions, providing support for implants, bridges, and dentures. According to the manufacturer, the bovinecollagen-based material is formulated to stimulate growth of the patient’s own bone at an accelerated rate while minimizing antigenicity. Foundation® comes in two sizes of solid bullet-shaped plugs, designed for easy handling and placement in the extraction socket. If desired, the plugs can
Volume 6 Number 6 Implant practice 15
implants were placed 6 weeks after the extractions on the left side. Ten weeks after the extraction, the lower left side filled with Foundation was restored with implants, which were immediately loaded by a provisional prosthesis. Four months later, the final prosthesis was inserted. Figure 8 depicts patient panoramic radiograph 2 weeks after the extractions and the placement of Foundation into the extraction sockets of the posterior lower left teeth. Figures 9 and 10 depict patient panoramic radiograph 6 and 10 weeks after the post-extraction ridge preservation procedure in the posterior lower left. Implants were also placed lower right. Figure 11 depicts patient panoramic radiograph 4 months after implant placement with definitive restoration in place. Figure 12 depicts patient 4 months after implant placement, and Figure 13 shows definitive restoration in place.
be trimmed or shaped for a better fit. It is radiolucent and resorbable. 31 The Foundation bullet-shaped plugs come in two sizes — small (8 mm x 25 mm) and medium (15 mm x 25 mm) — and are individually packaged in sterile containers. Figure 4 depicts the Foundation collagen plug placed in extraction socket and held by non-resorbable sutures. Immediately after extraction and socket curettage, forceps are used to place the Foundation plug on a 2 x 2 gauze pad before insertion into the extraction socket. There is no need to remove the product once it’s placed, and no membrane is required. The plugs can be shaped to mimic the root tip when needed. After placement, the Foundation plug is gently condensed into the socket. Figure 5 depicts 1 week post-op healing after suture removal with ridge maintaining width and height.31 According to the manufacturer, implants may be placed as soon as 8 to 12 weeks after Foundation is placed in the extraction socket. 16 Implant practice
Dr. Masa Suzuki, Suzuki Dental Clinic, Japan Figure 6 depicts ridge preservation with Foundation® immediately following extraction of tooth No. 8 and socket debridement. Figure 7 depicts excellent healing after several weeks with keratinized tissue buccal and no loss of vestibulum. Alveolar ridge height and width appear adequate for prosthetic restoration.
Case 3 Dr. Masa Suzuki, Suzuki Dental Clinic, Japan Case 3 pertains to teeth Nos. 17, 18, 20, and 21 due to secondary occlusal trauma in a bruxing patient with past periodontal disease. After the atraumatic extraction, granulomatous tissue was curetted out, and bone surface was exposed. Two pieces of S size and two pieces of SS size Foundation were placed in the sockets and sutured. In the lower right, GBR was performed to increase ridge width, and
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Not many studies have documented the histology of extraction-socket healing in human subjects, and most research involving extraction-socket healing has been performed on animals, which regenerate oral tissues much faster and more completely than humans.38 Accordingly, studies of extraction-socket healing in animals cannot be equated to human extraction-socket healing. Amler, et al.41 found that the blood clot filling the socket after extraction was replaced with granulation tissue after 7 days. After 20 days, the granulation tissue was replaced by collagen, and bone began forming at the base and the periphery of the extraction socket and at 5 weeks, twothirds of the extraction socket had filled with bone.38 Epithelium was found to require a minimum of 24 days to completely cover the extraction socket, with some extraction sites requiring up to 35 days to completely cover the socket.41 The epithelium was found to grow progressively, enveloping islands of granulation tissue, debris, and bone splinters. 38Amler noted that all stages of bone regeneration progressed from the apex and periphery, and proceeded finally to the center and crest of the extraction socket. Boyne found new bone formation after extraction only after 8 days under the socket wall but not on the surface of the bone lining the extraction socket.42 After
10 days, bone formation was occurred on the surface of the socket wall, and after 12 days, new bone formation continued along the socket wall and in the trabecular spaces surrounding the extraction site.42 In their histological samples, Devon and Sloan noted woven bone trabecula at the periphery of the socket 2 weeks after extraction. Osteoprogenitor cells, preosteoblasts, and osteoblasts surrounded the trabecula. The periodontal ligament was displaced to the center of the extraction socket and not attached to the socket wall.40 These findings indicate that, in humans, the first phase of extractionsocket healing is most likely osteoclastic undermining and rejection of the original socket wall into the healing socket.38 While it is generally assumed that after extraction bone lining the socket wall is stimulated into new bone growth, this contention is at odds with what is known about how bone responds to trauma and surgical exposure.38 During gingival flap surgery, raising the soft tissue off the bone will result in resorption of bone from the bone surface.6,43 Usualy after extraction the buccal plate is significantly resorbed, and the bony socket wall is exposed to bacterial colonization, while the body attempts to form a fibrin clot.41,44-46 Inflammatory cells trying to prevent infection infiltrate the fibrin clot. As seen in
Dr. Arthur Greenspoon, Montreal, Quebec, Canada Figure 14 depicts pre-extraction PA of tooth No. 13 after failed endodontic treatment and apicoectomy, post and core in place with defective restoration. Figure 15 depicts immediate postextraction PA of tooth No. 13 Figure 16 depicts placement of Foundation after the extraction of No. 13 and future implant planning. Figures 16 and 17 depict grafted extraction socket at 4 weeks and 8 weeks Figure 18 depicts implant in place at about 3 months after extraction and grafting with slight mesial angulation of the coronal part to improve prosthetic access and engage more of the native bone apically.
Case 5 Dr. Arthur Greenspoon, Montreal, Quebec, Canada Figure 19 depicts tooth No. 19 with sinus tract and radiolucent J-form lesion apically with inflammatory resorption, possibly mesial root fracture Figure 20 depicts tooth No.19 after root amputation and placement of Foundation into the mesial root socket Figure 21 depicts tooth No. 19 postop radiograph after definitive restoration and splint to adjacent premolar with PFM 18 Implant practice
Volume 6 Number 6
CLINICAL periodontal and endodontic diseases, bone is resorbed in the presence of inflammatory cells.47,48 It is more plausible that the socket wall will proceed through a phase of resorption before regeneration.38 The possible origins of osteoblasts in the human tooth extraction socket are Pericytes, Adipocytes, the periodontal ligament fibroblasts, the marrow stem cells, and the periosteum. We know that the periodontal ligament can regenerate alveolar bone, although guided tissue regeneration techniques, which allow further osteogenic differentiation of these cells, produce unpredictable clinical results. Osteoprogenitor cells in the periodontal ligament and bone marrow may contribute to bone regeneration following tooth extraction.40
Conclusion The resorption of alveolar bone following extractions results in a narrowing and shortening of the residual ridge.2 According to the literature, alveolar ridge resorption can be limited but not avoided. Complete preservation of the pre-extraction ridge dimensions should not be anticipated, even when alveolar ridge preservation techniques involving post-extraction socket grafting are applied. Ridge preservation requires thorough comprehension of tissue-healing procedures after the extraction of one or more teeth, as well as deep knowledge of bone substitute properties. The “socketplug” technique can help the clinician to provide the best possible outcome with the least patient discomfort. The results not only depend on the delicate handling of the tissues, but also on the resorption rate
J Periodontol. 2008;79(3):413-424.
1. Gupta D, Gundannavar G, Chinni DD, Alampalli RV. Ridge preservation done immediately following extraction using bovine bone graft, collagen plug and collagen membrane. Int J Oral Implantol Clin Res. 2012;3(1):8-16.
17. Lekovic V, Camargo PM, Klokkevold PR, Weinlaender M, Kenney EB, Dimitrijevic B, Nedic M. Preservation of alveolar bone in extraction sockets using bioabsorbable membranes. J Periodontol. 1998;69(9):1044-1049.
2. Luczyszyn SM, Papalexiou V, Novaes AB Jr, Grisi MF, Souza SL, Taba M Jr. Acellular dermal matrix and hydroxyapatite in prevention of ridge deformities after tooth extraction. Implant Dent. 2005;14(2):176-184.
18. Mardas N, D’Aiuto F, Mezzomo L, Arzoumanidi M, Donos N. Radiographic alveolar bone changes following ridge preservation with two different biomaterials. Clin Oral Implants Res. 2011;22(4):416-423.
3. Kotsakis G, Markou N, Chrepa V, Krompa V, Kotsakis A. Alveolar ridge preservation utilizing the ‘socket-plug’ technique. Int J Oral Implantol Clin Res. 2012;3(1):24-30.
19. Carmagnola D, Adriaens P, Berglundh T. Healing of human extraction sockets filled with Bio-Oss. Clin Oral Implants Res. 2003;14(2):137-143.
4. Atwood DA. Postextraction changes in the adult mandible as illustrated by microradiographs of midsagittal sections and serial cephalometric roentgenograms. J Prosthet Dent. 1963;13(5):810824.
20. Engler-Hamm D, Cheung WS, Yen A, Stark PC, Griffin T. Ridge preservation using a composite bone graft and a bioabsorbable membrane with and without primary wound closure: A comparative clinical trial. J Periodontol. 2011;82(3):377-387.
5. Ten Heggeler JM, Slot DE, Van der Weijden GA. Effect of socket preservation therapies following tooth extraction in nonmolar regions in humans: a systematic review. Clin Oral Implants Res. 2011;22(8):779-788.
21. Verardi S, Simion M. Management of the exposure of e-PTFE membranes in guided bone regeneration. Pract Proced Aesthet Dent. 2007;19(2):111-117.
6. Moghaddas H, Stahl SS. Alveolar bone remodeling following osseous surgery. A clinical study. J Periodontol. 1980;51(7):376381.
22. Landsberg CJ, Bichacho N. A modified surgical/prosthetic approach for optimal single implant supported crown. Part I-- The socket seal surgery. Pract Periodontics Aesthet Dent. 1994;6(2):11-17, 19.
7. Casey DM, Lauciello FR. A review of the submerged-root concept. J Prosthet Dent. 1980;43(2):128-132. 8. Wang HL, Kiyonobu K, Neiva RF. Socket augmentation: Rationale and technique. Implant Dent. 2004;13(4):286-296. 9. Sableman E. Biology, biotechnology and biocompatibility of collagen. In: Williams DF, ed. Biocompatibility of Tissue Analogs. Boca Raton, Florida: CRC Press; 1985:27. 10. Postlethwaite AE, Seyer JM, Kang AH. Chemotactic attraction of human fibroblasts to type I, II, and III collagens and collagenderived peptides. Proc Natl Acad Sci U S A. 1978;75(2):871-875.
23. Landsberg CJ. Implementing socket seal surgery as a socket preservation technique for pontic site development: surgical steps revisited—a report of two cases. J Periodontol. 2008;79(5):945-954. 24. Sclar AG. Preserving alveolar ridge anatomy following tooth removal in conjunction with immediate implant placement. The Bio-Col technique. Atlas Oral Maxillofac Surg Clin North Am. 1999;7(2):39-59. 25. Sclar AG. Strategies for management of single-tooth extraction sites in aesthetic implant therapy. J Oral Maxillofac Surg. 2004;62(9 Suppl 2):90-105.
of the graft material and its replacement by mature bone capable of withstanding functional loading.3 Obviously, the different anatomical and dimensional characteristics of hard tissue and soft tissue quantities, qualities, and gingival tissue biotypes, together with several other factors (e.g., reason for extraction, tooth location, etc.), may influence the final outcome of any socket preservation procedure and may be important in making the decision of whether or not a ridge preservation technique is indicated. Ultimately, the ridge preservation approach significantly limits the osseous resorption of the alveolar post-extraction ridge compared to extraction alone.1 IP
32. Becker W, Clokie C, Sennerby L, Urist MR, Becker BE. Histologic findings after implantation and evaluation of different grafting materials and titanium micro screws into extraction sockets: case reports. J Periodontol. 1998;69(4):414-421. 33. Vance GS, Greenwell H, Miller RL, Hill M, Johnston H, Scheetz JP. Comparison of an allograft in an experimental putty carrier and a bovine-derived xenograft used in ridge preservation: a clinical and histologic study in humans. Int J Oral Maxillofac Implants. 2004;19(4):491-497. 34. Postlethwaite AE, Seyer JM, Kang AH. Chemotactic attraction of human fibroblasts to type I, II, and III collagens and collagenderived peptides. Proc Natl Acad Sci USA. 1978;75(2):871-875. 35. Damien C, Parsons JR. Bone graft and bone graft substitutes: a review of current technology and applications. J Appl Biomater. 1991;2(3):187-208. 36. Bitter RN. A rotated palatal flap ridge preservation technique to enhance restorative and hard and soft tissue esthetics for tooth replacement in the anterior maxilla. Int J Periodontics Restorative Dent. 2010;30(2):195-201. 37. Bartee BK. Extraction site reconstruction for alveolar ridge preservation. Part 1: rationale and materials selection. J Oral Implantol. 2001;27(4):187-193. 38. Steiner GG, Francis W, Burrell R, Kallet MP, Steiner DM, Macias R. The healing socket and socket regeneration. Compend Contin Educ Dent. 2008 Mar;29(2):114-6,118,120-4 passim. 39. Misch CE. Contemporary implant dentistry (3rd ed). St Louis: Mosby Inc. 2007. 40. Devlin H, Sloan P. Early bone healing events in the human extraction socket. Int J Oral Maxillofac Surg. 2002;31(6):641-645. 41. Amler MH, Johnson PL, Salman I. Histological and histochemical investigation of human alveolar socket healing in undisturbed extraction wounds. J Am Dent Assoc. 1960;61(7):3244. 42. Boyne PJ. Osseous repair of the postextraction alveolus in man. Oral Surg Oral Med Oral Pathol. 1966;21(6):805-813.
11. Nam HW, Park YJ, Koo KT, Kim TI, Seol YJ, Lee YM, Gu Y, Rhyu IC, Chung CP. The influence of membrane exposure on post-extraction dimensional change following ridge preservation technique. J Korean Acad Periodontol. 2009;39(3):367-374.
26. Fowler EB, Whicker R. Modified approach to the Bio-Col ridge preservation technique: a case report. J Contemp Dent Pract. 2004;5(3):82-96.
12. Atwood DA, Coy WA. Clinical, cephalometric, and densitometric study of reduction of residual ridges. J Prosthet Dent. 1971;26(3):280-295.
27. Wang HL, Tsao YP. Mineralized bone allograft-plug socket augmentation: rationale and technique. Implant Dent. 2007;16(1):33-41.
44. Araújo MG, Sukekava F, Wennström JL, et al. Tissue modeling following implant placement in fresh extraction sockets. Clin Oral Implants Res. 2006;17(6):615-624.
13. von Wowern N, Winther S. Submergence of roots for alveolar ridge preservation. A failure (4-year follow-up study). Int J Oral Surg. 1981;10(4):247-250.
28. Iasella JM, Greenwell H, Miller RL, Hill M, Drisko C, Bohra AA, Scheetz JP. Ridge preservation with freeze-dried bone allograft and a collagen membrane compared to extraction alone for implant site development: a clinical and histologic study in humans. J Periodontol. 2003;74(7):990-999.
45. Covani U, Bortolaia C, Barone A, et al. Bucco-lingual crestal bone changes after immediate and delayed implant placement. J Periodontol. 2004;75(12):1605-1612.
14. Landsberg CJ. Socket seal surgery combined with immediate implant placement: a novel approach for single-tooth replacement. Int J Periodontics Restorative Dent. 1997;17(2):140149. 15. Tal H. Autogenous masticatory mucosal grafts in extraction socket seal procedures: a comparison between sockets grafted with demineralized freeze-dried bone and deproteinized bovine bone mineral. Clin Oral Implants Res. 1999;10(4):289-296. 16. Juodzbalys G, Sakavicius D, Wang HL. Classification of extraction sockets based upon soft and hard tissue components.
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29. Garg AK, Reddi SN, Chacon GE. The importance of asepsis in dental implantology. Implant Soc. 1994;5(3):8-11. 30. Zitzmann NU, Scharer P. Oral rehabilitation with dental implants. Aegis Communications. 2009;2(2). 31. J Morita USA. Foundation. http://www.morita.com/usa/ cms/website.php?id=/en/products/dental/partner/auxiliaries/ foundation.htm. Accessed October 10, 2013.
43. Pfeifer JS. The reaction of alveolar bone to flap procedures in man. Periodontics. 1965;20:135-140.
46. Stiebe B, Poethe I, Bernhardt H. The bacteriology of normal wound healing following tooth extraction with special reference to anaerobic microorganism diagnosis. Zahn Mund Kieferheilkd Zentralbl. 1990;78(3):247-251. 47. Coon D, Gulati A, Cowan C, et al. The role of cyclooxygenase-2 (COX-2) in inflammatory bone resorption. J Endod. 2007;33(4):432-436. 48. Taubman MA, Kawai T, Han X. The new concept of periodontal disease pathogenesis requires new and novel therapeutic strategies. J Clin Periodontol. 2007;34(5):367-369.
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Stem cell block grafts Dr. Paul Petrungaro delves into allogenic stem cell block grafts to facilitate reconstruction of localized/ severe ridge defects and reconstruct proper alveolar contours prior to dental implant placement
ne of the most challenging clinical situations to present to the implant team is advanced bone loss that leads to insufficient bone volume for proper implant placement. Rebuilding bone height and width has been a difficult technique and sensitive procedure, which usually requires the patient to undergo painful and aggressive surgeries to harvest autogenous bone from the ramus, symphisis, iliac crest, or tibia. Commonly, the site where the bone was harvested from caused more postoperative pain and sequella than the actual surgical site itself. Additionally, from the literature, a 16-20% loss in bone volume of the healed graft can be noticed at re-entry for implant placement. This can be a problem for the reconstruction of normal soft tissue architecture for implant esthetics and long-term maintenance.
Preoperative serial views
Paul Petrungaro, DDS, MS, graduated from Loyola University Dental School in 1986 and completed an independent study of Periodontics at the Welsh National Dental School in the United Kingdom. He completed a residency, specialty certificate, and Master of Science Degree in Periodontics from Northwestern University Dental School, and formerly served as the Coordinator of Implantology for the university’s Graduate Department of Periodontics. Dr. Petrungaro has maintained a private practice in Periodontics and Implantology since 1988, and holds licenses in Illinois, Minnesota, and Washington. As a world-renowned and pre-eminent educator, he has presented numerous seminars and lectures worldwide on topics of advanced periodontal, prosthetic, and implant interrelationships, bone regeneration, esthetic tissue formation, transitional implants, immediate restoration of dental implants, and the use of platelet rich plasma in bone grafting. In addition, he has authored over 75 articles on these topics including cosmetic bone grafting and esthetic implant procedures in such prestigious publications as Compendium, Inside Dentistry, and the American Academy of Cosmetic Dentistry’s Journal of Cosmetic Dentistry. Dr. Petrungaro’s consultant role to several biomedical companies and laboratories has resulted in many new innovations in surgical dentistry. He is a fellow of the International and American College of Dentists and a Diplomate of the International Congress of Oral Implantologists and holds memberships in several professional associations.
22 Implant practice
The following case report presents a new technique and allogenic grafting procedure to increase both bone volume in the height and width dimensions. Dr. Petrungaro is one of the only surgeons in the country using this state-of-theart material for the reconstruction of small to large intraoral osseous defects. A 42- year-old, non-smoking female presented for reconstruction of her lower arch with dental implants (Figures 1 and 2). The patient had a congenitally missing dentition, which contributed to large defects in her mandibular arch in the buccal-lingual dimension (Figure 3). The defects made conventional implant placement impossible without a prior bone reconstruction procedure. The patient had also obtained other opinions regarding treatment, which consisted of removal of over 20+ millimeters of bone and an All-on-4 type option, advanced bone harvesting procedures from the iliac crest region, and the option she chose in Dr. Petrungaro’s practice, localized ridge augmentation using a stem-cell infused allogenic block graft procedure. This technique negates the patient undergoing a painful bone harvesting surgical procedure, and provides a bone reconstruction and remodeling process in which her own osseous structures are stimulated and reconstructed prior to implant placement. After removal of tooth Nos. 24 and 25 (Figure 4), the large buccal-lingual defect can be seen clearly from this clinical view. Figures 5 and 6 show the undercut in the crest of the ridge from the buccal and occlusal views, respectively. This thin knifeedged ridge, and significant undercut, would make proper implant placement very difficult, if at all possible to achieve. Coronal flattening of the crest of the ridge (Figure 7) is necessary for closure of the wound and stimulation of the marrow spaces at the crest of the ridge by removing the cortical plate. Figure 8 shows the allogenic stem cell block grafts placed at the buccal aspect of the ridge from the tooth No. 19 area to the tooth No. 27 area. Over 140,000 stem cells are at the facial aspect of the crest of the ridge to stimulate the patient’s own osseous structures to help rebuild the insufficient buccal aspect.
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Additional allogenic cortical and cancellous particulate grafting is accomplished (Figure 9) prior to isolation and stabilization of the stem cell graft by a nonresorbable expanded polytetrafluoroethylene (e-PTFE) titanium-reinforced membrane (Figure 10). 24 Implant practice
This e-PTFE membrane allows for exclusion of soft tissue during the healing phase of the graft, and maintains the shape of the desired crestal bone dimension being regenerated. An additional membrane, BioXcludeâ„˘ (Snoasis Medical),
comprised of amniotic tissue (Figure 11) is then placed over the e-PTFE membrane prior to wound closure (Figure 12). This amniotic membrane contains stem cells also, and aids in the rapid soft tissue healing necessary to obtain optimal wound closure, and provides a stable wound throughout the healing phase. Figure 13 demonstrates optimal closure, while Figure 14 demonstrates the immediate fixed provisional restoration supported by a provisional implant in the tooth No. 18 position. Figure 15 shows 4-month postoperative serial views. Please note the significant increase in the buccal-lingual dimension of the ridge obtained. Figure 16 shows the 4-month clinical re-entry view, and Figure 17 shows the implant placement clinical view. The radiographic confirmation of the increase in buccal-lingual ridge dimension can be readily seen, and comparing to Figure 2, it is readily apparent. The introduction of stem cells to this allogenic material creates an ideal situation for rapid bone replacement in difficult osseous defect sites, eliminating the need for painful harvesting of bone from other parts of a patientâ€™s oral cavity or body. This is a much less invasive option for patients to consider. IP
Volume 6 Number 6
Ideal tissue management when immediate provisionalization is not appropriate Drs. Robert L. Holt and Bernard E. Keough illustrate a specific type of implant management Figures 1A and 1B Patient presented with a recent fracture of the crown and coronal aspect of the maxillary left central incisor tooth No. 9 (21). This was a second fracture of this tooth as it was repaired by clinical lengthening surgery, post and core, and a crown 5 years prior. The patient had a bite protective occlusal appliance, which she chose to not use. The current fracture included the facial cervical tooth structure to the osseous crest. The prosthodontist placed a provisional post-supported acrylic resin crown and made the decision that this tooth would be better replaced by an implant-supported crown, since this would offer the best opportunity to preserve the integrity of the alveolar bone and gingival framework. The radiographic image suggested that there may be no damage to the alveolar bone as a result of the fracture.
Figures 2A and 2B Following anesthesia by the infiltration of Articaine, the remainder of tooth No. 9 (21) was extracted without a gingival flap access. The acrylic crown with the provisional post was removed using crown
and bridge forceps, and the remaining root was atraumatically extracted using the Easy X-Trac (A-Titan) screwed into the endodontic canal post space. All bone walls of the socket were retained, and the gingival tissues were not traumatized or incised. The bone on the facial aspect of the socket was determined to be relatively thick (2 mm) and intact, and the socket anatomy was well suited for immediate implantation. An osteotomy was carefully prepared for a Straumann® implant, with intentional over-extension in depth at the apex. The 4.8 X 10 mm RC Straumann® Bone Level SLActive® implant was placed, following recommended protocol, until the implant shoulder was about 2+ mm below the facial gingival margin. A radiograph was taken, since the facial bone could no longer be visualized, with the implant and insertion device filling the space. The radiograph shows the relationship of the implant to the crestal bone and the available area of added osteotomy depth at the apex, which can be measured with the digital radiographic software. Based on the appearance of the radiograph, the implant was rotated into the osteotomy to achieve a final desired position relative to depth and the crestal bone and gingival tissues.
West Palm Beach, Florida-based Periodontist Robert L. Holt, DMD, earned a BA from Washington and Lee University in Lexington, Virginia, followed by his DMD from the University of Alabama in Birmingham in 1971. He was awarded a National Institutes of Health fellowship and earned a PhD in Microbiology and a Specialty in Periodontics. He served in the U. S. Navy as Chief of Periodontics for the 2nd Marine Division at Camp Lejeune, North Carolina. Dr. Holt has been President of the Atlantic Coast Dental Research Clinic and Co-Chairman of the Periodontal-Prosthetics Section and the Implantology Section. He is a former visiting Assistant Professor at Nova Southeastern University’s College of Dental Medicine and a Fellow of the American College of Dentists. Dr. Holt continues to serve as a consultant to multiple dental implant and pharmaceutical companies. Dr. Holt co-authored the textbook Periodontal and Prosthetic Management of the Advanced Case. He has lectured extensively in the U.S. and in Europe. He has vast experience and expertise in periodontal-implant-prosthetic management of patients with complex problems. His special areas of interest and treatment activity include bone and tissue regeneration, periodontal-prosthetics, esthetics, and dental implantology. Dr. Holt is a native of Florida. West Palm Beach, Florida-based Prosthodontist Bernard E. Keough, DMD, graduated Cum Laude from the University of Kentucky and received his DMD from the University Of Kentucky College Of Dentistry in 1972. There he was honored with the Academy of General Dentistry Award and the American Academy of Gold Foil Operators Achievement Award for excellence in restorative dentistry. Following active duty in the United States Air Force, Dr. Keough graduated from Boston University School of Graduate Dentistry receiving his Certificate of Advanced Graduate Study in Prosthetic Dentistry. He is a specialist in full-mouth reconstruction and dental esthetics, having extensive experience in complex dental and implant restorations, and the current use of CAD/CAM technology. Dr. Keough has presented his clinical findings at international symposiums in Germany, Italy, and Spain, and at meetings and study clubs throughout the United States. He has authored articles for publications including The International Journal of Periodontics & Restorative Dentistry, Practical Procedures and Aesthetic Dentistry and the Compendium of Continuing Education in Dentistry. In addition, he co-authored a chapter on periodontal-prosthetic dentistry in Clinical Dentistry (JW Clark, Ed.), as well as co-authoring the textbook Periodontal and Prosthetic Management for Advanced Cases (Quintessence). In 2001, as an Adjunct Assistant Clinical Professor at Nova Southeastern University School of Dentistry, Dr. Keough helped establish the curriculum for the school’s first PeriodontalProsthetic program. Dr. Keough is a member of the Omicron Kappa Upsilon Honorary Dental Society, the American College of Prosthodontics, the American Dental Association, as well as several state and local dental societies.
26 Implant practice
Figures 3A and 3B A customizable healing abutment (Straumann, 024.4270) was modified at Volume 6 Number 6
chairside by the surgeon and placed on the implant. The radiograph confirms full seating of the healing abutment and the proper level of the Bone Level implant in relationship to the alveolar bone. The customized healing abutment was shaped to have the appropriate trigonal shape and the sufficient size to maintain and preserve the three-dimensional contours of the scalloped gingival complex as if the tooth was still present. Immediate prosthetic provisionalization was not an option for this case given a positive history of parafunction and the two fractures of the No. 9 (21) tooth from occlusal loading. The patient wore a removable provisional that was adjusted to have no contact with the customized healing abutment.
tissue maturation, the patient presented to the prosthodontist for final impression and substitution of the removable appliance with a provisional abutment-supported temporary crown. A customized impression post (Straumann, 025.4201), modified to capture the anatomy of the formed soft tissue, was used so as to replicate those contours in the final master cast. A standard RC PEEK provisional abutment (Straumann 024.4370) was then modified and shaped by the prosthodontist to mimic the approximate subgingival, interproximal, and crestal gingival contours of the root of the tooth that the abutment was replacing. The supragingival contours of the abutment were shaped in classic tooth preparation form to support a cement-on provisional crown. Margin location on the abutment was established approximately Â˝ to 1 mm subgingivally circumferentially around the abutment. This resulted in a scalloped-shaped form as the margin followed the rise and fall of the gingival tissues around the abutment. At this time, the implant No. 9 (21) was then â€œloadedâ€? with a provisional restorative acrylic crown. Without the efforts of the prosthodontist to refine and appropriately reshape the
provisional restorative abutment to create the emergence profile and tooth shape, the contours that were retained by the custom healing abutment could have been lost at this stage.
Figures 4A and 4B Two-month healing reveals excellent preservation and maintenance of the gingival tissue contours, supported and maintained by the custom healing abutment. The implant did not yield to torque testing. Figures 5A and 5B Following implant integration and soft
Figures 6A and 6B A definitive restorative abutment was fabricated by the laboratory technician, as directed by the prosthodontist, to provide the same support of the tissues with a similar trigonal shape and scalloping margins. Figure 7 The final crown is in place, and the gingival tissue complex is intact and stable, supported by bone, formed by an appropriate abutment with appropriate emergence profile, and a porcelain-fusedto-metal crown cemented with shallow, scalloped margins. IP
Volume 6 Number 6 Implant practice 27
Reflections on the Straumann® Tissue Level (TL) implant Dr. Robert Margeas discusses a predictable and easy-to-use implant option Introduction
When patients present with missing teeth, there are several treatment options that can be considered. The tooth – or teeth – can be replaced with a removable appliance, a fixed partial denture, or implant restorations. Sometimes the decision is based on what the insurance is going to pay, or if the patient has adequate bone to support the implant and restoration. Also, the clinical skill of the dentist can often dictate the treatment. In the early 80s when root form implants became popular, there was a lot of extra equipment the dentist needed to have in order to provide an implant restoration. There were many parts and pieces, torque drivers, and some companies that only focused on surgeons and specialists providing these services. Today, implant restorations are the most profitable service I offer in my practice. One reason is the ease of use. The Straumann® Tissue Level (TL) implant offers simplicity at a reasonable cost with minimal equipment needed, and I find it to be the most predictable implant system in my office today. With supragingival or slightly subgingival margins, I am currently restoring most posterior cases with TL implants because of their simplicity, ease of impression taking, and delivery of the final restoration.
Robert Margeas, DDS, graduated from the University of Iowa College of Dentistry in 1986 and completed his AEGD residency the following year. He is currently an adjunct professor in the Department of Operative Dentistry at the University of Iowa. He is Board Certified by the American Board of Operative Dentistry. He is a Diplomate of the American Board of Aesthetic Dentistry, a Fellow of the Academy of General Dentistry, and International Team of Oral implantologists (ITI). He has written numerous articles on esthetic and implant dentistry, and lectures and presents hands-on courses nationally and internationally on those subjects. He serves on the Editorial Advisory board of Inside Dentistry, Compendium, and is a contributing editor to Dentistry Today and Oral Health in Canada. Dr. Margeas maintains a full-time private practice focusing on comprehensive restorative and implant dentistry in Des Moines, Iowa.
28 Implant practice
There is no typical day in my practice, so predicting which procedures I will be performing from day to day in my office is nearly impossible. Because of this, inventory management is critical to our success and ensures a readily available supply of impression copings, solid abutments of all sizes, implant analogs, and protection or temporary pieces. If the surgeon calls to say the patient is ready to have the implant restored, we can then have the patient come in that same day for final impressions. This usually takes
less than 10 minutes and can dramatically impact the bottom line. Without an adequate supply of restorative parts, this would not be possible, and I would lose the opportunity to get the patient in that day. The Straumann Dental Implant System TL has an array of implant and abutment sizes to accommodate different thicknesses of bone and the interocclusal height of the opposing teeth. The standard abutment heights for the Regular Neck (RN) implants are 4.0, 5.5, and 7.0 mm. Also available are Wide Neck (WN) implants with Volume 6 Number 6
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STRENGTH - The Advanced Roxolid Material ® SURFACE - The SLActive Technology SIMPLICITY - The Loxim™ Transfer Piece ®
Designed to increase your treatment options and help to increase patient acceptance of implant therapy. www.straumann.us 800/448 8168
two different abutment heights, as well as Tapered Effect (TE) implants for immediate placement. What I find to be the beauty of the Straumann TL implant system is that the abutments are made of solid titanium and are standard, which does not require a custom abutment. Because the margins of the restoration are on the implant, surgeons can place them at the tissue level, and with the Morse taper of the solid abutments, screw loosening is rarely an issue.
Case presentation A 55-year-old patient presented with missing posterior teeth in the lower right quadrant. The patient wished to have implants placed. Because of the tipped lower molar and the space not being wide enough for three implants and too wide for two, the decision was made to place two implants and cantilever a tooth off. Two Regular Neck (RN) 4.1 mm wide implants were placed with the healing abutments protruding through the tissue for a single stage surgery (Figure 1) â€“ an advantage for the patient as it does not require a second stage surgery. The implants were not submerged. The healing abutments were removed (Figure 2), revealing excellent tissue health with no bleeding. Impression-taking is easier than traditional crown and bridge. Solid abutments (5.5 mm and 7.0 mm) were selected for the clearance necessary to restore the teeth and were placed using an abutment carrier, and hand tightened (Figure 3). Next, the abutments were torqued to 35 Ncm using a torque wrench (Figures 4 and 5). Then impression cylinders were placed (Figure 6). A color-coordinated positioning cylinder was placed over the corresponding abutment and seated to be flush with the impression cap (Figure 7). A final impression was made, and the plastic pieces became incorporated into the impression (Figure 8). Laboratory analogs were then snapped into the impression and sent to the laboratory to be poured up (Figure 9). Protection caps (Figure 10) were then placed, and the patient was sent home. This impression procedure usually takes less than 10 minutes. The laboratory then fabricated a soft tissue model (Figure 11), and restorations for cementation (Figure 12). Figure 12 30 Implant practice
shows the final restorations on the day of insertion. The slight tissue blanching you will notice typically subsides within 4-5 minutes. The restorations were placed with resin-modified glass ionomer cement. The final occlusion was checked to confirm slight contact on the restorations (Figure 13*). The Straumann Tissue Level implant has been used in my practice for over 18 years with great success. The ease of use makes it my go-to implant system for most posterior restorations, and the addition of the bone level implant rounds out my armamentarium to meet the needs of my patients. IP
*The abutment carrier, screwdriver, and torque wrench were the only pieces of equipment required to restore this case. Volume 6 Number 6
Special Awards tribute from MedMark, llc and Pride Institute
10/22/2013 6:01:49 PM
Letter from the Publisher Dear Readers: As publisher of three dental specialty magazines, I have spoken with many dentists and seen many dental products over the years. That is why I am thrilled to have the opportunity to spotlight Pride Institute’s ”Best of Class” Technology Award winners on behalf of Orthodontic Practice US, Implant Practice US, and Endodontic Practice US. The evolution of products with a meaningful impact on dentistry is vital to patient care and practice progress. These products and services have undergone scrutiny by Pride Institute’s knowledgeable panel of judges who invested a year of their time and effort to explore the attributes that made them stand out from the competition. From fledgling products to those that have already achieved name recognition, the winners represent an amazing array of categories from clinical to business applications. Since panelists who receive compensation from dental companies are prevented from voting in that company’s category, the result is an unbiased look at the products and their practical applications to dentistry, providing the dental professional with a product perspective untainted by manufacturer intervention. Pride Institute’s ”Best of Class” Technology awards debuted in 2009, and through print and digital media coverage have grown to impact approximately 150,000 dentists. At the ”Tech Expo” at the American Dental Association’s Annual Awards Session, held October 31 – November 3 in New Orleans, attendees will be able to interact face-to-face with the companies and participate in technology-centered education provided by members of the panel and esteemed consultants of Pride Institute. The Pride ”Best of Class” Awards were created and are organized by Dr. Lou Shuman, President of Pride Institute, who works tirelessly to maintain the rigorous standards of the selection process and its communication process through all its multimedia partners. The panel’s unrelenting pursuit to select technologies that provide continuous improvement for the dental community has resulted in a huge following, which continues to grow each year, culminating in the ADA Pride Tech Expo at the ADA Annual Session. Attendees have the opportunity to experience all the winners in one location for a hands-on experience, as well as are provided CERP presentations by all the expert panel members themselves. This year’s winners are: 3Shape TRIOS®
Isolite Systems Isodry®
ActionRun® Clinical Reactivation®
Align Technology SmartTrack™
Lexicomp® Online™ for Dentistry featuring: VisualDX® Oral
DEXIS® Imaging Suite and DEXIS go®
Liptak Dental DDS Rescue™
Doxa Ceramir® Crown and Bridge
Gendex GXDP-700™ SRT™ Technology
SciCan STATIM G4
Glidewell Laboratories BruxZir® Shaded
Sesame Communications Sesame 24-7
Interactive Diagnostic Imaging Tru-Align®
Henry Schein Dental Viive™
LED Dental VELscope® Vx
i-CAT® FLX Cone Beam 3D
Enjoy this tribute to some very special products and services. We at MedMark hope that the insights you gain from reading these pages and the benefits that you reap from implementing the products will raise your practices to new levels of clinical excellence and business success. Thank you, and again, congratulations to the ”Best of Class” Technology Award winners for 2013!
Best regards, Lisa Moler Publisher MedMark, llc
10/22/2013 6:01:51 PM
Letter from the founder of Pride “Best of Class” Technology Awards Dear Readers: The excitement and enthusiasm surrounding Pride Institute’s 2013 ”Best of Class” Technology Awards continue to invigorate the winning companies long after they are announced. This initiative culminates in the honorees’ participation in the ”Tech Expo” at the American Dental Association’s Annual Session — where attendees have a chance to interact and gain insight into the dynamic and technology-centric products and services that are impacting the contemporary dental practice. The ”Best of Class” Awards have attained a reputation of the highest integrity due to its rigorous and unbiased selection process and its distinguished panel of technology experts. The panel searches for companies that show initiative, and commit time, resources, and expertise in developing new technologies or improving existing ones. Their characteristics differentiate them in a compelling way, thus creating significant value for the clinician. I am very proud of the integrity of our unbiased and not-for-profit process. The thoughtful and many times heated debate, which is the hallmark of the panel’s decision-making process, takes place with absolute honesty and openness. Panel members must divulge all paid relationships with manufacturers, and as a result, are not allowed to vote in that specific category. Also, we are not tied down to have to choose a winner for every technology category in dentistry. If there is no clear differentiator in a category, there is no winner. The mission is to provide the dental community the benefit of having the opportunity to discover what our dental technology experts would choose to have in their own practices. As you read about these companies, know that they can provide a significant benefit in achieving the ultimate goal of the ”Best of Class” award process — selecting the technologies that allow us to provide the best possible care to our patients. Sincerely,
THE DISTINGUISHED PANEL
Dr. Lou Shuman President of Pride Institute
Lou Shuman, DMD, CAGS President of Pride Institute, Best of Class founder John Flucke, DDS Writer, speaker, and Technology Editor for Dental Products Report Marty Jablow, DMD Writer, speaker, technology consultant, and columnist for Dr. Bicuspid Paul Feuerstein, DMD Writer, speaker, and Technology Editor for Dental Economics Parag Kachalia, DDS Vice-Chair of Preclinical Education, Research and Technology, University of Pacific School of Dentistry Larry Emmott, DDS Writer, speaker, and Technology Editor for dentalcompare.com Titus Schleyer, DMD, PhD Associate Professor and Director, Center for Dental Informatics at the University of Pittsburgh, School of Dental Medicine
10/22/2013 6:01:52 PM
DEXIS® IMAGING SUITE AND DEXIS GO® DEXIS® Imaging Suite is the latest software program in a long, dynamic history of bringing the best possible imaging solutions to general dentists and specialists alike. This innovative program has been rewritten on a next-generation code platform combining the image management capabilities of the award-winning DEXIS® 9 with a solid base for growth and exciting tools and applications. One such application is the new companion iPad app, DEXIS go® that provides a sleek, engaging new way for dental professionals to communicate with patients using an iPad®. It is designed to provide a great visual patient experience around image presentation in support of clinical findings and treatment recommendations. Like DEXIS Imaging Suite, DEXIS go functions as an imaging hub, displaying all radiographic and photographic images within a patient’s record. DEXIS users will find a comfortable familiarity with its simplicity and quad environment now infused with a modern iPadstyle flair and elegance.
i-CAT® FLX COMPLETE 3D TREATMENT SOLUTION
i-CAT® FLX is the complete 3D Treatment Solution. It optimizes clinical control over scan size, resolution, modality, and dose to help deliver optimum patient care, assist clinicians to quickly diagnose complex problems with less radiation, and aid in developing treatment plans more easily and accurately. Features include QuickScan+ for a full-dentition 3D scan at a lower dose than a 2D panoramic*; Visual iQuity™ technology for i-CAT’s clearest images*; SmartScan STUDIO’s touchscreen for easy selection of the appropriate scan size and resolution for each patient’s need; Tx STUDIO™ planning software with integrated tools for implant, surgical, and orthodontic applications; and i-PAN 2D panoramics. *Data on file
ISODRY® DENTAL ISOLATION SYSTEM The Isodry® dental isolation system is a proven, easy-touse alternative to traditional forms of dental isolation, such as the rubber dam or manual suction and retraction. The system aids in dental procedures by improving patient management and giving dental professionals unprecedented control of the oral environment: keeping the patient’s mouth open, improving visibility, controlling suction and oral humidity, and minimizing sources of contamination. The key to Isodry’s effectiveness are the Isolite Mouthpieces that work with the system. Morphologically correct Isolite Mouthpieces are available in five sizes and are designed to fit patients from pediatric to large adult. The wide range of mouthpieces means that it is now much easier to have effective isolation for every patient of every size. Isolite Mouthpieces also provide an added measure of safety during the dental procedure — protecting the patient from foreign body aspiration and shielding the tongue and cheek from injury by the handpiece or other dental instruments. For more information: www.isolitesystems.com
BRUXZIR® SHADED RESTORATIONS BruxZir® Shaded restorations are made of monolithic zirconia with no porcelain overlay. Exhibiting classleading durability with up to 1465 MPa of flexural strength and high fracture toughness, they can be used in almost any clinical situation, but are ideal for demanding situations like bruxers, implant restorations, and areas with limited occlusal space. Because BruxZir zirconia is a monolithic material, it can be milled to a feather edge, for a more natural and hygienic emergence profile. BruxZir Shaded restorations display translucency and color similar to natural dentition, making them a more esthetic alternative to PFMs with metal occlusals/linguals or full-cast gold restorations. The BruxZir Shaded formulation offers complete color penetration all the way through the restorations, ensuring greater shade consistency and preventing any shade change after occlusal adjustment. For the second consecutive year, The Pride Institute recognizes BruxZir restorations as ”Best of Class.” BruxZir Shaded restorations are available nationwide at an Authorized™ BruxZir Laboratory near you. For more information: www.bruxzir.com
10/22/2013 6:01:54 PM
VALO® AND VALO CORDLESS Ultradent created VALO in 2009 to address the many problems left unsolved by other curing lights on the market. Since its introduction, VALO has proven to be the most powerful light on the market, thanks to its multiwavelength light-emitting diode (LED) and optimally collimated beam capable of polymerizing any dental material, including porcelain and underlying resins. The ergonomic design of VALO’s wand-style body and large footprint of the curing head provides unprecedented access to the oral cavity where other curing lights simply cannot reach. Precision milled from a solid bar of high-grade, aircraft aluminum, VALO’s unique unibody construction ensures unsurpassed durability. The award-winning line of VALO curing lights now includes the original VALO, VALO Cordless, VALO Ortho, and VALO Ortho Cordless. Each one offers a unique combination of features that allows dental professionals to consistently deliver the right power in the right place. For more information: www.ultradent.com Call 1-800-552-5512
SESAME 24-7 CLOUD-BASED ONLINE PATIENT ENGAGEMENT MANAGEMENT SYSTEM Sesame 24-7 is a cloud-based online patient engagement management system that helps dental and orthodontic practices accelerate new patient acquisition, build patient loyalty, and transform the patient experience. Sesame 24-7 is an end-to-end system, which provides state-ofthe-art web design that optimizes viewing across any device, Search Engine Optimization (SEO), social network management, online sweepstakes and contests, and Search Engine Marketing (SEM) services. It also includes Dental Sesame, a robust patient engagement portal that helps practices maintain a loyal patient community that shows up for appointments, pays their bills on time, and refers friends to the practice. Sesame 24-7 delivers everything a dental practice needs to leverage the Internet to expand growth and profitability.
GENDEX GXDP-700™ SRT™ TECHNOLOGY VELSCOPE® VX SYSTEM Distributed by DenMat, Velscope® Vx is the industry’s leading adjunctive screening device used to discover oral mucosal abnormalities. When used in combination with standard examination procedures, Velscope Vx facilitates the early discovery and visualization of abnormal tissue, including oral cancer. A Velscope Vx examination is easy, painless to the patient, takes just one or two minutes to administer, and does not require additional rinses or stains. The portable Velscope Vx handpiece emits a safe blue light, which excites fluorophores from the surface tissue to the membrane where premalignant changes typically begin. The Velscope’s proprietary filter makes fluorescence visualization possible by blocking reflected blue light, and by enhancing the contrast between normal and abnormal tissue. The Velscope Vx system includes the handpiece, a charging station, and sanitary covers for the handpiece and lens. A digital camera accessory is also available to capture images of abnormal tissue.
SRT image optimization technology delivers 3D scans with higher clarity and detail around scatter-generating material. By using SRT Technology, clinicians are able to reduce artifacts caused by metal or radiopaque objects such as restorations, endodontic filling materials, and implant posts. When a scan is prescribed near a known area of scatter generating material, the user only needs to select the SRT button from the GXDP-700 touchscreen interface to utilize this new optimization technology. From endodontic to restorative and the post-surgical assessment of implant sites, SRT offers a significant improvement to image quality. Gendex’s design philosophy focuses on delivering awardwinning innovations with clinicians and patients in mind, and the addition of the SRT to the GXDP-700 platform aligns with that goal. The company’s strong history in continuing innovation, along with a deep dedication to deliver products that exceed the needs of dental professionals, have earned Gendex recognition as a global leader. For more information: www.gendex.com
10/22/2013 6:01:56 PM
10/22/2013 6:01:57 PM
HENRY SCHEIN’S VIIVE™
Henry Schein’s Viive (pronounced ”Vive”) is a clean and elegant new practice management system designed for the Apple Mac®. The system takes full advantage of the Mac’s simplicity and esthetics, allowing dentists to use the same robust features and tools they have come to love in the Mac . Because a group of dentists who are also Mac enthusiasts actually designed Viive, the system has a unique patient-centric workflow that helps dentists work the way they want to work using the tools they’re most comfortable using.
SciCan is proud to unveil the newest STATIM family member, the G4 series. The STATIM G4 is the same renowned and trusted autoclave it has been for over 20 years, but now boasts a new contemporary look and connectivity that is the first of its kind. The G4 technology will change the way you interact by providing a direct channel of communication through the Internet to you, or anyone you desire. Still powered by SciCan’s signature steam technology to provide sterilization and dryness at speeds faster than conventional chambered autoclaves, the STATIM has been drastically upgraded with a level of interactivity never seen before.
Right from startup, Viive focuses on the patient with a patient screen that gives team members fast and easy access to nearly every feature, function, and task associated with that patient. It boasts a design that makes most of these accessible with just a single click. Viive also includes integration with a variety of advanced services from trusted partners — including leading digital imaging solutions—to expand the capabilities of your modern digital practice. For more information: www.viive.com Call 855-Mac-Viive for a personal demo of Viive.
• Statim 2000 G4 cycles times: 6 minutes unwrapped – 14 minutes wrapped • Statim 5000 G4 cycle times: 9 minutes unwrapped – 17.5 minutes wrapped • A large 3.5” high-resolution touchscreen offers a vivid display of messages and current cycle information all with extraordinary clarity • SciCan’s STATIM G4 Technology offers a platform with endless possibilities. The product expansion and modes of communication will provide visibility from every facet, from usability to troubleshooting • Uses fresh steam distilled water with every cycle • Dri-Tec drying system for fast dry loads For more information: www.scicanusa.com Call 1-800-572-1211
3SHAPE TRIOS® COLOR NEXT-GENERATION INTRAORAL IMPRESSION SOLUTION 3Shape TRIOS® Color is a next-generation intraoral impression solution that is fast, accurate, and easy to use. TRIOS® Color is built on 3Shape’s Ultrafast Optical Sectioning™ technology, and its features include high accuracy capture in color, spray-and-powder-free scanning, clinical scan validation, intuitive Smart-Touch user interface and more. TRIOS® is optimized for a wide range of indications. Scanning is easy with 3Shape TRIOS® Color. There is no need to hold the scanner at a specific angle or distance, and dentists or assistants can even rest the scanner on the teeth for support as they scan. The system contains a broad array of smart tools that lets dentists edit their scans and easily rescan specific areas. The built-in Communicate™ software lets dentists and labs interact and exchange case information, 3D designs, 2D treatment previews, and comments. As an integral part of every TRIOS® system, 3Shape offers yearly software upgrades to keep the system ever-strong with new features and enhanced performance. For more information: www.3shapedental.com/trios Call 1-908-867-0144
DOXA CERAMIR® TECHNOLOGY Ceramir is a revolutionary technology used to create a new class of unique materials called Nanostructurally Integrating Bioceramics (NIB). This Ceramir technology, which holds more than 100 patents, is the result of more than 25 years of extensive bioceramic research by Doxa. Ceramir Crown & Bridge permanent cement is the first product utilizing NIB technology, creating a resilient, more natural, biocompatible dental luting cement that integrates with natural tooth structure, is stable in the mouth, and exhibits tooth-like physical and mechanical properties. It is a self-sealing material that results in an alkaline seal for permanent acid resistance. Ceramir Crown & Bridge is indicated for PFM, zirconia, gold, metal and lithium disilicate fullcoverage crowns and bridges, as well as gold inlays and onlays, and metal pre-fab or cast metal posts. Ceramir is incredibly easy to use because it eliminates the need for bonding agents, conditioners, special cleaners, and primers. It also cleans up extremely easily, and the patients are thrilled because of no pain during placement, or post-op sensitivity. It’s a new way to think about cementation!
10/22/2013 6:01:59 PM
SMARTTRACK™ ALIGNER MATERIAL Align Technology recently introduced SmartTrack – a new highly elastic aligner material that has been shown to improve control of tooth movements with Invisalign®. A study of 1,015 patients shows statistically significant improvement in the control of tooth movements such as rotation and extrusion (p<0.001). Percent of patients on track with treatment is also significantly higher at 5 months follow-up (p<0.001)* SmartTrack features: • More constant force over the two wear aligner wear to improve tracking SONICFILL™ SonicFill is the only easy to use, sonic-activated, Single-Fill™ dental posterior composite system for restorations that require no liner or additional capping layer. Proprietary sonic activation liquefies a highly-filled posterior composite, allowing it to flow into the cavity for effortless placement and superior adaptation. Along with low shrinkage stress and a high depth of cure, SonicFill lets you reliably place posterior cavities up to 5 mm in a single increment. It’s that fast, easy, and effective — greatly reducing procedure time. And with outstanding strength and Kerr’s patented 0.4 micron filler technology, restorations will last and look great.
• Higher elasticity to improve tracking
XV1 FROM ORASCOPTIC The new XV1 from Orascoptic is the first and only loupe with a built-in headlight. Traditional light systems employ an electrical cable that connects the headlight to a battery pack that is typically worn on a belt or in a pocket. These cables are notorious for breaking after getting caught on chairs, drawers, and doorknobs. By powering the headlight through circuitry embedded in the loupe frame itself, the XV1 eliminates the need for a separate battery pack, and consequently also eliminates the problematic cable. The XV1 delivers a powerful, shadow-less illumination in a compact, comfortable design. Innovative capacitive touch controls make it easy to operate, even with instruments in hand. Choose from five stylish colors, and magnification powers between 2.5x and 4.8x.
• More precise aligner fit to improve control of tooth movement and finishing
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Hard tissues Drs. William C. Martin, Emma Lewis, and Dean Morton examine adjacent implant restorations
redictable esthetic replacement of single missing teeth in the esthetic zone is made possible by a number of clinical factors. One important factor is related to the bone crests on the proximal surfaces of teeth adjacent to the edentulous space.1-5 In conjunction with the coronal anatomy and intercoronal contact points, these bone crests directly influence the presence, morphology, and predictability of the interdental papilla, and hence the quality of the esthetic outcome.6 Restoration of adjacent implants in the esthetic zone is made more challenging because the inter-implant space is characterized by an absence of these bone crests, resulting in a comparative deficit in vertical bone height when compared to natural teeth.7-11 When adjacent implants are placed, the deficiency in the inter-implant vertical bone height results in a consequent loss of support for the inter-implant papilla, and an esthetic compromise between dental implants (Figure 1).
Educational aims and objectives This article aims to show how effective planning and execution, in conjunction with the choice of appropriate implants, can lead to stability of the soft-tissue response and successful restoration of adjacent implants in the esthetic zone. Expected outcomes Correctly answering the questions on page 49, worth 2 hours of CE, will demonstrate the reader can: • Identify some factors for predictable esthetic replacement of single missing teeth in the esthetic zone. • Recognize some of the challenges of restoration of adjacent implants in the esthetic zone. • Identify some consequences when adjacent implants are placed, and there is a deficiency in the inter-implant vertical bone height.
An esthetic result While more difficult to achieve, successful esthetic outcomes can be made possible in extended edentulous situations (Figures 2-3). In order to achieve these results, it is important to understand that an accumulation of negative pretreatment factors can influence esthetic outcomes. As the number of “high risk” factors increase in a given clinical situation, the more difficult the challenge in achieving an esthetic result. The use of the Esthetic Risk Assessment analysis can be a key diagnostic aid in determining the potential
William C Martin, DMD, MS, is the associate professor and clinical director at the Center for Implant Dentistry, department of oral and maxillofacial surgery, University of Florida, College of Dentistry, Gainesville, Florida. Emma Lewis, BDS, MD, is clinical assistant professor at the department of oral and maxillofacial surgery, University of Florida, College of Dentistry, Gainesville, Florida.
Figure 1: Various clinical dimensions of importance with adjacent implants in the esthetic zone: (A) horizontal dimensions: implant-root and implant-implant, (B) vertical dimension related to planned restorative mucosal margin, (C) distance from interproximal bone on adjacent teeth to restorative contact point, (D) restorative contact points, (E) inter-implant crest height to mucosal margin
Figure 2: Frontal view of extended edentulous space: (A) gingival margin position, (B) height of existing papillae
Figure 3: Occlusal view of extended edentulous space: (A) facial contours of soft tissue, (B) width of edentulous ridge
Figure 4: Diagnostic try-in with radiopaque teeth for cone beam computed tomography planning
Dean Morton, BDS, MS, is professor and chair at the department of oral health and rehabilitation, University of Louisville, School of Dentistry, Kentucky.
42 Implant practice
Volume 6 Number 6
Table 1: Esthetic Risk Analysis â€“ Ref. ITI Treatment Guide Volume I
for an esthetic result (Table 1). This method takes into account various factors, such as medical status and smoking habit of the patient, lip line, gingival biotype, width of the gap, bone level at adjacent teeth, restorative status of neighboring teeth, soft tissue and bone anatomy, and the patientâ€™s esthetic expectations. In extended edentulous situations, the potential for an esthetic result is reliant on meticulous planning, proper site enhancement procedures, and detailed restoration-driven surgical and restorative procedures. The evaluation of the proposed sites is restoration-specific and based upon the diagnostic wax-up, diagnostic casts, and pretreatment radiographs that will assist in identifying the presence of vertical ridge deficiencies and residual pathoses. Prior to pretreatment radiographic evaluation, a diagnostic waxing, which accurately identifies the proposed mucosal zenith (highest point of the free mucosal margin), and the desired coronal extension of the papillae is mandatory (Figure 4). The wax-up relates the proposed implant margin to the oral tissues, and must
Figure 5: Three-dimensional view of site No. 8
Figure 6: Three-dimensional view of site No. 9
recognize the emergence of the planned restorations from the tissues. Together, these factors position the implant margin in the three dimensions. Because bone height (and ultimately papillary presence and morphology) is directly related to the position of this margin, every effort should be made to plan for implant positions as coronal as the mucosal architecture and emergence profile will allow. Radiographic evaluation of the vertical and horizontal extension of the bone crests on the teeth adjacent to and within the edentulous
space should be undertaken to determine the need for augmentation procedures (Figures 5-6).
In the surgery Examination of hard tissues should determine the facial-palatal dimension of the bone site, and relate this to the proposed restorations. It should be noted that residual ridge anatomy is unreliable as an indicator of bone dimension, and clinical procedures (e.g., sounding, CBCTs) should be employed to accurately map
Volume 6 Number 6 Implant practice 43
CONTINUING EDUCATION the osseous contour. The projection of the mucosal zenith will facilitate comprehensive assessment of soft tissues. The thickness and morphology of the mucosal tissues is significant as it influences the position of the implant shoulder in both an apicocoronal and orofacial position. The final position of the implant shoulder will influence the inter-implant vertical height of bone achievable around the implant as well as dictate the initiation of the emergence profile of the abutment and restoration. Therefore, in the case of the bone-level implant design, it is critical to place the implant shoulder at a minimum of 3 mm apical to the planned mucosal margin. This will allow for optimum maintenance of inter-implant bone crests as well as allow for establishment of ideal emergence profile contours of the abutment and restoration. Surgical placement of the implants requires careful attention to adjacent structures, particularly teeth. Further, surgical templates can be fabricated using the radiographic information, facilitating effective transfer of clinical information. The horizontal distance between implants and teeth should approximate 1.5 mm.7 This dimension will help prevent significant resorption of the bone crests during healing. An inter-implant distance of 3 mm has been advocated by Tarnow, et al., to reduce the likelihood of bone loss between implants (Figures. 7A-7B).7 Submucosal tissue support from adjacent structures is also required for the development of papillae. This is achieved by the placement of provisional restorations with appropriate emergence and anatomy to shape the transition zone (area between the implant shoulder and mucosal margin). The provisional restorations (and subsequent definitive restorations) should provide proximal contacts, which extend to within 5-6 mm of the inter-implant bone and remaining bone crests if developed papillae are to be viable in the long term (Figures 8A-8D). Attention to detail is required through customimpression procedures, which transfer the contours of the subgingival region to the dental technician for duplication in the final restorations (Figures 9A-9B).12 Prior to the final impression, shade selection is performed and photographed for communication with the laboratory. Using CAD/CAM technology, prefabricated ZrO2 abutments (Ivoclar Vivadent) were used, followed by fabrication of ZrO2 44 Implant practice
Figure 7A: Occlusal view of the surgical template postimplant placement
Figure 7B: Occlusal view of the final implant positions
Figure 8A: Unshaped transition zone immediately following removal of the healing abutments
Figure 8B: Provisional restoration exhibiting ideal contours to assist in shaping the transition zone and providing support for papillae formation
Figure 8C: Provisional restorations after 4 weeks of function
Figure 8D: Occlusal view of the implant transition zones and ovate pontic formation after 4 weeks of provisional use
Figure 9A: Customized impression coping generated from the provisional restorations
Figure 9B: Customized impression copings in place prior to the final impression
Volume 6 Number 6
Figure 11A: One-year follow-up – frontal view
copings (CAD/CAM by Straumann®), which were then veneered with porcelain (VITA VM 9, VITA Zahnfabrik, D-Bad Säckingen, Germany) [Figures 10A-10B].
Successful translation Effective communication of the planned implant positions is required for clinical success. The use of surgical templates is required if this goal is to be routinely satisfied. Subsequent to accurate, 3D implant placement, provisional restorations are required to facilitate maturation of the connective and epithelial tissues prior to definitive restorations being fabricated. Effective planning and execution, in conjunction with the choice of appropriate implants, can lead to stability of the softtissue response and successful restoration of adjacent implants in the esthetic zone (Figures 11A-11D). Acknowledgment: Thanks to Mr. Mitchell Jim for the laboratory support and ceramics used on the patients. IP
Figure 10A: Prefabricated ZrO2 abutments and veneered copings
Figure 10B: Final restorations prior to placement
Figure 11B: One-year follow-up – occlusal view
Figure 11C: One-year follow-up periapical radiograph
Figure 11D: One-year follow-up periapical radiograph
References 1. Choquet V, Hermans M, Adriaenssens P, Daelemans P, Tarnow DP, Malevez C. Clinical and radiographic evaluation of the papilla level adjacent to single-tooth dental implants. A retrospective study in the maxillary anterior region. J Periodontol. 2001;Oct;72(10):1364-71. 2. Kan JY, Rungcharassaeng K, Umezu K, Kois JC. Dimensions of peri-implant mucosa: an evaluation of maxillary anterior single implants in humans. J Periodontol. 2003;Apr;74(4):557-62. 3. Belser UC, Schmid B, Higginbottom F, Buser D. Outcome analysis of implant restorations located in the anterior maxilla: a review of the recent literature. Int J Oral Maxillofac Implants. 2004;19;Suppl:30-42. 4. Degidi M, Nardi D, Piattelli A. Peri-implant tissue and radiographic bone levels in the immediately restored single-tooth implant: a retrospective analysis. J Periodontol. 2008;Feb;79(2):252-9. 5. Lops D, Chiapasco M, Rossi A, Bressan E, Romeo E. Incidence of inter-proximal papilla between a tooth and an adjacent immediate implant placed into a fresh extraction socket: 1-year prospective study. Clin Oral Implants Res. 2008;Nov;19(11):1135-40.
8. Cardaropoli G, Wennström JL, Lekholm U. Peri-implant bone alterations in relation to inter-unit distances. A 3-year retrospective study. Clin Oral Implants Res. 2003;Aug;14(4):430-6. 9. Tarnow D, Elian N, Fletcher P, Froum S, Magner A, Cho SC, Salama MA, Salama H, Garber DA.Vertical distance from the crest of bone to the height of the interproximal papilla between adjacent implants. J Periodontol. 2003;Dec;74(12):1785-8. 10. Gastaldo JF, Cury PR, Sendyk WR. Effect of the vertical and horizontal distances between adjacent implants and between a tooth and an implant on the incidence of interproximal papilla. J Periodontol. 2004;Sep;75(9):1242-6. 11. Degidi M, Novaes AB Jr, Nardi D, Piattelli A. Outcome analysis of immediately placed, immediately restored implants in the esthetic area: the clinical relevance of different inter-implant distances. J Periodontol. 2008;Jun;79(6):1056-61. 12. Hinds, KF. Custom impression coping for an exact registration of the healed tissue in the esthetic implant restoration. Int. J Perio Rest Dent.1997;Dec;17(6):584-91.
6. Tarnow DP, Magner AW, Fletcher P. The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla. J Periodontol. 1992;63(12):995-996. 7. Tarnow DP, Cho SC, Wallace SS. The effect of interimplant distance on the height of inter-implant bone crest. J Periodontiol. 2000;71(4):546-549.
Volume 6 Number 6 Implant practice 45
The root of the matter Drs. Mike Lloyd Hughes and Graham Stuart Roy look at the placement of a first dental implant as part of an in-house implant mentoring program
n the growing field of implantology, there are numerous opportunities to learn how to place implants. The method of teaching/ training is different in countries all over the world, and one of the recommended approaches is to place implants with good one-to-one mentoring guidance. Implant mentoring is now considered an established pathway in long-term implant training. This case describes the treatment of a 70-year-old female, who, in May 2008, presented a lost upper right second premolar post crown. A diagnosis of a distally placed root fracture was made with poor prognosis, and extraction was advised. The patient wanted a dental implant as replacement, but did not have immediate financial resources. Bearing this in mind, the root orifice was sealed with a glass ionomer temporary filling. It was explained to the patient that her oral hygiene would need to be improved before an implant would be considered. Multiple hygiene visits and reviews were organized, initially with the hygienist, then with the clinician (Dr. Mike Lloyd Hughes). Once oral hygiene had been optimized, the upper right second premolar root was extracted with minimal trauma in January 2009, and a Straumann® tissue level implant was inserted at the beginning of March 2009 under the supervision of an ITI mentor. This was subsequently restored at the end of May 2009 with a cement-
Dr. Mike Lloyd Hughes graduated with merit from Cardiff Dental School, Wales, in 2004. He is currently studying for his MSc in clinical restorative dentistry with the University of Leeds. Dr. Hughes works full time in private practice on the Isle of Anglesey, Wales, and has an interest in oral surgery, implantology, endodontics, and periodontics. Dr. Graham Stuart Roy graduated from Liverpool, England in 1965, then worked in Liverpool Dental Hospital in periodontology, conservation, and radiology. He served for 5 years with the Royal Air Force before starting a practice in Menai Bridge in 1971, with first implants placed in 1985. He has a special interest in periodontics and restorative dentistry. He has been an ITI Fellow since 2007.
46 Implant practice
Educational aims and objectives This article aims to show how an implant mentoring program can facilitate implant training. Expected outcomes Correctly answering the questions on page 49, worth 2 hours of CE, will demonstrate the reader can: • Identify some training and mentoring methods. • View protocols in a specific case. • Recognize the importance of bone assessment.
Figure 1: Pre-op periapical radiograph
Figure 2: Pre-op study models
Figure 3: Surgical stent
Figure 4: Post-extraction
retained, porcelain-bonded crown. A year and a half later the peri-implant soft and hard tissues are stable.
either being straightforward (S), advanced (A), or complex (C). In parallel to this, it would be ideal to have a mentor who can help guide inexperienced clinicians in case selection, planning, and also in the surgical and restorative management of such cases. It is advisable when starting out placing or restoring implants to have the appropriate training and mentoring. An example of this in the UK is the new ITI Pathway 2011 – Foundation in Implant Dentistry with Concomitant Mentoring. This course is done as six 2-day modules, in a choice of two different venues, with
Training and mentoring The SAC classification system adopted by the ITI allows the clinician to assess beforehand the restorative and surgical risk for appropriate case selection and treatment planning (Dawson & Chen, 2009). Currently this classification has been integrated into an online assessment tool available on the ITI website (www.iti.org), which allows clinicians to pre-assess their cases in terms of risk and difficulty level,
Volume 6 Number 6
Figure 6: Surgery 8 weeks after extraction
Figure 7: Good healing site
Figure 8: On day of placement
Figure 9: Six weeks after implant placement
Figure 10: Implant at impression stage
Figure 11: Solid abutment
Figure 12: Impression â€œsnapperâ€? for closed tray
Figure 13: Impression cylinder inserted into fixed position
provide a denture, a bridge, or an implant. The advantages and disadvantages of each option were discussed, and the patient wanted a replacement that did not involve using the adjacent teeth. Unfortunately in July 2008, she could not finance the option of a dental implant until the end of the year. It was decided to temporarily seal the root surface of the 15 root with Fuji II LC (GC Europe N.V, Leuven, Belgium) to stop bacterial ingress and to postpone extraction to preserve the remaining alveolar bone. An examination done in August 2008 identified that the patient had BPE (Basic Periodontal Examination) readings of three, in both lower sextants with supragingival inflammation and increased plaque levels. Following extensive hygiene visits in-house,
her plaque control improved. In November 2008, impressions were taken for study models, diagnostic wax-up, and surgical stent construction (Figures 2 and 3). This case was then discussed by the authors in regard to suitability. It was deemed to be a suitable first case and fell into the category of straightforward (S), according to the SAC classification. In January 2009, the remaining 15 root was extracted gently with a sharp Luxator (Ash, Dentsply, Weybridge Surrey, UK) and root forceps. A periapical radiograph was taken after extraction to assess the future surgical site (Figure 4). In early March 2009, following an 8-week healing period, an ITI early placement protocol was utilized with soft tissue healing, without significant bone
concomitant practice-based (www.iti.org/ukeducation).
Case selection and presentation A suitable case presented itself in 2009 that could be carried out under an inhouse implant mentoring program. A medically fit 70-year-old female presented as an emergency to the author (MLH) in July 2008, with her debonded upper right second premolar (Figure 15) post crown. It had been present for 4 years. On examining the root surface, a clinical diagnosis of a distal root fracture was made. A previous periapical radiograph taken in 2007 shows the post crown in situ (Figure 1). An extraction was recommended to the patient, due to poor prognosis. The options discussed were to leave a space,
Volume 6 Number 6 Implant practice 47
Figure 5: At time of surgery
Figure 15: Cemented porcelain-bonded-to-metal crown
Figure 16: Occlusal view with acceptable esthetics
Figure 17: One-year follow up
Figure 18: Seventeen months after implant placement
tissue level and esthetics remain stable (Figure 18).
until after the extraction of the tooth before taking impressions for a surgical stent. It allows the stent to be more accurate if taken 2 weeks before implant placement, usually 6 weeks after tooth extraction. This is probably the best time to take a preoperative radiograph of the implant site to assess the bone, not on the day of extraction, as was done in this case. Overall the author is happy with this case, and the patient is on a long-term oral hygiene maintenance program.
Figure 14: Shade taking
healing (Chen & Buser 2008) [Figures 5-7]. A 10 mm tissue level RN 4.1 Straumann SLActive implant was placed (Figure 8) using the surgical stent (Figure 3). A 2 mm standard healing cap was placed and incisions sutured with 5/0 Prolene (Ethicon, Johnston & Johnston, Livingston, Scotland). The implant was left not submerged. Sutures were removed 1 week later with no surgical complications. Another postoperative radiograph was taken 6 weeks later at review (Figure 9), where a tapping test of the implant indicated good osseointegration.
Patient on return At the end of May 2009, the patient returned for impressions for a crown. There was good soft tissue healing around the healing cap (Figure 10). This was removed, and a 4 mm yellow Ti RN solid abutment was placed, and torqued to 35Ncm (Figure 11). A RN impression snapper and cylinder were placed, prior to a heavy bodied/wash polyvinyl siloxane impression taken with a closed special tray (Figures 12 and 13). Shade selection was done using a Vita Shade guide (Vita Zahnfabrik, Germany), choosing A3 dentin, and overlayered with C2 enamel (Figure 14). A porcelainfused-to-metal crown was prescribed to conform to the existing occlusion, and this was cemented with minimal occlusal adjustment at the beginning of June 2009 with Ketac™ Cem (3M™ Bracknell, Berkshire,UK) [Figures 15 and 16]. A 1-year follow-up radiograph showed good crown margins and a stable bone level around the implant (Figure 17). At a routine dental examination in July 2010, 17 months after implant placement, the soft 48 Implant practice
Assessing the bone This case is published to highlight the importance of implant mentoring. The SAC tool is extremely easy to use, and is readily accessible on the iti.org website. The tool is also helpful in documenting the case in the patient’s records. The importance of a clinical mentor cannot be overstated. The author is indeed fortunate to have an on-site mentor, and there are many implantologists around the world who give their clinical time to help others with different aspects and complexities of treatments. The ITI Section UK & Ireland has gone a long way in formalizing an agreement between mentor and trainee through the work and commitment of the mentoring working group. Another important aspect of implant mentoring is to keep a log book of all the surgical and restorative procedures one undertakes. The author keeps a meticulous log of all his clinical work, and his mentor signs off each procedure. It is also advisable to keep one of the implant detail stickers from the implant box in the log book, as well as in the patient’s clinical notes. If the author had the opportunity to do this case again, he would have waited
Acknowledgements I would like to thank Dr. Joe Bhat, ITI Fellow, corresponding editor (UK and Ireland) for helping with proofreading of this article prior to publication. I would also like to thank my dental technicians, Vano Filipini and Ian Gray, at Filipini & Gray Dental Laboratory, Mill Lane, Tottington Rd, Bury, Lancashire, UK. IP For more information about the ITI, please visit www.iti.org References Dawson A, Chen S, eds. The SAC Classification. In: Implant Dentistry. Berlin: Quintessence Publishing Co, Ltd.; 2009. Chen ST, Buser, D. Implants in post-extraction sites: a literature update. In: Buser D, Wismeijer D, Belser UC, eds. ITI Treatment Guide, Vol. 3. Berlin: Quintessence Publishing Co, Ltd.; 2008.
Volume 6 Number 6
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The root of the matter
1. The patient wanted a dental implant as replacement, but did not have immediate financial resources. Bearing this in mind, the root orifice ____with a glass ionomer temporary filling. a. was sealed b. was permanently restored c. was disinfected d. both b and c
2. It was explained to the patient that her _____would need to be improved before an implant would be considered. a. financial situation b. root fracture c. oral hygiene d. tissue healing capability
8. Another postoperative radiograph was taken 6 weeks later at review, where _____of the implant indicated good osseointegration. a. a visual examination b. a tapping test c. a CBCT scan d. a panoramic radiograph
3. ______later, the peri-implant soft and hard tissues are stable. a. Six months b. Eight months c. A year d. A year and a half 4. The SAC classification system adopted by the ITI allows the clinician to assess beforehand the _______for appropriate case selection and treatment planning. a. restorative risk b. surgical risk c. type of imaging needed d. both a and b 5. It is advisable when starting out placing or restoring implants to have ____. a. the appropriate training b. mentoring c. a CBCT unit d. both a and b 6. It was decided to temporarily seal the root surface of the 15 root with Fuji II LC to _____to preserve the remaining alveolar bone. a. stop bacterial ingress b. postpone extraction
both a and b none of the above
7. (In this case) Sutures were removed _____with no surgical complications. a. 1 week later b. 1-1/2 weeks later c. 10 days later d. 2 weeks later
9. Another important aspect of implant mentoring is to ______of all the surgical and restorative procedures one undertakes. a. help the clinician to memorize the outcomes b. keep a log book c. show the practitioner the importance of informing the patient d. share the fees 10. It allows the stent to be more accurate if taken 2 weeks before implant placement, usually _____ after tooth extraction. a. 3 weeks b. 4 weeks c. 5 weeks d. 6 weeks
Hard tissues 1. In conjunction with the coronal anatomy and intercoronal contact points, these bone crests (on the proximal surfaces of teeth adjacent to the edentulous space) directly influence the ______ of the interdental papilla, and hence the quality of the esthetic outcome. a. presence b. morphology c. predictability d. all of the above 2. Restoration of adjacent implants in the esthetic zone ______because the inter-implant space is characterized by an absence of these bone crests, resulting in a comparative deficit in vertical bone height when compared to natural teeth. a. is made more challenging b. is made much easier c. has no effect on the difficulty of the procedure d. does not affect clinical dimensions 3. In extended edentulous situations, the potential for an esthetic result is reliant on _____. a. meticulous planning b. proper site enhancement procedures c. detailed restoration-driven surgical and restorative procedures d. all of the above 4. The evaluation of the proposed sites is restoration-specific and based upon the diagnostic wax-up, diagnostic casts, and pretreatment radiographs that will assist in identifying the presence of ______. a. vertical ridge deficiencies b. residual pathoses c. future pathosis d. both a and b 5. _______, a diagnostic waxing, which accurately identifies the proposed mucosal zenith (highest point of the free mucosal margin), and the desired coronal extension of the papillae is mandatory.
a. After pretreatment radiographic evaluation b. Prior to pretreatment radiographic evaluation c. After site enhancement procedures d. After measurement of the facial- palatal bone 6. Examination of hard tissues should determine the _____of the bone site, and relate this to the proposed restorations. a. mesial-distal dimension b. soft tissue condition c. facial-palatal dimension d. none of the above 7. The _______ of the mucosal tissues is significant as it influences the position of the implant shoulder in both an apicocoronal and orofacial position. a. thickness b. morphology c. color d. both a and b 8. Therefore, in the case of the bone-level implant design, it is critical to place the implant shoulder at a minimum of ____ apical to the planned mucosal margin. a. 1 mm b. 2 mm c. 3 mm d. 4 mm 9. The horizontal distance between implants and teeth should approximate ____. a. 1.5 mm b. 2 mm c. 2.5 mm d. 3 mm 10. Prior to the final impression, _____is performed and photographed for communication with the laboratory. a. removal of residual ridge anatomy b. shade selection c. submucosal tissue support d. implant shoulder grafting
Volume 6 Number 6 Implant practice 49
Integrated implant technology – Galileos Cerec Integration (GCI) X-ray and CAD/CAM combined: With the unique process of integrated implantology, the necessary appointments for placing the implant and the final restoration are reduced. Thanks to GCI, the entire implant process, starting with the planning and ending with the manufacture of highly precise abutments and crowns, will remain in your practice. This gives you complete control over the process from start to finish, providing you with highly precise and esthetic results that save time and money.
First Session: SCAN/PLAN
Step 1: Take an optical impression of the bite with CEREC®, and plan the prosthetic restoration using the CEREC® software.
Step 2: With a GALILEOS® or ORTHOPHOS® XG 3D scan, the clinician diagnoses the bone structure and integrates the prosthetic recommendation into the X-ray volume, and plans the implant simultaneously according to the surgical and prosthetic conditions. Step 3: Order the surgical guide in the software and transmit the planning data to SICAT (in the case of the SICAT OPTIGUIDE process).
Second Session: PLACE
Third Session: RESTORE
Step 4: In the second session, the clinician places the implant using the surgical guide. In the case of immediate loading, restore it directly with a CEREC® temporary prosthesis. If necessary, you can also create a patient-specific, customized abutment with CEREC® in this session and incorporate it.
Step 5: With immediately loaded implants, the temporary prosthesis is replaced by the final prosthesis. With traditionally placed implants – after completion of the healing phase – the practitioner provides the implant with a temporary or final prosthesis (with CEREC) in this session.
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This information was provided by Sirona. IP Volume 6 Number 6
he VELscope Vx is LED Dental Inc.’s latest model release of the VELscope system. The VELscope Vx is the most powerful FDA- and Health Canadaapproved tool to screen for oral cancer, a growing health-care issue around the world. It is used by dentists to detect early stage oral cancer and pre-cancer, as well as other oral abnormalities such as viral, fungal, and bacterial infections that might otherwise go unseen. The technology is the first to offer both cordless convenience and an optional digital camera and customized bracket that make it easy for dentists to photo-document suspicious lesions. The VELscope Vx is: • cordless • compact • affordable – even for multiple operatories. The VELscope’s distinctive bluespectrum light causes the soft tissues of the mouth to naturally fluoresce. Healthy tissues fluoresce in distinctive patterns — patterns that are visibly disrupted by trauma or disease. Using the VELscope, a wide variety of oral abnormalities can be discovered — often before they’re visible to the unassisted eye. Discovering soft tissue abnormalities is particularly important in the fight against oral cancer. Because the VELscope Vx assists in early detection, cancer can be caught before it has time to spread, potentially saving lives through less invasive, more effective treatment. Used on a regular basis, the VELscope Vx helps dental professionals find a wide variety of soft-tissue abnormalities, allowing practices to aspire to an advanced level of patient care. The VELscope Vx is: • completely safe • simple to use • no unpleasant rinses or stains • entire exam in about 2 minutes. Occasionally, the VELscope system plays a crucial role in saving lives. IP
The VELscope Vx is the most powerful FDA- and Health Canada-approved tool to screen for oral cancer, a growing health-care issue around the world.
This information was provided by LED Dental Inc. 52 Implant practice
Volume 6 Number 6
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Osstell ISQ The ISQ Scale – a global standard ISQ (Implant Stability Quotient) is a measurement scale for use with the RFA (Resonance Frequency Analysis) method of determining implant stability and osseointegration, presented on a clinically useful scale of 1-100 ISQ. The ISQ scale correlates perfectly with micromotion: the higher the ISQ, the more stable the implant.
Here is how the Osstell ISQ works and what it achieves The Osstell ISQ instrument stimulates a SmartPeg mounted on the implant by emitting magnetic pulses. These cause the SmartPeg to resonate at certain frequencies depending on the stability of the implant. This is a wireless, noninvasive, and completely objective technique. The SmartPegs have been calibrated in such a way that they all show comparable values for the same degree of stability.
Diagnostics by Osstell personal commitment
More than 20 years ago, two scientists shared the frustration of not being able to determine osseointegration in an accurate, objective, and consistent way – beyond their own dexterity and tactile skills. The concept of Resonance Frequency Analysis was developed. The company was formed in 1999, and today more than 9,000 clinicians all over the world use the Osstell ISQ. All Osstell employees are personally committed to the worldwide adoption of our unique diagnostics solution and to the continuous growth of our company. To succeed, we ensure that our customers receive the unrelenting support and service they deserve. Osstell AB is based in Gothenburg, Sweden where we develop, manufacture, and market our products globally through distribution partners and direct representations. Since 2007, the company has been a part of the Biolin Scientific group, which is a leading provider of analytical instruments for the nanoscale study of interfaces. IP
The SmartPeg™ is attached to the implant. It screws effortlessly into the implant’s internal thread.
The hand-held probe stimulates the SmartPeg magnetically, without actually being connected to it – or even touching it – and the value is displayed in a second.
www.osstell.com Your guide to predictable surgical and restorative protocols
This information was provided by Osstell AB.
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Volume 6 Number 6
Visit Osstell at Booth 817 during the AAOMS Dental Implant Conference, December 5th-7th
ACE Surgical – infinity Dental Implant Systems TRI-CAM and INTERNAL HEX Implant Systems
or almost 50 years, ACE Surgical has been dedicated to dental surgical advancements. We continue to develop and manufacture the highest quality, stateof-the-art products at competitive prices, while keeping customer service at the core of our business. Our team of industry-leading professionals has taken every detail into account — designing, engineering and manufacturing the infinity Dental Implant Systems. Made in the USA, each infinity system allows you to place and restore our implants and prosthetics with confidence.
Resorbable Blast Media surface (RBM) All infinity Implants are treated with RBM technology, one of the most studied surface treatments in the industry.1 RBM is a surface treatment designed to roughen the exterior surface of an implant without leaving the residual embedded blast particles or debris in the treated substrate. To achieve the desired roughening, a biocompatible material with a suitable hardened particle size is used and then subsequently dissolved from the surface with a defined passivation treatment. The result is a rougher surface than the traditional acid-etch treatments, providing a greater surface area for osseointegration.
Secure connecting platform With the TRI-CAM or INTERNAL HEX designs, you will have the peace of mind that comes from a truly compatible system. Both systems provide a locking internal connection interface, which makes attaching infinity prosthetics to the implant a more secure and precise fit every time. Along with secure connecting prosthetics, each component is color-coded, delivering consistency and accuracy in matching components across the surgical, laboratory, and restorative phases.
Long-lasting precision surgical drills Every infinity surgical drill is manufactured from hardened, high-strength, corrosiveresistant surgical drilling materials. The 56 Implant practice
surgical drills are individually designed and sized allowing for the creation of an osteotomy that will match each individual implant’s geometry and assure an exact fit for implant placement. Each drill has precise laser markings for accurate drill identification and implant depth drilling.
Complete package infinity Implants are packaged sterile with the cover screw included in an easy-toaccess, color-coded suspension chamber for easy recognition, removal, and transfer. Every implant includes instructions for use and product labels required for labeling the patient record, lab orders, and the restorative practitioner’s documentation. Implants available: TRI-CAM • 5 popular implant lengths across each platform size — Ø3.5 mm, Ø4.3 mm, and Ø5.0 mm (implant cover screw included with each implant) • 4 popular healing caps with varying collar widths and heights across each platform size — Ø3.5 mm, Ø4.3 mm, and Ø5.0 mm • Prosthetics included for every platform diameter: prepable abutments, UCLA abutments, closed and open tray transfers, implant analogs, and a full array of Locator® abutments and restorative components INTERNAL HEX • 2 platform sizes with two implant diameter sizes
o Ø3.5 mm platform — Ø3.7 mm and Ø4.1 mm implants x five popular implant lengths (implant cover screw included with each implant) o Ø4.5 mm platform — Ø4.7 mm and Ø5.1 mm implants x five popular implant lengths (implant cover screw included with each implant) • Six popular healing cap options with varying collar widths and heights across each platform size for the Ø3.5 mm and the Ø4.5 mm • Prosthetics included for every platform diameter: prepable abutments, UCLA abutments, closed and open tray transfers, implant analogs, and a full array of Locator abutments and restorative components
Comprehensive lifetime warranty Our comprehensive lifetime warranty doesn’t stop at simply replacing implant components; it also addresses the potential for bone loss. The infinity TRI-CAM and INTERNAL HEX Dental Implant Systems are committed to delivering superior value through a truly premium, compatible, dental implant solution at a very affordable price to both you and your patients. IP This information was provided by ACE Surgical. Reference 1. Gonshor A, Goveia G, Sotirakis E. A prospective, multicenter, 4-year study of the ACE Surgical resorbable blast media implant. J Oral Implantol. 2003;29(4):174-180.
Volume 6 Number 6
VISIT US AT AAOMS Dental Implant Conference Booth #119
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SUPER STORE! i-CAT Models
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Dental technology gets a new look with Henry Schein’s augmented reality app
ome technologies have become so routine to our daily lives that it’s hard to believe they didn’t exist 20 years ago. Online banking first launched in 1994. Amazon opened its virtual doors in 1995. Text messaging became mainstream in 2001. Smartphones gained momentum and exploded in popularity with the introduction of the first Apple iPhone® in 2007. In just two decades, inventions that seemed impossibly futuristic have become practical, widely used tools. One of the newest technologies still in its infancy, but already making a major impact, is augmented reality. Henry Schein has long been an innovator and early adopter of cutting-edge technology, and once again, they lead the way and are embracing this exciting development. Henry Schein Dental’s first interactive Equipment and Technology Catalog using augmented reality technology was released in October, and it literally changes the way doctors and their teams view dental products and services.
What is augmented reality? Augmented reality projects a virtual layer of interactive features on top of an actual physical environment, when viewed on the screen of a mobile phone or tablet. Henry Schein’s catalog and other brochures give readers another world of options — a digital world — that is interconnected to the printed page they are reading. Viewing the page through their device’s camera, they can launch interactive product descriptions and specifications, training videos, current promotional offers, and one-click buttons that connect them quickly to a sales representative. It’s all done just by hovering over an augmented reality enhanced page with an iPad®, iPhone® or Android™ device loaded with the Henry Schein Xtra app. Augmented reality can be difficult to explain in words, and its benefits can’t be grasped fully unless you see the technology yourself. You will be amazed at how powerful and applicable it can be to your dental practice.
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Test drive Henry Schein’s augmented reality app — It’s quite a ride If you have a mobile device, you can try augmented reality right now by scanning the page right next to this article. Just go to the Apple App Store or Google Play and download the free augmented reality mobile app called Henry Schein Xtra. Next, open the Henry Schein Xtra app and hover over the page with your device, being sure the entire page is displayed on your screen. Your device will “scan” the page to find the augmented reality features, and then watch the ad come to life with an on-screen button that launches a video. As you’ll see, augmented reality puts you in control of your browsing experience because you engage with items that matter most to you in an informative new way. Plus augmented reality gives Henry Schein the
opportunity to constantly update materials with new information, promotions, videos, and more so you always have the latest news at your fingertips. Thanks to this new innovation, Henry Schein’s printed catalogs and brochures can remain a doctor’s go-to resource for what’s new in dental technology today, tomorrow and months from now. Search for Henry Schein Xtra in the Apple App Store or Google Play to give augmented reality a try today. IP This information was provided by Henry Schein Dental.
Download the Henry Schein Xtra App
Watch the Video Volume 6 Number 6
Customized Practice Solutions for ORAL SURGEONS
Scan this page with the Henry Schein Xtra App for an interactive experience!
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Office Design & Consultation
From the Front Office to the Treatment Room and every touchpoint in between, Henry Schein has the solutions you need to connect all of your practice technologies to maximize the digital workflow resulting in greater efficiencies. With your success in mind, let us help you determine which products and technologies will enhance patient care within your practice. Our specialists have the experience and knowledge to assist and guide you in all of your equipment and technology choices.
Service, Repair & Installation
Computer Solutions & Support
Operatory Equipment Practice Management
1-800-645-6594 prompt #1 www.henryscheindental.com
Contact your Henry Schein Sales Consultant to ask about equipment and technology to advance patient care in your practice.
Materials matter Dr. Paul A. Fugazzotto offers advice on avoiding therapeutic failure that can affect the implant practice Why would anyone want become a dentist today?
Patients don’t understand the merits of various therapies and quality care. Patients accept treatment based upon their insurance coverage and allowances. Competition between various specialists and/or specialists and “generalists” to perform specific therapies is increasing. Encroachment upon private practitioners by corporate dental entities threatens to destroy the “cottage industry” of private practice. Graduates are saddled with debt in the hundreds of thousands and the prospect of working for a corporation rather than maintaining their autonomy.
Why are people trying to get in to the profession? Doesn’t it make more sense to grab what you can and get out instead? This is the type of mewling that is all too often encountered at congresses, and when speaking with smaller groups when teaching courses to them. I do not understand, and certainly don’t endorse, such thinking. Having maintained a full-time private practice specializing in periodontics and implant therapies for over 32 years, I can state categorically and with full conviction
Dr. Paul Fugazzotto received his DDS from New York University in 1979 and a certificate in advanced graduate studies in periodontology from Boston University in 1981. Since that time, Dr. Fugazzotto has maintained a private practice in periodontics and implant therapy in Milton, Massachusetts. Dr. Fugazzotto has authored or co-authored over 80 articles in refereed scientific journals, as well as authoring a monograph entitled “Guided Tissue Regeneration: Maximizing Clinical Results” and three textbooks entitled Preparation of the Periodontium for Restorative Dentistry; Decision Making in Regenerative and Implant Therapies; and Periodontal Restorative Interrelationships: Maximizing Treatment Outcomes. Dr. Fugazzotto is an active member of many organizations, and is a fellow of the International Team of Implantology. Dr. Fugazzotto is Senior Editor of Implant Realities and the US ITI Study Club Coordinator. He is a visiting lecturer at Harvard University and Tufts University School of Dental Medicine. Dr. Fugazzotto lectures nationally and internationally on a multitude of topics.
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that we as clinicians are all fortunate to be practicing today. • Our understanding of therapeutic potentials has never been greater. • Available materials to actualize such potentials have never been better. • The willingness of our non-periodontist colleagues to participate in these treatments is exciting. • The public’s “dental IQ” for both basic and sophisticated care has never been higher. I practice 5 miles south of Boston, Massachusetts. Boston has the highest number of periodontists per capita, and the second or third of restorative dentists, of any area in the United States. This being said, my restorative colleagues, other dental specialists we work with, and I continue to experience significant practice growth and maturation.
Why? The answer is a multilevel, uncompromising commitment to excellence and interdisciplinary comprehensive care. Such a commitment must begin with the clinician, permeate his or her
staff, and govern every aspect of therapy from communication with the patient to diagnosis and treatment planning with cotherapists (including doctors, auxiliaries, and laboratory technicians) to therapeutic and material selection. Setting up your office, and thus your practice, to embrace comprehensive care is too large a topic to be discussed in one editorial. As a result, the focus will be upon some key aspects of the journey. Future columns will deal with other pertinent considerations. For example, the auxiliary staff of you and your therapeutic partners’ offices are crucial to the success of transformation into a comprehensive care practice. Auxiliaries means everyone, from the front desk to hygienists to chairside assistants to support staff such as your digital media specialist. It all begins with what you demand of yourself, both clinically, and from a practice management point of view. Your greatest office expense is therapeutic failure. As such, materials and treatment modalities must always be selected with this fact in mind. It is especially tempting in today’s environment, when companies continually offer us the Volume 6 Number 6
placed, the cost over Brand X would be $140 per implant, for a total of $70,000. A 98.5 % success rate would result in 7.5 Straumann failures for the year. The 95% success rate of Brand X would result in 25 failures for the year, yielding a difference of 17.5 more failures with Brand X. Assuming an efficient practice that books 1 hour for the implant surgery, a 10-minute postoperative visit, and a 10-minute X-ray visit prior to implant restoration for a total of 1 hour and 20 minutes, and allowing each of these implants only 10 minutes to explain the problem and the need for retreatment to the patient, and only half of these implants to require any type of second surgical procedure such as a 20-minute
doctor who, unbeknown to her, was given aftermarket screws by her laboratory. Three of the four screws broke in the implants. While I was able to retrieve them without damaging the implants, the patient left the doctor’s practice, taking her family with her (including her husband who was treatment planned for four implants and a palateless removable prosthesis retained by locator attachments). Did the “savings” of utilizing poorer screws prove to be worthwhile for this doctor? The same attitude of vision and uncompromising excellence must be applied to all aspects of our practices. The way to address and conquer the concerns mentioned in this article is through the life and practice changing concepts
Can such a philosophy as Comprehensive Interdisciplinary Care succeed and grow in a “regular” dental practice, while still allowing the dentist time to enjoy his or her life? The answer is a resounding yes.
appointment for a soft tissue plasty, the additional 17.5 failures equals a minimum of 31.97 hours of retreatment. Utilizing a surgical fee of $2,250 per implant, which according to a recent survey is below the national average, these 31.97 hours equal $71,932. These calculations do not take into account the damage done to my relationship with the patient, the potential loss of the patient both for active therapy, and as a practice emissary to her friends, the potential loss of a referring doctor as a long-term co-therapist, and the potential damage to my reputation. When a moderately robust situation is considered, in which the periodontist or oral surgeon places 1,000 fixtures a year, the cost to the practitioner of utilizing Brand X is even greater. If you are a restorative dentist, do you utilize a laboratory based on fee, or fit and esthetics? Do you want to spend excessive chair time “modifying” (i.e., attempting to fix) prostheses before inserting them, or to deliver a product that results in esthetic dissatisfaction? I recently worked with a restorative
of excellence and interdisciplinary comprehensive care. Does such a philosophy place unique demands upon the office and the therapists? Yes. Time must be spent working up and discussing cases with each other and with the patient. A commitment must be made to communicate clinical excellence. However, there is no doubt that the patient and the treating clinicians all benefit. Patient long-term oral health is maximized. Both the restorative and surgical team members perform the types of therapies they have longed for, and experience dramatic increases in practice revenues. Interdisciplinary comprehensive care represents a win-win-win scenario. However, the key question is: Can such a philosophy as Comprehensive Interdisciplinary Care succeed and grow in a “regular” dental practice, while still allowing the dentist time to enjoy his or her life? The answer is a resounding yes. Future columns will discuss in detail how to attain this goal, and the steps which must be taken in all aspects of the practice. IP
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newest miracles, which are “just as good as X, at a significantly reduced cost.” What does “just as good as” mean? As a periodontist, it is critical that the implant I utilize deliver the highest level of success possible. Such success is not short-term, and should not be based upon corporate propaganda. In addition, as a businessman, I must dig deeper than the price of purchasing a specific material to truly determine the cost to me. I utilize an implant (Straumann SLActive®), which has demonstrated success rates of between 98.6 and 99% long-term (at least over 5 years) in numerous independent or ITI blindly funded studies. Note that I believe 5 years should be the minimum study length considered. This is not 5 years mean time, but rather 5 years minimum time for any implants to be considered and assessed. I was recently approached and offered an implant with a reported 95% “success” rate, which I could purchase for $150 less per implant as an introductory offer! The problems with the data offered me included the following: Definitions of success versus survival were poorly defined: There is a great difference between successful implants (characterized by stable peri-implant bone circumferentially, healthy soft tissues, and esthetic satisfaction), and surviving implants (which may, for example, meet the criteria of Albrektsson, et al., and still demonstrate progressive buccal bone loss and/or esthetic dissatisfaction). Nevertheless, the terms “survival” and “success” are indiscriminately interchanged by many authors, clinicians, and corporate entities. In assessment of my patients’ implant therapies, I define success as the criteria of Albrektsson, et al., plus stable crestal peri-implant bone circumferentially as determined by bone sounding, stable soft tissues with no signs of inflammation or recession, and no increasing probing depths circumferentially. Many of the implants reported upon had been in function less than 5 years. All studies shown to me were company funded. Ignoring all of my aforementioned concerns, lessening the number of implants placed to the relatively miniscule number of 500 implants per year, granting implant X a 95% survival rate, and reducing Straumann’s success rate to 98.5%, an objective analysis yields the following: If only 500 Straumann implants were
ON THE HORIZON
3D at 38,000 feet Dr. Justin Moody reflects on the benefits of cone beam 3D imaging
lying home from Boston today allowed me precious quiet time to reflect upon what I was able to learn during this weekend. I was honored to speak at the 7th International Congress on 3D Dental Imaging with my colleagues, including Drs. John Russo, Scott Ganz, Dan Cullum, and many others. Having attended several of these events, I was excited to see and hear everyone talk about 3D imaging. Personally, 3D imaging has changed the way I practice dentistry. It is no longer acceptable to enter a surgery or any procedure with only a piece of the information needed. As a speaker at this meeting, I had the luxury of listening to everyone and seeing how my perspective was in sync with those around me. What I did not realize was that everyone had this extra sense of excitement, and this spring in their step about the positive direction that 3D image would make in their practices. The common theme that I heard that made the 7th International Congress on 3D imaging so different was the ability to take quick, full volume scans with such low radiation levels. We have always had our patients’ safety as our top priority, and that doesn’t ever change. What has changed is that now we can acquire all the needed information safely and efficiently. I can tell you firsthand that having the i-CAT® FLX CBCT machine (Imaging Sciences International) in my office has done just that. With the new touchscreen monitor and ability to integrate with my dental practice software, the process of taking the scan to treatment planning is a matter
...3D imaging has changed the way I practice dentistry. It is no longer acceptable to enter a surgery or any procedure with only a piece of the information needed.
of just a few minutes. Full volume scans at less than half the radiation of a digital pan, treatment planning software that is easy to navigate, and the confidence of knowing that you are providing your patient with the very best in dental treatment and diagnosis, all combine to create the “wow moment.” I encourage all of you to explore this amazing technology, and see how it can best fit into your practice. It’s not about can you afford it, but rather can you afford not to have it? IP
Image courtesy of Imaging Sciences International
Dr. Justin Moody is a Diplomate with the American Board of Oral Implantology and with the International Congress of Oral Implantologists, Fellow and Associate Fellow of the American Academy of Implant Dentistry, Adjunct Professor at the University of Nebraska Medical College, and Founder and Director of the Rocky Mountain Dental Institute. 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@rockymountaindentalinstitute. com or at drjustinmoody.com.
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Volume 6 Number 6
INDUSTRY NEWS The 6th Annual Ethics and Legal Aspects of Dentistry Conference The 6th Annual Ethics and Legal Aspects of Dentistry Conference sponsored by the American College of Legal Medicine will be held Friday and Saturday, February 28 – March 1, 2014, at the Westin Galleria in Dallas, TX. Dentists attending the conference will be able to: learn more about legal issues in dentistry and understand the government’s role and the role of dental education, describe ethical, moral and diagnostic issues as they relate to the dental practice, evaluate risk management considerations, and identify issues relating to patient care, access to care and dental health care coverage, electronic record keeping, licensure issues, and the current landscape for malpractice and more. For further information and registration, visit the ACLM website at www.aclm.org or contact Wendy Weiser at email@example.com or Dr. Bruce Seidberg at firstname.lastname@example.org.
MATERIALS lllllllllllll & lllllllllllll EQUIPMENT Straumann Roxolid® for All with the NEW Loxim™ transfer piece now available on tissue level implants The Straumann Roxolid® for All implant line featuring an advanced combination of the award-winning Roxolid® material and the SLActive® implant surface on all implant diameters is now available in Tissue Level with the NEW Loxim™ transfer piece for simplified handling. Roxolid for All with the Loxim transfer piece is designed to provide clinicians with confidence in all cases, the flexibility of more treatment options, to help increasing patient acceptance of implant treatment, improved osseointegration properties,1 and efficient implant placement through simplified handling. Loxim is a pre-mounted, self-retained transfer piece that offers clockwise and counter-clockwise rotations for one-step implant insertion. With Loxim, the holding key is no longer required to remove the transfer piece, helping to make implant placement more efficient. The Roxolid material and the SLActive surface technology each received the Frost & Sullivan Medical Device Technology of the Year Award. This award, which recognizes excellence in technological innovation, is one of the Best Practices Awards bestowed by Frost & Sullivan, the global growth consulting company. In 2005, the SLActive surface technology was noted as a “next generation dental implant surface technology,” and in 2009, the Roxolid material was noted as an “innovative high performance material for dental implants.” To learn more about Straumann, visit www.straumann.us. 1 Gottlow J, et al. Evaluation of a new titanium-zirconium dental implant: a biomechanical and histological comparative study in the mini pig. Clin Imp Dent Relat Res. 2012 Aug;14(4):538-545.
Zimmer Dental offers space-maintaining resorbable porcine membrane Zimmer Dental Inc., a leading provider of dental oral rehabilitation products and a subsidiary of Zimmer Holdings, Inc., has announced the availability of the CopiOs Extend™ Membrane — a biocompatible and resorbable, collagen-based membrane, derived from porcine dermis — for use in a variety of dental surgical procedures, including Guided Tissue Regeneration (GTR) and Guided Bone Regeneration (GBR). CopiOs Extend Membrane offers clinicians the synergy of space and time — promoting optimum resorption and space-maintaining conformance. Lasting 6 to 9 months, the membrane’s extended resorption profile is designed to allow implant placement while subsequently providing ample time for unhindered regeneration. In addition, CopiOs Extend Membrane has been designed to conform to the defect with enough structural integrity for necessary space creation. Its cell occlusive nature allows nutrients to permeate while blocking epithelial cells, thereby creating an environment more suitable for successful GTR and GBR procedures, for example. The biocompatible membrane is comprised of highly purified, intact dermis. Supplied sterile, it can be implanted dry or slightly hydrated. Once applied, the membrane is malleable and easy to reposition. For more information call 800-854-7019, or visit www.zimmerdental.com.
Carestream Dental’s CS Solutions for CAD/ CAM restorations makes single-appointment restorations possible Carestream Dental announced that its new product line for CAD/CAM restorations, CS Solutions, is now available. CS Solutions gives practitioners the ability to scan, design, mill, and place a restoration within their practice in just one appointment. The product portfolio consists of an intraoral scanner, CBCT impression scanning system, restoration design software, a milling machine, and a hosted, Web-based platform created to share and manage restoration cases between dentists and laboratories. The product line requires minimal training by offering a light guidance system during image capture, easy impression scanning, intuitive restoration design capabilities, and step-by-step milling instructions. For more information, call 800-944-6365 or visit www.carestreamdental.com.
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Volume 6 Number 6
The Ideal 3D Imaging Systems... • Availability of multiple imaging modalities in one machine (3D, anatomically accurate extraoral bitewing program, panoramic, and cephalometric)
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3.0mm GoDirect® Implants
1-Piece Simplicity, 2-Piece Versatility Implant Direct’s 3.0mmD Overdenture Implants
GoDirect Advantages vs Zest’s LODI
Zest’s 2.9mmD LOCATOR® Overdenture Implant (“LODI”)
Implant Design Options • Rounded apex for 28% greater surface area • Pointed apex for insertion with shorter drilling
1-Piece Implant Design
Simplifies insertion with 87% greater strength (3.0mmD GoDirect vs 2.9mmD LODI)
Implant Design Benefits • Micro-threads for reduced stress at crest • Longer grooves for self-tapping in dense bone
Prosthetic Platform Compatible with Zest LOCATOR® as well as GPS® Internal and External Cap Attachment (see GPS advantages below)
Prosthetic Versatility 1-Piece implant with internal threads accepts ball, multi-unit, custom-cast & GPS abutments
Reduced Profile Height GoDirect 1-Piece design is up to 1.7mm lower providing more room for denture teeth
All-in-1 Packaging: $175 includes implant, transfer, comfort cap, metal housing, black processing male, block-out spacer and GPS Internal cap attachment which provides vertical and rotational stress-breaking.
est’s Ad for its LOCATOR® Overdenture Implant (“LODI”) Claims “No More Compromise” but should just say “More Compromise.”
Under biting forces, the lateral walls of the GPS Internal liner flex outward - allowing the retentive ball to move downward into the internal cap.
100% 73% GoDirect Offers More Implant For Your Money
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GPS® Internal Attachment eliminates the unhygienic gap on rotation and initially maintains 100% of its retention at 10° 2
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Savings based upon US list price for Zest LODI implant and impression coping. 2 Data on file LOCATOR® & LODI are registered trademarks and products of Zest Anchors Company. The GoDirect™ and GPS™ Systems are neither authorized, endorsed nor sponsored by Zest Anchors Company 1
Zest's LOCATOR® Dual Retention creates a gap on rotation and initially loses 27% of its retention at 10° 2
Published on Nov 19, 2013