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clinical articles • management advice • practice profiles • technology reviews October/November 2017 – Vol 10 No 5

PROMOTING EXCELLENCE IN IMPLANTOLOGY Consecutive treatment failures of an immediate maxillary canine implant and replacement and reconstruction Drs. Howard Gluckman and Jonathan Du Toit

Review: AAP’s best evidence consensus on “The Use of CBCT in the Management of the Patient Requiring Dental Implants” Drs. Bradley S. McAllister, V. Thomas Eshraghi, and Hector F. Rios

Zest Dental Solutions® celebrates 40th anniversary Implant dentistry museum in Venice, Italy, to honor Drs. Leonard I. Linkow and Jack Wimmer Lori Kesselman, JD

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WE’VE MADE FIXED FULL-ARCH RESTORATIONS A SNAP. NO SCREWS. NO CEMENT. NO COMPROMISES.

Fixed for the patient. Easily removed by the clinician. LOCATOR F-Tx® is a simplified, time-saving solution for full-arch restorations with no compromise to prosthesis strength or esthetics. Optimized for efficiency and chair time savings compared to conventional screw-retained systems, LOCATOR F-Tx features a novel, “snap-in” attachment that eliminates the need for sub-gingival cement or screw access channels. LOCATOR F-Tx is the latest innovation from Zest Dental Solutions expanding treatment options for the edentulous patient— with less chair time and higher patient satisfaction. To learn more, please visit our website at www.zestdent.com/ftx or call 800.262.2310. ©2017 ZEST Anchors LLC. All rights reserved. F-Tx, LOCATOR F-Tx, ZEST and Zest Dental Solutions are registered trademarks of ZEST IP Holdings, LLC. Some products may not be regulatory cleared/released for sale in all markets. Please contact the local Zest Dental Solutions representative for current product assortment and availability.


October/November 2017 - Volume 10 Number 5

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-inchief 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

© FMC 2017. All rights reserved. FMC is part of the specialist publishing group Springer Science+ Business Media. The publisher’s written consent must be obtained before any part of this publication may be reproducedvw in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Implant Practice or the publisher.

Volume 10 Number 5

“A

photograph is usually looked at — seldom looked into.” — Ansel Adams We live in a digital world. Snap it; save it; swipe it; screenshot it. We utilize this technology each day, and we constantly evolve our practices to find practical and innovative solutions for our patients. Clinical digital photography is one of the greatest tools we can utilize. Each patient should have a chart that includes a full set of photographs that serves as a guide in the treatment process. To be a healer or a hitman: John C. Kois wrote an article about this in the Journal of Cosmetic Dentistry, and it resonates. Think about this: You are explaining to a patient that he needs extensive treatment. His face drops, and he becomes confused and upset. You just became the hitman. Now if you can show the patient his dental condition first; if you can present the problem and also the solution, you now become the healer. Photographs are key to achieving this patient communication. If you like it — snap it! When we say we want photographs in our practice, we want a full set. An in-focus full arch shot is a beneficial view to show the patient. For years, we have shown patients X-rays and single tooth photos. A full arch photograph is so powerful and puts into perspective the entire picture of the patient’s mouth and the clinical concerns, which allows us to educate the patient, and the patient to better understand. The diagnostic value of clinical photography is immeasurable in our practice. Numerous clinical procedures are divulged in these photos, and they are invaluable in making treatment decisions. In addition, they assist in our visual learning. Visually utilizing clinical digital photography enables us to see clinical changes over time, which in turn, enhances the patients’ perception of their care. Clinical digital photography is a great attribute to our offices for the following 10 reasons: 1. The biggest tool in our patient communication comes from showing clinical photographs. We cannot stress this point enough — be a healer! 2. Dental laboratories utilize the patient photos we take to create our cases and help with clinical parameters. 3. To make a more effective treatment plan, we can determine so much from a clinical photograph — use this tool! 4. Insurance often requires clinical photographs for claim determination. Without these photographs, there is a risk those claims would not be fully paid. 5. It is important to establish a protocol that leads to a smooth workflow. Even though it may be difficult to get the entire team in the habit, the whole team must be invested in using clinical photography. With everyone onboard, it can be a real asset. 6. If a legal conflict does arise, the use of clinical photography will be necessary to help determine a case. 7. We all read articles online and in print about our peers’ treatment plans, and those articles with photographs that illustrate the treatment being discussed are essential to our understanding. Use the photos for submitting your own articles to publications. 8. If you want to refer a patient to a specialist, he/she will want a full chart for that patient. An addition of clinical photographs assists in the co-treatment of your patient. 9. We take continuing education courses and seminars, and we read articles. But our own self-assessment through clinical photographs will help us improve our quality of care and continue our own education. 10. It is easy to get hooked on reality television shows. Whether it is for a home repair, hair styling, or fashion trends, we all love a good “before and after.” These clinical photographs are instrumental marketing tools to show the “before and after” of our clinical expertise. Take advantage of your team’s work, and use the photos to reach out to potential patients and show them what you can do. As photographer Elliott Erwitt said,“The whole point of taking pictures is so that you don’t have to explain things with words.” Let your clinical digital photography speak for and with you. Dr. Mike Freimuth, DDS, received his dental degree from Creighton University in Omaha, Nebraska, and then he completed his general practice residency at Veterans Administration Medical Center in Omaha. He is committed to continuing education and innovative dental technology. Dr. Freimuth is a Diplomate of the American Board of Oral Implantology, Diplomate of the International Congress of Implantologists, Master at the Misch Implant Institute, Mentor at the Kois Center, Associate fellow at the American Academy of Implant Dentistry, member of the American Academy of Facial Esthetics, member of the American Dental Association, member of the Colorado Dental Association, member of the Metropolitan Denver Dental Society, and Co-Director of Implant Pathway, an AGD/ADA-approved dental implant continuum. He can be reached at drmike@myprosmile.com.

Implant practice 1

INTRODUCTION

Clinical digital photography


TABLE OF CONTENTS

Making history

Corporate profile Proceed Finance

6

A fair and affordable patient-care financing solution

Implant dentistry museum in Venice, Italy, to honor Drs. Leonard I. Linkow and Jack Wimmer Lori Kesselman, JD, discusses recognition for two esteemed dental innovators ........................................10

Technique

Corporate milestones Zest Dental SolutionsÂŽ, developer and manufacturer of the genuine LOCATORÂŽ, celebrates 40th anniversary

2 Implant practice

8

The whole package: taking patients from implant to restorations in a multidisciplinary practice Dr. David Little discusses how digital technology opens up a myriad of treatment options.............................14

Volume 10 Number 5


Neither is the anatomy of your implant patients

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It’s time to challenge conventional thinking

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Conventional vs innovative approach

Dentsply Sirona does not waive any right to its trademarks by not using the symbols ® or ™. 32671114-US-1702 © 2017 Dentsply Sirona. All rights reserved.

OUR WORLD IS NOT FLAT


TABLE OF CONTENTS

Continuing education

22

A review of the AAP’s best evidence consensus on “The Use of CBCT in the Management of the Patient Requiring Dental Implants”

Continuing education Consecutive treatment failures of an immediate maxillary canine implant and the subsequent replacement and reconstruction of the site

Drs. Howard Gluckman and Jonathan Du Toit demonstrate the difficulties of rectifying previous mistakes........... 28

Drs. Bradley S. McAllister, V. Thomas Eshraghi, and Hector F. Rios discuss the implant application of CBCT technology as reported in the consensus

Technology spotlight

What does neuroscience have to do with dentistry? A lot! Sandra Marlowe discusses a method of achieving a profound mental state of peak performance.................... 36

Practice development

Industry awards

Cellerant “Best of Class” Technology Awards 2017 .................................................34

PUBLISHER | Lisa Moler Email: lmoler@medmarkmedia.com MANAGING EDITOR | Mali Schantz-Feld Email: mali@medmarkmedia.com | Tel: (727) 515-5118 ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkmedia.com NATIONAL SALES DIRECTOR | Kristin Sammarco Email: kristin@medmarkmedia.com

SEO: Scam or critical marketing service? Part 1

NATIONAL ACCOUNT MANAGER Celeste Scarfi-Tellez Email: celeste@medmarkmedia.com

Ian McNickle, MBA, defines SEO and discusses its importance............... 38

CLIENT SERVICES/SALES SUPPORT | Adrienne Good Email: agood@medmarkmedia.com

On the horizon Systems-driven dental implant practice

Dr. Justin Moody discusses going with the workflow......................... 40

CREATIVE DIRECTOR/PROD. MGR. | Amanda Culver Email: amanda@medmarkmedia.com E-MEDIA PROJECT COORDINATOR | Michelle Kang Email: michellekang@medmarkmedia.com FRONT OFFICE MANAGER | Mystey Helm Email: mystey@medmarkmedia.com MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 www.implantpracticeus.com | www.medmarkmedia.com SUBSCRIPTION RATES 1 year (6 issues) $149 | 3 years (18 issues) $399

4 Implant practice

Volume 10 Number 5


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Copyright© 2017 OCO Biomedical Inc. All Rights Reserved. OCO Biomedical, The Next Generation of Dental Implants, Engage, Mini Cortic-O, Bull Nose Auger, Dual Stabilization and other trademarks are trademarks of OCO Biomedical Inc. Other trademarks may be trademarks of their respective owner.


CORPORATE PROFILE

Proceed Finance A fair and affordable patient-care financing solution

D

uring a recent interview with Proceed Finance’s CEO, Dave Roehr, and Senior Director of Sales, Brad Bailor, on patientcare financing, Dr. Justin Moody and his team from top dental industry podcast “Dentists, Implants & Worms,” opined, “Proceed Finance really has built a better mousetrap.” As a patient-care financing company with a new, industry-disrupting finance model, that was high praise.

Cabela’s and a vision for better financing Proceed Finance started with the seed of an idea by founder Dave Roehr. Prior to founding Proceed Finance, Roehr was CFO of Cabela’s Inc. and had led the outdoor outfitter into the world of unsecured credit and finance. Under his guidance, Roehr created Cabela’s wholly owned finance institution, World’s Foremost Bank, the exclusive issuer of their popular Cabela’s/VISA co-branded credit card and, as the bank’s CEO, grew its assets to more than $2 billion over his tenure. After departing Cabela’s, Roehr, a former CPA and tax consultant, found himself talking with several dentists and oral surgeons about the difficulty providers had in aligning existing high-interest, high-penalty financing

“Proceed Finance really has built a better mousetrap.” — “Dentists, Implants & Worms” dental industry podcast

practices with their care-driven vocation and sensed an opportunity. Cabela’s customers had used financing to purchase sporting goods and outfitter trips, but Roehr believed a fair and affordable patient-care financing solution could give people purchasing power for something much more valuable — their health. Proceed Finance was born.

Building a better mousetrap

Dave Roehr, founder Proceed Finance 6 Implant practice

The need Roehr identified isn’t new, but the Proceed Finance approach is. Financial studies show 6 out of 10 Americans don’t have $500 in savings for emergencies or unplanned out-of-pocket expenses, and the American Dental Association’s dental care financing studies point to cost as a leading reason adults opt to forgo dental care at

much higher levels than they forgo prescription drugs, eyeglasses, and mental and physical health services. Patient-care financing bridges this gap, but current financing companies are regularly rated poorly by both customers and objective third-party creditrating sites like Credit Karma and have been at the center of journalistic inquiries about consumer protection and lending practices by sources like The New York Times. Proceed Finance’s business model was built with the needs of providers and dignity of patients at its core. Understanding the lingering havoc wreaked on consumers’ credit scores by the 2008 recession and the lack of patient-friendly credit options in the medical/dental space, the company developed an approval process that fully funds Volume 10 Number 5


Partnering with providers to boost practice profits One of Proceed Finance’s cornerstone concepts is the idea of quality patient care financing serving as a mechanism for

The goal of implementing these patient-centric processes was to put both credit and treatment within financial reach for patients, leading the industry away from “predatory” lending practices by presenting a new option for a “do no harm” patient-care financing offering.

supporting dental practice growth. After seeing how financing supported incremental revenue growth for Cabela’s, Roehr developed Proceed Finance’s processes to help dental providers increase their case acceptance and experience that same incremental growth factor through effective financing. Proceed Finance’s large FICO credit score acceptance range means a larger pool of potential clients for dental service providers. If a practice can add one or two additional cases per month through financing, the result will be higher revenues and net profits. In addition, as a former CPA and consultant with experience in business valuations, Roehr knows taking small steps to increase revenues through financing can help dentists and oral surgeons increase their practice valuations by up to 30%. Besides the competitive advantage of offering the most consumer-friendly financing in the marketplace, providers also benefit from Proceed Finance’s core concept of financing with dignity. Treating patients well in the financing experience creates intangible value for the practice, one that manifests itself in referrals and repeat business.

Other Lenders

Offering onboarding and support, one practice at a time The Proceed Finance model also differs from other offerings in the support it provides to dental practices and providers. Proceed Finance staff assist provider staff in implementing the instant pre-qualification application process, as well as exploring scenarios patient care and coordination staff might experience with live patients. Proceed Finance also offers collateral and informational tools to help dental staff talk with patients about financing options and explain how financing options make procedures more affordable. “There’s great opportunity for dental providers to improve their care to customers with Proceed Finance — dentally, financially, and interpersonally,” says Roehr. “Treating patients better financially builds relationships and creates opportunities for revenue growth in ways most practices never imagined. And that combination of smart relationships and smart growth is what Proceed Finance is all about.” IP This information was provided by Proceed Finance.

Proceed Finance If Practice Accepts Dental Insurance

If Practice Does Not Accept Dental Insurance

Standard Treatment Price

10,000

10,000

10,000

Estimated Insurance Adjustment

-3,000

0

Financing Amount

Loan Declined

7,000

10,000

Discount Fee (Ave. 7%)

-490

-700

Direct Incremental Cost of Treatment

-1,000

-1,000

Net Profit Per Procedure

0

5,510

8,300

2018 Annual Incremental Revenue (assuming 2 additonal treatments/month)

0

168,000

240,000

2018 Net Profit

0

132,240

199,200

Volume 10 Number 5

Implant practice 7

CORPORATE PROFILE

procedures for patients with FICO scores ranging from 640 (Fair) to 850 (Exceptional), which covers nearly 75% of recognized credit score ratings. Proceed Finance omitted from its processes industry-standard practices that were detrimental to borrowers, such as retroactive interest rate penalties for late payments (which pushed some rates to over 30% interest) or partial approval to lowerFICO patients. Proceed Finance also looked critically at interest rates, starting their rates at 4.99% and capping them at 15.99% — significantly lower than the 26.99% interest rate imposed by some existing lending companies. Funding ceilings were set at $55,000 per procedure, higher than any competitor in the industry, and loans offer terms of up to 8 years, also an industryleading move. The goal of implementing these patientcentric processes was to put both credit and treatment within financial reach for patients, leading medical and dental financing away from “predatory” lending practices by presenting a new option for a “do no harm” patient-care financing offering. “Unlike our competitors, we didn’t want to penalize patients arbitrarily for things like a late payment, or only partially fund their treatment — no one wants implants that are two different colors from two different procedures! We wanted to treat everyone with dignity, use credit as a steppingstone, and help dentists deliver quality treatments that increase the bottom line,” says Roehr.


CORPORATE MILESTONES

Zest Dental Solutions®, developer and manufacturer of the genuine LOCATOR®, celebrates 40th anniversary

Z

est Dental Solutions® (formerly Zest Anchors), the developer and manufacturer of the award-winning LOCATOR Attachment System, celebrated its 40th anniversary of providing innovative solutions for the treatment of edentulous patients. Zest’s humble beginning started in 1972 within a small dental laboratory in San Diego, California. From that point through 1976, the original founder, Max Zuest, recognized the continual problems his clinician customers were experiencing with patients’ overdentures. During this time, the Zest® Attachment originated, a solution considered to be far better than what was on the market at the time. In 1977, Mr. Zuest’s son, Paul Zuest, joined him officially forming Zest Anchors and releasing the second generation Zest Anchor Advanced Generation (ZAAG®) Attachment. The ZAAG Attachment was designed for all major implant systems, a product differentiator that proved to be an important growth driver resulting in the need for a larger manufacturing facility in Escondido, California. In 2000, realizing improvements could still be made to the product portfolio, Paul Zuest took over operations of the company and, together with Scott Mullaly, set forth to develop a product that would eventually become the most globally recognized and trusted brand for overdenture restorations, the LOCATOR Attachment System, commercially released in 2001. In late 2009, Zest Anchors was acquired by the private equity firm The Jordan Group. Today, Zest Dental Solutions is a portfolio company of Avista Capital Partners, a leading private equity firm. Day-to-day operations are led by Steve Schiess as President and CEO. The company’s flagship product LOCATOR has achieved worldwide acceptance as the premier overdenture attachment in the dental industry. More than 100 manufacturers have partnered with Zest to customize its patented LOCATOR Attachment System to be compatible with its respective implant platforms. Zest’s Global Headquarters is in Carlsbad, California, and the company has grown to a nearly 225 employee, 75,000 total facility footprint strong innovation-driven company. It provides removable and fixed implant restorative solutions, world-class narrow 8 Implant practice

diameter implant systems, and dental materials and products for overdenture modification and processing to clinicians treating the real-world problems associated with edentulism. The company has also further diversified its product portfolio with acquisitions of Danville Materials, a leader in small equipment and dental consumables, and Iveri Whitening. This diversification makes Zest a true solutions-based company for a continuum of patient care from the preservation of natural teeth to the treatment of total edentulism. “Forty years ago the Zuest Family set out to make a difference in patients’ lives,” said Steve Schiess, Zest Dental Solutions President and CEO. “I am honored to be a part of a company that has made such a large impact in the dental industry, supporting clinicians, and ultimately improving patients’ quality of life. I am excited for the bright future Zest has in bringing additional innovations to the dental community.”

To learn more about Zest Dental Solutions and the Zest Anchors Product Portfolio, please visit www.zestdent.com. To learn more about the Danville Product Portfolio, please visit www.danvillematerials.com.

About Zest Dental Solutions Zest Dental Solutions is a global leader in the design, development, manufacturing, and distribution of diversified dental solutions for a continuum of patient care from the preservation of natural teeth to the treatment of total edentulism. The company’s product portfolios consist of Zest Anchors, Danville Materials, and Perioscopy with global distribution through OEMs, dealer/distributor networks, as well as a domestic retail sales operation for the Zest Anchors Portfolio. Zest Dental Solutions’ corporate headquarters is in Carlsbad, California, with satellite operations in Anaheim and Escondido, California. IP This information was provided by Zest Dental Solutions®.

Volume 10 Number 5


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MAKING HISTORY

Implant dentistry museum in Venice, Italy, to honor Drs. Leonard I. Linkow and Jack Wimmer Lori Kesselman, JD, discusses recognition for two esteemed dental innovators

T

he American Academy of Implant Prosthodontics (AAIP) in cooperation with its Italian affiliate, NuovoGISI, will sponsor an implant dentistry section in an established Venice, Italy, museum of medicine. The implant section will be named in memory of two American innovators, Drs. Leonard I. Linkow and Jack Wimmer, who contributed greatly to the development of blade and subperiosteal implants. The museum is located inside the S.S. Giovanni e Paolo Civil Hospital, a wellrespected hospital in Venice. After World War II, Professor Umberto Saraval was director of stomatology at the hospital and also the first editor-in-chief and then director of Rivista Italiana di Stomatologia. The journal was edited and printed in Venice. The periodical published the articles of implant pioneer, Manlio Formiggini, who in 1947 described his method for inserting a selfmade screw immediately after tooth extraction. In 1955, the journal published Formiggini’s conclusions after having treated 25 patients. A number of articles fundamental to the advancement of implant dentistry throughout the years were printed in Dr. Saraval’s journal.

S.S. Giovanni e Paolo Civil Hospital of Venice (top), home of the implant dentistry museum. The main exhibit hall of the museum is pictured to the right

Dr. Leonard I. Linkow Leonard I. Linkow, DDS, DMSc, considered by his many colleagues and students as the “Father of Oral Implantology,” died on January 26, 2017, after a long illness at the age of 90. The name Linkow is synonymous with dental implants. Dr. Linkow is responsible for numerous innovations in implant dentistry. Among his major contributions are the blade implant, the self-tapping ventplant root form implant, the tripodal subperiosteal implant, immediate loading, and the internal hex design for root form implants. He held 36 patents. Dr. Linkow was the only dentist ever to be nominated for the Nobel Prize in Medicine. Dr. Linkow practiced dentistry in New York City throughout his career. He has been honored in many of the world’s greatest cities — Berlin, Madrid, Milan, Paris, Rome, Shanghai, Tokyo, and Zurich, among others. He maintained lifelong friendships with some of the most renowned people in the dental 10 Implant practice

Early original Linkow implant castings framed to hang in Dr. LInkow’s office Volume 10 Number 5


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MAKING HISTORY profession. He was the author of 19 textbooks and approximately 100 articles in dental and medical journals. Dr. Linkow developed and introduced numerous implant systems, many of which are in use today throughout the world. A number of international congresses and seminars bear his name. Dr. Linkow was Clinical Professor of Implant Dentistry at New York University College of Dentistry at the time of his death. He also served as a Clinical Professor in the Department of Prosthodontics at Temple University in Philadelphia for many years, where he demonstrated surgical and prosthodontic implant procedures, lectured to both undergraduate and advanced education students, and gave interested students and faculty unique training, which was unavailable at other dental schools at that time. In 1992, the New York University College of Dentistry created the first and only endowed chair in implantology in perpetuity with Dr. Linkow as the recipient.

Dr. Jack Wimmer Dr. Jack Wimmer, a highly respected and historically important innovator and contributor to the dental profession, died on May 24, 2017, at the age of 94. A Holocaust survivor whose entire family was murdered at the

Leonard I. Linkow, DDS, DMSc

Dr. Jack Wimmer

Belzec death camp in Poland, Dr. Wimmer met his wife, Sally, a year after his liberation. He completed his dental education in Würzburg, Germany, and began practicing dentistry in Munich. In 1951, he and his family immigrated to the United States. Dr. Wimmer opened his own dental laboratory, Park Dental Studios initially located at 30 Central Park South in Manhattan. Park Dental Studios became one of the most widely known and respected dental laboratories in the country. In the late 1950s, Dr. Wimmer developed a great interest in dental implantology.

He worked closely with Dr. Leonard I. Linkow and others pioneering the introduction of dental implants. Dr. Wimmer helped develop subperiosteal implants and lectured throughout the world on that topic. He authored chapters for implant textbooks and wrote articles on implants and dental laboratory technology for dental periodicals. Dr. Wimmer founded Park Dental Research Corporation, which introduced several innovative products. He is responsible for introducing to the profession the use of radiofrequency glow discharge for sterilizing and cleaning the surface of dental implants.

Linkow and Wimmer Museum of Oral Implant History

Early patient subperiosteal patient demonstration model showing Facial view of early maxillary subperiosteal implant casting and subperiosteal casting (left) and complete denture segment (right) fixed prosthesis from Park Dental Studios

The hospital museum will include a section devoted to the history of oral implantology. Dr. Linkow’s daughter, Sheree L. Mandelbaum, and Dr. Wimmer’s wife, Sally, have donated a large variety of the original initial castings and carvings of blade and subperiosteal implants to the museum. Dr. Linkow’s initial drawings and notes were also donated along with other items. Throughout the years Drs. Linkow and Wimmer gave their colleagues and close friends, Drs. Sheldon Winkler and Mike Shulman, numerous early implant castings, blade insertion instruments, old patient education models, drawings, and other historical implant objects. All of these items were also donated to the museum. All items will be exhibited at the museum in new modern display tables and cabinets donated by the American Academy of Implant Prosthodontics. IP

Acknowledgment

Facial view of early mandibular subperiosteal implant casting and fixed prosthesis from Park Dental Studios 12 Implant practice

Occlusal view of early mandibular subperiosteal implant casting and fixed prosthesis from Park Dental Studios

Early maxillary subperiosteal implant casting and fixed prosthesis from Park Dental Studios

Dr. Luca Dal Carlo of Venice, Italy, suggested a dental implantology museum in honor of Drs. Linkow and Wimmer, initiated the assistance and cooperation of the AAIP and NuovoGISI, and provided information for this article. Dr. Dal Carlo serves on the Board of Directors of the AAIP and is President of NuovoGISI.

Volume 10 Number 5


Address the Implant Complexities You Face Everyday with...

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October/November 2017 – Vol 10 No 5

PROMOTING EXCELLENCE IN IMPLANTOLOGY Consecutive treatment failures of an immediate maxillary canine implant and replacement and reconstruction Drs. Howard Gluckman and Jonathan Du Toit

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Drs. Bradley S. McAllister, V. Thomas Eshraghi, and Hector F. Rios

Zest Dental Solutions® celebrates 40th anniversary Implant dentistry museum in Venice, Italy, to honor Drs. Leonard I. Linkow and Jack Wimmer

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Review: AAP’s best evidence consensus on “The Use of CBCT in the Management of the Patient Requiring Dental Implants”

August/September 2017 – Vol 10 No 4

PROMOTING EXCELLENCE IN IMPLANTOLOGY

Dr. Ara Nazarian

Practice profile Dr. Nick Caplanis

Autologous bone grafting using extracted teeth

Clinical articles enhanced by high quality photography

Dr. Armin Nedjat

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Practice management advice on how to make implants more profitable Technology reviews of the latest products

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TECHNIQUE

The whole package: taking patients from implant to restorations in a multidisciplinary practice Dr. David Little discusses how digital technology opens up a myriad of treatment options

A

s a general practitioner who has been involved with implants since 1984, I’ve come to realize that patients don’t want implants, they want teeth. That’s why beginning a single-tooth implant case — which the majority of implant cases are — with the final restoration in mind is so crucial to success: both the success of the implant and the success rate of case acceptance. Fortunately, using an integrated digital workflow at my practice allows me to offer patients solutions that take them from implant to final restoration. The key I’ve found is advanced 3D technology that not only helps me visualize anatomy, plan and place implants, and restore teeth with confidence, but also plays a key role in patient education and case presentation.

The technology When it’s determined that a patient will need an implant, the typical workflow in my practice includes the following: • Thorough clinical exam, including radiographs and intraoral photographs (CS 1500, Carestream Dental) • CBCT scan (CS 9300C, Carestream Dental) • Digital impression taken with an intraoral scanner (CS 3600 intraoral scanner, Carestream Dental) While each link in this interconnected digital chain provides valuable information for planning the case, the CBCT system

David Little, DDS, received his doctorate degree in dentistry at the University of Texas Health Science Center at San Antonio Dental School and now maintains a multidisciplinary, state-of-the-art dental practice in San Antonio, Texas. An accomplished national and international speaker, professor, and author, he also serves the dental profession as a clinical researcher focusing on surgical placement and restoration of dental implants. As a professional consultant, Dr. Little also shares his expertise on emerging technologies, including CBCT, planning software, surgical guides, digital workflow, and a restorative technique with industry peers. Dr. Little serves as the clinical director for OsteoReady® Practical Implant Solutions. Disclosure: Dr. Little is one of Carestream Dental’s key opinion leaders.

14 Implant practice

allows for exceptional high-resolution 3D views of the bone so that I can evaluate the implant site. I’ll also be the first to admit that my CBCT system lets me know when more complicated cases should be referred out to a specialist. The key is confidence — whether that’s the confidence to handle the case in-house or confidence in knowing I made the best decision for the patient by referring them to a specialist. While I’ve always made CBCT a priority in my implant workflow, a more recent addition is the intraoral scanner. Although intraoral scanners are still new to the field of implants, they bring with them several advantages. The scanner gives me flexibility when working with custom healing abutments and surgical guides, and the ability to scan the same implant region of interest twice — once with scan body in place and then again with healing cap present — streamlines the process and saves valuable chair time. Introducing the CS 3600 intraoral scanner to my implant workflow has also cut back significantly on impression materials and turnaround time with the lab.

The consultation Using digital technology opens up a world of treatment options to the clinician, but those options can sometimes overwhelm patients. As previously mentioned, patients just want a tooth that’s going to look natural — the pros and cons of a custom abutment isn’t always their top priority. One way to boil things down for patients is to present a single-tooth case fee — which includes the diagnostics, the surgery, the type of restoration, etc. — and package that into one solution for the patient. I find it works better from a case presentation standpoint and aids in acceptance when the clinician can say: “The solution to take care of your tooth is X amount.”

The treatment plan After the patient has accepted treatment, we follow our typical implant treatment workflow, using the CBCT scan and digital impression that were were acquired in the diagnostic stage. In the most “ideal” case,

Implant Concierge™ (San Antonio, Texas) merges the CBCT’s DICOM files and the intraoral scanner’s .STL files, so I can easily see where the teeth are and where I want the final prosthesis to be. When planning with the end result in mind, the clinician can make a treatment plan with greater confidence and success. The .STL files are also used to fabricate a surgical guide for atraumatic surgery and to ensure implants are placed in the perfect position.

The restoration Once healing has taken place, there are several restoration options for single-tooth implants. A stock abutment allows the clinician to select the abutment chairside after measuring tissue height and checking for occlusal clearance. Then the abutment can be torqued into place and can be treated like a crown-and-bridge impression. Taking a fixture level impression allows a more “hands-off” approach for implant transfer. Using either a closed or open tray, the impression can be sent to the lab for the technician and clinician to select a custom titanium or zirconia abutment and fabricate the crown. Another option is to use a screw-retained restoration using a Ti-base abutment. The third, and in my opinion the most ideal, option is to place a scan body and capture a digital impression with the intraoral scanner. The data sets from the scan gives the clinician the ability to customize the abutment, which leads to more options for restorations — screw-retained restorations, customized abutment, and a cementretained crown, etc.

The patient I have found that implant patients tend to be the most satisfied patients, and the more implants I place, the more implants I place; i.e., happy implant patients spread the word. In fact, I recently had a patient who came to me on two different occasions for single implants in two different areas. First, the 71-year-old male patient presented for treatment with pain in the Volume 10 Number 5


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TECHNIQUE

Figure 1

lower right quadrant. A thorough clinical exam was conducted, and a PA and CBCT scan were taken (Figures 1-2). The diagnosis was a fractured root of the lower right first premolar. Options were discussed with the patient, including root canal, buildup; crown lengthening and crown; or extraction and single-tooth implant placement with abutment and crown. The patient previously had implants, showed a high dental IQ, and preferred implant treatment as the solution. Using the CS 3600, a digital impression was created so that .STL files could be merged with the CBCT DICOM files for implant planning and fabrication of a surgical guide by a third-party lab. Once the surgical guide was returned from the lab, an OsteoReady performance implant 11.5 x 5.0 was placed (OsteoReadyÂŽ Practical Implant Solutions, Concord, Massachusetts) and a PA was taken to confirm proper placement (Figure 3) and confirmation of seated healing abutment. The OsteoReady System was chosen because it is a high-quality simple system with flexible restorative options. After healing for 3 months, the abutment was removed (Figures 4-5), and the area was scanned with the CS 3600. Next, a scan body was placed (Figure 6) and a second digital impression taken. With these digital impressions, a custom abutment and crown were created from the printed model, and the restoration was successfully placed (Figures 7-10). When the patient was later experiencing pain in the upper left quadrant, he returned

Figure 2

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16 Implant practice

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TECHNIQUE

Figure 10

Figure 11

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Figure 15 18 Implant practice

Figure 16

for consultation. The reliability of digital technology and the accuracy of surgical guides allowed me to take a very similar approach as the first implant. Radiographs were taken with a Carestream Dental RVG intraoral sensor (Figure 11). Tooth No. 13 was fractured and non-restorable. The patient opted to extract the tooth and go with a single-tooth implant. Tooth No. 13 was extracted, thoroughly curetted, and grafted with freeze-dried allograft (BaseBone™, Concord, Massachusetts) (Figure 12). After 3 months of healing, a CBCT scan (Figure 13) was taken with the CS 9300C and merged with a digital impression from the CS 3600 intraoral scanner, and a surgical guide was fabricated by Implant Concierge™ (Figure 14). In this case, a 4.2 mm x 13 mm performance implant (OsteoReady® Practical Implant Solutions, Concord, Massachusetts) was placed (Figures 15 and 16). The implant had good primary stability, and it was decided to place a healing abutment to complete the first-stage surgery. Volume 10 Number 5


TECHNIQUE

Figure 17

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After 3 months of osseointegration, the healing abutment was scanned with the CS 3600 (Figures 17 and 18) and then removed (Figure 19) and a scan body placed (Figure 20). A PA was taken to verify seating (Figure 21). The scan body was scanned with the CS 3600 (Figure 22). For educational purposes, three restorations were fabricated by Watson Dental Lab, Austin, Texas, to show the restorative options for the single-tooth implant — stock abutment (Figure 23), custom abutment (Figure 24), and screw-retained Ti-base abutment (Figure 25) — before seating the final restoration (Figures 26-29).

Figure 27

The results

Figure 28 Volume 10 Number 5

Figure 29

A digital workflow allows me to offer patients everything they need from implant to restoration in one practice. A “full package” of digital 3D technology also lets me make a diagnosis, place implants, and restore teeth with confidence. Perhaps more than a naturallooking tooth, that’s what patients want most from their doctor — confidence to handle their case with the care it deserves. IP Implant practice 19


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A review of the AAP’s best evidence consensus on “The Use of CBCT in the Management of the Patient Requiring Dental Implants” Drs. Bradley S. McAllister, V. Thomas Eshraghi, and Hector F. Rios discuss the implant application of CBCT technology as reported in the consensus Abstract The October 2017 issue of the Journal of Periodontology includes the findings of an American Academy of Periodontology (AAP) best evidence consensus (BEC) meeting on cone beam computed tomography (CBCT) that was held in early 2017.1-4 The consensus meeting sought to answer three important clinical questions on the use of CBCT technology: 1. How is CBCT used in the management of the patient requiring dental implants? 2. When is CBCT imaging appropriate for diagnostic inquiry in the management of inflammatory periodontitis? 3. How is CBCT used in risk assessment of the dentofacial bone changes influenced by tooth movement (interdisciplinary periodontics/ orthodontics)? The purpose of this article is to give a brief overview of “Best Evidence Consensus on Cone Beam Computed Tomography: The Use of CBCT in the Management of the Patient Requiring Dental Implants,”1 which focuses on the consensus findings on the implant application of CBCT technology.

Educational aims and objectives

This article aims to explain “Best Evidence Consensus on Cone Beam Computed Tomography: The Use of CBCT in the Management of the Patient Requiring Dental Implants,” which focuses on the consensus findings on the implant application of CBCT technology.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 27 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Identify how CBCT is used in the management of the patient requiring dental implants.

Understand how CBCT technology can be used for guided implant surgery.

Realize the benefits of CBCT for anatomical characterization.

Realize how CBCT affects diagnosis and treatment outcome assessments.

Introduction With the BEC meetings, the AAP sought to develop a new conference model for emerging fields, such as CBCT, which enjoy widespread use but may not have sufficient research to create a traditional evidencebased review. Specific clinically relevant questions were developed, reviews were written, and then a panel of experts reviewed the findings and added expert opinion to help guide the clinician on use of CBCT technology. While implant reconstructions are clearly one of the largest applications for

Bradley S. McAllister, DDS, PhD, obtained his doctorate of dental surgery at the University of Washington. He then attended the University of Texas Health Science Center at San Antonio where he completed his residency in periodontics and earned his PhD. His ongoing research has been focused on techniques to improve surgical wound healing with growth factors and stem cell therapy. For more than 20 years, he’s practiced periodontology in Portland, Oregon, and currently serves as faculty in Oregon Health and Science University’s Department of Periodontology. Dr. McAllister serves on the American Academy of Periodontology scientific oversight committee and is chair of its Best Evidence Consensus advisory working group V. Thomas Eshraghi, DMD, completed both his periodontal specialty training and dental school at the Oregon Health and Science University. As an assistant professor, he also trains residents in Oregon Health and Science University’s periodontics graduate program. His active research is in the area of stem cell technology. Dr. Eshraghi actively lectures on periodontics, implantology and the incorporation of advanced digital technologies in the treatment of periodontal disease. Hector F. Rios, DDS, PhD, is an adjunct clinical associate professor in the Department of Periodontics and Oral Medicine at the University of Michigan. Dr. Rios received his dental degree at the University of Valle, Cali-Colombia. He completed his periodontics residency at the University of Michigan and earned an interdisciplinary PhD in oral biology and molecular biology at the University of Missouri-Kansas City. He is a Diplomate of American Board of Periodontology and maintains a private practice limited to periodontics and dental implants in Holland, Michigan. Disclosure: Dr. McAllister is one of Carestream Dental’s key opinion leaders.

22 Implant practice

CBCT technology, many other specialists have found the modality to be a critical part of their armamentarium. In fact, other professional societies have addressed specific scenarios regarding when their members should consider using CBCT. In 2015, the original 2010 joint position statement from the American Association of Endodontists (AAE) and the American Academy of Oral and Maxillofacial Radiology (AAOMR) was updated to include recommendations for when limited field of view CBCT “should be considered the imaging modality of choice” during diagnosis, initial treatment, retreatment (nonsurgical and surgical), and special conditions.5 In 2016, their statement was revised once again with an additional recommendation regarding CBCT, stating: “In the absence of signs and symptoms, if limited FOV CBCT was the imaging modality of choice at the time of evaluation and treatment, it may be the modality of choice for follow-up evaluation.”5 With the many different applications for CBCT technology within periodontology6 and the rapid expansion of CBCT use across all dental specialties, it is clear why the AAP’s best evidence consensus is so important. Implementation, use and support of CBCT in the field have led to many studies on its effectiveness. The AAP best evidence consensus Volume 10 Number 5


CBCT for diagnosis and treatment outcome assessments The studies reviewed for this section examined the effectiveness of CBCT for diagnosis before and after implant therapy. In these studies, CBCT was used to evaluate the site of the future implant before placement to identify unusual pathologies and to confirm bone quality, quantity, and proximity to vital anatomy (Figures 1-4). “Treatment outcome assessments” refers to the use of CBCT after treatment to evaluate the success and overall quality of the implant placement. Pathology/incidental findings Due to the high frequency of incidental findings outside of the initial purpose of the CBCT scan, studies in this category stressed the importance of scans being thoroughly reviewed within and beyond the area of interest. Common incidental findings include osseous or sinus pathology, intracranial or vascular calcifications, and airway asymmetry, to name just a few. One study found airway narrowing and asymmetry to be the most common incidental finding at 35%, with dental developmental anomalies and other pathology being the least common (0.7% and 0.1%, respectively).7 Of these incidental findings, 16.1% required intervention, and 15.6% required monitoring.7 The studies confirmed that based on the high volume of incidental findings — greater than 90%, many agreed — CBCT scans should be carefully reviewed by someone proficient in the field of CBCT analysis.7-12 Peri-implantitis/implant fate A current topic of research is whether CBCT could be used more effectively than 2D radiographic imaging methods to evaluate implant health and whether that evaluation could affect treatment outcomes. Monitoring the bone and tissue condition around dental Volume 10 Number 5

Note: All CBCT scans were captured with a CS 9300 system (Carestream Dental)

Figure 1: This CBCT rendering taken with a CS 9300 demonstrates the significant bone destruction on teeth Nos. 29 and 30, helping the clinician determine the treatment plan and best flap design for treatment

implants is essential not only during followup evaluation under functional loading, but also during the assessment of strategies for regenerating lost peri-implant bone. Using specific strict imaging protocols, periapical radiographs can assess mesial and distal peri-implant bone levels under the right conditions.12 Other studies found benefits to using CBCT, such as reducing scattering artifacts, when compared to medical CT.14 While CBCT is a useful diagnostic tool for evaluating advanced peri-implantitis defects in some cases, most studies confirmed that PAs remain an effective method for measuring bone loss. Alveolar ridge dimensional changes Studies in this category confirmed that CBCT evaluation contributes to a better understanding of tissue biology and other changes to bone structure that occur after tooth extraction or bone grafting. Immediate implant placement, ridge preservation, volume stability during advanced grafting procedures of the maxillary sinus, and regenerative outcomes after flapless procedures are just a few of the treatments that benefit when CBCT is used to properly treatment plan the case. Artifacts No matter which imaging modality is used, the metallic nature of implants causes artifacts and interference that makes diagnosis difficult, with noise and beam-hardening being the most common issue for CBCT. Studies in this category concluded that advanced imaging software algorithms are required to decrease the implant-related beam-hardening artifacts on CBCT scans.14

Figure 2: The CBCT cross-sectional slice from the case in Figure 1 shows the buccal bone loss, intact lingual plate, and exactly where the inferior alveolar nerve resides in relation to the tooth

Figures 3 and 4: 3. In this preoperative CBCT image, taken of fractured tooth No. 28, the image shows the absence of a buccal plate, the significant lingual undercut, and it identifies the inferior alveolar nerve allowing for accurate treatment planning of a challenging immediate implant case. 4. In this postoperative CBCT image of the completed immediate implant case shown in Figure 3, the buccal bone graft can be identified, and the appropriate implant proximity to the inferior alveolar nerve can be accurately verified

Research on reducing artifacts caused by implants is ongoing.

CBCT for implant treatment planning Many studies focus on the different ways CBCT technology can be used for treatment planning. Both guided implant surgery and full navigational surgery have received a considerable amount of research validating their use. Guided implant surgery CBCT-driven implant treatment planning for guided implant surgery cannot be accomplished without third-party software. Importing DICOM files into third-party software for virtual planning and simulation before fabricating a restrictive surgical guide is an increasingly common form of CBCT-aided implant treatment planning. Virtual planning aids in determining the ideal location and angulation of the implant and allows clinicians Implant practice 23

CONTINUING EDUCATION

on implants nicely takes into consideration this new research in order to give an overview of the different ways CBCT currently applies to implant dentistry. Rios and colleagues found 559 reports when searching CBCT/ Implant PubMed publications for the past 16 years.1 Of these, 161 were determined to be relevant to the purpose of their CBCT implant review. From that existing research, three distinct areas were identified where CBCT could be used in regard to implant dentistry: • CBCT for diagnosis and treatment outcome assessments • CBCT for use during treatment planning • CBCT for anatomical characterization


CONTINUING EDUCATION to sometimes take a flapless approach. More and more, CBCT data is being paired with optical imaging data from intraoral scanners and combined with CAD/CAM technology to simultaneously plan the implant and the final restoration. This merger of data sets is an evolving technology that has been found to have great precision (Figure 5). Surgical navigation systems are taking the CBCT-aided guided surgery to a new level. While the accuracy of this kind of surgery has been tested and looks promising, further research is needed. In comparison to both passive and active use of CBCT in preparation for surgery, studies found that freehand surgery was significantly less accurate.16 Accuracy of measurements In regards to treatment planning, CBCT is seen to be particularly useful in measuring the height and width of the alveolar ridge. Measurements of bone quantity in the maxilla and mandible taken from a CBCT scan have also been found to be reliable.

Angular accuracy: Studies in this subcategory evaluated angular deviation after virtually planned surgery by comparing the virtual angle to the actual angle of the final implant. It was found there is less deviation when performing virtually planned surgery than compared to freehand surgery.16 Another study found that even less deviation exists between the virtual and the final angle of the implant when restrictive dental drill guides are used during surgery. Linear accuracy: Linear measurements are more accurate when obtained with CBCT than 2D radiographs. Additionally, there is no significant difference in the linear measurements when using different field of views. Finally, studies in this sub-category found metallic artifacts don’t affect the accuracy of linear measurements taken with CBCT.16

CBCT for anatomical characterization CBCT gives clinicians high-resolution, three-dimensional views of ridge topography and the location of critical anatomy to

Figure 5: In this case, the DICOM data from the CS 9300 (tan) was merged with the .STL file generated from the CS 3600 intraoral scanner (red). Virtual crowns were created, and the implants were virtually placed as shown for fabrication of a restrictive tooth-borne surgical guide to allow for guided implant surgery to be performed

Figure 8: This CBCT rendering shows the vertical fracture on tooth No. 29 with no buccal plate remaining and limited space to the mental foramen 24 Implant practice

determine if advanced grafting procedures will be needed at the implant site (Figures 6-7). It’s been well established that 3D is superior to 2D imaging in this regard. CBCT studies on some of the relevant anatomy typically assessed during implant planning have been summarized below. Neurovascular canal and foramina CBCT can help clinicians avoid serious issues by clearly indentifying vital nerves and other anatomical structures that could be affected during implant surgery. Crosssectional imaging makes it easier to identify neurovascular anatomical structures, such as the inferior alveolar nerve and the mental foramen (Figures 8-9), to name just a few. Manuscripts on nerve identification software reveal that imaging technology is under development that could be used to automatically identify the mandibular canal.18 CBCT imaging has also been found to be useful in locating large blood vessels in the lateral wall of the maxillary sinus, which can allow for improved

Figures 6 and 7: 6. This CBCT scan of the posterior mandible shows the location of the mental foramen as well as how the region has limited vertical and horizontal bone. Bone grafting was performed with titanium mesh and a cellular allograft as shown in Figure 7. 7. This CS 9300 CBCT system rendering shows the postoperative result following bone grafting of the case shown in Figure 6

Figure 9: This CBCT-derived cross-sectional image of the case from Figure 8 clearly shows the mental foramen and how much bone is available to engage the planned immediate implant with substantial bone grafting

Figure 10: This CBCT-derived cross-sectional image of the maxillary sinus shows a large blood vessel in close proximity to the proposed lateral window location. The window was placed inferior to the blood vessel to avoid bleeding and maintain ideal vascularization to the area during healing Volume 10 Number 5


CONTINUING EDUCATION

Figure 12: The preoperative clinical view of the case in Figure 11, showing a high smile line

Figure 11: This 2D radiograph of failed tooth No. 9 does not give much information to aid the surgeon in deciding on the flap design and determining if this case would be an appropriate case for an immediate implant with bone grafting and a provisional crown

Figure 13: The CBCT scan shows much more information than the 2D radiograph — the significant periapical pathology and limited buccal plate. With this much destruction, a papillapreserving flap was elevated to allow for complete defect degranulation and aggressive bone grafting

Figure 14: This clinical view shows the defect degranulated, the implant in place prior to bone graft placement, and provisional crown placement

Figure 15: This CBCT-generated cross-sectional slice view was taken after 4 months of healing, just prior to the final restoration. The image shows the regenerated buccal bone exceeds 2 mm in dimension Figure 17: This clinical view shows the final clinical result of the implant restored. Restorative procedures were completed by Thomas Orazio, DMD, utilizing Davis Dental Lab

window location during sinus augmentation procedures (Figure 10). During surgery, only 10% of “adverse events” occurred when preoperative CBCT images of the aforementioned anatomy had been taken, though that number jumped to 30%-50% when using other imaging modalities.19

Figure 16: This CBCT-generated axial slice view taken after 4 months of healing shows the ideal position of the implant shown in Figures 11-17. The implant is ideally placed relative to the adjacent teeth and the nasopalatine canal, with the ideal 2 mm of buccal bone for gingival stability Volume 10 Number 5

Buccal/lingual bone The thin facial bone plate on teeth is prone to resorption following extraction, which makes accurate measurements of the buccal and lingual plate vital prior to

implant surgery (Figures 11-17). Studies have found CBCT imaging to be reliable in this area, and in fact, it is the only noninvasive means to evaluate the buccal and lingual plate.20 It should be noted that due to implant-related artifacts, CBCT accuracy in measuring the buccal plate tends to decrease during post-implant assessment of the buccal plate. However, studies have shown there are only minimal differences between CBCT measurements and histological measurements indicating that CBCT can be relied upon to provide useful Implant practice 25


CONTINUING EDUCATION

Figures 19 and 20: 19. This cross-sectional CBCT slice shows the extent of the cyst. 20. This cross-sectional CBCT slice verifies the elimination of the cyst following a small procedure performed 8 weeks prior to the sinus augmentation procedure Figure 18: This preoperative CBCT panoramic image shows a mucous retention cyst in the maxillary sinus. Due to the large size of the cyst, sinus grafting is contraindicated until the cyst is treated

measurements of bone levels on the buccal and lingual of implants.21 Maxillary sinus CBCT assessment of the maxillary sinuses prior to placing implants in the posterior maxilla has proven accurate in revealing anatomical and pathological variations. Particularly in regards to pre-sinus augmentation evaluation, studies confirm that CBCT is “significantly more reliable than panoramic imaging in detecting pathology and anatomic challenges”22 (Figures 18-21). Bone density CBCT’s use for evaluating bone density is an increasing area of interest. Due to the technology that powers the modality — acquisition algorithms, reconstruction of data sets, etc. — Hounsfield units and linear attenuation coefficients are not as easy to calculate with CBCT as medical CT. As of now, only relative bone quality can be assessed using CBCT. However, efforts are currently underway to standardize imaging variables to confirm the reliability of bone density measurements taken with CBCT. In the meantime, studies show that quantitative CBCT (QCBCT) may serve as an alternative tool for evaluating bone density prior to surgery.23

Conclusion The consensus concludes: “CBCT is a useful and widely available tool in implant dentistry that has the potential to improve today’s standard of care.” The valuable 3D views CBCT provides can significantly change the course of treatment. Additionally, new imaging software is rapidly enhancing the use of CBCT, making it more intuitive and 26 Implant practice

a better tool for virtual treatment planning. As an added benefit, the digital file format of CBCT scans is easily transferable when working with referrals. Research is ongoing in implant dentistry to demonstrate the value of CBCT, though it’s irrefutable that 3D imaging is supplanting traditional radiographic methods. The wealth of literature evaluated and the expert opinion generated during the BEC meeting will allow the AAP to continue to provide guidance for its members on CBCT use. This has been a brief review of some of the key findings from the conference, and the full consensus publications are now available in the Journal of Periodontology. These papers should be considered a must-read for those involved in implant dentistry and for all clinicians using CBCT technology. IP

REFERENCES 1. Rios HF, Borgnakke WS, Benavides E. The use of conebeam computed tomography in the management of the patient requiring dental implants: An American Academy of Periodontology best-evidence review. J Periodontol. 2017;88:946-959. 2. Kim DM, Bassir SH. When is cone-beam computed tomography imaging appropriate for diagnostic inquiry in the management of inflammatory periodontitis? An American Academy of Periodontology best-evidence review. J Periodontol. 2017;88:978-998. 3. Mandelaris GA, Neiva R, Chambrone L. Cone-beam computed tomography and interdisciplinary dentofacial therapy: An American Academy of Periodontology bestevidence review focusing on risk assessment of the dentoalveolar bone changes influenced by tooth movement. J Periodontol. 2017;88:960-977. 4. Mandelaris GA, Scheyer ET, Evans M, Kim DM, McAllister B, Nevins ML, Rios HF, Sarment D. American Academy of Periodontology’s best-evidence consensus statement on selected oral applications for cone-beam computed tomography. J Periodontol. 2017;88:939-945. 5. American Association of Endodontics and American Academy of Oral and Maxillofacial Radiology. AAE and AAOMR Joint Position Statement. Use of Cone Beam Computed Tomography in Endodontics 2015 Update. 2016; Special Committee to Revise the AAE/AAOMR Joint Position Statement on Cone Beam Computed Tomography. https://www.aae.org/uploadedfiles/clinical_resources/guidelines_and_position_statements/ cbctstatement_2015update.pdf. 6. Eshraghi T, McAllister N, McAllister B. Clinical applications of digital 2-D and 3-D radiography for the periodontist. J Evid Base Dent Pract. 2012;12(suppl 3):36-45 7. Price JB, Thaw KL, Tyndall DA, Ludlow JB, Padilla RJ. Incidental findings from cone beam computed tomography

Figure 21: This preoperative CBCT generated axial slice view shows multiple septa in the maxillary sinus, which will significantly complicate the sinus augmentation procedure

of the maxillofacial region: a descriptive retrospective study. Clin Oral Implants Res. 2012;23(11):1261-1268. 8. Mandian M, Tadinada A. Incidental findings in the neck region of dental implant patients: a comparison between panoramic radiography and CBCT. J Mass Dent Soc. 2014;63(2):42-45. 9. Kaeppler G, Mast M. Indications for cone-beam computed tomography in the area of oral and maxillofacial surgery. Int J Comput Dent. 2012;15(4):271-286. 10. Pette GA, Norkin FJ, Ganeles J, et al. Incidental findings from a retrospective study of 318 cone beam computed tomography consultation reports. Int J Oral Maxillofac Implants. 2012;27(3):595-603. 11. Barghan S, Tetradis S, Nervina JM. Skeletal and softtissue incidental findings on cone-beam computed tomography images. Am J Orthod Dentofacial Orthop. 2013;143(6):888-892. 12. Allareddy V, Vincent SD, Hellstein JW, Qian F, Smoker WR, Ruprecht A. Incidental findings on cone beam computed tomography images. Int J Dent. 2012;2012:871532. doi: 10.1155/2012/871532. 13. Malloy K, Wadhwani C, McAllister B, Wang M, Katancik J. Accuracy and reproducibility of radiographic images for assessing crestal bone height of implants using the precision implant X-ray locator (PIXRL) device. Int J Oral Maxillofac Implants. 2017;32(4):830-836. 14. Naitoh M, Nabeshima H, Hayashi H, et al. Postoperative assessment of incisor dental implants using cone-beam computed tomography. J Oral Implantol. 2010;36(5):377-384. 15. Pauwels R, Stamatakis H, Bosmans H, et al. Quantification of metal artifacts on cone beam computed tomography images. Clin Oral Implants Res 2013;24 (suppl A 100):94-99. 16. Vermeulen J. The accuracy of implant placement by experienced surgeons: guided vs freehand approach in a simulated plastic model. Int J Oral Maxillofac Implants. 2017;32(3):617-624. 17. Cremonini CC, Dumas M, Pannuti CM, Neto JB, Cavalcanti MG, Lima LA.. Assessment of linear measurements of bone for implant sites in the presence of metallic artifacts using cone beam computed tomography and multislice computed tomography. Int J Oral Maxillofac Surg. 2011;40(8):845-850. 18. Abdolali F, Zoroofi RA, Abdolali M, Yokota F, Otake Y, Sato Y. Automatic segmentation of mandibular canal in cone beam CT images using conditional statistical shape model and fast marching. Int J Comput Assist Radiol Surg. 2017;12:581-593. 19. Benavides E, Rios HF, Ganz SD, et al. Use of cone beam computed tomography in implant dentistry: the International Congress of Oral Implantologists consensus report. Implant Dent. 2012;21(2):78-86. 20. Miyamoto Y, et al. Analyses of PO Buccal Bone Thickness in Maxillary Anterior Implants. J Perio Rest Dent. CTBC  21. Huang Y, Van Dessel J, Depypere M, et al. Validating cone-beam computed tomography for peri-implant bone morphometric analysis. Bone Res. 2014;2:14010. 22. Tadinada A, Jalali E, Al-Salman W, Jambhekar S, Katechia B, Almas K. Prevalence of bony septa, antral pathology, and dimensions of the maxillary sinus from a sinus augmentation perspective: a retrospective cone-beam computed tomography study. Imaging Sci Dent. 2016;46(2):109-115. 23. Aranyarachkul P, Caruso J, Gantes B, et al. Bone density assessments of dental implant sites; 2. quantitative conebeam computerized tomography. Int J Oral Maxillofac Implants. 2005;20(3):416-424.

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A review of the AAP’s best evidence consensus on “The Use of CBCT in the Management of the Patient Requiring Dental Implants” MCALLISTER, ET AL.

Consecutive treatment failures of an immediate maxillary canine implant and the subsequent replacement and reconstruction of the site GLUCKMAN/DU TOIT

1.

1.

Restorative implant treatment is among the more advanced options, and yet it is ______ for the patient. a. highly predictable b. potentially very rewarding c. very unpredictable d. both a and b

2.

(After the implant removal phase) After _______ of healing, the edentulous site was reapproached and treatment planned from the start. a. 4 weeks b. 8 weeks c. 12 weeks d. 16 weeks

3.

(Treatment planning for the new implant) This included among many others a thorough clinical exam, periodontal examination, a holistic documentation of all pathologies and treatment needs, concise photographic documentation, study casts, restorative mock-up, and special investigative adjuncts, including _______. a. 2D film radiographs b. intraoral photos c. transillumination d. CBCT

4.

(After the new implant was placed) After _____ of healing, the implant was exposed, and its implant stability quotient (ISQ) checked — 78D 75M 75B. a. 4 weeks b. 12 weeks c. 16 weeks d. 18 weeks

2.

3.

4.

5.

Monitoring ______ around dental implants is essential not only during follow-up evaluation under functional loading, but also during the assessment of strategies for regenerating lost peri-implant bone. a. bone condition b. tissue condition c. the need for orthodontics d. both a and b

6.

Using specific strict imaging protocols, ____ can assess mesial and distal peri-implant bone levels under the right conditions. a. periapical radiographs b. bite wing radiographs c. tomograms d. panograms

7.

Immediate implant placement, ____ are just a few of the treatments that benefit when CBCT is used to properly treatment plan the case. a. ridge preservation b. volume stability during advanced grafting procedures of the maxillary sinus c. regenerative outcomes after flapless procedures d. all of the above Importing _______ into third-party software for virtual planning and simulation before fabricating a restrictive surgical guide is an increasingly common form of CBCT-aided implant treatment planning. a. traditional film negatives b. DICOM files c. CAM files d. CAD files In regards to treatment planning, CBCT is seen to be particularly useful in measuring ______. a. the height of the alveolar ridge b. the width of the alveolar ridge c. periodontal pockets d. both a and b

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8.

9.

Linear measurements _________. a. are equally as accurate when obtained with CBCT than 2D radiographs b. are less accurate when obtained with CBCT than 2D radiographs c. are more accurate when obtained with CBCT than 2D radiographs d. are more difficult to obtain with CBCT than with 2D radiographs During surgery, only 10% of “adverse events” occurred when preoperative CBCT images of the aforementioned anatomy had been taken, though that number jumped to ______ when using other imaging modalities. a. 12%-15% b. 20%- 24% c. 25%-28% d. 30%-50% The thin facial bone plate on teeth is prone to _______ following extraction, which makes accurate measurements of the buccal and lingual plate vital prior to implant surgery. a. infection b. resorption c. bleeding d. fracture Studies have found CBCT imaging to be reliable in this area, and in fact, it is _______ to evaluate the buccal and lingual plate. a. the only noninvasive means b. among several noninvasive means c. one of the few noninvasive means d. none of the above

10. Particularly in regards to pre-sinus augmentation evaluation, studies confirm that CBCT is “______ than panoramic imaging in detecting pathology and anatomic challenges.” a. significantly more reliable b. less reliable c. equally as reliable d. clearer

5.

A connective tissue graft (CTG) was harvested from the ______ and transferred into the pouch, sutured in position, thereby augmenting the soft tissue buccal and coronal to the site. a. cheek b. gum c. palate d. buccal vestibule

6.

At _______ of healing, a black triangle was evident where the distal papilla was absent. a. 2 weeks b. 4 weeks c. 6 weeks d. 8 weeks

7.

(After the first 4 weeks of healing) A further ______ of healing allowed time for soft tissue in-fill of the area. a. 4 weeks b. 8 weeks c. 12 weeks d. 16 weeks

8.

The foundation (of a correct approach and healthcare fundamentals) thereof is _______, a review of the patient’s risk factors — all to derive accurate diagnoses. a. a comprehensive patient history b. a thorough clinical examination c. the use of special adjunct investigations where necessary d. all of the above

9.

The value of a ______ in planning implant treatment cannot be overemphasized. a. full mouth series of 2D radiographs b. panoramic radiograph c. intraoral photograph d. CBCT scan

10. Literature does not necessitate CBCT as an absolute for every implant treatment case planned, but it is difficult to identify a planned implant, _______. a. identifying the best material for the graft b. verifying adequate bone circumferential to the implant c. locating anatomical structures of risk to orientate a correct restoratively planned placement positioning d. both b and c

Implant practice 27

CE CREDITS

IMPLANT PRACTICE CE


CONTINUING EDUCATION

Consecutive treatment failures of an immediate maxillary canine implant and the subsequent replacement and reconstruction of the site Drs. Howard Gluckman and Jonathan Du Toit demonstrate the difficulties of rectifying previous mistakes

T

he approach to treating an edentulous or partially edentulous jaw presents both clinician and patient with a clinical challenge addressed by several treatment options (Misch 2015). Restorative implant treatment is among the more advanced options, and yet it is highly predictable and potentially very rewarding for the patient. Fundamental principles, though, are to be adhered to (Moraschini, et al., 2015). Chief among these is thorough, concise, evidence-based treatment planning (Thajli 2016). The clinician is cautioned not to overlook the crucial importance thereof. All too often neglected are the most basic of examinations and thorough history taking. The reader may challenge himself/herself and ask, “When last did I carry out a standard, full mouth periodontal examination to identify any periodontal disease that requires treatment before embarking on implant therapy?” (Cho-Yan, et al., 2012) Thorough implant treatment planning almost always necessitates the use of special investigations and additional diagnostic aids. While costly, the value of a cone-beam computed tomography (CBCT) scan to visualize the edentulous ridge or site in its three-dimensional aspects cannot be stressed enough (Du Toit, et al., 2015). The treating clinician is to be cognizant of the recommended tissue parameters needed to support the dental implant and its restoration. The clinician is required to diagnose the need to augment these (Levine, et al., 2014; Puisys and Linkevicius 2015; Urban, et al., 2009). The previously mentioned by no means addresses the entirety of the possible implant Howard Gluckman, BDS, MChD (OMP) — a specialist in periodontics and oral medicine, is director of the Implant and Aesthetic Academy, Cape Town, South Africa. Jonathan Du Toit, BChD, Dipl Implantol, Dip Oral Surg, MSc Dent, works in the department of Periodontics and Oral Medicine at the School of Dentistry, Faculty of Health Sciences, University of Pretoria, South Africa.

28 Implant practice

Educational aims and objectives

This article aims to describe the management of a failing implant case.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 27 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Demonstrate recognition of treatment planning and managing complications.

Realize the importance of CBCT in implant treatment planning.

Realize the need for health care fundamentals in diagnostics before implant planning.

Recognize the importance of soft tissue augmentation that in turn supports healthy bone at the implant in certain cases.

Recognize the importance of knowledge of anatomy, biology, and prosthodontics as well as implant hardware during implant planning and implementation.

Figure 1: The preoperative presentation

Figure 2: A draining sinus was noted buccal to the implant crown at UR3

treatment planning aspects. However, the main shortcomings are highlighted, drawing attention to the case presented here and what led to the treatment failure.

inserted at the site. The implant developed an infection and was removed. A second implant was placed at the time of the first’s removal. This implant also became infected and was subsequently removed. The patient then saw a different practitioner who placed a third implant and restored it after a period of healing. Subsequent to the chronic draining sinus buccal to the implant, the patient was advised by his general dentist to seek a third opinion. Clinical examination of the patient noted a screw-retained, implant-supported crown at the UR3. Circumferential probing of the implant exceeded 15 mm, with bleeding upon probing, and exudate draining from a sinus midfacial at the implant site (Figures 1 and 2). CBCT examination noted a custom abutment that extended about 8 mm-10 mm

Case report A 21-year-old male presented with the main complaint of a persistent infection around an implant that had been placed about 1 year prior. The patient was a nonsmoker, healthy, with a clear medical history and currently not taking any chronic medication. According to the patient’s history, the infection had persisted, and the practitioner who placed the implant advised the patient that the situation was not a problem. The patient’s history entailed a retained deciduous canine with a congenitally missing tooth at UR3. The deciduous tooth was removed, and an immediate implant was

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restoration, allowing for a period of healing and resolution of infection, and a reassessment of the site’s treatment needs. The site was anesthetized, and a full-thickness flap was raised over the implant at UR3, exposing soft-tissue encapsulation of the abutment extending to the apices of the adjacent teeth (Figure 4). The pathologic soft tissue was removed to send for histological examination, and the extent of the bony destruction at the area was exposed (Figure 5). Bone appeared eroded at the surfaces proximal to the implant. The buccal bone had a large defect, yet the palatal bone remained coronal. The prosthesis and restoration were torqued and fractured from the implant, and thereafter, the implant torqued out (Figures

Figure 3: Preoperative CBCT showed a dental implant with about half the body inserted into the nasal cavity, a root remnant buccal, and an angled abutment as long as the implant fixed to a crown restoration

6-8). The root fragment was also located and removed, the area meticulously debrided, and copiously rinsed with saline. Platelet-rich fibrin (PRF) membranes were placed within the defect, and the site sutured closed with 6/0 nylon. After 8 weeks of healing, the edentulous site was reapproached and treatment planned from the start. This included among many others a thorough clinical exam, periodontal examination, a holistic documentation of all pathologies and treatment needs, concise photographic documentation, study casts, restorative mock-up, and special investigative adjuncts, including CBCT. The diagnostic list for the patient included a Class I malocclusion, recession

Figure 4: Full-thickness flap exposure of the site revealed an extensive buccofacial bony defect and soft tissue encapsulation of the implant abutment

Figure 5: Removal of the pathological soft tissue revealed the extent of the bony destruction

Figure 6: The abutment was torqued to fracture, revealing an external hex connection implant

Figure 7: The infective tissue at the implant and root remnant

Figure 8: After removal, the restoration and abutment to implant ratio could be appreciated

Figure 9: After initial healing of the site. Note the mesial of tooth 14 that was cut away. And the horizontal defect, as well as the extensive scarring is evident

Figure 10: Tooth UR4 was restored. Occlusal view accentuates the buccal defect

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in length, screw-retained to an external connection implant. The implant-abutment interface was positioned at approximately as deep as the root apices of the adjacent teeth with about half the implant body penetrating into the nasal cavity (Figure 3). There was also evidence of a root fragment adjacent to the implant. The extended custom abutment supported a cementretained crown in the occlusal position. The UR4 had been reduced mesially to accommodate the implant crown. A detailed examination predicated the diagnosis of a severely malpositioned implant with a chronic peri-implantitis and unacceptable restoration. The treatment planning proposed removal of the implant and


CONTINUING EDUCATION

Figure 11: Re-entry at the site illustrated the extent of the horizontal defect

Figure 12: The radiographic-surgical guide in position and zenith of the pontic

Figure 13: Placement via the guide confirmed a restoratively planned implant

Restorative implant treatment is highly predictable and potentially very rewarding for the patient.

defects, a mild fluorosis, and a missing UR3. Diagnosing the healed, edentulous site at UR3 noted a significant ridge defect, both horizontal and vertical, with a deficit of both hard and soft tissues. The soft tissue already showed significant scarring, recession distal to UR2, and severe recession mesial to UR4 with complete loss of the papillae (Figures 9 and 10). There was insufficient attached, keratinized tissue at the UR4 with a Class IV recession defect. The treatment planning entailed a bone augmentation of the hard tissue defect, augmentation of the soft tissue deficit, and implant placement to restore with a screw-retained crown. The UR4 was first restored to re-establish a normal emergence profile and anatomy (Figure 10). CBCT and virtual implant planning indicated that implant placement in the restoratively correct three-dimensional positioning with simultaneous augmentation with an autogenous corticocancellous bone block was a viable option. After local anesthesia, a full-thickness flap was again raised at the site, and the implant osteotomy was prepared via a restoratively planned surgical guide (Figures 11 and 12). A morse taper conical internal connection implant, (3.5 mm x 10 mm NobelActiveŽ, Nobel BiocareŽ) was inserted at the correct restoratively planned level, 2 mm below the palatal crest (Figures 13 and 14). A corticocancellous bone block was then harvested from the left mandibular ramus and split into two block veneer grafts as per Khoury’s protocol (Figures 15 and 16). The blocks were thinned with a bone scraper 30 Implant practice

Figure 14: The implant fully inserted with an extensive buccal dehiscence that required augmentation

Figure 15: The ramus block sectioned into two thinner grafts

Figure 16: Harvesting of the ramus block

Figure 17: Bone shavings harvested by scraping and refining the block grafts

Figure 18: The blocks fixed to the bony ridge buccal to the implant

Figure 19: Buccal view of the bone blocks fixed in place

Figure 20: The harvested autogenous bone shavings were packed beneath and around the blocks. Volume 10 Number 5


Figure 21: PRF membranes were layered atop the completed bone augmentation

Figure 22: Site closure with 6/0 nylon sutures

Figure 24: 12 weeks of healing

Figure 26: ISQ readings indicated high stability, positively confirming osseointegration Volume 10 Number 5

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(SafeScraper, Geistlich) further harvesting autogenous bone shavings (Figure 17). The blocks were then secured to the ridge buccal to the implant with fixation screws and the bone shavings packed within the defect between the implant and blocks (Figures 18- 20). PRF membranes were layered over the bone augmentation and the tension-free flap repositioned and sutured with 6/0 nylon (Figures 21 and 22). The site was then restored with a provisional partial denture free of pressure to the underlying augmentation site. After 12 weeks of healing, the implant was exposed, and its implant stability quotient (ISQ) checked — 78D 75M 75B (Figures 23-26). The buccal soft tissue was undermined by a tunneling approach, creating a splitthickness envelope. A connective tissue graft (CTG) was harvested from the palate and transferred into the pouch, sutured in position, thereby augmenting the soft tissue buccal and coronal to the site (Figures 26-28).

Figure 23: Immediate postoperative periapical radiograph. This short, wide healing abutment is not ideal

Figure 25: CBCT scan showed the healed bone augmentation buccal to the implant 2.2 mm thick

Figure 27: The connective tissue graft (CTG) harvested from the palate positioned over the recipient site Implant practice 31


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Figure 28: The implant exposed with CTG inserted and sutured inside a split-thickness tunnel flap

Figure 29: 10-day follow-up with the provisional restoration in place. The soft tissue augmentation healing without complication

Figure 31: A further 8 weeks allowed for soft tissue maturation and infill of the distal interproximal space

Figure 30: Four-week follow-up, soft tissues healed, provisional in place, yet the absence of a distal papilla is obvious

Figure 32: The final screw-retained crown in place. Adequate bulk of tissue buccal to the implant restoration

The implant was then restored with a provisional restoration to begin developing the soft tissue profile. At 4 weeks of healing, a black triangle was evident where the distal papilla was absent. A further 8 weeks of healing allowed time for soft tissue in-fill of the area (Figures 28-31). At final restoration of the implant, a bulk of ridge tissue buccal to the implant could be noted, with near complete restitution of both mesial and distal papillae (Figure 32). Functional treatment goals were realized, and adequate esthetic rehabilitation of the previously failed treatment was achieved. The patient was satisfied, with the tissues and outcomes remaining stable at the 2-year recall (Figure 32).

Discussion

Figure 33: Two-year follow-up, tissues stable with adequate esthetic and functional results

It is likely that with the ever-increasing availability of implant treatment, a greater number of implant procedures will produce increasing implant failure data (Derks, et al., 2016; Tarnow 2016). Implant treatment has become commonplace in daily practice, yet the practitioner should never discount the importance of a correct approach and healthcare fundamentals (Kuchler and von Arx 2014; Tahmaseb, et

al., 2014; Bornstein, et al., 2014). The foundation thereof is a comprehensive patient history, thorough clinical examination, the use of special adjunct investigations where necessary, a review of the patient’s risk factors — all to derive accurate diagnoses (Levine, et al., 2014; Buser, et al., 2017). It is evident from the failed case presented here that these principles were not adhered

32 Implant practice

to. The site and its retained root were not diagnosed properly, and thus, the patient went through multiple and unnecessary procedures that ultimately required extensive reconstruction to rehabilitate the site. The ridge deficits were not diagnosed correctly, and the need for bone and soft tissue augmentations was not identified. The value of a CBCT scan in planning implant Volume 10 Number 5


Volume 10 Number 5

The failure presented here underpins the importance of basic and fundamental principles when approaching any treatment. the previous two implant treatment attempts should have been investigated. Moreover, the UR4 should not have been cut away to accommodate the implant restoration. Managing increased crown height space to implant ratio is acceptable and common at resorbed, post-extraction sites. But extending a customized abutment transgingivally to bring the crown into occlusion — as with this case — is not acceptable. The cantilever forces exerted in the failed treatment are not conducive to health (Anitua, et al., 2014). Moreover, the soft

REFERENCES 1. Anitua E, Alkhraist MH, Piñas L, Begoña L, Orive G. Implant survival and crestal bone loss around extra-short implants supporting a fixed denture: the effect of crown height space, crown-to-implant ratio, and offset placement of the prosthesis. Int J Oral Maxillofac Implants. 2014;29(3):682-689. 2. Bornstein MM, Scarfe WC, Vaughn VM, Jacobs R. Cone beam computed tomography in implant dentistry: a systematic review focusing on guidelines, indications, and radiation dose risks. Int J Oral Maxillofac Implants. 2014;29(suppl):55-77. 3. Bornstein MM, Al-Nawas B, Kuchler U, Tahmaseb A. Consensus statements and recommended clinical procedures regarding contemporary surgical and radiographic techniques in implant dentistry. Int J Oral Maxillofac Implants. 2014;29(suppl):78-82. 4. Buser D, Chappuis V, Belser UC, Chen S. Implant placement post extraction in esthetic single tooth sites: when immediate, when early, when late? Periodontol 2000. 2017;73(1):84-102. 5. Canullo L, Pellegrini G, Allievi C, Trombelli L, Annibali S, Dellavia C. Soft tissues around long-term platform switching implant restorations: a histological human evaluation. Preliminary results. J Clin Periodontal. 2011;38(1):86-94. 6. Cho-Yan LJ, Mattheos N, Nixon KC, Ivanovski S. Residual periodontal pockets are a risk indicator for peri-implantitis in patients treated for periodontitis. Clin Oral Implants Res. 2012;23(3):325-333. 7. Derks J, Schaller D, Håkansson J, Wennstrom JL, Tomasi C, Berglundh T. Effectiveness of Implant therapy analyzed in a Swedish population: prevalence of peri-implantitis. J Dental Res. 2016;95(1):43-49. 8. Du Toit J, Gluckman H, Gamil R, Renton T. Implant injury case series and review of the literature part 1: inferior alveolar nerve injury. J Oral Implantol. 2015;41(4):e144-e151. 9. Khoury F, Khoury CH. Mandibular bone block grafts: diagnosis, instrumentation, harvesting, techniques and surgical procedures. In: Khoury F, Antoun H, Missika P, Bessade J, eds. Bone Augmentation in Oral Implantology. London: Quintpub; 2007. 10. Kuchler U, von Arx T. Horizontal ridge augmentation in conjunction with or prior to implant placement in the anterior maxilla: a systematic review. Int J Oral Maxillofac Implants. 2014;29(suppl):14-24. 11. Harris D, Horner K, Gröndahl K, et al. EAO guidelines for the use of diagnostic imaging in implant dentistry 2011. A consensus workshop organized by the European

tissues when healed at the neck of an implant crown seek to establish a biological zone, commonly of long junctional epithelium with underlying connective tissue along the abutment (Linkevicius and Apse 2008). A tissue seal and attachment along the entirety of the failed abutment here was unlikely. As such, the long junctional epithelium may allow for bacterial plaque ingress and colonization along the length of the abutment that cannot be cleaned by the patient, resulting in the infective, granulation tissue seen at the implant’s removal (Canullo 2011).

Conclusion A lack of sound knowledge in implant dentistry and an attempt at a compromise resulted in a drastic failure that required several additional procedures to rehabilitate. The failure presented here underpins the importance of basic and fundamental principles when approaching any treatment. Proper examinations, diagnoses, and treatment planning that substantiate ethical treatment options are key to a successful treatment outcome. IP

Association for Osseointegration at the Medical University of Warsaw. Clin Oral Implants Res. 2012;23(11):1243-1253. 12. Levine RA, Huynh-Ba G, Cochran DL. Soft tissue augmentation procedures for mucogingival defects in esthetic sites. Int J Oral Maxillofac Implants. 2014;29(suppl):155-185. 13. Linkevicius T, Apse P. Biologic width around implants. An evidence-based review. Stomatologija. 2008;10(1):27-35. 14. Mazor Z, Lorean A, Mijiritsky E, Levin L. Nasal floor elevation combined with dental implant placement. Clin Implant Dentistry Related Res. 2012;14(5):768-771. 15. Misch CE. Single-Tooth implant restoration: maxillary anterior and posterior regions. In: Dental Implant Prosthetics. 2nd ed. St. Louis: Mosby; 2015. 16. Moraschini V, Poubel LA, Ferreira VF, Barboza Edos S. Evaluation of survival and success rates of dental implants reported in longitudinal studies with a follow-up period of at least 10 years: a systematic review. Int J Oral Maxillofac Implants. 2015;44(3):377-388. 17. Nunes LS, Bornstein MM, Sendi P, Buser D. Anatomical characteristics and dimensions of edentulous sites in the posterior maxillae of patients referred for implant therapy. Int J Periodontics Restorative Dent. 2013;33(3):337-345. 18. Puisys A, Linkevicius T. The influence of mucosal tissue thickening on crestal bone stability around bone-level implants. A prospective controlled clinical trial. Clin Oral Implants Res. 2015;26(2):123-129. 19. Sanz M, Donos N, Alcoforado G, et al. Therapeutic concepts and methods for improving dental implant outcomes. Summary and consensus statements. The 4th EAO Consensus Conference 2015. Clin Oral Implants Res. 2015;26(suppl 11):202-206. 20. Tahmaseb A, Wismeijer D, Coucke W, Derksen W. Computer technology applications in surgical implant dentistry: a systematic review. Int J Oral Maxillofac Implants. 2014;29(suppl):25-42. 21. Tarnow DP. Increasing Prevalence of peri-implantitis: How will we manage? J Dental Res. 2016;95(1):7-8. 22. Thalji G ATS Prosthodontic considerations in the implant restoration of the esthetic zone. In: Sadowsky S, ed. Evidence-based Implant Treatment Planning and Clinical Protocols. Iowa: John Wiley & Sons; 2016. 23. Urban IA, Jovanovic SA, Lozada JL. Vertical ridge augmentation using guided bone regeneration (GBR) in three clinical scenarios prior to implant placement: a retrospective study of 35 patients 12 to 72 months after loading. Int J Oral Maxillofac Implants. 2009;24(3):502-510.

Implant practice 33

CONTINUING EDUCATION

treatment cannot be overemphasized (Bornstein, et al., 2014; Bornstein, et al., 2014; Nunes, et al., 2013). Literature does not necessitate CBCT as an absolute for every implant treatment case planned, but it is difficult to identify a planned implant, verifying adequate bone circumferential to the implant, and to locate anatomical structures of risk to orientate a correct restoratively planned placement positioning (Buser, et al., 2017; Harris, et al., 2012). Sound knowledge of the principles of implant dentistry is essential when delivering such treatment to a patient, and the clinician is required to have a thorough understanding of anatomy, biology, and prosthodontics as well as implant hardware. Evident in the original failed treatment, knowledge of the minimum bone required to accommodate the implant inserted at the correct height and position to ensure longterm tissue stability was lacking (Levine, et al., 2014). Recognizing the need for a soft tissue augmentation that in turn supports healthy bone at the implant — which can be developed and sculpted to frame the implant restoration, potentially creating pseudopapillae, as with the revised rehabilitation presented here — was also lacking (Linkevicius and Apse 2008). The attempt at placing a non-internal conical connection implant, and attempting to restore at occlusal level via a highly unconventional customized abutment contributed to the failure. Compromising established, evidence-based, reliable procedures and opting for an alternative compromise introduce a debate for clinical innovation versus jeopardizing treatment. But in this case, the third implant placement and restorative approach were both indisputably unacceptable. It is accepted clinical practice to place an implant beyond the sinus or nasal floor cortex contained within an intact membrane and most often a bone augmentation when a vertical ridge deficiency presents in the maxilla (Mazor, et al., 2012; Sanz, et al., 2015). But entirely perforating into the nose and placing a large portion of the implant body unsupported by augmented bone is not clinically acceptable and does not contribute to the integration of the implant. Of greatest concern in the case presented here was the disregard for the principles of beneficence and non-maleficence that underpin modern healthcare. The persistent infection was not addressed, and the underlying cause, likely the infected root fragment, was not diagnosed. The failure of


INDUSTRY AWARDS

Cellerant “Best of Class” Technology Awards 2017

W

ith a barrage of emerging technologies in the dental marketplace, clinicians seek expert advice to guide them toward the most innovative, impactful products that can provide significant benefits for their practices, their teams, and their patients. For the past 9 years, the prestigious Cellerant “Best of Class” Technology Awards have been doing just that — distinguishing outstanding products and services from the competition and establishing true leaders in their categories. The awards have received acclaim for their integrity and have been recognized by every major dental journal in North America and the American Dental Association. The

winners are decided by the Best of Class Advisory Board, comprised of respected experts in dental technology — Paul Feuerstein, DMD; John Flucke, DDS; Marty Jablow, DMD; Parag Kachalia, DDS; and creator and founder of the award, and president of Cellerant Consulting Group, Lou Shuman, DMD, CAGS. Each year, at the Chicago Dental Society’s Midwinter Meeting, the board convenes to review innumerable hours of

3Shape Trios Platform 5-time winner

research they have compiled regarding practice-changing technologies over the past year. The rigorous process is unbiased and nonprofit. If a technology is not considered exemplary, then no winner is chosen for that category. Any panelist with a consulting relationship with a company is exempt from voting in that specific category. The Cellerant “Best of Class” Technology Awards provide dentists with a “go-to list” of products that they can trust as remarkable and critical components of their technologyforward dental practice. Endodontic Practice US is excited to showcase these winners and shine a spotlight on the best and the brightest in dental technologies. IP

Ultradent Gemini 810 + 980 Diode Laser

Bien-Air Tornado

LED Velscope Vx 7-time winner

DEXIS CariVu

SimplifEye

4-time winner

Emerging

Orascoptic OmniOptic

MMG Fusion 2-time winner

Q-Optics Platform

Orascoptic Ease-In-Shields

Emerging

Orascoptic Spark 2-time winner

WEO Media 2-time winner

Shofu EyeSpecial C-II Camera

Smile Line USA Smile Lite MDP

3-time winner

Emerging

Form Labs Form 2 3D Printer DentLight FUSION Twinhead Curing Light Emerging

34 Implant practice

ZEST Dental Solutions LOCATOR F-Tx Fixed Attachment System

Blue Sky Bio Emerging

Valo and Grand Valo Curing Lights

Philips Sonicare DiamondClean Smart

5-time winner

Volume 10 Number 5


TECHNOLOGY SPOTLIGHT

What does neuroscience have to do with dentistry? A lot! Sandra Marlowe discusses a method of achieving a profound mental state of peak performance

I

magine a new way to practice dentistry — where your patients look forward to visits and arrive calm and relaxed. Where you are far more to your patients than just a way to prevent or get out of pain or have a more attractive smile. At your practice, patients are discovering a healthier, happier life in ways they never dreamed possible. Some patients have lost weight, others have found relief from anxiety and fear, and some even have you to thank for lower golf scores. Imagine, in this new dental practice, patients schedule recommended treatment because they trust you. They complete treatment plans because they feel safe in the office, and they regularly refer friends and family because you are more than just their dentist; you are their hero. How do you create such a practice? The surprising answer for a large and growing number of dentists has been found in the burgeoning field of neuroscience and new discoveries in brain wave entrainment. These methods work by balancing and harmonizing the brain in a way that creates a profound mental state of peak performance. BrainTap Technologies is leading the charge in delivering brain wave entrainment technology in an easily consumable manner. The benefits of braintapping include relaxation, stress reduction, restorative sleep, and lifestyle improvements that directly contribute to an enhanced patient experience.  BrainTap uses five mind technologies that, combined, create a powerful tool for you to use both in-office and for home care to help improve quality of life for your patients in every aspect of their lives. • Beats and tones — Imbedded tones emulate relaxed brain waves, guiding the brain to an extraordinary level of focus and performance that would

Sandra Marlowe has authored, co-written, or ghostwritten eight self-improvement books, including an award-winning bestseller. She has earned a Pushcart Prize nomination in literature. She regularly writes and speaks on topics related to brain health and self-development.

36 Implant practice

otherwise take years of practice to achieve. • Audio Library — Patrick K. Porter, PhD, BrainTap’s founder, created guided-visualization audio sessions to help people become the designers of their own lives. With a selection of more than 700 titles — all encoded to work with the BrainTap headset — users learn how to focus on everything they want out of life. • 10-cycle holographic music — The music on the Audio Library audiorecordings is designed to create a full 360-degree experience that delights the mind with calming thoughts and images. • Light frequencies — The BrainTap headset adds the dimension of light pulses that train the brain to produce a healthy balance of brain wave activity, transforming the listener into a mental powerhouse with the right mindset to accomplish just about any goal. • Auriculotherapy — The BrainTap headset also delivers light frequencies through the ears. There are specific points in the ears, called meridians, known to directly affect the body’s organs and systems. These are typically activated using acupuncture needles, but light frequencies are known to have the same effect. The headset’s earphones are uniquely equipped with nine LED lights set at the optimum frequency for providing a sublime feeling of serenity and balance, all without needles. The benefits to patients are innumerable and can be immeasurable. Virginia Beach home-care provider Carol Hooper is a great example. “I had been overweight nearly my entire life,” Hooper says, “Food was my comfort when I was sad, tired, or happy. In 1996, I met Dr. Patrick Porter (BrainTap’s founder), and my life changed forever. Dr. Porter taught me how to balance my brain, visualize my goals, and stay motivated for life.

I took off 95 pounds and, best of all, I kept it off for 20 years.” Stories like Hooper’s are not uncommon. But how do dentists benefit from providing BrainTap in their practices? By becoming licensees of the BrainTap system, any dentist can have the ability to increase income and build a more varied practice in at least five different ways: 1. BrainTap services can be offered to patients in the dental practice for profit. Now dentists can offer programs for sleep, weight loss, smoking cessation, stress reduction, pain reduction, or choose a more unique route of care by choosing from any of 700 single audio sessions offered on the BrainTap mobile app. You can also use BrainTap to add value (and higher fees) to some or all of your existing practice’s services. 2. Offer the BrainTap headset in office as a retail item. BrainTap offers the dental professional a generous wholesale rate. Dentists who retail just one BrainTap headset a week can drop an additional $12,500 to their bottom line. And once clients own their own BrainTap headset, they will likely opt for the mobile app membership, which adds to monthly income as well. 3. Sell the membership service to clients for added monthly revenue. For every client set up for membership, dentists earn 30% of the $30 monthly payment. Which means, if just four patients a week become members, this alone can add $7,000 to the bottom line with virtually no effort. And dentists who prescribe the membership service to stressed-out clients for home care see a growing residual income. 4. Use BrainTap Technologies products and services as your entrée for Volume 10 Number 5


TECHNOLOGY SPOTLIGHT

drawing in new patients, conducting training sessions, demos, seminars, and shows. Free demonstrations of the BrainTap headset provide you a unique way to introduce prospective new patients to your practice. They experience an immediate shift in how they feel and function, making it easy to convert them for long-term care. 5. Improve retention and increase referrals. Patients experiencing brain wave entrainment through the BrainTap headset and the membership tend to respond better to care and overall are happier and more compliant — which translates to patients who stay and refer. To make it simple for the practitioner, BrainTap allows dentists to gift patients a 15-day trial for FREE. Getting brain wave patterns back to normal, or closer to normal, during that 15-day free trial allows patients’ brains to start self-regulating and the autonomic nervous system to balance, helping all unconscious activity to function optimally. This helps regulate the functions that have been under control of the central nervous system (CNS). Patients feel the results in a short amount of time, allowing them to recognize the long-term benefit. So how do you apply this neuroscience to the real life dental practice? Consider for a moment how many dentists are now offering and profiting from treatment for sleep apnea, a disorder that causes breathing to frequently stop and start that has been associated with significant health risks, including high blood pressure, diabetes, obesity, and heart disease. In the national effort to understand, diagnose, and treat this disorder, dental professionals have emerged as an important part of the community aimed at alleviating human suffering due to sleep apnea. This specialized area of practice has become a rewarding and highly profitable part of those dental offices. Now, thanks to new advances in neuroscience, BrainTap is providing dentists unique and specialized tools for branching out into other arenas such as weight loss, stop smoking, stress management, chronic pain, and many more. And for the dental sleep practice, BrainTap is the logical complement to existing treatments for sleep apnea. The first step in discovering all that BrainTap can do for you and your practice is to try braintapping for yourself. Simply sign up for a complimentary trial here: www. mybrainoffer.com. IP

easy-graft

®

CLASSIC alloplastic bone grafting system

Designed for Easy Placement

Once the coated granules of GUIDOR® easy-graft® are syringed into the bone defect and come in contact with blood, they change in approximately one minute from a moldable material to a rigid, porous scaffold. Designed for ease of use and predictability 100% synthetic and fully resorbable Contains a macroporous and openly microporous structure with a total porosity of approximately 70% This product should not be used in pregnant or nursing women.

Watch video @ http://us.guidor.com/InAction

Have your customers tried GUIDOR easy-graft yet? Buy 1 GUIDOR easy-graft LARGE (C11-008),

Get 1 Trial size at no charge! Expires December 31, 2017. Free goods ship with order.

To purchase or learn more, visit http://us.GUIDOR.com/easy-graft/ or call 1-877-484-3671. Instructions for Use (IFU), including indications, contraindications, precautions and potential adverse effects, are available at http://us.GUIDOR.com/IFU/. © 2017 Sunstar Americas, Inc.All rights reserved. GDR17055 09082017v1 The trademarks GUIDOR, easy-graft and BioLinker are owned by Sunstar Suisse, SA.

This information was provided by BrainTap.

Volume 10 Number 5

Implant practice 37


PRACTICE DEVELOPMENT

SEO: Scam or critical marketing service? Part 1 Ian McNickle, MBA, defines SEO and discusses its importance

T

he world of online marketing can be quite confusing, if not downright aggravating. It can be challenging to know what to do, how to do it, and who should do it for you. One of the most popular services discussed these days is “Search Engine Optimization” (SEO). Most people understand that SEO is a sort of mysterious service that somehow gets you ranked highly on Google and the other search engines.

“What exactly is SEO?” SEO can be defined as a set of ongoing monthly activities that must be performed in order for your website to rank highly on Google and the other search engines. SEO includes both “on-page” optimization and “off-page” optimization. On-page optimization includes items done on the website itself (code, content, images, videos, sitemap, blogs, etc). Off-page optimization includes items that are on the Internet, but not the website (online reviews, social media, directories, backlinks, etc). So in a nutshell, SEO is some combination of all these things performed each month. Determining which items should be done and how much of each item should be done depends on your goals and local competition.

“I’ve tried SEO and got ripped off!” I frequently lecture all over North America about SEO and many other online marketing topics. If I had a dollar for every time I’ve heard a doctor complain about getting ripped off, I could probably retire. I feel their pain and frustration. It’s real. Hiring an SEO company is kind of like taking your car to the mechanic. You hope they are honest and

Ian McNickle, MBA, is a national speaker, writer, and marketer. He is a Co-Founder and Partner at WEO Media, winner of the 2016 Cellerant Best of Class Award for Online Marketing and Websites. If you have questions about any marketing related topic, please contact Ian McNickle directly at ian@weomedia.com, or by calling 888-246-6906. For more information, you can visit online at www.weodental.com.

38 Implant practice

Receive your free marketing consultation today: 888-246-6906 or info@weomedia.com good at what they do so you’ll get value for your money, but it is difficult for you to assess that ahead of time (or even afterwards). In my estimation, SEO is indeed one of the most misunderstood services, and therefore, a lot of doctors get taken advantage of when hiring an SEO company. My goal with this article series is to educate doctors and staff to prevent you from getting ripped off, or at least from making bad decisions.

“How does it work?” In order to understand why SEO needs to be done a certain way, it is important to first understand a little bit about how search engines operate. For most average websites, the search engines review your website about every 30 days. When a search engine reviews your website, it actually indexes (reads and stores on its servers) every line of content and code on your website. Each time it does this, it compares all of your code and content to what it indexed 30 days prior and looks for improvements, new content, etc. Search engines also take into account your online reviews (Google, Yelp, Healthgrades, Facebook, etc), as well as social media activity and engagement (Facebook, Instagram, Pinterest, Twitter, You Tube, etc). A well-designed SEO program will involve some combination of many of these activities every month so that each time the search engines index your website and online activity, your practice will be rewarded with

higher rankings (or at least by not dropping in the rankings). SEO takeaway No. 1 — SEO activities must be done every month in order to be rewarded by search engines. If not, your search rankings will plateau or decline.

“How can I tell if I’m getting real SEO?” Google has over 200 variables it evaluates when assigning search rankings to websites. I normally group the most important variables into five major categories: 1) website code, 2) website content, 3) incoming links to the website, 4) online reviews, and 5) social media. In part 2 of our SEO series, we will explore these five major categories, so practices will be able to understand what they need to do (or what their SEO company should be doing) in order to rank highly on Google and other search engines. In part 3 of our series, we will discuss questions to ask when interviewing SEO companies and how to spot scams (and low-end SEO services).

Marketing consultation If you have questions about your website, SEO, social media, or online marketing, you may contact WEO Media for a consultation to learn more about the latest industry trends and strategies. The consultation is free if you identify yourself as a reader of this publication. IP Volume 10 Number 5


2018 schedule SESSION 1:

SESSION 2:

Begin with the basics through sixteen one-hour modules, available online and on-demand 24/7.

Learn how to place dental implants into abundant bone reliably, predictably and efficiently. This course is packed with hands on exercises designed to prepare you for implant placement, flap design and suturing.

Online Only

✔ Implant rationale ✔ Medical history ✔ Dental history ✔ Pharmacology ✔ Implant design ✔ Radiology for dental implants ✔ Bone quality ✔ Anatomy for dental implants ✔ Grafting materials ✔ Restorative options ✔ Consults, records and photos ✔ Surgical setup ✔ Post operative follow-up ✔ Pricing dental implants ✔ Building the implant team

Hands-On Training

Session One: Online Only - Sixteen one-hour modules, on-demand videos. - Online access granted upon registration. Seattle, Washington - Session 2: February 9 and 10, 2018 - Session 3: March 9 and 10, 2018

✔ Single tooth implant placement ✔ Incision and flap designs for the implant surgical site ✔ Suturing rationale for predictable success ✔ Surgical tooth extraction techniques ✔ Ridge preservation grafting techniques and materials ✔ Implant placement for the edentulous mandible ✔ Hands-on training with one-on-one mentorship ✔ Questions and answers with Dr. Moody and his faculty

Brunswick, Maine - Session 2: February 16 and 17, 2018 - Session 3: March 16 and 17, 2018

16 CE Credit Hours

16 CE Credit Hours

Raleigh, North Carolina - Session 2: April 6 and 7, 2018 - Session 3: May 18 and 19, 2018

SESSION 3:

SESSION 4:

✔ Uncovery of the dental implant, soft tissue and healing ✔ Implant impression techniques ✔ Implant restorations ✔ Key implant restorations for the edentulous maxilla ✔ Fabrication of the implant retained denture ✔ Guide fabrication and use of guided kit ✔ Immediate dental implant placement criteria for success ✔ Uncovery of the dental implant, soft tissue manipulation and healing times ✔ Implant impression techniques ✔ Implant restorations ✔ Key implant restorations for the edentulous maxilla ✔ Fabrication of the implant retained denture

Put your dental implant education to the test by helping the very people that need it the most. Perform live implant placement and restorations on patients in Phoenix, AZ.

16 CE Credit Hours

24 CE Credit Hours

Hands-On Training

Arizona Live Surgery

✔ Preoperative case work up of each patient using CBCT ✔ Implant placement on multiple patients over 2 days ✔ At least one edentulous mandible of implants for a removable denture ✔ Restorative experience of uncover, healing abutment placement and soft tissue manipulation ✔ Patient management and post operative recaps of cases

Justin MOODY, dds Implant PATHWAY fOUNDER

Dr. Justin Moody is an internationally known dentist, entrepreneur, instructor and speaker in the fields of dentistry, practice management, technology and implantology. Dr. Moody has practices in Nebraska and South Dakota and is the founder of Implant Pathway, a leading Midwest dental CE provider. Dr. Moody knows how important dental continuing education is as well as the need for mentoring and hands-on training. His conversational, real-life approach solidifies his educational philosophy.

My Clinical Pathway (MCP) is an ADA CERP provider. CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/goto/cerp. Approval Term: 5/1/2015 through 6/30/2019

My Clinical Pathway (MCP) is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 4-1-2015 to 3-31-2019. Provider #: 342679

Chicago, Illinois - Session 2: June 8 and 9, 2018 - Session 3: July 13 and 14, 2018 Dallas, Texas - Session 2: September 13 and 14, 2018 - Session 3: October 12 and 13, 2018 Brunswick, Maine - Session 2: October 5 and 6, 2018 - Session 3: November 11 and 17, 2018 Phoenix, Arizona - Session 4: April 25 - 27, 2018 - Session 4: June 14 - 16, 2018 - Session 4: September 6 - 8, 2018 - Session 4: November 29 - Dec. 1, 2018 AND Introducing

IMPLANT PATHWAY: FAST TRACK One week intensive training in Phoenix, AZ. Exclusive Session 4 for Fast Track registrants only.

-

Session 1: Online Only Session 2: November 5, 2018 Session 3: November 6, 2018 Session 4: November 7 - 9, 2018

register at www.implantpathway.com


ON THE HORIZON

Systems-driven dental implant practice Dr. Justin Moody discusses going with the workflow

I

n October of 2008, I took a leap of faith and ventured out on my own as a referralbased dental implantologist, limiting my practice to the placement and restoration of dental implants. I had a vision of the type of practice I wanted to build, the passion to pursue it, and the help and support of my family and friends. But even with all of those positive aspects, I was very nervous. The fear was real — I worried that no one would use my services, what other dentists and specialists would think, and what strategies I could use to set myself apart. My first lunch and learn with an office went well; I set up my projector, gave a quick rationale for dental implants, and then talked about how to simplify the process. It was at this meeting that the doctors and staff talked about the difficulty of the referral process they used at the time. Two months into this project, I did an evening program for a family group practice about an hour from my office. I gave the same presentation and heard the same issues about their existing referral system being too difficult. On the drive back, I realized that is was imperative to teach them my systems; in essence, give all the information away, and make the process as uncomplicated as possible. I started from the beginning and developed a clean and simple system for referring a patient. The process spelled out what the referring doctor was comfortable doing, and what he/she expected for an end product. Previously, no one was asking what he/she could do with the end result in mind. Also at that time, within my own office, systems were being refined to provide workflow that allowed for quick turnaround times, inventory management, prosthetic solutions, and

Justin Moody, DDS, DICOI, DABOI, is a Diplomate of the American Board of Oral Implantology and of the International Congress of Oral Implantologists, Fellow and Associate Fellow of the American Academy of Implant Dentistry, and Adjunct Professor at the University of Nebraska Medical College. He is an international speaker and is in private practice at The Dental Implant Center in Rapid City, South Dakota. He can be reached at justin@justinmoodydds.com or at www.justinmoodydds.com. Disclosure: Dr. Moody is a paid speaker for BioHorizons® and Carestream Dental.

40 Implant practice

excellent communication with not only the referring office but also the patient and the dental laboratory. Today those systems are still in place but with a different workflow as things change, especially technology. My digital workflow allows not only for better patient care done faster and more accurately but also for patient management with the referring office to ensure

Figure 1: Prosthetic-Driven Implant Planning from Carestream Dental provides that digital workflow needed to deliver restoration first results

Figure 2: Edentulous treatment planning using the Carestream software

Figure 4: 3D slice showing virtual implant placement

Figure 3: 3D volume rendering from the Carestream 8100

Figure 5: Full upper and lower Zirconia with hand-stacked gingival porcelain from ProSmiles Dental Studio in Rapid City, South Dakota

efficient communication and a 5-star experience. If I was to credit any one thing for the success of the practice, it would by our relentless pursuit of customized service while doing the right thing for the patient 100% of the time. Remember those first two offices that I visited? They stuck with me, so much so that they took several of my courses along with others’ courses, and now they place implants in their own practices! What a great profession we are in; we can share everything we’ve got, and it comes back to us tenfold! IP

Figure 6: Digital scan bodies from Biohorizons allow for complete implant digital workflow allowing instant communication with the laboratory Volume 10 Number 5


no more

compromises

The Tapered Internal family of dental implants provides excellent primary stability, maximum bone maintenance and soft tissue attachment for predictable results. All implant diameters from 3.0 to 5.8 can be placed with the same instrument kit providing you surgical convenience and flexibility to choose the ideal implants for each patient’s needs. With all these features, you no longer have to accept the clinical compromises that come with other implant systems.

restorative ease

universal surgical kit

45° conical internal hex connection creates a robust, biologic seal and is color-coded for quick identification and component matching

intuitive color-coded instrumentation used to place all BioHorizons tapered implants*

connective tissue attachment Laser-Lok uniquely creates a physical connective tissue attachment and biologic seal

bone attachment Laser-LokÂŽ microchannels achieve superior osseointegration

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

Made in the USA

*Tapered Plus, Tapered Tissue Level, Tapered Internal and Tapered 3.0 SPMP13154 REV F JUL 2016


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The X-Guide system delivers interactive, turn-by-turn guidance giving you the ability to improve every movement of your handpiece during osteotomy and implant delivery for more exact implant placement - like GPS for your drill.

In surgery, control real-time movements of your drill and implant placement with remarkable precision - use the X-Point to navigate position, angle and depth.

POSITION • ANGLE • DEPTH SEE WHAT’S THE NEXT BIG THING IN 3D IMPLANT DENTISTRY

Implant Practice US October/November 2017 Vol 10 No 5  
Implant Practice US October/November 2017 Vol 10 No 5