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clinical articles • management advice • practice profiles • technology reviews Spring 2018 – Vol 11 No 1

Robert J. Mikhli, DDS

Corporate profile BrainTap

FIXED-HYBRID EMERGENCY!

Clinician spotlight

Why Redo When You Can Rescue?

PROMOTING EXCELLENCE IN IMPLANTOLOGY

The era of monolithic translucent zirconia Drs. Despoina Chatzistavrianou, Shakeel Shahdad, and Philip Taylor

Understanding bone augmentation and regeneration Dr. Amit Patel

Single implant placement in the esthetic zone Dr. David Furze and Kerstin Kress To learn more, please visit our website at www.zestdent.com/ ftxtotherescue or call 800.262.2310.

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Replace A Failed Implant, Rescue The Prosthesis. Learn how at WWW.ZESTDENT.COM/FTXTOTHERESCUE. ©2018 ZEST Anchors LLC. All rights reserved. F-Tx, LOCATOR F-Tx, ZEST and Zest Dental Solutions are registered trademarks of ZEST IP Holdings, LLC.


EDITORIAL ADVISORS Steve Barter, BDS, MSurgDent RCS

Changing lives in ways we never imagined

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 2018. 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 11 Number 1

F

rom the ancient times, when cultures of the world were known to substitute missing dentition with shells, stones, and ivory, to the many iterations of the actual dental implant, the most recent and prevailing standard being titanium, the advances in dentistry are undeniable. However, even with all the indisputable advances, most dentists in the industry probably would not have predicted the degree in which the introduction of digital technology would completely revolutionize the way we practice today. In doing so, these pioneers have made our jobs as clinicians less complicated, more enjoyable, and predictable. When I began my career as a young general dentist, I used Dr. Jumoke Adedoyin a panoramic radiograph and bone gauge as my only tools for implant treatment planning. Back then, our mindset was, “only surgeons with extensive post-dental school training and experience should place implants.” But thanks to and with the help of CBCT diagnostic tools and digital treatment planning being introduced into mainstream dentistry, general practitioners like me can now predictably, surgically place and restore implants to improve the quality of life for our patients. With cone beam technology, it’s much easier to preplan cases, avoid unnecessary complications, reduce surgical time, and have predictable restorative results. In addition, many patients who may not have been considered qualified candidates for implant treatment within a general practice can now benefit from this life-changing technology. Digital technology has put general dentists in the driver’s seat when it pertains to both the surgical and restorative phases of their patients’ care. Gone are the days of trying to restore a case where the implants were placed “where there was bone.” This is a good thing, considering one of the most populous generations, the baby boomers, also known as the “Me Generation,” are actively seeking out the best in technology and medicine to maintain a youthful appearance and lifestyle. Their dental care is no exception. Many general dentists are finding themselves having to step outside of the restorative box and into the rehabilitation mindset as they tackle some of the more pronounced challenges of varying degrees of edentulism. As a dentist who places implants every day in my practice, I have found that utilizing surgical guides has been very advantageous. Whether presented with challenges relating to bone quality, quantity, or esthetic considerations, modern technology has provided me with a plan for predictable outcomes by placing the implants in a virtual environment before I initiate treatment in the mouth. While this technology isn’t useful in every case, with proper training, it provides a solution for accurate implant placement, and it is an attractive option when dealing with the medically compromised patients. The patients get what they need using a safe, less invasive procedure, and the dentist reduces chair time — thus, increasing productivity. With increased technological innovations, the future of implant dentistry is excitingly bright as it continually evolves and presents with the opportunity to be a part of changing the lives of our patients in ways that we never imagined, and I just can’t wait! Dr. Jumoke Adedoyin

Jumoke Adedoyin, DDS, FICOI, MICOI, FAAIP, MAAIP, is a 2001 graduate of Howard University College of Dentistry. She has a removable- and implant-focused private practice in Cartersville, Georgia. Dr. Adedoyin is a faculty member of the Implant Pathway, a 4-Part Implant Training Continuum that includes Live Implant training at the Brighter Way Clinic in Phoenix, Arizona. She is a mentor and teacher. She is married with three beautiful sons.

Implant practice 1

INTRODUCTION

Spring 2018 - Volume 11 Number 1


TABLE OF CONTENTS

Clinical/case study

Corporate profile BrainTap

6

Multidisciplinary reconstruction of maxillary missing teeth Drs. Chris Wood and Cemal Ucer look at the multidisciplinary demands of complex cases.................................12

Sandra Marlowe discusses how a digital health firm is taking on the stress pandemic

Clinical/case study Single implant placement in the esthetic zone Dr. David Furze and Kerstin Kress demonstrate how they met challenging esthetic demands to wow their patient and the judges of the Aesthetic Dentistry Awards presented by FMC ........................................................18

Book review

Clinician spotlight

10

Robert J. Mikhli, DDS Expanding patients’ access to implant dentistry with the gift of knowledge

Competing Against Luck by Clayton M. Christensen, Taddy Hall, Karen Dillon, and David S. Duncan Harper, New York.............................25

ON THE COVER Cover photo courtesy of Dr. David Furze and Kerstin Kress. Article begins on page 18.

2 Implant practice

Volume 11 Number 1


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Call: 415.749.1444 Visit: RecordLinc.com

PATIENT PORTAL

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TABLE OF CONTENTS

Continuing education

26

Understanding bone augmentation and regeneration

Dr. Amit Patel offers up a primer in the techniques available to implant dentists for successful, predictable hard tissue management

Continuing education The era of monolithic translucent zirconia Drs. Despoina Chatzistavrianou, Shakeel Shahdad, and Philip Taylor evaluate the long-term outcomes of an increasingly popular restorative material......................................30

Industry news .................................................36

Small Talk Five powerful leadership and culture-building statements Dr. Joel C. Small discusses how to cultivate shared values and a common purpose...................................... 35

PUBLISHER | Lisa Moler Email: lmoler@medmarkmedia.com MANAGING EDITOR | Mali Schantz-Feld Email: mali@medmarkmedia.com | Tel: (727) 515-5118

On the horizon Digital implant workflow as we know it today Dr. Justin Moody discusses diving into the digital workflow...................... 40

ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkmedia.com NATIONAL ACCOUNT MANAGER Celeste Scarfi-Tellez Email: celeste@medmarkmedia.com CLIENT SERVICES/SALES SUPPORT | Adrienne Good Email: agood@medmarkmedia.com CREATIVE DIRECTOR/PROD. MGR. | Amanda Culver Email: amanda@medmarkmedia.com

Stay Connected Between Issues Like us on Facebook at facebook.com/ImplantPractice Watch our DocTalk Dental videos at doctalkdental.com Check out our Webinars at implantpracticeus.com/webinars Connect. Be Seen. Grow. Succeed. | www.medmarkmedia.com 4 Implant practice

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 (4 issues) $149 | 3 years (12 issues) $399

Volume 11 Number 1


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CORPORATE PROFILE

BrainTap Sandra Marlowe discusses how a digital health firm is taking on the stress pandemic

“G

rowing up the son of an alcoholic was the greatest blessing of my life,” says Dr. Patrick Porter, founder of BrainTap Technologies, a company with a mission no less audacious than Empowering Humanity. His goal started in the 1970s, long before stress was the devastating malady it is today, when Porter’s father, in one of many desperate attempts to conquer his alcohol addiction, attended an AA-sponsored relaxation seminar and learned how to calm his racing mind. It worked so well, he decided to teach it to his nine children. “At age 12, I was a struggling student and storied troublemaker,” says Porter, “but I dreamed of being a great football player.

Patient wearing BrainTap headset

Dr. Patrick Porter, founder of BrainTap

Sports is how my dad got me hooked on his method. That year, I recorded my first visualization on a cassette recorder and used it for myself daily. I went on to become a three-sport captain in track, wrestling, and football, as well as an honor roll student.” Patrick K. Porter, PhD, has since been on the leading edge of personal

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. Marlowe regularly writes and speaks on topics related to brain health and self-development.

6 Implant practice

performance technology and is an expert at teaching people to lead a stress-free lifestyle. He is the author of six books, including his popular Thrive in Overdrive and How to Navigate Your Overloaded Lifestyle. Porter and his technology have been featured in The Wall Street Journal, People, Entrepreneur, and Inc. magazines and on ABC, NBC, CBS and the Discovery® Channel. He is head of mind-based studies at the International Quantum University of Integrative Medicine and is a licensed master trainer of Neuro-Linguistic Programming.

The solution to 21st-century stress “In today’s society, people are faced with new kinds of stress,” says Porter. “With technology taking up every free moment, the human brain is no longer given a chance to relax and reboot.” A well-known way to achieve stress reduction is through meditation. That method became a $1 billion business in 2015 and was expected to reach $2 billion in 2017.

However, while millions of people want the benefits of meditation, it requires discipline. Thus, few people ever master it. “To put it simply,” Porter says, “BrainTap is an allnatural, drug-free solution for guiding the brain into deep meditative states naturally, which alleviates the effects of super-stress and resets the brain for optimal performance.” BrainTap can be accessed in many ways to fit a variety of lifestyles. • Anyone can easily get started with the BrainTap Pro app that features the company’s proprietary neuroencoding™ in its programs for stress, worry and anxiety, sleep, weight, and many others. • Braintappers can enhance their experience with the BrainTap headset, taking meditation to the next level with synchronized light pulses that create the deep, meditative brain states that even longtime disciplined meditators fail to achieve. The BrainTap Pro app can offer multiple solutions in every home. One family member may be using it to achieve physical fitness, Volume 11 Number 1


CORPORATE PROFILE

BrainTap headset with synchronized light pulses

while another uses it to advance a career or improve a golf game. The kids could be using BrainTap to accelerate learning or master a sport. All will benefit from peak brain performance, more restorative sleep, a positive mental attitude, and the energy to enjoy a productive fulfilling day, every day.

The science of brain wave entrainment Back in the 1970s, when Dr. Porter’s father initially learned how to relax and overcome his alcoholism, he used audio tones that match the brain wave state between 7 and 13 hertz called alpha. This is the state nearly all meditation programs try to achieve, and recordings featuring these sounds have recently become quite popular; but there are limits. “When the brain is at peak performance, all brain waves are engaged to some extent, something like a symphony, so it doesn’t make sense to put all our attention on a singular frequency,” Porter says, “My thought was, Let’s get that symphony perfectly tuned.” In 1986, Porter was introduced to the concept of brain wave synchronization through both light and sound. It’s also when a major breakthrough in electronics occurred with the invention of the Erasable Programmable Read-Only Memory chip (EPROM), which retains data even when there is no power supply. The EPROM chip allowed Porter’s team to synchronize light with sound and to store the algorithms on a device for repeated use. This first device was the MC2 (M-CSquare), and it was the world’s first personal light-and-sound device for brain wave entrainment. “This discovery allowed us to introduce to the world a new technology that takes the brain to the optimum state for restoring that symphony while the person simply relaxes.” Volume 11 Number 1

BrainTap Pro app program for sleep

“In 1989, we introduced the MC2 at the Consumer Electronics Show in Chicago, and the reception we received was phenomenal, culminating in our earning the ‘Best New Gadget of Year’ award.” As it turned out, the company was about 3 decades ahead of its time, and the technology proved difficult to sell in retail settings. Still, between the franchise company Porter founded and more than 1,500 clinics worldwide, he sold over a quarter of a million of these devices. Porter also came to realize that what people thought about while in the super brain states he was creating greatly affected

the outcome. “If your best thinking brought you to where you are, and it’s not working, then what needs to change is your thinking,” Porter says. He calls this “the Einstein factor” because, as Einstein said, you can’t solve the problem with the same thinking that created it. You must shift to solution thinking, then return to the problem with the solution in mind, which is a necessary step in creating new brain circuits. The addition of guided visualization, using Porter’s background in psychology and as a master trainer of Neuro-Linguistic Programming (NLP), brought it all together. “When we added guided visualization to the Implant practice 7


CORPORATE PROFILE

While stress has reached epidemic proportions, Dr. Porter’s message is clear — no one has to succumb to this silent killer. There are quick and easy solutions that can free us from its grasp.

light and sound mix, people started making profound changes in short periods of time — sometimes after a single session.” Dr. Porter uses a method of visualization he calls transformational thinking. “The first brain circuit that needs to change is the belief that you are a behavior,” he says. Even though the first law of psychology states you cannot be a behavior, many people use this kind of language all the time. As an example, people refer to themselves as “a smoker” all the time, and because of this belief, under stress, the first choice will be a cigarette. For others, it might be something different like food, alcohol, or whatever they believe is relief. “We’ve known for decades that beliefs are ruled by emotion, and what science now knows is that brain circuits are triggered by emotion. In fact, many brain circuits are only available in a specific emotional state,” Porter adds. Most people try to change beliefs with conscious effort or force of will. The problem is the conscious mind only controls 2% of the brain. The change needs to take place in the other 98% that’s really running the show.

8 Implant practice

Attempting to access those brain circuits in the reactionary state of mind known as beta, 14 to 40 hertz, will likely only trigger an emotional response that can set off the very behavior we’re attempting to change. This is where meditation and relaxation techniques really accelerate in transforming a person’s thinking.

The future of BrainTap Dr. Porter has been the established leader in brain wave entrainment using light, sound, and vibration for 3 decades, making enhancements as new technologies came available. Today, the BrainTap Pro mobile app and the BrainTap headset enhance brain function in two ways — balancing brain wave activity and activating the brain’s neuroplasticity. He is confident that, with this combination, we can all achieve a stress-free state of mind and reach our full potential. For example, with this new science of digitallyenhanced meditation, you can awaken each day with a 10-minute meditation that Porter calls a digital cup of coffee. And, anytime day or night, you can tap into your nervous system’s natural rest-digest-recover mode to relax and reboot your body and brain. “We can all start our day feeling rested, refreshed, and ready for whatever the day may offer,” says Porter. With stress-related health and lifestyle issues at an all-time high, BrainTap is emerging as the world leader in digital health and wellness. “In 2018, we’re focusing on bringing the most engaging content to our mobile subscription service,” Porter says. By all indications, the company is seriously upping its game. For example, in the first quarter of 2018, BrainTap will be launching programs

with national celebrities such as Dr. Mehmet Oz of “The Dr. Oz Show®” for his growing nonprofit organization, HealthCorps®, which sends mentors into schools to teach “a wellness lifestyle” to at-risk youth. Also in early 2018, BrainTap will release “Think Like a Shark” with Kevin Harrington, the original shark on Shark Tank®. While stress has reached epidemic proportions, Dr. Porter’s message is clear — no one has to succumb to this silent killer. There are quick and easy solutions that can free us from its grasp. With over 700 programs, BrainTap is quickly becoming an amazing component to people’s daily wellness routine, and over 1,500 health clinics worldwide recommend BrainTap to address the stress component of health and wellness. You can become an integral part of bringing transformational thinking and this digital health technology to your patients. BrainTap’s target market is head-ofhousehold wellness consumers — those who are struggling to manage an overloaded lifestyle and seeking a wellness solution for themselves and their families — one that fits into their busy lives and delivers genuine results. Dental professionals are uniquely positioned to reach this audience, and BrainTap is a perfect fit for the dental practice that’s already addressing sleep issues. Now you have a chance to experience transformational thinking by contacting BrainTap at 602-687-2147, or visiting www. BrainTapDental.com. IP This information was provided by BrainTap.

Volume 11 Number 1


CLINICIAN SPOTLIGHT

Robert J. Mikhli, DDS Expanding patients’ access to implant dentistry with the gift of knowledge

L 

earning is a significant part of expanding a dentist’s clinical skill set, but it is only one element of what is required. Refining the skill to perform dental surgery on patients calls for additional training and hands-on practice. For general dentists, taking the time to hone surgery skills pulls them away from their practice for an extended period to travel and attend lectures. Top-rated New York dentist, Robert J. Mikhli, DDS, spent years studying to excel in placing dental implants. After earning his B.A. from Yeshiva University, he earned his dental degree from Stony Brook School of Dental Medicine, followed by a residency in general practice dentistry at New York Hospital of Queens, and then a fellowship in oral and maxillofacial and implantology Robert J. Mikhli, DDS also at New York Hospital of Queens. surgery. Dr. Mikhli thought that, Through his experience, he has been for the right situation, if a patient praised for his remarkable ability to put had the option to stay with his/ patients at ease, especially those who her dentist for all procedures, it avoided the dentist for many years. He could provide the patient greater frequently shares with aspiring dentists what access to care and a higher level he has learned and realized his dream was to of comfort and trust with a familiar combine his passions of dental surgery and practitioner. This gave him the teaching for the betterment of the patient. idea to develop the concept for the INplant Surgical Mentorship Recognizing a patient’s need Program for general dentists. Typically, when a patient needs dental Teaching atraumatic tooth extraction and implant placement on an ovine jaw implants, he/she is already seeing a general The benefits of mentoring dental practitioner and is recommended to Dr. Mikhli has never been concerned The INplant Surgical Mentorship Program a specialist to perform the implant surgery. about creating more competition in the combines teaching and hands-on mentorWhile a general dentist does not have to New York dental industry because for him, ship with two live courses and added in-office be a specialist to perform implant surgery, it this program is about what it will do for mentoring sessions. Dr. Mikhli uses a 3D is recommended that the dentist trains and the patient. printer to print surgical guides for practitioners practices these advanced procedures to “This mentorship provides expanded to develop proficiency in surgical procedures. have the skill set equivalent to a specialist. access to dental surgery for thousands of “The didactic portion gives the practi“Most implant courses require days patients. Once properly trained and in the tioner the necessary biological basis for of lectures and practicing on plastic jaws. right situations, an implant placement can be predictable clinical outcomes. But the chairOthers require travel overseas where easier, more profitable, and certainly more fun side mentorship — in your own office with implants are placed in rapid succession,” than an MOD composite.” Dr. Mikhli added. your staff — is what gives the confidence Dr. Mikhli said. “Many colleagues told me The program provides 24 continuing necessary to actualize the skills gained into they still lacked the knowledge and confieducation (CE) credits. If you would like to everyday practice,” Dr. Mikhli said. dence to place implants when they return to register for the INplant Surgical Mentorship Along with teaching the proper techtheir practices.” Program, please visit www.inplantmentorniques, dentists will recognize the various Based on feedback from colleagues, the shipprogram.com. IP levels of treatment difficulty and differentiate courses needed a different approach to show between standard and more complex cases. dentists how to be effective with implant This information was provided by Karl Schumacher Dental. 10 Implant practice

Volume 11 Number 1


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CLINICAL/CASE STUDY

Multidisciplinary reconstruction of maxillary missing teeth Drs. Chris Wood and Cemal Ucer look at the multidisciplinary demands of complex cases

T

his case study demonstrates how a multidisciplinary and holistic approach is needed to provide a more satisfactory outcome to a complex restorative problem for the mutual benefit of both the patient and the treating dentist. As it is unusual for one clinician to develop expertise in all disciplines of advanced dental care, a multidisciplinary approach must be employed to explore an array of different options when looking to find the most optimum solution to a complex dental problem. Unfortunately, this could be difficult — particularly for the single-handed clinician who may not have in-house access to a multidisciplinary team. This article demonstrates how a more stable esthetic and functional solution was established by addressing all the key restorative requirements with a multidisciplinary dental team.

Initial presentation A middle-aged retired head teacher, who had previously been coping with an upper partial cobalt chrome denture, sought treatment when this denture fractured. He inquired about the availability of fixed or removable prosthodontics. He showed particular interest in dental implant options, as he no longer had the heavy professional pressures that had precluded him from receiving complex implant rehabilitation before his retirement. The patient presented with the situation shown in Figures 1-3. The initial examination revealed the following: 1. The patient was partially dentate in the upper arch (Kennedy Class IV Mod 2), which had been restored with a removable partial denture constructed in a cobalt chrome

framework. This prosthesis was less than ideal with disproportionately small denture teeth and a fracture through the acrylic component of the denture. 2. Class III skeletal and dental malocclusion. 3. Premaxillary disuse bone atrophy (Figure 4) due to absence of permanent teeth for many years — this enhanced the Class III skeletal appearance. 4. Patient had a desire for a fixed restorative solution if at all possible.

Preoperative assessment and treatment planning A full six-point periodontal assessment was carried out, which revealed no evidence of active periodontal disease although there had been some loss of attachment over the years. Investigations included a full assessment of the occlusion using study models mounted on a semi-adjustable articulator

with a facebow and “centric relation” record. Photographs were used to assist the treatment planning procedure and to communicate with and educate the patient. Dental wax was softened and gently applied to the buccal surface of the existing denture. This helped initially to evaluate how the “under contoured” lip support could be improved with treatment (Figure 5). Treatment options were discussed at length with the patient to ensure that proper informed consent was obtained prior to the onset of treatment. These included the following: 1. Treatment undertaken without orthodontic therapy and acceptance of Class III malocclusion: removable cobalt chrome-based partial denture or implant-retained overdenture 2. Treatment undertaken including orthodontic therapy to correct the Class III malocclusion: removable cobalt chrome-based partial denture or implant-retained overdenture.

Figure 2: The patient was partially dentate in the upper arch

Figure 1: Initial presentation of Class III malocclusion and inadequately sized prosthetic teeth

Dr. Chris Wood, BDS Hons, FFGDP Dip Rest Dent RCS Eng has run a referral restorative/surgical implant clinic with Professor Cemal Ucer for more than 20 years at Standish Street Dental Practice in Burnley, United Kingdom. He has mentored for the Royal College of Surgeons restorative dentistry diploma for 9 years and has been an active member of the British Society of Occlusal Studies for more than 25 years. Professor Cemal Ucer is a specialist oral surgeon and professor of dental implantology at Edge Hill University in Lancashire, United Kingdom. He is also clinical director of the ICE postgraduate dental institute in Manchester.

12 Implant practice

Figure 3: The fracture of his existing denture caused the patient to seek treatment Volume 11 Number 1


AN INSIDE LOOK AT WHO ANSWERS WHEN YOU REACH OUT FOR HELP Who has your back when the unexpected challenge arises? It’s a question you need to have an answer for before it’s ever asked. At Implant Direct, our Customer Care and Support Center opens at 5 in the morning and doesn’t shut down until 5 in the evening. During those 12 hours, we answer questions, supply solutions and provide insight to anyone who asks. Even if they’re not using an Implant Direct system. We don’t mind helping, even if the caller is using a competitor’s system. We just want every procedure to go well and every patient to love their results. So getting back to who has your back? That would be us, Implant Direct, no matter what the name on your implant system might be.

CALL Our Technical Service Representatives TODAY!

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CLINICAL/CASE STUDY

Figures 4A, 4B, and 4C: CBCT scan showing the preoperative view of the premaxillary bone deficiency

3. Orthodontic treatment combined with staged pre-maxillary block bone grafting to correct malocclusion and rehabilitation with implant-supported fixed bridgework. The nature of treatment, along with the advantages/disadvantages, realistic expectations, risks, and prognosis of each option, was explained to the patient. The esthetic expectations were discussed and evaluated carefully, as these were a key patient objective. The specific treatment objectives were to achieve: • A fixed prosthetic solution in a Class I mutually protected occlusion • A restoration that was easy to clean and maintain • Speech and labial esthetics maintained by achieving an ideal incisal position • Dental esthetics optimized by using the principles of the “golden proportion” to create harmonious tooth dimensions No medical abnormalities were noted, and therefore, all treatment options were available. The patient’s smile line was favorable, and he had accepted the use of some pink porcelain to optimize the gingival esthetics if necessary. The treatment plan included: Stage 1 Construction of a diagnostic partial denture to test the labial support, tooth position, and smile lines for achieving optimum esthetic and functional results. Stage 2 Orthodontic treatment to help to realign teeth in order to facilitate reorganizing the occlusion from Class II to Class I in combination with bone grafting. Stage 3 A staged premaxillary block bone grafting (using a composite graft of allograft blocks, 14 Implant practice

Figures 5A and 5B: Wax buildup using sheet of wax marked with indentation to illustrate the future tooth dimensions

Figure 6: Orthodontic treatment was carried out to help reorganize the occlusion

particulate xenografts [Bio-Oss® and BioGide®, Geistlich] and a-PRF technique). Stage 4 Implant placement surgery after a period of bone graft consolidation (6 months) using a CBCT-guided static surgical stent developed with the aid of the diagnostic denture used as a radiological stent.

Stage 5 Final prosthodontic rehabilitation with a fixed porcelain bridgework supported by Straumann® bone level fixtures, including bleaching and composite restorations to lower anterior teeth. Stage 6 Follow-up and stabilization phase. Volume 11 Number 1


light years beyond ‘frozen peas’ ®

De

Cool Jaw offers a full line of gel packs and facial wraps that are specifically designed to help patients recover from a range of dental procedures. Our Soft-sided Round Gel Packs are ideal for a variey of cold therapy applications including post-operative care. These reusable gel packs are 4” in diameter and remain flexible when frozen, allowing for uniform cold therapy. They feature one soft-sided surface to shield the skin from direct contact with the frozen pack and are a convenient, comfortable and economical cold therapy option for your patients. Our reusable gel packs can also be customized with your practice logo for long lasting promotion. Available in Cool Blue, Grape, Kiwi, Mango, Pink Ice and Vanilla.

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CLINICAL/CASE STUDY

Figure 7: The eight-unit screw-retained fixed porcelain-fused-to-metal bridge in titanium

Figure 8: An idealized occlusion was achieved

Treatment pathway The first stage was construction of a temporary acrylic partial denture to the assessed positions by an instant, simple wax-up technique. This achieved an edgeto-edge occlusion. Following this, orthodontic therapy was carried out in the lower arch (Figure 6) to retract the lower incisors and level the occlusal plate. The aim was to achieve a Class I occlusion in the incisor region, rather than the less desirable Class III relationship present at the onset. While this was ongoing, the upper right premolar was extracted. Further correction of the Class III skeletal relationship followed the extraction, with staged block grafting to the premaxilla using allografts, xenografts, and a PRF. Next, came a period of 6 months to allow osseous maturation of the premaxilla grafting site. Five Straumann bone level dental implants were placed in restoratively driven three-dimensional positions using a CBCT-guided static stent. By this time, the orthodontic correction had almost been concluded, and the dental implants were restored as soon as possible with temporary crowns or bridgework, now that the lower incisal position had been determined. The final stages of treatment included: • Definitive restorations for the dental implants (a splinted eight-unit screwretained porcelain-fused-to-metal bridge) (Figure 7) • At-home tray whitening of all the residual teeth • Replacement of the discolored composite restorations in the lower anterior teeth using IPS Empress® Direct (Ivoclar Vivadent). 16 Implant practice

Figure 9: Dr. Levin’s Golden Mean Gauge

Figure 10: Anterior teeth with Golden Proportion

Figure 11: Teeth positioned in ideal curve in harmony with lower lip

Figure 12: Optimal cleaning achieved with interdental spiral brushes (Curaprox)

Conclusion The esthetic, restorative, and functional objectives of the treatment plan were fulfilled satisfactorily: • The occlusion achieved was of an idealized, mutually protected, and centric relation-based occlusion (Figure 8). • Tooth dimensions were designed on the ideal proportions using Dr. Levin’s Golden Mean Gauge (PhiPoint Solutions) (Figures 9 and 10). This instantly created a wellbalanced esthetic smile (Figure 11) that allowed the patient to smile, eat, and be confident. • The fixed prosthesis was designed with access for cleaning aids as demonstrated in Figure 12.

• The design of the pontic areas was maintained in close proximity to the alveolar ridge using a modified ridge-lap design. Larger spaces were avoided while still allowing for adequate access for plaque control purposes because experience suggests that phonetics can be adversely affected in the maxilla due to air escape. IP

Acknowledgments Orthodontics was undertaken by Dr. Stephen Ward, consultant orthodontist. Implant surgery was undertaken by Professor Cemal Ucer. Restorative treatment was undertaken by Dr. Chris Wood. Laboratory work was undertaken by Impact Dental Laboratory. Volume 11 Number 1


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CLINICAL/CASE STUDY

Single implant placement in the esthetic zone Dr. David Furze and Kerstin Kress demonstrate how they met challenging esthetic demands to wow their patient and the judges of the Aesthetic Dentistry Awards presented by FMC

T

he survival of dental implants is well established with 10-year survival rates reported at 95%-98% (Torabinejad, et al., 2007). The success criteria of implants as stipulated by Albrekson, et al., 1986, and Buser, et al., 1990, are based on the biological and functional aspects of implant integration and its survival. With the equivalent high survival of dental implants within the esthetic zone, the criteria for success of dental implant treatment by both the profession and the patient population have changed. The esthetic result is now being challenged with excellence required for success. This article will demonstrate how the authors met these challenges to provide an implant restoration for a patient that provided a successful esthetic result and good chances for long-term survival.

Figure 1: Preoperative photograph

History This 38-year-old Caucasian female was referred for the potential placement of a single implant to replace the upper right central incisor. Both her upper central teeth had been traumatized when playing hockey as a teenager. Both central incisors had been root-filled and had discoloration. Both central incisors had been causing her pain, and she suffered recurrent infections.The upper left central incisor had been endodontically retreated, which had been successful. Medically, the patient was fit and well and a non-smoker. She now had two children and, as a present to herself, wanted the esthetics of her front teeth improved.

Examination The extraoral examination (Figure 1) revealed a very high smile line. Full gingival contour was visible on smiling. Other than the presenting complaint, she had a very healthy mouth with no caries or periodontal disease present. She had a soft tissue defect David Furze, BDS, MFDS RCS (Eng), MClinDent (Pros), is in practice restricted to advanced prosthodontics and dental implants. A widely published author, he has lectured widely on the surgical and restorative aspect of dental implants. Kirsten Kress is a dental technician.

18 Implant practice

Figure 2: Preoperative radiograph

Figure 3: Soft tissue healing at 6 weeks

associated with the upper right central incisor and discoloration of the upper left central incisor. A Class 1 incisal relationship was noted. Figure 2 shows the preoperative radiograph, while Table 1 shows the International Team for Implantology (ITI) esthetic risk assessment that was carried out.

Diagnosis and treatment plan The patient was diagnosed with an unrestorable upper right central incisor, and a discolored upper left central incisor. Treatment options were discussed with her as follows:

Upper right central incisor Extract and: 1. Denture 2. Adhesive bridge 3. Conventional bridge 4. Implant Upper left central incisor 1. Internal and external bleaching 2. Veneer 3. Crown

Treatment phase The tooth was extracted, and an immediate denture was placed. Implant surgery Volume 11 Number 1


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CLINICAL/CASE STUDY was performed at 6 weeks (Figures 3 and 4), following tooth extraction in accordance with an early implant placement protocol. Immediately placed and immediately restored implants were not considered due to the increased level of esthetic risk. Systemic antibiotics (single dose: 3 g amoxicillin per-orally) were administered to the patient 1 hour prior to the procedure, followed by 500 mg of amoxicillin every 8 hours for the first postoperative week. A 0.2% chlorhexidine mouthwash was given to the patient for 1 minute preoperatively. Local anesthesia was achieved by means of infiltration with articaine hydrochloride 4% together with adrenaline (epinephrine) at 1:100,000. A full thickness periosteal flap was raised by means of a crestal incision that was positioned palatally of the mid crest and completed with intracrevicular incisions on the adjacent teeth. The flap was relieved on one side with vertical releasing divergent incisions starting at the base of the neighboring interproximal papillae to create a triangular flap (Figure 5). The flap was retracted by means of a 4-0 Vicryl® suture (Ethicon).

Figure 4: Radiograph before implant placement

Figure 5: Triangular flap design with distal relieving incision

A Straumann® bone level SLActive® implant was placed. The preparation of the implant bed followed the manufacturer’s guidelines. The shoulder of the implant was placed approximately 3 mm below the proposed cervical margin of the future restoration. The implant was kept at least 1 mm away from the adjacent roots and placed 1 mm-1.5 mm palatally to the proposed emergence point. The long axis of the implant

Figures 6 and 7: Correct three-dimensional position of implant

exited through the proposed cingulum rest of the crown. A 2 mm healing cap was placed to allow tension-free flap closure following a fully submerged implant placement protocol (Figures 6-8). Autogenous bone chips were first collected from the flutes of the twist drills and locally harvested where access allowed from the anterior nasal spine, using a reverse action hoe. The autogenous bone chips were

Figure 8: Correct three-dimensional position of implant

Esthetic risk factor

Low risk

Medium risk

High risk

Medical status

Healthy

Smoking habit

Nonsmoker

Light smoker

Heavy smoker

Patient’s esthetic expectations

Low

Medium

High

Lip line

Low

Medium

High

Tissue biotype

Low-scalloped, thick

Medium-scalloped, medium thick

High-scalloped, thin

Shape of tooth crowns

Rectangular

Infection at implant site

None

Chronic

Acute

Bone level at adjacent teeth

Less than 5 mm to contact point

5-6 mm to contact point

7 mm to contact point

Restorative status of adjacent teeth

Virgin

Width of edentulous span

1 tooth greater than 7 mm

Soft tissue anatomy

Intact soft tissue

Bone anatomy of alveolar crest

No bone deficiencies

Reduced immune system

Triangular

Restored 1 tooth less than 7 mm

2 teeth or more Soft tissue defect

Horizontal bone defect

Vertical bone defect

Table 1 20 Implant practice

Volume 11 Number 1


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

Submitting articles Implant Practice US requires original, unpublished article submissions on implant topics, multidisciplinary dentistry, clinical cases, practice management, technology, clinical updates, literature reviews, and continuing education. Typically, clinical articles and case studies range between 1,500 and 3,000 words. Authors can include up to 15 illustrations. Manuscripts should be double-spaced, and all pages should be numbered. Implant Practice US reserves the right to edit articles for clarity and style as well as for the limitations of space available. Articles are classified as either clinical, continuing education, technology, or research reports. Clinical articles and continuing education articles typically include case presentations, technique reports, or literature reviews on a clinical topic. Research reports state the problem and the objective, describe the materials and methods (so they can be duplicated and their validity judged), report the results accurately and concisely, provide discussion of the findings, and offer conclusions that can be drawn from the research. Under a separate heading, research reports provide a statement of the research’s clinical implications and relevance to implant dentistry. Clinical and continuing education articles include an abstract of up to 250 words. Continuing education articles also include three to four educational aims and objectives, a short “expected outcomes” paragraph, and a 10-question, multiple-choice quiz with the correct answers indicated. Questions and answers should be in the order of appearance in the text, and verbatim. Product trade names cited in the text must be accompanied by a generic term and include the manufacturer, city, and country in parentheses. Additional items to include: • Include full name, academic degrees, and institutional affiliations and locations • If presented as part of a meeting, please state the name, date, and location of the meeting • Sources of support in the form of grants, equipment, products, or drugs must be disclosed • Full contact details for the corresponding author must be included • Short author bio • Author headshot Volume 11 Number 1

Pictures/images

Disclosure of financial interest

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

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

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

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

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

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

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

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

(Multiple) Doe JF, Roe JP

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

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

Implant practice 21


CLINICAL/CASE STUDY

Figure 9: Implant surface covered with bone chips

Figure 10: Contour augmentation with DBBM

Figure 11: Bilayer collagen membrane

Figure 14: Contour augmentation with DBBM

Figures 12 and 13: Three-month review

placed over the exposed implant surface (Figure 9) in any dehiscence or fenestration defects. Further contouring of the ridge was performed by a layer of deproteinized bovine bone mineral (DBBM) (Bio-Oss®, Geistlich; granule size 250–1000µm) over the already placed autogenous bone chips (Figure 10). This, in turn, was covered by a double layer of a 25 mm x 25 mm, porcine-derived collagen membrane (Bio-Gide®) (Figure 11). A tension-free flap was created by periosteum dissection at the base of the flap by means of a 15 scalpel. The flap was coronally positioned and sutured using 5.0 prolene sutures. Vertical suspended mattress sutures were utilized in the reconstruction of the papilla with single interrupted sutures for the relieving incisions.

Postoperative instructions and infection control The patient was prescribed paracetamol (1 g every 6 hours orally) and ibuprofen (400 mg every 8 hours orally) for pain control at her discretion. She was instructed to refrain from tooth brushing in the operated area and to rinse with 0.2% chlorhexidine digluconate mouthwash, 3 times per day, for 1 week. To avoid postoperative infection, the patient received systemic antibiotics: amoxicillin 500 mg every 8 hours for 1 week postoperatively. 22 Implant practice

Following the first week, the patient was instructed to resume normal oral hygiene procedures, including full interproximal cleaning, and to discontinue chlorhexidine mouth rinsing. All sutures were removed at the review appointment, 14 days after the surgical procedure. Following a period of between 12-16 weeks of healing (Figures 12 and 13), access to the implant was achieved by means of a crestal D-shaped incision, not extending to the adjacent papilla. The 2 mm healing cap was changed to a 4 mm conical healing cap for a further week of soft tissue healing.

Restorative phase The provisional implant-supported restoration was a laboratory-constructed composite screw-retained crown. A closedtray impression (Figure 14) was taken in polyether (Impregum™, 3M ESPE) using a stock tray. A Straumann® temporary cylinder was modified with dentin and enamel composite to obtain optimum esthetics and emergence profile. The provisional crown was inserted and torqued to 15Ncm (Figure 15). Peri-implant tissue conditioning (Figures 16-18) occurred utilizing the dynamic compression technique, with compression of the tissues followed by sequential reduction of the provisional restoration. The provisional

Figure 15: Provisional restoration

crowns were left in situ for 6 months to allow for soft tissue maturation.

Bleaching upper left central incisor During this soft tissue maturation phase, internal and external bleaching of the upper left central incisor was completed. All restorative procedures were completed under rubber dam The palatal restoration was removed, and the gutta percha removed to gingival level. The gutta percha was sealed with a resin-modified glass ionomer cement (Vitrebond™) and internal bleach (16% carbamide peroxide) placed into the access cavity. The access cavity was then restored with intermediate restorative material (IRM). The patient completed external bleaching using her pre-formed bleaching tray and 16% carbamide peroxide on a nightly basis. Once the patient was satisfied with the esthetic result, the temporary restorations were removed, along with the bleach, under rubber dam. Composite was then placed into the access cavity. Volume 11 Number 1


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CLINICAL/CASE STUDY

Figures 16-18: Soft tissue maturation and bleaching

Figure 19: Provisional crown placed onto original cast

Figure 22: Customized impression cylinder transferred to patient

Completion of definitive crown A customized impression coping was constructed by removing the provisional crowns and replacing onto the initial cast (Figure 19). A light-bodied fast-setting addition silicone impression was taken of the apical half of the provisional restoration (Figure 20). The provisional restoration was replaced in the patient’s mouth to prevent soft tissue collapse. Open-tray impression copings were inserted onto the cast with notable voids present between coping and silicone index. Bis-acrylic temporary crown and bridge material were injected into the space created in order to customize the impression coping and accurately record the emergence profile of the provisional (Figure 21). The customized impression cylinder was transferred to the patient to support the soft tissues with no soft tissue blanching (Figure 22). An open-tray polyether impression 24 Implant practice

Figure 20: Light-bodied impression coping

Figure 21: Customized impression coping

Figure 23: Final crown on placement

was taken using a customized individual tray, followed by an irreversible hydrocolloid impression of the provisional in situ. Clinical photographs were provided to the dental laboratory as additional guidance in terms of adjacent teeth shape and color and gingival contours. The abutments were designed using the CAD abutment function in the Straumann® CARES® CAD/CAM system. The exact emergence profiles were then duplicated. The crown was torqued to 35Ncm and composite placed in the screw access cavity. Occlusion was checked in centric occlusion and in anterior and lateral excursions to ensure a mutually protective occlusion.

Discussion The patient was very happy with the esthetic result achieved (Figure 23). The implant crown has very high pink and white esthetic scores. Both central incisors are

slightly darker than the adjacent lateral incisors. This was discussed with the patient, and a veneer on the upper left central incisor was not completed as the patient wanted to be as minimally invasive as possible. Due to the patient’s high esthetic demands and high smile line, this case had to be planned and executed to the highest level for success. The outcome in this case has exceeded the patient’s expectations. IP REFERENCES 1. Albrektsson T, Zarb G, Worthington P, Eriksson AR. The long-term efficacy of currently used dental implants: a review and proposed criteria of success. Int J Oral Maxillofac Implants. 1986; 1(1):11-25. 2. Buser D, Weber HP, Lang NP. Tissue integration of nonsubmerged implants. 1-year results of a prospective study with 100 ITI hollow-cylinder and hollow-screw implants. Clin Oral Implants Res. 1990;1(1):33-40. 3. Torabinejad M, Anderson P, Bader J, Brown LJ, Chen LH, Goodacre CJ, Kattadiyil MT, Kutsenko D, Lozada J, Patel R, Petersen F, Puterman I, White SN. Outcomes of root canal treatment and restoration, implant-supported single crowns, fixed partial dentures, and extraction without replacement: a systematic review. J Prosth Dent. 2007;98(4):285-311.

Volume 11 Number 1


BOOK REVIEW

Competing Against Luck by Clayton M. Christensen, Taddy Hall, Karen Dillon, and David S. Duncan Harper, New York

C

layton Christensen, best known for his theory and subsequent book, Disruptive Innovation, has combined his skill, knowledge, and expertise with three of his protégés to produce this new Theory of Jobs to Be Done, which concentrates on understanding customers’ struggles for progress. Rather than offer ivory tower speculations, they draw illustrations from real-world insights and experiences of people and companies that use Jobs Theory to make innovation a reliable engine of growth. Christensen explains how innovation transforms an existing market by introducing simplicity, convenience, accessibility, and affordability, but cautions that disruptive innovation doesn’t tell one where to look for new opportunities, explain how to innovate, where to create new markets, or how to avoid hitand-miss innovation that leaves your fate to luck. But the Theory of Jobs to Be Done will. At its core, Jobs Theory explains why customers hire others to resolve unsatisfied jobs that arise in their lives. Ultimately, customers don’t buy products or services; they pull them into their lives to make progress, i.e., the job they are trying to get done. And those jobs have an inherent complexity in that they have not only functional features but also social and emotional dimensions. The authors offer one particular example that has particular resonance for dentists as people attempt to have a smile that will make a good first impression, and the circumstances, obstacles, and imperfect solutions they face in achieving that goal. For dentists, these three or four pages may make the cost of the book worthwhile.

In a large way, these authors are reemphasizing profound insights popularized decades ago by Ted Levitt, who said, “People don’t want to buy a quarter-inch drill. They want a quarter-inch hole.” The late Peter Drucker also warned that customers rarely buy what the company thinks it sells. Therein lies the messy task of discovering what jobs people want done, and what has to get fired for your products and services to get hired. They list and explain how several wellknown companies whose brands are synonymous with the jobs they do achieve their results, e.g., Uber, TurboTax®, Disney, Toyota®, Amazon, Mayo Clinic, OnStar,

IKEA®, Google, Xerox®, and Netflix among many others. Conversely, they also offer examples of companies that by emphasizing processes unaligned with customers’ jobs simply got better and better at doing the wrong things and ultimately failed — some spectacularly like Kodak. Aside from regressing into needless repetition — a minor failing — this book offers an antidote to relying on luck and serendipity to help entrepreneurs and companies discover what jobs people want done and how they might go about doing them. IP Review by Dr. Larry White

Ultimately, customers don’t buy products or services; they pull them into their lives to make progress, i.e., the job they are trying to get done. Volume 11 Number 1

Implant practice 25


CONTINUING EDUCATION

Understanding bone augmentation and regeneration Dr. Amit Patel offers up a primer in the techniques available to implant dentists for successful, predictable hard tissue management

S

trong foundations are needed for successful dental implant placement. However, some patients present with insufficient quality or quantity of bone to support a dental implant, which can be caused by a variety of different reasons, including tooth loss, trauma, infection, and periodontal disease. Without sufficient healthy bone, instability and loss of a dental implant can occur, along with the functional and esthetic problems that go with it. Consequently, bone and soft tissue augmentation is often required to re-create the lost anatomy and to achieve the optimal occlusal function

Educational aims and objectives

This article aims to present an overview of the main approaches of augmenting hard tissues in implant dentistry.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 29 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Define the process of bone regeneration and realize some steps to a successful process.

Identify some types of grafting materials.

Recognize the technique for block bone grafting.

Identify when a sinus augmentation would be necessary.

Identify the need for socket preservation.

Figures 1-9: Case study 1: GBR combined with dental implant placement. One 4.2x11 mm Astra Tech Implant System™ EV implant was placed with a healing abutment. A buccal defect was present. At least 2 mm of buccal bone is required — therefore, a collagenated xenograft was placed and porcine membrane stabilized over the healing abutment utilizing the poncho technique. Figures 7-9 show the Geistlich Combi-Kit used with interrupted resorbable sutures Amit Patel, BDS, MSc MClinDent, FDS RCSEd, MRD RCSEng, is a specialist in periodontics. Alongside his private practice, he is also an associate specialist in periodontics and honorary clinical lecturer at the University of Birmingham Dental School in the United Kingdom. His special interests are dental implants, regenerative and esthetic periodontics. More information on augmentation or dental implant surgery is available from the Association of Dental Implantology (ADI) at www.adi.org.uk.

26 Implant practice

Volume 11 Number 1


Guided bone regeneration (GBR) Guided bone regeneration, or GBR, is a surgical technique where bone is regenerated using bone grafting material and a barrier membrane, maintaining a space

over the grafting material into which osteogenic cells can migrate and colonize to form increased volume of bone. It can be applied to extraction sockets, horizontal ridge augmentation, and the correction of defects around dental implants to build bone both vertically and horizontally. Predictable bone regeneration requires a high level of technical skill, as well as a comprehensive understanding of wound healing and the following main biological principles, known collectively as “PASS.” • P – primary wound closure to ensure undisturbed and uninterrupted wound healing • A – angiogenesis to provide necessary blood supply and undifferentiated mesenchymal cells

• S – space maintenance/creation to facilitate adequate space for clot stability and ultimately predictable bone growth • S – stability of wound and dental implant to induce blood clot formation and uneventful healing (Wang and Boyapati, 2006) In some situations, GBR should be performed as an entirely separate procedure, and only when the site is sufficiently healed should dental implant surgery begin. However, it is possible for clinicians to combine dental implant placement with bone grafting at the same time. This can reduce treatment time significantly and produce results that are difficult to achieve in other ways.

Figures 10-20: Case study 2: Sinus augmentation surgery and dental implant placement at 6 months’ post-surgery. A lateral wall approach utilizing piezosurgery was taken in this case. The thin alveolar ridge needed block grafts. Allograft blocks were trimmed to the correct shape and thickness and fixed with fixation screws. Bovine bone and porcine membrane were placed over the blocks to reduce resorption. A periosteal releasing incision was made to achieve passive closure over the graft. Horizontal mattress sutures were employed to stabilize the flap and interrupted sutures. When the site was uncovered at 6 months, a good ridge width had been reconstructed for implant placement Volume 11 Number 1

Implant practice 27

CONTINUING EDUCATION

and esthetic results that are essential for a successful outcome (Schneider, et al., 2010). The reconstruction of tissue and bone through surgical procedures is well published and predictable. There are various techniques that can be used (Fu and Wang, 2012) such as guided bone regeneration and bone block grafting, as well as procedures such as socket preservation and sinus augmentation — all of which can be used to great effect in a wide range of indications for both functional and esthetic purposes.


CONTINUING EDUCATION

Figures 21-29: Case study 3: Socket preservation post extraction and dental implant placement at 4 months post-surgery. Periapical area draining UL1. The tooth was removed, and the socket curetted. No buccal plate was present. Allograft bone was placed into the socket and a porcine membrane placed to reconstruct the buccal plate. The site was left to heal for 4 months until uncovered for implant placement. Good bone reconstruction of the ridge was noted, and the implant placed, with no GBR needed

Grafting materials Bone grafting materials are derived from allograft (human), xenograft (animals from another species such as bovine or porcine), or alloplast (synthetic material). They work as scaffold and stimulate the body to form natural bone at the site of the dental implant. Barrier membranes are made from a biocompatible material and are used to promote growth and guide bone regeneration. These can be used with or without bone grafting material and protect and stabilize the bone graft. In addition, as gingival tissue grows faster than bone, the membrane effectively isolates the graft site, preventing gingival tissue from filling the area.

Block bone grafting The technique of block bone grafting aims to restore the original anatomy using an autogenous graft (from the patient’s body), or xenogeneic or allograft normally from elsewhere in the oral cavity or from a secondary site such as the intraforamen region or the ramus in the mandible. This grafting material is both osteoinductive and osteoconductive, which means it will induce the growth of new bone cells, and 28 Implant practice

allow growth of bone cells in and around it. These unique properties generally allow for quicker bone formation, but some clinicians find this technique challenging because both the donor site and the treatment site must be managed. However, it is very effective in cases where there is a significant defect in order to improve the integrity of the site. All materials work well, but the gold standard is to utilize human bone.

Sinus augmentation In some patients — for example, those who have had periodontal disease or have lost molar teeth for many years — the maxillary sinuses can be positioned in close proximity to the jaw. In these cases, it is common to complete sinus augmentation (or a sinus lift). This involves lifting the sinus membrane and placing a graft to develop bone height in order to accommodate a dental implant.

Socket preservation Socket preservation may help reduce the bone volume and dimensional changes following tooth extraction (Ten Heggeler, et

al., 2011). This procedure helps to compensate for the resorption of the facial bone wall and is particularly beneficial when dental implant placement needs to be delayed. By preserving the socket immediately after extraction, further bone augmentation at a later date may not be necessary. In addition, reducing bone resorption and promoting bone formation in this way increases the likelihood of dental implant survival. In an experienced clinician’s hands, these techniques and many others are very effective for improving bone and tissue volume in order to achieve optimal function and esthetics with dental implants. IP

REFERENCES 1. Fu JH, Wang HL. The sandwich bone augmentation technique. Clinical Advances in Periodontics. J Periodontal. 2012;2(3):172-177. 2. Schneider D, Grunder U, Ender A, Hämmerle CH, Jung RE. Volume gain and stability of peri-implant tissue following bone and soft tissue augmentation: 1-year results from a prospective cohort study. Clin Oral Implants Res. 2011;22(1):28-37. 3. Ten Heggeler JM, Slot DE, Van der Weijden GA. Effect of socket preservation therapies following tooth extraction in non-molar regions in humans: a systematic review. Clin Oral Implants Res. 2011;22(8):779-788. 4. Wang HL, Boyapati L. “PASS” principles for predictable bone regeneration. Implant Dent. 2006;15(1):8-17.

Volume 11 Number 1


The FMC is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing 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 12/1/2016 to 11/30/2018. Provider ID# 325231

Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 24 CE credits for only $149; call 866-579-9496 to subscribe today. To receive credit, complete the 10-question test by circling the correct answer, then either: n Post the completed questionnaire to: Implant Practice US CE 15720 N. Greenway-Hayden Loop. #9 Scottsdale, AZ 85260 n Fax to (480) 629-4002.

REF: IP V11.1 PATEL

FULL NAME

AGD REGISTRATION NUMBER

LICENSE NUMBER

ADDRESS

CITY, STATE, AND ZIP CODE

To provide feedback on this article and CE, please email us at education@medmarkmedia.com Legal disclaimer: The CE provider uses reasonable care in selecting and providing accurate content. The CE provider, however, does not independently verify the content or materials. Any opinions expressed in the materials are those of the author and not the CE provider. The instructional materials are intended to supplement, but are not a substitute for, the knowledge, skills, expertise and judgement of a trained healthcare professional.

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Understanding bone augmentation and regeneration PATEL

1. The reconstruction of tissue and bone through surgical procedures is _______. a. well published b. predictable c. unpredictable d. both a and b 2. ________ is a surgical technique where bone is regenerated using bone grafting material and a barrier membrane, maintaining a space over the grafting material into which osteogenic cells can migrate and colonize to form increased volume of bone. a. Sinus augmentation b. Socket preservation c. Guided bone regeneration, or GBR d. Porcine membrane integration

Predictable bone regeneration requires a high level of technical skill, as well as a comprehensive understanding of wound healing and the following main biological principles, known collectively as “PASS.” 4. P – primary wound closure to ensure undisturbed and uninterrupted _______ a. angiogenesis b. wound healing c. bone resorption d. bone augmentation 5. A – angiogenesis to provide necessary blood supply and undifferentiated _______ cells a. mesenchymal b. dendritic c. microglial d. Langerhans

3. Guided bone regeneration can be applied to __________ to build bone both vertically and horizontally. a. extraction sockets b. horizontal ridge augmentation c. the correction of defects around dental implants d. all of the above

6. S – space maintenance/creation to facilitate adequate space for _______ a. sinus augmentation b. clot stability c. predictable bone growth d. both b and c

7. _________ to induce blood clot formation and uneventful healing a. S — sterile surgical procedure

Questions 4-7 are regarding the main biological principles outlined in the following paragraph:

Volume 11 Number 1

b. S — sinus augmentation c. S — stability of wound and dental implant d. S — socket preservation 8. ________, GBR should be performed as an entirely separate procedure, and only when the site is sufficiently healed should dental implant surgery begin. a. In some situations b. In every case c. For quicker results d. When patients request 9. Bone grafting materials are derived from ______. a. allograft (human) b. xenograft (animals from another species such as bovine or porcine) c. alloplast (synthetic material) d. all of the above 10. These unique properties (osteoinduction and osteoconduction) generally allow for ________, but some clinicians find this technique challenging because both the donor site and the treatment site must be managed. a. slower bone formation b. quicker bone formation c. only the use of human bone d. reduction of gingival tissue

Implant practice 29

CE CREDITS

IMPLANT PRACTICE CE


CONTINUING EDUCATION

The era of monolithic translucent zirconia Drs. Despoina Chatzistavrianou, Shakeel Shahdad, and Philip Taylor evaluate the long-term outcomes of an increasingly popular restorative material

M

onolithic translucent zirconia restorations offer improved esthetics, minimal tooth reduction, and elimination of ceramic chipping compared to traditional zirconia cores with veneered ceramic, but the scientific evidence on the survival of this type of restoration is scarce. This article presents two case reports demonstrating rehabilitation with monolithic translucent zirconia restorations and discusses the clinical challenges of this treatment modality. A patient with history of trauma to her maxillary anterior teeth and a patient with amelogenesis imperfecta were rehabilitated with monolithic translucent zirconia restorations. After 16 and 9 months, respectively, the patients were satisfied with function and esthetics, and no complications were noticed in the restorations or the opposing teeth.

Introduction Yttria-stabilized zirconia polycrystalline (Y-TZP) ceramics were introduced as a biomaterial in restorative dentistry to eliminate the incidence of bulk fracture in all-ceramic restorations (Conrad, et al., 2007). They attracted the interests of clinicians due to their high flexural strength and fracture toughness (Guazzato, et al., 2004; Guazzato, et al., 2004). Their 5-year survival rate ranges from 93.5% to 97.8% for toothsupported prostheses and from 97.1% to 100% for implant-supported prostheses (Le, 2015; Larsson and Wennerberg, 2014; Sailer, et al., 2007). Chipping of the veneering ceramic with incidence of 15.7% has been reported as the

Educational aims and objectives

This article aims to present two clinical case studies demonstrating rehabilitation with monolithic translucent zirconia restorations.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 34 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Identify the clinical challenges of rehabilitation using monolithic translucent zirconia restorations.

Identify some characteristics of monolithic translucent zirconia restorations.

Realize some uses for monolithic translucent zirconia restorations.

Recognize wear and fracture resistance of monolithic translucent zirconia restorations.

Realize some common drawbacks of this material.

Preliminary outcomes show high survival rates both for full-arch and single-unit tooth and implant-supported prosthesis. most common complication both for toothand implant-supported prostheses (Sailer, et al., 2007; Sailer, et al., 2015; Pjetursson, et al., 2015). Also, this type of prosthesis requires heavy tooth reduction, and the reduced translucency of the core compromises the esthetic outcome — factors that limit their use (Goodacre, et al., 2001; Heffernan, et al., 2002). Recently, monolithic translucent zirconia restorations were introduced in an effort to eliminate chipping of the veneering material, allowing minimal occlusal and axial tooth reduction of 0.5 mm — compared to

Despoina Chatzistavrianou, DDS, MClinDent (Pros), MPros RCSEdin, MFDS RCS Ed, is a specialist in prosthodontics and specialty registrar in restorative dentistry at Birmingham Dental Hospital and University of Birmingham School of Dentistry in the United Kingdom. Shakeel Shahdad, BDS MMedSc, FDS RCSEd FDS (Rest Dent), RCSEd DDS, is a consultant and honorary senior clinical lecturer in restorative dentistry at The Royal London Dental Hospital and Queen Mary University of London, Barts and The London School of Medicine and Dentistry. Philip Taylor, BDS (Ncle), MGDS (RCS Eng), MSc (Lond), MRD RCS (RCS Eng,) FDS (RCS Edin), is a senior lecturer and honorary consultant in restorative dentistry at The Royal London Dental Hospital and Queen Mary University of London, Barts and The London School of Medicine and Dentistry.

30 Implant practice

conventional zirconia restorations, which require reduction of 1.5 mm-2 mm (Nakamura, et al., 2015). The fracture resistance of monolithic translucent zirconia restorations is considerably higher than that of veneered zirconia cores and glass ceramics (Johansson, et al., 2014), but a minimal thickness of 0.5 mm is essential for optimal mechanical properties (Nakamura, et al., 2015). Monolithic translucent zirconia restorations show less wear to the antagonist tooth compared to traditional zirconia cores and glass ceramics (Mundhe, et al., 2015; Rosentritt, et al., 2012; Cardelli, et al., 2015), irrespective of whether they are polished or glazed (Jung, et al., 2010). Careful polishing is recommended after adjusting the prosthesis to keep surface roughness and phase transformation low (Preis, 2015). Furthermore, the increased translucency of monolithic translucent zirconia restorations results in improved esthetic outcomes compared to traditional zirconia cores (Harianawala, 2014). Volume 11 Number 1


CONTINUING EDUCATION

The introduction of a variety of shades, application of coloring liquids to the core, and staining of the occlusal surface improves the esthetic properties of monolithic zirconia restorations (Rinke and Fischer, 2013). Besides, they are claimed to be costeffective restorations as ceramic veneering is not required. Preliminary outcomes show high survival rates both for full-arch and single-unit toothand implant-supported prosthesis (Carames, et al., 2015; Venezia, et al., 2015; Moscovitch, 2015). Carames, et al., 2015, followed 14 patients with full-arch implant-supported prostheses for 24 months and showed a 96% survival rate. Other studies (Venezia, et al., 2015; Moscovitch, 2015) have shown 100% survival over a 36- and 68-month follow-up period. The aim of this article is to present two case reports of patients who were rehabilitated with monolithic translucent zirconia restorations and discuss the clinical challenges of this treatment modality.

Figure 1: Preoperative labial view showing the traumatized maxillary anterior teeth

Clinical report 1 A 25-year-old female patient with a history of trauma to her maxillary anterior teeth presented requiring restoration of the traumatized teeth. The fractured maxillary central incisors were provisionally restored with composite restorations, and the maxillary lateral incisors had fractured at the cervical margin. Intraoral and radiographic examination confirmed the diagnoses of failing restorations in the maxillary central incisors, an intruded maxillary right central incisor, and chronic apical periodontitis in the two maxillary incisors. The maxillary lateral incisors were retained as roots (Figures 1 and 2). The treatment plan included full-coverage crowns to restore the maxillary central incisors and single-tooth implant-supported crowns to replace the maxillary lateral incisors. A high lip line and the patient’s high esthetic expectations indicated the use of all-ceramic restorations to restore the traumatized teeth. The preoperative treatment planning was based on the SAC assessment tool (Dawson, et al., 2009) and involved diagnostic wax-ups, cone beam computed tomography (CBCT), and use of radiographic and surgical stents (Mericske-Stern, et al., 2000). Root canal treatment was performed in the maxillary central incisors prior to implant placement Volume 11 Number 1

Figure 2: Preoperative occlusal view showing the traumatized maxillary anterior teeth

Figure 3: Postoperative labial view showing the monolithic translucent zirconia restorations

Figure 4: Postoperative occlusal view showing the monolithic translucent zirconia restorations

to eliminate any active infection (Martin, et al., 2009). Type II (early-delayed) implant placement surgery with simultaneous guided bone regeneration was performed in the maxillary lateral incisor sites to augment ridge contour with deproteinized bovine bone and porcine collagen membrane (Geistlich Bio-Oss® and Bio-Gide®) (Buser, et al., 2009; Hämmerle, et al., 2004; Chen, et al., 2009). Crown lengthening surgery was performed in the upper left central incisor at the time of implant placement to correct the irregular gingival contour.

After an uneventful 3-month healing period, provisional restorations were placed in the maxillary lateral incisors to create an optimal emergence profile. Provisional crowns were also placed on the two central incisors based on the diagnostic wax-up aiming to assess function and esthetics (Jemt, 1999; Moscovitch and Saba, 1996; Lewis, et al., 1995). Lithium disilicate cement-retained crowns (IPS e.max®, Ivoclar Vivadent) on zirconia abutments (Straumann® CARES® abutment, zirconium dioxide) were planned as definitive restorations for the lateral incisors and Implant practice 31


CONTINUING EDUCATION the monolithic translucent zirconia crowns (Straumann® CARES® monolithic restorations) for the central incisors (Stawarczyk, et al., 2011). As a result of trauma, the remaining tooth structure in the central incisors was limited and mainly presented palatally. The use of monolithic translucent zirconia crowns allowed minimal tooth reduction of 0.5 mm palatally and 1 mm labially. The zirconia abutments and cores were scanned with a CS2 scanner and the CARES Visual software (Straumann® CARES® System 8.0) (Kapos and Evan, 2014). The monolithic translucent zirconia crowns for the central incisors were stained to optimize the esthetic outcome (Rinke and Fischer, 2013). The zirconia abutments were screwed and tightened to 35Ncm on each implant, and the screw access holes were sealed with composite restorative material. Subsequently, the implant crowns were cemented using soft temporary cement (Temp-Bond™, Kerr) (Mehl, et al., 2008). The monolithic translucent zirconia crowns on the central incisors were cemented with a resinous cement with zirconia primer (Multilink® Automix, Ivoclar Vivadent) (Thompson, et al., 2011). The patient was satisfied with the functional and esthetic outcome at the end of the treatment, and no complications were noticed at the 16-month review appointment.

Clinical report 2 A 25-year-old female patient with amelogenesis imperfecta required restorations of her posterior teeth to improve function and eliminate tooth sensitivity. The maxillary and mandibular anterior teeth were previously restored with definitive restorations. Intraoral and radiographic examination confirmed the diagnoses of hypocalcified type of amelogenesis imperfecta and acquired tooth loss of the mandibular right first molar (Figures 5 and 6) (Gadhia, et al., 2012). The treatment plan involved adhesive onlays to restore the maxillary and mandibular posterior teeth. Inadequate interocclusal space was present between the molar teeth, and the patient was not willing to accept metal restorations for the definitive prostheses. Preparation for glass ceramic onlays could have detrimental effects on the tooth vitality. Monolithic translucent zirconia onlays on the molar teeth were planned to facilitate the 32 Implant practice

Figure 5: Preoperative occlusal view of the maxillary teeth

Figure 6: Preoperative occlusal view of the mandibular teeth

Figure 7: Postoperative maxillary occlusal view showing the monolithic translucent zirconia restorations

Figure 8: Postoperative mandibular occlusal view showing the monolithic translucent zirconia restorations

rehabilitation allowing minimal tooth reduction of 0.5 mm. The preoperative treatment planning involved articulated study models and diagnostic wax-ups (Malik, et al., 2012). After completion of the diagnostic stages of the treatment plan, the definitive restorations were constructed using monolithic translucent zirconia onlays (Straumann CARES monolithic restorations) for the molar teeth and lithium disilicate onlays (IPS e.max, Ivoclar Vivadent) for the premolar teeth (Malik, et al., 2012). The casts were scanned with CS2 scanner and the CARES Visual software (Straumann CARES System 8.0) (Kapos and Evans, 2014). Subsequently, the restorations were stained to achieve an optimal color match (Rinke and Fischer, 2013). All restorations were cemented with a resinous cement with zirconia primer (Multilink Automix, Ivoclar Vivadent) (Figures 7 and 8) (Thompson, et al., 2011). The patient was satisfied with the functional and esthetic outcome at the end of the treatment, tooth sensitivity was controlled, and no complications were noticed in the

teeth or restorations at the 9-month review appointment.

Discussion The literature review revealed that the long-term survival of monolithic translucent zirconia restorations lacks evidence. Nevertheless, improved properties regarding esthetics, tooth reduction, and ceramic chipping in comparison to traditional zirconia cores are reported (Nakamura, et al., 2015; Jung, et al., 2010; Harianawala, et al., 2014). Preliminary outcomes show high survival rates for full-arch and single-unit tooth- and implant-supported prosthesis (Carames, et al., 2015; Venezia, et al., 2015; Moscovitch, 2015), but longer observation periods are necessary to draw definitive conclusions. Traditionally, metal restorations have been used in patients with developmental conditions, especially in cases of reduced interocclusal space, which show good longterm outcomes but compromised esthetics (Gadhia, et al., 2012; Malik, et al., 2012). Monolithic translucent zirconia restorations could offer an alternative restorative material in cases of reduced interocclusal space where esthetic requirements are Volume 11 Number 1


Improved properties regarding esthetics, tooth reduction, and ceramic chipping in comparison to traditional zirconia cores are reported. monitor the integrity of the prostheses, the condition of the abutment teeth, and to identify any complications at an early stage.

promising results, but longer observation periods are necessary as the use of monolithic translucent zirconia increases.

Summary

Acknowledgments

Monolithic translucent zirconia restorations may offer improved esthetics, minimal tooth reduction, and elimination of ceramic chipping compared to traditional zirconia cores and conventional metal restorations. However, there is limited evidence on the survival of monolithic translucent zirconia restorations. Preliminary outcomes suggest

The authors would like to thank Alaa Abou Hasan (dental technician, Ceramic Studios Ltd., London) for the ceramic work and Kali Ranshi (specialty registrar in restorative dentistry, The Royal London Dental Hospital and Queen Mary University of London, Barts and The London School of Medicine and Dentistry, London, UK) for her contribution in the second clinical case toward the completion of the definitive restorations of the anterior teeth. IP

REFERENCES 1. Buser D, Halbritter S, Hart C, et al. Early implant placement with simultaneous guided bone regeneration following single-tooth extraction in the esthetic zone: 12-month results of a prospective study with 20 consecutive patients. J Periodontol. 2009;80(1):152-162. 2. Carames J, Tovar Suinaga L, Yu YC, Pérez A, Kang M. Clinical advantages and limitations of monolithic zirconia restorations full arch implant supported reconstruction: case series. Int J Dent. 2015;392496 3. Cardelli P, Manobianco FP, Serafini N, Murmura G, Beuer F. Full-arch, implant-supported monolithic zirconia rehabilitations: pilot clinical evaluation of wear against natural or composite teeth. J Prosthodont. 2016;25(8):629-633. 4. Chen ST, Beagle J, Jensen SS, Chiapasco M, Darby I. Consensus statements and recommended clinical procedures regarding surgical techniques. Int J Oral Maxillofac Implants. 2009;24(suppl):272-278. 5. Conrad HJ, Seong WJ, Pesun IJ. Current ceramic materials and systems with clinical recommendations: a systematic review. J Prosthet Dent. 2007;98(5):389-404. 6. Esthetic Modifiers. In: The SAC Classification in Implant Dentistry. Chen S, Dawson A, eds. 2009; Berlin: Quintessence Publishing. 7. Arkutu N, Gadhia K, McDonald S, Malik K, Currie L. Amelogenesis imperfecta: the orthodontic perspective. Br Dent J. 2012;212(10):485-489. 8. Goodacre CJ, Campagni WV, Aquilino SA. Tooth preparations for complete crowns: an art form based on scientific principles. J Prosthet Dent. 2001;85(4):363-376. 9. Guazzato M, Albakry M, Ringer SP, Swain MV. Strength, fracture toughness and microstructure of a selection of all-ceramic materials. Part I. Pressable and alumina glass-infiltrated ceramics. Dent Mater. 2004;20(5):441-448. 10. Guazzato M, Albakry M, Ringer SP, Swain MV. Strength, fracture toughness and microstructure of a selection of all-ceramic materials. Part II. Zirconia-based dental ceramics. Dent Mater. 2004;20(5):449-456. 11. Hämmerle CH, Chen ST, Wilson TG. Consensus statements and recommended clinical procedures regarding the placement of implants in extraction sockets. Int J Oral Maxillofac Implants. 2004;19:26-28. 12. Harianawala HH, Kheur MG, Apte SK, Kale BB, Sethi TS, Kheur SM. Comparative analysis of transmittance for different types of commercially available zirconia and lithium disilicate materials. J Adv Prosthodont. 2014;6(6):456-661. 13. Heffernan MJ, Aquilino SA, Diaz-Arnold AM, Haselton DR, Stanford CM, Vargas MA. Relative translucency of six all-ceramic systems. Part II: core and veneer materials. J Prosthet Dent. 2002;88(1): 10-15. 14. Jemt T. Restoring the gingival contour by means of provisional resin crowns after single-implant treatment. Int J Periodontics Restorative Dent. 1999;19(1):20-29. 15. Johansson C, Kmet G, Rivera J, Larsson C, Vult Von Steyern P. Fracture strength of monolithic all-ceramic crowns made of high translucent yttrium oxide-stabilized zirconium dioxide compared to porcelain-veneered crowns and lithium disilicate crowns. Acta Odontol Scand. 2014;72(2):145-153. 16. Jung YS, Lee JW, Choi YJ, Ahn JS, Shin SW, Huh JB. A study on the in-vitro wear of the natural tooth structure by opposing zirconia or dental porcelain. J Adv Prosthodont. 2010;2(3):111-115. 17. Kapos T, Evans C. CAD/CAM technology for implant abutments, crowns, and superstructures. Int J Oral Maxillofac Implants. 2014;29(suppl):117-136.

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18. Larsson C, Wennerberg A. The clinical success of zirconia-based crowns: a systematic review. Int J Prosthodont. 2014;27(1):33-43. 19. Le M, Papia E, Larsson C. The clinical success of tooth and implant-supported zirconia-based fixed dental prostheses. A systematic review. J Oral Rehabil. 2015;42(6):467-480. 20. Lewis S, Parel S, Faulkner R. Provisional implant-supported fixed restorations. Int J Oral Maxillofac Implants. 1995;10(3):319-325. 21. Malik K, Gadhia K, Arkutu N, McDonald S, Blair F. The interdisciplinary management of patients with amelogenesis imperfecta - restorative dentistry. Br Dent J. 2012;212(11):537-542. 22. Martin W, Lewis E, Nicol A. Local risk factors for implant therapy. Int J Oral Maxillofac Implants. 2009;24(suppl):28-38. 23. Mehl C, Harder S, Wolfart M, et al. Retrievability of implant-retained crowns following cementation. Clin Oral Implants Res. 2008;19:1304-1311. 24. Mericske-Stern RD, Taylor TD, Belser U. Management of the edentulous patient. Clinical Oral Implants Research. 2000;11(suppl):108-125. 25. Moscovitch MS, Saba S. The use of a provisional restoration in implant dentistry: a clinical report. Int J Oral Maxillofac Implants. 1996;11(3):395-399. 26. Moscovitch M. Consecutive case series of monolithic and minimally veneered zirconia restorations on teeth and implants: up to 68 months. Int J Periodontics Restorative Dent. 2015;35(3):315-323. 27. Mundhe K, Jain V, Pruthi G, Shah N. Clinical study to evaluate the wear of natural enamel antagonist to zirconia and metal ceramic crowns. J Prosthet Dent. 2015;114(3):358-363. 28. Nakamura K, Harada A, Inagaki R, et al. Fracture resistance of monolithic zirconia molar crowns with reduced thickness. Acta Odontol Scand. 2015;30:1-7. 29. Pjetursson BE, Sailer I, Makarov NA, Zwahlen M, Thoma DS. All-ceramic or metal-ceramic tooth-supported fixed dental prostheses (FDPs)? A systematic review of the survival and complication rates. Part II: Multiple-unit FDPs. Dent Mater. 2015;31(6):624-639. 30. Preis V, Schmalzbauer M, Bougeard D, Schneider-Feyrer S, Rosentritt M. Surface properties of monolithic zirconia after dental adjustment treatments and in vitro wear simulation. J Dent. 2015; 43(1):133-139. 31. Rinke S, Fischer C. Range of indications for translucent zirconia modifications: clinical and technical aspects. Quintessence Int. 2013;44(8):557-66) 32. Rosentritt M, Preis V, Behr M, Hahnel S, Handel G, Kolbeck C. Two-body wear of dental porcelain and substructure oxide ceramics. Clin Oral Investig. 2012;16(3):935-943. 33. Sailer I, Fehér A, Filser F, Gauckler LJ, Lüthy H, Hämmerle CH. Five-year clinical results of zirconia frameworks for posterior fixed partial dentures. Int J Prosthodont. 2007;20(4):383-388 34. Sailer I, Makarov NA, Thoma DS, Zwahlen M, Pjetursson BE. All-ceramic or metal-ceramic tooth-supported fixed dental prostheses (FDPs)? A systematic review of the survival and complication rates. Part I: Single crowns (SCs). Dent Mater. 2015;31(6):603-623. 35. Stawarczyk B, Ozcan M, Roos M, Trottmann A, Hämmerle CH. Fracture load and failure analysis of zirconia single crowns veneered with pressed and layered ceramics after chewing simulation. Dental Materials Journal. 2011;30(4):554-562. 36. Thompson JY, Stoner BR, Piascik JR, Smith R. Adhesion/cementation to zirconia and other non-silicate ceramics: where are we now? Dent Mater. 2011;27(1):71-82. 37. Venezia P, Torsello F, Cavalcanti R, D’Amato S. Retrospective analysis of 26 complete-arch implant-supported monolithic zirconia prostheses with feldspathic porcelain veneering limited to the facial surface. J Prosthet Dent. 2015;114(4):506-512.

Implant practice 33

CONTINUING EDUCATION

critical, allowing minimal tooth reduction of 0.5 mm (Nakamura, et al., 2015). Careful polishing after adjusting the zirconia surfaces to prevent wear to the opposing teeth and cementation with a resinous cement with zirconia primer are prerequisite to a successful outcome (Preis, et al., 2015; Rinke and Fischer, 2013). There are limitations on the use of monolithic zirconia restorations. Their fabrication requires computer-aided design and computer-aided manufacturing (CAD/ CAM) technology and a multi-step polishing protocol after occlusal adjustment, which requires a variety of special diamond burs, diamond-impregnated silicone instruments, and diamond pastes. Besides, there is no evidence regarding the effect on the survival of the prostheses or the opposing teeth if the surface glaze wears off. Regular review appointments and individualized maintenance are suggested to


The FMC is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing 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 12/1/2016 to 11/30/2018. Provider ID# 325231

Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 24 CE credits for only $149; call 866-579-9496 to subscribe today. To receive credit, complete the 10-question test by circling the correct answer, then either: n Post the completed questionnaire to: Implant Practice US CE 15720 N. Greenway-Hayden Loop. #9 Scottsdale, AZ 85260 n Fax to (480) 629-4002.

REF: IP V11.1 CHATZISTAVRIANOU

FULL NAME

AGD REGISTRATION NUMBER

LICENSE NUMBER

ADDRESS

CITY, STATE, AND ZIP CODE

To provide feedback on this article and CE, please email us at education@medmarkmedia.com Legal disclaimer: The CE provider uses reasonable care in selecting and providing accurate content. The CE provider, however, does not independently verify the content or materials. Any opinions expressed in the materials are those of the author and not the CE provider. The instructional materials are intended to supplement, but are not a substitute for, the knowledge, skills, expertise and judgement of a trained healthcare professional.

EMAIL

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Please allow 28 days for the issue of the certificates to be posted.

Your CE certificate(s) will be emailed to the address you provided above. Please add medmarkmedia.com to your Approved Senders List in your email account. You may need to check your junk/spam folder for your certificate email.

The era of monolithic translucent zirconia CHATZISTAVRIANOU, ET AL.

1. Yttria-stabilized zirconia polycrystalline (Y-TZP) ceramics were introduced as a biomaterial in restorative dentistry to eliminate the incidence of bulk fracture in _________ restorations. a. all-ceramic b. porcelain-fused-to-metal c. stainless steel d. gold 2. (Y-TZP biomaterials) attracted the interests of clinicians due to their ________. a. high flexural strength b. fracture toughness c. low cost d. both a and b 3. Chipping of the veneering ceramic with incidence of _______ has been reported as the most common complication both for tooth-and implant-supported prostheses. a. 15.7% b. 24.7% c. 32.9% d. 43.3% 4. Also, this type of prosthesis requires heavy tooth reduction, and the reduced translucency of the core compromises the esthetic outcome — factors that _______.

Volume 11 Number 1

a. b. c. d.

increase their fracture resistance make polishing unnecessary limit their use increase their popularity

5. Recently, monolithic translucent zirconia restorations were introduced in an effort to eliminate chipping of the veneering material, allowing minimal occlusal and axial tooth reduction of 0.5 mm — compared to conventional zirconia restorations, which require reduction of ______. a. 1.5 mm-2 mm b. 2.5 mm-3 mm c. 3.5 mm-4 mm d. 5.5 mm-6 mm 6. The fracture resistance of monolithic translucent zirconia restorations is considerably higher than that of veneered zirconia cores and glass ceramics, but a minimal thickness of ______ is essential for optimal mechanical properties. a. 0.2 mm b. 0.5 mm c. 1 mm d. 1.5 mm 7. Monolithic translucent zirconia restorations show _______ wear to the antagonist tooth compared to traditional zirconia cores and

glass ceramics, irrespective of whether they are polished or glazed. a. more b. equal c. less d. considerable 8. Careful polishing ________ after adjusting the prosthesis to keep surface roughness and phase transformation low. a. is recommended b. should be avoided c. is not a prudent option d. none of the above 9. The ________ improves the esthetic properties of monolithic zirconia restorations. a. introduction of a variety of shades b. application of coloring liquids to the core c. staining of the occlusal surface d. all of the above 10. Preliminary outcomes show _______ survival rates for both full-arch and single-unit tooth and implant-supported prosthesis. a. reduced b. low c. high d. substantial

Implant practice 34

CE CREDITS

IMPLANT PRACTICE CE


SMALL TALK

Five powerful leadership and culture-building statements Dr. Joel C. Small discusses how to cultivate shared values and a common purpose

E

dgar Schein, a noted authority on the subject of organizational culture, has stated that the primary job of a leader is to establish an organization’s culture. An organizational culture is considered to be the guiding principles that dictate how people work together to achieve a common goal. It has its foundation in shared values and a common purpose as well as other less tangible beliefs and assumptions shared by members of the organization. Schein is not alone in his opinion as other distinguished authorities refer to the undeniable link between leadership and an organization’s culture. The leader is both the architect and the guardian of an organizational culture. Unfortunately, many of us fail to realize that we serve in this capacity and that like it or not, we cannot delegate this vital role that is so essential to organizational health. We have only to observe well-functioning, highly productive clinical practices to substantiate this statement. If we could pull back the curtain, we would find that every successful, highly productive, and well-functioning clinical practice has two essential ingredients — an engaged leader and a strong culture. Having studied and witnessed both effective and ineffective leadership practices in healthcare organizations, I have come to the conclusion that there are certain types of statements that serve to define a strong leader and help build an optimal culture. It is not necessary to use these phrases in their exact form. Please change them to suit your specific comfort zone. My purpose is to present a different style of communication that has been shown to be highly effective in

promoting strong leadership and developing optimal cultures.

“Tell me what you think.” I know of no better way to empower staff and provide them with a sense of relevance than to ask their opinion on important practice-related issues. They not only will feel more a part of the team, but also will be more willing to offer helpful suggestions in the future. We will be more prone to ask for their feedback as well because we will likely find that they have valuable insights. Like my coach often says, “No one is as smart as all of us!”

“I’m sorry. I made a mistake.” I am a firm believer that unless we are willing to be vulnerable, we will never fully realize our leadership potential. We often worry too much about being “right” and fail to acknowledge the importance of being “real.” Our team appreciates that we are knowledgeable, but they also want us to be approachable. A healthy mixture of both is the proper prescription for sound leadership and a healthy culture.

“How can I best support you?” Checking in with team members is an important way to let them know that we care about them and what they are doing. This is also helpful in ensuring that team members feel as though they have received adequate resources and training to complete tasks. Ultimately, we will no longer need to ask. As our team realizes that we are interested in their success, they will willingly let us know what they need to be successful.

Joel C. Small, DDS, MBA, ACC, FICD, is a practicing endodontist and the author of Face to Face: A Leadership Guide for Healthcare Professionals and Entrepreneurs. He received his MBA, with an emphasis in healthcare management, from Texas Tech University. He is a graduate of the University of Texas at Dallas postgraduate program in executive coaching and limits his coaching practice to motivated healthcare professionals. He is a nationally recognized speaker on the subjects of leadership and professional development. Dr. Small is available for speaking engagements and for coaching healthcare professionals who wish to experience personal and professional growth while taking their practices to a higher level of productivity.

“How does this action align with our practice values?” When actions and decisions are aligned with our shared values, our culture is operating at peak performance. Post the practice’s values throughout the office for everyone to see and refer to. (You do have shared values for your practice, right?) Whenever we need to evaluate our actions or decisions, we should ask this question of ourselves and others. There is no greater form of accountability than living our values.

“No one is perfect, including you and me.” Mistakes will happen. What is important is to determine the intent. If someone has the right intention but makes a mistake, we have an incredible opportunity to show what leadership and culture is all about. This is a time to soothe the pain rather than demean the person. By accepting a well-intended misstep, we are then able to create a powerful teachable moment by asking a critical question: “What did you learn from this?” I can almost guarantee that you will notice significant positive change in your staff’s attitude and performance if you become comfortable using these phrases. How do I know that communicating in this manner is effective? I know this because this form of communication is the foundation of executive coaching and has a long and proven track record for achieving results. Currently, I am working on a program designed to bring a coaching culture to clinical healthcare practices. The concept is to train healthcare professionals in basic coaching concepts, so they can improve their leadership skills and create a strong vibrant culture in their practice. Expect to hear more about this in the near future. *If you have not already defined your practice values, please contact me and I will send you a step-by-step practice value exercise. IP

*To receive a free copy of my “Core Values Exercise,” please contact me at joel@joelsmall.com. I am also available for a complimentary coaching session to discuss your practice-related issues.

Volume 11 Number 1

Implant practice 35


INDUSTRY NEWS Palmero™ introduces new pink safety eyewear to support National Breast Cancer Foundation Palmero™ Healthcare, a Hu-Friedy subsidiary, is adding a lightweight, disposable, cost-effective alternative eye protection, which reduces eye splash contamination incidents, to its line of Dynamic Disposables. A cost-effective alternative to traditional protective glasses, Dynamic Disposables can be worn comfortably with a clinician’s own prescription glasses. The lenses on our entire disposables line feature self-closing holes to prevent gaps and meet the OSHA and the CDC guidelines for protective eyewear. When the new pink safety eyewear is purchased, 5% of the proceeds will be donated to the National Breast Cancer Foundation, Inc.® To contact customer care, email customerservice@palmero health.com.

Intelligent Updates to CS 3600 software makes implant workflow smarter The new intelligent scanning features of Carestream’s CS 3600 intraoral scanner make it easier to capture scans correctly on the first try, making scanning more efficient and resulting in higher quality scans before they’ve even been rendered. Missing information is color-coded to indicate either holes or gaps, and guide arrows recommend the best direction to scan to recapture the data. The ability to scan in high resolution also improves quality and clinical details. The scanner’s dedicated workflow, designed specifically for implant-borne restorative scanning, supported abutments, and scanbodies, has also been updated with new features to make the digital implant workflow faster, smarter, and more efficient. When using multiple scanbodies on a single case, the new scanbody area selection tool lets users select the region around the scanbody to prevent an image mismatch. Then users unselect the area where the scanbody is located. Finally, the new scan replaces only the area within the selected area. Also new for all scanning workflows is color-coded occlusion mapping and a smaller third tip size. The new tip is the shortest autoclavable tip available and is designed for posterior scanning. All three of the CS 3600’s tips can be autoclaved up to 60 times.* To learn more, call 800-944-6365, or visit www.carestream dental.com. * Tips can be autoclaved up to 60 times if the exposure is limited to 134˚C at no more than 4 minutes and if gauze is used, as outlined in the CS 3600 Family Safety, Regulatory, and Technical Specifications User Guide (9J8269).

Implant Direct’s rebranding initiative will align the company’s strengths and values with branded imaging Originally launched as an online direct brand, Implant Direct has outgrown the “value” designation, transforming itself into a fullspectrum provider with a significant footprint in both the education and support elements of the dental implant profession. This evolving identity will be reflected in a new brand identity for Implant Direct that is being rolled out. “Because we entered the field as an online direct business, it’s important for clinicians to know that we have always held ourselves to the highest of standards,” said David Painter, Vice President of Commercial Operations at Implant Direct. “We felt this was an opportune time to begin transforming our brand identity to better reflect the depth of our expertise and ability to meet the changing demands of the marketplace. At the same time, we will continue evolving our position within the implant space including expanding the scope of our Customer Care and Support Center, expanding access to implant procedures and growing the overall implant market.” Implant Direct is part of the Danaher family along with Kavo Kerr, Nobel Biocare, and Ormco. For more information, visit http:// www.implantdirect.com/. 36 Implant practice

“Inspiring Imagination – Enhancing Health” is the theme for AO’s 2018 Annual Meeting in Los Angeles For clinicians who are interested in learning the newest techniques, observing demonstrations of the latest technologies, and interacting in discussions about the current issues affecting implant dentistry, the Academy of Osseointegration’s (AO) 2018 Annual Meeting will be hosted in Los Angeles, California, February 28 – March 3, 2018. The new formats AO will be introducing include: • Concurrent surgical and restorative sessions with a new point-counterpoint format. • “Reflection Panel” as part of the closing session. • Lunch with the Masters program. Continuing AO’s tradition of supporting research and innovation, the Oral Clinical and Oral Scientific Research and Clinical Innovations presentations will take place on Friday, March 2, 2018. With more than 250 abstracts and e-posters submitted for the 2018 Annual Meeting, attendees can get a first-hand look at a wealth of original and groundbreaking research conducted by its international implant dentistry member community. For more information, visit http://meetings.osseo.org/2018/. Volume 11 Number 1


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INDUSTRY NEWS American Academy of Implant Dentistry names Honored Fellows and Outstanding Dentists The American Academy of Implant Dentistry (AAID) named six dentists from around the world to the coveted status of Honored Fellow at its recently concluded 66th Annual Conference. The Honored Fellow designation is awarded to those members of the AAID who through their professional, clinical, research, or academic endeavors, have distinguished themselves within implant dentistry. Named as Honored Fellows were George Arvanitis, DDS (Waterloo, Ontario, Canada); Kirk Kalagiannis, DMD (Lyndhurst, New Jersey); Philip J. Kroll, DDS (Ventura, California); D. Timothy Pike, DDS (Rockville, Maryland); Dale Edward Spencer, DDS (Hickory, North Carolina); and Dr. Atsushi Takahashi (Tokyo, Japan). The following Outstanding Dentists also won awards: Alfred “Duke” Heller, DDS, MS, FAAID, DABOI/ID, of Lewis Center, Ohio, received the Aaron Gershkoff/Norman Goldberg Memorial Award that recognizes outstanding contribution to the AAID and the field of implant dentistry. Salah Huwais, DDS, FAAID, DABOI/ID, of Jackson, Michigan, received the Isaih Lew Memorial Research Award, presented by the AAID Foundation to an individual who has contributed significantly to research in implant dentistry. Hamilton Sporborg, DDS, FAAID, DABOI/ID, of Chatham, Massachusetts, received the 2017 Paul Johnson Service Award, which recognizes outstanding service to the AAID as exemplified by the late Dr. Paul Johnson. Mahesh Verma, MDS, MBA, PhD, of India has been chosen to receive the International Dentist of the Year Award. Established in 1951, the AAID’s membership now exceeds 6,000, including general dentists, oral surgeons, periodontists, and prosthodontists from the United States and in more than 60 other countries. For more information about the AAID, visit www.aaid.com, or call the AAID at 312-335-1550.

Karl Schumacher Dental debuts new PrecísPoint™ suture needles and launches comprehensive suite of regenerative products Using the ideal alloy to create premium suture needles, the PrecísPoint™ unique laser-drilled needles are designed to reduce tissue disruption. The silicone-coated needle ensures a smoother tissue passage, and with a finer point geometry, the needle stays sharper after multiple penetrations. The needle diameter adjusts according to the size of the attached suture material for a smooth transition from the needle to the suture. The company has also launched a new family of regenerative products that includes allograft, xenograft, synthetic, collagen membranes, and dental wound dressings. The allograft particulate, putty, and paste are used in oral surgical applications, socket preservation, periodontal defect regeneration, dental implant bone regeneration, sinus lifts, and ridge augmentation procedures. All allograft tissue is recovered in the United States under the most stringent screening and testing protocols. The xenograft particulate is an osteoconductive, porous, anorganic bone mineral with carbonate apatite structure derived from porcine cancellous bone, and the synthetic putty is a synthetic mineral-collagen composite bone graft matrix for use in bone repair during oral surgeries. The membranes are ideal for guided bone regeneration, socket preservation, alveolar ridge reconstruction, and augmentation around implants placed in immediate extraction or delayed extraction sockets. For more information visit www.karlschumacher.com.

Affordable Dentures & Implants partners with Brighter Way Institute Affordable Dentures & Implants is partnering with Brighter Way Institute of Phoenix, Arizona, for a nationwide program to deliver free dental implant, oral surgery, and prosthetic treatment to hundreds of U.S. military veterans and homeless citizens. The network of affiliated dental practices set a goal of contributing nearly $3.25 million in pro bono implant and prosthetic services in 2017. Affordable Dentures & Implants announced that it exceeded its goal and donated more than $3.5 million in dental services in 2017. Overall, 120 doctors from more than 20 states participated in the six Brighter Way events, where approximately 1,500 implants were placed and approximately 350 denture pieces were fabricated. Affordable Dentures & Implants looks forward to continuing the program in 2018 and again has six Brighter Way events scheduled. The company hopes to meet and exceed the level of donated care given in 2017. For information, visit https://www.affordabledentures.com/. 38 Implant practice

Glidewell Dental announces distribution of Align Technology’s iTero Element® scanner with glidewell. io™ In-office Solution Glidewell Dental announced an agreement with Align Technology, Inc., to distribute the iTero Element® intraoral scanning system in North America with the newly unveiled glidewell.io™ In-Office Solution, a chairside restorative ecosystem set to simplify the process of prescribing and delivering laboratory-quality dental restorations. The glidewell.io Solution will provide a streamlined workflow with Align’s iTero Element scanner and Glidewell’s fastdesign.io™ Software, which serves to auto-design restorations for the clinician’s approval or communicate with the lab’s digital design experts as needed. Final designs can be used to prescribe a laboratory restoration or sent to the fastmill.io™ In-Office Unit for immediate chairside milling. For more information, visit glidewelldental.com. Volume 11 Number 1


LEARN IMPLANT DENTISTRY IN FOUR SESSIONS FROM DR. JUSTIN MOODY AND HIS FACULTY, ONE OF THE MOST CREDENTIALED TEAMS OF IMPLANTOLOGISTS IN THE COUNTRY.

J U ST I N M O O DY, D D S

UPCOMING SESSIONS RALEIGH, NORTH CAROLINA APRIL 6 + 7 // MAY 18 + 19, 2018 CHICAGO, ILLINOIS JUNE 8 + 9 // JULY 13 + 14, 2018 DALLAS, TEXAS SEPT. 13 + 14 // OCT. 12 + 13, 2018

REGISTER ONLINE AT IMPLANTPATHWAY.COM OR CALL (888) 309-2423


ON THE HORIZON

Digital implant workflow as we know it today Dr. Justin Moody discusses diving into the digital workflow

D

igital dentistry is a focal point in dentistry, and it has been for many years now. Having been a dentist for 20 years, I have seen the first step in most people’s journey — the conversion from film to digital radiographs. I would bet that digital imaging has been implemented in over 95% of the offices today, and certainly the younger dentists have not worked with traditional film. CBCT is increasing in popularity and usage too. Years ago, I bought one of the first CBCT units in private practice in my state at a cost of $225,000. Today, you can get a good machine for far less, often under $100,000. A reduction in pricing is something you don’t see in dentistry every day! Digital restorations are now what dentists think of first when we are asked for the uses of digital dentistry. In the beginning, there was a scanner on a big bulky cart with a mill at thousands of dollars of investment, and you can still go that route for sameday crowns in your office, which is great. But today, all dentists can truthfully afford to go digital by scan-only sending to a lab of their choice. Implant dentistry workflow in my office is fun. It starts with the CBCT and software to virtually plan the case from virtual restoration to implant delivery via a surgical guide. I use an intraoral scanner to create both the surgical guide and the final impression for the restoration. But the digital portion doesn’t stop there — today’s dental laboratories are nearly 100% digital and can accept the scans, 3D print, and mill the restorations. With all of these innovations not only on the horizon, but already in practice in many dental offices, it’s time to hop off the fence, embrace the digital age, and get started! IP

Figure 1: Implant planning software from Carestream Dental showing nerve position, integration of the IOS scan of the patient, and virtual implant/crown placement

Figure 2: imes-icore® GmbH mills used in the fabrication of today’s restorations

Figure 3: Full arch zirconia restoration with hand-stacked gingival porcelain created by Josh Hoffman and Nick Herbert at ProSmiles Dental Studios

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®.

40 Implant practice

Figure 4: BioHorizons® 4.6 digital scan body

Figure 5: 3D Digital image rendering from the i-CAT™ FLX Volume 11 Number 1


confidence in compromised sites

Tapered Short Implants BioHorizons Tapered Short implants are available in 6 and 7.5mm lengths, offering a solution for cases with limited vertical bone height and minimizing the need for bone grafting. The implant design features an aggressive thread profile and tapered body for primary stability, even in compromised situations. A platform-switched, dual-affinity, Laser-LokÂŽ surface offers crestal bone retention and a connective tissue attachment for flexible placement in uneven ridges.

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

Not available in all countries. SPMP16254 REV D JAN 2018


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The Power of Performance Š2018 DentalEZ, Inc. DentalEZ, Star, and StarDental are registered trademarks and StarETorque is a trademark of DentalEZ, Inc.

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Implant Practice US Spring 2018 Vol 11 No 1  
Implant Practice US Spring 2018 Vol 11 No 1