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clinical articles • management advice • practice profiles • technology reviews Summer 2018 – Vol 11 No 2 •

Margaret Bradley, DDS

Rehabilitation of an atrophic maxilla with guided flapless implant surgery and immediate loading

Surviving implant failures Dr. Justin Moody

Team and technology — a collaborative approach to implant placement Dr. Riley Clark

Dr. Andoni Jones

Digital smile design in implant dentistry Dr. Rory McEnhill




Clinician spotlight

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FIXED-HYBRID EMERGENCY! Why Redo When You Can Rescue? When a failing implant needs to be replaced in a fixed-hybrid case, it often leads to a prosthesis emergency. Replacing the prosthesis was the only available option as it was impossible for the existing screw-retained components to realign back into the original position and maintain a passive fit. UNTIL NOW! The LOCATOR F-Tx® Fixed Attachment System is the ONLY immediate treatment solution available today that can rescue a patient’s existing fixed-hybrid prosthesis after replacing an implant. The novel, “snap-in” attachment is picked up chairside, ensures a passive fit, and works in harmony with the existing screw-retained fixtures saving both clinicians and patients substantial time, money and frustration.

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.


Implants and the spirit of inventiveness

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


’ve been placing and restoring implants in my practice for more than 22 years and have been teaching implant techniques to colleagues for 17 years. During that time, every aspect of implant treatment has evolved and dramatically improved. In my mind, the most significant development has been the use of 3D imaging for diagnosis and treatment planning. To name just a few benefits, CBCT scans enable us to precisely assess bone quality, determine the orientation of the implant to accommodate planned restorations, and virtually eliminate the risk of complications, such as nerve damage and sinus penetration, by taking the guesswork out of implant size selection. In Ara Nazarian, DDS, DICOI 2018, 3D imaging is unquestionably the standard of care for the implant dentistry. I can’t imagine practicing without it. Cone beam is just one component of implant treatment’s digital workflow. Combined with intraoral scanning, we can now create virtual models from which surgical guides can be made. Again, we’re removing the guesswork from the placement procedure. Bone grafting is another important aspect of implantology that I concentrate on in my courses. From innovative delivery modes to advanced chemistry and manufacturing, available systems for regenerating bone have made treatment a possibility for individuals who previously could not have supported an implant restoration. And of course, implants themselves are constantly changing as new design elements are discovered — a trend that’s been covered closely in the pages of Implant Practice US. Narrow diameters and short heights, innovative tapers and angles, and integration-promoting coatings and threading are just some of the advances that have increased the rates of clinical success. I work closely with researchers and manufacturers, and I can assure you that this spirit of inventiveness will continue. The goal: to simplify treatment, enhance predictability, and make implants an option for any patient. I am proud to introduce the 2018 summer issue of Implant Practice US, and I encourage you to check out this month’s featured articles. Whether you already place implants (you should be), are planning to, or simply restore them, you’ll find invaluable information on the latest technologies and techniques. Ara Nazarian, DDS, DICOI

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 2

Ara Nazarian, DDS, DICOI, maintains a private practice in Troy, Michigan, with an emphasis on comprehensive and restorative care. He is a Diplomate in the International Congress of Oral Implantologists (ICOI) and the director of the Ascend Dental Academy. He has conducted lectures and hands-on workshops on esthetic materials, grafting, and dental implants throughout the United States, Europe, New Zealand, and Australia.

Implant practice 1


Summer 2018 - Volume 11 Number 2


Case study Creating the FP1 prosthesis: a systematic case study

Clinician spotlight Margaret Bradley, DDS


Dr. Michael Freimuth discusses a technique for predictable and reproducible creation of the FP1 prosthesis........................................ 16

Bringing out the smiles, one song at a time

Continuing education

Case study Team and technology — a collaborative approach to implant placement Dr. Riley Clark discusses how virtual surgical planning (VSP) and cone beam computed tomography (CBCT) add to clinical accuracy and efficiency


Rehabilitation of an atrophic maxilla with guided flapless implant surgery and immediate loading Dr. Andoni Jones discusses the treatment of an edentulous patient using 3D planning to avoid complex grafting procedures..........................26

ON THE COVER Cover photo courtesy of Dr. Riley Clark. Article begins on page 8.

2 Implant practice

Volume 11 Number 2




1. Attach abutment to rigid holder.

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Small talk A critical distinction: problem solver versus people developer Dr. Joel C. Small offers a technique for creative problem-solving...............36

Continuing education Digital smile design in implant dentistry


Dr. Rory McEnhill examines the impact of digital technology on clinical dentistry and the patient experience

Practice management Recover, repair, and heal from super stress with BrainTap® Sandra Marlowe discusses how to nurture a relaxation response in everyday life and the dental office

................................................. 38

Product profiles

Materials & equipment.......................46

Star® ETorque™ Electric System

Industry news

Power, performance, and flexibility


................................................. 42 LOCATOR F-Tx® Immediately rescue a fixed-hybrid prosthesis after an implant failure

................................................. 44

PUBLISHER | Lisa Moler Email: MANAGING EDITOR | Mali Schantz-Feld Email: | Tel: (727) 515-5118 ASSISTANT EDITOR | Elizabeth Romanek Email: VP, SALES & BUSINESS DEVEL. | Mark Finkelstein Email:

On the horizon Surviving implant failures Dr. Justin Moody reflects on how implant failures affect both the dentist and the patient............................48


Stay Connected Between Issues Like us on Facebook at Watch our DocTalk Dental videos at Check out our Webinars at Connect. Be Seen. Grow. Succeed. | 4 Implant practice

OFFICE ASSISTANT | Lauren Drake Email:

MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Fax: (480) 629-4002 Tel: (480) 621-8955 Toll-free: (866) 579-9496 | SUBSCRIPTION RATES 1 year (4 issues) $149 | 3 years (12 issues) $399

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Margaret Bradley, DDS Bringing out the smiles, one song at a time


entists study and train for years to provide high-quality dental care. While the education and experience received during those years provides a solid foundation to perform skilled procedures, every dentist knows there’s more to comprehensive care of a patient. Dentists who form relationships built on trust have patients who are more comfortable and compliant for treatment. Dr. Margaret Bradley has been practicing dentistry for 8 years in the surrounding communities where she grew up. She is in her fourth year of ownership of her family and cosmetic dental practice in Highlands, Texas. Dr. Bradley quickly puts patients at ease with her approachable personality. She finds ways to uniquely connect with them — making them smile and laugh eases any anxiety they had and instead makes a trip to the dentist a fun experience.  Dr. Margaret Bradley working on a patient

The singing dentist Growing up in a small town outside of Houston, Dr. Bradley knew she wanted a job that was enjoyable and would make a difference. She loved going to see her dentist as a child and set her heart on this career path at a very young age. She attended Texas State University and the University of Texas Dental Branch in Houston. After achieving her dream of becoming a Doctor of Dental Surgery, she never forgot why she started — to be in a positive and happy environment and create meaningful experiences for her patients.

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Dr. Bradley has always enjoyed singing while she works. Patients quickly connected with this habit and almost always respond positively to the welcomed alternative of focusing on the typical noises heard in a dental office. “I have some patients who haven’t been to the dentist in years, for various reasons,” Dr. Bradley explained. “Whether I am performing a simple filling or preparing a tooth for a crown, singing makes the experience fun for everyone. I tell them there’s no extra charge for the serenade — it’s free — and I do take song requests!” Dr. Bradley has become known as “the singing dentist.” “I certainly don’t consider myself to be a professional singer, but I enjoy it, and when it can bring a smile or a laugh to a patient who hasn’t had a big smile in years — I feel like I have accomplished my goal,” Dr. Bradley said.

Finding your comfort

patients and herself. She finds confidence in using instruments that are comfortable in her hands and give her precise and repeatable performances. Dr. Bradley knows how crucial it is to have good quality materials. “Patients need to feel at ease when they come into my office, and having the right tools lets me do the dentistry with confidence,” she said. “It lets me focus on maintaining the positive energy and joy in the room while I am building the patient’s trust in our relationship.” Dr. Bradley believes it takes repeated good experiences to override negative experiences that may have caused trauma. “A dentist can be highly skilled, but with an instrument that is awkward or uncomfortable to use, it can make even a simple procedure challenging,” Bradley said. “If an instrument has the right weight and balance, is easy to grip, and is engineered to access tight areas easily, it gives me confidence in successful outcomes for my patient. My go-to is Karl Schumacher Dental instruments — they are the right fit for me in my practice.” IP

Dr. Bradley is a proponent of finding ways to make procedures comfortable for her

This information was provided by Karl Schumacher Dental.

Volume 11 Number 2













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Team and technology — a collaborative approach to implant placement Dr. Riley Clark discusses how virtual surgical planning (VSP) and cone beam computed tomography (CBCT) add to clinical accuracy and efficiency


ur teaching institute emphasizes practical education. A hallmark example of this is our “one-on-one” mentoring program. This collaborative approach is powerful, as doctor colleagues work together with one goal in mind — achieve the best treatment outcome for our patients. Embracing digital planning in our mentoring program has proven a powerful aid to our doctors’ ability to deliver better care for their patients. Digital technology opens doors to procedures that were never thought possible. In this case, an out-of-state doctor did more than just refer her patient to our institute for treatment, but traveled with him to gain hands-on experience with our technology and perform the surgery alongside my father and me. She walked away from the case impressed with how virtual surgical planning (VSP) and cone beam computed tomography (CBCT) augment surgical and prosthetic outcomes. Most importantly, the patient walked away with an amazing result. The male patient presented at the referring doctor’s office in need of a full-mouth rehab. Treatment options included crownand-bridge work to salvage the remaining teeth with conventional restorative methodology, extraction, and dentures, or a fixed implant solution. The patient opted for implants. Our mentoring program often lowers the barrier to entry that all our patients struggle with — price. For a fraction

Riley Clark, DMD, completed his Bachelor’s degree in biological sciences at Portland State University and then moved to Cleveland, Ohio, for his DMD program at Case Western Reserve University. Shortly after graduation, he attended advanced training in anesthesia. Professionally, Dr. Clark takes great pride in optimizing clinical efficiencies and digital workflows. He spends the majority of his time in private practice doing full-mouth dental implant rehab. Dr. Clark also teaches and mentors at WhiteCap Institute. He acts as a consultant to WhiteCap Dental Lab and Milling, where he focuses on full-mouth treatment sequencing and digital workflows in preoperative procedures and final restorative procedures. Dr. Clark is passionate about dentistry and transforming patients’ lives through their smiles with dental implants. Disclosure: Dr. Clark is a key opinion leader for Carestream Dental.

8 Implant practice

Figure 1

Figure 3

of the “retail” price, our mentoring doctors are able to offer premium implant services at a more manageable fee. To start designing the case, a PVS impression, bite registration, and a CBCT scan were taken by the referring doctor. The traditional impression was digitized by our lab, WhiteCap Dental Lab and Milling, and the STL file and DICOM from the CBCT were then merged in Dental Planning Software (DPS) (360imaging®) (Figures 3 and 4). Multiple implants were planned (Figure 1) with two thoughts in mind — first, maximize the primary stability of each implant, and second, ensure the implants were in a an ideal restorative position (Figure 2). To achieve this outcome, a digital wax-up was used (from exocad) in the planning phase. The digital wax-up was also used to finalize both full-arch temporaries — in this case,

Figure 2

Figure 4

milled polymethylmethacrylate (PMMA) (Figures 5 and 10). With both implants and temporaries planned, next we chose what guide type/ design will act as the vehicle to deliver this product to the patient. A variety of options are available for such a case. Because of our partnership with 360imaging, we were thrilled to use a new type of guide that, at the time, had a patent pending. This ingenious design features a buccal bone support, called the anatomical guide, to which all components of the case would seat to utilizing their patented diamond latch system. This leads to incredibly accurate relationships of the planned implants relative to bone and to the premade lab temporaries. Another highlight is the anatomical guide is seated from a vertical stop referenced to the natural teeth (Figures 6 and 11). This case, along with its thoughtful Volume 11 Number 2



With open-format image files, implant planning has never been easier. Carestream Dental’s digital imaging and implant planning software simplifies your workflow, allowing you to easily scan your patients and plan the implant placement. Plus, integration with third-party surgical guide software makes placing implants easier than ever.

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Figure 6

Figure 5

guide design, epitomizes clinical accuracy and efficiency in full-mouth implant rehab (Figures 7-9). To summarize some benefits of the diamond latch guide: • Up to 75% smaller than comparable guides • Requires no lingual or distal tissue reflection • One point of reference for all attachments (including vertical seating piece, implant guide, PMMA) • Increased accuracy compared to other guide systems • Stronger compared to other guide systems On the day of surgery, the patient was moderately sedated via IV access and locally anesthetized with Septocaine®. We started on the maxillary arch. The guide protocol dictated that a few teeth be removed first to ensure a passive fit of the anatomical guide and the vertical stop over the remaining maxillary teeth. After those few teeth were removed, a buccal flap was reflected, and the anatomical guide was seated to the buccal plate with the help of the vertical stop resting on the occlusal surface of the maxillary teeth (Figure 11).  After the anatomical guide was fixated to the buccal plate and the vertical stop removed (Figure 12), all remaining teeth were extracted (Figure 13), leaving No. 2. Tooth No. 2 and No. 31 were deemed helpful with this case by acting as an occlusal stop and providing proprioceptive feedback to the patient during the healing phase of the implants. One novel benefit of this guide design is the additional support the buccal plate has. Often during extractions, a thin (and sometimes not so thin) buccal plate can be fractured and may mandate a change in implant position. The anatomical guide supported the buccal plate and protected the bone from excessive trauma during the 10 Implant practice

Figure 8

Figure 7

Figure 9

Figure 10

Figure 11 Volume 11 Number 2


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Let’s get real with genuine Zimmer Biomet solutions. Call 1-800-342-5454 Unless otherwise indicated, as referenced herein, all trademarks are the property of Zimmer Biomet; and all products are manufactured by one or more of the dental subsidiaries of Zimmer Biomet Holdings, Inc., and distributed and marketed by Zimmer Biomet Dental (and, in the case of distribution and marketing, its authorized marketing partners). For additional product information, please refer to the individual product labeling or instructions for use. Product clearance and availability may be limited to certain countries/regions. This material is intended for clinicians only and does not comprise medical advice or recommendations. This material may not be copied or reprinted without the express written consent of Zimmer Biomet Dental. ZB0504 REV A 04/18 ©2018 Zimmer Biomet. All rights reserved.

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Figure 12

Figure 13

Figure 14

Figure 15

Figure 16

Figure 17

extractions. After extractions, bone reduction was done using the anatomical guide as a reference. With the teeth removed and the bone reduced, it was time to thoroughly debride the extraction sites with a curette and rotary side-cutting bur. Next, the implant guide was secured to the anatomical guide with two horizontal pins in the posterior and one vertical stop at the anterior (this is referred to as the diamond latch system). The implants were placed following the drilling protocol to maximize primary stability (Figure 14). Then the implant guide was removed from the anatomical guide, and non-hexed, temporary metal cylinders were placed in all implants. The cylinders had been prepped during the lab stage to ideally fit the PMMA temporaries. Since they were non-indexed, timing of the cylinders were visually determined based on their relative position on the lab printed analog model (Figure 15). Seating jigs were not used for this process because minor changes in implant position often exist and deem the seating jigs useless. After the cylinders were placed, bone grafting was performed in extraction sites around implants. Then dermal tissue was taken, with holes punched so it could fit over the temporary cylinders to cover the alveolar ridge. The use of dermal tissue leads to a thicker connective tissue layer after healing.  At this point, the surgical phase of the treatment was put on hold, and the temporary PMMA was seated (Figure 16). Again, the genius of this guide system is designing the diamond latch system into the PMMA (Figure 9). In this design, the anatomical guide served as a constant landmark to which all other components were referenced. 12 Implant practice

Figure 18

Figure 19

Minor adjustments were made to ensure ideal spacing for “pick up” material around the temporary abutments. A tissue spacer was placed between the PMMA and the dermal tissue. The “pick up” was done with a

Figure 20

dual-cure resin with the PMMA securely attached to the anatomical guide. The PMMA diamond latches were cut off, allowing the anatomical guide to be unscrewed from the buccal plate. The PMMA remained fixed to Volume 11 Number 2


Figure 21: Two weeks post-op

the implants, however; and suturing was done around PMMA. This PMMA “pick up” process took about 30 minutes (Figure 17). The same procedure was repeated on the lower arch. Our “pick up” procedure followed a more traditional approach of removing the PMMA and making adjustments extraorally, while suturing procedures

14 Implant practice

were completed. Ultimately, the lower “pick up” approach was advantageous because of the time efficiency and ability to contour the intaglio of the PMMA more exactly. Occlusal adjusted and refinements were made to the fit and feel of the PMMAs (Figure 18). Postoperative CBCT scans were taken with a CS 8100 3D (Carestream Dental) to

provide a baseline and track healing (Figures 19 and 20). The patient will begin final restorative procedures in 5-7 months. What made this case predictable and even possible? The answer is the synergy of a thoughtful clinical team and powerful technology. Technology helps us execute surgical and prosthetic rehabilitation with accuracy and efficacy. Technology allows us to convert complex cases into manageable and practical cases. In fact, I would say the least stressful part of the entire case was placing the actual implants, which was historically the most stressful part of these cases when I was freehanding implant placement. From the technology, to the labs and their technicians, to the mentoring doctor, to the assistants, to the patient, this was a collaborative effort, and I would call the case a collaborative win.

Acknowledgments • • • • •

Dr. Evon Heaser, Mentoring Doctor 360imaging®, Mark Palmer, CEO Dr. P.K. Clark, WhiteCap Institute Clinical Director WhiteCap Dental Lab and Milling, Jim Campbell, Guide Department Manager Whitecap Dental Lab and Milling, David Nowaskey, CAD Department Manager IP

Volume 11 Number 2

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Creating the FP1 prosthesis: a systematic case study Dr. Michael Freimuth discusses a technique for predictable and reproducible creation of the FP1 prosthesis Introduction As the world of implant dentistry continues to evolve, there are multiple treatment modalities to achieve clinical outcomes. The increasing use of social digital media and the Internet makes our patients exceedingly aware of the possibilities that exist. The awareness creates a perspicacious view of the results; in addition, the cost of the fullarch fixed restorations adds to the patients’ desire to be educated on their evolving expectations of treatment. There are countless articles and various franchises available offering full-arch fixed restorations and removable implant solutions. Some offer only one solution to all clinical situations, much like the track home method — cookiecutter dentistry. As a practice, clinically how do we decipher the best treatment option and material for our patients? How do we custom-build a plan for our patients? What are the clinical determents necessary? Furthermore, what steps are essential to execute and achieve the desired results? The purpose of this article is to examine creating the FP11 prosthesis (when the fixed prosthesis replaces only the crown and looks like a natural tooth) or “custom-built home” in a systematic process.

Figure 1: Preoperative full-face photo

Figure 2: Lateral view close-up

Case description A 65-year-old-female patient presented to the office with terminal dentition case Type III periodontitis2 with Grade III mobility. The patient wanted a plan that would create an overall change in her oral health and esthetics.

Michael Freimuth, DDS, is a graduate of Creighton University in Omaha, Nebraska. He completed his general practice residency at the Veterans Administration Medical Center in Omaha. He is committed to continuing education and innovative dental technology. Dr. Freimuth is a Diplomate of the American Board of Oral Implantology, Diplomate of the International Congress of Implantologists, Master at the Misch Implant Institute, Mentor at the Kois Center, and Fellow at the American Academy of Implant Dentistry as well as a member of the American Academy of Facial Esthetics, the American Dental Association, the Colorado Dental Association, the Metropolitan Denver Dental Society, and co-founder and partner of Implant Pathway. Dr. Freimuth has a private practice and dental laboratory in Wheat Ridge, Colorado. He can be reached at

16 Implant practice

Figure 3: Preoperative radiograph

The evaluation was made utilizing clinical digital photography, digital radiographs, 2D and 3D CBCT (i-CAT) diagnostic models (maximum intercuspation position) — moreover, clinical, medical, periodontal, functional, dentofacial, and biochemical evaluations.3  The collective and collaborative decision was made to initiate treatment. Treatment began in the lower arch and was done to completion. The final result was an FP3 (when the fixed prosthesis replaces missing crowns and gingival color4). The patient was happy

with the outcome; however, she was hoping to avoid pink porcelain on the maxilla due to added lingual thickness, and there was a phonetic concern as well. Maintaining the available bone and gingival architecture was highly desirable to the patient. Instituting this plan at this clinical juncture resulted in the FP1 prosthesis as a restorative possibility. After consent was obtained, the process of commencing and developing the roadmap to achieve the desired results began. Note that it is vital to coordinate and formulate all details Volume 11 Number 2

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Figure 4: Retracted upper and lower arch pretreatment

Figure 5: Maxillary arch pretreatment

and timelines with the patient, team, and laboratory. This begins the five stages of the FP1 treatment plan, prosthetic and surgical.

Prior to surgery Prior to stage 1 surgery, the diagnostic models at the correct vertical dimension on the articulator with clinical photography were sent to the laboratory. Written and verbal instructions were communicated to the technicians.

Stage 1: surgery Inaugural surgery and prosthetics included these steps: • Preparation (predetermination for key implant positions) of the teeth to support the custom-milled shell polymethyl methacrylate (PMMA)5 • Atraumatic extraction of teeth in decisive positions • Placement of endosseous implants6 in key positions with concurrent bone grafting • Finishing this stage with placement of the custom temporary

Figure 10: Stage 1 — milled-shell temporary occulusal view 18 Implant practice

Figure 6: Stage 1 — tooth preparations for PMMA

Figure 7: Stage 1 — atraumatic extraction sites

Figure 8: Stage 1 — implant placements in key positions

Figure 9: Stage 1 — cover screw placed

Figure 11: Stage 1 retracted frontal view — PMMA cemented in place on day of surgery Volume 11 Number 2

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CASE STUDY The patient was given the following preoperative medications: amoxicillin 500 mg for 7 days and dexamethasone 0.4 mg for 3 days.7 At initial assessment, the patient consented to oral sedation with a protocol prescription of triazolam 0.25 mg and hydroxyzine 50 mg. Anesthetic included 20% benzocaine topical for R/L-IA, LB. The total given was 3 cartridges of 2% lidocaine with epinephrine, 1:100,000 and 1 cartridge of 4% Septocaine® with epinephrine, 1:100,000, NADR.  Profound anesthesia was acquired.  Teeth Nos. 2, 6, 8, 9, 11, and 15 were prepped for prosthesis, and teeth Nos. 3, 4, 5, 7, 10, 12, 13, and 14 were extracted atraumatically with Luxator® (Directa Dental). Extraction sockets were debrided with curettes and flushed with chlorhexidine gluconate 0.12%. Osteotomies were performed into extraction sites, CAMLOG® implants (various diameters) were placed and torqued to 30Ncm. Cover screws were placed, and MinerOss® (BioHorizons®) allograft was placed into sockets;  BioPlugs (BioHorizons) were placed for graft containment. PMMA temporary was cemented on remaining teeth, and the temporary needed to remain for 4 months allowing for optimal HEALING. Postoperative instructions were given to the patient.

Stage 2: surgical uncovering after 4 months of healing The patient was anesthetized by placing 20% benzocaine topical for R/L- IA/L. The total given was 2 cartridges of 2% lidocaine with epinephrine, 1:100,000 and 1 cartridge of 4% Septocaine® with epinephrine, 1:100,000, NADR. Profound anesthesia was acquired. The process began with removal of the temporary PMMA prosthesis. The implants were uncovered atraumatically utilizing a CO2 laser (DEKA). The impression copings were placed, and it was confirmed radiographically that they were fully engaged. A traditional full-arch impression with additional poly vinyl siloxane (PVS) silicone heavy- and light-body wash technique was taken, and impression copings were removed. A bite registration was obtained at the desired vertical dimension.8 Healing abutments were placed, and radiographs taken to confirm complete engagement. The PMMA-milled shell temporary was modified to go over the healing abutments, then cemented in place. The patient was given postoperative instructions and scheduled for removal of the remaining dentition. The impression and clinical digital photographs were sent to the laboratory along with the written script. 20 Implant practice

Figure 12: Stage 1 — postoperative radiograph day of surgery

Figure 13: Stage 2 — uncovered with laser

Figure 14: Stage 2 — impression copings occlusal view

Figure 15: Stage 2 — impression copings frontal view

Figure 16: Stage 2 — PVS impression

Figure 17: Stage 3 — healing abutments in place

Figure 18: Stage 3 — atraumatic extractions Volume 11 Number 2





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HYDROPHILIC CRYSTAL CLUSTER STRUCTURE The crystallographic structure and geometry of a bone graft matters. OsteoGen® non-ceramic crystal clusters intertwine to form a hydrophilic 3D matrix leading to the immediate absorption of blood flow. This is critical for the initiation of bone formation, early angiogenesis and bone bridging even across 8.0mm critical size defects.3-5 1. Ganz (2002) 2. Artzi (2003) 3. Valen (2002) 4. Spivak (1990) 5. Ricci (1992) 6. Jensen (1998) Radiographs courtesy of German Murias DDS, ABOI/ID

The x-ray reveals when sufficient bone has formed and the site is ready for implant placement. OsteoGen® non-ceramic crystals are radiolucent on the day of placement & radiopaque in ~4-6 months following resorption and host bone formation.1-4

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Figure 19: Stage 3 — PMMA screw-retained to integrated implants occlusal view

Figure 20: Stage 3— PMMA screw-retained to integrated implant frontal view

Stage 3: surgical and prosthetic phase

Figure 21: Final radiograph of prosthesis; no cantilever or distal extension

Prognostic understanding and educating the patient are vital to achieving predictable clinical outcomes.

Figure 22: Final implant placements in key positions with adequate A-P spread 22 Implant practice

A preoperative prescription protocol was prescribed for amoxicillin 500 mg for 7 days and dexamethasone 0.4 mg. The patient was anesthetized by placing 20% benzocaine topical for R/L- IA/L. The total given was two cartridges of 2% lidocaine with epinephrine, 1:100,000 and one cartridge of 4% Septocaine® with epinephrine, 1:100,000, NADR.  Profound anesthesia was acquired. The PMMA temporary was removed, and the remaining teeth were extracted atraumatically. BioPlugs were placed into the extraction sockets, and PMMA implant screw-retained prosthesis was secured onto the integrated implants. Postoperative instructions were given, and the patient was instructed to return to the clinic in 4 weeks for the final impression.

Figure 23: Final implant placements in key positions with adequate A-P spread Volume 11 Number 2

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Figure 25: Final FP1 maxillary prosthesis occulsal view

Figure 24: Final FP1 maxillary prosthesis frontal retracted view

Stage 4: prosthetic phase after 4 weeks of healing The patient returned to the office, and the PMMA screw-retained temporary was removed. Impression copings were placed, and radiographs taken for confirmation of full engagement. Final implant level impressions were made with PVS material using a heavy- and light-body wash technique. The temporary was reinserted, and the access opening was filled with PVS material for easy retrieval. The patient was scheduled for final delivery in 4 weeks.

Final appointment The temporary was removed, and the final prosthetic torqued to 30Ncm based on manufacturer. The final access openings were filled with Teflon tape, Bisco’s All-Bond Universal®, and VOCO GmbH composite, and the final occlusion was equilibrated. The postoperative instructions were given to the patient, along with a water flosser and oral hygiene instructions, and she was scheduled in 2 weeks for evaluation as well as her maintenance plan.

Discussion Of course, there are a myriad of treatment possibilities for the terminal dentition.9 When to institute treatment is a collaborative effort that involves the patient and the treating doctor. Prognostic understanding and educating the patient are vital to achieving predictable clinical outcomes. The aforementioned treatment was initiated prior to loss of anatomy, and the patient desired to have a more functional and esthetic outcome. Furthermore, without extensive breakdown, the need for advanced bone grafting procedures can be avoided, and the aforementioned “key” implant positions10 can be placed. Prosthetic-wise as clinicians, we can bypass cantilevers and large pontic spans,11 resulting in less stress in implants due to tension being placed down 24 Implant practice

Figure 26: Final close-up lateral view

Figure 27: Final close-up facial view

the long axis of the implant rather than sheer forces. This allows for less crown height-toimplant height ratio, which creates less force on the implants. Consider this: Ovate pontic spaces with short spans are much more easily maintained due to crested bone architecture and are easier for the patients to preserve.


Conclusion Predictable and reproducible creation of the FP1 prosthesis is an attainable treatment module when the plan is initiated prior to excessive anatomic loss. Through taking clinical digital photographs, 3D scans, radiographs, comprehensive records, impressions, and thorough clinical examinations to screen patient, the treatment can be tailored to the patient. Considering the patient’s desire for his/her clinical outcome and determining the most effective way to educate him/her on the treatment path will increase acceptance. Although there are more clinical stages and patient visits, it has been the author’s experience that the patient’s expectations are met and often exceeded.  IP

1. Misch CE. Fixed prosthesis replaces only the crown; looks like a natural tooth. Contemporary implant dentistry. Saint Louis, MO: Mosby Elsevier; 1993, 2008. 2. The American Academy of Periodontology. Proceedings of the World Workshop in Clinical Periodontics. Chicago, IL: The American Academy of Periodontology; 1989:I/23- I/24. 3. Kois JC. AAP Case Type IV PSR Code 4, Advanced Periodontitis. Seattle, WA: Kois Center; 2005. 4. Misch CE. Fixed prosthesis replaces missing crowns and gingival color. In: Contemporary Implant Dentistry. Saint Louis, MO: Mosby Elsevier; 1993, 2008. 5. Frazer RQ, Byron RT, Osborne PB, West KP. J Long Term Eff Med Implants. 2005;15(6):629-639. 6. Wataha, JC. Materials for endosseous dental implants. J Oral Rehabil. 1996;23(2):79-90. 7. Laskin DM, Dent CD, Morris HF, Ochi S, Olson JW. The influence of preoperative antibiotics on success of endosseous implants at 36 months. Ann Periodontol. 2000;5(1):166-174. 8. Chee WW, Donovan TE. Polyvinyl siloxane impression materials: a review of properties and techniques. J Prosthet Dent. 1992;68(5):728-732. 9. Pikos MA, Magyar CW, Llop DR. Guided full-arch immediate-function treatment modality for the edentulous and terminal dentition patient. Compend Contin Educ Dent. 2015;36(2):116, 119-26, 128. 10. Misch CE. Stress treatment theorem for implant dentistry. In: Contemporary Implant Dentistry. St. Louis, MO: Mosby Elsevier; 2008. 11. Shillinburg HT, Hobo S, Lowell DW. Treatment Planning for the replacement of missing teeth. In Shillinburg HT, Hobo S, Lowell DW, Jacobi, R, Brackett SE, eds. Fundamentals of fixed prosthodontics. 3rd ed. Carol Stream, IL: Quintessence; 1997.

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Rehabilitation of an atrophic maxilla with guided flapless implant surgery and immediate loading Dr. Andoni Jones discusses the treatment of an edentulous patient using 3D planning to avoid complex grafting procedures


he rehabilitation of a patient with atrophic jaws can be challenging for the dental team. Costs, healing periods, morbidity, and complications can also be elevated for the patient. However, cone beam computed tomography (CBCT) and 3D implant planning software allow us to treat these patients in a less invasive and a more predictable way. Traditionally, treatment of patients with atrophic jaws requiring implant therapy involved complex grafting procedures and extended healing periods. Many patients rejected these treatment modalities due to their high complication and morbidity rates and costs. Nowadays, we are able to treat many of these patients in a much quicker, less invasive, and safer way by using 3D technology to place our implants in a safer way. Since computer-guided implant surgery was first introduced in 2002, digital technology has evolved into a very accurate tool. Inaccuracies in implant placement are considerably reduced, benefiting to a great extent those patients with atrophic jaws, in whom a very precise use of that limited bone for implant therapy is paramount. This article will discuss this approach and present a case report of a 56-year-old woman with an edentulous maxilla who wished to get a fixed restoration. The lack of teeth and use of a complete denture for 25 years had resulted in a considerable bone resorption. She was treated using 3D planning and a surgical guide to place five implants that allowed us to transform her complete denture into an immediate fixed

Educational aims and objectives

This article aims to demonstrate the benefits that guided surgery and extensive computer planning can have on implant treatment.

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: •

Realize the benefits of using modern clinical technologies to improve clinical outcomes in implant dentistry.

Realize some surgical techniques for correction of certain deficiencies to enable implant therapy.

Recognize the benefits of 3D diagnosis, and surgical and prosthetic planning.

Identify some key points for implant selection for immediate loading.

temporary restoration, and 3 months later she was restored with a permanent metalceramic fixed restoration.

Introduction The treatment of edentulous patients with dental implants has proved to be highly successful, and a paradigm shift in the management of patients with complete dentures (Dudley 2015). The loss of natural dentition along with the use of complete mucosa-borne dentures is related to different degrees of maxillary atrophy, on occasion making it very difficult to deliver fixed rehabilitation with implants. In the presence of an atrophic maxilla, different surgical techniques have been described for the surgical correction of such deficiencies to enable implant therapy (Sorní, et al., 2005). Sinus lifts, autogenous block grafts, and guided bone regeneration

procedures have been well described in the literature with good results. Nevertheless, it is a well-established fact that these complex procedures entail a high risk of surgical and postoperative complications such as infection, wound dehiscence, bone graft resorption, or damage to adjacent anatomical structures (Boffano and Forouzanfar 2014; Faverani, et al., 2014). Cost, the need for general anesthesia, a second surgical site for bone harvesting, number of surgeries, extended healing periods, and long treatment time — as well as the previously mentioned complications — are factors that negatively impact on patient acceptance for these treatment modalities. Since computer-guided implant surgery was introduced in 2002, the advances in 3D diagnosis and surgical and prosthetic planning allow the dental team to treat many

Andoni Jones, BDentSc, graduated from dental school in Bilbao, Spain, in 2010. He worked as a general dentist for 3 years, completing his postgraduate implant training in the same university before moving to Ireland in 2013. He currently works in private practice in Dublin, Ireland, where he carries out a lot of oral surgery and implant dentistry. Planning and executing implant treatments from surgery to restoration, Dr. Jones is a big advocate of 3D planning software and computer-guided surgery, which he uses from single to full arch implant supported rehabilitations.

Figures 1 and 2: Preoperative OPG and intraoral view 26 Implant practice

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Figures 3-7: Superimposition of scanned denture and the maxilla in order to prosthetically plan implant positioning

edentulous patients in a simpler and safer way (Ganz 2015). With this technology, clinicians can accurately transfer the preplanned position of the implants from the 3D software into the patient’s mouth, having the advantage of predictably performing minimally invasive (flapless) surgery with immediate load in many cases. With 3D implant planning software, it is possible to integrate the patient’s surgical and prosthetic treatment into one single platform. Having the restorative plan on the computer screen before placing the implants is a key point in the diagnosis and execution of a prosthetically driven implant treatment (Mora, et al., 2014). The transfer of CBCT images to 3D implant software considerably improves treatment planning, ensuring controlled implant insertion by the means of guided surgery. Doing this allows a surgical template to be created that will guide the implants into the right position, depth, angulation, and orientation. Better use of the patient’s existing bone can be made, thus considerably reducing the amount of patients that require complex reconstructive surgeries before implant therapy.

Case report A 56-year-old woman, medically fit and with no allergies, wanted to replace her complete upper denture with a fixed implant restoration. On initial examination, photographs and an OPG were taken. This radiograph revealed very pneumatized sinuses, Volume 11 Number 2

with practically no available bone for implants in the posterior regions (Figures 1 and 2). The current complete denture met with the esthetic criteria (incisal edge, midline, smile line, lip support), so it was used as a reference to prosthetically guide the implant planning. To transfer her denture — and with it, the position of the teeth — into the 3D planning software (NemoScan by Nemotec, Spain) a “dual scan” protocol was utilized. This involved inserting eight gutta-percha markers into her denture: four in the buccal flange and four in the palate. A CBCT was taken with the patient wearing the denture, and a second CBCT was taken of the denture alone. This allowed the 3D-planning software to superimpose the denture onto the maxillary CBCT, thus showing the bony architecture, the desired position of the future teeth, and the shape of the soft tissue (this being the gap between the denture and the bone) in one single screen. A key step is to ensure the perfect adaptation and stability of the scanning appliance (in this case, the patient’s denture) before taking the CBCT (Figures 3-7). After careful examination of this CBCT, a surgical plan was made to place five implants where bone was sufficient, but still obtaining proper prosthetic support, combining two anterior implants with three posterior ones, two of which were tilted to avoid the sinus. This option, as well as alternative grafting techniques, was explained to the patient, and the decision was made to continue with this original plan.

A mucosa-borne surgical guide was prepared from this 3D planning and used to place the implants in a flapless way (Figures 8 and 9). The patient took amoxicillin 2000 mg 2 hours before the surgery, and articaine was used for anesthesia. The surgical guide was fitted onto the maxilla, checking its perfect adaptation by direct visualization and tissue blanching. It was fixed to the maxilla with three titanium pins, and once in place, osteotomies as well as implant insertion were completed through the guide. All implants achieved an insertion torque in excess of 40Ncm, and over 66 ISQ. After removing the surgical guide, another CBCT was taken to ensure all implants were correctly placed between the bony housing, allowing also to make a comparison between the final implant position and the 3D planning (Figures 10 and 11) (Table 1). Multi-unit abutments were connected to all implants (Figure 12), using 30° angulated abutments on the tilted implants to correct the emergence and to keep it in the prosthetic corridor. The patient’s conventional denture was converted into a screw-retained temporary fixed restoration (Figures 13 and 14) using titanium abutments and a pick-up technique. The patient was given a postoperative prescription of ibuprofen (400 mg) for analgesia and a chlorhexidine 0.20% mouthwash, and instructed to keep a soft diet for 3 months. Healing was uneventful, and 3 months after implant placement, the Implant practice 27

CONTINUING EDUCATION temporary prosthesis was unscrewed to find all five implants well integrated. The final prosthetic phase was to fabricate a screwretained metal-ceramic fixed restoration, which met with the patient’s esthetic and functional needs (Figures 15-17).

Discussion In a society where time is so important, more and more patients are looking for immediate results, reluctant to go through longer and more uncomfortable treatments. The possibility of performing the surgical and prosthetic techniques of implant dentistry in the same clinical visit represents a very effective approach that significantly reduces the treatment time and dramatically improves the patient’s quality of life (Cannizzaro, et al., 2008; Tarnow, et al., 1997). Fewer hours spent chairside make the experience more pleasant for the patient and less tiring for the clinician. Flapless surgery is also a very effective way of treating patients with a fear of surgery. With no need to raise a flap or carry out suturing, postoperative pain and swelling are greatly reduced, as are recovery times (van Steenberghe, et al., 2005). Intraoperative complications and bleeding can also be minimized. Peri-implant tissues also benefit from flapless surgeries, as a quicker seal around the implants is possible from day one (Maló, et al., 2007). Current scientific evidence in implant dentistry dramatically changed Brånemark’s original guide for osseointegration. Immediate loading is a well-documented approach, with success rates similar to those of conventionally loading techniques (Salama, et al., 1995). For successful immediate load protocols, a number of factors must be considered. First, a careful examination of the radiologic images for implant planning is key. New computer-assisted three-dimensional image technologies have revolutionized this field, allowing the implant surgeon to study the different possibilities for implant

Figure 12: Multi-unit abutments connected 28 Implant practice

number and position for each patient in a virtual model. This way the most favorable surgical protocol can be established for each case (Marchack 2007). Bone density can also be accurately measured in order to ensure that immediate load will be predictable (Shahlaie, et al., 2003). Another key point is implant selection. Implants with a roughened surface that will improve osseointegration, and a macro geometry that will allow high insertion torques and good primary stability is essential for immediate load. These implants must always be splinted to provide favorable

absorption and distribution of the load and to reduce any micromovement during the healing phase. Avoiding micromovement is paramount if immediately loaded implants are to osseointegrate, so the patient has to keep to a soft diet for at least 6 weeks, progressively introducing soft chewing after this period elapses. It is well documented that an edentulous maxilla can be immediately loaded and restored with a fixed prosthesis using as few as four implants placed in strategic positions. The “All-on-four” technique that was first described by Maló, et al. (2003)

Table 1: Implant deviation from planning to final position Implant

Deviation at platform level (in mm)

Deviation at apex (in mm)
















Figure 8: Surgical guide in place, fixed to the maxilla with three pins

Figure 9: Implants placed without raising a flap

Figure 10: Postoperative CBCT showing final implant position

Figure 13: Transforming the complete denture into a screwretained provisional fixed prosthesis, using direct pick-up technique

Figure 11: Comparison between final implant position (green) and 3D planning (red and gray)

Figure 14: Immediate postoperative — showing provisional restoration Volume 11 Number 2

advocates the placement of two vertical implants in the anterior region and two more implants placed mesial to the sinus in a 30°-45° angulation. When implant placement in the posterior maxilla is not possible in a conventional way due to sinus pneumatization, this technique offers a very effective way of using the existing bone in the premaxilla to anchor the implants while still reducing distal cantilevers. Scientific literature also supports that tilted implants have similar success to axially placed implants when they are splinted (Aparicio, et al., 2001). Thus, tilted implants in the premaxilla present a very safe and predictable outcome to sinus augmentations. An essential advantage of computerassisted techniques is the precision that the implants are placed with. This accuracy can be measured by comparing the 3D planning with the final surgical position and angulation of the implants (Widmann and Bale 2006). It has been demonstrated that computerassisted implant placement is more precise than manual insertion (Brief, et al., 2005). However, it is also necessary to have a minimum safety margin of 1 mm from important anatomical structures, since some error can be accumulated from the transfer of the radiologic images to the 3D software and the positioning of the surgical guide. Despite this, it is the opinion of this author that computerassisted surgery should be considered the safest way of placing implants, since it is the technique least influenced by human error. One study showed that an experienced surgeon can have an average of 6.1 mm deviation when drilling an osteotomy manually, compared to an average of 0.5 mm when using computer-guided surgery (Schermeier, et al., 2001). Another study compared implant selection and planning between conventional radiographs and 3D software, and the length of the implants was increased in 77.7% of the cases when using the 3D software (Siebegger, et al., 2001). Longer, wider implants increase the contact surface between the implant and the bone, which is a very important factor in immediate load Volume 11 Number 2

protocols, where functional load of these implants happens before actual osseointegration occurs (Sanna, et al., 2007). In order to achieve an accurate transfer of implant position from the virtual platform to the oral cavity — and therefore achieve a successful guided surgery — a scrupulous protocol must be adhered to. The clinician should ensure that all steps, from the scanning of the patient to the surgical placement of the implants, are carried out meticulously. The scan appliance must be perfectly adapted and thoroughly assessed — relining it intraorally if necessary — before taking the CBCT. From here, the accuracy of the procedure is determined by the surgeon’s ability and proficiency with the technology, the precision that the surgical guide is made with, the compatibility and tolerance of the surgical drills and transfers, and the correct

fitting and fixing of the surgical drill. It must not be forgotten that the stability and position of the surgical guide has to be checked during all steps of the implant surgery.


12. Salama H, Rose LF, Salama M, Betts NJ. Immediate loading of bilaterally splinted titanium root form implants in fixed Prosthodontics — a technique reexamined: two case reports. Int J Periodontics Restorative Dent. 1995;15(4):344-361.

1. Aparicio C, Perales P, Rangert B. Tilted implants as an alternative to maxillary sinus grafting: a clinical, radiologic, and periotest study. Clin Implant Dent Relat Res. 2001;3(1):39-49. 2. Boffano P, Forouzanfar T. Current concepts on complications associated with sinus augmentation procedures. J Craniofac Surg. 2014;25(2): e210-e212. 3. Brief J, Edinger D, Hassfeld S, Eggers G. Accuracy of image-guided implantology. Clin Oral Implants Res. 2005;16(4):495-501. 4. Cannizzaro G, Torchio C, Leone M, Esposito M. Immediate versus early loading of flapless-placed implants supporting maxillary full-arch prostheses: a randomized controlled clinical trial. Eur J Oral Implantol. 2008;9(suppl 1):27-139. 5. Dudley J. Implants for the ageing population. Aust Dent J. 2015;60(suppl 1):28-43. 6. Faverani LP, Ramalho-Ferreira G, dos Santos PH, et al.. Surgical techniques for maxillary bone grafting - literature review. Rev Col Bars Cir. 2014;41(1):61-67. 7. Ganz SD. Three-dimensional imaging and guided surgery for dental implants. Dent Clin North Am. 2015;59(2):265-290. 8. Maló P, Araujo M, López A. The use of computer-guided flapless implant surgery and four implants placed in immediate function to support a fixed denture: preliminary results after a mean follow-up period of thirteen months. J Prosthet Dent. 2007;97(suppl 6):S26-S34. 9. Maló P, Rangert B, Nobre M. “All-on-Four” immediatefunction concept with Brånemark System implants for completely edentulous mandibles: a retrospective study. Clin Implant Dent Relat Res. 2003;(suppl 1):2-9.

Conclusions By reducing the number of surgeries to one, implementing immediate load protocols, and decreasing patient morbidity and complications with a minimally invasiveness philosophy, both the clinician and patient can benefit from more predictable and safer implant dentistry. Three-dimensional images help the implant surgeon plan the number, location, diameter, and length of the implants. The surgical stent guides the surgery, enabling the correct and precise placement of the implants to be able to load them with a fixed restoration at the same surgical session. IP

13. Sanna AM, Molly L, Van Steenberghe D. Immediately loaded CAD-CAM manufactured fixed complete dentures using flapless implant placement procedures: a cohort study of consecutive patients. J Prosthet Dent. 2007;97(6):331-339. 14. Schermeier O, Hildebrand D, Lueth T, Hein A, Szymanksy D, Bier J. Accuracy of an image-guided system for oral implantology. In: Lemke, HU, Vannier, MW, Inamura, K, Farman, AG. (eds). Computer-Assisted Radiology and Surgery, vol 1281. International Congress Series. New York: Elsevier Science; 2001. 15. Shahlaie M, Gantes B, Schulz E, Riggs M, Crigger M. Bone density assessments of dental implant sites: 1. Quantitative computed tomography. Int J Oral Maxillofac Implants. 2003;18(2):224-231. 16. Siebegger M, Schneider BT, Mischkowski RA, et al. Use of an image-guided navigation system in dental implant surgery in anatomically complex operation sites. J Cranio Maxillofac Surg. 2001;29(5):276-281. 17. Sorní M, Guarinós J, García O, Peñarrocha M. Implant rehabilitation of the atrophic upper jaw: a review of the literature since 1999. Med Oral Patol Oral Cir Bucal. 2005;10(suppl 1): E45- E56 18. Tarnow D, Emtiaz S, Classi A. Immediate loading of threaded implants at stage 1 surgery in edentulous arches: ten consecutive case reports with 1 -to 5-year data. Int J Oral Maxillofac Implants. 1997;12(3):319-324.

10. Marchack CB. CAD/CAM-guided implant surgery and fabrication of an immediately loaded prosthesis for a partially edentulous patient. J Prosthet Dent. 2007;97(6):389-394.

19. van Steenberghe D, Glauser R, Blomback U, et al. A computed tomographic scan-derived customized surgical template and fixed prosthesis for flapless surgery and immediate loading of implants in fully edentulous maxillae: a prospective multicenter study. Clin Implant Dent Relat Res. 2005;7(suppl 1): S111-S120.

11. Mora, MA, Chenin DL, Arce RM. Software tools and surgical guides in dental-implant-guided surgery. Dent Clin North Am. 2014;58(3):597-626.

20. Widmann G, Bale RJ. Accuracy in computer aided implant surgery — a review. Int J Oral Maxillofac Implants. 2006;21(2):305-313.

Implant practice 29


Figures 15-17: The final metal-ceramic screw-retained prosthesis


Digital smile design in implant dentistry Dr. Rory McEnhill examines the impact of digital technology on clinical dentistry and the patient experience


ith the rising tide of the digital workflow in all aspects of dentistry, the benefits of incorporating digital planning and digital smile design (DSD) into daily practice are considerable. The first and most important aspect is to motivate and stimulate the patient into making an emotional connection with the treatment plan. In cases where a considerable amount of treatment is required, the ability to offer patients a very clear indication of how their final prostheses could look is a very powerful tool. In addition, being able to fabricate provisional healing prostheses designed with digital smile design protocols allows the patient to have excellent esthetics from the start of treatment. In normal circumstances, the modification of a temporary denture into a healing bridge provides lessthan-perfect esthetics and potential patient dissatisfaction.

Great expectations Patient esthetic expectations are becoming increasingly stringent. With better education and more exposure to dental case reports on social media platforms, patients — quite rightly — wish to obtain a result that is realistic and lifelike. In the past, full arch implant cases would run in a linear

Educational aims and objectives

This article aims to present a discussion of digital smile design and show its impact on a clinical case.

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 protocols and benefits of applying digital smile design (DSD) principles to implant dentistry.

Realize the details that can be ascertained and confirmed by the DSD through 2D planning.

Realize the depth of information provided by the 3D planning aspect.

Identify some benefits of Pekkton® material.

fashion, starting with tooth removal, implant placement, and final prostheses provision. Implants would be placed where the bone was ideal, and the final bridge would be manufactured to suit. However, with the onset of DSD, we can work backwards from an ideal esthetic result and assess where implants need to be placed to facilitate this ideal result. Using facial landmarks, we can ascertain ideal tooth spatial dimensions and confirm optimal prosthetic envelope for the teeth. This allows us to decide on the breadth of smile, the smile curvature relative to the lower lip, and the position of the upper teeth relative to the wet border of the lower lip. Once the

2D planning is complete, digital scans of the upper and lower arches are taken, and the STL files sent to the laboratory. From these, the 3D planning commences, and a digital wax-up can provide a diagnostic template that can be used to carry out a mock-up intraorally. Digital videos can be used to assess esthetics, function, and phonetics. Following mutual agreement regarding the esthetics, implant planning can then begin. The CT DICOM file and the 3D planning STL files can be superimposed, and this allows the clinician to ascertain where the implants are best suited to enable the dentist to fabricate the healing/permanent prostheses. From here, the surgical guides

Figure 1: Preoperative full-face smile Rory McEnhill BDS(QUB), MSc(U.Man), MFGDP(UK), is practice principal of Blue Sky Dentistry, an award-winning practice in Northern Ireland.

Figure 2: Preoperative retracted smile 30 Implant practice

Volume 11 Number 2

Figure 4B: Intraoral smile frame

Figure 6: Surgical guides

can be milled and can offer partial or full surgical guidance.

Case study In this case, this patient presented with a partial denture that was uncomfortable, and its retention was compromised by the remaining mobile maxillary teeth. The patient was unequivocal in her demand that she should have a full arch implant solution as she did not want anything that was removable or to have palatal coverage. Volume 11 Number 2


Figure 3: Preoperative smile

Figure 4A: Smile frames

Figure 5: 3D implant planning

Figure 7: Surgical guides in situ

Consequently, the implant planning stage considered six strategically placed implants, providing effective support for an immediately loaded milled healing bridge. The patient attended for a number of presurgical hygiene appointments while the DSD planning was taking place. The surgical appointment involved the positioning of a pre-surgical guide. The remaining teeth were used to locate a guide that allows us to precisely drill pilot holes. The teeth were removed atraumatically.

Following the removal of the teeth, the osteotomy surgical guide was placed into position, and the implant sites were prepared using guided surgery MegaGen osteotomy burs. A silicone matrix was prefabricated to ensure that the upper bridge was in the right position relative to the lower arch. Following this, multi-unit abutments were chosen, with 3 mm angled abutments (29 degrees) placed on the distal implants, while 3 mm straight abutments were placed on the anterior implants. Abutment level cylinders Implant practice 31


Figure 8: Healing bridge in situ

Figure 10: PekktonÂŽ prefabrication framework

Figure 9: Healing bridge

Figure 11: IPS e.maxÂŽ crown fabrication

Digital dentistry: the benefits 1. Digital smile design can offer patients a clear indication of how their final smile will look. 2. Being able to visualize the entire treatment, step by step, provides excellent esthetics right from the start. 3. Digital videos can be used to assess esthetics, function, and phonetics. 4. Never underestimate the power of conventional techniques and methods with good quality lab work, but allow yourself to open up to the possibility of more accurate restorations and faster treatment times. Figure 12: Pink composite addition 32 Implant practice

Volume 11 Number 2

other finishing materials such as ceramics and composites. In addition, it is easy to mill and polish, which expedites laboratory turnaround, allowing the restoration to be fitted more expediently. Patients notice the decrease in weight of the bridge, while other attractive qualities such as no metal taste and no thermal or electrical conductivity are appreciated. In terms of the cantilever of the molar teeth on the bridge, Maló, et al. (2003; 2005), suggest that if there was an anteroposterior spread of 10 mm between the mesial and distal implants, then the cantilever can be 20 mm. In the maxilla, the cantilever is well within the remit as the screw holes are present at the UL5 and UR5. To provide further protection, a nighttime splint will also provide even and equitable occlusal forces. In addition, tooth wear will be limited by the wearing of a splint.

Final esthetics With regard to the final esthetics, I feel that the result is a very natural one. The incisal edges of the teeth mimic the lower

labial curve very nicely. The subtle graduation in colors in the crown’s esthetics with lovely incisal edge translucency adds to the overall result. Digital dentistry is the future, but it is also the present. While conventional techniques and methods aided by quality laboratory work will always provide top quality results, digital dentistry allows us to expedite treatment time and more accurate restorations — not to mention greater patient acceptance. IP REFERENCES 1. Alsadon OA, Pollington S, Wood D, Patrick D. Evaluation of the optical properties of PEKK based restoration [Poster 3667]. Exhibited at International Association for Dental Research: Boston MA; 2015. 2. Coachman C, Van Dooren E, Gürel G, et al. Smile design: from digital treatment planning to clinical reality. In: Cohen M (ed). Interdisciplinary Treatment Planning. Vol 2, Comprehensive Case Studies. Chicago, IL: Quintessence; 2012. 3. Dawson PE. Functional Occlusion: From TMJ to Smile Design. St Louis, MO: Mosby; 2007. 4. Dube C. Quantitative polygraphic controlled study on efficacy and safety of oral splint devices in tooth-grinding subjects. J Dent Res. 2004; 83(5):398-403. 5. Duyck J, Van Oosterwyck H, Vander Sloten J, De Cooman M, Puers R, Naert I. Magnitude and distribution of occlusal forces on oral implants supporting fixed prosthesis: an in vivo study. Clin Oral Implants Res. 2000; 11(5) :465-475. 6. Maló P, Rangert B, Nobre M. “All-on-Four” immediatefunction concept with Brånemark System implants for completely edentulous mandibles: a retrospective clinical study. Clin Implant Dent Relat Res. 2003;5(suppl 1):2-9. 7. Maló P, Rangert B, Nobre M. All-on-4 immediate-function concept with Brånemark System implants for completely edentulous maxillae: a 1-year retrospective clinical study. Clin Implant Dent Relat Res. 2005;7(suppl 1):88-94. 8. Pham VT. Pekkton® a new high performance polymer. Dental Technologies, US Edition. 2014;109:28-32. 9. Ritter RG. Multifunctional uses of a novel ceramic-lithium disilicate. J Esthet Restor Dent. 2010;22(5):332-341. 10. Rufenacht CR. Fundamentals of Esthetics. Chicago, IL: Quintessence; 1990. 11. Silva GH, Mendonça JA, Lopes LR, Landre J Jr. Stress patterns on implants in prostheses supported by four or six implants: a three-dimensional finite element analysis. Int J Oral Maxillofac Implants. 2010;25(2):239-246 . 12. Steiner M, Sasse M, Kern M. Fracture resistance of allceramic crown systems. Christian Albrechts University, Kiel, Germany; 2011.

Figure 13: Postoperative X-ray

Figure 14: Postoperative smile Volume 11 Number 2

13. van der Zaag J, Lobbezoo F, Wicks DJ, Visscher CM, Hamburger HL, Naeije M. Controlled assessment of the efficacy of occlusal stabilization splints on sleep bruxism. J Orofac Pain. 2005;19(2):151-158.

Figure 15: Final bridge Implant practice 33


were then picked up in hard cure acrylic inside the milled bridge. Following 3 months of hard and soft implant healing and integration, a Pekkton® bridge (anaxdent North America and Cendre + Metaux) was fabricated. The Pekkton bridge is an interesting material to use for full arch bridgework. It has a large number of benefits. It is metal-free, biocompatible, contains low water absorption, and high strength-to-weight ratio. Another property that is very attractive in an implant bridge is the compressibility or the shock absorbency of the material. Due to the loss of proprioception in the articulatory apparatus, this is a welcome addition as it gives a little more flexibility in occlusion. This would be especially important in a full mouth case, where the author’s normal protocol is a porcelain bridge in the maxilla with a hybrid acrylic or composite bridge in the mandible. However, with Pekkton bridges, there is the potential to go for porcelain in both arches. Other attractive features with this material include its flexibility and compatibility with

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 16 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.







To provide feedback on this article and CE, please email us at 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.



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 to your Approved Senders List in your email account. You may need to check your junk/spam folder for your certificate email.

Rehabilitation of an atrophic maxilla with guided flapless implant surgery and immediate loading

Digital smile design in implant dentistry










Cone beam computed tomography (CBCT) and 3D implant planning software allow us to treat these patients in a ________ way. a. less invasive b. more predictable c. less individualized d. both a and b Traditionally, treatment of patients with atrophic jaws requiring implant therapy involved ________. a. quicker treatment options b. complex grafting procedures c. extended healing periods d. both b and c Many patients rejected these (traditional) treatment modalities due to their _______. a. high complication b. high morbidity rates c. high costs d. all of the above It is a well-established fact that these complex procedures (sinus lifts, autogenous block grafts, and guided bone regeneration procedures) entail a high risk of surgical and postoperative complications such as ________ or damage to adjacent anatomical structures. a. infection b. wound dehiscence c. bone graft resorption d. all of the above Doing this (transferring CBCT images to 3D implant software) allows a surgical template to be created that will guide the implants into the right position, ________. a. depth b. angulation c. orientation d. all of the above The possibility of performing the surgical and prosthetic techniques of implant dentistry in

34 Implant practice

_______ represents a very effective approach that significantly reduces the treatment time and dramatically improves the patient’s quality of life. a. the same clinical visit b. 2 weeks c. 1 month d. less than 6 months 7.



With no need to _________, postoperative pain and swelling are greatly reduced, as are recovery times. a. rush the implant process b. raise a flap c. carry out suturing d. both b and c Avoiding micromovement is paramount if immediately loaded implants are to osseointegrate, so the patient has to keep to a soft diet for at least ____, progressively introducing soft chewing after this period elapses. a. 2 weeks b. 4 weeks c. 6 weeks d. 8 weeks It is well documented that an edentulous maxilla can be immediately loaded and restored with a fixed prosthesis using as few as ____ implants placed in strategic positions. a. 1 b. 2 c. 4 d. 6

10. One study showed that an experienced surgeon can have an average of ____ deviation when drilling an osteotomy manually, compared to an average of 0.5 mm when using computerguided surgery. a. 3.1 mm b. 4.1 mm c. 6.1 mm d. 8.1 mm


Using facial landmarks, we can ascertain ideal tooth spatial dimensions and confirm optimal prosthetic envelope for the teeth. This allows us to decide on _________. a. the breadth of smile b. the smile curvature relative to the lower lip c. the position of the upper teeth relative to the wet border of the lower lip d. all of the above Once the 2D planning is complete, digital scans of the upper and lower arches are taken, and the ______ files sent to the laboratory. a. STL b. PLY c. AMF d. STP

c. contains low water absorption d. all of the above 6.

Another property that is very attractive in an implant bridge is the ________ of the material. a. high water absorption property b. compressibility c. the shock absorbency d. both b and c


However, with Pekkton bridges, there is the potential to go for ________ in both arches. a. porcelain b. hybrid acrylic c. composite d. metal


Patients notice the _______ of the bridge, while other attractive qualities such as no metal taste and no thermal or electrical conductivity are appreciated. a. increase in weight b. decrease in weight c. unusual shade d. cost In terms of the cantilever of the molar teeth on the bridge, MalĂł, et al. (2003; 2005), suggest that if there was an anteroposterior spread of 10 mm between the mesial and distal implants, then the cantilever can be ______. a. 10 mm b. 15 mm c. 20 mm d. 25 mm


Digital videos can be used to assess __________. a. esthetics b. function c. phonetics d. all of the above


The CT DICOM file and the ________ can be superimposed, and this allows the clinician to ascertain where the implants are best suited to enable the dentist to fabricate the healing/ permanent prostheses. a. 2D planning STL files b. 3D planning STL files c. 2D planning STP files d. digital photographs



The Pekkton bridge has a large number of benefits. It is ________, and high strengthto-weight ratio. a. metal-free b. biocompatible

10. In addition, tooth wear will be limited _______. a. by implementing a limited diet b. by altering the opposing dentition c. by the wearing of a nighttime splint d. none of the above

Volume 11 Number 2



Making the Best Dentistry Affordable Patient Preferred Financial Services is a program designed to help health care providers offer their own custom payment plans to qualified patients. No two treatment plans are ever the same, so why offer a “one size fits all” payment plan? Patient Preferred empowers the treatment planning team to build profitable custom patient payment plans for every qualified patient. Then Patient Preferred handles all the administration, collection, and legal compliance, so the office staff can concentrate on serving more patients and not dealing with collecting fees. Patient Preferred’s cloud-based system qualifies patients in less than 10 seconds without using worthless FICO scores. Our technology is unique in the payment plan industry – built by the world’s best financial software developers, and our processing is FREE to the clinic. Our providers keep 100% of their treatment plan fees. Program highlights include: • Built by a doctor for the health care industry

• Completely paperless process

• Allows the practice to customize a payment plan for each patient

• Once trained, Patient Preferred is FREE to the clinic – no monthly minimums, no processing fees and no yearly software charges – providers keep 100% of their treatment plan fees

• Brings even the largest treatment plans within reach of most Americans • Live, instructor-led, in-clinic training for staff • Proprietary “Quick Qualify” system provides an accept or decline recommendation in about 10 seconds using patient root payment history • No FICO Credit Score checks...EVER • Smile lay away program • Removes road blocks to in-office financing

• Small service fee charged to patient – set by state mandates • Complies with all state and federal health, reporting and lending laws • Cloud-based system with all information available 24/7 through doctor/patient portal • Live telephone support for both the practice and the patient

Design the right program for your patients and your practice... Get started today! | 877-593-3745 © 2018 Patient Preferred Financial Services, LLC, 877 Executive Center Drive West Ste. 100, St. Petersburg, FL 33702


A critical distinction: problem solver versus people developer Dr. Joel C. Small offers a technique for creative problem-solving


often encounter doctor clients who are frustrated by their team’s lack of ability to achieve a pre-defined, desired result. The scenario goes something like this: Coach: I hear that you are frustrated. Give me more detail. Doctor: Okay. Well, no matter how many times I tell my staff what I want them to do, they are unable to consistently get it right. Even worse, they are constantly coming to me with problems that they should be able to manage. It seems as if they can’t make decisions on their own. I’m too busy to keep repeating myself, and I get frustrated when they come to me needlessly to solve every simple problem. I’ve tried everything I know to change this situation, but to no avail. Coach: Everything? Have you tried becoming a “People Developer”? Doctor: I don’t know what that means. Tell me more please. Any coach, in any industry, will recognize this scenario because the premise knows no boundaries. The good news is that even though the problem is universal, so is the solution. The answer lies in understanding the distinction between a “problem solver” and a “people developer.” The doctor in the above scenario is a problem solver. By this I mean that he/ she issues directives without tying them to the foundational principles of the practice. Secondly, he/she has failed to create a practice environment that is conducive to ongoing personal development. How do I know this to be true? Simple. If the doctor had been a “people developer,” he/she would not be plagued with these problems. As we shall see, it is the doctor, not the staff, who has created the problem.

Almost invariably, problem solvers fail to define the purpose of their directives and how the specific purpose correlates with the fundamental practice purpose and values. This is assuming that the doctor has even defined and shared these ideals with the staff. This lack of communication leaves a void that is filled by each team member’s own interpretation of purpose. Purpose is a strong determinant of action, so we can only imagine the confusion and frustration when a team with varying interpretations of purpose tries to achieve a common goal. Furthermore, problem solvers will always be plagued with never-ending questions from their team. Frankly, the problem and solution revolves around our expectations of our staff. Do we expect them to be helpless? Are we okay with their unwillingness and apparent inability to answer even the simplest of questions? I would expect that even the most devout problem solvers would say “No!” and yet they fail to see that they impose the very environment that promotes these forms of learned helplessness. The more we continue to answer questions, the more we become entrenched in the problem solvers’ mentality, and the more our staff is willing to abrogate their creative ability to solve problems on their own. The answer is for us to commit to developing these God-given skills in those who serve our cause. We do this by seeking their input to creative problem solving. We do this by becoming people developers. I am reminded of the old Chinese proverb, “Give a man a fish, and you feed him for a day. Teach a man to fish, and you feed him for a lifetime.” And so it is with people developers. We must first believe that someone is able to fish, or

Joel C. Small, DDS, MBA, 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. **To receive a free copy of Dr. Small’s “Core Values Exercise,” please contact the author at He is also available for a complimentary coaching session to discuss your practice-related issues.

36 Implant practice

in this case, solve problems on his/her own. Believing that something can be done will eventually become an expectation that it will be done, and expectations have been shown to be powerful self-fulfilling prophesies. Our team looks to us for answers when we fail to develop their problem-solving skills. If we find ourselves in this situation, here’s a simple solution. First, let the team know that you will be seeking their input to problem solving; then immediately quit answering questions. When someone comes to you seeking a solution to a problem, tell him/her that you have a solution, but you would like to hear their solution first. In many cases, that staff member’s solution will work quite well or will require minimal adjustments. Always make a clear correlation between the solution and the guiding practice values and purpose. Over time, staff members will realize that you will not be answering questions without their input. More importantly, they will realize that their solutions are good solutions, and with your support and encouragement, they will begin to solve problems independently within the confines of the practices purpose and values. It is important at this juncture to be clear regarding decisions that you feel require your input. Surprisingly, as the people development process progresses, you will find that your input is required less and less. Fundamental to the people development process is a willingness by the leader to encourage input, acknowledge it when received, and affirm its value. People developers will tell you that they have grown to rely on their staff’s problemsolving capabilities. I can tell you that I have personally observed very positive changes in practices that have adopted a peopledevelopment mentality. IP Volume 11 Number 2







Continuing Education Opportunity Earn up to 20 hours of implant-specific CE over four days. • Enhance your skills through hands-on workshops • Identify, treat, and avoid complications • Picture patient treatment clearer through digital dentistry • Experience the future of implant dentistry

Bring your Dental Team The Dental Implant Team Network will take place September 27-28. It includes more than 20 presentations including practice growth, treatment planning, and the team’s role in case presentations. Friday offers specific break-out sessions for each of your office staff.

Distinguished Keynote Experience Sanjay Gupta, MD Chief Medical Correspondent CNN Wednesday, September 26 5:00 pm – 6:00 pm Dr. Gupta is an Emmy® award winning chief medical correspondent for CNN. This session is included as a part of your meeting registration.

REGISTER NOW American Academy of Implant Dentistry (AAID) is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. AAID designates this activity for 20 continuing education credits.


Recover, repair, and heal from super stress with BrainTap® Sandra Marlowe discusses how to nurture a relaxation response in everyday life and the dental office


ighttime sleeplessness may be a result of our minds and our bodies combined response to stress. A study in International Journal of Psychophysiology pointed out Chinese researchers’ discovery that our bodies are primed to stay awake when we perceive threats, and nighttime stress may amplify this response. Our bodies are responding to stress much like our ancestors did when they faced nighttime threats from predators — our brain thinks we’re in danger and keeps us on high alert, diminishing the possibility of a good night’s sleep. Most people experience “super stress,” in their everyday lives, so the brain has to cope by generating high-intensity brain waves, which overpower calming brain waves, especially at night. Once your brain becomes used to this hyper alert state, it can become very difficult to wind down again. Super stress often manifests in disorders such as ADHD, obesity, diabetes, insomnia, headaches, and high blood pressure, to name but a few. To obtain a state of homeostasis (balance) for recovery, repair, and healing to take place, try the following five simple steps to optimal health.

Tip No. 1: Breathe deeply Deep breathing sends a message to your brain to calm the body. Detrimental stress responses — such as increased heart rate, increased hormone production, and high blood pressure — all decrease as you breathe deeply to relax. Just a few minutes of deep breathing can calm you and put the body back into recovery mode. For this reason, every audio session in our BrainTap® Library includes deep, relaxing, guided breathing designed to bring your body to ultimate relaxation.

To obtain a state of homeostasis (balance) for recovery, repair, and healing to take place, try the following five simple steps to optimal health. 1. Breathe deeply. 2. Focus on the moment. 3. Reframe the situation. 4. Keep your problems in perspective. 5. Practice mindful meditation and visualization.

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

38 Implant practice

Volume 11 Number 2


Once you enter this “relaxation response,” the brain sends out neurochemicals that neutralize the effects of stress on the body, allowing you to change your reactions to the stressful events going on around you. The sessions offered in the BrainTap Library are designed to help you reach the relaxation response.

BrainTap’s sessions for optimal health For Breathing deeply — Recommended BrainTap session: SR01 — Create Your Enchanted Forest for Stress Reduction For Focusing on the moment — Recommended BrainTap session: SR04 Putting Future Events into Perspective For Reframing the Situation — Recommended BrainTap session: SR05 Reducing Uncertainty and Doubt

Tip No. 5: Practice mindful meditation and visualization

state of deep rest that changes the physical and emotional responses to stress. Once you enter this “relaxation response,” the brain sends out neurochemicals that neutralize the effects of stress on the body, allowing you to change your reactions to the stressful events going on around you. The sessions offered in the BrainTap Library are designed to help you reach the relaxation response. In 20 relaxing minutes a day, you can reduce or eliminate brain fog and negative mind chatter, have more energy, relax and develop positive sleep habits, rid yourself of unwanted habits and behaviors, gain memory and focus, and improve the quality of your life. Fortunately, your BrainTap headset produces the relaxation response, which can help your brain relax and feel safe — giving your body precisely what it needs to get back in balance and reverse the effects of stress on the body. The BrainTap headset will help dental patients before, during, and after dental procedures as well. Regular use of BrainTap Technology will help rebalance your brain wave activity, allowing your brain to relax, rejuvenate and reboot itself — helping you to sleep more deeply and awaken refreshed. So, the next time you’re wide awake and feeling the stress, take comfort in knowing that your brain is doing exactly what evolution taught it to do, but you can take back control and ease into a great night’s sleep by using the BrainTap headset. IP

By practicing mindful meditation and visualization, you can achieve a physical

This information was provided by BrainTap®.

For Keeping Your Problems in Perspective — Recommended BrainTap session: SR 06 Eliminate Negative Thinking For Practicing Mindful Meditation and Visualization — Recommended BrainTap session: SR 10 Developing Spontaneous Relaxation

Tip No. 2: Focus on the moment When you are stressed and anxious, you may be worried about the future or regretting a past action. This can cause immense amounts of stress from which our bodies need recovery time. One way to lessen this type of stress is to bring yourself back to the moment. If you’re walking, feel the sensation of your legs moving your body. If you’re eating, focus on the taste, the smell, the sensation of the food you’re consuming. If you’re relaxing, be mindful of the heaviness of your limbs and the deep, rhythmic sound of your breathing. Rather than seeing only the negatives, focusing on the moment offers you a space to think differently about stress and respond in a more appropriate manner without past regrets or future worries.

Tip No. 3: Reframe the situation When you are stressed or overwhelmed, focus on a positive thought. (This is called “reframing” the situation.) It’s not as hard as you think. Look at the same situation in a new way that highlights the possibilities. Viewing our stressors as opportunities can help us stop feeling trapped and reduce 40 Implant practice

the physical effects of stress on our bodies almost immediately. Ways to reframe the situation 1. Look at what is actually stressing you. 2. Consider what you can change, if anything, about the situation. 3. Look for the positives. 4. Find the humor.

Tip No. 4: Keep your problems in perspective Don’t stress too much on a specific problem. It’s important to remind ourselves of the positives in our lives — we woke up this morning; we can see; we can walk; we have family and friends to support us. It might seem a little silly at first, but the next time you’re feeling stressed, consciously make the effort to think about the things you’re grateful for. This can be a surprisingly easy way to reduce the stress in your life.

Volume 11 Number 2

Start off your implant training with 20 online modules that are completed at your own pace, all available on-demand. Next, join us for Sessions 2 and 3, which are a combination of hands-on training and lectures Travel to your choice of either Chicago, IL (June 8 and 9 / July 13 and 14), Dallas, TX (September 13 and 14 / October 12 and 13), or take advantage of our FastTrack, combining all four sessions into one week in Phoenix, AZ (November 5 - 9).

session one: Online 20 Ce credits

session two & three: hands-on / lecture 24 ce credits

y r t s i t n e nt d

a l p m i n r lea


hoen p d n a s alla d , o g a c i s in ch


four ses

Finish off your implant training with two complete days of live surgeries, placing one implant right after the other. Treatment plans are catered to where you want your practice to go! Live surgeries are performed in the brand new, non-profit dental clinic New Horizon Institute, Inc. in Phoenix, Arizona. All patients receive treatment and restorative care— all pro bono.

session four: live implant surgery 24 ce credits


re a

o learn m

Instructed by Drs. Justin Moody and Mike Freimuth

by visit y a d o t r te nd regis

m o c . y a w h t a p t n


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

Implant Pathway (IP) is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 4-1-2015 to 3-312019. Provider #: 342679


Star® ETorque™ Electric System Power, performance, and flexibility


aunched at Chicago midwinter, DentalEZ introduces the new Star® ETorque™ Electric System. The ETorque Electric Motor System combines the power and performance you have come to expect from StarDental. With customizable settings for prep and endodontic procedures, the StarETorque seamlessly combines power with performance. From caries removal to root canal treatment, you can seamlessly move from high-speed to low-speed settings with one touch. The StarETorque’s lightweight, brushless motor delivers powerful, consistent speed, all with less noise and vibration — a real plus for both patient and dentist. The motor is also compliant with CDC Guidelines and can be autoclaved. The StarETorque’s redesigned touch screen and color display provide a simple, intuitive user interface to reduce time spent making adjustments. Flexibility is built-in.

42 Implant practice

The overall size of the Motor Control Unit has also been reduced and provides all the performance you need. So, if you are looking for a new product that brings all the power, flexibility, and performance you need, look no further than StarETorque.

Features • 60 W Brushless Motor • Lightweight at 62 g to minimize fatigue • 100–40,000 rpm motor speed and up to 200,000rpm with the speed increasing attachment • Fully autoclavable motor • User-friendly display with customizable operative modes • Compact design for stand-alone or detachable display for modular mounting • Multiple attachments cover a broad range of operatory needs

Top: Endodontic mode for powerful low-speed cutting Bottom: Preparation mode for high-speed procedures

• Textured finish on attachments for comfortable grip • Programmable motor torque accommodates all rotary file requirements • 3 customizable reverse settings for endo mode: auto stop, auto stopreverse and auto stop-reverse-forward • 6 presets for both endo and prep modes to save your favorite settings IP This information was provided by DentalEZ.

Volume 11 Number 2

Referrals Simplified Securely and easily send electronic referrals

Save time & stay compliant

Streamline communication among dental colleagues

Call: 415.749.1444 Visit:








LOCATOR F-Tx® Immediately rescue a fixed-hybrid prosthesis after an implant failure


hen challenging fixed-hybrid implant failures happen, a prosthesis emergency could result. In the past, replacing the prosthesis was the only option available as it was virtually impossible for the existing prosthesis to seat passively in the altered position of the screw-retained components at the replacement implant site. Zest Dental Solutions recently introduced the LOCATOR F-Tx Fixed Attachment System, revolutionizing the way clinicians think about fixed fullarch restorations by not requiring screws or cement to affix the prosthesis. The unique design of the LOCATOR F-Tx System also allows it to be the only immediate solution on the market today to rescue a fixedhybrid prosthesis when an implant fails. The unique design of the LOCATOR F-Tx Fixed Attachment System includes a

44 Implant practice

novel “snap-in” attachment that is picked up chairside, ensuring a passive fit, while working in harmony with existing screwretained abutments, and saving both clinicians and patients substantial time, money, and frustration. Zest Dental Solutions President and CEO Steve Scheiss, explains, “Now clinicians can not only offer a fixed full-arch restoration without using screws or cement to affix the prosthesis, they can also use the same technology to save a patient’s prosthesis when a fixed-hybrid emergency occurs. LOCATOR F-Tx arms clinicians with one product that provides multiple treatment solutions for fixed restorations.” “LOCATOR F-Tx represents another paradigm shift from Zest that allows clinicians to provide innovative treatment solutions to their edentulous patients,” Scheiss added.

Zest Dental Solutions is a global leader in the design, development, manufacturing, and distribution of diversified dental solutions for a continuum of patient care from the preservation of natural teeth to the treatment of total edentulism. The company’s product portfolios consist of Zest Anchors, Danville Materials, and Perioscopy with global distribution through OEMs, dealer/distributor networks, as well as a domestic retail sales operation for the Zest Anchors Portfolio. Zest Dental Solutions’ corporate headquarters is in Carlsbad, California, with satellite operations in Anaheim and Escondido, California. Please visit rescue for everything a clinician needs to rescue a fixed-hybrid screw-retained prosthesis after an implant failure. IP This information was provided by Zest Dental Solutions.

Volume 11 Number 2

Dental Sleep Practice is honored... to have been chosen to sponsor the Dental Sleep Education Track for the Greater New York Dental Meeting, Nov. 25-28, 2018

Dental Sleep Practice will sponsor two lectures each day from Sunday, November 25 through Wednesday, November 28. These eight seminars, taught by industry leaders who represent the top educators in sleep dentistry, will support dentists through practical sleep apnea education. The program will be led by DSP’s Editor in Chief Dr. Steve Carstensen. DSP in partnership with the GNYDM will give you the facts and information you need to expand your practice in this growing and important field of dentistry. Watch for more details this Summer: Connect. Be Seen. Grow. Succeed.


M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT Carestream Dental introduces new care management platform Carestream Dental’s new care management platform follows a software-as-a-service (SaaS) model, providing anytime, anywhere access through a modern web browser. For busy practices where multitasking is a daily reality, users can quickly and easily manage multiple records when answering the phone or performing tasks. Key patient information, consolidated into a single view and accessible from anywhere, allows users to handle the most common questions and requests without having to abandon their current work. This seamless navigation enhances overall staff productivity and allows for better patient interaction. For information, call 800-944-6365 or visit carestream

PREAT Corporation introduces the Bidra Conversion Smart Polishing Cap PREAT Corporation has introduced a new and innovative tool for all implant professionals: the Bidra Conversion Smart Polishing Cap, a must-have for your next conversion from a removable to a fixed prosthesis. Existing polishing caps protect only the inside of the coping, not the outside. Avinash S Bidra, DDS, MS, FACP, Director, UCONN Post-Graduate Prosthodontics, designed this innovation with the dental professional in mind. With an extended metal rim, the Bidra Conversion Smart Polishing Cap fully protects both the inside and outside of the metal coping, preventing damage to the coping during pickup, trimming, polishing, and finishing the prosthesis. External rough areas attract food, plaque, and bacteria and may lead to soft tissue inflammation and bone loss around the implants. Eliminate the headaches with the easy-to-use Bidra Conversion Smart Polishing Cap from PREAT Corporation. For information, visit or call 800-232-7732.

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Karl Schumacher Dental launches comprehensive suite of regenerative products Karl Schumacher Dental, LLC, marks its 70th year in business with the debut of 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. It contains 100% human demineralized bone matrix and BMP-2, free from additive excipients required in other products for improved handling. 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. The synthetic putty is a synthetic mineral-collagen composite bone graft matrix for use in bone repair during oral surgeries. Karl Schumacher’s collagen membranes and dental wound dressings offer the same high-quality as other Schumacher products. 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. When wound dressing is needed during dental surgery, the foam, plug, and tape dressing work in moist environments, controls bleeding, and protects the wound from further injury. For more information, visit

ASI touts its White Silk handpiece tubing ASI’s White Silk handpiece tubing is now the standard instrument tubing on its dental systems. Because this new tubing is lighter, softer, and smoother, it provides cling-free use. When a handpiece is removed from the holder, it glides smoothly across neighboring tubing. The silky smooth texture reduces the risk of tangling or accidentally dislodging other handpieces. All new ASI dental systems in 2018 will be equipped with white silk handpiece tubing. For more information, visit

Volume 11 Number 2

Osstell has teamed up with BioHorizons as an exclusive partner in the United States. BioHorizons offers a broad spectrum of products, including dental implants, restorative and laboratory components, soft and hard tissue biologic products, and surgical planning software. Osstell is a good fit in their surgical- and implant-product portfolios and will contribute to creating substantial value both for dentists and their patients. For information, visit

Ultradent Products, Inc., celebrates 40th anniversary

New product from Denali Corporation: Jazzy™ Dual Cure Acrylic Resin Denali Corporation, Hanover, Massachusetts announced Jazzy™ Dual Cure Acrylic, a dual cure acrylic resin for implant verification guides, abutment positioning, PFM copings, border molding, bridge repositioning, and many other operatory and lab uses. Jazzy™ is intended to replace the tedious, old powder and liquid “salt and pepper” technique. It allows for continuous addition of material with a self-cure time of about 1 minute and cures on demand with all wand-type curing lights in 20 seconds or less. For PFM copings and other castings, Jazzy™ burns out completely with no residue. Jazzy™ comes in a syringeable form that is easy to apply and is safe with no exothermic buildup — no pain. Jazzy™ also eliminates the use of dental curing ovens needing setting times of 5 to 40 minutes. Dental appliances can be fabricated in a matter of only a few minutes, compared to the 20-30 minutes for current materials. Jazzy™ bonds between layers, flows into place, and can be finished to a lustrous surface. Jazzy™ eliminates odor from open bottles of methyl methacrylate and offers enormous time and convenience advantages over other acrylic products, including no waste, no spills, and no clean-up. For more information, call 781-826-9190, or visit www.denali Volume 11 Number 2

This year, Ultradent Products, Inc., a family-owned, international dental supply and manufacturing company, is celebrating 40 years in the dental industry. Ultradent has become a worldwide leader in its field — known for its innovative dental products, rock-solid core values, and family-friendly, people-centered business culture. Ultradent is also a proud USA manufacturer. The company researches, designs, manufactures, packages, and ships 95% of what it sells in its South Jordan facility. It also exports 70% of its products beyond U.S. borders to over 100 countries throughout the world. Ultradent’s hallmark products include its expanded line of tissue management products, which still includes Astringedent® hemostatic, and its world renowned, industry-leading line of tooth whitening products, Opalescence® Whitening Systems. Ultradent’s product family also includes the multiple-award winning VALO® and VALO® Grand curing lights, Ultra-Etch® etchant, and its recently introduced dual-wave soft tissue diode Gemini® laser. For more information, visit or call 800-552-5512.

CS 8100SC 3D wins 2018 Edison Award for its innovative design The CS 8100SC 3D extraoral imaging system by Carestream Dental has been awarded a bronze 2018 Edison Award in the category of Dental/ Medical Digital Imaging by the internationally renowned Edison Awards™. The distinguished award, inspired by Thomas Edison’s persistence and inventiveness, recognizes innovation, creativity, and ingenuity in the global economy. To earn a bronze 2018 Edison Award, the CS 8100SC 3D was judged on its concept and development, value, and impact on the industry. The CS 8100SC 3D offers two-dimensional panoramic imaging, cephalometric imaging, cone beam computed tomography (CBCT) imaging, and model/impression scanning all in one compact system. That means doctors can go from diagnosis to treatment faster, without having to send patients to an imaging center. Not only is the system more convenient, but it’s also faster— featuring the fastest scanning cephalometric module on the market — and safer. The CS 8100SC 3D’s low dose program can deliver 3D imaging at a dose equal to or lower than panoramic imaging. For more information, visit or call 800-944-6365. Implant practice 47


Osstell teams up with BioHorizons as U.S. exclusive partner


Surviving implant failures Dr. Justin Moody reflects on how implant failures affect both the dentist and the patient


o one ever wants to hear the hygienist or the patient say, “Doctor, I think we have a problem with this implant,” yet if you place enough dental implants, you will indeed end up having this discussion. Complications and failures are part of the business and will happen to any dentist who places enough of them — the law of averages always wins. But why? We have taken all the precautions, are well educated, and the procedure went great, yet there is still an issue. If you really think about what we are asked to do with dental implants, it’s a small miracle that any of them survive. Being asked to place a cold piece of titanium metal into the dirtiest, most bacteria-infested part of the body, where motion occurs and foreign objects are placed all day long, is a lot to ask. I always tell my patients that although dental implants enjoy one of the highest success rates of any type of dental procedure, there is always the risk of complications and failure. How you handle these complications is your key to surviving the event and maintaining the positive relationship with the patient, but more importantly, we need to avoid giving implant dentistry a bad name. In my opinion, criticizing another dentist’s work when you see an issue is not only rude but also shameful; you have to believe that on that patient’s treatment day, the dentist was doing his/her very best. Will some patients just not understand? Yes, but in my experience, I have noticed that if you are honest with them and have a plan to resolve the issue, most will take comfort in that, and you may actually build more trust with the patient over how you handle the situation. There are three keys to surviving implant failures — first is education. You need to have a solid understanding of the science

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 or at Disclosure: Dr. Moody is a paid speaker for BioHorizons®.

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Figure 1: Vertical bone loss around a previously integrated dental implant — a number of factors may have contributed to the its failure

Figure 2: Uncovering the site reveals nearly complete fibrous tissue encapsulation of the dental implant

Figure 3: When an implant fails, it almost always takes good bone with it, leaving a defect that will need to be rebuilt and managed

and clinical procedures involved with good implant treatment. Second, you need to know your patient and the risk factors associated with this case. Many of our complications can be avoided by just getting to know the patient’s medical and dental history. And third, it’s about only setting realistic expectations. I am not necessarily talking about esthetics but about the fact that somehow the public has the perception that all dental work should last a lifetime, and if it doesn’t, they are upset and expect the resolution to be free of charge. Simply telling your patients that nothing in dentistry is forever can go a long way, especially if you plan to practice for 30 to 40 years. Don’t let a dental implant failure derail your career. I have seen too many dentists back away from implant dentistry after having

Figure 4: No one likes to see the implant on the tray, but an understanding of why it happened will make it a valuable learning experience

a negative outcome. Remember that we learn more from our failures than we ever do from our successes. Take a step back when something like this does occur, be a detective, find out what really went wrong, and then fix the situation in such a manner that you can lower the risk factors and get a good night’s sleep. Always do the right thing; it’s just that easy. IP Volume 11 Number 2

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

Not available in all countries. SPMP16254 REV D JAN 2018



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Implant Practice US Summer 2018 Vol 11 No 2  
Implant Practice US Summer 2018 Vol 11 No 2