Implant Practice US Summer 2019 Vol 12 No 2

clinical articles • management advice • practice profiles • technology reviews Summer 2019 – Vol 12 No 2 • implantpracticeus.com

PROMOTING EXCELLENCE IN IMPLANTOLOGY

Implementing dynamic navigation implant surgery in a modern dental practice Dr. Michael Hartman

A comprehensive clinical review of platelet-rich fibrin and its role in promoting tissue healing and regeneration: part 3 Drs. Johan Hartshorne and Howard Gluckman

Corporate profile ALPHAEON™ CREDIT

Clinician spotlight Lisa Rae Gaither, DMD

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by Zimmer Biomet Dental and 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. Distribution to any other recipient is prohibited. This material may not be copied or reprinted without the express written consent of Zimmer Biomet Dental. ZB0702 REV A 01/19 Š2019 Zimmer Biomet. All rights reserved.

Nurturing females in dentistry

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

© FMC 2019. 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.

I

t is estimated that by 2020, more than 30% of dentists will be women. While that seems like a small number, consider that it was a meager 3% in 1970. Clearly, over the past 50 years, great strides have been made to balance the gender gap in the dental profession.

With this major paradigm shift, we are seeing more women not only in dental specialties that were once dominated by men, but also in more leadership roles — from owning their own dental practices to presiding over organized dentistry organizations. I believe that as the future of dentistry becomes more female, it will have an overwhelmingly positive impact on the industry — patients and the dental ecosystem as a whole.

However, there are still fewer women in dental specialties such as implantology, due to perceived negative notions of being seen or heard in what has historically been a maledominated specialty. Invisible barriers still exist that need to be addressed and broken down, such as second-generation gender bias. To do this, continuing education and dialogue are needed to ensure women are included in all of the many facets of the pursuit of dental proficiency. Female dentists who step into this male-dominated specialty encounter success because they more often are better at blending “soft” skills — i.e., tapping into their nurturing and compassionate side, building collaborative and engaged teams, which together with their clinical skills are critical to Implant care success.

Life balance is still an area of struggle, not just for women in dentistry — but for every working woman out there with a family. Female dentists are able to navigate work-life balance more successfully. Dentistry offers the flexibility in scheduling needed to maintain a family life alongside a demanding career. This flexibility also allows time for pursuing continuing education studies needed to keep up-to-date with all the changes and developments in the dental profession, as well as to stay on top of new innovations and technology, so that we can always provide the best for our patients and continue growing our presence in the specialty fields.

In order to redefine the traditional gender roles within the dental profession, we need to be ready to step up and challenge the status quo; that is, step up to leadership roles to build expertise and increase our presence in academia. More females in academia would pave the way to creating a more supportive environment for women as a whole right from their first year in dental school. Glass ceilings still exist in dentistry, but we have come a very long way from what it used to be. Female dentists are here to stay, and supporting and developing the qualities they bring to the table will only strengthen the industry. There is strength in numbers, and our opinions matter, especially when it comes to issues that women dentists face. Let your voice be heard!

If you ask successful people what they did to get where they are, they’ll probably tell you they didn’t get there without the help or mentorship of another person. We have no excuse to not help one another succeed. There are a lot of amazing women in the profession who can mentor younger or less experienced female dentists by encouraging them and challenging them constantly. It’s important that as more women excel in implant dentistry, more women would be inspired to follow in their footsteps. We all need coaching; we need to see other female dentists in leadership roles that we can emulate and aspire to be like. While spending time networking and developing relationships often comes second to the priorities of home and work, our advancement as a formidable community requires a combination of skill and persistence, no matter the hurdles we face.

As we move into the future of implant dentistry, the importance of role models and mentors cannot be overemphasized. “Here’s to strong women: May we know them. May we be them.

May we raise them.” – Unknown Welcome to the future of implant dentistry — it looks like me!

Jumoke Adedoyin, DDS, MICOI, MAAIP, is a licensed general dentist and an implantologist. She mentors and teaches emerging female dental practitioners on how to build a thriving and successful implant practice without sacrificing their quality of life to achieving this. Dr. Adedoyin is a recipient of numerous awards for her community service within her professional network and has been featured on NBC 12 news and Implant Practice US magazine. She is a sought-after expert and mentor for females in dentistry because she understands the entrepreneurial challenges of building a practice and maintaining a balanced life. Dr. Adedoyin is a faculty member at Implant Pathway. You can find her online at www.drjumoke.com. She lives in Atlanta with her husband and three children.

ISSN number 2372-9058

Volume 12 Number 2

Implant practice 1

INTRODUCTION

Summer 2019 - Volume 12 Number 2

TABLE OF CONTENTS

Clinician spotlight Lisa Rae Gaither, DMD

8

Publisher’s perspective Taking a stand for success ..........................................................6

Always looking for growth, while maintaining patient care

Humanitarian efforts New Horizon Dental Institute

Corporate profile

10

Dr. Justin Moody discusses giving implant dentists a chance to sharpen their skills while offering patients dental care with dignity.............................. 12

ALPHAEON™ CREDIT Helping doctors help more patients

ON THE COVER Cover image courtesy of Dr. Michael Hartman.

Article begins on page 16.

2 Implant practice

Volume 12 Number 2

3Shape Implantology Open and efficient implant solutions

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TABLE OF CONTENTS

Continuing education A comprehensive clinical review of platelet-rich fibrin (PRF) and its role in promoting tissue healing and regeneration: part 3 Drs. Johan Hartshorne and Howard Gluckman discuss the clinical indications of PRF in implant dentistry, periodontology, oral surgery, and regenerative endodontics...............21

Lab link 3D printing possibilities for the present and future Joseph Lee, CTO at Friendship Dental Labs, shares his vision of 3D printing for the denture and implant practice

.................................................32

Continuing education

16

Implementing dynamic navigation implant surgery in a modern dental practice Dr. Michael Hartman discusses a technology that can have a positive effect on implant treatment outcomes

Product profile

On the horizon

Built to Last. Built for You. Built by Boyd...........................36

Start with the “why?�

Industry news...............38

Dr. Justin D. Moody discusses how to handle inevitable setbacks

................................................. 40

www.implantpracticeus.com READ the latest industry news and business WATCH DocTalk Dental video interviews with KOLs LEARN through live and archived webinars RECEIVE news and event updates in your inbox by registering for our eNewsletter

CONNECT with us on social media Connect. Be Seen. Grow. Succeed. | www.medmarkmedia.com

4 Implant practice

Volume 12 Number 2

Building a Monumental Reputation Would you recommend your implant system to a colleague? Recently we had our Net Promoter Score (NPS) measured relative to other implants. NPS is a simple metric to see if your customers would recommend you.

A score of 50 is excellent; anything over 70 is considered elite. Implant Direct scored a 73%, compared to 41% for other systems. This NPS score represents the kind of loyalty that can’t be bought; only earned through years of delivering results. If you’re a current Implant Direct customer, thank you for your confidence. If you’re not, why not give us a shot and see what the buzz is all about? We are Implant Direct and we are dedicated to the curators, creators and keepers of smiles everywhere. implantdirect.com l 888 649 6425

PUBLISHER’S PERSPECTIVE

Taking a stand for success

A

t a recent seminar on growing business practices, one particularly meaningful session started with the speaker asking people to stand if their business has lasted 1 to 5 years.

After that group sat down, next, the 5- to 10-year group was asked to rise. When recognizing people in the 10- to 15-year category, I looked around to see very few in that category standing in this large room. I was surprised and humbled, and also very proud that after 1½ decades, I was still standing — both literally and figuratively.

With the ever-changing business climate we are currently living in, it is often difficult to keep track of all of the details needed to keep your business in the public eye while staying laser-focused on expansion and growth. While general dentists Lisa Moler Founder/Publisher, MedMark Media and specialists alike need to concentrate on all of the technology and techniques that lead to better patient care, you also must remember, and already may be painfully aware, of the vital importance of understanding how to keep your business side booming. From social media to networking with colleagues, to methods for hiring and retaining employees who will have your back and your practice’s best interests in their minds, both entrepreneurs and dentists have to find a work-life balance between our personal and business lives.

In our upcoming issues, my column will offer tips on how to be a successful entrepreneur while being a caring business owner and running a profitable business! As a woman entrepreneur, I understand the frustrations and triumphs of tackling the world of business with all of its complexities and the competition of others who are also chasing success. It’s a massively competitive world we are living in!

Articles in this Summer issue of Implant Practice US also can help feed your inspiration.

We offer a CE on dynamic navigation. Dr. Michael Hartman discusses this technology, which when blended with an efficient workflow, leads to enhanced profitability and predictably of treatment outcomes in a modern dental implant surgery practice. In our second CE, Dr. Hartshorne continues his series with part 3 on platelet-rich fibrin and its role in tissue healing and regeneration. This article applies to a wide variety of fields, including implant dentistry, periodontics, oral surgery, and regenerative endodontics. In our Lab Link column, an article on 3D printing possibilities shows what is available now and future possibilities for in-house fabrication of dentures and implants. Groundbreaking implant dentist and teacher, Dr. Justin Moody, explores how to handle inevitable setbacks and move forward with solutions for the success of your practice.

Through my future columns, I hope to connect with you not just as dental specialists, but business people and entrepreneurs. At Implant Practice US, we care about your stress AND success, and the often challenging and even painful journey to achieving your goals.

After 15 years, I’m still standing — proud of the hard work that it took to get here, proud of my amazing, unwavering team that constantly has my back, and looking forward to all of the exhilaration of embracing and conquering business speed bumps and hurdles, while still learning with every step. I’m still standing. My goal is for you all to stand with me in the coming years, with our fierce entrepreneurial spirits — tackling life, propelling us upward, and pushing us forward to unlimited success in both your business and personal aspirations!

To your best success!

Lisa Moler Founder/Publisher MedMark Media

Published by

PUBLISHER Lisa Moler lmoler@medmarkmedia.com MANAGING EDITOR Mali Schantz-Feld, MA mali@medmarkmedia.com | Tel: (727) 515-5118 ASSISTANT EDITOR Elizabeth Romanek betty@medmarkmedia.com VP, SALES & BUSINESS DEVELOPMENT Mark Finkelstein mark@medmarkmedia.com NATIONAL ACCOUNT MANAGER Celeste Scarfi-Tellez celeste@medmarkmedia.com CLIENT SERVICES/SALES SUPPORT Adrienne Good agood@medmarkmedia.com CREATIVE DIRECTOR/PRODUCTION MANAGER Amanda Culver amanda@medmarkmedia.com MARKETING STRATEGIST Matt Simpson emedia@medmarkmedia.com SOCIAL & PR MANAGER April Gutierrez medmarkmedia@medmarkmedia.com CONTENT MARKETING Lauren Nash emedia@medmarkmedia.com FRONT OFFICE ADMINISTRATOR Melissa Minnick melissa@medmarkmedia.com

MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 | Fax: (480) 629-4002 Toll-free: (866) 579-9496 www.implantpracticeus.com www.medmarkmedia.com

SUBSCRIPTION RATES 1 year (4 issues) $149 | 3 years (12 issues) $399 Subscribe at www.medmarksubscriptions.com

6 Implant practice

Volume 12 Number 2

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CLINICIAN SPOTLIGHT

Lisa Rae Gaither, DMD Always looking for growth, while maintaining patient care

F

ixing things came naturally to Dr. Lisa Rae Gaither from an early age. “Even before dental school, I liked putting things together. I was the person in my grandparents’ house — if they bought something that needed to be assembled, that was my job,” she recalls.

Dr. Gaither graduated from the University of Kentucky’s School of Dentistry, which is centered in a highly edentulous state, providing her many opportunities to extend her surgical experience. It was this type of dentistry that she was drawn to — trauma cases that allowed her to “fix something that has been broken.”

Even so, she tried her hand at corporate dentistry and general dentistry, working in the Arizona State Prison System and the University of Texas Health Science Center.

Surgical cases, requiring extractions and denture expertise, continued to make their way onto her path, however, and Dr. Gaither happily took them on.

Recognizing her talents After years of exploration, Dr. Gaither realized two things: First, she enjoyed surgery. Second, she wanted complete clinical autonomy. This led her to contact Affordable Dentures & Implants (AD&I) and open her own affiliated practice only 6 months later in Winston Salem, North Carolina. At AD&I, Dr. Gaither says, “It’s hands off as to what you do with your patients. They allow you to do what you do best.” She continues, “I think my greatest skills lie with being able to extract teeth while causing the least amount of trauma to the bone, in preparation for immediate implant placement.”

Dr. Gaither checks in with Lab Manager, Aaron Taylor, as he uses the Ivoclar IvoBase Injection System 8 Implant practice

Dr. Gaither credits her expertise in extractions to the formal training she received during her Oral and Maxillofacial Fellowship at the University of Connecticut. However, she enjoys her implant cases the most, especially the opportunity to use the new BioHorizons® Tapered Short Implants.

“With these I’m able to place implants in the posterior and get a better anteriorposterior spread, which equates to less rocking of the denture and less potential for any nerve damage.”

Discussing preventative measures is also a key component to her patient conversations.

And prevention, she believes, will play a big role in the future of the dental industry.

“Looking at where we’re heading — stem cell research will continue to be discussed, and there is more research being done on preventive care, more chairside education, patient care, and teledentistry as well, which allows people to get access to care who wouldn’t be able to otherwise.”

Establishing trust

Growing up on Medicaid herself, Dr. Gaither knows firsthand the value of access to care. And having provided dental services to many low socioeconomic status patients throughout her career, she takes great pride in the work she does. She understands the need and the associated impact she has.

“People have to eat. They have to be able to go out with confidence in whatever they do on a daily basis,” she says.

Dr. Gaither feels blessed that she’s able to use her talents to impact lives. But she won’t stop there. She wants to continue to grow and give, both in the dental field and outside of it.

She has always pushed herself to be more.

“I don’t accept mediocrity or just getting by,” she says. “I want more education. I also hope to become an educator, taking on the role of motivating others, and helping other dentists who are developing their careers.”

Dr. Gaither is an affiliated Affordable Dentures & Implants dentist and practice owner in Winston Salem, North Carolina. IP

Patients who are unfamiliar with the clinical phrases will find that Dr. Gaither makes an effort to establish trust and has great patience while making the patient’s clinical diagnosis clear. “I believe in educating the patient prior to doing anything. I like to paint the full picture from start to finish — what the experience is going to be like as a denture wearer — I give them a realistic expectation.”

Dr. Gaither studies the CBCT of the upper and lower jaws of an implant patient with BioHorizons® Tapered Short Implants in the posterior mandible

Making an impact

This information is provided by Affordable Dentures & Implants.

Volume 12 Number 2

You specialize in creating the perfect fit.

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Contact us today to find your perfect fit!

CORPORATE PROFILE

ALPHAEON™ CREDIT Helping doctors help more patients Who are we?

In May 2014, ALPHAEON™ CREDIT began delivering on our promise to help doctors help more patients by providing an improved patient financing solution.

What do we do?

To be better, we needed to do a few things really well. Namely, we needed to deliver: • A revolving line of credit so patients and their family members could return again and again without needing to reapply each time they needed to finance.

• Stronger approval rates so more patients would be able to move forward with the treatment and care that doctors recommend.

• Superior credit limits so patients don’t have to compromise on care and can finance the full cost of their care easily and feel more comfortable pursuing higher cost treatment plans.

• A wide array of payment plans including the deferred interest plans and longer term with interest plans that patients had come to know and expect.

We also knew our rates for the doctor and the patient had to be as good as or better than other available options if we were going to compete effectively.

How do we do it?

To accomplish these goals, we partnered with Comenity Capital Bank, which is the bank behind many favorite branded credit cards, including Ann Taylor, Cost Plus World Market, IKEA, J. Crew, Kay Jewelers, Pottery Barn, Restoration Hardware, Sephora, Victoria’s Secret, and more. Comenity Capital Bank is the only bank with the experience and backing to deliver on our “must-haves.”

Initially, we also limited our focus to only a few medical specialties: dermatology, ophthalmology, and plastic surgery. Later in 2019, due to demand from doctors and patients with the ALPHAEON CREDIT card in their wallets, we expanded our program into dentistry as well. By limiting our markets, 10 Implant practice

ALPHAEON CREDIT booth at the Yankee Dental Congress

not only can we deliver a better experience, but the risk is lower from a lending perspective, and our partners are more easily able to provide on our approval rate and credit limit requirements.

Beyond the “must-haves,” we wanted our program to be stress-free for the doctors, their teams, and their patients. We know how busy a practice is and that dental offices are open at all hours and at all days of the week now. We also know how important it is to be able to resolve issues immediately, especially if a patient is waiting. That is why we are committed to being there anytime doctors or their teams need help. Today, when you call ALPHAEON CREDIT’s hotline, you will speak to someone immediately without waiting, without navigating a phone system, 24 hours a day, 7 days a week, 365 days a year. This hotline rings to our personal cell phones, including the President’s, so immediate help is always only a phone call away.

If you’re working, we’re working!

Where did we come from, and how do we know what is essential to doctors, their teams, and patients when it comes to patient financing?

Because we know healthcare AND patient financing.

Our parent company’s investors are doctors from across the country and across various medical specialties. In addition to other products and services, these doctors saw a need for a new patient financing solution in their respective specialties. That is how ALPHAEON CREDIT came to be.

Volume 12 Number 2

CORPORATE PROFILE

Dr. Ara Nazarian, Clinical Director of Ascend Dental Academy, with Anne Haines, Director of Dental Financing, at the International Congress of Oral Implantologists (ICOI)

Once they determined a new patient financing option was needed, the ALPHAEON CREDIT team was created. From the start, our senior leadership team was comprised of individuals with healthcare and patient financing backgrounds. As a result, they understand that at the end of the day, the real question is, How many patients did we help today? rather than, How much did we finance today? We understand what is important to doctors, their teams, and patients and built our patient financing solution to meet the needs of those individuals.

Who is leading?

Tony Seymour is our President. Prior to joining ALPHAEON CREDIT, he started and managed the specialty division at CareCredit, overseeing the audiology, bariatric, cosmetic, dermatology, ophthalmology, and plastic surgery markets for 14 years. Under his leadership at CareCredit, he took the specialty division portfolio from zero to $2.5 billion and helped countless patients along the way. Before CareCredit, he spent 10 years working in healthcare sales for Alcon and Bausch & Lomb as one of the top sales representatives in the country.

Katy Thomas, our Vice President of Marketing, joined ALPHAEON CREDIT in 2014. She had worked with Tony Seymour at CareCredit for 10 years. She started at CareCredit working in the field, consulting with practices as a Practice Development Manager, before moving on to managing National Accounts. Before her days at Volume 12 Number 2

Leslie Icenogle, speaker and practice management consultant, with Anne Haines at the ICOI

We understand what is important to doctors, their teams, and patients and built our patient financing solution to meet the needs of those individuals.

CareCredit, she was in marketing for TLC Vision. In that role, she was tasked with helping independent ophthalmologists grow their patient base and procedural volume through the use of various marketing tools and mediums, including patient financing.

Anne Haines, Director of Dental Financing, joined the team in January. She led the dental launch for Springstone Patient Financing in 2007. During her 10-plus years at Springstone (which became LendingClub®) she was a critical part of the sales and marketing teams while managing key accounts, strategic partnerships, and key opinion leaders. She has over 20 years in dental, beginning with Dentsply Caulk where she was an award-winning sales person and regional sales manager. Promoted to brand manager, she was responsible for the successful product launches of Aquasil Impression Material and AirTouch Air Abrasion.

She was also Vice President of Marketing for Young Dental where she implemented a dealer hotline, launched the Petite Prophy Cup and D-Lish prophy paste.

Tony Seymour, President of ALPHAEON CREDIT

Want to join us?

If you are a doctor or a member of a doctor’s team, enrolling with ALPHAEON CREDIT is easy. There are no application or enrollment fees, no monthly activity fees, and no cost for marketing materials. The enrollment form takes only a moment to complete and can be found at www.myalphaeoncredit. com/enroll/.

If you are a doctor or a member of a doctor’s team and have questions about our patient financing program, please call 949-284-4507, or email us at dental@ alphaeon.com.

We look forward to showing you the ALPHAEON difference! IP This information was provided by ALPHAEON CREDIT.

Implant practice 11

HUMANITARIAN EFFORTS

New Horizon Dental Institute Dr. Justin Moody discusses giving implant dentists a chance to sharpen their skills while offering patients dental care with dignity

S

ince the inception of dental care, our profession has been giving back to society through humanitarian efforts. Most of us are familiar with mission trips to underdeveloped countries orchestrated by religious groups and academic institutes to help those in need. I have seen these efforts provide millions of people with life-changing if not lifesaving dental work in all corners of the world. Having been involved with a clinic in Guadalajara, Mexico, that is helping these very people, while giving dentists from around the world a chance to give back and sharpen their skills for their private practice, I discovered that this model works for all.

Many years later, I found myself at a similar U.S.-based clinic helping the homeless and veterans obtain the very best in dental implant care at low to no cost to them.

It was here that I started to see the need for our help right here in the United States.

According to the Bureau of Labor Statistics, the average salary for a U.S. worker is $44,564. The average cost of replacing a single tooth with a dental implant is somewhere north of $4,000, so we are asking people to spend more than 10% of their gross income on one tooth. This is why New Horizon Dental Institute was formed, not only for the homeless and veterans, but also for all who need some help putting their smiles back together.

In October 2017, a group of dentists, business owners, and philanthropic individuals sat down to discuss how to help. New Horizon Dental Institute was conceived, and the process started to form a true 501(c)(3) nonprofit dental clinic. The clinic takes insurance, Medicaid, Veterans’ benefits, and for a

Justin D. Moody DDS, DABOI, DICOI, is a Diplomate in the American Board of Oral Implantology, Diplomate in the International Congress of Oral Implantologists, Honored Fellow, Fellow, and Associate Fellow in the American Academy of Implant Dentistry, and Adjunct Faculty at the University of Nebraska Medical Center. He is an internationally known speaker, founder of the New Horizon Institute Non-Profit Clinic, and Director of Implant Education for Implant Pathway.

You can reach Dr. Moody at justin@justinmoodydds.com.

12 Implant practice

Dr. Justin Moody, Grace Gonzalez, and Molly Antolin placing dental implants

select few, grants for donated dental work.

I am truly honored to have been elected the president of the board for this great organization, and our mission statement tells the story.

“We believe that dental wellness should not be reserved for the wealthy and that finances should never be the only barrier to receiving quality dental health care. As such, it is our mission to expand access to highquality dental health care for under-served populations, including those less fortunate, homeless, and our nation’s veterans.”

The dental clinic opened in Tempe, Arizona, in April 2018, in large part to the efforts of several companies that never thought twice about supporting our organization. ACTEON® North America was one of the first companies to donate to the clinic.

Taking care of our imaging and hygiene needs, they installed the new X-Mind® Trium Cone Beam CT machine, which is at the center of our clinical workflow. Henry Schein® Dental donated equipment and installation labor for much of the equipment in the facility. BioHorizons® dental implant systems donates the dental implants, prosthetic parts, and all the biologics for the

Dr. Justin Moody going over postoperative instructions for the patient

Implant surgery setup using the latest from BioHorizons dental implants and ACTEON North America

Volume 12 Number 2

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HUMANITARIAN EFFORTS

Implant course attendee and team after delivering a new smile for one of the many patients

work in the clinic; and companies such as Meisinger USA and Zoll-Dental came to the table with instruments, burs, and materials to stock the clinic. A big thank-you to the Oral Reconstruction Foundation for its generous financial support of the clinic — without all these companies and many more individuals, we wouldn’t be able to offer the services we do.

I am very involved with the training at the New Horizon Dental Center through the dental implant continuum, Implant Pathway.

This continuing education continuum focuses entirely on the surgical placement of dental implants, and its mission is to help as many people receive the often life-changing benefits of dental implants while training dentists from around the country to place dental implants.

Through generous donations by individuals, corporations, and Implant Pathways to New Horizon Institute, hundreds of people have received dental implants and their smiles back.

Our professional team is truly kindhearted with their time and clinical expertise. Clinic director, Heather Wilson, DDS, grew up the oldest of six children in rural southwest Missouri. She earned her degree in biology at Missouri State University before going on to attend dental school at the University of Missouri, Kansas City. Before moving to the Valley, she worked in Seattle, Washington, serving in a community health clinic. She and her family were excited to move to Arizona when I presented her with the opportunity to fulfill her passion of giving the best in dental care solutions, including affordable dental implant and tooth replacement, to those in her community.

The clinical team also includes Selay Karbasi, DMD, an Arizona native who completed her Doctorate of Dental Medicine 14 Implant practice

Implant patient after receiving her new smile

The New Horizon team (from left): Katie, Elizabeth, Molly, Griselda, Maria, Dr. Willson, and Dr. Moody

at the Arizona School of Dentistry and Oral Health. During her time in dental school, she participated in multiple dental mission trips and witnessed the impact that dentistry can have on her patients. Dr. Karbasi is beyond excited to bring the same passion and attention to her patients.

Chris Epperson, DMD, received his dental degree from A.T. Still University (Arizona School of Dentistry and Oral Health) in Mesa, Arizona. He discovered his passion for dentistry while on dental humanitarian trips to Mexico and the Dominican Republic.

New Horizon Dental Institute is currently celebrating its 1-year anniversary and is happy to report that we are doing exactly what we set out to do! With one full-time dentist, two part-time dentists, and a team

of 10 dedicated individuals, we are helping deliver more smiles and laughter than we ever could have imagined. In the first year alone, we have placed 1,788 dental implants on over 375 people, accounting for nearly $4 million in donated dental services. Clinic services also include comprehensive exams, fillings, cleanings, X-rays, root canals, extractions, oral surgery, and crowns. Each and every patient is treated with the same dignity and respect that we all deserve as humans.

Serving the greater Phoenix, Arizona, area and beyond, we have seen patients from 14 states and do not limit our care to only those in Arizona.

For more information on the clinic and how to help, please visit the website at www. newhorizondental.org. IP Volume 12 Number 2

CONTINUING EDUCATION

Implementing dynamic navigation implant surgery in a modern dental practice Dr. Michael Hartman discusses a technology that can have a positive effect on implant treatment outcomes Abstract The dental implant surgeon is becoming more and more restoratively focused. Digital technology allows virtual treatment plans to be created and replicated with great accuracy during dental implant surgery with the use of dynamic navigation. When implemented with an efficient workflow, the use of dynamic navigation leads to enhanced profitability and predictably of treatment outcomes in a modern dental implant surgery practice.

Introduction Digital technology is drastically changing the landscape for dental implant surgeons to develop a restoratively driven mindset. Through the use of dental implant treatment planning software, data sets from a CBCT and an intraoral scanner can be merged to create a precise virtual treatment plan. This virtual treatment plan can be carried out in an accurate manner using surgical guidance. The two methods of surgical guidance available for dental implant surgery are static guides and dynamic navigation. Both forms have similar accuracies that are superior to freehand dental implant placement.1 When comparing angular deviation between freehand and dynamic guided surgery, it was noted the average deviation was 7° buccal angle deviations for the former compared to 3° buccal angle deviations to the latter2 (Figure 1). Deviations from the planned surgery can result in less than optimal results, and damage may occur to adjacent vital structures such as roots, nerves, or sinus cavities.3 Restoring a dental implant not placed with the restorative component in mind may lead Michael Hartman, DMD, MD, is an oral and maxillofacial surgeon located in Mechanicsburg, Pennsylvania. Dr. Hartman graduated from Elizabethtown College with a BS in Biology. He continued his education, earning his DMD at Temple University School of Dentistry. Dr. Hartman then completed a 6-year dual degree oral and maxillofacial surgery residency at the University of Maryland Medical Center (UMMC), earning his MD and completing his residency. Dr. Hartman has a keen interest in evolving digital technology and how it can be applied in everyday dental implant practice.

Disclosure: The author has no financial disclosures.

16 Implant practice

Educational aims and objectives

The aim of this article is to discuss the implementation and uses of dynamic navigation implant surgery in a modern-day dental practice.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 20 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Recognize differences between the two methods of surgical guidance — static guides and dynamic navigation.

•

Identify the characteristics of dynamic navigation and how it works.

•

Identify the other technologies needed to utilize dynamic navigation.

•

Realize the characteristics of an ideal guide for dental implant placement.

Figure 1: 3º and 7º buccal angle deviations from planned (yellow) noted in red

to poor esthetic results and higher laboratory costs due to the need for custom prosthetic components. It can be overwhelming to an implant practitioner to research, implement, and develop a workflow that will be not only time efficient but cost-effective while also improving patient outcomes. This article intends to outline how the role of dynamic surgical navigation enhances the predictability, profitability, and efficiency within a modern dental implant surgery practice.

What is dynamic navigation?

Dynamic navigation is a system that allows the surgeon to visualize in real time implant site development on the virtual plan as the implant drills are in function.4 Figure 2 shows the information displayed during implant placement using the X-Guide (X-Nav Technologies, Inc., Lansdale, Pennsylvania)

dynamic navigation system, which is the system that I use. Multiple views are displayed simultaneously showing depth, deviations in angulation, proximity to adjacent structures, as well as handpiece orientation. Other important information such as proposed implant diameter and length is also displayed. (The X-Point Target that allows the clinician to view the position angle and depth all on a single target instead of having to look at multiple spots on the screen is patented to this brand.)

How does X-Guide work?

Optical technologies are used in a dynamic dental implant placement system to track the patient and handpiece and display the information onto a monitor.5,6,7 The X-Guide (Figures 3 and 4) uses a passive optical system that requires tracking arrays Volume 12 Number 2

CONTINUING EDUCATION

from the patient and the handpiece to be in view of its stereo cameras so the information can be relayed to the monitor.8-16 The patient array is attached to the patient via an X-Clip (Figure 5). The X-Clip is molded onto the patient’s dentition and worn during the cone beam CT scan. Once the CBCT is acquired, the X-Clip can be removed and stored for surgery to be done at a later date. The handpiece array is compatible with multiple surgical handpieces offering flexibility to the implant surgeon. Immediately prior to surgery, the patient array is attached to the X-Clip, and the assistant proceeds with the calibration of the patient and handpiece arrays. An experienced dental assistant familiar with the system can perform the calibration in under 4 minutes. During surgery, the surgeon recalibrates the handpiece after every drill change and watches the monitor during site preparation and dental implant placement. The drill recalibration takes less than 10 seconds.

Figure 2: Screen display of dynamic navigation monitor during surgery

Workflow The workflow for a dynamic navigation procedure can be broken down into three parts: 1. Patient implant diagnostic appointment 2. Virtual treatment planning 3. Dental implant surgery Patient implant diagnostic appointment The patient implant diagnostic appointment is scheduled for 30 minutes and is usually done 2 weeks prior to surgery.

During this appointment, a dental assistant molds the X-Clip onto the patient’s dentition and acquires the CBCT. Once the CBCT is verified to be free of motion distortion, the X-Clip is removed, labeled, and stored for the upcoming surgery. The X-Clip must be placed on the arch that the implant surgery will be performed. If implants are planned for both arches, both maxillary and mandibular clips may be placed at the same time for

Figure 4: Close-up of the training setup in Figure 3. The patient array is attached to the dentition using an X-Clip Volume 12 Number 2

Figure 3: The stereo cameras are positioned so that they are in the line of sight of the handpiece and patient tracking arrays.

The surgeon is focused on the monitor during the procedure, allowing a more upright and ergonomic position

Figure 5: X-Clip seated in position in the patient’s mouth Implant practice 17

CONTINUING EDUCATION

Figure 6: X-Clips on the mandible and maxilla. Both clips can be worn at the same time for the CBCT to be taken

the CBCT (Figure 6). The X-Clip is placed on the opposite side of the arch from the planned surgery site. When placing anterior implants, it is preferable to place the X-Clip on the surgeon’s contralateral side.

In order to ensure a firm attachment free of movement, the X-Clip itself requires three consecutive teeth to be molded onto. For instance, in a complete dentition, a righthanded surgeon would ideally have the X-Clip placed onto teeth Nos. 18,19, and 20 when placing implants in site Nos. 22-30.

A similar set up would be used for the maxillary arch. When the X-Clip is placed on the surgeon’s side, it is preferable to keep it as posterior as possible to avoid interference with the implant preparation site.

Although not required, intraoral scans may also be taken and imported in the treatment planning software. In cases where the patient does not have extensive restorative work, the scan is generally not needed.

Scans would be recommended in cases with extensive restorative work (artifact on the CBCT may make ensuring the system is properly calibrated difficult.) The software allows the scans to be imported in occlusion, which may be beneficial in cases where multiple adjacent missing teeth are to be replaced. It would be ideal to acquire maxillary and mandibular scans of the surrounding planned implant areas during the patient work up appointment. A shade can also be recorded at this appointment if an immediate provisional restoration is planned.

Virtual treatment planning The Digital Imaging for Communication in Medicine (DICOM) data set is uploaded into the X-Guide treatment planning software. As previously mentioned, intraoral scans may be uploaded and aligned to the DICOM. If 18 Implant practice

Figure 7: Preoperative photograph

Figure 8: Virtual treatment plan for implant replacement of missing tooth No. 5. The teal-colored crown is the virtual wax-up created in the software. The intraoral scan is visible on the 3D rendering of the DICOM. Its outline is visible as the marooncolored line on the axial, sagittal, and coronal slices of the DICOM on the left hand side of the plan. The dental implant line angle is planned to exit through the center of the restoration

a lower posterior implant is to be planned, the inferior alveolar nerve may be mapped.

The software allows for a virtual wax-up of the proposed restoration and gives the user the ability to freely move it into position and change its dimensions. Once the virtual wax-up is complete, implant planning can commence. The dental implants are planned in a generic fashion, allowing their height and width to be adjusted. In this manner, any size dental implant from any manufacturer may be planned easily.

Implant surgery Once the X-Guide system is calibrated and the X-Clip is properly placed on the patient’s dentition, implant surgery can then proceed in standard fashion.

Case illustration The patient was referred by her general dentist for evaluation of a dental implant in site No. 5. The patient had a current fixed

partial denture from teeth Nos. 2, 3, 4, and 5 with a metal wing on the lingual surface of tooth No. 6. The metal wing was no longer fixated onto No. 6 (Figure 7). Evaluation revealed the bridge was still in good condition on Nos. 2, 3, and 4. After collaboration between the implant surgeon and general dentist, a treatment plan was created and presented to the patient. The treatment plan involved sectioning the bridge on the mesial of No. 4 and placing a dental implant in No 5.

After the patient’s implant diagnostic appointment, a virtual treatment plan was created (Figure 8). The plan called for the dental implant to be placed in an ideal restorative position, with the planned restoration being screw retained.

The dental implant surgery was uneventful, and a follow-up radiograph was obtained showing the dental implant in good position (Figure 9).

Once the dental implant was osseointegrated and deemed ready to restore, Volume 12 Number 2

Figures 10-11: 10. Occlusal view with impression coping seated on dental implant No. 5. Healthy gingiva is noted, and the implant appears to be in excellent position for final restoration. 11. Final restoration placed with screw access in ideal position

a traditional impression was taken by the general dentist and sent to the dental laboratory for fabrication of a fixed screw-retained restoration. Figure 10 shows an occlusal view of the healing abutment in place with surrounding healthy gingival mucosa. Figure 11 shows the restoration and screw access hole in the middle of the occlusal surface of the crown. A screw-retained restoration was chosen due to its easy placement and retrievability if needed at a later date.

recommendations. X-Clips are stored at room temperature and placed in a chlorhexidine solution prior to use. Distortion or degradation of the product has not been encountered.

A significant advantage of dynamic surgery compared to static guides is visualization of the operative field during the entire procedure. The dental assistant watches the surgical site as the implant surgeon is focused on the monitor. Unlike a static guide case, the virtual treatment plan can be modified at any time during the procedure. With a static guide, if the plan required modification, the guide would have to be aborted and either canceled or proceed in a freehand manner. Drill irrigation is not impeded with a dynamic guide system where as static guides have been shown to have increased heat production of the surrounding bone.18 Consideration should always be given to the return on investment when purchasing new technology. For example, CBCTs have a high initial cost but negligible recurring costs.

It is easy for an office to estimate how many CBCTs will need to be taken before the initial cost has been recouped. This is done by dividing the cost of the machine by the amount charged per CBCT. While a dynamic navigation system may have a higher upfront cost, recurring costs are typically lower than static guides. By charging a nominal implant workup fee to the patient, the cost of the dynamic navigation unit can be recouped in approximately 280 implant cases.

Discussion In their article, Faurox, et al., describe the characteristics of an ideal guide for dental implant placement: 1. Precision: absence of defective manufacturing, perfect fit in the mouth, high stability during operation, and optimal drill guide for a perfect reproducibility.

2. The guide should be able to be stored, transported, and sterilized without distortion or degradation.

3. The guide should not interfere with visual inspection or drill irrigation.

4. The guide should not lead to a highcost increase for the surgery.17 With proper case selection, a high precision of a dynamic navigation can be achieved in almost every case. From the author’s experience, in 650 cases using dynamic navigation, only two had surgeries to be changed to a freehand placement due to poorly fitting X-Clips. Satisfactory calibration was not able to be achieved due to the X-clip positions. This correlates to a 99.7% calibration success rate. In one case, the patient had a crown placed on one of the teeth that was part of the X-Clip causing the poor fit. Before the decision has been made to perform a dental implant surgery using dynamic navigation, the implant surgeon must assess where the X-Clip may be potentially placed. Teeth that exhibit mobility, loose crowns, or short root structures on radiographs should be avoided. A static guide should be considered in these scenarios.

Guides should be stored and sterilized according to the manufacturer’s Volume 12 Number 2

Conclusion Due to advances in digital technology combined with decreasing costs of associated hardware and software, the future is within reach for the dental implant surgeon to plan and place all dental implants using surgical guidance. The case illustrated above shows that an excellent result can be obtained through the use of creating a precise virtual treatment plan and reproducing that by utilizing dynamic navigation.

This is done with a straightforward work flow and is accomplished mainly by auxiliary staff in a time-efficient manner.

Acknowledgment

The author would like to acknowledge the restorative work completed by Zachary S. Sisler DDS, Shippensburg, Pennsylvania. IP REFERENCES 1. Block MS, Emery RW, Lank K, Ryan J. Implant Placement Accuracy Using Dynamic Navigation. Int J Oral Maxillofac Implants. 2017;32(1):92-99.

2. Block MS, Emery RW, Cullum DR, Sheikh A. Implant Placement is More Accurate Using Dynamic Navigation. J Oral Maxillofac Surg. 2017;75(7):1377-1386.

3. Zhou W, Liu Z, Song L, Kuo CL, Shafer DM. Clinical Factors Affecting the Accuracy of Guided Implant Surgery – A Systematic Review and Meta-Analysis. J Evid Based Dent Pract. 2018;18(1):28-40.

4. Luebbers HT, Messmer P, Obwegeser JA, et al. Comparison of different registration methods for surgical navigation in cranio-maxillofacial surgery. J Craniomaxillofac Surg.

2008;36(2):109-116.

5. Block MS, Emery RW. Static or Dynamic Navigation for Implant Placement – Choosing the Method of Guidance. J Oral Maxillofac Surg. 2016;74(2):267-277.

6. Nijmeh AD, Goodger NM, Hawkes D, Edwards PJ, McGurk M. Image-guided navigation in oral and maxillofacial surgery.

Br J Oral Maxillofac Surg. 2005;43(4):294-302.

7. Bouchard C, Magill JC, Nikonovskiy V, et at. Osteomark: a surgical navigation system for oral and maxillofacial surgery.

Int J Oral Maxillofac Surg. 2012;41(2):265-270.

8. Strong EB, Rafii A, Holhweg-Majert B, Fuller SC, Metzger MC. Comparison of 3 optical navigation systems for computeraided maxillofacial surgery. Arch Otolaryngol Head Neck Surg. 2008;134(10):1080-1084.

9. Casap N, Wexler A, Eliashar R. Computerized navigation for surgery of the lower jaw: comparison of 2 navigation systems. J Oral Maxillofac Surg. 2008;66(7):1467-1475.

10. Poeschl PW, Schmidt N, Guervara-Rojas G, et al. Comparison of cone-beam and conventional multislice computed tomography for image-guided dental implant planning. Clin Oral Investig. 2013;17(1):317-324.

11. Ewers R, Schicho K, Undt G, et al. Basic research and 12 years of clinical experience in computer-assisted navigation technology: a review. Int J Oral Maxillofacial Surg.

2005;34(1):1-8.

12. Wittwer G, Adeyemo WL, Schicho K, Birkfellner W, Enislidis G. Prospective randomized clinical comparison of 2 dental implant navigation systems. J Oral Maxillofacial Implant.

2007;22(5):785-790.

13. Wanschitz F, Birkfellner W, Watzinger F, et al. Evaluation of accuracy of computer-aided intraoperative positioning of endosseous oral implants in the edentulous mandible. Clin Oral Implants Res. 2002;13(1):59-64.

14. Leuth TC, Wenger T, Rautenberg A, Deppe H. RoboDent and the Change of Needs in Computer-Aided Dental Implantology During the Past Ten Years. Presented at the 2011 IEEE International Conference on Robotics and Automation, May 9-13, 2011. IEEE Abstracts 2011:1.

15. Casap N, Laviv AW. Computerized Navigation for Immediate Loading of Dental Implants With a Prefabricated Metal Frame: A Feasibility Study. J Oral Maxillofac Surg.

2011;69(2):512-519.

16. Siessegger M, Schneider BT, Mischkowski RA, et al. Use of an image-guided navigation system in dental implant surgery in anatomically complex operation sites. J Craniomaxillofac Surg. 2001;29(5):276-281.

17. Fauroux MA, De Boutray MD, Malthiéry E, Torres JH. New innovative method relating guided surgery to dental implant placement. J Stomatol Oral Maxillofacial Surg.

2018;119(3):249-253.

18. Dos Santos PL, Queiroz TP, Margonar R, et al. Evaluation of bone heating, drill deformation, and drill roughness after implant osteotomy: guided surgery and classic drilling procedure. Int J Oral Maxillofac Implants. 2014;(29)1:51-58.

Implant practice 19

CONTINUING EDUCATION

Figure 9: Postoperative radiograph of the virtual treatment plan confirming the dental implant is in an acceptable position

REF: IP V12.2 HARTMAN

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Implementing dynamic navigation implant surgery in a modern dental practice HARTMAN

1. Through the use of dental implant treatment planning software, data sets from a(n) _______ and an intraoral scanner can be merged to create a precise virtual treatment plan. a. CBCT b. film X-ray c. digital photograph d. Excel spreadsheet 2. When comparing angular deviation between freehand and dynamic guided surgery, it was noted the average deviation was 7° buccal angle deviations for the former compared to ________ buccal angle deviations to the latter (Figure 1). a. 1° b. 3° c. 5° d. 8° 3. ___________ is a system that allows the surgeon to visualize in real time implant site development on the virtual plan as the implant drills are in function. a. Panoramic navigation b. Calibration navigation c. Dynamic navigation d. Static navigation

20 Implant practice

4. Optical technologies are used in a dynamic dental implant placement system to ________. a. track the patient and handpiece b. display the information onto a monitor c. disinfect the area d. both a and b 5. During surgery, the surgeon recalibrates the handpiece ________ and watches the monitor during site preparation and dental implant placement. a. before every drill change b. after every drill change c. only once during every surgery d. after every two patients’ procedures 6. The patient implant diagnostic appointment is scheduled for 30 minutes and is usually done ________ prior to surgery. a. an hour b. 2 days c. 2 weeks d. 1 month 7. The guide should be able to be ________without distortion or degradation. a. stored

b. transported c. sterilized d. all of the above 8. Before the decision has been made to perform a dental implant surgery using dynamic navigation, the implant surgeon must assess where the X-Clip may be potentially placed. Teeth that exhibit _______ should be avoided. a. mobility b. loose crowns c. short root structures on radiographs d. all of the above 9. X-Clips are stored ________ and placed in a chlorhexidine solution prior to use. a. in the freezer b. at room temperature c. in water d. in alcohol 10. Unlike a static guide case, the virtual treatment plan can be modified _______. a. at any time during the procedure b. just before the procedure begins c. only one time during the procedure d. only if the virtual treatment plan is aborted

Volume 12 Number 2

CE CREDITS

IMPLANT PRACTICE CE

Drs. Johan Hartshorne and Howard Gluckman discuss the clinical indications of PRF in implant dentistry, periodontology, oral surgery, and regenerative endodontics

P

latelet-rich fibrin (PRF) is a patient blood-derived living biomaterial with applications in a wide range of fields, including implant dentistry, periodontics, oral surgery, and regenerative endodontics. Improving one’s understanding of the clinical indications of this material will facilitate the ability to enhance the therapeutic applications of PRF in these fields, and this is the purpose of this article.

Introduction Key treatment objectives in dental implantology, periodontology, and oral surgery are the prospect of having new therapies, biomaterials, and bioactive surgical additives available that will improve success and predictability of patient outcomes in soft and bone tissue healing and regeneration.

PRF, a patient blood-derived and autogenous living biomaterial, is increasingly being investigated and used worldwide by clinicians as an adjunctive autologous biomaterial to promote bone and soft tissue healing and regeneration. The gold standard for in vivo tissue healing and regeneration requires the mutual interaction between a scaffold (fibrin matrix), platelets, growth factors, leukocytes, and stem cells (Kawase, 2015). These key elements are all active components of PRF and, when combined and prepared properly, are involved in the key processes of tissue healing and regeneration, including cell proliferation and differentiation, extracellular matrix synthesis, chemotaxis and angiogenesis (neovascularization) (Dohan, et al., 2012; 2014). An improved understanding of the development, biological and physiological Johan Hartshorne, BSc, BChD, MChD, MPA, PhD(Stell), FFPH RCP(UK), is a general dental practitioner working in Bellville, Cape Town, South Africa.

Howard Gluckman BDS, MChD (OMP) (Wits) is a specialist in periodontics and oral medicine. He is director of The Implant and Aesthetic Academy, Cape Town, South Africa.

Volume 12 Number 2

Educational aims and objectives

This article aims to describe the clinical indications of platelet-rich fibrin (PRF).

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 31 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Identify how PRF can be applied in implant dentistry, periodontology, oral surgery, and regenerative endodontics.

•

Read some evidence-based literature on the use of PRF in implant dentistry.

•

Realize where and how to use PRF.

•

Discuss sinus floor elevation using PRF as sole or combination graft biomaterial.

•

Discuss alveolar ridge preservation (socket augmentation) for early or late implant placement.

•

Discuss immediate post-extraction implant placement and jump-gap augmentation – peri-implant healing.

•

Realize various aspects of augmentation of dehiscence and fenestration defects.

•

Identify treatment of peri-implant osseous defects.

•

Realize various aspects regarding guided bone regeneration and periodontal surgery.

properties, and characteristics of PRF in tissue healing and regeneration over the past 2 decades has led to more successful therapeutic applications, especially in the fields of implant dentistry, periodontology, and oral surgery.

Methodology, search strategy, and inclusion criteria An electronic MEDLINE® (PubMed®) and Google Scholar search was performed for all articles on platelet-rich fibrin (PRF) and platelet concentrates up to May 2016. The search was complemented by an additional hand search of selected journals in oral implantology, oral surgery and periodontal, as well as gray literature. The reference lists and bibliographies of all included publications were also screened for relevant studies.

The search was limited to the English language. Randomized controlled trials (RCTs), controlled clinical trials (CCTs), case reports, case series, prospective, retrospective and in-vitro/in vivo studies were included in the narrative review. Animal studies were excluded from this review.

Where and how can I use PRF? A general rule of guidance is to use PRF in surgical situations where protection and stimulation of healing and regeneration is critical and where the prognosis for tissue repair is poor or potentially compromised in the absence of a tissue regeneration scaffold and addition of growth factors.

Implant dentistry Most of the PRF clinical research in implantology is currently focused in the fields of improving clinical outcomes with sinus floor elevations using PRF as sole grafting material, simultaneous with implant placement (Ali, et al., 2016; Simonpieri, et al., 2011) or SFE using a combination of PRF and bone allograft (FDBA) prior to implant placement (Choukroun, et al., 2006; Tatullo, et al., 2012).

Other focus areas of clinical research are use of PRF in alveolar ridge preservation (socket augmentation) (Hauser, et al., 2013), peri-implant tissue healing (Boora, et al., 2015), and improving implant stability (Öncu and Alaaddinoõglu 2015) (Table 1).

Implant practice 21

CONTINUING EDUCATION

A comprehensive clinical review of platelet-rich fibrin (PRF) and its role in promoting tissue healing and regeneration: part 3

CONTINUING EDUCATION Table 1: Evidence-based literature on the use of PRF in implant dentistry Application

Reference

Type of study

Evidence/Conclusion

Sinus floor elevation

Ali S, Bakry SA, Abd-Elhakam 2016

Systematic review

PRF as a sole filling material for sinus lift with simultaneous implant placement is a simple technique with promising results.

Addition of PRF to DFDBA accelerates graft maturation and decreases the healing period before implant placement. PRF membranes represent an easy and successful method to cover sinus membrane or osteotomy window.

Socket augmentation

Hauser F, Gaydarov N, Badoud I, et al., 2013

RCT

Use of PRF membranes to fill the socket after tooth extraction led to improved alveolar bone healing and better preservation of the alveolar crest width. These results support the use of a minimally traumatic procedure for tooth extraction and socket filling with PRF to achieve preservation of hard tissue.

Peri-implant stability and healing

Öncü E, Alaaddinoõglu E 2015

CCT

Results of this study demonstrated that PRF application into the osteotomy site increases implant stability during the early healing period. Simple application of this material seems to provide faster osseointegration.

Peri-implant tissue healing

Boora P, Rathee M, Bhoria M 2015

RCT

PRF can be considered as a healing biomaterial with potential beneficial effect on peri-implant tissue and can be used as a therapeutic adjuvant in the clinical scenario of one-stage, single-tooth implant placement procedure in maxillary anterior region.

Pre-implantology sinus floor elevation

Choukroun J, Diss A, Simonpieri A, et al., (part 5) 2006

CCT

Sinus floor augmentation with FDBA and PRF leads to a reduction of healing time prior to implant placement. From a histologic point of view, this healing time could be reduced to 4 months.

Pre-implantology sinus elevation

Tatullo M, Marrelli M, Cassetta M, et al., 2012

CCT

PRF together with deproteinized bovine bone (Bio-Oss) and piezosurgery favors optimal bone regeneration compared to bone graft material alone. At 106 days, it is already possible to achieve good primary stability of endosseous implants, though lacking of functional loading. PRF favors clot stability, and the membranous shape allows creating a natural “barrier effect” on the bone breaches that were opened in the surgical areas.

Note: Conclusions reached were within the limitations of the studies, and more and large samples rigorous clinical trials are required to validate the evidence.

Figure 1A: PRF used as sole grafting material in lateral window sinus floor elevation

Figure 1B: Multiple layers of PRF used for sinus floor elevation

Figure 1C: Sinus osteotomy covered with a collagen membrane

In vitro studies have shown PRF-induced gene expression of the early and late markers of osteogenesis stimulates bone and soft tissue healing (Clipet, et al., 2012). This finding suggests that PRF is indicated in numerous clinical applications, such as socket augmentation, jump gap filling during immediate extraction and implant placement, and stimulation of bone and soft tissue healing during bone augmentations or during sinus elevation.

The PRF membrane is recommended as an inexpensive and easily handled substitution biomaterial during sinus elevation to reduce the healing time before loading. It is a cheap and easily handled material with healing properties. Its fibrin matrix properties and ability of slowly releasing growth factors make it an ideal replacement biomaterial to replace xenogenic and expensive collagen membranes in some situations (Mazor, et al., 2009).

The review also suggests that PRF combined with a bone allograft or other bone substitutes accelerates graft maturation and decreases the healing period before implant placement. (Figures 2A-2E) The latter finding has also been confirmed by other clinical trials and case studies (Choukroun, et al., 2006; Tatullo, et al., 2012; Zhang, et al., 2012; Bölükbas, et al., 2013).

Various case studies have demonstrated that PRF membranes can be used successfully as a protective barrier to cover the sinus membrane during grafting procedures (Diss, et al., 2008; Toffler, et al., 2010; Kanayama,

et al., 2014) (Figure 3). PRF membranes also represent an easy and successful method to cover sinus membrane or osteotomy window to protect the Schneiderian membrane, to facilitate wound closure, and to enhance healing (Ghetiu, et al., 2015).

Cases have also been reported showing that A-PRF membrane can be used as a healing barrier when perforations or tears of the Schneiderian membrane occur (Diss, et al., 2008; Toffler, et al., 2010).

Sinus floor elevation using PRF as sole or combination graft biomaterial A systematic review showed that PRF used as a sole filling material in SFE with simultaneous implant placement is a simple technique with promising results (Ali, et al., 2016; Kanayama, et al., 2016). Various clinical case reports describe the lateral approach for sinus floor elevation using only PRF as the grafting material (Mazor, et al., 2009; Simonpieri, et al., 2011; Tajim, et al., 2013) (Figures 1A-1C).

22 Implant practice

Alveolar ridge preservation (socket augmentation) for early or late implant placement Use of PRF membranes to fill the socket after tooth extraction has shown to improve alveolar bone healing and preservation of the alveolar crest width. PRF plugs or membranes can also be used to fill extraction sockets, even when associated with compromised extraction sockets (Peck, et al., 2011), severe cystic destructions, or after cyst enucleations (Choukroun, et al., 2006; Volume 12 Number 2

Figure 2B: Sinus floor elevated and grafted with simultaneous implant placed

Figure 2C: Sinus floor grafted with xenograft mixed with PRF fragments

Figure 2D: Lateral window sinus osteotomy covered with a collagen membrane

Figure 2E: PRF membrane (double layer) draped over the collagen membrane to facilitate soft tissue wound healing

Figure 3: PRF membrane used as a protective barrier to cover the sinus membrane (Schneiderian membrane) before grafting

Figures 4A-4B: 4A. Fresh extraction socket curetted and ready for augmentation. 4B. PRF fragments placed into the socket

Figures 4C-4D: 4C. Bone putty alloplast injected into the socket. 4D. Plugger used to condense PRF fragments and bone putty into the socket

Figure 4E: PRF plug placed on top of the bone putty Volume 12 Number 2

Figure 4F: Socket closed with PRF plug and used as a protective cover over the grafted socket

Magremanne, et al., 2009) to allow early bone and gingival regeneration required for implant placement. Clinical and histological findings suggest that filling a fresh extraction socket with PRF provides a viable therapeutic alternative for implant site preparation (Zhao, et al., 2011).

Alternatively, PRF can also be mixed with a bone substitute to fill the socket and used as a protective cover over the grafted socket (Figures 4A-4G). This is particularly important when gingival wound closure is impossible or difficult with the sutures (Del Corso, et al., 2012).

The purpose of the PRF membrane is not only to stimulate gingival healing, but also to protect the bone graft from the oral environment and to maintain it within the extraction socket, like a biological barrier. It is suggested that this technique negates the need for using more complex flaps and GBR

Figure 4G: Provisional removable prosthesis with ovate pontic seated over the grafted socket Implant practice 23

CONTINUING EDUCATION

Figure 2A: Lateral window osteotomy ready for sinus floor elevation

CONTINUING EDUCATION

Figures 5A-5B: 5A. Residual root to be extracted for immediate implant placement. 5B. Jump gap between implant and socket defect grafted with xenograft mixed with PRF fragments and covered with a PRF membrane

protocols to close and augment extraction sockets.

Immediate post-extraction implant placement and jump-gap augmentation — periimplant healing PRF can be considered as a healing biomaterial with potential beneficial effect on peri-implant tissue and can be used as a therapeutic adjuvant with immediate implant placement in the clinical scenario of one-stage, single-tooth implant placement procedure in maxillary anterior region (Del Corso, et al., 2012).

With immediate implant placement, the peri-implant jump gap can be augmented with PRF clot (A-PRF or L-PRF) or solution (i-PRF) mixed with a bone substitute (Rao, et al., 2013) (Figures 5A and 5B).

In the latter case study, it is suggested that the augmented jump gap is covered with cross-linked collagen membrane, overlaid by a double layer of PRF and the flap closed by

sutures. Studies have demonstrated that the use of leukocyte-platelet rich fibrin (L-PRF or A-PRF) membranes for the stimulation of bone and gingival healing around the implant is particularly significant (Öncü and Erbeyo 2015) (Figures 6A-6C). The elastic consistency of the PRF membrane allows the clinician to punch a hole in the membrane to facilitate draping the membrane over the healing abutment (Figures 7A and 7B).

Augmentation of dehiscence and fenestration defects Case reports indicate that PRF membrane cut in pieces or i-PRF combined with bone substitutes may offer an easy and simple method of handling and delivery of a fibrin scaffold, growth factors, and cells during the augmentation of dehiscence and fenestration defects, and at the same time reduce soft tissue and bone healing time (Simonpieri, et al., 2009; 2009; Toeroek and Dohan 2013).

Figure 6A: Implant site ready to be draped with PRF membrane

Figure 6B: PRF membrane draped around an implant to stimulate bone and gingival healing

Figure 7A: PRF membrane draped over the healing abutment to stimulate bone and gingival healing

Figure 7B: Flap closure over PRF membrane and around healing abutment

24 Implant practice

PRF has also been successfully used to treat fenestration defects around implants (Vijayalakshmi 2012). PRF membrane cut in pieces (Figure 8), or platelet liquid (I-PRF) (Figure 9) can be mixed with bone graft material to cover the defect. The graft is covered with a resorbable collagen membrane to maintain form and shape and to confer graft stability and space maintenance on the bone particles.

PRF membrane is then placed on top of the collagen membrane to prevent tissue dehiscence and aid in soft tissue healing.

The application of PRF to GBR procedures offers several advantages including promoting wound healing, bone growth, and maturation, graft stabilization, wound sealing, and hemostasis, and improving the handling properties of graft materials.

Treatment of peri-implant osseous defects One clinical study showed that treatment of peri-implant defects with PRF was clinically more effective than with conventional flap surgery alone, irrespective of the type of defect (Hamzacebi, et al., 2015).

In another study, a successful treatment outcome was also reported after debridement and detoxification with a Cr,CR:YCGG later, followed by filling the defect with a synthetic hydroxyapatite embedded in native blood and covered with a PRF membrane to prevent soft tissue infiltration into the grafted area. The authors concluded that the use of PRF added to the maintenance of the graft homeostasis due to release of growth

Figure 6C: Flap sutured

Figure 8: PRF membrane fragments mixed with bone particulate can be used successfully to augment alveolar ridge defects using GBR principles Volume 12 Number 2

Augmentation of alveolar ridges (horizontal and vertical) and buccal bone defects (GBR) Several cases have been reported of successful augmentation of alveolar ridges where there is a buccal bone defect (GBR) using PRF combined with a bone substitute (Inchingolo, et al., 2010; Krasny, et al., 2011; Kim, et al., 2013; Joseph, et al., 2014) and in cases of the severely resorbed posterior mandible.

Del Corso and Dohan (2013) suggest that three layers of L-PRF membranes used alone were adequate to use as competitive interposition barrier to protect and stimulate the bone compartment, and as healing membranes to stimulate the periosteum and gingival healing and remodeling. Periosteal incisions were done on the flaps to promote their tension-free closure.

The concept of using PRF alone as a GBR barrier still raises many questions as well as limitations and needs to be investigated with robust RCTs to determine appropriate indications and relevant combinations (Toeroek and Dohan 2013). PRF liquid (i-PRF) can be injected, or PRF membrane placed above the GBR, or GTR membrane to act as an interposition barrier to protect and stimulate the bone compartment and as a healing membrane in order to improve the soft tissue healing and remodeling, and thus avoid soft tissue dehiscence.

Guided bone regeneration Place harvested autogenous bone adjacent to the implant or defect that requires grafting. The next layer is made up of a mixture of bone grafting material with i-PRF or PRF membrane or clot cut in small pieces.

The objective of this mixture is to help the rapid vascularization of the bone grafting material through the PRF fibrin matrix making the bridge between bone particles and allowing a quick new bone growth, while the xenograft material serves as space maintainer for the regenerative volume and supports the nucleation and accumulation of newly formed bone matrix.

The bone/PRF mixture in the augmented site is covered with a cross-linked collagen membrane to maintain the bone compartment and to prevent ingrowth of soft tissue.

The collagen membrane is overlaid with a double layer of PRF membranes (Figures 10A-10C). These membranes are used as a competitive interposition barrier to protect and stimulate the bone compartment, and as healing membranes to stimulate the periosteum and gingival healing and remodeling.

Periosteal releasing incisions are done on the flaps to promote their tension-free closure.

Increasing implant stability and osseointegration Case studies suggest that PRF application into the osteotomy site (Figures 11A-11C) increases implant stability during the early healing period, as evidenced by higher ISQ values. Simple application of this

Figure 9: i-PRF mixed with bone particulate can be used successfully to augment alveolar ridge defects using GBR principles

material also seems to provide faster osseointegration (Ă–ncu and AlaaddinoĂľglu 2015).

Periodontal surgery Most of the clinical research in periodontology is currently focused in the fields of improving clinical outcomes with treatment of intrabony periodontal pockets, furcation defects, gingival recession defects, and healing of connective tissue graft sites in the palate (Table 2).

Intrabony and furcation periodontal defects The regenerative and wound healing effects have been very promising with PRF treating intrabony defects (see also Table 3).

The clinical evidence is supported by several case studies reporting on the

Figure 10A: Using PRF fragments mixed with autogenous bone to fill spaces in guided bone regeneration procedure

Figure 10B: Bone graft covered with collagen membrane

Figure 10C: UBone graft and collagen membrane covered with multiple PRF membranes

Figure 11A: PRF inserted into an osteotomy site before placing the implant to facilitate bone healing

Figure 11B: Implant wetted with PRF exudate containing growth factors

Figure 11C: Implant is inserted into the socket containing the PRF membrane

Volume 12 Number 2

Implant practice 25

CONTINUING EDUCATION

factors, thus contributing to the successful outcome of treatment (Shilbli, et al., 2013).

CONTINUING EDUCATION successful application of PRF to regenerate bone and gingival tissues around teeth presenting with intrabony defects and furcation lesions.

Another study has also reported on using PRF successfully as a regenerative material in cases of aggressive periodontitis (Desarda, et al., 2013).

Surgical periodontal therapy accompanying the placement of PRF in angular defects of aggressive periodontitis patients showed decreased probing pocket depth, increased attachment level, and radiographic bone fill when baseline and 9-month followup data was compared. Surgical reconstructive therapy with placement of PRF in angular defects can is suggested as an effective approach to enhance periodontal regeneration.

Platelet gel acts as a stabilized blood clot and therefore is recommended as a perfect filling material for natural tissue regeneration and healing. Clinically, the general concept of “natural tissue regeneration” (NTR) and natural bone regeneration (NBR) (Del Corso, et al., 2012) requires to fill the periodontal intrabony defect with L-PRF, most times in association with a bone substitute used as a solid space maintainer, and then to cover the filled intrabony defect with L-PRF membranes, used for the protection of the grafted area and as a healing booster for the soft tissues above the defects. The objective of this cover is not only to protect the blood clot and/or the filling material, like in the GTR concept, but also to promote the induction of a strong and thick periosteum and gingiva.

The boosted periosteum functions as a true barrier between the soft tissue and bone compartments, and constitutes probably the best protection and regenerative barrier for the intrabony defects. The NTR protocol is very simple and gives excellent results in most clinical situations, with no contraindication or risk of negative effects. However, in order to get the best results, the choice and the quantity of the adequate bone substitute has yet to be determined in various clinical configurations.

Theoretically, PRF can be used as a sole grafting material or in combination with bone substitutes can be used as a filling material in intrabony defects, following GTR principles. PRF membrane is a solid material with the advantage that it is easy to handle and to position in bony defects.

PRF membranes can also be used as a protection membrane after the filling of the intrabony defect (Figures 12A and 12B). In comparison to GTR membranes, PRF will undergo a quicker remodeling in situ than a resorbable collagen membrane, but will 26 Implant practice

Table 2: Clinical evidence on the use of PRF in periodontology Application

Reference

Type of study Evidence/Conclusion

Furcation defects

Troiano G, Laino L, Dioguardi M, et al., 2016

Meta-analysis

The addition of autologous platelet concentrate (PRP and PRF) to open flap debridement (OFD) may improve clinical parameters: horizontal and vertical clinical attachment level, probing depth and level of gingival margin in the treatment of mandibular Class II furcation defects compared to OFD alone.

Furcation defects

Sharma, et al., 2011

RCT

Significant improvement with PRF implies its role as a regenerative material in treatment of furcation defects.

Recession defects

Moraschini V, dos Santos E, Barboza P 2015

Meta-analysis

The results suggest that the use of PRF membranes did not improve the root coverage, keratinized mucosa width, or clinical attachment level of Miller Class I and Class II gingival recessions compared to the other treatment modalities.

Recession defects

Keceli HG, Kamak G, Erdemir EO, et al., 2015

RCT

The addition of PRF did not further develop the outcomes of coronally advance flap combined with a connective tissue graft treatment except increasing the tissue thickness.

Recession defects

Rajaram V, Thyegarajan R, Balachandran A, et al., 2015

RCT

The additional application of PRF failed to improve root coverage after double lateral sliding bridge flap in Miller Class I and Class II defects.

Intrabony defects

Shah M, Deshpande N, Bharwani A 2014

Meta-analysis

The meta-analysis showed clinically significant improvements in periodontal parameters such as clinical attachment levels and intrabony defect reduction, and reduction in probing depth when IBDs were treated with PRF alone when compared to OFD.

Intrabony defects

Gamal AY, Ghaffar KAA, Alghezwy OA 2016

RCT

PRF and PRGF platelet concentrate failed to augment the clinical effects achieved with the xenograft alone in treating intrabony defects. Periodontal defects could not retain extraphysiologic levels of GF suggested to be associated with platelet concentrate.

Intrabony defects

Shah M, Patel J, Dave D, Shah S 2015

RCT

PRF has shown significant results after 6 months, which are comparable to DFDBA for periodontal regeneration in terms of clinical parameters. PRF has several advantages when used as a graft material for infrabony defects.

Intrabony defects

Sharma et al., 2011

RCT

Greater pocket depth reduction and periodontal attachment level (PAL) gain, and bone fill at sites treated with PRF combined with conventional open-flap debridement compared to conventional open-flap debridement alone.

Intrabony defects

Pradeep AR, Rao NS, Agarwal P, et al 2012

RCT

The use of autologous PRF or PRP was effective in the treatment of 3-wall IBDs with uneventful healing of sites.

Treatment with autologous PRF or PRP stimulated a significant increase in the PD reduction, GML, and bone fill compared with OFD at 9 months.

Intrabony defects

Bansal C and Bharti V 2013

CCT

PRF combined with demineralized freeze-dried bone allograft (DFDBA) demonstrated better results in probing pocket depth reduction and clinical attachment level gain as compared to DFDBA alone in the treatment of periodontal intrabony defects.

Intrabony defects

Thorat MK, Pradeep AR, Pallavi B 2011

RCT

Greater reduction in pocket depth, more clinical attachment level gain and greater intra-bony defect fill at sites treated with PRF compared to open flap debridement alone.

Intrabony defects

Pradeep AR, Bajaj P, Rao NS, et al., 2012

RCT

PRF when added to porous hydroxyapatite (HA) increases the regenerative effects observed with PRF in treatment of human three-wall intra-bony defects.

Palatal bandage

Femminella B, Iaconi MC, Di Tullio M, 2016

RCT

The PRF-enriched palatal bandage significantly accelerates palatal wound healing and reduces the patient’s morbidity.

Note: Conclusions reached were within the limitations of the studies, and more and large samples rigorous clinical trials are required to validate the evidence.

Volume 12 Number 2

Recession defects and guided tissue regeneration (GTR) The clinical evidence is less promising with the treatment of recession defects (Moraschini, et al., 2015; Keceliet, et al., 2015; Rajaram, et al., 2015) (Table 2). Within the limitations of available clinical trials, the clinical evidence indicates that PRF does not improve root coverage or increases the width of keratinized mucosa in Miller’s Class I and II gingival recessions, compared to other treatment modalities.

However, cases have been reported where PRF was successfully used for treating localized (Eren and Atilla 2014; Aroca, et al., 2009; Aleksic, et al., 2010; Jankovic, et al., 2010; Jankovic, et al., 2012) and multiple (Agarwal, et al., 2013) gingival recessions.

Another case study reported that the use of PRF membrane along with the VISTA technique allows clinicians to successfully treat multiple recession defects with optimal esthetic results and excellent soft tissue biotype (Gupta, et al., 2015).

Palatal bandage PRF membranes can also be used as a palatal wound bandage or protection membranes after harvesting connective tissue Volume 12 Number 2

Figures 12A-12B: 12A. Intrabony defect after root planning and soft laser decontamination, filled with bone putty and covered with a PRF membrane to protect the grafted site area and to facilitate bone and soft tissue healing. 12B. Closure of flap over the grafted intrabony defect

grafts in the palate (Femminella, et al., 2015; Kulkarni, et al., 2014; Jain, et al., 2012).

Case studies show that PRF membrane used as a palatal bandage is an efficacious approach to protect the raw wound area of a palatal donor site and significantly accelerates palatal wound healing and reduces patient discomfort and healing time (Aravindaksha, et al., 2014; Femminella, et al., 2016).

Interdental papilla augmentation A case study reported that PRF combined with bone graft for regeneration of interdental bone may contribute towards improved clinical success with augmentation of lost dental papilla (Arunachalam, et al., 2012). The reconstructed papilla in the new position was stable when reviewed at 3 and 6 months postoperatively.

Oral surgery Most of the evidence-based research in the field of oral surgery is primarily focused on enhancing bone healing (Singh, et al., 2012; Gurbuzer, et al., 2010; Rao, et al., 2013) and reducing postoperative complications following third molar extractions. Research is also emerging on promoting healing of apicomarginal defects in root end surgery (Table 3). Numerous case and case series studies have been reported that support the use of PRF in various clinical applications in the field of oral surgery.

Post-extraction socket augmentation and healing The healing and remodeling of an extraction socket is highly dependent on the initial stabilization of the blood clot and the quick gingival wound closure. This can be achieved by placing fibrin plug in the socket (with or without a bone substitute) and closing with a fibrin membrane. The use of PRF as a post extraction sockets filling biomaterial is recommended as a useful procedure in order to reduce the early adverse effects of the inflammation, such as postoperative pain (Eshghpour, et al., 2014;

Uyanik, et al., 2015) and to promote the soft tissue healing and bone regeneration process (Manernzi, et al., 2015).

Clinical situations where post-extraction socket augmentation with PRF is specifically indicated are for early or delayed implant placement and immediate post-extraction implant placement (Simon, et al., 2009; Simon, et al., 2011; Triveni, et al., 2012; Rao, et al., 2013; Basarli, et al., 2015).

Reduce post-extraction complications in medically compromised cases PRF can be used to minimize postextraction complications such as osteitis, dry or infected sockets resulting from delayed or potentially compromised healing or bleeding situations in systemic conditions such as such as with diabetics, patients receiving oral bisphosphonate medication presenting a risk of osteonecrosis of the jaws, or patients receiving anticoagulants (Sammartino, et al., 2011).

Delayed or compromised healing of extraction sockets is mostly related to an unstable blood clot within the socket. In such case a fibrin clot is simply placed in the socket, covered with a collagen plug or membrane and sutured. Placing PRF in a socket could amplify the natural coagulation process and enhance socket healing.

Prevention of periodontal complications in third molar surgery Complex third molar extractions frequently result in critical size bone defects and compromised healing impacting negatively on the outcome of periodontal tissues distal of the second molar. When bone defects after extraction are critical-sized (and often associated with cystic lesions), using PRF as a filling material or mixing PRF with a bone substitute in order to use a significant volume of solid biomaterial for filling is considered as reliable option.

These treatments are not, however, simple dental extractions, and are often at the border of guided bone regeneration Implant practice 27

CONTINUING EDUCATION

promote a strong induction on the periosteum and gingival tissue due to the slow release of growth factors and other matrix proteins (Dohan 2009; Del Corso, et al., 2009; Dohan, et al., 2009).

GTR membranes are cell-proof barriers, whereas a PRF membrane is a highly stimulating matrix, attracting cell migration and preferential differentiation allowing new blood vessel formation within the matrix, and also reinforcing the natural periosteal barrier. The hard and soft tissues migrate and interact within the PRF matrix. The PRF matrix becomes the interface between the tissues and therefore avoids the migration of the soft tissues deeper within the grafted defect or augmented site. This biological characteristic is referred to as a competitive barrier.

These bioactive interactions are very important during tissue regeneration since the periosteum covers the internal part of the gingival flap and is a key actor of bone healing and gingival maturation. While GTR membranes block the periosteum healing potential and bone/gingival interactions, PRF membranes stimulate the periosteum’s regenerative properties. However, even if PRF membranes do not block the migration of the cells, no invagination of the soft tissues within the bone area was observed when PRF membranes covered a filled intrabony defect (Simonpieri, et al., 2011).

CONTINUING EDUCATION Table 3: Evidence-based literature on the use of PRF in oral surgery Application

Reference

Type of study

Evidence/Conclusion

Reducing complications in third molar extractions

Eshghpour et al., 2014

RCT

PRF application may decrease the risk of alveolar osteitis development after mandibular third molar surgery.

Enhance bone healing after third molar extractions

Gurbuzer B, Pikdöken L, Tunalı M et al., 2010

CCT

PRF might not lead to enhanced bone healing in soft tissue impacted mandibular third molar extraction sockets 4 weeks after surgery.

Bone regeneration after third molar extractions

Rao SG, Bhat P, Nagesh KS, et al., 2013

CCT

PRF accelerates regeneration of bone after third molar extraction surgery in cases treated with PRF as compared to the control group postoperatively.

Bone healing and postoperative complications after third molar extractions

Singh A, Kohli M, Gupta N 2012

CCT

PRF is a valid method in promoting and accelerating soft and hard tissue wound healing and regeneration, and decreasing pain in mandibular third molar extractions.

Postoperative complications following third molar extractions

Uyanık LO, Bilginaylar K, Etikan I 2015

CCT

PRF and combination use of PRF and piezosurgery have positive effects in reducing postoperative complications (pain and trismus) after impacted third molar surgery.

Root-end surgery / healing of apico-marginal defects

Dhiman M, Kumar S, Duhan J, et al., 2015

RCT

A high success rate may be attained in apico-marginal defects with endodontic microsurgery, and addition of PRF may not necessarily improve the outcome.

Note: Conclusions reached were within the limitations of the studies, and more and large samples of rigorous clinical trials are required to validate the evidence.

(GBR) or bone grafting. The use of a PRF as a filling material significantly promotes soft tissue healing and also faster regeneration of bone in these sites and neighboring periodontal tissues (Ruga, et al., 2011; Yelamai and Saikrishna 2014).

Closing oroantral fistulas Oroantral communications can complicate dental surgery, particularly during extraction of a posterior maxillary root. PRF clots can be used successfully for atraumatic or minimal intervention closure of oroantral communications, thus eliminating the need to raise mucoperiosteal buccal sliding flaps (Gülen, et al., 2015). The technique for closure of an oroantral fistula using plateletrich fibrin is described by Argawal and co-workers (2016).

Apical/root end surgery PRF clot (gel) serves as an ideal scaffold in root-end surgical procedures to enhance soft tissue healing and bone regeneration (Kuz’minykh 2009; Singh, et al., 2013; Shivashankar, et al., 2015; Nagaveni, et al., 2015).

Other researchers (Dhiman, et al., 2015) report that PRF may not necessarily improve the outcome of treatment.

The combination of PRF membrane as a matrix and MTA can prove to be an effective alternative for creating artificial rootend barriers and to induce faster periapical healing with large periapical lesions (Kathuria, et al., 2011). It is suggested that the combination of PRF and β-TCP for bone augmentation in treatment of periapical defects is also a more effective at increasing healing time compared to using bone substitute material alone (Jayalakshmi, et al., 2012).

28 Implant practice

PRF combined with an alloplastic bone substitute has been successfully used for the management of combined endodonticperiodontal lesions (Goyal 2014).

and non-functioning pulp by stimulation of existing dental pulp stem and progenitor cells present in the root canal under conditions that are favorable to their differentiation.

Other oral surgical applications The use of PRF has also been reported in other therapies including: alveolar cleft grafting (Findik and Byakul 2013).

Management of open apex Recent case reports have shown that the combined use of platelet-rich fibrin (PRF), and mineral trioxide aggregate (MTA) as root filling material is beneficial for the endodontic management of an open apex (Sundar, et al., 2015; Woo, et al., 2016). It is hypothesized that the combination of MTA and PRF may have a synergistic effect on the stimulation of odontoblastic differentiation of stem cells.

Bisphosphonate-related oral necrosis of the jaw Recent case reports suggested that PRF might stimulate gingival healing and act as a barrier membrane between alveolar bone and the oral cavity, therefore offering a simple, though effective treatment for the closure of bone exposure in bisphosphonate-related oral necrosis of the jaw (BRONJ) (Soydan and Uckan 2014; Kim, et al., 2014; Lundquist, et al., 2008; Nørholt and Hartley 2016).

Compromised wound healing situations (diabetics) PRF has also been used as an adjuvant in the management of problematic chronic wounds (Lundquist, et al., 2008). The authors have shown that growth factors in PRF are protected from proteolytic degradation. This may be advantageous in the treatment of chronic wounds characterized by high proteinase activity.

Regenerative endodontic therapy Regenerative endodontic procedures are widely being added to the current armamentarium of pulp therapy procedures (Huang, et al., 2010; Hotwani and Sharma 2014; Khetarpal, et al., 2013; Li, et al., 2013).

These biologically based procedures are designed to restore function of a damaged

Revascularization and revitalization Revascularization is the most studied and successful approach of regenerative endodontics (Sundar, et al., 2015). Revitalization of necrotic infected immature tooth is possible under conditions of total canal disinfection combined with the additive effect of PRF (Shivashankar, et al., 2012; Nagaveni, et al., 2015). PRF is proposed as an ideal biomaterial for pulp-dentin complex regeneration because it is a potentially valid scaffold material containing leukocyte and growth factors to facilitate tissue healing and regeneration in immature necrotic teeth in children (Woo, et al., 2016).

Repair and regenerative potential of PRF and enhanced cellular metabolism with laser bio stimulation, in combination with the sealing ability of MTA enhances the clinical success outcomes in pulpotomy and apexification procedures (Sundar, et al., 2015). Revitalization, revascularization, and regenerative pulp therapies still need to be validated with robust clinical trials.

Volume 12 Number 2

PRF is increasingly being investigated and used by clinicians worldwide as an adjunctive autologous biomaterial to promote bone and soft tissue healing and regeneration. PRF technology has grabbed the attention of clinicians for several reasons: PRF is derived from the patients’ own blood, is readily available, can be produced immediately at the chairside, and is easy to prepare and is easy to use.

Furthermore, PRF technology is widely applicable in dentistry, while being financially realistic for the patient and the clinician, and with virtually no risk of a rejection reaction (foreign body response).

Clinicians are using PRF extensively and successfully in various clinical applications in dental implantology, periodontology, maxillofacial and oral surgery, and lately in regenerative endodontics to promote wound healing and tissue regeneration. The use of PRF in revitalization, revascularization, and regenerative pulp therapies are currently attracting a lot of attention, and several case studies in the field of regenerative endodontics are being reported. These applications, however, still need to be validated with robust clinical trials.

One of the clinical limitations to note is the heterogeneity in the quality of platelets and blood components due to use of different PRF preparation protocols in the various studies reviewed. Irrespective of the protocol used, all studies have all reported successful outcomes with regards to soft and bone tissue healing and regeneration. It should also be noted that at this stage in time there is not a single RCT or CCT to compare the effectiveness of A-PRF or L-PRF protocols. Furthermore, in vitro studies that claim superiority or inferiority of a specific PRF preparation have yet to be validated by independent clinical trials.

The future of PRF and its applications in clinical dentistry, especially in the field of soft tissue and bone regeneration, has enormous implications, but developing and strengthening its role in dentistry is dependent on its coherence and scientific clarity. The clinical effectiveness of different PRF preparation protocols in various clinical settings remains to be validated with a greater number of independent and robust RCTs, preferably with a split-mouth design, and larger sample sizes.

Independent, coherent, and scientific validation of PRF is needed to enhance the potential of this technology, thereby extending its therapeutic applications with improved successful and predictable outcomes for the benefit of the patient. PRF technology is in its infancy and will in future have a big impact in dentistry.

Volume 12 Number 2

The benefits derived from the using PRF in various clinical applications for promoting wound healing and tissue regeneration, its antibacterial and anti-hemorrhagic effects, the low risks with its use, and the availability of easy and low-cost preparation methods should encourage more clinicians to adopt this technology in their practice for the benefit their patients. IP

REFERENCES 1. Agarwal K, Chandra C, Agarwal K, Kumar N. Lateral sliding bridge flap technique along with platelet rich fibrin and guided tissue regeneration for root coverage. J Indian Soc Periodontol. 2013;17(6):801-805.

2. Agarwal B, Pandey S, Roychoudhury A. New technique for closure of an oroantral fistula using platelet-rich fibrin. Br J Oral Maxillofacial Surg. 2016;54():e31–e32 3. Aleksić Z, Janković S, Dimitrijević B, et al. The use of platelet rich fibrin membrane in gingival recession treatment [in Serbian]. Srp Arh Celok Lek. 2010;138(1-2):11-18.

4. Ali S, Bakry SA, Abd-Elhakam H. Platelet rich fibrin in maxillary sinus augmentation: a systematic review. J Oral Implantol. 2015;41(6):746-753.

5. Aravindaksha SP, Batra P, Sood V, Kumar A, Gupta GT. Use of platelet-rich fibrin (PRF) membrane as a palatal bandage.

Clin Adv Periodontics. 2013;4:1-6.

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8. Bajaj P, Pradeep AR, Agarwal E, et al. Comparative evaluation of autologous platelet-rich fibrin and platelet-rich plasma in the treatment of mandibular degree II furcation defects: a randomized controlled clinical trial. J Periodont Res. 2013;48(5):573-581.

9. Barone A, Ricci M, Romanos GE, et al. Buccal bone deficiency in fresh extraction sockets: a prospective single cohort study. Clin Oral Implants Res. 2015;26(7):823-830.

10. Bansal C, Bharti V. Evaluation of efficacy of autologous platelet-rich fibrin with demineralized freeze dried bone allograft in the treatment of periodontal intrabony defects. J Indian Soc Periodontol. 2013;7(3):361-366.

11. Baslarli O, Tumer C, Ugur O, Vatankulu B. Evaluation of osteoblastic activity in extraction sockets treated with platelet- rich fibrin. Med Oral Patol Oral Cir Bucal. 2015;20(1) e111-e116 12. Bolukbasi N, Ersanli S, Keklikoglu N, Basegmez C, Ozdemir T. Sinus augmentation with platelet-rich fibrin in combination with bovine bone graft versus bovine bone graft in combination with collagen membrane. J Oral Implantol.

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14. Choukroun J, Diss A, Simonpieri A, et al. Platelet-rich fibrin (PRF): a second-generation platelet concentrate. Part IV clinical effects on tissue healing. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;101(3):299-303.

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17. Del Corso M, Sammartino G, Dohan EDM. Clinical evaluation of a modified coronally advanced flap alone or in combination with a platelet-rich fibrin membrane for the treatment of adjacent multiple gingival recessions: a 6-month study. J Periodontol. 2009;80(11):1694-1697.

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41(7):985-991 23. Diss A, Dohan DM, Mouhyi J, Mahler P. Osteotome sinus floor elevation using Choukroun’s platelet-rich fibrin as grafting material: a 1-year prospective pilot study with microthreaded implants. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.

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32. Gamal AY, Abdel Ghaffar KA, Alghezwy OA. Crevicular Fluid Growth Factors Release Profile Following the Use of Platelets Rich Fibrin (PRF) and Plasma Rich Growth Factors (PRGF) in Treating Periodontal Intrabony Defects (Randomized Clinical Trial). J Periodontol. 2016;87(6):654-662.

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35. Gülen U,Entürk MF, Mehdiyev. Flap-free treatment of an oro-antral communication with platelet-rich fibrin. Br J Oral Maxillofac Surg. 2016;54(6):702-703.

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37. Gupta G, Puri K, Bansal M, Khatri M, Kumar A. Plateletrich fibrin-reinforced vestibular incision subperiosteal tunnel access (VISTA) technique for recession coverage. Clin Adv Periodontics. 2014;7:1-13.

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39. Hamzacebi B, Oduncuoglo B, Alaaddinogl EE. Treatment of peri-implant bone defects with platelet-rich fibrin. Int J Periodont Restorative Dent. 2015;35(3):415-422.

40. Hauser F, Gaydarov N, Badoud I, et al. Clinical and histological evaluation of postextraction platelet-rich fibrin socket filling: a prospective randomized controlled study. Implant Dent. 2013;22(3):295-303.

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42. Huang FM, Yang SF, Zhao JH, Chang YC. Platelet-rich fibrin increases proliferation and differentiation of human dental pulp cells. J Endod. 2010;36(10):1628-1632.

Implant practice 29

CONTINUING EDUCATION

Conclusion

CONTINUING EDUCATION 43. Inchingolo F, Tatullo M, Marrelli M, et al. Trial with PlateletRich Fibrin and Bio-Oss used as grafting materials in the treatment of the severe maxillary bone atrophy: clinical and radiological evaluations. Eur Rev Med Pharmacol Sci. 2010;14(12):1075-1084.

44. Jain V, Triveni MG, Kumar AB, Mehta DS. Role of plateletrich fibrin in enhancing palatal wound healing after free graft.

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45. Jankovic S, Aleksic Z, Milinkovic I, Dimitrijevic B. The coronally advanced flap in combination with platelet-rich fibrin (PRF) and enamel matrix derivative in the treatment of gingival recession: a comparative study. Eur J Esthet Dent.

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47. Jayalakshmi KB, Agarwal S, Singh MP, et al. Platelet-rich fibrin with beta-tricalcium phosphate — a novel approach for bone augmentation in chronic periapical lesion: a case report. Case Rep Dent. 2012; doi:10.1155/2012/902858.

48. Joseph VR, Raghunath A, Sharma N. Clinical effectiveness of autologous platelet rich fibrin in the management of infrabony periodontal defects. Singapore Dent J. 2012;33(1):5-12.

49. Joseph VR, Sam G, Amol NV. Clinical evaluation of autologous platelet rich fibrin in horizontal alveolar bony defects. J Clin Diagn Res. 2014;8(11):ZC43-ZC47 50. Kanayama T, Horii K, Senga Y, Shibuya Y. Crestal Approach to Sinus Floor Elevation for Atrophic Maxilla Using Platelet-Rich Fibrin as the Only Grafting Material: A 1-Year Prospective Study. Implant Dent. 2016;25(1):32-38.

51. Kathuria A, Chaudhry S, Talwar S, Verma M. Endodontic management of single rooted immature mandibular second molar with single canal using MTA and platelet-rich fibrin membrane barrier: A case report. J Clin Exp Dent.

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52. Kawase T. Platelet-rich plasma and its derivatives as promising bioactive materials for regenerative medicine: basic principles and concepts underlying recent advances. Odontology.

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54. Khetarpal A, Chaudhry S, Talwar S, Verma M. Endodontic management of open apex using MTA and platelet-rich fibrin membrane barrier: A newer matrix concept. J Clin Exp Dent.

2013;5(5):e291-e294.

55. Kim JS, Jeong MH, Jo JH, Kim SG, Oh JS. Clinical application of platelet-rich fibrin by the application of the Double J technique during implant placement in alveolar bone defect areas: case reports. Implant Dent. 2013;22(3):244-249.

56. Kim JW, Kim SJ, Kim MR. Leucocyte-rich and platelet-rich fibrin for the treatment of bisphosphonate-related osteonecrosis of the jaw: a prospective feasibility study. Br J Oral Maxillofac Surg. 2014;52(9):854-859.

57. Krasny K, Kaminski A, Krasny M, et al. Clinical use of allogeneic bone granulates to reconstruct maxillary and mandibular alveolar processes. Transplant Proc. 2011;43(8):3142-3144.

58. Kulkarni MR, Thomas BS, Varghese JM, Bhat GS. Platelet-rich fibrin as an adjunct to palatal wound healing after harvesting a free gingival graft: A case series. J Indian Soc Periodontol.

2014;18(3):399-402.

59. Kuz’minykh IA. Clinical experience in osteoplastic material Allomatrix-implant and fibrin rich platelets use in surgical treatment of jaw radicular cysts [in Russian]. Stomatologiia (Mosk). 2009;88(1):51-53.

60. Lekovic V, Milinkovic I, Aleksic Z, et al. Platelet-rich fibrin and bovine porous bone mineral vs. platelet-rich fibrin in the treatment of intrabony periodontal defects. J Periodontal Res. 2011;47(4):409-417.

61. Li Q, Pan S, Dangaria SJ, Gopinathan G, et al. Platelet-rich fibrin promotes periodontal regeneration and enhances alveolar bone augmentation. Biomed Res Int. 2013; doi:10.1155/2013/638043.

62. Lundquist R, Dziegiel MH, Ågren MS. Bioactivity and stability of endogenous fibrogenic factors in platelet-rich fibrin. Wound Rep Reg. 2008;16(3):356-363.

67. Moraschini V, dos Santos EBP. Use of Platelet-Rich Fibrin Membrane in the Treatment of Gingival Recession: a Systematic Review and Meta-Analysis. J Periodontol.

2016;87(3):281-290.

92. Shivashankar VY, Johns DA, Vidyanath S, Sam G. Combination of platelet rich fibrin, hydroxyapatite and PRF membrane in the management of large inflammatory periapical lesion. J Conserv Dent. 2013;16(3):261-264.

68. Nagaveni NB, Poornima P, Joshi JS, Pathak S, Nandini DB. Revascularization of immature, nonvital permanent tooth using platelet-rich fibrin in children. Pediatr Dent.

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93. Shivashankar VY, Johns DA, Vidyanath S, Kumar MR. Platelet Rich Fibrin in the revitalization of tooth with necrotic pulp and open apex. J Conserv Dent. 2012;15(4):395-398.

69. Nacopoulos C, Dontas I, Lelovas P, et al. Enhancement of bone regeneration with the combination of platelet-rich fibrin and synthetic graft. J Craniofac Surg. 2014;25(6):2164-2168.

70. Nagaveni NB, Kumari KN, Poornima P, Reddy V. Management of an endo-perio lesion in an immature tooth using autologous platelet-rich fibrin: a case report. J Indian Soc Pedod Prev Dent. 2015;33(1):69-73.

71. Nørholt SE, Hartlev J. Surgical treatment of osteonecrosis of the jaw with the use of platelet-rich fibrin: a prospective study of 15 patients. Int J Oral Maxillofac Surg. 2016; 45(10):1256-1260.

72. Öncü EA, Erbeyoğlu AA. Enhancement of immediate implant stability and recovery by platelet-rich fibrin. Int J Oral Maxillofacial Surg. 2019;39(2)e58-e63.

73. Öncu E, Alaaddinoõglu E. Effect of platelet-rich fibrin on osseointegration. Int J Oral Maxillofacial Surg. 2015; 42(10):1265-1266.

94. Simon BI, Zatcoff AL, Kong JJW, O’Connell SM. Clinical and Histological Comparison of Extraction Socket Healing Following the Use of Autologous Platelet-Rich Fibrin Matrix (PRFM) to Ridge Preservation Procedures Employing Demineralized Freeze Dried Bone Allograft Material and Membrane.

Open Dent J. 2009;3:92-99.

95. Simonpieri A, Del Corso M, Sammartino G, Dohan Ehrenfest DM. The relevance of Choukroun’s platelet-rich fibrin and metronidazole during complex maxillary rehabilitations using bone allograft. Part I: a new grafting protocol. Implant Dent.

2009;18(2):102-111.

96. Simonpieri A, Del Corso M, Sammartino G, Dohan Ehrenfest DM. The relevance of Choukroun’s platelet-rich fibrin and metronidazole during complex maxillary rehabilitations using bone allograft. Part II: implant surgery, prosthodontics, and survival. Implant Dent. 2009;18(3):220-229.

74. Panda S, Jayakumar ND, Sankari M, Varghese SS, Kumar DS. Platelet rich fibrin and xenograft in treatment of intrabony defect. Contemp Clin Dent. 2014;5(4):550-554.

97. Simonpieri A, Choukroun J, Del Corso M, Sammartino G, Dohan EDM. Simultaneous sinus-lift and implantation using micro threaded implants and leukocyte- and platelet-rich fibrin as sole grafting material: a six-year experience. Implant Dent.

2011;20(1):2-12.

75. Panda S, Ramamoorthi S, Jayakumar ND, Sankari M, Varghese SS. Platelet rich fibrin and alloplast in the treatment of intrabony defect. J Pharm Bioallied Sci. 2014;6(2):127-131.

98. Singh A, Kohli M, Nimish Gupta N. Platelet Rich Fibrin: A Novel Approach for Osseous Regeneration. J Maxillofac Oral Surg.

2012;11(4):430-434.

76. Patil PA, Kumar R V, Kripal K. Role and Efficacy of L- PRF matrix in the Regeneration of Periodontal Defect: A New Perspective. J Clin Diagn Res. 2014;8(12):ZD03-ZD05

99. Singh S, Singh A, Singh S, Singh R. Application of PRF in surgical management of periapical lesions. Natl J Maxillofac Surg. 2013;4(1):94-99.

77. Peck MT, Marnewick J, Stephen L. Alveolar ridge preservation using leukocyte and platelet-rich fibrin: a report of a case.

Case Rep Dent. 2011; doi:10.1155/2011/345048.

100. Soydan SS, Uckan S. Management of bisphosphonate-related osteonecrosis of the jaw with a platelet-rich fibrin membrane: technical report. J Oral Maxillofac Surg. 2014;72(2):322-326.

78. Pradeep AR, Sharma A. Treatment of 3-wall intrabony defects in chronic periodontitis subjects with autologous platelet rich fibrin: a randomized controlled trial. J Periodontol.

2011;82(12):1705-1712.

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Sundar JS, Varma KM, Kalyan Satish RK, Sajjan GS, Tanikonda R. A Biological Approach in Repair of Damaged Dental Pulp and Periapical Tissues using Platelet Rich Fibrin, Mineral Trioxide Aggregate and Laser Bio stimulation. IJSS Case Reports & Reviews. 2015;1(11):44-50.

79. Pradeep AR, Rao NS, Agarwal E, Bajaj P, Kumari M, Naik SB. Comparative evaluation of autologous platelet-rich fibrin and platelet-rich plasma in the treatment of 3-wall intrabony defects in chronic periodontitis: a randomized controlled clinical trial. J Periodontol. 2012;83(12):1499-1507.

80. Pradeep AR, Bajaj P, Rao NS, Agarwal E, Naik SB. PlateletRich Fibrin Combined With a Porous Hydroxyapatite Graft for the Treatment of 3-Wall Intrabony Defects in Chronic Periodontitis: A Randomized Controlled Clinical Trial. J Periodontol. 2017;88(12):1288-1296.

102. Tajima N, Ohba S, Sawase T, Asahina I. Evaluation of sinus floor augmentation with simultaneous implant placement using platelet- rich fibrin as sole grafting material. Int J Oral Maxillofac Implants. 2013;28:77-83.

103. Tatullo M, Marrelli M, Cassetta M, et al. Platelet Rich Fibrin (P.R.F.) in reconstructive surgery of atrophied maxillary bones: clinical and histological evaluations. Int J Med Sci. 2012;9(10):872-880.

81. Rajaram V, Thyegarajan R, Balachandran A, Aari G, Kanakamedala A. Platelet Rich Fibrin in double lateral sliding bridge flap procedure for gingival recession coverage: An original study. J Indian Soc Periodontol. 2015;19(6):665-670.

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2011;38(10):925-932.

82. Ranganathan AT, Chandran CR. Platelet-rich fibrin in the treatment of periodontal bone defects. J Contemp Dent Pract.

2014;15(3):372-375.

105. Toeroek R, Dohan EDM. The concept of Screw- Guided Bone Regeneration (S-GBR). Part 3: Fast Screw- Guided Bone Regeneration (FS-GBR) in the severely resorbed preimplant posterior mandible using allograft and Leukocyte- and Platelet-Rich Fibrin (L PRF): a 4-year follow-up. POSEIDO. 2013;1(2):93-100.

83. Rao SG, Bhat P, Nagesh KS, et al. Bone Regeneration in Extraction Sockets with Autologous Platelet Rich Fibrin Gel. J Maxillofac Oral Surg. 2013;12(1):11-16.

84. Ruga E, Gallesio C, Boffano P. Platelet-rich fibrin and piezoelectric surgery: a safe technique for the prevention of periodontal complications in third molar surgery. J Craniofac Surg.

2011;22(5):1951-1955.

85. Sambhav J, Rohit R, Ranjana M, Shalabh M. Platelet rich fibrin (PRF) and B-tricalcium phosphate with coronally advanced flap for the management of Grade II furcation defect. Ethiop J Health Sci. 2014;24(3):269-272.

86. Sammartino G, Dohan Ehrenfest DM, Carile F, Tia M, Bucci P (2011). Prevention of hemorrhagic complications after dental extractions into open heart surgery patients under anticoagulant therapy: the use of leukocyte- and platelet-rich fibrin. J Oral Implantol 37: 681-690 87. Shah M, Deshpande N, Bharwani A, et al. Effectiveness of autologous platelet-rich fibrin in the treatment of intra-bony defects: A systematic review and meta-analysis. J Indian Soc Periodontol. 2014;18(6):698-704.

106. Toffler M, Toscano N, Holtzclaw D. Osteotome-mediated sinus floor elevation using only platelet-rich fibrin: an early report on 110 patients. Implant Dent. 2010;19:447-456.

107. Triveni MG, Tarun Kumar AB, Vinita Jain, Dhoom S Meh. Alveolar Ridge Preservation with beta-TCP Graft and PlateletRich Fibrin. Int J Oral Implant Clin Res. 2012;3:96-100.

108. Troiano G, Laino L, Dioguardi M, et al. Mandibular Class II Furcation Defects Treatment: Effects of the Addition of Platelet Concentrates to Open Flap. A Systematic Review and Metaanalysis of RCT. J Periodontol. 2016;87(9):1030-1038.

109. Uyanık LO, Bilginaylar K, Etikan I. Effects of platelet- rich fibrin and piezosurgery on impacted mandibular third molar surgery outcomes. Head Face Med. 2015;11:25.

110. Vijayalakshmi R, Rajmohan CS, Deepalakshmi D, Sivakami G. Use of platelet rich fibrin in a fenestration defect around an implant. J Indian Soc Periodontol. 2012;16(1):108-112.

63. Magremanne M, Baeyens W, Awada S, Vervaet C. Solitary bone cyst of the mandible and platelet rich fibrin (PRF). Rev Stomatol Chir Maxillofac. 2009;110(2):105-108.

88. Shah M, Patel J, Dave D, Shah S. Comparative evaluation of platelet-rich fibrin with demineralized freeze-dried bone allograft in periodontal infrabony defects: a randomized controlled clinical study. J Indian Soc Periodontol.

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111. Woo SM, Kim WJ, Lim HS, et al. Combination of Mineral Trioxide Aggregate and Platelet-rich Fibrin Promotes the Odontoblastic Differentiation and Mineralization of Human Dental Pulp Cells via BMP/Smad Signaling Pathway. J Endod.

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64. Marenzi G, Riccitiello F, Tia M, di Lauro A, Sammartino G. Influence of Leukocyte- and Platelet-Rich Fibrin (L-PRF) in the Healing of Simple Postextraction Sockets: A Split-Mouth Study. BioMed Res Int. 2015; doi:10.1155/2015/369273.

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90. Sharma A, Pradeep AR. Autologous platelet-rich fibrin in the treatment of mandibular degree II furcation defects: a randomized clinical trial. J Periodontol. 2011;82(10):1396-1403.

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30 Implant practice

91. Shilbli JA, Blay A, Tunchel S, et al. Treatment of peri-implantitis using L-PRF and ER,CR:YSGG laser in the esthetic zone: Longitudinal aspects. In: Rosetti EHO and Bonachela WC, eds, Complex situations on Implant Dentistry: Specialized Clinical Solution. São Paulo, Brazil: VM Vultural; 2013.

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Volume 12 Number 2

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A comprehensive clinical review of platelet-rich fibrin (PRF) and its role in promoting tissue healing and regeneration: part 3 HARTSHORNE/GLUCKMAN

1. PRF, a/an ______ biomaterial, is increasingly being investigated and used worldwide by clinicians as an adjunctive autologous biomaterial to promote bone and soft tissue healing and regeneration. a. patient blood-derived b. autogenous living c. synthetic d. both a and b 2. The gold standard for in vivo tissue healing and regeneration requires the mutual interaction between a scaffold (fibrin matrix), _______ , and stem cells. a. platelets b. growth factors c. leukocytes d. all of the above

c. accelerates graft maturation and totally eliminates the healing period after implant placement d. will not act as a protective barrier to cover the sinus membrane 5. Case reports indicate that PRF membrane cut in pieces or i-PRF combined with bone substitutes may offer an easy and simple method of handling and delivery of ________ during the augmentation of dehiscence and fenestration defects, and at the same time reduce soft tissue and bone healing time. a. a fibrin scaffold b. growth factors c. cells d. all of the above

3. A systematic review showed that PRF used as a sole filling material in SFE with simultaneous implant placement is a ________. a. simple technique with promising results b. complex technique with promising results c. simple technique but cost-prohibitive d. simple technique but unproven in clinical situations

6. One clinical study showed that treatment of periimplant defects with PRF was clinically _______ with conventional flap surgery alone, irrespective of the type of defect. a. more effective than b. less effective than c. equally as effective as d. incomparable

4. The review also suggests that PRF combined with a bone allograft or other bone substitutes _______. a. decreases graft maturation and decreases the healing period before implant placement b. accelerates graft maturation and decreases the healing period before implant placement

7. Case studies suggest that PRF application into the osteotomy site _____ implant stability during the early healing period, as evidenced by higher ISQ values. a. increases b. decreases c. has no effect on

Volume 12 Number 2

d. interferes with 8. Surgical periodontal therapy accompanying the placement of PRF in angular defects of aggressive periodontitis patients showed ________, and radiographic bone fill when baseline and 9-month follow-up data was compared. a. increased probing pocket depth, increased attachment level b. decreased probing pocket depth, decreased attachment level c. decreased probing pocket depth, increased attachment level d. increased probing pocket depth, decreased attachment level 9. _______ acts as a stabilized blood clot and therefore is recommended as a perfect filling material for natural tissue regeneration and healing. a. GBR b. Platelet gel c. Bone/PRF mixture d. PRF membrane 10. PRF is derived from the patients’ own blood, is readily available, ________ , and is easy to prepare and is easy to use. a. can be produced immediately at the chairside b. can be produced in a few days at the lab c. eliminates all postoperative complications d. slows coagulation

Implant practice 31

CE CREDITS

IMPLANT PRACTICE CE

LAB LINK

3D printing possibilities for the present and future Joseph Lee, CTO at Friendship Dental Labs, shares his vision of 3D printing for the denture and implant practice What are 3D-printed dentures?

3D-printed dentures are a paradigm shift away from a traditional perspective on what a denture is. While many labs offer dentures, few actually do a good job in the traditional sense. If a veneer has a defined parameter (margin, thickness, etc.) a denture is all about tolerances to achieve success. 3D-printed dentures offer the potential for a level of accuracy and esthetics that were truthfully only accessible by a few. To me, a 3D-printed denture is the future capstone for the removable space in dental.

What is the process? What are some benefits or potential challenges?

The immediate benefit of printing dentures is “footprint.” The 3D-printed space really requires only your CAD workstation, a Form 2 printer or their brand-new Form 3 Friendship Dental Lab Form 2 work station

Formlabs Form 2 printing digital dentures

Joseph Lee has been in the dental industry for over a decade. He received a degree in Biology and Political Science at Washington University in St. Louis. He went on to pursue his DMD/JD but discovered his passion for the restorative portion in dental, and the rest is history. He has served as R&D manager and COO at some of the best labs in the country. He is currently the CTO of Friendship Dental Laboratories in Baltimore, Maryland. When he isn’t working, he is co-managing his Yellow Labrador’s YouTube page: Andie_the_Lab.

32 Implant practice

printer, Form Wash + Form Cure with some Pyrex® and glycerin. Additionally, you would need a polishing station and an area to do composite staining if you wanted. All in all?

A 60" sturdy table would suffice.

The biggest hurdle is the lack of edentulous scanning solutions today. I’ve had ideas of shrinking NDT methods, but we are still far from that. Or even being able to digitally map a scaled-up form of DH-QPM? Right now our best solution is scanning the impression, but typically a removable impression requires

quite a bit of work even after being poured up — so scanning the impression is also still a limiting solution. With that being said, one of the largest hurdles is proper records.

The second largest hurdle with 3D-printed dentures would be the stigma behind quality.

Companies tout the simplicity — which, invariably, clinicians perceive as “cheap and affordable.” If a 3D-denture breaks today, there isn’t the notion that maybe our perceived requirements for design need to be shifted. Instead it’s an immediate crucifixion that this “technology” is cheap and broken.

The biggest benefit to printing over packing, injecting, or milling is the opportunity to create the best-fitting denture in the world. Hypothetically, you don’t need to post-dam the case, wax over undercuts, etc.

If the scan is of good quality, and it’s accurate, what is designed off of that can achieve new levels of intimate fit.

The biggest challenge in the lab is deciding how far you want to go with your esthetics.

Right now, we highly suggest composite veneering and characterization for final dentures, but none for immediate dentures.

Is there a big learning curve?

Yes, but it is related to how the dental space has fostered experience in removables.

Volume 12 Number 2

Contact 800-526-9343 or Shop Online at www.impladentltd.com ®

ONE STEP BONE GRAFTING SOLUTION FOR SOCKET PRESERVATION WITHOUT THE NEED FOR A MEMBRANE

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Available in Two Sizes

Clinical Case Example

At only $50 per piece, the Impladent Ltd OsteoGen® Bone Grafting Plug combines bone graft with a collagen plug to yield the easiest and most affordable way to clinically deliver bone graft for socket preservation and ridge maintenance, all without the need for a membrane!

Clinical images courtesy of German Murias DDS, ABOI/ID

1 Two Slim OsteoGen® Plugs are in place. Suture over top of socket to contain. No membrane is required

Tooth #15, set to be extracted

The surgical site was initially debrided to induce bleeding and establish the Regional Acceleratory Phenomenon

2

3 Insert Large or Slim sized OsteoGen® Bone Grafting Plugs and allow blood to absorb

OsteoGen® is a low density bone graft and the will OsteoGen® Plugs show radiolucent on the day of placement

As the OsteoGen® crystals are resorbed and replaced by host bone, the site will become radiopaque

4

5

6

The collagen promotes 7 keratinized soft tissue coverage while the OsteoGen® resorbs to form solid bone. In this image, a core sample was retrieved

8

Implant is placed. Note the histology showing mature osteocytes in lamellar bone formation.

Some of the larger OsteoGen® crystals and clusters are slowly resorbing. Bioactivity is 9 demonstrated by the high bone to crystal contact, absent of any fibrous tissue encapsulation

Contact 800-526-9343 or Shop Online at www.impladentltd.com

LAB LINK

Digital dentures in Form Wash

Usually the oldest, most experienced technicians are the ones who carry the torch in most removable departments. Unfortunately, that also usually means that the learning curve to design on a Wacom® Cintiq using a 3D space mouse is very difficult to adopt.

In fact, we saw better adoption using virtual reality (VR) (HTC Vive Pro) than any other style of digital design. Additionally, production schedules drastically change because this process deviates so greatly from traditional denture fabrication.

Truthfully, the biggest learning curve is patience.

What type of other equipment do you need to go with it?

A good scanner and good CAD software.

I highly suggest designing on a Wacom Cintiq Pro and pairing it with nothing below an 7700K (9900K preferred) and a 1080Ti or even better a RTX2070 (or higher). The best space mouse to use is not the larger ones, but the wireless Bluetooth one from 3Dconnexion.

It’s VERY important to have a proper digital denture tooth library. Right now, the best one on the market is is the Ivoclar Vivadent tooth library: SR Vivodent® S DCL. It’s very easy to scale with form. Start off with a Form 2 and the Form Cure.

The flowable composite by anaxdent North America is great, as is the Creation VC light curing composite system by Creation Willi Geller (which fluoresces, by the way).

Before jumping in and purchasing or even leasing a printer, a very strong reason to go with Formlabs will be what you need. Few printers are doing multi-head prints, so if you scale, you scale with the need for more printers as well. It’s easier to have two to four or even six Form 2’s than it is to spend $15,000 and then $45,000, just so you can simultaneously print different gum shades and tooth shades.

Very important question for our readers — how does this process 34 Implant practice

Digital dentures in Form Cure

help implant dentists serve their patients better, more efficiently, quicker (any other ways that it may help).

With regards to implant dentistry, we have barely scratched the surface. Right now, we are only looking at printing immediate dentures for faster turnaround time.

It’s not just dentures; it’s the way cases are planned, staged, prepped, and the types of prosthesis we can make that haven’t even been thought of yet.

In terms of how this process helps implant dentists serve patients better, it’s the following: • Being able to create densities and bone structure under other structures to perfectly plan out the surgery/ practice.

• Being able to replicate the surgery with other technologies and provide a perfect implant denture with no conversion process.

• It’s not just the denture itself, but being able to use the denture tooth materials for other things, and also rapid printing in case something breaks.

• All files are digital, so we can always replicate what we’ve made.

For implant-focused dentists, does 3D printing entail making your own surgical guides for implant surgery?

How does this create more accurate implant placement?

Yes, for implant-focused clinicians, 3D-printing enables them the option of printing their own guides. The guides, as long as they are designed right, provide the opportunity for better placement.

How quickly can these guides be made in office?

Printing the guides themselves takes only about 90-ish minutes. Between sterilization

Formlabs digital dentures resin

Formlabs digital dentures

and post-processing, you could easily finish your own guide in a day.

Is it difficult to design and print 3D-surgical guides in the office?

It’s not difficult to print guides in the office. There are varying difficulties with regards to software — but the bigger question that needs to be asked is where is your time most valuable? In-house printing is a lovely notion, but it is still messy, and clean space or any sort of extra space in the office is a luxury. We’ve seen tremendous success with printing guides with a local lab to keep down inventory stock and real estate that isn’t necessarily always there. IP Volume 12 Number 2

Silent Partners Invest Cash In Your Practice Claim Your No Cost Valuation In the last six months we have helped our client doctors put over $100,000,000+ in their pockets from silent partners. Doctors remain as partial owners, running their practice under their brand and management. The silent partner provides capital, support and broad resources as needed to accelerate growth.

When ready to retire—years or decades in the future— doctors have a known exit for their retained practice ownership. Clients (average age under 50) are not seeking a short term retirement strategy, but a cash secured future and a silent partner which provides the tools and

ammunition to compete more effectively and profitably.

We have advised clients across the U.S. that values are peaking.

The unique LPS approach creates value not possible with other advisors. We can confidentially show you the value of your practice under various custom structures at no cost or obligation.

Even if you are not interested in monetizing all or part of your practice today, it pays to understand what makes your practice more or less valuable to “Invisible DSOs.”

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You might be surprised…

PRODUCT PROFILE

Built to Last. Built for You. Built by Boyd.

B

uilt to Last. Built for You. Built by Boyd is more than a tagline. It signifies the commitment that everyone at Boyd makes to each and every one of our customers.

Best known for the durability and reliability of our award-winning products — including exam and treatment chairs, surgery tables, mobile storage, and clinical cabinetry — we combine over 60 years of design and manufacturing expertise to perfectly fit your unique space and personal style. The Boyd team takes great pride in the craftsmanship and longevity of all products built at our U.S.-based facility, so you can take pride in your office for years to come.

Featured product: S2614 Oral Surgery Chair

Boyd’s flagship S2614 Surgical Chair is the profession’s benchmark for oral surgery.

Designed specifically for your needs, the S2614 Surgical Chair combines ergonomic, reliable functionality with elegant design. Like the majority of Boyd Industries’ products, the S2614 Surgical Chair can be personalized to best suit your office, just as its design will best suit your specialization’s needs.

What makes the S2614 design unique?

• Ergonomic and reliable design. The S2614’s thin, tapered-style back was created for ease-of-access to the oral cavity and with your long-term comfort in mind. Dual-articulating headrest included.

• Cantilevered style lift base with 14" of vertical travel and independent

•

•

•

•

powered seat tilt for Trendelenburg positioning. Runs on low-voltage DC motors. Additionally, the chair’s durable all-steel frame will last the test of time and frequent use.

Quad-function foot control for convenient movement of the chair. Enjoy personalized, convenient settings with three (3) operator-designated pre-set positions, and an automatic “return to home” switch. We prioritize safety with a built-in power “lock-out” switch.

Integrated medical-grade duplex 115vAC outlet to accommodate your electrical needs.

Additional standard features include “On-Track” surgical armboard/ accessory rail system; choice of dual-articulating headrests, snapon/snap-off upholstery; vinyl foot protector; and body restraint strap.

Options include upholstery style, base color (standard “Putty” or “Black”), and choice of IV and patient armboards.

Featured product: Dental Implant Cart Like the S2614, this mobile operatory cart is prepared to perfectly fit into your practice. This Prestige Dental Implant Cart has been fitted with a durable steel body and all the features you need: sectioned drawers for intuitive organization, a full powder coat to withstand medical-grade cleaners, and a sleek, contemporary esthetic. It matches seamlessly with the rest of our Prestige suite, including the Surgical Care Cart and Surgical Devices Cart.

Boyd’s flagship S2614 Oral Surgery Chair with cantilevered style lift base with 14" of vertical travel and independent powered seat tilt for Trendelenburg positioning 36 Implant practice

Prestige Dental Implant Cart

Standard Features: • Three 3”-deep drawers and two 6”-deep drawers with soft-close ball-bearing technology. Integrated key lock to safeguard high-value implants.

• Adjustable drawer dividers designed for efficient organization of your implant inventory.

• A removable plastic top designed for easy disinfection, alongside a slideout surface for added work space.

• Lockable, 5" easy-rolling casters for smooth transit from patient to patient.

• Durable, scratch-resistant, nylonreinforced polycarbonate bumper to protect cart wheels and exterior.

The Boyd team has made every effort to create specialized products that are truly Built for You. These featured products can be combined with additional products — such as our PTC653 Patient Transfer Chair or S200 LED Surgery Light — as well as Boyd’s custom clinical and office cabinetry to create a fully cohesive office space. Personalize your office with nearly limitless combinations of color and print laminates and the widest range of upholstery choices on the market. Reach out to your regional sales representative today to get started!

To learn more, visit us at www.boyd industries.com, or stop by our booth during the AAOMS 101st Annual Meeting or Dental Implant Conference 2019! You can also follow us on Instagram and Twitter @boydindustries.

Boyd Industries is an ISO 13485:2016 certified company. IP This information was provided by Boyd Industries.

Volume 12 Number 2

September 4-8

Registration is FREE! Basic registration for ADA FDI 2019 is FREE for all ADA member dentists and North American attendees. Flexible pricing makes it easy to maximize your meeting experience.

Courses to consider include: WORKSHOP A New Era in Fixed and Removable Prosthesis Attachments COURSE CODE: 7205 & 7206, CE HOURS: 3 FEE LECTURE Immediate Implantation and CAD-CAM Restorations at Aesthetic Zone COURSE CODE: 6120, CE HOURS: 1 WORKSHOP Cadaveric Hands-on Implant Placement and Bone Grafting COURSE CODE: 7202, CE HOURS: 7 FEE LECTURE Enhancing Implant Diagnosis Using the Latest Technology COURSE CODE: 8114, CE HOURS: 2.5

Register today at ADA.org/meeting.

Be a part of something extraordinary.

INDUSTRY NEWS 3Shape wins two Red Dot design awards

AOCI launches American Society of Ceramic Implantology: call for officers and volunteers The International Academy of Ceramic Implantology (IAOCI.com) has announced the creation of the American Society of Ceramic Implantology. ASCI, as it will be known, is dedicated to provide quality and unbiased dental implant education that focuses on ceramic and metal-free implantology. There are now seven different FDA-approved ceramic implant systems in the United States and more to be approved in the next few months. The search by patients for metal-free implantologists is ever-increasing. ASCI aims to organize, gather, and provide programs that will introduce and educate in an unbiased manner specialists and general dentists to ceramic implantology.

The American Society of Ceramic Implantology has been established to support the public’s desire to have all dentists in the U.S. gain a basic understanding of ceramic and metal-free implantology.

The society aims to provide the necessary educational support for those dentists who wish to become involved in providing such treatment in their practices.

For more information, visit https://iaoci.com/.

Zimmer Biomet and RTI Surgical partner with AAID Foundation to expand access to dental care for veterans ®

Zimmer Biomet and RTI Surgical Holdings, Inc. announced its donation of a supply of dental implants and wound care products to the American Academy of Implant Dentistry Foundation (AAIDF) for an initiative benefiting veterans of the United States Armed Forces.

The AAIDF is the charitable arm of the American Academy of Implant Dentistry, a Chicago-based professional organization that advances the science and practice of implant dentistry through education and research support and serves as the credentialing standard for implant dentistry. Under the new partnership, Zimmer Biomet, through its dental division, donated thousands of collagen wound care products that will be used in socket preservation procedures preparing veterans to receive dental implant therapy. RTI’s donation includes allograft implants that provide options for veterans undergoing dental implant surgery.

For more information on AAID, visit www.aaid.com/foundation.

For more information on Zimmer Biomet, visit www.zimmerbiomet. com, and for more information on RTI Surgical, visit www.rtix.com.

38 Implant practice

3Shape, a global leader in 3D scanners and CAD/CAM software solutions, has received two Red Dot awards — the international distinction for high design quality. The two design awards were presented to the just-released 3Shape TRIOS® 4 intraoral scanner and the TRIOS® MOVE+. The 3Shape solutions were selected by the Red Dot global jury from more than 5,500 entrees. The distinction now marks the fifth and sixth 3Shape solution given a Red Dot product design award over the past 3 years.

For more information, visit www.3shape.com

AO elects Dr. Jay Malmquist as 33rd President to lead its global initiatives Jay P. Malmquist, DMD, an oral and maxillofacial surgeon from Portland, Oregon, became the Academy of Osseointegration’s (AO) newest president at the organization’s Annual Business Meeting in Washington, DC. As the Academy’s 33rd President, Dr. Malmquist succeeds Dr. James C. Taylor from Ottawa, Canada at the helm of AO. The 2019-2020 Board of Director officers serving with Dr. Malmquist follow: • President-elect: Clark M. Stanford, DMD, PhD, a prosthodontist from Chicago, Illinois.

• Vice President: Tara L. Aghaloo, DDS, MD, PhD, an oral and maxillofacial surgeon from Los Angeles, California.

• Secretary: Jeffrey D. Lloyd, DDS, a general practitioner from Rancho Cucamonga, California.

• Treasurer: Amerian D. Sones, DMD, MS, a prosthodontist from Dallas, Texas.

• Past President: James C. Taylor, DMD, MA, a prosthodontist from Ottawa, ON, Canada.

For more information, visit www.osseo.org

Volume 12 Number 2

INTRODUCING OUR NEW

ADVANCED CONTINUUM TAKE YOUR DENTAL IMPLANT TRAINING ONE STEP FURTHER WITH OUR ADVANCED COURSES, SUCH AS COMPLICATIONS, SINUS GRAFTING, AND RESTORATIVE SOLUTIONS. SPACE IS LIMITED!

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ON THE HORIZON

Start with the “why?”

Dr. Justin D. Moody discusses how to handle inevitable setbacks

I

mplant dentistry works very well most of the time, thank goodness. But when we have issues or complications, it often means lost chair time, materials, and lab fees. To me, those things are just a part of dentistry.

It happens to all of us, but what defines us is how we handle these setbacks. Before charging forward to fix the problem, clinicians must take a step back and investigate — start with the “Why did this happen?” It’s only after you discover this that you truly can move forward with the solution.

When talking with other dentists who place and/or restore dental implants, it seems

Figure 3: Bony defect created around the dental implant. It was a good thing in this case since all the walls are still intact to hold the graft material

Figure 5: A sheet of Mem-Lok membrane was trimmed and placed over the graft material to keep the soft tissue out of the particles

Figure 1: Periapical radiograph showing vertical bone loss

Figure 4: Defect was cleaned, and 0.5cc of MinerOss Cancellous graft material was placed into the defect

Figure 6: The crown/abutment were cleaned and sanitized prior to placement back in the mouth

Justin D. Moody DDS, DABOI, DICOI, is a Diplomate in the American Board of Oral Implantology, Diplomate in the International Congress of Oral Implantologists, Honored Fellow, Fellow, and Associate Fellow in the American Academy of Implant Dentistry, and Adjunct Faculty at the University of Nebraska Medical Center. He is an internationally known speaker, founder of the New Horizons Institute Non-Profit Clinic, and Director of Implant Education for Implant Pathway.

You can reach him at justin@justinmoodydds.com.

Disclosure: Dr. Moody is a paid consultant for BioHorizons® and ProSmiles Dental Studio.

40 Implant practice

Figure 7: Periapical radiograph post-graft showing the material for future reference

Figure 2: Existing crown and abutment were removed through access on the occlusal surface. You can see the residual cement attached to the abutment

the number one complication is bone loss around the dental implant. For some, this happens immediately after implant placement, and for others, it takes months and in many cases years before we see these effects on the radiographs or in a clinical manifestation.

I want to share the story of a patient who recently came in after treatment over 10 years ago. Unfortunately, he was never good about coming in for re-care. The hygienist found a deep probing and took a periapical radiograph that was less than flattering to the eye — the tooth had bone loss and purulence around what was until recently a very solid and longtime functional restoration. I discussed my findings with the patient and told him that I would like to remove the crown/abutment to get a better look, maybe even grafting the case.

I accessed the crown/abutment and removed it only to find residual cement and granulation tissue all around the implant.

There was my why! I removed the granulation tissue, cleaned the implant with an iBrush (NeoBiotech), rinsed with citric acid, placed some MinerOss® Cancellous graft material (BioHorizons®) around it and a sheet of Mem-Lok® (BioHorizons) over the graft, seated the cleaned-up crown/abutment, and sutured the tissue with some 4-0 PGA. I will follow the case at 1-week, 1-month, and 6-month intervals in hopes of achieving some resolution.

You may be wondering if I charged him for that day’s treatment. In this case, I elected to treat the patient for free, understanding that he was not the most loyal re-care patient, but when you stop to look at it, I was the one who left the residual cement behind, me and only me. Just do the right thing; it always works out best and lets you sleep well at night. IP Volume 12 Number 2

don’t be fooled.

chairside system for the production of Leukocyte- and Platelet-Rich Fibrin

choose an FDA-cleared medical device for the production of L-PRF® no anticoagulant, heating, pipetting, second spin, chemical additives or expensive consumables • simple & economical1 • quality guarantee • quick three-step processing protocol • up to 80% reduction in undesirable vibrations2 • high quality German engineering and manufacturing For more information, contact BioHorizons Customer Care: 888.246.8338 or shop online at www.biohorizons.com 1.Intra-lock.com/scientific-literature.html. IntraSpin® and L-PRF® are trademarks of Intra-Lock® International Inc. 2. David M. Dohan Ehrenfest, Nelson R. Pinto, Andrea Pereda, Paula Jiménez, Marco Del Corso, Byung-Soo Kang, Mauricio Nally, Nicole Lanata, Hom-Lay Wang & Marc Quirynen (2017): The impact of the centrifuge characteristics and centrifugation protocols on the cells, growth factors, and fibrin architecture of a leukocyte- and platelet-rich fibrin (L-PRF) clot and membrane, Platelets, DOI: 10.1080/09537104.2017.1293812 SPMP18276 REV C FEB 2019

DUAL PRESENTERS