Implant Practice US August/September 2015 Issue - Vol8.4

clinical articles • management advice • practice profiles • technology reviews August/September 2015 – Vol 8 No 4

Immediate esthetic rehabilitation with one-piece implants Drs. Shahram Nik and Kaveh Golab

Dr. Charles D. Schlesinger

The effect of osteoporosis on dental treatments

THE NEW ANGLE ON

From edentulous space to walking out with a tooth: a 40-minute experience

O-BALL IMPLANTS

PROMOTING EXCELLENCE IN IMPLANTOLOGY

Dr. Elena Calciolari

Guided surgical immediate implant placement with immediate load and CAD/CAM temporary provisionalization Dr. Bart W. Silverman

Corporate profile DENTSPLY Implants

Practice profile Dr. Scott Ganz

The new SATURNO™ Narrow Diameter Implant System

For more information, please call 800.262.2310 or visit www.zestanchors.com/sndi/10

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THE NEW ANGLE

ON O-BALL IMPLANTS Introducing the new SATURNO™ Narrow Diameter Implant System.

SATURNO is a narrow diameter, O-Ball implant designed as a permanent solution for overdenture retention. Engineered with straight and innovative 20° angled O-Ball implant options, SATURNO gives clinicians something new in a narrow diameter O-Ball implant—Flexibility.

The 20° angled O-Ball implant option allows for placement following the natural slope of the maxillary ridge. This ZEST Anchors innovation diminishes O-Ball facial emergence, a problem that could produce areas of thin denture acrylic and compromise denture strength and/or esthetics.

Both SATURNO Implants provide the patented Pivoting O-Ring technology pioneered by ZEST Anchors. That technology allows for passive denture seating when convergent/ divergent implants are present. With passive seating, patients will experience easier prosthesis insertion/removal, and less wear on their O-Rings.

SATURNO Narrow Diameter Implant System: Self-tapping for ease of implant insertion and increased implant stability Progressive thread provides increased primary stability Proven RBM surface on the entire length of the implant Available in straight or 20° angled O-Ball implant options; 2.0, 2.4, or 2.9mm diameters; and 2 or 4mm cuff heights Patented pivoting technology for resiliency and 30° angle correction

Change your point of view on O-Ball implants with SATURNO, please visit www.zestanchors.com/sndi/10 or call 800.262.2310 for more information today!

©2015 ZEST Anchors LLC. All rights reserved. ZEST is a registered trademark and SATURNO is a trademark of ZEST IP Holdings, LLC.

Know your market!

August/September 2015 - Volume 8 Number 4 EDITORIAL ADVISORS Steve Barter BDS, MSurgDent RCS Anthony Bendkowski BDS, LDS RCS, MFGDP, DipDSed, DPDS, MsurgDent Philip Bennett BDS, LDS RCS, FICOI Stephen Byfield BDS, MFGDP, FICD Sanjay Chopra BDS Andrew Dawood BDS, MSc, MRD RCS Professor Nikolaos Donos DDS, MS, PhD Abid Faqir BDS, MFDS RCS, MSc (MedSci) Koray Feran BDS, MSC, LDS RCS, FDS RCS Philip Freiburger BDS, MFGDP (UK) Jeffrey Ganeles, DMD, FACD Mark Hamburger BDS, BChD Mark Haswell BDS, MSc Gareth Jenkins BDS, FDS RCS, MScD Stephen Jones BDS, MSc, MGDS RCS, MRD RCS Gregori M. Kurtzman, DDS Jonathan Lack DDS, CertPerio, FCDS Samuel Lee, DDS David Little DDS Andrew Moore BDS, Dip Imp Dent RCS Ara Nazarian DDS Ken Nicholson BDS, MSc Michael R. Norton BDS, FDS RCS(ed) Rob Oretti BDS, MGDS RCS Christopher Orr BDS, BSc Fazeela Khan-Osborne BDS, LDS RCS, BSc, MSc Jay B. Reznick DMD, MD Nigel Saynor BDS Malcolm Schaller BDS Ashok Sethi BDS, DGDP, MGDS RCS, DUI Harry Shiers BDS, MSc, MGDS, MFDS Harris Sidelsky BDS, LDS RCS, MSc Paul Tipton BDS, MSc, DGDP(UK) Clive Waterman BDS, MDc, DGDP (UK) Peter Young BDS, PhD Brian T. Young DDS, MS CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day BDS, VT Julian English BA (Hons), editorial director FMC Dr. Paul Langmaid CBE, BDS, ex chief dental officer to the Government for Wales Dr. Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-in-chief Private Dentistry Dr. Chris Potts BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin Dr. Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral implant surgeon

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Volume 8 Number 4

The baby-boom shift is occurring, and it is making a huge impact.

Scientific research has shown that the number of edentulous patients is disproportionately higher in patients above the age of 65,1 and many patients above 65 are highly motivated to improve their health and quality of life.

Implant overdentures are a proven treatment to improve quality of life for edentulous patients, and clinical evidence has shown that even when cost was a factor, patients still would resoundingly recommend the treatment again.2 It is simple to see the writing on the wall for your clinical practice; implant overdentures are a way to increase revenue and improve patient’s lives!

Michael Scherer, DMD, MS, FACP

Does your market know about you?

Ask yourself, “When is the last time I bought something on Amazon or went to a new restaurant without looking at an online review?” Google, Yahoo, Facebook, Yelp, Angie’s List, and Healthgrades® — just to name a few — are online sites for reviews, but there are many others.

Do you capitalize on them by having 5-star and glowing reviews? If the answer is anything other than YES!, you should be revising your marketing efforts; and considering online reviews cost very little in comparison to other marketing dollars, it’s important to consider this marketing strategy.

The baby-boom generation has substantial buying power and frequently tells others about both in-person and online experiences. They are avid word-of-mouth advertisers and are willing to tell the world about how you’ve improved their lives! Start smart, and solicit your best patients, your raving fans, for positive 5-star reviews on Google and Yelp.

Make sure you have a compelling website full of patient testimonials to back up your growing reputation. Most importantly, offer excellent service and treatment that is compelling to the baby-boomer population.

Narrow diameter overdenture implants: my secret to revenue growth I used to turn away patients on a regular basis, but I didn’t know I was doing it. I thought I was offering them what they wanted. You know what I mean — “the best.” Then I recognized that “the best” wasn’t always a fixed bridge or eight implants and porcelain. I realized that I had options that nobody else could offer, and I keep those treatment options at a fee that many people could afford.

I love doing full arch implant dentistry — from implant overdentures to All-on-4 to 6-8 implants and screw-retained metal ceramic restorations. What I found was that I used to turn away patients who either couldn’t come up with $25,000-$50,000 for dental treatment or those who had adequate financial resources but didn’t want to go through extensive bone augmentation procedures. While we are implantologists and a group of clinicians who enjoy complex surgical procedures, many of our patients want a solution that is simple, less invasive, and can be performed immediately.

Narrow diameter implants, such as the ZEST Anchors’ LOCATOR® Overdenture Implant (LODI) and the SATURNO® Narrow Diameter Implant System (SNDI) are long-term, permanent implant options that I provide for my patients who want a solution that’s simple and just plain works. I have been using narrow diameter implants from Zest for over 2 years with an implant success rate of close to 98%. I have found tremendous growth of implant overdenture therapy in my practice; in fact, it has resulted in a year-over-year increase in revenue of over 30%!

Because of the fantastic results with narrow diameter implants, my patients tell others about what great treatment we provide, both in-person and online. As a result, I give narrow diameter implants a 5-star review!

REFERENCES 1.

Polzer I, Schimmel M, Müller F, Biffar R. Edentulism as part of the general health problems of elderly adults. Int Dent J. 2010;60(3):143-55.

2.

Awad MA, Rashid F, Feine JS. The effect of mandibular 2-implant overdentures on oral health-related quality of life: an international multicentre study. Clin Oral Implants Res. 2014;25(1):46-51.

Michael Scherer, DMD, MS, FACP, is a full-time private practice prosthodontist in Sonora, California. He is currently an Assistant Clinical Professor at Loma Linda University, a former Assistant Professor in Residence at University of Nevada – Las Vegas, and a fellow of the American College of Prosthodontists. He has published articles related to clinical prosthodontics, implant dentistry, and digital technology with a special emphasis on implant overdentures. As an avid technology and computer hobbyist, Dr. Scherer’s involvement in digital implant dentistry has led him to develop and utilize new technology with CAD/CAM surgical systems, implement student-facilitated CBCT implant planning, and outside-of-the-box radiographic imaging concepts. Dr. Scherer has served as the director of the implant dentistry curriculum at UNLV and is actively engaged in guided surgical placement and prosthetic restoration of implants in private practice. Dr. Scherer also maintains LearnLODI, LearnLOCATOR, and LearnSATURNO — interactive YouTube channels on standard and narrow diameter dental implant procedures.

Implant practice 1

INTRODUCTION

Maximizing practice revenue

TABLE OF CONTENTS

Case study Guided surgical immediate implant placement with immediate load and CAD/CAM temporary provisionalization Dr. Bart W. Silverman discusses how technology can result in more predictable treatment outcomes .......................................................15

Practice profile Scott D. Ganz, DMD

6

From edentulous space to walking out with a tooth: a 40-minute experience Dr. Charles D. Schlesinger discusses the benefits of immediate-loading implants........................................... 20

Through the lens of life

Case pictorial Dental rehabilitation after excision of an ossifying fibroma

Corporate profile

12

Dr. Parit Ladani presents a case where implants were used in the reconstruction of a young patient’s mandible........................................ 24

DENTSPLY Implants: Remaining at the forefront of implant dentistry

2 Implant practice

Volume 8 Number 4

Patients rely on you in order to eat, speak, and smile with confidence. It can be said, you are actually restoring quality of life.

To succeed, you need technology that is well founded and documented in science. That is why we only deliver premium solutions for all phases of implant therapy, which have been extensively tested and clinically proven to provide lifelong function and esthetics.

Moreover, with an open-minded approach, we partner with our customers and offer services that go beyond products, such as educational opportunities and practice development programs.

Reliable solutions and partnership for restoring quality of life—because it matters.

www.dentsplyimplants.com

These products may not be regulatory cleared/released/licensed in all markets. 32670004-US-1402 Š 2014 DENTSPLY. All rights reserved.

Restoring quality of life

TABLE OF CONTENTS Seeing the light SuperPulse 10.6 µm CO2 laserassisted, closed flap treatment of peri-implantitis Drs. Eric Linden and Peter Vitruk explore the peri-implantitis ablative laser treatment protocol................. 30

Continuing education Immediate esthetic rehabilitation with one-piece implants

Continuing education

36

The effect of osteoporosis on dental treatments

Dr. Elena Calciolari looks at the ramifications of osteoporosis on patients undertaking dental treatments

Drs. Shahram Nik and Kaveh Golab discuss the minimal postoperative discomfort when providing a patient with a fixed prosthesis immediately after implant placement ............... 40

Implant insight Optimizing health in integrative dentistry: whole-body approach Dr. Saynur Vardar explores how the connection between the body and mouth can affect the implant practice

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

Technology Restoring implant supported maxillary single central incisors using Nobel Biocare® Angulated Screw Channel (ASC) abutments and ASC Straight Abutments

Practice management Industry news Guide to Going Paperless Going paperless means replacing paper records and paper forms with digital records and electronic communication. Going paperless is about reducing office costs and clutter and improving efficiency.................48

On the horizon Technology leads to better results

Dr. Richard Elliott illustrates a screw-

Dr. Justin Moody offers his experience with equipment and materials that make bone grafting more predictable

retained esthetic restoration.......... 46

.................................................52

4 Implant practice

...................................................... 54

Product profile The Hahn™ Tapered Implant: 45 years in the making An inside look at the history of an innovative implant that makes treatment simpler and more predictable................................. 56

Volume 8 Number 4

See the TSI in action on page 20!

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The TSI’s patented implant body with its 2mm Embedded Tapered Platform™, Bull Nose Auger™ tip, Mini Cortic-O™ threads and SLA surface provides the perfect support for all your restorative needs, whether they be a single restoration or a full mouth reconstruction.

Dental Implant with Provisional Restoration in 40 Minutes!

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PRACTICE PROFILE

Scott D. Ganz, DMD Through the lens of life What can you tell us about your background?

In my undergraduate college years, my first official major was in Art, which was necessary to get into the studio art courses so I could gain actual hands-on experience.

I was also an avid photographer, with my own darkroom (remember the days of film?).

I never really thought that I could make a career from art or photography, and knew that I did not want to be in a medical profession dealing with life and death issues. At that point in time, I had not considered dentistry as a career path. While trying to decide a path for the future, my uncle, Dr. Mel Ganz, who practiced in Long Island, New York, invited me to visit his dental practice to see what it was like. I then realized how much “art” was involved with dentistry as a creative process, and I made the decision to pursue becoming a dentist. I attended undergraduate dental school at what is now Rutgers School of Dental Medicine, and then completed a 3-year specialty program in Maxillofacial Prosthetics at M.D. Anderson Cancer Institute and at the Dental School in Houston, Texas. I soon realized that I could combine my interests in art, photography, writing, and eventually educating others within this exciting field. Add to that my early interest in computers, graphical software applications, and video editing; you have the foundation for my career.

Is your practice limited to implants?

As a Prosthodontist specialist, my practice encompasses all aspects of oral reconstruction. Therefore, we offer all related services, including but not limited to crowns, bridges, removable partial dentures, complete partial dentures, porcelain laminate veneers, composite restorations, from single tooth to full-mouth reconstruction. That stated, my practice has been mostly implantspecific for a large majority of my patients who are missing, or will be missing teeth.

Why did you decide to focus on implantology?

I was very fortunate to be exposed to dental implants early in my postgraduate training, when Brånemark’s work was introduced in the early 1980s. I was surrounded 6 Implant practice

With my colleagues, Dr. Ernesto Moran and Dr. Carlos Rubio: Our live surgery courses held in Los Algodones, Mexico, help educate clinicians, while providing needed dental work for local patients. More information can be found at www.hands onsurgery.org

by forward-thinking clinicians at the University of Texas Health Science System in Houston and San Antonio, when Brånemark first introduced his root-form implant system to the United States. I was initially intrigued and then totally convinced that dental implants would become the future of restorative dentistry. I followed that path, learning as much as I could, early on, and then decided to focus my efforts on dental implants to improve the quality of life for patients under my care. When I completed my residency in Houston, I moved back to the New York area to work with a well-known Prosthodontist.

Unfortunately, he was not in favor of dental implants, as were many specialists of that era. I then had a dream opportunity to work with one of the true dental implant pioneers, Dr. Leonard Linkow. During my 3-year term with Dr. Linkow in the mid-1980s, I was exposed to every aspect of implantology, including blade and subperiosteal implants.

It was at Dr. Linkow’s office that I first learned about 3D imaging and CT scan technology, used at that time for the diagnosis, design, and fabrication of subperiosteal implants.

3D diagnostic imaging technologies (CT and CBCT), and interactive treatment planning software became one of the cornerstones of my practice as noted in dozens of

It has also been a great thrill to present and moderate at the annual Imagina Dental CAD/CAM 3D Imaging Conference held in Monaco each year

publications and a main focus for most of my presentations worldwide.

How long have you been practicing, and what systems do you use?

I have been placing and restoring dental implants since 1982. During that time, I have Volume 8 Number 4

Long working time for you.

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Short setting time for them.

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PRACTICE PROFILE accumulated over 20 systems in my office so that I could become knowledgeable in the variations of implant design, surgical protocols, and restorative components. It’s important to me to understand what works well in different clinical situations. It wasn’t long after I started placing and restoring root-form implants, that potential restorative limitations were found with the original 0.7-mm high external hex, and therefore, I moved to an internal connection in 1986. I have continued to use internal connection implants from various implant manufacturers ever since. I have used systems ranging from the original Brånemark, to Core-Vent®, LifeCore®, Zimmer (in the various company names and incarnations), Dentsply, Astra, Straumann®, BioHorizons®, and many others.

Thanks to my wonderful office staff! Lillian, Mary Lou, Stephanie, and Michelle — I couldn’t do it without them

It was 2 years ago that I was able to introduce the inaugural issue of our new Cone Beam International Magazine of Cone Beam Dentistry at the Grimaldi Forum in Monaco

Who has inspired you?

Within our industry, I have been inspired by so many individuals that it would be hard to name them without leaving someone important off of the list. I have been inspired by people who pursued their passion, who put pen to paper to express What a great moment meeting Prince Albert II, whose foundation through their ideas, who documented their the Principality of Monaco helps sponsor this meeting, making Monaco clinical expertise, who educated one of the centers for digital dentistry and innovation in Europe others without ego, did meaningful research, treated patients with yet direct manner. The full-color illustrarespect, maintained high ethical standards, tions have had a direct influence on case and who were generous with their time for acceptance for dental implant applications in those who were curious. many countries around the world, and is still What is the most satisfying aspect in demand today. The book was conceived and created entirely on the computer, of your practice? never on paper. This was quite an accomBeing able to communicate effectively to plishment in 1992-1993 when computing our patients on how their quality of life can power was not even as good as our smart be changed, and then having the opportuphones today. Now 22 years later, I cannot nity of being able to deliver on that vision. be more proud of my recent collaboration When patients leave with their new smile, it with Drs. Marco Rinaldi and Angelo Mottola is extremely satisfying for my staff, and me. co-authors of our recently released textbook, Professionally, what are you most Computer-Guided Applications for Dental Implants, Bone Grafting, and Reconstrucproud of? tive Surgery published by Elsevier. Finally, I I have been very fortunate to have been was honored to have been asked to become involved with the advent of 3D imaging Editor-in-Chief of Cone Beam International (CT/CBCT), interactive treatment planning Magazine of Cone Beam Dentistry, a publisoftware, CAD/CAM technology, and the cation by Dental Tribune International, now ever-evolving world of “digital dentistry.” in its second year, reaching thousands of It has been a great experience having interested clinicians worldwide. helped introduce many concepts and digitally related products like SimPlant®, What has been your biggest and Atlantis™ patient-specific CAD/CAM challenge? abutments to our industry. However, I am Trying to find solutions for every patient perhaps most proud that my first book, An who presents for treatment. Certain patients Illustrated Guide to Understanding Dental present more of a challenge than others, but Implants, has served to educate patients, they all have individual issues based on their staff, and dentists since 1993, in a simple, 8 Implant practice

All surgical procedures are done under supervision in our state-of-the-art facility with HD video capturing each procedure. Clinicians also have the opportunity to utilize instrumentation like the innovative shadowless headlamp worn by the clinician doing the surgery (3D DEX, Langhorne, Pennsylvania) or the Osstell IDx device (not shown) by Osstell USA.

individual anatomy, lifestyle, dental/medical history, and their desires. Finding the right solution for each patient remains a day-today challenge.

What would you have become if you had not become a dentist?

I can only dream about that question ...

If I could have been good enough, I would have liked to become a professional golfer, a professional wildlife photographer, software developer, or perhaps a graphic artist.

What is the future of implants and dentistry?

While it is easy to say that our future is “digital,” it has been a long time coming. I started with CT scan imaging modalities for the diagnosis and treatment planning of dental implants in 1985. When I was first invited to present on the national podium in the early Volume 8 Number 4

Soft from the syringe.

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Instructions for Use (IFU), including indications, contraindications, precautions and potential adverse effects, are available at GUIDOR.com/IFU/. © 2015 Sunstar Americas, Inc. All rights reserved. GDR15041 07012015v1 GUIDOR is a registered trademark of Sunstar Suisse, SA. easy-graft is a registered trademark of Degradable Solutions AG.

PRACTICE PROFILE 1990s at the Academy of Osseointegration and other professional organizational meetings, I was naive enough to think that in 3 to 5 years, every case would be planned with 3D technology and interactive treatment planning software. When we started to develop CAD/CAM technology for milling of titanium bars, patient-specific abutments, or zirconia crowns, it seemed to me that our industry would move quickly to adapt to advances in materials and manufacturing processes. Cone Beam CT, intraoral optical scanners, in-office milling machines, guided-surgery applications for the placement of implants — all of these technologies have evolved for general use much slower than I originally thought.

Our industry may be slow to adapt to change for many reasons, especially within the educational system. However, we are moving forward. I am thankful that dental implants have finally become such an important part of everyday dentistry. We do need more education at both the undergraduate and postgraduate levels because today, dental implants ARE conventional dentistry. But, I do believe that the future is the refinement of the digital workflow for all aspects of dentistry, and specifically dental implants. With advanced diagnostic imaging from CBCT devices, we can take the guesswork out of the equation for most situations and determine in advance if we can place an implant, need bone grafting, or have the ability to deliver a transitional prosthesis the day of placement with the appropriate restorative components. But 3D imaging alone cannot confirm implant stability. This can only be determined at the time of implant placement. One new digital device, the Osstell IDx (Osstell USA) can reduce subjective measurements of implant stability for most available implant systems,

providing meaningful data for clinicians at the time of surgery, and after healing. ISQ values or “implant stability quotients” are obtained through the use of Resonance Frequency Analysis, which allows a more precise and objective measurement of the osseointegration process. I feel much more confident having a baseline ISQ number, which helps me decide when to load an implant.

The next best thing? Watch out for significant developments related to 3D printing!

What advice would you give to budding implantologists?

Follow your passion. Always keep learning. Use 3D imaging to assess patient anatomy even in cases that you think may be simple — it’s always better than guessing, and you might be surprised with what you find. Today there are endless opportunities to learn more about dental implants, avoiding complications, surgical and restorative techniques, bone grafting, etc. Find out which procedures you enjoy most. Try to combine your hobbies such as photography, video editing, or computer

Top 10 favorites 1.

2.

3.

4.

5.

6.

imaging to improve documentation of your cases. It’s amazing what you learn from the photos you take of your own work!

Join implant organizations, and get involved. You might make a new friend, and meet colleagues from all over the world.

There are three major implant organizations: the Academy of Osseointegration (AO), the American Academy of Implant Dentistry (AAID), and the International Congress of Oral Implantologists (ICOI). These organizations all offer many opportunities for on-site learning at their annual meetings, online webinars, videos, and satellite meetings. Join a committee, and get involved!

Having fun with my granddaughter Barbecuing on my backyard grill Great sushi Hawaii Golf Implants with high ISQ values (above 75) for immediate restorations 7. Cone Beam CT and interactive treatmentplanning software 8. Everything Apple®: Apple® computers, iPhone®, Apple Watch™, etc.

9. Watching our four dogs playing together 10. Watching our three daughters grow up

I have had the great opportunity to combine great skiing with exceptional learning, meeting colleagues from around the world at the Meisinger High Altitude Comprehensive Implant Symposium (far left). Thanks to Alex Miller (second from right), President of Meisinger USA, who has sponsored this educational event for the past 5 years. Next year a great lineup of speakers back in Vail, Colorado!

10 Implant practice

Education is universal, and the demand is high for many types of surgical procedures including implants and bone grafting. This past June, I co-directed a live hands-on sinus augmentation surgery course with the doctors of the CIAEO group and Dr. Patricia Uribe in Bogota, Colombia

Our four dogs — keep us all busy and happy!

What are your hobbies, and what do you do in your spare time?

I am having a great time being a grandfather and spending quality time with my family. I am an avid golfer, although it takes up a lot of time, which means I don’t get to play often, but wish I did. I continue to pursue photography, and enjoy incorporating my photographic and video skills in creating clinical presentations, but really enjoy photographing bald eagles in the wild. Photography allows me to be creative outside of the office. I am very thankful that I have had the wonderful opportunity to meet and learn from colleagues through my travels to different regions of the world bringing a unique perspective and appreciation to my life through the many truly meaningful friendships that have developed over the years.

Social Media has enabled us all to keep in touch on a regular basis, no matter where we are. IP Volume 8 Number 4

CORPORATE PROFILE

DENTSPLY Implants: Remaining at the forefront of implant dentistry

A

t DENTSPLY Implants, our vision of a world where everyone eats, speaks, and smiles with confidence permeates and inspires everything we do. We are committed to an open-minded, passionate, and genuine approach to the products and services we provide and the way we do business. We are dedicated to providing clinically proven products of the highest quality and backed by extensive documentation. By integrating biology and biomechanics, our products and services are designed to support functional and esthetic solutions that last a lifetime. We believe these aspects and considerations matter for the peace of mind of our customers and for the satisfaction of the patients whom they serve.

DENTSPLY Implants: what’s in a name?

Headquarter office for DENTSPLY Implants North America in Waltham, Massachusetts houses both corporate functions and state-of-the art manufacturing for ATLANTIS patientspecific solutions

For many, the name optimal and longterm, individualized “DENTSPLY” resonates and results. While many is associated with all different companies make a aspects of dental supplies similar claim, what and solutions across the lifecycle of a tooth. Founded makes DENTSPY in 1899, DENTSPLY InternaImplants truly unique tional Inc. is a leading manuis the comprehenfacturer and distributor of sive breadth of each dental and other consumable product line within medical device products. For every category of Scott Root, President of DENTSPLY Implants over 115 years, DENTSPLY’s treatment phase North America from computercommitment to innovation and professional collaboration has enhanced guided implant treatment (SIMPLANT®), its portfolio of branded consumables and to hard bone and membrane regeneration small equipment. Headquartered in the United (SYMBIOS™); from three choices of implant States, the Company has global operations systems, each with its own distinguishing with sales in more than 120 countries. features and benefits (ANKYLOS®, ASTRA However, for just as many, the story TECH Implant System™, and XiVE®), to patient-specific restorative solutions for behind DENTSPLY Implants may still remain one to be discovered. While the name cement-, screw- and attachment-retained “DENTSPLY Implants,” was first introduced implant-supported prostheses that go to the market beginning only 3 years ago in beyond CAD/CAM (ATLANTIS™). These late 2012, DENTSPLY Implants is a culminasolutions are further supplemented by over tion of over 40 years of expertise, knowledge, 500 educational opportunities annually in and experience in all relevant fields and techNorth America and practice-marketing tools. nologies of implant dentistry.

Scott Root, President of DENTSPLY Implants North America, says, “By providing Comprehensive solutions solutions for all aspects of dental implant therapy needs, we are able to offer oneToday, DENTSPLY Implants is a leading stop convenience for our customers. In provider of premium solutions throughout all phases of implant therapy that allow for addition, continued product developments 12 Implant practice

are designed to connect all the solutions together so that dental laboratories, clinicians, and their patients can further benefit from improved efficiency in treatment process, experience enhanced communication and coordination with the confidence of successful, long-term outcomes.”

A tradition of innovation DENTSPLY Implants began as the union of two successful and innovative dental implant businesses, DENTSPLY Friadent and Astra Tech Dental. Collaborating with universities, dental professionals, researchers and industry leaders all over the world, the Company has always been at the forefront of market trends and customer needs while maintaining the highest level of quality product and solutions.

DENTSPLY Implants’ legacy in implantology dates back to 1974 with FRIALIT®-1 — the first root-analog dental implant developed by DENTSPLY Friadent (former Friedrichsfeld AG) and professor Dr. Willi Schulte from Tübingen University, Germany — with the first immediate implant placement protocol that revolutionized implant dentistry.

More advanced treatment protocols such as immediate-loading procedures followed.

Astra Tech Dental began development of the Astra Tech Implant System™ in the early 1980s, and the evolution continued Volume 8 Number 4

Volume 8 Number 4

guided surgery for ASTRA TECH Implant System EV, SIMPLANT has continuously proven to be the market-leading solution for digital dentistry and guided surgery.

Today, over 1,200 DENTSPLY Implants employees worldwide represent market companies in 26 countries, and additional presence through distribution channels in over 40 countries for a total access to 95% of the global implant market.

Some things never change: a commitment to science and documentation Changes both big and small have continued to shape and define DENTSPLY Implants’ offering. Yet a firm dedication to research, documentation, and clinically proven products has remained unchanged.

Since clinical efficacy and quality is a core focus of DENTSPLY International, it is understandable this value can be found in all its business units. The combination of decades of experience in the area of science

and research through the companies that have been brought together to form one DENTSPLY Implants allows the Company to deliver the highest level products across all areas of digital planning, regeneration, and surgical and restorative implant therapy.

Most DENTSPLY Implant products are put through several years of development and verification before they are even introduced to the market. Documented research is essential in the development of products and solutions. Their research and development focuses on all aspects of implant treatment, including more demanding, compromised cases, and treatment procedure simplification and extensive pre-clinical and clinical studies. In fact, a comprehensive study program includes over 1,550 published scientific references.

The Company proudly stands behind its products by providing one of the most comprehensive warranty programs within each product category for added peace of mind.

DENTSPLY Implants North America welcomes over 500 visiting dental professionals each year to its office for tours of the ATLANTIS manufacturing facility and on-site lectures and hands-on programs covering various aspects of implant therapy

Implant practice 13

CORPORATE PROFILE

with innovations such as Conical Seal Design™, Connective Contour™, TioBlast™ surface, and MicroThread™. In 2004, OsseoSpeed™, the first chemically modified implant surface, was launched. The unique combination of these key features is referred to as the ASTRA TECH Implant System BioManagement Complex™, well documented for its long-term marginal bone maintenance and esthetic results. In 2011, OsseoSpeed TX Profile launched as a unique, patented implant that is anatomically designed for sloped ridges.

ANKYLOS was developed by DENTSPLY Friadent in 1986, with a unique combination of tissue-stabilizing features called the ANKYLOS TissueCare Concept. The progressive thread design allows for excellent primary stability, while the subcrestal implant placement protocol helps provide an optimal emergence profile and supports bone on the implant shoulder for long-lasting esthetics.

The launch of XiVE in 2001 was based on a foundation of more than 25 years of experience in implant dentistry. Prosthetically, XiVE is fully compatible with FRIALIT, offering a well-structured line of color-coded abutments that already set the standard in the 1990s.

In 2007, Astra Tech Dental acquired Atlantis Components, an innovative dental CAD/CAM company providing patientspecific abutments. With the patented ATLANTIS VAD™ (Virtual Abutment Design) software, abutments are uniquely designed from the final tooth shape for a more natural esthetic result and optimal mechanical properties.

As a result of the union of Astra Tech Dental and DENTSPLY Friadent, the three implant systems, ATLANTIS patient-specific abutments and SYMBIOS regenerative solutions were brought together within the product portfolio.

In late 2013, Materialise Dental, another company owned by DENTSPLY International, was merged into DENTSPLY Implants in order to fully integrate all solutions supporting implant therapy under one roof. With that came the SIMPLANT digital treatment planning solution for guided surgery, developed

by Columbia Scientific Inc., a U.S.-based company that specialized in the design and development of dental application software using CT data and Materialise, a global leader in rapid prototyping technology utilizing CAD and other 3D file formats. With the launch of innovative products, such as Immediate Smile™ featuring ATLANTIS Abutment and

CORPORATE PROFILE Market-leading developments In today’s world, technology enhances the ability to provide a personalized approach to patient care and helps support communication and collaboration among treatment team members, which is a critical aspect of dental implant therapy. Leveraging technology helps in visualizing the clinical situation and treatment planning. Products designed specifically to accommodate a patient’s particular anatomical and clinical situation are also able to provide improved function and esthetics over time.

“There is an old phrase I learned early in my career that says, ‘Change does not necessarily equate with progress, but without change there can be no progress,’” states Matt Gassel, Director of Marketing, DENTSPLY Implants North America. “Innovation is the key to driving implant dentistry forward and helping more patients benefit from the therapy. The market demands constant improvements in order to meet their practice, business, and patient needs.

At DENTSPLY Implants, we continually strive to make our solutions and the customer experience the best possible. Many of our innovations come from just listening to our customers.”

DENTSPLY Implants’ innovations are designed to support the varying demands from simple to challenging cases, as well as alternative protocols for increased patient comfort, reduced treatment time, and simplified procedures, as illustrated through the recent introduction of OsseoSpeed Profile EV and the ATLANTIS Conus concept.

OsseoSpeed Profile EV is specially designed for efficient use of existing bone in sloped ridge situations. The sloped design of the implant neck allows for implant placement level with the bone in the existing anatomy, which may be in a lingual-to-buccal or even mesial-to-distal slope, preserving marginal bone and supporting soft tissue 360° around the implant. In addition, the implant design can help to reduce the need for bone augmentation.

OsseoSpeed Profile EV is an integral part of the new ASTRA TECH Implant System™ EV and is supported by the unique ASTRA TECH Implant System BioManagement Complex™, well documented for its long-term marginal bone maintenance and esthetic results.

Available for all major implant systems, ATLANTIS Conus concept is a patientspecific overdenture solution that provides a friction-fit, non-resilient prosthetic restoration 14 Implant practice

ATLANTIS Conus concept — a removable prosthesis with the comfort of a fixed restoration

DENTSPLY Implants’ firm dedication to research, documentation, and clinically proven products has remained unchanged.

for fully edentulous patients. The solution consists of a uniquely designed, conicalshaped abutment with corresponding caps that incorporates an implant-borne prosthesis while being removable like an overdenture.

Your implant patients look to you to deliver the best possible treatment outcomes Do you want a company with a strong history of experience, expertise, and documented success? Would you enjoy the convenience of a one-stop-shop for comprehensive solutions for all your implant needs?

Are products and services of the highest quality important to your practice success and your patients’ satisfaction?

Tens of thousands of dental professionals from around the world rely on DENTSPLY Implants for implant-supported solutions from root to crown that are as individual as their patients. In addition to products of the

OsseoSpeed Profile EV for sloped ridge situations

highest quality, they also provide access to the support and tools you need for developing your business further.

At DENTSPLY Implants, they believe that simplicity you can trust, uncompromised quality, and service beyond products matter for restoring happiness to their customers and the implant patients they treat. If you agree, visit www.dentsplyimplants.com, call your local DENTSPLY Implants representative, or the Customer Service department at 800-531-3481 to learn more. IP This information was supplied by Janie Shen, Director, Corporate Communications, DENTSPLY Implants.

Volume 8 Number 4

Dr. Bart W. Silverman discusses how technology can result in more predictable treatment outcomes

D

igital technology continues to revolutionize implant dentistry, benefiting every phase of the workflow. Integrating 3D digital technologies for comprehensive dentistry has advantages for both the treating dentist as well as our patients. The availability of cone beam computed tomography (CBCT) in the dental practice has made visualization of a patient’s anatomy prior to implant placement an invaluable tool when it comes to implant dentistry. Guided surgical implant placement has allowed precise placement of implant restorations1 — we now start with a final predicted prosthetic result and work backwards, planning our cases with the end result in mind. With the use of a computer-manufactured resin guides, we now place our implants where they should be placed in order to restore our patients’ dentitions to a more predictable occlusion.

Intraoral digital scanning allows the treating dentist to digitally capture a patient’s occlusion and transfer that to a prosthetic center, where a temporary or final restoration can be computer milled. These computeraided design/computer-aided manufactured, or CAD/CAM, restorations are then delivered to the patient with more exactness

than before, thereby cutting down chair time and increasing profit margins. By combining these technologies, we have more predictable restorative outcomes that are clinically efficient for the doctors and take less time to final restoration for our patients.

Case overview A 30-year-old male presented to the office following an altercation a few days prior when he reportedly was hit in the face with a barstool (Figure 1). The patient had a medical history, which was significant for stomach ulcers, and he was on dexilant medication with no known drug allergies. His oral and maxillofacial examination was significant for a horizontally fractured maxillary left lateral incisor. Our treatment plan included several options: • endodontic therapy with possible extrusion, crown lengthening, post and core and crown; • extraction, bone graft, delayed implant placement with possible soft tissue graft; or • extraction, bone graft with immediate implant placement and load, with a temporary crown.

One concern was provisionalization. If we chose to extract the tooth and place a bone graft with an immediate implant, we could place an immediate restoration, if insertional torque values warranted. If torque values were not sufficient for an immediate crown, then we could consider a Valplast®, an Essix appliance, or a bonded temporary bridge. If we chose to extract the maxillary left lateral tooth and bone graft for a delayed implant, a bonded or removable temporary prosthesis could serve as a provisional restoration. And finally, if we elected to do a fixed bridge without an implant, a temporary fixed bridge could be fabricated on the day of the extraction. We needed to consider the patient’s age, nature of injury, possible compliance with temporary restorations, and the preservation of hard and soft tissue architecture when deciding on our ultimate treatment plan.

There have been documented studies demonstrating that — when placing immediate implants into extraction sites — alveolar width and height can be preserved while reducing tissue loss and the need for subsequent soft tissue surgeries.2 After consultation with the patient and restorative

Bart W. Silverman, DMD, is in private practice limited to Oral and Maxillofacial Surgery in New City, New York and is an attending Physician at Westchester County Medical Center, Department of Oral and Maxillofacial Surgery, and Nyack Hospital, Department of Dentistry. He is also a Clinical Associate Professor at New York Medical College. He lectures nationally on several different implant systems and is president of the Bi-State and Hudson River Implant Study Clubs. He is a past president of the Rockland County Dental Society and previously served on the Board of Governors of the Ninth District Dental Society.

Dr. Silverman graduated from Fairleigh Dickinson University in 1982 summa cum laude and received his doctorate in Dental Medicine in 1986 from Fairleigh Dickinson Jr. School of Dentistry, where he was a member of the Omicron Kappa Upsilon Honor Society. He completed his Oral and Maxillofacial Surgical residency at Westchester County Medical Center in 1989 and was Chief Resident during his final year. Dr. Silverman is currently a Diplomate of the American Board of Oral and Maxillofacial Surgery.

Figure 1 Volume 8 Number 4

Implant practice 15

CASE STUDY

Guided surgical immediate implant placement with immediate load and CAD/CAM temporary provisionalization

CASE STUDY dentist, we decided on immediate implant placement and temporary provisionalization, as this would allow for the best longterm prosthetic result.1 A guided surgical flapless approach would allow the implant to be placed where it ideally needed to be placed in order to create optimum prosthetics.2,3,4,5 Since we preoperatively knew where the implant would be placed, we fabricated a temporary abutment and temporary crown. They could be inserted at the time of implant placement and help maintain soft tissue contour and preserve the bony anatomy.1 A fixed temporary placed at the time of immediate implant placement would obviate the need for a removable prosthesis as well as reduce the overall time for case completion.

sent to ROE Dental Labs in Garfield Heights, Ohio, where 3Shape’s Implant Studio™ software was used to plan a surgical guide, and their Dental Design system was used to fabricate the temporary abutment and crown. The temporary abutment was milled

in PEEK acrylic material, and the temporary crown was milled out of A2 Shaded PMMA (Figures 5-10).

The patient was taken to the surgical operatory where blood pressure and pulse oximeter were placed, and an intravenous

Treatment plan A preoperative cone beam scan with the CS 9300 system (Carestream Dental) was performed (Figure 2) as well as an intraoral digital impression using the CS 3500 intraoral scanner (Figures 3 and 4). Both files were

Figure 2

Figure 3

Figure 4

Figure 5

Figure 6

Figure 7

Figure 8

Figure 9

Figure 10

16 Implant practice

Volume 8 Number 4

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CASE STUDY

Figure 11

Figure 12

Figure 13

Figure 15

Figure 16: Three days’ post-op

Figure 14

line was started. Anesthesia was maintained using a balanced technique. Local anesthesia was infiltrated to place with articaine 4% with epinephrine 1:100,000.

The fractured maxillary left lateral incisor was atraumatically removed using appropriate elevators and forceps without raising a flap (Figure 11), and the surgical guide was placed and confirmed to be seated well in proper position (Figure 12). Using the BioHorizonsÂŽ guided surgical kit and protocol, a 3.8 mm x 15 mm tapered internal implant was placed (Figures 13-14).

Initial stability was confirmed and mineralized cortical bone placed in the buccal gap. An Osstell reading of 68 was obtained, and according to our loading protocol, the temporary custom-milled PEEK abutment was placed. The temporary crown was adjusted and cemented with a light rim of temporary cement (Figures 15-17).

Discussion Planning the case with the end result in mind and working backwards and following the steps necessary to achieve 18 Implant practice

Figure 17

this help provide an optimum result for our patients. Guided surgical placement of the implant allows for optimum positioning.

Additionally, digital technology allows for the pre-op planning of a custom temporary abutment and crown, which can be placed at the surgical procedure. This immediate provisionalization allows for preservation of osseous and gingival tissues, as well as the guided tissue growth during the healing phase. Placing the implant immediately with same-day restoration decreases the number of surgical procedures and recovery time for our patients, while same-day temporization promotes ideal esthetics. IP

REFERENCES 1. Lazzara RJ. Immediate implant placement into extraction sites: surgical and restorative advantages. Int J Periodontics Restorative Dent. 1989;9(5);333-343.

2. Rosenfeld AL, Mandelaris GA, Tardieu PB. Prosthetically directed implant placement using computer software to ensure precise placement and predictable prosthetic outcomes. Part 3: stereolithographic drilling guides that do not require bone exposure and the immediate delivery of teeth. Int J Periodontics Restorative Dent. 2006;26(5):493-499.

3. van Steenberghe D, Glauser R, Blombäck U, Andersson M, Schutyser F, Pettersson A, Wendelhag I. A computed tomographic scan-derived customized surgical template and fixed prostheses for flapless surgery and immediate loading of implants in fully edentulous maxillae: a prospective multicenter study. Clin Implant Dent Relat Res. 2005;7(suppl 1):S111-S120.

4.

Abboud M, Wahl G, Guirado JL, Orentlicher G. Application and success of two stereolithographic surgical guide systems for implant placement with immediate loading. Int J Oral Maxillofac Implants. 2012;27(3):634-643.

5. Sarment DP, Sukovic P, Clinthorne N. Accuracy of implant placement with a stereolithographic surgical guide. Int J Oral Maxillofac Implants. 2003;18(4):571-577.

Volume 8 Number 4

The best decisions are based on facts.

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www.instradent.us *All documented data on file at Neodent.

© Copyright 2015 All rights reserved.

CASE STUDY

From edentulous space to walking out with a tooth: a 40-minute experience Dr. Charles D. Schlesinger discusses the benefits of immediate-loading implants

W

ould your patients appreciate going from missing a tooth to having one in less than 40 minutes?

Today’s patients do not want to spend a lot of time in the dental chair and definitely do not want to spend 3-4 months to complete their implant treatment. If you are not able to provide what they are looking for, they will find a practitioner that can meet their needs.

But, if you treatment plan accordingly, evaluate each case independently, and patients meet the criteria necessary for immediate loading, this can be a reality in your practice.

In 2004, the International Team of Implantology (ITI) defined “immediate loading” as a restoration placed in occlusion with the opposing dentition within 48 hours of implant placement.1 With modern implants and a simplified surgical protocol, the ability to provide expedient and successful implant treatment can be accomplished by anyone with the skills to provide implant treatment. The key to implant success and especially important in immediate-loading treatment protocols is primary stability of the dental implant at the time of surgery.

Immediate loading of dental implants has been shown to be a viable treatment option with success rates that approach those of implants loaded after integration.2 The key to success is primary stability and OCO Biomedical’s patented implant design.

This design results in very high primary stability due its ability to be dual stabilized by the auger tip and the divergent imbedded

Charles D. Schlesinger, DDS, FICOI, completed his dental training at The Ohio State University College of Dentistry. After graduation, he completed a GPR at the VA San Diego Medical Center and then went on to become the Chief Resident at the VA Medical Center West Los Angeles. While in Los Angeles, he received extensive training in implantology, oral surgery, and complex restorative dentistry. Upon completion of his training, Dr. Schlesinger returned to San Diego where he ran a thriving dental practice for 14 years. During this time, he became an educator for various dental implant companies and has lectured across the United States, Canada, the United Kingdom, and China. In 2012, he became the Director of Education and Clinical Affairs for OCO Biomedical and, in 2013, took on the position of Chief Operating Officer.

20 Implant practice

tapered platform. The design modifies the biology around the implant due to its ability to create tension rather than compression on the bone. Kobayashi showed that this results in an environment conducive to promote accelerated osseointegration.3 The tension increases the expression of TGF-β1 and OPG that recruit osteoblasts and shuts down the activity of osteoclasts. This will prevent the normal dip in stability standard implants experience at 4-6 weeks.

Without this dip in stability and the high initial mechanical stability achieved with these implants, successful immediate loading is possible.4 The immediate application of mechanical stimulus of moderate intensity may even aid osseointegration, accelerating the response of the bone tissue in the healing phase.5

flapless approach was treatment planned for the case.

Profound anesthesia was accomplished with 4% Septocaine® (Septodont USA) by local infiltrate of the soft tissue starting at the buccal and walking the anesthetic over the crest of the ridge to the lingual. A No. 8 carbide round bur on a high-speed handpiece was used to create an access through the soft tissue and divot the crestal bone (Figure 3). A 1.8 mm pilot drill with an 8 mm depth stop was taken to length, and then

Clinical case A 38-year-old female with no significant medical history presented to our clinic with a missing lower left first molar. This tooth had been extracted approximately 2 years prior by her general dentist. A CBCT was taken (Vatech America) at the consultation appointment. A significant amount of bone volume had been maintained with a slight sloping buccal defect (Figures 1 and 2). A 5.0 x 10 tissue level implant along with a

Figure 1: Pre-op intraoral

Figure 2: Pre-op CBCT Volume 8 Number 4

CASE STUDY

Figure 3: Divot produced by No. 8 round bur

Figure 4: Paralleling pin showing intended implant position

Figure 5: 5 mm guided tissue punch

Figure 6: Countersink

Figure 7: 1.8 mm pilot drill with depth stop

Figure 8: 5.0 mm final osteotomy former

Figure 9: TSI implant fully seated

Figure 10: Final torque value

typically associated with other systems. All site preparation was accomplished with an AEU-6000 implant motor and Mont BlancÂŽ handpiece at 1200 rpm (Aseptico). The site is then rinsed with sterile saline, and the integrity of the osteotomy was checked with a small paddle curette.

A 5.0 x 10 TSI implant (OCO Biomedical) was delivered to the site with the Ultem™ Delivery Cap. Once resistance was met, the cap was removed, and the implant was then

driven to final position with a torque wrench.

Final position is indicated when the restorative platform is approximately 1 mm-1.5 mm below the intended free gingival margin (Figure 9). A final delivery torque value of 90 N/cm was achieved (Figure 10). This is well above the 35 N/cm threshold that is required for successful immediate loading.6 Therefore, the decision to place a solid crown and bridge abutment and take the final impression was decided upon. Most implant companies will

a paralleling pin was placed to assess the proposed implant position (Figure 4).

A 5 mm guided tissue punch was used to gain access to the crestal bone (Figure 5), and the resultant tissue plug removed with a No. 8 round bur. Since there was abundant keratinized soft tissue on the crest, a flapless approach was decided upon to decrease postoperative discomfort and healing time, and to facilitate immediate restoration if sufficient primary stability was achieved.

The crestal bone was instrumented with a countersink (Figure 6). The countersink is crucial to assure that the micro-threads of the implant are completely encased in bone, and that the imbedded tapered platform seats without undue pressure on the surrounding crestal bone.

Once the crest has been prepared with the countersink, a 1.8 mm pilot drill with a 10 mm depth stop is taken to full length (Figure 7). This is then followed by a 5 mm osteotomy former (4.7 mm) to complete depth (Figure 8).

A two-drill protocol allows for a rapid surgery.

This is possible due to the unique step drill design of the osteotomy former, which eliminates the usual serial progression of burs Volume 8 Number 4

Implant practice 21

CASE STUDY caution against such high insertion torque values, but with the OCO system, the high value is not from compressive forces, but rather from the implant reaching the bottom of the osteotomy, pulling bone in tension, and then condensing the bone around the auger tip.

A solid crown and bridge abutment was torqued to 30 N/cm (Figure 11), and a profiling bur was used to remove excess

tissue in preparation for the final impression (Figures 12 and 13). A tissue retraction impression pickup (TRIP) impression coping was snapped onto the implant to take the final impression. Light body VPS material was syringed (Figure 14) around and into the impression coping, and then heavy body material in a quadrant tray picked up the rest of the impression (Figure 15). A corresponding metallic implant analog

was placed into the impression, and an opposing alginate was taken along with a blue bite registration. Utilizing a Protemp™ crown (3M ESPE) over an acrylic coping, a temporary was fabricated. The temporary was cemented with IRM temporary cement in full occlusion (Figure 16).

Ten days later, the patient returned to the clinic for delivery and final cementation of a PFG crown. The temporary was removed,

Figure 12: Tissue profiling bur

Figure 13: Profiling bur removing excess tissue before impression

Figure 11: Solid crown and bridge abutment torqued into place

Figure 14: Light body impression material syringed into TRIP 22 Implant practice

Figure 15: Final impression

Figure 16: Temporary in place Volume 8 Number 4

CASE STUDY

Figure 17: 10 days’ post-op

the abutment cleaned with a rotary prophy brush, and dried (Figure 17). The crown was checked for marginal integrity and the occlusion adjusted using articulation paper.

Once the adjusted areas were repolished, the crown was cemented with Rely-X™ Dental Cement (3M) (Figures 18 and 19). Excess cement was removed, and the patient was dismissed.

The patient was seen 1-year later at follow-up (Figures 20 and 21). This type of healing is characteristic of these TSI implants.

The patient has been asymptomatic and said that “Getting her implant hurt less than the crown she just received.”

The satisfaction level this patient experienced by having an implant placed along with the impressions and temporary in less than an hour is priceless when trying to build an implant practice. The single unit implant is the “bread and butter” of implantology. The more efficient the procedure is, the more satisfied your patients will be, and the more production you will produce per chair hour of time. Placing implants can be highly enjoyable when treatment is planned correctly, and practicing implantology this way can also make it one of the most rewarding aspects of your practice. IP

Figure 18: Final restoration at delivery

Figure 19: Final restoration occlusal view

Figure 20: 1-year follow-up film

Figure 21: 1-year post-op CBCT REFERENCES 1. Cochran DL, Morton D, Weber HP. Consensus statements and recommended clinical procedures regarding loading protocols for endosseous dental implants. Int J Oral Maxillofac Implants.

2004;19(suppl):109-113.

2. Rizkallah N, Fischer S, Kraut RA. Correlation between insertion torque and survival rates in immediately loaded implants in the maxilla: a retrospective study. Implant Dent. 2013;22(3):250-254.

3. Kobayashi Y, Hashimoto F, Miyamoto H, Kanaoka K, Miyazaki-Kawashita Y, Nakashima T, Shibata M, Kobayashi K, Kato Y, Sakai H. Force-induced osteoclast apoptosis in vivo is accompanied by elevation in transforming growth factor beta and osteoprotegerin expression. J Bone Miner Res. 2000;15(10):1924-1934.

4. Schlesinger CD. Predictable Immediate Implant Stabilization and Restoration. J Implant Advanced Clin Dent. 2013;5(8):17-23.

5. Linkow LI, Glassman PE, Asnis ST. Macroscopic and microscopic studies of endosteal bladevent implants (six month dog study). Oral Implantol. 1973;3(4):281-309.

6. Glauser R, Lundgren AK, Gottlow J, Sennerby L, Portmann M, Ruhstaller P, Hämmerle CH. Immediate occlusal loading of Brånemark TiUnite implants placed predominantly in soft bone: 1-year results of a prospective clinical study. Clin Implant Dent Relat Res. 2003;5(suppl 1):47-56.

Volume 8 Number 4

Implant practice 23

CASE PICTORIAL

Dental rehabilitation after excision of an ossifying fibroma Dr. Parit Ladani presents a case where implants were used in the reconstruction of a young patient’s mandible

A

n 18-year-old male patient presented complaining of swelling over the right side of his lower jaw. This swelling was diagnosed as a benign ossifying fibroma.

Surgery was planned for excision of the lesion and reconstruction of the area using an iliac crest cortico-cancellous bone graft.

The bone graft was fixed to the defect using a reconstruction plate.

Figure 1: Preoperative photo showing hard, nonfluctuant, non-tender swelling over right side of mandibular parasymphysis, extending from the right corner of the mouth to the upper neck and from the midline to the body of the mandibular area

Figure 2: Preoperative view showing hard bony swelling obliterating buccal vestibule from lower left central incisor to lower right first molar region

Parit Ladani, MDS (maxillofacial surgery), is an Indian BoardCertified Oral and Maxillofacial Surgeon (IBOMSI). He is the project director and chief cleft and craniofacial surgeon at the Swiss Cleft Centre (Cleft Children International) in Zurich, Switzerland, and also works at the BSES MG Hospital in Mumbai, India.

24 Implant practice

Figure 3: Three-dimensional CT of face and X-ray OPG show well-defined, unilocular radiolucent area with cotton wool appearance and a well-demarcated radiopaque border extending from the lower left central incisor to the lower right first molar. There is expansion of both the buccal and lingual plates Volume 8 Number 4

CASE PICTORIAL

Figure 4: The lesion covered with a thin shell of bone after mucoperiosteal flap reflection, and the 5 cm x 7 cm lesion after excision. Histopathology report suggests the lesion is an ossifying fibroma

Figure 6: Iliac crest cortico-cancellous bone graft (approximately 7 cm x 5 cm) harvested from right iliac crest region

Figure 5: The defect in the mandible is apparent after excising the lesion with only a very thin shell of bone left behind.

A 2.5-mm reconstruction plate is fixed to the defect area to avoid pathologic fracture, and intermaxillary fixation is performed

Figure 8: Following closure of the defect 26 Implant practice

Figure 7: Graft fixed to mandibular defect using reconstruction plate and screw

Figure 9: OPG taken immediately postoperatively Volume 8 Number 4

More than primary stability.

The new tapered standard.

Flexibility in challenging clinical and anatomical situations – the Straumann® Bone Level Tapered Implant: • Roxolid® material – Permits the use of smaller-diameter implants with the same clinical performance as regular-diameter titanium implants1 • SLActive® surface – Designed to maximize treatment success and predictability in stability critical treatment protocols • Apically tapered – Overcomes anatomical restrictions and is designed to enable placement in under-prepared sites • Crossfit® Connection – Delivers simplified handling and assurance that the abutment is seated properly straumann.us/blt

In combination with: 1 Benic GI, Gallucci GO, Mokti M, Hämmerle CH, Weber HP, Jung RE. Titanium-zirconium narrow-diameter versus titanium regular diameter implants for anterior and premolar single crowns: 1-year results of a randomized controlled clinical study. Journal of Clinical Periodontology 2013 Nov;40(11):1052–61. Epub 2013 Sep 8.

CASE PICTORIAL

Figure 10: Postoperative images taken after 8 months show the patient’s face looking normal, with no external deformation

Figure 12: OPG at 8 months postoperatively shows formation of new, good quality bone to support the implant

Figure 11: Healing of the lower ridge after 8 months. Occlusion is normal

Figure 13: Alpha Dent classic 5 mm x 13 mm implants in situ in new bone

After 1 year, it was possible to see adequate bone formation at the defect side.

The missing teeth were replaced using three Alpha Dent 5 mm x 13 mm classic implants (Alpha Dent Implants Ltd., London, United Kingdom). IP

Figure 14: Alpha Dent implants in situ at 15 days postoperatively 28 Implant practice

Volume 8 Number 4

Practical Education for the Practicing Implant Dentist ® Essential information about: • Science of implant dentistry • Pharmacology of implant dentistry • Future of dental implants • Soft tissue management • Formulas for success • Management of complications 20 Hours of implant-specific CE

Where Classic Principles Support Cutting-Edge Implant Dentistry

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SuperPulse 10.6 µm CO2 laser-assisted, closed flap treatment of peri-implantitis Drs. Eric Linden and Peter Vitruk explore the peri-implantitis ablative laser treatment protocol Introduction Dental implants are widely used to replace missing teeth with a high rate of success and patient satisfaction.1,2 However, biological complications, such as periimplantitis, pose a serious challenge for dental clinicians. Different studies estimated that peri-implantitis occurs in 10.7% – 47.2% of patients with dental implants of over 10 years old.3

Peri-implantitis: definition, symptoms, and pathogenesis Peri-implantitis is an “inflammatory process” that affects the tissue around the body or apex of an already osseointegrated implant leading to the loss of supporting bone.4,5 Peri-implantitis is characterized by inflammatory response to anaerobic gramnegative plaque bacteria, motile organisms, and spirochetes, associated with a biofilm.6,7 Quirynen, et al.,7 noted that implants with peri-implantitis reveal a complex microbiota that includes conventional periodontal pathogens. The inflammatory response typically results in increased peri-implant probing depths, bleeding on probing and/or suppuration, possibly fistulas, progressive periimplant bone loss, and ultimately, dental implant mobility and loss.6 In addition to the submucosal presence of the aforementioned bacteria, numerous other factors have been associated with

peri-implantitis. Among such factors are inadequate oral hygiene,8 design of the implant, surface texture of the implant;6 contamination, corrosion, and residual dental cement on submucosal implant surfaces,9,10 excessive occlusal forces,6,11 smoking, history of periodontitis on adjacent natural teeth,12,13 poorly controlled diabetes mellitus,8 and host carriage of IL-1RN gene polymorphisms.14

Treatment modalities If the implant is still stable and the bone resorption is not overly severe, peri-implantitis can be treated and the implant saved. Periimplantitis can be treated conventionally (with the use of mechanic debridement) or with the assistance of lasers.6,15,16 Conventional therapy involves surgery and debridement along with antibiotic therapy. Debridement consists in attempted mechanical removal of the calculus, cement, diseased tissue, and elimination of as much bacteria as possible. Debridement is performed with plastic instruments. Citric acid, chlorexidine, and topical tetracycline are used as adjunct therapeutic modalities.17,18 Once debridement is complete, bone grafting is performed in an attempt to regenerate peri-implant bone. The patient’s occlusion is evaluated, and if mechanical overload is present, it is corrected. The patient’s oral hygiene is improved.6 However, Leonhard and colleagues19 reported that 42% of

Eric Linden, DMD, MSD, is a periodontist specializing in the field of Laser Periodontal Surgery. He serves as Professor of Periodontics and Oral Medicine at Columbia University/Columbia Presbyterian Medical Center in New York. He teaches and lectures to the Postgraduate Periodontal and Implant residents and conducts research on lasers, implants, and the treatment of periodontal and implant disease.

Dr. Linden is a member of American Dental Association, American Academy of Periodontology (AAP), New Jersey Dental Association, Bergen County Dental Society, American Association of Dental Research, Northern Bergen County Dental Study Club (President), Northeast Society of Periodontists, and Institute for Advanced Laser Dentistry, New York County Dental Society, and Academy of Laser Dentistry.

Dr. Linden serves as a consultant on Editorial Board of Dentistry Today, and as a consultant for the International Journal of Periodontics and Restorative Dentistry and currently serves on the AAP Task Force on establishing a framework for the treatment of peri-implantitis and establishing guidelines for the AAP worldwide membership.

Peter Vitruk, PhD, MInstP, CPhys, is a founder of LightScalpel, LLC. He is a member of the Institute of Physics, United Kingdom, and is the member of the Science and Research Committee, Academy of Laser Dentistry, United States. He is also on the faculty of the California Implant Institute and Global Laser Oral Health, both in the U.S. Dr. Vitruk can be reached at 1-866-589-2722 or pvitruk@lightscalpel.com.

30 Implant practice

implants treated for peri-implantitis using conventional therapy failed.

Laser-assisted therapy is performed via open or closed procedures. The lasers studied for peri-implantitis treatment are mainly the Nd:YAG, diode, Erbium, or CO2.20 Open procedure presupposes a laser incision to gain access to the body of the implant. The granulation tissue is vaporized.

Depending on the type of laser used, the bone is debrided with piezo scalers or laser (if Erbium laser is utilized), and the body of the implant is sterilized with the laser energy.

Bone grafting is performed, if necessary, and the flap is sutured. However, the clinician needs to take into account that different laser wavelengths affect titanium implants differently, and some can potentially induce thermal injury to the underlying bone and negatively affect the bone regeneration.21 Closed flap procedure for treatment of peri-implantitis does not involve surgical incision. This article examines the use of the CO2 laser in closed procedure for treatment of peri-implantitis.

Laser-tissue and laser-implant interaction physics Efficient decontamination of the implant surfaces can be achieved by photo-thermal laser ablation of the diseased tissue and bacterial matter around and off the surfaces of the implant without heating or damaging the implant if: 1. laser energy is efficiently deposited into the target tissue (diseased tissue and bacterial biofilms on implant surface) 2. laser-generated heat inside the target tissue is confined to the irradiated volume and is not thermally conducted away into the implant (which act as a highly efficient heat sink) 3. laser-generated heat inside the target tissue is sufficient for vaporizing it 4. laser energy is efficiently reflected off the surfaces of the implant once the biofilms are ablated off of its surface The first condition (efficient laser energy deposition into the biofilm) is met when laser Volume 8 Number 4

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Figure 1: Absorption depth, Thermal Relaxation Time, and ablation threshold fluence spectrum for 85% water-rich soft tissue with 10% blood content24

wavelength’s absorption depth22-24 is less or comparable to the target tissue thickness, which is clearly the case for 10.6µm CO2 laser wavelength even for the bacterial biofilms in 5-15µm range,25 as illustrated in Figure 1.

The second condition (of thermal confinement of laser energy within the irradiated tissue) is met when the laser pulse duration is shorter than Thermal Relaxation Time (TRT)23-26 also presented in Figure 1.

TRT defines the rate of how fast the irradiated tissue diffuses the heat away. TRT is defined through the thermal diffusion time: TRT = A2/K,23-26 where A is the Absorption Depth discussed above. The physics behind the thermal diffusivity process is similar to diffusion and Brownian motion first described

by Einstein in 1905.24,27 Coefficient K is the tissue’s thermal diffusivity; K = λ /(ϱ C) ≈ 0.155 (+/-0.007) mm2/sec (derived from heat conductivity λ ≈ 6.2-6.8 mW/cm ºC; specific heat capacity C ≈ 4.2 J/g ºC; and density ϱ ≈ 1 g/cm3 for liquid water for temperatures in 37º-100ºC range).28 The most efficient heating of the irradiated tissue takes place when laser pulse energy is high, and its duration is much shorter than TRT. The most efficient cooling of the tissue adjacent to the ablated zone takes place if time duration between laser pulses is much greater than TRT. Such laser-pulsing methodology, called SuperPulse, minimizes the depth of coagulation and is a must-have feature of any state-of-the-art soft tissue surgical CO2 laser.

For 10 µm thick 80%-90% water-rich biofilm at 10.6 µm wavelength, the TRT is approximately 700 µsec. For thicker soft tissue (like epithelium) the TRT is approximately 1.5 msec. The SuperPulse CO2 lasers with pulses under 800 µsec (Luxar LX-20SP25 and Volume 8 Number 4

Figure 2: Titanium surface absorption spectrum derived from titanium surface reflectivity at normal angle of incidence30

LightScalpel LS-100529) efficiently confine the heat generated by the laser during the pulse within the targeted tissue.

The third condition (of efficient vaporization [or ablation] of the irradiated target tissue) is met when laser fluence during the SuperPulse pulse exceeds laser ablation threshold Eth23,24 also presented in Figure 1. The more efficiently the laser energy is absorbed (Erbium and CO2 lasers), the lower the ablation threshold is. The less efficiently the laser energy is absorbed (diode and Nd:YAG lasers), the higher the ablation threshold is. During each SuperPulse pulse, the ablation depth δ is given by the formula δ = A (E – Eth) / Eth for the steady-state ablation conditions,23,24 where A is the absorption depth and Eth is the ablation threshold fluence, and E is the fluence during the SuperPulse pulse. The ablation threshold at the 10.6 µm CO2 laser’s wavelength for a biofilm with an assumed 75%-95% water content equals approximately Eth = 3 J/cm2.

The fourth condition is easily met for Ti implants,25 as illustrated in Figure 2, for any angles of incident of the laser beam in view of high reflectivity (>90%) of 10.6µm CO2 laser wavelength from titanium.30 This property makes the CO2 laser the safest wavelength for peri-implantitis treatment. Diode, Nd:YAG and Erbium laser wavelengths produce 3-4 times greater rate of the implant heating for comparable dose of laser energy used in the treatment.

CO2 laser treatment settings

A review of CO2 laser peri-implantitis treatment31 reports an open flap protocol with average laser power in 2-4 watt range, resulting in good healing with new bone formation. Such protocol31 does not

specify the laser spot size and whether or not the SuperPulse was used. A closed flap sulcular debridement protocol32 with low divergence tip with 0.73 watt average power was proven inefficient with respect to bacterial reduction; only a single sideway pass was administered. Given inefficient bacterial reduction in one treatment,32 multiple treatments with weekly intervals are recommended.33 A single treatment closed flap sulcular debridement protocol34 with low beam divergence,32 and LightScalpel high beam divergence (14º — see below) perio tip utilizes the high power SuperPulse settings of 4 watts and uses multiple sideway passes of the perio tip within the sulcus: A high degree of bacterial reduction is observed with highpowered optical microscopy.

The laser used in the peri-implantitis treatment reported in this article was a CO2 laser (10.6 µm ) LX-20SP set to SuperPulse mode at 2 watts (13.3mJ pulses with >50 watt peak power at 150Hz). The laser was operated in Repeat Pulse 10msec mode at 20 Hz averaging 0.4 watt (LightScalpel LS-1005/LS-2010 laser equivalent mode is SuperPulse 2 watt Repeat Pulse F1-2). Such relatively low average power (compared to open31 and closed32 flap protocols) still results in high laser fluence out of the tip and high clinical efficacy of the single treatment protocol due to small spot size and high beam divergence laser tip, and multiple sideways and up-and-down passes of the tip within the sulcus during treatment.32

Perio tip and CO2 laser treatment geometry Laser handpiece LightScalpel PN LS9002-02 was fitted with a 0.25 mm spot size diameter hollow waveguide Implant practice 31

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Figures 3A-3C: Superficial laser ablation and coagulation of the soft tissue (porcine) as perio tip moves at several mm/sec. 3A. Perio tip oriented is normal (within a few degrees) to the surface of the tissue.

3B. Perio tip oriented parallel (within a few degrees) to the surface of the tissue surface. 3C. Multiple sideway passes spaced by 0.5-1 mm

ceramic Al2O3 perio tip (distal OD=0.5mm, ID=0.3mm, working length 10mm) LightScalpel PN LS9005-05. The fluence level at the tip’s distal aperture exceeds 26 J/cm2 during each individual SuperPulse, which is sufficient for efficient ablation of the soft tissue24 and bacterial biofilms.25 The laser beam out of the perio tip diverges at approximately 14º, which is important for delivering laser energy to the walls of the sulcus and the implant during the closed peri-implantitis treatment procedure. Laser tissue interaction for different tip orientations (normal and parallel to the tissue) is illustrated in Figure 3.

Both orientations produce efficient ablation and coagulation of the soft tissue.

Simulated sulcular debridement is shown in Figure 4. For epithelial crest ablation, the perio tip is oriented normal to the surface of the soft tissue as illustrated in Figures 3A and 4C. For sulcular and peri-implant pocket debridement applications, the perio tip is oriented parallel to the walls of the pocket, as indicated in Figures 3B and 3C and Figures 4A and 4B. Constant airflow through the hollow core of the tip pushes the sulcular debris and fluids (blood, saliva, and irrigation) out of the way of the laser beam; airflow also prevents the clogging of the hollow tip.

Laser energy from the tip, directed at the surface of the tissue at the shallow angles of a few degrees, ablates/coagulates the surface of the soft tissue. When moved sideways, laser energy ablates/coagulates a strip of approximately 0.5 mm-1 mm width (see Figure 3B). Multiple passes of the tip produce multi-mm wide strip of superficial ablation and coagulation (see Figures 3C and 4B). During intra-pocket lasing, laser energy is also partially directed at the surface of the implant, which results in ablation of the biofilms off the surface of the implant, and its bacterial decontamination provided25 SuperPulse fluence exceeds approximately 3 J/cm2. Laser energy is also reaching the infected, granulated tissue at the bottom of the sulcular pocket.

32 Implant practice

Figures 4A-4C: Simulated laser sulcular debridement utilizing titanium implant embedded in the porcine soft tissue. 4A. Perio tip distal end is inserted between the implant and the soft tissue. 4B. Superficial laser ablation and coagulation of the soft tissue wall. 4C. Simulated ablation of the epithelial crest

Figure 5: Pre-op X-rays showing the presence of peri-implantitis with bone loss

Figure 6: Preoperative bone sounding (under local anesthesia) was needed to determine the bone topography

Protocol and case study Closed CO2 laser treatment is recommended for early- to medium-stage periimplantitis and mucositis when bone loss around the cervical portion of the implant is involved. In the closed procedure, the CO2 laser energy is applied outside and inside the peri-implant pocket without making incisions, raising flaps, or bone grafts (laser de-epithelialization). Due to its bactericidal effects and the low absorption of the 10.6 µm wavelength by titanium implants, the CO2 laser is capable of killing bacteria on the surface of the implant25 without damaging the implant or, potentially, the peri-implant bone.6, 35-37 If peri-implantitis is more severe and affects the tissue around the apical aspect of the implant, then the open-flap surgical laserassisted treatment technique would be recommended that involves incisions, flaps, and bone grafts.6 The peri-implantitis treatment protocol used for the case described in this article includes the following steps: • closed procedure under local anesthesia • bone sounding to determine accurate bone topography • modified fiberotomy/closed elevation to the osseous crest • CO2 laser is used on the SuperPulse setting with specially designed perio tip • laser treatment of the entire circumference of the implant

• piezo scaler • re-introduction of laser into the pocket — initiation of bleeding and hemostasis • occlusal adjustment • oral antibiotics for 7 days following the treatment • adapted oral hygiene regiment • dietary restrictions for 4-5 days following the treatment Patient A 50-year-old female, nonsmoker, with noncontributory medical history came in for a routine checkup. Clinical examination revealed increased pocket depths around two maxillary implants and bleeding upon probing. The pocket depths ranged between 5 mm-8 mm facially and 4 mm-9 mm lingually.

Preoperative X-ray showed circumferential bone defects around both implants (Figure 5). Diagnosis of peri-implantitis was made with the bone loss to the 3-5 threads of the implants. The possible causes include bacterial invasion of the titanium surface, occlusal trauma, and anatomical placement issues relative to the crest of bone, obstructing access for maintaining oral hygiene.

The procedure involved the following steps: Anesthesia: The patient received local anesthesia (2 carpules of 2% xylocaine with 1:100 epinephrine).

Bone sounding: Once anesthesia took effect, bone sounding was performed in order Volume 8 Number 4

Figure 7B: Preoperative palatal view

Figure 8: Modified fiberotomy. Pre-laser treatment in order to provide better access for the CO2 laser tip and ensure precise and efficient delivery of the laser energy

to precisely determine the bone topography (Figure 6). This step is crucial with the closed technique. The data obtained guides the clinician as to how far the laser tip needs to go into the pocket. The clinician will then move the laser tip staying 1 mm-2 mm away from the bone.

Fiberotomy: After bone sounding was complete, the modified fiberotomy procedure was performed (Figure 8). A small elevator was used to sever gingival fibers around the affected implants in order to open up the coronal aspect of the crest of gingival tissue (2 mm-4 mm deep). This step is important as it helps to introduce the laser tip into the pocket, ensuring the most efficient delivery of the laser energy to the target tissue.

Laser settings: De-epithelialization and implant biofilm removal: 0.25 mm periodontal tip was used. The air purge was on throughout the entire laser treatment procedure (the setting was “High”). The laser was used in the SuperPulse mode at 2 watts; the laser was set to 20% duty cycle which produced the average power of 0.4 watts.

Coagulation after de-epithelialization and removal of implant biofilm: 0.4 mm tip was used. The air purge was on. The laser was

used in the non-SuperPulse mode at 2 watts.

(10 msec pulses, 20 Hz, 20% duty cycle — resulted in 0.4 watts of average power.)

Laser procedure: First, the crest epithelium was removed (SuperPulse laser settings) outside the peri-implant pockets in order to vaporize bacteria and to delay the down growth of epithelium into the pocket. Then the laser perio tip was introduced into the peri-implant pocket. The tip was backed off to maintain 1 mm-2 mm “safety margin” from the depth of the pocket. The tip was slowly moved sideways circumferentially the full width of the pocket (Figure 9A). Then the tip was brought up 1 mm, and another circumferential stroke was made, 1 mm up — and another circumferential stroke — until the top of the pocket was reached. The hand speed is crucial for this procedure: It should be slower — approximately 1 mm/sec for thicker epithelium — and slightly faster for thinner epithelium — approximately 2-3 mm/sec.

Implant cleaning with piezo scaler: After pocket de-epithelialization and ablation of implant biofilm were competed, the implant was cleaned with the ultrasonic piezo scaler with irrigation. The goal of this step

was to remove the residual tissue, calculus, and cement from the implants and pockets.

Hemostasis: The laser was then reintroduced into the peri-implant pockets with the coagulation settings. Laser energy was used to coagulate the blood and cause formation of a clot that would slow down epithelial migration inside the pocket. The laser coagulation technique is similar to the de-epithelialization one described above, when the laser tip was moved circumferentially with approximately 1 mm/sec hand speed for strongly bleeding blood vessels (to cause 0.3 mm deep coagulation) and approximately 2-3 mm/sec for blood vessels that were bleeding less profusely.

Occlusal adjustment: Minor occlusal adjustment was performed.

Postoperative instructions: After the laser treatment, the patient was prescribed oral antibiotic, doxycycline, 100 mg twice a day for 7 days. For pain management as well as for the anti-inflammatory effect on wound healing, the patient was prescribed ibuprofen, 800 mg 3 times a day for 2 days.

The patient was instructed to avoid chewing on the treated side for 4-5 days following the procedure. Dietary restrictions included abstaining from acidic and/or spicy foods or drinks.

The patient was put on an adapted oral hygiene regimen that included no brushing or flossing for 5-7 days postoperatively.

Starting on day 2, warm salt rinses were recommended.

Follow-up examination: The patient returned for the first follow-up examination

Figure 10A: Buccal view of the treated site at 1-week post-op

Figure 10B: Occlusal view of the treated site at 1-week post-op

Figure 10C: Palatal view of the treated site at 1-week post-op

Figure 9A: CO2 laser treatment in progress. Note that the laser perio tip is parallel to the long axis of the implant

Volume 8 Number 4

Figure 9B: The bubble is the result of the stream of air that is forced through the laser perio tip

Implant practice 33

SEEING THE LIGHT

Figure 7A: Preoperative occlusal view

SEEING THE LIGHT

Figure 11A: Buccal view at 6 months’ post-op. The healing was uneventful, and the infection did not reoccur

Figure 11B: Palatal view at 6 months’ post-op. No signs of infection are present, and the pocket depth was significantly reduced

at 1 week postoperatively (Figures 10A-10C).

The healing progressed well, and no signs of swelling or inflammation were present.

During follow-up examination at 6 months postoperatively, the treatment site was completely healed with no signs of periimplantitis (Figures 11A-11C). The pocket depth, measured during the 6-month postoperative visit, was reduced to 3 mm-4 mm.

(Significant improvement in comparison with the initial probing depths of up to 9 mm.)

periodontitis and (2) the reduction of the treatment time through increasing the average laser power within the 4 watts SuperPulse mode gated at 20-30 Hz in the 50%-100% Duty Cycle range. IP

Conclusions

REFERENCES

Clinically efficient CO2 laser-assisted, closed flap peri-implantitis treatment protocol is detailed in this report. Also presented is the physics of the laser wavelength and pulsing effects on laser-tissue and laser-implant interaction, allowing for the science-guided optimization of the clinical protocol and instrumentation.

A single session treatment resulted in reduced pocket depths, diminished bleeding, and improved tissue health. Such protocol, together with its non-laser stages, includes: 1. CO2 laser wavelength 10.6 µm characterized by high reflectivity from titanium and by strong absorption by water rich epithelium and bacterial matter 2. SuperPulse laser settings with low average power to minimize heat effects 3. high fluence, high divergence, and high strength hollow ceramic perio tip with continuous air jet to facilitate the maximum reach of laser energy within the pocket 4. multiple sideways circumferential movement of the perio tip for efficient pocket debridement throughout its volume. The procedure is less traumatic than conventional or laserassisted open-flap techniques, because it does not involve incisions, raising flaps or scaling of the bone.

Future work will be aimed at (1) extending the protocol reported here to the treatment of 34 Implant practice

Acknowledgments Authors greatly appreciate the support and contribution from Anna Glazkova, PhD, in preparing this material for publication.

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Mouhyi J, Dohan Ehrenfest DM, Albrektsson T. The peri-implantitis: implant surfaces, microstructure, and physicochemical aspects. Clin Implant Dent Relat Res. 2012;14(2):170-183.

10. Linkevicius T, Puisys A, Vindasiute E, Linkeviciene L, Apse P. Does residual cement around implant-supported restorations cause peri-implant disease? A retrospective case analysis. Clin Oral Implants Res. 2013;24(11):1179-1184.

Figure 11C: X-ray of the treated peri-implantitis site at 6 months’ post-op

15. Stübinger S, Henke J, Donath K, Deppe H. Bone regeneration after peri-implant care with the CO2 laser: a fluorescence microscopy study. Int J Oral Maxillofac Implants.

2005;20(2):203-210.

16. Deppe H, Horch H, Helmut G, Brill T, Wagenpfeild S, Donathe K. Peri-implant care with the CO2 laser: In vitro and in vivo results. Med Laser Appl. 2005;20(1):61-70.

17. Mombelli A. Microbiology and antimicrobial therapy of periimplantitis. Periodontol 2000. 2002;28:177-189.

18. Santos VR, Duarte PM. Surgical anti-infective mechanical therapy for peri-implantitis: a clinical report with a 12-month follow-up. Gen Dent. 2009;57(3):230-235, 236-237.

19. Leonhardt A, Dahlén G, Renvert S. Five-year clinical, microbiological, and radiological outcome following treatment of peri-implantitis in man. J Periodontol.

2003;74(10):1415-1422.

20. Romanos GE. Treatment of periimplant lesions using different laser systems. J Oral Laser Appl. 2002;2:75.

21. Moritz A. Oral Laser Application. Berlin, Germany: Quintessenz Verlags; 2006.

22. Jacques SL. Optical properties of biological tissues: a review. Phys Med Biol. 2013;58(11):R37-61.

23. Vogel A, Venugopalan V. Mechanisms of pulsed laser ablation of biological tissues. Chem Rev. 2003;103(2):577-644.

24. Vitruk P. Oral soft tissue laser ablative and coagulative efficiencies spectra. Implant Pract US. 2014;7(6):22-27.

25. Cobb C, Vitruk P. Effectiveness of a Super Pulsed CO2 Laser for Removal of Biofilm from Three Different Types of Implant Surfaces: An in vitro Study. Implant Pract US. 2015;8(3):20-28.

26. Svaasand LO. Lasers for biomedical applications. In: Driggers RG, ed. Encyclopedia of Optical Engineering. New York, NY: CRC Press; 2003:1035-1041.

27. Einstein A. Über die von der molekularkinetischen Theorie der Wärme geforderte Bewegung von in ruhenden Flüssigkeiten suspendierten Teilchen. Annalen der Physik.

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35. Deppe H, Horch H, Helmut G, Brill T, Wagenpfeild S, Donathe K. Peri-implant care with the CO2 laser: In vitro and in vivo results. Med Laser Appl. 2005;20(1):61-70.

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Volume 8 Number 4

CONTINUING EDUCATION

The effect of osteoporosis on dental treatments Dr. Elena Calciolari looks at the ramifications of osteoporosis on patients undertaking dental treatments

O

steoporosis is a common systemic skeletal disease characterized by a decrease in bone mass and microarchitectural changes in bone structure, which dramatically increase the risk of fractures. It is diagnosed as a level of bone mineral density (BMD), calculated with a DEXA (dual-energy X-ray absorptiometry) scan, 2.5 standard deviations (SD) or more below the average mean value for young healthy women (T-score ≤ -2.5) (Kanis, et al., 2013).

The prevalence of osteoporosis in Europe was estimated to be of 27.6 million people (22 million women and 5.6 million men) in 2010, but due to the population growth and the increase in life expectancy, this number is likely to rise in the future, as shown by Hernlund and colleagues (2013). Projections for the United Kingdom hypothesize that the number of fragility fractures will increase from 536,000, as recorded in 2010, to 682,000 by 2025 (+27%) (Svedbom, et al., 2013).

Women after menopause and men after 70 years old are the most affected demographic due to the detrimental effect a lack of estrogen/androgen has on bone metabolism. Considering the increase in life expectancy, the number of osteoporotic patients requiring dental care is expected to significantly rise in the coming years, and therefore, it is important for dentists to be well aware of any possible effect of osteoporosis (and its medications) on the success of dental treatments and on the incidence of possible complications.

This article will try to answer the following questions: • Does osteoporosis also affect the jawbones?

Elena Calciolari, DDS, MS, graduated with honors in 2010 from the University of Parma, Italy. She then undertook a 2-year master’s degree in periodontology at the University of Siena under the supervision of Professor Massimo De Sanctis. In 2012, she won a prestigious scholarship from the Italian Society of Periodontology to do a PhD at UCL Eastman Dental Institute under the supervision of Professor Nikolaos Donos and Dr. Nikolaos Mardas on bone regeneration and osteoporosis. The importance and innovation of her research projects have already been recognized by the Italian Society of Periodontology, awarding her with the 2013 Goldman Award for clinical research, and the Alpha Omega London Charitable Trust, where she received the 2014 John Zamet Memorial Prize.

36 Implant practice

Educational aims and objectives

This article aims to discuss the effect of osteoporosis on patients undergoing dental treatment, as well as any risks, side effects, and practical tips for clinicians.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 39 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Realize the characteristics of osteoporosis.

• Identify types of patients who are most at risk for osteoporosis.

• Discover if osteoporosis affects the jawbones.

• Realize if dentists are able to place implants in patients with osteoporosis.

• Identify the effect of osteoporosis medications on the success/survival of dental implants.

• Realize the risk of developing an osteonecrosis of the jaw after a dental implant.

• Can we place implants in patients with osteoporosis?

• What is the effect of osteoporosis medications on the success/survival of dental implants?

• What is the risk of developing an osteonecrosis of the jaw after a dental implant?

Where possible, this article will try to give practical tips to the clinician.

Does osteoporosis also affect the jawbones?

Before taking into consideration how to relate with osteoporotic patients, it is of primary importance to understand if osteoporosis does exist in the jawbones, or if it is a disease strictly confined to long bones and vertebrae.

It is, of course, plausible to hypothesize that osteoporosis-induced systemic bone loss may include also bone loss at the jaws, as bones of the skeleton. As a proof of that, some clinical studies reported that there is an increased alveolar bone resorption in osteoporotic versus non-osteoporotic edentulous patients (Hirai, et al., 1993; Singhal, et al., 2012), and that medications affecting systemic bone density (like hormone replacement therapy and bisphosphonates) are associated with a slower loss of alveolar bone (Graziani, et al., 2008).

However, the evidence is not so clear.

Although several animal and clinical studies have reported a positive correlation between bone density at the jaws and bone density at

several other skeletal sites (such as the femur neck, the lumbar spine, the calcaneus, and the forearm), other studies did not confirm these findings. As highlighted by a recent systematic review (Calciolari, et al., 2015a), one of the biggest limits we face today is the lack of a standardized and accurate technique to measure jawbone density, since a DEXA software for jawbones does not exist.

Despite these controversial results, in the past 20 years, many studies have claimed a role of the dentist in the early diagnosis of osteoporosis by measuring specific quantitative/qualitative indices on dental panoramic radiographs (OPGs). A meta-analysis of the accuracy of these indices has reported that, for example, 80% of people with erosions of the mandibular cortex, as assessed by a qualitative evaluation on the OPG, are at least osteopenic and therefore would benefit to be referred to a specialist (Calciolari, et al., 2015b).

Can we place implants in patients with osteoporosis?

It is biologically plausible that the alterations in bone metabolism associated to osteoporosis can also impair bone healing around dental implants and affect their osseointegration. Some animal studies have confirmed a reduced bone-to-implant contact, reduced mechanical properties, and a delay in bone healing in osteoporoticlike conditions, and a few prospective and retrospective clinical studies indicated that osteoporosis could jeopardize implant Volume 8 Number 4

period for the osseointegration of the implants (up to 50% more than normal).

The best way to pre-surgically assess jaw bone mineral density remains quantitative computed tomography, and recently Chai and colleagues suggested Hounsfield units (HU) cutoffs for identifying osteoporotic patients in the dental practice (460 HU for spine T-score) (2014).

A rapidly growing research field is now related to the use of implant surfaces that can be bioactivated, drug loaded, or chemically modified to improve osseointegration and bone formation in challenging conditions (such as osteoporosis). Animal studies have tested, for instance, the use of phosphate ceramic-coated implants, hydroxyapatitecoated implants, bisphosphonate-coated implants, and hydrophilic titanium surfaces (Mardas, et al., 2011; Alghamdi and Jansen, 2013) to promote better bone healing when the host bone is osteoporotic, but these data, though encouraging, still have to be thoroughly investigated in clinical trials.

What is the effect of osteoporosis medications on the success/ survival of dental implants?

Several medications have been used to treat osteoporotic patients. In general, we distinguish between antiresorptive treatments that slow bone loss and bone anabolic agents that stimulate bone formation. Bisphosphonates (BPs), and in particular alendronate, are still the most commonly prescribed antiresorptive medications for osteoporosis and represent the gold

Many studies have claimed a role of the dentist in the early diagnosis of osteoporosis by measuring specific quantitative/ qualitative indices on dental panoramic radiographs (OPGs) Volume 8 Number 4

standard in fracture prophylaxis. They can be administered either orally (more frequently) or intravenously, and they are stored in the bone for decades due to their strong affinity for hydroxyapatite. Contrasting results have been reported in relation to the influence of BPs on dental implant osseointegration and success.

Considering that these medications inhibit the formation and activation of osteoclasts and induce their apoptosis, thus reducing bone turnover, they may potentially reduce the regenerative capacity of bone around dental implants, thus impairing osseointegration. At the same time, the slower osseous remodeling allows more time for secondary mineralization, so that there is an increase in bone density and stiffness, together with an increase in microdamage of bone.

Although the available clinical evidence comes mainly from retrospective and case series studies, it seems that systemic BPs do not have a huge impact on the success and survival of dental implants (OR = 1.43, P = 0.156) (Ata-Ali, et al., 2014). The number of dental implants that must be exposed to BPs in order to cause a single implant failure, which otherwise would not have occurred (“number needed to harm�), was reported to be 509 dental implants.

This, however, does not mean that patients taking bisphosphonates are to be considered as complication-free, as described in the next paragraph.

What is the risk of developing an osteonecrosis of the jaws (ONJ) after a dental implant?

One of the most serious complications that have been related to the use of bisphosphonates is the development of osteonecrosis of the jaws (ONJ). This rare albeit serious event was first reported in 2003, and since then, the interest and the number of related publications has rapidly increased.

ONJ usually presents as an area of exposed bone that does not heal spontaneously within 8 weeks, and it is usually, but not always, associated with pain (Ruggiero, et al., 2014).

There is general consensus on considering intravenous bisphosphonate treatment in cancer patients as an absolute contraindication for implant placement. This has to do mainly with the serious medical condition affecting these patients, which could not only jeopardize the success of dental implants, but could also put at risk their general health (Donos and Calciolari, 2014).

Conversely, osteoporosis treatment with oral Implant practice 37

CONTINUING EDUCATION

success, especially in case implants are placed in augmented bone. Nevertheless, a systematic and a literary review on this topic failed to identify osteoporosis as an absolute contraindication for implant therapy (Slagter, Raghoebar, and Vissink, 2008; Tsolaki, Madianos, and Vrotsos, 2009).

From the available evidence, we can conclude that dental implants can be successfully placed in osteoporotic patients, but it is advisable to follow a few recommendations to guarantee a more predictable outcome.

In particular, clinicians should carefully assess and try to control for concomitant risk factors that can affect bone metabolism and bone density (such as deficiencies of vitamin D and calcium, smoking, and alcohol abuse), as well as for the presence of systemic diseases (such as diabetes mellitus) with a recognized impact on bone tissue. It is also advisable to consider osteoporotic bone as equivalent to type IV according to Lekholm and Zarb classification, thus porous and on average of poor quality. Hence, the clinician should take into consideration under preparation of the site longer healing periods before siting the prosthesis and a careful implant/bone loading distribution.

It has been argued that bone density is not uniformly distributed in the jaws. In particular, the lowest values of BMD have been recorded in the anterior maxilla and premolar region by Gulsahi and colleagues (2010). Therefore, especially in these areas, it is recommended that the clinician should avoid immediate loading and allow a longer

CONTINUING EDUCATION (or less frequently intravenous) bisphosphonates is not considered an absolute contraindication for dental implants. Only limited clinical studies have tried to address the risk of ONJ subsequent to implant placement, but it is recommended to consider it comparable to the one associated to a tooth extraction.

ONJs tend to occur more frequently in patients taking nitrogen-containing BPs (such as zoledronic acid and pamidronate) and intravenous bisphosphonates. The incidence of BPs-associated ONJ described in the literature ranges from 0.001% to 0.01%, with highest levels for long-term treatments, up to 0.2% in patients with greater than 4 years of exposure (Lo, et al., 2010). Taking into consideration the aspect of treatment duration, the American Association of Oral and Maxillofacial Surgeons suggested that, for patients taking BPs for more than 4 years, a drug holiday might be considered for at least 2 months before an oral surgery procedure (Ruggiero. et al., 2014).

In order to reduce the incidence of ONJs before an implant surgery, the clinician should first identify and address comorbidities and risk factors that may increase the possibility of developing this serious complications, such as smoking, oral mucosal irritation associated to denture wearing, periodontitis, treatment with corticosteroids, and diabetes mellitus. Furthermore, it is important to reduce the surgical trauma as much as possible, to use abundant irrigation when drilling the bone, and to suture in order to promote primary intention closure of the wound.

The Association of Dental Implantology stresses the importance of ensuring a high level of hygiene to reduce the need of surgical procedures in these patients, but whenever these are needed, it recommends the use of topical antiseptics (e.g., chlorhexidine) and systemic antibiotics (2012).

The reader should note that, though traditionally osteonecrosis of the jaw has been related to the use of bisphosphonates (mainly intravenous), it can be caused also by other antiresorptive medications, such as RANK ligand inhibitor (denosumab), and antiangiogenic medications. This is why the American Association of Oral and Maxillofacial Surgeons now prefers the term medication-related osteonecrosis of the jaw (MRONJ) instead of bisphosphonate-related osteonecrosis of the jaw (BRONJ) (Ruggiero, et al., 2014).

patients is still poor and warrants further investigation. However, both the pathogenesis and the medications of osteoporosis can plausibly interfere with the success of dental treatments involving osseous healing of the jawbones (such as rehabilitation with dental implants or bone regeneration therapies). Before starting any of these treatments, the clinician needs to inform the patient about the possible complications and the risk of failures.

There is no absolute contraindication in placing dental implants in osteoporotic patients, but a longer osseointegration healing period should be taken into consideration. A correct patient selection is also crucial, and the dentist needs, in particular, to address possible concomitant risk factors that may increase the chances of implant failures, such as smoking, corticosteroid treatment, or diabetes mellitus.

Though rare, the association between BP use and osteonecrosis of the jaw can’t be overlooked. Clinicians should be well aware of the risks of dental implant placement in patients under BP treatment (especially intravenous infusion or oral BP therapy

greater than 4 years), and should inform the patients accordingly.

Whenever a traumatic procedure such as an extraction or the positioning of an implant is performed in a patient taking BP, extra attention should be paid to ensure an atraumatic surgical technique, an adequate postoperative control, and an adequate occlusal adjustment of the prosthesis.

The dentist should discuss with the GP or the rheumatologist the possibility of a drug holiday in patients taking BPs for more than 4 years.

Patient education and motivation regarding dental care and tight recall programs have to be seen as a priority when dealing with osteoporotic patients in order to reduce the need for surgical procedures.

Last, but no less important, the clinician needs to balance the advantages and disadvantages related to a surgical procedure in patients with combined risk factors and to take into consideration that on some occasions nonsurgical options can be equally well tolerated/accepted with fewer chances of complications. IP

REFERENCES 1.

Association of Dental Implantology. Dental management of patients receiving anti-resorptive bone therapy - ADI guidance. 2012.

2.

Alghamdi HS, Jansen JA. Bone regeneration associated with nontherapeutic and therapeutic surface coatings for dental implants in osteoporosis. Tissue Eng Part B Rev. 2013;19(3):233-253.

3.

Ata-Ali J, Ata-Ali F, Peñarrocha-Oltra D, Galindo-Moreno P. What is the impact of bisphosphonate therapy upon dental implant survival? A systematic review and meta-analysis. Clin Oral Implants Res. 2014 epub ahead of print.

4.

Calciolari E, Donos N, Park JC, Petrie A, Mardas N. Panoramic measures for oral bone mass in detecting osteoporosis: a systematic review and meta-analysis. J Dent Res. 2015;94(suppl 3):17S-27S.

5.

Calciolari E, Donos N, Park JC, Petrie A, Mardas N. A systematic review on the correlation between skeletal and jawbone mineral density in osteoporotic subjects. Clin Oral Implants Res. 2015 epub ahead of print.

6.

Chai J, Chau AC, Chu FC, Chow TW. Diagnostic performance of mandibular bone density measurements in assessing osteoporotic status. Int J Oral Maxillofac Implants. 2014;29(3):667-674.

7.

Donos N, Calciolari E. Dental implants in patients affected by systemic diseases. Br Dent J. 2014;217(8):425-430.

8.

Graziani F, Rosini S, Cei S, La Ferla F, Gabriele M. The effects of systemic alendronate with or without intraalveolar collagen sponges on postextractive bone resorption: a single masked randomized clinical trial. J Craniofac Surg. 2008;19(4):1061-1066.

9.

Gulsahi A, Paksoy CS, Ozden S, Kucuk NO, Cebeci AR, Genc Y. Assessment of bone mineral density in the jaws and its relationship to radiomorphometric indices. Dentomaxillofac Radiol. 2010;39(5):284-289.

10. Hernlund E, Svedbom A, Ivergård M, Compston J, Cooper C, Stenmark J, McCloskey EV, Jönsson B, Kanis JA. Osteoporosis in the European Union: medical management, epidemiology and economic burden. A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA).

Arch Osteoporos. 2013;8:136.

11. Hirai T, Ishijima T, Hashikawa Y, Yajima T. Osteoporosis and reduction of residual ridge in edentulous patients. J Prosthet Dent.

1993;69(1):49-56.

12. Kanis JA, McCloskey EV, Johansson H, Cooper C, Rizzoli R, Reginster JY; Scientific Advisory Board of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis, Committee of Scientific Advisors of the International Osteoporosis Foundation. European guidance for the diagnosis and management of osteoporosis in postmenopausal women.

Osteoporos Int. 2013;24(1):23-57.

13. Lo JC, O’Ryan FS, Gordon NP, Yang J, Hui RL, Martin D, Hutchinson M, Lathon PV, Sanchez G, Silver P, Chandra M, McCloskey CA, Staffa JA, Willy M, Selby JV, Go AS; Predicting Risk of Osteonecrosis of the Jaw with Oral Bisphosphonate Exposure (PROBE) Investigators. Prevalence of osteonecrosis of the jaw in patients with oral bisphosphonate exposure. J Oral Maxillofac Surg. 2010;68(2):243-253.

14. Mardas N, Schwarz F, Petrie A, Hakimi AR, Donos N. The effect of SLActive surface in guided bone formation in osteoporoticlike conditions. Clin Oral Implants Res. 2011;22(4)406-415.

15. Ruggiero SL, Dodson TB, Fantasia J, Goodday R, Aghaloo T, Mehrotra B, O’Ryan F, American Association of Oral and Maxillofacial Surgeons. American Association of Oral and Maxillofacial Surgeons position paper on medication-related osteonecrosis of the jaw--2014 update. J Oral Maxillofac Surg. 2014;72(10):1938-1956.

16. Singhal S, Chand P, Singh BP, Singh SV, Rao J, Shankar R, Kumar S. The effect of osteoporosis on residual ridge resorption and masticatory performance in denture wearers. Gerodontology. 2012;29(2):e1059-1066.

17. Slagter KW, Raghoebar GM, Vissink A. Osteoporosis and edentulous jaws. Int J Prosthodont. 2008;21(1):19-26.

Conclusive recommendations The available evidence on the risks associated with the treatment of osteoporotic 38 Implant practice

18. Svedbom A, Hernlund E, Ivergård M, Compston J, Cooper C, Stenmark J, McCloskey EV, Jönsson B, Kanis JA; EU Review Panel of IOF. Osteoporosis in the European Union: a compendium of country-specific reports. Arch Osteoporos. 2013;8:137.

19. Tsolaki IN, Madianos PN, Vrotsos JA. Outcomes of dental implants in osteoporotic patients. A literature review. J Prosthodont.

2009;18(4):309-323.

Volume 8 Number 4

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The effect of osteoporosis on dental treatments CALCIOLARI

1. Women after menopause and men after 70 years old are the most affected demographic due to the detrimental effect ______ estrogen/androgen has on bone metabolism. a. a lack of b. an overabundance of c. a mixture of d. that synthetic 2. As a proof of that (osteoporosis-induced systemic bone loss may include also bone loss at the jaws), some clinical studies reported that there is ______ alveolar bone resorption in osteoporotic versus non-osteoporotic edentulous patients, and that medications affecting systemic bone density (like hormone replacement therapy and bisphosphonates) are associated with a slower loss of alveolar bone. a. a decreased b. an increased c. not significant d. immeasurable 3. A meta-analysis of the accuracy of these indices has reported that, for example, ____ of people with erosions of the mandibular cortex, as assessed by a qualitative evaluation on the OPG, are at least osteopenic and therefore would benefit to be referred to a specialist. a. 25% b. 40% c. 63% d. 80%

Volume 8 Number 4

4. Some animal studies have confirmed a _______ in osteoporotic-like conditions, and a few prospective and retrospective clinical studies indicated that osteoporosis could jeopardize implant success, especially in case implants are placed in augmented bone. a. reduced bone-to-implant contact b. reduced mechanical properties c. delay in bone healing d. all of the above 5. It has been argued that bone density ______ in the jaws. a. is not accurately measureable b. is uniformly distributed c. is not uniformly distributed d. is not as important as other factors 6. A rapidly growing research field is now related to the use of implant surfaces that can be ______ to improve osseointegration and bone formation in challenging conditions (such as osteoporosis). a. bioactivated b. drug loaded c. chemically modified d. all of the above 7. One of the most serious complications that have been related to the use of bisphosphonates is the development of ______. a. osteonecrosis of the jaws (ONJ) b. odontogenic cysts

c. reactive bone lesions (RBL) d. central giant cell granuloma (CGCG) 8. ONJ usually presents as an area of exposed bone that does not heal spontaneously within ___ weeks, and it is usually, but not always, associated with pain. a. 2 b. 4 c. 6 d. 8 9. Taking into consideration the aspect of treatment duration, the American Association of Oral and Maxillofacial Surgeons suggested that for patients taking BPs for more than 4 years, a drug holiday might be considered for at least _______ before an oral surgery procedure. a. 1 week b. 1 month c. 2 months d. 6 months 10. Whenever a traumatic procedure such as _____ is performed in a patient taking BP, extra attention should be paid to ensure an atraumatic surgical technique, an adequate postoperative control, and an adequate occlusal adjustment of the prosthesis. a. a root canal b. an extraction c. the positioning of an implant d. both b and c

Implant practice 39

CE CREDITS

IMPLANT PRACTICE CE

CONTINUING EDUCATION

Immediate esthetic rehabilitation with one-piece implants Drs. Shahram Nik and Kaveh Golab discuss the minimal postoperative discomfort when providing a patient with a fixed prosthesis immediately after implant placement

I

mmediate loading of dental implants is a valuable technique that can decrease the treatment period, minimize surgical sessions, and increase patient satisfaction.

In comparison with conventional techniques, immediate loading has shown same success in Cochrane reviews (Esposito, et al., 2013).

One-piece implants are newly introduced implants in order to facilitate oral rehabilitation and accelerate the tooth replacement procedure. With the high-tech design of these implants, it seems that using onepiece implant can satisfy both surgical and prosthetic requirements of patients.

These implants have also demonstrated long-term survival rate. They are designed with the aim of fewer complications compared with two-piece implants (Barrachina-Diez, et al., 2013; Finne, Rompen, and Toljanic, 2012; Prithviraj, et al., 2013). One-piece implants not only do not have microleakage and micromovements between abutment and fixture, but also do not have the common screw-loosening complications, according to Prithviraj and colleagues (2013).

The dentist and his/her assistant can feel relaxed in the implant clinic because these implants do not need different types of screwdrivers, stock of various abutment sizes, and collars. In addition, they are completely welcomed from meticulous patients due to precise preparation of the abutment crown with gingival margin and simplicity of provisionalization. Solid design

Shahram Nik, DDS, MSc, PhD, runs a private dental and maxillofacial implant clinic that he established in 1998. He was awarded an MSc in Oral Surgery at Manchester Dental Hospital in 1993, and a PhD in 1998 from the University of Manchester for his clinical and laboratory studies into the factors affecting the success of implant treatment, GBR, and free bone grafts. Since 1998, he has been clinical director of the multi-center study of one-piece dental implants. His team has trained and mentored more than 300 dentists worldwide. His current clinical research interests include one-piece and immediate-implant loading dental implants and immediate replacement and immediate restorations.

He is the CEO and R&D director of S&S Biomat in Manchester, United Kingdom, where his team designed one-piece screw and one-piece cylinder dental implants.

Dr. Kaveh Ghaleh Golab, DDS, is in private practice in Tehran, Iran.

He has done research at the Tehran University of Medical Science.

40 Implant practice

Educational aims and objectives

This article aims to demonstrate the equal success of immediate esthetic rehabilitation with immediate implant placement and delayed implant placement.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 43 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Recognize the benefits of one-piece implants.

• See a case where this method is used on a specific patient.

• Identify some steps in the treatment of a patient with one-piece implants.

• Recognize some possible issues after this type of treatment and how to treat them.

Figure 1: The right central incisor has infrabony pocket

of these implants ensure small diameter manufacturing; therefore, they can be used in the esthetic zone with adequate distance from adjacent teeth, resulting in preservation of interdental bone and gingival papillae (Sohn, 2011; Zembic, 2012). In patients with thin mucosa and possible exposure of abutment margin, the finishing line of crown preparation can be extended on solid abutment to cover the titanium surface.

One Piece Screw (OPS) implants (S&S Biomat Ltd., Manchester, United Kingdom) have threads with variable depth; they gradually increase from the coronal toward apical end (from 0.3 mm-0.03 mm). The threads on the apical area are V-shaped, which enable self-tap characteristics of the implant. These threads are transforming to Acme threads on the coronal parts of the fixture. Transmucosal parts are flared with a different gingival height size (2 mm, 4 mm), which can be selected due to the mucosal width of the site. Solid abutments have two anti-rotational elements that can be prepared same as conventional fixed prosthesis.

Figure 2: Full-thickness flap reflection after conservative extraction of the incisor with pre-elevator

Material and methods The patient in this article had severe bone resorption around mandibular anterior tooth.

In addition, this tooth was mobile. The patient received antibiotics (amoxicillin and metronidazole) and an analgesic before the surgery and continued 1-week post-surgery. After a local anesthesia, the incisor was extracted using a traumatic technique with pre-elevator (S&S Biomat) to preserve remaining alveolar bone. Then the soft tissues in the sockets were carefully removed, and a full-thickness flap was reflected.

Under a copious irrigation, serial drilling of implants (Dr. Nik, S&S Biomat) was done to prepare the implant socket. The drills are specially designed to collect the bone debris in their flutes. This debris can not only indicate the quality of bone but can also be used in the case of autogenous bone grafts.

After measuring of the soft tissue thickness, proper implants were selected and inserted into the socket. The inserted implants gained the 35Ncm insertion torque, which is acceptable for immediate loading of implants.

Volume 8 Number 4

The temporary acrylic bridge, which had been made for the patient, was relined with self-cure acrylic resin. Afterward the bridge was cemented on the abutments with zinc phosphate cement. It was trimmed in a natural way to simulate previous teeth contour, which will lead to soft tissue formation with a natural contour to be formed near crowns. Three months after insertion surgery, the implants were osseointegrated, and the abutments were prepared using high-speed carbide burs (SS White). Direct impression using additional silicones was made. A resin framework was tried in intraorally to ensure the passive fitness of the final bridge, and finally, after confirmation of the esthetic characteristics of the bridge by the patient, the bridge was cemented.

Figure 4B: The gap has been closed by fracture of the remained alveolar bone on the titanium. The crack of this fracture is evident in the picture

Figures 5A-5B: Sterile rigid plastic rings have been cemented on the abutments using conventional cements

Results and discussion The implants were integrated successfully after 3 months. There was no sign of inflammation near the temporary bridge and/or implants. The patient was instructed to maintain oral hygiene. Immediate replacement of extracted teeth has the advantage of a shorter treatment period and less surgical procedures as well as resulting in better esthetic results, according to Hamouda and colleagues (2015).

It is likely after tooth extraction to encounter a remained alveolar bed with different bone level in the buccal and lingual surface of the socket. This problem can easily be solved with selection of a one-piece implant with different gingival heights. OPS implants are the only system that provides implants with variable gingival heights. The clinical point is that by considering the more apical bony wall of the remained socket as the reference point for drilling, the dentist should select a gingival height size, which can compensate for the difference between alveolar walls.

The temporization phase of these one-piece implants helped the dentist and patient have a clear idea of the final prosthesis. Furthermore, the soft tissue maturation near the temporary bridge had the Volume 8 Number 4

Figure 6: The custom-made temporary bridge has been cemented on the abutments. The acrylic resin can be formed same as the natural tooth contour; therefore, the final healing of the soft tissue will result in favorable esthetic results

Figure 7: After osseointegration of implants, the abutments were prepared intraorally to produce a passive path of insertion for the final bridge Implant practice 41

CONTINUING EDUCATION

Figure 3: Implant bed preparation after serial drilling

Figure 4A: OPS implants inserted in the socket. Due to the oval shape of the socket after extraction, the remained alveolar walls can be fractured on the titanium surface to seal the gap between bone and titanium

CONTINUING EDUCATION

Figure 8: After the indirect impression of the implants, the acrylic framework was made on the final cast

same characteristics as the natural tooth soft tissue. Implant patients have shown to prefer restoring their missing teeth rapidly (Schropp, 2004), and our patient did not experience the edentulous period. It seems that precise debridement of the sockets after conservative extraction ensured an infectionfree site for successful osseointegration (Blus and colleagues, 2015).

It is necessary for the practitioner to be provided with a detailed surgery protocol to have an accurate implant bed beyond the extraction socket. The Dr. Nik Implant System has determined a simple and practical protocol with regard to the amount of bone debris accumulated in the drill flutes. It is important to examine the primary stability of the intended implant by placement of the same size drill into the socket and checking the axial stability of the drill. Implementation of this protocol guaranteed proper selection of the one-piece implant with enough primary stability. The Dr. Nik Implant System is designed for precise insertion of four types of implant with the same surgical kit. If the final drill of the implant bed preparation lacks sufficient stability in the bone, we would insert conventional two-piece screw-type implants (S&S Biomat) in the socket. IP

Figure 9: In the try-in session, the accuracy of finish line was checked circumferentially; in the case of gap or other maladaptation, the coping can be relined intraorally using cold cure acrylic resin. It is necessary to have enough space for ceramic to be added on occlusal and axial surfaces

Figure 10: The casted framework should be checked for fitness and accuracy of finish line adaptation and rocking

Figure 11: Final restoration

REFERENCES 1.

Barrachina-Diez JM, Tashkandi E, Stampf S, Att W. Long-term outcome of one-piece implants. Part I: implant characteristics and loading protocols. A systematic literature review with metaanalysis. Int J Oral Maxillofac Implants. 2013;28(2):503-518.

2.

Blus C, Szmukler-Moncler S, Khoury P, Orrù G. Immediate implants placed in infected and noninfected sites after atraumatic tooth extraction and placement with ultrasonic bone surgery. Clin Implant Dent Relat Res. 2015;17(suppl 1):e287-297.

3.

Esposito M, Grusovin MG, Maghaireh H, Worthington HV. Interventions for replacing missing teeth: different times for loading dental implants. Cochrane Database Syst Rev. 2013;3:CD003878.

4.

Finne K, Rompen E, Toljanic J. Three-year prospective multicenter study evaluating marginal bone levels and soft tissue health around a one-piece implant system. Int J Oral Maxillofac Implants.

2012;27(2):458-466.

5.

Hamouda NI, Mourad SI, El-Kenawy MH, Maria OM. Immediate implant placement into fresh extraction socket in the mandibular molar sites: a preliminary study of a modified insertion technique.

Clin Implant Dent Relat Res. 2015;17(suppl 1):e107-116.

6.

Prithviraj DR, Gupta V, Muley N, Sandhu P. One-piece implants: placement timing, surgical technique, loading protocol, and marginal bone loss. J Prosthodont. 2013;22(3):237-244.

7.

Schropp L, Isidor F, Kostopoulos L, Wenzel A. Patient experience of, and satisfaction with, delayed-immediate vs. delayed single-tooth implant placement. Clin Oral Implants Res. 2004;15(4):498-503.

8.

Sohn DS, Bae MS, Heo JU, Park JS, Yea SH, Romanos GE. Retrospective multicenter analysis of immediate provisionalization using one-piece narrow-diameter (3.0-mm) implants. Int J Oral Maxillofac Implants. 2011;26(1):163-168.

9.

Zembić A, Johannesen LH, Schou S, Malo P, Reichert T, Farella M, Hämmerle CH. Immediately restored one-piece single-tooth implants with reduced diameter: one-year results of a multi-center study. Clin Oral Implants Res. 2012;23(1):49-54.

42 Implant practice

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Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement 12/1/2012 to 11/30/2016 Provider ID# 325231

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Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 16 CE credits for only $99. To receive credit, complete the 10-question test by circling the correct answer, then either: n Post the completed questionnaire to: Implant Practice US CE 15720 N. Greenway-Hayden Loop. #9 Scottsdale, AZ 85260 n Fax to (480) 629-4002.

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CITY, STATE, AND ZIP CODE

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

EMAIL

TELEPHONE/FAX

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

Immediate esthetic rehabilitation with one-piece implants NIK/GOLAB

1. Immediate loading of dental implants is a valuable technique that can ________. a. decrease the treatment period b. minimize surgical sessions c. increase patient satisfaction d. all of the above

which enable self-tap characteristics of the implant. a. V-shaped b. C-shaped c. U-shaped d. not threaded

2. Solid design of these implants ensure small diameter manufacturing; therefore, they can be used in the esthetic zone with adequate distance from adjacent teeth, resulting in preservation of ________. a. interdental bone b. gingival papillae c. rotational elements d. both a and b

5. The patient received antibiotics (amoxicillin and metronidazole) and an analgesic _________. a. for 2 months post-surgery b. before the surgery c. continued 1-week post-surgery d. both b and c

3. In patients with _________, the finishing line of crown preparation can be extended on solid abutment to cover the titanium surface. a. thin mucosa b. possible exposure of abutment margin c. a thick mucosa d. both a and b 4. The threads on the apical area are _____,

Volume 8 Number 4

6. The drills are specially designed to collect the _____ in their flutes. a. excess soft tissue b. bone debris c. bacteria d. carious material 7. (In this case) The inserted implants gained the ______ insertion torque, which is acceptable for immediate loading of implants. a. 5Ncm b. 20Ncm

c. 35Ncm d. 50Ncm 8. _________ after insertion surgery, the implants were osseointegrated, and the abutments were prepared using highspeed carbide burs (SS White). a. Two weeks b. One month c. Three months d. Six months 9. It seems that ____________ after conservative extraction ensured an infection-free site for successful osseointegration. a. using acrylic framework b. use of zinc phosphate cement c. precise debridement of the sockets d. using an oval-shaped socket 10. It is important to examine the primary stability of the intended implant by _______. a. only using a resin frame-work b. placement of the same size drill into the socket c. checking the axial stability of the drill d. both b and c

Implant practice 43

CE CREDITS

IMPLANT PRACTICE CE

IMPLANT INSIGHTS

Optimizing health in integrative dentistry: whole-body approach Dr. Saynur Vardar explores how the connection between the body and mouth can affect the implant practice

Dr. Vardar’s personal journey to integrative and functional medicine Is it possible to bridge East and West?

At first they may seem very different from each other, but in fact, they are “two sides of the same coin.” Even though they appear to be opposites, in truth, one does not exist without the other. Together they make one — together they are the whole.

I was born and raised in Turkey, a place where East definitely meets West, a place where these two worlds live together in harmony. I have known this my whole life, and I believe it is my path, my dharma, to bridge these two worlds — both personally and professionally. So it is natural for me to ask the question, Can we apply this integrative approach to dentistry? Can we blend conventional, modern (Western) dental techniques with complementary (Eastern), holistic practices? Can we look at today’s dentistry in terms of whole-body wellness?

44 Implant practice

I had been practicing conventional dentistry and periodontics for several years until I became sick and personally experienced the healing benefits of an integrative and functional approach. I was diagnosed (through the lens of conventional medicine) with 10 different diseases and left with no answers, many questions, and bottles of pills. I went to numerous specialists, and every one of them suggested that the cause of each illness was something totally separate from the others. There was no one who could connect the symptoms and give me a more satisfying “big picture” answer.

So I started searching for answers. I thought about whether these diseases were actually connected. I took an integrative and functional medicine approach. I changed my diet, did detox programs, increased my yoga and meditation practice, began to exercise daily, and got rid of as many negative

influences as I could control — and I started to feel healthy again. It worked — without pills and without “symptom band-aids.”

Changing what I ate, how I breathed, how I relaxed, and how I detoxed, and putting back what my body was missing cured me. It was so amazing that I knew I wanted to share this with my patients. I started taking classes on integrative and functional medicine. I got certified by the Institute for Functional Medicine on “Applying Functional Medicine to Clinical Practice.” I became a yoga and meditation instructor and became certified in hypnotherapy. I took courses on dental homeopathy. I started working with amazing healthcare practitioners who were committed to integrative and functional medicine. And as I continued to learn, I started sharing my discoveries with my patients. Eventually, this journey led me to the concept of integrative dentistry.

Volume 8 Number 4

ur mouth is not separate from the rest of our body. Everything is connected.

What happens in one part of our body affects all the other parts of our body.

There is not only a physical connection through the blood stream, digestive tract, or nervous system, but also these systems are all connected energetically through meridians or “energy highways,” which is the basis of acupuncture. Oral bacteria can travel through the body and is found in the plaque in the heart, in the amniotic fluid of pregnant women, and in colorectal tumors.

The integrative and functional approach to health and wellness considers the person as a whole-body being and strives to support natural healing activities and restore balance across the mind, body, and spirit.

Gaining more attention and recognition in the healthcare industry, integrative dentistry combines conventional modern dental techniques with complementary, whole-body modalities and practices. In the integrative approach, the focus changes from “disease” to “health” so that the ultimate goal is overall quality of life and well-being — not just “disease-free.”

Gum disease is one of the most common chronic diseases. It has been reported that 47.2% of the U.S. population has periodontitis, which is a form of gum disease that causes bone loss around the teeth and ultimately results in tooth loss. Periodontitis prevalence is approximately 70% in adults over 65 years old and is still the No. 1 reason for tooth loss.1 To prevent tooth loss due to periodontal disease or to restore lost teeth with dental implants and maintain healthy tissues and jaw alignment is crucial for overall quality of life and well-being; 47.7% of the U.S. population has at least one chronic disease such as diabetes, cardiovascular disease, and rheumatoid arthritis.2 Chronic diseases are considered lifestyle diseases by an integrative and functional approach, and periodontitis is related to many of these chronic diseases. An underlying factor in every one of these chronic diseases is inflammation.

In the integrative and functional approach, we focus on underlying causes, not the symptoms. We guide our patients to make whole-body, lifestyle changes to achieve a healthy balance, while at the same time, we use state-of-the-art dental techniques to help the body heal better and regain natural balance.

At my practice, about 2 weeks before periodontal and implant surgery, we suggest that our patients start to prepare their bodies physically for the upcoming surgery by

Volume 8 Number 4

Our mouth is not separate from the rest of our body.

Everything is connected.

engaging in healthy nutrition that includes enough macronutrients, vitamins, minerals, drinking enough water, eating protein, and taking some of the supplements in deficiency.

Nutrition in general plays an important role in the wound-healing process. Adequate protein intake is essential to successful post-surgery healing since the body uses it to create healthy tissue. Lean protein is definitely the way to go, and it can be readily found in eggs and meats like fish, chicken, and turkey or in beans, nuts, quinoa, and leafy greens. It’s important to eat whole food and stay away from canned and processed food to reduce the detoxification process, so energy and minerals can be available for regeneration and repair in the healing process.

We recommend adding probiotics and fiber to your diet before and after oral surgery.

Administration of antibiotics can cause an imbalance in the gut microbial flora. Use of probiotics can positively influence postoperative health by stabilizing the intestinal barrier, enhancing overall immunity, and reducing the incidence of infections.

We also suggest that our surgical patients take 1-2 gm of vitamin C per day during the healing period. Vitamin C is essential for the synthesis of collagen, proteoglycans, and the organic components of the intracellular matrix of tissues, such as bones, skin, capillary walls, and other connective tissues. Taking high dosages of vitamin C for a 2-week period before surgery and during the postoperative period will ensure that a high blood-level of vitamin C is maintained to aid the healing process. Some hospitals even administer high doses of vitamin C intravenously in the emergency room.

As well as traditional periodontal techniques and treatments, our integrative approach extends to the materials we use such as metal-free, zirconia implants and a de-emphasis on conventional painkillers.

Instead of chemicals and pharmaceuticals, we primarily use homeopathic remedies for pain and swelling, which work via vibrations — without side effects or drug interactions.

In an integrative holistic approach, we

suggest biocompatibility material testing for patients who have allergies and autoimmune diseases to make sure that they do not have reactions to materials used in their mouth, even though we know all the materials used in dentistry are tested in hundreds of patients. This way there is no guessing; rather, it is customized and tested that materials are biocompatible for that individual because every person is different. A simple blood test can be done for dental materials.

We also focus on preparing our patients mentally for surgery and healing. We introduce them to breathing exercises, yoga, meditation, and guided imagery to reduce anxiety and increase healing potential by engaging their mind for healing. Research shows that patients who undergo guided imagery and relaxation techniques before surgery heal faster, need less pain medications, and leave the hospital sooner than control groups. We also use electromagnetic BioRegulation therapy devices routinely to help accelerate healing and optimize recovery by tuning the cells in a balanced electromagnetic energy field.

Through this whole-body approach, patients can manage their oral health with better healing and less complication risk as well as improve their overall wellness with the ultimate goal of health and happiness. IP

REFERENCES 1. Eke, PI, Dye BA, Wei L, Thornton-Evans GO, Genco RJ. Prevalence of periodontitis in adults in United States: 2009 and 2010. J Dent Res. 2012;91(10):914-920.

2. Global Spa Summit, SRI International. Spas and the global wellness market: synergies and opportunities. Presented at Global Spa Summit. May 2010. 1-91. http://www.sri.com/ sites/default/files/publications/gss_sri_spasandwellnessreport_rev_82010.pdf.

Saynur Vardar-Sengul, DDS, PhD, Board Certified Periodontist, of The South Florida Center for Periodontics and Implant Dentistry (http://www.flsmile.com) in Boca Raton, Florida, provides integrative and functional periodontal and dental implant services. With more than 15 years as a practitioner, researcher, and educator, Dr. Vardar-Sengul combines a range of natural and holistic modalities alongside state-of-the-art dental techniques, providing patients with customized treatment plans that approach dental health as an integral part of a whole-body wellness program. Dr. Vardar-Sengul also teaches at Nova Southeastern University, College of Dental Medicine, Postgraduate Periodontics as an Associate Professor.

Implant practice 45

IMPLANT INSIGHTS

O

TECHNOLOGY

Restoring implant supported maxillary single central incisors using Nobel Biocare® Angulated Screw Channel (ASC) abutments and ASC Straight Abutments Dr. Richard Elliott illustrates a screw-retained esthetic restoration

T

he esthetic restoration of implantsupported maxillary single central incisors remains one of the most challenging treatments in modern dentistry. Achieving the correct soft tissue contour and ceramic esthetics to mirror the natural adjacent central incisor is the key to success.

In my experience, implant dentists are requesting screw-retained options wherever possible due to the ability to easily retrieve the restoration without compromising the framework or the ceramics. The launch of the NobelProcera® Angulated Screw Channel (ASC) abutment by Nobel Biocare® has made screw retaining these cases much easier by allowing the technician to “bend” the screw access channel into a more favorable position

(up to 25 degrees). Where the screw access channel of a restoration on an implant incisor cannot be corrected using the ASC software (greater than 25 degrees) and a cementable restoration is indicated, the Straight ASC abutment gives much greater strength due to its titanium interface, which secures it into the implant head, reducing the chances of a fracture in this area.

Case 1: ASC Screw Retained This case demonstrates an UL1 ASC screw-retained zirconia abutment (Nobel Biocare® “Light” shaded zirconia and IPS e.max® Ceram® [Ivoclar Vivadent]). Ceramic is layered directly onto the abutment for a one-piece screw-retained crown.

Figures 3 and 4: NobelProcera® 2G scanner screen shots depicting the angulation of the screw channel

Figures 1 and 2: NobelProcera® 2G scanner screen shots showing the anatomic design of the abutment framework using the transparent diagnostic tooth to verify ceramic support

Figure 5: Completed restoration after initial placement (blanching of the soft tissue present)

Richard Elliott completed a BTEC National Diploma in Dental Technology at Newcastle College in 1999. He qualified from Manchester Metropolitan University with an Honors Degree in Dental Technology in 2002. In 2007, Dr. Elliott was awarded a Postgraduate Diploma in Dental Implantology with Distinction also from Manchester Metropolitan University. He also is on the council of management of the British Institute of Dental and Surgical Technologists (BIDST) as its current Treasurer.

In September 2013, he became the first United Kingdom technician to study at the world-renowned Kois Center® in Seattle, Washington, under Dr. John Kois, and in November 2014 became the first United Kingdom “Kois Recognized Specialist” Technician. He has worked in gold and ceramic positions, but his real interest lies in implantology. Dr. Elliott will start his Clinical Dental Technician training in the next 12 months.

Disclosure: Dr. Elliott lectures for Nobel Biocare and is Platinum Approved by Straumann.

Figure 6: Completed restoration after 5 minutes of placement (blanching of soft tissue has completely gone) 46 Implant practice

Volume 8 Number 4

This case presents an UL1 IPS e.max® crown cemented onto a “white” shaded zirconia abutment with a cementable e.max coping pressed in an MO1 ingot and layered with e.max Ceram.

For more information, visit www.nobelbiocare.com. IP

Figure 7: NobelProcera® 2G scanner screen shot of abutment design within the transparent diagnostic

Figure 9: NobelProcera® 2G scanner screen shot showing final abutment design

Figure 8: NobelProcera® 2G scanner screen shot using the cross-sectional view tool to view the distance between the abutment and the opposing dentition

Figures 10 and 11: Smile and retracted smile photos of previous restoration

Figures 12 and 13: Smile and retracted smile photos of new implant-supported restoration

Volume 8 Number 4

Implant practice 47

TECHNOLOGY

Case 2: ASC Straight

PRACTICE MANAGEMENT

Guide to Going Paperless

Going paperless means replacing paper records and paper forms with digital records and electronic communication. Going paperless is about reducing office costs and clutter and improving efficiency.

G

oing paperless is one of the most talked-about topics in dental offices today. Many practices are trying to find ways to streamline workflow, reduce waste, increase efficiency, and improve profitability by going paperless.

Dental practices want to go paperless for many different reasons. Some are looking to become chartless and begin storing patient treatment information electronically. Some want to reduce office costs and clutter and use as little paper as possible. And some want to find new ways to keep patient information and data secure.

Henry Schein Practice Solutions knows this is an important topic, and we want to help you reach this goal, which is why we have created this framework to guide your practice through the process of going paperless.

This guide lists the tasks an average dental practice performs with paper and compares them to the way you can perform them with less paper using your Vision software eServices. It also lists suggestions about preparing to go paperless.

Before you begin Going paperless is a process, and it will take time and preparation. Before you begin the process of going paperless, make sure you have adequate equipment, create new office policies, and ensure that your team members have the necessary skills required to work in a paperless office.

Equipment You need to have computers in every operatory, the doctor’s office, the front desk, 48 Implant practice

consultation room, etc. You should also have one or more computers in the lobby for patients to use to fill out forms. It is also best if your computers have a high-speed Internet connection. Because you will still have paper in your office (EOBs from insurance companies, receipts, written letters, etc.), you’ll need a multi-page scanner. You’ll also need a digital camera, digital X-ray devices, and one or more electronic signature devices.

Policies You need to perform a daily, off-site backup to ensure that your data is secure and easily accessible in the event of a disaster. You should also be familiar with HIPAA compliance and other federal regulations related to computers in the dental office.

You should have documented computer and Internet usage policies so your staff is aware of what is acceptable in your practice.

Team skills The biggest change you and your staff will have to make is the way you work, which is why it is necessary to make sure you and your staff get training to ensure a smooth transition. The better your skills, the easier the transition will be.

What you can do Each day, there are specific tasks you must perform for your practice to operate smoothly. You can do several, if not all, of these tasks with less paper. The most important thing to remember about going paperless is to digitize when and where you can.

The following table lists the tasks an average dental practice performs with paper and compares them to the way you can perform them with less paper using your Vision practice management software and eServices.

Patient Check-in With Paper

With Less Paper

Print out or photocopy patient forms, and have patients fill them out with a pen and a clipboard.

Create forms in the Questionnaires module, and allow patients to fill them out electronically on a Vision kiosk in your office or online using PBHS truForms.

Make a photocopy of patient information (driver’s license, insurance card, etc.), and store it in patient files.

Scan patient information (driver’s license, insurance card, etc.), and store it digitally in each patient’s file in the Document Center using a multi-page scanner.

Take pictures of patients, print the photos, and clip them inside paper charts.

Take digital pictures of patients and import them into in the Patient Picture module.

Have patients and providers sign paper consent forms, and store them in paper charts and Patient Info Center.

Have patient sign consent forms electronically, and store them in the Narratives, Letters Log, EHR, or Document Center.

Volume 8 Number 4

All Smiles. Every Step of the Way. From a first dental visit to hygiene, orthodontics and implants, the CareCredit credit card can make it easier for families — mom, dad and the kids — to get care when they want and need it. And CareCredit gives them a financing resource they can use again and again as credit becomes available. *

*Subject to credit approval.

Help more families achieve healthy, happy smiles. For more ways to optimize CareCredit in your practice, contact your Practice Development Team by calling 800-859-9975, option 1, then 6.

Not yet enrolled? Call 866-246-6401

carecredit.com IMPLT0815DA

PRACTICE MANAGEMENT Charting

Scheduling

With Paper

With Less Paper

With Paper

Document patient clinical treatment in a paper chart.

Document completed, existing, and planned treatment in the Patient Chart. Document perio exams in the EHR or ClinicalVision.

Store paper charts in a file room.

Scan paper charts into the Document Center.

Print patient route slips and pull paper charts to prepare for each appointment.

With Less Paper

Schedule appointments in a paper schedule.

Schedule appointments using the Appointment Book.

Print paper schedules for the day, and post them in each operatory.

View your daily schedule, with up-to-theminute changes, in the operatory using the Appointment Book.

View appointment information and patient treatment in the Patient Info Center or Appointment Book as needed during each appointment.

Manually calculate and track recall due dates.

Set up patients for continuing care in the Appointment Book and have due dates automatically calculated and tracked for you.

Develop X-ray films.

Use one of the many digital imaging devices and software programs compatible with your Vision software to view X-rays electronically.

Print, address, and mail appointment reminder cards.

Outsource appointment reminder cards to a fulfillment center, and send automatic appointment reminders via email or text messages using DemandForce or Televox.

Handwrite clinical notes and procedure information in paper charts.

Type clinical notes in the Patient Chart or use Dragon for hands-free clinical note dictation.

Billing With Paper

Treatment Plan Presentation and Patient Education With Paper

With Less Paper

Document treatment options in paper charts.

Chart treatment options in the Treatment Planner.

Draw treatment options on paper, or use mouth models to present treatment options and educate patients.

Present multiple treatment options and compelling patient education using the Phasing Treatment Planner.

Print, stuff, seal, address, and mail billing statements for each patient.

Outsource the printing, stuffing, sealing, addressing, and mailing of billing statements to a fulfillment center using ExpressBill.

Make photocopies of billing statements, and store them in paper charts.

Import copies of billing statements into the Document Center, and store them in electronic patient files.

Insurance Management

Patient Check-Out With Paper

With Less Paper

Print or handwrite patient care instructions.

Create patient care instructions using the word processing program or Narratives, and then e-mail them to patients.

Print and mail patient records and referral information to other doctors.

Send referral information to other doctors electronically using PBHS Collaborator.

Print and mail lab case requests and information to labs.

Create and track lab cases, and send lab requests electronically using DDX.

With Paper

With Less Paper

Print and mail paper claims and claim attachments.

Send claims electronically using eClaims.

Use the Screen Capture tool to create electronic attachments. Send attachments electronically with eClaims.

Store paper copies of EOBs in paper charts.

Receive and post electronic EOBs directly into your Vision software, and store electronic copies in patient files. Scan paper EOBs into the Document Center.

Where to get help

Reporting With Paper Print reports, and store in paper archives on or off-site.

With Less Paper

With Less Paper Generate reports and store electronically in your Vision software, and share with key staff.

Going paperless is a process, and it will take time and preparation.

Look at the recommendations in this guide, and evaluate your staff’s proficiency with your Vision software and eServices.

If you need training on any of these tools, visit the training section on your Vision product website, where you will find information about in-office training, on-demand resources in the Resource Center, and other training events like Expert Series seminars, phone trainings, and webinars.

To purchase the eServices tools you need to go paperless, such as EHR, eClaims, PBHS tools, or ExpressBill, contact Specialty Software Sales at 800-680-6902 Opt.1. IP This information was provided by Henry ScheinÂŽ Dental

50 Implant practice

Volume 8 Number 4

no more

compromises

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

restorative ease

universal surgical kit

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

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

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

bone attachment Laser-LokÂŽ microchannels achieve superior osseointegration

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

Made in the USA

*Tapered Plus, Tapered Tissue Level, Tapered Internal and Tapered 3.0 SPMP13154 REV E MAY 2015

ON THE HORIZON

Technology leads to better results Dr. Justin Moody offers his experience with equipment and materials that make bone grafting more predictable

W

ouldn’t it be great if we never had to worry about having enough bone volume for dental implant surgery? That would certainly make the procedure easier, but unfortunately, that is just not the case.

As matter of fact, with bone loss being 10 times greater the first year after tooth loss, we find ourselves needing to regenerate bone more than ever. Over the years, I have found that about 35% of my patients need hard tissue augmentation to regain lost bone volume, and in my opinion, that’s a significant percentage.

We have not always had the product options that are available today, and in my experience, as a result of new materials and equipment, grafting has become easier and far more predictable. Autogenous bone is always the best, but when we need a large volume, that is not always easy to harvest.

In my practice, I have had good results over the years with allograft materials such as MinerOss® from BioHorizons®.

Technology has stepped into this area and is showing us how we can save time and money. 3D cone beam imaging (I use i-CAT™) along with Tx STUDIO™ 5.4 by Anatomage now allows us to estimate the graft volume so that we can use just the right amount of material. With the detailed anatomical information that I can obtain from the i-CAT scan, I can determine the precise location of the graft, making surgery shorter and safer for the patient. The ability to have

Supplemental grafting at the time of implant placement with cancellous MinerOss

Buccal defect being grafted with MinerOss using a tent-pole technique

6-month post graft CBCT slice showing results

... we find ourselves needing to regenerate bone more than ever.

this information ahead of time makes the clinician more efficient, the procedure more predictable, the outcome more reliable, and the ultimately more profitable — all while giving the patient the best care possible.

Knowing all the facts and having all of these tools at my fingertips gives me more confidence and allows me to be more creative and offer more options for patient care. IP MinerOss

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

Disclosure: Dr. Moody is a paid speaker for BioHorizons and i-CAT. He has no ties to Anatomage.

Tx STUDIO 5.4’s graft estimating feature 52 Implant practice

Volume 8 Number 4

INDUSTRY NEWS ZEST Anchors — standing behind its narrow diameter implants with an extended warranty program ZEST Anchors is offering a 10-year warranty for its narrow diameter (less than 3 mm) dental implants. The company strives for and has a long history of producing high-quality products for overdenture applications. The company is also committed to providing best-in-class service to its valued customers, allowing them to provide trusted products and services to their patients. It is this commitment to quality and strong belief in the product designs that has allowed the company to establish a 10-year warranty for its line of narrow diameter dental implants. The warranty will replace a LOCATOR® Overdenture Implant (LODI) or SATURNO™ Narrow Diameter Implant (SNDI) Product for a $25 processing fee for each qualifying implant.

Complete details of the ZEST Anchors Narrow Diameter Implant Warranty can be found on the ZEST Anchors’ Website at www.zestanchors.com

PLANMECA announces open registration for Power of Digital Dentistry Conference PLANMECA announced open registration for The Power of Digital Dentistry Conference, the first-ever conference bringing together PLANMECA Romexis, Imaging and CAD/CAM Users.

The conference will be held October 16-17, 2015, at the Gaylord Texan Resort in Grapevine, Texas. Low rates are available for auxiliary teams and other attendees.

The conference will host more than 20 distinguished panelists, speakers, and industry leaders, and feature over 30 educational and hands-on courses led by top imaging and CAD/CAM industry leaders. The lead sponsor for the conference is PLANMECA, and additional sponsors include Ivoclar-Vivadent and Premier Dental.

Topics include: • Restorative success with digital dentistry • Advanced utilization of 3D technology • Patient virtualization — digital implant diagnosis • The ultimate dental assistant • The power of teamwork in restorative diagnosis and care • Marketing your high-tech practice To register, visit www.powerof digitaldentistry.com.

54 Implant practice

KaVo Kerr Group Imaging launches inaugural dental 3D University Registration is open for the first Dental 3D University (3DU) hosted by KaVo Kerr Group’s imaging brands Gendex™, NOMAD™, SOREDEX™, and Instrumentarium™. This exciting 2-day event promises to provide dental professionals with an educational environment dedicated to cone beam CT solutions that will enhance their practices and put them in full control of treatment outcomes. 3DU will be held Oct 1-2, 2015, at the Hilton Chicago, in Chicago, Illinois. Up to 12 CE credits can be earned.

Featured topics include: • Successfully incorporating 3D into your practice • Implant planning with 3D and surgical guides • Reading 3D scans • Insurance and billing for a smoother reimbursement process For more information, visit dental3DU.com.

CS 3500 Intraoral Scanner wins 2015 Edison Award for its innovative design The CS 3500 intraoral scanner by Carestream Dental has been awarded a bronze 2015 Edison Award in the category of Dental 3D Printers and Services by the internationally renowned Edison Awards™. The distinguished award, inspired by Thomas Edison’s persistence and inventiveness, recognizes innovation, creativity, and ingenuity in the global economy.

The CS 3500 allows practitioners to easily acquire true color, 2D, and 3D images. Requiring no external heater or trolley system, the CS 3500 features high-angulation scanning of up to 45 degrees and to a depth from -2 mm to +13 mm. Additionally, the CS 3500 uses open-format STL files for easy sharing and can be plugged directly into a computer’s USB, making it truly portable. The scanner offers workflows for restorative dentistry, orthodontics, and implantology.

Volume 8 Number 4

Zest IP Holdings, LLC and Zest Anchors, LLC have settled the patent and trademark infringement lawsuit brought by Zest against Implant Direct Mfg. LLC, Implant Direct LLC, and Implant Direct Int’l (Collectively, “Implant Direct”), Implant Direct Sybron Manufacturing LLC, and Implant Direct Sybron International LLC (Collectively, “IDSI”).

Within the agreement, IDSI will manufacture and sell the GoDirect® products under a license from Zest. IDSI will also phase out the GPS® abutments and males and begin selling the Locator® Attachment System under a distribution agreement with Zest. The settlement was designed to provide IDSI’s customers a seamless experience transitioning back to the Locator Attachment System, which is considered the gold standard in the industry.

ZEST Anchors pioneered the pivoting and self-aligning design of the LOCATOR Attachment System and continues its innovative path by consistently giving clinicians the tools to provide worldclass overdenture therapy. Implant Direct offers a broad range of surgical, prosthetic and regenerative solutions and is a joint venture within the KaVo Kerr portfolio of brands.

Prosthetic Materials & Solutions

Each week subscribers can look forward to receiving relevant and innovative information including: • CE articles • Practice Profiles • Case Studies • Cutting-Edge Technology • and more Subscribe for free today: http://implant-us.link/implantnewsignup

Your Total Solution Provider

Implant

Fabrication

Subscribe to the Implant Practice US newsletter!

Scan Body

Biodenta has established its position within the dental field on the concept of the Total Solution Provider. This is a systems based approach to dentistry. Our two main product groups are Dental Implant System (DIS) and Digital Dentistry System (DDS).

We believe that the future belongs to those who successfully can integrate these modules in a smart and efficient way. Our mission is to help clinicians to do this through advancements in products, workflows, and clinical procedures.

Biodenta stands for the highest Swiss quality and precision. Our staff collaborates with dental professionals and specialists from other industries on a daily basis in order to improve products and solutions for increased reliability, predictability, and simplicity. We invite you to learn more about Your Total Solution Provider and how we can work together to improve implant dentistry.

Planning and Design

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Biodenta North America LLC | 11E Firstfield Rd. | Gaithersburg, MD 20878 | USA | Tel +1 240 482 8484 | usa@biodenta.com

www.biodenta.com/learnmore Volume 8 Number 4

Implant practice 55

INDUSTRY NEWS

Zest Anchors and Implant Direct Announce Settlement

PRODUCT PROFILE

The Hahn™ Tapered Implant: 45 years in the making An inside look at the history of an innovative implant that makes treatment simpler and more predictable

S

ince placing his first implant nearly 45 years ago, Dr. Jack Hahn has spent much of his career as an implantologist thinking of ways to make treatment more accessible to the practitioner as well as the patient. From the early blade-form implants he helped develop in the late 1970s to the newly released Hahn™ Tapered Implant, Dr. Hahn’s efforts have been driven by the desire to continually improve in order to make treatment simpler and more predictable.

“The easier we make it to position the implant for a restoration that looks like a natural tooth, the better results we’ll have,” noted Dr. Hahn in a recent interview. It was this line of Designed to maximize clinical efficiency, predictability, and primary stability, the Hahn Tapered Implant thinking that inspired Dr. is the culmination of Dr. Hahn’s 45-year career as an innovator and implantologist Hahn’s idea for the first tapered implant. After a long day that included “The better we make implant design, the more several cases in which he had difficulty placing accessible we can make implant dentistry to parallel-walled implants doctors, so they can improve their practices and in the anatomically restricted space of the the quality of life of their patients.” anterior maxilla, Dr. Hahn Dr. Hahn in his Cincinnati office holding the patent had an epiphany: “The for the original tapered implant design tooth I was replacing results. “When I first visited their facilities, it would serve as the basis was taper-shaped, so was immediately apparent that their manufor a new implant design that he considers why was I putting in a square peg?” That facturing capabilities are state-of-the-art. his best.

“I had this implant that would be very night, he sketched out the concept.

Their engineering team is superb, and their easier for doctors to place, with a simpler Steve Hurson, former chief scientist for expertise on the prosthetic side of implant drilling protocol and a thread design that Nobel Biocare, has said of this industrydentistry has been invaluable in creating an would allow for efficient placement and a changing innovation: “Dr. Hahn identified a implant that is as simple to restore as it is high degree of primary stability.” need for an implant with a narrower apex, to place.”

To take his design concept to the next which would achieve higher primary stability With a career that speaks volumes on the level, Dr. Hahn’s efforts eventually led him to in soft bone. The concept was to have an importance of continual innovation, Dr. Hahn the implant manufacturing division of Glidewell implant design that would have the tapered is proud to have his name on an implant Laboratories, where he reunited with some of shape of a tooth root … resulting in a system that contributes to the forward progression the same engineering personnel with whom with outstanding predictability.” of implant dentistry.

“The better we make he had successfully collaborated in the past.

Nearly twenty years later, Dr. Hahn’s implant design, the more accessible we can In owner Jim Glidewell, he found an individual vast experience with placing and restoring make implant dentistry to doctors, so they equally committed to enhancing the quality of implants afforded clinical observations that can improve their practices and the quality treatment while reducing the cost of care, with of life of their patients.” the ultimate goal of expanding the availability Keith Peters is a contributing editor for Inclusive magazine.

Visit HahnImplant.com for information. IP of implant therapy to more patients.

He works closely with dentists in developing articles and case This partnership culminated in the recent studies on the latest techniques, protocols and advancements Hahn™ Tapered Implant is a trademark of Glidewell Laboratories. launch of the Hahn Tapered Implant System, in implant therapy.

This information was provided by Glidewell Laboratories. and Dr. Hahn couldn’t be happier with the 56 Implant practice

Volume 8 Number 4

Experience the advantages of Hahn™ Implants “The Hahn™ Tapered Implant System offers practitioners some distinct advantages: an easy-to-use surgical kit with length-specific drills, a thread pattern that engages the bone precisely as directed with a high degree of initial stability, and esthetic healing and restorative components for a natural emergence profile. Add to this the support of an industry-leading laboratory, and you won’t find a more complete implant system anywhere on the market.”

– Timothy Kosinski, DDS, MAGD; Bingham Farms, Michigan “The simplified surgical protocol of the Hahn Tapered Implant System has helped me boost my case efficiency, with the wide-ranging assortment facilitating predictable placement in all regions of the mouth. The implant performs exceptionally well in fresh extraction sites.

Anyone looking to confront the challenges of implant therapy will appreciate the versatility and performance of this exciting new system.”

– Paresh Patel, DDS; Mooresville, North Carolina

$100* per implant with special offer $160* per implant list price Already have a NobelReplace® surgical kit? Use your existing kit and order five Hahn Tapered Implants for just $500 ($300 savings). This offer also includes a set of four FREE Hahn Tapered Implant drivers ($200 value).

7.0 mm

3.0 mm

3.5 mm

5.0 mm 4.3 mm

IMMEDIATE LOADING

LIMITED SPACE

MOLAR EXTRACTIONS

Achieve high primary stability, facilitating nonfunctional provisionalization where indicated.

Robust 3 mm implant allows for restoration of narrow ridges and tight interproximal spaces.

Wide-diameter implant ideally suited for “titanium grafting” of posterior extraction sites.

NobelReplace is a registered trademark of the Nobel Biocare group. Hahn Tapered Implant is a trademark of Prismatik Dentalcraft, Inc. *Price does not include shipping or applicable taxes.

For more information

877-708-7972 www.hahnimplant.com

Hahn implants and components are manufactured in our Irvine, California, facility.

3034532_1.0 ECO #3034511

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Each implant body design promotes self-tapping, initial stability and reduced crestal bone stress The NEW SwishActive also features a platform-shifting conical hex connection with six indexing positions for precise prosthetic placement. Matched transgingival profiles on prosthetics allow for consistent soft tissue management throughout treatment.

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SwishPlus and SwishTapered fully compatible with Straumann tissue level implants, with some restrictions for 3.3mm and 5.7mm diameter implants. SwishActive surgically compatible with Straumann drills with exception of profiling drills and Bone-Level Tapered drills. Promotion valid for new customers only and cannot be combined with other offers. Promotion expires September 30, 2015. Price comparisons based upon US list prices for comparable items as of January 2015. All trademarks are property of their respective companies.