Implant Practice US December/January 2015/2016 Issue - Vol8.6 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews December 2015/January 2016 – Vol 8 No 6

Evaluation and management of common dental implant complications Dr. Jay B. Reznick

Peri-implant diseases: prevention and management Drs. Richard Horwitz, Eddie Scher, and Nikos Donos

Tony Robbins and Tom Zgainer advise how to achieve peak performance in retirement plans

BETTER. SIMPLER. STRONGER.

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Company spotlight Zimmer Biomet

Practice profile Dr. Richard Hughes

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Industry standard .050"/1.25mm hex drive mechanism.

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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

PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com MANAGING EDITOR | Mali Schantz-Feld Email: mali@medmarkaz.com | Tel: (727) 515-5118 ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkaz.com EDITORIAL ASSISTANT | Mandi Gross Email: mandi@medmarkaz.com NATIONAL ACCOUNT MANAGER | Adrienne Good Email: agood@medmarkaz.com CREATIVE DIRECTOR/PRODUCTION MANAGER | Amanda Culver Email: amanda@medmarkaz.com FRONT OFFICE MANAGER | Theresa Jones Email: tjones@medmarkaz.com

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ith apologies to Bob Dylan, change has indeed come. That stalwart standard of implant overdentures, the Locator® by ZEST Anchors, is changing. Now, before people take to the streets, allow me to explain that this is evolution, carefully preserving the traits that make the Locator a worldwide success while selecting away baggage that inevitably accumulates around a status quo. The Locator has been the undisputed champ of overdenture anchors with a dominant share of the world market. Fourteen years ago, attachment selection was typically limited to complex designs or Mark Montana, DDS alternatives exclusive to implant systems, and frustration was common when replacement of parts was complicated and time-consuming. ZEST solved these shortcomings by providing an abutment to fit almost any implant system, by increasing the wear resistance of the replaceable member, and by making that insert replacement quick and easy. Reduced time required to replace worn inserts allowed dentists to reduce their maintenance fees. As popularity of the system grew, the network of dentists expanded, so patients could find a “Locator dentist” almost anywhere. The same: The general functionality of the system and processing techniques remain unchanged: The new Locator, or Locator® R-Tx™ as it is named, is still a titanium abutment that fits directly to dental implants, and yes, it has a nylon retentive insert to retain a dental prosthesis. The inserts are again offered in graduated retention distinguishable by their colors, and they can be easily removed and replaced with a simple, hand-held tool. The insert is imbedded into a metal housing as before, which is processed into the dental prosthesis either in the dental laboratory or chairside; capture of the attachment apparatus is unchanged, including the use of a block-out spacer. What’s new: The first thing you notice is the all-in-one packaging that includes the abutment as well as all the processing components. The abutment is shaped differently than its predecessor, with a stepped, conical form — making insertion by the patient easier than before. It has dual exterior retention features and is delivered with a .050"/1.25 mm hex driver rather than a specific insertion tool, making it much more convenient for dentists and surgeons to remove, replace, or tighten the Locator R-Tx, as most healing abutments require the same driver. The new abutment is no longer golden, but rather a pinkish-bronze; this is not an esthetic nuance, but rather the color of the new, harder titanium carbon nitride coating used in the Locator R-Tx that promises to be much more resistant to abrasion. The new nylon inserts are fewer in choices than the legacy as there is no longer a need for the center-male portion; therefore, all nylon couplings are similar to the Extended Range Males, reducing redundant inventory. The metal housing is pink, allowing it to camouflage within the denture resin color — a nice feature. It also sports flats on the side to keep from rotating in the prosthesis. The new housing allows the nylon insert to pivot up to 30 degrees per implant, without a loss of retention. This should be particularly helpful with angled implant placement or in reducing the fulcrum effect when more than two abutments are employed. The take-away: The Locator R-Tx is a thoughtfully designed and carefully planned improvement of The Standard in implant overdentures. Where the Locator was limited, the Locator R-Tx is configured to provide solutions with easier delivery by the dentist to the patient, greater pivoting of the inserts, reduced wear, and simpler parts inventory. Change brings uncertainty, but my early experience has been overwhelmingly positive as the system is easy to use and delivers on performance for the patient. So, “Don’t stand in the doorway; don’t block up the hall,” because “Locators they are a changin’.” Say hello to Locator R-Tx.

$129 $319

© FMC 2013. All rights reserved. FMC is part of the specialist publishing group Springer Science+ Business Media. The publisher’s written consent must be obtained before any part of this publication may be reproducedvw in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Implant Practice or the publisher.

Volume 8 Number 6

Mark Montana, DDS, is a 1987 graduate of the University of Southern California (USC) School of Dentistry and completed his Certification in Advanced Prosthodontics at USC in 1989. He has been primarily involved in private practice in Tempe, Arizona, emphasizing fixed, removable, and implant prosthodontics. Dr. Montana has been involved in clinical instruction while attending USC and as a preclinical instructor at the Arizona School of Dentistry. He has lectured domestically and internationally on the topics of implant, fixed, and removable prosthodontics. He has served on several of his state’s dental committees. Dr. Montana’s memberships to professional organizations include the American College of Prosthodontists, the Academy of Osseointegration, the Academy of Fixed Prosthodontics, the Pacific Coast Society for Prosthodontics, and the American and Arizona Dental Associations.

Implant practice 1

INTRODUCTION

December 2015/January 2016 - Volume 8 Number 6

“Evolution in the air, and changes, they are a comin’”

MESSAGE FROM THE PUBLISHER

When inspiration meets reality Dear Readers: With this issue of Implant Practice US, I am delighted to introduce a new series of articles that have the potential to change the course of your life. I know this to be true because over the years, the author of these articles, Tony Robbins, has impacted me both professionally and personally. This story begins when I was in my 20s. At that time, life’s challenges were daunting, and the road ahead seemed not only to be winding, but filled with potholes and roadblocks. Also, I was searching for a career path that would also be my life’s passion. It was then I discovered peak performance strategist and bestselling author Tony Robbins. Listening to his motivational tapes in my car on the way to and from work was often the only positive voice that I would hear all day. “Human beings have the awesome ability to take any experience of their lives and create a meaning that disempowers them or one that can literally save their lives.” His insights catapulted me to achievement of my professional aspirations, as well as personal fulfillment. I remember wishing that I could attend one of Tony’s seminars in person. Fast-forward 25 years later. As a successful publisher and entrepreneur, I had the opportunity to attend CEREC® 30, an educational event sponsored by one of our long-term clients, Sirona Dental, Inc. I was beyond excited that Tony was going to be a featured speaker at this event! It was a surreal moment when I had the opportunity to stand up in front of upwards of 6,000 attendees and ask a question of my mentor, Tony Robbins, peak performance strategist and bestselling author, who wasn’t even aware of the impression he had made on me over the years. It was with Lisa Moler, publisher and CEO of MedMark, LLC, at CEREC 30 even more incredible when he was gracious enough to schedule a personal interview with MedMark for our magazines. This brings me to good news for our readers. I am so proud and honored that Tony Robbins and Tom Zgainer, founder and CEO of America’s Best 401k, will be authoring a Financial Focus column for our publications in 2016. This column will discuss what to look for in a 401k plan, show how fees can erode 401k savings, and will also discuss the fiduciary responsibility of plan sponsors and the serious ramifications of non-compliance with The Employee Retirement Income Security Act of 1974 (ERISA). This federal law sets minimum standards for most voluntarily established pension and health plans in private industry to — Tony Robbins provide protection for individuals in these plans. Sadly, many plan sponsors do not live up to their duties, and as a result, the savings of all the participants in their plan may be subjected to needless and excessive fees. Tony said, “The abuse is mind-boggling.” At MedMark, we pride ourselves on educating the dental community on new techniques, the latest products, and creative practice management methods. Now, Tony Robbins and Tom Zgainer will share their expertise to protect and help grow your retirement savings. At our interview, Tony Robbins and I discussed living in the moment and letting go of the ghosts of the past. He once said, “In life, you need either inspiration or desperation.” It was in times of desperation that I found inspiration in his powerful insights. Now, I am honored that it’s my turn to be a catalyst, through this new Financial Focus column, for our readers to have more control over their financial success in retirement. All the best,

“In life, you need either inspiration or desperation.”

Tom Zgainer, founder and CEO of America’s Best 401k, with Lisa Moler at CEREC 30 2 Implant practice

Volume 8 Number 6

FINANCIAL FOCUS

Tony Robbins and Tom Zgainer advise how to achieve peak performance in retirement plans MedMark is proud to launch a new column that will help dental professionals make important decisions about retirement plans

isa Moler, publisher and CEO of Robbins’ knowledge has been widely recognized. He was named to the Worth Power MedMark, LLC, recently experienced one of the pinnacle events of her career at 100 as No. 49 on the list of the world’s most the CEREC® 30 conference in Las Vegas. powerful players in global finance. Working with America’s Best 401k, She had the privilege of holding an in-person business owners can alleviate their fiduciary meeting with peak performance strategist and responsibility while providing their employees bestselling author, Tony Robbins, and Tom with a plan that does not sacrifice perforZgainer, founder and CEO of America’s Best mance for lower fees. The company has 401k. These two visionaries discussed the worked with numerous dental practice changing landscape of employer-sponsored retirement plans andknow the information that owners to help them drastically reduce the You can’t where you are going business owners need to adhere to the investment fees associated with their plans, if you don’t know where you are. Department of Labor regulations. helping clients save an average of 57%. This topic was discussed at the event At the meeting with Robbins and Zgainer, is also highlighted in Tony Robbins’ Lisayour Moler discussed Stepand 1. Send us your fee disclosure (also called abest408b2) from existing provider. Ifthe you changing don’t where landto locate it, call us and we will direct you.the Keep in mind7that scape Department of 401k Labor space, regularlywhat requires plan pracselling book, MONEY: Master Game: of the dental sponsors to benchmark their plan so this will fulfill your fiduciary obligation. Simple Steps to Financial Freedom. After titioners across the country need to know 401k’s unique, lowin your order toon meet DOL member regulations, and the destination Best is a financially secure retirement, is 401k course? A of our team Stepseeing 2. If theAmerica’s will walk through your complimentary comparison so you can see the impact that costyou approach firsthand, Tony“side-by-side” Robbins feepair’s mission to save America’s retirement. higher fees will have on your account balance over time. became a partner in the business, and the “If you offer your employees a run-ofSteppair 3. Take the to switch America’s Best 401k. There is noplan, conversion fee a and our team the-mill 401k there’s good chance set action out onand a make mission helptoAmericans makes the conversion process painless. The quicker you make the change, the quicker your savings begin. across the country rescue their retirement. you are vulnerable to Department of Labor

YOUR NEXT STEPS

Volume 8 Number 6

AmericasBest401k.com

oversight, which has become more aggressive in recent months,” Zgainer said. Robbins adds, “Small business owners often have no idea that they are the fiduciaries for their plan. That means that they have to benchmark that plan annually, or they have to pay penalties, with average penalties that can reach $600,000. We can help these people meet their responsibilities in this area.” In as little as 60 seconds, dentists and other business owners can access the company’s free Fee Checker (americas best401k.com/medmark), which can help them meet their fiduciary obligation and ensure their retirement plans are for the sole benefit of their employees. When a dentist sponsors a retirement plan, he/she takes on new responsibilities in addition to being a doctor and a business owner. They also need to meet their fiduciary obligation and fulfill their trustee responsibility. Robbins and Zgainer’s advice can lead to employees keeping more of what they’ve saved, and enjoying a longer, more-secure retirement. America’s Best 401k has assembled a team of world-class retirement plan experts across design, administration, recordkeeping, and actuarial disciplines to offer an alternative to expensive, complex plans. Working with America’s Best, business owners can alleviate their fiduciary responsibility while providing their employees with a plan that doesn’t sacrifice performance for lower fees. For information, contact America’s Best 401k at 855-905-4015 or info@americas best401k.com. Readers of Implant Practice US will be able to share more of this exciting and informative conversation with Robbins and Zgainer through a series of interview articles that will appear in upcoming issues. IP Implant practice 3

TABLE OF CONTENTS

Financial focus Tony Robbins and Tom Zgainer advise how to achieve peak performance in retirement plans .........................................................3

Practice profile Richard Hughes, DDS

Intellect, skills, and a strong work ethic

Case study Immediate extraction and implantation: the single-tooth solution for anterior esthetics Dr. Paresh B. Patel discusses an implant case using a tapered implant .......................................................18

Seeing the light Implant-safe settings for SuperPulse 10,600 nm CO2 laser-assisted, closed flap peri-implantitis treatment

Company spotlight

Drs. Eric Linden and Peter Vitruk explore the peri-implantitis ablative laser treatment protocol.................. 26

Zimmer Biomet Together, the Zimmer Biomet dental division is doing more

ON THE COVER Cover photo courtesy of Dr. Paresh B. Patel. Article begins on page 18.

4 Implant practice

Volume 8 Number 6

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Follow nature‘s contour

TABLE OF CONTENTS

Industry News............. 44

Continuing education

Peri-implant diseases: prevention and management

Drs. Richard Horwitz, Eddie Scher, and Nikos Donos look at the appearance, prevention, and management of peri-implant diseases

Technology Fully integrated digital implant dentistry using Sirona’s CEREC® Guide 2 and Straumann’s Variobase™ for CEREC Dr. Farhad E. Boltchi provides a step-by-step overview of his digital workflow..................................... 45

On the horizon Immediate implant — immediate smile Dr. Justin Moody discusses treatment of a challenging lateral incisor........ 52

Continuing education Evaluation and management of common dental implant complications Dr. Jay B. Reznick presents a comprehensive discussion of implant failures and their management

6 Implant practice

Practice development Crafting your practice profile In the third part of his series on marketing, Toks Oyegunle explains how to craft your practice’s unique selling point to better attract patients

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

Volume 8 Number 6

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PRACTICE PROFILE

Richard Hughes, DDS Intellect, skills, and a strong work ethic What can you tell us about your background? I earned a B.S. in microbiology from the University of Maryland, College Park, and a Doctor of Dental Surgery from Meharry Medical College in Nashville, Tennessee. I was exposed to subperiosteal dental implants while a student at Meharry. The surgical and prosthetic faculty at Meharry had a collaborative effort with the VA Medical Center located on the Vanderbilt campus. At the time, I thought the surgery for a subperiosteal implant was way too much for a person to go through for the sake of eating and having teeth. I thought dental implants were quackery. To say the least, I was an extremely narrow-minded dental student. Fast-forward to 1990. Dr. Sammeh Hannah, an oral surgeon with an infectious enthusiasm for dental implants, sent some other GPs and me to a Core Vent prosDrs. Linkow and Hughes at the 2015 AAID Eastern District Conference Meeting in Baltimore, Maryland thetic course in Timonium Maryland. I did not understand a thing from the course! I felt like an absothe American Academy of even perform implant revisions for other lute moron. I reluctantly got into Implant Prosthodontics, doctors’ patients. dental implants in 1991. A patient and a couple of years came in and specifically requested later Associate Fellow of Why did you decide to focus on Richard Hughes, DDS dental implants. He explained that the American Academy of implantology? he was done with partial dentures. Dental Implant Dentistry. After that, I went through I realized that I could not effectively treat implants were not as popular then as they a divorce and focused on my children and prosthetic patients without dental implants. are today, but the way he described his plight not so much on implant dentistry. About 10 Plus, more patients were asking for dental struck a chord with me! I changed his life, and years after the divorce, I met my better half, implant treatment as time progressed. So I this experience changed my life. I soon thereDr. Cindy Vu, and with her support, soon merged dental implants into my prosthetic after took a Core Vent surgical and prosthetic became a Diplomate, American Board of services. It’s emotionally and professionally weekend course. I buckled down, applied satisfying to rehabilitate patients with deep Oral Implantology/Implant Dentistry (ABOI), myself, and mastered the material from this dental needs. and Fellow of the American Academy course. A month later, I placed the implants of Implant Dentistry. Several years after in the gentleman, and subsequently restored becoming an ABOI Diplomate, I was chosen How long have you been practicing, him with cement-retained fixed prosthetics in to sit on the ABOI Part One Test Construction and what systems do you use? two quadrants. The implants from this first Committee and to be an oral examiner for I’ve been a doctor since 1982 and case are still functional, but prosthetics have the ABOI and a reviewer for the Journal of started placing and restoring dental implants subsequently been re-restored twice. Oral Implantology. I subsequently became a in 1991. I use A.B.™ Dental, Bicon® Dental Soon after this, I enrolled in the 13-monthconsulting oral examiner for the AAID. I take Implants, and Quantum™ Implants. I still long dental implantology program at Howard these responsibilities very seriously. I am also place and restore blades (Pacific Implants University College of Dentistry in Washington, on the faculty of the Vancouver AAID Maxi Inc., Ultimatics Inc., and Parc Dental), ramus DC, which was in conjunction with the Amercourse, Vancouver, BC, Canada. frame, and subperiosteal implants. ican Academy of Implant Dentistry. I was bitten by the bug, especially after listening Is your practice limited to dental What training have you undertaken? to Drs. Leonard Linkow, Morton Parel and implants? I took a fantastic year-long dental Bob James. These three men changed my Pretty much, yes. I have about a 90% Implantology program at Howard Univerlife. I subsequently earned Fellow status with surgical and prosthetic implant practice. I sity College of Dentistry. Even though I was 8 Implant practice

Volume 8 Number 6

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PRACTICE PROFILE already keenly interested in dental implants, I became absorbed by this field after I was exposed to Drs. Morton Parel, Bob James, and Leonard Linkow in the Howard University program. After hearing them, I never looked back. There I was exposed to a wide array of surgical and prosthetic methods. I was taught by Drs. Leonard Linkow, Terry Reynolds, C. Benson Clark, and Hilt Tatum, to name a few. I took classes from Drs. Joel Rosenlicht, Richard Borgner at Tatum Surgical, Anthony Sclar, Joseph Chakroun, and James Rutkowski. I’ve also had personal instruction from Drs. Leonard Linkow and Ralph Roberts in subperiosteal, ramus frame, ramus blade, and blade implants in general. There are many more that I cannot recall. My training was multimodal, so I feel fortunate that I have many reliable ways to treat my patients. My staff and I recently trained at the Sclar Center in Miami, Florida, in the All on 4® concept. The Sclar Center did an excellent job teaching this concept.

From left to right: Drs. Leonard Linkow, Richard Hughes, and Manuel Chanavaz at the 2015 Eastern District AAID conference in Baltimore, Maryland, where Dr. Linkow received the AAID Lifetime Achievement Award

Who has inspired you? My parents and family were always behind me and encouraged me to study dentistry or medicine. My childhood family dentist, Dr. Jack Reynolds of Edgewood, Maryland, inspired and encouraged me to become a dentist. Dr. Cindy Vu, my better half, has always been an immeasurable source of support; without her by my side, I would not have made the professional strides I’ve made. I was very fortunate to have been mentored by Drs. Leonard Linkow and Ralph Roberts. They opened my mind and taught me many ways to treat and help patients. I give thanks to Maurice Valen of Impladent Ltd. for imparting his vast knowledge of bone physiology to me.

Drs. Richard Hughes and Cindy Vu celebrating Dr. Vu’s birthday; July 2015 in the Jefferson Hotel restaurant, Washington, DC.

What is the most satisfying aspect of your practice? Improving people’s quality of life, selfesteem, appearance, and function. I like getting people out of their physical and mental pain. I am blessed to practice a profession that I love. Getting up and going to the office is not a chore but an enjoyable experience. Many patients, both men and women, tear up when I tell them I can treat them, after they have been told by other doctors that they are not candidates for dental implants. Many hug my staff and me when we complete their treatment, which for us is always a big deal. I thank God for giving me the intellect and skills to help people, and my parents for teaching me a strong work ethic and to always do my best. 10 Implant practice

From left to right: Drs. Thomas Carroll, Richard Hughes, and Ralph Roberts with Jean Roberts (daughter of Dr. Roberts and Rita Roberts, wife of Ralph Roberts) at the 2015 AAID conference in Las Vegas, Nevada, where Dr. Hughes presented the AAID Isaih Lew Memorial Research Award to Dr. Ralph Roberts Volume 8 Number 6

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PRACTICE PROFILE

Dr. Hughes’ able-bodied staff from left to right — Codi Croson, Saba Zehra, and Vicky Artola

Professionally, what are you most proud of? I am proud of several things. I was made an AAID Honored Fellow last year. I am still humbled by this distinction. Dr. Ralph Roberts, who is one of the early pioneers in implant dentistry, asked me to place one of his implants in him. He flew from California to Virginia for treatment. I extracted his fractured maxillary right lateral incisor and placed one of his STR (Single Tooth Replacement) implants. I made an impression immediately after implantation for the final crown and provided provisionalization on the same visit. There are several other things I’m proud of as an implant dentist. I’m proud of the credentials I have earned and activities, which were discussed earlier. I also testified with Dr. Ralph Roberts before the U.S. Food and Drug Administration on July 13, 2013, for the reclassification of blade-form dental implants from a Class III to a Class II medical device. Thus, blade-form dental implants have the same classification as root-form dental implants. I’m an officer for the Southern District of the AAID. I also sit on the Board of Directors of the American Academy of Implant Prosthodontics and the International Academy of Implants and Transplants. The fact that other dentists in my community and implant dentists seek me out for dental implant treatment on themselves is also a distinction. As I mentioned earlier, I am humbled and do not take any of this for granted.

What do you think is unique about your practice? My staff and I treat people as if they are houseguests. It is also unique that I place and restore a relatively high volume of implants. I treat several implant patients every day, performing the different stages of implant 12 Implant practice

Paris Valley in Fauquier County Virginia, not far from Dr. Hughes’ home. Such majestic beauty

There is more than one modality and way to treat a patient. I like the phrase, “I would rather have a mind opened by wonder, than closed by belief.” treatment, employing several dental implant modalities from root forms, blades, and subperiosteal implants. I even employ the All-on-4® concept to treat patients. I also give one-on-one instruction to dentists who want to learn about implant dentistry.

What has been your biggest challenge? I transitioned from a general practice to a surgical and prosthetic implant practice when the economy was tanking. It was hard enough practicing dentistry during 20082013, let alone shifting from a general to a specialty practice. This transition was tricky — balancing marketing efforts for general and implant patients while developing brand recognition as an implant dentist. This also impacted negatively on cash flow for a while, but everything clicked, and I’m in full gear. This was particularly difficult, but I had faith and believed in myself! One needs a vision and a plan. Cindy and my staff were extremely supportive during this time. They also believed in me and my leadership. I am also challenged and intrigued by the exciting changes in prosthetic dental materials and digital imaging.

What would you have become if you had not become a dentist? That’s an interesting question! It’s hard for me to imagine not being a dentist/implantologist! Perhaps a virologist, medical pathologist, general or orthopedic surgeon. I could

even see myself as a civil engineer building roads, bridges, dams, or buildings.

What is the future of implants and dentistry? I can see more dental implants placed and restored by general dentists as patients’ demands increase and as dental schools introduce dental implants into the basic curriculum. Obviously, there will be changes in implant surface technology and the constituents of the implants themselves. I am keeping an eye on the zirconia and short-body implants. There will be a resurgence in blade, disc, and subperiosteal dental implants once doctors realize the limits of bone grafting. I can see a move away from using xenografts and allografts, toward strictly autografts and alloplasts combined with platelet-rich plasma (PRP) and platelet-rich fibrin (PRF). There is and will continue to be a revolution in regenerative dentistry. Just look at how PRP and PRF have changed our regenerative capabilities. We should keep a sharp eye on stem cell research. God only knows how it will change dentistry and medicine. I would also keep an eye on using stem cells to grow teeth. This could be a big game changer. CAD/CAM restorations will become more feasible to employ in the dental office by way of cost, prosthetic fit, and esthetic results. The changes in pharmacology will have a demonstrable impact, both good and bad, on dentistry and oral implantology. The changes in dental materials and imaging are Volume 8 Number 6

What are your top tips for maintaining a successful implant practice? Always keep the patient in mind, and pay attention to your bottom line. I do not believe in employing more people than it is necessary to efficiently run my practice. Always treat your staff with respect; you cannot build a respectable practice without good staff. Hire slowly, and fire fast; there is no need to keep deadwood on the payroll. Keep your treatment plans as uncomplicated as possible but well engineered. Be firm on collections but flexible on payment plans. Don’t rush patients into treatment. Again, there is no substitute for hard work. Sometimes patients who request dental implants are best managed with conventional prosthetic dentistry.

Prosthetic Materials & Solutions

What advice would you give to a budding implantologist? We all start as beginners, so get well trained in basic surgical principles and prosthetics, inclusive of occlusion. Take an AAID Maxi course; it’s a great start. Find a willing, knowledgeable, and experienced mentor. Always keep an open mind. There is more than one modality and way to treat a

Top 10 favorites 1. 2. 3. 4.

My family and country Being a grandfather My fantastic staff My Titleist® 910D3 driver and fairway woods 5. Learning in general 6. A good beef pot roast 7. Old movies (starring Humphrey Bogart and Gary Cooper) 8. Fly-fishing, golf, and hunting 9. AB dental Implants and drill stopper burs 10. OsteoGen® products by Impladent Ltd.

What are your hobbies, and what do you do in your spare time? I enjoy downtime with my family. I also enjoy golf, hunting, fly-fishing, and learning in general. I also like following Maryland Terps’ sports. IP

Your Total Solution Provider

Implant

Fabrication

patient. I like the phrase, “I would rather have a mind opened by wonder, than closed by belief.” Listen to your patients, and help them discover the best way for their treatment. Get involved with the American Academy of Implant Dentistry and the American Academy of Implant Prosthodontics. These organizations and others I’ve mentioned are fantastic, and each one brings different elements to the table. The International Academy of Implants and Transplants meeting offers a lot of unscripted live surgery for the attendees to view and study. There is no substitute for hard work and burning the midnight oil! Measure 3 times, and cut once. Always maintain a balance with your family and practice. Family and health are the most important, hands down.

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

Digital Impression

www.biodenta.com/learnmore Volume 8 Number 6

Implant practice 13

PRACTICE PROFILE

stimulating to say the least and will continue to evolve. There will be discoveries in craniobiology, growth, and development that will positively affect orthodontics and dentistry in general.

COMPANY SPOTLIGHT

Zimmer Biomet Together, the Zimmer Biomet dental division is doing more

immer Dental and BIOMET 3i have joined forces to become a leader in oral healthcare as the Zimmer Biomet dental division. With a collective 62 years of experience in the dental implant industry, the dental division is united in its rich history, in-depth knowledge, and reputation for providing high-quality service and solutions to customers. General Manager of the Zimmer Biomet dental division, David Josza, commented, “As a combined force, we are even stronger and more equipped to serve the needs of dental professionals and patients on a worldwide basis. We believe that each patient who receives dental implant therapy should be treated like a member of our own family, with the best possible options made available to them.”

Research and innovation As an affiliate of one of the largest musculoskeletal companies in the world, the Zimmer Biomet dental division has access to the latest technology, talent, and resources to drive growth and accelerate the development of innovative solutions to address clinical needs. Collectively, the dental division has conducted more than 175 preclinical and clinical research studies in the past 10 years, and there are more than 650 published articles on the surgical, restorative, and regenerative products. Zimmer Dental and BIOMET 3i collectively hold over 315 combined issued patents worldwide with another 116 pending. Josza reinforced, “Research and development will continue to be a high priority with an impressive team dedicated to developing new techniques, technologies, and materials that will help advance all aspects of implant dentistry.”

Comprehensive product portfolio The division’s combined portfolio of products includes a broad spectrum of surgical, restorative, regenerative, and digital dentistry solutions designed to improve the quality of life for patients. Groundbreaking technologies such as the Zimmer® Trabecular 14 Implant practice

Metal™ Implant, the 3i T3® Implant and the BellaTek® Encode® Impression System are a sampling of the comprehensive range of products that address clinician’s daily clinical challenges. Advances in technology have been essential to our goal of achieving optimal patient outcomes, such as the 3i T3 Implant, which is designed to deliver esthetic results through tissue preservation. The implant incorporates a contemporary hybrid surface, a tight implant/abutment interface, and integrated platform switching. Another advance coming from the dental division’s portfolio will be the launch of the Zimmer Dental 3.1 mmD Eztetic™ Implant, which has a conical prosthetic connection designed to reduce micro-movement and microleakage.

“We believe that each patient who receives dental implant therapy should be treated like a member of our own family, with the best possible options made available to them.” — David Josza Volume 8 Number 6

COMPANY SPOTLIGHT

Zimmer Biomet Institute in Parsippany, New Jersey

The digital dentistry solutions at the dental division range from guided surgical offerings to open architecture CAD/CAM systems, and the regenerative portfolio is extensive, with materials for both hard and soft tissue applications, including allograft and xenograft bone products, demineralized bone matrix collagen membranes, and wound dressings.

Educational excellence Recognizing the importance of education, the Zimmer Biomet dental division has established state-of-the-art training centers throughout the world and will continue to offer a broad spectrum of educational offerings focused on current and emerging procedures, technologies, and products. Last year, there were over 1,200 combined programs worldwide, instructing over 9,500 clinicians, and the dental division will continue to focus on meeting the educational needs of clinicians and labs.

Personalized solutions and exceptional service Superior customer service has been at the core of the Zimmer Biomet dental division’s business, and now with an expanded network of trained field and inside sales representatives, customer service, and technical support, they will continue to provide Volume 8 Number 6

Zimmer Biomet Manufacturing Facility in Palm Beach Gardens, Florida

the high levels of service that customers have come to expect. “Our support teams are able to provide immediate help customized to our customers’ needs,” mentioned Josza. “With this extended network, we know that together, we are able to do more.” Headquartered in Palm Beach Gardens, Florida, the Zimmer Biomet dental division has close to 2,000 employees worldwide, with four manufacturing facilities to serve customers around the world.

For more information, call 1-800342-5454, or visit www.zimmerbiomet dental.com. IP Zimmer Dental products and BIOMET 3i products may not be cross-compatible. Please refer to individual product labeling for compatibility information. Due to regulatory requirements, Zimmer Biomet’s dental division will continue to sell products under Zimmer Dental Inc. and BIOMET 3i LLC until further notice. This information was provided by Zimmer Biomet dental division.

Implant practice 15

Together we can do more.

It’s not just what we make... It’s what we make possible. Zimmer Dental and BIOMET 3i have joined forces to become a leader in oral healthcare solutions as the Zimmer Biomet dental division. Each company has innovated and introduced market-defining solutions, creating long proud histories of commercial and clinical success. Together, with our combined 62 years of dental industry experience, we are committed to redefining dentistry for today. The Zimmer Biomet dental division puts patients and professionals first in all things. With surgical, regenerative, restorative and digital dentistry solutions that work alongside world-class educational opportunities and responsive, personalized service, Zimmer Dental and BIOMET 3i are collectively committed to helping your progress—that is the essence of our commitment to you. A commitment that comes to life in all that we do, all that we strive to become in close collaboration with you.

For more information, please contact us at 1-800-342-5454 www.zimmerbiometdental.com Due to regulatory requirements, Zimmer Biomet’s dental division will continue to manufacture products under Zimmer Dental Inc. and Biomet 3i LLC respectively until further notice.

Surgical

Regenerative

Supporting clinicians with solutions for...

Restorative

Digital Dentistry

Education

CASE STUDY

Immediate extraction and implantation: the single-tooth solution for anterior esthetics Dr. Paresh B. Patel discusses an implant case using a tapered implant

lthough single-unit cases tend to be the most straightforward of implant restorations, tooth replacement in the anterior presents a unique array of challenges, with patient anatomy and the critical importance of esthetics in the smile zone chief among them. This has led many clinicians to adopt a conservative approach to treatment or refer such cases to a more experienced practitioner. As implant design, CAD/CAM dentistry, and treatment protocols have advanced, however, achieving a desirable outcome in the anterior has become a less complex undertaking. The traditional approach to single tooth replacement has involved leaving the extraction site to heal prior to implantation and allowing the implant to fully osseointegrate prior to loading. Even clinicians who have opted for immediate implant placement have often been hesitant to load the implant before the healing phase is complete. But with a better understanding of the benefits of immediate implantation and provisionalization, including preservation of the hard and soft tissue that are so fundamental to an esthetic outcome, there is substantial incentive to follow a more progressive protocol when indicated.1 The progression toward more predictable results in the anterior has been aided by the advent of the tapered dental implant, which has simplified implant positioning in situations where there is limited anatomical space or bone volume. The Hahnâ&#x201E;˘ Tapered Implant (Glidewell Direct; Irvine, California) takes the proven concept of an anatomically

correct body shape and combines it with a pronounced thread design, which helps the clinician both situate the implant in the ideal labial-lingual position and achieve the primary stability needed for an optimal outcome. This design is ideal for immediate implantation procedures, as maintaining the proper distance from the facial plate is of paramount importance. There are numerous advantages to immediately placing the implant following tooth extraction, including preservation of the alveolar ridge, soft tissue, and interdental papillae.2 This is crucial for cases in the anterior, where patients are more attuned to gingival contours and margins due to the visibility of soft tissue in the esthetic zone. Once the implant has been placed in the extraction site, delivering a healing abutment prevents the soft tissue from collapsing, maintaining the patientâ&#x20AC;&#x2122;s natural gingival architecture.3 When the primary stability of the implant is sufficient, provisionalization affords additional benefits by training the gingiva around the shape of a temporary crown, establishing more natural-looking esthetics while the tissue heals.

Immediate implantation also provides the bone with the continued stimulation it needs to mitigate the resorption that occurs in the absence of the natural tooth.4 By maintaining a maximum amount of stability and bone volume for the eventual implant restoration, this helps support an outcome that is both functional and esthetic. The following case presentation featuring the Hahn Tapered Implant will demonstrate how immediate extraction, implantation, and provisionalization can produce a predictable, highly esthetic result in the anterior. Techniques for achieving maximum primary stability, proper labial-lingual positioning, and a natural emergence profile will be described. By following some essential guidelines, practitioners can confidently address the challenges of single tooth replacement in the esthetic zone.

Case report A 45-year-old female presented with a failed post-and-core crown restoration that had separated from the root of tooth No. 8 (Figure 1). An endodontist had assessed the tooth, which was stricken by recurrent

Paresh Patel, DDS, is a graduate of the University of North Carolina at Chapel Hill School of Dentistry and the Medical College of Georgia/American Academy of Implant Dentistry MaxiCourse. He is co-founder of the American Academy of Small Diameter Implants and a clinical instructor at the Reconstructive Dentistry Institute. Dr. Patel has placed more than 3,500 small diameter implants and has worked as a lecturer and clinical consultant on mini-implants for various companies. He can be reached at pareshpateldds2@gmail.com. Disclosure: Dr. Patel receives no compensation from Glidewell Laboratories.

18 Implant practice

Figure 1: Preoperative condition of the patient, whose post-and-core crown for tooth No. 8 had debonded after years of function and was deemed non-restorable. The patientâ&#x20AC;&#x2122;s tooth was temporarily cemented to serve the patient until implant treatment could be performed Volume 8 Number 6

placement toward the palatal aspect of the alveolar ridge, and increase the likelihood of immediate provisionalization. The thread design of the implant is pronounced enough to thoroughly engage the bone of the extraction site, but not so pronounced that it compromises thin bone during placement or is difficult to fully seat in denser bone (Figures 3A and 3B). The tapered design of the implant would provide flexibility in positioning the implant within the available amount of bone. At the surgical appointment, the tooth was extracted without causing any trauma to the socket site, which is crucial in this type of case, as immediate implant placement is typically contraindicated if the periodontium is compromised (Figure 4). Next, the implant osteotomy was created following a simplified surgical protocol (Figure 5). Care was taken to create an osteotomy that would situate the implant approximately 1.5 mm from the adjacent teeth and 2 mm from the facial plate, with the platform 2 mm below the adjacent CEJ (Figure 6). A 5.0 mm x 11.5 mm Hahn

Figures 3A and 3B: The buttress thread design of the Hahn Tapered Implant achieves optimal initial stability in all types of bone, making it ideal for immediate implantation procedures

Figure 5: The osteotomy was created immediately following tooth extraction Volume 8 Number 6

CASE STUDY

decay, and provided an unfavorable prognosis for further endodontic treatment. Intraoral and radiographic evaluation indicated that the patient was an excellent candidate for immediate extraction, implantation, and temporization (Figure 2). The patient, who did not want a conventional bridge, accepted a treatment plan for immediate tooth replacement after being presented with the restorative options. The patient found this mode of treatment appealing because it would maintain her gingival tissue and underlying bone while providing the potential for immediate provisionalization. The maxillary incisors surrounding tooth No. 8 also exhibited significant decay and would be prepared and restored with conventional crowns following completion of implant treatment per the patientâ&#x20AC;&#x2122;s desire to have single-unit restorations spanning teeth Nos. 7â&#x20AC;&#x201C;10. The Hahnâ&#x201E;˘ Tapered Implant was selected for the procedure to ensure a maximum amount of initial stability, ease

Figure 2: Radiographic evaluation revealed plenty of bone apical, mesial, and distal to the non-restorable tooth. Note how the post connecting the crown to the root canal had broken in half

Figure 4: The tooth was extracted atraumatically, preserving the hard and soft tissue that would be essential to an esthetic outcome

Figure 6: The osteotomy was positioned slightly to the lingual of the socket left by the natural tooth root Implant practice 19

CASE STUDY

Figure 7: The surgical site was sutured closed, and the temporary crown was placed

Tapered Implant was then threaded into place and firmly engaged the lingual wall of the socket site, helping maintain a position that was both a safe distance from the facial plate and in the ideal location for an esthetic prosthetic outcome. The implant achieved excellent primary stability, allowing for the chairside fabrication and immediate delivery of a screw-retained provisional crown. A temporary cylinder was seated and trimmed to a height that would help keep the provisional crown out of occlusion. Then a provisional crown was fabricated with light interproximal contacts and an incisal edge approximately 1 mm out of occlusion in order to minimize the occlusal and lateral forces applied to the implant. The provisional restoration was then placed and would provide support for the soft tissue in the manner of a natural tooth throughout healing, helping contour the gingiva for an ideal outcome (Figure 7). Postoperative radiography exhibited excellent integration of the implant with the bone of the socket site (Figure 8). Following 3 months of healing, the patient returned, so the progress of healing and osseointegration could be assessed. The screw-retained provisional was removed, revealing excellent gingival color and contours (Figure 9). Immediate provisionalization was crucial in maintaining an emergence profile that mimics that of a natural tooth. The stability of the implant was excellent. Thus, a transfer coping was seated, and final impressions were taken (Figure 10). The lab produced master casts from the final impressions, which were scanned so they could serve as the basis for the CADdesigned custom abutment and final crown. 20 Implant practice

Figure 8: Postoperative X-ray illustrates engagement of the implantâ&#x20AC;&#x2122;s threads with the bone of the socket site, slightly subcrestal positioning of the platform, and full seating of the temporary restoration

Figure 9: When the patient returned after 3 months of healing, and the screw-retained temporary was removed, healthy tissue was observed, including the development of an esthetic, physiologically correct emergence profile

Figure 10: An impression post was attached to the implant so the final impression could be taken Volume 8 Number 6

Figure 11: Dental CAD software was used to produce an Inclusive速 Zirconia Custom Abutment with titanium base and a BruxZir Anterior crown to optimize esthetics

A zirconia custom abutment with a titanium base was fabricated, and the final crown was milled from BruxZir速 Anterior Solid Zirconia (Figure 11). This combination would produce ideal esthetics for the smile zone, including incisal translucency and the appearance of underlying dentin. After receiving the case from the lab, the patient was called in for delivery of the final restoration. The custom abutment was tried in and torqued into place according to manufacturer specifications. The contours of the digitally designed custom abutment conformed precisely to the margins and sulcus form of the implant site (Figure 12). Lastly, the final crown was tried in and cemented into place, creating a naturallooking restoration that surpassed the expectations of the patient (Figure 13).

Conclusion

Figure 12: The Inclusive Zirconia Custom Abutment provided optimal support for the soft tissue and was essential in establishing a natural emergence profile for the final restoration

Immediate extraction and implantation offers a predictable approach to tooth replacement in the esthetic zone. The restorative outcome can be further enhanced by immediate provisionalization, which supports and contours the gingiva in preparation for the final crown. And because this approach reduces the total number of appointments, in addition to providing patients with an esthetic outcome, clinicians can reap the benefits of having more chair time available to see other patients. IP

REFERENCES 1. Noelken R, Neffe BA, Kunkel M, Wagner W. Maintenance of marginal bone support and soft tissue esthetics at immediately provisionalized OsseoSpeed implants placed into extraction sites: 2-year results. Clin Oral Implants Res. 2014;25(2):214-20. 2. Guarnieri R, Ceccherini A, Grande M. Single-tooth replacement in the anterior maxilla by means of immediate implantation and early loading: clinical and aesthetic results at 5 years. Clin Implant Dent Relat Res. 2015;17(2):314-26. 3. Qi Y, Zhang J, Hasi BG, Sun Y, Zhu ZH, Wang RJ. [Clinical study of healing abutment on sealing socket and preservation of the gingival natural profile in single-tooth immediate implantation]. Zhonghua Kou Qiang Yi Xue Za Zhi. 2008;43(5):299-301.

Figure 13: The final restoration of tooth No. 8 exhibited ideal gingival margins and improved upon the esthetics with which the patient presented for treatment. To further improve the outcome and establish consistency in the smile zone, tooth Nos. 7, 9, and 10 were prepared and restored with new BruxZir Anterior crowns. Volume 8 Number 6

4. Covani U, Cornelini R, Calvo JL, Tonelli P, Barone A. Bone remodeling around implants placed in fresh extraction sockets. Int J Periodontics Restorative Dent. 2010;30(6):601-607.

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CASE STUDY

The progression toward more predictable results in the anterior has been aided by the advent of the tapered dental implant ...

CASE STUDY

Extraction with immediate placement and immediate temporization: the ultimate in patient satisfaction Dr. Charles Schlesinger discusses an immediately placed implant with a temporary restoration Introduction When faced with an impending extraction, the first thought in the patient’s mind is, “What are you going to put there?” An immediately placed implant with a temporary restoration can be the solution the patient is looking for. But in order to provide an immediate implant-supported restoration, a few factors must be achievable: • Minimally traumatic extraction • Immediate primary stability of the implant in the socket • Ongoing stabilization of the implant and restoration after placement • A temporary restoration with optimal occlusion In today’s modern world of implantology, we try to provide the best short- and

long-term treatment for the patient. The hard part is juggling the two, sometime diametrically opposed, demands. One should never sacrifice the long-term success of a case for short-term immediate gratification. Essentially, if you cannot load it — don’t. The principles of immediate placement, primary stability, and sound occlusion are the necessary predictors for the success of a case that all conscientious practitioners shoot for, and every patient desires.

Clinical case A 53-year-old female presented to the clinic with a symptomatic lower left cuspid (Figures 1 and 2). She had chosen to forgo endodontic treatment, buildup, and crown,

for an extraction and immediately placed dental implant. The patient’s medical history was unremarkable except for a recent 1-year history of bisphosphonate usage. The patient was apprised of the situation, and we discussed any potential negative issues that could arise as a result of her bisphosphonate usage. A preoperative alginate was taken in order to later fabricate the temporary restoration (Figure 3). Since an extraction was required, and the site was sufficiently anterior to the mental foramen, an inferior alveolar block was administered with 2% lidocaine with 1:100k epinephrine (Henry Schein®, USA). After profound anesthesia was achieved, the cuspid was extracted using a spade proximator (Figure 4) and a No. 33 lower

Figure 2: Radiograph of failing cuspid

Figure 1: Preoperative view of cuspid No. 22 Dr. Charles Schlesinger, DDS, FICOI, an internationally renowned implant educator for the past 9 years, graduated from The Ohio State University College of Dentistry in 1996. After completing a General Practice Residency at the VAMC San Diego, he went on to become the Chief Resident of the GPR Program at the VAMC West Los Angeles. During his time in L.A., he received extensive training in oral surgery, implantology and complex restorative dentistry. Dr. Schlesinger maintained a thriving practice in San Diego for 14 years before he relocated with his family to Albuquerque to become the Director of Education and Clinical Affairs for OCO Biomedical. In 2013, he became the Chief Operating Officer in addition to his clinical duties at OCO.

22 Implant practice

Figure 3: Alginate impression to be used for temporary fabrication Volume 8 Number 6

three-dimensional position for the implant. The pilot drill will naturally want to follow the path of least resistance; and in this case, it is the existing socket walls. In order to re-direct away from the socket left after extraction, you must first create a purchase point through the lamina dura of the socket (Figure 7). Once this purchase point is established, it is easy to create the correct path in the softer medullary bone with the pilot drill. A crucial requirement for successful immediate placement is the establishment of primary stability.1 On top of that, this primary stability is required in order to successfully place a temporary at the time of surgery. In an extraction/immediate placement protocol, this primary stability can come from a few sources. It can come from placing

the implant beyond the apex of the existing socket and engaging apical bone for stability, or it can come from the lateral walls of the socket. The mesial, distal, or lingual walls are all good options. The potentially fragile facial wall should not be engaged in order to preserve this crucial bone. This is especially important in clinical situations where the facial wall is thin. The engagement of this wall by the implant threads would likely result in a facial dehiscence occurring as a remodeling took place. A 1.8 mm pilot is taken to full depth of the intended implant (Figure 8). Following the establishment of the trajectory with the pilot, a 4.0 mm final osteotomy former was used to prepare the site for implant placement (Figure 9). Initially, a bone level

Figure 4: Spade proximator

Figure 5: Extraction site with preserved facial wall

Figure 6: Measuring extracted root fragment

Figure 7: Perforating the lamina dura

Figure 8: Pilot drill to full length Volume 8 Number 6

Figure 9: 4.0 mm osteotomy former Implant practice 23

CASE STUDY

forceps using only a rotational movement. The use of these two instruments facilitated an atraumatic extraction that was able to preserve the very thin facial wall observed in the CT scan (Figure 5). Once the tooth was extracted and the integrity of the facial wall was verified, the socket was debrided with a small paddled serrated curette (Zoll Instruments, Chicago, Illinois). The extracted root was measured using a measuring pin (OCO Biomedical, Albuquerque, New Mexico). The facial CEJ was at 12 mm and the lingual at approximately 14.5 mm (Figure 6). From these measurements, a 14 mm long implant was treatment planned for the case. One of the most difficult aspects of immediate placement in an extraction site is re-directing the pilot to create the intended

CASE STUDY

Figure 10: ENGAGE implant

Figure 13: Cut OsteoGen plug

ENGAGEâ&#x201E;˘ implant (OCO Biomedical) was chosen (Figure 10), but due to the apical position (Figure 11) of the facial crest midroot, it was determined that a TSI implant (OCO Biomedical) would better handle the case by not only moving the restorative platform occlusally (Figure 12), but also negating the low mid-facial position of the crestal bone. A final benefit was the sealing of the socket at the crest by the flair of the imbedded tapered platform. By engaging the mesial and distal walls at the crest with a platform, which flairs from 4.0 mm to 4.7 mm, it provides dual stabilization along with the bull nose auger tip at the apex. The imbedded tapered platform is machined rather than polished; therefore, it is possible to place the 2 mm of titanium nitride surface either in the bone or in the soft tissue zone without the normal dieback associated with polished collars. Prior to placing the 4.0 mm x 14 mm TSI implant, an OsteoGenÂŽ Plug (Impladent, LTD.) was cut and inserted to fill the gap between the implant and the facial wall (Figures 13 and 14). The OsteoGen plug is comprised of OsteoGen (Bioactive Resorbable Calcium Apatite) and Type 1 collagen (bovine Achilles tendon collagen matrix). The plug is easily cut and formed; this material makes for an easy-to-use and economical 24 Implant practice

Figure 11: Position of ENGAGE implant

Figure 12: 4.0 x 14 TSI Implant

Figure 14: Insertion of OsteoGen plug against facial wall of socket

Figure 15: Final insertion torque of implant

Figure 16: Osstell unit used to quantify stability

Figure 17: Fabricating temporary using an acrylic coping

graft material in cases like this. Studies have shown that it is possible for a 4 mm gap to resolve on its own, but in order to assure predictability and increase the chances for an esthetic outcome, the decision to graft was taken.2 The implant had a seating torque of 50N/ cm (Figure 15). An Osstell meter (Osstell, Gothenburg, Sweden) was used to determine the stability in the surrounding bone. Measurements were taken in the M-D and BL directions. The resultant ISQ values were 67 and 58, respectively. It was expected that the B-L measurement was to be lower since the OsteoGen plug cannot give the same degree of stability as native bone. The higher M-D measurement is due to the engagement

of the crestal bone by the platform of the implant (Figure 16). The patented dual stabilization design of the TSI implant allows the implant to be mechanically locked into the site at initial placement. The ability to then load this implant changes this from a passive placement (if it was just buried) to a biomechanically active one. The micro-stimulation of the peri-implant bone by masticatory forces, as long as kept within acceptable limits, will allow for the potential for faster healing of the site as was initially postulated by Linkow.3 A 7-mm tall solid crown and bridge abutment was placed and torqued to 30N/cm. After re-torquing the abutment again, an acrylic coping (Figure 17) was used along Volume 8 Number 6

CASE STUDY

with bis-acryl temporary material to fabricate a temporary using a pre-op alginate impression as a matrix (Figure 18). The occlusion was checked and the restoration cemented with Improv® temporary cement (Alvelogro, Washington). All excess cement was carefully removed and the patient dismissed with a prescription for post-op antibiotics and an analgesic medication. The final radiograph shows the position of the platform (Figure 19 and 20). Some remodeling of the interproximal crestal bone is expected, but due to the thickness of the keratinized tissue present and the emergence profile created by the temporary, complete papillary fill is expected once complete healing has taken place. This implant will be allowed to integrate 3 months with the temporary in place in order to allow for full turnover of grafting material and integration to occur. If a higher ISQ reading had been achieved in the B-L direction at the time of placement, then transition to the final restoration would have taken place in about 6 weeks. Also, since this is a cuspid, and it will be restored as a guiding cusp in lateral excursive movements, thereby taking a significant amount of lateral load, erring on the side of conservative treatment protocol was a prudent decision in this case. At 2.5 months, the temporary restoration was removed, and a VPS impression was taken using a snap on impression coping. A metallic analog was placed in the impression; an opposing alginate was taken along with a bite registration. This was sent to the lab for the fabrication of an IPS e-max® (Ivoclar Vivadent®) final restoration. Two weeks later, the final restoration was cemented (Figure 21) with resin cement after the occlusion was adjusted. The patient was dismissed after any remaining cement was cleaned up and a final radiograph taken (Figure 22).

Figure 18: Final temporary

Figure 19: Final CBCT before placing abutment

Figure 20: Final implant with temporary crown

Conclusion With all the advances modern dentistry affords us as practitioners, many times the best option either clinically or for the patient’s needs is to extract a tooth. Whichever is the case, the loss of a tooth can be traumatic for the patient not only physically but mentally. If patients can leave with a temporary crown on an implant, they will not only feel better about themselves, but the clinical outcome esthetically will be better too. Implant dentistry can be one of the most rewarding aspects of one’s practice, and performing implant dentistry in this manner can magnify those good feelings to a higher level. IP Volume 8 Number 6

Figure 21: Final restoration

Figure 22: Final X-Ray

REFERENCES 1. Schlesinger C. Predictable immediate implant stabilization and restoration. The Journal of Implant and Advanced Clinical Dentistry. 2013;5(8):17-23. 2. Chu SJ, Salama MA, Salama H, Garber DA, Saito H, Sarnachiaro GO, DDS, Tarnow DP. The dual-zone therapeutic concept of managing immediate implant placement and provisional restoration in anterior extraction sockets. Compend Contin Educ Dent. 2012;33(7):524-532, 534. 3. Linkow LI. Intraosseous implants utilized as fixed bridge abutments. J Oral Implant Transplant Surg. 1964;10:17:23.

Implant practice 25

SEEING THE LIGHT

Implant-safe settings for SuperPulse 10,600 nm CO2 laser-assisted, closed flap peri-implantitis treatment Drs. Eric Linden and Peter Vitruk explore the peri-implantitis ablative laser treatment protocol Introduction The sulcular debridement laser settings used in part 1 of this study (Linden and Vitruk3) were determined by four requirements for efficient decontamination of the implant surfaces by photo-thermal laser ablation3: 1. Laser energy is efficiently deposited into the target tissue (diseased tissue and bacterial biofilms with optical absorption and photothermal ablation properties dominated by water4-7). 2. Laser-generated heat inside the target tissue is confined to the irradiated volume and is not thermally conducted away into the implant (which acts 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. As was stated in Linden and Vitruk3, the 10.6 µm (or 10,600 nm) CO2 laser wavelength is highly reflected (>90%) from titanium, which makes the CO2 laser the safest wavelength for peri-implantitis treatment (diode, Nd:YAG and Erbium laser wavelengths produce a 3-4 times greater rate of heating of the implant for a comparable amount of laser energy used in the treatment). The present article focuses on the 1,2

fourth condition, and specifically explores the laser settings that (a) do not modify the implant surface and (b) do not result in elevated implant temperatures during the course of laser treatment.

CO2 laser Perio Tip geometry and treatment settings Laser tests reported here were performed with the LightScalpel LS-1005 Surgical/Dental SuperPulse 10,600 nm CO2 laser. The sulcular debridement1,2 and the peri-implantitis treatment protocols3 utilize the 0.25 mm small aperture laser beam tip (“Perio Tip” PN LS9005-05 from LightScalpel LLC) with >90% optical transmission and a distal end design suitable for the intra-sulcus procedures. The OD of the Perio Tip’s distal end is approximately 0.5 mm, and its tapered design allows for easy insertion into the deep pockets of up to 9 mm–10 mm. The Perio Tip was inserted into the LightScalpel dental angled laser handpiece PN LS9010-02. Recent work on efficiency of the bacterial biofilms removal with 10,600 nm SuperPulse CO2 laser justifies the safe and efficient use of 0.4 watts of average laser power configured as 4 watts SuperPulse (26.7 mJ pulses at 150 Hz) Gated with LightScalpel LS-1005 laser Repeat Mode M2-2 (10 msec @ 10 Hz).7 Laser fluence during each individual SuperPulse is 54 J/cm2, which greatly exceeds the ablation threshold of 3 J/cm2 for water-rich

soft tissue and bacterial biofilms.3,5-7 The low average power of 0.4 watts minimizes the heat impact on the implant and the tissues while effectively vaporizing the epithelium, diseased tissue, and bacterial biofilms inside the perio pocket. The laser beam that exits 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 flap peri-implantitis treatment procedure.3 Constant airflow through the hollow core of the Perio Tip pushes the sulcular debris and fluids (blood, saliva, irrigation) out of the way of the laser beam; airflow also prevents the clogging of the hollow tip.

CO2 laser impact on implant surface

The surfaces of the Biomet 3i NanoTite™ NIITP4310 and Biomet 3i Osseotite™ IFNT510 (trade names and trademarks of Biomet) implants were treated as illustrated in Figure 1. The implant was centered on the rotating platform (31 seconds for a full revolution), and the laser Perio Tip delivered the laser energy from approximately a 0.5 mm–0.75 mm distance. The laser beam scanning velocity over the

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 is currently serving 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, USA. He is also on the faculty of the California Implant Institute and Global Laser Oral Health, both in the United States. Dr. Vitruk can be reached at 1-866-589-2722 or pvitruk@lightscalpel.com.

Figure 1: Implant centered on the rotating platform. 10,600 nm CO2 laser beam from the Perio Tip (on the right) is directed at the implant surface 26 Implant practice

Volume 8 Number 6

Figure 2: SEM x5,000 magnified surface of the laser-treated NanoTite™ implant

Figure 3: SEM x5,000 magnified surface of the NanoTite™ implant not treated with laser

Figure 4: The EDS spectrum of the laser-treated NanoTite implant

Figure 5: The EDS spectrum of the NanoTite implant not treated with laser

Implant heating during CO2 laser treatment During the 31-second long laser treatment described above, a total of 12.4 joules of energy were directed at the implant. Some of the laser energy was reflected from the implant surface, and the rest of the energy was absorbed by the implant resulting in its heating. A series of implant temperature measurements (with Thermocouple Tip (Figure 6) and Meter manufactured by Control Company, model 4015, SN 101756285) were taken to quantify the rate of implant heating during the laser treatment. Figure 7 illustrates the implant suspended on the tip of the thermocouple (inserted into the implant); such laser irradiation configuration represents an extreme case of an implant with severe bone loss around it. The laser Perio Tip is delivering laser energy to the implant from the side at a short distance from the implant surface. The thermocouple is inserted into the implant as shown in Figure 8. Volume 8 Number 6

Figure 6: Thermocouple Tip is photographed against 1-mm mark scale

Figure 7: The implant is suspended on the Thermocouple Tip inserted into the NanoTite implant

Laser treatment with settings described above (31 second duration, 0.4 watts average laser power), and with 1.5 cc/sec air purge (setting “High” for LightScalpel LS-1005) through the Perio Tip, resulted in a 3.1ºC temperature increase. The same laser settings, but without an air purge through the Perio Tip, resulted in a temperature increase of 10.6ºC. To simulate the more realistic implanttissue thermodynamic conditions (i.e., implant is not suspended in the air or is not thermally insulated), in the next set of measurements the Nanotite™ type implant was embedded in an approximately 22 mm x 22 mm x 8 mm block of soft poultry tissue at

room temperature, as shown in Figure 8, or in the approximately 20 mm x 20 mm x 10 mm block of pork rib bone at room temperature, as shown in Figure 9. The laser Perio Tip delivered laser energy to the implant from the side at a short distance from the implant surface. The thermocouple was inserted into the implant, as shown in Figure 9. The laser treatment with settings described above (31 second duration, 0.4 watts average laser power), and with 1.5 cc/sec air purge (setting “High” for LightScalpel LS-1005) through the Perio Tip, resulted in, respectively, 0.8ºC and 1.2ºC temperature increase. The same laser settings, but without the air purge through Implant practice 27

SEEING THE LIGHT

surface of the implant was 0.4 mm/sec–0.5 mm/sec — such slow motion greatly amplifies the fluence on the implant surface (vs. approximately 1 mm–2 mm handspeed used in Linden and Vitruk3). Figures 2 and 3 illustrate the SEM photographs of the NanoTite™ implant surface unaffected by the laser treatment. Figures 4 and 5 illustrate the typical EDS spectral analysis of the implant surface with no changes due to the laser treatment described, thus further reaffirming the unchanged integrity of the laser-treated implant surfaces. The SEM and EDS measurements (Figures 2-5) were performed at the Electron Microscope Laboratory, School of Dentistry, University of Missouri, Kansas City, Missouri. Also worth noting is that due to a small aperture tip we used, the laser fluence in our studies greatly exceeded laser fluence in Cobb and Vitruk7. Despite the significantly higher fluence, both NanoTite™ and Osseotite™ type implant surfaces were unaffected by the laser treatment. The total laser fluence delivered was 320 J/cm2 –360 J/cm2 — a much greater total fluence than studied in Cobb and Vitruk7 (6.3 J/cm2– 113 J/cm2) — due to a considerably smaller tip size of 0.25 mm. NanoTite™ implants feature the calcium phosphate crystals that form the sub-1-µm isles on the surface of titanium (see SEM images in Figure 2 and 3). Such sub-1-µm calcium phosphate crystals are efficiently heat-sunken by the titanium and are not able to heat up during CO2 laser pulses from LightScalpel LS-1005.

SEEING THE LIGHT

Figure 8: NanoTite™ implant embedded in a block of poultry soft tissue and irradiated by CO2 laser

the Perio Tip, resulted in a temperature increase of, respectively, 1.6ºC and 2.8ºC. Based on the implant temperature measurements above, the air purge for the proposed treatment protocol was set to “High” to provide efficient cooling to the implant. The value of high air purge for implant cooling is even greater during open flap laser treatment with compromised heat transfer geometry from the implant into the surrounding bone and soft tissue.

Excessive implant heating during 810 nm laser treatment To test the wavelength’s impact on the implant’s temperature change, the same implant (Figure 10) was irradiated by the 810 nm NIR diode laser light at often recommended perio settings of 1 watt,8 which resulted in a temperature increase of 20.3ºC at 30 seconds and 28.7ºC at 60 seconds.9 The clean, non-initiated tip of the diode laser delivered 810-nm laser energy to the implant from the side, at a short distance from the implant surface, as shown in Figure 10. The thermocouple was inserted into the implant as shown in Figure 10. The measured temperature increase is approximately 20 times greater than with the CO2 laser settings above, which illustrates the potential dangers of the NIR diode perio protocols (i.e., severe implant overheating).

CO2 laser treatment settings summary The relatively low average 0.4 watt laser power at 10,600 nm in SuperPulse mode minimizes the heat load on the implants, and yet results in high laser fluence exiting the tip and high clinical efficacy of the single 28 Implant practice

Figure 9: NanoTite™ implant embedded in a block of pork rib bone and irradiated by CO2 laser

Figure 10: NanoTite™ implant embedded in a block of pork rib bone and irradiated by diode laser

Table 1: Summary of the recommended protocol settings De-epithelization and Bacterial Decontamination

Coagulation

Laser tip

0.25 mm spot PN LS9005-05 0.4 mm spot PN LS9005-02

LightScalpel laser power setting

4 watts SuperPulse repeat gate pulsed M2-2

2 watts repeat gate pulsed F1-2

Average power

0.4 watt

Air purge

“High”

Handspeed

1-2 mm/sec

Laser-ON duration in the pocket

< 30 seconds

Energy delivered during Laser-ON

< 12 Joules

Laser-OFF duration between laser treatments

10 seconds

treatment protocol due to (1) small spot size and high beam divergence laser tip, and (2) zigzag passes of the tip within the sulcus during treatment.3 As our measurements demonstrate, even at the slowest handspeed of 0.4 mm/sec–0.5 mm/sec, no damage to the implant surface was observed. Table 1 summarizes the recommended protocol settings proposed in Linden and Vitruk3 for implant-safe and efficient SuperPulse 10,600 nm CO2 laser-assisted, closed flap peri-implantitis treatment. IP

Acknowledgments The authors greatly appreciate Charles Cobb, DDS, MS, PhD, and Vladimir M. Dusevich, PhD, at the School of Dentistry, University of Missouri, Kansas City, Missouri, for providing the SEM and EDS measurements of implant surfaces, and Anna (Anya) Glazkova, PhD, and Olga Vitruk, BSc, at LightScalpel LLC for preparing this material for publication.

REFERENCES 1. FDA 510(k) Clearance K141658. LightScalpel LS-1005 & LS-2010 CO2 Laser Systems 2. LightScalpel LS-1005 & LS-2010 CO2 Laser Systems. User Manual. PN 00961. 3. Linden E, Vitruk P. SuperPulse 10.6 µm CO2 laser-assisted, closed flap treatment of peri-implantitis. Implant Practice US. 2015;8(4):30-34. 4. Jacques SL. Optical properties of biological tissues: a review. Phys Med Biol. 2013;58(11):R37-61. 5. Vogel A, Venugopalan V. Mechanisms of pulsed laser ablation of biological tissues. Chem Rev. 2003;103(2):577-644. 6. Vitruk P. Oral soft tissue laser ablative and coagulative efficiencies spectra. Implant Practice US. 2014;7(6):22-27. 7. 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 Practice US. 2015;8(3):14-20. 8. Blayden J, Mott A. Soft-Tissue Lasers in Dental Hygiene. Ames, Iowa:Wiley-Blackwell;2013:87. 9. Lavere E, Sagor J, Mikulski L, Andreana S. Antimicrobial Effects of the 810 nm Diode Laser in the Treatment of Peri-Implantitis: An Ex Vivo Pilot Study. J Laser Dent, 2015;23(1):37-43.

Volume 8 Number 6

EDUCATOR INSIGHT

A conversation with Dr. William Martin Please introduce yourself to our readers. What is your background? I’m the Director for the Center for Implant Dentistry at the University of Florida, College of Dentistry. I received my DMD training at the University of Florida and furthered my education attending Baylor College of Dentistry for Prosthodontics. I am a Diplomate of the American Board of Prosthodontics and a Fellow of the International Team for Implantology (ITI).

Do you see any trends in implant dentistry? Over the past 6-7 years, our patient consultations have shifted from initiation of treatment to management of implant complications. Most patients we see today have implants in place and are having problems with them, such as peri-implantitis or prosthetic problems. I think that’s the evolution that we’re faced with in implant dentistry. As a broader range of people start incorporating implants in their practice, and as more people get implants, you are going to have a higher number of complications.

How do you use Osstell in your clinic, and what are the main clinical benefits you have experienced? We were one of the early adopters of Osstell. It used to be case-specific, but now it is used on a daily basis to gather additional information for the overall treatment of the patient. For example, we have patients that come in with complications, where we have no previous background on them; we have no history on the implant, whether it was placed in a compromised situation, lacked stability, grafted, etc. So we use tools to try to diagnose what the problem is with that particular implant. Utilizing the Osstell with its Implant Stability Quotient (ISQ) readings gives us additional information in determining the health of the implant. I feel when access to the implant connection is possible, the Osstell gives us a minimally invasive approach to evaluating the health of the implant. The other area where Osstell plays a big role is in the education of young clinicians. We use the ISQ values after placement to 30 Implant practice

I am a firm believer in Dr. Dennis Tarnow’s “one miracle at a time.”

give them a parameter to relate to the feel of the osteotomy preparation and how this may correlate to implant stability. We also see a benefit with the Osstell device based upon our patient population. Most of our patients fall under a category of advanced or complex, most often referred to us for treatment due to difficulty. It is not uncommon to see patients that either have a history of implant failure or are in the need of large amounts of augmentation. So we often find ourselves using all the tools available to diagnose and treat in an effort to ensure a successful outcome.

How do you determine the degree of osseointegration before the final restoration? We are trying to integrate Osstell in the new surgeons’ environment so that they use that in combination with their experience to determine osseointegration. Osstell can play a role in confirming the osseointegration before sending the patients back to whoever referred them. Osstell is extremely beneficial when you get measurements over time, at time of placement, and before loading. I always want to see the progression — that the numbers are getting bigger.

How do you decide which protocol to use? It is really based upon what clinical characteristics our patients present with. I am a firm believer in Dr. Dennis Tarnow’s “one miracle at a time.” We often find our patients exploring broad options to finance their treatment, so it’s not in our best interest to do anything that could put the implant(s) and rehabilitation in jeopardy.

How much does a failure cost? We use a dental implant system that will replace the implant at no cost after failure. So when patients are compliant with our recall and maintenance program, they will not incur a cost for the implant, but will be responsible for any grafting, radiographs, and adjuncts needed to replace the implant. Where it really hurts you is in the restorative side of things. Many of those costs are passed on to the patient, depending on what you offer as far as a warranty. We educate patients that nothing is permanent, that there are associated risks, and that maintenance and followup is required. I can tell you an example I heard in a lecture regarding the cost of failure: In his practice, a clinician had a 96% implant success rate, and he was placing 1,200 implants a year. That means he had about 4% failures, which is about 48 failures a year. Each one of these failures would be negotiated with the patient, and the price would be determined. If another company then comes along and says it can increase your success rate from 96% to 98%, that’s a significant difference. You have then reduced the number of failures to 24 a year. Even small changes in percentages make a huge difference in chair time and overhead. Don’t miss Dr. Martin’s lecture at the Osstell Corporate Forum at the Annual Meeting of the Academy of Osseointegration in San Diego, California, on February 18, 2016, from 10:15 a.m. to noon. For more information, please visit the website: osstell.com/ao2016. IP This article was provided by Osstell.

Volume 8 Number 6

You have the know-how. Now get the know-when.

The Osstell IDx helps you to objectively determine implant stability and to assess the progress of osseointegration â&#x20AC;&#x201C; without jeopardizing the healing process. It is an accurate and non-invasive method that will provide the objective information needed to determine when to load the implant.

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CONTINUING EDUCATION

Peri-implant diseases: prevention and management Drs. Richard Horwitz, Eddie Scher, and Nikos Donos look at the appearance, prevention, and management of peri-implant diseases

owadays, peri-implant diseases are an increasing reality that we are confronted with in our profession. If they are not prevented, recognized early, or managed appropriately, they may lead to failure of the implant. This article aims to provide an update into the nature of peri-implant disease, the diagnosis, and appropriate prevention and management.

What are peri-implant diseases? In general, peri-implant diseases are characterized by a host inflammatory response to opportunistic oral microbiota and are classified into peri-implant mucositis and peri-implantitis. Peri-implant mucositis can be defined as a reversible inflammatory process residing in the soft tissues surrounding a functioning dental implant, whereas peri-implantitis is defined as an inflammatory process characterized by loss of surrounding bone in addition to the symptoms of the soft tissues (Lang, et al., 2011a).

How big a problem is this? Dental implants present with very high survival rates (Albrektsson, et al., 1987; Pjetursson, et al., 2008). These, however, only report whether the implant is present at a certain moment in time, without evaluating whether it presents with biologic or technical complications. At the same time, implant success includes various clinical and radiographic criteria (Ong, et al., 2008), which may often be reported using different terms (Needleman, et al., 2012).

Educational aims and objectives

This article aims to discuss the growing issue of peri-implantitis and present some suggestions for its prevention and management.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 35 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify the etiology of peri-implant diseases. • Identify the steps needed to be taken during the clinical examination for diagnosis of peri-implant disease. • Recognize the risk factors and indicators of peri-implant disease. • Realize the current thinking regarding management of peri-implant disease in patients. • Realize the predictability of various treatment of peri-implant mucositis and peri-implantitis.

The prevalence of peri-implantitis in the United Kingdom is still relatively unknown. Other reports have suggested that prevalence of peri-implantitis affects between 28% and 56% of severe chronic periodontitis patients and 12% and 43% of implant sites (Zitzmann and Berglundh, 2008). Another systematic review suggested prevalence at a patient level of 20% (Mombelli, et al., 2012).

How do we know if an implant is affected? To diagnose peri-implant disease, the following steps need to take place during clinical examination: Probing around the implant The European Federation of Periodontology (EFP) consensus paper supports the use of a standard periodontal (UNC15) probe (Lang and Berglundh, 2011a). There is no conclusive evidence to demonstrate any detrimental effect that probing per se

Richard Horwitz, BDS, MFDS, RCSEd, FHEA, graduated from the University of Sheffield Dental School. After working as a clinical teacher at Kings College Hospital London and in general practice, Dr. Horowitz is now in his third year of specialist training (periodontology) at the Eastman Dental Institute (UCL). Eddie Scher, BDS, LDS, RCS, MFGDP, is a specialist in oral surgery and prosthodontics. He is a visiting professor of implantology at Temple University, Philadelphia, and is editor-in-chief of Implant Dentistry Today. Professor Nikolaos Donos, DDS, MS, FHEA, FRCSEng, PhD, is the chair of periodontology and implant dentistry and head of the center for oral clinical research at the Institute of Dentistry, Barts and The London School of Medicine and Dentistry, Queen Mary University of London (QMUL). He is also the director of the Clinical Research Facility, also at the QUML Institute of Dentistry. Until recently, Professor Donos was the head and chair of periodontology, director of research, and program director for the MClinDent training program in periodontology at the UCL Eastman Dental Institute. Professor Donos is involved as editorial board member in a number of peerreviewed journals in the field of periodontology and implant dentistry and has also published extensively in both fields.

32 Implant practice

could pose around the implant (plastic or metal). Probing needs to take place after loading of the implant, as a baseline, and at every maintenance visit. If possible, removing the prosthesis can provide a more reliable probing depth reading (Serino and Ström, 2009). Radiographical examination Periapical radiographs should be taken at the time of loading the implant fixture so that a comparison can be made with future radiographs taken at assessment visits. Following clinical change such as increased probing pocket depths, bleeding on probing or suppuration around an implant, an additional radiograph should also be taken, in order to evaluate the bone levels around this implant. Bleeding on probing (BOP) BOP has been shown to be a high negative predictor for implant disease (Jepsen, et al., 1996; Fransson, Wennström, and Berglundh, 2008). This means if there is no bleeding, there is a low probability of disease. At the same time, suppuration is associated with active forms of disease, according to Fransson, Wennström, and Berglundh, especially in smokers (2008). Peri-implantitis can be classified as an incidence of probing pocket depth (PPD) ≥5 mm with bleeding on probing and/or suppuration and radiographic signs of bone loss Volume 8 Number 6

Risk factors/indicators Plaque Plaque accumulation around dental implants was shown to increase the level of mucosal inflammation and pocket probing depths in an experimental study where patients were asked to refrain from cleaning for 3 weeks (Pontoriero, et al., 1994). As such, it is now accepted that periimplant mucositis is plaque-induced and that this may then progress to periimplantitis if left untreated, as shown by Lang and colleagues (2011b). Adequate oral hygiene measures and a cleansable prosthesis are very important in order to prevent peri-implant infection (Serino and Ström, 2009). Over-contoured restorations, poor pontic design, or close approximation of implants can provide obstacles for patients in the maintenance of their implants. An observational study conducted in 2009 showed that approximately 50% of implants with peri-implantitis had a lack of accessibility for oral hygiene practices (Serino and Ström, 2009). It has also been found that with poor oral hygiene, the patient presents with an odds ratio of approximately 14 times and is more likely to develop peri-implantitis (Ferreira, et al., 2006). History of periodontal disease There is a statistically significant risk of developing peri-implantitis in patients with periodontitis, even in those patients who are treated previously and declared as “periodontally stable.” It has been calculated that in patients with previously treated periodontitis, the reported odds ratio of their developing periimplantitis is 3.1 to 4.7 (Heitz-Mayfield and Huynh-Ba, 2009).

While this is significant, the reported implant survival rate for this cohort was still above 90%. Despite this, the success rates that indicate incidence of biological complications vary between studies from 58% to 100%. However, this is based on 5-year data, and different groups have suggested that the real long-term damage of peri-implantitis may present itself in survival data after 5 years (Heitz-Mayfield and Huynh-Ba, 2009). Residual probing pocket depths ≥5 mm can serve as an even greater risk for peri-implant disease. Prevalence of periimplantitis was found to be 11.8% to 13.3% in patients with a history of periodontitis (with no residual probing depths >5mm), compared to 30.1% of patients with active periodontitis (with periodontal probing depths >5mm) (Cho-Yan Lee, et al., 2012). Smoking Smoking not only has a negative impact on the periodontal tissues, but also has been shown to influence the prevalence and progression of peri-implant diseases (RoosJansåker, et al., 2006). Smokers have been shown to have a higher incidence of periimplant bone loss in periodontal patients under maintenance (Fransson, Wennström, and Berglundh, 2008). Diabetes Patients with poorly controlled diabetes and periodontitis have been shown to present with an increase level of systemic “inflammation, oxidative stress, and apoptosis” (Retzepi, Lewis, and Donos, 2010; Genco and Borgnakke, 2013). This can contribute to destruction of periodontal tissues and impair wound healing, as shown by Genco and Borgnakke (2013). Studies of patients with diabetes also reflect an increase in prevalence for periimplantitis (Ferreira, et al., 2006). The degree of glycemic control may also have a role, as early investigations seem to

suggest that there may be limited clinical and microbiological differences in patients without diabetes and those with good glycemic control (Tatarakis, et al., 2014). Other risk indicators, which we need to be aware of in our patients with implant fixtures, include but are not limited to genetic factors, alcohol consumption, systemic disease, and stress (Heitz-Mayfield, 2008; Dereka, et al., 2012).

How do we manage the patient with peri-implantitis? Following diagnosis of peri-implant diseases, an appropriate management is vital in order to prevent deterioration of the peri-implant tissues. The goal of any treatment should be elimination/reduction of the pockets around the implants, with absence of suppuration, BOP, bone loss, and maintenance of healthy re-established peri-implant tissues (Heitz-Mayfield and Mombelli, 2014). The Cumulative Interceptive Supportive Therapy (CIST) protocol has been suggested as a step-by-step guideline for the treatment of peri-implant diseases (Lang, et al., 2004). The protocol, which is adapted in a flow diagram in Figure 1, provides guidance as to the stage/type of intervention that may be indicated at different clinical conditions. As probing depths increase along with BOP and bone loss, cumulative interventions are displayed in Figure 1 (A to D). It also reinforces the need to take periapical radiographs when there are probing depths ≥5mm with bleeding on probing. Other protocols have been written, including the Association of Dental Implantology (ADI) guidelines on treatment of periimplant diseases (2012). As peri-implant disease is bacterial in origin with contamination of the surface of the implant, mechanical debridement is the first line to any approach to therapy. Many treatment modalities have been suggested for mechanical debridement and decontamination of the implant surfaces, including titanium curettes, plastic-coated ultrasonic inserts, air abrasion units, titanium brushes, and the use of chemical or photodynamic therapies — just some of the approaches that have been attempted.

How predictable is treatment?

Figure 1: CIST protocol (adapted from Lang, 2004) Volume 8 Number 6

Nonsurgical therapy has been shown to be effective in the treatment of peri-implant mucositis. However, treatment of periimplantitis has shown a limited response (Klinge, et al., 2012). Implant practice 33

CONTINUING EDUCATION

of ≥2.5mm or bone loss extending ≥ the first three threads (Ong, et al., 2008). However, other definitions exist in the literature.

CONTINUING EDUCATION The adjunctive uses of local or systemic antibiotics have been shown to reduce bleeding on probing and pocket depth, but with modest outcomes (Renvert, et al., 2008). Due to the different implant surface characteristics and therefore limited access to the biofilm, surgical treatment may be indicated at an earlier stage and more frequently compared to conventional periodontal therapy (Heitz-Mayfield and Lang, 2010).

Summary Preventive approach should start in the implant planning stages and case selection. It is important to assess the patient risk profile so that maintenance can be targeted appropriately. Figure 2 (Donos, Laurell, and Mardas, 2012) demonstrates these risk profiles in a simple way for us to start this preventive process and case selection from the early stages in treatment planning. The majority of patients would fit into this lower risk category. It is of upmost importance to continually monitor the health of our patients and their implants. Regular maintenance visits are essential depending on the risk profile of the patient. Supportive periodontal therapy is vital in the prevention of peri-implant disease, as reported by Donos, Laurell, and Mardas (2012). A summary of what can be included in the visit is shown as follows: • Parallel periapical radiographs taken immediately post-implant fixture placement at the time of loading and at the 1-year review appointment (Lang and Berglundh, 2011a) • Detailed oral hygiene advice, demonstrating how to perform efficient plaque removal • Depending on the severity of periodontal disease and presence of risk factors for disease progression, examination should take place every 3, 6, or 12 months. This should include PPD, BOP, and plaque scores (Donos, Laurell, and Mardas, 2012) • Further radiographic examination should take place in the presence of a peri-implant site with BOP and PPD ≥5 mm (Lang, et al., 2004) • Professional hygiene treatments including supra- and subgingival debridement should be performed every 3 to 6 months with appropriate instruments (Donos, Laurell, and Mardas, 2012) 34 Implant practice

REFERENCES

High-risk profile

1. Albrektsson T, Dahl E, Enbom L, Engevall S, Engquist B, Eriksson AR, Feldmann G, Freiberg N, Glantz PO, Kjellman O et al. Osseointegrated oral implants. A Swedish multicenter study of 8139 consecutively inserted Nobelpharma implants. J Periodontol. 1988;59(5):287-296.

Moderate-risk profile

2. Cho-Yan Lee J, Mattheos N, Nixon KC, Ivanovski S. Residual periodontal pockets are a risk indicator for peri-implantitis in patients treated for periodontitis. Clin Oral Implants Res. 2012;23(3):325–333.

Low-risk profile

3. Dereka X, Mardas N, Chin S, Petrie A, Donos N. A systematic review on the association between genetic predisposition and dental implant biological complications. Clin Oral Implants Res. 2012;23(7):775–788.

Figure 2: Risk assessment pyramid (adapted from Donos, et al., 2012)

Risk assessment pyramid

4. Donos N, Laurell L, Mardas N. Hierarchical decisions on teeth vs. implants in the periodontitis-susceptible patient: the modern dilemma. Periodontol 2000. 2012;59(1):89–110. 5. Ferreira SD, Silva GL, Cortelli JR, Costa JE, Costa FO. Prevalence and risk variables for peri-implant disease in Brazilian subjects. J Clin Periodontol. 2006;33(12):929–935. 6. Fransson C, Wennström J, Berglundh T. Clinical characteristics at implants with a history of progressive bone loss. Clin Oral Implants Res. 2008;19(2):142–147.

High-risk profile

7. Genco RJ, Borgnakke WS. Risk factors for periodontal disease. Periodontol 2000. 2013;62(1):59–94.

Patient level

8. Heitz-Mayfield LJ, Lang NP. Comparative biology of chronic and aggressive periodontitis vs peri-implantitis. Periodontol 2000. 2010;53:167–181.

Site level

Suggestion

Aggressive or refractory periodontitis, high plaque and bleeding on probing, smoking and high esthetic demands Compromise in alveolar bone quantity and quality, need for hard and soft tissue augmentation with neighboring teeth presenting with residual probing depths >4mm, and bleeding on probing Implant therapy to be avoided

Moderate-risk profile Patient level

History of periodontal disease previously treated but with few residual pockets, the oral hygiene suboptimal

Site level

Suboptimal alveolar bone availability. Adjacent teeth may require periodontal retreatment

Suggestion

Periodontal conditions need to be stabilized prior to implant therapy provision

Low-risk profile

9. Heitz-Mayfield LJ, Mombelli A. The therapy of peri-implantitis: a systematic review. Int J Oral Maxillofac Implants. 2014;(29 Suppl):325–345. 10. Heitz-Mayfield LJ. Peri-implant diseases: diagnosis and risk indicators. J Clin Periodontol. 2008;35(8 Suppl):292–304. 11. Heitz-Mayfield LK, Huynh-Ba G. History of treated periodontitis and smoking as risks for implant therapy. Int J Oral Maxillofac Implants. 2009;(24 Suppl):39–68. 12. Klinge B, Meyle J, Working Group 2. Peri-implant tissue destruction. The Third EAO Consensus Conference 2012. Clin Oral Implants Res. 2012;23(6 Suppl):108–110. 13. Lang NP, Berglundh T, Heitz-Mayfield LJ, Pjetursson BE, Salvi GE, Sanz M. Consensus statements and recommended clinical procedures regarding implant survival and complications. Int J Oral Maxillofac Implants. 2004;19 Suppl:150–154. 14. Lang NP, Berglundh T, Working Group 4 of Seventh European Workshop on Periodontology. Periimplant diseases: Where are we now? – Consensus of the Seventh European Workshop on Periodontology. J Clin Periodontol. 2011;38(11 Suppl):178–181. 15. Lang NP, Bosshardt DD, Lulic M. Do mucositis lesions around implants differ from gingivitis lesions around teeth? J Clin Periodontol. 2011;38 (11 Suppl):182–187. 16. Mombelli A, Müller N, Cionca N. The epidemiology of periimplantitis. Clin Oral Implants Res. 2012;23(6 Suppl):67-76. 17. Needleman I, Chin S, O’Brien T, Petrie A, Donos N. Systematic review of outcome measurements and reference group(s) to evaluate and compare implant success and failure. J Clin Periodontol. 2012;39(12 Suppl):122–132. 18. Ong CT, Ivanovski S, Needleman IG, Retzepi M, Moles DR, Tonetti MS, Donos N. Systematic review of implant outcomes in treated periodontitis subjects. J Clin Periodontol. 2008;35(5):438–462. 19. Pjetursson BE, Tan WC, Zwahlen M, Lang NP. A systematic review of the success of sinus floor elevation and survival of implants inserted in combination with sinus floor elevation. J Clin Periodontol. 2008;35(8 Suppl):216–240. 20. Pontoriero R, Tonelli MP, Carnevale G, Mombelli A, Nyman SR, Lang NP. Experimentally induced peri-implant mucositis. A clinical study in humans. Clin Oral Implants Res. 1994;5(4):254–259.

Good response to periodontal therapy with optimal oral hygiene is systemically healthy

21. Renvert S, Roos-Jansåker AM, Claffey N. Non-surgical treatment of peri-implant mucositis and peri-implantitis: A literature review. J Clin Periodontol. 2008;35(8 Suppl):305–315.

Site level

Bone quantity adequate, adjacent teeth periodontally and endodontically stable

23. Roos-Jansåker AM, Renvert H, Lindahl C, Renvert S. Nine- to fourteen-year follow-up of implant treatment. Part III: Factors associated with peri-implant lesions. J Clin Periodontol. 2006;33(4):296–301.

Suggestion

Successful implant therapy is achievable

Patient level

22. Retzepi M, Lewis MP, Donos N. Effect of diabetes and metabolic control on de novo bone formation following guided bone regeneration. Clin Oral Implants Res. 2010;21(1):71–79.

24. Jepsen S, Rühling A, Jepson K, Ohlenbusch B, Albers HK. Progressive peri-implantitis. Incidence and prediction of peri-implant attachment loss. Clin Oral Implants Res. 1996;7(2):133–142. 25. Serino G, Ström C. Peri-implantitis in partially edentulous patients: association with inadequate plaque control. Clin Oral Implants Res. 2009;20(2):169–174.

Following a management protocol is vital in preventing peri-implant diseases. This empowers the clinician to recognize this condition and manage appropriately. IP

26. Tatarakis N, Kinney JS, Inglehart M, Braun TM, Shelburne C, Lang NP, Giannobile WV, Oh TJ. Clinical, microbiological, and salivary biomarker profiles of dental implant patients with type 2 diabetes. Clin Oral Implants Res. 2014;25(7):803–812. 27. Zitzmann NU, Berglundh T. Definition and prevalence of peri-implant diseases. J Clin Periodontol. 2008;35(8 Suppl):286-91.

Volume 8 Number 6

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Peri-implant diseases: prevention and management HORWITZ/SCHER/DONOS

1. In general, peri-implant diseases are characterized by a host inflammatory response to ________________ and are classified into peri-implant mucositis and peri-implantitis. a. opportunistic oral microbiota b. fungal infections c. dental trauma d. hereditary lesions 2. Probing needs to take place ____________. a. after loading of the implant b. as a baseline c. at every maintenance visit d. all of the above 3. __________ should be taken at the time of loading the implant fixture so that a comparison can be made with future radiographs taken at assessment visits. a. CBCT scans b. Periapical radiographs c. Tomograms d. A panoramic X-ray 4. Following clinical change such as __________ an additional radiograph should also be taken, in order to evaluate the bone levels around this implant.

Volume 8 Number 6

a. increased probing pocket depths b. bleeding on probing c. suppuration around an implant d. all of the above 5. __________ has been shown to be a high negative predictor for implant disease. a. Healthy bone b. Blanching on probing c. Bleeding on probing d. Pink soft tissue 6. Plaque accumulation around dental implants was shown to _____ the level of mucosal inflammation and pocket probing depths in an experimental study where patients were asked to refrain from cleaning for 3 weeks. a. increase b. decrease c. have no effect on d. slightly reduce 7. ________ is/are very important in order to prevent peri-implant infection. a. Close approximation of implants b. Adequate oral hygiene measures c. A cleansable prosthesis d. both b and c

8. An observational study conducted in 2009 showed that approximately ___________ of implants with peri-implantitis had a lack of accessibility for oral hygiene practices. a. 25% b. 35% c. 50% d. 70% 9. The _____________ has been suggested as a step-by-step guideline for the treatment of peri-implant diseases. a. Deep Pocket Interactive protocol (DPIP) b. Oxidative Stress Therapy protocol (OST) c. Cumulative Interceptive Supportive Therapy (CIST) protocol d. Heitz-Mayfield protocol 10. The adjunctive uses of ________________ have been shown to reduce bleeding on probing and pocket depth, but with modest outcomes. a. local or systemic antibiotics b. steroids c. saline rinses d. interceptive interventions

Implant practice 35

CE CREDITS

IMPLANT PRACTICE CE

CONTINUING EDUCATION

Evaluation and management of common dental implant complications Dr. Jay B. Reznick presents a comprehensive discussion of implant failures and their management

t is important to appreciate the fact that dental implant surgery is SURGERY. It is invasive and can have irreversible effects on patients. Before dentists begin incorporating implant surgery in to their practice, they must understand the difference between a technician and a doctor. The technician understands, usually quite well, “how” to do a procedure. But in order to be successful as an implant surgeon, it is necessary to be a doctor. There is nothing that we can do in surgery that is without complications. So, in order to properly manage and hopefully avoid most complications, a doctor must also understand the “why,” the “why not,” and the “what if” of the procedure he/she is performing. One of the most important things we do as part of the treatment planning process is to educate our patients about the benefits and potential risks of surgery. Patients and clinicians both want to think of dental implants as being permanent replacements for missing teeth. I like to tell my patients that “dental implants are as permanent as your permanent teeth.” That is, with good care and a bit of luck, the implants can last them a very long time. But just as their permanent teeth can be lost prematurely, so can dental implants, and no matter how good our technology and surgical skills, we cannot do better than nature. That goes a long way to help them understand the situation when implants do fail. There are a number of reasons that dental implants can fail. These can be due to patient factors, such as diabetes, smoking, medications that

Educational aims and objectives

This article aims to discuss various types of implant failures and ways to manage them.

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 complications related to implant placement. • Identify complications related to implant position. • Realize some complications that could occur during the integration phase. • Identify some complications that can occur once the implant has been restored. • Realize some causes and treatment for peri-implantitis.

impair wound healing, and bone repair,1 as well as parafunctional habits that can put excess biomechanical stress on a dental implant.2 Sometimes implants are doomed to fail because the clinician failed to completely examine the patient and was not aware of an anatomical factor that put the fixture in a compromised position. Other times, it is inadequate surgical technique or perioperative care that is responsible for implant failure. But sometimes, no matter how wellplanned, executed, and cared-for implant treatment may be, good old bad luck may be the culprit. A comprehensive discussion of implant failures and their management would fill an entire textbook and still be incomplete. Due to space limitations, I will only discuss some of the common ones. Implant failure can occur at any point in time, but for discussion, let’s categorize complications into those that occur at the time of placement, those during the integration phase, and those once the implant has been restored.

Jay B. Reznick, DMD, MD, is a Diplomate of the American Board of Oral and Maxillofacial Surgery. He received his dental degree from Tufts University, his MD degree from the University of Southern California (USC) and trained in Oral and Maxillofacial Surgery at LAC+USC Medical Center. His special clinical interests are in the areas of facial trauma, jaw and oral pathology, dental implantology, sleep disorders medicine, laser surgery, and jaw deformities. He also has extensive expertise in the integration of digital photography, 3D imaging, and CT-guided implant surgery in clinical practice. He frequently lectures at continuing education meetings, and has published articles in JADA, Journal of the California Dental Association, Oral Surgery Oral Medicine Oral Pathology, Compendium of Continuing Education in Dentistry, Dentaltown magazine, CE Digest, and Gastroenterology. Dr. Reznick is one of the founders of the website OnlineOralSurgery.com, which educates practicing dentists in basic and advanced oral surgery techniques, and he is on the Editorial and Advisory Boards of a number of journals and organizations. He is the Director of the Southern California Center for Oral and Facial Surgery (www.sccofs.com) in Tarzana, California, and a consultant for many dental and surgical manufacturers. He can be reached at jreznick@sccofs.com.

36 Implant practice

Complications related to implant placement Implant position complications The primary causes of implant failure can be attributed to poor planning and placement. A natural tooth, which is attached to the alveolar bone through a vascularized periodontal ligament space, may be only partially supported within bone. In contrast, it is imperative that there be an adequate volume of healthy bone surrounding a dental implant. Most of the data suggest that there should be at least a thickness of 1.8 mm–2.0 mm of healthy bone on the buccal (facial) and lingual (palatal) aspects of each implant fixture, as well as 1.5 mm or more between an implant and a natural tooth,3 and 3.0 mm between adjacent implants.4 One should keep in mind that these values are minimums. Violation of this minimal bone thickness leads to compromised vascular supply to the surrounding bone at the crest, lower loading handling during function, and ultimately bony resorption, resulting in implant failure, as well as potential loss of neighboring teeth. This is a situation that should be a thing of the past. When I trained in oral and maxillofacial surgery, we used only a panoramic radiograph, study models, and clinical examination to treatment plan implant surgery cases. It was impossible to accurately appreciate the three-dimensional anatomy of the patient’s jaws to determine ridge form and volume. Surgical guides, if they were even Volume 8 Number 6

Figure 3: A fully guided implant surgery kit utilizes a master sleeve in the surgical guide to control the position, angulation, and depth of each osteotomy drill and the implant fixture so that the implant placement is exactly where planned in the 3D software

used, were only reference appliances for the initial and subsequent osteotomies. Even if the first drill was placed through a sleeve in the guide, there was no depth control, and subsequent drills were all used freehand, so the implant trajectory could deviate during site preparation. As the radiographs being used only provided a 2D image, a clinician could not easily assess the shape of the ridge in the buccal-lingual dimension unless a full flap was placed. This could lead to implant placement outside the confines of the ridge which may not be apparent until failure initiated (Figures 1 and 2). In addition, most implant sites were accessed through surgical flaps. It was not unusual for the implant position, size, and/or angulation to require modification once the ridge was directly visualized. This type of placement error should now be a thing of the past, as 3D CBCT imaging and treatment planning software are readily available in an increasing number of dental practices, and more implant systems are Volume 8 Number 6

Figure 4: Implant planning software uses the 3D image from a CBCT to evaluate the bony anatomy and plan the ideal sites and positions for dental implant placement

developing fully guided (CBCT-based) implant surgery kits (Figure 3). These advancements in implantology allow the clinician to fully evaluate the bony and soft tissue architecture based on a prosthetically driven treatment plan helping eliminate any surprises at the surgical phase. This allows the implant positions to be planned on a 3D image of the jaws such that they are within an adequate volume of bone, correctly spaced and in line with the proposed prosthesis (Figure 4). The surgical guide produced from this data, along

with the corresponding surgical kit, allows the implant fixtures to be placed as planned, with a minimal margin of error, which is below the threshold of what the human eye can discern. If, during planning, there is determined to be a deficiency in bone volume, that issue can be addressed in a pre-implant surgical procedure or at the time of implant placement, whichever is most appropriate. With todayâ&#x20AC;&#x2122;s technology and surgical techniques, implant placement errors should be a rare occurrence. Implant practice 37

CONTINUING EDUCATION

Figures 1 and 2: This healthy 23-year-old woman had a dental implant placed to replace her congenitally absent maxillary lateral incisor. Her dentist failed to evaluate the anatomy of the edentulous site, and as a result, the implant fixture was placed facially in a narrow ridge. The implant was visible through the buccal mucosa, and she experienced tenderness in the gingival and occasional pain

CONTINUING EDUCATION Sinus violation Another potential source of implant failure is the violation of the floor of the maxillary sinus and Schneiderian membrane at the time of surgery. For the most part, minor perforations should have little or any adverse consequences.5 The body has a remarkable capacity for recovery, and minor tears in the membrane will heal uneventfully the majority of the time. When an oral and maxillofacial surgeon performs a Le Fort osteotomy procedure for a congenital jaw deformity, the sinus walls are completely severed, and the sinus membrane is circumferentially divided. Titanium plates and screws are used to stabilize the maxilla in its new position. No attempt is made to repair the sinus membrane, and the circumvestibular incision is closed in two layers. Even with this massive violation, sinus infections and screw failures are extremely rare (Figure 5). So, the fear of a small sinus floor perforation and tear in the lining membrane resulting in implant failure is significantly overrated. What usually leads to posterior maxillary implant failure is an inadequate thickness of bone to provide primary mechanical stabilization to the implant fixture. With the lower density and thus quality of bone in the posterior maxilla, a minimum of 5 mm of solid bone is required to give a high likelihood of success. When this minimum requirement is violated, implant mobility leading to infection and failure is inevitable.6 Again, 3D CBCT treatment planning combined with an adequate amount of education will prevent most occurrences of this complication. Soft tissue problems Another factor that frequently leads to implant failure is an inadequacy of keratinized tissue around the fixture, potentiating the possibility of peri-implantitis, which then leads to bone loss and implant mobility. A very common statement I hear from inexperienced implantologists is the belief that having a CBCT, digital plan, and a surgical guide based on this plan, gives them the ability to place implants through a tissuepunch incision. This demonstrates a lack of understanding of implant surgical principles. The ability of performing â&#x20AC;&#x153;flaplessâ&#x20AC;? implant surgery is based on having an adequate bone and keratinized tissue volume. If either is deficient and requires modification, than an open surgical approach with a flap is required. A natural tooth has a defined biologic width, which is the sum of the thickness of the connective tissue, junctional epithelium, and sulcus depth. This usually measures 2.0 mmâ&#x20AC;&#x201C;3.0 mm around a healthy tooth.7 For a dental implant, a minimum of 2.0 mm of 38 Implant practice

attached gingival tissue around the emergence of the fixture is necessary to avoid violation of the biologic width and development of peri-implant soft tissue inflammation. If less than this is available, the tissue should be modified to develop additional keratinized tissue.7 Nerve injury Another complication related to treatment planning is injury to the inferior alveolar or lingual nerves. Lingual nerve injury can generally be avoided by keeping incisions away from the lingual aspect of the posterior mandibular ridge, and by ensuring that reflection of any lingual tissue is kept in the plane between the periosteum and alveolar bone. A full thickness flap in this area elevates the lingual nerve with the tissue lessening an incidence of damage to this nerve, which may occur if a partial thickness flap was utilized. Injury to the inferior alveolar nerve

is caused by violation of the inferior alveolar canal by implant osteotomy drills or fixtures. This is something that is easier to prevent with proper treatment planning and careful surgical technique. The mandibular (inferior alveolar) nerve passes through the mandible from the lingula to the mental foramen, transversing the body of the mandible, then exiting via the mental foramen into the lower lip. The position of the mandibular canal is extremely variable. Periapical radiographs are completely inadequate for determining the distance between the mandibular canal and the alveolar crest due to elongation or foreshortening artifact. At the minimum, a panoramic radiograph is required, taking into account a 20%-25% magnification factor in images taken on a panoramic unit. This magnification varies unit brand to unit brand and is not constant over the width of the panoramic image. The implant surgeon must keep in mind that for most systems, the tip

Figure 5: When a Le Fort osteotomy is performed, the palate is separated from the maxilla through the sinus walls and mucosa, and nasal septum. Titanium plates and screws are used to fixate the new position without repair of the sinus membrane

Figure 6: A postoperative panoramic radiograph demonstrates the penetration of a dental implant into the inferior alveolar canal. Planning was based on a panoramic radiograph and placed freehand by an experienced implantologist Volume 8 Number 6

Figure 8: A digital treatment plan from the CBCT scan allows identification of the mandibular nerve and facilitates treatment planning based on anatomy and the final restoration Volume 8 Number 6

that the implant fixture is in close proximity or within the mandibular canal, prudent management dictates removal of the implant. The use of corticosteroids may have some benefit to reduce the duration of deficit for neuropraxia or mild axonotmesis cases. Return of sensation may be in days or could take 6 months or more, depending on severity. Gabapentin may help patients with painful sensations. In cases of neurotmesis, especially when there is total anesthesia or dysesthesia, surgical intervention may be indicated if improvement is minimal after 3 months. Referral to a neurologist is appropriate and, when indicated, should be done as early as possible to limit further damage to the nerve. This complication is a good one to avoid, as it is a common cause of litigation against dentists. With the technology available to the implant surgeon today, it should be extremely rare. Three-dimensional imaging with CBCT allows for very accurate analysis of the position of the inferior alveolar canal at the sites of implant placement. Computerized treatment planning can be used to select the ideal fixture size, width, and position to avoid the mandibular nerve and maximize implant success (Figure 8). Combined with a surgical guide derived from this plan, CBCT-guided surgical techniques control the position, angulation and depth of each osteotomy and fixture placed (Figures 9-10). Following this protocol, inferior alveolar nerve injury can be completely avoided. The only other etiology for injury to either the mandibular, long buccal, or lingual nerve remains that from injection of local anesthetic. For many simple implant cases, a block injection can be avoided by

Figure 9: A surgical guide designed from software based on the CBCT image is digitally created to control the position, angulation, and depth of osteotomies and implant placement Implant practice 39

CONTINUING EDUCATION

of the osteotomy drills extends up to 0.5 mm beyond the apical end of the implant fixture. A margin of safety of 2.0 mm should be factored in when planning the length of the fixture to be placed.8 If this distance is violated, by either an osteotomy drill or an implant fixture, injury to the inferior alveolar nerve may occur (Figure 6). We categorize the injury by the Seddon Classification, which stratifies severity of injury and prognosis for recovery (Figure 7). Figure 7: Seddon Classification of peripheral nerve injury The least severe injury is generally due to blunt trauma or stretching of the nerve, is referred to as “neuropraxia.” In this backing it out of the osteotomy to relieve the category, there is no physical disruption of pressure on the nerve before implant intenerve fibers. There may be contusion and the gration can occur and atrophy of the nerve resulting hematoma beneath the epineurium, results. The most severe injury is classified the sheath, which surrounds the bundle of as a “neurotmesis.” Here, there is severance nerve fibers; but there is no loss of continuity and disruption of individual nerve fibers. It of the nerve. Patients will describe a sensamay be partial or complete. These patients tion of “tingling” in their lip or tongue, have will have areas of total anesthesia and may reduced sensation, but no areas of total lack have painful “dysesthesia” (abnormal altered of sensation or pain. This group has the best sensation), and have the worst prognosis. prognosis for a full recovery. Next is “axonotWhen a patient reports symptoms of mesis” in which there is damage to the nerve a nerve injury after surgery, the first step is fibers, but the perineurium, which surrounds explanation to the patient of what occurred, nerve bundles, is intact. This may result due followed by careful examination and docuto the implant “crushing” the nerve, and the mentation of the deficit, followed by a discusresulting pressure leads to the deficit. The sion of the severity of the injury, what to deficit will be more profound, and recovery expect, and what to do about it. In the case of will be slower and possibly incomplete. The mandibular nerve injury, immediate imaging key to treatment of this type injury when the with CBCT or medical CT scanning is recomimplant is impinging on the nerve is early idenmended to determine the extent of violation tification and either removal of the implant or of the inferior alveolar canal. If imaging shows

CONTINUING EDUCATION prevent this include using copious irrigation with isotonic saline to cool and lubricate the drills, using light pressure on drills, utilizing short intermittent strokes to remove drilling debris and facilitate irrigant getting into the osteotomy sites, and reducing drill speeds as the drill diameter increases.12

Complications during the integration phase

Figure 10: Postoperative CBCT of the implant planned in Figure 8 and placed using the surgical guide in Figure 9. There is no clinically significant difference between the planned and actual fixture placement

simple infiltration of local anesthetic directly over the surgical site. Since the only innervation to an edentulous region is via the periosteum, good local anesthesia can be obtained for implant placement by infiltration alone.9 Bleeding Bleeding during implant surgery can come from either inside the bone or from the soft tissues outside the bone. As long as the inferior alveolar vessels are avoided, most intraosseous bleeding encountered during implant site preparation can be stopped by simply placing the implant in the osteotomy. Bleeding from the soft tissue can be much more problematic. The most problematic area is from the sublingual and submandibular regions due to penetration of an osteotomy drill through the lingual cortex of the mandible (lingual perforation). Depending on the degree and location of injury, bleeding can be minor and cause a small hematoma to develop in the floor of the mouth (Figure 11) or result in severe hemorrhage, which can cause life-threatening obstruction of the airway.10 Firm direct pressure over the area

of bleeding should be the first response.11 Surgical exposure for the purpose of cauterization or ligation of vessels should be performed by only those experienced in this procedure. The status of the airway should be carefully monitored, and intubation or tracheostomy should be considered if any airway compromise is observed. Those patients who have this issue arise should not be dismissed until the surgeon is confident that the bleeding has stopped or should be transported to the ER for further treatment so that the airway is not compromised. Again, this complication is best avoided by obtaining a 3D CBCT scan prior to surgery in order to identify any anatomic factors, such as concavity below the mylohyoid ridge, which may increase the risk of this complication. Accurate implant placement, utilizing a guided implant protocol will minimize or eliminate this possible risk. Overheating injury Overproduction of heat during osteotomy preparation results in necrosis of bone, leading to implant failure. Measures to

Figure 11: Clinical appearance of patient following moderate floor of mouth hemorrhage after penetration of a dental implant drill through the lingual mandibular plate 40 Implant practice

Peri-implant soft tissue inflammation Despite meticulous treatment planning and surgical technique, an implant may present with inflammation, swelling, and pain in the surrounding tissues.13 A periapical radiograph should be taken to rule out severe bone loss or the development of a radiolucent margin between the implant and bone. Both of these findings suggest implant failure, and the fixture should be considered for removal (Figure 12). If the implant is otherwise stable, and there are no radiographic changes, conservative management should include light debridement by the clinician with implant curettes, along with irrigation with chlorhexidine rinse.14 The patient should be placed on a broad-spectrum antibiotic, such as amoxicillin, cephalexin, or clindamycin. For home care, gentle irrigation with a pulsed-water flosser once daily is helpful. Adding a few drops of sodium hypochlorite to the water reservoir will serve as a very effective bacteriocidal agent to sterilize the sulcus around the implant. The patient should be monitored carefully until the situation resolves. This inflammation could be an early sign of implant failure. Occlusion on the implantsâ&#x20AC;&#x2122; prosthetics should also be evaluated and adjusted as needed to rule out an occlusion component. Sinusitis In general, a minor penetration of an implant fixture into the maxillary sinus, even

Figure 12: A radiolucent border between a dental implant and the alveolar bone is an indication of implant failure Volume 8 Number 6

Implant mobility If implant mobility is detected during the integration stage, the likelihood of the implant integrating is low, and further bone loss will occur if conservative management and observation are employed. The implant should be removed as soon as this is observed, the site thoroughly debrided of the inflammatory and fibrous tissue that formed between the implant and bone, followed by copious irrigation and bone grafting of the defect in anticipation of new implant placement 3 to 6 months in the future following complete site healing and fill of the osteotomy by the osseous graft placed.

lead to restorative failure in some cases. Mesial tooth migration is a known phenomenon. We have all seen mesial tipping of third molars into the second molar space after it has been extracted. Any tooth has the potential to tilt mesially into an edentulous space over time (Figure 13). Teeth may also hypererupt toward the other arch when the opposing tooth is missing. The rate at which this occurs is extremely variable. Patients can be missing a tooth for years, and no movement of the opposing or distal teeth will occur. Or, it can happen in a matter of months. If a dental implant was placed into the edentulous ridge, movement of surrounding teeth can dramatically affect the restorability of the implant. Since it is difficult to predict which patients will exhibit rapid tooth movement, I always recommend some type of space-maintaining appliance be worn until a provisional or final restoration can be placed. My preference is an Essix bridge, which is inexpensive to make and does not rest on the extraction site or implant head. Generally, 8 hours per day of wear is sufficient to prevent this complication.

Complications once the implant has been restored

Tooth movement This complication during the integration phase is rarely mentioned because it does not lead to implant fixture failure. But it can

Peri-implantitis Most post-restoration implant complications are related to inflammation and resulting bone loss. The signs and symptoms include tenderness, pain, inflammation, purulent drainage, and bone loss.13 Once the integration period has passed, debridement around the implant fixture can be more aggressive versus during the first few months. All surrounding granulation tissue should be debrided using implant-safe curettes, and then copiously irrigated with sterile saline.14 As mentioned with peri-implantitis during the integration phase, a broad-spectrum

Figure 13: Mesial drift is a well-established phenomenon that may occur over time. It can be slow or rapid. Use of a space-maintaining appliance will prevent this from occurring between the time of extraction and implant restoration

Figure 14: Excess cement, which is left behind in the sulcus around a dental implant (between the two implants), results in an inflammatory response leading to bone loss. This is referred to as â&#x20AC;&#x153;cement sepsisâ&#x20AC;?

Volume 8 Number 6

antibiotic is recommended, as well as intrasulcular irrigation with a pulsed-water flosser once daily. A few drops of sodium hypochlorite added to the reservoir tank helps maintain a relatively healthy sulcus. There may be some gingival recession as the inflammation subsides. If there is bone loss around the implant, but it is still stable, bone regenerative techniques may be used in addition to the preceding protocol to attempt to improve bone levels and reduce pocket depth. The prosthesis should be removed, and a cover screw placed to facilitate access and allow for coverage with a membrane. In addition, the defect should be treated with citric acid or tetracycline solution, and followed by sterile saline rinses before bone grafting material and a membrane are added. If despite attempts to salvage the implant, bone loss continues and mobility develops, the implant fixture should be removed, the site thoroughly debrided, and bone regeneration techniques employed. Early intervention when these issues are initially identified increases the prognosis of treating an ailing implant, whereas watching and waiting tends to lead to implant loss as the bone loss progresses to the point where salvaging the implant is not possible. Cement sepsis Fixed implant-supported prostheses can be either screw-retained or cementretained. A properly made crown should be closely adapted to the implant abutment, with space for only a thin layer of cement. If an excess amount of cement is used, this will extravasate through the interface between the crown and abutment when the crown is seated extruding into the sulcus. Cement in the sulcus around a dental implant sets up an inflammatory response, and significant bone loss can result (Figure 14), even leading to failure of the fixture when intervention is not initiated soon enough.15 This situation is best avoided by using a very thin layer of a zinc oxide-based temporary cement for implant crowns. A bitewing radiograph may show cement if it is located in the interproximal areas, but it will not be radiographically visible on the lingual or buccal sulci. The margins should be carefully cleaned and checked for excess cement. Ideally, in the posterior non-esthetic regions, cemented margins should be kept supragingival. In the anterior esthetic zone, they should be no more than 1 mm subgingival. Cement sepsis should always be considered when Implant practice 41

CONTINUING EDUCATION

with a small violation of the sinus membrane, does not lead to any untoward sequelae. However, occasionally, patients will report sinus pressure, pain, or drainage in the weeks, or sometimes months, following maxillary implant placement.5 Initial management should be conservative, consisting of antibiotics and sinus irrigation with saline. Augmentin or ciprofloxacin are good empiric choices. Treatment should be for 10â&#x20AC;&#x201C;14 days. There are also a number of over-the-counter medications that will reduce swelling in the sinus and improve resolution. These include non-sedating antihistamines such as loratadine or fexofenadine, along with intranasal corticosteroids such as fluticasone or triamcinolone sprays. If the patient fails to improve, a Caldwell-Luc osteotomy to drain the sinus may be necessary. If the above treatments are not successful, consideration should be given to removal of the implant, with anticipation that an oral-antral communication will exist and will require surgical closure.

CONTINUING EDUCATION a patient presents with peri-implantitis, especially in the first 6 months after crown cementation. It should be treated using the same technique as for peri-implantitis.

Closing thoughts Once a dental implant issue is recognized, it should be managed immediately. Implant problems will not get better on their own. One of the basic principles taught in surgical residency is that a clinician should be comfortable managing the most common complications associated with any particular procedure before that clinician ever attempts that procedure. The same principle applies to all dentists who begin placing dental implants in their practice. As I mentioned in the first paragraph of this article, dental implant surgery is invasive and can cause irreversible injury to patients. Clinicians should be sure to educate themselves on both the science and technical aspects of implant surgery before performing their first procedure and then build upon that experience before attempting more advanced cases. IP

42 Implant practice

REFERENCES 1. Klokkevold PR, Han TJ. How do smoking, diabetes, and periodontitis affect outcomes of implant treatment? Int J Oral Maxillofac Implants. 2007;22 (suppl):173–202. 2. Koldsland OC, Scheie AA, Aass AM. Prevalence of implant loss and the influence of associated factors. J Periodontol. 2009;80(7):1069–1075. 3. Buser D, Martin W, Belser UC. Optimizing esthetics for implant restorations in the anterior maxilla: anatomic and surgical considerations. Int J Oral Maxillofac Implants. 2004;19(suppl):43-61. 4. Tarnow DP, Cho SC, Wallace SS. The effect of inter-implant distance on the height of inter-implant bone crest. J Periodontol. 2000;71(4):546-549. 5. Jung JH, Choi BH, Zhu SJ, Lee SH, Huh JY, You TM, Lee HJ, Li J. The effects of exposing dental implants to the maxillary sinus cavity on sinus complications. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;102(5):602-605. 6. Peleg M, Garg AK, Mazor Z. Predictability of simultaneous implant placement in the severely atrophic posterior maxilla: A 9-year longitudinal experience study of 2,132 implants placed into 731 human sinus grafts. Int J Oral Maxillofac Implants. 2006;21(1):94-102. 7. Wennström JL, Derks J. Is there a need for keratinized mucosa around implants to maintain health and tissue stability? Clin Oral Implants Res. 2012; 23(Suppl 6):136–146. 8. Worthington P. Injury to the inferior alveolar nerve during implant placement: A formula for protection of the patient and clinician. Int J Oral Maxillofac Implants. 2004;19(5):731-734. 9. Heller AA, Shankland WE 2nd. Alternative to the inferior alveolar nerve block anesthesia when placing mandibular dental implants posterior to the mental foramen. J Oral Implantol. 2001;27(3):127-133. 10. Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JY. Clinical complications with implants and implant prostheses. J Prosthet Dent. 2003;90(2):121-132. 11. Park SH, Wang HL. Implant reversible complications: Classification and treatments. Implant Dent. 2005;14(3):211-220. 12. Eriksson RA, Albrektsson T. Temperature threshold levels for heat-induced bone tissue injury: A vital-microscopic study in the rabbit. J Prosthet Dent. 1983;50(1):101-107. 13. Khammissa RA, Feller L, Meyerov R, Lemmer J. Peri-implant mucositis and peri-implantitis: clinical and histopathological characteristics and treatment. SADJ. 2012;67(3):122,124–126. 14. Persson GR, Samuelsson E, Lindahl C, Renvert S. Mechanical non-surgical treatment of peri-implantitis: a single-blinded randomized longitudinal clinical study. II. Microbiological results. J Clin Periodontol. 2010;37(6):563–573. 15. Mombelli A, Lang NP. The diagnosis and treatment of peri-implantitis. Periodontol 2000. 1998;17:63–76. 16. Wilson TG Jr. The positive relationship between excess cement and peri-implant disease: a prospective clinical endoscopic study. J Periodontol 2009;80(9):1388–1392.

Volume 8 Number 6

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

REF: IP V8.6 REZNICK

CONTINUING EDUCATION BROUGHT TO YOU BY

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Evaluation and management of common dental implant complications REZNICK

1. Most of the data suggest that there should be at least a thickness of 1.8 mmâ&#x20AC;&#x201C;2.0 mm of healthy bone on the buccal (facial) and lingual (palatal) aspects of each implant fixture, as well as 1.5 mm or more between an implant and a natural tooth, and _______ between adjacent implants. a. 1.0 mm b. 2.0 mm c. 3.0 mm d. 4.0 mm 2. Violation of this minimal bone thickness leads to ________, resulting in implant failure, as well as potential loss of neighboring teeth. a. compromised vascular supply to the surrounding bone at the crest b. lower loading handling during function c. bony resorption d. all of the above 3. When an oral and maxillofacial surgeon performs a _____ procedure for a congenital jaw deformity, the sinus walls are completely severed, and the sinus membrane is circumferentially divided. a. Le Fort osteotomy b. osteotomy of the mandibular ramus c. inverted C osteotomy d. mandibular body segmental osteotomy 4. The implant surgeon must keep in mind that for

Volume 8 Number 6

most systems, the tip of the osteotomy drills extends up to _______ beyond the apical end of the implant fixture. a. 0.5 mm b. 1.5 mm c. 2.5 mm d. 3.0 mm 5. For a dental implant, a minimum of ______ of attached gingival tissue around the emergence of the fixture is necessary to avoid violation of the biologic width and development of peri-implant soft tissue inflammation. a. 0.5 mm b. 1.0 mm c. 2.0 mm d. 3.0 mm 6. The most severe (nerve) injury is classified as ____________. Here, there is severance and disruption of individual nerve fibers. a. neurotmesis b. neuropraxia c. axonotmesis d. blunt trauma 7. __________ allows for very accurate analysis of the position of the inferior alveolar canal at the sites of implant placement. a. 2D radiographs

b. Three-dimensional imaging with CBCT c. 2D panoramic X-rays d. Tomograms 8. The most problematic area (in the case of bleeding) is from the ________ regions due to penetration of an osteotomy drill through the lingual cortex of the mandible (lingual perforation). a. sublingual b. submandibular c. palatal d. both a and b 9. (If an implant presents with inflammation, swelling, and pain in the surrounding tissues) A periapical radiograph should be taken to rule out _______. a. trigeminal neuralgia b. severe bone loss c. the development of a radiolucent margin between the implant and bone d. both b and c 10. Cement sepsis should always be considered when a patient presents with peri-implantitis, especially in the first ________ after crown cementation. a. 6 months b. year c. 18 months d. 2 years

Implant practice 43

CE CREDITS

IMPLANT PRACTICE CE

INDUSTRY NEWS Sirona hosting a super event! Sirona Dental, Inc., the leading manufacturer of innovative dental technology, is hosting a superhero-themed party at the House of Blues on February 26, 2016, in Chicago during the 2016 Chicago Dental Society Midwinter Meeting. This party is a membership benefit of SIROWORLD, Sirona’s new event-based community. After saving the day, attendees are encouraged to emulate their favorite superheroes by dressing up in tights, capes, and masks to celebrate into the night at Sirona’s Superheroes of Dentistry party. Membership into SIROWORLD includes access to parties like this — along with SIROWORLD’s educational events held at major U.S. trade shows like the Greater New York dental meeting and the CDA South meeting in Anaheim, California. The highlight of SIROWORLD membership is the Inaugural SIROWORLD Celebration in Orlando, Florida, where entertainment and education collide at digital dentistry’s premiere event. During these educational events, members can speak to leading experts in the field of digital dentistry and compare stories with fellow members about the technologies that have helped integrate their practices into the digital age. For more information on SIROWORLD membership and events, visit www.SIROWORLD.com, or call 844-422-3226.

X-Nav Technologies brings surgical navigation into the dental office for more accurate implant results X-Nav Technologies, LLC, has received 510(k) clearance from the U.S. Food and Drug Administration (FDA) for the X-Guide™ Dynamic 3D Navigation system. The X-Guide system is designed to elevate the surgeon’s control and precision over the entire implant process, including planning and placement. This results in the ability to deliver a more desirable functional and esthetic outcome in dental implant surgeries. The X-Guide™ system utilizes the surgeon’s plan to provide turn-by-turn guidance during live surgery, giving the ability to visualize precise movements of the handpiece during osteotomy and implant delivery for more exact placement — it’s like GPS for the drill. The X-Guide system makes it easy to be exact by providing robust treatment software plus new, patent-pending X-Point™ navigation technology — the first, single-view guidance of implant position, angle, and depth. For more information, visit www.X-NavTech.com.

Restful Jaw Company introduces new medical device The Restful Jaw Company is the manufacturer and distributor of the Restful Jaw®, an easy-to-use, clinically proven device that supports the jaw during treatment. Designed by renowned dental researcher and educator, Eric L. Schiffman, DDS, the device has been tested in clinical trials for more than a decade. Karen Kloser, company founder, president, and CEO notes, “After 10 years of clinical study, dentists and hygienists alike have reported significant improvement in many of their treatment procedures — everything from preventing jaw locking, overextension, and the onset or worsening of jaw pain. It’s also been especially effective for movement disorders and involuntary muscle movement.” According to a recent TMD study, more than 30% of all cases are attributed to opening the jaw too wide, too long, or having too much force on their jaw. The study also found prolonged mouth opening is associated with a 400% increase in TMD issues. According to the company, this type of pain can lead to a malpractice suit against the dental professional. For more information on The Restful Jaw, contact Karen Kloser at karen@restfuljaw.com or 651-231-1838.

44 Implant practice

Instrumentarium Dental™ OP300 Maxio receives 2015 Danaher Innovation Recognition Award The Danaher Innovation Recognition process was created to recognize and celebrate individuals and teams who bring innovation to life by contributing to the company’s most recent and important new products, services, and business models that have moved from concept to commercial success. The award recognized a number of exciting features of the system, including extended imaging areas, the option to reduce radiation dose, and patient-specific imaging parameters substantially increasing the efficiency and versatility of OP300 Maxio system. For more information on OP300 Maxio, visit http://www. instrumentariumdental.com.

Volume 8 Number 6

TECHNOLOGY

Fully integrated digital implant dentistry using Sirona’s CEREC® Guide 2 and Straumann’s Variobase™ for CEREC Dr. Farhad E. Boltchi provides a step-by-step overview of his digital workflow Introduction Sirona revolutionalized digital implant dentistry by providing a completely integrated digital workflow incorporating all aspects of surgical and restorative implant dentistry. The introduction of in-house milling of surgical guides and in-house fabrication of custom abutments and screw-retained crowns was visionary in this regard. Sirona’s recent introduction of CEREC® Guide 2 coupled with innovative restorative components for the CEREC digital implant dentistry workflow such as Straumann® Variobase™ for CEREC®, Vita Enamic® Implant Solutions block, and Ivoclar Vivadent IPS. e.max® hybrid abutment crown block significantly improves the digital implant dentistry workflow, thereby enabling the clinician to perform very precise and efficient in-house digital implant therapy with the CEREC CAD/CAM system. This article will provide a step-by-step overview of this digital workflow.

arches was obtained via scanning with the CEREC Omnicam. A virtual restoration was then designed in the CEREC chairside software 4.4, and the corresponding CAD/CAM data was exported into the Galileos Implant treatment planning software where it was merged with the CBCT scan. The Galileos Implant treatment planning software was utilized to plan a Straumann Bone Level Roxolid® SLActive® RC 4.8 mm x 12 mm guided implant in site No. 19 (Figure 4). The treatment planning data was then exported from the Galileos Implant treatment planning software and imported back into the CEREC chairside software. A CEREC Guide 2 was virtually designed in the CEREC Chairside

Figure 1: Preoperative facial view of edentulous site No. 19

Case example This patient is a 32-year-old male patient with a non-contributory medical history, who presented for implant therapy to replace a missing tooth No. 19. The initial clinical and periapical radiographic evaluation revealed an edentulous site with clinically adequate ridge width and with adequate bone and soft tissue volume for dental implant therapy (Figures 1-3). A cone beam CT radiographic evaluation was performed with the Sirona ORTHOPHOS XG 3D CBCT machine and a digital impression of the patient’s maxillary and mandibular

Figure 2: Preoperative occlusal view of edentulous site No. 19

Figure 3: Preoperative periapical radiograph site No. 19

Farhad E. Boltchi, DMD, MS, has a private practice limited to periodontics and dental implants in Arlington, Texas. He is a Clinical Assistant Professor for the Graduate Periodontics Program at the Baylor College of Dentistry — Texas A&M University System, Dallas, Texas. He is a Diplomate of the American Board of Periodontology and a Fellow of the International Team for Implantology (ITI).

Figure 4: Galileos Implant CBCT implant treatment plan for site No. 19 Volume 8 Number 6

Implant practice 45

TECHNOLOGY software 4.4, and the corresponding CEREC Guide 2 was milled out of a CEREC Guide Bloc Maxi PMMA block in the CEREC MC XL milling unit (Figures 5-9). In order to verify the preoperative accuracy of this CEREC Guide 2, a model-based guided surgery was performed on the preoperative stone model, and a 4.2-mm Straumann depth gauge was placed in the prepared guided osteotomy in the stone

model (Figures 10-11). This stone model with the inserted depth gauge was scanned with the CEREC Omnicam, and the corresponding CAD/CAM data was exported, merged with the preoperative CBCT scan, and layered over the preoperative implant plan, revealing the accuracy of the milled CEREC Guide 2 (Figure 12). The surgical procedure was performed under local anesthesia, and implant

Figure 5: CEREC Guide 2 design in CEREC software 4.4

placement in site No. 19 was accomplished via a flapless guided approach. The CEREC Guide 2, the corresponding Sirona CEREC Guide keys for the Straumann system, and the corresponding Straumann Guided Surgery drills were then utilized to prepare the guided implant osteotomy according to the virtual treatment plan in the Galileos Implant software; and a Straumann 4.8 mm x 12 mm SLActive Roxolid Bone Level implant

Figure 6: Mill preview of finalized CEREC Guide 2 design

Figure 7: CEREC Guide 2 being milled in the CEREC MC XL milling unit

Figure 8: Completed CEREC Guide 2 surgical guide in the CEREC Guide 2 Maxi Bloc

Figure 10: Model-based CEREC Guide 2 guided surgery 46 Implant practice

Figure 9: Close-up view of the completed CEREC Guide 2

Figure 11: Direction indicator in prepared model osteotomy

Figure 12: Merging of the direction indicator CAD file with the preoperative CBCT scan Volume 8 Number 6

was obtained, and the CAD/CAM data of the optical scan of the previously scanned stone model with the inserted depth gauge was once again imported into the Galileos Implant treatment planning software but this time merged with the postoperative CBCT scan. A virtual implant was then placed in the exact position dictated by the depth gauge and layered over the final implant position revealing complete accuracy of the

Figure 14: Close-up view of the intraorally seated CEREC Guide 2

Figure 13: Intraorally seated CEREC Guide 2

Figure 15: Precise guided tissue punch preparation

Figure 16: Fully guided implant placement

Figure 18: Tangential view of the merged direction indicator CAD file with the postoperative CBCT scan Volume 8 Number 6

final implant position in a tangential, crosssectional, and axial dimension, and thereby confirming the high degree of precision achieved with the CEREC Guide 2 process in this case (Figures 18-20). In order to start developing the implant tissue transition zone, the peri-implant bone and soft tissues were adjusted using the Straumann Guided Bone Profiling System (Figures 21-23). A Sirona ScanPost for the Straumann Bone Level RC implant and the corresponding Scanbody were then inserted onto the implant, a CEREC Omnicam digital impression/scan of the Scanbody was obtained, and a custom tissue former was designed in the CEREC software based on a split abutment design of the full contour preoperative virtual design (Figures 24-27). The corresponding custom tissue former was then milled out of

Figure 19: Cross-sectional view of the merged direction indicator CAD file with the postoperative CBCT scan

Figure 17: Flapless guided implant placement

Figure 20: Axial view of the merged direction indicator CAD file with the postoperative CBCT scan Implant practice 47

TECHNOLOGY

was placed through the CEREC Guide 2 in a fully guided fashion in the restoratively correct and preplanned position (Figures 13-16). The implant achieved excellent primary stability and was placed in a flapless approach within the confines of the osseous alveolar housing (Figure 17). In order to verify the accuracy of the CEREC Guide 2 and the performed guided surgery in this case in a three-dimensional plane, a postoperative CBCT scan

TECHNOLOGY a Vita Enamic Implant Solutions A14 block, adjusted and polished, and then bonded to a Straumann RC Bone Level Variobase for CEREC with the Ivoclar Multilink Hybrid Abutment Cement (Figures 28-32). This custom tissue former was screwed onto the implant to develop the ideal peri-implant soft tissue profile (Figures 33-34). After an uneventful healing period of 6 weeks, the previous digital full contour design in the CEREC software was used to mill a screw-retained crown, which was then once again bonded to a Straumann RC Bone Level Variobase for CEREC with the Ivoclar Multilink Hybrid Abutment Cement to obtain a one-piece screw-retained implant crown. The final crown can be milled either out of an Ivoclar IPS e.max A16 Hybrid Abutment Crown block or out of a

Vita Enamic A16 Implant Solutions block. (Figures 35-41). The custom tissue former was then removed revealing an ideally contoured peri-implant soft tissue transition zone.

The screw-retained implant crown was inserted and torqued to 35 N/Cm, and the screw access hole was sealed with Teflon tape and a composite restoration (Figures 42-45).

Figure 21: Straumann Guided Bone Profiler guide in place

Figure 22: Straumann guided soft tissue and bone profiling

Figure 23: Peri-implant tissue contours after profiling

Figure 24: Sirona ScanPost and Scanbody in place

Figure 25: CEREC Omnicam scan of ScanPost/Scanbody

Figure 26: CEREC split abutment design

Figure 28: Vita Enamic A14 Implant Solutions block 48 Implant practice

Figure 27: CEREC split abutment design

Figure 29: Vita Enamic A14 Implant Solutions block with inserted Straumann Variobase for CEREC

Figure 30: Milled Vita Enamic custom tissue former Volume 8 Number 6

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.

TECHNOLOGY

Figure 31: Vita Enamic custom tissue former bonded to Straumann Variobase for CEREC

Figure 34: Immediate postoperative periapical radiograph

Figure 32: Completed Vita Enamic custom tissue former

Figure 35: Six-week postoperative facial view of custom tissue former

Figure 37: CEREC full contour virtual design

Figure 38: CEREC full contour virtual design

Figure 33: Custom tissue former inserted onto implant

Figure 36: Six-week postoperative occlusal view of custom tissue former

Figure 39: Ivoclar IPS e.max A16 Hybrid Abutment Crown block

Figure 40: Vita Enamic A16 Implant Solutions block

Figure 41: Final IPS e.max screw-retained crown bonded to Straumann Variobase for CEREC 50 Implant practice

Figure 42: Fully developed peri-implant tissue transition zone Volume 8 Number 6

Figure 44: Occlusal view of final implant restoration

TECHNOLOGY

Figure 43: Facial view of final implant restoration

Soft from the syringe. Hard in the defect. Prep. Dispense. Shape.

Placing bone graft has never been this easy. • Designed for ease of use and predictability • 100% synthetic and fully resorbable • Ideal for ridge preservation and filling voids around immediate implant placements This product should not be used in pregnant or nursing women.

Figure 45: Final postoperative periapical radiograph

easy-graft ® CLASSIC alloplastic bone grafting system

Discussion This case report demonstrated the high degree of precision and efficiency that can be achieved with the CEREC digital implant dentistry workflow. In an ideal scenario such as the case previously described, the entire implant treatment can be accomplished in two appointments. The first appointment would consist of a preoperative digital impression, virtual implant planning, in-house fabrication of the CEREC Guide, guided implant placement, digital impression of the implant, and the digital fabrication of a custom tissue former. The second appointment would then consist of the in-house digital fabrication of the final implant restoration without the need for an additional digital impression, removal of the custom tissue former, and the insertion of the final implant restoration. IP

Volume 8 Number 6

91%

rated it excellent or good and worthy of trial by colleagues.* Full-report is available at www.guidor.com/cliniciansreport/

*Source: Gordon J. Christensen Clinicians Report®, September 2015. Published by CR Foundation, an independent, non-profit, dental education and product testing foundation.

Register on the New GUIDOR.com to receive 15% Off your first online purchase. To purchase or learn more, visit GUIDOR.com/easy-graft/ or call 1-877-484-3671. Instructions for Use (IFU), including indications, contraindications, precautions and potential adverse effects, are available at GUIDOR.com/IFU/. © 2015 Sunstar Americas, Inc. All rights reserved. GDR15071 10012015v1 GUIDOR is a registered trademark of Sunstar Suisse, SA. easy-graft is a registered trademark of Degradable Solutions AG.

Implant practice 51

ON THE HORIZON

Immediate implant — immediate smile Dr. Justin Moody discusses treatment of a challenging lateral incisor

linicians so often get wrapped up in the technical side of implant dentistry that we forget that a person’s smile is often one of his/her greatest assets and source of pride. Immediate dental implants and restorations when done within known parameters are not only predictable procedures but practice builders as well. This recently happened to me with a patient’s lateral incisor. Tooth No. 7 experienced a vertical fracture rendering it non-restorable. Upon evaluation of the CBCT, I was able to determine that she in fact had good bone volume and was potentially a great candidate for an immediate dental implant with an immediate restoration. My challenge was to extract this tooth with maximum bone preservation and place the implant in an ideal location which will preserve the bony and soft tissue architecture for the final restoration. The tooth was removed with no bone loss using my favorite instrument, the

PEEK plastic BioHorizons abutment

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.

52 Implant practice

Perio Probe measuring distance from CEJ

Final position of implant

BioHorizons 2.0 drill

Post-op radiograph with temporary

Temporary restoration in place

Zoll-Dental Zator® 3s. The site was curetted to remove any soft tissue remnants and to act as a physical probe for any weak bone or fenestration and irrigated with chlorhexidine (CHX). The trick to these implants, in my opinion, is getting the pilot drill to engage the lingual plate in the clinician’s desired location, not at the apex of the tooth. With the incisal edge as my landmark for the center of the implant, I was able to place a 4.6 mm x 15 mm BioHorizons® Tapered Plus dental implant into the space along with a temporary crown built upon a PEEK plastic

abutment and a vacuum stent made from a mold of her original tooth. The temporary was trimmed, contoured, and polished for seating. As you can imagine, the occlusion and excursions of this restoration are of the utmost importance as we want to minimize the lateral forces on this restoration. The end result was esthetically pleasing, done in the same appointment, and has set up the final restoration for success. Stay tuned as the next column will talk about the final restoration and the digital workflow. IP Volume 8 Number 6

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 patientâ&#x20AC;&#x2122;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

45Â° 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

PRACTICE DEVELOPMENT

Crafting your practice profile In the third part of his series on marketing, Toks Oyegunle explains how to craft your practice’s unique selling point to better attract patients

magine you have suddenly been given an opportunity to give a brief presentation about your dental practice to a group of new potential patients who all match your perfect patient profile. This group represents potential “best patients” who could easily be worth thousands of dollars to your practice. There is no time to prepare for this presentation, so what exactly will you say to them? Why are you communicating this particular message over others? This scenario highlights the need for having a unique selling point (USP) — a clear benefit to your “perfect patient” that sets you apart from the competition. In this series, I am using my “triple M” profitable marketing framework as a tool to clarify what needs to be done to significantly improve your marketing efforts. This framework is a simple tool that helps us simplify, understand, and apply the essence of what profitable marketing really is. It is about getting the right message to the right market using the right media and methods — effectively, efficiently, and profitably. In the last issue, we explored the concept of developing a “perfect patient avatar” for your practice. If you did the exercises suggested, you should now have a detailed profile of the ideal patient you want to attract to your practice. This will become the foundation on which to build subsequent stages. Let us now take a dive into crafting an ideal USP for your practice.

There are a few pointers that should help you develop your personalized USP. Consider the following questions, and answer them as clearly as you can: 1. What are your core strengths? 2. What are your patients’ biggest needs? 3. What are your patients’ biggest wants? 4. Why will patients choose you over others? To help, keep the profile of your perfect patient in mind while answering these questions — a great USP must speak directly to patients’ wants and desires. This process confirms one of the reasons for initially developing a robust perfect patient avatar as a foundation for your marketing strategy.

To help you answer these questions effectively, let us look at them in more detail. What are your core strengths? Think about the strengths of your practice — is it your extensive experience or your customer service? Is it the fact that you are the best specialist in your market, or the fact that you offer the best payment plans? There must be some areas where you are clearly stronger than other practices in the local area. Discussing them with your team will help you come up with a list of your practice’s true strengths. What are your patients’ biggest needs? Having studied your patients, you should have a good understanding of what their needs are. You need to be careful not to

Unique selling point A USP is usually a phrase or sentence that clearly summarizes and explains the key benefits you can offer your patients ahead of any competition. It is a simple marketing message that you can use to easily convert potential patients into actual ones.

Toks Oyegunle is a leading business coach and award-winning entrepreneur in the United Kingdom who enjoys helping dentists achieve success using proven techniques and strategies. The Harvard Business School alumnus is the founder of Thriving Practices — profitable marketing solutions; experience-based, technology driven.

54 Implant practice

Volume 8 Number 6

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 â&#x20AC;&#x201D; mom, dad and the kids â&#x20AC;&#x201D; 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

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PRACTICE DEVELOPMENT get too technical with this; as a dentist, you will obviously see their needs from a clinical viewpoint — however, this should be described as simply as possible. When patients come to you, what do they ask for? What exactly do they think they need from you as a solution to whatever challenge they may have? What are your patients’ biggest wants? This is a tricky one — it requires you to read between the lines. In many cases, our needs differ significantly from our wants. You must try to understand the unspoken desire that is really driving your patient. When your patients say they need implants or a sparkling white smile, is that what they really want, or do they simply want to regain their self-esteem after a painful divorce? Or do they want to look their very best for a major upcoming event, like a wedding? Make sure you really understand this as people generally prioritize their wants over their needs. Why will patients choose you over others? This is a critical question. By now you should understand your strengths, your patients’ needs, and even their unspoken wants. The next thing is to single out what exactly makes them choose your practice over the competition — what features or qualities make your practice special in the eyes of the patients? Once you fully understand this, you must make it a core part of your unique selling point. There are a number of ways you can get this, including testimonials and referrals. Hopefully, you already have a system for collecting both, so you should check to see what patients are saying in their testimonials. What exactly did they enjoy so much about their experience with your practice, and why do they come back? You also need to understand what patients referred to you were told about your practice, as this is one of the best ways to know what your market really thinks about your practice.

Target your market Once you have answered these questions, you are ready to progress to the next stage, which is to research and understand what other companies are using as their own USP. Ideally, you want to study your competitors, as well as a few other general companies to get a feel for other USPs: 56 Implant practice

What is your unique selling point? Consider the following: • Your practice’s core strengths • Your patients’ biggest needs • Your patients’ biggest wants • Why patients will choose you over others

What features or qualities make your practice special in the eyes of the patients? Once you fully understand this, you must make it a core part of your unique selling point.

Check advertisements, websites, and available directories; and write down different company USPs. This exercise will help you understand the ways other companies are developing and communicating their USP, giving you great ideas for developing your own. Now, couple your answers from the three earlier questions with examples of other USPs from your research, and come up with a few sample USPs for your practice. There are a number of factors to bear in mind as part of this process; if you study your perfect patients thoroughly, you will be able to understand their deepest fears and desires. For example, do they come to you for health reasons or for cosmetic reasons? The more detailed your understanding of your perfect patients, the easier it will be for you to communicate effectively with them. You must communicate your USP using words and phrases that patients can easily understand and relate to. When developing your own USP, feel free to use my company’s perfect client avatar as a basis; it can sometimes be easier to do these things if we have an example that makes us take a position. My company’s

perfect client avatar follows: “A professional dentist who owns his/her private dental practice or is a partner in a small private dental practice with a maximum of two owners. They will have extensive knowledge and experience in dentistry and will be quite passionate about it. At the core, they are a professional intellectual but increasingly find themselves having to become an entrepreneur in order to succeed in business. “They may struggle with this transition as they prefer the operational side of dentistry, and need to understand and accept the importance of effective and efficient marketing as the real source of wealth creation. As experienced professionals, they are clearly technically competent but may lack business savvy and need to be educated on the many benefits of strategy, marketing, and technology as major contributors to the growth of their practice.” A complete avatar will be more detailed, including demographic and psychographic details, among others, but this will give you a general overview of who your company is targeting. For instance, my company provides a mix of top-end marketing education, coaching, consultancy, and community to clients who are typically the leaders — or aspiring leaders — in their fields. This leads to our USP being crafted as follows: Thriving Practices — profitable marketing solutions, experience-based, technology-driven.

Painting the future Consider how this USP communicates our key strengths and benefits (experience-based, technology-driven, profitable marketing solutions) directly to our target market (private practice owners). You need to use your answers to the earlier questions, coupled with your research on other USPs, to adapt and personalize this USP for your practice. Your goal here is simple: When perfect patients see your USP, they should be automatically attracted to your practice because you have clearly communicated a benefit they specifically want. Next month, we will explore the media concept further. Now that we are crystal clear on who you should be targeting with your marketing and what you should be saying, we are ready to explore where exactly you should communicate your message with your target market and why. IP Volume 8 Number 6

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www.implantdirect.com | 888-649-6425 1 Some limitations apply. Call for details. Promotion valid for new customers only, limited to single use and cannot be combined with other offers. Expires January 31, 2016. All trademarks are property of their respective companies.