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clinical articles • management advice • practice profiles • technology reviews

Fully integrated digital implant dentistry with Sirona’s CEREC-GALILEOS integration workflow Dr. Farhad E. Boltchi

Dynamic image navigation — implementation in the esthetic zone utilizing a multidisciplinary approach Drs. Robert W. Emery, Keith Progebin, and Kim Knoll

Torque versus RFA at implant placement: a case study

unique dental implant products with proven surgical and esthetic results

Predictable implant therapy

innovative solutions

PROMOTING EXCELLENCE IN IMPLANTOLOGY

SPMP16232 REV A JUL 2016

August/September 2016 – Vol 9 No 4

Dr. Maher Kemmoona

Dr. Charles D. Schlesinger

Practice profile Dr. Tarun Agarwal

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Be a mentor!

EDITORIAL ADVISORS Steve Barter, BDS, MSurgDent RCS Anthony Bendkowsk,i 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

O

ne of the highlights for me each summer is hosting a 4th-year dental students from the University of Nebraska Medical Center College of Dentistry. As they spend 3 weeks watching, learning, and doing dentistry in a private practice setting, I am always encouraged by how observant and thirsty they are for real-world experience. One of the cases my last 4th-year dental student saw was a full arch of extractions and implant placement for a future implant-retained overdenture. I do my best to talk through the case, and then afterwards, once we see the post-op CBCT, we have a discussion Justin Moody, DDS, DICOI, DABOI, about how it went, and what could have been done better. I was expecting him to ask about the alveoloplasty of the ridge or the positions of the implants, but instead he made the comment, “I think the key to implants in a person’s practice is being good at oral surgery and the removal of teeth.” That night, I thought about that statement and was taken aback by how simple, yet spot-on it was. Good oral surgery principals and fundamentals are the cornerstone to positive outcomes and great patient experiences. Dentistry needs these young doctors with bright minds and big hearts to do good in this world — what these doctors need more than anything is a mentor. Be a mentor!

Christopher Orr, BDS, BSc Fazeela Khan-Osborne, BDS, LDS RCS, BSc, MSc Jay B. Reznick, DMD, MD Nigel Saynor, BDS Malcolm Schaller, BDS Ashok Sethi, BDS, DGDP, MGDS RCS, DUI Harry Shiers, BDS, MSc, MGDS, MFDS Harris Sidelsky, BDS, LDS RCS, MSc Paul Tipton, BDS, MSc, DGDP(UK) Clive Waterman, BDS, MDc, DGDP (UK) Peter Young, BDS, PhD Brian T. Young, DDS, MS

CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day, BDS, VT Julian English, BA (Hons), editorial director FMC Dr. Paul Langmaid, CBE, BDS, ex chief dental officer to the Government for Wales Dr. Ellis Paul, BDS, LDS, FFGDP (UK), FICD, editor-inchief Private Dentistry Dr. Chris Potts, BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin Dr. Harry Shiers, BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral implant surgeon

© FMC 2016. 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 9 Number 4

Dr. Justin Moody with 4th-year dental student observing

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.

Implant practice 1

INTRODUCTION

August/September 2016 - Volume 9 Number 4


TABLE OF CONTENTS

Financial focus

Practice profile Tarun Agarwal, DDS

6

Is your retirement plan strategy due for an annual checkup? Tom Zgainer discusses the benefits of reviewing your 401(k) plan on a regular basis....................................12

On cultivating, motivating, and inspiring his patients and team

Case study Fully integrated digital implant dentistry with Sirona’s CERECGALILEOS integration workflow Dr. Farhad E. Boltchi provides a step-by-step overview of his digital workflow..........................................22

Soft tissue re-contouring and digital implant dentistry

Case study Torque versus RFA at implant placement: a case study

14

Dr. Carlos Repullo Sanchez presents a case where digital techniques were used to place esthetic-fixed bridgework while keeping one eye on future maintenance..........................28

Dr. Charles D. Schlesinger discusses instrumentation that is more predictable and safe during the healing process ON THE COVER Cover photo courtesy of Drs. Robert W. Emery, Keith Progebin, and Kim Knoll. Article begins on page 32.

2 Implant practice

Volume 9 Number 4


NEITHER IS THE ANATOMY OF YOUR IMPLANT PATIENTS Your world is already full of clinical challenges so why work harder because of conventional thinking? Instead of augmenting sloped ridges to accommodate flat-top implants, it’s time to discover a simpler solution by using an implant that follows the bone. Because sloped-ridge situations call for anatomically designed sloped implants.

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It’s time to challenge conventional thinking

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DENTSPLY Implants does not waive any right to its trademarks by not using the symbols ® or ™. 32671114-USX-1605 © 2016 DENTSPLY. All rights reserved.

OUR WORLD IS NOT FLAT


TABLE OF CONTENTS

Continuing education Predictable implant therapy Dr. Maher Kemmoona illustrates how to achieve predictable, lasting, and esthetic outcomes with dental implant therapy regardless of whether it’s a simple or complex restoration

Continuing education

32

Dynamic image navigation — implementation in the esthetic zone utilizing a multidisciplinary approach Drs. Robert W. Emery, Keith Progebin, and Kim Knoll discuss some principles of modern digital implant dentistry

.................................................39

Implant insights

PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com

Avoiding mistakes

GENERAL MANAGER | Alan Lobock Email: alobock@medmarkaz.com

In part 1 of a series, Dr. Diyari Abdah looks for ways to rise above dental

MANAGING EDITOR | Mali Schantz-Feld Email: mali@medmarkaz.com | Tel: (727) 515-5118

implant complications...................44

ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkaz.com

Technology Clinical Usage Review Accuracy assessment and surgeon feedback on Navident Dynamic Navigation System.......................47

On the horizon It all starts with surgery Dr. Justin Moody offers tips on oral surgery in preparation for implants

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

NATIONAL ACCOUNT MANAGER | Warren Kaufman Email: wkaufman@medmarkaz.com MANAGER – CLIENT SERVICES | Adrienne Good Email: agood@medmarkaz.com CREATIVE DIRECTOR/PROD. MGR. | Amanda Culver Email: amanda@medmarkaz.com WEBSITE MANAGER | Anne Watson-Barber Email: anne@medmarkaz.com

Practice development Product profile Here’s the roadmap for taking your implant practice to “great”

Laschal® flexible, fractureresistant periotomes

Jim Smyros of Affordable Care/ Affordable Dentures & Implants shares discoveries from a decade of advising hundreds of clinicians...................50

Micro-serrated for simple and efficient separation of the periodontal ligament. Coated with titanium for greater hardness and longer service life..... 56

E-MEDIA PROJECT COORDINATOR | Michelle Kang Email: michellekang@medmarkaz.com FRONT OFFICE MANAGER | Theresa Jones Email: tjones@medmarkaz.com MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 www.implantpracticeus.com | www.medmarkaz.com SUBSCRIPTION RATES 1 year (6 issues) $129 | 3 years (18 issues) $319

4 Implant practice

Volume 9 Number 4


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PRACTICE PROFILE

Tarun Agarwal, DDS On cultivating, motivating, and inspiring his patients and team

Dr. Agarwal reviewing treatment options with a patient

What can you tell us about your background? I was born in India, and my family moved to the United States when I was 2 years old. My father was a dentist in India; due to licensing restrictions, he never practiced in the United States. Instead, to make a life for our family, he purchased a motel in rural North Carolina. I grew up working and living in that motel, literally 24 hours a day. When I wasn’t in school, I was helping our family business by cleaning rooms, moving air conditioners, helping at the front desk or the laundry room — for us to continue to survive and do well. This experience influenced and guided how I have built and run my dental practice. It was important for me to have that experience of starting a business and ensuring that it continued to grow 6 Implant practice

and kept up with the times. At the end of the day, a dental practice is a business, and some of the fundamental concepts are the same. So, even though there were some negative aspects, I was fortunate to grow up living in that motel and being exposed to business. Having grown up in Rockingham also had a great influence on how not to run a business. The city was thriving in the ’70s and ’80s but didn’t have a vision for the future — its leaders didn’t provide for the possibility that the textile industry was going to go away or build the infrastructure to keep NASCAR there. It gave me a perspective on how to live my own business life and prevent my practice from becoming irrelevant. I realized that we need to stay on top of new procedures and

Dr. Agarwal — better known as T-Bone — is a nationally recognized speaker and workshop leader

maintain a wonderful working environment for team members and patients. I realized in 8th grade that I wanted to be a dentist. Although we owned the motel, to make extra money, my dad was a denture technician in the hotel basement — it was his way of staying in touch with the profession and skills that he was trained for. My fascination with dentistry started in Volume 9 Number 4


PRACTICE PROFILE

that motel basement. I would watch my father make dentures, and on occasion, I traveled with him to the dental offices that he would work for. His face would light up when he could work with the patients. When they thanked him, he felt that he made a difference in their lives. After watching all of this, I decided to apply to an advanced program in which I could complete undergrad and dental school in 6 years versus the traditional 8 years. I was accepted into the University of Missouri-Kansas City directly from high school. I was 23 when I graduated dental school and wanted to move back to North Carolina to be close to my family, but I didn’t want to live in such a rural town, so I moved to Raleigh. I worked as an associate and then started my practice from scratch 1 year later.

Is your practice limited to implants? Not at all. Our practice is a familycentric, bread-and-butter general dental practice with two hygienists and several team members. We participate in dental insurance. We place implants, and most of those implant patients come from our family dentistry patient base.

Full-time general dental practice located in Raleigh, North Carolina

Why did you decide to focus on implantology? For the first 8 years of my dental career, my exposure to dental implants was limited to the restoration of implants that I saw in dental school, and those were few and far between. As my practice grew, we started to do more interdisciplinary cases where implants were part of our overall game plan. I began to get frustrated with some of the surgical results because prosthetic restoratives were much more difficult due to implant location. In addition, case acceptance was limited because patients had to travel to different offices to see a surgeon and to have the implant placed, making treatment inconvenient and costly. Sometimes patients refused treatment because the overall cost was too high, and even worse, some patients agreed to start treatment but ended up spending so much money and time that they grew frustrated and didn’t want to complete the treatment we initially planned. It was these frustrations that led me to start focusing on implantology. I wanted to place my own dental implants to give me more surgical control over implant location and positioning, as well as to control the cost, so the overall restorative case could be more affordable for patients. Volume 9 Number 4

Dr. Agarwal’s dedicated training center — 3D Dentists (www.3D-Dentists.com) — located within his practice. The focus is training dentists in the latest implant techniques using digital dentistry

How long have you been practicing, and what systems do you use? I graduated dental school in 1999 and opened my private practice in 2001. My first foray into surgical placement of dental implants wasn’t until 2007. Over the years I have used many systems — Bicon, Implant Direct, Biomet 3i, and Nobel Biocare’s Nobel Replace and NobelActive. For the past 5 years my system of choice has been the NobelActive implant. I find that

it is tremendously beneficial in immediate implant placement, supports guided surgery, and supports a digital workflow.

What training have you undertaken? My implant story is unique. I had little surgical experience and desire coming out of dental school. In fact, I was that student who passed out watching a tooth being removed! My initial exposure to dental implants came from a 5-day course that focused on Implant practice 7


PRACTICE PROFILE a specific implant system. From there I was hooked. I have relied on a combination of books, online learning, and CE programs. That being said, my most meaningful learning has come from my oral surgeon, Dr. Uday Reebye. This mentor relationship has really allowed me to expand my scope of implant dentistry, improve my skills, and continuously learn. Uday never shied away from letting me learn from him, whether observing him in his office or even having him hold my hands as I was doing the surgery. Having someone “hold my hands” gave me the confidence to flourish with dental implants.

Who has inspired you? In life and business, there is no greater inspiration than my father, Ram Agarwal. Growing up in our environment, I never felt poor, always felt loved, and was given freedom to learn from mistakes. Our family stressed education above all else. I was always told that education in life will always take me where I wanted to go. And it has proven to be true. I have always been very close to my father and spent time with him, whether in the denture lab, in the motel, or just being inquisitive about how business works. We had a very open relationship. Specific to my inspiration regarding implants, the oral surgeon Dr. Reebyee gave me the confidence and freedom to do implantology on my own and to be able to tackle some cases that I wouldn’t have tackled without him by my side.

What is the most satisfying aspect of your practice? The most satisfying part is growing. It is not about growing financially, although that is important, but also growing the practice in terms of services. When I started my practice, I was a restorative dentist — I didn’t extract teeth or do root canals; I did only fillings and crowns. And we didn’t even restore implants at the beginning. But over time, slowly we added nearly every discipline to the practice, and I am proud that we have evolved into a practice where we can take a patient from beginning to end and do almost everything here. If clinically, we cannot achieve the result or address the complexity that the patient needs, I can work with a specialist. It is also satisfying to see my team members grow. I have seen their knowledge grow, and I love seeing how they get excited about learning new things and not staying stagnant. 8 Implant practice

Dr. Agarwal with his father on a recent family vacation

Professionally, what are you most proud of? We have all grown in many aspects, and the practice has grown along with this. We are a general practice, and we can also provide a broad range of services for our patients quite well.

What is unique about practice? We can give complete, complex dental care in a modern location. We continue to evolve and add more services within our practice. And we are doing this type of complex dentistry all while being a network insurance provider. We take insurance; we submit the claims; and we take insurance fees, while maintaining clinical excellence, productivity, and profitability. It is unique that

we can service insurance patients and give them the option to say yes to the best.

What has been your biggest challenge? My biggest challenges are the team and insurance. I have an unbelievable desire and the clinical ability to do many procedures, but can’t do them alone. I have to cultivate, motivate, and inspire team members to want some of those same things — to push them to really grow out of their comfort zone. Also, dental insurance has changed patients’ mindsets. Insurance affects your fees, and a majority of our patients are still a part of the general practice. Insurance affects that component of our practice so greatly that it feels as if we are caught in a hamster Volume 9 Number 4


nothing gets past

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PRACTICE PROFILE wheel dealing with the small things related to the general practice, so we can miss out on some of the bigger opportunities going on around us.

What would you have become if you had not become a dentist? Part of me is afraid that if I had not completed the 6-year dental program, I would have gotten lost and unfocused in college. But if I had not become a dentist, I would have been a businessperson and returned to grow and expand the family business. Probably my parents would have forced me to get an MBA in business to utilize more advanced knowledge to help build and grow the business.

What is the future of implants and dentistry? That is a tough question because over time, the implant business model will change. In the United States, currently 20% of general dentists are placing implants. I estimate that figure will jump to 50% in the next decade. I envision that a majority of implants will be placed by general dentists. I see dental implant companies feeling pressure to provide more value-driven implant pricing options and not necessarily service-driven implant options. I think we will see more consolidation in implant dentistry allowing major companies to provide a value proposition to service general dentists who may not need as much rep support outside of the initial beginning phase. Over time, there will be a greater need for dental implant growth within the U.S. market. Patients are living longer, and we have unbelievable solutions that are proven to work over the long term. I think we will see significant changes in materials, biological coatings, and maybe a move to zirconia. The future is very bright. It’s a great time to be an implant dentist.

What are your top tips for maintaining a successful practice? Continuing education — if you ask professionally successful or financially successful dentists their secret, I think they have one thing in common. They invest in education that drives, motivates, and inspires them and, in turn, motivates and continues to create growth in their practices. When your practice grows professionally, it will grow financially as well. Investing in a digital camera — it is really inexpensive. If you can take photos and share them with patients to show the condition of their mouths, you can also document and show them what’s possible to improve their dental health. You can show other cases similar to their own to give them confidence in what you’re doing, and how you’re doing it. My practice has grown through the use of digital photography. Patients are skeptics. But digital photography creates frank conversations and opens doors. You can’t complete this journey alone — to grow your practice to significant heights means you must take other people along with you. You must partner with other dentists to learn. And team members have to grow with you, so always encourage them.

What advice would you give to budding implantologists? Never stop learning. Implantology, unlike anything I have done in the past, is like a rabbit hole; you never know how deep it goes. There are many aspects, like single tooth implants, complex grafting, soft tissue

procedures, multiple implants, full arch cases, zygomas, and full reconstructions, just to name a few. You can dedicate your professional career to mastering implants and never finish learning. Partnering with someone in a surgical specialty or surgically oriented dentist whom you can learn from and grow together presents an unbelievable opportunity. Take calculated risks and push yourself — never to the detriment of the patient — but know that you can probably do more than you think. Realize when you are outside of your comfort zone. If you are not clinically competent to do a certain procedure, don’t do it. Instead, work with another dentist, a specialist, or refer your patient to someone who can help.

What are your hobbies, and what do you do in your spare time? Outside of my work and family time, my only hobby is playing golf. I have a 6 handicap. I spend 25-30 weekends per year inspiring other dentists to get the most out of the professional and personal lives at various speaking events and leading handson workshops at my training center. Recently I started my own podcast — T-Bone Speaks (www.TBoneSpeaks. com). This podcast allows me to share my thoughts and knowledge to wider audience. I am a husband of 15 years to a wonderful, brilliant wife who has kept me on my toes and supported most of my crazy ideas. We have three wonderful children — ages 10, 8, and 6. IP

Top 10 favorites 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Tesla Model S Digital camera Sirona ORTHOPHOS SL 3D CEREC by Sirona Titleist® Vokey sand wedge Zoom H6N podcast recorder iPhone® 6 Plus Taking a nap Family vacations Podcast app Dr. Agarwal with his family — wife, Dr. Mona Gupta, and children, Yash, Arya, and Abhi

10 Implant practice

Volume 9 Number 4


3.1mmD Eztetic™ Dental Implant

The 3.1mmD Eztetic Implant offers a strong, esthetic solution for narrow anterior sites. Designed to reduce micromovement and microleakage, the implant-abutment connection consists of a conical interface, platform switch and Double Friction-Fit™ technology. Please contact us at 1-800-342-5454 for more information. zimmerbiometdental.com

All trademarks herein are the property of Zimmer Biomet or their affiliates unless otherwise indicated. 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. AD073. ©2016 Zimmer Biomet Dental. All rights reserved.


FINANCIAL FOCUS

Is your retirement plan strategy due for an annual checkup? Tom Zgainer discusses the benefits of reviewing your 401(k) plan on a regular basis

R

egular maintenance regarding our health, be it a twice a year teeth cleaning or an annual physical, allows the experts to determine if we are as fit as we think we are, or see if there might be some issues under the hood that need attention. Likewise, each April, we are reminded of whether our tax planning is sufficient or perhaps needs a tuneup. Similarly, your retirement plan strategy is worth reviewing with a pension plan expert as well. Often the original plan and strategy you implemented get away from your intended individual and corporate goals. Your employee populace may experience turnover, the actual age demographics of your staff may take on a different makeup, and by the way, you are now a year closer to retirement. You can find these changes limit your personal contributions due to required employer contributions or, more positively, open up new opportunities to design a plan that accelerates your personal contributions. Retirement plans — whether a 401(k), profit-sharing plan, a defined benefit, or

Tom Zgainer is CEO of America’s Best 401(k). He has helped over 2,800 businesses obtain a new or improved retirement plan over the past 13 years with a focus on strategic plan design to help achieve individual and corporate objectives. You can learn more at www. americasbest401k.com/medmark.

12 Implant practice

a cash balance plan — all require some give-and-take. For owners, principals, key associates, or partners to take advantage of the opportunity to maximize annual contributions, you’ll need to give a proportional amount that passes all the required compliance tests to eligible employees. These employer contributions at first might not be palatable to you and your bottom line. However, utilizing a long vesting schedule — for example up to 6 years — can help ensure an employee needs to stay and contribute to your practice that long to earn any 1 year’s contribution. Plus, you receive the tax deduction benefit of the full amount of employer contributions in the tax year of the contribution, up to 25% of gross payroll. A great reason to go through an annual plan design checkup is to see if there is a better plan type option for you. As you get closer to retirement, generally over age 45, plan types, such as a new comparability profit-sharing plan, a cash balance or defined benefit plan, can be paired with a 401(k) to rapidly accelerate your personal contribution objectives. For 2016, you can defer $18,000 into a 401(k) plan, with a $6,000 catch-up provision if over age 50. That’s generally the best first thing to try and accomplish. If your plan

demographics are suitable, meaning staff is younger than the owners, principals, or partners (HCEs), and you are over age 45, a new comparability profit-sharing plan can provide a maximum benefit for a select employee group, while providing the lowest possible contribution to non-key groups allowed by law. This plan design can help you add to your deferrals and get up to the $53,000/$59,000 maximum annual limits from combined employee and employer contributions. To really accelerate your contributions, consider looking into adding a cash balance or defined benefit plan to the 401(k). Maximum contributions for these plans range from $102,000 at age 45 to $237,000 at age 62. When added to the 401(k)/profit-sharing contributions, it’s like squeezing 20 years of retirement saving into 10, not to mention the significant reduction to your tax liability that you will enjoy. Just as you might make an appointment with your physician or CPA, this is a great time of year to get a retirement plan checkup as well. It’s easy and painless, as a census with your current firm demographics will enable a experienced pension specialist or actuary help determine if there is a better way to proceed into the years ahead for your retirement planning. IP

Receive your retirement plan checkup here: http://americasbest401k.com/medmark. Volume 9 Number 4


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monthly payment assumes a 60-month term Extended Plan loan with an amount financed of $4,250 and an APR of 13.99%. Actual monthly payment amount and APR may vary based on amount financed, term and credit history. Subject to credit approval. Amount financed is based on an average single implant procedure cost of $4,250. Source: www.dentalimplantcostguide.com. © 2016 Lending Club Patient Solutions products and services provided through Springstone Financial, LLC, a subsidiary of LendingClub Corporation. Payment plans made by issuing bank partners.


CASE STUDY

Torque versus RFA at implant placement: a case study Dr. Charles D. Schlesinger discusses instrumentation that is more predictable and safe during the healing process

F

or years and for most practitioners, torque has been the gold standard for determining the stability of an implant. It has, and is, used to determine primary stability, integrated stability, and can be used to determine the minimum threshold when immediately loading dental implants. Studies and anecdotal evidence have shown that 30 N/cm is the value considered to be sufficient for primary stability. Below this level, an implant has always been considered highly susceptible to failure by lack of stability. There are two types of torque that we see when placing an implant — insertion torque and seating torque. When immediately loading dental implants, it is the final insertion torque that is the key to successful treatment. In order to follow an immediate load protocol, a minimum seating torque value of 45 N/cm-50 N/cm is necessary.1

While torque values are useful and usually good predictors of success,2 we now have instrumentation that is more predictable and can be used safely during the healing process. This technology utilizes RFA, and the device is an Osstell IDx (Osstell, Sweden). Not all patients are the same, and when we place an implant in a patient, the speed and extent to which they heal is highly variable from one individual to another. Wouldn’t it be nice to be able to monitor that healing process and know when you can restore rather than waiting for some generally advised average time period?

Torque Webster’s Dictionary defines torque as a force to rotate an object about an axis (Figure 1). By Newton’s Third law of Motion, we can confidently deduce that the torque value a practitioner gets when placing an implant is equal to the resistance to the original rotational force. Basically, you can turn the implant, which is a screw, until it either cannot move axially in a downward

direction anymore or the bone around the implant exceeds its deformational limit and can no longer resist the axial rotation (stripping). This deformational limit will vary from a high value in D1 cortical bone to a lower value in D4 medullary bone. The limitation of just looking at torque is that it does not take into account the stability of the implant in lateral directions (Figure 2). It is this lateral stability, or resistance to sliding motion between the implant and the osteotomy, that is crucial to success. Therefore, it is possible to have a low torque value with high lateral stability or the opposite situation where you have high rotational stability (torque) and low lateral stability (ISQ). A potentially devastating way to check integration has been the use of reverse torque to check an implant. The issue with this technique is that if the implant is integrating, yet not fully integrated, the use of reverse torque can unscrew an implant by breaking the integration that has already occurred. The result of this could jeopardize the success of the case or facilitate starting all over.

Figure 1: Rotational torque 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.

14 Implant practice

Figure 2: Lateral micro-motion. Source: Albrektsson T, Zarb GA. Current interpretations of the osseointegrated response: Clinical significance. Int J Prosthodont 1993: 6: 95-105 Volume 9 Number 4


The use of RFA opens up a whole new possibility to be predictable not only in determining initial primary stability, but also the change in biologic stability that occurs as the

osseointegrative process proceeds (Figure 3). With RFA, we can gently check the integration process without the potential for disturbing the integration process. The Osstell IDx uses a SmartPeg™ (Figure 4),

Figure 3: Mechanical versus biologic stability

which is screwed into the implant platform, and when pulsed by the transducer, it vibrates. This, in turn, is picked up by the receiver in the wand. This works on the same principle as a tuning fork (Figure 5). The tighter the implant is in bone, the higher the frequency vibration that is recorded when pulsed, and this is shown as a higher ISQ value. The use and evaluation of ISQ allows the clinician to know what degree of initial mechanical lock the implant has. This mechanical lock is crucial to prevent detrimental micro-motion between the implant and the surrounding bone. According to the most recent literature published, an Osstell reading of 70 is desired for loading of an implant.3 Below this value, the lateral stability may not be high enough to resist a sliding motion of 150 microns. Movement greater than this will result in the formation of a soft tissue capsule and eventual failure of the implant. The use of an implant designed for maximum mechanical lock into bone along with the use of RFA technology is a true game changer when treating implant patients.

Clinical case

Figure 4: Osstell SmartPeg

Figure 6: Fractured tooth No. 20 Volume 9 Number 4

Figure 5: The SmartPeg is analogous to a tuning fork

The patient who presented was a 64-year-old female with an unremarkable medical history other than a history of diagnosed osteoporosis without bisphosphonate usage. Her chief complaint was a fractured lower premolar. The tooth had the coronal tooth structure missing, previous endodontic treatment, and no infection was evident clinically or radiographically. Preoperative CBCT showed the length of the root to be 10.3 mm from crest to apex with adequate vertical bone below the apex of the tooth (Figures 6-7). After profound soft and hard tissue anesthesia was established with an infiltrate of SeptocaineÂŽ (Septodont USA), the root was atraumatically extracted utilizing periotomes, a spade proximator, and forceps (Figure 8). Once extracted, a curette

Figure 7: Pre-op CBCT Implant practice 15

CASE STUDY

Resonance frequency analysis (RFA)


CASE STUDY

Figure 8: Atraumatic extraction

Figure 9: Pilot drill taken to 15-mm depth

Figure 10: Final osteotomy former with drill stop

Figure 11: DBM allograft placement

Figure 12: ENGAGE implant

Figure 13: Final position of implant

was used to verify that the buccal wall was still intact and remove any remnants of the periodontal ligament. A high-speed handpiece and a long-shanked surgical carbide bur were then used to create a hole through the lingual lamina dura approximately ž of the way down the root socket. This provided a purchase point for the 1.8 mm pilot drill (Figure 9). An initial pilot hole was made to a depth of 15 mm from the remaining buccal crestal bone. Vertical position was verified using a depth stop on the pilot. Utilizing the OCO Biomedical two-step drilling protocol, a proprietary 3.7 mm stepped final osteotomy former with a depth stop (Figure 10) was used to enlarge the pilot hole to the final osteotomy size. The step drill design of the osteotomy former performs the serial progression usually carried out by

Figure 14: Panorex after placement

16 Implant practice

Volume 9 Number 4


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 – 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.

Less guesswork. More Insight.

Don’t miss the Osstell Scientific Symposium at EAO Paris

Speakers: Drs. Jay Malmquist, Joerg Neugebauer & Marcus Dagnelid Lectures will also be available online if you cannot attend the event in person

For more information, please visit osstell.com/eao


CASE STUDY multiple burs in most systems. The non-end cutting drill also prevents over preparation of the osteotomy, which could affect the primary stability of the implant. Once the osteotomy had been completed, a DBM allograft putty was placed against the buccal wall to fill in the gap that will be present once the implant is seated (Figure 11). Management of gaps larger than 2 mm is recommended. A 4.0 mm x 14 mm ENGAGE™ implant (OCO Biomedical) was placed (Figure 12) with the platform approximately 1 mm below the facial crest. This translates to the platform being approximately 3 mm below the current and intended FGM (Figures 13-14). A value of 30 N/cm was recorded for the final seating torque. This lower torque value was predicted due to the less than optimal bone quality (D4) based on the Hounsfield unit calculation of the CBCT. A SmartPeg was inserted into the implant, and ISQ values were taken in both the BL and MD directions. Both of the values were greater than 70 (Figure 15). Due to both values being above the minimum threshold for loading, the decision to load immediately despite a low seating torque value was made. A PEEK abutment (Figure 16) was used along with a 3M Protemp™ crown to create a screw-retained temporary restoration (Figure 17). Chu, et al., has shown in the Dual Zone Management Model that the use of a temporary crown along with grafting of the buccal gap results in the least amount of hard and soft tissue changes.4 The contours of the temporary with its emergence profile, will maintain the soft tissue contours along with sealing the socket during healing. Once trimmed and polished, the temporary was replaced, and the fixation screw was tightened to finger tight — approximately

Figure 16: PEEK temporary abutment 18 Implant practice

20 N/cm. The access hole was filled with a cotton pellet followed by flowable composite. The patient was released after the 45-minute appointment and was followed up at 1-week and 1-month intervals. At the 1-month postoperative appointment, the temporary was removed, and an Osstell reading was taken. The ISQ value was recorded as 75 in both directions. Since this did not deviate dramatically from the initial

values at placement, the decision to move forward with a final impression was carried out. An impression coping was placed, and a closed tray VPS full arch impression was taken (Figure 18). The impression coping was removed from the implant, screwed into an analog, and then it was placed back in the impression for fabrication of the final restoration by the lab (Figure 19). After recording a shade for the lab, the temporary abutment

While torque values are useful and usually good predictors of success, we now have instrumentation that is more predictable and can be used safely during the healing process.

Figure 15: Final ISQ readings

Figure 17: Temporary before final finishing and access-hole sealing Volume 9 Number 4


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CASE STUDY

Figure 18: Impression post placed onto implant

Figure 19: Impression coping with analog placed into impression

Figure 20: Delivery of final crown No. 20 at 6 weeks

was replaced. The restorative phase is simplified with this system since all of the components (stock straight abutment, impression coping, and analog) come with the implant. Two weeks later, the patient returned to the office for delivery of the final stock abutment and crown. The temporary crown was unscrewed, and an ISQ reading of 75 was recorded in all directions. The abutment was placed, and the abutment screw torqued to 30 N/cm. It was re-torqued after 10 minutes to accommodate any potential pre-stretch. The access hole was plugged with cotton and Cavit™ (3M), and the occlusion checked before final cementation with Improv® cement (Alvelogro). After removal of any excess cement, a final radiograph was taken to assure complete cleanup and seating of the crown (Figures 20-21), and the patient was dismissed. 20 Implant practice

Figure 21: Final radiograph

Conclusion Combining the stability challenges of immediate placement along with the compromised bone quality due to the patient’s previously diagnosed osteoporosis made this a less than ideal case. Without an implant designed for maximal bone engagement, even primary stability may not have been possible. If the decision to proceed with immediate loading would have been determined by looking at torque alone, this patient would have had a cover screw placed, and a 3-4 month healing period would have begun. Instead, she was immediately temporized and definitively restored in 6 weeks. Though torque can be a great predictor of stability, it is limited in its scope. It is like comparing a 2D pan to a 3D CBCT. Both work, but the one with the advancement in technology provides a far more accurate

assessment of the situation. If you want to place implants at the highest level and provide your patients with the best care available, then there is no reason not to utilize the very best implant and the very best technology to assure your success and your patients’ satisfaction. IP REFERENCES 1. Schlesinger CD. Immediately loading dental implants: doing it right for long term success. Dent Today. 2016;35(5):84-89. 2. Anitua E, Piñas L, Alkhraisat MH. Long-term outcomes of immediate implant placement into infected sockets in association with immediate loading: a retrospective cohort study. J Periodontol. 2016;13:1-15. 3. Kokovic V, Jung R, Feloutzis A, Todorovic VS, Jurisic M, Hämmerle CH. Immediate vs. early loading of SLA implants in the posterior mandible: 5-year results of randomized controlled clinical trial. Clin Oral Implants Res. 2104;25(2):e114-119. 4. Chu SJ, Salama MA, Salama H, Garber DA, Saito H, Sarnachiaro GO, 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.

Volume 9 Number 4


CASE STUDY

Fully integrated digital implant dentistry with Sirona’s CEREC-GALILEOS integration workflow Dr. Farhad E. Boltchi provides a step-by-step overview of his digital workflow Introduction Sirona’s CEREC-GALILEOS integration workflow provides a completely integrated digital implant dentistry workflow incorporating all aspects of surgical and restorative implant dentistry. This article will provide a step-by-step overview of this digital workflow.

Case example This patient is a 38-year-old male patient with a noncontributory medical history, who presented for implant therapy to replace 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 1-2). 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 arches was obtained via scanning with the CEREC Omnicam. A virtual restoration was then designed in the CEREC Chairside software, 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 BioHorizons® Tapered Internal Plus 5.8 mm x 12 mm implant in site No. 19 (Figure 3). The treatment planning data was then exported from the GALILEOS Implant treatment planning software and sent to SICAT in Bonn, Germany for the design and fabrication of a SICAT OPTIGUIDE surgical guide (Figure 4).

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

Figure 2: Preoperative periapical radiograph of site No. 19

Figure 3: GALILEOS Implant CBCT implant treatment plan for site No. 19

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

Figure 4: Close-up view of the completed SICAT OPTIGUIDE 22 Implant practice

Volume 9 Number 4


CASE STUDY

Figure 5: Close-up view of the intraorally seated SICAT OPTIGUIDE

Figure 7: Guided implant osteotomy preparation

Figure 9: Fully guided implant placement with handpiece driver Volume 9 Number 4

Figure 6: Precise guided tissue-punch preparation

Figure 8: BioHorizons Tapered Internal Plus implant with guided mount

Figure 10: Fully guided implant placement with ratchet driver

The surgical procedure was performed under local anesthesia, and implant placement in site No. 19 was accomplished via a flapless guided approach. The SICAT OPTIGUIDE and the BioHorizons guided surgery system were then utilized to prepare the guided implant osteotomy according to the virtual treatment plan in the GALILEOS Implant software, and a BioHorizons Tapered Internal Plus 5.8 mm x 12 mm implant was placed through the SICAT OPTIGUIDE in a fully guided fashion in the restoratively correct and preplanned position (Figures 5-12). The implant achieved excellent primary stability and was placed in a flapless approach within the confines of the osseous alveolar housing (Figure 13). A Sirona ScanPost and the corresponding Scanbody were then inserted onto the implant, and a CEREC Omnicam digital impression/scan of the Scanbody was obtained to allow for the fabrication of a screw-retained provisional restoration while Implant practice 23


CASE STUDY

Figure 11: Precise fully guided implant placement

Figure 13: Flapless guided implant placement

Figure 15: Wide healing abutment in place 24 Implant practice

Figure 12: Implant placement in the preplanned and restorative ideal position

Figure 14: Sirona ScanPost and Scanbody in place

Figure 16: Immediate postoperative periapical radiograph Volume 9 Number 4


CASE STUDY

Figure 17: CEREC Omnicam scan of ScanPost/Scanbody

Figure 19: Occlusal view of the digital restorative design in the CEREC Chairside software

Figure 21: Inferior view of the digital restorative design to assess gingival tissue pressure

Figure 22: Chairside milled screw-retained provisional restoration Volume 9 Number 4

Figure 18: Buccal view of restorative emergence profile design in CEREC Chairside software

Figure 20: Buccal view of the digital restorative design in the CEREC Chairside software

the implant was undergoing the osseointegration healing phase (Figure 14). In order to start developing the implant tissue transition zone, a wide healing abutment was then placed on the implant (Figures 15-16). Based on the CEREC Omnicam digital impression/scan of the Scanbody, a fullcontour screw-retained crown was designed in the CEREC chairside software (Figures 17-21). The corresponding custom screwretained provisional restoration was then milled out of an Ivoclar Vivadent® Implant Solutions Telio® CAD A16 block, adjusted and polished, and then bonded to a Sirona TiBase with Ivoclar Vivadent’s Multilink® Hybrid Abutment cement (Figure 22). After an uneventful healing period of 8 weeks,

Figure 23: Peri-implant tissue contours after removal of healing abutment Implant practice 25


CASE STUDY this custom screw-retained provisional restoration was screwed onto the implant to develop the ideal peri-implant soft tissue profile (Figures 23-25). After an additional 3 weeks, the previous digital full-contour design in the CEREC software was used to fabricate the final implant restoration as a split custom abutment with a cemented final implant crown. The final clinical, periapical radiographic, and CBCT radiographic evaluation revealed an optimal hard and soft tissue integration of the final implant-supported restoration (Figures 26-27).

Discussion This case report demonstrates the high degree of precision and efficiency that can be achieved with the CEREC-GALILEOS integration digital implant dentistry workflow. In an ideal scenario such as the case described previously, the entire implant treatment can be accomplished in two-to-three appointments. The first appointment would consist of a preoperative digital impression, virtual implant planning, guided implant placement, digital impression of the implant, and the digital fabrication of a custom provisional implant restoration as needed. The second appointment would be optional and would consist of the insertion of the custom provisional restoration for the development of the peri-implant tissue transition zone as needed. The third 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 provisional restoration, and the insertion of the final implant restoration. IP

Figure 24: Occlusal view of screw-retained provisional restoration

Figure 25: Buccal view of screw-retained provisional restoration

Figure 26: Buccal view of final restoration 26 Implant practice

Figure 27: Final postoperative CBCT scan Volume 9 Number 4


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CASE STUDY

Soft tissue re-contouring and digital implant dentistry Dr. Carlos Repullo Sanchez presents a case where digital techniques were used to place esthetic-fixed bridgework while keeping one eye on future maintenance

A

39-year-old female patient attended the practice reporting that 5 years earlier she had lost her upper right second premolar, which was subsequently restored by means of a three-unit porcelain bridge. Since that time, she had been suffering discomfort due to food retention and difficulty carrying out effective hygiene care at home. Two days prior to her appointment at the practice, the bridge fell off, and she was looking for a new solution. The intraoral examination and X-ray exploration demonstrated there was no decay or periodontal involvement, and the soft tissues looked healthy in form and color. In addition, there was no presence of plaque or tartar, and the occlusion was stable.

The digitally assisted protocol (DAP) workflow

Treatment options Based on the patient’s presentation, it was considered that two possible treatment options could achieve a good outcome: 1. A new three-unit fixed porcelain bridge, re-adapting the margins and the pontic in order to avoid food retention and to facilitate hygiene procedures 2. A dental implant and a screwretained crown to replace the UR5 and two single porcelain crowns to restore the UR4 and UR6

Figure 1A: Preoperative situation

Carlos Repullo Sanchez, DDS, graduated from the ISCS-SUL in Lisbon, Portugal. He currently practices implant dentistry in a dental practice in Seville, Spain, and has been doing so for 18 years. He holds a diploma in Implant Dentistry and an Advanced Certificate in Implant Dentistry, both awarded by the Royal College of Surgeons of England. Dr. Sanchez lectures on an international level on CAD/CAM and implant dentistry. He will be speaking about depicting the beauty of nature at the BioHorizons® symposium in London on September 30 titled, “A contemporary renaissance awakening: esthetics in implant dentistry.” The symposium will offer evidence-based information alongside practical guidance.

Figure 1B: Digital impression of teeth preparation and implant 28 Implant practice

Volume 9 Number 4


CASE STUDY

Figure 2: Digital design of final restoration immediately after implant placement

The patient was advised that the first restorative option was the best for her in the given circumstances: • Single crowns allow patients access to the interproximal space for optimal hygiene and maintenance. • Overloading of the abutment teeth is avoided, which means longevity. • Dental implants stimulate and preserve bone, helping to prevent bone loss. (Otherwise, free spaces are used for bone resorption.) • Highly esthetic materials can be used for single crowns (milled lithium disilicate), which are not recommended for three-unit bridges in the posterior area. The patient agreed to allow three single crowns to be made that would facilitate good interdental access and offer a better gingival contour than previously to help avoid food retention between the teeth.

Figure 3: Shape reduction of implant restoration to create a customized healing abutment. The original shape is saved

Figure 4: Milled provisional crowns on UL4 and UL6, and customized healing abutment at UL5 placed immediately after implant insertion

Figures 5 (left) and 6 (right): New emergence profile after soft tissue healing Volume 9 Number 4

Implant practice 29


CASE STUDY

Figures 7 (left) and 8 (right): After the osseointegration period, the original designs were recovered and milled in lithium disilicate

Figures 9 (left) and 10 (right): New digital impressions are not needed. Treatment was completed in two appointments. The customized healing abutment has the same shape but reduced occlusally to avoid immediate masticatory loads, and the definitive implant restoration is placed, achieving perfect adaptation over the soft tissue

Treatment plan The treatment was planned in accordance with the digitally assisted protocol (DAP) technique. This protocol offers optimized dental implant treatment by making full use of in-practice CAD/CAM technology. It allows the dental professional to perform fully digital dental implant treatment, from planning through restoration, without the need for impressions, plaster models, wax diagnoses, and so on. This means fewer clinical procedures, and therefore, fewer appointments are necessary to complete the treatment, as well as obtaining better esthetic and functional results. At the first appointment, the implant placement surgery took place. Digital impressions were taken, and provisional crowns (for the UR4 and UR6) and a customized healing abutment (of reduced shape for the UR5) were designed and milled. The soft tissue contour was molded using a customized healing cup that had the same shape as the final restoration to be placed following the osseointegration 30 Implant practice

The treatment was planned in accordance with the digitally assisted protocol (DAP) technique. period and soft tissue healing, except it was reduced above the gingiva. This technique allowed the treatment to be completed in just two appointments. Therefore, placement of the final crowns took place at the second appointment; definitive crowns were milled keeping the original design but changing the material.

Soft and hard tissue outcomes The emergence profile was re-designed, creating a nice contour and a healthy gingiva. The postoperative X-ray confirmed bone

stability, which is crucial for the success of the DAP technique. If there is bone loss, soft tissue outcomes may be compromised, affecting the whole treatment outcome. BioHorizonsÂŽ implants with Laser-LokÂŽ technology are therefore ideal for the DAP technique due to their ability to maintain bone stability. The patient was very happy with the treatment outcome, from both an esthetic and a functional perspective. Local discomfort has been eliminated, and the hygiene access is now comparable to that of her natural dentition. In addition, the new soft tissue contour avoids food retention and helps the restorations to look natural. The patient was also happy about the speed with which the treatment was completed and that only two appointments were needed. The patient was returned to her general dentist with conventional hygiene procedures recommended; no special care or product recommendations were needed. She was advised to attend a plaque/tartar control appointment within 6 months. IP Volume 9 Number 4


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CONTINUING EDUCATION

Dynamic image navigation — implementation in the esthetic zone utilizing a multidisciplinary approach Drs. Robert W. Emery, Keith Progebin, and Kim Knoll discuss some principles of modern digital implant dentistry Abstract The use of cone beam computed tomography and intraoral scanners has allowed the implant team to diagnose and treatment plan cases with remarkable accuracy and precision. The active use of these diagnostic tools has been limited due to the expense and complexity of CAD/CAM surgical guides. New dynamic navigation systems now allow dental surgeons to scan, plan, and execute guided surgery on the same day in their office with no need for laboratory fabricated parts. Real-time, turn-by-turn navigation of the implant leads to accurate and precise implant placement. Increased accuracy and precision leads to the better restorative and esthetic outcomes with minimal incisions and pain. This is done in a time and cost-efficient fashion. This article will present two esthetic zone cases that illustrate the principles of modern digital implant dentistry: multidisciplinary dentistry, pre-surgical orthodontics, dynamic navigation of implant placement immediately after extraction, minimally invasive soft tissue surgery, and immediate analog and milled CAD/CAM provisional restorations. The vast majority of dental implants are placed freehand, many with good results. Unfortunately, the precision with which freehand implants are placed is variable, and

Educational aims and objectives

This article aims to illustrate the indications and implementation of dynamic navigation with a modern implant multidisciplinary dentistry approach.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 38 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Realize that implants placed freehand are less accurate and precise than implants placed with dynamic guidance. •

Realize that there are a number of unique advantages to dynamic navigation.

Realize that dynamic navigation can be implemented with both a traditional analog approach and a fully digital approach.

even the best surgeon can have a “bad day” resulting in difficult restorative situations, and worse, damage to adjacent anatomic structures and loss of the implant or adjacent natural teeth.1,2 To improve accuracy and precision of implant placement, computerassisted surgery (CAS) has been developed. There are two forms of CAS: static guides also known as prefabricated CT-generated computer-aided stents (CAD/CAM) with metal tubes and coordinated instruments — and the other, dynamic navigation. Both dynamic and static guidance are highly accurate and precise.3,4 Scherer, et al., in a porcine model showed that freehand placement is significantly less accurate (p < 0.001)

Robert W. Emery, BDS, DDS, is a board-certified Oral and Maxillofacial Surgeon in private practice in Washington, DC. Dr. Emery received the Nobelpharma Oral and Maxillofacial Surgery Research Award and Grant from the Oral and Maxillofacial Surgery Research Foundation. He is actively involved in numerous research projects with an emphasis on image-guided surgery and is a founding partner of X-Nav Technologies, LLC. Presently, he is Director of the Capital Center for Oral and Maxillofacial Surgery, Senior Attending Surgeon at the Washington Hospital Center, and Chief Medical Officer of X-Nav Technologies. Keith Progebin, DDS, is a former Associate Clinical Instructor, Department of Prosthodontics and Occlusion, New York University College of Dentistry; Member of the Academy of Osseointegration and American College of Prosthodontics; Fellow of the Greater New York Academy of Prosthodontics; Fellow, International College of Dentists; Fellow, American College of Dentists; and in Private Practice in Advanced Restorative Dentistry and Implant Prosthodontics in Washington, DC. Kim Knoll, DDS, is a general dentist practicing in Washington, DC, since 1988. He graduated from Georgetown School of Dentistry. He is a member of the American Dental Association, DC Dental Society, an Associate Fellow of the World Clinical Laser Institute, and a founding member of the Renaissance Study Club. He specializes in advanced restorative procedures involving digital modalities to achieve his reconstructive outcomes. He has been using implants and other innovative techniques to accomplish many desirable restorative solutions for complicated cases. Disclosure: Dr. Emery has a proprietary interest in X-Nav Technologies, LLC. Drs. Progebin and Knoll have no conflicts to disclose.

32 Implant practice

than static guidance.5 Block, et al., compared implant placement to a new dynamic navigation system (X-Guide®, X-Nav Technologies, LLC, Lansdale, Pennsylvania), to freehand implant placement by experienced surgeons in clinical trials and showed again that guidance was significantly (p < 0.05) more accurate than freehand.6 The mean (standard deviation) angular deviation for freehand was 7.69 (4.92) degrees, for the X-Guide 3.62 (2.73). Entry point lateral deviation freehand was 1.15 mm (0.59) for X-Guide 0.87 mm, (0.42) and for apical lateral deviation, freehand was 2.21 mm (0.99), and for the X-Guide 1.09 (0.66). In a clinical simulation model study on the accuracy of the X-Guide system, it was shown to be highly accurate with mean angular deviations from the planned position of 1.09 degrees ± 0.55, mean entry lateral deviations of 0.33 mm ± 0.19, and mean apical lateral deviations of 0.36mm ± 0.20.7 Model studies are useful to evaluate the true accuracy of a system for comparisons with other guided systems as they remove some of the confounding variables of clinical trials. CAS also gives the surgeon a way to decrease pain for patients. Fortin,8 in a randomized clinical trial comparing the pain experience of patients that underwent traditional freehand open flap procedures to guided flapless procedures, found significantly higher (P<.01) visual analog pain Volume 9 Number 4


surgical implant community with over 2,000 implants placed using the X-Guide since its introduction to the market. It also means that every implant can now be guided — improving predictability, decreasing pain for patients, and hopefully, improving the longterm outcome of our restorations.

Dynamic navigation versus static guides

How do you choose which form of guidance you want to use? Block pointed out some of the following advantages of dynamic navigation:11 • Patients can be scanned and planned on the same day as surgery. • There is no laboratory-fabricated guide so the plan can be changed at any time. • Any implant system can be guided. Dynamic navigation is “open architecture.” • The surgical field can be visualized at any time. Guides do not obstruct views. • When implemented by a trained team, implant placement is rapid and efficient. • Plans can be shared with the entire multidisciplinary team and altered at any time. • Patients with minimal mouth opening can undergo dynamic navigation. • Tube size limitations and fabrication issues are not present with dynamic navigation. • Dynamic navigation allows real-time, turn-by-turn guidance with a headsup practitioner posture. • Dynamic navigation allows the use of intraoral scanning without the need of physical models.

Figure 1: Surgical site No. 10 optimized orthodontically for implant placement Volume 9 Number 4

Case reports The following cases will illustrate some of the indications for dynamic image navigation in the esthetic zone with a multidisciplinary approach. The first case will illustrate use of dynamic navigation with a traditional analog approach, and the second case will present a totally digital approach both using dynamic navigation, intraoral scanning, and model-less milling of a provisional for an immediate screw-retained provisional. Case 1 The first case involves a 24-year-old female presenting for implant reconstruction of a congenitally missing lateral incisor No. 10. She has undergone pre-surgical orthodontics to optimize the implant site (Figure 1). Her soft tissue is noted to be thin with tall papilla. Her prosthodontist fabricated an imaging guide prior to CBCT acquisition (Figure 2). The prefabricated, thermoplastic fiducial tracking device (X-Clip®, X-Nav Technologies, LLC, Lansdale, Pennsylvania), was heated in warm water and placed in the patient’s mouth. This was then removed and placed in cold water to harden. The X-Clip was then replaced in the same location with the imaging guide and a CBCT taken at 0.3 voxel resolution. The DICOM files were imported into the X-Guide software (XOS®, X-Nav Technologies, LLC, Lansdale, Pennsylvania). The arch was defined, a virtual tooth placed, and the virtual implant planned using the XOS. Implants are planned generically using the implant platform, apical and length dimensions. In this case,

Figures 2A-2C: A. Imaging guide with radiopaque tooth fabricated from diagnostic wax-up. Area in left maxilla removed for placement of an X-Clip. B. X-Clip before placement in water bath. Thermoplast is opaque and hard. C. X-Clip warming in a water bath. Thermoplast is soft when it becomes clear and ready to place intraorally Implant practice 33

CONTINUING EDUCATION

scale scores for open procedures.Pain also decreased faster with flapless procedures (P = .05). The number of patients reporting no pain was higher with flapless procedures, 43% versus 20% for open procedures. Dynamic navigation allows the surgeon to perform closed-flap procedures, thus offering the patient decreased pain. This is done without blocking the surgical visual field as with a static surgical guide. Often overlooked when discussing pain is the fact that up to 73.9% of dentists will develop musculoskeletal symptoms and pain during their careers.9 Ratzon noted that dentists who alternated their work position from standing to sitting had less low back pain and recommended frequently changing postures to decrease the incidence of lower back pain.10 Using dynamic guidance allows the surgeon to sit or stand with a “heads-up view” while guiding the implants with realtime, magnified, turn-by-turn control of the surgical drill. If CAS is more accurate and precise, what has held back its use? CAD/CAM static guides must be fabricated in a laboratory. This requires the dentist to take either a conventional or optical intraoral impression, create models, plan, and then fabricate the guide. This is inconvenient for the patient and the doctor. Static guides also add considerable expense to the procedure. Guide costs vary from $300 for single tooth to over $1,000 for full arch case. This has led implant surgeons to “only guide the high-risk cases.” Dynamic navigation requires no lab-fabricated parts. Every step can be completed in a single visit with costs below $100 per arch. This decrease in complexity and cost has led to a rapid acceptance of the technology within the


CONTINUING EDUCATION a StraumannÂŽ 3.3 mm x 12 mm Bone Level (StraumannÂŽ USA LLC, Andover, Massachusetts) was planned (Figure 3). The patient was then ready for surgery. The surgical staff followed the prompts in the X-Guide software and calibrated the drill and the X-Clip patient tracking assembly. Each step takes 30 to 60 seconds. Surgery was then able to begin. The surgeon watched the screen during guidance, and the assistant suctioned,

retracted and watched the patient at all time to avoid soft tissue trauma from instruments (Figure 4). In this case, a subepithelial connective-tissue graft was harvested from the left tuberosity and placed via a microflap/cinch suture technique (Figure 5). The patient then went to her prosthodontist for an immediate provisional using a stock prefabricated provisional abutment and chair side fabrication (Figure 6). Figure 7 shows

Figure 3: Virtual planning the implant using the XOS software

Figure 5: Subepithelial connective tissue graft being cinched into position to bulk out the buccal deficiency for a more natural esthetic relationship to the adjacent root prominences

Figure 7: Two weeks post surgery. Peek provisional abutment with customized patient and site specific restoration 34 Implant practice

the patient 2 weeks after provisional restoration. The patient left the country for studies abroad, and after a period of 12 months of tissue maturation, a final UCLA custom gold abutment with an all ceramic lithium disilicate crown was fabricated duplicating the idealized soft tissue (Figures 8). This was made using standard analog impressions of the implant body. This was cemented with a ZOE-based temporary cement.

Figure 4: Surgeon watches the screen during guidance, and first assistant watches patient. The X-Guide stereo cameras, LED lights, and drill pattern tracking array can be seen

Figure 6: Prefabricated PEEK provisional abutment placed on the implant for chair side customization

Figure 8: Final restoration consisted of a custom gold UCLA abutment and all ceramic lithium disilicate crown. (Kaz RDT Dental Laboratory) Volume 9 Number 4


Figures 10A-10B: A. Patient presented with thick soft tissue, minimal recession, and a high smile. B. Root blunting with internal resorption teeth Nos. 7, 8, and 9

Figure 9 shows the final highly esthetic result after cementation with temporary cement showing natural emergence profile, ceramic esthetics, and mature thick tissue around the implant.

Figure 11: Virtual planning screen showing intraoral scan STL file superimposed on DICOM file for detailed treatment planning

Figure 12: Surgical tracking view. Blue arrow, tip of drill on implant entry site. Red arrow, top of drill ideally centered over drill tip to indicate angle. Green arrow pointed at depth indicator. The green color of the depth indicator ring indicates the drill tip is within 1 mm of the planned depth. The yellow arrow is pointing at the patient tracking array. The orange arrow is pointed at the drill array Volume 9 Number 4

Case 2 The second case involves a 47-yearold male with a history of orthodontics 20 years ago. He subsequently developed root blunting of the maxillary incisors and internal resorption of the right maxillary lateral incisor and left central incisor (Figures 10A and 10B). Recently the right lateral and both central incisors had become symptomatic with increased mobility. After endodontic consultation, the decision was made to extract the teeth and place immediate implants. Prior to diagnostic CBCT, an X-Clip was warmed in hot water and placed on teeth Nos. 12, 14, and 15. The clip was removed and placed in ice water. It was then returned to its intraoral position, and a CBCT was taken. After review of the CBCT, it was noted that the patient had thick buccal bone and was ideally suited for extraction and immediate implant placement. An intraoral laser scan (TRIOSÂŽ, 3Shape A/S, Copenhagen, Denmark; in North America, Warren, New Jersey) was performed. The DICOM file from the CBCT and the STL files from the laser scan were imported into the X-Guideâ&#x20AC;&#x2122;s system software (XOS). This merged dataset was used for planning of the implants. The resolution of superimposed intraoral scans is detailed enough that virtual teeth are not required for treatment planning. Three Straumann 3.3 mm x 12 mm, parallel wall, Bone Level Implants were placed, with implant No. 7 being 3.3 mm in diameter and implant Nos. 8 and 9 being 4.1 mm. Bone Level Implants were planned (Figure 11). The planning was completed using the X-Guide software, and Implant practice 35

CONTINUING EDUCATION

Figure 9: Natural emergence profile, ceramic color matching, and mature soft tissue with ideal root eminence, full papilla, and stippled gingival surface texture. (Kaz RDT Dental Laboratory)


CONTINUING EDUCATION the decision was made to place the implants and immediately provisionalize with screwretained milled temporaries. Prior to surgery, the staff calibrated the X-Clip patient tracking array assembly and drill, each taking 30 to 60 seconds. Additionally, prior to surgery, an intraoral scanner (TRIOS®, 3Shape A/S) was used to acquire shade and a threedimensional scan. The teeth were then extracted atraumatically. The X-Guide was used to place the implants immediately. Figure 12 shows the live tracking screen, which has information for both the surgeon and the staff. The X-Guide indicates the entry point for the virtual drill, or the center of the implant platform, with the “X” in the center of the target view. In Figure 12, the tip of the virtual drill is shown at the entry point. The drill tip is indicated on the screen as a blue dot and is indicated by the blue arrow. A small circle indicates the back of the virtual drill, and the red arrow is pointed at this circle. During surgery, the dentist guides the blue dot over the center of the X of the target and then centers the back of the drill with a “bird’s-eye view” centered on the blue dot. This gives the surgeon entry point and angle. Next while drilling, the surgeon can visualize depth by watching the large and small circle change color. The large circle, with the green arrow pointed at it in Figure 12, changes from yellow to green when the tip of the drill is within 1 mm of the predetermined depth. When the drill reaches or exceeds the depth of the implant, the circle will turn red. The maximum depth is always located at the 9 o’clock position on the circle no matter what the length. The clinical staff use these windows to aim the cameras at the two tracking arrays. The yellow area on the left shows the tracking array attached to the X-Clip brightly illuminated to indicate the excellent quality of tracking. The orange arrow on the right is pointed at the tracking array attached to the drill again brightly illuminated to indicate the excellent quality of tracking. Each array has hundreds of unique points that are being tracked and used to triangulate the position of the patient and the drill for real time navigation. The window in the top-left corner gives the entire team a 3D view of the arch. This view can be oriented any way the surgeon likes relative to the surgeon’s operative position as can the target view. The implants all had torque values greater than 35 Ncm and ISQ values over 66. The 3Shape scanner was then used to acquire an image for virtual modeling of the soft tissues (Figure 13A). Scan bodies were placed and an impression taken with 36 Implant practice

Figures 13A-13C: A. Scan of sockets for soft tissue modeling. B. Scan bodies in place for virtual impression via intraoral scanning. C:. Xenograft (Bio-Oss®, Geistlich Pharma North America, Princeton, New Jersey) to fill buccal horizontal defects around the implants that were just inserted

Figure 14: Virtual designing of the provisional restorations for screw retention demonstrating projection of the access screws. (Nextek Dental Studio)

the scanner (Figure 13B). After the scan, the scan bodies were removed, healing abutments placed, and a buccal horizontal bone graft accomplished using xenograft (Figure 13C). The patient was than given an Essex provisional and sent home for the evening. During the evening, the laboratory designed and milled a provisional restoration (Figure 14). The next morning, the patient returned

to his restorative dentist for placement of a splinted screw-retained PMMA acrylic-milled provisional restoration (Figures 15A-15B). Urethane dimethacrylate (Revotec LC™, GC America Inc., Alsip, Illinois) was used to seal the screw access holes. A nano-hybrid hybrid composite (IPS Empress® Direct, Ivoclar Vivadent®, Amherst, New York) was used for esthetic incisal matching. Occlusion Volume 9 Number 4


CONTINUING EDUCATION

was checked in centric as well as protrusive with the aim to have no contacts on the integrating implant provisionals during the healing phase. Figure 15C shows an occlusal view with no centric or protrusive contacts.

Summary These two cases illustrate the versatility of dynamic navigation. Both cases were in the challenging esthetic zone and involved immediate provisional placement. In the first case, classic analog technology was used, an imaging guide was fabricated prior to CBCT acquisition, and a chairside provisional was fabricated. The second case involved a model-less, state-of-the-art, alldigital approach with a screw-retained, milled restoration. The advantages of dynamic navigation are: • Patients can be scanned and planned on the same day as surgery. • There is no laboratory-fabricated guide, so the plan can be changed at any time. • Any implant system can be guided. Dynamic navigation is “open.” • The surgical field can be visualized at any time. Guides are not obstructing views. • When implemented by a trained team, implant placement is rapid and efficient. • Plans can be shared with the entire multidisciplinary team and altered at any time. • Patients with minimal mouth opening can undergo dynamic navigation. • Tube size limitations and fabrication issues are not present with dynamic navigation. • Dynamic navigation allows real-time, turn-by-turn guidance with a headsup posture. • Dynamic navigation allows the use of intraoral scanning without the need of physical models. IP Volume 9 Number 4

Figures 15A-15C: A. Splinted provisional PMMA acrylic restoration seated and screwed in place demonstrating the screw access through the restorations (Nextek Dental Studio). B. Composite placed to finish provisional sealing the screw access holes. C. Occlusal view showing absence of centric or protrusive contacts

Acknowledgments Lab work for first case was performed by Kaz RDT Dental Laboratory. Restorative dentistry for the second case was performed by Dr. Kim Knoll. Lab work for the second case was performed by Nextek Dental Studios, Manassas, Virginia. REFERENCES: 1. Kim S. Clinical complications of dental implants. In: Turkyilmaz I, ed. Implant Dentistry – A Rapidly Evolving Practice. InTech. 2011:467–490. 2. Goodacre CJ, Kan JY, Rungcharassaeng K. Clinical complications of osseointegrated implants. J Prosthet Dent. 1999;81(5):537-552. 3. Tahmaseb A, Wismeijer D, Coucke W, Derksen W. Computer technology applications in surgical implant dentistry: a systematic review. Int J Oral Maxillofac Implants. 2014;29(suppl):25-42 4. Jung RE, Schneider D, Ganeles J, et al. Computer technology applications in surgical implant dentistry: a systematic review. Int J Oral Maxillofac Implants. 2009;24(suppl):92-109. 5. Scherer U, Stoetzer M, Ruecker M, Gellrich NC, von See C. Template-guided vs. non-guided drilling in site preparation of dental implants. Clin Oral Investig. 2015;19(6):1339-1346. 6. Block MS, Emery RW, Lank K RJ. Accuracy using dynamic navigation. Int J Oral Maxillofac. In press. 7. Emery, RW, Merritt SA, Lank K, Gibbs JD. Accuracy of dynamic navigation for dental implant placement — model-based evaluation. J Oral Implantol. In press. 8. Fortin T, Bosson JL, Isidori M, Blanchet E. Effect of flapless surgery on pain experienced in implant placement using an imageguided system. Int J Oral Maxillofac Implants. 2006;21(2):298-304. 9. Gopinadh A, Devi KN, Chiramana S, Manne P, Sampath A, Babu MS. Ergonomics and musculoskeletal disorder: as an occupational hazard in dentistry. J Contemp Dent Pract. 2013;14(2):299-303. 10. Ratzon NZ, Yaros T, Mizlik A, Kanner T. Musculoskeletal symptoms among dentists in relation to work posture. Work. 2000;15(3):153-158. 11. Block MS, Emery RW. Static or dynamic navigation for implant placement—choosing the method of guidance. J Oral Maxillofac Surg. 2016;74(2):269-277.

Implant practice 37


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Dynamic image navigation — implementation in the esthetic zone utilizing a multidisciplinary approach EMERY/PROGEBIN/KNOLL

1. Unfortunately, the precision with which freehand implants are placed is variable, and even the best surgeon can have a “bad day” resulting in ___________. a. difficult restorative situations b. damage to adjacent anatomic structures c. loss of the implant or adjacent natural teeth d. all of the above 2. To improve _________, computer-assisted surgery (CAS) has been developed. a. accuracy of implant placement b. precision of implant placement c. static guidance d. both a and b 3. Scherer, et al., in a porcine model showed that freehand placement is ________ than static guidance. a. significantly more accurate b. significantly less accurate c. more effective d. more precise 4. ___________ allows the surgeon to perform closed-flap procedures, thus offering the patient decreased pain.

38 Implant practice

a. Freehand placement b. Using laboratory fabricated parts c. Dynamic navigation d. An imaging guide 5. Often overlooked when discussing pain is the fact that up to ______ of dentists will develop musculoskeletal symptoms and pain during their careers. a. 16.4% b. 37.6% c. 73.9% d. 92.3% 6. Using dynamic navigation: Patients can be scanned and planned ___________. a. on the same day as surgery b. 1 month after surgery c. 6 weeks after surgery d. 2 months after surgery 7. (For case number 2) Prior to surgery, the staff calibrated the X-Clip patient tracking array assembly and drill, each taking __________. a. 30 to 60 seconds b. 2 to 5 minutes

c. 10 to 15 minutes d. about 30 minutes 8. Each array has hundreds of unique points that are being tracked and used to triangulate the position of the patient and the drill for ____________. a. avoidance of soft tissue trauma b. avoiding a connective tissue graft c. preparation for the cinch suture technique d. real-time navigation 9. (With dynamic navigation) Plans can be __________. a. shared with the entire multidisciplinary team b. altered at any time c. laboratory fabricated d. both a and b 10. __________ is/are not present with dynamic navigation. a. Ability to treat patients with minimal mouth opening b. Tube size limitations c. Fabrication issues d. both b and c

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Dr. Maher Kemmoona illustrates how to achieve predictable, lasting, and esthetic outcomes with dental implant therapy regardless of whether it’s a simple or complex restoration

A

ny dental therapy should aim at restoring a patient’s dental occlusion. This is not always the case, nor is it always the patient’s desire. And why would it be? Our patients are not dentists after all; they do not share our understanding of oral health, the need for sufficient number of teeth in good occlusal relationship to each other, the knowledge of interrelationship of chronic oral disease, such as periodontitis, and general well-being. Not surprisingly, we see many patients in the middle-aged group who have a significantly destructed dentition, possibly due to caries with further complexities such as advanced non-carious tooth surface loss due to factors such as erosion and wear, often resulting in the lack of an adequate posterior occlusal support. These patients often feel they have had a lot of dental treatment in the past, and truthfully, they often have; but often enough the main reasons for the destruction of their dentition over extensive periods of time have never been addressed appropriately.

Prevention Treatment planning for simple and complex rehabilitations takes time and a certain knowledge bank; there is a need for in-depth examination of the patient. Most of all, we ought to establish why patients find themselves in the dilemma in the first place in order to prevent the story from repeating itself after treatment. Why should the treatment planning for dental implants differ from those previously mentioned? In order to prescribe the

Maher Kemmoona, M. Dent. Ch (Perio), specializes in the provision of complex dental care and has practiced exclusively in implant dentistry and periodontology since completing the postgraduate course in periodontology at Trinity College Dublin in 2007. Maher qualified at the University of Erlangen-Nurnberg, Germany, in 1999 and worked both as a general dentist and in perio-prosthetic specialist practice before returning to Ireland in 2002. He has a keen interest in the management of periimplantitis and failing implant prosthetics.

Volume 9 Number 4

Educational aims and objectives

This article aims to offer suggestions on achieving predictable, lasting, and esthetic outcomes with dental implant therapy.

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: • Identify a defined protocol to derive the most appropriate treatment options for presentation to patients. •

Identify questions to ask patients regarding the etiology of the destruction of their dentition.

Realize some contraindications for dental implant therapy.

Recognize the possibility of reducing risk by implementing a sequential in-depth examination of the patient.

Recognize, through viewing case studies, various treatment plans that illustrate the need for adequate data collection prior to treatment.

necessary therapy, dentists ought to follow a defined protocol — a repeated sequence in examining the patient. This subsequently allows clinicians to derive the most appropriate treatment options for presentation to patients. Unfortunately, it is here that we as dentists may encounter resistance on our patients’ behalf. Often they only sought our advice in regard to a problem with a single or just a few teeth and are now overwhelmed with the depth of the deeper problem. This frequently becomes an ethical dilemma in therapy, and the resulting questions are not easily answered. Taking a medical-scientific point of view, to repeat a sequential pattern in the dental record taking, an accurate physical and social history, as well as an in-depth physical examination, has proven itself. In complex cases, this should be augmented by specific laboratory data collection and analysis, such as a facebow transfer of jaw position followed by a simple wax-up or setup of denture teeth. This will assist in planning and may show up problems that could likely be encountered later along the way in treatment. Most of all, it will allow dentists to prescribe treatment based on reproducible data derived from the different aspects of the examination — it appears to be the safest way in coming to a diagnosis and a therapeutic plan.

When determining the etiology of the destruction of our patients’ dentition, it can help to ask patients simple questions, such as: • When did problems begin? • Where did problems begin? • Has the patient had any treatment for the problems? • Has previous treatment affected the patient’s condition? Answering these questions will allow us to see if the patients are engaged in treatment, have understood the relevance of our findings, and taken aboard their own role in the making of the dental problems apparent. Can we ethically engage in complex therapy with patients who have not taken responsibility for their own health — especially when it comes to dental implant therapy, which for most of its course remains elective treatment?

A good option? Most of the existing research on dental implant therapy and the outcome relates to healthy individuals — maybe with the exception of diabetes and periodontitis. At the same time, very little has been published on the long-term survival of dental implants in patients who are susceptible to aggressive periodontal disease. Given the prevalence of chronic diseases and an aging population, we should be Implant practice 39

CONTINUING EDUCATION

Predictable implant therapy


CONTINUING EDUCATION cautious in treatment prescription and reflect on the true need for dental implants in patients. Currently, we accept the following absolute contraindications for dental implant therapy in a dental practice setting (Hwang, Wang, 2006): • Recent myocardial infarction and cerebro-vascular accident, heart valve replacement • Recent immunosuppressive therapy • Bleeding disorders • Patients receiving active treatment of malignant tumors • Drug abuse • Certain psychiatric illnesses • Intravenous bisphosphonate use To a lesser degree, we have scientific support for the relative contraindications to implant therapy in practice, and these mirror very much what is accepted to be good practice for oral surgery procedures under these circumstances (Hwang, Wang, 2007). We ought to respect illnesses that impair the normal healing cascade and as such have the potential to worsen surgical success. Certain disorders, when well controlled, allow implant survival rates that match those in healthy patients — among these we find factors such as osteoporosis, smoking, diabetes, positive interleukin-1 genotype, HIV, cardiovascular disease, and hypothyroidism. Generally speaking, we find higher rates of immediate postoperative complications, significantly increased levels of long-term complications, e.g., mucositis, peri-implantitis, and implant loss, in smoking patients. To date, research has not been able to improve definitive treatment modalities to rectify these on a reproducible level. It is suggested that in diabetic patients, complications arising during dental implant treatment may result from early disruption of adequate bone healing in the first few weeks after surgery; these complications may even be important in long-term failure, but research into the exact mechanisms at play here is still ongoing.

If we can control co-factors such as poor oral hygiene, smoking, unstable periodontal status, a stabilization of glycemic control (HbA1c at around 7%) in diabetic patients, we may achieve a good outcome for therapy. In these cases, it is of utmost importance to take preventive measures against infection immediately post-surgery. Looking at the periodontal patient, it appears that, short-term, similar levels of implant success/survival can be expected. This changes significantly in the long-term, and there is clear evidence of a higher rate of complications developing, including mucositis and peri-implantitis, and, worst case, even the loss of implant integration. Unfortunately, there is little medium- or long-term scientific data present on implant success/ survival in patients who have been treated for aggressive periodontitis, which makes this a higher risk cohort of patients to treat in practice.

Figure 1: Presentation at implant consultation

Figures 2A and 2B: Resulting defect after tooth removal

40 Implant practice

Sequence of examination One way to assess the issues outlined previously, and in order to reduce risk during therapy, is the implementation of a sequential in-depth examination of the patient who desires to undergo dental implant treatment. During this examination, it is advisable to work through the following points: • Evaluation of relevant medical and social history • Assessment of oral mucosal tissues in form, function texture, including salivary flow for any pathological changes • Recording of remaining teeth and their restorative/endodontic status • Determining the occlusion reflected from both a dental and skeletal perspective • Screening or, if necessary, a full periodontal examination • Reflection on mobility of remaining

teeth to determine whether this is due to traumatic occlusion or loss of periodontal support • Evaluation of amount of attached gingiva present, including phenotype of gingiva: thin or thick • Palpation of site — with increasing experience, a lot of information can be gained easily and noninvasively • Radiographic examination — including periapical radiographs, OPG, or 3D scans. The relative findings can be brought into perspective with the patient’s overall wishes, and this should always allow to define a common ground to agree on a treatment path for the patient.

Case 1 The first case presented is a result of trauma due to a motor accident in which a lower and upper incisor were avulsed. The upper incisor was replanted, but the tooth became non-vital over time, and the infection meant loss of both hard and soft tissue. The patient suffered significant other traumatic injuries in this accident. Both the dental clinical examination and radiographic evaluation revealed a threedimensional hard and soft tissue defect at the tooth UL1. Extraction of the tooth was necessary, and the size of the defect resulted in a vague prognosis for implant therapy at a later stage. These findings were discussed with the patient, and the resulting treatment plan included the need for a 3D bone graft as well as soft tissue augmentation in order to provide a fixed dental restoration. The patient was in his mid-30s, was a nonsmoker, and his medical history was clear. He had fully recovered from the injuries of previous trauma at this stage. Figure 2 shows the resulting defect after tooth removal. At this time, a maxillary frenectomy had been completed to ensure

Volume 9 Number 4


CONTINUING EDUCATION

tension-free closure after the grafting procedure. The bone graft was completed using titanium pins and bone block screws in addition to a mix of autogenous bone and bovine-derived xenograft substitute material. Healing was uneventful. Six months after bone augmentation, a narrow platform dental implant as well as a connective tissue graft could be placed, which ultimately allowed for repair of the previous 3D defect in this case. The intraoperative sequence of the bone graft procedure and the resulting postoperative view after implantation are presented in Figure 3.

Case 2 The second clinical case was significantly dependent on the initial planning procedure described previously. This patient had a complex medical history and was taking several different types of medication for chronic diseases. The existing long-span Maryland bridge had successfully restored the occlusion for almost 20 years. At the time of its failure, there were multiple unrestorable teeth present, and the distribution of the remaining restorable teeth was not favorable to retaining them (Figure 4). In this case, a set of study models was mounted after facebow transfer and a partial setup of denture teeth utilized to assure the correct vertical treatment position and esthetics prior to any treatment being provided. The nine remaining maxillary teeth were extracted and seven tapered

dental implants placed immediately for the patient. The same afternoon, a temporary bridge was fitted, screw-retained to the five implants that showed the highest insertion torque on implantation. The initial diagnostic setup allowed for a provision of a surgical guide to assure parallel implant placement. The same setup was

used by the lab in the transition to the sameday temporary acrylic bridge. Implant-level silicone impressions were taken immediately after insertion of the dental implants, and these were sent with an accurate bite registration to the dental lab. The transition from an acrylic denture derived from the previous diagnostic setup to the

Figure 4: Maxillary arch after failure of Maryland bridge

Figure 5: Immediate implant placement in the maxilla

Figure 6: Postoperative OPG

Figures 3A-3D: Intra- and postoperative view of augmented site

Figures 7A-7C: Temporary bridge on the model and in situ Volume 9 Number 4

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CONTINUING EDUCATION

Figures 8A-8C: Predictable esthetics and function

Treatment planning for simple and complex rehabilitations takes time and a certain knowledge bank. Figures 9A and 9B: Implant-supported full-arch restorations

Figures 10A-10C: Predictable screw retention based on optimal implant placement

transitional acrylic bridge was achieved in just a few hours. This allowed the patient to leave the practice the same evening with a fixed temporary implant-supported bridge. The accuracy of fit can be related to the amount of data collected prior to treatment and is, for most cases, reproducible. Six months after insertion, the implants are integrated, and the patient is due to progress into the final restoration planned as a titanium acrylic hybrid bridge. Once again, the initial diagnostic setup will aid in the laboratory procedures necessary, providing reference to jaw relationship and tooth position.

Cases 3 and 4 Figures 8 to 10 show a series of complex implant cases. These include the treatment of severely atrophic maxillary arches with implant reconstructions, leading to a good esthetic and functional outcome (Figures 8-9). In all the cases, the patients had lost their natural dentition due to progressive 42 Implant practice

periodontal disease, resulting in having limited bone available. A combination of appropriate diagnostic work-up and surgical pre-planning allowed for a good esthetic and functional outcome despite the limitations given at the outset of therapy. Figure 10 illustrates both the treatment of congenitally missing lateral incisors after orthodontic treatment and a case of combined surgical/prosthetic retreatment of previously apicetomized teeth, which had to be extracted. The final implant crowns were screw-retained. This can be difficult due to the angulation of implant placement. Despite the lack of adequate bone at the outset of therapy, the goal was achieved.

Conclusion In all the cases presented, the previously described assessment sequence was followed, and very simple and cost-effective data analysis, including diagnostic setups/ wax-ups, resulted in a predictable outcome of therapy, fulfilling the patientsâ&#x20AC;&#x2122; expectations.

None of these cases were simple to start with, but the relevant data collection and analysis allowed for a reproducible outcome. The case studies illustrating various treatment scenarios hopefully underpin the need for adequate data collection prior to treatment. Dental implant therapy has long moved from hoping to see the titanium screw integrate; very complex treatment is now predictably possible, even for patients with a complex history. We do need to understand the limitations in order to assess these cases appropriately. Only by collecting the right information can a treatment plan be put together that will ensure a predictable, lasting, and esthetic outcome to dental implant therapy. IP

REFERENCES 1. Hwang D, Wang HL. Medical contraindications to implant therapy: part I: absolute contraindications. Implant Dent. 2006;15(4):353-60. 2. Hwang D, Wang HL. Medical contraindications to implant therapy: part II: relative contraindications. Implant Dent. 2007;16(1):13-23.

Volume 9 Number 4


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 V9.4 KEMMOONA

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Predictable implant therapy KEMMOONA

1. Taking a medical-scientific point of view, to repeat a sequential pattern in the dental record taking, _______ has/have proven itself. a. an accurate physical history b. an accurate social history c. an in-depth physical examination d. all of the above 2. Most of the existing research on dental implant therapy and the outcome relates to healthy individuals â&#x20AC;&#x201D; maybe with the exception of ________. a. diabetes b. periodontitis c. colitis d. both a and b

c. endodontic procedures d. periodontal procedures 5. It is suggested that in diabetic patients, complications arising during dental implant treatment may result from ________; these complications may even be important in long-term failure, but research into the exact mechanisms at play here is still ongoing. a. mucositis b. positive interleukin-1 c. early disruption of adequate bone healing in the first few weeks after surgery d. undetected cardiovascular issues

3. Given the prevalence of ________, we should be cautious in treatment prescription and reflect on the true need for dental implants in patients. a. obesity b. chronic diseases c. an aging population d. both b and c

6. (Implant success/survival) This changes significantly in the long-term, and there is clear evidence of a higher rate of complications developing, including __________. a. mucositis b. peri-implantitis c. loss of implant integration d. all of the above

4. To a lesser degree, we have scientific support for the relative contraindications to implant therapy in practice, and these mirror very much what is accepted to be good practice for _______ under these circumstances. a. oral surgery procedures b. orthodontic procedures

7. (During the in-depth examination of the patient who desires to undergo dental implant treatment, clinicians are advised to work through several factors, one of which is) Radiographic examination, including ________. a. periapical radiographs b. OPG

Volume 9 Number 4

c. 3D scans d. all of the above 8. (For case 1) _________ after bone augmentation, a narrow platform dental implant as well as a connective tissue graft could be placed, which ultimately allowed for repair of the previous 3D defect in this case. a. One month b. Two months c. Six months d. One year 9. The case studies illustrating various treatment scenarios hopefully underpin the need for _________ prior to treatment. a. adequate data collection b. a long-term treatment schedule c. multiple radiographs d. the patient to wean off medications 10. Dental implant therapy has long moved from hoping to see the titanium screw integrate; very complex treatment is ________________. a. now predictably possible, even for patients with a complex history b. not predictable for patients with a complex history c. never an option for patients with a complex history d. only for severe implant reconstructions

Implant practice 43

CE CREDITS

IMPLANT PRACTICE CE


IMPLANT INSIGHTS

Avoiding mistakes In part 1 of a series, Dr. Diyari Abdah looks for ways to rise above dental implant complications

D

espite the predictability of dental implants in today’s dentistry as a treatment modality instead of dental bridges or dentures, it can present many problems if not planned, executed, and maintained correctly. There is no doubt that we have come a long way from the early days of placing an implant and waiting nearly a year before restoring it. Today, implants can be placed predictably straight after extractions. Some even restore the implant — with varying degrees of success — immediately after placement with a provisional or final restoration. But what is the rationale for immediately placing an implant after extracting a tooth and restoring it sometimes on the same day? Why do people want everything done so fast — and do they always work, or are we just pushing the envelope? Worse is when we do this without any in-depth knowledge or consideration to the biological and mechanical factors that determine the prognosis of the case. In reality, there is enough evidence in the literature to support the idea of immediate placement of an implant to maintain bone and soft tissue architecture as long as the case is planned properly; this treatment modality is not for every case. Surprisingly, implants are one of the most widely researched areas of dentistry, yet people can still get it wrong at times, and the results can be short of acceptable. While there are dental practices that thrive on rectifying mistakes, we have to ask why this is happening. Clinicians just need to listen to some experienced colleagues who lecture around the world, showing cases that had to be rectified after someone mismanaged a case at some point, and the results were not exactly as the patient desired. Even companies are pouring millions into research. Implant dentistry is a very exciting and rewarding

topic for researchers and dentists alike, but who are the real winners? The winners should ultimately be the patients, as they are the end receivers of these products; they put all their trust in them (and us). The dentist is, of course, the end user. Both dentist and patient are on the receiving end of the production line and the research around it. The question is, Do implant companies do enough to reduce the risks of implants being mismanaged by certain “dentists”? Well, respectfully, some do. They are committed to providing good and solid education and do not allow their implants to end up in the wrong hands. But most of the education is understandably about the company’s implant range and the protocols it suggests. Statistically, the majority of manufacturers don’t believe it’s their job to check on the operators’ surgical and restorative backgrounds before they sell their products. So who needs to make sure that the dentists possess the right skills to place implants in practice? Without a doubt, it is the dentist’s sole responsibility to acquire the right knowledge

Diyari Abdah, DDS, MSc, ImpDent, is a cosmetic and implant dentist in private practice in Cambridge, England. He deals with all aspects of implant dentistry and grafting techniques and has been actively promoting dental implants among GPs through lecturing, workshops, articles, and mentoring programs. Dr. Abdah is a visiting academic at the University of Warwick on the implant MSc program and runs a successful mentoring program that emphasizes avoiding and solving problems in implant dentistry.

44 Implant practice

and skills for managing these cases predictably — and making sure that they remain successful even after a long period of time. To make cases more predictable and to achieve the desired results take many hours of study, attending hands-on courses, and critically reading and researching the available papers. What’s more, remaining at the forefront of the latest advances means exchanging ideas and attending forums. Some research results are groundbreaking, and they have certainly been used as benchmarks for many aspects of implant surgery. However, a lot of money and resources are wasted doing the same studies time and time again. Learning to critically read these research papers is paramount if we want to filter out the best information.

Blame game When things do go wrong, whose fault is it? Is it always the surgeon’s fault for not following the right protocols or not paying enough attention to all the anatomical variations in relation to the restorative outcomes? Or does blame lie with the restorative and planning dentist who fails to communicate correctly with the surgeon? We have all seen cases where integrated implants have had to be removed because they could not be restored correctly. This is devastating for everyone and especially the patient. Volume 9 Number 4


Whose responsibility is it to make a case successful? More and more companies are offering lifetime guarantees on their implants with a “no matter what” return policy. Does this mean that their implants are so good that they have very few returns? Otherwise, why would they offer a lifetime guarantee? And what about the patients? Do they also play a part in making an implant successful and prolonging its lifespan? Or is it entirely the responsibility of the surgeon and the restorative dentist to make sure that they choose the right implant for the right site, under the right conditions, and using the correct protocols laid out by the respective implant manufacturer? Should these practitioners never mix these protocols with other forms of dentistry they have been doing for years or with other manufacturers’ protocols in case of multi-system users?

Problems and solutions In this article I will touch upon some of the factors that can make or break a case. We are all in the improving and restoring business — so the more we know, the better we become, and the more we can help our patients. Because of this, we need to constantly improve and polish our skills through lifelong learning and by being very observant, critical, and open to receiving new information. It is not possible to cover all implant problems and solutions in this article, nor is it my intention. However, it will hopefully trigger a curiosity among some to review their protocols and do an audit to see what has or hasn’t worked, and what could be done about it. Some of the most common problems will be covered in part 2 of this series.

Avoiding mistakes and mishaps The nature of implant dentistry is that there will be a lot of variations to bear in Volume 9 Number 4

IMPLANT INSIGHTS

Implant dentistry is a multidisciplinary treatment modality. Sometimes the same dentist with the right skills can provide all the solutions. Ideally, we want the best people with the best skills to do their parts in order to achieve the desired results. This is why the best policy is to know when to do something and when to refer — before it is too late. That will be called correcting mismanagement. Implant treatment, especially in large cases, can be tricky without a doubt, but the trick is to orchestrate the whole case correctly in a timely manner so that every step is done correctly and skillfully in the right sequence.

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Implant practice 45


IMPLANT INSIGHTS mind: surgical site variations, patients’ health variations, implant design and surface morphology variations, dentists’ skills variations, and so on. The fact is that “things” will happen from time to time. As long as we follow the right indications, respect the surgical and restorative protocols and the workflow, combined with the patient’s needs, then ideally very little — or nothing — should go wrong. But things sometimes still go wrong whether we like it or not. So why is that? Implant dentistry is not easy. Yes, it is manageable and sometimes very predictable, but it takes skill and effort to achieve a successful end result. The question is how we recognize the signs when something is wrong, what we do about it, and very importantly, what we learn from it, so it doesn’t happen again. For some, one problem is enough to make the clinician anxious for a long time and avoid a situation in future. This is understandable, but the real answer is to study more, acquire more knowledge to fill the gaps, and maybe get a trusted mentor that the dentist can work closely with. Thankfully, the majority will learn from the experience and will never allow it to happen again. Sometimes the same problem has to happen several times before we realize that something is wrong, and a change has to be made, either to our protocol, choice of cases, or even the system used. Remember that not all systems are created equal.

Following protocol In my years of mentoring and observing, I have found that one of the main issues people have is not following the protocol recommended by the implant manufacturer. This can obviously lead to all sorts of shortcomings and subsequent problems that could have been simply avoided by following the protocol. This is how it goes: The dentist has been using a particular system for years, maybe placing hundreds of that particular implant, so is well experienced through practice. One day, a friendly dental rep pays him a visit to show him a new system that has all the bells and whistles. He decides the new system will make his life easier and orders 10, 20, or 30 implants with a “free” kit, maybe — all looking good so far. Now, instead of following the new implant’s surgical protocol accurately, he becomes rather “creative” with it! So he invents his own set of protocols. While I am not against creativity per se — we dentists are creative people by nature — certain 46 Implant practice

It’s our sole responsibility to acquire the right knowledge and skills for doing and managing cases predictably. things have been laid out in a certain pattern for a reason. It happens to most of us, and that’s fine, as long as we don’t do any harm. But a protocol is there to be followed and if, for any reason, there is an improvement to be made, I am sure any sensible manufacturer will be more than happy to listen to our suggestions. We notice implants 2 mm above bone level when there is enough bone in the opposite direction (apically). You get the picture. Solution follows the protocol to measure and re-measure between surgical sequences. When an implant comes out of its protective sleeve, ideally you want to use it once and not keep trying it several times because the site wasn’t prepared accurately. Guide pins are there to be used. For most implants, the site has to be prepared accurately in order for the implant to sit exactly where it’s meant to. Some implants through their design allow the implant to create its own path, which can be a good feature. But in inexperienced hands, it could be dangerous, as there is no “bottom” to the site! In that case, the simplest thing to do is unscrew gradually, and if no vital anatomical structure has been touched, the implant could be left at a desired depth, i.e., at or just below the marginal bone level as the system dictates. It is the “little big things” that make or break a case. But the real problem comes when they happen, and nothing is done about it — this is what leads to potential problems. Remember, while the site is open, you can rectify anything that needs correcting. Once the flap is repositioned and closed, you need a very good reason and argument to persuade the patient to allow you in again. Just remember root canal therapy! You can correct most things while still working on it. Sometimes one simple and easily avoidable mistake can lead to partial or total failure of an otherwise successful placement. One example is poor suturing, allowing bacteria to invade the site and leading to a less than desirable result. Suturing is an art, and it has to be mastered. The secret is simple: Practice, practice, practice! Chose the right indication for the right suturing method, and you

will have very few problems. Understanding why we suture in a certain way, using certain materials, is crucial for the overall success of the implant. Understanding the biology behind implant placement and the subsequent treatment sequences is paramount — and how to help restore the biology by suturing is crucial. There are many good books and courses that cater for this obvious but overlooked stage in implant surgery.

Adequate healing Fully understanding the biology and tissue behavior in the implant site is paramount for successful implant therapy. Once we understand how the hard and soft tissues behave, we can choose the right-flap repositioning technique and suturing to aid the overall healing process. Inadequate repositioning and suturing can result in flaps not healing correctly or esthetically — or worse, allowing the hard tissue or grafting materials to be exposed, leading to partial or complete implant failure. Implant angulation is also one of those problem areas that we can sometimes find out about too late — namely, at impression or restorative stage. The obvious step (while still inexperienced) seems to be the use of a surgical guide, even for simpler cases. Usually there are plenty of reference areas in the mouth that could be used for aligning the surgical drills, but if in doubt, take control radiographs (although these must kept to a minimum), and use the neighboring teeth (being mindful of anatomical root variations), the occlusion table, and other anatomical features as a guide. Until then, a correctly made surgical guide is the best solution. It is no surprise that every once in a while on the lecture circuit dentists see presentations of implants that could not be restored because of angulation problems or malpositioning.

Next time The second part of this series, to be published in the next issue of Implant Practice US, will detail some of the most common problems in implant dentistry. IP Volume 9 Number 4


TECHNOLOGY

Clinical Usage Review Accuracy assessment and surgeon feedback on Navident Dynamic Navigation System

N

avident guides the surgeon to place implants as planned on a CBCT image volume similar to a GPS that guides drivers along a route planned on a map. The system combines restoration-guided planning and surgical guidance in a single laptop and a stereoscopic pose tracking camera hovering over the patient’s chest. Being much simpler and faster than static guides, Navident allows the full workflow of CBCT scanning, planning, and guided implantation to be performed in a single, short patient appointment. The system’s developer, ClaroNav Inc., headquartered in Toronto, Canada, has been successfully developing and marketing imaging and navigation solutions to the global medical community for over 15 years. Navident is the result of close collaboration between ClaroNav Inc. and the University of Toronto Faculty of Dentistry. The system has received CE Mark clearance in July of 2015 and has since seen rapidly rising sales in Europe and East Asia. At the time of the study reported here, FDA clearance was pending.

Dr. Shogo Mimura of Kyoai Dental Clinic in Japan was the first of 15 Japanese surgeons to target perfection with Navident in 2015/2016

The study To assess the early impact of Navident in clinical usage, in March of 2016, ClaroNav contacted Navident users and requested that they participate in a Clinical Usage Study consisting of case reports, accuracy assessments, and surgeon feedback collected through detailed questionnaires on Navident’s impact on each case and an overall practice impact. Seven surgeons practicing at sites located in Canada, Belgium, Italy, Sweden, and Colombia responded to ClaroNav’s request. Respondents’ implantation experience ranged from a recent graduate to placing 6,000 implants over 20 years. Collectively, by the time they responded, they have performed about 350 Navident-guided implantations in 150 patients. None of the surgeons received, or expected to receive, financial support from ClaroNav. Twenty-one patient cases containing 36 implants were submitted. In instances where the clinicians provided post-surgical CT data, a validated plan-to-implant comparison Volume 9 Number 4

OMFS Dr. Robert Barron of Concord Oral Surgery in Canada uses Navident Implant practice 47


TECHNOLOGY program was used to obtain placement-error measurements.

Case reports and placement accuracy No adverse events or complications were reported, and no major usability issues interfering with effective usage were identified. Where post-implantation CT images were provided for cases, placement accuracy could be reliably measured by carefully registering the pre- and post-images and measuring the geometric deviation between the planned and actual positions of each implant. One surgeon submitted nine cases with 14 guided implantations, enabling statistically significant accuracy numbers to be computed. The results are shown in Table 1. Table 1: The experienced surgeon’s results Avg.

Max

Entry deviation

0.8 mm

1.6 mm

Apex deviation

0.9 mm

1.6 mm

Angular deviation

3.5º

5.7º

These accuracy results compare favorably with those obtained with static guides. For example, a systematic review of published static guide accuracy studies, including ones done on models or cadavers, published by Tahmaseb, et al., in 2014, reported on corresponding average/max of reported errors of 1.1/4.5 mm, 1.4/7.9 mm and 3.9/21°. The remaining implantations were evaluated based on clinical and radiographic assessments and were deemed by all surgeons to be accurately placed.

Clinical usage feedback The participating surgeons were asked to mark their degree of agreement with a set of statements related to the usage of the system. The combined results are tabulated in Table 2 with each star representing one response.

Dr. Ido Bermanis, Clinical Specialist for ClaroNav, with the compact and portable Navident system

Of particular note is that the highly agreeable responses to the last statement indicate that Navident is having the intended benefit of increased confidence in the quality and safety of implantation for surgeons across a wide spectrum of experience and skill levels. Participants were also asked to comment on their experiences with Navident in a freeform format. The majority of the comments praised the system’s design and clinical usefulness. Other statements proposed improvements to some aspects of the system design, but there were no repetitions, implying perhaps, that these issues are mostly a matter of personal preferences and the case mix of each surgeon.

Table 2: Experienced surgeons’ rating statements Strongly Agree Agree Fabricating of NaviStents is easy.

****

***

NaviStent provides adequate stability and retention.

**** ***

*** ****

The planning function is intuitive and easy to use.

*****

**

Screen guidance is effective in directing my motions.

****

**

Navident did not interfere with my ability to drill and insert the implant.

****

***

Navident increases my confidence in the quality and safety of my implantations.

*****

Scanning with the NaviStent and CT-Marker is easy.

48 Implant practice

**

Neutral

*

Disagree

Strongly Disagree

One surgeon reported that in one case, navigation usage was aborted following a failed accuracy check. Subsequent investigation revealed that the inaccuracy was caused by modifications made by the surgeon, contrary to usage instructions to the jaw-tracking attachment, NaviStent, following the CBCT scan. This appears to indicate that, unlike with static guides, the accuracy of dynamic navigation systems can be assessed prior to performing any osteotomy, making them inherently safer to use.

Conclusions The results of this survey provide strong evidence supporting the following claims: • Navident is safe: Usage errors that may lead to incorrect guidance are rare and are caught by the accuracy check prior to drilling. • Navident is effective: It boosts surgeon’s confidence in the quality and safety of the implantations and enables flapless surgery with accuracy matching or surpassing that of static guides. • Navident is easy to use: Users are satisfied or very satisfied with all key aspects of Navident’s design. IP The Navident is currently undergoing 510(k) premarket review by the FDA. This information was provided by ClaroNav Inc.

Volume 9 Number 4


The Navident is currently undergoing 510(k) premarket review by the FDA.


PRACTICE DEVELOPMENT

Here’s the roadmap for taking your implant practice to “great” Jim Smyros of Affordable Care/Affordable Dentures & Implants shares discoveries from a decade of advising hundreds of clinicians

B

y now, you might have crossed the first great plateau of implant dentistry — simply adopting the trade. It’s neither easy nor cheap to develop and hone your clinical skills to the point of offering implants in your practice. But as you’ve probably discovered, more plateaus lie ahead. This is where true “implantologists” find their calling, and

discover the thrill of placing large volumes of implants consistently. Like any business challenge, it’s important to first identify the barriers between you and the implant practice you aspire to build. I have spent more than 10 years in implant manufacturing, distribution, and sales, helping dentists plot their roadmaps — and I still enjoy sharing that moment when a

Jim Smyros is Senior Director of Operations, implant services, for Affordable Care, the dental support organization affiliated with Affordable Dentures & Implants. A dental implant industry veteran, Smyros advises the network’s affiliated practice owners on nonclinical best practices for building and growing implant services. More than 230 affiliated practices in 39 states provide Affordable Dentures & Implants to thousands of patients seeking tooth replacement services. Prior to joining Affordable Care, Smyros most recently served as director of business development for Implant Direct Sybron International. He lives in Gilbert, Arizona, with his wife, Jill, and 5-year-old son, Ty. Visit careers.affordabledentures.com to learn about practice ownership and affiliation.

50 Implant practice

dentist discovers he/she has accomplished implant mastery. It’s a special feeling that should always motivate you. I am on call for most of the 230 Affordable Dentures & Implants practices across the United States every week in my role at dental support organization Affordable Care. It’s a unique vantage point that has shaped my perspective of how you can take an implant practice “from good to great,” to borrow Jim Collins’ famous quip. So, as you plot your own roadmap and begin to identify those barriers currently stopping your practice management improvement, you may find some of these anecdotes helpful.

Volume 9 Number 4


You FOCUS ON IMPLANTS. We’ll help with the rest. Imagine owning a practice without having to worry about the start-up expenses and business details… • 100% practice ownership • Industry-beating average income • Opportunities to pursue state-of-the-art training, including our Clinical Pathway for Excellence in Implantology • Access to the emerging technology like cone beam 3D imaging on-site • No nights or weekends

Discover 360° Support Call (800) 313-3863 or visit careers.affordabledentures.com


PRACTICE DEVELOPMENT 1. Pick one path, and pave it in stone. We’re taught to avoid tunnel vision, but many general practitioners struggle because their portfolio of services lacks focus. When you choose to also offer endodontics, orthodontics, veneers, whitening, and other capabilities, you’re forfeiting resources — and practice time — that might have otherwise been spent on building your implant skills and armamentarium serving this competency. Great implant dentists consider implantology their core competency. They are laser focused on it, and align all aspects of their business toward implants, from marketing to hiring. You won’t get to play at Yankee Stadium every day unless you’re wearing pinstripes, and good things happen when everyone under your roof is thinking about implants. This is the first point where your level of passion for implants can truly separate you from your peers. Is this really what you want to do? If so, commit 100% to the improvement of your clinical training and business investments.

2. Streamline the patient experience. We know implant fees can be exorbitant. Even patients earning high-income levels are apt to object to the high-ticket prices commonly seen with implants. If it is clinical consensus that implants are becoming the standard of care, then we need to re-evaluate margin and improve access to treatment. At Affordable Dentures & Implants, we talk about “democratizing the smile.” Practices benefit when middle- to lowincome patients can enjoy candidacy, too. Great practices streamline the experience in other ways. Think about the GP who tells a patient her tooth is blown, but then directs her to an oral surgeon, and after multiple trips to the chair, must return to the GP to seat the crown on a single-tooth implant. Why can’t that be done under one roof? This is what patients are asking. So, too, can the laboratory workflow shift the nature of the implant patient’s journey. It can be exhausting playing the waiting game with an outsourced lab — patients don’t want to hear that they have to wait on the U.S. Postal Service to get their bite correct. If it’s within your means, consider the benefits of folding lab operations into your practice. This has proven incredibly beneficial for patient satisfaction, but also for turnaround times — and margin. 52 Implant practice

Great implant practices are invested in making real improvement to the patient experience and delivering cases frequently and predictably.

This isn’t easy, and it’s one of the big reasons more implant dentists are choosing to affiliate with organizations like Affordable Dentures & Implants that can easily facilitate full-service labs. The number of removable technicians is dwindling, and so the value of an experienced lab tech is growing. If operating your own lab is simply not feasible, affiliating with a dental support organization or simply partnering with a lab in close proximity to your practice might help.

3. Use edentulous real estate as your yardstick. I’ll let you in on one of the secrets behind the success our affiliates have enjoyed. They simply have more opportunities to learn thanks to what we call edentulous real estate. For more than 40 years, a significant percentage of patients who have visited Affordable Dentures & Implants practices are in need of one or both full arches. While single tooth cases can be very lucrative for some, full arch restorations mean accelerated growth in implant unit volume. What will that do for your practice? For starters, full arches are margin-friendly; one patient electing several units, plus a final overdenture, will boost your average ticket. You also will reap the benefit of getting better through repetition of placing a great number of implants. Coincidentally, these patients typically report more satisfaction than a single-tooth implant or bridge. It’s simple: With full-arch restorations, you’re influencing function.

Think about how motivated you feel when your patients are so happy, they’re moved to tears. That kind of thing happens every single day in our affiliated practices. So, do things that make you feel good! Our affiliates often place large implant orders with BioHorizons®, one of the more popular implant manufacturers within our network. The Affordable Dentures & Implants business model in implantology creates a very competitive landscape for the manufacturers. This allows an implant business to push cost away from the space and offer the patient a fair and reasonable fee for service while maintaining a healthy margin. It is not uncommon for our affiliates to average 50 or more implants placed on a monthly basis. Serving tooth replacement with implants is what our centers do. Reaching these volumes in implants placed is much more attainable when your primary patients need full-mouth restorations. High volume of these procedures creates highly skilled clinicians. Great implant practices define a formula and then doggedly pursue it out of a passion for getting better. They’re invested in making real improvement to the patient experience and delivering cases frequently and predictably. Implant dentistry in this form is most enjoyable for all parties involved — patients win by receiving a cost-effective and positive clinical experience that impacts their lives for the better, and dentists and staff thrive in their business while appreciating a service so positively impactful for those they serve. IP

Aspects of a successful implant practice 1. Pick one path, and pave it in stone. 2. Streamline the patient experience. 3. Use edentulous real estate as your yardstick.

Volume 9 Number 4


THE cutting-edge dental lab FOR ALL YOUR CUSTOM NEEDS.

THE NExt EVOLUTION in ZIRCONIA p r o s m i l es d e n ta l st ud i o.c o m


ON THE HORIZON

It all starts with surgery Dr. Justin Moody offers tips on oral surgery in preparation for implants

P

eople often ask me how much harder implant surgery is than oral surgery, and my answer is, It’s all really very similar. If you can remove a tooth, you can place a dental implant! The keys to oral surgery are fairly simple, and when you follow good surgical protocols, the procedures become efficient and predictable. Access and visualization have always been key to good oral surgery; you can’t do quality work in the dark. Being able to visually see the site, whether it’s taking a tooth out, grafting a site, or placing an implant, is of the utmost importance. If you can remove teeth, you can place dental implants — it’s that simple. There is always an unknown with the extraction of teeth, curved roots, ankylosed teeth, or endodontically treated brittle teeth, for example. Dental implants do not have those issues. As a matter of fact, the whole process is much kinder to the patient both during and after the procedure. Flap design and soft tissue maintenance is becoming the most important part of my

Figure 1: Extractions and ridge alveoloplasty for implant placement

Figure 3: Placement of a BioHorizons® Tapered Plus dental implant

Figure 5: Extraction and grafting using BioHorizons’ Mem-Lok® collagen membrane and MinerOss® allograft 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®.

54 Implant practice

procedures as the final cosmetic and longterm esthetic outcomes are directly dependent upon bone maintenance and tissue management. Creating flaps that have releasing incisions away from the surgical site, broad bases for good blood flow, and clean incisions significantly reduce the risk of complications. With the increased use of cone beam CT in dentistry, we can start to move away from large flaps and look for anatomical structures such as the mental

Figure 2: Alveoloplasty of a knife ridge

Figure 4: Osteotomy for implant placement using the BioHorizons surgical drills

Figure 6: Cross-section slice of mandible using the Carestream 8100

foramen. The idea of working smarter, not harder, has taken on a whole new meaning. Thankfully, today’s oral surgery is far less invasive, safer for the patient, and easier on the dentist. When implemented into the general dentistry practice, I find that the patient satisfaction is greatly increased from the decreased number of visits, and it’s good for revenue too! So get out there, and refresh your surgical skills by finding a good CE course or program — you won’t regret it! IP Volume 9 Number 4


multi-unit abutments simple. flexible. smart.

full arch solutions for every scenario Your patients are unique, shouldn’t your treatment plans be as well? The BioHorizons Multi-unit abutment system provides the tools to restore even compromised edentulous cases. With a wide variety of abutment angles, collar heights and platform diameters, no system better equips you to plan for your patients’ individual needs. The abutment’s intelligent design and restorative flexibility is matched only by its ease of use and surgical efficiency. The Multi-unit abutment system will provide your patients with secure, beautiful smiles.

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

Made in the USA

SPMP14072 REV C JUN 2015


PRODUCT PROFILE

Laschal® flexible, fracture-resistant periotomes Micro-serrated for simple and efficient separation of the periodontal ligament. Coated with titanium for greater hardness and longer service life.

T

he new, flexible periotomes by Laschal® offer a new dimension to the function and safety of severing the periodontal ligament in preparation for extraction. Made of flexibly resilient stainless steel, serrated, and engineered with varying positions of “stress relief,” two distinct sets of periotomes are offered. The MSP-1F and MSP-2F have ranges of motion of 6+ degrees, and the MSP-1XXF and MSP-2XXF have ranges of motion of 10+ degrees. Both sets are highly resistant to spontaneous fracture and provide different features and benefits. The MSP-1F and MSP-2F provide the stiffness needed in situations that require strength, while the MSP-1XXF and MSP-2XXF provide the flexibility necessary to follow

root surface curvatures during operation and even help to locate the most efficient path of insertion.

MSP-1F / MSP-2F Moderate flexibility — provides the safety of fracture resistance with the rigidity needed

See the new periotomes at the AAP annual meeting, Booth No. 2006, and at the Pikos Symposium. IP

MSP-1XXF / MSP-2XXF Greater flexibility — with stress relief provides maximal flexibility with limited rigidity This information was provided by Laschal®.

56 Implant practice

Volume 9 Number 4


Scheduling Simplified Get more appointments in less time

Online scheduling

Patients can schedule an appointment with you anytime

Call: 415.749.1444 Visit: RecordLinc.com

PATIENT PORTAL

REFERRALS

SCHEDULING

INTEGRATION

MESSAGING

eFORMS


Introducing TM

simply the smarter case approach

This new versatile system enables you to easily tailor case treatment and coordinate with restorative partners. Simply pair a mount-free implant with one of the treatment-specific prosthetic SMART PACKS. Both the implant and SMART PACK include the necessary components for that treatment phase – which means you not only know treatment costs upfront but can also practice more efficiently. Choose the smarter case approach. TAKE BACK YOUR TIME Order by case, not component so you can focus on the dentistry

ELIMINATE SURPRISES Know your costs upfront by having all the components – the right components – at the start

AVOID CONFUSION Have all your components conveniently in one place for easy team communication & coordination

Legacy™ Internal Hex Connection Compatible with Zimmer, BioHorizons®, MIS®1

SMART PACK Mount-free Implant

InterActive™ 12° Conical Hex Connection Compatible with NobelActive™1

Start transforming your practice. Call to ask about the special INTRO OFFER!

RePlant® & ReActive® Internal Tri-Lobe Connection Compatible with NobelReplace™

simply crown & bridge

simply fixed

simply removable

simply digital

simply à la carte

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 September June 30, 2016. 30, 2016. All trademarks All trademarks are property are property of their of respective their respective companies. companies.

Implant Practice US August September 2016 Vol 9 No 4  
Implant Practice US August September 2016 Vol 9 No 4