DENTAL LEARNING 3i (WEB).pdf · seven clinical trials, ˚nding insuf˚cient evidence favoring...

Knowledge for Clinical Practice

WWW.DENTALLEARNING.NET

A PEER-REVIEWED PUBLICATIONA PEER-REVIEWED PUBLICATION

DENTAL LEARNINGVOLUME 2 | ISSUE 5

INSIDEEarn 2

CECredits

Written fordentists, hygienists

and assistants

Harold S. Baumgarten, DMD, Alan M. Meltzer, DMD, MScD, Lee R. Walker, MD, DMD, Robert A. del Castillo, DMD, Ernesto A. Lee, DMD — Page 2

Advances in Implant Therapy: Immediate Implant Placement and Restoration

2

EDUCATIONAL OBJECTIVES

The overall goal of this course is to provide the reader with informa-tion on immediate implant placement and restoration at extraction sites. On completion of this course, participants will be able to:

1. Describe the rationale for immediate implant placement and restoration.

2. Review the survival and success rates of immediate implant placement.

3. List and describe the factors involved in achieving excellent results in the anterior esthetic zone.

4. Review the in� uence of implant design and adjunctive restor-ative and surgical components on short- and long-term func-tional and esthetic success.

SPONSOR/PROVIDER: This is a Dental Learning, LLC continuing education activity. COMMERCIAL SUPPORTER: This course has been made possible through an unrestricted educational grant from BIOMET 3i. DESIGNATION STATE-MENTS: Dental Learning, LLC is an ADA CERP recognized provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Dental Learning, LLC designates this activity for 2 CE credits. Dental Learning, LLC is also designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by AGD for Fellowship, Mastership, and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 2/1/2012 - 1/31/2016. Provider ID: # 346890. Dental Learning, LLC is a Dental Board of California CE provider. The California Provider number is RP5062. This course meets the Dental Board of California’s requirements for 2 units of continuing education. EDUCATIONAL METHODS: This course is a self-instructional journal and web activity. Information shared in this course is based on current information and evidence. REGISTRATION: The cost of this CE course is $29.00 for 2 CE credits. PUBLICATION DATE: September, 2013. EXPIRATION DATE: August, 2016. REQUIREMENTS FOR SUCCESSFUL COMPLETION: To obtain 2 CE credits for this educational activity, participants must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%. AUTHENTICITY STATEMENT: The images in this course have not been altered. SCIENTIFIC INTEGRITY STATEMENT: Information shared in this continuing education activity is developed from clinical research and represents the most cur-rent information available from evidence-based dentistry. KNOWN BENEFITS AND LIMITATIONS: Information in this continuing education activity is derived from data and information obtained from the reference section. EDUCATIONAL DISCLAIMER: Completing a single continuing education course does not provide enough information to result in the participant being an expert in the � eld related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. PROVIDER DISCLOSURE: Dental Learning does not have a leadership position or a commercial interest in any products that are mentioned in this article. No manufacturer or third party has had any input into the development of course content. CE PLANNER DISCLOSURE: The planner of this course, Tricia Branch, does not have a leadership or commercial interest in any products or services discussed in this educational activity. She can be reached at [email protected]. TARGET AUDIENCE: This course was written for dentists, dental hygienists, and assistants, from novice to skilled. CANCELLATION/REFUND POLICY: Any participant who is not 100% satis� ed with this course can request a full refund by contacting Dental Learning, LLC, in writing. Go Green, Go Online to www.dentallearning.net take your course. Please direct all questions pertaining to Dental Learning, LLC or the administration of this course to [email protected].

Immediate implant placement and provisional restoration serve to provide shorter treatment times than alternative protocols do and are intended to preserve alveolar bone as well as to develop and preserve the adjacent soft-tissue architecture. Success and survival rates for immediately placed implants are comparable to those for early and delayed placement implants. In the anterior esthetic zone in particular, great care and planning must precede immediate im-plant placement. With respect to esthetics, preservation of crestal bone and a natural-looking soft-tissue architecture are essential. Considerations include implant design, the implant-abutment interface, the patient’s biotype, the buccal bone plate and crestal bone position, and positioning of the implant.

ABSTRACT


Introduction

Since the beginnings of modern dentistry in the late 1700s, much has changed, and with respect to modern implant dentistry, rapid change has occurred since its

beginnings around three decades ago. The � rst root-form endosseous implants were constructed of smooth surface titanium, and early protocols required 2-stage surgery with the implants submerged during osseointegration, then exposed and subsequently restored. The rationale for this lengthy, multi-phase treatment was to leave the implant undisturbed to allow for osseointegration with no risk of loading or exposure to oral bacteria, in the belief that this would negatively impact clinical outcomes. Over time, more sophisticated implant designs and treatment protocols were developed. Currently, protocols include immediate, early, and delayed implant placement depending on the clinical situation, as well as immediate and delayed loading.

Integrated Media Solutions/Dental Learning LLC is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Integrated Media Solutions/Dental Learning LLC designates this activity for 2 continuing education credits.

Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement.2/1/2012 - 1/31/2016 Provider ID: # 346890AGD Subject Codes: 690, 691

ABOUT THE AUTHORSHarold S. Baumgarten, DMDDr. Harold Baumgarten is a Clinical Professor with the Department of Periodontics at the University of Pennsylvania. He maintains a private practice in Philadelphia, PA.

Alan M. Meltzer, DMD, MScDDr. Alan Meltzer maintains a private practice in the Greater Philadelphia area, where he specializes in periodontics.

Lee R. Walker, MD, DMDDr. Lee Walker maintains a practice limited to oral and maxillofacial surgery in Los Gatos, CA, and lectures on dental implants and reconstruc-tive surgery.

Robert A. del Castillo, DMDDr. Robert del Castillo maintains a practice limited to periodontics, with an emphasis on implantology and regenerative therapies. Dr. del Castillo is an Adjunct Professor in the Department of Periodontics at Tufts University.

Ernesto A. Lee, DMDDr. Ernesto Lee maintains a practice limited to periodontics and prosth-odontics in Bryn Mawr, PA.

Disclaimer: The authors of this course are speakers and clinical consul-tants for BIOMET 3i.


3September 2013

Extraction Socket Healing and Bone ResorptionBiologically, without socket preservation or placement of

an implant, healing of extraction sites is accompanied by sig-ni�cant vertical and horizontal bone resorption.1 Schropp et al determined in their study of bone healing that approximately 50% of the ridge width is lost in the �rst year post-extraction, mainly buccally, and the majority of this within the �rst 3 months; ridge height is also reduced.2 Systematic reviews have led to the conclusion that a mean horizontal bone loss (loss of ridge width) of 3.8 mm and a loss of 1.24 mm in vertical bone height can be anticipated at extraction sites in the six months following tooth extraction.3

Ridge preservation using mineralized particulate xeno-grafts has been shown in some studies to reduce the vertical and horizontal bone loss at extraction sites.1,4 Statistically sig-ni�cant differences in bone resorption were found in a study using bovine bone, with a horizontal bone loss of on average 1.04 mm vs 4.48 mm for ungrafted sites at 4 months post-extraction, and vertical bone loss of 0.46 mm vs 1.54 mm.1

The Rationale for Immediate Implant Placement One of the rationales for immediate implant placement

and provisional restoration is preservation of the alveolar bone and adjacent soft-tissue architecture following tooth extraction, together with the achievement of an outcome that is both functional and esthetic. Other objectives include shorter and less invasive treatment. Immediate implant placement should not be performed at sites with non-intact buccal bone plates.

Survival and Success Rates with Immediate Implant Placement and Restoration

High survival and success rates can be achieved with immediate implant placement. In 2008, den Hartog et al re-ported on a review of 19 studies, �nding an overall survival rate after 1 year of 95.5%, with no statistically signi�cant differences for immediate, early or delayed implant place-ment.5 A Cochrane review conducted in 2010 analyzed seven clinical trials, �nding insuf�cient evidence favoring immediate, immediate-delayed, or delayed implant place-

ment, while noting that the risk of complications might be higher with immediate implant placement but also that esthetic outcomes might be better.6

Immediate provisional restoration, as well as immedi-ate, early, or delayed loading, are also currently performed, with one meta-analysis �nding similar success rates and outcomes for all three loading protocols.7 Grütter et al reported an implant survival rate of 96.7% in a study with 1-5 years of follow-up of immediate implants placed in the anterior esthetic zone that were provisionally restored and not loaded, and implants that were conventionally loaded.8

Individual studies have also supported the use of immediate and early loading, with success rates for immediate load-ing of up to over 99% reported for single and multi-unit implant-supported restorations.9 In one study in patients ages 16.5-80.4 years (n=195), implants and immediately loaded prostheses were placed, with an overall success rate of 96.7%.10 Gillot et al found no signi�cant differences in the survival rates for immediately placed, immediately loaded implants (n=352) as compared with delayed place-ment, immediately loaded implants (n=323) in a study of 113 patients receiving cross-arch maxillary �xed prosthe-ses. At six months, the overall implant survival rate was 99.1% with no signi�cant differences between immediate placement and delayed placement of the implants.11 A small study by Barbier et al found an implant survival rate of 100% with immediate placement, immediate loading of im-plants supporting �xed prostheses.12 In a systematic review, the 1-year-in-function survival rate for the 15 studies that had included survival data (509 implants in 499 patients) was 95.5%, with no differences between immediate and de-layed implant placement or between immediate and delayed loading. For implants with >1 year in function, the survival rate for immediate placement, immediate loading implants was 97.5% vs 92.4% for delayed placement, immediate loading implants (P<0.05).13

Recently, a prospective clinical study was conducted by Östman et al to assess the one-year cumulative survival and success rates for 102 immediately loaded, platform-switched implants supporting �xed prostheses in 35

DENTAL LEARNING www.dentallearning.net

4 VOLUME 2 | ISSUE 5

patients. A cumulative survival rate of 99.2% was found.14

In addition to high survival and success rates, esthetic results must also be considered, especially in the anterior esthetic zone.

Anterior Zone Esthetic RequirementsEsthetic demands are highest in the anterior esthetic

zone, necessitating great care and planning. The adjacent anatomy and teeth (if present) must permit placement of the implant in such a manner as to achieve good outcomes both functionally and esthetically. The ultimate hard tissue and gingival architecture achieved is of particular concern in the anterior esthetic zone, since even a moderate amount of mucosal recession following implant placement or lack of a papillary structure can signi�cantly compromise esthetics and result in dissatisfaction. Based upon a review of publications assessing recession following immediate placement of single implants, up to 27% of cases resulted in recession of >1 mm while a lesser amount of recession was described in the majority of reports.15 In a review of 91 studies of at least 1-year duration and a minimum of 10 patients, risk factors for mucosal recession at the facial margin included malpositioning of the implant, a thin biotype, and a thin (or non-intact) buccal bone plate.16 The patient’s soft-tissue biotype, crestal bone level, buccal bone plate thickness, available mesio-distal space and biologic width must all be considered.

Crestal Bone PositionThe position of the crestal bone in the most apical por-

tion of the crown of the tooth to be extracted (ie, at the zenith) and the distance from the bone to the contact point must be determined prior to implant treatment. In cases where the zenith bone level is ≤3 mm, less recession can be anticipated. If the distance from the contact point is ≤5 mm, excellent papillary architecture is achievable (Fig. 1). However, in other cases, the dreaded black triangle may be present due to an absence of papillary architec-ture.17,18 Care must be taken to optimize implant and con-tact point positioning for esthetic soft-tissue results.19

Mesio-distal SpaceSuf�cient space must be present between adjacent im-

plants, or between an implant and an adjacent tooth, for papillary regeneration to be possible.20 If insuf�cient space is present, it was determined in one study that the inter-implant papilla will be absent with corresponding compromised es-thetics.18 Inadequate inter-implant space has also been found to be a determinant for increased crestal bone loss.21

Biotype: Thick vs ThinAn esthetic and natural-looking peri-implant soft-tissue

architecture is more predictable and easier to achieve in patients with a thick biotype and a �at gingival contour as compared to patients with a thin and scalloped biotype who are more likely to experience mucosal recession. A thicker biotype has also been found recently to be indicative of a thicker buccal bone plate.22

Buccal Bone Plate ThicknessBuccal plate thickness at the time of extraction in�uences

horizontal and vertical loss of alveolar bone.23 Further-more, in and of itself, immediate implant placement does not prevent buccal bone plate resorption.24 The thickness of the buccal bone crest at the time of immediate implant placement and the width of the horizontal gap between the implant and the buccal bone plate are signi�cant factors for ridge resorption. Sites with thicker buccal bone (>1 mm), and where the horizontal gap is >1 mm and well-�lled, ex-perience less ridge resorption.25 In addition, Artzi et al also found statistically signi�cantly lower crestal bone resorp-tion at immediate implant sites vs implants placed in healed sockets, with provisional restoration occurring at the time of implant placement. At six months, crestal bone resorp-tion for immediately placed implants and implants placed in healed sockets was an average of 0.18 mm and 0.31 mm, respectively, and 0.79 mm and 1.1 mm, respectively, at three years (P <0.05).26

Caiazzo et al reported on augmentation with the bone graft material placed in a soft-tissue pouch created on the external aspect of the buccal bone plate. This was found


5September 2013

to help preserve or increase the buccal bone plate width and reduce the risk of recession.27 In the anterior esthetic zone, a thin buccal bone plate results in soft-tissue reces-sion and poor esthetic outcomes (Table 1).27

Appropriately selecting patients and following a strict protocol is important for preserving buccal bone plate dimensions.28 Buccal bone plates of at least 2 mm in width, atraumatic extraction, and palatal/lingual immediate implant placement have been found to minimize loss of buccal plate bone and the associated sequelae, as have ridge preserva-tion and placement of bone grafting material around the gap between the implant and the osteotomy-extraction site.24,29,30

The In�uence of Implant System Design on Short- and Long-term Results

Implant design, and that of adjunctive and restor-ative components, can in�uence the success of implant treatment both short- and long-term. Primary stability, osseointegration, esthetic and functional results, and the potential for peri-implantitis, can all be in�uenced by implant system design (Table 2).

Primary StabilityPrimary stability requires excellent bone-to-implant

contact at the time of implant placement and is essential to resist micromotion and for subsequent osseointegra-tion.31,32,33 Factors in�uencing this include the bone density and quality, the morphology and surface characteristics of the implant, and surgical technique. Higher bone density favors greater primary stability, with the least dense bone typically found in the posterior maxilla.34 The surgical pro-tocol must include use of matching-size bone drills for the implant being placed, with the diameter of the drill result-ing in an osteotomy matching the minor diameter of the implant (ie, the diameter of the implant not including any threads or �ns). Excessive removal of bone during creation of the osteotomy site must be avoided so that an intimate initial contact can be achieved between the implant surface and the adjacent bone.35 It has also been shown that a self-cutting implant design with lateral threads that enter the bone result in moderate compression of the bone adjacent to the osteotomy site, which may enhance primary implant stability prior to osseointegration.36

Östman et al reported on a prospective clinical trial involving placement of 139 tapered implants with a microroughened topography and lateral threads. Their �ndings included a high degree of primary stability and a survival rate of 99.2%. The initial stability quotient (ISQ) was 73.3, more than the ISQ of 65 that is considered to be adequate for immediate loading of implants.37 In a separate study, immediate implant placement using the same implant design resulted in ISQs of 73 and 77 for the maxilla and mandible respectively.38

TABLE 1. Considerations Impacting Esthetics

Natural soft-tissue architecture

Regeneration of papillae

Suitable emergence pro�le for function and esthetics

Adequate bone height, width and volume

Buccal bone plate width

Inter-implant or implant-tooth distance

Position of bone at zenith

Position of contact point

Figure 1. Crestal bone position and contact points

≤5 mm

≤3 mm



Osseointegration and Implant SurfacesDuring the healing process, osseointegration results in

long-term (secondary or biologic) stability, and involves the growth of bone onto the implant surface and particularly into rough implant surfaces.

The surface topographies of rough implant surfaces result in an increase in the surface area available for osseo-integration, and are known to positively in�uence osseoin-duction and the precursors of bone growth.39 Such surfaces have also been shown to result in higher torque removal val-ues and improved long-term stability, including at compro-mised sites, as compared to smooth surfaces.40,41,42 Designs in recent years have included: sand-blasted etched surfaces; oxidized surfaces; blasted and �uoride-etched surfaces; and surfaces with hydroxyapatite deposition.43

One recent implant includes a hybrid design with a machine-turned implant neck and dual acid-etched over the body of the implant with micron-level etching superimposed on an etched surface. Another implant recently introduced has three different surface topographies including a dual acid-etched surface with the same micron-level etched sur-face over another microroughened suface extending over the implant neck and with a rougher surface also on the more apical portion of the implant surface.

A recent randomized-controlled prospective study investigating 137 implants demonstrated the higher level of osseointegration and increased torque removal force in implants with a multi-topography surface roughened at the micron level.44 Baldi et al also found that these fully etched implants resulted in statistically signi�cantly less crestal bone resorption than did implants with a turned neck sur-face (0.6 mm vs 1.5 mm).45

Implant Surfaces and Peri-Implantitis Historically, there have been concerns related to the

incidence of peri-implantitis adjacent to rough-surface implants, where recession and bone loss around a smooth machined implant neck has resulted in exposure of the rough-surface implant body.46 However, recent studies on implants with more microscopically roughened surfaces

found a different result. While minimally roughened (eg, etched) surfaces are biologically compatible, surfaces that are much rougher are more likely to be associated with peri-implantitis when exposed.47 A microscopically-rough-ened surface with additional pitting on the already rough-ened surface, obtained by dual-acid etching of the implant surface, and still with a smooth titanium neck, was found to result in less peri-implant tissue complications and to have survival rates of up to over 99%.48-51 Implants that are dual acid-etched and also fully etched at the neck of the implant have also been studied. A study published in 2009 (Baldi et al) reported on 1-year results of fully etched implants, �nding reduced crestal bone loss as compared to implants with a smooth neck.45

A prospective, randomized, controlled 5-year study evaluated the incidence of peri-implantitis in implants with a dual acid-etched surface that were fully etched coronally and compared these to implants with a smooth coronal surface. No differences were found in the incidence of peri-implantitis, con�rming that implant necks with a fully etched, microroughened topography are a safe and effective option.52

Most recently, one implant design includes an implant neck with dual acid-etched surfaces over a minimally rough surface, while the more apical body of the implant includes coarser roughness as well and results in a triple-level surface. Studies have demonstrated that this design results in increased bone in-growth and greater torque removal force, while the fully etched neck is proven to reduce crestal bone loss.52-55

The Implant-Abutment InterfaceThe design of the implant-abutment interface is a statisti-

cally signi�cant factor in implant success rates.56 In a study assessing immediately loaded implants in premolar sites, buccal bone changes were observed with CBCT scans one year postoperatively, with more width loss at the level of the implant-abutment interface as compared to the mid-implant or the apical region of the implant.57 Horizontal buccal bone resorption was found to be greatest at the level of the


7September 2013

implant platform in a study assessing resorption at 1-year using CBCT scans,58 underscoring the importance of the platform and interface.

While historically implant-abutment interface designs were based on platforms with the same diameters, more recent studies have demonstrated that use of platforms of different diameters (platform-switching) results in preserva-tion of crestal bone height levels and was also described in a recent systematic review of ten studies with 1,238 implants. The conclusion from this review was that platform-switch-ing resulted in signi�cantly less crestal bone loss than with platform-matched implants.59

Thus, platform-switching designs now expressly in-corporate abutments with a narrower diameter than the diameter of the implant at the implant-abutment inter-face.60 The successful use of platform-switching was shown to be statistically signi�cant at the 1-year follow-up in one

study and to result in a vertical bone loss of 0.01 mm vs 0.42 mm using a standard platform design (ie, without platform-switching).61 Platform-switching is believed to permit tissue-forming to occur inwards towards the implant and with a greater surface distance, resulting in a well-sealed biologic width between the oral environment and the peri-implant bone before crestal bone loss can occur.62,63

Poorly sealed interfaces result in greater bacterial colonization, microleakage, and greater potential for peri-implantitis. A stable and tightly-engineered implant/abutment connection results in reduced micromotion and leakage. An implant-abutment connection with a positive seating design together with a connection with very narrow tolerances, results in avoidance of seating errors and an intimate, stable relationship between the implant and the abutment.64,65

Immediate Provisionalization and Abutment DesignImmediate provisional restoration preserves the mucosal

level and reduces the risk of midfacial recession. Following immediate implant placement, the emergence pro�le of the abutment used for the provisional restoration is critical — if too much pressure is placed on the peri-implant tissues and crestal bone, an increased level of bone resorption is ob-served, which in turn reduces the ability of the peri-implant tissue to increase in volume. Using a single-stage technique minimizes trauma, and immediate provisional restoration when performed properly provides for soft-tissue sculpting starting from the day of implant placement and results in excellent esthetics.

From the patient’s perspective, the ability to immediately provide an esthetic provisional restoration is an important factor in case acceptance and patient satisfaction, especially in the anterior esthetic zone. The case presented here dem-onstrates immediate implant placement with microrough-ened implants possessing three levels of surface roughness and built-in platform switching, for immediate implant placement and provisional restoration and the highly esthetic long-term results that are obtained.

TABLE 2. The In�uence of Design and Other Factors

Primary Stability Surgical technique

Matching drill sizes

Bone density and quality

Palatal positioning of implant

Self-cutting implant design

Osseointegration Primary stability

Microroughened topography

Rough surface implant

Crestal Bone Preservation Positioning of implant

Bone grafting

Implant design

Abutment emergence pro�le

Provisional restoration contours

Platform/platform-switching

Implant-abutment seal



Case Presentation – Immediate Implant Placement in the Anterior Esthetic Zone

The patient presented with failing central incisors, complaining of some mobility of one of the two crowns, bleeding at the gingival margin of one, and discomfort. On examination, the endodontically-treated central incisors were found to have unsalvageable restorations with caries extending below the bone level (Figs. 2a, 2b, 3). Following discussion with the patient, the decision was made to remove the central incisor roots and to place implant-supported restorations. The patient was concerned about not having teeth or having to wear a removable partial denture and was pleased to discover she was a candidate for immediate implant placement and provisional restoration. Bone sounding, together with an assessment of the patient’s biotype and bone adequacy including thickness of the buccal bone plate, were made. The patient’s biotype was favorable, both thick and with a �at pro�le, and suf�cient width of buccal bone plate was present.

At the surgical appointment, �apless atraumatic extractions were performed, taking care to preserve all socket walls and the integrity of the buccal plate. The implants selected were 3i T3® Tapered Implants (BIOMET 3i) and have dual acid-etched microrough-ened collars, while the implant body has three levels of surface roughness consisting of a moderately rough sur-face, overlaid with 1-3 micron pitting on top of which a submicron layer exists, to enhance osseointegration and to help preserve crestal bone levels. The implants were 13 mm in length, with a 4 mm diameter and a 3.4 mm diameter restorative seating surface.

The osteotomy sites were prepared with the implant system’s matching-size drills, parallel to the palatal walls such that the osteotomies were more palatal than the origi-nal root positions. Depth/direction indicators were used to ascertain the depth and positioning of the implants that would be placed (Fig. 4). The implants were then placed in the osteotomy sites with achievement of excellent primary stability (Fig. 5), and bovine xenografts were placed in

Figure 3. Radiograph of central incisors

Figure 2b. Clinical presentation of central incisors

Figure 2a. Clinical presentation of central incisor crowns


9September 2013

the gap between the implants and the bone plates to aid bone regeneration (Fig. 6). The lateral threads of these implants aid primary stability, as does placing the implants more palatally. The relatively palatal placement also cre-ates space for internal bone grafting against the buccal bone plate and helps to preserve adequate buccal bone width, without which mucosal recession would be likely. Xenografts are known to resorb more slowly than either autografts or allografts (in addition to avoiding the trauma and potential morbidity associated with autografts), and as such, provide for a more durable scaffold while bone regeneration takes place. Postoperative radiographs were taken of the implants.

Next, 3.4 mm diameter non-hexed provisional cyl-inders were inserted and screw-retained to the implants with abutment screws (Fig. 7). Platform-switching helps to preserve crestal bone levels and soft-tissue stability. The customized splinted provisional restorations were then placed over the cylinders, the heights of the cyl-inders were adjusted, the spaces between the cylinders and the provisional restorations were �lled with resin material, and the provisional restorations were secured (Figs. 8, 9).

The patient returned four months later to her general dentist for placement of the de�nitive restorations. Tissue healing had been checked at the 2-week postoperative ap-pointment and in the interim. The end result was a soft-tissue peri-implant architecture that was well-sculpted and would provide for a natural-looking appearance provided it was properly maintained (Fig. 10).

Composite resin was utilized to fabricate customized impression copings to record the soft-tissue pro�le (Fig. 11). After making the de�nitive impression, it was used to create a soft-tissue model that replicated the soft-tissue contours (Figs. 12-13).

At the time of restoration delivery, zirconia abutments were placed on the implants. Using abutments with a �at or parallel emergence pro�le (vs �ared abutments) provides a contour that supports the soft tissue and optimizes esthetic results.66

Figure 5. Implants placed towards the palatal wall

Figure 6. Placement of bovine xenografts

Figure 4. Incisal view of depth/direction indicators



Figure 9. Post-operative view of completed provisional restoration

Figure 8. Placement of provisional restoration

Figure 10. Peri-implant soft tissues Figure 7. Provisional cylinders in position

Figure 12. De�nitive impression with impression copings- composites picked-up in the impression

Figure 11. Placement of impression copings with composite resin added to maintain soft-tissue form during impression-making


11September 2013

Figure 15. De�nitive restorations

The abutment screw used with this implant design (Gold-Tite® Abutment Screw, BIOMET 3i) possesses a microscopic soft gold coating that behaves as a solid lubricant. This mini-mizes friction and allows for greater pre-load with the same amount of torque, increasing seal integrity.67 The de�nitive esthetic restorations were then cemented over the abutments (Figs. 13-14). The occlusion was checked to ensure that there were no occlusal interferences.

The end result was highly esthetic restorations with excellent emergence profiles, papillae and soft-tissue architecture, and a very satisfied patient (Fig. 15).

SummaryUsing implants with microroughened surfaces, buc-

cal bone grafts and platform-switching has been shown to aid osseointegration and the preservation of hard and soft peri-implant tissues. This results in excellent short- and long-term results with preservation of the crestal bone and soft-tissue architecture. The ability to provide patients with immediate implants and provisional restorations at the time of extraction has signi�cantly expanded treatment options, shortened treatment times, provided for less-invasive treat-ment, and results in patient satisfaction.

Figure 14. Radiograph following placement of abutments

Figure 13. Zirconia abutments



References1. Cardaropoli D, Tamagnone L, Roffredo A, Gaveglio L, Cardaropoli G. Socket preservation using bovine bone mineral and collagen membrane: a randomized controlled clinical trial with histologic analysis. Int J Perio Restor Dent. 2012;32(4):421-30.

2. Schropp L, Wenzel A, Kostopoulos L, Karring T. Bone healing and soft tissue contour changes following single-tooth extraction: a clini-cal and radiographic 12-month prospective study. Int J Perio Restor Dent. 2003;23(4):313-23.

3. Hämmerle CH, Araújo MG, Simion M; Osteology Consensus Group 2011. Evidence-based knowledge on the biology and treatment of extraction sockets. Clin Oral Implants Res. 2012;23 Suppl 5:80-82.

4. Barone A, Aldini NN, Fini M, Giardino R, Calvo Guirado JL, Covani U. Xenograft versus extraction alone for ridge preservation after tooth removal: a clinical and histomorphometric study. J Periodontol. 2008;79(8):1370-1377.

5. den Hartog L, Slater JJ, Vissink A, Meijer HJ, Raghoebar GM. Treatment outcome of immediate, early and conventional single-tooth implants in the aesthetic zone: a systematic review to survival, bone level, soft-tissue, aesthetics and patient satisfaction. J Clin Periodontol. 2008;35(12):1073-1086.

6. Esposito M, Grusovin MG, Polyzos IP, Felice P, Worthington HV. Timing of implant placement after tooth extraction: immediate, immediate-delayed or delayed implants? A Cochrane systematic review. Eur J Oral Implantol. 2010;3(3):189-205.

7. Hunter P. Limited evidence for evaluating differences in marginal bone loss between conventional, early and immediate loading pro-tocols for mandibular two-implant overdentures. J Am Dent Assoc. 2011;142:427-428.

8. Grütter L, Belser UC. Implant loading protocols for the partially eden-tulous esthetic zone. Int J Oral Maxillofac Impl. 2009;24(Suppl):169-179.

9. Nelson K, Semper W, Hildebrand D, Özyuvaci H. A retrospective analysis of sandblasted, acid-etched implants with reduced healing times with an observation period of up to 5 years. Int J Oral Maxillo-fac Impl. 2008;23(4):726-732.

10. Kopp S, Behrend D, Kundt G, Ottl P, Frerich B, Warkentin M. Den-tal implants and immediate loading: Multivariate analysis of success factors. Rev Stomatol Chir Maxillofac Chir Orale. 2013;114(3):146-154.

11. Gillot L, Cannas B, Buti J, Noharet R. A retrospective cohort study of 113 patients rehabilitated with immediately loaded maxillary cross-arch fixed dental prostheses in combination with immediate implant placement. Eur J Oral Implantol. 2012;5(1):71-79.

12. Barbier L, Abeloos J, De Clercq C, Jacobs R. Peri-implant bone changes following tooth extraction, immediate placement and loading of implants in the edentulous maxilla. Clin Oral Investig. 2012;16(4):1061-1070.

13. Knoernschild KL. Early survival of single-tooth implants in the es-thetic zone may be predictable despite timing of implant placement or loading. J Evid Based Dent Pract. 2010;10(1):52-55.

14. Östman PO, Wennerberg A, Albrektsson T. Immediate occlu-sal loading of NanoTite PREVAIL Implants: A prospective one-year clinical and radiographic study. Clin Implant Dent Relat Res. 2010;12(1):39-47.

15. Cosyn J, Hooghe N, De Bruyn H. A systematic review on the frequency of advanced recession following single immediate implant treatment. J Clin Periodontol. 2012;39(6):582-589.

16. Chen ST, Buser D. Clinical and esthetic outcomes of implants placed in postextraction sites. Int J Oral Maxillofac Implants. 2009;24(Suppl):186-217.

17. Grunder U. Stability of the mucosal topography around single-tooth implants and adjacent teeth: 1-year results. Int J Perio Restor Dent. 2000;20(1):11-17.

18. Gastaldo J, Cury PR, Sendyk WR. Effect of the vertical and hori-zontal distances between adjacent implants and between a tooth and an implant on the incidence of interproximal papilla. J Periodon-tol. 2004;75:1242-1246.

19. Cosyn J, Sabzevar MM, De Bruyn H. Predictors of inter-proximal and midfacial recession following single implant treatment in the anterior maxilla: a multivariate analysis. J Clin Periodontol. 2012;39(9):895-903.

20. Degidi M, Novaes AB Jr, Nardi D, Piattelli A. Outcome analysis of immediately placed, immediately restored implants in the esthetic area: the clinical relevance of different interimplant distances. J Peri-odontol. 2008;79(6):1056-1061.

21. Tarnow DP, Cho SC, Wallace SS. The effect of inter-implant distance on the height of inter-implant bone crest. J Periodontol. 2000;71(4):546-549.

22. Cook DR, Mealey BL, Verrett RG, Mills MP, Noujeim ME, Lasho DJ et al. Relationship between clinical periodontal biotype and labial plate thickness: an in vivo study. Int J Perio Restor Dent. 2011;31(4):345-354.

23. Brownfield LA, Weltman RL. Ridge preservation with or without an osteoinductive allograft: a clinical, radiographic, micro-computed tomography, and histologic study evaluating dimensional changes


13September 2013

and new bone formation of the alveolar ridge. J Periodontol. 2012;83(5):581-589.

24. Viña-Almunia J, Candel-Martí ME, Cervera-Ballester J et al. Buc-cal bone crest dynamics after immediate implant placement and ridge preservation techniques: review of morphometric studies in animals. Impl Dent. 2013;22(2):155-160.

25. Ferrus J, Cecchinato D, Pjetursson EB, Lang NP, Sanz M, Lindhe J. Factors influencing ridge alterations following immediate implant placement into extraction sockets. Clin Oral Impl Res. 201021(1):22-

26. Artzi Z, Kohen J, Carmeli G, Karmon B, Lor A, Ormianer Z. The efficacy of full-arch immediately restored implant-supported recon-structions in extraction and healed sites: a 36-month retrospective evaluation. Int J Oral Maxillofac Impl. 2010;25(2):329-335.

27. Caiazzo A, Brugnami F, Mehra P. Buccal plate preservation with immediate post-extraction implant placement and provisionalization: preliminary results of a new technique. Int J Oral Maxillofac Surg. 2013;42(5):666-670.

28. Degidi M, Nardi D, Daprile G, Piattelli A. Buccal bone plate in the immediately placed and restored maxillary single implant: a 7-year retrospective study using computed tomography. Impl Dent. 2012;21(1):62-66.

29. Chu SJ, Salama MA, Salama H et al. 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.

30. Saadoun A, LeGall M, Touati B. Current trends in implantology: Part II – treatment Planning aesthetic considerations and tissue regeneration. PPAD. 2004;16(10):707-714.

31. Szmukler-Moncler S, Salama H, Reingewirtz Y, Dubruille JH. Timing of loading and effect of micro-motion on bone-implant interface. A review of experimental literature. J Biomed Mat Res. 1998;43:192-203.

32. Meredith N. Assessment of implant stability as a prognostic determinant. Int J Prosthodont. 1998;11(5):491-501.

33. Meltzer AM. Primary stability and initial bone-to-implant con-tact: The effects of immediate placement and restoration of dental implants. J Implant Reconstr Dent. 2009;1(1):35-41.

34. Farré-Pagés N, Augé-Castro ML, Alaejos-Algarra F, Mareque-Bueno J, Ferrés-Padró E, Hernández-Alfaro F. Relation between bone density and primary implant stability. Med Oral Patol Oral Cir Bucal. 2011;16(1):62-67.

35. Javed F, Romanos GE. The role of primary stability for successful

immediate loading of dental implants. A literature review. J Dent. 2010;38(8):612-620.

36. Nevins M, Nevins M, Schupbach P, Fiorellini J, Lin Z, Kim DM. The impact of bone compression on bone-to-implant contact of osseointegrated implants: A canine study. Int J Perio Rest Dent. 2012;32(6):637-645.

37. Östman PO, Wennerberg A, Ekkestubbe A et al. Immediate occlu-sal loading of NanoTite tapered implants: A prospective 1-year clinical and radiographic study. Clin Implant Dent Relat Res. 2012.

38. Block MS. Palcement of implants into fresh molar sites: Results of 35 cases. J Oral Maxillofac Surg. 2011;69(1):170-174.

39. Davies JE. Understanding peri-implant endosseous healing. J Dent Educ. 2003;67(8):932-949.

40. Cochran DL. A comparison of endosseous dental implant sur-faces. J Periodontol. 1999;70(12):1523-1539.

41. Balshe AA, Assad DA, Eckert SE, Koka S, Weaver AL. A retro-spective study of the survival of smooth- and rough-surface dental implants. Int J Oral Maxillofac Impl. 2009;24(6):1113-1118.

42. Ivanoff CJ, Hallgren C, Widmark G, Sennerby L, Wennerberg A. Histologic evaluation of the bone integration of TiO(2) blasted and turned titanium microimplants in humans. Clin Oral Impl Res. 2001;12(2):128-134.

43. Gubbi P, Towse R. Quantitative and qualitative characterization of various dental implant surfaces. European Academy of Osseointegra-tion, October 2012, Copenhagen, Denmark, P-421.

44. Montoya C. Affect of surface on mucosal health and integration testing: A prospective, randomized-controlled clinical study of multi-topography surfaced implants in early loading cases. International Symposium on Periodontics and Restorative Dentistry, June 2013, Boston, Massachusetts, USA.

45. Baldi D, Meninin M, Pera F, Ravera G, Pera P. Plaque accu-mulation on exposed titanium surfaces and peri-implant tissue behavior. A preliminary 1-year clinical study. Int J Prosthodont. 2009;22:447-455.

46. Bollen CM, Papaioanno W, van Eldere J et al. The influence of abutment surface roughness on plaque accumulation and peri-im-plant mucositis. Clin Oral Implants Res. 1996;7:201-211.

47. Albrektsson T, Wennerberg A. Oral implant surfaces: Part I – review focusing on topographics and chemical properties of different surfaces and in vivo responses to them. Int J Prosthodont. 2004;17(5):536-543.

48. Testori T, Wiseman L. A prospective multicenter clinical study of



the Osseotite implant: Four-year interim report. Int J Oral Maxillofac Implants. 2001;16:193-200.

49. Feldman S, Boitel N, Weng D et al. Five-year survival distributions of short-length (10mm or less) machined-surfaced and Osseotite implants. Clin Implant Dent Relat Res. 2004;6:16-23.

50. Sullivan DY, Sherwood RL, Porter SS. Long term performance of Osseotite implants: A 6-year clinical follow-up. Compend Contin Educ Dent. 2001;22:326-334.

51. Khang W, Feldman S, Hawley CE et al. A multi-center study com-paring dual acid-etched and machined-surfaced implants in various bone qualities. J Periodontol. 2001;72:1384-1390.

52. Zetterqvist L, Feldman S, Rotter B, Vincenzi G, Wennström JL, Chierico A et al. A prospective, multicenter, randomized-controlled five-year study of hybrid and fully etched implants for the incidence of peri-implantitis. J Periodontol. 2010;81(4):493-501.

53. Ogawa T, Ozawa S, Shih JH et al. Biomechanical evaluation of os-seous implants having different surface topographies in rats. J Dent Res. 2000; 79(11):1857-1863.

54. Klokkevold PR, Johnson P, Dadgostari S et al. Early endosseous integration enhanced by dual acid etching of titanium: A torque re-moval study in the rabbit. Clin Oral Implants Res. 2001. 12(4):350-357.

55. Baker D, London RM, O’Neal R. Rate of pull-out strength gain of dual-etched titanium implants: A comparative study in rabbits. Int J Oral Maxillofac Implants. 1999;14(5):722-728.

56. Kopp S, Behrend D, Kundt G, Ottl P, Frerich B, Warkentin M. Den-tal implants and immediate loading: Multivariate analysis of success factors. Rev Stomatol Chir Maxillofac Chir Orale. 2013;114(3):146-154.

57. Vera C, De Kok IJ, Chen W, Reside G, Tyndall D, Cooper LF. Evaluation of post-implant buccal bone resorption using cone beam computed tomography: a clinical pilot study. Int J Oral Maxillofac Implants. 2012;27(5):1249-1257.

58. Roe P, Kan JY, Rungcharassaeng K, Caruso JM, Zimmerman G, Mesquida J. Horizontal and vertical dimensional changes of peri-implant facial bone following immediate placement and pro-visionalization of maxillary anterior single implants: a 1-year cone beam computed tomography study. Int J Oral Maxillofac Impl. 2012;27(2):393-400.

59. Atieh MA, Imrahim HM, Atieh AH. Platform switching for marginal bone preservation around dental implants: a systematic review and meta-analysis. J Periodontol. 2010;81(10):1350-1366.

60. Lazzara RJ, Porter SS. Platform switching: a new concept in im-plant dentistry for controlling postrestorative crestal bone levels. Int J Periodontics Restor Dent. 2006;26(1):9-17.

61. Fernández-Formoso N, Rilo B, Mora MJ, Martínez-Silva I, Díaz-Afonso AM. Radiographic evaluation of marginal bone maintenance around tissue level implant and bone level implant: a randomised controlled trial. A 1-year follow-up. J Oral Rehabil. 2012;39(11):830-837.

62. Fickl S, Zuhr O, Stein JM et al. Peri-implant bone level around implants with platform-switched abutments. Int J Oral Maxillofac Implants. 2010;25(3):577-581.

63. Al-Nsour MM, Chan HL, Wang HL. Effect of the platform-switch-ing technique on preservation of peri-implant marginal bone: A systematic review. Int J Oral Maxillofac Implants. 2012;27(1):138-145.

64. Towse R, Ouelette D, Suttin Z. A theoretical analysis of com-ponent-level vertical restorative error. Poster presentation (P190): Academy of Osseointegration, 27th Annual Meeting, March 2012; Phoenizx, AZ.

65. Suttin Z, Towse R, Cruz J. A novel method for assessing implant-abutment connection seal robustness. Poster Presentation (P188): Academy of Osseointegration, 27th Annual Meeting; March 2012; Phoenix, AZ.

66. Schoenbaum TR, Chang YY, Klokkevold PR, Snowden JS. Abut-ment emergence modification for immediate implant provisional restorations. J Esthet Restor Dent. 2013;25(2):103-107.

67. Byrne D, Jacobs S, O’Connell B et al. Preloads generated with repeated tightening in three types of screws used in dental implant assemblies. J Prosthodont. 2006; 15(3):164-171.

Webliography Esposito M, Grusovin MG, Polyzos IP, Felice P, Worthington HV.Timing of implant placement after tooth extraction: immediate,immediate-delayed or delayed implants? A Cochrane systematicreview. Eur J Oral Implantol. 2010 Autumn;3(3):189-205. Abstractavailable at: http://www.ncbi.nlm.nih.gov/pubmed/20847990.Strub JR, Jurdzik BA, Tuna T. Prognosis of immediately loadedimplants and their restorations: a systematic literature review. JOral Rehabil. 2012 Sep;39(9):704-17. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/22607161.

AcknowledgementThe case in this course was provided by Dr. Alan Meltzer and the definitive restorative care provided by Dr. Pamela Doray.


15September 2013

1. The �rst root-form endosseous implants were constructed of __________.a. machined titaniumb. acid-etched titaniumc. smooth-surface chromiumd. none of the above

2. Systematic reviews have led to the conclusion that a mean horizontal bone loss (loss of ridge width) of __________ can be anticipated at extraction sites in the six months following tooth extraction.a. 1.8 mmb. 2.8 mmc. 3.8 mmd. 4.8 mm

3. Ridge preservation using mineralized particulate xenografts has been shown in some studies to reduce __________ bone loss at extraction sites. a. vertical and horizontalb. triagonal and verticalc. triagonal and horizontald. vertical, horizontal and triagonal

4. In a study using bovine xenografts, a horizontal bone loss of on average __________ was found with the use of xenografts vs __________ for ungrafted sites at four months post-extraction. a. 0.4 mm; 3.48 mmb. 0.84 mm; 3.98 mmc. 1.04 mm; 4.48 mmd. none of the above

5. A __________ following implant placement can signi�cantly com-promise esthetics and result in dissatisfaction.a. moderate amount of soft-tissue recession or lack of a diastema b. minimal amount of soft-tissue recession or lack of a papillary

structurec. moderate amount of soft-tissue recession or lack of a papillary

structured. none of the above

6. Östman et al assessed the 1-year cumulative survival and suc-cess rates for 102 immediately loaded, platform-switched im-plants supporting �xed prostheses, �nding a cumulative survival rate of__________.a. 95.2% b. 97.2%c. 99.2%d. none of the above

7. __________ is an objective of immediate implant placement and restoration.a. Preservation of crestal bone and soft-tissue architectureb. Patient satisfaction c. Shorter and less invasive treatmentd. all of the above

8. In a review of 19 studies, den Hartog et al found __________ for immediate, early and delayed loading protocols.a. a survival rate after one year of 95.5%b. statistically signi�cant differences c. no statistically signi�cant differencesd. a and c

9. __________ is a risk factor for mucosal recession at the facial margin following implant placement. a. A thin biotypeb. A thin or non-intact buccal bone platec. Malpositioning of the implantd. all of the above

10. A self-cutting implant design with lateral threads may enhance __________.a. primary implant stabilityb. micromotionc. soft-tissue formingd. all of the above

11. If the distance from the contact point to the crest of the bone is __________ , excellent papillary architecture is achievable.a. ≥5 mmb. ≤5 mmc. ≥5 mmd. ≤3 mm

12. Inadequate inter-implant space is a determinant for__________.a. increased crestal bone loss b. lack of papillary regenerationc. the type of interfaced. a and b

13. An esthetic and natural-looking peri-implant soft-tissue architecture is more predictable and easier to achieve in patients with a __________. a. thick biotype and scalloped gingival contourb. thin biotype and scalloped gingival contour c. thick biotype and �at gingival contourd. thin biotype and �at gingival contour

CEQuizTo complete this quiz online and immediately download your CE veri�cation document, visit www.dentallearning.net/IIP-ce, then log into your account (or register to create an account). Upon completion and passing of the exam, you can immediately download your CE veri�cation document. We accept Visa, MasterCard, and American Express.



14. __________ helps to minimize bone loss.a. A buccal bone plate of at least 2 mm width b. Atraumatic extraction c. Palatal/lingual implant placement d. all of the above

15. Ridge preservation and placement of bone grafting material around the gap between the implant and the osteotomy extrac-tion site, have been found to minimize __________.a. change in soft-tissue morphologyb. the required inter-implant distancec. peri-implantitisd. all of the above

16. Primary stability __________.a. requires excellent bone-to-implant contact at the time of

implant placement b. helps resist micromotionc. helps with osseointegrationd. all of the above

17. __________ in�uence(s) the achievement of primary stability. a. Surgical technique b. Bone density and qualityc. Using drills that mimic the minor diameter of the implantd. all of the above

18. Implants with a fully etched implant neck were found by Baldi et al to __________ as compared to implants with a smooth neck. a. increase crestal bone loss b. reduce crestal bone lossc. have no impact d. none of the above

19. The surface topography of microscopically roughened surfaces results in an increase in the surface area available for __________.a. primary stabilityb. soft-tissue migrationc. osseointegration d. none of the above

20. Xenografts resorb more slowly than __________ . a. autograftsb. allografts c. zinc oxided. a and b

21. It has been found that coarse, rough implant body surfaces increase the likelihood of __________ if exposed.a. peri-implantitisb. fracturec. crestal bone preservationd. none of the above

22. Poorly sealed interfaces may result in __________.a. greater bacterial colonizationb. microleakage c. greater potential for peri-implantitis d. all of the above

23. Platform-switched implant designs now expressly incorporate abutments with a __________ diameter than the diameter of the implant. a. wider b. narrowerc. varying thickness d. any of the above

24. Immediate provisional restoration __________a. may reduce the risk of midfacial recession b. may aid in the conservation of the mucosal level c. increases bacterial colonizationd. a and b

25. A recent study found no differences in the incidence of __________, in comparing implant necks with a microroughened topography versus a smooth neck surface. a. osseointegrationb. peri-implantitisc. satisfactiond. none of the above

26. In a study assessing immediately loaded implants in premolar sites, more buccal bone changes and width loss occurred at the __________.a. mid-implant region of the implantb. level of the implant-abutment interfacec. apical region of the implantd. none of the above

27. Recent studies have demonstrated that the use of platforms of different diameters (platform-switching) results in preservation of __________.a. crestal bone heightb. functionc. microroughened surfacesd. none of the above

28. The emergence pro�le of the abutment used for the provisional restoration in�uences __________.a. the pressure placed on the peri-implant tissues b. the ability of the peri-implant tissue to increase in volumec. the level of bone resorptiond. all of the above

29. Using an abutment with a �at or parallel design emergence pro�le __________.a. provides the best opportunity to maintain soft-tissue morphologyb. reduces pressure on the facial soft tissue c. is ill-advisedd. a and b

30. A high-integrity implant-abutment junction seal relies on __________.a. narrow tolerancesb. an abutment screw design that helps to ensure excellent

sealingc. the implant surface topographyd. a and b

CE QUIZ

17September 2013

Please direct all questions pertaining to Dental Learning, LLC or the administration of this course to [email protected]. COURSE EVALUATION and PARTICIPANT FEEDBACK: We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included with the course. INSTRUCTIONS: All questions should have only one answer. Participants will receive con�rmation of passing by receipt of a veri�cation form. Veri�cation forms will be mailed within two weeks after taking an examina tion. EDUCATIONAL DISCLAIMER: The content in this course is derived from current information and evidence. Any opinions of ef�cacy or perceived value of any products mentioned in this course and expressed herein are those of the author(s) of the course and do not necessarily re�ect those of Dental Learning. Completing a single continuing education course does not provide enough information to give the participant the feeling that s/he is an expert in the �eld related to the course topic. It is a combination of many educa-tional courses and clinical experience that allows the participant to develop skills and expertise. COURSE CREDITS/COST: All participants scoring at least 70% on the examination will receive a veri�cation form verifying 2 CE credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/Mastership credit. Please contact Dental Learning, LLC for current term of acceptance. Participants are urged to contact their state dental boards for continuing education requirements. Dental Learning, LLC is a California Provider. The California Provider number is RP5062. The cost for courses ranges from $29.00 to $110.00. Many Dental Learning, LLC self-study courses have been approved by the Dental Assisting National Board, Inc. (DANB). To �nd out if this course or any other Dental Learning, LLC course has been approved by DANB, please RECORD KEEPING: Dental Learning, LLC maintains records of your successful completion of any exam. Please contact our of�ces for a copy of your continuing education credits report. This report, which will list all credits earned to date, will be generated and mailed to you within �ve business days of receipt. CANCELLATION/REFUND POLICY: Any participant who is not 100% satis�ed with this course can request a full refund by contacting Dental Learning, LLC in writing or by calling 1-888-724-5230. © 2013

PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.

1. A B C D

2. A B C D

3. A B C D

4. A B C D

5. A B C D

6. A B C D

7. A B C D

8. A B C D

9. A B C D

10. A B C D

11. A B C D

12. A B C D

13. A B C D

14. A B C D

15. A B C D

16. A B C D

17. A B C D

18. A B C D

19. A B C D

20. A B C D

21. A B C D

22. A B C D

23. A B C D

24. A B C D

25. A B C D

26. A B C D

27. A B C D

28. A B C D

29. A B C D

30. A B C D

Fill in the circle of the appropriate answer that corresponds to the question on previous pages.

EDUCATIONAL OBJECTIVES• Describe the rationale for immediate implant placement and restoration• Review the survival and success rates of immediate implant placement• List and describe the factors involved in achieving excellent results in the anterior esthetic zone• Review the in�uence of implant design and adjunctive restorative and surgical components on short- and

long-term functional and esthetic success.

If you have any questions, please email [email protected] or call Dental Learning at 888-724-5230.

CE ANSWER FORM (E-mail address required for processing)

To obtain credits:

1. Read the entire course.

2. Complete this entire answer sheet in either pen or pencil.

3. Mark only one answer for each question.

4. A score of 70% will earn your credits.

OR

For Immediate results:

1. Read the entire course

2. Go to www.dentallearning.net/IIP-ce

3. Choose this course from the course listing

4. Log in to your account or register to create an account

5. Complete course and submit for grading to receive your CE veri�cation document

Dental Learning, LLC

500 Craig Road, Floor One

Manalapan, NJ 07726

*If paying by credit card, please note:

Master Card | Visa | AmEx | Discover

*Account Number ______________________________

*Expiration Date _______________________________

The $29 charge will appear as Dental Learning, LLC.

If paying by check, make check payable to Dental Learning, LLC.

AGD Codes: 690, 691

ALL FIELDS MARKED WITH AN ASTERISK (*) ARE REQUIRED

COURSE EVALUATIONPlease evaluate this course using a scale of 5 to 1, where 5 is excellent and 1 is poor

1. To what extent were the course objectives accomplished overall? 5 4 3 2 1

2. Please rate your overall mastery of the educations objectives? 5 4 3 2 1

3. How would you rate the educational methods? 5 4 3 2 1

4. How do you rate the author’s mastery of the topic? 5 4 3 2 1

5. Please rate the instructor’s effectiveness. 5 4 3 2 1

6. Do you feel the references were adequate? 5 4 3 2 1

7. Would you participate in a similar course? 5 4 3 2 1

8. Was any subject matter confusing – please describe. 5 4 3 2 1

Price: $29 CE Credits: 2Save time and the environment by taking this course online.


*Name: Title: Specialty:

*Address: *E-mail:

*City: *State: *Zip:

*Telephone: License renewal date: AGD Identi�cation No.

Practice Name NPI No.

DENTAL LEARNING 3i (WEB).pdf · seven clinical trials, ˚nding insuf˚cient evidence favoring...

Documents

Transcript of DENTAL LEARNING 3i (WEB).pdf · seven clinical trials, ˚nding insuf˚cient evidence favoring...