Implant News & Views News & Views “Keeping you up-to-date on implant dentistry” Page 1 Zirconium...

IN THIS ISSUE

Vol. 17 No. 1January/February 2015

Implant News & Views “Keeping you up-to-date on implant dentistry”

Zirconium Dioxide Implant

Solutions - A Metal-Free Option

David DiGiallorenzo, DMD

Page 6

Bailout Procedure for Cement

Retained Implant Supported

Crowns

Gerald Rudick, DDS

Page 8

Tidbits

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Zirconium Dioxide Implant SolutionsA Metal-Free Option

David DiGiallorenzo, DMD

Zirconia dioxide has a long history of use in orthopedic and

dental applications. Zirconium (Zr) is a metal; however, through a

chemical reaction with oxygen, zirconium is converted to zirconia or

zirconium dioxide (ZR02). Currently, there are several manufactur-

ers of zirconia dioxide dental implants.

Z-Systems, a Swiss-manufactured single-piece dental implant,

was FDA approved more than four years ago for use in tooth-re-

placement therapy. Developed in 2001 by Dr. Ulrich Volz, in collabo-

ration with Metoxit, a world leader in the production of ceramic ma-

terial, the new implants offered a predictable way to produce strong,

dimensionally stable, metal-free implants using the isostatic process.

Fig. 1: The single-stage design

eliminates the effects of the

microgap and micromotion on the

crestal interface of bone and soft

tissue. (A) - a uniform Cad-Cam

abutment for all standard impants

without insertion hexagon; opti-

mized by large surface transmis-

sion of force on two parallel sur-

faces; retention groove for hold-

ing tools and accessories se-

curely; angulation and individu-

alization by simple grinding. (B)

Optimized possibilities of indica-

tion thanks to new implant sizes

with reduced shoulder width;

Perfiect individualo aesthetics bygrindable preparation border (C)Tapering thread with widened

core diameter in the upper part

of the thread guarantees opti-mum mechanical strength andbetter primary stability. (D) Im-

proved self-tapping thread;

Newly designed bone chip reser-voir.

A

B

C

D

A key el-ement of suc-cess in the pro-cess is the qual-ity of the rawmaterials andthe technologyof the produc-tion.

Not allzirconia is cre-ated equal. Cur-rently, worldwideit is estimatedthat 3 percent ofpatients may besensitive to tita-nium. 1-7

In addi-tion, the sys-temic toxicity as-sociated with ti-tanium nanotechnology is still unknown.8 However, it does appear there isperipheral organ accumulation of metal ions in certain clinical situations.9-10

How this affects overall health is still unknown. With increasing fre-quency, patients are requesting metal-free biologic implants and restorativesolutions. Many holistic and esthetically oriented doctors and patients arelooking for a metal-free esthetic option in tooth replacement therapy.

Zirconia biocompatibility has been successfully documented in animalstudies and human studies. These studies have found zirconia to be biologi-cally compatible with osseointegration. Specifically, they have reportedcellular responses similar to titanium, similar bone-to-implant contact, simi-

Implant News & Views

Fig. 3

Fig. 4 Fig. 5

lar healing times, similar biomechanical strength and similar soft-tissue biologic width, and similar removaltorque values.11-25

Additionally, several studies have shown less inflammatory infiltrate at the implant abutment junctionand less bacterial colonization in this region, which may have clinical significance regarding short and long-term biofilm accumulation and susceptibility.26-30

The only human clinical retrospective study to date in the literature on human success rates ofzirconia reported a 92 percent success for smooth surface zirconia and 97 percent for rough surface zirconiaover five years and 831 subjects.31

The ImplantThe Z-look Evo is a single-stage threaded implant with a prep-able abutment. It is imperative to use

the 49 micron zirconia prep bur for reduction to reduce microcrack propagation. Preparation can be com-pleted at placement. There is no risk of heating of the implant body because of the low thermal conductivityof the material.32 The apical thread pattern is self-tapping. The current surface is sandblasted to improvesurface character- istics. However, a new dual-processed sand-blasted and laser-etched surface is nowavailable.

The single-stage design eliminates the effects of the microgap and micromotion on the crestalinterface of bone and soft tissue [Fig. 1]. The current diameters range from 3.3 to 5.5 mm and from 8.5 to 15mm length [Fig 2].

Fig. 2: The current diameters range from

3.3 to 5.5 mm and from 8.5 to 15 mm length.

Diagnosis and Treatment PlanningThe author has been selectively placing zirconium Im-

plants during the last three years. The following consider-ations should be strictly adhered to when considering diagno-sis and placement. Consider guided surgery for optimal align-ment from a top (crown)-down approach. The abutment canbe prepped up to 20 degrees. Any misalignment beyond 20degrees will cause restorative complications. Snap Caps andAnalogs are available for impressions and lab processes [Figs.

3-5].

Only place the implant in healthy patients with no sys-

Figs. 3-5: Snap Caps and Analogs are available for impressions and

lab processes.

temic and local risk factors such assmoking, diabetes, poor bone qual-ity and metabolic deficiencies. Type1-2 host bone is ideal for successfulintegration.

Zirconia tends to lag fourweeks behind in cellular biologic fixa-tion, according toanimal studies. In sites with nativebone, I will allow implants to remainundisturbedfor four months on the lower and sixmonths on the upper.

Limiting any micromotion at

the bone to implant interface is crucial. An essex appliance is recommended during healing. Because graftedsites still contain areas of devitalized bone, longer healing times are important.

The following healing times are suggested for grafted sites. Allow grafted bone in extraction socketson the maxillary arch to heal a minimum of six months, even when using bioactive modifiers; sinus grafts aminimum of eight months; and lateral ridge augmenta- tions on the upper and lower arch eight months priorto implant placement.

Consider undersizing the osteotomy to develop optimal primary stability. Progressive long-term load-ing in provisionals is highly recommended to begin the accommodative physiologic bone response at thecellular level. There is no replacement for experience, and the success of zirconia implant therapy is directlyrelated to the operators’ surgical and prosthetic skills and experience.

BiologyThe primary means of surface modification to enhance surface microtexture on zirconia include acid

etching, laser etching and sandblasting. These processes will enhance the hosts’ cellular response andsecondary fixation. However, remember zirconia’s secondary fixation occurs about four weeks slower than

Fig.4Fig. 6


Fig 4

titanium. Therefore, not only is protected healing required, but longer healing times are beneficial.

Fig. 6: As a result of the im-

plant design, 2 mm of bone

loss will occur upon place-

ment to provide room for

biologic width.

Fig. 7: Soft-tissue response is re-markable with crestal creeping soft-tissue attachment over time.

Fig. 8: The bone to implant contact

and removal torque analysis for zir-

conium and titanium is the same.

Fig. 9: The esthetic benefits of zirco-

nia prevent the grey show-through

associated with many titanium im-

plants, particularly in the thin bio-types.

Crestal biologic bone responsewill always include accommodativebone resorption to the first thread. Asa result of the implant design, 2 mm ofbone loss will occur upon placementto provide room for biologic width [Fig,

6].

A two-piece design with amedialized offset will eventually pro-vide the opportunity to preserve cr-estal bone, while providing optimal re-storative interface options. Immediateloading and implants placed into ex-traction sockets is not recommendedat this time, as there is not enoughclinical information or literature to sup-port this approach.

Soft-tissue response is remark-able with crestal creeping soft-tissueattachment over time [Fig. 7]. It hasbeen shown fibroblasts migrate ex-

tremely well on zirconia surfaces.35-36 As well, biofilm developmentis retarding as result of the surface biodynamics.37

To date, I have not reported any biomechanical failures in-cluding fracture, nor have any been reported in the literature.

It appears from the literature that at the 12-week point inanimal studies, the bone to implant contact and removal torque analysisfor zirconium and titanium is the same [Fig 8].

Stress distribution for zirconia and titanium is the same. Theesthetic benefits of zirconia prevent the grey show-through associ-ated with many titanium implants, particularly in the thin biotypes[Fig. 9].

Fig. 11: A 4.0 by 13 Z–Look was se-

cured under 50 ncm of torque.

Fig. 12: An essex appliance wasplaced for the duration of the four-

month healing interval.

Fig. 10: A 55-year-old man with re-

markable health had lost #8 fiveyears prior. The area was never

grafted. Zirconia success is optimalin host bone.

Case StudyA 55-year-old man with

remarkable health had lost #8five years prior. The area wasnever grafted. Zirconia successis optimal in host bone [Fig.

10]. A 4.0 by 13 Z–Look wassecured under 50 ncm oftorque [Fig. 11]. An essex ap-pliance was placed for the du-ration of the four-month heal-ing interval [Fig. 12]. A four-week post-op revealed dy-namic soft tissue health andcomposition.

A provisional wasplaced at four months and pro-gressively loaded over the nexttwo months [Fig. 13].

A final all-zirconiumcrown was placed at sixmonths. X-ray and cone beamat the one-year mark revealcrestal bone loss to the first

Fig. 13: A provi-sional was placedat four months

and progressivelyloaded during the

next two months.


thread. However, they also show excellent tissue stability and esthetics [Figs. 14-17].

Figs. 14-15: A final all-zirconium crown was placed at six

months.

Figs. 16-17: X-ray and cone beam at one-year

mark reveal crestal bone loss to the first thread;

however, they also show excellent tissue sta-

bility and esthetics.

David DiGiallorenzo, DMD, maintains two private practices in Pennsylvania, focused on laser estheticand reconstructive periodontics, dental implantology, advanced reconstructive case management, ad-vanced teeth-in-a-day and TMJ. He is a past clinical instructor at the University of Pennsylvania,Department of Periodontics. He lectures both nationally and internationally and is a consultant for DENTSPLY,Synthase, Keystone, Z-Look (Zirconium Metal Free Implants) and Orapharma. He can be reached at 610-409-6064 or [email protected].

References

1. Stejskal J, Stejskal VD. The role of metals in autoimmunity and the link to nueroendocrinology. Neuroendo-

crinology lett 1999;20:351-364.

2. Valentine-Thon E, Schiwara HW, Validity of MELISA for metal sensitivity testing. Neuroend lett.2003;24:57-

64.

3. Hypersensitivity To Titanium:Clinical and Laboratory Evidence. Muller KE, Valentine-Thon E.Nueroendocrinol

letter. 2006;27 suppl 1:31-35.

4. Elizabeth Valentine-Thon1, PhD; Kurt Müller2, MD; Gianpaolo Guzzi3, DDS; Sybille Kreisel4, MD; Peter

Ohnsorge5, MD & Martin Sandkamp1, MD Neuroendocrinol Lett 2006; 27(Suppl 1):17–24.

5. Stejskal V. Human hapten-specific lymphocytes: biomarkers of allergy in man. Drug Inform J. 1997; 4: 379–

82.


6. Sicilia A, Cuesta S, Coma G, Arregui I, Guisasola C, Ruiz E, Maestro A. Clin Oral Implants Res. 2008

Aug;19(8):823-35.

7. Egusa H, Ko N, Shimazu T, Yatani HJ Prosthet Dent. 2008 Nov;100(5):344-7.

8. Wennberg Ann et al, Inter J Oral maxifac implants 2011;26:1161-1166.

9. Bianco PD, et al, J of Biomedical Research,1996:31:227-234.

10. Weingart et al, Inter nat Journal Maxofacial Surgery, 1994:23:450-452.

11. Shin D, Blanchard SB, Ito M, Chu TM Clin Oral Implants Res. 2010 Sep 10.

12. Shin D, Blanchard SB, Ito M, Chu T-MG. Peripheral quantitative computer tomographic, histomorphometric, and

removal torque analyses of two different non-coated implants in a rabbit model. Clin. Oral Impl. Res. xx, 2010.

13. 2008 Depprich et al Head Face Med. 2008; 4:30.

14. Stadlinger B, Hennig M, Eckelt U, Kuhlisch E, Mai R. Department of Oral & Maxillofacial Surgery, Faculty of

Medicine, University of Technology Dresden, Germany.

15. Koch FP, Weng D, Krämer S, Biesterfeld S, Jahn-Eimermacher A, Wagner W JOMI Vol 21, Issue 3, p.350-

356, March 2010.

16. Kohal RJ, Weng D, Bachle M, Strub G. Loaded custom Zirc and titanium implants show similar

osseointegration. An animal experiment. J Perio . 2004. 75: 1262-1268

17. Albrektsson et al, Interface analysis of ti and zir implants. Biomaterials 1985:6:97-101.

18. Akagawa Y, et al. Interface histology of unloaded and early loaded partially stabilized zirconia. J Prosth

Dent 1993;69:599-604.

19. Akagawa Y Et al, Comparison between freestanding and tooth connected partiallystabilized zirconia

implants after 2 years in function in monkeys. Clinical and Histology. J Prosth Dent.1998;80:551-558.

20. Ichikawa Y et al, Tissue Compatibility and stability of a new zirconium ceramic. In vivo. J Prosth Dent

1992: 68:322-326.

21. Kohal et al, 3 dimensional computerized stress analysis of ti and zirc implants. Int J Prosth 2002:15:189-194.

22. Sennerby et al. Bone tissue response to zirconia implants: A histomorphometric and removal torque

study. Clin Implants Dent Res 2005:s13-20.

23. Andreiotelli M, kohal RJ. Survival rate and fracture resistance of zirconium Dioxide implants after exposure

to the artificial mouth: An in vitro study. Freidburg, 2006. Reprinted in 2008.

24. Caglar A, Bal BT, Aydin C, Yilmaz H, Ozkan S Evaluation of stresses occurring on three different zirconia

dental implants: three-dimensional finite element analysis Int J Oral Maxillofac Surg. 2010 Jun;39(6):585-92.

25. M.Nevins,M.Nevins,M.Camela,P. Schupback,D.Kim. Pilot Clinical and Histologic Evaluation of a 2 piece

zirconium Implant. Int Journal of Perio and Rest. Dent.2011:31:157-163.

26. Degidi et al. Inflammatoy infiltrate,microvessel density, nitric oxide expression,vascular endothelial growth

factor expression, and profilerative activity in peri-implant soft tissues around ti and zirc oxide healing Caps.

J PERIO 2006;77:73-78.

27. Rimondini et al. Bacterial Colonization of ceramic surfaces: An In Vitro Study and In Vivo Study. Int J Oral

and Max Implants 2002;17;793-798.

28. Scarano A, Piatelli M et al. Bacterial Adhesion on Pure Zirc and Ti discs. An in vivo human study. J Perio

2004; 75:292-296.

29. Linkevicious T Et al. Influence of abutment material on stability of periimplant tissues. A systemic

Review. Int J Oral Max Implants 2008;23:449-456.

30. M. Nevins, M. Nevins, M. Camela, P. Schupback, D.Kim. Pilot Clinical and Histologic Evaluation of a 2-piece

zirconium Implant. Int Journal of Perio and Rest. Dent.2011:31:157-163.

31. Oliva J, Oliva X, Oliva JD Five-year success rate of 831 consecutively placed Zirconia dental implants in humans:

a comparison of three different rough surfacesInt J Oral Maxillofac Implants. 2010 Jan-Feb;25(1):95-103.

32. Caglar, A et al, Int J Oral Maxillofac Implants 2011;26; 961-969.

33. Marco Degidi,*† Luciano Artese,‡ Antonio Scarano,† Vittoria Perrotti,† Peter Gehrke,§ and Adriano

Piattelli:Journal of Perio January 2006, Vol. 77, No. 1, p. 73-80.

34. Antonio Scarano , Maurizio Piattelli , Sergio Caputi , Gian Antonio Favero , Dr. Adriano Piattelli Journal of

Periodontology Feb 2004, Vol. 75, No. 2, Pages 292-296: 292-296.


Fig.

g

u

Bailout Procedure for Cement RetainedImplant Supported Crowns

Gerald Rudick, DDS

Over the many years that dental implants have become a reliable treatment option for

replacing missing teeth, there has always been the controversial issue of whether the final crowns

should be screw retained or cemented - the objective in both situations is safe, easy removal and

retrievability if it becomes necessary.

Fig. 1: Radiograph of the pre-

viously grafted edentulous

site.

Fig. 2: Radiograph of pilot

hole with trial pin.

Fig. 3: Radiograph of AdinTouareg S 5 x 16 mm implant

and crown after three years[Adin Dental Implant Sys-

tems, Israel].

A screw retained crown is very simpleto retrieve as it is just a matter of uncover-ing the access hole to the screw, and re-versing it. The advantage to screw-retainedimplant supported crowns, in addition to theease of removal, is that there is never anissue of excess cement getting stuck deepunder the gingival tissues.

In cementable situations the excesscement (always use temporary cement) issometimes difficult to see visually under themargins. If the cement used was not veryradiopaque, it will not show up as a foreignbody, but might appear as particulate graft-ing material. The decision to use a cementretained crown depends largely on wherethe access to the screw will be in relationto the anatomy of the crown, and this ofcourse depends on the position of the im-plant as it is usually determined by the avail-able bone.

In the case of anterior teeth, if the access hole cannot be in thecingulum, then it cannot be used, and a cementable restoration is the onlysolution. For the posterior teeth, the screw access hole cannot be on acusp, and is best to be in the occlusal fossa, to prevent porcelain fractureand appropriate axial loading.

Over the years, research has shown that a custom-made abutmentis probably the safest option for cement retained crowns, because it followsthe contour of the gingival tissues at what should be the CE junction; butthis adds significant cost to the treatment. The excess cement that isreleased under the gingival tissues, will be close to the surface, be visablewith the naked eye, and is easy to spot and remove; whereas in the case ofusing stock abutments, it might be more difficult to spot the excess cement,since it is at the bottom of the gingival sulcus at the bone level; the dentistmay only become aware of this problem when tissue irritation is evident orthere are destructive radiographic changes around the implant.

Weak LinkIt does not matter what type abutment is used in a cementable

case, stock or custom made; the weak link is always the risk of the abut-ment screw loosening. In multiple joined crowns, it is a simple matter to

insert a crown and bridge remover under the joint and tap off the crowns. In

the case of a well formed single unit, it is almost impossible to remove the cemented crown, as there isnothing for the crown and bridge remover to grip on to, or an instrument to push the crown off theabutment; and a loose abutment that is unsecured is like a tug of war with a rubber rope.


Fig. 4

Fig. 8

Case StudyThe case presented is

of two upper central incisorcrowns inserted three yearspreviously, one on an endo-dontically treated tooth, andone on an implant placed intoa previously grafted site for ahealthy 60 year old female.The patient came back to ouroffice with the fear that herimplant was failing, as the im-plant crown was loose.

Upon examination shehad no pain, as pain would beindicative of a failing implant,and the gingival tissues ap-peared normal. The crown fitvery well, and there was noedge or margin on which toseat a crown gripper, or a den-tal instrument. But a vibrationcould be felt when finger tap-ping on the crown.

TechniqueHere is a simple solu-

tion to retrieve a loose ce-mented implant crown – nodamage to the crown and nocost to the dentist! In thepast, I have tried securing acopper band to the crown withcompound and utilizing a pa-per clip to create a handle orpurchase point for the crownremover. However, the back

action force of the crown and

Figs. 4a-4c: The implant analog with

prosthetic screw as it appears on the

lab model without soft tissue en-

hancement

Figs. 5a–5e: A copper band with com-

pound and paper clip handle, whichallowed for the C&B remover to gripthe crown, but copper was too soft

and tore when the crown and bridge

remover was applied.

bridge remover would often tear the relatively soft copper band [Figs

5a – 5e]. So, thanks to the suggestion of Frank Higgenbottom, DDSof Dallas, TX, I was able to utilize a stainless steel matrix band[Henry Schein] secured with a Tofflemire matrix band holder, to cre-ate a similar but stronger grip and purchase point [Figs. 6a-6b].

Fig. 6a: Crown with a stainless

steel matrix band around it.

Fig. 6b: Cemented crown removed

and held by matrix band.


SummaryThe crown was simply

removed, the abutment un-screwed and the implant andabutment cleansed withDakin’s solution (water and5% chlorine). The stock im-plant abutment that wasoriginally modified at the timeof crown fabrication was se-curely screwed back, andtemporary cement was usedto secure the crown. It ismost important that when re-moving a screwed on stan-

dard abutment, that its ex-

Fig. 7: Standard Adin hexagonal abut-ment cut down to allow space forcementable restoration. It was re-moved and placed without checkingits exact position when replacing thecrown; it had to be removed beforethe fresh cement set; this is the photoafter the crown was removed – hencethe splattering of cement particles.

Fig. 8: Implant crown replaced andcemented with temporary cement,with the abutment in the exact posi-

tion.

act position be verified prior to placing the cement in the crown.

Gerald Rudick, DDS maintains a private surgical, restorative and implant practice in Montreal, Canada.He is an Associate Fellow of The American Academy of Implant Dentistry, Fellow & Diplomate of TheInternational Congress of Oral Implantology and is a Master in the Implant Prosthodontic Section (ICOI).

He can be contacted at 1.514.342.4444 or [email protected].

TidbitsTidbits

Tidbits

Online Discussion GroupsWe try to monitor various online discussion groups to share their views on implants with our readers.Recently, there was an interesting discussion on grafting options in the Maxilla on the ImplantologyInternet Discussion List, [email protected] [[email protected]], moderatedby John Cliff, DMD. To learn about the benefits & how to join, go to http://lists.dental-implant-forum.com/listinfo.cgi/implantology-dental-implant forum.com.

Extractions were done approximately three weeks ago. Nowpatient wants implants. What are my grafting options in themaxilla? Should I wait several months until sockets heal andsinuses pneumatize and then do sinus lifts, or should placeparticulate grafts into the defects now? Not sure there ismuch buccal plate remaining to contain graft material. Also,should I graft the lower left now or wait? Pt is a 55 year-oldfemale. She says she has given up smoking for vaporizing.William H. Pippin, DDS

What does the patient want? Other things of interests hereare (1) Lip line (2) Perio status of remaining teeth - Withoutlooking at photos it is hard to say but I feel a full upperclearance- wait 6-10 weeks then re-assess is a safer option.What are your thoughts?Henry Mulla, NARELLAN Australia

I try to graft these sockets at the time of extractions andstage the sinus lift. But if that wasn’t discussed before andshe wants implants now then I would graft the sinus in 5weeks after getting and scan. Get some soft tissue closure


At this point insufficient bone to support the implants if placedso would go and do sinus grafts (lateral approach) and sock-ets on lower wait 3 months and place the lower implants andthe upper implants let heal 3 months on lower and 5 on upperbefore loading and restoring.Gregori M. Kurtzman, DDS, MAGD, FPFA, FACD, FADI, DICOI,DADIA

At this stage please wait 3 months and then do a CT to see

over the sockets and initial bone growth in the mean time, which will make it easier to elevate and close thesurgery. The lower...I would see the scan before making a decision. I am not sure about the vapor cigarettes,but as far as I am concerned it’s the same garbage with regard to bone grafts. If it can’t help it then it takesaway from it. And patient should be aware IMHO.Michael Katzap DDS, MAGD

how much buccal plate is left. No rush, let the bone level and remodel, and then decide what to do.Raul R. Mena, DMD

I’m concerned about how sinus floor dropping down would affect final bone height if I perform lift now. Also,it appears to me that the membrane would be easier to access and elevate after the floor levels out.Perhaps my concerns are unfounded.Bill Pippin

Wait until you have soft tissue continuity and then you can use a trephine to the floor of the sinus to thenin-fracture that segment. After that you would then graft the space you just created when you mobilizedthe segment upward.William Schlesinger, DDS, MAGD, ABGD

I think a lateral approach would give you more control since you have to lift the entire sinus but will alsorequire grafting at the crest to fill the voids created when the teeth were extracted. I would wait till you getsoft tissue closure then go in and do the grafting. Others may have differing opinions and would be great tohear them.Gregori M. Kurtzman

Certainly the lateral approach has a lot more history and documentation. Also I don’t have experience withthis infracture technique however I think it may help the residual crest of bone be in a more ideal position asit relates to the remaining natural teeth.Dr. William Schlesinger

If the crest didn’t have the large defects from the recent extractions I could agree but I think that is goingto make the trephine approach harder – at time of extraction.Gregori M. Kurtzman

I want to see the 3D - I am thinking we will have a different idea.Jeffrey C Hoos DMD, FAGD

You removed the rotten teeth but you still have a filthy, diseased mouth with no posterior occlusion or stops!To really gain the patients confidence put out the fire before design and rebuilding.1. Make a couple of cheap wrought wire partial with a full palate on the upper. Will allow her experience ofwhat full dentures will be like. Establish an occlusal plane for later, if more teeth are lost can be added easilyand can be relived to protect grafted areas later.2. Put her on an oral disease program. Period scaling, proxy brushes with Dakar’s solution and peroxide afterthorough brushing all taught her by your assistant and checked weekly. When there is no bleeding andplaque, address decay. She now has a healthy mouth and confident that whatever you suggest will work andlast.3. Now you can graft. Where needed, do sinus augmentation best as per CBCT, place implants and finallyfinish to an established occlusion. Not a HO, have done many like cases and they worked long term.Dave Dalise

Dave’s suggestion is the only predictable way to treat this case. I would never place an implant into a


Fig. 4mouth where there is any bleeding at anylocation. Now that sounds kind of dogmatic but that it where I amat this point in implantology. When there is absolutely no bleeding anywhere in the mouth, then think aboutreconstruction of the posterior. That is what time and experience has taught us. There are mouths full ofplaque and calculus but the key to implant success is no bleeding anywhere. That is going to be the key tothis case. The reconstruction of the maxilla with a sinus lift will be easy. Once the mandible is healed,without a bunch of nonsensical bone grafting being done, it can be evaluated for implants. At the time of theextractions some plumbers tape can be glued over the sites and create a blood compartment. That worksjust like placing an immediate denture. For those who do not do a lot of immediate dentures, they changehealing of extraction sites remarkably. I have never seen a dry socket under an immediate denture, and I donot think my experience is unique. Just placing a denture on extraction sites creates enough of a compart-ment for healing so that we do not see dry sockets and much better healing. Placement of a stayplate wouldhave been equally effective in helping bone heal.Douglas M. Martin DDS. FAAID, FICOI, MAIT, Diplomate ABOI/ID.

Retreating Anterior Implant Case for Maxillary Lateral Incisors

Here is a case I would like to getsome opinions on - 29 year oldfemale with congenitally missinglateral incisors. Implants placed9 years ago are Nobel ReplaceSelect 3.5mm. As you can see,the position of the implants is notideal. What are the options toget this young woman a bettersmile? We did discuss removingthe implants, grafting and replac-

Are we looking at because of the age of the patient at time of placement? Way to young and this is whathappens. Removing is going to be challenging without tremendous defect. Graft and growing tissue andgetting tissue mature. I would think at least 6 months. For me would be multiple procedures - love to seethe progression - How old now?Jeffrey C Hoos, DMD FAGD

I can see why the other implant wasn’t placed. I would refer to an oral surgeon to remove and possible blockgraft the defect. Do you have a CT? I’ve see restorative heroics but most leave more than a little to bedesired.Richard D. Cottrell, DDS

Removing it is the only choice.Raul R. Mena DMD

ing the implantswith better posi-tioned implants aswell as veneers onthe Central Inci-sors. However, re-moving the implantin the left lateralposition will be dif-ficult due to itsproximity to the ca-nine.Craig O’Donoghue,DDS, Fairbanks,Alaska


Not all cases need implants and this case may be better managedwith ceramic bridges since the centrals need work to improve es-thetics. Craig should remove them since it’s a female and the pre-maxilla (bone shouldn’t be real dense) what about placing a place-ment head into the implant and try to counter rotate it to break theintegration which in theory should leave less of a defect compared tocutting it out worse case go to plan two and use piezo to removethem via the buccal (think once flapped there won’t be much thick-ness of buccal bone). In this case we did a gingivectomy on 1st.premolars, right cuspid and both centrals to make the tooth longergingivally. The implants were removed as they were too apical andtoofacial in placement. Can graft and place new implants or do threeunit ceramic bridges [6-8 and 9-11] with pontics at the laterals. Centrals and cuspids will need to be madewider for better dimensions esthetically. The lateral at #7 currently is too wide in comparison to the central.Gregori M. Kurtzman, DDS, MAGD, FPFA, FACD, FADI, DICOI, DADIA

Ideally one would redo the implant placement. Another option might be designing an abutment to look likegingival tissue and a tooth prep. Then do crowns on the lateral and veneers on the central - Thinking outsidethe box.Richard G Knecht, RGK Dental Lab, Inc

Pink porcelain was used on the left lateral - which I just temporarily screwed back in. The angle and positionstill put the implant crown much more labially than the central incisors. I would rather bury the implants anddo bridges than try and polish these turds.Craig O’Donoghue

I know I’ll get a lot of bitching about this, since it is an implant forum and everyone is titanium happy, but donot discount eliminating the fixtures, doing some tissue recontouring to the canines and centrals, and doingfixed bridgework. Her centrals are way too narrow, and given her bone heights - unless you want to subjecther to multiple bone augmentation procedures to gain vertical height, it is going to be extremely difficult toget a good aesthetic result with fixtures. It should be part of your differential treatment planning.Gary L. Henkel DDS MAGD

Only way I can see this one Craig is removal and grafting then re-do later in ideal place as you suggestedwith other veneers.Wayne Sutton, DDS,FACE,FAGD,FDOCS,FADIA

If you’re going to restore the centrals and also veneer the cuspids anyway for better esthetics, why notforget implants at the laterals and place ceramic bridges? I agree Craig is highly capable of treating this butas I mentioned yesterday not every case has to be treated with implants. This case may be better managedwith ceramic bridges then one has to decide do we take out the two implants or bury them and placeosseous graft over them and place some all ceramic bridges in

Gregori M. Kurtzman

This is why I tend to shy away from replacing laterals in young patients. They should live another 80 years,lots of time for something to go wrong. I prefer a very conservative prep on the cuspids and a cantileverbridge to replace the laterals, if the occlusion allows. If the centrals need cosmetic help, I’d still go withconservative veneers on the centrals instead of a 3 unit bridge.John Highsmith DDS, Clyde, NC

I have done a handful of cases like Craig posted using 3 unit emax veneer bridges 6-8, 9-11 from Bob Clarkand Williams Lab. You need a great lab to pull that off. Standard minimal prep veneer preps on canines andcentrals with some possible additional reduction on mesial of canines and distal of centrals for path of draw/connector room. eMax bonded entirely to enamel so it’s very strong and aesthetic. Proper case selection isimportant as you mentioned.Arturo R. Garcia DMD

Yep, that’s a good conservative approach. Don’t know why I didn’t think of that.Gary L. Henkel


Implant News & Views“Keeping you up-to-date on

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Becoming CredentialedThe American Academy of Implant Dentistry (AAID) inducted 90 newAssociate Fellows and Fellows into the Academy at its 63rd Annual Meet-ing. This brings the total number of current AAID credentialed membersto 989. The Academy is the only organization recognized by the U.S.Federal and State Courts as having a bona fide implant dentistrycredentialing program. Credentialing by the AAID means that the dentisthas (1) Demonstrated qualifications, knowledge, skills and competencein implant dentistry (2) Education, training and experience in implantdentistry (3) Completed 300 or more hours of postdoctoral or continuingeducation related to implant dentistry (4) Trained in dental implant pro-cess, including diagnosis and surgical placement of dental implants and/or the placement of replacement teeth (5) Meets national standards ofeducation and practice in oral implantology. For more information aboutthe AAID and its credentialed members, please visit www.aaid.com or

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