Implant Practice US July 2012 Vol.5.4

clinical articles management advice practice profiles technology reviewsJuly/August 2012 – Vol 5 No 4

CE Articles

Inside!

ALSO INSIDE:Product profile Practice development 3D dialogue

Practice ProfileDr. Daniel Brunner

Dr. Shane McCreaComprehensive dental implantology: part two

Dr. David HolmesPeri-implantitis: causes, treatment, and prevention

Dr. Attiq RahmanPlacement of a single central incisor implant to replace a severely fractured tooth

Practice ProfileDr. Daniel Brunner

Dr. Shane McCreaComprehensive dental implantology: part two

Dr. David HolmesPeri-implantitis: causes, treatment, and prevention

Dr. Attiq RahmanPlacement of a single central incisor implant to replace a severely fractured tooth

Memo from the PublisherJuly/August 2012 – Volume 5 Number 4

MISSION STATEMENT To be a practical journal promoting excellence in implant dentistry by providing a full range of clinical, continuing education, practice management, and technology articles written by leading specialists.

EDITORIAL ADVISORY BOARD Steve Barter BDS, MSurgDent RCS Anthony Bendkowski BDS, LDS RCS, MFGDP, DipDSed, DPDS, MsurgDent Philip Bennett BDS, LDS RCS, FICOI Stephen Byfield BDS, MFGDP, FICD Sanjay Chopra BDS Andrew Dawood BDS, MSc, MRD RCS Professor Nikolaos Donos DDS, MS, PhD Abid Faqir BDS, MFDS RCS, MSc (MedSci) Koray Feran BDS, MSC, LDS RCS, FDS RCS Philip Freiburger BDS, MFGDP (UK) Jeffrey Ganeles, DMD, FACD Mark Hamburger BDS, BChD Mark Haswell BDS, MSc Gareth Jenkins BDS, FDS RCS, MScD Stephen Jones BDS, MSc, MGDS RCS, MRD RCS Gregori M. Kurtzman, DDS Jonathan Lack DDS, CertPerio, FCDS Samuel Lee, DDS David Little DDS Andrew Moore BDS, Dip Imp Dent RCS Ara Nazarian DDS Ken Nicholson BDS, MSc Michael R. Norton BDS, FDS RCS(ed) Rob Oretti BDS, MGDS RCS Christopher Orr BDS, BSc Fazeela Khan-Osborne BDS, LDS RCS, BSc, MSc Jay B. Reznick DMD, MD Nigel Saynor BDS Malcolm Schaller BDS Ashok Sethi BDS, DGDP, MGDS RCS, DUI Harry Shiers BDS, MSc, MGDS, MFDS Harris Sidelsky BDS, LDS RCS, MSc Paul Tipton BDS, MSc, DGDP(UK) Clive Waterman BDS, MDc, DGDP (UK) Peter Young BDS, PhD Brian T. Young DDS, MS

PUBLISHER Lisa Moler Email: [email protected] Tel: (480) 403-1505

MANAGING EDITOR Mali Schantz-Feld Email: [email protected] Tel: (727) 515-5118

ASSISTANT EDITOR Kay Harwell Fernández Email: [email protected]

PRODUCTION MANAGER/CLIENT RELATIONS Kim Murphy Email: [email protected] Tel: (480) 580-8008

NATIONAL SALES/MARKETING MANAGER Drew Thornley Email: [email protected] Tel: (619) 459-9595

E-MEDIA MANAGER/GRAPHIC DESIGNER Deidra Cole Email: [email protected]

PRODUCTION ASSISTANT/SUBSCRIPTION COORDINATOR Lauren Peyton Email: [email protected]

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© FMC 2012. All rights reserved. FMC is part of the specialist publishing group Springer Science+Business Media. The publisher’s written consent must be

obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Implant Practice or the publisher.

Volume 5 Number 4 practice 1

Dear Readers:

Summertime is finally here (as the Kenny Chesney song goes)! While school is out, and many of your patients are happily involved with their summer vacations, we know that you are still hard at work, determined to provide them with the best implant treatments all year round.

As always, Implant Practice US is dedicated to helping you reach your treatment goals by providing new information about every aspect of the implant experience. Part two of Dr. Shane McCrea’s CE presents some implant techniques to use in the presence of soft tissue issues. Dr. Holmes’ CE explores treatment options for peri-implantitis, an obstacle to implant success. In Lab Link, Steve Tyler discusses the advantages of bringing digital technology into the practice, and Dr. Justin Moody shows how mentoring can be helpful and fulfilling for both the beginning practitioner and the “seasoned” clinician. In his 3D Dialogue column, Dr. Steven Guttenberg offers some thought-provoking information on CBCT imaging.

Staying connected and building a relationship with patients is becoming increasingly more important. Just as patients want to know that their dentist cares about them in between appointments, the Implant Practice US team wants to keep you involved in between issues! Please look for us on Facebook, Twitter, LinkedIn, and our website: www.medmarkaz.com/web/.

The MedMark editorial team is always interested in authors for our clinical and CE articles, practice profiles, practice management and development, or technology columns. Please feel free to contact us for more details or writers’ guidelines for submitting an article.

We are all grateful to our authors, peer reviewers, editorial advisory board, advertisers, and columnists, for helping Implant Practice US to evolve into the enriching, thought-provoking, engaging publication it is today. As I say on our website: “The success of our business is achieved as a direct result of helping others succeed in their business.”

I hope that your business continues to thrive and grow, and while you’re at it, remember to save room for some summer fun!

All the best,

Lisa Moler Publisher

Guest editorial

The Digital RevolutionToday, dental implants are presented more and more often as a treatment option to individuals with missing teeth.

The predictable outcome offered by a surface technology that can allow for faster osseointegration, and in many cases, allow a patient to leave the office with immediate tooth replacement, is no longer just a dream. It is becoming the expectation. While the dental profession has celebrated this success, there are still far more teeth removed than are replaced with dental implants. There are many reasons for this, including cost, lack of patient education, and lack of third-party payment coverage. However, one of the most challenging obstacles is that a great number of dentists do not restore dental implants. This is why I am so passionate about encouraging restorative dentists to educate their patients on the many benefits of dental implant placement.

Thanks to advanced technology, the complexities of dental implant restorations are becoming easier. We are on the front lines of an amazing revolution in implant dentistry. At long last, the art and science of dentistry is incorporating the latest engineering principles to create a full digital workflow. We can now employ 3D cone beam technology and guided software for the fabrication of surgical guides that allow us to predictably place implants in the patient’s jaw and help us to avoid vital structures such as nerves and the sinus. Furthermore, we can build upon that technology and have a pre-fabricated provisional ready at the time of dental implant placement, providing us with a predictable and clean restoration for the surgical wound.

The accuracy of dental implant impressions is now enhanced with digital impression units that capture the implant position in the mouth and create a virtual model to allow the technician to fabricate customized abutments and restorations without the need for a traditional stone model. These models, complete with removable analogs, abutments, and restorations, can all be designed and printed or milled with the latest CAD/CAM software and milling machines. This delivers an exceptionally designed restoration with accurate marginal integrity resulting in a precise overall fit of the restoration.

All of these tools are available now and will become a regular part of dental implant education over the next few years. As these technologies continue to advance, we will see an increase in dentists presenting the dental implant treatment option as the standard of care. Why? The cost of restorations will become more predictable and should, in turn, provide the restorative dentist with a restoration that will result in more profit. Secondarily, digital solutions will simplify the implant restorative process for both the dentist and the patient. Digital impressions will decrease chair time by eliminating the time associated with the setting of and potential need to repeat impressions. Digital impressions also promise greater accuracy and predictability of final restorations with regard to marginal integrity, interproximal contacts, and occlusion.

In a recently published report, the global dental implant and prosthetics market was valued at $6,781.7 million in 2011, and it is expected to reach $10,562.2 million by 2016.1 Don’t you want to be a part of this growing market? We have just tapped into the potential of this revolution. I invite you to join me on this cutting-edge journey of digitalization. We are the future of dentistry.

Best regards,

Dr. Scott Bolding

Scott L. Bolding, DDS, MS, is the President and Founder of MaxSurge Healthcare Solutions, a consulting and business resource firm working to enhance the delivery of healthcare to the public by improving business processes for the provider, patient, and employer. A Diplomate of the American Board of Oral and Maxillofacial Surgeons who formerly served as a Board Examiner, Dr. Bolding is a leader in the evolution of digital implant dentistry. He provides extensive training in the latest technologies and has been instrumental in the development of new orthodontically facilitated surgical techniques that have increased the knowledge of alveolar bone development and provide significant advancements in orthodontic results for patients around the country. He has a Bachelor of Science Degree in Medical Sciences from the University of Arkansas, a Doctor of Dental Science from Baylor College of Dentistry in Dallas, Texas, and a Master of Science in Craniofacial Biology from Baylor University, Waco, Texas. He received Oral and Maxillofacial Surgery Training at Baylor University Medical Center.

1. PR Newswire. MarketsandMarkets: Global Dental Implants & Prosthetics Market Worth $10,562.2 Million by 2016. Retrieved June 20, 2012 from http://www.prnewswire.com/news-releases/marketsandmarkets-global-dental-implants--prosthetics-market-worth-105622-million-by-2016-1462453.

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Contents


10Dr. Daniel Brunner

10

14

PRACTICE PROFILE

Through the keyholeDr. Daniel Brunner: Reflections on practicing dentistry and placing implants in paradise

CORPORATE PROFILE

StraumannConfidence on every level

CLINICAL

Reduced-diameter implants as a treatment alternative in risk patients to avoid augmentation proceduresDrs. Hannes P. Schierle, Hans O. Werner, and Franziska Nagel explore treatment for a patient with complicated health issues

Placement of a single central incisor implant to replace a severely fractured toothDr. Attiq Rahman describes how he placed a single central incisor implant in an esthetically demanding young patient with a high lip line and highly characterized adjacent teeth

From intraoral scan to final custom implant restorationDr. Perry E. Jones demonstrates how to fabricate custom all-ceramic implant abutments and a four-unit fixed prosthesis

Tom's storyDr. Will Murphy shares his experience on placing an implant in the esthetic zone and some lessons learned

14Straumann

22Dr. Attiq Rahman

18

26

22

30

Contents


47Dr. Steven A. Guttenberg

CONTINUING EDUCATION

Comprehensive dental implantology:part twoIn the second part of his series, Dr. Shane McCrea explains the importance of soft tissues in implant treatment

Peri-implantitis: causes, treatment, and preventionDr. David Holmes explores this obstacle to implant success

LABORATORY LINK

The digitalization of dentistrySteve Tyler urges dentists to prepare for the future by joining the digital revolution

3D DIALOGUE

Updated information on CBCT safetyDr. Steven A. Guttenberg discusses how the benefits of CBCT imaging outweigh the risks

PRODUCT PROFILE

BIOMET 3iThe PREVAIL® Implant SystemPreservation by Design

PRACTICE DEVELOPMENTThe art of mentoringDr. Justin Moody offers tips on how to be “not just a teacher, but an awakener“

Author's guidelines

Diary

Materials & equipment/Industry news

41Dr. David Holmes

52Dr. Justin Moody

34

45

50

41

47

52

56

54

55

Practice profile


What can you tell us about your background?I am an oral and maxillofacial surgeon in private practice at East Cobb Oral Surgery in Marietta, Georgia. I completed my dental school training at the University of Missouri-Kansas City in 1996, where I received my DDS. I then went on to medical school at the University of Southern California School of Medicine where I received my MD in 1999. I completed my Oral and Maxillofacial Surgery residency in 2002, also at the University of Southern California. I am currently an instructor at the Dental Implant Training Center (DITC) in New Jersey. I am also the founder of Impact Health International and Implants in Paradise, a hands-on surgical training program in the Dominican Republic for dental implant surgery. I have lectured throughout the United States and internationally on implant reconstruction.

Is your practice limited to implants? No, but it is large part of my practice. I practice full-scope oral and max-illofacial surgery in my office.

Why did you decide to focus on implantology? It is very rewarding to reconstruct a patient’s dentition and improve the quality of their life through dental implant reconstructive procedures. Patients who are dentally handicapped are able to have normal function restored through the use of dental implants.

How long have you been practicing, and what systems do you use?I have been in practice for 9 years. I use the MIS® Implants system in my practice. I have been a strong MIS user since 2004. They are an excellent company to work with both on a professional and personal level. The implant and restorative system is both

innovative and predictable. I have had fantastic and consistent results with their system for years.

What training have you undertaken? I completed a 6-year residency in oral and maxillofacial surgery in 2002 from the University of Southern California. The following year, I completed a general surgery internship at St. Joseph Hospital in Denver, Colorado. I also completed the Maxi-Course in Atlanta, Georgia in 2005.

Who has inspired you?My father has probably inspired me the most. He taught me the value of working hard and persevering through difficult situations. He also taught me the value and importance of treating others as I would like to be treated. This has been incorporated into my practice in the way I interact with patients and how I have instructed my staff to treat our patients as well.

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Practice profile


What is the most satisfying aspect of your practice?I have patients who come into my office in pain and suffering. As a surgeon, I have the opportunity to alleviate their suffering almost instantaneously.

Professionally, what are you most proud of?Five years ago, I started a non-profit, Impact Health International, to provide continuing dental education training through hands-on dental implant surgery in the Dominican Republic. The implant training program, “Implants in Paradise,” is a hands-on course in which I train dentists in current dental implant surgery and bone grafting techniques, while providing free dental care to the impoverished in the Dominican Republic. Since the program was started, we have provided over $750,000 worth of dental implant care to those unable to afford even the

most basic dental care. It is amazingly rewarding to see dentists who have never done implant surgery, learn to feel comfortable placing implants after a week of learning, and to see the quality of life improved for the people of the Dominican Republic.

What has been your biggest challenge?I think the biggest challenge has been weeding out employees with a poor work ethic. I pride myself on doing all things with excellence. This is something I want reflected by my staff. Finding employees with this same mentality towards patients and quality of care is of the utmost importance. A great staff is an essential element to a successful practice.

What would you have become if you had not become a dentist?There is nothing else I would rather be doing on a daily basis, than oral and

maxillofacial surgery. I am blessed to get up every morning and do what I love, surgery.

What is the future of implants and dentistry?When I teach general dentists implant surgery, I always tell them that the practice of implant reconstruction is early in its development in the dental profession. Although we have been placing and restoring implants for 30 to 40 years, it is just starting to become mainstream in most practices. I think that we will continue to see refinement of the implant designs as well as new biomaterials that will decrease healing time and increase success. I think that we will continue to see more and more general dentists placing and restoring implants in their practices with the guidance of cone beam technology and guided surgery. I think that the biggest change will be the area of biologicals for bone

What do you think is unique about your practice?My oral surgery office is a boutique practice, designed for patient comfort with the highest quality of care. We built the office with the ability to perform complex oral surgical procedures in an environment that promotes tranquility and minimizes patient anxiety.

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Practice profile


and soft-tissue regeneration. One of the most challenging aspects we face in implant reconstruction today is reconstructing atrophic ridges to ensure proper implant placement and restoration. Bone augmentation procedures are often painful and expensive for our patients. I think we will continue to see more engineered biomodifiers such as rhBMP and WNT being used in site preparation surgeries prior to implant placement. What are your top tips for maintaining a successful practice?Hiring the right staff is key to a successful practice. The front office is the first impression of your practice. More patients are turned off by the staff than by the doctor. You can be the best surgeon, but have horrible staff, and you will see patients fleeing from your practice. Secondly, listen to your patients and determine what their needs and desires are. Patients like to know that their desires are understood and responded to.

What advice would you give to budding implantologists?I would recommend that they would be perpetual students of their practice. The more they can invest in themselves

as far as educational opportunities, the better their practice is going to be. I would also encourage them to give back. As part of the dental profession, we have been given so much in terms of financial success and quality of life. The philosophy of “to whom much is given, much is required,” should be how we operate daily.

What are your hobbies, and what do you do in your spare time?I recently had the opportunity to SCUBA dive in the Red Sea. This was on the top of my to-do list for years, and I would recommend it for any diving enthusiast. We also enjoy English fox hunting in the fall, and the experience of galloping through the Georgia countryside on horseback is a must for any horse lover. We own a small farm and spend time growing and cultivating organic fruits and vegetables.

The philosophy of “to whom much is given,much is required,” should be how we operate daily.

Top Ten Favorites List

1. Family

2. Fellowship with friends

3. Dedicated office staff

4. My German Shepherds

5. Sitting on the shore of the Sea of Galilee

6. MIS® Drill Stopper Kit

7. Piezosurgery® unit

8. Versed® IV

9. Dominican Republic chinola with raw cane sugar

10. Morning coffee

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Corporate profile


Straumann® – a global leader in implant dentistry offering

surgical, restorative, regenerative, and digital solutions for the dental and lab business – is a pioneer of innovative technologies. With world-class customer service, highly skilled technical support, and a team of experienced professionals readily available to you, Straumann strives to be your commercial partner of choice.

When clinicians think quality, they think Straumann. Straumann delivers products, systems, and services designed to improve efficiency and streamline workflows, offering confidence on every level. From the complete line of Soft Tissue Level and Bone Level implants to the implementation of a full digital portfolio, Straumann has transformed into a total solutions company on the cutting edge of today’s – and tomorrow’s – market needs. Innovation is an important industry driver. New materials and minimally invasive techniques, along with educated consumers, can open the door to a larger number of patients who have

not been able to – or have avoided – implant treatment. Straumann works with you to open those doors. With its corporate headquarters in Basel, Switzerland, and North American headquarters in Andover, Massachusetts, Straumann’s products and services are available in more than 70 countries. Having pioneered many influential technologies and techniques in dentistry, the company’s mission is to enable dental professionals to restore their patients’ dental function and overall oral health.

History

Straumann’s long history of simply doing more began in 1954 when Reinhard Straumann, drawing on his experience in engineering and the Swiss watch industry, founded the Dr. Ing. R. Straumann Research Institute AG, focusing on metallurgical research. The company – having remained true to the vision of its founder – still draws upon Dr. Straumann’s legacy of precision, scientific proof and pushing

StraumannConfidence on every level

“Straumann continues to develop products and solutions that enable us to treat our patients based on the latest research. Most importantly, these solutions and products are well documented and evidence based.“ – Dr. Robert A. Levine, Philadelphia, PA

“Straumann is not just my implant partner. Straumann is my dental partner.“ – Dr. Dean Morton, University of Louisville School of Dentistry, KY

the boundaries of innovation. Between 1954 and 1970, the company specialized in materials testing and alloys used in timing instruments. A breakthrough in the use of non-corroding alloys for treating bone fractures prompted Dr. Fritz Straumann, the founder’s son, to enter the fields of orthopedics and dental implantology. With a commitment to the core principles of simplicity, precision, and innovation, Straumann evolved into a leading manufacturer of dental implants between 1970 and 1990.

Confidence based on evidence

Straumann has won the confidence of its customers with this promise: A strong foundation of scientific and clinical evidence supporting the specialization, reliability, and simplicity that define every Straumann solution. With more than 3,000 published peer-reviewed studies along with what has been learned in more than 50 years of research in various scientific fields, Straumann products have demonstrated their long-term effectiveness through research studies following good clinical practice. This reliability made the Straumann® Dental Implant System one of the most widely used systems in the world with more than 9 million implants sold. Straumann’s 30-year relationship with the International Team for Implantology (ITI) unites more than 11,000 dental professionals from all fields of implant dentistry and dental tissue regeneration. An independent academic association, ITI actively promotes networking and exchange among its members at meetings, courses, and congresses with the

objective of improving treatment methods and outcomes for the benefit of their patients.

Tradition of innovationThe number of innovations Straumann has produced continues to grow, from the SLA® implant surface in 1998 to the hydrophilic SLActive® implant surface in 2006, the Roxolid® material in 2009 to a new generation of small diameter implant – the Narrow Neck CrossFit® – in 2012. Straumann’s dedication to innovation provides clinicians with the products they need to meet the clinicial demands in daily practice.

The Straumann Dental Implant System – Surgical and Restorative SolutionsWhat does simplicity mean? One system. One kit. A variety of indications. Straumann offers a complete line of both Soft Tissue Level and Bone Level implants for maximum flexiblity and efficiency with SLA and SLActive surface technologies designed for treatment predictability and your choice of titanium grade 4 or Roxolid material, which is designed to provide more confidence in small diameter implants. With characteristics such as double roughness treatment for greater bone-to-implant contact, the SLA implant surface is designed to allow loading in just 6 weeks after implant placement in healthy patients with sufficient bone quality and quantity. The SLActive surface takes the topography of the SLA surface to the next level. Through its surface chemistry, it is designed to deliver faster osseointegration1 to enhance confidence in all treatments, reduce healing times from 6-8 weeks to 3-4 weeks2 and increase predictability in stability-critical treatment protocols. The Roxolid material enabled the design of the Narrow Neck CrossFit Implant. Roxolid, the first titanium-zirconium alloy developed specifically for the needs of dental implantology,

features higher fatigue and tensile strengths3 and osseointegration when compared to Straumann SLActive titanium implants. The CrossFit Connection is designed to provide a secure and precise fit between the Straumann implant and authentic Straumann abutments. Straumann Regeneration SolutionsStraumann offers a complete portfolio of oral tissue regeneration solutions for various treatment situations. Some of the most exciting research and development within the dental market is being conducted on regeneration, showing the body’s potential to rebuild lost structures. Straumann is on the forefront of this research with the development of the polyethylene glycol (PEG) technology and more expansive research on enamel matrix derivative (EMD) and its uses.

With over 400 clinical publications, including results over 10 years, Straumann® Emdogain™ is a protein-based gel designed to promote predictable regeneration of lost periodontal hard and soft tissue, helping to save and stabilize teeth. Clinicians have learned that treating gingival recession cases may be an

important strategy in practice growth, and the use of Emdogain4 may decrease unpleasant tooth sensitivity and pain, support the regeneration of lost bone and tissue5, and boost confidence by providing a more natural-looking appearance6. Straumann® Bone Graft Solutions provide a choice of quality products designed to support the regeneration of the patient’s own vital bone. Straumann® AlloGraft is processed with LifeNet Health®’s proprietary and patented Allowash XG® technology, designed to remove and inactivate viruses and bacteria with a Sterility Assurance Level (SAL) of 10-6 and maintain the biomechanical and/or biochemical properties of the tissue. Straumann delivers several AlloGraft products, each designed to meet a specific clinical and patient need. The latest addition to the regeneration family is Straumann® MembraGel®, an advanced technology hydrogel membrane used in treatment with GBR. This next generation membrane is precise, simple, and quick in application. With its gel-like consistency and its formation in situ, MembraGel is adaptable to various types and sizes of bone defects and can be precisely applied to the surgical site. MembraGel is designed to function as a barrier to prevent ingrowth of soft tissue into the defect region and to stabilize the underlying bone graft material, confining it to the site of bone augmentation. Straumann MembraGel launched in conjunction with a well-received, specialized education program that includes hands-on product training and covers all aspects of the application.

On the cutting edge of digital dentistryWhat will shape the future of

Corporate profile


“If you really want to make narrow diameter implants, new materials will be needed.“ – Jan Gottlow, University of Gothenburg

“The addition of Emdogain to my practice has not only been a practice builder, but it has truly been a game changer. Its addition has helped me achieve outstanding results in otherwise extremely challenging situations.“ – Dr. Jennifer Doobrow, Birmingham, AL

Corporate profile


References

1. Compared to SLA® in an animal model

2. Compared to SLA

3. Data on file. Norm ASTM F67 (states min. tensile strength of annealed titanium).

4. In combination with coronally advanced flap

5. McGuire, MK and Nunn, M (2003). Evaluation of human recession defects treated with coronally advanced flaps and either enamel matrix derivative or connective tissue. Part 2: Histologic evaluation. J Periodontol 74:1126-1135.

6. McGuire, MK and Nunn, M (2003). Evaluation of human recession defects treated with coronally advanced flaps and either enamel matrix derivative or connective tissue. Part 1: Comparison of clinical parameters. J Periodontol 74:1110-1125.

dentistry? Digitalization. Straumann’s complete digital package is designed for seamless connectivity to simplify workflows and offer interdisciplinary care among the treatment team. Straumann® CARES® Digital Solutions delivers a full prosthetic digital workflow across guided surgery, intraoral scanning, and CAD/CAM technology that is reliable, precise, and dedicated to the needs of clinicians and laboratory technicians. Straumann® CARES® Digital SolutionsStraumann® CARES® Guided Surgery offers a clear view of patient bone structure, nerve position, vascular structures, and the final implant location to simplify the planning and execution of complex procedures with the goal of reducing surgical and prosthetic complications. Guided surgery based on computerized 3D treatment planning software can offer the surgeon more predictable outcomes and more accurate financial estimates for the patient. Guided surgery and 3D treatment planning have expanded the ability to communicate with referrals and patients. This can lead to improved case acceptance and practice growth. Straumann® CARES® CAD/CAM is an integrated prosthetic design system, including a state-of-the-art scanner, software, and a leading material offering and applications range. Through alliances with industry leaders such as Ivoclar Vivadent AG®, 3M ESPE, and VITA, Straumann offers high-performance ceramic materials for first-class esthetic restorations. From customized abutments to screw-retained bar and bridge solutions,

applications are available for a multitude of patient situations. Intraoral scanning from Align iTero™ can replace conventional impression taking and enables the lab to digitally design CAD/CAM crowns, bridges or customized abutment restorations without the need for a stone model. Straumann’s goal is to help you reduce time to the final restoration, eliminate manual processes, and decrease remakes via a CAD/CAM production process via a digital workflow.

Simply Doing MoreSM

Straumann is invested in much more than scientifically supported products, world-class service and total solutions. The company is honored to play a vital role in the support of NFED – the National Foundation of Ectodermal Dysplasias (ED) – a non-profit organization that provides comprehensive services with loving care to individuals affected by ectodermal dysplasias and their families. Their mission is to empower and connect people touched by ectodermal dysplasias through education, support, and research. Straumann has a long-standing commitment supporting the NFED and raised more than $201,000 in 2011 alone. In addition to financial support, the company offers free implants and prosthetic components to ED patients, while many clinicians dedicate and donate their time and talent in treating these patients.

The future is nowStraumann is working on multiple initiatives that will help shape the

future of dentistry. Dedication to research has allowed Straumann to deliver meaningful innovations that help clinicians improve the quality of care and life for patients. Straumann values the long-standing trust of customers, working with clinicians to help grow their practices through a variety of channels. From comprehensive continuing education courses designed to deliver the latest technologies and clinically relevant scientific information for surgical and restorative clinicians, office staff and dental labs to customer loyalty programs, Straumann stands behind more than just their products – Straumann stands behind their customers. With a full pipeline of innovative technologies, products, services and solutions to address the changing trends in dentistry, clinicians should want to choose Straumann as their partner of choice. At Straumann, the future is today.

This information was provided by Straumann.

“Straumann is on the front lines with me every day. They have the ability to evolve while my practice evolves.“ – Dr. Mark Gutt, Miami, FL

DIGITAL IMPRESSIONSCHAIRSIDE DIGITAL IMPLANT IMPRESSIONS

CADCAMDIGITAL DESIGN & MANUFACTURING

GUIDED SURGERY COLLABORATIVE TREATMENT PLANNING

CONFIDENCE ON EVERY LEVEL IMPLANTS PROSTHETICS REGENERATIVE THERAPIES DIGITAL DENTISTRY

Please contact us at 800/448 8168

More information on www.straumann.us

Clinical


New implant material for extended indication where bone supply is limited The ITI (International Team for Implantology) began very early on to make strict demands with regard to the diameter of implants for treating different indication classes. On the one hand, this gave the clinician a certain safety margin regarding the employed implant components, but on the other hand, a restoration that complied with the ITI was often possible only after previous and sometimes complex augmentation. With the development of Roxolid™ (Straumann®), the new implant material, we are now able to treat even situations with a limited bone supply in unusual indications without comprehensive augmentation measures.

Case descriptionThis case describes the treatment of a 52-year-old patient with severe osteoporosis of the skeletal system who was on a daily dose of 150 mg of Bonviva® (Roche) (oral bisphosphonate). She was not a smoker. Her wish was for a fixed dental prosthesis, but this could not be met in the conventional prosthetic manner because of the abutment situation. Because of the previous history, apicectomies had been performed on teeth Nos. 24 and 26, and in conjunction with the final extraction of the teeth, this led to loss of the buccal layer of the alveolar process in this region. Harvesting of a bone block and other invasive measures to prepare the implant site were declined by the patient out of concern regarding complications because of her existing underlying disease and medication, and she also declined a two-stage procedure.

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Reduced-diameter implants as a treatment alternative in risk patients to avoid augmentation proceduresDrs. Hannes P. Schierle, Hans O. Werner, and Franziska Nagel explore treatment for a patient with complicated health issues

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FindingsThe clinical and radiographic examination shows moderate generalized horizontal bone atrophy in the maxilla and mandible, and atrophy of the alveolar process in the vertical dimension of region 26 with loss of the buccal layer at teeth Nos. 24 to 25 (Figures 1 and 2). There was no increased tooth mobility, and the probing depths were not in the pathological range. The patient’s oral hygiene at home could be classified as good, and the reduced residual dentition was adequately restored prosthetically and conservatively. Teeth Nos. 16, 15, and 45 had had endodontic treatment. There were no occlusion problems, and the functional parameters were in the normal range.

DiagnosisA diagnosis was made of a saddle area in region 24 to 26, vertical alveolar ridge atrophy in region 26, and bone deficit in the transverse direction in region 24 to 26 with deficit of the buccal layer at 24.

Treatment planningTo restore the saddle area in region 24 to 26, an implant-borne bridge was planned with implants in positions 24 and 26. The treatment plan provided for sinus floor augmentation in region 26 via a facial approach. Teeth 24 and 26 had been removed approximately

12 weeks before the start of treatment. The residual bone supply was considered adequate to allow a single-stage procedure. Insertion of a reduced-diameter implant in region 24 was planned. This was intended to circumvent an onlay bone graft in the form of a bone plug or extension graft in this region. The planning documentation consisted of study models, X-ray gauge, and drill template, and orthopantomograph with X-ray gauge and drill template (Figure 3).

Surgical procedureThe bony structures were first exposed through a ridge incision with a mesial relieving incision on the vestibular aspect, sparing the papilla distal to tooth No. 23 and leaving it in situ

Professor H. P. Schierle is a specialist in oral and maxillofacial surgery and plastic surgery, has a teaching contract at the Medical College Hannover, Germany, is director of several post-graduate courses in oral surgery and implantology, a continuing education consultant, and has an oral surgery practice in Karlsruhe and Landau, Germany.

Dr. H. O. Werner is a specialist in oral and maxillofacial surgery, a continuing education consultant, and has an oral surgery practice in Karlsruhe and Landau, Germany.

Dr. Franziska Nagel is a specialist resident in oral surgery, Karlsruhe and Landau, Germany.

Clinical


(Figure 4). The facial window for sinus augmentation was first dissected extensively with a bone scraper (Safescraper® TWIST, Osteogenics Biomedical), and the area of dissection was extended as far as the cranial regions of the zygomaticoalveolar crest (Figure 5). The next step was preparation of the lateral window for sinus floor elevation with a spherical diamond bur. The site was prepared for sinus augmentation by dissecting off the Schneiderian membrane in all three spatial directions, first filling the space

palatal to implant 26 with bone chips from the zygomaticoalveolar crest. With the drill template inserted, pilot holes were then drilled in regions 24 and 26. Because of the very spongy and soft type III bone quality, subsequent preparation of the implant bed was with osteotomes. An innovative bone level implant with a reduced diameter (Ø 3.3 mm, SLActive® 12 mm) made of titanium and zirconium (Roxolid) was inserted in region 24. A Straumann NC Bone Level Implant was inserted in region 26 (Ø 4.1 mm, SLActive 10

mm). Following insertion, there was a facial fenestration defect in region 24 (Figures 7 and 8). This defect was covered with a mixture of autologous bone chips and blood. The remaining bone chips were used together with a hemostyptic to reinforce the sinus floor (Figures 6 and 7).

Membrane for GBR technique An absorbable membrane was then applied to the facial bone defect in region 24, and the access window in region 26 for protection and to stabilize the position of the graft (Figures 7

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Clinical


and 8). The wound was closed with interrupted sutures (Figure 9). The postoperative orthopantomogram (OPG) shows the positioning of the inserted implants, which corresponds with the optimal prosthetic position given by the drill template (Figure 10).

ExposureAfter a healing period of about 10 weeks, the implants were exposed. The OPG after exposure shows very good peri-implant bone, especially crestally in the area of the implant shoulders (Figure 11).

Prosthetic restorationProsthetic restoration took place after an interval of 2 weeks following

exposure. Figures 12 and 13 show the completed restoration 6 months after implant insertion.

ConclusionThe ideal restoration with a fixed implant-borne dental prosthesis continues to be based on conditioning the hard and soft tissue structures with a view to the final prosthetic result. Deviation from this concept is possible in special cases in agreement with the patient and outside the esthetic area. However, in order to avoid compromises with regard to the long-term stability, the new Roxolid implant material represents an ideal addition to the Straumann Dental Implant System.

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References

Barter S, et al., (2008). Clinical results presented at the 17th annual scientific meeting of the European Association for Osseointegration (EAO), Warsaw, September 2008.

Gottlow J, et al., (2008). Preclinical data presented at the 23rd annual meeting of the Academy of Osseointegration (AO), Boston, February 2008, and at the 17th Annual Scientific Meeting of the European Association for Osseointegration (EAO), Warsaw, September 2008.

Buser D, Von Arx T, Ten Bruggenkate, et al., (2000). Basic surgical principles with ITI implants. Clin Oral Impl Res 11:59-68.

Clinical


The most challenging scenario for an esthetic dentist to deal with

must be that of a single central incisor implant in an esthetically demanding young patient with a high lip line and highly characterized adjacent teeth. Thankfully such a “perfect storm” is a relatively rare occurrence – however in practice, the most challenging cases can present themselves without warning, and in the unlikeliest of patients.

Case studyThis case is of a 27-year-old female patient who attended the practice in the hope of finding an effective method of whitening her teeth. There was no significant medical history, and her oral hygiene and periodontal condition were excellent. She had tried various teeth-whitening systems before, but none had been particularly successful. Her teeth were judged to be similar to C1 on the Vita shade guide, and it was decided to treat the patient with deep bleaching (Figure 1). For this patient, we achieved BL1/ BL2 on the bleached shade guide, and naturally, she was very happy with the result (Figure 2). In an ideal world, the story would have ended there. However in this case, an unfortunate event was literally just around the corner. Having left the practice, the patient was on her way to meet some friends when she slipped on an icy pavement and fell, fracturing tooth No. 21 both horizontally and vertically (Figures 3 and 4). The patient returned the next morning, and the tooth was examined, confirming the fact that it was unrestorable. Having listened to all the treatment options, the patient decided to opt for an implant, but she

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Placement of a single central incisor implant to replace a severely fractured toothDr. Attiq Rahman describes how he placed a single central incisor implant in an esthetically demanding young patient with a high lip line and highly characterized adjacent teeth

Dr. Attiq Rahman graduated in 1994 from the University of Glasgow and is the clinical director of Visage Lifestyle Clinic, a multidisciplinary practice in Glasgow City Centre, Scotland. He is a full-time esthetic dentist and has led Visage to seven national industry awards including Smile Makeover of the Year, Most Innovative Practice, and most recently, Practice of the Year at the 2010 Dentistry Awards. He has pursued a relentless program of post-graduate study in the field of implants, esthetics, and occlusion, and has attended many courses in the U.K. as well as the U.S., Turkey, Spain, Portugal and Monaco. In 2009, he established Visage Dental Lab, which now serves some of the U.K.’s best-known esthetic dentists.

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was not prepared to wear a denture after extraction.

Surgical procedureUnder normal circumstances, I would have waited 6 weeks post-extraction before implant placement to allow for the inevitable resorption of bundle bone (the bone directly lining the socket and to which the PDL is attached) and soft tissue closure. This approach usually requires some guided bone regeneration at the time of placing the implant to replace the lost volume after extraction, but it has the advantage of creating extra height of soft tissue that can be subsequently manipulated with the

use of a screw-retained temporary resin crown (Sinfony). However, in this case, the luxury of time wasn’t there, and therefore, it was decided to extract the tooth and place an immediate implant and temporary crown. The disadvantage of this approach is that in some cases the aforementioned resorption can result in recession of the gingival cuff, especially when it is not well supported by an abutment that allows soft tissue integration. In an effort to minimize this risk, it was decided to create an abutment that was an exact copy of the original root, thus optimizing the soft tissue support. Periotomes were used to extract

Clinical


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the tooth without loss of the labial plate and an implant placed (Nobel Replace® Select™ Tapered 4.3 mm [Nobel Biocare®]). An impression of the implant was taken using a closed tray technique, after which some BioOss® (Geistlich) was used to fill the extraction socket around the implant. An immediate temporary abutment was fitted, together with an acrylic crown (Luxatemp) made from a pre-extraction alginate of tooth No. 21 after a composite repair. This not only looked acceptable but also preserved the gingival architecture that is so important in a patient like this with a high lip line (Figure 5).

Restorative procedureThe extracted tooth No. 21 was then sectioned and accurately positioned on the working model with the aid of resin matrices made from the pre-op model (Figures 6-9). A soft tissue

mask was then applied in order to replicate the original soft tissue, and the final abutment shape was waxed up to the correct form onto a stock titanium abutment (Figures 10 to 14). This was then used to create the final shaded IPS e.max® abutment (Ivoclar Vivadent) [Figures 15 and 16], which was bonded to the stock titanium abutment using Ivoclar’s Multilink® Implant cement. It was fitted a couple of weeks later together with a cement-retained temp crown. The fact that the abutment was identical in shape to the original root meant that there was no pressure on, or deflection of, the soft tissue when the abutment was placed. This would suggest good long-term stability for the gingival position of tooth No. 21. Following 3 months of healing time, impressions were taken for the final crown at 21; however, the highly characterized nature of the

adjacent teeth meant that this was an exceptionally challenging case (Figures 17 and 18). It was also found that during the course of even the shortest shade-matching appointment, the adjacent teeth would dehydrate and become higher in value. Since the patient breathed through her mouth when asleep, her teeth were a higher value in the morning than they were at midday, and so it became necessary to assess the shade in the afternoon when the teeth had rehydrated. The patient also had to be asked to refrain from talking on the phone while walking to the practice, as bizarrely, the exposure to cold air had a profound effect on the value. The crown was tried in as a bisque bake and checked for size, shape, hue, and value. Occlusal adjustments were completed after which the final touches were applied to the crown while it was in situ (Figure 22). It

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Clinical


was then carefully removed from the mouth and put through final staining and glazing fires in the furnace. The crown was finally cemented (Figure 23) using clear temporary cement (Tempbond Clear, Kerr).

ConclusionThis case was extremely challenging,

not only because of its “perfect storm” combination of complicating factors, but also because it was completely unexpected. Overcoming these challenges was highly rewarding for all concerned, especially when the patient reports that most of her friends and family don’t even know that she has lost a tooth.

AcknowledgementsThanks are due to specialist technician Andrew Conboy at Visage Dental lab for his skills in making the anatomically accurate abutment. Thanks also to master ceramist Ian Smith at Visage Dental Lab, whose artistry and patience helped in achieving a beautiful result and a happy patient.

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Clinical


IntroductionThis case demonstrates the optical scanning of Inclusive® Scanning Abutments (Glidewell Laboratories) utilizing the iTero™ digital scanning system (Align Technology) with software version 4.0. Digital data was used with laboratory CAD/CAM planning to fabricate custom all-ceramic implant abutments and a four-unit fixed prosthesis. The abutments and fixed prosthesis were fabricated using advanced computer-aided milling technology.

Dental historyThe patient was a 52-year-old healthy Hispanic male who sustained a traumatic avulsion and lost his maxillary incisors in an automobile accident. Following healing, a four-tooth transitional, removable partial denture was constructed. He was seen by the oral and maxillofacial surgery service of Virginia Commonwealth University for dental implant therapy.

Treatment planThe patient was informed of the alternatives, benefits, and potential complications of various treatment options before deciding to pursue implant restoration of his missing teeth. The treatment plan included placement of two Replace® Select Straight RP 4.3 x 13 mm implants (Nobel Biocare®) with 5 mm healing abutments, followed by a 6-month healing period and restoration with all-ceramic custom abutments and a four-unit all-ceramic fixed prosthesis to restore the anterior incisors to form and function.

Surgical procedureUsing local anesthesia, two Replace Select Straight RP implant fixtures were placed in the area of teeth Nos. 7 and 10 using standard Nobel implant placement protocol. Placement angulation and depth were verified and deemed satisfactory. Standard RP

5 mm healing abutments were placed, and the fully reflected tissue flap was closed with interrupted sutures.

Restorative procedureFollowing 6 months of healing post-implant placement, intraoral photos were taken to record and confirm the healthy remaining dentition. Osseous integration was confirmed with a panoramic X-ray, followed by resonance frequency analysis (RFA) using an Osstell® ISQ implant stability meter with SmartPeg™ attachment (Osstell Inc. USA), which displayed an implant stability quotient (ISQ) of 78 on a minimum-to-maximum scale of 1–100. Counter rotation with a torque wrench confirmed no rotation to 35 Ncm. The implant fixtures were considered acceptable for restoration. The 5 mm healing abutments were removed, Inclusive Scanning Abutments were placed on the implants, and the accompanying titanium screws were tightened (Figure 1). Using the iTero scanner with updated software (version 4.0), a full maxillary arch scan, full mandibular arch scan, and centric bite in maximum intercuspation were completed. A three-dimensional digital record of the patient’s anatomy was created from these scans and electronically submitted to Glidewell Laboratories to be used in the CAD/CAM restoration process. At Glidewell Laboratories, the virtual scan was registered to the scanning abutments, providing the dental technicians with the implant system, size, axis, position relative to the adjacent anatomy, and locking feature orientation. A virtual zirconia abutment was designed using 3Shape’s DentalDesigner™ software (3Shape Inc. and the Glidewell Digital Abutment Library, Figure 2). From this, the corresponding physical Inclusive All-Zirconia Custom Abutments (Glidewell Laboratories)

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From intraoral scan to final custom implant restorationDr. Perry E. Jones demonstrates how to fabricate custom all-ceramic implant abutments and a four-unit fixed prosthesis

Dr. Perry Jones received his DDS from Virginia Commonwealth University School of Dentistry, where he has held adjunct faculty positions since 1976. He maintains a private practice in Richmond, Virginia. One of the

first GP Invisalign® providers, Dr. Jones has been a member of Align’s Speaker Team since 2002, presenting more than 250 Invisalign presentations. He has been involved with Cadent optical scanning technology since its release to the GP market and is currently beta testing its newest software. Dr. Jones belongs to numerous dental associations and is a fellow of the AGD.

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Clinical

were milled. Similarly, a BruxZir® Solid Zirconia four-unit fixed bridge (Glidewell Laboratories) was designed and milled using state-of-the-art CAD/CAM technology. The custom zirconia abutments were trial-fitted in the patient’s mouth with some slight tissue blanching noted (Figure 3). In the same visit, the final four-unit all-ceramic milled BruxZir Solid Zirconia bridge was tried in and examined for proper occlusion. There was “tight” anterior coupling for this case as evidenced by the history of provisional denture fracture. The occlusion was checked and presented as so precise that no adjustment was required. The anterior view of the final prosthesis demonstrates optimal mesial-distal width proportion, incisal edge proportion, pontic-tissue contact, and excellent shade/esthetics (Figure 4). Further, the occlusal view demonstrates an optimal incisal edge arch form. The soft tissue lip position and speech phonetics appeared to be

ReferencesBaldissara P, Llukacej A, Ciocca L, Valandro FL, Scotti R (2010). Translucency of zirconia copings made with different CAD/CAM systems. J Prosthet Dent. Jul;104(1):6-12.Birnbaum NS, Aaronson HB (2008). Dental impressions using 3D digital scanners: virtual becomes reality. Compend Contin Educ Dent. Oct;29(8): 494, 496, 498-505.Chang YB, Xia JJ, Gateno J, Xiong X, Zhou X, Wong ST (2010). An automatic and robust algorithm of reestablishment of digital dental occlusion. IEEE Trans Med Imaging. Sep;29(9):1652-63.Christensen GJ (2008). Will digital impressions eliminate the current problem with conventional impressions? J Am Dent Assoc. Jun;139(6):761-3.Drago C, Saldarriaga RL, Domagala D, Almasri R (2010). Volumetric determination of the amount of misfit in CAD/CAM and cast implant frameworks: a multicenter laboratory study. Int J Oral Maxillofac Implants. Sep-Oct;25(5):920-9.Ender A, Mehl A (2011). Full arch scans: conventional versus digital impressions — an in-vitro study. Int J Comput Dent. 14(1):11-21.Fasbinder DJ (2010). Digital dentistry: innovation for restorative treatment. Compend Contin Educ Dent. 31(4):2-11.Garg AK (2008). Cadent iTero’s digital system for dental impressions: the end of trays and putty? Dent Implantol Update. Jan;19(1): 1-4.

Henderson, S (2011). Align Technology completes acquisition of intra-oral scanning leader Cadent. May 2 [cited 2011 Oct 17]. Available from: http://investor.aligntech.com/releasedetail.cfm?releaseid=573469.Jones PE (2009). Cadent iTero digital impression case study: full-arch fixed provisional bridge. DC Dentalcompare. Jul 8 [cited 2011 Jul 28]. Available from: http://www.dentalcompare.com/Featured-Articles/2082-Cadent-iTero-Digital-Impression-Case-Study-Full-Arch-Fixed-Provisional-Bridge/. Jones PE (2011). Cadent iTero optical scanning digital impressions for restorative and invisalign. Dental Product Shopper. Jun 28 [cited 2011 Jul 29]. Available from: http://dentalproductshopper.reachlocal.net/articles/cadent-itero-optical-scanning-digital-impressions-restorative-and-invisalign. Kurbad A (2011). Impression-free production techniques. Int J Comput Dent. 14(1):59-66.Priest G (2005). Virtual-designed and computer-milled implant abutments. J Oral Maxillofac Surg. Sep;63(9 Suppl 2):22-32.Smith R (2010). Creating well-fitting restorations with a digital impression system. Compend Contin Educ Dent. Oct;31(8):640-4.Touchstone A, Nieting T, Ulmer N (2010). Digital transition: the collaboration between dentists and laboratory technicians on CAD/CAM restorations. J Am Dent Assoc. 141 Suppl 2:15S-9S.Zweig A (2009). Improving impressions: go digital! Dent Today. Nov;28(11):100, 102, 104.

optimal. Following the trial seating, the fixed bridge was removed, the zirconia abutment retention screws torqued to 35 Ncm, the abutment screws covered with cotton/Cavit™ Temporary Filling Material (3M™

ESPE™), and the prosthesis cemented with GC Fuji PLUS™ (GC America).

Note: Cadent Inc. was acquired by Align Technology in May 2011.


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Clinical


Tom was a new patient who presented to our practice

requesting a replacement front tooth. Eighteen months previously, Tom had been assaulted resulting in the loss of his upper left central incisor tooth. His general dental practitioner had made a partial acrylic denture at the time. Tom indicated that he was dissatisfied with having a removable tooth and wished to discuss the options for having a fixed tooth. Our discussion included adhesive and conventional bridges, along with implant therapy. Tom did not wish to have extensive sound enamel removed from neighboring teeth in order to support a bridge, and decided that he would prefer a dental implant to support a crown. He was also unhappy with the appearance of his upper right central incisor, which was chipped and discolored. He indicated that he would be prepared to have a veneer with a small amount of preparation on this tooth to restore esthetics and function. It was pointed out that from a visual inspection, he might expect that the buccal plate of bone could be compromised, and this would need further investigation. It was explained that in this circumstance, a small amount of his own bone could be taken from his chin or mandible and grafted onto the site to provide sufficient bone volume in which to place an implant. A small section cone-beam CT was taken, which revealed that the width of the alveolus was insufficient to house an implant. It also demonstrated the position of the inferior dental nerve at the donor graft site. Study models were cast and a tooth waxed up, along with the construction of a temporary Rochette-type bridge. The surrounding hard and soft tissue was waxed up in pink wax to demonstrate the alveolar dehiscence and enhance the communication and consent

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Tom’s StoryDr. Will Murphy shares his experience on placing an implant in the esthetic zone and some lessons learned

Will Murphy, Clinical Director, BDS, MFGDP (UK), DipImpDent RCS (England), graduated from The University of Birmingham in 1991 and has practiced in the city ever since. He has a special interest in implant dentistry and cosmetic dentistry. Dr. Murphy plays an active role in post-graduate education and has, for many years, tutored candidates for their membership exams at the Royal College of Surgeons. He has completed many advanced courses in restorative esthetic dentistry, holds the membership of the FGDP (UK), and has recently passed the prestigious Implant Diploma at the Royal College of Surgeons. He also holds the position of Clinical Assistant in Oral Surgery at the Queen Elizabeth Hospital in Birmingham, England.

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Clinical


process. I find that this is vital for setting patient expectations in esthetic areas. An autogenous block graft was taken from the ascending ramus of the mandible using piezosurgery. Although some surgeons find this a slow process, I really like the precision of the cuts and the safety of knowing soft tissues won’t be damaged. Tom was monitored closely over the following 8 weeks. After 10 weeks, the head of the screw was beginning to show through the soft tissues,

indicating that some resorption of the graft was starting to occur. Tom was scheduled for implant placement 2 weeks later. The placement surgery was uneventful and stress-free, knowing that suitable dimensions of bone were present for implant placement with adequate buccal bone to allow good soft tissue support. Soft tissue healing continued over the next 10 weeks. A transfer post impression was taken at the same time as a veneer preparation for tooth No.

11. Acrylic temporary restorations were constructed, which were adjusted regularly with flowable composite over the following 12 weeks. At the end of this period, the temporaries had sculpted the soft tissues to promote the most favorable emergence profile. I like to try in copings to check marginal integrity before the porcelain is added. This allows me to pick up the coping and get an up-to-date impression of the soft tissue profile. Tom was pleased with the overall result of his restoration. His

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Clinical


expectations were to restore his upper left central incisor and be rid of his removable acrylic denture. Both he and I feel that these expectations were met. On reflection, I should have spent more time discussing the postoperative discomfort of the grafting procedure, as he felt significant discomfort from

the donor site. I also could have used a much larger graft in terms of length, as this would have improved the soft tissue support. I was fortunate that the base of the alveolus did not have the same extent of dehiscence as the crest of the ridge. Tom’s soft tissue biotype was quite thick, which was advantageous for the soft tissue

emergence profile. I have definitely learned to be much more vigilant in assessing soft tissue biotypes in the esthetic regions, as this can almost certainly be a deciding factor in the final cosmetic result.

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Continuing education

Historically, implant dentistry has been plagued by a lack of

knowledge and uncertainty as to the clinical outcomes from various surgical techniques. This uncertainty has restricted the application of many tried and tested surgical techniques, such that they are applied with extreme caution and only as individual surgical experiences. This article presents the application of multiple techniques with the rationale for their usage, all of which will aid the successful clinical outcome of dental implant therapy. This multiple usage scenario is carried out within a single surgical setting to the benefit and comfort of the patient.

SynopsisThis series is the step-by-step description of the comprehensive application of a number of surgical procedures that can be carried out by the able/skilled practitioner in a single surgical sitting, illustrated by a multitude of cases with a minimum of 12 months post-loading follow-up. The following will be illustrated: tooth extraction and immediate insertion of implants into modified sockets, whether suffering apical or chronic periodontitis with marked bone loss. Consecutive xenograft application followed by the creation of a mucogingival complex that can be stable in an area prone to gingival recession as a result of “thin-gum” phenotype, or reduced width of keratinized gingival tissue using the subepithelial connective tissue graft (SCTG) in a variety of fixations and the pocket-lining pedicle flap (PLPF). The results will be the establishment of an esthetically-pleasing peri-implant mucogingival complex.

Correction of pre-existing gingival recessionProvided full diagnostic assessment is

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Comprehensive dental implantology: part twoIn the second part of his series, Dr. Shane McCrea explains the importance of the soft tissues in implant treatment

Educational aims and objectivesThe aim of this article is to present multiple techniques for implant treatment.

Expected outcomesCorrectly answering the questions on page 40, worth 2 hours of CE, will demonstrate the reader can:

recession.

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34 practice

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undertaken, it is possible in individual cases to improve/correct the presence of labial gingival recession that is present at natural teeth prior to extraction. Figure 1 illustrates a case of chronic adult periodontitis where tooth No. 13 (FDI notation) exhibited grade 3 mobility, crestal bone loss and “saucerization,” and gingival recession measured at 5.5 mm with loss of attachment. The 18-month post-loading results show the marginal gingival tissues as being in harmony with the adjacent teeth.

Width of keratinized gingival tissueAn intact band of attached keratinized gingival tissue (KGT) is considered as critical to the protective function of the mucogingival complex, although there is no agreement as to the minimum requirements (Kennedy, et al., 1985, Aguido 2009). The rationale for gingival augmentation around both natural teeth and dental implants includes improved plaque control and improving patient comfort with restorative, prosthetic, or orthodontic procedures, and the prevention of

practice 35

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gingival recession (Hall and Lundgren 1993). The stability of soft and hard tissues at implant sites has been investigated by Bouri, et al., (2008). They found that the mean gingival index score, plaque index score, and radiographic bone loss were significantly higher for those implants with a narrow zone (<2mm) of KGT. Further, implants with a narrow zone of KGT were more likely to bleed upon

probing. Additionally, they found a significant independent association between the width of keratinized mucosa and radiographic bone loss. They concluded that an increased width of KGT around implants is associated with lower mean alveolar bone loss and improved indices of soft tissue health. Figure 2 illustrates a thin gingival biotype case. Teeth 12 and 14 were

extracted only 3 years previously, with an ensuing extreme loss of normal hard and soft tissue morphology – implants had been requested as the replacements. In this case, the pre-implant width of KGT was measured as being less than 2 mm, and as such, the supposition that alveolar bone loss would be extreme was made. Further, the long-term health of the soft tissues would be optimized

36 practice

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practice 37

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38 practice

if the width of KGT could be increased, with the added benefit of a visible increase in esthetics via re-establishment of hard and soft tissue morphology. Figure 3 illustrates the classical

results of extraction and conventional fixed bridge placement: the mesial abutment has subsequently been root treated and suffered decoronation, while the distal abutment has suffered bone saucerization and now exhibits

grade 3 mobility. There was classical loss in bucco-palatal bone width. Rather than simply accept the concave bone and tissue profile, both were augmented. The fixation of the subepithelial

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practice 39

connective tissue graft (SCTG) was facilitated by suturing the graft to the underside of the mucoperiosteal flap. That same technique is shown in Figure 4, which additionally utilizes the bicortical fixation of the implant into the floor of the sinus.

This article is based on a presentation made at the ADI members’ National Forum on November 12, 2011, King’s College, London.

Clarification: In the first part of this article, published in the May/June 2012 issue of Implant Practice US, Vol. 5, No. 3, the caption for Figure 1B should have read: Tooth No. 21 has been extracted atraumatically using periotomes. The alveolus has been debrided with no attempt to remove any cervical granulations.

References

Aguido G, Nieri M, Rotundo R, Franceschi D, Cortellini P, Pini Prato GP (2009). Periodontal conditions of sites treated with gingival-augmentation surgery compared to untreated contralateral homologous sites: a 10- to 27-year long-term study. J Periodontol 80: 1399-1405.

Bouri A Jr, Bissada N, Al-Zahrani MS, Faddoul F, Nouneh I (2008). Width of keratinized gingiva and the health status of the supporting tissues around dental implants. Int J Oral Maxillofac Implants 23: 323-6.

Hall WB, Lundergan WP (1993). Free gingival grafts: current indications and techniques. Dent Clin North Am 37: 227-243.

Kennedy JE, Bird WC, Palcanis KG, Dorfman HS (1985). A longitudinal evaluation of varying widths of attached gingiva. J Clin Periodontol 12: 667-675.

Shane McCrea, MMedSci (Dental Implantology), MSc (Dental & Maxillofacial Radiology), BDS, LDSRCS, MFGDP, is the coordinator of postgraduate education for the British Society of Oral Implantology. He is in private practice at The Dental Implant and Gingival Plastic Surgery Centre in Bournemouth, England, and can be contacted at [email protected].

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Implant Practice US CE

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Comprehensive dental implantology: part two1. Provided full diagnostic assessment is undertaken, it is possible in individual cases to ______the presence of labial gingival recession that is present at natural teeth prior to extraction.a. improveb. correctc. overlookd. either a or b

2. The 18-month post-loading results show the marginal gingival tissues as ________ with the adjacent teeth.a. being in harmonyb. creating a conflictc. interfering d. both b and c

3. An intact band of attached keratinized gingival tissue (KGT) is considered as ______to the protective function of the mucogingival complex, although there is no agreement as to the minimum requirements.a. criticalb. inconsequentialc. of minimal importanced. of minor relevance

4. The rationale for gingival augmentation around both natural teeth and dental implants includes improved plaque control and improving patient comfort with__________, and the

prevention of gingival recession.a. restorative proceduresb. prosthetic proceduresc. orthodontic proceduresd. any of the above

5. The stability of soft and hard tissues at implant sites has been investigated by Bouri, et al., (2008). They found that the mean gingival index score, plaque index score, and radiographic bone loss were ______ for those implants with a narrow zone (<2mm) of KGT.a. significantly lowerb. significantly higherc. the samed. none of the above

6. Further, (for Figure 1, they found) that implants with a narrow zone of KGT were ______ to bleed upon probing.a. not likelyb. less likelyc. more likelyd. not expected

7. They concluded that _____ width of KGT around implants is associated with lower mean alveolar bone loss and improved indices of soft tissue health.a. a decreasedb. a marginalc. an increasedd. a thinner

8. In this case (Figure 2), the pre-implant width of KGT was measured as being ______, and as such, the supposition that alveolar bone loss would be extreme was made.a. more than 2 mmb. less than 2 mmc. exactly 2 mmd. 3 mm

9. Further, the long-term health of the soft tissues would _____if the width of KGT could be increased, with the added benefit of a visible increase in esthetics via re-establishment of hard and soft tissue morphology.a. be compromisedb. be delayedc. be optimizedd. be shortened

10. Figure 3 illustrates the classical results of _______: the mesial abutment has subsequently been root treated and suffered decoronation, while the distal abutment has suffered bone saucerization and now exhibits grade 3 mobility.a. infectionb. extractionc. conventional fixed bridge placementd. both b and c

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

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REF: IP V5.4/McCREA

Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement 12/1/2010 to 11/30/2012 Provider ID# 325231

!is quiz is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 24 CE credits for only $99. To receive credit, complete the 10-question test by circling the correct answer, then either:

Post the completed questionnaire to: Implant Practice US CE15720 N. Greenway-Hayden Loop. #9Scottsdale, AZ 85260

Fax to (480) 629-4002.



Peri-implant disease is a growing problem in implant dentistry.

Despite our best efforts to refine implant design and surface features, the problem persists, and in some cases, appears to be growing. As more and more implants are placed by clinicians of varying skill levels and clinical backgrounds, the numbers of patients presenting with the disease seem to be increasing. Peri-implant diseases are infectious in nature and can be broken into two types: peri-implant mucositis and peri-implantitis. Peri-implant mucositis describes an inflammatory lesion that resides in the mucosa, while peri-implantitis also affects the supporting bone1. As with most things in dentistry, early diagnosis is often key to successful resolution of the problem. Adequate baseline radiographs should be taken at the time of insertion of the final prosthesis to determine the baseline alveolar bone levels. This can then be compared to future radiographs to determine if additional bone loss, beyond “normal” has occurred. Careful monitoring of implants should look for changes in clinical parameters such as bleeding on probing, suppuration on probing, and increased probing depths. The clinician should then consider taking a radiograph to evaluate possible bone loss.

CausesLocal iatrogenic factors can often contribute to the initiation and/or maintenance of peri-implantitis. These can include excess cement, poorly fitting abutment/crowns, over contouring of restorations, and poorly positioned implants2. Poorly controlled chronic periodontitis also increases the risk of peri-implant disease.

Peri-implantitis: causes, treatment, and preventionDr. David Holmes explores this obstacle to implant success

Educational aims and objectivesThe aim of this article is to explore the causes, treatment, and prevention of peri-implantitis.

Expected outcomesCorrectly answering the questions on page 44, worth 2 hours of CE, will demonstrate that the reader can:

TreatmentPeri-implant mucositis is a reversible condition and requires only minimal intervention to treat. Thorough mechanical debridement of the area along with local antimicrobials (chlorhexidine irrigation, Dentomycin) is usually sufficient to resolve the problem. A thorough examination of the area should also be completed to ensure there are no local iatrogenic factors contributing to the problem. If the disease has progressed further, and bone loss is evident, the initial treatment phase is the same; antimicrobials (chlorhexidine, Dentomycin), mechanical debride-ment, and strict oral hygiene protocols, including chlorhexidine mouthwash.

Administration of systemic antibiotics should also be considered to reduce the number of pathogens present. Numerous methods have been used to debride the plaque-contam-inated implant surface, including mechanical, sonic, and ultrasonic scalers, lasers, air-powder abrasion, and various chemical solutions such

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David Holmes, BDS, MS, currently divides his time between Dr. Michael Norton’s Harley Street practice, as well as practices in Putney and Ashford, Kent, England while continuing to study

implantology. Originally from Australia, he has studied in Sydney and New York.

practice 41


as chlorhexidine digluconate, citric acid, hydrogen peroxide, and saline3,4. At the Centre for the Treatment of Peri-implant Disease (CTPID), we use a combination of methods including chlorhexidine digluconate, tetracycline solution, saline and mechanical debridement. However, every case is unique and requires a tailored solution. The clinician can then consider whether to attempt to regenerate the bone around the implant. This decision is made based on the amount of bone

lost, the defect morphology, and the patient’s response and motivation5. The goal here is to re-establish bone volume around the implant; however, there is ongoing debate about the ability to “re-osseointegrate” the previously contaminated implant surface.

PreventionPreventing peri-implantitis requires thorough oral hygiene instruction, adequate surgical technique, and the use of dental implants with appropriate

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Protocol for treating peri-implantitis

1.

preoperatively

2. Preoperative 1 minute mouthwash

3. Full-thickness flap elevation

sound tissues (Figure 2)

4.

Mechanical curettage of implant

5. chlorhexidine around implant, into defect and under the mucoperiosteal flap. Leave in situ for 5 minutes

6.

sterile saline (Figure 4)

7. Graft defect with synthetic, allogeneic, xenogenic graft material rehydrated in the tetracycline solution (Figure 5)

8.

rehydrated in tetracycline solution (Figure 6)

42 practice


moderately rough surfaces and implant thread and body design. Adequate periodontal disease control is also essential in the partially edentulous patient to prevent cross contamination from the periodontal lesion to the implant surface. The presence of untreated chronic periodontitis has shown to increase the risk of implant failure by 5%. When restoring an implant, it is absolutely essential to ensure all excess cement has been removed and the area is cleansable with an oral hygiene product. My preferred device is the TePe® interproximal brush. I always make sure that the restoration is cleansable with at least the smallest brush. If necessary, I will adjust the prosthesis to open the embrasure space to allow easy access by the patient during their home oral hygiene routine. Pontic areas should also be convex in the area over gingival tissues, rather than concave, to ensure that plaque and food debris is easily cleansable.Peri-implant disease remains a controversial subject in implant dentistry. There is ongoing debate over the exact cause and ideal treatment for this persistent disease. Prevention, early diagnosis, and referral to specialist care, if necessary, remain the keys to successful management of the disease.

This article was reprinted courtesy of PPD. http://www.ppdentistry.com.

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References

Lindhe, J, Meyle J (2008). Peri-implant diseases: consensus report of the sixth European workshop on periodontology. J Clin Periodontol .35 (suppl. 8), 282–285. Lang, NP, Bosshardt DD, Lulic M (2011). Do mucositis lesions around implants differ from gingivitis lesions around teeth? J Clin Periodontol. 38 (suppl. 1), 182–187. Schou, S, Berglundh T, Lang NP (2004). Surgical treatment of peri-implantitis. Int J Oral & Maxillofac Implants. 19 (suppl.): 140–149. Schou, S, Holmstrup P, Jorgensen T, Skovgaard LT, Stoltze K, Hjorting-Hansen E, Wenzel A. (2003). Implant surface preparation in the surgical treatment of experimental peri-implantitis with autogenous bone graft and ePTFE membrane in cynomolgus monkeys. Clin Oral Impl Res 14: 412–422. Parlar A, Bosshardt DD, Cetiner D, Schafroth D, Unsal B, Haytac C, Lang NP (2009). Effects of decontamination and implant surface characteristics on re-osseointegration following treatment of peri-implantitis. Clin Oral Impl Res 20; 391–399.

Norton, M (2009). The decontamination and treatment of peri-implant mucositis and peri-implantitis. Implant Practice Vol 2, May; 14-17.

Protocol for treating peri-implant mucositis

1. Mechanical scaling of implant surface

2.

3.

deepest level of the pocket on all sides of the implant

4.

practice

Implant Practice US CE

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Peri-implantitis: causes, treatment, and prevention1. As more and more implants are placed by clinicians of varying skill levels and clinical backgrounds, the number of patients presenting with the disease seems to be _____.a. decreasingb. stabilizingc. increasingd. more trackable

2. Peri-implant diseases are _____ in nature and can be broken into two types: peri-implant mucositis and peri-implantitis.a. infectiousb. benignc. bloodyd. persistent

3. Peri-implant mucositis describes _______ that resides in the mucosa, while peri-implantitis also affects the supporting bone. a. a parasiteb. an inflammatory lesionc. a small abrasiond. none of the above

4. Adequate baseline radiographs should be taken ______insertion of the final prosthesis to determine the baseline

alveolar bone levels.a. the day beforeb. one week afterc. one week befored. at the time of

5. Careful monitoring of implants should look for changes in clinical parameters such as _______.a. bleeding on probingb. suppuration on probingc. increased probing depthsd. all of the above

6. Poorly controlled chronic periodontitis also _____ the risk of peri-implant disease.a. decreasesb. increasesc. neutralizesd. continues to inhibit

7. Peri-implant mucositis is a reversible condition and requires ______ intervention to treat.a. extremeb. only minimalc. the patient’sd. daily

8. If the disease has progressed further and bone loss is evident, the initial treatment phase is the same: _______ including chlorhexidine mouthwash.a. antimicrobials (chlorhexidine, Dentomycin) b. mechanical debridement c. strict oral hygiene protocolsd. all of the above

9. Adequate periodontal disease control _____ in the partially edentulous patient to prevent cross contamination from the periodontal lesion to the implant surface.a. should be suggestedb. is not entirely necessaryc. is also essentiald. none of the above

10. The presence of untreated chronic periodontitis has shown to increase the risk of implant failure by ___.a. 5%b. 10%c. 25%d. 50%

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

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Legal disclaimer: !e CE provider uses reasonable care in selecting and providing accurate content. !e CE provider, however, does not independently verify the content or materials. Any opinions expressed in the materials are those of the author and not the CE provider. !e instructional materials are intended to supplement, but are not a substitute for, the knowl-edge, skills, expertise and judgement of a trained healthcare professional.

>/1?@%A1'1)%'23%B/7%>"3)*

REF: IP V5.4/HOLMES

Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement 12/1/2010 to 11/30/2012 Provider ID# 325231

!is quiz is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 24 CE credits for only $99. To receive credit, complete the 10-question test by circling the correct answer, then either:

Post the completed questionnaire to: Implant Practice US CE15720 N. Greenway-Hayden Loop. #9Scottsdale, AZ 85260

Fax to (480) 629-4002.


Laboratory link

Digital dentistry is the future, and the future is closer than you

may think. Right now, it is possible to take a digital impression, send it electronically to a laboratory that will then design the restoration via CAD (computer-aided design), and then electronically send this information to a CAM center (computer-aided manufacture) that will, in turn, produce milled or rapid prototype models, and mill or laser sinter the framework, ready for the technician to produce the esthetic final stage of the process. The benefits of going digital are many. Doing so cuts out many steps that are not only time consuming but prone to error. Digitalization will improve workflow, precision, fit and even, although not necessarily the first thing you might think of, profitability. By embracing the digital revolution, a lot of processes will be streamlined and quicker, plus remakes or adjustments will be dramatically reduced, saving a considerable amount of surgery time. Digitalization also opens the door to new and exciting materials. These savings and benefits can be had across all standards. The cost of surgery time is an area many dentists seem not to take into account when making decisions. By far the most expensive thing in a dental surgery is normally surgery time. It may be an eye opener to some dentists to sit down and work out just how much it costs them to run the practice for an hour. Such an exercise will highlight the savings getting things right the first time could make. Maybe a move to digital impression-taking would not seem so expensive or, possibly contrary to general thinking, requesting CAD/CAM restorations from the laboratory would actually save money. So what exactly are the benefits of digital dentistry? As we all know the “old” analog system is prone to many problems and inaccuracies.

The digitalization of dentistrySteve Tyler urges dentists to prepare for the future by joining the digital revolution

Conventional impression materials have a number of inherent issues. The simplest areas to highlight include the impression material itself. It must be mixed correctly, impressions must be sterilized, and stored correctly. Any small deviation from the correct procedures and instructions will lead to inaccuracies. Moving onto impression- taking, there are many issues that hinder a successful restoration such as tissue compression, marginal accuracy or even a poor gag reflex. A digital impression does away with virtually all

of the associated problems of analog impression-taking, not to mention being a much better experience for the patients. What about in the laboratory? Not all laboratories are equal, and

Steve Tyler can be reached at Maurice Hood Dental Laboratory Ltd., Houghton Street, Oldbury, West Midlands, B69 2BB, England. Tel: 0121 544 8855, email: [email protected] or on the web: www.mauricehood.co.uk.


Laboratory link

many will suffer from similar types of issues as dental surgeries do, such as time and cost restrictions. Material instructions have to be followed exactly, but even when this is done, the nature of the materials used bring their own issues. Simply pouring plaster, which often hardens due to an exothermic reaction, can lead to the deformation of the impression. Waxing and metal casting are prone to their own stresses and strains potentially causing further imprecision. Non-precious metal dental casting alloys often contain undesirable trace elements such as nickel and beryllium, and the process of lost wax casting can also add impurities to the restoration. Obtaining a passive fit in a cast substructure, which is required in all restorations and especially implant work, is difficult and often requires considerable work and expense. In the current world of analog dentistry, there are obviously things that can be done to minimize problems, such as making sure all materials are used and stored correctly, using a laboratory that has a recognized quality system, such as DAMAS or ISO 9001, and that has other awards such as being a Straumann Platinum Laboratory to show they have spent the time, money, and resources to ensure they are doing things correctly and consistently. However, given the inherent problems of analog dentistry, even that is not enough to guarantee everything is right the first time. So what is the next step towards getting things right the first time? Step into the future, and turn to digital dentistry. Even without a digital impression,

the majority of issues can be eliminated by using a CAD/CAM system. A laboratory using a CAD/CAM system to produce restorations on conventional models means the framework can easily be produced to the correct dimensions and anatomical shape to maximize support for the porcelain. Undercuts are automatically blocked out, the desired amount of cement space will be programmed in, the path of insertion will be optimized, and model preparation will be minimized. When the framework is being milled or laser sintered, it is being done to a tolerance of a few microns with no possibility of any impurities being introduced, resulting in a high precision, passive fitting restoration that is right the first time. Communication can also be improved as systems, such as Straumann CARES®, allow photographs of scanned designs and models to be emailed to the dentist so any issues can be resolved quickly. On top of all the previous benefits, the metal used for the milling or laser sintering is a very high quality with none of the trace elements mentioned previously — all in all a far superior metal. But it is not just metal restorations that are better. It is now possible to reproduce virtually all restorations via CAD/CAM, from all-ceramic restorations such as zirconia and IPS e-max® (Ivoclar Vivadent) to hybrid composites of 3M™ ESPE™ Lava™ Ultimate Restorative, through to pure metals such as chrome and titanium, with various long-term temporary materials also available. Not only are the materials comprehensive,

the types of restorations are also extensive from single crowns to full arch restorations. Most implant restorations, and even denture bars, are all available now with even more types of restorations on the horizon. So with CAD/CAM produced restorations, you have perfectly designed, accurately fitting prostheses that are better for the patient and minimize wasted surgery time. Add in full digitization with digital impressions, and you can have a complete digital solution that will reduce the number of patient visits significantly. It will also be more comfortable for the patient, quicker, be reversible, with less surgery/chair time, speed up workflow, and as a result, lower costs. The start of the transition to digital dentistry has well and truly begun, and it is going to be an interesting time for everyone in dentistry, even the patients. There is no doubt digitalization will increase, and will undoubtedly lead to substantial changes in dentistry for both dentists and laboratories. As many other professions and industries have found, once the digital revolution starts, there is no stopping it. With the highlighted benefits, however, why would anyone want to stop it in dentistry? Indeed, digitalization brings so many benefits, it would be far better to embrace it now, and look to capture the opportunities and benefits the move to digital dentistry will undoubtedly create ahead.


3D dialogue

The American Academy of Oral and Maxillofacial Radiology

(AAOMR) has recently updated its position statement concerning cross-sectional imaging, saying that CBCT is the preferred imaging method for presurgical assessment of dental implant sites. The authors of the statement, Drs. Tyndall, Price, Tetradis, Ganz, Hildebolt, and Scarfe, noted that placing implants in alveolar bone necessitates a plan for prosthetic restoration, and CBCT scans provide the most efficient views of the oral-bone anatomy for proper corrective treatment before implant placement. The AAOMR recommends that the radiographic exam of any potential implant site should include cross-sectional imaging orthogonal to the site of interest; and recommends that CBCT be considered the imaging modality of choice for preoperative cross-sectional imaging of potential implant sites, as well as in the case of augmentation procedures, site development or bone reconstruction. Of course, all of these recommendations are to be implemented in the light of clinicians’ adherence to ALARA (as low as reasonably achievable) principles. With this in mind, practitioners who are considering an investment in an in-office CBCT scanner should look for one that offers clinical control over radiation dose. The machine that I use (i-CAT®, Imaging Sciences International) lets me capture fields ranging from a single arch to full skull, and anything in between, so that I can determine the type of scan needed to serve the needs of the individual patient. While I have the opportunity to capture a full field-of-view scan, which is important for certain maxillofacial procedures, I can also diminish the exposure time, scale

Updated information on CBCT safetyDr. Steven A. Guttenberg discusses how the benefits of CBCT imaging outweigh the risks


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down the size or raise the voxel size, to further decrease radiation dose. For example, I can capture a collimated lower-dose post-operative scan to ensure correct implant positioning. Many people have asked about

the risks of CBCT radiation in comparison with other common life risks. A statistical calculation, known as the Loss of Life Expectancy (LLE) compares the risks of CBCT scans with other occurrences in everyday life.1

3D dialogue


If you have a question regarding 3D imaging that you want Dr. Guttenberg to address in a future column, please email: [email protected].

For more information on how 3D imaging can improve your practice, please fax this information to(480) 629-4002, visit www.implantpracticeus.com/web/imagingsciences.html to submit this form online,or mail this form to: Implant Practice US | 15720 N. Greenway Hayden Loop #9 | Scottsdale, AZ 85260.

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!

Interestingly, a fast scan of 8 x 8 cm resulted in far less life days diminished than smoking cigarettes (risk of 2,300 days lost), being 30 lbs. overweight (risk of 900 days lost), or even air pollution (risk of 80 days lost). The LLE of that CBCT scan was 0.0039 of a day, or a little less than 6 minutes (5.616). When using CBCT imaging with attention to ALARA, dentists can control and limit the exposure to the patient, while obtaining a significant amount of clinical information that can be used to determine the best possible position for an implant while preventing a possible nerve injury or discovering a tumor or other anatomical anomaly that would not be visible on a traditional 2-dimensional X-ray. According to a report by iData Research, a firm that studies the medical device, dental and pharmaceutical market, the U.S. market for dental implants is expected to gain double-digit growth by 2013, and by 2016, more than 20% of general

practitioners are expected to place dental implants. As an early adopter of this imaging modality, I have found that it has become an indispensable surgical treatment tool. With a 3D scan, I am able to rotate, zoom in on, or explore the volume from any angle to determine the viability of an implant site and the proper inclination, length, and diameter for the fixture. This information can be integrated into other helpful applications such as implant-positioning and CAD/CAM surgical guide software programs. With the growing acceptance of CBCT as a preferred imaging method for implants, it is important to continue learning more about it through reading, continuing education courses, and at webinars featuring the latest research on the Internet. As requests from the public for implants continue to grow, it makes sense to provide this procedure to patients with as much precision and detailed information as possible.

Steven A. Guttenberg, DDS, MD, is an oral and maxillofacial surgeon practicing in Washington, D.C., where he is director of the Washington Institute for Mouth, Face and Jaw Surgery. He is a Diplomate of the American Board of Oral and Maxillofacial Surgery and a fellow of the American Association of Oral and Maxillofacial Surgeons and of the American College of Oral and Maxillofacial Surgeons, of which he is currently the past-president. Guttenberg teaches at the Washington Hospital Center and is the chairman of its Oral and Maxillofacial Surgery Residency Training and Education Committee. He frequently lectures nationally and abroad. Guttenberg’s numerous scientific articles and book chapters have been published in dental and medical literature. He is the editor of a new textbook entitled Cosmesis of the Mouth, Face and Jaws in which several chapters are devoted to dental esthetics and implants. The book provides a unique, whole-face approach to cosmetic procedures, focusing on oral, facial and gnathic components.

Reference

1. Carlson S (2012). Understanding CBCT dosimetry. Orthodontic Practice US 3(3): 34-35.

Product profile


Preservation of hard- and soft-tissues around a dental implant is

key to achieving long-term sustainable esthetic outcomes for the patient. The PREVAIL Implant System incorporates specific features that are designed for achieving sustainable esthetics.

PREVAIL Implant features designed for enhanced osseointegrationPrimary stability plays an important role in influencing osseointegration. Both the BIOMET 3i Tapered and OSSEOTITE® 2 Parallel Walled Implants are designed to create a tight implant-to-osteotomy fit by providing Initial Bone-to-Implant Contact (IBIC) upon placement into the osteotomy. The amount of IBIC helps to establish the primary stability important to the implant’s ability to withstand early micromotion during the healing process. In turn, by placing more implant body in direct contact with the bone, the surface can play its role in early peri-implant bone healing. Good IBIC can also facilitate secondary stability (bone healing). OSSEOTITE and NanoTite™ Surface Topographies are two well- researched surface options for bone apposition during early healing. The OSSEOTITE® Surface is designed to facilitate the osseointegration process. With the NanoTite Implant Surface, the OSSEOTITE Surface serves as the substrate for the Discrete Crystalline Deposition (DCD) of calcium phosphate. This renders the NanoTite Implant Surface Bone Bonding® via the mechanical interlocking of the cement line matrix of bone with the implant surface. Once an OSSEOTITE or NanoTite Implant has integrated, the top of the implant may also influence esthetics. Considering the risk of peri-implantitis with a fully roughened implant, a prospective randomized-controlled study designed to assess the risk and incidence of peri-implantitis for fully-Dual Acid Etched (DAE)-surfaced implants (Full OSSEOTITE) was conducted. This study by Zetterqvist, et al., showed

no substantial differences in mucosal health outcomes between test (Full OSSEOTITE Dual Acid Etched Surface) and control (machined collar OSSEOTITE Surface) groups throughout a 5-year follow-up. In addition, in this study, Full OSSEOTITE Implants had less crestal bone loss than the machined collar implant (~0.6mm vs. ~1.1mm).1

PREVAIL Implant features designed for soft-tissue protectionSuccessful osseointegration is the first step towards a long-term esthetic outcome. A second contributing factor is the implant connection design. The implant connection must work synergistically with the implant, abutment, and screw to provide the strength required for long-term esthetic performance. A stable, tight implant/abutment interface minimizes abutment micromotion and reduces the potential for microleakage. Decreasing both of these has been theorized to reduce the inflammatory processes associated with bone and/or tissue loss. Recent research demonstrates both of these points: Connection strength: The unique design of the Certain® Internal Connection provides strength and durability through its deep internal engagement. Fatigue tests on the PREVAIL® Implant demonstrate that the Certain Internal Connection has a higher fatigue strength2 (45%) as compared to three competitive averages. Seal integrity: Additionally, dynamic fluid leakage testing on the PREVAIL Implant showed a higher seal strength2 (50%) as compared to three competitive averages. This can be attributed to the BIOMET 3i Gold-Tite® Screw that was used, with its 113% increase in clamping forces versus a non-coated screw.3

PREVAIL Implant features designed for crestal bone preservationThe integrated platform switching feature of the PREVAIL® Implant is

designed for bone preservation. Recent studies have shown that implants with the PREVAIL integrated platform switching feature demonstrated crestal bone loss as low as 0.37 mm after 1-year post restoration.4

With the best interests of the patient in mind, BIOMET 3i offers the PREVAIL Implant, incorporating technological innovations designed to optimize clinical outcomes and long-term sustainable esthetics.

THE PREVAIL®

Implant SystemPreservation By Design

About BIOMET 3i BIOMET 3i LLC is a leading manufacturer of dental implants, abutments and related products. Since its inception in 1987, BIOMET 3i has been on the forefront in developing, manufacturing and distributing oral reconstructive products, including dental implant components and bone and tissue regenerative materials. The company also provides educational programs and seminars for dental professionals around the world. BIOMET 3i is based in Palm Beach Gardens, Florida, with operations throughout North America, Latin America, Europe, and Asia-Pacific. For more information about BIOMET 3i, please visit www.biomet3i.com or contact the company at 800-342-5454; outside the U.S. dial 561-776-6700.

References

1. Zetterqvist L, et al (April 2010). A prospective, multicenter, randomized-controlled 5-year study of hybrid and fully etched implants for the incidence of peri-implantitis. J Periodontology 81(4):493-501.2. Baumgarten H†, Meltzer A† (March 2012). Improving outcomes while employing accelerated treatment protocols within the aesthetic zone: From single tooth to full arch restorations. Presented at the Academy of Osseointegration, 27th Annual Meeting; Phoenix, AZ. 3. Byrne D, Jacobs S, O’Connell B, Houston F, Claffey N (May-June 2006). Preloads generated with repeated tightening in three types of screws used in dental implant assemblies. J. Prosthodont 15(3):164-71. 4. Östman PO†, Wennerberg A, Albrektsson T (March 2010). Immediate occlusal loading of NanoTite Prevail Implants: A prospective 1-year clinical and radiographic study. Clin Implant Dent Relat Res 12(1):39–47.

†Aforementioned have financial relationships with BIOMET 3i LLC resulting from speaking engagements, consulting engagements, and other retained services.

Practice development


As my practice has grown over the years, I have discovered

that some of my most valuable educational experiences involved mentors. Scientist and inventor Ben Franklin once wrote, “Tell me and I forget, teach me and I may remember, involve me and I learn.” Mentors do just that — and in the dental profession, having someone who provides instruction, but also can watch and offer constructive advice, can mean the difference between just learning and being able to add another treatment option to your professional armamentarium. Before we continue to the “how,” a quick bit of history trivia — the word “mentor” originated from Greek mythology. In Homer’s Odyssey, the warrior Odysseus must fight in the Trojan War, but he needs a trusted friend to have the responsibility of teaching and guiding his son, Telemachus. He chose his friend named Mentor, who was actually the goddess Athena in disguise, and returned home 20 years later to find his son safe, sound, and smart. In any profession, being a good mentor can help your peers perfect their new skills with confidence. Here are my top 3 qualities for becoming a good mentor:

Listening skillsListening skills and patience are imperative. We all have experienced lecturers who do just that — lecture without knowing whether the attendees are “getting it” or not. A good mentor listens to the student’s questions or concerns, and slows

down to ensure understanding. This is inherent in Ben Franklin’s quote, to involve your student so that he/she can “learn while doing.”

AvailabilityOne of the main problems, even with a good teacher, is inaccessibility after class. To be a good mentor, be available for questions after the session has ended. Of course, it is understood that with busy practices, you cannot always be there in person, but a quick text, email, or phone call can often work wonders to answering a question, or setting the person in the right direction.

NetworkingShare names of colleagues who you know can be of assistance, or can steer your student in the right direction. Do you have an implant company or rep that has always been helpful for you? Is there a brand of imaging or certain piece of equipment that has made these procedures easier? The more information available, even to a “seasoned” dentist who is seeking more knowledge, the better. Mentors should remember that their “students” are also dental professionals, so while sharing expertise, respect their education and experience level as well. Be flexible and realistic; discuss the challenges involved in taking on new procedures, realizing that since everyone’s anatomy is different, protocols will change for individual needs. Motivate the student to think independently, based on the new and developing skills being taught.

At my dental implant centers in Nebraska, South Dakota, and Minnesota, I truly enjoy educating patients and colleagues on the subject of dental implants. I have experienced many dental continuing education classes and have also served as a speaker at many of these types of learning events. When I decided to establish the Rocky Mountain Dental Institute, which is starting its first class in September, part of my vision for educating dental professionals on the art of the implant was to include mentors (one mentor for every 5 attendees) as a part of the total experience. I want GPs and specialists alike to be comfortable enough to ask their questions, voice their concerns, and be able to maintain contact even after they take their knowledge home to implement the new implant procedures into their practices. Poet Robert Frost once said, “I am not a teacher, but an awakener.” Being a mentor can make you an awakener too, and a leader in helping your colleagues reach new levels of excellence.

Dr. Justin Moody offers tips on how to be “not just a teacher,

but an awakener“

The art of mentoring

Justin Moody, DDS, DICOI, DABOI, is a graduate of the University of the Oklahoma College Of Dentistry. As a supporter of organized dentistry and continuing education, he is a member of the American Academy of Implant Dentistry, International College of Oral Implantologists,

Academy of Osseointegration as well as the ADA, state and local societies. He is a Diplomate in the American Board of Oral Implantology/Implant Dentistry and the ICOI, Fellow of the AAID and holds Mastership and Fellow status at the Misch International Implant Institute. Dr. Moody lectures throughout the country on Implant Dentistry and is in private practice in Rapid City, South Dakota. He is also the Founder and Director of the Rocky Mountain Dental Institute in Denver, Colorado. He can be reached at [email protected].

ImplantPRACTICE ˙ US

clinical articles • management advice • practice profiles • technology reviewsMay/June 2012 – Vol 5 No 3

Practice ProfileDr. Stuart J. Froum

Dr. Shane McCreaComprehensive dental implantology: part one

Dr. Eddie ScherEvery picture tells a story:Immediate placement

Dr. K. Kevin NeshatCompressing treatment time and enhancing esthetic results with the use of narrow-diameter implants in single anterior sites

Smalle

r Diam

eter

Implant

Focus

ALSO INSIDE:Product profiles Practice management Research3D dialogueCE articles

Author guidelines


Implant Practice US is a peer-reviewed, bimonthly publication containing articles by leading authors from around the world. Implant Practice US is designed to be read by specialists in Periodontics, Oral Surgery, and Prosthodontics.

Submitting articlesImplant Practice US requires original, unpublished article submissions on implant topics, multidisciplinary dentistry, clinical cases, practice management, technology, clinical updates, literature reviews, and continuing education. Typically, clinical articles and case studies range between 1,500 and 3,000 words. Authors can include up to 15-25 illustrations. Manuscripts should be double-spaced, and all pages should be numbered. Implant Practice reserves the right to edit articles for clarity and style as well as for the limitations of space available. Articles are classified as either clinical, continuing education, technology, or research reports. Clinical articles and continuing education articles typically include case presentations, technique reports, or literature reviews of a clinical topic. Research reports state the problem and the objective, describe the materials and methods (so they can be duplicated and their validity judged), report the results accurately and concisely, provide discussion of the findings, and offer conclusions that can be drawn from the research. Under a separate heading, research reports provide a statement of the research’s clinical implications and relevance to implant dentistry. Clinical and continuing education articles include an abstract of up to 250 words. Continuing education articles also include three to four learning objectives, a short “expected outcomes” paragraph, and a 10-question, multiple-choice quiz with the correct answers indicated. Questions and answers should be in the order of appearance in the text, and verbatim. Product trade names cited in the text must be accompanied by a generic term and include the manufacturer, city, and country in parentheses.

and institutional affiliations and locations

state the name, date, and location of the meeting

grants, equipment, products, or drugs must be disclosed

corresponding author must be included

Pictures/images

numbered in sequential order, and accompanied by a caption. Digital images must be high resolution, 300 dpi minimum, and at least 90 mm wide. We can accept digital images in all image formats (preferring .tif or jpeg).

TablesEnsure that each table is cited in the text. Number tables consecutively and provide a brief title and caption (if appropriate) for each.

ReferencesReferences must appear in the text as numbered superscripts (not footnotes) and should be listed at the end of the article in their order of appearance in the text. The majority of references should be less than 10 years old. Provide inclusive page numbers, volume and issue numbers, date of publication, and all authors’ names. References must be submitted in Harvard

Greenwall, L (2000). Combining bleaching techniques. Aesthetic & Implant Dentistry

Greenwall L (2001). Bleaching Techniques in Restorative Dentistry: An Illustrated Guide

PermissionsWritten permission must be obtained by the author for material that has been published in copyrighted material; this includes tables, figures, pictures, and quoted text that exceeds 150 words. Signed release forms are required for photographs of identifiable persons.

Disclosure of financial interestAuthors must disclose any financial interest they (or family members) have in products mentioned in their articles. They must also disclose any developmental or research relationships with companies that manufacture products by signing

form after their article is accepted. Any commercial or financial interest will be acknowledged in the article.

Manuscript ReviewAll manuscripts are peer reviewed and accepted, accepted with modification, or rejected at the discretion of the editorial review board. Authors are responsible for meeting review board requirements for final approval and publication of manuscripts.

ProofingPage proofs will be supplied to authors for corrections and/or final sign off. Changes should be limited to those that are essential for correctness and clarity.

Articles should be submitted to:Kim Murphy, Production [email protected]

Reprints/Extra issues

they must be ordered from the publisher when the page proofs are reviewed by the authors. The publisher does not stock reprints; however, back issues can be purchased.

Guidelines for Authors

Checklist for article submissions:

including all pictures (low res) necessary for reviewers

references, figure legends and tables

outcomes paragraph

Harvard style

authors

Please contact Managing Editor Mali Schantz-

[email protected]

Dates for your diary

Implant Dentistry Continuum 2012-2013Dr. Arun K. GargAugust 4-5, 2012August 25-26, 2012September 8-9, 2012Charlotte, NC 800-561-3065www.implantseminars.com

Full Arch Implant Restorations Made Simple, Predictable and Cost-EffectiveDr. James Rivers and Henry Martin, CDTJuly 26, 2012Charleston, [email protected]

Advancements and Innovations in Implant DentistryDr. Ed McGlumphy, Dr. Tim Silegy, Dr. Marco Padilla and Ron Baggott, CDT MAAIPAugust 10, 2012Las Vegas, NV619-694-7523 / [email protected]

Solutions for Advanced Surgical Procedures IIDr. Gary Ross and Dr. David DaliseAugust 11-12, 2012Albuquerque, NMwww.ocobiomedical.com

Incorporating Implants into Your PracticeDr. Ara NazarianAugust 25, 2012Salt Lake City, UTwww.ocobiomedical.com

1-Day Computer-Guided Implant DentistrySeptember 7, 2012Miami, FL800-561-3065www.implantseminars.com

Bicon Dental Implants Hands-On Practical CourseSeptember 7, 2012Boston, MAwww.bicon.com

AAOMS 94th Annual Meeting September 10-15, 2012San Diego, CAwww.aaoms.org

Preconference Maxillofacial Oncology & Reconstructive SurgerySeptember 11, 2012San Diego, CAwww.aaoms.com

Implant Treatment Rationale and Planning – Session 1The Rocky Mountain Dental Institute September 13-15, 2012Denver, COwww.RockyMountainDentalInstitute.com

CE listings


Materials & equipment

The all-new infinity Implant from ACE Surgical Supply

The all-new infinity Implant from ACE Surgical Supply allows you to purchase familiarity at a fraction of the cost. Designed to work with your existing implant system, you have the flexibility to use your existing surgical drills, drivers, and prosthetics to place and restore the implant.

The infinity line currently offers two implant types with others in development. The infinity Tri-Cam Implant is surgically compatible with Nobel Replace™ and Replace™ Select. The infinity Internal Hex Implant is compatible with the Zimmer Tapered Screw-Vent® dental implant.

For more information, contact ACE Surgical Supply by phone, toll-free: 800-441-3100, or email [email protected].

LightWalker lasers — advanced, versatile and proven technology

Technology4Medicine’s LightWalker lasers provide the oral surgeon with the most advanced, versatile and proven technology for both hard and soft tissues. The award-winning LightWalker ALL tissue laser encompasses the two superior proven wavelengths in dentistry, with both high power Nd:YAG and Er:YAG lasers in one easy-to-use system, at less than the price of one competing laser. You have the most advanced, best-in-class, wavelengths at your finger tips. Revolutionize your practice with advanced laser hard and soft tissue procedures including uncovering implants, bloodless incisions and soft tissue surgeries, sinus lifts, apicoectomies, and extractions, with less post-op pain, swelling and medications. For more information, call 949-276-6650 or visit www.t4med.com.

Immediate Smile® bridge gives patients and dentists something to smile about

Today, Materialise Dental’s 3D Digital Dentistry is allowing dentists to remove teeth, place implants, and fit bridges during same-day surgeries, translating to high patient comfort and fewer visits. Exclusive to Materialise Dental, by combining SimPlant® and SurgiGuide® with CAD/CAM technology, this workflow is fully digitized. Since the bridge and SurgiGuide® are delivered together before surgery, dentists can perform the surgery and placement of the bridge in a single visit. Innovative and versatile, this technology can also be used for predictable esthetics even for cases with tooth extractions. If patients still have their natural teeth, tooth extractions are simulated with SimPlant®.

For more information, visit www.materialisedental.com.


New Quick Up method eliminates the risk of accidental locking of dentures to the implant and cuts procedure time in half.

VOCO has introduced Quick Up, an innovative and complete implant pick-up system that virtually eliminates the risk of interlocking and cuts chairside time in half. With the new Quick Up technique, the recess holes will be filled only 2/3 with the self-cured Quick Up SC and after intraoral setting finished with the light-cured Quick Up LC fill. The overall procedure time is cut in half compared to the classic methods. The kit also includes Fit Test C&B — used to check whether the openings in the denture base provide enough space to receive the attachments and for blocking out undercuts in overdentures. For more information, call VOCO America Inc. at 888-658-2584, email [email protected], or visit www.vocoamerica.com.

Industry news

Rocky Mountain Dental Institute has announced that in conjunction

with the International Congress of Oral Implantologists (ICOI), RMDI classes will count towards the distinguished designation of ICOI Fellow. RMDI’s classes will uphold ICOI’s already established standard of excellence and add its own distinctive and innovative style of teaching. Upon completing a specified plan of study at RMDI, attendees will have the opportunity to differentiate themselves among those who have

achieved a level of professional excellence. “We are honored to be recognized by ICOI, and are excited about joining forces to ensure quality continuing education,” said Dr. Justin Moody, founder of RMDI. ICOI credentials recognize dedication, qualifications, training, and experience, allowing doctors to improve their implant skills, and as a result, to better serve their patients. Rocky Mountain Dental Institute (RMDI) is a state-of-the-art facility that provides a high-tech and

mentor-guided continuing education experience. Located in beautiful Denver, Colorado, RMDI prides itself on a personal approach to CE classes, with knowledgeable mentors to help guide dentists through the sessions and procedures. Taught by practicing implant dentists, continuing education classes at RMDI will provide attendees with valuable techniques that enhance implant skills and enrich their practices. For more information, contact RMDI toll-free at 888-484-0355.

Rocky Mountain Dental Institute classes count toward International Congress of Oral Implantologists (ICOI) Fellow designation

Implant Practice US July 2012 Vol.5.4

Documents

Transcript of Implant Practice US July 2012 Vol.5.4