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LABS
SPRING 2013
Implantology
An Urban Landscape
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contents
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Navigating the Landscape
Congenitally missing maxillary lateral incisors: treatment option with the new Straumann® NNC implant
On the cover Multiple implant components depicting an urban landscape, each structure with its own individual architecture and personality.
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Photography by, Cristian Angelescu
cover story
The Evolution of Multi-Unit Fixed Implant Prostheses
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Challenge of a Lifetime A BUSINESS INFORMATION GROUP PUBLICATION ORAL HEALTH LABS IS A SUPPLEMENT TO ORAL HEALTH EDITORIAL DIRECTOR
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from the editor
NAVIGATING THE LANDSCAPE Recent years have seen the increased use of implantology as a clinical procedure for dental rehabilitation treatments. Cost effectiveness, improved clinical and technical protocols along with long-term successful outcomes, have benefited the treatment evolution, for improved patient care. The academic world of implantology is a complex one, whereby laboratory technicians need to maintain a level of understanding and knowledge of the clinical and technical landscape that is constantly changing and evolving. I was privileged to have been living and working in Scandinavia at the time when Dr. Branemark introduced dental implants commercially to the dental profession. Many years later it is interesting to look back and recollect that innovative introduction and to witness the transformation and development that has occurred over the years. When thinking of the improvement to patient health, both dentally and physiologically, it is difficult to think of a single restorative technique that has had such an impact on dental health care satisfaction in recent years. No doubt there will be others, but this moment in dental history, belongs to the dental implant and the advancements to patients dental care. As always, images showcase the impact to the welfare of a patient’s well being, after a successful restorative treatment plan incorporating dental implants. The following images illustrate the before and after of a patient treated by Dr. Bruce Glazer. The patient, missing both lateral maxillary incisors, underwent a treatment plan that included replacement of missing teeth with implantology, incorporated into an aesthetic reconstruction of additional anterior maxillary anterior teeth.
Treatment by Dr Bruce Glazer
Before
After
Trevor Laingchild’s sense of adventure has taken him on an international road in his profession. After formal Dental Education in London, England, he managed a Dental Laboratory in Germany and served as Chief Dental Technician for an American Hospital in Saudi Ara-
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bia. Further experiences included, expanding his technical horizons whilst working in Norway, Scandinavia. He currently owns and operates dentalstudios in Burlington and in Yorkville, Toronto. Trevor is an Accredited member and an Examiner within the American
Academy of Cosmetic Dentistry, in addition is a Certified LVI Master Aesthetic Technician. Trevor is very active lecturing and teaching whilst conducting numerous hands on courses in all aspects of restorative aesthetics, of which, he has had numerous articles published.
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During the historical evolution of implantology, the introduction of Cad-Cam technology and various applications of machine-milling of dental restorative materials has allowed for more cost-effective and laboratory -challenging materials to be utilized into the treatment plan. The many and varied machining techniques have improved the accuracy of fit within the implant componentry and assisted in the accuracy of the aesthetic placement of implant – infrastructures into the full contour restorative planning process. However, integrity within the differing machining protocols should be encouraged, as to optimize patient health care, which includes the validity and warranty of the components within their treatment plan.
Examples of : Machined Restorative Materials
Milled titanium framework
Milled zirconium framework
The urban landscape was used as a metaphorical scene depicting the implant market place where implant manufacturing companies co-exist within the Laboratory as suppliers of original implant components and digital machining, along with various machining companies. Thanks to Cristian Angelescu for the creative photograph used on the front cover. For photography aficionados: Camera • Nikon D 600 – Lens • Nikon 105 mm f/2.8 – Flash • Nikon Wireless R1C1 I feel Oral Health Labs should dedicate more upcoming space to implantology, exploring new techniques both clinically and technically, therefore the article published here by Dr. Matt Illes of Vancouver will be continued into the next issue. There are many viable options for a restorative technique and Dr. Illes explores and explains a technique being used within his practice on page 11. Edentulous patients have received the most improvement in their well being, as a result of implantology. With the use of implants, mechanical bone anchoring, whether fixed or semi-fixed, can ensure an unprecedented level of confidence to a patient, whether they are edentulous, or soon to be. The article by Dr. Paulo Malo discusses and illustrates a challenging clinical situation, that when appropriately restored, has the potential to give a life changing resolution to the patients’ well being, the impact of which cannot be over estimated. Read Dr. Malo’s article on page 16. Partially edentulous patients require an accurate approach to the implant location, due to the complex positioning of the restoration. The final aesthetics of tooth position, gingiva displacement and function dictate clinical considerations, implant protocols, fabrication techniques and material selections. The clinical presentation of congenitally missing maxillary lateral incisors has allowed for a less invasive restorative treatment plan with the use of Implantology. Past scenarios of traditional fixed bridge restorations requiring significant tooth reduction can be avoided with the careful placement of the ideal sized implant fixture and restored appropriately. On page 6 follow the clinical procedures for such a treatment plan with Mario Roccuzzo. Preserving and augmenting bone, not removing tooth structure and reconstructing with an aesthetic and long term prosthesis, is the path of continuing evolution in the world of aesthetic dentistry. Further in- depth laboratory protocols for similar clinical treatment plans will be discussed in the next issue, at a greater detail. In the meantime I am privileged to be travelling to to Seoul, South Korea, for the first time, as an invitee from the Seoul International Dental Technology Symposium. Naturally I am excited to participate and witness the development of Dental Technology in that country and to experience the everincreasing synergy of international co-operation within the global workplace. Until then.
Editor Trevor Laingchild, RDT, AAACD SPRING/SUM MER
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Congenitally missing maxillary lateral incisors: treatment option with the new Straumann NNC implant ÂŽ
by Mario Roccuzzo, DMD
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n February 2010, a 42-year-old non-smoker with a congenitally missing upper right lateral incisor was referred by her orthodontist for a consultation prior to orthodontic treatment. (Fig.1) The various treatment options were presented: 1> to close the space with orthodontic treatment or to open the space to was performed, and the patient ultimately gave her informed allow for prosthodontic replacement either with consent for the latter treatment. 2 > a fixed dental prosthesis or The patient, who teaches at a university, expressed the de> 3 a single-tooth implant. Each of the ap- sire to maintain esthetics during treatment. For this reason, proaches could potentially compromise esthetics, periodontal health and function. A thorough interdisciplinary analysis
lingual orthodontics with the IncognitoÂŽ technique was used, with the aim of creating adequate mesio-distal space (Fig. 2).
Dr. Mario Rocuzzo DMD Lecturer in Periodontology at the University of Siena/Italy. Private practice limited to Periodontology and Implantology in Torino/ Italy. Extensive research in the field of
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mucogingival surgery, bone regeneration, implant loading protocols and implants in perio- dontally compromised patients. Active member of the Italian Society of Periodontology and ITI Fellow.
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At the end of the treatment, radiographic examination revealed sufficient mesio-distal space along the roots and normal interproximal bone level (Fig. 3). A space of almost 6 mm was measured with the caliper, which is insufficient for a standard implant diameter. A ø 3.3 mm fixture is preferred (Figs. 4, 5). The patient’s medical history turned up nothing significant, and she was in good general health. After onset of local anesthesia, an intrasulcular incision was made one tooth mesially and one tooth distal to the gap. A full-thickness flap was elevated to expose the bone, and sutures were used for retraction on the palatal aspect of the alveolar ridge. On the facial aspect, no vertical releasing incision was made to avoid the risk of cicatrices and/or recessions. Initial drilling was limited to a ø 2.2 mm pilot drill at 680 RPM to facilitate the use of osteotomes at the implant sites (Fig. 6). The final osteotomy site was prepared using Straumann
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osteotomes to preserve as much bone as possible. Screw taps were not used. A Straumann Standard Plus, ø 3.3 mm NNC, SLActive® 10 mm, Roxolid® implant was placed as indicated in the manufacturer’s instructions. The Implant was manually inserted without tapping to achieve primary stability. (Fig. 7) The implant was placed with the edge of the SLActive® surface approximating the alveolar bone crest leaving the machined neck portion in the transmucosal area (Fig. 8). A healing screw was placed into the implants, and the flap was sutured. The radiographic examination confirmed the correct positioning of the implant (Fig. 9). Three weeks after surgery, the peri-implant mucosa showed no inflammation. The patient was then instructed to brush properly for optimal plaque control with limited risk of soft tissue recession. An impression for the temporary restoration was
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11 12 taken (Fig.10). Thanks to the SLActive® surface properties, which promote improved BIC at an early stage, it was possible to place a screw-retained temporary restoration on the implant four weeks after surgery. Minimal gingival countering was performed to eliminate excessive soft tissue (Fig. 11). Temporary restoration was kept in place for six weeks (Fig. 12) to facilitate soft tissue maturation so that impression could be taken under ideal final conditions. (Figs. 13, 14). The slightly submucosal implant shoulder position is visible on the master cast. This allows for a submucosal crown margin position. The implant shoulder region is accessible for later cement removal from the metal-ceramic crown (Figs. 15, 16). The clinical situation prior to cementing confirms the positioning of the implant “as shallow as possible, as deep as necessary” according to the principles of the third ITI Consensus Conference (Fig. 17).
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Eleven weeks after surgery, the gold abutment was tightened with a torque of 35 Ncm (Fig. 18), the final crown cemented (Fig. 19) and the x-ray taken (Fig. 20). Probing depth is within the expected physiological limit both around the implant and the adjacent teeth. Plaque control is satisfactory, no bleeding on probing is present, all leading to pleasing esthetic results. L
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The team’s work was made possible, thanks to the cooperation of: Dr. Riccardo Rizzo, Orthodontist Moncalieri (TO), Italy. Francesco Cataldi, Master Dental Technician Torino, Italy.
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cover story
The Evolution of Multi-Unit Fixed Implant Prostheses by Matt Illes
HBSc, DDS FAGD, FICOI
Synopsis:
This article will review the rationale and contemporary science available to support the use of CAD/CAM, implant supported, fixed partial and complete dentures featuring individual abutment frame design for single unit cementable crowns.
Dr. Matthew Illes, is a graduate of the University of Western Ontario and serves as a prosthodontic consultant at the University of British Columbia. He is a fellow of both the AGD and
International Congress for Oral Implantologists. Dr. Illes has a practice limited to prosthodontics in Vancouver, B.C. He also serves as current president of the B.C. AGD. SPRING/SUM MER
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The Evolution of Implant Supported, Screw Retained, Fixed Dentures he clinical application of a computer numeric control (CNC) milled, screw retained, titanium, implant supported, fixed denture (ISFD) prosthesis was first reported in the literature over a decade earlier with short term data suggesting at that time the potential for a viable alternative to its conventional cast gold predecessor.1 This article will serve as part one of a two part series with a specific focus on the rationale and science supporting the use of CAD/CAM technology coupled with modern, millable material options and contemporary, machined frame design principles. Recent CAD/CAM finite element analysis computer modelGlobal industrialization combined with ecoing and in vitro studies have demonstrated a relationship benomic pressures have served to propel the development, application and acceptance of CAD/ tween screw retained ISFD framework fit and the stress which CAM dental technology into the stratosphere is applied to the implant component system as well as the strain over the past decade. The rapidly escalating cost incurred by the peri-implant crestal bone tissues.4,5 These studof gold has served as the impetus for the quest ies suggest the potential for CAD/CAM produced frames to yield for new dental materials. Modern materials a reduced incidence of mechanical prosthodontic complications such as titanium and zirconia have expeditious- such as abutment or prosthesis screw loosening and/or fracture ly gained popularity and have spurred the need (figures 1-3) as well as negative biological sequela including aberto evolve from the use of traditional lost wax rant peri-implant bone loss (figure 4). CNC milling in dentistry provides its users with a choice and casting technique to the implementation of optical, laser scanning, virtual computer soft- of permanent materials comprised of titanium, zirconia and cobalt chromium. Data on titanium for use in the fabrication ware design and assisted machining.
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The preference to use CAD/CAM implant supported, fixed dentures in lieu of their cast gold alloy brethren has also been strongly influenced by the former’s postulated superiority of fit. Recent reports in the literature by Karl and Almasri have contributed to the development of mounting evidence to support the aforementioned contention.2,3 Reduction in frame misfit has provided numerous benefits including the minimization of complications at the level of the dental laboratory. Cast metal distortion resulting primarily from cooling shrinkage following exposure to high temperatures has long been the bane of dental technicians. The need to section and reconnect cast frames utilizing technique sensitive laser welding or soldering procedures has been eliminated through the incorporation of CAD/CAM technology.
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of screw retained ISFDs is relatively weak yet arguably the strongest in comparison to the alternative materials. The first ten year CAD/CAM ISFD clinical study was recently published as a comparative report and unequivocally demonstrated the survival rate of machined titanium to rival that of cast gold.6 No further reports investigating the clinical performance for screw retained ISFDs exceeding five years of service are currently available. Zirconia was introduced as an esthetic alternative to titanium and has shown promising, but very limited, early to mid range scientific support for effective use as a screw retained ISFD material with the data extracted from one small sample, cohort, prospective study.7 The primary concern with zirconia is the oft-reported issue of deviant rates of premature veneering
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porcelain fracture or chipping ranging up to 40% for cementable, zirconia, implant supported, fixed, complete dentures (ISFCDs).8 Cobalt chromium is arguably the least utilized of the available CAD/CAM materials for screw retained ISFDs. The literature reveals an absence of evidence to support its use for this specific purpose despite some of its proponents’ vehement claims that it is a superior material for utilization as a screw retained ISFD. One retrospective report by Teigen featuring approximately two hundred patients exists to lend some degree of credence to the use of cobalt chromium as a potential material for screw retained ISFDs. This study demonstrated comparable performance of screw retained ISFDs between cast cobalt chromium and gold alloy in regards to prosthesis survival over a median time period of twelve years with some patients followed up to eighteen years.9 No data currently exists which assesses the clinical performance of CAD/CAM, milled cobalt chromium for use as a screw retained ISFD. Unfortunately, cobalt chromium has achieved the debatably unwarranted stigma of being an inferior material by many in the profession. This label seems to have stemmed largely from cobalt chromium’s origins in dentistry as a base metal and it’s known potential to induce allergic reaction and exhibit susceptibility to corrosion in an acidic environment. Cobalt chromium has also garnered significant attention in recent years due to the accumulation of scientific documentation in the orthopedic literature devoted to its potential to elicit metallosis. This problem is suspected to have emanated from the nanoparticle byproducts which are produced through the process of metal on metal prosthetic hip joint contact.10 Similar reports are not available in the dental literature but questions do exist regarding the potential long term health hazards of cobalt chromium. Indisputably, all materials have limitations with respect to their properties. Titanium has been shown to be plagued by a unique and profound sensitivity to heat. When exposed to high temperature, titanium undergoes a violent reaction with O2 to form TiO2 which appears as a thick, black soot-like debris on the surface of the metal.11 Consequently, this precipitate requires removal and this in turn creates a new dilemma related to the potential unknown discrepancy in the intimacy of fit between the prostheses and fixture interface. Hence, one could reasonably contend that the utilization of traditional porcelain layering protocols with titanium is contra-indicated due to the lack of science examining this conundrum. The profession has responded to this technical challenge by revising the ISFD frame design to employ individual, cementable abutments to permit for the use of single unit, cementable crowns (figures 5 and 6). This surrogate model resolves the issue pertaining to TiO2 formation by allowing for the independent fabrication of crowns from the frame. In
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7 8 9 addition, current data has revealed that protecting titanium, or any other material, from heat might act to curb the possible decrease in frame passivity of fit which accompanies porcelain application procedures.12 The use of composite bonding to titanium, albeit a questionable procedure with respect to its long term in vivo performance due to an absence of data, does permit the frame to be engineered in such a manner that the soft tissues can be replicated with the assistance of a halogen light as opposed to a porcelain furnace. Individual abutment design also serves to provide both the dentist and the patient the opportunity to manage a single unit porcelain fracture on a multiple unit prosthesis with improved simplification through bypassing the removal of the complete prosthesis in favour of sectioning and extraction of individual crowns. The data on ISFDs indicates that multiunit, fixed, implant prostheses are at elevated risk for porcelain fracture. This is speculated to be partly attributable to the impact of reduced implant proprioception related to a lack of a periodontal membrane and its inherent mechanoreceptors. Linkevicius reported in a retrospective study, ceramic fracture
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rates ranging from 6.7% for implant supported, fixed, partial dentures (ISFPDs) to 38% for ISFCDs. The study’s median follow up time was approximately ten months and included a sample of approximately two hundred and fifty patients and over two hundred ISFPDs.13 Often ISFDs oppose their own kind and consequently the risk for porcelain fracture is further escalated. Kinsel demonstrated, in a retrospective investigation, a seven fold increase with porcelain fracture for ISFPDs in a sample of approximately one hundred and fifty patients featuring nearly one hundred ISFPDs.14 Use of the individual cementable abutment frame design circumvents the obligatory need to strip traditional metalceramic frames of their porcelain for the purpose of complete reapplication to manage esthetic fractures. Patients with ISFDs no longer need to face the potential for considerable treatment and the associated fees in the event that they should incur an innocuous ceramic chip that poses an esthetic issue (figures 7-9). The individual abutment design frame provides the supplemental benefit of allowing for greater flexibility with respect to porcelain modification. This is of particular concern for patients
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who display high esthetic demands or those who demonstrate unreasonable or unrealistic esthetic expectations. Repeated heat exposure of a metal or zirconium frame for the addition of porcelain creates the risk of porcelain fracture resulting from a coefficient of thermal expansion mismatch between the two materials (figure 10).15 This issue is believed to originate from the differential which develops in the rate of contraction of metal and porcelain upon cooling following porcelain firing in a furnace. Magnification of the problem is thought to result from the variation in cross-sectional thickness of the materials throughout the length of the prosthesis. The evolution of prosthesis design has lead to the fabrication of individual crowns featuring screw access holes. This modification to the original protocol has permitted for the fabrication of a prosthesis that can boast unobstructed removal capability (figures 11-12). The next segment of this article will discuss the process of copy milling as it pertains to the ISFD. It will also serve to outline the clinical and laboratory particulars for the fabrication of an ISFPD. L References
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1. O rtorp A, Jemt T; Clin Implant Dent Relat Res. 2000; 2(1):2-9 2. A lmasri R, Drago CJ, Siegel SC, Hardigan PC; J Prosthodont. 2011 Jun;20(4): 267-74 3. K arl M, Holst S; Int J Prosthodont. 2012 Mar-Apr; 25(2): 166-9 4. A ssunção WG, Gomes EA, Rocha EP, Delben JA; Int J Oral Maxillofac Implants. 2011 Jul-Aug;26(4):788-96 5. A bduo J, Swain M; Int J Oral Maxillofac Implants. 2012 May-Jun;27(3):529-36 6. O rtorp A and Jemt T; Clin Implant Dent Relat Res. 2012 Mar;14(1): 88-99 7. Papaspyridakos P, Lal K; Clin Oral Implants Res. 2012 Mar 13 8. L arsson C, Vult Von Steyern P.; Acta Odontol Scand. 2012 Dec 4 9. T eigen K, Jokstad A; Clin Oral Implants Res. 2012 Jul;23(7):853-60 10. D alal A, Pawar V, McAllister K, Weaver C, Hallab NJ; J Biomed Mater Res A. 2012 Aug; 100(8): 2147-58 11. O shida Y, Hashem Al; Bio-Medical Materials and Engineering Journal; 1993(4): 185-198 12. K arl M, Graef F, Wichmann M, Beck Nl; Dent Mater J. 2012;31(3):338-45 13. L inkevicius T, Vladimirovas E, Grybauskas S, Puisys A, Rutkunas V; Stomatologija, 2008; 10(4): 133-9 14. Kinsel RP, Lin D; J Prosthet Dent. 2009 Jun; 101(6): 388-94 15. L iu Y, Fenga H, Baob Y, Qiub Y, Xingc N, Shen Z; Journal of the European Ceramic Society 30; 2010; 1297–1305 SPRING/SUM MER
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of a
Lifetime
Years ago, a young dentist was confronted with the issue of total edentulism in a poignant situation that was, at the time, all too common in the dental profession. by Dr. Paulo Malo
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was meeting with a patient whose quality of life would have improved enormously, had I only been able to provide him with a complete bone-anchored solution. Unfortunately, I had to tell him that placing implants in his maxilla was virtually impossible due to the lack of viable bone tissue there. Back in the nineties, in his situation, the only practicable implant solution involved preparatory bone grafting, also known as bone augmentation, but such a cost- tulous population for permanent solutions far outstrips the ly procedure was out of my patient’s reach number of best-of-circumstances cases. financially, and his history of heart problems indicated that it would not be wise to proceed with such an invasive course of action in any case. Unfortunately, cases like his were—and continue to be— common-place among seniors. Under the best of circumstances, bone grafting can provide an effective foundation for implant-based prostheses. Unfortunately, the aggregate need among the totally eden-
Paulo Malo, President of the MALO CLINIC Health & Wellness graduated in 1989 from the Faculty of Dental Medicine, University of Lisbon, and founded MALO CLINIC in 1995. The innovative concept All-on-4® and related products developed by Prof. Paulo Malo have revolutionized Oral Surgery, mainly in the
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Looking at the big picture, it became obvious to me that the optimal general solution to the problem of total edentulism was not going to comprise bone augmentation.
New thinking Think of it this way: As the number of teeth in a full-arch restoration increases, so does the amount of bone needed to support the underlying implants that support it.
scope of Implantology and Fixed Oral Rehabilitation. With a PhD in Oral Biology, he is a co-author of several books and has published several scientific articles, as well as a frequent guest speaker in numerous international conferences. Aside from his clinical practice and corporate management, he is a visiting profes-
sor in several prestigious Universities, as well as leading consultant in four major dental medicine international companies. Throughout his career he has also received several distinctions and awards, either for his medical breakthroughs, or for his managing, leadership and entrepreneurial skills..
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In order to determine the minimum number of teeth needed to guarantee good mastication and esthetics, we devised something we called the “nut test.” We gave our test subjects a standardized portion of almonds, asked them to chew for ten seconds, and then we aspirated the crushed nuts in order to subsequently measure the size of the particles; the idea being that the smaller the particles, the greater the masticatory efficiency. We compared the results from subjects with arches comprising 10 teeth (2nd premolar to 2nd premolar) to others with 12 teeth in each arch (1st molar to 1st molar) and to yet others with 14 teeth per arch (2nd molar to 2nd molar). The results showed that while 14 teeth per arch provided the greatest chewing efficiency, 12-tooth arches worked almost as well, and even 10 teeth provided acceptable mastication in terms of facilitating ingestion. From the esthetic point of view, it was easy to demonstrate that, while smiling, most of our subjects showed half of the first molar. To maintain good esthetics then, we determined that a 10-tooth arch was not adequate. On the other hand, the most posterior teeth of a 14-tooth arch would rarely, if ever, be seen by the subjects’ acquaintances.
Optimizing the arch
With these results in hand, we knew how to proceed and began to develop an oral rehabilitation solution that would deliver 12 teeth per arch (1st molar to 1st molar). In the mandible, we typically find enough bone to place straight implants in between the foramina mentalis, but not enough to place any posterior to the foramina. Depending on the position of the foramina, we found that we could place between six and eight teeth with no substantial cantilevers. Our goal, of course, was to produce a 12-tooth bridge. Reviewing the literature, we found clinical cases (albeit not routine protocols) in which as many as three teeth were placed on cantilevers and were reported to work well.
Undesirable bending Evaluating the force on the implants due to cantilever bending in situations like these, however, one finds that the implant closest to the cantilever is subjected to substantial (and escalating) forces as the cantilever increases. Such forces do not bode well for successful long-term prognoses. In order to reduce the length of the cantilever by one or two teeth, and thus improve the biomechanical long-term SPRING/SUM MER
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outcome, we chose to incline the posterior implant. Literature reviews showed us that angled implants had been in use for decades by Professor Brånemark and his colleagues (Kallus et al. 1990) and had no higher failure rates than straight, axially loaded, implants. In a fruitful cooperative effort with the late bioengineering professor Bo Rangert at Nobel Biocare, we realized that the use of long, well-angled posterior implants would be one of the keys to reaching our objectives. Together with the straight anterior implants, these angled posterior implants become components in a virtual truss, making it possible to avoid vulnerable anatomical structures, while offering improved support of the prosthesis by reducing cantilevers. What’s more, the apex of the angled implant can be placed in better quality anterior bone. A straightforward treatment design innovation, angled posterior implants help to eliminate the need for bone grafting by increasing bone-to-implant contact. As Bo was fond of demonstrating on a chalkboard, napkin or a computer, from a biomechanical point of view, four implants provide an optimal solution for a full-arch and are eminently suitable for immediate loading strategies.
All-on-4 concept in a nutshell Consider the following: when the cantilevers of a complete prosthetic arch are loaded, only the supporting posterior implants are subjected to load. The remaining two implants, placed in the anterior, are subjected to no compression transferred over the fulcrum from the cantilever load and only negligible tension, which makes additional implants superfluous. The use of ancillary implants actually makes the surgery more difficult, as each additional implant competes for precious space, which is usually in short supply, and sometimes completely unavailable. Also, for the sake of good, long-term prognoses, one simple fact must always be taken into consideration: the closer the implants are placed to each other, the greater the potential for marginal bone loss. Another factor that needs to be taken into consideration when designing a full-arch solution: the greater the number of implants used, the greater the number of holes in the prosthetic structure. In this context, it is important to remember that the inherent tensile strength of the prosthetic arch is always compromised to some degree by each additional hole. What about hygiene and fit? Basing each arch on only four implants facilitates oral hygiene, especially for older patients, the most common demographic among the edentulous. The use of four implants also makes it easier to achieve passive fit, which is of critical importance whenever a cantilever is called for. In short, the use of four implants reduces treatment com-
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plexity, which yields many benefits. Costs for both the doctor and the patient are reduced because less surgical time and product are used. The lab technician can profit from reduced intricacy in the fabrication of prostheses—leading directly to more predictable workflow patterns—and simplified hygiene bodes well for improved long-term oral health all around.
Our first case Having completed this preliminary analysis, I felt very secure about our proposed procedure and was eager to tackle our first case. To minimize risk, I chose a healthy, highly motivated candidate with good bone density. As I proceeded with the surgery in April 1998, it became clear that inclining the posterior implants at approximately 45° was not going to be easy working freehand. As there were no teeth to provide points of reference, I ran the risk of missing the biomechanically correct position as I drilled. To preclude this problem, I designed a universal guide that could be used for all mandibles. Made of metal, so it could be sterilized and reused, ours was a fixed guide, which was a remarkable innovation at the time. The second and following surgeries went much more smoothly not only because of the guide but also because we were moving up the learning curve. After completing approximately ten cases, we decided to carry out twelve months of follow-up on those cases in order to evaluate results, before continuing. After one year, the results were extraordinary. We were looking at a success rate approaching 100%, no more marginal bone loss than normal, and a huge degree of acceptance by the patients. These were heady days. From the moment we took those first tentative steps, we decided to continue along the same path, fastidiously documenting every step. Tremendous things transpired as a result. In this case of moderate bone resorption, the All-on-4 concept—with NobelGuide in the maxilla and the flap approach in mandible—provided complete rehabilitation with a minimally invasive solution. The totally edentulous female patient depicted here was a removable denture wearer in her early 50s, and in good general health. At the time she approached our clinic for alternative treatment, she had had her dentures for 15 years and was complaining about poor retention and the general instability of her removable dentures. In addition to the discomfort she experienced, the patient found it difficult to speak clearly and chew well, and she was unhappy with the overall appearance of her mouth. She was well-motivated for the fixed, implant supported rehabilitation that we subsequently proposed.
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Our oral examination showed moderate bone resorption in the maxilla (at least 5 mm width and 10 mm bone height between the canines in the maxilla) and severe bone resorption in the mandible (at least 5 mm width and 8 mm bone height between the mental foramina in the mandible). The patient presented a low smile line. We implemented fixed, implant supported, bimaxillary rehabilitation through the All-on-4 concept, following the NobelGuide protocol (flapless) in the maxilla, and the conventional flap approach with the All-on-4 Guide in the mandible. Four implants were placed in each of the jaws, followed by immediate placement of provisional, fixed, all-acrylic bridges, providing the patient with an immediate function solution. In the maxilla, a NobelProcera Implant Bridge Titanium framework with individually designed and cemented zirconia crowns and pink acrylic was used. In the mandible, a NobelProcera Implant Bridge Titanium framework wrapped in pink acrylic and denture teeth was used. (Both placed six months after surgery according to the Malo Clinic protocol.)
Maxillary Treatment Intra-oral view of the removable dentures. Since the patient’s denture did not meet the functional and esthetic requirements, a new removable upper denture was fabricated. After the intra-oral examination, special consideration was given to the low smile line and mouth opening capability of over 50 mm.
Figure 1
Pre-op radiograph together with the 3D radiographic analysis shows the moderate bone resorption in the maxilla and severe bone resorption in the mandible. Please note the lack of available bone for implant placement in the posterior maxilla and mandible.
Figure 2
Figure 3 All-on-4 treatment planning with the NobelClinician Software, for a detailed diagnostic process in both jaws. Prostheticdriven planning based on the patient’s anatomy and prosthetic needs was chosen to ensure optimal implant support for an optimal restorative solution.
In the maxilla, a flapless procedure was chosen using the NobelGuide Surgical Template to optimally position the four implants and ensure minimally invasive treatment
Figure 4
Figure 5 Post-op occlusal view immediately after the placement of the four implants and the multi-unit abutments. The straight multiunit abutments were placed in the axial anterior implants. The 30° multiunit abutments non-engaging were placed using a custom jig for the correct positioning of the angulated abutments. SPRING/SUM MER
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Contact:
Mandible After the traditional treatment planning in the mandible, a conventional flap procedure was done. The All-on-4 Guide was positioned to assist implant placement. The purpose of the All-on-4 Guide is to assist in the correct angulations for posterior implant placement between 30° and 45°.
Figure 6
Jumping ahead 6 months, the immediately loaded temporary bridges were replaced with a Malo Clinic ceramic bridge in the maxilla and—following the same protocol— an acrylic arch built upon a NobelProcera Titanium framework on the mandibular implants below.
Figure 7
Radiograph at 6 months shows successful All-on-4 treatment with four implants in combination with precision manufactured NobelProcera frameworks in each jaw. They were milled from a solid monobloc of titanium to secure precision of fit and longevity, and designed to meet the patient’s esthetic and functional needs.
Figure 8
Extra-oral view of the patient showing the definitive rehabilitation with fixed bridges to fulfill the phonetic, masticatory and esthetic needs of the patient. The base of the definitive and provisional bridges are designed to be convex or flat, and polished for minimum plaque retention and easy cleaning.
Figure 9
All-on-4 treatment for the maxilla followed and thousands of patients have subsequently been treated in accordance with this concept. Equally important, dozens of clinical studies have uncontestably documented the safety and efficacy—and remarkably high success rates—of the All-on-4 treatment concept for the rehabilitation of the totally edentulous. Anyone who does implant-based oral rehabilitation should consider learning All-on-4. L References Kallus T, Henry P, Jemt T, Jorneus L. Clinical evaluation of angulated abutments for the Branemark system: a pilot study. Int J Oral Maxillofac Implants, 5: 39-45, 1990. Adell R, Eriksson B, Lekholm U, Branemark PI, Jemt T. Long-term follow-up study of osseointegrated implants in the treatment of totally edentulous jaws. Int J Oral Maxillofac Implants, 5: 347-359, 1990. Gelb DA, Lazzara RJ. Hierarchy of objectives in implant placement to maximize esthetics: use of pre-angulated abutments. Int J Periodontics Restorative Dent, 13: 277-287, 1993. Maló P, Rangert B, Nobre M. “All-on-Four” Immediate-Function Concept with Brånemark System Implants for Com-
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pletely Edentulous Mandibles: A Retrospective Clinical Study. Journal: Clin Implant Dent Relat Res, vol. 5, no. 1, pp. 2-9, 2003. Maló P, Rangert B, Nobre M. All-on-4 immediate-function concept with Brånemark System implants for completely edentulous maxillae: a 1-year retrospective clinical study. Clin Implant Dent Relat Res, vol. 7, Suppl 1: S88-94. 2005.
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Dental Marketplace
Contact: Karen Shaw • tel: 416-510-6770 • fax: 416-510-5140 • e-mail: kshaw@oralhealthgroup.com Toll free: CDA 1-800-268-7742 ext 6770 • Toll free: USA 1-800-387-0273 ext. 6770
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Practices & Offices
Associateships WILLIAMS LAKE, BRITISH COLUMBIA DENTAL ASSOCIATE POSITION
Full Time Dental Associate needed for large multidisciplinary family dental practice. Whether you’re someone who’s just starting off in your dental career or a seasoned provider we would welcome you to join our team. We are a digital and paperless practice, newly renovated with the latest technology (including CBCT). Come and work in an office where you can experience a variety of dental cases, work with the latest technology and be supported by our highly trained and skilled team. We have a very successful clinic that is a great place to practice dentistry! This is an excellent environment to gain experience and earn a six figure income while enjoying a healthy lifestyle. Position Available July 2013. Call Perry @ 250-398-0532 Vitoratos@shaw.ca and visit us at www.cariboodentalclinic.com
DENTAL MARKETPLACE LOOKING TO SELL YOUR PRACTICE? HELP
• Stay on or sell outright • Get full value for your practice • Confidentiality respected • No charge Appraisal • 0% commission • Win/Win scenario Please email: dentalcare@live.ca
CALGARY, AB
Full time associate needed for a new dental office in the Calgary northwest. Please submit your resume to: DrRichardKolen@hotmail.com or fax your resume to 403-638-3604.
MARKHAM, ON
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Practice for Sale; 400k+ production and low overhead; 2-3 days per week; hygiene program; MD and Pharmacy in plaza; 3 ops + 4th plumbed and Panorex; easily expand and increase revenue. Please email: urbanlifestylist@gmail.com
BRAMPTON, ON
Practice for Sale, $1 million. Share sale. Gross in excess of $850,000. Cash flow: $380,000. Contact: practicesale@minnaar.ca
Practices & Offices INGLESIDE, ON
1200 square foot space available for sale or lease. Terms are flexible. Great demand for dentist in the community. Privy to other opportunities in community if current location deemed unsuitable. Please call Bryan (Pharmacy Owner) at 613-537-2477 or email me at inglesidepharmacy@hotmail.com for more information.
YOUR ADVISOR IS IN
KARENASHAW ssociateships TEL: 416-510-6770 FAX: 416-510-5140 MISSISSAUGA, ON Looking To Get Paid What You Are Worth? Growing Mississauga, Practice is looking Be Fully Supported, Continue E-MAIL: Your Education, kshaw@oralhealthgroup.com for a part time ENDODONTIST to work Work With A Skilled TEAM,FREE CDN: TOLL 6770 1-21-800-268-7742 days per month. We areext currently While Earning Performance referring out of our office. TOLL FREE USA: 1-800-387-7742 ext 6770 Bonuses & Incentives… Please contact Bonnie: Is This YOUR New “Dental Home”? bonnie.rockwooddental@bellnet.ca WEBSITE: www.oralhealthgroup.com Careers
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Tel: 905 624 8917.
Associate position part-time is available in busy mall location. Will be busy from day one. Position best suited to Cantonese or Vietnamese speaking. Can begin immediately. Friendly and personable is preferable. Please reply to Oral Health Labs Box 16 — e-mail: kshaw@oralhealthgroup.com
ARE YOU A DENTAL ASSOCIATE LOOKING FOR A FULL SCHEDULE?
Newly Renovated, State of The Art Equipment, 10 Operatories, Skilled TEAM, Performance Bonuses & Incentives… Is This YOUR New “Dental Home”? www.DentalDreamTeam.ca/Dentist
TABER, AB
Full-time dental associate required for a busy, well established dental practice. Future opportunity to buy in. New grads welcome. No evenings or weekends Please respond by e-mail to griziffin@hotmail.com
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OMFS ASSOCIATES REQUIRED
Busy satellite office requires associates to help manage high patient volumes. Our practice is located 3 hours from the GTA. Flexible schedule available but minimal commitment of 5 days per month required. Outstanding income potential for individuals that are looking for fully booked days, performing high quality oral surgery. You can continue to reside in the GTA and supplement your professional income with this opportunity. Forward CV in confidence to: 2020omfs@gmail.com
A FULL TIME ASSOCIATE IS REQUIRED IN CALEDONIA, ONTARIO.
We’re particularly interested in a candidate who has enthusiasm, self-motivation, dedication, good communication skills, attention to detail and a positive attitude. Please forward resumes to info@grandriverdental.ca or call 905-745-3961
KITCHENER-WATERLOO AREA Full Time Associate — leading to partnership, neeeded asap. We are a busy small town group of practices with current equipment, long standing staff and great hours. Please reply to dentistsreply@yahoo.ca
BARRIE, ONTARIO
OTTAWA, ON
Full-Time Associate Needed. Outstanding opportunity for a dynamic, dedicated team-oriented individual to join a large, well-established group practice in Kanata, (Ottawa) Ontario. Please submit CV by email: hazeldeandental@gmail.com
BRAMPTON, ON
Needed : F/T Associate DDS position available ASAP. Evenings & Saturdays are a must. E-mail: dental_manager@hotmail.com
Part time associate needed to start immediately for busy Brampton office. Days offered are Friday evenings and Saturdays. Please forward resumes to fletcherswalia@yahoo.ca
MEDICINE HAT, AB
EAST OF GTA — ASSOCIATE
Associate position available in a progressive, busy and collegial practice. The city of Medicine Hat, the clinic and the remuneration are exceptional. Please e-mail CV to cindy@broadwaydental.ca
Peterborough 1.5 hours from Toronto. Digital X-rays, Paperless Chart. Contact at Dr. Alex at alexrheedds@gmail.com or 905-706-7665.
Are you having enough fun at work? With the core values of Health, Growth & JOY, Sierra is expanding and accepting applications for Pediatric Dentists & General Practitioners in Calgary, Alberta.
Why Calgary?
This beautiful city sees more days of sunshine than any other major Canadian city. Home to 1.3 million people, Calgary is diverse and community-minded. It is also the mecca of business & financial growth with the strongest economy in the entire country.
Why Sierra Dental? Because you deserve to feel joy at work!
Sierra believes in cultivating and sharing positive energy and strives for a joy-filled environment for all staff & patients. If you are clinically strong, high energy, and self-starting, we look forward to meeting you. With over 12,000 active patients and a tremendously successful internal referral program we are excited to welcome the right doctor. If you are passionate, clinically committed and seeking happiness in your work environment, send resume & cover letter to lavonne.keal@sierracentre.com
GRANDE PRAIRIE, AB A full time associate dentist required to take over an existing full patient load from the current associate, you will be busy from day one. Office is bright, modern and very well equipped, computerized, digital, paperless. Opening July 1, 2013. Please send resume to: pmdcgp@telus.net
STRATHMORE, AB
Part time associate position in Strathmore — 30 minutes east of Calgary. If you are passionate about the art and science of dentistry and would like to work in a busy office that provides you with the best to produce the high quality dentistry that you dream of, send your resume to strathmoreassociatedentist@gmail.com
KITCHENER/WATERLOO, ON
A great FT or PT Associate position is available in a very busy family practice in KW area. Excellent opportunity, very busy office with large patient base. Current associate relocating. Minimum 2 years experience required. The candidate must be proficient in molar RCT and surgical extractions. Please email your resume to: susandellx2@yahoo.ca CAMBRIDGE, STRATFORD, ORANGEVILLE, ON
www.sierradental.ca
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Cambridge, ON (right off the 401) Stratford, ON (between Kitchener and London) Orangeville, ON (just north of Brampton) Full time or part time. Busy and established offices. Fully paperless/digital, new equipment and leading edge technologies (cerec, lasers, implants, ortho...). Restorative hygienist available. Potential for buyout or partnership for the right person. Email resume to: dentalgroupswo@gmail.com
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