CPOI

CPOI_V3N3_Summer 2012_Spectrum 7/9/2012 11:20 AM Page 1

The Science and Practice of Oral Implantology Summer 2012

Volume 3 • Number 3

Clinical

Practical Oral Implantology

The Train of Titanium Creation and Preservation of Natural Soft Tissue Emergence Profiles Around Dental Implants in the Esthetic Zone A “Flexiable” Option for Osseous Ridge Widening in the Mandible Another String to Our Bow

CPOI_V3N3_Summer 2012_Spectrum 7/9/2012 11:20 AM Page 2

Nobel Biocare Symposium 2012 – Toronto Revisit Toronto 30 years later October 19–20, Sheraton Centre Toronto Hotel, Toronto / Canada

For more on the Toronto Symposium, watch a message from Dr. George Zarb, Scientific Committee Chair, on our YouTube channel: youtube.com/nobelbiocareamericas

Join us in Toronto as we celebrate the innovation of osseointegration at this anniversary symposium.

A world-class group of speakers will discuss the past, present, and future of osseointegration Oded Bahat Edmond Bedrossian Urs Belser Steven Bongard Robert Carmichael Lyndon Cooper Forrest Cottrell Joe Coursey Lesley David Yvan Fortin

Bertil Friberg Xinquan Jiang Sascha Jovanovic Joseph Kan Sreenivas Koka Trevor Laingchild Ulf Lekholm Michael MacEntee Peter Moy

Kenneth Parrish Peter Schupbach Eric Van Dooren Thomas Wade Georg Watzek Peter Wöhrle Johan Wolfaardt George Zarb John Zarb

Nobel Biocare Canada, Inc., 9133 Leslie Street, Unit 100, Richmond Hill, ON L4B 4N1 Phone 905 762 3500; Toll free 800 939 9394

Register now!

Reserve your place today by contacting— In Canada: 800.939.9394; symposium2012.canada@nobelbiocare.com In the US: 800.579.6515; educationusa@nobelbiocare.com Watch your email inbox for more details, or go to nobelbiocare.com/toronto2012 to learn more.

Nobel Biocare USA, LLC, 22715 Savi Ranch Pkwy., Yorba Linda, CA 92887 Phone 714 282 4800; Toll free 800 322 5001

Nobel Biocare, the Nobel Biocare logotype and all other trademarks are, if nothing else is stated or is evident from the context in a certain case, trademarks of Nobel Biocare.

www.nobelbiocare.com

CPOI_V3N3_Summer 2012_Spectrum 7/9/2012 11:21 AM Page 3

The Science and Practice of Oral Implantology

Clinical

Practical Oral Implantology

Editorial Board Jonathan Adam, BSc, FRCDC, MSc, Dip ABP, Clinical Demonstrator, Department of Periodontics, University of Toronto, ON Don Callan, DDS, Cert. Periodontology, Private Practice, Little Rock, AR David L. Cochran, DDS, MS, PhD, Chair of the Department of Periodontics at the University of Texas Health Science Center Lyndon F. Cooper, DDS, PhD, Chair and Program Director of the Department of Prosthodontics at the University of North Carolina at Chapel Hill School of Dentistry Ronny Dagher, BSc, DDS, MSc, FRCD(C), Clinical Instructor, Department of Endodontics, University of Toronto, Faculty of Dentistry; Board Examiner for the Royal College of Dentists of Canada, Div. of Endodontics, Toronto, ON

Summer 2012 • Vol. 3 • No. 3

In this issue 4 6

Editorial

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Creation and Preservation of Natural Soft Tissue Emergence Profiles Around Dental Implants in the Esthetic Zone – Paul S. Petrungaro, DDS, MS, FICD, FACD, DICOI

Douglas Deporter, DDS, PhD, Professor, University of Toronto, Faculty of Dentistry, Toronto, ON Anastasios (Tassos) Irinakis, DDS, MSc, Dip. Perio, FRCD(C), Director of Graduate Periodontics & Implant Surgery, UBC, Certified Specialist in Periodontics, Clinical Associate Professor, UBC, Vancouver, BC Sascha Jovanovic, DDS, MSc, Private Practice, Los Angeles, CA Sonia Leziy, DDS, Dip. Periodontics, FCDS (BC), FRCD(C), Private Practice, North Vancouver, BC

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A “Flexiable” Option for Osseous Ridge Widening in the Mandible – Allen Aptekar, BSc., DMD

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Another String to Our Bow for Prostheses on Implants: The Camlog® Vario Sr Abutment – Dr Eric Normand

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Products & People

Mark Lin, B.Sc. D.D.S, M.Sc., Dip. Prostho, F.R.C.D.(C) Brahm Miller, DDS, Dip. Prosthodontics, FCDS (BC), FRCD(C), Private Practice, North Vancouver, BC Craig M. Misch, DDS, MDS, Private Practice, Oral and Maxillofacial Surgery & Prosthodontics, Sarasota, FL

The Train of Titanium - A rare interview with Professor Per-Ingvar Branͦemark – Frederic Love

Michael A. Pikos, DDS, Adjunct Assistant Professor, Dept. of Oral Maxillofacial Surgery, Ohio State University, University of Miami, and Nova Southeastern University; Private Practice, Oral Maxillofacial Surgery, Palm Harbor, FL Yvan Poitras, DMD, Private Practice, Montmagny, PQ Michael Razzoog, DDS, MS, MPH, Professor, University of Michigan, School of Dentistry, Biologic & Materials Science, Division of Prosthodontics, Ann Arbor, MI John Russo, DDS, MHS Periodontics, Clinical Assistant Professor in Periodontics, Medical University of South Carolina, Private Practice, Sarasota, FL Peter C. Shatz, DDS, Assistant Clinical Professor, Medical College of Georgia, School of Dentistry, Dept of Periodontics Lee H. Silverstein, DDS.,MS.,FACD.,FICD Associate Clinical Professor, Medical College of Georgia, School of Dentistry, Dept of Periodontics

Publisher: Ettore Palmeri, MBA, AGDM, B.Ed., BA Palmeri Publishing Inc. Canadian Office: 35-145 Royal Crest Court, Markham, ON L3R 9Z4 Tel: 905-489-1970 Fax: 905-489-1971 Email: ettore@palmeripublishing.com

•

Editor-in-Chief: Allen Aptekar, BSc., DMD editor@jcpoi.com

Bernard Touati, DDS, Private Practice, Paris, France

Consulting Editor: David J. Stern, DDS

Istvan Urban, DMD, MD, Adjunct Assistant Professor, Restorative Dentistry, School of Dentistry, Loma Linda University, Loma Linda, CA

Design & Layout: Tim Faller, Sophie Faller, Lindsay Hermsen, B.Des.Hons.

Hom-Lay Wang, DDS, MSD, PhD, Professor and Director of Graduate Periodontics, Department of Periodontics and Oral Medicine, School of Dentistry, University of Michigan, Ann Arbor, MI Amr Zahran, BDS, MDS, PhD, Professor of Periodontology, Cairo University, Egypt

CPOI — Vol. 3 No. 3 — Summer 2012

Publication Dates: Spring, Summer, Fall, Winter

Printed in Canada Canadian Publications Mail Product Sale Agreement 9386690

Clinical Practical Oral Implantology is published four times a year, and is distributed to dental practitioners across Canada and the United States. The journal is committed to better the knowledge of dental practitioners in discipline of dental implantology. All statements of opinion and supposed fact are published on the authority of the submitting author and do not necessarily express the views of the CPOI, CPOI Holdings Inc, the Editor(s), and the Editorial Board. The publisher disclaims any responsibility for loss or damage due to errors and omissions. Content of the CPOI does not constitute medical advice.

The editor reserves the right to edit all copy submitted to the CPOI. Publication of an advertisement does not imply that CPOI endorses the claims therein. The publisher, CPOI, and CPOI Holdings Inc. disclaim responsibility for any injury to persons or property resulting from any ideas or products referred to in the articles or advertisements.

Articles published express the viewpoints of the author(s) and do not necessarily reflect the views and opinions of the Editorial Board.

All rights reserved. The contents of this publication may not be reproduced either in part or in full without written consent of the copyright owner.

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CPOI Editorial

Ettore Palmeri MBA, AGDM, B.Ed., BA

Kaizen: Change for the Better

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could make local adjustments which can be tested and then love the opportunity to communicate with the implemented. Here, a culture of continual aligned small readership of the 13 dental magazines we publish. improvements is believed to yield large results in the form of However, in CPOI I usually stand back and let Dr. compound productivity improvement.

Aptekar communicate with the readers. This issue which This is not just management speak - it is common sense, features Dr. Aptekar as an author gives me the chance to step up to the plate and swing my thoughts to you. and applies extremely well to the running of a dental practice.

The people that know me are aware that my background Any right thinking business person - and certainly a switched is in education and that I used to provide motivational on practice owner like the reader of CPOI - would always be messages to my students and organizations alike. In looking to improve the way things are done in their preparing for my next presentation I just reviewed some organization. And what better way to do it than to involve the notes with the Japanese business concept of Kaizen. Kaizen people on the ground - the assistants, hygienists and is a management principle from Japan which seems to me administration staff - in looking at how they work and where to chime perfectly both with things could constantly be what we aim to do with CPOI, reviewed, fine tuned and and what I suspect many of our improved by the people doing Kaizen involves all employees, from the readers do or strive for in it. Perhaps the reception staff could look at the way phone looking for success in their CEO to the production line workers, and calls are handled over the lunch private practices.

Originally the name Kaizen break, or the nurses at systems covers all processes and standardised was a revelation for me and it in the sterilisation area, or activities. It is a daily, ongoing process, has been key to our solid purchase of inventory. achievements as a media These could be small factors requiring everyone’s participation. but they are vital elements in provider during the last 19 the successful and smooth years. Roughly translated, the running of the practice. In term means “continued improvement” and refers to activities that continually addition, there’s no doubt that people feel much stronger improve all functions within the workplace. It was introduced ownership of systems they develop themselves! We all like into several Japanese businesses after the second world-war to have our opinion sought and followed, and if many and has since then been taken up in areas beyond business small steps are constantly being taken, it will lead to major and productivity, including healthcare. leaps overall.

What’s more, Kaizen involves all employees, from the We are certainly taking Kaizen on board at CPOI and value CEO to the production line workers, and covers all all our stakeholders’ input and suggestions. We are already processes and standardized activities. It is a daily, ongoing making continual improvements and innovations in small ways process, requiring everyone’s participation. At Toyota, where throughout the magazine – most of them so minor that only Kaizen is an integral part of the way they operate, we are consciously aware of them. But we hope that the net employees are encouraged to have input into their own result is an improvement in the whole. Maybe try introducing particular area; when things go wrong, or if it is felt that they a little Japanese culture into your practice implant could go better, as a small group they look at how they component and see what results can be obtained. n

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CPOI_V3N3_Summer 2012_Spectrum 7/9/2012 11:21 AM Page 6

The Train of Titanium -

A rare interview with Professor Per-Ingvar Branͦemark Frederic Love

Science is what you know. Philosophy is what you don’t know.

Per-Ingvar Branͦemark remains interested in both.

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t its annual inventor awards ceremony this spring, the European Patent Office (EPO) presented Professor Pre-Ingvar Branͦ e mark with the organization’s lifetime achievement award for his discovery and development of osseointegration.

Regarded as the most prestigious prize for European inventors, the award went to Branͦemark because, “During the course of his career, he has continued to refine his approach into what has become the gold standard of dental implantation globally-the method of osseointegration.”

According to the EPO, “more than eight million people have benefited from Branͦemark’s landmark methods,” since he treated his first osseointegration patient, Gosta Larsson, in 1965.

Serendipity and Hard Work I met with Professor Branͦemark recently, not far from the University of Gothenburg, Sweden, where he has worked most of his life. When I asked about the award, he replied simply, “I have received quite a few prizes and awards over the years, but this beats everything else. It represents recognition from colleagues and laymen alike that my method has already helped an enormous number of people. What greater commendation can a scientist hope to receive?”

He has come a long way since those early days in the 1950s when, as a young researcher, he was completely absorbed in the study of the anatomy of blood flow.

As part of that work, he attached a titanium-housed optical component to a rabbit’s leg, which made it possible to study microcirculation in the bone tissue through specially modified microscopes. The work at hand

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was completed successfully, but when it came time to remove the metal-framed optics from the bone, Branͦemark famously discovered that the bone and the titanium had become virtually inseparable.

“Not long afterward,” Branͦemark said, “we changed the direction of our work to investigate the body’s ability to tolerate titanium”.

Multidisciplinary Enterprise To gain a proper understanding of what he would later call “osseointegration,” Branͦ e mark recruited experts from other fields-such as physics, chemistry and biology-to his quest. Physicians, dentists and biologists all joined the effort.Together they developed diligent, methodical techniques for the insertion of implants. At the same time, engineers, physicists and metallurgist studied the metal’s surface and how the design of the implant might have an effect on bone healing and growth.

For the best part of two decades, Branͦ e mark faced opposition from the medical establishment in his native Sweden. “Our findings that the body would accept titanium over the long term, and even allow it to integrate in bone, flew in the face of conventional wisdom,” he explains.

“Theorists’ textbook opposition asserted that our implants would trigger initial inflammation and would ultimately be rejected by the body’s immune system.”

The 1960s were trying times for Branͦemark. Funding from Swedish research organizations dried up, yet he persevered. With his physician’s certification at stake, he repeatedly demonstrated the accuracy of his claims and the viability of osseointegration. Finally, in the mid-1970s, the Swedish National Board of Health and Welfare approved the Branͦemark method.

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To reach beyond the world of the university clinic, Branͦ e mark looked for an industrial partner. “I chose Bofors, an antecedent to Nobel Biocare, because they were one of the few companies who knew how to machine titanium,” says the professor. Thus a long-term relationship began.

Over the years, this relationship has had its ups and downs, but both parties have benefited from long term devotion to the support and practice of good science.

When I asked Branͦemark what characterizes good science for him personally, he responded thoughtfully.

“Good science is all about good method. Making observations, collecting facts and data and creating a hypothesis to explain what you’ve seen-it all starts there.

Then you have to deduce the implications of the hypothesis and put the implications to the test. It is very important that all data be considered, not just those that support your ideas. Finally, you have to subject your findings to peer review. At the end of the day, there may be no “final” truth, but in our field, a valid hypothesis will inevitably lead to practical achievement as it stands up to the scrutiny of other researchers in the field.”

As successful as Branͦemark has been as a scientist, he has also been successful as an evangelist for the “good news” of osseointegration. When I point out that people listen to him, and ask why, he responds with a smile on his face.

“They listen to me because I know what I’m talking about.

Before treating the first patient, I had accumulated more than ten years of experience in the lab, for example. I don’t rush to conclusions, and I think people appreciate that.”

Followers Everywhere I follow up with the question, “How much of your success can be accounted for by such personal characteristics as perseverance-stubbornness, if you will-and how much by the apostles you recruited around the world?”

“One person alone can’t have much impact on the world.

I’ve been privileged to meet and collaborate with some extremely talented people over the years. In addition to all the dental and medical students who have passed my way, I had something like 44 doctoral candidates at the University of Gothenburg over the years, and almost all of them taught me as much as they learned.”

Per-Ingvar Branͦemark has coined many words and phrases that have become commonly used terms in dentistry.

“Fixtures”, “anaplastology” and “osseointegration” come immediately to mind, of course. When he introduced the concept of the “third dentition,” Branͦemark got thousands of professionals to start thinking of implant-based solutions not as “false teeth” but “total rehabilitation. “I chose these words because I found them succinctly descriptive. There’s a beauty in language like that.

CPOI — Vol. 3 No. 3 — Summer 2012

I certainly didn’t anticipate how widely they would be accepted, but was pleased, of course, to see how quickly they gained traction in both scientific literature and clinical communication.”

When asked to comment on the practicalities of cooperative efforts between science and industry, Branͦ e mark takes the high ground. “We have always needed each other’s expertise and have generally enjoyed a symbiotic relationship. In an ideal world, maybe talented scientists would also be gifted production engineers and marketers; and maybe industrialists would be able to see beyond the bottom line; but in the real world-in order to achieve our goals-we each do what we do best and turn to others with complementary skills for help with the rest.”

To the question, “Do you think that Nobel Biocare has succeeded in being a good steward of the trust that you long-ago established among dentists?” Branͦ e mark replies: “I think I see a company today that wants to build on its scientific heritage. Together we ushered in a new era, but we all have to remember to respect the molecules. Our method stands for reconstructive biology, not carpentry.” Looking toward the future, he adds, “I’ll be very happy if Nobel Biocare keeps the rigorous scientific philosophy of the early years alive in its corporate culture.”

Eye on the Horizon While we’re on the subject of the future, I ask, “What’s next?”

“If you’ll allow me to speculate a bit, I believe that we may be on the threshold of a paradigm shift in the professions we practice. Once we realize that biologyespecially immunology-lies at the heart of both modern dentistry and medicine, I think we’ll start educating dentists and doctors along similar lines at the same institutions.

Perhaps the traditional partitions between them will even disappear altogether in the next generation or two”.

“As far as my own research is concerned, I see great strides being made in the area of osseoperception, whereby bone-anchored prostheses transmit information that can be intuitively interpreted via the central nervous system. I have patients with osseointegrated limbs, who can actually ‘feel’ the texture of the rugs on which they’re walking today. This aspect of osseoperception is a bountiful field for further research”.

Eighty-two years-old and still full of enthusiasm for the work at hand, Professor Per-Ingvar Branͦemark remains the best known personality in the world of osseointegration to this day.

He has certainly earned the title, “Father of modern clinical implantology”. n

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Creation and Preservation of Natural Soft Tissue Emergence Profiles Around Dental Implants in the Esthetic Zone Paul S. Petrungaro, DDS, MS, FICD, FACD, DICOI

The integration of restorative and cosmetic dentistry principles into the discipline of implant dentistry has allowed for esthetic implant restorations to be achieved on a more predictable basis.

Incorporation of these principles into the surgical phase of implant treatment, along with adoption of more minimally invasive surgical placement and bone grafting protocols, in addition to placing an immediate provisional restoration, can simplify the implant treatment process, and increase the probability for preservation of natural soft tissue emergence profiles around implants in the esthetic zone. This article presents a conservative treatment approach to the replacement of the natural tooth system in the esthetic zone, allowing for natural soft tissue emergence profiles to be maintained and/or sculpted from the initial surgical visit, throughout the healing phase, and into the post-treatment phase of the implant process.

Introduction: Clinical Significance Esthetics in implantology are becoming increasingly important in the contemporary reconstructive and surgical dental practice. Preservation and/or creation of natural soft tissue emergence profiles lead to the foundations for esthetics in the final implant-supported restoration.

Provisionalization at implant placement supports the preservation of these natural tissue emergence profiles.

The use of dental implants for the replacement of the natural tooth system has become widely accepted as a viable treatment option in the contemporary restorative,

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cosmetic, and surgical dental practice.1-3 Implants’ use for tooth replacement have been well documented in the dental literature, and they have allowed many patients to enjoy a more comfortable and fulfilling lifestyle.1-3 The conventional, multistage approach to implant reconstruction has accounted for the bulk of implant placement and restorative protocols that have amassed the success rates that are routinely referred to when discussing the use of dental implants, and their long-term success. While the multistage protocol is predictable and reliable for long-term success, due to the multiple surgical procedures they usually require, soft tissue contours are often compromised and the esthetics of the final restoration can be put in jeopardy. This

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Table 1: Immediate restoration procedure success rates (eight-year period).

Implant Sites

Implants, non-integrated prior to final loading

Initial rate of success

Immediate Extraction/ Implant Placement

1,636

15

99%

Edentulous Ridges

1,053

5

99.5%

is a complicating factor in the esthetic zone, where the balance and symmetry of the gingival margin and emergence profile of the restoration are imperative for the esthetic result of the case. 4 Additionally, conventional surgical protocols usually require extended healing phases and removable provisional appliances, and do not allow for parameters of the final restoration to be worked out in the provisional phase.

To address some of the concerns that exist with the conventional multistage implant approach, advancements in surgical protocols were developed that have allowed the implant surgeon to provide the patient and restorative/ cosmetic dentist with an immediate provisional restoration at the surgical visit.5-9 The insertion of a fixed provisional at implant placement has been shown to contribute to the formation of natural soft tissue emergence profiles and contours throughout the healing phase and into the final treatment phase of the implant process.5-9 The foundation for these procedures must start in the treatment-planning phase. In addition to maxillary and mandibular study models being obtained, a facebow transfer is recommended to correctly align the models.

Once this has been accomplished, the dental laboratory creates a diagnostic waxing of both the hard and soft tissue contours that need to be replaced/altered.10-11 This allows for the implant team to properly plan for the dimensions of the final restoration, and its translation to a surgical visit. A surgical guide can be constructed from the waxing obtained—converted into a provisional restoration—and possess all the parameters of a surgical guide and its use in implant placement. This guide should be a duplicate of the diagnostic wax-up, and can be converted at the surgical visit into an esthetic provisional restoration.10-11 Clinical examination should include a full periodontal analysis and radiographic examination (periapical/ panoramic radiographs), and a cone-beam image of the planned treatment site is also recommended. Evaluation of papillary height contours,12 interproximal heights of bone,13-14 and risk factors for periimplant esthetics15 are contributing pieces of information that allow the implant team to properly

CPOI — Vol. 3 No. 3 — Summer 2012

understand, interpret, and formulate a treatment sequence that allows for the predictable management of the extraction/edentulous site.12-15 Assessment of the aforementioned information allows for the implant team to determine whether adequate amounts of alveolar structure exist to proceed with the implant placement procedure; or whether a separate bone replacement, and/or soft tissue procedure will be necessary prior to implant placement.12-15 With proper alveolar structure present to stabilize the implant fixture, and allow for the proper angulation of the implant for correct emergence profile formation to be obtained, minimally invasive surgical protocols for implant placement and bone grafting are recommended.9 These protocols allow for the maintenance of existing soft tissue contours, contained areas for graft placement, and less traumatic postoperative healing phases.9 After implant placement, selection of an appropriate provisional abutment is made. The provisional abutment should help support the pre-existing soft tissue contours, or help to sculpt and create those contours in the edentulous site, which usually has lost papillary contours and interproximal heights of bone. Retro-fitting of the surgical guide/provisional restoration completes the immediate restoration procedure.

This can be done by the implant surgeon, or in conjunction with the restorative/cosmetic dentist. The provisional restoration must be properly contoured; the line angles of the provisional should allow for passive support to the facial/mesial and distal-free gingival margins. The facial emergence profile of the restoration should be balanced and symmetrical to that of the contralateral tooth to be replaced, and should be free of contact in the protrusive, centric, and lateral excursive movements (immediate non-functional load). The provisional restoration should remain in place for a three-month healing phase, at which time the provisional and abutment are removed and a fixture-level impression is obtained. Fabrication of a ceramic or zirconia abutment and final esthetic restoration complete the streamlined implant treatment process.

Table 1 shows the success rates I have observed over an eight-year period utilizing an immediate restoration protocol previously published in the dental literature.7-9

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Figure 1 — Preoperative clinical view.

Figure 2 — Preoperative digital periapical radiograph.

Figure 3 — Atraumatic extraction, left central incisor.

Figure 4 — Minimally invasive implant placement.

The following case studies demonstrate the immediate restoration procedure outlined above in an immediate extraction site and an edentulous site. Minimally invasive protocols for implant placement, bone grafting, and emergence profile formation are described, while demonstrating the blending of the surgical and restorative/cosmetic disciplines of the implant treatment process.

sounding measurements of the right and left maxillary central incisors, and study models mounted on an articulator), a diagnostic waxing of the maxillary left central incisor was obtained. Utilizing the wax-up, a surgical guide was fabricated that would also serve as an esthetic provisional restoration, should the natural tooth shell be damaged in the removal of the tooth.

Due to the patient’s esthetic requirements, it was decided to utilize the existing natural tooth shell (which had had a facial bonding procedure at some time in the past) as the esthetic provisional restoration, and retro-fit that back to the provisional abutment at the initial surgical visit. After reviewing all the preoperative information, the decision was made to proceed with a minimally invasive surgical protocol to replace the left central incisor, preserving the pre-existing gingival architecture present.

After administration of an appropriate local anesthetic, an incisal edge registration was obtained across the maxillary anterior sextant with bite registration material. This registration served to index the contact points, buccalpalatal spatial alignment, incisal edge, and facial emergence

Case 1 A 34-year-old, non-smoking female presented for replacement of an externally resorbing left central incisor (Figs. 1 & 2). The patient’s chief concern was to preserve the natural appearance of the gingival complex, and for the final restoration to duplicate the existing left central.

Due to the patient’s esthetic concerns and high lip line, a fixed provisional was desirable.

After gathering the necessary preoperative information (which consisted of digital periapical radiographs, a digital panoramic radiograph, periodontal analysis with bone-

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Figure 5 — Pregrafted peri-implant defect.

Figure 6 — Minimally invasive peri-implant grafting.

Figure 7 — Contour abutment placement.

Figure 8 — Final contouring of the emergence profile on the immediate provisional.

profiles of the preoperative site, and would aid in the retrofitting of the tooth shell for the esthetic provisional restoration. Following the incisal edge restoration, sounding measurements were reconfirmed prior to tooth removal. The sounding measurement was important as the depth of the collar of the implant was placed at a line drawn from the facial height of contour of bone of the contralateral tooth to be replaced.16 Therefore, the sounding measurement of 4 mm at the facial height of contour of bone at the right central incisor dictated the implant collar being placed approximately 4 mm above the facial of the free gingival margin of the left central incisor. Following confirmation of the sounding measurements, the tooth was removed by atraumatic means (Fig. 3), preserving the natural soft tissue contours present. Once the tooth had been removed, debridement of the extraction socket was accomplished by mechanical (curette) and rotary instruments (coarse diamond with water irrigation) means, removing all remnants of the periodontal ligament, granulation, or infected tissues.

Evaluation of the buccal plate’s integrity was accomplished utilizing a petro 1 or petro 2 elevator (Salvin

Dental; Charlotte, NC). This elevator was inserted underneath the facial gingival tissue, and a full-thickness “pouch” was created over the buccal plate, or an existing dehiscence and/ or fenestration. In the minimally invasive protocol, evaluation of the buccal plate must be accomplished in these means by tactile sensation, as the buccal tissues are not elevated aggressively in this technique. The pouch is carried to the mucogingival junction, or in the case of a fenestration and/or dehiscence, 2 to 3 mm past the margin of the defect noted.

Once the dimensions of the buccal plate of bone were established, the surgical guide was placed, and initial site development was accomplished. Widening the site to receive a 3.7-mm implant preceded the placement of a 3.7 mm x 13 mm length tapered screw vent implant (Zimmer Dental; Carlsbad, CA). The implant was placed to the appropriate depth predetermined by the sounding measurements (Fig. 4). Under-sizing the final drill prior to implant seating allowed for the implant to seat by selftapping means when it was inserted, and to register a torque measurement of 30 Ncm.

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Figure 9 — Immediate postoperative clinical view, left central incisor.

Figure 10 — Immediate postoperative protrusive management.

Figure 11 — Seven-day postoperative clinical view.

Figure 12 — Two-month post-implant placement tissue emergence profile.

Removal of the implant carrier preceded the placement of the cover screw to aid in the minimally invasive grafting procedure. Figure 5 shows the occlusal view of the implant placed into the extraction socket. Note the optimal position of the implant placement in relationship to the outline of where the natural tooth root was positioned. Fabrication of the graft complex—a mineralized bone graft and cancellous chips (1- to 2-mm particle size)—was rehydrated with an activated platelet-rich plasma (PRP) solution harvested presurgically from the patient. The PRP/graft complex was then heavily condensed into the peri-implant defect from the implant surface to the mesial-buccal and distal aspects of the extraction socket (the buccal plate was intact) (Fig. 6).

The graft was condensed to the collar of the implant (Fig. 6).

The larger particle cancellous chips and heavy condensation added support to maintain the buccal dimension of the emergence profile that was to be obtained.

Removal of the cover screw preceded the insertion of a contoured abutment (Zimmer Dental) that was placed into the implant and hand-tightened, allowing for the friction fit internal connection to provide for initial stability of the abutment (Fig. 7). Altering a provisional coping and applying bonding agent to the acrylic coping aided in the retrofitting process by registering the margins of the abutment.

After removing the root of the tooth from the clinical crown at the cemento-enamel junction (CEJ) and hollowing out the natural tooth shell, bonding agent was applied to the internal aspect of the crown. The crown was then filled with composite (Filtek, 3M ESPE; St. Paul, MN) and placed into the incisal edge index obtained presurgically. The crown was then placed over the coping/abutment complex, and the complex cured with a curing light. The initial alignment of the natural tooth was transferred to the implant site in this process.

The provisional complex was then removed from the abutment, placed on a lab analog, and the margins of the provisional contoured with Filtex Flow and discs (Shofu Dental; San Marcos, CA) (Fig. 8). Note the facial emergence profile of the provisional, which would help to place passive pressure on the facial gingival margin and support the emergence profile in the tissue. The provisional restoration was then cemented with a strong temporary cement.

The immediate postoperative view can be seen in Figure 9.

Note how the provisional restoration possesses the correct contact point relationships, and the facial emergence profile mimics that of the preoperative view in Figure 1.

Figure 10 shows the protrusive relationship. The provisional restoration is free from occlusion in the centric relation, protrusive, and right/left excursive movements.

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Figure 14 — One-year postoperative clinical view.

Figure 15 — One-year postoperative digital periapical radiograph.

Figure 13 — One-year postoperative cone-beam image.

Figure 16 — Preoperative clinical view, left central incisor.

The seven-day postoperative clinical view can be seen in Figure 11. Note the appearance of the papillary contours, and how they fill the embrasure spaces of the provisional restoration. A two-month postoperative view is shown in Figure 12. Note the natural appearance of the soft tissue emergence profile.

After a three-month healing and observation phase, the patient was referred back to the restorative clinician for construction of a zirconia abutment and all-ceramic restorations. After routine fixture-level impressioning techniques were perfor med, a CAD-CAM zirconia abutment (Atlantis; Cambridge, MA) was created, followed by the laboratory fabrication of an all-ceramic restoration for the left central incisor.

Figure 13 shows the one-year post-treatment conebeam image. Note the alveolar structures present on the facial aspect of the implant. Figure 14 shows the one-year post-treatment clinical view; and Figure 15, the one-year

16

Figure 17 — Preoperative digital periapical radiograph, edentulous site, left central incisor.

post-treatment periapical radiograph view. Compare Figure 14 to Figure 1, and how preservation of the interdental tissues, the facial emergence profile, and the mesial and distal line angles have allowed for an esthetic implant restoration to be obtained.

Case 2 A 32-year-old, non-smoking female presented for treatment of an edentulous maxillary left central incisor (Figs. 16 & 17). The patient had an existing resin bonded bridge that failed, and the pontic tooth temporary bonded into place at the initial consultation visit. Esthetics were of primary concer n to the patient, and the cosmetic/reconstructive dentist had planned for esthetic enhancement of the adjacent teeth, as well as an esthetic implant-supported restoration at the edentulous site. After

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The treatment protocol decided upon by the implant team was to treat the edentulous central incisor site by minimally invasive means, and utilize the “pouch” grafting procedure previously described to reconstruct the natural soft tissue emergence profile that had been lost from the previous tooth removal procedure.

Additionally, the immediate provisionalization of the implant would allow not only for a fixed provisional option, but also help to sculpt and maintain the desired emergence profiles.

After administration of an appropriate local anesthetic, the pontic was removed. The Figure 18 — Creation of the planned soft tissue esthetic emergence profile. surgical guide/provisional system utilized by the author was then inserted, and an initial site marked in the pontic site. Following this marking, the natural emergence profile was created in the soft tissue utilizing a footballshaped diamond, mimicking the appearance as if the tooth were just removed (Fig. 18). This reshaping of the gingivae aids in the reconstruction of the emergence profile of the planned restoration. Additionally, by reshaping the tissue, the depth of the pontic site now has access to the crest of the ridge, allowing for evaluation of the buccal plate, and for implant placement by minimally invasive means.

Figure 19 — Minimally invasive implant placement, left central incisor.

Utilizing a petro 2 elevator, a full-thickness elevation of the facial tissue was accomplished gathering the necessary preoperative information (as past the muco-gingival junction, thereby creating the previously described), a diagnostic waxing was obtained “pouch” in which the graft complex would be placed. The for the teeth to be altered, and of the edentulous site. The concavity noted presurgically in the facial tissue was diagnostic waxing, in addition to the radiographic accentuated at this point, and would be reconstructed after analysis, dictated that a bone replacement procedure implant placement. would be necessary at the facial of the left central incisor, Reinsertion of the surgical guide/provisional system in addition to implant placement, in order to allow for the allowed for appropriate site development, which was natural emergence profile of the restoration and soft followed by the placement of a 3.7 mm by 13 mm in length tissues to be obtained. tapered screw vent (Zimmer Dental) implant (Fig. 19).

Figure 20 — Minimally invasive peri-implant grafting, pregrafted view.

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Figure 21 — Minimally invasive peri-implant grafting, allogenic graft/prp complex into “pouch” created.

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Figure 22 — Contour abutment placement.

Figure 23 — Provisional coping analog appearance.

Figure 24 — Provisional complex after final contouring, custom staining, and marginal correction.

buccal tissues. Insertion of the graft complex (as previously described) was performed into the full-thickness “pouch” created prior to implant placement (Fig. 21). Note how the distal contour of the facial aspect of the grafted site resembles that of the distal aspect of the right central incisor (Fig. 21).

Figure 25 — Immediate postoperative view, left central incisor.

Once the grafting was completed, removal of the cover screw preceded placement of a 341s contour abutment (Zimmer Dental), which was hand-tightened (Fig. 22). A provisional coping was then roughened, bonding agent applied, and the internal aspect of the initial surgical guide/provisional restoration also roughened and bonding agent applied. This was followed

by Filtek composite being placed into the provisional, and the provisional restoration being placed over the coping, which had previously been placed over the abutment. Once the provisional complex was cured, it was removed and placed on an analog to achieve marginal integrity, and the proper management of the facial emergence profile and line angles (Fig. 23).

Figure 26 — Eleven-day postoperative view.

Figure 24 shows the final appearance of the custom-stained, properly contoured provisional Following the procedure previously mentioned, the collar of restoration. The immediate postoperative view can be seen in the implant was placed at the level of the crest of bone at Figure 25. Note the proper contact point relationships, and the the facial height of contour of the contralateral tooth. After management of the mesial and distal line angles. The 11-day removal of the carrier mechanism, reconstruction of the postoperative view can be seen in Figure 26. Note how the facial defect was accomplished. Figure 20 shows the papillary tissues have migrated to fill the interproximal spaces position of the implant in relationship to the concavity of the at this short time frame postoperatively. After a three-month

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Figure 27 — Contour zirconia abutment, laboratory casts, adjacent restorations.

Figure 28 — Final all-ceramic restoration on the laboratory casts.

Figure 29 — Completed case, smile view.

Figure 30 — Completed case, clinical view.

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healing and observation phase, the patient was referred back to the restorative dentist for final restorations.

The restorative clinician utilized a contour zirconia abutment for the final abutment, and completed fullcoverage ceramic restorations on teeth #4-13. Figures 27 and 28 show the contour zirconia abutment and adjacent restorations on the laboratory casts. The completed case clinical view of the patient’s smile can be seen in Figure 29, and a close-up view of the full-coverage, all-ceramic restoration on the implant at the left central incisor can be seen in Figure 30. Figure 31 shows the completed case digital periapical view, and Figure 32 the completed case cone-beam image.

The one-year postoperative view can be seen in Figure 33. Compare Figure 30 to Figure 33 and observe how the soft tissue contours have been maintained in the healing phase.

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Figure 31 — Complete case, digital periapical radiograph.

Figure 32 — Completed case, cone-beam image, left central incisor.

CPOI — Vol. 3 No. 3 — Summer 2012

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Implant Surgery for the General Practitioner Dr. Allen Aptekar BSc., D.M.D.

OCTOBER 12-14, 2012 $1995.00 (OAGD, TACD and ADIA members receive a $200 courtesy discount)

Aurora Dental College • 201-372 Hollandview Trail, Aurora, ON L4G 0A5 Introducing an Implant Surgery course for the general practitioner, taught by a general practitioner!

Dr. Allen Aptekar has restored and placed thousands of implants, with a success rate of above 98%. He will take you from the introductory stage of treatment planning cases from the G.P.s perspective, to the surgical phases and techniques, keeping in mind the important restorative phase a general practitioner must always keep in the back of their minds, as this is a RESTORATIVELY DRIVEN PROCESS.

DAY 1 - TREATMENT PLANNING

DAY 3 – LIVE SURGERY

• • • • • • • • •

• • • •

Patient Identification Treatment Planning Diagnosis Force Factors Single implants, i) mandible ii) maxilla Multiple implants –fixed prostho., i) mandible ii) maxilla Removable implant retained prosthetics, i) mandible ii) maxilla Contraindications Medical History Review

DAY 2 – SURGICAL PROTOCOLS & TECHNIQUES • • • • • • • •

Surgical Protocol Review Live Patient Surgery The healing period and Patient Protocol Review

OPTIONAL – IN OFFICE SURGICAL CHAIRSIDE MENTORSHIP IN YOUR OWN OFFICE • In office chair side mentoring for live patient surgeries in participant’s office • Assistant training for supplies, set up, and assisting Fee: Based and determined on a Case by Case basis

Tissue Health Bone Physiology, quality and quantity Implant Design Surgical Protocol Surgical Technique Complications Pharmacology Hands-on model implant placement

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For more information or to register: 905.489.1970 • 866.581.8949 events@palmeripublishing.com

CPOI_V3N3_Summer 2012_Spectrum 7/9/2012 11:31 AM Page 22

Acknowledgments: The author thanks Edgar Jimenez, CDT (North Oaks, MN), for his excellence in the laboratory aspect of these cases; and Dr. Steven Gorman (North Oaks, MN) and Dr. Steven Lorentzen (Golden Valley, MN) for their clinical excellence.

References: 1.

2.

3.

4.

5.

Figure 33 — One-year postoperative clinical view.

6.

7.

Conclusion The presence of natural tissue emergence profiles around teeth and dental implants in the esthetic zone is paramount to the overall clinical success of the esthetic enhancement of the natural dentition, as well as to tooth replacement procedures.

Minimally invasive surgical protocols have demonstrated clinically to decrease surgical trauma to both hard and soft tissue, and to allow for a more rapid healing phase to occur.

Incorporation of restorative principles into the surgical phase of implant dentistry has allowed for immediate provisionalization of dental implants to become a more simplified procedure for the implant team to accomplish, allowing the patient to have an esthetic, fixed provisional throughout the healing phase.

The additional benefits of a properly contoured immediate implant provisional are as follows: • proper contouring of the facial gingival emergence profile • proper contact point relationships, which can lead to the formation and maintenance of interproximal tissues • proper contouring of the line angles of the provisional, which leads to a natural soft tissue emergence profile result.

Maintaining the soft tissue emergence profile and, subsequently, the alveolar contours, allows for a mature dento-implant-gingival complex to be established prior to the final implant restoration being seated; this is a common procedure for the alteration of the natural tooth prior to partial and full-coverage procedures.9 This allows for the dental laboratory to be more predictable when creating the contact points, line angles, and emergence profiles of the final restoration, as these parameters have already been worked through in the healing phase.

I have performed the procedure described above on more than 2,600 sites over a period of eight years. Additional clinical studies are necessary to document and substantiate the longterm success of the procedure outlined in this article. n

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8.

9.

10.

11.

12.

13.

14.

15.

16.

Adell R, Lekholm U, Rockler B, et al. A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg 10(6):387-416, 1981.

Adell R, Eriksson B, Lekholm U, et al. Long-term follow-up study of osseointegrated implants in the treatment of totally edentulous jaws. Int J Oral Maxillofac Implants 5(4):347-359, 1990.

Babbush CA. Dental Implants: The Art and Science (pp. 201-216).

Philadelphia, PA: W.B. Saunders; 2001.

Kois JC. Altering gingival levels: The restorative connections. Part 1: Biological variables. J Esthet Dent 6:3-9, 1994.

Worhle PS. Single-tooth replacement in the aesthetic zone with immediate provisionalization: Fourteen consecutive case reports. Pract Perio Aesthet Dent 10(9):1107-1114, 1998.

Saadoun AP, Le Gall MG. Periodontal implications in implant treatment planning for aesthetic results. Pract Perio Aesthet Dent 10:655-664, 1998.

Petrungaro PS. Immediate implant placement and provisionalization in edentulous, extraction, and sinus grafted sites. Compend Contin Educ Dent 24(2):95-113, 2003.

Petrungaro PS. Implant placement and provisionalization in extraction, edentulous, and sinus grafted sites: A clinical report on 1500 sites.

Compend Contin Educ Dent 26(12):879-890, 2005.

Petrungaro PS. An update on implant placement and provisionalization in extraction, edentulous and sinus grafted sites: A clinical report on 3200 sites over 8 years. Compend Contin Educ Dent 29(5): 288-300, 2008.

Petrungaro PS. Using the TempStent technique to simplify surgical stent and esthetic temporary fabrication in immediately restored implants in the aesthetic zone. Contemp Esthet Rest Pract 6(5)84-90, 2002.

Petrungaro PS, Maragos C, Matheson O. Using the Master Diagnostic Model® to enhance restorative success in implant treatment. Compend Contin Educ Dent 21:33-42, 2000.

Tarnow DP, Magne AW, Fletcher P. The effect from the distance from the contact point to the crest of one on the presence or absence of interproximal dental papillae. J Periodontol 53(12):995-996, 1992.

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

Salama H, Salama MA, Garber D, et al. The interproximal height of bone: The guidepost to predictable aesthetic strategies and soft tissue contours in anterior tooth replacement. Pract Perio Aesthet Dent 10(9):1131-1141, 1998.

Kois JC. Predictable single-tooth peri-implant esthetics: Five diagnostic keys. Compend Contin Educ Dent 25(11), 895-905, 2004.

Petrungaro PS. Immediate restoration of implants utilizing a flapless approach to preserve interdental tissue contours. Pract Proced Aesthet Dent 17(2)A-H, 2005.

About the Author Dr. Paul Petrungaro graduated from Loyola University Dental School and completed an independent study of Periodontics at the Welsh National Dental School in the United Kingdom. He completed a residency, specialty certificate and Master of Science Degree in Periodontics from Northwestern University Dental School and formerly served as the Coordinator of Implantology for the university's Graduate Department of Periodontics. He has maintained a private practice in Periodontics and Implantology since 1988 and holds licenses in Illinois and Minnesota. An international renowned educator, he has presented numerous seminars and lectures worldwide on advanced periodontal, prosthetic and implant interrelationships, bone regeneration, esthetic tissue formation, transitional implants, immediate restoration of dental implants, and the use of platelet rich plasma in bone grafting. He has authored many articles on these topics, as well as cosmetic bone grafting and esthetic implant procedures. Dr. Petrungaro serves as a consultant to numerous biomedical companies and laboratories, and has contributed to many new innovations in surgical dentistry. He is a fellow of the International and American College of Dentists, and a Diplomat of the International Congress or Oral Implantologists.

CPOI — Vol. 3 No. 3 — Summer 2012

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8 Full Day & Half Day Seminars

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Friday, September 14, 2012 Do Small Diameter Implants Have a Place in the Fixed Restoration World?

Friday, September 21, 2012 New Opportunities for Enhancement in the Esthetic Zone

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Friday, September 28, 2012 Minor Tooth Movement: An Introductory Hands-on Training Seminar (with separate fee)

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Friday, October 12, 2012 Panel Discussion – Digital Day

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Friday, October 26, 2012 The Occlusion – TMJoint and Restorative Connection: Predictable Procedures for Predictable Results

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Tuesday, October 30, 2012 Keys to a Successful Imlant Practice Through the Use of New Technologies Effrat Habsha, B.Sc., D.D.S., Dip. Prostho., M.Sc., F.R.C.D.(C) | Sponsor(s): Biomet 3i

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Tuesday, November 13, 2012 Complications in Implant Dentistry: Prevention & Treatment: Part 2 Friday, November 16, 2012 Panel Discussion – Cosmetic Evolution Day

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| Various Speakers | Sponsor(s): ADIA, 3M ESPE, Ivoclar Vivadent Canada, GC America, Vident

Friday, November 30, 2012 Practical Usage of Tooth Coloured Restorative & Prosthodontic Materials & Techniques in Everyday Practice Dr. Mike Racich | Sponsor(s): ADIA

Wednesday, December 5, 2012

Mini Clinics – 8 Table Rotation

| Various Speakers | Sponsor(s): ADIA

www.adiacanada.com | events@palmeripublishing.com | 905.489.1970 | Toll Free 1.866.581.8949 Academy of General Dentistry Approved PACE Program Provider | FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. 1/1/2011 to 12/31/2014. Provider ID# 219289 This activity has been planned and implemented in accordance with the standards of the Academy of General Dentistry Program Approval for Continuing Education (PACE) through the joint program provider approval of Ontario AGD and the Aesthetic Design & Implant Academy (ADIA). The Ontario AGD is approved for awarding FAGD/MAGD credit. Co-sponsored by the Ontario AGD.

CPOI_V3N3_Summer 2012_Spectrum 7/9/2012 11:32 AM Page 24

Oral Surgery Academy for General Dentists presents

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Academy of General Dentistry Approved PACE Program Provider | FAGD/MAGD Credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. 1/1/2011 to 12/31/2014. Provider ID# 219289. This activity has been planned and implemented in accordance with the standards of the Academy of General Dentistry Program Approval for Continuing Education (PACE) through the joint program provider approval of Ontario AGD and the Aesthetic Design & Implant Academy (ADIA). The Ontario AGD is approved for awarding FAGD/MAGD credit. Co-sponsored by the Ontario AGD.

CPOI_V3N3_Summer 2012_Spectrum 7/9/2012 11:32 AM Page 25

Oral Surgery Academy for General Dentists

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Academy of General Dentistry Approved PACE Program Provider | FAGD/MAGD Credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. 1/1/2011 to 12/31/2014. Provider ID# 219289. This activity has been planned and implemented in accordance with the standards of the Academy of General Dentistry Program Approval for Continuing Education (PACE) through the joint program provider approval of Ontario AGD and the Aesthetic Design & Implant Academy (ADIA). The Ontario AGD is approved for awarding FAGD/MAGD credit. Co-sponsored by the Ontario AGD.

CPOI_V3N3_Summer 2012_Spectrum 7/9/2012 11:33 AM Page 26

Allen Aptekar, BSc., DMD

A “Flexiable” Option for Osseous Ridge Widening in the Mandible

One of the many challenges of placing implants in the posterior mandible is adequate bone quantity and quality. As we know, when a patient is missing posterior mandibular premolars and/or molars for quite a number of years, bone width can become an issue. There are many ridge widening techniques available, both Autogenous and Allograft that show excellent results that one can use in areas of narrow bone. Our present allograft bone technology is excellent and therefore one can make an argument in using allograft bone, due to some of its advantages, rather then the long time gold standard of Autogenous bone. Grafton DBM Flex sheet is an allograft in a demineralized bone matrix. This Case Report shows how this Allograft Flex sheet can be used as an additional technique in osseous ridge widening in the posterior mandible.

O

ne of the many challenges we face when placing implants in the posterior mandible is adequate bone quantity and quality. Once it is determined that a patient has insufficient bone width, the next question we ask ourselves as dental implant practitioners is: “ What types of bone augmentation options do I have in order to restore the osseous deficiency in the mandible?”

The majority of the ridge widening options in the posterior mandible that have been published and lectured on are listed below: 1. Autogenous Particulate grafting with or without Tent Screws 2. Autogenous Block grafting 3. Allograft Particulate grafting with or without Tent Screws

26

4. Allograft Block grafting 5. Ridge Splitting Many of the above options have excellent success rates and results.5,6,7 Some practitioners prefer one of the above techniques to others, as that is what works best in their hands. With our allograft bone technology these days, many will argue that a high percentage of intraoral grafting can be exclusively done with allograft bone rather than the long time gold standard of autogenous bone. One of the main advantages one finds with Allograft grafting is less pain and trauma to the patient, as well as one less surgical site due to there not being a need to harvest bone from a donor site.

An additional technique for osseous ridge widening is using allograft sheets. A product carried by Biohorizons called Grafton® DBM Flex, is an allograft in a sheet form.

These Flex sheets, as the name suggests has flexible

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properties, where one can adapt it to a deficient ridge in order to restore a ridge to adequate width to facilitate future implant placement (Figure 1). These sheets come in a 1.5cm x 1.5cm size. Grafton DBM Flex is a allograft in a demineralized bone matrix, which has osteoconductive properties (1). Some in-vivo studies show osteoinductive properties as well (2,4).

Figure 1

Case Report A 38 year old healthy non-smoking Caucasian female presented for consultation regarding interest in dental implants. Her chief complaint was that her 3.4 to 3.7 bridge was failing. Medical history was insignificant, as the patient was very healthy with no known drug allergies. Upon clinical examination it was determined that the 3.5 and 3.6 tooth sites were edentulous for 10 plus years. Severe bone resorption in ridge width and moderate resorption in height was clinically evident. In order to determine exactly how much bone height and width the patient had, the patient was referred out to have a dental CT Scan. After evaluating the dental CT Scan results, it was determined that the patient had insufficient bone width in the 3.5 and 3.6 site in order to facilitate dental implant placement. As seen on the CT Scan slices, the width calculated was approximately 2mm apical to the most coronal point, and was 4.05 to 4.25mm wide (Figure 2). Bone height in this region was borderline at about 8.86 to 9.67mm in height. However if osseous grafting in width was considered from the very peak of the boney ridge, 9 to 10.5mm length implants could be considered in the future. Therefore the patient needed osseous ridge widening in this region. Many of the ridge widening options were given and discussed with the patient at length.

The patient wanted the least invasive option, which did not require an

Figure 2

Figure 3

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Figure 4

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Figure 5

Figure 6

Figure 7

Figure 8

extra surgical donor site such as needed in an autogenous graft. After discussing all the allograft augmentation options, the patient was comfortable with using an allograft flex sheet in order to help restore the lost ridge width that had occurred in the 3.5 and 3.6 region.

On the day of the surgical procedure, the patient was given 1g Amoxicillin and 400mg Ibuprofen 1 hour preoperatively peri-orally. The patient was also given a 1 minute pre-surgical rinse with chlorohexidine. Under local anesthesia a crestal incision was extended from 3.4 to 3.7, along with a buccal releasing incision mesial to tooth 3.7, and a full thickness flap was elevated (Figure 3). Upon reflection of the flap, the most coronal osseous ridge thickness was 2-2.5mm in thickness .

The buccal aspect of the ridge was decorticated in the 3.5 and 3.6 area, in order to produce a regional acceleratory phenomenon (RAP) of blood flow for the allograft to be placed (Figure 4). The next step involved placing the Grafton Flex sheet on the buccal aspect of the 3.5 and 3.6 site (Biohorizons, Birmingham, Alabama). Prior to placing the Grafton Flex sheet into position, a periosteal releasing

incision was performed on the buccal flap in order to release the buccal tissue so that primary closure would be obtained.

The flex sheet was hydrated with sterile NaCl 0.9%, and placed on the buccal aspect (Figure 5). Once this sheet was moistened, it was much easier to manipulate the sheet to the ridge and put in place. Once the sheet was in place 0.5cc-1cc of mineralized cortico-cancellous allograft particulate was placed in any uneven gaps between the decorticated ridge and the flex sheet (Community Tissue Services, Dayton, Ohio). A Cytoplast RTM 30x40mm collagen membrane (Osteogenics Biomedical, Texas) was placed over the flex sheet, and this sandwich technique was all manipulated and stabilized into place at suture closure with 3.0 chromic gut and 3.0 silk sutures (Figure 6).

The area had 2x2 gauze digital pressure applied to the site for 3 minutes in order to obtain hemostasis, prevent hematoma formation under the site, and confirm stabilization of the grafted site. One can see how much wider the ridge was at post op on day zero. The patient was placed on Amoxcillin 500mg for 1 week, a chlorohexidine rinse, and analgesics were prescribed.

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Figure 9

Figure 10

Figure 11

Figure 12

The patient was seen for suture removal at 1 week post op, and was followed up at 6 weeks, 3 months, and finally at 5 months. At 5 months, based on clinical and radiographic examination, the grafted site was ready for implant placement (Figures 7 and 8). A surgical appointment was scheduled. On the day of surgery, the same pre-op medication was given to the patient as when grafting was done. Under local anesthesia a crestal incision was extended from 3.4 to 3.7, along with a buccal releasing incision mesial to tooth 3.7, and a full thickness flap was elevated (Figure 9).

One will note the increased thickness of the ridge compared prior to grafting (Figure 4). With the increased thickness of the ridge after grafting with Grafton Flex, the site is now ready for implant placement. Therefore a slight alveoplasty was performed to flatten the coronal portion of the ridge (Figure 10). A 2mm twist drill osteotomy was prepared in site 3.5 and 3.6, direction indicators were placed and a periapical radiograph was taken. The angulations were corrected and the osteotomies in site 3.5

and 3.6 were prepared for 4.0mm diameter and a length of 9mm (Figures 11 and 12). Two 4.0x9mm Biohorizons Parallel Internal LaserLok implants (Biohorizons, Birmingham, Alabama) were placed in site 3.5 and 3.6, and 35nm stability was achieved with both implants (Figure 13).

Cover screws were placed (Figure 14), and primary closure was obtained using 3.0 chromic gut and 3.0 PGA sutures (Figure 15).

Note that 9mm length implants were used due to the fact that the inferior alveolar nerve canal would be quite close to any implant longer then 9mm in length.

However we know that the success rate of 9mm implants in a biomechanical approach can show excellent success (3). After continuous follow up over a 4-month period, both implant cover screws were exposed, and healing caps placed. Impressions were taken with the abutment and ball top screw technique, and the 3in1 abutments were prepared by the lab. Both implants were restored with porcelain fused to metal implant crowns that were splinted (Figure 16).

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Figure 13

Figure 14

Figure 15

Figure 16

Conclusion There are many ridge widening techniques available, both Autogenous and Allograft that show excellent results that one can use. As mentioned previously, our present allograft bone technology is excellent and therefore one can make an argument in using allograft bone, due to some of its advantages, rather then the long time gold standard of Autogenous bone. The technique shown above uses Grafton DBM Flex (Biohorizons, Birmingham, Alabama).

This DBM Flex sheet is an allograft in a demineralized bone matrix. The Case Report above shows how this Allograft Flex sheet can be used as an additional technique in osseous ridge widening in the posterior mandible.

References: 1.

2.

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Callan, DP. Regenerating the Ridge: Performance of the Grafton Allograft. Dental Implantology Update 2000; 11(2) 9-14.

J Louis-Ugbo, SD Boden, et al. “Evidence of Osteoinduction by Grafton Demineralized Bone Matrix in Non human Primate Spinal Fusion” SPINE Volume 29, No.4. February 2004.

3.

4.

5.

6.

7.

Misch CE, et al. “Short Dental Implants in Posterior Partial Edentulism: A Multicenter Retrospective 6-Year Case Series Study. Journal of Periodontology, August 2006, Vol. 77, No.8, Pages 1340- 1.347 B Peterson, MD, et al. “Osteoinductivity of Commerically Available Demineralized Bone Matrix: Preparations in a Spine Fusion Model.

Journal of Bone & Joint Surgery, October 2004, 86-A No.10.

Felice P, et al. “Reconstruction of an atrophied posterior mandible with the inlay technique and inorganic bovine bone block: a case report.”, Int J Periodontics Restorative Dent. 2010 Dec; 30(6): 583-91.

Fu JH, Wang HL. “ Horizontal bone augmentation: the decision tree”, Int J Periodontics Restorative Dent. 2011 Jul-Aug; 31(4): 429-36.

Mertens et al. “Reconstruction of Severely Atrophied Alveolar Ridges with Calvarial Onlay Bone Grafts and Dental Implants.”, Clin Implant Dent Relat Res. 2011 Oct 18. doi: 10.1111/j. 1708-8208.2011.00390.x.

About the Author Dr. Allen Aptekar studied at the University of Toronto, earning his Bachelors of Science degree in Biology. He received his Doctor of Dental Medicine degree with distinction at the University of Saskatchewan College of Dentistry. Dr. Aptekar then completed a one year hospital residency at Sunnybrook Health Sciences Center and the University of Toronto. He has authored and coauthored several articles in refereed professional dental journals, and is a lecturer in dental implant procedures for dentists and denturists. He practices in the greater Toronto area, with a special interest and focus on dental implantology.

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SPECTRUM dialogue Techno-Clinical Day October 12, 2012 Time: 8:00am – 9:00pm

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Another String to Our Bow

Dr Eric Normand

for Prostheses on Implants: The Camlog® Vario Sr Abutment CASE REPORT

Initial situation

Information on Patient and Treatment A 50 year old healthy male, who was an ex-athlete, presented to my office. He had been wearing a removable partial denture for more than five years to compensate for right maxillary tooth loss when he came to us for the first time. His request was clear, "I don't want to have an appliance anymore." His goal was more functional than cosmetic. The existing fixed prostheses covering the sectors adjacent to the missing teeth were fully satisfactory to him both cosmetically and functionally. The edentulous space was large, and a bridge over teeth would have led to short-term failure. The treatment plan was therefore straightforward: replace 13,14,15,16 with a fixed prosthesis over implants.

Clinical evaluation of the case showed a sufficient interarch space, good occlusion, and a significant amount of attached gingiva. The mucogingival junction was located far enough away from the middle of the crest. The mesiodistal distance was insufficient to replace the four missing teeth. We opted to make three teeth - one canine, one premolar, and one molar. The cone beam tomography showed significant residual bone volume, which gave us the best conditions for the implant insertion. It was therefore not necessary to perform preimplant surgery to augment hard tissue or soft tissue.

The following figures show the steps of the treatment.

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Figure 1 — Preoperative radiologic exam: tomography.

Figure 2 — Postoperative clinical view. The full-thickness flap with no incision for tension reduction was raised after placing the three implants (3.8 x 11 in position 13, 4.3 x 11 in 14 and 16) and their healing screws (wide body, 4 mm high). The small pedicle flaps, technique derived from Palacci, provided for closure of the edges without tension, forming the future papillae.

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Figure 3 — Postoperative radiologic exam: periapical radiograph.

Prosthesis steps

Figure 4 — Clinical view after healing: note the irregular wounds corrected later by gingivoplasty with a cautery knife.

Figure 5 — Clinical view after eight weeks at the time of impression-taking.

Figure 6 — Pop-in impression transfers in place.

Note the use of closed-tray impression transfers, which are easier to use than open-tray transfers and are just as precise in the CAMLOG® Implant System when the implants show little angulation towards each other.

Figure 7 — Impression. Note that the colored caps have been removed.

Figure 8 — Positive model with artificial gingiva and view of the parts used by the laboratory for making the bridge.

Figure 9 — Vario SR abutment in place. Because the implants show little divergence, straight abutments were used.

Figure 10 — Burn-out copings (no anti-rotation plane) in place.

Figure 11 — Fitting of copings.

Figure 12 — Wax model.

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Figure 13 — Cast framework.

Figure 14 — Checking the framework on the model.

Figure 15 — Rough framework.

Figure 16 — View of the gingival wells formed by the healing caps.

Figure 17 — Vario SR prosthetic abutments in place.

Figure 18 — Detail. Note the gingiva quality promoting overall long-term stability.

Figure 19 — Framework try-in.

Figure 20 — X-ray check. Several x-rays were taken in between insertion of abutment screws to check for complete passivity of the framework.

Figure 21 — Ceramic-veneered framework on the model.

Figure 22 — X-ray check of the bridge during the try-in: note the slight gaps in the mesial implants. They were due to a contact point with 13 that was too tight.

Figure 23 — Another x-ray after adjustments: note the absence of a gap.

Figure 24 — Occlusal view of the bridge during the trial. The abutment screws were then tightened to 20 Ncm, and the prosthetic screws were tightened to 15 Ncm.

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Prosthesis steps

Figure 25 — Occlusal view after the occlusal access wells were filled with a cotton pellet and an addition of composite. Note the irregular non-homogeneous appearance, which was accentuated by the flash picture. As clinicians, we find this appearance non-cosmetic, but it has not bothered the patient in the least.

CPOI — Vol. 3 No. 3 — Summer 2012

Figure 26 — Buccal view three months after insertion of the prosthesis.

Figure 27 — Palatine view three months after insertion of the prosthesis.

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Comments The one-stage surgical procedure enables one to take advantage of the longer period of mucosal healing at the same time as bone healing versus cases where burying of the implant is done, therefore requiring 2nd stage surgery.

The significant amount of attached gingiva and bone volume in this case allowed us to perform surgery with minimal detachment of soft tissues. With raising of the flaps,

we do not have to work blindly in the bone crest, and we can manage the inter-implant gingiva volume optimally.

It is important to adjust the temporary removable denture properly during the osseointegration phase and to warn the patient, because any contact between the temporary prosthesis and the healing screw can result in loss of the underlying implant.

The pop in impression system shows excellent accuracy and precision. However one must make sure that the implants are not too divergent when using this impression technique.

Initial post-surgery situation

Figure 29 — Preoperative tomography.

Figure 28 — View immediately after surgery.

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Final situation throughout the treatment, and splinted crowns. The screw-retained prosthesis also avoids any risk of residual cement around the implant neck. n

About the Author

Figure 30 — Final view before composite is placed in the screw access wells.

Conclusion The Vario SR abutments allow one to make a screw-retained prosthesis on implants in a straightforward and precise manner.

In addition, time is saved, with no concessions on precision or quality, by using clinical protocols that are more straightforward and rational than "traditional" protocols: one-stage surgery, limited non-invasive flaps, impression with pop-in transfers, easy repositioning of abutments, use of only one screwdriver

CPOI — Vol. 3 No. 3 — Summer 2012

Figure 31 — Final x-ray.

Eric Normand practices in Bordeaux, where he was born and began his studies. After his academic training in periodontology and implantology in Bordeaux, Paris, and New York, he taught these subjects at the University of Bordeaux 2. He has then devoted a full-time private practice exclusively to periodontology and implantology. He is still a lecturer at the Bordeaux Dental School and also provides continuing education instruction for scientific societies.

References Semper W, Heberer S, Mehrhof J, Schink T, Nelson K - Effects of repeated manual disassembly and reassembly on the positional stability of various implant-abutment complexes: an experimental study. Int J Oral Maxillofac Implants. 2010 Jan-Feb;25(1):86-94.

Palacci P, Nowzari H - Soft tissue enhancement around dental implants.

Periodontol 2000. 2008;47:113-32.

Michalakis Kx, Hirayama H, Garefis Pd - Cement-retained versus screwretained implant restorations: a critical review. Int J Oral Maxillofac Implants. 2003 Sep-Oct;18(5):719-28.

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CPOI Products and People

Canadian Dentist Elected President of the AACD

Dr. Ron Goodlin of Aurora, Ontario, took the helm as president of the American Academy of Cosmetic Dentistry (AACD) during the AACD’s 28th Annual Scientific Session in Washington, DC, May 2-5. Dr. Goodlin is an Accredited member of the AACD and has been involved in the organization since 1997. Dr. Goodlin practices dentistry at Smiles Dental, located in Aurora, Ontario and is working to open a dental clinic in Tanzania. His objective is to encourage dentists from Canada, the U.S., and Europe to spend a day or two at the clinic as they pass through Tanzania during safari vacations, as well as create an opportunity for dental students to visit and do some work there. In addition to his work at AACD, he is currently the president of the Toronto Academy of Cosmetic Dentistry, is a co-founder of the Canadian Academy of Cosmetic Dentistry, and served as the Editor of the Canadian Journal of Cosmetic Dentistry from 2000-2008. He remains the Associate Editor and is on the editorial boards of both Spectrum and Teamwork dental journals.

He graduated from the University of Toronto Faculty of Dentistry in 1980.

Implant Dentistry and Festive Mood in the Swiss Alps The 4th International CAMLOG Congress held in early May in Lucerne offered science, practice and events on literally the highest level. The workshops and two marvelous parties took place at spectacular locations high above Lake Lucerne. The mix of science and practice was also well received by the more than 1,300 participants. In addition to an exciting overview of the state of research, all sorts of practical tips were offered and discussions held. Even the legendary CAMLOG Party had been sold out early. Therefore, the party was held twice on the summit of Mount Rigi, the so-called "Queen of Lucerne mountains". Guests enjoyed pure Swiss tradition with alphorns, banner swingers, dancers in traditional costumes, cheese, chocolate and much more. The parties raised the roof twice on Mount Rigi while participants danced deep into the night with hot live bands and the right dance mix. On Saturday, Professor Jürgen Becker (University of Düsseldorf/Germany), president of the host CAMLOG Foundation, heartily said goodbye to the CAMLOG Family. The 5th International CAMLOG Congress will be held in Spain in 2014.

Zimmer Dental Launches Game-Changing Trabecular Metal Dental Implant Zimmer Dental Inc., is pleased to announce the availability of the revolutionary Zimmer® Trabecular Metal™ Dental Implant in the U.S. and select global markets. The Trabecular Metal Dental Implant adds dimension to implant dentistry and is The Best Thing Next to Bone®. The Trabecular Metal Dental Implant features an osteoconductive mid-section that is structurally similar to cancellous bone. Portions of the implant also utilize Zimmer Dental’s MTX® microtextured surface, which has been documented to achieve high levels of bone-to-implant contact. Human studies of the Trabecular Metal Dental Implant started in 2010. In a study of Trabecular Metal Dental Implants in canine mandibular models, evidence of ingrowth by maturing bone was documented as early as two weeks after implantation. Further data is being collected to document clinical results in human dental applications. Combining the popular features of the Tapered Screw-Vent® Implant (including Platform Plus™ Technology and crestal options) with the unique properties of Trabecular Metal Material, the Trabecular Metal Dental Implant is compatible with the Tapered Screw-Vent Surgical Kit and prosthetics for easy incorporation into treatment plans. Contact a Zimmer Dental Sales Consultant or Customer Service at (800) 265-0968 or (905) 567-2073, or visit www.TrabecularMetal.ZimmerDental.com for more information.

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Mineralized Cortico-Cancellous Allograft A natural and predictable way to regenerate bone. Allograft particulates are options for ridge augmentation, extraction sockets, and sinus augmentation. Bone particulates are ground and sifted to specification during our manufacturing process. Strict processing procedures are taken by the tissue bank to ensure quality and safe tissue grafts for transplantation. The tissue bank complies with guidelines and regulations with the American Association of Tissue Banks (AATB), Food and Drug and Administration (FDA), and Health Canada. Extensive tests for infectious diseases such as AIDS, Hepatitis B&C and Syphilis are performed on all donors recovered by the tissue bank. All musculoskeletal grafts are soaked and rinsed in antibiotics, hydrogen peroxide, alcohol, and sterile water. Partical size comes in 0.5-1.0mm chips. Vial Sizes come in: 0.5cc, 1.0cc, 2.0cc. Also available in Cortical only, and Cancellous only. Can be purchased through Implant Solutions. Contact: www.implant-solutions.ca, sales@implant-solutions.ca, t. 1-877-857-8333, f. 1-905-773-1722.

Camlog Implants NOW available in Canada The Camlog Implant System is based on years of clinical and laboratory experience and is a user-friendly, reliable and prosthetically oriented implant system. The flagship “SCREW-LINE implants are conical self-tapping screw implants and are available with a Promote Plus 0.4mm machined implant collar, just above the abrasive-blasted, acid etched surface. The patented “Tube-in-Tube” inner configuration ensures a highly precise, stable and anti-rotation connection to the prosthetic components. The design also allows the user Platform Switching options before or after the implant has been placed. With one instrument for both surgical and restorative placement, combined with drill stops on every drill, this system is very easy to use as well as adding peace of mind during surgery. For more information, visit www.camlog.com.

The Aurum Ceramic/Classic Implant-Based Restoration Warranty Program The Aurum Ceramic/Classic Implant-Based Restoration Warranty Program covers Aurum Ceramic/Classic- supplied restoration, abutment, related screws/components and even the implant itself! Now get up to five years protection against normal wear and tear with the Aurum Ceramic/Classic Implant-Based Restoration Warranty Program. And, get up to two years on Screw retained Dentures. Our warranty covers Aurum Ceramic/Classic-supplied implant-based final restorations; abutments fabricated by Aurum Ceramic/Classic, related screws and components! Any problems with materials or craftsmanship, and we’ll remake it all - free of charge. Contact your closest Aurum Ceramic/Classic Dental Laboratory location or call 1-800-661-1169 for full details.

BioHorizons Laser-Lok® 3.0 Implant Treat small spaces with confidence. Laser-Lok 3.0 is the first 3mm implant that incorporates Laser-Lok technology to create a biologic seal and maintain crestal bone on the implant collar.

Designed specifically for limited spaces in the esthetic zone, the Laser-Lok 3.0 comes with a broad array of prosthetic options making it the perfect choice for high profile cases.

• Two-piece 3mm design offers restorative flexibility in narrow spaces.

• 3mm threadform shown to be effective when immediately loaded.

• Laser-Lok microchannels create a physical connective tissue attachment (unlike Sharpey fibers).

For more information: BioHorizons, 1.866.468.8338, www.biohorizons.com

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The Science and Practice of Oral Implantology

Clinical

Practical Oral Implantology

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