TW-V5N6_Layout 1 7/13/2012 4:11 PM Page 1
The Insiders’ Guide to Quality Dentistry Vol.5 No.6 -July 2012
Implant-Prosthetic Rehabilitation of Several Missing Teeth Ingenuity in Implant Treatment Considerations for Single Tooth Replacement in the Esthetic Zone Imitating the Natural Color in an Elderly Patient Dentists are Trained to Save Teeth Sleep Dentistry Saves Lives
TW-V5N6_Layout 1 7/13/2012 4:11 PM Page 2
8 Full Day & Half Day Seminars
8 Evening Seminars
3 Panel Discussions
2 Hands-on Workshops
Holiday Inn 7095 Woodbine Avenue, Markham , ON L3R 1A3 Wednesday, September 12, 2012 Implant Dentistry – Make it Simple
| Murray Arlin, D.D.S., dip Perio, F.R.C.D.(C), Mark Nicolucci, D.D.S., M.S., cert. Perio Implant, F.R.C.D.(C)
Sponsor(s): MIS Implants
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
| Dr. Bruno Lemay | Sponsor(s): CMI Institute
| Dr. Eric Van Dooren | Sponsor(s): Nobel Biocare
Friday, September 28, 2012 Minor Tooth Movement: An Introductory Hands-on Training Seminar (with separate fee)
| Dr. Neil Warshawsky DDS, MS, PC
Sponsor(s): Dentsply Canada
Friday, October 12, 2012 Panel Discussion – Digital Day
| Various Speakers Sponsor(s): ADIA, 3M ESPE, Exan Mercedes, Straumann, Patterson, Velscope
Friday, October 26, 2012 The Occlusion – TMJoint and Restorative Connection: Predictable Procedures for Predictable Results
Dr. Dennis Marangos, DDS | Sponsor(s): Shaw Group of Dental Laboratories, Ivoclar Vivadent Canada
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
Friday, November 9, 2012 Hot topics in Ceramics, Cements, Adhesion, and Anterior Implant Esthetics
ADIA’s 1/2 Year Program Package Join Today for only $449!
Dr. Ed McLaren | Sponsor(s): 3M ESPE, Krest, Heraeus, Bisco, Vident
Tuesday, November 13, 2012 Complications in Implant Dentistry: Prevention & Treatment: Part 2 Friday, November 16, 2012 Panel Discussion – Cosmetic Evolution Day
| Dr. Leslie Lee | Sponsor(s): Hi Tec Implant Canada
| 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.
TW-V5N6_Layout 1 7/13/2012 4:11 PM Page 3
Who’s who? Palmeri Media Group Publisher: Ettore Palmeri, MBA, AGDM, B.Ed., BA Editor – Clinical: Dr. Lyndon Cooper Editor – Technical: Lee Culp, CDT
Office Administrators: Tina Ellis – accounting@palmeripublishing.com Sanaz Moori, B.SC, Eng. – sanaz@palmeripublishing.com Bahar Palmeri, B.SC – bahar@palmeripublishing.com Adriana Palmeri – adriana@palmeripublishing.com Sales and Marketing: Gino Palmeri – gino@palmeripublishing.com Editorial Director: Frank Palmeri, H.BA, M.Ed – frank@palmeripublishing.com Production Manager: Samira Sedigh, Design Dip. – production@palmeripublishing.com Graphic Art: Samira Sedigh, Design Dip., Tim Faller & Lindsay Hermsen, B.Des.Hons.
• Clinical Editor: Dr. Lyndon Cooper • Technical Editor: Lee Culp • Executive Advisor: Dr. Robert Zena • Dr. Allen Aptekar • Dr. Katya Archambault • Dr. Marcus Blatz • Dr. Dennis Brave • Dr. Paul L. Child Jr. • Dr. Ken Koch • Dr. John Kois
Internet Marketing Director: Rashid Qadri
• Dr. Greg Kurtzman
Event Coordinators: Sara Famili, MArch – events@palmeripublishing.com
• Dr. Sonia Leziy
Canadian Office: 35-145 Royal Crest Court, Markham, ON L3R 9Z4 Tel: 905-489-1970, Fax: 905-489-1971 Email: info@palmeripublishing.com Website: www.palmeripublishing.com TEAMWORK is published nine times a year by Palmeri Publishing Media. TEAMWORK is a clinically focused publication that recognizes the contribution and importance of various specialties that comprise the dental team in providing high standard dental treatment for dental patients. Articles published in TEAMWORK express the viewpoints of the author(s) and do not necessarily reflect the view and opinions of the Editor and Advisory Board. All right reserved. The contents of this publication may not be reproduced either in part or in full without written consent of the copyright owner. Publication Dates: January, February, March, April, May/June, July, August/September, October, November/December Printing: Point-one Graphics Inc. Printed in Canada. Canadian Publications Mail Product Sale Agreement 40020046. TEAMWORK ISSN #1922-7558 is published nine times a year by Palmeri Publishing Inc., 35-145 Royal Crest Court, Markham, ON. Canada, L3R 9Z4. Periodicals Postage Rates paid at Niagara Falls, NY 14304. U.S. Office of publication 2424 Niagara Falls Blvd, Niagara Falls, N.Y. 14304. U.S.
TEAMWORK Vol.5-No.6 - July 2012
• Dr. Pascal Magne • Dr. Ziv Mazor • Dr. Ed McLaren • Dr. Ali Nassah • Dr. Dennis Nimchuk • Dr. Maurice Salama • Dr. Paresh Shah • Dr. Lee Silverstein • Dr. John Sorensen • Dr. douglas Terry • Dr. Olivier Tric • Dr. Ron Zokol
3
In This Issue
TW-V5N6_Layout 1 7/13/2012 4:11 PM Page 4
Editorial .....................................................................................................6 News and Views.........................................................................................8 People and Products ...............................................................................10 Nobel Biocare News ...............................................................................14 The Train of Titanium - A rare interview with Professor Per-Ingvar Branͦemark
Frederic Love
Implantology............................................................................................16 Implant-Prosthetic Rehabilitation of Several Missing Teeth Using Regenerative Surgery and Tissue Conditioning Techniques
Dr. Giovanni Zorzetto
Implantology............................................................................................22 Ingenuity in Implant Treatment
Raymond J Voller, DMD, MAGD, FADI, FACE
Implantology............................................................................................30 Considerations for Single Tooth Replacement in the Esthetic Zone
Dean Morton, BDS, MS, FACP
Implantology............................................................................................38 Imitating the Natural Color in an Elderly Patient
Luke S. Kahng, CDT
Sleep Apnea ............................................................................................46 Dentists are Trained to Save Teeth Sleep Dentistry Saves Lives
Brock Rondeau, DDS
In My Practice .........................................................................................58 Don’t Worry, Be Happy
Mike Racich, DMD, Dipl ABOP, FAGD
Dental Economy......................................................................................60 Practice Matters – Part 2
Nadean Burkett
Dental Marketing.....................................................................................62 ‘This Manual Won’t Work Here’ – And Other Dental Tales
Bryce Gibney
Adlink ......................................................................................................66 Cover Art by Lindsay Hermsen, B.Des.Hons.
4
TEAMWORK Vol.5-No.6 - July 2012
TW-V5N6_Layout 1 7/13/2012 4:12 PM Page 5
Advancing the Science of Dentistry through Innovation and
Digital Technology CUSTOMIZED IMPLANT SOLUTIONS Experience the New World of CAD/CAM Implant Dentistry A leader in innovation and digital technology, Protec Dental Laboratories offers CAD designed precision milled custom abutments and overdenture bars for a wide variety of implant platforms.
CUSTOM ABUTMENTS
MILLED TITANIUM OVERDENTURE BARS
Custom implant abutments are available in titanium or zirconia. The custom milled implant abutments offer superior esthetics and precision fit.
Titanium implant bars are CAD designed and precision milled from medical grade titanium to achieve exceptional quality overdenture bars.
Editorial
TW-V5N6_Layout 1 7/13/2012 4:13 PM Page 6
Summer thoughts to ponder on‌
S
Katya Archambault, DMD
ummer is upon us! Did you also think that spring seemed difficult this year? Conflicts were all over the newspapers, people were in the streets fighting to express their point of view, even the dental community was criticized by the La Presse, a newspaper in the province of Quebec. Now we are dealing with the issue of dental radiographs, endangering our patients’ health. I truly hope that the sun and the relax will be a balm for everybody and that you use summer to plan for future projects that will be done in the fall. As many of you know, I work in the Bois-Francs area of Quebec. By percentage this region is one of the most edentulous area in the whole world. In fact, in the Bois-Francs area to receive a set of denture was considered as a nice wedding gift.
Things have changed for the better, but still a tooth is one of the few organs that when lost we do not automatically think of replacing it.
In the Bois-Francs area things have changed for the better, but still a tooth is one of the few organs that when lost people there do not automatically think of replacing it. Of course teeth are less essential organs, if we can categorize them that way. If we lose a thumb, we can now have it replaced by surgery with a toe or with a prosthesis. So, in our world it still happens that we have a patient in the office that we do an extraction on an hopeless tooth and after explaining to the patient all the possibilities of replacement, he or she will choose to do nothing. Why is it like this? Some will say that it is still possible to chew food with fewer teeth. It will not be the end of the world. But does the patient realize that we are breaking the muscular and functional equilibrium of the mouth and there are consequences for doing so? I think we all should work hard to sensitize our patients to the fragility of that equilibrium and to his entire dentition. To propose a socket preservation treatment will allow us to save on average bone loss up to 3.7mm in a bucco-lingual
6
width and up to 1mm in height. According to Shropp et al, 2003, fifty percent of the alveolar ridge will be lost after the first year following the extraction, two thirds of that remodeling will occur within the first three months following the loss of the tooth. Hämmerle et al (COIR 2012), stated that 3.8mm average bone loss buco-lingually and 1.24 of vertical loss will take place even after six months after the extraction. We also have studies by Araujo, Esposito, Cardaropli, supporting the same findings. The literature has plenty of these articles showing the same conclusions.
However, we know that by placing a graft material in the alveolus, we can help the bone from resorption and to ease the placement of future implants. This buys time and gives the patient time to think about what he wants as a replacement, and even if he chooses a removable or fixed prothesis and a non-implant restoration, the dentist will have some more tissue for support later on. I think that time has come to offer this treatment modality to our patients. Nobody will blame us for doing so. The opposite could be true. As a community we have a great opportunity to tell the population that losing a tooth can have serious long term health consequences. I strongly feel that this issue should be addressed by the dentist as if the patient was losing any other organ of the human body. What do you think? I leave you with that thought. In the meantime I wish you and your loved ones a great summer. Enjoy. You deserve it!
TEAMWORK Vol.5-No.6 - July 2012
TW-V5N6_Layout 1 7/13/2012 4:13 PM Page 7
SPECTRUM dialogue Techno-Clinical Day October 12, 2012 Time: 8:00am – 9:00pm
TORONTO
Free Admission
Speakers Lee Culp, CDT Luke Kahng, CDT Peter Pizzi, MDT Domenico Cascione, MDT Richard Napolitano, CDT Carlo Zanon, DD
Dr. Mark Lin Dr. Joseph Fava Dr. Murray Arlin Dr. Allen Aptekar
... and more
www.spectrumdialogue.com Palmeri Publishing Inc. 1.905.489.1970 1.866.581.8949
News and Views
TW-V5N6_Layout 1 7/13/2012 4:14 PM Page 8
Molar Replacement With Two Narrow-Diameter Dental Implants
A
study by Dr. Ziv Mazor et al, published in Implant Dentistr y, presents results of a single-molar area rehabilitated by 2 narrowdiameter dental implants. The study evaluated a retrospective cohort of 33 consecutive patients from 2 private practices between the years 2008 and 2009. Patients who had a single first molar replaced by 2 narrow-diameter implants (3 mm wide) were included in this case series. The patients' demographics, site and implant characteristics, and the times of their follow-ups were recorded from the medical files. The study found that 33 patients received 66 implants replacing 33 missing first molars. The patients' ages ranged from 23 to 76 years with an average of 49.2 ± 12.7 years. Most of the implants were used to replace a mandibular molar (76%) and 16 were used to replace 8 maxillary molars. In 2 patients, immediate implantation was performed. The mean distance between the adjacent teeth was 12.1 ± 1.0 mm. Follow-up times ranged from 10 to 18 months (average, 12.2 ± 1.9 months). It was found that all implants survived the follow-up time. One implant presented with one mm of bone loss at the 12month follow-up. The study concludes that replacing a single missing molar with 2 narrowdiameter dental implants might serve as a viable treatment option providing good and predictable long-term results. (Source: Implant Dentistry, 2012, Volume 21, Issue 1, pages 36 to 38)
Successful Dental Implants for Patients Taking Biphosphonates
R
educing a patient’s treatment time and simplifying the treatment can increase patient acceptance and reduce the risk of complications. For dental implants, this means moving away from the traditional two-stage
8
surgical approach and toward a one-stage procedure. The success of this concept, when combined with another complication—that of patients receiving drug therapy for osteoporosis—was studied to determine the best method of treatment in this situation. Osteoporosis is a well-known disease that weakens bone and increases the risk of fracture, particularly among postmenopausal women. Biphosphonates, an inhibitor of bone resorption, are widely used as a drug therapy for those with osteoporosis. Prolonged use of biphosphonates, however, can lead to a painful refractory bone exposure in the jaws, known as “biphosphonateinduced osteonecrosis of the jaw” (BONJ). This condition usually develops after dental treatment, indicating that oral surgery and implants placed into the jawbone can precipitate BONJ. Although the process is not fully understood, it appears that prolonged use of biphosphonates may suppress the bone’s repair function, interfering with healing after implants. A study published in the Journal of Oral Implantology involved a total of 54 implants installed in 9 osteoporotic patients, 8 of them female, who ranged from ages 45 to 68 years. All had been taking oral biphosphonates for less than 3 years; a significant increase in risk of developing BONJ is associated with more than 3 years of biphosphonate therapy. Immediate occlusal loading procedures were used, which require that motion at the bone-implant interface be kept below a certain threshold during healing. This study demonstrated a 100% success rate, with all patients rehabilitated with a fullarch prosthesis supported by 6 dental implants. Two years of follow-up found no adverse events of infection, tissue swelling, or lesions, showing this to be a viable one-stage treatment. (Source: Journal of Oral Implantology, 2012, Volume 38, Number 1; news release March 8, 2012)
I
Aspirin May Help Form New Bone n 1899, German doctors and pharmacists began receiving the first of the sample packets from the drug company Bayer AG. The packets contained a fluffy white powder, called acetylsalicylic acid, which Bayer executives described as the latest modern miracle from the emerging field
TEAMWORK Vol.5-No.6 - July 2012
TW-V5N6_Layout 1 7/13/2012 4:14 PM Page 9
of organic chemistry. They asked the practitioners, in modern terms, to pilot test the compound on their patients, explaining that it had been shown in their initial human studies to relieve common pain and inflammation without the debilitating side effects of other drugs. But, as they also explained, other uses certainly weren’t out of the picture. Bayer encouraged the practitioners to publish their results and, in a sign of 20th century things to come, to refer to the new drug by its trade name: Aspirin. More than 110 years later, researchers continue to discover new uses for Aspirin. In an issue of Nature Medicine, National Institute for Dental and Craniofacial Research (NIDCR) scientists and grantees report in mouse studies that Aspirin, applied directly to the site of an experimental skull wound, helps bone marrow mesenchymal stem cells (BMMSCs) form new bone. Aspirin does so by reducing the concentration of immune cell signaling proteins interferongamma (INF-γ) and tumor necrosis factor-alpha (TNF-α) in the tissue microenvironment, where the wound healing occurs. By jamming these specific wavelengths of molecular communication, the scientists found they could control certain types of T-cells that inhibit the implanted BMMSCs from forming new bone. Importantly, Aspirin has no negative effects on other T-cells subtypes that the researchers found are helpful to engineer new bone. The researchers concluded, “Although Aspirin reduces TNF-α and INF-γ production with improved BMMSC-based tissue regeneration, the therapeutic effect of Aspirin in preclinical tests and clinical trials (for example, in improving fracture healing) may be the focus of future studies.”(Source: NIDCR, Science News in Brief, February 13, 2012)
A
Sleeping Versus Loaded Implants
study compared the outcome up to 12 years of “sleeping” versus loaded implants in the mandible, which involved 14 patients with overdentures, for a total of 28 loaded implants and 14 sleeping implants. During follow-up visits, intraoral radiographs were taken to observe changes in bone level. The study found that, at each observation visit, compared with abutment connection, the submerged nonloaded (sleeping) implants had less bone loss than their neighboring functional (loaded) implants. The difference was primarily due to more significant bone loss during the first year of loading; following the first year, changes in bone level remained similar for both types of im plants. The study suggests that the first months of loading of
TEAMWORK Vol.5-No.6 - July 2012
implants have a significant impact on the bone level, resulting in the initial difference between sleeping versus loaded implants. This is followed by a more physiological bone level change. The study notes that this initial difference in bone level might be explained by the adaptation of the surrounding bone to the loaded implant. (Source: Clinical Oral Implants Research, first published online November 25, 2011; DOI: 10.1111/j.1600-0501.2011.02263.x)
N
Jaw Size Linked to Diet
ew research suggests that many of the common orthodontic problems experienced by people in industrialized nations are due to their soft modern diet causing the jaw to grow too short and small relative to the size of their teeth. Dr. Noreen von Cramon-Taubadel, of the University of Kent's School of Anthropology and Conservation, tested the long-debated theory that the transition from a largely hunter-gatherer to an agricultural subsistence strategy across many parts of the world has had an effect on the growth and development of the human skull and lower jaw. The shapes of the cranium and mandible of 11 globally distributed populations were compared against models of genetic, geographic, climatic, and dietary differences. She found that lower jaw shape, and to some extent the shape of the upper palate, was related to the diet of populations, while the cranium was strongly related to the genetic relationships of the populations. The lower jaw reflects whether populations are primarily huntergatherer or agriculturalist in nature, irrespective of what part of the world they come from. This suggests that chewing behavior causes the lower jaw to grow and develop differently in different subsistence groups, while the skull is not affected in the same way. Overall, the hunter-gather groups had longer and narrower mandibles, indicating more room for the teeth to erupt correctly, while the agriculturalists had generally shorter and broader mandibles, increasing the likelihood of dental crowding. Dr. von Cramon-Taubadel says, "Chewing behavior appears to cause the lower jaw to develop differently in hunter-gatherer versus farming populations, and this holds true at a global level. What is interesting is that the rest of the skull is not affected in the same way and seems to more closely match our genetic history." (Source: ScienceDaily, November 22, 2011)
9
People p and Products
TW-V5N6_Layout 1 7/13/2012 4:14 PM Page 10
Implant Dentistry and Festive Mood in the Swiss Alps
T
he 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.
Canadian Dentist Elected President of the AACD
D
r. Ron Goodlin of Aurora, Ontario, took the helm as president of the American Academy of Cosmetic Dentistry (AACD) during the
10
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 cofounder 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.
F
Opalite® Esthetic, Screw-Retained Prosthetic Bars
or the ultimate in custom implant bar precision and esthetics, look to Aurum Ceramic/Classic’s exclusive Opalite® ScrewRetained Prosthetic Bars. Available in two costeffective alternative formats suitable for all implant indications, both are custom CAD designed from your fixture level impression and precision-milled for unparalleled strength, perfect fit and easy seating! Opalite® Full Arch, Full Contour All-Zirconia offers amazing translucency and a full spectrum of shades. When a non-engaging “metal-to-metal” connection is desired, a universal connection on the bottom of the Zirconia bar allows the insertion of Titanium interfaces for a precision fit to the appropriate implant. Contact your closest Aurum Ceramic/Classic Dental Laboratory location or call 1-800-661-1169 for full details.
TEAMWORK Vol.5-No.6 - July 2012
TW-V5N6_Layout 1 7/13/2012 4:14 PM Page 11
T
Focusable Task-Vision Loupe he Focusable Task-Vision Loupe is worn like spectacles and is easy to adjust. The loupe has a focusable working distance between 10-17 inches. It is fine focusing on both telescopes, has adjustable nose pads for height and comfort and the widest field of view (3 inches). Economically priced at $149.95. Aspheric (distortion free) and Achromatic (color correct) Hard coated optics with 2.5 X magnification. For more information or to order, contact your dealer or call Vision USA at 1-800-257-5782 or 856-795-6199. To view our full line of products, go to www.visionusasupplies.com.
Auritex-LP From Aurident Helps Dental Laboratories Cut Costs!
A
uritex-LP from Aurident, Inc. is an economical white High Noble alloy for porcelain fused to metal applications. Containing 40% gold, 32% palladium, and 20.5% silver, Auritex-LP is designed to help dental Laboratories reduce costs when dentists require a white high noble alloy for PFM applications. Compatible with a wide range of porcelains, Auritex-LP is easy to use and work with. The alloy is an ideal alternative to higher gold content alloys, while still maintaining high noble classification. Auritex-LP can be used for high stress applications such as long span bridges as well as single units. For more information or to place an order, call Aurident at 800-422-7373 or visit www.aurident.com.
R
The Dentist’s Role in Snoring & Sleep Apnea ondeau Seminars is pleased to announce the launch of our online sleep apnea course “The Dentist’s Role in Snoring & Sleep Apnea”. The focus of the web seminar is to give dentists basic step-by-step information on snoring and sleep apnea. You will obtain a clear understanding of this disorder and how to treat it. You will also gain the ability to communicate effectively with patients and sleep specialists regarding snoring and sleep apnea. Rondeau Seminars online sleep course is an efficient and cost effective way to learn how to detect and treat patients with Snoring & Sleep Apnea. Dr. Rondeau recently received his diplomate status with the Academy of Clinical Sleep Disorders Disciplines. Dr. Rondeau has been treating patients with snoring and sleep apnea for over 20 years, and has been lecturing to dentists on sleep apnea for 8 years. For more information please visit www.rondeauseminars.com, or call 1-877-372-7625.
TEAMWORK Vol.5-No.6 - July 2012
11
TW-V5N6_Layout 1 7/13/2012 4:15 PM Page 12
T
NobelReplace CC and PS
he two additions to the NobelReplace tapered implant system merge biomechanical and prosthetic advantages and have been developed with clinical and esthetic needs in mind. NobelReplace now offers even more restorative options with the advanced third-generation internal conical connection of the new NobelReplace Conical Connection (CC) and the addition of the platform-shifting feature to the existing internal tri-channel connection to create the NobelReplace Platform Shift (PS). The NobelReplace implant system combines the well-proven tapered implant body, which facilitates high primary stability, with a strong and tight connection for maximum restorative outcome. The implant system offers a safe and reliable solution for all indications in soft and hard bone alike. It is a versatile and easy-to-use implant system and serves all the needs of both new and experienced restorative and surgical implant users. For more information call customer support at 1-800-939-9394.
A
Cortico-Cancellous Allograft 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 the 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 AATB, 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. Available in Cortical only, and Cancellous only. Can be purchased through Implant Solutions. Contact: www.implantsolutions.ca, sales@implant-solutions.ca, t. 1-877-857-8333.
Camlog Implants NOW in Canada
T
he 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-inTube” 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.
FiBER FORCE® IT NOW ...or fix it later!
FiBER FORCE® is a system of pre-impregnated light-curable meshes, braids and UD fibers. • Fast, easy and inexpensive • Bonds to acrylic and adds no weight • Esthetically pleasing
12
Call SYNCA today or visit our website
www.fiberforcedental.com
1-888-582-8115 in Canada: 1-800-667-9622
TEAMWORK Vol.5-No.6 - July 2012
TW-V5N6_Layout 1 7/13/2012 4:16 PM Page 13
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
Nobel Biocare News
TW-V5N6_Layout 1 7/13/2012 4:16 PM Page 14
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. At its annual inventor awards ceremony this spring, the European Patent Office (EPO) presented Professor Pre-Ingvar Branͦemark 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 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
14
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,” Branͦemark recruited experts from other fields-such as physics, chemistry and biology to his quest. Physicians, dentists and biologists all joined in 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, Branͦemark 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 Branͦ e mark. 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. To reach beyond the world of the university clinic, Branͦemark 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
TEAMWORK Vol.5-No.6 - July 2012
TW-V5N6_Layout 1 7/13/2012 4:16 PM Page 15
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.
TEAMWORK Vol.5-No.6 - July 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, Branͦemark 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 longago established among dentists?” Branͦemark 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 biology-especially immunologylies 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 boneanchored 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”.
15
TW-V5N6_Layout 1 7/13/2012 4:16 PM Page 16
Implantology
Implant-Prosthetic Rehabilitation of Several Missing Teeth Using Regenerative Surgery and Tissue Conditioning Techniques Author: Dr. Giovanni Zorzetto received his bachelor's degree in Padua in 1999 in Dentistry and Dental Prosthesis with highest honors. He specialized in Oral Surgery in 2001. He completed his Master in Fixed Prosthetics and Prosthetic Materials in 2003 and Master in Osseointegrated Implants in 2006. He is a member of ANDI and the Italian Academy of Prosthetic Dentistry. Since 2004, Dr. Zorzetto has also been an instructor in BLS-D (Basic Life Support - Defibrillation) of the Italian Resuscitation Council. E.C.M. speaker for the Ministry of Health in courses involving dentistry and Adjunct Professor at the University of Padua in the Degree Course in Dentistry and Dental Prosthesis. He currently runs a private practice at his office at Zero Branco (TV).
16
TEAMWORK Vol.5-No.6 - July 2012
TW-V5N6_Layout 1 7/13/2012 4:17 PM Page 17
N
owadays, modern implantology increasingly avails itself of association with other branches of dentistry with the scope of achieving a rehabilitation of our patients that is as complete as possible, from both a functional and an aesthetic point of view. This type of orientation can be found both in complex and in partial rehabilitations, always, however, respecting the optimizing principle of the steps, which consists in not considering any moment of the therapy as the main one, but giving every moment the same therapeutic value. That is why when planning treatment a route will be designed where, for each phase, a series of technical details will be entered that will seek to obtain one sole best result: the final one. Each objective will have a summary of the most suitable techniques. Following is an example of this principle in which the rehabilitation, designed from the outset, starts with planning the same surgical avulsion technique to finalize the prosthetic implant.13 In April 2009, a patient came to my office, C.M. 32 years old, sent to me by a colleague for prosthetic-implant rehabilitation of element 36. During anamnesis the patient, male, average smoker (10 cigarettes per day), appears to be in good general health.
From a dental standpoint there is widespread gingivitis mainly due to poor oral hygiene and the consumption of cigarettes, it is also noted that there are various restorations that are not perfectly congruent, and root residues in area 36 (Figs. 1 and 2). The proposed treatment plan consists in surgical removal of residual roots, bone regeneration at the post-extraction site, due to the presence of a vestibular bone fenestration, followed by the insertion of an implant in the affected area fitted with a metal-ceramic crown. In May 2009 (T0), the patient, after anesthesia with articaine 1:200,000, undergoes the surgical removal of root residuals of element 36 (Fig. 3). The extraction is performed very carefully in order to cause as little damage as possible to the remaining bone, which is subsequently curetted.6 During the same session a particulate Bonitmatrix artificial bone in inserted in the postextraction site (Fig. 4) and covered with palatal epithelialconnective tissue (Fig. 5) which is stabilized by non-absorbable sutures 5.0 (Ethilon-Johnson and Johnson). The used connective tissue serves a dual purpose, one is to protect and contain the bone graft (particulate) and the other is to increase the amount of peri-implant keratinized mucosa, mucous membrane easily conditioned during the prosthetic phase.11
Fig. 1
Fig. 2
Fig. 3
Fig. 4
TEAMWORK Vol.5-No.6 - July 2012
17
TW-V5N6_Layout 1 7/13/2012 4:17 PM Page 18
The choice of bio-filling material, in our case, falls on a product that is easily manageable and has proven to be stable over time.1, 2, 3 Bonitmatrix in particular is a synthetic material, fully resorbable, with 87% of its weight composed of 2 nanocrystalline calcium phosphates, hydroxyapatite and betatricalcium phosphate, embedded in a nano-porous matrix of silicon dioxide (13% of the weight). The ratio of hydroxyapatite and beta-tricalcium phosphate is 60/40. Since the material is produced synthetically, this rules out any infection or transmission of animal diseases. Bonitmatrix is a medical product characterized by a system of interconnected microporosity: the individual grains are highly porous with a free surface of 90 m 2 per gram, thus ensuring an excellent intervention of osteoinductive factors through the spread of biological fluids. The intense cohesion forces between individual grains cause the material, once it is easily compacted, to remain stable in the bone defect area acting as a good space maintainer.3 Approximately 2 weeks (T1), after rinsing with chlorhexidine-based disinfectant, the sutures at the palatal site and the bone graft area were removed. After five months (T2) an x-ray is taken and a clinical evaluation made of the pre-implant area (Figs. 6 and 7), an
18
evaluation that shows good dimensional bone stability, both vestibule-lingual and apex-coronal, with a well represented presence of keratinized mucosa.1, 2, 9, 12 After 1 week (T3) a cylindrical 4.2 x 11.5 mm (Dyna s.r.l.) implant was inserted. During surgery, after anesthesia with articaine 1:200.000, a trapezoidal incision is made through the full-thickness that does not involve the marginal zone of adjacent elements8 and the center of the bone crest, but moves lingually (Fig. 8). Under a copious irrigation with saline solution, preparation is made of the implant site (Fig. 9) that shows good bone consistency supported by the final implant tightening torque that is measured using a calibrated instrument, in 45-Ncm2 (Fig. 10). At this point the flap is closed with Vycril 5.0 sutures (Fig. 11) and the prosthetic phase is scheduled at 3 months 4,10, in view of the high primar y stability, as per the implant manufacturer’s protocol. After 2 weeks (T4) the patient is called for a control and to remove the suture.7 In January 2010 (T5), after assessing the X-Ray (Fig. 12), the next step was to connect a 4 mm high healing screw to the fixture. In this phase as well, the choice of flap is not random; in fact, once the location of the implant head is identified, a small trapezoidal incision is made, slightly moved lingually, to
Fig. 5
Fig. 6
Fig. 7
Fig. 8
TEAMWORK Vol.5-No.6 - July 2012
TW-V5N6_Layout 1 7/23/2012 10:45 AM Page 19
Fig. 9
obtain a mucosa trap to be buccally overturned by the thrust of the healing screw itself. In this case sutures are not used since the flap will stabilize naturally with the tension caused by the healing screw (Fig. 13). In this manner, when healed, there will be a fair gain of mucosal thickness over the implant on the vestibular side of the crown. The next stage takes place after 4 weeks (T6) and a good ripening peri-implant tissue can already be seen, facilitated also by the excellent sealing at the cone metric connection of this type of implant .
TEAMWORK Vol.5-No.6 - July 2012
Fig. 10
During the appointment for taking the print, the shade will also be determined using, as is our habit, a Spectroshade spectrophotometer in order to obtain a detailed mapping of the color. After 10 days (T7) the patient is called in to test the metal structure of the crown (Figs. 14 and 15) and after another 10 days (T8) the case is finalized by combining the aesthetic test to the occlusal test (Figs. 16 and 17). The restoration is carried out by our technician always with the intention of pushing the implant buccal mucosa present in order to simulate the natural curve of soft tissue as seen in Figures 15 and 19.
19
TW-V5N6_Layout 1 7/13/2012 4:17 PM Page 20
Fig. 11
Fig. 12
Fig. 13
Fig. 14
Fig. 15
Fig. 16
It should be noted that all these procedures for conditioning tissue depend on the presence of a thick keratinized mucosa; if thin tissues were also present the vestibular thrust instead of producing a curve would cause a recession. In controlling the occlusion, since the teeth are more or less intact, proceed to carefully check that, even though contact is made, the new crown does not change the preexistent chewing 5 (Figs. 18 and 19). At the end of rehabilitation we obtained a restoration that not only restored functionality, but which, thanks to the use of biomaterials as well as techniques, can be valuable in aesthetic terms, in support of
20
Fig. 17
the mucosa component created during rehabilitation. We wish to thanks the Favaretto Francesco Dental Laboratory for their valuable collaboration.
TEAMWORK Vol.5-No.6 - July 2012
TW-V5N6_Layout 1 7/13/2012 4:18 PM Page 21
Fig. 18 References
1. Araujo et al. Dimensional ridge alteration following tooth extraction. An esperimental study in the dog. J Clin Periodontol 2005 Feb; 32(2): 212-8 2. Botticelli D et al. Hard-tissue alterations following immediate implant placement in the extraction sites. J Clin Periodontol 2004 Oct; 31(10):820-8 3. Bulnheim U et al. In vitro studies of mesenchymal stem cell on the calcium phosphate xerogel composite Bonitmatrix. Biomaterialien 7(SI) 2006 4. Covani U et al. Buccolingual crestal bone changes after immediate and delayed implant placement. J Periodontol 2004 Dec; 75(12):1605-12 5. Dawson PE et al. Evalutations, diagnosis and treatment of occlusal problems. St. Louis: Mosby, 1989 6. Fumagalli L et al. Il riassorbimento osseo perimplantare nella tecnica postestrattiva.Italian Oral Surg 2007; 6: 21-26 7. Jemt T et al. Osseointegrated implants in the tratment of partially edentulous jaws: a preliminary study on 876 consecutively placet fi xtures. Int J Oral Maxillofac Impl 1989; 4:211-7
TEAMWORK Vol.5-No.6 - July 2012
Fig. 19 8. Lekholm U et al. Osseointegrated implants in the treatment of partially edentulous jaws: a prospective fi ve-year multicenter study. Int J Oral Maxillofac Impl 1994; 9:627-35 9. Mecall RA et al. The infl uence of residual ridge resorption patterns on fi xture placement and tooth position. Part 1. Int J Periodont Rest Den 1991; 11:8-23 10. Nemcovsky CE et al. Comparative study of buccaldehiscence defects in immediate, delayed, and late maxillary implant placement: Clinical healing between placement and second stage surgery. J Periodontol 2002; 73(7):754-761 11. Schropp L et al. Bone healing and soft tissue contour changes following singletooth extraction: a clinical and radiographic 12-month prospective study. Int J Periodontics Restorative Dent 2003 Aug; 23(4):313-23 12. Scropp L et al. Bone healing following immediate versus delayed placement of titanium implants into extraction sockets: a prospective clinical study. 13. Testori T et al. Considerazioni estetiche e funzionali in implantologia. Linee guida. Dental Cadmos 1998; 14:11-29
21
TW-V5N6_Layout 1 7/13/2012 4:18 PM Page 22
Implantology
Ingenuity in Implant Treatment Author: Raymond J Voller, DMD, MAGD, FADI, FACE, maintains a private practice in Kittanning, Pennsylvania, USA, that emphasises aesthetic and reconstructive dentistry and orthodontics. He is a clinical instructor in digital photography and is on the advisory board of directors of the Academy of Comprehensive Esthetics. He can be reached at drvoller@comcast.net.
22
TEAMWORK Vol.5-No.6 - July 2012
TW-V5N6_Layout 1 7/13/2012 4:18 PM Page 23
O
ccasionally the restoration of an area that has been devoid of natural dentition for many years requires additional procedures that complement the restorative process. Bone grafting is one option and the refinement of the techniques has made this modality a very successful procedure. However, there are many patients who, for economic reasons or for reasons involving a lack of desire for additional surgical procedures, elect not to have these performed. To treat these patients adequately, supplemental restorative procedures and materials are required.
Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 1: Retracted buccal view of upper left quadrant illustrating implant fixtures with healing cuffs in place. Notice severe ridge resorption, particularly in area of UL5 Fig. 2: Full arch occlusal view of patient with implant fixtures and healing cuffs in place. Implant fixture with healing screw is covered at the UL5 position Fig. 3: Quadrant view of same
Fig. 4: Periapical radiograph of Zimmer 4.7 implant fixtures with impression posts in place Fig. 5: Periapical radiograph of Zimmer 4.7 implant fixtures with healing cuffs in place
TEAMWORK Vol.5-No.6 - July 2012
Fig. 5
23
TW-V5N6_Layout 1 7/13/2012 4:18 PM Page 24
As we acquire more demanding patients whose expectations exceed those to which we have become accustomed, it is imperative that we employ some basic common sense and ingenuity to accommodate them. Sometimes we may not be able to satisfy these types of patients, but the savvy clinician is generally able to ascertain from the diagnosis and chief complaint that viable treatment options exist. The most important thing to remember is that we obviously cannot make all of our prospective patients happy, but the challenge of the dental profession is to provide aesthetic and functional options that rectify what looks like an impossible situation to the average practitioner.
Aesthetic ‘tweaking’ of implant crowns
In this case, extractions and the associated loss of the alveolar ridge made it possible to replace the missing dentition (UL5 and UL6) and the supporting structures (using pink porcelain/gingival tissues) as part of the implant-retained crown restoration. Figure 1 illustrates the
24
Compromising
In this case, the implant surgeon apologized for the position of the distal implant, which resulted from him being unable to
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 6: Panoramic radiograph of patient with fixtures in place at UL5 and UL6 positions Fig. 7: Occlusal close-up view of Zimmer 4.7 implant fixtures in place.
loss of alveolar bone, requiring restorative procedures to replace this missing structure, and the implants in position. The periodontist who had placed the implants sent the patient to our practice after approximately four months. The fixture that had been placed at the UL5 position was found to be subgingival, while the one at the UL6 position was actually above tissue level (Figs. 2 and 3). The periodontist sent periapical radiographs to confirm proper placement and sufficient osseous integration (Figs. 4, 5 and 6). With long-standing edentulous spaces, not only is the alveolar ridge often resorbed, particularly in a palatal direction, but arch length loss also further complicates the restoration. The palatal loss of the alveolus often necessitates palatal placement of the implant cylinders in patients who do not want bone grafting procedures.
Fig. 8: Seated impression posts
Fig. 9: Periapical radiograph of implants with impression posts to check for proper seating
TEAMWORK Vol.5-No.6 - July 2012
TW-V5N6_Layout 1 7/13/2012 4:19 PM Page 25
TW-V5N6_Layout 1 7/13/2012 4:19 PM Page 26
Fig. 10
Fig. 11
Fig. 12
Fig. 13
Fig. 14
Fig. 15
Fig. 16
Fig. 17
Fig. 10: Shade tab to match adjacent dentition
Fig. 14: Periapical radiograph of seated custom abutments
Fig. 12: Occlusal view of custom abutments with wax over access hole prior to cementation of final crowns
Fig. 16: Facial unretracted view of final crowns with pink tissue porcelain seated for try-in
Fig. 11: Matching gingival tissue for pink porcelain using Dentsply tissue matching shade guide
Fig. 13: Buccal view of custom abutments
26
Fig. 15: Facial unretracted view of buccal corridor prior to insertion of implant crown restorations, illustrating missing structure with full smile
Fig. 17: Buccal view of final crowns cemented
TEAMWORK Vol.5-No.6 - July 2012
TW-V5N6_Layout 1 7/13/2012 4:19 PM Page 27
Fig. 18: Buccal view of final crowns cemented
utilize the surgical stent provided to place the implant in the desired way (Fig. 7). As a result, the lab technician was forced to ‘bend’ the implant abutment and associated crown towards the most advantageous position in terms of the occlusion. Impression posts were placed (Fig. 8) and their seating confirmed with a periapical radiograph (Fig. 9). When the shade was taken for the tooth (Fig. 10), a shade was also obtained to match the associated natural gingiva in the area (Fig. 11). The laboratory technician then constructed the implant abutments (UCLA/wax-to-gold custom abutments) and associated crowns to restore the teeth to a position that fills in the void found pre-operatively in the buccal corridor (Figs. 12 and 13). Proper seating of the custom abutments was again confirmed with a radiograph, prior to torquing to 35Ncm (Fig. 14).
Fig. 19: Full contour of restored smile
Patient satisfaction Upon full smile, the restored teeth mimic the natural contours and with the pink porcelain (Figs. 15 to 19) replacing the gingiva, this makes up for the loss of the supporting structures with these crowns in the aesthetic zone. After these were inserted, the patient admitted to ‘not smiling wide’ prior to this restoration because of the ‘dark hole’. This case required a bit more thought than the conventional implant abutment and crown. It also necessitated a laboratory technician who was not only very familiar with normal tooth and supporting bone morphology but who also had the artistic sense to create such beautiful restorations.
accelerate your implant practice . . . Implant systems that we help drive BioHorizons / Biomet 3i / camlog / DentsplyImplants / MDI MiS / NobelBiocare / straumann / Sybron / Zimmer
TEST DRIVE Shaw implant restorative expertise today!
TEAMWORK Vol.5-No.6 - July 2012
27
TW-V5N6_Layout 1 7/13/2012 4:19 PM Page 28
Oral Surgery Academy for General Dentists presents
The most successful course on...
Oral Surgery for the GP: A Practical Approach Dr. Lawrence I. Gaum DDS, FADSA, FICD, FADI
A Three Day Hands-on Seminar: Hilton Suites Hotel & Spa (Toronto/Markham) • 8500 Warden Ave, Markham, ON L6G 1A5
SOLD OUT!
SOLD OUT!
Calgary
Sep. 24 - 26, 2010
SOLD OUT!
Vancouver
Jan. 14 - 16, 2011
Toronto
Jun. 10 - 12, 2011
Toronto
Oct. 14 - 16, 2011
*NEW DATE!
SOLD OUT!
SOLD OUT!
Toronto
SOLD OUT!
Toronto
Jan. 20 - 22, 2012 April 27-29, 2012
Toronto
Oct. 12 - 14, 2012
$2295.00
EW haN * wit onent on comp umatic atra tions! c extra
ADIA, OAGD & TACD Member Rate: $1995 • Includes a $299 Lab Fee To register contact Palmeri Publishing at 905-489-1970 or email events@palmeripublishing.com
21 credits for seminar attendance
•
Each dentist that signs up for the course receives:
1) FREE Dr. Gaum Textbook & Surgical Videos DVD 2) FREE ACUSURG - A cutting & electrocautery instrument, extremely valuable for soft tissue surgery 3) In addition, all participants are eligible to call Dr. Gaum following the seminar for advice and consultation. Participants will receive a 10% discount when they sign up for the NEW “LIVE PATIENT HANDS-ON” course. Upon completion of both courses, participants will receive a beautifully framed FELLOWSHIP CERTIFICATE from the Oral Surgery Academy for General Dentists. *Additional Instruments Required. 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.
TW-V5N6_Layout 1 7/13/2012 4:20 PM Page 29
Oral Surgery Academy for General Dentists
Finally a Clinical Hands-on Oral Surgery Session for the GP 2-day live component with your patients! Dr. Lawrence I. Gaum DDS, FADSA, FICD, FADI
November 2-3, 2012 Aurora Dental College • 201-372 Hollandview Trail, Aurora, ON L4G 0A5
$2950.00 Enhance your surgical capacity and skills! Gain immediate confidence by registering for this outstanding live surgery event! It will sell out! Dentists will work on their patients under the guidance of oral surgeon Dr. Lawrence Gaum!
“Attendees that complete the Oral Surgery for the GP course & the Oral Surgery Live component will receive a Fellowship Certificate from the Oral Surgery Academy for GP’s!”
Previous Oral Surgery Attendees Receive a 10% Courtesy Discount!
To register contact Palmeri Publishing at 905-489-1970 or email events@palmeripublishing.com
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.
TW-V5N6_Layout 1 7/13/2012 4:20 PM Page 30
Implantology
Considerations for Single Tooth Replacement in the Esthetic Zone Author: Dean Morton, BDS, MS, FACP is a Professor and Interim Chair in the Department of Oral Health and Rehabilitation at the University of Louisville School of Dentistry. He also serves as Assistant Dean for Multidisciplinary Implant and Esthetic Dentistry. Dr. Morton is a Diplomate of, and certified by the American Board of Prosthodontics. He is a Fellow or member of many professional organizations, including the International Team for Implantology (ITI), American College of Prosthodontists, American Academy of Fixed Prosthodontics, International College of Prosthodontists, International College of Dentists, International Association for Dental Research and the American Dental Association (ADA). He is a consultant for the ADA Commission on Dental Accreditation, and is a current or past reviewer for several scientific publications. He has previously served on the editorial boards of the Journal of Prosthetic Dentistry and International Journal of Oral and Maxillofacial Implants. Dr. Morton has authored or co-authored many scientific articles and abstracts. He was the primary author of the ITI Treatment Guide, Volume 2., Loading Protocols in Implant Dentistry, and a contributing author of the ITI Treatment Guide, Volume 1. Dr. Morton lectures extensively both nationally and internationally on implants and esthetic dentistry. He maintains a practice limited to Implant and Esthetic Dentistry and Prosthodontics wintin the University of Louisville Dental Associates, and has research interests including dental implant loading protocols, implant design and esthetic dental biomaterials.
30
TEAMWORK Vol.5-No.6 - July 2012
TW-V5N6_Layout 1 7/13/2012 4:20 PM Page 31
T
he esthetic zone may be considered objectively as any dento-alveolar segment that is visible upon a full smile, and subjectively, as any area of esthetic importance to the patient. Predictable outcomes in this region rely on comprehensive assessment and clinical management by the treatment team, with emphasis placed on contemporary options. Appropriate management of the proposed implant site can reduce the need for pre-treatment surgical intervention. Manipulation of the site with a provisional restoration subsequent to tooth extraction, but before implant placement, can improve the odds of a conservative and satisfactory result. The prosthodontic phase of therapy must consider not only the missing teeth, but also disharmonies from a spatial and occlusal perspective. Complete esthetic risk analysis should form part of a routine evaluations process, in an effort to minimize the likelihood of negative results.
Pretreatment Considerations
Several factors should be given consideration during the planning process. These include: a) The patient’s pretreatment expectations b) The patient’s smoking habits c) The height of the lip-line on smiling d) The gingival biotype in the treatment area e) The shape of the missing and surrounding teeth f) The presence of infection at the implant site and the bone level at the adjacent teeth g) The restorative status of teeth adjacent to the edentulous space
Fig. 1
Fig. 3
TEAMWORK Vol.5-No.6 - July 2012
h) The character of the edentulous space i) The width and the hard and soft tissues in the edentulous space j) The height of the hard and soft tissues in the edentulous space Further, esthetic therapy requiring the use of dental implants is considered an advanced or complex procedure and prosthodontic planning and treatment should routinely adhere to the following principles: 1. Address the patient’s concerns 2. Identify patients with elevated risk using site analysis and general patient assessment 3. Encompass comprehensive interdisciplinary treatment planning and consideration of all treatment options 4. Incorporate a treatment chronology that will maximize the benefit to the patient and minimize discomfort or inconvenience 5. Utilize augmentation of deficient soft and hard tissue regions where necessary, prior to or concurrently with implant placement 6. Incorporate a restoration-based philosophy for implant planning and placement
Fig. 2
Fig. 4
31
TW-V5N6_Layout 1 7/13/2012 4:20 PM Page 32
7. Utilize provisional restorations for tissue development, and maturation, and as a template for the definitive restoration 8. Carry out adjunctive procedures on adjacent teeth when necessary 9. Utilize a team approach
Clinical Example
A middle-aged female patient presented for treatment requesting replacement of a failing central incisor. The tooth was characterized by a failing endodontic re-treatment and foundation (Fig. 1), and a crown considered
32
esthetically unacceptable by the patient (Fig. 2). The patient was a non-smoker and considered to be philosophic with regard to her treatment expectations. A comprehensive oral examination revealed no active disease, though evidence of previous periodontal concerns was evident. She was characterized by a moderate-to-high smile line (Fig. 3), with complete maxillary tooth display on full smile. For the most part her gingival biotype was considered to be thin. The site was considered to be asymmetric with the contra-lateral central incisor (Fig. 4). In addition, the existing restoration was considered to be square in overall form, while the contra-lateral tooth was considered triangular. Although single tooth edentulous spans are predominantly considered
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10
TEAMWORK Vol.5-No.6 - July 2012
TW-V5N6_Layout 1 7/13/2012 4:21 PM Page 33
ALL ON 4 /6 FULLY REVEALED! COMING APRIL 2013! THE FIRST OF ITS KIND IN CANADA
ALL SECRETS REVEALED Learn all the ins and outs from the surgery to the temporization and prosthetic phases of
ALL ON 4 /6 A 3 Day Course with live surgery and hands-on component! Limited space available. THIS COURSE WILL SELL OUT! Call 416.294.9744 to inquire
TW-V5N6_Layout 1 7/13/2012 4:21 PM Page 34
to be favorable sites for implant restorations, asymmetric sites adjacent to the midline can present particular problems. Also considered favorable in this instance was the sound, nonrestored character of the teeth adjacent to the failing tooth. Further, the underlying bone and soft tissue dimension and health was also considered satisfactory. Several treatment options were discussed in detail with the patient, including likely compromises to outcomes for each. Ultimately, the patient decided against the pursuit of orthodontic and endodontic therapy as part of her retreatment. The decision was therefore made to extract the central incisor, and replace the tooth with an implantsupported and retained restoration.
34
Because of the thin tissue character, immediate placement of an implant was considered to unreasonably elevate risk to the achievement of an esthetic outcome. Therefore, a removable, vacuform matrix enclosed provisional restoration was fabricated (Fig. 5) and delivered at the time of extraction to encourage contoured healing of the site. The tissue response was considered satisfactory for implant placement twelve weeks subsequent to tooth removal (Figs. 6 and 7). Placement surgery was cognizant of the soft tissue character, and the need to reduce surgical trauma to the inter-proximal tissues. Detailed radiographic evaluation, utilizing radiographic templates illustrating the proposed implant position and inclination was undertaken using cone-beam computerized
Fig. 11
Fig. 12
Fig. 13
Fig. 14
Fig. 15
Fig. 16
TEAMWORK Vol.5-No.6 - July 2012
TW-V5N6_Layout 1 7/13/2012 4:22 PM Page 35
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
Sponsored by:
For more information or to register: 905.489.1970 • 866.581.8949 events@palmeripublishing.com
TW-V5N6_Layout 1 7/13/2012 4:22 PM Page 36
tomography. The site was considered to be appropriate for a f lapless placement procedure, which was performed utilizing templates developed from the diagnostic articulation and the radiographic analysis (Figs. 8 and 9). The implant was partially submerged and allowed to heal for a period of six weeks. Healing was noneventful, and adequate for the placement of an implant-supported provisional restoration (Figure 10). The provisional restoration was contoured to support the surrounding tissues and contour the Fig. 17 transition zone — from the restorative margin of the implant to the oral cavity. This process is considered to be essential to predictable esthetic outcomes. The site was evaluated after a further four weeks of healing, and was thought to be in excellent condition and prepared for definitive restoration (Figs. 11 and 12). Communication of the soft tissue contours in the planned region of restoration emergence to the dental technician also
elevates the likelihood of a satisfactory outcome. Customized impression copings can be fabricated and utilized to transfer the tissue contours to the master cast (Fig. 13). As the soft tissue character was considered to be thin, and the implant inclination conducive to a cemented restoration, a customized connection mechanism was thought to be appropriate. A titanium abutment capable of supporting a screw-retained customized coping was chosen (Fig. 14). This restorative option maintained machined alloy contact at the level of the implant margin. Utilizing a contoured metal-ceramic coping provided for tooth-colored emergence through the thin tissue supporting tissues, and a contoured restorative margin easily accessible for cement removal (Fig. 15). The definitive all-ceramic crown was fabricated using Cad-Cam technology, and was characterized by a zirconium core and feldspathic ceramic veneer (Fig. 16). Radiographic evaluation confirmed all components were adequately seated. The patient was completely satisfied with the functional and esthetic outcome (Fig. 17), and has been in follow-up for a period exceeding five years. Acknowledgements
Surgical placement of the implant was performed by Dr. James Ruskin, University of Florida, Center for Implant Dentistry. Laboratory procedures were provided by Mitchell Jim, M and M Dental Laboratory, Gainesville, Florida.
Visit us on www.TEAMWORKDENTISTRY.com
A platform for all TEAMWORK’s readers, advertisers and fans to get the latest news on their favourite dental journal
Have access to: • Archived issues of TEAMWORK journal • A sneak peak of the upcoming issues of TEAMWORK journal • Get the latest promotional subsctiption rates • Up to the minute news on PPI’s publications and many more... Thinking about promoting your business online? Advertise at TEAMWORKDENTISTRY.com
For Banner advertising, Flash advertising, Logo advertising and other advertising opportunities, please contact:
Tel: 905.489.1970 or 866.581.8949 • Email: sales@palmeripublishing.com
36
TEAMWORK Vol.5-No.6 - July 2012
TW-V5N6_Layout 1 7/13/2012 4:22 PM Page 37
TW-V5N6_Layout 1 7/13/2012 4:22 PM Page 38
Implantology
Imitating the Natural Color in an Elderly Patient Author: Luke S. Kahng, CDT is the owner of LSK121 Oral Prosthetics, a dental laboratory in Naperville, Illinois. In addition to being a board member for several dental publications, he has published more than 100 articles with major dental journals. He also lectures internationally, offering hands-on seminars to dental technicians and clinicians alike. The first and second editions of his highly successful Chairside Shade Selection Guide were launched in 2009 and 2010, with international sales worldwide. The third edition, produced in 2012, encompasses the same concept but as a ceramic shade tab. Hand-made, the shade tabs are grouped according to natural dentition as dictated by the aging process, and sold in sets of twenty as: 3.0 (Young, Cosmetic), 4.0 (Middle Years), 5.0 (Later Years), 6.0 (Molars, Premolars and Canines) and 7.0 (Surface Texture, Tissue Color and After Prep Color), for clinicians and technicians alike. He is the author of four hardback books: Anatomy from Nature, The Esthetic Guide Book, Smile Selection + CS続 Clinical Cases and the Kaleidoscope Wax-up Book.
38
TEAMWORK Vol.5-No.6 - July 2012
TW-V5N6_Layout 1 7/13/2012 4:23 PM Page 39
Introduction The patient, a 68 year old male, was in good overall health, taking no medications and having no known allergies. His chief complaint was with his upper front teeth which had been treated endodontically, then re-treated, followed by periapical surgery. He did not care for their appearance. He also suggested that he would like to repair the space in the #12 area, where the tooth had been extracted. Pre-operatively, crowns on teeth numbers 8 and 9 were unnatural and discolored in appearance, with decay on the canine (Fig. 1). In addition, the centrals were separated by a large diastema, the margins dark, and #7 was gray in color while the opposing symmetrical tooth, #10, was brown³. In the clinical setting, the dentist evaluated the patient’s oral health and discovered traumatic occlusion induced fremitus² on numbers 7, 8, 9 and 10 with Grade II – Grade II+ mobilities on all incisors. Tooth #12 was missing and #11 had a very large leaking class III amalgam that restored about 2/3 of the clinical crown. Radiographs revealed endodontic
Fig. 1
failures of 8 and 9, a silver point fill of #10 with a scar from a prior surgery above the apex. There were no significant periodontal probings. An occlusion view substantiated tooth positioning and status (Fig. 2). Multiple occlusal adjustments were made in an attempt to reduce the mobilities and fremitus of teeth numbers 7-10. A temporary bite guard was also fabricated for the patient but mobilities were not improved by these modifications. The patient was then given an endodontic evaluation and the retreatment/apical surgery prognosis was good to be guarded. After reviewing his options, the patient decided that rather than endodontically retreat and re-restore the teeth, he was interested in pursuing dental implants³.
Case Study
To begin the work, the amalgam in #11 was removed along with recurrent decay, requiring a full coverage crown. An immediate interim partial denture was fabricated by the laboratory and
Fig. 2
Fig. 1: Pre-operative view
Fig. 2: Occlusion view to indicate tooth positioning and status Fig. 3: Implant placement, post-extraction
Fig. 4: Stick bite - horizontal and vertical positioning
Fig. 3
TEAMWORK Vol.5-No.6 - July 2012
Fig. 4
39
TW-V5N6_Layout 1 7/13/2012 4:23 PM Page 40
ready for delivery upon extraction of teeth numbers 7-10. It was noted that #6 would need an elective crown to improve spacing, proportions and overall esthetics. The patient was prepped for extractions of numbers 7-10. The Periodontist removed the teeth, performed osseous grafting on 7, 8, 9 and 10 and an onlay bone graft for number 12 using the following: Puros Mineralized Cancellous Allograft, Mineross cortical and Cancellous Mineralized Allograft, Bio-Oss Mineralized Bovine Xenograft, Bioguide Collagen membrane, Gem 21S Platelet Derived Growth Factor and Collaplug. Once healing occurred, a CBCT scan was done and a stent was generated for computer guided placement of implants. Nobel Biocare/Tapered Groovy implants were used - all 3.5 diameter (Fig. 3). The incisors were 13 mm long and #12 was 11.5. Healing abutments were all 4.5 x 3. In office, the clinician took a stick bite measurement in order to verify horizontal and vertical planes (Fig. 4). Once osseointegration and tissue maturation was achieved, an
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 5: Custom made shade tabs help with checking the custom color
Fig. 6: GC Milling Center custom abutments scanned by CAD/CAM
40
impression was made of the implants and crowns for numbers 6 and 11. A closed tray technique was used with corresponding closed tray impression copings fixed to the implants. Aquasil Ultra Xtra tray and wash material were used along with the surfactant, B4. Aquasil Ultra by Dentsply was used due to its great ability to capture detail and minimize voids compared to other impression materials. In addition we find that Aquasil's tear strength is second to none! There was not a need for traditional implant tissue site development in this case because it was already established that this would be an FP-5- removable prosthesis, overdenture supported by soft tissue and implants (according to Carl Misch’s Prosthodontic Classification of implant restorations). The patient was appointed for custom shading to be performed in the laboratory setting. Using the Chairside Shade Guide Seasons of Life shade tabs, the technician found the patient to have intensive dentin color in his lower anterior teeth (Fig. 5). The patient’s shading was recorded
Fig. 7: On the original cast, great fit and retention
Fig. 8: Various porcelain colors utilized include Dentin A1 and C1, plus Enamel Translucency
TEAMWORK Vol.5-No.6 - July 2012
TW-V5N6_Layout 1 7/13/2012 4:23 PM Page 41
TW-V5N6_Layout 1 7/13/2012 4:23 PM Page 42
with a wide variation of colors noted, along with brown horizontal lines and light enamel4 mixed together on tooth #11. There was also a discrepancy in proportion and size. The technician’s responsibility was to harmonize the color and blend the teeth appropriately. Final color choices were IT15 and IT19 (IT= Intensive Color). After CAD/CAM scanning, the GC Milling Center fabricated custom implant abutments (Fig. 6). On the original cast model passive fit and retention were verified at the laboratory (Fig. 7).
Laboratory Procedures
Some of the porcelain colors to be used in the case were Dentin A1 with C1 added and multiple Enamel Translucencies (Fig. 8).
After the third bake, the technician created the final contour for the build-up and created tissue color with enamel (Fig. 9). After baking, the restoration was tried on the model (Fig. 10) for a color and texture check. The technician used mechanical design for natural form (Fig. 11). After glazing, different porcelain applications were used for the incisal edge and body 1/3 in order to imitate the patient’s lower dentition with staining techniques (Fig. 12). The 4 unit implant bridge, teeth numbers 7-10 (Fig. 13), was verified for fit check with a prep view. After immediate insertion, color integrity was checked (Fig. 14). The two single unit crowns fabricated for teeth numbers 6 (Fig. 15) and 11 (Fig. 16) were next tried in the mouth in order to compare with the lower dentition. An orange-brown tone with a light grey hue was mixed into the enamel and dentin
Fig. 9
Fig. 10
Fig. 11
Fig. 12
Fig. 13
Fig. 14
Fig. 9: Contouring for final build-up after bake
Fig. 12: After glaze
Fig. 11: Mechanical desing for natural form
Fig. 14: Color integrity check
Fig. 10: After firing, texture, color evident
42
Fig. 13: Implant placement with prep view
TEAMWORK Vol.5-No.6 - July 2012
TW-V5N6_Layout 1 7/13/2012 4:24 PM Page 43
colors and blended in order to match the mandibular area of the mouth. With the patient’s head resting back slightly, the technician was able to photograph the dentition and compare the maxillary color of the restorations to that of the natural dentition in the mandibular (Fig. 17). Natural dentition is comprised of six or seven colors, especially as we become older. Matching can be a complicated process with focused attention
on the dominant coloring. In the retracted view (Fig. 18) the texture line in the incisal 1/3 was clearly delineated 5 . Immediately after insertion, the patient’s right (Fig. 19) and left (Fig. 20) sides were photographed. Note the gum color with pink tissue extended in order to create a shorter appearance to the teeth with natural artistry in the incisal edge position. The gum lines were appropriately diminished and harmonized through this process.
Fig. 15
Fig. 16
Fig. 17
Fig. 18
Fig. 19
Fig. 20
Fig. 15: Immediate insertion checking
Fig. 18: Retracted view
Fig. 17: With patient’s head tilted back mandibular color check
Fig. 20: Left side view – pink tissue addition to diminish tooth length
Fig. 16: Canine comparisons to the lower anterior for color comparison
TEAMWORK Vol.5-No.6 - July 2012
Fig. 19: After immediate insertion, right side view
43
TW-V5N6_Layout 1 7/13/2012 4:24 PM Page 44
Fig. 21 Fig. 21: Pre-operative view
Fig. 22: Post–operative view
Fig. 22
Fig. 23: Facial view
Fig. 24: Post facial view
Before the preparation and various procedures were performed (Fig. 21) the patient had this appearance. Final modifications to contour, incisal edge position, and shade were made chairside at the laboratory. The full crowns 6 and 11 were cemented with GC FujiCem™ cement and the implant prosthesis was cemented with Bosworth’s Super EBA cement. (The abutment screw holes were filled with a PVS impression material, Aquasil). After insertion (Fig. 22), there is a vast improvement to the patient’s smile. In the full facial view (Fig. 23) before dental work completion, the patient’s smile view was very different than after his work was completed (Fig. 24). References
1. Gebhard W. Restoring esthetics and function in fixed prosthodontics. Quintessence of Dental Technology 2003; 26: 21-44. 2. Ratcliff S, Brady L. 3 mm can save your case: making beauty function. General Dentistry, November/December 2011; 432-437 http://www.agd.org/publications/ articles/?ArtID=10176 3. Torabinejad M Goodacre CJ. Endodontic or dental implant therapy the factors affecting treatment planning: The Journal of the American Dental Association July 2006; 137:7 973-977.
44
Fig. 23
Fig. 24
4. Chu S, Ahmad I, Devigus A. Fundamental of Color, Chapter 3; Chicago: Quintessence 2004. 5. Sulikowski A, Yoshida A. Surface texture: a systematic approach for accurate and effective communication, QDT 2003; 26: 17.
Acknowledgement
Case courtesy of Dr. Jack Manikowski, Chicago, IL
TEAMWORK Vol.5-No.6 - July 2012
TW-V5N6_Layout 1 7/13/2012 4:24 PM Page 45
r u o Y k r Ma ! s r a d n Cale
1st Annual
NOVEMBER 23, 2012 9:00am – 10:30am Powerprox Six Month Braces Dr. Rick DePaul
Coming to:
10:30am – 11:00am Break
Hilton Suite s Ho (Toronto/M tel & Spa arkham) 8500 Ward Markham, en Ave, ON L6G 1A 5
11:00am – 12:30pm Distalization Techniques Dr. Bruce McFarlane 12:30pm – 1:30pm
Lunch
1:30pm – 3:00pm Minor Tooth Movement: A Streamlined Solution for the Social Six Dr. Neil Warshawsy
Admission (Lunch & Br
$159.00
eaks Includ
ed)
For additional information and to register please call or email:
PPI Events @ 905.489.1970
•
events@palmeripublishing.com
www.orthotechniques.net Aesthetic Design & Implant Academy is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 01/01/2007 to 12/31/2014.
TW-V5N6_Layout 1 7/13/2012 4:25 PM Page 46
Sleep Apnea
Dentists are Trained to Save Teeth Sleep Dentistry Saves Lives Author: Brock Rondeau, DDS is a Diplomate of the International Board of Orthodontics, Diplomate American Board of Craniofacial Pain, Diplomate-Academy of Clinical Sleep Disorders Disciplines, Master Senior Certified Instructor for the International Association for Orthodontics and was awarded the IAO's highest honor - the Leon Pinker Award and Duane Stanford Award. He has published over 30 articles and numerous videos on orthodontics and is also a contributing editor for the Journal of Clinical Pediatric Dentistry and the Journal of General Orthodontics. Dr. Rondeau is one of North America's most sought after clinicians whose practice is limited to the treatment of patients with orthodontic, orthopedic, TMJ and snoring and sleep apnea problems for the past 30 years. His expertise in teaching, combined with his insatiable thirst for knowledge in the orthodontic arena has pushed Dr. Rondeau to the very top of the orthodontic/orthopedic lecture circuit. He is without a doubt perhaps the most prolific speaker on the topic of functional orthodontic treatment.
46
TEAMWORK Vol.5-No.6 - July 2012
TW-V5N6_Layout 1 7/13/2012 4:25 PM Page 47
I
t has been estimated that approximately 90 million people in North America suffer from insomnia, snoring or sleep apnea. Dentists see these patients on a regular basis in their practices and therefore have an opportunity to diagnose and treat these patients with oral appliances when that is determined to be the treatment of choice. In the January 2006 issue of the medical journal, Sleep, the American Academy of Sleep Medicine (medical sleep specialists) issued guidelines stating that for patients with mild to moderate OSA (Obstructive Sleep Apnea), the oral appliance was the number one treatment option. These guidelines also mentioned that the oral appliance was a viable option for patients who do not respond to weight loss or have tried the CPAP device and were unable to tolerate it. For this serious sleep disorder, there are basically three treatment options: 1. Oral appliances 2. CPAP (Continuous Positive Air Pressure) 3. Surgical intervention The majority of patients who come to my office are either encouraged to seek a solution for their snoring problem or because they were diagnosed with sleep apnea (OSA) and were unable to wear the CPAP device. The statistics on the success of the CPAP device vary greatly according to what articles you read, but the consensus is that approximately 60 – 70% of patients are not wearing it after one year. This means there is a tremendous opportunity for dentists to try and relieve the snoring and OSA with oral appliances. The diagnosis for OSA is made using an AHI (Apnea – Hypopnea Index). This is made during an overnight sleep study in a hospital or private sleep clinic. The sleep study is
known as a PSG (polysomnogram). The number of apneic and hypopnic events are recorded as follows: It is important to distinguish between mild, moderate and severe OSA. Patients that are diagnosed with severe OSA should be encouraged by the dentist and sleep specialist to wear the CPAP device since this is considered to be the gold standard for the treatment of severe OSA. The CPAP device delivers oxygen to the patient through a mask which fits over the nose, or over the nose and mouth, via an air compressor and a humidifier. The CPAP device is effective in opening the airway as the air pressure is gradually increased during the follow-up sleep study (PSG). The air pressure successfully displaces the tongue, uvula and soft palate and allows an adequate amount of oxygen to enter the lungs. When the patient wears the CPAP and the air pressure is correct, it is extremely effective in eliminating OSA. Patients that are happy with their CPAP devices should not be encouraged to replace them with oral appliance therapy. Oral appliances are mainly to be used for patients who cannot tolerate the CPAP device or who have mild to moderate OSA. Patients will sometimes ask you about oral appliances that they see advertised on the internet. Most of these appliances are a “boil and bite” type and put the jaw in only one position. They cannot be adjusted and are often ineffective. The other important fact is that one device that is advertised, called “Pure Sleep”, clearly states that it is not designed to treat patients with TM dysfunction or sleep apnea. The company is correct. No one can legally treat sleep apnea unless a diagnosis has been made by a medical professional, usually a sleep specialist. Therefore, the majority of patients do not qualify for these internet devices.
SLEEP APNEA — Tongue Completely Blocks Airway APNEA: A cessation of breath for 10 seconds or more HYPOPNEA: The blood oxygen level decreases 4% or more Cessation of breath for less than 10 seconds MILD SLEEP APNEA (OSA): 5 – 15 events per hour MODERATE SLEEP APNEA (OSA): 16 – 30 events per hour SEVERE SLEEP APNEA (OSA): More than 30 events per hour
TEAMWORK Vol.5-No.6 - July 2012
47
TW-V5N6_Layout 1 7/13/2012 4:25 PM Page 48
After my patients are properly educated, they are not interested in any appliance that will not solve their serious health issue, which is obstructive sleep apnea. My patients who have tried these appliances tell me that they are not nearly as comfortable as the custom oral appliances fabricated for them at our office. The diagnosis of OSA can only be made by medical practitioners such as sleep specialists or E.N.T. specialists. Dentists have one of the solutions for treating this medical disorder but must learn to work with their medical colleagues to make the system work for the benefit of the patients. OSA is an extremely prevalent disorder with some serious health consequences. Some facts that health care professionals need to be aware of include the following:
Fig. 1
Co-Morbidity Correlations with Obstructive Sleep Apnea • • • • • • • •
Hypertension Coronary heart disease Congestive heart failure Diabetes Erectile dysfunction Renal disease Fibromyalgia Nocturnal strokes
There is also a high correlation between patients who have GERD (gastroesophageal reflux)1 and OSA. With regard to diabetes, excessive apneic events affect the production of insulin which encourages the onset of type 2
Fig. 2
Fig. 3
Fig. 4 Fig. 1: Rhinometer
Fig. 2: Pre-Treatment Enlarged Turbinates AHI 76 Severe OSA
Fig. 3: Ressection Inferior Turbinates AHI 32 50% Improvement AHI
48
40 – 50% 34% 34% 65% 50% 50% 80% 84%
Fig. 5 Fig. 4: Enlarged Tonsils Grade 4 Fig. 5: Large UVULA
TEAMWORK Vol.5-No.6 - July 2012
TW-V5N6_Layout 1 7/13/2012 4:26 PM Page 49
TW-V5N6_Layout 1 7/13/2012 4:26 PM Page 50
diabetes2. These apneic events also affect the permeability of the endothelial lining of the arteries. This increases the buildup of plaque in the arteries and the chance of cardiovascular complications, such as a heart attack. The weakening of the walls of the arteries increases the susceptibility of rupturing of these vessels which occurs during strokes3,4. Obstructive sleep apnea is an extremely dangerous health risk. Six out of ten patients over age 40 snore and two out of six have OSA. The other rather alarming fact is that 85% of patients with OSA have been undiagnosed5. This means that massive numbers of patients have the problem but are totally unaware of the dangers they are facing in the future if they are not diagnosed and do not receive proper treatment. Studies have indicated that a patient with severe OSA, left untreated, will die 8 – 10 years earlier than a patient without OSA. The fact is that patients with severe sleep apnea are definitely at risk to die prematurely and spend many years in poor health with cardiovascular disease, GERD, type 2 diabetes and possibly strokes. To assist practitioners in the diagnosis of OSA, we need to focus on airway obstruction in three areas: nasal, oropharyngeal and hypopharyngeal.
1. Nasal Obstruction
Prior to treatment, clinicians must determine whether or not there are any nasal obstructions which would interfere with the patient’s ability to breathe through their nose. If the patient is a chronic mouth breather, the patient should be referred to an
Fig. 6: Enlarged Tongue
50
Fig. 7: Rhinometerr
E.N.T. specialist to check for a deviated septum, enlarged turbinates, polyps or other nasal obstructions. A determination must be made whether or not the nasal mucosa is swollen due to allergies which might cause a nasal obstruction6. In our office, we have a diagnostic device known as a rhinometer which is an initial screening device to determine if there is a nasal obstruction in either nostril. The rhinometer is an accurate, non-invasive device which evaluates the potential obstruction by sending sound waves up the nose and any obstructions are recorded on a computer. This evaluation of the nasal cavity is also important if the sleep specialist decides to use the CPAP device to force air through the nose. Obviously, if there is a nasal obstruction, the pressure would have to be much higher on the CPAP device. The acceptance of the CPAP treatment is better when the pressure is lower. Therefore, an evaluation of a patient’s airway is an important prerequisite to a successful oral appliance or CPAP therapy7.
2. Oropharyngeal Obstructions
Prior to the fabrication of the oral appliance or CPAP therapy, an evaluation must be done of the oral cavity to check for obstructions. The areas of concern would be enlarged tonsils or adenoids, large tongue, enlarged uvula, large mandibular tori, excess tissue in the area of the soft palate. Patients with narrow maxillary arches and high palates could also be more susceptible to snoring and OSA. Oropharyngeal obstructions must be surgically corrected prior to oral appliance or CPAP therapy.
Fig. 8: Pharyngometer
TEAMWORK Vol.5-No.6 - July 2012
TW-V5N6_Layout 1 7/13/2012 4:26 PM Page 51
SomnoDent
®
The comfortable, effective, custom treatment for Obstructive Sleep Apnea.
Features and Benefits • • • • • • • •
Permits normal mouth opening Allows speech & drinking Unrestricted tongue space Full lip-seal Easily adjustable Safe & effective Clinically validated Custom-fit
Orthodent Ltd. 311 Viola St. Oshawa, ON L1H 3A7 tel: (905) 436-3133 toll free: (800) 267-8463 fax: (905) 723-2331 info@orthodent.ca www.orthodent.ca
TW-V5N6_Layout 1 7/13/2012 4:26 PM Page 52
3. Hypopharyngeal Obstructions Oral appliances are most effective when there are no nasal or oropharyngeal obstructions and the problem is behind the tongue in the area of the throat. Class II skeletal patients with retrognathic mandibles are the patients that are more likely to have hypopharyngeal obstructions. Their lower jaws are already retruded which subsequently cause their tongues to be retruded. This is particularly serious when the patient sleeps on their back. The tongue falls back further and blocks the airway. If the tongue partially blocks the airway, the patient snores. If it completely blocks the airway for 10 seconds or more, for more than six times an hour, the patient is diagnosed with OSA. The main function of the oral appliance is to move the lower jaw forward, increase the posterior vertical dimension and, subsequently, move the tongue forward and open up the pharyngeal airway. The pharyngometer is a diagnostic device which is utilized in our office to diagnose the size of the airway during the daytime as well as nighttime. It is utilized at the initial appointment to check the patient’s normal airway (daytime) and the collapsed airway (nighttime). To assess the size of the collapsed airway at night, the patient is instructed to exhale all the air from their lungs and a measurement of the airway is taken. The normal size of a collapsed airway is 2.0 cm8. Patients with OSA always
Fig. 9
have a much smaller collapsed airway. Bite registrations in different positions are taken to try and see how large the airway may be increased. Our office uses a system called Airway Metrics which gives a number of plastic bite gigs to help measure the size of the airway in different positions. Various bite registrations are taken including some which may be end to end and open 6 mm, 1 mm protrusive and open 4 mm, end to end and open 4 mm, etc. By moving the mandible forward at different vertical heights, we determine if the oral appliance will open the airway in that position significantly. In most cases, when a bite registration reveals that the airway opens significantly when the oral appliance is fabricated in that position, the treatment is usually successful.
Pharyngometer
The results using different bite registrations are not always successful if the patient has a physiologically narrow airway or has excessive swelling in the area of the uvula and soft palate due to excessive snoring or smoking. The pharyngometer helps to give the clinician a starting position to fabricate the oral appliance. It is important to select a position that is comfortable for the patient. It is advisable then to use an oral appliance such as a Somnodent, EMA, Modified Herbst or TAP Appliance that can be adjusted to move the mandible slowly forward to reduce the snoring and OSA9.
Fig. 10
Figs. 9 and 10: Embletta 100 Home Sleep Study
52
TEAMWORK Vol.5-No.6 - July 2012
TW-V5N6_Layout 1 7/13/2012 4:27 PM Page 53
As mentioned previously, airway obstructions in the nasal and oropharyngeal (mouth) areas must be eliminated prior to the fabrication of the oral appliance. When oral appliances are utilized in these cases, they are highly effective. Our success rate with oral appliance therapy is over 90%. I routinely evaluate my patients’ nasal airways (rhinometer), oropharyngeal and hypopharyngeal airways (pharyngometer) prior to treatment. If you cannot properly diagnose the problem, your treatment will be less successful. Patients much prefer to wear an oral appliance rather than the CPAP device. However, for severe OSA, the CPAP is the treatment of choice. If a patient is unable to wear the CPAP and they have severe OSA, or if they have mild to moderate OSA, the oral appliance is the treatment of choice. I recently spoke with a sleep specialist in Nevada who estimated that 18 to 30% of the population is suffering from mild, moderate or severe OSA. Whether you live in the U.S. with a population of 350 million or in Canada with a population of 38 million, this means there are a large number of patients who are suffering from these sleep disorders who desperately need treatment. If you start helping these patients achieve a higher level of health and extend their lifespan, you will feel better about your practice and yourself. We are presently treating approximately 10 – 15 patients per month at $3,000 per case. Obviously, this can positively affect your income while you are helping patients become healthier. In Canada, most insurance companies will pay for the CPAP device but will not pay for oral appliances. In the U.S., many medical plans will pay for both CPAP and oral appliances. I strongly believe that it is the responsibility of the medical and dental profession to identify patients who have airway obstructions leading to snoring and sleep apnea. The two main signs of obstructive sleep apnea (OSA) are snoring and excessive daytime sleepiness. To assist dentists in determining the level of sleepiness, Dr. Murray Johns, Epworth Hospital in Melbourne, Australia, introduced the Epworth Sleepiness Scale in 1991. I have enclosed a copy for your information. I recommend that any patient who snores should complete this questionnaire. It is also advisable to have the bed partner complete the form as well. Our experience has been that many patients, particularly males, underestimate the extent of their daytime sleepiness and the report from the bed partner is usually more accurate. The Epworth Sleepiness Scale is extremely helpful in determining the extent of the daytime sleepiness which is one of
TEAMWORK Vol.5-No.6 - July 2012
the main symptoms of obstructive sleep apnea (OSA). This scale determines how likely the patient is to fall asleep in certain situations. A zero means they would never doze off, one means a slight chance of dozing, two means a moderate chance of dozing, and three means a high chance of dozing in various situations. The number of patients with daytime sleepiness, especially those over age 50, will be astounding. I had one dentist in my sleep course, involved in a group practice, go back to his office and give the Epworth Sleepiness Scale to all patients who snored. Remember, snoring is one of the main symptoms of obstructive sleep apnea. Within three weeks, he had 50 patients who scored high on the Epworth Sleepiness Scale and who were therefore candidates for oral appliances or the CPAP device. It is important to educate the staff including receptionists, dental assistants and hygienists regarding the diagnosis and treatment of these patients. I find the hygienists are particularly important in conveying the information to patients and asking them to complete the Epworth Sleepiness Scale. For any patient that has an Epworth Sleepiness Scale higher than 8, it is recommended to seek medical attention in terms of a sleep study in order to diagnose the presence or absence of OSA10. Patients who snore but do not have OSA may be treated by the dentist with an oral appliance. Prior to the fabrication of the oral appliance, the dentist must receive a report from a sleep specialist, stating that the patient does not have sleep apnea. When the patient only snores and does not have sleep apnea, no follow-up sleep study is necessary. If the patient is diagnosed with mild to moderate OSA and the sleep specialist and patient agree, the dentist can then fabricate an oral appliance.
Fig.11
53
TW-V5N6_Layout 1 7/13/2012 4:27 PM Page 54
EPWORTH SLEEPINESS SCALE The Epworth Sleepiness Scale (ESS) was developed and validated by Dr. Murray Johns of Melbourne, Australia. It is a simple, self-administered questionnaire and widely used by sleep professionals in quantifying the level of daytime sleepiness. (Johns, M.W. “A new method for measuring daytime sleepiness: The Epworth Sleepiness Scale.” Sleep 14 (1991): 540-545.)
NAME __________________________________________________ DATE __________________________________________ How likely are you to doze off or fall asleep in the following situations, in contrast to feeling ‘just tired’? This refers to your usual way of life at present and in the recent past. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation: 0 = Would never doze 1 = Slight chance of dozing
2 = Moderate chance of dozing 3 = High chance of dozing
SITUATION
CHANCE OF DOZING
Sitting and reading Watching television Sitting, inactive in a public place (e.g. theatre, meeting) As a passenger in a car for an hour without a break Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone Sitting quietly after lunch without alcohol In a car, while stopped for a few minutes in traffic
___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________
TOTAL SCORE 0-7: 8-9: 10-15: 16-24:
It is unlikely that you are abnormally sleepy You have an average amount of daytime sleepiness You may be excessively sleepy, depending on the situation, and may want to consider seeking medical attention You are excessively sleepy and should consider seeking medical attention
After the oral appliance has been adjusted over several months, the patient must have a follow-up sleep study (PSG) to confirm the efficacy of the appliance. It is imperative that the dentist establish a good working relationship with a sleep specialist in the sleep lab if they want to be successful in the field of sleep dentistry. I advise all dentists who are interested in expanding their practice to educate themselves and their staff as a first essential step. They must contact a sleep specialist to diagnose these patients with a sleep study prior to treatment and then afterwards to confirm the efficacy of the oral appliance. Most sleep specialists will welcome the opportunity to work with competent dentists. Once a good relationship has been established, this will result in referrals for patients with mild sleep apnea and who cannot tolerate their CPAP device. Another excellent diagnostic device that I have found to be
54
very useful in my sleep practice is the Embletta 100, a home sleep study. Patients much prefer this home sleep study compared to the hospital sleep study (polysomnogram). The Embletta 100 cannot be used to diagnose OSA, but it is useful during the titration or adjustment period for the oral appliance. Most oral appliances are not 100% effective when they are first inserted. The uvula and soft palate tissues can be quite swollen due to snoring and/or smoking. As the swelling subsides, the appliance is slowly adjusted to move the mandible and tongue further forward, sometimes taking 2 – 4 months. During the titration period, it is often advisable to test the efficacy of the oral appliance with the home sleep study (Embletta 100). The advantages of this device are that it is extremely comfortable, accurate and the patient feels that they get a more normal sleep since they are sleeping in their own bed. The cost is reasonable as the value of the disposables for
TEAMWORK Vol.5-No.6 - July 2012
TW-V5N6_Layout 1 7/13/2012 4:27 PM Page 55
this home sleep study is only five dollars. Therefore, patients can be given several economical and convenient sleep studies to ensure that the oral appliance is effective in eliminating the snoring and OSA. The Embletta 100 home sleep study device is more acceptable to the medical profession and sleep specialists because it has a nasal cannula, pulse oximeter and chest and abdominal straps. Some sleep specialists in the sleep centers have utilized the Embletta 100 for patients who are unsuccessful with the polysomnogram (PSG). Some patients do not like the polysomnogram due to the odor of the electrodes, suffer from claustrophobia or who cannot sleep in a strange bed with 16 electrodes attached to their body. Most patients feel that they get a more accurate sleep study when they sleep in their own bed with the Embletta 100 home sleep study device. In Europe, most of the studies are home sleep studies due to the significant cost savings as compared to the cost in private or hospital sleep clinics. It is extremely important that you successfully titrate (adjust) the oral appliance with the Embletta 100 home sleep study device prior to sending the patient for a PSG to a private or hospital sleep clinic. This will prove to the sleep specialists and the E.N.T. specialists that oral appliances are effective in reducing snoring and obstructive sleep apnea. The Embletta 100 will help you to achieve these objectives. This will result in you having more patients referred to you by the sleep specialists and E.N.T.s for treatment with oral appliances. The Embletta 100 is the home sleep study that is reputed to be number one in Europe for the past eight years. It has been well researched and the results correlate very accurately with the polysomnogram at the sleep clinics.
TEAMWORK Vol.5-No.6 - July 2012
The patient is instructed to return to the sleep center for a follow-up PSG, with the oral appliance, to confirm that the appliance is effective. Insurance companies and patients much prefer this approach. You cannot expect insurance companies to pay for three or four sleep studies. The sleep specialists are usually impressed with the results and will, therefore, be encouraged to refer more patients to your office who cannot wear the CPAP or have mild to moderate OSA and request an oral appliance. Be advised that it is critical for the successful treatment of our patients to work closely with the medical profession. Reports must be sent to the patient’s primary care physician to keep them informed of their treatment. Dentists should also inform the sleep specialists that patients with severe OSA must be referred for treatment with the CPAP or BiPAP devices. Patients that are diagnosed with severe OSA should be encouraged to wear the CPAP device since this is the gold standard for the treatment of severe OSA. The CPAP consists of a mask which the patient wears over the nose. This mask is attached to a hose connected to an air compressor and humidifier. The CPAP is extremely effective in opening the airway as the air pressure is increased gradually during the polysomnogram (sleep study) until it successfully displaces the tongue, uvula and soft palate and allows an adequate amount of oxygen to enter the lungs. When the patient wears the CPAP and the air pressure is correct, it is extremely effective in eliminating sleep apnea. Once the patient is diagnosed by the sleep specialist at the sleep clinic, the patient usually returns for a second sleep study when the technician determines what air pressure will be necessary to eliminate the OSA. The more serious the problem
55
TW-V5N6_Layout 1 7/13/2012 4:27 PM Page 56
and, in some cases, the more obese the patient, the pressure must be increased substantially to obtain the desired result. The lower the air pressure usually results in better compliance. The exception to this would be patients with severe sleep apnea who seem to benefit the most from the CPAP. These patients feel so exhausted prior to wearing the CPAP and feel so refreshed afterwards that their compliance rate is high. My observation has been that patients with mild to moderate OSA are not as compliant. This is where, I believe, the dental profession needs to become involved. If the patient is mild to moderate and there is no necessity for surgery, then the oral appliance fabricated by the dentist is the best option. The fact is that a larger number of patients who are prescribed CPAP devices, cannot tolerate them11. Recently in the U.S, Medicare has started to pay for patients with obstructive sleep apnea. Medicare is willing to pay for a CPAP device but they want confirmation on compliance. They do not want to pay for the device if it is not being utilized on a regular basis by the patient. The newer devices can be integrated with the telephone line and the data is analyzed by a third party to verify compliance. If there is no compliance, Medicare will not pay for the device. References
1. Somers VK, White DP, Amin R, Abraham WT, Costa F, Culebras A, Daniels S, Floras JS, Hunt CE, Olson LJ, Pickering TG, Russell R, Woo M, Young T. Sleep apnea and cardiovascular disease: an American Heart Association/American College of Cardiology Foundation scientific statement from the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council and Council on Cardiovascular Nursing Council. J Am Coll Cardiol 2008:52:686-717. 2. Babu AR, Herdegen J. Fogelfeld L, et al., “Type 2 diabetes, glycemic control and continuous positive airway pressure in obstructive sleep apnea”, Arch Intern Med, 165, 447-452, 2005
Since 1850, the History of Disinfection has been one of
3. Jean-Louis, G, Zizi, F. Clark LT, Brown, CD, McFarlane, SI, “Obstructive Sleep Apnea and Cardiovascular Disease: Role of the Metabolic Syndrome and Its Components”, J. Clin Sleep Med 2008: 4(3):261-272. 4. Lee SA, Amis TC, Byth K, Larcos G, Kairaitis K, Robinson TD, Wheatley JR, “Heavy snoring as a cause of carotid artery atherosclerosis”, SLEEP 2008:31(9):1207-1213. 5. Young T, Evans I, Finn I, Palta M, Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women, SLEEP 1997: 20:705-6. 6. Hilberg O, Jackson A, Switf D, Pedersen O. Acoustic rhinometry: evaluation of nasal cavity geometry by acoustic reflection. Journal of applied physiology 1989;66(1):295-303. 7. Young t, Finn L, Kim H. Nasal obstruction as a risk factor for sleep disordered breathing. Journal of Allergy and Clinical Immunology 1997;99(2):S757-S62. 8. Austin C, Foreman J,. Acoustic rhinometry compared with posterior rhinomanometry in the measurement of histamine-and bradykinin-induced changes in nasal airway patency. British Journal of Clinical Pharmacology 1994;37(1):33. 9. Cistulli PA, Gotsopoulos H, Marklund M, Lowe AA. Treatment of snoring and obstructive sleep apnea with mandibular repositioning appliances. Sleep Mediceine Reviews 2004;8(6):443. 10. Kushida CA, Morgenthaler TI, Littner MR, Alessi CA, Bailey D, Coleman Jr J, et al. Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances: an update for 2005. Sleep 2006;29(2):240. 11. Engleman, et al: Compliance with CPAP therapy in patients with sleep apnhea/hypopnea syndrome, Respiratory Medicine Unit, City Hosp, Edinburgh EH10 5SB. 12. Kushida CA, Morgenthaler TI, Littner MR, Alessi CA, Bailey D, Coleman Jr J, et al. Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances: an update for 2005. Sleep 2006;29(2):240. 13. Young, T., et al. The occurrence of sleep-disordered breathing among middleaged adults. New England Journal Med, 1993, 328(17):1230-1235.
NOW, with Green Team from Micrylium, disinfection is
Poisons Rust
Feels Nicer, Smells Fresher, Works faster in One Step
& Two Steps 1-800-489-8868 www.micr ylium.com
56
TEAMWORK Vol.5-No.6 - July 2012
TW-V5N6_Layout 1 7/13/2012 4:28 PM Page 57
In Myy Practice
TW-V5N6_Layout 1 7/13/2012 4:28 PM Page 58
Don’t Worry, Be Happy
Mike Racich, DMD, Dipl ABOP, Dipl ICOI, FAGD Even with the day to day challenges of dental practice, as long as a dental team follows a consistent routine and devote treatment methodology then harmonious practice environments will prevail. The dental team has followed evidence-based dental guidelines and has secured the patient’s informed consent. The dental team has actually worked as “a team” throughout care and each step of the way has been approved by the patient before proceeding. The dental team has also made doubly sure that important clinical information has been accurately communicated to all individuals involved in the treatment process (laboratories, specialists, etc). The dental team has met or exceeded their patient’s expectations and has effectively communicated ownership responsibilities and duties (diet, hygiene, parafunction). The dental team has set realistic timeframes for warranty based on transparently discussed prognosis outcomes. All parties involved, therefore, can rest assured that all commitments will be honoured. Thus, don’t worry, be happy! Prognosis is defined by Stedman’s Medical Dictionary as: “an opinion or judgment, given in advance of treatment, of the prospects for success in the construction and usefulness of a denture or restoration.”1 We must be candid with our patients at the outset of care, throughout care, and for the inevitable follow-up that will ensue. We also have to level with our patients about our abilities and whether or not the course of treatment we are embarking on is within our skill set, i.e. our patients will not be used as guinea pigs. Then we can confidently profess an opinion as to
what we believe to be the longterm chances for minimal complications and inconveniences. Being honest and forthright pays dividends. We remain happy in our profession and we don’t come to work worrying about who might call our office and what about. Prognosis for an oral rehabilitation, for example, the dental team should easily be able to confess a minimum of 5 years and reasonably confide 10 years. Where do I get these numbers? The 5 years is the period of limitations as set by the insurance industry in North America and it is the lowest “remake” starting date. The
“The miracle is not that we do this work, but that we are happy to do it.” — Mother Teresa
Fig. 1
Figs. 1 to 3: 15 year post-op
58
Fig. 2
10 years comes from published reports on single crowns, fixed partial dentures, etc and my own practice experience after 30 years.2-10 Everything I do should last at least 5 years with minor, if any, problems and having that in mind I want to do treatment that I think will last at least 10 years with little or no problems (Figures 1-3). Obviously, I want my restorative and prosthodontic projects to last longer but these are rough guesstimates. Don’t we wish our automotive friends would think like this! We can have successful, happy, worry free practices by treating people just like we like to be treated. We exercise all the skill, care and judgment that we would use if we were treating ourselves. We do treatments that are going to last, at least in our minds and from our experience, the longest and be the least invasive to give the result that we desire and our comfortable with. No exceptions
Fig. 3
TEAMWORK Vol.5-No.6 - July 2012
TW-V5N6_Layout 1 7/13/2012 4:28 PM Page 59
to this rule, right?11 The best part of all is that we don’t have to go looking for work or spend our time inventing it, it finds us from all our trusting, satisfied clientele. It’s a long hard climb but once the train gets rolling it’s almost like perpetual motion. One great patient after another appears in your office. Treatment planning becomes a pleasure as we work with our patient and other health care professionals to optimize oral health … and then we get to practice our craft. What could be more fun then that? We also get to make a decent living and enjoy our lives to the fullest. Following a consistent routine and devote treatment methodology in our day to day practice of dentistry contributes to our welling being as a health care providers and assists us in practicing happy and worry free. I hope you have enjoyed reading my brief thoughts on this topic as much as I have enjoyed sharing them with you. I look forward to spending time with you again soon. And please, always feel free to contact us at your convenience. References
1. Stedman’s Medical Dictionary. 28th ed. Baltimore: Lippincott Williams & Wilkins; 2005. 2. Burke FJ. Dentists' influence on restoration longevity. Dent Update 2006;33:69. 3. Burke FJ. Patient factors influencing restoration longevity. Dent Update 2006;33:133. 4. Carlsson GE. Facts and fallacies: an evidence base for complete dentures. Dent Update 2006;33:134-42. 5. Donovan TE. Longevity of the tooth/restoration complex: a review. J Calif Dent Assoc 2006;34:122-8. 6. Janus CE, Unger JW, Best AM. Survival analysis of complete veneer crowns vs. multisurface restorations: a dental school patient population. J Dent Educ 2006;70:1098-104. 7. Larson TD. Part two: The restoration of non-vital teeth: structural, biological, and micromechanical issues in maintaining tooth longevity. Northwest Dent 2006;85:23-32. 8. Thomas MV, Beagle JR. Evidence-based decision-making: implants versus natural teeth. Dent Clin North Am 2006;50:451-61. 9. Miyamoto T, Morgano SM, Kumagai T, Jones JA, Nunn ME. Treatment history of teeth in relation to the longevity of the teeth and their restorations: outcomes of teeth treated and maintained for 15 years. J Prosthet Dent 2007;97:150-6. 10. Opdam NJ, Bronkhorst EM, Roeters JM, Loomans BA. A retrospective clinical study on longevity of posterior composite and amalgam restorations. Dent Mater 2007;23:2-8. 11. Racich MJ. The basic rules of oral rehabilitation. Markham: Palmeri Publishing; 2010.
Author: Dr. Racich, a 1982 graduate from University of British Columbia, has a general dental practice emphasizing comprehensive restorative dentistry, prosthodontics and TMD/orofacial pain. Dr. Racich is a member of many professional organizations and has lectured nationally and internationally on subjects relating to patient comfort, function and appearance. He is a Fellow of the Academy of General Dentistry and the American College of Dentists as well as a Diplomate of the American Board of Orofacial Pain and the International Congress of Oral Implantologists. Dr. Racich has published in peer-reviewed scientific journals such as the Journal of Prosthetic Dentistry and the Canadian Dental Journal and has authored the books: The Basic Rules of Oral Rehabilitation and The Basic Rules of Occlusion. Currently he mentors the didactic/clinical FOCUS Dental Education Continuum (study clubs, proprietary programs, coaching, 2nd opinions only). www.DrRacich.ca; mike@DrRacich.ca
TEAMWORK Vol.5-No.6 - July 2012
Dr. Michael Racich The Basic Rules of Oral Rehabilitation
$59.0
0
+ S&
H
Softcover: 144 pages Dimensions: 6” x 9” Publication Date: 2010
The Basic Rules of Oral Rehabilitation will create and simplify for the reader a practical approach for the diagnostic, treatment, and maintenance phases of patient care by providing 33 Basic Rules which are memorable, sequential, and gratifying. Appropriate references are included with each Basic Rule for further study by the reader. The Basic Rules are divided into 4 major sections: The Patients, The Plan, The Process, The Payoff.
The Basic Rules of Occlusion
$59.0
0
+ S&
H
Softcover: 100 pages Dimensions: 6” x 9” Publication Date: 2012
The Basic Rules of Occlusion outlines an evidenced-based practical approach to the understanding and implementation of occlusal therapy in everyday practice. An intimate understanding of these Basic Rules will enhance all aspects of the practitioners practice for the benefit of all the stakeholders, the dental team and patients.
Two Books - One Outstanding Price!
$99.00
+ S&H
Mail orders to: Palmeri Publishing Inc., 35-145 Royal Crest Court, Markham, ON L3R 9Z4 Canada Phone Orders: 905.489.1970 Fax Orders: 905.489.1971 Order Online at www.spectrumdialogue.com
59
Dental Economyy
TW-V5N6_Layout 1 7/13/2012 4:28 PM Page 60
Practice Matters – Part 2 Nadean Burkett
We continue with our “Practice Matters – Part 1”, published in Spectrum Dialogue Vol.11 No.6. Dentists have complained that they feel that dental school did not prepare them for the challenges of private practice; in particular the management of people that they work with (partners, associates, Principals, and employees) and those that they work for (patients). This is the single most common concern of owners who find themselves struggling to meet the demands and expectations of others in their lives. We’ve talked about protecting interests in working relationships by communicating effectively: having written agreements signed by both parties when dealing with contractors and partners, using informed consent when dealing with patients, and clearly documenting expectations and policies when managing employees. Tracking performance matters. To know how effectively your team is meeting the needs of your patients is as important to monitor as production stats and AR history – in fact, I will risk being a little controversial when I say that it is actually more important in the long term. Why? Simply because how effectively patients needs and expectations are managed will ultimately determine the quality of our relationships with them. And the quality of our relationships with patients will determine the sustainability and growth through loyalty and referrals. When policies are established for who, how and when team members communicate with patients, consider your patient profile – if your patients are technically savvy the most effective way to communicate with them to confirm appointments for example, would probably be through e mail. Some may argue that text messages are more direct, however, it is more difficult to track and organize using texts. Discussing financial arrangements is normally more effective in person. Technology can be an effective tool in many aspects of practice – we use
them in our business every day – but we should be less concerned with the ease of the task and more concerned with enhancing relationships with the patient. How often do you track patient recall activity? An annual review with comparison to the previous 12month period is effective in catching patients who may have missed their regular recall appointment. Since recall activity is considered the life-blood of general practice, it is vitally important to maintain an accurate and current active recall patient list. Another area which is often challenging for administrative personnel is collection of fees/ billings which results in poor AR performance. Many receptionists and patient coordinators tell us that asking for money from patients, particularly after a difficult or lengthy procedure, is the worst part of their job. When you feel uncomfortable about something, your patient will also be uncomfortable. Regardless of when you collect from the patient, how you do it can mean the difference between a satisfied patient or an unhappy one. Use a respectful, professional approach. Talk about that “elephant” in the room – acknowledge that discussion of money makes most patients uncomfortable, but that it is a necessary part of the process. A straight-forward approach can diffuse the discomfort for you and your patient and make future financial discussions less “painful”. Be proactive. Broach the subject at the time that you are explaining the preauthorization and/or response from the patient’s benefit provider. Some strategies that can be effective include pre-arranging payment with the patient prior to the appointment day or time, pre-approved credit card payment, or third-party financing. Next time, we will discuss some strategies to deal with “difficult” people. Your feedback is always welcome. Contact Nadean via e mail practicefairy@gmail.com or visit our website www.empoweredbynba.com. Follow us on Twitter; like us on Facebook.
Author: Nadean Burkett is a career and business transition coach with more than 30 years experience in the dental profession – now assisting accountants and other professionals in private practice by referral. Trusted practice evaluator, business planner and respected coach and advisor for the past 7 years - Nadean facilitates The EMPOWERMENT Program series, Career & Practice Management for Dentists both online and from NBAI’s head office situated in beautiful Vancouver, BC. Visit www.empoweredbynba.com email burkett@empoweredbynba.com for listings, job postings, & more resources with your practice transition coach.
60
TEAMWORK Vol.5-No.6 - July 2012
TW-V5N6_Layout 1 7/13/2012 4:29 PM Page 61
Dental Marketingg
TW-V5N6_Layout 1 7/13/2012 4:29 PM Page 62
‘This Manual Won’t Work Here’ – And Other Dental Tales Bryce Gibney
Everything that is done in any dental practice is subject to repetition - so why do so few have functioning Systems Manuals? I don’t mean a ‘book’ somewhere that had some important phone numbers or contacts – I mean an honest to goodness detailed ‘How To’ manual for each team position. In most practices today, the majority of the training (including software training) is ‘hand me down’ from the person in that position previously. This is done from a time expediency standpoint, or as generally misguided fiscal prudence. We recently realized nobody could pull a single report in one practice. We contacted the software provider and they said nobody in that practice had been trained for over 4 years. A full 80% of the team were not on staff when the last software training or upgrade was completed. Of course they were underutilizing their computer system because it was a stranger to all! There should be anywhere up to 8 such manuals. If you think that is too many, McDonalds Restaurants uses 32 manuals to run the world’s most profitable burger joint. Do you think Ray Kroc wanted those adolescent kids to ‘decide’ what temperature to cook the fries today? It is either ‘on’ or ‘off’. A new hire is handed the manual for whatever position – is responsible for reading and agreeing to adhere to the system – and you now have a form of an employment contract. Your practice should be no different. Plus, the majority of discipline problems and hard feelings arise from policies that should be laid out right up front. In the event of a serious issue, this is far cheaper than dealing with either Labour Standards in your jurisdiction or worst case scenario – the court system. Very infrequently do we encounter problems in a practice that couldn’t have been eliminated or diminished had the team member read, understood,
and signed off on the dentist’s expectations on the very first day of employment. Wouldn’t this make your reception duties, CDA/RDA functions, hygiene duties, treatment scheduling, accounting, and general office policies much easier to administer? So, why do certain members fight systems like crazy? We ran into this situation recently where someone who cannot put a paragraph together to a grade 8 standard told her dentist that ‘nothing works’ with the manual template, and it would be easier for her to start all over and rewrite it. Translation: I am too lazy to do it – and I don’t want to share information. We’ve seen samples of her material and she couldn’t write a letter to Santa without a spelling mistake. She can possibly edit, but writing is not and will never be her forte. It is painstaking work to edit any team dental manual, let alone write one from scratch. However, it only needs to be done once. We know from experience the issues that must be addressed in each category, and it is a ‘starting point’ not a finished
“It is painstaking work to edit any team dental manual, let alone write one from scratch. However, it only needs to be done once.”
62
product. Ever y practice uses different tools, preferred techniques, and has their own unique ways. We encourage you to adopt a true franchise model by first getting your house in order. Do this, before you entertain any ideas of expansion or hiring new team members. The term ‘franchise model’ is important here, because the day you look at your practice and systemize it to the point it could become the blueprint for another location is a watershed moment. You may choose to sell it, you may choose to expand it, or you may choose to
TEAMWORK Vol.5-No.6 - July 2012
TW-V5N6_Layout 1 7/13/2012 4:29 PM Page 63
simply keep it. Realize one thing – if you cannot sell it for your desired price, you just ‘bought’ it. Any facet of your practice that is running in a clean, organized, and profitable manner can be readily duplicated. A purchasing dentist will appreciate that, and it will add value to your business. Any loose end that appear to be unresolved, or dependent on one specific team member’s memory or experience frighten a prospective purchaser. What happens if this individual leaves, or if she is being paid too much in that position? We encourage you to make your practice system and position dependent (with each accompanying manual), because it will then provide you with the freedom you deserve.
Your team members should take anywhere from 8 to 30 hours to itemize their areas of responsibility. You should pay them for this time, or you may receive from some a thoroughly sloppy incomplete job. If it is done across the board you should eliminate the fear of job security that frequently crops up with insecure employees. Once complete – this ‘work in progress’ should be brought to every single team meeting. Of course you will change procedures and details, and they should be penciled right into the hard copy. They can be digitally edited periodically. This is how any well functioning business is run. Doesn’t your practice deserve the same?
Author: Bryce Gibney is a practice management coach, seminar leader, and marketing consultant operating specifically in the dental profession for a decade now. His ‘hands on’ approach to solving everything from advertising issues to dental team sales training has been invaluable to practices across the continent. He is available at 1-800-492-2118 or info@patientmoneyinc.com
TEAMWORK Vol.5-No.6 - July 2012
63
TW-V5N6_Layout 1 7/13/2012 4:29 PM Page 64
TW-V5N6_Layout 1 7/13/2012 4:30 PM Page 65
Adlink
TW-V5N6_Layout 1 7/13/2012 4:30 PM Page 66
American Express
www.amexforbusiness.ca/dentists
1.877.818.8955
37
Baluke Dental Studios
www.baluke.com
1.800.263.3099
21 • 55
BioHorizons
www.bonferro-ce.com
1.866.468.8338
02
Dentsply Canada Implant Solutions
www.dentsply.ca www.implant-solutions.com
1.800.263.1437 1.866.857.8333
41 25
1.877.INCISAL
44
Incisal Edge Dental Laboratory Krest Dental Ceramics
www.krestlab.com
1.416.467.6674
11
Micrylium
www.micrylium.com
1.800.489.8868
56
Nadean Burkett & Associates Inc.
www.practiceempowerment.com
1.604.939.5009
61
Nobel Biocare
www.nobelbiocare.com
1.800.939.9394
13
Orthodent Ltd.
www.orthodent.ca
1.800.267.8463
51
Patient Money Inc.
www.patientmoneyinc.com
1.800.492.2118
63
Protec Dental Laboratories Ltd.
www.protecdental.com
1.800.663.5488
05
Rondeau Seminars
www.rondeauseminars.com
1.877.372.7625
49
Shaw Group of Dental Laboratories
www.shawlabgroup.com
1.877.444.7429
27
SmileTech Dental Laboratory
www.smiletechdentallabs.com
1.888.358.8190
19
Synca
www.fiberforcedental.com
1.888.582.8115
12
Continuing Education Aesthetic Design & Implant Academy (Adia)
www.adiacanada.com
All on 4 / 6 CARDP 20th Annual Scientific Meeting
www.cardp.ca
Implant Surgery for the General Practitioner
www.palmeripublishing.com
1.866.581.8949
02
1.416.294.9744
33 68
1.866.581.8949
35
Oral Surgery for the GP: A Practical Approach
www.palmeripublishing.com
1.866.581.8949
28
Oral Surgery Academy for General Dentists
www.palmeripublishing.com
1.866.581.8949
29
Ortho Techniques Symposium
www.orthotechniques.net
1.866.581.8949
45
Spectrum Dialogue Techno-Clinical Day Toronto
www.spectrumdialogue.com
1.866.581.8949
07
Women in Dentistry Symposium
www.womenindentistrysymposium.com
1.866.581.8949
57
• To become a TEAMWORK subscriber contact us at 905.489.1970 • To advertise in TEAMWORK contact us at 905.489.1970
66
TEAMWORK Vol.5-No.6 - July 2012
TW-V5N6_Layout 1 7/13/2012 4:30 PM Page 67
Join us in Halifax this September! The Canadian Academy of Restorative Dentistry and Prosthodontics l’Académie canadienne de dentisterie restauratrice et de prosthodontie
20th Annual Scientific Meeting, September 6%8, 2012 Halifax Marriott Harbourfront Hotel
•
1959 Upper Water Street, Halifax, NS B3J 3J5
T: 902.421.1700
•
Reservations Link: http://cwp.marriott.com/yhzmc/cardp
•
Toll Free: 800.943.6760
An Invitation from the President of CARDP
Introduction to CAD/CAM and Digital Dentistry 2012
Greetings from Halifax and Céad Míle Fáilte! (One Hundred Thousand Welcomes)
Thursday, September 6th, 9:00am ; 4:00pm Hands on Course presented by Dr. Joseph Carpentieri
It is an honor as President of the Canadian Academy of Restorative Dentistry and Prosthodontics to welcome you to the 2012 Annual Scientific Meeting. The members of the Atlantic Provinces are thrilled to be hosting this meeting in the unique city of Halifax. The meeting will be held September 6 8, a wonderful time of year to visit this beautiful port city. Our venue is the Marriott Halifax Harbourfront situated in a premier location with wonderful views of the harbour, just a walk away from the downtown sites and scenes.
Dr. Carpentieri graduated from the University of Maryland College of Dental Surgery. Practiced general dentistry for eight years before receiving a Certificate in Prosthodontics from Einstein Montefiore Medical Center. Subsequent to that time he completed a four year surgical implant fellowship at the Department of Periodontology and Implant Dentistry at NYU. Currently, he is an associate clinical professor, Dept of Prosthodontics/Implant Fellowship, at Columbia University College of Dental Medicine Department, headed by Dr. Dennis Tarnow. Speaker, Publisher, Mentor and BIOMET 3i Consultant; Dr. Carpentieri speaks both nationally and internationally on all phases of surgical and implant dentistry.
CARDP is steeped in great traditions. In 1993, two highly respected organizations, the Canadian Academy of Prosthodontics and the Canadian Academy of Restorative Dentistry, joined forces to create this Academy. The Academy has always offered its members and guests a highly educational Scientific Program and a sincere social program – and this year will be no different!
Synopsis:
From each meeting to the next, members and their families, guests and sponsors of the Academy enjoy the social events that bring everyone together. The flavour of the Maritimes will continue to be the theme in Halifax and we look forward to lots of laughter and learning. Mark these dates in your calendar and join us for a fun filled, memorable meeting. See you there!
The purpose of this hands on lecture is to present a thorough and concise overview of CAD/CAM and Digital Dentistry; it has absolutely revolutionized the practice of clinical dentistry and significantly changed what we do and how we do it. • Evidenced based perspective of advantages/disadvantages or benefits and limitations of these technologies • Review ‘new workflow options’ from both a conventional and digital perspective • Understand how a CAD/CAM manufactured prosthesis provides us with the most cost effective modality for most implant restorations • Present literature supported rationale for utilization of CAD/CAM abutments and full arch CNC frameworks • Discuss step by step clinical guidelines, abutment and material choice, and review controversies associated with zirconia abutments with new guidelines • Review other controversies including third party abutments, the zirconia titanium interface, veneering of various framework designs • Introduce concept reverse engineering; one of the hottest topics in implant dentistry • Introduce the “players”; making this a diverse presentation of all implant companies • Review BIOMET 3i’s CAD/CAM Portfolio; ie, BellaTek™ Encode® Impression System. How does this company fit into this space and why is it different? • Demonstrate integration of digital impression taking review of devices • How to select a scanner? Does it really work? Benefits to patient and practice?
Respectfully,
Learning Objectives:
Dr. Maureen Andrea CARDP President
To increase knowledge, confidence and predictability that will lead to improved aesthetic and functional patient outcomes.
Dr. Peter Thomson, the Essay Committee Chair, has created a lecture program that will generate a dialogue of scientific information as it relates to Restorative Dentistry and Prosthodontics. Dr. Mark Sutherland, the Clinic Committee Chair, brings us a Saturday morning of short lectures that will keep us intellectually stimulated! The Table Clinic portion of the meeting offers the ability to interact one on one with speakers, presenters and the dental Industry providing an intimate setting to discuss and learn. Our Academy continues to have a strong relationship with its sponsors the Industry leaders. Many thanks to these long standing relationships and we look forward to seeing you again.
CE CREDITS
Thursday, September 6th, 2012 Friday, September 7th, 2012
•
Saturday, September 8th, 2012
•
Hands-on Course
Scientific Sessions •
6 CE Credits
• •
Scientific Sessions
7 CE Credits •
7 CE Credits
Plus 13 Aftern oo Table Clinics! n 3 CE Credits
For more information and to register for the meeting, visit www.cardp.ca
TW-V5N6_Layout 1 7/13/2012 4:30 PM Page 68