Implant Practice US Jan-Feb 2013 Vol 6 No 1 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews January/February 2013 – Vol 6 No 1

PROMOTING EXCELLENCE IN IMPLANTOLOGY Every picture tells a story: chlorhexidine conundrum Dr. Eddie Scher

SonicWeld Rx™ — A novel replacement for traditional titanium mesh in particulate bone grafting Dr. Lewis Cummings

Straumann’s 2013 Dental Implant Complications Symposium

Clinical Case: All-on-4™ and NobelGuide™ in an atrophic mandible

The Most Efficient Clinical Workflow in Dentistry

SCAN

Drs. Paulo Malo, Armando Lopes, Mariana Nunes, André Rodrigues, Ana Ferro, and Miguel De Araújo Nobre

Corporate profile

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

PUBLISHER Lisa Moler

Email: lmoler@medmarkaz.com Tel: (480) 403-1505

MANAGING EDITOR Mali Schantz-Feld

Email: mali@medmarkaz.com Tel: (727) 515-5118

ASSISTANT EDITOR Kay Harwell Fernández

Email: kay@medmarkaz.com

PRODUCTION MANAGER/CLIENT RELATIONS Kim Murphy Email: kmurphy@medmarkaz.com

Dear Readers: Happy 2013! It seems like only yesterday that we were busily preparing to welcome 2012, but in fact, so much has happened in the dental profession and in our publications, that the time has just flown by. The positive momentum of the past year continues to propel us forward. We are happy to note that this year brings a fresh, contemporary look for the magazines. New design elements, an easy-to-read print style, and expanded page size are just a few of the exciting changes that you will find in this, and future issues. Implant Practice US is growing and evolving to help you grow and evolve. We strive to keep up with current implant trends and to keep our readers up-to-date on the latest techniques and technology in the specialty. Our dentist-authors give of their time and expertise to share the methods that result in better dental care for patients. We are always seeking out new ideas and innovation in our clinical, technology and continuing education articles, and case studies. Our corporate profiles tell the stories of companies that facilitate innovation, and practice profiles share the insights and concepts that inspire practice excellence. And, practice management columns spotlight ways to improve the business aspects of the dental office that can make lives easier for the staff and the boss! Besides our magazine, Implant Practice US also features a vital and continually changing website (www.medmarkaz.com/web) and e-newsletter with the latest industry news, articles, and information. Our social media mavens keep the action going on Facebook, Twitter, and LinkedIn. So whether you like to turn the pages or click the mouse, information can be in your lap or on your laptop! Publishing a thought-provoking, diverse magazine with such high standards is a difficult task, but our authors, peer reviewers, editorial advisory board, advertisers, and columnists make it a smooth and enjoyable process. Our editors, sales and production staff, and I appreciate all of our authors and readers and value feedback as we continue to strive for excellence. Please feel free to call or email – we’d love to hear from you. January is a time for resolutions. We strive to keep up the momentum so that we all can grow together in 2013. All the best,

NATIONAL SALES/MARKETING MANAGER Drew Thornley Email: drew@medmarkaz.com Tel: (619) 459-9595 NATIONAL SALES REPRESENTATIVE Sharon Conti Email: sharon@medmarkaz.com Tel: (724) 496-6820 E-MEDIA MANAGER/GRAPHIC DESIGN Email: greg@medmarkaz.com Greg McGuire PRODUCTION ASST./SUBSCRIPTION COORDINATOR Email: lauren@medmarkaz.com Lauren Peyton MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Fax: (480) 629-4002 Tel: (480) 621-8955 Toll-free: (866) 579-9496 Web: www.endopracticeus.com SUBSCRIPTION RATES Individual subscription 1 year (6 issues) 3 years (18 issues)

Lisa Moler Publisher

$99 $239

© FMC 2013. All rights reserved. FMC is part of the specialist publishing group Springer Science+Business Media. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Implant Practice or the publisher.

Volume 6 Number 1

Implant practice 1

MEMO FROM THE PUBLISHER

January/February 2013 - Volume 6 Number 1

5 Great Reasons to CONNECT with the ITI in Chicago. What puzzle pieces are you missing in your practice? Attend the ITI Congress and complete your puzzle for a successful future. 1. G row your practice revenue by attending Thursday’s Pre-Congress Practice Management Forum and learn about: Money, How to Make it, How to Grow it & Case Acceptance. 2.

Learn from top international experts and educators: • Urs Belser: University of Geneva, Switzerland • Daniel Buser: University of Bern, Switzerland • David Cochran: University of Texas San Antonio,USA • Jocelyne Feine: McGill University, Canada • Hans-Peter Weber: Tufts University, USA • and many more

3. Connect and be a part of the largest dental Network; share best practices at the ITI Congress Party on Friday to benefit the NFED (National Foundation for Ectodermal Dysplasia) 4.

Elevate your skill in the Technology Pods with demonstrations taught by Key Opinion Leaders in the Technology Hall. (Digital Dental Photography, LOCATOR® Techniques, Cementing on Dental Implants, Provisional Fabrication, Augmentation techniques and more...)

5. T ackle Complications – attend Saturday’s “Managing Puzzle Problems” Session and approach complications with confidence. The program will start with complications from the restorative and surgical aspects in the esthetic zone. The International Team for Implantology (ITI) is a unique network that unites professionals around the world from every field of implant dentistry and related tissue regeneration. Not a member? Sign up today to take advantage of the highest quality educational support and a wealth of benefits to enhance professional activities. Find out how you can get a $200 discount on the ITI North America Congress fee.

www.iti.org/congressnorthamerica

Do not wait, take advantage of the early bird rate which expires January 31st and save $100.

ITI Congress North America Chicago, USA April 4 â&#x20AC;&#x201C; 6 2013

Connectivity in Implant Dentistry: Putting the Pieces Together.

INTRODUCTION

The best gift – education

erhaps the best gift I have ever given myself was the pursuit of education. I remember the day I received my dental degree, knowing that a long journey was ahead. I had a plan, and my goal was simple: I would take continuing education courses that interested me and lay the foundation for my future success. It began with restorative treatment and included esthetics. At the same time, my self-confidence in endodontics was lacking, and I committed years to that discipline. Confident with the ability to heal and restore ailing teeth, I set my sights on surgery. Unfortunately, dental school and residency could only prepare me so far. I yearned to understand the finer points of saving teeth with periodontal surgery, and when unable, then to extract those teeth. After 14 years of more education and honing my craft, I was awarded a Mastership in the Academy of General Dentistry. Yet, even with that, I always knew there was one discipline in which I was lacking, and it was dental implants. I wasn’t simply interested in learning the science of restoring dental implants. I wanted much more. I sat through many weekend-warrior implant courses, often with a hands-on component using dentoform style models. But rubber and plastic models are a poor substitute for the real thing. For me, the holy grail of dentistry was learning, understanding, and acquiring the wisdom to surgically place the implant in vivo. I had always felt that all other fundamentals had to be acquired, and at that time, I believed those elements were in my repertoire. With the groundwork laid out, and the foundation solid, I stood at the precipice, wanting to dive into the implant surgical arena. What held me back was fear. Fear of the unknown. Fear of those anatomical structures that haunted me, leading me to believe that with one wrong move, I would violate the maxillary sinus, the mental foramen, or the inferior alveolar nerve. I knew those areas well enough, and frankly, they scared me. So, one day, I decided that it was time to overcome my anxiety and discover if those bugaboos were really a threat or just the primal fear they inject you with at the undergraduate level. I needed big time education. I sought something that was a commitment of time and funds, the two ingredients integral to any worthwhile venture. For me personally, I discovered and developed this talent (and continue to do so) in a “mini-residency.” Akin to the famed maxi-course, the location was Englewood, New Jersey, a 3-hour drive from my Baltimore home. It was a 6-month commitment of bimonthly lectures, participation, and over-the-shoulder live placement. And yes, there were lots of homework and tests. My teacher and mentor, Dr. John Minichetti, assembled an all-star cast of educators, and between his excellent teaching skills, guidance, and care, I began my journey. I was thrilled when I learned not only the mechanics of implantology, but also all of the supporting pieces needed for success. I relearned how to extract a tooth, this time ensuring that the event was as atraumatic as possible. I discovered the art of bone grafting extraction sockets, and when they weren’t intact, then how to grow bone. I even deprogrammed my fear of those once dreaded anatomical sites, learning how to correct them (the sinus lift) or avoid them (the mandibular nerves). Once the course was complete, I was sent back into my world to begin this wonderful and exciting journey. Initially, I began cherry-picking my cases, staying within my comfort zone, and as my self-confidence grew, so did my treatment. Today, I am a proud recipient of the Associate Fellowship in the American Academy of Implant Dentistry. Yet, I am even more proud to be considered a kindred spirit with all of you, my fellow implantologists. I look forward to continued discovery and collaboration in 2013!

Ian E. Shuman, DDS, MAGD

4 Implant practice

Volume 6 Number 1

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TABLE OF CONTENTS

Through the keyhole Dr. Scott Marshall Blyer: An affinity for accessibility and approachability A strong medical and surgical background, dedication to customer service, and a penchant for “pushing the envelope” keeps this clinician’s practice immersed in innovation

10 Corporate profile Biomet 3i Sustainable esthetic treatment, comprehensive tissue management, accelerated therapy, and digitally-driven patient and practice management solutions

Clinical Every picture tells a story: chlorhexidine conundrum Dr. Eddie Scher raises the alarm on the potentially dangerous effects of chlorhexidine digluconate mouthwash................................. 20 Customized impression of an implant-supported fixed partial denture in the esthetic zone Dr. David Furze and Mr. Ashley Byrne describe a method in which all four maxillary incisors are replaced with an implant-supported fixed partial denture............................. 22

Continuing education

Case study Clinical Case: All-on-4™ and NobelGuide™ in an atrophic mandible Drs. Paulo Malo, Armando Lopes, Mariana Nunes, André Rodrigues, Ana Ferro, and Miguel De Araújo Nobre explore an implant solution for extreme cases

SonicWeld Rx™ — A novel replacement for traditional titanium mesh in particulate bone grafting Dr. Lewis Cummings discusses an improved method for particulate bone grafting............................... 32 Secure bonding: implants and overdentures Dr. Ludwig Hermeler demonstrates how to modify an existing overdenture for use with implants and secure it with direct intraoral adhesion..................................... 36

6 Implant practice

Volume 6 Number 1

Abutments as individual as your patients Available for all major implant systems and in your choice of titanium, gold-shaded titanium and four shades of zirconia, ATLANTIS™ patient-specific

ATLANTIS BioDesign Matrix™ The four features of the ATLANTIS BioDesign Matrix™ work together to support soft tissue management for ideal functional and esthetic result. This is the true value of ATLANTIS™ for you and your patients.

CAD/CAM abutments help to eliminate the need for inventory management of stock components and simplify the restorative procedure.

ATLANTIS VAD™ Designed from the final tooth shape.

Natural Shape™ Shape and emergence profile based on individual patient anatomy.

Soft-tissue Adapt™ Optimal support for soft tissue sculpturing and adaptation to the finished crown.

Find out how ATLANTIS™ can bring simplicity and esthetics to your practice. Just take an implant-level impression, send it to your laboratory and ask for ATLANTIS today.

Custom Connect™ Strong and stable fit – customized connection for all major implant systems.

800-531-3481 • www.dentsplyimplants.com

TABLE OF CONTENTS

Socket grafting made simple

Research

Event preview

Early loading versus immediate

Straumann’s 2013 Dental Implant

loading: case examples Drs. Alberto Maltagliati, Andrea Ottonello, Giulio Raffaghello, and Andrea Mascolo explore esthetics and function of early and immediate loading implants............................40

Complications Symposium Providing Solutions for Your Practice. .....................................................48

Industry news

Practice management Know your liability as a business owner Dr. Robert M. Fleisher discusses how to mitigate general liability risks besides malpractice claims............54

Aribex acquired by the KaVo

Step-By-Step BondBone® Socket grafting made simple.........44

Product profile Aseptico Aseptico’s AEU-7000L-70V fiber optic motor system................................46

8 Implant practice

Group Aribex, the leader in portable X-ray technology, joins the KaVo Group’s portfolio of dental brands...............50

Abstracts Treatment of peri-implant diseases: a compilation of systematic reviews Dr. Maria Retzepi rounds up the current thinking on an increasingly important aspect of implant dentistry .....................................................52

Materials & equipment......................56

Volume 6 Number 1

PRACTICE PROFILE

Dr. Scott Marshall Blyer An affinity for accessibility and approachability What can you tell us about your background? I grew up in the streets and went to the school of hard knocks. My first experience with dental implants was getting my teeth knocked out after a mix-up of mistaken identity with the local crack dealer. Ok, none of that is true, but what is more boring than a being a dentist from Long Island? The genesis of my interest was after volunteering for an oral surgeon in college.

Is your practice implants?

limited

In my practice, I perform the full scope of oral and maxillofacial surgery, although a large portion is dedicated to dental implants.

Why did you decide to focus on implantology? We actually chose each other. I was well trained in my residency in dental implants and continued my learning thereafter. Many of the dentists in my community have a high dental IQ and perform many simple cases themselves. The cases I was getting were cases that were complex, “hopeless,” and failing. It allowed me to push the envelope of science, and in many cases, be the hero doing what others deemed impossible. This excited me as a surgeon and a scientist.

How long have you been practicing, and what systems do you use? I graduated dental school in 2000 and residency in 2006. I have been in private practice for over 6 years. I have worked with many different systems. Straumann® is my personal preference, but Nobel is the most popular in my community, and therefore, my most commonly placed implant.

What training have you undertaken? I

graduated

from

10 Implant practice

the

Pennsylvania

State University with a BS in nutritional biochemistry. I then went to Stony Brook dental school. I completed my 6-year oral and maxillofacial surgery training at Long Island Jewish Hospital. In the program, I earned a medical degree (MD) from Stony Brook, and completed a year of general surgery at North Shore University Hospital. I then did a fellowship in cosmetic surgery at Willow Bend Cosmetic Surgery Center in Plano, Texas.

Who has inspired you? On a personal level, my parents are responsible for who I am. My practice’s logo is a portrait of my deceased mother and is a constant reminder of the values she taught me. Professionally, Dr. Uday Reebye is a great friend and an amazing young surgeon who will change dental implantology as we know it. My list of people inspiring me is quite long. These are people who were not afraid to take chances, do the right thing by people, work hard, and who earned everything they have.

What is the most satisfying aspect of your practice? Like Frank Sinatra said, “I did it my way.” It is not the typical office in terms of patient care, ambiance, or services rendered. We don’t stand on ceremony and are very “down to earth.” I love offering different options to patients, and together make their expectations a reality.

Professionally, what are you most proud of? I have done pro bono work, taught, held fundraisers for breast cancer and MS in my community, but my biggest pride comes from my daily dedication to those who

trusted me to care for them. I have visited my out-of-town patients after treatment in their hotels and even walked their dogs for them, and drove out of state to see a patient because she couldn’t come in. It is a tremendous responsibility to operate on someone, and it is a responsibility I do not take lightly. My accessibility and approachability to my family of patients is what I am most proud of. I have instilled this work ethic into my entire team.

What do you think is unique about your practice? Certainly my training. With a strong medical and surgical background, it allows me to undertake cases where others may not. I also find myself thinking differently than most other implant surgeons, placing more importance on how the teeth fit to the face and the perioral structures. We also hold customer service as a top priority. Upon entering through our glass doors, our waterfall, marble and teak floors set up a serene environment. Our warm, welcoming Volume 6 Number 1

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I am the Zimmer® Trabecular Metal™ Dental Implant, the first dental implant to offer a mid-section with up to 80% porosity—designed to enable bone INGROWTH as well as bone ONGROWTH. Through osseoincorporation, I harness the tried-and-true technology of Trabecular Metal Material, used by Zimmer for over fifteen years in orthopedics. My material adds a high volume of ingrowth designed to enhance secondary stability.... and I am Zimmer.

Visit TrabecularMetal.zimmerdental.com to view a special bone ingrowth animation and request a Trabecular Metal Technology demo. www.zimmerdental.com ©2012 Zimmer Dental Inc. All rights reserved. * Data on file with Zimmer Dental. Please check with a Zimmer Dental representative for availability and additional information.

PRACTICE PROFILE

Dr. Blyer and his mother

Dr. Blyer in action during a consultation

Dr. Blyer sponsoring the Carol Baldwin breast cancer fundraiser, 2011

team will offer you a warm cup of coffee and a seat on our leather lounge chairs. We often send flowers after surgery, and even have a top-of-the-line full-service spa in the office.

What advice would you give to budding implantologists?

What has been your biggest challenge? Treatment room

Trying to find the balance between family and professional life. I work essentially 7 days a week, and even when I am at home, it is difficult to get our profession off my mind. Different ideas are always racing through my mind.

What would you have become if you had not become a dentist?

Front desk

My father wanted me to be a chiropractor, my uncle a caterer, and my mother, the president. I love being creative and thinking of new ideas. I think I would have enjoyed a career in television marketing.

Find yourself a mentor or someone you can turn to with a problem or question. It is unfortunate more people can’t work like colleagues rather than competitors. Don’t be a robot. Think before you act. The specialty must continue to evolve, so don’t listen to naysayers. If it makes sense biologically, give it a shot.

What are your hobbies, and what do you do in your spare time? I love the New York Knicks, Giants, and Penn State Football. In my spare time, I am always reading and writing scientific articles (yes, I am a nerd). I enjoy going to the gym, playing golf, and spending time with my family, fiancé, and my Daisy (my Chihuahua-Rat Terrier rescue; she’s delicious). With only 24 hours in a day, sleep is not overrated. IP

What is the future of implants and dentistry? In the titanium arena, immediate placement of CAD/CAM customized one-piece implants and crowns are the future. Zirconium implants are getting some buzz in the U.S., as we await long-term data. I am currently involved with research using stromal vascular fractions for implant site development, with promising early results. At some point, stem cells will probably replace implants entirely. Main waiting room

TOP FAVORITES 1. CVS gummy bears 2. Piezosurgery® unit — I love that little sucker 3. Daydreaming and getting a deep tissue massage 4. Making people happy 5. Waking up in the middle of the night and realizing I have another 2 hours of sleep left 6. When things work out

What are your top tips for maintaining a successful practice? Always be available. Maintain great communication with your referrals. Treat your patients like one of the family. Every patient gets my cell phone number and a call after surgery. With texting, it allows my patients to reach me at any time and is a welcoming security blanket for them.

7. Lecturing/teaching 8. Sitting back with an interesting article and keeping up with current literature 9.

Foundation bone graft material for socket preservation grafts: easy placement, compressible, no membrane needed, and converts to rock solid bone

10. Hand torquing to 40 Ncm..... ahhhhhh heaven!

Dr. Blyer’s office team 12 Implant practice

Volume 6 Number 1

www.icoivegas2013.org

ICOI is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about CE provider may be directed to the provider or to ADA CERP at www.ada.org/cerp.

ICOI 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 April 1, 2010 to March 31, 2014. Provider ID# 217378.

CORPORATE PROFILE

BIOMET 3i

ounded in 1987 by a periodontist and an engineer who wanted to be more responsive to dental needs, BIOMET 3i is now one of the largest dental implant companies in the world. Headquartered in Palm Beach Gardens, Florida, the company spans the globe with nearly 1,000 team members, 18 subsidiaries, and operations in more than 40 countries. sustainable aesthetic Through treatment, comprehensive tissue management, accelerated therapy and digitallydriven patient and practice management solutions, BIOMET 3i strives to enhance the lives of patients – one at a time.

Comprehensive tissue management solutions Successful patient outcomes begin with effective tissue management. BIOMET 3i provides a portfolio of site-specific options that are designed to achieve better results at crucial steps in the process – laying the foundation for successful Guided Bone Regeneration procedures.

Accelerated therapy solutions BIOMET 3i provides patients with the option of immediate full arch rehabilitation in as little as one day* with DIEM®2. This innovative solution is designed to allow clinicians to differentiate their practices while increasing productivity and patient satisfaction.

Sustainable aesthetic treatment solutions The PREVAIL® Implant System with integrated platform-switching uses “The Science of Aesthetics” to deliver outcomes through tissue protection1, enhanced osseointegration,2-9 and crestal bone preservation2-6.

RegenerOss® Allograft

DIEM® 2

Digitally-driven patient and practice management solutions OsseoGuard Flex™ Membrane

BIOMET 3i NanoTite™ Tapered Certain® PREVAIL® Implant

BIOMET 3i NanoTite™ Certain® PREVAIL® Implant

For patients, too many dental visits over too long a period of time are barriers to implant dentistry being the treatment of choice. BIOMET 3i delivers a digital solution with a streamlined workflow from start to finish – the BellaTek® Encode® Impression System. The patented BellaTek Encode Impression System with intraoral scanning eliminates the need for impression copings, streamlining the process while improving the patient experience.

Endobon® Xenograft Granules

BellaTek® Encode® Impression System

OsseoGuard® Membrane 14 Implant practice

Volume 6 Number 1

The PREVAIL® Implant System The key to achieving long-term sustainable aesthetic outcomes is preservation of hard and soft tissues. The PREVAIL Implant System’s unique features are designed for preservation.

enHAnceD o s s e o i n T e g r AT i o n 1-6,8,9

c r e s TA l b o n e P r e s e r VAT i o n 1 - 5

preservation BY DESIGN™ Optimized aesthetics with as little as 0.37mm of bone recession1

Tissue ProTecTion7

Higher seal strength as compared to the competitive average 2,3 Seal integrity test was performed by BIOMET 3i on December 2011. Testing was done under testing standard ISO 14801. Five (5) BIOMET 3i PREVAIL Implant Systems and five (5) of three (3) competitors’ implant systems were tested. Bench test results are not necessarily indicative of clinical performance.

Implants designed for primary stability with two well-researched surface options for bone apposition

Please contact us at 561.776.6700 or visit us online at www.biomet3i.com to learn more. 1. Östman PO†, Wennerberg A, Albrektsson T. Immediate occlusal loading of NanoTite Prevail Implants: A prospective 1-year clinical and radiographic study. Clin Implant Dent Relat Res. 2010 Mar;12(1):39–47. 2. Baumgarten H†, Meltzer A†. Improving outcomes while employing accelerated treatment protocols within the aesthetic zone: From single tooth to full arch restorations. Presented at the Academy of Osseointegration, 27th Annual Meeting; March 2012; Phoenix, AZ. 3. Suttin Z†, Towse R†, Cruz J†. A novel method for assessing implant-abutment connection seal robustness. Poster Presentation 188: Academy Of Osseointegration, 27th Annual Meeting: 2012 March 1–3; Phoenix, Arizona. http://biomet3i.com/Pdf/Posters/Poster_Seal%20Study_ZS_AO2012_no%20logo.pdf. Testing done by BIOMET 3i, Palm Beach Gardens, FL; n = 20. 4. Byrne D, Jacobs S, O’Connell B, Houston F, Claffey N. Preloads generated with repeated tightening in three types of screws used in dental implant assemblies. J. Prosthodont. 2006 May–Jun;15(3):164-71. 5. Boitel N, Andreoni C, Grunder U†, Naef R, Meyenberg, K†. A three year prospective, multicenter, randomized-controlled study evaluating platform-switching for the preservation of peri-implant bone levels. Poster presentation P83: Academy of Osseointegration, 26th Annual Meeting: 2011 March 3–5; Washington DC. 6. Lin A, Wang CJ, Kelly J, Gubbi P, Nishimura I. The role of titanium implant surface modification with hydroxyapatite nanoparticles in progressive early bone-implant fixation in vivo. Int J Oral Maxillofac Implants. 2009 Sep–Oct;24(5):808–816. 7. Zetterqvist et al. A prospective, multicenter, randomized controlled 5-year study of hybrid and fully etched implants for the incidence of peri-implantitis. J Periodontol. April, 2010. 8. Östman PO†, Wennerberg A, Ekestubbe A, et al. Immediate occlusal loading of NanoTite™ Tapered Implants: A prospective 1-year clinical and radiographic study. Clin Implant Dent Relat Res. 2012 Jan 17. [Epub ahead of print] 9. Block MS†. Placement of implants into fresh molar sites: Results of 35 cases. J Oral Maxillofac Surg. 2011 Jan;69(1):170-4. †

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

CORPORATE PROFILE References 1. Zetterqvist L, et al. A prospective, multicenter, randomized controlled 5-year study of hybrid and fully etched implants for the incidence of peri-implantitis. J Periodontol. April, 2010. 2. Baumgarten H†, Meltzer A†. Improving outcomes while employing accelerated treatment protocols within the aesthetic zone: From single tooth to full arch restorations. Presented at the Academy of Osseointegration, 27th Annual Meeting; March 2012; Phoenix, AZ. 3. Suttin Z††, Towse R††, Cruz J††. A novel method for assessing implantabutment connection seal robustness. Poster Presentation 188: Academy Of Osseointegration, 27th Annual Meeting: 2012 March 1–3; Phoenix, Arizona. http://biomet3i. com/Pdf/Posters/Poster_Seal%20Study_ZS_ AO2012_no%20logo.pdf. Testing done by BIOMET 3i, Palm Beach Gardens, FL; n = 20.

IIRD® lecture hall

4. Byrne D, Jacobs S, O’Connell B, Houston F, Claffey N. Preloads generated with repeated tightening in three types of screws used in dental implant assemblies. J. Prosthodont. 2006 May–Jun;15(3):164-71. 5. Östman PO†, Wennerberg A, Albrektsson T. Immediate occlusal loading of NanoTite Prevail Implants: A prospective 1-year clinical and radiographic study. Clin Implant Dent Relat Res. 2010 Mar;12(1):39–47. 6. Boitel N, Andreoni C, Grunder U†, Naef R, Meyenberg, K†. A three year prospective, multicenter, randomized-controlled study evaluating platform-switching for the preservation of peri-implant bone levels. Poster presentation P83: Academy of Osseointegration, 26th Annual Meeting: 2011 March 3–5; Washington DC.

IIRD® operatory

World-class learning for dental clinicians Located in Palm Beach Gardens, Florida, the Institute for Implant & Reconstructive Dentistry (IIRD®) is a BIOMET 3i initiative for continuous learning and training for dental professionals. This state-of-the-art facility provides clinicians with the latest techniques and courses, empowering clinicians to provide outstanding patient care. The IIRD® was founded by Richard Lazzara, DMD, MScD, who passionately believes that education, evidence-based research and advanced techniques are essential in providing the best solutions to clinicians and patients.

*Not all patients are candidates for immediate load procedures. All trademarks herein are the property of BIOMET 3i LLC unless otherwise indicated. For additional product information, including indications, contraindications, warnings, precautions, and potential adverse effects, see the product package insert and the BIOMET 3i website. Want more information regarding BIOMET 3i? Please visit the company’s website at www.biomet3i.com or call 1-800-3425454. Outside the US, please dial +561776-6700.

7. Lin A, Wang CJ, Kelly J, Gubbi P††, Nishimura I. The role of titanium implant surface modification with hydroxyapatite nanoparticles in progressive early boneimplant fixation in vivo. Int J Oral Maxillofac Implants 2009 Sep–Oct;24(5):808–816. 8. Östman PO†, Wennerberg A, Ekestubbe A, et al. Immediate occlusal loading of NanoTite™ Tapered Implants: A prospective 1-year clinical and radiographic study. Clin Implant Dent Relat Res 2012 Jan 17. [Epub ahead of print] 9. Block MS†. Placement of implants into fresh molar sites: Results of 35 cases. J Oral Maxillofac Surg. 2011 Jan;69(1):170-4. Dr. Baumgarten, Dr. Block, Dr. Grunder, Dr. Meltzer, Dr. Meyenberg and Dr. Östman have financial relationships with BIOMET 3i LLC resulting from speaking engagements, consulting engagements and other retained services.

†

Dr. Gubbi, Mr. Cruz, Mr. Suttin and Mr. Towse contributed to the above research while employed by BIOMET 3i.

††

This information was provided by BIOMET 3i.

16 Implant practice

Volume 6 Number 1

California Implant Institute is the worldâ&#x20AC;&#x2122;s premier dental implant educator California Implant Institute offers a comprehensive fellowship program in oral implantology. This training program includes 4 sessions (five days each) designed to provide dentists with practical information that will be immediately useful to them. The fellowship program offers more than 300 combined hours of lectures, laboratory sessions, online webinars, and LIVE surgical demonstrations performed at the California Implant Institute facility. The curriculum of the fellowship program is divided between the biomedical sciences related to implant dentistry and clinical implant education and it exceeds the guidelines set by the AAID for a 300 hours of instruction program. Whether you're just starting out or looking to enhance your existing surgical or prosthetic skills, our dental implant programs are exactly what you're looking for. California Implant Institute pursues excellence above all else. Please visit our website or call for more information on the fellowship and other programs offered by CII.

The fellowship program is very comprehensive. It will get you the clinical confidence to know how to plan and what to expect when doing the surgery. Live surgeries were excellent and the review of the related anatomy and pharmacology was invaluable. It was money and time well spent. Dr. Michael Shashaty, Los Angeles, CA

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CLINICAL

Every picture tells a story: chlorhexidine conundrum Dr. Eddie Scher raises the alarm on the potentially dangerous effects of chlorhexidine digluconate mouthwash

Figure 1: Acute allergic reaction due to chlorhexidine mouthwash

ack in 2005, I wrote an article warning colleagues about the possibility of an allergic reaction to chlorhexidine digluconate (Figure 1). This is a compound used in many medical procedures, and of course, is also used as a mouthwash in dentistry. In the U.S., its use is controlled, but in the UK, we can still buy the mouthwash over the counter.

The right mouthwash There is no question that this drug is very useful when performing surgery, as a presurgical rinse, and a follow-up mouthwash (Lambert, et al., 1997; Young, et al., 2002). It also has a major place in the treatment of different types of periodontal disease. In my 2005 article, I included Figure 2 to demonstrate the effect of changing from a chlorhexidine mouthwash to a hot saltwater mouthwash only. Figure 3 shows almost complete healing after 7 days. In that article, I warned colleagues that they must look out for any signs of allergic response when using this compound. However, at that time, there were very few cases reported in the literature.

Fatalities Since then, there have been at least

Eddie Scher, BDS, LDS, RCS, MFGDP, is a specialist in oral surgery and prosthodontics. He is a visiting professor of implantology at Temple University, Philadelphia, and is editorin-chief of Implant Dentistry Today.

20 Implant practice

Figure 2: Changing the mouthwash to hot saltwater: improvement after 3 days

Figure 3: Improvement after 7 days of hot saltwater

two cases reported in the press, where chlorhexidine has been linked to a fatal anaphylactic reaction. The Daily Mail reported one such case on March 22, 2011 with the headline “Patient, 30, collapses and dies at dentist after suffering allergic reaction to mouthwash.” Another such case was reported on February 16, 2011, in the Whitehaven News, this time with the headline “Mouthwash linked to death of patient, 63.”

Council, and the Association of Anaesthetists of Great Britain and Ireland.

Plan of action Since then, the Medicines and Healthcare products Regulatory Agency (MHRA) has issued a Medical Device Alert dated October 25, 2012 (MDA/2012/075). It warns of the risk of anaphylactic reaction due to a chlorhexidine allergy. It gives the following action points, which I am quoting: • Be aware of the potential for an anaphylactic reaction to chlorhexidine • Ensure that known allergies are recorded in patient notes • Check the labels and instructions for use to establish if products contain chlorhexidine prior to use on patients with a known allergy • If a patient experiences an unexplained reaction, check whether chlorhexidine was used or was impregnated in a medical device that was used • Report allergic reactions to products containing chlorhexidine to the MHRA • Further guidance on anaphylaxis is available from National Institute for Health and Clinical Excellence, the Resuscitation

First aid training As well as the above guidance, I would add that, in my view, it is essential for practices to keep all staff members fully trained in emergency procedures and first aid, including the treatment of anaphylactic shock. Adrenaline should be available in your emergency kit, and all practitioners should be able to recognize the symptoms of anaphylaxis, and be well-versed in how to treat it.

The patient background Finally, prevention is better than treatment, and if the patient has a history of allergies, this must alert us immediately to potential problems. The Care Quality Commission suggests that medical histories are updated each time we see our patients: I believe that this is an excellent suggestion, as we can also check their allergy status at this time. IP

References Lambert PM, Morris HF, Ochi S. The influence of 0.12% chlorhexidine digluconate rinses on the incidence of infectious complications and implant success. J Oral Maxillofac Surg. 1997;55:25-30,Suppl 5. Young MPJ, Korachi M, Carter DH, Worthington HV, McCord JF, Drucker DB. The effects of an immediately pre-surgical chlorhexidine oral rinse on the bacterial contaminants of bone debris collected during dental implant surgery. Clin Oral Impl Res. 2002;13:20-29.

Volume 6 Number 1

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CLINICAL

Customized impression of an implant-supported fixed partial denture in the esthetic zone Dr. David Furze and Mr. Ashley Byrne describe a method in which all four maxillary incisors are replaced with an implant-supported fixed partial denture

Figure 1: Pre-op

Figure 2: Surgical stent and implants in place with delivery system still attached

Figure 3: Bone ceramic with lots of blood covering implant and pontic site

Introduction

papillary heights, an equivalent gingival height, and buccal soft tissue contour. This clinical report aims to document a technique of provisional restorations to condition the soft tissue, followed by a customized fixed partial denture (FPD) impression designed to give the technical team the correct emergence profiles of both the implant and pontic sites.

problems that would contraindicate implant therapy. On examination, she had failing restorations of her upper central incisors and her upper left lateral incisor. Bone resorption was clearly noted in the upper right lateral position. Occlusally, she was an incisal class 1 relationship and group function in lateral excursions. The unrestorable incisor teeth were removed without raising a mucoperiosteal flap, consistent with an early implant placement protocol. An immediate composite resinbonded FPD with metal wings on both canines was modeled to support the interdental papilla and cemented using a glass ionomer cement (Fuji IX, GC). A 6-week healing period was followed by implant placement (Straumann® bone level 4.1 mm diameter, 12 mm length SLActive®, Straumann®) in the central incisor positions according to early implant protocol utilizing a surgical stent. The lateral incisor positions were not used for the implants due to the requirement of a block bone graft. The ridge was contoured using Straumann bone ceramic at both the implant and pontic sites, and a bilayered cross-linked collagen membrane (Bio-Gide®, Geistlich) in a two-layered technique. A further healing period of 3 months was observed prior to a second-stage surgical uncovering of the implants. Composite (Gradia® Direct, GC America, Inc.) was added to the palatal surfaces of both canines to return the patient to canine guidance. A closed-tray impression technique was taken in polyether (Impregum™ Penta™;

With the advances in implant surfaces and regenerative techniques, the survival rates of dental implants are quoted between 96% and 99%. As such, there has been a change in ethos of implant placement that should now be placed in a restoratively driven manner. The success of implant treatment is no longer merely based on the survival of the implant, but a greater influence is being placed on the esthetic result achieved. The most challenging of aspects of esthetic implant treatment lies within the soft tissue management. Treatment planning the replacement of multiple teeth in the esthetic zone may be considered to be complicated. The number and position of the implants to be placed should carefully consider the soft tissues and, in particular, obtaining the correct

Clinical report A 55-year-old female was referred for an implant consultation (Strand on the Green Dental Surgery, London, England). Her main complaints were continued loss of post crowns, poor esthetics of her resin-bonded FPD, and the loss of bone following the extraction of her upper right lateral incisor. The patient was a nonsmoker and revealed no systemic medical

David Furze, BDS, MFDS RCS, qualified from Cardiff in 2000 and joined the Royal Army Dental Corp where he achieved the rank of Major. He has served in Germany, Brunei, Bosnia, and all over the U.K. He left the army in 2006 and has since been based in private practice. Dr. Furze has quickly increased his implant exposure by working in Ilkley, London, and Cornwall in implant referral practices. He is currently completing his MClinDent with Kings College London in Fixed and Removable Prosthodontics. He holds an honorary research contract at the Eastman Dental Institute and is currently awaiting several papers for publication. He has recently completed a month fellowship at the University of Bern, Switzerland, working alongside world-renowned implant surgeons. He has lectured nationally and internationally on both the surgical and restorative aspects of implant dentistry, including at the Royal College of Surgeons where he is involved in the teaching and examination of the IQE and MJDF examinations. Dr. Furze is a member of the ITI, the BDA, and SAAD (Society for the Advancement of Anaesthesia in Dentistry). His main area of interest is in implants in the esthetic zone, temporization of implants, customizing impressions, and bone regeneration techniques. Ashley Byrne, RDT, BSc (Hons), graduated from Manchester Metropolitan University in 2001 and is co-founder and director of Byrnes Dental Laboratory in Oxfordshire, England. He has lectured across the U.K. and Europe on CAD/CAM technology and has been involved in the research and development of the Etkon CAD/CAM system from Straumann.

22 Implant practice

Volume 6 Number 1

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CLINICAL

Figure 4: Membrane covering

Figure 5: Provisional in situ

Figure 6: Gingival contour with provisional removed

Figure 7: Provisional attached to primary cast

Figure 8: Silicone impression of provisional

Figure 9: Impression copings in situ

Table 1 1. The provisional FPD is removed from the patient and replaced onto the initial cast. Care is taken to ensure that there is no contact of the pontics with the cast. 2. A light-bodied, fast-setting addition silicone (Provil® Novo CD 2, Heraeus Kulzer) impression is then taken of the apical half of the provisional FPD. 3. The provisional FPD is then removed and replaced in the patient. 4. Open-tray impression copings are then inserted into the cast. 5. Bis-acrylic temporary crown and bridge material, (Integrity®, Dentsply) is used to customize the impression copings to provide an exact replica of the provisional FPD. 6. The FPD is removed from the patient, and the customized impression coping is immediately screwed into position supporting the soft tissue contour. 7. An open-tray polyether impression is taken (Impregum Penta; 3M ESPE). A video of the technique may be accessed via www.brynesdental.com.

3M™ ESPE™), and a composite provisional bridge was manufactured. Following 6 months of tissue conditioning, a customized FPD impression was taken. The procedure is summarized in Table 1. An irreversible hydrocolloid impression was taken of the provisional FPD in situ, and a full series of clinical photographs was emailed to the laboratory. From the customized implant FPD, impression two casts were constructed. The first was a soft tissue and the second a solid stone. An additional cast of the provisional FPD was used as a guide for the definitive case. The casts were mounted on a semiadjustable articulator, using the previous lower to ensure the face bow recorded maintained constant. A customized anterior guidance table was constructed using light-cured acrylic resin. A silicone 24 Implant practice

index of the current provisional was taken to aid in the design of the metal work ensuring correct support of the porcelain. Two gold cylinders (Straumann bone level regular crossfit) were screwed to the cast and cut down to fit within the index. The metal work was then waxed up allowing 1.5 mm of clearance for the porcelain. The wax was sprued and invested with a phosphate investment (Fujivest® premium, GC America, Inc.) using a 25% liquid to distilled water mix. The FPD was cast in Implant 58 alloy (Cendres Metaux, Biel/ Bienne, Switzerland) and allowed to bench cool. The investment was removed, and the metal heat treated in accordance to the Cendres Metaux guidelines. The metal framework was then veneered with porcelain (GC Initial™, GC America, Inc.). The pontic and implant emergence were matched in the ceramic and consistent

on both the soft tissue and stone casts. The definitive FPD is tried in at a bisque bake stage and modifications made. The definitive FPD is then torqued to 35N and access holes filled with composite.

Discussion This use of provisional restorations to condition the tissue is now considered routine if the optimum esthetics are to be achieved. It would seem sensible to provide the technical team with every piece of information required. The use of customized impressions in single tooth replacement has been well documented, but extending the customized impression into the pontic site can further provide the technical team with accurate soft tissue information. The soft tissues collapse almost immediately following the removal of the provisional bridge. In customizing Volume 6 Number 1

CLINICAL

Figure 10: Impression

Figure 11: Hard tissue cast

Figure 12: Soft tissue cast

Figure 13: Final restoration with black diffuser

Figure 14: Final restoration with black diffuser

the impression copings, the soft tissues are adequately supported while the impression material sets. This information is replicated on the master casts. The accuracy of the impression technique is shown by the immediate support of the soft tissues with no blanching of the tissues at any point. The extent of soft tissue management that may be achieved during this restorative phase is limited. It is regarded that the most important factor in achieving an esthetic result is the correct three-dimensional positioning of the implants. A correct waxup and surgical stent are therefore required in all esthetic cases. 26 Implant practice

The choice of positioning the implants in these cases of replacing all the maxillary incisors is critical. The treatment outcome may have been greater if the implants had been placed in the lateral incisor positions. This configuration would remove the potentially hazardous position of placing two adjacent implants. In this case report, this would have required a lateral ridge augmentation procedure, and as such the central incisors sites were chosen. This esthetic risk is minimized as there will only be one midline papilla, and therefore, symmetry will not be altered in this case of placing two adjacent implants. In order to

give the best potential to create a midline papilla, the implants were placed more than 3 mm apart and were of a platformswitched design. This design appears to protect the crestal bone and the subsequent overlying tissue. This clinical report describes a simple, fast, and effective impression technique that accurately replicates the soft tissue emergence from the implant as well as the soft tissue sculpturing of the pontic site. IP References available upon request.

Volume 6 Number 1

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CASE STUDY

Clinical Case: All-on-4™ and NobelGuide™ in an atrophic mandible Drs. Paulo Malo, Armando Lopes, Mariana Nunes, André Rodrigues, Ana Ferro, and Miguel De Araújo Nobre explore an implant solution for extreme cases

Figure 1: Extraoral preoperative frontal photograph

Figure 2: Extraoral preoperative lateral photograph

Figure 3: Intraoral preoperative photograph - mandible

Introduction

Case presentation

Edentulous patients with extremely resorbed jaws have serious limitations when using a removable prosthesis: lack of retention, pain, masticatory and phonetic difficulties, lack of lip support, and loss of vertical dimension. The All-on-4™ concept (Nobel Biocare AB, Gothenburg, Sweden) enables the rehabilitation of extremely resorbed edentulous maxillae or mandibles, placing only four implants, avoiding complex surgical techniques such as bone graft procedures. The NobelGuide™ system (Nobel Biocare AB) allows not only a minimally invasive and simplified surgery, but also the previous planning of the exact position and direction of the implants in the 3D software. This results in a great advantage in “extreme cases.”

A 61-year-old healthy female patient attended the private practice (Malo Clinic, Lisbon, Portugal) concerned with poor retention and lack of prosthetic stability due to the severely resorbed mandible. Her goal was to obtain an implant-retained fixed rehabilitation that fulfilled the functional and esthetical demands.

A surgical guide was manufactured by Nobel Biocare according to the plan. The surgical template was used as a guide to obtain a stone cast and to make all the laboratory work. A surgical index was made with silicone (Silagum® Putty; DMG, Hamburg, Germany), and all prosthetic procedures were performed before surgery.

Diagnosis

Surgical procedure

Radiological and clinical evaluations determined that all the inclusion criteria were fulfilled to perform an All-on-4™ surgery following the NobelGuide procedure. The radiographic examination – orthopantomography and CBCT – demonstrated bone availability of 8 mm in height and 5 mm in width between the mental foramina. The clinical evaluation determined an adequate keratinized gingival thickness, low smile line, and mouth opening capability over 40 mm. Because the jaw was completely edentulous, there were no teeth interfering with the surgical planning.

Following the NobelGuide protocol, the surgical guide was stabilized with anchor pins using a surgical index. The surgery was performed following a similar protocol of the All-on-4™ conventional technique. NobelSpeedy™ Groovy RP 13 mm implants (Nobel Biocare AB) were placed in the posterior area, and NobelSpeedy™ Groovy RP 11.5 mm implants (Nobel Biocare AB) were placed in the anterior area according to a flapless approach. All implants were placed with an insertion torque over 50N/ cm, and after the implant placement, the surgical guide was removed and the multi-unit abutments (Nobel Biocare AB) were connected using custom positioning guides. The full-arch acrylic resin (Heraeus Kulzer GmbH, Hanau, Germany) prosthesis was screwed on immediately, and occlusal adjustments were performed. The patient was enrolled in an implant maintenance program and instructed to eat a soft diet for 2 months. Oral hygiene appointments were performed postoperatively on day 10, on months 2, 4 and 6, and every 6 months

Paulo Malo, DDS, PhD, is the president of the Malo Clinic in Lisbon, Portugal. Armando Lopes, DDS, is the director of implantology at the Malo Clinic. Mariana Nunes, DDS, works in the department of implantology at the Malo Clinic. André Rodrigues, DDS, works in the prosthodontic department at the Malo Clinic. Ana Ferro, DDS, is the sub-director of implantology at the Malo Clinic. Miguel De Araújo Nobre, RDH, MSc, is the director of oral hygiene at the Malo Clinic.

28 Implant practice

Planning A new removable denture was manufactured, taking into account the esthetic and functional requirements of the patient, which was used as a radiographic guide. The DICOM files were converted to 3D images by the NobelClinician™ Software (Nobel Biocare AB), and the implants’ virtual planning followed the Allon-4™ concept.

Volume 6 Number 1

CASE STUDY

Figure 4: Evaluation of the mouth opening capability

Figure 5: Preoperative orthopantomography

Figure 6: 3D view of mandible

Figure 7: Computer planning NobelClinician Software™

Figure 8: Intraoral photograph with the radiographic guide and the radiographic index bite registration (Occlufast®, Zhermack SpA, Badia Polisione, Rovigo, Italy) in position before the CBCT according to the double scan technique

Figure 9: Surgical template - mandible

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Volume 6 Number 1

1. Data on file at Exactech.

Implant practice 29

CASE STUDY

Figure 10: 30° non-engaging multi-unit abutment guides

Figure 11: Surgical index

Figure 12: Pre-made removable denture converted into screw-retained fixed acrylic resin complete prosthesis

between 1 and 5 years of follow-up, without registering any signs or symptoms of peri-implant pathology, or presence of significant marginal bone resorption (radiographically confirmed).

with acrylic resin prosthetic teeth (Heraeus Kulzer GmbH) was connected. In this final bridge, the occlusion was adjusted according to the patient’s natural dentition: bilateral anteroposterior harmonious contacts more pronounced in the posterior teeth, anterior group incisor protrusive guide, and lateral canine excursive guide. A final orthopantomography was made after fitting of the final rehabilitation. The clinical and radiographic parameters remained stable during the 5-year followup.

Conclusion

Final prosthetic protocol Six months after surgery, a Malo Clinic acrylic bridge was manufactured, finalizing the rehabilitation, and fulfilling functional, phonetic, and esthetic requirements. A titanium-acrylic resin implantsupported fixed prosthesis (NobelProcera titanium framework; Nobel Biocare AB)

When there is a suitable patient selection and a good surgical planning, the use of the All-on-4™ and NobelGuide presents advantages. The time required to perform the surgery is reduced when compared with other methods, making it more convenient to the patient. As this is a flapless procedure, the patient’s well-being is maximized by ensuring greater comfort and minor edema in the oral region. For the surgeon, this technique presents as a precise and predictable approach. This case shows that the rehabilitation of atrophic mandibles with immediate fixed bridges is possible using the All-on-4™ concept. The NobelGuide planning decreases the surgical risks, adding to the known advantages the possibility of using it on extreme cases.

References

Figure 13: Intraoral postoperative photograph

Figure 14: Final orthopantomography (3-year follow-up)

van Steenberghe D, Ericsson I, Van Cleynenbreugel J, Schutyser F, Brajnovic I, Andersson M. High precision planning for oral implants based on 3D CT scanning. A new surgical technique for immediate and delayed loading. Appl Osseoint Res. 2004;4:27-31. Maló P, Rangert B, Nobre M. All-on-Four immediate-function concept with Branemark System implants for completely edentulous mandibles: a retrospective clinical study. Clin Implant Dent Relat Res. 2003;5(Suppl 1):2-9.

Figure 15: Occlusal photograph of Malo Clinic acrylic bridge

30 Implant practice

Figure 16: Frontal intraoral photograph of Malo Clinic acrylic bridges

Maló P, Nobre M, Lopes A. The use of computerguided flapless implant surgery and 4 implants placed in immediate function to support a fixed denture: preliminary results after a mean follow-up period of 13 months. J Prosthet Dent. 2007;97:S26-S34.

Volume 6 Number 1

CASE STUDY

Figure 1: Extraoral preoperative frontal photograph

Figure 2: Extraoral preoperative lateral photograph

Figure 3: Intraoral preoperative photograph - mandible

Introduction

Case presentation

Diagnosis

Surgical procedure

28 Implant practice

Planning A new removable denture was manufactured, taking into account the esthetic and functional requirements of the patient, which was used as a radiographic guide. The DICOM files were converted to 3D images by the NobelClinicianTM Software (Nobel Biocare AB), and the implants’ virtual planning followed the Allon-4TM concept.

Volume 6 Number 1

CASE STUDY

Figure 4: Evaluation of the mouth opening capability

Figure 5: Preoperative orthopantomography

Figure 6: 3D view of mandible

Figure 7: Computer planning NobelClinician Software™

Figure 9: Surgical template - mandible

Academy of Osseointegration

Booth # 1210

1. Data on file at Exactech.

Volume 6 Number 1 Implant practice 29

CASE STUDY

Figure 10: 30° non-engaging multi-unit abutment guides

Figure 11: Surgical index

Figure 12: Pre-made removable denture converted into screw-retained fixed acrylic resin complete prosthesis

between 1 and 5 years of follow-up, without registering any signs or symptoms of peri-implant pathology, or presence of significant marginal bone resorption (radiographically confirmed).

Conclusion

References

Figure 13: Intraoral postoperative photograph

Figure 14: Final orthopantomography (3-year follow-up)

Figure 15: Occlusal photograph of Malo Clinic acrylic bridge

30 Implant practice

Figure 16: Frontal intraoral photograph of Malo Clinic acrylic bridges

Volume 6 Number 1

CONTINUING EDUCATION

SonicWeld Rx™ — A novel replacement for traditional titanium mesh in particulate bone grafting Dr. Lewis Cummings discusses an improved method for particulate bone grafting

ith the increased predictability of tissue augmentation and implant dentistry, it is commonplace to design a final prosthesis from the ideal restorative position rather than simply from where bone is available. Though hard tissue can be regenerated in a variety of defects, its position must be statically maintained during the revitalization period. Traditionally, large particulate bone grafts have been stabilized with a titanium mesh and fixation screw system. Although effective, complications with mesh exposure during healing, and with its inevitable removal, are often encountered. The desire to eliminate factors such as these has led to the development and introduction of a resorbable, rigid fixation system for particulate bone grafting. The following is a case study demonstrating the use of the SonicWeld Rx™ system to increase the ridge within an edentulous site prior to implant replacement. A 49-year-old male presented with a significant buccal osseous defect resulting from the longstanding loss of the mandibular right first molar and second premolar (Figures 1A-1C) with an implantsupported restoration planned as the final prostheses. Given the volume of bone loss

Lewis Cummings, DDS, MS, received his dental degree from the University of Texas Health Science Center at San Antonio. While there, he received the Horace Wells Anesthesiology Award and the Annual Student Award for outstanding achievement in Periodontics from the American Academy of Periodontology. He did his residency at the University of Nebraska Medical Center in Lincoln, where he completed a Master’s Degree in Oral Biology and received his certificate in periodontics. While in Lincoln, Dr. Cummings began to research tissue engineering and has since lectured nationally on the topic. Additionally, Dr. Cummings has advanced his dental implant training by attending the Misch International Implant Institute. Currently, he holds associate professor positions with both the University of Texas Dental School at Houston and the University of Nebraska Medical Center in Lincoln, teaching soft tissue grafting and dental implants in the post-graduate programs. He is also an instructor with the Center for Advanced Dental Education in Dallas, Texas and the Rocky Mountain Dental Institute in Denver, Colorado.

32 Implant practice

Educational aims and objectives The aim of this article is to introduce the reader to an alternative to traditional titanium mesh. Expected outcomes Correctly answering the questions on page 35, worth 2 hours of CE, will demonstrate the reader can: • Realize the advantages and disadvantages of titanium mesh in particulate bone grafting. • Describe the need for a resorbable, rigid fixation system for particulate bone grafting in certain cases. • See the various steps involved in the SonicWeld Rx system.

Figure 1A: Preoperative ridge defect

in the molar site and the desire to minimize postoperative morbidity, an allogenic particulate bone graft using freeze-dried bone allograft (FDBA) was chosen for defect regeneration. Though particulated FDBA has proven successful for osseous regeneration1, lateral ridge augmentation often requires rigid, three-dimensional support as the graft mineralizes. This support must be resilient enough to withstand the compressive forces of the overlying soft tissue flap and potential traumatic contact during mastication. Historically, titanium mesh has served as the primary material from which to create three-dimensional, rigid membranes for guided bone regeneration2,3. Titanium mesh offers the advantages of being biocompatible and malleable, easily conforming to defect dimensions. Following manipulation, fixation of the mesh is often required to prevent micromovement during graft maturation. This fixation is often accomplished with the placement of screws or tacks through the mesh into the host bone. This containment and fixation

Figure 1B: Preoperative ridge defect

Figure 1C: Occlusal view of osseous ridge defect

provide rigid stability for the particulate graft, allowing for bony regeneration in a variety of defects. Though successful in space maintenance, a significant drawback to titanium mesh is the requirement of a second surgical procedure for removal following graft ossification. Often, the overlying soft tissue may partially encase the mesh framework making removal complicated, requiring generous flap access. Additionally, if the titanium mesh becomes exposed during the healing process, complications may arise.4 To overcome drawbacks associated Volume 6 Number 1

Figure 3: SonicPin Rx placement

Figure 4: Coronal edge of membrane containing FDBA

Figure 5: Buccal view of coronal edge of membrane containing FDBA

Figure 6: Acellular dermal matrix overlying the grafted site

Figure 7: Incision closure using 6.0 polypropylene and 4.0 PTFE suture

with titanium mesh, a resorbable, rigid fixation system has been introduced. The SonicWeld Rx system of resorbable fixation pins and membranes eliminates the need for device removal once healing is complete. The system is comprised of fixation pins and rigid membranes composed of a 50:50 blend of D- and L-isomers of polylactic acid that are broken down over time through hydrolysis. For device placement, an ultrasonic vibrating handpiece is employed that generates frictional heat, allowing the transformation of the solid polymer pins to a temporary liquefied state for insertion at the surgical site. This transformation allows for the engagement of the partially liquefied pin into the ever-narrowing recipient preparation created in the host bone. During this process, a minimal elevation in temperature is created, but only for very short periods of time where the two hard surfaces are in contact.5 After the placement of SonicPin Rx’s, the membrane is cut to the shape desired, and the same frictional heat process is used to weld the two together. The heat created between the two solid pieces of polymer Volume 6 Number 1

To overcome drawbacks associated with titanium mesh, a resorbable, rigid fixation system has been introduced. The SonicWeld Rx system of resorbable fixation pins and membranes eliminates the need for device removal once healing is complete.

creates a “spot weld” in the specific location and secures the membrane to the pin. Vertical augmentation can be accomplished by bringing the coronal edge of the membrane to the desired future height of bone. This same technique can be employed in sites where a lingual osseous defect is present. For this case, local anesthetic was administered, and a traditional full-thickness mucoperiosteal flap was elevated for access to the surgical site. Using rotary instruments, superficial decortication of the edentulous molar site was performed in the area to be augmented (Figure 2).

Three 2.1 x 4 mm SonicPin Rx’s were placed using the SonicWeld Rx protocol (Figures 2 and 3) to stabilize the membrane used for graft containment. For this case, a pin was placed in the interdental space between the lower right premolars, on the mesial of the second molar, and at the apex of the augmentation site. A 12 mm x 30 mm foil was trimmed and welded to the pinheads using the standard protocol (Figure 4). Once welded, the membrane creates a three-dimensional containment system for the particulated bone graft. Following rehydration of FDBA (MinerOss®, BioHorizons® Osteotech) and application Implant practice 33

CONTINUING EDUCATION

Figure 2: Perforation holes and SonicPin Rx placement

CONTINUING EDUCATION

Figures 8A-8C: Four-month reentry compared to preoperative ridge width

Figure 9: Implant placement with healing abutment

of platelet rich plasma, the graft was inserted into the recipient preparation (Figure 5). Once the defect was completely filled with particulate graft, the entire area was covered with an acellular dermal matrix graft (Figure 6). The dermal matrix, rehydrated with platelet rich plasma, was utilized for graft containment and augmentation of the overlying gingiva. Complete and passive site closure was obtained using a combination of 4.0 PTFE and 6.0 polypropylene sutures (Figure 7). A traditional post-surgical protocol was followed for 7 days consisting of antiinflammatory and antibacterial agents, with the patient being instructed to not masticate in the area.

abutments were placed, preventing the need for a future uncover surgery. The site was then closed with absorbable sutures, and a traditional post-implant placement protocol was followed by the patient for the first week. Following an additional 4-month healing period to allow for proper implant integration, the patient returned to his restorative dentist to begin fabrication of the final restoration. By utilizing the resorbable system and eliminating the need for a second procedure for mesh removal, the patient’s experience was enhanced, and the operator’s chair time was reduced, while an excellent quality of bone was regenerated.

Following 4 months of uneventful healing (Figures 8A-8C), the site was reentered for implant placement. At this time, the particulate bone graft was clinically well integrated with the host bone, and excellent density was noted clinically (Figure 8). Minimal access was necessary at the reentry, as the SonicWeld Rx graft containment system did not have to be removed and was breaking down by hydrolysis. Two implant osteotomies were prepared to receive a 3.8 mm diameter and 4.6 mm diameter BioHorizons® tapered internal hex implants with the Laser-Lok® surface (Figure 9). Given the good bone density and adequate torque placed on the implants during insertion, healing

References 1. Rummelhart JM, Mellonig JT, Gray JL, Towle HJ. A comparison of freeze-dried bone allografts and demineralized freeze-dried bone allografts in human periodontal osseous defects. J Periodontol. 1989;60:655-663. 2. Assenza B, Piattelli M, Scarano A, Iezzi G, Petrone G, Piattelli A. Localized ridge augmentation using titanium micromesh. J Oral Implantol. 2001;27(6):287-292.

3. Malchiodi L, Scarano A, Quaranta M, Piattelli A. Rigid fixation by means of titanium mesh in edentulous ridge expansion for horizontal ridge augmentation in the maxilla. Int J Oral Maxillofac Implants. 1998;13(5):701-5. 4. Miyamoto I, Funaki K, Yamauchi K, Kodama T, Takahashi T. Alveolar ridge reconstruction with titanium mesh and autogenous particulate bone graft: computed tomography-based evaluations of augmented bone

quality and quantity. Clin Implant Dent Relat Res. 2012;14(2):304-11. 5. Pilling E, Mai R, Theissig F, et al. An experimental in vivo analysis of the resorption to ultrasound activated pins (Sonicweld) and standard biodegradable screws (ResorbX) in sheep. Br J Oral Maxillofac Surg. 2007;45:447.

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34 Implant practice

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Volume 6 Number 1

CONTINUING EDUCATION

SonicWeld Rx™ — A novel replacement for traditional titanium mesh in particulate bone grafting Dr. Lewis Cummings discusses an improved method for particulate bone grafting

32 Implant practice

Figure 1A: Preoperative ridge defect

Figure 1B: Preoperative ridge defect

Figure 1C: Occlusal view of osseous ridge defect

Figure 3: SonicPin Rx placement

Figure 4: Coronal edge of membrane containing FDBA

Figure 5: Buccal view of coronal edge of membrane containing FDBA

Figure 6: Acellular dermal matrix overlying the grafted site

Figure 7: Incision closure using 6.0 polypropylene and 4.0 PTFE suture

Volume 6 Number 1 Implant practice 33

CONTINUING EDUCATION

Figure 2: Perforation holes and SonicPin Rx placement

CONTINUING EDUCATION

Figures 8A-8C: Four-month reentry compared to preoperative ridge width

Figure 9: Implant placement with healing abutment

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34 Implant practice

Volume 6 Number 1

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SonicWeld Rx™ — A novel replacement for traditional titanium mesh in particulate bone grafting 1. Though hard tissue can be regenerated in a variety of defects, its position must be statically maintained during _________. a. the patient’s childhood b. the year prior to treatment c. the revitalization period d. a period of retention 2. Traditionally, large particulate bone grafts have been ______ with a titanium mesh and fixation screw system. a. stabilized b. removed c. resorbed d. liquefied 3. Though particulated FDBA has proven successful for osseous regeneration, lateral ridge augmentation often requires rigid, threedimensional support as the graft _____. a. breaks down b. mineralizes c. elevates d. rehydrates 4. This (rigid, three-dimensional) support must be resilient enough to withstand ______. a. the pull of the titanium mesh b. the compressive forces of the overlying soft tissue flap

Volume 6 Number 1

c. potential traumatic contact during mastication d. both b and c 5. Historically, _______has served as the primary material from which to create threedimensional, rigid membranes for guided bone regeneration. a. particulated FDBA b. polylactic acid c. titanium mesh d. L-isomers 6. The SonicWeld Rx system of resorbable fixation pins and membranes ______device removal once healing is complete. a. eliminates the need for b. increases the need for c. helps to facilitate d. ensures 7. For device placement, an ultrasonic vibrating handpiece is employed that _____, allowing the transformation of the solid polymer pins to a temporary liquefied state for insertion at the surgical site. a. causes gingival movement b. encases the mesh c. dispenses polylactic acid d. generates frictional heat

8. The heat created between the two solid pieces of polymer creates a ______ in the specific location and secures the membrane to the pin. a. reduction in temperature b. decortication c. “spot weld” d. vertical augmentation 9. ______ can be accomplished by bringing the coronal edge of the membrane to the desired future height of bone. a. Decortication b. Vertical augmentation c. Malleability d. Flap access 10. Given ______placed on the implants during insertion, healing abutments were placed, preventing the need for a future uncover surgery. a. the good bone density b. adequate torque c. absorbable sutures d. both a and b

Implant practice 35

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IMPLANT PRACTICE CE

CONTINUING EDUCATION

Secure bonding: implants and overdentures Dr. Ludwig Hermeler demonstrates how to modify an existing overdenture for use with implants and secure it with direct intraoral adhesion

he secure hold of full dentures, particularly in the lower jaw, decreases with age. This is essentially due to progressive jaw atrophy in connection with soft tissue changes and reduced salivation. Implants can help to remedy this. In many cases, the existing restoration can still be used if connecting elements, such as locators, provide a reliable connection between the implants and the functional overdenture. To allow such attachments to be bonded in at chairside, Voco has developed the Quick Up set that makes the clinical workflow both simple and safe for the dentist. Dental implants were originally developed for use in edentulous jaws. As patients become increasingly older, the natural changes in the edentulous alveolar ridge, and, in particular in the lower jaw, result in a deterioration in the hold of the denture. A firm bite can be recreated using various types of implants (one-piece, twopiece, mini-implants). The existing restoration can often be used, but is modified for the connection between the implants and the denture. This is where the attachments, which are precisely aligned to the implant system, come into play. These are bonded into the basis of the denture at the chairside. Thanks to this method, the workflow can be handled internally at the practice, the costs and time required are significantly reduced, and the patient is spared the otherwise unavoidable waiting time due to external laboratory work. Direct intraoral adhesion ensures the maximum possible accuracy. The Quick Up set by Voco (Figure 1) includes all of the necessary components for safe and simple luting. • Fit Test C and B, a low-viscosity liquid control silicone

Dr. Ludwig Hermeler, Med Dent, qualified at the Westfälische Wilhelms Universität Münster in 1988 and established his own practice in Rheine, Germany in 1991. He has had articles published on the subjects of esthetic dentistry, bleaching, implantology, and endodontics. He is a member of the German Association of Oral Implantology (DGOI).

36 Implant practice

Educational aims and objectives The aim of this article is to show a reliable and effective procedure for the adhesion of implants to overdentures at the chairside. Expected outcomes Correctly answering the questions on page 39, worth 2 hours of CE will demonstrate that the reader can: • See the benefit that a reliably secured overdenture can have for patients. • Learn one protocol for achieving this through dental implant treatment. • Gain a better knowledge of the process of intraoral adhesion at the chair side.

Figure 1: The Quick Up set (Voco)

• Quick Up adhesive, a bonding agent between the denture material and Quick Up • Quick Up, a self-curing luting composite in the color of the denture base (gingiva colored) • Quick Up LC, a light-curing, also gingiva colored, luting composite for amendments/ corrections after the luting of attachments with the self-curing material Quick Up.

Case study Initial clinical situation: Two OsseoSpeed™ TX implants (Astra Tech) with a diameter of 3.5 mm were inserted in parallel alignment in the atrophied jaw of a 77-year-old male patient. Around 4 months later, they were

exposed following a complication-free period of healing and osseointegration. The fit of the margins and the base of the existing lower jaw dentures are fully functional, the hold is to be enhanced using locators because of jaw atrophy. Figure 2 shows measurement of the height of the mucosa using an abutment depth gauge (Astra Tech). The retentive part of the locator abutments selected according to height should be located supragingivally with sufficient spacing. Placement of the finished overdenture is easier for the patient if the locator secondary components are at the same horizontal height. Volume 6 Number 1

Figure 3: Placement of the selected locator abutments in the OsseoSpeed TX implants

Figure 4: Resilience spacers and metal matrices in position

Figure 5: Determining the position with a felt-tip pen for copying in the denture base

Figure 6: Checking of the space required in the denture base using the Fit Test C and B

Figure 7: Covering of the vestibular face of the abutment

Figure 8: Filling of the openings up to two-thirds full, using self-curing Quick Up

Figure 9: Visible ditchings upon removal from the mouth

The abutments are screwed in and tightened to 25Ncm (Figure 3). The resilience spacers, which serve to compensate for mucosal resilience, are positioned on the locator abutments, and then, the locator metal matrices are placed on the locator abutment analogues (Figure 4). Using Quick Up, attachments are secured chairside in three simple steps.

Step one: preparation Using a felt-tip pen (alternatively, articulating paper, occlusion spray, or similar can be used), the position of the locator metal matrix can be transferred to the denture base by simple copying (Figure 5). The marked areas are relief-ground only enough to enable the denture to be easily inserted over the implants with attached secondary components. Large-scale relief-grinding, and the creation of drainage channels is not necessary when using Quick Up. As well as the clinical check, with the control and covering silicone Fit Test C and B, the correct relief-grinding is simply shown in the denture base (Figure 6). Fit Test C and B can also be used in particular to block out and protect undercut interface areas between the implant and gingiva. The slim, angled cannulae ensure simple and delicate application. Figure 7 shows the applied silicone

Figure 10: Polymerization of Quick Up LC

Volume 6 Number 1 Implant practice 37

CONTINUING EDUCATION

Figure 2: Initial situation and measuring of the gingival height for the correct locator height

CONTINUING EDUCATION

Figure 11: Polishing of the denture after bonding in

Figure 12: Placement of the desired locator insert in the metal matrix using the insertion instrument

for demonstration purposes; as there were no undercuts, it was not required and removed again.

Step two: luting The prepared denture base is wetted with the Quick Up adhesive. The overdenture openings intended for the attachments are filled two-thirds full (i.e., not completely) with Quick Up (Figure 8). The denture is reinserted, and correct occlusion is checked without exerting too much pressure on the soft tissue. After a Quick Up curing time of 3-1/2 minutes, the lower dentures can be removed from the mouth. The locator abutments are now bonded into the base both securely and precisely. 38 Implant practice

Step three: polishing

corrections

Figure 13: Trouble-free and close fit of the finished lower prosthesis

and

Since the ground openings in the denture are deliberately not completely filled with Quick Up, ditchings (Figure 9) are evident. These can be filled under visual inspection with the light-curing Quick Up LC and polymerized (Figure 10). With finishing and polishing, successful adhesion with Quick Up (Figure 11) is concluded. On the locator abutment, the black working insert is exchanged for a locator insert with the desired bond strength – here, initially blue (680g retention force) – and the resilience spacers are removed (Figure 12). Handling is practiced together with the patient, optimal oral hygiene (including

the use of Solostix and chlorhexidine gel) is shown, and the necessary frequent recalls are arranged. Weeks later, a happy patient, who can bite powerfully again, comes to the followup session (Figure 13).

Conclusions With the Quick Up method – whereby firstly self-curing Quick Up material, followed by light-curing Quick UP LC is used to lute the attachments, and secondary components – disastrous adhesion to the implant in the mouth is avoided. The Quick Up components included in the set have been specially designed and combined to enable the simple and safe luting of attachments at the chairside. IP Volume 6 Number 1

Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement 12/1/2012 to 11/30/2016 Provider ID# 325231

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Secure bonding: implants and overdentures 1. The secure hold of full dentures, particularly in the lower jaw, ______ with age. a. increases b. decreases c. never changes d. retains its original fit 2. This (change in the hold of full dentures) is essentially due to progressive jaw atrophy in connection with _______. a. soft tissue changes b. bruxation c. reduced salivation d. both a and c 3. In many cases, the existing restoration can still be used if connecting elements, such as locators, provide a ________between the implants and the functional overdenture. a. reliable connection b. modified restoration c. supragingival space d. higher mucosa 4. A firm bite can be recreated using various types of implants, (__________). a. one-piece b. two-piece c. mini-implants d. all of the above

Volume 6 Number 1

5. (In the case study) The retentive part of the locator abutments selected according to height should be located _________. a. below the gingival margin b. supragingivally c. with sufficient spacing d. both b and c 6. Placement of the finished overdenture is easier for the patient if the locator secondary components are _______ horizontal height. a. at the same b. at a different c. at the maximum d. not measured by 7. (In this case) The abutments are screwed in and tightened to_____. a. 10Ncm b. 15Ncm c. 25Ncm d. 30Ncm

a. greatly increase b. greatly decrease c. serve to compensate for d. determine 9. (In step one: preparation) Using _______ (alternatively, articulating paper, occlusion spray, or similar can be used), the position of the locator metal matrix can be transferred to the denture base by simple copying. a. an explorer tip b. a felt-tip pen c. the resilience spacer d. Quick Up adhesive 10. (In step two: luting) After a Quick Up curing time of ______, the lower dentures can be removed from the mouth. a. 2 minutes b. 3-1/2 minutes c. 4 minutes d. 4-1/4 minutes

8. The resilience spacers, which _______ mucosal resilience, are positioned on the locator abutments, and then, the locator metal matrices are placed on the locator abutment analogues.

Implant practice 39

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IMPLANT PRACTICE CE

RESEARCH

Early loading versus immediate loading: case examples Drs. Alberto Maltagliati, Andrea Ottonello, Giulio Raffaghello, and Andrea Mascolo explore esthetics and function of early and immediate loading implants Introduction “Immediate loading” is a favorite way to maintain appropriate anatomic and topographic proportions between dental arches, to maintain the contact with periodontal tissues, and for the “occlusal/ contact memory”.1-2 An edentulous area that remains this way for a long period of time may modify and even preclude the possibility of recreating an occlusion that is esthetic, functional, always predictable, and similar to the original.3 The concept of “primary stability,” torque wrench, osseointegration, and adequate/suitable denture, are the fundamental factors for immediate and long-distance clinical results.4-5 With immediate loading, the management of peri-implant soft tissues can lead to a long-term predictability with 30-year old case-studies;6-7 moreover, the waiting time for osseointegration allows for modulation/mediation of some human mistakes not managed in the early loading phases in the 72-hour prosthetic technique.8 The use of autologous fibrin glue in the same surgery increases the neoangiogenesis and the healing factors’ activity, also obtaining a better predictability regarding soft-tissue management.9-10

Case 1

Figure 1A: Initial OPG

Figure 1B: Intra surgery: extractions and inserting fixtures

Figure 1C: Immediately after surgery: taking impression

Figure 1D: Detail

Figure 1E: Immediately after restoration

Figure 1F: OPG check after surgery

Aim of the study Alberto Maltagliati, DDS, earned his dental degree from the University of Genoa, in Italy. He has taught at the University of Genoa and the University of Chieti. Andrea Ottonello, DDS, PhD, received his degree from the University of Genoa, and also earned a PhD at the same university. He has been a visiting PhD student and obtained a Fellowship in Periodontology at the Department of Periodontics and Oral Medicine at the University of Michigan, and is now a professor in Periodontology at the University of Genoa. Giulio Raffaghello, DDS, graduated from the University of Pavia, Italy, and attended a course in endodontics. He is in private practice, with Dr. Mascolo, DDS, in research activities. Andrea Mascolo, DDS, has a Master in Oral Surgery from the University of Pisa, Italy. He qualified for Implantology at the Brånemark Clinic, Gothenburg, Sweden and attended the Summer School Clinical Implantology Periodontology at the University of Heidelberg, Germany. He is founder and an active member of the Computer Aided Implantology (CAI) Academy and has been a Professor at the University of Genoa since 2001. He is a speaker and author in Italy and abroad, and is an international peer reviewer. He maintains a private practice in Novi Ligure, Italy, devoted to minimally invasive surgical procedures on compromised patients. He is UK GDC registered, and is an expert in periodontics and implantology in private clinics.

40 Implant practice

The aim of this study was to demonstrate the concept of middle and long-term esthetic and functional predictability differentiating: - full arch implant restoration, cemented technique, with loading after 60-90 days (early loading) - full arch implant restoration, screwed technique, with loading after 72 hours (immediate loading) since fixture insertion.

Materials and methods A retrospective analysis was conducted of patients undergoing implant therapy with a load time period shorter than the standard; the inclusion criteria was a follow-up period of over 2 years. Included in the study were Volume 6 Number 1

RESEARCH 233 implants, of which 110 were in the jaw and 123 were in the maxilla: 18 patients, eight male and 10 female, received early loading treatment; two patients were under 50 years old, seven were under 60 years old, and the last nine were under 70 years old. Some patients presented systemic conditions: three were affected by heart disease, and one patient was affected by diabetes. In this patients’ group, we had 10 totally edentulous patients and eight only one arch edentulous patients. Thirteen patients, seven male and six female, received immediate load treatment; eight patients were under 60 years old and five were under 70 years old. Two patients presented with heart disease. In this patients’ group, we had eight totally edentulous patients and five only one arch edentulous patients. For the patients selected, two kinds of implants were used: Intra-Lock® International (Boca Raton, FL) and Tekka In-Kone® (Brignais, FR/EU), with a length from 4 to 13 mm. One hundred and seven implants were fitted with the finished prosthesis with a cemented technique after 60-90 days (early loading); 126 implants were fitted with the finished prosthesis with screwed technique after 72 hours (immediate loading). The chosen technique was opercular and flapless, with the insertion of the implants at least 1 mm under the crestal bone level, to avoid the conic reabsorption peri-implant process. The impression was taken with the pick-up technique with polyvinyl siloxane (Identium® Kettenbach GmbH & Co. KG., Eschenburg, Germany). In the following 36 hours, we tried on the structure. Pick-up impression technique cemented. The prosthesis in metal-ceramic was cemented after 72 hours from implant placement. Autologous fibrin glue was used with PRF methodic to increase peri-implant connective tissue formation and manage inflammation and healing, and accelerate vascularization by the growth factors (i.e. VEGF, PDGF) contained in the buffy coat. All clinical cases have been monitored radiographically with the same machine 12 and 24 months after the loading date. The same doctor monitored all the clinical cases performing a periodontal probe after 6, 12, 18, and 24 months.

with a totally edentulous maxilla and previous maxillary sinus augmentation before implant restoration, with three 3I™ implants with external hexagon supporting a mandibular overdenture. It was decided that the best course of action was immediate loading with cemented technique adding five Intra-Lock CT 4 mm implants and using the previous implants. The technique chosen was the opercular one, flapless, with the insertion of the implants at least 1 mm under the crestal bone level, to avoid the conic reabsorption peri-implant process. The impression was taken with the pick-up technique with polyvinyl siloxane. In the following 36 hours, the structure was tried on and cementation of the prosthesis in metal-ceramic took place 72 hours after surgery. Case 2 (Figures 2A-2F) A 45-year-old female patient was affected by chronical periodontitis. The treatment involved immediate loading at the maxilla with eight Intra-Lock CT implants 4 mm; we maintained first and second superior left molars for inter arch occlusal contacts. The prosthetic technique included a posterior

region flat-one bridge with composite filling with screwed technique, with the intercanine area in metal-ceramic. Multiple extractions were performed with maintenance of vestibular and interproximal cortical, and insertion of six Tekka In-Kone implants, which we chose for the excellent esthetic profile given by the switch-platform that reduces prosthetic spaces, increasing the periimplant connective tissue. Implant insertion 2 mm under the cortical bone allows for peri-implant bone regeneration. Pickup impression technique cemented. The prosthetic restoration was in metal-ceramic cemented after 72 hours from implant placement.

Results After 18 months, we report a 2 mm conical peri-implant reabsorption on six implants loaded after 72 hours in parafunctional patients, having natural teeth opposing prosthetic full-arch rehabilitations. No reabsorption was noticed in patients with upper and lower full-arch restorations.11-12 Two implants in the maxilla (first left molar and first right molar in the same patient), both loaded after 72 hours (immediate

Case 2

Figure 2A: Fixture insertion: operculum

Figure 2B: Immediately after surgery: taking impression

Figure 2C: Impression: parallelism between fixtures

Figure 2D: Abutment inserted immediately after surgery

Figure 2E: Restoration cementation

Figure 2F: OPG

Case examples Case 1 (Figures 1A-1F) A 60-year-old female patient presented 42 Implant practice

Volume 6 Number 1

RESEARCH

Table 1

Table 2

Table 3

loading), failed. Results confirmed an augmentation in short-term esthetics in the immediate loading technique within 24 months, with a physiological maintenance of the interimplant papilla and a good trophism of the periodontal tissues.

Every technique used needed a good mid- and long-term predictability and repeatability, and with both methods we can assure esthetics and function.13

Conclusions Finally, in our opinion, supported from

the recorded data, the immediate loading technique (full-arch with screwed technique) represents the current “gold standard” in implant prosthetic restoration, because it reduces intraoperatory time and increases wound healing, in hard and soft tissues, with excellent patient compliance. IP

References 1. Cochran DL, Morton D, Weber HP. Consensus statements and recommended clinical procedures regarding loading protocols for endosseous dental implants. Int J Oral Maxillofac Implants. 2004:109-13.

6. Balshi SF, Allen FD, Wolfinger GJ, Blashi TJ. A resonance frequency analysis assessment of maxillary and mandibular immediately loaded implants. Int J Oral Maxillofac Implants. 2005;20(4):428-34.

2. Nkenke E, Fenner M, Vairaktaris EG, Neukam FW, Radespiel-Tröger M. Immediate versus delayed loading dental implants in the maxillae minipigs. Part II: histomorphometric analysis. Int J Oral Maxillofac Implants. 2005;20(4):540-6.

7. Grotowski T, Dal Carlo L, Garbaccio D. Carico funzionale immediato di impianti a vite bicorticale di Garbaccio post-estrattivi immediati – studio multicentrico prospettico su 15 anni di esperienza impianto protesica. Chrurgia Orale; 2007.

3. Sabattini B. Tecniche ricostruttive e rigenerative dei mascellari atrofici. Torino: TU.E.OR.; 2007:298-301.

8. Glauser R, Sennerby L, Meredith N, Rée A, Lundgren A, Gottlow J, Hämmerle CH. Resonance frequency analysis implants subjected immediate or early functional occlusal loading. Successful vs. failing implants. Clin Oral Implants Res. 2004;15(4):428-34.

4. Nkenke E, Fenner M. Indications for immediate loading of implants and implant success. Clin Oral Implants Res. 2006;7(2):19-34. 5. Lorenzon G. Implantologia funzionale dalla osteointegrazione alla fisiointegrazione. Martina; 2010:4-123.

9. Grotowski T. Syncrystallization - technique for joining dental implants. Physical and clinical observation in 17-year old. Magazyn Stomatologiczny (Polonia). 2007;6:58-69.

10. Linkow L. The Legends of Implant Dentistry. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd.; 2010.79-172. 11. Jokstad A, Carr AB. What is the effect on outcomes of time-to loading of fixed or removable prosthesis placed on implant(s)? Int J Oral Maxillofac Implants. 2007;22(suppl):19-48. 12. Diotallevi P, Moglioni E, Pezzuti E,Pierazzini A, Pasqualini ME, Floris P. Correlazioni biomeccanicoradiologiche nel riassorbimento osseo perimplantare. Studio comparativo su 47 soggetti. DoctorOS. 2007;18(2). 13. Klineberg I, Kingston D, Murray G. The bases for using a particular occlusal design in tooth and implantborne reconstructions and complete dentures. Clin Oral Implants Res. 2007;18(3)151–167.

Volume 6 Number 1 Implant practice 43

STEP-BY-STEP

Socket grafting made simple BondBone®

ocket preservation has become a hot topic for specialists and general practitioners alike. The amount of bone loss following extractions can be greatly reduced by placing bone graft material immediately post extraction. BondBone® is a unique biphasic calcium sulfate bone augmentation material that can be used for this purpose as a stand-alone product. The term “bi-phasic” refers to the combination of hemihydrate and dihydrate calcium sulfate particles in this product. BondBone does not need a catalyst to set and will set in the presence of blood and saliva. Once BondBone has been hydrated with sterile saline, the pre-set seed particles initiate the setting process. The entire setting process takes 3-5 minutes to occur. In bony defects larger than 10 mm, BondBone can be used as part of a composite graft. This is done by mixing BondBone with a particulate graft material of the clinician’s choice at a ratio of 2:1 BondBone to particulate graft. This allows the paste that is formed to become cementable in the site. Depending on the particulate graft material used, the resorption time of the composite graft could be extended. BondBone used alone has been shown to fully resorb within 3-4 months after placement. Following extraction, the following steps should be followed in a simple socket preservation procedure using BondBone as a stand-alone product.

44 Implant practice

1. Follow normal post-extraction protocol, which includes fully debriding the socket of all granulation tissue. This will ensure that good bone-to-product contact will be achieved. BondBone begins to set immediately after the hydration process is started. It will fully set within 2-3 minutes after hydration so it is important not to hydrate the BondBone until the graft site is fully prepared.

Prepare the BondBone in the driver in which it is packaged. Remove the outer small tip, and place the tip of a long, sterile needle filled with sterile saline into the driver. Holding the driver horizontally, slowly express the saline into the driver at a 1:1 ratio of saline to BondBone. Continue until you see a couple of drops of saline drip out of the driver. Remove the needle from the driver.

Slowly push down on the BondBone driver to express all of the excess liquid and to compress the BondBone in preparation for placement into the socket. Push down until you feel resistance.

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STEP-BY-STEP

4. Remove the second tip from the driver. You will notice excess moisture at the opening of the driver. Remove the excess moisture by gently blotting the end of the driver on a piece of sterile gauze.

5. Extrude the BondBone directly into the extraction socket. Slightly overfill the socket just above the crest of the ridge.

6. Take dry gauze, and place it over the BondBone graft while applying pressure to the graft with your thumb. This draws out any excess moisture from the graft.

7. Hydrate gauze with sterile saline, and place the gauze over the graft. Have the patient bite down, and relax for 2 minutes. This will allow the graft to set completely and bond to the bone.

8. After the BondBone is set, cut and place a membrane of choice over the graft, and suture into place. IP

This information was provided by MIS Implants Technologies, Inc. www.misimplants.com Phone: 866-797-1333 Email: service@misimplants.com

Volume 6 Number 1 Implant practice 45

PRODUCT PROFILE

Aseptico’s AEU-7000L-70V fiber optic motor system

ll Aseptico-branded products are built in the United States, fully regulatory compliant to U.S. and international manufacturing and safety standards.

AEU-7000L-70V fiber optic motor system The AEU-7000L-70V fiber optic motor system is designed for many specialties, including implant, endo, restoration, and oral surgery. Features include a powerful, 40K rpm, autoclavable micromotor with LED illumination. An advanced handpiece calibration system automatically detects the properties of individual implant or endo contra angles for highly accurate speed, torque, and efficiency results at the time of treatment. Adjustable torque up to 80 Ncm ensures compatibility with most implant systems available. Dr. Ara Nazarian, the director of the Reconstructive Dentistry Institute in Troy, Michigan, and noted lecturer says, “The AEU-7000 Aseptico motor with corresponding Mont Blanc handpiece has always performed exceptionally well.” He continues, “I have used the AEU-7000 for root canals, drilling for implants, leveling bone, augmentation procedures, and wisdom teeth removal. Most importantly, when doing large cases, the last thing you want is your surgical motor not working properly. I always rely on Aseptico motors for consistent reliability and superb performance.” The firm’s dedication to customer service is another advantage. Dr. Nazarian says, “Having the very best trained staff and service department, I have found that when I have had a question or needed any assistance when setting up my units, Aseptico fulfilled my needs beyond my expectations. I am so pleased with my Aseptico AEU-7000 units that I recommend them to all my students at the Reconstructive Dentistry Institute as well as at my lectures at various dental societies and conferences.” Dr. Paresh Patel, co-founder of the American Academy of Small-Diameter Implants and clinical instructor at the Reconstructive Dentistry Institute, has used the Aseptico AEU-7000 motor/ handpiece for 3 years. He says, “As a wetfingered dentist whose practice focuses 46 Implant practice

on extractions, implant placement, and overdentures, the Aseptico unit is one thing I would not want to practice without.” He describes, “My old unit, from another manufacturer, became obsolete as newer versions were released. With Aspetico’s upgradeable software, it is as easy as inserting a flash card into the unit to get the latest features activated.” For more control, Dr. Patel’s preference is to place implants with the surgical motor. He says, “With a push of the button on the foot pedal, I can switch from the implant drill speed preset to the implant placement mode preset. This kind of efficiency reduces our chair time when placing multiple implants. There are six fully programmable buttons. The real advantage for our practice and patients is the ability to change the display name. No longer do I have to look at every part of the screen to see if the speed, torque, water flow, and other variables are correct. If the display says ‘implant placement,’ I know all my individual preferences are set and ready for me to use. This powerful unit has unbelievable torque when it comes to bone leveling or any oral surgery procedure. With 80 Ncm available, smooth, chatter- and vibration-free bone shaping and cutting is possible.” “Once the implants are fully seated, the Aseptico motor is still going to be put to work,” says Dr. Patel. With the ability to handle just about any attachment, I am able to place a straight E-type nose cone on the motor, and relieve dentures, and create space for our overdenture housings with ease. The need to step out of the operatory and into the lab is no longer necessary. A quick push on the foot pedal

to activate another preset is all that is needed. Adjustable torque to grind away metal is available with this unit.” Dr. Patel notes that his assistant, Shannon, likes the easy-to-load irrigation pump when she is setting up for implant cases. She points out that the built-in dynamometer calibrates the motor and each handpiece. “So if you ask the motor to give you 1500 rpm at 40 Ncm, that is what you are ensured to get, and it will even tell you the efficiency,” she says. “This is huge for us, as it lets me know if my handpiece is in need of offsite maintenance.” The LED illumination is also an advantage where the overhead light or head-mounted light has difficulty lighting up the surgical field. The LED is built into the motor so no bulbs or cables are necessary. The clinician can even control the intensity of the LED and save it to any preset. “On a personal note,” says Dr. Patel, “I am glad that Aesptico motors are manufactured in the U.S. The ability to connect with highly trained staff by phone was most appreciated when I needed to set up my first unit 3 years ago. If you are looking to purchase a high quality American made motor, then you should consider the Aesptico AEU-7000. With the ability to handle implant, endo, oral surgery, and restorative attachments, you can have it all.” For information about Aseptico’s full range of motors, handpieces, and accessories, visit www.Aseptico.com, call 866-244-2954 or 425-487-3157, or e-mail info@aseptico.com. This information was provided by Aseptico.

Volume 6 Number 1

Implant & Oral Surgery

4,995

LED Motor & Fiber Optic Implant Handpiece Works with Any Implant System on the Market AEU-7000L-70V & AHP-85MBFO-CX

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EVENT PREVIEW

Straumann’s 2013 Dental Implant Complications Symposium Dental Implant Complications: Providing Solutions for Your Practice will be held on Friday, May 17, 2013 in San Francisco, California

Images were provided by Alexander Mangold

n Friday, March 23, 2012, 400 dental professionals joined Straumann and the Center for Advanced Implant Training for the first annual Dental Implant Complications Symposium in New York City. This event, highlighting Dr. Stuart Froum’s book of the same title, featured nine top Key Opinion Leaders in the dental industry who spoke on a variety of topics including Medical-Legal Concerns, Treatment Planning, Peri-implantitis, Prosthetic Complications, Surgical Handling of Esthetic Implant Failure Complications, Soft Tissue Complications, and Sinus Complications. In 2013, this highly-regarded event will be held on Friday, May 17 in San Francisco, California, with returning speakers as well as new field experts. The much anticipated presenters are: Drs. Stuart J. Froum, Paul S. Rosen, Ronald E. Jung, Dean Morton, Kirk L. Pasquinelli, Sang-Choon Cho, and moderater Ray C. Williams. The 2012 program attendees spoke highly of the presentations: Dr. Jennifer Hirsch Doobrow noted,

48 Implant practice

“Thank you for organizing an exceptional symposium. I truly gained an invaluable wealth of knowledge and cannot thank you and the entire panel of speakers enough for sharing your pearls of wisdom with all in attendance.” Dr. Jay Freedman concurred, “Course was amazing. Engaging speakers and was able to apply things I learned the next day I was in my office! As a restorative dentist who works in the same office as my surgical team, I have always enjoyed learning the surgical end so that it can enhance my ability to communicate the complete treatment to patients during case presentations.” Dr. Joseph E. Gian-Grasso added his congratulations to the symposium team, along with his intention of learning more at the next session. “I will certainly be in San Francisco next year.” Stuart J. Froum, DDS, also shared his personal feedback about the Symposium: “The Second Annual Implant Complications Symposium, which will take place in San Francisco on May 17, 2013 promises to continue what the first symposium

began. This will be a program like the first, which will present the latest evidencebased information for the prevention and treatment of implant complications. The latest techniques will be shown and discussed with examples of how to avoid common and uncommon pitfalls that can occur to anyone placing or restoring implants. The speakers are ‘world class,’ and even the most experienced clinicians will come home with practical solutions to problems that may arise during and after treatment. It’s a meeting you don’t want to miss.” Four hundred people attended the sold-out event in 2012, and there were more than 100 people on the waiting list, so those who are interested in attending in 2013 should register early. Visit http://straumann.cvent.com/ DIC2013 for complete details and to register. See the Straumann ad in Implant Practice US to receive $20 off your registration. IP This information Straumann.

was

provided

Volume 6 Number 1

INDUSTRY NEWS

Aribex acquired by the KaVo Group Aribex, the leader in portable X-ray technology, joins the KaVo Group’s portfolio of dental brands

n November 2012, Aribex, a worldwide leader in portable and handheld X-ray products, was acquired by the KaVo Group, an affiliation of leading global dental equipment brands. Aribex, best known for the NOMAD™ handheld and portable X-ray systems, will continue to be the center of excellence for the portable X-ray business. Handheld and portable X-ray systems are the fastest growing segment in intraoral Xray systems, and Aribex’s innovative products are supported by strong patents, intellectual property, and a robust new product pipeline. Aribex NOMAD X-ray systems are now used in clinical, remote, and mobile facilities throughout the world, from professional offices to humanitarian missions. The NOMAD significantly decreases costs 50 Implant practice

and provides hundreds of safe, high-quality images on a single battery charge. “We are thrilled to be joining forces with the KaVo Group, a world class dental organization that shares common values and a passion for future success. The KaVo Group combines over 500 years of dental experience with leading global brands and will certainly bolster Aribex’s ability to further accelerate the adoption of handheld X-ray technology,” says Ken Kaufman, President of Aribex. The KaVo Group consists of marketleading brands such as KaVo, Gendex, DEXIS®, i-CAT®, Instrumentarium, SOREDEX, Pelton & Crane, and Marus. With the acquisition of Aribex, the KaVo Group will reinforce its global imaging

footprint and commitment to marketleading innovation. “We enthusiastically welcome the Aribex team and look forward to further acceleration and expansion of the portable X-ray market,” says Henk van Duijnhoven, Senior Vice President, Dental. “The synergies across our platform are immense from integrated R&D, advances in workflow, technology integration, and a passion to advance the quality of care that our health care providers deliver. We also share a passion for serving our dealer partners with excellence.” IP This information was provided by the KaVo Group.

Volume 6 Number 1

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ABSTRACTS

Treatment of peri-implant diseases: a compilation of systematic reviews Dr. Maria Retzepi rounds up the current thinking on an increasingly important aspect of implant dentistry Non-surgical therapy for the management of peri-implantitis: a systematic review Muthukuru M, Zainvi A, Esplugues EO, Flemmig TF (2012). Clinical Oral Implants Research. 23(Suppl 6): 77-83. The aim of this systematic review was to evaluate the efficacy of non-surgical treatment modalities employed for the management of peri-implantitis. The authors included randomized controlled clinical trials that assessed nonsurgical treatment of peri-implantitis with a minimum follow-up period of 3 months. Following application of the inclusion criteria, nine clinical studies were identified and included in this systematic review. The use of Er:YAG laser treatment adjunctively to submucosal debridement has been reported to result in greater reduction in bleeding on probing scores compared to submucosal debridement with adjunctive submucosal irrigation with chlorhexidine digluconate. Likewise, submucosal glycine powder air polishing has been demonstrated to reduce bleeding on probing scores to a greater extent than submucosal irrigation with chlorhexidine digluconate, when used as an adjunct to submucosal debridement with hand instruments. No differences in terms of clinical effectiveness have been found when submucosal glycine powder air polishing was compared with Er:YAG laser treatment. Locally delivered antibiotics (minocycline microspheres or doxycycline hyclate) as an adjunct to submucosal debridement have resulted in greater reduction in bleeding on probing scores and in probing pocket depths compared to submucosal debridement with adjunctive submucosal

Maria Retzepi, DipDS, PhD, MSc, CertClinSpec(Perio), is a registered specialist in periodontics and honorary clinical lecturer in periodontology at the UCL Eastman Dental Institute. She currently works in specialist private practice in central London, England.

52 Implant practice

irrigation with chlorhexidine digluconate. It should be noted that no progressive peri-implant bone loss has been found following any of the assessed treatments over a maximum observation period of 12 months. In addition, only two studies reported implant survival rates, which were 100% over a 6-month follow-up period. The authors concluded that the available evidence neither supported nor refuted the clinical efficacy of submucosal debridement using curettes or ultrasonic scalers alone and that it was insufficient to indicate whether any of the assessed nonsurgical treatments arrested peri-implant bone loss. It was therefore suggested that long-term randomized controlled trials are needed to assess the efficacy of non-surgical therapy on progressing peri-implant bone loss, on implant survival rates, as well as on measures of oral health-related quality of life.

Surgical therapy for the control of peri-implantitis Renvert S, Polyzois I, Claffey N (2012). Clinical Oral Implants Research. 23(Suppl 6): 84-94. The aim of this systematic review was to evaluate the effectiveness of different surgical treatment modalities in the management of peri-implantitis. The review was based on 26 clinical studies investigating surgical procedures for the treatment of peri-implantitis lesions with a minimum population of seven patients. Overall, the authors suggested that there was marked heterogeneity with regards to the study designs and case definitions for peri-implantitis employed by the clinical trials included in this review, which limited the potential to generalize the reported results. A case series and a controlled clinical trial have reported that the performance of access flap surgery with removal of granulation tissue and implant surface decontamination was successful in reducing the plaque index, the bleeding on

probing, the suppuration and the probing depths, and in arresting the bone loss on 58% of affected implant sites over 5 years. Resective surgery alone or combined with implant surface modification (implantoplasty) has also demonstrated effectiveness in treating patients with periimplantitis. although systemic Interestingly, antibiotics have been used adjunctively to surgical treatment in most studies, no trials have actually evaluated the additional benefit from systemic administration of antibiotics, and therefore, at present, there is no scientific evidence to support one approach over the other. The clinical trials included in the present review have indicated overall that it is possible to obtain defect fill of peri-implantitis defects following surgical treatment with concomitant placement of autogenous bone or deproteinized bovine bone mineral. However, the authors reported that, at present, there is no evidence to support that the placement of membranes adjunctively to bone grafting procedures provides any additional defect fill. Two clinical studies have reported that the decontamination of the implant surfaces with a CO2 laser or Er:YAG laser, in combination with augmentive or resective procedures, constitutes an effective modality for treating peri-implantitis defects. However, the adjunctive use of laser treatment has not demonstrated additional benefits and, as such, it is suggested that the use of lasers as an adjunct to surgical treatment needs to be further elucidated before any firm conclusions can be drawn. Overall, the authors stated that surgical therapeutic modalities for the management of peri-implantitis constitute a predictable method for treating peri-implant disease, and that the obtained clinical outcomes can be retained long-term.

Systematic review of quality of reporting, outcome measurements, and methods to study Volume 6 Number 1

Graziani F, Figuero E, Herrera D (2012). Journal of Clinical Periodontology. 39(Suppl 12): 224-244. The aim of this systematic review was to evaluate the quality of reporting and the methodology of clinical research on preventive and therapeutic approaches for the treatment of peri-implant diseases such as peri-implant mucositis and periimplantitis. The authors conducted a search for randomized and controlled clinical trials reporting on preventive or therapeutic interventions in patients with periimplantitis or peri-mucositis. The reporting and the methods were evaluated through an analysis of the risk of biases and quality score. Following application of the inclusion criteria, 32 trials were included in this review. Of these, seven focused on prevention, six

Volume 6 Number 1

on therapeutic treatment of peri-mucositis, 10 on non-surgical treatment of periimplantitis, and nine on surgical treatment of peri-implantitis. In terms of trials evaluating preventive treatment, the use of triclosan/copolymer mouthwash, and 1% chlorhexidine gel inside the internal part of the implant during abutment placement after 6 months, was related with improved clinical and microbiological parameters. Clinical studies evaluating topical application of chlorhexidine for the treatment of peri-mucositis have reported no adjunctive beneficial effect. Furthermore, trials evaluating different plaque control regimes indicated a superior performance of an essential oils mouthrinse and of a triclosan/copolymer-containing toothpaste, when compared with a sodium fluoride toothpaste. Regarding the non-surgical treatment of peri-implantitis, no additional benefits were found in a 6- to 12-month followup, with the use of different debridement

approaches such as air abrasion, ultrasonic scaling or Er:Yag lasers in periimplantitis lesions. However, a significant improvement on probing pocket depths has been consistently observed in clinical trials testing local application of antibiotics against scaling alone. All trials evaluating the effectiveness of surgical treatment for peri-implantitis lesions reported some improvements of clinical conditions. However, complete resolution of peri-implantitis has not been reported and, furthermore, significant differences among different surgical treatment modalities have not been reported by studies with a higher quality value. The authors stated that, overall, the current literature on peri-mucositis and peri-implantitis prevention and treatment offers limited potential to extract clinically applicable information, and that the quality of methods and reporting guidelines in clinical methodology should be encouraged.

Implant practice 53

ABSTRACTS

efficacy of preventive and therapeutic approaches to periimplant diseases

PRACTICE MANAGEMENT

Know your liability as a business owner Dr. Robert M. Fleisher discusses how to mitigate general liability risks besides malpractice claims

s small business owners, a category in which most of us as dentists fall, there are many rules and regulations we must follow. One area of importance that is rarely discussed has to do with our general liability to protect our patients, our staff, and our personal assets. Let’s explore other areas of risk aside from malpractice claims that may help keep you out of trouble.

Innocent chores – major risk Many practitioners find it convenient to have an employee run chores for them. These tasks range from making bank deposits to picking up supplies to transferring patient charts from one office to another. Some utilize the services of their assistants,

secretaries, and office managers rather often. If possible, it is best to avoid any and all of these types of requests. Here is a scenario involving an auto accident that takes place every day in one city or another all around the country. Mary is riding to the bank to make your daily deposit when a dog runs into her path (hopefully she wasn’t texting). She veers off the street, onto the curb at the school bus stop where she kills three children, and four others are paralyzed to varying degrees; an unimaginable tragedy! The families will sue Mary, and since she was acting as your agent when the accident occurred, they will sue you as well and win.

Robert Fleisher, DMD, graduated from Temple University School of Dental Medicine in 1974 and received his certificate in endodontics from The University of Pennsylvania in 1976. He taught at Temple University and The University of Pennsylvania and is now a member of the Affiliate Attending Staff – Albert Einstein Medical Center, Philadelphia, Department of Dental Medicine, Division of Endodontics, Philadelphia, Pennsylvania. Dr. Fleisher is the founding partner of Endodontics Limited, P.C., one of the larger endodontic practices in the United States. After retiring from practice, he now devotes his time to writing about practice management, aging and health issues, and fiction with a medical bent. You can read about all of Dr. Fleisher’s methods to improve bedside manner in his book Bedside Manner - How to Gain Your Patients’ Respect, Love & Loyalty. www.bedsidemanner. info. Dr. Fleisher can be reached at: drfleisher@bedsidemanner.info.

54 Implant practice

There is much temptation to use others to run chores, but try to do them yourself if at all possible. If an employee does have to run errands, make sure he/she has a valid license and automobile insurance of his/her own. Make sure whoever runs chores for you is responsible, not driving under the influence or distracted by his/her cell phones. You must make sure you have liability insurance as well since, as noted, you will be sued, too. Purchasing an umbrella liability policy provides a large amount of coverage for little cost. Your umbrella policy should be between 5 and 10 million dollars. Get as much coverage as you can reasonably afford to protect yourself as best as you can in an unreasonable climate. Your umbrella policy is usually applicable to your home and offices as well, giving you an extra boost of protection against a lawsuit.

Personal liability While your homeowner’s and automobile insurance policies protect you from most personal injury claims, the bigger worries are the catastrophic claims that require the umbrella policy noted above. People slip and fall all the time. They often try to find Volume 6 Number 1

Vicarious liability Anyone who works for you can pose a threat by any and all of his/her actions. This is called vicarious liability – liability incurred due to the actions of others. These actions can include having your secretary or assistant making suggestions for managing postoperative pain to an associate who provides patient care. The rationale for vicarious liability is based on the legal concept respondeat superior. This model was developed many years ago and means that the master is responsible for the acts or omissions of the servant. This states that you are responsible for the negligent actions of your staff members, including associates and possibly even independent contractors who offer services in your practice. To reduce your liability, it is imperative to define and control all work-related procedures, and supervise all staff

contractor. However, remember you are going to be held responsible for any of your regular associates if the plaintiff can prove that you should have been aware of the poor quality of the associate’s work. How hard is it to subpoena several charts of patients your associate worked on to show a pattern of poor quality? Get rid of anyone who doesn’t practice quality care. Make sure you have vicarious liability insurance coverage. Require a certificate of insurance from all professional employees, and make sure you check yearly that they have paid up policies. You should be listed as an additional insured on their policy just as your associates should be listed as an additional insured on your policy. Examine all educational credentials of any employees requiring licensure, and make sure they have valid licenses. Check references on job applications to make sure they are legitimate. Get

Make sure you have a protocol in place to manage emergencies, whether it’s from a slip and fall, or a medical emergency related to patient care. members. Make sure you script exactly what you want your staff to tell patients regarding postoperative care and sequelae as well as any instructions you have auxiliary staff provide to patients. Having written handout information is the best way to make sure you control instructions to patients, and it makes it much easier for your staff to learn the exact contents of the handouts. This allows them to offer the same instructions verbally when queried by the patient. A patient who sees your associate, the independent contractor, will likely sue you as well if a claim of malpractice arises unless you inform the patient of the independent status. Without this notification, the patient has good reason to believe that the associate is an employee under the supervision of the owner of the practice, and therefore, making the owner liable for the actions of the associate. A notification of the independent status of the associate, on the patient registration/ informed consent form that the patient signs, will help to reduce your vulnerability from the actions of the independent

written permission to contact an applicant’s references, and have the applicant sign a release form authorizing former employers to provide references. Call all the names on the reference list, not just the top ones. Any question you ask a reference must abide by all non-discrimination laws. It’s easy to be lazy about hiring, but the liability consequences can be enormous. Do your homework! Protect yourself by employing these ideas. They will help make you bulletproof to lawsuits. Many people and lawyers are just waiting for the opportunity to file a claim. Don’t let yourself remain vulnerable. Most of all, consult with your lawyer and insurance agent to help you properly institute the ideas contained herein. IP This article is an excerpt from Dr. Fleisher’s soon to be published, From Waiting Room to Courtroom – How Doctors Can Avoid Being Sued.

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PRACTICE MANAGEMENT

an excuse for their misfortune by blaming others and exaggerating the claim. There are some protective measures that will keep your personal and business properties less risk-prone, and reduce the chance for a fall in the first place. Tour your properties periodically to look for potential problems like defective pavements, potholes, loose carpeting, defective waiting room chairs, sharp edges, heavy objects on flimsy shelving, and any potential threats to the safety of visitors to your home and practice. Parking lots should be well lit and properly paved with safe and easy access to your building. Periodically have a serviceman check the stability of your overhead lights and X-ray equipment. Equipment falling onto your patient can result in considerable damage and grief for all involved. If you practice in a colder climate, make sure that icy conditions are managed appropriately with application of salt or sand, snow is removed in a timely manner, and any water that may result in slippery surfaces is attended to. Assign someone on your staff to be in charge of safety, and make sure that he/she develops a list that documents that he/she is doing the inspections regularly. Discuss your accident prevention program with your staff, and stress the importance of safety. Make sure you have a protocol in place to manage emergencies, whether it’s from a slip and fall, or a medical emergency related to patient care. Rather than running around in panic mode, each person should have a responsibility that allows for attending to the patient and a prompt call for emergency personnel. During an emergency, it is not the time to run around looking for your emergency kit or checking the dates on the contents. With a well-run emergency program in place, there should be no sign of panic, and most other patients in your office will not realize that an emergency has occurred until the ambulance pulls up to your door. Having periodic emergency drills will allow you to handle most emergency problems in a professional and discreet manner. The last thing you want is chaos, considering there will likely be several witnesses to what took place during an emergency. You don’t want the plaintiff to show the jury how you were not prepared, and the resultant panic delayed timely and appropriate care resulting in further injury.

DEXIS connects with the all-new Dentrix Developer Program and with Dentrix® users

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DEXIS, LLC, whose premier product is the only digital X-ray system that fully integrates with Dentrix, is now a member of the Dentrix Developer Program, created for those companies that want to develop specific Dentrix G5 Connected applications. Both the DEXIS® Digital Imaging System and the DEXIS® Integrator™ for DENTRIX® have also been accepted into the Dentrix MarketPlace program. The Dentrix MarketPlace online portal provides a central location for users to easily review and select technologies that are associated with their Dentrix program and which ultimately enhance their practices. The DEXIS Digital Imaging System with its award-winning Platinum Sensor and the feature rich DEXIS® Imaging Suite software provides clinicians with the best image quality, most comfortable sensor, and fastest workflow. For more information on DEXIS Imaging Suite and the DEXIS® Platinum Sensor, and to learn about DEXIS imaging solutions, visit www.dexis.com.

PREAT Corporation introduces the new Hader Alignment Housing

RGP signs license to produce Relax and Hydro armrests

Dental professionals now have a choice between the popular Horix/Hader thin housings and the new knurled Hader Alignment Housings. The alignment groove on top of the Alignment Housing provides an easy way to maintain clip alignment, assure that the clips have not rotated prior to processing, and maintain a parallel path of insertion/draw. The Alignment Housings work with all retentions of Hader clips.

RGP has long been selling its articulating armrests, and under a newly signed license agreement, RGP owns the rights to manufacture the armrests. According to Sales Manager, Jason DeCosta, “The Relax arm is a two-dimensional armrest that moves with you to accept the weight of your arm off your back, neck and shoulder. It allows the user to hold a mirror or retract for long periods while alleviating the tension and strain usually associated with longer procedures. The Hydro arm is a three-dimensional armrest designed to provide ‘full rangeof-motion’ for the dominant-instrument arm.” Visit RGP’s web site at: www.rgpdental.com; call: 800-5229695 x5534, or fax: 401-254-0157.

For more information, or to place an order, contact www.preat. com, 800-232-7732.

The Wand® STA® All-Injection System Ideal for pediatric dentistry, endodontics, implant, and general dentistry, the Wand® STA® AllInjection System allows clinicians to gently, precisely, and quickly administer most injections (PDL, block, palatal, etc.) without the fear or anxiety of traditional syringes. Single tooth injections eliminate numbness of the cheek, lips, or tongue for a more pleasant experience during and after the procedure. Doctors can perform bilateral dentistry during a single visit! The Wand® STA® is made in the USA and provides real-time audio and visual guidance. For more information, call 866-244-2954 or visit www.Aseptico. com.

56 Implant practice

CareCreditSM announces free practice management CD featuring Dr. Rhonda Savage CareCredit is offering a complimentary educational audio CD, Accountability = Energized Teams and Satisfied Patients, featuring Dr. Rhonda Savage, chief operating officer of Miles Global, a practice management and consulting firm exclusively serving dentists. In this audio program, Dr. Rhonda Savage shares how accountability “done right” can improve communications, efficiency and help the practice run smoother. Practices that currently accept CareCredit can request a copy of this complimentary audio CD by contacting their Practice Development Team at 800-859-9975. Practices that have yet to add CareCredit as a payment option can call 800-300-3046, ext. 4519 to request their complimentary copy.

Volume 6 Number 1