clinical articles • management advice • practice profiles • technology reviews March/April 2013 – Vol 6 No 2
PROMOTING EXCELLENCE IN IMPLANTOLOGY
Preventing the dreaded black triangle during implant placement in the esthetic zone: part 1 Dr. Scott M. Blyer
Practice profile
Dr. Coury Staadecker
Corporate profile Straumann
Trabecular Metal™ implants from orthopedics to dental implantology Dr. Suheil M. Boutros
PAYING SUBSCRIBERS EARN 24 CONTINUING EDUCATION CREDITS PER YEAR!
Uncovering peri-implantitis Dr. Nikos Donos
March/April 2013 - Volume 6 Number 2 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
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Volume 6 Number 2
H
aving recently celebrated my 27th year in private practice as a periodontist, I have been reflecting on the changes that have occurred in the profession. It is hard to believe that at the beginning of my career I was a “full-time” specialist limiting my practice to the prevention, diagnosis, and treatment of periodontal disease. As a resident, implant dentistry was not a part of our curriculum, and discussions involving this topic were relegated to lunch hour debates in the cafeteria. At that time, it was performed by a select few who later became known as pioneers in the field. In the mid- to late 1980s, many clinicians, including myself, were taking the courses necessary to place dental implants and recognized the fact that one can change people’s lives by simply restoring form and function. However, at that time, patients with hopelessly involved dentitions often had treatment plans that were in excess of 18 months. Patient acceptance was often difficult to obtain, as they did not necessarily understand the advantages of implant dentistry. With time, several innovations, some of which include an internal hex connection and a second-generation roughened surface technology (micro and macro roughness), improved the predictability of patient care and addressed some of the patient’s resistance to time-intensive treatment plans. This led to wider acceptance of implant dentistry and a paradigm shift in the 1990s, making this a treatment of choice in clinical situations that would require sophisticated, less predictable procedures to salvage failing dentitions. In response to market demands, esthetics became the focus of our profession. It was no longer enough to simply restore form and function. Our endpoint had to be an esthetically pleasing restoration. As a result, the last 10 to 15 years found clinicians changing their mantra from surgically driven implant placement to restoratively driven implant placement. Often, this would require one- and two-stage hard and soft tissue grafting procedures to satisfy the esthetic demands of a consumer-educated patient population. There was, and always will be, a percentage of the population who is comfortable with an “at any cost” treatment approach. However, due to motivation, time, and financial constraints, many patients would seek treatment alternatives that also resulted in an esthetic restoration. Implant companies responded with a number of innovations centering on surface technology and the introduction of new implant materials (alloys) developed specifically for narrow interdental spaces, expanding our treatment options. More recently, another surface technology was introduced that enhanced osseointegration through its hydrophilic and chemically active properties, resulting in an improved surface chemistry. This is noteworthy, as these properties enable faster osseointegration, reducing the overall loss of implant stability, which is typical after mechanical stability due to an osteopenia. This technology is designed to give clinicians the confidence to proceed with immediate placement in extraction sites. A byproduct of the improved surface chemistry is the ability to load the fixture sooner, increasing the appeal and patient acceptance of implant treatment. Another technology that is allowing for more and more implant candidates is the advent of new implant materials. There is a titanium-zirconium alloy that has shown higher strengths when compared to implants made of grade 4 titanium manufactured by the same company. Smaller diameter implants can now be placed with confidence, as fixture fracture is less of a concern. This is clinically relevant, as often patients will not accept treatment recommendations if large grafting procedures are necessary to create an environment for successful implant placement. When I graduated from my residency, I had no idea that the profession would change as much as it has. I feel blessed to be practicing in a time when dentistry continues to evolve where we now have the ability to meet and exceed patient expectations with respect to restoring form and function — as well as replacing teeth that are indistinguishable from those lost. I can only hope that the innovations that will occur in the next 27 years will be as noteworthy as those in the past.
Dr. Robert Miller Miami and Boca Raton, Florida
Implant practice 1
INTRODUCTION
Reflections on an ever-evolving profession
TABLE OF CONTENTS
Clinical
Practice profile
6
Dr. Coury Staadecker: The art of harnessing synergy Dr. Staadecker discusses the many facets of his practice that set the stage for guiding and maintaining true patient wellness.
Uncovering peri-implantitis Dr. Nikos Donos talks about the growing importance of peri-implant disease and explains how the latest research is shaping treatment...... 14 Guided surgery – understanding the risks Dr. Peter Sanders explains the importance of gaining experience in conventional implant placement prior to using CT guided surgery.......... 18
Continuing education Preventing the dreaded black triangle during implant placement in the esthetic zone: part 1 Dr. Scott M. Blyer examines ways to avoid a frustrating complication of dental implant therapy................. 22 Treatment planning of implants
Corporate profile
10
Straumann: Shaping the future together Straumann® – a global leader in implant dentistry offering surgical, restorative, regenerative, and digital solutions for the dental and lab business – is a pioneer of innovative technologies.
2 Implant practice
in the esthetic zone: part 1 In the first part of a series of articles, Drs. Sajid Jivraj, Mamaly Reshad, and Winston Chee look at the diagnostic factors that affect the predictability of peri-implant esthetics ..................................... 28
Volume 6 Number 2
ORTHOPHOS XG 3D The right solution for your diagnostic needs.
Implantologists Endodontists
Orthodontists will benefit from highquality pan and ceph images for optimized therapy planning.
General Practitioners will achieve greater diagnostic accuracy for routine cases.
ORTHOPHOS XG 3D
will enjoy instantly viewable 3D volumetric images for revealing and measuring canal shapes, depths and anatomies.
will appreciate the seamless clinical workflow from initial diagnostics, to treatment planning, to ordering surgical guides and final implant placement.
The advantages of 2D & 3D in one comprehensive unit ORTHOPHOS XG 3D is a hybrid system that provides clinical workflow advantages, along with the lowest possible effective dose for the patient. Its 3D function provides diagnostic accuracy when you need it most: for implants, surgical procedures and volumetric imaging of the jaws, sinuses and other dental anatomy. For standard 2D images, it offers the most comprehensive selection of pan and ceph programs to meet virtually all needs, from standard panoramic programs for adults and children, to extraoral bitewing, sinus, TMJ options and many more.
Automatic patient positioning The new Auto-Positioner measures the exact tilt of the patient’s occlusal plane and automatically adjusts the height for an optimal panoramic image within the sharp layer, thereby preventing incorrect positioning and reducing re-takes.
For more information, visit www.Sirona3D.com or call Sirona at: 800.659.5977 www.facebook.com/Sirona3D
TABLE OF CONTENTS
34
Small-diameter implant treatment
Step-By-Step
Product profile
Event preview
Fast, profitable, and patient-
CPK – Complete Prosthetic Kit
friendly denture stabilization 3M™ ESPE™ MDI Mini Dental Implants .....................................................34
from MIS Implants Technologies Simplifies the restorative component of Implant Dentistry .......................46
4th annual NYU College of Dentistry Global Implantology Week ...........................................52
Technology Trabecular Metal implants from orthopedics to dental ™
implantology Dr. Suheil M. Boutros focuses on the applications for a new type of implant .....................................................38
4 Implant practice
i-CAT® FLX — the latest advancement in Cone Beam 3D For greater flexibility in scanning, planning, and treatment ................48 Introducing a new implant designed exclusively for overdentures - the LOCATOR® Overdenture Implant system ....50
Diary.......................................56 Materials & equipment .....................62
Volume 6 Number 2
79459-US-1208 © 2012 DENTSPLY International, Inc.
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
PRACTICE PROFILE
What can you tell us about your background? I earned my dental degree from Ohio State University in 1997 and my Periodontics Certificate from the Naval Postgraduate Dental School in Bethesda, Maryland. While pursuing my periodontics certificate, I also earned a Master of Science degree from George Washington University. When on staff at the Naval Medical Center San Diego, I mentored numerous general practice residents and lectured extensively. While in private practice in Seattle, Washington, I continued my involvement with academics as a Clinical Instructor and Affiliate Professor at the University of Washington, Department of Graduate Periodontics. Additionally, I am the former Senior Clinical Editor of the Seattle Study Club Journal, reaching over 8,000 dentists worldwide. I am a Diplomate of the American Board of Periodontology and an Accredited Fellow of the American Society of Dental Anesthesiology.
Is your practice implants?
limited
to
As a periodontist, there are three distinct facets of my practice that include (1) treatment of periodontal disease, (2) implant therapy, and (3) periodontal plastic surgery. Being well versed in all three areas sets the stage to guide and maintain true patient wellness. Additionally, these facets blend seamlessly not only to establish health, but also to maintain optimal function and esthetics.
Why did you decide to focus on implantology? While I was attending dental school during the mid-1990s, it was the birthplace of modern day implantology. Implant design and technology have continued to evolve, but with all the different manufacturers, implants have become similar. We can now provide our patients with a tooth replacement that predictably makes them “whole” again. I can emotionally identify with the innate and powerful sense of selfpreservation. With prosthetic treatment other than implant therapy, the treatment is either collaterally destructive or foreign to the patient. Patients simply perceive implants as being a part of themselves 6 Implant practice
and therefore self-preserving. Having the opportunity to return a sense of selfesteem and confidence is just as joyful for me as it is for my patients.
How long have you been practicing, and what systems do you use? I have been practicing dentistry for more than 15 years. I exclusively use Straumann® and Nobel Biocare® dental implant products.
What training undertaken?
have
you
Following graduation from Dental School at The Ohio State University, I continued my training in an Advanced Education General Dentistry (AEGD) Residency in the U.S. Navy. The AEGD Residency piqued
my interest in periodontics and implants. Shortly thereafter, I applied and graduated from a 3-year residency in periodontics from the Naval Postgraduate Dental School. Over the course of the following 8 years, I was a didactic instructor and Affiliate Professor at the Naval Medical Center, San Diego and the University of Washington, respectively. I also had the good fortune of becoming part of the Seattle Study Club “university without walls” continuing education organization as a co-director and Senior Clinical Editor.
Who has inspired you? After I had reached my goals within the military and was ready to pursue private practice, I was introduced to Dr. Michael Cohen, founder of the Seattle Study Club. Dr. Cohen invited me to become partner Volume 6 Number 2
PRACTICE PROFILE
Pairing sound clinical knowhow with new technology and materials is an art form. Critically evaluating and reevaluating yourself and each other
Humanitarian operation while Dr. Staadecker was in the Navy in Mombasa, Kenya
allows us to grow in a positive direction from which our patients
Dr. Staadecker and his partner Dr. Donald C. Dornan
benefit most.
in his practice, co-director in the Seattle Study Club and Senior Clinical Editor in the SSC Journal. The Seattle Study Club is recognized as one of the most advanced and exciting dental continuing education groups today. Dr. Cohen is one of the few practitioners in the country to have constructed a successful bridge between didactic and clinical programming. Building on the traditional study club model, he has added original and more powerful programming to maximize member interest. I then had the good fortune to return to California in Newport Beach and partner with Dr. Donald C. Dornan in private practice. Dr. Dornan is the most skilled, humble, and accomplished periodontist I know. The proof of Dr. Dornan’s deft clinical abilities resides in our hygiene
maintenance program for over 40 years.
What is the most satisfying aspect of your practice? The interpersonal relationships that I have forged with my patients over the years is daily motivation. This energy is like oxygen in my blood. There is a symbiotic relationship in caring for my patients who I consider friends for life.
Professionally, what are you most proud of? I have been blessed often with being in the right place at the right time. In my professional training and in life, I have had the opportunity to be guided by gifted mentors that have molded the way I think and approach patients. As an Affiliate Professor at the University of Washington
in the Graduate Periodontics Department, I had the chance to give back to the dental community. The residents at UW were intelligent, eager, and passionate to learn. Passing along the techniques that I have developed throughout my career is like opening my heart. Years later, I have continued to stay in touch with many of my former residents.
What do you think is unique about your practice? There is a great deal of diversity, innovation, and experience within our practice. Pairing sound clinical knowhow with new technology and materials is an art form. Critically evaluating and reevaluating yourself and each other allows us to grow in a positive direction from which our patients benefit most.
Volume 6 Number 2 Implant practice 7
PRACTICE PROFILE
During a Half Ironman—swimming, biking, and running
What has been your biggest challenge?
The future of dentistry resides in molecular biology and the capability to harvest cells. Stem cell research has come a long way but has not made it to our practices yet. Influencing stem cells to down or up regulate in the presence of disease is also becoming more noteworthy. Clinicians and the general population are becoming more aware of the periodontal-systemic relationship.
clinicians is a joy! Now, I have started a study club, Apres Continuum, based upon interdisciplinary treatment planning. The doctors involved in Apres Continuum are dedicated to the advancement of team treatment planning and total case management as the ultimate tool for achieving ideal comprehensive care. They have also committed themselves to excellence in their profession and in the management of their practices. As we settle into the 21st century, technological advances continue to shape a challenging and innovative future for the dental health care profession. How can the demands of this rapidly changing field be met? What skills and knowledge will be necessary to move comfortably into the future? How can all aspects of dentistry, whether periodontics, oral surgery, or endodontics, be incorporated into one’s practice, thereby “bridging the disciplines?” The answers to these questions are crucial to comprehending the role that continuing education will play in the future of our profession.
What are your top tips for maintaining a successful practice?
What advice would you give to budding implantologists?
My top tip for maintaining a successful practice is to find what makes you passionate, and leverage off of that passion. I found myself involved in many cases that required a comprehensive approach, which led me to becoming involved with interdisciplinary study clubs. The challenging nature of these cases and the opportunity to work closely with astute
First, know your strengths, work within your strengths, and pass those gifts along to your patients. Secondly, develop a strong level of communication between the restorative dentist and implant surgeon. Working together as a team will benefit your patients and practice immensely. Finally, work with an interdisciplinary
I believe that dentists are often perfectionists. I am no exception to this, which is both a blessing and a curse. Even with all of the advances in technology that we have available to us, there are still limitations in our biology. Accepting these limitations can be challenging.
What would you have become if you had not become a dentist? An architect.
What is the future of implants and dentistry?
8 Implant practice
team that values treatment planning.
What are your hobbies, and what do you do in your spare time? I am an avid outdoorsman and former triathlete. Ski trips with my friends and family are always the highlight of the year. IP
TOP FAVORITES 1. Periolase® by Millennium 2. Acellular Dermal Matrix 3. Tunneling Instrument (KMIS1) by G. Hatzell & Son 4. DASK Lateral Wall Sinus Bur by Dentium USA 5. SonicWeld by KLS Martin 6. Straumann® immediate temporary abutment 7. Molly Moon’s Salted Caramel Ice Cream, Seattle, WA 8. Paseo’s Caribbean Roast Plato, Seattle, WA 9. Thurman Café’s Thurman Burger, Columbus, OH 10. Ikko’s Sweet Shrimp in Miso Soup, Costa Mesa, CA 11. Juliette Kitchen & Bar’s Pork Cheek small plate, Newport Beach, CA 12. W Hotel, South Beach (Miami Beach), FL 13. Earl Grey at Uva’s in Vancouver, BC 14. Backcountry at Whistler Blackcomb, BC 15. Ohmi Filet at The Met, Seattle, WA 16. Osso Bucco at Caffé dei Poeti in Madrid, Spain 17. Portola Coffee in Costa Mesa, CA
Volume 6 Number 2
Roxolid® for All featuring the Loxim™ Transfer Piece
Designed to give you confidence in all cases through the combination of advanced material and surface technology Roxolid implants with Loxim can increase your treatment options, expand your prosthetic options and make implant insertion and restoration as easy as 1–2–3. www.straumann.us 800/488 8168
CORPORATE PROFILE
Straumann
Who we are Straumann® – a global leader in implant dentistry offering surgical, restorative, regenerative, and digital solutions for the dental and lab business – is a pioneer of innovative technologies. We are SM committed to Simply Doing More for dental professionals and patients. With world-class customer service, highly skilled technical support, and a team of experienced professionals readily available to you, our vision is to be the commercial partner of choice in implant, restorative, and regenerative dentistry. With its corporate headquarters in Basel, Switzerland, and North American headquarters in Andover, Massachusetts, Straumann’s products and services are available in more than 70 countries. Having pioneered many influential technologies and techniques in dentistry, the company’s mission is to enable dental professionals to restore their patients’ dental function and overall oral health.
What drives us – our core beliefs Reliability is our trademark We deliver peace of mind. Our customers and patients trust us for consistent quality and service excellence. Simplicity is our strength In an increasingly complex world, we seek solutions that make life simpler for customers and patients. Customers are our inspiration We are dedicated to the success of all our 10 Implant practice
Shaping the future together
customers. We always seek to understand their perspective and to deliver what we promise. People are our success Our success depends on skilled, caring, trustworthy, and diverse individuals who work as a team and share our passion for innovative solutions and service excellence. Achieving more is our future We strive relentlessly for better solutions and to create value for our stakeholders. We must always believe in our ability to achieve more.
Why dental professionals trust in our products Straumann has won the confidence of its customers with this promise: a strong foundation of scientific and clinical evidence supporting the specialization, reliability, and simplicity that define every Straumann solution. With more than 3,000 published peer-reviewed studies, along with what has been learned in more than 50 years of research in various scientific fields, Straumann products have demonstrated their long-term effectiveness through research studies following good clinical practice. This reliability made the Straumann® Dental Implant System one of the most widely used systems in the world with more than 9 million implants sold. Straumann’s 30-year relationship with the International Team for Implantology (ITI®) unites more than 11,000 dental professionals from all fields of implant dentistry and dental tissue regeneration.
Straumann has won the confidence of its customers with this promise: a strong foundation of scientific and clinical evidence supporting the specialization, reliability, and simplicity that define every Straumann solution.
Volume 6 Number 2
Our tradition of innovation The number of innovations Straumann has produced continues to grow, from the SLA® implant surface in 1998 to the hydrophilic SLActive® implant surface in 2006, the Roxolid® material in 2009 to a new generation of small diameter implant – the Narrow Neck CrossFit® – in 2012. Beginning April 2013, Straumann makes Roxolid available in all implant diameters with the introduction of Roxolid® for All – Straumann strength, simplified. Roxolid for All with the new Loxim™ transfer piece is designed to provide you with confidence in all cases through the advanced material and surface combination with the flexibility of more treatment options and efficient implant placement through simplified handling. Straumann’s dedication to innovation provides clinicians the products they need to meet the clinicial demands in daily practice.
The Straumann® Dental Implant System – surgical and restorative solutions What does simplicity mean? One system. One kit. A variety of indications. Straumann offers a complete line of both Soft Tissue Level and Bone Level implants for maximum flexibility and efficiency with SLA and SLActive surface technologies designed for treatment predictability and your choice of titanium grade 4 or Roxolid material, which is designed to provide more confidence when placing small diameter implants. With characteristics such as double
roughness treatment for greater bone-toimplant contact, the SLA implant surface is designed to allow loading in just 6 weeks after implant placement in healthy patients with sufficient bone quality and quantity. The SLActive surface takes the topography of the SLA surface to the next level. Through its surface chemistry, it is designed to deliver faster osseointegration1 to enhance confidence in all treatments, reduce healing times from 6-8 weeks to 3-4 weeks,2 and increase predictability in stability-critical treatment protocols. The Roxolid material enabled the design of the Narrow Neck CrossFit Implant. Roxolid – the first Titanium Zirconium alloy developed specifically for the needs of dental implantology — features higher tensile3 and fatigue4 strengths and osseointegration when compared to Straumann SLActive titanium implants5. The CrossFit Connection is designed to provide a secure and precise fit between the Straumann implant and authentic Straumann abutments. This year, Roxolid for All offers you the advanced material of Roxolid and the surface technology of SLActive combined with simplified handling with the development of the Loxim transfer piece. Loxim is pre-mounted to the implant, self-retained and designed for clockwise and counter-clockwise rotations with one-step implant insertion. The additional treatment options offered by Roxolid for All may result in a less invasive procedure or fewer procedures, helping to increase the acceptance of implant treatment to patients.
Excellent restorative outcomes – authenticity As the company that pioneered single-stage tissue-level implants, Straumann has a strong track record in, and vision for, dental implantology. Precision is the hallmark of the Straumann product portfolio. From Bone Control Design® to the implantabutment connections, Straumann products are manufactured to exacting specifications.
Look-alike implant and abutment systems attempt to copy the original manufacturer’s design, but cannot give assurance of equal precision or material quality. Compromises, such as a poor connection between the implant and abutment, can lead to complications. When it comes to long-term stability and excellent restorative outcomes, providing genuine Straumann components from our complete prosthetic portfolio is important. Now you can eliminate all doubt with the Straumann Online Verification Tool and NEW Laser Etched Titanium Abutments that enable you to confirm that you have purchased and received an original Straumann component.* Straumann Implants. Straumann Abutments. Straumann Authenticity.
Straumann regeneration solutions Straumann offers a complete portfolio of oral tissue regeneration solutions for various treatment situations. Some of the most exciting research and development within the dental market is being conducted on regeneration, showing the body’s potential to rebuild lost structures. Straumann is on the forefront of this research with the use of the polyethylene glycol (PEG) technology in dental applications and more expansive research on enamel matrix derivative (EMD). With over 400 scientifically supported clinical publications, including results over 10 years, Straumann® Emdogain™ is a protein-based gel designed to promote predictable regeneration of lost periodontal hard and soft tissue, helping to save and stabilize teeth. Clinicians have learned that treating gingival recession cases may be an important strategy in practice growth, and the use of Emdogain6 may decrease
Volume 6 Number 2 Implant practice 11
CORPORATE PROFILE
An independent academic association, ITI actively promotes networking and exchange among its members at meetings, courses, and congresses with the objective of improving treatment methods and outcomes for the benefit of their patients.
CORPORATE PROFILE tooth sensitivity to hot and cold, support the regeneration of lost bone and tissue,7 and boost confidence by providing a more natural-looking appearance.8 Emdogain was recently featured on Lifetime TV’s The Balancing Act as a treatment of choice to fight the effects of gum disease. Straumann® Bone Graft Solutions provide a choice of quality products designed to support the regeneration of the patient’s own vital bone. Straumann® AlloGraft is processed with LifeNet Health®‘s proprietary and patented Allowash XG® technology, designed to remove and inactivate viruses and bacteria with a Sterility Assurance Level (SAL) of 10-6, and maintain the biomechanical and/ or biochemical properties of the tissue. Straumann delivers several AlloGraft products, each designed to meet a specific clinical and patient need. Straumann® MembraGel®, an advanced technology hydrogel membrane used in treatment with Guided Bone Regeneration (GBR), is a precise, simple and quick application – a next generation membrane. With its gel-like consistency and its formation in situ, MembraGel is adaptable to various types and sizes of bone defects and can be precisely applied to the surgical site. MembraGel is designed to function as a barrier to prevent ingrowth of soft tissue into the defect region and stabilize the underlying bone graft material, confining it to the site of bone augmentation. Straumann MembraGel was launched in conjunction with a wellreceived, specialized education program that includes hands-on product trainings and covers all aspects of the application.
On the cutting edge of digital dentistry What will shape the future of dentistry? Digitalization. Straumann’s complete digital package is designed for seamless connectivity to simplify workflows and offer interdisciplinary care amongst the treatment team. Straumann® CARES® Digital Solutions delivers a full prosthetic digital workflow across guided surgery, intraoral scanning, and CADCAM technology that is reliable, precise, and dedicated to the needs of clinicians and laboratory technicians.
Straumann® solutions
CARES®
digital
Guided Surgery offers a clear view of patient bone structure, nerve position, 12 Implant practice
vascular structures, and the final implant location to simplify the planning and execution of complex procedures with the goal of reducing surgical and prosthetic complications. Guided Surgery, based on computerized 3D treatment planning software, is designed to offer the surgeon more predictable outcomes and more accurate financial estimates for the patient. Guided Surgery and 3D treatment planning has expanded the ability to communicate with referrals and patients. This can lead to improved case acceptance and practice growth. Straumann® CARES® CADCAM is an integrated prosthetic design system, including a state-of-the-art scanner, software, and a leading material offering an applications range. Through alliances with industry leaders such as Ivoclar Vivadent AG®, 3M ESPE, and VITA, Straumann offers high-performance ceramic materials for first-class esthetic restorations. From customized abutments to screw-retained bar and bridge solutions, applications are available for a multitude of patient situations. Intraoral scanning can replace conventional impression taking and enables the lab to digitally design CADCAM crowns, bridges, or customized abutment restorations without the need for a stone model. Straumann’s goal is to help you reduce time to the final restoration, eliminate manual processes, and decrease remakes via a CADCAM production process by employing a digital workflow.
Simply Doing MoreSM Straumann is not only a commercial partner for premium products. Even more importantly, we strive to help you grow your practice. From a wide range of patient education materials to practice growth tools that are developed based on your needs, we will work with you every day to differentiate your practice. When you work with Straumann, you have a network of dental professionals who are by your side every day. We are committed to your success – and the esthetic results your patients demand.
Today. Tomorrow. Together. Straumann invites you to grow with us. We are working on multiple initiatives that will help shape the future of dentistry. Dedication to research has allowed Straumann to deliver meaningful innovations that help clinicians improve
the quality of care and life for patients.9 Straumann values the longstanding trust of customers, working with clinicians to help grow their practices through a variety of channels. From comprehensive continuing education courses designed to deliver the latest technologies and clinically relevant scientific information for surgical and restorative clinicians, office staff, and dental labs to customer loyalty programs, Straumann stands behind more than just their products – Straumann stands behind their customers. With a full pipeline of innovative technologies, products, services, and solutions to address the changing trends in dentistry, clinicians should want to choose Straumann as their commercial partner of choice. At Straumann, the future is today. IP
This information Straumann.
was
provided
by
References *Straumann recommends that you use only original Straumann prosthetic components to restore Straumann implants. 1. Compared to SLA® in an animal model. 2. Compared to SLA. 3. Norm ASTM F67 (states min. tensile strength of annealed titanium). 4. Data on file. 5. Gottlow J, et al. Evaluation of a new titaniumzirconium dental implant: a biomechanical and histological comparative study in the mini pig. Clin Imp Dent Relat Res. 2012;14(4);538-545. 6. In combination with coronally advanced flap. 7. McGuire MK, Nunn M. Evaluation of human recession defects treated with coronally advanced flaps and either enamel matrix derivative or connective tissue. Part 2: histologic evaluation. J Periodontol. 2003;74:1126-1135. 8. McGuire MK, Nunn M. Evaluation of human recession defects treated with coronally advanced flaps and either enamel matrix derivative or connective tissue. Part 1: comparison of clinical parameters. J Periodontol 2003;74:1110-1125. 9. Academy of Osseointegration. What are the benefits of dental implants? Retrieved February 7, 2013. http://www.osseo.org/FAQ4.htm. Accessed February 7, 2013.
Volume 6 Number 2
Dental Implant ComplICatIons: Providing SolutionS for your Practice friday, May 17, 2013
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Mark your calendars! Back by popular demand, this year’s event will take place friday, May 17, 2013 in San francisco, ca. our group of seven speakers will come together at the Westin St. francis to provide you information from their experiences on this topic that is coming to the forefront of the dental world.
receive $20 off your tuition by entering discount code “ImplantUS”
the Westin St. francis
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San francisco, ca
program date: Friday, May 17, 2013
speakers: Sang-Choon Cho, DDS Stuart J. Froum, DDS Ronald E. Jung, DMD, PhD Dean Morton, BDS, MS Kirk L. Pasquinelli, DDS Paul S. Rosen, DMD, MS Ray C. Williams, DMD
agenda: 7:00am – 8:00am 8:00am – 5:00pm 5:00pm – 6:00pm
Registration Program Cocktail Reception
“Your program was terrific! The speakers were knowledgeable and their material was outstanding! You even arranged great weather! Please let me know when I can sign up for next year’s program.” –Dr. Kenneth R. Levine
Location:
“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. Jay Freedman
Straumann will provide 7.0 Continuing Education Credits for this program
Visit http://straumann.cvent.com/dic2013 to learn more and register *$20 off cannot be combined with other available discounts. Please see website for complete program details and pricing.
The Westin St. Francis 335 Powell Street San Francisco, CA 94102
Straumann would like to thank the following sponsors:
CLINICAL
Uncovering peri-implantitis Dr. Nikos Donos talks about the growing importance of peri-implant disease and explains how the latest research is shaping treatment What is peri-implantitis – and how does it differ from periodontitis? Peri-implantitis is a disease affecting the tissues around a dental implant, whereas periodontitis is a disease affecting the tissues surrounding a natural tooth. They share a lot of common clinical features in terms of pocket formation, bleeding upon probing, inflammation, and bone loss. However, at a recent consensus conference of the European Federation of Periodontology (EFP), it has been shown that despite similarities in terms of clinical features and etiology between peri-implantitis and periodontitis, critical histopathological differences exist between the lesions created by these diseases.
How can dentists diagnose it? It is usually by a combined clinical and radiographic diagnosis. During clinical examination, pockets and bleeding upon probing might be seen. In this case, a radiographic evaluation is needed – you can compare the bone loss in association with the clinical signs that have occurred during the intervals between X-rays. It is recommended by the EFP that in order to establish baseline, a radiograph should be taken to determine alveolar bone loss after physiologic remodeling has been completed. In the same report, it is suggested that time of prosthesis installation is the point to establish baseline criteria.
Should it be treated differently than periodontitis? There is usually a two-step procedure: a nonsurgical treatment initially, and finally a surgical treatment. While it has been shown that nonsurgical treatment might be adequate
Nikos Donos, DDS, MS, FHEA, FRCSEng PhD, has held the positions of Head and Chair of Periodontology, as well as the Director of Research, and Chair of Department of Clinical Research, and Director of Eastman Clinical Investigation Centre, UCL-Eastman Dental Institute in London, England.
14 Implant practice
to treat the clinical symptoms for periimplant mucositis, this is often not the case with peri-implantitis. Furthermore, today we are not in a position to claim that we have a predictable surgical approach that will eliminate or resolve the disease. Unfortunately, there are studies indicating that even after a surgical procedure, a number of peri-implantitis cases continue to progress with the loss of implant as a result. Nevertheless, there are two surgical
approaches: the resective and the regenerative approach. The resective approach aims to eliminate the pockets around the implants and expose the contaminated implant surface, in order for the patient to perform oral hygiene procedures and control the plaque formation. The regenerative approach, when the defect configuration allows it, leads to bone regeneration around the implant (with a significant variability, if any, of Volume 6 Number 2
CLINICAL
reosseointegration) through the use of membranes and bone grafts, according to the treatment principle of guided bone regeneration. Again, there is no long-term data discussing/evaluating the efficacy of these two surgical approaches. It is important to add that we often need to use antibiotics for both surgical and nonsurgical techniques.
Is peri-implantitis problem?
a
“When we discuss implant failure, we are usually talking about the complete loss of the implant.”
growing
Peri-implant disease could well become a bigger issue in the future, given that many patients wish to be treated with dental implants. As they become more accessible to more people, there is the possibility that we’ll see more cases of peri-implantitis in the future. But there is also the possibility that dentists are becoming more aware of the disease and case selection, whereas peri-implantitis was not previously thought of as a common problem. IMPLANT PRACTICE AD_2PR.pdf
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prior to the placement of implants; and, at the end, the regular maintenance of these patients. There is a lot of discussion about identifying these susceptible patients, but unfortunately, there is still no easy way to define who, within the periodontallycompromised population, will be more susceptible to further complications than others.
Can improperly managing the soft tissues lead to implant failure? Soft tissue management is a very important element to consider within implant treatment. But when we discuss implant failure, we are usually talking about the complete loss of the implant. Therefore, as far as complete failure, I do not think that solely managing the soft tissues in a non-optimal manner will always lead directly to failure. However, if we talk about failure in terms of making cosmetic compromises, then this can, of course, result directly from improper management
Does it only affect those with a previous diagnosis of periodontitis? There is a significant amount of literature indicating that patients with periodontitis are definitely more susceptible to developing biologic complications (peri-implantitis). The important element in these cases is appropriate case selection by the dentist; the complete resolution of the periodontal disease by the specialist in periodontics 2/18/13
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Volume 6 Number 2 Implant practice 15
CLINICAL of the soft tissues. The dentist needs to be very well trained in managing the soft tissues because the esthetic demands these days are very high – patients being treated with dental implants often expect to have the same smiles as “the models in the implant brochures.” There is a very high level of expectation in this field on the part of patients.
the specialty of periodontology, and it is regarded as a complex level of treatment. The ADEE (Association for Dental Education in Europe) held a workshop in Prague in 2008 that decided the treatment of periimplantitis is a major competency where a significant level of training is required (specialist level).
Is this a mistake inexperienced implant dentists are more likely to make?
I think that an understanding of periimplantitis and periodontitis will become very important in the future. A significant number of dental implants will continue to be placed on a global level, and the data so far shows that a proportion of these patients will present biologic complications with their implants, and they will require treatment with predictable outcomes. The demand for very good esthetic results, and the fact that patients wish to have faster treatments, will, most probably, lead to further exciting research in terms of implant surfaces. I also think we will see exciting developments in the restorative components, too, where new materials will appear that allow better esthetics and better resistance to fracture.
I think that any inexperienced dentist in any type of dental discipline is more likely to make mistakes, but experienced dentists can make mistakes, too. As with all disciplines, it’s important to have the right training for the safety of your patients.
Is peri-implantitis only an issue for dentists treating complex cases? All dentists who do implant dentistry – but also those who do not – should be mindful of peri-implantitis, and be able to advise their patients on how to avoid it. Treatment of peri-implantitis, though, is a condition that forms part of the official curriculum for
What does the future hold for implant dentistry?
References Claffey N, Clarke E, Polyzois I, Renvert S. Surgical treatment of peri-implantitis. J Clin Periodontol. 2008;35(suppl):316-332. Dereka X, Mardas N, Chin S, Petrie A, Donos N. A systematic review on the association between genetic predisposition and dental implant biological complications. Clin Oral Implants Res. 2012;23(7):775-788. Donos N. Summary of: Specialists’ management decisions and attitudes towards mucositis and peri-implantitis. Br Dent J. 2012;212(1):30-31. Donos N, Laurell L, Mardas N. Hierarchical decisions on teeth vs. implants in the periodontitis-susceptible patient: the modern dilemma. Periodontol 2000. 2012;59(1):89-110. Donos N, Mardas N, Buser D. An outline of competencies and the appropriate postgraduate educational pathways in implant dentistry. Eur J Dent Educ. 2009;13(suppl 1):45-54. Lang NP, Berglundh T. Periimplant diseases: where are we now? Consensus of the Seventh European Workshop on Periodontology. J Clin Periodontol. 2011;38(suppl 11):178-181. Lindhe J, Meyle J. Peri-implant diseases: Consensus report of the Sixth European Workshop on Periodontology. J Clin Periodontal. 2008;35(suppl 8):282-285. Nibali L, Donos N. Radiographic bone fill of peri-implantitis defects following nonsurgical therapy: report of three cases. Quintessence Int. 2011;42(5):393-397.
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CLINICAL
Guided surgery – understanding the risks Dr. Peter Sanders explains the importance of gaining experience in conventional implant placement prior to using CT guided surgery
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t is commonly known that cone beam computed tomography (CBCT) and computed tomography (CT) guided surgery can improve the placement of implants, with great precision and accuracy. Technologies such as cone beam scanning, 3D imaging software, and surgical guides can achieve a level of precision that up until recent years was unheard of. When planned and executed well, the use of CT guided surgery improves comfort in treatment, lowers the volume of local anesthetic required, reduces surgical trauma, and cuts down on chair time for the patient. But while the potential for complication decreases and higher levels of precision are achieved, there are certain risks associated with surgical guidance that remain. These risks are related to the tactile feedback we sacrifice when relying on such technology.
Earning experience To successfully place a dental implant using CT guided surgery, a strong knowledge of the anatomy is critical. But as more and more dental surgeons are using guided surgery, many (especially those new to implants) are foregoing the vital foundation of experience gained through manual or conventional implant procedures. Consequently, the anatomical knowledge and experience gained through such procedures may be missing. CT guided surgery has relieved the surgeon of making many decisions that are commonly experienced in conventional placement during surgery. However
Dr. Peter Sanders is the clinical director and lead implant dentist at Dental Confidence. He was recently awarded the Fellowship of the Faculty of General Dental Practice by the Royal College of Surgeons (RCS) in London and regularly attends implant conferences and training events across the globe. Dr. Sanders is also responsible for delivery of the FGDP(UK) Implant Diploma program at Leeds Dental School and examining at the Royal College of Surgeons of England. For more information visit www.dentalconfidence.com.
18 Implant practice
Figure 1: Planning in SimPlant
without this experience, the risk relating to anatomical hazards can increase and therefore precision can be compromised – potentially leading to iatrogenic damage or implant failure. In actual fact, the use of guided surgery requires the same skills, experience, and anatomical knowledge as manual placement, to ensure any potential risks are recognized and avoided. For example, if during the osteotomy protocol a higher or lower level of resistance occurs while drilling the bone, previous experience of manual implant placement will alert you to the unpredicted resistance, indicating bone density or alignment issues. Conversely, little prior experience of conventional surgical placement may leave this warning sign unheeded.
Guiding principles Other potential risks lie in using stereolithographic surgical guides. Stereolithographic guides provide superior accuracy in the placement of implants, especially tooth- and bone-supported guides. However, this accuracy needs to be supported with experience to achieve the precision the technology is capable of.
Mucosa-supported guides are often misconstrued as the easiest to use, but they can be the least accurate in terms of positioning. If a guide is positioned, but there is a slight misalignment in the initial stages, or the guide is moved from its original position, this could potentially make the implant’s proximity to adjacent nerves, teeth, or blood vessels a hazard. Additional tissue pressure on seating the guide may also result in implants being placed more deeply than planned. The use of a tissue punch approach during mucosaguided surgery may also lead to the permanent loss of useful or critical attached mucosa, potentially compromising the final outcome. Bone-supported guides are very stable, and therefore accurate, but require a much larger flap to be raised than may otherwise be desirable, with the inherent consequences of increased trauma and risks. When using a guide, the surgeon is compelled to follow the path of the drilling sleeves, without being able to visually verify the accuracy of the guide, which can also obscure the view of the implant position. This may mean that errors such as Volume 6 Number 2
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CLINICAL
Figures 2A-2D: Screenshots showing the planning stages. This ensures that not only are the implants placed in the ideal position from surgical and prosthetic perspectives, but also that the abutment angles and collar heights can be preselected
Figures 3A-3B: Stereolithographic drill guides with metal collars to control drill angle and depth
Figures 4A-4C: Bone level drill guide in position and in use
control over the depth of the drilling may be more difficult to assess as visual access is impaired. In such cases, conventional implant experience is critical. A lack of knowledge may lead one to accept a misaligned guide position that an experienced surgeon (with a history of manual implant placement) would recognize as incorrect. Stereolithographic surgical guides can improve accuracy and precision, but they can sometimes present certain limitations. For example, a guide may only be used when there is sufficient ridge width. This means that some conservative techniques such as ridge expansion, ridge splitting, or bone condensing are not possible. Guided surgery is also incompatible with techniques such as internal sinus lifts and deep implant placements. Without the experience of manually placing implants, a good knowledge of these techniques may not have been acquired. If primary stability is an issue, a surgeon may need to be able to improvise using such techniques, if 20 Implant practice
Figure 5: Pre-selected abutments aligned as planned
treatment is to be successful.
Hot under the collar Overheating is also a risk. Inadequate cooling from irrigation of the surgical area can cause necrosis of the bone, leading to implant failure. By using a guide, the likelihood of overheating the bone can often be increased. Most systems use external irrigation, whereby coolant saline is used to reduce the temperature of the external area of the drill, but with this, there is an increased risk of the bur and bone overheating. The most effective way of cooling the drill is through internal irrigation, where the possibility of overheating is significantly reduced. The alternative is to continually remove the drill completely in order to cool it, but this will lead to a less accurate osteotomy, as the hole gets larger and less precise with each reinsertion. Without a background of conventional methods of placement, a surgeon increases his/her chances of overheating
bone as his/her frame of reference – in terms of understanding when irrigation has not been effective is limited.
Acknowledging experience Overall, CT guidance can greatly enhance precision and accuracy, but in order to eliminate possibilities of risk, hazards, or potential failure, first-hand experience of manual implant procedure should always be gained prior to its use. While the advances of technology should be embraced, it is important that we do not forget the value of first-hand knowledge and experience. Using CT/CBCT guided surgery is often perceived as the “easier� way to place implants, which in many cases may be true. However, as with any form of surgery, it is vital to have a thorough understanding of all of the potential risks and hazards so they can be both recognized and avoided before damage or failure occurs. IP
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CONTINUING EDUCATION
Preventing the dreaded black triangle during implant placement in the esthetic zone: part 1 Dr. Scott M. Blyer examines ways to avoid a frustrating complication of dental implant therapy
A
s the evolution of dental implant therapy in terms of technology and technique marches on, still one of the greatest challenges remains — the achieving of predictable esthetic results. The implant practitioner must have a strong grasp conceptually, surgically, and prosthetically to deliver not only what patients want, but what they expect in the esthetic zone. As a specialist, barriers to an esthetically pleasing result should be identified and related to the patient and the restoring dentist. When they are explained before they occur, they are a warning; when explained after they occur, they become an excuse. The focus of this article is the avoidance of a frustrating complication, the open gingival embrasure, also referred to as the black triangle. Preventive interventions for the black triangle should be considered (1) preoperatively, (2) surgically, and (3) postoperative prosthetically (Figure 1). 1. Preoperative assessment/interventions: Always when planning on implantation in the esthetic zone, gingival biotype should be identified before continuing further. Patients with a thin biotype often have long narrow maxillary central incisors. This type of gingival support is more susceptible to recession and open embrasures. When a thin biotyped patient requiring a tooth extraction and implant placement is identified, there should be meticulous
Dr. Blyer is a dual-degree, double boardcertified oral and maxillofacial surgeon with offices in Islandia and New York City. He has teaching positions in multiple hospitals, authored textbook chapters and books, written numerous research papers, and lectured around the globe. He is a reviewer for two well-respected medical publications, and his resume reflects numerous awards in leadership, research, patient care, and compassion. He was voted one of America’s 80 top oral and maxillofacial surgeons by his peers in 2010. He is a certified speaker for Straumann® Dental Implants.
22 Implant practice
Educational aims and objectives This article aims to identify preventative interventions for the black triangle preoperatively, surgically, and postoperative prosthetically. Expected outcomes Correctly answering the questions on page 26, worth 2 hours of CE, will demonstrate the reader can: • Identify the importance of gingival biotypes when planning implantation in the esthetic zone. • Learn about surgical considerations such as flap design, supporting bone, angulation, and mesio-distal relationships. • Realize the various aspects of prosthetic planning such as platform switching, contact points, temporization, tooth shape, and final crown position.
Figure 1: To avoid creating an open gingival embrasure during implant placement and restoration, many considerations must be in place from before one starts until final restoration
attention to performing an “atraumatic extraction.” Considering a hard and/ or soft tissue graft and a 3- to 6-month consolidation period should be considered prior to implant placement.1 Patients with a thicker biotype typically have short and wide central incisors.2 They have thicker osseous structure with thick and wide papilla. These thicker biotype patients have less recession, better vasculature to the papilla, and better tissue resilience. If a tooth with poor gingival support is planned for an extraction and implant placement, this tooth can be orthodontically extruded over a period of 4
weeks. The extrusion should be parallel to the long axis of the tooth to advance the buccal and interdental bone supporting the papilla coronally (Figures 2A and 2B). This should be considered in those areas with an apically positioned gingival margin, and flat gingival scallop.3 A 2 mm coronal overcorrection is ideal anticipating some recession over time.4 Cochran, et al., (2002) reported that soft-tissue changes (e.g., recession) of approximately 1 mm take place in the first year after the restorative therapy is performed on a one-stage implant.5 Anticipating this with overcorrection is ideal.
Volume 6 Number 2
CONTINUING EDUCATION
Figure 2A: Orthodontic extrusion (before)
Figure 2B: Orthodontic extrusion (after)
To quote Dr. D. Garber, “Soft tissue is the issue, but bone sets the tone.” Bone loss around an implant will increase the distance from the contact point to the bone, resulting in an inadequate papilla.
Figure 3: Papilla-sparing incision
2. Surgical considerations: Fabricating a surgical guide prior to implant placement can help determine the need for site development and help assist proper angulation and positioning of an implant in the esthetic zone. A) Flap design: Numerous interdental papilla-preserving incisions have been described. Most of these incisions restrict the vertical release component in the papilla area (Figure 3). Restricting flap elevation can minimize the amount of bone resorption,6 thus helping in the preservation of the interdental papilla. Different variations of techniques for papilla preservation have been described, most of them emphasizing limiting the vertical releasing incisions in the papillary area.7 B) Supporting bone: To quote Dr.
D. Garber, “Soft tissue is the issue, but bone sets the tone.” Bone loss around an implant will increase the distance from the contact point to the bone, resulting in an inadequate papilla. For a two-piece implant, changes occur after placement of the abutment. Biological width is reestablished as 1.5 to 2 mm of bone resorption occurs circumferentially. If proper spacing were not respected, the resultant interproximal bone resorption will not support the papilla, and it will be evident in papilla loss. Bone resorption along the gingival margins has been most pronounced when the facial thickness was less than 1.4 mm, while the possibility of bone gain has been seen at a 2 mm thickness. This is why the authors concluded that 2 mm is a critical thickness for the integrity of facial plate
after stage 2.8 C) Angulation: Proper angulation of implant placement will preserve bonesupporting gingival tissue around the implant. This angulation should resemble the angulation of the long access of the adjacent teeth. In the maxilla, a slight palatal inclination can help preserve thin buccal bone.2 D) Buccolingual position is critical for a proper esthetic result (Figure 1). This can best be estimated on a model. The center of the implant should be 4 mm from an imaginary line connecting the incisal edges of adjacent teeth. The buccal aspect of the implant should touch that imaginary incisal edge line. There are times when slight variations of this can be favored (Figure 4). E) Mesio-distal relationship: Implants
Volume 6 Number 2 Implant practice 23
CONTINUING EDUCATION
Figure 4: The center of the implant should be 4 mm from an imaginary line drawn from the incisal edges of the adjacent teeth
Figure 5: Implant placement should be 3 to 5 mm apical to the gingival margin of adjacent teeth
Figure 6: The platform matched side (A) of the implant shows an abutment with the same diameter implant. This implant/abutment interface will result in bone loss around the microgap. The platform switched side (B) shows a smaller diameter abutment which shifts the microgap medially, preserving crestal bone attachment and papilla support
should be placed no closer than 1.5 mm to a natural tooth. Two adjacent implants should be placed no closer than 3 mm.9 F) Apically: The implant should be placed 3 to 5 mm below the gingival margin of the adjacent teeth10 (Figure 5). 3. Prosthetic planning A) Platform switching: Platform switching is another technique employed to preserve crestal bone height around the implant which helps support the papilla. At the implant abutment interface, also referred to as the microgap, 1.2 to 1.3 mm of horizontal and vertical bone loss can be anticipated. Platform switching has been a proven method for minimizing or even eliminating this unwanted loss11 (Figure 6). B) Contact point: Tarnow, et al.,12 examined the existence of interdental papillae in humans, and this study has been duplicated multiple times since.13 24 Implant practice
The authors found that when the distance from the contact point to the alveolar bone was less or equal to 5 mm, the papilla was present 98% of the time, while at 6 mm, it dropped to 56%, and at 7 mm it was only present 27% of the time between natural teeth and implants. In two adjacent implants, the distance between contact point to alveolar bone was <3.5 mm to maintain papilla formation9 (Figure 7). The mean papilla length for an implanttooth relationship was found to be 6.5 mm; for an implant-implant relationship, the mean papilla length was 4.5 mm.14 In another study, the papilla length was determined to be 3.4 mm between adjacent implants.15 The importance of the alveolar bone to contact point distance is of colossal importance in maintaining or creating proper interdental papilla formation. C) Temporization: The provisional
restoration placed in the edentulous space will also impact the gingival architecture. If a pontic should be placed, it should be ovoid and not overbulked on the facial. The pontic should extend initially 2.5 mm below the free gingival margin. This will allow the pontic to be situated within 1 mm of the facial and interproximal bone and will give support to the surrounding facial gingiva and the interdental papilla. After a 4-week healing period, the height of the pontic should be adjusted to extend approximately 1.5 mm below the tissue.16 If a removable appliance should be placed, it should lay passive and not impinge on the tissues. Placement of a provisional restoration at the time of stage 2 can also reshape the interdental papilla tissue favorably. When possible, a provisional restoration is helpful in prosthetically guiding the soft tissue into its final position for a 4- to 6-week period.17 Volume 6 Number 2
Figure 7: Mesio-distal spacing of implants in relationship to natural teeth and adjacent implants to maintain the interdental papilla. The contact point between alveolar bone and crown is also demonstrated
References 1. Park J, Tai K, Morris J, Modrin D. Clinical considerations of open gingival embrasures. In: Buduneli N, ed. Pathogenesis and treatment of periodontitis. New York, NY: InTech; 2012:113-126. 2. Al-Sabbagh M. Implants in the esthetic zone. Dent Clin North Am. 2006;50(3):391-407, vi. 3. Sclar AG. Esthetic implant complications: Prevention and management. J Oral Maxillofac Surg. 2006;64(suppl 9):4-5. 4. Brindis MA, Block MS. Orthodontic tooth extrusion to enhance soft tissue implant esthetics. J Oral Maxillofac Surg. 2009;67(suppl 11):49-59. 5. Cochran DL, Buser D, ten Bruggenkate CM, Weingart D, Taylor TM, Bernard JP, Peters F, Simpson JP. The use of reduced healing times on ITI implants with a sandblasted and acid-etched (SLA) surface: early results from clinical trials on ITI SLA implants. Clin Oral Implants Res. 2002;13(2):144–153.
The shape and contours of this provisional will have a tremendous impact on the final position of the soft tissue. Excessive contouring on the facial aspect will cause the free gingival margin to migrate apically. Adding interproximal contour will help create an ideal papillary shape. D) Tooth shape: When the tooth shape is considered, square-shaped teeth may have a more favorable esthetic outcome than ovoid or triangular-shaped teeth because of a longer interproximal contact and implicitly a less amount of papilla to fill in the space.18 E) Final crown position: The final crown should be centered no farther than
implant sites primarily closed by a rotated palatal flap following extraction. Int J Oral Maxillofac Implants. 2000;15(4):550–558. 8. Spray JR, Black CG, Morris HF, Ochi S. The influence of bone thickness on facial marginal bone response: stage 1 placement through stage 2 uncovering. Ann Periodontol. 2000;5(1):119-128. 9. Tarnow D, Elian N, Fletcher P, Froum S, Magner A, Cho SC, Salama M, Salama H, Garber DA. Vertical distance from the crest of bone to the height of the interproximal papilla between adjacent implants. J Periodontol. 2003;74(12):1785-1788. 10. Park J, Tai K, Morris J, Modrin D. Clinical considerations of open gingival embrasures. In: Buduneli N, ed. Pathogenesis and treatment of periodontitis. New York, NY: InTech; 2012:113-126. 11. Gardner DM. Platform switching as a means to achieving implant esthetics. N Y State Dent J. 2005;71(3):34-37.
6. Wilderman MN, Pennel BM, King K, Barron JM. Histogenesis of repair following osseous surgery. J Periodontol. 1970;41(10):551–565.
12. Tarnow DP, Magner AW, Fletcher P. The effect of distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla. J Periodontol. 1992;63(12):995-996.
7. Nemcovsky CE, Artzi Z, Moses O, Gelernter I. Healing of dehiscence defects at delayed-immediate
13. Choquet V, Hermans M, Adriaenssens P, Daelemans P, Tarnow DP, Malevez C. Clinical and
half of the abutment radius from the center of the implant. This will prevent thin buccal bone recession. Having too much tissue is like having too much money. It is usually a good problem to have. When placing implants in the marginally tissued individual, one must properly plan and respect the biological ecosystems that have been well established. Having a surgical guide on hand can quicken surgical time and improve surgical results in the esthetic zone. Fighter pilots will always map out their coordinates before aiming at their targets, and implant surgeons should do the same.
radiographic evaluation of the papilla level adjacent to single-tooth dental implants. A retrospective study in the maxillary anterior region. J Periodontol. 2001;72(10):1364–1371. 14. Salama H, Salama MA, Garber D, Adar P. The interproximal height of bone: a guidepost to predictable aesthetic strategies and soft tissue contours in anterior tooth replacement. Pract Periodontics Aesthet Dent. 1998;10(9):1131-1142. 15. Hartmann R, Müller F. Clinical studies on the appearance of natural anterior teeth in young and old adults. Gerodontology. 2004;21(1):10-16. 16. Spear, FM. Maintenance of the interdental papilla following anterior tooth removal. Pract Periodontics Aesthet Dent. 1999;11(1):21-28, 30. 17. Rocci A, Martignoni M, Gottlow J. Immediate loading in the maxilla using flapless surgery, implants placed in predetermined positions, and prefabricated provisional restorations: a retrospective 3-year clinical study. Clin Implant Dent Relat Res. 2003;5(suppl 1):2936. 18. Kois JC. Predictable single tooth peri-implant esthetics: five diagnostic keys. Compend Contin Educ Dent. 2001;22(3):199-206, 208.
Volume 6 Number 2 Implant practice 25
CONTINUING EDUCATION
Having too much tissue is like having too much money. It is usually a good problem to have. When placing implants in the marginally tissued individual, one must properly plan and respect the biological ecosystems that have been well established.
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IMPLANT PRACTICE CE 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
REF: IP V6.2 BLYER
CONTINUING EDUCATION BROUGHT TO YOU BY
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Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 16 CE credits for only $99. To receive credit, complete the 10-question test by circling the correct answer, then either: n Post the completed questionnaire to: Implant Practice US CE 15720 N. Greenway-Hayden Loop. #9 Scottsdale, AZ 85260 n Fax to (480) 629-4002.
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To provide feedback on this article and CE, please email us at education@implantpracticeus.com Legal disclaimer: The CE provider uses reasonable care in selecting and providing accurate content. The CE provider, however, does not independently verify the content or materials. Any opinions expressed in the materials are those of the author and not the CE provider. The instructional materials are intended to supplement, but are not a substitute for, the knowledge, skills, expertise and judgement of a trained healthcare professional.
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Preventing the dreaded black triangle during implant placement in the esthetic zone 1. Preventive interventions for the black triangle should be considered _______. a. preoperatively b. surgically c. postoperative prosthetically d. all of the above 2. Always when planning on implantation in the esthetic zone, _______should be identified before continuing further. a. gingival biotype b. flap design c. flap elevation d. bone support 3. Patients with a thin biotype often have ______maxillary central incisors. a. long b. narrow c. both a and b d. wide 4. Patients with a thicker biotype typically have ______central incisors. a. long and narrow b. short
26 Implant practice
c. wide d. both b and c
c. 1.5 mm d. 2 mm
5. These thicker biotype patients have _______. a. less recession b. better vasculature to the papilla c. better tissue resilience d. all of the above
8. _______around an implant will increase the distance from the contact point to the bone, resulting in an inadequate papilla. a. Restorative therapy b. Bone loss c. Overcorrection d. Vertical releasing incisions
6. If a tooth with poor gingival support is planned for an extraction and implant placement, this tooth can be orthodontically extruded for a period of ___ weeks. a. 4 b. 8 c. 6 d. 12
9. At the implant abutment interface, also referred to as ______, 1.2-1.3 mm of horizontal and vertical bone loss can be anticipated. a. the minigap b. the microgap c. the gingival scallop d. the micro triangle
7. Cochran, et. al., (2002) reported that soft-tissue changes (e.g., recession) of approximately _____ take place in the first year after the restorative therapy is performed on a one-stage implant. a. .5 mm b. 1 mm
10. The final crown should be centered no farther than _____of the abutment radius from the center of the implant. a. one quarter b. one third c. half d. three quarters
Volume 6 Number 2
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.
PREVAIL is a registered trademark of BIOMET 3i LLC. Preservation By Design and Providing Solutions - One Patient At A Time are trademarks of BIOMET 3i LLC. ©2013 BIOMET 3i LLC.
CONTINUING EDUCATION
Treatment planning of implants in the esthetic zone: part 1 In the first part of a series of articles, Drs. Sajid Jivraj, Mamaly Reshad, and Winston Chee look at the diagnostic factors that affect the predictability of peri-implant esthetics
A
chieving esthetics with implant restorations is significantly more challenging than with conventional restorations. Diagnosis and appropriate treatment planning are critical in obtaining a successful outcome. Many manufacturers will identify their systems as esthetic — from an objective perspective, components in and of themselves are not esthetic. There is not a single component available that would be the ideal replacement for a maxillary central incisor. Esthetic outcomes are based on many variables. It is not the specific implant design, surface characteristics, or type of abutment that will guarantee an esthetic result. It is the time spent on data collection in reaching a correct diagnosis that pays dividends in terms of function and esthetics (Sullivan, 2001). Root form cylindrical implants placed following surgical techniques described by Branemark, et al., have proven to be a predictable method for anchoring replacement teeth to the jaw bone (Branemark, et al., 1990; Naert, et al., 1992). Today, clinicians can prescribe the use of implants with the knowledge and confidence that they will predictably integrate into the jawbone. The successful integration of an implant, however, is not sufficient to declare success; implants placed in poor restorative positions result in unesthetic restorations that provide little satisfaction for the clinician or the patient. Figures 1-3 demonstrate the complexity of implant use in esthetic zones and the
Sajid Jivraj, DDS, MSEd, is clinical associate professor at Herman Ostrow USC School of Dentistry in Los Angeles, California. He is a board member of the British Academy of Restorative Dentistry and honorary clinical teacher at Eastman Dental Institute London, England. He owns a private practice in Ventura, California. Mamaly Reshad, BDS, MSc, is honorary clinical teacher at Eastman Dental Institute London, England. He works in private practice at 30a Wimpole Street, London. Winston WL Chee, DDS, FACP, is Ralph and Jean Bleak professor of restorative dentistry, director of implant dentistry at the School of Dentistry, University of Southern California in Los Angeles, California, codirector of the advanced prosthodontics program and Herman Ostrow USC School of Dentistry.
28 Implant practice
Educational aims and objectives The aim of this article is to discuss the fundamental considerations of treatment planning implants in the esthetic zone. Expected outcomes Correctly answering the questions on page 32, worth 2 hours of CE, will demonstrate the reader can: • Learn the factors that affect predictability. • See the aspects that affect the esthetics of the final outcome. • Understand the major indications for dental implant treatment.
Figure 2: Smile view of restoration fabricated for implant in Figure 1
Figure 1: Laboratory photograph of implant in poor position angled labially
Figure 3: Labial view of restoration for implant on Figure 1. Pink ceramics used to disguise poor implant position
importance of proper treatment planning prior to implant placement. Providing an esthetic outcome requires understanding of the objective and subjective criteria related to hard and soft tissue esthetics (Belser, 1982). Both dental and gingival esthetics act together to provide a smile with harmony and balance. The clinician must be aware of parameters related to gingival morphology, form and dimension, characterization, surface texture, and color (Magne, Belser, 2002) [Figure 4]. Ceramists can often produce restorations to match adjacent teeth in terms of color. However, if the surrounding tissues are not reconstructed, an esthetic outcome is not likely (Figures 5A and
5B). The ultimate aim is for the implant restoration to harmonize into the frame of the smile, face and, more importantly, the individual. Treatment planning must address hard and soft tissue deficiencies and combine this with precision in implant placement; only with this approach can implant restorations be indistinguishable from the adjacent teeth (Figure 6). Recreating what nature provided can be a formidable challenge. The physiology of wound healing after tooth extraction creates an unfavorable soft tissue complex. The remaining mucosa often recedes palatally and apically. Often this results in a restoration that appears long, and this is compounded by the absence of interdental Volume 6 Number 2
Figure 5A: Implants in lateral incisor position placed too buccally. Note how position of implant affects position of gingival margin
Figure 5B: Cemented implant restorations placed on custom abutments. Note asymmetrical gingival margins
Figure 6: Implant restoration on right lateral incisor in harmony with the existing hard and soft tissue
Figure 7: Wound healing following extraction of a tooth can result in apical and palatal migration of the interdental papilla
Figure 8: A perfect indication for a dental implant is nonpreparation of the adjacent teeth
Figure 9: Low smile line
Figure 10: Average smile line
Figure 11: High smile line. The color and contour of the restorations and associated hard and soft tissues become very visible to the observer
papilla (Figure 7). The predictability of the esthetic outcome of an implant restoration is dependent on many variables including, but not limited to: 1. Patient selection and smile line 2. Tooth position 3. Root position of the adjacent teeth 4. Biotype of the periodontium and tooth shape 5. The bony anatomy of the implant site 6. The position of the implant.
defined parameters that lead to successful esthetics with long-term stability of the peri-implant tissues. The major indication for a single tooth implant restoration is preservation (nonpreparation) of one or more of the adjacent teeth (Figure 8), and reduction in the rate of alveolar resorption. Additional indications would be restoration of a missing tooth to maintain a diastema and preservation of extensive fixed restorations that are intact. A patient’s esthetic expectations must also be evaluated together with his/her lip activity and lip length. In an average smile, 75-100% of the maxillary incisors and the interproximal gingiva are displayed. In a high smile line, additional gingival tissue is exposed. Less than 75% of the incisors are exposed in a low smile line (Figures 9-11) [Tjan, Miller, The, 1984]. The clinician should be aware that the patient who presents with unacceptable tooth health, shade, or position may not give a full smile when asked. Previous photographs may aid in determining the natural position of
the patient’s lip when smiling. A high smile line poses considerable challenges when planning for implantsupported restorations in the esthetic zone because the restoration and gingival tissues are completely displayed. In these types of clinical situations, maximal efforts towards maintaining peri-implant tissue support throughout the planning, provisional, surgical, and restorative phases will be required. The low smile line is a less critical situation because the implant restoration interface will be hidden behind the upper lip. However, this cannot be assumed, and the patient’s input must be sought to confirm this.
Patient selection and smile line Patients who are candidates for replacement of an anterior tooth with an implant-supported restoration must understand its benefits. They must also understand the additional length of time required for treatment and additional costs that will be incurred. The clinician must also understand the patient’s desires. In most cases, the patient’s primary demand is an esthetic tooth replacement. With this in mind, it is important to establish sound clinical concepts with clearly
Tooth position The tooth needs to be evaluated in three planes of space: apicocoronal, faciolingual, and mesiodistal. The existing tooth position will significantly influence the presenting gingival architecture. In many instances, teeth with a poor prognosis are thoughtlessly extracted. These teeth can
Volume 6 Number 2 Implant practice 29
CONTINUING EDUCATION
Figure 4: Restoration of implants must satisfy objective and subjective esthetic criteria. There should be sufficient interradicular space for placement of the implant and sufficient intertooth distance for fabrication of an esthetically pleasing restoration
CONTINUING EDUCATION
Figure 12: The right lateral incisor has been treatment planned for an implant restoration. The level of the soft tissues mimic that of the contra lateral tooth
Figure 13: Immediate extraction of the right lateral incisor would result in apical migration of the soft tissue. Orthodontic extrusion will allow the clinician to position the tissue more coronally so that on extraction there is a margin of error
Figure 14: The mesiodistal width of the tooth requiring replacement must equal that of the contra lateral tooth
Figure 15: Implant restoration replacing the right central incisor
Figure 16: Excessive mesiodistal space in the region of the tooth requiring an implant restoration
Figure 17: Implant restoration in the region of the right central incisor. Note absence of interdental papilla as a result of inadequate support of the soft tissue by the restoration
Figure 18: Clinical presentation of patient with congenitally missing maxillary lateral incisors post orthodontic treatment
Figure 19: Radiograph of patient in Figure 18 revealing that there is insufficient inter radicular space for implants
significantly influence both the hard and soft tissue configuration. Apico-coronal On assessment of the apico-coronal position of the tooth, it may be more apical, more coronal, or ideal, and mimic the level of the adjacent gingival margin (Figure 12). Numerous authors have shown that following extraction and insertion of an ovate pontic, there is likely to be up to 2 mm of gingival recession, and on extraction and placement of an implant immediately the migration of the gingival margin is likely to approximate 1 mm (Kois, 1998; Saadoun, et al., 1999). The implication of this is that if there is a hopeless tooth positioned ideally or apically, and this is extracted, the gingival margin is likely to migrate apically. Restoratively, long clinical crowns, pink porcelain, or visible metal margins will compromise the esthetic outcome. These teeth can benefit from orthodontic extrusion (Figure 13) prior to extraction, which will serve to position the gingival level at a more harmonious level (Kois, 2004; Salama, Salama, Kelly, 1996). Faciolingual In this dimension, the tooth position may present with different concerns. The tooth may be positioned too far facially; this often results in very thin or nonexistent labial bone. These teeth are not good candidates for orthodontic extrusion because of inadequate underlying bone. Extraction 30 Implant practice
of these teeth results in significant vertical bone loss and collapse of the gingival architecture. This type of situation would benefit from bone augmentation procedures prior to implant placement. A tooth positioned more lingually would benefit from the presence of an increased amount of facial bone. This situation is more favorable prior to extraction since the resultant discrepancy in the facial free gingival margin may be minimal (Kois, 2004). Mesiodistal The proximity of the adjacent teeth necessary to provide proximal support and volume of interdental papillae should be evaluated. Ideally, the mesiodistal tooth width should be equal to that of the contra lateral tooth so that an esthetic outcome can be achieved (Figures 14 and 15). Excess or deficiencies in this dimension should be addressed through the use of orthodontics, enameloplasty, or restorations. For patients with diastemas, it is imperative that the decision to maintain or close the space be made prior to implant placement. If the patient refuses the above options to close the space and insists on closing the space with the implant restoration, there is a likelihood that a black triangle may ensue. This results from inadequate support from the adjacent tooth to maintain the papilla. It is important that the clinician discusses this with the patient ahead of time so disappointment
with the final outcome is avoided (Figures 16 and 17).
Root position of the adjacent teeth Part of the diagnostic work for patients who need implants is a periapical radiograph, as often root position will preclude placing of implants. Many of these patients can benefit from orthodontics to reposition malposed teeth. If the patient illustrated in Figures 18 and 19 desired implant restorations to replace congenitally missing maxillary lateral incisors, orthodontic therapy would be necessary to move the roots of the cuspid and central incisor to allow room for ideal implant placement. Teeth with root proximity also possess very little interproximal bone, and this thin bone creates a greater risk of lateral resorption, which will decrease the vertical bone height after extraction or implant placement. When teeth are present, the use of orthodontics serves as a valuable adjunct to create space. This can be advantageous for support of proximal gingival architecture (Tarnow, Cho, Wallace, 2000; Tarnow, Magner, Fletcher, 1992).
Biotype of tooth shape
periodontium
and
The position of the gingival tissue around a tooth is determined by the connective tissue attachment and by the bone level. Two different periodontal biotypes have been described in relation to the Volume 6 Number 2
Figure 21: Biotype 2 periodontium, not thick and flat tissues. Implant provisional restoration in the position of left central incisor
morphology of the interdental papilla and the osseous architecture â&#x20AC;&#x201D; the thin scalloped periodontium and the thick flat periodontium (Becker, et al., 1997). The thin scalloped periodontium, found in less than 15% of cases, is characterized by a delicate soft tissue curtain, a scalloped underlying osseous form, and often has dehiscences and fenestrations, and a reduced quantity and quality of keratinized mucosa. Generally, interproximal tissue does not completely fill the space between adjacent teeth. This form of gingiva reacts to insults by receding facially and interproximally. As recession occurs and the interroot bone resorbs, the subsequent soft tissue loss compromises the overall esthetic result (Figure 20). The tooth form in this type exhibits a contact point towards the incisal third essentially triangular anatomic crowns and contact areas of teeth that are small faciolingually and apico-coronally. Due to extreme taper of the roots, the bone interproximally tends to be thicker. Characteristics of the soft tissue biotype will play a prominent role in final planning for the shoulder position of the implant. A thin biotype with highly scalloped tissue will require the implant body and shoulder to be placed more palatal to mask any titanium show-through. When implants are placed toward the palate, a slightly deeper placement is required to allow for proper emergence profile. Combining previous factors in a patient with a high lip line and a thin biotype is extremely difficult to treat. Patients who fit into these treatment categories should be made aware of the challenges involved in obtaining an esthetic result before treatment begins. The thick flat periodontal biotype is characterized by a denser more fibrotic soft tissue curtain, a flat thicker underlying osseous form, and an increased quantity and quality of attached keratinized gingiva. This tissue often reacts to insults by pocket
Figure 22: Loss of interproximal soft tissue in the presence of a triangular tooth form can result in unsightly black triangles
formation. Flat gingiva is associated with a tooth form that is more bulbous; contact areas are located more toward the middle third of the tooth primarily square anatomic crowns and contact areas that are wide faciolingually and apico-coronally (Figure 21). The tooth morphology appears to be correlated with the soft tissue quality. The triangular tooth shape is associated with the scalloped and thin periodontium. The contact area is located in the coronal third of the crown, underlining a long and thin papilla. The square anatomic crown shape combines with a thick and flat periodontium. The contact area is located at the middle third, supporting a short and wide papilla. Loss of interproximal tissue in the presence of a triangular tooth form will display a wider black triangle than in a situation when a square tooth is present (Figure 21). In some cases when the adjacent teeth are to be restored, the crown form can be modified prosthetically to compensate for partial interproximal tooth loss. The contact area of the prosthetic tooth is positioned more cervically, reducing the volume of the interdental space. The presenting tooth shape will also influence the implant restoration shape. The implant restoration should mimic its contra lateral natural tooth coronal to the free gingival margin (Figure 22). However, apical to the free gingival margin, the implant restoration will not be an anatomic replica. A delicate balance must be developed that provides adequate support of the gingival architecture, yet does not provide excessive pressure. Ideally, the facial contour should be slightly flatter than the contra lateral natural tooth to minimize apical displacement of the free gingival margin after insertion (Figure 23) [Phillips, Kois, 1998]. Parts of this article were reprinted with permission from the British Dental Journal.
Figure 23: Over contour of the implant restoration as it emerges from the free gingival margin can result in apical migration of the soft tissues
References Belser UC. Esthetic checklist for the fixed prosthesis. Part II: Biscuit bake try-in. In: Schärer P,Rinn LA, Kopp FR, eds. Esthetic guidelines for restorative dentistry. Chicago, IL: Quintessence; 1982:188-192. Becker W, Ochsenbein C, Tibbetts L, Becker BE. Alveolar bone anatomic profiles as measured from dry skulls. Clinical ramifications. J Clin Periodontol. 1997;24(10):727-731. Adell R, Eriksson B, Lekholm U, Brünemark PI, Jemt T. Long term follow-up study of osseointegrated implants in the treatment of totally edentulous jaws. Int J Oral Maxillofac Implants. 1990;5(4):347-359. Kois JC. Esthetic extraction site development: The biological variables. Contemp Esthet Restorative Pract. 1998;2:10-18. Kois JC. Predictable single tooth peri-implant esthetics: five diagnostic keys. Compend Contin Educ Dent. 2004;25(11):895-896, 898, 900, 906-907. Magne P, Belser U. Natural oral esthetics. In: Bonded porcelain restorations in the anterior dentition: a biomimetic approach. Chicago, IL: Quintessence; 2002:57-99. Naert I, Quirynen M, van Steenberghe D, Darius P. A study of 589 consecutive implants supporting complete fixed prostheses. Part II: Prosthetic aspects. J Prosthet Dent. 1992;68(6):949-956. Phillips K, Kois JC. Aesthetic peri-implant site development. The restorative connection. Dent Clin North Am. 1998;42(1):57-70. Saadoun AP, LeGall M, Touati B. Selection and ideal tridimensional implant position for soft tissue esthetics. Pract Periodontics Aesthet Dent. 1999;11(9):1063-1072, 1074. Salama H, Salama M, Kelly J. The orthodonticperiodontal connection in implant site development. Pract Periodontics Aesthet Dent. 1996;8(9):923-932, 934. Sullivan RM. Perspectives on esthetics in implant dentistry. Compend Contin Educ Dent. 2001;22(8):685-692. Tarnow DP, Cho SC, Wallace SS. The effect of inter-implant distance on the height of inter-implant bone crest. J Periodontol. 2000;71(4):546-549. Tarnow DP, Magner AW, Fletcher P. The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla. J Periodontol. 1992;63(12):995-996. Tjan AH, Miller GD, The JG. Some esthetic factors in a smile. J Prosthet Dent. 1984;51(1):2428.
Volume 6 Number 2 Implant practice 31
CONTINUING EDUCATION
Figure 20: Biotype 1 periodontium, note thin and scalloped tissue
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IMPLANT PRACTICE CE 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
REF: IP V6.2 JIVRAJ
CONTINUING EDUCATION BROUGHT TO YOU BY
Full Name
Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 16 CE credits for only $99. To receive credit, complete the 10-question test by circling the correct answer, then either: n Post the completed questionnaire to: Implant Practice US CE 15720 N. Greenway-Hayden Loop. #9 Scottsdale, AZ 85260 n Fax to (480) 629-4002.
AGD REGISTRATION NUMBER
LICENSE NUMBER
ADDRESS
CITY, STATE, AND ZIP CODE
To provide feedback on this article and CE, please email us at education@implantpracticeus.com Legal disclaimer: The CE provider uses reasonable care in selecting and providing accurate content. The CE provider, however, does not independently verify the content or materials. Any opinions expressed in the materials are those of the author and not the CE provider. The instructional materials are intended to supplement, but are not a substitute for, the knowledge, skills, expertise and judgement of a trained healthcare professional.
TELEPHONE/FAX
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Treatment planning of implants in the esthetic zone: part 1 1. Providing an esthetic outcome requires understanding of the objective and subjective criteria related to ____________. a. hard tissue esthetics b. soft tissue esthetics c. both a and b d. the preservation of fixed restorations 2. The ultimate aim is for the implant restoration to harmonize into _______. a. the frame of the smile b. the face c. the individual d. all of the above 3. The physiology of wound healing after tooth extraction creates an unfavorable soft tissue complex. The remaining mucosa often recedes ______. a. labially b. palatally c. apically d. both b and c 4. In an average smile, _____ of the maxillary incisors and the interproximal gingiva are displayed.
32 Implant practice
a. 75-100% b. 60-70% c. 50-60% d. 40-50% 5. Less than _____ of the incisors are exposed in a low smile line. a. 85% b. 75% c. 60% d. 65% 6. The low smile line is a less critical situation because __________ will be hidden behind the upper lip. a. the implant restoration interface b. the apico-coronal architecture c. the peri-implant tissue d. the palatal migration 7. Restoratively, ________will compromise the esthetic outcome. a. long clinical crowns b. pink porcelain c. visible metal margins d. any of the above
8. A tooth positioned more _______would benefit from the presence of an increased amount of facial bone. a. gingivally b. lingually c. buccally d. mesially 9. ________, found in less than 15% of cases, is characterized by a delicate soft tissue curtain, a scalloped underlying osseous form, and often has dehiscences and fenestrations, and a reduced quantity and quality of keratinized mucosa. a. The loss of interproximal tissue b. The thin scalloped periodontium c. Reduced alveolar resorption d. The thick flat periodontium 10. Loss of interproximal tissue in the presence of a triangular tooth form will display a _____ black triangle than in a situation when a square tooth is present. a. wider b. narrower c. darker d. more fibrotic
Volume 6 Number 2
STEP-BY-STEP
Fast, profitable, and patient-friendly denture stabilization 3M™ ESPE™ MDI Mini Dental Implants
A
s the demand for dentures continues to increase, there has never been a better time to start offering small-diameter implant treatment in your practice. The 3M™ ESPE™ MDI Mini Dental Implant System is a market-leading, small-diameter implant system with a 90-minute flapless placement procedure that can be learned in a 1-day certification seminar. This minimally invasive treatment enables immediate stabilization of ill-fitting dentures and gives dentists an outstanding tool to improve denture patients’ quality of life. MDIs are a simple and profitable offering for dental practices, providing a valuable alternative to conventional implants. Not only are MDIs more affordable than traditional implants, but they can also be used to treat patients who are poor candidates for traditional implants, whether due to bone height or overall health. Their ability to be immediately loaded (given sufficient initial stability is achieved) means that patients can walk out of the practice after placement and instantly appreciate the added denture stability. Data on the implant system has shown 1-year success rates as high as 98.3 percent, making MDIs not only fast and affordable, but reliable as well. The following steps illustrate the simple, flapless procedure for performing a standard mandibular denture stabilization with MDI implants. 1. Preoperative Planning • After patient selection and evaluation protocols have been completed, the number of MDI implants required (minimum of four) is determined and thoroughly discussed with the patient. The patient’s lower denture is then modified or fabricated, followed by identification of appropriate implant sites. After site selection, the MDI implants should be placed at least 5 mm apart. For mandibular placement, the implants should be placed beginning at least 7 mm anterior to the mental foramen.
2. Site Preparation • Entry points for each implant are marked on the patient’s tissue via bleeding points or a marker. • The 1.1 mm Pilot Drill is delicately placed over the entry point and lightly pumped up and down until the cortical plate is penetrated. No incision is necessary. • The average depth is one-third to one-half the threaded length of the implant. Sterile irrigation is utilized throughout the drilling procedure. o In extremely dense bone, an extended penetration may be required. o The pilot hole depth should never equal the length of the implant, as the tip of the drill is wider than the tip of the implant. • Recommended motor rpm is 1200-1500.
3. Use of Finger Driver • Open the implant vial. (All MDI implants are delivered sterile.) • Carry implant to the site using the vial cap, or grasp the body of the implant firmly with titanium locking pliers, and attach the Finger Driver to the head of the implant. (It has a friction grip o-ring and can be used as a carrier to the patient’s mouth, as well as a beginning surgical driver.) • After inserting the implant into the pilot opening through the attached gingiva, rotate clockwise while exerting downward pressure. • This procedure initiates the self-tapping process and is used until noticeable bony resistance is encountered. 34 Implant practice
Volume 6 Number 2
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Changing patients’ lives. Building doctors’ practices.
Coming to a City Near You! MDI Introductory Certification Course Learn how 3M™ ESPE™ MDI Mini Dental Implants can help offer a solution to patients who may be contra-indicated for conventional implant treatment. Already placing Mini’s? Register for an advanced course today!
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Register Today by Visiting: 3MESPE.com/ImplantSeminars Enter Promo Code* “IP200” Buy any 12 Implants Get 4 FREE!** Call 800-634-2249 to order.
Code Date u 1 u 1 u 1 u 8 u 9 ● 9 u 15 u 15 u 16 u 20 u 22 u 22 u 23
Location Baton Rouge, LA Albuquerque, NM Louisville, KY San Francisco, CA San Francisco, CA Buffalo, NY Jacksonville, FL Memphis, TN Memphis, TN Atlanta, GA Detroit, MI Seattle, WA Detroit, MI
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Location Kansas City, KS Houston, TX Dallas, TX Philadelphia, PA Mitchellville, MD Salt Lake City, UT Anaheim, CA Madison, WI New York, NY Madison, WI New York, NY Minneapolis, MN Sacramento, CA Phoenix, AZ Phoenix, AZ New Orleans, LA New Orleans, LA
u = Introductory Training Program u = Advanced Training Program ● = Mini Dental Residencies n = CARD Events
**Promo Code “IP200” only available for 2013 3M ESPE MDI Introductory Courses **Applies to implants of equal or lesser value
For more information or to enroll today visit
3MESPE.com/ImplantSeminars 3M ESPE Customer Care: 1-800-634-2249 3M, ESPE and Espertise are trademarks of 3M or 3M Deutschland GmbH. Used under license in Canada. © 3M 2013. All rights reserved.
MDI
Mini Dental Implants
STEP-BY-STEP
The 3M™ ESPE™ MDI Mini Dental Implant System is a market-leading, smalldiameter implant system with a 90-minute flapless placement procedure that can be learned in a 1-day certification seminar. This minimally invasive treatment enables immediate stabilization of ill-fitting dentures and gives dentists an outstanding tool to improve denture patients’ quality of life.
4. Use of the Winged Thumb Wrench • Use the Winged Thumb Wrench to thread the implant into place until the wrench becomes difficult to turn. Important: If no significant resistance is met during this midstage of insertion, the prognosis for the implant reaching its full potential is doubtful. The patient’s bone at this site possibly lacks the required density for predictable success.
5. Use of the 3M ESPE Graduated Torque Wrench with Adaptor • The 3M ESPE Graduated Torque Wrench will then finalize the insertion process. • Ensure the 4x4 Adaptor is inserted into the wrench with correct directionality. • Push the appropriate MDI Ratchet Adapter into the 4x4 Adaptor. • Place the MDI Ratchet Adapter portion of the assembly over the head of the MDI Implant. • Stabilize the head of the wrench with finger, pressing down perpendicular to the implant site for better control and to limit lateral forces being applied during tightening procedure. • For use as a torque wrench: Apply pressure only to the torque arm and turn the wrench in the direction of the arrow until the desired torque is achieved. • For use as a ratchet wrench: Grip the body of the wrench and turn in the direction of the arrow. • The ideal implant position allows the abutment head to protrude from the gingival soft tissue at its full length, but with no neck or thread portions visible. • Advance the implant with the Torque Wrench to a minimum of 35 Ncm to allow immediate load.
6. Final Implant Positioning • A minimum of 4 MDI implants are required to stabilize a full lower denture. For complete procedural steps including denture reline and seating, please visit the literature section of 3MESPE.com. IP This information was provided by 3M ESPE.
Reference 1. Stability and peri-implant bone resorption of the mini implants as complete lower denture retainers. Prof. Dr. Aleksandar Todorovic, Prof. Dr. Aleksa Markovic, Ass. Prof. Dr. Miodrag Šcepanovic. Faculty of Dentistry, University of Belgrade, Serbia.
36 Implant practice
Volume 6 Number 2
TECHNOLOGY
Trabecular Metal™ implants from orthopedics to dental implantology Dr. Suheil M. Boutros focuses on the applications for a new type of implant Trabecular Metal™ (Zimmer), a porous (80%) tantalum biomaterial with trabecularlike structure for three-dimensional bone in-growth, has been used for more than a decade in orthopedic surgery.1 As a result of great success in orthopedics, a new tapered, threaded, titanium dental implant with a TM midsection has been developed and has been tested in animal models followed by human cases. The current findings suggest that TM implants with both on-growth and in-growth (due to active bone formation in the TM pores) provide good bone anchorage during the early healing period. This preliminary pilot study showed that immediately loading Trabecular Metal implants with nonoccluding provisional restorations within 48 hours, and definitively loading the implants with fully occluding restorations 7 to 14 days later in selected patients, was safe and effective over the 6-month follow-up period.8
Introduction A porous tantalum material™ has an ability to facilitate osseointegration and provide a substrate for cell adhesion that has made it desirable to use in orthopedic surgery.1 In a dog study, Trabecular Metal implants were compared to standard titanium implants (control). Osseointegration of control implants was achieved via on-growth, whereas the TM implants achieved both osseointegration via on-growth around the threaded sections, as well as in-growth through the pores of the TM shell. The ISQ values illustrated an increasing trend for TM implants over a 12-week healing period, whereas the control implants, though ISQ values were
Suheil M. Boutros, DDS, MS, is a Diplomate of the American Board of Periodontology (ABP), the American Board of Oral Implantology (ABOI), and the ICOI. He is in practice at Periodontal Specialists of Grand Blanc in Michigan, and is visiting assistant professor at the University of Michigan. He can be reached at: smboutros@periodonticsonline.com. www. periodonticsonline.com
38 Implant practice
greater than 60, did not demonstrate any such trend. The histopathology findings indicated that there was no evidence of acute inflammation for any TM or control group.2-3 In a Proof-of-Principle study, two investigational sites with up to 20 subjects at each site, with up to 2 implants per subject, were examined. Implant sizes were 4.7 mm and 6.0 mm diameter; 10 mm, 11.5 mm, and 13 mm lengths with posterior indication only. Healthy, sufficient bone volume and primary stability (>35 Ncm) were the inclusion criteria. The prosthetic treatment uses One Abutment – One Time™ (Zimmer) restoration protocol with immediate provisionalization within 48 hours and the final restoration at or before 2 weeks post placement. The 6-month follow-up with a survival rate of 35/36 (97.2%) was comparable to the 97.9% survival rate of immediately loaded molar implants reported in a systematic review and meta-analysis of seven studies with 188 implants by Atieh, et al. (2010). Within the limitation of the preliminary pilot study, immediately loading Trabecular Metal implants, with non-occluding provisional restorations, within 48 hours, and definitively loading the implants with fully occluding restorations 7 to 14 days later in selected patients, was safe and effective over the 6-month follow-up period.
administration of local anesthesia, a full thickness flap was reflected, the osteotomy was prepared using pointed starter drill, followed by 2.3 mm twist drill. It was determined that the bone quality was D2-3 bone. Using soft bone drilling protocol,6,7 the next drill was 2.8, 2.8/3.4x13 mm. No bone taps were used to ensure the implant stability (Figure 2). A 4.1 mm diameter x 13 mm length Trabecular Metal implant was inserted. The insertion torque exceeded to 35Ncm (Figures 3 and 4). The fixture transfer coping was prepared to support a non-functional provisional crown. The deficient alveolar ridge was augmented using allograft (Puros® Cortical 70%, Cancellous 30%, Zimmer) [Figures 5 and 6]. The patient was given postsurgical instructions, including the use of 0.12% chlorhexidine gluconate (Peridex™, Procter & Gamble) three times daily and was prescribed 500mg of amoxicillin (every 6 hours for 7 days). The patient was seen for a follow-up visit 10 days later, and her healing was uneventful (Figure 7).
Patient (1) presentation
Follow-up and maintenance After 6 months, the patient returned for a follow-up visit. The clinical and radiographic exam showed that the implant had been a great success (Figures 9 and 10). The patient was placed on a 6-month recall to properly maintain the implant and the restoration.
A 30-year-old female patient without medical contraindication for implant therapy presented with a congenitally missing maxillary right lateral incisor. The clinical and radiographic examination showed that the patient was a good candidate for a Trabecular Metal implant placement and restoration (Figure 1). The patient was given the option of implant placement and immediate nonocclusal load as an alternative to a staged approach if the implant did not achieve good primary stability. Surgical treatment At the surgical appointment, following the
Prosthetic treatment After allowing the soft tissue to heal, the implant was loaded with the definitive final occluding restoration (Figure 8).
Patient (2) presentation A 65-year-old male patient without medical contraindication for implant therapy presented with a fractured maxillary right central incisor. The clinical and radiographic examination showed that the patient was a good candidate for the extraction of the tooth and immediate implant placement Volume 6 Number 2
TECHNOLOGY
Patient (1) presentation
Figure 1: Preoperative view of missing upper right lateral incisor
Figure 2: Osteotomy preparation
Figure 3: Engaging the TM portion of the implant allows for early bone in-growth
Figure 4: The coronal microgrooves engage the cortical bone and allow for better primary stability
Figure 5: Prepared transfer coping in place with Puros allograft
Figure 6: Non-occluding provisional restoration with the flap suture using chromic gut suture
Figure 7: Ten days post-implant placement
Figure 8: Final crown 3 months following the implant placement
Figure 9: Final crown 6 months following the implant placement
Figure 10: Radiograph 6 months post loading
(Figure 11). The patient was given the option of immediate implant placement and immediate non-occlusal load as an alternative to a staged approach if the implant did not achieve primary stability of >35Ncm of insertion torque.
Surgical treatment At the surgical appointment, following the administration of local anesthesia, a flapless atraumatic extraction of the maxillary right central incisor was performed using periotomes. The osteotomy was prepared using a pointed starter drill followed by 2.3 mm twist drill. It was determined that the
bone quality was D2-3 bone. Using a soft bone drilling protocol, the next drill was 2.8, 2.8/3.4x13 mm. No bone taps were used to ensure the implant stability (Figure 12). A 4.1 mm diameter x 13mm length Trabecular Metal implant was inserted. The insertion torque exceeded to 35Ncm (Figures 13 and 14).
Volume 6 Number 2 Implant practice 39
TECHNOLOGY Patient (2) presentation
Figure 12: The final 2.8/3.4 x 13 mm drill
Figure 11: Fractured nonrestorable central incisor
Figure 13: 4.1mm x 13 mm length TMT implant
Figure 14: Trabecular Metal implant placement in extraction socket
Figure 15: Prepared transfer coping with Puros allograft filling the critical gap
Figure 17: Two weeks post implant placement
Figure 18: Final restoration 6 months post placement
The fixture transfer coping was prepared to support a non-functional provisional crown. The critical gap between the extraction socket and the implant was grafted using allograft (Puros Cortical 70%, Cancellous 30%) [Figures 15 and 16]. Prosthetic treatment After allowing the soft tissue to heal, the 40 Implant practice
implant was loaded with the definitive final occluding restoration (Figure 18). Follow-up and maintenance After 6 months, the patient returned for a follow-up visit. The clinical and radiographic exam showed that the implant was a great success (Figures 18 and 19). The patient was placed on a 6-month recall to properly maintain the implant and the restoration.
Figure 16: Non-occluding provisional restoration at the same time of implant placement
Figure 19: Final radiograph 6 months post placement
Patient (3) presentation A 55-year-old male patient without medical contraindication for implant therapy presented with a hopeless upper first primary tooth. The clinical and radiographic examination showed that the patient was a good candidate for the extraction of the primary tooth, maxillary sinus lift using the sinus lateral approach (SLA), and immediate Trabecular Metal implant Volume 6 Number 2
TECHNOLOGY Patient (3) presentation
Figure 20: Preoperative radiograph with a retained primary tooth and pneumatized sinus
Figure 21: A notch was placed on the lateral wall of the sinus to allow the engagement of the LS reamer
Figure 22: 6.5 mm x 4mm LS reamer was used to enter the sinus cavity
Figure 23: LS reamer was used to enter the sinus cavity
Figure 24: Schneiderian membrane was intact
Figure 25: Osteotomy preparation using soft bone drilling protocol
Figure 26: Puros Cortical/Cancellous
Figure 27: A 4.7 x 10 Trabecular Metal implant was placed immediately into the grafted sinus
Figure 28: The crestal microgrooves engage the cortical plate for better primary stability
Figure 29: Trabecular Metal implant in place, and the sinus window was covered with a BioMend速 (Zimmer) membrane
Figure 30: Radiograph taken immediately post placement
Figure 31: Radiograph taken 3 months after placement at the time of uncovering
placement (Figure 20). The patient was given the option of immediate implant placement along with the sinus lateral approach load as an alternative to a sinus lift staged approach. Surgical treatment At the surgical appointment, following the administration of local anesthesia, atraumatic extraction of the maxillary 42 Implant practice
left first primary molar was performed. A notch was placed on the lateral wall of the sinus to allow the engagement of the LS reamer (Figures 21-23). The Schneiderian membrane was elevated (Figure 24), and the osteotomy was prepared using a soft bone drilling protocol (Figure 25). The sinus cavity was grafted using Puros Cortical/Cancellous mix (Figure 26). A 4.7x10 mm TMM implant was
placed (Figures 27-29). The patient was given post-surgical instructions, including the use of 0.12% chlorhexidine gluconate (Peridex, Procter & Gamble) three times daily and was prescribed 500mg of amoxicillin (every 6 hours for 7 days). The patient was seen for a follow-up visit 14 days later, and the healing was uneventful.
Volume 6 Number 2
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
I feel I have made the right choice by taking the fellowship program at CII. I found answers to many questions left unanswered from other implant dentistry classes I have taken in the past. I highly recommend this program. Dr. Mary Spencer, San Diego, CA
www.implanteducation.net or Call +1 858 496 0574
SAN DIEGO | WORLDWIDE
TECHNOLOGY Patient (3) presentation, continued
Figure 32: The final restoration 6 months post implant placement
Prosthetic treatment The implant was uncovered 3 months following placement after allowing enough time for osseointegration/incorporation to take place (Figure 31). A final fixture level impression was taken, and a final casted custom abutment was used to support the porcelain fused to metal crown (Figure 32). After 6 months, the patient returned for a follow-up visit. The clinical and radiographic exam showed that the implant had been a great success (Figure 33). The patient was placed on a 6-month recall to properly maintain the implant and the restoration. Clinical relevance With higher demand for immediate implant
Figure 33: Six months post placement radiograph shows the stable bone level around the apical and coronal aspect of the TM implant
placement and immediate loading by patients, the use of tapered implants that provide a high degree of primary stability and the addition of the Trabecular Metal technology provides faster secondary stability through bone in-growth, and can help achieve quick and predictable final restorations.
Conclusions A total of 48 Trabecular Metal TMT, TMM implants were placed, 32 in the maxilla, 16 in the mandible. *Surgery Insertion torque: â&#x2030;Ľ 35 Ncm 90% of implants Level of placement: 85% placed at the crest of bone.
References
Washington, DC, March 3-6, 2010. Unpublished Data.
1. Koussostathis SD, Tsakotos G, Parkostas I, Marcheras G. Biological processes at bone-tantalum interface. J of Orthopedics. 2009;6(4)e.
4. Shimko DA, Shimko VF, Sander EA, Dickson KF, Nauman EA. Effect of porosity on the fluid flow characteristics and mechanical properties of tantalum scaffolds. J Biomed Mater Res. Part B: Appl Biomater. 2005;73B:315-325.
2. Battula S, Lee J, Papanicolaou S, Wen HB, Collins M. Implant in a canine model. The 19th Annual Scientific Meeting of European Association for Osseointegration, Oct. 6-9 2010, Glasgow, UK, p410. Unpublished Data. 3. Kim D-G, Huja SS, Larsen PE, Kreuter KS, Chien H-H, Joo W, Wen HB. Trabecular Metal dental implants in an animal model. Presented at the Annual Meeting of the American Association for Dental Research,
44 Implant practice
5. Tsao AK, Roberson JR, Christie MJ, Dore DD, Heck DA, Robertson DD, Poggie RA. Biomechanical and clinical evaluations of a porous tantalum implant for the treatment of early-stage osteonecrosis. J Bone Joint Surg. 2005;87-A(suppl 2):22-27.
*Restoration -18 implants received provisional restoration at the time of placement. -16 implants were in full functional occluding final restorations as early as 2 weeks. The remaining 32 implants that were placed in poor quality bone including extraction sockets, grafted sites, and sinuses were loaded 3 to 4 months following placement, where in traditional implants healing will take 6 to 9 months of healing time. *Nine-months data, 30 TM implants have been successfully restored with no signs of implant failures, and the remaining 18 implants are in the process of receiving the final restoration. IP
implants supporting maxillary full-arch prostheses: a randomized controlled clinical trial. Eur J Oral Implantol. 2008;1:127-139. 7. Calandriello R, Tomatis M, Rangert B. Immediate functional loading of BrĂĽnemark System implants with enhanced initial stability: a prospective 1- to 2-year clinical and radiographic study. Clin Implant Dent Relat Res. 2003;5:10-20. 8. Collins M, Bassett J, Wen HB, Gervais C, Lomicka M, Papanicolaou S. Trabecular Metal dental implants: overview of design and development research. Zimmer Dental Inc, 2012.
6. Cannizzaro G, Torchio C, Leone M, Esposito M. Immediate versus early loading of flapless-placed
Volume 6 Number 2
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PRODUCT PROFILE
CPK – Complete Prosthetic Kit from MIS Implants Technologies Simplifies the restorative component of Implant Dentistry
I
mplant dentistry has become the standard of care in the industry. Clinicians can easily discuss the benefits of this option with their patients when missing teeth are to be replaced. There are many options for restoring implants, and cementable restorations are very popular. MIS Implants Technologies offers Complete Prosthetic Kits (CPK) for their Seven and C1 implant systems. These kits contain all of the components necessary for a dentist to restore a straightforward implant case, from the initial impression to the final single crown or multiple implant bridge. The CPK was specifically designed to allow the restorative dentist to take accurate impressions and perform the transfer technique before sending the impression to the dental lab. Inside each CPK is a transgingival abutment (with appropriate screw), an abutment analog, transfer plastic cap, burn-out anti-rotation cap, burn-out plastic cap, and a PEEK comfort cap. Here is a more detailed look at the individual components and their use:
Abutment For the Seven implant system (internal hex connection), the transgingival abutment is available with different collar heights and crown heights. The collar heights range from 1-4 mm (in 1mm increments) while the crown height options are 4, 6, or 8 mm. Any combination of those choices is available. The abutment for the C1 implant system (MIS’ conical connection implant system) comes with a choice of four collar heights – 1, 2, 3, or 4 mm. The crown height that is currently available is 6 mm. Once the abutment is placed, the prosthetic screw should be tightened to 30 Ncm.
Impression Coping Plastic Cap (Transfer Coping) The MIS Impression Coping snaps on to the abutment, which has been screwed into the implant. In order to find the proper placement, the groove on top of the plastic 46 Implant practice
sleeve should face the flat surface of the abutment. An audible snap ensures proper seating and position of the impression coping. The snapping action is truly a “can’t miss” feature of the MIS Impression Coping. This Impression Coping will release into the impression material once it is set. Once the impression is removed from the patient’s mouth, the impression Coping Plastic Cap will be visible in the impression material. A proper impression must have the impression copings stable in the material.
PEEK Healing Cap Once the impression is taken, the dentist can prepare a temporary restoration, remove the abutment, and place healing caps, or utilize the plastic healing cap that comes in the CPK kit, and use temporary cement to secure it to the abutment. This saves a great deal of time for the dentist since the abutment does not need to be reseated and retightened at following visits. The comfort cap also provides protection for the abutment and disguises the metal color.
Abutment analog The abutment analog should be inserted into the impression coping plastic cap, which is now in the impression material. Proper alignment and seating is critical. The flat surface of each analog should be aligned with the corresponding surface in the impression coping. This analog will also “snap” into place. The lab can now pour up the stone model.
Remaining components The remaining components will be utilized by the lab technician. The burn-out antirotation plastic cap (red) is utilized for a single crown restoration. The rotational burn-out plastic cap (white) is used on the analogs when a bridge will be fabricated by the laboratory technician. Adjustments to the burn-out caps can be made in the lab to customize them according to each case. The lab will then complete the restoration
using standard techniques. While possible, it is not recommended for the restorative doctor to alter the abutment (like a typical prepable abutment). This will make the remainder of the kit unusable, since the abutment analog will no longer match the abutment. The CPK can be utilized for straightforward cases. For bridges, the implants should be as parallel as possible. For more complicated cases, it may be necessary to use an angulated or custom abutment for the best possible final restorative outcome. MIS offers a wide range of restorative components for more challenging cases. For doctors who are performing the implant surgery, these Complete Prosthetic Kits are available at no cost when 10 or more implants are purchased at one time. This value-added product is a benefit to both the restorative doctor and surgeon. MIS Implants Technologies’ products are sold in more than 65 countries around the world. Their products are designed and manufactured in their own facility with a state-of-the-art quality assurance program. In the United States, they have professional representatives in most major cities, as well as offices on the East and West Coasts to expedite shipping to their customers. Please visit their website – www.misimplants.com, or call directly for more information at 1-866-797-1333. IP This information was provided by MIS Implants Technologies. Volume 6 Number 2
PRODUCT PROFILE
i-CAT® FLX — the latest advancement in Cone Beam 3D For greater flexibility in scanning, planning, and treatment i-CAT award-winning cone beam 3D dental imaging has already gained a wide reputation for image quality, patient safety, and smooth workflow. In the field of implantology, 3D scanning helps to increase surgical predictability and facilitate precise implant placement. i-CAT scans show true anatomy in full 3D volume and high-resolution individual slices for accurate measurement of bone thickness and alveolar nerve location. With the precise data gathered from viewing an i-CAT scan and utilizing proprietary software tools, clinicians can map an entire course of treatment from surgical placement of the implant and abutment, all the way to final restoration. Practitioners can obtain a more thorough analysis of bone structure and tooth orientation, and as a result, treat patients with greater confidence. Developed on the foundation of i-CAT excellence, the new i-CAT FLX cone beam 3D system offers a range of innovative features for greater clarity, easeof-use, and control. Practitioners can take advantage of these dynamic tools: • Visual iQuity™ advanced image technology delivers i-CAT’s clearest 3D and 2D images • Full dentition 3D imaging at a dose lower than a 2D Panoramic X-ray with QuickScan+* • Ergonomic Stability System (ESS) offers seated positioning, robust head stability, and adjustable seating controls to minimize patient movement and reduce the need for retakes. The unit is also wheelchair accessible • i-Collimator electronically adjusts the field-of-view to limit radiation only to the area of scanning interest. • The i-CAT FLX offers a lower radiation dose than a panoramic X-ray • i-PAN™ produces traditional 2D panoramic images SmartScan STUDIO also works toward more clinical control by providing an easy, customizable solution for a more guided, controlled workflow in the dental practice. With its easy-to-use, touchscreen interface, and integrated acquisition system, SmartScan STUDIO offers step48 Implant practice
by-step guidance, allowing the clinician to select the appropriate scan for each patient at the lowest acceptable radiation dose. In addition to all of the clinical advantages, the small footprint of the i-CAT FLX also allows it to fit easily and seamlessly into any practice. Of course, the i-CAT FLX also includes Tx STUDIO™ technology that is an integral part of all i-CAT cone beam 3D systems, which are known for their clinical and dose control, as well as the fastest workflow. Tx STUDIO leverages the best in anatomy imaging software and cone beam 3D technology that benefits a gamut of specialties, from diagnostics to implant and orthodontic treatment planning. Using the software in conjunction with scans, practitioners can virtually place single or multiple implants from an extensive implant library that takes the guesswork out of planning, and also conveniently order surgical guides from all leading surgical guide providers through the Tx STUDIO software. These software tools facilitate communication with other clinicians, and help dentists educate patients about their dental conditions, improving the possibility of case acceptance.
i-CAT continues to revolutionize 3D dental and maxillofacial radiography, with the launch of the new i-CAT FLX. IP About Imaging Sciences International Since 1992, Imaging Sciences International has been an innovator in advanced dental imaging, specifically with i-CAT cone beam technology. i-CAT solutions have been installed in more than 3,000 sites around the world. Imaging Sciences offers highly specialized service and support through the i-CAT Network and continuing education through the 3D Imaging Institute, the only entity of its kind dedicated to helping dentists and specialists use the latest in cone beam technology. * Data on file. Based on the number of scan options currently available at time of printing. For more information on the i-CAT FLX or other i-CAT products, visit: http://www.i-cat.com/ This information was provided by Imaging Sciences International.
Volume 6 Number 2
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©2013 Imaging Sciences International, LLC | ISI-Mktg-DM-0003Rev0
3D imaging for lower dose than a 2D panoramic* is not magic… …it’s The new i-CAT FLX is a reality! This latest advancement of our award-winnning technology offers a range of innovative features that deliver increased clarity, ease-of-use, and control. Now with Visual iQuity™ and QuickScan+ technologies, the power of capturing diagnostic 3D images at a lower dose than a 2D panoramic x-ray is in your hands.
Schedule a demo today! Call 1-800-205-3570 or visit www.i-CAT.com Available exclusively through
*Utilizing the i-CAT FLX QuickScan+ exposure protocol. Data on file.
PRODUCT PROFILE
Introducing a new implant designed exclusively for overdentures - the LOCATOR® Overdenture Implant system.
F
or years, mini implants have suffered a bad reputation due to historically weak materials, poor designs, and misuse. An increasing number of clinicians are now recognizing the unique benefits of using the next generation of narrow diameter implants for retaining overdentures. This is in large part due to the fact that patients present to dental offices edentulous, with severe resorption, and very narrow ridges for implant placement. Typically, the treatment plan for these edentulous patients would be bone grafting; however, this is a longer process with additional surgeries required and added expense, and for these reasons, patients many times decline dental implant treatment, even though it may be the best treatment option for their particular scenario. Finally, there is a treatment alternative for these patients, the LOCATOR® Overdenture Implant System (LODI), featuring narrow diameter implants with the world’s leading overdenture attachment from the originators of the trusted LOCATOR Attachment, Zest Anchors. Designed with the best in class Locator Attachment, LODI offers a less invasive, predictable, and durable implant retained overdenture for patients requiring an effective, cost conscious technique for securing their denture. The LOCATOR Overdenture Implant (LODI) System is comprised of 2.4 mm and 2.9 mm diameter endosseous dental implants (available in 10, 12, and 14 mm lengths) with a detachable LOCATOR attachment (abutment) that is available in a 2.5 mm and 4 mm cuff height. The LODI is used to restore masticatory function for the patient and may be suitable for immediate function if sufficient primary stability of the implant is achieved at the time of placement. The unique two-piece coronal design of LODI, not found with O-ball mini implants, is a critical feature that optimizes patient satisfaction. The LOCATOR attachment is seated after implant placement, making case planning, implant surgery, and the restorative process easier. LODI demonstrates remarkable resiliency and exceptional durability, while allowing for easy replacement of the attachment, 50 Implant practice
Included with LODI, the LOCATOR Attachment provides all of the superior benefits known worldwide, including its patented pivot technology, customizable levels of retention, and draw correction of divergent implants up to 40 degrees — all of this while having a dramatically reduced vertical height compared to O-ball mini implants.
should wear occur throughout time. In addition, LODI is manufactured from the strongest titanium available and features a proven RBM roughened surface. The system also features uniquely designed, intuitive placement instrumentation, and may be used with a flapless technique for better patient comfort.
The LODI system now allows you to treat patients with the minimum standard of care* of an implant overdenture, at a reduced cost and with greater satisfaction. IP
For more information contact: ZEST Anchors Phone: 800-262-2310 Website: www.zestanchors.com *The McGill consensus statement on overdentures. Mandibular two-implant overdentures as first choice standard of care for edentulous patients. Montreal, Quebec, May 24-25, 2002. This information was provided by Zest Anchors.
Volume 6 Number 2
EVENT PREVIEW
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he NYU College of Dentistry and Zimmer Dental are sponsoring the 4th Annual Global Implantology Week, from March 18 to 21, 2013, an educational offering combining the expertise, knowledge, and resources of NYU and Zimmer Dental. This 4-day, intermediate-to-advanced, interactive program is designed for practicing clinicians with established competencies within the field of implant dentistry. Various dental implant therapy topics and techniques in the surgical, restorative, and regenerative fields will be addressed. Some of the topics include: “Top to bottom implant dentistry;” “Applications of intraoral scanners: benefits, limitations and future considerations;” “Applicationbased implant selections: titanium or trabecular implant?” “New productive protocols for the reconstruction of the alveolar ridge;” “Avoiding complications and how to manage complications in implant dentistry;” “Treatment of periimplantitis: diagnosis, surgical, and regenerative strategies;” “Techniques for limited tissue volume: ridge augmentation and short implants;” “Future treatment options for challenging clinical situations;” and “Delayed provisional restorations for immediate anterior implants: is it good for teeth or tissue?” This year’s program will address many topics in the growing and innovative implant field. One session will focus on avoiding complications, and will examine cases submitted by some attendees prior to the course. A full day will be dedicated 52 Implant practice
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This 4-day, intermediateto-advanced, interactive program is designed for practicing clinicians with established competencies within the field of implant dentistry.
to exploring clinical applications of new products and technologies. An interesting optional experience will take place in Parsippany, NJ on Tuesday, March 19 from 4:30 to 7:30 p.m. “Your
inside look at how Zimmer Trabecular Metal material is Made.” Trabecular Metal Technology is a three-dimensional material, not an implant surface or coating. Utilizing a thermal deposition process, elemental tantalum is deposited onto a substrate, creating a nanotextured surface topography to build Trabecular Metal Material, one atom at a time. Attendees are invited to watch this revolutionary process in action and see how the Zimmer® Trabecular Metal Dental Implant is made. At the Product Fair and reception on Wednesday, March 20 from 4 to 7pm at NYU College of Dentistry, a hands-on opportunity will include a complimentary showcase of Zimmer’s portfolio of surgical, restorative, and regenerative products, including a special look at recently launched products. Demo products will be available for attendees to touch and feel, with Zimmer product experts on hand to answer product-related questions. NYU will provide 26 CDE credits for this program. IP Registration can take place by phone, fax or email. Please contact: Joy Celeste NYU College of Dentistry Continuing Dental Education Phone 212-998-9762 Fax 212-995-4084 Joy.celeste@NYU.edu This information was provided by Zimmer Dental.
Volume 6 Number 2
AUTHOR GUIDELINES
Implant Practice US is a peer-reviewed, bimonthly publication containing articles by leading authors from around the world. Implant Practice US is designed to be read by specialists in Periodontics, Oral Surgery, and Prosthodontics.
Submitting articles Implant Practice US requires original, unpublished article submissions on implant topics, multidisciplinary dentistry, clinical cases, practice management, technology, clinical updates, literature reviews, and continuing education. Typically, clinical articles and case studies range between 1,500 and 3,000 words. Authors can include up to 15 illustrations. Manuscripts should be double-spaced, and all pages should be numbered. Implant Practice US reserves the right to edit articles for clarity and style as well as for the limitations of space available. Articles are classified as either clinical, continuing education, technology, or research reports. Clinical articles and continuing education articles typically include case presentations, technique reports, or literature reviews on a clinical topic. Research reports state the problem and the objective, describe the materials and methods (so they can be duplicated and their validity judged), report the results accurately and concisely, provide discussion of the findings, and offer conclusions that can be drawn from the research. Under a separate heading, research reports provide a statement of the research’s clinical implications and relevance to implant dentistry. Clinical and continuing education articles include an abstract of up to 250 words. Continuing education articles also include three to four educational aims and objectives, a short “expected outcomes” paragraph, and a 10-question, multiple-choice quiz with the correct answers indicated. Questions and answers should be in the order of appearance in the text, and verbatim. Product trade names cited in the text must be accompanied by a generic term and include the manufacturer, city, and country in parentheses. Additional items to include: • Include full name, academic degrees, and institutional affiliations and locations • If presented as part of a meeting, please state the name, date, and location of the meeting • Sources of support in the form of grants, equipment, products, or drugs must be disclosed • Full contact details for the corresponding author must be included • Short author bio • Author headshot 54 Implant practice
Pictures/images
Disclosure of financial interest
Illustrations should be clearly identified, numbered in sequential order, and accompanied by a caption. Digital images must be high resolution, 300 dpi minimum, and at least 90 mm wide. We can accept digital images in all image formats (preferring .tif or jpeg).
Authors must disclose any financial interest they (or family members) have in products mentioned in their articles. They must also disclose any developmental or research relationships with companies that manufacture products by signing a “Conflict of Interest Declaration” form after their article is accepted. Any commercial or financial interest will be acknowledged in the article.
Tables Ensure that each table is cited in the text. Number tables consecutively and provide a brief title and caption (if appropriate) for each.
References References must appear in the text as numbered superscripts (not footnotes) and should be listed at the end of the article in their order of appearance in the text. The majority of references should be less than 10 years old. Provide inclusive page numbers, volume and issue numbers, date of publication, and all authors’ names. References should be submitted in American Medical Association style. For example: Journals: (Print) Greenwall L. Combining bleaching techniques. Aesthetic & Implant Dentistry. 2000;1(1):92-96. (Online) Author(s). Article title. Journal Name. Year;vol(issue#):inclusive pages. URL. Accessed [date].
Manuscript Review All manuscripts are peer reviewed and accepted, accepted with modification, or rejected at the discretion of the editorial review board. Authors are responsible for meeting review board requirements for final approval and publication of manuscripts.
Proofing Page proofs will be supplied to authors for corrections and/or final sign off. Changes should be limited to those that are essential for correctness and clarity. Articles should be submitted to: Kim Murphy, Production Manager kmurphy@medmarkaz.com
Reprints/Extra issues If reprints or additional issues are desired, they must be ordered from the publisher when the page proofs are reviewed by the authors. The publisher does not stock reprints; however, back issues can be purchased.
Or in the case of a Book: Greenwall L. Bleaching techniques in Restorative Dentistry: An Illustrated Guide. London: Martin Dunitz; 2001. Website: Author or name of organization if no author is listed. Title or name of the organization if no title is provided. Name of website. URL. Accessed Month Day, Year. Example of Date: Accessed June 12, 2011. Author’s name: (Single) Doe JF
(Multiple) Doe JF, Roe JP
Permissions Written permission must be obtained by the author for material that has been published in copyrighted material; this includes tables, figures, pictures, and quoted text that exceeds 150 words. Signed release forms are required for photographs of identifiable persons.
Checklist for article submissions: 3 A copy of the manuscript and figures/ captions, including all pictures (low res) necessary for reviewers 3 Manuscript: double-spaced including separate references, figure legends, and tables 3 Abstract, educational objectives, expected outcomes paragraph 3 References: double-spaced, alphabetical, American Medical Association style 3 Tables: titled and cited in the text 3 Mandatory submission form, signed by all authors Please contact managing editor Mali SchantzFeld with any questions via email: Mali@medmarkaz.com
Volume 6 Number 2
Implant & Oral Surgery with LED Fiber Optics
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DIARY
lllllllllllllllllllllll OF EVENTS llllllllllllllllllllllllllllllllllllllllllllllllllll
Star of the South Dental Meeting March 7-9, 2013 Houston, TX www.starofthesouth.org
Pacific Dental Conference March 7-9, 2013 Vancouver, BC www.pdconf.com/cms2013
American Dental Implant Association Symposium 2013 March 15-16, 2013 San Francisco, CA www.americandentalimplantassociation.com
The 81st Annual Nationâ&#x20AC;&#x2122;s Capital Dental Meeting March 7-9, 2013 Washington, DC www.dcdental.org/capmeet.asp
Academy Of Osseointegration Annual Meeting March 7-9, 2013 Tampa, FL www.osseo.org/events/meetings/2013/ index.html
Arizona Dental Association Western Regional Dental Convention March 7-9, 2013 Phoenix, AZ www.westernregional.org/2013
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Rocky Mountain Dental Institute Implant I Dr. Scott Lingle March 7-9, 2013 Denver, CO www.rockymountaindentalinstitute.com
Kentucky State Dental Meeting March 7-10, 2013 Louisville, Kentucky www.kyda.org/ky_meeting.html
Big Apple Dental Meeting March 13-14, 2013 Mahwah, NJ bigappledentalmeeting.us
Implant Surgery and Restoration Mini-Residency â&#x20AC;&#x201C; Session III of IV (Rotation A) March 15-16, 2013 Oklahoma City, OK mcgarryinstitute.com
ADEA Annual Session & Exhibition March 16-19, 2013 Seattle, WA www.adea.org/Secondary. aspx?id=13859
The Art, Science and Business of Clinical Implant Practice: Precision, Productivity and Profitability of Implant Dentistry March 22-23, 2013 Houston, TX www.straumann.us
Volume 6 Number 2
DIARY
lllllllllllllllllllllll OF EVENTS llllllllllllllllllllllllllllllllllllllllllllllllllll
Implant Dentistry Continuum March 23-24, 2013 Los Angeles, CA www.implantseminars.com
Implant Dentistry Continuum March 29-30, 2013 San Francisco, CA www.implantseminars.com
Implant Dentistry Continuum April 6-7, 2013 New Orleans, LA www.implantseminars.com
Is Fructose Addictive and Hazardous to Your Health? April 11, 2013 San Francisco, CA dental.pacific.edu
Rocky Mountain Dental Institute Implant II Dr. Scott Lingle April 11-13, 2013 Denver, CO www.rockymountaindentalinstitute.com
Soft Tissue Grafting Around Teeth and Implants April 11-13, 2013 Milton, MA www.straumann.us
Implant Surgery and Restoration MiniResidency â&#x20AC;&#x201C; Session IV of IV (Rotation A) April 12-13, 2013 Oklahoma City, OK mcgarryinstitute.com
The - GHSU/AAID Maxi-Course Comprehensive Training Program in Implant Dentistry April 18-21, 2013 Atlanta, GA www.straumann.us
58 Implant practice
Implant Dentistry Continuum April 20-21, 2013 Boston, MA www.implantseminars.com
Implant Dentistry Continuum April 26-27, 2013 San Francisco, CA www.implantseminars.com
Itâ&#x20AC;&#x2122;s Alive! The Anatomical Basis of Dentistry April 27, 2013 San Francisco, CA dental.pacific.edu
Implant Dentistry Continuum April 27-28, 2013 Los Angeles, CA www.implantseminars.com
Volume 6 Number 2
The must-read journal for US Implantologists! 3 EASY WAYS TO SUBSCRIBE VISIT www.implantpracticeus.com EMAIL kmurphy@medmarkaz.com CALL 1.866.579.9496
$99 1 year $239 3 years SUBSCRIBERS BENEFIT FROM: Clinical articles enhanced by high quality photography Analysis of the latest ground breaking developments in implant Practice management advice on how to make implants more profitable Real-life profiles of successful implant practices Technology reviews of the latest products to hit the market
www.ImplantPracticeUS.com
Komet USA launches one-step polishers for final polishing of composites
MATERIALS lllllllllllll & lllllllllllll EQUIPMENT llllllllllllllllllllllllllllllllllllllllllllllllll GUM® Soft-Picks® GUM® Soft-Picks® feature 76 flexible rubber bristles that are gentle on sensitive gingival tissue. As they brush away plaque and bacteria, the bristles massage the gums, increasing blood flow and accelerating the body’s natural healing process. Because SoftPicks contain no metal parts, they will not scratch implants or cause painful galvanic shock. To learn more about Soft-Picks, an effective and easy-to-use alternative to string floss, contact Sunstar by calling 800-528-8537 or visiting GUMbrand.com.
LAPIP protocol The LAPIP protocol is a modification of the well-defined LANAP protocol to effectively treat the unique challenges of failing implants and destroy perio pathogens and endotoxins. The LAPIP protocol eliminates local inflammatory response with consistent, positive results in the regeneration of alveolar bone. Leveraging the unique properties of the PerioLase® MVP-7™ Nd:YAG laser, the LAPIP protocol is a patient-friendly, minimally invasive laser treatment. The LAPIP protocol is part of the 5 days of guided, hands-on training included in the PerioLase® Periodontal Package®, taught by the Institute of Advanced Laser Dentistry.
Exclusively designed for one-step final polishing of composites, Komet’s new light-yellow polishers feature a special silicone bond that provides outstanding flexibility and conformation to tooth anatomy. The polishers incorporate ultrafine-grit diamond particles for efficient delivery of a high-shine polish on composite materials in a single step, following the thorough finishing of restoration surfaces. Constructed of heat-tolerant, highquality materials, the instruments can be safely sterilized in an autoclave and resist degradation and deformation. The light-yellow polishers are available in flameshaped (long and short), cup-shaped, and wheel-shaped versions and are color-coded with a white ring according to diamond grit (ultrafine) for ease of identification. They are offered in packages containing five instruments of a single configuration. For more information about Komet USA or one-step yellow polishers, call 888-566-3887 or visit www.komet-usa.com.
The BIOMET 3i PREVAIL® Implant System Crestal bone preservation through the PREVAIL Implant’s integrated platform switching feature; optimizing patient esthetics with as little as 0.37 mm of bone recession and 50% reduction in crestal bone remodeling versus non platformswitched implants. The PREVAIL Implant’s unique Certain® Internal Connection design; providing higher seal strength as compared to the competitive average. Enhanced osseointegration with OSSEOTITE® and NanoTite™ PREVAIL Implants; two implant systems designed for primary stability with surface topographies targeting bone apposition and early healing. Additionally, research shows peri-implantitis risk mitigation with the OSSEOTITE surface.
Call Millennium Dental Technologies at 888-49-LASER, or visit www.LANAP.com.
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Volume 6 Number 2
BONE GRAFTING SOLUTIONS
Introducing GUIDOR® AlloGraft (provided by LifeNet Health)
• Sunstar, in partnership with LifeNet Health®, is now offering GUIDOR® Allograft. • An osteoconductive graft material that promotes rapid healing. • Helps maintain space and volume with a strong matrix structure. • Sterilized using LifeNet Allowash XG® technology (Sterility Assurance Level of 10-6).
GUIDOR® Bioresorbable Matrix Barrier • Double sided bioresorbable material.
5090 P3 15mm x 20mm Matrix Barrier
• Unique two-layer matrix design stabilizes the wound site. • Aids in the regeneration and augmentation of jaw bone in conjunction with dental implant surgery. GUIDOR® Matrix has not been clinically tested in pregnant women, Immuno-compromised patients (diabetes, chemotherapy, irradiation, infection with HIV) or in patients with extra large defects or for extensive bone augmentation.
also available in: 5081 P6 20mm x 28mm Matrix Barrier
Possible complications following any oral surgery include thermal sensitivity, flap sloughing, some loss of crestal bone height, abscess formation, infection, pain and complications associated with the use of anesthesia.
Complementary products provide an easy and predictable grafting solution ORDER TODAY! 1-877-GUIDOR1 (1-877-484-3671) www.GUIDOR.com ©2013 Sunstar Americas, Inc. GDR13012 21413 v2
MATERIALS lllllllllllll & lllllllllllll EQUIPMENT PerioLase® MVP-7™ Digital TruePulse™ Nd:YAG laser The award-winning PerioLase® MVP-7™ Digital TruePulse™ Nd:YAG laser is the world’s first medical device to incorporate an Android™ tablet display, combining advanced laser components with the latest LCD display technology for optimum operating experience. Manufactured by Millennium Dental Technologies, the PerioLase® MVP-7™ is specifically designed for the LANAP® protocol, an evidence-based, patient-friendly laser periodontitis treatment. For more information, call 888-49-LASER or visit the company at www.lanap.com.
Gendex introduces Scatter Reduction Technology (SRT™) to Cone Beam 3D Gendex introduces SRT, Scatter Reduction Technology, to its award-winning GXDP-700™ Cone Beam 3D system. This new feature allows clinicians to reduce artifacts caused by metal or radio-opaque objects such as restorations, endodontic filling materials, and implant posts. The use of SRT image optimization technology delivers 3D scans with higher clarity and detail around scatter-generating material. SRT represents a significant aid when 3D scans are required for a variety of procedures from endodontic to restorative and the post-surgical assessment of implant sites. The activation of SRT is a very simple and easy step. When a scan is prescribed near a known area of scatter-generating material, the user only needs to select the SRT button from the GXDP-700 touchscreen interface to utilize this new optimization technology. Learn more about the full line of Gendex products and visit the company at www.gendex.com.
INDUSTRY HAPPENINGS llllllllllllllllllllllllllllll BIMEDIX and Laschal — partners in technology
Morita to host speakers at the ITI Congress in Chicago Morita will be hosting speakers at the upcoming ITI (International Team For Implantology) Congress North America. As an event sponsor, Morita will hold a Corporate Forum from 4:30 p.m. to 6:30 p.m. on Thursday, April 4, 2013.
Bimedix and Laschal are partnering in the representation of innovative technologies for all dental specialties. Laschal Surgical discovered the unique properties of flexibly resilient stainless steel and adapted those principals to dramatically reduce instrument failure, while at the same time eliminating or reducing the common stresses dentists face each and every day through the design of innovative, problem solving endodontic, surgical, and restorative instrumentation. Bimedix is a group of highly experienced professionals who have unique qualifications in bringing new and innovative products to market. For additional information please contact www.laschalsurgical.com or service@laschalsurgical.com.
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Presenters will include well-known industry experts Drs. Daniel Buser, David L. Cochran, and Bruno Azevedo. Focused on applications of CBCT in perio and implantology, topics will include preoperative analysis of implant patients (Buser, 5:45 p.m.), evaluation of bone grafting procedures (Cochran, 4:30 p.m.), and Reuleaux Triangle reconstruction and multiple fields of view for implant planning (Azevedo, 5:15 p.m.). Lectures will be held in Salon II located on the 7th floor of the Chicago Marriott downtown located at 540 North Michigan Avenue. Hors d’oeuvres and refreshments will be served. For more information: www.morita.com/usa/iti or 1-877-JMORITA(566-7482).
Volume 6 Number 2