Implant Practice US June 2012 Vol.5.3 by MedMark, LLC

clinical articles t management advicF t practice profiMFT t technology reviews May/June 2012 â&#x20AC;&#x201C; Vol

5 No 3

Practice Profile

Dr. Stuart J. Froum

Dr. Shane McCrea Comprehensive dental implantology: part one

Dr. Eddie Scher Every picture tells a story: Immediate placement

Dr. K. Kevin Neshat

Compressing treatment time and enhancing esthetic results with the use of narrow-diameter implants in single anterior sites ALSO INSIDE: Product profiles Practice management Research 3D dialogue CE articles

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Introduction May/June 2012 – Volume 5 Number 3 MISSION STATEMENT To be a practical journal promoting excellence in implant dentistry by providing a full range of clinical, continuing education, practice management, and technology articles written by leading specialists. EDITORIAL ADVISORY BOARD Steve Barter BDS, MSurgDent RCS Anthony Bendkowski BDS, LDS RCS, MFGDP, DipDSed, DPDS, MsurgDent Philip Bennett BDS, LDS RCS, FICOI Stephen Byfield BDS, MFGDP, FICD Sanjay Chopra BDS Andrew Dawood BDS, MSc, MRD RCS Professor Nikolaos Donos DDS, MS, PhD Abid Faqir BDS, MFDS RCS, MSc (MedSci) Koray Feran BDS, MSC, LDS RCS, FDS RCS Philip Freiburger BDS, MFGDP (UK) Jeffrey Ganeles, DMD, FACD Mark Hamburger BDS, BChD Mark Haswell BDS, MSc Gareth Jenkins BDS, FDS RCS, MScD Stephen Jones BDS, MSc, MGDS RCS, MRD RCS Gregori M. Kurtzman, DDS Jonathan Lack DDS, CertPerio, FCDS Samuel Lee, DDS David Little DDS Andrew Moore BDS, Dip Imp Dent RCS Ara Nazarian DDS Ken Nicholson BDS, MSc Michael R. Norton BDS, FDS RCS(ed) Rob Oretti BDS, MGDS RCS Christopher Orr BDS, BSc Fazeela Khan-Osborne BDS, LDS RCS, BSc, MSc Jay B. Reznick DMD, MD Nigel Saynor BDS Malcolm Schaller BDS Ashok Sethi BDS, DGDP, MGDS RCS, DUI Harry Shiers BDS, MSc, MGDS, MFDS Harris Sidelsky BDS, LDS RCS, MSc Paul Tipton BDS, MSc, DGDP(UK) Clive Waterman BDS, MDc, DGDP (UK) Peter Young BDS, PhD Brian T. Young DDS, MS

PUBLISHER Lisa Moler Tel: (480) 403-1505

Email: lmoler@medmarkaz.com

MANAGING EDITOR Mali Schantz-Feld Tel: (727) 515-5118

Email: mali@medmarkaz.com

ASSISTANT EDITOR Kay Harwell Fernández

Email: kay@medmarkaz.com

PRODUCTION MANAGER/CLIENT RELATIONS Kim Murphy Email: kmurphy@medmarkaz.com Tel: (480) 580-8008 NATIONAL SALES/MARKETING MANAGER Drew Thornley Email: drew@medmarkaz.com Tel: (619) 459-9595 E-MEDIA MANAGER/GRAPHIC DESIGNER Deidra Cole Email: dcole@medmarkaz.com

The Mini Implant A viable choice A

s implants continue to become a more mainstream option for treatment, old debates begin to rear their heads. As a general dentist who has been placing traditional and mini implants for nearly 7 years, I have listened to pundits go back and forth on the issue of the “validity” of mini implants and their “place in implant dentistry.” I understand the confusion and the myths surrounding mini implants as a grouping, and would like to take this opportunity to discuss their purpose and place in our profession. Comparing success rates between traditional implants and mini implants is much like being in a rocking chair— it will give you something to do, but it won’t get you anywhere! Mini implants are designed for prosthetic stabilization, which in most cases involves a very atrophic ridge, a patient that is medically compromised, and bone that is less than ideal in any surgeon’s hands. One should expect to see a slight uptick in failures when trying to overcome such challenges. More often than not, despite the challenges, these cases are successful using mini implant therapy. Naturally one might wonder, “Why even place a mini when I could just place a traditional implant?” Few edentulous ridges meet the vertical and/or horizontal minimum ridge dimensions that would allow for successful placement of traditional implants, without invasive graft procedures to improve bony architecture. With that being said, most elderly patients (who on average are taking no less than three prescription drugs) would be better served having less surgery rather than more. Patients such as these are left with few options in today’s economy. Cost is on the forefront of every patient’s mind. When choosing elective procedures such as implants, we, as health care providers, have a duty to provide multiple options to achieve the same goal. In the case of denture stabilization, I would argue that three to four mini implants can achieve the same treatment outcomes of traditional implants with less of a cost burden to the patient. When trying to understand mini implants and their place in implant dentistry, I believe it is not only important to consider the aforementioned points, but to consider that case selection is vitally important to the argument. We have to remember that in order to best serve our patient’s needs, having every tool available in the proverbial “toolbox” gives the patient options needed to make an informed decision. Patients seek our time, skill, care, knowledge, and judgment in these matters, and having an arsenal of options with which to treat is to our advantage. Mini implants are not replacements to traditional implants, but rather a member of a much bigger family that deserves a place at the table. All the best, Timothy M. Bizga, DDS Private practice in Cleveland, Ohio Member of the American Dental Association Member of the Academy of General Dentistry Member of the American Academy of Cosmetic Dentistry Graduating member of Whitecap Institute Graduating member of the American Academy of Facial Aesthetics Clinical consultant for The Dental Advisor Volunteer with Healing the Children dental mission

PRODUCTION ASSISTANT/SUBSCRIPTION COORDINATOR Lauren Peyton Email: lauren@medmarkaz.com MedMark, LLC 15720 N Greenway Hayden Lp. #9 Scottsdale, AZ 85260 Tel: (866) 579-9496 Fax: (480) 629-4002 SUBSCRIPTION RATES: One year: $99 | Three years: $239 Tel: 1-866-579-9496 Web: www.medmarkaz.com © FMC 2012. All rights reserved. FMC is part of the specialist publishing group Springer Science+Business Media. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Implant Practice or the publisher.

Volume 5 Number 3

0TWSHU[ practice 1

Contents PRACTICE PROFILE 6

Through the keyhole

Dr. Stuart J. Froum shares his thoughts about teaching, learning, growing, and changing in an evolving specialty

CLINICAL 10

6 Dr. Stuart J. Froum

Compressing treatment time and enhancing esthetic results with the use of narrow-diameter implants in single anterior sites Dr. K. Kevin Neshat discusses two case studies that illustrate how narrow-diameter implants help to overcome significant challenges

3.0 mm diameter mini implants for retention of a mandibular overdenture

Drs. David Cummings and Christopher P. Travis explore this solution to denture instability 18

Every picture tells a story: Immediate placement

Dr. Eddie Scher asks: can you visualize the end result before you start your case?

Drs. David Cummings and Christopher P. Travis

CONTINUING EDUCATION 22

Comprehensive dental implantology: part one

In the first of a series, Dr. Shane McCrea examines the options available to practitioners for tackling implant cases in a single sitting 32

32 Dr. Gerald Niznick 2 0TWSHU[ practice

One-piece, application-specific implants for treatment of narrow ridges

Dr. Gerald Niznick discusses the steps involved in mini-implant placement

Volume 5 Number 3

Contents RESEARCH 40 U.S. and Canadian markets for dental

implants and final abutments continue to show signs of recovery Dr. Kamran Zamanian and Jeff Wong, B.Sc, Senior Analyst, iData Research Inc., explore the economic factors that affect dental implants and abutments in the U.S. and Canada

PRACTICE MANAGEMENT

44 Ross Vera

44 New school marketing made simple Ross Vera, consultant at Pride Institute, shows how updating your marketing strategy can make a world (wide web) of difference to your practice

3D DIALOGUE 47 Using software for implant planning and

implementation While 3D scans offer greater information for implant planning, Dr. Steven Guttenberg notes that the proper software makes the entire process even more precise

PRODUCT PROFILE

47 Dr. Steven Guttenberg

50 Straumann速 Narrow Neck Crossfit速 A new generation of small diameter soft tissue level implant

52 Intra-Lock速

Spotlights its small-diameter implant systems

38 Author's guidelines 54 Diary 56 Materials & equipment

50 Narrow Neck Crossfit速 4 0TWSHU[ practice

Volume 5 Number 3

– the freedom of unlimited possibilities

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ATLANTIS™ abutments are comprised of a unique combination of four key features, known as the ATLANTIS BioDesign Matrix™. Together, these features work to support soft tissue management for ideal functional and esthetic results. Just take an implant-level impression, send it to your laboratory and ask for ATLANTIS today.

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Practice profile

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Tell us about your background. I was born in Brooklyn, New York and attended Brooklyn Technical High School and Brooklyn College. I won a Regentsâ&#x20AC;&#x2122; Dental Scholarship with the condition that I attend a dental school located in New York State. Stony Brook did not exist, Buffalo was too cold in the winter, and New York University Dental Center, a private dental college, had an excellent reputation. Moreover, it was in Manhattan, and my family, mother and brother, and friends lived in New York City. So it was there that I attended and received my dental degree. When did you decide to become a specialist and why? Following graduation from dental school, I was accepted to a General Practice Residency Program at the Veterans Administration Hospital in Brooklyn, New York where I was exposed to all aspects of dentistry. I wanted to be able to practice in a specialty so that I could study and keep current with all the new literature, materials, and techniques that would be introduced in a constantly evolving field. I felt the specialty that 6 0TWSHU[ practice

was closest to the basic sciencesâ&#x20AC;&#x201C; anatomy, histology, pathology, and physiology was periodontics. I realized that the foundation of the teeth (i.e. the periodontium) was the key to a successful restorative result and decided to pursue this specialty. Fortunately, I was accepted into a periodontal residency program (these were rare at the time) and actually earned a salary while obtaining my certificate in periodontics as a resident at the Veterans Administration Hospital in New York City. It was there that I received my clinical, periodontal, and oral medicine training. The chief of the dental service at the time was Dr. Irwin Scopp, an expert in oral medicine. I received my didactic periodontal training from Dr. Sigmund Stahl (one of the brightest periodontists Iâ&#x20AC;&#x2122;ve ever known) at New York University College of Dentistry in the Periodontal Department. It was Dr. Stahl who encouraged my interest in clinical periodontal research. Is your practice limited solely to periodontics/implants? My practice is limited to periodontics and implant dentistry. I became

interested in these fields through my research and clinical studies in the field of periodontal regeneration, encompassing the regrowth of both hard and soft tissue that support natural teeth. I also used the skills and knowledge gained from my research to help my implant patients by building bone (i.e. sinus and ridge augmentations, etc.) and soft tissue, which not only enable implant placement but also help to maximize the esthetic restorative result. Why did you decide to specialize in periodontics and implants? Again, these were two areas I felt were key to retaining, and if necessary, restoring missing dentition. Early in my training, periodontal therapy consisted of scaling, root planning and resecting tissue. Treatment goals changed with the advent of newer materials and regenerative techniques. Now we replace lost bone and gingiva with a variety of procedures and save many teeth, which in the past were considered hopeless and extracted. Implants presented a way of replacing the teeth that were lost or required removal with a restoration Volume 5 Number 3

Practice profile

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supported by a fixed root (an endosseous implant). All the risk factors, systemic conditions, and surgical skills learned in periodontics come into play with implants. Moreover, similar to the condition of periodontitis with loss of bone and attachment that occur around natural teeth, implants may develop peri-implantitis, characterized by inflammation in the surrounding mucosa and bone loss around the implant. This presents an even greater challenge for the clinician attempting to save the implant and regenerate lost bone and soft tissue. Do your patients come from referrals? Most patients come from referrals, from other patients, or dentists. Occasionally, I will get referrals from physicians or other specialists who practice out of the area but have read my book, articles, or attended one of my lectures. How long have you been practicing periodontics, and what implant systems do you use? I have been practicing periodontics for over 35 years and placing implants for over 25 years. As a clinical professor and director of clinical research at New York University Department of Periodontics and Implant Dentistry, I have, for over the 20 years, been part of a department that utilized almost all of the implant systems. In my office, Volume 5 Number 3

I mainly use Straumann®, Nobel Biocare®, Biomet 3i™, BioHorizons®, Ankylos and Dentatus narrow-bodied implants, depending on the clinical situation and following a consultation with the dentist who is restoring the patient. What training have you undertaken? Literally, thousands of hours of CE and courses. Most of the implant companies come to New York University Dental College (NYUDC) each year and give special hands-on presentations updating their newest innovations and new data on recommendations for placement and restoration of their implants.

Who has inspired you? I was lucky enough to know and meet some of the great teachers and mentors in my profession; Drs. Sigmund Stahl, Jan Lindhe, Gerald Kramer, Morris Ruben, Edwin Rosenberg, Leonard Abrams, Gerald Bowers, Saul Schlugar, Cliff Ochsenben, Walter Cohen, John Pritchard, Sig Ramfjord, Bill and Burt Becker, Bob Gottsegan, Jay Siebert, Jim Mellonig, Dennis Tarnow, Bob Schallhon, Bill Hiatt and others, and of course, my students from whom I always learn. What is the most satisfying aspect of your practice? Getting to know and being able to help my patients. I’ve known and treated many of my patients for 20 to 0TWSHU[ practice 7

Practice profile

35 years. I have treated their parents and grandparents, and in many cases, their children and grandchildren. In most cases, weâ&#x20AC;&#x2122;ve been able to exceed their expectations in saving, restoring or replacing their teeth with implants by providing a result that makes them happy they originally came to our office. Professionally, what are you most proud of? I am proud I have contributed to clinical dentistry by studying, testing, and using materials and techniques that rebuild and restore oral health, function, and esthetics. I am proud to have contributed to the knowledge of regenerating bone and soft tissue. These regeneration techniques and materials not only save natural teeth but enable patients with alveolar defects, which have precluded them as implant candidates in the past, to have implants placed. I am proud to be one of the clinicians who early on recognized the significance of implant complications. I edited a book on dental implant complications that hopefully will serve as a reference on how the implant dentist can prevent, avoid, and treat problems that can and do occur. This knowledge can be used to reduce the risks of implant therapy. The successful treatment and resolution of these problems, which oftentimes seem insurmountable, is well described in the book. A large percentage of my practice consists of patients who are referred due to implant restoration problems. We are usually able to provide solutions and restore their confidence in modern implant dentistry. What do you think is unique about your practice? I and my staff are able to deliver the most up-to-date, evidence based and patient-centered services in a caring, 8 0TWSHU[ practice

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kind and warm environment. My affiliation with an excellent teaching school, NYUDC, in a world-renowned periodontal and implant department, coupled with the latest research in a dedicated facility (Bluestone Research Center) enables me to clinically evaluate and use products, materials, and techniques that have proven to provide safe, predictable outcomes. In my private practice, I am supported by an excellent and caring staff. I have had the pleasure of working with most of them for many years. My office manager, assistant, and hygienist all have been working with me for more than 25 years. Two newer staff members are excellent assistants who hold dental degrees from their home countries. Another dentist has worked for me for more than 10 years lending continuity in maintaining the results we obtain. Finally, my daughter, a registered hygienist, works with me 2 days a week while raising my granddaughter, an Akita, and two cats. In our office, we offer the latest in implant dentistry, with immediate implant placement, implant temporization, and immediate loading whenever applicable. We also use the latest in diagnostics, including CBCT scans, SimPlantÂŽ (Materialise) computer implant simulation, and DEXISÂŽ digital X-rays. Computerguided placement and intravenous sedation are used where and when

indicated. All of this is performed in a patient-centered atmosphere, working closely with the restorative dentist and other specialists when treatment requires a multidisciplinary approach. What has been your biggest challenge? Balancing my time. Maintaining an active private practice, a clinical professorship and continuing clinical research at NYUDC, raising three wonderful children, keeping up with the literature, writing research articles, and currently being the vice president of the American Academy of Periodontology requires an ability to organize and prioritize. This ongoing challenge requires support, which I get from my family, friends and staff. I feel fortunate I have these people in my life. What would you have been if you had not become a periodontist? Probably a physician or teacher. I respect both fields and feel they are important to the well-being of our society. What is the future of periodontics and implant dentistry? The future will be exciting. Research resulting in new and improved materials and techniques combined with newer computer applications for diagnosis and treatment promise Volume 5 Number 3

Practice profile

a bright future. However, we must reach more of the population both in the U.S. and abroad. In our country as well as in other areas around the world, there are too many people whose periodontally involved teeth are not being saved and too many unhappy edentulous individuals living with dentures. Implant dentistry should allow an improvement in quality of life for all patients requiring tooth replacement. However, the caveat remains proper training is required not only in placement and restoring implants but in dealing with implant complications. The latter certainly will increase as more dentists place and restore implants in greater numbers of people with greater expectations for success. The dental schools, implant companies, dental laboratories, and dentists must be responsible if this bright future is to come to fruition. What are your top tips for maintaining a successful specialty practice? The specialist must keep current in education, evolve, and consider incorporating new technology and techniques that show positive evidence-based results. The specialist must also embrace change while avoiding the hype that comes with being the first one on the block to incorporate a new yet unproven system or product. Remember, it was on a maiden voyage that the Titanic sunk. It is prudent to keep the focus of your practice on improving the oral and general health and function of your patients. Working as a team with talented and knowledgeable restorative dentists, is a prerequisite for good results and satisfied patients. These are the patients that refer their friends and family members. It is essential to treat every patient as an individual who sees you care about them as well as successful outcomes. Volume 5 Number 3

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What advice would you give to a budding periodontist? Keep budding. Learn all you can from the clinicians you admire, study their methods and teachings (even visit their offices if possible), and do all you can to emulate their practices in your own style. Once you’ve done that, do not stop learning and growing.

Top Ten Favorites List

What are your hobbies, and what do you do in your spare time? I love to exercise; years ago it was weights and jogging; now it’s stretching and a lot of walking. Walking helps me mentally and physically to balance mind and body. I also am a student of nutrition, reading all I can about foods and vitamins, trying to integrate them into my personal life. I love listening to classical music, especially Beethoven and Mozart. But most important to me is spending time with my children, grandchildren, and pet dogs. I exchange ideas with my son Scott, a very talented periodontist, my daughter Hana, an excellent hygienist, and my daughter Holly, a stellar lawyer. They along with the rest of my family help me keep current and keep me going.

5. Challenging cases (with good outcomes)

1. Family and friends 2. My patients and staff 3. My students and colleagues at New York University Dental Center, Department of Periodontology and Implant Dentistry 4. The American Academy of Periodontology

6. Bone replacement grafts– demineralized and mineralized freeze dried bone, anorganic bovine bone 7. Absorbable membrane barriers 8. Enamel matrix derivative, growth factors 9. Cone beam CT–SimPlant® 3D digital dentistry 10. Dylan and Billy (our family’s Akita and Bulldog)

With 35 years in private practice, Stuart J. Froum, DDS, is a Diplomate of the American Board of Periodontolgy and a Diplomate of the International Congress of Oral Implantology. Dr Froum has served the American Academy of Periodontology (AAP) in a variety of positions; most currently, he is Vice President of the AAP and will be AAP President in 2014. Dr Froum is a Clinical Professor and the Director of Clinical Research, Department of Periodontology and Implant Dentistry, New York University College of Dentistry.

0TWSHU[ practice 9

Clinical

Compressing treatment time and enhancing esthetic results with the use of narrowdiameter implants in single anterior sites Dr. K. Kevin Neshat discusses two case studies that illustrate how narrowdiameter implants help to overcome significant challenges Introduction Placement of dental implants in anterior single-tooth sites has long posed some of the most significant challenges for surgical and restorative dentists. Although patient esthetic expectations for this region are high, the presence of thin alveolar bone and limited mesiodistal space are common. After implant exposure, mean horizontal bone loss of 1.3 to 1.4 mm has been documented to occur.1 Many patients with congenitally missing anterior teeth or microdontia have thus been treated with removable retainers, resinbonded bridges, or cantilever crowns. While orthodontia is another option, the treatment time required and the additional expense often makes it unacceptable, particularly for younger patients who already have undergone lengthy orthodontic procedures. Additionally, orthodontia may not always be possible when the remaining dentition is in proper alignment, and distalization of the teeth to widen the space to be implanted will create, rather than solve, more issues. When the buccolingual ridge dimensions are inadequate to accommodate standard-diameter implants, autogenous onlay grafting offers a way to achieve acceptable implantplacement conditions.2 Onlay grafting also increases the morbidity and complications at both the donor and recipient sites.3 Again however, bone augmentation significantly lengthens the requisite treatment time and added expense. In response to increasing patient demands for shorter treatment options, some manufacturers have recently introduced 3.0-mm diameter implants intended for use in constrained singletooth sites. Some of these narrow implants have been one-piece designs requiring the restorative doctor to prepare the implant head if angulation issues require modification using 10 0TWSHU[ practice

time-consuming conventional toothpreparation techniques. Moreover, at times, the natural buccolingual alveolar angulation in the anterior maxillary region does not allow placement of these one-piece implants in an acceptable restorable position. The newly introduced NobelActiveâ&#x201E;˘ 3.0-mm implant (Nobel Biocare), however, has a two-piece design that offers clinicians significant advantages for anterior single-tooth indications over one-piece designs. All NobelActive implants have several features that make them extraordinarily effective at maintaining peri-implant bone and soft tissue. The internal conical connection features an internal hex that provides an antirotational effect as well as prosthetic indexing. This connection is designed to maintain the structural integrity of even the narrow-body NobelActive implant. Restoration of the NobelActive is straightforward, with most of the work accomplished in the laboratory using custom or stock abutments. The surface of the NobelActive 3.0 implant features TiUniteâ&#x201E;˘. This proprietary titanium-oxide surface has clinically demonstrated the ability to increase the predictability and speed at which dental implants osseointegrate.4 It stimulates osseoconductivity by creating a higher bone-to-implant contact during early healing, which results in faster integration of the implant in the surrounding bone.5,6 NobelActive implants also incorporate a .25-mm platform shift. This design feature has been hypothesized to reduce the inflammatory response around the implant-abutment junction.7 A recent review and meta-analysis of 10 studies involving 1,239 implants from various dental implant systems found that marginal bone loss around platformshifted implants was significantly less than around platform-matched

implants.8 Moreover, a recent study found that bone levels were maintained when platform-switched implants were placed only 1-mm from adjoining teeth.9 The following case reports illustrate the use of the NobelActive 3.0-mm implant in single anterior sites. Case Reports Case No.1 The patient was a 16-year-old female who presented requesting permanent restorations for her congenitally missing lateral incisors. Completed growth was confirmed prior to considering dental implant placement. She had completed orthodontic treatment and was wearing orthodontic retainers. A thorough intraoral examination was performed, and a full cone beam computed tomographic (CBCT) scan was taken (Figures 1 and 2). The edentulous spaces were determined to be adequate for accommodating esthetic crowns. However, the mesiodistal alveolar width was only 4.68 mm in site No.7 and 4.45 mm in site No.10, and the buccolingual dimensions were 4.56 mm in site No. 7 and 4.33 mm in site No.10. These measurements precluded the use of standard diameter implants without additional procedures. The patient was informed that she could undergo re-orthodontic treatment to increase the mesiodistal dimensions of the implant-placement sites, and autogenous onlay grafting

K. Kevin Neshat, DDS, MD, is a board certified oral and maxillofacial surgeon and is the founder of Nu Image Dental Implant Center in Raleigh, North Carolina. He is an assistant clinical professor at the UNC Chapel Hill School of Dentistry, Department of Oral and Maxillofacial Surgery.

Volume 5 Number 3

Clinical Case 1

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Volume 5 Number 3

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0TWSHU[ practice 11

Clinical could be employed to increase the buccolingual ridge width at both sites. However, during consultation with the patient and her parents, narrow diameter implants were presented as a treatment alternative. They both elected to proceed with this treatment option. Because the soft-tissue contours around the canines and central incisors were not ideal (Figure 3), the patient returned to her restorative dentist for presurgical laser recontouring to improve the width to length ratios and provide a more ideal esthetic appearance (Figure 4). This helped with planning the optimal emergence profile for the implant-supported lateral incisor crowns. A few days later, the patient returned to the author for implant placement. After utilization of intravenous sedation techniques and local anesthetic injections, a No.15 blade was used to make

mucoperiosteal incisions, using a papilla-sparing technique and taking care not to expose the buccal bone (which could compromise the blood supply and further reduce the buccal bone thickness). Once the tissue was reflected and subperiosteal dissection was completed, a 702 bur with a high-speed handpiece and copious irrigation was used to perform coronal alveoloplasties to optimize the ridge height at both sites. Osteotomies were created using the sequence of burs recommended by the implant manufacturer (Nobel Biocare), and 3.0-diameter NobelActive implants were placed and torqued to 45N cm. Radiographs were taken to document the bone level and verify implant placement (Figures 5 and 6). Healing abutments were connected to the implants, and the patient was discharged. Although she was offered the option of having the implants immediately loaded with provisional

crowns, she and her parents chose to avoid this expense by using her existing orthodontic retainer for provisional restoration (Figure 7). Four months later, regeneration of the soft tissue was so abundant that the gingiva had partially overgrown the healing abutments (Figure 8), so additional gingival recontouring was performed utilizing a diode laser (Figures 9, 10, and 11). The patient was then sent back to the restorative dentist for impression taking and delivery of the final abutments and crowns. Case No.2 This 34-year-old male presented seeking an implant-supported crown to replace missing tooth No. 9, which had been traumatically avulsed 19 years earlier and restored with an unesthetic partial denture (Figure 12). Comprehensive clinical examination and a CBCT scan revealed that the

Case 2

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Volume 5 Number 3

Clinical ridge at the edentulous site had sufficient height and mesiodistal width to accommodate placement of a standard implant (Figure 13 and 14). However, the buccolingual dimensions were too narrow due to an enlarged incisive foramen (Figure 14). To avoid bone augmentation, the patient elected to have a narrow-diameter implant placed and immediately temporized. The tissue was reflected as described in the previous case, and a coronal alveoloplasty was performed to create the optimal ridge height. After creation of the osteotomy, a 3.0 mm NobelActive implant was placed, and a radiograph was taken to document proper placement of the implant (Figure 15). A temporary abutment was connected to the implant, and a temporary tooth was then fabricated intraorally utilizing a presurgical impression of the temporary partial denture. The temporary tooth was designed to be out of occlusion to ensure that excessive force would not be applied to the implant during the osseointegration phase. The patient also reported a pre-existing diastema

References 1. Tarnow DP, Cho SC, Wallace SS (2000). The effect of inter-implant distance on the height of interimplant bone crest. J Periodontol 71: 546-549. 2. Misch CM (2011). Maxillary autogenous bone grafting. Dent Clin North Am 55(4): 697-713 3. Clavero J, Lundgren S (2003). Ramus or chin grafts for maxillary sinus inlay and local onlay augmentation: comparison of donor site morbidity and complications. Clin Implant Dent Relat Res. 5(3):15460. 4. Glauser R, Portmann M, Ruhstaller P, Lundgren AK, Hämmerle

Volume 5 Number 3

that he wished closed for the final result. Therefore, the provisional crown was made slightly larger than tooth No. 8. The size discrepancy was to be corrected in the final restorative phase. The gingival tissue was then secured around the temporary tooth using 4-0 chromic gut sutures to ensure adequate soft-tissue contouring (Figure 16). At two week post-op, excellent soft-tissue healing was confirmed (Figure 17). The patient returned to his restorative dentist for definitive restoration plans in 4 months. Discussion The process of creating osteotomies for placement of NobelActive 3.0 implants was designed to retain as much bone as possible. The implant body and thread design condenses bone during insertion enhancing initial stability. The sharp apex and cutting blades enables adjustment of the implant position for optimal restorative orientation. In addition to providing the strength and stability of traditional-sized NobelActive implants, NobelActive 3.0 implants

C, Gottlow J (2001). Stability measurements of immediately loaded machined and oxidized implants in the posterior maxilla: a comparative clinical study using resonance frequency analysis. Appl Osseointegration Res 2: 27-29. 5. Zechner W., Tangl S, Fürst G, Tepper G, Thams U, Mailath G, Watzek G (2003). Osseous healing characteristics of three different implant types. Clin Oral Implant Res 14(2): 150-157. 6. Ivanoff CJ, Widmark G, Johansson C, Wennerberg A (2003). Histologic evaluation of bone response to oxidized and turned titanium microimplants in human jawbone. Int J Oral Maxillofac Implants 18(3): 341348.

enable the achievement of esthetic results that were unattainable when using earlier small diameter one-piece dental implant designs. However, at sites where the buccolingual ridge dimensions are so narrow that a fracture of the buccal bone may be inevitable, the author prefers to use osteotomes in combination with a ridge-splitting technique, in order to achieve the maximum amount of control over the ridge fracture site. Conclusion For narrow anterior spaces, the NobelActive 3.0 implant offers significant benefits. The two-piece design allows for maximum restorative flexibility, while the platform shift results in excellent hard- and softtissue preservation. By allowing patients to avoid lengthy and expensive orthodontic and bone-augmentation procedures, they can enjoy the benefits of an implant-supported restoration earlier in the course of treatment, sometimes immediately after implant placement.

7. Lazzara RJ, Porter SS (2006). Platform switching: a new concept in implant dentistry for controlling postrestorative crestal bone levels. Int J Periodontics Restorative Dent 26(1): 9-17. 8. Atieh MA, Ibrahim HM, Atieh HA (2010). Platform switching for marginal bone preservation around dental implants: a systematic review and meta-analysis. J Periodontol 81(10): 1350-1366. 9. Vela X, Méndez V, Rodríguez, X, Segalá M, Tarnow DP (2012). Crestal bone changes on platform-switched implants and adjacent teeth when the tooth-implant distance is less than 1.5mm. Int J Periodontics Restorative Dent 32: 149-155.

0TWSHU[ practice 13

Clinical

3.0 mm diameter mini implants for retention of a mandibular overdenture Drs. David Cummings and Christopher P. Travis explore this solution to denture instability

ini or small-diameter implants (SDIs) were initially used as provisional or transitional implants during the osseointegration phase of standard-diameter, root-form implants. As a result of their clinical success, SDIs were first cleared by the FDA for long-term use in 1997. Since then, the FDA has cleared several brands of SDIs for long-term use. While mini implants can be as narrow as 1.8 mm, the 3.0 mm diameter mini implant is an option if the patient has adequate bone width. The onepiece design provides strength and eliminates an abutment-implant interface. The following case report details the preoperative workup, as well as the surgical and prosthetic procedures used to provide increased retention of a patient’s mandibular denture.1–5 Preoperative workup The patient, a 77-year-old woman, presented with well-fitting full mandibular and maxillary dentures. She desired improved stability of her lower denture. Her health history included well-controlled diabetes, which did not contraindicate dental treatment. A clinical examination revealed a severely atrophic mandibular ridge. To provide added support for the patient’s mandibular denture, the lingual flanges in the retromylohyoid region of the denture were extended with a permanent lab-processed soft reline. While this resulted in increased retention, the patient was still experiencing lifting of the anterior segment of the denture. Implants were reviewed as a potential treatment option. In order to determine if the patient was a candidate for implants, the patient’s existing denture was modified to create the scan appliance. Six to eight small divots were drilled into the denture flanges with a No. 4 round bur. 14 0TWSHU[ practice

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Gutta percha was packed into the divots to create radiographic markers. After the dual CBCT scan was performed, implant treatmentplanning software was used to merge the two scans by matching the guttapercha markers. When the scan was complete, the gutta-percha markers were removed and replaced with pink acrylic. Next, a scan index was fabricated. This bite registration, made from a radiolucent material, ensures that the scan appliance (modified denture) remains fully seated during the CBCT scan. Using a dual-scan protocol, the patient was scanned with the scan appliance and scan index, and then the scan appliance was scanned alone. The scan revealed severe vertical and horizontal atrophy. Note the thin crestal cortical plate and the thicker plate at the inferior border. Four implants were planned in the symphysis to provide retention for the overdenture. There was adequate width and length to virtually place four 3.0 mm diameter implants (Figure 1). The Inclusive® Mini Implant System (Glidewell Laboratories) was selected for use in this case. The system offers three implant diameters (2.2 mm, 2.5 mm, and 3.0 mm), each in three different lengths (10 mm, 13 mm, and 15 mm). Corresponding to the minor diameter of the threaded

portion of the respective implants are three drill diameters (1.5 mm, 1.7 mm, and 2.4 mm). Selection of the appropriate drill, however, should be based not only on the diameter of the implant, but also on the quality of the bone. While the 2.4 mm drill is normally indicated for a 3.0 mm implant, the 1.7 mm drill was selected for this case in deference to radiographic evidence of the patient’s

David Cummings, DDS, received his undergraduate degree in applied mathematics from University of California, San Diego. He completed his dental degree at USC School of Dentistry, and his training in oral and maxillofacial surgery in 1996, followed by a fellowship in orthognathic surgery. Dr. Cummings has been an assistant clinical professor at USC School of Dentistry since 1998, specializing in the field of dental implants. He can be contacted at: drcummings@mnc.occoxmail.com. Christopher P. Travis, DDS, received his dental degree and certificate in prosthodontics from USC School of Dentistry, where he served as an assistant clinical professor in predoctoral and graduate prosthodontics. For the past 30 years, he has maintained a full-time private practice specializing in prosthodontics in Laguna Hills, California. Dr. Travis is director of the Charles Stuart Study Group in Laguna Hills, prosthodontic coordinator for the Newport Harbor Academy of Dentistry, and active member of the Pacific Coast Society for Prosthodontics, American College of Prosthodontists and AO, as well as a Fellow of the ACD. Contact him at 949-683-7456 or surfnswim@fea.net.

Volume 5 Number 3

Clinical

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bone density, and to provide a clinical feel of the implant site prior to utilizing a drill that could potentially prove to be too large. Surgical procedure Before starting the surgical procedure, a surgical guide was fabricated for the 1.7-mm drill by exporting a manufacturing file from the implant treatment-planning software, and then printing the appliance with UV-cured acrylic. Appropriate diameter sleeves were added to complete the surgical guide. The distance from the top of each planned implant to the top of each sleeve was set at 9 mm. After the patient was anesthetized, the surgical guide was tried in to verify seating and stability. Initially, the 1.7 mm diameter drill was used to a depth of 14.5 mm (approximately one-half the length of the implant, plus the distance from the top of the sleeve to the top of the implant) [Figure 2]. Upon insertion of the first implant, it was determined that the osteotomies should be widened. The 2.4 mm drill was used to widen the 1.7 mm pilot holes. To act as a paralleling aid, the first implant was not completely seated. After the implants were started by hand in the osteotomy sites, they were threaded into place using a handpiece driver. Final seating of the implants was done by hand using a torque wrench in controlled, quarterturn increments. These smaller increments allow for heat dissipation and bone expansion. When the implants are in their final positions, the tops of the collars Volume 5 Number 3

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of the implants should be slightly above the crest of the soft tissue to discourage tissue overgrowth (Figure 3). Prosthetic procedure at the time of surgery While adequate primary stability was obtained during the surgical procedure, the decision was made to relieve the patient’s existing denture for a soft reline. A new denture, incorporating the O-ring housings, will be fabricated for placement in approximately 3 to 4 months. A cast framework will be incorporated into the new denture to provide strength to the prosthesis and support to the housings. The O-ball heads of the implants were marked using Dr. Thompson’s Sanitary Color Transfer Applicators (Great Plains Dental Products Co. Inc.). The overdenture was seated intraorally and then removed, thereby transferring the locations of the implants to the intaglio surface of

the denture. The areas marked by the implant locations were relieved by burring wells into the denture. Once the denture was properly adjusted, Trusoft™ (Bosworth® Company) soft reline material was added to the relieved areas, and the denture was seated. The patient was instructed to bite lightly in centric occlusion. Once the soft reline material achieved an initial set, the denture was removed, and excess material was trimmed (Figure 4). A postoperative CBCT scan was taken to verify the positions of the implants (Figure 5). When the patient was recalled for a one-week postoperative checkup, her healing was found to be within normal limits. Discussion The success of any implant overdenture begins with a well-made, well-fitting denture with proper extensions and 0TWSHU[ practice 15

Clinical

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balanced occlusion.6,7 If the patient’s existing denture does not fit these criteria, a new denture should be fabricated prior to implant placement. While the placement of minis may appear to be relatively straightforward, their positions must be precisely planned. The anatomical locations of the mandibular canal, including the possibility of an anterior loop, and the mental foramina must be identified. This should be done utilizing proper radiography. To maximize denture stability, the four implants should be placed with as wide an anteriorposterior spread as possible. The tops of the polished collars should be slightly above the crest of the soft tissue over the ridge. This will help to discourage mucosa from growing over the collar rim, where it may be pinched between the implant and the denture. Primary stability of the implants is critical because they will be immediately loaded. The drilling protocol should be based on the quality of the bone. In denser bone, such as Type II bone, the drill that matches the minor diameter of the threaded section of the implant should be utilized. In bone that is less dense, a

smaller diameter drill can be used and the implant allowed to self-tap during placement. If good primary stability is not achieved, the next wider diameter implant may be an option, provided there is adequate bone. With smaller diameter mini implants, such as 2.2 mm and 2.5 mm, it is recommended that a single drill be utilized to prepare the osteotomy to a depth of approximately one-half the length of the threaded portion of the implant, taking into account any additional depth such as soft tissue and surgical template thickness. The 3.0 mm diameter falls between the smaller diameters and conventional-sized implants. Ideally, one drill should be used here as well. Another option, as illustrated with this case, is to start with a smaller diameter drill to get a clinical feel for the bone quality and then adjust your protocol as needed. The one-piece dental implant design of a mini implant is intended strictly for the retention of an overdenture. From a prosthetic perspective, the vertical and horizontal space also must be taken into account. For example, each O-ring housing provided with the Inclusive Mini Implant System is 3.5

References 1. Christensen GJ (2006). The ‘mini’-implant has arrived. J Am Dent Assoc. 137(3):387–90. 2. Bryant SR, MacDonald-Jankowski D, Kim K (2007). Does the type of implant prosthesis affect outcomes for the completely edentulous arch? Int J Oral Maxillofac Implants. 22 Suppl:117–39. 3. Bulard RA, Vance JB (2005). Multi-clinic evaluation using mini-dental implants for long-term denture stabilization: a preliminary biometric evaluation. Compend Contin Educ Dent. 26(12):892–97. 4. Rodriguez AM, Orenstein IH, Morris HF, Ochi S (2000). Survival of 16 0TWSHU[ practice

mm in height and 4.75 mm in diameter. The housings must be completely encased in acrylic, and there should be at least 3 mm of acrylic above the top of each housing to provide adequate strength. If vertical space is limited, a cast framework incorporated into the prosthesis may be required. While the O-ring housings can be rotated to correct for up to 30 degrees of divergence between implants when they are processed into the denture, all efforts should be made to make the implants and housings as parallel as possible. This will also extend the life of the O-rings within the housings. Conclusion When using small-diameter implants, the clinician should be aware of the indications and the contraindications of this type of implant. In appropriate cases, and with proper selection, planning and execution of surgical and prosthetic procedures, smaller diameter implants can provide an excellent solution to denture instability. Copyright © April 2011, Inclusive magazine, Glidewell Laboratories.

various implant-supported prosthesis designs following 36 months of clinical function. Ann Periodontol. 5(1):101–08. 5. Nedir R, Bischof M, Szmukler-Moncler S, Belser UC, Samson J (2006). Prosthetic complications with dental implants: from an upto-8-year experience in private practice. Int J Oral Maxillofac Implants. 21(6):919–28. 6. Boucher CO, Hickey JC, Zarb GA (1975). Prosthodontic treatment for edentulous patients. 7th ed. St. Louis: Mosby. 7. Brewer AA, Morrow, RM (1980). Overdentures, 2nd ed. St. Louis: Mosby. Volume 5 Number 3

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Clinical

Every picture tells a story: Immediate placement Dr. Eddie Scher asks: can you visualize the end result before you start your case?

his patient referred himself to me, following his dentist’s recommendation for treatment regarding his upper left first premolar, which was loose (Figure 1). He instructed me, as a specialist, to take this tooth out, place an immediate implant, and then an immediate crown on top. The job would have to be finished on the same day, as the patient is often on television. He would not contemplate any treatment plan other than this. He allowed me to take a periapical X-ray of the region (Figure 2), and was totally shocked when I explained to him that an immediate implant was not appropriate in this situation, and that the tooth behind should also be extracted. The patient vehemently disagreed with my diagnosis, and told me that if I did not do as he requested, he would go elsewhere. I strongly recommended that he should seek a second opinion, as I was certainly not prepared to go ahead with his dentist’s suggested treatment plan. I explained to him he would probably have to wear some form of removable temporary restoration while we waited for healing to occur and for bone to grow in this region. The patient left my practice extremely annoyed, but I knew that this case would surely end in disaster if we were to follow his dentist’s treatment plan and the patient’s wishes. This patient went to another dental implant specialist in the city, who immediately suggested he should return to me, as I was absolutely right. He went to a third dental surgeon, who said the same. To his credit, this gentleman returned to me and allowed me to work out a treatment plan once I had reassured him that we would provide a minimally invasive, removable, temporary denture that would last him 18 0TWSHU[ practice

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for the healing part of his treatment. Our first surgical procedure was to gently remove the roots of upper left teeth Nos. 4 and 5, using piezosurgery and periotomes (Testori, 2008). At that appointment, we debrided the infected sockets very carefully, and immediately placed a temporary twotooth denture. Six to 8 weeks later, when the tissues had totally healed, we reentered the area with a wide incision, to perform a bone augmentation procedure to regrow new bone in the area. I was astounded to see how much destruction the infection had caused the bone (Figure 3). Our treatment for this bony defect was to

curettage all chronically infected areas, decorticate the bone, and then add in our demineralized freeze-dried bone product mixed with PRP (plateletrich plasma) [Marx, 2004]. The defect was so large that we decided to use a nonresorbable Gore-Tex® membrane reinforced with titanium to hold its shape. Figure 4 shows the membrane in place. The incision was closed very

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

Volume 5 Number 3

Where

goes, hard and soft tissue follow.

It’s time to measure tissue response in gains, not losses.

C. Sachs, Little Silver, NJ* 2 years post placement

Natural-looking esthetics that last. That’s the beauty of the ANKYLOS Implant System. UÊ V> ÊV iVÌ ÊÜ Ì Ê Ê VÀ Ûi i Ì 1 UÊ } ÌiÀ Ê >À`Ê> `ÊÃ vÌÊÌ ÃÃÕiÊÃÌ>L ÌÞ 2 UÊ > Ê Ê«>« >iÊ i } Ì 3 Call 1-800-662-1202 for a bibliography of clinical studies or to learn more from a fellow clinician in your area. ANKYLOS Implants. Bringing the importance of tissue response front and center. Distributed By:

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1. The ANKYLOS tapered connection shows no micromovement as shown by Zipprich using a chewing simulator. No clinical data is available. Zipprich, H., et al., Erfassung, Ursachen und Folgen von Mikrobewegungen am Implantat-Abutment-Interface. Implantologie, 2007. 15(1): p. 31-46. 2. The ANKYLOS offset tapered implant abutment-connection provides long-term hard and soft tissue stability over a mean period of 56 months as demonstrated by Nentwig’s clinical observation of no progressive bone or peri-implant mucosa loss in 95.8% and 97.8% of 5439 cases respectively. Nentwig, G.H., Ankylos implant system: concept and clinical application. J Oral Implantol, 2004. 30(3): p. 171-7. 3. Abboud noted that clinical observation showed esthetic outcomes and a gain in interdental papilla height in 16 patients when the ANKYLOS offset tapered connection was used. This effect persisted for a period of over 12 months after implant placement. Abboud, M., et al., Immediate loading of single-tooth implants in the posterior region. Int J Oral Maxillofac Implants, 2005. 20(1): p. 61-8. I >ÃiÊ«À Û `i`ÊV ÕÀÌiÃÞÊ vÊ ÀÃ°Ê >ÀÞÊ À ÕÃi Ê> `Ê > >Ê >

Clinical

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gently, being sure to have a complete seal above the Gore-Tex membrane. Figure 5 shows an X-ray taken after 3 months, with the membrane in place. After a 6-month healing period, the Gore-Tex membrane was surgically removed. Figure 6 shows the healed bone. Then, using a surgical template, the implants were placed (Figure 7). There was an interesting dilemma here. The implants needed to be placed quite close together for two reasons. Firstly, the mesiodistal space of the two-tooth gap was only just wide enough for two narrow implants. Secondly, there was the problem that the canine tooth had its root slanting distally. I therefore decided to make the mesial of the two implants shorter, so that there would be no risk of interfering with the integrity of the canine’s periodontal membrane. Figure 8 shows an X-ray of the healing implants in place. The area healed satisfactorily. Four months later, the implants were

exposed. Impressions of the implants were taken, and posts made, as well as provisional plastic crowns (Figures 9 and 10). We always go for provisional plastic crowns in the first instance, as this allows healing of the tissues at the gingival level. It also allows these narrow implants in poor quality bone to be “progressively bone-loaded,” so that the bone around becomes a better stress-bearing structure (Misch, 1995). The definitive restorations were performed by a prosthodontist in the U.S., as the patient’s employer had transferred him across the Atlantic. In conclusion, the most important lesson to be drawn from this case is not to proceed unless one can visualize the end result at the start of the case. Here, I could not visualize anything but disaster if I had proceeded with an immediate implant.

20 0TWSHU[ practice

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References Marx RE (2004). Platelet-rich plasma: evidence to support its use. J Oral Maxillofac Surg 62: 489-496. Misch C (1995). Progressive bone loading. Dent Today 14: 80-83. Testori et al (2008). Repair of large sinus membrane perforations using stabilized collagen barrier membranes: surgical techniques with histologic and radiographic evidence of success. Int J Periodontics Restorative Dent 28: 9-17.

Volume 5 Number 3

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Continuing education

Comprehensive dental implantology: part one In the first of a series, Dr. Shane McCrea examines the options available to practitioners for tackling implant cases in a single sitting

istorically, implant dentistry has been plagued by a lack of knowledge and uncertainty as to the clinical outcomes from various surgical techniques. This uncertainty has restricted the application of many tried and tested surgical techniques such that they are applied with extreme caution and only as individual surgical experiences. This article presents the application of multiple techniques, with the rationale for their usage, all of which will aid the successful clinical outcome of dental implant therapy. This multiple-usage scenario is carried out within a single surgical setting to the benefit and comfort of the patient. Synopsis This article is the step-by-step description of the comprehensive application of a number of surgical procedures that can be carried out by the able/skilled practitioner in a single surgical sitting, illustrated by a multitude of cases with a minimum of 12 months post-loading follow-up. This includes tooth extraction and immediate insertion of implants into modified sockets, whether suffering apical or chronic periodontitis with marked bone loss. Consecutive xenograft application, followed by the creation of a mucogingival complex that can be stable in an area prone to gingival recession as a result of â&#x20AC;&#x153;thin-gumâ&#x20AC;? phenotype or reduced width of keratinized gingival tissue using the subepithelial connective tissue graft (SCTG) in a variety of fixations and the pocket-lining pedicle flap (PLPF) will be illustrated. The results will be the establishment of an esthetically pleasing peri-implant mucogingival complex. Bone resorption at the new extraction socket is continuous, with the greatest amount occurring within 22 0TWSHU[ practice

Educational aims and objectives This article presents the case for incorporating multiple surgical techniques into a single session for implant treatment. Expected outcomes Correctly answering the questions on page 31, worth 2 hours of CE, will demonstrate the reader can: s $ESCRIBE THE MECHANICS OF BONE RESORPTION s %XPLAIN THE REPERCUSSIONS OF TOOTH EXTRACTION AND IMMEDIATE INSERTION OF implants into modified sockets. s )DENTIFY THE ROLE THAT TISSUE BIOTYPE PLAYS IN lNAL RESTORATION ESTHETICS

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the first month, averaging 3 to 5 mm loss in width at 6 months (Nevins et al, 2006) or an estimated 23% loss of bone mass in that 6 months, with an additional 11% within 2 years (Covani et al, 2003). This bone resorption may have a profound effect on esthetics and compromise the placing of dental implants (Araujo and Lindhe 2005). Pietrokovski et al, (2007), studied 123 human edentulous dry

bone specimens, concluding that, in the maxilla, bone resorption was centripetal and apical, i.e. bone resorption was overwhelmingly from the buccal surface of every socket with significantly reduced resorption from the palatal aspect of the socket. In the mandible, resorption was centrifugal and apical, forming an edentulous crest central to the former tooth sockets.

This difference in resorption produced a reverse horizontal overlap of the residual crests, where the edentulous maxilla was at the same level or internal to the facing edentulous mandible. Thus, the mandible resorbs more than the maxilla, and the buccal side loses more volume than the lingual (Smukler et al, 1999). Following extraction, techniques

6OLUME .UMBER

0TWSHU[ practice 23

Continuing education

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can be used that arrest or minimize the bone resorption process—i.e. treatment that aims to preserve the natural tissue contours. Regeneration of hard and/or soft tissue appears to restore the alveolar process and prepare the surrounding peri-implant structures for pleasingly esthetic implant-supported restorations (McCrea 2010). However, following a systematic review by Ten Heggler et al, (2011), it was concluded that the technique 24 0TWSHU[ practice

of socket preservation may hinder dimensional bone changes following tooth extraction, but does not actually stop bone resorption; the surgeon must still expect a loss in width and height. Today, there are many studies showing that the presence of infection at a proposed implant site does not contraindicate implant surgery (Lindeboom et al, 2006; Casap et al, 2007). Apical and periodontal lesions have been shown not to lower success

rates. The gross removal of the apical lesion during osteotomy preparation appears to be sufficient to give success rates that compare well with “healed” periapical (Chang 2009) and periodontal sites (McCrea 2011). In a systematic review by Waasdorp et al, (2010), it was shown that implants can be placed into sites with periapical and periodontal infections and achieve success rates equal to those placed conventionally, with the proviso that antibiotic therapy 6OLUME .UMBER

Continuing education

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was utilized. Construction of esthetically pleasing restorations involves harmonizing the size, shape, position and color of each prosthetic tooth with the adjacent natural teeth (Meijer et al, 2005) and establishing periimplant soft tissue compatible with the surrounding gingiva and mucosa. This is of particular importance in the esthetic zone (Higginbottom 2004).

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6OLUME .UMBER

Implant position Natural bone resorption, whether in the maxilla or mandible, sees the loss of the buccal plate (Araujo and Lindhe 2005; Araujo et al, 2006; Pietrokovski et al, 2007; Evans and Chen 2008; Van Der Weijden et al, 2009; Caneva et al, 2010). Implant positioning must still be both biological and prosthetically

driven to give a location that achieves optimal function and esthetics. Therefore, it is now contemporary practice to displace the axis of an osteotomy site to the palatal aspect of an extraction socket (Chen et al, 2007). Thus, in this series, all implants were placed on the palatal wall to gain soft and hard tissue contour. Figure 1 illustrates this contemporary practice. Tissue biotype Peri-implant soft tissue has a profound effect on dental implant esthetics. There are primarily two tissue biotypes: thin and thick. However, there are no clear criteria for defining the two forms. Historically, thin gingival tissues were thought to cover thin marginal bone around teeth (Hirschfield 1923). Selbert and Lindhe (1989) developed the concept of periodontal biotype, 0TWSHU[ practice 25

Continuing education

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describing gingival and alveolar bone contours as “flat-thick” biotype and “scalloped-thin” biotype. However, this early description was highly subjective. Claffey and Shanley (1986) defined gingival thickness of less than 1.5 mm as “thin biotype” and greater than 2mm as “thick biotype.” Bashutski and Wang (2007) reiterated the importance of tissue

thickness, transferring the concepts to implant treatment planning. Current understanding is geared toward establishing a thick tissue biotype around implants because of its contribution to the esthetic result of an implant-supported restoration. A thick biotype resists recession (Kois and Kan 2001; Small et al, 2001; Kao et al, 2008), is able to better conceal titanium (Jung et al, 2007), and helps

26 0TWSHU[ practice

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6OLUME .UMBER

Continuing education

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to maintain gingival morphology (Van Der Weijden et al, 2009). Thus, thick biotype is preferred to thin biotype around dental implants. Evans and Chen (2008) performed a study on immediate implants, defining biotype by probe transparency. The study found that peri-implant marginal stability was dependent on the baseline tissue thickness: increasing soft tissue thickness minimizes the potential for peri-implant mucosal recession. Soft tissue thickness can be increased by the Abram’s Roll and by the placement of a subepithelial connective tissue graft (SCTG). In implant therapy, bone grafting will be necessary where residual 6OLUME .UMBER

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volume is inadequate for housing/ covering a dental implant. Inherent thick tissue biotype is important here because thick tissues have an increased blood supply that will enhance the neovascularization of bone grafts, leading to increased rate of healing and graft incorporation. Another advantage of thick tissues is their ability to attain and maintain primary wound closure. Adequacy of soft tissue coverage is one of the main factors in ensuring periodontal regeneration. Flap exposure results in a reduction of the bone regenerated in grafting techniques, primarily as a result of bacterial contamination (Park et al, 2008). Figure 2 incorporates tooth

extraction and immediate placement with debridement of the infected alveolus, repair of the bony dehiscence with the xenograft Bio-Oss® (Geistlich) and its protective membrane BioGide®, while the SCTG assists in reestablishing the original position of the mucogingival junction (MGJ) following the coronally advanced flap (CAF) that was necessary for wound closure. Figure 3 shows a case of distinct regions of both thin tissue biotype (the left maxilla) and thick tissue biotype (the right maxilla). Once again, there is tooth fracture, its extraction, immediate implant placement, GBR, and GTR via the SCTG. The 42-month follow-up demonstrates the mimicking 0TWSHU[ practice 27

Continuing education

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of the original labial tissues that have been achieved.

in fibrous encapsulation instead of osseointegration (Lioubavina-Hack et al, 2006). Immediate implant placement into vacated â&#x20AC;&#x153;infectedâ&#x20AC;? sockets, whereby the socket osteotomy provides access to the sinus floor and the resulting bicortical fixation in the sinus floor, thus increasing primary stability, has now been described (McCrea, in

press). That bicortical fixation is defined as having both an apical and a coronal component, the apical component being the circumferential cortical bone of the sinus floor that will surround the implant apex. The coronal component varies from case to case, being dependent on which part of the crestal bone is engaged. As is contemporary

Primary stability The success of dental implants is now recognized as multifactoral. The achievement of high primary stability is considered as a prerequisite for that success (Esposito et al, 2009), since any micromovement will result 28 0TWSHU[ practice

6OLUME .UMBER

Continuing education

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6OLUME .UMBER

!"#$%&'(O*'L5,60,%0"S&0'-&%",-".,/'%,0"1#%,-2' &3-14&0',5'MN':16524'421?"6#':,"65,"6&0'.%&45,/' E16&'/&H&/4@'O2&'6,4,/'7/11%'E16&'%&:,"64'"6' &3&:-/,%8',0,-5"16'?"52'52&'":-/,65',-&3@'O2&%&' "4',/41'E16&',--14"5"16'16'52&'6,4,/'7/11%',0C,.&65' 51'52&'":-/,65',-&3')T@'9:-/,65'$4&0'?,4'P9L' LBUB)>'''(@V'3'MJ':: 0TWSHU[ practice 29

Continuing education practice, the implant axis will be palatally displaced; therefore; we can normally expect engagement of the palatal aspect of the crestal alveolus and consequently, the palate. The engagement of the remaining three walls (buccal, mesial, and distal) will be dependent on the dimensions of the alveolus–normally, the buccal wall will not be engaged, but the other two may or may not. This concept can be transferred to the intentional perforation of the nasal floor during implant placement, thus gaining an increase in primary stability via the dense cortical bone of the nasal floor.

Figure 4 is an example of the apically infected fractured root (which had suffered an apicectomy) that was extracted and immediately replaced by a dental implant that was intentionally placed through the nasal floor to increase its primary stability. A SCTG was placed that would resist the coronal disposition of the MJG that occurs in wound closure by virtue of the coronally advanced flap (CAF): the 12-month post-functional loading of the crown shows no discernable change in the position of that junction. Additionally, there has been an increase in the thickness of the nasal floor with deposition of bone on the

References Araujo MG, Lindhe J (2005). Dimensional ridge alterations following tooth extraction. An experimental study in the dog. J Clin Periodontol 32; 212-218. Araujo MG, Wennstrom JL, Lindhe J (2006). Modeling of the buccal and lingual bone walls of fresh extraction sites following implant installation. Clin Oral Implants Res 2006b; 17: 606-614. Bashutski JD, Wang HL (2007). Common implant aesthetic complications. Implant Dent 16: 340-348. Caneva M, Salata LA, de Souza SS, Baffone G, Lang NP, Botticelli D (2010). Influence of implant positioning in extraction sockets on osseointegration: Histomorphometric analyses in dogs. Clin Oral Implants Res 21: 43-49. Casap N, Zeltser C, Wexler A, Tarazi E, Zeltser R (2007). Immediate placement of dental implants into debrided infected dentoalveolar sockets. J Oral Maxillofac Surg 65: 384. Chang SW, Shin SY, Hong JR et al (2009). Immediate implant placement into infected and non-infected extraction sockets: a pilot study. Oral Surg Oral Med, Oral Path Oral Radiol Endo 107: 197-203. Chen ST, Darby IB, Reynolds EC (2007). A prospective study of non-submerged immediate implants. Clinical outcomes and esthetic results. Clin Oral Impl Res 18: 552-562. Claffey N, Shanley D (1986). Relationship of gingival thickness and bleeding to loss of probing attachment in shallow sites following nonsurgical periodontal therapy. J Clin Periodontol 13: 654-657. Covani U, Cornelini R, Barone A (2003). Bucco-lingual bone remodeling around implants placed into immediate extraction sockets: a case series. J Periodontol 74: 268-273. Esposito M, Grusovin MG, Achille H, Coulthard P, Worthington HV (2009). Interventions for replacing missing teeth: different times for loading dental implants. Cochrane Database Syst Rev Jan 21 1:CD003878. Evans CJD, Chen ST (2008). Esthetic outcomes of immediate implant placements. Clin Oral Implants Res 19: 73-80. Higginbottom F, Belser U, Jones JD, Keith SE (2004). Prosthetic management of implants in the esthetic zone. Int J Oral Maxillofac Implants 19(Suppl): 62-72. Hirschfield J (1923). A study of skulls in the American Museum of Natural History in relation to periodontal disease. J Dent Res 5: 251-265. Jung RE, Sailor I, Hammerle CH, Attin T, Schmidlin P (2007). In vitro color changes of soft tissues caused by restorative materials. Int J Periodontics Restorative Dent 27: 251-257. Kao RT, Fagan MC, Conte GJ (2008). Thick vs thin gingival biotypes: a key determinant in treatment planning for dental implants. J Calif Dent Assoc 36: 193198.

30 0TWSHU[ practice

apex of the implant. This CE is based on a presentation from the Association of Dental Implantology members’ National Forum on November 12, 2011, held at Kings College, London.

Shane McCrea, MMedSci (Dental Implantology), MSc (Dental & Maxillofacial Radiology), BDS, LDSRCS, MFGDP, is the coordinator of post-graduate education for the British Society of Oral Implantology. He is in private practice at The Dental Implant and Gingival Plastic Surgery Centre in Bournemouth, England, and can be contacted by email at shanemccrea@aol. com.

Kois JC, Kan JY (2001). Predictable peri-implant gingival aesthetics: Surgical and prosthodontic rationales. Pract Proced Aesthet Dent 13: 123-144. Lindeboom JA, Tijook Y, Kroon FH (2006). Immediate placement of implants in periapical infected sites: a prospective randomized study in 50 patients. Oral Surg Oral Med Oral Path Radiol Endo 101: 705-10. Lioubavina-Hack N, Lang NP, Karring T (2006). Significance of primary stability for osseointegration of dental implants. Clin Oral Implants Res 17: 244-250. McCrea SJJ (2010). Comprehensive dental implantology: the complete surgical approach with 30-month follow-up. Oral Surg (Nov) 3(4): 143-151. McCrea SJJ (2011). Use of the pocket-lining tissue as pedicle flap to facilitate wound closure after extraction to preserve the alveolar ridge or protect an implant site. Clin Adv Periodontics (Nov) 1(3): 183-191. McCrea SJJ. Trans-socket elevation/fracture/perforation of the sinus floor through the ‘infected’ maxillary tooth socket to facilitate bicortical fixation of dental implants. Clin Adv Periodontics. Meijer HJ, Stellingsma K, Meijndert L, Raghoebar GM (2005). A new index for rating aesthetics of implant-supported single crowns and adjacent soft tissues – The Implant Crown Aesthetic Index. Clin Oral Implants Res 16: 645-649. Nevins M, Camelo M, De Paoli S, et al (2006). A study of the fate of the buccal wall of extraction sockets of teeth with prominent roots. Int J Periodontics Restorative Dent 26: 19-29. Park SH, Lee KW, Oh TJ, Misch CE, Shotwell J, Wang HI (2008). Effect of absorbable membranes on sandwich bone augmentation. Clin Oral Implants Res 19: 32-41. Pietrokovski J, Starinsky R, Arensburg B, Kaffe I (2007) Morphologic characteristics of bony edentulous jaws. J Prosthodontics 16(2): 141-147. Selbert J, Lindhe J (1989). Esthetics and periodontal therapy. Lindhe J (ed). Textbook of Clinical Periodontology. Ed 2. Copenhagen Munksgaard 477-514. Small PN, Tarnow DP, Cho SC (2001). Gingival recession around wide-diameter versus standard-diameter implants: A 3- to 5- year longitudinal prospective study. Pract Proced Aesthet Dent 13: 143-146. Smukler H, Landi L, Setayesh R (1999). Histomorphometric evaluation of extraction sockets and deficient alveolar ridges treated with allograft and barrier membranes: a pilot study. Int J Oral Maxillofac Implants 14: 407-416. Ten Heggler JMAG, Slot DE, Van der Weijden GA (2011). Effect of socket preservation therapies following tooth extraction in non-molar regions in humans: a systematic review. Clin Oral Implants Res 22: 779-788. Van der Weijden F, Dell’Acqua F, Slot DE (2009). Alveolar bone dimensional changes of post-extraction sockets in humans: a systematic review. J Clin Periodontol Dec 36: 1048-1058. Waasdorp JA, Evian CI, Mandracchia M (2010). Immediate placement of implants into infected sites: A systematic review of the literature. J Periodontol 81(6): 801808.

6OLUME .UMBER

Implant Practice US CE Certificate details

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This quiz 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 24 CE credits for only $99. To receive credit, complete the 10-question test by circling the correct answer, then either: Q Post the completed questionnaire to: Implant Practice US CE 15720 N. Greenway-Hayden Loop. #9 Scottsdale, AZ 85260

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Comprehensive dental implantology: part one 1. In a systematic review by Waasdorp et al, (2010), it was shown that implants can be placed into sites with periapical and periodontal infections and achieve success rates equal to those placed conventionally, with the proviso that ______ was utilized. a. antibiotic therapy b. patient education c. debridement d. tissue grafting 2. Construction of esthetically pleasing restorations involves harmonizing the _________of each prosthetic tooth with the adjacent natural teeth (Meijer et al, 2005) and establishing peri-implant soft tissue compatible with the surrounding gingiva and mucosa. a. size and shape b. position c. color d. all of the above 3. Natural bone resorption, whether in the maxilla or mandible, sees the loss of the _____. a. palatal wall b. gingival tissue c. residual volume d. buccal plate

4. Peri-implant soft tissue has a profound effect on dental implant ______. a. strength b. esthetics c. longevity d. length 5. There are primarily two tissue biotypes: _____. a. scalloped and thick b. scalloped and recessed c. thin and thick d. flat and thin 6. Current understanding is geared toward establishing ______ around implants because of its contribution to the esthetic result of an implant-supported restoration. a. a thick tissue biotype b. a thin tissue biotype c. a periodontal flap d. graft incorporation 7. Soft tissue thickness can be increased by the ______. a. bicortical fixation b. Abramâ&#x20AC;&#x2122;s Roll c. placement of a subepithelial connective tissue graft (SCTG) d. both b and c

8. In implant therapy, bone grafting will be necessary where residual volume is _____ for housing/covering a dental implant. a. inadequate b. abundant enough c. not esthetic enough d. too vascular 9. Inherent thick tissue biotype is important here because thick tissues have (a)an _____blood supply that will enhance the neovascularization of bone grafts, leading to increased rate of healing and graft incorporation. a. alternate b. hidden c. increased d. decreased 10. The achievement of high primary stability is considered as a prerequisite for that success, since any _________ will result in fibrous encapsulation instead of osseointegration. a. vascularization b. tissue graft c. micromovement d. perforation

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0TWSHU[ practice 31

Continuing education

One-piece, application-specific implants for treatment of narrow ridges Dr. Gerald Niznick discusses the options involved in mini-implant placement

here are many clinical situations in which bone limitations may necessitate the use of a narrow diameter. The term â&#x20AC;&#x153;mini implantsâ&#x20AC;? is generally attributed to implants with a diameter of 3 mm or less, 2.4 mm and 2.8 mm being the most popular diameter. Mini implants are available from many companies with either Ball, ERA, or O-ring abutment platforms for retention of overdentures. There are also 3.0 mmD one-piece implants with application-specific platform options available (Implant Direct): GoDirectâ&#x201E;˘ with a Zest LOCATORÂŽ-compatible platform for retaining overdentures with GPSâ&#x201E;˘ attachments, ScrewIndirectÂŽ with a multi-unit platform for screw-retained restorations, and ScrewDirectÂŽ with a tapered abutment for cemented restorations. Implants less than 3 mm have not received FDA premarket approval for claims of being a permanent tooth replacement, although they can be marketed with claims of â&#x20AC;&#x153;long-termâ&#x20AC;? usage, an upgrade from their prior classification as temporary solutions. Traditional mini implants have a sharp, pointed apex to allow insertion in a socket not fully prepared to depth. These implants have gained popularity in part due to their relatively low cost compared to traditional implants from the major implant companies and because the narrow diameter encourages placement without laying a soft tissue flap. Both of these â&#x20AC;&#x153;simplifiedâ&#x20AC;? surgical procedures have risks and drawbacks that should be considered. Preparing a socket half the depth of the implant, and screwing in the pointed implant into unprepared bone will undoubtedly increase initial stability, but given the narrow diameter of mini implants, there is an increased risk of implant fracture if dense bone is encountered. 32 0TWSHU[ practice

Educational aims and objectives The aim of this article is to explore the clinical situations that necessitate the use of a narrow diameter implant. Expected outcomes Correctly answering the questions on page 35, worth 2 hours of CE, will demonstrate that the reader can: s 2ECOGNIZE THE DIFFERENCE BETWEEN DIFFERENT TYPES OF MINI IMPLANTS s 2EALIZE THE TYPES OF DENTAL ANATOMY THAT WOULD BEST BE TREATED WITH MINI IMPLANTS when an implant procedure is necessary. s %XPLAIN THE NECESSARY CONCEPTS TO FACILITATE PLACEMENT OF THE MINI IMPLANT

The alternative procedure if dense bone is encountered is to unscrew the implant, prepare the socket to its full depth, and re-insert the implant. Tapered implants with a rounded apex require preparation of the socket to full depth, giving the dentist the opportunity to determine the density of the bone. If soft bone is encountered, the tapered implant can be inserted into the undersized socket, expanding and compressing the bone for increased stability. If dense bone is encountered, the dentist follows up with a final sizing drill closer to the diameter of the implant, eliminating the need to remove the implant after insertion is initiated. Narrowing the apical end to a point reduces the strength of the implant compared to the same diameter implant with a rounded apex because of greater metal diameter in the lower half of the implant. A recent study published by CLINICIANS REPORTâ&#x201E;˘, Dr. Gordon Christensenâ&#x20AC;&#x2122;s research group, compared fracture strengths of the 3.0 mm and 3.7 mm GoDirect one-piece implants to commercially available 2.4 mm and 2.9 mm mini implants.1 Although there was only a 3.5% increase in diameter between the 2.9 mm and 3.0 mm implants, there was a 42% greater strength. The 3.7 mm GoDirect implant demonstrated 30% greater strength, which is more proportional

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Gerald Niznick, DMD, MDS, graduated from the University of Manitoba Dental School in 1966 and then earned a masterâ&#x20AC;&#x2122;s degree in prosthodontics at Indiana University in 1968. He has been awarded 36 U.S. patents and has received honorary doctorate degrees. He is president and CEO of Implant Direct. Contact him at: gniznick@implantdirect.com.

6OLUME .UMBER

Continuing education Strength Comparison as Measured by Break Force (Newtons)

Source: Gordon J. Christensenâ&#x20AC;&#x2122;s #,).)#)!.3 2%0/24 &EBRUARY

to the 23% increase in diameter compared to the 3.0 mm GoDirect. Wider implants also provide greater surface area, thereby reducing the number of implants needed to provide the same amount of load-carrying capabilities. The difference in diameter between 2.4 mm and 3.0 mm is only 0.6 mm/2 = 0.3 mm (0.012â&#x20AC;?) on each side, which is about the thickness of three human hairs, so the diameter of the osteotomy required to place each of these diameter implants is not significant, especially with tapered implants in soft bone. Mini implants gained popularity in part due to the belief that narrower implants better facilitated insertion without requiring a soft-tissue flap. This is a misconception because if the narrow implant was selected because of a narrow ridge, it is exceedingly unpredictable to blindly place an 6OLUME .UMBER

implant in the center of the narrow ridge without causing buccal or lingual perforations. On the other hand, if the ridge is wide enough to predictably place the implant flapless in the center of the ridge, a mini implant, if placed in the center of the ridge, would only engage cancellous bone. A 3.7 mm or wider implant would provide greater strength and stability in this situation, and fewer implants would be needed to achieve the same or even greater surface area for load support. A slight increase in implant diameter from 2.4 mm to 3.0 mm can also provide an adequate dimension as it emerges from the crest of the ridge, to provide a more natural emergence profile for cemented restorations and an adequate width for multi-unit (screw-retained) restorations. The decision to place an implant without laying a flap depends on the

clinicianâ&#x20AC;&#x2122;s ability to visualize the ridge width in order to determine adequate bone to support the implant. This can be accomplished by probing or by the use of a CT scan. Flapless surgical techniques in edentulous jaws are best done in combination with imageguided surgery, adding to the cost of the procedures, which obviates the savings that have perpetuated the use of mini implants. Once the decision is made to lay a flap and visualize the ridge width, narrow lower edentulous ridges can often be flattened to create adequate width to place a 3.7 mmD implant. The visualization allows placement in the center of the ridge without perforations or compromise to the labial or lingual cortical plates. In narrow maxillary ridges, laying a flap provides opportunities to surgically spread and widen the ridge before 0TWSHU[ practice 33

Continuing education

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implant placement, with or without bone grafting. A 3.0 mm, evenlytapered screw implant with a rounded apex can be inserted into an undersized osteotomy using only a 2.3 mmD drill, gradually expanding the cortical walls of the socket, compressing the soft bone, and increasing mechanical retention for initial stability.2 In the case shown, four 3.0 mmD, 13mmL GoDirect™ implants were placed freehand with a flapless surgery in a rather narrow ridge by a very experienced clinician. The X-ray reveals that there was more than adequate bone height to allow for removal of 4-6 mm of crestal bone to achieve a wider ridge since the symphysis widens towards it base. Visualization of the edentulous ridge would have 34 0TWSHU[ practice

assured optimum placement in the center of the modified ridge without risking compromise to the buccal or lingual cortical plates. These onepiece implants provide a cost-effective option for stabilizing overdentures, and with the launch of the 3.0 mmD with a pointed apex in the third quarter of 2012, will provide dental professions a full range of diameter and surgical options with this system. As can be seen in the X-ray, the GoDirect implant is internally threaded, allowing subsequent attachment of different abutment options if required for tissue overgrowth or a change of treatment options, such as conversion to a screw-receiving abutment. The GoDirect implant is not recommended for use in situations

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where the implants diverge more than 20-30 degrees. The GPS™ attachments are available with GPS™ abutments for a variety of popular implant platforms in both straight, 15, and 30 degrees. References 1. Successful use of mini implants: 2012. Gordon J. Christensen CLINICIANS REPORT. 5(2): 1-3. 2. Niznick, GA (2000). Achieving osseointegration in soft bone: the search for improved results. Oral Health: 27-32.

6OLUME .UMBER

Implant Practice US CE Certificate details

Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement 12/1/2010 to 11/30/2012 Provider ID# 325231

!"#$%&'()* REF: IP V5.3/NIZNICK

+,-%$)./01$'1/"2%2"* </=)20)%2"* +33$)00* >/1?@%A1'1)%'23%B/7%>"3)*

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Please allow 28 days for the issue of certificates to be posted.

One-piece, application-specific implants for treatment of narrow ridges 1. The term “mini implants” is generally attributed to implants with a diameter of _____or less, 2.4 mm, and 2.8 mm being the most popular diameter. a. 3 mm b. 4 mm c. 5 mm d. none of the above 2. Mini implants are available from many companies with either _____ abutment platforms for retention of overdentures. a. Ball b. ERA c. O-ring d. Either a, b, or c 3. Implants less than 3 mm have not received FDA pre-market approval for claims of being a permanent tooth replacement, although they can be marketed with claims of _____ usage, an upgrade from their prior classification as temporary solutions. a. “short-term” b. “intermediate term” c. “long-term” d. “simplified” 4. Traditional mini implants have a ______ to allow insertion in a socket not fully prepared to depth. a. tapered apex

b. sharp, pointed apex c. alternative socket d. wider diameter 5. Tapered implants with a rounded apex require preparation of the socket to full depth, giving the dentist the opportunity to determine the ____ of the bone. a. quality b. softness c. density d. health 6. If _____ is encountered, the tapered implant can be inserted into the undersized socket, expanding and compressing the bone for increased stability. a. soft tissue b. soft bone c. hard bone d. a narrow ridge 7. The decision to place an implant without laying a flap depends on the clinician’s ability to visualize the ridge width in order to determine adequate bone to support the implant. This can be accomplished by _____. a. a traditional 2D film X-ray b. probing c. use of a CT scan d. either b or c

8. Once the decision is made to lay a flap and visualize the ridge width, narrow lower edentulous ridges can often be ______to create adequate width to place a 3.7 mmD implant. a. flattened b. reinforced c. grafted d. restored 9. In narrow maxillary ridges, laying a flap provides opportunities to surgically ______ the ridge before implant placement, with or without bone grafting. a. reinforce b. spread c. widen d. both b and c 10. [In the case shown] Visualization of the edentulous ridge would have assured optimum placement in the _____of the modified ridge without risking compromise to the buccal or lingual cortical plates. a. center b. buccal aspect c. lingual aspect d. narrow part

0TWSHU[ practice 35

Paying subscribers turn to page 22 & 32 to earn your CE credits!

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Author guidelines

Guidelines for Authors 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 1525 illustrations. Manuscripts should be double-spaced, and all pages should be numbered. Implant Practice 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 of 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 learning 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. UÊ V ÕìÊ vÕ Ê > i]Ê >V>ì VÊ ì}ÀiiÃ]Ê and institutional affiliations and locations UÊ vÊ«ÀiÃi Ìi`Ê>ÃÊ«>ÀÌÊ vÊ>Ê iiÌ }]Ê« i>ÃiÊ 38 0TWSHU[ practice

state the name, date, and location of the meeting UÊ - ÕÀViÃÊ vÊ ÃÕ«« ÀÌÊ Ê Ì iÊ v À Ê vÊ grants, equipment, products, or drugs must be disclosed UÊ Õ Ê V Ì>VÌÊ `iÌ> ÃÊ v ÀÊ Ì iÊ corresponding author must be included UÊ - ÀÌÊ>ÕÌ ÀÊL UÊ ÕÌ ÀÊ i>`Ã Ì Pictures/images ÕÃÌÀ>Ì ÃÊ Ã Õ `Ê LiÊ V i>À ÞÊ `i Ì wi`]Ê 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). 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 must be submitted in Harvard ÃÌÞ i°Ê ÀÊiÝ> « i\ Greenwall, L (2000). Combining bleaching techniques. Aesthetic & Implant DentistryÊ££®\Ê Ó È

Disclosure of financial interest 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 >Ê º y VÌÊ vÊ ÌiÀiÃÌÊ iV >À>Ì »Ê form after their article is accepted. Any commercial or financial interest will be acknowledged in the article. 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 vÊÀi«À ÌÃÊ ÀÊ>`` Ì > Ê ÃÃÕiÃÊ>ÀiÊ`iÃ Ài`]Ê 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.

"ÀÊ ÊÌ iÊV>ÃiÊ vÊ>ÊL \ Greenwall L (2001). Bleaching Techniques in Restorative Dentistry: An Illustrated Guide°Ê >ÀÌ Ê Õ Ìâ\Ê ` ° 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: UÊ ÊV «ÞÊ vÊÌ iÊ > ÕÃVÀ «ÌÊ> `Êw}ÕÀiÃ]ÊÊ Ê including all pictures (low res) necessary for reviewers UÊ > ÕÃVÀ «Ì\Ê` ÕL i Ã«>Vi`Ê V Õ` }ÊÃi«>À>ÌiÊÊ references, figure legends and tables UÊ LÃÌÀ>VÌ]Ê i>À }Ê L iVÌ ÛiÃ]ÊiÝ«iVÌi`ÊÊ Ê outcomes paragraph UÊ ,iviÀi ViÃ\Ê` ÕL i Ã«>Vi`]Ê> « >LiÌ V> ]ÊÊ Ê Harvard style UÊ />L iÃ\ÊÌ Ì i`Ê> `ÊV Ìi`Ê ÊÌ iÊÌiÝÌ UÊ > `>Ì ÀÞÊÃÕL ÃÃ Êv À ]ÊÃ } i`ÊLÞÊ> ÊÊ authors Please contact Managing Editor Mali Schantz i `ÊÜ Ì Ê> ÞÊµÕiÃÌ ÃÊÛ >Êi > \Ê mali@medmarkaz.com Volume 5 Number 3

Research

U.S. and Canadian markets for dental implants and final abutments continue to show signs of recovery Dr. Kamran Zamanian and Jeff Wong, B.Sc, Senior Analyst, iData Research Inc., explore the economic factors that affect dental implants and abutments in the U.S. and Canada

he market for dental implants and final abutments also includes dental implant instrument kits and computer-guided software. This market is highly sensitive to economic trends as implant procedures are considerably more expensive compared to their alternatives. The sensitivity of the market was apparent during the economic crisis of 2008 and 2009, when global implant sales declined compared to the previous years. However, as the U.S. and Canadian economies began to recuperate in 2010, a recovery was exhibited by their dental implant and final abutment markets. Dental implants can be segmented by procedure type, connection type, shape, application, and size. The most common type sold in 2011 was two-stage, parallel-walled, internal connection implants used for single tooth restorations. Final abutments, which act as the interface between the dental implant and prosthesis, can also be segmented into different categories such as by fabrication process, material, and retention method. As the market continues to recover, the U.S. segment is expected to exceed $1.5 billion by the end of the forecast period. Furthermore, leading dental implant companies such as Nobel Biocare have utilized CAD/CAM technology to induce a shift in the unit share composition of abutment material types. U.S. dental implant and final abutment market to exceed $1.5 billion by 2018 The U.S. dental implant market includes not only implants but abutments, instrument kits, and computer-guided surgery products as well. The market was greatly affected by the economic recession of 2008 40 0TWSHU[ practice

and 2009, as it sent the dental implant market into a decline. During times of financial instability, patients are more likely to opt for more affordable alternatives such as bridges and dentures. As implant procedures are not considered necessary treatments, discretionary income often is spent elsewhere in such economic conditions. As the U.S. economy began to recover in 2010, the dental implant market followed suit, as more patients were once again able to afford the luxury of dental implants. In 2011, the overall U.S. dental implant market had grown by 5.2% from 2010. It is forecasted that through 2018, the market will grow rapidly to exceed $1.5 billion. An increasing demand for dental implants will automatically translate into sustained growth for the abutment, instrument kit, and computer-guided surgery markets too, as they are all highly correlated to dental implant demand. The increasing prevalence for implantology is derived from both the dentist and patient. As more dentists familiarize themselves with implant procedures, the availability of implant treatments increases. Furthermore, the more educated patients become aware of implant treatments, the more likely they are to choose those options. Of the forecasted $1.5 billion, dental implants will comprise the largest portion of the market. This will be due to the vast number of implant units sold by 2018, which is expected to be in the millions. Implants will be followed by final abutments, which will also experience high volumes of unit sales due to their range of applications. Mini implants will comprise the smallest market share, as it is mostly a niche market aimed primarily to be used with overdentures. However, as the

standard of care gradually shifts from conventional dentures to those retained by implants, the mini implant market is expected to experience double-digit growth. Nobel Biocare led the U.S. and Canadian dental implant and final abutment markets in 2011 Nobel Biocare, a pioneer in implant technology, led the U.S. and Canadian markets for dental implants and final abutments. Nobel Biocare is a market leader in the dental implant industry, with an offering of four different implant systems, including the NobelActive™, NobelSpeedy™, NobelReplace®, and the popular Brånemark System®. The latter has had over four decades of industry presence and an innumerable amount of scientific data to support the safety and success of its use. On the abutment side of the market, Nobel offers an array of temporary, final, and individualized CAD/CAM abutments. The company held leading market shares in both the implant and final abutment markets in both the U.S. and Canada in 2011. In addition to implants and abutments, Nobel’s leading share in these two markets also resulted in their leading share of the implant instrument kit market in 2011. As instrument kits are required for the placing of dental implants, the share of competitors in the implant market frequently coincides with their share in the instrument kit market. Furthermore, Nobel is a top and active competitor in the dental CAD/CAM market. By offering individualized prosthetic solutions via NobelProcera™, the company is able to utilize its strengths in each market to augment the other. Nobel’s individualized CAD/CAM abutments, Volume 5 Number 3

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I am the Zimmer® Trabecular Metal™ Dental Implant, the first dental implant to offer a mid-section with up to 80% porosity—and the ability to mimic size, shape and structure of cancellous bone. I harness the tried-and-true technology of Trabecular Metal Material, used by Zimmer Orthopedics for over a decade.... and I am Zimmer. Visit TrabecularMetal.zimmerdental.com to view product animations and request a Trabecular Metal Technology demo. www.zimmerdental.com ©2012 Zimmer Dental Inc. All rights reserved. Please check with a Zimmer Dental representative for availability and additional information.

Research Chart 1-2: Dental Implant Market, U.S., 2008 – 2018

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for example, are manufactured by Nobel Biocare and often paired with NobelProcera crown and bridges. Other prominent competitors in the U.S. and Canadian dental implant and final abutment markets include Straumann®, BIOMET 3i™, Zimmer Dental, and Astra Tech. Each competitor offers a unique set of products that market various advantages over competitive products. For example, Straumann’s Roxolid® and SLActive® market enhances osseointegration abilities through proprietary surface treatments. Through these unique offerings, competitors will continue to challenge Nobel Biocare’s position in the market. In July of 2011, Dentsply, another top competitor in the market, acquired Astra Tech from its mother company, AstraZeneca. With the addition of Astra Tech’s business, Dentsply is expected to exhibit a significant increase in market share for 2012. Ceramic final abutments to experience double-digit growth over forecast period The market for final abutments can be segmented in a variety of ways, including by material, type, or fabrication process. When analyzing the market by material, the final 42 0TWSHU[ practice

abutment market can be divided into three segments: titanium, ceramic, and gold. Titanium has traditionally been the material of choice for abutments due to its durability and biocompatibility. However, with an increasing demand for higher esthetics, the use of ceramic materials is gradually becoming more prevalent in both the U.S. and Canadian markets. Gold abutments, conversely, will continue to see a decline in unit sales–a trend that is primarily driven by the constant rise of pricing in the gold market. In 2011, ceramic abutments exhibited the highest level of growth at a rate of nearly 22% and 28% in the U.S. and Canada, respectively. In addition to the improved esthetic qualities over its counterparts, technological advancements in ceramic materials have also made ceramics as reliable as titanium. Among the different types of ceramics available, zirconia is the most widely used; however, alumina is also popular. Throughout the forecast period, the growth of ceramic abutment sales will continue to increase. A portion of growth in the ceramic abutment market will be cannibalized from the gold segment. As a result, the markets for gold abutments will be on a

steady decline throughout the forecast period in both the U.S. and Canada. However, due to a lower penetration rate of gold abutments in Canada, this market is expected to exhibit a decline to a lesser degree than in the U.S. By the end of the forecast period, gold abutments are forecasted to comprise less than 2% of all abutment units in both countries. Additional information is available The information contained in this article is taken from two detailed and comprehensive reports published by iData Research (www.idataresearch. net) entitled “U.S. Market for Dental Implants, Final Abutments and Computer Guided Surgery 2012” and “Canadian Market for Dental Implants, Final Abutments and Computer Guided Surgery 2012.” For more information and a free synopsis of the above reports, please contact iData Research at: dental@idataresearch.net iData Research is an international market research and consulting firm focused on providing market intelligence for the medical device, dental and pharmaceutical industries. Watch their short company movie at: http://www. idataresearch.net/discoveridata.html Volume 5 Number 3

Practice management

New school marketing made simple Ross Vera, consultant at Pride Institute, shows how updating your marketing strategy can make a world (wide web) of difference to your practice

n these challenging times, it is essential that every specialty and general practice focuses on creating new levels of awareness, engagement, and commitment with their referring providers, existing patients, potential new patients, and their medical/ dental community! According to the 2010 ADA Survey of Dental Practice, the dental industry as a whole has endured a decline of 9.1% over the previous several years, with specialists taking the most significant hit. So as an implantologist, you are likely to be intimately aware of this. What happened to the days where a lunch meeting actually resulted in a referral? Our clients have lost complete faith in traditional specialty marketing approaches. If you are a general practitioner, your ability to deliver a beautifully restored implant may exist in perpetual dormancy. The passive approach to growing your referral practice will no longer do. So, it’s back to the drawing board for those of you who are brave enough to invest your resources in your practice to focus on growth. Tried and true internal marketing will always make a difference. Referring dentists and allied health care professionals cannot be ignored. And “new school” online marketing and social media strategies are absolutely essential elements to continuous improvement in 2012 and beyond. In short, the latest marketing strategies provide you with a blueprint to create new levels of awareness, relationships, and conversion. Learn and assimilate these new skills and tools, to market your practice effectively and thrive. Choose not to, and struggle. Social media–old principles, new models Acquiring new patients by referral from existing patients continues by far to be the most cost-effective and easiest way of growing your practice. The Social Media Age doesn’t change this one bit! In fact, it magnifies the equation. And if you think that as a referral practice, “existing” patients don’t truly exist, think again! If you make an impact, positive or negative, it may be echoed throughout the Internet. Word of mouth has now become world of mouth! You know the basic premise: a referral is a genuine testament to how much your patients value your practice. Patients recommend your practice to others when their clinical and customer-service expectations have been met and exceeded. Patients who act as referrers to your practice are, in fact, your ambassadors–your raving fans! In the old days, I would tell my wife, my buddy, and probably a co-worker or two. Now, I can tell approximately 359 people in the blink of an eye! Now that’s an ambassador on steroids! Tweeting for dollars The primary objective of the entire team is still to create raving fans who constantly recommend you to their loved ones. But now, they will also “Yelp,” “Tweet,” and submit online reviews, which will drive more new patient prospects to you in far greater numbers. Because of 44 0TWSHU[ practice

Ross Vera has 15 years of experience in dental practice management and serves as a consultant at Pride Institute in San Francisco, California. He specializes in leadership, human resources, and specialty dental practice building. He can be reached via email at rossv@prideinstitute.com.

Volume 5 Number 3

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Practice management the new social media component, the verbal skills necessary to engage your patient ambassadors is fundamentally different. It has always been about a great experience for the patient, which doesn’t change. What does change, is the formerly shotgun approach of asking every patient for a referral following a compliment about the practice. Don’t misunderstand, that’s still important. But what needs to be added to the standard referral is your team’s ability to identify and engage the powerful social butterflies of the web world. These are the individuals who take enormous pride in the size of their personal Internet fiefdoms (Facebook, Yelp, and Twitter) and pledge to pass on the secrets of living the good life to their subjects. No joke! Each and every digital pronouncement about a great experience is a plea for social validation, something we all crave. If you don’t believe me, go to www. pinterest.com, a virtual corkboard whose tag line is “Organize and Share the Things You Love.” So how do we encourage our patients to pass on their great experience to others? By asking! Here is how: Let’s say a patient compliments a member of the team. We could say: “Thank you so much for telling me that! You know, we love getting compliments from our patients; it really makes our day. We also love it when our patients shout it from the rooftops by posting those compliments online! Would you be willing to post this compliment on our Google or Yelp profile? I can even send you the link and type up what you said to make it really easy for you.” If you are wondering, you are correct. Some patients will say no. That should not stop you. At Pride Institute, we routinely coach our teams to steadily build their online review bank, and it works! Referral relationships–something old, something new The Social Media Age continues to present paradigm shifts to all businesses, including ours. But beneath these shifts, traditional laws continue to operate. So why do referring dentists and allied professionals refer? 46 0TWSHU[ practice

This is straightforward. The thinking is “If you can do something well that I don’t know how to do well or don’t like to do, I may refer to you. If you can make life easier for me, I may refer to you. If my patients like you, and you make me look good for referring them to you, I may refer to you. But if you violate any of the above, I probably won’t refer to you.” Superimposing the new world of Internet and social media, the law operates in augmented fashion. Historically, most of the proof source of the criteria above was demonstrated through conventional methods like mailed X-rays and individual patient word of mouth. Now, a referring dentist can easily go to Yelp and learn that a patient thought the specialist’s team was rude or the dentist, “doesn’t give a damn about anything but money.” That’s a real review excerpt! Do you think the referrer will be nervous about referring? Consider it for a minute. How can I, knowing that my patients read sites like Yelp, send my patients to providers with scorching, negative reviews right out there in the open? It’s a huge dilemma! Fortunately, the converse is that your Google review page may be flooded by four and five star reviews saying all of the positive things that the referring dentist wants his patients to feel about his referral choice. Do you think you could use that data to your advantage in your personal communications with your referring doctors? Would it carry weight in your newsletter? Would it look good in your direct marketing campaign or your new patient packet? You bet it would! Again, the key is to create a remarkably positive experience for your patients. But to go “out-of-thebox” just a bit, you can engender good will among your referring providers by asking your patients to generate positive reviews for them. Simply repurpose the script above and send a link with instructions for posting on their Yelp, Dr. Oogle, or Doctor Base page. Finally, don’t forget to notify the practice that they received a compliment, and you supported them by requesting a stellar online review.

starts with your primary source of real estate in your online community–your website! A website is a key component of any dental practice marketing plan. Admittedly, it is almost a cliché at this point, which is sad. Previously no more than an online brochure, your website can now position you to recruit patients, internally market your practice more effectively, invite testimonials, and create interactive engaging experiences with all who click on your site. It’s a 24-hour virtual community that enhances relationships with existing patients, referring practices, and potential new patients. What most dentists don’t understand is that search engines like Google host web-wide competitions for websites and businesses to duke it out for the attention of consumers. If your website is your real estate in a virtual community, your neighborhood is how you place when someone does a “dental implant” search. The art of search placement is called Search Engine Optimization (SEO)[organic] and Search Engine Marketing (SEM) [pay per click]. Google will reward those whose websites know best how to play the game. If you have the right trainers (hosting company, site designers, consultants, etc), your website can stand atop the online search rankings, ready to seize the next patient who comes along looking for an implant. And that’s just the beginning. So get off of the ropes, get solid trainers, and get in the game! So if everyone agrees that marketing is vital for growth in 2012 and that new school solutions offer the biggest, most immediate return on resource investment, then let the action planning begin! Start with your internal marketing, followed by the website, SEO/SEM strategies and head straight into the wonderful world of social media. If you aren’t confident in how to approach your plan–use your experts wisely. We’ve heard it for a while now, but word is, the economy is rebounding. Stake out your territory now, so you aren’t left behind!

Un-real estate–websites matter So, if you are ready to begin to put your toes in the waters of social media strategies, where do you begin? It all Volume 5 Number 3

3D dialogue

Using software for implant planning and implementation While 3D scans offer greater information for implant planning, Dr. Steven Guttenberg notes that the proper software makes the entire process even more precise The theme of this issue on mini and skinny implants brings to mind the many choices that implantologists have when choosing the appropriate implant of any size for individual patients. In last issue’s column, I addressed how having the CBCT scan itself facilitates precise diagnosis and treatment planning. Using the scan to the best advantage of the dentist and the patient is the next step. This entails using specialized software that helps to implement treatment as well. A relatively new software, Tx STUDIO™, is exclusive to the CBCT system (i-CAT®) that I use. Easily accessed directly through the i-CAT, I use this software to visualize the implant site in a more realistic way, so that I can fully evaluate the implant receptor site from all anatomic aspects. I can slice the high resolution 3D volume for extremely accurate measurements of bone thickness and density and location of the inferior alveolar nerve and the maxillary sinuses. One of the best features of Tx STUDIO software is the comprehensive implant library. Whether I will be using single or multiple implants, I can select an implant from the library and place it virtually into the 3D image. With all of the possibilities for implant size, location, type, and angulation, having the opportunity to plan using the exact implant for the patient before surgery is invaluable. Once I virtually place the implant in the jaw, I can view the 3D model in a skeletal view, from an axial, cross-sectional or sagittal viewpoint. This truly allows me to choose and place the most appropriate implant. I can precisely identify and locate the inferior alveolar nerve canal and then virtually “draw” it into the Volume 5 Number 3

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image in three dimensions to evaluate its position relative to the implant. In the restoration design mode, besides placing the implant, I can also plan the abutment and final restoration before starting treatment. Knowing the next step during every part of the process gives me and the patient confidence that this procedure will have a positive outcome. Besides giving me all of this

important information before picking up my scalpel, I can also educate my patients more easily with the aid of the CBCT scan and this software. The patient can see the implant in relation to the bone, adjacent teeth, sinuses and nerves. Seeing all of these details on their own scan results in a much greater understanding than they would get if they viewed a generic video or brochure. 0TWSHU[ practice 47

3D dialogue These images illustrate how having specialized software such as Tx STUDIO adds vital information and helpful guidance to the implant experience for both the clinician and the patient. Once again, I encourage and invite Implant Practice US readers to share comments with me. I will try to address any questions in future columns.

Steven Guttenberg, DDS, MD, is an oral and maxillofacial surgeon practicing in Washington, D.C., where he is director of the Washington Institute for Mouth, Face and Jaw Surgery. He is a diplomate of the American Board of Oral and Maxillofacial Surgery and a fellow of the American Association of Oral and Maxillofacial Surgeons and of the American College of Oral and Maxillofacial Surgeons, of which he is currently the past-president. Dr. Guttenberg teaches at the Washington Hospital Center and is the chairman of its Oral and Maxillofacial Surgery Residency Training and Education Committee. He frequently lectures nationally and abroad. Dr. Guttenbergâ&#x20AC;&#x2122;s numerous scientific articles and book chapters have been published in dental and medical literature. He is the editor of a new textbook entitled Cosmesis of the Mouth, Face and Jaws in which several chapters are devoted to dental esthetics and implants. The book provides a unique, whole-face approach to cosmetic procedures, focusing on oral, facial and gnathic components.

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If you have a question regarding 3D imaging that you want Dr. Guttenberg to address in a future column, please email: 3DDialogue@implantpracticeus.com.

For more information on how 3D imaging can improve your practice, please fax this information to (480) 629-4002, visit www.implantpracticeus.com/web/imagingsciences.html to submit this form online, or mail this form to: Implant Practice US | 15720 N. Greenway Hayden Loop #9 | Scottsdale, AZ 85260. Check more than one, if interested.

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Volume 5 Number 3

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Available exclusively through

Product profile A new generation of small diameter soft tissue level implant Straumann® Narrow Neck CrossFit® Standard Plus Implant

t the 27th Annual Academy of Osseointegration Meeting in Phoenix, Arizona, Straumann® introduced the Ø 3.3 mm Narrow Neck CrossFit® Standard Plus Soft Tissue Level Implant (NNC), now available in the U.S., Europe and Australia. Combining the high fatigue strength1 of Straumann’s Roxolid® material, the SLActive® surface that accelerates the osseointegration process,2 and the self-guiding CrossFit® connection, NNC is designed to provide excellent treatment outcomes in challenging treatment situations3 where space or bone is limited. Confidence when placing small diameter implants Small diameter implants are designed for placement in limited interdental spaces or narrow bone ridges and recommended for use in single-unit, multiple-unit, and fully edentulous situations3. The Roxolid® material has been the key to the development of NNC. Its high fatigue strength1 allowed for the development of a small diameter implant with an internal connection, while the SLActive® implant surface—one of the most investigated implant surfaces on the market with a multitude of studies providing scientific evidence to support its hydrophilic properties4— accelerates the osseointegration process2 and helps provide predictability in implant treatment. Wide range of treatment options The NNC offers comprehensive prosthetic options due to its narrow Ø 3.5 mm prosthetic platform with internal connection to include screw-retained and cement-retained restorations and your choice of implant-level or abutment-level impression workflow. The new implant has been integrated into Straumann’s Dental Implant System, which includes a full range of Soft Tissue and Bone Level options and requires only one surgical kit. Simplicity in daily use The self-guiding CrossFit® connection at soft-tissue level guides the abutment 50 0TWSHU[ practice

precisely into the correct position, offering improved prosthetic flexibility and optimized abutment insertion,5 while the New Transfer Piece with its snap-fit connection to implant and no need for use of a holding key simplifies handling during surgical placement. This Soft Tissue Level implant is designed to save time and increase efficiency in the dental practice. Innovative solutions Straumann is a pioneer of innovative solutions for implant dentistry, including the introduction of the SLA® surface in 1998, the revolutionary SLActive® surface in 2006, and the technologically advanced Roxolid® implant material in 2009. Now, 2012 heralds a new generation of small diameter tissue-level implant, thanks to the innovation and combination of Straumann’s innovative technologies, designs, and materials. The Roxolid® material The combination of the Roxolid® material and the SLActive® surface are designed to address the challenge of reduced surface area for osseointegration and the increased risk for implant fracture in cases where there is reduced availability of alveolar ridge width or interdental space. The first human study showing performance and tolerability of Roxolid® implants over 2 years showed that Roxolid® combines high implant stability and good osseointegration properties while still retaining adequate mechanical strength with a reduced implant diameter6 to give the clinician confidence when treating areas of limited space. This information was provided by Straumann USA.

About Straumann USA Straumann is a leading provider of solutions in implant dentistry and dental tissue regeneration. Its mission is to enable dental professionals to restore their patients’ oral function and esthetics through effective, reliable, and safe treatment methods. Straumann USA, LLC, located in Andover, Massachusetts, is the U.S. subsidiary of Straumann Holding, headquartered in Basel, Switzerland. As the largest dental implant company in the world, the Straumann Group of companies has an active presence in more than 50 countries.

References 1. Fatigue strength according to ISO 14801 internal tests, data on file (B679A/B567A). 2. Compared to SLA in an animal model. 3. Small diameter implants are not recommended for use in the molar region. 4. Straumann SLActive Scientific Evidence Brochure, 2011 (USLIT196). 5. Compared to Straumann Narrow Neck Implant. 6. Barter S, Stone P, Brägger U (2011). A pilot study to evaluate the success and survival rate of titanium-zirconium implants in partially edentulous patients: Results after 24 months follow-up. Clin Oral Implants Res. [Epub ahead of print]. Volume 5 Number 3

CONFIDENCE IN LIMITED SPACE STRAUMANN ® NARROW NECK CrossFit ® The Straumann Soft Tissue Level solution to address space limitations Confidence when placing small diameter implants

Wide range of treatment options

OSSEOIN OF TE TION RA G

!* ·

® oxolid ann R

Straum

· THE FU SIO

Simplicity in daily use

N AT E RIA L STR E

Please contact us at 800/448 8168. More information on www.straumann.us

*Fatique Strength according to ISO 14801 internal tests. Data on File (B679A/B567A)

Product profile

spotlights its small-diameter implant systems

MDL® - Mini Drive-Lock Intra-Lock’s MDL® small-diameter dental implant system is thoughtfully engineered to provide ergonomic efficiency, prosthetic versatility, and tissue compatibility for superior denture stability. The implants, available in 2.0 and 2.5 mm diameters, are profiled for strength, stability, and ease of insertion. They feature patented Drive-Lock™ technology that optimizes single motion delivery, from pick-up to placement. Intra-Lock’s MDL® implants are the only small diameter implants in the world that have the bioactive OSSEAN™ surface.

MILO®- multifunctional one-piece 3.0 mm implant MILO® is Intra-Lock’s one-piece 3.0 mm diameter dental implant system. Engineered as a true “convertible” small diameter implant, it is endowed with qualities that render it ideal for long-term denture stabilization or fixed-prosthetic options. Patented Cement-Over Abutments™ available in straight, 15 degree, wide and castable designs simply fit over the O-Ball assembly, converting the implant from removable to fixed-prosthetic options. As with MDL® Implants, MILO® implants feature Drive-Lock™ technology for mountless, efficient placement, and they have the bioactive OSSEAN™ surface.

For more information, visit www.intra-lock.com or call 877-330-0338. This information was provided by Intra-Lock International.

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Volume 5 Number 3

CE listings

Dates for your diary Canadian Association of Oral & Maxillofacial Surgeons

Pacific Northwest Dental Conference

May 23â&#x20AC;&#x201C;27, 2012 Banff, AB www.zimmerdental.com

June 14-16, 2012 Seattle, WA www.tulsadentalspecialties.com

Journees Dentaires Internationales

Pacific Coast Society for Prosthodontics

May 28-29, 2012 Montreal, QC www.zimmerdental.com

Introducing Implants in a Complex Economy I

June 20-23, 2012 Victoria, BC www.tulsadentalspecialties.com

Virginia State Dental Meeting

June 2, 2012 Columbus, OH www.ocobiomedical.com

2012 WSOMS Annual Meeting In conjunction with the Washington State Society of Oral and Maxillofacial Surgeons

Solutions for Advanced Surgical Procedures II

July 21-24, 2012 Suncadia Resort Cle Elum, WA www.wsoms.org

Academy Of General Dentistry Annual Meeting

June 9-10, 2012 San Antonio, TX www.ocobiomedical.com

Indiana State Dental Meeting

Garden State Dental Conference and Expo

Introducing Implants in a Complex Economy I June 16, 2012 Salt Lake City, UT www.ocobiomedical.com

Introducing Implants in a Complex Economy I June 23, 2012 Albuquerque, NM www.ocobiomedical.com

Introducing Implants in a Complex Economy I July 14, 2012 Denver, CO www.ocobiomedical.com

Florida National Dental Convention June 14-16, 2012 Orlando, FL www.tulsadentalspecialties.com

June 7-8, 2012 www.planmecausa.com

Indian Health Service National Meeting June 13-15, 2012 www.planmecausa.com

June 14-16, 2012 www.planmecausa.com

June 21-23, 2012 www.planmecausa.com

June 22-23, 2012 www.planmecausa.com

Multi-Cultural Oral Health Summit (NDA) July 21-22, 2012 www.planmecausa.com

New Mexico Dental Association Annual Meeting June 14-15, 2012 www.planmecausa.com

Florida National Dental Conference June 14-16, 2012 www.planmecausa.com

Alabama State Dental Meeting June 14-16, 2012 www.planmecausa.com

Pacific Northwest Dental Conference June 14-15, 2012 www.planmecausa.com

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Volume 5 Number 3

THE SYNTHETIC SOLUTION TO BONE REGENERATION

A B C

NOVABONE DENTAL PUTTY CARTRIDGE SYSTEM NA3620 ........... 0.5cc Cartridges....................... 2/pkg $225.00 NA3640 ........... 0.5cc Cartridges....................... 4/pkg 430.00 NA3621 ........... 1.0cc Cartridges....................... 2/pkg 410.00 NA3600 ........... Cartridge Dispenser...................... each 99.99 NOVABONE DENTAL PUTTY SYRINGE NA1610 .......... 0.5cc Syringe .........................1/Pack $105.00 NA1611 .......... 1.0cc Syringe .........................1/Pack 190.00 NA1612 ........... 2.0cc Syringe .........................1/Pack 335.00 NOVABONE DENTAL PUTTY CLAM SHELL NA0610 .......... 0.5cc Shell ............................1/Pack $90.00 NA0660 .......... 0.5cc Shell.............................6/Pack 439.49 NA0611 .......... 1.0cc Shell.............................1/Pack 170.00 NA0622 ........... 1.5cc Shell.............................2/Pack 391.99

NOVABONE速 is the only dental bone graft putty that is completely synthetic with excellent and reliable bone formation characteristics. It is indicated primarily for implant related surgeries including but not limited to sinus elevation surgeries, extraction sockets, ridge augmentations, etc. Putty does not require mixing as it is dispensed in a pre-mixed state ready for implantation! NovaBone Dental Putty is available in multiple delivery mechanisms including syringes, shells & cartridges. The consistency and formulation of the putty is identical in the various delivery systems. Limited Time FREE PRODUCT Offers Buy a Cartridge 4-pack get 1 NA0610 FREE! 1 FREE Dispenser with initial cartridge purchase.

For more information, visit ACE Surgical Supply

www.acesurgical.com

All offers expire April 30th 2012.

or call us today

800.441.3100

Materials & equipment The miniMARK™ Implant System-minimum size, maximum ease Now it’s possible to offer reliable, affordable, predictable miniature implants to denture wearers, right in the dental office. The miniMARK™ Miniature Dental Implant System, precision engineered by ACE Surgical Supply, features the renowned Locator® Attachment by Zest Anchors. With the miniMARK™ System, patients can be cared for easily and comfortably, in the familiar surroundings of the dental office they’re used to. With this miniature implant, the dentist can restore dental function with a standard, minimally invasive procedure. No longer will it be necessary to refer denture wearers out of their practice. ACE has offered technical advances to the dental specialty market for over 40 years, earning a solid reputation for quality products, reliable service, and commitment to customer support. This advance, the miniMark™ System, offers a restorative dental solution that both dentists and patients can count on. For more information, visit ACE Surgical Supply at www.acesurgical.com, email to info@acesurgical.com, or call 800-441-3100.

BondBone™—innovative bonding graft material BondBoneTM is a resorbable, osteoconductive, bioactive bone grafting material taking the best qualities of hemihydrates and dihydrate calcium sulfate and combining them into a unique product. It is the only pure calcium sulfate graft material that can set in 3-5 minutes in the presence of blood and saliva. When used on its own, BondBoneTM is a highly effective material for small bony defects such as extraction sites. When combined with other granular bone augmentation products, BondBoneTM increases their binding properties, volume and effectiveness as bone grafts. Its optimal properties facilitate a bone regeneration process that contributes to the success of future implant procedures. For more information, please visit, www.misimplants.com or call 866-797-1333

Softech, Inc. releases DenChart™ Restorative For Windows

Zimmer Dental offers best of both worlds with cortical-cancellous mix

Softech, Inc., the developer of DENTECH Practice Management Software, has released DenChart™ Restorative for Windows users.

Zimmer Dental Inc., a leading provider of dental oral rehabilitation products and a subsidiary of Zimmer Holdings, Inc., has announced the availability of Puros® Cortico-Cancellous Particulate Allograft, an anatomic-based mixture of cortical and cancellous bone, designed to provide clinicians with the best of both worlds in an effort to simplify the grafting process.

Some DenChart Restorative features include: r 6UL JSPJR PTHNL HJJLZZ ^OPJO HSSV^Z [OL WYHJ[P[PVULY [V ]PL^ one or all images associated with the patient while in the patient’s chart. r :PKL I` :PKL ;YLH[TLU[ WSHU ZPTWSPÊLZ [OL JVU]LYZH[PVU between the doctor and the patient. r (\[V *OHY[ 7H[PLU[ /PZ[VY` HSSV^Z [OL KLU[PZ[ [V H\[VTH[PJHSS` pull a complete patient history from most practice management systems into DenChart.

For more information regarding this regenerative option, contact a Zimmer Dental Sales Consultant or Customer Service at (800) 854-7019, or visit www. zimmerdental.com.

DenChart Restorative for Windows can be purchased by calling a Softech representative at (800) 233-4998 ext. 239.

3M ESPE—MDI seminars

system

and

For more than a decade, 3M ESPE’s (formerly IMTEC) MDI Minimally Invasive Implant System has been enabling dentists to offer a solution for patients who may be contraindicated for conventional implant treatment. The MDI system consists of one-piece titanium alloy implants in diameters of 1.8 mm, 2.1 mm, 2.4 mm and 2.9 mm at lengths of 10 mm, 13 mm, 15 mm and 18 mm, coupled with complete restorative system of parts for both denture and crown and bridge indications. The minimally invasive MDI procedure can be learned in a one-day certification seminar, where experienced clinicians teach the responsible indications that make this system such a powerful and profitable tool. Learn more about MDI training courses at www.3MESPE.com/ ImplantSeminars or call 800-634-2249 to learn whether small diameter implants might be something to consider implementing in the dental practice.

56 0TWSHU[ practice

ACTEON, North America releases new Essential Tip Kit for the Piezotome 2 (*;,65 5VY[O (TLYPJH has introduced a new set of ultrasonic tips for the Piezotome 2, Implant Center 2 LED, and Piezotome Solo LED devices for piezoelectric osseous surgery. The Essential Kit includes six of the most popular tips for the Piezotome that can be used for a variety of procedures such as sinus lifts, tooth extraction, and bone block grafting during pre-implant bone surgery. The ultrasonic frequency of Piezotome makes the instruments active only on bone so there is reduced risk of damaging delicate structures such as gingiva and nerves. These uniquely designed tips can only be powered by Piezotome [LJOUVSVN` L_JS\ZP]LS` MYVT (*;,65 7SLHZL JVU[HJ[ `V\Y SVJHS KLHSLY VY (*;,65 MVY TVYL PUMVYTH[PVU I` LTHPSPUN 0UMV' us.acteongroup.com, calling 800-289-6367 or visiting the website www.us.acteongroup.com.

Volume 5 Number 3

CLINICAL VERSATILITY DEFINED

ProMax®

3D Mid

2D / 3D FUSION • 3D, Panoramic, Ceph, 2D Extraoral Bitewing, and more in one unit to meet your clinical needs • Widest range of volume sizes available from single impaction to a ø16 x 16 cm • High resolution, low dose limits excess radiation

VERSATILITY • Adjustable KV and MA • Pediatric Mode • Works natively in MAC OS environment • Provides volume sizes for every clinical application • Cephalometric upgrade available

EASE OF USE • Fully intregratable with 3rd party software • Comes with a complete software system for diagnosis • SmartPan for intelligent panoramic imaging

PLANMECA® ProMax 3D Mid ®

For a free in office consultation please call

1-855-245-2908 or visit us on the web @ www.planmecausa.com

GPS Attachment Pat. Pend.

Leading the Way GPS® with Internal Connection

- Retention Initially Retained when Tipped 10° - Vertical Resiliency for Less Stress on Implant

100%

Unlike GPS Internal Attachment, Zest's LOCATOR® initially loses 27% of its retention when tipped 10° 1

GPS® Overdenture Attachment System

73%

New Internal Cap Attachment with Added Advantages External Retention

Internal Retention

Pink Anodized Titanium Cap with increased retention in denture base

Maintains greater % of initial retention over the first year in function than Zest’s LOCATOR® Attachment (Insertion at 0° for 1200 cycles1)

Black Processing Cap made from high melting point plastic Abutment inserted with standard insertion tools for each system

Internal cavity of abutment allows for increased vertical resiliency with occlusal loading Titanium & nylon cap rotate together eliminating cavity for plaque and debris present with Zest’s LOCATOR Attachment

Straight Abutment with Cap Attachment, Transfer, Spacer & Comfort Cap: $100

Zimmer: $166; Straumann: $195 Nobel Biocare: $149, Zest Anchors Co: $156

GPS® Internal

LOCATOR® Dual Retention

Only GPS offers 15° & 30° Angled Abutments with LOCATOR®-compatible platforms Rated “Excellent” for “Tolerance of Non-Parallelism” in an Independent Report - Gordon J. Christensen CLINICIANS REPORT, November 2011

15° relative divergence

30° Distally inclined

15° relative divergence

15° Labially inclined

GoDirect® implants 60° relative divergence

GPS angled abutments accommodate the greatest degree of relative divergence available on the market Straight and angled GPS abutments are available for: NobelReplace, NobelActive, Straumann Tissue Level, Zimmer’s Screw-Vent, BioHorizons®, MIS & Blue Sky Bio GoDirect® 1-piece implants with LOCATOR®-compatible platform. $150 includes transfer and comfort cap. Internal threads allow for attachment of multi-unit abutment to convert treatment to fixed prosthesis. Watch “All-over-4” 3D Graphic Video GPS angled abutments combined with GoDirect implants provide an economical solution for treating edentulous jaws.

www.implantdirect.com | 888-649-6425 Data on file regarding GPS Internal and Zest Anchor’s LOCATOR attachment with dual retention. LOCATOR® is a registered trademark of Zest Anchors Company. The GoDirect® and GPS® Systems are neither authorized, endorsed, nor sponsored by Zest Anchors Company. Price comparisons based upon US list prices as of February 2012. All trademarks are the property of their respective companies. 1