Implant Practice US - August/September 2013 - Vol 6 No 4 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews August/September 2013 – Vol 6 No 4

PROMOTING EXCELLENCE IN IMPLANTOLOGY

Corporate profile Henry Schein Dental Surgical Solutions

Minimally invasive crestal approach technique for sinus elevation Drs. Ziv Mazor, Andreas Ioannou, Narayan Venkataraman, George Kotsakis, and Udatta Kher

Practice profile Dr. David Feinerman

PAYING SUBSCRIBERS EARN 24 CONTINUING EDUCATION CREDITS PER YEAR!

The evolution and advancement of dental implants Drs. Robert J. Miller and Randi J. Korn

Treatment planning of implants in the esthetic zone: part three Drs. Sajid Jivraj, Mamaly Reshad, and Winston Chee

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EDITORIAL ADVISORS Steve Barter BDS, MSurgDent RCS Anthony Bendkowski BDS, LDS RCS, MFGDP, DipDSed, DPDS, MsurgDent Philip Bennett BDS, LDS RCS, FICOI Stephen Byfield BDS, MFGDP, FICD Sanjay Chopra BDS Andrew Dawood BDS, MSc, MRD RCS Professor Nikolaos Donos DDS, MS, PhD Abid Faqir BDS, MFDS RCS, MSc (MedSci) Koray Feran BDS, MSC, LDS RCS, FDS RCS Philip Freiburger BDS, MFGDP (UK) Jeffrey Ganeles, DMD, FACD Mark Hamburger BDS, BChD Mark Haswell BDS, MSc Gareth Jenkins BDS, FDS RCS, MScD Stephen Jones BDS, MSc, MGDS RCS, MRD RCS Gregori M. Kurtzman, DDS Jonathan Lack DDS, CertPerio, FCDS Samuel Lee, DDS David Little DDS Andrew Moore BDS, Dip Imp Dent RCS Ara Nazarian DDS Ken Nicholson BDS, MSc Michael R. Norton BDS, FDS RCS(ed) Rob Oretti BDS, MGDS RCS Christopher Orr BDS, BSc Fazeela Khan-Osborne BDS, LDS RCS, BSc, MSc Jay B. Reznick DMD, MD Nigel Saynor BDS Malcolm Schaller BDS Ashok Sethi BDS, DGDP, MGDS RCS, DUI Harry Shiers BDS, MSc, MGDS, MFDS Harris Sidelsky BDS, LDS RCS, MSc Paul Tipton BDS, MSc, DGDP(UK) Clive Waterman BDS, MDc, DGDP (UK) Peter Young BDS, PhD Brian T. Young DDS, MS CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day BDS, VT Julian English BA (Hons), editorial director FMC Dr. Paul Langmaid CBE, BDS, ex chief dental officer to the Government for Wales Dr. Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-in-chief Private Dentistry Dr. Chris Potts BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin Dr. Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral implant surgeon

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Volume 6 Number 4

This is no longer your father’s implant dentistry!

he axiom “I placed the implant where the bone was” is a dated concept in implant dentistry today and no longer accepted as the “norm.” Osseous grafting has become an integral part of implant treatment, allowing ideal implant placement without the compromises we accepted in the past related to where the residual bone remained. Practitioners who have been involved with implant treatment, both surgically and restoratively for 20 or more years have witnessed the evolution afforded by advances in creating bone where is it needed so that the fixtures can be placed where restorative demands dictate. It has been long preached that implant dentistry is a restorative treatment with a surgical component. In the past due to resorptive patterns, restoratively we had to compromise in some patients where the fixtures could be placed. This often forced compromises in the esthetic results or created challenges to home hygiene care for the patient. Advances in grafting materials and techniques permit a true restorative-driven treatment resulting in ideal placement of the fixtures regardless of where the bone lies prior to treatment. Predictability was not always the word associated with oral osseous grafting. Early endeavors using rib, tibia, hip, and other areas distant from the oral cavity resulted in mixed results, often demonstrating resorption of the host graft over time and postoperative issues (i.e., discomfort) at the donor site. Yet, what “goes around comes around.” Philip Boyne, one of the early pioneers (1970s) in the use of titanium mesh as a cage to contain graft materials at the host site, has seen his concepts generally embraced with the advances in grafting materials. Titanium mesh is available from multiple manufacturers, pre-shaped to the different regions of the arch that can be placed either with or without simultaneous fixture placement, allowing the graft to be undisturbed until integration has occurred to the underlaying bed. The sinus augmentation techniques of Hilt Tatum, also from the 1970s, have seen new light with embracing of his pioneering approach of crestal-driven augmentation. Simpler, easier, more predictable crestal sinus augmentation has opened the door to more practitioners being able to provide this service and allow implant placement in the deficient posterior maxilla, as well as providing the patient with a less traumatic approach to improving bone height in this region of the mouth. We have also witnessed remarkable improvements in the osseous graft materials themselves. The demineralized bottled bone allograft materials that were the standard years ago have been replaced by materials that are better processed and engineered to direct bone growth (osseoconductive) and stimulate bone growth (osseoinductive), and provide improved handling. Bovine osseous products continue to be utilized, but synthetic osseous grafting materials have evolved to provide grafts that are completely replaced by native host bone leaving no remnants behind following healing of the site. Bone morphogenic proteins (BMP) provided from select companies, along with factors derived from the patient’s own plasma, are helping us better engineer our grafts providing better quality results in less time. Additionally, “putty” forms of osseous graft materials available, both alloplastic and synthetic, allow improved ease of placement without unwanted distribution of the graft material beyond the site, and shaping of the graft to the dimensions of the desired ridge at placement. This circumvents the issues associated with granular graft materials that had been accepted yet undesired. CBCT has opened new frontiers permitting better evaluation of osseous structure and related anatomical features. The CAD/CAM-derived surgical stents from the 3D planning allow the restorative team to determine where the coronal portion of the restoration needs to be placed and where bone may need to be created to accomplish those restorative goals. Today, implant dentistry is truly a restoratively-driven treatment modality allowing us to replicate what Mother Nature had originally provided the patient.

Gregori M. Kurtzman DDS, MAGD, FACD, FPFA, FADI, DICOI, DADIA

Implant practice 1

INTRODUCTION

August/September 2013 - Volume 6 Number 4

TABLE OF CONTENTS

Case study An advanced mini dental implant case: 25 extractions and insertion of 15 MDIs for a

Practice profile

Dr. David Feinerman: Communication, attention to detail, and hard work This clinician strives to balance a full-scope oral and maxillofacial surgery practice and family fun.

quadriplegic patient Dr. M. Dean Wright uses MDIs to treat a challenging case............... 14 Adjunctive laser treatment in extraction/immediate implant placement Dr. Robert J. Miller discusses technology that is changing the face of implants at the speed of light... 18

Clinical Minimally invasive crestal approach technique for sinus elevation utilizing a cartridge

Corporate profile

Henry Schein Dental Surgical Solutions From cotton rolls to cone beams, this new division is a one-stop shop for the specialty practice.

2 Implant practice

delivery system Drs. Ziv Mazor, Andreas Ioannou, Narayan Venkataraman, George Kotsakis, and Udatta Kher delve into ways to overcome insufficient vertical bone height in the posterior maxilla in conjunction with maxillary sinus lift....................................... 20 An affordable overdenture option for an edentulous ridge Dr. Ara Nazarian discusses the benefits of a small diameter implant ................................................... 26

Volume 6 Number 4

TABLE OF CONTENTS

Best of class Implant Practice US congratulates the 18 winners of Pride Institute’s “Best of Class” Technology Awards ........................................30

Continuing education Treatment planning of implants in the esthetic zone: part 3 In the final part of the series, Drs. Sajid Jivraj, Mamaly Reshad, and Winston Chee look at the considerations for multiple implant placement............32 Monitoring, diagnosis, and treatment of peri-implant diseases Drs. Cemal Ucer, David Speechley, Simon Wright, and Eddie Scher look at the clinical headlines from the Association of Dental Implantology UK’s consensus meeting...............36

Step-by-step Osstell ISQ As easy as 1, 2... ..........................42

Technology The evolution and advancement of dental implants Drs. Robert J. Miller and Randi J. Korn discuss some history behind new implant technology ................44 4 Implant practice

Monitoring, diagnosis, and treatment of peri-implant diseases

On the horizon

Product profile

Innovative practices and

LAPIP protocol from Millennium Dental Technologies, Inc. offers a patient-friendly, predictable solution for ailing implants .......54

innovations in technology Dr. Justin Moody introduces his technology column with insights to improve the implant planning and placement process........................48

Industry news Straumann® introduces Emdogain™ 015 – designed to provide versatility in patient treatment New smaller size syringes will help clinicians provide Emdogain regenerative therapy to more patients .....................................................50 Zimmer Dental Implant receives

Southern Anesthesia & Surgical Inc. adds synthetics to the Osteo-i® line of regenerative products .....................................56 Luster® kits by MEISINGER.......58

Diary.......................................60 Materials & equipment .....................64

2013 MDEA Silver Medal ...........52 Volume 6 Number 4

DENTSPLY Implants offers a comprehensive line of implants, including ASTRA TECH Implant System™, ANKYLOS® and XiVE®, digital technologies such as ATLANTIS™ patient-specific abutments, regenerative bone products and professional development programs.

We are dedicated to continuing the tradition of DENTSPLY International, the world leader in dentistry with 110 years of industry experience, by providing high quality and groundbreaking oral healthcare solutions that create value for dental professionals, and allows for predictable and lasting implant treatment outcomes, resulting in enhanced quality of life for patients.

We invite you to join us on our journey to redefine implant dentistry. For more information, visit www.dentsplyimplants.com.

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DENTSPLY Implants is the union of two successful and innovative dental implant businesses: DENTSPLY Friadent and Astra Tech Dental.

PRACTICE PROFILE

Dr. David Feinerman Communication, attention to detail, and hard work What can you tell us about your background? I am Board Certified as an Oral and Maxillofacial Surgeon and have been practicing oral surgery since 1995. Originally from Queens, New York, I moved to South Florida in 1997 and opened Boynton Oral and Maxillofacial Surgery and Implant Center, PA. I graduated Summa Cum Laude from the State University of New York at Albany (SUNY), and received my DMD (Cum Laude) from Harvard School of Dental Medicine and my MD degree from The University of Connecticut. Following completion of a 1-year General Surgery and 4-year Oral and Maxillofacial Surgery internship and residency at The University of Connecticut, I went on to do a 1-year hospital-based maxillofacial surgery fellowship at St. Francis Hospital and Medical Center. During this time, I received post-graduate training in advanced aspects of oral and maxillofacial surgery, dental implantology, head and neck oncologic surgery, maxillofacial reconstruction, and cosmetic facial surgery. From 1995–1997, I was an associate with Connecticut Maxillofacial Surgeons, LLC in Hartford, Connecticut, as well as a clinical instructor in oral and maxillofacial surgery at The University of Connecticut School of Dental Medicine. In addition to private practice, I am an Adjunct Clinical Professor at Nova Southeastern University College of Dental Medicine, co-chairman of the Oral Implantology Course at the Atlantic Coast Dental Research Clinic, and I lecture nationally at oral and maxillofacial surgery and oral implantology conferences. I have published several articles in peer reviewed journals on various oral surgery topics and currently serve as a reviewer for several journals including the International Journal of Oral and Maxillofacial Surgery, the Journal of Oral and Maxillofacial Surgery and the Oral Surgery, Oral Pathology, Oral Medicine, Oral Radiology and Endodontics Journal. I have served on the South Palm Beach County Dental Association Board for the past 6 years and am currently on staff at Delray Medical Center and Boca 6 Implant practice

David M. Feinerman, DMD, MD

Raton Outpatient Laser and Surgery Center. I am a Diplomate of the American Board of Oral and Maxillofacial Surgery, fellow of the American Association of Oral and Maxillofacial Surgeons, a member of the Florida Society of Oral and Maxillofacial Surgeons, the American Dental Association, Florida Dental Association, American Medical Association, Florida Medical Association, Atlantic Coast Dental Association, South Palm Beach County Dental Association, the Academy of Osseointegration, the International Team of Implantology, and the American Academy of Implant Dentistry.

Is your practice implants?

limited

My practice is a full-scope oral and maxillofacial surgery practice consisting of dental implantology, dentoalveolar surgery, oral pathology, facial trauma, orthognathic surgery, orofacial reconstruction, and ambulatory anesthesia.

Why did you decide to focus on implantology? When I practiced in Connecticut, I worked

in a hospital-based oral and maxillofacial surgery practice with a heavy emphasis on orthognathic surgery, TMJ surgery, and cancer reconstruction. When I moved to Florida, the demographics of the surrounding population leant itself to a more office-based practice. Many patients were being sent 15 miles north (to Palm Beach) and 15 miles south (to Boca Raton) for their implant surgery. There seemed to be a void in my area (Boynton Beach), and I decided to focus my practice in the area of implantology.

How long have you been practicing, and what systems do you use? I have been in private practice since 1995. The Straumann® Dental Implant System is the one I use most, but I occasionally place Zimmer®, Nobel Biocare®, Astra, Ankylos® and Biomet 3i™. We have all the systems in the office.

What training undertaken?

have

you

As an oral and maxillofacial surgeon, I did 5 years of dental school (with one extra Volume 6 Number 4

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PRACTICE PROFILE year of research at Harvard) and a 5-year oral and maxillofacial surgery residency. This included a 1-year internship in general surgery that afforded me the time to complete my medical degree. When the residency concluded, I completed a 1-year hospital-based fellowship in advanced maxillofacial reconstruction, which included many aspects of dental implantology and bone grafting. My training began at the Harvard School of Dental Medicine. Harvard had a very strong pre-doctoral implant program because of the pioneering work being

I am proud that we have an established reputation and that dentists from all over the country feel comfortable to call me if one of their patients is vacationing in Florida and experiences an issue that requires attention.

The staff at Boynton Oral and Maxillofacial Surgery and Implant Center

Feinerman family in Beaver Creek, Colorado

done there by Dr. Paul Schnitman. As an oral and maxillofacial surgery resident at the University of CT, I had the benefit of additional instruction and clinical training because of Dr. Tom Taylor and Dr. Leon Assael (who were both heavily involved early on with the ITI). At that time, only oral surgeons were allowed to take surgical implant training courses and, as a resident, I took the ITI, Branemark, and IMZ implant courses. Today, I pursue as much continuing education as my schedule will allow for, and I am involved with the ITI.

refer patients to the practice. Some of them have become very close personal friends, and it makes it easy and enjoyable to discuss cases while working together daily to provide comprehensive patient care.

Who has inspired you? When I was a first-year resident in oral surgery at the University of CT, Drs. Belzer and Buser visited from Switzerland and gave a lecture to the oral surgeons. It was a â&#x20AC;&#x153;privateâ&#x20AC;? lecture with only 20-30 of us in the room, and they presented the most unbelievable, cutting-edge, implant-related 8 Implant practice

treatment. We were all amazed at what they were doing. Also, at the University of CT, I was fortunate to be taught by great surgeons and terrific people. Many of them have been mentors and role models not only professionally, but personally as well. Lastly, having a loving wife and family is extremely motivating; it pushes me to be the very best that I can be.

What is the most satisfying aspect of your practice? Our goal in the practice is to deliver superior oral surgical care. Providing great service to our patients is not only satisfying to the patients, but to the entire practice. We become very close with some patients, and it is rewarding to help someone who is in need of your expertise. Equal to this are the professional and personal relationships I have developed with the dentists who

Professionally, what are you most proud of? Professionally, I am proud of a few things. I am proud that our practice has become one of the largest implant practices in Florida as well as nationally. I am proud that we have an established reputation and that dentists from all over the country feel comfortable to call me if one of their patients is vacationing in Florida and experiences an issue that requires attention. I am proud that many of my staff members have been with me since the day I started my practice in Florida. My two surgical assistants have been with me for 15 and 16 years, my office manager for Volume 6 Number 4

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PRACTICE PROFILE

14 years and other staff for about 10 years now. I am proud of the loyalty and bond I have developed with them.

What do you think is unique about your practice? Our practice was one of the first oral and maxillofacial surgery practices in the country to go digital. We have been leaders in developing a digital workflow that allows computer-guided placement of dental implants with immediate provisionalization. I have lectured around the country on this topic, and we have received national recognition for our work in this field. We have always tried to be “trendsetters” in the field of dental implants. We were one of the first practices to start immediately loading implants, and most recently, we were the first practice in South Florida to become totally Roxolid® for All Straumann.

What has been your biggest challenge? My biggest challenge is probably not unique to me, but it would be balance. It is hard to balance a busy practice, facial trauma call at the hospital, coaching my sons’ baseball and basketball teams, making it to all the school events, and being a great dad and a devoted husband.

What would you have become if you had not become a dentist? In my dreams, a professional tennis player (I played college tennis). In reality, probably an ophthalmologist!

What is the future of implants and dentistry? The future is very bright for implant dentistry. The majority of dentists in the U.S. are still treatment planning three-unit bridges over single implants. As the education for implants improves (especially at the pre-doctoral level), implants will become more mainstream and will become more accepted and therefore, more popular. The U.S. lags behind many European countries as far as implants placed per capita. In addition, advancing technologies and honing the digital workflow will make implant surgery and restorations easier, faster, and even more predictable.

What are your top tips for maintaining a successful practice? There are a number of factors that are 10 Implant practice

Kathy and Jake Feinerman

Drew Feinerman (with brother Jake in the background)

necessary to maintain a successful practice. If I had to choose the top three, I would say communication, attention to detail, and hard work. Good communication is paramount, whether it is with the referring dentists, the staff, or the patients. We pride ourselves on sending prompt, detailed letters to our referring dentists immediately after seeing their patients. We also have monthly staff meetings as well as a separate monthly meeting with our office manager in order to keep the lines of communication open. Patients are encouraged to call the office with any questions or concerns. Patients also receive a detailed, written treatment plan for implant procedures. We stress the “attention to detail” aspect of practice to our staff. We frequently say that almost any practice can get things 90-95% correct, but it is that last 5% that will differentiate us from the other specialty practices in the area. Hard work is a given. There are no “silver platters,” and it takes work to be successful at anything. Fortunately for me, it is a “labor of love.” I arrive at the office by 6:30 a.m. each day, and I usually get home around 7 p.m. I have dinner meetings with referring dentists, study club meetings, “lunch and learns,” and many other activities to help promote the practice.

What advice would you give to budding implantologists? I would suggest that you know both the surgical and restorative aspects of implantology, regardless of whether you are a surgeon or restorative dentist. Knowing both aspects makes treatment

planning and execution markedly easier. Also, choose one or two implant systems, and become an expert on those systems. Lastly, do not “cut corners.” Look at the big picture, and do not risk early failures just to “get a case.” This is a sure way to give implants (and yourself) a bad reputation. Take your time, do it right, and treat the patients as if they were family members.

What are your hobbies, and what do you do in your spare time? Golf, ski, travel, fine wine, fine dining, coaching my kids’ sports teams, and spending time with family. IP

Top 10 Favorites (in and out of the office) 1. Anytime my family is all together 2. Having a patient say “thank you” after treatment 3. Going to the Miami Heat, Miami Dolphins, Miami Marlins, or Florida Panthers games with my kids 4. Straumann® Guided Surgery 5. Watching each of my sons perform with their jazz band 6. The Roxolid® implant 7. Watching my sons’ varsity basketball or baseball games 8. The SLActive® surface technology 9. Playing golf with my sons 10. The Loxim™ transfer piece

Volume 6 Number 4

YOU TAKE CARE OF PATIENTS. WEâ&#x20AC;&#x2122;LL TAKE CARE OF THE REST.

Surgical Solutions, a new division of Henry Schein Dental, is focused exclusively on the evolving needs of surgical specialists. We redefine the customer experience by bringing you a team of experts that combine a complete product offering with exceptional service and proven practice-building solutions specifically designed for the Surgical Specialist.

To learn about exclusive promotions for surgical specialists, visit our AAP booth 639 or AAOMS booth 707.

CORPORATE PROFILE

Henry Schein Dental Surgical Solutions From cotton rolls to cone beams, this new division is a one-stop shop for the specialty practice

n an efficient and fast-paced specialty office, choosing appropriate supplies and equipment and finding quality products and services in one place is essential. This year, Henry Schein Dental, the largest worldwide distributor of dental products, took a step towards its goal of serving the very specialized needs of oral surgeons and periodontists by creating a new division, Henry Schein Dental Surgical Solutions. From cotton rolls to cone beam scanners, specialists can rely on Surgical Solutions as a one-stop shop for materials, technology, and services for oral surgeons and periodontists. Surgical Solutions is a result of Henry Schein Dental’s increased focus on bringing more comprehensive services to oral and maxillofacial surgeons and periodontists. For nearly 80 years, Henry Schein Inc. has been North America’s most reliable resource for dental supplies, dental equipment, and dental financing services. Neil Park, DMD, general manager of Surgical Solutions, says, “Henry Schein Dental is already a proven partner for general dentists, but specialists have specific practice requirements. As a result, we created Surgical Solutions, with a whole new team and a specialized focus, and with a growing cadre of representatives concentrated only on serving the entire spectrum of specialists’ needs.” Dr. Park continues, “Besides the 15,000 SKUs in our database, Henry Schein Dental Surgical Solutions also provides our specialist customers with pharmaceuticals, equipment and technology, as well as financing options for doctors and patients, consulting services, office design, and architectural services.” The American College of Oral and Maxillofacial Surgeons has already endorsed Henry Schein’s exclusive purchasing program for oral surgery products. As implant procedures evolve and improve, specialists seek new implant options for their armamentarium. According to a recent report by iData Research (www. idataresearch.net), a medical device, dental, and pharmaceutical market research firm, the U.S. market for dental implants 12 Implant practice

is expected to regain double-digit growth by 2013 and will help drive the dental prosthetic market to reach over 82 million prosthetic placements by 2016. Surgical Solutions offers its oral surgeon and periodontist customers the tools and materials for a successful and less stressful implant experience.

Productive products As an example, Surgical Solutions is the U.S. distributor for the Camlog implant system. As the market leader in Germany, Camlog systems are known for their extremely high precision, surgical simplicity, and excellent restorative flexibility. Camlog® Screw-Line implants are tapered, and suitable for immediate, late, and delayed implantation. The self-tapping thread provides a continuous grip on the bone and high primary stability. A new system, called Conelog®, has exactly the same outer geometry as Camlog, except for the height of the Promote® surface that reaches up to the implant shoulder. The conical internal configuration of the implant in conjunction with the Conelog® abutments allows integrated platform switching. For more convenience, both systems use the same surgical instrument kit. In a separate category, where a smaller diameter implant is indicated, Surgical Solutions offers the miniMark™ Dental Implant System, precision engineered by ACE Surgical Supply, a company serving the dental specialty market for more than 40 years. This implant features the popular Locator® Attachment by Zest Anchors— a trusted name in securing implant-retained dentures. This small diameter implant can restore dental function with a standardized, minimally invasive procedure. ACE Surgical also offers a high quality, value priced, fullline of bone and regenerative materials, membranes, allografts, xenografts, and other materials needed to prepare implant sites. With Surgical Solutions’ CAD/CAM options, specialists can explore the advantages of intraoral scanners from E4D (D4D Technologies), 3M™ ESPE,™ and 3Shape. Digitally recording the position

Neil Park, DMD

of the implant during placement greatly simplifies the restorative procedure. “We will be offering the scanning equipment, the scan bodies, and everything else needed to incorporate the technology into the surgeon’s implant practice,” says Dr. Park. In the fall, Surgical Solutions will be launching a nationwide program to introduce this technology to surgeons through a series of courses to help bring the equipment, concepts, and training into the practice. Surgical Solutions also offers a full line of imaging products, including the DEXIS digital X-ray system, with its stateof-the-art DEXIS® Platinum sensor and intuitive, easy-to-use imaging software. The single-sensor system has remarkable image quality, is direct USB portable, and automatically saves, dates, and tooth numbers, and correctly orients the image when the sensor detects radiation. For a busy office, the One-Click-Full-Mouth series makes it possible to reduce a 25-minute FMX procedure to 5 minutes. The DEXIS go, a companion app to the DEXIS Imaging Suite software, functions as an imaging hub, displaying all images within the patient’s record, and allowing the clinician to communicate with patients using an iPad®. Volume 6 Number 4

CORPORATE PROFILE

Surgical Solutions was created by a team of dedicated, experienced professionals who bring their individual expertise to the new division.

For those specialists who want to add an additional dimension to their imaging and obtain three-dimensional data and greater precision for surgical procedures, Surgical Solutions offers many brands of CBCT units. Henry Schein Dental is the exclusive distributor in the U.S. of the award-winning i-CAT® (Imaging Sciences International) brand of cone beam 3D imaging. The company recently debuted the i-CAT® FLX, to help clinicians quickly diagnose complex problems with less radiation* (i-CAT has data on file) and develop treatment plans more easily and accurately. The i-CAT FLX offers 3D planning and treatment tools for implants, restorations, oral and maxillofacial surgery, orthodontics, TMD, and airway disorders. The SmartScan STUDIO™ touchscreen interface promotes ease-ofuse and flexibility, and Visual iQuity™ image technology provides i-CAT’s clearest 2D and 3D images. The most compelling part of this system is that specialists can gain all of the benefits of CBCT imaging, and with the QuickScan+ feature can capture a fulldentition 3D scan at a lower radiation dose than a panoramic image. Tx STUDIO™ optimized treatment planning software provides immediate access to integrated treatment tools for implant planning, surgical guides, and other applications. All of these quality products demonstrate that state-of-the-art technology is a priority at Surgical Solutions. Dr. Park describes, “The firm sells more X-ray equipment, CBCT scanners, and intraoral CAD/CAM units than everyone else, so we understand how they work for the specialty practice.” He adds, “For instruments, we offer the full line of Hu-Friedy and other quality instrument

The management team at Henry Schein Dental Surgical Solutions (Left to right) Todd Colvin, Neil Park, DMD, Donald Boyd, Maritza Alford, Kerri Leslie, Robert Riley

makers, and we also have the Henry Schein brand of value-priced instruments. Our representatives are a veteran group who are committed to this industry.”

Meet the team Surgical Solutions was created by a team of dedicated, experienced professionals who bring their individual expertise to the new division. Dr. Park is a dentist with 19 years of experience with Nobel Biocare, a global leader and pioneer in implant systems. Dr. Park notes, “The importance of offering focused services to oral and maxillofacial surgeons and periodontists is a strategy that has received tremendous support from the very top of Henry Schein’s executive team. George Guttroff, president of the Dental Specialties Group, and I have worked together very closely to bring this new division to fruition.” Kerri Leslie, the new head of marketing, brings her 8 years of experience in the medical field to spread the news of the expanding endeavor. The knowledgeable and enthusiastic sales team, which has already grown to 34 reps and managers with more expected, brings expertise across a gamut of categories. National Director of Sales, Maritza Alford brings her extensive management experience from within the Henry Schein group. Todd Colvin, who directs sales in the Northeast region, spent many years with the implant giant, Zimmer, before joining Camlog/

Henry Schein 6 years ago. Donald Boyd, regional manager for the Southeast, spent 16 years with Nobel Biocare. Robert Riley, CDT, will serve as Director of Training and Technical services, from a new technical resource center in San Antonio, Texas that answers technical questions related to any product offered by the group. Riley has extensive experience that includes several key positions in the implant and orthodontic industries. The entire Surgical Solutions’ team is dedicated to bringing quality technology and products to the specialty office in a convenient and efficient way. Dr. Park sums up, “We will prove that we can meet the needs of oral and maxillofacial surgeons and periodontists. These professionals typically purchase their products from a variety of vendors — drugs from one company, implants from another, bonerelated products from yet another. We can streamline that process while providing additional value to the practice. Our surgical sales consultants will become a part of the practice family in that targeted field and help to bring our customers’ practices to higher levels of clinical and business success.” Customers are already sharing positive feedback on how Surgical Solutions brings targeted and professional service to surgical specialists. IP This information was provided by Henry Schein Dental Surgical Solutions.

Volume 6 Number 4 Implant practice 13

CASE STUDY

An advanced mini dental implant case: 25 extractions and insertion of 15 MDIs for a quadriplegic patient Dr. M. Dean Wright uses MDIs to treat a challenging case Abstract: A previously published article by the author reviewed the current data on mini dental implants and their use in denture stabilization. The case showed the insertion of six mini implants in the maxilla to stabilize a full upper denture, as well as four mini implants in the mandible to support a partial. Such a case may be categorized as a “classic” and straightforward MDI denture stabilization treatment. In contrast, the case illustrated in this article — a medical first — demonstrates the more advanced treatments made possible by MDIs. The patient in this case was a quadriplegic who underwent extraction of 25 teeth, followed by placement of eight MDIs in the maxilla and seven MDIs in the mandible. The procedure was performed in less than 9 hours under general anesthesia in a hospital.

n an article previously published in the May/June issue of this magazine, I outlined my decades of experience with dental implants, along with my belief in the practicality and utility of mini dental implants (MDIs) as a more affordable and accessible alternative to traditional implants for many patients. As stated in that article, MDIs require less bone to place, are less invasive, and treatment can be completed much faster than with traditional implants. MDIs have been used for more than 10 years, and a recent prospective clinical study showed a 98.3% success rate after a 1-year observation period.1 A 5-year study following 2,500 mini dental implants found a success rate of 94.2%.2 I estimate that I place approximately 100 MDIs each month, and have seen many times over the enthusiastic responses of patients for whom they make

M. Dean Wright, DDS, is a 1972 graduate of Wichita State University in Wichita, Kansas, with a BS in Chemistry and a 1976 graduate of the Kansas City School of Dentistry. Dr. Wright has been placing implants since 1977, and has to date personally placed and restored over 12,000 implants – both traditional and small-diameter. Dr. Wright is the owner and director of Cambridge Family Dentistry, a 20-operatory general practice and implant center located in Wichita, Kansas.

14 Implant practice

Figure 1: Panoramic X-ray showing 25 severely abscessed and decayed teeth. Initial measurements for implant locations and sizes were drawn on during the consultation

Figure 2: X-ray following placement of eight maxillary and seven mandibular MDIs. Divergence of the implants is of no consequence

a life-changing difference. While these implants can be used to support crowns and bridges, they are primarily utilized for the stabilization of dentures. Patients experience an immediate and dramatic boost in retention with these implants, making it a very rewarding treatment to offer. The simplicity of the basic MDI denture stabilization treatment makes it an attractive procedure for many dentists, but MDIs can also be utilized in complex cases such as the one shown in this article. While the individual techniques used in the case illustrated here were not new to the team involved in the procedure, I believe that the case itself may be a medical first.

placing MDIs, combined with the fact that I have hospital privileges at the facility where he would be treated, presented a strong opportunity. An initial panoramic X-ray was taken, which showed 25 severely abscessed and decayed teeth (Figure 1). (A CT scanner could not be used during treatment planning due to the patient’s condition and mobility restrictions.) A treatment plan to extract the decayed teeth and place eight MDIs in the maxilla and seven in the mandible was presented to the patient and accepted. The panoramic image was used to determine initial implant locations and sizes. On the day prior to the surgery, slots were cut into the immediate denture to accommodate the future sites of the implants, and a bite registration was taken outside of the mouth. On the day of the procedure, after nasal intubation and general anesthesia, a 4 x 4 throat pack was placed, and the 25 teeth were extracted. Any bone loss due to breakage or tooth attachment was harvested and used for autogenous grafting where needed later. Alveoplasty was then performed as needed, and the 15 3M™ ESPE™ MDI Mini Dental Implants were placed. The MDIs ranged from 10 mm to 18 mm in length and 1.8 mm to 2.4 mm in diameter. Space limitations prohibit the inclusion of details on the advanced technique of threading an implant between two opposing extraction sites, but it should be noted that varying

Case presentation The patient in this case was a 52-yearold male who had become quadriplegic in a tree-trimming accident some 20 years prior to this treatment. The patient’s medical condition was a C4, C5 complete, meaning he was paralyzed from the lower neck down. The injury prevented proper oral care and rapidly led to the destruction of the patient’s teeth. The patient’s benefits from the state of Kansas entitled him to a single hospital treatment for the condition. He had seen a number of local specialists prior to visiting my office, none of whom could come up with a satisfactory solution given the constraints of the case. When I met with the patient, however, I was able to propose a realistic — although ambitious — treatment plan. My experience

Volume 6 Number 4

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Mini Dental Implants

CASE STUDY

Figure 3: Immediate state following placement of implants and suturing of extraction sites

densities, widths, and depths of bone were encountered. Multiples of every size and diameter of MDI were on hand for the procedure in order to be prepared for any necessary adjustments. Experienced readers reviewing the radiographs may note that one more implant could have been placed in the No. 31 area above the inferior alveolar nerve; however, without having the 3D scan and not knowing the precise length of bone, I did not want to risk any chance of a nerve parasthesia, especially with this patient. The radiographs also show how some of the lower implants are slanted away from the nerve areas (Figure 2). 3M ESPE MDIs can withstand up to 30 degrees of divergence, and this slight angle actually adds to the final denture retention. This is done regularly, and the visual slanting of the MDIs on the X-rays is of no consequence. Following placement of the implants, the autogenous grafts were placed where necessary and into extraction sites along with collagen plugs, and the sites were closed with 4-0 Vicryl™ suture (Figure 3). These steps help to preserve bone and minimize bleeding. Practitioners are encouraged to do a thorough job of this, as it greatly helps in the final product. Metal housings were snapped onto the O-ball heads of the implants, and rubber base reline impressions were taken using the bite registration as a guide. Analogs were placed in the impressions, and the case was sent to Kaylor Dental Lab in Wichita, Kansas, which processed the snaps and relined the denture within a few hours. The laboratory’s assistance was greatly appreciated, as insertion of the dentures on the same day helps to minimize swelling and bleeding, and to lessen the patient’s discomfort. Before the conclusion of surgery, the patient was given 10 carpules of Marcaine so that he would be numb all day and when the dentures were placed. Antibiotics were 16 Implant practice

Figure 4: The implants at 1 month post-op

Figure 5: Final result with dentures

Figure 6: The author and patient

given before and after surgery, as well as an anti-inflammatory and a narcotic painkiller. By 5 p.m., the patient returned to the dental office, and the new dentures were seated. At a post-op visit 3 days later, the patient stated that the procedure wasn’t as bad as he had anticipated. Examination revealed the implants held the dentures tightly and kept them from compressing the ridge. Our observation was that the patient had less pain than if he had no implants and just the immediate dentures. A visit 1 month later showed satisfactory healing of the tissue and a very satisfied patient (Figures 4-6).

Their affordability, small size, and minimally invasive nature give them capabilities that traditional implants simply can’t match. Eleven years ago, skeptics of MDI treatments were numerous and vocal. I continue to know doctors who do not believe in MDIs, and that is, of course, their choice. However, I believe that in the nottoo-distant future, MDIs will be as common as amalgams and offered routinely by most dentists. The benefits for patients are too great to overlook, and I believe that MDIs are one of the finest solutions you can offer to patients who have lost or are losing their natural teeth. IP References

Conclusion The two articles presented in this series represent both the basic and advanced capabilities of MDI treatment. As both cases illustrate, MDIs provide dentists with a valuable tool for denture stabilization, proving versatile enough to be used in everyday cases or in very challenging treatments such as the one shown here.

1. Todorovic A, Markovic A, Šcepanovic M. Stability and peri-implant bone resorption of the mini implants as complete lower denture retainers [Espertise Scientific Facts brochure]. St. Paul, MN: 3M ESPE; 2012. 2. Shatkin TE, Shatkin S, Oppenheimer BD, Oppenheimer AJ. Mini dental implants for long-term fixed and removable prosthetics: a retrospective analysis of 2514 implants placed over a five-year period. Compend Contin Educ Dent. 2007;28(2):92-101.

Volume 6 Number 4

CASE STUDY

Adjunctive laser treatment in extraction/immediate implant placement Dr. Robert J. Miller discusses technology that is changing the face of implants at the speed of light

hroughout the history of oral implantology, strategies have been based on the paradigm of placing endosseous dental implants in healed sites. With diminishing numbers of completely edentulous patients being treated, there is an increasing need to place implants at the time of tooth removal. Additionally, over the past decade, our discipline has seen a dramatic change with either earlier loading times or immediate loading. Unlike the healed site with balanced bone density and soft tissue coverage, extraction sites present additional challenges with respect to implant stability and potential presence of infection. Therefore, if our paradigm is going to change from placement of implants in healed sites to one of immediate placement in extraction sites, new modalities must be developed. These changes, known as â&#x20AC;&#x153;biologically-drivenâ&#x20AC;? surgical strategies, reflect our understanding of the interaction of implanted materials and living tissue. However, they also reflect our new respect for the consequences of placing implants in compromised osteotomies. Extraction site defects bring increasing complexity with respect to initial healing of implants. In most cases, periodontally involved teeth or failed endodontically treated teeth are removed, and the site is prepared to accept an implant. Unlike the healed site in which pathology has been resolved, extraction sites may contain pathogenic bacteria or granulomatous

Robert J. Miller, MA, DDS, FACD, received both a Bachelor of Arts and Master of Arts in Biology and then continued his education at New York University College of Dentistry where he received his Doctor of Dental Surgery degree (DDS) in 1981. Upon graduation, Dr. Miller was honored to be chosen as one of 200 applicants to complete a residency program at Flushing Hospital and Medical Center. He is one of the few Dentists in the United States to be Board Certified by the American Board of Oral Implantology (ABOI). Dr. Miller is also a Diplomate of the International Congress of Oral Implantologists (DICOI) and holds current memberships in the The American College of Dentists, The American Dental Association (ADA), The Florida Dental Association (FDA), and the South Palm Beach County Dental Association (SPBCDA). He has been practicing dentistry in Delray Beach, Florida for 30 years.

18 Implant practice

Figure 1: Fracture of an endodontically treated maxillary cuspid with recurrent decay

Figure 2: Remnants of an apical granuloma still attached to the root apex

Figure 3: Introduction of a 14 mm zirconium tip into the extraction site

Figure 4: Completion of laser debridement of the apical granuloma and de-epithelialization of the gingival sulcus

lesions that can cause infection or implant failure. The key components of a strategy to reduce potential complications following implant placement in this type of site is complete debridement of the hard tissue and removal of epithelium in the gingival sulcus. Sulcular epithelium harbors periodontal pathogens that may cause inflammation following implant placement. These pathogens can migrate to the walls of the portion of the implant not covered by bone. They can delay or even prevent integration of these exposed portions of the implant, predisposing the implant body to future infection and bone loss. Apical granulomas have a different type of biologic response. Granulomas that have formed as a result of incomplete endodontic debridement may harbor vegetative forms of pathogenic bacteria. However, they may also result in an untoward immunologic response different from that of bacterial origin. This may result in a cyclical biologic process that perpetuates production of inflammatory tissue that results in a retrograde peri-implantitis, starting at the implant apex and moving coronally. The following case illustrates how an Erbium, Chromium;YSGG laser

Figure 5: Placement of the dental implant and healing abutment

(Biolase Technologies) can be used as an effective means of debridement and de-epithelialization prior to immediate implant placement.This patient presented with fracture of an endodontically treated maxillary left cuspid as a result of recurrent decay (Figure 1). The decay reached the osseous crest making the tooth unrestorable without a crown extension. However, with a high smile line, the patient opted for tooth removal and immediate implant placement to maintain the position of tissue architecture. Following nondestructive tooth removal and maintenance of the facial plate, the retained root was evaluated for depth and length. Remnants Volume 6 Number 4

CASE STUDY

BONE GRAFTING SOLUTIONS

GUIDOR® AlloGraft Figure 6: Removal of the healing abutment at 2 months demonstrating regeneration of the dentogingival complex

Figure 7: One-year post-op photograph reflecting stable gingival architecture and a healthy tissue response

of a portion of the apical granuloma can be seen still attached to the root apex (Figure 2). Following extraction, an erbium laser with a 14-mm zirconium tip is introduced into the osteotomy (Figure 3). Careful debridement of the entire extraction site is carried out until all remnants of granulomatous tissue is removed. Additionally, the inner lining of the sulcus up to the free gingival margin is ablated to reduce the bacterial load and to create a bleeding interface to accelerate soft tissue attachment to the healing abutment (Figure 4). Following implant placement, a healing abutment is placed and the facial defect grafted (Figure 5). In some cases, if there is adequate initial stability, a temporary abutment and provisional may be placed. The implant is allowed to heal for at least 2 months. When the healing abutment is removed, we can demonstrate the formation of a new gingival sulcus coronal to the top of the implant and a bleeding interface apical to that zone which indicates the presence of a hemidesmosomal attachment to the healing abutment (Figure 6). This represents regeneration of biologic width at the coronal aspect of the implant. The prosthetic phase is completed, and final crown placed on a milled titanium abutment. The final photograph (Figure 7) was taken at 1-year post-op. This demonstrates a stable and healthy dentogingival complex, even in a tooth position with highly parabolic architecture and long papillae. The use of an ablative erbium laser is ideal in implant cases when dealing with potentially infected sites and to enhance initial healing of soft tissue architecture. Erbium, Chromium;YSGG lasers can also be used for many other procedures in oral implantology. These include gingival recontouring, removal of hyperplastic tissue, flap incisions, osseous recontouring, bone harvesting, lateral wall sinus grafts, ridge splitting, preparation of the implant osteotomy, implant debridement, treatment of peri-implantitis, and removal of failed implants. IP

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Volume 6 Number 4 Implant practice 19

CLINICAL

Minimally invasive crestal approach technique for sinus elevation utilizing a cartridge delivery system Drs. Ziv Mazor, Andreas Ioannou, Narayan Venkataraman, George Kotsakis, and Udatta Kher delve into ways to overcome insufficient vertical bone height in the posterior maxilla in conjunction with maxillary sinus lift Introduction Dental implants are successfully used to replace both the form and the function of missing teeth. The main prerequisite for implant placement is sufficient volume of bone in the edentulous ridge to support the body of the implant. In the maxilla, when severe atrophy of the edentulous ridge exists in combination with maxillary sinus pneumatization, maxillary sinus augmentation surgery is frequently employed to provide adequate vertical bony dimensions for the placement of an implant. A variety of surgical techniques and materials have been used to overcome the problem of insufficient vertical bone height in the posterior maxilla in conjunction with maxillary sinus lift. This procedure aims to increase the dimensions of the available bone in the area by placement of bone-graft material in the space created following the elevation of the maxillary sinus, performed

Ziv Mazor, DMD, is a leading Israeli periodontist. He graduated the periodontal department of Hadassah School for Dental Medicine-Jerusalem, Israel, where he served as clinical instructor and lecturer for undergraduate and postgraduate dental students. Dr. Mazor maintains private practice limited to periodontal and implant dentistry in Raanana, Israel. Since 1993, Dr. Mazor has been engaged in clinical research in the field of bone augmentation and sinus floor elevation. Dr. Mazor is the past president of the Israeli Periodontal Society and is currently the president elect of the Israeli Association of Oral Implants. George Kotsakis, DDS, is a Resident in the Advanced Education Program in Periodontology at the University of Minnesota. Dr. Kotsakis graduated from the University of Athens, Greece and spent 3 years in private practice where he focused in implant treatment and complex restorative cases. During that time he got involved in practice-based clinical research that led him to pursue specialty training. Dr. Kotsakis has published numerous scientific publications in peer-reviewed journals with a main interest in clinical and histological outcomes of bone augmentation with different types of grafts. Andreas Ioannou, DDS, is a Resident, Advanced Education in Periodontology at the University of Minnesota. Narayan Venkataraman, MDS, is an Implantologist in Bangalore, India. Udatta Kher, MDS, is an Oral Surgeon in Mumbai, India.

20 Implant practice

Figure 1: In contrast to the original osteotome technique, before the in-fracture of the sinus floor with the osteotome, a small quantity of CPS is inserted in the osteotomy to function as a protective “cushion’’ during percussion

in two distinct ways: the direct sinus lift procedure using a lateral approach and the indirect sinus lift procedure through a crestal approach which was introduced by Summers in 1994.1 When the treatment of choice is the direct sinus elevation technique, complications can occur, including a possibility of sinus membrane perforation. The indirect sinus elevation technique is less invasive, less time-consuming, and reduces the postoperative discomfort for the patient. The lack of direct visualization of the membrane and the use for the osteotomes for the fracture of the sinus floor may lead to a risk of Schneiderian membrane perforation as high as 26%.2 The limit of bone volume gained with the Summers technique is approximately up to 5 mm.3 Technique-related risks such as reports of benign paroxysmal positional vertigo following sinus elevation utilizing the osteotomes technique have led to the innovation of more atraumatic modifications of the original technique. Such one is the minimally invasive antral membrane balloon elevation (MIAMBE).4 In this technique, a transalveolar approach is utilized, and the endosteal implant osteotomy is prepared 1-2 mm below the floor of the antrum. This surgical approach includes causing a small fracture in the antral floor and slowly elevating the sinus membrane with the aid of hydraulic pressure utilizing a balloon that inflates and ‘‘pushes’’ the Schneiderian membrane. The gap present between the initial position of the sinus floor and

Figure 2: The putty absorbs part of the forces that are applied to the bone and evenly distributes the remaining force while minimizing the risk of membrane perforation

the elevated membrane is filled with graft materials, and an implant is placed. In another technique, novel atraumatic drills and reamers that can rotate in proximity to the sinus membrane and without perforating the Schneiderian membrane have been utilized to make the use of osteotomes redundant. In this technique, an atraumatic drill is advanced to the floor of the sinus, and then a reamer is employed to drill any bone left at the floor of the sinus and elevate the membrane. Following slight elevation of the membrane with the reamer, a carrier is used to deliver bone graft through the osteotomy and further advance the membrane.5 Various bone grafting materials are frequently used in sinus lift procedures, such as autogenous bone, freeze-dried bone, demineralized freeze-dried bone, xenogeneic bone, and alloplastic bone substitutes.6-7 Recent data have shown that bone substitutes displaying a putty consistency can present a valuable alternative in bone-grafting procedures.8-9 The handling characteristics of putty bone substitutes have expanded the available Volume 6 Number 4

CLINICAL treatment options for bone grafting in narrow spaces, and their physical properties can be exploited to increase the safety and predictability of sinus lift procedures. In this improvisation, viscoelastic calcium phosphosilicate alloplastic putty (CPS), available in a unique cartridge delivery system, is utilized. CPS is a completely synthetic graft substitute that is approved for bone repair and regeneration in dental and orthopedic osseous defects. It is a premixed composite of 70% calcium phosphosilicate particulate and 30% synthetic absorbable binder. Bioactivity of CPS results from the chemical release of ionic dissolution products: silicon, sodium, calcium, and phosphate, and has shown to stimulate multiple generations of undifferentiated cells into osteoblasts.10 CPS has been successfully used in various osseous defects with no reported adverse events.11,12 CPS not only acts as a “protective cushion” but also provides hydraulic pressure to lift the Schneiderian membrane. This approach minimizes risks of benign paroxysmal positional vertigo or mechanical perforations of the Schneiderian membrane associated with the traditional osteotome technique. In the first case example, a modification of the MIAMBE technique with the use of CPS instead of an inflatable balloon will be presented. In the second case example, a series of atraumatic drills will be utilized in conjunction with CPS to perform an indirect sinus lift without the use of osteotomes.

Illustration of the minimally invasive technique using hydraulic pressure The technique illustrated aims to describe a modification of MIAMBE technique that employs hydraulic pressure for sinus membrane elevation. This improvisation is made possible by the unique consistency and delivery mechanism of the CPS graft. The technique also helps to minimize complications associated with the use of osteotomes. A Transalveolar Sinus Floor Elevation (TSFE) technique is utilized, and the osteotomy site is prepared to the size of the final implant diameter and stopped 0.51 mm short of the sinus floor (Figures 1A and 1B). A small quantity (~0.25 cc) of the putty graft is inserted in the implant bed to function as a “cushion,’’ thus preventing 22 Implant practice

Figure 3:The narrow tip of the delivery system allows it to enter the narrow osteotomy and reach the floor of the sinus

Figure 4: The viscosity of the CPS that surrounds the apex of the implant aids in achieving increased primary stability

perforation of the membrane before the osteotome is used to tap firmly and produce a green-stick fracture (Figure 2). A putty cartridge is snapped into the dispensing gun, and the bent cannula of the cartridge is placed in the osteotomy site. The width of the cannula is narrow enough to allow it to be inserted into the osteotomy following the use of a 2.0 mm pilot drill. While applying pressure against the bone, CPS is injected into the site. The hydraulic pressure from delivery of the graft material elevates the sinus membrane (Figures 3A and 3B). For every 0.5cc injected into the sinus, the floor is elevated approximately by 2 mm. Following adequate elevation of the sinus floor, an implant is placed in the socket (Figures 4A and 4B). Approximately 85% of the graft gets remodeled into vital bone in 5-7 months with approximately 15% residual graft after 6 months in the site.13

Representative case of the modified reamer technique A 50-year-old, healthy female (nonsmoker) presented for implant placement in the edentulous upper left premolar area. The subantral bone height was measured at 9.3 mm in the 24 area and 5.3 mm in the 25 area (Figure 5A). The patient was premedicated with 2g amoxicillin 1 hour before the surgery. Following local anesthesia, initial drilling with a 2 mm twist drill, followed by a 2.9 mm drill to widen

the osteotome to approximately 1.0 mm short of the sinus floor was performed utilizing a crestal approach (Neobiotech SCA™ kit). Subsequently, an appropriately sized (2.8 mm in 24 area and 3.2 mm in 25 area) S-reamer was utilized until the sinus floor was breached, while leaving the membrane intact owing to the design of the reamer. Separation of the sinus floor was performed using a round-ended depth gauge. Approximately 0.5 cc CPS was injected into the No. 24 area and 1.5 cc into the No. 25 area (Figures 5B and 5C) using the cartridge delivery system and continued until the hydraulic pressure caused elevation of the sinus membrane. Once the membrane was adequately elevated as evidenced by the tactile sensation of resistance to additional bone grafting, the grafted material was laterally spread using a paddle-shaped bone spreader with a stopper running at 70 rpm. 4 mm x 10 mm and 5 mm x 8.5 mm CMI IS II implants were placed in No. 24/25 areas, respectively. Implants were inserted with a primary stability greater than 35N/ cm2 in both sites, and a healing abutment was placed for non-submerged healing. A 7-month postoperative radiograph demonstrated trabecular pattern in the grafted area indicative of the graft turnover and bone regeneration.

Discussion In cases where adequate amount of bone is not available for the placement of implants Volume 6 Number 4

CLINICAL in the posterior maxilla area, maxillary sinus lift is indicated. The approach using the Summers’ osteotomy was developed to simplify the sinus-lift procedure using simultaneous sinus floor elevation and implantation in one stage through the socket. However, the lateral approach offers a better control of the surgical site, particularly in a severely resorbed maxilla or when extensive implantation is needed. Both approaches seem to yield similar success rates.14-17 By exploiting the superior handling characteristics and unique delivery system of CPS, a less invasive, with minimal osteotomy preparation, and more predictable trans-alveolar sinus floor elevation technique, was conceived. Due to the consistency of CPS material, this technique also helps in minimizing membrane perforations and associated adverse events. The technique is also an attempt to reduce the grafting volume to the minimum while generating adequate bone volume required for optimal osseointegration and anchorage of the implants. CPS in unidose cartridges facilitates precise delivery of the graft material and controlled elevation of the sinus membrane. Additional advantages of this technique are reduced chair-side times and minimal graft wastage. CPS in the cartridge system for sinus floor elevation offers a more conservative procedure, localized augmentation of sinus, and less postoperative morbidity. This technique can be successfully used for sinus augmentation with immediate implant placement, as it offers key primary stability to the implant. All these advantages make TSFE along with the use of calcium phosphosilicate alloplastic putty (CPS) a

Figure 5A:The cross-sections reveal the concave anatomy of the floor of the sinus. Also note thickening of the sinus mucosa. Significant elevation of the floor of the sinus has to be performed in the area of the second premolar to allow for implant placement

Figure 5B: The reamer is specially designed to allow for removal of the bony floor of the sinus without perforating the Schneiderian membrane. Note the loss of continuity of bone at the end of the reamer consistent with direct clinical contact of the reamer with the membrane

Figure 5C: Immediate postoperative radiograph shows the sinus elevation achieved was adequate, and both implants were successfully placed using this atraumatic technique

Figure 5D: Seven-month postoperative radiograph demonstrates the trabecularization of the hard tissue at the apex of the implants, in the area of the sinus lift, is almost identical to the trabecularization of the native bone

viable option for implant placement in the posterior maxilla.

introduces a technique for indirect sinus elevation with the placement of a calcium phosphosilicate putty bone substitute as a graft material. The use of CPS for indirect sinus lift provides a clinically safe and effective option for simultaneous placement of implants that allows for a less invasive approach, less complications, and minimum discomfort for the patient. IP

Conclusions The objective of an indirect sinus lift procedure is to increase the height of the vertical bone in the posterior maxilla and provide the opportunity for implant restoration in that area with adequate primary stability of the implant. This article

References

2011;16(2):e210-214.

1. Summers RB. A new concept in maxillary implant surgery: the osteotome technique. Compendium. 1994;15(2):152, 154-156, 158, 162.

7. Rickert D, Slater JJ, Meijer HJ, Vissink A, Raghoebar GM. Maxillary sinus lift with solely autogenous bone compared to a combination of autogenous bone and growth factors or (solely) bone substitutes. A systematic review. Int J Oral Maxillofac Surg. 2012;41(2):160-167.

2. Hernández-Alfaro F, Torradeflot MM, Marti C. Prevalence and management of Schneiderian membrane perforations during sinus-lift procedures. Clin Oral Implants Res. 2008;19(1):91-98. 3. Engelke W, Deckwer I. Endoscopically controlled sinus floor augmentation. A preliminary report. Clin Oral Implants Res. 1997;8(6):527–531. 4. Kfir E, Goldstein M, Yerushalmi I, Rafaelov R, Mazor Z, Kfir V, Kaluski E. Minimally invasive antral membrane balloon elevation – results of a multicenter registry. Clin Implant Dent Relat Res. 2009;11(suppl 1):e83–91. 5. Ahn SH, Park EJ, Kim ES. Reamer-mediated transalveolar sinus floor elevation without osteotome and simultaneous implant placement in the maxillary molar area: clinical outcomes of 391 implants in 380 patients. Clin Oral Implants Res. 2012;23(7):866–872. 6. Aloy-Prósper A, Maestre-Ferrin L, Peñarrocha-Oltra D, Peñarrocha-Diago M. Bone regeneration using particulate grafts: an update. Med Oral Patol Oral Cir Bucal.

24 Implant practice

8. Kotsakis G, Chrepa V, Marcou N, Prasad H, Hinrichs J. Flapless alveolar ridge preservation utilizing the ‘’socketplug’’ technique: clinical technique and review of the literature. J Oral Implantol. November 12, 2012 epub ahead of print. 9. Kotsakis G, Chrepa V, Katta S. Practical application of the newly introduced natural bone regeneration (NBR) concept utilizing alloplastic putty. Int J Oral Implantol Clin Res. 2011;2(3):145-149. 10. Xynos ID, Edgar AJ, Buttery LD, Hench LL, Polak JM. Gene-expression profiling of human osteoblasts following treatment with the ionic products of Bioglass 45S5 dissolution. J Biomed Mater Res. 2001;55(2):151-157. 11. Kotsakis G, Chrepa V, Katta S. Practical application of the newly introduced natural bone regeneration (NBR) concept utilizing alloplastic putty. Int J Oral Implantol Clin Res. 2011;2(3):145-149. 12. Mahesh L, Salama MA, Kurtzman GM, Joachim FP.

Socket grafting with calcium phosphosilicate alloplast putty: a histomorphometric evaluation. Compend Contin Educ Dent. 2012;33(8):e109-115. 13. Mahesh L, Kotsakis G, Venkataraman N, Shukla S, Prasad H. Ridge preservation with the socket-plug technique utilizing an alloplastic putty bone substitute or a particulate xenograft: a histological pilot study. J Oral Implantol. June 17, 2013 June epub ahead of print. 14. Peleg M, Garg AK, Mazor Z. Predictability of simultaneous implant placement in the severely atrophic posterior maxilla: A 9-year longitudinal experience study of 2132 implants placed into 731 human sinus grafts. Int J Oral Maxillofac Implants. 2006;21(1):94-102. 15. Peleg M, Mazor Z, Chaushu G, Garg AK. Sinus floor augmentation with simultaneous implant placement in the severely atrophic maxilla. J Periodontol. 1998;69(12):13971403. 16. Peleg M, Mazor Z, Garg AK. Augmentation grafting of the maxillary sinus and simultaneous implant placement in patients with 3 to 5 mm of residual alveolar bone height. Int J Oral Maxillofac Implants. 1999;14(4):549-556. 17. Fermergard R, Astrand P. Osteotome sinus floor elevation and simultaneous placement of implants -- a 1-year retrospective study with Astra Tech implants. Clin Implant Dent Relat Res. 2008;10(1):62-69.

Volume 6 Number 4

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To learn more about what a great image can do for your practice, visit carestreamdental.com/3DIP or call 800.944.6365 today.

9438 DE AD 0713

CLINICAL

An affordable overdenture option for an edentulous ridge Dr. Ara Nazarian discusses the benefits of a small diameter implant

s the Baby Boomer population increases in number and size, so does the number of edentulous patients, since tooth loss and age are totally related. Whether it is due to neglect, caries, medications, or other systemic reasons, patients are presenting to practices all over America with their teeth already extracted. However, patients who have been wearing removable prosthetics for several years may discover the common denture problems of instability, sores, and pain. Their dentures no longer fit very well, unless they incorporate some type of implants into the plan. Implants, whether small or traditional, allow patients with dentures to eat and function like they once did when they had teeth. Endosseous implants have been successfully used to restore edentulous ridges with implant-supported fixed bridges, hybrid prosthetic dentures, and removable overdenture prostheses for many years. However, due to deficiencies in the remaining bone, complicated medical history, or financial reasons, not everyone is a candidate for traditional-sized implants. Small diameter implants placed with flapless surgery to support dentures present an alternative method of restoring patients with atrophic jaws. They dramatically broaden the spectrum of overdenture patients who can be successfully treated. These small diameter implants (1.8 mm-3.0 mm) differ from their full-sized counterparts in a number of significant ways. The configuration of the implant permits a more conservative placement protocol. No tissue flaps or tapping procedures are

Ara Nazarian, DDS, DICOI, maintains a private practice in Troy, Michigan with an emphasis on comprehensive and restorative care. He is a Diplomate in the International Congress of Oral Implantologists (ICOI). His articles have been published in many of today’s popular dental publications. Dr. Nazarian is the director of the Reconstructive Dentistry Institute. He has conducted lectures and hands-on workshops on esthetic materials and dental implants throughout the United States, Europe, New Zealand, and Australia. Dr. Nazarian is also the creator of the DemoDent patient education model system. He can be reached at 248-457-0500 or at the Web site www.aranazariandds.com.

26 Implant practice

Figure 1: Preoperative retracted view of maxillary arch

Figure 2: Denture with radiopaque markers

Figure 3: Virtual treatment plan from 3DDX

Figure 4: Pilot surgical guide

Figure 5: 1.6 mm pilot drill

Figure 6: Paralleling pins

required, which results in fewer traumas to both gingival tissue and bone. Their smaller size also permits placement in ridges that might not otherwise be suitable for full-sized implants.

implants (Figure 1). Because of this, it was decided to get a CT scan to accurately detect the amount and quality of bone remaining in the maxilla. Using a dual scan technique, the patient’s denture was scanned individually as well as in the patient’s mouth. It is important to note the denture had radiographic markers (gutta-percha points) placed on the facial and palatal aspects of her existing denture held by sticky wax (Figure 2). The DICOM file was then seamlessly uploaded to 3DDX.com (3D Diagnostics) for conversion and a treatment planning session using SimPlant (Materialise). With the assistance of the doctor on staff, we identified the most ideal areas for placement of the implants within the boundaries of the prosthesis (Figure 3). In order to stabilize her maxillary denture, four dental implants would be placed in the premaxilla area to

Case history A woman in her early 60s presented to our office frustrated with her upper complete denture that opposed a lower complete overdenture supported by five dental implants with corresponding Locator® (Zest) attachments. She complained that her upper denture was currently nonretentive, always moving around during eating. She was pleased with her lower overdenture, so she requested a similar type of restoration for the upper arch. Palpation and radiographic examination revealed a moderately narrowed maxillary ridge that would not allow adequate width for traditional-sized dental

Volume 6 Number 4

depth using a surgical motor (AEU-7000E, Aseptico) with generous amounts of cooled sterile water at a set speed of 1200rpm. Once the initial osteotomies were created, the surgical guide was removed. The pilot drill was then reintroduced into the sites with a surgical stop ensuring adequate length was achieved (Figure 5). Paralleling pins (Zest) were placed in the sites of the osteotomies (Figure 6), and an X-ray taken to check the angulations to ensure proper orientation among the implant sites. Once the osteotomies were completed, four (2.9 mm x 10 mm) LODI dental implants (Figure 7) were placed in the osteotomies using the implant latch driver (Figure 8) set at a speed of 50rpm with a placement torque at 35Ncm until increased torque was necessary. The ratchet wrench was then connected to the adapter, and the implants torqued to final depth reaching a torque level of 55Ncm (Figure 9). Since the final seating torque measured over 30Ncm, the implants were immediately loaded.

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aid in the retention of this prosthesis. Our selection consisted of four 2.9 mm x 10 mm Zest LODI (Locator Overdenture Dental Implants) dental implants. Once implant size and location were agreed upon, a surgical pilot guide was ordered by 3DDX and fabricated by SimPlant® (Materialise) (Figure 4). Freestanding small diameter implants with attachments like the Locator Overdenture System (Zest) used to retain overdentures provide numerous advantages, including enhanced esthetics, phonetics, ease of maintenance, low cost, and simplified hygiene for patients who don’t have the bone for traditionalsized dental implants. It is important to remember that this type of prosthesis is primarily tissue-borne with the implants providing retention and stability. According to Misch’s classification, this would be a RP5 restoration. Utilizing the pilot surgical guide for alignment, a 1.6 mm pilot drill was placed into the sites and advanced to the full

Figure 7: Zest’s LODI implants

Figure 8: LODI implant ready for insertion

Figure 9: Placement of LODI implants

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Volume 6 Number 4 Implant practice 27

CLINICAL

Figure 10: 2.5 mm gingival height Locator attachment

Figure 11: Locator attachments tightened onto implants

Figure 12: Locator caps with block out rings

Figure 13: VOCOâ&#x20AC;&#x2122;s fit test check

Figure 14: Placement of adhesive for pick-up material

Figure 15: Placement of Quick Up into denture

Figure 16: Placement of Quick Up onto Locator caps

Figure 17: Denture with picked up housings

A 2.5 mm height Locator attachment was placed onto the implants (Figures 10 and 11) with a white block out spacer ring and Locator denture cap (Figure 12). Utilizing a marking stick (Dr. Thompsonâ&#x20AC;&#x2122;s Marking Sticks), we identified the areas in the denture that would require removal for the overdenture housings. Once relieved, Quick Up Test C&B silicone (VOCO America) was injected into the overdenture recesses. The overdenture was seated over the attachment caps and the Quick Up Test C&B (VOCO America) was allowed to set before the overdenture was removed. Any interference that was detected between the denture base and attachments was checked and eliminated (Figure 13). Adhesive was added to the cleaned and dried recesses (Figure 14) that we created in the denture and filled with cold cure acrylic (Quick Up, VOCO America) [Figure 15]. Additionally, Quick Up material was also placed onto the Locator caps (Figure 16). The denture was then seated onto the implants and allowed to polymerize. Upon setting, the denture was relieved of any excess flash (Figure 17). The patient was very pleased with the fit, function and esthetics of the modified denture prosthesis. The Panorex X-ray of the implants depicted an ideal placement (Figure 18). 28 Implant practice

Figure 18: Final panorex

With the addition of small diameter implants such as the Locator Overdenture Implants, thin ridges can now benefit from denture stabilization with the huge benefit of the Locator (Zest) overdenture attachment system. Some of the advantages of the Locator (Zest) attachment system include a self-aligning feature, dual-retention, and

one of the lowest implant attachment profiles available. Most importantly, these small diameter implants give dentists and their patients an easy, less expensive, and rapid way of solving many of the difficult problems that arise with complete dentures. IP

Volume 6 Number 4

G N I H T T E S N E O B B E H T NEXT TO

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abe

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th*

r Metal M at

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

Visit TrabecularMetal.zimmerdental.com to view a special bone ingrowth animation and request a Trabecular Metal Technology demo. www.zimmerdental.com ©2013 Zimmer Dental Inc. All rights reserved. * Data on file with Zimmer Dental. Please check with a Zimmer Dental representative for availability and additional information.

BEST OF CLASS

Implant Practice US congratulates the 18 winners of Pride Institute’s “Best of Class” Technology Awards F

or 5 years, these prestigious awards have become renowned for recognition of products and services that impact clinicians and demonstrate excellence. Pride Institute’s “Best of Class” Technology Awards, created by Dr. Lou Shuman, President of Pride Institute, are determined through thoughtful, unbiased discussion by a panel of dental professionals. The distinguished panel of experts works all year assessing products, culminating in a spirited and honest debate and final decision process that occurs annually at the Chicago Midwinter Meeting. The winning technologies can have a profound impact on purchasing decisions by the dental community, leading to better patient care and more effective practice management. The Awards allow a variety of products — obscure, well-known, basic, and aspirational — the chance to be honored. “I am very proud of the integrity and unbiased selection process provided by our panel,” said Dr. Shuman. “Not every category has a winner – only those products that are truly differentiated from the competition. The purpose of these awards is to provide the dental community with products of excellence that will have the greatest impact.” IP

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• Parag Kachalia, DDS — Vice-Chair of

Preclinical Education, Research and Technology, University of Pacific School of Dentistry

30 Implant practice

Volume 6 Number 4

CONTINUING EDUCATION

Treatment planning of implants in the esthetic zone: part three In the final part of the series, Drs. Sajid Jivraj, Mamaly Reshad, and Winston Chee look at the considerations for multiple implant placement

reviously, this series has looked at some of the factors that the predictability of the esthetic outcome of an implant restoration is dependent on, including: • Patient selection and smile line • Tooth position • Root position of the adjacent teeth • Biotype of the periodontium and tooth shape • The bony anatomy of the implant site This article will look at the considerations for multiple implants.

Educational aims and objectives This article aims to highlight the specific considerations that must be kept in mind when placing multiple implants. Expected outcomes Correctly answering the questions on page 41, worth 2 hours of CE, will demonstrate the reader can: • Understand the mechanism of bone loss. • Learn the best way to plan soft tissue management. • See how to approach cases for a predictably esthetic result.

Considerations for multiple implants Patients with extended edentulous spaces present greater anatomic and esthetic challenges, making it even more difficult to obtain an esthetic result with certainty. Following extraction and wound healing of two adjacent teeth, the ensuing apical and faciolingual resorption results in an edentulous segment that is flattened. The same diagnostic considerations need to be addressed as when looking at singletooth edentulous sites. The aim prior to implant placement is to have a three-dimensional configuration of hard and soft tissue, which will allow placement of implants in an ideal position. The placement of two missing central incisors poses an additional challenge. Following surgical placement, additional peri-implant bone remodelling takes place. In the frontal plane, two processes occur –

Sajid Jivraj, DDS, MSEd, is clinical associate professor at Herman Ostrow USC School of Dentistry in Los Angeles, California. He is a board member of the British Academy of Restorative Dentistry and honorary clinical teacher at Eastman Dental Institute London, England. He owns a private practice in Ventura, California. Mamaly Reshad, BDS, MSc, is honorary clinical teacher at Eastman Dental Institute London, England. He works in private practice at 30a Wimpole Street, London. Winston W.L. Chee, DDS, FACP, is the Ralph and Jean Bleak Professor of restorative dentistry, director of implant dentistry, and the co-director of the advanced prosthodontics program at the Ostrow School of Dentistry of the University of Southern California.

32 Implant practice

Figure 1: When implants are placed 3 mm and greater apart, the bone loss from the adjacent implants does not overlap, resulting in minimal crestal bone loss (modified from Tarnow, et al., 2000)

Figure 2: When implants are placed too close together, bone loss from adjacent implants overlaps, resulting in additional loss of the crestal bone (modified from Tarnow, et al., 2000)

Figure 3: Bone loss is circumferential around the implants. When implants are placed too close together, the vertical and horizontal components of bone loss compromise the peak of the interproximal bone and thus the resulting soft tissues

Figure 4: Ideal implant theoretically will maintain the interproximal peak of bone; however, there are no longterm studies to support this

one between the implant and the adjacent natural tooth and one between the two adjacent implants. On the tooth-implant side, the predictability of the interdental papilla is governed by the height of the interproximal bone crest of the tooth. If this height is favorable, there is a good certainty that the interdental papilla will be maintained following implant placement. The bone crest between the two implants is likely to undergo further resorption in an apical direction. This is accompanied by a loss of inter-implant soft tissue that, in the case of multiple edentulous sites, will result

in black triangles between the adjacent restorations.

Tackling adjacency Many clinicians have sought after the ideal implant distance required to maintain the interdental papilla. Tarnow, et al., (2000), performed a radiographic study to address this clinical problem. Radiographic measurements were taken at a minimum of 1 and 3 years after implant exposure. All radiographs were taken with a paralleling technique. Radiographs were computer scanned, imaged, and magnified for measurement. Volume 6 Number 4

3.4 mm with a range of 1-7 mm. Although this was a retrospective study, and there were many variables such as operator, implant type, placement, and so forth, it did give us information that soft tissue between two adjacent implants in the esthetic zone is not a predictable procedure. The patient must be aware of this when treatment planning, or alterations must be made in the treatment plan to provide an esthetic result. Recreating interdental papilla between two adjacent implants is a formidable task. Restoratively, clinicians alter the position of the contact point to give the illusion of papilla. The thin spicule of bone remaining between the implants may be sufficient to maintain the papilla during the first few years of the restorations service. However,

with implants allows for the use of fixed partial dentures and the opportunity to utilize ovate pontics to help support the soft tissue and give an illusion of papillae. The authors have encountered many situations where a one implant per tooth philosophy is espoused to. This can be particularly detrimental in the esthetic zone. The literature is quite clear that maintaining papillae between implants is not predictable. Even with the advent of scalloped-type implants, there are no longterm studies showing papilla maintenance. For an esthetic outcome, it is more predictable to place implants away from each other so that the intervening soft tissue can be sculpted to give the illusion of papilla. One common error often published in the literature is placement of four implants

Figure 5: If implants are placed too facially, this will compromise the thickness of the facial bony plate, which can eventually resorb. This will result in apical migration of the soft tissue

Figure 6: Ideal implant placement will allow fabrication of restorations with ideal contours

Figure 7: Implants placed too close together will result in compromised restorative contour

Figure 8: Placement of adjacent implants compromises the inter-implant peak of bone, resulting in resorption and soft tissue loss

there are no clinical studies with longterm results presented to date to illustrate the predictability of papilla between two adjacent implants.

to replace lateral incisor to lateral incisor. This philosophy of implant placement will not yield an esthetic outcome (Figure 8). Placement of two implants in both lateral incisor regions and fabrication of a fixed partial denture, sculpting the intervening tissue with ovate pontics, is likely to produce an illusion of papilla, which will be more pleasing to the observerâ&#x20AC;&#x2122;s eye (Figures 9A, 9B, and 9C). This placement philosophy can also be reserved for extended edentulous spans where esthetics are of paramount importance (Figures 10-15). Placement of implants in multiple edentulous spaces must follow the same principles as for single tooth situations: placement must follow appropriate diagnosis and treatment planning,

Clinical challenges Another clinically challenging situation is replacement of a maxillary canine and adjacent lateral incisor. This becomes clinically more challenging because the edentulous space is smaller, and the inter-implant soft tissue tends to be less voluminous. Consideration in this instance should be given to placement of a single implant in the canine region and cantilevering a lateral incisor from it. Placement of the implant should follow all the principles discussed previously. Replacement of several missing teeth

Volume 6 Number 4 Implant practice 33

CONTINUING EDUCATION

The following measurements were taken: 1. Lateral distance from the crest of the inter-implant bone to the implants 2. Vertical crestal bone loss 3. Distance between the implants at the implant/abutment interface When implants were placed too close together, the bone remodelling overlapped to a great degree, and consequently resulted in loss of vertical bone height. This subsequently had soft tissue implications. When implants were placed 3 mm and greater, lateral bone loss from the adjacent implants did not overlap, with minimal resultant crestal bone loss. They concluded that it is more difficult to create or maintain papilla between two adjacent implants than it is between an implant and a natural tooth. Their recommendation was that when two implants are placed adjacent to each other in the esthetic zone, a minimum of 3 mm of bone should be retained between them at the implant/abutment level (Figures 1 and 2). This particular study addressed bone loss between the implants. It should be remembered that the bone saucerization has two dimensions â&#x20AC;&#x201C; a horizontal and vertical. Radiographs only demonstrate the horizontal aspect of bone saucerization. Bone loss occurs circumferentially around the implant, and when two implants are placed adjacent to each other, facial bone loss also occurs (Figures 3 and 4). This has implications in terms of stability of the facial gingival margin. If the implants are placed too far forward, there will be less facial bone, and this will ultimately result in apical migration of the free gingival margin (Figure 5). Placement of adjacent implants is also critical for restorative contours: placing implants too close together makes it difficult for the laboratory technician to fabricate restorations with pleasing esthetic contours. Tarnow, et al., (2003), also performed a study to determine the height of the soft tissue to the crest of the bone between two adjacent implants. This was done independent of the location of the contact point. They looked at 136 inter-implant papillary heights in 33 patients by eight examiners. A standardized periodontal probe was used and placed from the height of the papilla to the crest of the bone. They found that the mean height of papilla between two adjacent implants was

CONTINUING EDUCATION

Figure 9A: It is easier to develop illusion of papilla between an implant and an adjacent pontic. Implant placement philosophy should take advantage of such techniques

Figure 9B: Patient suffered trauma. This patient has been treatment planned for extraction of the lateral incisors, root banking of the central incisors, and placement of implants in lateral incisor region to support a four-unit bridge

which includes a diagnostic wax-up and fabrication of a surgical guide to facilitate implant placement. If these techniques are not followed, it is all too easy to find implants in the wrong position where prosthetic strategies have to be utilized to satisfy the patientâ&#x20AC;&#x2122;s demand for esthetics. In situations like these, patient expectations are unlikely to be met (Figures 12, 13, and 14).

Conclusion When a patient has a missing anterior tooth and desires replacement, a decision must be made by the dentist and patient as to the method of replacement. Common choices include a conventional fixed partial denture, a resin-bonded fixed partial denture, or an 34 Implant practice

Figure 9C: Four-unit bridge on two implants in lateral incisor region. Note how tissue in central incisor region has been sculpted. Also note how buccal contours of tissue in central incisor region has been maintained

implant-borne restoration. Each has its advantages and disadvantages. The conventional fixed partial denture has the advantages of being an established treatment procedure, having predictable esthetics, and being expedient. It has the disadvantage of requiring preparation of adjacent teeth, and potential risk for periodontal and pulpal tissue. The resin-bonded partial denture has the advantages of preserving tooth structure, having predictable esthetics, and reduced cost. It has the disadvantages of being technique sensitive for the dentist and technician, and often losing retention, which may lead to decay. Implants used to replace missing teeth in the esthetic zone have many advantages

from preservation of unrestored adjacent teeth, halting the resorption of edentulous spaces, and providing support. However, at present, they have the disadvantages of long treatment time, requiring a provisional restoration during implant integration, surgical placement of the implant, surgical uncovering of the implant, a provisional after the implant is uncovered, and having higher cost. Much effort is being directed at shortening the treatment time and making delivery of the service more time efficient. Immediately loading implants is one direction that many researchers and clinicians are taking; however, the parameters of when immediately loading implants is possible have not been Volume 6 Number 4

Figure 11: Facial view of slide in Figure 10

Figure 12: Intraoral photograph depicting placement of two implants in upper right lateral incisor and upper left canine region

Figure 13: Laboratory slide illustrating a five-unit splinted screw-retained bridge with pontics designed to compress tissue and provide illusion of interproximal papilla

Figure 14: Lateral view of five-unit screw-retained zirconia bridge. Note how soft tissue has been developed

Figure 15: Buccal view of bridge depicting sculpting and maturation of soft tissue to give appearance of interproximal papilla

established, and until that time, immediately loading implants must be made on an individual and case-by-case basis, taking into account all the factors that affect loading of the initially non-osseointegrated implants. Even with all the disadvantages

listed, the implant-supported single tooth restoration can be successfully executed when all the factors discussed in this series of articles are addressed. When one or more of the adjacent teeth are unrestored or in need of only a minor restoration, the single tooth implant

should be considered the restoration of choice. IP

References

retrospective study in the maxillary anterior region. J Periodontol. 2001;72(10):1364-1371.

Parts of this article were reprinted with permission from the British Dental Journal.

Adell R, Eriksson B, Lekholm U, Brånemark PI, Jemt T. A long-term follow-up study of osseointegrated implants in the treatment of totally edentulous jaws. Int J Oral Maxillofac Implants. 1990;5(4):347-359.

D’Addona A, Nowzari H. Intramembranous autogenous osseous transplants in aesthetic treatment of alveolar atrophy. Periodontol 2000. 2001;27:148-161.

Parel SM, Sullivan DJ. Esthetics and Osseointegration. San Antonio, TX: Uniiversity of Texas Health Science; 1989. Phillips K, Kois JC. Aesthetic peri-implant site development. The restorative connection. Dent Clin North Am. 1998;42(1):57-70.

Agar JR, Cameron SM, Hughbanks JC, Parker MH. Cement removal from restorations luted to titanium abutments with simulated subgingival margins. J Prosthet Dent. 1997;78(1):43-47.

Esposito M, Ekestubbe A, Gröndahl K. Radiological evaluation of marginal bone loss at tooth surfaces facing single Brånemark implants. Clin Oral Implants Res. 1993;4(3):151-157.

Saadoun AP, LeGall M, Touati B. Selection and ideal tridimensional implant position for soft tissue esthetics. Pract Periodontics Aesthet Dent. 1999;11(9):1063-1072, 1074.

Becker W, Ochsenbein C, Tibbetts L, Becker BE. Alveolar bone anatomic profiles as measured from dry skulls. Clinical ramifications. J Clin Periodontol. 1997;24(10):727-731.

Kan JY, Rungcharassaeng K, Umezu K, Kois JC. Dimensions of peri-implant mucosa: an evaluation of maxillary anterior single implants in humans. J Periodontol. 2003;74(4):557-562.

Salama H, Salama M, Kelly J. The orthodontic-periodontal connection in implant site development. Pract Periodontics Aesthet Dent. 1996;8(9):923-932, 934.

Belser UC. Esthetic checklist for the fixed prosthesis. Part II: Biscuit bake try in. In: Scharer P,Rinn LA, Kopp FR, eds. Esthetic guidelines for Restorative Dentistry. Chicago, IL: Quintessence; 1982: 188-192.

Kois JC. Esthetic extraction site development: The biological variables. Contemp Esthet Restor Pract. 1998;2:10-17.

Buser D, Martin W, Belser UC. Optimizing esthetics for implant restorations in the anterior maxilla: anatomical and surgical considerations. Int J Oral Maxillofac Implants. 2004;19(suppl):43-61. Chee WW. Provisional restorations in soft tissue management around dental implants. Periodontol 2000. 2001;27:139-147. Chee WW. Treatment planning and soft-tissue management for optimal implant esthetics: a prosthodontic perspective. J Calif Dent Assoc. 2003;31(7):559-563. Chiche FA, Leriche MA. Multidisciplinary implant dentistry for improved aesthetics and function. Pract Periodontics Aesthet Dent. 1998;10(2):177-186. Choquet V, Hermans M, Adriaenssens P, Daelemans P, Tarnow DP, Malevez C. Clinical and radiographic evaluation of the papilla level adjacent to single-tooth implants. A

Kois JC. Predictable single-tooth peri-implant esthetics: five diagnostic keys. Compend Contin Educ Dent. 2004;25(11):895-6, 898, 900, 906-907. Kois JC, Kan JY. Predictable peri-implant gingival esthetics: surgical and prosthodontic rationales. Pract Proced Aesthet Dent. 2001;13(9): 691-698, 700, 721-722.

Sullivan RM. Perspective on aesthetics in implant dentistry. Compend Contin Educ Dent. 2001;22(8):685-692. Tarnow DP, Magner AW, Fletcher P. The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla. J Periodontol. 1992;63(12): 995-996. Tarnow DP, Cho SC, Wallace SS. The effect of inter-implant distance on the height of inter-implant bone crest. J Periodontol. 2000;71(4):546-549.

Magne P, Belser U. Natural oral esthetics. In: Magne P, Belser U. Bonded Porcelain Restorations in the Anterior Dentition. A Biomimetic Approach. Chicago, IL: Quintessence; 2002: 57-98.

Tarnow D, Elian N, Fletcher P, Froum S, Magner A, Cho SC, Salama M, Salama H, Garber DA. Vertical distance from the crest of bone to the height of the interproximal papilla between adjacent implants. J Periodontol. 2003;74(12):1785-1788.

Naert I, Quirynen M, van Steenberghe D, Darius P. A study of 589 consecutive implants supporting complete fixed prostheses. Part II: Prosthetic aspects. J Prosthet Dent. 1992;68(6):949-956.

Thilander B, Odman J, Jemt T. Single implants in the upper incisor region and their relationship to the adjacent teeth. An 8-year follow-up study. Clin Oral Implants Res. 1999;10(5):346-355.

Neale D, Chee WW. Development of implant soft tissue emergence profile: a technique. J Prosthet Dent. 1994;71(4):364-368.

Tjan AH, Miller GD, The JG. Some esthetic factors in a smile. J Prosthet Dent. 1984;51(1):24-28.

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Figure 10: Clinical slide showing implant placement so that illusion of papilla can be developed

CONTINUING EDUCATION

Monitoring, diagnosis, and treatment of peri-implant diseases Drs. Cemal Ucer, David Speechley, Simon Wright, and Eddie Scher look at the clinical headlines from the Association of Dental Implantology UK’s consensus meeting Best practice The Association of Dental Implantology UK (ADI) expert panel was asked to discuss the pathogenesis, diagnosis, and management of peri-implant diseases and reach a consensus based on the best available evidence and their expert opinion. The results of the consensus meeting have been summarized as best practice guidelines in two papers: the ADI guidelines on monitoring and maintenance of peri-implant diseases, and the ADI guidelines on treatment of peri-implant diseases. These papers are available online to ADI membership.

ental implants have created new restorative possibilities and treatment modalities only dreamed of two or three decades ago, which are now commonplace in clinical practice. Coupled with better understanding of patient assessment, diagnosis, treatment planning, and restorative loading principles, dental implant therapy today offers a highly cost-effective long-term solution for the reconstruction of missing teeth for millions of patients worldwide. Nevertheless, as biomechanical de-

Educational aims and objectives The aim of this article is to discuss the monitoring, diagnosis, and treatment of peri-implant diseases (PID). Expected outcomes Correctly answering the questions on page 41, worth 2 hours of CE, will demonstrate the reader can: • Recognize the clinical signs of PID. • Identify the risk factors of PID. • See the difference between peri-implant lesions and periodontal lesions. • Learn about surgical and non-surgical treatment of PID.

vices, dental implants need to work constantly under adverse mechanical and biological conditions that make them prone to complications during long-term function. Although the mechanical complications have been reduced up to a certain extent due to advances in implant technology and design, there is still uncertainty among the dental team on how to prevent, monitor, and manage the biological complications around implant restorations (ADI survey, 2012). Recognizing the importance of this, the Association of Dental Implantology (ADI) convened an expert panel consensus meeting in November 2012 in Westminster,

London. The focus of the meeting was to review the current evidence on peri-implant diseases and produce best practice guidelines on how to monitor, prevent, and treat this increasingly common problem. The panel of experts, under the chairmanship of the ADI president Dr. Cemal Ucer and scientific coordinator Dr. Eddie Scher, included professors Mariano Sanz (Spain), Tord Berglundh (Sweden), Nikos Donos (UK), Nicola West (UK), and Drs. Maria Retzepi (UK), Simon Wright (UK), and the immediate past president of the British Society of Dental Hygiene and Therapy (BSDHT), Sally Simpson.

Peri-implant diseases Professor Donos opened the conference by explaining that peri-implant diseases (PID) are infectious conditions as a direct cause and effect relationship that has now been clearly demonstrated between dental plaque (biofilm) and peri-implant diseases

Dr. Cemal Ucer is the clinical lead of the diploma/MSc in dental implantology at the University of Salford, Manchester, England, and runs a referral practice at Oaklands Hospital, also in Salford. He is president of the ADI. Dr. David Speechley is joint principal of the Glencairn Dental Practice in Bebington and Heswall, England, and northwest representative for the ADI. Dr. Simon Wright is joint principal of the Glencairn Dental Practice in Bebington and Heswall, England, and director of education at the ADI. Dr. Eddie Scher, London, England, is editor-in-chief of Implant Dentistry Today and scientific coordinator for the ADI.

36 Implant practice

Figure 1: “Surviving” implants with radiological sign of varying levels of crestal bone loss (CBL)

Figure 2: A surviving implant with advanced CBL and at risk of being lost due to it (image courtesy of Dr. Koray Feran) Volume 6 Number 4

Figure 3: Probing is a valid method of assessment

individualized according to each patient’s periodontal condition and predisposing risk factors. As always, prevention is better than treatment and, in this respect, each member of the dental team, including the patient (by compliance on home care), has responsibilities in maintenance, early diagnosis, and appropriate management of problems. Professor Nikos Donos reminded the audience that the periimplant diseases may be broken down into two distinct entities: mucositis, a reversible inflammatory response contained within the soft tissues, and peri-implantitis, involving further tissue destruction and irreversible peri-implant bone loss that is less amenable to treatment. Both conditions have similarities, respectively, to gingivitis and periodontitis in pathogenesis (Okayasu and Wang, 2011), but the disease progression is thought to be faster around implants due to physiological differences in connective tissue morphology (Lang and Berglundh,

2011). Figure 1 shows “surviving” implants with radiological sign of varying levels of crestal bone loss (CBL). Questions arise: has CBL been stopped or will it continue? Are these implants at risk of being lost? What is the optimum management of an implant with CBL? Figure 2 shows a surviving implant with advanced CBL. The definition of “success” of an implant depends on the criteria used. There is consensus that “no crestal bone loss” is a prerequisite for success – meaning that this implant is therefore classified as “at risk” of being lost.

of assessment, as there is a correlation between recorded bone levels and the radiographic probe penetration (Quirynen, et al., 1991). BOP and PPD are essential diagnostic tests, and the use of titanium probes is recommended routinely (ADI, 2013). However, false positive results could occur when excess pressure is applied. Therefore, use of light pressure or ideally a calibrated probe (to apply less than 25N pressure) is essential. The clinical diagnosis of peri-implantitis is characterized by increased probing depths (PPD of more than 3 mm), bleeding on probing

Figure 4: Inappropriate restorative contours (or implant abutment design) may restrict adequate plaque control and make probing difficult or impossible

Assessment and clinical signs While the most common alleged negligence in implant dentistry relates to failures in assessment and treatment planning, failure to diagnose and treat peri-implant diseases in a timely fashion is becoming highly represented in the litigation league tables. If we are to be able to measure and assess peri-implant disease progression in our patients, then the recording of baseline data is imperative. Lang and Berglundh (2011) proposed the time of prosthesis installation was the time to record baseline criteria, and should include: • A radiograph to determine crestal bone levels • Peri-implant probing (PPD) [ideally six point probing] and bleeding on probing (BOP). Assessment of plaque control is also recommended • When changes in clinical parameters indicate disease (e.g., BOP, increasing in PPD) an X-ray should be repeated. Probing (Figure 3) is a valid method

(BOP), pain, swelling, and suppuration. Radiographic evidence of crestal bone loss is necessary to confirm the diagnosis of peri-implantitis. Suppuration occurs more frequently around implants with “progressive” bone loss, particularly in smokers, and may be associated with episodes of active tissue destruction. Implant mobility obviously denotes “end stage” failure, which may or may not be painful (Misch, et al., 2008; Okayasu, Wang, 2011; Subramani, Wismeijer, 2012). Inappropriate restorative contours (or implant abutment design) may restrict adequate plaque control and make probing difficult or impossible (Figure 4). As there is a direct cause and effect relationship between plaque and periimplant infection, inappropriate restorative design is a common predisposing factor for peri-implant diseases. Bone loss around implants often occurs as a saucer defect (with or without vertical bone loss), as can be seen here radiographically. It

Volume 6 Number 4 Implant practice 37

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(Mombelli, et al., 2007). The incidence of PID is not fully known, but literature reports indicate that it could be as high as 56% depending on how the disease is categorized or defined (Tomasi and Derks, 2012). Whatever the controversies or uncertainties are, the main consensus on PID management is that dental implant restorations must be meticulously monitored and maintained as soon as the implants are introduced into the oral environment. To ensure the best possible survival, this must be done through a systematic maintenance program that is

CONTINUING EDUCATION must be noted that visualizing bone loss on the buccal or lingual aspects of the implant shoulder is not possible using 2D images, so periapical X-rays could result in underdiagnosis of the extent of bone loss around implants. The pattern of bone loss varies between subjects, is nonlinear in progression, and the rate of bone loss increases over time (Fransson, et al., 2010). The evidence for or against the advantages of using a particular type of implant surface or abutment design on the stability of crestal bone is however inconclusive (ADI, 2012). Since failing implants often demonstrate few, if any, signs or symptoms that are perceptible to the patient in early stages of the disease, the entire dental team has responsibility for monitoring and recognizing it – especially in the early and reversible stages. When clinical signs are overlooked by healthcare professionals due to failure to monitor and maintain implants adequately, implant mobility may be the patient’s first perceived symptom, by which time all treatment options are gone, and the implant has failed. An equally distressing situation also arises when gross crestal bone loss (CBL) is suddenly recognized, making the remedial treatment difficult or impossible (often with esthetically undesirable results). The cardinal rule therefore applies here, too: monitor and prevent, and intervene early when it’s still treatable.

Risk factors There is compelling evidence that poor oral hygiene, history of periodontitis, and cigarette smoking are major risk factors for the development of peri-implant disease (ADI Guidelines, 2013). Insufficient data exists to link the risk of peri-implant disease to alcohol consumption and diabetes, although the evidence linking diabetes and peri-implant disease would support the level of metabolic control of diabetes is itself an important factor in assessing risk. The evidence linking genetic traits and implant surfaces is also limited and somewhat conflicting, although all the above may coexist, and their effects may be synergistic. Bacterial infection is the most significant causative factor for periodontal and peri-implant diseases. Colonization occurs rapidly on introduction of the implant in the oral environment, with a shift towards gram-negative proliferation and a thickening of biofilms in the progression of disease. Implant malpositioning and 38 Implant practice

Figure 5: Peri-implantitis is characterized by bacterial infection, inflammation, bleeding, swelling, deep pocketing, and crestal bone loss (image courtesy of Dr. Koray Feran)

Figure 6: Treatment of peri-implantitis involves thorough debridement with metal (preferably titanium) instruments and decontamination of the implant surface. Surgical access is often required to achieve this (image courtesy of Dr. Koray Feran)

inappropriate prosthesis design leading to increased plaque retention are two important predisposing risk factors in the etiology of peri-implant diseases (ADI Guidelines in PID, 2013). Studies have shown that the 5-year survival statistics of patients with a past history of controlled periodontitis are not significantly lower than those who have never been affected. The longer-term prognosis, however, may be less positive, with significantly higher risk of crestal bone loss (CBL) occurring in patients with a history of periodontal disease. Recent work suggests that patients with residual probing depths of 5 mm or more at the end of periodontal therapy run a higher risk of peri-implantitis and implant loss than patients with lower values (Pjetursson, et al., 2012). Aggressive periodontitis is much more rare than chronic forms, but it is a significant risk factor for dental implant therapy, with significantly lower implant survival (Mengel and Flores-de-Jacoby, 2005). There is consensus, therefore, that the implant patient with a history of periodontal disease requires more intensive peri-implant maintenance and monitoring.

for soft tissue attachment is fundamentally different around teeth compared with implants. While collagenous fibers attach to the cementum in a horizontal fashion, the attachment in the case of the implant is by a simple tissue repair process of weaker hemidesmosomal attachment. Bacterial challenge induces inflammatory changes around both teeth and implants, though not all cases of gingivitis or mucositis progress to become periodontitis or peri-implantitis. Early diagnosis renders treatment more likely to succeed, but peri-implantitis diagnosis and management is frequently complicated by overbuilt or poorly-designed prostheses or crown work. Failure to adequately monitor disease progression also appears to be a major problem. Once the soft tissue seal has broken down around an implant, it becomes vulnerable to infection as a result of plaque adhesion and accumulation. It is therefore paramount to put in place effective oral hygiene measures directed at prevention and disruption of the biofilm that starts forming as soon as an implant is placed in the mouth. Calculus formation, suppuration, and fistula formation are all easy to recognize – however early signs of disease may be difficult to recognize, and disease progression may be incipient. In periodontitis, the inflammatory process is contained and encapsulated within the pocket, progression being by ulceration of the pocket epithelium. The base of the pocket in the case of peri-implantitis does not have an epithelial component, hence the disease progresses apically more rapidly. The absence of a periodontal ligament also means the inflammatory

Are peri-implant lesions different from periodontal lesions? Professor Berglundh’s studies have shown that although the two disease processes appear clinically similar, there are significant and critical histopathological differences between periodontal and peri implant disease progression (Berglundh, Zitman, and Donati, 2011). It has been shown that although there are distinct morphological similarities, the mechanism

Volume 6 Number 4

Professional attitudes Dr. Simon Wright presented the results of a recent survey conducted by the ADI on the current attitudes and protocols of UK implant dentists towards the monitoring, maintenance, and management of peri-implant diseases. The results clearly demonstrated a wide diversity in maintenance protocols for implant patients in the UK, indicating an urgent need for clear guidance in this area. There was little consensus among the respondents on a standardized implant maintenance protocol and what parameters should be routinely monitored or recorded. There was also disagreement on how to treat periimplant diseases. In accordance with current evidence, the specialist and experienced clinicians stated that they used metal (titanium) scalers so that plaque could be removed effectively, despite the risk of damaging/ scratching the implant surfaces. Surprisingly, some dentists advocated the use of plastic scalers even though the current evidence shows these to be ineffective for plaque removal. Although the evidence is weak, the majority of respondents relied on the use

Non-surgical treatment

Figure 7: Thorough cleaning and decontamination can be achieved by using a variety of techniques that are not yet well validated

of oral rinses as an essential adjunct in the treatment of mucositis and peri-implantitis. A wide selection of systemic antibiotics were prescribed (in absence of conclusive evidence), the most common of which were amoxicillin and metronidazole in combination (for all severity of diseases). The respondents agreed that mucositis may be treated without surgery; however 40% of specialists, and 30% of the most experienced still felt it necessary to raise a flap to debride and disinfect the implant surface effectively. The more severe the lesion, the more respondents advocated surgical treatment. Interestingly, although the literature suggests that regeneration of the tissue is also a key objective, relatively few used grafting or regenerative procedures to treat peri-implant bony defects (only 20% of the specialists and 30% of the GPs grafted even the most severe cases). Simon resummarized the findings of this survey and highlighted once again the urgent need to develop practical clinical guidelines on the maintenance and treatment of peri implant diseases. Sally Simpson reminded the audience that implant dentistry is a teamwork discipline, and summarized the role of dental hygienists and therapists. With the passage of time, hygienists and therapists are gaining patient acceptance and confidence, and have now become a vital part of the implant team, not only for the post treatment care and maintenance but also for the pre-surgical assessment and treatment of the periodontal condition of the prospective implant patients.

Dr. Maria Retzepi discussed how nonsurgical treatment of periodontitis encompasses a variety of therapeutic modalities, which are performed without deliberately injuring the epithelial mucosa and which are characterized by an infection control strategy. It should be noted that peri-implant diseases are polymicrobial anaerobic infections, and the disruption of the bacterial biofilm from the implant surface constitutes the fundamental part of the first line treatment of PID. Furthermore, it is advocated that the instruments used for surface decontamination should not make the surface more biofilm-retentive, but they should aim to minimize de novo biofilm formation while allowing effective removal of plaque. In vitro studies have reported that the use of metal instruments increases the titanium surface roughness. Titanium curettes, non-metal instruments, rubber cups, and air abrasives seem to be the instruments of choice for the treatment of a smooth or rough implant surface, especially if the preservation of surface integrity is the primary goal. Air abrasion, Er:YAG irradiation, and photodynamic treatment have also demonstrated efficiency in removing plaque biofilms, but the evidence to show which technique (if any) is better is still lacking. The presence of the suprastructure, the implant design, and the implant surface characteristics may limit access to infected sites, and as a result, the non-surgical therapy may be rendered ineffective. For the treatment of mucositis, significant reduction in BOP and probing depth (PDD) values can be achieved following mechanical debridement, whereas no additional benefit from the adjunctive application of chlorhexidine gel or systemic antibiotic delivery have been shown. In the presence of peri-implantitis, submucosal mechanical debridement alone may have limited efficacy especially in deeper lesions, due to the difficulty of gaining access. While minor additional beneficial effects have been reported for Er:YAG therapy and for air-abrasive therapy with the application of amino acid glycine powder, these new techniques still require general validation. The delivery of local antibiotics, (e.g., doxycycline polymer device, minocycline microspheres, and chlorhexidine gluconate chips) present additional beneficial effects when used adjunctively to submucosal

Volume 6 Number 4 Implant practice 39

CONTINUING EDUCATION

reaction is intimately associated with the implant surface and bone, with no protective element. Preclinical studies conducted by Professor Berglundh and his coworkers have demonstrated that disease progression around an implant can be affected by the surface characteristics of the implant. Infection control can resolve both peri-implant mucositis and incipient periimplantitis, however surface characteristics have a major influence on the ease of biofilm removal and decontamination. Generally, less rough surfaces were shown to be more amenable to successful treatment than rougher surfaces. However, further studies are required to show if implant surface characteristics make any significant clinical difference in pathogenesis or progression of peri-implant disease. Professor Berglundh emphasised once again that the goal of therapy must be to bring about resolution of peri-implant lesions, and arrest further loss of supporting structures. This necessitates the first line treatment of meticulous debridement, plaque removal, and disruption of the biofilm. Figure 5 shows pocket formation and the loss of supporting tissue, with active destructive disease processes.

CONTINUING EDUCATION

mechanical debridement, but the evidence is still inconclusive. Dr. Retzepi concluded her presentation by reiterating the strong message of the meeting â&#x20AC;&#x201C; that a regular individualized maintenance program is paramount for the prevention, as well as long-term management, of peri-implantitis lesions.

Figure 8: The ultimate aim in treatment of peri-implantitis is to reserve the tissue loss by regenerating lost bone and achieving reosteointegration. This was discussed in detail during the consensus meeting

Surgical treatment Professor Mariano Sanz commented that although the evidence is still limited and somewhat confusing on the surgical management of peri-implantitis, patients present on a regular basis with periimplantitis-related problems, and it is our responsibility to treat these people in the most appropriate manner, with many procedures based on the principles employed in the treatment of periodontitis. In other words, lack of evidence for the effectiveness of a surgical treatment should not be seen as evidence of no benefit, but caution is required to manage PID surgically. The primary aim of initial therapy is the reduction of the inflammatory response, reduction of predisposing factors, and local non-surgical measures. Surgical periodontal therapy should only be initiated following careful and intense initial (non-surgical) therapy, which must include debridement, plaque removal, and decontamination of the implant surface, along with local or systemic antibiotics when appropriate. The consensus is that if nonsurgical mechanical therapy and adjunct antimicrobials do not resolve the lesion, then access flap surgery is recommended as a second line treatment (Figures 5-7). Access flap surgery, removal of granulation tissue, and implant surface decontamination may decrease plaque indices, BOP, suppuration, and probing depths (PDD). Such measures may result in control of further bone loss in up to 58% of implant sites over 5 years (Renvert, et al.). The evidence suggests that reconstruction using a variety of bone regenerative materials may be beneficial in producing defect infill including reosseointegration (Figure 8). However, no one technique or material has been shown to be more reliable. Further research and clinical validation is urgently required in this area. 40 Implant practice

Pocket depths Once roughened surfaces have become exposed and contaminated, it is likely that smoothing the surface may reduce plaque retention. This, in combination with resective surgery, could aid the resolution of peri-implantitis defects (Romeo, et al., 2007). Care must be taken to limit heat production when smoothing the titanium surface. Attempts should also be made to limit the scatter of titanium debris. The degree of disease resolution seems to be dependent on the initial bone loss around the implants (Serino and Turri, 2011). The evidence relating to the importance of keratinized mucosa is conflicting. However, most researchers conclude that presence of a band of keratinized mucosa will help to reduce peri-implant soft tissue trauma, mobility, and inflammation occurring at the shoulder of the implant. The incidence of peri-implant infection is greater around cement restorations than screw-retained restorations due to extrusion of excess cement into the periimplant soft tissues. This is now known as â&#x20AC;&#x153;cementitis.â&#x20AC;? Removal of any excess cement at the time of placement may be difficult and hampered by complicated superstructure design, or deep implant placement. Research has shown that approximately half the cases of periimplantitis when treated surgically do not have successful outcomes (ADI Guidelines, 2013). Smoking and early onset of disease are risk factors, while bone recontouring and antibiotics during the surgical stages, along with excellent oral hygiene regimes, seem to be associated with increased rates of success (Charalampakis, et al., 2011). The use of antibiotics seems to be generally agreed to be beneficial in these cases, but since almost no papers on the surgical treatment of peri-implantitis have been carried out without the use of antibiotics, it is impossible to quantify their effect.

Conclusions Long-term success of implant treatment primarily depends on satisfactory maintenance of the health of the periimplant tissues. The overall objectives of routine implant maintenance are similar to that of periodontal maintenance: establish presence of health or disease and offer supportive maintenance to improve plaque removal and oral hygiene (ADI Guidelines, 2013). Following the completion of treatment, the implant patient should be instructed on adequate home care and plaque control measures focusing on interdental cleaning with interproximal brushes. The patient should also be enrolled in an individually designed supportive periodontal therapy and infection control program according to their specific risk assessment profile (Donos, et al., 2012). The objective is to prevent development or recurrence of infection around the natural dentition and the implants. Since peri-implantitis has an infective etiology, its treatment is aimed at plaque removal, surface decontamination, and anti-infective measures (Mombelli and Lang, 1998). Studies have shown that implant scaling and meticulous plaque removal should be the first line of treatment for eliminating peri-implant mucositis and early peri-implantitis lesions (Faggion and Schmitter, 2010). If there is no improvement in attachment levels and PPDs, surgical interventions aimed at better debridement and decontamination (with or without adjunctive use of antibiotics) should be considered as a second line of treatment. It should also be noted that according to Renvert (2008), non-surgical therapy does not result in treatment of periimplantitis or resolution of the defect (ADI guidelines, 2013). IP References available upon request.

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Treatment planning of implants in the esthetic zone: part 3 JIVRAJ

Monitoring, diagnosis, and treatment of periimplant diseases UCER

1. Following extraction and wound healing of two adjacent teeth, the ensuing apical and faciolingual resorption results in an edentulous segment that ________. a. is flattened b. is scalloped c. is overlapped d. is rounded

1. Professor Donos opened the conference by explaining that peri-implant diseases (PID) are infectious conditions as a direct cause and effect relationship that has now been clearly demonstrated between ________and periimplant diseases. a. excessive probing b. connective tissue morphology c. dental plaque (biofilm) d. saucer defects

d. all of the above

2. The incidence of PID is not fully known, but literature reports indicate that it could be as high as ______ depending on how the disease is categorized or defined. a. 25% b. 36% c. 56% d. 74%

7. Suppuration occurs more frequently around implants with “progressive” bone loss, particularly in _______, and may be associated with episodes of active tissue destruction. a. alcohol drinkers b. smokers c. runners d. coffee drinkers

3. To ensure the best possible survival, this must be done through a systematic maintenance program that is individualized according to each patient’s _______. a. periodontal condition b. scheduling availability c. predisposing risk factors d. both a and c

8. When clinical signs are overlooked by healthcare professionals due to failure to monitor and maintain implants adequately, _________ may be the patient’s first perceived symptom, by which time all treatment options are gone, and the implant has failed. a. pulsating pain b. implant mobility c. swelling d. saucerization

2. Following surgical placement, additional _________takes place. a. crestal bone loss b. peri-implant bone remodeling c. osteoporosis d. soft tissue displacement 3. On the tooth-implant side, the predictability of the interdental papilla is governed by the ______ of the interproximal bone crest of the tooth. a. width b. depth c. height d. exposure 4. The bone crest between the two implants is likely to undergo further resorption in an apical direction. This is accompanied by a loss of inter-implant soft tissue that, in the case of multiple edentulous sites, will result in ________ between the adjacent restorations. a. a spicule of bone b. saucerization c. black triangles d. apical migration 5. When implants were placed ______ and greater, lateral bone loss from the adjacent implants did not overlap, with minimal resultant crestal bone loss. a. 1 mm b. 2 mm

c. 3 mm d. 4 mm 6. If the implants are placed _______, there will be less facial bone, and this will ultimately result in apical migration of the free gingival margin. a. too quickly b. too deeply c. too far back d. too far forward 7. The conventional fixed partial denture has the advantage(s) of ___________. a. being an established treatment procedure b. having predictable esthetics c. being expedient d. all of the above 8. The resin-bonded partial denture has the advantage(s) of __________. a. preserving tooth structure b. having predictable esthetics c. reduced cost d. all of the above 9. Implants used to replace missing teeth in the esthetic zone have many advantages from ________, and providing support. a. preservation of unrestored adjacent teeth b. halting the resorption of edentulous spaces c. requiring a provisional restoration d. both a and b 10. Much effort is being directed at _______. a. shortening the treatment time b. making delivery of the service more time efficient c. training more technicians d. both a and b

4. Whatever the controversies or uncertainties are, the main consensus on PID management is that dental implant restorations must be meticulously monitored and maintained ______the implants are introduced into the oral environment. a. as soon as b. 3 weeks after c. 1 month after d. 6 months after 5. As always, prevention is better than treatment and, in this respect, each member of the dental team, including the patient (by compliance on home care), has responsibilities in ________. a. maintenance b. early diagnosis c. appropriate management of problems

6. The clinical diagnosis of peri-implantitis is characterized by ________, swelling, and suppuration. a. increased probing depths (PPD of more than 3 mm) b. bleeding on probing (BOP) c. pain d. all of the above

9. There is compelling evidence that _________are major risk factors for the development of peri-implant disease. a. poor oral hygiene b. history of periodontitis c. cigarette smoking d. all of the above 10. The incidence of peri-implant infection is greater around cement restorations than screw-retained restorations due to extrusion of excess cement into the peri-implant soft tissues. This is now known as _____. a. cementosis b. mucositis c. cementitis d. none of the above

Volume 6 Number 4 Implant practice 41

CE CREDITS

IMPLANT PRACTICE CE

STEP-BY-STEP

Osstell ISQ As easy as 1, 2...

2 The SmartPeg™ is attached to the implant. It screws effortlessly into the implant’s internal thread.

The hand-held probe stimulates the SmartPeg magnetically, without actually being connected to it – or even touching it – and the value is displayed in a second.

The ISQ Scale – a global standard ISQ (Implant Stability Quotient) is a measurement scale for use with the RFA (Resonance Frequency Analysis) method of determining implant stability and osseointegration, presented on a clinically useful scale of 1-100 ISQ. The ISQ scale correlates perfectly with micromotion: the higher the ISQ, the more stable the implant.

Here is how the Osstell ISQ works and what it achieves The Osstell ISQ instrument stimulates a SmartPeg mounted on the implant by emitting magnetic pulses. These cause the SmartPeg to resonate at certain frequencies depending on the stability of the implant. This is a wireless, noninvasive, and completely objective technique. The SmartPegs have been calibrated in such a way that they all show comparable values for the same degree of stability.

Diagnostics by Osstell personal commitment

–

The company was formed in 1999, and today more than 9,000 clinicians all over the world use the Osstell ISQ. All Osstell employees are personally committed to the worldwide adoption of our unique diagnostics solution and to the continuous growth of our company. To succeed, we ensure that our customers receive the unrelenting support and service they deserve. Osstell AB is based in Gothenburg, Sweden where we develop, manufacture, and market our products globally through distribution partners and direct representations. Since 2007, the company has been a part of the Biolin Scientific group, which is a leading provider of analytical instruments for the nanoscale study of interfaces. IP This information was provided by Osstell AB. www.osstell.com Your guide to predictable surgical and restorative protocols

More than 20 years ago, two scientists shared the frustration of not being able to determine osseointegration in an accurate, objective, and consistent way – beyond their own dexterity and tactile skills. The concept of Resonance Frequency Analysis was developed. 42 Implant practice

Volume 6 Number 4

TECHNOLOGY

The evolution and advancement of dental implants Drs. Robert J. Miller and Randi J. Korn discuss some history behind new implant technology

he advent of implant dentistry is considered by many as one of the most important innovations in our profession. It has given those who have no conventional options a second chance to enjoy the benefits of an intact dentition. A 15-year retrospective article published in 1981 was instrumental in changing the way in which practitioners treatment plan tooth replacement1. For the first time, it was documented that one can predictably replace teeth with dental implants. Dental implants have evolved in several respects over the past three decades. Changes have included design and morphology of the implant body and prosthetic connection, surface characteristics, and technology. Initially, implants were made from commercially pure titanium, Grades 1 through 4, which is determined by the percentages of carbon and iron. The first cylindrical implants were typically smooth surface that provided a reasonable level of success. The threaded design provided the implant with a degree of initial stability thought to aid in the osseointegration process. With

Dr. Robert J. Miller received his dental degree from Boston University Goldman School of Dentistry in 1984. He received his Certificate for Advanced Graduate Study in periodontics from Boston University in 1986 and has maintained a private periodontal practice in Plantation, Florida for over 25 years. He is an active member of the Academy of Periodontology, Academy of Osseointegration, Pierre Fauchard Academy, Academy of Dentistry International, American Dental Association, Florida Dental Association, South Palm Beach County Dental Association, Broward County Dental Association, and is a Fellow of the International Team for Implantology (ITI). He has a courtesy appointment with the Community Based Division Program at the University of Florida Hialeah Dental Clinic. Dr. Randi J. Korn received her dental degree from Nova Southeastern University School of Dental Medicine. She then went on to receive her Certificate in Periodontics, receiving advanced training in periodontics and implant dentistry at Nova Southeastern University. Dr. Korn is also a Diplomate of the American Board of Periodontology. She currently works in a private periodontal practice in Plantation, Florida. She is a member of numerous dental societies, including The American Academy of Periodontology, American Academy of Osseointegration, the International Team for Implantology (ITI), Florida Academy of Periodontology, Florida Dental Association, and the American Dental Association.

44 Implant practice

Figures 1 and 2: Patient presents 02/16/2010 with tooth No. 30 missing. Tooth extracted 1 year prior with no GBR procedure, resulting in the loss of buccal plate

the introduction of a coated surface in the 1980s, greater surface area was achieved providing an increase in the quantity of bone in contact with the body of the implant2. Typically, this was either a hydroxyapatite (HA) or titanium plasma spray (TPS) coating that increased the rate of osseointegration in these “press fit” implants. Enthusiasm for implant surface coatings decreased when significant failure rates were observed by several investigators for both TPS3 and HA.4 The SLA® (Sand Blasted, Large Grit, Acid Etched) surface, which was introduced in 1998 by Straumann,® changed the standard as it increased the surface area of the implant. The surface was revolutionary in the sense that it reduced the osseointegration process from 6 to 8 months to 2 months; however, it was still a hydrophobic surface. The next big innovation came in 2006 when Straumann manufactured the first true hydrophilic dental implant surface — SLActive®. The SLActive surface technology has an osteoconductive surface, which reduces healing from 6 to 8 weeks to between 3 and 4 weeks. This is due in part to the hydrophilicity of the surface, which is designed to enable blood and blood proteins to be adsorbed more readily into its micropores due to the absence of a passive carbon layer. In the 1980s, there were very few choices for the practitioner due to the fact that only a single diameter (3.75 – 4.0 mm) was available. By the early 1990s, surgeons had a greater selection of implants, which included a variety of different diameters to choose from (3.0 – 3.5 mm; 5.0, 6.0 mm). This became particularly useful from a prosthetic standpoint, as the emergence

Figure 3: Straumann Ø 4.8 mm RC Bone Level implant placed

profile could be more closely emulated in teeth with a narrow diameter, such as lower incisors. Criteria such as alveolar ridge width, bone quality, bone height, restorative tooth dimensions, degree of implant-to-bone contact, initial implant stability, prosthetic support and stability, abutment screw stress, and emergence profile were determining factors in implant selection. This was partly a result of the fact that guided bone regeneration was not predictable, and surgeons tended to choose implants that they thought would make up for deficiencies in the surgical site. The surgical protocol for implant selection soon became the longest possible implant with the most appropriate diameter.5 This encouraged a movement to the use of small diameter implants in situations with narrow alveolar ridges and wider implants in areas permitting their use. The wider diameter implants were also used in extraction sockets, areas with poor bone quality, and anatomical limitations, which arise with proximity to the maxillary sinus or mandibular nerve. When smaller diameter implants were first introduced to the market, there were some prevalent challenges involving the potential for fracture. Some of the Volume 6 Number 4

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TECHNOLOGY

Figures 4 and 5: Implant restored with a Porcelain Fused to Metal (PFM) crown on a Straumann stock abutment, 06/2010

Figures 6A, 6B, and 6C: A. Preoperative radiograph, B. Radiograph, time of placement of the crown, 6C. 11-month post op

leading causes included parafunctional habits, cantilever restorations, and screw loosening, which led to movement of the prosthesis, thus resulting in implant failure or fracture. These experiences led clinicians to be very conservative in their treatment planning of narrow diameter implants. An interesting theory that was advanced by several investigators was the concept of bicortical stabilization.6 The premise was that the wide diameter implants had the ability to engage both the medial and lateral cortical plates. If placed properly, it was postulated that it would aid in the initial stabilization of the implant and ultimately resist lateral occlusal forces. Over time the concept fell out of favor as photoelastic studies did not show a clear transfer of forces to the engaged lingual plate.6 A second long-held belief that has been dispelled through the years is the need to place the longest implant possible. Over time, it has been shown that the success rate of shorter implants is comparable to that of longer fixtures. In a retrospective study, it was shown that in clinical practice 6, 7, 8, and 9-mm implants placed in a variety of clinical situations had a success rate ranging from 98.1% to 99.7%.7 It is clear that trends in implant dentistry are not uncommon, but true resolution to issues that affect predictability come a little less often. Literature dispelling the myth that one must be placing longer fixtures to ensure success has made surgeons more comfortable placing implants in areas with sinus and mandibular nerve proximity. Documented success with shorter implants and the advent of a hydrophilic implant (SLActive) surface that is designed 46 Implant practice

to facilitate the osseointegration process are examples of paradigm shifts that have advanced our ability to deliver predictability. Another clear innovation that continues to change the way implant dentistry is conducted is the introduction of the Roxolid® implant material, which occurred in 2009. This material, which is an alloy comprised of titanium and zirconium (TiZr), is the first material designed specifically for implant dentistry. The Roxolid material offers higher tensile strength than Straumann’s TiGr4 implants8 and has demonstrated improved osseointegration over Straumann Titanium SLActive implants in a pre-clinical study9. The combination of these factors makes it the ideal choice for clinical situations where there is limited space between the adjacent teeth or the ridge is narrow. Practitioners will often face resistance from patients with a compromised ridge necessitating bone grafting procedures. Although the procedures result in excellent outcomes allowing for the placement of wider diameter implants, augmentation is not always universally accepted by the public or 100% successful. Having the option of placing a slightly narrower diameter implant that can deliver a predictable result is desirable. This ultimately translates into simpler, less traumatic procedures, and a greater acceptance of treatment. With the recent announcement that the Roxolid implant material will be made available in all diameters, a new trend will be developing in implant dentistry. The TiZr alloy is designed to enable predictable placement not only in deficient ridges and narrow clinical spaces, but will also allow for placement in the posterior sextants

where you may not necessarily have room for a 4.8 mm diameter fixture. Typically in molar sites, many surgeons prefer to place a wider diameter implant, as sinus and mandibular nerve proximity can be an issue. Wider diameter implants provide a greater surface area and are less prone to fracture. The Roxolid material gives the surgeon an option to place a smaller diameter implant than would have been traditionally planned with more confidence in sites that would have typically required a wider fixture. It is interesting to note that many of the problems in implant dentistry arise from implants placed too close to the buccal plate, which over time has shown that it is subject to dehiscence formation and esthetic nightmares. The option to use a smaller diameter implant will enable the surgeon to orient the implants within the boney envelope, making the loss of the buccal plate less likely. This will have a profound effect on our ability to place implants in both anterior and posterior sites that may have required sophisticated grafting procedures. The pendulum has shifted several times in implant dentistry. It wasn’t long ago when practitioners had no choice with respect to size or dimensions of implants. Now with the introduction of the Roxolid alloy, surgeons can move toward a smaller diameter implant with confidence. This will ultimately have a huge impact on how implant-assisted cases will be planned in the future. IP References 1. Adell R, Lekholm U, Rockler B, Brånemark PI. A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg. 1981;10(6):387-416. 2. Zablotsky MH. Hydroxyapatite coatings in implant dentistry. Implant Dent. 1992;1(4):253-257. 3. Vallecillo Capilla M, Romero Olid Mde N, Olmedo Gaya MV, Reyes Botella C, Zorrilla Romera C. Cylindrical dental implants with hydroxyapatite- and titanium plasma spray-coated surfaces: 5-year results. J Oral Implantol. 2007;33(2):59-68. 4. Wheeler SL. Eight-year clinical retrospective study of titanium plasma-sprayed and hydroxyapatitecoated cylinder implants. Int J Oral Maxillofac Implants. 1996;11(3):340-350. 5. Lazzara RJ. Criteria for implant selection: surgical and prosthetic considerations. Pract Periodontics Aesthet Dent. 1994;6(9):55-62, 64. 6 Jeong CM, Caputo AA, Wylie RS, Son SC, Jeon YC. Bicortically stabilized implant load transfer. Int J Oral Maxillofac Implants. 2003;18(1):59-65. 7. Fugazzotto PA. Shorter implants in clinical practice: rationale and treatment results. Int J Oral Maxillofac Implants. 2008;23(3):487-496. 8. Straumann® Roxolid™ tensile strength in accordance with Standard ASTM F67 (states min. tensile strength of annealed titanium). Data on file. Based on internal specifications and ASTM F67. 9. Gottlow J, Dard M, Kjellson F, Obrecht M, Sennerby L. Evaluation of a new titanium-zirconium dental implant: a biomechanical and histological comparative study in the mini pig. Clin Implant Dent Relat Res. 2012;14(4):538-545.

Volume 6 Number 4

ON THE HORIZON

Innovative practices and innovations in technology Dr. Justin Moody introduces his technology column with insights to improve the implant planning and placement process

here is always something new to learn, especially in implant dentistry. The field is growing fast, and technology and techniques are evolving. Patients are sophisticated in their tastes and are demanding high quality, esthetically pleasing, low pain results. As practitioners, we want to meet patients’ expectations while keeping chair-time to a minimum and promoting the profitability of our practices. The way to achieve these objectives is by utilizing and understanding the latest technology and also by staying up-to-date on new discoveries and methodology. As an implant practitioner, continuing education proponent, and technology buff, I am excited to contribute this column, which will highlight the new and exciting trends in implants.

CBCT taken with i-CAT and treatment planned via Tx STUDIO™

Future columns will discuss: Regeneration and biologics are used in conjunction with most successful dental implant procedures. Companies, such as BioHorizons®, offer biologic options for whatever the specific case demands, from biologics for bone grafting substitutes to membranes. I personally use many of these products since the results have been excellent, the products are easy to use, and are of great value to the practice. CBCT imaging is essential for accurate treatment planning of dental implants. The images provide more detail than traditional film X-rays, which promotes predictable results in the hands of well-trained dentists. CBCT machines, like the ones produced by i-CAT®, offer added benefits of the option of lower radiation doses and faster exposure times. The i-CAT® FLX has a feature called QuickScan+ that allows for a

Justin Moody, DDS, DICOI, DABOI, is a Diplomate with the American Board of Oral Implantology and with the International Congress of Oral Implantologists, Fellow and Associate Fellow of the American Academy of Implant Dentistry, Adjunct Professor at the University of Nebraska Medical College, and Founder and Director of the Rocky Mountain Dental Institute. He is an international speaker and is in private practice at The Dental Implant Center in Rapid City, South Dakota. He can be reached at justin@rockymountaindentalinstitute. com or online at drjustinmoody.com.

48 Implant practice

Use of technology and equipment allows for patient and doctor comfort

full-dentition 3D scan at a lower dose than a panoramic image. Another tool is the SmartScan STUDIO touchscreen interface that lets the dentist choose the lowest possible radiation dose for the individual patient. Treatment planning software is becoming a must-have for practices that pride themselves on quality care and 21st century advancements. This type of product, in addition to treatment planning, often also provides a way to formulate treatment goals, create surgical guides and templates, and communicate with staff and patients. Implant design allows for easy placement with predictable results and the desired esthetic result, from special designs for placement locations with limited space to designs formulated to replace specific teeth. With surface treatments like

BioHorizons’ Laser Lok®, which allows for soft tissue attachment to both the implant and prosthetic components, predictable results in the most highly esthetic areas are possible. Continuing education is an often overlooked component to a highly functioning dental office. You and your staff may have the latest advancements, but without the knowledge of how to implement the technology, it is useless. As founder of the Rocky Mountain Dental Institute in Denver, Colorado, I believe in hands-on learning, so that the new skills are easier to implement in your practice. The learning is more than theory when participants practice using state-of-the-art technology in a hands-on setting. This column will delve into these topics and more, exploring what is on the horizon for the modern dental practice. IP Volume 6 Number 4

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INDUSTRY NEWS

Straumann introduces Emdogain 015 – designed to provide versatility in patient treatment ®

™

New smaller size syringes will help clinicians provide Emdogain regenerative therapy to more patients

traumann has introduced Emdogain 015, a versatile and cost-effective way to treat patients with periodontal disease. Emdogain 015 is the same effective product clinicians have relied on for treatment of more than 1 million patients, now in a new, convenient package size of five syringes, each filled with 0.15 ml of product. Emdogain 015 gives clinicians an ideal and more cost-effective solution for the treatment of small periodontal defects. Straumann Emdogain is a proteinbased gel designed to promote predictable regeneration of lost periodontal hard and soft tissue, helping to save and stabilize teeth. The addition of Emdogain 015 to Staumann’s regenerative treatment portfolio gives clinicians the flexibility to select the right amount of Emdogain for their patients. When added into the periodontal treatment plan, Emdogain can provide an excellent result with less pain and discomfort compared to connective tissue graft (CTG)1, while improving the potential for patients to keep their natural teeth. “Using Emdogain, I’ve seen positive outcomes for my patients; however, there have been times when I wanted to use Emdogain in conjunction with periodontal surgery but couldn’t justify the excess material that would go to waste when treating smaller defects,” said Dr. Jennifer Hirsch Doobrow. “Now, with Emdogain 015, I can provide the power of regenerative therapy to more patients because the size of the defect is no longer an issue.” According to the Centers of Disease Control and Prevention (CDC), about half of the U.S. population is affected by periodontal disease2, which if left untreated, may lead to tooth loss. Periodontitis treatment involves controlling the causative bacteria and inflammation, as well as subsequent regeneration of the lost periodontal hard and soft tissues in order to regain tooth attachment. Straumann Emdogain supports the predictable regeneration of the lost periodontal hard

50 Implant practice

“Emdogain has had strong long-term results, and we believe that every patient – whether the clinical situation is a small defect or a large grafting procedure – should have the opportunity to experience these benefits.” — Andy Molnar, Executive Vice President, Straumann North America

and soft tissue caused by periodontitis, helping to save and preserve the tooth.3 Scientifically supported in more than 400 publications, Emdogain is designed to help clinicians produce long-lasting results that will, in turn, help them in developing a successful practice through satisfied patients. “Emdogain has had strong long-term results, and we believe that every patient – whether the clinical situation is a small defect or a large grafting procedure – should have the opportunity to experience these benefits. This is why we created Emdogain 015,” said Andy Molnar, Executive Vice President, Straumann North America. “With longer life expectancies, today’s patients want more options when it comes to their oral health. We are committed to giving clinicians innovative and effective products to help them provide the best possible care for their patients.” IP

To learn more about Straumann, visit www.straumann.us. This information Straumann.

was

provided

References 1. McGuire, MK & Nunn, M. Evaluation of human recession defects treated with coronally advanced flaps and either enamel matrix derivative or connective tissue. Part 1: Comparison of clinical parameters. J Periodontol. 2003;74:1110-1125. 2. Eke PI, Dye BA, Wei L, Thornton-Evans GO, Genco RJ. Prevalence of periodontitis in adults in the United States: 2009 and 2010. J Dent Res. 2012;Oct;91(10):914-20. 3. Bosshardt DD. Biological mediators and periodontal regeneration: a review of enamel matrix proteins at the cellular and molecular levels J Clin Periodontol. 2008;35(Suppl. 8):87105.

Volume 6 Number 4

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INDUSTRY NEWS

Zimmer Dental Implant receives 2013 MDEA Silver Medal

immer Dental Inc., a leading provider of dental oral rehabilitation products and a subsidiary of Zimmer Holdings, Inc., was recently honored with a Silver Medal at the 2013 Medical Design Excellence Awards (MDEA) in the category of “Dental Instruments, Equipment, and Supplies” for its revolutionary Zimmer® Trabecular Metal™ Dental Implant. Zimmer Dental’s entry stands out as the only dental implant recognized in the highly regarded, global competition, which is sponsored by the Medical Device and Diagnostic Industry (MD+DI). According to the MD+DI website, the MDEA competition is the premier awards program for the medical technology community, recognizing the achievements of medical product manufacturers and the many people behind the scenes — engineers, scientists, designers, and clinicians — who are responsible for the groundbreaking innovations that are changing the face of healthcare. This recognition follows the recent coining of the term “osseoincorporation” in describing the unique bone development process made possible with this porous dental implant. Osseoincorporation refers to the growth potential of bone, both onto an implant surface and into an implant structure. The Trabecular Metal Dental Implant features an osteoconductive mid-

52 Implant practice

section, formed from Trabecular Metal material, designed for ingrowth as well as ongrowth in a process new to implant dentistry—osseoincorporation. Manufactured In the U.S. at Zimmer’s TMT facility in Parsippany, New Jersey, and used in Zimmer’s cutting-edge orthopaedic devices for more than 15 years, Trabecular Metal material is a threedimensional, highly biocompatible material — not an implant surface or coating — with up to 80% porosity for bone ingrowth and a structure comparable to cancellous bone. The interconnected porosity is designed to enhance secondary stability through a high volume of ingrowth. For decades, Zimmer Dental has gained the trust of thousands of clinicians worldwide who count on its comprehensive line of products to deliver successful patient outcomes. By looking to new and innovative technologies and leveraging its relationship with its parent company, Zimmer Holdings, Zimmer Dental continues to reinforce its commitment to offering state-of-the-art dental solutions. For more information, contact a Zimmer Dental sales consultant or customer service at 800-854-7019 or 760-929-4300, or visit TrabecularMetal. ZimmerDental.com. IP This information was provided by Zimmer. Volume 6 Number 4

PRODUCT PROFILE

LAPIP protocol: patient-friendly, predictable solution for ailing implants

he LAPIP™ protocol from Millennium Dental Technologies, Inc. offers a patient-friendly, predictable solution for ailing and failing implants. The LAPIP protocol is an implantspecific modification of the well-defined LANAP® protocol for the treatment of periodontitis redesigned to treat periimplantitis. The LAPIP protocol uses a selective denaturing of pathologic proteins to reduce the inflammatory response, remove inflamed pocket tissue, disrupt biofilms, and decontaminate the implant surface. A laser-induced hemostasis step further decontaminates the tissue and creates a durable blood clot to close the system. The LANAP protocol is an FDAcleared treatment that provides cementum-mediated new periodontal ligament attachment to root surfaces in the absence of long junctional epithelium. This patientfriendly periodontal surgery treats the periodontal pocket walls to remove diseased epithelium, and then seals them with a laser-generated blood clot. The therapy results in greater probing depth reduction and clinical probing attachment level gains.

of a vertically oriented flap is needed, the integrity of the structural tissue is retained. Thus, all other future treatment options remain possible.

Patient-preferred treatment option

Unique power of the Nd:YAG PerioLase MVP-7

What makes the LAPIP protocol unique is that it actually brings the tissue back to health, regrowing bone, and allowing for reintegration of the implant. There is no need for removal of the implant, waiting for the healing to take place, and then replacement weeks after, if at all. The process requires a single appointment with shorter recovery time – key benefits for your patients. In addition, patient satisfaction increases with the ability to retain the implant.

The LAPIP protocol leverages the positive effects that the optimally configured PerioLase® MVP-7™, a free-running pulsed Nd:YAG laser, has on treating peri-implantitis. Specifically, the PerioLase MVP-7’s ability to penetrate the soft tissue to achieve an effective kill of bacteria and promote hemostasis without damaging healthy tissue, make it uniquely designed to support the LAPIP protocol.

Successful and versatile Multiple case studies indicate ailing or failing implants treated with the LAPIP protocol have reintegrated in the pocket and stabilized with bone growth of threeeight threads. Because no resection or reflection 54 Implant practice

Training to ensure success Millennium Dental Technologies understands the key to success is the clinician’s ability to replicate results in his/her own patients. For most dentists, hands-on learning in a small group environment is the best possible structure for comprehensive learning, therefore, we include 5 days of live-patient training with a three-student

to one-instructor ratio. This training is a comprehensive coverage of the LANAP and LAPIP protocols to promote clinical success. Even after training is completed, each student has access to his or her clinical instructor and the founders of the company for support. IP For more information visit www.LANAP.com or call 877-LANAP-LZR. This information was provided Millennium Dental Technologies.

About Millennium Dental Technologies, Inc. Millennium Dental Technologies, Inc., a manufacturer and distributor of dental products, seeks to bridge the growing divide between gum disease patients and treating clinicians by providing simple and comfortable patient experiences with bone-building clinical results. By removing their fear, the dental community has the opportunity to bring patients back to seek treatment for their gum disease. The FDA-cleared and patented LANAP® protocol offers a proven patient-friendly treatment alternative to conventional scalpel/suture flap surgery; and the LAPIP™ protocol offers a solution for ailing/failing implants.

Volume 6 Number 4

PRODUCT PROFILE

Southern Anesthesia & Surgical Inc. adds synthetics to the Osteo-i® line of regenerative products

ynthetics offer freedom from inherent risks of allograft and xenograft products like prions, viruses, extraneous DNA and RNA, and animal antigens. They are often less expensive while providing the same clinical outcome, but all synthetic bone graft materials are not the same. There are those that resorb too quickly and do not provide a scaffold for new vital bone to grow on and into, and there are those that never resorb, preventing the implant space from ever becoming all new vital bone. Therefore, attention to detail in the manufacture of bone graft products is essential to creating a product that both resorbs and allows complete bone replacement of the implant material with new vital bone in an ideal time frame.

How we do it All steps of the process are controlled inhouse to ensure the best possible product characteristics. • All materials used in the manufacture of our synthetic bone graft products are sourced in the US. • All packaging for our synthetic bone graft products are sourced in the US. • Well-known and recognized vendors are used for our raw materials, and they supply certificates of analysis with those raw materials to document their quality. • Additional testing of raw materials is conducted to meet our high standards.

Specific characteristics created in manufacturing

Materials

Porosity Porosity increases surface area of product exposed to cellular action for maximum bioactivity. Microporosity helps to wick up fluids and the essential growth components carried in them. Macroporosity of the correct dimensions (100-600 microns) encourages cells to grow on and in the pores of the particles more than seen in comparable nonporous materials.

Ideal raw materials are necessary to manufacture the best possible bone graft products. Good and/or bad trace minerals and impurities in raw materials can make their way into the final product. Finding raw materials without any trace impurities is not feasible. Knowing what these impurities are, and at what level they occur, allows these considerations to be interwoven into the final product performance at the outset of manufacturing. In fact, human bone contains carbonate and low levels of minerals that play important and specific roles in bone formation and maintenance. The key is getting the right ones and in the right concentrations. That takes a thorough understanding and a commitment to make the best possible bone graft material.

Sintering Sintering is one of the final stages in manufacturing synthetic bone graft materials, and it is critical to achieve the correct in vivo residence time for the graft material. Minimal or no sintering creates a soft product that will handle poorly and resorb too quickly resulting in a scaffold inadequate for osteoconductivity. The literature defines this as graft failure. Excessive sintering makes a product that is too hard and a product that will not be resorbed in an appropriate time period. Extreme sintering of certain bone graft products can create a product that will never resorb. Incomplete resorption results in a graft site that does not contain the

8WK rabbit, H&E stain showing bone apposition on Osteo-i ß-TCP ceramic granules, H&E, original magnification = 79x 56 Implant practice

8WK rabbit, H&E stain showing incorporation of Osteo-i ß-TCP ceramic granules into the healing defect, H&E, original magnification = 50x

normal ratio of mineral phase to collagen, which creates the full strength of natural bone. Additionally, unchanged graft particles may be hard or impossible to drill through and will not accept implants properly. Purity Avoiding the introduction of new metals to the product prevents discoloration and altered performance. Our product design avoids nonresorbable components. Some products contain components like PMMA (polymethyl methacrylate) that will not metabolize or resorb. These components then prevent the complete turnover of the implant material to new vital bone, and as a result, these components remain as a permanent implant. IP This information was provided by Southern Anesthesia & Surgical, Inc.

Southern Anesthesia & Surgical, Inc. (SAS) is the exclusive distributor of Osteo-i® regenerative products. SAS has been in business since 1984, specializing in pharmaceuticals and surgical supplies for the oral surgery, periodontal, and dental markets. SAS is best known for its knowledgeable customer service, competitive pricing, and ability to maintain consistent availability of key pharmaceutical products. The company is keenly focused on customer satisfaction. It is our goal to be our customers’ single source for their pharmaceutical and surgical supply needs. Visit www.southernanesthesia.com or call 800-624-5926 for more information. Volume 6 Number 4

R e g e n e ra t i ve P r o d u c t s Osteo-i® products are produced to provide predictable outcomes for surgeons and their patients. Processing is executed to meet or exceed Food and Drug Administration (FDA) regulations and American Association of Tissue Banks (AATB) Standards.

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PRODUCT PROFILE

Luster® kits by MEISINGER Luster® Lithium Disilicate and Zirconia Polishers by MEISINGER Ideal for today’s new dental restorations

Luster® for Zirconia Adjusting and Polishing Kit #LUS85 Extraoral adjusting and polishing kit

Extraoral Kits

Luster® for Lithium Disilicate Adjusting and Polishing Kit #LUS80 Extraoral adjusting and polishing kit

This kit was designed to adjust and reglaze monolithic zirconia restorations such as BruxZir® crowns.

Luster® for Zirconia Adjusting and Polishing Kit #LUS91 Intraoral adjusting and polishing kit

This kit features the MEISINGER specially designed polishers for Lithium Disilicate restorations. The 9736G wheel allows for adjustments, and the two-step polishing system will reglaze the restoration.

Intraoral Kits

Luster® for Lithium Disilicate Adjusting and Polishing Kit #LUS100 Intraoral adjusting and polishing kit

This kit, with specially formulated polishers, was designed to adjust and reglaze monolithic zirconia restorations such as BruxZir® crowns intraorally.

This kit contains specially formulated diamonds to make adjustments to Lithium Disilicate as well as the two-step polishing system to reglaze Lithium Disilicate intraorally after the restoration has been placed.

All four kits are rated “CR Choice” by Clinicians Report®* for best polishing on Lithium Disilicate and Zirconia. In a recent clinical study conducted by “THE DENTAL ADVISOR” all four MEISINGER kits received a ++++1/2 rating. IP This information was provided by Meisinger. *“An independent, nonprofit, dental education and product testing foundation, Clinicians Report®, February 2013. For the full report to be sent directly to you, please contact MEISINGER USA customer service.”

58 Implant practice

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.00 5 9 4 , $1 ll Today! Ca

4th Annual High Altitude

Bone Management® Winter Camp February 5th – February 8th 2014 Beaver Creek, Colorado, USA

Scan to watch our Bone Management® Winter Camp Video 2013!

Case presenters were excellent, hotel was comfortable, topics were excellent Dr. Tina Kokosis

Wide variety of speakers, newer techniques, skiing was great Dr. Bob Hunt

Availability of speakers, Clarity of topics Dr. Art Missirlian

Quality of lectures was 1st class!, Combination of Lectures + hands-on, Location, Location-Stay in Colorado Dr. Michael Schwab

Meisinger USA. L.L.C. • 10200 E. Easter Avenue • Centennial, Colorado 80112 • USA Phone: +1 (303) 268-5400 • Toll free: +1 (866) 634-7464 • Fax: +1 (303) 268-5407 • E-Mail: info@meisingerusa.com • Internet: http://meisingerusa.com

DIARY

lllllllllllllllllllllll OF EVENTS llllllllllllllllllllllllllllllllllllllllllllllllllll

Implant Dentistry Continuum 2013 Miami September 7-8 October 5-6 Miami, FL www.implantseminars.com

The GHSU/AAID Maxi-Course â&#x20AC;&#x201C; Comprehensive Training Program In Implant Dentistry September 19-22 Atlanta, GA www.straumann.us

Implant I â&#x20AC;&#x201C; Rocky Mountain Dental Institute September 19-21 Denver, CO www.rockymountaindentalinstitute.com

Ohio Dental Association Annual Session September 19-22 Columbus, OH www.oda.org

2-D and 3-D Imaging: The Future Is Now September 21 San Francisco, CA Dental.pacific.edu

60 Implant practice

Implant Dentistry Continuum 2013 New York September 21-22 New York, NY www.implantseminars.com

American Academy of Small Diameter Implants October 4-5 Dallas, TX www.aaosdi.com

Aesthetics Through Innovation September 25 Palm Beach Gardens, FL www.biomet3i.com

The Art and Science of Aesthetic Dentistry October 4-6 San Francisco, CA Dental.pacific.edu

Implant Dentistry Continuum 2013 Washington DC September 28-29 Washington, DC www.implantseminars.com

American Academy Of Periodontology Annual Meeting (AAP) September 28-October 1st 2013 Philadelphia, PA www.perio.org

American Association of Oral & Maxillofacial Surgeons Annual Meeting (AAOMS) October 10-12 Orlando, FL www.aaaoms.org

7th Annual Aiden Morris Memorial Symposium October 16 Long Grove, IL www.biomet3i.com

Advanced Live Surgery October 3-5 Denver, CO www.rockymountaindentalinstitute.com

Practical Solutions For Immediate Full Arch Restoration With Hands-On October 4 Glen Cove, NY www.biomet3i.com

Volume 6 Number 4

MATERIALS lllllllllllll & lllllllllllll EQUIPMENT Crosstex® launches RAPICIDE® OPA/28 highlevel disinfectant Crosstex International, a leading global provider of infection prevention and control products, has introduced RAPICIDE OPA/28, an ortho-phthalaldehyde (OPA)based high-level disinfectant for the reprocessing of heat-sensitive semi-critical devices. RAPICIDE OPA/28 is an FDA, 510K cleared product that has a reuse period of 28 days, twice the reuse life of all other OPAbased high level disinfectants available on the market with the fastest disinfection time – 10 minutes at room temperature. Unlike glutaraldehydes that are recognized causes of occupational asthma and skin irritations, RAPICIDE OPA/28 has only .55% of the active ingredient so it causes less irritation to the eyes, nose, and throat. For more information, contact Crosstex International Customer Care at 1-888-CROSSTEX or visit www.crosstex.com.

Introducing Straumann’s Sterile Healing Solution Straumann is Simply Doing MoreSM by providing simplicity through two new offerings: New Sterile Packaging for all Straumann Healing Components - Straumann healing components in their new sterile packaging are designed for convenient handling with direct pick-up from the package with an SCS screwdriver. This new packaging is easy to open and provides a solution for organized storage* and maintenance of a practice’s inventory. Improved Bone Level RC Healing Abutments - The improved BL RC Healing Abutments feature a modified shape that more closely matches the dimensions of respective BL final abutments. This change to the company’s existing offering is designed to address a clinician’s needs for improved handling and patient comfort during final restoration.

Netsertive: Local patients rely on the Internet Local patients rely on the Internet to find the right clinician for their needs. Practices can now increase production and attract qualified patients with Netsertive’s Digital Extend™ marketing programs that combine the power of search, display, mobile, retargeting, and other online tactics to ensure that practices and top services are highly visible to patients doing research in specific local markets. The company’s experts will review the practitioner’s marketing goals and estimate what can be achieved within budget using the firm’s patent-pending technology. For more information, visit www.netsertive.com/ dental or call 800-940-4351.

Essential Dental Systems introduces C-Mor™ Ultra-Bright Mouth Mirrors Essential Dental Systems new ultra-bright mouth mirror makes performing all aspects of dentistry easier by allowing dentists to see-more clinically. These mirrors revolutionize the visual field of dentistry by incorporating a special hi-tech process giving the practitioner the highest reflectance, light, and definition available. With superior reflection, sharpness, and contrast the practitioner can literally see more without distortion or cloudiness. For more information on the C-Mor Ultra-Bright Front Surface Mirrors and other products, please visit www.edsdental.com or call 201-487-9090.

Air Techniques, Inc., has announced the latest solution for digital radiography with the all new ScanX Swift™ ScanX Swift is a chairside digital radiography system that is fast, easy, more comfortable for patients, and offers a better value for the dental practice. Using flexible, cordless phosphor sensors, ScanX Swift delivers exceptional diagnostic clarity while offering a convenient workflow for the dental staff. This digital system fits on the countertop in the operatory and produces images in 9 seconds or less. It provides a larger image area, greatly reducing the need for retakes. The workflow with the ScanX Swift is virtually identical to film. It’s the same easy technique but with sharp, high contrast digital images in a fraction of the time, and no messy, costly chemicals. For more information on Air Techniques, visit: www.airtechniques. com. “Like” Air Techniques on Facebook, and follow the company on Twitter.

To learn more about Straumann, visit www.straumann.us.

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Volume 6 Number 4

The Ideal 3D Imaging Systems... • Availability of multiple imaging modalities in one machine (3D, anatomically accurate extraoral bitewing program, panoramic, and cephalometric)

• Versatile volume sizes (small ø4 x 5 cm, medium ø8 x 8 cm, large ø8 x 11 cm or ø8 x 14 cm with vertical blending) for a single impaction to full dentition, and beyond • Over 30+ Imaging Programs • Space saving - small footprint and compact design • Delivered with PLANMECA Romexis™ software for viewing, image enhancement, and treatment planning • Mac OS compatible and DICOM compliant Optional 2D SmartPan Panoramic and bitewing images are taken with the same flat panel sensor as the 3D images are taken, eliminating the risk of equipment damage and time constraints from switching sensors

PLANMECA®

Not ready for 3D yet? Enter for your chance to win an upgradeable, 3D-ready ProMax S3 panoramic machine! Schedule a free in-oﬃce demo and be entered automatically for a chance to win a FREE ProMax S3-2D panoramic machine!

For a free in-oﬃce consultation, please call

1-855-245-2908 or email

WinProMaxS3@planmecausa.com Winner will be announced live at the 2014 Chicago Midwinter Dental Conference!!!

Dare to Compare on Innovation, Quality, Service and Value Legacy™3 Implant All-in-1 Packaging includes implant, abutment, transfer, cover screw & healing collar

$200 vs $6331 from Zimmer Dental Reality Check Zimmer Customers Save $433 with Legacy3

SwishPlant™ Implant All-in-1 Packaging includes implant, abutment, transfer, cover screw, healing collar & comfort cap

$200 vs $737 2 from Straumann® Reality Check Straumann Customers Save $537 with SwishPlant

ReActive™ Implant All-in-1 Packaging includes implant, abutment, transfer & cover screw

$200 vs $718 3 from Nobel Biocare™ Reality Check Nobel Customers Save $518 with ReActive

Implant Product Page

NEW All-in-1 Shopping Visit our new online store, ﬁnd the implant you want and the compatible components, abutments, instruments, biologics, literature are just a click away! There’s no need to jump through different product categories or pages, you can ﬁnd it all in one spot.

16 CE

CREDITS

3D Implantology: 2 Day Advanced Course Featuring Anatomage Passage surgical guide starter software

August 16-17 | October 18-19

View Dr. Niznick’s 2-hour lecture & earn 2 CE credits FREE Dr. Gerald Niznick discusses how the latest implant design innovations are shaping the future of implantology.

Introductory Offer: Make the switch & receive three FREE implants.4 Price comparisons based upon US list prices as of January 2013. All trademarks are property of their respective companies. 1 US list price for Tapered Screw-Vent with micro grooves, healing collar & straight abutment 2 US list price for SLActive Tapered Effect implant, closure screw, healing abutment, solid abutment, transfer and comfort cap. 3 US list price for NobelActive with cover screw, impression coping & abutment 4 Terms and conditions apply

www.implantdirect.com | 888-649-6425 Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement 8/1/2012 to 7/31/2015 Provider ID# 316714