Implant Practice US - March/April 2014 Issue - Vol7.2

clinical articles • management advice • practice profiles • technology reviews March/April 2014 – Vol 7 No 2

Product profile Intra-Lock

Flap vs. Flapless Drs. Michael Scherer and Andrew Ingel

Staged extraction and guided bone regeneration (GBR) Drs. John Lupovici and Robert Raimondi

Corporate profile Henry Schein Dental Surgical Solutions

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Practice profile

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All-on-4® using guided surgery

Introduces the

PROMOTING EXCELLENCE IN IMPLANTOLOGY

WHEN THE OSTEOTOMY MUST BE NARROW -

SO MUST YOUR IMPLANT CHOICE Choose the LOCATOR® Overdenture Implant System 2.5mm Cuff Heights 4mm

2.4mm

Diameters

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It’s a fact – denture patients commonly have narrow ridges and will require bone grafting before standard implants can be placed. Many of these patients will decline grafting due to the additional treatment time or cost. For these patients, the new narrow diameter LOCATOR Overdenture Implant (LODI) System may be the perfect fit. Make LODI your new go-to implant for overdenture patients with narrow ridges or limited finances and stop turning away patients who decline grafting. Your referrals will love that LODI features all the benefits of the LOCATOR Attachment system that they prefer, and that all of the restorative components are included.

Discover the benefits that LODI can bring to your practice today by visiting www.zestanchors.com/LODI/31 or calling 855.868.LODI (5634).

©2013 ZEST Anchors LLC. All rights reserved. ZEST and LOCATOR are registered trademarks of ZEST IP Holdings, LLC.

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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A

s an oral and maxillofacial surgeon, I’m passionate about making the experiences of my patients and referring dentists deeply satisfying. Today, technological advances are driving these experiences. They’re helping the implant team to deliver better, more beautiful, and accurate results for patients and to do so faster, more easily, and at a lower cost. In my practice, I see three broad areas of technology affecting the experience of my patients and referring dentists.

CBCT scanning Obtaining a cone-beam computed tomographic (CBCT) scan at the initial consultation has a number of benefits. Such scans can be powerful tools for improving communication with both the patient and the referring doctor. This imaging makes it possible for patients to better understand proposed treatment and to accept care more easily. The surgeon, restoring dentist, and dental laboratory are able to better collaborate and deliver more predictable outcomes. When combined with a digital impression, 3D modeling of bone and soft tissue provides an added dimension of information and predictability. Improved case planning helps to ensure better patient outcomes and simplifies a complex process, building restorative doctors’ confidence in their ability to achieve exceptional patient results.

New surface technology in implants As implant designs have become more and more sophisticated, it is now possible to shorten overall treatment time while predictably achieving better outcomes — often with fewer procedures. In my own practice, I’m shortening the surgical treatment time by 27% by using a technologically advanced implant design (the 3i T3® Tapered Implant, BIOMET 3i). My patients are returning to my restorative dentists after 3 months of healing, an improvement attributed in large part to the improved surface technology.

The 3i T3 Tapered Implant, designed for primary stability and initial bone-to-implant contact, allows me to extract a tooth and place the implant into the fresh extraction site with a high degree of clinical confidence. Combining two surgeries into one shortens treatment time, decreases patient costs, and improves patient satisfaction. In the posterior maxilla, an area known for poorer quality and quantity bone, larger diameter implants, such as the platform-switched 6 mmdiameter x 10 mm-long 3i T3 Implant, has made me and my fellow surgeons feel more comfortable placing implants into fresh extraction sockets. Doing this also avoids costly, time-consuming, and uncomfortable sinus bone-grafting procedures. In the anterior esthetic zone, placing a narrower platform-switched implant, such as the 4/3 3i T3 Tapered Implant (4 mm diameter x 3.4 mm platform), has been shown in studies to help preserve the peri-implant bone while delivering a narrowed prosthetic platform emergence profile.1 Intraoral digital scanning I’ve found digital scanners to be a powerful tool for enhancing the “wow” factors of both my patients and restorative dentists. For most patients, recording the intraoral topography transforms their experience. Instead of being a messy and intrusive penance, it becomes a simple procedure that often is downright entertaining as patients see the three-dimensional digital images of their mouths being captured on the computer monitor. This is compounded when, 10 days later, they receive their beautiful crown and a patient-specific, machined-titanium abutment.

Working with a digital scan of coded healing abutments (BellaTek® Encode® Healing Abutments, BIOMET 3i) is usually a transformative experience for restorative dentists as well. The digital impression becomes the portal through which the restoring dentist gains access to digital design and manufacturing. He or she forms new laboratory relationships grounded in computer-aided design and computer-aided manufacturing (CAD/CAM) processes.

That’s an empowering change, and it has several concrete benefits. Suddenly, the restorative dentists are working with digital files that can be transmitted electronically and viewed on their smartphones instead of traditional elastomeric impressions that require cumbersome shipping and handling. From the digital impression of the BellaTek Encode Healing Abutment(s), the dentist gains control over the design process and oversees the digital fabrication of milled-titanium abutments, copings, and crowns. This enables the restoring doctor to better manage costs, while helping to improve the accuracy of the finished product, as compared to traditional methods and materials.

As enthusiastic and excited as I sometimes get about technology, I believe it’s worthless unless it can be used to change lives. In dentistry today, however, the technological improvements are having a positive impact on the lives of both patients and my restoring general dentists. It’s a “wow” for everyone!

Dr. Lee R. Walker* Lee R. Walker, MD, DDS, received his dental degree from the University of the Pacific, San Francisco, California, and his medical degree and oral and maxillofacial surgery certificate from The University of Texas, Southwestern Medical Center at Dallas. He is a Diplomate of the American Board of Oral and Maxillofacial Surgery, a Fellow of the American Association of Oral and Maxillofacial Surgeons, and a member of the Academy of Osseointegration. Dr. Walker has lectured extensively both nationally and internationally on dental implants and maintains a private practice in Los Gatos, California. Östman PO, Wennerberg A, Albrektsson T. Immediate occlusal loading of NanoTite prevail implants: A prospective 1-year clinical and radiographic study. Clin Implant Dent Relat Res. 2010 Mar; 12(1):39-47.

1

*This clinician has a financial relationship with BIOMET 3i LLC resulting from speaking engagements, consulting engagements, and other retained services.

3i T3, BellaTek design and Encode are registered trademarks of BIOMET 3i LLC. 3i T3 Implant design is a trademark of BIOMET 3i LLC. ©2014 BIOMET 3i LLC.

Volume 7 Number 2

Implant practice 1

INTRODUCTION

March/April 2014 - Volume 7 Number 2

Redefining the roles of patients and dentists in implant dentistry

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TABLE OF CONTENTS

Clinical All-on-4速 using guided surgery Dr. Andy Denny and Mr. Mike Fuse illustrate a case involving immediateloaded fixed-implant bridge reconstruction ............................ 14

Practice profile

8

Dr. M. Dean Wright: Changing lives, one implant at a time Hard work, enthusiasm, and continuing education keep Dr. Wright on the right road to practice success.

Corporate profile

11

Henry Schein Dental Surgical Solutions

Case study Staged extraction and guided bone regeneration (GBR) before implant placement Drs. John Lupovici and Robert Raimondi illustrate a collaborative surgical and restorative clinical treatment for esthetic replacement of a compromised maxilla central incisor.......................................... 21

This new division of HSD is the only company with the ability to be the sole provider for an oral surgery or periodontal practice ON THE COVER Cover photo courtesy of Dr. Michael Scherer.

Article begins on page 36.

4 Implant practice

Volume 7 Number 2

TABLE OF CONTENTS

30

Implant insight

Treating compromised sites with narrow implants Dr. Cary Shapoff discusses the great clinical significance of narrow implants for practitioners in private practice .....................................................24

AO preview The 2014 Annual Meeting of the Academy of Osseointegration: “Real Problems, Real Solutions” AO President, Dr. Stephen L. Wheeler shares thoughts on this year’s conference focusing on addressing patients’ emerging issues with older implants ........................................30

Continuing education Peri-implant disease: a growing problem Drs. Reena Wadia and Neesha Patel discuss peri-implant disease, a multifactorial disease that appears to be on the rise ...............................32 Flap vs. Flapless: a practical guide with indications, recommendations, and techniques for effective planning and surgical placement of narrow diameter overdenture implants in the mandible Drs. Michael Scherer and Andrew Ingel summarize their rationale on when a flap or a flapless surgical procedure should be performed when placing Zest LODI narrow diameter implants for mandibular overdentures .................................................... 36 6 Implant practice

Technology Restoring the edentulous patient with narrow diameter implants Dr. Paresh B. Patel illustrates a case that benefited from narrow diameter implants ........................................42

Beneficial implications of a new cutting technology for the dental implant architecture: BLOSSOM™ .....................................................62

On the horizon Product profile LightScalpel LS-1005™ SuperPulse CO2 laser..........................46 BIOMET 3i launches its new 3i T3® Implant ........................................58 Renovix® Guided Healing Collagen Membrane ..................................60

Don’t Fear the Narrow Space Dr. Justin Moody discusses his solution for narrow implant sites ...49

Diary .....................................50 Materials & equipment .....................56 Volume 7 Number 2

32670262-US-1401 © 2013 DENTSPLY Implants. All rights reserved.

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PRACTICE PROFILE

Dr. M. Dean Wright Changing lives, one implant at a time What can you tell us about your background?

I was born and raised in Wichita, Kansas.

I’ve been married 42 years and have one son Matthew, an attorney with Koch Industries.

I come from a middle-class family (I’m one of five brothers), and I’ve been working since I was 15 years old. While in college studying to become a medical doctor, I worked at St. Francis Hospital in Wichita as a medical technician. Because of that experience, I realized that being an on-call medical doctor and having a family was going to be difficult; so I switched paths and went on to obtain a dental degree from the University of Missouri, Kansas, hoping to have more regular office hours.

Is your practice implants?

limited

to

No, we handle all phases of general dentistry. Our practice has 20 operatories and five dentists. Probably two-thirds of my day is spent doing implants, mainly 3M™ ESPE™ MDI Mini Dental Implants and Bicon Implants.

Why did you decide to focus on implantology?

People with missing teeth really suffer.

In the past, partials and dentures were pretty inferior, and when we didn’t have implants, it was the best we had. I enjoy the challenge of combining oral surgery, advanced prosthodontics, and helping to put people back into everyday function by having their normal teeth back. Each day is new and exciting, and it keeps me going.

How long have you been practicing, and what systems do you use?

I began in 1976. I use 3M™ ESPE™, Bicon®, and Straumann®.

What training undertaken?

have

you

I am a 1972 graduate of Wichita State University in Wichita, Kansas, with a BS in Chemistry and a 1976 graduate of the University of Missouri - Kansas City Dental School.

8 Implant practice

Dr. Wright and a happy implant patient in his implant center

Who has inspired you?

It really started with Dr. Gerald Niznick.

He was the first American to build his own implant. When he started Core-Vent®, I took his courses and studied with him back in the late 1970s. He inspired me because having worked in the hospital, I could see the Core-Vent system made more sense and was simpler to understand. Dr. Ronald Bulard of Imtec Corporation and Dr. Victor Sendax of New York have also inspired me.

What is the most satisfying aspect of your practice?

The ability to change people’s lives is the most satisfying aspect of our practice.

People really struggle with their teeth.

When you see that you can give hope to people who have given up hope, that’s so satisfying.

Professionally, what are you most proud of?

I’m pretty proud of that fact that I’ve placed over 15,000 implants. I’m sure I’ve placed more 3M™ ESPE™ MDI Mini Dental Implants than any other person in North America — over 100 implants a month at our practice.

What do you think is unique about your practice?

The fact that we can just about do it all, in-house, under one roof. When a patient comes into our office, we can do the 3D cone-beam computed tomography (CBCT) scan, surgery, prosthetic, and ongoing maintenance.

What has been your biggest challenge?

Keeping up with technology has been my biggest challenge. Every day this business changes with new equipment and materials

Dr. Wright’s wife — he says, “I couldn’t have made it without her.”

coming out all the time. You have to really filter through and try to figure out what’s good to use, what isn’t, what’s going to help you, what isn’t. Holding it all together while still treating patients is the biggest challenge.

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

That’s an interesting question. When I was young, I thought about becoming a professional musician. I could have easily been a medical doctor or an architect. (I earned a draftsman award in school.)

What is the future of implants and dentistry?

The future is enormous. I look at all the empty spaces in people’s mouths and the amount of implants they could potentially have. There’s no way we can even keep up right now, with twice as many people wanting them as before. And yet, we somehow have to keep implants costeffective.

Volume 7 Number 2

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MDI Expanded Indications Training Seminar — 7 CE Credits DAY 2: Build on your knowledge from the certification course with the focus on: • Removable partial dentures, maxillary dentures and single tooth restorations • Addressing challenging cases This course is for doctors who have completed the certification course or have experience placing mini implants.

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MDI

Mini Dental Implants

PRACTICE PROFILE

Favorite vacation spot — Indian Wells Country Club, Palm Springs, California

Dr. Wright in hospital

When you see that you can give hope to people who have given up hope, that’s so satisfying.

Kiss from Marie Osmond

Top 10 favorites

Dr. Wright with staff, Wichita State Final Four Run 2013

Son Matthew, attorney, on business in Shanghai

1. The strawberry shortcake at the Grand Luxe Café at the Venetian Resort in Las Vegas (as big as a dinner plate) 2. My wife, son, three dogs, and cat 3. 3M™ ESPE™ MDI Mini Dental Implants

What are your top tips for maintaining a successful practice?

1. Work hard.

2. Be very good to your patients; we’re here for them.

3. Do your very best work.

4. Be enthusiastic, and stay excited about what you’re doing.

What advice would you give to budding implantologists?

advanced doctors to be your mentors, and do whatever it takes to keep advancing your education. You’re going to have to learn to just go out there and do it!

What are your hobbies, and what do you do in your spare time?

I love to play golf, and I love to travel. I like going to live shows and movies. I love to work out, and work out everyday. I really enjoy sports of all kinds, and family. IP

4. Hitting golf balls on the driving range 5. Palm Springs, California 6. Star Trek movies 7. Hiking in Colorado 8. Financial and economic planning 9. The Beach Boys 10. Wichita State University basketball

This field’s too complicated to not give it your all. Learn, learn, and learn. Take continuing education courses. Get more 10 Implant practice

Volume 7 Number 2

This new division of HSD is the only company with the ability to be the sole provider for an oral surgery or periodontal practice

F

or nearly 80 years, Henry Schein Inc. has been North America’s most reliable resource for dental supplies, dental equipment, and dental financing services.

Now, with an increased focus on bringing more comprehensive services to oral and maxillofacial surgeons and periodontists, the worldwide distributor of dental products serves the specialized needs of oral surgeons and periodontists through its new division, Henry Schein Dental Surgical Solutions (HSDSS). The division is the first and only provider of every product that an oral surgery or periodontal practice needs to maintain and grow a surgical practice.

In addition to products, HSD Surgical Solutions is a partner to the surgical specialist by delivering innovative and personalized business solutions that make a measurable difference for both surgeons and their referrals.

Neil Park, DMD, general manager of Surgical Solutions, describes, “Many surgical specialist customers are not aware of our extensive offerings. In addition to basic supplies, we carry pharmaceuticals, equipment and technology, financing options for doctors and patients, consulting services, office design, architectural services, implants, bone grafting materials, and many other specialized products for the surgical practice.”

Dr. Park adds, “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 team of representatives concentrated only on serving the entire spectrum of specialists’ needs.” The Surgical Solutions’ team is dedicated to bringing quality technology and products to the specialty office in a convenient and efficient way. Dr. Park notes, “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, bone-related product from yet another. We can streamline that process

Neil Park, DMD

Robert Riley

Maritza Alford

Todd Colvin

Kerri Leslie

Donald Boyd

while providing additional value to the practice. Our surgical sales consultants will become a part of the team in surgical practices and help to bring our customers’ practices to higher levels of clinical and business success.”

Surgical Solutions’ representatives are equipped with strong backgrounds in surgery and implant dentistry, leading to a greater understanding of dental procedures, and therefore the products and tools necessary for effective treatment planning and successful outcomes. Reps provide much more than advice on surgical items. They also have an understanding of the special requirements of oral surgeons and periodontists and have keen perception of how to analyze a business to help it grow. Consultations with specialists are complimentary, an added perk of becoming an HSD Surgical Solutions’ customer.

Another aspect of the relationship between Surgical Solutions’ representatives and specialty clinicians is the reps’ referral base network. The Henry Schein Dental team has spent years understanding the General Dentistry Practice and

Scott Ryan

making a measurable impact in their customers’ practice. Surgical Solutions field representatives connect with their counterparts from the General Practitioner division and help put specialists in touch with more referring GPs. Surgical Solutions customers can also employ proven Henry Schein business tools to attract, retain, and grow referrals.

A team of dedicated, experienced professionals bring their individual expertise to lead this 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

Volume 7 Number 2 Implant practice 11

CORPORATE PROFILE

Henry Schein Dental Surgical Solutions

CORPORATE PROFILE closely to bring this new division to fruition.”

Kerri Leslie, the new head of marketing, brings her 9 years of experience in the medical field to spread the news of the expanding endeavor. The knowledgeable and enthusiastic sales team, which has already doubled in size, 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 Eastern region, spent many years with the implant giant, Zimmer, before joining Camlog/Henry Schein 6 years ago. Donald Boyd, regional manager for the Central region, spent 16 years with Nobel Biocare. Scott Ryan, Area Sales Manager of the Western region, has held various sales and marketing leadership roles over the past 12 years in the implant/dental industry. 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.

Henry Schein has made a continuous effort to provide innovative and specialized products to the surgical specialist through acquisitions and strategic partnerships.

HSD owns OMS Vision®, which is a leader in practice management software for oral surgeons. OMS vision is committed to continuous improvement and evolution of their software to meet the needs of the modern oral surgeon. OMS Vision has had an exclusive partnership with the American Association of Oral and Maxillofacial Surgeons for more than 10 years, and through this partnership, OMS vision has developed a fully integrated implant tracking module and implant inventory management system.

For implant-focused practices, Surgical Solutions offers its oral surgeon and periodontist customers the tools and materials for a successful and less stressful implant experience. This division is a solution provider in tooth replacement therapy options.

For example, Henry Schein has entered into an exclusive distribution relationship with Osstell. Osstell specializes in instruments for analyzing dental implant stability. Osstell ISQ, measures the stability of implants in an objective, non-invasive manner using the universal ISQ scale 12 Implant practice

(Implant Stability Quotient). The ISQ values help dentists determine the optimal time to load each implant. Also, by detecting decreasing stability, Osstell ISQ can help prevent failure caused by premature loading. Over 550+ studies and 10 years of clinical experience around the world confirm the usefulness of Osstell ISQ for dentists and surgeons.

Also, 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 implant system, called Conelog®, has the same outer geometry as Camlog, with the added benefit of the proven conical connection.

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.

With Surgical Solutions’ CAD/ CAM options, specialists can explore the advantages intraoral scanners from PlanScan (formerly E4D), 3M™ ESPE™, and 3Shape. Digitally recording the position 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®.

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’s i-CAT® FLX, can help clinicians to 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, “Henry Schein is a market leader in the distribution of X-ray equipment, CBCT scanners, and intraoral CAD/CAM units, 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 makers, and we also have the Henry Schein brand of value-priced instruments.

Our representatives are a veteran team, and they are using their experience to implement business solutions that make the surgical practice more profitable and efficient, allowing our customers to focus on patient care. Henry Schein works hard to epitomize this motto: ‘Take care of your patients, and we’ll take care of the rest.’” IP This information was provided by Henry Schein Dental Surgical Solutions.

Volume 7 Number 2

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CLINICAL

All-on-4® using guided surgery Dr. Andy Denny and Mr. Mike Fuse illustrate a case involving immediate-loaded fixed-implant bridge reconstruction

T

he All-on-4® treatment concept was developed in the 1990s as a way to best restore the full arches of the upper and lower jaws. The procedure uses only four implants to secure all teeth in place, hence the name “All-on-4.” The All-on-4 treatment concept, using biomechanics, computer simulation, and clinical research, was developed by implant manufacturer Nobel Biocare® and European implant dentist Dr. Paulo Malo. Their results provided patients with high-quality, full-arch restoration for edentulous, compromised-bone patients without the use of bone grafting in the shortest time possible.

For candidates eligible for the All-on-4 treatment concept, the general process for treatment involves just two stages: consultation/assessment and surgery.

During the consultation, the candidate undergoes an assessment where eligibility is determined, dental needs are assessed, and a solution is prescribed. The next step in the consultation process is 3D CT scanning where state-of-the-art technology is employed to plan the surgery. The final step in the consultation process is taking impressions so a prosthetic setup can be created to produce the teeth that will be fitted the day of the surgery. Following

Figure 1: Old, worn dentures pre-treatment

Figure 3: Edentulous lower arch pre-treatment

Figure 5: Lower radiographic guide

Andy Denny, BDS, MFGDP(UK), MGDS RCS(Eng), is joint principal of Twenty 2 Dental, a private cosmetic and implant dentistry practice in Weston-super-Mare, England. He is interested in helping patients have the “beautiful smile” they always wanted, and has a reputation for the esthetic integration of complex restorative treatments involving the interdisciplinary management of prosthodontics, implants, and particularly cosmetic adult orthodontics. Having studied extensively in the United States, Europe, and the UK, Dr. Denny lectures and teaches dentists and their teams, nationally and internationally, on Implantology, Cosmetic Dentistry, and the Six Month Smiles® system and has authored numerous articles in dental journals covering a wide range of topics, such as implant, cosmetic dentistry, and short-term orthodontics. Dr. Denny was winner of a 2013 Aesthetic Dentistry Award for the Restorative Case — Full Mouth Category. He is a full member of The British Academy of Cosmetic Dentistry, British Periodontal Society, the International Team for Implantology, the Association of Dental Implantology, and a member of The American Academy of Cosmetic Dentistry. He receives referrals for esthetic and implant dentistry from practices throughout the South and South West of England.

Mike Fuse has more than 15 years of experience in dental technology. He quickly built a reputation for creating natural-looking teeth and providing superior levels of craftsmanship. Mr. Fuse has a particular interest in complex dental implantology and full-mouth rehabilitation. He established Fusion Dental Ceramics in Cardiff in 2005. The laboratory specializes in all aspects of digital dentistry, implants, cosmetic restorations, and prosthetics. Mr. Fuse has attended specialist courses globally to further his knowledge and skill levels. He is currently studying for his Dip CDT RCS and is one of only a handful of CDTs in the UK who is an All-on-4® treatment concept specialist. He has been involved with Nobel Biocare® and NobelProcera® for well over a decade and is a lecturer for them, as well as for the Association of Dental Implantologists (ADI). He is a member of the Dental Laboratories Association, the Association of Clinical Dental Technicians, as well as the ADI.

14 Implant practice

Figure 2: Edentulous upper arch pre-treatment

Figure 4: Upper radiographic guide

Figure 6: Nobel clinician plan upper

the consultation stage, the next stage is surgery during which the implants are placed into the patient’s mandible, and/ or maxilla, and new teeth are fitted to the dental implants. Four implants can be used to support a fixed prosthesis with 12 to 14 teeth that is placed immediately on the day of surgery.

Case presentation Assessment and pre-surgical work-up The patient attended the practice for an initial consultation to find out what his options were to replace his old full upper and lower dentures. His dentures were loose, ill-fitting, and uncomfortable, and he specifically wanted to investigate implant treatment options, having read an article Volume 7 Number 2

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CLINICAL

Figure 7: Nobel clinician plan lower

Figure 8: Proposed tooth setup dentures

Figure 9: Lower surgical guide in situ

Figure 10: Soft-tissue and marker drill – lower arch

Figure 11: Fixture drill – lower arch

Figure 12: Fixture placement – lower arch

Figure 13: All lower fixtures placed with surgical guide – lower arch

Figure 14: Rigid/linked open tray impression copings – lower arch

Figure 15: Pick-up impression – lower arch

Figure 16: Upper surgical guide in situ

Figure 17: Initial 2-mm twist drill and guide-key – upper arch

Figure 18: Fixture drill – upper arch

about the All-on-4 treatment concept in the press.

From the options presented, the patient chose the All-on-4 treatment concept as it offered the best fixed solution to meet his needs, and his clinical and radiographic assessment indicated that it was possible.

As the patient’s old dentures were inadequate, impressions and records for new mock-up teeth were set up to try-in, and were approved by the patient. The new acrylic dentures were then created ready for the surgical appointment and duplicated to make acrylic radiographic guides with 8–10 radiopaque markers in.

A dual arch CBCT scan was performed on a J. Morita Veraviewepocs 3D R100 using 80 x 80 FOV. Individual scans were taken of the guides too. All data were imported in to Nobel Biocare’s NobelClinician™ software, and the images married together to show detailed relationship between guides and patient scan.

The digital imaging was evaluated, and a detailed plan formulated in conjunction with technician Mike Fuse of Fusion Dental Ceramics. This plan included the positioning for best anterior-posterior spread and

Options: • Dental implant-supported denture on multiple fixtures with custom-milled retaining bar.

• Dental implant-retained denture on fixtures with locator attachments.

• 6–10 dental implants with multiple short-span ceramic bridges and crowns (potentially involving hard and soft tissue grafting/augmentation).

• All-on-4 treatment concept.

16 Implant practice

Volume 7 Number 2

CLINICAL

Figure 20: All upper fixtures placed with surgical guide – lower arch

Figure 19: Fixture placement – upper arch Figure 21: Rigid/linked open tray impression copings – upper arch

Figure 22: Pick-up impression – upper arch

Figure 23: Denture locating pick-up copings – upper arch 001

Figure 24: Denture locating pick-up copings – upper arch 002

Figure 25: Lab process – temporary cylinders and silicon guide – lower arch

Figure 26: Lab process – denture locating pick-up copings – upper arch 001

Figure 27: Lab process – denture locating pick-up copings – upper arch 002

distribution of forces using angled distal fixtures (as per the treatment protocol), and the type of implants identified along with abutment selection to give optimum prosthetic screw access.

Once approved, the plan was digitally sent to Nobel Biocare for production of upper- and lower-guided surgery drill positioning guides.

pins laterally into the ridges, and four NobelReplace™ Tapered Groovy implants were placed in each jaw, using the guided surgery kit, allowing for accurate fixture placement to the pre-assigned depth and position as planned using a flapless surgical technique.

The lower jaw was done first in order that the patient’s bite could be registered against the new upper denture, followed by the upper arch surgery. The distal implants were placed at approximately a 30o angle to achieve maximum advantage to the

existing bone structure. Once the four implants were secured, the guides were removed, and 30º angled abutments were attached to the distal fixtures.

Multi-unit screw-retained impression copings were used for open-tray pickup.

The copings were linked using LuxaBite® (DMG), and Honigum® heavy automix putty (DMG) was used for the impression, allowing the technician to cast up implant replica models.

The lower denture position was registered over locating copings on the

Surgery and immediate bridge fit Following local anesthetic, the drill guides were secured in place with guide 18 Implant practice

Volume 7 Number 2

CLINICAL

Figure 28: Lab process – final lower provisional bridge

Figure 29: Lab process – final lower provisional bridge

Figure 30: Post op – upper Same-Day Teeth 001

Figure 31: Post op – lower Same-Day Teeth 001

Figure 32: Post op – Same-Day Teeth 003

Figure 33: Post op – Same-Day Teeth 006

fixtures with O-Bite™ (DMG) and against the upper denture in centric occlusion.

and filling it up inside the patient’s mouth with cold-cure acrylic. The approach used in this case is far less messy, and far more accurate. The main work is done lab-side while the patient is having a rest from the treatment.

The beauty of this procedure is the sheer convenience. The implants developed for this treatment allow for the immediate fitting of replacement teeth to the abutments. This means that with only four implants, patients can leave the practice with a full set of new replacement teeth (in most cases) with no bone grafts necessary.

The teeth are fixed, so there is no need for patients to be without teeth or to endure temporary dentures for an extended time period. The patient is enabled to come for a morning appointment and leave that same afternoon with a brand-new smile!

Occasional review appointments take place over the course of the following weeks and months to ensure that that the soft tissues have properly healed and that the implants have successfully integrated.

Following this, the patient is required to schedule the final visits for construction of the definitive long-term titanium-reinforced bridge and to arrange regular hygienist appointments for routine maintenance.

The result is a brand-new long-lasting smile with maximum comfort, support, and functionality. Most importantly, patients will walk out of the practice with a boost of selfconfidence and an irresistible urge to smile more often, losing any previous feelings of discomfort or self-awareness. IP

Lab procedure Before beginning an All-on-4 treatment concept full dual-arch rehabilitation case, it is important to establish a solid occlusion for working on one arch — you can’t just guess where teeth are going to go.

As this was a guided case, it was possible to make the lower provisional from the guided model before the surgery was carried out. The two anterior fixtures were attached so the prosthesis was partially completed and ready to be screwed onto the implants on the day of surgery.

Once the lower prosthesis was screwed in, this gave a solid occlusion to work with when placing the upper arch. As previously described, custommade transfer copings were used as a reference when registering the upper-arch relationship. These copings were screwed on top of the implant fixture/abutments, and an impression/registration taken inside the denture. The copings were then removed from the patient’s mouth and screwed back into the model to create an accurate reference for adjusting the upper arch.

This compares very favorably with the more common approach that involves cutting large access holes in the denture 20 Implant practice

Finishing stages While the lab process was being completed, the patient was able to have a light lunch and read while awaiting delivery of his provisional fixed bridges.

After a couple of hours, the finished upper- and lower-arch provisional bridges were ready. They were tried in, the esthetics, phonetics, and occlusion checked, and the abutment screws torqued down to 15 Ncm. The access holes were filled with PTFE and Cavit™ (3M™ ESPE™) temporary filling material.

The patient was delighted with the result and the efficiency of the whole process. At the 1-week review, the patient reported little postoperative discomfort: He was able to eat comfortably once more, his speech was normal, and he was amazed with the result.

Because only four implants are used in the procedure, and no extended surgical flaps need to be raised, the entire process is much less invasive and involves less surgical time than other full arch treatment modalities.

Volume 7 Number 2

Drs. John Lupovici and Robert Raimondi illustrate a collaborative surgical and restorative clinical treatment for esthetic replacement of a compromised maxilla central incisor

W

ith the rapid advancement in understanding of the biomechanical interaction of implants and bone, implants no longer can be deemed successful simply based on their ability to retain a functional restoration. Instead, the faithful re-creation of natural esthetics has also become imperative. In order to solve the substantial challenge of achieving natural esthetics in compromised situations, a number of techniques and materials have developed to restore deficient alveolar bone and maintain existing bone and soft tissue. This case study will exhibit an example of a collaborative surgical and restorative clinical treatment to achieve an esthetic replacement of a compromised maxilla central incisor.

Figure 1: Systemically healthy 31-year-old male who presented with asymptomatic external resorption of the right central incisor. Preoperative facial view of maxillary anteriors. Note thin gingival biotype

Case report The 31-year-old male patient presented with asymptomatic external resorption of the right central incisor. A review of his medical and social history proved uneventful. Extraoral examination revealed a moderate to high smile line that displayed approximately 2 mm of gingiva when he

John Lupovici, DDS, is a periodontist and Diplomate of the American Board of Periodontology, practicing in New York City. Dr. Lupovici received his DDS from New York University College of Dentistry, followed by a certificate of specialty in Periodontology. While at NYU, he participated in numerous research studies, and he was awarded three Dean’s Student Research awards.

Dr. Lupovici also received first place in the American Dental Association/NYU Research Day Competition for his work. Dr. Lupovici currently maintains a faculty position at NYU’s Department of Periodontics as well as Implant Dentistry. He represents NYU by presenting to his peers on the national and international platform.

He is an international lecturer and a widely published author on clinical topics.

Robert Raimondi, DDS, performed the final restoration in this case. He maintains a private prosthodontics practice on the Upper East Side of Manhattan in New York City. He also teaches at the Brooklyn Veterans Affairs (VA) General Practice Residency, the Manhattan VA Advanced Education in Prosthodontics Program, and the New York Hospital at Queens Advanced Education in Prosthodontics residency program.

Figure 3: Tooth No. 8 was atraumatically elevated from the alveolus. Care was taken to avoid traumatizing the facial alveolus. All granulation tissue was carefully curetted from the socket, which then was filled with the particulate mineralized allograft (Musculoskeletal Transplant Foundation Cortical/Cancellous Allograft Granules, .5 cc)

Figure 2: Radiograph displaying external resorption of tooth No. 8

Figure 4: A 2-mm-thick slice of a collagen wounddressing material was placed over the graft to better contain the particulate material. The tissues were sutured, and no attempt to achieve primary closure was made

Volume 7 Number 2 Implant practice 21

CASE STUDY

Staged extraction and guided bone regeneration (GBR) before implant placement

CASE STUDY

Figure 7: Three months after implant placement. Intraoral examination revealed successful integration with healthy surrounding peri-implant tissue

Figure 5: Three months post extraction and augmentation, the patient presented for implant placement. Hard tissue preservation was radiographically and clinically confirmed

Figure 6: Six weeks post implant placement, radiographic confirmation of implant integration. Note the preservation of crestal bone

Figure 8: Using Atlantis™ 3D Editor, the technician and restorative dentist can manipulate the design prior to milling. (Atlantis, Dentsply Implants)

Figure 9: One-piece zirconia abutment prior to delivery (Atlantis, Dentsply Implants)

smiled. Intraoral and radiographic examination revealed the presence of external palatal resorption of the maxillary right central incisor, in conjunction with a thin gingival biotype (Figures 1 and 2).

Although a variety of boneaugmentation strategies (onlay, inlay, 22 Implant practice

veneer grafts, ridge splitting, and expansion) are all well documented to have a record rate of success, we chose a staged extraction and guided bone regeneration (GBR) technique because of the patient’s prominent smile line in conjunction with thin gingival biotype (Figure 1).

Following administration of local anesthesia (Lidocaine with epinephrine 1:100,000), tooth No. 8 was atraumatically elevated from the alveolus, and socket augmentation was performed with the particulate mineralized allograft (Musculoskeletal Transplant Foundation Volume 7 Number 2

CASE STUDY

Figure 10: Shaded (020 [vita A2]) Atlantis Custom Zirconia Abutment (Atlantis, Dentsply Implants)

Symbios™ Mineralized Cortical/Cancellous Granules, .5 cc (Dentsply Implants) (Figure 3) and a collagen sponge. The patient was provided with a non-load-bearing Essix retainer. Three months after the extraction and augmentation, implant placement using OsseoSpeed™ (4.5 x 13 mm) (Dentsply Astra Tech) implants was performed.

Figure 11: A final restoration was fabricated out of lithium disilicate (IPS e.max®, Ivoclar Vivadent) (MDT, Marco Boschiroli) and cemented using clear resin cement (Calibra® Esthetic Resin Cement)

Six weeks after implant placement, implant integration was confirmed (Figure 6). An open-tray impression was made using Impregum™ soft medium body (3M™ ESPE™) in a custom tray. Using the patient’s original tooth, a zirconia custom Atlantis™ abutment (Atlantis Abutments, Dentsply Implants) was reverse engineered (Figure 8). The abutment (Figure 9) was

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then delivered and torqued to 25 Ncm, and a provisional restoration was fabricated (Figure 10). Over the course of 3 months, the tissue was matured prior to fabrication of the final restoration. The final restoration was then delivered successfully (Figure 11).

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Volume 7 Number 2 Implant practice 23

IMPLANT INSIGHT

Treating compromised sites with narrow implants Dr. Cary Shapoff discusses the great clinical significance of narrow implants for practitioners in private practice

I

n my practice, I encounter patients with congenitally missing maxillary lateral incisors and fractured maxillary and mandibular incisors. These sites often present restricted dimensions not only buccolingually but also interproximally.

In the past, loss of a single lower incisor often created the need for extensive fixed restorative care. Congenitally missing lateral incisors, often restored with bonded bridges, have the untoward consequence of frequent debonding. Narrow implants may serve as a provisional anchoring device to protect the site during a traditional implant healing phase. The use of the narrow dental implant now allows the clinician to treat most of these specific sites with the conservative alternative of the single dental implant compared to the need for extensive fixed restorative care. Occasionally, other forms of interdisciplinary care need to be considered prior to or in conjunction with the placement of dental implants.

Since the advent of dental implants as an alternative for replacing missing teeth or replacing damaged existing teeth, the development of numerous implant styles and sizes has improved our ability to treat sites otherwise considered compromised.

Narrow dental implants are available as a one-piece fixture or traditional two-piece.

The advantages of the two-piece implant include the opportunity to allow delayed loading and the flexibility of using different prosthetic components. My choice has been the BioHorizons® Tapered Internal 3.0 implant as well as the small diameter 3.5 mm platform implant for restricted spaces.

These implants offer prosthetic abutment

Cary A. Shapoff, DDS, has practiced in Fairfield, Connecticut for over 36 years. He is in private practice as a periodontist, and is a Diplomate and past director of the American Board of Periodontology. He lectures both nationally and internationally on periodontal disease and its treatment, bone grafting procedures, and dental implant surgery. He has also written articles published in the Journal of Periodontology, Compendium, the International Journal of Periodontics and Restorative Dentistry, and The Dental Guide (Canada). He has been a consultant and lecturer for BioHorizons for 7 years.

Dr. Shapoff can be contacted at cas@shapoff.com.

24 Implant practice

Case 1

Figure 1

Figure 5

Figure 2

Figure 3

Figure 6

choices with a variety of provisional abutments, stock abutments, and CAD/ CAM titanium or ceramic abutments with Laser-Lok® microchannels. This microchannel technology on the collar allows for enhanced soft tissue “functional” attachment to the abutment surface.

This article describes the use of narrow implants in a variety of common clinical situations and a discussion of the treatment sequence and modalities utilized for each case. Each of the cases presented in this article provided different surgical and restorative challenges.

Case 1 A 44-year-old female was seen for dental implant consultation for tooth No. 26 in December 2009. She has previously had tooth No. 26 extracted 6 months earlier without socket grafting (Figure 1). The existing alveolar ridge was narrow and required additional bone augmentation to improve the ridge dimension (Figure 2). Five months after ridge grafting, a BioHorizons 3.0 mm implant (3.0 x 12 mm) was placed and allowed to heal for 3 additional months (Figures 3, 4, and 5). Following secondstage surgery, a screw-retained provisional crown was placed to shape the gingival tissue (Figure 6). The final crown was

Figure 4

Figure 7

Figure 8

placed 10 weeks later. Figures 7 and 8 represent the 3-year follow-up visit (July 2013) with a custom cast UCLA abutment and EMAX crown. Metallic abutment showthrough was evident on the thin marginal tissue. The 3.0 Ti-Base CAD/CAM milled ceramic abutment became available after restoration of this implant. This case represented the first clinical anterior restoration of the BioHorizons 3.0 implant in private practice (restoration by Dr. David Wohl, Fairfield, Connecticut).

Case 2 A 67-year-old male was referred for generalized periodontal care prior to a maxillary full-arch rehabilitation with a new bridge to replace a failed restoration. In addition to generalized, moderate to severe periodontitis, the patient demonstrated a periodontal abscess with severe bone loss on tooth No. 24, and was given a hopeless prognosis (Figures 9-10). He also demonstrated clinical signs of bruxism with significant incisal and occlusal wear.

Numerous restorative options were discussed with the patient for site No. 24.

A single dental implant with adjacent, fullcrown coverage was selected, assuming that the first phase bone grafting procedure would allow proper dimension for implant Volume 7 Number 2

IMPLANT INSIGHT

Case 2

Figure 9

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placement. The patient preferred individual teeth rather than fixed bridgework. A provisional bridge was placed, leaving the root of tooth No. 24 in place (root banking), to prevent soft tissue shrinkage and bone loss secondary to extraction prior to the ridge augmentation procedure.

The surgical procedure consisted of surgical flap entry, debridement of subgingival calculus from all involved teeth,

products that And promote better patient relationships.

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IMPLANT INSIGHT Case 3

Figure 15

Figure 17

Figure 16

Figure 18

meticulous defect debridement, and ridge augmentation. A combination graft of MinerOssŽ particulate (mineralized cortical and cancellous bone) and rh-PDGF-BB biologic modifier (Gem-21SŽ, Osteohealth) was utilized and then covered with a contoured titanium reinforced PTFE barrier (Cytoplast™, Osteogenics Biomedical) and allowed to heal for 6 months (Figure 11). A BioHorizons 3.0 implant was placed (Figure 12) and allowed to heal for an additional 3-month period. After provisionalization of the implant, a final crown was placed on a custom cast abutment (Figures 13-14) (Dr. Jeffrey Babushkin, Trumbull, Connecticut).

Case 3 A 57-year-old female patient presented with localized bone loss and pocketing in the lower anterior region (Figure 15). Tooth No. 25 had previously been surgically treated in another office and veneer restorations were placed on the two central incisors. Tooth No. 24 was rotated with a closed interproximal embrasure. Tooth No. 24 exhibited minimal mobility, but tooth No. 25 was significantly mobile. Various treatment options were discussed with the patient, including fixed bridgework, bonded bridge, replacement of missing teeth with implant-retained restorations. The patient preferred individual tooth replacement with a dental implant but refused extraction and replacement of tooth No. 24. She was presented with a two-phased approach, involving alveolar ridge reconstruction 26 Implant practice

Figure 19

Figure 20

of site No. 25 and re-evaluation of the periodontal status of tooth No. 24. A CBCT was required before treatment plan discussions. The patient also requested a fixed provisional restoration during the treatment phases.

The axial view of the CBCT (Figure 16) clearly demonstrated the significant loss of ridge dimension from the failure of the prior regenerative procedure. Ridge grafting was accomplished with MinerOss cortical and cancellous bone hydrated with rhPDGFBB. A tenting screw was fixed to the lingual wall of the defect to serve as a support for the graft material and barrier (Figure 17).

Bovine pericardium (CopiOs) was used as the barrier material and primary closure of the defect was obtained and maintained with 6-0 propylene sutures. Healing was uneventful, and the patient was seen on a regular post-operative schedule.

Following 6 months of successful graft healing, the tenting screw was removed, and a BioHorizons Tapered Internal 3.0 implant (12 mm length) was placed after determining adequate ridge dimension by direct measurement (Figures 18-19). The implant was allowed to heal for an additional 3 months until second-stage surgery and screw-retained provisionalization utilizing a PEEK abutment and composite crown.

The tooth was then restored utilizing a 3.0 titanium custom cast abutment and a lithium disilicate crown (Figures 20-21) (restoration by Dr. David Wohl, Fairfield, Connecticut).

Figure 21

Slight metal show-through of the abutment was evident because the patient demonstrated thin biotype, and a connective tissue was performed upon her request.

Case 4 This 47-year-old female recently had a missing maxillary lateral incisor replaced with a long narrow one-piece implant of unknown origin (Figure 22). Unfortunately, the prosthetic platform of the implant was improperly positioned, resulting in the platform being very coronal to the osseous crest and the resulting crown (provisional) being very short and unesthetic (Figure 23).

It was determined that despite the recent procedure in another office, the appropriate solution was to remove the existing dental implant, repair the site, and consider another narrow implant, placed at the proper prosthetic level. CBCT radiographic analysis was necessary to determine ridge width and intraosseous implant positioning.

After raising a full thickness mucoperiosteal flap on the facial surface, the implant was removed utilizing a vertical cut in the facial wall alveolus with a piezotome handpiece and reverse rotation of the implant with a surgical extraction forcep (Figure 24). The initial plan was to reconstruct the site, allow 4 months of healing, and then place a narrow two-piece dental implant. At the time of the first surgery, the ridge dimension width, the facial location of the initial implant in the alveolus, and the minimal ridge Volume 7 Number 1

Figure 22

Figure 23

IMPLANT INSIGHT

Case 4

Figure 24

Figure 25

Figure 26

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destruction during its removal allowed placement of a BioHorizons 3.0 narrow implant in an ideal position using a surgical guide provided by the prosthodontist.

The implant was placed in a more palatal position in the alveolar ridge allowing 2 mm of distance from the implant surface to the facial plane of the alveolus (Figure 25). Allograft bone (MinerOss) was placed in the surgical defect and an additional onlay bone graft was placed and covered with a resorbable collagen barrier. The site was allowed to heal for 4 months before a second-stage surgery and placement of a

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Volume 7 Number 2 Implant practice 27

IMPLANT INSIGHT

Figure 28

Figure 32

Figure 29

Figure 33

screw-retained provisional crown to shape the gingival tissue. The final crown and custom abutment were delivered 3 months later (Figures 26-27). (restoration by Dr. Jeffrey O’Connell, Bridgeport, Connecticut) Opportunities to use narrow dental implants can assist the clinician in providing support for interim prosthesis during a bone graft or dental implant healing phase.

The case below (Figures 28-31) shows use of a narrow implant (MDL, Ultimatics, Inc.) to support a removable prosthesis and to reduce or eliminate pressure on the surgical site where two BioHorizons Tapered Internal implants (3.5 mm platform) were placed simultaneous to extraction of teeth No. 8 and No. 10 following horizontal fracture of the abutment teeth at the gingival level. The patient had a strong bruxing habit and frequent travel schedule, which negated the consideration of immediate provisionalization. The “provisional implant” was connected to the removable provisional with an “O-ring” in the provisional to provide an axial stop and prevent pressure on the implant and bone graft healing site. (final restoration — Dr. Michael Reynolds, Southport, Connecticut)

Discussion In all cases presented, various treatment options were discussed with the patients.

For example, in Case No. 1, the other restorative options considered for her were bonded bridge or fixed bridgework. Key elements to the success of the restoration appeared to be use of CBCT to allow 28 Implant practice

Figure 30

Figure 34

Figure 31

Figure 35

a three-dimensional view of the bone anatomy, additional grafting to create an adequate ridge, and a screw-retained provisional to support the facial and interproximal gingival contours.

Since the restoration of this case, BioHorizons has introduced the TiBase CAD/CAM milled custom ceramic abutment with Laser-Lok microchannels on the abutment margin. These nonrandom nano-dimensioned (8 micron) grooves have been in clinical practice for 14 years, and enhanced crestal bone maintenance has been demonstrated in the literature by this author, as well as others.

In addition, recent human and animal histology (Nevins, et al.) has confirmed an enhanced response of bone and soft tissue to the Laser-Lok surface, providing a “functionally-oriented” attachment of connective tissue to the implant collar, as well as the abutment surface above the implant/abutment connection.

Success of several of these cases was a result of adequate reconstruction of the alveolar ridge and the use of the narrow BioHorizons Tapered Internal Implants (Case No. 2 — 3.5 mm platform, Case No. 3 — 3.0 mm platform). Regeneration of lost alveolar bone involved the use of allograft bone material, biologic modifiers, and space maintaining barriers. In addition, adequate time was necessary to allow graft incorporation and maturation. Selection of the appropriate implant size was also a component of success. Literature suggests that implant site preparation should provide

for at least 2 mm of facial bone and at least 1.5 mm of interproximal bone around the implant body. There is an advantage in using an implant system, such as BioHorizons.

The system offers various narrow platform dimensions to allow the clinician flexibility in selecting the appropriate implant body size to maintain proper alveolar bone around the implant. Placing the implant too close to the facial bone wall can result in untoward bone resorption, exposure of implant threads, esthetic compromises in thin tissue biotypes, and possibly loss of implant integration. Use of an implant style that has a thread design capable of providing excellent initial biomechanical stability also allows for immediate provisional loading, where appropriate.

Proper treatment planning and the use of 3-dimensional imaging are also essential in cases of restricted space. The opportunity to allow sites to heal undisturbed, following bone grafting as in Case No. 4, is a clear advantage of the two-piece narrow dental implant over the one-piece implant. In addition, the variety of prosthetic abutment choices allows for creation of a more ideal contour of the subgingival abutment anatomy resulting in better esthetics and marginal tissue and bone health.

Finally, at the time of this writing, two interesting cases were treated by me on two consecutive days, clearly demonstrating the need and the advantage of using narrow dental implants as part of the implant family of sizes available to the clinician. Both cases, one with crown and root fracture (Figures 32-33) and the other with external root resorption (Figures 3435) presented with restricted spaces and narrow alveolar anatomy. Both were able to be surgical treated with extraction and simultaneous implant placement.

Today, clinicians tackle complex dental problems with more sophisticated diagnostic procedures and surgical techniques that utilize superior grafting materials and biologic modifiers. Our restorative colleagues utilize intraoral scanning devices to replace impressions and CAD/CAM milling services to create custom-contoured abutments and crowns. The use of narrow dental implants that provide predictable strength and restorative flexibility are an additional “tool in the armamentarium” that offers the clinician the opportunity to treat restricted space situations. IP

Volume 7 Number 1

AO PREVIEW

The 2014 Annual Meeting of the Academy of Osseointegration: “Real Problems, Real Solutions” AO President, Dr. Stephen L. Wheeler, DDS, shares thoughts on this year’s conference focusing on addressing patients’ emerging issues with older implants

P

roblems with root-form titanium implants are rare, so most of the science and literature available today doesn’t effectively address how to diagnose, treat, and prevent these issues.

These issues and many others surrounding decades-old implants will be the focus of the 29th Annual Meeting of the Academy of Osseointegration (AO) taking place from March 6-8 at the Washington State Convention Center in Seattle. “Real Problems, Real Solutions” is the theme of the conference, which will also provide timely information on the most important research and innovations in the field to better prepare clinicians to offer patients implants for a lifetime.

This 2-1/2-day symposium starts with an impressive lineup of speakers in the Opening Symposium, including Jonathan Ferencz, DDS; Burton Langer, DMD; Torstem Jemt, DDS, PhD; Hom-Lay Wang, DDS, MSD, PhD; Stefan Renvert, DDS; and Frank Schwarz, DMD; who will offer practical and actionable insight into the techniques and technologies to correct implant problems and prevent future complications both surgically and restoratively.

The AO — which has more than 6,000 members from 70 countries — is a nexus where specialists and generalists come together to advance the vision of implant dentistry by sharing best practices and

Stephen L. Wheeler, DDS, Board-Certified Oral and Maxillofacial Surgeon, earned his undergraduate degree from Stanford University in 1974 and completed his postgraduate and residency training at the University of Southern California School of Dentistry, graduating in 1981. He specializes in the field of implant reconstruction, which presently involves 80 percent of his time. Over the past 30 years, he has placed thousands of implants of various types on patients of all ages and has become an international lecturer on grafting and implant placement. Dr. Wheeler is the President of the Academy of Osseointegration (www. osseo.org) until the 29th Annual Meeting in March, at which time he will assume the role of Immediate Past President.

30 Implant practice

coordinating optimal patient care. This year’s programming reflects this global perspective like never before with the firstever half-day international symposium dedicated to a single country: Japan. Highly regarded dental implant thought leaders from Japan will address a wide variety of topics with simultaneous Japaneseto-English and English-to-Japanese translation.

In addition to the educational symposia and exhibit hall attractions, the AO Annual Meeting President’s Reception will be a memorable event for attendees.

Held at the Boeing Museum of Flight, one of the largest air and space museums in

the world, the evening of celebration will include food stations displayed in various locations throughout the entire facility, as well as live entertainment.

AO President Stephen L. Wheeler, DDS, discussed this year’s Annual Meeting along with other issues facing dental implant practitioners in 2014 and beyond.

What are the most pressing issues leading to this year’s AO Annual Meeting?

Technology, market pressures, and patient demand will be major discussion topics for both speakers and attendees at this year’s AO Annual Meeting. Improvements Volume 7 Number 2

How can dentists respond to this demand?

The simple answer is education and experience. This is where the AO is uniquely positioned. We are dedicated to providing evidenced-based education. We have had three international consensus conferences and have a fourth planned for this August to investigate scientifically what techniques and technologies are safe and predictable. Secondarily, we have experts with extensive experience from around the world present at our annual meeting.

These are not “case studies”: these are overviews based on years of experience.

To stay on top of implant dentistry takes more than the 25 hours of CME a year required by the Dental Board. A good place to supplement this education is at the AO Annual Meeting, which offers members and nonmembers an opportunity to take part in many educational symposia, networking, and social events. The meeting offers something for every attendee interested in gaining cutting-edge, evidence-based insights, and continuing education from the world’s most noted researchers and clinicians in the field.

What do you hope dentists take home with them after the meeting?

The “Real Problems, Real Solutions” theme of this year’s meeting is critically important to all dental implant practitioners — whether a specialist or general dentist, and whether they are actively placing and/or restoring dental implants or just getting started. Our opening symposium, “Strategies to Address Implant Retreatment — Dealing With the 25-Year Old Implant” will include presentations that address the unique circumstances surrounding retreating implants several years after initial placement. Topics will include crestal bone loss around titanium implants, periimplantitis, the nature of complications and failures pertaining specifically to mature implants, and other high-interest talks by thought leaders in the field. The event concludes on Saturday with the forward-

looking Closing Symposium theme, “Our Better Future,” where experts will present on current and advancing technology in managing teeth and implants, such as advances in biotechnology, digital dentistry, materials selection, and prosthetic design.

As implant dentistry has become a standard of care today, all professionals in the field will have to be able to competently address any issues that present to their practices, and treat or refer them as necessary. I am confident that the Annual Meeting will offer tremendous professional and personal value to the nearly 2,000 dentists attending this year.

This momentum will build throughout the year as this dynamic community continues to work together, discovering the advancements that will carry us forward into the future, giving us the ability to provide more successful dental implant treatment and improve patient care. IP

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Volume 7 Number 2 Implant practice 31

AO PREVIEW

in implant design and surface technology, along with digital prosthetic design and construction, have given us the potential to restore patients faster and more efficiently.

These advances are not without risks. As more dentists are placing implants, we are seeing more complications, especially when dentists start working outside of their “comfort zone.” We all need to know what really works and what the potential risks are to hopefully prevent these problems from occurring. With a proper understanding (evidenced-based, not marketing), dentists can be better prepared not to succumb to patient demands or market pressures, and know better when to refer to specialists. I am a firm believer in 3D technology and treatment planning, but even this technology is not “bullet proof.”

Many of the educational sessions during this year’s Annual Meeting delve into, or are completely devoted to, advances and opportunities around digital dentistry and 3D imaging technology. These advances in technology, when used properly, can lead to shorter treatment times, but we all have to be careful when confronted with increasingly aggressive marketing and a growing patient demand for these techniques.

CONTINUING EDUCATION

Peri-implant disease: a growing problem Drs. Reena Wadia and Neesha Patel discuss peri-implant disease, a multifactorial disease that appears to be on the rise

I

n 1977, Brånemark, et al., published an article entitled “Osseointegrated implants in the treatment of the edentulous jaw.

Experience from a 10-year period.” This study revolutionized clinical dentistry by demonstrating that it was possible to successfully use titanium implants to replace missing teeth. Implant-retained prostheses have since become a popular treatment modality, aiming to fulfill functional and esthetic needs.

As dental practitioners, we are constantly bombarded with updates about the latest dental implants, new techniques, and expanded indications. However, the complications that may arise with implant rehabilitation are less commonly advertised and understood.

Peri-implant disease is unarguably one of the most significant risks associated with implants. It is a multifactorial disease that, if not diagnosed at early stage, can ultimately lead to failure of the implant. As more and more implants are placed by clinicians of varying skill levels and clinical backgrounds, the numbers of patients presenting with the disease appears to be on the rise.

Educational aims and objectives This article aims to discuss the management of peri-implant diseases in clinical practice.

Expected outcomes Correctly answering the questions on page 35, worth 2 hours of CE, will demonstrate the reader can: • Define peri-implant mucositis and peri-implantitis.

• Identify the etiology of peri-implant disease.

• Discuss various challenges to diagnosis.

• Realize some treatments for peri-implant disease.

• Recognize some additional causes of implant failure besides peri-implant mucositis and peri-implantitis.

What is peri-implant disease?

Peri-implant disease is a condition that affects the tissues surrounding a functional implant; it includes both peri-implant mucositis and peri-implantitis.

Peri-implant mucositis can be defined as “reversible inflammatory reactions in the soft tissues surrounding a functioning implant” (Albrektsson, Isidor, 1994). Periimplantitis is characterized by “inflammatory reactions with loss of supporting bone

Reena Wadia, BDS Hons (Lon), MJDF RCS (Eng), is an associate at Pure Periodontics, London, and specialist registrar in periodontology at Guy’s Hospital, London.

Neesha Patel, BSc Hons (Can), BDS (Glasg), MFGDP (UK) MClinDent Periodontics (Lon), MRD RCS (Ed), is practice principal at Pure Periodontics, a specialist in periodontics, as well as a consultant periodontist at King’s College Hospital, London.

32 Implant practice

Figure 1A: Periodontitis

Figure 1B: Peri-implantitis

in the tissues surrounding a functioning implant”(Lindhe, Meyle, 2008).

Peri-implantitis yields many features in common with chronic periodontitis (Mombelli, et al., 1987). Both involve alveolar bone loss, for instance. However, there is a zone of connective tissues that is attached to the root surface in periodontitis. In contrast, connective tissue does not attach directly onto implants, and there is no periodontal ligament. Therefore, the inflammatory lesion in peri-implantitis extends closer to the bone surface, which can be associated with a faster rate of progression and more aggressive consequences (Figures 1A and 1B).

The prevalence of peri-implant disease

is significant, with peri-implant mucositis affecting up to 80% of implant patients and peri-implantitis affecting 25% of patients (Zitzmann, Berglundh, 2008).

Etiology and risk factors Bacterial infections play the most important role in the failure of dental implants. Bacterial flora associated with periodontitis and periimplantitis are found to be similar (Hydenrjik, Majjer, 2002). Studies have shown that the bacteria at the failing implant site consist of gram-negative anaerobic bacteria, such as Porphyromonas gingivalis, Prevotella intermedia, and Actinobacillus actinomycetemcomitans (Mombelli, Long NP, 1998).

Volume 7 Number 2

• Bleeding on probing • Suppuration from the peri-implant space Studies have shown that successful implants generally allow a probe penetration of approximately 3 mm to 4 mm in the periimplant sulcus. Bleeding on probing and suppuration are clear indications of disease (Figure 3) (Gupta, et al., 2011).

Adequate baseline radiographs determine the peri-implant bone status as well as the marginal bone level. These can

measure in detecting early implant failure. More advanced peri-implantitis is characterized by mobility of the fixture, indicating failure of osseointegration.

Figure 2: Inflammation of peri-implant tissues

Figure 3: Bleeding on gentle probing

Management Comprehensive treatment of peri-implant disease remains an enigma to most dentists but is largely dependent on the underlying etiology at play.

When the main etiological factor

Diagnosis Early diagnosis and treatment is often the key to complete resolution of the problem.

However, although advanced cases of the disease will be clearly identifiable, it is often a great challenge to diagnose early and successfully.

Diagnosis of peri-implant disease relies on crude parameters commonly used for the diagnosis of periodontal disease.

Swelling and redness of the peri-implant marginal tissues and plaque/calculus accumulation are important signs of periimplant disease (Figure 2).

Probing the peri-implant sulcus with a blunt, straight, plastic, or metal periodontal probe allows the assessment of the following: • Peri-implant probing depth

Figure 4: Evidence of “saucer-shaped” bone loss around implant

then be compared to future radiographs to determine if additional bone loss beyond “normal” has occurred.

Progressive bone loss is a definite indicator of peri-implantitis (Figure 3), but it should not be confused with physiological bone remodeling around the implant during the first year of function (Albrektsson, et al., 1986; Meffert, 1992).

Implant mobility is an insensitive

is bacterial infection, the first phase of treatment involves the control of acute infection and the reduction of inflammation.

This involves the removal of plaque deposits and improved patient compliance with oral hygiene until a healthy peri-implant site is established. This may be sufficient to reestablish gingival health.

The implants that are affected with peri-implantitis are contaminated with soft

Volume 7 Number 2 Implant practice 33

CONTINUING EDUCATION

The correlation between the presence of periodontitis and the development of peri-implantitis has been supported by a recent systematic review (Kotsovilis, et al., 2008; Renvert, Persson, 2009).

Implants in partially dentate patients appear to be at a greater risk of periimplantitis than implants in fully edentulous patients. There is a marked quantitative decrease in the number of periodontal pathogens around the implants in completely edentulous patients. It is possible that the natural teeth serve as reservoirs for periodontal pathogens from which colonization of the implant sites occur (Aspe, et al., 1989).

Other patient-related risk factors include the following: • Inadequate oral hygiene • Smoking • Parafunctional habits • Underlying systemic conditions such as diabetes.

Biomechanical factors, such as an occlusal overload, may play an important role in implant failure by resulting in progressive bone loss around the implant.

The implants that suffer from traumatic failure have subgingival microflora representing a state of periodontal health (Mombelli, Mericske-Stern, 1990).

Iatrogenic factors — such as lack of primary stability, poorly positioned implants, premature loading during the healing period, and poorly fitting abutments or restorations — also appear to increase the likelihood of peri-implant disease (Quirynen, et al., 1993; Lang, Bosshardt, Lulic, 2011).

CONTINUING EDUCATION tissue cells, microorganisms, and microbial byproducts. The defect must be debrided.

Prophy jet and the use of a highpressure air powder abrasive has been advocated, as this removes the microbial deposits, does not alter the surface topography, and has no adverse effect on cell adhesion.

Various chemotherapeutic agents, such as contact with a supersaturated solution of citric acid, have been used for the preparation of the implant surfaces.

Soft tissue laser irradiation has also been used (Deppi, et al., 2001).

Additionally, the systemic administration of antibiotics that specifically target gram-negative anaerobic organisms has shown an alteration in the microbial composition and a sustained clinical improvement (Roos-Jansaker, et al., 2003).

A local delivery device with fibers containing polymeric tetracycline has been tried, and this resulted in significantly lower total anaerobic counts (Mombelli, et al., 2001).

The type of osseous defects should be identified before deciding on the surgical treatment modality. If vertical oneto two-wall defects (less than 3 mm) are found, then the resective surgery may be used to reduce the pockets, to smoothen the rough implant surfaces, to correct the osseous architecture, and to increase the area of the keratinized gingiva (Jovanovic, 1993).

To arrest the progression of the disease and achieve a maintainable site for the patient, surfaces with threads may be indicated for alteration with high-speed diamond burs and polishers to produce a smooth continuous surface (Jovanovic, Spickermann, Richter, 1992).

Various bone grafting techniques and materials and guided bone regeneration (Figures 4A and 4B) have been successfully used for the regeneration in threewall or circumferential defects. Porous titanium granules have also recently been advocated to try and treat advanced periimplant osseous defects.

When biochemical forces are considered as the main etiological factors, occlusal equilibration (i.e., improvement of the implant number and position, and changes in the prosthetic design) can arrest progression.

Long-term success of any periimplant treatment strategy requires a strict maintenance program carried out at regular intervals.

34 Implant practice

Figure 5A: Peri-implant bone defect (image courtesy of Dr. Patty Chou)

Figure 5B: Use of regeneration (image courtesy of Dr. Patty Chou)

Conclusion

for a predictable therapy. Assiduous research is still required for the treatment of peri-implantitis, because there is still no standard protocol for its management. IP

Given the large number of implant placements each day around the world, a high prevalence of peri-implantitis can be anticipated, which underlines the necessity

References 1. Brånemark PI, Hansson BO, Adell R, Breine U, Lindström J, Hallén O, Ohman A. Osseointegrated implants in the treatment of the edentulous jaw.

Experience from a 10-year period. Scand J Plast Reconstr Surg Suppl. 1977;16:1-132.

2. Albrektsson T, Isidor F.Consensus report of session IV. In: Lang NP, Karring T, eds. Proceedings of the 1st European Workshop on Periodontology.

London, England: Quintessence; 1994: 365-369.

3. Lindhe L, Meyle J. Peri–implant diseases: consensus report of the Sixth European Workshop on Periodontology. J Clin Periodontol. 2008;35(suppl 8):282–285.

4. Mombelli A, van Oosten MA, Schurch E Jr, Land NP. The microbiota associated with successful or failing osseointegrated titanium implants. Oral Microbiol Immunol. 1987;2(4):145-151.

5. Ho C, Tang T. Failing implants, maintenance and recall. Australasian Dental Practice. 2011;138-146.

6. Zitzmann NU, Berglundh T. Definition and prevalence of peri-implant diseases. J Clin Periodontol. 2008;35(suppl 8):286-291.

7. Heydenrijk K, Meijer HJ, van der Reijden WA, Raghoebar GM, Vissink A, Stegenga B. Microbiota around root-form endosseous implants: a review of the literature. Int J Oral Maxillofac Implants.

2002;17(6):829-838.

8. Mombelli A, Lang NP. The diagnosis and treatment of peri-implantitis. Periodontal 2000.

1998;17:63-76.

9. Kotsovilis S, Karoussis IK, Trianti M, Fourmousis I. Therapy of peri–implantitis: A systematic review. J Clin Periodontol. 2008;35:621–629.

10. Renvert S, Persson GR. Periodontitis as a potential risk factor for peri–implantitis. J Clin Periodontol. 2009;36(suppl 10):9–14.

11. Apse P, Ellen RP, Overall CM, Zarb GA. Microbiota and crevicular fluid collagenase activity in the osseointegrated dental implant sulcus: a comparison of sites in edentulous and partially edentulous patients. J Periodontol Res. 1989;24(2):96-105.

13. Quirynen M, van der Mei HC, Bollen CM, Schotte A, Marechal M, Doornbusch GI, Naert I, Busscher HJ, van Steenberghe D. An in vivo study of the influence of the surface roughness of implants on the microbiology of supra- and subgingival plaque. J Dent Res. 1993;72(9):1304-1309.

14. Lang NP, Bosshardt DD, Lulic M. Do mucositis lesions around implants differ from gingivitis lesions around teeth? J Clin Periodontol. 2011;38(suppl 11):182–187.

15. Gupta HK, et al. Peri-implantitis: A risk factor in implant failure. J Clin Diagn Res. 2011;5(1):138-141.

16. Alberktsson T et al. The long-term efficacy of currently used dental implants: a review and proposed criteria of success. Int J Oral Maxillofac Implants.

1986;1(1):11-25. Meffert RM. Treatment of the ailing, failing implant. J Calif Dent Assoc. 1992;20(6):42-45.

17. Deppe H, Horch HH, Henke J, Donath K. Periimplant care of ailing implants with the carbon dioxide laser. Int J Oral Maxillofac Implants. 2001;16(5):659667.

18. Roos-Jansåker AM, Renvert S, Egelberg J. Treatment of Perio-implant infections. a literature review. J Clin Periodontol. 2003;30(6):467-485.

19. Mombelli A et al. Treatment of peri-implantitis by local delivery of tetracycline. Clinical, microbiological and radiological results. Clin Oral Implants Res. 2001;12(4):287-294.

20. Jovanovic SA. The management of peri-implant breakdown around functioning osseointegrated dental implants. J Periodontol. 1993;64(suppl 11):11761183.

21. Jovanoic SA, Spickermann H and Richter EJ. Bone regeneration around titanium dental implants in dehisced defect sites: a clinical study. Int J Oral Maxillofac Implants. 1992;7(2):233-245.

22. Newman MG, Takei HH, Carranza FA. Carranza’s Clinical Periodontology. 9th ed. Philadelphia, PA: W.B. Saunders Company; 2002: 936-940.

23. Chou, P. Guided Bone Regeneration Case, Image. http://www.drpattychou.com.au/casestudies/ guided-bone-regeneration-case/. Accessed April 28, 2013.

12. Mombelli A, Mericske-Stern R. Microbiological features of stable osseointegrated implants used as abutments for overdentures. Clin Oral Implants Res. 1990;1(1):1-7.

Volume 7 Number 2

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Peri-implant disease: a growing problem

Flap vs. Flapless

WADIA-PATEL

SCHERER

1. ______ is unarguably one of the most significant risks associated with implants. a. Peri-implant disease b. Porphyromonas intermedia c. Actinomycetemcomitans gingivalis d. Saucer-shaped bone

a. Intraoral photographs b. Adequate baseline radiographs c. Tomograms d. Bone tracings

2. The prevalence of peri-implant disease is significant, with peri-implant mucositis affecting up to _____ of implant patients, and peri-implantitis affecting 25% of patients. a. 75% b. 80% c. 90% d. 95%

7. When the main etiological factor is bacterial infection, the first phase of treatment involves the control of acute infection and the reduction of inflammation.

This involves ______until a healthy periimplant site is established. a. the removal of plaque deposits b. improved patient compliance with oral hygiene c. surgical curettage of the site d. both a and b

3. Studies have shown that the bacteria at the failing implant site consist of gramnegative anaerobic bacteria, such as _____. a. Porphyromonas gingivalis b. Prevotella intermedia c. Actinobacillus actinomycetemcomitans d. All of the above

8. The implants that are affected with peri-implantitis are contaminated with ______. a. soft tissue cells b. microorganisms c. microbial byproducts d. all of the above

4. There is a marked quantitative decrease _______ around the implants in completely edentulous patients. a. in fixture mobility b. in inflammatory lesions c. in the number of periodontal pathogens d. progressive bone loss

9. Various chemotherapeutic agents, such as contact with a supersaturate solution of _____, have been used for the preparation of the implant surfaces. a. citric acid b. vinegar c. calcium phosphate d. hydroxyapatite

5. Studies have shown that successful implants generally allow a probe penetration of approximately _____ in the peri-implant sulcus. a. .5 mm – 1 mm b. 1 mm – 2 mm c. 3 mm – 4 mm d. 5 mm – 6 mm

10. A local delivery device with fibers containing _____ has been tried, and this resulted in significantly lower total anaerobic counts. a. citric acid b. polymeric tetracycline c. gentamicin d. bisphosphonates

6. _______ determine the peri-implant bone status as well as the marginal bone level.

1. The commonly accepted first choice treatment for addressing edentulism is an implant-retained complete denture, commonly known as ______. a. complete denture b. an overdenture c. 5-implant fixed hybrid bridge d. 6-implant fixed porcelain-metal restoration

procedure) does require an adequate band of attached gingiva that leaves a minimum of _____of attached gingiva on the buccal and lingual following use of the tissue punch. a. 2 mm b. 3 mm c. 4 mm d. 5 mm

2. The placement of two to four dental implants assisting an overdenture prosthesis greatly improves _____ as compared to traditional complete dentures. a. a patient’s comfort b. masticatory efficiency c. overall quality of life d. all of the above

7. The traditional reasons for more extensive flap procedures, such as greater visualization of the surgical site and surrounding anatomy, can be seen as relative disadvantages when considering _____. a. required surgical time b. extent of tissue manipulation c. time savings d. both a and b 8. Implant placement of narrow diameter implants is efficiently and readily performed because the size of the implant allows for _____. a. greater flexibility within narrower alveolar ridges b. bone recontouring c. greater irrigation d. increased prosthetic volume

3. Ongoing residual ridge resorption can be _______with the addition of dental implants, allowing for greater ridge height to permit increased stability of a prosthesis. a. substantially reduced b. totally eliminated c. increased d. recontoured 4. _____ is a better approach when either the ridge is very narrow in the buccal/lingual dimension, or there is limited attached gingiva that would be lost using a punch at the crest. a. The bone-tissue method b. A flapless approach c. A flapped approach d. Transmucosal placement 5. The main disadvantage of this technique (the flap procedure) is the increased amount of surgical morbidity due to an increased amount of ______. a. surgical access b. increased trauma c. increased tissue and bone loss d. all of the above 6.

This approach (flapless implant surgical

9. Bone conformation is also an important factor in regards to when a flap procedure is needed. Patients who have had recent extractions _______ typically present with incomplete healing or, in some cases, fractured labial plates from the extraction procedure. a. within 6 months b. within a year c. within 16 months d. within 2 years 10. Narrow diameter dental implants were developed as a ______alternative to larger diameter implants. a. minimally invasive b. low-cost c. more profitable d. both a and b

Volume 7 Number 2 Implant practice 35

CE CREDITS

IMPLANT PRACTICE CE

CONTINUING EDUCATION

Flap vs. Flapless: a practical guide with indications, recommendations, and techniques for effective planning and surgical placement of narrow diameter overdenture implants in the mandible Drs. Michael Scherer and Andrew Ingel summarize their rationale on when a flap or a flapless surgical procedure should be performed when placing Zest LODI narrow diameter implant for mandibular overdentures.

Abstract Implant overdentures are a popular and clinically significant treatment option to present to patients because of the large improvement achieved with a small surgical and financial investment. Narrow diameter overdenture implants, as a result, have gained in popularity in the recent years due to their unique ability to be placed in compromised mandibular alveolar ridges with minimal cost expenditure as osseous grafting may be avoided. Confusion exists, however, in regards to surgical technique for placing these implants. The decision when to elevate a flap or placing the implants with a closed, flapless procedure remains elusive. This article aims to address principles, advantages, disadvantages, and indications of when each procedure is best utilized.

Introduction The commonly accepted first choice treatment for addressing edentulism is an implant-retained complete denture, commonly known as an overdenture.1 The placement of two to four dental implants assisting an overdenture prosthesis greatly improves a patient’s comfort, masticatory efficiency, and overall quality of life as compared to traditional complete dentures.2-4 Ongoing residual ridge

Educational aims and objectives The aim of this article is to review indications, advantages, and disadvantages of flap and flapless surgical procedures for placement of narrow diameter overdenture implants.

Expected outcomes Correctly answering the questions on page 35, worth 2 hours of CE, will demonstrate the reader can: • Make an assessment of a patient to determine if implants can be placed flapless or if flap elevation is necessary.

• Recognize the advantages and disadvantages of performing a flap or flapless implant procedure.

• Understand critical steps involved in treatment planning narrow diameter overdenture implants.

resorption can be substantially reduced with the addition of dental implants, allowing for greater ridge height to permit increased stability of a prosthesis.5 As the world population ages and the baby boom generation peaks, the rising number of edentulous patients and increasing acceptance of implants dramatically increases the demand for dental implant therapy.6

Implant placement can be performed by two methods: flap or flapless. In the flap procedure, surgical access is achieved by making an incision through the gingival tissue down to alveolar bone. After incision, hand instruments are utilized to elevate the tissues away from the bone, giving direct visual access to the surgical

Michael Scherer, DMD, MS, is an Assistant Professor in Residence at University of Nevada, Las Vegas (UNLV), an Assistant Clinical Professor at Loma Linda University, and a fellow of the American College of Prosthodontists. He has published articles related to clinical prosthodontics and implant dentistry and completed a master’s degree related to implant overdentures with multiple publications pending. Dr. Scherer serves as the director of the implant dentistry curriculum at UNLV and is actively engaged in guided surgical placement and prosthetic restoration of implants.

Andrew Ingel, DMD, received his dental degree from the University of Pittsburgh and completed a GPR at the Hospital of the University of Pennsylvania. He served as an Attending Staff Dentist, Chief of Restorative Dentistry, and Director of the Implant program at the Department of Dental Medicine, Hospital of the University of Pennsylvania and was clinical faculty at the University of Pennsylvania, School of Dental Medicine. Dr. Ingel practiced in the Baltimore-Annapolis area for 17 years prior to moving to Las Vegas where he is an Assistant Professor of Clinical Sciences at the University of Nevada – Las Vegas School of Dental Medicine. Dr. Ingel has interests in both the surgical and restorative aspects if implant dentistry, with a special focus on the clinical applications of small diameter implants.

Krystle Kendall, BS, is currently a senior dental student at University of Nevada, Las Vegas, and has conducted research with published articles in oral cancer, which have been presented at the IADR and ADA annual sessions.

Kendall is actively engaged in surgical placement and prosthetic restoration of implants with the co-authors. She is enrolled and will be attending University of Chicago, Illinois, for a prosthodontics residency program.

Disclosure: Dr. Michael Scherer and Dr. Andrew Ingel receive occasional reimbursement for speaking engagements on behalf of Zest Anchors.

36 Implant practice

site. Typically, these flaps are performed with full-thickness or periosteal elevating procedures where the bone-tissue periosteum is elevated with the tissue revealing only bone structure underneath.

Osteotomies are performed using drills in sequence from smaller to larger diameters, and the implant is placed according to this drill orientation. After the implant is placed, the tissue is re-approximated and closed with sutures. This method of implant placement is the traditional method of dental implant placement because it allows for direct visualization of the bone and is a predictable surgical procedure. A flapped approach is a better approach when either the ridge is very narrow in the buccal/lingual dimension, or there is limited attached gingiva that would be lost using a punch at the crest. Additionally, this also allows the surgeon the ability to reduce height of a knife-edge ridge to develop a crestal table that can accommodate the small diameter implants. The main disadvantage of this technique is the increased amount of surgical morbidity due to an increased amount of surgical access, increased trauma, and increased tissue and bone loss.7 Flapless implant surgical procedures are typically performed through the mucosal tissue without elevation of the soft tissue covering the alveolar bone. In this method, osteotomies are performed Volume 7 Number 2

Figure 2: Caliper measurement illustrating insufficient prosthetic space

using drills in sequence from smaller to larger diameter directly through the tissue.

In addition to these drills, the clinician may utilize a precision tissue-incising drill, known as a tissue punch. This approach does require an adequate band of attached gingiva that leaves a minimum of 2 mm of attached gingiva on the buccal and lingual following use of the tissue punch. Once osteotomies are completed, an implant is placed through the hole in the tissue and bone, and no sutures are typically needed.

The benefits of this approach are largely due to the reduced amount of tissue trauma necessary to place the dental implant.

Flapless procedures, however, also tend to be more difficult due to the inability of the surgeon to directly visualize anatomical landmarks and vital structures. The flapless procedure is best suited when a wider ridge and an adequate band of attached gingiva are present. The ridge width can be evaluated when questionable to determine the actual width of the osseous ridge and to rule out thick overlaying tissue that may give the illusion of a wide ridge. Local anesthetic is placed into the soft tissue on both the buccal and lingual; then a periodontal probe is pressed through the gingiva until it contacts the underlying bone. The thickness of the tissue as measured is then added to the thickness of the tissue on the other side of the ridge and then subtracted from the width of the crest to determine the actual width of the osseous crest. These traditional perceived difficulties of flapless procedures can be reduced with the use of cone-beam computed tomography (CBCT) imaging and computerized surgical guides.

Minimally invasive surgical techniques have become an essential part of the dental armamentarium. Routine use of CBCT imaging, along with computerguided surgical techniques and guides, has given dentists the ability to predictably and reliably place implants through the tissues. Because transmucosal-guided implant placement is typically performed

Figure 3: Sharp projections and a narrow anterior ridge require flap procedures to correct poor bone configuration and to ensure implant placement is within bony contours

Figure 4: Rounded and U-shaped alveolar ridge allows for flapless implant placement

Table 1: Comparison of flap vs. flapless overdenture implant surgical procedures Advantages

Flapless

Flap

✓ ✓ ✓ ✓ ✓ ✓ ✓

Disadvantages

Minimal incision and less trauma Patient comfort Less bone resorption Allows for immediate loading Improved esthetics Decreased surgical time Patient perception of “minimally invasive surgery”

✓ Surgical visibility enhanced ✓ Allows for bone and soft tissue re-contouring ✓ Increased surgical control for osteotomy site selection

without flap elevation, the use of guides also allows for decrease in surgical time, reduced healing times, and increased patient comfort. The development of minimally invasive surgical techniques undoubtedly arose from the disadvantages of a traditional surgical flap approach. The dental profession has largely operated in an outpatient setting, with patients receiving care in an office and returning home to recover. In this setting, dentists are acutely aware of the needs for gentle tissue management, surgical time constraints, and the post-operative complications that many patients endure. The traditional reasons for more extensive flap procedures, such as greater visualization of the surgical site and surrounding anatomy, can be seen as relative disadvantages when considering required surgical time and extent of tissue manipulation. Ultimately, flap procedures have the potential for increased postoperative morbidity, such as swelling and hemorrhage, need for sutures and suture removal, and post-operative pharmaceuticals.

Implant placement of narrow diameter implants is efficiently and readily performed because the size of the implant allows for greater flexibility within narrower alveolar ridges. These narrow ridges may accommodate traditional implant

– Lack of surgical visibility especially near vital structures – Greater learning curve – Limited irrigation to osteotomy – Limited hard/soft tissue manipulation – Greater surgical exposure required – Increased postoperative sequelae – Delayed recovery time – Reduced blood supply after flap – Patient perception of “more invasive surgery” – Increased surgical time

diameters and lengths but often require extensive bone augmentation procedures, such as ridge splitting or onlay bone grafting. Many patients seek treatment with narrow diameter implants because of the clinician’s ability to achieve similar results with a less invasive method.

Criteria for flap vs. flapless surgery Clinically, the most important first step in assessment of a patient for flapless technique is dependent upon how much prosthetic volume is present with the patient’s existing complete denture. One method of assessing this space is to use a caliper to measure a point from inside the intaglio to the occlusal surface of the complete denture. The minimum height requirement needed for a LOCATOR® attachment is 9-11 mm from the crest of the bone to the height of the denture.

This breaks down as 1-3 mm soft tissue thickness and a minimum of 3 mm attachment height, including male/female, and 5 mm for overlaying acrylic and teeth of the denture. The denture caliper measurement should be a minimum of 6mm ensuring enough denture material exists to accommodate the attachment and housing complex (LOCATOR, Zest Anchors), which is approximately 3 mm in height (Figure 1). If the caliper measurement

Volume 7 Number 2 Implant practice 37

CONTINUING EDUCATION

Figure 1: Caliper measurement illustrating sufficient prosthetic space for LOCATOR attachments and housings

CONTINUING EDUCATION

Figure 5: Alveolar ridge examination reveals well-healed, resorbed alveolar ridge with little undercut; ideal candidate for flapless implant placement

Figure 6: Clear acrylic resin duplicate of the patient’s existing complete denture with holes marked with gutta percha to indicate proposed implant sites

Figure 7: Panoramic radiograph confirms adequate positioning of proposed implant sites

Figure 8: Radiographic guide was modified to create a flat stop for the drill stop, allowing 8 mm of penetration into the mucosa and alveolar bone

Figure 9: Initial 1.2 mm pilot drill osteotomy performed through the guide

Figure 10: 1.2 mm pilot drill holes indicating proposed implant positions on the ridge

Figure 11: Rotary tissue punch placed into initial osteotomy allows for easy tissue removal

Figure 12: Larger drills (1.6 mm and 2.1 mm) utilized to prepare osteotomy holes using directional indicating pins to ensure implants will be placed parallel to each other

Figure 13: Implant (LODI, Zest Anchors) placed into osteotomy with a handpiece

Figure 14: Attachment (LOCATOR, Zest Anchors) placed using LOCATOR core tool and hand-tightened

is less than 6 mm, insufficient room exists to accommodate the attachment and housing complex, and ridge reduction will be required (Figure 2).

Bone conformation is also an important factor in regards to when a flap procedure is needed. Patients who have had recent extractions within a year typically present with incomplete healing or, in some cases, fractured labial plates from the extraction procedure. Other cases where the bone is very sharp and with shapes that are challenging to place implants can complicate flapless implant surgical procedures (Figure 3). These types of patients will generally require alveolar ridge reduction due to the need for sufficient alveolar bone dimensions surrounding the implant. Patients who present with large, U-shaped, and well-healed alveolar ridges are more favorable for flapless surgical procedures (Figure 4).

Case 1: Narrow diameter overdenture implant flapless placement A 63-year-old male patient was treated 38 Implant practice

Figure 15: Occlusal view of attachments (LOCATOR, Zest Anchors)

Figure 16: Panoramic radiograph made confirming, verifying proper depth and angulation

with traditional tissue-supported complete dentures and was told he was a high-risk candidate for dental implants due to his complex medical history. A few months later, however, he indicated that he never was able to get used to a tissue-supported mandibular denture and indicated that he is seeking a minimally invasive dental implant procedure to help stabilize his denture. Intraoral examination revealed a fully healed atrophic ridge with adequate keratinized soft tissues (Figure 5). To determine if he was a candidate for implant placement, his denture was assessed for adequate prosthetic volume, and a clear acrylic resin replica of his existing complete denture was made (Figure 6). A panoramic radiograph was made with the patient wearing the duplicate denture with gutta percha in drill holes indicating proposed implant sites (Figure 7). A CBCT scan was also performed to further analyze the alveolar ridge conformation, the position of the inferior alveolar nerve, and to better visualize the proposed flapless surgical sites (Figure 4). Four narrow-diameter overdenture implants (LODI, Zest Anchors)

Figure 17: Chairside acrylic resin utilized to intraorally attach LOCATOR housings to denture

were chosen: 2- 2.9 mm x 12 mm implants in the lateral incisor region and 2- 2.9 mm x 10 mm implants in the mandibular first molar region.

The radiographic guide was modified, converting it to a surgical guide by flattening the area around the proposed implant sites to allow for a flat surface and drill path height of 6 mm. This allowed for the authors to utilize a 14 mm drill stop, knowing the thickness of the guide over the site and the underlying soft tissue for the 1.2 mm pilot drill to penetrate 8 mm into the soft tissue and bone (Figure 8). The guide was placed onto the ridge, and the 1.2 mm pilot with the 14 mm drill stop was drilled through the guide to mark implant osteotomy sites (Figures 9 and 10). Gingival tissue was removed from each site by placing the selfguided rotary tissue punch into the initial osteotomy holes (Figure 11). Osteotomy sites in posterior regions were prepared to 10 mm-depth with 1.2 mm and 1.6 mm diameter drills, and 6-mm depth with the 2.4 mm drill. Osteotomy sites in the anterior region were prepared 12-mm depth with 1.2 mm and 1.6 mm diameter drills, and Volume 7 Number 2

Figure 19: Alveolar ridge examination reveals a narrow and tall alveolar ridge with large undercuts; ideal candidate for traditional flap elevation implant placement

Figure 20: Clear acrylic resin duplicate of the patient’s existing complete denture with gutta-percha plugs to indicate proposed implant sites

Figure 21: Panoramic radiograph indicates proposed implant positions; excessive vertical bone height is determined

Figure 22: Flap elevation illustrating a sharp, narrow, and undercut alveolar ridge

Figure 23: Alveolar reduction performed with proposed implant sites marked with a sterile pencil

Figure 24: Osteotomies performed with direction indicator pins to ensure parallel implant placement

Figure 25: Final osteotomy holes illustrating flexibility of overdenture implants (LODI, Zest Anchors) in extremely narrow ridges

Figure 26: LOCATOR attachments placed, verifying proper angulation and position

Figure 27: Chromic gut sutures placed, ensuring adequate flap closure with minimal tension

8-mm depth with 2.4 mm drill. Parallelism of osteotomy sites were verified during the osteotomy procedure, allowing for minor corrections to angulation discrepancies (Figure 12). Two 2.9 mm x 10 mm implants were placed in the posterior osteotomy sites, and two 2.9 mm x 12 mm implants were placed in the anterior osteotomy sites (Figure 13). Final insertion torque values exceeded 35Ncm and was confirmed with the assistance of a manual torque wrench, and 2.5 mm attachments (LOCATOR, Zest Anchors) were placed and hand-tightened on all four implants (Figures 14 and 15).

A panoramic radiograph was made to verify implant angulation, depth, and the full seating of the attachments (Figure 16).

Since adequate primary stability obtained (> 30N cm) during surgery, the authors decided to immediately attach and load the implants. Should inadequate insertion torque be present, the practitioner can hand-tighten the attachment and place a soft liner inside the denture. The authors recommend if this approach is taken, that the denture be relieved over the implants to avoid contact during function

Figure 28: Panoramic radiograph confirms implant position and angulation

Figure 29: Appearance of alveolar ridge after 2 months of healing

while integration is progressing until a period when the implants can receive the attachments and be activated.

The patient’s denture was adjusted, attachments (LOCATOR, Zest Anchors) torqued to 30Ncm, and the LOCATOR housings were picked up using chairside hard reline material (Figure 17). The black processing inserts were removed, and an extra-light extended range attachment was inserted into the housings (Figure 18). The patient was re-evaluated weekly and had excellent healing at each appointment. He expressed a tremendous improvement with the stability of his mandibular dentures and a huge improvement in his quality of life.

Case 2: Narrow diameter overdenture implant placement with flap elevation A 70-year-old male presented with complaints about the fit of his mandibular complete denture and wanted dental implants to provide a more comfortable solution. An examination was performed, and it was determined that he exhibited

Figure 30: Mandibular complete denture relined to incorporate LOCATOR housings

an undercut mandibular ridge form with uneven profile that would likely require preprosthetic surgery (Figure 19). The patient has seen multiple different dentists seeking a solution and was told each time that he was not a candidate for dental implants because his mandibular ridge is too narrow.

A CBCT scan was performed to allow for improved visualization of the alveolar ridge; upon review, the scan confirmed that he would require pre-prosthetic surgical procedures (Figure 3). The authors determined that his existing complete dentures were acceptable; however, insufficient prosthetic space and a sharp alveolar ridge dictated a flap procedure was indicated. The authors estimated that 4-5 mm of alveolar ridge reduction was necessary to ensure sufficient alveolar ridge width and prosthetic space for longterm clinical success.

The patient’s existing mandibular denture was duplicated with clear acrylic resin duplicate, and gutta percha was placed in proposed implant sites (Figure 20). A panoramic radiograph confirmed that these proposed sites were acceptable

Volume 7 Number 2 Implant practice 39

CONTINUING EDUCATION

Figure 18: Final intaglio of mandibular complete denture with extra light extended-range LOCATOR male inserts

CONTINUING EDUCATION positions (Figure 21). Four narrow-diameter overdenture implants (LODI, Zest Anchors) were chosen: 4-2.4 mm x 12 mm implants in the lateral incisor and first premolar regions.

Flap elevation was performed with a surgical scalpel and periosteal elevators, reflecting enough tissue facial and lingual to the proposed sites to fully visualize the alveolar ridge contour (Figure 22).

Proposed implant sites were marked with a sterile pencil, and approximately 5 mm of alveolar ridge height reduction was performed using surgical acrylic burs (Figure 23). Initial osteotomy sites were prepared to 12 mm depth with 1.2 mm pilot drills using paralleling pins to verify parallelism between the four implants (Figure 24). Final osteotomies were prepared to 8 mm depth with the 1.6 mm drill (Figure 25). Four 2.4 mm x 12 mm implants were placed; insertion torque values exceeded 35Ncm and was confirmed with the assistance of a manual torque wrench, and 2.5 mm LOCATOR attachments placed and torqued to 30Ncm (Figure 26). The tissue was re-approximated, and 3-0 chromic gut sutures were placed using interrupted sutures ensuring minimal tension closure of the flap (Figure 27). A panoramic radiograph was made to verify implant angulation, depth, and the full seating of the attachments (LOCATOR, Zest Anchors) (Figure 28). Even though adequate primary stability obtained (> 30Ncm) during surgery, the authors decided against immediate loading, and a soft tissue liner was applied to the intaglio surface of the denture. Minimal adjustment to the patient’s existing denture was required because of the alveolar ridge reduction.

The patient was re-evaluated weekly, and at 8 weeks of healing, integration was confirmed with radiographs, percussion, and stability testing (Figure 29). A laboratory reline procedure was performed with the attachments (LOCATOR, Zest Anchors) incorporated into the reline procedure; the authors decided that only the anterior two inserts were needed. During adjustment, the patient noted that he had difficulty removing the denture with all four light attachments, and the patient wished to have less retention (Figure 30). Gray inserts (zero retention) were placed in the distal housings 1 week after the reline procedure.

The gray inserts allow the posterior implants to be used as positive tissue stops providing less anterior posterior rotation of the denture. The patient had excellent healing 40 Implant practice

and expressed a tremendous improvement with the comfort of his mandibular denture.

Discussion Narrow diameter dental implants were developed as a minimally invasive, lowcost alternative to larger diameter implants.

While this implant was intended for use in the stabilization for dentures and as a transitional or salvage approach for failing fixed restorations, it was also intended to be used in immediate function.8 Initial insertion stability is achieved by bicortical stabilization between the buccal and lingual osseous plates, and in combination with compressive loading, leads to high levels of initial bone-implant contact.9 Since the introduction of implants less than 3 mm in diameter for long-term use, several authors have evaluated the surgical placement technique, immediate loading, denture stabilization, fixed applications, and short and long-term success rates.10-12 Given the high success rates comparable to larger diameter implants, there has been tremendous interest in narrow diameter implants for both removable and fixed applications. Most systems now feature simplified and minimally invasive surgical protocols, increased patient comfort, improved ability to immediate load, and lower cost.

The cases presented represent typical cases seen by the authors. Based upon the initial exam, both patients are good candidates for denture stabilization utilizing narrow diameter overdenture implants. A rigorous diagnostic evaluation reveals two distinctly different cases requiring different surgical protocols. The first case report presented with a sufficiently resorbed ridge and good prosthetic space. The remaining bone had sufficient width and height as determined by clinical exam and CBCT analysis; this allowed for minimally invasive surgery using a flapless approach and facilitated immediate loading. Postoperative sequelae were minimal with the patient reporting little discomfort.

The second case report, however, was deceptive in that width and height were good on clinical and radiographic exam, but the topography of the interforaminal area, as seen on CBCT, was irregular. Using a flapless surgical approach would have presented a substantial surgical challenge.

Analysis of the prosthetic space indicated that without bony reduction, the result would have been a prosthetic challenge due to limited room for the attachment

housing in the denture. The surgical protocol included a full-flapped exposure of the implant sites, intra-foraminal bony reduction, implant placement, and suture closure. The denture was not immediately loaded in this case despite good intraoperative torque values.

Conclusion Proper treatment planning and patient assessment for narrow diameter overdenture implants is a critical step and requires careful pre-operative assessments.

Limited information has been previously described when a clinician can place implants using a flapless procedure versus traditional flap elevation. Advantages and disadvantages of flapless and flap surgical procedures were described, including indications of when a flapless procedure can be utilized. The two patients’ treatments described represent appropriate examples of when each procedure is indicated.

Narrow diameter overdenture implants, such as the Zest Anchors LODI system, are an excellent treatment option for patients with narrow ridges who previously could not get implant therapy and those who wish to have minimally invasive surgical procedures. IP

References 1. Feine JS, Carlsson GE, Awad MA, Chehade A, Duncan WJ, Gizani S, Head T, Lund JP, MacEntee M, Mericske-Stern R, Mojon P, Morais J, Naert I, Payne AG, Penrod J, Stoker GT Jr, Tawse-Smith A, Taylor TD, Thomason JM, Thomson WM, Wismeijer D. The McGill consensus statement on overdentures. Int J Prosthodont.

2002;15:413-414.

2. Toman M, Toksavul S, Saracoglu A, Cura C, Hatipoglu A. Masticatory performance and mandibular movement patterns of patients with natural dentitions, complete dentures, and implant-supported overdentures.

Int J Prosthodont. 2012;25(2):135-137.

3. Rashid F, Awad MA, Thomason JM, Piovano A, Spielberg GP, Scilingo E, Mojon P, MĂźller F, Spielberg M, Heydecke G, Stoker G, Wismeijer D, Allen F, Feine JS. The effectiveness of 2-implant overdentures - a pragmatic international multicentre study. J Oral Rehabil.

2011;38(3):176-184.

4. Heydecke G, Penrod JR, Takanashi Y, Lund JP, Feine JS, Thomason JM. Cost-effectiveness of mandibular twoimplant overdentures and conventional dentures in the edentulous elderly. J Dent Res. 2005;84(9):794-799.

5. Kordatzis K, Wright PS, Meijer HJ. Posterior mandibular residual ridge resorption in patients with conventional dentures and implant overdentures. Int J Oral Maxillofac Implants. 2003;18(3):447-452.

6. Carlsson GE, Omar R. The future of complete dentures in oral rehabilitation. A critical review. J Oral Rehabil. 2010;37(2):143-156.

7. Wood DL, Hoag PM, Donnenfeld OW, Rosenfeld LD. Alveolar crest reduction following full and partial thickness flaps. J Periodontol. 1972;43(3):141-144.

8. Sendax VI. Mini-implants as adjuncts for transitional prostheses. Dent Implantol Update. 1996;7(2):12-15.

9. Sendax, V. Mini Dental Implants: Principles and Practice. St. Louis, Mo: Elsevier/Mosby; 2013.

10. Bulard RA, Vance JB. Multi-clinic evaluation using mini-dental implants for long-term denture stabilization: a preliminary biometric evaluation. Compend Contin Educ Dent. 2005;26(12):892-897.

11. Ahn MR, An KM, Choi JH, Sohn DS. Immediate loading with mini dental implants in the fully edentulous mandible. Implant Dent. 2004;13(4):367-372.

12. Balkin BE, Steflik DE, Naval F. Mini-dental implant insertion with the auto-advance technique for ongoing applications. J Oral Implantol. 2001;27(1):32-37.

Volume 7 Number 1

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TECHNOLOGY

Restoring the edentulous patient with narrow diameter implants Dr. Paresh B. Patel illustrates a case that benefited from narrow diameter implants

F

or centuries, dentists have struggled to create a conventional complete denture that can satisfy the vast majority of patients in terms of retention, stability, and most importantly, function. It has been found that the average biting force for patients that have teeth is in the range of 150 to 250 psi. That figure reduces by 50 psi soon after teeth are lost and reaches a staggering low of 5.6 psi after 15-plus years of struggling with dentures. Up to 7 times more chewing strokes are required than a dentate patient. In addition to these deficiencies, the complete denture patient suffers from denture sores, reduced salivary flow, and iatrogenic resporbtion of the alveolar bone.

Most of these patients will not have the necessary width of bone to adequately accept the standard body implant with 1.5 mm of bone in all dimensions. Whether the patient is medically, financially, or anatomically compromised, the advent of the narrow body implant with a LOCATOR速 attachment (Zest Anchors) allows the clinician to offer a widely accepted solution.

Narrow diameter implants (NDIs) typically can be placed in a flapless manner, greatly reducing surgical time, healing time, and patient discomfort. They also allow a greater number of patients who wish to have implant therapy to become candidates without additional surgical procedures that can potentially drive up economic costs.

Case history A 66-year-old male presented to our office with the chief complaint that his upper denture was no longer as retentive

Dr. Paresh Patel is a graduate of the University of North Carolina at Chapel Hill School of Dentistry and the Medical College of Georgia/American Academy of Implant Dentistry Maxi-Course. He is co-founder of the American Academy of Small Diameter Implants and a clinical instructor at the Reconstructive Dentistry Institute. Dr. Patel has placed more than 3,500 smalldiameter implants and has worked as a lecturer and clinical consultant on mini-implants for various companies. He can be reached at pareshpateldds2@ gmail.com.

42 Implant practice

Figure 1: Preoperative ridge Figure 2: i-CAT FLX CBCT slice

Figure 3: SimPlant速 (Materialise Dental) conversion

as it once was, even after a recent reline 2 months prior. He was opposing a lower implant-retained overdenture that was supported by four implants with the LOCATOR attachments. Although a visual exam showed an adequate maxillary ridge, upon performing a clinical exam, it was discovered that most of the tissue was mobile and unattached (Figure 1).

Bone sounding demonstrated a highly thick area of tissue both buccal and lingual with a thin ridge of supporting bone. Due to these findings, a CBCT scan was ordered (i-CAT速 FLX, Imaging Sciences International) (Figure 2). A dualscan technique was prescribed as that would allow for two things: an accurate assessment of where the implants would emerge prosthetically, and that would also allow for the fabrication of a tissue-level surgical guide to minimize surgical trauma.

The CBCT scan file was then transmitted to 3DDX.com (3D Diagnostix) for conversion and treatment planning (Figure 3). Initially, four NDIs were planned from the clinical exam; however, with the added benefit of the i-CAT scan, two additional NDIs could be placed for a total of six implants to support a new maxillary overdenture. Six 2.9 x 12 mm Zest LOCATOR Overdenture Implants (LODI) were selected. This would

Figure 4: Pilot bit

Figure 5: LODI implants inserted

allow for a low-profile attachment that selfaligns and would be compatible with what the patient was used to on his lower ridge.

A tissue-level surgical guide was ordered and used to create the initial osteotomies with the 2.1 mm pilot bit (Figure 4). Due to the presence of soft bone, the self-tapping feature of the Zest LODI was utilized to compress and condense the bone. All six implants were inserted with the aid of an implant handpiece (Aseptico AEU-7000) (Figure 5). It is my preference to place the implants with a handpiece to avoid tipping or creating off-axis vector forces. Due to the excessive gingival tissue height, a 4-mm cuff height LOCATOR attachment was selected and was torqued to 30 Ncm Volume 7 Number 2

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TECHNOLOGY

Figure 7: i-CAT FLX post-op scan

Figure 6: LOCATOR attachments Figure 8: Fit Test relief areas

Figure 9: Ufi Gel soft-lined denture

Figure 11: Black processing rings Figure 10: LOCATOR housings

(Figure 6). It is important to note that the implant packaging includes the LOCATOR and associated housing and inserts. A final CBCT scan was taken to ensure proper placement and confirm that the surgical guide was accurate (Figure 7).

To create a totally passive fit of the existing denture areas that would require relief was identified with the use of Fit Test (VOCO America) (Figure 8). The process was repeated until no show-through areas of pink were observed. The denture was 44 Implant practice

then cleaned and soft-lined with Ufi Gel (VOCO America). This would allow for an intimate fit of the denture against the tissue while the implants osseointegrated and the new overdenture was being fabricated (Figure 9).

At the final delivery appointment, the newly constructed overdenture was triedin and verified for passive fit. All six housings were placed over the LOCATOR attachments (Figure 10) and were picked up chairside with the use of a self-cure mate-

rial Quick Up (VOCO America) (Figure 11).

Utilizing NDI-supported overdentures can provide a better quality of life for most patients. The use of CBCT and surgical guides significantly reduce surgical and healing time as well as postoperative healing. Those patients that otherwise would not be ideal candidates for a standard body implant can now be offered an alternative to the O-ball style mini dental implant. IP Volume 7 Number 2

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uilt on the Luxar tradition of excellence since 1991, the LightScalpel LS-1005™ represents state-of-the-art laser technology for all soft tissue surgeries in the implant-focused practice. With over 12,000 units installed in offices worldwide, the new LightScalpel LS-1005™ pushes the envelope with an affordable high-performance soft tissue laser.

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The LightScalpel LS-1005™ can precisely remove cell layers, as in Laser Assisted Periodontal Therapy (LAPT), or rapidly cut an incision with a clear bloodless field.

Post-operatively, this translates to minimal discomfort, faster healing, and the reduced need for pain medication for the patient.

Unlike diode glass fibers, which cut slowly in-contact by a thermal “hot tip,” the CO2 wavelength is highly absorbed by intracellular water that is instantaneously vaporized in a non-contact method. This superior “radiant” process happens in an extremely rapid, highly controlled, and precise fashion. This results in a char-free cut with minimal thermal interaction with the adjacent tissues to no more than 50 to 100 micrometers, or 5 to 10 cell layers deep! All this and the safety for use around implant structures1 make it the perfect surgical instrument for your practice.

tipless) and the ceramic-tipped handpieces allow total access and greater visualization of the entire oral cavity.

The large bright touchscreen allows the user to choose the appropriate treatment modes directly from the Main screen. So whether its Continuous (CW), Pulsed, or Micro-second Super-Pulse mode, you have complete control. Also, from the Main screen, user-defined presets can be saved for your most commonly used settings. As examples, if you are doing anything from safely treating peri-implantitis1 to second stage implant uncovering, one touch, and you are ready to go!

External calibration at the point-ofdelivery is a unique feature allowing the user to verify proper operation and exact power to tissue.

CO2 technology reimagined — smaller, lighter, cost effective

LightScalpel laser tube technology — superior performance and longevity

The LightScalpel LS-1005™ introduces a new level of CO2 laser technology.

The ultra-flexible 1.75-meter hollowfiber delivery system provides years of effortless use without the typical fragile mirrors and articulated arm systems originally developed in the 1980s. In addition, the newly designed optical (or

LightScalpel CO2 all-metal laser tubes are superior to the antiquated glass tube. Allmetal laser tube technology retains lasing ability for up to 45,000 hours, making CO2 laser surgery highly profitable for the clinician.

All-metal laser tubes are inexpensively rechargeable, capable of handling up to

40 g shocks and vibrations, and are easily pulsed and air-cooled under the heaviest operating conditions. All-metal tubes are no different from the durable, longlasting tubes used in military and industrial applications, as well as top of the line cosmetic fractional and medical lasers.

American engineering, manufacturing, and support LightScalpel is an American-based surgical CO2 laser design, manufacturing, and service company located in Woodinville near Seattle, Washington.

LightScalpel’s laser engineers have over 100 years of combined technical experience in both the industrial and medical CO2 laser marketplaces, including positions at Laakmann Electro-Optics, Xanar, Coherent Medical, Synrad Inc., Luxar Corporation, ESC Medical Systems, Lumenis Inc., Luxarcare LLC, and Aesculight LLC.

To experience for yourself what the all new LightScalpel LS-1005 can do for you and your patients, call 1-866-589-2722 or visit www.lightscalpel.com. IP This information LightScalpel.

was

provided

by

Reference 1. Romanos G, Ko HH, Froum S, Tarnow D. The Use of CO2 Laser in the Treatment of Peri-implantitis. Photomed Laser Surg. 2009 Jun,27(3): 381-386. doi:10.1089/pho.2008.2280.

46 Implant practice

Volume 7 Number 2

ON THE HORIZON

Don’t Fear the Narrow Space Dr. Justin Moody discusses his solution for narrow implant sites

I

n the evolution of implant dentistry, one of the last hurdles dental practitioners had to clear was the solution for narrow or tight spaces. Initially, this was solved with smalldiameter dental implants, but this solution was always clinically challenging due to this style of implant being one piece. Precision placement and the need to immediately temporize these fixtures was an issue for many clinicians.

Today, we have solutions that not only remove these fears, but actually turn these previously untreated sites into everyday implant dentistry. In my office, a 3D scan helps me to see the exact details of the implant site that will impact my ability to achieve a successful outcome.

The i-CAT® FLX CBCT and Tx STUDIO™ designed with Anatomage, (Imaging Sciences International) give me all the necessary tools to diagnose and treatment plan narrow spaces as well as the ability to deliver the dental implant to the precise position via a surgical guide. (For more information on 3D imaging, please fill out the card attached to this article.)

Implant selection, in my opinion, is just as important as the treatment planning for the case. Having a two-piece design is essential for having the prosthetic options needed in today’s highly esthetic world.

I have been using the BioHorizons® 3.0 two-piece dental implant for several years.

Not only do I get the benefit of the LaserLok microchannels at the collar, creating a physical connective tissue attachment, but I also get the restorative flexibility that comes from having a two-piece design.

This implant allows for all of the traditional

Tx STUDIO implant body positioning

Tx STUDIO with restorations

i-CAT FLX post-op ceph

Custom Zirconia abutment 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 at drjustinmoody.com.

Tx STUDIO implant body positioning

Tx STUDIO with restorations

i-CAT FLX post-op slice

Handstacked IPS e.max® (Ivoclar Vivadent)

prosthetic components such as PEEK abutments, UCLA, and stock esthetic abutments as well as the ability to do a custom patient-specific zirconia to TiBase abutment.

The images included in this column are from a case I did with i-CAT scans,

DEXIS® Platinum post-op image

BioHorizons 3.0 dental implants

Tx STUDIO, 3.0 BioHorizons dental implants with final restorations and custom abutments created by Prosmiles Dental Studio. Proper planning through technology and materials should keep dentists who are planning and placing implants from fearing the narrow space. IP

Volume 7 Number 2 Implant practice 49

DIARY

lllllllllllllllllllllll OF EVENTS llllllllllllllllllllllllllllllllllllllllllllllllllll

CE Intuitive Workflow for Same Day Restoration Dr. Richard Steinberg March 6, 2014 Winter park, FL www.carestreamdental.com/us/en Rocky Mountain Dental Institute: Marketing & Team Training Drs. Joe Trowbridge and Justin Moody March 6-8, 2014 Denver, CO www.rockymountaindentalinstitute.com Russo Seminars: Bone and Soft Tissue Grafting Dr. John Russo March 6-8, 2014 Las Vegas, NV www.russoseminars.com 3D Implantology Dr. Gary O’Brien March 7-8, 2014 April 4-5, 2014 May 2-3, 2014 Las Vegas, NV site.implantdirect.com Place the OCO Biomedical Dual Stabilization™ Line of Dental Implants March 8, 2014 Kansas City, MO www.ocobiomedical.com

50 Implant practice

Implant Dentistry 101 — Getting Started Drs. Todd Engel, Jon Julian, and Gary O’Brien March 13-15, 2014 April 10-12, 2014 May 15-17, 2014 Las Vegas, NV site.implantdirect.com Fundamental Principles of Restorative Implant Dentistry for the Single Missing Tooth Dr. Baldwin Marchack March 14-15, 2014 Los Angeles, CA dentistry.usc.edu Place the OCO Biomedical Dual Stabilization™ Line of Dental Implants March 15, 2014 Boston, MA www.ocobiomedical.com Advanced Guided Surgery with Zygoma Implants Drs. Thomas J. Balshi and Glenn Wolfinger March 17, 2014 Fort Washington, PA www.nobelbiocare.com/en_us/splash

Cone Beam Computed Tomography in Endodontics Dr. Martin D. Levin Dr. Barry Pass March 20 - 21, 2014 Washington, DC www.endonet.com Rocky Mountain Dental Institute: Advanced Implant Prosthetics Dr. Jeff Babushkin March 20-22, 2014 www.rockymountaindentalinstitute.com 2-Day Cadaver Workshop — Fundamental of Dental Implants March 21-22, 2014 Las Vegas, NV www.ocobiomedical.com Implant Dentistry 102 — Accelerating Confidence Dr. Jon Julian March 21-22, 2014 Anaheim, CA site.implantdirect.com Intuitive Workflow for Same Day Restoration March 27, 2014 Dr. Daniel Delrose Livingston, NJ www.carestreamdental.com/us/en

Volume 7 Number 2

2014

OCO IMPLANT SYMPOSIUM TWO DAYS...TEN LECTURES...A LIFETIME OF KNOWLEDGE!

June 6 -7, 2014 Sandia Resort & Casino Albuquerque, NM

The 2014 OCO Biomedical Implant Symposium presents ten exciting lectures over two days by some of the industry’s top implant practitioners.

This event, being held at the beautiful Sandia Resort & Casino in Albuquerque, NM promises not only to be informative, but fun.

Lecture topics to include: • surgical & restorative topics • sinus elevation & bone grafting • all-on-6 protocol • cone beam technology & its uses in diagnosing & treatment planning • CAD/CAM technology in implantology • Keynote Speaker: Howard Farran

Don’t miss this opportunity to advance your implant knowledge and join your colleagues from around the U.S. and Canada at this event. This is the educational symposium you do not want to miss.

Pre-register before April 1 - $750.00 After April 1 - $900.00 Staff - $450.00

OUR SPEAKERS: Howard Farran

DentalTown Magazine

Rob Heller, DDS

Midwest Implant Institute

Erik Evans DDS, MD University of Cincinnati

Tim Kosinsky, DDS

Bingham Farms, Michigan

Eric Smith, DDS

Las Lunas, NM

16 CE Units

SIGN UP NOW!

Call one of our Sales Representatives at (800) 228 0477 to pre-register or find out more about the 2014 OCO Implant Symposium!

(800) 228-0477

www.ocobiomedical.com © 2014 OCO Biomedical Inc.

Dave D’Alise, DDS OCO Biomedical

Drs. Morales, Li & Galvan New You Smile Center

And more!

Designed and Manufactured in Albuquerque, NM

U.S. Patent: US 8,277,218,B2 ISO 13485:2003 CERTIFIED 0344

DIARY

lllllllllllllllllllllll OF EVENTS llllllllllllllllllllllllllllllllllllllllllllllllllll Rocky Mountain Dental Institute: Implant Placement & Socket Grafting Drs. Justin Moody and Dan Domingue March 28-29, 2014 Albuquerque, NM rockymountaindentalinstitute.com Place the OCO Biomedical Dual Stabilization™ Line of Dental Implants March 29, 2014 Chicago, IL www.ocobiomedical.com Place the OCO Biomedical Dual Stabilization™ Line of Dental Implants April 5, 2014 Charlotte, NC www.ocobiomedical.com Intuitive Workflow for Same Day Restoration Dr. Daniel Delrose April 10, 2014 Troy, MI www.carestreamdental.com/us/en Place the OCO Biomedical Dual Stabilization™ Line of Dental Implants April 12, 2014 Denver, CO www.ocobiomedical.com Intuitive Workflow for Same Day Restoration Dr. Steinberg April 17, 2014 Baton Rouge, LA www.carestreamdental.com/us/en Place the OCO Biomedical Dual Stabilization™ Line of Dental Implants April 19, 2014 Louisville, KY www.ocobiomedical.com Implant Dentistry 102 — Accelerating Confidence Dr. Jon Julian April 25-26, 2014 Travelers Rest, SC site.implantdirect.com

52 Implant practice

Implant & Laser-Assisted Surgery 103: Training on New Age, Powerful, Minimally Invasive Surgical Solutions with Proven Benefits Dr. Blair Losee and Mary Lynn Smith, RDH April 25-26, 2014 Las Vegas, NV site.implantdirect.com Place the OCO Biomedical Dual Stabilization Line™ of Dental Implants April 26, 2014 Pittsburgh, PA www.ocobiomedical.com Place the OCO Biomedical Dual Stabilization™ Line of Dental Implants May 3, 2014 Memphis, TN www.ocobiomedical.com Place the OCO Biomedical Dual Stabilization™ Line of Dental Implants May 10, 2014 Seattle, WA www.ocobiomedical.com

EVENTS Academy of Osseointegration 2014 Annual Meeting March 6-8, 2014 Seattle, WA www.osseo.org Western and Central Districts’ Annual Meeting April 11-12, 2014 San Francisco, CA www.aaid.com/index.html

WEBINARS

Part I – Provisional – The Blueprint for Success in Implant Dentistry – Part II Screw Retained vs. Cemented Implant Restoration Dr. Saj Jivraj implanteducation.net Graft-less Solutions in Implant Dentistry Dr. Saj Jivraj implanteducation.net Into Thin Air: Maxillary Sinus Dr. E. Dwayne Karateew Saj Jivraj implanteducation.net

FREE WEBINARS Improve Your Success with Soft Tissue Grafting Using Acellular Dermal Matrix Dr. Edward P. Allen www.biohorizons.com Infection Prevention and Recent Infection Control Breaches Mary Govoni April 15, 2014 www.hu-friedy.com Advanced Dental Implant Care: Assessment on Demand Lynn Mortilla April 19, 2014 www.hu-friedy.com Advanced Dental Implant Care: Maintenance on Demand Lynn Mortilla May 9, 2014 www.hu-friedy.com

Diagnosis and Treatment Planning in the Esthetic Zone – Part I Dr. Saj Jivraj implanteducation.net Diagnosis and Treatment Planning in the Esthetic Zone – Part II Dr. Saj Jivraj implanteducation.net

Volume 7 Number 2

dental iMplant CoMpliCations syMposiuM:

lEARN TO PREVENT, DIAGNOSE, TREAT & COllABORATE Friday, May 9, 2014 DAllAS/FORT WORTH, TX

Register Now! The 3rd annual Dental Implant Complications Symposium will take place Friday, May 9, 2014 in Dallas/Ft. Worth, TX. Dr. Stuart Froum, current AAP President, and seven additional distinguished speakers will explore the full gamut of dental implant complications and provide you information from their experiences on this topic that is coming to the forefront of the dental world.

PROGRAM DATE:

WHAT 2013 ATTENDEES HAVE SAID ABOUT THE PROGRAM:

SPEAkERS:

“Complications - the future of dental implants. Very important to begin looking at this in detail and evaluate the possible solutions with evidence based treatment options. I look forward to hearing more as this is likely to become more of my practice over time. Thank you bringing these fine speakers together. Excellent program!”

–Dr. Mark Buchman

Stuart J. Froum, DDS Paul S. Rosen, DMD, MS Will Martin, DMD, MS Kanyon Keeney, DDS

“Totally excellent course and experience. The team of lecturers blended together very well, making for a comprehensive look at complications and the interdisciplinary influence of the various components of implant periodontal, oral surgical and restorative care.”

–Dr. Steven Peiser

*$50 off cannot be combined with other available discounts.

Please see website for complete program details and pricing.

Friday, May 9, 2014

lOCATION: The Worthington Renaissance 200 Main Street Fort Worth, TX 76102

Receive $50 off your tuition by using discount code “IPUS2014”

Bobby Butler, DDS Don Clem, DDS Ray C. Williams, DMD David Cochran, DDS, PhD

AGENDA: 7:00 AM – 8:00 AM 8:00 AM – 5:00 PM 5:00 PM – 6:00 PM

Registration Program Cocktail Reception

Straumann will provide 7.0 CE Credits for this program Visit http://straumann.cvent.com/dic2014 to learn more and register

4-DAY LIVE PATIENT SURGICAL EXTERNSHIP

Baja California, Mexico June 4-7, 2014 Key Educational Objectives: • Implement step-by-step implant surgical protocols on live patients under the direction of Dr. Louie Al-Faraje and staff.

• Place multiple implants (8-12 implants) and assist with multiple implants on live patients.

• Gain the surgical experience to safely place implants with predictability.

• Accelerate your learning curve to transition from classroom to surgically placing implants in your office.

• Increase your knowledge and skill in the areas of flap design, implant placement, bone grafting, and suturing techniques.

• Learn to manage surgical complications which may possibly arise while placing implants.

• Level II program available and covers advanced techniques such as lateral window sinus lifting, ridge expansion and block grafting.

Register today: call 858.496.0574 or online at www.ImplantEducation.net

Tuition: CII Non-Graduates .....$8,995.00 CII Graduates .............$6,995.00 Limited availability. Call today!

Tuition includes: 32 CE Units, all materials and implants, daily continental breakfast, lunch, dinner and course certificate.

MATERIALS lllllllllllll & lllllllllllll EQUIPMENT DEXIS® photo™ available on the Apple App Stores DEXIS announces the immediate availability of DEXIS® photo™ on the Apple App Stores® in the United States and Canada. The free app provides a fast and easy way to add photos directly into DEXIS® Imaging Suite using an iPhone or iPod Touch. Clinicians can now simply frame the shot and capture the photo right into the patient record — wirelessly, automatically, and instantaneously — no cards, no readers, no manual file transfer.

With the two functions of DEXIS photo, dental professionals can choose to capture patient photo IDs that can be viewed from any imaging screen in DEXIS or to take images for the software’s extraoral photo screen. Not only is this app effortless and enjoyable to use, it can help to maintain HIPAA compliance since images are not stored on the mobile device; rather, they are securely stored within DEXIS.

BIOMET 3i launches new Slim Kit Dental implant manufacturer, BIOMET 3i has launched a new Tapered Implant Slim Surgical Kit. The Tapered Implant Slim Surgical Kit is designed to provide a compact set of instruments for placing 3.25 mm and 4 mm diameter implants in 8.5 mm – 13 mm lengths. The kit provides two insert options: one for both Certain® and External Hex Components and one for Certain® only.

Other features include: • A reduced footprint to better fit in smaller autoclaves • A sleek, modern clamshell design with a latch for easy opening • Clear pathways that follow BIOMET 3i Surgical Guidelines • Spaces labeled with product descriptions for easy identification and population • Three “open” spaces for any additional instruments desired • Wrenches located on the insert for easy access • A silicone mat for storage of additional instruments For more information about BIOMET 3i, visit www.biomet3i.com or contact the company at 800-342-5454.

OTA Fixture Removal Kit for implant removal The OTA Fixture Removal Kit is comprised of a combination of trephine drills and removal instruments for the simple removal of failed implants. The kit contains seven Trephine Drills, three Fixture Removers, one Remover Wrench, one Manual Knob for finger usage and one Adapter.

For more information, visit http://www.osseoustech.net/store/ index.php

For more information, visit www.dexis.com.

INDUSTRY NEWS New book on oral implantology from Quintessence Publishing Anatomical textbooks and atlases often fail to meet the clinical demands of defining intraoperative structures for oral implantologists because of the overwhelmingly detailed minutia.

Because certain anatomical landmarks are hard to illustrate in a diagram format, students and professionals can be confused when confronted with actual specimens in the dissecting room or in the operatory. This book, however, shows the structures of the maxilla, the mandible, and the nasal cavity as they actually exist in the dissected or live body, through the presentation of cadaver specimens and clinical cases. Several of the chapters include full-page images of specific cadaver sections with all the relevant anatomical parts labeled for convenience. This book will simplify the learning and execution of implant-related surgical procedures in a region of the body that presents special topographic and anatomical difficulties.

To order, please call Quintessence at 800-621-0387 or order online at: www.quintpub.com.

56 Implant practice

Air Techniques wants to find the oldest air compressor and vacuum system still in use today Air Techniques, Inc., an innovator and manufacturer of dental equipment, is excited to announce The Oldest Air Tech Air Compressor and Vacuum System contest. This contest will run through September 30, 2014. Air Tech wants to reward those dentists who have these long-running compressors and vacuum systems, and the service technicians who keep them running.

Send Air Techniques a picture of your old unit, along with a note of when it was installed and your dealer information. The dental office with the oldest Air Tech compressor in North America will win a new AirStar compressor.

Sign up online at www.airtechniques.com/Dental/oldest_unit_ contest.cfm. Sign up by email by sending your information to: airtechny@gmail.com. Sign up by snail mail (your unit must be really old!) at the following address: Air Techniques, Inc., Oldest Air Compressor & Vacuum Contest, 1295 Walt Whitman Road, Melville, NY 11747.

Volume 7 Number 2

Please visit us at the AO, Booth #1027!

Own the New Piezosurgery

速

for as low as

*$276

per month!

*On Approved Credit - US Dentists only - Special 3.98% Interest Arrangement with Highland Capital Corp.

PRODUCT PROFILE

BIOMET 3i launches its new 3i T3® Implant Leading dental implant manufacturer BIOMET 3i is launching its new 3i T3 Implant.

The 3i T3 Implant is a contemporary hybrid implant with a new multi-surface topography designed to deliver esthetic results through tissue preservation: •

•

•

•

•

Coarse Micron Topography: A resorbable media blasting process using calcium phosphate particles provides 10 micron features, which facilitate blood clot retention along the threaded body of the implant.1,2 Fine Micron Topography: A dual acid-etching process provides a 1-3 micron peak-to-peak surface (OSSEOTITE®) that supports platelet activation.3,4 This surface overlays the coarse micron topography and is designed to mitigate the risk of periimplantitis at the coronal aspect of the implant.5 Sub-Micron Topography: The option exists for a more complex topography with the discrete crystalline deposition of calcium phosphate nanoparticles.

This surface treatment has demonstrated increased integration throughout the early healing process, helping to facilitate Bone Bonding®.*6 Integrated Platform Switching: BIOMET 3i Implants with integrated platform switching (3i T3 and PREVAIL® Implants) have smaller restorative platforms relative to the total implant platform. This medializes the Implant-Abutment junction inward, helping to maintain bone levels.

Studies show that BIOMET 3i Implants with integrated platform switching demonstrated crestal bone loss as low as 0.37 mm.7 Certain® Internal Connection and the Gold-Tite® Screw: The Certain Internal Connection in conjunction with the Gold-Tite Screw is designed to reduce microleakage through its exacting interface tolerances and maximized clamping forces.8 The Gold-Tite Screw design increases the clamping force by 113% versus non-coated screws, maximizing abutment stability. The Gold-Tite Surface lubricates and compresses to

58 Implant practice

provide a tighter fit between implant components.9 For more information, please contact your local BIOMET 3i Sales Representative.

About BIOMET 3i BIOMET 3i LLC is a leading manufacturer of dental implants, abutments, and related products. Since its inception in 1987, BIOMET 3i has been on the forefront in developing, manufacturing, and distributing oral reconstructive products, including dental implant components and bone and tissue regenerative materials.

The company also provides educational programs and seminars for dental professionals around the world. BIOMET 3i is based in Palm Beach Gardens, Florida, with operations throughout North America, Latin America, Europe, and Asia-Pacific.

For more information about BIOMET 3i, please visit www.biomet3i.com or contact the company at (800) 342-5454; outside the U.S. dial (561) 776-6700. * Bone Bonding is the interlocking of the newly formed cement line matrix of bone with the implant surface. IP This information was provided by BIOMET 3i.

References 1. Kuzyk PR, Schemitsch EH. The basic science of peri-implant bone healing. Indian J Orthop. 2011 Mar;45(2):108-15.

2. Davies JE†. Understanding Peri-Implant Endosseous Healing. J Dent Educ. 2003 Aug;67(8):932-49.

3. Kikuchi L, Park JY, Victor C, Davies JE†. Platelet interactions with calcium-phosphate-coated surfaces.

Biomaterials. 2005 Sep;26(26):5285-95.

4. Park JY, Gemmell CH, Davies JE†. Platelet interactions with titanium: modulation of platelet activity by surface topography. Biomaterials. 2001 Oct;22(19):2671-82.

5. Zetterqvist et al. A prospective, multicenter, randomized controlled 5-year study of hybrid and fully etched implants for the incidence of perimplantitis. J Periodontol. April, 2010.

6. Lin A, Wang CJ, Kelly J, Gubbi P††, Nishimura I. The role of titanium implant surface modification with hydroxyapatite nanoparticles in progressive early bone-implant fixation in vivo. Int J Oral Maxillofac Implants. 2009 Sep–Oct;24(5):808–816.

7. Östman PO†, Wennerberg A, Albrektsson T. Immediate occlusal loading of NanoTite Prevail Implants: A prospective 1-year clinical and radiographic study. Clin Implant Dent Relat Res. 2010 Mar;12(1):39-47.

8. Suttin Z††, Towse R††, Cruz J††. A Novel Method for Assessing Implant-Abutment Connection Seal Robustness. BIOMET 3i, Palm Beach Gardens, Florida, USA. Poster Presentation, Academy of Osseointegration, 27th Annual Meeting; March 2012; Phoenix, AZ. http://biomet3i.com/Pdf/Posters/Poster_ Seal%20Study_ZS_AO2012_no%20logo.pdf.

9. Byrne D, Jacobs S, O’Connell B, Houston F, Claffey N. Preloads generated with repeated tightening in three types of screws used in dental implant assemblies. J. Prosthodont. 2006 MayJun;15(3):164-71.

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

†

Joell Cruz, Prabhu Gubbi, Ph.D., Zach Suttin and Ross Towse conducted this research while employed

by BIOMET 3i.

††

Volume 7 Number 2

Introducing the

Preservation By Design® • Contemporary hybrid surface design with a multi-level surface topography • Integrated platform switching with as little as 0.37mm of bone recession*1 • Designed to reduce microleakage through exacting interface tolerances and maximized clamping forces

For more information, please contact your local BIOMET 3i Sales Representative today!

In the USA: 1-888-800-8045 Outside the USA: +1-561-776-6700 Or visit us online at www.biomet3i.com

1. Östman PO†, Wennerberg A, Albrektsson T. Immediate Occlusal Loading Of NanoTite™ PREVAIL® Implants: A Prospective 1-Year Clinical And Radiographic Study. Clin Implant Dent Relat Res. 2010 Mar;12(1):39-47. n = 102.

Dr. Östman has a financial relationship with BIOMET 3i LLC resulting from speaking engagements, consulting engagements and other retained services.

†

Reference 1 discusses BIOMET 3i PREVAIL Implants with an integrated platform switching design, which is also incorporated into the 3i T3® Implant. *0.37mm bone recession not typical of all cases.

For additional product information, including indications, contraindications, warnings, precautions, and potential adverse effects, see the product package insert and the BIOMET 3i Website.

3i T3, Preservation By Design and PREVAIL are registered trademarks and 3i T3 Implant design, NanoTite and Providing Solutions - One Patient At A Time are trademarks of BIOMET 3i LLC. ©2014 BIOMET 3i LLC. All trademarks herein are the property of BIOMET 3i LLC unless otherwise indicated. This material is intended for clinicians only and is NOT intended for patient distribution. This material is not to be redistributed, duplicated, or disclosed without the express written consent of BIOMET 3i.

AD006

PRODUCT PROFILE

Renovix® Guided Healing Collagen Membrane

T

he Renovix® Guided Healing Collagen Membrane from Salvin Dental is getting excellent reviews from doctors using it for pre-implant grafting procedures, including socket preservation, ridge augmentation, and sinus lifts. It combines the ability to drape and conform to the specific anatomy of a grafted defect, while maintaining structural integrity and elasticity. This combination of ideal handling characteristics helps make grafting procedures easier and more predictable.

When it comes to selecting the perfect membrane for guided bone and tissue regeneration, there are many choices. Yet most clinicians are still looking for the ideal barrier that combines the best handling and performance characteristics. Some collagen membranes remain stiff even after being hydrated, making it difficult to place over a ridge and conform to the shape of the defect. Other membranes have no memory and resemble wet tissue paper, making it extremely difficult to manipulate during surgery.

Renovix® was originally created for use in repairing pediatric cardiac defects.

Cardiac surgeons needed a resorbable membrane to protect the surgical site without migration, and to have it crosslinked in a way that significantly reduced the chance of an inflammatory response.

Based on these specific requests, the material used for Renovix® was developed.

Renovix® is fabricated from Type 1 porcine collagen, known to be one of the purest forms of collagen available.

It is cross-linked with polysaccharide, a naturally occurring sugar, with excellent biocompatibility. The combined performance and handling characteristics of this membrane, along with specific requests from many implant surgeons, encouraged Salvin Dental to introduce Renovix® for guided bone-regeneration procedures.

Case reports and clinical documentation are an important part of the decisionmaking process when determining how regenerative products will perform. Steve Wallace, DDS, MHS, from Wilmington, North Carolina, has used Renovix® in over 25 cases as a guided regeneration barrier after extraction and grafting of maxillary first and second molars in preparation for implant placement. Dr. Wallace made the 60 Implant practice

following statement detailing his clinical experience with Renovix®: “Primary flap closure over maxillary molar extraction sites is always difficult to achieve. I have been using Renovix® as my barrier over these grafted sites to exclude soft tissue ingrowth. I have seen that Renovix® remains intact up to 13 weeks and consistently promotes soft tissue closure over it with minimal inflammation.”

When it is first removed from its sterile packaging, Renovix® is transparent and fairly rigid. Once hydrated, Renovix® becomes opaque, making it easy to identify when brought into the surgical field, and very easy to manipulate. Doctors have said that they get their best results when trimming it after it has been hydrated.

Renovix® is very thin, yet has remarkable tensile strength. This characteristic provides several clinical advantages. First and foremost, it can easily be tacked or sutured to the surgical site if needed. Next, it can be tucked into small tunnel incisions using a micro periosteal elevator without concern that the instrument will easily puncture through the membrane. Finally, the fact that Renovix® is thin and resilient enables the clinician to elevate smaller flaps, leaving more of the periosteum and blood supply undisturbed for faster healing and less patient discomfort.

James Woodyard, DMD, MS, from Newburgh, Indiana, made the following statement regarding his experience with Renovix®: “The thinness and excellent tensile strength of Renovix® allows me to create small tunnel incisions and tuck it under the tissue without tearing the membrane. With thicker membranes that I used in the past, I had to create large fullthickness flaps, and many of the other thin membranes had a tendency to tear when I tried to tuck them. When I decrease the size of the flap elevated and exposure of bone, I decrease postoperative swelling, pain, bone loss, and discomfort for the patient. The less invasive I can be, the less complications I have. I am extremely pleased with the results that I have seen when using Renovix®.”

Renovix® is available in three different sizes and is individually packaged sterile for immediate use. Many doctors like 15 mm x 25 mm size because it will typically fully cover a grafted extraction socket from the

buccal to the opposing lingual plate, maintaining full coverage over the ridge, without having to select a larger size. This unique size reduces waste and saves money by often eliminating the need to select the next larger size.

For more information about Renovix®, check out the product video on the company’s website at www.salvin.com, or contact the team of experts at Salvin Dental at 800-535-6566. They’ll take great care of you! IP This information was provided by Salvin Dental.

Volume 7 Number 2

Everything For Your Implant Practice But The Implants®

Enhancing Care For Your Patients™

Guided Healing Collagen Membrane • Resorbable Porcine Collagen Membrane For Guided Tissue & Bone Regeneration • Optimal Mechanical & Elastic Handling Characteristics • Biocompatibility With No Inflammatory Response • Easily Sutured Or Tacked Over Your Surgical Site • Easily Cut & Shape To Your Desired Size • Compare To Ossix™ Or Bio-Gide® Ossix™ is a registered trademark of Johnson & Johnson Bio-Gide® is a registered trademark of Geistlich

Socket Graft Without Primary Closure

+

Grafted Extraction Socket

Renovix® Placed Double Layer

Mineralized Cortical / Cancellous

Sutured Without Primary Closure

16 Week Post-Op Mature Tissue Closure

16 Week X-Ray Ideal Bone Formation

Surgery & Photos: Dr. James Woodyard, Periodontist, Newburgh, IN

Socket Graft Without Primary Closure

+

Grafted Extraction Socket

Renovix® Draped Over Surgical Site

Mineralized Cancellous

Sutured Without Primary Closure

4 Week Post-Op Mature Tissue Closure

16 Week X-Ray Ideal Bone Formation

Surgery & Photos: Dr. Steve Wallace, Periodontist, Wilmington, NC

Salvin Dental Specialties, Inc Toll Free (US & Canada) 800-535-6566 • www.salvin.com Phone 704-442-5400 • Fax 704-442-5424 • Email: orders@salvin.com 3450 Latrobe Drive • Charlotte, NC 28211 • USA © 2014 Salvin Dental Specialties, Inc. All Rights Reserved. REV. 01-2014

PRODUCT PROFILE

Beneficial implications of a new cutting technology for the dental implant architecture: BLOSSOM™ Introduction Dental implants have undergone numerous modifications in order to make their placement more predictable, their stability more immediate, and the treatments of which they are a part more successful. The average success rate for dental implant treatments that has been cited in the literature is between 95% and 98% when they are placed according to conventional principles and accepted researchsupported recommendations.

Dental implant treatment success, however, is predicated on multiple factors. Among the most important are osseointegration and stability, both of which are influenced by the bone quality/surface area into which the implant is placed, as well as bone remodeling.

As knowledge of the biological and mechanical effects of dental implants and their placement protocol have broadened, aspects of the implants themselves (e.g., implant length and diameter, coatings and surface roughness, and thread design, etc.) and implant surgical techniques have evolved. The goals of alternations have been to provide patients with more immediate benefits, enhanced and shorter healing experiences, and an overall less traumatic and successful treatment.

However, even under the most optimal conditions (e.g., adequate quantity and quality of available bone, sufficient volume and health of periodontal tissue), implant placement has inherently necessitated application of force and pressure by the dentist, and recovery from an invasive procedure by the patient. Although some consider a failure rate of 3% to 5% to be minimal, dental implant failures present a heavy burden for dentists and their patients when negative sequelae occur. Additional material expenses, procedural and healing time, and trauma affect the patient, and skepticism and degraded confidence leave their mark on dentists and their practices.

Therefore, a scientifically-engineered innovation that can help to lower the dental implant failure rate — or even reduce the annual number of failures that occur in a practice by one or more — should be embraced, especially because the mere “ability to integrate” is no longer the sole measure of dental implant success. Instead, 62 Implant practice

DT Intra-Lock Implant with “traditional” cutting design VS. DT Intra-Lock Implant with BLOSSOM

more extensive and refined success criteria include the clinician’s ability to re-engineer the osteotomy biology, enhance initial stability for faster integration, and preserve tissue biotype and crestal bone. When achieved collectively, shorter healing times to final reconstruction result, and a more favorable esthetic environment is created.

A new science and engineeringbased paradigm To facilitate ease, efficiency, and predictability in achieving these prerequisites for success, a new and patent-pending cutting technology for self-tapping, screwtype dental implant architectures has been introduced (BLOSSOM™, Intra-Lock® ™ International). The BLOSSOM crescentshaped, helical, self-tapping configuration consists of a unique series of strategically placed and angled cutting surfaces, with at least one on each thread. This feature enables dentists to continually cut through bone with increased surgical efficiency, minimal force, and less trauma.

Additionally, the BLOSSOM™ architecture incorporates spiral channels that eliminate buildup of a large concentration of fractured bone in the cutting area (e.g., crowding) and produce fewer, more evenly distributed bone particles. This “self-clearing” action promotes faster osseointegration, since the bone particles originating from the cutting threads serve as nucleating sites for new bone formation.

They act like an autologous micro-graft over the full length of the treads of the implant, creating the perfect biomaterial for osteoblastic attachment.

These subtle yet meaningful changes correct the shortcomings of standard self-tapping implant thread designs that could lead to deleterious outcomes. With conventional self-tapping implant designs, a significant increase in torque develops as the implant is driven through bone. If high torque forces remain during final seating, over compression of bone can produce

trabecular microfractures and excessive bone remodeling. Additionally, a loss of surface area in the apical third and buildup of a large concentration of fractured bone in the cutting area (e.g., crowding) can occur.

Scientists and bioengineers at IntraLock® addressed these problems by focusing on the mechanical and biological interactions of implants and bone, which ultimately led to eliminating the need for conventional flutes and vents that traditionally define self-tapping implants.

Instead, BLOSSOM™ features a fully integrated tapping configuration that is evenly spaced and distributed along the implant. As a result, BLOSSOM™ implant placement lowers insertion torque and friction and minimizes compression microfractures. Additionally, BLOSSOM™ contributes to decreased micromovement by enhancing intimate bone contact and engaging a larger volume of surface area.

Conclusion The BLOSSOM® cutting design brings dentists providing implant treatments closer to the biologic paradigm of accelerated implant healing by minimizing bone trauma.

It enables them to efficiently cut through the osteotomy while preventing the over compression of bone that could lead to fibrous encapsulation and subsequent implant failure. By reducing compressionmediated (i.e., torque-related) microfracture, BLOSSOM® shortens early bone remodeling and promotes faster integration and increased bone-to-implant contact, creating a stable foundation for subsequent restoration. The Blossom® implant architecture accomplishes this using finesse, not force, to increase oral implantology success rates. IP This information was provided by IntraLock International Inc.

Volume 7 Number 2

Welcome to the New Cutting Edge.

A cutting edge that’s immediately apparent from the moment of insertion…and it’s no accident.

As Parameters for success in oral implantology have changed beyond just “integration”, so have new technologies in manufacture and design.

They enable the development of dental implant systems that specifically address mechanical and biological interactions of implants and bone in ways only dreamed of in the past.

A perfect example is BLOSSOM®. Its unique macro architecture (patent pending) allows the implant to cut through bone with surgical efficiency. This lowers insertion torque, minimizes compression micro

fracture and also provides for decreased micro movement*.

BLOSSOM® Implants seat like nothing you’ve ever experienced… you can actually feel the difference.

New advances in high definition controlled micro-blasting coupled with proprietary manufacturing processes gave birth to the bioactive surface OSSEAN®. Studies** found it to be the only surface incorporating three important characteristics: fractal architecture, nanoroughness and CaPO4 Molecular Impregnation (1000x smaller than nanoparticles).

See the changes. Feel the difference. 888.330.0338

www.intra-lock.com * The effect of implant design on insertion torque and immediate micromotion. Freitas AC Jr, Bonfante EA, Coelho PG. Amilcar C., et al. Clinical Oral Implants Research: January 2012, Volume 23, Issue 1, pages 113–118. **Identification card and codification of the chemical and morphological characteristics of 14 dental implant surfaces. David M. Dohan Ehrenfest, Lydia Vazquez, et al. Journal of Oral Implantology: October 2011, Vol. 37, No. 5, pp. 525-542.

!

NEW

InterActive™

NobelActive™ Compatible Conical Connection1 with Simply Smarter Surgical & Restorative Design

Simply Smarter Surgery

IQity™ - Simply Smarter Impression Technique

Neck Matched to Major Diameter • Seals opening at crest of ridge reducing need for bone grafting

• • •

Micro-threads and Grooves • Micro-grooves to improve soft tissue attachment and micro-threads to increase stability and reduce stress in crestal bone area

The ease of a closed-tray impression The accuracy of an open-tray impression The versatility to create impression at either implant-level or abutment-level

Cutting Edge of Grooves Face Clockwise • Three long grooves for self-tapping insertion vs reverse cutting grooves for removing implant

Simply Smarter Restorations Matched Concave Transgingival Profile on Abutments & Components • Shape soft tissue for improved esthetics

Apical 1/3rd Tapers 2º • Slight body taper increases initial stability without over-compression and facilitates self-tapping insertion in dense bone

Compatible Abutments with Longer Hex/Shorter Bevel2 • Reduce the need to confirm seating with X-rays

Rounded Apex • Reduces risk during insertion of implant diverging from path created by drilling and the risk of sinus perforation

Two Color-coded Implant Platforms for Four Implant Diameters • Restore more implants with a smaller prosthetic inventory and easily identify the correct size

Visit us at AO Annual Meeting booth #1311

Reality Check Nobel Customers

Save $553!

All-in-1 Packaging

Includes implant, cover screw, healing collar & new fixture-mount that provides simply accurate impression taking as well as functions as a preparable abutment – $225 SBM, $250 SBActive™ surface

InterActive implants compatible with NobelActive™ titanium abutments up to 15° angulations.

Straight titanium, straight temporary, and 15° angled titanium abutments.

Price comparisons based upon US list prices as of June 2013. All trademarks are property of their respective companies.

US list price for NobelActive with cover screw, impression coping, healing abutment & abutment.

Measurements based upon 4.3mm diameter, 13mm length implants. Dimensions can vary.

Straight Abutment

Laboratory Straight 15° Angled Abutment Contoured Contoured

Gold/ Plastic

Plastic Multiple-Unit Temporary Ball w/Cap & Transfer Angled Abutment Abutment Straight

Implant Direct price

$227 $120

$194 $85

$195 $100

$232 $100

$223 $120

N/A $40

N/A $90

$235 $100

$281 $120

Reality Check Savings

$107

$109

$95

$132

$103

N/A

N/A

$135

$161

Nobel Biocare™ price

1 2

www.implantdirect.com | 888-649-6425