Implant Practice US - October 2013 - Vol 6 No 5 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews

PROMOTING EXCELLENCE IN IMPLANTOLOGY

Legacy™4 Implant A Legacy of Innovation

October 2013 – Vol 6 No 5

Corporate profile Carestream Dental

Missing lateral incisors: overcoming the problem of insufficient space Dr. Ian Hallam

Practice profile Dr. Robert J. Miller

Product profile BIOMET 3i launches its new 3i T3® Implant

CAD/CAM anterior esthetic implant restorations Dr. Dean Vafiadis

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

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Shifting trends: osseointegration to peri-implant esthetics

he implant world is rapidly evolving. Final restorative seating of cases with a more natural look with scalloped tissues is the newest, fastest growing trend in implantology. The implant field has progressed: we no longer discuss modification of the implant surface to promote osseointegration; more focus is on the soft tissues surrounding the implant. The focus is now on maintaining tissue height, contour, and esthetics by using surgical techniques or by using implant surface modifications such as Laser-Lok® (BioHorizons®) or platform switching. “This is clearly the focus of implant dentistry today. Crestal bone preservation at the head of the implant. Platform switching, slopping shoulder, laser microchannels and microgrooves are the predominant macro and micro geometries currently discussed,” according to Maurice Salama, DDS. Implants have been shown to be successful in the treatment of multiple restorative needs: replacing single teeth, multiple teeth, or a full mouth of teeth with fixed or removable restorations. Technology and research have improved to modify the surfacing of the implant to help increase bone-to-implant contact, decrease healing times, and improve the long-term restorability of implants. Initial research was first focused on the integration of titanium to bone, and long-term followup was needed to show if this therapy was a good treatment option for patients. Today, we have over 50 years of research to show that implants integrate with bone and have long-term success rates. We also have the benefit of state-of-the-art technology, like CBCT imaging, and improved surgical techniques, such as guided surgery, to remove much of the guesswork from procedures, and aid in the success rates of implant therapy and placement. Due to this paradigm shift in the implant world from simply getting implants to work to emphasizing esthetic outcomes, there has been a change in the focus of implant dentistry from osseointegration to peri-implant esthetics. Proper soft tissue development is of the utmost importance to today’s clinicians, because it improves both the peri-implant esthetics of the final case and also the longterm stability of implants. Prior to implant placement, the soft tissue can be modified, using one of many techniques, to promote proper tissue contour. There are different ways of improving the peri-implant tissue. It can be achieved by grafting with soft tissue or alloderm, modifying the amount of keratinized tissue with various surgical techniques, or developing the soft tissue scallop/papilla around an anterior tooth before making the final crown. The long-term esthetic success of an implant is dependent upon maintenance of the implant by the doctor to help avoid infection that could lead to failure of the implant. This is done by properly placing implants in the correct position, and secondly, by properly restoring implants. Clinicians should always avoid concave pontics, ridge-lapped crowns, and open contacts. These make it hard for patients to clean and maintain, ultimately leading to complications such as peri-implantitis. Getting the patients invested in the hygienic care of their implant can also help mitigate potential issues before they become big problems that can threaten the success of the implant. Integration of implants has proven to be successful long term, but in a still-developing field, there remains a need for more research to develop the soft tissue around implants. Dentists placing implants need to be more concentrated on how to properly develop tissue in order to avoid complications in the future. Using what we learned yesterday, and focusing on research today, will give us better outcomes tomorrow.

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Volume 6 Number 5

Daniel Domingue, DDS, FICOI, MICOI, DICOI, ASAAID, FAAID, DABOI Mentor/Lecturer: Rocky Mountain Dental Institute, Denver, Colorado Lecturer: Implants in Black and White, Lafayette, Louisiana

Implant practice 1

INTRODUCTION

October 2013 - Volume 6 Number 5

TABLE OF CONTENTS

Clinical

Practice profile

Dr. Robert J. Miller: Setting the bar high This clinician discusses the true joy of treatment success and his recipe for delivering high quality care in a predictable fashion.

CAD/CAM anterior esthetic implant restorations: the BellaTek Encode healing abutment and CADBlock ceramics Dr. Dean Vafiadis delves into the use of a coded healing abutment....... 12 Restoring the edentulous maxilla Dr. Ross Cutts discusses a cost effective way to restore the edentulous upper arch................. 20 Bridge construction in the anterior tooth area of the maxilla Dr. Steffen Wolf juggles esthetic requirements to produce pocketfriendly results for a patient with very particular needs .......................... 26

Case study Hybrid dentures provide a

Corporate profile

practical solution Dr. Daniel Domingue illustrates a case treated with fixed-detachable dentures...................................... 30

Carestream Dental This company continues to develop imaging systems and software and enter new markets.

2 Implant practice

Volume 6 Number 5

TABLE OF CONTENTS

Continuing education Missing lateral incisors: overcoming the problem of insufficient space Dr. Ian Hallam presents a case study providing a solution for a patient who does not wish to undergo orthodontic treatment, using narrow implants...34 Dental rehabilitation of a 6-yearold boy with a rare tumor of the mandible Drs. T. Nyunt, K. George, H. Chana, and G.I. Smith discuss treatment and maintenance of an unusual pediatric case................................40

On the horizon “Lok”-ed and loaded Dr. Justin Moody explores Laser-Lok implant technology........................44

Technology CBCT and implants: the new era in treatment planning and diagnosis Dr. Randolph Resnik discusses the benefits of 3D imaging in a modern implant practice ............................46

Industry news

CBCT and implants: the new era in treatment planning and diagnosis

Implant essentials

Product profile

The big debate Drs. Michael Norton and Julian Webber discuss — implants or endodontics?................................50

BIOMET 3i launches its new 3i T3® Implant ........................................58

Practice development

Diary.......................................62

Apply current tax laws to improve patient care Bob Creamer explains Section 179 and Bonus Depreciation................54

Osteogenics Biomedical to host 2014 Global Bone Grafting

Practice management

Symposium in Scottsdale, Arizona World-renowned speakers showcase latest in bone grafting techniques, materials, and research.................48

Growing the money tree William H. Black, Jr. discusses the financial advantages of having a good plan in place..................................56

4 Implant practice

GALILEOS® Comfort Plus by Sirona ..........................................60

Materials & equipment .....................63

Volume 6 Number 5

The comprehensive offering includes the ANKYLOS®, ASTRA TECH Implant System™ and XiVE® implant lines, digital technologies such as ATLANTIS™ patient-specific abutments, Symbios ™ regenerative bone products and professional development programs.

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

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PRACTICE PROFILE

Dr. Robert J. Miller Setting the bar high What can you tell us about your background? I am a graduate of Hobart College in Geneva, New York where I earned a BS in Chemistry. I received my DMD at the Henry M. Goldman School of Dentistry at Boston University. I also did my residency in Periodontics at Boston University, receiving a CAGS (Certificate of Advanced Graduate Study). I have been in private practice since 1986 in Plantation, Florida.

Is your practice implants?

limited

No, we also offer all phases of periodontal therapy, including regenerative therapy, mucogingival surgery, and anterior esthetic procedures. When I was a resident, implant dentistry was still not widely accepted and was not part of the curriculum. As a result of my early training, when confronted with a compromised tooth, my instinct is to try save it. I believe that this is an advantage, as comprehensive treatment has to include salvaging teeth whenever it is appropriate.

Why did you decide to focus on implantology? I received my first training in implant placement in 1987. This course changed the way I viewed dentistry. For the first time, there was a predictable option for tooth replacement. Taking this course opened my eyes to what I perceived as cutting edge and the future of dentistry. With this in mind, I ultimately dedicated myself and my practice to providing state-of-the-art implant therapy to my patients. At some point, I recognized that many patients who would like implant therapy were not necessarily candidates due to anatomical limitations. This was an impetus to work towards focusing on restorative-driven implant solutions versus surgically-driven. Guided bone regeneration soon became the focus of the practice, and is still a large part.

How long have you been practicing, and what systems do you use? I began private practice in 1986 and placed 6 Implant practice

my first dental implants in November of 1987. This patient still returns for periodontal maintenance, and I am proud to say that the original prosthesis is still in position. I have used several systems through the years, including the original NobelPharma system for approximately 10 years. I switched to Straumann® in 1998, which I have been using exclusively for the past 13 years. This system provides me with all the surgical and restorative options that are necessary for state-of-the-art implant rehabilitations.

What training undertaken?

have

you

I have taken many courses through the years, including the NobelPharma surgical certification course at Boston University in 1987. Early on, there were very few comprehensive courses, and learning was more a function of groups of people getting together and discussing the various issues facing implant surgery and restoration. As implant dentistry evolved, certain individuals began to separate themselves as the true leaders and innovators in the profession. These included Drs. Ron Nevins, Dennis Tarnow, Burt Langer, and Alan Meltzer. These people were instrumental in my early training in surgical placement. More recently, I have had the opportunity to take the Masters Level Bone Grafting course with Dr. Danny Buser at the University of Bern, Switzerland. There are many people who have been part of the evolution of implant dentistry, and I would

like to think that the next 27 years will be equally as exciting.

Who has inspired you? I have had many people inspire me through the years; however, as a resident, there are two people who come to mind. Drs. Steve Pollins and Simao Kon each had a hand in helping me to develop a practice philosophy and setting the bar high. As a periodontal resident at Boston University, they would spend hours discussing cases and aspects of treatment for which they were passionate. I learned from them the true joy of treatment success and a recipe to deliver high quality care in a predictable fashion.

What is the most satisfying aspect of your practice? I often say that my practice is primarily composed of my “friends” coming to “my house” to visit me. Having been in practice for 27 years, I have many patients who have been part of the “family” for a number of years. It is extremely gratifying to have patients return to the office for periodontal maintenance who have had their implant rehabilitations functioning for over 20 years.

Professionally, what are you most proud of? I am most proud of becoming a Fellow of the ITI (International Team of Implantology). Attaining this goal was a culmination of a lot of hard work and dedication. Five years ago, with the urging of my close friend Dr. Jeff Volume 6 Number 5

have been an option. However, as they say, don’t give up your day job!

What do you think is unique about your practice?

What is the future of implants and dentistry?

One of the nicest parts of our practice is the fact that we have four hygienists who have each been working in our office no less than 20 years. Patients continually remind me how comforting it is to see the same familiar faces. My surgical assistant has been with me for 15 years, making her truly my right hand.

I am extremely excited about the future of implants and dentistry. I see restorative dentistry moving more towards CAD/CAM restorations comprised of materials that are even more esthetic. Ultimately, dentists who are not involved in digital dentistry are being left behind. As far as the future of dental implants per se, I feel that there will be a push towards robotic implant placement removing human involvement. In the short term, with the advent of zirconia dental implants, the concept of custommilled dental implants may get some traction. However, due to the fact that these are medical devices, FDA approval will be an uphill battle, making the concept very difficult to get off the ground.

What has been your biggest challenge?

My biggest challenge to date has been incorporating the new technologies in our office in a cost-effective and efficient manner. Dentistry changes every 6 months, particularly from a technological perspective, but in the end, they may not be adding value to our practices. Weeding through technology that is relevant and appropriate for my practice has been an ongoing challenge; however, this is never a chore as I have always embraced change and innovation.

What would you have become if you had not become a dentist? More than likely I would have worked with my father in the dress business. However, as I have been more involved in product development, I have a lot of respect for biomedical engineers. As I learn more about their importance in the medical device industry, I find myself more intrigued with this profession. Perhaps this would

What are your top tips for maintaining a successful practice? The best tip that I can give is to empathize with patients. I firmly believe that one should keep the Golden Rule in mind, which is, “One should treat others as one would like others to treat them.” If you use this as your mantra while treatment planning, you will always have the patient’s best interest in mind. This translates to patient satisfaction that results in a successful practice.

you to choose your cases carefully, as there is no worse feeling than failure. Often, less experienced clinicians will undertake procedures that may be too advanced for their experience level, resulting in an undesirable outcome. This results in a black eye for both the clinician and the profession as a whole. I also strongly suggest that less experienced clinicians should hitch their star to a surgical or restorative mentor and should also seek out top quality companies, as this is an area that one shouldn’t compromise. If clinicians undertake procedures that are within their comfort zone using high quality materials, there is no reason that they should not enjoy success.

What are your hobbies, and what do you do in your spare time? My favorite hobby is skiing. However, for a South Florida resident, it becomes logistically difficult. I try to ski on average 10 to 15 days a year, which is admirable for the geographically challenged. Other hobbies include squash, photography, fly fishing, yoga, and working out.

Top Favorites 1. A nice sinus graft 2. My i-CAT 3. Straumann Dental Implant System 4. Single Malt Scotch 5. Good initial stabilization 6. A “white out” at Ajax Mountain 7. Quiet time with my family 8. Finishing a bike ride up Maroon Bells 9. New attachment! 10. Salmon roll with brown rice 11. Downshifting into third gear and accelerating in an open road!

What advice would you give to budding implantologists? My advice to budding implantologists would be to find a mentor who can help

Volume 6 Number 5 Implant practice 7

PRACTICE PROFILE

Ganeles, I began to pursue the fellowship, which requires a high level of activity in education, research, or leadership. It was at that time I decided to take advantage of publishing opportunities and went on staff as a Courtesy Appointment with the Community Based division program at the University of Florida Hialeah Dental Clinic. Becoming a Fellow of the ITI has opened up many doors and continues to be a source of inspiration and resources for education and leadership.

CORPORATE PROFILE

A history of proven technology, a future dedicated to innovation

ith roots that can be traced back to the 19th century, Carestream Dental certainly has a long history of innovation when it comes to dental specialties— including implantology. This legacy carries on still, as the company continues to develop imaging systems and software and enter new markets. It’s because of this proud tradition that more than 800 million images are captured each year on products from the company’s imaging portfolio. Today, Carestream Dental is focused on providing implantologists with the products they need to facilitate treatment planning and improve patient care.

History of Carestream Dental The Carestream Dental of today was built on the shoulders of major industry leaders of the past — starting in 1896 when Eastman Kodak introduced the first photographic paper designed specifically for dental X-rays. As technology improved and became more digitalized, Trophy Radiologie filed a patent for the world’s first digital intraoral sensor in 1983. Already known for producing intraoral X-ray generators, the digital intraoral sensor earned Trophy a reputation as the world’s leader in dental digital radiography. In 2000, PracticeWorks emerged as a dominant dental software company when it acquired several other software companies. PracticeWorks went on to acquire Trophy Radiologie in 2002, and was purchased the next year by Eastman Kodak to expand its presence in the dental business. With the integration of PracticeWorks/Trophy, Eastman Kodak built the industry’s leading portfolio of film, digital imaging systems, and practice management software. Then, in 2007, Onex Corporation purchased Kodak’s Health Group, and Carestream Dental was born.

The Carestream Dental Factor “We exist to make your practice better,” said Marc Gordon, Carestream Dental’s General Manager, U.S. Equipment and Software. “Our number one goal is to make user-friendly, yet sophisticated, technology to put our customers’ practices at the forefront.” 8 Implant practice

3D Symposium

Carestream Dental’s dedication to advancing implantology can be summed up by the Carestream Dental Factor; three pillars on which the company bases all of its products and services. Incorporating the key elements at the heart of Carestream Dental’s philosophy, the company’s main focus is on delivering diagnostic excellence, workflow integration, and humanized technology. Workflow integration: Administrative tasks cut into time that can be better spent communicating with and treating patients. For this reason, Carestream Dental designs systems and software to enhance treatment planning and fit seamlessly into busy implant practices. Ensuring that every link in the chain fits and contributes to the workflow as a whole allows implantologists to increase productivity and efficiency. Intuitive technology and software are the hallmarks of Carestream Dental. By developing imaging systems that can be quickly utilized by practitioners — and are even compatible with third-party products — implant specialists can eliminate time that would have been spent troubleshooting problems and instead focus on patients. Humanized technology: Patients are an integral part of every implant

practice, so Carestream Dental is committed to providing solutions that facilitate communication between the implant specialist and patient. When communication is optimized, patients are happier and healthier — allowing them to make better, more informed decisions regarding their proposed treatment plan and, in turn, increasing case acceptance. Diagnostic excellence: When evaluating sites for implant placement, details are everything. To facilitate faster, more reliable implant planning, Carestream Dental has created a number of cuttingedge diagnostic tools that enable implant specialists to capture sharp, high-quality images quickly. From industry-leading 3D imaging systems to high-resolution intraoral sensors, Carestream Dental offers a range of solutions that allow practitioners to identify areas of concern and determine the best course of action.

Technology developed clinicians, by clinicians

for

The Carestream Dental Factor isn’t the only thing driving user-focused and innovative products, and services — the clinicians at the heart of the company also play a large role. Through meetings and forums with doctors in the field, Carestream Dental Volume 6 Number 5

It’s amazing what a great image can do for your practice. The CS 9000 3D and CS 9300 Select are ready to work hard for your practice. These technologically advanced systems will finally give you clarity, flexibility and, most importantly, complete control of your image quality and dosimetry. It will also show your patients how dedicated you are to their dental health. • Optimize your image quality and dosimetry • Make accurate assessments, diagnoses and treatments • Experience seamless integration • One system for superior 3D exams, 2D panoramic scans and optional one-shot cephalometrics

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

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CORPORATE PROFILE

Implant planning

Implant planning with software

is better able to understand the needs of implant specialists in order to develop — and modify — products. In fact, the voice of the customer (VOC) is critical throughout the development process. To ensure quality, Carestream Dental also keeps tight control over the products they develop. “We are the only company that is designing its own practice management software and imaging equipment,” said Mr. Gordon. “By controlling every step in the process — from development and manufacturing all the way to support — we make it easier for implantologists to deliver better patient outcomes.”

Innovative products to facilitate implant planning Implant specialists require high-resolution images to evaluate the implant site, and Carestream Dental certainly delivers. The following is just a sample of the imaging products Carestream Dental has designed to meet the specific needs of implant practices: CS 9300: As a two-in-one unit (or threein-one, for doctors who choose the cephalometric option), the CS 9300 allows users to select from panoramic and cone beam computed tomography (CBCT) imaging. Users can also choose from seven selectable fields of view for the Premium model (ranging from 5 cm x 5 cm to 17 cm x 13.5 cm) and four selectable fields of view for the Select model (5 x 5 cm to 10 x 10 cm) to tailor their image 10 Implant practice

based on the specific clinical application. And, the system features Intelligent Dose Management for greater control over patient exposure. CS 3D Imaging Software: Included with Carestream Dental’s CBCT imaging units, CS 3D Imaging Software allows practitioners to view images slice by slice in axial, coronal, sagittal, cross-sectional and oblique views to enhance diagnostic interpretation. In addition, the software includes two sophisticated implant planning modules so users can select from a comprehensive library of implant manufacturers or create their own custom implant sizes. RVG 6100: With greater than 20 lp/ mm resolution per image, Carestream Dental’s RVG 6100 sensors deliver the highest image resolution in the industry. Each sensor undergoes rigorous testing to provide maximum durability and flexibility, and the RVG 6100 features a rear-entry cable, three different sizes, and rounded corners to improve comfort for patients and make positioning easier for users.

Comprehensive education When implant specialists understand how to fully maximize their imaging capabilities, they are better able to get the most of out of their equipment. For this reason, Carestream Dental is committed to providing thorough training and education to ensure their customers have the skill and

knowledge necessary to use their imaging products and software. In addition to providing web-based and in-person training, Carestream Dental holds 3D Symposiums, where dental practitioners can learn how to use 3D imaging equipment in their daily practice. This event features leaders in the industry who share advice and insights, as well as information on the latest industry trends in 3D, to make participants’ practices more efficient and successful.

Next steps With the launch of CS Solutions, a oneappointment CAD/CAM restoration system, Carestream Dental will once again enter an entirely new market—and it certainly will not be the last. As an integrated, openarchitecture system, practitioners can scan an impression with a CBCT unit or scan the patient’s mouth directly with the CS 3500 intraoral scanner, design the crown, inlay, or onlay using the CS Restore software, and mill the crown in-office with the CS 3000 milling machine. For doctors who would rather send the design or milling off to the lab, they can easily submit the information electronically to their dental lab of choice. As always, Carestream Dental will continue to focus on customer service. “Our number one goal is to provide superior customer experience through best-in-class products and best-in-class support,” said Mr. Gordon. To learn more about Carestream Dental’s portfolio of imaging products and software for implant practices, please call 800-944-6365 or visit carestreamdental. com today. This information was Carestream Dental.

provided

Volume 6 Number 5

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. ©2013 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.

CLINICAL

CAD/CAM anterior esthetic implant restorations: the BellaTek Encode healing abutment and CADBlock ceramics Dr. Dean Vafiadis delves into the use of a coded healing abutment

Figure 1

Introduction Digital design software programs for teeth and implant restorations have evolved over the past 5 years.1-3 Using CBCT scans and digital preoperative scans, the clinician can properly plan the placement of implant fixtures.4 Various software programs and intraoral scanners offer analysis of proper implant position, angle of implant placement, and depth of tissue and occlusal clearance.5,6 The utilization of coded healing abutments (BellaTek®, Encode®, Biomet 3i) may also add to the

Dean Vafiadis, DDS, prosthodontist, is Program Director of the Full Mouth Rehabilitation CE Course at NYUCD, Clinical Associate Professor of Prosthodontics and Implant Dentistry, New York University College of Dentistry; former Coordinator of Prosthodontics and Implant Dentistry, St. Barnabas Hospital in New York City, and Founder of New York Smile Institute. He has published many articles on CAD/CAM, esthetics, and implant dentistry and is currently on the Clinical Advisor Board of Journal of Clinical Advanced Implant Dentistry, World Journal of Dentistry, Dental XP, and Stemsave.com. He is radio show host of Talk N’ Teeth, on COSMOS 91.5 FM and has given 500 programs and educated over 8,000 dentists over the past 18 years in the U.S. and abroad. He is a member of ACP, ADA, AO, ICOI, and AACD and in in private practice in New York City. He can be reached at: New York Smile Institute 693 Fifth Avenue New York, NY 10022 212-319-6363 www.NYSI.org

12 Implant practice

Figure 2

precision of design and calibration of all tissue contacting points of the emerging abutment.7-10 The proper design of a healing abutment circumferentially can support the tissues when necessary or can relieve the areas of thin tissue or underlying bone. Each area of the healing abutment contact surface plays an integral role for the final tissue position. Although prefabricated abutments are widely used, CAD/CAM customized healing abutments can be designed to support tissue. Instead of using fixture level impression technique, a coded healing abutment was used. The intraoral scanner captured the codes on this healing abutment. The use of intraoral scanners to capture the Encode healing abutment rather than a conventional impression material provide benefits in accuracy of models in maximum intercuspation position (MIP) and model fabrication.11 Unlike stone casts that may have expansion and water-sorption properties, digitally printed models can avoid these potential sources of error, especially in mounting, indexing, margination, casting, and most importantly, occlusion. This article will introduce and describe a current model for fabrication of ideal abutments, and fabrication of CAD/ CAM restorations for the anterior esthetic zone.

Figure 3:

Case presentation anterior central incisor No.8 Materials used and steps to final restoration • CBCT scan of planned surgery, GALILEOS® 3D CT Scanner (Sirona) • NanoTite Certain®( Biomet 3i) internal connection 4.0 mm implant fixture • Coded abutments (BellaTek Encode, Biomet 3i) • Final impression with intraoral digital acquisition; Lava™ Chairside Oral Scanner (C.O.S.) [3M ESPE] • SLR models created • CAD/CAM Abutment Design (3-Shape Abutment Designer/BellaTek, Biomet 3i) • Final abutment; Zirconia, internal connection (Certain, Biomet 3i) • Final impression of abutment and teeth with Cerec® Blue Cam (Sirona) • Restorative material: monolithic leucitereinforced ceramic (Empress® CAD-HT, Ivoclar ) • Laboratory: NY Smile Labs • Cement Utilized = RelyX™, (permanent) [3M ESPE] • Restoration time = five visits - 3 months Patient presented with a traumatic fracture of the upper left central incisor (Figure 1). The tooth was extracted atraumatically without incisions to preserve interproximal tissue. Software was utilized in conjunction with a CBCT scan to fabricate Volume 6 Number 5

CLINICAL

Figure 4

Figure 7

a surgical guide. The precise measurement of this particular central incisor width at the root section, 3 mm above the CEJ restoration, was measured at 5.73 mm. Because the natural tooth was available for measurement, the root was also measured after extraction and was measured at 5.97 mm. (Note: The average of these two measurements would be used as the final abutment width later in the design phase.) Considering that the natural tooth is not always available, the measurement from the CBCT scan could be used as a guide in other instances. A 4.0 mm wide endosseos implant was placed (NanoTite™ Certain, Biomet 3i) [Figure 2]. The site was sutured and healed with primary closure. It was determined that the adjacent teeth would also need restorations in the future. A bonded provisional was fabricated from a composite, autopolymerizing provisional material (Luxatemp®, DMG) and placed for a 6-month healing period. The provisional was removed after implant healing, and the implant fixture was exposed without flapping the gingival tissues. A prefabricated abutment was used to develop and scallop the tissue to conform to the ideal central incisors cervical shape (Performance® Post, Biomet 3i). This was made using highly polished flowable composite material (LuxaFlow, DMG) with a screw-retained method for a period of 6

Figure 5

Figure 6

weeks. After the tissue had matured, the provisional abutment was removed, and a coded healing abutment was placed (BellaTek, Encode impression abutment, Biomet 3i) [Figures 3 and 4]. At this time, a digital impression of the coded healing abutment was made with an intraoral scanner (Lava C.O.S., 3M ESPE) [Figures 5-7].

the transfer of digital information from the clinical environment to the laboratory in a matter of minutes. The digital scan begins with isolation of the coded abutment, ensuring that it is more than 2 mm above the gingival tissues. The tissues must be dry and clean. A series of scans from the occlusal view of the abutment are captured. After this is completed (approximately 2 minutes), an additional scan of the lower opposing arch is made (approximately 1 minute). A third scan of the teeth in MIP is also made (approximately 1 minute). The software program merges these three scans onto a virtual model on the computer screen. The clinician chooses the tooth area to be restored, confirms the accuracy and capture of all the data points, and approves the scan. The clinician completes the laboratory prescription form and sends the file via email to the corresponding laboratory for model fabrication and final abutment fabrication. Many variables such as implant width and connection, depth of tissue, abutment material, margin placement, surface texture, shade, and final restorative material are all chosen by the clinician. This ensures that the clinician will achieve the exact result that was planned for each patient. The digital scan of the occlusal

Intraoral scanning and design Fabrication and design of implant abutments has been previously published.7-10 Using CAD/CAM software to design the final abutments has increased the precision of designs and decreased laboratory fabrication times. The specific design programs require information from the clinician to better understand each specific tooth emergence for each site. Using radiographs, tissue biotypes, and algorithmic equations, the design technician, in conjunction with the clinician, can better design the final contours and emergence that are necessary for ideal tissue support and long-term tissue stability. The use of intraoral digital acquisition units (Table 1) can also help the fabrication of CAD/CAM restorations that follow the emergence from the abutment to the final restoration. Using a coded healing abutment such as Encode can facilitate

Table 1: Various digital acquisition software

Digital Impression

Digital Impression + In-Office Milling

CAD/CAM Abutments

Lava/3M ESPE

E4D/D4D Technologies

Encode/Biomet 3i

iTero/Cadent Trios/3-Shape

Procera/Nobel Biocare Cerec AC 4.0/Sirona

Atlantis/Astra Tech Akton System/Straumann

Volume 6 Number 5 Implant practice 13

CLINICAL relationships in MIP position is more precise and accurate than stone casts because they are captured digitally in a static mode, as opposed to models being mounted with a bite registration. The files are emailed to the digital facility (BellaTek Production center, Biomet 3i) and are then transferred to 3-D shape software for design. Design of final abutments There are four areas of clinical importance for designing the abutment. Their relative importance is as follows: 1- Gingival margin position as it relates to thick or thin biotype of tissue 2- Depth of tissue around abutment circumferentially as it relates to the radiograph of the bone 3- Angle of the emergence as it relates to algorithmic equation to determine tissue displacement, especially on the facial aspect of this patient treatment (Figure 8) 4- Width of the gingival floor as it relates to the support of all ceramic materials as they seat on the abutment.12 In this patient, it was measured at 1.7 mm. Note: The width of the final abutment will be designated at 5.8 mm based on the original width of the natural tooth that was extracted (Figures 9-13). Once the design is approved by the clinician or the laboratory, the final abutment is milled from either a titanium or zirconia material. The abutment is polished and finished, and returned with the digital model to the laboratory. The laboratory delivers the final abutment to the clinician. The provisional restoration is removed, and the ideal final abutment is placed into position. The final abutment is placed and torqued to proper position based on the manufacturerâ&#x20AC;&#x2122;s recommendation (30Ncm) [Figures 14-16]. The adjacent teeth were prepared for ceramic crowns due to decay at the root surfaces. A highly polished provisional is placed to secure the tissue position and to allow the interproximal tissue to grow as much as possible. The provisional was fabricated with autopolymerizing composite provisional material (LuxaTemp, DMG) [Figures 1719]. The tissues were allowed to heal for 3 weeks. The preparations and abutment were now ready for the final impression.

Digital scanning of the abutments and teeth

Figure 8

Figure 9

Figure 11

Figure 14

Figure 17

Figure 10

Figure 12

Figure 15

Figure 13

Figure 16

Figure 18

Intraoral scanning The provisional is removed, and the teeth and the implant abutment are cleaned. 14 Implant practice

Volume 6 Number 5

CLINICAL

Figure 19

Figure 21

Light powder is applied to the abutments, and the access hole is temporarily sealed with Teflon tape and flowable lightcured composite resin. Using a CAD/ CAM intraoral scanner (Cerec 3D blue/ cam, Sirona), the abutment and teeth are scanned in the mouth (Figure 20). Also needed are an occlusal scan of the sextant, a frontal scan in MIP position, and the scan of the opposing arch. The software merges the three scans onto one design virtual model on the computer screen. In the preparation window of the design software, digital scans are captured of the abutment and teeth. The amount of digital scans depends on the size of the restoration and how many adjacent teeth are involved. The average is seven to eight scans. Computer Assisted Design - CAD Once the digital images have been approved, the abutment margin and teeth margins are highlighted and verified for exact position. This is called margination, the exact margin that the restoration will be milled to. In the settings mode, the parameters for each type of restoration can 16 Implant practice

Figure 20

Figure 22

be adjusted for each clinician’s preference. Some of these parameters include occlusal offset, margin thickness, cement spacer, and restoration thickness. A scan of the perfectly contoured provisional restorations is used in “correlation” mode to best mimic what has been created, in terms of contour, contacts, and shape. Each restoration must be designed separately and then merged together in the final master digital mode. Additional design features such as “add” and “smooth” tool can be used to finalize the shape each restoration. Occlusion The ideal occlusion contact position is carefully designed with freedom in the anterior from MIP. This position is critical in the anterior implant restoration because the adjacent teeth have an adaptive PDL that is different than a fixed dental implant. Careful occlusion analysis needs to be performed so that initial contact is on natural teeth first. Using articulating paper with a 20-micron thickness (AccuFilm® red/black, Parkell) can show the clinician the variable contact points of natural teeth compared to the

implant restoration. It seems logical that the 20-micron articulating paper should be free of contact on the implant restoration when the adjacent teeth are in contact and marking the paper. Other thickness of articulating paper may be used to further examine the movement of the anterior adjacent teeth, in protrusive movement, before the implant restoration comes into contact. Interproximal contacts are also adjusted to desired position, one at a time. Computer Assisted Milling - CAM Various CAD block materials have reportedly been used as final crowns and veneers.13-14 The restoration is designed for each tooth position. After the final design is approved, it is sent to the milling center for final mill. The designated blocks chosen for this patient treatment were Empress CAD blocks LT (Ivoclar/Vivadent). In the pre-glazed phase after milling, they are tried intraorally for final occlusion and interproximal contact points. Selective grinding with a high speed handpiece is necessary to get the proper contour and transmission of light on each tooth. Shaping, incisal thinning, and polishing Volume 6 Number 5

CLINICAL are critical to the natural appearance of the restorations. After approval of fit and position, they are placed in the firing oven for final crystallization and glaze with the appropriate shade and stain match for the adjacent teeth. Final radiographs are taken, and then the restoration is cemented with final cement. A dual-cured resin cement (RelyX™ 3M ESPE) was used for cementation. Final occlusion was confirmed with digital occlusion analysis (Tekscan®). The patient returned for follow-up in 3 and 6 weeks, respectively. The restorations were checked for gingival health, occlusion verified, and final photos taken (Figures 2123).

Advantages of CAD/CAM impressions and restorations • Avoiding conventional steps such as impression material, strong gag reflex, pouring, mounting, alginate, bagging, delivery, pindex, ditching, etc. • Reduces laboratory costs and lab time • Saves time for clinician, laboratory, and patient • Most accurate interocclusal records • Margin capture and review more easily seen than cast ditching • Fewer remakes • Saves office costs due to materials, trays, dental assistant • Impressive technology for patients • Promotes better preparations • Digital files can be transferred with backup and no loss of cases • Digitally trained designers

Disadvantages • Cost of scanners

Figure 23

Figure 24

• Learning curve of 2 to 3 months • Complete isolation, which means no tissues and no fluids in the scanning field • Bulky equipment in the operatory • Continuing education

translucency in addition to fit and marginal integrity. Computerized and CAD/CAM prosthodontic care of our patients can be more efficient, more predictable, and save chair time for our patients.

Conclusions

Acknowledgements

The use of in-office CAD/CAM techniques has been highlighted to fabricate anterior implant crowns. Utilizing the coded healing abutments can save time and increase efficiency with the digital designs of final abutments. The clinician can use clinical knowledge to help designers make ideal final abutments. Monolithic leucitereinforced and feldspathic ceramic blocks can be utilized to fabricate life-like color and

The author would like to thank NY Smile labs and Carlos Carranza, MDT, New York City, and Roe Dental Laboratory, Cleveland, Ohio for their dedication to digital technologies, the Bellatek production team at Biomet 3i for their digital designs and endless work ethic, Dr. Jim Jacobs, Periodontist, New York City, and John Kim, dental digital officer for their efforts on this patient’s successful treatment. IP

References 1. Binon PP. Evaluation of machining accuracy and consistency of selected implants, standard abutments and laboratory analogs. Int J Prosthodont. 1995;8(2):162-178. 2. Finger IM, Castellon P, Block M, Elian N. The evolution of external and internal implant/ abutment connections. Pract Proced Aesthet Dent. 2003;15(8):625-632, 634. 3. Priest G. Virtual-designed and computer-milled implant abutments. J Oral Maxillofac Surg. 2005;63(9) (suppl 2):22-32. 4. Patel N. Integrating three-dimensional digital technologies for comprehensive implant dentistry. J Am Dent Assoc. 2010;141(suppl 2):20S-24S. 5. Birnbaum NS, Aaronson HB. Dental impressions using 3D digital scanners: virtual becomes reality. Compend Contin Educ Dent. 2008;29(8):494, 496, 498-505.

18 Implant practice

6. Christensen GJ. Will digital impressions eliminate the current problems with conventional impressions? J Am Dent Assoc. 2008;139(6):761-763. 7. Drago CJ. Two new clinical/laboratory protocols for CAD/CAM implant restorations. J Am Dent Assoc. 2006;137(6):794-800. 8. Grossman Y, Pasciuta M, Finger IM. A novel technique using a coded healing abutment for the fabrication of a CAD/CAM titanium abutment for an implant-supported restoration. J Prosthet Dent. 2006;95(3):258-261. 9. Vafiadis DC. Computer-generated abutments using a coded healing abutment: a two-year preliminary report. Pract Proced Aesthet Dent. 2007;19(7):443-448. 10. Vafiadis DC. Full arch restorations using computerized abutments. Implant Dent Today. 2011;June:30-35.

11. Ramsey CD, Ritter RG. Utilization of digital technologies for fabrication of definitive implantsupported restorations. J Esthet Rest Dent. 2012;24(5):299-308. 12. Akbar JH, Petrie CS, Walker MP, Williams K, Eick JD. Marginal adaptation of Cerec 3 CAD/CAM crowns using two different finish line preparation designs. J Prosthodont. 2006;15(3):155-163. 13. Guess PC, Zavanelli RA, Silva NR, Bonfante EA, Coelho PG, Thompson VP. Monolithic CAD/CAM lithium disilicate versus veneered Y-TZP crowns: comparison of failure modes and reliability after fatigue. Int J Prosthodont. 2010;23(5):434–442. 14. Vafiadis D, Goldstein G. Single visit fabrication of a porcelain laminate veneer with CAD/CAM technology: a clinical report. J Prosthet Dent. 2011;106(2):71-73.

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CLINICAL

Restoring the edentulous maxilla Dr. Ross Cutts discusses a cost effective way to restore the edentulous upper arch Case study This case demonstrates the successful use of Straumann Locator® abutments in the atrophic anterior maxilla.

hen restoring the edentulous maxilla, there are many different methods dictated by various implant systems. Each differs in cost and the number of implants required to support the restoration – and more importantly, in how well-supported they are by sufficient levels of clinical research that demonstrate long-term success rates. Therefore, it can be difficult selecting the most suitable system and methods for your patients. The Straumann Locator abutment was launched in its current form in 2009, following years of research and development, and many clinicians haven’t looked back since. The ease of use – both in the practice and in the laboratory – make for a very simple yet successful and safe method for fixating an upper overdenture with a cement-retained restoration (Figure 1).

Figure 1: Locator abutment

Figure 2: Failing natural dentition

Figure 3: Restored natural dentition

Figure 4: Lack of soft tissue support

Figure 5: Soft tissue replaced with pink acrylic

Figure 6: Previously extracted full arch, showing emphasized bone loss with a thin flabby ridge

especially for those who are used to a loose, removable prosthesis, or who have a severe gag reflex. These types of patients will often want to avoid a removable denture-type restoration. Loose dentures are often caused, or a result of bony resorption of the denturebearing area. Most bone resorption occurs 1 to 3 years post-extraction, but it never really stops – it merely decreases in rate. It is this lack of bone structure that often means fixed prostheses are unavailable to the patient without the need for extensive bone-grafting procedures.

Patients with a hopeless residual dentition are also more likely to favor a fixed prosthesis for rehabilitation (Figures 2 and 3). However, it is important that we have an open and honest discussion with our patients regarding the limitations of a fixed prosthesis. As these restorations are far more demanding in terms of maintenance, patients with a failed natural dentition are often not appropriate, because if fixed prostheses are not properly maintained and cared for, this can lead to problems 5 to 10 years post-rehabilitation.

Patient’s perspective When deciding upon the design of a full arch maxillary prosthesis, there are often various options available. However, any prosthesis must be comfortable, retentive, functional, and esthetic with good appearance of both hard and soft tissues. The patient’s speech and taste must not be impaired and, at all times, we must consider how all of these factors can influence his/her self-esteem. From the patient’s perspective, a fixed restoration is sometimes preferred,

Dr. Ross Cutts is the principal dentist at Cirencester Dental Practice, Gloucestershire, England. Having graduated from Guy’s Hospital, Dr. Cutts is a general dentist with special interests in advanced restorative procedures and dental implants. He has been awarded the highly regarded Diploma in Implant Dentistry from the Royal College of Surgeons, London, and is a committed member of the International Team for Implantology (ITI), where he is a study club director and clinical mentor. He regularly holds implant courses at his Cirencester practice, and lectures nationwide on a variety of topics at different levels. He is also a member of the Association of Dental Implantology, the British Academy of Cosmetic Dentistry, and the Royal College of Surgeons.

20 Implant practice

Volume 6 Number 5

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CLINICAL

Figure 7: Recently extracted teeth next to overdenture locators

Figure 8: Edentulous maxilla showing marked resorption and knife-edge nature due to long-term tooth loss

Figure 9: Edentulous maxilla with opposing teeth following recent extraction

Figures 10 and 11: The atrophic maxilla with evidence of pronounced incisive papilla, showing extensive maxillary atrophy and opposing lower arch model

Figures 12 and 13: Surgical implant placement in the narrow ridge with simultaneous-guided bone regeneration to increase ridge width

Careful planning Often in cases of moderate maxillary atrophy, there is a large deficiency in hard and soft tissue volume. This means that a fixed prosthesis can have long proclined teeth, which is not necessarily esthetically or phonetically successful. Careful planning of the final appearance of the prosthesis is therefore crucial. 22 Implant practice

Often this discrepancy can be rectified with an overdenture-type restoration, allowing the appropriate choice of tooth size. In addition, the use of pink acrylic to replicate the support for lips and missing keratinized tissue will create highly esthetic results (Figures 4 and 5). Itâ&#x20AC;&#x2122;s worth noting that if teeth have been recently extracted to become a full

arch, the fixed solution is likely to create more esthetic results. Similarly, the longer the teeth have been missing, the greater the chance of substantial hard and soft tissue loss (Figures 6 and 7).

Successful full arch rehabilitation As it has been well documented that an edentulous maxilla opposed by a Volume 6 Number 5

CLINICAL BONE GRAFTING SOLUTIONS

Figure 14: Exposure of the implant fixtures and placement of Straumann Locator abutments

Figure 15: The pick-up impression copings attached to the Straumann Locator abutments

complete natural lower dentition causes severe maxillary atrophy, it’s important that we evaluate interarch relationships in the planning stage, and discuss this with patients, stressing that early intervention of treatment will greatly reduce the need for complicated grafting procedures (Figures 8 and 9). However, we do know that there is scientific evidence, which clearly shows that either removable or fixed implantsupported rehabilitation of an edentulous jaw can significantly improve a patient’s quality of life (Wismeijer, et al., 1992; 1995; 1997). We understand that in the maxilla we have less favorable bone quality and quantity than in the mandible, so our options are reduced. Weng, et al., (2007), clearly showed that placing only two implants in the anterior maxilla is a risky procedure with poor long-term survival and success rates. In light of this research, we now know that placing four maxillary implants is the minimum for a successful full arch rehabilitation. If we use locator abutments such as Straumann Locator abutments – a relatively more cost-effective and straightforward method for retaining an

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Volume 6 Number 5 Implant practice 23

CLINICAL

Figure 16: The laboratory-made model

Figures 17 and 18: The overdenture and lower acrylic denture fabricated in a traditional manner

Figure 19: The healed soft tissue around the locator abutments

implant overdenture â&#x20AC;&#x201C; it can offer lifechanging results for patients.

Conclusion

Figures 20 and 21: The final postoperative photographs, demonstrating good hard and soft tissue support

24 Implant practice

The benefits of locator abutment-retained overdentures are vast. As well as providing a very cost-effective method for restoring a full arch prosthesis, they offer ease of maintenance and repair in the future due to removable nature, and can replicate both hard and soft tissue loss, producing highly esthetic results. However, as with all treatments, they are not suitable for all patients. Some patients may not psychologically want this treatment modality and instead will request a fixed solution. There are many different ways to restore the edentulous maxilla each with varying degrees of long-term clinical research behind them. Further evidencebased options can be found in the book from the International Team for Implantology (ITI) Treatment Guide 4. IP Volume 6 Number 5

CLINICAL

Bridge construction in the anterior tooth area of the maxilla Dr. Steffen Wolf juggles esthetic requirements to produce pocket-friendly results for a patient with very particular needs

67-year-old patient presented in the dental practice for implant consultation. The medical history revealed some specific conditions, in particular an allergy to dental metals. At this time, prosthetic restoration in the area to be reviewed consisted of an insufficient crown block in the anterior tooth area corresponding with an attachment-monoreducer-combination denture. Significant loosening of the abutment teeth in the anterior tooth area was found, and posts and cores that had already loosened several times were found in the insufficiently filled root canals, probably due to monoreducer leverage (Figure 1). The prognosis for conservative restoration was thought to be extremely poor. During the consultation, the patient expressed a preference for an implant solution. The patient also specified a cost limit.

Procedure Treatment planning For optimum assessment of the initial situation and subsequent treatment planning, after assessing the clinical situation, a panoramic radiograph with intraoperative assessment of the implant site was favored as method of choice (Figure 2). This would take into account a minimally invasive therapeutic concept of surgical augmentation. Surgical planning involved the extraction of non-restorable teeth and immediate placement of a Straumann® bone level implant in the region. Two implants were to be inserted in the premolar region. We planned to expand the bone with a bone-spreading procedure and to use two Straumann Standard Plus Narrow Neck

Steffen A. Wolf, Dr. med. Dent., MSc (DGI) is in private practice in Halberstadt, Germany. He graduated from the Clinic for Oral and Maxillofacial Surgery at the Free University of Berlin. He received his MSc in oral implantology in 2010.

26 Implant practice

Figure 1

Figure 2

Figure 3

Figure 4

Crossfit® implants (NNC) made from the implant material Roxolid® if the transversal bone at the site was compromised. The prosthetic restoration needed to fulfill the requirements of an allergyfree dental prosthesis. The prosthetic construction was to be manufactured with the Straumann® Cares® system in the inhouse dental master laboratory.

for implant augmentation in the central left incisor area. Once the implant site had been carefully prepared by means of bone spreading (Figure 4) and the final implant cavities drilled, the prepared bone was meticulously examined with a bulbous probe and gauges from the Straumann surgery set. Two NNC implants were then inserted in the controlled, intact bony structures (Figure 5). The NNC SLActive® implant (3.3 mm x 14 mm) was inserted in the region of the first premolars. The 3 mm reduced height NNC healing cap was used for both the implant seal as well as primary soft tissue conditioning. We decided to use NNC SLActive implant (3.3 mm x 12 mm) and the identical 3 mm closure screw for the region of the second premolars. Once this stage of the operation was complete, alveolar implant restoration in the central anterior tooth area was performed. The immediate implantation of a Straumann bone level implant (4.1 mm x 10 mm), fitted with a 0.5 mm regular Crossfit (RC) closure screw, was then performed. The alveolar walls were undamaged, and primary implant stability was good. As a sufficient amount of autologous bone chips had been gained from maxillary

Surgical procedure Due to the impaired vasoconstriction, anesthetization was adrenaline-free with local anesthetic and one subsequent injection during the operation. Extraction of the middle and left lateral incisors was carried out without complication. A central crestal incision was made with little crestal bone denudation and no relief incision. The anticipated reduction of the transverse bone then became clearly visible, and as the method of choice, the bone-spreading procedure was performed, and two NNC implants were placed (Figure 3). The insertion site in the region of both left premolars was prepared by manually shaving the bone until an even bone plateau had been created. The autologous bone chips gained here were later used

Volume 6 Number 5

the various fixations of the implant insertion aids was easily possible (Figure 7). To assess postoperative treatment success – in particular with regard to adequate periimplant bone coverage – a control DTV was made on which the correct implantbone relation could be verified. This meant additional augmentation measures could be safely dispensed with (Figure 8). Perioperative medication included antibiotic endocarditis prophylaxis; the patient was also given postoperative pain medication for 1 day. Prosthetic restoration Following integration of a provisional denture and complication-free healing time, individual gingival recontouring then was performed in the anterior tooth area. To facilitate continued wearing of the

provisional denture during the gradual process of soft tissue conditioning, our dental laboratory prepared and shortened an RC temporary abutment with hard polymer plastic, individualized to the area of the soft tissue profile (Figures 9-11). The impression for the individual incisor abutment was made with a gingival former on the basis of an RC impression post to match the individual impression post. The NNC implants were incorporated into the impression (Figure 12) with the ready-made NNC impression posts. On account of the patient’s allergy and in consideration of the esthetic aspect, we decided to use titanium abutments (Figure 13) as well as a zirconium-based bridge framework with ceramic veneering (Figures 14 and 15). The titanium abutments and zirconium bridge were constructed

Figure 5

Figure 6

Figure 7

Figure 9

Figure 8

Figure 10

Volume 6 Number 5 Implant practice 27

CLINICAL

crest levelling in the premolar area, this was used as volume filler for the alveolar augmentation. The distance between the body of the implant and the alveolar wall that required augmentation was 1–2 mm. Augmentation was vertical with slight overlap by means of a platform switch at the implant shoulder. Alveolar restoration of the lateral incisor was performed using a collagen matrix. Suture closure in the area of the anterior tooth implant resulted in complete coverage of the augmentation area: the closure screw lay only minimally exposed approximately 3 mm below the mucogingival soft tissue. Soft tissue closure at the NNC closure screw supported transgingival healing of the implant (Figure 6). Intraoperative haptic assessment of

CLINICAL

Figure 11

Figure 12

Figure 13

Figure 14

Figure 15

Figure 16

Figure 17

Figure 18

virtually in CAD/CAM procedure with the Straumann CS2 scanner in our own dental laboratory, and the framework was made at the Straumann Milling Centre in Leipzig, Germany. Because of the interocclusal distance, the decision was to use an anatomicallyformed zirconium morsal surface, which could be optimally prepared with the Straumann Cares system processing software during the construction phase. In consideration of the esthetic aspect, 28 Implant practice

the individual veneer was mostly in the vestibular region (Figures 16 and 17). A postoperative control X-ray confirmed the correct positioning of the prosthetic components (Figure 18).

Conclusion The patient is extremely satisfied with both the result and its cost-effectiveness. The appropriate design of the emergence profile, titanium abutment, and zirconium bridge entirely fulfill the esthetic

requirements of the visible areas. In the event of later loss of the second molars, the patient wishes to undertake prosthetic restoration of the ensuing end gap situation. As shown here, the use of NNC implants can lead to very positive results in cases where the bone is compromised and when esthetics or the use of different CAD/CAM materials need to be considered. IP

Volume 6 Number 5

CASE STUDY

Hybrid dentures provide a practical solution Dr. Daniel Domingue illustrates a case treated with fixed-detachable dentures

ccording to the American Association of Oral and Maxillofacial Surgeons, “69% of adults ages 35 to 44 have lost at least one permanent tooth…[and] by age 74, 26% of adults have lost all of their permanent teeth.”1 Every patient’s dentition is different, and each patient requires an individualized treatment plan. Hybrid dentures, also called fixed-detachable dentures, present a solution that combines both function and esthetics. This method is generally used when there is bone loss, possibly due to long-term denture wear. The bridge is attached to implants providing teeth and artificial gums. The following case study illustrates where this type of implant solution resulted in a happy patient and an effective treatment. A female patient came to our office for a new patient exam. She had a denture for 25 years and was unhappy with her limited chewing ability, phonetics, and the large range of denture mobility. A panoramic X-ray showed adequate height of bone (Figure 1), but clinical finding supported a narrow ridge (Figure 2). A CBCT scan (GXCB-500 HD, Gendex) was taken of this patient. The scan verified atrophic anterior mandible width, Class III bite, and insufficient height of alveolar ridge in posterior segments

Daniel Domingue, DDS, FICOI, MICOI, DICOI, AFAAID, DABOI/ID, graduated from Louisiana State University in Baton Rouge in 2003 and obtained his DDS degree from the LSU School of Dentistry in New Orleans in 2007. After dental school, he completed 3 years in advanced training at Brookdale University Hospital and Medical Center in New York City, and he served as Chief Resident of the Dental and Oral Surgery Department. His training included 1 year in General Practice Residency and 2 years in Dental Implantology Fellowship. During these years, he was awarded the Certificate of Achievement from the American Academy of Implant Dentistry for outstanding leadership in Implant Dentistry, a Fellowship from the International Congress of Oral Implantologists, and an Associate Fellowship of the American Academy of Implant Dentistry in New York City. After residency and during his first years in private practice, Dr. Domingue was awarded the Diplomate from the American Board of Oral Implantology in Las Vegas, Nevada. He was also recognized as the youngest recipient of this award in the world. Dr. Domingue was later given a Mastership and Diplomate award from the International Congress of Oral Implantology in New York City for his outstanding work in Implant Dentistry and a Fellowship award from The American Academy of Implant Dentistry in Phoeniz, Arizona. Dr. Domingue is a member of the American Dental Association as well as the Acadiana District Dental Association, and American Academy of General Dentistry, where he is the current president.

30 Implant practice

Figure 1

Figure 2

Figure 3

Figure 4

Figure 5

Figure 6

(Figures 3-6). The decision was made to remove the top 10 mm of bone in the anterior region revealing healthy dense bone and graft the posterior region with OraGRAFT® (Salvin® Dental Specialties/ LifeNet Health®) mineralized freeze-dried bone allograft with calcium sulfate and gentamycin. Under local anesthetic, a full thickness incision was placed releasing buccal and lingual tissues (Figure 7). Then, 10 mm of bone was removed from the anterior segment with a surgical high speed drill and copious irrigation (Figures 8 and 9). Also, six osteotomies were made: four anterior to mental foreman and two posterior (Figure 10). All BioHorizons® tapered internal implants were inserted at 50Ncm in the following locations (Figures 11-16). #19 - 4.6 x 9 #21 - 3.8 x 12 #23 - 3.8 x 15 #26 - 3.8 x 15 #28 - 3.8 x 12 #30 - 4.6 x 9 Healing abutments were placed and sutured with interrupted 3.0 chromic gut

sutures. After tissues were approximated around implants properly, the abutments were removed, and cover screws were placed to idealized soft tissue for prosthetics (Figure 17). Careful manipulation for her peri-implant tissue to promote proper healing was the most important step in this surgical procedure. The patient did not wear her denture during the entire healing period. After 12 weeks (Figure 18), the tissues looked great, so the implants were uncovered, and healing abutments were placed (Figure 19). Impressions were taken of the tissues and implants (Figure 21). A verification jig was fabricated to ensure implant position in the prosthetic work up. The lab fabricated a custom framework for a hybrid denture taking into account her skeletal Class III profile (Figure 20). The hybrid denture was delivered, torqued, and access holes were covered. Then the patient’s bite was verified and adjusted (Figures 22 and 23). One-year post prosthetics, the patient has chewed a piece of gum every day since we delivered. Chewing ability has dramatically increased; denture mobility Volume 6 Number 5

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CASE STUDY

Figure 7

Figure 8

Figure 9

Figure 10

Figure 11

Figure 12

Figure 13

Figure 14

Figure 15

Figure 16

Figure 17

Figure 18

Figure 19

Figure 20

Figure 21

Figure 22

Figure 23

Figure 24

and phonetics are no longer problems, and for the first time, the patient is in a Class 1 occlusion, thanks to the alveolarplasty and the hybrid denture combination (Figure 24). The patient has lost weight, primarily due to a healthier diet and happier overall selfimage. While traditional dentures work

for some, hybrid dentures are often a good option when the patient needs both hard and soft tissue replacement. Additionally, hybrid dentures also solve the patientâ&#x20AC;&#x2122;s problems of inconvenience or embarrassment when having to remove his/her own dentures. This patientâ&#x20AC;&#x2122;s hybrid dentures promoted a more functional

solution to traditional dentures while also providing a more natural look. IP

32 Implant practice

Reference American Association of Oral and Maxillofacial Surgeons. Dental Implants. http://www.aaoms. org/conditions-and-treatments/dental-implants/. Accessed September 10, 2013.

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CONTINUING EDUCATION

Missing lateral incisors: overcoming the problem of insufficient space Dr. Ian Hallam presents a case study providing a solution for a patient who does not wish to undergo orthodontic treatment, using narrow implants History This 36-year-old school teacher was referred by a colleague for an implant consultation. She presented with a missing upper left lateral incisor, which had recently been replaced by a partial acrylic denture following fracture of the pontic from a porcelain bridge fitted to the upper left canine. The patient explained that both upper lateral incisors had been congenitally absent and, as a teenager, she had a course of orthodontic treatment to move the central incisors mesially to close a median diastema. This was followed by having a two-unit cantilever bridge fitted onto each canine to replace the missing lateral incisors. In recent years, the bridges had repeatedly fallen off or fractured, and the patient wished to have something more permanent.

Educational aims and objectives The aim of this article is to demonstrate the importance of allowing both the patient and the clinician time to decide on the optimum treatment protocol in challenging cases. Expected outcomes Correctly answering the questions on page 38, worth 2 hours of CE, will demonstrate the reader can: â&#x20AC;˘ See the necessity of offering various options to the patient. â&#x20AC;˘ Learn about treatment options for patients with space constraints. â&#x20AC;˘ Gain an understanding of how to use narrow diameter implants for a patient who does not wish to undergo orthodontic treatment.

Figure 1: Anterior view showing missing lateral incisors

Figure 2: Right side view showing missing lateral incisor

Examination On examination, the bridge fitted to the upper right canine was a porcelain veneer with a pontic to replace the right lateral incisor, and the one fitted to the left canine was a full coverage porcelain crown, with the pontic replacing the lateral incisor fractured off. The central incisors had veneers, which were esthetically poor. I took photographs and intraoral radiographs (Figures 1-5). The periapical radiographs showed the central incisors to be tilted mesially towards the midline. The space between the roots of the central incisors and canines was only 3 mm-3.5

Ian Hallam, MBE, BDS, qualified in dentistry at Birmingham University in 1971 and worked as an associate in practices in Nottingham, Derby, Chichester, and Havant in Hampshire, England while pursuing a sporting career as a racing cyclist. He was a double Olympic medalist, World Championship medalist and triple Commonwealth Champion and was awarded an MBE for services to cycling in 1978. He owns two private practices in Petersfield, Hampshire concentrating his time on his cosmetic practice, Meon Dental. He is also a visiting clinical teacher in facial esthetics for the MSc course in Esthetics at Kings College London. He can be contacted at www.meondental.com and www. meonface.com.

34 Implant practice

mm (Figures 4 and 5). The treatment options were explained to the patient, and in view of the limited space, it was explained that it would not be possible to place implants unless orthodontic treatment was carried out first.

Second consultation At the second consultation appointment, the patient stated very clearly that, having had orthodontic treatment as a teenager, she did not want to undergo further orthodontic treatment. Her treatment options were explained as follows: 1. Orthodontic treatment to move the central incisors bodily towards the midline in order to open the space, followed by placing implants to replace the missing lateral incisors 2. Replacement all-ceramic two-unit bridges fitted to the upper canines to replace the missing lateral incisors 3. Removing the pontic from the upper right canine bridge and making a chrome/cobalt denture 4. Replacement of the existing veneers on the central incisors and, in options 1 and 3, also replacing the veneer on

Figure 3: Left side view showing missing lateral incisor

the upper right canine and the crown on the upper left canine. Her oral hygiene was also poor, and it was explained that improving this prior to any treatment commencing was essential. The patient was advised to take time to consider the options, and a further consultation appointment was set.

Third consultation The patient returned for a third consultation and explained that she had decided to go ahead with bridgework. However, I was keen to allow her further time to consider this option before going ahead, and so it was suggested that she have a consultation with an orthodontist to consider what would be involved in orthodontic treatment. She accepted this and was subsequently Volume 6 Number 5

Figure 5: Radiograph upper left lateral incisor showing measurements

referred to a local consultant orthodontist, and a further consultation appointment was made. Meanwhile, a local consultant oral surgeon was contacted to discuss the case. It was decided that if very narrow implants were used, it may be possible to angle them in a more palatal direction in order to avoid the roots of the adjacent teeth, still leaving sufficient bone between the implants and root surfaces. A reply was subsequently received from the orthodontist who explained that moving the teeth sufficiently to create space between the roots would involve fixed orthodontic treatment and would probably take 2 years to complete.

Treatment two: provisional crowns

Fourth consultation At this visit, the patient was adamant that she did not want to go ahead with a long course of orthodontic treatment. However, when it was explained that implant placement using the narrowest available was a possibility, she was very keen to go ahead. The proviso was stressed to the patient that the procedure would be abandoned if it was felt that the implants were too close to the roots of the adjacent teeth. She accepted this and made the necessary appointment.

Figure 6: Radiograph to check initial angulation

Treatment one: implant placement Firstly, alginate impressions were taken to add the upper right lateral incisor to the existing partial denture. When this was returned, the upper right bridge was

Figure 7: Radiographs of implants in position

Upon review, everything was symptomless, and the gum had healed well (Figures 8-10). The possibility of replacing the central incisor veneers, as well as the veneer and crown on the canines, was discussed. The proposal to fit provisional abutments and crowns on the implants in order to manipulate the soft tissues was also explained. An appointment was made for 1 month later. At that visit, the patient had decided that she wished to have the central incisor veneers replaced, but costs prohibited her from going ahead with replacing the restorations on the canines, the esthetics of which she was happy to accept. Intraoral photographs were taken, including ones with shade tabs in position, and emailed to the technician (Figure 11). Implant-level impressions were then taken and sent to the technician to construct provisional

Volume 6 Number 5 Implant practice 35

CONTINUING EDUCATION

Figure 4: Radiograph upper right lateral incisor showing measurements

divided mesially to the canine to remove the lateral incisor pontic, leaving the veneer intact, and the denture fitted. A series of hygienist appointments was arranged in order to improve the periodontal condition. At the implant appointment, 10mg of Midazolam was administered for intravenous sedation, along with 0.6mg Atropine to reduce saliva production. After giving local anesthetics in the sites, a small flap was raised on each side and a pilot bur, angled from the crest of the ridge in a palatal direction, was used. Diagnostic periapical radiographs were taken to gauge the angulation between the adjacent roots (Figure 6). The angulations were satisfactory, so the osteotomy preparations were made before placing two 3 mm x 15 mm XiVE速 S Dentsply Friadent implants. The bone was quite soft, but there was reasonable primary stability with both implants. Gingival formers were fitted. The procedure was completed by placing 0.25 grams of Bio-Oss速 (Geistlich) small granule spongious bone over the labial plate of bone to compensate for the horizontal bone loss resulting from the absence of the incisor teeth, and covering this with a resorbable collagen membrane before closing and suturing the flaps. Further radiographs were taken to confirm the implant positioning (Figure 7). A suture removal appointment was made and a review appointment for 3 months later.

CONTINUING EDUCATION

Figure 8: After implant placement – anterior view

Figure 9: After implant placement – right side

Figure 10: After implant placement – left side

Figure 12: Provisional crowns on model – note labial position of access holes Figure 11: Shade taking for provisional crowns

Figure 13: Provisional abutment fitted UR2

Figure 14: Provisional abutment fitted UL2

Figure 15: Provisional crowns fitted

crowns. These were fitted 2 weeks later (Figures 12-16). It can be seen that the access holes are on the labial surfaces, which reflects the palatal angulation of the implants. The patient was reviewed 1 month later, and quite a lot of inflammation was noted. The importance of meticulous oral hygiene was stressed, and a further hygienist appointment arranged. The provisional crown on the right lateral incisor was removed and composite added to the mesiolabial surface to further contour the gingiva in order to create an interdental papilla. Further photographs were taken (Figure 16) where blanching of the gum can be seen.

and angulation. It was decided to reshape them and prepare a mock-up by adding composite to give the desired esthetics (Figures 18 and 19). The veneers on the central incisors were then removed and the teeth reprepared for new veneers. Implant-level impressions were taken, incorporating impressions for the veneers, the provisional crowns refitted, and temporary veneers fitted to the central incisors. Photographs of the shade tabs were taken to email to the technician. The final definitive crowns were due to be fitted 2 weeks later, but the patient’s oral hygiene was still not good, so a further hygienist appointment was arranged. The crowns were not fitted. The definitive crowns were eventually fitted 4 weeks later, along with the central incisor veneers (Figures 20-24).

Treatment three: definitive crowns This appointment was to replace the central incisor veneers and take impressions for the definitive crowns on the implants. The gingival contours were now good, although again the oral hygiene was disappointing (Figure 17). Local anesthetics were given, and before preparing the teeth, the central incisors were assessed for shape, length, 36 Implant practice

Discussion This was a challenging implant case, and it was essential that the patient was given time to consider the treatment options. Since she was keen to have implants, it was

Figure 16: Provisional crown UR2 after adding composite to contour the papilla

Figure 17: Provisional crowns at review showing correct gingival contour

felt that she should consider orthodontic treatment in order to make this possible. It was also important that I had time to consider the treatment in order to decide whether I was prepared to go ahead with implant treatment. I felt that it was important to seek another opinion before making my decision about offering implants, and I was reassured by my discussion with the oral surgeon. The patient would have accepted replacement bridges, but implants were her first choice, and I was pleased to be able to provide them in spite of the challenges that I faced.

Conclusion The ideal treatment in this case would have Volume 6 Number 5

Figure 18: Mock-up of central incisors Figure 20: Definitive implant crowns and veneers fitted

Figure 21: Crowns fitted left side view

Figure 22: Crowns and veneers fitted – occlusal view

Figure 23: Radiographs of completed case

Figure 24: Completed case – a happy patient

References Buser D, Martin W, Belser UC. Optimizing esthetics for implant restorations in the anterior maxilla: anatomic and surgical considerations. Int J Oral Maxillofac Implants. 2004;19(suppl):43-61. Eger DE, Gunsolley JC, Feldman S. Comparison of angled and standard abutments and their effect on clinical outcomes: a preliminary report. Int J Oral Maxillofac Implants. 2000;15(6):819-823. Hebel K, Gajjar R, Hofstede T. Single-tooth replacement: bridge vs. implant-supported restoration. J Can Dent Assoc. 2000;66(8):435-438. Jivraj S, Chee W. Treatment planning of implants in the aesthetic zone. Br Dent J. 2006;201(2):77-89. Kois JC, Kan JY. Predictable peri-implant gingival aesthetics. surgical and prosthodontic rationales. Pract Proced Aesthet Dent. 2001;13(9):691-698, 700, 721-722.

involved orthodontic treatment to create sufficient space to be able to place implants in a conventional position. However, since the patient was not willing to accept this, I had to consider an alternative solution. I was able to overcome the problem of limited space by placing the implants at an unconventional angulation. I was not totally happy with the final result in this case because the patient’s oral hygiene was not satisfactory, in spite Kois JC. Predictable single-tooth peri-implant esthetics: five diagnostic keys. Compend Contin Educ Dent. 2004;25(11):895-896, 898, 900, 906-907. Kokich VG. Maxillary lateral incisor implants: planning with the aid of orthodontics. J Oral Maxillofac Surg. 2004;62(9 suppl 2):48-56. Kokich VO Jr, Kinser GA. Managing congenitally missing lateral incisors. Part 1: Canine substitution. J Esthet Restor Dent. 2005;17(1):5-10. Reddy MS, O’Neal SJ, Haigh S, Aponte-Wesson R, Geurs NC. Initial clinical efficacy of 3-mm implants immediately placed into function in conditions of limited spacing. Int J Oral Maxillofac Implants. 2008;23(2):281288. Richardson G, Russell KA. Congenitally missing maxillary lateral incisors and orthodontic treatment considerations for the single-tooth implant. J Can Dent Assoc. 2001;67(1):25-28. Romeo E, Lops D, Amorfini L, Chiapasco M, Ghisolfi

of the best efforts of our hygienist. We are continuing to work with the patient to improve this. I would also like to have replaced the restorations on the upper canines to give a better esthetic result, but the patient was not able to afford this treatment. However, the outcome was very satisfactory, and the patient was absolutely delighted with the functional and esthetic result. IP

M, Vogel G. Clinical and radiographic evaluation of small-diameter (3.3-mm) implants followed for 1-7 years: a longitudinal study. Clin Oral Implants Res. 2006;17(2):139-148. Saadoun AP, LeGall M, Touati B. Selection and ideal tridimensional implant position for soft tissue aesthetics. Pract Periodontics Aesthet Dent. 1999;11(9):1063-1072, 1074. Sethi A, Kaus T, Sochor P. The use of angulated abutments in implant dentistry: five-year clinical results of an ongoing prospective study. Int J Oral Maxillofac Implants. 2000;15(6):801-810. Tuna SH, Keyf F, Pekkan G. The single-tooth implant treatment of congenitally missing maxillary lateral incisors using angled abutments: A clinical report. Dent Res J (Isfahan). 2009;6(2):93-98. Winkler S, Boberick KG, Braid S, Wood R, Cari MJ. Implant replacement of congenitally missing lateral incisors: a case report. J Oral Implantol. 2008;34(2):115-118.

Volume 6 Number 5 Implant practice 37

CONTINUING EDUCATION

Figure 19: Checking incisal levels with patient smiling

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Missing lateral incisors: overcoming the problem of insufficient space 1. (During the first examination) The treatment options were explained to the patient, and in view of the limited space, it was explained that it would not be possible to place implants unless orthodontic treatment was carried out _____. a. after implant placement b. after fitting a new two-unit cantilever bridge c. as well as periodontal therapy d. first 2. (In this case) It was decided that if very narrow implants were used, it may be possible to angle them in a more ______ direction in order to avoid the roots of the adjacent teeth, still leaving sufficient bone between the implants and root surfaces. a. facial b. palatal c. mesial d. distal 3. A reply was subsequently received from the orthodontist who explained that moving the teeth sufficiently to create space between the roots would involve fixed orthodontic treatment and would probably take ______to complete. a. 1 year b. 1.5 years c. 2 years d. 2.5 years

38 Implant practice

4. The proviso was stressed to the patient that the procedure would be abandoned if it was felt that the implants were _______. a. too close to the roots of the adjacent teeth b. too costly c. too close to the upper left lateral incisor d. a worse option than a bridge

8. (At the third treatment) Local anesthetics were given, and before preparing the teeth, the central incisors were assessed for ______. a. shape b. length c. angulation d. all of the above

5. Firstly, _______were taken to add the upper right lateral incisor to the existing partial denture. a. radiographs b. 3D scans c. extraoral images d. alginate impressions

9. The ideal treatment in this case would have involved ______ to create sufficient space to be able to place implants in a conventional position. a. orthodontic treatment b. endodontic treatment c. bone level implants d. unconventional angulation

6. A series of _______was arranged in order to improve the periodontal condition. a. grafting procedures b. hygienist appointments c. provisional crowns d. veneers 7. Diagnostic periapical radiographs were taken to gauge _____between the adjacent roots. a. bone loss b. gingival loss c. the angulation d. the amount of restorable collagen membrane

10. I (Dr. Hallam) was able to overcome the problem of ______ by placing the implants at an unconventional angulation. a. poor dental hygiene b. failing central incisor veneers c. limited space d. too much space

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Dental rehabilitation of a 6-year-old boy with a rare tumor of the mandible Drs. T. Nyunt, K. George, H. Chana, and G.I. Smith discuss treatment and maintenance of an unusual pediatric case Abstract Neuroblastoma is the most common extracranial pediatric solid tumor and is derived from neural crest cells. It usually forms a mass in the adrenal medulla or anywhere along the sympathetic neural chain, with 50% of cases having distant masses detected at the time of diagnosis. We present a case of a 6-year-old boy who was diagnosed with an extremely rare form of a primary neuroblastoma in the mandible and discuss his immediate and long-term management.

Educational aims and objectives This article aims to show the treatment of a rare tumor of the mandible. Expected outcomes Correctly answering the questions on page 42, worth 2 hours of CE, will demonstrate the reader can: • Define neuroblastoma and its effect on the dentition. • Determine treatment for this rare condition from a dental standpoint. • Realize a way to treat this form of the condition using implants.

Introduction The management of a 6-year-old boy with a rare primary neuroblastoma of the mandible is discussed. This required a multidisciplinary team approach involving pediatric medical oncology, surgical treatment, and then adjuvant chemotherapy. Subsequent dental rehabilitation was with an implant-retained prosthesis.

Case report A previously fit and well 6-year-old boy presented to the department of maxillofacial surgery in June 2009 with a 3-month history of an exophytic lesion of the anterior mandible. Investigations included an incisional biopsy, fine needle aspiration of lymph nodes, bone scans, computed tomography (CT) from the skull base to the pelvis, ultrasound scan of the abdomen, and bone marrow aspirate. Figure 1 shows an axial view of the mandible. A diagnosis of Stage IV mandibular neuroblastoma was made. There was no evidence of distant metastatic spread. The case was discussed in a regional head and neck multidisciplinary team meeting (MDT), and a treatment plan was formulated. This consisted of rapid COJEC (cyclophosphamide, vincristine, carboplatin, etoposide protocol) therapy, an autologous bone marrow transplant, surgery, and adjuvant chemotherapy. The child underwent a total of eight cycles of chemotherapy preoperatively. 40 Implant practice

Figure 1: Axial CT scan of mandible

Figure 2: Excised lesion showing the expansion of the mandible

This resulted in a reduction in the size of the lesion prior to surgery. Following this, he underwent a mandibulectomy from the lower right 6 to the lower left E with resection of the overlying soft tissue (Figures 1 and 2) and a bilateral selective neck dissection (SND) levels I-III. The resulting defect was reconstructed with a left composite fibula free flap that provided both bone for mandibular reconstruction and skin for the oromucosal rehabilitation (Figures 3 and 4). Histopathological examination showed residual neuroblastoma bilaterally in the mandible and invading adjacent soft tissue. Six of 40 lymph nodes were positive, with one having extracapsular spread giving a pathological classification of pT4N2cM0. Therefore, a further course of high dose chemotherapy was administered. Clinical follow-up of the patient, including surveillance CT scans, showed that the patient remains well, and there was no evidence of recurrence.

Dental rehabilitation Four

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implants of 3.5 mm in diameter and 10 mm in length were placed in the premolar and lateral incisor region of the mandible. The fasciocutaneous component of the free flap has been positioned to enable the implants to emerge through non-mobile, keratinized mucosa. Healing abutments were placed. NobelActive Implants were chosen to facilitate early loading and prosthetic rehabilitation. Two weeks later, a temporary removable lower partial denture was constructed. A definitive removable lower denture was made 2 months later (Figure 5). Unfortunately, the retention was reduced as the denture proved to be a novelty for this young boy, which led to repeated removal to show his classmates. Abutments were changed, and a fixed prosthesis provided. Six months review confirmed that the fixed prosthesis remains secure with good esthetics, function, and oral hygiene (Figure 6).

Discussion Neuroblastoma is the most common extracranial solid tumor with a prevalence of 7% of all childhood malignancies. The peak Volume 6 Number 5

Figure 4: Intraoral view of the vascularized free flap immediately post-op

Figure 5: An orthopantamogram showing the position of the dental implants and the removable partial denture constructed 2 weeks postoperatively

Figure 6: Shows good facial form 6 months postoperatively.

incidence is at 2 years of age, and in 1-2% of cases, there appears to be linked family history of the disease1. The prognosis of this disease is highly dependent on staging. The diagnosis of primary neuroblastoma is very rare, and only eight cases have been reported in the literature2. The decision was made by the MDT to continue to treat it with surgery and adjuvant chemotherapy. A vascularized fibula free flap was chosen as this has proven to result in a reliable outcome with sufficient bone density and volume for placement of osseointegrated dental implants. There will be future changes to his occlusion with continued growth and development. The majority of the mandibular growth occurs in the mandibular condylar growth plates that have not been affected. There is likely to be appositional growth that will result in burial of the reconstruction plate over time. In this case, it could be argued that early placement of dental implants may have compromised the construction of the final implant-retained denture as the implants may become positioned further lingually in relation to the maxilla and the edentulous ridge. The study by Schmelzeisen, et

al., found that seven out of nine patients with immediate implants required further implant placement.3 This may apply in this case as the child grows, however there have been improvements in the design and osseointegration of dental implants since that study. Bone grafting and orthognathic surgery could also have a future role once growth has been completed to maintain esthetics and function. The risks of complications with removal of an embedded reconstruction plate will have to be considered.4 IP

References 1. Lanzkowsky P. Manual of Pediatric Hematology and Oncology. 5th ed. New York, NY: Elsevier; 2011. 2. Tang PH, Cohen PA. Primary neuroblastoma of the mandible. Singapore Med J. 2009; 50(1):e5e7. 3. Schmelzeisen R, Neukam FW, Shirota T, Specht B, Wichmann M. Postoperative function after implant insertion in vascularized bone grafts in maxilla and mandible. Plast Reconstr Surg. 1996;97(4):719-725. 4. Phillips JH, Rechner B, Tompson BD. Mandibular growth following reconstruction using a free fibula graft in the pediatric facial skeleton. Plast Reconstr Surg. 2005;116(2):419-426.

Volume 6 Number 5 Implant practice 41

CONTINUING EDUCATION

Figure 3: The reconstructed mandible showing the plate and fibular bone

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Dental rehabilitation of a 6-year-old boy with a rare tumor of the mandible 1. Neuroblastoma is the ______ extracranial pediatric solid tumor and is derived from neural crest cells. a. most common b. most unusual c. most painful d. least difficult to treat 2. It (neuroblastoma) usually forms a mass in the _______or anywhere along the sympathetic neural chain, with 50% of cases having distant masses detected at the time of diagnosis. a. cerebellum b. hypothalamus c. adrenal medulla d. cerebral cortex 3. The peak incidence (of this disease) is at ___ year(s) of age, and in 1-2% of cases, there appears to be linked family history of the disease. a. 1 b. 2 c. 3 d. 4

42 Implant practice

4. The prognosis of this disease is highly dependent on ____. a. working around the lesion b. lymph node classification c. delaying implant placement d. staging 5. (In this case) A vascularized fibula free flap was chosen as this has proven to result in a reliable outcome with sufficient _______ for placement of osseointegrated dental implants. a. bone density b. volume c. facial form d. both a and b 6. There will be future changes to his ______ with continued growth and development. a. bone density b. occlusion c. soft tissue d. keratinized mucosa 7. The majority of the mandibular growth occurs in the mandibular condylar growth plates that have _____.

a. b. c. d.

been affected not been affected been irradiated are positioned further lingually

8. There is likely to be appositional growth that will result in ______ over time. a. burial of the reconstruction plate b. failure of the fibula free flap c. increased retention d. mobilization of the keratinized mucosa 9. The study by Schmelzeisen, et al., found that ______patients with immediate implants required further implant placement. a. two out of three b. four out of five c. six out of ten d. seven out of nine 10. Bone grafting and orthognathic surgery could also have a future role once growth has been completed to maintain ____. a. esthetics b. function c. the reconstruction plate d. both a and b

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ON THE HORIZON

“Lok”-ed and loaded Dr. Justin Moody explores Laser-Lok implant technology

mplant dentistry has come a long way in a short amount of time. I look back over my career from the time I was in dental school to today and realize that science has been the driving force in implant design. I applaud those who have given back to our profession in the form of research and development since this is the backbone of advancement. When I find a new technology or technique that I am passionate about, I like to share it with my colleagues; as an advocate of continual learning, especially through mentorship, gaining knowledge from others is a guiding principle in my life. Not only has the dental implant changed over time, but so too has the mindset of the population and our profession. It is no longer just acceptable to restore the patient to function; we must now concentrate on the esthetics and health of the implant for years to come. In my practice, there has been one item in particular that has continued to outperform my expectations in this area; that is the Laser-Lok® (BioHorizons®) surface treatment. Laser-Lok technology uses lasers to machine cell-sized channels into implants and abutments that are precisionengineered for effectiveness.1 When I was first approached about using this technology, I was somewhat skeptical. The thought of having a physical connective tissue attachment to the zone of the implant that would inhibit epithelial downgrowth and preserve crestal bone sounded too good to be true. However,

Dr. Justin Moody 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.

44 Implant practice

Figure 1

Figure 2

after reading articles from experts like Drs. Jack Ricci and Myron and Marc Nevins, I thought that the possibility of better bone maintenance was worth pursuing. I first started putting the Laser-Loktreated BioHorizons implants in the anterior esthetic zone to test this technology. Since I was already placing BioHorizons implants, I decided to not tell the referring doctors of this switch to see if any of them would notice a difference in the outcomes. The feedback did not come right away — I started to hear about it as these patients were coming back for their first 6-month recall appointments. I had doctors telling me how much better the tissue and bone levels looked with my latest work. It was flattering, but I had not changed anything other than the use of Laser-Lok. Impressed by the successful

outcomes and positive feedback, I now only place Laser-Lok implants along with healing caps and abutments that have this treatment as well. This is the kind of technology that excites me and makes me love to come to work each and every day. IP

References 1. BioHorizons. Laser-Lok microchannels. http:// www.biohorizons.com/laserlok.aspx. Accessed September 9, 2013.

Volume 6 Number 5

TECHNOLOGY

CBCT and implants: the new era in treatment planning and diagnosis Dr. Randolph Resnik discusses the benefits of 3D imaging in a modern implant practice

ver the years, evolving imaging technology has allowed clinicians to be more succinct in their diagnosis and more precise in treatment planning and implementation. My history with dental implants began 25 years ago, and I have always considered 3D imaging to be an important part of the process. That is why I chose the topic of CT radiology for my master’s thesis in my residency. At the time, if a CT scan was indicated for a dental procedure, the patient was referred for a medical CT scan in a hospital; a bit later, it was relegated to an imaging center. Now, we have the opportunity and luxury of having CBCT technology conveniently in our offices. In the past, medical-grade CT scans were associated with many disadvantages — including availability, cost, and radiation exposure to the patient. In- office CBCT units have revolutionized this form of imaging and have virtually eliminated those disadvantages. 3D imaging has changed the way that clinicians treatment plan, prepare for and perform surgery, and approach prosthetic rehabilitation. Whether the clinician is a general practitioner or a specialist, there is no differentiation in whether the patient will benefit from having a CBCT scan prior to an implant procedure. A head- andneck surgeon, neurologist, or orthopedic surgeon would not embark on a difficult surgery without a 3D scan of the patient. While not every patient needs a scan, and the necessity for scanning should

Randolph Resnik, DMD, MDS, is a specialist in Prosthodontics and Oral Implantology. He received his dental degree from the University of Pittsburgh School of Dental Medicine. Upon his graduation from dental school, he continued his training at the University of Pittsburgh by receiving a specialty degree in Prosthodontics. Dr. Resnik then furthered his post-graduate education at the University of Pittsburgh by completing a fellowship in Oral Implantology and then receiving a Masters degree in Radiology for his research on dental implants. In addition to his practice in Pittsburgh, he teaches at two universities and is the surgical director of the world famous Misch International Implant Institute. Dr. Resnik is a paid consultant for Imaging Sciences.

46 Implant practice

3D CBCT technology depicting accurate anatomic features

be decided based on the particular case, performing an implant procedure without a CBCT scan can jeopardize a successful outcome, or result in nerve impairment, or other complications that can be avoided with the detailed information and measurements that a CBCT provide. Having a 3D scan increases the predictability of the procedure, since the clinician can view the location of anatomical landmarks such as the inferior alveolar nerve, maxillary sinus, nasal cavity, and mandibular lingual concavities. Besides that, Oral Implantologists may benefit from having information about the third dimension of the bone, which cannot be achieved with two-dimensional technology — an extremely significant factor. Knowing the entire three-dimensional anatomy of the patient before surgery puts my mind at ease. While the radiation emitted from an in- office CBCT is lower than a medical-grade

scan, within the many brands and types of CBCT scanners available on the market today, CBCT units vary in the amount of radiation exposure to the patient. One important aspect when implementing an in-office CBCT for implant purposes is the ability to control field of view (collimation) and choose resolution, to focus the scan only on the area of interest, and to capture the detail that this particular patient’s situation requires. Two types of technology utilized in the new i-CAT FLX® CBCT unit, Scan STUDIO and QuickScan+, help achieve these important goals. First, I easily choose the appropriate scan size, and with the latter, I can take a full-dentition 3D scan at a lower dose than a 2D panoramic X-ray*. As a result, if I need to repeat a scan after an implant is placed or to evaluate healing of a bone graft, I am confident that the radiation is minimal and within the limits of ALARA. Along with complete control over Volume 6 Number 5

TECHNOLOGY

Some of the many different field-of-views (FOV) available with the i-CAT CBCT units

New in-office CBCT units allow for easy, fast, and low radiation images of the patient’s anatomy A wide range of images including coronal, sagittal, axial, cross-sectional, and panoramic are available with CBCT units

radiation dose, i-CAT FLX has a technology that produces extremely clear 2D and 3D images. Many practitioners need to realize that today most CBCT systems offer clear images; however almost all the units on the market today expose their patients to much more than with the i-CAT units. The control aspect and variable field of view has many advantages, which I believe will be

the future of cone beam technology. I no longer even have a panoramic X-ray in my office because with an i-CAT 3D scan, I can achieve much more valuable information with lower radiation dose and the ability to take a 2D pan if indicated. In the pioneering days of Oral Implantology, medical CT was our only choice for evaluation of a patient’s anatomy

in the third dimension. Currently in-office cone beam 3D scanning is becoming more the standard of practice. With the integration and advantages of surgical guide applications for precise implant placement, the benefits far outweigh any negatives. IP *Data on file with i-CAT

Volume 6 Number 5 Implant practice 47

INDUSTRY NEWS

Osteogenics Biomedical to host 2014 Global Bone Grafting Symposium in Scottsdale, Arizona

World-renowned speakers showcase latest in bone grafting techniques, materials, and research

he Osteogenics 2014 Global Bone Grafting Symposium, with its focus on dental bone grafting and treatment planning, will be held April 3–5, 2014 at the Hyatt Regency Resort & Spa at Gainey Ranch in Scottsdale, Arizona. symposium will feature The presentations by world-renowned speakers, interactive treatment planning sessions with an expert panel, and optional hands-on workshops. Speakers include Dr. Massimo Simion, Dr. Marco Ronda, Dr. Michael Pikos, Dr. Gustavo Avila-Ortiz, Dr. Thomas Wilson, Dr. Brian Mealey, Dr. Istvan Urban, Dr. Sascha Jovanovic, Dr. Daniel Cullum, Dr. Kirk Pasquinelli, and Dr. Hom-Lay Wang. On April 4 and 5, the symposium will feature main podium lectures, question and answer sessions, and interactive treatment planning sessions. Optional hands-on workshops will be offered on Thursday, April 3. Workshop topics include: vertical ridge augmentation using GBR techniques, clinical guidelines and surgical techniques for implant site development, and stateof-the-art sinus elevation and grafting techniques. “This symposium is unique in that it offers a broad scope in treatment perspectives and protocols from several of the more prominent clinicians and researchers in our field,” said Dr. Philip Bird. “I would recommend it to anyone treating patients in the field of implant and regenerative dentistry.” For attendees and their guests, the Hyatt Regency Resort & Spa at Gainey Ranch is an ideal location due to Scottdale’s enjoyable spring weather and breathtaking views. Explore the endless wonders of the 27-acre property set amidst the majestic McDowell Mountains. Enjoy picturesque vistas blended with intriguing Native American culture and pampering amenities 48 Implant practice

The symposium will feature presentations by world-renowned speakers, interactive treatment planning sessions with an expert panel, and optional hands-on workshops.

featuring championship golf, Spa Avania, a 2.5 acre water playground, tennis, or Camp Hyatt Kachina. Or, attendees can find their own opportunity for adventure just minutes from the resort. For more information on the Osteogenics 2014 Global Bone Grafting Symposium, visit www.osteogenics.com/ courses, or call Andrea Wilson at 806-7961923. Tuition for the main symposium on April 4 and 5 is $895, assistants and office personnel $450. The symposium offers up to 13 CE credits. IP This information was Osteogenics Biomedical.

provided

About Osteogenics Biomedical Headquartered in Lubbock, Texas, Osteogenics Biomedical is a leader in the development of innovative dental bone grafting products serving periodontists, oral and maxillofacial surgeons, and clinicians involved in regenerative and implant dentistry throughout the world. Osteogenics offers a complete line of bone grafting products, including enCore™ Combination and Mineralized Allografts, Cytoplast PTFE™ membranes, Cytoplast™ collagen membranes, Vitala™ porcine collagen membranes, Cytoplast™ PTFE suture, and the Pro-fix™ Precision Fixation System. Volume 6 Number 5

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IMPLANT ESSENTIALS

The big debate Drs. Michael Norton and Julian Webber discuss — implants or endodontics?

ndodontics or implants? It’s a question that’s been keeping dental philosophers occupied since Professor Brånemark discovered osseointegration – and it’s taken one step closer to being answered. The treatments went head to head as two of Harley Street’s (London, England) finest took to the stage to fight their corner. Dr. Michael Norton – pulling aside the veil on dental implants – faced off against Dr. Julian Webber, eloquently arguing in favor of endodontics. The topic for debate was “Implants versus endodontics: addressing a contemporary conundrum.” But anyone hoping the evening would descend into a free-for-all was set to be disappointed. Dr. Webber, presenting his lecture first, set the tone by declaring an early ceasefire. “It’s not a battle,” he said. “We’re on the same wavelength.” Dr. Norton was quick to agree, explaining how closely he has worked with Dr. Webber over the years – and acknowledging how “bizarre” it was that they were very good referrers to one another. He paid tribute to the positive effect that relationship has had on his own practice, adding: “I’ve had the good fortune to work with two great endodontists, and there is no question that doing so has refocused my approach to my own implant dentistry.”

Julian Webber, BDS, MS (Endo), DGDP, FICD, is the director of the Harley Street Centre for Endodontics, a state-of-the-art facility dedicated to endodontic excellence. He has been a practicing specialist in the West End of London, England for more than 30 years and was the first UK dentist to receive a Masters Degree in Endodontics from Northwestern University Dental School, a university in Chicago, Illinois. He is currently editor-in-chief of Endodontic Practice Journal and lectures widely on the subject. www.roottreatmentuk.com. Dr. Michael Norton, who was formally visiting professor at Marquette University Dental School in Milwaukee, Wisconsin has recently taken up a new faculty position as Adjunct Clinical Professor at the internationally renowned Ivy League University of Pennsylvania dental school (UPenn). Dr Norton will be working with colleagues in the Department of Periodontology on joint educational and research activities related to dental implant therapy and treatment of peri-implantitis.

50 Implant practice

Working in harmony Ignoring the enmity that has sprung up between adherents of each treatment in recent years, the pair sent out a very clear message: implants and endodontics can work in harmony to the benefit of patients. The entente cordiale continued as the evening wore on, treating the audience to an eloquent, reasoned – but still passionate – debate on how the two approaches fit together in modern dentistry. And if anything, the two clinicians were united against a common enemy, with traditional measures of success swiftly coming into the firing line. Dr. Webber said: “The problem with endodontics and implants is that if we’re going to compare the two treatment modalities, then we need to define our success criteria. It’s interesting, because the success criteria are very different between the two. For dental implant studies, success is measured in terms of survival. For endodontics, it’s measured in terms of ability to cure existing disease – and endodontic success studies measure both that and the occurrence of new disease.

where we – from both the endodontic and the implant side – find ourselves with something of a problem.” The quality of the scientific literature came under scrutiny from both speakers, who pointed to the pronounced imbalance between who performs the treatment. Most implant studies concentrate on work carried out by specialists or in hospital settings, they argued, while the majority of endodontic papers look at work by general practitioners or students. When dealing with a more level playing field – and excluding anything not of a higher caliber, as in Iqbal and Kim’s 2007 paper – the long-term results for both treatments are comparable. Quoting from Iqbal, Dr. Norton added: “The decision to treat a tooth endodontically or replace it with an implant must be based on factors other than treatment outcomes.”

Save first, replace last The ultimate factor, both speakers argued, was that every decision should be made with the best interest of patients in mind – but if a tooth can be saved, they should always be given the option. Dr. Norton said: “If I

...The pair sent out a very clear message: implants and endodontics can work in harmony to the benefit of patients. So the success criteria are different. And that’s a problem: you can’t compare apples with oranges.”

Difficult reading Dr. Norton backed this up: “Historically, there’s been confusion in the implant literature, and a free exchange of the terms ‘survival’ and ‘success’ – and these are not the same thing.” And he agreed with Dr. Webber’s problem with the current literature on the debate, adding: “Currently, no guidelines are really set forth to help us make a decision about when to go one way, and when to go the other. And that’s

can save a tooth, even if it’s just in the short term, then I will. Implant treatment cannot be justified for a restorable tooth needing first time root canal treatment. Where the debate starts is with teeth requiring further treatment. Problems set in when teeth are endodontically mismanaged for too long. Failed endo cases are usually associated with longstanding chronic infection, which damages the bone and causes problems for implant treatment.” The criteria for establishing the suitability of a case for endodontic treatment do not have to be complicated, Dr. Webber added. He said: “In my view, Volume 6 Number 5

IMPLANT ESSENTIALS

Dr. Julian Webber

Dr. Michael Norton

Drs. Michael Norton and Julian Webber field questions at their lecture

endodontic therapy should be given priority in treatment planning for periodontally sound single teeth with pulpal and periradicular pathology that are restorable. And to me, that’s very simple. Implants should be given priority in treatment planning for teeth that are planned for extraction.” Dr. Webber was happy to explain his cut-off for referring patients for implant treatment. “It’s pretty simple,” he explained. ‘”If you can’t restore it, and it’s periodontally unsound – it’s time to go.”

When treatment fails Both clinicians agreed that trying to root treat a hopeless case was damaging, with the critical decision resting on when to “pull the plug.” “Endodontic treatment on a hopeless tooth is just as unethical as implant treatment on a tooth that could be restored,” said Dr. Webber. And Dr. Norton corroborated this, adding: “The problem with endodontics is that if it’s done badly, you scar that patient’s attitude towards endodontics forevermore. Perhaps dentists doing bad endodontics make it easier for patients to make the wrong decision about retreatment.” There is no mystery about why a lot of root canal treatment fails, Dr. Webber 52 Implant practice

explained. “Without doubt,” he said. “One of the biggest causes of failure in endodontics is lack of coronal seal.” And he warned: “If you’re going to embrace endodontics – if you want it to be successful – then you’ve got to embrace the technology as well. Modern endodontics is driven by the technology, but you’ve got to come out of the dark ages to see that.” Keeping up with technology is also a must when it comes to implant placement, said Dr. Norton. And complications are just as important to bear in mind when considering either treatment. He asked: “What about the potential for procedural complications? We all know that not every implant case is a slam dunk, either.” “If I see that the risks of extracting a tooth to replace it with an implant are possibly greater than the risks of keeping the tooth, then I will encourage the patient to give endodontics a try. What have we got to lose?” He concluded: “If it’s not a good implant candidate, it’s going to be a disaster. Implants are an expensive alternative to root canal treatment, so they need to be better in every way.”

Complementary closure Despite the very different makeup of

the speakers’ practices, there was only one message to the evening. Forget the competition, because endodontics and implants complement each other. That sentiment was even echoed by the sponsors for the evening, with Dentsply Implants and Dentsply jointly supporting the debate. Drs. Webber and Norton regularly refer patients to one another, and their cast-iron belief that this is the best possible way forward for patients was evident throughout. Dr. Norton closed his lecture by quoting from the AAE guidelines that both speakers referred to throughout their presentations. He said: “Endodontic and implant treatment are most predictable procedures when undertaken with complete care and attention to diagnosis, planning, and execution of treatment.” “The natural tooth is the ultimate implant,” Dr. Webber said, quoting endodontist Cliff Ruddle in his own closing remarks. “The question of when to save and when to replace comes down to the considerations for treatment planning. One of the main considerations is ethics. So before you answer it, first ask yourself this: what’s best for the patient?” IP Volume 6 Number 5

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PRACTICE DEVELOPMENT

Apply current tax laws to improve patient care Bob Creamer explains Section 179 and Bonus Depreciation

hriving dental practices understand that patients are the lifeblood of the dental practice. Indeed, without patients, a dental practice does not exist. Success is therefore determined by the quality of patient care provided and the overall patient experience. In the last decade, we have seen many important and amazing advancements in dental equipment that have assisted dentists in the delivery of ultimate patient care. One of the newest, but well-proven advancements is with 3D CBCT technologies. Investing in equipment and technology upgrades can provide a number of benefits for your practice – a competitive advantage, expanded services, improved efficiency, and overall patient comfort. These advantages can certainly make a difference to your bottom line, especially when you incorporate significant tax incentives for investing in your practice and yourself. In recent years, we have enjoyed a series of tax laws enabling dentists to take accelerated tax deductions when purchasing equipment and technology. A couple of tax code provisions that have been very beneficial to dentists are known as Section 179 and Bonus Depreciation. Both provisions allow for accelerated deductions even when purchases are financed. These laws are so advantageous that I am often asked, “Should I purchase some new equipment this year to help reduce taxes?” I trust their true objective in upgrading their practice is not to simply create a tax deduction, but rather to provide better services and improved care. Patients recognize and appreciate the dentist who makes patient care the focal point of the practice. During the recent

Bob Creamer, CPA, is president of the accounting firm Creamer & Associates, PC, specializing in financial and retirement planning, dental transitions, practice enhancement, wealth creation, tax savings and related services. He is also a founding member of the Academy of Dental CPAs. Bob can be reached at 800-248-1120 or Bob@bestcpas.com.

54 Implant practice

struggles in our country’s economy, I witnessed that dentists who invested in their practices to improve the quality of care they provided, attracted a loyal patient following and a market share that continued to increase even while others struggled. It is with these practices that patients were willing to spend their precious dental dollars. However, investing in the practice provides a reward for dentists far beyond income and tax deductions – the peace of mind of knowing that they are delivering the highest level of patient care possible.

Section 179 and Bonus Depreciation Section 179 of the IRS Tax Code was introduced as a way to stimulate the economy by allowing business owners to deduct the full cost of a qualified asset in the year it is acquired, rather than spreading deductions over the normal depreciable life or many years. During its early years, Section 179 allowed a maximum accelerated tax deduction of $10,000 to $24,000. This amount has varied as needed to spur

Volume 6 Number 5

economic growth, and was increased to a very generous $500,000 maximum deduction in 2010 and 2011. That amount dropped to a $139,000 deduction for 2012, but was retroactively raised after the first of this year back to $500,000 for tax calculation purposes for 2012. Additionally, the maximum deduction for Section 179 for 2013 was originally set at $25,000. However, during Congressional wrangling early in the year to address the ominous “fiscal cliff” predictions, Congress adjusted the law to again allow a maximum Section 179 deduction in the amount of $500,000, with a spending cap of $2,000,000 before phase-outs begin. Looking ahead, the law as currently written (as of the writing of this article) has deduction limits scheduled to drop all the way down to $25,000 for 2014, unless Congress acts to change the law and keep the deduction limit elevated. Therefore, there may be a drastic reduction in deduction limits for those who wait until next year to make their purchases. Section 179 provides tax incentives for purchasing both new and used equipment and technology. The complementary

Bonus Depreciation provides incentives for new purchases only. For new equipment and technology purchases in 2013, a dentist can take a 50% Bonus Depreciation deduction on all purchases without purchase limitation. While Section 179 has a $2,000,000 cap with a dollar phase-out for every dollar spent over the cap, Bonus Depreciation has no spending cap. Unlike Section 179, which is scheduled to simply be reduced, Bonus Depreciation is currently scheduled to end on January 1, 2014. Today’s tax laws allowing accelerated deductions have led many dentists to rightfully consider them as a key aspect of their yearly tax and financial planning. As the tax rates continue to increase, there is greater incentive to invest in yourself and your practice. In addition to tax laws that make practice investments attractive and accessible, historically low interest rates on equipment loans have made it easier to incorporate practice upgrades that may have seemed out of reach just a few years ago. While today’s accelerated tax

deductions can be highly advantageous from a business perspective, they are not permanent as I have already illustrated. When considering the forthcoming expiration or reduced deduction laws, and the recent significant tax rates increases for those making $250,000 or more, it certainly makes sense to invest in equipment and technology where needed. When you couple this with low interest rates, which may soon be on the rise, there seems to be a window of opportunity for dentists to make their purchases during 2013. I strongly advise my doctors to invest in their practices and purchase equipment and technology, provided it’s for the right reasons. After all, it is not tax rates, accelerated tax deductions, or even low interest rates that determine whether or not you need to invest in your practice, it’s the need to continually take extraordinary care of your patients. So if you need to invest to deliver the care you desire, why wouldn’t you take advantage of Section 179 and Bonus Depreciation to help you accomplish your professional goals? It only makes great sense! IP

Volume 6 Number 5 Implant practice 55

PRACTICE DEVELOPMENT

Patients recognize and appreciate the dentist who makes patient care the focal point of the practice. During the recent struggles in our country’s economy, I witnessed that dentists who invested in their practices to improve the quality of care they provided, attracted a loyal patient following and a market share that continued to increase even while others struggled. It is with these practices that patients were willing to spend their precious dental dollars. However, investing in the practice provides a reward for dentists far beyond income and tax deductions – the peace of mind of knowing that they are delivering the highest level of patient care possible.

PRACTICE MANAGEMENT

Growing the money tree William H. Black, Jr. discusses the financial advantages of having a good plan in place

our practice is established. You have a good reputation and a good management team in place. Gone are the days of building the practice and putting all profit back toward growth. That’s the good part! But success creates other questions and concerns. When clients first come to us they typically have the same refrain: “I am paying salaries, sick pay, vacation pay, major medical, matching Social Security and Medicare, paying into unemployment and Workman’s Comp. I have to pay a lot of money in income taxes…How do I keep more of what I make? No one has any solutions for me!” What I’ve found clients really mean is they want an idea that is not “outside the box,” that won’t increase their audit profile, an idea that won’t get them in trouble with Internal Revenue. The simple answer is to consider a custom-designed qualified plan! In other words, consider a form of a pension plan (known as “qualified” because the contribution qualifies for an income tax deduction). Think about it this way: there is not a company on the New York Stock Exchange, a union, or government agency that doesn’t have a pension plan. So using the rules that are on the books to create a custom-designed plan for the closely held professional practice may be the answer.

• Plan assets grow tax deferred • Plan assets are protected from judgment creditor claims1 • Plan assets are eligible for tax-free rollover to one’s IRA account • Qualified plans receive up-front approval from Internal Revenue in the form of a Favorable Determination Letter Let me clear up a few myths straightaway. These plans are not about retirement; they are about the tax benefits and asset accumulation features, i.e., your money tree. Who’s worried about retirement? It’s the employees putting $25 a week into their 401(k) plan. More power to those employees, but we, as business owners, are past that. Look at a plan as a way to pay yourself on a tax-favored basis! Here is how to look at the merits. Assume a 39% federal income tax rate and assume a 6% state income tax rate. So, for brevity, we will assume an overall tax rate of 45%. Since there is no requirement to have a plan, what does it look like without one? For every $10,000 in taxable income, what does it look like with a plan or without one? (We use $10,000 in this analysis because it is scalable. Want to know what $50,000 would do? Multiply by 5. $75,000? Multiply by 7.5, etc.) Here is where it gets interesting. On one hand you have $10,000 working for

Consider the benefits: • Contributions are income tax deductible

William H. Black, Jr. has been in the pension administration business for 34 years. The firm Pension Services, Inc. administers both defined contribution and defined benefit plans, employs an ERISA attorney, an Enrolled Actuary, and complete clerical staff. Mr. Black is qualified to give continuing education to CPAs in 47 different states. He has spoken nationally and internationally on retirement plans, has been quoted in USA Today, written articles for several industry journals and has appeared on many financial radio shows discussing the topic of retirement and financial matters. He may be contacted at bill@pensionsite.org.

56 Implant practice

you; on the other, you have $5,500. The tax benefits alone give you 81% more (10,000 ÷ 5,500) right out of the gate. Now, consider the plan’s assets grow tax deferred while the non-plan grows taxably. Add it all together, and you can see the benefits growing with every passing year! Many believe, initially, that the plan will cause all employees to come in, with contributions for all, and any employee is entitled to take his/her contribution out immediately. While plans like that do exist, they are not well designed or well thought out. ERISA, the Employee Retirement Income Security Act of 1974, gives us 39 years of instruction on how to design a plan. In other words, these plans are black and white, really no gray area. Now the question becomes how to design a plan to benefit the rainmaker? That is the easy part! Many different options exist, hence the need for customization. Many “cookie cutter” plans are out there, a one-size-fitsall approach. These are commonly referred to as “bundled” plans. While those plan designs have their place, they cannot be all things to all people. What to do? Start with a checklist of basic questions. What is the annual budget for the contribution? How is the business set up, as a Corporation either

Without a Plan

With a Plan

Taxable Income

$10,000

Tax at 45%

$4,500

After-tax Balance

$5,500

$10,00

Comments on graph: • No tax on the “with a plan” column as the contribution is income tax deductible. • After-tax balance is as of the present day. In the future, monies coming out of an IRA or qualified plan are subject to ordinary income taxes. • The chart does not take into account asset protection benefits. • This is scalable. Considering a $50,000 contribution? The values are five times as much, etc.

Volume 6 Number 5

us they typically have the same refrain: “I am paying salaries, sick pay, vacation pay, major medical, matching Social Security and Medicare, paying into unemployment and Workman’s Comp. I have to pay a lot of money in income taxes…How do I keep more of what I make?

S or C, as an LLC, LLP, PA, Partnership, or Sole Proprietor? How many employees? Are there existing plans in place now? How is the ownership structured, all in the hands of one person, or two or more? With the above, and an employee census, i.e., employee names, dates of birth and dates of hire, job titles and annual salaries, a projection can be created that will show, in black and white, what the benefits and detriments are. Look at it in conjunction with your CPA and make a

business decision on what is right for your situation. IP This discussion is not intended as tax advice. The determination of how the tax laws affect a taxpayer is dependent on the taxpayer’s particular situation. A taxpayer may be affected by exceptions to the general rules and by other laws not discussed here. Taxpayers are encouraged to seek help from a competent tax professional for advice

about the proper application of the laws to their situation.

References 1. Patterson v. Schumate (http:// financial-dictionary.thefreedictionary.com/ Patterson+v.+Shumate)

Volume 6 Number 5 Implant practice 57

PRACTICE MANAGEMENT

When clients first come to

PRODUCT PROFILE

BIOMET 3i launches its new 3i T3® Implant BIOMET 3i, one of the world’s leading dental implant manufacturers, announced the launch of its new BIOMET 3i T3 Implant. The BIOMET 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 acidetching 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 (BIOMET 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 provide a tighter fit between implant components.9 For more information, please contact your local BIOMET 3i Sales Representative. IP 58 Implant practice

The BIOMET 3i T3 Implant is a contemporary hybrid implant with a new multisurface topography designed to deliver esthetic results through tissue preservation.

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.

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,

* Bone Bonding is the interlocking of the newly formed cement line matrix of bone with the implant surface. 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 6 Number 5

PRODUCT PROFILE

Galileos® Comfort Plus For a new dimension of success in your practice

he high-end CBCT unit with HD mode, large field-of-view and integrated FaceScan offers maxillofacial surgeons, orthodontists, radiologists, general dentists, and ENT doctors all of the options they need for diagnosis, treatment, and patient consultation. The optional HD mode of Galileos® Comfort Plus ensures the highest image quality for a clear and quick diagnosis, even in difficult cases. • 15.4 cm spherical volume with MARS • Close-up feature with 125μ resolution for endodontic applications • Lateral and AP/PA cephalometric views • One of the lowest diagnostic doses per volume size available and stable patient positioning • 14-second scan for minimized patient movement • Seamless workflow integration • Software with superior diagnostic features

Integrated FaceScan The FaceScan plots the patient’s facial surfaces at the same time the X-ray image is taken. With a realistic image of their own face, patients understand and accept treatment recommendations more readily.

Integrated implantology Achieve implants with a final prosthesis in fewer visits. The prosthetic suggestion from the CEREC® software is united with the 3D X-ray data, helping to achieve the perfect final outcome.

Compatible with Dolphin software The Dolphin 3D imaging software is a powerful tool for orthodontists that makes processing 3D data from any Sirona CBCT X-ray system extremely simple. Dolphin 3D features tools for on-screen manipulation and analysis of volumetric datasets. Images are easily oriented and rotated, and tissue density thresholds can be adjusted for detailed views of the craniofacial anatomy. Measurements and digitalization can be performed in both 3D and traditional 2D views. In addition to Dolphin integration, Sirona CBCT systems are also compatible 60 Implant practice

with other popular orthodontic software programs. IP For more information, visit sirona3D.com. This information was provided by Sirona. Volume 6 Number 5

DIARY

lllllllllllllllllllllll OF EVENTS llllllllllllllllllllllllllllllllllllllllllllllllllll

Soft Tissue Grafting Around Teeth and Implants Dr. Paul A. Fugazzotto October 17–19, 2013 Milton, MA www.straumann.us/en/professionals/ continuing-education/courses.html

Aesthetics through Innovation October 22, 2013 Novi, MI October 29, 2013 Chicago, IL October 30, 2013 Denver, CO

Contemporary Soft Tissue Grafting for Implant Reconstruction Dr. Mike Pikos October 17-19, 2013 Trinity, FL www.pikosinstitute.com/programscourses/implant-soft-tissue-grafting-forimplant-reconstruction

Practical Solutions for Immediate Full Arch Restoration with Hands-On October 18, 2013 Vienna, VA www.biomet3i.com

Practical Solutions for Immediate Restoration of the Full Arch Dr. Brent Boyse and Dr. Sheldon Sullivan October 26, 2013 www.biomet3i.com

November 5, 2013 Quincy, MA www.biomet3i.com

Chicago Implant Forum–A Multidisciplinary Perspective of Advanced Esthetics from Treatment Planning to Final Restorations Dr. Bach Le October 23, 2013 Chicago, IL www.biohorizons.com/ chicagoimplantforum.aspx

62nd Annual American Academy of Implant Dentistry Annual Meeting (AAID) October 24-26, 2013 Phoenix, AZ

AAP National Conference & Exhibition October 26–29, 2013 Orange County Convention Center Orlando, FL www.aapexperience.org

American Dental Association (ADA) Annual Session October 31–November 2, 2013 New Orleans, LA www.ada.org

The GHSU/AAID Maxi-Course Comprehensive Training Program in Implant Dentistry November 14-17, 2013 Atlanta, GA www.straumann.us/en/professionals/ continuing-education/courses.html

The Realities of Advanced Bone Grafting and Implant Placement Dr. Paul A. Fugazzotto November 14-16, 2013 Milton, MA www.straumann.us/en/professionals/ continuing-education/courses.html

3D Summit November 15-16, 2013 Bellevue, WA www.3DSummit.com

62 Implant practice

Volume 6 Number 5

MATERIALS lllllllllllll & lllllllllllll EQUIPMENT Hu-Friedy introduces the Black Line Surgical Collection New group of instruments designed for performance. Hu-Friedy, a global leader in the manufacturing of dental instruments and products, has launched the Black Line Surgical Instrument Collection, featuring a performance-engineered coating to enrich contrast and reduce light reflection during procedures in order to consistently deliver optimized clinical outcomes. The 51 meticulously handcrafted HuFriedy Black Line instruments include periosteals, periodontal knives, periotomes, luxating elevators, surgical curettes, bone chisels, and sinus lift instruments. The instruments were engineered to deliver efficiency throughout the entire perio and surgical procedure. The collection features a performance engineered coating for a harder, smoother surface, providing enhanced lubricity and superior edge retention. In addition, the black finish allows for visual acuity at the surgical site and underlying tissue. For more information call 1-800-HU-FRIEDY or visit www.hu-friedy.com

enCore® combination allograft: a synergistic combination enCore® combination allograft is the first particulate dental bone grafting product combining mineralized and demineralized bone in a single bottle. Already a popular combination among many specialists, enCore® leverages the complementary benefits of spacemaintaining mineralized bone with osteoinductive demineralized matrix to optimize the environment for the regeneration of vital bone. Throughout processing, steps are taken to not only ensure each lot is safe for the patient, but to also verify that each lot of enCore® is osteoinductive. For more information, contact Osteogenics Biomedical at 888796-1923 or visit osteogenics.com.

Sunstar GUM® announces new size and redesign of Proxabrush® Go-Betweens® Cleaners The new Ultra Tight size is ideal for healthy patients and will help improve compliance, effectiveness, and the overall comfort of the patient. To continue the innovation in its line of custom fit interdental brushes that help prevent disease, Sunstar GUM® has introduced its new size of Proxabrush® Go-Betweens® Cleaners – Ultra Tight. Proxabrush Go-Betweens are clinically proven to remove plaque as well as string floss and are convenient, reusable and easy-touse. Highlights of the newly designed Ultra Tight Proxabrush GoBetweens include: • More Plaque Removal. The redesigned Proxabrush family of interdental brushes has been constructed to remove up to 25 percent more plaque with new unique triangular bristles. Additionally, it stays clean between uses through an antibacterial agent that has been incorporated into the bristles. The central wire of each brush is coated for added comfort and to help prevent galvanic shock. • New Flexible Handle. The new, flexible handle has been ergonomically designed for better comfort, control, and grip in order to make it easier to use. The bendable neck and longer length also makes it easier for patients to clean their posterior teeth. In addition, Sunstar will be applying the new design elements to each of the existing Proxabrush Go-Betweens Cleaners sizes: Tight, Moderate and Wide. For more information, visit www.US-Professional.GUMbrand.com.

NuOss® XC expandable composite The latest development in natural bone substitutes: • Supports bone growth in periodontal and oral maxillofacial defects. • Is a composite bone grafting material comprised of mineralized deproteinated bovine granules and purified Type I bovine collagen. When placed into a bleeding site, the material expands to a predetermined size and shape. • Available in both socket and sinus forms. Features and Benefits: • Self-expanding composite material allows for placement while in a compressed form, then fills the entire defect upon hydration. • Simple implantation technique. • Composite nature of the material enhances graft stability and minimizes particulate migration. • Optimizes spacing between particulate to allow for bone ingrowth. • Expands immediately after implantation with blood contact. For more information on NuOss XC or other NuOss products, please contact ACE Surgical Supply at www.acesurgical.com or by calling 800-441-3100.

Volume 6 Number 5 Implant practice 63

MATERIALS lllllllllllll & lllllllllllll EQUIPMENT Ultradent Products announces new whitening product: Opalescence Go Opalescence Go comes in an innovative, ready-made UltraFitâ&#x201E;˘ tray that adapts instantly and comfortably to the teeth for a better fit and improved whitening experience. Opalescence Go provides powerful, professional whitening for the on-the-go lifestyle. The Opalescence Go 10% hydrogen peroxide gel allows for a 30-60 minute wear time with flavor choices of mint, melon, or peach. The 15% hydrogen peroxide gel is available in mint flavor and allows for a 15-20 minute wear time.

DenMat introduces Perfectemp10 DenMat has introduced Perfectemp10, a premium multifunctional acrylic crown and bridge temporary material that delivers the strength that patients need at a competitive price that dentists desire. Perfectemp10 features a 10:1 auto-mix formulation, accelerated set times (1:30 intra-oral, 4:30 full cure), minimal shrinkage, minimal oxygen inhibited layer for optimal handling, bio-compatibility with natural dentin and enamel, and a natural looking luster with minimal to no polishing required. It is free of Bisphenol A and has minimal heat generation for maximum patient comfort and safety. Perfectemp10 is available in a 50ml cartridge pack that includes auto-mix tips and comes in five Vita shades; A1, A2, A3.5, B1 and BL2. It is also available in a 10ml syringe that includes auto-mix tips and comes in three Vita shades; A1, A2 and A3.5. Dentists can purchase Perfectemp10 by phone at 1-800-4DENMAT (1-800-433-6628), online at www.denmat. com/perfectemp10, or through their outside field representatives.

Early warning from Osstell

The unique UltraFit tray material easily conforms to any patientâ&#x20AC;&#x2122;s smile and offers molar-to-molar coverage, ensuring that the gel comes into contact with more posterior teeth than before. The trayâ&#x20AC;&#x2122;s superior adaptability ensures that the maximum amount of gel stays in contact with the teeth during whitening. The convenient, pre-filled trays cans be worn right out of the package. Additionally, Opalescence Go contains potassium nitrate and fluoride (PF). Potassium nitrate has been shown to help reduce sensitivity. For more information, call 800-552-5512 or visit www.ultradent. com.

64 Implant practice

Osstell gives clinicians an early warning if the biological process is not progressing as expected. It helps avoid costs due to premature loading and allows dentists to treat more patients with risk factors in a more predictable manner. If the initial mechanical stability is high enough, a one-stage approach is often used together with immediate or early loading. By measuring stability with Osstell before final restoration, and comparing the value to the baseline value taken during placement, the practitioner gains a better basis for deciding whether to proceed. For more information, please visit www.osstell.com, call 1-877296-6177, or email osstellusa@osstell.com.

Volume 6 Number 5

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

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

PLANMECA®

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

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

A Legacy of Innovation New

Legacy™4 Implant All-in-1 Packaging includes implant, fixturemount, abutment, transfer, cover screw & healing collar — $225 SBM, $250 HA surface

Torque- safety feature prevents damage to implant interface

Square top detaches with impression for

Concave transgingival profile

metal to metal transfer accuracy

matched with healing collar to shape soft tissue for improved esthetics

Two-Piece fixture-mount (patent pending) with

preparable abutment Quadruple-lead micro-threads Progressively deeper buttress threads

A Legacy of Innovation from Dr. Gerald Niznick

Legacy 4 – the culmination of 30 years of evolution Introducing a revolutionary 2-piece fixture-mount/abutment that provides the accuracy of an open-tray transfer with the simplicity of a closed-tray transfer.

Square top detaches with the impression, providing a snap attachment for abutment/analog.

Three long cutting grooves

The abutment portion of the fixture-mount snaps onto the transferred top for the accuracy of a metal-to-metal connection

Angled Multiple-Unit Plastic GPS™ Laboratory Straight Straight 15° Angled Gold/ Zirconia/Ti Temporary w/Cap & Transfer Ball GPS™ Abutment Snap-On Contoured Contoured Plastic Abutment Abutment Attachment Attachment Attachment Straight Angled Our price

$85

$100

$120

$40

$112

$100

$120

$100

$120