Implant Practice US Vol 10 No 1 - Feb March 2017 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews February/March 2017 – Vol 10 No 1

Drs. Patrik Zachrisson and Eddie Scher

Implant treatment for a patient with combination syndrome Dr. Douglas Wright

Full arch implantsupported oral rehabilitation: a literature review

WE’VE MADE FIXED FULL-ARCH RESTORATIONS A SNAP.

Intrusion of natural teeth when connecting teeth to implants

NO SCREWS. NO CEMENT. NO COMPROMISES.

PROMOTING EXCELLENCE IN IMPLANTOLOGY

Dr. Vasileios Soumpasis

Educator profile Dr. Frank Spear

Practice profile Dr. Ian Topelson

To learn more, please visit our website at www.zestdent.com/FTx or call 800.262.2310.

PAYING SUBSCRIBERS EARN CONTINUING EDUCATION CREDITS PER YEAR!

WE’VE MADE FIXED FULL-ARCH RESTORATIONS A SNAP. NO SCREWS. NO CEMENT. NO COMPROMISES.

Fixed for the patient. Easily removed by the clinician. LOCATOR F-Tx® is a simplified, time-saving solution for full-arch restorations with no compromise to prosthesis strength or esthetics. Optimized for efficiency and chair time savings compared to conventional screw-retained systems, LOCATOR F-Tx features a novel, “snap-in” attachment that eliminates the need for sub-gingival cement or screw access channels. LOCATOR F-Tx is the latest innovation from Zest Dental Solutions expanding treatment options for the edentulous patient— with less chair time and higher patient satisfaction. To learn more, please visit our website at www.zestdent.com/FTx or call 800.262.2310. ©2017 ZEST Anchors LLC. All rights reserved. ZEST and LOCATOR F-Tx are registered trademarks and Zest Dental Solutions is trademark of ZEST IP Holdings, LLC.

February/March 2017 - Volume 10 Number 1

A treatment solution requiring no screws and no cement EDITORIAL ADVISORS Steve Barter, BDS, MSurgDent RCS Anthony Bendkowsk,i 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

dentulism is a major public health problem. It fulfills the World Health Organization’s (WHO) definition of a physical impairment or disability due to important body parts (teeth) that have been lost. Patients with advanced decay and/or end-stage periodontal disease suffer for many years because of their edentulism. Edentulism limits a patient’s ability to perform two essential tasks in life: speaking and eating. To address this disability, the 2002 McGill Consensus Statement on Overdentures established as a minimal treatment objective a two-implant mandibular overdenture as the first choice standard of care to address the edentulous patient. The two-implant overdenture is an appropriate starting point for treatment of the edentulous mandible. Historically, Zest Anchors’ LOCATOR® attachment system has been accepted as the gold standard starting point treatment option for the edentulous mandible. Guidelines for the mandibular overdenture treatment should not be extrapolated to the maxillary arch. More sophisticated types of treatment options such as multiple implant bar overdenture and fixed hybrid overdenture prosthesis techniques have been employed successfully to meet the challenging demands of both arches. The most prosthetically challenging and expensive reconstruction for both the mandibular and maxillary arches has been the implant-supported fixed prosthesis. For the average clinician, this treatment option is very demanding and complex. For the average patient, it’s unaffordable. Advanced technologies available today allow the clinician to diagnose, treatment plan, and perform implant-supported therapy in a more sophisticated and profound way. Our patients are treated with greater accuracy, lower morbidity, and in shorter time frames to meet their demands. Incorporating digital treatment planning with guided implant placement has allowed the author to deliver the implant in a very precise and predictable manner. The author though has still been challenged by the prosthetic complexity required to finalize the full arch implant-supported fixed prosthesis. Recent developments by Zest Dental Solutions™ to address the challenging full arch implant-supported fixed prosthesis have had a dramatic impact on the time and simplification to deliver such prosthesis.

Nigel Saynor, BDS Malcolm Schaller, BDS

The new LOCATOR F-Tx® Fixed Attachment System

Ashok Sethi, BDS, DGDP, MGDS RCS, DUI

The LOCATOR F-Tx System reduces clinicians’ and patients’ time and cost by simplifying the restorative procedure with fewer chances of complications and treatment delays. The system utilizes no screws or subgingival cements to affix the prosthesis. Instead it features a secure snap-fit design utilizing a patent-pending design that works similar to a ball and socket, allowing the Denture Attachment Housing to securely snap into place and then pivot to the desired position. Once in place, it’s fixed for the patient and can easily be removed by the clinician at hygiene and maintenance visits. LOCATOR F-Tx offers us a new way to think about fixed full arch restorations by allowing us to provide our patients a simple, strong, esthetically pleasing, and timesaving treatment option. My clinical experience with the LOCATOR F-Tx System has been extremely positive and rewarding. I have been able to reduce the clinical time to deliver a same-day immediate full arch implant-supported fixed prosthesis with six implants from 7-8 hours to under just 3.5 hours. We have had no postoperative prosthetic adjustments that have been required for any of our cases to date. I have used the system to rescue an All-on–4® screw-retained case that had a terminal implant failure and keep the existing prosthesis in function. Most importantly though, I have experienced an extremely high degree of overall patient satisfaction. In my opinion, the LOCATOR F-Tx is the next logical evolutionary advancement for the implant–supported, fixed-arch prosthesis.

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-inchief 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

© FMC 2017. All rights reserved. FMC is part of the specialist publishing group Springer Science+ Business Media. The publisher’s written consent must be obtained before any part of this publication may be reproducedvw in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Implant Practice or the publisher.

Volume 10 Number 1

Robert A. del Castillo, DMD, received his dental degree and his Certificate in Periodontics from Tufts University School of Dental Medicine. He has served as an Adjunct Professor, Department of Periodontics at Tufts University School of Dental Medicine. He is presently a member of the editorial review board for the Journal of Prosthodontics and is affiliated with the American Academy of Periodontology. Dr. del Castillo maintains a private practice, limited to periodontics with a strong emphasis on implant and regenerative therapies in Miami Lakes, Florida. He lectures extensively nationally and internationally and has published articles on regenerative and implant therapies.

Implant practice 1

INTRODUCTION

The latest advancement in fixed full arch restorations

TABLE OF CONTENTS

Financial focus Five things your 401(k) provider does not want you to know

Practice profile Ian Topelson, DMD, FICOI, FAAIP

Tom Zgainer delves into possible pitfalls of 401(k) plans......................12

Implants â&#x20AC;&#x201D; the intersection of science and art

Educator profile Frank Spear, DDS, MSD Coaching dentists to believe in their capabilities......................................22

In memoriam Dr. Carl E. Misch ....................................................... 28

Meeting news

Case study Implant treatment for a patient with combination syndrome

AO Orlando preview by Jill Helms, DDS, PhD, Professor of Surgery, Stanford Medicine..............29

Dr. Douglas Wright illustrates a successful restoration using mini implants

ON THE COVER Cover photo courtesy of Dr. Douglas Wright. Article begins on page 16.

2 Implant practice

Volume 10 Number 1

IMPLANTING CONFIDENCE

IMPL ANT WORKFLOW MADE EASY FOR YOU

ÂŠ Carestream Health, Inc. 2017. 15014 OM IN AD 0117

With open-format image files, implant planning has never been easier. Carestream Dentalâ&#x20AC;&#x2122;s digital imaging and implant planning software simplifies your workflow, allowing you to easily scan your patients and plan the implant placement. Plus, integration with thirdparty surgical guide software makes placing implants easier than ever. For more information, call 800.944.6365 or visit www.carestreamdental.com

Come see us at Chicago Midwinter Booth #3602

TABLE OF CONTENTS

Continuing education Intrusion of natural teeth when connecting teeth to implants Drs. Patrik Zachrisson and Eddie Scher assess the impact of connecting implants to the neighboring dentition in “mixed-bite” patients...................................... 37

Continuing education Full arch implant-supported oral rehabilitation: a literature review

Dr. Vasileios Soumpasis looks at the evidence base for complete oral rehabilitation using implant-retained prostheses

Product profile LOCATOR F-Tx® fixed attachment system Zest Dental Solutions™ has made fixed full arch restorations a snap

.................................................42

Practice development Important Facebook® developments Ian McNickle, MBA, discusses how to stay face-to-face with patients using Facebook....................................43

On the horizon Scan and you shall receive! Dr. Justin Moody discusses starting the digital revolution one office at a time......................................... 44

Industry news.............46

PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com MANAGING EDITOR | Mali Schantz-Feld Email: mali@medmarkaz.com | Tel: (727) 515-5118

Materials & equipment......................47 Technology news Study finds accuracy of X-Guide™ Navigation is 11 times better than freehand implant placement The Journal of Oral Implantology (JOI) reported a new study that confirms the accuracy of placing dental implants using the industry-leading X-Guide™ dynamic 3D navigation system.......................................48

ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkaz.com NATIONAL SALES DIRECTOR | Kristin Sammarco Email: kristin@medmarkaz.com NATIONAL ACCOUNT MANAGER Celeste Scarfi-Tellez Email: celeste@medmarkaz.com CLIENT SERVICES/SALES SUPPORT | Adrienne Good Email: agood@medmarkaz.com CREATIVE DIRECTOR/PROD. MGR. | Amanda Culver Email: amanda@medmarkaz.com WEBSITE MANAGER | Anne Watson-Barber Email: anne@medmarkaz.com E-MEDIA PROJECT COORDINATOR | Michelle Kang Email: michellekang@medmarkaz.com FRONT OFFICE MANAGER | Theresa Jones Email: tjones@medmarkaz.com MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 www.implantpracticeus.com | www.medmarkaz.com SUBSCRIPTION RATES 1 year (6 issues) $149 | 3 years (18 issues) $399

4 Implant practice

Volume 10 Number 1

The BellaTek® Encode® Impression System

The BellaTek Encode Impression System is the gateway to creating a customized solution for you and your patients. • A more efficient workflow and less inventory to stock provide a vehicle for practice growth. • Create and select aesthetic BellaTek Patient Specific Abutments available in titanium or with titanium nitride coating. • No need to remove the healing abutment, preserving tissue and resulting in aesthetic outcomes.

It’s not just what we make… it’s what we make possible.

For more information please contact your local Zimmer Biomet Sales Representative or visit our online store at zimmerbiometdental.com

All trademarks are the property of Zimmer Biomet or its affiliates, unless otherwise indicated. Due to regulatory requirements, Zimmer Biomet’s dental division will continue to manufacture products under Zimmer Dental Inc. Biomet 3i, LLC respectively until further notice. BellaTek Encode is manufactured and distributed by Biomet 3i. Please note that not all products are registered or available in every country/region. Please contact your Zimmer Biomet Dental representative for product availability and additional information. AD060 REV B 09/16 ©2016 Zimmer Biomet, All rights reserved.

PRACTICE PROFILE

Ian Topelson, DMD, FICOI, FAAIP Implants — the intersection of science and art What can you tell us about your background?

When did you decide to focus on implants, and why?

I’m originally from Mexico City, and I moved to the United States when I was 14. I graduated from the University of San Diego with a BA in biology and a minor in chemistry and art. I realized in college that I loved the intersection of science and art. That took me to Tufts University School of Dental Medicine, and later the Advanced Education in General Dentistry Program from Lutheran Medical Center in Rochester, New York. I had lived in Colorado prior to coming back to practice dentistry there. I bought my first practice in 1997. After selling my practice in 2015, I acquired my Affordable Dentures & Implants practice in Aurora, Colorado, at the beginning of 2016.

As a general dentist with a focus toward implantology, I decided that I needed to find a course that allowed me to really dive in and learn, so around 2012, I attended an Implant Seminars course with Dr. Arun Garg. My wife was battling cancer around that time, and I had to delay some training, but I finally got the opportunity to begin placing implants in my practice around 2013. And today, thanks to my Affordable Dentures & Implants practice’s niche focus on tooth replacement, I get to present the implant opportunity to every patient who walks in my door. I am a Fellow with the International Congress of Oral Implantologists and the American Academy of Implant Prosthodontics. I’m also proud to be part of the

International Dental Implant Association fellowship and the Colorado Prosthodontics Society, where I can stay focused on continuing education and adopt a progressive stance on implant restoration techniques.

Dr. Ian Topelson in front of his practice 6 Implant practice

Volume 10 Number 1

PRACTICE PROFILE

Dr. Topelson with his staff. He opened his Affordable Dentures & Implants practice in Aurora, Colorado, in January 2016

Is your practice limited solely to implants, or do you practice other types of dentistry? We’re exclusively focused on tooth replacement — implants, dentures, partials, and extractions. We do offer single-tooth systems with crowns, but most of my implant patients are full-arch cases. It is a great environment for a dentist who has a keen interest in implantology.

Why did you decide to focus on implant dentistry? It is an exciting science. It’s also exciting to be able to tell a patient that he/she has more options than simply cutting perfectly sound teeth or fitting a denture. No matter the patient’s situation, the possibility exists that we can still fix their teeth and restore their mouth to normal function and appearance. For me, that is one of the coolest things. To be able to give patients the opportunity to stabilize that lower denture or to get rid of the palate so a patient can eat, taste, and feel normal again — that’s pretty cool. Very few professions have that kind of impact on people.

Volume 10 Number 1

Dr. Topelson shows off his Ivoclar IvoBase system. Affordable Dentures & Implants began widely deploying denture injection systems to affiliates in 2016 Implant practice 7

PRACTICE PROFILE

Lab and dental staff examine a new denture set with Dr. Topelson. His Affordable Dentures & Implants practice features an on-site lab for same-day service

Dr. Topelson with his wife, Regina

Do your patients come through referrals? Since my practice is new, a lot of patient flow does come from advertising to edentulous patients. We’re fortunate to be located in a visible, well-trafficked area. In the Aurora market, I observe lots of dental shoppers who want to know what makes a practice unique, and for us, that’s easy — we’re able to talk about our on-site lab or our low implant fees.

How long have you been practicing implant dentistry, and what systems do you use? I have practiced implant restoration since 1995 with a number of systems, such as Nobel Biocare®, BioHorizons®, Straumann® and others. Today, I place BioHorizons implants and love working with their guided surgery kit. To me, the biggest difference between many of these systems today is cost, and I spend a lot of effort working to pass those savings along to the patient. So we’re doing it for half the cost of other providers, while still going with a really reputable company we can stand behind in BioHorizons.

What training you have undertaken?

In dental school during the 1990s, we had an arrangement to learn on the Brånemark system, which was a great opportunity early in my career. Beyond my Implant Seminars course, I’ve studied with Dr. Virgil Mongalo and Dr. Justin Moody. I’m always looking to do more hands-on coursework with implants. The only way you get good is through repetition and focusing on more complex cases. 8 Implant practice

Dr. Topelson demonstrates his Carestream CS8100 3D system. Topelson believes investing in technology helps drive his practice’s success

Who has inspired you? I always have had my family’s backing. My wife always backs me up, and I strive to be successful as my dad, so I can support my kids the way he did. Professionally, I listen to as many people as I can. You have to learn a little bit from everybody. There are people out there who have a great reputation, but when you listen to them, you’re not impressed. I like to learn from somebody who shows me his/her mistakes. I can show you some amazing cases, but I want you to learn from my mistakes. That’s the best kind of teacher you can get.

What is the most satisfying aspect of your practice? Today, it’s the fact that we are able to help a lot of people who maybe don’t have the financial means, but who need help and are interested in implants. Finances don’t have to restrict you anymore.

Professionally, what are you most proud of? We’re helping people with critical needs. I’m most proud of my reputation among patients and colleagues. Being able to say, “I know I did the best I could on this patient,” is a rewarding feeling. And I don’t take anything for granted. Volume 10 Number 1

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PRACTICE PROFILE

Top 10 favorites 1. My family, of course 2. The profession of dentistry — we help a lot of people 3. My dental practice 4. Being able to place and restore implants 5. Dentures in 1 day — my on-site lab 6. Soccer — my favorite team is Cruz Azul 7. My Carestream CS 8100 cone beam imaging system 8. Traveling the world — my favorite trip was to Israel 9. Being a dentist 10. Living the good life with my wife

What do you think is unique about your practice? Thanks to our on-site lab, we can give someone a denture in 1 day. In Colorado, hardly anyone can do that at an affordable price. I’m most proud of creating that unique opportunity for patients. They say, “Wow, my last denture took a month.” Even our highestend denture, the UltimateFit, can be done in 1 week at most.

What has been your biggest challenge? I strive for perfection, but perfection doesn’t exist. I want to be able to sleep 10 Implant practice

Dr. Topelson with his wife, Regina, children Max and Marc, and dog Lucky

at night and be comfortable but am never willing to cut corners. So many dentists aim for the intersection of affordability and quality yet fall short, but achieving both is the standard in my practice.

the technology. Any dentist that’s placing implants ought to consider using a cone beam, especially to utilize surgical guides. We also have a Denture Satisfaction Guarantee and a Craftsmanship Warranty for all our dentures. I’m proud of my lab, and we stand behind our work.

I would have been an architect! My dad was an architect, and most of the people in my family are architects. I even applied to architectural school. I’m glad I didn’t do it because I love what I’m doing now.

What advice would you give to a budding implant dentist?

What would you have become if you didn’t become a dentist?

What is the future of implants and dentistry? My point of view is that implant dentistry should be the standard of care for a broken tooth that is not restorable or maybe has been restored multiple times. I am excited about the science of implants and what’s possible. I hope that in the future, we get implants that better mimic natural teeth.

What are your top tips for maintaining a successful specialty practice? Implant dentists must keep up with

Learn implantology, practice it, get good at it, and do a lot of CE. Don’t take a weekend course — go live it. Live training is so critical. I was confident coming out of my training course, so I placed more than 80 implants in my first year. I started placing the same month as live training — I ordered all my equipment and then scheduled that first case quickly.

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

Spending time with my family is important to me. I have two boys, Max and Marc. I’ve been married to my wife Regina for 16 years. I like to play golf and soccer, and I’m a huge Broncos fan. And of course I like to ski — I live in Colorado for a reason. IP Volume 10 Number 1

You focus on implants. We’ll help with the rest.

Over 230 affiliated practices in 39 states…and growing each year. One of the most popular advantages our affiliated practice owners enjoy is 360° business support —from operations to marketing and everything in between. Let us take care of your nonclinical duties, so you can devote your energy towards implants and improving the lives of thousands of patients each year.

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Learn more: info.affordabledentures.com/focus

FINANCIAL FOCUS

Five things your 401(k) provider does not want you to know Tom Zgainer delves into possible pitfalls of 401(k) plans

magine giving up 50% or more of your future nest egg to excessive fees. This is precisely what is happening when you utilize a traditional 401(k) plan (which represents 95% of the plans in existence). Seemingly, small percentages have a massive impact when you look at how they impact your account growth over time. Just 1% in excessive annual fees can add up to hundreds of thousands, even millions, of lost retirement dollars.

1. Fees matter, and their impact can be devastating. Have you ever been told your plan is “free?” Many 401(k) providers will market their plans as essentially “free” because there are no explicit checks being cut for recordkeeping, administrative fees, etc. But we all know there is no “free lunch” in this world. If you encounter a “free” plan, ironically, you could be in an extremely expensive plan. The fees are simply being subtracted from your retirement savings, which can act like a hole in your boat! Make no mistake. Just

Tom Zgainer is CEO and founder of America’s Best 401(k) and has helped thousands of companies repair or rescue their retirement plans over the past 15 years. You can learn more at http://americasbest401k.com/feechecker-medmark.

12 Implant practice

because you may not be cutting a check for your plan, you still may be cutting into your future nest egg. Figure 1 is a real-life example of two identical plans with the same growth rate, same ongoing contributions, but with different fee structures (0.65% versus 1.68% annually). All things being equal, the additional fees erode more than a million dollars in potential retirement savings.

2. Layers upon layers of fees are hidden in plain sight. The traditional providers have been pushing the same old 401(k) plan for 30 years, but in 2012, the law finally required fees to be fully disclosed. The good news

is that the curtain was pulled back. The bad news is their layer cake of fees is hidden in 30-50 page fee disclosures that the average person has no chance of deciphering. This is evident by the fact that 71% of Americans think they pay NO 401(k) fees. Nothing could be further from the truth. Not only do providers make money by kickbacks from mutual funds, they are also happy to layer on additional, seemingly arbitrary fees that can double or even triple the cost of your plan. If that weren’t enough, many will also hit you with a onetime sales charge (aka commission) on every single dollar that goes into the plan. It’s an expensive and entirely unnecessary toll for the “privilege” of saving money.

Figure 1: Assumes both plans have a starting balance of $1 million, a 7% annual growth rate, and $100,000 in annual contributions Volume 10 Number 1

FINANCIAL FOCUS Here are the charges that should raise red flags. • Contract asset charge/asset management charge — a layer of fees charged on the entire balance of your plan. This is over and above the cost of the investments. • Required revenue — an almost comical line item, this is a fee charged to smaller plans where the providers insist they aren’t making enough. • Sales charge — a one-time commission that subtracts 3% to 6% from every dollar you deposit. • Surrender charge — many insurance company providers have figured out a way to have your 401(k) held within a “group annuity.” This means they can penalize you with hefty surrender charges if you decide to switch plans to another provider.

3. The mutual funds in your plan menu are often chosen for all the wrong reasons. The vast majority of 401(k) providers make huge sums of money from kickbacks from the mutual funds in the plans they sell. This payment for “shelf space” is a legal but opaque process called revenue sharing. The net result is what we call “menu stuffing” — stuffing your plan’s fund menu with the funds that are most profitable for the provider. Worse yet are the providers that stuff the menu with their own more profitable namebrand funds. Odds are that your 401(k) plan is packed full of expensive “actively managed” mutual funds that are hoping to beat the market by being the best stock pickers. The problem is that although they may have a hot streak, the studies overwhelmingly show that in due time, they will often lag the market. So you are usually overpaying for underperformance. What’s the alternative? A great number of Nobel laureates and investment legends such as Jack Bogle and Warren Buffet would recommend that most investors use low-cost index funds. Index funds simply track a basket of leading stocks like the S&P 500, for example. David Swensen, the Chief Investment Officer responsible for growing Yale’s endowment from $1 billion to $24 billion, warns us, “When you look at the results on an after-fee, after-tax basis, over reasonably long periods of time, there’s almost no chance that you end up beating the index fund.” Most plans do not offer access to lowcost index funds because they can’t receive kickbacks (aka revenue sharing) from these 14 Implant practice

ultra-low-cost funds. Many small or midsize plans will be told they don’t qualify for index funds because their 401(k) is not large enough. (Translation: “We wouldn’t make enough money off of you if we granted you access.”) Or worse, if they do offer them, they charge an outrageous markup. One plan we reviewed offered index funds with a 3,000% markup from its normal retail price. That’s like buying a $30,000 car for $900,000. All clients of America’s Best 401k have access to same low-cost index funds regardless of the size of the plan. No commissions, no kickbacks, and no markups.

4. Many of the biggest providers have been named in lawsuits for excessive fees and self-dealing. There has been a flurry of recent lawsuits against 401(k) providers. The primary reason is for excessive fees and the use of proprietary products. Interestingly, it’s not just the customers who are suing, but many providers have been sued by their OWN employees for their own in-house plan. Providers were caught with their hand in the cookie jar by peddling their own, more expensive namebrand mutual funds and, thus, profiting from their employees’ retirement savings. Business owners beware! You have a legal obligation to make sure the fees in your plan are both fair and reasonable. As the plan sponsor, the Department of Labor states that the fiduciary obligation falls on you to make sure the plan is set up for the sole benefit of your employees. Nothing external can influence the decisions you make for your plan, including a relationship with the existing broker. More importantly, it’s your legal duty to periodically benchmark your plan, so a side-by-side comparison is a task that is in your best interest to perform. America’s Best 401k will provide a complimentary benchmark at your request.

5. The traditional model is being disrupted and rapidly becoming a dinosaur. The 401(k) industry is ripe for disruption. Much like Uber has the transportation industry on its heels, our company is seeking to transform a decades-old industry that is riddled with conflicts of interest and often puts profits ahead of people. They have seemingly forgotten that it’s YOUR money, NOT theirs. America’s Best 401k is a next generation solution that eliminates brokers, levels the playing field with transparency, and provides a combination of high-tech and high-touch interaction for our clients.

Your next step: Get a complimentary side-by-side plan comparison. Most of our prospective clients are astonished when they see the results of their sideby-side plan comparison. In many cases, the immediate savings is more than $10,000 in the first year alone. But the real impact is what happens over 10, 20, or even 30 years. Below is a chart showing a 401(k) with $1 million in total assets. Here we show our average plan cost versus two other common providers. Note that although fees vary from plan to plan, we often see fees that are even higher from these two providers as well as other major insurance companies and national payroll companies. Assuming the plan is growing at 7% and has modest contributions of $60,000 per year, there are millions in potential savings being left on the table if a switch is not made immediately. These savings will go right back into the pockets of you and your employees and make sure your money will last as long as possible into retirement. By sending us your fee disclosure form (to info@americasbest401k.com), which we can help you locate, and by taking 15 minutes to review the results, we hope to show irrefutable evidence why a switch is in your best interest. IP

Table 1: 401(k) with $1 million in total assets America’s Best 401k Fees

Transamerica*

John Hancock*

0.65%

1.50%

2.25%

Year 1 (start)

$1,000,000

Year 5

$1,722,690

$1,660,243

$1,606,716

Year 10

$2,705,886

$2,523,154

$2,371,881

Year 20

$5,863,251

$5,124,922

$4,553,892

Year 30

$11,707,110

$9,569,117

$8,024,433

*These examples above are actual examples of specific plans where the fee disclosure was provided for both Transamerica and John Hancock. We have analyzed hundreds of plans from Transamerica and John Hancock where the fees are both higher and lower than the amounts listed above. Fees in plans vary drastically even from the same provider

Take control, start here: http://americasbest401k.com/fee-checker-medmark. Volume 10 Number 1

Address the Implant Complexities You Face Everyday with...

clinical articles • management advice • practice profiles • technology reviews

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clinical articles • management advice • practice profiles • technology reviews February/March 2017 – Vol 10 No 1

24 continuing education credits per year Clinical articles enhanced by high quality photography Analysis of the latest groundbreaking developments in implant dentistry

Drs. Patrik Zachrisson and Eddie Scher

Implant treatment for a patient with combination syndrome Dr. Douglas Wright

Full arch implantsupported oral rehabilitation: a literature review Dr. Vasileios Soumpasis

Educator profile Dr. Frank Spear

Practice profile Dr. Ian Topelson

Practice management advice on how to make implants more profitable Real-life profiles of successful implant practices Technology reviews of the latest products

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CASE STUDY

Implant treatment for a patient with combination syndrome Dr. Douglas Wright illustrates a successful restoration using mini implants Background There are over 35 million edentulous patients in the United States. About 178 million Americans are missing at least one tooth.1 Restoring a patient who needs an upper complete denture over a lower jaw containing only the six anterior teeth is a common challenge. Along with difficulties of making a stable lower partial denture with a Kennedy Class I relationship, the long-term function of lower anterior teeth against an upper denture leads to combination syndrome. Combination syndrome has been described as the changes that occur when a patient has no maxillary teeth and only natural mandibular anterior teeth (Kennedy Class I). The syndrome can include loss of bone in the anterior maxillary ridge, overgrowth

of maxillary tuberosities, extrusion of the remaining mandibular teeth, and loss of bone height in the posterior areas of the mandible.

Introduction While tooth loss and denture fabrication is something often associated with the later phases of life, younger patients can be affected. A young patient will have to successfully wear a maxillary denture and mandibular partial denture for 4 or even 5 decades. In addition, younger patients may have less disposable income for their dental care because of their recent entry into the workforce and the financial needs of their children. While options such as All-on-4® may be clinically available, the financial requirements of this treatment may be impossible for the younger patient.

Case report CC is a 44-year-old mother of two who presented with two remaining upper teeth (teeth Nos. 7 and 8) and 7 remaining lower (teeth Nos. 22-28). She hoped to get a maxillary denture, so she could go to interviews with more confidence and get a better job to support her family. Her medical history was clear with no reported allergies. She did not have diabetes, osteoporosis, or kidney disease. She had recently quit smoking. A CBCT scan was exposed (GALILEOS SICAT, Sirona), and the inferior alveolar nerves were highlighted on the software. Alginate impressions for diagnostic casts were made. Using Dawson’s technique, the patient was manipulated into centric relation.2 She had a Class I skeletal relationship, and her centric stop was on her upper incisors. This allowed us to use polyvinyl siloxane putty (Express™ 3M ESPE) to capture centric relation and vertical dimension record (Figure 1). From these models and other more detailed models, an immediate upper denture was fabricated. After scaling and root planning of the lower teeth and restoration of carious lesions, teeth Nos. 7 and 8 were removed, and the immediate upper denture was inserted. To restore the lower dentition, the patient elected to have implant-supported crowns made instead of a lower partial denture. With a cast of the upper denture mounted in centric

Figure 1: Pretreatment models mounted in centric relation Douglas Wright, DDS, graduated from the University of Maryland in 1985. After serving 4 years in the United States Navy, Dr. Wright operated a private practice in Maryland. After 10 years in practice, he joined the staff at the Washington DC Veterans Administration Medical Center. Now, Dr. Wright is in private practice in Harrisonburg, Virginia. He is married to Karen Wright and has three children: Nicholas, Julia, and Rosemary.

Figure 2: Suck-down stent fabricated after diagnostic wax up is copied 16 Implant practice

Volume 10 Number 1

distal edge of the most distal tooth in the arch and from the crest of the bone to the inferior alveolar nerve canal. With these clear reference points, a factory-made surgical guide was deemed unnecessary (Figures 5A-5B).

Figure 4A: CBCT with stent in place

Figure 4B: Planned location of teeth can clearly be seen for planning implant placement

Figure 5A: Measurements for implant placement Volume 10 Number 1

Figure 3: Stent filled with FUTAR barium bite registration and ready for patient

The patient elected to have each side of the lower arch restored separately. On the day of treatment, the patient rinsed with chlorhexidine gluconate (CHG) for 30 seconds prior to anesthesia. Local anesthesia was provided via a nerve block with 3% mepivicaine and infiltration with 4% articaine 1:200,000 epinephrine (Septocaine®). Mini dental implants (Intralock® 2.4 mm x 13 mm) were placed using an electric surgical torque handpiece (Aseptico®). Once the implants were in place, the exposed-ball attachments were covered with a thin coating of flowable composite. The composite coating makes the exposed implants smooth, less detailed, and easier for scanning with CEREC Bluecam camera. Once covered and powdered, the implants were scanned for digital models. The restoration was made using IPS e.max®

Figure 5B: Using CBCT, measurements are taken from distal tooth and from crest of alveolar bone Implant practice 17

CASE STUDY

relation to the lower cast, denture teeth were added to the lower model in an ideal location for support and function of the upper denture. Once the waxup of the denture teeth on the lower model was completed, a copy of this model was fabricated, and a suck-down plastic stint was fabricated (Figure 2). Once the patient returned, this stent was filled with a polyvinyl-barium mixture (Futar® Scan by Kettenbach Dental) and placed into the patient’s mouth. Once set, the stent was trimmed and smoothed (Figure 3). Then an additional CBCT scan of her mouth was captured with the stent in place. This particular scan showed the buccal cusps of the lower teeth located very close to the crest of the alveolar bone (Figures 4A-4B). The SIDEXIS (Sirona) software allowed for easy measurement of the distance from a hard reference point, such as from the

CASE STUDY

Figure 6A: Application of flowable to implant

Figure 6B: CEREC scan of site

Figure 6C: CEREC image

Figure 7A: Fluoric acid applied to IPS e.max restorations

Figure 7B: Resin cement placed in restoration

Figure 7C: Restoration in place

lithium disilicate ceramic (Ivoclar VivadentÂŽ) (Figures 6A-6C). The completed restoration was adjusted to allow for easy cleaning with a floss threader. The restoration was treated with fluoric acid, mono-link silane, and cemented with Kerr NX3 cement (Figures 7A-7C). After several months, the other side was restored using the same technique. Mini dental implants were used because they can be immediately loaded, and they cost less than conventional implants. The patient was very pleased with her lower dentition. She made inquiries as to what would be available to stabilize her upper denture. While complete restoration of her upper arch using implants and fixed bridges was out of reach financially, the patient was able to afford placement of four mini dental implants in the upper arch. On the day of treatment, the patient again rinsed with CHG and was anesthetized with articaine 4% with epinephrine 1:200,000. This time, four Zest LOCATORÂŽ (Zest Dental Solutionsâ&#x201E;˘) implants 2.5 x 14 were placed in the anterior maxilla. Again, measurements on the CBCT scan were taken, this time from the center of the incisal foramen giving the position of the implants with careful examination of the bone providing the information needed to select the length of the implant (Figure 8A-8D). 18 Implant practice

Figure 8A: Maxillary CBCT with measurements from incisive foramen

Figure 8C: Measurements taken from incisal papilla

Figure 8B: Incisal papilla marked

Figure 8D: Pilot hole placement. Note finger and thumb of left hand used for guidance Volume 10 Number 1

material. Implant analogs were attached to the snaps, and these were placed back into the set polyvinyl material. Snap stone was poured into the denture and allowed to harden. After set, the denture was removed from the stone. The stone model was lubricated with petroleum jelly. The impression material was removed from the denture, and pink Jet acrylic was mixed. The wet acrylic

was poured into the openings made in the denture and lightly coated onto the Zest snaps. The denture was placed onto the lubricated stone cast. This was held together with rubber bands and placed into a pressure pot for 20 minutes at 20 psi (Figures 9A-9H). After the denture was removed from the pressure pot, the cast was separated from the denture, and the restoration was smoothed.

Discussion

Figure 9A: Implant position captured in PVS inside denture

Figure 9B: Zest attachment and analog inside denture

Fabrication of an immediate complete upper denture in this case immediately reduced the complexity of treatment. With this new upper denture, critical aspects of the occlusion such as the Frankfort plane and the inter-pupillary line are restored. With this, the prosthetic portion of the case is greatly simplified. The implant retained lower crowns were built to this restoration. Using mini dental implants with CEREC to restore the lower arch allowed for immediate 1

Figure 9C: Fast-setting stone flowed into denture

Figure 9D: Zest attachments placed back onto abutments after lubrication

Figure 9E: Mix of acrylic placed inside denture. Rubber band holds denture to model.

Figure 9F: Stone model separated after cure in pressure pot. Volume 10 Number 1

Figure 9G: Palate removed, denture polished Implant practice 19

CASE STUDY

After these implants were seated, the denture was hollowed. The four Zest metal housings were placed onto the implants, and the hollowed area of the denture was filled with regular body polyvinyl siloxane impression material. Once set, the denture was removed and taken to the laboratory. After disinfection, the snaps were removed from the polyvinyl impression

CASE STUDY day restoration of each side of the mandible. This was less expensive than traditional implant restoration of an edentulous space and allowed the patient to have the site restored with crowns immediately after placement of the implants. Restoring the upper with an immediate denture followed by restoration of the lower left and the lower right made this case easier for the patient to afford. Using mini dental implants to support immediately placed permanent ceramic restorations is controversial, however; there is ample support in the literature for using mini dental implants to support single tooth and multiple tooth restorations.4, 5, 6 Once the patient grew accustomed to the implant-supported lower bridges, she asked to have her upper denture stabilized with implants as well. The upper arch was restored with mini implants supporting Zest LOCATOR attachment because the attachment housings have a lower vertical profile than the traditional ball-shaped mini dental implant abutments. While the increased height of the traditional mini implants are advantageous for fixed bridge restorations, in the anterior maxilla, a taller implant may require adding acrylic to the anterior portion of the denture. This could have an undesirable effect on the patient’s phonetics. Zest LOCATOR attachments require 4 mm of acrylic versus 6 mm to 7 mm for a ball attachment-type mini dental implant. Because of bone height and the health of the patient, only four implants were necessary to stabilize the upper denture. This case highlights some common problems with mini implant stabilization of a removable appliance. The problem with any acrylic restoration supported by implants is weak areas in the acrylic of the denture base. This can lead to fracture of the denture. Using chairside pickup materials exacerbates these problems because the pickup materials are not methyl acrylic but typically a BIS-GMA product. The BIS-GMA does not create a chemical bond with the acrylic, only a mechanical attachment. This makes the denture base even weaker and prone to fracture. By performing the laboratory technique described here and having the attachments held in place with pressure cured methyl acrylic, the strength of the removable is maximized. These patients must be warned that they can generate stronger chewing forces than a patient who has simple conventional partial and complete dentures. There are denture teeth available with more resistance 20 Implant practice

Figure 9H: Implant-retained denture in place

to wear than conventional acrylic teeth.7 Because of their additional strength, SR Phonares® (Ivoclar Vivadent) denture teeth were used in the maxillary denture. In spite of this, the patient was told that implantsupported dentures will wear considerably faster than most dentures wear and will need to be replaced much more often than traditional dentures.

Conclusion A young, partially edentulous patient was successfully restored using mini dental implants and CEREC-fabricated restorations for the lower arch. Her upper arch was restored with a complete denture supported on four Zest locator mini implants.

The advantages of this treatment include: • Providing the patient with affordable dental implant treatment options. • Treatment can be provided in phases for financial purposes. • Use of CEREC technology with mini dental implants provides immediate results for the patient. The disadvantages of this treatment are that the upper denture will need to be replaced much more frequently than a traditional denture. This information must be related to the patient prior to treatment. IP

Acknowledgement Special thanks to Mr. Dan Emmerman and DBE Photography.

REFERENCES 1. American College of Prosthodontists. Missing teeth. American College of Prosthodontists website. https://www.gotoapro.org/ facts-figures/. Accessed January 3, 2017. 2. Dawson PE. Evaluation, Diagnosis and Treatment of Occlusal Problems. 2nd Edition. St. Louis, MO: Mosby; 1989:41-44. 3.

The Journal of Prosthetic Dentistry. Glossary of prosthodontic terms. J Prosthet Dent. 2005;94(1):10-92.

4. Kumari P, Verma M, Sainia V, Gupta A, Gupta R, Gill S. Mini-implants, mega solutions: a case series. J Prosthodont. 2016;25(8):682-686. 5. Flanagan D. Fixed partial dentures and crowns supported by very small diameter dental implants in compromised sites. Implant Dent. 2008;17(2):182-191. 6. Shatkin TE, Shatkin S, Oppenheimer BD, Oppenheimer AJ. Mini dental implants for long-term fixed and removable prosthetics: a retrospective analysis of 2514 implants placed over a five-year period. Compend Contin Educ Dent. 2007;28(2):92-99. 7. Hahnel S, Behr M, Handel G, Rosentritt M. Two-body wear of artificial acrylic and composite resin teeth in relation to antagonist material. J Prosthet Dent. 2009;101(4)269-278.

Volume 10 Number 1

We’ve saved patients time and money and created higher treatment plan acceptance. — Kim B., Financial Coordinator

At Lending Club Patient Solutions, we’ve spoken with thousands of patients and practices. During our conversations, we’ve learned that straightforward payment plans lead to more satisfied patients. That’s why we only partner with banks that offer simple, budget-friendly payment plans like True No-Interest Plans.* As the name suggests, the plans are free from the all too painful expense of retroactive interest (or deferred interest). And that’s a simple way to keep your patients and team happy. When you’re looking for payment plans to complement your care, give us a call.

To see how straightforward patient financing can be: Call (844) 936-6673 Visit lendingclub.com/providers * No interest for 6, 12, 18 or 24 months, after that 23.23% variable APR. Interest will be charged to your account at the standard variable APR of 23.23% (based on the Prime Rate) from the end of the promotional period on the remaining balance if the purchase balance is not paid in full within the promotional period. Minimum monthly payments for this plan during the promotional period will be the greater of: the amount of the purchase divided by the number of months in the promotional period (rounded up to the nearest $1.00); or $5. Required minimum purchase of $499 for the 6-month plan; $999 for the 12-month plan; $1,499 for the 18-month plan; $2,499 for the 24-month plan. Lending Club Patient Solutions credit accounts are offered by Comenity Capital Bank who determines qualifications for credit and promotion eligibility. Minimum interest charge is $1.00 per credit plan. Standard variable APR of 23.23%. © 2017 Lending Club Patient Solutions products and services provided through Springstone Financial, LLC, a subsidiary of LendingClub Corporation. Payment plans made by issuing bank partners.

EDUCATOR PROFILE

Frank Spear, DDS, MSD Coaching dentists to believe in their capabilities

What can you tell us about your background? Fife, Washington, population 1,500, where I was born and raised, is a small rural farming community where my parents were also raised 30 years earlier. Fife is an hour south of Seattle, Washington. My mother was a second-grade schoolteacher, and my father was a mechanic who owned a gas station and garage. My interests when younger were the same as most small town boys — sports, fishing, hunting, and eventually, girls and cars. When I left for college, I went to Pacific Lutheran University (PLU), the same small college my parents went to about 30 minutes from where I grew up. I really didn’t have any idea what I wanted to be, just that I wanted to play football in college and have a good time. And I did have fun, finishing my first year of college with a 2.3 GPA and a D in a religion class. My second year in college, it was required to choose a major, so I chose physical education, with a goal of becoming a football coach. One of the hardest classes for that major was anatomy; I decided to sign up for it first semester of my second year. I loved the professor, a woman named Ruth Sorenson, and the class and topic. At the end of the semester, she asked if she could meet with me after finals. She looked at me across the desk and asked me what I was going to do with my life, to which I replied become a football coach. She said that was what she thought, and she then asked me what else I had considered; I had no answers. Next, she asked if I had ever considered becoming a physician, a dentist, or perhaps a veterinarian. I replied no to all three. In my small town, both of my parents were raised very poor, and we viewed the physician, dentist, and veterinarian in the town as being at a different level than we were; there was no way I ever would have considered becoming any of the three. Ruth Sorenson then looked me straight in the eye and said, “I think you should consider one of the three, because I see a lot more capability in you than you do.” She then informed me that she had arranged a meeting for her and me down the hall. We walked down to a room that I 22 Implant practice

Dr. Frank Spear lectures at Spear Study Club Summit 2016 in Scottsdale, Arizona

had never been in before — it was Harald Leraas, the Pre-Med Pre-Dent advisor’s office. We sat down across from Harald, and it turned out he was a dentist. Fifteen minutes after sitting at that desk, I decided to become a dentist; to this day I can’t tell you how that happened. I went on to finish my undergrad with one B in a lab class, and all the rest A’s — how motivating clarity and direction can be. I did still finish playing football for all 4 years — just gave up on the physical education part as well as becoming a coach. From there I went to the University of Washington School of Dentistry for my DDS and then onto an MSD in Perio-Pros.

What originally attracted you to dental education? What aspects of your training inspired you to add “educator” to your list of accomplishments? As I said, my mother was a secondgrade schoolteacher, and both my mother and father believed very strongly in education being the most important thing you can give anybody. In addition, mom was very gifted at

what she did. She passed away at age 92 in 2014, and many of her former students attended her memorial service, some she had taught over 50 years earlier. They all remarked how much they remembered the experience of being in Mrs. Spear’s secondgrade class. In addition, while I was in my senior year of dental school, I was chosen as a faculty member to help teach second-year dental students in their first clinical denture course. Part of that experience involved the students giving the prosthetics department written feedback about each member of the faculty. Thankfully, my feedback was very positive, and I realized how much I enjoyed helping others learn. Along with those experiences, in my Perio-Pros residency, you had to learn how to give presentations. We had an entire year course on every aspect of a presentation — graphics, title slides, organizing content, timing, etc. I loved it, and our final exam was a 1-hour presentation in front of the faculty of the periodontics, prosthetics, and restorative departments. I had taken some public speaking courses in my undergrad days, and Volume 10 Number 1

Who has inspired you as a clinician and an educator? The list of people I have been inspired by would be fairly long, but some names definitely stand out. I have already mentioned the one who had the most impact on me as an educator, Ruth Sorenson, my undergrad anatomy professor. Without her and that meeting after finals with Harald Leraas, I wouldn’t be writing this for you right now. In fact, one of my major prayers is that I can be Ruth Sorenson for people in my audiences. In other words, I can help them see that they are more capable than they believe they are. In dentistry, the one who most formed the direction I went was the director of my PerioPros program, Dr. Ralph Yuodelis. He was gifted as a clinician, but he was one of the least dogmatic educators I have ever seen in dentistry. While everyone else would be telling you there was a right way and a wrong way to do things, and their way was the right way, Ralph would be telling us to try all the different ways and learn for ourselves what works for us as individuals. Not to mention the work he would show was so inspiring, I knew that was what I wanted to do. Another name that readily came to mind would be Dr. Lloyd Miller from Tufts — one of the true gentleman of dentistry — massively talented esthetically and so nurturing of young dentists. He wanted only the best for everyone he taught. Dr. Richard V. Tucker

is another in that same vein as Lloyd, so humble, but his work was simply spectacular. And finally I would add Dr. Pete Dawson, someone I have considered a friend for 30 years. I have learned so much from Pete, and I also had the good fortune of teaching with him a week a year for 9 years starting in the mid-’90s at The Pankey Institute. We would stay in the same condo for the week, and after the day was done, some of my most enjoyable memories were he and I drinking a Scotch and talking about life and his history in dentistry.

What are your proudest moments in the clinical and teaching aspects of your life? As a clinician, I have always loved the experience of watching a patient’s selfconfidence transform following treatment that took a debilitated dentition and turned it into something beautiful. In addition, anytime a patient gives you a hug because of what you have done to help him/her, that is hard to beat. As an educator, the greatest rewards for me have always been watching students who didn’t think they could see something, do it, or understand it, and then those students suddenly gets it. Seeing that aha flash across their faces is wonderful. The other thing I love about education is getting feedback about how what you have taught someone has impacted their life, either in practice or personally. I have been fortunate to have been doing what I do for close to

35 years, and I have gotten lots of cards, letters, notes, etc., from students over those years, and I have kept all of them in “attaboy boxes.” You are probably wondering what an attaboy box is. I mentioned that I played college football, and my coach was one of the most amazing men I have ever met. His name was Frosty Westering; he coached football, but in reality, Frosty coached young men about life. In his 32 years at PLU, he won six Division II national championships and was in the finals game another 6 times, so he was very successful as a coach. He would tell us life lessons he had learned, and one was about his attaboy box — a box where he kept all the things people sent him that were positive so that when he was down or life seemed hard, he could go to the box and remind himself who he really was. It is amazing how well it works.

What do you think is unique about the topics that you teach? I would like to think I am like Frosty. I teach dentistry, but in reality, I would like to think that I am also a coach about the life of a dentist, so it is not a procedure or technique necessarily, but also how to integrate what you learned into your practice, your case presentation, and your fees. One thing I learned a long time ago about dentistry is that if you teach dentists a technique, but not how to integrate it into their practices, they will learn the technique but never get to do it. That philosophy fits perfectly with our goals at SPEAR Education for our students. We have four very simple-to-understand goals for the dentists we work with: 1. Help you have more fun in practice on a daily basis, basically help you enjoy dentistry more. 2. Help you become more profitable. 3. Help you have more free time. 4. Help you grow as a clinician to whatever level of clinical excellence you aspire. We accomplish those goals by not teaching just techniques, but on focusing on all aspects of the practice, including TEAM training.

As an educator, what have you learned from your clinicianstudents?

From “The Art of Treatment Planning and Case Presentation” to “Treating the Worn Dentition,” Dr. Frank Spear teaches at several seminars each year, both on Spear Education’s campus and select locations around the U.S. Volume 10 Number 1

The greatest learning I have gotten from students comes from the evaluations that I want to see the least, ones with negative feedback. At first there is a tendency to rationalize the feedback, blame it on whoever Implant practice 23

EDUCATOR PROFILE

I was very comfortable with it, so extending that to dentistry was enjoyable for me.

EDUCATOR PROFILE wrote it as being incompetent, etc., but almost universally, if you allow yourself to read it and ask the question, “How could I have presented this differently so this person would have understood it?” you will become a better teacher. To this day, all of us who teach at SPEAR Education read every one of our evaluations, and to this day, I learn how to improve after every course I teach. One of the things I am most proud of about my teaching is getting feedback that I take complicated topics and make them easily understandable, but part of why that has occurred is because of the feedback I have gotten over the years about what students didn’t understand.

What has been your biggest challenge in sharing information and educating clinicians? The answer to this is interesting because it goes back to me at PLU and sitting across from Ruth Sorenson. I had never considered being a dentist because I didn’t believe it was possible. My students are dentists, they have already gotten there, but the biggest issue I have is helping them get a clear vision of what is possible for them in practice — most don’t clearly see the possibilities.

I hear things such as “I just don’t see those patients in my practice,” “My patients only want what the insurance will cover,” etc. In other words, they don’t believe that any patients in their practice want more than basic single-tooth dentistry. Yet I promise in almost any town in America there are patients who want more and the dentists who are providing it. But if you don’t believe that is possible, it is a self-fulfilling prophecy because you won’t present anything more because you believe it will be turned down. To clarify, our goal for our students is not for them to have complex restorative practices or boutique cosmetic practices, but instead a robust patient base with a good hygiene-recall program, while at the same time hopefully treating one or two patients a month who do want more. My experience is that if a general practitioner can do one or two more involved cases a month, it moves them significantly in the direction of our four goals: fun, profitability, free time, and clinical growth.

What would you have become if you had not become a dentist? The first thing that comes to mind would have been a football coach, but you heard

Top 10 favorites Unlike perhaps some people in education, I tend to be somewhat material agnostic, meaning that I believe there are several different bonding agents that can work well, several different composites that are excellent, and I tend to tell students to find what works for them, and stick with it until there are some obvious reasons to change. I can certainly tell students what we use in the office, but that doesn’t mean there aren’t other products just as good. If I was to tell you the things I think are indispensable in practice, the list would look like this: 1. A digital SLR clinical camera, Nikon® or Canon®, both work well. Learn how to use it, or have someone on your TEAM learn how to use it. Take photos on every adult patient in your practice at the new patient appointment and at any recall where you re-do radiographs. Show the patient the photos, and he/she will ask for more dentistry than you ever would have presented. 2. Brasseler USA®/NSK electric handpiece. I switched from air to electric in 1995 and would never go back. 3. Straumann® implants have been my primary implant system since 1994. I have never had an implant or component failure with the system, not even a loose abutment screw. 4. 3M Rely-X™ Luting Cement, a predictable, simple-to-use, resin-reinforced glass ionomer cement. 5. 3M Scotchbond™ Universal bond dentin adhesive can be used as a total etch, selective etch, or self etch product, will also bond to zirconia, and can be used as a light-cure or dualcure product. We use it for our direct composites in a light-cure mode, as well as all of our indirect-bonded restorations. 6. 3M Rely-X™ Veneer Cement, a light-cure-only cement for translucent veneers or all ceramic restorations. I has excellent color stability, easy cleanup, and great shade choices. 7. 3M Rely-X™ Ultimate Adhesive Resin Cement, a dual-cure resin cement for all ceramic inlays, onlays, and crowns, contains the catalyst for the Universal adhesive, making their use together seamless. 8. Magnification, at least 4x power. I have and use both Designs for Vision, Inc., and Orascoptic™. 9. 3M Protemp™ 4 Temporization Material is incredibly durable, especially if cured in a light- and heat-curing oven for 2-3 minutes and also easy to work with and esthetic. 10. Ivoclar Vivadent® IPS e-max® Lithium Disilicate is just a great product, and almost the only material I use for indirect restorations.

24 Implant practice

that story. My most likely other choice besides dentistry would have been plastic surgery, but I am happy I chose dentistry.

What are your top tips for maintaining a successful practice? My top tips are not very complicated — solid clinical quality and a great patient experience. I view dentistry the way I see any customer service business — you have to identify who you want to be as a practice, clearly communicate that to your potential client base so they have the correct expectations about who you are, and then deliver what they were expecting. One of the biggest problems I see for many dentists is they don’t know who they are, and they don’t know what they would like their practice to be like; instead they just take whatever comes their way. Also learning how to treatment plan and to communicate that plan to patients is imperative. Learn to present the results of your examination as a report of findings instead of a treatment plan. Most dentists examine the patient, look at radiographs, and then sit down and formulate a treatment plan, agonizing over how much or how little they should present. That plan then gets put on paper, and now the anxiety level goes up higher as the paper is handed to the patient who immediately looks at the bottom line. Now the dentist tries to justify why they put what they did on the paper; it is a completely illogical order to the process. Instead, do the exam, get radiographs and photographs, and sit down with patients with three goals in mind: 1) to make them aware of all the problems you found, 2) to tell them what you think the consequences will be if no treatment is done, and 3) finally, to inform them of how treatment will benefit the prognosis. Ask patients if they would be interested to hear what the actual treatment options and costs would be for the problem; and if they say no, move on to the next problem. If they say yes, write down the problem, and list potential treatment choices. The fees will be listed later after all the problems have been covered. This allows you, as Dr. Bob Barkley used to say, to “co-diagnose” the patient’s mouth and co-treatment plan, having the patient identify what is a concern for him/her. At the end you may need to phase the treatment over time due to finances and insurance, but the patients now actually know the condition of their mouths, and what the most urgent concerns are, instead of the dentist not sharing the reality of what Volume 10 Number 1

MENTOR YOUR INTERDISCIPLINARY COMMUNITY

Focus your time and energy by bringing a small group of your interdisciplinary community into a Spear Study Club. Six to eight times a year, your study club will work on building clinical skills by collaborating and improving communication on larger, more complex cases provided by Spear.

Visit us at: www.startmystudyclub.com or call 480.738.4094 STUDY CLUB

EDUCATOR PROFILE

(Above) Dr. Frank Spear and his wife, Charlene Spear, dressed to impress at the 1920s-themed party during the Spear Faculty Club Summit 2014. (Right) At the 2015 Spear Faculty Club Summit party, Frank and Charlene wore their best Kentucky Derby-themed outfits

is going on out of the FEAR of scaring the patients away. I would also say I cannot emphasize enough the importance of a cohesive wellaligned and trained TEAM to both growing and maintaining a successful practice. At SPEAR Education, we have surveyed thousands of dentists about what they see as their biggest obstacles in practice; their TEAM always comes out as the number one or two issue they want help with, which is why we have added an entire TEAM training curriculum for all the different TEAM members.

What advice would you give to clinicians who are starting their practices? My daughter got out of dental school in 2008, so I have recent experience with this issue. There can be many different ways of addressing the issue, all of which can be right for different dentists. Whether going into a residency of some type, corporate dentistry, working as an associate, purchasing an existing practice, or opening your own office from scratch, all can work but have different challenges and risks. And one driver today that has to be realized is the amount of debt the new graduate is carrying and what the rate of payback will be. My wife, who retired after 28 years in practice, and I told our daughter we really wanted her to get experience before having her own practice, and we wanted her to get a lot of different experiences. Over 4 years, she worked as an associate in several different 26 Implant practice

offices — some in urban settings, some in rural settings, some fee-for-service-only practices, some all PPO practices — all of them were great learning opportunities for her, but not all were enjoyable learning opportunities, which was part of our intention for her. Dentistry can be very enjoyable, but it can also be very stressful, and the nature of the practice, the patients you are seeing, people you are working with, and procedures you are doing, all impact the ratio of enjoyment to stress, but most dentists never consciously consider that. They just assume if they are busy with patients, all should be fine. After the 4 years, our daughter had a clear picture of the practices she liked, the procedures she enjoyed, and also those she didn’t, which prepared her to move forward looking for a practice suited to her. Her choice was to purchase an existing practice in a suburban setting that was 16 years old. It wasn’t large or fancy, and was roughly 60%-70% PPO patients, but had a fairly large, mostly blue-collar demographic she could draw from, had four operatories equipped with decent equipment, and could be enhanced esthetically fairly inexpensively with some paint and furniture. It also was very reasonably priced, as the previous dentist wasn’t overly productive, meaning there was a lot of dentistry left to do. My point in telling our daughter’s story relates to one other piece of advice I would give young dentists; when it comes time to have your own practice, if you can, try to avoid getting underneath too much overhead too soon. The enjoyment and stress level

of practice are highly correlated to financial burden. Our daughter’s approach allowed her to see patients and get to know them without feeling she had to run them through and produce something every minute of every day. My last piece of advice to young dentists is to continue your education as soon as possible. Dentists are interesting in that they tend to only talk to patients about things they feel competent doing. The reality is there is a lot that a new graduate doesn’t feel competent at, and there is a lot they simply don’t see in a patient’s mouth. An example may be how to diagnose and treatment plan a patient with significant tooth wear. The reality is that we can only treat what we see, and we only see what we have been taught to see. Continuing education expands your vision and competence, and those two things lead to an increased confidence, which leads to an entirely new set of patient conversations. Suddenly, you have patients choosing to do dentistry that you never would have even presented.

What are your hobbies, and what do you do in your spare time? Photography, music (particularly listening to vinyl LPs), golf with my wife, our two mini-Australian labradoodles (Barney and Bailey), fly-fishing for trout or steelhead, cars, food and wine, and most enjoyably, spending time with family and friends, either on trips to Europe, or just hanging around the house. IP Volume 10 Number 1

AUTHOR GUIDELINES Implant Practice US is a peer-reviewed, bimonthly publication containing articles by leading authors from around the world. Implant Practice US is designed to be read by specialists in Periodontics, Oral Surgery, and Prosthodontics.

Submitting articles Implant Practice US requires original, unpublished article submissions on implant topics, multidisciplinary dentistry, clinical cases, practice management, technology, clinical updates, literature reviews, and continuing education. Typically, clinical articles and case studies range between 1,500 and 3,000 words. Authors can include up to 15 illustrations. Manuscripts should be double-spaced, and all pages should be numbered. Implant Practice US reserves the right to edit articles for clarity and style as well as for the limitations of space available. Articles are classified as either clinical, continuing education, technology, or research reports. Clinical articles and continuing education articles typically include case presentations, technique reports, or literature reviews on a clinical topic. Research reports state the problem and the objective, describe the materials and methods (so they can be duplicated and their validity judged), report the results accurately and concisely, provide discussion of the findings, and offer conclusions that can be drawn from the research. Under a separate heading, research reports provide a statement of the research’s clinical implications and relevance to implant dentistry. Clinical and continuing education articles include an abstract of up to 250 words. Continuing education articles also include three to four educational aims and objectives, a short “expected outcomes” paragraph, and a 10-question, multiple-choice quiz with the correct answers indicated. Questions and answers should be in the order of appearance in the text, and verbatim. Product trade names cited in the text must be accompanied by a generic term and include the manufacturer, city, and country in parentheses. Additional items to include: • Include full name, academic degrees, and institutional affiliations and locations • If presented as part of a meeting, please state the name, date, and location of the meeting • Sources of support in the form of grants, equipment, products, or drugs must be disclosed • Full contact details for the corresponding author must be included • Short author bio • Author headshot Volume 10 Number 1

Pictures/images

Disclosure of financial interest

Illustrations should be clearly identified, numbered in sequential order, and accompanied by a caption. Digital images must be high resolution, 300 dpi minimum, and at least 90 mm wide. We can accept digital images in all image formats (preferring .tif or jpeg).

Authors must disclose any financial interest they (or family members) have in products mentioned in their articles. They must also disclose any developmental or research relationships with companies that manufacture products by signing a “Conflict of Interest Declaration” form after their article is accepted. Any commercial or financial interest will be acknowledged in the article.

Tables Ensure that each table is cited in the text. Number tables consecutively, and provide a brief title and caption (if appropriate) for each.

References References must appear in the text as numbered superscripts (not footnotes) and should be listed at the end of the article in their order of appearance in the text. The majority of references should be less than 10 years old. Provide inclusive page numbers, volume and issue numbers, date of publication, and all authors’ names. References should be submitted in American Medical Association style. For example: Journals: (Print) Greenwall L. Combining bleaching techniques. Aesthetic & Implant Dentistry. 2000;1(1):92-96. (Online) Author(s). Article title. Journal Name. Year; vol(issue#):inclusive pages. URL. Accessed [date].

Manuscript Review All clinical and continuing education manuscripts are peer reviewed and accepted, accepted with modification, or rejected at the discretion of the editorial review board. Authors are responsible for meeting review board requirements for final approval and publication of manuscripts.

Proofing Page proofs will be supplied to authors for corrections and/or final sign off. Changes should be limited to those that are essential for correctness and clarity. Articles should be submitted to: Mali Schantz-Feld, managing editor mali@medmarkaz.com

Reprints/Extra issues If reprints or additional issues are desired, they must be ordered from the publisher when the page proofs are reviewed by the authors. The publisher does not stock reprints; however, back issues can be purchased.

Or in the case of a Book: Greenwall L. Bleaching techniques in Restorative Dentistry: An Illustrated Guide. London: Martin Dunitz; 2001. Website: Author or name of organization if no author is listed. Title or name of the organization if no title is provided. Name of website. URL. Accessed Month Day, Year. Example of Date: Accessed June 12, 2011. Author’s name: (Single) Doe JF

(Multiple) Doe JF, Roe JP

Permissions Written permission must be obtained by the author for material that has been published in copyrighted material; this includes tables, figures, pictures, and quoted text that exceeds 150 words. Signed release forms are required for photographs of identifiable persons.

Checklist for article submissions: 3 A copy of the manuscript and figures, captions, including all pictures (low res) necessary for reviewers 3 Manuscript: double-spaced including separate references, figure legends, and tables 3 Abstract, educational objectives, expected outcomes paragraph 3 References: double-spaced, alphabetical, American Medical Association style 3 Tables: titled and cited in the text 3 Mandatory submission form, signed by all authors Please contact managing editor Mali SchantzFeld with any questions via email: Mali@medmarkaz.com

Implant practice 27

IN MEMORIAM

In Memoriam — Dr. Carl E. Misch

ith profound sadness, the Implant Practice US team reports the passing of Carl E. Misch, DDS, MDS, PhD, a pioneer, innovator, and inspiration to the dental profession, who passed away on January 4, at 69 years old. Dr. Misch graduated Magna Cum Laude in 1973 from the University of Detroit Dental School and then received his Prosthodontic Certificate, Implantology Certificate, and Master’s Degree in Dental Science from the University of Pittsburgh. The University of Yeditepe in Istanbul, Turkey, and Carol Davila University of Medicine and Pharmacy in Bucharest, Romania, each awarded Dr. Misch a PhD (honoris causa). His other postgraduate honors included 12 fellowships in dentistry, including the American College of Dentists, International College of Dentists, Royal Society of Medicine, American Association of Hospital Dentistry, and the Academy of Dentistry International. He founded the Misch International Implant Institute in 1984, and it grew to be the primary implant education forum for six dental school specialty residencies. As Director, Dr. Misch trained more than 4,500 doctors in a hands-on, yearly forum of education in implant dentistry. The Misch Implant Institute noted on its Facebook page, “Dr. Misch’s dream was for his principles and concepts to be taught forever as part of his legacy. In doing so, Dr. Misch chose his close friend and colleague of over 30 years, Dr. Randolph Resnik, to succeed him. Dr. Resnik has been by Dr. Misch’s side for every surgical course over the last 30 years and has been the primary speaker for the past year at all Misch programs.”

Dr. Resnik told Implant Practice US, “Carl Misch was a true pioneer who stimulated a renaissance in implantology that will continue to touch everyone he met. Along with his gifts as a highly skilled clinician, he had an uncanny ability to engage and teach fellow dentists what he had learned along the way. He unselfishly gave others the gift of his knowledge, as his true belief was to always ‘share what you have learned.’ Carl Misch was, in the truest sense of the words, a pioneer, teacher, clinician, friend, and colleague who will be missed by all.” Other colleagues offered their recollections of Dr. Misch. “Carl’s long career in dental implantology, his lectures, articles, and textbooks have done more to educate and advance implantology then any other single person. He and his contributions will be missed.” – Dr. Gregori M. Kurtzman “I am very saddened by the passing of a dear friend and colleague. I feel very fortunate to have had Carl in my life as a valued friend as well as a fantastic teacher. I was privileged to be with Carl in August, September, and October 2016 doing what he loved most in the last months of his life — teaching with conviction and passion the principals of implant dentistry that must be followed to insure success. I first met Carl in 1977, when he came to Cincinnati to watch me do live surgical demonstrations in placing aluminum-oxide root-form implants. He demonstrated at that time his tremendous thrust for knowledge regarding implant surgery and prosthetics that he carried the remainder of his professional life. “When Carl wanted to do something,

“Carl Misch was a true pioneer who stimulated a renaissance in implantology that will continue to touch everyone he met. Along with his gifts as a highly skilled clinician, he had an uncanny ability to engage and teach fellow dentists what he had learned along the way. ...” 28 Implant practice

whether it was professional or private, he did it. I first witnessed this in about 1987 in a course that we did together in Iowa. The course was at a hotel in late summer or early fall. Carl decided that he wanted to go swimming at the end of the day after we finished the course. The swimming pool was closed and was surrounded by a tall chain link fence. That didn’t deter Carl. He climbed that tall fence and jumped into the pool. At that moment, I thought that this guy is strong, smart, determined, and nothing is going to stop him from accomplishing his goals. “May Dr. Misch rest in peace. I will miss him, but he will continue to live in my good memories. I am thankful that in our last course that we did together this past October, I got the chance to tell him that I love him.” – Dr. Jack Hahn “Every dentist who places dental implants and every patient who has ever had a dental implant or will ever need one owes Dr. Carl Misch a debt of gratitude. Without his unwavering faith in dental implants being the best solution for tooth replacement, we would not be where we are today. He took the arrows to the back so that we can provide our patients the very best in care. Many of us lost a friend, mentor, and a colleague in the passing of Dr. Misch; the planet lost a giant who truly made a difference in millions of peoples’ lives and left this world in a better place.” – Dr. Justin Moody In lieu of flowers, memorial contributions may be made to the Misch Legacy Endowment www.icd.org/global-visionaryfund. The Misch Legacy Endowment, a joint venture of the International Congress of Oral Implantology and the International College of Dentists, is a $1 million campaign to advance oral healthcare worldwide. IP Volume 10 Number 1

by Jill Helms, DDS, PhD, Professor of Surgery, Stanford Medicine Dental clinicians need to redefine beauty Dental clinicians often play instrumental roles in restoring the integrity of a patient’s face; they also are in a unique position to help their patients appreciate the internal beauty as well. This is what I plan to address during my keynote presentation, titled “Beauty Reconsidered,” at AO’s 2017 Annual Meeting. Neuroscientists tell us that our brains are hard-wired to recognize and respond to beauty. There is a region of the brain where neurons specifically fire when we gaze upon a face. Within months of birth, infants use this brain region to recognize and discriminate among faces and the emotions portrayed by these faces. So, when something disrupts our facial appearance — whether it is caused by disease, deformity, or trauma — it can have a profound impact on how others see us — and how we see ourselves. Facial changes affect our sense of well-being. That’s why it is critical for dental clinicians to treat the whole person. You aren’t just restoring a part of patients’ anatomy; you are restoring their sense of completeness. There may be surgical limitations to the repair, but as you approach patients’ restorative plan, I urge to you to consider how you can assist them in redefining what is beautiful. Join me at AO’s 2017 Annual Meeting, being held March 15-18 in Orlando, Florida. Let’s do this together. Let’s teach ourselves and your patients that beauty is not be determined by a surgical outcome alone. Beauty is defined by authenticity, compassion, and perseverance in the face of adversity. I hope this talk helps to guide you on a journey that goes beyond a validation of external beauty and gets to the deeper business of appreciating the beauty that exists inside each of us.

About the 2017 Annual Meeting The meeting will be collaboration with the American Association of Oral and Maxillofacial Surgeons (AAOMS), the American Academy of Periodontology (AAP), and the American College of Prosthodontists (ACP). It will also feature an innovative session focusing on practice delivery systems called, “The Business of Implant Dentistry” moderated by Bill Ryan. Dr. Ole Jensen will be moderating a session highlighting developments that have occurred since the AO Sinus Consensus Conference. This session will feature Drs. Alan Herford, Craig Misch, Paul Fugazzotto, and Eric Dierks. The closing session will focus on the “team approach” to the treatment of various clinical problems. Several international teams will be presenting. The closing session will focus on the “team approach” to the treatment of various clinical problems. For registration, program, and travel details, visit http://meetings.osseo.org/. Volume 10 Number 1

MEETING NEWS

AO Orlando preview

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easy-graft ® CLASSIC alloplastic bone grafting system

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rated it excellent or good and worthy of trial by colleagues.* Full-report is available at http://us.guidor.com/cliniciansreport/

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For more information, go to http://us.guidor.com or stop by SUNSTAR booth at Chicago Midwinter (#4201), Hinman (#1218) or AO Annual Meeting (#433) Now available through your Preferred Dealer Your e Choic or Direct from Sunstar. For more information visit: http://us.guidor.com/yourchoice

To learn more, visit http://us.GUIDOR.com/easy-graft/ or call 1-877-484-3671. Instructions for Use (IFU), including indications, contraindications, precautions and potential adverse effects, are available at http://us.GUIDOR.com/IFU/. © 2017 Sunstar Americas, Inc. All rights reserved. GDR17001 01052017v1 The trademarks GUIDOR, easy-graft and BioLinker are owned by Sunstar Suisse, SA.

Implant practice 29

CONTINUING EDUCATION

Full arch implant-supported oral rehabilitation: a literature review Dr. Vasileios Soumpasis looks at the evidence base for complete oral rehabilitation using implant-retained prostheses

ehabilitation of complete maxillary arches is often complicated by bone that is not only of poor quality but also scarce (Mozzati, et al., 2012). Corrections can be made, in part, through constructive surgery and bone grafting. These more complex techniques, however, can cause discomfort and disturbance to the patient and often are poorly accepted because they take longer and involve more surgical procedures compared to less invasive techniques (Mozzati, et al., 2012). A number of studies have shown that treatment with tilted implants (that is, implants placed at positions off the vertical axis) may be a viable alternative in the distal parts of the mouth. Tilting allows for the use of a longer implant that is able to reach better-quality bone, which can lead to a final prosthesis built with the aim of reducing or eliminating cantilevers (Malo, et al., 2003, 2005, 2011; Testori, et al., 2008). Agliardi proposed tilted implants that do not interfere with the maxillary sinus floor for the rehabilitation and immediate loading of complete maxillary arches with atrophic posterior sections, which can lead to high degrees of patient satisfaction (Agliardi, et al., 2010; Capelli, et al., 2007; SzmuklerMoncler, et al., 2000). Moreover, this procedure eliminates the need for the patient to wear provisional removable dentures during the periods before and after healing, which is a typical requirement of the traditional protocol (Drago, Lazzara, 2006). The benefits of this protocol are not limited to time reductions but also include enhanced tissue stimulation induced by the immediate loading, which has a beneficial effect on both the healing process and the time required before good-quality tissue is visible (Davies, 1998; Duyck, 2006). According to Del Fabbro and Ceresoli (2014), tilting of the implants does not induce

Vasileios Soumpasis, DDS, MSc, is a resident clinician at Evodental Heathrow.

30 Implant practice

Educational aims and objectives

This clinical article aims to present a literature review on the existing evidence base for full arch implant-supported oral rehabilitation.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 36 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Recognize tilted implants as a viable alternative in certain circumstances.

•

Realize some benefits of immediate implant placement.

•

Identify some accepted parameters for assessing oral implant success.

•

Identify four risk factors for implant failure.

•

Identify biomechanics of full arch implant-supported prostheses.

significant alteration to crestal bone level as compared to conventional axial placement after 1 year of function. This trend seems to be unchanged over time even though the amount of long-term data is still scarce. The use of tilted implants to support fixed partial and full arch prostheses for the rehabilitation of edentulous jaws can be considered to be a predictable technique with an excellent prognosis in both the short- and mid-term. Further long-term trials, possibly randomized, are needed to determine the efficacy of this surgical approach and the remodeling pattern of marginal bone in the long term (Del Fabbro, Ceresoli, 2014). The use of tilted implants with angled abutments to reduce cantilever length could be considered a viable therapeutic option from a biomechanical point of view (Francetti, et al., 2015). Tilted implants should be placed mesially or in direct contact with the mesial walls of the maxillary sinus without invasion or rupture of the Schneiderian membrane (Jensen, et al., 2010).

Immediate placement The reported advantages of immediate implant placement include a reduction in the number of surgical interventions, shortened rehabilitation time, and higher patient satisfaction compared with late implant placement (Gokcen-Rohlig, et al., 2010;

Penarrocha-Diago, et al., 2011; Soydan, et al., 2013). Another advantage of implant placement in the extraction socket is the counteracting of the hard tissue resorption that occurs following tooth extraction (Bhola, et al., 2008). Altintas, et al. (2016), stated the success rate of immediately placed implants is 97.8%. With thorough patient evaluation, the extraction of all residual teeth and implant placement in a single surgical procedure are a safe and predictable treatment modality for successfully rehabilitating the edentulous patient with a fixed prosthesis. Implant placement in fresh extraction sockets is technique sensitive because primary implant stability is critical (Altintas, et al., 2016). Implants placed immediately into fresh extraction sites engage precisely prepared bony walls only in their apex, whereas the coronal space is filled by the end of the healing phase (Polizzi, et al., 2000). It has been stated that the procedure should be limited to alveoli with sufficient bone for primary stability, which is generally achieved by exceeding the apex by 3 mm-5 mm or by using implants that are wider than the alveolus (De Rouck, et al., 2008). To achieve these conditions, a minimum of 4 mm-5 mm of alveolar crest width and a residual bone length no less than 10 mm is recommended (Becker, Goldstein, 2008). It is also suggested that periodontitis-affected Volume 10 Number 1

Volume 10 Number 1

Buser, et al. (1991), showed that bone implant contact increased from 37.5% for titanium plasma-sprayed implants to 55% for those with a sandblasted, large grit, and acid-etched surface. The insertion of dental implants in fresh extraction sockets affects the implant failure rates. However, Chrcanovic, et al. (2015), found that it does not affect the marginal bone loss or the occurrence of postoperative infection. A statistically significant difference was not found for implant failures when studies evaluating implants inserted in maxillae or in mandibles were pooled, or when the studies using implants to rehabilitate patients with full arch prostheses were pooled. The difference was statistically significant between the procedures for the studies that rehabilitated patients with implant-supported single crowns. After a follow-up of 18 and 24 months, both Mozzati, et al. (2012), and Grandi, et al. (2012), found 100% success rates for immediately placed implants and definitive prostheses for 45 and 47 patients, respectively, suggesting that immediately loaded mandibular cross-arch fixed dental prostheses can be supported by four postextraction implants.

Survival and success Fixed-implant prosthetic restorations supported on four implants represent a wellproven treatment modality for rehabilitation of the edentulous mandible (Malo, et al., 2003; Grandi, et al., 2012; Crespi, et al., 2012; Krennmair, et al., 2016). However, recently the main focus in oral implant surgery has shifted from survival to success and to peri-implant infections (Zitzmann, Berglundh, 2008; Klinge, Meyle, 2012; Tomasi, Derks, 2012). Therefore, the most frequently used and accepted parameters for assessing oral implant success are related to peri-implant marginal bone loss, peri-implant soft tissue health, prosthesis stability, and patientsâ&#x20AC;&#x2122; subjective evaluation (Krennmair, et al., 2016). Concerning the influence of the prosthetic rehabilitation on the failure rates, Chrcanovic, et al. (2015), found a statistically significant difference between the procedures when studies only evaluating patients with implant-supported single crowns were pooled, the same not happening when full arch prostheses were the only prosthetic rehabilitation performed. The splinting of the implants in full arch prostheses allows a more even distribution of the occlusal forces, thereby reducing stresses at the bone-implant interface

(Wang, et al., 2002) as well as micromotion (Vogl, et al., 2015). The following variables were assessed: implant success rate; peri-implant soft tissue conditions; biological and prosthetic post-loading complications; radiographic peri-implant marginal bone loss; patient satisfaction; and quality of life following implant therapy. In their systematic review, Kwon, et al. (2014), stated that implants and full arch fixed-dental hybrid prostheses showed rather high short-term survival rates, but due to limited available literature, their long-term survival rates could not be obtained. Furthermore, selected studies were vulnerable to potential bias sources. Clinicians should therefore be aware of the aforementioned limitations in existing literature, and apply this treatment concept in clinical practice on carefully selected cases. Although an implant-supported fixed-dental hybrid prosthesis may be a valuable option for a patient with a completely edentulous ridge, the strategic removal of teeth with satisfactory prognosis for the sake of delivering an implant-supported full arch dental hybrid prosthesis should also be voided. Various risk factors can threaten oral implant treatment success, and four risk categories can be identified: 1. Complications during surgery 2. Loss or impending loss of implant 3. Fracture or wear of supra-structure parts 4. Patient dissatisfaction with outcomes (Fischer and Stenberg 2013) Fischer and Stenberg (2013) found that for patients, prosthodontists, and third-party providers (such as insurance companies, for example), modifications, repairs, or remakes of the initially expensive implant-supported reconstructions can lead to monetary, emotional, and social costs, if information concerning these costs is not explained prior to treatment. Pterygoid (Balshi, et al., 1999) and tuberosity (Bahat, 1992; Khayat, Nader, 1994; Venturelli, 1996) implants represent other treatment options to restore the edentulous maxilla. Although these techniques may represent viable therapeutic options, because they provide suitable posterior anchorage, they require considerable surgical experience (Galan Gil, et al., 2007; Aparicio, et al., 2008). In the literature, the available data provided promising results for CAD/CAMfabricated implant-supported restorations (Patzelt, et al., 2015); nonetheless, current Implant practice 31

CONTINUING EDUCATION

tissues may have a negative local influence on the failure rates due to the presence of infra-bony defects, which could increase the gap between bone and implant (Cosyn, et al., 2012) or jeopardize the achievement of primary stability (Ivanoff, et al., 1996) at immediate implant placement. However, it is not known to what extent periodontitis may contribute to the difference in failure rates between immediate and non-immediate implants (Chrcanovic, et al., 2015). The higher failure rate of immediate implants in relation to non-immediate implants in the maxilla in comparison to the mandible may be attributed to the low density of medullary bone and thin cortical plates (Kourtis, et al., 2004), which may have resulted in significant reduction in insertion torque for implants in the maxilla and fewer implants with primary stability, and further resulted in a lack of resistance to mechanical stresses (Horwitz, et al., 2007). For that reason, achieving bicortical fixation and splinting of the implants with a rigid metal framework within 10 days after surgical placement is crucial. Raes, et al. (2013), observed that a trend toward bone gain was found following insertion in fresh extraction sockets, which may be explained by the fact that the gap between the original bone and implant diminishes during healing, and the bone-to-implant contact increases in coronal direction during the healing phase. These findings can be related to a coronal bone remodeling around immediate implants and a healing pattern with new bone apposition around the neck of the implants (Covani, et al., 2003). Most of the studies, if not all, do not reveal how many implants were inserted and survived/lost in several different conditions. The use of grafting in some studies is a confounding risk factor, as well as the placement of implants in different locations, with different healing/loading periods, different prosthetic configurations, varying types of opposing dentition, implant splinting, and the presence of smokers, diabetics, or periodontally compromised patients. Moreover, in these studies, different implant brands and surface treatments were used (Chrcanovic, et al., 2015). It is not clear whether, in general, one surface modification is better than another (Wennerberg, Albrektsson, 2010). The initial studies on osseointegration were conducted on implants with turned surfaces. Since then, enhanced implant surface technology has been developed to improve the predictability, rate, and degree of osseointegration.

CONTINUING EDUCATION evidence is limited due to the quality of available studies and the paucity of data on longterm clinical outcomes of 5 years or more. In the sense of an evidence-based dentistry, the authors recommend further studies designed as randomized controlled clinical trials and reported according to the CONSORT statement.

The biomechanics of implantsupported full arch prostheses Impression procedures should be executed with the mouth half-closed using individual anatomic impression trays, under conditions of muscle relaxation (Fischman, 1990). The reported biomechanical problems resulting from torsional mandibular deformation are more critical in patients showing parafunctional habits, such as bruxism. In implant-supported fixed prostheses, an optimal biomechanical distribution of stresses at the prosthetic superstructure and implant infrastructure is of paramount importance (Rangert, et al., 1989), being influenced by many different factors such as correct prosthetic design and occlusal scheme (Apicella, et al., 1998), among others. Several opinions on optimal mandibular cantilever length are found in the literature, including that the length should be no more than 20 mm (Naert, et al., 1992); less than 20 mm; and preferably less than 15 mm — equivalent to two teeth distal to the most posterior abutment (Adell, et al., 1981); the shorter, the better (Jacques, et al., 2009; Greco, et al., 2009); and equivalent to double the diameter of the abutment in the anterior region and to the diameter of the abutment in the posterior region (Apicella, et al., 1998). Conversely, others believe that bone loss around implants and/or loss of osseointegration are mainly associated with biologic complications such as infection around the implant (Naert, et al., 2012), stating that the evidence is not enough to support the hypothesis that occlusal overload leads to marginal bone loss. However, it bears emphasizing that occlusal overload may lead to mechanical complications, such as screw loosening and/or fracture, prosthesis fracture, and implant fracture (Schwarz, 2000). The clinical success of osseointegration and long-term survival of dental implants depend on several biomechanical factors, and they are influenced by the way the mechanical stresses are transferred from the implant to the surrounding bone (Kregzde, 1993). Studies related to the biomechanics of implant-supported prostheses (Barbier, et al., 1998; Teixeira, et al., 1998; Chun, et 32 Implant practice

al., 2005) have shown that a major cause of bone resorption is excessive load on the implant once, when submitted to the load application, it transmits the stresses generated directly to the bone (Brånemark, et al., 1977; Skalak, 1983). This may be influenced by the type of loading, the nature of the bone/implant interface; the length, diameter, shape, and surface characteristics of the implant; the type and properties of prosthesis material; and the quantity and quality of surrounding bone (Geng, et al., 2001). In the classical protocol, Brånemark, et al., recommended acrylic resin as the material of choice for the occlusal surface of implant-supported fixed dentures. The acrylic occlusal surfaces would cushion the masticatory forces due to its resilience, leading to a relatively physiological load on bone-implant interface (Skalak, 1983; Adell, et al., 1981). Although acrylic resin presents low stress levels in the bone and around the implants (Yalçın, Canay, 2000) when used on the occlusal surface, it shows complications such as wear and tooth fracture clinically (Stegaroiu, et al., 1998; Soumeire, Dejou 1999). Porcelain is another material option for artificial teeth and presents greater wear resistance and provides more favorable esthetic results than acrylic resin. However, some authors report that porcelain is a more rigid material and does not absorb stress, meaning the forces developed in the occlusal surface are transmitted directly to the prosthesis, implant and bone/implant interface, unless they are interrupted somehow (Geng, et al., 2001; Van Rossen, et al., 1990; Jemt, et al., 1989). Hence, a combination of a rigid prosthetic superstructure with a resilient esthetic veneering material is mandatory for the success of full arch rehabilitation via implantsupported fixed prostheses. This approach requires site-specific placement to maximize the biomechanical advantage of the All-on-4® distribution (Malo, et al., 2003). This is best facilitated by bone reduction — not augmentation — to create the All-on-4 shelf, which serves multiple functions for both surgeon and prosthodontist, as follows: 1. Establishment of prosthetic restorative space 2. Establishment of a level alveolar plane and uniform implant levels 3. Establishment of alveolar width for implant diameter selection 4. Bone reduction makes basal bone accessible for implant fixation

5. Helps establish arch form, implant distribution, and anterior posterior spread 6. Identifies optimal implant sites 7. Identifies secondary implant sites 8. Exposes lingual plate width and lingual concavities 9. Facilitates posterior implant placement with respect to the nerve 10. Provides bone stock for secondary bone grafting (Jensen, et al., 2011) Several techniques have been employed to evaluate the biomechanical behavior of an implant-supported prosthesis — for example, photoelasticity (Bernardes, et al., 2009; Karl, et al., 2009), strain gauges (Karl, et al., 2007, 2005) and two- or three-dimensional finite element analysis (FEA) (Lin, 2008; Ding, et al., 2009). Bone remodeling followed, as anticipated from Wolff’s law: Bone in a healthy person or animal will adapt to the loads under which it is placed (Klineberg, et al., 2012). Bone reacts to strain (through deformation), and where bone strain surrounding implants is in “mild overload” (1,500-3,000 micro-strains), bone apposition (derived from finite element analysis [FEA] and mathematical modeling) appears to be facilitated. It also appears from FEA modeling that there is a generic threshold of bone strain below, which remodeling does not occur, and predisposes to resorption and peri-implant bone loss (Frost, 2004; Blanes, 2009). Optimal design of implant superstructures should maximize bone density and bone remodeling, reduce healing time, and increase bone-implant contact Although there is minimal research focusing on this issue, given the preceding data, the clinical recommendations are that occlusal design should follow a narrow occlusal table, with central fossa loading in intercuspal contact and low cusp inclination to minimize lateral loading in function and parafunction. Clinical recommendations are based on available data: There is justification for specific occlusal design features to include: 1. Anterior guidance for protrusive and lateral contacts in function and parafunction 2. Posterior occlusal form of low cusp inclines 3. Central fossa location of opposing supporting cusps for minimizing lateral loads on teeth and implants Variables of occlusal design influence bone strain and bone mineral density, and microarchitecture varies within the jaw. This data confirms the anterior mandible as the Volume 10 Number 1

Regarding grafting The rehabilitation of the posterior edentulous maxilla with implant-supported prostheses is often challenging because of the Volume 10 Number 1

The use of bone grafting and sinus elevation to increase bone volume may be a viable treatment option. poor quality and quantity of residual jawbone, especially in patients with long-term edentulism (Agliardi, et al., 2009). The use of bone grafting and sinus elevation to increase bone volume may be a viable treatment option (Del Fabbro, et al., 2004; Menini, et al., 2012) to allow implant placement in the atrophic maxilla; however, these procedures are associated with more frequent complications, higher morbidity, increased costs, and duration of treatment time (Sorni, et al., 2005). Grafted sites usually do not attain sufficient primary stability for immediate loading protocols, and delayed loading protocols are needed (Menini, et al., 2012). Patient acceptance of these protocols is low, due to the invasive nature, increased duration, and costs of treatment (Testori, et al., 2008; Del Fabbro, et al., 2004).

Patient outcomes, decision making, and treatment planning Edentulism can be disabling and has a profound negative impact on the quality of life of patients (Fiske, et al., 1998; Strassburger, et al., 2006). The latter is particularly relevant in the mandible, where conventional dentures more frequently have a negative impact on the patient’s quality of life (Perea, et al., 2013). The increased request for implant therapy results from a combination of various factors, including age-related tooth loss, anatomic condition of edentulous ridges, psychological needs, decreased performance of removable prostheses, predictable long-term results of implant-supported prostheses, and increased awareness from both clinicians and patients of the benefits of implants (Weinstein, et al., 2012). Most patients wearing complete dentures complain about progressive loss of stability during phonetics and mastication, and request for a fixed rehabilitation. Furthermore, progressive bone loss in the posterior mandible may lead to a superficialization of the alveolar nerve, which may cause pain to denture wearers during mastication. All attempts to minimize stress should be done at the treatment planning stage, healing, and provisional stages, and finally, at the delivery of the permanent prosthesis. This

can be accomplished by selecting implants of proper size, with width being more important than length (Lum, Osier, 1992; Lum, 1991), proper implant number, proper position, and by having an appropriate occlusal scheme (Gittelson, 2002).

Loading The existing literature provides high evidence that immediate loading of microtextured dental implants with one-piece fixed interim prostheses in both the edentulous mandible and maxilla is as predictable as early and conventional loading (Gallucci, et al., 2014). It is possible to successfully load dental implants immediately or early after their placement in selected patients, although not all clinicians may be able to achieve optimal results with immediate loading. A high degree of primary implant stability (high value of insertion torque) seems to be one of the prerequisites for a successful procedure (Esposito, 2007). Primary stability can be improved by using a tapered implant in a slightly underprepared implant site. This may lead to high compression forces and elevated insertion torques. Khayat, et al. (2013), showed that there was no difference in marginal bone loss between implants placed at low torque (mean = 37.1 Ncm) and those placed at a very high experimental torque (mean = 110.6 Ncm). It had previously been postulated that osteonecrosis would result due to disturbance of local microcirculation at high torque values. Tilted implants significantly improve prosthesis support, while also allowing for longer implants to be placed with improved bone anchorage (Krekmanov, et al., 2000). Static continuous loads on implants result in increased bone density (Gotfredsen, et al., 2001). The transient loads generated in function trigger bone remodeling (Heitz-Mayfield, et al., 2004). Klineberg, et al. (2012), found that a key element is the primary stability of the implant, which varies with bone density in different regions of the mouth. Mechanical stress may have a positive and negative consequence on remodeling bone dependent on the magnitude, frequency, and type of loading. There is an optimal functional strain which encourages Implant practice 33

CONTINUING EDUCATION

most suitable bone structure for implant loading (Klineberg, et al., 2012). The so-called “postoperative remodeling process” may be attributed to several factors such as implant type, implant positioning, and different surgical procedures followed by different prosthodontic procedures (Krennmair, et al., 2016). According to the accepted remodeling process, success criteria established by Albrektsson, et al. (1986), 1 mm remodeling of the bone contour and an additional 0.2 mm of bone loss during the following years are considered as an acceptable healing outcome. Splinting is important to limit micromovement of implants and ensure osseointegration. The rigid splinting of the implants by a cast metal bar to support a full arch implantsupported prosthesis has shown successful outcomes. Paniz, et al. (2013), concluded in an in vitro study that: • Absolute passive fit cannot be achieved, regardless of the type of material and technique used. • Anatomic cast frameworks showed significantly larger center point deviations compared to milled anatomic frameworks fabricated through digital technology. Anatomic cast framework accuracy is strictly related to adaptation of the framework through cutting and soldering. • Anatomic milled frameworks fabricated in titanium or cobalt-chrome displayed reduced center point deviation compared to the cast frameworks. No statistically significant differences were present between the two milled materials (Millen, et al., 2015). Millen, et al. (2015), in a systematic review came to the conclusion that a higher incidence rate of technical and biologic complications was seen with cementretained prostheses. Karl and Taylor, in their randomized clinical trial (2016), observed that bone adaptation around statically and dynamically loaded implants occurred, causing a decrease in misfit strain evoked by non-passively fitting prostheses. Hence, for maintaining osseointegration of dental implants, passivity of fit of multi-unit restorations seems not to be as critical as previously thought.

CONTINUING EDUCATION bone remodeling with increased bone volume and density, which maintains osseointegration and implant stability. Where stress levels are within the physiological load-bearing capacity of the bone, remodeling occurs. High stress leads to bone remodeling where stress levels are within the load-bearing capacity of the bone.

Immediate loading Immediate loading of implant-supported full arch prostheses for the edentulous mandible and maxilla is today a predictable procedure, associated with high level of satisfaction for the patients in terms of esthetics, phonetics, and functionality (Esposito, 2007; Castellon, et al., 2004; Chiapasco, 2004; Misch, et al., 2004; Ioannidou, Doufexi, 2005; Attard, Zarb, 2005; Del Fabbro, et al., 2006; Jokstad, Carr, 2007). Immediate loading of the implants not only has a positive impact on the patient’s esthetics and functional comfort, but also improves the outcome of the implants (Collaert, De Bruyn, 2008). Between the two, the mandible is ideal for immediate loading compared with the maxilla because of the better condition of the bone in relation to quality, quantity, and axial loading conditions. Early short-term studies on immediate loading in the completely edentulous maxilla show survival rates between 87.5% and 100% (Collaert, DeBruyn, 2008). The use of an immediate loading protocol decreases the duration of treatment and the number of visits necessary to complete it, eliminates the discomfort that comes from wearing a removable prosthesis over the surgical site, and yields the patient the opportunity to be under the care of a prosthodontic team even at remote distances (Balshi, Wolfinger, 2002). Because of new implant designs and surface configurations and better surgical procedures, the time frame between implant placement and functional loading has been shortened (Vervaeke, et al., 2013). Additionally, the rigid splinting of the implants 0-10 days after placement will avoid micromotion during the healing phase. It appears that premature loading per se does not lead to fibrous tissue encapsulation (Chrcanovic, et al., 2015). There is no consensus on the threshold that cannot be surpassed, but it is believed to range between 50μm and 150μm (SzmuklerMoncler, et al., 2000; Soballe, 1993; Soballe, et al., 1992; Szmukler-Moncler, et al., 1998). Dental implants in periodontally susceptible patients show radiographic bone changes 34 Implant practice

similar to previous reports in the literature regarding patients with and without a history of periodontitis. After the first year, immediately restored implants exhibited bone loss rates similar to those seen around conventionally restored implants (Horwitz, Machtei, 2012). Immediate loading of dental implants results in a significant reduction in treatment time and morbidity for patients by avoiding a second surgery to uncover the implants. A comparative clinical trial showed that this protocol results in significantly higher patient satisfaction (Schropp, et al., 2004). IP

prostheses supported by either upright or tilted implants: a multicenter clinical study. Int J Oral Maxillofac Implants. 2007;22(4):639-644. 19. Castellon P, Blatz MB, Block MS, Finger IM, Rogers B. Immediate loading of dental implants in the edentulous mandible. J Am Dent Assoc. 2004;135(11):1543-1549. 20. Chiapasco M. Early and immediate restoration and loading of implants in completely edentulous patients. Int J Oral Maxillofac Implants. 2004;19(suppl):76-91. 21. Chrcanovic BR, Albrektsson T, Wennerberg A. Dental implants inserted in fresh extraction sockets versus healed sites: a systematic review and meta-analysis. J Dent. 2015; 43(1):16-41. 22. Chun HJ, Park DN, Han CH, Heo SJ, Heo MS, Koak JY. Stress distributions in maxillary bone surrounding overdenture implants with different overdenture attachments. J Oral Rehabil. 2005;32(3):193-205. 23. Collaert B, De Bruyn H. Immediate functional loading of TiOblast dental implants in full-arch edentulous maxillae: a 3-year prospective study. Clin Oral Implants Res. 2008; 19(12):1254-1260. 24. Cosyn J, Vandenbulcke E, Browaeys H, Van Maele G, De Bruyn H. Factors associated with failure of surfacemodified implants up to four years of function. Clin Implant Dent Relat Res. 2012;14(3):347-358.

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25. Covani U, Cornelini R, Barone A. Bucco-lingual bone remodeling around implants placed into immediate extraction sockets: a case series. J Periodontol. 2003;74(2):268-273. 26. Crespi R, Vinci R, Cappare P, Romanos GE, Gherlone E. A clinical study of edentulous patients rehabilitated according to the “all on four” immediate function protocol. Int J Oral Maxillofac Implants. 2012;27(2):428-434. 27. Davies JE. Mechanisms of endosseous integration. Int J Prosthodont. 1998;11(5):391-401. 28. Degidi M, Nardi D, Piattelli A. Immediate rehabilitation of the edentulous mandible with a definitive prosthesis supported by an intraorally welded titanium bar. Int J Oral Maxillofac Implants. 2009; 24(2): 342-347. 29. Del Fabbro M, Testori T, Francetti L, Weinstein R. Systematic review of survival rates for implants placed in the grafted maxillary sinus. Int J Periodontics Restorative Dent. 2004;24(6):565-577. 30. Del Fabbro M, Testori T, Francetti L, Taschieri S, Weinstein R. Systematic review of survival rates for immediately loaded dental implants. Int J Periodontics Restorative Dent. 2006;26(3):249-263. 31. Del Fabbro M, Ceresoli V. The fate of marginal bone around axial vs. tilted implants: a systematic review. Eur J Oral Implantol. 2014; 7(suppl 2):S171-189. 32. De Rouck T, Collys K, Cosyn J. Single-tooth replacement in the anterior maxilla by means of immediate implantation and provisionalization: a review. Int J Oral Maxillofac Implants. 2008;23(5):897-904. 33. Ding X, Zhu XH, Liao SH, Zhang XH, Chen H. Implant-bone interface stress distribution in immediately loaded implants of different diameters: a three-dimensional finite element analysis. J Prosthodont. 2009;18(5):393-402. 34. Drago CJ, Lazzara RJ. Immediate occlusal Loading of Osseotite implants in mandibular edentulous patients: a prospective observational report with 18-month data. J Prosthodont. 2006;15(3):187-194. 35. Duyck J, Vandamme K, Geris L, et al. The influence of micro-motion on the tissue differentiation around immediately loaded cylindrical turned titanium implants. Arch Oral Biol. 2006;51(1):1-9. 36. Esposito M, Grusovin MG, Willings M, Coulthard P, Worthington HV. The effectiveness of immediate, early, and conventional loading of dental implants: a Cochrane systematic review of randomized controlled clinical trials. Int J Oral Maxillofac Implants. 2007;22(6):893-904. 37. Fischer K, Stenberg T. Prospective 10-year cohort study based on a randomized, controlled trial (RCT) on implantsupported full-arch maxillary prostheses. part II: prosthetic outcomes and maintenance. Clin Implant Dent Relat Res. 2013;15(4):498-508. 38. Fischman B. The rotational aspect of mandibular flexure. J Prosthet Dent. 1990;4(4):483-485. 39. Fiske J, Davis DM, Frances C, Gelbier S. The emotional effects of tooth loss in edentulous people. Br Dent J. 1998;184(2):90-93. 40. Francetti L, Rodolfi A, Barbaro B, Taschieri S, Cavalli N, Corbella S. Implant success rates in full-arch rehabilitations supported by upright and tilted implants: a retrospective investigation with up to five years of follow-up. J Periodontal Implant Sci. 2015;5(6):210-215. 41. Frost HM. A 2003 update of bone physiology and Wolff’s Law for clinicians. Angle Orthod. 2004;74(1):3-15. 42. Galan Gil S, Penarrocha Diago M, Balaguer Martinez J, Marti Bowen E. Rehabilitation of severely resorbed maxillae with zygomatic implants: an update. Med Oral Patol Oral Cir Bucal. 2007;12(3):E216-E220.

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68. Kourtis SG, Sotiriadou S, Voliotis S, Challas A. Private practice results of dental implants. Part I: survival and evaluation of risk factors--Part II: surgical and prosthetic complications. Implant Dent. 2004;13(4):373-385.

44. Geng JP, Tan KB, Liu GR. Application of finite element analysis in implant dentistry: a review of the literature. J Prosthet Dent. 2001;85(6):585-598.

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46. Gӧkçen-Rohlig B, Meriç U, Keskin H. Clinical and radiographic outcomes of implants immediately placed in fresh extraction sockets. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;109(4):e1-e7. 47. Gotfredsen K, Berglundh T, Lindhe J. Bone reactions adjacent to titanium implants subjected to static load of different duration. A study in the dog (III). Clin Oral Implants Res. 2001;12(6):552-558. 48. Grandi T, Guazzi P, Samarani R, Grandi G. Immediate loading of four (All-on-4) post-extractive implants supporting mandibular cross-arch fixed prostheses: 18-month follow-up from a multicenter prospective cohort study. Eur J Oral Implantol. 2012;5(3):277-285. 49. Greco GD, Jansen WC, Landre Junior J, Seraidarian PI. Stress analysis on the free-end distal extension of an implant-supported mandibular complete denture. Braz Oral Res. 2009;23(2):182-189. 50. Heitz-Mayfield LJ, Schmid B, Weigel C, et al. Does excessive occlusal load affect osseointegration? An experimental study in the dog. Clin Oral Implants Res. 2004;15(3):259-268. 51. Horwitz J, Zuabi O, Peled M, Machtei EE. Immediate and delayed restoration of dental implants in periodontally susceptible patients: 1-year results. Int J Oral Maxillofac Implants. 2007;22(3):423-429. 52. Horwitz J, Machtei EE. Immediate and delayed restoration of dental implants in patients with a history of periodontitis: a prospective evaluation up to 5 years. Int J Oral Maxillofac Implants. 2012;27(5):1137-1143. 53. Ioannidou E, Doufexi A. Does loading time affect implant survival? A meta-analysis of 1,266 implants. J Periodontol. 2005;76(8):1252-1258. 54. Ivanoff CJ, Sennerby L, Lekholm U. Influence of initial implant mobility on the integration of titanium implants. An experimental study in rabbits. Clin Oral Implants Res. 1996;7(2):120-127. 55. Jacques LB, Moura MS, Suedam V, Souza EA, Rubo JH. Effect of cantilever length and framework alloy on the stress distribution of mandibular-cantilevered implant-supported prostheses. Clin Oral Implants Res. 2009;20(7):737-741. 56. Jemt T, Lekholm U, Adell R. Osseointegrated implants in the treatment of partially edentulous patients: a preliminary study on 876 consecutively placed fixtures. Int J Oral Maxillofac Implants. 1989; 4(3):211-217. 57. Jensen OT, Adams MW, Cottam JR, Parel SM, Phillips WR 3rd. The all-on-4 shelf: mandible. J Oral Maxillofac Surg. 2011; 69(1):175-181. 58. Jensen OT, Adams MW, Cottam JR, Parel SM, Phillips WR 3rd. The all-on-4 shelf: maxilla. J Oral Maxillofac Surg. 2010; 68(10):2520-2527. 59. Jokstad A, Carr AB. What is the effect on outcomes of time-to-loading of a fixed or removable prosthesis placed on implant(s)? Int J Oral Maxillofac Implants. 2007;22(suppl):19-48. 60. Karl M, Rosch S, Graef F, Taylor TD, Heckmann SM. Static implant loading caused by as-cast metal and ceramic-veneered superstructures. J Prosthet Dent. 2005; 93(4):324-330. 61. Karl M, Graef F, Taylor TD, Heckmann SM. In vitro effect of load cycling on metal-ceramic cement- and screw-retained implant restorations. J Prosthet Dent. 2007;97(3):137-140. 62. Karl M, Dickinson A, Holst S, Holst A. Biomechanical methods applied in dentistry: a comparative overview of photoelastic examinations, strain gauge measurements, finite element analysis and three-dimensional deformation analysis. Eur J Prosthodont Restor Dent. 2009;17(2):50-57. 63. Karl M, Taylor TD. Bone adaptation induced by nonpassively fitting implant superstructures: a randomized clinical trial. Int J Oral Maxillofac Implants. 2016;31(2):369-375. 64. Khayat P, Nader N. The use of osseointegrated implants in the maxillary tuberosity. Pract Periodontics Aesthet Dent. 1994;6(4):53-61. 65. Khayat PG, Arnal HM, Tourbah BI, Sennerby L. Clinical outcome of dental implants placed with high insertion torques (up to 176 Ncm). Clin Implant Dent Relat Res. 2013;15(2):227-233. 66. Klineberg IJ, Trulsson M, Murray GM. Occlusion on implants - is there a problem? J Oral Rehabil. 2012; 39(7):522-537. 67. Klinge B, Meyle J. Peri-implant tissue destruction. The Third EAO Consensus Conference 2012. Clin Oral Implants Res. 2012;23(suppl 6):108-110.

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72. Kwon T, Bain PA, Levin L. Systematic review of short(5-10 years) and long-term (10 years or more) survival and success of full-arch fixed dental hybrid prostheses and supporting implants. J Dent. 2014;42(10):1228-1241. 73. Lin CL, Wang JC, Ramp LC, Liu PR. Biomechanical response of implant systems placed in the maxillary posterior region under various conditions of angulation, bone density, and loading. Int J Oral Maxillofac Implants. 2008;23(1):57-64. 74. Lum LB. A biomechanical rationale for the use of short implants. J Oral Implantol. 1991;17(2):126-131. 75. Lum LB, Osier JF. Load transfer from endosteal implants to supporting bone: an analysis using statics. Part one: Horizontal loading. J Oral Implantol. 1992;18(4):343-348. 76. Malo P, Rangert B, Nobre M. “All-on-Four” immediatefunction concept with Brånemark System implants for completely edentulous mandibles: a retrospective clinical study. Clin Implant Dent Relat Res. 2003;5(suppl 1):2-9.

91. Rangert B, Jemt T, Jorneus L. Forces and moments on Brånemark implants. Int J Oral Maxillofac Implants. 1989;4(3):241-247. 92. Schropp L, Isidor F, Kostopoulos L, Wenzel A. Patient experience of, and satisfaction with, delayed-immediate vs. delayed single-tooth implant placement. Clin Oral Implants Res. 2004;15(4):498-503.

94. Skalak R. Biomechanical considerations in osseointegrated prostheses. J Prosthet Dent. 1983;49(6):843-848.

96. Soballe K. Hydroxyapatite ceramic coating for bone implant fixation. Mechanical and histological studies in dogs. Acta Orthop Scand. 1993;255(suppl):1-58. 97. Sorni M, Guarinos J, Garcia O, Peñarrocha M. Implant rehabilitation of the atrophic upper jaw: a review of the literature since 1999. Med Oral Patol Oral Cir Bucal. 2005;10(suppl 1):E45-E56. 98. Soumeire J, Dejou J. Shock absorbability of various restorative materials used on implants. J Oral Rehabil. 1999;26(5):394-401. 99. Soydan SS, Cubuk S, Oguz Y, Uckan S. Are success and survival rates of early implant placement higher than immediate implant placement? Int J Oral Maxillofac Surg. 2013;42(4):511-515. 100. Stegaroiu R, Sato T, Kusakari H, Miyakawa O. Influence of restoration type on stress distribution in bone around implants: a three-dimensional finite element analysis. Int J Oral Maxillofac Implants. 1998; 13(1):82-90.

77. Malo P, Rangert B, Nobre M. All-on-4 immediate-function concept with Brånemark System implants for completely edentulous maxillae: a 1-year retrospective clinical study. Clin Implant Dent Relat Res. 2005;7(suppl 1):88-94.

101. Strassburger C, Kerschbaum T, Heydecke G. Influence of implant and conventional prostheses on satisfaction and quality of life: A literature review. Part 2: Qualitative analysis and evaluation of the studies. Int J Prosthodont. 2006;19(4):339-348.

78. Malo P, de Araujo Nobre M, Lopes A, Moss SM, Molina GJ. A longitudinal study of the survival of All-on-4 implants in the mandible with up to 10 years of follow-up. J Am Dent Assoc. 2011;142(3):310-320.

102. Szmukler-Moncler S, Salama H, Reingewirtz Y, Dubruille JH. Timing of loading and effect of micromotion on bonedental implant interface: review of experimental literature. J Biomed Mater Res. 1998; 43(2):192-203.

79. Menini M, Signori A, Tealdo T, et al. Tilted implants in the immediate loading rehabilitation of the maxilla: a systematic review. J Dent Res. 2012;91(9):821-827.

103. Szmukler-Moncler S, Piattelli A, Favero GA, Dubruille JH. Considerations preliminary to the application of early and immediate loading protocols in dental implantology. Clin Oral Implants Res. 2000; 11(1):12-25.

80. Millen C, Bragger U, Wittneben JG. Influence of prosthesis type and retention mechanism on complications with fixed implant-supported prostheses: a systematic review applying multivariate analyses. Int J Oral Maxillofac Implants. 2015;30(1):110-124. 81. Misch CE, Hahn J, Judy KW, Lemons JE, et al. Workshop guidelines on immediate loading in implant dentistry. November 7, 2003. J Oral Implantol. 2004;30(5):283-288. 82. Mozzati M, Arata V, Gallesio G, Mussano F, Carossa S. Immediate postextraction implant placement with immediate loading for maxillary full-arch rehabilitation: A two-year retrospective analysis. J Am Dent Assoc. 2012;143(2):124-133. 83. Naert I, Quirynen M, van Steenberghe D, Darius P. A study of 589 consecutive implants supporting complete fixed prostheses. Part II: Prosthetic aspects. J Prosthet Dent. 1992; 68(6):949-956. 84. Naert I, Duyck J, Vandamme K. Occlusal overload and bone/implant loss. Clin Oral Implants Res. 2012; 23(suppl 6):95-107. 85. Patzelt SB, Spies BC, Kohal RJ. CAD/CAM-fabricated implant-supported restorations: a systematic review. Clin Oral Implants Res. 2015;26(suppl 11):77-85. 86. Paniz G, Stellini E, Meneghello R, Cerardi A, Gobbato EA, Bressan E. The precision of fit of cast and milled fullarch implant-supported restorations. Int J Oral Maxillofac Implants. 2013;28(3):687-693. 87. Perea C, Suarez-Garcia MJ, Del Rio J, Torres-Lagares D, Montero J, Castillo-Oyague R. Oral health-related quality of life in complete denture wearers depending on their socio-demographic background, prosthetic-related factors and clinical condition. Med Oral Patol Oral Cir Bucal. 2013;18(3):e371-e80. 88. Penarrocha-Diago MA, Maestre-Ferrin L, Demarchi CL, Penarrocha-Oltra D, Penarrocha-Diago M. Immediate versus nonimmediate placement of implants for full-arch fixed restorations: a preliminary study. J Oral Maxillofac Surg. 2011; 69(1):154-159. 89. Polizzi G, Grunder U, Goene R, et al. Immediate and delayed implant placement into extraction sockets: a 5-year report. Clin Implant Dent Relat Res. 2000;2(2): 93-99. 90. Raes F, Cosyn J, De Bruyn H. Clinical, aesthetic, and patient-related outcome of immediately loaded single implants in the anterior maxilla: a prospective study in extraction sockets, healed ridges, and grafted sites. Clin Implant Dent Relat Res. 2013;15(6):819-35

104. Teixeira ER, Sato Y, Akagawa Y, Shindoi N. A comparative evaluation of mandibular finite element models with different lengths and elements for implant biomechanics. J Oral Rehabil. 1998;25(4):299-303. 105. Tomasi C, Derks J. Clinical research of peri-implant diseases--quality of reporting, case definitions and methods to study incidence, prevalence and risk factors of peri-implant diseases. J Clin Periodontol. 2012;39(suppl 12):207-223. 106. Testori T, Del Fabbro M, Capelli M, Zuffetti F, Francetti L, Weinstein RL. Immediate occlusal loading and tilted implants for the rehabilitation of the atrophic edentulous maxilla: 1-year interim results of a multicenter prospective study. Clin Oral Implants Res. 2008;19(3):227-232. 107. Van Rossen IP, Braak LH, de Putter C, de Groot K. Stressabsorbing elements in dental implants. J Prosthet Dent. 1990;64(2):198-205. 108. Venturelli A. A modified surgical protocol for placing implants in the maxillary tuberosity: clinical results at 36 months after loading with fixed partial dentures. Int J Oral Maxillofac Implants. 1996;11(6):743-749. 109. Vervaeke S, Collaert B, De Bruyn H. Immediate loading of implants in the maxilla: survival and bone loss after at least 2 years in function. Int J Oral Maxillofac Implants. 2013;28(1):216-221. 110. Vogl S, Stopper M, Hof M, Wegscheider WA, Lorenzoni M. Immediate occlusal versus non-occlusal loading of implants: a randomized clinical pilot study. Clin Implant Dent Relat Res. 2015;17(3):589-597. 111. Wang TM, Leu LJ, Wang J, Lin LD. Effects of prosthesis materials and prosthesis splinting on peri-implant bone stress around implants in poor-quality bone: a numeric analysis. Int J Oral Maxillofac Implants. 2002;17(2):231-237. 112. Weinstein R, Agliardi E, Fabbro MD, Romeo D, Francetti L. Immediate rehabilitation of the extremely atrophic mandible with fixed full-prosthesis supported by four implants. Clin Implant Dent Relat Res. 2012;14(3): 434-441. 113. Wennerberg A, Albrektsson T. On implant surfaces: a review of current knowledge and opinions. Int J Oral Maxillofac Implants. 2010; 25(1):63-74. 114. Citçı Y, Canay Ş. The effect of veneering materials on stress distribution in implant-supported fixed prosthetic restorations. Int J Oral Maxillofac Implants. 2000;15(4):571-582. 115. Zitzmann NU, Berglundh T. Definition and prevalence of peri-implant diseases. J Clin Periodontol. 2008;35(suppl 8):286-291.

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43. Gallucci GO, Benic GI, Eckert SE, et al. Consensus statements and clinical recommendations for implant loading protocols. Int J Oral Maxillofac Implants. 2014;29(suppl):287-290.

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Full arch implant-supported oral rehabilitation: a literature review SOUMPASIS

1. Tilting allows for the use of a _______ that is able to reach better-quality bone, which can lead to a final prosthesis built with the aim of reducing or eliminating cantilevers. a. shorter implant b. longer implant c. wider implant d. smaller diameter implant 2. The reported advantages of immediate implant placement include __________ compared with late implant placement. a. a reduction in the number of surgical interventions b. shortened rehabilitation time c. higher patient satisfaction d. all of the above 3. Altintas, et al. (2016), stated the success rate of immediately placed implants is _____. a. 38% b. 57% c. 75% d. 97.8% 4. It has been stated that the procedure (implant placement in fresh extraction sockets) should be limited to alveoli with sufficient bone for primary stability, which is generally achieved by exceeding

36 Implant practice

the apex by _______ or by using implants that are wider than the alveolus. a. 3 mm-5 mm b. 6 mm-8 mm c. 9 mm-12 mm d. 14 mm

the ______ using individual anatomic impression trays, under conditions of muscle relaxation. a. mouth closed as much as possible b. mouth open c. mouth half-closed d. patient sedated

5. For that reason (the low density of medullary bone and thin cortical plates), achieving bicortical fixation and splinting of the implants with a rigid metal framework within ____ after surgical placement is crucial. a. 10 days b. 21 days c. 1 month d. 6 weeks

8. In the classical protocol, BrĂĽnemark, et al., recommended ________ as the material of choice for the occlusal surface of implant-supported fixed dentures. a. porcelain only b. acrylic resin c. porcelain fused to metal d. zirconia metal oxide

6. Recently, the main focus in oral implant surgery has shifted from survival to success and to periimplant infections. Therefore, the most frequently used and accepted parameters for assessing oral implant success are related to peri-implant marginal bone loss _________. a. peri-implant soft tissue health b. prosthesis stability c. patientsâ&#x20AC;&#x2122; subjective evaluation d. all of the above 7. Impression procedures should be executed with

9. Optimal design of implant superstructures should _________. a. maximize bone density and bone remodeling b. reduce healing time c. increase bone-implant contact d. all of the above 10. Most patients wearing complete dentures complain about progressive loss of stability during ___ and request for a fixed rehabilitation. a. bruxism b. phonetics c. mastication d. both b and c

Volume 10 Number 1

CE CREDITS

IMPLANT PRACTICE CE

Drs. Patrik Zachrisson and Eddie Scher assess the impact of connecting implants to the neighboring dentition in “mixed-bite” patients

hen restoring a dentition, we are sometimes faced with a “mixed bite,” containing natural teeth that are to be kept and spaces that are to be restored with an implant-supported prosthesis. The restoration of multiple teeth and implants has been debated for some time and was discussed as part of long-span bridge treatments (Scher, 1991) as early as the late 1980s. The use of a rigid or non-rigid connection between a natural tooth and a dental implant has been shown to occasionally result in complications. One such reported side effect is the intrusion of the natural tooth. While a retrospective case study of toothand implant-supported bridgework suggests that this is not commonplace, it is nevertheless a factor to be aware of. This article aims to consider some of the various approaches to reducing intrusion tested by a number of authors. Their results suggest that it is advisable in some situations to connect implants to natural teeth, but that this should be done with caution. The use of a permanently cemented gold coping on the tooth and an open-ended slide PA connection will also be discussed.

Background In partially edentulous patients, we are at times challenged with the dilemma of connecting natural teeth, with a periodontal ligament allowing some movement, to the rigid support of a bone-supported implant. There have been reservations about the longterm success of connecting natural teeth to implants, mainly due to the difference in Patrik Zachrisson, LEG TDL CertDentImp, FICOI, is a partner at the Wensleydale Dental Practice. He has worked in the United Kingdom since graduating from the Karolinska Institute in Stockholm in 1996. A member of the ITI and BACD, Dr. Zachrisson focuses his clinical work on restorative and preventive dentistry, Invisalign®, and dental implants. Eddie Scher, BDS, LDS RCS, MFGDS RCS, is a specialist in prosthodontics and oral surgery. A founder and life member of the ADI, he is visiting clinical professor at Temple University, Philadelphia, and is the editor in chief of Implant Dentistry Today.

Volume 10 Number 1

Educational aims and objectives

This clinical article aims to discuss the risk factors of causing the intrusion of natural teeth when using patients’ existing dentition as an additional support for bridgework in implant restorations.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 41 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Recognize some reasons for intrusion of natural teeth.

•

Define disuse atrophy.

•

Identify the differential energy dissipation theory.

•

Identify mandibular flexure.

•

Identify the impaired rebound memory theory.

•

Identify rachet effect.

•

Identify debris impaction.

mobility. The term tooth-implant supported prosthesis (TISP) is sometimes used when referring to a restoration of this type. The periodontal ligament (PDL) around a natural tooth allows 50 μm-200 μm of mobility. An implant has been shown to allow less than 10 μm of mobility (Cohen, Orenstein, 1994). It has been suggested that the success of an implant is dependent on the lack of mobility (Brånemark, et al., 1985). The inclusion of natural teeth in a restoration can be a benefit due to the improved proprioception. In some situations, it may also be beneficial to maintain natural teeth in order to preserve the soft tissue profile and appearance, as well as phonetics. Natural teeth may also need to be used because of lack of bone or the anatomical features present, a need to reduce cost, to avoid potential augmentation procedures, or to provide more support for the restoration. Experience suggests that when faced with restoring multiple implants and natural teeth, a number of factors affect the longterm success rate. Parafunction is a major factor, as is also the degree of mobility in individual teeth. The subsequent overloading of natural teeth and implants in a situation where parafunction is present has been

thought to affect both the support of the implant as well as the mechanical structure of the TISP. The number of teeth and implants to be restored is likely to affect the outcome as the load can be spread over a greater number of supports. The use of a TISP cemented with temporary cement and supported by a natural tooth with a coping as one abutment and an implant as the other has been shown to allow apical intrusion of the natural tooth if the cement dissolves (Garcia, Oesterle, 1998; Schlumberger, et al., 1998; Pesun, 1997; Chee, Cho, 1997; Cho, Chee, 1992). The apical movement of a tooth is known as intrusion and has been defined by Nikolai (1985) as “a translational form of the tooth movement directed apically and parallel to the long axis,” whereas Burstone (1977) defined it as “apical movement of the geometric center of the root in respect to the occlusal plane or a plane based on the long axis of the tooth.”

Reasons for intrusion It has been suggested that a number of factors may individually or in combination cause intrusion of natural teeth more frequently. Several theories have been Implant practice 37

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Intrusion of natural teeth when connecting teeth to implants

CONTINUING EDUCATION suggested to explain the intrusion effect seen when combining implants and natural teeth (Pesun, 1997). Disuse atrophy Several authors (Pesun, et al., 1999; Cohn, 1965; 1966) suggest that when an implant (rigid in bone) is splinted to a natural tooth (with a periodontal membrane allowing some movement), this connection may lead to disuse atrophy of the PDL. However, as a tooth in hypofunction often tends to erupt spontaneously until in contact, this would suggest that it should maintain its position, rather than intrude (Rieder, Parel, 1993). An interesting parallel is the intrusion that can be observed in orthodontic treatments using the Invisalign® system where teeth are, in effect, splinted together in a plastic aligner. If there is a lack of space, teeth under load often intrude orthodontically. The orthodontic movement of teeth is well documented in literature (Edwards, 1979). Differential energy dissipation The differential energy dissipation theory suggests that when a partial denture restoration is loaded, the energy from the stress is dissipated through the abutments to the implants. As the implants are rigid, the natural tooth would end up with an increased level of energy, which could potentially stimulate osteoclastic activity in the periodontal ligaments (Sheets, 1993; 1997). Mandibular flexure A slight flex can be observed in the mandible under load and movement as a result of the forces applied by jaw muscles (McDowell, Regli, 1961). Likewise, a flex can be observed in the restoration as a result of forces applied when loading the construction (Burch, 1972; Mahan, Alling 1991). Intrusion has been observed, not only in the mandible but also in the maxillae (Chee, Cho, 1997). This would suggest that the flex of the mandible during mastication and load is of less importance. Impaired rebound memory The impaired rebound memory theory suggests that the PDL can become compressed under load and lose its elastic memory due to a constant load (Chiba, Komatsa, 1993). This in turn would induce remodeling of the PDL at a lower level until no compressive forces push the tooth farther apically. This is similar to the movements that take place during orthodontic treatments. 38 Implant practice

Ratchet effect The ratchet effect theory is, in some ways, similar to the impaired memory theory. A heavy occlusal load resulting in vertical force may intrude a tooth orthodontically. However, a precision attachment placed on a restoration may prevent the rebound and thus create an orthodontic force. This may, in turn, cause the PDL to begin remodeling (Edwards, 1979; Chiba, Komatsa, 1993). Debris impaction If debris is impacted under a restoration, as occurs when chewing food, this may lead to a compression of the PDL, which in turn can induce remodeling of the bone. If this is ongoing for long enough, it may have an orthodontic effect (Edwards, 1979). Some studies (Rangert, et al., 1991; Cavicchia, Bravie, 1994; Van Steenburghe, 1989; Cohn, 1965; Vohn, 1966; Sheets, Earthman, 1993) report no complications in the use of a toothimplant support for a restoration. Indeed anecdotally, one of the authors of this article (Scher) found a large number of successful restorations that never caused any concern.

Discussion Overloading of an implant when connecting teeth to implants may cause an implant or its restoration to fail. It has also been observed that intrusion of the natural tooth may take place. There are concerns regarding the intrusion of natural teeth when connected to dental implants. The main issues are overloading, cementation failures, and the stress put on the implant components and restoration. Multiple factors affect the success of an implant. The main concern is ensuring the implant has maximum surface area in contact with (ideally) dense bone (Misch 2004; Brånemark, Ismail, 1993). Greenstein, et al. (2009), showed the angulations of abutments should be no more than 15˚-25˚. Authors agree that a well-aligned implant in a balanced occlusion with good bony support has a good long-term prognosis. The use of copings, ideally with grooves to increase the surface area, may be beneficial, as long as the cementation bond does not break down. The suggestion is that the coping should be cemented with definitive cement, and the copings will protect the prepared surface of the tooth from decay. It is essential that the prosthodontist’s attention is brought to the fact that intrusion can occur when restoring implants and teeth with a fixed-tooth, implant-supported prosthesis. An intrusion rate ranging between 3%

and 5.2% has been noted. However, it has been reported by Rieder and Parel (1993) that patients with parafunctional habits seem to strongly affect the resulting intrusion, with a nearly 50% ratio of intrusion. Intrusion has been observed in both rigid and non-rigid situations, with authors reporting that intrusion is more prevalent in patients with non-rigid restorations, due to the natural tooth acting as a female part of a stress breaker. The assumption that the use of a rigid connection would cause additional strain and load on an implant when the tooth moved under functional stress led to the use of a non-rigid connection or telescopic crowns (Sullivan, 1986; Ericsson, et al., 1986; Kirsch, Mentag, 1986; Kay, 1993). This, however, has allowed for intrusion in some cases. A comparison by Nickenig, et al. (2006), compared the use of nonrigid and rigid connections and found that after 5 years, 8% of the abutment teeth required some sort of therapeutic measure (restorations, periodontal therapy, and so on). However, they found an increased incidence of problems of a technical nature in the non-rigid group. The rigid restorations showed only a limited number of technical problems, and the study concluded that a high success rate was prevalent with rigid connections.

Review The authors reviewed published data where important articles were analyzed. The search terms were connecting teeth to implants, tooth implant connections, and intrusion. A number of patients treated by a single experienced implant surgeon and restorative dentist were also reviewed, where an attempt was made to analyze the presence of intrusion. The outcomes were listed, and in the case of intrusion, the type of connection was recorded. A large number of implants were seen to be successfully restored both individually, in implant-to-implant situations, and in implant-to-tooth situations over a number of years. (All cases were over 10 years old.) The use of implants in a restoration together with natural teeth has, for this practitioner, proved successful, but a small number of cases demonstrated clinical intrusion over time. The relationship between the bridgework and the tooth coping was observed at the treatment planning stage, the fit stage, and at various follow-up appointments. The presence of intrusion was noted on X-rays and where possible measured in a comparison Volume 10 Number 1

Results and discussion An abundance of data indicated that intrusion of natural teeth can occur in situations where natural teeth and implants are connected, but through careful planning the risks can be minimized, and a successful outcome achieved. It is suggested that in some situations, when we connect teeth and implants, the benefits outweigh the risks, and it is worth considering keeping a natural tooth. The use of a screw-retained restoration can be beneficial due to the ease of retrievability. The use of cement carries a risk of cement failure, but this technique is widely seen as good practice. Intrusion can be observed in some cases where cement has been used. Dr. John Ismail, speaking at an Association of Dental Implantology (ADI) conference in 1989, advised the use of a permanent cement, although this is not retrievable. In the authors’ hands, a firmer cement such as Improv® implant cement allows a degree of retrievability while still allowing greater adhesion. A number of approaches can be envisaged in order to improve the success rate of a TISP situation. The use of stronger or permanent cement is likely to improve the outcome and reduce the risk of cementation failure between restoration and coping. The introduction of grooves to increase the surface area should be considered. This, however, may make the provision of the labwork more difficult to produce in a predictable way and should be considered with caution, but it may be advisable to consider a softer cement such as Temp Bond™ NE. Finally, the use of an open-ended slide is an option to get a more functional use and flexible support. This has, however, been debated and a mix of results achieved. It has been reported by several authors that the use of stress-breaking connectors is associated with more intrusion than rigid connections (Lang, et al., 2004; Naert, et al., 2001; Linde, et al., 2001; Greenstein, et al., 2009). On the other hand, some authors (Sullivan, 1986; Rieder, 1990) suggest that, as a way of reducing or avoiding overloading, the use of various types of connections should be considered. Authors (Naert, et al., 2001; Block, 2002; Bragger, et al., 2005) report a mix of success both using rigid and non-rigid connections, with some reporting more intrusion in cases with non-rigid Volume 10 Number 1

connections. Biomechanically, the stress on a superstructure varies depending on the type of connector used. Rigid connections cause extensive load on the implant and internal screw. There is a risk of fracture of the prosthesis, abutment screw, or the actual implant, or loss of bone or even the actual implant itself. Overloading a natural tooth may lead to a widening of the periodontal ligament, increased tooth mobility, bone loss and pain, or discomfort. Non-rigid connections potentially cause intrusion. A non-rigid connection may result in benefits from preserving teeth, preventing rotation of implant-supported restoration, and getting support from natural teeth that may be present. It has been suggested that the non-rigid connection may increase the load on the implant but help reduce the load in the TISP. A rigid connection may cause failure of the implant or screw loosening due to uneven forces applied. Stable support for the natural tooth is important. Some authors believe that there is sufficient flexibility in the implant systems to allow a rigid connection. Ericsson, et al. (1986), Rangert, et al. (1995), Lundgren and Laurell (1994), Rangert, et al. (1991), all considered these factors. When connecting teeth permanently to implants, the use of a gold coping allows control of the alignment of natural teeth and also a degree of retrievability. The use of a softer semi-permanent or temporary cement allows retrievability, but there is a risk in that if it dissolves, there is a higher likelihood of intrusion. The use of a rigid connection and permanent cement may provide a lower risk of intrusion but a higher risk of secondary caries and less retrievablity. A lack of long-term data and limited number of cases suggests that there is no clear picture, but the presence of intrusion in some TISP situations should be a complication to consider. The general consensus seems to be that when connecting teeth to implants, the use of gold copings, use of a rigid connector, and permanent or semipermanent cements is beneficial. The problem of differing support between the implant and the natural tooth has been discussed for many years (Rieder, 1990). There is only limited long-term data available for the use of tooth and implants together as abutment support. In practice, a longterm retrospective follow-up from clinical cases (Scher, 1991) suggests that intrusion of natural teeth does occur, ranging from a mild-but-significant to a considerable intrusion in one case.

Tooth-implant connections have a higher rate of complications than restorations based on conventional bridgework or fully implant-supported bridgework. There have been suggestions that root-treated teeth are more prone to intrude, possibly because of the lack of proprioception when compared to natural, non-root-treated teeth. This was observed in the cases of Dr. Scher that were studied anecdotally but may be due to the fact that extensive root treatments are more common in patients with an already heavily restored dentition. This may affect the load the tooth is subjected to, as the patient may lack some of the proprioception compared to a healthy tooth.

Personal experiences Dr. Eddie Scher has been restoring and placing implants in complex cases since the mid-1980s. A retrospective study of his cases suggests that although most have no or very limited complications, some show a degree of intrusion in TISP situations. In some instances, the effect was enough to justify corrective procedures such as redesigning the bridgework or replacing the superstructure. The use of lab-made gold copings cemented with a permanent cement such as zinc-phosphate cement or glass ionomer cement to the natural tooth was observed in all cases with intrusion, in combination with a superstructure cemented with TempBond™ with a modifier, IRM or in later cases Improv cement. It was noted that a dominating number of TISP restorations with intrusion were supported by root-treated teeth, and a majority of the failed connections were in teeth with a root treatment present.

Precision attachments with an open-ended slide Some complications in the form of intrusion were noticed to a varying degree. Some cases had some remedial work carried out. No fractures of superstructure were noted, nor loss of implants or decay in the natural teeth. One method of avoiding the pitfalls of a tooth-implant supported prosthesis is to use a shorter bridge span to reduce the load. Occlusal equilibration prior to placement and careful management of the occlusion in the provisional and final prostheses are also likely to be beneficial. The use of a Michigan splint (nocturnal hard splint) to allow a stable bite and protect the implant and superstructure as well as maintaining a healthy TMJ is recommended. The use of gold copings allows correction of Implant practice 39

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of the distance (on X-ray) of the margin of restoration to the margin of the gold coping.

CONTINUING EDUCATION the angulation of the prosthesis as well as preventing decay in the natural tooth. The use of placing sleeper implants to allow for a future design can also be useful in case the design needs to be altered at a later date, or should a tooth or implant fail. The use of precision attachments and open ended-slides has had a mixed reception, as several published studies indicate, and no obvious outcome was observed from the cases studied. It has been discussed that root-treated teeth fail more often. A number of Dr. Scher’s intrusion cases include root-treated teeth. There is a possibility that the lack of proprioception in a root-filled tooth may lead to higher load and more intrusion, but this may just be due to the fact that patients with heavily restored dentitions have more rootfilled teeth. No difference was noted between male/ female cases (8/7), nor was there any obvious medical history background. Although Dr. Scher believed that teeth were potentially less likely to intrude in bisphosphonatetreated patients, there were not enough cases to be able to assess this. All cases were treated with gold copings and cemented bridgework. This subject needs a bigger study, but our best results occurred when we use gold copings with a rough surface or an increased surface area with parallel grooves and more permanent but still-retrievable cement.

Conclusion Having reviewed cases where intrusion is present, it can be suggested that it is a complication that may occur in a TISP situation, albeit relatively rare. The data suggests that the majority of intrusion-related complications are noted on teeth with a root filling present. The intrusion occurred several years after placement, and may be caused by a multitude of factors. The use of a gold coping in order to prevent decay on the natural tooth in case of cementation failure is strongly advised. The authors suggest the use of a stronger and more permanent cement, such as Improv, in order to reduce the risk of intrusion from cementation failure. The use of a rough surface on the coping or the inclusion of parallel grooves may also be considered in order to maintain better cementation. The use of an open-ended slide can also be considered as a way to allow a non-rigid connection and act as a stress breaker, but the best results seem to be reported from the use of rigid connections. The most 40 Implant practice

predictable results seem to occur when a restoration is supported wholly by implants, but in some cases, the inclusion of natural teeth may be beneficial and should be considered. The use of a short span bridge is recommended if more than one pontic is to be used then additional support from tooth or further implants is advisable. A well-balanced occlusion is of importance to ensure an evenly distributed occlusal load. Rieder and Parel (1993) reported that 50% of intrusions occurred in patients with parafunctional habits such as bruxism. They also noted intrusion was more common in situations where the TISP had non-rigid semi-precision attachments. One must give careful consideration to the use of a TISP in a patient that exhibits parafunction. Data and experience suggest that implants can be connected to natural teeth, provided that care has been taken to consider the risk of implant overload and the intrusion of natural teeth. Proper treatment planning and informed consent is essential. IP

REFERENCES 1. Block MS, Lirette D, Gardiner D, et al. Prospective evaluation of implants connected to teeth. Int J Oral Maxillofac Implants. 2002;17(4):473-487. 2. Bragger U, Karoussis I, Persson R, Pjetterson B, Lang N. Technical and biological complications/failures with single crowns and fixed partial dentures on implants: a 10- year prospective cohort study. Clin Oral Implants Res. 2005;16(3):326-334. 3. Brånemark PI, Zarb GA, Albrektsson T. Tissue Integrated Prosthesis. Osseointegration in Clinical Dentistry. Chicago, IL: Quintessence Publishing; 1985. 4. Burch JG. Patterns of change in human mandibular arch width during jaw excursions. Arch Oral Biol. 1972;17(4):623-631. 5. Burstone CR. Deep overbite correction by intrusion. Am J Orthod. 1977;72(1): 1-22. 6. Cavicchia F, Bravi F. Free-standing vs tooth-connected implant supported fixed partial restorations: a comparative retrospective clinical study of the prosthetic results. Int J Oral Maxillofac Implants. 1994;9(6):711-718. 7. Chee WW, Cho GC. A rationale for not connecting implants to natural teeth. J Prosthodont. 1997;6(1):7-10. 8. Chiba M, Komatsu K. Mechanical responses of the periodontal ligament in the transverse section of the rat mandibular incisor at various velocities of loading in vitro. J Biomech. 1993; 26(4-5):561-570. 9. Cho GC, Chee WW. Apparent intrusion of natural teeth under an implant-supported prosthesis: a clinical report. J Prosthet Dent. 1992;68(1):3-5. 10. Cohen SR, Orenstein JH. The use of attachments in combination implant and natural-tooth fixed partial dentures: a technical report. Int J Oral Maxillofac Implants. 1994;9(2):230-234. 11. Cohn SA. Disuse atrophy of the periodontium in mice. Arch Oral Biol. 1965;10(6):909-919.

16. Greenstein G, Cavallaro J, Smith R, Tarnow D. Connecting teeth to implants: a critical review of the literature and presentation of practical guidelines. Compend Contin Educ Dent. 2009;30(7):440-453. 17. Kirsch A, Mentag PJ. The IMZ endosseous two phase implant system: a complete oral rehabilitation treatment concept. J Oral Implantol. 1986;12(4):576-589. 18. Kay H. Free-standing versus implant-tooth-interconnected restorations: understanding the prosthodontic perspective. Int J Periodontics Restorative Dent. 1993;13(1):47-69. 19. Lang N, Pjetursson B, Tan K, Brägger U, Egger M, Zawlen M. A systematic review of the survival and complication rates of fixed partial dentures (FPDs) after an observation period of at least 5 years. II. Combined tooth-implant-supported FPDs. Clin Oral Implants Res. 2004;15(6):643-653. 20. Lindh T, Dahlgren S, Gunnarsson K, et al. Tooth-implant supported fixed prostheses: a retrospective multicenter study. Int J Prosthodont. 2001;14(4):321-328. 21. Lundgren D, Laurell L. Biomechanical aspects of fixed bridgework supported by natural teeth and endosseous implants. Periodontol 2000. 1994;4:23-40. 22. Mahan PE, Alling CC. Mandibular dimensional stability. In: Mahan PE, Alling CC, eds. Facial Pain. 3rd ed. Philadelphia, PA: Lea & Febiger; 1991. 23. McDowell JA, Regli CP. A quantitative analysis of the decrease in width of the mandibular arch during forced movements of the mandible. J Dent Res. 1961;40:1183-1185. 24. Misch CE. Dental Implant Prosthetics. St. Louis, MO: Mosby; 2004. 25. Misch CM, Ismail YH. Finite element stress analysis of tooth-to-implant fixed partial denture designs. J Prosthodont. 1993;2(2):83-92. 26. Naert IE, Duyck JA, Hosny MM, Quirynen M, van Steenberghe D. Free-standing and tooth-implant connected prostheses in the treatment of partially edentulous patients. Part II: an up to 15-years radiographic evaluation. Clin Oral Implants Res. 2001;12(3):245-251. 27. Naert IE, Duyck JA, Hosny MM, van Steenberghe D. Freestanding and tooth-implant connected prostheses in the treatment of partially edentulous patients. Part I: an up to 15-years clinical evaluation. Clin Oral Implants Res. 2001;12(3):237-244. 28. Nickenig HJ, Schäfer C, Spiekermann H. Survival and complication rates of combined tooth-implantsupported fixed partial dentures. Clin Oral Implants Res. 2006;17(5):506-511. 29. Nikolai RJ. Response of dentition and periodontium to force. In: Bioengineering Analysis of Orthodontic Mechanics. Philadelphia, PA: Lea & Febiger; 1985. 30. Pesun IJ. Intrusion of teeth in the combination implant-tonatural-tooth fixed partial denture: a review of the theories. J Prosthod. 1997;6(4):268-277. 31. Pesun IJ, Steflik DE, Parr GR, Hanes PJ. Histologic evaluation of the periodontium of abutment teeth in combination implant/tooth fixed partial denture. Int J Oral Maxillofac Implants. 1999;14(3):342-350. 32. Rangert B, Gunne J, Sullivan DY. Mechanical aspects of a Brånemark implant connected to a natural tooth: an in vitro study. Int J Oral Maxillofac Implants. 1991;6(2):177-185. 33. Rangert B, Gunne J, Glantz PO, Svensson A. Vertical load distribution on a three-unit prosthesis supported by a natural tooth and a single Brånemark implant. An in vivo study. Clin Oral Implants Res. 1995;6(1):40-46. 34. Rieder CE. Copings on tooth and implant abutments for superstructure prostheses. Int J Periodontics Restorative Dent. 1990;10(6):436-453. 35. Rieder CE, Parel SM. A survey of natural tooth abutment intrusion with implant-connected fixed partial dentures. Int J Periodontics Restorative Dent. 1993;13(4):335-347. 36. Scher ELC. The use of an osseointegrated implant in long-span bridgework. Int J Oral Maxillofac Implants. 1991;6:351-353. 37. Schlumberger TL, Bowley JF, Maze GI. Intrusion phenomenon in combination tooth-implant restorations: a review of the literature. J Prosthet Dent. 1998;80(2):199-203.

12. Cohn SA. Disuse atrophy of the periodontium in mice following partial loss of function. Arch Oral Biol. 1966;11(1):95-102.

38. Sheets CG, Earthman JC. Natural tooth intrusion and reversal in implant-assisted prosthesis: evidence of and a hypothesis for the occurrence. J Prosthet Dent. 1993;70(6):513-520

13. Edwards JG. A study of the periodontium during orthodontic rotation of teeth. Am J Orthod. 1979;54(6):441-461.

39. Sheets CG, Earthman JC. Tooth intrusion in implantassisted prostheses. J Prosthet Dent. 1997;77(1):39-45.

14. Ericsson I, Lekholm U, Brånemark PI, Lindhe J, Glantz PO, Nyman S. A clinical evaluation of fixed-bridge restorations supported by the combination of teeth and osseointegrated titanium implants. J Clin Periodont. 1986;13(4):307-312.

40. Sullivan DY. Prosthetic considerations for the utilization of osseointegrated fixtures in the partially edentulous arch. Int J Oral Maxillofac Implants. 1986;1(1):39-45.

15. Garcia LT, Oesterle LJ. Natural tooth intrusion phenomenon with implants: a survey. Int J Oral Maxillofac Implants. 1998;13(2):227-231.

41. Van Steenberghe D. A retrospective multicenter evaluation of the survival rate of osseointegrated fixtures supporting fixed partial edentulism. J Prosthet Dent. 1989;61(2):217-223.

Volume 10 Number 1

Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement 12/1/2016 to 11/30/2018 Provider ID# 325231

REF: IP V10.1 ZACHRISSON

CONTINUING EDUCATION BROUGHT TO YOU BY

FULL NAME

AGD REGISTRATION NUMBER

LICENSE NUMBER

ADDRESS

CITY, STATE, AND ZIP CODE

TELEPHONE/FAX

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

Intrusion of natural teeth when connecting teeth to implants ZACHRISSON/SCHER

1. There have been reservations about the longterm success of connecting natural teeth to implants, mainly due to the __________ . a. difference in mobility b. sensitivity of natural teeth c. length of natural teeth d. hyperfunction of the natural tooth 2. Natural teeth may also need to be used because of lack of bone or ___________, or to provide more support for the restoration. a. the anatomical features present b. a need to reduce cost c. to avoid potential augmentation procedures d. all of the above

increased level of energy, which could potentially __________. a. cause the tooth to ankylose b. prevent a rebound and thus create an orthodontic force c. stimulate osteoclastic activity in the periodontal ligaments d. make the tooth less mobile 5. Greenstein, et al. (2009), showed the angulations of abutments should be no more than _______. a. 5˚-10˚ b. 15˚-25˚ c. 30˚-40˚ d. 50˚

3. The apical movement of a tooth is known as __________ and has been defined by Nikolai (1985) as “a translational form of the tooth movement directed apically and parallel to the long axis,” whereas Burstone (1977) defined it as “apical movement of the geometric center of the root in respect to the occlusal plane or a plane based on the long axis of the tooth.” a. parafunction b. intrusion c. proprioception d. disuse atrophy

6. A comparison by Nickenig, et al. (2006), compared the use of non-rigid and rigid connections and found that after 5 years, _____ of the abutment teeth required some sort of therapeutic measure (restorations, periodontal therapy, and so on). a. 8% b. 15% c. 36% d. 47%

4. (In differential energy dissipation) As the implants are rigid, the natural tooth would end up with an

7. Overloading a natural tooth may lead to _______, or discomfort.

Volume 10 Number 1

a. b. c. d.

a widening of the periodontal ligament increased tooth mobility bone loss and pain all of the above

8. When connecting teeth permanently to implants, the use of ______ allows control of the alignment of natural teeth and also a degree of retrievability. a. a gold coping b. a ceramic coping c. a Ni-Ti coping d. permanent cement 9. Tooth-implant connections have __________ of complications than restorations based on conventional bridgework or fully implantsupported bridgework. a. a lower rate b. a higher rate c. an equal rate d. no bearing on the type 10. One method of avoiding the pitfalls of a toothimplant supported prosthesis is to use _______ to reduce the load. a. temporary cement b. a longer bridge span c. a shorter bridge span d. sleeper implants

Implant practice 41

CE CREDITS

IMPLANT PRACTICE CE

PRODUCT PROFILE

LOCATOR F-Tx® fixed attachment system Zest Dental Solutions™ has made fixed full arch restorations a snap

new restorative solution requiring no screws and no cement addresses the inherent limitations of conventional screwretained and cemented solutions such as the need for screw access channels or the potential for sub-gingival cement when attaching the prosthesis to the abutments. Fixed for the patient, yet easily removed by the clinician, LOCATOR F-Tx® is a simplified, timesaving fixed attachment system for full arch restorations with no compromise to prosthesis strength or esthetics. Optimized for efficiency and chairtime savings compared to conventional

screw-retained systems, LOCATOR F-Tx features a novel, “snap-in” attachment that eliminates the potential for sub-gingival cement or the need for retaining screws. Further adding to the flexibility of the system, LOCATOR F-Tx accommodates divergent/ convergent scenarios up to 40˚ between implants without the need for angled abutments. A patient-friendly solution, the prosthesis is easily removed by the clinician for hygiene and maintenance visits utilizing a revolutionary prosthesis removal system that quickly disengages the prosthesis in a matter of minutes.

Zest Dental Solutions™ is a global leader in the design, development, manufacturing and distribution of diversified dental solutions for a continuum of patient care from the preservation of natural teeth to the treatment of total edentulism. Zest Dental Solutions’ corporate headquarters is in Carlsbad, California, with satellite operations in Anaheim and Escondido, California. For more information about the new LOCATOR F-Tx Fixed Attachment System, please visit www.zestdent.com/ftx. IP This information was provided by Zest Dental Solutions™.

“LOCATOR F-Tx represents the culmination of Zest’s many years of expertise with the LOCATOR® Attachment System and our deep understanding of full arch solutions for edentulous patients,” said President and CEO of Zest Dental Solutions Steve Schiess. “With LOCATOR F-Tx, we strived to create a simpler, more efficient system for fixed full arch implant restorations requiring less chairtime and providing higher patient satisfaction.” 42 Implant practice

Volume 10 Number 1

PRACTICE DEVELOPMENT

Important Facebook® developments

Ian McNickle, MBA, discusses how to stay face-to-face with patients using Facebook

t should be no surprise that the largest social media site on the planet continues to change and innovate at a rapid pace. It has been very interesting to monitor recent developments and understand their impact for dental practice marketing.

Facebook® newsfeed algorithm — how to get seen Last year, Facebook announced they would be making a change to the newsfeed algorithm so that they could better deliver relevant content to their users. They started to track what users were engaging with (likes and comments) and then gave higher relevance to similar stories being in someone’s newsfeed. This means if someone has liked or commented on a post from your practice, he/she would be more likely to see your posts again in the future. Facebook is essentially trying to understand your interests and match those topics with what would be Ian McNickle, MBA, is a national speaker, writer, and marketer. He is a co-founder and partner at WEO Media, winner of the 2016 Cellerant “Best of Class” Award for Dental Marketing and Dental Websites. If you have questions about any marketing related topic, please contact Ian McNickle directly at ian@ weomedia.com, or call 888-246-6906. For more information, visit www.weodental.com.

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shown to you in the future. This is similar to Internet radio stations like Pandora® that learn what you like and attempt to give you more of what you like over time. Earlier this year, Facebook announced another change to take this concept a step further. Now they are going to track how long you interact with an article or piece of content after leaving Facebook. Monitoring engagement time gives them additional insight into what a particular user likes to read and see in their newsfeed.

What does this mean for your practice? Relevant and engaging content is more important than ever! If a Facebook user clicks on your content and immediately bounces right back to Facebook without taking much time to read it, then this could negatively impact your visibility in the future. On the other hand, if a user goes to your page and takes the time to read the entire article, then you’re likely to rank higher in the newsfeed. The interesting thing to note is that although this information is valuable to track user engagement and relevant content, it’s also part of Facebook’s push to get

publishers using their new tool “Instant Articles,” which means more content is being published behind Facebook’s wall and less on other sites. Essentially, they are trying to keep people within the walls of Facebook and not link to external websites, thereby leaving Facebook during that browsing session. For now, it’s important for your practice to take note of the changes and be sure that your blogs and other social media posts are engaging and targeted specifically to your audience. In addition to creating engaging posts and content, there are other strategies to generate new patient leads from Facebook. These strategies primarily fall into two categories: 1) boosted posts, and 2) paid ads. In our next marketing column, we will continue with our Facebook theme and dig deeper into these new patient-generating strategies.

Marketing consultation If you have questions about your website, social media, or online marketing, you may contact WEO Media for a consultation to learn more about the latest industry trends and strategies. The consultation is free if you identify yourself as a reader of this publication. IP

Receive your free marketing consultation today: 888-246-6906 or info@weomedia.com Implant practice 43

ON THE HORIZON

Scan and you shall receive! Dr. Justin Moody discusses starting the digital revolution one office at a time

“H

urry up and wait” has always been the standard motto in dental practices for laboratory work. We would create cases, place in a box, drive to the post office or have a service like UPS pick it up, and take it to the lab of our choice. This process had been the norm for nearly 100 years but now — the times they are a-changin’. We as dentists have had the option to scan and even mill some restorations chairside for some time now, but we are often limited by the machines, software, and technology at that time. Same-day single restorations have been commonplace for many years now, but what about for dental implants? This too is becoming commonplace but largely for only single-unit restorations and predominately posterior as well. What can be done for multiple implant units and bridges? Today’s scanners and scan bodies have made this easy and very predictable, but the workflow is now very efficient and can start to point to a real ROI for the purchase of these units. Technology always comes at a price, and let’s face it: Dentistry is a customer-service business, and we are in the business of selling our time. The real ROI of scanning technology comes as one of the following three questions: 1. Does this save me time? 2. Does this save me money or make the product better? 3. Can this do both? The answer is 3. Both. Imagine a scenario where the patient is blocked for 10 minutes to have a final implant-crown impression. Your team has seated the patient, taken the scan of the upper and lower area, including

Justin Moody, DDS, DICOI, DABOI, is a Diplomate of the American Board of Oral Implantology and of the International Congress of Oral Implantologists, Fellow and Associate Fellow of the American Academy of Implant Dentistry, and Adjunct Professor at the University of Nebraska Medical College. 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@ justinmoodydds.com or at www.justinmoodydds.com. Disclosure: Dr. Moody is a paid speaker for BioHorizons®.

44 Implant practice

Figure 1: 3Shape TRIOS® color scanner

Figure 2: BioHorizons® implant scan bodies

Figure 3: Custom screw-retained zirconia crowns on BioHorizons® Ti-Bases fabricated by ProSmiles Dental Studio

Figure 4: Imes 450i mill at ProSmiles milling zirconia crowns for implants

the bite, and has registered it in the system. The doctor sits down, removes the healing abutment or temp crown, places the scan body, and only has to scan that area of the scan body. The clinician removes the scan body, replaces the healing abutment, verifies the shade and bite, and he/she is done! What happens next is up to your system. Maybe you mill it chairside, but most of us will send this file directly to Figure 5: Full-arch monolithic zirconia with hand-stacked gingival the lab for fabrication. It’s that simple. tissue and custom staining by ProSmiles Dental Studio from a scan And if you have any questions, you can call the lab that minute before you release the patient and ask them to check it. lab the same day or even print chairside for What a service that is; that’s a remake timesame-day surgical guides. All of this techsaver for sure, not to mention that there is nology is here now, and I encourage you to no outbound postage. get off the fence and dive in. Quit waiting Many of these scanner units can do for the next big thing. Technology is always full arch, enabling us to take tooth-borne changing, and there is never a better time surgical-guide scans and send them to the than now to start your digital revolution. IP Volume 10 Number 1

why choose BioHorizons Laser-Lok implants? improved crestal bone maintenance reduced probing depths conventional implant

Laser-Lok implant

enhanced esthetics

ÂŽ

Tapered Laser-Lok family Developed from over 25 years of research, the unique Laser-Lok surface has been shown to elicit a biologic response that includes the inhibition of epithelial downgrowth and the attachment of connective tissue.1 This physical attachment produces a biologic seal around the implant that protects and maintains crestal bone health. The Laser-Lok phenomenon has been shown in post-market studies to be more effective than other implant designs in reducing bone loss.2

For more information, contact BioHorizons Customer Care at 888.246.8338 or shop online at www.biohorizons.com

Made in the USA

1. M Nevins et al. Int J Periodontics Restorative Dent. Vol. 28, No. 2, 2008. 2. S Botos et al. Int J Oral Maxillofac Implants. 2011; 26:492-498. SPMP16251 REV A AUG 2016

INDUSTRY NEWS 3M hosts first annual Oral Health Council 3M welcomed professionals and policymakers from around the world to its first-ever Oral Health Council in November 2016 at the 3M Innovation Center. The meeting served as a forum for industry leaders from Chile, China, Bolivia, Colombia, the United Kingdom, Peru, Russia, and the United States to share the challenges their countries face in delivering care to patients. Attendees learned from industry experts about preventive science innovations, how to better care for elderly, special needs, and pediatric patients, and how to implement effective policy for oral health. 3M plans to continue this global initiative, and looks forward to the impact this council will have on the future of worldwide oral health. Learn more about 3M’s creative solutions at www.3M.com or on Twitter @3M or @3MNewsroom.

American Academy of Implant Dentistry elects new officers The American Academy of Implant Dentistry elected Shankar Iyer, DDS, MDS, FAAID, DABOI/ID, of Elizabeth, New Jersey, as President at its recently concluded 65th Annual Conference. Selected as President-elect was David G. Hochberg, DDS, FAAID, DABOI/ID, of Atlanta, Georgia. The newly elected Vice President is Natalie Wong, DDS, FAAID, DABOI/ID, of Toronto, Ontario, Canada, and Bernee Dunson, DDS, FAAID, DABOI/ID, of Atlanta, Georgia, was elected Treasurer. Adam Foleck, Shankar Iyer, DDS, MDS, FAAID, DMD, FAAID, DABOI/ID, of Norfolk, DABOI/ID Virginia, was elected Secretary. For more information about the AAID, visit www.aaid.com, or call 312-335-1550, or 877-335-AAID (2243).

OCO Biomedical and the new Ascend Dental Academy to take implant education to new heights The Ascend Dental Academy will serve as OCO Biomedical’s exclusive education partner to provide today’s dentists with comprehensive dental implant surgical and restorative training. OCO Biomedical pledges to be the best resource and product provider for implant dentists, which includes providing the most practical and comprehensive training in the industry. This has led to the partnership with Dr. Ara Nazarian, world-renowned educator and widely respected implantologist. The Ascend Dental Academy, a joint venture with Dr. Nazarian, was created to meet this demand and will be the exclusive OCO Biomedical education partner. As the Chief Clinical Officer, Dr. Nazarian will oversee the program and share his knowledge of no-nonsense, comprehensive dental implant training with dentists who want to learn the most efficient, effective, and profitable ways to place dental implants. For more information, please visit ascenddentalacademy.com and ocobiomedical.com.

46 Implant practice

LED announces transformative transaction and private placement financing LED Medical Diagnostics Inc. announced that it entered into a definitive purchase agreement to acquire 100% of Apteryx, Inc., a profitable, software development company. The company expects the transaction to be closed in the first quarter of 2017, subject to financing and regulatory and other approvals customary for a transaction of this nature. This transaction provides LED with a range of software applications to augment its hardware offerings, establishing the company as an end-to-end dental imaging solution provider in a growing market. The company also announced the results of a meta-analysis on the clinical use of autofluorescence to assess its accuracy for oral squamous cell carcinoma (OSCC) and oral potentially malignant disorders (OPMD) and investigate its applicability in general dental practice. The study by Luo, et al., titled “Accuracy of Autofluorescence in Diagnosing Oral Squamous Cell Carcinoma and Oral Potentially Malignant Disorders: A Comparative Study with Aero-Digestive Lesions,” was published in Scientific Reports, an online, open-access journal from the publishers of Nature, a leading weekly international scientific journal. For more information, call 884-952-7327.

Ultradent receives Medal of Honor from French university On January 9, 2017, the University of Montpellier in Dardilly, France, presented the Medal of Honor, the university’s highest recognition, to Dr. Dan Fischer, founder and CEO of Ultradent Products, Inc., who received the award on behalf of the company. The dean of the University of Montpellier, Philippe Gibert, called the award a “mark of gratitude for the involvement of Ultradent in the training of future dentists at Montpellier and, overall, for their important contribution to the teaching of dentistry.” Since 2009, Ultradent has been involved in the University of Montpellier’s dental program, helping provide practical training to students in tooth whitening, adhesions, veneers, and even management and leadership through product support, training, and lecturing. Additionally, Ultradent supported the creation of a postgraduate diploma by Dr. Bruno Pelessier in esthetic and restorative dentistry, which has become the most widely recognized and reputable professional diploma for working dentists in France. Ultradent has also helped the university develop a master class on posterior restorations that not only is available at the University of Montpellier’s main campus in France, but also is at outposts on the islands of Réunion, Guadeloupe, and Martinique. For information about Ultradent, call 800-552-5512, or visit ultradent.com.

Volume 10 Number 1

M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT

3Shape TRIOS® intraoral scanner gets Dentrix® Connected 3Shape announced that its TRIOS® intraoral scanner is Dentrix® Connected with Henry Schein® Dentrix® patient management system. The integration, powered by Digital Dental Exchange (DDX) OS — a web-based service that enables practitioners to quickly and efficiently exchange and manage casework with a laboratory partner — marks the first time that the Dentrix patient management platform Version 6.1 integrates with a digital impression solution. Dentrix practices using the TRIOS intraoral scanner can insert its digital color impressions directly into Dentrix patient charts, which can then be automatically transferred to the TRIOS system when doctors begin new cases with TRIOS. The Dentrix Connected version of TRIOS also allows Dentrix users to open intraoral scans of patients from within the patient management system, offering a comprehensive view of the patient’s billing information and clinical history on one digital platform. At the same time, having real color TRIOS scans easily accessible in Dentrix makes it more convenient for practices to discuss treatment planning and oral health with their patients. Integration roll out begins Quarter 2, 2017. For more information, email triosdentrix@3shape.com, or go to www.henryscheindental. com/3shapetrios.

BruxZir® Milling Blanks receive price reduction Glidewell Dental, announced a price decrease for BruxZir® Milling Blanks, the material used to fabricate authentic BruxZir Solid Zirconia crowns and bridges. The entire line of BruxZir Milling Blanks, including BruxZir Anterior, BruxZir Shaded, BruxZir Shaded 16, and BruxZir HT, will receive a significant price decrease across all milling blank thicknesses (12 mm, 15 mm, 20 mm, and 25 mm) to enable dental laboratories of any size to provide the this zirconia material. In addition to the price reduction, a 10-mm–thick milling blank will join the BruxZir Shaded 16 line. This new blank size aims to empower dental labs with even more versatility and access to the monolithic revolution by creating less material waste during the fabrication of copings and frameworks. For more information, call 888-303-3975, or visit bruxzir.com.

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New software solution gives doctors a boost with easy access to clinical, practice management information CS Boost allows doctors to have in- and out-of-office web and mobile access to their clinical information. This new software solution for Carestream Dental cloud users gives doctors secure, fast access to appointments, patient search, and clinical information through a modern web app on traditional computing devices or via a native mobile application on iOS and Android devices. Doctors can easily access their schedules and filter them by provider and/ or location. When viewing the schedule, appointment details can be accessed to view notes, alerts, provider, and even chair location. Doctors can also search by patient name for quick access to patient contact information and clinical history. The Clinical Snapshot allows for easy viewing of contact information, appointment history, recently completed procedures and all clinical notes. When viewed on a smart phone, the doctor can even contact the patient’s pharmacy or find the closest one in an emergency from within the app. For more information, call 800-944-6365, or visit www. carestreamdental.com.

Kerr launches Harmonize™ Kerr has launched Harmonize™, a next-generation universal composite infused with Adaptive Response Technology (ART), a nanoparticle filler network with features that help dentists achieve a lifelike restoration with ease and simplicity. ART creates an enhanced structural integrity to provide exceptional strength, handling, and esthetics. Harmonize diffuses and reflects light in a similar way as human enamel, leading to an enhanced chameleon effect for better blending. In addition, the particle size and structure is designed to offer superior gloss retention, and easy polishability compared to leading composites. Harmonize is softer while sculpting, holds its shape without slumping, and does so without the stickiness of other composites due to the high loading, spherical shape, and rheological modifier of ART. The ART filler system allows for high loading at 81%, plus a unique reinforced nano-scale filler particle network, which leads to better polymerization, more integration with resin, strength, and durability. For more information, visit kerrdental.com, or call 800-KERR123.

Implant practice 47

TECHNOLOGY NEWS

Study finds accuracy of X-Guide™ Navigation is 11 times better than freehand implant placement The Journal of Oral Implantology (JOI) reported a new study that confirms the accuracy of placing dental implants using the industryleading X-Guide™ dynamic 3D navigation system.

he model-based study appearing in JOI (the official publication of the American Academy of Implant Dentistry) was used to determine the accuracy of placing dental implants using the X-Guide™ dynamic navigation system. The study focused on measurements of the overall accuracy of implant placement relative to the virtual plan. It also compared accuracy of static guides, implants placed freehand, as well as other navigation systems on the market. The results show that the 3D angular accuracy of the X-Guide™ system is approximately 11 times better than freehand, and 2D lateral positional accuracy is approximately 8 times better than freehand. The X-Guide™ system by X-Nav Technologies is a dynamic navigation surgical system that gives the ability to achieve more accurate placement of implants, right in your office. Interactive, turn-by-turn guidance during live surgery gives the ability to control the exact POSITION, ANGLE, and DEPTH — like a GPS for your handpiece.

that are precluded from CAD/CAM static guides by prolongation height • The inability to take impressions due to hyper-exaggerated gag reflex

Increased accuracy is immediate and in-office In addition to the X-Guide system’s robust implant planning software, surgeons are also excited to bring navigation technology into the dental office. Increased accuracy is now immediate. Same-day guided surgery can be a reality for more surgeons and patients. There are no additional processing or shipping delays that are common in the static guide process — and it’s a fraction of the cost of traditional guides. With the X-Guide’s patented technology, learning and integrating navigation technology is easy. It is important to note that with this system, the surgeon concentrates on a single target to assist in precisely guiding the implant. The result — consistently achieve a more desirable functional and esthetic outcome.

Dynamic navigation and static guides

Industry-leading technology

The authors also stated, while both static and dynamic image navigation are highly accurate, dynamic navigation systems have the following advantages: 1. The patient can be scanned, planned, and undergo surgery on the same day. 2. The plans can be altered during surgery when clinical situations dictate a change. 3. The entire field can be visualized at all times. 4. Accuracy can be verified at all times. Further clinical indications of dynamically guided systems include: • Limited mouth opening • Tight interdental spaces that preclude the use of guidance tubes in CAD/ CAM guides • Distal implants (i.e., second molars)

Lately, the X-Guide system has gathered a lot of attention as the industry-leading navigation system among surgeons, key opinion leaders, speakers, dental journals, and associations. It’s safe to say that the implant industry has eagerly embraced the X-Guide navigation system as “the next big thing.” According to X-Nav Technologies, surgeons have navigated over 7,500 dental implants using the X-Guide dynamic 3D navigation system. Surgeons using X-Guide navigation like that they can offer their patients minimally invasive and accurate surgery, while referring dentists appreciate that navigated implant placement offers them better restorative accuracy. Another benefit to surgeons using this technology is the potential for decreased neck and back pain due to the improved surgical position ergonomics.

48 Implant practice

Here is what actual surgeons using X-Guide navigation have to say: “My first surgical experience with live navigation was not only relaxing but enjoyable and stress-free.” — Dr. Jennifer Houck, Rock Hill, South Carolina “We are thrilled to finally have the X-Guide navigation system! The entire experience from purchase to implementation has been easy and fun. I couldn’t be more pleased.” — Dr. Aaron Quitmeyer, Harrisonburg, Virginia “This system helps me to more accurately place multiple implants in better positions for my referrals.” — Dr. Mark Fagan, San Jose, California “The X-Guide has taken my practice to the next level in implant surgery. Not only does it allow precise surgery, it also gives valuable information to explain to patients what is needed.” — Dr. Gregory McGee, Albuquerque, New Mexico “The wonderful thing about dynamic guidance and the X-Guide is that the intraoperative plan can be changed to adjust depth relative to clinical decisions that need to be made as far as soft tissue height and thickness during surgery — this is not possible with static guides.” — Dr. Robert Emery, Washington, DC IP This information was provided by X-Nav Technologies.

Volume 10 Number 1

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DYNAMIC 3D NAVIGATION FOR MORE ACCURATE IMPLANT SURGERY

11X

ACCURATE THAN

FREEHAND SURGERY

INDUSTRY LEADING BY X-NAV TECHNOLOGIES

www.X-NavTech.com

SCAN

PLAN

NAVIGATE

ABSOLUTE IMPLANT PRECISION

DELIVER IMPLANTS WITH CONFIDENCE

Expand Your Control Over The Implant Process

Easy Navigation & Precise Placement

The X-Guide system delivers interactive, turn-by-turn guidance giving you the ability to improve every movement of your handpiece during osteotomy and implant delivery for more exact implant placement - like GPS for your drill.

In surgery, control real-time movements of your drill and implant placement with remarkable precision - use the X-Point to navigate position, angle and depth.

POSITION • ANGLE • DEPTH SEE WHAT’S THE NEXT BIG THING IN 3D IMPLANT DENTISTRY

Dr. Justin Moody and his faculty will mentor and guide you down the implant pathway. You’ll learn... ✔

Live Implant Surgery and Restorations Done by YOU

✔ Patient Selection, Medical History and Pharmacology ✔ Treatment Planning and Case Acceptance ✔ Surgical Implant Placement

✔ Ridge Preservation and Bone Grafting ✔ Guided Implant Surgery

✔ Complications When It Don’t Go Right

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Diplomate - American Board of Oral Implantology Diplomate, Master and Fellow - International Congress of Oral Implantologists Fellow and Associate Fellow - American Academy of Implant Dentistry Master and Fellow - Misch International Implant Institute Adjunct Professor - University of Nebraska Medical Center Mentor - Kois Center

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