Implant Practice US Vol 10, No 2 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews REACH FOR THE BETTER GRADE

April/May 2017 – Vol 10 No 2

Removable partial dentures and strategic implant placement Dr. Charlotte Stilwell

From “adamantly opposed” to “absolutely loved” on the anterior maxilla Dr. Jason Souyias

High-performance polymers Dr. Paul Tipton

What defines implant success? Dr. Justin Moody

Practice profile Dr. Jay B. Reznick

The Proximator The instrument you wish you always had.

PROMOTING EXCELLENCE IN IMPLANTOLOGY

The use of dynamic navigation to prevent implant complications — every patient, every time Drs. Robert W. Emery and Keith Progebin

PAYING SUBSCRIBERS EARN CONTINUING EDUCATION CREDITS PER YEAR!

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INTRODUCTION

Innovative technologies lead to accurate predictable implants

April/May 2017 - Volume 10 Number 2

EDITORIAL ADVISORS Steve Barter, BDS, MSurgDent RCS Anthony Bendkowsk,i BDS, LDS RCS, MFGDP, DipDSed, DPDS, MsurgDent

t is an exciting time to be involved in implant dentistry. As a periodontist who has been involved in implant dentistry for over 25 years, I am very excited about the future of dental implants. Digital workflow, starting with digital radiography, makes diagnosis and treatment planning more accurate than ever. From 3D imaging, printed models can be generated that will allow for the planning and printing of surgical guides that will make implant placement more precise. Guided implant placement has become more accurate allowing for implants to be placed in an ideal position, depth, and angulation that will result in restorative-driven implant Dr. Suheil M. Boutros placement. As a result of improved guided surgery, complex implant treatment is becoming more accurate and predictable, especially for less experienced clinicians. Today, with implants placed in a guided and controlled way, the final restoration can be done using CAD/CAM technology. The use of intraoral scanners can give the restoring dentist and the laboratory technician several restorative options that will provide patient-specific solutions. It is my opinion that implant dentistry is shifting greatly from analog to digital. Biologics such as allografts, xenografts, and bone-morphogenic proteins have been widely used in recent years to regenerate bone and permit compromised cases to be treated with dental implants. Advanced research in regenerative medicine shows great promise for tissue and bone regeneration. The application of stem cell technology can hopefully make some impossible implant therapy in compromised cases possible to treat with dental implants. Modern implant designs and geometry allows for better primary stability that can predictably allow for the placement of fixed provisional restorations at the time of implant placement. New surface technology such as Trabecular Metal™ (Zimmer Biomet) material, a highly porous tantalum (a natural element), has been extensively used since 1997 in orthopedic hip, knee, and spine implants to achieve anchorage through osseoincorporation, a combination of three-dimensional bone in-growth through the interconnected pores, and conventional osseointegration (bone on-growth) with the internal and external surfaces of the material. This can enhance secondary stability that can predictably allow implant placement in medically compromised patients as well as compromised sites and possibly allow for early implant loading. Since more patients demand dental implants using a minimally invasive approach, the use of narrow diameter implants such as the Eztetic™ Implant (Zimmer Biomet) with platform switching makes implant placement in the esthetic zone more predictable. The use of short implants in recent years has become more predictable due to improved surface technology resulting in higher patient acceptance. In summary, as we see an increased patient demand for implant therapy, treatment solutions with digital planning, and CAD/CAM restorations will continue to rise. I also see a great demand for narrow diameter implants in the esthetic zone as well as short implants in the posterior region that could possibly provide a great alternative to bone grafting. Dr. Suheil M. Boutros

Philip Bennett, BDS, LDS RCS, FICOI Stephen Byfield, BDS, MFGDP, FICD Sanjay Chopra, BDS Andrew Dawood, BDS, MSc, MRD RCS Professor Nikolaos Donos, DDS, MS, PhD Abid Faqir, BDS, MFDS RCS, MSc (MedSci) Koray Feran, BDS, MSC, LDS RCS, FDS RCS Philip Freiburger, BDS, MFGDP (UK) Jeffrey Ganeles, DMD, FACD Mark Hamburger, BDS, BChD Mark Haswell, BDS, MSc Gareth Jenkins, BDS, FDS RCS, MScD Stephen Jones, BDS, MSc, MGDS RCS, MRD RCS Gregori M. Kurtzman, DDS Jonathan Lack, DDS, CertPerio, FCDS Samuel Lee, DDS David Little, DDS Andrew Moore, BDS, Dip Imp Dent RCS Ara Nazarian, DDS Ken Nicholson, BDS, MSc Michael R. Norton, BDS, FDS RCS(ed) Rob Oretti, BDS, MGDS RCS Christopher Orr, BDS, BSc Fazeela Khan-Osborne, BDS, LDS RCS, BSc, MSc Jay B. Reznick, DMD, MD Nigel Saynor, BDS Malcolm Schaller, BDS Ashok Sethi, BDS, DGDP, MGDS RCS, DUI Harry Shiers, BDS, MSc, MGDS, MFDS Harris Sidelsky, BDS, LDS RCS, MSc Paul Tipton, BDS, MSc, DGDP(UK) Clive Waterman, BDS, MDc, DGDP (UK) Peter Young, BDS, PhD Brian T. Young, DDS, MS

CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day, BDS, VT Julian English, BA (Hons), editorial director FMC Dr. Paul Langmaid, CBE, BDS, ex chief dental officer to the Government for Wales Dr. Ellis Paul, BDS, LDS, FFGDP (UK), FICD, editor-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

Suheil Boutros, DDS, MS, received his DDS degree from the University of Detroit Mercy and his master’s degree and specialty certificate in periodontics from the University of Minnesota. He maintains a full-time private practice limited to periodontics and dental implants in Grand Blanc and Clarkston, Michigan. Dr. Boutros is a Diplomate of the American Board of Periodontology (ABP) and the American Board of Oral Implantology (ABOI) and is a Fellow the Academy of Osseointegration (AO) and the American College of Dentists (ACD). He serves on the Dean’s Faculty as a visiting assistant professor at the University of Michigan. Dr. Boutros lectures extensively both nationally and internationally on dental implants, advanced bone grafting, and periodontal plastic surgery. He is the author of number of professional publications, including several textbook chapters. Disclosure: Dr. Boutros is a consultant and opinion leader for Zimmer Biomet.

2 Implant practice

© 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 2

IMPLANTING CONFIDENCE

WORKFLOW INTEGRATION I HUMANIZED TECHNOLOGY I DIAGNOSTIC EXCELLENCE

With open-format image files, implant planning has never been easier. Carestream Dental’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 third-party surgical guide software makes placing implants easier than ever.

For more information, call 800.944.6365 or visit carestreamdental.com

TABLE OF CONTENTS

Financial focus Is your retirement plan tax savvy?

Practice profile Jay B. Reznick, DMD, MD

Tom Zgainer discusses the impact of taxes on your financial future........... 14

Technology, teaching, and triathalons

Technology The use of dynamic navigation to prevent implant complications — every patient, every time Drs. Robert W. Emery and Keith Progebin discuss navigation for accurate and precise implant planning .......................................................20

Abstracts

Case study From “adamantly opposed” to “absolutely loved” on the anterior maxilla

Research update: peri-implant disease Implant Practice US presents the latest abstracts published on the subject of diseases affecting peri-implant tissues .......................................................25

Dr. Jason Souyias discusses a patient who benefited from CBCT imaging

ON THE COVER Cover photo courtesy of Dr. Justin Moody. Article begins on page 48.

4 Implant practice

Volume 10 Number 2

light years beyond ‘frozen peas’ TM

Our hands-free hot/cold therapy system helps promote patient compliance and reduce post-op complications. Cool Jaw provides mutliple options of facial wraps and gel packs which assist in recovery following dental implants and other oral surgeries. Our Clear Cold Gel Packs freeze solid and remain cold up to an hour. Our Blue Hot/Cold Gel Packs, as well as our Green Peas Hot/Cold Gel Packs, remain pliable when frozen, contour to the face and provide patients with more post-op therapy options. All of our products can be customized with your practice logo and information for long lasting promotion. Cool Jaw’s reusable hands-free system arrives with preprinted, patient-friendly instructions for added convenience.

TABLE OF CONTENTS

Continuing education Continuing education High-performance polymers In the first of two articles, Dr. Paul Tipton introduces some of the advances in restorative materials with a discussion of polyetheretherketone — a new prosthodontic material

................................................. 34

Technology

Removable partial dentures and strategic implant placement

Dr. Charlotte Stilwell assesses the strategic use of implant overdenture abutments with removable partial dentures

Materials & equipment......................44

PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com

Industry news.............47

ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkaz.com

A decade of rapid improvement Dr. David Reaney looks back on advances made in the world of dental implants and dental implant technology over the past 10 years

NATIONAL ACCOUNT MANAGER Celeste Scarfi-Tellez Email: celeste@medmarkaz.com CLIENT SERVICES/SALES SUPPORT | Adrienne Good Email: agood@medmarkaz.com

Practice development

CREATIVE DIRECTOR/PROD. MGR. | Amanda Culver Email: amanda@medmarkaz.com

Top five dental marketing scams

Product profile

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

NATIONAL SALES DIRECTOR | Kristin Sammarco Email: kristin@medmarkaz.com

.................................................38

Cory Roletto, MBA, discusses some marketing tactics to avoid.............40

WEBSITE MANAGER | Anne Watson-Barber Email: anne@medmarkaz.com

On the horizon What defines implant success?

alloOss® allografts

Dr. Justin Moody reflects on two decades of implant placement

Pure. Predictable. Proven..............42

................................................. 48

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

6 Implant practice

Volume 10 Number 2

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 23.48% variable APR. Interest will be charged to your account at the standard variable APR of 23.48% (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 23.48%. © 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.

PRACTICE PROFILE

Jay B. Reznick, DMD, MD Technology, teaching, and triathalons What can you tell us about your background? I was born and raised in Los Angeles and attended University of California, Berkeley, for my undergraduate education. I then took a year off and did research for 1 year at Los Angeles County Hospital before going to Tufts University for my dental degree. After dental school, I did my Oral and Maxillofacial Surgery residency at LAC+USC Medical Center. It was there that I realized that I wanted to get my medical degree, so that I could understand more about my patients and be more competent at managing the whole patient. After graduating from the University of Southern California School of Medicine, I did a 1-year internship in General Surgery. While I was in medical school and internship, I managed to practice oral surgery about 20 hours per week; so when I started full time in private practice, I had already begun to establish myself.

Is your practice limited to implants? As a Board-Certified oral and maxillofacial surgeon, I am able to perform the full scope of the specialty I was trained in. For the first half of my career, I did a significant number of cases of facial trauma, jaw tumors, and orthognathic surgery. As I started spending more time away from the office teaching and lecturing, I stopped doing surgery in the hospital. Now, my practice emphasis is on implantology, bone and tissue regeneration, as well as removal of impacted and failing teeth.

Why did you decide to focus on implantology? Oral and maxillofacial surgeons have been the pioneers and leaders in implantology since the beginning. We were trained in implantology from the first year of residency and continued with increasing complexity through the senior year. It has been a key part of my practice since I finished training.

How long have you been practicing, and what systems do you use? I have been in full-time practice since 1995. I started with the classic Brånemark 8 Implant practice

Dr. Reznick and his team performing third-molar surgery under general anesthesia in the office

implant system, and over the years, have used many of the major systems on the market. I have two primary systems that I currently use — Astra Tech Implant System® EV and BioHorizons® Tapered Internal Plus. I also occasionally place Straumann®, Nobel Biocare® and 3i™, as well as mini provisional implants.

What training have you undertaken? Implantology was an integral part of my surgical residency, and I continue to take continuing education courses to expand my knowledge and skills. Our knowledge Volume 10 Number 2

Who has inspired you? I had a number of really great attending physicians and surgeons through dental school, medical school, general surgery, and oral and maxillofacial surgery residency. I credit Dr. William Gilmore at Tufts dental school, with whom I did research and published a couple of scientific articles, with getting me going on the path of my career.

surgeons that that they were not candidates for implants, or at high risk for other procedures, come back to the office truly happy that we were able to treat them successfully.

Professionally, what are you most proud of? It has been very gratifying to be able to teach and inspire so many dentists over the years and give them the confidence and skills to deliver treatment that wasnâ&#x20AC;&#x2122;t part of their

undergraduate dental education. Whether it is implant dentistry or office oral surgery, they learn to put their patients first and only perform procedures that are within their comfort zone and not beyond.

What do you think is unique about your practice? My practice is at the forefront of technology. I was one of the first surgeons to embrace fully guided dental implant surgery

What is the most satisfying aspect of your practice? I really enjoy seeing patients, who came to me because they were told by other

Dr. Reznick and members of his office team

Dr. Reznick addressing a conference of oral surgeons, prosthodontists, general dentists, periodontists, lab technicians, and implant industry leaders in Chicago

Dr. Reznick saying goodbye to one of the many patients he treated at a charity dental clinic in Guatemala Volume 10 Number 2

Implant practice 9

PRACTICE PROFILE

and techniques are always evolving, so it is important as a clinician to always be learning.

PRACTICE PROFILE

3D digital technology allows Dr. Reznick to accurately evaluate the problem for which the patient presents and then discuss the best treatment options

Dr. Reznick using his GALILEOS CBCT image to educate his patient about why she is having pain around her lower wisdom tooth

for the great majority of my cases and was the first specialist in the United States to integrate CAD/CAM and CBCT in to the office. I also have an amazing staff that supports me so that our patients have an incredible experience in our office. Those two things really set us apart from other practices in our area.

What has been your biggest challenge? With the explosion of technology, the biggest challenge is keeping up. We are constantly upgrading our systems to accommodate greater volumes of data and the need for faster processing speed so that we can continue to provide cutting-edge surgical care. The other is my quest to get greater acceptance of digital technology among surgical specialists. Many of them see 3D technology as unnecessary and as a â&#x20AC;&#x153;crutchâ&#x20AC;? for untrained dentists to place implants. In fact, the technology elevates the game for GPs and specialists alike. It allows us to be more accurate and more efficient with our implant planning and surgery at all levels and leads to better results for our patients.

What would you have become if you had not become a dentist? Airline pilot or a rock star. But, since I have never taken flying lessons or played an instrument, those would be a long shot. I probably would have gone into plastic surgery or ENT surgery.

What is the future of implants and dentistry? I definitely feel that 3D technology will take over the practice of dentistry for the future, and that future will be sooner than we all expect. Guided implant surgery makes prosthetically driven planning easily achievable so that implants are accurately 10 Implant practice

A group of dentists learning the Fundamentals of Implantology from Dr. Reznick

placed with the final result as the goal. And with CAD/CAM and digital impressions improving and gaining acceptance, the techniques we learned in dental school will soon be obsolete.

What are your top tips for maintaining a successful practice? Always do what is best for your patients. Treat them all like you would treat you family (assuming you like your family members). If you are a general practitioner, sometimes that means knowing when to refer your patient to a specialist who can use his/her expertise and training to achieve the best outcome. Never do anything that makes you uncomfortable or that you might lose sleep over. And assemble a really good office team, and take good care of them. Success will follow you if you remember these two things.

What advice would you give to budding implantologists? Always remember that implant surgery is surgery. It is invasive and can harm your patient if not done properly. Start your journey slowly. Remember, it is a journey, not a race. Become educated on the principles of implantology and surgery and start with very simple cases and get very good at them before moving forward. Just because you have the time to do a procedure doesnâ&#x20AC;&#x2122;t mean you should. What is best for your patients always comes first.

What are your hobbies, and what do you do in your spare time? What spare time? Life is pretty busy these days. Between private practice, running OnlineOralSurgery.com, and a busy lecture schedule, I manage to get some good skiing in during the winter. From spring until Volume 10 Number 2

Neither is the anatomy of your implant patients

Astra Tech Implant System® OsseoSpeed® Profile EV – for sloped ridge situations Your world is already full of clinical challenges so why work harder because of conventional thinking? Instead of augmenting sloped ridges to accommodate flat-top implants, it’s time to discover a simpler solution by using an implant that follows the bone. Because sloped-ridge situations call for anatomically designed sloped implants.

It’s time to challenge conventional thinking

www.profiledentalimplants.com

Conventional vs innovative approach

OUR WORLD IS NOT FLAT

PRACTICE PROFILE fall, I spend the early mornings and weekends open-water swimming, running, and cycling to get ready for the triathlon season. I also like to go out stand-up paddle boarding on my way home from the office and have recently taken up surfing.

More about Dr. Reznick Dr. Reznick is the Director of the Southern California Center for Oral and Facial Surgery in Tarzana, California, and a Diplomate of the American Board of Oral and Maxillofacial Surgery. A frequent lecturer, he has published numerous articles in JADA, Journal of the California Dental Association, Oral SurgeryOral Medicine-Oral Pathology, Implant Practice US, Compendium of Continuing Education in Dentistry, Dentaltown Magazine, CE Digest, and Gastroenterology. Dr. Reznick was a very early adopter of 3D imaging and CBCT-guided dental implant surgery and was one of the first specialists in the U.S. to integrate CAD/CAM technology in to implant work flow. He is the founder of the educational website OnlineOralSurgery, which has educated clinicians all over the world. Between his busy schedule of teaching, lecturing, and private practice, Dr. Reznick finds time to ski, ocean paddleboard, and train for his upcoming Ironman races. IP

Dr. Reznick enjoys staying active and frequently volunteers doing in-race medical support to give back to his community

Top 10 favorites 1. My GALILEOS (Dentsply Sirona Imaging) cone beam CT has to be first on the list — it is the essential piece of technology that helps me diagnose and treat my patients by giving me accurate information. 2. A great office team — I can’t do it all myself. They make me look good. 3. Headlight and surgical loupes — being able to see what you are doing allows you to perform better surgery. 4. Proximators™ (Karl Schumacher Instruments) — I have a spade Proximator on every extraction tray in the office. It is the essential instrument for performing minimally invasive atraumatic exodontia. 5. Piezotome (Satelec Acteon) — this is far superior to a drill or saw for performing sinus lifts, ridge splits, and bone grafts. 6. CEREC (Dentsply Sirona) — allows me to capture digital impressions, do virtual “wax-ups” for implant planning, and mill custom implant provisional restorations in the office. 7. Astra Tech Implant System® EV Guided surgery kit (Dentsply Sirona Implants) — makes implant surgery more efficient, more accurate, and less stressful. 8. 3D Printer (Formlabs) — lets me print custom implant surgical guides in the office, which significantly improves turnaround time between consultation and surgery. 9. A fast bike. Because I am otherwise slow and need all the help I can get. 10. Living at the beach — should need no explanation. Dr. Reznick spends a lot of time in the ocean when he is not in surgery or on the lecture stage 12 Implant practice

Volume 10 Number 2

INSTRUMENTS OF THE BETTER GRADE

Celebrating 70 Years

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The Karl Schumacher Proximators ™ and RoBa ™ Forceps are precise instruments for minimally invasive extraction procedures, which are perfect for implant placement. The grip and leverage these instruments provide allow for easier extraction, and save valuable chair time. Joseph Kan, DDS, MS

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FINANCIAL FOCUS

Is your retirement plan tax savvy?

Tom Zgainer discusses the impact of taxes on your financial future

hat’s your retirement plan? Do you have a pension? A 401(k)? Do you think this will be enough for you to live comfortably on? While millions of Americans have a retirement account in place, the scary truth is they have not considered the impact that taxes have on how much of their money they will actually keep. If you haven’t noticed already, our government has some serious spending habits. They’ve racked up not only more than $17.3 trillion in debt, but also $100 trillion in unfunded liabilities with Social Security 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/feecheckermedmark.

14 Implant practice

and Medicare as well. So what do you think this means for taxes? Will taxes be higher or lower in the future? You have probably been taught to maximize your 401(k) or IRA contributions for tax purposes because each dollar is tax deductible. This, of course, means that you don’t have to pay tax on that dollar today, but instead will defer the tax to a later day. Here is the problem: It’s impossible to know what tax rates will be in the future. So you have no idea how big of a bite taxes will take out of your retirement fund. Most experts will tell you that over time, the only logical direction for taxes to go is up. After all, someone has to pay for those staggering levels of debt the government has accumulated. What does this mean for your retirement plan? In short, it means that what you actually get to keep could be a lot less than you anticipated.

To help you determine which retirement plan is right for you, we help answer some of the most important questions you may have about the impact of taxes on your financial future.

Q: Should you participate in your 401(k) plan? A: The bottom line is that you have to do something. But you have to be smart about it. The 401(k) can be a great piece of tax code that, if structured right, can fuel your retirement for years. But, as we see in most of today’s plans, many 401(k) plans are chock-full of fees and unseen costs. In 2012, service providers became required by law to disclose these fees, but despite this change, the majority of employees still aren’t aware of how much they’re paying — and really, how much they’re losing. Volume 10 Number 2

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2. After a brief call to review the results, we will send you a complimentary copy of UNSHAKEABLE.

FINANCIAL FOCUS Just be sure to know how your company’s plan stacks up. Go to http://Americasbest401k.com/401k-fee-checker, and click on “Fee Checker” to assess your company’s plan.

Q: What should you do if you think taxes are going up? A: If you think that taxes will go up in the future, then you may want to consider a Roth retirement plan. A Roth IRA, and more recently the addition of the Roth 401(k), is often overlooked but is actually one of the most tax-efficient solutions to retirement out there. With a Roth account, we pay taxes today, then deposit the after-tax amount, and never have to worry about taxes again. So our money grows tax-free, and we don’t have to worry about taxes when we take our money out. You are completely protected if the government decides to raise taxes in the future. And most importantly, you will know with absolute certainty how much money you will actually have when you decide to start making withdrawals. Most of today’s 401(k) plans allow you “check a box,” and your contributions will

receive the Roth tax treatment. This means you can pay tax today and let your growth and withdrawals steer clear of the tax man. And while a Roth IRA is limited to a $5,500 annual contribution, the Roth 401(k) allows you to deposit $18,000 every year. Just remember, if you decide to check the box and make your 401(k) contributions Roth eligible, you will still be investing in the same list of funds. The only difference will be that you are paying taxes on the income today, while securing your money from taxes in the future.

Q: Is there anything you can do with your traditional IRA? A: Yes, there is. If you think taxes will be going up in the future, then you may want to consider a Roth conversion. With a Roth conversion, the government will allow you to pay the tax on your IRA today (because they could use the money now), and you will never have to pay tax again. Confused? Take John, for example. John has an IRA with $10,000 and is in the 40% tax bracket. This means he would pay $4,000 today and allow the remaining $6,000 to grow and be withdrawn tax-free!

You must learn how to protect your money from unforeseen changes in the environment, particularly taxes.

Some people are automatically turned off from the idea of paying tax today. But remember, you will have to pay taxes eventually. And by doing it now, you are protecting yourself and your nest egg from future tax hikes.

Q: Are there any additional options to save? A: Small business owners or highincome earners who have a steady income and want to reduce their taxes today can find big benefits by coupling a cash-balance plan with their 401(k) plan. A cash-balance, or CB plan, is basically a pension plan that happens to have elements of a 401(k). Like a pension, you won’t be investing any of your own money into the plan. You also don’t have control over the investment choices. But rather than your overall benefits being based on a specific formula that considers how long you’ve worked at the company or what your average salary has been, the CB plan simply takes a set percentage of your salary each year, plus a set interest rate, and adds it into your account. The best part is that you can max out your 401(k) plan and a profit-sharing plan and then still add a CB plan to create some substantial — and fully deductible — contributions. A cash-balance plan starts to get very exciting when you get older, as you can put a more substantial amount of money away while reducing your tax liability. A cash-balance plan essentially allows you to squeeze 20 years of savings into 10 years. Remember, it’s not enough to just protect your nest egg from the unscrupulous fees and costs that some 401(k) plans impose; you must learn how to protect your money from unforeseen changes in the environment, particularly taxes. Whether this means selecting a plan in which you pay your taxes today, or one that allows you to defer your taxes until later, you must find a way to optimize your growth and be fully aware of how much you will get to keep. Don’t be blindsided by the hit the tax man will take on your nest egg. Protect your nest egg, and protect your road to retirement because by doing so, you are ultimately protecting your financial future. IP

Is your plan tax savvy? Find out here: http://americasbest401k.com/fee-checker-medmark. 16 Implant practice

Volume 10 Number 2

Dr. Jason Souyias discusses a patient who benefited from CBCT imaging

ome patients know exactly what they want, or rather, what they don’t want. When a woman presented at my office with a failing bridge across the anterior maxilla, she was adamantly opposed to removable work. As people live longer, healthier, more active lives, dentures and bridges are seen as something for “old people.” However, what do you do when the patient’s anatomy makes a fully fixed solution seemingly impossible? I find that the right technology, close collaboration with the patient’s referring doctor and having an open mind to alternative solutions can give the patients what they want — even if they didn’t realize they wanted it.

Case report A 65-year-old female presented at my practice upon referral from her general practitioner. Her chief complaint was a failing bridge across the anterior maxilla from tooth No. 6 to tooth No. 11. She had no significant medical history. The patient did not want removable work and was looking for a permanent solution.

practitioner, who insisted any fixed option would be impossible and that a removable solution was the only course of action. After further reviewing the CBCT scan, it was decided to augment the bone in the anterior maxilla and place four implants with a precision attachment partial denture, which would be later restored by the general practitioner. The patient was hesitant but understanding when told that a fixed solution would fail due to her bite, and she accepted the treatment.

Treatment Treatment in my practice spanned from November 2015 to October 2016. Before the first surgery, Valium was prescribed to keep the patient calm, in addition to 300 mg of clindamycin every 8 hours starting

the day before the procedure. The surgery was performed under IV conscious sedation with midazolam. Teeth Nos. 6, 9, and 11 were extracted and ridge augmentation was performed across the entire anterior maxilla, using particulate mineralized freeze-dried bone. Resorbable collagen membranes and platelet-rich fibrin were used to aid in the healing, and three tacks were placed to hold the membrane down. The procedure took about 2½ hours. The patient was prescribed Peridex™ (3M) mouthwash for postoperative care. Ultram 5 mg was prescribed for post-op discomfort due to an allergy to NSAIDs. The patient experienced very little discomfort. The patient returned 2 weeks later for a post-op appointment to remove sutures that had been placed during the surgery.

Diagnosis The initial examination and review of the radiographs shared by the referring doctor did not indicate any particular challenges. However, a cone beam computed tomography (CBCT) scan with a CS 9300 (Carestream Dental) showed a severely width-deficient ridge across the anterior maxilla; a very deep Class 2 bite was also diagnosed. It appeared as if ideal soft tissue contours could not be achieved with a fixed case. I consulted with the referring general

Figures 1-2: Initial case photographs of failing bridge

Jason Souyias, DDS, went to the University of Detroit Mercy for his dental education and graduated with his doctorate of dental surgery in 2002. He completed a 3-year periodontal residency program at Oregon Health and Science University in 2005. Souyias became a Diplomate of the American Board of Periodontology in 2007 and is a former part-time assistant clinical professor, Department of Periodontology and Hygiene, at the University of Detroit Mercy.

Figure 3: CBCT scan reveals severely width-deficient ridge Volume 10 Number 2

Implant practice 17

CASE STUDY

From “adamantly opposed” to “absolutely loved” on the anterior maxilla

CASE STUDY Six months later, a CBCT scan was taken to confirm healing. Prior to the second procedure, 4 mg of dexamethasone was prescribed — two tablets the morning of the surgery, one the next morning, and one the following morning. Again, the procedure was performed under IV conscious sedation with midazolam. Implants Nos. 6, 8,

9, and 11 were placed. The three tacks that had been used to hold the membrane down after the first procedure were removed. Peridex mouthwash and Ultram were again prescribed as part of postoperative care. The implants were allowed to heal for 4 months before second-stage surgery. The patient returned to her referring doctor for

Figure 4: Post-augmentation CBCT scan to confirm healing

Figure 5: Final panoramic radiograph showing the implant positions

the precision attachment partial denture, finishing in December 2016.

Overview CBCT is able to tell a completely different story than what we see during physical examinations and on 2D radiographs. In this case, CBCT gave me the confidence to present a treatment plan that provided the patient with a compromise — implants and a partial denture — while still ensuring exceptional results. It also improved my communication with the patient’s referring general practitioner, as I was able to clearly present my proposed treatment plan. In the past, I would have planned two scenarios for surgery, assuming one of those two things were going to happen, but could never be certain which. Had I not used CBCT in this case, I would have been in for a surprise, and the patient may have come out of surgery without the results she was hoping for. If there were one machine in my office that if you removed it, I’d just go ahead and retire, it would be the CS 9300; I simply cannot imagine practicing in the implant field without it. To be able to see the vital structures, such as the alveolar nerve, and to know how many millimeters of bone I have to work with provide an extra layer of safety for our patients. When a patient comes to my office with his/her mind set on a certain outcome, I do everything in my power to make that happen. Sometimes, it means taking a different approach than what both the patient and I originally planned. Fortunately in this case, the patient absolutely loved the solution that my practice, in combination with her restorative dentist, Jim Cotter, DDS, Bolla, Cotter & Associates, Port Huron, Michigan, was able to deliver, which is what I’d call a successful case. IP

Figures 6-7: Final case images 18 Implant practice

Volume 10 Number 2

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PRODUCTS TO MEET YOUR NEEDS. NOT OURS. We have always taken care to carefully curate a portfolio of necessary components that respect scientific evidence and research. Through the years, trends have appeared that, though popular, have not proven a conclusive benefit. Developing additional products to satisfy the demand for trends would certainly make us money, but we cannot use that as our guiding principle. This is because our primary focus is our clinicians and their patients. We are doing what is right. We are doing what matters.

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TECHNOLOGY

The use of dynamic navigation to prevent implant complications — every patient, every time Drs. Robert W. Emery and Keith Progebin discuss navigation for accurate and precise implant planning

omplications related to dental implants fall into two broad categories: infectious and mechanical. The underlying etiology of these two categories often results from poor implant position.1–3 Computerassisted surgery (CAS) allows the dental team, including restorative dentist, surgeon, and dental technician, to plan and place implants more accurately and precisely. There are two forms of CAS: • Static guidance, which uses prefabricated CAD/CAM splints, proprietary tubes, and drills to guide the surgeon’s instruments. These guides cannot be altered after fabrication and are thus “static.” • Dynamic guidance, which uses a stereotactic tracking system to dynamically guide the surgeon’s instruments to the correct location. The plan can be altered at any time and is thus “dynamic.” With the advent of dynamic navigation for the placement of dental implants, the dental surgeon can place implants accurately and precisely every time in an efficient and costeffective fashion.4 A complete digital workflow used with dynamic guidance requires no lab work. The patient can be scanned,

Robert W. Emery, BDS, DDS, is a board-certified Oral and Maxillofacial Surgeon in private practice in Washington, D.C. Dr. Emery received the Nobelpharma Oral and Maxillofacial Surgery Research Award and Grant from the Oral and Maxillofacial Surgery Research Foundation. He is actively involved in numerous research projects with an emphasis on image-guided surgery and is a founding partner of X-Nav Technologies, LLC. Presently, he is Director of the Capital Center for Oral and Maxillofacial Surgery, Senior Attending Surgeon at the Washington Hospital Center, and Chief Medical Officer of X-Nav Technologies.

the case planned, and the implant placed in one visit. The typical cost for a dynamically guided case is less than $100. Presently, dental surgeons often guide only the “tough” or “complex” cases. This “complexonly” approach has resulted from the difficulty and cost of using static guides. Static guides require that the guides be fabricated ahead of time. Once fabricated, the guides cannot be changed. The cost varies from $300 to $1,200 per case. The literature clearly shows that dentists are not as accurate and precise when they place implants freehand compared with any form of guided surgery.5–8 This case study illustrates the management of a significant complication related to the placement of a single implant in the wrong position. The “simple” becomes “complex.” This 45-year-old male presented to the surgeon with a complaint of a failed implant and loose adjacent teeth. The implant had been placed by another surgeon 3 months earlier. Initially, the patient was told he had a vertically fractured tooth No. 4 that was not restorable (Figure 1). The tooth was extracted and an immediate implant placed freehand (Figure 2). The patient described pain and tenderness that persisted following implant placement. The patient went back to the surgeon on a weekly basis and received

Figure 1: Pre-surgical periapical, tooth No. 4 fractured vertically

Figure 2: Postoperative periapical showing incorrect implant position with impingement of periodontal ligament of tooth No. 3

Keith Progebin, DDS, is a former Associate Clinical Instructor, Department of Prosthodontics and Occlusion, New York University College of Dentistry. Dr. Progebin is a Member of the Academy of Osseointegration and the American College of Prosthodontics. He is also a Fellow of the Greater New York Academy of Prosthodontics, the International College of Dentists, and the American College of Dentists. Dr. Progebin is in Private Practice in Advanced Restorative Dentistry and Implant Prosthodontics in Washington, D.C.

Figure 3: CBCT showing periapical abscess and attachment loss of teeth Nos. 3 and 5 20 Implant practice

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TECHNOLOGY two-dimensional radiographs. The postoperative course included an infection treated with antibiotics for 1 month and eventual removal of the implant No. 4. The patient now had tenderness around the implant site with mobility and deep periodontal pockets on teeth Nos. 3 and 5. Cone beam computed tomography (CBCT) revealed periapical abscesses of teeth Nos. 3 and 5 with loss of adjacent periodontal attachments (Figure 3). The patient was referred for prosthetic consultation, and a treatment plan was developed. The plan included the following: 1. Intraoral scanning for virtual treatment planning. Diagnostic wax-up and fabrication of a removable provisional prosthesis for areas Nos. 3, 4, 5 (Essix retainer) 2. Extraction of teeth Nos. 3 and 5 with immediate guided-tissue regeneration using cortico-cancellous allograft, PRF, and dense PTFE membrane 3. Allow the area to heal for 2 months 4. Placement of implant Nos. 3, 4, and 5 using dynamic navigation (X-Guide, X-Nav Technologies, LLC, Lansdale, Pennsylvania) and osseodensification (DensahÂŽ, Versah, LLC, Jackson, Michigan) 5. Allow 4 months for osseointegration followed by ISQ evaluation 6. Provisionalization for 2 to 4 months 7. Final fixed restoration The patient underwent extraction and immediate guided-tissue regeneration (Figures 4 and 5). A removable provisional restoration interim appliance was placed with soft tissue conditioner, and the graft then matured for 2 months. At 2 months, the patient underwent presurgical CBCT with an X-Clip. The DICOM of the CBCT was imported in the X-Guide planning software and the pre-extraction

Figure 5: The immediate post-surgical panoramic 22 Implant practice

Dynamic navigation has given the dental team the ability to immediately and efficiently scan, plan, coordinate our care, and place implants more accurately and precisely on every patient, every time, thus avoiding complications.

Figure 4: Surgical view at the time of extraction and immediate guided-tissue reconstruction. Note the loss of adjacent periodontal attachment

Figure 6: Post-op CBCT (dark blue) superimposed on pre-surgical plan (light blue) to illustrate accuracy of dynamic image navigation Volume 10 Number 2

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TECHNOLOGY STL file imported for planning purposes. The implants were dynamically guided into position using the X-Guide. The postsurgical CBCT was superimposed on the pre-surgical plan to evaluate the accuracy of implant placement (Figure 6). The accuracy (mean) angular deviation from the plan for all three implants was 4.2 degrees. The precision (standard deviation) was 1.6 degrees. The accuracy (mean) platform entry deviation was 0.5 mm, and the precision (standard deviation) was 0.36 mm. After a period of 4 months, ISQ values greater than 70 were found for all three implants. A fixed provisional restoration was fabricated to manipulate the tissue, transitionally load the implants, and develop an appropriate hygiene regime for the patient (Figure 7). Only after the patient’s confidence and expectations were met was the definitive prosthesis fabricated and then restored. The patient is currently on a 3-month maintenance program to reevaluate his oral hygiene, restore his confidence in dentistry, and ensure a successful outcome. The final splinted ceramometal bridge was cemented with Temrex cement on gold custom abutments. (Figure 8). Prevention is the best way to avoid complications. Published data has shown that implants placed freehand are statistically less precise and accurate in every measure.5–7,9,10 Block showed freehand mean angular deviation was 6.5 degrees with a standard deviation of 4.21 degrees, compared to dynamically guided implants with a mean angular deviation of 2.9 degrees with a standard deviation of 1.36 degrees for fully guided.5 This case illustrates the time efficient digital workflow with no pre-surgical laboratory work necessary to implement dynamic guidance. The efficient workflow and decreased costs relative to static guidance allow this form of guidance to be used on every patient, every time. Had this patient had this “simple” case performed with any form of guidance, this “complex” complication could have been avoided. In summary, dynamic navigation has given the dental team the ability to immediately and efficiently scan, plan, coordinate our care, and place implants more accurately and precisely on every patient, every time, thus avoiding complications. IP

24 Implant practice

Figure 7: Fixed splinted provisional acrylic-cemented restorations

Figure 8: Fixed ceramometal bridge cemented on gold custom abutments Nos. 3I-4I-5I

REFERENCES 1. Link-Bindo EE, Soltys J, Donatelli D, Cavanaugh R. Common Prosthetic Implant Complications in Fixed Restorations. Compend Contin Educ Dent. 2016;37(7):431-436. 2. Roos-Jansåker AM. Long time follow up of implant therapy and treatment of peri-implantitis. Swed Dent J Suppl. 2007;188:7-66. 3. Shim HW, Yang BE. Long-term cumulative survival and mechanical complications of single-tooth Ankylos Implants: focus on the abutment neck fractures. J Adv Prosthodont. 2015;7(6):423-430. 4. Block MS, Emery RW. Static or Dynamic Navigation for Implant Placement — Choosing the Method of Guidance. J Oral Maxillofac Surg. 2016;74(2):269-277. 5. Block MS, Emery RW, Cullum DR, Sheikh A. Implant Placement is more accurate using dynamic navigation. J Oral Maxillofac Surg. 2017. Article in Press. http://www.joms.org/article/S0278-2391(17)30252-5/fulltext?rss=yes. Accessed March 21, 2017. 6. Block MS, Emery RW, Lank K, Ryan J. Implant Placement Accuracy Using Dynamic Navigation. Int J Oral Maxillofac Implants. 2017;32(1):92-99. 7. Emery RW, Merritt SA, Lank K, Gibbs JD: Accuracy of Dynamic Navigation for Dental Implant Placement–Model-Based Evaluation. J Oral Implantol. 2016;42(5):399-405. 8. Tahmaseb A, Wismeijer D, Coucke W, Derksen DW. Computer Technology Applications in Surgical Implant Dentistry: A systematic Review. Int J Oral Maxillofac Implants. 2014;29(Suppl):25-42. 9. Vercruyssen M, Cox C, Coucke W, Naert I, Jacobs R, Quirynen M: A randomized clinical trial comparing guided implant surgery (bone- or mucosa-supported) with mental navigation or the use of a pilot-drill template. J Clin Periodontol. 2014;41(7):717-723. 10. Kramer FJ, Baethge C, Swennen G, Rosahl S. Navigated vs. conventional implant insertion for maxillary single tooth replacement. Clin Oral Implants Res. 2005;16(1):60-68.

Volume 10 Number 2

Implant Practice US presents the latest abstracts published on the subject of diseases affecting peri-implant tissues Non-surgical therapy for periimplant diseases: a systematic review Suárez-López Del Amo F, Yu SH, Wang HL (2016). J Oral Maxillofac Res 7(3): e13 Objectives The purpose of this paper was to systematically evaluate the effectiveness of non-surgical therapy for the treatment of peri-implant diseases, including both mucositis and peri-implantitis lesions. Materials and methods An electronic search in two different databases was performed, including MEDLINE® (PubMed®) and Embase®, from 2011 to 2016. Human studies reporting non-surgical treatment of peri-implant mucositis and periimplantitis with more than 10 implants and at least 6 months’ follow-up published in the English language were evaluated. A systematic review was performed to evaluate the effectiveness of the different methods of decontamination employed in the included investigations. Risk of bias assessment was elaborated for included investigations. Results Twenty-five articles were identified of which 14 were further evaluated and included in the analysis. Due to significant heterogeneity in between included studies, a meta-analysis could not be performed. Instead, a systematic descriptive review was performed. Included investigations reported the use of different methods for implant decontamination, including selfperformed cleaning techniques and professionally delivered treatment such as laser, photodynamic therapy, supra-/sub-mucosal mechanical debridement, and air-abrasive devices. Follow-up periods ranged from 6 to 60 months. Conclusions Non-surgical treatment for peri-implant mucositis seems to be effective while modest and not predictable outcomes are expected for peri-implantitis lesions. Limitations include Volume 10 Number 2

Search criteria These abstracts were curated from a search on Pubmed using the keywords peri-implantitis and peri-implant disease.

different peri-implant disease definitions, treatment approaches, as well as different implant designs/surfaces, and defect characteristics.

Effect of mechanical debridement with adjunct antimicrobial photodynamic therapy in the treatment of peri-implant diseases in type-2 diabetic smokers and nonsmokers Abduljabbar T (2016). Photodiagnosis Photodyn Ther doi: 10.1016/j. pdpdt.2016.11.005 [Epub ahead of print] Objective The aim of the present 6-month follow-up study was to assess the effect of mechanical debridement (MD) with adjunct antimicrobial photodynamic therapy (aPDT) in the treatment of peri-implant diseases in type-2 diabetic smokers and nonsmokers. Methods Patients were divided into two groups: (a) Group-1: type-2 diabetic smokers; and (b) Group-2: type-2 diabetic nonsmokers. In both groups, hemoglobin A1c (HbA1c) levels and peri-implant bleeding on probing (BOP) and probing depth (PD) ≥4 mm were measured at baseline and after 6 months of follow-up.

Group comparisons were performed using the Kruskall-Wallis test, and for multiple comparisons, Bonferroni post hoc test was used. Level of significance was set at P < 0.05. Results Sixty-four individuals (33 in Group-1 and 31 in Group-2) were included. At baseline, 55BOP and PD ≥ 4 mm were comparable among individuals in groups 1 and 2. The mean age of individuals in groups 1 and 2 were 52.6±0.8 and 54.4±1.2 years, respectively. The mean duration of type-2 DM among patients in groups 1 and 2 was 8.2±0.3 years and 10±0.2 years, respectively. In Group-1, the participants were smoking 6.3±1.5 cigarettes daily since 12.7±3.3 years. At 6 months’ follow-up, there was no statistically significant difference in BOP and PD ≥ 4 mm among patients in groups 1 and 2 compared with the respective baseline values. HbA1c levels were comparable in all groups at all time intervals. Conclusion Outcomes of the treatment of periimplant diseases using MD with adjunct aPDT are comparable among type-2 diabetic smokers and nonsmokers. Implant practice 25

ABSTRACTS

Research update: peri-implant disease

ABSTRACTS Bleeding on probing around dental implants: a retrospective study of associated factors Farina R, Filippi M, Brazzioli J, Tomasi C, Trombelli L (2017). Clin Periodontol 44(1): 115-122 Objectives To identify factors associated with the probability of a peri-implant site to be positive to bleeding on probing (BoP+) and compare BoP+ probability around dental implants and contra-lateral teeth. Methods In 112 patients, data related to 1,725 periimplant sites and 1,020 contra-lateral dental sites were retrospectively obtained. To analyze the association between patient-, implantand site-related factors, and BoP+ probability, a logistic, three-level model was built with BoP as the binary outcome variable (+/). Results BoP+ probability for a peri-implant site with probing depth (PD) of 4 mm was 27%, and the odds ratio increased by 1.6 for each 1 mm increment in PD (p < 0.001). Also, BoP+ probability was higher in females compared to males (OR = 1.61; p = 0.048), and lower at posterior compared to anterior dental implants (OR = 0.55; p < 0.01). No significant difference in BoP+ probability was observed between peri-implant and contra-lateral dental sites when controlling for the difference in PD. Conclusions The probability of a peri-implant site to bleed upon probing is associated with PD, implant position, and gender, and similar to that observed at contra-lateral dental sites when controlling for the effect of PD.

Effects of low-intensity pulsed ultrasound on implant osseointegration in ovariectomized rats Zhou H, Hou Y, Zhu Z, Xiao W, Xu Q, Li L, Li X, Chen W (2016). J Ultrasound Med 35(4): 747-754 Objectives To investigate the effect of low-intensity pulsed ultrasound (US) on peri-implant bone healing and osseointegration under osteoporotic conditions. Methods Seventy-two 12-week-old female Sprague Dawley rats received bilateral ovariectomies. Twelve weeks later, titanium implants 26 Implant practice

were bilaterally placed in the proximal tibial metaphysis. The right tibia was exposed to low-intensity pulsed US (40mW/cm2, spatial and temporal average) for 20 min/d starting the second day after implantation, and the left tibia served as a control without stimulation. The rats were randomly assigned to 6 groups of 12 each according to the US duration (group 1: weeks 0-2, 280 minutes; group 2: weeks 0-4, 560 minutes; group 3: weeks 0-6, 840 minutes; group 4: weeks 0-8, 1120 minutes; group 5: weeks 0-10, 1400 minutes; group 6: weeks 0-12, 1680 minutes). At the end of the 2nd, 4th, 6th, 8th, 10th, and 12th weeks, the rats were euthanized, and bilateral tibias were harvested. Peri-implant bone volume and bone-implant contact were assessed by micro-computed tomography; the implant-bone interface was assessed histologically, and implant fixation strength was determined by a removal torque test. Results Low-intensity pulsed US increased boneimplant contact at the 4th, 6th, 8th, 10th, and 12th weeks (P = .019, .017, <.001, <.001, and <.001, respectively) and peri-implant bone volume at all times (P = <.001, .002, .012, .007, .005, and .010). Removal torque on the US side was improved at the 6th, 8th, 10th, and 12th weeks (P= .012, <.001, .006, and .009). Ultrasound evoked a favorable bone response in the histologic study. Conclusions Low-intensity pulsed US might enhance new bone formation, especially at an early stage, and improve osseointegration in osteoporotic bone as an auxiliary method. However, further studies are needed to elucidate the mechanisms underlying its action.

Adjunctive efficacy of probiotics in the treatment of experimental periimplant-mucositis with mechanical and photodynamic therapy: a randomized, cross-over clinical trial Mongardini C, Pilloni A, Farina R, Tanna GD, Zeza B (2016). J Clin Periodontol doi: 10.1111/jcpe.12689 [Epub ahead of print] Objectives To evaluate the adjunctive clinical efficacy of probiotics in the treatment of peri-implant mucositis (p-iM) with professionally administered plaque removal (PAPR) and photodynamic therapy (PDT). Methods Following p-iM induction, patients

underwent PAPR+PDT and were randomly assigned to receive the professional and home-based administration of probiotics (Lactobacillus plantarum and Lactobacillus brevis) (test treatment) or placebo preparation (control treatment) according to a crossover design. Clinical parameters were assessed at six sites for each implant before as well as at 2 and 6 weeks after professional treatment administration. Results Twenty patients contributing one dental implant each were included. Immediately before treatment and at 6 weeks, the median number of sites with bleeding on probing (BoP+) sites per implant unit was 4 (3-6) and 2 (0-2) (p < 0.001), respectively, for test treatment, and 3.5 (2-4) and 2 (0-3) (p = 0.03), respectively, for control treatment. No significant difference in clinical outcomes was observed between treatment groups. Conclusions The combination of PAPR and PDT either alone or associated with probiotics determined a significant reduction of the number of BoP+ sites at 2 and 6 weeks around implants with p-iM. The adjunctive use of probiotics did not significantly enhance the clinical outcomes of PAPR + PDT.

Effects of enamel matrix derivative on non-surgical management of peri-implant mucositis: a doubleblind randomized clinical trial Kashefimehr A, Pourabbas R, Faramarzi M, Zarandi A, Moradi A, Tenenbaum HC, Azarpazhooh A (2016). Clin Oral Investig doi: 10.1007/s00784-016-2033-7 [Epub ahead of print] Objectives Peri-implant diseases have been recognized as being among the ever-increasing complications related to dental implants. The aim of this study was to evaluate the adjunctive use of enamel matrix derivative (EMD) to mechanical debridement (MD) in patients with these conditions in terms of clinical parameters and cytokine levels of peri-implant crevicular fluid (PICF). Methods In the present double-blind clinical trial, 46 patients with peri-implant mucositis (PM) were randomly divided into control and test groups. Two different therapeutic protocols, consisting of non-surgical MD alone (control group) and Volume 10 Number 2

Results Three-month post-interventional assay revealed significant improvements in BOP and PD in the test group in comparison to the control group (P < 0.0001). Relative to control, IL-6 and IL-17 levels were reduced significantly (p < 0.05) in the test group compared to the control group.

ABSTRACTS

MD with the application of EMD (test group), were considered for the two groups. Clinical parameters [bleeding on probing (BOP) and probing depth (PD)] and sampling from PICF were carried out before treatment and 3 months postoperatively. The levels of IL-6 and IL-17 cytokines in PICF were evaluated by enzyme-linked immunosorbent (ELISA).

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Conclusions Application of EMD can be considered an adjunct to MD in the non-surgical treatment of PM. However, complete recovery was not observed using either treatment approach showing that management of implant-associated disease is still a significant clinical problem.

The treatment of peri-implant diseases: a new approach using HYBENX® as a decontaminant for implant surface and oral tissues Lopez MA, Bassi MA, Confalone L, Silvestre F, Arcuri C (2016). Oral Implantol (Rome) 9(3): 106-114 Objectives The aim of the present study is to demonstrate the efficacy of HYBENX to decontaminate the implant surface, both in the case of mucositis and severe peri-implantitis and to allow future bone regeneration. Methods and materials The study describes three case reports of peri-implantitis successfully treated with HYBENX. In our study, we have used microbiological tests to demonstrate the efficacy of HYBENX in decreasing bacterial load. Results The microbiological results of the clinical cases described show that there was a reduction in the total bacterial count after treatment. Conclusions The ability of HYBENX to dry the surface and remove biofilm may explain the efficacy of the decontamination and subsequent clinical improvements in all three cases. IP Volume 10 Number 2

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Implant practice 27

CONTINUING EDUCATION

Removable partial dentures and strategic implant placement Dr. Charlotte Stilwell assesses the strategic use of implant overdenture abutments with removable partial dentures

issing teeth have an enormous impact on psychosocial and physical wellbeing. As dentists, we have an important role in helping afflicted individuals improve their quality of life. Conventional fixed and removable prosthodontic solutions are increasingly assisted by the strategic advantages that implant therapy can offer. There has been consensus agreement since 2002 (Feine, et al., 2002) that a complete denture retained by two implants should be regarded as the minimum standard of care for the edentulous mandible. Equally, for replacement of a single anterior tooth with adjacent virgin teeth neighbors in an otherwise sound dentition, an implant-supported crown is considered the evidence-based option of choice (Pjetursson and Lang, 2008). These two examples represent the extremes in the edentate spectrum. They also represent fairly clear-cut indications in favor of implant assistance. This is not always the case. Prosthodontic treatment planning is a multifactorial exercise in addressing and satisfying the wishes and needs of the individual patient. The best option in some cases may therefore not be a choice between conventional and implant-assisted options. It could also include a combination of options. A particular and emerging example of such prosthodontic combinations is the indication for the strategic use of implants in the prosthodontic area of removable partial dentures (RPDs). This article will discuss the treatment planning principles for RPDs in general and the advantages that may be offered by combining RPDs with implant therapy.

Dr. Charlotte Stilwell is a specialist in prosthodontics. She qualified from The Royal Dental College in Copenhagen in 1983 and moved to London to pursue her interest in removable prosthodontics at the Prosthetic Department at the London Hospital Dental School. She practices at the multidisciplinary Harley Street Dental Clinic (www. harleystreetdentalclinic.co.uk) in London. Over the past 20 years, Dr. Stilwell has lectured widely and published articles on removable prosthodontics. She is a lecturer at the Dental Faculty, University of Geneva, and she is senior editor of the ITI Online Academy.

28 Implant practice

Educational aims and objectives

This clinical article aims to present the current evidence relating to the use of dental implants with removable partial dentures (RPDs).

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 33 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Recognize the rationale for using implant overdenture abutments in combination with RPDs and the suggested approach for their use.

•

Realize the advantages and disadvantages of RPDs.

•

Recognize the strategic use of implants for support and/or retention.

•

Identify some strategic implant configurations for RPDs.

RPDs: a gray area in dentistry RPDs are traditionally associated with lower patient satisfaction and a potential negative impact on oral health. The biological risks to the remaining dentition, in general, and to abutment teeth, in particular with ensuing tooth loss, are extensively documented in the literature. RPDs also represent a particular professional challenge. Each partially edentulous dentition is unique (Figures 1A-1C) and requires bespoke design and construction for the RPD to be really effective and acceptable. In the RPD situations with free-end saddles, these also require an understanding (on the part of both clinician and dental technician) of how best to compensate for missing strategic tooth support. The difference in resilience between teeth and soft tissues must be reconciled to achieve a functional and stable RPD. RPDs may be seen as the economical prosthodontic solution, but they remain a mainstay of prosthodontic care for partially edentulous patients. If appropriately designed, they can be a comprehensive, effective, and successful prosthodontic rehabilitation (Lynch, 2012).

RPD indications A literature review from 2005 (Wostman, et al., 2005) concluded that there were no evidence-based indications per se. The

Figures 1A-1C: Each partially edentulous dentition is unique and represents its own professional challenge for an effective RPD solution Volume 10 Number 2

CONTINUING EDUCATION

published literature only offers limited treatment planning principles to assist clinical decision making for RPDs. In support of choosing RPDs, the literature lists the presence of sound abutment teeth and/or the need for lower cost prosthodontic solutions. Against RPDs are the presence of individual risks factors for biological complications, caries and periodontal disease, and lack of patient acceptance. A particular contraindication for RPDs is the presence of â&#x20AC;&#x201D; or potential for (Figure 2) â&#x20AC;&#x201D; a sound and stable shortened dental arch occlusion (SDA) (Kaeser, 1989) (Figure 3). In patient cases where an SDA configuration will provide adequate esthetics and function, the SDAs have been shown to perform well and last in excess of 27 years (Gerritsen, et al., 2013). Additional replacement of missing posterior teeth with free-end saddle RPDs is not recommended for these cases.

Figure 2: This dentition has only one pair of occluding premolars. This opens a prosthodontic choice between rehabilitation by upper and lower RPDs and a shortened dental arch concept with replacement of the missing three pairs of premolar units

Prosthodontic advantages of conventional RPDs In spite of the limited literature support for RPDs, there are undoubtedly clinical situations where RPDs are both indicated and able to offer significant advantages over other options. Based on empirical experience these include (Stilwell, 2010): 1. Design versatility. In the presence of teeth with a guarded prognosis, the RPD can be designed with addition of these in mind. Equally, in the event of mobile teeth, the RPD can serve as a semi-permanent splint. This is illustrated in Figure 4. 2. Replacement of lost hard and soft tissue contours. A carefully constructed and tinted RPD acrylic flange can make up for missing volume in the alveolar process. This also allows the RPD teeth to emerge in harmony with the remaining natural teeth as seen in Figure 5. This is a noninvasive and, in some cases, more predictable alternative to surgical hard and soft tissue augmentation procedures. 3. Strategic use of overdenture abutments. For teeth that have an unfavorable crown-to-root ratio, a reduction to gingival level can improve their prognosis. As overdenture abutments, they will still provide valuable support and thereby can be of strategic value to avoid free-end saddles. They can also provide retention for the RPD; an example is seen in Figure 6. Volume 10 Number 2

Figure 4: A cast framework has been designed to act as a semipermanent splint for the upper anterior teeth and also provide future means of addition of the two upper lateral incisors

Figure 3: The shortened dental arch concept is illustrated here with 10 upper and 10 lower teeth and a posterior occlusion made up by the four pairs of opposing premolars

Figure 5: A carefully constructed and tinted RPD acrylic flange can make up for missing volume in the alveolar process. It also allows the RPD teeth to emerge in harmony with the remaining natural teeth

Combining implants and RPDs Similar to the support and retention that can be offered by teeth converted to overdenture abutments, there is emerging evidence that strategic implants can serve the same purpose. Two separate literature reviews (Shamiri and Atieh, 2010; de Freitas, 2012) have evaluated the effect of this type of implant assistance for uni- and bilateral free-end saddle RPDs (Figure 7). The reviews looked at patient satisfaction, implant survival rates, and prosthetic complications and maintenance. Both reported limited but positive and promising evidence for a definite increase in patient RPD satisfaction. The data also indicated high implant survival rates and complications and maintenance that were comparable to those of RPDs in general.

Figure 6: The upper right central incisor had an unfavorable crown-to-root ratio. Reduction to an overdenture abutment has turned it into a strategic point of both support and retention for an upper RPD

Figure 7: A bilateral free-end saddle situation in a mandible where placement of an implant in the molar regions can offer strategic support and/or retention for an RPD Implant practice 29

CONTINUING EDUCATION

Figure 8: A single implant acting as an overdenture abutment for a unilateral RPD saddle can offer significant support for an RPD and a simple, effective, and economical prosthodontic solution overall

Figure 9: A single strategic implant in the upper left canine site provides strategic retention for the patientâ&#x20AC;&#x2122;s RPD. There is also an esthetic advantage in the retention being hidden under the denture saddle

As such, both reviews concluded that strategic use of implants for support and/ or retention has great promise as a valuable advantage for free-end saddle RPDs and as a simple, economical, and less invasive prosthodontic treatment option for rehabilitation of the partially edentulous patient (Figure 8).

Implant indications for RPDs The implant indications can be divided into the assistance they lend specifically to RPDs and the advantages they can offer for forward prosthodontic planning.

Figure 10: Kennedy classification Class III with potential strategic tooth support in each corner offered by the two molars and two first premolars

Figure 11: Kennedy classification Class I bilateral free-end saddle situation where an implant has been placed in each molar region to regain the strategic advantages of a Class III configuration

Figure 12: Kennedy classification Class II unilateral free-end saddle situation where an implant has been placed in the left molar region to regain the strategic advantages of a Class III configuration

Figure 13: Kennedy classification Class IV anterior saddle situation where one or two implants would improve on the tooth configuration and provide specific anterior support and retention

overdenture abutment or by performing a ridge preservation procedure at the time of tooth removal.

The optimal choice in this classification is a Class III where the RPD can derive support and/or retention from a tooth in each corner of the design; this situation is illustrated in the diagram in Figure 10. In the Class I bilateral free-end saddle, Class II unilateral free-end saddle, and Class IV anterior saddle seen in Figures 11-13, the implants would take the place of the missing strategic teeth and convert the three examples back into Class III.

RPD assistance This includes improvement of support, retention, and esthetics. An example of support is seen in Figure 8. A combined example of assistance with retention and esthetics can be seen in Figure 9 â&#x20AC;&#x201D; a single strategic implant in the upper right canine site provides hidden but strategic advantages for the patientâ&#x20AC;&#x2122;s RPD. Forward prosthodontic planning This includes ridge preservation, single tooth replacement and gradual conversion to complete removable denture (CRD). The loss of a natural tooth is followed by an atrophy of the related alveolar process (Van der Weijden, et al., 2009). In turn, this atrophy is likely to be further aggravated by the pressure of a soft tissue-supported RPD saddle. The extent of this atrophy can be reduced if not arrested by early recognition and placement of an implant in the tooth site. A delayed realization may lead to a need for bone augmentation. In a new patient, the clinical situation may not yet be suitable for implant placement. If so, the option of future implant placement can be facilitated by either maintaining the tooth in the short term as an 30 Implant practice

Strategic implant configurations for RPDs For the planning of implant assistance for RPDs, it is helpful to consider the optimal RPD situation. The Kennedy classification is often used to describe partially edentate configurations.

Volume 10 Number 2

In planning for a gradual conversion to a CRD, it would seem sensible to aim for the recommended minimum implant configurations for full edentulous arches. The current recommendations are a minimum of two implants in the mandible and four implants in the maxilla (Gallucci, et al., 2014).

General considerations for implant therapy The general treatment planning principles for implant therapy in combination with RPDs also apply to these indications. These include: Risk factors In common with treatment planning for implant therapy in general, the patientâ&#x20AC;&#x2122;s social, medical, and dental risk factors in remaining dentition should be considered. Risks posed to the outcome of implant therapy by, for example, smoking, diabetes, and periodontal disease may outweigh any strategic benefit. History of previous implant complications with peri-implantitis or implant loss together with the patientâ&#x20AC;&#x2122;s motivation and ability to care for the implant, remaining natural teeth, and RPD are also important. Specific instruction and support may be needed for the elderly RPD patient. Suitable conditions for implant placement The atrophy of the edentulous alveolar processes in most long-standing RPD patients precludes adequate bone volume for safe placement. Early recognition prior to or soon after loss of an abutment tooth is therefore important to ensure that adequate hard and soft tissue conditions still exist. The continuing improvements in implant surfaces and alloys may allow use of reduced Volume 10 Number 2

Figure 16: The denture teeth on either side of the natural upper left canine are shaped as bridge pontics. This allows clearance of the marginal gingiva of the adjacent teeth

Figure 15: Hygienic design prescription demonstrating the desired RPD gingival clearance of both abutment and nonabutment teeth

diameter and/or shorter implants for the RPD indications, but the evidence for these options is limited at present. Hygienic and effective RPD design The literature support for biomechanical RPD principles is at best ambivalent. However, it would seem logical that an RPD design should take advantage of the scope for tooth support and retention. An example of this for a Kennedy Class III configuration can be seen in Figure 14 with appropriate use of rests and clasps (Stilwell, 2010). By contrast, there is definite evidence that open hygienic RPD design can be of benefit to long-term health of teeth and soft tissues (Owall, 2002; Rehmann, et al., 2013). The denture components need to be designed, as seen in Figure 15, to reduce risks of tissue injury as well as providing gingival clearance. In the upper and lower RPD examples shown, the major connectors are kept away from both abutment teeth and non-abutment teeth, and there is an interproximal space below the contact points between the first denture tooth and the neighboring natural abutment tooth (Figure 16). The first denture tooth is shaped as a bridge pontic to mimic a natural interproximal space. This also allows access for interdental brushes even when the denture is in situ (Figure 17).

Figure 17: The interproximal space above the contact point between natural tooth abutment and first denture tooth allows insertion of an interdental brush. This assists effective cleaning of the distal aspect of the natural tooth

Implant prosthodontic options A multicenter study (Wismeijer, et al., 2013) reported significant improvement in patient satisfaction between a conventional Kennedy Class I mandibular RPD and the same RPD supported by single strategic implants placed under each free-end saddle. Initially, traditional healing caps provided the support. A further significant increase in patient satisfaction was recorded when the healing caps were replaced by retentive anchors (ball attachments). There are a range of attachments available; these include other types of retentive anchors and magnets (Figures 18 and 19). The choice of attachment is determined by the same factors that apply to any overdenture situation: space requirement, degree of desired retention, ease of use and cleaning, and cost.

Patient example A partially edentate patient was first provided with an RPD in 1979. At the time, she had only seven upper natural teeth of her own. The extensive tooth loss at the early age of 32 had both shocked and motivated her to adopt optimal oral hygiene, and this was maintained forthwith. Implant practice 31

CONTINUING EDUCATION

Figure 14: An example of an RPD for Kennedy Class III situation. The RPD is supported in each corner of the design by rests (red). Clasps (green) are planned for the upper right premolar and upper left molar. Together they form a clasp axis (dotted line), which, in combination with anti-rotation provided by the other two corners of support, ensure overall effective retention of the RPD

CONTINUING EDUCATION

Figure 18: A strategic implant replacing the upper right canine has been fitted with a resilient locator attachment

Figure 20: Upper RPD with one unilateral using free-end saddle (Class II). The RPD is a molar and the two canines for support and retention via crowns incorporating precision attachments

The upper RPD had one unilateral freeend saddle (Class II) and used a molar and the two canines for support and retention via precision attachments. The RPD was successfully replaced in 1994, and after a further 16-year period, replacement was considered again in 2010. At this point, concerns were arising about the longevity of the upper three precision attachment abutment teeth. Strategic implant placement was agreed to provide for eventual loss of the upper and lower RPD abutments and, at the same time, to carry forward the long-standing RPD abutment configuration. It was further agreed to also place an additional strategic implant in the upper left molar region to convert the upper RPD configuration to a Class III. The implant situation can be seen in Figures 20 and 21 at the 5-year follow-up in 2015.

Summary and conclusions This article has addressed the specific indications for strategic use of implants to provide support and retention for RPDs. 32 Implant practice

Figure 19: Strategic implant replacing upper left lateral incisor has an abutment with a blank for use with a magnet attachment

Figure 21: Strategic implants placed to provide for loss of the upper canine RPD abutments and upgrade the RPD abutment configuration overall to a Kennedy Class III situation

There is emerging evidence that use of implants in this way offers positive functional and esthetic benefits and a significant increase in patient RPD satisfaction. The literature also suggests that it is a simple, economical, and less invasive use of the implant treatment modality. The article suggests that the specific planning principle for use of strategic implants in combination with RPDs is to preserve or convert Kennedy Class I, II, and IV situations to more favorable Class III configurations. The article also explains that conventional prosthodontic and implant planning principles and considerations still apply. IP

Acknowledgment International Team for Implantology (ITI) for modifiable graphics.

Montreal, Quebec, May 24-25, 2002. Int J Oral Maxillofac Implants. 2002;17(4):601-602. 3. 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. 4. Gerritsen AE, Witter DJ, Bronkhorst EM, Creugers NH. An observational cohort study on shortened dental arches — clinical course during a period of 27-35 years. Clin Oral Investig. 2013;17(3): 859-866. 5. Kayser AF. Shortened dental arch: a therapeutic concept in reduced dentitions and certain high-risk groups. Int J Periodiontics Restorative Dent. 1989; 9(6):426-449. 6. Lynch CD. Successful removable partial dentures. Dent Update. 2012;39(2):118-120, 122-126. 7. Owall B, Budtz-Jörgensen E, Davenport J, et al. Removable partial denture design: a need to focus on hygienic principles? Int J Prosthodont. 2002;15(4):371-378. 8. Pjetursson BE, Brägger U, Lang NP, Zwahlen M. Comparison of survival and complication rates of tooth-supported fixed dental prostheses (FDPs) and implant-supported FDPs and single crowns (SCs). Clin Oral Implants Res. 2007;18 (Suppl 3):97-113. 9. Rehmann P, Orbach K, Ferger P, Wöstmann B. Treatment outcomes with removable partial dentures: a retrospective analysis. Int J Prosthodont. 2013;26(2):147-50. 10. Shahmiri RA, Atieh MA. Mandibular Kennedy Class I implanttooth-borne removable partial denture: a systematic review. J Oral Rehabil. 2010;37(3):225-234. 11. Stilwell C. Revisiting the principles of partial denture design. Dent Update. 2010;37(10): 682-684, 686-688, 690.

REFERENCES

12. Van der Weijden F, Dell’Acqua F, Slot DE. Alveolar bone dimensional changes of post-extraction sockets in humans: a systematic review. J Clin Periodontol. 2009;36(12):1048-1058.

1. de Freitas RF, de Carvalho Dias K, da Fonte Porto Carreiro A, Barbosa GA, Ferreira MA. Mandibular implant-supported removable partial denture with distal extension: a systematic review. J Oral Rehabil. 2012;39(10):791-798.

13. Wismeijer D, Tawse-Smith A, Payne AG. Multicentre prospective evaluation of implant-assisted mandibular bilateral distal extension removable partial dentures: patient satisfaction. Clin Oral Implants Res. 2013;24(1):20-27.

2. Feine JS, Carlsson GE, Awad MA, et al. The McGill consensus statement on overdentures. Mandibular two-implant overdentures as first choice standard of care for edentulous patients.

14. Wöstmann B, Budtz-Jørgensen E, Jepson N, et al. Indications for removable partial dentures: a literature review. Int J Prosthodont. 2005; 18(2):139-45.

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Removable partial dentures and strategic implant placement STILWELL

1. There has been consensus agreement since 2002 that a complete denture retained by ______ implants should be regarded as the minimum standard of care for the edentulous mandible. a. two b. three c. four d. five 2. In support of choosing RPDs, the literature lists the presence of ________. a. caries b. sound abutment teeth c. the need for lower cost prosthodontic solutions d. both b and c 3. Against RPDs are ________ and lack of patient acceptance. a. the presence of individual risks factors for biological complications b. caries c. periodontal disease d. all of the above 4. In a new patient, the clinical situation may not yet be suitable for implant placement. If so, the

Volume 10 Number 2

option of future implant placement can be facilitated by ___________. a. maintaining the tooth in the short term as an overdenture abutment b. performing a ridge preservation procedure at the time of tooth removal c. building up the tooth to gingival level d. both a and b 5. The ________ classification is often used to describe partially edentate configurations. a. Angle b. G.V. Black c. Kennedy d. Hollenback 6. The optimal choice in this classification is a ____ where the RPD can derive support and/or retention from a tooth in each corner of the design. a. Class I b. Class II c. Class III d. Class IV 7. Risks posed to the outcome of implant therapy by, for example, ________ may outweigh any strategic benefit. a. smoking

b. diabetes c. periodontal disease d. all of the above 8. History of previous implant complications with ________ together with the patientâ&#x20AC;&#x2122;s motivation and ability to care for the implant, remaining natural teeth, and RPD are also important. a. peri-implantitis b. implant loss c. caries d. both a and b 9. The atrophy of the edentulous alveolar processes in most long-standing RPD patients ________ adequate bone volume for safe placement. a. has no effect on b. improves the possibility for c. precludes d. ensures 10. The denture components need to be designed, as seen in Figure 15, to reduce risks of tissue injury as well as providing ________ . a. hygienic esthetics b. gingival clearance c. gradual conversion to a CRD d. a free-end saddle

Implant practice 33

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High-performance polymers In the first of two articles, Dr. Paul Tipton introduces some of the advances in restorative materials with a discussion of polyetheretherketone — a new prosthodontic material

he high-performance polymers (HPPs) are the uppermost class of plastics, possessing better temperature and chemical stability and mechanical properties than the commodity plastics, but typically being manufactured in lower volumes and costing more. The family of HPPs that have entered dentistry are called the polyarletherketones (PAEKs), of which there are several members with varying chemical structures. Many of us in the dental industry are inadvertently familiar with the family member called PEEK (polyetheretherketone) through its use in healing caps, temporary abutments, and scan bodies. However, the reason for the recent enthusiasm surrounding PAEKs has been their potential for use as a metal alternative in broader indications such as removable dentures (Figures 1 and 2) and implantborne prosthetics (Figure 3). It is here that the shock-absorbing characteristics of the material could be extremely interesting for immediate loading or long-term frameworks (Figure 4). This article will describe the background to these materials.

Educational aims and objectives

The aim of this article is to explain the material properties and clinical potential of the high-performance polymer family of plastics within implant dentistry.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 37 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Identify the scientific principles underlying the PAEK family of materials.

•

Realize some uses of PAEKs in the medical practice

•

Realize some uses of PAEKs in the dental practice.

•

Identify types of PAEKs for prosthetics.

•

Realize some methods of framework manufacture.

Figure 1: PAEK removable denture

Figure 2: PAEK removable denture

Professor Paul Tipton, BDS, MSc, DGDP RCS, is a specialist in prosthodontics with more than 30 years of experience in private practice. He is professor of restorative and cosmetic dentistry at the City of London Dental School. The author of more than 100 scientific articles, Professor Tipton is the founder of Tipton Training, a private dental training academy that has trained more than 3,000 dentists since opening in 1991. He practices at his clinics in Manchester, Watford, and London’s Harley Street. More details can be found at www.drpaultipton.co.uk.

Figure 3: PAEK implant-borne prosthesis 34 Implant practice

Figure 4: Long-term framework in PAEK Volume 10 Number 2

PEEK is the most well-known and most widely used member of the PAEK family. PEEK was invented in the United Kingdom in 1978 (ICI – now trading as Victrex) and was selected by aerospace, semiconductor, automotive, and medical industries as a standard material of use in all these sectors. It is typically used as a metal replacement, due to its strength-to-weight ratio and corrosion resistance. Other family members also exist, which are variations of the chemistry (e.g., PEK and PEKK), and these materials can also be filled with pigments or reinforcing agents. In their unaltered, unfilled state, the materials are beige in color.

PAEKs in medical Several of the properties of PEEK that were being exploited in industry (such as their strength-to-weight ratio, chemical and wear resistance, radiolucency, and reduced stiffness versus metals) were naturally intriguing for medical use. The first published PEEK medical research came in the 1980s (Williams, et al., 1987) followed by the first implantable grade from Invibio™ Biomaterial Solutions in the 1990s (Victrex/Invibio, United Kingdom). Medical grades have a much tighter specification and increased quality control than industrial grade materials, which is important in the wake of the silicone breast

Natural Bone

implant scandal. (See ttp://www.nhs.uk/ conditions/breast-implants/pages/pip-introduction.aspx.) PEEK remained the only medical PAEK for many years. Spine surgeons in particular adopted Invibio’s PEEK, liking the reduced Young’s Modulus (stiffness) of the material and the scatter-free CT and MRI imaging. PEEK has since become the standard alternative to titanium for load-bearing spinal cage devices for the spine. Today, manufacturer Invibio claims PEEK has been used in around 5 million implantable devices, spanning some 500 separate US FDA 510(k) regulatory clearances. In more recent years, additional versions of PEEK and PEKK have appeared on the medical marketplace but have been limited in use.

PAEKs in dentistry Short-term devices such as temporary healing caps and abutments have been sold directly to dentists through the dental companies for many years. In these situations, either unfilled PEEK or PEEK with a 10% titanium dioxide pigment filler is typical and has been used in these temporary devices for over a decade. In the case of customized prostheses, the upstream material or shape becomes the “device” and is regulated and cleared for use for a defined set of indications. Here, the PAEKs have appeared as materials for

PEEK

Gold

use in injection press systems or as discs for computer-aided design/manufacture (CAD/CAM).

Types of PAEKs for prosthetics There are now many brands of PAEK dental devices becoming available for use in prosthetic frameworks. The most common formulations of the PAEKs are: • Unfilled, pure 100% PEEK (such as JUVORA™ [Invibio/Juvora]). This is a beige material. • 80% PEEK with 20% nanoceramic filler (such as BioHPP [Bredent]). This is a white material. • 80% PEEK with 20% titaniumdioxide filler (such as Dentokeep disc [NT Trading]). This is a white material. • 80% PEKK with 20% filler including titanium dioxide (such as Pekkton® ivory [Cendres & Métaux]). This is an off-white material. Typically, the particle size of these fillers (circa 300-500 nanometers for the nanoceramic) is not likely to give significant reinforcing properties to the material, since they are not fibers. Instead the fillers act more as a pigment and alter surface topography. These levels of 20% filler will make the material stiffness slightly higher, but consequently also slightly increase its brittleness. It should also be noted that the inclusion of titanium dioxide means that these

Titanium

Cobalt Chrome

Rho JY. Young’s modulus of trabecular and cortical bone material. Journal of Biomechanics. 1993;26(2):111-119.

Figure 5: Elastic modulus comparison of different dental materials and natural bone Volume 10 Number 2

Implant practice 35

CONTINUING EDUCATION

The PAEK family

CONTINUING EDUCATION brands — Biohpp, Dentokeep, and Pekkton — should not be pitched as “metal free” since this could be in breach of Advertising Standards and/or governing bodies. The reader should also take note as to the cleared indications for use, as the different materials and forms may have varying clearances. To date, PAEKs with these specific 20% fillers have only a limited history of use in dental and actually no prior medical history in any other medical applications. Therefore, it is fair to say that the jury is still out as to the effects of adding these levels of these specific fillers to the PAEKs, and the author advises the use only of the pure material where there are long-term studies.

The reason for the recent enthusiasm surrounding PAEKs has been their potential for use as a metal alternative in broader indications such as removable dentures and implant-borne prosthetics. ... The shock-absorbing characteristics of the material could be extremely interesting for immediate loading or long-term frameworks.

Methods of framework manufacture There are two methods for laboratories to manufacture substructure frameworks from PAEKs. These are 1) injection molding, or 2) CAD/CAM. Injection molding Industrial injection molding machines process the polymer under very high speed and pressure (with a bar pressure in the thousands), which are typically two orders of magnitude higher than the typical benchtop pressing machines available to the dental laboratory (which have a bar pressure in the 10s). This means that small-scale injection molding of PAEK is no mean feat, due to tight processing windows and design limitations. Also, these re-melting of PAEKs can also increase the risk of unpredictable mechanical and physical properties (such as brittleness, flexibility, color, warping) if the framework has not cooled and recrystallized correctly. Finally, re-melting of PAEK materials can also cause degradation of the polymer (such as generation of phenol) unless very closely controlled using the correct equipment. This polymer degradation can be accentuated by the inclusion of fillers in the materials (such as reinforcing agents or pigments). Therefore, melt processing of these materials should only be done by a competent laboratory and using the equipment recommended by the supplier. CAD/CAM The alternative manufacture route uses CAD/CAM technology. This manufacturing route avoids all of the risks mentioned previously for re-melting the polymer. The material properties remain consistent, and the framework manufacture can also benefit from the increase precision and reproducibility of a digital workflow. 36 Implant practice

Although it does require a more significant capital investment by the laboratory, many laboratories are seeing that it is necessary to align with other industries and adopt digitization to increase efficiencies. PAEK materials further extend these CAD/CAM efficiencies when compared to milling metal substructures, since there is typically less tool wear and faster milling times, and the capital equipment necessary to mill them does not need to be as expensive as machines for milling metal frameworks. It is the author’s view that the optimum use of these materials only comes from the CAD/CAM milling process as opposed to the injection molding process.

Polymer properties When handling a prosthetic framework made from a PAEK, a striking thing is the difference in weight. When identical full-arch implant prosthetic substructure frameworks were made from four different materials, the results from weighing were: • PAEK — 4.9 g • Titanium — 17 g • Zirconia — 23 g • Cobalt chrome — 33 g However, it is the possibility to introduce shock absorption to a prosthesis that is perhaps the most exciting. This could have positive implications for patient comfort and for damage limitation. In the author’s view, the most relevant mechanical property related to the aspect of shock absorption is not ultimately compressive strength (as is sometimes promoted), but

actually flexural strength and elastic modulus. Obtaining an increasingly stronger material becomes academic since clearly it would be simplistic to prefer the highest value. Metals have very high compressive strengths relative to PAEKs but are not shock absorbing. Naturally, a design must also consider the influence of thickness and shape as well, but values for flexural strength and elastic modulus are more indicative of the stiffness of a material and how much it will deflect the load. Stiffer materials, like metals, have a high elastic modulus (see Figure 5) meaning that metals require high loads to elastically deform them. Therefore, one can look at natural materials like bone for clues as to an ideal for stiffness. Common denture materials like PMMA have an elastic modulus range of 1.8-3.1 GPa but limited strength. The PAEKs have an elastic modulus closer to bone (4-5GPa) allowing the framework to be stiffer, yet still shock absorbing. However, PAEKs also additionally possess sufficient strength to be considered as a metal alternative.

Conclusions The high-performance polymers called PEEK and PEKK have exciting potential in dentistry as a metal alternative for removable and implant prosthetic frameworks. Their stiffness properties confer promise as a substructure that could add an element of shock absorption. This may have benefits for patient comfort, addressing parafunction, and damage limitation. IP

REFERENCE 1. Williams DF, McNamara A, Tutner RM. Potential of poly ether ether ketone (PEEK) and carbon-fiber-reinforced PEEK in medical applications. Journal of Materials Science Letters. 1987;6(2):188-190.

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

High-performance polymers TIPTON

1. The family of HPPs that have entered dentistry are called the _______ of which there are several members with varying chemical structures. a. polypropylenes b. polyarletherketones c. polymethyl methacrylate d. olefinic polymers 2. Many of us in the dental industry are inadvertently familiar with the family member called PEEK (polyetheretherketone) through its use in _______. a. healing caps b. temporary abutments c. scan bodies d. all of the above 3. It is here (in PAEKâ&#x20AC;&#x2122;s potential for use as a metal alternative in broader indications such as removable dentures and implant-borne prosthetics) that the _______ characteristics of the material could be extremely interesting for immediate loading or long-term frameworks. a. shock-absorbing b. sterility c. fibrous d. color 4. In their unaltered, unfilled state, the materials are _______ in color.

Volume 10 Number 2

a. pink b. beige c. white d. brown 5. PEEK has since become the standard alternative to ______ for load-bearing spinal cage devices for the spine. a. titanium b. nickel c. stainless steel d. silicone 6. Short-term devices such as temporary healing caps and abutments have been sold directly to dentists through the dental companies for many years. In these situations, either unfilled PEEK or PEEK with a _____ titanium dioxide pigment filler is typical and has been used in these temporary devices for over a decade. a. 10% b. 20% c. 30% d. 40% 7. Typically, the particle size of these fillers (circa 300-500 nanometers for the nanoceramic) ______ to give significant reinforcing properties to the material, since they are not fibers.

a. b. c. d.

is very likely is not likely has been designed is expected

8. Therefore, melt processing of these materials _________. a. should only be done by a competent laboratory b. should only be done when using the equipment recommended by the supplier c. should be done quickly d. both a and b 9. (When manufacturing with CAD/CAM technology) The material properties remain consistent, and the framework manufacture can also benefit from _________. a. the modulus range b. the increased precision c. reproducibility of a digital workflow d. both b and c 10. Metals have very high _______ relative to PAEKs but are not shock absorbing. a. heat margins b. milling times c. compressive strengths d. flexibility

Implant practice 37

CE CREDITS

IMPLANT PRACTICE CE

TECHNOLOGY

A decade of rapid improvement Dr. David Reaney looks back on advances made in the world of dental implants and dental implant technology over the past 10 years

entistry has undergone significant changes over the past decade, with implant dentistry in particular being one of the major growth areas. Patients are better informed about treatment options and the benefits afforded by implant treatment than ever before. Of these options, it is becoming widely understood that implants are the best solution for missing teeth. An implant-retained crown is often the best option for single tooth replacement because it does not result in the loss of healthy tooth tissue associated with conventional bridgework. In the same way, multiple teeth can be replaced using several implants to support bridgework for fixed restorations or implants with attachments or implant-supported bars used to retain removable prostheses. We have seen significant advances in implant design too, with a move from parallelsided to tapered implants, and modifications in thread design resulting in implants that engage bone more aggressively — which prove particularly effective in immediate placement and loading protocols, where excellent primary stability is required. Even more recently, we have seen implant systems introduced with “short” or “narrow” implants allowing placement in situations where conventional implants cannot be used.

Diagnosis and treatment planning This important aspect of treatment has been much improved through the use of modern diagnostic procedures — in particular the introduction and use of cone beam computerized tomography (CBCT). This relatively low-dose radiographic imaging technique allows three-dimensional bone volume assessment and, in combination with implant treatment planning software, can assist with implant site selection. A major benefit of this technique is the avoidance of certain David Reaney, BDS (Edin), DGDP (UK), MClinDent (Prosthodontics), London, is a clinical consultant for Southern Cross Dental. For more information, visit www.scdlab.co.uk.

38 Implant practice

anatomical structures such as the inferior dental nerve, for example, thus reducing some of the risks associated with implant surgery. Guided surgery is also facilitated by CBCT imaging with implant treatment planning software (Figure 1) used to aid guidedsurgical stent production.

Prosthodontic considerations We are continuing to see a move away from cement-retained restorations toward screw retention, and also — especially in fullarch cases — a preference for removable prostheses retained by implant-supported bars or locator attachments. The main advantage of screw retention is that restorations are more readily retrieved should their removal be required.

The removal of cement-retained prostheses is less predictable and may involve destruction of the restoration. Screw-retained prostheses do not require a luting cement, which in some situations can result in peri-mucositis and periimplantitis, especially if cement is not cleared from a subgingival area. Improved diagnostic techniques, advanced implant planning, and the use of guided surgery have resulted in optimal implant positioning, which facilitates the provision of screw-retained restorations. Recently, abutments have been produced with so-called “angled screw access” where the implant driver used to torque the abutment screw engages the screw head from an angle other than the customary approach (along the long axis of the implant). This

Figure 1: Implant simulation as depicted by planning software (SimPlant®, Image Diagnostic Technology)

Benefits of overdentures 1. Oral hygiene techniques and plaque control around implants is much easier to carry out when the bulk of the prosthesis can be removed. 2. Implant-retained overdentures may require the placement of fewer implants compared to a full-arch fixed prosthesis. This may simplify treatment as augmentation procedures such as sinus grafting can often be avoided. This approach may also reduce surgical risk and keep the cost of treatment down for the dentist and ultimately for the patient. 3. In cases where there is significant loss of hard or soft tissue, replacement of these tissues can be more effectively replaced, especially where lip support is required. Phonetic outcome may also be best achieved using removable prostheses in situations where significant resorption has occurred. 4. Ease of repair.

Volume 10 Number 2

TECHNOLOGY

Figure 2: A typical metal framework

Figure 3: A simulated full-arch implant-supported bridge

Figure 5: A zirconia abutment with a titanium interface restored with an IPS e.max® crown (Ivoclar Vivadent®) delivers optimum esthetics with good biocompatibility

allows screw retention to be used in situations that would previously have been considered unfavorable. The use of angled abutments placed on the restorative platform of the implant also permits the provision of a screw-retained prosthesis (while also increasing the height of the restorative platform). In full-arch cases, the trend appears to be toward implantretained overdentures and away from fixed prostheses (Figures 2 and 3). Bars and clips or locator attachments can retain these. The “Benefits of overdentures” chart explains some of the key advantages that this modality offers clinicians and patients.

Technical advances Over the past decade, there has been a transition from cast restorations (Figure 4) toward CAD/CAM techniques, with restorations being designed by computer and milling techniques (Figures 6 and 7) employed to prepare abutments, bars, crowns, and bridges instead of the more traditional casting methods. There are a number of advantages that milling has over casting: • More biocompatible materials can be Volume 10 Number 2

Figure 4: A conventional cast framework

Figure 6: Industrial milling of a zirconia block

utilized with milling techniques, such as titanium and zirconia (Figure 5). • Milling techniques provide significantly greater accuracy than casting. Thermal distortion is often a cause of casting errors. Casting porosity is another problem encountered in conventional casting techniques that does not occur in milled products. • Milled restorations are more costeffective than their cast counterparts. • The improved workflow inherent in milling techniques results in faster turnaround times, elimination of production errors, and lower remake rates. We have seen significant developments in implant dentistry over the past decade. This rate of progress is likely to increase exponentially with the introduction of intraoral scanning systems, improvements in implant systems, the development of new materials, especially ceramic systems, and laser-sintering technology. More accurate digital workflows will almost certainly result in greater efficiency, lower production costs, and faster turnaround times — all of which will be of significant benefit to dentists and ultimately their patients. IP

Figure 7: A modern milling unit Implant practice 39

PRACTICE DEVELOPMENT

Top five dental marketing scams Cory Roletto, MBA, discusses some marketing tactics to avoid

e have all received the letters, seen the emails, and may have even answered a call from a company claiming something that is not true or promising something too good to be true. Over the past 7 years working with dental offices, we have seen our share of less than reputable marketing practices. In this article, we will talk about the top five dental marketing scams. 1. You receive a letter that your domain is expiring and needs to be renewed. This letter may look very official, and many have the word domains in the company name. The form asks you to fill out information about your domain, give your approval to renew the domain, and send payment. The payment request is often $100 or more. With rules established by The Internet Corporation for Assigned Names and Numbers (ICANN), the governing body for domain purchase and transfer, you are unlikely to actually lose control of your domain, but you may not even notice your money didn’t go to pay for domain renewal. If you are in doubt, you can verify the domain registrar by doing a WHOIS lookup on your website domain; most domain registrars have this feature. Here is a link to the WHOIS lookup page on Network Solutions: https://www.networksolutions.com/whois/index-res.jsp 2. You receive an email that they have evaluated your website, and it has not been SEOed. These emails are often automated spam emails with wording that makes it sound like they have evaluated your website, but upon closer inspection don’t give any specifics about what they found — because no one actually evaluated your website. They will often make nonsensical statements such as your website is not web

Cory Roletto is partner and co-founder of the dental marketing firm WEO Media, www. weodental.com, where he leads the operations team. He holds a MBA and BS in Chemical Engineering from the University of Washington.

40 Implant practice

Avoid marketing scams. Receive your free marketing consultation today: 888-246-6906 2.0 compliant and have a link to test your site, or one of the following blanket statements: a. You have low online presence for many competitive keyword phrases. b. Your social media accounts are unorganized. c. You have many bad back links to your website. d. Your website is not compatible with all mobile devices. e. Your website is being penalized by Google. These types of spam emails have become more sophisticated often using search scrapers to pull some easy-toobtain data about your website that is added to the email to make it appear legitimate. They may also have a graph showing made-up metrics; for example, social media completeness. One other obvious red flag that is the email will not have any information on the company that supposedly evaluated your website, giving just a callback number or a Gmail email to respond. 3. A review directory representative states he/she can get negative reviews removed or make your positive reviews show up more, if you sign up for an advertising package. We have actually had salespeople for a very large, well-known review directory system state this to us and many of our clients. This is always stated over the phone, and they have never put it in writing — because it is flat-out not true. I am sure the directory involved would not condone this type of sales tactic, but

we have seen it so many times, it had to be mentioned. The truth is any reputable directory does not let advertising dollars influence what reviews do or do not show up when searching for a service. 4. They say they have a special relationship with Google. In this instance, the claim is that due to a special relationship, they can do things others cannot, such as getting special pricing on Google payper-click (PPC) campaigns or obtaining a No. 1 ranking on Google search. They may also misuse Google Partner to imply special treatment. Being a Google Partner means that personnel at the company have passed one or more Google certification tests showing they are proficient in some aspect of SEO or PPC. Being a Google Partner is a good thing, but it does not provide any special privilege or advantage other than the fact that the company has taken the time to be certified. 5. They assert that your Google PPC campaign is showing up in Europe because it is using the default settings. This was one of the most outlandish claims we have seen. To start, Google requires the region for the PPC campaign be set as part of the creation of the PPC campaign. Second, there is no way for someone to accurately detect Google PPC campaign settings. Also, if someone guarantees a No. 1 ranking in Google, they can only be referring to Google PPC where the No. 1 ranking can be bought by paying more per click, which is less than optimal. If a salesperson makes any of these claims, run. IP Volume 10 Number 2

PRODUCT PROFILE

alloOss allografts ®

Pure. Predictable. Proven. alloOss® (allograft) is offered in particulate, block, or putty. alloOss is a safe, predictable, and effective bone-grafting solution, providing a scaffolding for cell ingrowth and for promoting the growth of new bone. alloOss allograft particulates and blocks combine natural collagen and minerals with the bony structure of allograft. The existence of these natural minerals and collagen facilitates remodeling of the host bone suitable for implantation. alloOss allograft putty combines demineralized bone with cancellous bone and an organic-based carrier. The complete line of alloOss allograft products have been obtained, processed, and sterilized in accordance with the highest standards set forth by the American Association of Tissue Banks (AATB®) and the U.S. Food and Drug Administration (FDA) regulations. Operating to these standards and regulations allows ACE to provide you with one of the purest, predictable, and proven allografts available today.

alloOss® cortical and cancellous particulate alloOss allograft particulates offer the structural strength required to maintain space and volume during the remodeling phase. Used alone or as a composite graft, alloOss particulates are an effective alternative to intraoral graft harvesting. • Provides scaffold for cell ingrowth • Remodels completely • Predictable guided bone regeneration • Stabilizes implants after 4-6 months • Fills voids and extensive bone defects • Regeneration of periodontal defects

alloOss® demineralized allograft particulate alloOss demineralized allograft cortical bone is appropriate for use in any procedure where bone healing is desired. Routine testing for osteoinductivity is performed to ensure the highest quality and efficacy for your regeneration procedures. • Fills voids and bone defects • Used alone or composite graft • Augmenting prosthetic implants 42 Implant practice

alloOss® allograft particulate

alloOss® allograft block alloOss allograft block is comprised of cortico/cancellous bone used for restoring volume in severely resorbed ridges without the need to harvest an autogenous block graft from the patient. • Approximate healing in 5-6 months • Maintains strength and volume with predictable remodeling • Cancellous component for predictable healing and revascularization of host bone to the new graft • Cortical component for strength and rigidity of the graft with volume enhancement

alloOss® allograft putty alloOss® allograft putty is a combination of DBM (demineralized bone matrix), cancellous FDBA (freeze-dried bone allograft), and a carrier medium of CMC (carboxymethylcellulose). This mixture results in a highly viscous, easy handling, dental bone-grafting putty with inductive potential and excellent osteoconductive scaffolding. Characteristics: • High osteoconductive ability • Forms freely and is moldable • High viscosity • Osteoinductive ability • Excellent biocompatibility

alloOss® allograft block

Recommended for: • Extraction socket preservation • Ridge and sinus augmentation • Periodontal defects • Sinus elevation • Grafting for implant placement • Composite sinus grafting

About the company ACE Surgical Supply Co., Inc., is proud to be an AATB® accredited organization. For more information about alloOss allografts, contact ACE Surgical Supply Co., Inc., at 800-441-3100 or info@acesurgical.com, or visit www.acesurgical.com. IP alloOss® is a registered trademark of ACE Surgical Supply Co., Inc., copyright © 2017. alloOss® allograft particulate is manufactured by ACE Surgical Supply Co., Inc. alloOss® allograft block and putty are manufactured for ACE Surgical Supply Co., Inc. AATB® is a registered service mark of the American Association of Tissue Banks. This information was provided by ACE Surgical Supply Co.

alloOss® allograft putty Volume 10 Number 2

LAY THE PROPER GROUNDWORK FOR A HEALTHY SMILE.

Allograft Block and Particulate

Allograft Cellular Bone Matrix

Allografts – Xenografts – Alloplasts Solid solutions for maintaining and promoting

Expandable Bone Grafting Composite Granules and Collagen Block

healthy bone. Backed by years of documented and proven success, our products have been engineered to meet your specific surgical needs.

ACE Surgical Supply Co., Inc.

Calcium Sulfate Hemihydrate

Synthetic Bone Particulate

Resorbable Collagen Membrane

www.acesurgical.com 800.441.3100 Resorbable Collagen PLUG - FOAM - TAPE

M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT Brasseler USA® introduces ImplantPro® Titanium Probes

Carestream Dental introduces new four-in-one extraoral imaging solution The innovative CS 8100 3D system is now available with a cephalometric imaging option, in addition to several new 3D applications. Built on the award-winning compact design of the CS 8100 panoramic system and featuring multi-functional, four-in-one imaging capabilities, the CS 8100SC 3D system enhances doctors’ diagnoses with high-quality images and improves workflow for doctors of all specialties. The CS 8100SC 3D features the fastest scanning time of any scanning cephalometric unit on the market —as little as 3 seconds.1 The system includes exclusive Carestream Dental imaging software that recognizes anatomical structures and traces them automatically. The unit offers panoramic, cephalometric, and cone beam computed tomography (CBCT) imaging options, including multiple 3D fields of view — from 4 cm x 4 cm to 8 cm x 9 cm. For more information, please call 800-944-6365, or visit www.carestreamdental.com. 1. For 18 x 24 cm image in fast scan mode

Straumann® original implant bars and bridges available to 3Shape users 3Shape and Straumann® announced that 3Shape users can now scan and design using their 3Shape scanner and obtain original Straumann implant bars and implant bridges from Straumann’s manufacturing global facilities. Dental lab technicians using 3Shape Dental System software can access the original Straumann implant bar and bridge libraries directly in the 3Shape software. The 3Shape design files are then sent to Straumann global production facilities for the manufacture of Straumann original implant bars and implant bridges. Straumann® CARES® Screw-Retained Bridges and Bars allow for the construction and manufacturing of complex superstructures. They are available in two materials — titanium-grade 4 and cobalt-chromium alloy (coron®) — for the restoration of Straumann® implants. For more information, visit www.3Shape.com.

44 Implant practice

Brasseler USA®, has announced the expansion of its ImplantPro® family of products with new ImplantPro® Titanium Probes. A reliable alternative to plastic probes, ImplantPro Titanium Probes are ideal for use on both implants and natural dentition. Designed with a winning combination of innovative design and superior ergonomics, ImplantPro Titanium Probes feature precise, black color markings on a smooth surface for a more gentle diagnostic evaluation and improved patient comfort. ImplantPro Titanium Probes are made from non-heat-treated 6Al-4V titanium, keeping the Rockwell C hardness at a low 25-31 HRC and comparable to most implant abutments, then coated in bright zirconium nitride for superior color contrast. All feature Brasseler USA’s distinctive, lightweight PEEK (polyether ether ketone) handles for outstanding ergonomics. For more information, visit www.BrasselerUSA.com, or call 800-841-4522.

Orthophos SL: The ideal 3D System for your practice now with 3D I-X Low Dose mode. Coming soon. The 3D I-X mode offers diagnostic optimization for a large number of indications, is intuitively selectable for an efficient workflow, and provides intelligent technical realization and optimal clinical results. In addition to existing high definition (HD) and standard dose (SD) modes, the 3D I-X with low dose mode gives users access to 3D information for specific clinical issues with significantly reduced dose. As a new addition, owners of this technology can clarify clinical issues for which a significantly reduced dose is sufficient with the 3D I-X function. This effect is achieved by using intelligent filters. The dense structures such as bones are retained for greater diagnostic reliability. All Orthophos SL 3D units can be upgraded to include the 3D I-X mode, and if you are a member of the Dentsply Sirona 3D Club, the upgrade is free of charge. Visit www.dentsplysirona.com for more information.

Volume 10 Number 2

Address the Implant Complexities You Face Everyday with...

clinical articles • management advice • practice profiles • technology reviews

3 EASY WAYS TO SUBSCRIBE

REACH FOR THE BETTER GRADE

PROMOTING EXCELLENCE IN IMPLANTOLOGY Removable partial dentures and strategic implant placement Dr. Charlotte Stilwell

From “adamantly opposed” to “absolutely loved” on the anterior maxilla Dr. Jason Souyias

High-performance polymers

EMAIL subscriptions@medmarkaz.com

Dr. Paul Tipton

What defines implant success? Dr. Justin Moody

CALL 1.866.579.9496

Practice profile Dr. Jay B. Reznick

The use of dynamic navigation to prevent implant complications — every patient, every time Drs. Robert W. Emery and Keith Progebin

149 $ 3 years 399 1 year

The Proximator The instrument you wish you always had.

VISIT www.implantpracticeus.com

April/May 2017 – Vol 10 No 2

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Category: Oral Surgery & Implant Hand Instruments

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

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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3M partners with BlueLight Analytics to offer the checkMARC® curing light testing service 3M has partnered with BlueLight Analytics to offer checkMARC®, a professional service (NIST*-traceable) for validating curing light performance and determining the required curing times for each curing light and material combination in a dental clinic. With the checkMARC system, 3M will test and identify the efficacy of a dental office’s curing lights. Based on the results, 3M will review the light-curing protocols currently in practice and work together with the dental clinic to identify evidence-based opportunities to improve clinical outcomes and patient satisfaction. For information, call 1-800-634-2249 to set up an appointment to have your curing lights tested and light-curing protocols reviewed. Visit 3M.com/curinglights for more information. For more information about the checkMARC technology, visit www.checkmarc.net. * NIST stands for National Institute of Standards and Technology.

Convergent Dental introduces Solea SW 3.1.1 Convergent Dental Inc., developer of Solea®, the computeraided, CO2 all-tissue dental laser system, has launched Solea SW 3.1.1. The latest software provides dental professionals with unprecedented usability and control while further enhancing the patient experience. With updated algorithms that control how the laser cuts both hard and soft tissue, Solea SW 3.1.1 facilitates the onset of analgesia more quickly and effectively than ever before, and provides exceptional cutting-speed ability in both hard and soft tissue. For more information, visit www.convergentdental.com, or call 844-GOSOLEA.

3Shape makes CAD/CAM more affordable for dental laboratories 3Shape introduced its brand new E scanners for dental labs. The new 3Shape E scanners deliver the highquality, advanced scanning features and precision CAD/ CAM workflows that 3Shape is recognized for, but at a more affordable price. Featuring two 5 megapixel (MP) cameras, blue LED, and multi-line high-speed scanning for optimal detail capture and accuracy, 3Shape E scanners enable labs to complete more cases in less time. The E scanners improve lab productivity with time and cost-saving features such as 3Shape’s reliable impression scanning and Auto-start. Impression scanning allows labs to scan traditional impressions directly without having to pour a model. Auto-start starts the scanning as soon as the model is placed inside the E scanner. From the industry’s most powerful, D2000, to new and more affordable E scanners, 3Shape now provides labs with the widest selection of scanners to meet their needs and budget. For more information, visit www.3shape.com.

46 Implant practice

PreXion, Inc., announces launch of new PreXion Excelsior CBCT PreXion, Inc., global provider of advanced CBCT equipment in the dental industry, has launched its new PreXion Excelsior 3D CBCT into the dental market. Still having the smallest focal point in the industry, PreXion has also advanced all other core CBCT technologies, including the X-Ray tube and the Flat Panel Detector (FPD). The new Excelsior CBCT couples the smallest focal spot (0.3 mm) with the following: a voxel size of 0.1 – 0.2; 1024 volume size; 360° gantry rotation; and advancements in the PreXion software. Because of these advances, PreXion can deliver 30% lower radiation exposure without compromising the image quality. The PreXion software flawlessly integrates into the customer’s network without any specialized hardware. The PreXion3D Viewer can be installed on any Windows PC on the network, allowing scans to be viewed from any computer (with no additional or annual viewer licensing fees). For more information, email info@prexion.com.

Volume 10 Number 2

AO appoints Dr. Michael R. Norton as 31st President to lead its global initiatives Michael R. Norton, BDS, FDS, RCS (Ed), an oral surgeon from London, England, was appointed Academy of Osseointegration’s (AO) newest president. He succeeds Alan S. Pollack, DDS, as Academy president. Other officers are: • President-elect: James C. Taylor, DMD, MA, a prosthodontist from Ottawa, Ontario, Canada • Vice President: Jay P. Malmquist, DMD, an oral and maxillofacial surgeon from Portland, Oregon • Secretary: Tara L. Aghaloo, DDS, MD, PhD, an oral and maxillofacial surgeon from Los Angeles • Treasurer: Clark M. Stanford, DMD, PhD, a prosthodontist from Chicago • Past President: Alan S. Pollack, DDS, a practicing periodontist from New York City For more information, visit www.osseo.org.

Formlabs, the designer and manufacturer of powerful 3D printing systems and 3Shape, the global leader in 3D scanning and CAD/CAM software for dental practices and labs, announced a partnership to introduce software integration solutions to bring seamless dental 3D printing workflows to the worldwide market. As its first and flagship integration solution, Formlabs and 3Shape debuted a dental-3D printing workflow that streamlines the guide design and manufacturing workflow for dental practitioners, making it easier and more affordable than ever to produce surgical guides. With the Formlabs-3Shape integration solution, dental practitioners can create guides ready for surgery by scanning with 3Shape TRIOS intraoral scanners and designing with 3Shape Implant Studio software, followed by simply hitting “print” with Formlabs’ PreForm software, to finally 3D printing and manufacturing the guides with Formlabs’ biocompatible Dental SG resin — all within a matter of hours. While it used to take weeks, the Formlabs-3Shape integration creates a cost-effective chairside 3D printing workflow that makes even same-day guided surgery possible. For more information, visit www.3shape.com.

Watch for It

Volume 10 Number 2

Implant practice 47

INDUSTRY NEWS

Formlabs and 3Shape announce partnership to introduce software integration solutions

ON THE HORIZON

What defines implant success? Dr. Justin Moody reflects on two decades of implant placement

uch talk has been made about restorative success and implant success, but my question is, Can you have one without the other? How should we actually measure success? Is it by a beautiful PA showing no bone loss, or a clinical photo in which we are unable to tell the implant from the natural teeth, or is it all of the above at 5, 10, or 20 years? I tend to practice with an eye toward the future because it’s not what the restoration looks like at the time of seating but rather what it will look like in 10 years. For me, that is the true test of time. Having practiced now for about 20 years, I can tell you that this is important to me. There are other factors to achieving a successful implant outcome as well — it’s the clinician’s skill set at the time of treatment as well as the current technology available. I wish I could say that the implants I placed 20 years ago were all perfect, but I can’t. My clinical judgment and ability early in my career were neither what they are today, nor are the materials. I remember placing machined smooth titanium with polished collars and external hexes. Today, when you incorporate superior tread designs, surface treatments such as Laser-Lok® (BioHorizons®), and years more of research studies and literature to guide us in good surgical and restorative practices, I can’t help but think that even the procedures that I am doing now will be judged differently in 10 years. Now that 20 years of implants are behind me, there are days when repair, replace, and restore are real and sometimes not a lot of fun. But I am a firm believer in doing the right

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®.

48 Implant practice

Figure 1: Residual cement left from a cementretained crown on a custom hybrid abutment

Figure 2: Custom titanium abutment fabricated by ProSmiles Dental Studio

Figure 3: Custom Hybrid Zirconia abutment on a BioHorizons Ti-Base by ProSmiles Dental Studio

Figure 4: Custom-layered zirconia screw-retained crown on a BioHorizons Ti-Base by Prosmiles Dental Studio

Figure 5: Bone loss and granulation tissue around a failing dental implant

Figure 7: Two-year follow up radiograph of a BioHorizons Tapered PLUS with custom titanium abutment and zirconia crown

Figure 6: Bone loss down to the first thread on an older squarethreaded parallel-walled dental implant

thing 100% of the time. Sometimes that is not very profitable, and sometimes people are upset; but every time, I can keep my head held high knowing I did the best I could on that day under those circumstances.

My practice has gravitated toward subcrestal implant placement, screwretained crowns when at all possible, and the use of Laser-Lok on the implants and the restoration for increased soft tissue volume and increased implant health. Don’t be quick to judge but rather quick to learn — that’s what true success looks like! IP Volume 10 Number 2

no more

compromises

The Tapered Internal family of dental implants provides excellent primary stability, maximum bone maintenance and soft tissue attachment for predictable results. All implant diameters from 3.0 to 5.8 can be placed with the same instrument kit providing you surgical convenience and flexibility to choose the ideal implants for each patientâ&#x20AC;&#x2122;s needs. With all these features, you no longer have to accept the clinical compromises that come with other implant systems.

restorative ease

universal surgical kit

45Â° conical internal hex connection creates a robust, biologic seal and is color-coded for quick identification and component matching

intuitive color-coded instrumentation used to place all BioHorizons tapered implants*

connective tissue attachment Laser-Lok uniquely creates a physical connective tissue attachment and biologic seal

bone attachment Laser-LokÂŽ microchannels achieve superior osseointegration

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

Made in the USA

*Tapered Plus, Tapered Tissue Level, Tapered Internal and Tapered 3.0 SPMP13154 REV F JUL 2016

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