Implant Practice US August/September 2017 Vol 10 No 4

Atlantis® CustomBase solution

clinical articles • management advice • practice profiles • technology reviews August/September 2017 – Vol 10 No 4

PROMOTING EXCELLENCE IN IMPLANTOLOGY

Dr. Ara Nazarian

Practice profile Dr. Nick Caplanis

Autologous bone grafting using extracted teeth Dr. Armin Nedjat

Dr. Charles D. Schlesinger

Atlantis CustomBase solution (left) vs. stock titanium base (right)

Time to go old school: time to grab that osteotome

Do you have all your bases covered?

Dr. Robert Hayes

Full arch fixed provisionals with dual stabilization dental implants

It is time to take control of your screw-retained restorations.

Immediate full arch restoration

Learn more: page 3

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To learn more, please visit our website at www.zestdent.com/ftx or call 800.262.2310. ©2017 ZEST Anchors LLC. All rights reserved. F-Tx, LOCATOR F-Tx, ZEST and Zest Dental Solutions are registered trademarks of ZEST IP Holdings, LLC. Some products may not be regulatory cleared/released for sale in all markets. Please contact the local Zest Dental Solutions representative for current product assortment and availability.

EDITORIAL ADVISORS Steve Barter, BDS, MSurgDent RCS Anthony Bendkowsk,i BDS, LDS RCS, MFGDP, DipDSed, DPDS, MsurgDent Philip Bennett, BDS, LDS RCS, FICOI Stephen Byfield, BDS, MFGDP, FICD Sanjay Chopra, BDS Andrew Dawood, BDS, MSc, MRD RCS Professor Nikolaos Donos, DDS, MS, PhD Abid Faqir, BDS, MFDS RCS, MSc (MedSci) Koray Feran, BDS, MSC, LDS RCS, FDS RCS Philip Freiburger, BDS, MFGDP (UK) Jeffrey Ganeles, DMD, FACD Mark Hamburger, BDS, BChD Mark Haswell, BDS, MSc Gareth Jenkins, BDS, FDS RCS, MScD Stephen Jones, BDS, MSc, MGDS RCS, MRD RCS Gregori M. Kurtzman, DDS Jonathan Lack, DDS, CertPerio, FCDS Samuel Lee, DDS David Little, DDS Andrew Moore, BDS, Dip Imp Dent RCS Ara Nazarian, DDS Ken Nicholson, BDS, MSc Michael R. Norton, BDS, FDS RCS(ed) Rob Oretti, BDS, MGDS RCS Christopher Orr, BDS, BSc Fazeela Khan-Osborne, BDS, LDS RCS, BSc, MSc Jay B. Reznick, DMD, MD 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

© 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 4

A true “paradigm shift” in implant therapy

T

hose of us who attend large and small congresses and meetings hear the phrase, “paradigm shift,” all the time.

Every time a new implant shape, size, surface, or prosthetic connection hits the market, we are told about a “paradigm shift” that will transform implant dentistry. Truth be told, some of these advances actually do improve therapy to some extent.

But how many actually change the way we treatment plan for our patients?

In the 21 years that I have been in private periodontal practice, the manner in which we treatment plan for our edentulous or soon-to-be-edentulous patients has always started Dr. Barry Levin with the discussion of whether the goal is to provide a “fixed” or “removable” solution. Over 20 years ago, removable meant four implants in the maxilla to affix a cast bar and either two or four implants in the mandible with either a bar or individual retentive anchors. A fixed solution meant placing approximately six-to-eight implants in each arch for either a traditional hybrid or crown and bridge-type of restoration. Since this time, the evolution of retentive anchors has simplified treatment and reduced costs. The digital “paradigm shift” has facilitated less invasive guided surgeries and CAD/CAM frameworks. However, we were still thinking “fixed” versus “removable” and, thus, very little really changed — until recently.

As a periodontist, I have unfortunately seen my share of peri-implant mucositis and peri-implantitis. The etiology is almost always multifactorial. However, the inability to perform proper home care due to the design of the prosthesis is an all too common cause of these inflammatory lesions. The lip support necessary to achieve patient satisfaction results in prostheses requiring flanges and significant amounts of “pink.” Some of these patients are also unaccepting of a “removable” solution. Dentsply Sirona Implants’ introduction of the Atlantis® Conus abutment has changed everything. For the first time, I can offer patients the esthetics of a removable overdenture and/or palate-free comfort with the retention of a fixed prosthesis that can be removed to perform oral hygiene. My referrals have embraced the Atlantis Conus concept as well because they can now offer the best of both fixed and removable worlds for their patients.

The second half of this paradigm shift came with the introduction of the SmartFix® concept (Dentsply Sirona Implants) for patients who desire a fixed solution but are unable or unwilling to undergo procedures such as sinus elevation and/or ridge augmentation. It can be very challenging to place an adequate number of implants (often four to six) in an edentulous arch with a satisfactory alignment for traditional laboratory and restorative techniques. With the “easy” angulation correction made possible with the SmartFix components, the maximum anterior-posterior spread of implants to support fixed restorations is easier to achieve. Combined with the use of computer-guided implant placement such as Simplant and CAD/CAM-milled prostheses such as Atlantis, treatment is optimized by reducing the need for augmentation and treatment time, and lowering costs.

The innovation of treatment concepts such as these further expands the accessibility of implant therapy and allows clinicians to offer solutions that are more desirable for edentulous patients — thereby creating a true “paradigm shift” in implant dentistry.

Dr. Barry Levin

Barry Levin, DMD, is is a Diplomate of the American Board of Periodontology and a Clinical Associate Professor of Periodontology at the University of Pennsylvania. He maintains a private specialty practice in Jenkintown, Pennsylvania.

His clinical research and writings focus on new and novel methods of tissue regeneration and immediate implant placement. Dr. Levin holds a trademark for the Dermal Apron Technique™.

Implant practice 1

INTRODUCTION

August/September 2017 - Volume 10 Number 4

TABLE OF CONTENTS

Practice profile Nick Caplanis, DMD, MS

6

Event news...................... 17

Keeping pace with implant dentistry

Technique Time to go old school: time to grab that osteotome Dr. Charles D. Schlesinger discusses a simple and versatile instrument ....................................................... 18

Case study

12

Full arch fixed provisionals with dual stabilization dental implants Dr. Ara Nazarian discusses implant treatment with fewer appointments

2 Implant practice

Volume 10 Number 4

Dentsply Sirona does not waive any right to its trademarks by not using the symbols ® or ™. 32671202-US-1701 © 2017 Dentsply Sirona. All rights reserved.

All trademarks, company names and implant designs are the property of their respective owners.

Atlantis®

Do you have all of your bases covered?

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Adjustable core height A shared emergence between abutment and crown Eliminates the need for stock components Available in titanium or gold-shaded titanium

Take control of your screw-retained restorations with Atlantis CustomBase solution. www.dentsplysirona.com

Atlantis CustomBase solution vs. stock titanium base

TABLE OF CONTENTS

Humanitarian efforts M. Joe Mehranfar, DMD, MS

Continuing education

23

Making a difference for patients in need

Autologous bone grafting using extracted teeth Dr. Armin Nedjat explains how using the patient’s own extracted teeth can provide a readily available and effective grafting material...............26

Practice development Do your patients know that you place dental implants?

Dr. Bobbi Stanley discusses three ways to maximize your internal marketing.................................... 36

How social media can help your SEO performance Ian McNickle, MBA, discusses the impact of search engine optimization

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

Continuing education Immediate full arch restoration Dr. Robert Hayes discusses a predictable novel treatment modality for treating failing dentitions, edentulous, and potentially edentulous patients......................30

On the horizon Dental implants and social media: part 1 Dr. Justin Moody begins a series on social media and its impact on dental practices..................................... 40

PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com MANAGING EDITOR | Mali Schantz-Feld Email: mali@medmarkaz.com | Tel: (727) 515-5118 ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkaz.com NATIONAL SALES DIRECTOR | Kristin Sammarco Email: kristin@medmarkaz.com NATIONAL ACCOUNT MANAGER Celeste Scarfi-Tellez Email: celeste@medmarkaz.com CLIENT SERVICES/SALES SUPPORT | Adrienne Good Email: agood@medmarkaz.com CREATIVE DIRECTOR/PROD. MGR. | Amanda Culver Email: amanda@medmarkaz.com WEBSITE MANAGER | Anne Watson-Barber Email: anne@medmarkaz.com E-MEDIA PROJECT COORDINATOR | Michelle Kang Email: michellekang@medmarkaz.com FRONT OFFICE MANAGER | Terri Burud Email: terri@medmarkaz.com MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 www.implantpracticeus.com | www.medmarkaz.com SUBSCRIPTION RATES 1 year (6 issues) $149 | 3 years (18 issues) $399

4 Implant practice

Volume 10 Number 4

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PRACTICE PROFILE

Nick Caplanis, DMD, MS Keeping pace with implant dentistry

Dr. Caplanis and his surgical staff preparing for implants

What can you tell us about your background?

I was born and raised in northern New Jersey to immigrant parents from Greece.

I went to Rutgers University and majored in Math and Biology. I received my dental degree in 1991 from New Jersey Dental School, now known as Rutgers Dental School. I completed a General Practice Residency in 1992 at Englewood Hospital in Englewood, New Jersey, and then moved to Southern California to attend the 3-year implant dentistry residency program at Loma Linda University (LLU) from 1992-1995.

After that, I completed a master’s degree in Oral Implantology and a residency in Periodontics. I am happily married to my high school sweetheart for 25 years, and we have three wonderful children.

Is your practice limited to implants?

Not exactly. As a dual specialist and double-board certified by the American Board of Oral Implantology and the American 6 Implant practice

Board of Periodontology, I am limited to both Implants and Periodontics and also perform some minor implant restorative treatment.

Why did you decide to focus on implantology?

I fell into it by accident. I had the privilege of having a famous implantologist as an instructor in dental school. His name was Dr. Norman Cranin. He would talk to me and a few of my classmates about this exciting, and to us, “new” field of implant dentistry that we never were exposed to in school. He encouraged us to attend his AAID-sponsored 1-year continuum MaxiCourse® in implant dentistry, which we did while still in our senior year in dental school. After graduating dental school, I was actually able to place a few implants during my general practice residency with one of my instructors, Dr. John Minichetti, which further increased my interest in implant dentistry and made me decide to focus my career on the specialty. That’s when I applied and was accepted to the world-renowned

implant dentistry program at LLU to study under another well-known implantologist, Dr. Robert James. The implant dentistry program at LLU has contributed to the education of some of the most influential practitioners in the field of implant dentistry today, including Drs. Jaime Lozada, Joseph Kan, Sascha Jovanovic, Istvan Urban, and many more. While there, I was fortunate to have Dr. Ulf Wikesjö, the postgraduate director of periodontics, direct my Master’s thesis, which was on bone regeneration. Dr. Wikesjö is a well-known researcher in the field of periodontal regeneration, and he was the one that encouraged me to complete my third and final residency in periodontics.

This training was an excellent adjunct to the implant and prosthetic training I received in the implant dentistry program.

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

I’ve been in practice since 1997 in Mission Viejo, California, which is in South Volume 10 Number 4

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Cool Jaw offers a full line of gel packs and facial wraps that are specifically designed to help patients recover from a range of dental procedures. Our Soft-sided Round Gel Packs are ideal for a variey of cold therapy applications including post-operative care. These reusable gel packs are 4” in diameter and remain flexible when frozen, allowing for uniform cold therapy. They feature one soft-sided surface to shield the skin from direct contact with the frozen pack and are a convenient, comfortable and economical cold therapy option for your patients. Our reusable gel packs can also be customized with your practice logo for long lasting promotion. Available in Cool Blue, Grape, Kiwi, Mango, Pink Ice and Vanilla.

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PRACTICE PROFILE Orange County. As a large referral-based practice, we use many systems. These include Nobel Biocare®, Straumann®, Zimmer Biomet Dental, Astra Tech, and Implant Direct. Our office uses Dentrix as our practice management software and DEXIS™ for digital radiography. And we have the E-WOO double sensor CBCT unit manufactured by Vatech.

What is the most satisfying aspect of your practice?

Definitely my staff, some of whom have been with me from the very beginning. My office manager, Debbie, runs a smooth and drama-free office. My office

administrator, Jeanne, takes care of our marketing, including social media, and puts a smile on my face every day. My hygienists, Maria and Marie, are great clinicians and understand periodontal disease better than most dentists. Marie also helps run our two study clubs. And my clinical staff, Jessee, Eric, and Zachary, keep our busy surgical schedule running like a well-tuned clock and at the same time create a fun working environment.

Professionally, what are you most proud of?

I am most proud of having served as president of the Orange County Dental

Society, the California Society of Periodontists, and the American Academy of Implant Dentistry. I think I left a small but significant mark on each of those organizations for the better.

What do you think is unique about your practice?

My training in Prosthodontics during the LLU Implant Dentistry residency program has given me a unique background on prosthetic planning and treatment, which I think is appreciated by my referring doctors. We work as a team, but depending on my referring doctors’ background and comfort level, I can help supplement the prosthetic planning and even treatment when needed.

What has been your biggest challenge?

Keeping up with the furious pace of technological advances in the field of implant dentistry.

Digital workflows, milling, printing, file merging, virtual planning, virtual 3D surgery, etc., are making it an exciting time to practice but also a challenge to keep up with the advances, not to mention the costs.

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

I remember telling people in high school that I wanted to go to dental school, so I’m not too sure what else I would have done. My Greek mother was always clear that I could be anything I wanted — a doctor, lawyer, or engineer.

Anything!

Welcoming office and friendly staff

Three surgical suites are located in a separate wing of the office

Dr. Caplanis lecturing to the local community on full arch implant reconstruction 8 Implant practice

Dr. Caplanis with his team Volume 10 Number 4

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With premier implant financing through LendingClub Patient Solutions, the average patient can finance a single implant, including all restorative work, for $99/month.1 So you can: Close more large cases Present implants more confidently Help more patients move forward with treatment

Learn more about how to become one of our premier implant financing providers: Call 844-936-6673 Visit lendingclub.com/implants $99 monthly payment assumes a 60-month term Extended Plan loan with an amount financed of $4,250 and an APR of 13.99%. Actual monthly payment amount and APR may vary based on amount financed, term and credit history. Subject to credit approval. Amount financed is based on an average single implant procedure cost of $4,250. Source: www.dentalimplantcostguide.com. Š 2017 LendingClub Patient Solutions products and services provided through Springstone Financial, LLC, a subsidiary of LendingClub Corporation.

Payment plans made by issuing bank partners.

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PRACTICE PROFILE

Enjoying a Dunkel with Dr. Glenn Bickert after lecturing in Munich

One of the doctor’s hobbies is racing around with his Porsche® 911 turbo

Dr. Caplanis with his wife, Roulla

Top 10 favorites 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

My patient and understanding wife My three beautiful and smart children God My friends Beer My German shepherd Southern California beaches Digital dentistry Racing my Porsche® 911 turbo Good wine

What is the future of implants and dentistry?

In the near term over the next 10-20 years, it will be increased technology, including robotics. The days of human hands drilling into bone will be coming to an end. Virtual planning and virtual surgery will eventually lead to robotic controls, improving efficiency and safety by reducing human error. In the long term, 30-50 years from now, biologics and genetic engineering will replace the need for man-made substrates such as titanium altogether. We’ll simply go to the dentist or perhaps the physician and get an injection that will turn on the genes that activate the embryologic cascade to biologically grow a new tooth or teeth when they are lost.

10 Implant practice

Dr. Caplanis with his family

What are your top tips for maintaining a successful practice?

Watch the overhead closely, but don’t worry about making money. The money will take care of itself if you take care of your patients as though they are your family. Be honest, truthful, and empathetic.

The trust that patients grant us is sacred.

Respect it. Continue growing professionally as well as personally. If your personal life is in conflict, so will your practice. Finally, find excellent staff members who share your vision for your practice and concern for patients. Pay them well to stay with you.

And let go of “trouble” staff quickly and early.

They are a cancer to the practice and the rest of the staff.

What advice would you give to budding implantologists?

Get the appropriate quantity and quality of education and training, and then practice within your expertise and comfort level. Join an implant organization that will provide this

education and will also help promote your continued professional growth in the discipline. The American Academy of Implant Dentistry is a great group for everyone but in particular for general dentists who want to become proficient in implant dentistry.

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

Teaching is my main passion and one of my hobbies. I lecture across the country as well as abroad on various topics related to implant dentistry. When I do have some free time, I generally spend it with my family. We like visiting our daughter, Angelina, in Seattle who attends the University of Washington. We spend a lot of time watching our boys, John and Stephen, wrestle for their high school.

My boys and I are also avid shooters. We like going to the range and do a fair amount of target shooting. And I also love cars. My two boys and I are looking forward to a 4-day trip to the Rubicon Trail four-wheeling with our Jeep® in July. And every once in a while, I’ll take my Porsche® 911 turbo racing on a track through the local Porsche club. IP Volume 10 Number 4

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CASE STUDY

Full arch fixed provisionals with dual stabilization dental implants Dr. Ara Nazarian discusses implant treatment with fewer appointments

W

hen a patient presents to your dental practice with questionable and/ or non-restorable teeth requiring full-mouth extractions, the biggest concern is whether or not implants can be placed at the same surgical visit and, if so, will the patient be able to walk out with fixed teeth. Having an implant within your practice that allows you to load or progressively load so that these patients’ demands are met allows you to position your practice to a whole new level.

Of course, certain parameters must be met in order to facilitate this type of treatment.

This includes, but is not limited to, the quality and quantity of bone, the presence of infection, the patient’s health, and the skills

of the dental provider. Additionally, the selection of the most appropriate materials for the most ideal situation must be met.

A patient presented to my practice for a consultation wanting to restore his dentition to proper form and function (Figure 1). He complained of generalized discomfort in these teeth due to the gross caries and periodontal disease that was readily apparent (Figure 2).

There were several teeth in both arches that were already removed due to recurrent decay and/or fracture, which were previously restored with endodontic treatment, cores, and crowns.

Also, there was hyper-eruption in certain areas of his posterior dentition, as well as a deep impinging bite in the anterior (Figures 3 and 4).

Figure 1: Preoperative view of smile

Figure 3: Preoperative maxillary occlusal view

Figure 2: Preoperative retracted frontal view

Figure 4: Preoperative mandibular occlusal view

Planning Ara Nazarian, DDS, DICOI, maintains a private practice in Troy, Michigan, with an emphasis on comprehensive and restorative care. He is a Diplomate in the International Congress of Oral Implantologists (ICOI) and the director of the Ascend Dental Academy.

He has conducted lectures and hands-on workshops on esthetic materials, grafting, and dental implants throughout the United States, Europe, New Zealand, and Australia.

12 Implant practice

A CBCT scan using the CS 8100 3D (Carestream Dental) (Figure 5) was taken to accurately capture the information needed to properly treatment plan this case and ensuring the most ideal outcome, especially since the patient discussed his frustration with previous treatment that did not last very long or address his primary needs and requests.

To further develop a treatment plan, diagnostic model impressions were taken

Figure 5: CS 8100 3D Volume 10 Number 4

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CASE STUDY using Silginat® (Kettenbach), poured up and forwarded to the dental lab. These models were then mounted on an articulator (Stratos® 100, Ivoclar Vivadent®) for further analysis in order to meet the patient’s esthetic and functional needs. Additionally, a 3D virtual treatment plan was created with the assistance of 3DDX (3D Diagnostix.com) (Figures 6 and 7).

The patient desired having fixed restorations supported by dental implants in both upper and lower arches.

Financing options using a third-party payment option (Lending Club®) were discussed with the patient. This discussion was a very important part of facilitating acceptance of his care since it made the cost of treatment more feasible.

The implants utilized in this case were OCO Biomedical’s Engage™ dental implants.

These implants are known for their unchallenged high implant stability at placement, which is a critical success factor in these immediate load cases. With the combination of their patented Bull Nose Auger™ Tip and Mini Cortic-O Thread™, the Engage™ implant system offers practitioners a bone level implant with high initial stability for selective loading options.

The Engage™ implant is self-tapping for an enhanced mechanical lock in the bone.

The Bull Nose Auger™ Tip will not proceed any deeper than the initial pilot drill preparation locking into the base of the osteotomy.

Engage™ implants have a proprietary surface treatment designed to increase the surface area of the implant for optimal bone ingrowth and stability.

Once the teeth were extracted, the tissue was reflected in order to get the surgical guide seated and fixed with its respective retention pins. Using this universal surgical guide provided by 3D Diagnostix, the sites for the implants were initiated with a designated 1.8-mm pilot drill from the OCO Biomedical Guided Kit (Figure 8), utilizing the

Figure 8: OCO Biomedical Guided Surgical Kit 14 Implant practice

Figure 6: 3DDX virtual treatment plan maxilla

Figure 7: 3DDX virtual treatment plan mandible

Figure 9: Dual stabilization dental implant (Engage) Volume 10 Number 4

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CASE STUDY Mont Blanc® surgical handpiece and Aseptico® surgical motor (AEU 7000) at a speed of 1,200 rpm with copious amounts of sterile saline. Sequential osteotomy formers from the OCO Biomedical Guided Kit were then used to shape the final osteotomies. Once the osteotomies were complete, an implant driver was used to place the dental implants until increased torque was necessary (Figure 9). The ratchet wrench was then connected to the adapter and the implants torqued to final depths reaching a torque level of about 40-50Ncm. A baseline ISQ reading was taken of these implants utilizing the Osstell ISQ unit (Figure 10). Since the initial readings were all around 70, and the quality of bone after leveling was good, temporary abutments (OCO Biomedical) were tightened into the Engage (OCO Biomedical) dental implants and prepped with copious amounts of water for immediate provisionalization.

Any residual areas around the implants or in the sockets were grafted with a cortical mineralized and demineralized bone grafting material to optimize the area for regeneration.

With the proper training and appropriate materials, a dental provider may provide extraction, grafting, and implant placement within one appointment at one location.

Primary closure was achieved by suturing the tissue with resorbable sutures.

The prefabricated immediate provisional restorations were tried in to ensure a passive fit over the temporary abutments.

Once confirmed, rubber dam material was placed to avoid the restoration from locking on during the relining procedure with Visalys® Temp (Kettenbach) temporary material.

After the material polymerized, the immediate provisional restoration was removed, and any access material was removed with the Torque Plus (Aseptico) lab handpiece and acrylic bur (Komet). Once trimmed and polished, the provisional restorations were seated with Temp-Bond™ Clear (Kerr Dental) (Figure 11).

Seven days postoperatively, the patient returned with very little discomfort, swelling, or bruising. He was very pleased with his new upper- and lower-fixed provisional restorations (Figure 12). Now that the patient was no longer anesthetized, the occlusion was checked again to confirm there were no interferences in lateral and protrusive movements. The next step in his treatment would consist of full arch impressions for

the definitive restorations approximately 4-5 months postoperatively.

Conclusion Having the ability to take a patient from start to finish in a fewer amount of appointments within your practice allows you to position yourself as a provider that can fulfill your patient’s surgical and restorative needs. With the proper training and appropriate materials, a dental provider may provide extraction, grafting, and implant placement within one appointment at one location. Not only does this allow you to reduce the amount of visits for the patient, but this type of service also helps maintain the cost to the patients since they are not seeing multiple dental providers. Most importantly, this enables the dental provider full control of the surgical and prosthetic outcome. Depending on the patient’s desires, the clinical conditions of the oral environment present, and the skills of the provider, a dentist may choose to extract teeth, level bone, and graft with guided dental implant placement within his/her dental practice. IP

Figure 10: Osstell reading illustrating great fixation

Figure 11: Postoperative retracted frontal view 16 Implant practice

Figure 12: Postoperative view of smile Volume 10 Number 4

Actor, musician, producer, and philanthropist Will Smith is joining the agenda at Denstply Sirona World. Regaling event attendees during a one-on-one interview led by Dr. Mike DiTolla, followed by an open Q&A with the audience, Smith is the perfect addition to this educational festival. You won’t want to miss this witty exchange between the pair on Thursday evening, September 14. Dentsply Sirona World, hosted at The Venetian and The Palazzo® in Las Vegas, September 14-16, combines premium education with exceptional entertainment.

Visit www.dentsplysironaworld.com to register to view the complete event agenda. For additional information on Dentsply Sirona World 2017, contact the help desk by email at events@dentsplysironaworld.com or by phone at 1-844-462-7476.

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To submit an abstract, visit https://osseo2018.abstract central.com/ and follow the prompts.

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Twenty $1,000 Student Travel Grants will be awarded to the recipients of the top-scoring oral research and E-Poster abstracts submitted for the 2018 AO Annual Meeting. This award is open to both AO student members and student non-members who submit an abstract for the 2018 meeting and are currently enrolled in a dental school program.

Abstracts must be submitted by Friday, September 29, 2017, at 11:59 p.m. EST via the electronic abstract submission site at https://osseo.org/student-travel-grant-program/. Only authors indicating their interest via the abstract submission site will be considered for a Student Travel Grant. Members of the AO Research Submissions and E-Poster committees will review and score the submitted abstracts to determine the best student presentations based on the quality of the research and relevance to the field of Osseointegration.

For more information, visit www.osseo.org

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Volume 10 Number 4

Implant practice 17

TECHNIQUE

Time to go old school: time to grab that osteotome Dr. Charles D. Schlesinger discusses a simple and versatile instrument

D

oes a clinician really have to have the “latest and greatest”? Believe me, I am a huge advocate of using the very best technology to achieve better results in less time.

I wholeheartedly embrace the technologies that not only make me a better practitioner, but also those things with which I surround myself that improve my quality of life. Our industry is chock-full of devices. Dentists love gadgets, and I am no exception. Over my career, there have been those “latest and greatest” things that have looked great and performed as advertised and those that did not live up to their intended greatness.

In implantology, like the rest of dentistry, we are bombarded every day by manufacturers with the newest, the best, and the most innovative products known to man.

The problem is there can be the erroneous assumption that “more complex” is analogous to innovation. We can be easily sucked into thinking that the more “gimmicky” a procedure is that it must perform to a higher standard and give better results than the “lower tech” devices we have been using.

When it comes to implantology, one of the most simple instruments is also the most versatile. I am speaking of the crude-looking, often overlooked osteotome. In the right hands and used properly, this simple set of instruments can achieve so much and do it in a predictable, well-proven manner.

Dr. Charles Schlesinger, DDS, FICOI, is a dental implant educator and clinician who has been lecturing internationally for the past 10 years. He graduated with honors from The Ohio State College of Dentistry in 1996. After graduation, he completed a General Practice residency at the VAMC San Diego and then went on to become the Chief Resident at the VAMC West Los Angeles. During his time in Los Angeles, he completed extensive training in oral surgery, implantology, and advanced restorative treatment. Once he completed his residency, Dr. Schlesinger maintained a thriving restorative and implant practice in San Diego, California, for 14 years. In 2012, he relocated to Albuquerque, New Mexico, to become the Director of Education and Clinical Affairs for OCO Biomedical. In 2013, he took over as Chief Operating Officer of OCO Biomedical along with his clinical responsibilities. In 2016, Dr. Schlesinger left OCO Biomedical and founded The CD Schlesinger Group, LLC, to help practitioners gain knowledge and experience with implants and became a Key Opinion Leader for The Hahn Implant System. Additionally, he continues to provide comprehensive implant care to patients in a private practice setting in Albuquerque, New Mexico.

What is an osteotome?

Basically an osteotome is a tapered or straight-walled instrument with a handle that can be manipulated by hand or tapped with a surgical mallet (Figure 1). It comes in two main varieties, convex- (Figure 2) and concave(Figure 3) tipped, and are also are available in both straight and offset configurations. The offset style allows the osteotome to be placed in the posterior maxilla while allowing the force of the instrument to be directed vertically.

These instruments usually are available in matched sets that start with a small diameter and incrementally enlarge to a wider diameter.

There are both generic kits and those that are matched to the taper of the specific implant you are using. My personal choice is to use a set that is tapered to match the implant system I am utilizing since it not only has the correct taper for the implant, but also has the specific implant lengths laser etched on the shaft (Figure 4). When used to either expand or compact bone, it allows for more predictable primary stability upon implant insertion.

Figure 1: A set of matched osteotomes

Figure 3: Concave-tipped osteotomes 18 Implant practice

Why is an osteotome so versatile, and what can it do?

Depending on the tip style used, osteotomes can be used to expand bone, change the consistency of medullary bone, or up-fracture the sinus floor in a crestalapproach sinus elevation.

Bone expansion After growth has ceased, the single most important factor governing the gross morphological shape of the bone is related to the presence or absence of the teeth. After tooth extraction, there follows a phase of remodeling that may result in an extensive loss in the height of the jaws.1 It is not uncommon to lose a significant amount of bone volume in a relatively short period of time (Figure 5). This loss in volume can be accelerated as a result of trauma at the time of surgery, advanced periodontal disease, and the constant pressure of a removable appliance. Knife-edge residual alveolar bone ridges or non-spacemaintaining defects of the alveolar bone

Figure 2: Convex-tipped osteotomes

Figure 4: Implant-specific style of instrument Volume 10 Number 4

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TECHNIQUE limit or complicate the successful placement of dental implants.2 As the bone is reduced in height by periosteal osteoclastic resorption, there is an accompanying endosteal apposition,3 but at no time is new bone formation seen on the periosteal surface of the residual ridge, which remains porous, never developing a complete cortical layer.4,5 Further internal remodeling results in a loss of organization and a thinning of the trabeculae as well as disruption in the arrangement of the lamellar and Haversian systems.6 Many times, the loss of horizontal bone volume will not allow a conventionally sized implant to be placed using standard drilling protocols (Figure 6). In these cases, if the osteotomy is created using drills, the removal of bone will result in an insufficient thickness of bone either buccally, lingually, or in both areas.

For successful integration, at least 1-2 mm of bone must remain in these areas in order to avoid potential dehiscence of the implant.

In the maxillary arch, with its thinner buccal cortical walls, it is possible to “bend” the bone

outward to accommodate the desired implant diameter without compromising the remaining bone thickness. The other side effect of this type of site preparation is the compaction of the bone to help it stand up better to the lateral forces that will be placed against it when the implant is eventually restored. For this type of procedure, an osteotome with a convex profile is recommended.

Here we can see a case where there is plenty of vertical bone in the area of tooth No. 10, but is sorely lacking in BL volume (Figure 7). This lack of bone volume necessitates either a mini-implant placement or expansion to accommodate a standard diameter implant. By using a straight, convex-tipped osteotome, the ridge was expanded in order to accommodate a 3.0-mm implant (Figure 8).

Bone compaction The primary stability of an implant is proportionate to the consistency of the bone in which it is being placed. The literature has defined primary stability as 30N/cm upon seating torque or an ISQ reading of 55 with

Figure 5: The progression of maxillary bone resorption

an Osstell unit.7 Many times the native bone quality will not allow this minimal stability to be achieved, let alone the stability necessary to immediately load a dental implant. The maxillary arch usually demonstrates a bone quality of D3 or D4, but it is not uncommon to also see it in the mandibular arch in geriatric patients (Figure 9). These bone density types have the consistency of balsa wood and Styrofoam™, respectively. You wouldn’t want to try and hang an expensive piece of art on a wall that was made of either of these materials would you?

These poor bone types usually arise from medullary bone that has a sparse or open trabecular pattern and is most commonly found in the posterior maxillary arch. The posterior maxilla has the lowest bone mineral density8 even when compared to the premaxilla and, therefore, may require additional procedures to make the site suitable for implant placement.

Instead of moving through your progression of drills to create your final osteotomy, a series of incrementally increasing diameter

Figure 6: Implant perforation due to insufficient BL bone

Figure 7: Pre-op CBCT showing diminished bone volume

Figure 8: Gently tapping an osteotome with a surgical mallet 20 Implant practice

Figure 9: Wide trabecular pattern

Figure 10: Condensing bone with an offset osteotome Volume 10 Number 4

TECHNIQUE

Figure 11: Implant in place with sufficient primary stability

Figure 12: Lateral versus crestal approach lifts

Figure 13: Osteotome-assisted lift

osteotomes are used after a pilot hole in the intended trajectory has been established (Figure 10). By using a convex-tipped osteotome, we can condense the trabecular bone and thereby change the consistency of it.

By slowly compressing the bone rather than cutting it away, the trabeculae will condense and thereby mimic denser bone in quality, essentially producing bone with better characteristics to achieve sufficient initial implant primary stability (Figure 11).

Sinus elevation A maxillary sinus can be lifted with either a lateral or osteotome-facilitated crestal approach (Figure 12).

Prior to the use of osteotomes for sinus elevation, the lateral wall or Caldwell-luc approach was the standard of care. In the 1980s, both Tatum9 and Misch reported success with the elevation of the sinus floor through the lateral wall of the maxilla. This procedure works very well and in many cases is still the chosen method for gaining alveolar bone height, but by its nature is a more invasive approach to elevation with a relatively long healing time.

In 1994, Dr. Robert Summers, using a special set of matched and tapered osteotomes, proposed a method for inserting implants in the posterior maxilla. Summers’ method has made the crestal approach less traumatic and invasive when placing implants coronal to the sinus floor.10 The procedure is quite elegant in its simplicity. A pilot drill is used to within 1 mm of the sinus floor to establish the intended implant trajectory. Now, using progressively larger instruments, the osteotomy is created.

With the final diameter osteotome, the floor is up-fractured (Figure 13) by gentle tapping with a mallet. Either a convex or concave tip can be used, and each has its advantages and disadvantages.

The convex-tipped osteotome has the advantage of condensing the bone circumferentially around the site and will up-fracture the floor using slightly less force. But the 22 Implant practice

Figures 14 and 15: 14. Completed lift with implant in place. 15. Large lift with multiple implants placed. Blue line is sinus floor and red line shows lift

disadvantage of this type of tip is that the up-fracure can be unpredictable. The floor can splinter, and the possibility of perforation of the Schneiderian membrane is potentially higher.

The concave-tipped style of osteotome will not condense the bone to the same extent as the convex tip since the leading edge of the concave instrument will shave off bone as it progresses. This contributes to the advantage of having bone collecting in the concavity and being pushed ahead of the instrument. This bolus of bone will help buffer the trauma to the floor and have the side effect of decreasing the potential for membrane tearing. This bone along with grafting material of your choice will be added to hydraulically lift the membrane (Figure 14).

With this technique being utilized in multiple adjacent sites, it is possible to achieve a significant lift (Figure 15).

Conclusion The key to proper expansion, compaction, and elevation is a slow, gradual technique with controlled force application that leads to the desired result with minimal site trauma. The outcome of dental implant placement in terms of implant survival seems to be similar to that of implants placed by means of the conventional implantation technique.11 As a practitioner, my goal is to use the simplest protocols that will give me the consistent results I desire and my patients expect. It is easy to get caught up in the

newest device or protocol, and it is our responsibility to explore everything that may prove to be a better way to do things, but do not abandon what is tried and true. Sometimes not being on the “bleeding edge” gives better and more consistent results. So, slap in that 8-track, crank up the volume, and embrace what works! IP

REFERENCES 1. Kingsmill VJ. Post-extraction remodeling of the adult mandible. Crit Rev Oral Biol Med. 1999;10(3):384-404.

2. Siddiqui AA, Sosovicka M. lateral bone condensing and expansion for placement of endosseous dental implants: a new technique. J Oral Implantology. 2006;32(2):87-94.

3. Pudwill ML, Wentz FM. Microscopic anatomy of edentulous residual alveolar ridges. J Prosthet Dent.

1975;34(4):448-455.

4. Neufeld JO. Changes in the trabecular pattern of the mandible following the loss of teeth. J Prosthet Dent.

1958;8(4):685-697.

5. Atwood DA. Post-extraction changes in the adult mandible illustrated by microradiographs of midsagittal sections and serial cephalometric roentgenograms. J Prosthet Dent.

1963;13:810-824.

6. Seipel CM. Trajectories of the jaws. Acta Odontol Scand.

1948;8(2):81-191.

7. Schlesinger C. Torque versus RFA in implant placement: a case study. Implant Practice US. 2016;9(4):14-20.

8. Devlin H, Horner K, Ledgerton D. A comparison of maxillary and mandibular bone mineral densities. J Prosthet Dent.

1998;79(3):323–327.

9. Tatum H Jr. Maxillary and sinus implant reconstructions.

Dent Clin North Am. 1986;30(2): 207-229.

10. Drew HJ, Chiang T, Simon BI. The osteotome technique: modifications to the original approach. Inside Dentistry.

2007;3(10):58-65.

11. Shalabi MM, Manders P, Mulder J, Jansen JA, Creugers NH. A meta-analysis of clinical studies to estimate the 4.5 year survival rate of implants placed with the osteotome technique. Int J Maxillofac Implants. 2007;22(1):110-116.

Volume 10 Number 4

HUMANITARIAN EFFORTS

M. Joe Mehranfar, DMD, MS Making a difference for patients in need

T

he gift of knowledge is something that is given and passed on to benefit others.

Dr. M. Joe Mehranfar sees his expertise in dentistry and implantology as a gift he continuously gives to make a difference in the lives of those in need.

As a leading dental implantology practitioner in Arizona, Dr. Mehranfar spent many of his early years receiving comprehensive training in microbiology, dentistry, and implantology. After establishing his practice, he served as an adjunct assistant professor to share what he learned in his studies and his hands-on experience caring for patients.

Teaching and mentoring others has always been a dream for Dr. Mehranfar, but when he was presented with an opportunity to mentor and also provide high-quality dental care regardless of financial status, it was an opportunity he couldn’t refuse.

The brighter way Dental care is a necessity that not everyone can afford. Providing exceptional dental care and bringing a smile to the patient is the reason why Dr. Mehranfar studied dentistry and implantology.

In 2015, Dr. Mehranfar was approached

by Dr. Kris Volcheck, CEO and founder of Brighter Way Institute, to join his team as the director of dental implant education at the Brighter Way Dental Institute.

Brighter Way provides dental care at its three centers to military veterans, children who are uninsured and in foster care, homeless individuals, and low income families. At the Brighter Way Dental Institute, Dr. Mehranfar has a unique role of leading and providing live-streaming teaching opportunities for dental surgeons wanting to refine implantology skills, while providing dental implants to a veteran.

“It is incredibly rewarding to mentor future dental leaders and simultaneously help deserving individuals in desperate need of dental care,” Dr. Mehranfar said. “As a dental surgeon, my mission is to execute the highest quality dental care and provide a prosperous learning experience for colleagues in the dental industry.”

Volume 10 Number 4

Dr. M. Joe Mehranfar is a leading dental implantology practitioner in Phoenix

Through his teaching at Brighter Way, Dr. Mehranfar mentors residents from the Lutheran Medical Center of New York, and clinicians across the country can learn from his live-streaming teaching procedures.

Patients are the priority Operating a practice can significantly consume time. After seeing patients during the day, there are business matters to

Dr. M. Joe Mehranfar with Dr. Kris Volcheck Implant practice 23

HUMANITARIAN EFFORTS

Dr. M. Joe Mehranfar teaches during a dental implant procedure

“It is incredibly rewarding to mentor future dental leaders and simultaneously help deserving individuals in desperate need of dental care.”

address. For any dental practitioner who desires to give back, but hasn’t found the right balance of time spent in a practice and volunteering services, Dr. Mehranfar says there is just one thing to remember: “Put the patients’ needs first.”

In addition to his own practice in Phoenix limited to surgical and prosthodontic implant treatment, plus teaching at the Brighter Way Dental Institute, Dr. Mehranfar performs implant surgeries at general dental offices.

He also serves as a consultant for Karl Schumacher Dental, a provider of premier dental instruments.

“I remember my mission daily,” Dr. Mehranfar adds. “As a busy dental practitioner, there’s always more to do, but I choose to focus on why I became a dental surgeon, and that means making patients the priority.”

Karl Schumacher Dental is proud to provide dental instrumentation for Brighter Way. If you would like to help Brighter Way, please visit www.brighterwaydental.org/ brighterway-live. IP This information was provided by Karl Schumacher Dental.

Dr. M. Joe Mehranfar with his dental practice team in Phoenix 24 Implant practice

Volume 10 Number 4

Celebrating 70 Years

INTRODUCING

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Gamma irradiated to achieve a Sterility Assurance Level (SAL) 10-6 without compromising the inherent biomechanical or biochemical properties of the graft.

All allograft is tested to ensure osteoinductivity.

Putty and Paste contains 100% human DBM with bone morphogenetic proteins (BMP2).

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CONTINUING EDUCATION

Autologous bone grafting using extracted teeth Dr. Armin Nedjat explains how using the patient’s own extracted teeth can provide a readily available and effective grafting material

I

n Germany alone, more than about 9 million adult teeth are extracted every year, all of which need replacing. When socket preservation is not performed after extraction, the hard and soft tissues can lose up to 50% of their volume. Consequently, delayed implantation is often associated with bone grafts.

For decades, bone grafts have been scientifically documented to achieve good results. A variety of graft materials — from autologous bone (derived from the patient’s chin, ramus, or hip) or synthetic bone (BetaTCP), to xenogenous bone — have all seen some measure of success.

A new technique has been developed that allows the clinician to transform extracted teeth into autologous bone graft material that, when used correctly, will ankylose and undergo a direct attachment with bone.

Educational aims and objectives

This article aims to illustrate and explain the process of utilizing a patient’s own extracted teeth into an effective grafting material.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 29 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Identify various types of bone graft materials.

•

Recognize some applications for natural teeth material as bone grafts.

•

Recognize some studies regarding improving or maintaining soft tissue stability during the implant process.

•

Recognize the steps in using this material for bone grafting.

A win-win situation For some time, this author has incorporated this concept in his practice. The concept, which originates from the United States and Israel, is deceptively simple:

Instead of discarding extracted teeth, the teeth are bio-recycled chairside and cleaned directly after extraction in order to use them as osteoinductive autologous bone graft.

Figures 1-3: The extracted teeth are cleaned. Amalgam, composites, and endodontic filling material are removed from the teeth with a diamond, under water cooling, and with a turbine. The tooth fragments are then thoroughly dried and placed in the chamber

Figures 4-6: The chamber is tightly closed. The “grind” setting is adjusted to 3 seconds and “sort” to 20 seconds before the grinding process begins. The unit sorts the granules into two filtration chambers

Dr. Armin Nedjat is founder and managing director of Champions® Implants. He is also the developer of the minimally invasive method of implantation (MIMI) procedure.

For more information, visit www.gbr.championsimplants.com.

26 Implant practice

Figures 7 and 8: The ground and filtered material is immersed in a cleanser solution for 10 minutes. The cleanser, which is bactericidal, consists of sodium hydroxide with 20% ethanol Volume 10 Number 4

Discussion In immediate placement cases, the graft can be prepared while the implant is placed. It is recommended that the implant be placed first (ideally, at a primary stability of 30 Ncm), and then the graft added to fill the bone-implant cavity. A prospective study

by Barone documented stable soft tissue with a success rate of 95% after 7 years following an immediate implantation and immediate restoration (Barone, et al., 2016).

The palatinal/lingual position of the implant in the “biological envelope” seems to contribute to success.

For about 15 years, as has been said in clinical studies, this author has postulated that it is paramount to prevent the graft and/or the implant from applying pressure on the buccal bone lamella (even if it is very thin, with an intact periosteum) (Slagter, et al., 2016; Slagter, et al., 2016; Chochlidakis 2016; Khoury 2016).

The buccal resorption is independent of the biotype. With a minimally invasive method of implantation (i.e., without raising flaps), there is likely to be resorption of only 0.3 mm (Merhab, et al., 2016), which is a satisfactory and even long-term esthetic clinical result.

In addition, a significant correlation of lasting esthetic results with the vestibular bone thickness has not been found. A prospective study found that for immediate implantation, it was not significant whether the vestibular bone wall measured 0.4 mm or 1.2 mm (Arora and Ivanovski 2016).

If a graft is placed in the cavity between the bone and the implant, the buccal lamella can be stabilized (Arora and Ivanovski 2016).

A meta-analysis has shown that a connective tissue graft for immediate implantation is not more esthetic in the long term and is therefore questioned (de Oliveira-Neto, et al., 2016).

Another randomized study showed there was not a difference between the peri-implant soft tissue volume increase in the group with xenogenous collagen matrix and the group with a connective tissue graft (Thoma, et al., 2016). In a study conducted by Kim, et al., 2016, with 30 patients, it was shown that demineralized and ground autologous teeth, in combination with PRP, were suitable for sinus lifts.

A study conducted by Pohl, et al., in Austria (2016) also demonstrated the use of ground third molars in sinus lift procedures.

In the author’s experience, the Smart Dentin Grinder (KometaBio Tissue Engineering) has been very successful, providing 100% physiologically/biologically compatible material, without incidence of dehiscences and clinical complications. Psychologically, patients do not need to be informed about foreign material anymore — since their own teeth can be reused.

Conclusion and economic considerations The general dentist during the treatment of his/her patients will typically extract teeth

Figures 9-11: The resulting particulate is carefully dried, before being neutralized in a buffering solution for 3 minutes and then again dried with sterile swabs. A third optional stage, involving the use of EDTA solution for 1 minute, can be added between cleansing and neutralizing if so desired. After the tooth has been ground and processed, the resulting “sticky bone” can be used as graft in the alveolus. In practice, the graft does not crumble and exhibits a capacity to bond. A membrane and sutures do not seem to be necessary when patients are advised not to drink, rinse, or brush their teeth for 2½ hours after the procedure

Figures 12 and 13: The resulting “sticky bone” can be used as a grafting material Volume 10 Number 4

Implant practice 27

CONTINUING EDUCATION

The tooth fragments contain important bone growth factors. Many studies have confirmed the benefits of the natural teeth material as bone graft, and the cost-efficient restoration for the patient can be easily and quickly fitted in any dental office. Socket preservation techniques, as an alternative to immediate implant placement, are also suitable for use with this technique.

In socket preservation procedures, a graft is placed at the time of extraction, but the implant is typically not placed for another 3 to 4 months. It is the belief of this author that the Champions Smart Grinder Concept (CSGC) has the potential to be a win-win situation for patients and dentists.

CONTINUING EDUCATION that cannot be preserved and go on to fit a prosthesis of some description. As clinicians, we know that tackling an alveolar resorption rate of around 50% after extraction requires an efficient, non-traumatic treatment that can be carried out chairside and without a big investment in laboratory material.

In the author’s opinion, the Smart Dentin Grinder device, which has been validated by the EC and approved by FDA 510(k) in the U.S., fits this bill. In Europe, the machine is distributed by Champions Implants, a company whose philosophy is that nontraumatic, reliable treatment, requiring fewer surgery sessions should be a priority. With a Smart Dentin Grinder, grafting treatment is quick, efficient, reliable — and also affordable.

From an economical point of view, compared to “classical” socket preservation that uses bovine or alloplastic material, the cost of a chairside procedure using the patient’s own teeth is significantly lower. This author suggests that all clinical colleagues should look at the potential afforded by no longer discarding extracted teeth from the patient. Instead, implant dentists can reuse them as bone graft material, inform their patients about it, and simplify their socket preservation techniques. IP

REFERENCES 1. Anitua E, Alkhraist MH, Piñas L, Begoña L, Orive G. Implant survival and crestal bone loss around extra-short implants supporting a fixed denture: the effect of crown height space, crown-to-implant ratio, and offset placement of the prosthesis. Int J Oral Maxillofac Implants.

2014;29(3):682-689.

Figures 14-17: The tooth at UR6 could not be preserved (Figure 14). After antibiotic treatment, it was extracted. During immediate implant placement of a Champions (R)Evolution 10x4-mm implant, the tooth was cleaned and prepared. After placing the implant at a primary stability of 30 Ncm (Figure 13), the particulate was placed in the alveolus (Figure 14). After only 10 weeks, very satisfactory results were achieved (Figure 15) with the autologous graft using the Champions Smart Grinder Concept, also in combination with immediate implantation or during an efficient and cost-efficient socket preservation.

Additionally, the distal bone at UR5 seemed to regenerate well 11. Du Toit J, Gluckman H, Gamil R, Renton T. Implant injury case series and review of the literature part 1: inferior alveolar nerve injury. J Oral Implantol. 2015;41(4):e144-151.

2. Arora H, Ivanovski S. Correlation between pre-operative buccal bone thickness and soft tissue changes around immediately placed and restored implants in the maxillary anterior region: A 2-year prospective study. Clin Oral Implants Res.2016.

12. Khoury F, Khoury C. Chapter 6, Mandibular bone block grafts: Diagnosis, instrumentation, harvesting, techniques and surgical procedures. In: Khoury F, Antoun H, Missika P, eds. Bone Augmentation in Oral Implantology. Quintpub: London; 2007.

3. Bornstein MM, Scarfe WC, Vaughn VM, Jacobs R. Cone beam computed tomography in implant dentistry: a systematic review focusing on guidelines, indications, and radiation dose risks. Int J Oral Maxillofac Implants. 2014; 29(suppl):55-77.

13. Kuchler U, von Arx T. Horizontal ridge augmentation in conjunction with or prior to implant placement in the anterior maxilla: a systematic review. Int J Oral Maxillofac Implants. 2014;29(suppl):14-24.

4. Bornstein MM, Al-Nawas B, Kuchler U, Tahmaseb A. Consensus statements and recommended clinical procedures regarding contemporary surgical and radiographic techniques in implant dentistry. Int J Oral Maxillofac Implants. 2014;29(suppl):78-82.

5. Buser D, Chappuis V, Belser UC, Chen S. Implant placement post extraction in esthetic single tooth sites: when immediate, when early, when late? Periodontol 2000.

2017;73(1):84-102.

6. Canullo L, Pellegrini G, Allievi C, Trombelli L, Annibali S, Dellavia C. Soft tissues around long-term platform switching implant restorations: a histological human evaluation.

Preliminary results. J Clin Periodontal. 2011;38(1):86-94.

7. Chochlidakis KM, Geminiani A, Papaspyridakos P, Singh N, Ercoli C, Chen CJ. Buccal bone thickness around single dental implants in the maxillary esthetic zone. Quintessence Int. 2016;48(4):295-308.

8. Cho-Yan Lee J, Mattheos N, Nixon KC, Ivanovski S. Residual periodontal pockets are a risk indicator for periimplantitis in patients treated for periodontitis. Clin Oral Implants Res. 2012;23(3):325-333.

9. de Oliveira-Neto OB, Barbosa FT, de Sousa-Rodrigues CF, de Lima FJ. Quality assessment of systematic reviews regarding immediate placement of dental implants into infected sites: An overview. J Prosthet Dent.

2017;117(5):601-605.

10. Derks J, Schaller D, Håkansson J, Wennstrӧm JL, Tomasi C, Berglundh T. Effectiveness of implant therapy analyzed in a Swedish population: prevalence of peri-implantitis. J Dent Res. 2016;95(1):43-49.

28 Implant practice

14. Harris D, Horner K, Grondahl K, et al. EAO guidelines for the use of diagnostic imaging in implant dentistry 2011. A consensus workshop organized by the European Association for Osseointegration at the Medical University of Warsaw. Clin Oral Implants Res. 2012;23(11): 1243-1253.

15. Levine RA, Huynh-Ba G, Cochran DL. Soft tissue augmentation procedures for mucogingival defects in esthetic sites.

Int J Oral Maxillofac Implants. 2014; 29(suppl):155-185.

16. Linkevicius T, Apse P. Biologic width around implants. An evidence-based review. Stomatologija. 2008;10(1):27-35.

17. Mazor Z, Lorean A, Mijiritsky E, Levin L. Nasal floor elevation combined with dental implant placement. Clin Oral Implants Res. 2012;14(5):768-771.

18. Merheb J, Vercruyssen M, Coucke W, Beckers L, Teughels W, Quirynen M. The fate of buccal bone around dental implants. A 12-month postloading follow-up study. Clin Oral Implants Res. 2017;28(1):103-108.

19. Misch CE. (2015) Chapter 21 - Single-Tooth Implant Restoration: Maxillary Anterior and Posterior Regions. Dental Implant Prosthetics (Second Edition). St. Louis: Mosby 499-552 20. Moraschini V, Poubel LA, Ferreira VF, Barboza Edos S. Evaluation of survival and success rates of dental implants reported in longitudinal studies with a follow-up period of at least 10 years: a systematic review. Int J Oral Maxillofac Surg. 2015;44(3):377-388.

21. Nunes LS, Bornstein MM, Sendi P, Buser D. Anatomical characteristics and dimensions of edentulous sites in the posterior maxillae of patients referred for implant therapy.

Int J Periodontics Restorative Dent. 2013; 33(3):337-345.

22. Pohl V, Schuh C, Fischer MB, Haas R. A New Method Using

Autogenous Impacted Third Molars for Sinus Augmentation to Enhance Implant Treatment: Case Series with Preliminary Results of an Open, Prospective Longitudinal Study. Int J Oral Maxillofac Implants. 2016;31(3):622-30.

23. Puisys A, Linkevicius T. The influence of mucosal tissue thickening on crestal bone stability around bone-level implants. A prospective controlled clinical trial. Clin Oral Implants Res. 2015;26(2):123-129.

24. Sanz M, Donos N, Alcoforado G, et al. Therapeutic concepts and methods for improving dental implant outcomes. Summary and consensus statements. The 4th EAO Consensus Conference 2015. Clin Oral Implants Res. 2015;26(suppl 11):202-206.

25. Slagter KW, Meijer HJ, Bakker NA, Vissink A, Raghoebar GM. Immediate Single-Tooth Implant Placement in Bony Defects in the Esthetic Zone: A 1-Year Randomized Controlled Trial. J Periodontol. 2016;87(6):619-629.

26. Slagter KW, Raghoebar GM, Bakker NA, Vissink A, Meijer HJ. Buccal bone thickness at dental implants in the aesthetic zone: A 1-year follow-up cone beam computed tomography study. J Craniomaxillofac Surg.

2017;45(1):13-19.

27. Tahmaseb A, Wismeijer D, Coucke W, Derksen W. Computer technology applications in surgical implant dentistry: a systematic review. Int J Oral Maxillofac Implants. 2014;29(suppl):25-42.

28. Tarnow DP. Increasing Prevalence of Peri-implantitis: How Will We Manage? J Dent Res. 2016; 95(1):7-8.

29. Thalji G, Al-Tarawneh S. Prosthodontic considerations in the implant restoration of the esthetic zone. In: Sadowsky S, ed. Evidence-based Implant Treatment Planning and Clinical Protocols. Iowa: John Wiley & Sons; 2016.

30. Thoma DS, Zeltner M, Hilbe M, Hammerle CH, Husler J, Jung RE. Randomized controlled clinical study evaluating effectiveness and safety of a volume-stable collagen matrix compared to autogenous connective tissue grafts for soft tissue augmentation at implant sites. J Clin Periodontol.

2016;43(10):874-885.

31. Urban IA, Jovanovic SA, Lozada JL. Vertical ridge augmentation using guided bone regeneration (GBR) in three clinical scenarios prior to implant placement: a retrospective study of 35 patients 12 to 72 months after loading. Int J Oral Maxillofac Implants. 2009;24(3):502-510.

Volume 10 Number 4

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Autologous bone grafting using extracted teeth NEDJAT

1. When socket preservation is not performed after extraction, the hard and soft tissues can lose up to _____ of their volume. a. 20% b. 30% c. 40% d. 50% 2. A variety of graft materials — from autologous bone (derived from the patient’s ______ ) or synthetic bone (Beta-TCP), to xenogenous bone — have all seen some measure of success. a. chin b. ramus c. hip d. all of the above 3. Instead of discarding extracted teeth, the teeth are ________ in order to use them as osteoinductive autologous bone graft. a. bio-recycled chairside b. cleaned directly after extraction c. preserved in disinfecting solution until the following appointment d. both a and b 4. In socket preservation procedures, a graft is placed at the time of extraction, but the implant

Volume 10 Number 4

is typically not placed for another _______. a. 2 to 3 weeks b. 6 weeks c. 3 to 4 months d. 6 months 5. It is recommended that the implant be placed first (ideally, at a primary stability of ______ ), and then the graft added to fill the bone-implant cavity. a. 30 Ncm b. 40 Ncm c. 45 Ncm d. 50 Ncm 6. A prospective study by Barone documented stable soft tissue with a success rate of _____ after 7 years following an immediate implantation and immediate restoration. a. 43% b. 57% c. 75% d. 95% 7. With a minimally invasive method of implantation (i.e., without raising flaps), there is likely to be resorption of only ______, which is a satisfactory and even long-term esthetic clinical result.

a. b. c. d.

0.3 mm 0.5 mm 0.6 mm 0.8 mm

8. A prospective study found that for immediate implantation, it was ______ whether the vestibular bone wall measured 0.4 mm or 1.2 mm. a. very significant b. not significant c. critical d. complicated to ascertain 9. If a graft is placed in the cavity between the bone and the implant, the buccal lamella _______. a. can be stabilized b. cannot be stabilized c. is endangered d. can be compromised 10. As clinicians, we know that tackling an alveolar resorption rate of around 50% after extraction requires a/an ________. a. efficient, non-traumatic treatment b. treatment that can be carried out chairside c. treatment without a big investment in laboratory material d. all of the above

Implant practice 29

CE CREDITS

IMPLANT PRACTICE CE

CONTINUING EDUCATION

Immediate full arch restoration Dr. Robert Hayes discusses a predictable novel treatment modality for treating failing dentitions, edentulous, and potentially edentulous patients

B

ased on studies from many authors over 5 decades (Lopes, et al., 2106; Drago, 2016; Meloni, et al., 2017; Chan and Holmes, 2015; Patzelt, et al., 2014; Francetti, et al., 2008), this article is written from long clinical experience and deep understanding of the biomechanics of immediate load full arch treatment to emphasize and establish important parameters for successful technique (Holtzclaw, 2016).

Following careful investigation of the patient’s medical history and a tooth-by-tooth analysis, a detailed discussion that covers all treatment options — from living with gaps to wearing removable dentures or utilizing natural teeth as fixed bridge abutments or supplementing with sectional implant prosthetics — must also cover the anticipated scenarios and lifelong costs associated with each option.

Analyzing these cases is rather like highlevel chess — how many strong pieces should be sacrificed early in order to win the long game?

Full arch implant treatment Full arch implant treatment has a number of attractions. By eliminating the teeth, it removes the risks of decay, pulp necrosis, and periodontal infection. The first case was undertaken in 1965 by Dr. PerIngvar Brånemark, and many studies report the unassailable long-term success rates.

The implants are linked by a supragingival metal bar providing cross-arch bracing and splinting, so no implant is ever bearing load alone. Full arch treatment is also an opportunity to establish an idealized version of the patient’s occlusion with canine rise/group function, balance, and harmony while eliminating destructive features such as crossarch interference.

Since the 1960s, it has been recognized how a high-quality acrylic occlusion can protect the metal elements and bone from overloading Robert N Hayes, MSc Imp Dent (Lon), BDS (Lon), MFGDP (UK), Dip Imp Dent RCS (Eng), is the founding author of the implant section of the Standards in Dentistry document. He was the first dentist to hold the diploma in implant dentistry from the Royal College of Surgeons as well as an MSc in implant dentistry.

30 Implant practice

Educational aims and objectives

This article aims to explain the benefits of and protocols for successful immediate load full arch treatment planning.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 34 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Read about this protocol and be aware of the evidence base supporting it.

•

Read about some history of the full arch implant.

•

Identify some aspects of prosthesis design.

•

Recognize some aspects of angulation and load that facilitate successful outcomes.

•

Identify the process for establishing the shelf.

•

Realize how to determine access position.

•

Realize how to guard against destructive bruxism.

as it softens impact and wears harmoniously, preventing the development of occlusal interferences (Brånemark, et al., 1977).

Research has also shown the development of hemidesmosomal attachment to acrylic, which we now utilize to control bacterial ingress and protect the bone from peri-implantitis (Listgarten and Lai, 1975).

Ongoing investigations are evaluating the effects of incorporating antimicrobial and antibiotic agents into the prosthesis (Nazirkar, et al., 2014).

The long established adsorption of chlorhexidine gluconate onto acrylic supports transferring the prosthesis from the laboratory in such a solution and establishing a home-care regime that will refresh the antimicrobial reservoir (Bonesvoll and Olsen, 1974).

Prosthesis design Since postoperative resorption of bone is inevitable, this author favors replacing the initial prosthesis at 4 months with a milled-titanium acrylic wrap that can be relined for years, with the original acrylic bridge being refurbished on the definitive models to provide a spare during laboratory procedures. The model ridge is trimmed by 1 millimeter to provide controlled gingival compression and development of a gingival trough in intimate contact with the dense, highly polished convex underside of the prosthesis. High-quality pressure-formed acrylic

Figure 1: Patient at presentation

is used with great care on choice of fully chemically compatible teeth, metal prime, bond, mechanical retention on the bar and the teeth to achieve strength and durability.

The esthetic result from high-quality acrylic work is far superior and easier to achieve than any other ceramic or composite alternative, and reparations can be much more readily accomplished.

Angulation and load Biomechanical research has clearly demonstrated the advantage of placing long tilted implants to resist the high posterior Volume 10 Number 4

Application in the maxilla The All-on-4 concept is absolutely applicable to the maxilla, but it must be recognized that the original papers were specific to a population of edentulous Portuguese pensioners accepting of a short arch Volume 10 Number 4

CONTINUING EDUCATION

load in the human jaw. Since the human jaw is a Class 3 lever (as is a nutcracker), the highest forces are always on the posterior implants (Lopes, et al., 2016; Silva, et al., 2010; Agliardi, et al., 2010). Thus placing short upright posterior implants below the sinus or above the nerve is inviting failure.

To understand something of this, imagine a high occlusal point force on a single vertical implant — the bone contact surface has to bear all the force directly to prevent the implant being driven in like a nail.

With a 45º tilted implant, imagine the bone providing only a midpoint support. The force on the abutment would push the abutment end down, and the apical end would rise. Actually, the implant doesn’t move because the bone below the abutment end provides resistance, just as the bone above the apical end prevents the tilt. The forces are equal and opposite, so the load at such a point on the bone is halved.

None of the force applied during function — or more importantly parafunction — is directly along the long axis of the implant, so the resultant vectors of force along this natural path of movement of the implant are minimal. This angulation contributes to the near 99% implant success rates repeatedly reported, and it is incumbent on surgeons to apply this knowledge to full arch cases (Bhering, et al., 2016; Afrashtehfar, 2016; Saleh Saber, et al., 2015; Li, et al., 2015; Khatami and Smith, 2008).

The anatomy of the maxillary sinus and the mental nerve also lends itself to providing a resistant cortical surface immediately distal to the distal tilted implant, further enhancing its use, along with the widely understood benefit of reducing the cantilever and increasing the anterior-posterior spread of the abutments.

In extreme cases, it will be necessary to cross the anterior aspect of the sinus, place a zygomatic implant, or provide a posterior tilt in the opposite direction into the pterygoid plate. The most extreme maxillary cases are treated with quad zygoma, but in the mandible almost all can be treated with intra foraminal All-on-4 (All-on-3 in extreme cases) (De Moraes, et al., 2016; Jensen, et al., 2014; Malo, et al., 2013; Bedrossian, 2011; Ferreira, et al., 2010).

Figure 2: Preoperative CBCT

Figure 3: Postoperative radiograph of BioHorizons® implant array and interim prosthesis

Figures 4A-4E: Final bridge

concept and a 10-year survival (Malo, et al., 2011). When applying the concept to immediate placement in younger individuals with greater demands, it is wise to take into account the additional factors, including the lower density and reduced reliability of maxillary bone.

In many cases, the classic two tilted posterior and two anterior vertical implants should be supplemented by a third or fourth anterior implant and immediate load applied to all cases so that the implants are

immediately splinted (Tallarico, et al., 2016; Silva, et al., 2010; Pomares, 2009). Placement of the biomechanically derived implant array must be prosthetically driven using a clear acrylic duplicate stent that informs positioning in all three dimensions.

This approach is derived from treatment of longstanding edentulous cases where fully guided surgery is a viable option using clear stereolithographically produced CAD/ CAM devices produced digitally from CBCT planning software. In immediate cases, the Implant practice 31

CONTINUING EDUCATION dimensions of the surgical field are altered by reflection of full arch flaps, removal of teeth, roots and a sufficient depth of bone to accommodate the prosthesis (Faeghi Nejad, 2016; Butura, 2011; Pomares, 2009).

Establishing the shelf It is vital to assess all aspects of the smile at the records appointment to determine the correct level of the transition line between the artificial and real gingivae, so that this is never visible in any expression of the lips, either anteriorly or within the buccal corridor.

The consequent requirement for ridge reduction must be communicated to the technician to inform the initial model ridge trimming, which must be flat rather than socketed to create a smooth, cleansable prosthetic junction (Abi Nader, et al., 2015; Krenmair, et al., 2014). The average case will require 3 millimeters of bone removal in the region of the extraction sockets — more if a gummy smile is to be corrected, and less if there has been significant bone loss due to severe periodontitis or a longstanding area of edentulous ridge (Jensen, et al., 2011a; Jensen, et al., 2010).

Access position As each implant approaches final torque, account needs to be taken of the rotational position of the internal flats as these will determine the eventual access position of the prosthetic screws, which ideally occurs in the cingulum of the anterior teeth and the occlusal surface of the premolar or molar.

Any facial deviation from this will risk an unsightly buccal access, and any lingual or

palatal deviation will adversely affect the bulk of the prosthesis.

Some surgeons find it easier to use an external hex implant to directly observe the flats, but most manufacturers provide implant placement devices marked to indicate the internal flats. With the common hex design, this gives six positions for placing a 17º or 30º degree multi-unit abutment, three of which will be potentially restorable, giving a facial, mid, and lingual choice to abutment insertion, which should be chosen with reference to the clear stent by carefully referencing it to the final restorative position immediately prior to abutment connection.

It is wise to initially slightly under-prepare the osteotomies so that high primary stability (35-65 Ncm) of each implant is produced as the final rotational position is achieved, and abutments should be tightened to 15 Ncm, confirming full seating, which may require bone removal around any subcrestal aspect of the implant (Babbush, 2011; Jensen, et al., 2011b; Butura, 2011).

Guarding against bruxism It should be recognized that many patients presenting for immediate full arch have destructive bruxism (De Rossi, et al., 2014). This is often apparent as a battle between the upper and lower teeth with units failing until eventually there are no opposing teeth in contact.

The pattern varies but, for example, the upper right and lower left buccal segments may be edentulous; then the lower incisors fail, and eventually the upper canines. Each loss depletes the dentition, and posterior loss in particular limits the parafunctional

force. The “bruxism center” of the brain is searching for satisfying feedback and immediately introduces high forces to the transitional prosthesis. Creation of a protective, minimal overbite, minimal overjet, and idealized, close to edge-to-edge occlusion limited to first molars will protect the screws and implants from overloading.

Tightening abutments to 15 Ncm gives a positive fit, which will hold in most circumstances but release with more active bruxism — immediately protecting the implant bone attachment and alerting the clinician at the 2-month review. Protective steps can then be taken: retightening the screw to 10 Ncm to avoid over-torquing the healing bone, reducing the molars out of contact, and possibly adding an anterior bite plane to convert the prosthesis to an effective Michigan splint during the first 4 months.

Immediate full arch Once all multi-unit abutments are tight, temporary titanium abutments are attached at 10 Ncm, and the transparent surgical guide is used carefully again to note the exact positioning and inform the opening of insertion channels through the interim prosthesis.

This must eventually seat freely onto the mucosa, exactly like an immediate denture without interference from metal components once all the channels are completed.

The final position can be checked visually, focusing on features such as an esthetic occlusal plane, incisal display, lip support, centric occlusion, and alignment of center lines or checked using a putty bite provided by the laboratory from the articulated setup.

Figures 5A-5C: Final restoration — retracted views 32 Implant practice

Volume 10 Number 4

the final fit. Specific oral hygiene instruction is delivered and emphasized with an illustrated leaflet, and all patients are recalled at 1 month for a 15 Ncm retightening of the prosthetic screws, review of oral hygiene, oral health, and esthetic and occlusal outcome. Patientappropriate hygiene, screw checking, and radiographic reviews are organized, and feedback recorded. IP

REFERENCES 1. Abi Nader S, Eimar H, Momani M, Shang K, Daniel NG, Tamimi F. Plaque Accumulation Beneath Maxillary All-on-4 Implant-Supported Prostheses. Clin Implant Dent Relat Res. 2015;17(5): 932-937.

2. Afrashtehfar KI. The all-on-four concept may be a viable treatment option for edentulous rehabilitation. Evid Based Dent. 2016; 17(2):56-57.

3. Agliardi E, Clericò M, Ciancio P, Massironi D. Immediate loading of full-arch fixed prostheses supported by axial and tilted implants for the treatment of edentulous atrophic mandibles. Quintessence Int. 2010;41(4):285-293.

4. Babbush CA, Kutsko GT, Brokloff J. The all-on-four immediate function treatment concept with NobelActive implants: a retrospective study. J Oral Implantol.

2011;37(4):431-445.

5. Bedrossian E. Rescue implant concept: the expanded use of the zygoma implant in the graftless solutions. Oral Maxillofac Surg Clin North Am. 2011;23(2):257-76 6. Bhering CL, Mesquita MF, Kemmoku DT, Noritomi PY, Consani RL, Barão VA. Comparison between all-on-four and all-on-six treatment concepts and framework material on stress distribution in atrophic maxilla: A prototyping guided 3D-FEA study. Mater Sci Eng C Mater Biol Appl.

2016;69:715-725.

7. Boulos PJ. Immediate loading of implants and fixed complete dentures: a simplified prosthetic procedure. Gen Dent. 2010;58(5):406-409.

8. Bonesvoll P, Olsen I. Influence of teeth, plaque and dentures on the retention of chlorhexidine in the human oral cavity. J Clin Periodontol. 1974;1(4):214-221.

9. Brånemark PI, Hansson BO, Adell R, Breine U, Lindström J, Hallén O, Ohman A. Osseointegrated implants in the treatment of the edentulous jaw – experience from a 10-year period. Scand J Plast Reconstr Surg Suppl. 1977;16:1-132.

10. Butura CC, Galindo DF, Jensen OT. Mandibular all-on-four therapy using angled implants: a three-year clinical study of 857 implants in 219 jaws. Oral Maxillofac Surg Clin North Am. 2011;55(4):795-211.

11. Chan MH, Holmes C. Contemporary “All-on-4” concept.

Dent Clin North Am. 2015; 59(2):421-470.

12. de Moraes PH, Olate S, Nóbilo Mde A, Asprino L, de Moraes M, Barbosa Jde A. Maxillary “All-On-Four” treatment using zygomatic implants. A mechanical analysis. Rev Stomatol Chir Maxillofac Chir Orale. 2016;117(2):67-71.

13. De Rossi M, Santos CM, Migliorança R, Regalo SC. All on Four® fixed implant support rehabilitation: a masticatory function study. Clin Implant Dent Relat Res. 2014;16(4):594-600.

14. Drago C. Cantilever Lengths and Anterior-Posterior Spreads of Interim, Acrylic Resin, Full-Arch Screw-Retained Prostheses and Their Relationship to Prosthetic Complications. J Prosthodont. 2016; doi:10.1111/jopr.12426. [Epub ahead of print] 15. Faeghi Nejad M, Proussaefs P, Lozada J. Combining guided alveolar ridge reduction and guided implant placement for all-on-4 surgery: A clinical report. J Prosthet Dent.

2016;115(6):662-667.

16. Ferreira EJ, Kuabara MR, Gulinelli JL. “All-on-four” concept and immediate loading for simultaneous rehabilitation of the atrophic maxilla and mandible with conventional and zygomatic implants. Br J Oral Maxillofac Surg.

2010;48(3):218-220.

Figure 6: Final, full smile Volume 10 Number 4

17. Francetti L, Agliardi E, Testori T, Romeo D, Taschieri S, Del Fabbro M. Immediate rehabilitation of the mandible with fixed full prosthesis supported by axial and tilted implants: interim results of a single cohort prospective study. Clin Implant Dent Relat Res. 2008;10(4):255-263.

18. Holtzclaw D. All-on-4® Implant Treatment: Common Pitfalls and Methods to Overcome Them. Compend Contin Educ Dent. 2016;37(7):458-465;quiz466.

19. Jensen OT, Adams MW, Cottam JR, Parel SM, Phillips WR 3rd. The All-on-4 shelf: maxilla. J Oral Maxillofac Surg.

2010;68(10):2520-2527.

20. Jensen OT, Adams MW, Cottam JR, Parel SM, Phillips WR 3rd. The all on 4 shelf: mandible. J Oral Maxillofac Surg.

2011;69(1):175-181.

21. Jensen O, Cottam J, Adams M, Adams S. Buccal to lingual transalveolar implant placement for all on four immediate function in posterior mandible: report of 10 cases. J Oral Maxillofac Surg. 2011;69(7):1919-1922.

22. Jensen OT, Cottam JR, Ringeman JL, Graves S, Beatty L, Adams MW. Angled dental implant placement into the vomer/nasal crest of atrophic maxillae for All-onFour immediate function: a 2-year clinical study of 100 consecutive patients. Int J Oral Maxillofac Implants.

2014;29(1):e30-e35.

23. Khatami AH, Smith CR. “All-on-Four” immediate function concept and clinical report of treatment of an edentulous mandible with a fixed complete denture and milled titanium framework. J Prosthodont. 2008;17(1):47-51.

24. Krennmair S, Seemann R, Weinländer M, Krennmair G, Piehslinger E. Immediately loaded distally cantilevered fixed mandibular prostheses supported by four implants placed in both fresh extraction and healed sites: 2-year results from a prospective study. Eur J Oral Implantol.

2014;7(2):173-184.

25. Li X, Cao Z, Qiu X, Tang Z, Gong L, Wang D. Does matching relation exist between the length and the tilting angle of terminal implants in the all-on-four protocol? stress distributions by 3D finite element analysis. J Adv Prosthodont.

2015;7(3):240-248.

26. Listgarten MA, Lai CH. Ultrastructure of the intact interface between an endosseous epoxy resin dental implant and the host tissues. J Biol Buccale. 1975;3(1):13-28.

27. Lopes A, Maló P, de Araújo Nobre M, Sánchez-Fernández E, Gravito I. The NobelGuide® All-on-4® Treatment Concept for Rehabilitation of Edentulous Jaws: A Retrospective Report on the 7-Years Clinical and 5-Years Radiographic Outcomes. Clin Implant Dent Relat Res. 2017;9(3):e474-e488.

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

29. Maló P, Nobre Md, Lopes A. Immediate loading of ‘Allon-4’ maxillary prostheses using trans-sinus tilted implants without sinus bone grafting: a retrospective study reporting the 3-year outcome. Eur J Oral Implantol.

2013;6(3):273-283.

30. Meloni SM, Tallarico M, Pisano M, Xhanari E, Canullo L. Immediate Loading of Fixed Complete Denture Prosthesis Supported by 4-8 Implants Placed Using Guided Surgery: A 5-Year Prospective Study on 66 Patients with 356 Implants.

Clin Implant Dent Relat Res. 2017;19(1):195-206.

31. Nazirkar G, Bhanushall S, Singh S, Pattanaik B, Raj N. Effect of Anatase Titanium Dioxide Nanoparticles on the Flexural Strength of Heat Cured Poly Methyl Methacrylate Resins; An In-vitro Study. J Indian Prosthodont Soc. 2014;14(suppl 1):144-149.

32. Patzelt SB, Bahat O, Reynolds MA, Strub JR. The all-onfour treatment concept: a systematic review. J Clin Dent Relat Res. 2014;16:836-855.

33. Pomares C. A retrospective clinical study of edentulous patients rehabilitated according to the ‘all on four’ or the ‘all on six’ immediate function concept. Eur J Oral Implantol.

2009;2(1): 55-60.

34. Saleh Saber F, Ghasemi S, Koodaryan R, Babaloo A, Abolfazli N. The Comparison of Stress Distribution with Different Implant Numbers and Inclination Angles In All-on-Four and Conventional Methods in Maxilla: A Finite Element Analysis.

J Dent Res Dent Clin Dent Prospects. 2015;9(4):246-253.

35. Silva GC, Mendonça JA, Lopes LR, Landre J Jr. Stress patterns on implants in prostheses supported by four or six implants: a three-dimensional finite element analysis.

Int J Oral Maxillofac Implants. 2010;5(2):239-246.

36. Tallarico M, Canullo L, Pisano M, Peñarrocha-Oltra D, Peñarrocha-Diago M, Meloni SM. An up to 7-Year Retrospective Analysis of Biologic and Technical Complication With the All-on-4 Concept. J Oral Implantol.

2016;42(3):265-271.

Implant practice 33

CONTINUING EDUCATION

The prosthesis is then washed and dried, and a bonding agent is applied to the channels. The prosthesis is then attached using an intraoral reline process and removed for extraoral final finishing by uncovering and counter rotating the screws, which have been protected by packing PTFE tape to the full height of each hollow abutment (Boulos, 2010).

The alternative to picking up all supragingival abutments intraorally is to just pick up the anteriors, take a full arch impression with multi-unit impression abutments, and transfer both to the laboratory to create the posterior access and finish the bridge on the resulting model.

The author finds this alternative keeps the patient in the chair longer, especially if inadvertent occlusal inaccuracies are introduced by the impression and model production — but in cases where the posterior abutments are at very divergent angles, it results in a stronger, neater interim prosthesis.

The resulting interim acrylic bridge is then inserted with the screws at 10 Ncm and the screw access protected with new PTFE tape packed firmly and finished a millimeter below the prosthetic surface and sealed over with color-matched glass ionomer or resin.

At 4 months, the occlusion is recorded.

The bridges are removed and copied using putty. All abutment screws are tightened to 20 Ncm, impression copings are placed at 10 Ncm, and accurate open tray impressions are taken. The bridges are replaced at 10 Ncm, and the patient chooses the final shade and characterization for the definitive try-in.

Once the try-in is successful, the definitive model ridges are reduced by 1 millimeter so that controlled compression is achieved at

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

REF: IP V10.4 HAYES

CONTINUING EDUCATION BROUGHT TO YOU BY

FULL NAME

Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 24 CE credits for only $149; call 866-579-9496 to subscribe today.. To receive credit, complete the 10-question test by circling the correct answer, then either: n Post the completed questionnaire to: Implant Practice US CE 15720 N. Greenway-Hayden Loop. #9 Scottsdale, AZ 85260 n Fax to (480) 629-4002.

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To provide feedback on this article and CE, please email us at education@medmarkaz.com Legal disclaimer: The CE provider uses reasonable care in selecting and providing accurate content. The CE provider, however, does not independently verify the content or materials. Any opinions expressed in the materials are those of the author and not the CE provider. The instructional materials are intended to supplement, but are not a substitute for, the knowledge, skills, expertise and judgement of a trained healthcare professional.

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Immediate full arch restoration HAYES

1. Full arch implant treatment has a number of attractions. By eliminating the teeth, it removes the risks of _______. a. decay b. pulp necrosis c. periodontal infection d. all of the above 2.

The first case (full arch implant treatment) was undertaken in 1965 by ________, and many studies report the unassailable long-term success rates. a. Dr. Per-Ingvar Brånemark b. Dr. Norman Ross c. Dr. Isaiah Lew d. Dr. Victor Sendax

3. Since postoperative resorption of bone is inevitable, this author favors replacing the initial prosthesis at ________ with a milled-titanium acrylic wrap that can be relined for years, with the original acrylic bridge being refurbished on the definitive models to provide a spare during laboratory procedures. a. 3 weeks b. 2 months c. 4 months d. 6 months 4. The model ridge is trimmed by ______ to provide controlled gingival compression and development of a gingival trough in intimate contact with the dense, highly polished convex underside of the prosthesis. a. 1 millimeter

34 Implant practice

b. 3 millimeters c. 4 millimeters d. 6 millimeters 5.

None of the force applied during function — or more importantly parafunction — is directly along the long axis of the implant, so the resultant vectors of force along this natural path of movement of the implant are ________. a. normal b. minimal c. expected d. maximized

6. The anatomy of the _________ also lends itself to providing a resistant cortical surface immediately distal to the distal tilted implant, further enhancing its use, along with the widely understood benefit of reducing the cantilever and increasing the anteriorposterior spread of the abutments. a. canine rise b. maxillary sinus c. mental nerve d. both b and c 7. In extreme cases, it will be necessary to cross the anterior aspect of the sinus, place a zygomatic implant, or provide a posterior tilt in the ______ into the pterygoid plate. a. same direction b. opposite direction c. long axis d. none of the above

8. Placement of the biomechanically derived implant array must be prosthetically driven using a clear acrylic duplicate stent that informs positioning in all three dimensions. This approach is derived from treatment of longstanding edentulous cases where fully guided surgery is a viable option using clear stereolithographically produced CAD/ CAM devices produced digitally from __________. a. CBCT planning software b. high-resolution digital photographs c. panoramic radiographs d. 2D digital X-rays 9. The consequent requirement for ridge reduction must be communicated to the technician to inform the initial model ridge trimming, which must be __________ to create a smooth, cleansable prosthetic junction. a. socketed rather than flat b. flat rather than socketed c. curved rather than flat d. curved and socketed 10. The final position can be checked visually, focusing on features such as an esthetic occlusal plane, ________ and alignment of center lines or checked using a putty bite provided by the laboratory from the articulated setup. a. incisal display b. lip support c. centric occlusion d. all of the above

Volume 10 Number 4

CE CREDITS

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Clinical images courtesy of German Murias DDS, ABOI/ID 1

Two Slim OsteoGen® Plugs are in place. Suture over top of socket to contain. No membrane is required

Tooth #15, set to be extracted

The surgical site was initially debrided to induce bleeding and establish the Regional Acceleratory Phenomenon

2

3 Insert Large or Slim sized OsteoGen® Bone Grafting Plugs and allow blood to absorb

OsteoGen® is a low density bone graft and the will OsteoGen® Plugs show radiolucent on the day of placement

As the OsteoGen® crystals are resorbed and replaced by host bone, the site will become radiopaque

4

5

6

The collagen promotes 7 keratinized soft tissue coverage while the OsteoGen® resorbs to form solid bone. In this image, a core sample was retrieved

8

Implant is placed. Note the histology showing mature osteocytes in lamellar bone formation.

Some of the larger OsteoGen® crystals and clusters are slowly resorbing. Bioactivity is 9 demonstrated by the high bone to crystal contact, absent of any fibrous tissue encapsulation

Contact 800-526-9343 or Shop Online at www.impladentltd.com

PRACTICE DEVELOPMENT

Do your patients know that you place dental implants?

Dr. Bobbi Stanley discusses three ways to maximize your internal marketing Give them a sign As a general practitioner, we provide comprehensive dental care to our patients.

Our services include general dentistry, hygiene, and pediatric dentistry but can also include advanced services like orthodontics, periodontal grafting, oral surgery, or dental implants. It is imperative that we inform our patients of the services that we provide, or they may assume we offer only basic services as a general dental practice.

Many patients visit our office for a specific procedure because their dentist “does not offer that service.” We assume that our patients visit our website and research us on a regular basis. Or we may assume that if the patient needs or wants the treatment, they will ask for it. This is often not the case.

Are your patients seeing another dentist for a service you provide?

Several years ago, I spoke with a longtime patient at her 6-month hygiene appointment.

She informed me of her recent bridge removal and implant placement at a nearby dental office. When I inquired why she did not allow us to place the implant for her, she looked surprised and said, “I didn’t know that you placed dental implants!” It only takes one of these conversations with a patient to realize that you are not fully utilizing your internal marketing, and immediate action is required.

The solution was to put our offerings in writing, and we implemented “stations of the cross” for dentistry. Dentistry consists of many disciplines, and it is important that our patients know which of these services we provide. We established stations on the walls around our office to inform and educate our patients. These strategically placed signs are tasteful and cannot be missed.

Each station has a large sign that is perpendicular to the wall, so when they look

down the hallway, they can see one or more signs that protrude above their head. The signs clearly state, “We Do ___________” (fill in the blank with Implants, Braces, and Invisalign®, etc.) These signs serve a dual purpose of educating the patient on the depth of our services and reinforcing our credibility as comprehensive dentists. To support the signage, there are multiple photos of our patients who have received the featured service. This shows our dental skills, and the featured patient is honored to be on one of our “Walls of Fame.” We ceremoniously ask our patients to sign their photo, which solidifies the value of the completed. Having a patient write, “Thank you for my new smile,” or “I only trust my smile to Stanley Dentistry,” gives us more credibility in the patients’ mind.

In addition to the stations located in the hallways, we have slideshows on the televisions in each operatory, the lobby, and common areas. In the past, we allowed patients to watch TV while they received treatment. Now, we have a carefully curated slide show scrolling on the monitors. Each slide is different and ranges from dental trivia, slides for each of our team members with their families and a bit of personal information, and most importantly, a slide that says “We Do _________” for each of our services. The slideshow is playing throughout their appointment.

Bobbi Stanley, DDS, received her dental degree from the University of North Carolina School of Dentistry at Chapel Hill in 1993. She immediately opened her Cary, North Carolina, dental office with her husband, Dr. Robert Stanley.

Their office has grown into one of the most successful, comprehensive practices in North Carolina. Dr. Stanley earned her mastership with the Academy of General Dentistry, her Diplomate with the International Congress of Oral Implantologists, and her fellowship with the Las Vegas Institute for Advanced Dental Studies. She is a member of the American Academy of Cosmetic Dentistry (AACD), the American Academy of Implant Dentistry (AAID), the American Orthodontic Society (AOS), and the American Dental Association (ADA). Dr. Bobbi Stanley is an Adjunct Professor in the Department of Prosthodontics at the University of North Carolina at Chapel Hill, her alma mater. She is Cofounder and Lead Orthodontics Instructor at The Stanley Institute for Comprehensive Dentistry in Cary and a Senior Instructor at the International Association of Orthodontics (IAO) in Milwaukee, Wisconsin, and the Facial Beauty Institute in Memphis. She has lectured nationally in the areas of dental implants, implant restorations, cosmetics, orthodontics, and practice management.

36 Implant practice

Show your work It is often said that a picture is worth a thousand words. Therefore we capture high quality photos of our patients once treatment is complete. When possible, we exhibit a before-and-after comparison photo collage.

This opens conversations for patients to ask questions about the photos and note the differences in the before and after. Many times a new patient will comment, “That’s what I want,” while pointing to a photo.

Tell them We also engage the patient with our radio. We have a custom channel made for us that provides soft music to foster a spalike atmosphere. About every 10 songs, there is a promotional message that reinforces an aspect of our practice. For example, “Did you know that Dr. Stanley is a leader in dental implants? If you are interested in replacing your teeth or a missing tooth, ask about our dental implants today.” The message is brief but supports our other internal marketing and ensures there isn’t a competitor’s commercial playing in our practice.

Internal marketing is the least expensive form of marketing with potentially the largest return. We have a captive audience that has already entrusted us with their oral health.

Before you spend thousands on traditional advertising, be sure to maximize your internal marketing. You may be surprised how these simple ideas can increase the revenue per patient in your practice. IP Volume 10 Number 4

PRACTICE DEVELOPMENT

How social media can help your SEO performance Ian McNickle, MBA, discusses the impact of search engine optimization

B

y now most people are aware of social media and its prevalence in the world.

Over 70% of U.S. adults who are online use Facebook®, and around 30% use other popular channels such as Instagram®, Pinterest, Twitter®, and LinkedIn®. As I lecture around the country, one of the most common questions I encounter focuses on the actual benefits of social media for a practice.

Social media itself can have numerous benefits for a practice, but the focus of this article is on the impact of search engine optimization (SEO). SEO commonly refers to the set of activities that affect how a website will rank on Google® and the other search engines. Google looks at over 200 variables to determine how highly to rank a website for a given set of terms and geography.

Google says social media is not a ranking factor What is interesting about social media is that Google has stated that social media is not a ranking factor. However, many SEO agencies have done studies and found a high correlation with certain aspects of social media and search rankings. If you create interesting posts, and lots of people interact with your posts, then the shares create links back to your social media pages and to your website. Incoming links to your website are a well-known factor to help SEO rankings.

In the dental industry, the most important social media channel is clearly Facebook due to its large audience and useful business tools (boosted posts, geo-targeted ads, and engagement dashboard). A well-designed Facebook campaign would include a large percentage of “personal”-type posts, which highlight the personality and human side of the practice.

Ian McNickle, MBA, is a national speaker, writer, and marketer. He is a Co-Founder and Partner at WEO Media, winner of the 2016 Cellerant Best of Class Award for Online Marketing and Websites. If you have questions about any marketing-related topic, please contact Ian McNickle directly at ian@weomedia.com, or by calling 888-246-6906. For more information, you can visit online at www.weodental.com.

38 Implant practice

For example, let’s say it’s Sally’s birthday, and you’re all in the break room having some birthday cake. Someone feeds Sally a piece of cake and smears it on her face.

Everyone laughs! Since you caught this on video with your phone, you can easily post it to your practice Facebook page. This type of post will generate FAR more engagement (and potential SEO benefit) than your clinical posts. While you should have clinical topic-type posts, please remember the personal posts will generate much more engagement.

The key is to create frequent and interesting content on Facebook in order to generate positive SEO benefit.

What about YouTube While most people understand Google is the largest overall search engine, many find it surprising to learn YouTube is the second largest search engine. The major difference is, of course, people searching on Google are in “research/buying” mode, whereas searchers on YouTube are in “social” mode.

This means despite the massive search volume on YouTube, people are not using YouTube to search for a dentist or specialist.

So how does YouTube help with SEO? The best strategy for using YouTube is to create a series of videos that are hosted on YouTube and also reside on other online

properties such as your website, Facebook page, etc. Google and other search engines look at videos as high-quality content (assuming they are properly optimized with a title and description). Therefore, embedding videos into your website should help the website SEO and search rankings.

Since Google purchased YouTube years ago, Google has integrated YouTube videos into their search results. Let’s say you have 10 videos on your YouTube channel. If you properly optimize these video titles and descriptions, then there is a chance some of these videos can appear in search results just like your website. This essentially multiplies your online presence.

While there are many aspects of social media that can help your online marketing efforts, we highly recommend posting frequent, interesting content on Facebook, and leveraging videos on YouTube, Facebook, and your website. These simple strategies can yield nice results indeed.

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

Receive your free marketing consultation today: 888-246-6906 or info@weomedia.com Volume 10 Number 4

HANDS-ON DENTAL IMPLANT TRAINING FROM DR. JUSTIN MOODY AND HIS FACULTY, ONE OF THE MOST CREDENTIALED TEAMS OF IMPLANTOLOGISTS IN THE COUNTRY.

D R. J U ST I N D . M O O DY

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ON THE HORIZON

Dental implants and social media: part 1 Dr. Justin Moody begins a series on social media and its impact on dental practices

S

itting at my desk today going through my mail, I noticed what appeared to be a bill. Upon further evaluation, I noticed that it was a request to advertise in the Yellow Pages disguised as a bill. Why would a company resort to such a junk mail ploy to get me to advertise? I further questioned, Do they really need to trick me into using them? I went back to work. Next on my agenda was making arrangements to go to my 20-year dental school reunion — 20 years — where does the time go?

Thinking back 20 years made me realize how much things have really changed, especially in how dentistry communicates and advertises. My reunion is a prime example.

No one called me to set things up, nor did they send me a formal invitation in the mail. I first read about it on Facebook with a request to “like” the class page. Second was an email about when, where, and how to register, none of which involved a phone number or an address. All I had to do was just a click on the links to the hotel and the registration page, and now I was ready to see all my peers in Napa Valley!

Social media has changed the way dentists communicate forever! State meetings and study club attendance is down, but dental podcasts and Facebook groups are

Figure 2: Implants in Black and White Facebook group

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.

40 Implant practice

Figure 1: Dentists, Implants, and Worms podcast

Figure 3: Dental Hacks Nation Facebook group

growing by hundreds per week. I too am the host of a dental podcast called “Dentists, Implants and Worms.” Drawing from the energy of people like Alan Mean and Jason Lipscomb, who started the Dental Hacks Podcast, it has been an amazing adventure and one of the most enjoyable things I do each week. Facebook is alive with dental groups sharing ideas and information; some of my favorites are “Implants in Black and White,” “Zero Bone Loss Concepts,” and the “Dental Hacks Nation.”

Figure 4: Zero Bone Loss Concepts Facebook group

Now I remember why I quit advertising in the Yellow Pages back in 2010.

I remember looking over the thousands of dollars my Yellow Page ad was costing me and the total lack of people who actually said that’s where they found out about me. I went home that night and asked my teenage kids how they would find a dentist (if I wasn’t one), and they both told me that they would either ask a friend or Google “dentist” — and there you have it. IP Volume 10 Number 4

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

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

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

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1. M Nevins et al. Int J Periodontics Restorative Dent. Vol. 28, No. 2, 2008.

2. S Botos et al. Int J Oral Maxillofac Implants. 2011; 26:492-498.

SPMP16251 REV A AUG 2016